Understanding and responding to the long-term burdens of childhood sexual abuse
Authors: Lena Sanci
Journal: The Lancet Psychiatry (2019)

Childhood sexual abuse is a serious maltreatment of considerable magnitude worldwide. It affects all ages, genders, ethnicities, and socioeconomic groups and is associated with adverse physical and psychological health, as well as economic, effects throughout life.1Sapp MV Vanden AM Update on childhood sexual abuse.Curr Opin Pediatr. 2005; 17: 258-264Crossref PubMed Scopus (48) Google Scholar Measures of prevalence vary and are underestimated as a result of inconsistent definition and measurement methods, and difficulty in identifying abuse in young children and those with physical and intellectual disabilities.1Sapp MV Vanden AM Update on childhood sexual abuse.Curr Opin Pediatr. 2005; 17: 258-264Crossref PubMed Scopus (48) Google Scholar, 2Stoltenborgh M van Ijzendoorn MH Euser EM Bakermans-Kranenburg MJ A global perspective on child sexual abuse: meta-analysis of prevalence around the world.Child Maltreat. 2011; 16: 79-101Crossref PubMed Scopus (1104) Google Scholar The association of childhood sexual abuse with long-term outcomes is also inconsistent between studies for similar reasons, along with difficulties in disaggregating the impact of childhood sexual abuse from other co-occurring adversities.1Sapp MV Vanden AM Update on childhood sexual abuse.Curr Opin Pediatr. 2005; 17: 258-264Crossref PubMed Scopus (48) Google Scholar, 2Stoltenborgh M van Ijzendoorn MH Euser EM Bakermans-Kranenburg MJ A global perspective on child sexual abuse: meta-analysis of prevalence around the world.Child Maltreat. 2011; 16: 79-101Crossref PubMed Scopus (1104) Google Scholar In The Lancet Psychiatry, the study by Helen Hailes and colleagues3Hailes HP Yu R Danese A Fazel S Long-term outcomes of childhood sexual abuse: an umbrella review.Lancet Psychiatry. 2019; (published online Sept 10.)http://dx.doi.org/10.1016/S2215-0366(19)30286-XSummary Full Text Full Text PDF PubMed Scopus (196) Google Scholar assists in clarifying the longer-term impact of childhood sexual abuse by use of an umbrella review methodology to synthesise findings from previous meta-analyses. This review advances knowledge by comparing the relative strength of association with childhood sexual abuse, and the population attributable risk due to childhood sexual abuse, for a broad range of health, psychosocial, and psychiatric outcomes. The review also compares the quality of included meta-analyses with a metric that takes account of their AMSTAR (A Measurement Tool to Assess Systematic Reviews) score,4Shea BJ Grimshaw JM Wells GA et al.Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews.BMC Med Res Methodol. 2007; 7: 10Crossref PubMed Scopus (2944) Google Scholar heterogeneity, prediction intervals, and publication bias as assessed with tests for excess statistical significance and small study effects. Studies were excluded if outcome data for childhood sexual abuse were not disaggregated from other forms of abuse. This robust analysis signposts future research priorities such as associations with bipolar and obsessive-compulsive disorder, for which there are no meta-analyses. Most meta-analyses reviewed included studies relying on adults' retrospective reporting of childhood sexual abuse, prompting Hailes and colleagues to call for prospective empirical studies to examine developmental pathways from childhood sexual abuse to health outcomes. The advantages of prospective analyses in determining causality are clear; however, they are more expensive and time consuming, and carry ethical and legal challenges of potentially distressing children or caregivers and needing protocols for reporting abuse identified during the research.5Baldwin JR Reuben A Newbury JB Danese A Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis.JAMA Psychiatry. 