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Journal of Child Sexual Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wcsa20

Perpetration, Revictimization, and SelfInjury: Traumatic Reenactments of Child Sexual Abuse in a Nonclinical Sample of South African Adolescents a

a

Susan L. Penning & Steven J. Collings a

University of KwaZulu-Natal, Durban, South Africa Published online: 12 Aug 2014.

Click for updates To cite this article: Susan L. Penning & Steven J. Collings (2014) Perpetration, Revictimization, and Self-Injury: Traumatic Reenactments of Child Sexual Abuse in a Nonclinical Sample of South African Adolescents, Journal of Child Sexual Abuse, 23:6, 708-726, DOI: 10.1080/10538712.2014.931319 To link to this article: http://dx.doi.org/10.1080/10538712.2014.931319

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Journal of Child Sexual Abuse, 23:708–726, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1053-8712 print/1547-0679 online DOI: 10.1080/10538712.2014.931319

Perpetration, Revictimization, and Self-Injury: Traumatic Reenactments of Child Sexual Abuse in a Nonclinical Sample of South African Adolescents SUSAN L. PENNING and STEVEN J. COLLINGS University of KwaZulu-Natal, Durban, South Africa

Risk factors for traumatic reenactments of child sexual abuse experiences (perpetration, revictimization, and self-injury) were examined in a sample of 718 South African secondary school adolescents. Logistic regression analyses indicated that the most consistent predictors of reenactments were a history of child sexual abuse (rape and/or indecent assault) and respondents’ gender, with males being significantly more likely than females to report perpetration (OR = 13.5) and females being more likely to report revictimization (OR = 3.2) and self-injury (OR = 2.5). An analysis restricted to respondents with a history of child sexual abuse indicated that negative abuse-related cognitions were the most consistent predictor of all forms of traumatic reenactment. KEYWORDS adolescents, child sexual abuse, perpetration, self-injury, South Africa, traumatic reenactment, revictimization

It is generally acknowledged that child sexual abuse (CSA) constitutes a risk factor for various forms of traumatic reenactment (Boyd, Hagan, & Cho, 2000; Classen, Palesh, & Aggarwal, 2005; Lang & Sharma-Patel, 2011; Mallie, Viljoen, Mordell, Spice, & Roesch, 2011; Rasmussen, 2013; Riser, Pegram, & Farley, 2013; Senn, Carey, & Vanable, 2008; Seto & Lalumière, 2010). In addition to subjective reexperiencing symptoms (e.g., flashbacks), various forms

Received 17 July 2013; revised 16 January 2014; accepted 6 March 2014. Address correspondence to Steven J. Collings, School of Applied Human Sciences, University of KwaZulu-Natal, Durban 4041, Republic of South Africa. E-mail: collings@ukzn. ac.za 708

