This article reviews studies that have tried to confirm empirically the effects of child sexual abuse cited in the clinical literature. In regard to initial effects, empirical studies have indicated reactions - in at least some portion of the victim population - of fear, anxiety, depression, anger and hostility, aggression and sexually inappropriate behaviour. Frequently reported long-term effects include depression and self-destructive behaviour, anxiety, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, a tendency toward revictimization, substance abuse and sexual maladjustment. The kinds of abuse that appear to be most damaging according to the empirical studies, are experiences involving father figures, genital contact and force. The controversy over the impact of child sexual abuse is discussed and recommendations for future research efforts are suggested.Although clinical literature suggests that sexual abuse during childhood plays a role in the development of other problems ranging from anorexia nervosa to prostitution, empirical evidence about its actual effects is sparse. In this article we review the expanding empirical literature on the effects of child abuse, discuss its initial and long-term effects, review studies on the impact of different kinds of abuse and conclude with a critique of the current literature and some suggestions for future research.
Child sexual abuse consists of two overlapping but distinguishable types of interaction: (a) forced or coerced sexual behaviour imposed on a child, and (b) sexual activity between a child and a much older person, whether or not obvious coercion is involved ( a common definition of "much older" is 5 or more years). As might be expected, not all studies relevant to our purposes share these parameters. Some have focused on experiences with older partners only, excluding coerced sexual experiences with peers. Others have looked only at sexual abuse that was perpetrated by family members. Such difficulties in samples make comparisons among these studies difficult. However, we include all the studies that looked at some portion of the range of experiences that are bounded by these two criteria. (See Table 1 for a breakdown of sample composition of the studies reviewed.)
Two areas of the literature are not included in our review. A small number of studies on the effect of incest (e.g., Farell, 1982; Nelson, 1981), as well as one review of the effects of child sexual experiences (Constantine, 1980), combine data on consensual, peer experiences with data that involve either coercion or age disparity. Because we are unable to isolate sexual abuse in these studies, we had to exclude them. Secondly, we decided to limit our review to female victims. Few clinical and even fewer empirical, studies have been done on male victims (for exceptions see Finkelhor, 1979; Rogers and Terry, 1984; Sandfort, 1981; Woods and Dean, 1984) and it seems premature to draw conclusions on this point. Under "empirical" studies, we include any research that attempted to quantify the extent to which a sequelae to sexual abuse appeared in a specific population. Some of these studies used objective measures, whereas others were based primarily on the judgments of clinicians.
Although several empirical studies have given support to clinical observations of generally negative emotional effects resulting from childhood sexual abuse, only two used sttandartized measures and compared subjects' scores to general population norms. In an early study of the effects of sexual abuse on children, DeFrancis (1969) reported that 66% of the victims were emotionally disturbed by the molestation: 52% mildly to moderately disturbed and 14% seriously disturbed. Only 24% were judged to be emotionally stable after the abuse. However, this sample was drawn from court cases known to Prevention ofCruelty to Children services or to the police and because the subjects came primarily from low income and multiple-problem families who were on public assistance, these findings may have little generalizability.
In investigatiing a different type of special population, Anderson, Bach and Griffith (1981) reviewed clinical charts of 155 female adolescent sexual assault victims who had been treated at the Harborview Center in Washington and reported psychosocial complications in 63% of them. Reports of "internalized psychosocial sequelae" (e.g., sleep and eating disturbances, fears and phobias, depression, guilt, shame and anger) were noted in 67% of female victims when the abuse was intrafamilial and 49% when the offender was not a family member. "Externalized sequelae" (including school problems and running away) were noted in 66% of intrafamilial victims and 21% of extrafamilial victims. However, no standartized outcome measures were used, so the judgments of these effects may be subjective.
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In evaluating the initial psychological effects of child sexual abuse, Tufts (1984) researchersfound differences in the amount of pathology reported for different age groups. Seventeen percent of the 4- to 6-year-olds in the study met the criteria for "clinically significant pathology," demonstrating more overall disturbance than a normal population but less than the norms for other children their age who were in psychiatric care. The highest incidence of psychopathology was found in the 7 - 13-year-old age group, with 40% scoring in the seriously disturbed range. Interestingly, few of the adolescent victims exhibited severe psychopathology, except on a measure of neuroticism.
