Childhood Sexual Abuse in Adolescents Adjudicated for Sexual Offenses: Mental Health Consequences and Sexual Offending Behaviors

Abstract

Most studies on the mental health consequences of childhood sexual abuse (CSA) focus predominantly on CSA survivors who do not commit sexual offenses. The current study examined the effects of CSA on 498 male adolescents adjudicated for sexual offenses who represent the small portion of CSA survivors who engage in sexual offenses. The prevalence of internalizing symptoms, parental attachment difficulties, specific sexual offending behaviors, and risk for sexually offending were compared among participants with and without a history of CSA. Results indicated that participants with a history of CSA were more likely to be diagnosed with major depression and posttraumatic stress disorder than those who did not report a history of CSA. A history of CSA was also positively correlated with risk for sexually offending and with specific offense patterns and consensual sexual behaviors. No significant differences emerged on parental attachment difficulties. These results highlight that adolescents adjudicated for sexual offenses with a history of CSA present with differences in sexual and psychological functioning as well as markedly different offending patterns when compared with those without a CSA history. Clinical implications and future directions are discussed.

Keywords

adolescent sexual abusers child sexual abuse juvenile sex offender sexual abuse victim age delinquency

Childhood sexual abuse (CSA) has been consistently identified as a general correlate of short- and long-term mental health difficulties, particularly internalizing disorders (Browne & Finkelhor, 1986; Easton, Renner, & O’Leary, 2013; Finkelhor, 1990; Fuller-Thomson, Bejan, Hunter, Grundland, & Brennenstuhl, 2012; Kendall-Tackett, Williams, & Finkelhor, 1993). CSA survivors are significantly more likely to be diagnosed with major depression, generalized anxiety, and posttraumatic stress disorder (PTSD). Longitudinal findings indicate that approximately 95% of those exposed to CSA are diagnosed with a mental health disorder before the age of 30 (Fergusson, McLeod, & Horwood, 2013). Previous findings also indicate that the experience of CSA has distinct, long-term mental health consequences when compared with other forms of abuse. Fergusson, Boden, and Horwood (2008) found that children exposed to CSA were more than twice more likely to be diagnosed with a mental health disorder later in life than individuals who were not exposed to CSA. In contrast, Fergusson et al. (2008) found that children exposed to childhood physical abuse (CPA) were only 1.4 times more likely to be diagnosed with a psychological disorder than participants who did not experience CSA. Similarly, the experience of CSA is positively correlated with the frequency of psychological treatments for mood and anxiety disorders, as well as trauma-related symptoms (Fergusson et al., 2013; Spataro, Mullen, Burgess, Wells, & Moss, 2004), which may indicate that CSA survivors are more likely to be identified as candidates for psychological treatment than the general population.

In addition to its association with the development of mental health difficulties, CSA is among the most frequently cited antecedents to the development of sexual behavior problems (Hershkowitz, 2014; Johnson & Knight, 2000; Seto & Lalumière, 2010; Worling, 1995a). The focus on CSA as a potentiating factor in the development of future maladaptive sexual behaviors is not surprising given the high prevalence of CSA reported by individuals convicted of sexual crimes. Whereas the prevalence of CSA in the general population ranges from 7% to 36% for women and from 3% to 29% for men (Pereda, Guilera, Forns, & Gómez-Benito, 2009), a meta-analysis by Jespersen, Lalumière, and Seto (2009) revealed that the prevalence of CSA in adults convicted for sexual offenses ranged from 4% to 74%, with most of the studies indicating CSA rates above 30%. Similarly, Craissati, McClurg, and Browne (2002) found that 46% of all adult males convicted of sexual crimes in England and Wales reported being survivors of CSA. The prevalence of CSA is similarly high in adolescents, with estimates indicating that as many as 40% to 52% of males convicted of sexual offenses report a history of sexual victimization (Hunter & Figueredo, 2000; Worling, 1995a). In an exhaustive meta-analysis of correlates of adolescent sexual offending, Seto and Lalumière (2010) found that male adolescents convicted of sexual offenses were nearly 6 times more likely than non-offending adolescents to have experienced CSA. Moreover, adolescents adjudicated for sexual offenses were generally more likely to develop anxiety problems than non-offending adolescents.

Mental Health and CSA Among Adolescents With Adjudicated Illegal Sexual Behavior

Despite the high prevalence of CSA in both the general population and in populations of individuals with sexual behavior problems, only a very small portion of CSA survivors commits sexual offenses. In one of the few prospective studies on the relationship between CSA and sexual offending, Hershkowitz (2014) followed a national sample of children who had been referred to public services for CSA for a period of 10 years. This prospective analysis revealed that only 2% of CSA survivors were charged with a sexual offense before the age of 14. Similarly, Salter et al. (2003) followed 224 male survivors of CSA from the ages of 7 to 19 and found that only 12% of participants committed a subsequent sexual offense. Thus, it is unlikely that CSA survivors will commit future sexual offenses.

