Victorian Institute of Forensic Mental Health, Department of Psychological Medicine, Monash University
Mental Health Research Institute of Victoria
Department of Forensic Medicine, Monash University, Victorian Institute of Forensic Medicine
Department of Psychology, Monash University, Victoria, Australia
Correspondence: Professor Paul E. Mullen, Thomas Embling Hospital, Locked Bag 10, Fairfield, Victoria 3078, Australia. E-mail: paul.mullen{at}forensicare.vic.gov.au
Declaration of interest J.S. received an Australian Postgraduate Award. Additional funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To examine the association between child sexual abuse in both boys and girls and subsequent treatment for mental disorder using a prospective cohort design.
Method Children (n=1612; 1327 female) ascertained as sexually abused at the time had their histories of mental health treatment established by data linkage and compared with the general population of the same age over a specified period.
Results Both male and female victims of abuse had significantly higher rates of psychiatric treatment during the study period than general population controls (12.4% v. 3.6%). Rates were higher for childhood mental disorders, personality disorders, anxiety disorders and major affective disorders, but not for schizophrenia. Male victims were significantly more likely to have had treatment than females (22.8% v.10.2%).
Conclusions This prospective study demonstrates an association between child sexual abuse validated at the time and a subsequent increase in rates of childhood and adult mental disorders.
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INTRODUCTION |
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METHOD |
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Data linkage
The child sexual abuse cohort was linked with cases registered on the
Victorian Psychiatric Case Register. The Register was established in 1961 and
has been described as one of the worlds largest psychiatric databases
(Eaton et al, 1992).
The register records all contacts with public in-patient and community mental
health services and currently contains over 500 000 names. The register does
not include admissions to beds in the private health sector (approximately 6%
of total beds) or outpatient contacts with private providers such as general
practitioners and mental health professionals in private practice. The
register varies in how adequately it captures different types of mental
disorder. The vast majority of those with schizophrenia, or other forms of
psychotic disorder, will have contact with public mental health services and
appear on the register. Conversely, in affective disorders, only a selected
sample of the predominantly more severe cases will be referred to public
mental health services and appear on the register.
The case linkage was performed via the implementation of a computer-matching algorithm that extracted potential matches from the child sexual abuse cohort and the Victorian Psychiatric Case Register based on full name and date of birth. This algorithm has been checked against 200 manually rated matches, showing better than 90% agreement, and two independent raters favoured the algorithms solutions in every disputed match. Complete psychiatric record details for the matches were then extracted from the Register.
A diagnostic hierarchy was implemented to specify a single diagnosis for cases where multiple diagnoses were recorded. This was to ensure that cases were counted only once. Comorbidity tends to be the rule rather than the exception but is difficult to accommodate within this methodology. The diagnostic categories in order of precedence were: schizophrenic disorders; major affective disorders; organic disorders; other affective and somatoform disorders; anxiety disorders and acute stress reactions; childhood mental disorders; personality disorders; conduct disorders; and alcohol and drug-related disorders. A significant minority of cases had no diagnosis recorded on the register. These cases were largely related to single, or brief, contacts with services, often in the context of a crisis or an emergency department consultation.
General population controls
To ensure valid comparisons, the control population employed was restricted
to the same age range as cases (1 January 19501 July 1991). To ensure
further comparability, the period over which contacts with services were to be
examined was restricted to the same specific time period for the two groups (1
July 199130 June 2000).
Australian Bureau of Statistics population data were obtained for the 9-year follow-up period (19912000) and the estimated resident population of the State of Victoria at 30 June each year for males and females was obtained for this period. The population data by age bands were comparable to the increasing age range of the child sexual abuse cohort in each of the 9 years of follow-up. A growth factor was then calculated for each year and added to the final year population to obtain a single figure for the total estimated resident population in Victoria. The general population estimate was reduced by the number of victims of child sexual abuse, and the control population on the Victorian Psychiatric Case Register by the number of cases of child sexual abuse on the Register.
Ethical issues
Ethical approval was granted by three independent bodies: the Monash
University Standing Committee of Ethics in Research on Humans and the ethics
committees of the Department of Human Services and the Victorian Institute of
Forensic Medicine.
