Child sexual abuse, attachment style, and depression: the role of the characteristics of abuse.

535101 research-article2014

JIVXXX10.1177/0886260514535101Journal of Interpersonal ViolenceCantón-Cortés et al.

Article

Child Sexual Abuse, Attachment Style, and Depression: The Role of the Characteristics of Abuse

Journal of Interpersonal Violence 2015, Vol. 30(3) 420–436 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260514535101 jiv.sagepub.com

David Cantón-Cortés, PhD,1 María Rosario Cortés, PhD,2 and José Cantón, PhD2

Abstract The aim of the current study was to examine the effects of secure, avoidant, and anxious attachment styles on depressive symptomatology in child sexual abuse (CSA) among young female adult victims. The role of attachment style was studied by considering possible interactive effects with the type of abuse, the relationship with the perpetrator, and the continuity of abuse. Participants were 168 female victims of CSA. Information about the abuse was obtained from a self-reported questionnaire. Attachment style was assessed with the Attachment Style Measure (ASM), and the Beck Depression Inventory (BDI) was used to assess depressive symptomatology. Secure and anxious attachment styles were correlated with low and high depression scores respectively. The effects of attachment style were stronger in cases where the abuse consisted of oral sex/penetration, a non-family member as perpetrator, and in isolated, compared with continued, abuse. These results confirm that characteristics of CSA (type of abuse, relationship with the perpetrator, and continuity of abuse) can affect the impact of attachment style on depressive symptomatology.

1University 2University

of Málaga, Spain of Granada, Spain

Corresponding Author: David Cantón-Cortés, Facultad de Psicología, Department of Developmental and Educational Psychology, University of Málaga, Campus de Teatinos, Málaga 29071, Spain. Email: [email protected]

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Keywords child sexual abuse, attachment, abuse characteristics, depression

Introduction Studies have consistently shown that survivors of child sexual abuse (CSA) experience a myriad of social and psychological difficulties, including interpersonal, sexual, and emotional disorders (Beaudoina, Hébert, & Bernier, 2013; Han et al., 2013; Mikaeili, Barahmand, & Abdi, 2013; Pereda, 2010). However, the psychological adjustment to CSA varies widely (CantónCortés, Cortés, & Cantón, 2012). Thus, several variables have been investigated for their potential influence on the healing process after CSA. Some studies have highlighted the important role of abuse characteristics, such as the type of acts experienced, the frequency of these acts, and the type of victim–perpetrator relationship (Lemieux & Byers, 2008; Ullman, 2007). However, other studies have indicated that sociocognitive factors outweigh abuse characteristics in determining psychological adjustment (CantónCortés, 2013). These sociocognitive factors include variables such as social support (Rakow, Smith, Begle, & Ayer, 2011), attribution of blame (Esnard & Dumas, 2013), the emotional response to abuse (Dorahy & Clearwater, 2012), and the attachment style of the victim (McElheran et al., 2012). The present research focused on the role of attachment style of CSA victims on depressive symptomatology. As proposed by Bowlby (1969), attachment theory is derived from the idea that interpersonal relationships and social support are an innate necessity for people. Children develop internal working models of significant others depending on the quality of early interpersonal experiences (e.g., caregiver responsiveness and support). Based on these models, expectations of the availability of support and how to obtain that support and protection are created by the child (Bowlby, 1988). Theoretically, these representations influence an individual’s emotions, expectations, and relationship behavior in all close relationships (Cantón & Cortés, 2008). Based on the work of Bowlby (1969) and Ainsworth and Wittig (1969), three attachment styles have been identified: secure, avoidant, and ambivalent. Secure attachment is developed when the primary caregiver responds to the child’s distress on a consistent basis, thus promoting trust in relationships. An avoidant attachment style is developed when a child’s distress is consistently ignored or he or she is rejected on a continuous basis. This pattern results in an avoidance of seeking attachment figures for support and protection, and diminishes the ability to express emotions appropriately. Finally, an anxious-ambivalent attachment style develops when a child’s distress is