Adolescents with a history of CSA who later develop sexual behavior problems comprise a small portion of all CSA survivors. Consequently, this unique subpopulation may be underrepresented in epidemiological and prospective studies on the association between CSA and mental health outcomes. This represents an important consideration as responses to psychological trauma are highly variable, and specific characteristics of CSA have been demonstrated to differentially potentiate the development of future mental health problems. For instance, offenses committed by family members are associated with higher rates of future psychopathology than offenses committed by peers or non-family members (Browne & Finkelhor, 1986; Marshall, Serran, & Cortoni, 2000). The severity and duration of CSA has also been found to moderate the development of future mental health problems (Easton et al., 2013). Thus, it is possible that CSA survivors who commit sexual offenses may present with differential rates of mental health and behavioral problems when compared with adolescents with sexual offense convictions who do not have a history of CSA.

Comparatively less attention has been devoted to the mental health consequences of CSA on victims who engage in sexual offending as studies have focused heavily on elucidating the developmental pathways through which the experience of CSA leads to subsequent offending. One proposed mechanism linking CSA to future sexual offending is adherence to deviant sexual fantasies by CSA survivors, which has been reported in studies of adult sex offenders (Lambie, Seymour, Lee, & Adams, 2002; Seto & Lalumière, 2010). Grabell and Knight (2009) found a similar effect in adolescents adjudicated for sexual offenses; however, the age of CSA onset moderated this effect as only those who were victimized between the ages of 3 and 7 presented with deviant sexual fantasies. CSA has also been associated with specific aspects of victim selection. Male adolescents who target male victims are more likely to report a history of CSA; furthermore, when male victims are targeted, they are generally younger than the offender (Jespersen et al., 2009; Veneziano, Veneziano, & LeGrand, 2000; Worling, 1995a). In contrast, adolescents who offend against female children and those who offend against peer-age females have not been found to differ significantly on the experience of sexual victimization (Worling, 1995b).

The mechanism through which previous sexual victimization contributes to specific aspects of subsequent sexual offending (e.g., victim selection) has also been examined through the framework of established models of sexual offending. The development of attachment difficulties has been widely implicated in the development of sexual behavior problems (Burk & Burkhart, 2003; Cortoni & Marshall, 2001; Marshall, 1989; Marshall & Marshall, 2010; McKillop, Smallbone, Wortley, & Andjic, 2012; Ward, Hudson, Marshall, & Siegert, 1995). Marshall and Barbaree (1990) highlight the impact of early attachment problems on the proclivity to sexually offend, with particular emphasis on the experience of developmentally damaging events such as sexual and physical abuse. Experiences of childhood abuse are postulated to contribute to relational and attachment problems in adolescence and adulthood (Ward, Polaschek, & Beech, 2006). Attachment difficulties that culminate in a failure to establish and maintain appropriate intimate relationships may potentiate the selection of sexual partners deemed non-threatening (e.g., younger victims), as well as attempts at fulfilling attachment needs through sexual, often aggressive, contact (Marshall, 1989; Marshall & Marshall, 2010). In a test of predictions from attachment theory, Miner et al. (2010) assessed the direct and indirect contributions of attachment difficulties and peer isolation to child sexual abuse committed by adolescents. Miner and colleagues found that adolescents who sexually abused children were more likely to present an anxious attachment style than those with adult or peer-aged victims and juvenile delinquents without a history of sexual offending. In addition, the direct effect of peer isolation accounted for attachment anxiety and reported difficulties in interpersonal relationships with girls and women.

Comparatively more is known about the effects of CSA on specific aspects of sexual offenses than about its impact on the development of mental health problems in CSA survivors who commit sexual offenses. Findings from the adult literature, however, indicate that offenders with a history of CSA differ from offenders who do not report being sexually victimized in several important domains. Those who experienced CSA are significantly more likely to have contact with mental health services and to be diagnosed with a thought disorder or alcohol abuse (Cutajar et al., 2010). Moreover, Cutajar et al. (2010) found that adult sexual offenders who were sexually abused by more than one offender were more likely to have mental health contact or be diagnosed with serious and persistent mental illness, anxiety, alcohol abuse, or a personality disorder. Accordingly, the experience of CSA is both a correlate of specific aspects of sexual offending and denotes an increased risk for the development of mental health problems (Jespersen et al., 2009; Seto & Lalumière, 2010; Worling, 1995a). Thus, early sexual victimization may be understood as a risk factor for the development of mental health concerns and a specific diathesis to potentiate a basis for victim selection algorithms (Burk & Burkhart, 2003; Craissati et al., 2002; Worling, 1995a).

As CSA survivors who develop later sexual behavior problems may be underrepresented in studies on the consequences of sexual abuse, the specific effects of CSA on adolescents adjudicated for sexual offenses remain unclear. Importantly, psychological treatments aimed at adolescents adjudicated for sexual offenses require the assessment of risk, the identification of specific areas of vulnerability, and an evaluation of each individual’s capacity to respond to treatment (Smallbone & McCabe, 2003; Ward, Melser, & Yates, 2007; Worling & Langston, 2012). Thus, in delineating interventions for adolescents, it is important to consider the effects of CSA on the individual’s general mental health, in addition to its impact on specific offense characteristics like victim selection.