Statistical methods
Data analysis was undertaken predominantly using the Statistical Package
for the Social Sciences version 10, for Windows. The extent to which
continuous variables differed between two groups was analysed using
t-tests. Chi-squared analyses were conducted to determine whether or
not the distinction of some categorical variable varied as a function of
another categorical variable. Chi-squared goodness-of-fit tests were conducted
to examine gender differences in the predicted and observed frequencies of
diagnoses and differences between the child sexual abuse cohort and the
comparative samples for each diagnosis. The STATA Release 6 for Windows
program was used to obtain relative risks, confidence intervals and P
values of the child sexual abuse cohort receiving public mental health
treatment and having each of the diagnoses under investigation during the
specified 9-year follow-up period. For all analyses the significance level was
set at P=0.05.
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RESULTS |
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The estimated population in Victoria born between 1 January 1950 and 1 July 1991 was 3 139 745, with males accounting for 1 566 972 and females 1 572 773. The age distribution between cases and controls differed, with controls having a significantly higher mean age for both males and females.
Associations between child sexual abuse and mental disorder
A record of contact with the public mental health services was found in
12.4% (135 females and 65 males) of cases between 1 July 1991 and 30 June
2000. There were no significant differences between the age at which the abuse
was reported between the 200 individuals found on the Victorian Psychiatric
Case Register and those not on the Register. Over the same time period,
significantly fewer of the comparison population (3.6%) recorded a contact
(relative risk=3.8, 95% CI 3.34.4, P<0.001)
(Table 1). The rates of contact
relative to the control population were significantly greater for both males
(relative risk=7.2, 95% CI 5.59.6, P<0.001) and females
(relative risk=3.3, 95% CI 2.83.9, P<0.001)
(Table 2). Major affective
disorders were found more frequently among cases. The anxiety and acute stress
disorders were even more strongly associated with child sexual abuse than the
major affective disorders, although of the adult diagnostic groupings it was
the personality disorders that had the highest relative risk
(Table 1). Among the childhood
disorders, conduct disorder was associated with child sexual abuse, as was the
broader grouping of the other childhood disorders. Those who had contact with
the services but never had a diagnosis recorded were significantly more common
among cases of child sexual abuse. The rates of schizophrenic disorders,
alcohol- and drug-related disorders and other affective and somatoform
disorders did not differ significantly from the general population controls
(Table 1). When male cases were
compared with male population controls, anxiety disorders, personality
disorders, organic disorders, childhood mental disorders and conduct disorders
remained significantly higher among cases of child sexual abuse but major
affective disorders ceased to be significant. Female cases were significantly
more likely than their population controls to be found on the register for
major affective disorders, anxiety disorders, personality disorders, organic
disorders, childhood mental disorders and conduct disorders, but this was not
the case for other affective and somatoform disorders
(Table 2).
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Comparisons of the period of prevalence for psychiatric contacts in males and females
Male cases were significantly more likely than female cases to have had
contact with public mental health services (22.8% v. 10.2%,
2=12.13, P<0.001). In the category of childhood
disorders, males were overrepresented for both conduct disorders (1.8%
v. 0.2%,
2=13.87, P<0.001) and other
childhood mental disorders (5.6% v. 1.0%,
2=27.95,
P<0.001). No significant differences were found between male and
female cases for the rates of contact in adult life for specific diagnostic
groups such as schizophrenia (1.1% v. 0.8%) and major affective (0.7%
v. 1.1%), anxiety (2.8% v. 1.7%) and personality disorders
(1.1% v. 0.4%), but for the group without a recorded diagnosis the
male cases were more numerous (8.4% v. 4.1%,
2=8.72,
P=0.01).
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DISCUSSION |
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Limitations
This study has limitations. Those whose sexual abuse comes to official
notice at the time are a minority, possibly drawn from among the more severely
abused. The outcome measure employed was contact with the public mental health
services, which is an extreme indicator of psychopathology. Many people suffer
significant mental health problems without seeking professional help, or
confine their contact to general practitioners, counsellors or private
psychiatrists and psychologists.
The results of this study, therefore, do not give information on the absolute frequency of those seeking therapy for the total spectrum of mental disorders. What the study does quantify is the severe and disabling end of the psychopathology spectrum. That nearly four times as many of those in the child sexual abuse group had received treatment in public mental health services is a dramatic indicator of the association between abuse and mental disorder, with its implied impact on mental health services. In a sense, this study documents not the breadth but the depth of the psychiatric problems associated with child sexual abuse.