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of behavioral reenactment have been identified in the literature (cf., van der Kolk, 1989), including (a) perpetration, (b) revictimization, and (c) self-injury. Perpetration is a form of behavioral reenactment in which CSA survivors take on the role of the aggressor and go on to victimize others. Although such a cycle of abuse has by no means been found to be inevitable, research studies have consistently identified an association between a history of CSA and subsequent sexually abusive behavior (Bleil Walters et al., 2013; Burton, Miller, & Shill, 2002; Mallie et al., 2011; Renner & Whitney, 2012; Riser et al., 2013; Seto & Lalumière, 2010). Findings from studies of sexually abusive adolescents indicate that an average of 55% of respondents (range: 20%– 92%) report a history of CSA (Burton, 2003; Hunter & Figueredo, 2000; Miner, 2002; Tardif & Van Gijseghem, 2001; Zakireh, Ronis, & Knight, 2008), with identified risk factors for a victim–perpetrator cycle including exposure to incestuous forms of CSA (Rice & Harris, 2002), a younger age at the time of victimization and delayed disclosure (Hunter & Figuerdo, 2000), and forced victimization (Burton et al., 2002). Behavioral reenactments of CSA also take the form of revictimization, in which CSA survivors face an increased risk of experiencing subsequent victimization by others. Although such a cycle of victimization is not experienced by all CSA survivors, a history of CSA has consistently been identified as a risk factor for subsequent sexual victimization (Fargo, 2009; Lacelle, Hebért, Lavoie, Vitaro, & Tremblay, 2012; Lestrade, Talbot, Ward, & Cort, 2013; Loeb, Gaines, Wyatt, Zhang, & Liu, 2011; Messman-Moore, Walsh, & DiLillo, 2010; Simmel, Postmus, & Lee, 2012; Smith, Davis, & Fricker-Elhai, 2004). In their 15-year prospective study of 89 children who had experienced contact forms of incestuous abuse, Barnes and colleagues (Barnes, Noll, Putnam, & Trickett, 2009) found that, when compared with nonvictimized controls, subsequent sexual victimization experiences were almost twice as likely (OR = 1.99) among participants who reported a CSA history. Risk factors for revictimization following CSA have been found to include: (a) CSA characteristics such as abuse severity, duration, and coerciveness (Arata, 2000; West, Williams, & Siegel, 2000); (b) psychological distress, including posttraumatic stress disorder (PTSD), dissociation, and affective dysregulation (Arata, 2000; Cuevas, Finkelhor, Clifford, & Ormrod, 2010; Messman-Moore et al., 2010; Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003; Risser, Hetzel-Riggin, Thomsen, & McCanne, 2006); (c) maladaptive coping strategies, including self-blame, substance abuse, social withdrawal, and risky sexual behavior (Arata, 2000; Casey & Nurius, 2005; Filipas & Ullman, 2006; Fargo, 2009; Orcutt, Cooper, & Garcia, 2005); (d) a combination of exposure to both physical and sexual abuse during childhood (Arata & Lindman, 2002; Desai, Arias, Thompson, & Basile, 2002; Merrill et al., 1999); and (e) the extent of polyvictimization experienced by CSA survivors (Jankowski, Leitenberg, Henning, & Coffey, 2002; Moeller, Bachmann, & Moeller, 1993).

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Finally, behavioral reenactments of CSA have been found to include self-injury, in which CSA survivors take on the role of self-victimizer, leading to acts of self-injurious behavior (e.g., Asgeirsdottir, Sigfusdottir, Gudjonsson, & Sigurdsson, 2011; Bolen, Winter, & Hodges, 2013; Briere & Gil, 1998; Glassman, Weierich, Hooley, Deliberto, & Nock, 2007; Shenk, Noll, & Cassarly, 2010; van der Kolk, Perry, & Herman, 1991). Research on nonsuicidal self-injury (NSSI) has clearly established that NSSI is associated with a history of CSA (Asgeirsdottir et al., 2011; Bolen et al., 2013; Glassman et al., 2007; Shenk et al., 2010; van der Kolk et al., 1991; Yates, Carlson, & Egeland, 2008), with the association between CSA and NSSI having been found to be mediated or moderated by affective dysregulation (Bolen et al., 2013), dissociation (Bolen et al., 2013; Gratz, Conrad, & Roemer, 2002; Rodriguez-Srednicki, 2001; Yates et al., 2008), depressed mood (Asgeirsdottir et al., 2011), self-criticism (Glassman et al., 2007), and the extent of polyvictimization (Lang & Sharma-Patel, 2011). Attempts to conceptualize the relationship between CSA and various forms of behavioral reenactments have drawn on a number of theoretical frameworks, including psychoanalysis (Trippany, Helm, & Simpson, 2006), social learning theory (Burton et al., 2002), attachment theory (van der Kolk et al., 1991), feminist theory (Yilo, 1993), the traumagenic dynamics model (Lacelle et al., 2012), and ecosystemic theory (Rasmussen, 2013). Although there is little consensus in the literature regarding which of these perspectives most adequately captures the dynamics of traumatic reenactment, it is generally acknowledged that there are likely to be multiple pathways as well as numerous mediating and moderating factors that influence the relationship between child maltreatment and subsequent traumatic reenactments (Simmel et al., 2012).