Current Study

The objective of the current study was to test the general hypothesis that the prevalence of mental health problems, particularly internalizing symptoms, would be greater for adolescents convicted for sexual offenses with a history of CSA, defined as any unwanted sexual experience before the age of 12, than for those without a history of sexual abuse. Based on the extant literature on the effects of CSA on sexual behaviors and victim selection, the current study also hypothesized that when compared with non-abused peers, participants with a history of CSA would present with (a) an earlier onset of sexualized behaviors, (b) a larger number of victims than non-CSA participants, (c) a selection of younger victims, and (d) a selection of male victims compared with their peers with no history of CSA. Second, based on extant theories of sexual offending, the current study examined the impact of CSA on participants’ parental attachment. Because developmentally damaging events such as physical and sexual abuse have been implicated in the development of attachment difficulties (Marshall & Barbaree, 1990; Miner et al., 2010), participants with a history of sexual victimization were expected to present with greater attachment difficulties than their non-victimized peers.

Method

Participants

Participants consisted of 498 male adolescents who were adjudicated for a sexual offense and mandated by a Southeastern state to receive residential sex offender treatment. The average age of participants was 15.93 years (SD = 1.52 years). Demographic information indicates that 57% of participants identified as White, 39% as African American, and 3.4% identified as belonging to other ethnic and racial groups.

Procedure

The current study was approved by the Institutional Review Board of a major university in a Southeastern state in the United States and by the state’s Department of Youth Services. All participants provided their informed assent for inclusion of data in the study, whereas the legal guardian provided consent for each participant. All adolescents in the facility received a psychological assessment as part of their residential treatment. Participants were informed that although the psychological assessment was a necessary part of their treatment protocol, the inclusion of their data in a research study was completely voluntary. Moreover, participants were informed that they could withdraw their data from the study without penalty at any point during their treatment.

Approximately 2 weeks after placement in the juvenile residential treatment facility, participants underwent a comprehensive pre-treatment psychological evaluation in which extensive data were collected including indices of exposure to environmental stressors, social and developmental history, family and criminal history, as well as psychiatric functioning.

Measures

Semi-structured interview

Clinical data were obtained via a 90-min semi-structured interview that included general demographic information (e.g., date of birth, ethnicity), sexual developmental history (e.g., age of first sexual experiences, age of first masturbation), sexual victimization history (e.g., experience of sexual abuse, relationship to perpetrator), an assessment of home environment (e.g., family structure, history of abuse), and a history of delinquency and sexual offending. A history of CSA consisted of at least one unwanted sexual experience before the age of 12. History of CSA was obtained during the clinical interview when the participants were asked about their history of sexual and physical abuse and neglect. Reports of CSA were corroborated with file information including reports from the state’s Department of Human Resources (DHR). A documented report from DHR indicating a history of CSA superseded participants’ self- report (i.e., when participants did not report a history of CSA, however, DHR documented the occurrence of sexual abuse). As clinicians administering the current clinical interview were mandated reporters, each new individual disclosure of CSA (i.e., no prior DHR report) was documented and reported to DHR.

The Juvenile Sex Offender Assessment Protocol–II (JSOAP-II)

The JSOAP-II is a 28-item checklist designed to assess risk factors related to sexual and criminal offending in adolescents (Prentky & Righthand, 2003). The JSOAP-II has four factors (Sexual Drive/Preoccupation, Impulsive/Antisocial Behavior, Intervention, and Community Stability/Adjustment) and yields two summary scores: static (i.e., a typically unchanging score) and dynamic (i.e., a score that can change over time), as well as a total score. Each item is scored on a scale from 0 to 2. The absence of a risk factor, based on the item description, results in a score of 0. A score of 2 is based on the clear presence of the risk factor as outlined in the manual. A score of 1 is applied when partial evidence exists that a risk factor is present, but the evidence is insufficient to warrant a score of 2. An advanced graduate research assistant with training in risk assessment and a staff psychologist coded the interview and records for the purposes of this study. Internal consistency on the subscales was between .64 and .95, and the measure has been shown to demonstrate concurrent validity with parallel measures and sexual offense information (Parks & Bard, 2006; Righthand et al., 2005). Although the extant literature on the utility of JSOAP-II scores in predicting sexual recidivism is inconsistent, a meta-analysis by Viljoen, Mordell, and Beneteau (2012) found that aggregated correlations for total scores on the JSOAP-II significantly predicted sexual reoffending. At the factor level, the Sexual Drive/Preoccupation factor of the JSOAP-II predicted sexual reoffending but not general reoffending, whereas the Impulsive/Antisocial Behavior factor predicted both sexual and general reoffending.

The Inventory of Parent and Peer Attachment (IPPA)

The IPPA is a 28-item self-report measure of parental (i.e., adolescent to parent) and adolescent (i.e., adolescent to peer) attachment (Armsden & Greenberg, 1987). The measure utilizes 5-point Likert-type scale responses (1 = almost always true, 5 = almost never true) and yields three subscale scores: Trust, Communication, and Alienation, as well as a total score. Internal consistency for the IPPA is adequate and has been found to be between .72 and .93 (Armsden & Greenberg, 1987; Gullone & Robinson, 2005).

