Sexual abuse and suicidality: gender differences in a large community sample of adolescents☆
Introduction
Child sexual abuse (CSA) is known to have serious adverse effects on the psychosocial development of children and young adolescents, effects extending into adulthood (Beitchman, Zucker, Hood, daCosta, & Akman, 1991; Mullen, King, & Tonge, 2000; Tyler, 2002). Recent research argues for a multifaceted model of traumatisation rather than a specific sexual abuse syndrome (Paolucci, Genuis, & Violato, 2001), and CSA may be best conceptualized as a non-specific risk factor for adverse adult outcomes (Romans, Martin, & Mullen, 1997). Although abuse of all forms is more frequent in those from disturbed and disrupted family backgrounds, not all apparent associations between abuse and adult problems are accounted for by childhood disadvantage (Mullen, Martin, Anderson, Romans, & Herbison, 1996). Stevenson (1999) suggests abused children are at risk of long-term psychological sequelae related to the abuse itself, not merely as a consequence of other associated background factors. Prospective studies of abused children (Calam, Horne, Glasgow, & Cox, 1998), longitudinal studies of adolescents and young adults (Brown, Cohen, Johnson, & Smailes, 1999; Silverman, Reinherz, & Giaconia, 1996), retrospective studies of adults (Barker Collo, 2001) and adult twins (Nelson et al., 2002) all indicate significant disturbance in the psychological functioning of survivors of abuse.
One particular outcome of CSA is increased suicidality (Beckinsale, Martin, & Clark, 1999; Bensley, Van Eenwyk, Spieker, & Schoder, 1999; Martin, 1996). Beautrais (2000) reviewed risk factors for youth suicide and found mental disorders and adverse childhood experiences to be strong risk factors, with odds ratios for suicide attempt ranging from 1.5 to 11.8 for sexually abused youth, compared to non-abused. In a large US-based survey (n=5,877, 15–54 years old), Molnar, Berkman, and Buka (2001) found a strong association between CSA and suicidal behavior mediated by psychopathology, with the odds of suicide attempt in sexually abused women 2–4 times that of non-abused women, and in men 4–11 times, controlling for other adversities.
The nature of CSA is an important factor in determining outcomes, with more extreme forms of abuse involving force or penetration associated with more harmful long-lasting effects (Tyler, 2002) and increased distress (Pillay & Schoubben Hesk, 2001). Worse CSA and increased distress also increase severity of suicidal behavior (Fergusson, Lynskey, & Horwood, 1996; Lipschitz et al., 1999).
Gender differences may also be important. The incidence of sexual abuse is lower in boys than girls, and the community believes that sexual abuse of boys is less serious and less harmful (Broussard, Wagner, & Kazelskis, 1991; Smith, Fromuth, & Morris, 1997). Of importance, this may adversely influence decision-making with regard to their care and protection. In fact, the experience carries more consequences for boys than for girls in regard to alcohol/drug use, aggressive behavior, and truancy as well as suicidality (Garnefski & Arends, 1998). Gender differences in the interplay between psychological functioning and suicidality of young adolescents have been found by others (Allison, Roeger, Martin, & Keeves, 2001; Lewinsohn, Rohde, Seeley, & Baldwin, 2001; Rich, Kirkpatrick Smith, Bonner, & Jans, 1992), and further work to clarify the area has been recommended (Mazza & Reynolds, 1998).
Many existing studies in the area of sexual abuse are retrospective reports from adults, providing insight long after the event (abuse generally in the pre-pubertal period, 8–12 years) (Goldman & Padayachi, 1997). Much valuable contextual and perceptual data is missing or forgotten. Greater knowledge is required at a stage where early intervention with depression and suicidal behavior can provide the opportunity for effective prevention of the possible outcome of suicide. Reviews of CSA studies suggest that future work should use appropriate contrast groups (i.e., normal populations) at identified chronological and developmental age periods (Paolucci et al., 2001). This also makes sense given that some youth suicides occur outside “psychiatric populations,” suggesting studies of community samples are needed to provide information about risk factors beyond the boundaries of psychopathology.
Measures of suicidality in children and adolescents can be influenced by the instrument, retrospection, and who does the reporting (Klimes Dougan, 1998), and multiple method assessments including clinical judgment and self-report are most likely to indicate actual risk (Prinstein, Nock, Spirito, & Grapentine, 2001). Despite this, self-report measures are valuable tools, in that they tap current and contextually relevant emotional states of the respondent in a non-judgmental and non-threatening manner.
This paper contributes to the literature in a number of important ways. First we attempt to clarify gender differences in response to CSA, to address community perceptions that it is less serious for boys. Second, we use a large community sample of young adolescents rather than a clinical or adult population. Third, we highlight the association between CSA and suicidality. Specifically, gender differences in associations between sexual abuse and suicidal behavior (comprising suicidal ideation, plans, threats, and deliberate self-injury [DSI], and suicide attempts) are the prime focus of the study. Depression, hopelessness, and family functioning, also known to be associated with sexual abuse and suicidality (Bergen, Martin, Richardson, Allison, & Roeger, 2003), are controlled for in logistic regression analyses.
Section snippets
Participants
This work derives from the Early Detection of Emotional Disorders program, a 3-year repeated measures longitudinal study of young adolescents, focusing on early detection of suicidal behaviors, and risk and protective factors implicated in later suicide. Following approval from the South Australian Department of Education and Children’s Services, and the Flinders Medical Centre Ethics Committee on Clinical Investigations, 25 government schools in the mental health service catchment area
Results
Approximately 85–87% of the 2,485 students fully completed each section of the questionnaire relevant to this study. Descriptive statistics are reported in Table 1.
Reported experience of sexual abuse was more prevalent amongst girls (girls 5.4% vs. boys 2.0%). Current distress from past sexual abuse was not associated with the identity of the abuser, but was related to depressive symptomatology [χ2(1)=8.50, p<.05] with 86.2% of those reporting high distress levels (scores 3–6) following abuse
Discussion
The findings of this cross-sectional study of a large community sample of adolescents indicate that the experience of sexual abuse is strongly associated with suicidal ideation and suicidal behavior comprising plans, threats, deliberate self-injury and attempts. Striking gender differences are apparent. In girls, although an association between sexual abuse and suicidality is evident initially, depressive symptomatology, hopelessness, and family functioning appear to mediate the relationship.
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Financial support was provided by the South Australian Health Commission.