The prevalence and circumstances of child sexual abuse: changes across a decade

Intergenerational pathways linking childhood sexual abuse to HIV risk among women

Childhood sexual abuse is prevalent among women, and it has been linked to a number of problems affecting women's health and functioning, including women's parenting practices. Another body of literature has linked specific maternal parenting practices--including mother-daughter sex communication, monitoring/knowledge about daughters' activities, mother-daughter relationship quality, attitudes toward sex, and modeling of sexual values--to daughters' HIV risk. This article reviews and links these two bodies of literature to indicate how mothers' histories of childhood sexual abuse may compromise their parenting practices, which may in turn impact daughters' HIV risk. We also build upon R. Malow, J. Devieux, and B. A. Lucenko's (2006) model of the associations between childhood sexual abuse and HIV risk to present a model indicating potential intergenerational pathways between childhood sexual abuse and HIV risk among women. The literature supporting this model and gaps in the literature are described.

Unwanted early sexual experiences among Belgian and South African university women students

This study examined the unwanted early sexual experiences of 736 South African and 1,587 Belgian women students. The Early Sexual Experiences Checklist was administered to all consenting women students attending orientation programmes at a Belgian and a South African university. Respondents were Belgians (M age = 18.2 yr., SD = 1.0) and South Africans (M age = 19.6 yr., SD = 4.1). Such experiences were found for 31.3% (231) of South African respondents and 14.2% (226) of Belgian respondents. 64% of South African women indicated that such an experience occurred only once, and 65% of Belgian women reported this also. 34% of Belgian and 32% of South African respondents reported not being bothered at all by the unwanted experience at the time the event took place; 23% of Belgian and 36% of South African respondents were extremely bothered by the experience.

Childhood Sexual Abuse and Intimate Partner Violence among Women in Methadone Treatment: A Direct or Mediated Relationship?

Women in substance use treatment report rates of childhood sexual abuse and intimate partner violence that far exceed those reported by women in the general population. Previous research with nonrandom samples of women in substance use treatment suggests that there is a statistically significant relationship between childhood sexual abuse and intimate partner violence; however, little is known about the mechanisms of risk between these two public health concerns among this population of women. To address this gap in knowledge and to inform intervention strategies, this study examined direct and mediated relationships between childhood sexual abuse and intimate partner violence risk among a random sample of 416 women in methadone treatment. In addition to high rates of childhood sexual abuse (57.9%), intimate partner violence (lifetime prevalence, 89.7%; 6-month prevalence, 78.4%), posttraumatic stress disorder (PTSD, 28.6%), and global psychological distress (19.5%), findings suggest that the relationship between childhood sexual abuse and intimate partner violence is mediated by mental health problems and that women experiencing PTSD or global psychological distress are 2.7 and 2.4 times more likely to experience intimate partner violence than women without such experiences, respectively. Although not a mediator in this relationship, financial independence reduced women's risk of partner violence by two-thirds. The paper includes discussion of social learning and stress and coping theories to explicate the findings and to inform intervention strategies.

The Extensive Sexual Violation and Sexual Abuse Histories of Incarcerated Women

A growing body of research reports on the lifetime prevalence of sexual victimization experiences among incarcerated women. However, none of this research provides a detailed account of the many types and levels of sexual violations and sexual abuses, the age of occurrence, and the victim–offender relationship. This study used the Sexual Abuse Checklist (designed by the first author) and a modified version of the Sexual Experiences Survey (SES) to obtain a detailed account of 391 incarcerated women's self-reported sexual violation and abuse histories. Seventy percent of the women reported at least one violation consistent with what qualifies as “rape” in most states in the United States today, and half of the women reported child sexual abuse victimization. The most prevalent victim–offender relationships were male strangers, male lovers or boyfriends, male dates, husbands, uncles, brothers, male cousins, and stepfathers.

Adverse childhood experiences and prescription drug use in a cohort study of adult HMO patients

Background

Prescription drugs account for approximately 11% of national health expenditures. Prior research on adverse childhood experiences (ACEs), which include common forms of child maltreatment and related traumatic stressors, has linked them to numerous health problems. However, data about the relationship of these experiences to prescription drug use are scarce.

Method

We used the ACE Score (an integer count of 8 different categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. We prospectively assessed the relationship of the Score to prescription drug use in a cohort of 15,033 adult HMO patients (mean follow-up: 6.1 years) and assessed mediation of this relationship by documented ACE-related health and social problems.

Results

Nearly 1.2 million prescriptions were recorded; prescriptions rates increased in a graded fashion as the ACE Score increased (p for trend < 0.0001). Compared to persons with an ACE Score of 0, persons with a Score ≥ 5 had rates increased by 40%; graded relationships were seen for all age groups (18–44, 45–64, and 65–89 years) (p for trend < 0.01). Graded relationships were observed for the risk of being in the upper decile of number of classes of drugs used; persons with scores of ≥ 5 had this risk increased 2-fold. Adjustment for ACE-related health problems reduced the strength of the associations by more than 60%.

Conclusion

ACEs substantially increase the number of prescriptions and classes of drugs used for as long as 7 or 8 decades after their occurrence. The increases in prescription drug use were largely mediated by documented ACE-related health and social problems.