METHODOLOGICAL CONSIDERATIONS While there are sound theoretical reasons for regarding perpetration, revictimization, and self-injury as traumatic reenactments of developmental trauma (van der Kolk, 1989), available research on traumatic reenactments of CSA experiences has tended to be characterized by a silo effect, with three quite distinct literatures relating to perpetration, revictimization, and self-injury. As a result it has not been possible to (a) assess the relative importance of different forms of traumatic reenactment, (b) explore the extent of multiple/poly forms of reenactment, or (c) adequately explore risk factors for different forms of traumatic reenactment in any given sample. A further limitation of available studies relates to an overreliance on CSA as the sole independent measure in studies of subsequent reenactment behaviors. Although CSA has consistently been found to be associated with various forms of traumatic reenactment (perpetration, revictimization, and

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self-injury), there is emerging literature that suggests such outcomes may be equally, if not more strongly, predicted by exposure to other forms of child maltreatment or by the extent of polyvictimization experienced by the child. Thus, in addition to CSA, sexually abusive behavior has been linked to childhood exposure to community violence (Ward, McMahon, & Ingram, 2006), physical abuse (Ryan, Miyoshi, Metzner, Krugman, & Fryer, 1996), emotional abuse (Lee, Jackson, Pattison, & Ward, 2002), and neglect (Ryan et al., 1996); sexual revictimization has been linked to childhood physical abuse (Classen et al., 2005; Messman-Moore et al., 2010), emotional abuse (Moeller et al., 1993), and polyvictimization (Classen et al., 2005); and self-injurious behavior has been linked to childhood exposure to physical abuse (Gratz, 2006), neglect (Weiderman, Sansone, & Sansone, 1999), and emotional abuse (Weiderman et al., 1999). There is, consequently, a need for further research designed to clarify whether CSA accounts for a significant proportion of the variance in traumatic reenactments after controlling for both other forms of child maltreatment and for the extent of polyvictimization.

THE PRESENT STUDY In an attempt to address some of the limitations of previous research, the present study explored traumatic reenactments of CSA experiences (perpetration, revictimization, and self-injury) in a nonclinical sample of South African adolescents. In order to adequately capture respondent’s full victimization profile, child maltreatment experiences were surveyed using a standardized instrument that is designed to provide a comprehensive assessment of participants’ full victimization profiles as well as an indication of the extent of childhood polyvictimization experienced by respondents.

METHOD Respondents The sampling frame for the study was all students attending a secondary school located in the greater Durban metropolitan area of KwaZulu-Natal in South Africa in 2011. Of the 802 students registered at the school, 752 (94%) consented to participate in the study, and 718 (90%) submitted usable questionnaires. Respondents were predominantly male (66%), with a mean age of 15.5 years (SD = 1.61). Respondents’ self-declared race were black African (95.2%), white (1.5%), Asian (0.6%), or “other” (2.7%). With respect to family structure, 348 respondents (48.5%) were raised by both biological parents, 266 (37.0%) by a single biological parent, and 104 (14.5%) by a caretaker or caretakers who were not biological parents. Data obtained from the school’s registration records indicated that respondents did not differ significantly from nonrespondents with respect to gender, age, or race.

