The role of childhood sexual abuse sequelae in the sexual revictimization of women: an empirical review and theoretical reformulation

There is now widespread empirical evidence that child sexual abuse (CSA) survivors are at greater risk for sexual revictimization in adulthood, but less is known of the mechanisms underlying this relationship. Despite the lack of a conceptual framework to guide research, there has been a recent influx of studies examining explanatory variables, with most focusing on the psychological sequelae of CSA: alcohol and drug use, sexual behavior, dissociation, posttraumatic symptomatology, poor risk recognition, and interpersonal difficulties. With the exception of sexual behavior, the studies reviewed here provide limited or mixed support for the role of intrapersonal factors in revictimization. Future research may benefit from a focus on the function of psychological distress that is expressed as psychological vulnerability, as opposed to individual forms of psychopathology or maladaptive behavior. An ecological framework may be useful as a guide to future investigations, as this model focuses on factors outside of the victim, including childhood factors such as family environment, contextual factors including the behavior of the perpetrator, and societal and cultural factors that impact revictimization. Future investigations should focus on the interaction between victim vulnerability and perpetrator behavior. Implications for prevention programming, clinical intervention, and future research are discussed.     

Interpersonal functioning among women reporting a history of childhood sexual abuse: empirical findings and methodological issues.

A subset of research exploring the long-term impact of child sexual abuse (CSA) has examined the adult interpersonal functioning of female survivors. The present review discusses empirical findings and critical methodological issues related to this important but often overlooked aspect of adult adjustment. Though characterized by several methodological limitations, this literature, as a whole, suggests that early sexual abuse represents a risk factor for a range of interpersonal dysfunction among female survivors, including problems with intimate partner relations, disturbed sexual functioning, and difficulties in the parental role. Suggested methodological improvements for future research include new approaches to the measurement of CSA and interpersonal variables, the need for comprehensive assessment of significant third variables, and the use of more representative sampling strategies.     

Self‐concept and attributions about other women in women with a history of childhood sexual abuse

Self‐concept literature and literature on childhood sexual abuse (CSA) suggests that women with a history of CSA may have particular ways of perceiving themselves, which, as well as impacting upon relationships within their everyday lives, may also have implications for therapy; whether this is on an individual basis or within a group. This research investigated self‐concept and attributions about other women using an adapted version of the self‐concept sorting task. Three groups of women were compared: women with a history of CSA, women experiencing depressed mood but without a history of CSA and a healthy non‐clinical comparison group of hospital staff. To some extent the current findings supported previous studies indicating that women attempting to cope with the consequences of a history of CSA have a negative self‐concept. However, there was evidence to suggest that certain self‐aspects are protective or protected. Similarly, there is some support for previous evidence of difficult relationships with mothers. Possible explanations for these findings were discussed and areas for future research suggested. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Massage: ? Although women with a history of CSA and depression have a negative view of themselves in comparison to a non‐clinical group, there is no qualitative difference between these two groups. ? Nor do women with a history of CSA have a more negative view of other women in general than women who are depressed. ? Therefore, being aware of the likelihood that an individual may preceive herself, but not other women negatively, a therapist may use therapy to actively increase awareness and address this issue.     

Dissociative experiences during sexual behavior among a sample of adults living with HIV infection and a history of childhood sexual abuse

Little attention has been given to the occurrence of dissociative symptoms during sexual behavior in adults who have experienced childhood sexual abuse (CSA). For this study, 57 adults living with HIV infection who had experienced CSA and were entering a treatment study for traumatic stress completed study assessments and clinical interviews, including a 15-item scale of dissociative experiences during sexual behavior. Predictor variables included Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnoses of posttraumatic stress disorder (PTSD) and dissociative disorders, rape by an intimate partner, duration of CSA, number of perpetrators of CSA, and current sexual satisfaction. A multiple regression analysis was conducted to identify significant associations between predictors and dissociation during sex. Mean differences by clinical diagnosis were also examined. Results indicated that PTSD, dissociative disorders, rape by an intimate partner, duration of CSA, and number of perpetrators of CSA were associated with increased dissociation during sexual behavior. Dissociation during sex likely increases vulnerability to sexual revictimization and risky sexual behavior. Standard behavioral prevention interventions may be ineffective for sexual situations when dissociation occurs, and prevention efforts should be integrated with mental health care for those who have experienced CSA.     

