British Journal of Psychiatry (1991), 159, 115—122
Early Sexual Abuse and Clinical Depression in Adult Life A. BIFULCO,G. W. BROWNand Z. ADLER Sexual abuse in childhood and adolescence was studied in 286 working-class mothers living in lslington, who were contacted on three occasions over a two-year period. The sample was collected primarily to study current vulnerability factors in the onset of depression, but childhood measures were also included to look at longer-term risk factors. Twenty-five women —¿ 9% of the sample - reported sexual abuse involving physical contact before age 17 and, of these, 64% had case depression in a three-year period (which included the year before first interview). While such abuse was related to other earlier stressful
experiences
such as parental indifference,
violence to the child and institutional stay, it was associated with an increased risk of depression over and above these factors. Sexual abuse before age 17 also related to having been divorced/separated
or never having married/cohabited.
to engage in sexual activity, being forced to witness sexual activity or receiving obscene
Since the 1970s there has been increasing interest in both the prevalence and the effects of sexual abuse in childhood, although the current concern is only a reawakening of a topic which has intermittently received public attention since the late 19th century (McIntosh, 1988). The matter has recently been given widespread media coverage in Britain. Particularly
phone calls. (b) Age of victim and perpetrator: definitions commonly include any sexual activity between an adult and a child; the age differential between perpetrator and victim being wide
notable has been the introduction of the child help
enough
line where abused children can speak to professional helpers in confidence, and also the Cleveland case, where the introduction of a new screening procedure to determine instances of abuse led to controversy at a national level over both the accuracy of identifying sexual abuse, the rights of parents in refuting allegations of abuse, and the intervention by social services (HMSO, 1988). What has emerged is the need for more research in this area so that children at risk can be more readily identified, social workers and doctors can be more certain in their diagnoses and the harmful effects of childhood
‘¿peers'. (c)
sexual abuse commonly
children
and adolescents
(d) Relationship to perpetrator. most operational definitions of childhood sexual abuse include
both relatives and non-relatives as perpetrators, although some use a more stringent criterion for the inclusion of sexual experiences of teenage children with non-related adults. For example, Russell (1984) included all types of
they
(a) Contact v. non-contact: most studies of childhood sexual abuse have included all instances of contact and non-contact experiences (Finkelhor, 1986). Non-contact experiences in clude encounters with exhibitionists, solicitation
of the
avoided. The question of the ‘¿independence' of the incident, that is whether the child herself could have provoked it, are similarly considered irrelevant for these reasons.
do not truly comprehend to which they are unable to give informed consent, or that violate the social taboos of family roles.― (Kempe & Kempe, 1978)
Differences in criteria for including experiences as examples of sexual abuse involve the following issues:
because
For this reason the term sexual ‘¿assault' is often
cited are:
in sexual activities
or coercion:
adults and children, and the inability of young children to give informed consent, proof of violence, threats or coercion are not usually necessary for incidents to be included.
“¿The exploitation of a child for the sexual gratification of an adult.― (Fraser, 1981) “¿The involvement of dependent, developmentally im mature
Use of force
inappropriateness of sexual activity between
sexual abuse more clearly documented. Definitions of childhood
to exclude sexual activity between
sexualcontact up to age 13,butforthose over this age included only extra-familial con tact where there was completed or attempted forcible rape. Given such potential differences it is not surprising that a wide range of rates of abuse have been reported. For studies using community samples (as opposed to specially selected populations such as students or psychiatric patients) and using a criterion of at least one experience of sexual abuse
115
116 in childhood,
BIFULCO
a range of between 6% and 62% has
been reported (Finkelhor, 1986).However, differences
ET AL
Mullen et a!, 1988). Clinical studies have been less consistent:
Peters
(1984)
found
an association
between childhood sexual abuse and depressed in patient status, but other studies have reported no association (Meiselinan, 1978; Herman, 1981). Other long-term consequences indicated are low self-esteem as an adult (Courtois, 1979; Herman, 1981; Bagley & Ramsey, 1985), poor quality of relationships, and a greater incidence of divorce (Mullen et a!, 1988; self-administered questionnaires havereported rates Finkelhor eta!, 1990). In addition, for women a fear of under 22% and telephone surveys have yielded of men has been identified as a possible consequence rates of under 13%. Finkelhor also found that the (Meiselman, 1978), and because of this a greater more questions asked, and the more specific the likelihood of remaining single (Courtois, 1979). questions about the abuse, the higher the rates Sexual abuse in childhood has also been linked to obtained. Therefore, there may well be a problem experience of violent relationships in adulthood cannot be totally attributed to differences in definition. Finkelhor (1986) has shown that they also relate to the method of data collection. For instance, surveys using face-to-face interviews appear to yield higher rates - of four studies using such an approach two have reported a prevalence rate of over 50°loand a further two of 22010or more, whereas studies using
of under-reporting in some studies. Ways of avoiding this include use of face-to-face interviews with detailed questioning and the use of a mixture of general trawling or screening questions followed by specific ones to elicit full information.
