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IICSA Independent Inquiry into Child Sexual Abuse

The impacts of child sexual abuse: A rapid evidence assessment

1. Impacts of CSA on victims and survivors

The research reviewed as part of this REA shows that being a victim and survivor of CSA is associated with an increased risk of adverse outcomes in all areas of victims and survivors’ lives. Additionally, long-term longitudinal research suggests that – in many cases – these adverse outcomes are not just experienced over the short and medium term following abuse, but instead can endure over a victim and survivor’s lifetime.[1]

In the words of victims and survivors, taken from one of the qualitative studies included in this review:

“What he did to me affected my whole life, every relationship, my personal identity and the general trajectory of my life’s path. Childhood sexual abuse manifested in all aspects of my life.” [2]

“The effects of what happened have stayed with me, un-dealt with and unprocessed, throughout my life. The damage from my early years has coloured everything else at all stages of my life. I know it sounds dramatic but I’m just telling it like it is.” [3]

The outcomes which emerged from the studies reviewed can be grouped into seven areas, as shown in Figure 1 below.

Figure 1: CSA victim and survivor outcome areas with example outcomes

 

The way in which the outcomes or impacts in each of these areas emerge and subsequently play out in the lives of victims and survivors constitutes a complex and dynamic process. The outcomes in these areas have been shown to interact with, cause, compound or (in some cases) help to mitigate outcomes in other areas. Outcomes can occur, or recur, at any stage of the victim and survivor’s life course.

Simply because victims and survivors are not experiencing a particular outcome at one point in their lives does not mean they will not experience it at a later stage.

Victims and survivors are not a homogeneous group, and as a result the nature and extent of the consequences of CSA can differ significantly between groups of victims and survivors – and indeed between individual victims and survivors. Indeed, the evidence suggests that it is not inevitable that a victim and survivor will experience significant long-term harm as a result of CSA. Some victims and survivors are said to display resilience or to achieve recovery following CSA if they either appear to experience no major adverse consequences, or else find their way back to ‘adaptive’ or ‘positive’ functioning after a period of difficulty (which might last several years or even decades). Some studies suggest that a minority of victims and survivors even appear to display post-traumatic growth or positive adaptation following CSA victimisation.

The outcomes experienced by victims and survivors across these seven areas are explored in more depth below.

Physical health

Experiencing CSA has been associated with a wide range of adverse physical health outcomes. Acute physical injuries to the genital area can result from penetrative abuse, as can sexually transmitted infections.[4] In the longer term, CSA has been linked to a range of illnesses and disabilities: in one study, one CSA victim and survivor in four reported a long-standing illness or disability, compared with one in five of the general population.[5]

Physical health outcomes include increased body mass index (BMI),[6] heart problems[7] and issues surrounding childbirth.[8] Research suggests that people with a history of CSA have a greater number of doctor and hospital contacts – 20 per cent higher than those who have not experienced CSA[9] – which can be an indicator of poor physical health. Some victims and survivors report ‘medically unexplained’ symptoms, which can include non-epileptic seizures[10] and chronic pain.[11]

Emotional wellbeing, mental health and internalising behaviours

The experience of CSA can have a detrimental effect on general emotional wellbeing, leading to low self- esteem and loss of confidence.[12] Mental health outcomes/internalising behaviours include depression, anxiety disorders, post-traumatic stress disorder (PTSD), self-harm and suicide, as well as a range of other mental health conditions.[13]

Depression has been found in 57 per cent of young people who have experienced CSE.[14] The increased likelihood of major depression following a history of CSA has been shown to be 2.05[15] in young adults and 1.83[16] in women victims and survivors, relative to comparison groups. Among victims and survivors of CSE, 37 per cent had generalised anxiety disorder, 58 per cent had separation anxiety disorder, and 73 per cent had PTSD.[17] Rates of self-harm have been shown to be as high as 49 per cent among adult survivors in treatment[18] and 32 per cent among victims and survivors of CSE.[19] The risk of CSA victims and survivors attempting suicide can be as much as six times greater than in the general population.[20]