Childhood sexual abuse moderates genetic influences on age at first consensual sexual intercourse in women

We examine interactive effects of childhood sexual abuse (CSA) on heritable variation in age at first consensual sexual intercourse in a young cohort of 3,350 female and 2,724 male Australian twins. Consistent with hypotheses, genetic influences explained little if any variation in age at first consensual sexual intercourse for female twins reporting CSA (CSA(+)), with shared environment explaining 73%. For female twins reporting no history of CSA (CSA(-)), 39% of variation in age at first consensual sexual intercourse was explained by genetic effects, with shared environment accounting for 30%. For male twins, significant interactive effects of CSA on genetic and environmental variation in age at first consensual sexual intercourse were not observed. Overall genetic influences explained 51% of variation in age at first consensual sexual intercourse for male twins, with shared environment accounting for 8%. For both female and male twins, results from models that included conduct disorder as a covariate were near identical to results from models without conduct disorder.

School-based education programmes for the prevention of child sexual abuse

BACKGROUND

Child sexual abuse is a significant problem that requires an effective means of prevention.

OBJECTIVES

To assess: if school-based programmes are effective in improving knowledge about sexual abuse and self-protective behaviours; whether participation results in an increase in disclosure of sexual abuse and/or produces any harm; knowledge retention and the effect of programme type or setting.

SEARCH STRATEGY

Electronic searches of Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, CINAHL, Sociological Abstracts, Dissertation Abstracts and other databases using MESH headings and text words specific for child sexual assault and randomised controlled trials (RCTs) were conducted in August 2006.

SELECTION CRITERIA

RCTs or quasi-RCTs of school-based interventions to prevent child sexual abuse compared with another intervention or no intervention.

DATA COLLECTION AND ANALYSIS

Meta-analyses and sensitivity analysis, using two imputed intraclass correlation coefficients (ICC) (0.1, 0.2), were used for four outcomes: protective behaviours, questionnaire-based knowledge, vignette-based knowledge and disclosure of abuse. Meta-analysis was not possible for retention of knowledge, likelihood of harm, or effect of programme type and setting.

MAIN RESULTS

Fifteen trials measuring knowledge and behaviour change as a result of school-based child sexual abuse intervention programmes were included. Over half the studies in each initial meta-analysis contained unit of analysis errors. For behaviour change, two studies had data suitable for meta-analysis; results favoured intervention (OR 6.76, 95% CI 1.44, 31.84) with moderate heterogeneity (I(2)=56.0%) and did not change significantly when adjustments using intraclass coefficients were made. Nine studies were included in a meta-analysis evaluating questionnaire-based knowledge. An increase in knowledge was found (SMD 0.59; 0.44, 0.74, heterogeneity (I2=66.4%). When adjusted for an ICC of 0.1 and 0.2 the results were SMD 0.6 (0.45, 0.75) and 0.57 (0.44, 0.71) respectively. Heterogeneity decreased with increasing ICC. A meta-analysis of four studies evaluating vignette-based knowledge favoured intervention (SMD 0.37 (0.18, 0.55)) with low heterogeneity (I(2)=0.0%) and no significant change when ICC adjustments were made. Meta-analysis of between-group differences of reported disclosures did not show a statistically significant difference.

AUTHORS' CONCLUSIONS

Studies evaluated in this review report significant improvements in knowledge measures and protective behaviours. Results might have differed had the true ICCs from studies been available or cluster-adjusted results been available. Several studies reported harms, suggesting a need to monitor the impact of similar interventions. Retention of knowledge should be measured beyond 3-12 months. Further investigation of the best forms of presentation and optimal age of programme delivery is required.

Factors affecting sexuality in older Australian women: sexual interest, sexual arousal, relationships and sexual distress in older Australian women

OBJECTIVE

To investigate the sexual behavior, sexual relationships, sexual satisfaction, sexual dysfunction and sexual distress in a population of older urban Australian women.

METHOD

In 2004, 474 women participating in the Longitudinal Assessment of Ageing in Women (LAW) Study completed a series of questionnaires about sexuality. They included the Short Personal Experiences Questionnaire (SPEQ), Relationship Assessment Scale (RAS), Female Sexual Distress Scale (FSDS), questions concerning past sexual abuse based on the Sex in Australia Study, and questions comparing present and past sexual interest and activity.

RESULTS

The percentage of women with partners ranged from 83.3% in the 40 - 49-year age group to 46.4% women in the 70 - 79-year age group. The sexual ability of partners diminished markedly with age, with only 4.8% of the partners using medication to enable erections. Only 2.5% of women reported low relationship satisfaction. The incidence of sexual distress was also low, being reported by only 5.7% of women. Younger women and women with partners had higher levels of distress than older women. Indifference to sexual frequency rose from 26.7% in women aged 40 - 49 years to 72.3% in the 70 - 79-year age group. Past sexual abuse was recalled by 22.7% of women and 11.6% recalled multiple episodes of abuse. Women who recalled abuse had lower scores for satisfaction with sexual frequency.

CONCLUSIONS

It appears from this study that there is a wide range of sexual experience amongst aging women, from never having had a sexual partner, to having solitary sex, to having a relationship with or without sex into the seventh decade. As women age, they experience a decrease in sexual activity, interest in sex, and distress about sex. This may be associated with the loss of intimate relationships as part of separation, divorce or bereavement. Decreased sexual activity with aging may be interpreted as a biological phenomenon (part of the aging process) or as sexual dysfunction, or it may be the result of adapting to changed circumstances.