A systematic bias is introduced by the presence of people who were subjected to child sexual abuse in the general population, which will act to reduce or even obscure the differences between cases and controls. The children in the study cohort were predominantly subjected to abuse involving actual or attempted penetration. This gross form of abuse is sadly not a rarity in our community. Estimates of the prevalence of child sexual abuse involving penetration vary widely but a rate of 5% is a plausible approximation (Fergusson & Mullen, 1999; Andrews et al, 2002). Correcting for the bias that this introduces would not just be a matter of making a 5% adjustment. The preponderance of the evidence about child sexual abuse and adult mental disorder indicates that those who have experienced abuse involving penetration are overrepresented among some mental disorders (Fergusson & Mullen, 1999; Andrews et al, 2002). Taking major depression as an example where there is at least twice the risk in victims of child sexual abuse, this implies that at least 10% of those with major affective disorders among the control population will come from those with histories of penetrative abuse. This introduces a major bias against detecting increased associations with mental disorder among the child sexual abuse cohort.
A further systematic bias against detecting higher rates of disorder among those who have suffered child sexual abuse is introduced by comparing child sexual abuse cases established by data-matching with a control population, which is derived from relating all known cases on the register back to the known population base. Data-matching inevitably misses cases because of, for example, technical failures in the matching process, incorrect data entry and people changing their names or giving false names. The comparative data from controls, in contrast, involve no loss of data because the totality of cases is compared with the base population. Further, those in the child sexual abuse cohort who have moved state or country will not be recorded on the register even if they have had treatment in their new abode. In contrast, the control data are calculated from the population known to have been present in Victoria at the time. These various factors introduce powerful systematic biases against finding differences between cases and controls. Conversely, they increase confidence in those associations that do emerge.
Associations between child sexual abuse and mental disorders in adult life
The systematic biases noted in this study all decrease the probability of
finding a positive association between child sexual abuse and mental
disorders. Despite this, a nearly fourfold increase in contacts with the
mental health services was demonstrated, compared with the general population.
Significant increases were apparent for major affective disorders, anxiety
disorders, personality disorders and disorders of childhood.
The failure to demonstrate any association with alcohol- and drug-related disorders runs counter to much of the existing literature (Burnam et al, 1988; Fergusson & Mullen, 1999; Andrews et al, 2002). This could well reflect the influence of the biases discussed above, combined with the influence of our diagnostic hierarchy, which placed substance misuse at the bottom, thus potentially allocating many cases with substance use problems to their comorbid groupings.
There have been suggestions of a link between child sexual abuse and schizophrenia, a hypothesis that has claimed considerable public, if not professional, attention (Sansonnet-Hayden et al, 1987; Briere et al, 1997; Read & Argyle, 1999). The differences between cases and controls for schizophrenic disorders did not reach significance in this analysis and a discussion of trends is unlikely to be contributory. The findings to date do not support an association between child sexual abuse and schizophrenia. Care must be taken in interpreting this and other negative findings. The average age of our subjects was in the 20s, thus many have yet to pass the peak years for developing schizophrenia and related disorders. The control group in contrast are an older population and although restricting contacts to the years 19912000 controls this disparity to some extent, it by no means removes its potential influence.
Individuals in the child sexual abuse cohort had twice the rate of major affective disorders, which is consistent with the literature, although this literature is based almost exclusively on female victims (Bifulco et al, 1991; Fergusson & Mullen, 1999). Interestingly, in this study, an increased risk for major affective disorder was confined to female victims of abuse. This gender difference could reflect depressive disorders being more readily evoked by child sexual abuse in females (Horwitz et al, 2001).
An association was found between the category of organic disorder and child sexual abuse. Individuals with organic disorders were more likely to be registered on the Victorian Psychiatric Case Register prior to the abuse being reported, suggesting that these disorders were already present when these individuals were sexually abused. The most likely explanation for this is that children with intellectual and neurological impairments are more vulnerable to abuse. This finding highlights the need to protect children rendered vulnerable by such disabilities from sexual exploitation.
Anxiety disorders and acute stress reactions were the most frequently recorded diagnostic category among victims of child sexual abuse, being equally prominent in males and females. Included in this broad category of anxiety and stress disorders are post-traumatic stress disorders. Individuals in the child sexual abuse cohort were more than three times more likely to be diagnosed with an anxiety disorder or an acute stress reaction. Previous research has focused predominantly on females and these results extend those findings of a positive association to males.