2019; 76: 584-593Crossref PubMed Scopus (460) Google Scholar, 6Newbury JB Arseneault L Moffitt TE et al.Measuring childhood maltreatment to predict early-adult psychopathology: comparison of prospective informant-reports and retrospective self-reports.J Psychiatr Res. 2018; 96: 57-64Crossref PubMed Scopus (191) Google Scholar Prospective measures used so far (eg, official abuse records, medical record examination, researcher observation, and interviews with caregivers and other key informants) are also criticised for under-detection as not all childhood sexual abuse is officially recorded, caregivers might withhold information or be unaware abuse is occurring, and study attrition over time might bias individuals more likely to develop psychopathology.6Newbury JB Arseneault L Moffitt TE et al.Measuring childhood maltreatment to predict early-adult psychopathology: comparison of prospective informant-reports and retrospective self-reports.J Psychiatr Res. 2018; 96: 57-64Crossref PubMed Scopus (191) Google Scholar Retrospective assessment more cheaply and efficiently identifies adults exposed to childhood sexual abuse and thereby avoids mandatory reporting requirements; however, over and under-reporting of such abuse can occur.5Baldwin JR Reuben A Newbury JB Danese A Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis.JAMA Psychiatry. 2019; 76: 584-593Crossref PubMed Scopus (460) Google Scholar Reasons for under-reporting include failure to encode the maltreatment memory, overriding, forgetting or repressing the memory to avoid distress, and brain injury or ageing.5Baldwin JR Reuben A Newbury JB Danese A Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis.JAMA Psychiatry. 2019; 76: 584-593Crossref PubMed Scopus (460) Google Scholar Reasons for over-reporting include a greater likelihood of recalling memories when experiencing negative affective states, hence biasing the association of psychopathology with abuse.6Newbury JB Arseneault L Moffitt TE et al.Measuring childhood maltreatment to predict early-adult psychopathology: comparison of prospective informant-reports and retrospective self-reports.J Psychiatr Res. 2018; 96: 57-64Crossref PubMed Scopus (191) Google Scholar A recent landmark systematic review and meta-analysis on the agreement between prospective and retrospective measures of childhood maltreatment5Baldwin JR Reuben A Newbury JB Danese A Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis.JAMA Psychiatry. 2019; 76: 584-593Crossref PubMed Scopus (460) Google Scholar confirms mounting observations6Newbury JB Arseneault L Moffitt TE et al.Measuring childhood maltreatment to predict early-adult psychopathology: comparison of prospective informant-reports and retrospective self-reports.J Psychiatr Res. 2018; 96: 57-64Crossref PubMed Scopus (191) Google Scholar, 7Reuben A Moffitt TE Caaspi A et al.Lest we forget: comparing retrospective and prospective assessments of adverse childhood experiences in the prediction of adult health.J Child Psychol Psychiatry. 2016; 57: 1103-1112Crossref PubMed Scopus (404) Google Scholar that prospective and retrospective measures of childhood sexual abuse, and other forms of maltreatment, have poor agreement and that each measure identifies a different group of individuals who have been abused and therefore these measures cannot be used interchangeably.5Baldwin JR Reuben A Newbury JB Danese A Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis.JAMA Psychiatry. 2019; 76: 584-593Crossref PubMed Scopus (460) Google Scholar The Dunedin longitudinal study7Reuben A Moffitt TE Caaspi A et al.Lest we forget: comparing retrospective and prospective assessments of adverse childhood experiences in the prediction of adult health.J Child Psychol Psychiatry. 2016; 57: 1103-1112Crossref PubMed Scopus (404) Google Scholar included both prospective and retrospective measures of adverse childhood experiences, and both objective measures (eg, waist circumference, serum lipids, and blood pressure) and subjective measures (self-report) of later life outcomes. Adverse childhood experiences identified both prospectively and retrospectively predicted later life outcomes, but retrospectively identified abuse was more strongly associated with self-reported adult outcomes such as affective psychopathology.7Reuben A Moffitt TE Caaspi A et al.Lest we forget: comparing retrospective and prospective assessments of adverse childhood experiences in the prediction of adult health.J Child Psychol Psychiatry. 