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Dependent Measures Consistent with van der Kolk’s (1989) conceptualization of traumatic reenactment, three forms of reenactment were considered in the study: perpetration (had respondents engaged in any sexually abusive behavior in the past 12 months), revictimization (had respondents experienced any sexual victimization in the past 12 months), and self-injury (had respondents engaged in self-injurious behavior over the past 12 months). In addition, an index of the extent of traumatic reenactment (polyreenactment) was calculated for each respondent. PERPETRATION Perpetration was scored as being absent or present (0 or 1), with perpetration being deemed to be present if respondents indicated that they had engaged in one or more of the following behaviors over the past 12 months: “Touching someone in a sexual way when the other person did not want you to,” “Attempting to have sex with another person against his or her will,” or “Having sex with someone against his or her will.” REVICTIMIZATION Revictimization was scored as being absent or present (0 or 1), with revictimization being deemed to be present if respondents indicated that they had one or more of the following experiences over the past 12 months: “Someone touched me in a sexual way when I did not want him or her to,” “Someone attempted (unsuccessfully) to have sex with me against my will,” or “Someone had sex with me against my will.” SELF-INJURY Seven probe questions were used to assess for NSSI in the past 12 months: “I have deliberately cut myself with a knife, a blade, or a sharp object,” “I have deliberately burned myself,” “I have deliberately hurt myself by banging my head against hard surfaces,” “I have deliberately hit or punched myself,” “I have deliberately bitten myself hard enough to leave marks,” “I have deliberately choked myself until I felt dizzy or passed out,” or “I have deliberately injured myself in a way not mentioned above (please specify).” Scale items were scored using a 7-point Likert scale, ranging from 0 (never) to 6 (several times a week), with Cronbach’s alpha for the seven scale items in the study sample being .72. Consistent with proposed Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013) criteria for NSSI, self-injury was deemed to be present if respondents had engaged in self-injurious behavior on at least five different occasions in the past year.

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POLYREENACTMENT For purposes of analysis, polyreenactment was defined as the presence of two or more of the forms of traumatic reenactment considered in the study.

Independent Measures

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DEMOGRAPHIC

VARIABLES

Standard demographic questions were used to survey respondent demographics, including age (coded as a continuous variable), gender (coded as a binary category: male versus female), race (coded as a binary category: black African versus other), and family structure (coded as an ordinal variable in terms of the number of biological parents present in the home). EXPOSURE

TO DEVELOPMENTAL TRAUMA

A history of early exposure (before the age of 13 years) to developmental trauma was assessed using the Developmental Trauma Inventory (DTI). Developed by Collings, Valjee, and Penning (2013), the DTI is a 33-item retrospective, self-administered screen for interpersonal childhood trauma experiences developed specifically for the South African context. The DTI assesses traumatic exposure across nine domains: emotional abuse, domestic neglect, being assaulted by nonfamily, domestic assault, witnessing community violence, witnessing domestic violence, nonaccidental domestic injury, rape, and indecent assault. In validation studies (Collings et al., 2013), DTI domains have been found to have adequate levels of internal consistency (α = .70 to .81) and high levels of concurrent criterion related validity in the sense that all scale scores are significantly correlated with scores on clinical measures of PTSD and/or complex PTSD. In the present study, Cronbach’s alpha for the nine DTI domains ranged from .70 to .81, indicating moderate to high levels of internal consistency. In addition to victimization probes, the DTI contains follow-up questions designed to explore the chronicity of exposure, age at first victimization, identity of the perpetrator, and the nature and supportiveness of disclosure. POLYVICTIMIZATION Consistent with the work of Finkelhor and associates (Finkelhor, Ormrod, & Turner, 2007a, 2007b), a measure of multiple (or poly) exposure to different types of victimization was obtained using a median split of the number of different types of exposure reported by respondents on the DTI scales. This procedure defined two categories of polyvictimization: a high polyvictimization category (exposure to 5+ types of victimization) and a low polyvictimization category (exposure to < 5 types of victimization).

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ABUSE-RELATED

S. L. Penning and S. J. Collings APPRAISALS

In addition to surveying the nature and extent of traumatic exposure, the DTI contains a seven-item scale designed to assess abuse related cognitions. These seven items are scored on a five-point Likert scale ranging from 1 (not at all) to 5 (extremely), with scale items being designed to assess fight, flight, or freeze reactions that are typical of PTSD (“At the time I felt: angry/afraid/numb or in shock”) as well as trauma related causal attributions (“I have felt guilty or to blame for what happened”) and cognitive appraisals/adaptations that have been found, or theorized, to be associated with complex PTSD experiences (“Since the experience I have found it hard to trust others,” “The experience changed me in a negative way,” and “Because of the experience I no longer believe that the world is a safe place”) (cf., Ford & Courtois, 2009). Cronbach’s alpha for scale items in the present sample was .91 indicating that the items can be meaningfully regarded as composing a continuous scale.