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responded to on an inconsistent basis leading to a high level of anxiety and difficulty in expressing emotions. Research has shown that the effects of attachment style are carried into adulthood and can influence parenting and peer relationships, as well as romantic relationships (Bartholomew & Shaver, 1998; Kim, Trickett, & Putnam, 2011). It has been suggested (Mikulincer & Florian, 2004) that a secure attachment style is related to a healthy regulation of negative affect, and can act as a protective factor in the ability to lower anxiety arising from stressful events. Conversely, an insecure attachment style leads to an unproductive and excessive focus on negative emotions, or turning away from feelings of distress, leading to inappropriate emotional regulation (Moran, Neufeld, Gleason, Deoliveira, & Pederson, 2008). The effects of attachment style on an individual’s adjustment following a stressful event such as CSA have been analyzed. To date, several relationships have been found between attachment style and psychological adjustment among victims of CSA (Beaudoina et al., 2013; Dimitrova et al., 2010; Lutz-Zois, Phelps, & Reichle, 2011; McElheran et al., 2012; Pierrehumbert et al., 2009). Beaudoina et al. (2013) analyzed the role of parental psychological distress, characteristics of the abuse, and child attachment style on symptomatology in a sample of 116 preschool-aged child victims of sexual abuse. Disorganized/disoriented attachment, along with parental psychological distress and intra-familial CSA, predicted internalizing behavior problems. Externalizing problems were predicted by disorganized/disoriented attachment, avoidant attachment, and child age. Dimitrova et al. (2010) studied the effects of interpersonal relationships on the psychological well-being of a sample of 28 women who had experienced episodes of CSA and 16 control women (no CSA). The closeness dimension of attachment (being comfortable with close relationships) was found to mediate the severity of CSA effects on the survivor’s psychological functioning (the higher the closeness score, the better the psychological adjustment). The present study analyzed the role of attachment styles in depressive symptomatology of adult female victims of CSA. It was hypothesized that higher levels of avoidant and anxious attachment would result in higher depression scores while higher levels of secure attachment would result in lower depression scores. An intrinsic problem of retrospective studies that maintain the anonymity of participants is the use of a single source of information (the participant) to assess both attachment style and adjustment. According to common method variance, it can be argued that individuals with poorer psychological adjustment may be more likely to assess themselves as maintaining an avoidant and anxious attachment and are less likely to present a secure attachment



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(Dimitrova et al., 2010). However, real interactions may be lessened by correlated error (Rodríguez, Bravo, Peiró, & Schaufeli, 2001), and the possible existence of interactive relationships would indicate that the effects found cannot be easily attributed to method variance (Escamilla-Quintal, RodríguezMolina, Peiró, & Marco, 2008). Thus, a second objective of the current research was to obtain results that would exclude a bias due to measuring both variables (attachment style and depressive symptomatology) simultaneously. The assumption that the effects of attachment style on depression may be different depending on the characteristics of CSA guided the design of the study. Therefore, the expected tendency of individuals with poorer adjustment to show higher scores on avoidant and anxious attachment style and lower scores on secure attachment style would be unlikely to explain results supporting the previous argument. Based on the latter assumption, the hypothesis formulated was that the role of attachment style on depression would vary substantially when taking into account the interactive effects with the type of abuse suffered, the relationship to the perpetrator, and the continuity of the abuse.

Methods Participants The initial sample consisted of 2,381 women students from the University of Granada (Spain), aged between 18 and 24 years (M = 19.50; SD = 1.69). Onehundred eighty participants (7.55%) from the sample reported experiencing some type of sexual abuse involving physical contact prior to age 14. Twelve participants were excluded from the analysis because they did not complete all the questionnaires. Thus, the final sample consisted of 168 CSA victims, with an average age of 19.83 (SD = 1.70). With respect to family structure, 79.8% came from intact families, 7.7% from a divorced family, 6.5% from a household with a deceased parent, 4.2% from a household with a remarried parent, and 1.8% from an adoptive family. Regarding the highest educational level completed by the victims’ parents, 23.4% of their fathers and 27.1% of their mothers had completed primary studies; 21.5% of fathers and 22.9% of mothers had completed compulsory secondary studies; 8.2% and 9.6% had completed a non-compulsory vocational training cycle; 17.7% and 21.1% had completed non-compulsory secondary studies; and 29.1% and 19.3% had received a college degree.