(Russell, 1986) as well as victimisation in the form of later rape (Miller et a!, 1978; Fromuth, 1983;
Russell, 1986). Effects on sexualfunctioning have onlybeenstudied inclinical samplesandthese have consistently
found adverse effects among
women
Variousfactors associated withsexualabusein sexually abused in childhood (Meiselman, 1978; childhood have been identified: girls are at higher Herman, 1981). risk than boys (Badgley et a!, 1984), those abused Inthecurrent study, sexual abuseinchildhood and are less likely to have been brought up by their real adolescence wasexpected tobeassociated withcase parents (Landis, 1956; Dc Francis, 1969), and are depression inthestudyperiodand thislinkto be less likely to have had higher education (West, 1985).
Some studies have shown parental conflict to relate
mediated by a history of problems in marriage. A relationship between sexual abuse and other
negative childhood experiences found to be important in depression such as inadequate parental care was However, no studies have yet directly explored the expected and the need to explore the role of each in relationship of sexual abuse to other stressful the development of depression anticipated. experiences in childhood such as neglect by parent The Islington study involved in-depth interviewing figures. Studies of sexual abuse have not generally of a population sample of London women, the main considered whethersexual abuseoccurs inisolationfocus of which was to determine the role of current or is generally part of a neglectful context —¿ if the vulnerability factors in onset of case depression. latter occurs thenitisnecessary toseewhether sexual During the course of the study it was possible abuseortheneglectful context isthemoreimportant to question about childhood sexual abuse, and for later negative outcomes. to examine its association with other negative Thereisgeneral agreement thatthere areno social childhood experience, the quality of relation class orethnic differences, atleast instudies inthe ships in adulthood, and with subsequent adult US and UK (Finkelhor, 1978; West, 1985). The lack depression. of a relationship between lower social class status and childhood sexual abuse could, of course, be con founded by a higher reporting rate among middle Method to abuse (Finkelhor, 1979; Newman, 1983), but results have not been entirely consistent (West, 1985).
class subjects.
However,
among the studies failing
tofindanyassociation isRussell's (1984) whichhad Thesample consisted ofwomen agedbetween 18and50 theadvantages ofa highthreshold forinclusion of years, of European or Afro-Caribbean background, living incidents ofabuse,a large samplesize and detailedin lslington and registered with one of five general practice questioning, suggesting thattheresult may notbe surgeries. The women all had at least one child under age 16 living at home, and either had husbands in manual due to bias in reporting. occcupations or were single mothers (i.e. not married or The long-term effects of early sexual abuse have cohabiting at time of interview). Women with these received relatively little attention. An association with characteristics were selected by means of screening adult depression has been indicated, but this has been questionnaire and among suitable women (i.e. taking into largely based on the study of non-clinical samples account those who had moved away, etc.); the response rate (Sedney & Brooks, 1984; Bagley & Ramsey, 1985; was estimated to be 70°lo.Of those contacted 92°loagreed
EARLY SEXUAL ABUSE AND ADULT DEPRESSION to be interviewed
(Brown
et a!,
1985)
and
the sample
consisted of 395 women. The women were then followed up twice at one-year intervals. At the first follow-up 353
women agreed to be seen, and at second follow-up 286 women completed an interview. Since the questions about childhood
sexual abuse were only administered
at the third
interview(secondfollow-up),this wasused for the current analysis. The 109 women not seen at second follow-up did not differ from the 286 seen, in terms of demographic
variablessuchas age, classor ethnicbackground,and were no different
in terms
of their rates of case depression
at
point of first contact.
Lack of care ‘¿Lack of care' is an index made up of two measures of inadequate care in childhood: parental indifference and lax control (Harris et a!, 1986; Bifulco et a!, 1987). ‘¿Parental indifference' was assessed in terms of answers to detailed questions
about physical
was defined involvement
or emotional
neglect.
Its presence
in terms of parental lack of interest and in material
care, school
work and friends
and
so forth. ‘¿Parentalcontrol' was approached in the same way and reflected the amount of supervision provided by parents
and the amount
of discipline
imposed.