There are some gender differences noted in the prevalence of mental health conditions. In particular, it has been argued that females are more likely to demonstrate internalising behaviours and males are more likely to demonstrate externalising behaviours.[21] The quality of interpersonal relationships has been shown to be instrumental in mitigating or compounding the impacts of CSA on mental health conditions.[22]

Externalising behaviours

Victims and survivors of CSA may exhibit a range of externalising behaviours in response to the abuse they have experienced. These are often maladaptive coping strategies, adopted as a way of dealing with or gaining temporary relief from the distress of the abuse, including distress caused by other outcomes (such as mental health problems).[23]

Behaviours exhibited following CSA can vary depending on the age and gender of the victim and survivor.[24] However, limited evidence was found on younger children’s behaviour; most research has focused on behaviour in adolescence and adulthood, often illustrating how behaviours in adolescence can persist into adulthood.[25]

Research suggests that CSA is associated with an increased risk of externalising behaviours, including substance misuse, inappropriate or ‘risky’ sexual behaviours, anti-social behaviour and offending.[26] Additionally, one study found that young victims and survivors are up to 12 times more likely than comparison groups to report conduct disorder.[27]

Victims and survivors have been found to be 1.4 times more likely to have contact with the police, and almost five times more likely to be charged with a criminal offence, than those who have not experienced CSA.[28]

Externalising behaviours can serve as an indicator of CSA, and as a means of communicating that something is wrong and signalling a need for help.[29] Supportive family relationships and increased levels of education among victims and survivors have been found to reduce the risk of these maladaptive behaviours.[30]

Interpersonal relationships

CSA can have a profound effect on victims and survivors’ ability to form and/or maintain positive relationships. Only 17 per cent of CSA survivors are said to have a secure attachment style,[31] important for forming strong emotional connections, behaviours and interactions between people.

One of the most prominent themes to emerge in this section relates to the impacts of CSA on intimate relationships. Victims and survivors are at increased risk of experiencing issues such as poor relationship stability, interpersonal violence and sexual dysfunction.[32] Health and behavioural impacts can also negatively affect intimate relationships.[33]

In relation to parent–child relationships, the evidence suggests that having children can have a positive influence on victims and survivors and can even help to aid recovery.[34] However, the role of parenthood can also activate a range of emotions and initiate particular parenting practices which can ultimately harm the parent–child relationship. Negative parenting outcomes can also manifest as a result of victims and survivors’ internal lack of belief or confidence in their own parenting capability.[35] These can be compounded if individuals also suffer from depression.[36]

A clear gender bias can be observed in the literature relating to interpersonal – and particularly parent–child – relationships. For example, studies looking at the risks associated with ‘negative’ parenting practices of CSA victims and survivors tend to focus on mothers.[37]

Socioeconomic outcomes

There is evidence of an enduring association between CSA and reduced life chances that begins during the school years and extends well into adulthood, affecting victims and survivors’ educational attainment, employment rates and income levels.

CSA has been associated with an overall reduction in educational engagement and attainment at school and in higher/further education.[38] In some individual cases, however, it has also been linked to increased attainment.[39] In these cases, educational engagement appears to function as a coping strategy for dealing with – or escaping mentally and physically from – the abuse.

CSA has also been associated with increased unemployment/time out of the labour market,[40] increased receipt of welfare benefits,[41] reduced incomes[42] and greater financial instability.[43] The evidence suggests that poor physical or mental health could be the link between CSA and lower socioeconomic outcomes in many cases.[44] As with education, it is important to recognise that some victims and survivors use work and career achievement, or ‘overwork’, as a means of coping with the after-effects of abuse, including psychological impacts such as low self-esteem.[45]

Recent studies which have explored the links between CSA and homelessness are limited in quantity and quality. Those that do exist point to possible links between CSA victimisation and homelessness/housing issues during both youth[46] and adulthood,[47] suggesting that this issue warrants further research.

