Division of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK
See pp. 482494, this
issue.
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THE PERILS OF PREDICTION |
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The study is based on a sample of adults attending a forensic psychotherapy centre for treatment of sexual deviation and delinquency. Using mainly case note information, the authors estimate that 35% of the male child sex abusers in this sample were themselves victims of childhood sexual abuse compared with 11% of the males who had not abused children. The data are further analysed according to type of self-reported childhood abuse. The authors find that 51% of the males who reported that they had suffered incest during childhood were also perpetrators of child sexual abuse, 61% who reported childhood paedophile abuse were perpetrators and 75% of those who reported both incest and paedophile abuse in childhood were perpetrators. The authors claim that this "stepwise" increase in the "risk" of being a perpetrator according to childhood abuse experience provides support for a "victim to victimiser cycle". But does it? Let us examine some other explanations for this effect.
Sources of bias
This is a highly-selected sample based on a national tertiary referral
centre. Referrals came from a variety of sources including medical,
psychology, psychotherapy, social and probation services. By the time of their
assessment at the clinic, these individuals had managed to make their way
through this complex referral system and may not be representative of all
child sexual abusers.
The use of self-reports of childhood sexual abuse from individuals who are, themselves, child abusers is bound to raise questions about the reliability of these data. Reporting sexual victimisation in childhood may be an attempt on the part of the perpetrators to explain their abusive behaviour and elicit sympathy from the therapist. Glasser et al used information in social service, probation and medical reports to complement self-report data for the assessment of perpetrator status but it is not clear whether this was also done for victim status. Recall bias is usually thought of as an unconscious action, a form of search after meaning rather than deliberate lying or fabrication, but all these processes will lead to biased associations. Additionally, a form of interviewer bias may have operated if the therapists subscribed to the idea of a cycle of child sexual abuse and were more likely to enquire about such childhood experiences during assessment of perpetrators.
Sources of confounding
The relationship between childhood sexual abuse and becoming a child abuser
in adulthood may be confounded by childhood environment and family situation.
Seghorn et al (1987)
carried out a study with a similar design to that of Glasser et al
but with access to more detailed objective information about childhood
circumstances. They found that child sex abusers who were themselves sexually
abused in childhood were more likely than those who were not abused to have
had fathers with a criminal and/or substance use history, parents with
psychiatric problems, sexual deviance within the family and a high incidence
of childhood neglect. It is difficult to covary out the effects of sexual
abuse alone from such global family pathology.
Glasser et al examined two measures of childhood adversity as potential confounders: a self-report of maternal emotional care and a measure of loss in childhood (parental divorce, separation or death). Poor maternal emotional care was related to victim status, and experience of parental loss was a significant predictor of later perpetrator status. Sexual abuse in childhood remained a significant risk factor for later perpetrator status when adjusted for both these other variables in the logistic regression analysis. However, adjusted estimates are not necessarily free from confounding and much depends on the adequacy of information about the confounder. Inadequate information will give rise to residual confounding even after statistical adjustment (Leon, 1993). "Poor maternal emotional care" and "parental loss" are used as proxy measures for general childhood neglect and deprivation, but the complex mix of factors contributing to global family pathology or childhood deprivation cannot be accurately summed up in one or even two variables. In this study the higher "risk" of later perpetrator status associated with being a reported childhood victim of both incest and paedophilia, compared with incest or paedophilia separately, may actually reflect a greater degree of parental neglect and household chaos, rather than a true dose-response relationship with degree of childhood sexual abuse.
Complex causal models
There is (almost) never just one causal agent for a single outcome.
Adequate prediction of later disturbance or illness requires consideration of
multiple risks and protective factors and their interplay
(Cicchetti & Sroufe, 2000).
We should not be asking "What is the reason that X becomes a child sex
abuser?" but "What are the factors that have initiated and
maintained X on a developmental pathway that is associated with becoming a
child sex abuser?". We should ask why two individuals with the same risk
factor have different outcomes. An analogy of vulnerability to trauma has been
described in the context of three dolls made respectively of glass, plastic
and steel that were exposed to the same standard blow from a hammer
(Anthony, 1968). Under impact
the glass doll shattered, the plastic one showed a dent and the steel one
remained unscarred. The retrospective design of Glasser et al's study
does not allow us to estimate what proportion of children who have been
sexually abused go on to become child abusers in adulthood, but it is,
presumably, a small minority. Future research needs to examine cases where
children appear to have overcome or been protected from negative consequences
of their early childhood adversities. Such knowledge would have important
implications for the development of prevention and treatment programmes for
children who experience early victimisation.
The ideal way to answer these questions and look for links between childhood abuse and adult outcomes is to carry out longitudinal studies that carefully trace the developmental pathways of abused and non-abused children throughout life (Kraemer et al, 2000). It may be possible to speed up this long and costly process by using preexisting cohorts or official sources of information. Widom & Ames (1994) used a prospective cohort design to assess the criminal consequences of childhood sexual abuse. Official criminal records were traced for a large sample (n=908) of children with a validated history of sexual abuse, physical abuse or neglect, and a control group matched for age, gender, race and family socio-economic status. The authors found no evidence for a cycle of sexual abuse as proposed by Glasser et al. Rather, they found that all three of the abuse groups (sexual, physical and neglect) were significantly more likely to be arrested for a sexual offence (including prostitution) than were the controls. In fact, although children who had been sexually abused were significantly more likely than controls to have an adult arrest for prostitution, they were not significantly more likely than controls to have adult arrests for other sex crimes.
How little we know
No single study, no matter how large, can provide all the answers about the
complex topic of child abuse. We need to know more about the psychological and
functional outcomes of victims of childhood sexual abuse and we urgently need
to know more about why some adults sexually abuse children. Epidemiological
information on sexual perversions is notoriously poor
(Meyer, 1995). The legacy of
Freud encourages psychiatrists and psychologists to look to childhood for the
roots of adult behaviours. We do not wish to be seen to blame the victim, but
how can we protect children from adverse consequences of abuse if we do not
even know what these are? How can we devise effective treatments or
interventions for child abusers if we have no idea what drives their actions?
Glasser et al, with this fascinating study which exposes
psychoanalytic theory to epidemiological scrutiny, have opened the scientific
debate on this important issue and shown us how little we really know.
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REFERENCES |
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Cicchetti, D. & Sroufe, L. A. (2000) The past as prologue to the future: The times, they've been a changin. Development and Psychopathology, 12, 255-264.[CrossRef][Medline]
Glasser, M., Kolvin, I., Campbell, D., et al
(2001) Cycle of child sexual abuse: links between being a
victim and becoming a perpetrator. British Journal of
Psychiatry, 179,
482-494.
Kraemer, H. C., Yesavage, J. A., Taylor, J. L., et al
(2000) How can we learn about developmental processes from
cross-sectional studies, or can we? American Journal of
Psychiatry, 157,
163-171.
Leon, D. A. (1993) Failed or misleading adjustment for confounding. Lancet, 342, 479-481.[Medline]
Meyer, J. K. (1995) Paraphilias. In Comprehensive Textbook of Psychiatry (vol. 1) (6th edn) (eds H. I. Kaplan & B. J. Sadock), pp. 1334-1346. Baltimore, MD: Williams and Wilkins.
Seghorn, T., Prentky, R. & Boucher, R. J. (1987) Childhood sexual abuse in the lives of sexually aggressive offenders. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 262-267.[Medline]
Widom, C. S. & Ames, M. (1994) Criminal consequences of childhood sexual victimization. Child Abuse and Neglect, 18, 303-318.[CrossRef][Medline]
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