In a review of the impacts of institutional child sexual abuse, Blakemore and colleagues (2017) likened institutional abuse to intra-familial sexual abuse, noting similarities in terms of its chronicity, severity and relational aspects, and described impacts as “pervasive, numerous and connected”. These authors noted negative impacts across psychological (e.g. post-traumatic stress symptomology, depression, anxiety), physical (e.g. self-reported quality of health, sleep problems), social (e.g. relationship, parenting and sexual difficulties), educational (e.g. school completion, engagement) and economic (e.g. obtaining and maintaining employment) domains.
Child sexual abuse is associated with a range of detrimental and often inter-related outcomes. While child sexual abuse has been shown to be associated with individually increased risks for public mental health service contacts, offending, subsequent victimisation and deaths by suicide or drug overdose, a study by Papalia and colleagues (2017) has shown that these adverse outcomes also tend to co-occur among survivors. For example, this research showed a three-way interaction between public mental health service contact, criminal history and subsequent victimisation – notably, the presence of a psychiatric history increased the likelihood of co-occurring offending and further victimisation among survivors of child sexual abuse (Papalia, Luebbers, Ogloff, Cutajar & Mullen, 2017).
An umbrella review synthesising meta-analytical findings on the outcomes of child sexual abuse found evidence for associations between sexual abuse and a wide range of psychiatric diagnoses, as well as negative psychosocial and physical health outcomes in adulthood, with particularly strong evidence existing for links between child sexual abuse and later post-traumatic stress disorder, schizophrenia, and substance misuse (Hailes Yu, Danese & Fazel, 2019).
Many reviews have described the various long term impacts of child sexual assault, while indicating that child sexual assault does not reliably predict any one condition or set of difficulties (Barnes & Josefowitz, 2014). In this way, the experience of child sexual abuse has been described as a non-specific risk factor for a multitude of adverse outcomes (Cashmore & Shackel, 2014).
Barnes and Josefowitz (2014) listed a number of outcomes that have been associated with experience of child sexual assault, include psychological difficulties such as depression, anxiety, sleep disorders, personality disorders and psychotic disorders, behavioural problems such as substance abuse, self-harm, eating disorders, conduct disorders and antisocial behaviour, as well as relationship difficulties, poorer physical health, and poorer educational and occupational achievement.
A study of over 1,000 children with both objective court-documented evidence of maltreatment and subjective reports of childhood maltreatment made as adults, found that, even for severe cases of maltreatment identified in court records, psychopathology was less likely when these children, as adults, did not also make subjective reports of maltreatment. Risk of psychopathology increased, however, when children made subjective reports of maltreatment as adults. This research suggests that the impact of childhood sexual assault emerges as a result of subjective experiences, rather than objective experiences of childhood maltreatment (Danese & Spatz Widom, 2020).
Research has identified several key factors that are predictive of increased negative impact into adulthood, including a child’s younger age at first experience, greater number of sexual assault episodes, longer duration of the abuse, the presence of coercion, force or threats, more invasive sexual contact, more than one perpetrator, parental mental illness, criminal activity and substance use, and perpetration by a father or father figure (Barnes & Josefowitz, 2014; Martin & Silverstone, 2013). Social support, meanwhile, has been shown to mediate the effect of trauma and reduce the likelihood of negative outcomes resulting from experiences of child sexual abuse (Charuvastra & Cloitre, 2008).
In addition to socio-emotional and mental health sequelae, numerous studies have highlighted that child sexual abuse victims are vulnerable to later sexual re-victimisation (Lalor & McElvaney, 2010).
A prospective-longitudinal study of 2,759 Australian children (<17 years old) who experienced contact sexual abuse, followed these children and a matched comparison group to age 35 years on average, and found that child sexual abuse victims experienced significantly higher rates of revictimization, with marked increases in odds for interpersonal revictimization, including sexual and physical assault, threats of violence, and stalking (Papalia, Mann & Ogloff, 2020). Widom, Czaja and Dutton (2008) report the findings of a prospective study of children physically and sexually abused between 1967 and 1971, and a comparison group of non-abused children matched for sex, age race and socioeconomic status. Both groups were followed up and interviewed between 2000 and 2002 (at a mean age of 39.5 years). Those who experienced abuse/neglect in childhood had significantly higher rates of sexual assault/abuse in adulthood (47.7% vs. 28.6%).