The Kaufman Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL)

The K-SADS-PL is a semi-structured interview used in the assessment of current and past symptoms of psychological disorders (Kaufman, Birmaher, Brent, Rao, & Ryan, 1996). The K-SADS-PL can be administered by interviewing parents, the child, or both. The present study interviewed adolescent participants alone, as they were currently detained. The K-SADS-PL takes approximately 1 hr to administer. Symptom ratings are scored using a 4-point Likert-type scale (0 = no information available, 1 = not present, 2 = subthreshold, 3 = threshold) and a dichotomous (i.e., present and not present) rating is assessed for disorders specified in the Diagnostic and Statistical Manual of Mental Disorders based on symptom severity and diagnostic criteria. A classification of subthreshold indicated symptomatology at a level that would not lead to a clinical diagnosis, but may necessitate additional investigation. Conversely, a classification of threshold indicated a sufficient level of clinical symptomatology was present and met diagnostic criteria. Interrater reliability on the K-SADS-PL has been found to be 99.7% for current diagnoses and 100% for past diagnoses; test–retest reliability has been found to be between .50 and .70 (Kaufman et al., 1997).

Data Analysis

Initially, data were examined for assumptions of normality, and no violations were observed. A missing values analysis indicated that 1.9% of participants had items missing from the dependent measures. Missing data for cases with fewer than 20% of missing values were imputed using the expectation maximum algorithm; 10 participants were excluded from the analyses due to missing data. No other statistical correctional measures were required for the present study. However, because Item 8 of the JSOAP-II addresses a history of sexual abuse and therefore presents as a confounding variable for the CSA group, this item was removed from Factor 1, Sexual Drive/Preoccupation, and the Total JSOAP-II scores in the current analyses.

Chi-square tests for independence were run to assess for differences in sexual behaviors, psychopathology, history of psychiatric treatment, and offense characteristics between participants with and without a history of CSA. Given the large number of between-group comparisons made, a Bonferroni correction for chi-square tests for independence was used to control for Type I error; results were deemed significant at the .003 alpha level. Univariate ANOVAs were run to assess for differences in victim age, victim sex, number of victims, and age of masturbation onset between survivors of CSA and adolescents with no CSA history, and between individuals with intrafamilial CSA (participant’s relationship with the perpetrator of their CSA was familial) and extrafamilial CSA (participant’s relationship with the perpetrator of their CSA was not familial) and participants with no CSA. Again, a Bonferroni correction was used to control for Type I error and ANOVA results were deemed significant at the .020 alpha level. Finally, separate MANOVAs were run to asses for differences in JSOAP-II and IPPA scores based on two independent variables: whether participants reported a history of CSA or not, intrafamilial CSA or extrafamilial CSA, and participants with no CSA.

Results

Characteristics of Sexual Abuse History

From a sample of 498 adjudicated adolescents with illegal sexual behaviors, 166 (33.3%) reported a history of CSA. Participants who reported CSA were further asked about their relationship with the perpetrator of their sexual abuse. These participants disclosed their relationships with their sexual abusers indicating the following perpetrator–participant relationships: biological or step-parent (n = 23, 14%), sibling or step-sibling (n = 13, 8%), other relative (n = 50, 30%), friend of the family (n = 36, 22%), stranger (n = 9, 5%), and other or unidentified relationship to the participant (n = 35, 21%).

Demographics

Demographic characteristics were compared between participants with CSA and participants who did not report a history of sexual abuse. The t tests were run to determine whether age and grade level differed between participants who endorsed CSA and those who denied CSA, and a chi-square test for independence was used to examine whether racial/ethnic group differences were present. Results indicated no significant differences in age (p = .214), with an average age of 15.99 years. Moreover, no between-group differences were observed on grade level (M = 8.65, p = .955). There were significant differences in race/ethnicity and reported CSA, χ²(4) = 29.25, p < .001, as the majority of participants who disclosed CSA identified as White (72%), whereas only 23% identified as Black/African American, and 4% of participants identified as Other racial/ethnic group.

Illegal Sexual Behaviors

Several offense characteristics associated with illegal sexual behavior were examined among participants with and without a history of CSA (Table 1). Although both groups had a comparable number of victims, F(1, 496) = 0.05, p = .823, participants differed on important offense characteristics. Participants with a history of CSA had significantly younger victims than participants who did not report CSA, F(1, 482) = 8.71, p = .003. In addition, CSA participants were more likely to offend against a male victim (42% vs. 25%), χ²(1) = 15.86, p < .001, and reported offending against fewer female victims.

Table 1.

Offense Characteristics.

	Sexual abuse		No sexual abuse
	M	SD	M	SD
No. of victims	1.28	0.77	1.30	0.89
Victim age in years	8.23	4.40	9.41	5.14
	Sexual abuse (n = 166)		No sexual abuse (n = 332)		Odds ratio [95% confidence interval]
	n	%	n	%	Odds ratio [95% confidence interval]
Female victim**	96	57.83	247	75.30	0.77 [0.67, 0.89]
Male victim**	70	42.20	81	24.70	1.71 [1.32, 2.21]

p < .001.

