Steel, Jennifer L. PhD1,2; Herlitz, Claes A. DrMedSc2
The relationship between childhood and adolescent sexual abuse or sexual assault as an adult and subsequent sexual dysfunction has been well documented.1,2 A review of the literature suggests that adult women with a history of child sexual abuse have a greater prevalence of sexual dysfunction, homosexual experiences, depression, and revictimization when compared with nonabused women.3 Women who have a history of sexual assault as an adult also have been found to have psychological (eg, posttraumatic stress disorder) and sexual sequelae.1,4–6
The majority of the studies that have been conducted have been in clinical samples undergoing treatment for sexual abuse or sexual dysfunction3,7,8 and have focused primarily on women.3,7,8 In studies that have been conducted in nonclinical populations, the association exists, but often the methods that have been employed to measure abuse or sexual dysfunction are not well defined.2 Furthermore, few studies have been conducted regarding sexual abuse in men. It is estimated that approximately 8–10% of men report a history of childhood sexual abuse.9,10 For the most part, men reported single-childhood sexual abuse, and the association between childhood sexual abuse and sexual dysfunctions has not been reported in the literature.7,10 Rather, unemployment was the greatest predictor of sexual dysfunction in men.7 Finally, a few studies investigating the relationship between childhood sexual abuse and sexual dysfunction in women also did not report an association.11
The psychological and sexual consequences of sexual assault as an adult have also been documented by several researchers.4,5 Women who were reported to have been sexually assaulted as an adult were more likely to experience sexual dysfunction than women who had never been raped.1,5,12 A paucity of research has addressed sexual assault as an adult in men. One study found that men being treated for sexual dysfunction after an assault were unable to function sexually for a 2-year period after the assault.13 Underlying causes of the dysfunction seem to be associated with anxieties about sexual performance and neutralization of spectator roles.13 Revictimization, defined as being sexually abused as a child and sexually assaulted as an adult, has been found to have the greatest consequences in regard to sexual functioning.14,15
The aims of the present study were to investigate the increased risk of sexual dysfunction as a result of a past history of childhood sexual abuse, sexual assault as an adult, or both in males and females in a randomly selected nonclinical sample. The present study addressed limitations of previous research by including 1) a random sample of the general population, 2) both genders and type of sexual assault (childhood sexual abuse and sexual assault as an adult) drawn from the same population, 3) questionnaires and interviews developed by experts in the field to assess childhood sexual abuse and assault and sexual dysfunction, and 4) a control group with no history of abuse or assault from the same population in which rates of sexual dysfunction will be compared.
MATERIALS AND METHODS
The present investigation was part of a larger study concerning knowledge, beliefs, and attitudes regarding sexuality and sexual behavior in the Swedish general public.16 In 1996, 5,250 individuals from the Sex in Sweden study, between the ages of 18 and 74 years, were randomly selected from the Swedish Post Address Register (database of Swedish population), which includes 6,119,000 Swedish citizens. The final number of participants to survey was derived based on the initial aims of the study and the sample size necessary for proposed analyses. From this sample, 469 persons were excluded secondary to 1) lack of fluency or literacy in Swedish or 2) reported sensory disorders impairment including difficulties with communication, poor visual acuity, or impaired hearing or both. The final recruitment sample consisted of 4,781 persons. Data were collected using both oral administration of questions as well as a paper and pencil self-report measure with a total of 322 items.
Sexual abuse was defined as “unwanted” or “forced” sexual contact during childhood or adolescence. For the contact to be defined as childhood sexual abuse, the contact must have occurred before the age of 18 years. A differentiation was made between “unwanted” and “forced” childhood sexual abuse in this study. The participants were first asked if they were forced to take part in sexual acts followed by a question regarding whether they took part in such acts that were “unwanted” but were not “forced” to engage in (Table 1).
Sexual assault as an adult was defined as unwanted or forced sexual contact after the age of 18 years by someone familiar to the individual. For the contact to be defined as sexual assault the contact must have occurred after the age of 18 years.