2016; 57: 1103-1112Crossref PubMed Scopus (404) Google Scholar Similarly, the longitudinal study by Newbury and colleagues6Newbury JB Arseneault L Moffitt TE et al.Measuring childhood maltreatment to predict early-adult psychopathology: comparison of prospective informant-reports and retrospective self-reports.J Psychiatr Res. 2018; 96: 57-64Crossref PubMed Scopus (191) Google Scholar found a weakened association of prospective report with affective psychopathology, whereas retrospective reports had a stronger association when both were simultaneously modelled. They concluded that adults who had been abused and who also recalled being abused were at higher risk of affective psychopathology than those who had forgotten or chose not to disclose past abuse.6Newbury JB Arseneault L Moffitt TE et al.Measuring childhood maltreatment to predict early-adult psychopathology: comparison of prospective informant-reports and retrospective self-reports.J Psychiatr Res. 2018; 96: 57-64Crossref PubMed Scopus (191) Google Scholar Hence, it appears that, in contrast to the recommendation by Hailes and colleagues, future studies should include both prospective and retrospective measures of abuse as pathways to adverse outcomes might be different for each.5Baldwin JR Reuben A Newbury JB Danese A Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis.JAMA Psychiatry. 2019; 76: 584-593Crossref PubMed Scopus (460) Google Scholar With electronic medical records and the growing potential for linkage of individuals' routinely collected data across health, education, welfare, and legal systems, it will be possible to aggregate prospectively or retrospectively detailed descriptions of pathways towards adult outcomes, along with contextual confounders. Yet, the potential of harnessing big data has its own methodological and ethical challenges8Crawford K Miltner K Gray ML Critiquing big data: politics, ethics and epistemology. Special section introduction.Int J Commun. 2014; 8: 1663-1672Google Scholar and, for childhood sexual abuse research, must be reconciled with protecting an individual's right to privacy and the ethical obligation to identify individuals if patterns of data analysed prospectively indicate risk for childhood abuse. The clinical implications discussed by Hailes and colleagues focus on the need for effective approaches in identification and treatment of abuse either in direct care or in settings such as schools. However, advances in direct clinical care will not assist in changing siloed approaches to identification, prevention, and management of childhood sexual abuse across the health, policy, education, legal, and welfare sectors, which all interface with vulnerable families. Childhood sexual abuse instigates complex care that is challenged by lack of coordination and integration.9Murray LK Nguyen A Cohen JA Child sexual abuse.Child Adolesc Psychiatr Clin N Am. 2014; 23: 321-337Summary Full Text Full Text PDF PubMed Scopus (130) Google Scholar Research is thus also required into how best to translate knowledge about pathways from childhood sexual abuse to long-term outcomes into integrated policy and system approaches to prevention, detection, and management.10Wathen CN MacMillan HL The role of integrated knowledge translation in intervention research.Prev Sci. 2018; 19: 319-327Crossref PubMed Scopus (26) Google Scholar Finally, it is important to identify the best methods for measuring prevalence of childhood sexual abuse and instituting regular population assessments to ensure that implementation of evidence-based interventions is effective in curbing this damaging public health issue.2Stoltenborgh M van Ijzendoorn MH Euser EM Bakermans-Kranenburg MJ A global perspective on child sexual abuse: meta-analysis of prevalence around the world.Child Maltreat. 2011; 16: 79-101Crossref PubMed Scopus (1104) Google Scholar I declare no competing interests. Long-term outcomes of childhood sexual abuse: an umbrella reviewAlthough childhood sexual abuse was associated with a wide range of psychosocial and health outcomes, systematic reviews on only two psychiatric disorders (post-traumatic stress disorder and schizophrenia) and one psychosocial outcome (substance misuse) were of a high quality. Whether services should prioritise interventions that mitigate developing certain psychiatric disorders following childhood abuse requires further review. Higher-quality meta-analyses for specific outcomes and more empirical studies on the developmental pathways from childhood sexual abuse to later outcomes are necessary. Full-Text PDF Open Access