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

Abstract

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.

Résumé

French-language abstract not available at time of publication.

Resumen

Spanish-language abstract not available at time of publication.

Introduction

Approximately 1 in 7 women reported childhood sexual abuse (CSA), according to a national study (Molnar, Buka, & Kessler, 2001); this falls in the middle of rates determined by other national probability studies, which range from 3 to 27% for women. In response to these prevalence rates, considerable research has addressed the problem of CSA and its consequences. Understanding CSA, however, has been complicated by challenges in measuring prevalence, including inconsistent definitions, varied sampling techniques, and different methods of data collection (Finkelhor, 1994; Wyatt and Peters, 1986a, Wyatt and Peters, 1986b). Despite efforts by the National Center for Child Abuse and Neglect to standardize the definition of CSA, inconsistencies from one study to another persist (Wyatt & Peters, 1986a), particularly in terms of the upper age of the victim, inclusion of non-contact experiences, and wanted versus unwanted episodes (Rowan & Foy, 1993). Study samples vary widely from mandated reports using child welfare or protective service records and court-mandated documents to reports from parents who voluntarily came forward for interviews.

Measures of CSA are inconsistent across studies. For example, some researchers use a dichotomous measure, such as the presence or absence of any CSA (Briere & Runtz, 1988; Marcenko, Kemp, & Larson, 2000). This method, however, has been criticized as overly simplifying an experience that has multiple dimensions (Beitchman et al., 1992; Rodriguez, Ryan, Rowan, & Foy, 1996). Further, CSA severity has been operationalized inconsistently across studies; for example, some researchers have used characteristics such as frequency, duration, and the relationship of the perpetrator to the victim as discrete indicators of severity (Fleming, Mullen, Sibthorpe, & Bammer, 1999; Peters, 1988), whereas other researchers have used the abusive act and its level of invasiveness (e.g., Kendler et al., 2000; Rowan & Foy, 1993; Russell, 1986). Efforts have been made to develop CSA severity scales that encompass different abuse characteristics, some using subjective researcher rating systems to incorporate various dimensions of the abusive episode (Silk, Lee, Hill, & Lohr, 1995; Wyatt & Mickey, 1987). Objective, multidimensional measures of CSA severity have been developed. Edwards and Alexander (1992), studying the influence of family relationships and CSA characteristics, created a composite score of severity from three dichotomous variables: sexual victimization by a father figure, sexual penetration, and the use of physical force. Leserman et al. (1997), examining the impact of CSA on physical health, developed a CSA severity measure that included the presence of rape, serious injury during abuse, and multiple life threatening experiences. Studying relationships between CSA and other early life experiences, Draucker (1997) used both subjective and objective components in a scale that combined three researcher-derived, subjective scores, each rating the severity of particular aspects of the abuse: degree of violence, degree of closeness in the perpetrator-victim relationship, and frequency of the abuse. Each of these studies included only three characteristics of the CSA experience in their scales, and none compared the scale to another form of measurement.

Over the past two decades, research has demonstrated a relationship between the presence of CSA and adult outcomes. For example, psychological distress and depression (Bagley & Ramsay, 1986; Briere & Runtz, 1988; Mullen, Martin, Anderson, Romans, & Herbison, 1993), including suicide attempts (Bagley & Ramsay, 1986; Jackson, Calhoun, Amick, Maddever, & Habif, 1990), have been found to a greater extent or more often among women with CSA than women without CSA. Lower self-esteem (Bagley & Ramsay, 1986; Wind & Silvern, 1992) and alcohol and other drug dependence (Galaif, Stein, Newcomb, & Bernstein, 2001; Marcenko et al., 2000, Mullen et al., 1993, Peters, 1988) have also been associated with a history of CSA.

