The ideal response to child sexual abuse would be primary prevention strategies aimed at eliminating, or at least reducing, the sexual abuse of children (Tomison, 1995). This review has, however, focused on issues related to the deleterious outcomes linked to child sexual abuse rather than on the characteristics of abusers and the contexts in which abuse is more likely to occur, which are relevant to primary prevention. From the information presented here, the implications are for secondary and tertiary preventive strategies aimed at ameliorating the damage inflicted by abuse, and reducing the subsequent reverberations of that damage.
Child sexual abuse may be a necessary, but rarely (if ever) a sufficient, cause of adult problems. Child sexual abuse acts in concert with other developmental experiences to leave the growing child with areas of vulnerability. This is a dynamic process at every level, and one in which there are few irremediable absolutes. Abuse is not destiny. It is damaging, and that damage, if not always reparable, is open to amelioration and limitation.
Those who have been abused who subsequently have positive school experiences where they feel themselves to have succeeded academically, socially or at sport, have significantly lower rates of adult difficulties (Romans et al. 1995). Those whose relationship with their parents subsequent to abuse was positive and supportive fared better, and a good relationship with the father appeared to have a strong protective influence regarding subsequent psychopathology (Romans et al. 1995). Even aspects of the parental figures’ relationship to each other seem to have an influence. Expressions of physical affection between parents was associated with better outcomes, and marked domestic disharmony, particularly if associated with violence, added to the damage (Romans et al. 1995; Spaccarelli and Kim 1995). Finally, those who can establish stable and satisfactory intimate relationships as adults have significantly better outcomes.
There is no reason why a well-organised and funded school system should not provide all children with a positive experience academically, socially or in sport. There is no need to identify and target abuse victims, but simply to make every effort to ensure adolescents have the opportunity to share in the enhanced social opportunities, the increased mastery, and the pleasure of achievement that school should provide at some level to all.
The encouragement of sport may seem trivial, but it has a protective influence on psychiatric disorders in all adolescents, not just those with histories of child abuse (Romans et al. 1996; Thorlindsson et al. 1990; Simonsick 1991). Similarly in adult life, success in tertiary education and in the workforce is associated with reduced vulnerability to psychiatric problems for the abused and the non-abused alike, but particularly for the abused (Romans et al. 1996).
The secondary preventive strategies of relevance in reducing the impact of child sexual abuse are equally relevant to reducing a wide range of adolescent and adult problems unrelated to abuse. These include improved parental relationships, reduced domestic violence and disharmony, improved school opportunities, work opportunities, better social networks, and better intimate relationships as adults. The list is so familiar as to be platitudinous, but is nonetheless of central importance.
The model advanced in this paper is of child sexual abuse contributing to developmental disruptions that lay the basis for interpersonal and social problems in adult life. These, in turn, increase the risks of adult psychiatric problems and disorders. If this is correct, then focusing on improving the social and interpersonal difficulties of those with histories of child sexual abuse may be the most effective manner of reducing subsequent psychiatric disorder.
This argues for tertiary prevention strategies aimed at improving self-esteem, encouraging more effective action in work and recreational pursuits, attempting to overcome sexual difficulties, and working specifically on improving the victim’s social networks and capacities to trust in, and accept, intimacy. This does not imply that established affective disorders or eating disorders should not be treated in their own right, but suggests that focusing on current vulnerabilities and deficits may be more productive than extended archeologies of past abuse in the search of an elusive retrospective mastery.
The hypothesis advanced in this paper is that, in most cases, the fundamental damage inflicted by child sexual abuse is to the child’s developing capacities for trust, intimacy, agency and sexuality, and that many of the mental health problems of adult life associated with histories of child sexual abuse are second-order effects. This hypothesis runs counter to the post-traumatic stress disorder model, and suggests different therapeutic strategies and strategies of secondary prevention.
In practice, both models may be of value. The post-traumatic stress disorder like mechanisms may predominate in the short term, and in those who have been exposed to the grossest form of child sexual abuse. The developmental and social model may carry the weight of causality in the far commoner, but less utterly overwhelming, forms of child sexual abuse.
References (see Library)
Long-term Effects of Child Sexual Abuse
by Paul E. Mullen and Jillian Fleming