The role of child abuse and age in vulnerability to emotional problems after surgery for breast cancer

Emotional problems are common after breast cancer, but patients differ in their vulnerability. Childhood abuse is a risk factor for emotional problems in adult women, and we tested whether it explains some of the variability in emotional problems after breast cancer. Women with primary breast cancer (N=355) 2-4 d after surgery (mastectomy or wide local excision) self-reported current emotional distress, post-traumatic stress, self-blame, bodily shame and recollections of childhood sexual, physical and emotional abuse. Multiple logistic regression analyses tested the relationship of each emotional problem to abuse, distinguishing three age-groups, divided at 50 and 65 years. Emotional distress, post-traumatic stress, self-blame and shame were present in 49%, 8%, 22% and 13% of women, respectively. Each problem was more common in women who recalled one or other form of abuse. Apart from emotional distress, emotional problems were less common in older women. Older women were also less likely to recall abuse, and recall of abuse contributed statistically to explaining the relationship of youth to emotional problems. Childhood abuse is a risk factor for emotional problems after surgical treatment for breast cancer, and the challenge of identifying and helping those patients in whom emotional problems reflect pre-morbid vulnerabilities needs careful consideration. Because both emotional problems and abuse are strongly age-linked, future research should avoid generalisations across the age spectrum.

Childhood sexual abuse among Black women and White women from two-parent families

Differences in childhood sexual abuse (CSA) between Black women and White women are explored in a community sample of 290 women raised in two-parent families.A self-administered questionnaire and a face-to-face interview assessed CSA characteristics, aftermath, and prevalence as well as family structure and other childhood variables. Siblings served as collateral informants for the occurrence of CSA. Overall, comparisons of the nature, severity, and aftermath of CSA showed similarities by race; some differences, for example, in age of onset, are potentially relevant for the planning of prevention programs. Logistic regression models examined effects of childhood variables on CSA prevalence. Initial analyses showed a higher CSA prevalence among Black women (34.1% [45] of Black women vs. 22.8% [36] of White women) that was attenuated when family structure (e.g., living with two biological parents throughout childhood or not) and social class were considered. Of interest, differences in family structure remained important even among these two-parent families. Understanding the dynamics of abuse by race and family structure will facilitate the design of more targeted CSA prevention programs.

Violence and abuse among HIV-infected women and their children in Zambia: a qualitative study

HIV and violence are two major public health problems increasingly shown to be connected and relevant to international mental health issues and HIV-related services. Qualitative research is important due to the dearth of literature on this association in developing countries, cultural influences on mental health syndromes and presentations, and the sensitive nature of the topic. The study presented in this paper sought to investigate the mental health issues of an HIV-affected population of women and children in Lusaka, Zambia, through a systematic qualitative study. Two qualitative methods resulted in the identification of three major problems for women: domestic violence (DV), depression-like syndrome, and alcohol abuse; and children: defilement, DV, and behavior problems. DV and sexual abuse were found to be closely linked to HIV and alcohol abuse. This study shows the local perspective of the overlap between violence and HIV. Results are discussed in relation to the need for violence and abuse to be addressed as HIV services are implemented in sub-Saharan Africa.

Severity of child sexual abuse, post- traumatic stress and risky sexual behaviors among HIV-positive women

Child sexual abuse (CSA) has been shown to enhance risk for HIV infection and other adverse outcomes. However, most studies examine the effects of a single incident of CSA rather than the full burden of abuse over the life span in predicting these adverse outcomes. A multi-dimensional approach was used in this study to examine the severity of abuse as a predictor of post-traumatic stress, depression, sexual symptoms, and risky sexual behaviors in a multi-ethnic sample of 147 HIV-positive women. Multivariate models indicated that experiencing both intrafamilial and extrafamilial CSA, adult sexual abuse (ASA) and Latina ethnicity predicted PTSD symptoms. ASA also predicted sexual trauma symptoms. Also, CSA and adult re-victimization contributed independently to risk for PTSD and sexual trauma symptoms, but not for risky sexual behaviors. The results support the need for interventions for HIV-positive women that address the full burden of abuse experienced and its sequelae.

Behavioral science and the task of resolving health disparities in cancer

BACKGROUND

Behavioral scientists use health behavior theories to assess beliefs, feelings, and coping styles that predict cancer screening, choice of cancer treatments, or postcancer quality of life.

METHODS

However, research testing these theories is typically based on middle-class, White populations.

RESULTS

Research needs to be culturally appropriate and relevant for minority and underserved populations.

CONCLUSIONS

The knowledge gained from such studies will help in designing and evaluating culturally sensitive interventions to reduce health disparities by modifying unhealthy behaviors such as poor diet, smoking, lack of regular physical activity, or failure to get timely cancer screening.

Relational outcomes of childhood sexual trauma in female survivors: a longitudinal study

This longitudinal study examines the effects of childhood sexual abuse (CSA) on the intimate and marital relationships of adult survivors from a sample composed primarily of African American women. In addition, the authors explore the protective role of maternal support. Interview data are collected on 136 women with documented histories of CSA who indicate the quality and nature of their current marital relationships and other interpersonal connections. Results suggest that CSA survivors with poor maternal attachment are more likely to enter into marital or cohabiting relationships. However, more severe sexual trauma in childhood correlates with greater marital dissatisfaction. Good maternal attachment during childhood has a negative main effect on adult interpersonal problems and a buffering effect on the relationship between abuse and marital dissatisfaction. These data can help guide future research on the adult relational outcomes of female CSA survivors, especially among minority populations.

