The impact of child sexual abuse on health: A systematic review of reviews
Introduction
Awareness of the impact on human development that may result from early experiences of sexual abuse is of relatively recent origin. Ongoing concern over the potential consequences of child sexual abuse is reflected in the exponential increase in research in this area. A growing number of studies and literature reviews on child sexual abuse have appeared over the past twenty years.
However, such large amount of research has not been unanimous in its conclusions. Indeed, there is considerable controversy concerning the relationship between child sexual abuse and later negative outcomes. While many studies and reviews have concluded that survivors of childhood sexual abuse are highly likely to experience several adverse effects, strongly implying a causal relationship between child sexual abuse and the later development of psychopathology, others have been more cautious, arguing that outcomes are variable, rather than being consistently and intensely negative (see, for example, ⁎Paolucci et al., 2001, ⁎Rind and Tromovitch, 1997, ⁎Rind et al., 1998, ⁎Sharpe and Faye, 2006, ⁎Smolak and Murnen, 2002).
Furthermore, there is no conclusive agreement concerning those variables (such as gender, age when abused, type and severity of abuse, and relationship to the perpetrator) which are usually highlighted as potential contributors to the outcomes of child sexual abuse. For example, while some reviews have concluded that girls react more negatively than boys, others have implied that sexual abuse is an equivalent experience for boys and girls in terms of its negative impact (⁎Rind and Tromovitch, 1997, ⁎Rind et al., 1998).
Therefore, although efforts to synthesize the literature have resulted in several qualitative and quantitative reviews, even these have generated conflicting results and conclusions have not yet been definitively drawn.
Although several theoretical explanations of how child sexual abuse affects children's development have been proposed (see Cicchetti and Toth, 2005, Freeman and Morris, 2001, Hulme, 2004), in the absence of consistent empirical evidence, theories accounting for the impact of child abuse on human development lack support.
Much of the controversy in the literature may be a reflection of the differences between studies (Roodman & Clum, 2001) as well as of the methodological limitations of the literature (⁎Rind and Tromovitch, 1997, ⁎Rind et al., 1998, ⁎Sharpe and Faye, 2006). Many studies are characterized by serious design and measurement problems, including poor sampling methods, absence of matched comparison groups, and inadequate control for effect modifiers and confounders (see Briere, 1992, Kilpatrick, 1987, ⁎Sharpe and Faye, 2006). Moreover, many literature reviews are characterized by imprecision and subjectivity (⁎Rind and Tromovitch, 1997, ⁎Rind et al., 1998). For example, some reviewers have specified neither the data sources that were searched nor the criteria used for including studies, paying more attention to study findings indicating harmful effects.
A more objective process has been provided by some meta-analytic reviews, which have attempted to infer whether child sexual abuse is significantly associated with specific outcomes and to estimate the strength of this association. Based on the transformation of the results of all the relevant studies to a common statistical metric, which are then combined into one overall statistic, these reviews have used a more rigorous and transparent approach to reduce the potential for bias, avoiding imprecision and subjectivity.
However, some have criticized the aggregation of findings from studies that are too diverse (either clinically or methodologically) to be combined in a meta-analysis (see Centre for Reviews and Dissemination, 2008, Lipsey and Wilson, 2000), because such aggregation might be inappropriate and meaningless, and genuine differences in effects might be obscured (Higgins & Green, 2006). Further, it should be noted that meta-analysis does not allow for causal inferences to be made, thus findings must be interpreted with caution (Hall & Rosenthal, 1995).
In conclusion, although studies and reviews abound, the inconsistency in their conclusions along with their methodological differences and limitations may create interpretative difficulties, mistaken beliefs, or confusion among all individuals (including policymakers, physicians, psychologists, other professionals who treat children, and other individuals responsible for the welfare of children) who turn to this literature for guidance.
In response to these difficulties and with the current high level of societal interest in child maltreatment, it seems evident that, despite a growing body of literature addressing the potential impact of child sexual abuse on health, the issue needs further careful consideration. An analysis of what is currently known about the consequences of childhood sexual abuse is required in order to implement research and health policy.
In order to address the best available scientific evidence on the topic, this paper provides a qualitative and semi-quantitative analysis of the findings of the several reviews that have investigated the literature on the short- and long-term effects of child sexual abuse.
Section snippets
Methods
According to recent guidelines for systematic reviews (Centre for Reviews and Dissemination, 2008, Egger et al., 2001, Higgins and Green, 2006, Lipsey and Wilson, 2000, Petticrew and Roberts, 2006, Stroup et al., 2000), a protocol was prospectively developed by the author, R.M., detailing the specific objectives, criteria for study selection, approach to abstracting data and assessing study quality, outcomes, and statistical methods.
Results
The results of the fourteen reviews included in this systematic review are synthesized in Table 2.
Discussion
Fourteen reviews addressing the potential impact of child sexual abuse on health and having no important limitations that could invalidate their results were included in this systematic review.
In considering the results as a whole, there is evidence that across methodologies, samples, and measures survivors of child sexual abuse are significantly at risk of a wide range of health problems, i.e. psychotic symptomatology (especially paranoid ideation), depression, anxiety (including posttraumatic
Acknowledgments
I would like to thank Oronzo Greco, MD, University of Salento, Lecce, Italy, for his help on study selection, data abstraction, and quality assessment.
Disclaimer: The views expressed are those of the author.
This study has no external funding source and was not financial supported. The author reports no financial interests, affiliations, conflicts of interest, or other relationship relevant to the subject matter of this paper.
Author contributions: Dr. Maniglio had full access to all of the data
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References marked with an asterisk indicate studies included in the systematic review.