Researchers have reported associations between particular characteristics of a CSA experience and adult outcomes. The frequency and duration of the CSA (Peters, 1988) as well as the nature of the victim's relationship to the perpetrator have been associated with increased psychological distress (Elliott & Briere, 1992), lower self-esteem, depression, and suicidal ideation (Bagley & Ramsay, 1986; Thakkar, Gutierrez, Kuczen, & McCanne, 2000). Women abused by multiple perpetrators had greater psychological distress in adulthood (Elliott & Briere, 1992) than women abused by one perpetrator. While there are some conflicting reports, incest has been more consistently associated with trauma symptoms than CSA by a non-family member (Browne & Finkelhor, 1986; Wind & Silvern, 1992). Furthermore, incest victims had poorer social adjustment, lower self-esteem, and a higher level of depression than CSA victims who did not experience incest (Jackson et al., 1990). When rape victims, non-rape victims, and non-CSA victims have been compared, rape victims experienced the most mental health problems (Bagley & Ramsay, 1986; Kendler et al., 2000), including higher rates of suicide attempts (Saunders, Villeponteaux, Lipovsky, Kilpatrick, & Veronen, 1992), lower self-esteem (Mullen et al., 1993; Romans et al., 1996, Romans et al., 1997), and more alcohol problems (Kendler et al., 2000). In contrast, research with an adolescent psychiatric population demonstrated that specific characteristics of CSA, such as incest or rape, may not predict symptoms, after adjusting for physical and emotional abuse (Naar-King, Silvern, Ryan, & Sebring, 2002).

While the literature has typically focused on undesirable adult outcomes, some researchers (Briere & Elliott, 1994; Liem, James, O’Toole, & Boudewyne, 1997) have identified subsamples of women with CSA but without adult adjustment problems. The search for explanations for the range of outcomes among CSA victims has led researchers to look beyond the abusive experience to the influence of the family environment (Bagley, 1996; Briere & Elliott, 1993; Fleming et al., 1999, Liem et al., 1997; Wyatt & Mickey, 1987).

CSA researchers have hypothesized that characteristics of the family of origin make significant independent contributions to adult psychosocial outcomes (Edwards & Alexander, 1992). Until recently, family characteristics have been used primarily to demonstrate that CSA is often accompanied by other childhood risks. For example, childhood families of women with CSA were reported to be less cohesive (Alexander & Lupfer, 1987; Yama, Tovey, Fogas, & Teegarden, 1992) and to have higher levels of conflict (Edwards & Alexander, 1992; Higgins & McCabe, 1994; Yama et al., 1992) than the families of women without CSA. In addition, Long and Jackson (1991) found that female college students reporting multiple perpetrators had families with lower cohesion and expressiveness and greater conflict than those reporting a single perpetrator or no CSA history.

Multivariate techniques have been used to explore the contribution of the family environment to CSA and adult outcomes, encouraging a more contextual perspective of CSA. Findings from these studies have not been consistent. Some researchers have reported no differences in psychological adjustment between those who experienced CSA and those who did not, when results were adjusted for family environment (e.g., Fromuth, 1986; Harter, Alexander, & Neimeyer, 1988; Higgins & McCabe, 1994). Other researchers have found that the occurrence of CSA contributed to psychological dysfunction even after adjusting for family environment (e.g., Merrill, Thomsen, Sinclair, Gold, & Milner, 2001; Peters, 1988, Romans et al., 1997), or that CSA and family conflict each contributed to long-term psychological distress (Edwards & Alexander, 1992). CSA victims who had been physically abused or had a mother with poor mental health were more likely than CSA victims without such a home environment to have poor adult mental health outcomes, including more long-term psychological distress (Bagley, 1996, Fleming et al., 1999).

The current study presents an empirically derived, multidimensional CSA Severity Scale that includes a set of factors different from those reported in other studies. The predictive value of the scale was assessed for a broad range of adult outcomes and compared with the predictive value of a dichotomous measure of the presence or absence of CSA. The additional contribution of family environment was then assessed. This study contributes to the CSA literature by (1) comparing a multidimensional CSA Severity Scale to a dichotomous measure of the presence or absence of CSA and (2) exploring the contribution of family environment. The study adds to the CSA literature by using a community sample of women from intact families who did and did not experience CSA, and testing the scale on a broad range of adult psychosocial outcomes, both positive and negative.