Risk of Sexual Reoffending

As it was hypothesized that adolescents with illegal sexual behavior who disclosed CSA would present with differential risk for sexual reoffending, a MANOVA was run with scores on all four JSOAP-II factors and the Total JSOAP-II score as the dependent variables. The omnibus model was significant (Wilks’s Λ = .91), F(4, 493) = 12.07, p < .001 (see Table 2). Follow-up ANOVAs indicated that a history of CSA was associated with significantly higher scores on Sexual Drive/Preoccupation, F(1, 496) = 19.26, p < .001, d = .40, and Impulsive/Antisocial Behavior, F(1, 496) = 8.53, p = .004, d = .28. Moreover, participants who reported CSA had lower Intervention Items scores, F(1, 496) = 10.02, p = .002, d = .31. There were no significant between-group differences on Community Stability/Adjustment, F(1, 496) = 0.19, p = .662, nor were there significant between-group differences on Total JSOAP-II score, F(1, 496) = 2.49, p = .115.

Table 2.

JSOAP-II and IPPA Scores.

	No sexual abuse		Sexual abuse^a		Intrafamilial sexual abuse		Extrafamilial sexual abuse
	M	SD	M	SD	M	SD	M	SD
JSOAP-II Factor 1	2.79	2.30	3.84	2.86	4.00	2.72	4.89	2.94
JSOAP-II Factor 2	7.15	3.75	8.21	3.80	8.56	3.96	7.29	3.82
JSOAP-II Factor 3	8.39	3.32	7.37	3.22	7.28	3.18	7.40	3.30
JSOAP-II Factor 4	3.39	2.14	3.56	2.25	3.56	2.27	3.56	2.51
IPPA Comm	35.33	6.83	34.52	7.2	34.7	6.65	35.42	7.90
IPPA alienation	18.90	7.13	19.10	7.0	18.84	7.14	18.78	6.73
IPPA trust	37.4	7.43	35.91	7.9	35.64	7.53	37.87	7.60

Note. JSOAP = Juvenile Sex Offender Assessment Protocol; IPPA = Inventory of Parent and Peer Attachment; Comm = Communication.

JSOAP-II Factor 1 scores in the CSA group do not include Item 8.

An additional MANOVA was conducted to assess whether JSOAP-II factor and total scores differed as a function of familial CSA (i.e., intrafamilial CSA, extrafamilial CSA, and no CSA; Table 3). The omnibus model was significant (Wilks’s Λ = .91), F(8, 984) = 6.28, p < .001. Follow-up ANOVAs indicated significant between-group differences on the following scales: Sexual Drive/Preoccupation (p < .001), Impulsive/Antisocial Behavior (p = .007), and Intervention Items (p = .007), and no between-group differences on Intervention Items (p = .841) and JSOAP-II Total scores (p = .209). Post hoc pairwise comparisons using Tukey’s honestly significant difference test (HSD) indicated that on Sexual Drive/Preoccupation, participants with no CSA scored significantly lower than both participants with a history of intrafamilial CSA (p < .001) and extrafamilial CSA (p = .016); however, participants with a history of intrafamilial CSA did not have statistically significantly different scores than participants with extrafamilial abuse (p = .661). On Impulsive/Antisocial Behavior, non-CSA participants scored significantly lower than participants with a history of intrafamilial CSA (p = .007), but not statistically differently than participants with extrafamilial CSA (p = .323), and scores among intrafamilial and extrafamilial CSA groups were comparable (p = .436). Similarly, on Intervention Items, participants with a history of intrafamilial CSA had significantly higher scores than non-CSA participants (p = .018) but not statistically different than participants with a history of extrafamilial CSA (p = .922); furthermore, differences in scores between participants with extrafamilial CSA and those without a history of CSA displayed marginal significance (p = .078).

Table 3.

Psychopathology and History of Psychological Treatment.

	Sexual abuse (n = 166)		No sexual abuse (n = 332)		Odds ratio (95% confidence interval)
	n	%	n	%	Odds ratio (95% confidence interval)
Depression**	80	48.19	116	34.94	1.40 [1.11, 1.71]
PTSD**	69	41.57	72	21.69	1.92 [1.5, 2.52]
GAD	37	22.29	63	18.98	1.17 [0.807, 1.66]
Prior psychological tx**	136	81.93	200	60.24	1.36 [1.21, 1.52]
Prior psych med**	121	72.89	164	49.40	1.50 [1.3, 1.7]
Current psych med**	65	39.16	68	20.48	2.0 [1.44, 2,54]
	Intrafamilial CSA		Extrafamilial CSA		Odds ratio (95% confidence interval)
	n	%	n	%	Odds ratio (95% confidence interval)
Depression*	37	43.02	28	62.22	1.45 [1.04, 2.02]
PTSD	34	39.53	20	44.40	1.12 [0.74, 1.7]
GAD	20	23.26	12	26.70	1.15 [0.62, 2.13]

Note. PTSD = posttraumatic stress disorder; GAD = generalized anxiety disorder; tx = treatment; Psych med = psychotropic medication; CSA = childhood sexual abuse.

p <. 05. **p < .001.