Procedure Ethical clearance for the research was obtained from the Humanities Research Ethics Committee at the University of KwaZulu-Natal in 2011. Written parental consent was obtained in all cases, with respondents providing written assent for their participation. Prior to assenting, each respondent was provided with a study information sheet that described the purpose of the study, emphasized the voluntary nature of participation, and ensured confidentiality of the study’s findings. Research questionnaires were administered to groups of consenting participants during life orientation lessons, with offers of free counseling support (from the school guidance teacher) and/or free psychological counseling (at a university clinic) being made to all respondents.

Data Analysis All analyses were conducted using IBM SPSS Statistics 21 (IBM, 2012), with variables being included in the final models if they accounted for a significant proportion of the variance in criterion measures (p < .05). In order to identify risk factors that accounted for a unique proportion of the variance in traumatic reenactments, separate forward conditional entry binary logistic regression analyses were conducted for each of the four dependent measures considered in the study: perpetration, revictimization, self-injury, and polyreenactment. Independent measures included in these analyses were respondent demographics (age, gender, ethnic identity, and family structure) and childhood exposure to interpersonal violence (the nine domains of traumatic exposure assessed by the DTI).

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A subsequent series of forward conditional entry binary logistic regression analyses, which were restricted to respondents who reported a CSA experience, were conducted in order to assess the impact of CSA characteristics on traumatic reenactments. Dependent variables entered in this analysis were the four criterion variables used in the study (perpetration, revictimization, self-injury, and polyreenactment). In addition to the independent variables considered in previous analyses (demographic variables and exposure to different forms of interpersonal violence), the within-group analysis considered various CSA characteristics—age at first exposure to CSA, chronicity of CSA exposure, supportiveness of disclosure, victim–perpetrator relationship, and negative CSA appraisals—as predictor variables.

RESULTS Prevalence of Child Maltreatment Prevalence rates for child maltreatment were high, with 82.2% of respondents reporting some form of child maltreatment, 24.8% reporting exposure to CSA, and 48.8% reporting exposure to polyvictimization (5+ types of child maltreatment).

Incidence of Reenactments Reenactments were relatively common in the study sample with, 374 respondents (52.1%) reporting at least one form of reenactment in the past year. One hundred and ninety respondents (26.5%) reported that they had sexually abused another person during the previous year, 249 (34.7%) reported that they had been sexually abused during the past year, and 90 (12.5%) reported that they had engaged in self-injurious behavior on at least five separate occasions in the past 12 months. A history of CSA significantly increased the risk of engaging in each of the three forms of reenactment: perpetration (OR = 2.9, p = .000), revictimization (OR = 3.3, p = .000), and self-injury (OR = 1.9, p = .000). Polyreenactment was relatively common, with 34% of respondents reporting one form of reenactment during the past year, 14.6% reporting 2 forms of reenactment, and 3.5% reporting all three forms of reenactment (see Table 1). An analysis of the extent of reenactment by CSA history indicated that polyreenactment was more than three times as likely among respondents who reported a history of CSA (OR = 3.2, p = .000).

Risk Factors for Reenactments From Table 2 it is evident that a history of CSA (indecent assault and/or rape) emerged as a consistent predictor of reenactments, with a CSA history

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S. L. Penning and S. J. Collings TABLE 1 Extent of Polyvictimization in the Study Sample CSA Exposure No (n = 540)

Yes (n = 178)

Total (n = 718)

n (%)

n (%)

n (%)

300 (55.6)

44 (24.7)

344 (47.9)

69 91 8 168

(12.7) (16.9) (1.5) (31.1)

27 (15.2) 37 (20.8) 12 (6.7) 76 (42.7)

96 128 20 244

(13.4) (17.8) (2.8) (34.0)

36 3 26 65

(6.7) (0.6) (4.8) (12.0)

24 (13.5) 6 (3.4) 10 (5.6) 40 (22.5)

60 9 36 105

(8.4) (1.2) (5.0) (14.6)

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Polyreenactment No reenactment One type Perpetration (PER) Revictimization (REV) Self-injury (SIY) Total (one type) Two types PER + REV PER + SIY REV + SIY Total (two types) All 3 types PER + REV + SIY

7 (1.3)

18 (10.1)

25 (3.5)

Note. N = 718. CSA = child sexual abuse.