The impacts of child sexual abuse are thought to occur across at least three stages, with the child’s initial reaction to their victimisation, followed by their accommodation to ongoing abuse (if relevant), and the longer term impact on adolescent and adult functioning (Briere & Elliott, 1994).
SHORT TERM IMPACTS
Children exposed to complex trauma may experience impacts and show impairment across seven primary domains – attachment (e.g. development of insecure attachment patterns), biology (e.g. failure to develop brain capacities necessary for modulating emotions), affect regulation (e.g. inability to discriminate among and label affective states), dissociation (e.g. detachment from awareness of emotions and self), behavioural regulation (e.g. under-controlled and over-controlled behaviour patterns), cognition (e.g. lower grades and poorer academic achievement), and self-concept (e.g. self-perception as defective, helpless, deficient) (Cook et al., 2005).
Australian linkage projects have found that children who have contact with the child protection system are more likely than other children to have contact with the juvenile justice system and homelessness services, and to have lower literacy and numeracy achievement (AIHW 2015, 2016).
A study examining behavioural problems over childhood and adolescence in sexually abused versus maltreated, but non-sexually abused children, showed that those with a history of sexual abuse had significantly greater internalising and externalising behaviour problems over time when compared to those without sexual abuse histories (Lewis, McElroy, Harlaar, & Runyan, 2016).
In the short term, Kendall-Tackett and colleagues’ (1993) review of 45 studies showed that children who have experienced child sexual abuse have more symptoms, including for example, behaviour problems, poor self-esteem, and sexualised behaviours, than those who have not experienced sexual abuse.
A recent longitudinal matched-cohort study has shown that sexual abuse is associated with a 1.27 increased risk of infectious disease diagnoses in children and adolescents (Dargan et al., 2019).
A study of 14-18 year old adolescents in Canada found that while overall, boys had higher levels of self-esteem than girls, the opposite was true among victims of child sexual assault: boy victims had lower self-esteem than girl victims. Among victims of CSA, boys reported lower levels of self-esteem than girls, which in turn was associated with an increased risk of displaying delinquent behaviours (Gauthier-Duchesne, Hebert & Blais, 2021).
The experience of sexual abuse during childhood is a key antecedent of complex trauma symptoms. Research has shown that the symptoms of complex trauma most often result from prolonged exposure to multiple forms of interpersonal trauma (including sexual abuse), typically during childhood, by caregivers who are expected to provide a safe, predictable, and secure environment (Courtois & Ford, 2013). Sexual abuse perpetrated by a caregiver is associated with particularly severe complex trauma symptoms into adulthood (Kluft, 2011).
The International Society for Traumatic Stress Studies (Cloitre et al., 2012) task force’s definition of complex trauma includes the core symptoms of posttraumatic stress disorder alongside disruptions in self-regulatory capacities across five domains: (a) emotion regulation, (b) self/relational capacities, (c) alterations in attention and consciousness, (d) belief systems, and (e) somatic symptoms and/or medical problems.
Complex trauma is distinguished by its pervasive effects; it is not only a range of functions which are negatively impacted but also development and functioning of the self (Courtois & Ford, 2013). In contrast to “single incident” trauma (which relates to an unexpected and “out of the blue” event), complex trauma is cumulative and repetitive. When this occurs at critical developmental periods, it compromises psychobiological, social and emotional development (Courtois & Ford, 2013).
LINKS TO MENTAL HEALTH AND SUICIDE
A study using data from the WHO World Mental Health surveys (conducted across 21 countries with more than 51,000 adult participants) examined the prevalence and associations of retrospectively reported childhood adversities (ACEs) with first onset of a wide variety of mental disorders across the lifespan. Findings show that eradication of childhood adversities would lead to a 22.9% reduction in mood disorders, 31% reduction in anxiety disorders, 41.6% reduction in behaviour disorders, 27.5% reduction in substance disorders and 29.8% reduction in all disorders. In sum, ACEs were found to account for 30% of all mental disorders worldwide (Kessler et al., 2010).