Psychopathology Associated With Sexual Abuse History

To test the hypothesis that adolescents with illegal sexual behaviors with a history of sexual victimization present higher rates of internalizing psychopathology, chi-square tests for independence were conducted on the following K-SADS-PL variables: major depressive disorder, generalized anxiety disorder, and PTSD. In addition, psychotropic medication usage and whether psychotherapeutic services had been received were compared between the two groups (Table 3).

Participants who disclosed CSA reported significantly more symptoms of major depressive disorder (48%) than participants with no CSA (35%), χ²(1) = 8.14, p = .004; odds ratio = 1.73, confidence interval (CI) = [1.19, 2.53]. Follow-up comparisons indicated comparable levels of major depressive disorder symptoms (p = .167) among participants who experienced intrafamilial CSA (43%) compared with participants who experienced extrafamilial CSA (54%). In addition, PTSD symptom levels were significantly higher for participants with a history of CSA (42%) than for participants who did not report a history of sexual abuse (22%), χ²(1) = 21.55, p < .001; odds ratio = 2.57, CI = [1.72, 3.85]. A follow-up chi-square test for independence showed equivalent levels (p = .582) of PTSD symptoms among participants who experienced intrafamilial CSA (40%) compared with participants who experienced extrafamilial CSA (44%). Follow-up comparisons indicated no differences in symptoms of generalized anxiety disorder among participants who experienced intrafamilial CSA (23%) compared with participants who experienced extrafamilial CSA (21%; p = .76). Conversely, rates of generalized anxiety disorder did not differ as a function of CSA, χ²(1) = 0.62, p = .431; odds ratio = 1.20, CI = [0.76, 1.90].

Regarding treatment seeking, participants with a history of CSA (82%) were more likely to have received psychotherapeutic services than participants with no CSA history (60%), χ²(1) = 23.71, p < .001; odds ratio = 0.33, CI = [0.21, 0.53]. In addition, participants who reported CSA (73%) were significantly more likely than participants with no CSA (49%) to have been prescribed psychotropic medication, χ²(1) = 24.96, p < .001; odds ratio = 0.36, CI [0.24, 0.54], and also were significantly more likely (39% vs. 21%) to be using psychotropic medication on their admission to the detention facility, χ²(1) = 19.72, p < .001; odds ratio = 0.40, CI [0.27, 0.60].

Between-Groups Differences in Sexual Behaviors

Participants were compared on their history of consensual sexual experiences and sexual behaviors (Table 4). Participants with a history of CSA reported significantly higher rates of oral sex (10% vs. 3%), χ²(1) = 10.01, p = .002, odds ratio = 3.32, CI = [1.52, 7.28]; vaginal sex (56% vs. 41%), χ²(1) = 10.45, p = .001, odds ratio = 0.54, CI = [0.37, 0.79]; and anal sex (19% vs. 9%), χ²(1) = 9.90, p = .002, odds ratio = 2.32, CI = [1.36, 3.96], a finding that is not surprising, yet interesting, given that survivors of CSA were more likely to select male victims. Participants in both groups reported comparable use of pornographic material (51% for the CSA group vs. 42% for the non-CSA group; p = .075), and they were equally likely to report masturbation (90% for the CSA group vs. 89% for the non-CSA group; p = .541). Despite finding comparable reports of masturbation, results from a t test indicated a significant difference in age of masturbation onset, t(439) = 2.90, p = .004, with participants with a history of CSA (M = 12.01 years, SD = 1.68 years) reporting masturbating at an earlier age than participants with no CSA history (M = 12.55 years, SD = 1.95 years). No significant group differences were found regarding masturbation frequency (i.e., number of times weekly).

Table 4.

Consensual Sexual Behaviors.

	Sexual abuse		No sexual abuse		Odds ratio (95% confidence interval)
	n	%	n	%	Odds ratio (95% confidence interval)
Oral sex**	17	10.2	11	3.3	3.1 [1.5, 6.4]
Vaginal sex**	68	40.96	187	56.33	1.40 [1.13, 1.61]
Anal sex**	32	19.28	31	9.34	2.1 [1.31, 3.30]

p < .001.

Parent–Child Attachment

The experience of sexual victimization was hypothesized to be associated with parental attachment difficulties. To test this hypothesis, a MANOVA was conducted with IPPA scores as criteria. The omnibus model was not significant (Wilks’s Λ = .99), F(3, 494) = 1.61, p = .187, indicating adolescents with adjudicated illegal sexual behaviors who also reported a history of CSA did not differ significantly from their non-victimized peers in parental attachment difficulties (Table 2). A MANOVA was conducted to assess whether relationship to the abuser (i.e., intrafamilial, extrafamilial) affected parent–child attachment levels. The omnibus model for this analysis was also not significant (Wilks’s Λ = .98), F(3, 121) = 0.81, p = .486. Findings suggest CSA participants who experienced intrafamilial CSA did not differ significantly in parent–child attachment scores from CSA participants who experienced extrafamilial CSA or participants with no CSA.