The items used to assess sexual dysfunction reflected major sexual dysfunctions according to the Diagnostic and Statistical Manual IV (DSM-IV) of the American Psychiatric Association,17 with the exception of lubrication problems. The items that were queried of female participants included symptoms associated with hypoactive sexual desire, dyspareunia <and> 12 months, anorgasmia <and> 12 months, lubrication problems <and> 12 months, and vaginismus <and> 12 months. For males, items included assessment of hypoactive sexual desire, pain <and> 12 months, male erectile dysfunction <and> 12 months, retarded ejaculation <and> 12 months, and premature ejaculation <and> 12 months.
The study was approved by the Swedish institutional review board before the commencement of recruitment. Interviewers were hired from a research and development firm (Swedish Institute for Opinion Surveys). Before data collection commenced, the interviewers underwent intensive training and were supervised throughout the study by doctoral-level researchers who have specialized education and training in issues regarding sexuality and health. The participants were initially contacted with a letter describing the study (eg, rationale, confidentiality). Within approximately 5 days of the letter being received, an interviewer called the participant and scheduled an interview. Before the commencement of the interview, participants gave informed consent for their involvement in the study. The average time to complete the interview and questionnaire was approximately one and one half hours.
Data were analyzed using SPSS 14 on a personal computer and descriptive statistics were performed to obtain information regarding demographic variables. Age-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were used to test the increased risk of sexual dysfunction as a result of reporting a history of childhood sexual abuse and sexual assault as an adult. Descriptive statistics χ2 analyses and analysis of variance (ANOVA) were employed to test differences on help sought for sexual dysfunction by gender and abuse or assault history.
Of those persons, 2,810 (59%) participants agreed to participate in the study. Analysis of variance or χ2 analyses were employed to test the differences between responders and nonresponders. No significant differences between the respondents and the nonrespondents were found on any demographic variables with the exception that older persons were somewhat underrepresented in the final sample. Table 2 provides demographic information for those who participated in the study. The participants' age range was between 23 and 79 years. There were approximately an equal number of males (53%) and females (47%). The majority of the participants were Scandinavian (95%), and 27% reported having a university education. Seventy-three percent were in a steady relationship. The majority of participants lived in rural (41%) areas, followed by suburban (29%) and urban (22%) areas (Table 2).
Of the entire sample, a total of 6.8% of the participants (9.7% of the women and 3.7% of men) reported a history of childhood sexual abuse before the age of 18 years. The majority of the participants who reported childhood sexual abuse were female (70%). Of the participants who reported sexual abuse, 86% reported unwanted sexual abuse, 58% reported forced sexual abuse, and 44% reported both unwanted and forced sexual abuse before the age of 18 years. The mean age at the time of the abuse was approximately 11.5 years for males and 12.5 years for females. Approximately one half of the sample reported that the abuse occurred on multiple occasions. Information regarding the type of abuse by gender and the reported offender is provided in Table 1.
In regard to sexual assault, approximately 6% of the sample reported a history of sexual assault as an adult. Of these participants, 79% were women and 21% were men. The mean age of assault was 24.7 years for women and 28.6 years for men. Approximately 60% of men and 44% of women reported the assault occurred only on one occasion. Table 1 contains information regarding victim and offender characteristics for participants reporting sexual assault as an adult.
Age-adjusted odds ratios and 95% confidence intervals were calculated for the risk of sexual dysfunction with a history of childhood sexual abuse and sexual assault as an adult. For females with a history of childhood sexual abuse, an increased risk of anorgasmia for greater than 12 months was found for women between 31 and 45 years (OR 1.21, P=.009; 95% CI 1.01–1.92).
For females with a history of sexual assault as an adult; an increased risk for hypoactive sexual desire disorder was found for women who between the ages of 16 and 30 years (OR 1.51, P=.03; 95% CI 1.00–2.01), 31 and 45 years (OR 1.28; P=.02; 95% CI 1.06–1.55), 46 and 60 years (OR 1.21, P=.03; 95% CI 1.00–1.47), and 61 and 84 years (OR 1.62, P=.04; 95% CI 1.07–2.47); lubrication problems for women between 46 and 60 years for less than 12 months (OR 1.28, P=.02; 1.03–1.59) and more than 12 months (OR 1.38, P=.05; 95% CI 1.02–1.86).