Religious and spiritual belief

The evidence suggests that feelings of disillusionment with religion and spiritual belief are common among victims and survivors following CSA, with victims reporting feeling abandoned or punished by a cruel god.[48]

Studies on the impacts of CSA perpetrated by church clergy talk in particularly strong terms about the “spiritual devastation” and “deep spiritual confusion” which can result when the abuse is perpetrated by someone who is a representative of God in the eyes of the victim – an experience which can cause victims and survivors to question their entire belief systems and ways of understanding the world.[49] The literature suggests that these impacts can be compounded by church responses, which minimise or deny the CSA, or require victims and survivors to forgive the perpetrators of the abuse.[50]

To a lesser extent, the role of faith as a coping mechanism and protective factor for resilience and recovery also emerged from the studies reviewed.[51]

Vulnerability to revictimisation

The evidence shows that victims and survivors of CSA can be vulnerable to subsequent revictimisation, and may be two to four times more likely to be revictimised compared with the likelihood of those who have not experienced CSA becoming victims for the first time.[52] Health and behavioural outcomes of CSA have been found to increase victims and survivors’ vulnerability to revictimisation (for example, PTSD and feelings of self-blame).[53]

Revictimisation can take a range of forms and is not limited to sexual victimisation. For example, victims and survivors of CSA have been found to be twice as likely as those without experience of CSA to be physically abused during adolescence or early adulthood.[54]

The research suggests a complex relationship between initial and subsequent victimisation, and some research suggests that the revictimisation of CSA victims and survivors should be understood as a perpetuating condition, rather than in terms of isolated or episodic incidents.[55]

Outcomes by life stage and gender

While the studies reviewed suggest that there is significant variation in outcomes and impacts at both the sub-group and the individual victim and survivor level, it is challenging to draw conclusions from the current evidence base about how these outcomes differ by demographic and other characteristics. The research findings reviewed only enable tentative conclusions to be drawn about differences according to victim and survivor life stage and gender.

Following a developmental approach, the evidence suggests that certain outcomes are only relevant for – or may emerge during – particular life stages. For example, physical injuries resulting from CSA,[56] early onset of puberty,[57] conduct disorders,[58] sexually inappropriate behaviours[59] and low educational attainment[60] are more salient for victims and survivors during childhood and adolescence, while longer- term chronic physical health conditions,[61] challenges in relation to emotional and sexual intimacy and interpersonal relationships,[62] and employment issues[63] tend to affect victims and survivors in adulthood. Various outcomes, such as mental health conditions, including PTSD and anxiety[64] and an increased vulnerability to sexual revictimisation,[65] have been found to cut across life stages.

Where evidence of an association between CSA and an outcome at a particular life stage is lacking, it is not necessarily proof that an individual is not at increased risk of that outcome during the life stage in question. Instead, studies exploring this issue may simply not yet have been undertaken.

Differences in outcomes by victim and survivor gender can also be identified in the research reviewed, although in some cases study findings are contradictory, and the lack of specific evidence on male victims and survivors makes it hard to draw robust conclusions. Outcomes that the evidence suggests differ along gender lines include those relating to mental health conditions,[66] internalising and externalising behaviours,[67] offending,[68] intimate relationships and sexuality,[69] and pregnancy and childbirth.[70]

Resilience and recovery: risk and protective factors and triggers

The concepts of resilience and recovery are used to describe how victims and survivors can maintain or recover a healthy level of functioning following CSA.[71] Resilient individuals are said to sustain relatively healthy levels of functioning after exposure to a potentially traumatic event. Recovery, on the other hand, is characterised by a significant decline in wellbeing in the immediate aftermath of the traumatic events; this decline may last several months, years or even decades. Subsequently, there is a gradual improvement in functioning and a reduction in symptoms, until the individual achieves a level of functioning and wellbeing which is more or less equivalent to that which they experienced before the trauma. Both resilience and recovery are thought to be dynamic rather than static states, and to be influenced by an individual’s interaction with the social environment.[72]