Discussion

Consistent findings indicate that the experience of CSA contributes to significant and long-lasting psychological problems (Beitchman et al., 1992; Browne & Finkelhor, 1986). Despite consistent findings highlighting the deleterious future consequences of CSA, the extant sexual abuse literature also indicates that a majority of CSA victims do not develop future sexual behavior problems (Hershkowitz, 2014). However, the present findings indicate that the few adolescents with a history of CSA who are later adjudicated for sexual offenses present differences in sexual and psychological functioning as well as offending patterns when compared with those without a history of CSA. Despite empirical evidence which indicates that CSA survivors are unlikely to develop sexual behavior problems (e.g., Fromuth & Burkhart, 1989), the experience of CSA represents a developmentally harmful event for adolescent CSA victims who are later adjudicated for sexual offenses.

Findings from the current study elucidate two important characteristics of CSA in adolescents who engage in sexually inappropriate behaviors. First, the prevalence of sexual abuse among adolescents with adjudicated sexual offenses is high, with those reporting CSA comprising approximately one third of the current sample. These results are consistent with previous findings illustrating the high incidence of CSA within adolescent forensic samples (e.g., Burton, Miller, & Shill, 2002; Hunter & Figueredo, 2000). Second, approximately half of participants who reported CSA indicated a familial relationship with their abusers. Because intrafamilial sexual abuse is associated with significantly negative, long-term mental health outcomes, this finding is of particular relevance to treatment planning for adolescents with adjudicated sexual offenses who have a history of CSA (Browne & Finkelhor, 1986; Easton et al., 2013; Fergusson et al., 2008).

Sexual Behaviors and Offense Characteristics

Participants with a history of CSA reported a distinct set of consensual sexual behaviors when compared with their peers who did not disclose CSA. The current findings indicate that CSA was associated with an earlier onset of masturbation, consistently with previous research (e.g., Smallbone & McCabe, 2003), and a higher prevalence of both vaginal intercourse and anal sex. Moreover, CSA participants were more likely to offend against male victims and younger victims. These findings may indicate that the experience of CSA potentiates early sexualization, because the onset of normative sexual behaviors appears to occur at an earlier age in the CSA group relative to the group with no CSA history. Findings from the present study are also consistent with the victim selection patterns of adults with sexual offense convictions, largely because adult offenders with a history of CSA are more likely to offend against males (Craissati et al., 2002). Thus, the experience of CSA is not only related to specific consensual sexual behaviors among adolescents with adjudicated sexual offenses, but it is also correlated with specific offense characteristics.

One of the most significant differences between participants with a history of CSA and those with no such history was a higher risk for sexual recidivism among participants with CSA. Another large difference was the demonstration of greater sexual preoccupation, greater impulsivity, and more severe antisocial conduct among participants with a history of CSA compared with participants who did not report CSA. These findings may indicate that the participants who experienced CSA have unique treatment needs. Furthermore, our findings indicate CSA was not significantly associated with environmental stability, which is important in understanding CSA as a harmful developmental event that may be distinct from exposure to physical abuse or environmental violence (Fergusson et al., 2008).

Psychological Functioning

Participants who reported CSA were more likely to have symptoms of major depressive disorder and PTSD. However, rates of generalized anxiety did not differ significantly between CSA and non-CSA participants, despite PTSD symptoms being observed at significantly higher rates in the presence of CSA. Such findings may indicate that anxiety symptoms reported by participants with a history of CSA are centered on the experience of emotional trauma, likely alongside the experience of sexual abuse. Notably, these findings indicate that adolescent CSA survivors who are later adjudicated for sexual offending behaviors present a similar pattern of mental health difficulties when compared with CSA survivors in the general population (Fergusson et al., 2008).

Beyond internalizing symptoms associated with mental health disorders, adolescents who disclosed CSA were more likely to have received psychological treatment and to have been prescribed psychotropic medications. Findings of increased contact with mental health care providers parallel those found by Cutajar et al. (2010) and suggest that participants who report CSA may have a greater need for psychological services. However, it is likely that the non-CSA group could also benefit from psychological services, particularly because internalizing problems were observed, albeit with lower prevalence, in the non-CSA group.

Attachment

Although we anticipated that parent–child attachment would be affected by CSA, parental attachment did not differ as a function of the experience of CSA or as a function of intrafamilial CSA. It is possible that a ceiling effect might account for the lack of differences in the degree of parental attachment difficulties among CSA and non-CSA participants as adverse developmental events (e.g., exposure to domestic violence) characterize the histories of most adolescents involved with the juvenile justice system (Marshall & Marshall, 2010; Miner et al., 2010). This interpretation is supported by our finding that CSA and non-CSA participants did not differ in community stability scores, which may be seen as a distal indicator of general interpersonal interactions.