For males with a history of childhood sexual abuse, the risk of sexual dysfunction was increased but not significantly for males for any age group. Males with a history of sexual assault as an adult had a significantly increased risk of retarded ejaculation for less than 12 months was found between the ages of 31 and 45 years (OR 2.00, P=.008; 95% CI 1.37–1.92) and 46 and 60 years (OR 2.11, P=.02; 95% CI 22.214.171.124).
Descriptive statistics and analysis of variance were employed to test differences by gender and history of sexual abuse or assault on assistance sought for sexual dysfunction based on gender and history of childhood sexual abuse or sexual assault as an adult. For males the profession most often sought for evaluation and treatment of their sexual dysfunction was physicians (5.6%) and urologists (4.3%) and for women, gynecologists (18%) and midwives (8.4%), which most women in Sweden with children have contact with after childbirth. Analysis of variance was performed, and women with a history of childhood sexual abuse were more likely to seek assistance for their sexual dysfunction through written help (F[1,1283]=11.1, P=.001) when compared with women without a history of childhood sexual abuse. For men, those with a history of childhood sexual abuse were more likely to seek assistance from a physician (F[1,1468]=5.3, P=.02); from psychiatry (F[1,1453]=14.3, P=.001); a minister (F[1,1451]=19.8, P=.001) or an organization (F[1,1474]=12.7, P=.001).
Consistent with other studies of clinical populations, individuals with a history of childhood sexual abuse or sexual assault as an adult were found to have greater sexual dysfunction when compared with individuals from the general population1–8,13–15. The strengths of this study are that the relationship between sexual abuse or assault and sexual dysfunction were found in a large, randomly selected sample of the general population rather than from individuals from clinics treating sexual abuse, sexual assault, or sexual dysfunction. In addition, a control group from the same general population was used to assess differences in rates of sexual dysfunction after childhood sexual abuse or sexual assault.
As expected, a history of childhood sexual abuse resulted in short- and long-term sexual consequences. Although several different sexual dysfunctions were assessed, it seemed that women with a history of childhood sexual abuse primarily reported the consequence of Orgasmic Disorder. Although childhood sexual abuse resulted in an increased risk for sexual dysfunction, only anorgasmia had a significantly increased risk compared with the general population. The increased risk may be secondary to the negative associations with sex later in adulthood and may result in the inability to enjoy and be sexually stimulated to orgasm. As reported in previous studies, males who were sexually abused as children did not report sexual dysfunctions. This does not imply that men do not experience psychological or other long-term sexual consequences as a result of childhood sexual abuse, but rather the variables included in the present study did not capture potential negative consequences of childhood sexual abuse for males.
Sexual assault, on the other hand, resulted in the report of several sexual problems for both males and females. Women with a history of sexual assault reported increased rates of Hypoactive Sexual Desire Disorder and difficulty with lubrication (less than 12 months and more than 12 months). Similarly, men with a history of sexual assault, although few in number, reported an increased risk for several dysfunctions; however, a statistically significant increased risk was reported only for retarded ejaculation (less than 12 months and more than 12 months). Controversy exists regarding the extent to which men may be traumatized by unwanted sexual advances or forced sexual contact. The results of the present study are consistent with previous research that suggests that men do experience sexual consequences as a result of sexual assault as an adult and to a lesser extent if they have a history of childhood sexual abuse.7,10,13
Interestingly, males between the ages of 31 and 84 years with a history of sexual assault as an adult reported a lower risk of hypoactive sexual disorder when compared with individuals without a history of sexual assault. Although it is difficult to explain why individuals with a history of sexual assault have lower rates of hypoactive sexual desire disorder, one explanation may be that the victims knew their offender in all cases, and no sexual assault by a stranger was reported. Post hoc analysis demonstrated that patients with a history of sexual assault had more lifetime partners than those persons in the study that did not report sexual assault. It is not to say individuals who are more sexually active are more likely to be sexually assaulted, but rather with increased number of partners, the probability of having a partner who might sexual assault you may increase.
The primary limitations to the study include the high nonresponse rate to the initial recruitment of participants. Approximately 41% of participants refused to participate. It would be expected that a large number of these participants experienced difficulties with sex and may explain why they did not participate in the study. Therefore, the reported rates of sexual abuse, assault, and dysfunction in this sample may be an underestimate. Secondly, the items that queried the participants about sexual dysfunction were not as thorough as a complete clinical assessment of sexual dysfunction and organic causes of sexual dysfunction could not be ruled out. Finally, the sample size by age group was small; however, the results reflected analyses performed for the entire population and therefore are likely reliable.