Child sexual abuse and childhood mental disorders
Childhood mental disorders were significantly more common in the child
sexual abuse group with males having an even higher risk than females. The
general finding of increased rates of disorders in children was no surprise,
although the even greater excess of such cases in male subjects has not been
reported previously. Previous research has concentrated on girls where a wide
variety of emotional and behavioural problems, including depression, anxiety,
social withdrawal and somatic complaints, have been described among victims of
abuse (Mian et al,
1996). Given the damage that child sexual abuse can cause to a
childs self-concept, sense of trust and perception of the world as a
relatively safe place, irrespective of gender, it is reasonable to assume that
male victims will also experience childhood adjustment difficulties. Indeed,
the present investigation demonstrated that childhood mental disorders were
the second most frequently recorded diagnostic category on the Victorian
Psychiatric Case Register for both males and females in the child sexual abuse
cohort.
The present findings on conduct disorders accord with research that has consistently demonstrated higher levels of behavioural problems in sexually abused males compared with females (Darves-Bornoz et al, 1998; Horwitz et al, 2001). However, the present study also demonstrated that conduct disorders are significantly more likely in sexually abused females relative to their non-abused female counterparts. Conduct disorders are not exclusive to males and even the higher prevalence of this disorder in males may reflect more a willingness to recognise and refer conduct disorders in boys.
Child sexual abuse and personality disorders
Individuals in the child sexual abuse cohort had almost five times the rate
of a primary diagnosis of personality disorder. This finding is consistent
with existing research on child sexual abuse and personality disorders in
adulthood (Goldman et al,
1992; Weiler & Widom,
1996). Again, the increased vulnerability to personality disorders
was not gender specific. It is worth emphasising that the Australian public
mental health services, like those in the UK, are predominantly a psychosis
service and only the more extreme and disabling forms of personality disorder
tend to receive services. Another factor that may have affected the
ascertainment of personality disorder in this study was the frequency with
which such states are accompanied by depressive or anxiety disorders, which
took precedence when allocating to a diagnostic group.
Male and female differences in the association with abuse
Males and females in the child sexual abuse cohort were both significantly
more likely than their gender-matched controls to have had contact with public
mental health services. When, however, rates of contact were compared between
males and females who had been abused, the males were significantly more
likely to have had contact. This runs counter to the assumption often made in
the literature that female victims of child sexual abuse are more likely than
males to disclose their sexually abusive experiences and subsequently seek
treatment (Watkins & Bentovim,
1992). Counter at least to assumptions about treatment-seeking,
care should be taken not to overinterpret this finding. It may well be that
females are seeking help more frequently than males from the wide range of
mental health services outside of the public system. Possibly the male excess
in public mental health contacts relates to their failing to seek help until
the situation is so severe that admission or community treatment in the public
services is necessary. The excess of males seen in the public child
psychiatric services may also reflect a paucity of services for male as
opposed to female victims of child sexual abuse outside of the public
services. Certainly, in the early years of the period studied, the main
providers of such services outside of public child psychiatry were the Centres
Against Sexual Abuse, which tended to be more accessible to female clients.
This changed dramatically later in the 1990s as more open and informed
attitudes towards male victims of abuse pervaded these service providers.
Nevertheless, more males, particularly early in the 1990s, may have been
selectively re-routed to public services. Such a trend may also reflect the
high rates of conduct disorder among male victims, who may be more difficult
to manage in counselling and psychotherapeutically oriented services and
therefore more likely to gravitate to the public services as a last
resort.
Placing child sexual abuse in context
This study implemented a prospective cohort design to examine the long-term
associations between child sexual abuse and mental illness. No previous
investigation into child sexual abuse has prospectively examined such a large
sample of males and females subjected to abuse. The study lends powerful
support to there being an association between child sexual abuse and adverse
mental health outcomes and, more clearly than previous studies, demonstrates
that the negative mental health outcomes of abuse are remarkably similar for
males and females. The study confirms the increased rates of affective,
personality and childhood mental disorders, but gave no support to child
sexual abuse being associated with schizophrenic disorders in later life. A
greater utilisation of public mental health services among victims of child
sexual abuse is also documented.
Child sexual abuse has, for a number of years, occupied a privileged position relative not only to physical and emotional abuse but to the whole gamut of childhood adversity. This study further emphasises the associations specifically between child sexual abuse and adverse mental health outcomes. In our view, however, child sexual abuse often emerges from a nexus of adversity and its impact is mediated by a range of family, social, psychological and biological variables. The doubts about whether there are true associations between child sexual abuse and significant disturbances of mental health both in childhood and in adult life, which continue to be raised (Rind et al, 1998; Coid et al, 2003), can now be answered unequivocally in the affirmative. It is time to turn our attention to investigating those factors that mediate, and potentially ameliorate, the impact not only of sexual abuse but of the whole range of childhood adversities in order to be able to mitigate the damage that abuse and disadvantage inflicts on children.