Sexual abuse and reproductive health among unmarried young women seeking abortion in China

OBJECTIVE

To investigate sexual violence and its impact on reproductive health in unmarried young women seeking abortion in China.

METHODS

A total of 2002 participants were surveyed by questionnaire, gynecologic examination, and laboratory tests for sexually transmitted disease (STD).

RESULTS

Overall, 14% of participants had experienced sexual violence and 43.4% were diagnosed with STD. Among victims of sexual abuse, 8.6% had their first sexual encounter when they were younger than 18 years; 42.7% had had 2 or more sexual partners; and 21.6% never used contraception. Multivariate analysis revealed that sexual abuse, multiple sexual partners, sexual activity before the age of 18 years, and not using contraception were important indicators of the presence of STD.

CONCLUSION

The prevalence of sexual abuse is high in China; and among unmarried young women seeking abortion, those who experience sexual abuse are at significantly increased risk for STD.

Sexual abuse history, risk behavior, and sexually transmitted diseases: the impact of age at abuse

OBJECTIVE

The objective of this study was to examine the relationship between age at onset of sexual abuse, risk behaviors, and a diagnosis of sexually transmitted disease (STD) in a clinic-attending adolescent population.

METHODS

Bivariate analyses were used to test association among age at onset of sexual abuse, risk behaviors, and STD diagnosis (n = 2175). Relationship between sexual abuse and STD acquisition was assessed by regression analysis.

RESULTS

More females than males reported sexual abuse, 26.75% and 5.4%, respectively. Abuse at or before 10 years of age was associated with more lifetime and recent partners. History of abuse was associated with higher rates of STD tests. In regression analysis, for males and females, the odds of having an STD were 2.5 times greater if abuse occurred at 10 years or younger.

CONCLUSION

Sexual abuse at a younger age is associated with more sexual risk behaviors and is a risk factor for STDs.

Group therapy for survivors of childhood sexual abuse who have chronic mental illness

Medication and supportive services are usually the approaches used to treat women with chronic mental illness (CMI). The goal of this study was to evaluate the outcomes of group therapy for women with CMI in comparison with those for women without CMI, all of whom experienced childhood sexual abuse. The sample ( N=121) consisted of women, all of whom were sexually abused as children. The results indicated that abused women with CMI had improved self-esteem and decreased symptom scores at the same rate as abused women without CMI. It was suggested that nurses can play an essential role in their practice with this population.

Differences in psychological health and family dysfunction by sexual victimization type in a clinical sample of African American adolescent women

We examined levels of sexual victimization among a sample of 249 14- to 19-year-old African American adolescent women. Victimization was common: 32.1% reported having been raped, 33.7% had experienced sexual coercion, and 10.8% reported an attempted rape. Only 23.4% had never been victimized. We investigated whether levels of psychological health and family dysfunction varied as a function of the type of sexual victimization. Girls who had been raped had lower levels of self-esteem and mastery and higher levels of depression compared to girls who reported no sexual victimization. Significantly higher levels of family cohesion and significantly lower levels of family support were reported by girls who had been raped versus girls who reported no sexual victimization. These findings are a starting point for future studies by providing evidence that levels of mental health and family dysfunction vary by the type of sexual victimization experienced.

Reasonable suspicion: a study of Pennsylvania pediatricians regarding child abuse

OBJECTIVE

It has long been assumed that mandated reporting statutes regarding child abuse are self-explanatory and that broad consensus exists as to the meaning and proper application of reasonable suspicion. However, no systematic investigation has examined how mandated reporters interpret and apply the concept of reasonable suspicion. The purpose of this study was to identify Pennsylvania pediatricians' understanding and interpretation of reasonable suspicion in the context of mandated reporting of suspected child abuse. Methodology. An anonymous survey was sent (Spring 2004) to all members of the Pennsylvania chapter of the American Academy of Pediatrics (n = 2051). Participants were given several operational frameworks to elicit their understanding of the concept of reasonable suspicion, 2 of which are reported here. Respondents were asked to imagine that they had examined a child for an injury that may have been caused by abuse and that they had gathered as much information as they felt was possible. They then were asked to quantify (in 2 different ways) the degree of likelihood needed for suspicion of child abuse to rise to the level of reasonable suspicion. The physicians were asked to identify (using a differential-diagnosis framework) how high on a rank-order list "abuse" would have to be for it to rise to the level of reasonable suspicion (ie, first on the list, second, third, and so on, down to tenth). The second framework, estimated probability, used a visual analog scale of 0% to 100% to determine how likely suspected abuse would have to be for physicians for them to feel that they had reasonable suspicion. That is, would they need to feel that there was a 99% likelihood that abuse occurred before they felt that they had reasonable suspicion, a 1% likelihood, or something in between? In addition to standard demographic features, respondents were queried regarding their education on child abuse, education on reasonable suspicion, frequency of reporting child abuse, and (self-reported) expertise regarding child abuse. The main outcome measures were physician responses on the 2 scales for interpreting reasonable suspicion.