TABLE 2 Significant Predictors of the Nature and Extent of Reenactments: Forward Conditional Entry Binary Logistic Regression Analyses Form of Reenactment Perpetration Revictimization

Self-injury

Polyreenactment

Predictor

Wald (1 df )

Male gender Polyvictimization Indecent assault Female gender Indecent assault Rape Community assault Rape Domestic assault Female gender Domestic injury Indecent assault Rape Neglect Community assault

51.91 15.70 12.62 38.02 27.35 23.66 11.87 16.65 12.97 5.65 5.62 14.64 10.01 8.16 10.28

OR (95% CI) 13.5 2.5 2.2 3.2 3.1 2.9 1.9 4.4 2.4 2.5 1.8 2.4 2.3 2.1 2.0

(6.6–26.3) (1.6–3.8) (1.4–3.4) (2.2–4.7) (1.9–4.1) (2.2–4.4) (1.3–2.7) (2.2–8.9) (1.4–4.0) (1.2–5.4) (1.1–2.8) (1.5–3.7) (1.5–6.4) (1.3–3.5) (1.3–3.1)

p .000 .000 .000 .000 .000 .000 .001 .000 .000 .017 .018 .000 .002 .004 .001

Cox & Snell R2 (p) .193 (.000) .151 (.000)

.142 (.000)

.148 (.000)

Note. N = 718. OR = odds ratio; CI = confidence interval.

accounting for a significant proportion of the explained variance across all four criterion measures. Gender also emerged as a consistent predictor of reenactments, with males being significantly more likely to engage in perpetration (OR = 13.5, p = .000) and females being more likely to experience revictimization (OR = 3.2, p = .000) or self-injury (OR = 2.5, p = .008) in the past year.

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TABLE 3 Significant Predictors of the Nature and Extent of Traumatic Reenactments among Respondents Who Reported a CSA Experience: Forward Conditional Entry Binary Logistic Regression Analyses Form of Reenactment

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Perpetration

Predictor

Male gender Negative CSA appraisals Witnessed domestic violence Revictimization Negative CSA appraisals Self-Injury Emotional abuse Negative CSA appraisals Polyreenactment Negative CSA appraisals Male gender Neglect

Wald (1 df )

OR (95% CI)

p

26.31 14.63 5.16

32.3 (8.7−125) 6.5 (2.5−16.7) 2.7 (1.1−5.5)

.000 .000 .023

.256 (.000)

.000 .000 .022 .000 .010 .045

.207 (.000) .181 (.000)

23.42 8.61 5.23 16.48 6.69 4.00

5.7 2.4 2.7 5.9 3.3 2.4

(2.8−11.5) (1.5−5.4) (1.2−6.3) (2.5−13.9) (1.3−8.4) (1.0−5.7)

Cox & Snell R2 (p)

.223 (.000)

Note. N = b178. OR = odds ratio; CI = confidence interval.

The nature and extent of reenactment was also predicted by nonsexual forms of traumatic exposure, with perpetration being predicted by the extent of polyvictimization, revictimization by childhood exposure to community violence, self-injury by exposure to domestic neglect and nonaccidental domestic injury, and polyreenactment by exposure to neglect and community assault.