Future research should focus on predictors of sexual dysfunction and factors that may predict resilience and the absence of sexual dysfunction subsequent to childhood sexual abuse or sexual assault as an adult. For example, women who may be more likely to have sexual difficulties after childhood sexual abuse or sexual assault may have been assaulted on more than one occasion, the offender may have been someone significant to him or her, or they may have a comorbid psychological symptoms that are more likely to be associated with sexual dysfunction (eg, depression). Factors that may predict resilience may include social support, intact intimate relationship with a healthy sexual functioning, or the absence of self attributions of the abuse or assault to oneself.
Of particular importance, of the women who sought assistance the majority sought assistance for the sexual dysfunction from their gynecologists or midwives. It may be recommended that as part of routine clinical interview that clinicians working in the field of obstetrics and gynecology query patients about sexual dysfunction and history of childhood sexual abuse or assault. The cause of the sexual dysfunction may be rooted in the individual's history rather than be a result of medical conditions or medication side effects. Although men tend not to report sexual dysfunction as a result of childhood sexual abuse, sexual assault seems to have significant sexual consequences for men and a history of sexual assault, albeit rare, should also be included in a clinical interview of men presenting with a sexual dysfunction.
1. Becker JV, Skinner LJ, Abel GG, Cichon J. Level of post assault sexual functioning in rape and incest victims. Arch Sex Behav 1986;15:37–49.
2. Mullen PE, Martin JL, Anderson JC, Romans SE. Herbison GP. The effect of child sexual abuse on social, interpersonal and sexual function in adult life. Br J Psychiatry 1994;165:35–47.
3. Beitchman JH, Zucker K, Hood JE, DaCosta GA. Akman D, Cassavia E. A review of the long-term effects of child sexual abuse. Child Abuse Negl 1992;16:101–18.
4. Martinez TA. Sexual dysfunction as a sequelae of rape: a review of the literature. Rev Latinoam Sexologia 1989;4:151–61.
5. Moscarello R. Psychological management of victims of sexual assault. Can J Psychiatry 1990;35:25–30.
6. Nadelson CC, Notman MT, Zackson H, Gornick J. A follow-up study of rape victims. Am J Psychiatry 1982;139:1266–70.
7. Sarwer DB, Durlak JA. Childhood sexual abuse as a predictor of adult female sexual dysfunction: A study of couples seeking sex therapy. Child Abuse Negl 1996;20:963–72.
8. Wind TW, Silvern LE. Type and extent of child abuse as predictors of adult functioning. J Fam Violence 1992;7:261–81.
9. Holmes GR, Offen L, Waller G. See no evil, hear no evil, speak no evil: why do relatively few male victims of childhood sexual abuse receive help for abuse-related issues in adulthood? Clin Psychol Rev 1997;17:69–88.
10. Kinzl JF, Traweger C, Biebl W. Sexual dysfunctions: relationship to childhood sexual abuse and early family experiences in a nonclinical sample. Child Abuse Negl 1995;19:785–92.
11. Greenwald E, Leitenberg H, Cado S, Tarran MJ. Childhood sexual abuse: long-term effects on psychological and sexual functioning in a nonclinical and nonstudent sample of adult women. Child Abuse Negl 1990;14:503–13.
12. Kilpatrick DG, Best CL, Saunders BE, Veronen LJ. Rape in marriage and in dating relationships: how bad is it for mental health? Ann N Y Acad Sci 1988;528:335–44.
13. Masters WH. Sexual dysfunction as an aftermath of sexual assault of men by women. J Sex Martial Ther 1986;12:35–45.
14. Mackey TF, Hacker SS, Weissfeld LA, Ambrose NC, Fisher MG, Zobel DL. Comparative effects of sexual assault on sexual functioning of child sexual abuse survivors and others. Issues Ment Health Nurs 1991;12:89–112.
15. Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatry 1988;145:75–80.
16. Lewin B, Fugl-Meyer K, Helmius G, Lalos A, Masson SA. Sex i Sverige: Om sexuallivet I Sverige. Folkhalsoinstitutet 1998:11.
17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington (DC), American Psychiatric Association; 1994.