In this issue of the Journal, Bebbington and colleagues (1) report findings from the 2000 British National Survey of Psychiatric Morbidity, which indicated that a history of childhood sexual abuse was strongly associated with suicide attempts and suicide intent. The odds ratio, which the team used to look at the strength of the association, was higher for women than men but remarkably high in both groups (9.6 and 6.7, respectively). The population attributable risk factor (the proportion of suicide attempts linked to childhood sexual abuse) was 27.8% for women and 6.9% for men. The authors used the Clinical Interview Schedule—Revised to examine affective disturbance at the time of the interview and found this measure to be a mediator of the relationship between childhood sexual abuse and suicide attempts and suicide intent.
A strength of this report is that it comes from a large, randomized, cross-sectional survey of the British population (N=8,580). Many of the early studies of the sequelae of childhood sexual abuse were based on convenience samples drawn from clinical populations. A growing body of the evidence from population-based samples is providing a much more reliable estimate of the health problems posed by this trauma of childhood. An interesting feature of this and other large studies is that they are documenting constellations of negative outcomes. In this study, the connections among childhood sexual abuse, gender, affective disturbance, and suicide attempt/intent draw our attention to a web of interconnections.
The relationship between gender and childhood sexual abuse appears to be quite solidly established. Girls are at greater risk for such abuse, but boys are not immune, as demonstrated in the data presented by Bebbington et al. One recent HIV prevention study of 4,295 men who have sex with men documented that 39.7% had a history of childhood sexual abuse (2). Although the intervention being studied was effective among those without a history of childhood sexual abuse, it was not effective among those who reported such abuse. The relationship between HIV infection and childhood sexual abuse was mediated by drug use, depression, and other factors.
Childhood sexual abuse does not seem to cause a single well-defined harm, but rather it sets off disturbances in many systems and subsystems of the body, potentially leading to a plethora of physical and mental symptoms and disorders—that is, to complex comorbidities (3). These are costly for the sufferer. In one study of adults with psychiatric illness (4), the authors concluded that the impact of childhood sexual abuse on illness burden was “roughly comparable to the effects of adding 8 years of age.” It was even more extreme, adding 20 years of age, for activities of daily living and body pain.
Childhood sexual abuse never happens solely to a single individual but troubles whole family systems. Abuse may be a symptom of a family that is not functioning properly. In a study of adverse childhood experiences conducted at Kaiser Permanente (5), a large Western health plan, plan members were likely to report an adverse experience of childhood, and all 10 of the adverse experiences the researchers inquired about were significantly associated with each of the others. Thus, childhood sexual abuse may occur in a context of family violence, separation or divorce, substance abuse, mental illness, or crime.
On the other hand, the exposure of childhood sexual abuse brings a family into contact with health and criminal justice systems that may be poorly coordinated, hostile and blaming of families, and otherwise inept in the delivery of care. Such systems problems may cause secondary traumatization. This can further aggravate dysfunction in families that are struggling. It could even cause new problems in families that were otherwise functioning in a satisfactory manner (6).
Families are creatures of social systems, and the state of those social systems is critical to family well-being and child safety. Rates of abuse fluctuate. We do not know the reasons for the rates identified in all cases, but in some instances we do. A 1996 study of risk factors for excess mortality in Harlem found that rates of childhood abuse were three times higher for men and 2.5 times higher for women than the national averages (9.6 versus 3.2 for men; 13.2 versus 4.8 for women) (7). Harlem was a poor neighborhood that had suffered from redlining, urban renewal, and planned shrinkage, leading to massive destruction of the area’s built environment and serial displacement of its population. This environmental upheaval had truncated social networks, disrupted family functioning, and added many social burdens to people with few resources.
A particularly discouraging observation has emerged from studies in the new field of epigenetics. Massive harms, of the kind caused by neighborhood collapse, can cause heritable phenotypic alternations. Although such physiological changes are not changes to the DNA sequence itself, the epigenetic alterations can pass along the injury for one or more generations (8).
Bebbington and colleagues point out the need for clinicians to hear a report of suicide attempt/intent as a clue to ask about childhood sexual abuse. This is an excellent suggestion, although not as straightforward to implement as one might wish. My colleagues examined the implementation of trauma-informed treatment and found that mandating inquiry about trauma did not lead to incorporating that information in a treatment plan. There was all too little change on follow-up 10 years later (9). This means that we have to ask, “What prevents clinicians from acting?” Of course, as I just noted, clinicians’ actions can lead to secondary traumatization; a sensitivity to possible harm is to be lauded. Another major problem is the paucity of well-established treatments.
However, these limitations should not be used as an excuse not to act but rather as spur to greater engagement in containing and defusing the effects of this noxious agent. Based on their findings from a study of childhood sexual abuse in China, Luo and colleagues (10) pointed out the following: “The findings suggest a need for increasing public awareness of child sexual abuse through open discussions of various abusive behaviors and the potential impact of these behaviors lingering into adulthood. The findings are consistent with a need for public health campaigns that tackle the stigma…[and] new efforts to alleviate the negative long-term impact of childhood sexual abuse by following up on the victims and to address their needs.”
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Mimiaga MJ, Noonan E, Donnell D, Safren SA, Koenen KC, Gortmaker S, O’Clereigh C, Chesney MA, Coates TJ, Koblin BA, Mayer KH: Childhood sexual abuse is highly associated with HIV risk-taking behavior and infection among MSM in the EXPLORE Study. J Acquir Immune Defic Syndr 2009; 51:340–348
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Fullilove RE, Fullilove MT, Northridge ME, Ganz ML, Bassett MT, McLean DE, Aidala A, Gemson DH, McCord C: Risk factors for excess mortality in Harlem: findings from the Harlem Household Survey. Am J Prev Med 1999; 16(suppl 3):22–28
Jablonka E: Epigenetic epidemiology. Int J Epidemiology 2004; 33:929–935
Posner J, Eilenberg J, Friedman JH, Fullilove MJ: Quality and use of trauma histories obtained from psychiatric outpatients: a ten-year follow-up. Psychiatr Serv 2008; 59:318–321
Luo Y, Parish WL, Laumann EO: A population-based study of childhood sexual contact in China: prevalence and long-term consequences. Child Abuse Negl 2008; 32:721–731
Address correspondence and reprint requests to Dr. Fullilove, Community Research Group, 1051 Riverside Drive Unit 29, New York, NY 10032; firstname.lastname@example.org (e-mail). Editorial accepted for publication July 2009 (doi: 10.1176/appi.ajp.2009.09071058).
The author reports no competing interests.