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CLINICAL IMPLICATIONS |
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LIMITATIONS |
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ACKNOWLEDGMENTS |
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REFERENCES |
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Bifulco, A., Brown, G.W. & Adler, Z. (1991) Early sexual abuse and clinical depression in adult life. British Journal of Psychiatry, 159, 115 -122.[Abstract]
Briere, J., Woo, R., McRae, B., et al (1997) Lifetime victimisation history, demographics, and clinical status in female psychiatric emergency room patients. Journal of Nervous and Mental Disease, 185, 95 -101.[CrossRef][Medline]
Burnam, M. A., Stein, J. A., Golding, J. M., et al (1988) Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology, 56, 843 -850.[CrossRef][Medline]
Calam, R., Horne, L., Glasgow, D., et al (1998) Psychological disturbance and child sexual abuse: a follow-up study. Child Abuse and Neglect, 22, 901 -913.[CrossRef][Medline]
Cold, J., Petruckevitch, A., Chung, W. S., et al
(2003) Abusive experiences and psychiatric morbidity in women
primary care attenders. British Journal of Psychiatry,
183, 332
-339.
Darves-Bornoz, J. M., Choquet, M., Ledoux, S., et al (1998) Gender differences in symptoms of adolescents reporting sexual assault. Social Psychiatry and Psychiatric Epidemiology, 33, 111 -117.[CrossRef][Medline]
Dinwiddie, S., Heath, A. C., Dunne, M. P., et al (2000) Early sexual abuse and lifetime psychopathology: a co-twin control study. Psychological Medicine, 30, 41-52.[CrossRef][Medline]
Eaton, W.W., Mortensen, P. B., Herrman, H., et al (1992) Long-term hospitalization for schizophrenia: Part I. Risk for rehospitalization. Schizophrenia Bulletin, 18, 217 -228.[Medline]
Fergusson, D.M. & Mullen, P. E. (1999 Childhood Sexual Abuse: An Evidence-Based Perspective. Thousand Oaks, CA: Sage.
Fergusson, D. M., Lynskey, M. T. & Horwood, L. J. (1996) Childhood sexual abuse and psychiatric disorder in young adulthood: II. Psychiatric outcomes of childhood sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1365 -1374.
Goldman, S. J., DAngelo, E. J., DeMaso, D. R., et al (1992) Physical and sexual abuse histories among children with borderline personality disorders. American Journal of Psychiatry, 149, 1723 -1726.[Abstract]
Horwitz, A.V., Spatz Widom, C., McLaughlin, J., et al (2001) The impact of childhood abuse and neglect on adult mental health: a prospective study. Journal of Health and Social Behavior, 42, 184 -201.[Medline]
Kendler, K. S., Bulik, C. M., Silberg, J., et al
(2000) Childhood sexual abuse and adult psychiatric and
substance use disorders in women: an epidemiological and cotwin control
analysis. Archives of General Psychiatry,
57, 953
-959.
Mezey, G. C. & King, M. G. (1992) Male Victims of Assault. Oxford: Oxford University Press.
Mian, M., Marton, P. & LeBaron, D. (1996) The effects of sexual abuse on 3- to 5-year-old girls. Child Abuse and Neglect, 20, 731 -745.[CrossRef][Medline]
Mullen, P. E., Martin, J.L., Anderson, J.C., et al (1994) The effect of child sexual abuse on social, interpersonal and sexual function in adult life. British Journal of Psychiatry, 165, 35 -47.[Abstract]
Read, J. & Argyle, N. (1999)
Hallucinations, delusions, and thought disorder among adult psychiatric
inpatients with a history of child abuse. Psychiatric
Services, 50, 1467
-1472.
Rind, B., Tromovitch, P. & Bauserman, R. (1998) A meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychological Bulletin, 124, 22 -53.[CrossRef][Medline]
Sansonnet-Hayden, H., Haley, G., Marriage, K., et al (1987) Sexual abuse and psychopathology in hospitalized adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 753 -757.
Watkins, B. & Bentovim, A. (1992) The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology and Psychiatry and Allied Disciplines, 33, 197 -248.[Medline]
Weiler, B. L. & Widom, C. S. (1996) Psychopathy and violent behaviour in abused and neglected young adults. Criminal Behavior and Mental Health, 6, 253-271.
Received for publication June 2, 2003. Revision received December 8, 2003. Accepted for publication January 6, 2004.
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