Research into the relationship between child sexual abuse and alcohol abuse began with reports that clients with substance abuse problems reported high levels of exposure to child sexual abuse. A review of 12 studies conducted prior to 1995 indicated that the rates of child sexual abuse among those in treatment for alcohol abuse varied from as high as 84 per cent to as low as 20 per cent (Fleming et al. in press (b)).
Other evidence suggesting a relationship between child sexual abuse and alcohol abuse came from studies of women with histories of child sexual abuse who were attending treatment for mental health problems. These studies generally found higher rates of alcohol abuse in women with a history of child sexual abuse (Pribor and Dinwiddie 1992; Swett and Halpert 1994).
Recent research into the relationship between child sexual abuse and alcohol abuse has been methodologically more sophisticated than in the past, and has used community samples with larger sample sizes, random samples and more adequate definitions for both alcohol abuse and child sexual abuse (Peters 1988; Bushnell et al. 1992; Fergusson et al. 1996). However, conflicting results on the possible linkage between child sexual abuse and alcohol abuse have been reported. This has given rise to doubt about the strength of an association, the extent to which this relationship reflects a causal connection, and how any connection is mediated and influenced by other aspects of background and development.
The link between child sexual abuse and alcohol abuse may not be a simple causal chain. Fleming et al. (in press, (b)) in a case-control study examining the relationship between a reported history of child sexual abuse and the development of alcohol abuse in a sample of 710 Australian women, proposed that a history of child sexual abuse was not, by itself, sufficient to cause alcohol dependency in women. The relationship between child sexual abuse and alcohol abuse more likely reflects a complex interplay between child sexual abuse and a range of other factors in a woman’s life. Their results showed that in combination with the perception of a mother who was uncaring and overly controlling, being sexually abused did increase the risk of alcohol abuse in women. These results also suggest evidence for protective effects such that the perception of having a kind, caring and loving mother may help overcome some of the potentially adverse effects of child sexual abuse on subsequent vulnerability to alcohol abuse.
The proposition that the long-term effects of child sexual abuse may be modified by an individual’s experience subsequent to the abuse has also been suggested. Romans et al. (1995 and 1997) demonstrated that long-term problems following child sexual abuse were significantly lower in those who had supportive and confiding relationships with their mothers. In addition, in adults with a history of child sexual abuse, a three-way interaction was found between child sexual abuse, having an alcoholic partner, and having high expectancies of alcohol as a sexual disinhibitor.
The research on child sexual abuse and alcohol abuse illustrates the complexity of the interactions between abuse and the emergence of adult problems. As a minimum, there are interactions between the severity of the abuse, the family relationships prior and subsequent to the abuse, the adult victims’ preconceptions about alcohol reducing sexual anxieties and, finally, the drinking habits of their eventual partner. Even this list fails to convey the complexity of the dynamic interactions between development, abuse and family and social experiences. This is not complexity for the sake of complexity. Understanding the impact of child sexual abuse in a developmental and interactive perspective is central to effective therapy for adults and child victims, and for secondary prevention strategies.
Unravelling the associations between abuse and long-term problems
There is a wide range of potential adverse adult outcomes associated with child sexual abuse. However, there is no unique pattern to these long-term effects and no discernible specific post-abuse syndrome. This suggests that child sexual abuse is best viewed as a risk factor for a wide range of subsequent problems.
In studies on the long-term impact of child sexual abuse that employ adult subjects, it is all too easy to forget the abuse occurred in childhood, and to resort to applying inappropriately adult-centred conceptualisations. In deriving models of the link between child sexual abuse and adult difficulties, the heavy reliance on the concept of post-traumatic stress disorder may be an example of such an error.
The sexual abuse of children occurs during a period in life where complex and, hopefully, ordered changes are occurring in the child’s physical, psychological and social being. The state of flux leaves the child vulnerable to sustaining damage that will retard, pervert or prevent the normal developmental processes. The impact of abuse is likely to be modified by the developmental stage at which it occurs. It will also vary according to how resilient the child is in terms of their psychological and social development up to that point. A child who has already had to cope with, for example, a problematic family background or prior emotional abuse, will be more vulnerable to the additional blow of child sexual abuse. A child from a more secure and privileged background may well be equally distressed at the time by the abuse, but is likely to sustain less long-term developmental damage.
These suppositions are born out by studies that have demonstrated powerful interactions between the child’s prior exposure to potentially damaging situations, and the degree of adult disturbance apparently associated with a history of child sexual abuse (Mullen et al. 1993 and 1994; Fergusson et al. 1996 and 1997).
The long-term effects of child sexual abuse will also be modified by the individual’s experience subsequent to the abuse. Romans et al. (1995 and 1997) demonstrated that long-term problems following child sexual abuse were significantly lower in those who had supportive and confiding relationships with their mothers and in those who, as adolescents, experienced some success at school or with peers. The nature of this success (academic, social or sporting), is probably less important than the accompanying strengthening of self-esteem and enhancement of opportunities for effective social interactions with peers.
The relationship between the potential damage inflicted on elements in the child’s development and subsequent mitigating factors is, of necessity, complex. For example, the observation that those victims of child sexual abuse who manage to establish and maintain stable marital relationships are protected against some of the potentially adverse outcomes of child sexual abuse (Cole et al. 1992) may reflect, in part, the mitigating and healing influence of effective intimacy. However, equally, the association may be a product of the ability of those, who have for other reasons avoided the worst effects of child sexual abuse, to enter and sustain intimate relationships.
Peters (1988) suggested that child sexual abuse interacts with family background to produce disruption of the child’s developing self-esteem and sense of mastery of the world (agency). It is these deficits, in turn, that increase the likelihood of psychological problems in later life. This model of developmental deficits leading to social and personal vulnerabilities in adult life, which in their turn create an increased risk of mental health problems, can usefully be expanded.
Those with histories of child sexual abuse, particularly of the more physically intrusive types, have an increased risk of social, interpersonal and sexual problems in adult life. This association may play a role in mediating at least some of the far better known associations between child sexual abuse and mental health problems.
Greater vulnerability to depression is found in women who lack an intimate and confiding relationship (Henderson and Brown 1988; Harris 1988; Romans et al. 1992). Depression is also associated with lowered self-esteem and a sense of hopelessness about one’s ability to influence one’s life (Browne et al. 1986, Ingram et al. 1986). Thus the social, interpersonal and sexual problems associated with a history of child sexual abuse may themselves provide fertile ground for the development of mental health problems, particularly in the area of depressive disorders.
A plausible hypothesis can be advanced that the developmental disruption engendered by child sexual abuse in the victims’ sense of self-esteem, sense of agency, sense of the world as a safe enough environment, in their capacity for entering trusting intimate relationships and, finally, in their developing sexuality, leads in adult life to an increased risk of low self-esteem, social and economic failure, social insecurity and isolation, difficulties with intimacy and sexual problems.
This constellation of difficulty is a pattern of disadvantage likely to leave the subject prone to depressive and anxiety disorders. The vulnerability may be expressed if, and when, the subject encounters psychosocial or physical stressors, particularly if those stressors target specific areas of developmental vulnerability. (See Figure 1)
Long-term Effects of Child Sexual Abuse
by Paul E. Mullen and Jillian Fleming