Instruments Childhood Sexual Abuse Questionnaire. The Childhood Sexual Abuse Questionnaire collects sociodemographic and CSA-related information Downloaded from jiv.sagepub.com at UZH Hauptbibliothek / Zentralbibliothek Zürich on January 1, 2015

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anonymously. Participants report their age and gender, and answer a series of questions regarding experiences with CSA, such as the type of abuse suffered (touching vs. penetration/oral sex), relationship with the perpetrator (member of the family vs. non-member), continuity of abuse (an isolated incident, several incidents or continued abuse), and the age at which abuse happened or started in the case of continuous abuse. The definition of CSA provided to participants to identify themselves as victims is contacts and sexual interactions between a minor and an adult or between minors if there is a 5-year age difference between them or if the child/adolescent perpetrator is in a situation of power or control over the victim, even if there is no age difference. (Hartman & Burgess, 1989; pp. 95-128)

To create a behavioral definition, the questionnaire listed a series of sexual activities and asked participants to indicate which ones they had experienced. The activities ranged from situations involving no physical contact, to those involving the touching of erogenous zones, to oral sex and/or penetration. The above information was used for participant inclusion/exclusion criteria. For the present study, CSA victims were confined to those for whom the abuse began prior to age 14. Moreover, only incidents consisting of touching or penetration were considered as sexual abuse (episodes of exhibitionism were excluded from the definition). This questionnaire also allows the assessment of other forms of abuse and neglect during childhood. Five questions were included with regard to emotional abuse (How often did a parent or caregiver act in a way that made you afraid of being physically hurt?), physical abuse (How often did a parent or caregiver slap or hit you?), and neglect (How often did a parent or caregiver ignore your need for affection?). Questions were answered on a 1 to 5 Likerttype scale with the categories never, once or twice, sometimes, often, or very often. Participants were identified as being victims of physical or emotional abuse or neglect during childhood if they responded often or very often to at least one question. Attachment Style Measure (ASM). The ASM (Simpson, 1990) is a self-reported, 13-item scale developed to expand on Hazan and Shaver’s Adult Attachment Styles (AAS; Hazan & Shaver, 1987). The AAS was developed based on descriptions of avoidant, secure, and anxious-ambivalent attachment styles. Using the AAS, participants classify themselves in accordance with one of three attachment vignettes, each representing one mutually exclusive attachment category. Alternatively, the ASM seeks to establish a more precise measure of an individual’s attachment style by breaking down the three categories Downloaded from jiv.sagepub.com at UZH Hauptbibliothek / Zentralbibliothek Zürich on January 1, 2015


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of the AAS into 13 items. Each item corresponds to one of the three attachment vignettes (from the AAS) and participants respond on a 7-point Likerttype scale, ranging from strongly disagree (1) to strongly agree (7). Thus, the scale assess three types of adult attachment: secure (5 items, e.g., “I find it relatively easy to get close to others”), avoidant (4 items, e.g., “Others often want me to be more intimate than I am comfortable being”), and anxious attachment (4 items, e.g., “I often worry that my partner(s) don’t really love me”). Sperling, Foelsch, and Grace (1996) found the ASM to be the best instrument for examining attachment in a continuous way, largely due to the direct link to Ainsworth and colleagues’ attachment style distinctions. These authors reported internal consistencies (Cronbach’s alpha) of 0.70 for the secure style, 0.82 for the avoidant style, and 0.65 for the anxious style scale. Beck Depression Inventory (BDI). The BDI (Beck, Rush, Shaw, & Emery, 1990) is the most widely used self-assessment inventory for measuring depressive symptoms, due to its psychometric qualities. It contains 21 items with responses ranging from 0 to 3. It has a test–retest reliability of 0.86 and an internal consistency of 0.86.

Procedure In a classroom setting, participants anonymously completed the CSA, the ASM, and the BDI, as described above. Participants who had been abused by different perpetrators at different times were asked to answer questionnaires regarding their most traumatic experience. Permission to conduct the study was obtained from the ethical committee of the University of Granada. Participation was voluntary and participants signed an informed consent. Participants were offered extra credit for their participation. To maintain anonymity of the CSA victims, non-CSA volunteers completed questionnaires relating to a different significant negative experience. We guaranteed the confidentiality of the data by identifying the surveys with a numerical code. Statistical analyses were performed with IBM SPSS (Statistical Package for the Social Sciences) version 20. Following protocol (Cohen & Cohen, 1983), centered scores were used as a means of addressing the problem of multicollinearity. Interaction analyses were carried out following the Aiken and West (1991) procedure (see also Cohen & Cohen, 1983).