A number of risk/protective factors have been identified which may increase or reduce the likelihood of a victim and survivor experiencing resilience or recovery following CSA. Risk and protective factors include:

  • characteristics of the individual victim and survivor (for example, emotions, beliefs and attitudes)[73]
  • circumstances of the abuse (for example, identity of the perpetrator, age at onset)[74]
  • the victim and survivor’s interpersonal relationships and immediate environment (for example, attitudes of caregivers,[75] partners and peers;[76] experiences of parenthood[77])
  • the victim and survivor’s wider social and environmental context (for example, experiences of disclosure to professionals,[78] experiences of other services, such as education[79] and healthcare[80])

In addition to these longer-term risk and protective factors, certain shorter-term situations, events or sensations can (re)trigger the trauma associated with the CSA for victims and survivors. These situations can cause distressing emotions and traumatic memories to resurface, and can lead to victims and survivors feeling as though they are back in the abusive situation, thereby disrupting resilience and recovery.[81]

Common features of triggering situations identified in the literature include:

  • physical or sexual contact
  • feeling powerless or vulnerable
  • having to talk about or recount abusive experiences
  • sights, sounds or smells which remind victims and survivors of the CSA

Specific triggering situations include medical and dental examinations[82]; childbirth[83]; coming into contact with the perpetrator following abuse[84]; therapy[85]; sexual activity[86]; going through legal proceedings relating to the CSA[87]; their own child experiencing CSA[88]; and needing to seek emotional support.[89]

In particular, the experience of childbirth has been found to be deeply traumatic for some female victims and survivors.[90] While they are at increased risk of dissociation and perinatal mental health issues, sensitive and caring practice by medical professionals can help to reduce the risks of these outcomes occurring.[91]

The role of wider society

The response of society to victims and survivors of CSA can impact on their resilience and recovery in a variety of ways, for example by maximising protective factors or (re)triggering traumatic experiences. Although this review was not designed to produce an exhaustive list, it has identified a number of ways in which society might be helping or hindering resilience and recovery within this group.

Unsupportive responses by caregivers or professionals to a disclosure of CSA may exacerbate victims and survivors’ feelings of guilt and shame, and may deter them from seeking support in the future.[92] Supportive responses to disclosure,[93] and supportive relationships,[94] have been found to be significant factors in promoting recovery.

The research suggests that specialist support services following CSA are likely to be most effective if they are tailored to the needs of particular sub-groups of victims and survivors,[95] and are based on an assessment of the individual’s needs.[96] Studies have found that the availability of specialist services for children and young people falls short of the demand.[97] Inappropriate responses by services can compound the impacts of CSA and place victims and survivors at greater risk.[98]

Wider services including health,[99] social services and the criminal justice system,[100] and domestic violence and substance misuse services,[101] can support patients or service users with a history of CSA by delivering sensitive practice that accommodates individuals’ needs and avoids triggering trauma.

Participation in the criminal justice process can be a risk factor for experiencing harm following CSA,[102] although sensitive practice by professionals can help to mitigate these impacts.[103] Fear of blame and retraumatisation can discourage victims and survivors from seeking accountability and reparations for CSA.[104] There has been a recent international trend towards legislative and policy changes that aim to improve victims and survivors’ access to justice.[105]