Predictors of bystander behaviors and sexual assertiveness among college women attending a sexual assault prevention program

Identifying predictors of bystander behaviors and sexual assertiveness can help to inform sexual assault prevention programs on college campuses. College sorority members (N = 141) completed measures of sexual assault history, rape myth acceptance, bystander self‐efficacy, sexual assertiveness, and bystander behaviors before attending The Women's Program, which is a bystander‐based sexual assault prevention program. Regression analyses were conducted. Lower rape myth acceptance and greater bystander self‐efficacy predicted more engagement in bystander behaviors and higher sexual assertiveness. A total of 28 participants completed a 2‐week follow‐up survey that included measures of rape myth acceptance, bystander self‐efficacy, and sexual assertiveness. T‐test analyses were conducted. Rape myth acceptance was significantly lower among participants at 2‐week follow‐up compared to baseline. Implications for sexual assault prevention on college campuses are discussed.     

The relationships of attachment style and social maladjustment to death ideation in depressed women with a history of childhood sexual abuse

The current study examined the interaction of attachment orientation and acute social maladjustment as risk factors for death ideation in a sample of women with Major Depression and histories of childhood sexual abuse. Social maladjustment was associated with greater endorsement of death ideation. Avoidant and anxious attachment orientations moderated the social maladjustment and death ideation associations in some domains. Work-related maladjustment was associated with greater odds of death ideation for those with higher attachment avoidance. Parent-role maladjustment was associated with greater odds of death ideation for those with lower attachment anxiety. Findings demonstrate strong associations between death ideation and social maladjustment, and suggest that death ideation may be specific to certain domains of adjustment for anxious and avoidant attachment styles.     

Cardiovascular reactivity and proactive and reactive relational aggression among women with and without a history of sexual abuse

This study examined the association between cardiovascular reactivity and proactive and reactive functions of relational aggression among women with and without a history of sexual abuse. Heart rate reactivity, blood pressure reactivity, and respiratory sinus arrhythmia reactivity while recounting a relational stressor (e.g., being left out) were assessed. Participants provided self-reports of relational aggression and a history of sexual abuse prior to age 16. Results indicated that cardiovascular reactivity was only associated with relational aggression among women with a history of sexual abuse. In addition, whereas blunted reactivity was associated with proactive relational aggression, exaggerated reactivity was associated with reactive relational aggression. These findings highlight the importance of considering contextual moderators of the association between cardiovascular reactivity and aggression; moreover, results highlight distinct cardiovascular correlates of different functions of aggression. Finally, the findings underscore the need for additional research examining the physiological correlates of aggressive behavior among women.     

Medical and psychiatric symptoms in women with childhood sexual abuse.

Although there is increasing awareness of the short-term psychological and social adaptations to childhood sexual abuse, little is known about the long-term effects of such abuse, particularly its effect on subsequent medical utilization and the experience and reporting of physical symptoms. We re-analyzed data from a previous study of 100 women scheduled for diagnostic laparoscopy (50 for chronic pain, 50 for tubal ligation or infertility evaluation) who received structured, physician-administered psychiatric and sexual abuse interviews. Women were regrouped by severity of childhood sexual abuse, and we compared the groups with respect to lifetime psychiatric diagnoses and medically unexplained symptom patterns. Unadjusted odds ratios showed that risk for lifetime diagnoses of major depression, panic disorder, phobia, somatization disorder and drug abuse, and current diagnoses of major depression and somatoform pain disorder were significantly higher in the severely abused group compared with women with no abuse or less severe abuse. Logistic regression analysis demonstrated that number of somatization symptoms, lifetime panic disorder and drug dependence were predictive of a prior history of severe childhood sexual abuse. Psychiatric disorders and medical symptoms, particularly chronic pelvic pain, are common in women with histories of severe childhood sexual abuse. Clinicians should inquire about childhood sexual and physical abuse experiences in patients with multiple medical and psychiatric symptoms, particularly patients with chronic pelvic pain.     

Self-definition as a survivor of childhood sexual abuse among navy recruits

This study explored how specific childhood sexual experiences (CSEs) might be related to self-identification as a victim of sexual abuse and to gender differences in self-defined victimization. Hierarchical logistic regression was used to estimate the relationship of demographic and CSE characteristics with self-definitions. The characteristics most strongly associated were threats-force, incest, and younger age at the time of the experience. Men were less likely than were women to acknowledge abuse and to report CSE characteristics indicative of abuse. Women were more likely to identify themselves as victims the more CSEs they reported involving sexual penetration. Finally, in an analysis of familial abuse, men were more likely to define themselves as victims if the perpetrator was also male.     