Results Descriptive data for all measures are displayed in Table 1 and Table 2. A multiple regression analysis (Table 3) was conducted for BDI scores to test


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Table 1. Depression Symptomatology and Attachment Styles. Variable BDI score Secure attachment Avoidant attachment Anxious attachment

M

SD

Minimum

Maximum

9.77 11.97 11.65 6.93

7.16 2.14 2.60 2.03

0 4 5 0

35 18 19 12

Note. BDI = Beck Depression Inventory.

Table 2. Characteristics of Abuse and Existence of Other Maltreatments. Variable

n

%

Other maltreatments Type of abuse Touching Oral/penetration Relationship with perpetrator Non-family member Family member Continuity of abuse Isolated Several incidents Continued

40

23.8

125 43

74.4 25.6

59 109

35.1 64.9

73 42 53

43.5 25 31.5

the relative effects and the proportion of variance explained by attachment style on depressive symptomatology, controlling for the characteristics of the abuse, and the existence of other maltreatments. The other maltreatment variable, along with the type of abuse, relationship with the perpetrator and continuity of abuse were introduced in a first step, while the types of attachment were introduced in the second step. After introducing the three attachment styles (Step 2), the regression final model, with an adjusted R2 = 0.258, showed that both secure (β = −0.19, p < .01) and anxious attachment (β = 0.36, p < .001) were related to BDI scores. However, there was no significant relationship between the avoidant attachment score and BDI score of victims (β = −0.13, ns). The relationships between other maltreatments and type of abuse with depressive symptomatology remained significant (β = 0.13, p < .05 and β = 0.15, p < .05, respectively). Three hierarchical multiple regression analyses (Tables 4, 5, and 6) were performed to test the hypothesis that the relationship between attachment


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Cantón-Cortés et al. Table 3. Regression Analysis of Depression Symptomatology According to Attachment Style, Controlling for the Characteristics of the Abuse and Other Maltreatments in CSA Victims. Variable Step 1 Other maltreatment Type Relationship Continuity Step 2 Other maltreatment Type Relationship Continuity Secure attachment Avoidant attach Anxious attach

Adjusted R2 Δ

FΔ

.068

4.058**

B 3.18 3.07 0.47 −1.04

.19

14.866*** 2.15 2.50 −0.96 0.73 −0.63 −0.37 1.28

SE 6.91 1.827 1.28 0.68 1.17 6.17 1.16 1.15 1.05 0.61 0.24 0.20 0.25

β .19 .18 .05 −.07 .13 .15 −.06 .08 −.19 −.13 .36

t 2.49** 2.40* 0.69 −0.89 1.86* 2.17* −0.91 1.19 −2.54** −1.88 5.11***

Note. CSA = child sexual abuse. *p < .05. **p < .01. ***p < .001.

style and depression score varies according to abuse characteristics. The interactions of attachment styles × CSA characteristics were tested using a three-step regression approach. In three different hierarchical multiple regressions, all the characteristics of the abuse (type of abuse, relationship with the perpetrator, continuity of abuse) and the occurrence of other maltreatments were entered in the first step. The three attachment styles were entered in a second step, and the interaction term (the product of attachment styles and one of the characteristics of the abuse) in a third step. Step 1 and Step 2 are shown in Table 3, while Step 3 is shown in Tables 4 (interaction with type of abuse), 5 (relationship), and 6 (continuity). When the interaction of the type of abuse with attachment style was added as a predictor (Table 4), 27% of the total variance in depressive symptomatology was accounted for. This result supports an interactive role of type of abuse with attachment styles. Furthermore, an interaction between type of abuse with avoidant attachment accounted for this result (β = −0.13, p < .05). An interactive effect of the relationship with the perpetrator and attachment style was also found (Table 5). In this case, anxious attachment style (β = −0.19, p < .001) had a significant interaction with the relationship variable. This model explained 29% of the variance on depression score.