References

Footnotes

  1. In other words the initial months and years following the onset of abuse.
  2. One In Four (2015) Survivors’ voices: breaking the silence on living with the impact of child sexual abuse in the family environment, p.16
  3. Ibid., p.24
  4. Heger, A., Ticson, L., Velasquez, O., and Bernier, R. (2002) Children referred for possible sexual abuse: medical findings in 2,384 children. Child Abuse and Neglect, 26, pp.645-659
  5. Allnock, D., Hynes, P., and Archibald, M. (2015) Self-reported experiences of therapy following child sexual abuse: messages from a retrospective survey of adult survivors. Journal of Social Work, 15(2), pp.115-137
  6. Trickett, P. K., Noll, J. G., and Putnam, F. W. (2011) The impact of sexual abuse on female development: Lessons from a multigenerational, longitudinal research study. Development and Psychopathology, 23 (2), pp.453-476; McCarthy-Jones, S., and McCarthy-Jones, R. (2014) Body mass index and anxiety/depression as mediators of the effects of child sexual and physical abuse on physical health disorders in women. Child Abuse & Neglect, 38(12), pp.2007-2020; Havig, K. (2008) The health care experiences of adult survivors of child sexual abuse: A systematic review of evidence on sensitive practice. Trauma, Violence, & Abuse, 9(1), pp.19-33; Mamun, A. A., Lawlor, D. A., O’Callaghan, M. J., Bor, W., Williams, G. M., and Najman, J. M. (2007) Does childhood sexual abuse predict young adult’s BMI? A birth cohort study. Obesity, 15(8), pp.2103- 2110; Richardson, A. S., Dietz, W. H., and Gordon-Larsen, P. (2014) The association between childhood sexual and physical abuse with incident adult severe obesity across 13 years of the National Longitudinal Study of Adolescent Health. Pediatric Obesity, 9(5), pp.351-361
  7. Kamiya, Y., Timonen, V., and Kenny, R. A. (2016) The impact of childhood sexual abuse on the mental and physical health, and healthcare utilization of older adults. International Psychogeriatrics, 28(3), pp. 415-422; Allnock et al. (2015), op. cit.; McCarthy-Jones and McCarthy-Jones (2014), op. cit.
  8. Trickett et al. (2011), op. cit.; Wosu, A. C., Gelaye, B., and Williams, M. A. (2015) Maternal history of childhood sexual abuse and preterm birth: an epidemiologic review. BMC Pregnancy and Childbirth, 15; Hooper, C.-A., and Warwick, I. (2006) Gender and the politics of service provision for adults with a history of childhood sexual abuse. Critical Social Policy, 26(2), pp.467-479; Leeners, B., Gorres, G., Block, E., and Hengartner, M. P. (2016) Birth experiences in adult women with a history of childhood sexual abuse. Journal of Psychosomatic Research, 83, pp.27-32
  9. Kamiya et al. (2016), op. cit.
  10. Nelson, S., Baldwin, N., and Taylor, J. (2012) Mental Health Problems and Medically Unexplained Physical Symptoms in Adult Survivors of Childhood Sexual Abuse: An integrative literature review. Journal of Psychiatric and Mental Health Nursing, 19(3), pp.211-220; Chen, L. P., Murad, M. H., Paras, M. L., Colbenson, K. M., Sattler, A. L., Goranson, E. N., Elamin, M. B., Seime, R. J., Shinozaki, G., Prokop, L. J., and Zirakzadeh, A. (2010) Sexual Abuse and Lifetime Diagnosis of Psychiatric Disorders: Systematic Review and Meta-analysis. Mayo Clinic Proceedings, 85(7), pp.618-629; Maniglio, R. (2009) The impact of child sexual abuse on health: A systematic review of reviews. Clinical Psychology Review, 29(7), pp. 647-657; Sharpe, D., and Faye, C. (2006) Non-epileptic seizures and child sexual abuse: A critical review of the literature. Clinical Psychology Review, 26 (8), pp.1020-1040
  11. Kamiya et al. (2016), op. cit.; Chen et al. (2010), op. cit.