Risk Factors: Within-Group Comparisons The binary logistic regression analyses that were restricted to respondents who reported a CSA experience (Table 3) indicated that negative CSA appraisals were the most consistent predictor of traumatic reenactments, with negative appraisals accounting for a significant proportion of the variance across all dependent measures. Nonsexual forms of child maltreatment that were found to be associated with traumatic reenactments were witnessing domestic violence (associated with perpetration), emotional abuse (associated with self-injury), and neglect (associated with polyreenactment). Moreover, male gender emerged as a significant predictor of both perpetration and polyreenactment.

DISCUSSION Incidence rates for traumatic reenactment in the study sample were high, with 52% of respondents reporting some form of traumatic reenactment in the past 12 months and 18% reporting more than two forms of traumatic reenactment. Consistent with findings from previous studies (Boyd et al., 2000; Classen et al., 2005; Lang & Sharma-Patel, 2011; Rasmussen, 2013), a history of CSA emerged as the most consistent predictor of all

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three forms of traumatic reenactment considered in the study (perpetration, revictimization, and self-injury), with a unique finding of the study being that a CSA history was also predictive of the extent of polyreenactment reported by respondents. Respondents’ gender also emerged as a significant predictor of traumatic reenactments, with the pattern of findings observed in the present study appearing to provide some resolution to what could be termed the cycle of abuse paradox (cf., Calder, 1999; Townsend & Dawes, 2004). Most CSA survivors are female (Townsend & Dawes, 2004), and, therefore, if a cycle of abuse hypothesis were to be accepted, one would expect that the majority of offenders to be female (which of course is not the case; Townsend & Dawes, 2004). The broader lens—provided by the extended definition of traumatic reenactment employed in the present study—suggests that it might be more accurate to talk about a cycle of traumatic reenactments (rather than a cycle of abuse), with there being gender differences in the nature of traumatic reenactments. Support for such a view is provided by the results of the present study in which male CSA survivors were found to be overrepresented among respondents who reported sexually abusive behavior while female survivors were overrepresented among respondents who reported other forms of traumatic reenactment (revictimization and self-injury). The study findings provide support for the view that forms of traumatic reenactment that have tended to be regarded as being linked to CSA are also predicted by other forms of child maltreatment (cf., Classen et al., 2005; Gratz, 2006; Lee et al., 2002; Messman-Moore et al., 2010; Ryan et al., 1996; Ward et al., 2006; Weiderman et al., 1999). In the present study, polyvictimization accounted for a unique proportion of the variance in perpetration, domestic assault was linked to self-injury, and community assault was associated with both revictimization and polyreenactment. Although an association between polyvictimization and subsequent sexually abusive behavior is consistent with findings obtained in previous studies (for a review see Classen et al., 2005), the present findings provide only qualified support for a link between domestic forms of child physical abuse (CPA) and traumatic reenactments, which has been consistently reported in the literature (e.g., Cloitre, Tardiff, Marzuk, Leon, & Portera, 1996; Jankowski et al., 2002; Merrill et al., 1999). Although domestic forms of CPA did emerge as a significant predictor of self-injury in the present study, perpetration was not uniquely predicted by domestic forms of CPA, while revictimization and polyreenactment were significantly predicted by assault bt nonfamily and not by domestic forms of CPA. Although the reasons for these discrepant findings are unclear, it is possible that the obtained pattern of findings may reflect an increased salience of non–domestic violence in a contemporary South African context in which exposure to community violence has been found to constitute one of the most prevalent forms of child maltreatment (Collings et al., 2013). The discrepant findings also may