MMPI-2 profiles of women differing in sexual abuse history and sexual orientation

Four groups of women (N = 115) self-identified as having histories of childhood sexual abuse or no such histories and self-identified as either heterosexual or lesbian were compared using a questionnaire and the MMPI-2. Subjects ranged in age from 21–60 years with 60% between ages 30–50 years. Results of a Three-Way MANOVA for abuse history and sexual orientation repeated across MMPI-2 clinical scales showed a between-subjects effect for abuse, and within-subjects effects for orientation and abuse. T scores of women with abuse histories were significantly higher than those of women without abuse histories on Hs, D, Pd, Pa, Pt, Sc, and Ma scales of the MMPI-2. Profiles indicated an 8-4 codetype and a Scarlett O'Hara V configuration for the group with abuse history. Heterosexual women obtained significantly higher t scores than did lesbians on the Depression scale. Results show that the MMPI-2 can be used to help detect lesbian as well as heterosexual adults who were sexually molested as children. © 1997 John Wiley & Sons, Inc. J Clin Psychol 53: 791–800, 1997     

Effects of a coping intervention on transmission risk behavior among people living with HIV/AIDS and a history of childhood sexual abuse

OBJECTIVES: To examine the effect of a 15-session coping group intervention compared with a 15-session therapeutic support group intervention among HIV-positive men and women with a history of childhood sexual abuse (CSA) on sexual transmission risk behavior. DESIGN: A randomized controlled behavioral intervention trial with 12-month follow-up. METHODS: A diverse sample of 247 HIV-positive men and women with histories of CSA was randomized to 1 of 2 time-matched group intervention conditions. Sexual behavior was assessed at baseline; immediately after the intervention; and at 4-, 8-, and 12-month follow-up periods (5 assessments). Changes in frequency of unprotected anal and vaginal intercourse by intervention condition were examined using generalized linear mixed models for all partners, and specifically for HIV-negative or serostatus unknown partners. RESULTS: Participants in the HIV and trauma coping intervention condition decreased their frequency of unprotected sexual intercourse more than participants in the support intervention condition for all partners (P < 0.001; d = 0.38, 0.32, and 0.38 at the 4-, 8-, and 12-month follow-up periods, respectively) and for HIV-negative and serostatus unknown partners (P < 0.001; d = 0.48, 0.39, and 0.04 at the 4-, 8-, and 12-month follow-up periods, respectively). CONCLUSION: A group intervention to address coping with HIV and CSA can be effective in reducing transmission risk behavior among HIV-positive men and women with histories of sexual trauma.     

Psychological and behavioral moderators of the relationship between trauma severity and HIV transmission risk behavior among MSM with a history of childhood sexual abuse

Childhood sexual abuse (CSA) is associated with post-traumatic stress disorder (PTSD), which can be associated with condomless sex among men who have sex with men (MSM). However, the impact of moderating factors on the relationship between PTSD symptom severity and condomless sex is poorly understood. We examined whether PTSD symptom severity was associated with condomless sex among MSM with CSA histories, and whether substance dependence, self-esteem, and distress tolerance moderated that relationship (n = 288). Notably, no direct relationship between PTSD symptom severity and condomless sex was found. Adjusted models indicated that condomless sex was differentially impacted by PTSD symptom severity among those without substance dependence (ΔR² = 0.03, p = 0.034) and, counterintuitively, those with high self-esteem (ΔR² = 0.07, p = 0.005). PTSD symptom severity was associated with condomless sex across levels of distress tolerance. Findings indicate that substance use, self-esteem, and distress tolerance should be targeted in high-risk MSM with CSA even if they do not have PTSD.     

Childhood sexual abuse and sexual risk behavior among men and women attending a sexually transmitted disease clinic

Childhood sexual abuse (CSA) is associated with a wide range of negative outcomes. The authors investigated the relation between CSA and sexual risk behavior in 827 patients recruited from a sexually transmitted disease (STD) clinic. Overall, CSA was reported by 53% of women and 49% of men and was associated with greater sexual risk behavior, including more sexual partners, unprotected sex, and sex trading. Alcohol use for men and drug use for women mediated the relation between CSA and the number of sexual partners in the past 3 months; intimate partner violence mediated the relation between CSA and the number of episodes of unprotected sex in the past 3 months for women. These results document the prevalence of CSA among patients seeking care for an STD and can be used to tailor sexual risk reduction programs for individuals who were sexually abused.     