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Table 4. Significance Test of the Moderating Effect of the Type of Abuse on the Relation Between Attachment Style and Depression Symptoms in CSA Victims. Variable

Adjusted R2Δ

FΔ

.013

3.91*

Step 3 Other maltreatment Type Relationship Continuity Secure attachment Avoidance attachment Anxiety attachment Type × Secure attachment Type × Avoidant attachment Type × Anxious attachment

B

SE

β

t

2.38 2.68 −1.12 0.80 −0.65 −0.33 1.24 0.83 −0.78 0.45

6.12 1.15 1.14 1.05 0.61 0.24 0.19 0.25 0.60 0.39 0.71

.14 .16 −.07 .09 −.19 −.12 .35 .10 −.13 .04

2.06* 2.34* −1.06 1.3 −2.64** −1.68 5.00*** 1.4 −1.98* 0.48

Note. Step 1 and Step 2 are shown in Table 3. CSA = child sexual abuse. *p < .05. **p < .01. ***p < .001.

Table 5. Significance Test of the Moderating Effect of the Relationship With the Perpetrator on the Relation Between Attachment Style and Depression Symptoms in CSA Victims. Variable Step 3 Other maltreatment Type Relationship Continuity Secure attachment Avoidance attachment Anxiety attachment Relationship × Secure attachment Relationship × Avoidant attach Relationship × Anxious attach

Adjusted R2Δ

FΔ

.032

8.26***

B

SE

β

t

2.30 2.37 −1.06 0.80 −0.63 −0.36 1.22 1.95

6.04 1.13 1.12 1.03 0.60 0.24 0.19 2.46 1.26

.13 .14 −.07 .09 −.19 −.12 .34 .11

2.02* 2.10* −1.02 1.34 −2.61** −1.73 4.96*** 1.51

1.10

1.01

.08

−1.35

0.47

−.19

1.11 −2.87***



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Table 6. Significance Test of the Moderating Effect of the Continuity of Abuse on the Relation Between Attachment Style and Depression Symptoms in CSA Victims. Variable Step 3 Other maltreatment Type Relationship Continuity Secure attachment Avoidance attachment Anxiety attachment Continuity × Secure attach Continuity × Avoidant attach Continuity × Anxious attach

Adjusted R2 Δ

FΔ

.042

10.73***

B

SE

β

t

2.55 2.57 −0.80 0.55 −0.64 −0.39 1.34 1.05

5.99 1.13 1.11 1.02 0.59 0.24 0.19 0.24 1.10

.15 .15 −.05 .06 −.19 −.12 .38 .07

2.25* 2.30* −0.78 0.93 −2.66** −1.80 5.48*** 1.04

0.69

1.13

.03

−0.84

0.25

−.21

0.55 −3.27***


Finally, there was a significant effect of the interaction between continuity of abuse suffered and anxious attachment style (β = −0.21, p < .001; Table 6). This last model explained 30% of the variance on BDI scores. After finding that the relationship between attachment style and BDI score was dependent on the characteristics of the abuse, we carried out three independent multiple regression analyses to determine the moderated relationship pattern. The interaction of attachment style with each characteristic of abuse (avoidant attachment in the case of type of abuse, and anxious attachment in the case of the relationship with the perpetrator and the continuity of abuse) was introduced as a predicting variable. The sample was divided according to the type of abuse (touching vs. penetration/oral sex), the relationship with perpetrator (intra-familial vs. extra-familial), and the continuity of abuse (continued vs. isolated). When type of abuse was considered, there was a significant negative correlation between the avoidant style interaction term and BDI score when abuse consisted of oral sex/penetration (adjusted R2 = 0.030, β = −0.23, p < .05), but there was no significant correlation when abuse consisted of touching only (adjusted R2 = 0.007, β = 0.02, ns). The interaction pattern between


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14

14

13

12

Depression

Depression

12 11 10 9 8

Touching

7

Oral/ Penetration

6

Depression

Low Avoidant

High Avoidant

14 13 12 11 10 9 8 7 6 5 4

10 8 Extrafamilial

6 4

Intrafamilial

2 Low Anxious

High Anxious

Isolated Several Continued

Low Anxious

High Anxious

Figure 1. Relationships of BDI score with avoidant attachment as a function of the type of abuse suffered, and with anxious attachment as a function of the relationship with the perpetrator and the continuity of abuse. Note. BDI = Beck Depression Inventory.