Friedrich, Urquiza and Beilke (in press) also used a standardized measure in their study of 61 sexually abused girls. Subjects were referred by a local by a local sexual assault for evaluation or by the outpatient department of a local hospital. Using the Child Behavior Check List (CBCL; see Achenbach and Edelbrock, 1983, for a description of this measure), Friedrich et al. reported that 46% of their subjects had significantly elevated scores on its Internalizing scale (including fearful, inhibited, depressed and overcontrolled behaviours) and 39% had elevated scores on its Externalizing scale (aggressive, antisocial and undercontrolled behaviours). This was compared with only 2% of the normative sample who would be expected to score in this range. [...]
Breaking down emotional impact into specific reactions, we find that the most common initial effect noted in empirical studies, similar to reports in the clinical literature, is that of fear. [...]
Another initial effect in children is reactions of anger and hostility. [...]
Guilt and shame are other frequently observed reactions to child sexual abuse, but few studies give clear percentages. DeFrancis (1969) observed that 64% of his sample expressed guilt, although this was more about the problems created by disclosure than about the molestation itself.
Physical symptoms indicative of anxiety and distress are noted in the empirical literature as well as in clinical reports. In their chart review of female adolescent victims, Anderson et al., (1981) found that 17% had experienced sleep disturbances and 5% - 7% showed changes in eating habits. J. Peters (1976), in a study of child victims of intrafamilar sexual abuse, reported that 31% had difficulty sleeping and 20% experienced eating disturbances. However, without a comparison group, it is hard to know if this is seriously pathological for any group of children, or for clinical populations in particular. [...]
Reactions of inappropriate sexual behaviour in child victims have been confirmed by two studies using standardized measures (Friedrichs et al., in press; Tufts, 1984). In the Tufts (1984) study, 27% of the 4- to 6-year-old children scored significantly above clinical and general population norms on a sexual behaviour scale that included having had sexual relations (possibly a confounding variable in these findings), open masturbation, excessive sexual curiosity and frequent exposure of genitals. [...]
Other aftereffects of child sexual abuse mentioned in the literature include difficulties at school, truancy, running away from home and early marriages by adolescent victims. Herman (1981) interviewed 40 patients in therapy who had been victims of father-daughter incest and compared their reports with those from a group of 20 therapy clients with seductive, but not incestuous, fathers. Of the incest victims, 33% attempted to run away as adolescents, compared with 5% of the comparison group. Similarly, Meiselman (1978) found that 50% of the incest victims in her sample had left home before the age of 18, compared with 20% of women in a comparison group of nonvictimized female patients. [...]
A connection between sexual abuse, running away and deliquency is also suggested by several studies of children in special treatment or deliquency programs. Reich and Gutierres (1979) reported that 55% of the children in Maricopa County, Arizona who were charged with running away, truancy, or listed as missing persons were incest victims. In addition, in a study of female juvenile offenders in Wisconsin (1982) researchers found that 32% had been sexually abused by a relative or other person close to them.
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[...] Sedney and Brooks (1984) in a study of 301 college women, found a greater likelihood for subjects with childhood sexual experiences to report symptoms of depression (65% vs. 43% of the control group) and to have been hospitalized for it (18% of those depressed in the childhood experience group vs. 4% of women in the control group). [...] These resultats are consistent, however, with those from a carefully controlled survey of 278 undergraduate women by Briere and Runtz (1985) using 72 items of the Hopkins Symptom Checklist, which indicated that sexual abuse victims reported that they experienced more depressive symptoms during the 12 months prior to the study than did nonabused subjects. [...]
[...] In an extensive study of 153 "walk-ins" to a community health centre, Briere (1984) reported that 51% of the sexual abuse victims, versus 34% of nonabused clients, had a history of suicide attempts. [...]
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Women who have sexually victimized as children report problems in relating both to women and men, continuing problems with their parents and difficulty in parenting and responding on their own children. [...]