RESULTS

Pediatricians (n = 1249) completed the survey (61% response rate). Their mean age was 43 years; 55% were female; and 78% were white. Seventy-six percent were board certified, and 65% reported being in primary care. There were no remarkable differences in responses based on age, gender, expertise with child abuse, frequency of reporting child abuse, or practice type. The responses of pediatric residents were indistinguishable from experienced physicians, and the responses of primary care pediatricians were no different from pediatric subspecialists. Wide variation was found in the thresholds that pediatricians set for what constituted reasonable suspicion. On the differential-diagnosis scale (DDS), 12% of pediatricians responded that abuse would have to rank first or second on the DDS before the possibility rose to the level of reasonable suspicion, 41% indicated a rank of third or fourth, and 47% reported that a rank anywhere from fifth to as low as tenth still qualified as reasonable suspicion. On the estimated-probability scale (EPS), 35% of pediatricians responded that for reasonable suspicion to exist, the probability of abuse needed to be 10% to 35%. By contrast, 25% of respondents identified a 40% to 50% probability, 25% stipulated a 60% to 70% probability, and 15% required a probability of >or=75%. In comparing individual responses for the 2 scales (ie, paired comparisons between each pediatrician's DDS ranking and the estimated probability he or she identified), 85% were found to be internally inconsistent. To be logically consistent, any score >or=50% on the EPS would need to correspond to a DDS ranking of 1; an EPS score of >or=34% would need to correspond with a DDS ranking no lower than 2; an EPS score of >or=25% no lower than a DDS ranking of 3; and so on. What we found, however, was that pediatricians commonly indicated that reasonable suspicion required a 50% to 60% probability that abuse occurred, but at the same time, they responded that child abuse could rank as low as fourth or fifth on the DDS and still qualify as reasonable suspicion.

CONCLUSIONS

The majority of states use the term "suspicion" in their mandated reporting statutes, and according to legal experts, "reasonable suspicion" represents an accurate generalization of most mandated reporting thresholds. Our data show significant variability in how pediatricians interpret reasonable suspicion, with a range of responses so broad as to question the assumption that the threshold for mandated reporting is understood, interpreted, or applied in a coherent and consistent manner. If the variability described here proves generalizable, it will require rethinking what society can expect from mandated reporters and what sort of training will be necessary to warrant those expectations.

The impact of sexual assault history and relationship context on appraisal of and responses to acquaintance sexual assault risk

Although a major predictor of sexual victimization is previous victimization, the mechanism underlying this effect is not well understood. Sexual assault history's impact on appraisal of and responses to sexual assault risk was examined in an experimental analog study. Intimacy with perpetrator was also examined as a potential contributor to appraisal and responses. Young women varying in sexual assault history were randomly assigned to receive a scenario in which type of perpetrator was manipulated (someone just met, friend, date, boyfriend). Respondents appraised the man's actions as sexual interest or assault and indicated intentions to respond (resistance and nonresistance). Sexual assault history did not directly influence appraisal or intended responses but had modest indirect effects on resistance via sexual assertiveness. The primary influence on appraisal and responses was perpetrator intimacy. Women facing advances within a more intimate relationship were less likely to appraise those advances as threatening and less likely to resist.

Perceptions of parenting versus parent-child interactions among incest survivors

OBJECTIVES

Although women with histories of child sexual abuse (CSA) perceive themselves as less competent mothers and report greater parenting difficulties than nonabused women, few investigators have actually observed the parenting behaviors of CSA survivors. The primary aim of this study was to examine whether incest history was related to maternal perceptions of parenting efficacy and interactional patterns with their children. The secondary aim of this study was to explore the constructs of internal working models of relationships and maternal psychological adjustment as potential mediators of the relation between incest history and parenting.

METHODS

A community sample of 17 incest survivors, 18 nonabused women and their 3-6 year-old children participated. Mothers completed self-report measures of parenting efficacy, parental bonding (i.e., internal working models of relationships), and psychological adjustment. In addition, mothers interacted with their children in a problem-solving task.

RESULTS

Although incest survivors reported less parenting self-efficacy than did nonabused mothers, their interactional styles with their children were positive overall and comparable to those of nonabused mothers. Specifically, survivors displayed moderate to high levels of support, assistance, and confidence, and their children showed high levels of affection towards their mothers. Incest survivors reported less bonding with their own mothers in childhood and poorer current psychological adjustment.

CONCLUSIONS

Findings suggest that incest survivors' perceptions of their parenting abilities may be more negative than their actual parenting behaviors.

Posttraumatic symptoms and self-dysfunction as consequences and predictors of sexual revictimization

Posttraumatic symptomatology (PTS) and self-dysfunction (SD) were examined as correlates and predictors of sexual revictimization in a prospective study of 339 college women. Both PTS and SD were associated with a history of child and adult sexual victimization. Compared to a history of child victimization, a history of adult victimization was associated with greater self-dysfunction. Both PTS and SD predicted revictimization during the study; however, self-dysfunction also predicted victimization in the absence of prior victimization. In a multivariate model, PTS did not directly predict victimization during the study, although SD mediated the relationship between PTS and victimization. Sexual victimization (child or adult) prior to the study predicted PTS, which predicted SD, which predicted victimization during the study. Findings suggest that prior child and adult victimization are directly related to later sexual victimization, and are indirectly related to later sexual victimization via the impact of PTS on SD.

Predicting long-term outcomes for women sexually abused in childhood: contribution of abuse severity versus family environment

OBJECTIVE

Child sexual abuse (CSA) has been associated with adverse adult psychosocial outcomes, although some reports describe minimal long-term effects. The search for explanations for the heterogeneous outcomes in women with CSA has led to an examination of a range of CSA-related factors, from the severity of individual CSA incidents to the childhood family environment. This study compares three factors for predicting adult outcomes: a multidimensional CSA Severity Scale, the presence or absence of CSA, and family environment.