Examination of three conditions directly linked to child abuse and neglect: anxiety disorders, depressive disorders, and suicide and self-inflicted injuries, were estimated to have been responsible for 0.5% of all deaths and 2.2% of the burden of disease and injury in 2015 (AIHW, 2019). More specifically, it was estimated that there would have been 26% less suicide and self-inflicted injuries, 20% less depressive disorders and 27% less anxiety disorders in 2015 if no one in Australia had ever experienced child abuse and neglect during childhood (AIHW, 2019).
Men’s experience of child sexual abuse has been shown to be positively associated with depressive and somatic symptoms as well as hostility into middle and late adulthood (Easton & Kong, 2017).
A study of child sexual abuse, its co-occurrence with other forms of maltreatment, and mental health outcomes among males has shown that having a history of child sexual abuse only, and of child sexual abuse co-occurring with other types of maltreatment, was associated with higher odds for many mental disorders and suicide attempts compared to having a history of child maltreatment without sexual abuse (Turner, Taillieu, Cheung, & Afifi, 2017).
A New Zealand birth cohort study found that sexual abuse prior to age 16 was associated with a range of adverse outcomes at age 30, including depression, anxiety, PTSD symptoms, and reduced self-esteem and life satisfaction (Fergusson, McLeod & Horwood, 2013). These negative outcomes were also found to increase alongside the increasing severity of abuse experienced (Fergusson et al., 2013).
One study analysing seven meta-analyses on child sexual abuse and adult psychopathology found sexual abuse to be a nonspecific risk factor for a range of adverse mental health outcomes (Hillberg, Hamilton-Giachritsis & Dixon, 2011).
Rates of suicide are significantly higher among victims of child sexual abuse than comparison groups. One study found sexual abuse victims were 18 times more likely to commit suicide than those in the general population (male abuse victims 14 times more likely and female victims 40 times more likely) (Cutajar, Mullen, Ogloff, Thomas, Wells, & Spataro, 2010).
LINKS TO PHYSICAL HEALTH
A survey study with a representative sample of Canadian adults showed that experience of all types of child abuse, including child sexual abuse, was associated with having a physical health condition in adulthood. Child sexual abuse was also associated with an increased risk of obesity in adulthood (Afifi, MacMillan, Boyle, et al., 2016).
A study of the prevalence of child sexual abuse and its impact on the health of adults in Saudi Arabia found that participants who reported child sexual abuse had 1.7, 2,2 and 3.8 times the odds of diabetes, coronary heart disease and obesity diagnosis respectively compared to participants with no history of child sexual abuse (Almuneef, 2021).
Women with a history of sexual abuse were more likely to use mental health services, pharmacy services, primary care services and speciality care (Bonomi, 2008).
Compared to those with no history of abuse, annual health care costs were 16% higher for women who reported childhood sexual abuse (Bonomi, 2008).
LINKS TO DRUG AND ALCOHOL MISUSE
Forty-seven articles included in a recent systematic review, covering a range of topics related to child sexual abuse and later substance use issues, found a clearly supported link between child sexual abuse and substance use issues later in life (Fletcher, 2020).
Experience of child sexual abuse has been shown to be associated with heavy drinking, hazardous drinking, and the use of marijuana and other illicit drugs – these associations have also been shown to be only marginally attenuated when controlling for depression and self-reported emotional and mental health (Tonmyr & Shields, 2017).
A New Zealand birth cohort study found that sexual abuse prior to age 16 was associated with a range of adverse outcomes at age 30, including alcohol and drug dependence, as well as depression, anxiety, PTSD symptoms, and reduced self-esteem and life satisfaction (Fergusson, McLeod & Horwood, 2013).
Rates of accidental fatal overdoses are significantly higher for victims of child sexual abuse than comparison groups. Sexual abuse victims were 49 times more likely to die as a result of an accidental overdose than those in the general population (male abuse victims 38 times more likely and female victims 88 times more likely) (Cutajar et al., 2010).