  12. One in Four (2015), op. cit.; Nelson (2009), op. cit.
  13. Maniglio (2009), op. cit.
  14. Health Working Group on Child Sexual Exploitation (2014) Health Working Group Report on Child Sexual Exploitation
  15. Mills, R., Kisely, S., Alati, R., Strathearn, L., and Najman, J. (2016) Self-reported and agency-notified child sexual abuse in a population-based birth cohort. Journal of Psychiatric Research, 74, pp.87-93
  16. Kendler, K. S., and Aggen, S. H. (2014) Clarifying the causal relationship in women between childhood sexual abuse and lifetime major depression. Psychological Medicine, 44(6), pp.1213-1221
  17. Health Working Group on Child Sexual Exploitation (2014), op. cit.
  18. Bolen, R. M., Winter, V. R., and Hodges, L. (2013) Affect and State Dysregulation as Moderators of the Relationship Between Childhood Sexual Abuse and Non-suicidal Self-injury. Journal of Interpersonal Violence, 28(1), pp.201-228
  19. Health Working Group on Child Sexual Exploitation (2014), op. cit.
  20. McCarthy-Jones and McCarthy-Jones (2014), op. cit.; Tomasula, J. L., Anderson, L. M., Littleton, H. L., and Riley-Tillman, T. C. (2012) The association between sexual assault and suicidal activity in a national sample. School Psychology Quarterly, 27(2), pp.109-119
  21. Hooper and Warwick (2006), op. cit. citing Lisak, 1995; Finkelhor et al., 1990; Lisak, 1994; Durham, 2003; van Toledo, A., and Seymour, F. (2013) Interventions for caregivers of children who disclose sexual abuse: A review. Clinical Psychology Review, 33(6), pp.772-781 citing Baker & Duncan, 1985; Fergusson et al., 2000
  22. Knott, T. (2014) Maternal Response to the Disclosure of Child Sexual Abuse: Systematic Review and Critical Analysis of the Literature. Issues in Child Abuse Accusations, 20(1), pp.1-6; Parent-Boursier, C., and Herbert, M. (2015) Security in Father-child Relationship and Behavior Problems in Sexually Abused Children. Journal of Family Violence, 30(1), pp.113-122; Canton-Cortes, D., Cortes, M. R., and Canton, J. (2015) Child sexual abuse, attachment style, and depression: the role of the characteristics of abuse. Journal of Interpersonal Violence, 30(3), pp.420-436
  23. Nelson, S. (2009) Care and Support Needs of Men who Survived Childhood Sexual Abuse: Report of a qualitative research project. The University of Edinburgh: Edinburgh; O’Riordan, M., and Arensman, E. (2007) Institutional child sexual abuse and suicidal behaviour: outcomes of a literature review, consultation meetings and a qualitative study. National Suicide Research Foundation; Sneddon, H., Wager, N., and Allnock, D. (2016) Responding sensitively to survivors of child sexual abuse: an evidence review. Victim Support; Chouliara, Z., Karatzias, T., and Gullone, A. (2014) Recovering from childhood sexual abuse: a theoretical framework for practice and research. Journal of Psychiatric and Mental Health Nursing, 21(1), pp.69-78
  24. See for example Nelson (2009), op. cit.
  25. See for example Lown, E. A., Nayak, M. B., Korcha, R. A., and Greenfield, T. K. (2011) Child Physical and Sexual Abuse: A Comprehensive Look at Alcohol Consumption Patterns, Consequences, and Dependence From the National Alcohol Survey. Alcoholism - Clinical and Experimental Research, 35(2), pp.317-325; Nelson (2009), op. cit.; One in Four (2015), op. cit.
  26. Nelson (2009), op. cit.; One in Four (2015), op. cit.; Maniglio (2009), op. cit.
  27. Maniglio, R. (2015) Significance, nature, and direction of the association between child sexual abuse and conduct disorder: A systematic review. Trauma, Violence, & Abuse, 16(3) pp.241-257