METHODS

The effect of CSA on adult outcomes was examined among 290 community-dwelling women raised in intact families. Standardized measures and a focused interview were used to collect data, with siblings as collateral informants.

RESULTS

Comparison of a multidimensional CSA Severity Scale to a dichotomous measure of the presence or absence of CSA showed that the Severity Scale did not have greater predictive value for adult outcomes than the dichotomous measure, nor was it as parsimonious. Childhood family environment scales added significantly to the predictive ability of the dichotomous measure.

CONCLUSION

The specific characteristics of a CSA experience may be less important than the occurrence of CSA and the family environment of women for predicting long-term outcomes.

Does a History of Childhood Sexual Abuse Affect Sexual Outcomes in Breast Cancer Survivors?

Purpose

Little is known about a history of childhood sexual abuse (CSA) in breast cancer survivors and its relationship to sexual functioning after cancer. As part of a larger survey study examining sexuality and intimacy in breast cancer survivors, we conducted in-person interviews with a subsample of participants.

Methods

A total of 147 women in Los Angeles, CA, and Washington, DC, completed a structured interview that addressed sexual socialization and a history of sexual abuse. Trained female interviewers conducted the interviews. Descriptive statistics and regression analyses were used to examine the prevalence of CSA, and its potential impact on sexual health and functioning.

Results

One in three women reported at least one CSA incident. Among women who had experienced CSA, 71% reported a single incident, and 22% reported a penetrative form of sexual contact. In multivariate regression analyses examining physical and psychological aspects of sexuality and body image, CSA was not a significant predictor of physical discomfort. However, a history of penetrative CSA was a significant predictor of psychological discomfort (P = .02).

Conclusion

The prevalence of CSA in this sample was similar to the general population literature on this topic. In this small sample, a past history of CSA did not contribute significantly to the physical discomforts associated with sexual intimacy after breast cancer; however, our findings suggest that a past history of penetrative CSA is associated with increased psychological discomfort, and may warrant additional examination in future research.

Differential suicide rates in typologies of child sex offenders in a 6-year consecutive cohort of male suicides

Earlier research identified 3 typologies of Child Sex Offenders [CSO] with high rates of suicide. To test this finding suicide rates of 3 types of CSO were compared in a 6-year cohort of regional suicides. All male suicides were identified from Coroners" inquest files and CSO data drawn from police records to calculate CSO suicide rates. The results show that suicide in "Multi-criminal" CSO is 12 times higher than the general population but not statistically significantly. Two significant results were "Sex Only" CSO suicides were 183 times the general population and 15 times the Multi-criminal CSO rates, with no suicides amongst the Violent CSO's. Implications for suicide prevention and child protection are presented.

The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories

Child sexual abuse (CSA) is associated with HIV risk behaviors [Bensley, L., Van Eenwyk, J., and Simmons, K. W., 2003.] and more prevalent among women living with HIV than in the general population [Koenig, L. J., and Clark, H., 2004]. This randomized Phase~I clinical trial tested the impact of a culturally congruent psychoeducational intervention designed to reduce sexual risks and increase HIV medication adherence for HIV-positive women with CSA histories. An ethnically diverse sample of 147 women were randomized to two conditions: an 11-session Enhanced Sexual Health Intervention (ESHI) or an attention control. Results based on "intent to treat'' analyses of pre-post changes are reported here. Additional analyses explored whether the observed effects might depend on "intervention dose,'' i.e., number of sessions attended. Women in the ESHI condition reported greater sexual risk reduction than women in the control condition. Although there were no differences between women in the ESHI and control groups on medication adherence, women in the ESHI condition who attended 8 or more sessions reported greater medication adherence at posttest than control women. The findings provide initial support for this culturally and gender-congruent psychoeducational intervention for HIV-positive women with CSA, and highlight the importance of addressing the effects of CSA on sexual risk reduction and medication adherence in preventive interventions for women.

Adolescents who experienced sexual abuse: fears, needs and impediments to disclosure

OBJECTIVE

Understanding the impediments that prevented sexually abused adolescents from disclosure to their family or to professionals, and analyzing the responses they received when they did disclose.

METHODS

In depth anonymous interviews were conducted in Italy through a toll-free telephone line with 36 young people who experienced sexual abuse in adolescence. A qualitative analysis was carried out of the adolescents' feelings, fears and needs, and of the help received, if any.

RESULTS

The main impediments to disclose to a family member were fear of not being believed, shame, and fear of causing trouble to the family. The main impediments for not seeking services were ignorance of the existence/functioning of protective agencies, wish to keep the secret, lack of awareness of being abused, mistrust of adults and professionals, and fear of the consequences of disclosure. When they did disclose to professionals, the teens received very limited support.

CONCLUSION

Adolescents need to receive proper information about the risk of being sexually abused and about the help they can receive from their social network and protective agencies. There is a crucial need for appropriate training of professionals.

The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction

OBJECTIVE

Childhood abuse and other adverse childhood experiences (ACEs) have historically been studied individually, and relatively little is known about the co-occurrence of these events. The purpose of this study is to examine the degree to which ACEs co-occur as well as the nature of their co-occurrence.