LINKS TO CRIME
A prospective study examining the effects of child sexual abuse on life-course offending found that victims of sexual abuse were more at risk of offending (non-sexual offences) than were controls, but that so too were their siblings. Only female victims were more likely to offend than their siblings. The authors concluded that family and environmental factors were most important in explaining life-course offending among male sexual abuse victims, while these factors were not sufficient to explain the link between child sexual abuse and offending among females (de Jong & Dennison, 2017).
A large-scale Australian study, which followed-up 2,759 substantiated cases of child sexual abuse over 31 years alongside a large comparison group, showed that child sexual abuse victims were significantly more likely to have a recorded offence (24%) than those who were not sexually abused as children (6%). The average number of charges among child sexual abuse victims was also significantly higher than among those in the comparison group (Ogloff, Cutajar, Mann & Mullen, 2012).
A later examination of this same longitudinal data-set of 2,759 substantiated CSA cases found that CSA victims were more likely to engage in all types of criminal behaviours including violent, sexual and other offending, and that there were stronger associations between CSA and general and violent offending among females, and between CSA and sexual offending among males. This study also showed that sexual and violent revictimisation subsequent to the index sexual abuse was strongly associated with an increased likelihood of most forms of offending behaviour, for both males and females (Papalia, Ogloff, Cutajar, & Mullen, 2018).
Almuneef, M. (2021). Long term consequences of child sexual abuse in Saudi Arabia: A report from national study. Child Abuse & Neglect, 116, https://doi.org/10.1016/j.chiabu.2019.03.003
Australian Institute of Health and Welfare (2015). Educational outcomes for children in care: Linking 2013 child protection and NAPLAN data. Cat. no. CWS 54. Canberra: AIHW.
Australian Institute of Health and Welfare (2016). Vulnerable young people: interactions across homelessness, youth justice and child protection—1 July 2011 to 30 June 2015. Cat. no. HOU 279. Canberra: AIHW.
Australian Institute of Health and Welfare (2019). Family, domestic and sexual violence in Australia: continuing the national story. Cat. no. FDV 3. Canberra: AIHW.
Afifi, T.O., MacMillan, H.L., Boyle, M., Cheung, K., Taillieu, T., Turner, S., & Sareen, J. (2016). Child abuse and physical health in adulthood. Health Reports, 27(3), 10-18.
Barnes, R., & Josefowitz, N. (2014). Forensic assessment of adults reporting childhood sexualized assault: Risk, resilience, and impacts. Psychological Injury and Law, 7, 34-46.
Blakemore, T., Herbert, J.L., Arney, F., & Parkinson, S. (2017). The impacts of institutional child sexual abuse: A rapid review of the evidence. Child Abuse & Neglect, 74, 35-48.
Bonomi, A. (2008). Heath care utilisation and costs associated with childhood abuse. Journal of General Internal Medicine, 23(3): 294-299.
Cashmore, J., & Shackel, R. (2014). Gender differences in the context and consequences of child sexual abuse. Current Issues in Criminal Justice, 26, 75-104.
Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301-328.
Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., et al. (2012). The ISTSS expert consensus treatment guidelines for complex PTSD in adults. Retrieved from https://www.istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdf
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., et al. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390-398.
Courtois, C.A., & Ford, J.D. (2013). Treating complex trauma. New York, NY: Guilford Press.
Cutajar, M., Mullen, P., Ogloff, J., Thomas, S., Wells, D., & Spataro, J. (2010). Suicide and fatal drug overdose in child sexual abuse victims: A historical cohort study. Medical Journal of Australia, 192, 184-187.
Danese, A., & Spatz Widom, C. (2020). Objective and subjective experiences of child maltreatment and their relationships with psychopathology. Nature Human Behaviour, https://doi.org/10.1038/s41562-020-0880-3
Dargan, S., Daigneault, I., Ovetchkine, P., Jud, A., & Frappier, J. (2019). Associations between child sexual abuse and infectious disease diagnosis. Child Abuse & Neglect, 97, 104142.
De Jong, R., & Dennison, S. (2017). Recorded offending among child sexual abuse victims: A 30-year follow up. Child Abuse & Neglect, 72, 75-84.
Easton, S.D., & Kong, J. (2017). Mental health indicators fifty years later: A population-based study of men with histories of child sexual abuse. Child Abuse & Neglect, 63, 273-283.