  28. Ogloff, J. R. P., Cutajar, M. C., Mann, E., and Mullen, P. (2012) Child sexual abuse and subsequent offending and victimisation: A 45 year follow-up study. Trends & issues in crime and criminal justice No. 440. Australian Institute of Criminology
  29. See for example Nelson (2009), op. cit.; One in Four (2015), op. cit.; Warrington, C., Beckett, H., Ackerley, E., Walker, M., and Allnock, D. (2017) Making noise: Children’s voices for positive change after sexual abuse. Children’s Commissioner for England
  30. Bick, J., Zajac, K., Ralston, M. E., and Smith, D. (2014) Convergence and divergence in reports of maternal support following childhood sexual abuse: Prevalence and associations with youth psychosocial adjustment. Child Abuse & Neglect, 38(3), pp.479-487; Draucker, C. B., and Mazurczyk, J. (2013) Relationships between childhood sexual abuse and substance use and sexual risk behaviors during adolescence: An integrative review. Nursing Outlook, 61(5), pp.291-310; Young, M. D., Deardorff, J., Ozer, E., and Lahiff, M. (2011) Sexual Abuse in Childhood and Adolescence and the Risk of Early Pregnancy Among Women Ages 18-22. Journal of Adolescent Health, 49, pp.287-293
  31. Fitzpatrick, M., Carr, A., Dooley, B., Flanagan-Howard, R., Flanagan, E., Tierney, K., White, M., Daly, M., Shevlin, M., and Egan, J. (2010) Profiles of adult survivors of severe sexual, physical and emotional institutional abuse in Ireland. Child Abuse Review, 19(6), pp.387-404; Sprober, N., Schneider, T., Rassenhofer, M., Seitz, A., Liebhardt, H., Konig, L., and Fegert, J. M. (2014) Child sexual abuse in religiously affiliated and secular institutions: a retrospective descriptive analysis of data provided by victims in a government-sponsored reappraisal program in Germany. BMC Public Health, 14; see also Bowlby, J. (1958) The nature of the child’s tie to his mother. International Journal of Psycho-Analysts, 39(5), pp.350-73
  32. Cashmore, J., and Shackel, R. (2014) Gender Differences in the Context and Consequences of Child Sexual Abuse. Current Issues in Criminal Justice, 26(1), pp.75-104; Friesen, M. D., Woodward, L. J., Horwood, L. J., and Fergusson, D. M. (2010) Childhood exposure to sexual abuse and partnership outcomes at age 30. Psychological Medicine, 40(4), pp.679-688; Grossman, F. K., Sorsoli, L., and Kia-Keating, M. (2006) A gale force wind: Meaning making by male survivors of childhood sexual abuse. American Journal of Orthopsychiatry, 76(4), pp.434-443; Havig (2008), op. cit.; Hunter, S. V. (2009) Beyond Surviving Gender Differences in Response to Early Sexual Experiences With Adults. Journal of Family Issues, 30(3), pp.391- 412; Kia-Keating, M., Sorsoli, L., and Grossman, F. K. (2010) Relational Challenges and Recovery Processes in Male Survivors of Childhood Sexual Abuse. Journal of Interpersonal Violence, 25(4), pp.666-683; Kristensen, E., and Lau, M. (2011) Sexual function in women with a history of intrafamilial childhood sexual abuse. Sexual and Relationship Therapy, 26(3), pp.229- 241; Liang, B., Williams, L. M., and Siegel, J. A. (2006) Relational outcomes of childhood sexual trauma in female survivors: a longitudinal study. Journal of Interpersonal Violence, 21(1), pp.42-57; Nelson (2009), op. cit.; Sneddon et al. (2016), op. cit.; Wilson, H. W., and Widom, C. S. (2010) Does physical abuse, sexual abuse, or neglect in childhood increase the likelihood of same-sex sexual relationships and cohabitation? A prospective 30-year follow-up. Archives of Sexual Behavior, 39(1), pp.63- 74; Senn et al. (2012), op. cit.; One in Four (2015), op. cit.; Wilson et al. (2010), op. cit.