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Findings of long-term impact are especially persuasive. Eight non-clinical studies of adults (Bagley and Ramsey, 1985; Briere and Runtz, 1985; Finkelhor, 1979; Frohmuth, 1983; S. Peters, 1984; Russel, in press; Sedney and Brooks, 1984; Seidner and Calhoun, 1984), including three random sample community surveys, found that child sexual abuse victims in the "normal" population had identifiable degrees of impairment when compared with nonvictims. Although impairment in these non-clinical victims are not necessarily severe, all the studies that have looked for long-term impairment have found it, with the exception of one (Tsai et al, 1979).
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Unfortunately, although the studies indicate higher risk, they are not so informative about actual extend of impairment. In terms of simple self-assessments, 53% of intrafamilar sexual abuse victims in Russel's (in press) community survey reported that the experience resulted in "some" or "great" long-term effects on their live. Assessment with standardized clinical measures show a more modest incidence of impairment: In Bagley & Ramsey's (1985) community survey, 17% of sexual abuse victims were clinically depressed as measured by the CES-D and 18% were seriously psychoneurotic. Thus, most sexual abuse victims in the community, when evaluated in surveys, show up as slightly impaired or normal. It is possible, however, that some of the impairment associated with childhood molestation is not tapped by these survey evaluation.
Summarizing then, from studies of clinical and nonclinical populations, the findings concerning the trauma of child sexual abuse appear to be as follows: In the immediate aftermath of sexual abuse, from one-fifth to two-fifth of abused children seen by clinicians manifest pathological disturbance (Tufts, 1984). When studied by as adults, victims as a group demonstrate impairment when compared with their nonvictimized counterparts, but under one-fifth evidence serious psychopathology. These findings give reassurance to victims that extreme long-term effects are not inevitable. Nonetheless, they also suggest that the risk of initial and long-term mental health impairment for victims of child abuse should be taken very seriously.
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Although many clinicians take for granted that the longer an experience goes on, the more traumatic it is, this conclusion is not clearly supported by the available studies. Of the nine studies, only four found duration associated with greater trauma. (We are treating duration and frequency synonymously here because they tend to be so highly correlated.) Three found no relation and two found some evidence that longer duration is associated with less trauma.
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What has been consistently reported is greater trauma from experiences involving fathers or father figures compared with all other types of perpetrators, when these have been separated out. Russell (in press) and Finkelhor (1979) both found that abuse by a father or stepfather was significantly more traumatic for victims than other abuse occuring either inside or outside the family. [...]
Results of empirical studies generally suggest, with a couple of important exceptions, that the type of sexual activity is related to the degree of trauma in victims. [...]
Two studies of long-term effects do suggest that younger children are more vulnerable to trauma. [...]
However, four over studies found no significant relation between age at onset and impact. [...]
There is a general clinical assumption that children who feel compelled to keep the abuse a secret in the aftermath suffer greater psychic distress as a result. However, studies have not confirmed this theory. Begley and Ramsey (1985) did find a simple zero-order relation between not telling and a composite mearsure of impairment based on depression, suicidal ideas, psychiatric consultation and self-esteem. However, the association became nonsignificant when controlled for other factors. [...]
Only two studies have looked at children's trauma as a function of parental reaction, even though this is often hypothesized to be related to trauma. The Tufts (1984) study found that when mothers reacted to disclosure with anger and punishment, children manifested more behavioral disturbances. However, the same study did not find that positive responses by mothers were systematically related to better adjustment. Negative responses seemed to aggrevate, but positive responses did not ameliorate, the trauma. Anderson et al., (1981) found similar results: They noted 2.5 times the number of symptoms in the children who had encountered negative reactions from their parents. Thus although only based on two studies of initial effects, the available evidence indicated that negative parental reactions aggrevate trauma in sexually abused children.
There is a great deal of interest in how institutional response may affect children's reaction to abuse, but little research has been done. Tufts (1984) researchers found that children removed from their homes following sexual abuse exhibited more overall behaviour problems, particularly aggression, than children who remained with their families. However, the children whe were removed in the Tufts study were also children who had experienced negative reactions from their mothers, so this result may be confounded with other factors related to the home environment.