METHOD

We used data from 8,629 adult members of a health plan who completed a survey about 10 ACEs which included: childhood abuse (emotional, physical, and sexual), neglect (emotional and physical), witnessing domestic violence, parental marital discord, and living with substance abusing, mentally ill, or criminal household members. The bivariate relationship between each of these 10 ACEs was assessed, and multivariate linear regression models were used to describe the interrelatedness of ACEs after adjusting for demographic factors.

RESULTS

Two-thirds of participants reported at least one ACE; 81%-98% of respondents who had experienced one ACE reported at least one additional ACE (median: 87%). The presence of one ACE significantly increased the prevalence of having additional ACEs, elevating the adjusted odds by 2 to 17.7 times (median: 2.8). The observed number of respondents with high ACE scores was notably higher than the expected number under the assumption of independence of ACEs (p <.0001), confirming the statistical interrelatedness of ACEs.

CONCLUSIONS

The study provides strong evidence that ACEs are interrelated rather than occurring independently. Therefore, collecting information about exposure to other ACEs is advisable for studies that focus on the consequences of a specific ACE. Assessment of multiple ACEs allows for the potential assessment of a graded relationship between these childhood exposures and health and social outcomes.

Parent Expectations and Comfort With Discussion of Normal Childhood Sexuality and Sexual Abuse Prevention During Office Visits

BACKGROUND

The American Academy of Pediatrics recommends that pediatricians provide anticipatory guidance about sexual development and sexual abuse prevention.

OBJECTIVE

To examine parents' expectations, comfort level, and experience discussing sexual development and sexual abuse prevention with pediatricians.

METHODS

A consecutive sample of parents presenting for care at 9 pediatric offices completed a self-administered survey. The survey included demographic information and questions related to parents' expectations, past experience, and comfort discussing normal childhood sexuality and sexual abuse prevention with their children's provider. Analyses examined relationships with parental recall of provider discussion about these topics and demographic characteristics.

RESULTS

Of the 605 parents offered participation, 536 responses (89%) were analyzed. Respondents were 83% mothers, 62% white, 23% Hispanic, 7% African American, 6% Asian, 2% "other," and 65% college graduates. Nearly all respondents (98%) indicated pediatricians should discuss normal sexuality, and 96% indicated physicians should discuss sexual abuse prevention. Most parents (77%) indicated both the parent and the doctor are responsible for introducing these topics. Over 90% of parents reported that they were comfortable discussing these topics. Only 45% of respondents reported their child's pediatrician had discussed normal sexuality, and 29% had discussed sexual abuse prevention. Logistic regression modeling found the highest rates of discussion for normal sexuality were among parents with older children and the highest rates of discussion for child sexual abuse prevention topics were for mothers and those with older children.

CONCLUSIONS

Pediatricians can discuss normal sexuality and sexual abuse prevention without fear of alienating parents.

Index of suspicion: feeling not believing

Throughout the U.S., state laws require professionals who work with children to report cases of suspected child abuse to child protection services. Both practically and conceptually, however, significant problems arise from a lack of clarity regarding the threshold that has been set for reporting. Specifically, there is no consensus as to what constitutes reasonable suspicion, and little direction for how mandated reporters should gauge their legal and professional responsibilities when they harbor suspicion. In this paper we outline the context of the problem, discuss the nature and scope of its conceptual underpinnings, and offer recommendations for moving towards a concrete, practical solution.

The relationship of exposure to childhood sexual abuse to other forms of abuse, neglect, and household dysfunction during childhood

OBJECTIVE

This study assesses the relationship of childhood sexual abuse (CSA) to nine other categories of Adverse Childhood Experiences (ACEs), including childhood abuse, neglect, and multiple types of household dysfunction.

METHODS

Retrospective cohort study data were collected from 17,337 adult health plan members who responded to a survey questionnaire. Regression models adjusted for age, race, and education were used to estimate the strength of the association of CSA to each of the other nine ACEs and a graded relationship between measures of the severity of CSA and the number of other ACEs (ACE score).

RESULTS

CSA was reported by 25% of women and 16% of men. In comparison with persons who were not exposed to CSA, the likelihood of experiencing each category of ACE increased 2- to 3.4-fold for women and 1.6- to 2.5-fold for men (p < 0.05). The adjusted mean ACE score showed a significant positive graded relationship to the severity, duration, and frequency of CSA and an inverse relationship to age at first occurrence of CSA (p < 0.01).

CONCLUSIONS

CSA is strongly associated with experiencing multiple other forms of ACEs. The strength of this association appears to increase as the measures of severity of the CSA increases. The understanding of the interrelatedness of CSA with multiple ACEs should be considered in the design of studies, treatment, and programs to prevent CSA as well as other forms of ACEs.

Is child sexual abuse declining? Evidence from a population-based survey of men and women in Australia

OBJECTIVE

Substantiated cases of child sexual abuse (CSA) in the United States have declined significantly over the past decade. This may, or may not, reflect change in the underlying rate in the general population. This study examines age-cohort differences in the prevalence of self-reported CSA experiences of men and women aged 18-59 years in a community-based sample from a comparable western nation.

METHOD

In April 2000, we completed a cross-sectional, telephone-based survey of a randomly selected national sample of men and women in Australia. Volunteers (876 males, 908 females) answered a range of questions about health status and sexuality, including unwanted sexual experiences before the age of 16 years. Of selected adults with publicly-listed telephone numbers, 61% agreed to participate. There were few differences between the volunteers and the Australian population on demographic variables and health indicators.