Implications for Sexual Offender Treatment

The current findings have several clinical implications. The higher prevalence of depressive and trauma-related difficulties in participants with a history of CSA is an important consideration in the assessment of immediate needs and in treatment planning. Notably, the higher prevalence of internalizing psychopathology in the CSA group closely resembles the relationship between CSA and mental health difficulties in the general population of CSA survivors (Fergusson et al., 2008). Keeping these results in mind, one important clinical consideration regarding evidence-based interventions for illegal sexual behaviors may be to orient treatment toward the resolution of maladaptive sexual behaviors while also focusing on the amelioration of trauma symptoms that may contribute to future sexual offenses (McMackin, Leisen, Cusack, LaFratta, & Litwin, 2002; Ricci & Clayton, 2008). Although the high prevalence of trauma-related difficulties in forensic populations is well documented, trauma-informed care is not ubiquitous in forensic settings. For instance, in a study of the relationship between CSA and PTSD in adolescents receiving sex offender treatment, McMackin et al. (2002) found that despite a 65% overall prevalence rate of PTSD and an 86% rate for those who experienced both sexual and physical abuse, only 26% of participants received trauma-focused group treatment. Ultimately, addressing trauma-related symptoms that contribute to sexual offenses may be useful in reducing the risk for reoffending.

It is important to note, however, that some CSA victims do not develop psychological difficulties following the experience of abuse. Several studies have found that between 21% and 49% of CSA victims remain asymptomatic (Caffaro-Rouget, Lang, & vanSanten, 1989; Conte & Schuerman, 1987; Kendall-Tackett et al., 1993; Mannarino & Cohen, 1986; Tong, Oates, & McDowell, 1987). Kendall-Tackett et al. (1993) provide several possible explanations for these findings. First, current assessment instruments may not be sensitive or specific enough to capture a broad range of psychological symptoms associated with CSA. Another possible explanation is that the onset of psychological difficulties varies significantly among CSA victims; therefore, whereas some participants in cross-sectional samples may demonstrate clinical symptoms, others may manifest mental health concerns in the future. Gomes-Schwartz, Horowitz, Cardarelli, and Sauzier (1990) found that 30% of a sample of asymptomatic CSA victims developed symptoms during an 18-month follow-up. Finally, one explanation is that some children and adolescents may not be affected by their abuse due to its severity and duration or the child’s resiliency factors. For such children, trauma-focused treatment may be unwarranted, which highlights a need for individualized assessment and treatment of CSA victims.

In addition, an elevated level of sexual preoccupation in the CSA group may be relevant for treatment planning as hypersexual behaviors may be more salient treatment targets for CSA survivors. Similarly, higher sexual preoccupation should be considered in safety planning and in the development of relapse-prevention strategies. Addressing alternative, adaptive coping mechanisms as a means of anxiety reduction may reduce the reliance on sexually inappropriate behaviors, which is consistent with current treatment modalities that incorporate skills such as fulfilling developmentally appropriate needs through healthy, adaptive behaviors. In addition, the current findings may suggest that some participants experienced one of their first, if not first, sexual experiences through abuse, particularly abuse by a family member. This finding suggests that treatment planning for CSA participants should focus on addressing the development of healthy, pro-social relationships and the establishment of appropriate interpersonal and sexual boundaries. Accordingly, psychoeducation may be essential in addressing sexual behavior problems related to early, abusive sexualization.

Limitations

As the treatment protocol from which the data for the current study were derived was designed to address sexual offenses, it was less oriented toward the CSA experiences of participants who commit sex offenses. Thus, the data gathered regarding specific aspects of participants’ sexual victimization were somewhat limited (e.g., did not include level of force). The absence of these and related data comprises an important limitation as the correlates of severity of CSA could not be assessed. Another limitation of the current design was the use of pre-treatment data as psychological treatment tends to potentiate the report of CSA experiences (Hunter & Figueredo, 2000). Thus, it is possible that the pre-treatment prevalence of CSA was significantly lower than rates of CSA reported during treatment or post-treatment. Nevertheless, even if CSA is underreported before treatment, clinically meaningful effects were correlated with the willingness to report the experience of CSA before the formation of a therapeutic alliance (i.e., for participants for whom DHR reports indicating CSA were not available). In addition, the sample is comprised of a specific subpopulation of adolescents who have a history of CSA, a history of adjudicated sexual offenses, and are currently in treatment. Therefore, the results may not generalize to other adolescent populations (e.g., other trauma survivors, confined adolescents with non-sexual offenses). Finally, the present study utilized self-report measures primarily (e.g., self-report of CSA, IPPA, and K-SADS-PL). Implementing other assessments measuring different types of parental attachment and using multiple instruments may provide a more accurate assessment of attachment difficulties. Furthermore, the use of objective measures of internalizing symptoms and trauma experiences, rather than self-report, is warranted in future studies.

Conclusion and Future Directions

Adolescents with adjudicated illegal sexual behaviors who report a history of CSA present with several unique characteristics when compared with adolescents who do not have a history of CSA. During treatment planning, it is important to note that CSA is associated with increased depressive and posttraumatic symptoms along with an increased risk of sexual offending. Therefore, future studies should assess whether these presenting problems are associated with differential responses to treatment when compared with adolescents without a history of CSA.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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