Gender as a predictor of posttraumatic stress symptoms and externalizing behavior problems in sexually abused children
Introduction
Sexual abuse (SA) is an important social issue that affects both girls and boys. According to a worldwide meta-analysis, 1 in 5 women and 1 in 10 men report being sexually victimized prior to the age of 18 (Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). Past studies have clearly demonstrated that childhood SA is a significant risk factor for depression, anxiety, low self-esteem, suicide attempts, as well as alcohol and drug dependence (Fergusson, McLeod, & Horwood, 2013). In the short term, children who have disclosed SA are likely to show posttraumatic stress disorder (PTSD) symptoms (Hébert, Langevin, & Daigneault, 2016). In addition, relative to their non-abused peers, child victims present significant depressive and anxiety symptoms and externalizing behavior problems such as anger and aggressiveness (Hébert, 2011).
With the aim of orienting treatment priorities and identifying relevant targets for intervention, studies have explored factors that impact severity of symptoms, including characteristics of the abuse sustained (severity of the acts, duration of the abuse, the perpetrator’s relationship to the child), attributions, coping strategies, as well as social support (Cantón-Cortés, Cantón, Justicia, & Cortés, 2011; Zajac, Ralston, & Smith, 2015). Besides these potential factors, gender of the child victim may be associated with outcomes of SA. Yet, few studies have explored gender differences among sexually abused children. In the vast majority of childhood SA studies, boys are either completely absent from samples or insufficiently represented, making it difficult to conduct gender-specific analyses (Maikovich-Fong and Jaffee, 2010, Villeneuve Cyr and Hébert, 2011).
Past studies of adult samples suggest that sexually abused women report more internalizing problems than sexually abused men, as well as PTSD (Blain, Galovski, & Robinson, 2010). For women survivors of SA, some studies suggest that they show more anxiety and depressive symptoms (Banyard, Williams, & Siegel, 2004). However, other studies report no gender differences between men and women victims of SA regarding depressive symptoms (Arnow, Blasey, Hunkeler, Lee, & Hayward, 2011) and PTSD (Tolin & Foa, 2006). Adult victims were also found more likely to have alcohol and drug problems than non-adult victims, but those risks appear similar for men and women (Dube et al., 2005). From their 30-year longitudinal study on survivors of SA, Fergusson et al. (2013) observed that gender did not impact adult developmental outcomes. While studies among adult samples are important to document long-term SA consequences, retrospective studies may include biases related to memory and may introduce significant measurement error (Hardt & Rutter, 2004).
Gender differences have also been explored in samples of teenagers and children. Sexually abused teenaged boy victims seem to express more externalizing difficulties, such as delinquent behaviors, sexual risk behaviors and alcohol and drug abuse compared to sexually abused girls (Chandy, Blum, & Resnick, 1996; Garnefski & Arends, 1998). In their study based on examination of judicial and social reports, Soylu et al. (2016) observed that girl victims under 18 had more psychiatric and major depressive disorder than boys (n = 248), yet PTSD was as prevalent in girls and boys. According to Villeneuve Cyr and Hébert (2011), school-aged SA girls reported more PTSD and anxiety symptoms than boys. Boys (n = 33) tended to have more externalizing behaviors than girls whereas no gender difference was found for internalizing problems (Villeneuve Cyr & Hébert, 2011). These results are in contrast with those reported by Coohey (2010) with preteens aged 11–14. This study pointed out that boys (n = 31) were twice as likely to have internalizing behaviors (52% vs. 24%) than girls (Coohey, 2010). However, Coohey argued that “sexually abused boys may be more likely to internalize during early adolescence and externalize during later adolescence, whereas sexually abused girls may be more likely than boys to exhibit internalizing behavior throughout adolescence” (Coohey, 2010, p. 860). Another study conducted by Maikovich-Fong and Jaffee (2010) observed no difference between boy (n = 117) and girl victims of SA, aged 4–16, for internalizing, externalizing and PSTD symptoms.
These contradictory results may relate to methodological differences, including the age of the participants in the different samples, the definition of SA that varied across these studies, and the underrepresentation of boys. Indeed, studies on children and adolescents who have disclosed SA usually included around 30 boys only (Feiring, Taska, & Lewis, 1999), which limits the power to detect significant differences. Analyses of gender differences among SA victims are often limited to descriptive analyses and few studies have examined possible explanatory mechanisms. The present study will attempt to overcome these limitations by testing mediators of the relation between gender and outcomes in a large school-aged sample of SA victims.