avoidant attachment and BDI score as a function of the type of abuse is plotted in Figure 1. With regard to relationship with the perpetrator, the correlation between anxious attachment interaction term and depression was significant and negative and stronger in the case of extra-familial than intra-familial abuse (adjusted R2 = .340, β = −.59, p < .001 vs. adjusted R2 = .103, β = .33, p < .001, respectively). The relationship between anxious attachment style and depression as a function of the relationship with perpetrator is plotted in Figure 1. Finally, regarding the continuity of abuse, there was a significant negative correlation between anxious attachment interaction term and depression in the case of both isolated and several incidents of abuse, with a slightly stronger relationship found in the isolated cases (adjusted R2 = 0.343, β = −0.59, p < .001 vs. adjusted R2 = 0.272, β = 0.54, p < .001, respectively). There was no significant relationship between anxious interaction term and depression in cases of continued abuse (adjusted R2 = 0.022, β = 0.18, ns; Figure 1).



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Discussion The present study focused on the role of attachment style in young adult CSA victims on depression. The data are consistent with previous studies (Dimitrova et al., 2010; Mikulincer & Florian, 2004), suggesting that a secure attachment style predicted lower depression after controlling for characteristics of abuse and occurrence of other maltreatments. The present results also agree with Lutz-Zois et al. (2011) and ReeseWeber’s (2011) studies, who found that an anxious attachment style was related to a higher risk of negative psychological outcomes in a sample of female victims of CSA. However, our results show no relationship between avoidant attachment and subsequent depressive symptomatology. This result contradicts other studies such as Unger’s (2011), who found that avoidant attachment mediated the relationship between CSA and psychological distress and self-esteem problems. In addition to attachment styles, the existence of other maltreatments and the type of abusive acts committed influenced depressive symptomatology. This finding has been obtained by several prior studies (Lemieux & Byers, 2008). However, we found no significant correlation between BDI scores and the relationship with perpetrator or the continuity of the abuse. While some authors have found a relationship between these variables and psychological adjustment of the victim (Ullman, 2007), others have failed in demonstrating such a link (Quas, Goodman, & Jones, 2003). The interaction of attachment style and the characteristics of abuse have not previously been studied. Our hypothesis that the effects of attachment style on BDI score would depend on CSA characteristics was confirmed. The relationship between attachment style, especially an anxious attachment style, and depression was found to be stronger in the case of more severe abuse, abuse committed by a non-family member, and abuse consisting of an isolated incident. Contrary to our expectations, the relationship between attachment style and depression was negative in the case of more severe abuse. In other words, higher scores on avoidance attachment in cases of oral sex/penetration were related to lower scores on depressive symptomatology. One possible explanation for this surprising finding may be that under the above abuse characteristics, survivors with insecure attachment styles may be more likely to disclose the abuse. Most importantly, the findings from the present study suggest that depressive symptomatology cannot simply be explained by individual adjustment traits. In other words, it is not simply that the less stable participants scored higher on avoidant and anxious attachment styles. The effect, in fact, was interactive with characteristics of abuse suffered.