  33. See for example Friesen et al. (2010), op. cit.; Liang et al. (2006), op. cit.; Nelson (2009), op. cit.; Hunter (2009), op. cit.; Kia-Keating et al. (2010), op. cit.; Senn, T. E., Carey, M. P., and Coury-Doniger, P. (2012) Mediators of the relation between childhood sexual abuse and women’s sexual risk behavior: A comparison of two theoretical frameworks. Archives of Sexual Behavior, 41(6), pp.1363-1377; One in Four (2015), op. cit.; Kristensen and Lau (2011), op. cit.
  34. Sneddon et al. (2016), op. cit.; Nelson (2009), op. cit.; Price-Robertson, R. (2012) Child sexual abuse, masculinity and fatherhood. Journal of Family Studies, 18(2), pp.130-142; Seltmann, L., and Wright, M. (2013) Perceived Parenting Competencies following Childhood Sexual Abuse: A Moderated Mediation Analysis. Journal of Family Violence, 28(6), pp.611-621
  35. One in Four (2015), op. cit.; Allbaugh, L. J., Wright, M. O. D., and Seltmann, L. A. (2014) An Exploratory Study of Domains of Parenting Concern among Mothers Who Are Childhood Sexual Abuse Survivors. Journal of Child Sexual Abuse 23(8), pp.885-899; Sneddon et al. (2016), op. cit.; Pazdera, A. L., McWey, L. M., Mullis, A., and Carbonell, J. (2013) Child Sexual Abuse and the Superfluous Association with Negative Parenting Outcomes: The Role of Symptoms as Predictors. Journal of Marital and Family Therapy. 39 (1), pp.98-111; Quadara, A., Stathopoulos, M., and Carson, R. (2016) Family Relationships and the Disclosure of Institutional Child Sexual Abuse. Australian Institute of Family Studies. Royal Commission into Institutional Responses to Child Sexual Abuse, Australia
  36. Allbaugh et al. (2014), op. cit.; Baril, K., Tourigny, M., Paillé, P., and Pauzé, R. (2016) Characteristics of sexually abused children and their non-offending mothers followed by child welfare services: the role of a maternal history of child sexual abuse. Journal of Child Sexual Abuse, 25(5), pp.504-523; Pazdera et al. (2013), op. cit.; Cross, D., Kim, Y. J., Vance, L. A., Robinson, G., Jovanovic, T., and Bradley, B. (2016) Maternal child sexual abuse is associated with lower maternal warmth toward daughters but not sons. Journal of Child Sexual Abuse, 25(8), pp.813-826; Seltmann and Wright (2013), op. cit.; Mapp, S. C. (2006) The effects of sexual abuse as a child on the risk of mothers physically abusing their children: A path analysis using systems theory. Child Abuse & Neglect, 30(11), pp.1293-1310
  37. Testa, M., Hoffman, J. H., and Livingston, J. A. (2011) Intergenerational transmission of sexual victimization vulnerability as mediated via parenting. Child Abuse and Neglect, 35(5), pp.363-371; Cross et al. (2016), op. cit.; Kim, K., Trickett, P. K., and Putnam, F. W. (2010) Childhood experiences of sexual abuse and later parenting practices among non-offending mothers of sexually abused and comparison girls. Child Abuse & Neglect, 34(8), pp.610-622; Pazdera et al. (2013), op. cit.; Mapp (2006), op. cit.
  38. Zeglin, R. J., DeRaedt, M. R., and Lanthier, R. P. (2015) Does having children moderate the effect of child sexual abuse on depression? Journal of Child Sexual Abuse: Research, Treatment, & Program Innovations for Victims, Survivors, & Offenders, 24 (6), pp. 607-626; Trickett et al. (2011), op. cit.; Boden, J. M., Horwood, J., and Fergusson, D. M. (2007) Exposure to childhood sexual and physical abuse and subsequent educational achievement outcomes. Child Abuse and Neglect, 31(10), pp.1101- 1114; Fergusson, D. M., McLeod, G. F. H., and Horwood, L. J. (2013) Childhood sexual abuse and adult developmental outcomes: Findings from a 30-year longitudinal study in New Zealand. Child Abuse and Neglect, 37 (9), pp.664-674; Pereira, P., Li, L., Power, C. (2017) Child maltreatment and adult living standards at 50 years. Pediatrics, 139(1)
  39. Nelson (2009), op. cit.
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