Thus,
playing
in the streets unattended for lengths of time when under age 10, and going out until late at night with boys in teenage
Measures
years were considered
indicators
of low control.
Lack of care
itself was defmed as either a high rating of parental indiffer ence (marked or moderate on a four-point scale) or low con sequentlytranscribedand rated accordingto pre-established trol (point three on a three-point scale) for a minimum of one
The information was collected by means of lengthy semi structured interviews which were tape-recorded and sub rules and rating procedures.
Inter-rater
reliability
on the
scales has been reported elsewhere and was generally high (Brown et a!, 1986b; Bifulco et al, 1987).
year before age 17. Ratings were made for natural parents,
and in the event of parental loss, for parent substitutes. Sexual abuse was not taken into account when assessing lack of care.
Sexual abuse Early sexual abuse was defined as any sexual contact before
Parental violence towards the respondent
theageof17—¿ excluding willing contact inteenage years An assessment was made of any violence shown towards withnon-related peers.Instances of abuseinvolvedsexual
the respondent by parents before the age of 17 (Andrews
intercourse, oral sex, and touching of breasts and genitals. There were no instances of being forced to witness sexual
& Brown,1988). Thistooktheformofactual beatings or
activity.
Encounters
with exhibitionists
were not included,
of threats with knives, belts, etc. consistent with Straus's definition
(Straus eta!,
1980). Violence
used by parents
in
obscene phone calls. Details were collected about severity and
controlling andpunishing thechild wasthemainfocus of thescale; there werenoinstances wheretheviolence only
frequency
occurred at the time of the sexual abuse.
nor were any verbal sexual encounters with strangers or of the abuse
and relationship
to the perpetrator.
Inaddition tosexual abuse inchildhood andadolescence, respondents were asked about sexual abuse in adulthood involving sexual contact against volition and accompanied by threats, coercion or force. Questions about sexual abuse were asked at two points in the interview. First, during
questioning about recent life events respondents were asked: “¿Have you at any time in your life been sexually
Institutional stay
Anyperiod oftimespent inaninstitution inchildhood was recorded. This included local authority care, Dr Barnardo's homes, or borstals. Hospital stays and boarding schools were not included.
assaulted?―. Second, in the childhood section of the interview respondents were asked: “¿Were you ever inter fered with sexually?―. Where there was any hint of a positive response, additional questions covered the nature
Adult measures
of the abuse, and relationship to perpetrator. The present analysis only concerns sexual abuse before the age of 17. Twenty-two women (8%) initially reported sexual abuse
This was used to collect symptoms of affective disorder in the 12 months before each interview and ratings of ‘¿caseness'
before the age of 17. However, a further study of a sub
(Finlay-Jones et a!, 1980). The threshold for caseness was
sampleof 104of these286Islingtonwomenhas sincebeen
designed tobecomparable inseverity tothat foundamong
conducted and the women questioned further about sexual abuse. This added only three further instances (Andrews,
psychiatric out-patients. This criterion for caseness has been compared with two other well-known systems, the Research
(a) Present State Examination. Depression was measured by means of the PSE (Wing eta!, 1974;Cooper eta!, 1977).
werebased onthefrequency andseverity ofkeysymptoms
Criteria (RDC;Spitzer eta!,1978) andtheID personal communication) andthese will beincluded inthe Diagnostic present enquiry. (Nonehadbeendepressed inthestudy (level 5) of the PSE (Wing & Sturt, 1978), and the threshold period and their inclusion,
if anything,
works against the
hypothesis being investigated.) The final figure for sexual abuse before the age of 17 is therefore 9°lo (25 women).
The womenwhoreportedchildhoodsexualabusedid not differ from those who did not in terms of age, cultural back ground, social class or whether born in Britain. However, it should be borne in mind that the sample was only of mothers who were largely working class and included only
found to be higher than either (Dean eta!, 1983).Borderline cases of depression had depressed mood but fewer than four
other ‘¿core' symptoms (Finlay-Jones eta!,1980). Inthe present analysis prevalence of case depression at any time in the three years of the study period was used as the dependent variable. (b) Marital history. Marital history was examined in terms of whether the women were ever divorced or separated or
those fromEuropean orAfro-Caribbean backgrounds.never married/cohabited.
118
BIFULCO
Results Sixty-four
ET AL
adoptive fathers (1) or stepfathers (2), 28% (7/25) were
per cent (16/25) of those with childhood
sexual
abuse were depressed at caseness level at some point in the three-year study compared with 2601o(67/261) of the rest
of the women (P