RESULTS

Non-penetrative CSA was twice as common among women (33.6%) than men (15.9%). Approximately 12% of women and 4% of men reported unwanted penetrative experiences. CSA was reported significantly less often by younger males, with a linear decline from the oldest to youngest men. Among all females who had intercourse before age 16, older women were much more likely than younger women to say they were an unwilling partner on the first occasion. If first intercourse occurred at age 16 or later, there were no age-cohort differences in risk of first-time abuse. Self-reported "openness" and "comfort" during the telephone interviews was not systematically related to prevalence of CSA.

CONCLUSION

These population-based findings provide evidence of a decline in the underlying rate of CSA in Australia. Although every measure of CSA inevitably is flawed to some extent, these trends in self-report complement official statistics that show substantial decline in recent years.

Social reactions to child sexual abuse disclosures: a critical review

Recent studies have examined disclosure of child sexual abuse to determine the correlates and consequences of telling others about this form of victimization. The present article reviews the current empirical literature on disclosure and reactions to adult survivors to assess what is known about the process of disclosure and whether telling others is therapeutic and leads to positive outcomes. Most studies assessing social reactions in detail have concerned adult survivors retrospectively reporting on their disclosures of child sexual abuse. Few empirical studies have been conducted in this area but research suggests that few victims tell anyone about child sexual abuse as children, and that the type of reactions to disclosure vary according to when disclosure occurs (childhood or adulthood), the extent and nature of the disclosure, and the person to whom one discloses. Clear evidence shows that negative social reactions are harmful to survivors' well-being, but better assessment of specific reactions and their effects are needed in theoretically-based studies to evaluate how these responses affect survivors' recovery in the context of other variables. Suggestions for future research on social reactions of others to adult survivors disclosing child sexual abuse are presented.

Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy

OBJECTIVES

We investigated history of abuse and other HIV-related risk factors in a community sample of 490 HIV-positive and HIV-negative African American, European American, and Latina women.

METHODS

Baseline interviews were analyzed, and logistic regressions were used to identify predictors of risk for positive HIV serostatus overall and by racial/ethnic group.

RESULTS

Race/ethnicity was not an independent predictor of HIV-related risk, and few racial/ethnic differences in risk factors for HIV were seen. Regardless of race/ethnicity, HIV-positive women had more sexual partners, more sexually transmitted diseases, and more severe histories of abuse than did HIV-negative women. Trauma history was a general risk factor for women, irrespective of race/ethnicity.

CONCLUSIONS

Limited material resources, exposure to violence, and high-risk sexual behaviors were the best predictors of HIV risk.

The perpetrator's strategy as a crucial variable: a representative study of sexual abuse of girls and its sequelae in Switzerland

OBJECTIVE

Little is known about the long-term consequences of "soft" perpetrator strategies. The purpose of the present study is to assess the consequences of love-bargaining strategies compared to those involving force.

METHOD

A representative sample of 980 women, aged 20 to 40 years, in the German-speaking part of Switzerland was asked questions regarding psychosomatic well-being, sexual actions, and perpetrator strategies, as well as motivations for tolerating long periods of abuse. The answers regarding strategies were factor analyzed. The effect on psychosomatic well-being was determined by means of stepwise regression analysis and correlation analysis.

RESULTS

The prevalence of child sexual abuse (CSA) was 39.8% overall and 14.7% for severe abuse. Using the three variables love-bargaining strategy, self-blaming, and need for affection, an adjusted R2 of .44 was reached in the 3rd step as a dependent variable with a General Symptomatic Index (GSI) calculated from an abbreviated version of the SCL-90-R. The first of the three variables mentioned was by far the most influential. Force was not included in the equation but was closely correlated on a bivariate level with the SCL-90 partial scale "anxiety."

CONCLUSIONS

The consequences of CSA produced by the use of soft strategies have been underestimated in the past.

Enhancing the health care experiences of adult female survivors of childhood sexual abuse

This article addresses the medical issues presented by women who were sexually abused in childhood and provides a detailed and direct link between the existing literature and its implications for the medical system. A profile of the sexual abuse survivor is given, including child sexual abuse (CSA) characteristics and sequelae that influence the adult female survivor's health. Post-traumatic Stress Disorder is outlined as part of a complex interplay of physiological and psychological symptomatology that can compromise the CSA survivor's ability to access health care treatment and forge a positive provider/patient relationship. This article emphasizes that effective treatment with sexual abuse survivors must include interdisciplinary collaboration among health care professionals. Management of the CSA patient, a case vignette illustrating salient themes, and finally, guidelines for the health care practitioner are presented.

Interdisciplinary action supporting sexual assault prevention efforts in rural elementary schools

The purpose of this study was to evaluate if knowledge is gained by rural, elementary school-aged children of sexual assault prevention concepts following implementation of an interdisciplinary prevention program. Rural children (N = 294 pretest and N = 301 posttest) were tested before and after delivery of a theater program developed for teaching sexual assault prevention concepts. The program was delivered to children enrolled in the 3rd and 4th grades of 3 rural elementary schools. Analysis of variance results indicate an increase in knowledge gained in all age groups. Significant difference in knowledge gained occurred in concept areas related to touch by authority figures, secrets, uncomfortable touch by individuals known to them, strangers, and boys' risk of abuse. Results support the need for ongoing interdisciplinary efforts to teach children sexual assault prevention concepts.