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While the current study adds important contributions to the literature on attachment style and psychological adjustment of victims of sexual abuse, it is important to take into account certain limitations. First, we used a crosssectional approach, using a unique source of information to assess both attachment style and depression concurrently. In the absence of a prospective design, beginning when the abuse first occurred, it is not possible to determine the cause and effect (Cantón-Cortés, Cantón, Justicia, & Cortés, 2011). We sought to lessen this limitation by studying the interactive role of abuse characteristics. It is unlikely, therefore, that the findings can be explained by a measurement bias as a result of both variables being collected simultaneously (Escamilla-Quintal et al., 2008; Rodríguez et al., 2001). Another limitation of the study arises from the use of retrospective reports. However, previous studies have shown that the small amount of bias present in retrospective reports is not strong enough to invalidate research on major adversities (Bifulco, Moran, Baines, Bunn, & Stanford, 2002; Hardt & Rutter, 2004). Moreover, there is wide consensus that the majority of CSA victims reveal information belatedly (if at all) indicating that retrospective studies may be the only way to obtain information from these individuals (CantónCortés et al., 2011). Other traumatic adult experiences could increase the magnitude of depressive symptomatology. Events such as poly-victimization during adulthood, traffic accidents, and terrorism could also contribute to adult depressive symptoms of CSA survivors. Recent studies (Xie et al., 2009) have suggested that a specific allele of the serotonin transporter gene increases the risk for psychological maladjustment after a traumatic event in adults who have also suffered child abuse. These findings suggest the importance of other factors in victims of child abuse on the development of depression and should be considered in future studies. A final limitation of the current study concerns the applicability of the findings to clinical practice, given that subjects were university students. Kallstrom-Fuqua et al. (Kallstrom-Fuqua, Weston, & Marshall, 2004) suggested that the psychological impact of CSA may be higher in individuals who actively seek help. Nevertheless, given that only a minority of CSA victims reveals their abuse, there remains a clear need for studies involving nonclinical samples (Cantón-Cortés et al., 2011). Despite the discussed limitations, the present study identified a number of areas for the therapeutic treatment of women who have experienced CSA. The approach survivors use to cope with interpersonal experiences and intimacy can diminish negative outcomes. Therefore, therapeutic strategies should include building secure and trusting relationships, while diminishing mental models related to anxious attachment, especially in cases of abuse



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committed by a non-family member and consisting of an isolated incident, and avoidant attachment, in the case of oral sex/penetration incidents.

Conclusions The present study confirms previous findings that attachment style is related to psychological adjustment in victims of CSA. Specifically, a secure attachment style was related to lower scores on depression, while an anxious attachment style was related to higher depression scores and no relationship existed between avoidant attachment style and depression. The interactive effects between attachment style and characteristics of abuse found in the present study indicate that the relationships between attachment style and depression are not due to a cross-sectional method bias. The role of attachment styles on the development of depression after CSA varied depending on the type of abuse suffered, the relationship with the perpetrator, and the continuity of abuse. The effects of attachment style on depression were higher in cases of oral sex/penetration, extra-familial abuse, and abuse consisting of an isolated incident. 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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Author Biographies David Cantón-Cortés, PhD, is a professor of forensic psychology at the University of Málaga, Spain. He earned his PhD in developmental psychology from the University of Granada. His research interests focus in the area of family violence, and specially child sexual abuse. María Rosario Cortés, PhD, is a professor at the Department of Developmental and Educational Psychology of the University of Granada, Spain. His main criminological research interests focus on the effects of child abuse and neglect on the victim. José Cantón, PhD, is a professor at the Department of Developmental and Educational Psychology of the University of Granada, Spain. His areas of interest include the impact of exposure to violence, child abuse, and neglect on development.


Child sexual abuse.

The consequences of child sexual abuse.

Consequences of child sexual abuse.

Child abuse and child protection: The role of the expert.

Child sexual abuse and the limits of responsibility.

Parent-Focused Prevention of Child Sexual Abuse.

Adult sequelae of child sexual abuse.

The Psychiatric Consequences of Child and Adolescent Sexual Abuse.

Child sexual abuse and HIV infection.

Interpreting child sexual abuse: the impact of victim response.

Child sexual abuse: An undermining of the polis.

Child sexual abuse research knowledge among child abuse professionals and laypersons.

Child sexual abuse and the media: a literature review.

Rethinking child sexual abuse: an anthropological perspective.

Incidence and impact of sexual abuse in a child outpatient sample: the role of direct inquiry.

Sexual abuse allegations in child custody disputes.

Child sexual abuse research: a methodological quagmire.

Child sexual abuse in Hong Kong.

The role of the paediatric surgeon in alleged child sexual abuse.

Maternal and child reflective functioning in the context of child sexual abuse: pathways to depression and externalising difficulties.

The impact of case characteristics on child abuse reporting decisions.

Child Maltreatment and Adult Substance Abuse: The Role of Memory.

Child abuse by child abuse committees?

Caregiver-youth communication about sex in South Africa: the role of maternal child sexual abuse history.