A number of interpretations can be considered to account for gender differences in SA outcomes. First, gender role in socialization may contribute to gender differences. For example, boys may be less often reprimanded than girls for displaying aggressive behaviors, making them more likely to develop externalizing symptoms, and making the latter more prone to develop internalized symptoms.
Second, the SA experienced by boys and girls might be different, which could impact the type and intensity of outcomes. For example, some studies have revealed that SA perpetrated toward boys is more likely to involve severe or intrusive gestures (Edinburgh, Saewyc, & Levitt, 2006; Soylu et al., 2016, Villeneuve Cyr and Hébert, 2011). The greater severity of SA experienced by boys may explain the higher level of externalizing problems observed among male victims (Banyard et al., 2004). Being a girl seems to be associated with longer duration of SA and a closer perpetrator (Coohey, 2010, Soylu et al., 2016, Villeneuve Cyr and Hébert, 2011). These characteristics may negatively influence SA outcomes (Hébert, Tremblay, Parent, Daignault, & Piché, 2006; Yancey & Hansen, 2010).
Third, boys may experience more guilt because of the internalized stigma related to same gender perpetrator (Banyard et al., 2004). The vast majority of reported child abusers are male (Dube et al., 2005, Soylu et al., 2016), which means that boys, compared to girls, are often abused by a same gender person. This might create an additional issue, unique to boys, about masculinity and sexual orientation (Banyard et al., 2004). Boys may report a greater sense of guilt because they may perceive that they were not able to protect themselves, which is a prescribed role for men. In fact, these gender norms may reinforce guilt felt by boys, which may influence outcomes and delay disclosure (Gagnier & Collin-Vézina, 2016). Sense of guilt and self-blame are correlates that have been shown to mediate SA outcomes (Feiring & Cleland, 2007), such as PTSD symptoms (Cantón-Cortés et al., 2011). According to the traumagenic dynamics theory of Finkelhor and Browne (1985), stigmatization, which encompasses guilt and shame, contributes to the apparition of externalizing behavior problems (drug and alcohol abuse, criminal activity, suicide attempts). If boys do indeed have a higher sense of guilt than girls, they may consequently develop more externalized behavior problems following SA.
The aim of this study is to examine the role of gender in SA outcomes across 6–12 year old child victims of SA. A predictive model of SA outcomes including SA characteristics and sense of guilt as mediators (see Fig. 1) is proposed. We hypothesize that being a girl will predict more PTSD symptoms and that this association will be mediated by the frequency of SA and the relationship with the perpetrator. We also hypothesize that being a boy will be associated with more behavior problems and that this relationship will be mediated by the severity of the abuse and sense of guilt.
Section snippets
Participants
The sample consisted of 447 sexually abused children (319 girls and 128 boys), aged 6–12 (M = 8.99, SD = 2.05) and one of their non-offending parental figures (347 mothers, 51 fathers, 45 other significant parental figures and 4 youth center educators). Participants were recruited during the initial evaluation at different centers located in the province of Quebec offering specialized services for sexually abused children. All families of children aged 6–12 consulting the agencies were invited to
Gender differences in characteristics of SA
Chi-square tests showed some gender differences in characteristics of SA experienced (see Table 2). First, boys (74.6%) were more likely than girls (56.4%) to have suffered intrusive acts (χ2(2) = 12.64; p = 0.002). Second, regarding duration of the SA, half (51.3%) of the boys had experienced some events of SA, compared to 1 in 3 (36.4%) girls (χ2(2) = 7.87, p = 0.020). Girls (38.1%) were more likely to report repetitive or chronic events than boys (30.2%), but this difference was not statistically
Discussion
The aim of this study was to examine the role of gender in SA outcomes in school-aged victims of SA by testing a predictive model including abuse characteristics and sense of guilt as mediators. Results indicated that boy and girl victims of SA seem to manifest different symptoms. Indeed, boys were more likely to display externalizing behavior problems, which is consistent with the literature (Banyard et al., 2004). The association between gender and PTSD seemed to be more complex. Results
Conclusion
Our goal was to highlight that boys represent a significant proportion of child victims of SA, and perhaps boys express their pain differently than girls. Including boys in SA studies and trying to explain gender differences may help to better understand the reality of these young victims, and thus promote more effective therapeutic and preventive interventions.
Acknowledgements
This research was funded by a grant from the Canadian Institutes of Health Research (#77614) awarded to Martine Hébert. This work was submitted as part of the Master’s thesis in sexology of the first author. The first author was supported by graduate scholarships from the Social Sciences and Humanities Research Council (SSHRC), the Fonds de recherche du Québec – Société et culture (FRQSC) and the Chaire interuniversitaire Marie-Vincent sur les agressions sexuelles envers les enfants. We wish to
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