Fergusson, D.M., McCleod, G.F.H., & Horwood, L.J. (2013). Childhood sexual abuse and adult developmental outcomes: Findings from a 30-year longitudinal study in New Zealand. Child Abuse and Neglect, 37, 664-674.
Fletcher, K. (2020). A Systematic Review of the Relationship between Child Sexual Abuse and Substance Use Issues. Journal of Child Sexual Abuse, DOI: 10.1080/10538712.2020.1801937
Gauthier-Duchesne, A., Hebert, M., & Blais, M. (2021). Child sexual abuse, self-esteem, and delinquent behaviors during adolescence: The moderating role of gender. Journal of Interpersonal Violence, DOI: 10.1177/08862605211001466.
Hailes, H.P., Yu, R., Danese, A., & Fazel, S. (2019). Long-term outcomes of childhood sexual abuse: An umbrella review. Lancet Psychiatry, 6, 830-839.
Hillberg, T., Hamilton-Giachritsis, C., & Dixon, L. (2011). Review of meta-analyses on the association between child sexual abuse and adult mental health difficulties: A systematic approach. Trauma, Violence, and Abuse, 12(1), 38-49.
Kendell-Tackett, K.A., Myer Williams, L., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113(1), 164-180.
Kessler, R., McLaughlin, K.A., Greif Green, J., et al. (2010). Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. British Journal of Psychiatry, 197, 378-385.
Kluft, R.P. (2011). Ramifications of incest. Psychiatric Times, January 12, 2011. Retrieved from http://www.psychiatrictimes.com/sexual-offenses/ramifications-incest
Lalor, K., & McElvaney, R. (2010). Child sexual abuse, links to later sexual exploitation/high-risk sexual behavior, and prevention/treatment programs. Trauma, Violence and Abuse, 11, 159-177.
Lewis, T., McElroy, E., Harlaar, N., & Runyan, D. (2016). Does the impact of child sexual abuse differ from maltreated but non-sexually abused children? A prospective examination of the impact of child sexual abuse on internalizing and externalizing behavior problems. Child Abuse & Neglect, 51, 31-40.
Martin, E., & Silverstone, P. (2013). How much child sexual abuse is “below the surface”, and can we help adults identify it early? Frontiers in Psychiatry, 4, 1-10.
Ogloff, J. R. P., Cutajar, M. C., Mann, E., & Mullen, P. (2012). Child sexual abuse and subsequent offending and victimisation: A 45 year follow-up study (Trends & Issues in Crime & Criminal Justice No. 440). Canberra: Australian Institute of Criminology.
Papalia, N.L., Luebbers, S., Ogloff, J.R.P., Cutajar, M., & Mullen, P.E. (2017). The long term co-occurrence of psychiatric illness and behavioural problems following child sexual abuse. Australian & New Zealand Journal of Psychiatry, 51(6), 604-613.
Papalia, N., Mann, E., & Ogloff, J.R.P. (2020). Child sexual abuse and risk of revictimization: Impact of child demographics, sexual abuse characteristics, and psychiatric disorders. Child Maltreatment, DOI: 10.1177/1077559520932665
Papalia, N., Ogloff, J.R.P., Cutajar, M., & Mullen, P.E. (2018). Child sexual abuse and criminal offending: Gender-specific effects and the role of abuse characteristics and other adverse outcomes. Child Maltreatment, 23(4), 399-416.
Tonmyr, L., & Shields, M. (2017). Childhood sexual abuse and substance abuse: A gender paradox? Child Abuse & Neglect, 63, 284-294.
Turner, S., Taillieu, T., Cheung, K., & Afifi, T.O. (2017). The relationship between childhood sexual abuse and mental health outcomes among males: Results from a nationally representative United States sample. Child Abuse & Neglect, 66, 64-72.
Widom, C.S., Czaja, S. and Dutton, M.A. (2008). Childhood victimization and lifetime revictimization. Child Abuse and Neglect, 32, 785-796.
Zwi, K.J., Woolfenden, S.R., Wheeler, D.M., et al. 2007. School-based education programmes for the prevention of child sexual abuse. Oslo: Campbell Collaboration.