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reflect the fact that the extant literature on traumatic reenactments has, to a large degree, tended to employ somewhat restrictive measures of child maltreatment that fail to encompass children’s direct and/or vicarious exposure to community violence or provide a comprehensive measure of the extent of polyvictimization experienced during childhood. In this context, further research would appear to be indicated in order to not only validate the present findings but also to more comprehensively assess the impact of children’s full victimization profiles on traumatic reenactments. Among respondents who reported a CSA history, negative CSA appraisals constituted the most consistent predictor of all forms of traumatic reenactment, including polyreenactment. This finding is not particularly surprising as there are both theoretical and empirical reasons (cf., Cromer & Smyth, 2010; Spaccarelli, 1994) to believe that abuse-related appraisals are likely to play an influential mediating role in developmental trauma outcomes. The fact that CSA survivors who had perpetrated sexually abusive behaviors in the past year were more likely to be male and/or to have been exposed to domestic violence during childhood is consistent with findings from recent studies that suggest a relationship between exposure to domestic violence and subsequent gender-based violence perpetrated by males (e.g., Iverson, Jimenez, Harrington, & Resick, 2011). Similarly, the finding that selfinjurious behavior was associated with emotional abuse is consistent with findings from both qualitative and quantitative studies that have consistently identified a link between emotional abuse and NSSI (Buser & Hackney, 2012; Glassman et al., 2007). Finally, the link between polyreenactment and childhood neglect that emerged in the present study is congruent with the view that neglect and related forms of attachment trauma are likely to be associated with a proclivity toward a wide range of traumatic reenactments (Stein & Allen, 2007).

Implications and Limitations A unified conceptualization of traumatic reenactment that encompasses perpetration, revictimization, and self-injury proved to be of heuristic value in the present research and would appear to hold promise as a useful conceptual framework for future studies. Further research is indicated in order to not only validate the present findings but also to extend the present findings through the multivariate exploration of various risk pathways that are likely to mediate the relationship between CSA experiences and subsequent traumatic reenactments. In addition to utilizing research designs that permit reasonable causal inference, the present findings suggest that future research could profitably utilize measures of child maltreatment that provide a comprehensive measure of respondents’ full victimization profiles and measures of respondents’ abuse related cognitions and appraisals.

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With respect to interventions, the present findings suggest that abuserelated cognitions and appraisals might constitute an effective and readily modifiable target for intervention programs designed to prevent subsequent traumatic reenactments in samples of CSA survivors. Intervention programs that have been found to be effective in addressing abuse-related cognitions and that are therefore likely to be useful for this purpose, include cognitivebehavioral therapy and contextual behavior trauma therapy (cf., Courtois & Ford, 2009). While such interventions are likely to be effective across all forms of traumatic reenactment, the present findings suggest that they are likely to be particularly effective in the prevention of revictimization experiences. Moreover, the fact that 33% of CSA survivors in the present study reported multiple forms of traumatic reenactment (see Table 1) suggests that broadbased interventions, which focus on multiple forms of traumatic reenactment, may constitute the intervention of choice. These recommendations do, however, need to be considered in the context of the study limitations. The present findings were derived from a sample of South African high school adolescents and may not generalize to samples drawn from the general population or to samples drawn from other regions. In addition, the retrospective design employed in the present study places limits on the confidence with which causal inferences can be made and may have led to errors in recall regarding child maltreatment experiences. Furthermore, only a limited range of mediating/moderating factors were considered in the study. The study findings do, nevertheless, provide provisional support for the heuristic value of a unified conceptualization of traumatic reenactments that could serve as a useful organizing framework for future research.

FUNDING This work is based on research supported by the South African National Research Foundation (NRF). Any opinion, findings, conclusions, and recommendations expressed in this material are those of the authors, and, therefore, the NRF does not accept any liability in regard thereto.

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AUTHOR NOTES Susan L. Penning, MSS, is a doctoral student in the School of Applied Human Sciences at the University of KwaZulu-Natal in South Africa. Her current

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research interests focus on traumatic reenactments in the aftermath of exposure to interpersonal developmental trauma. She received her MSS from the University of KwaZulu-Natal.

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Steven J. Collings, PhD, is a professor in the School of Applied Human Sciences at the University of KwaZulu-Natal in South Africa. His current research interests focus on the psychological effects of exposure to complex developmental trauma. He obtained his PhD from the University of Natal.

Perpetration, revictimization, and self-injury: traumatic reenactments of child sexual abuse in a nonclinical sample of South African adolescents.

Risk factors for traumatic reenactments of child sexual abuse experiences (perpetration, revictimization, and self-injury) were examined in a sample o...
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