Moroccan women with a history of child sexual abuse and its long-term repercussions: A population-based epidemiological study

Summary. Childhood sexual abuse is defined as sexual contact imposed on a child whose development is still, from the emotional, cognitive and maturity point of view, lacking. The objective of this epidemiological study, conducted among a representative sample of the female population aged 20 and over in Casablanca, Morocco, is to determine the prevalence of the childhood sexual abuse and its long-term repercussions.The main results were that 9.2% (n=65) reported childhood sexual abuse. The mean age of this subgroup was 31.34±9.43 years (20–63); 66.1% were housewives; 40% were single and 10.8% were divorced. The prevalence of genital abuse with penetration was 33.8% (22 cases). The abuser was known in 56.2% and was a family member in 20.4% of the cases. Of the 728 women interviewed, 27 (43.5%) abused women and 83 (29.5%) non-abused women during childhood reported depressive symptoms with a positive association (p=0.03). There was also an association between the most severe types of abuse and vaginismus. Generally speaking, all those who were abused during their childhood suffered sexual disturbances during their adult life.     

Risky sexual behavior in american white college women: the role of sex guilt and sexual abuse

Ninety-five sexually active White American female college students participated in a questionnaire study about their sexual behavior in the past 12 months. A path model was tested in order to assess specific hypothesized predictors of risky sexual behavior. As predicted, participants with greater sex guilt reported using condoms more and having had fewer sexual partners. The findings of this study suggest that White American female college students are at some degree of risk due to risky sexual behavior. Taking into account attitudes about sexuality and past sexual abuse along with the requisite training in condom use self-efficacy may enhance the success of interventions designed to reduce risky sexual behavior among White American female college students.     

Affect management in group therapy for women with posttraumatic stress disorder and histories of childhood sexual abuse

Affect dysregulation is pervasive among women with histories of childhood sexual abuse. It is an important aspect of the clinical presentation of posttraumatic stress disorder (PTSD), a disorder that frequently characterizes survivors of childhood abuse. Based on distinctions between approach and avoidance orientations to coping, there is controversy regarding whether initial treatment for trauma survivors should employ an exposure-based approach to increase affect or an affect-management approach to reduce it. In this article, we review theoretical and empirical literature regarding affect dysregulation and its relations with childhood sexual abuse and PTSD. We then describe a new affect-management group for adult survivors of childhood sexual abuse that is based on a stage approach to the treatment of trauma. This group emphasizes skill acquisition, symptom reduction, and patient stabilization. Affect-management strategies such as mindfulness, crisis planning, and challenging distorted thinking are presented to patients. Preliminary research findings support the use of this treatment.     

The relationship of childhood sexual abuse and depression with somatic symptoms and medical utilization

BACKGROUND: Previous research suggests that childhood sexual abuse is associated with high rates of retrospectively reported medical utilization and medical problems as an adult. The goal of this study was to determine if abused females have higher rates of medical utilization using self-report and objective measures, compared with non-abused females. A further goal was to determine whether findings of prior research would be replicated when childhood physical abuse level was controlled. This study also examined the moderating impact of depressed mood on current health measures in this population. METHODS: Six hundred and eight women recruited from a health maintenance organization completed self-report measures of health symptoms for the previous month and doctor visits for the previous year. Objective doctor records over a 2 year period were examined for a subset of 136 of these women. RESULTS: Results showed significantly more self-reported health symptoms and more self-reported doctor visits in abused participants compared with those who reported no childhood history of sexual abuse. Objective doctor visits demonstrated the same pattern with abused participants exhibiting more visits related to out-patient surgery and out-patient internal medicine. In addition, persons who were both sexually abused and depressed tended to visit the emergency room more frequently and to have more in-patient internal medicine and ophthalmology visits than sexually abused participants who reported low depressed mood and non-abused controls. CONCLUSIONS: These results replicate prior studies and suggest that current depression may moderate the relationship between sexual abuse and medical problems in adulthood.