Sexual abuse and psychiatric disorder in
England: results from the 2007 Adult Psychiatric
S. Jonas1, P. Bebbington1*, S. McManus2, H. Meltzer3, R. Jenkins4, E. Kuipers4, C. Cooper1, M. King1
and T. Brugha3
1Department of Mental Health Sciences, University College London, UK
2National Centre for Social Research, London, UK
3Department of Health Sciences, University of Leicester, Leicester General Hospital, UK
4King’s College London, UK
Background. Evidence is accumulating that child sexual abuse (CSA) is associated with many psychiatric disorders
in adulthood. This paper uses the detailed information available from the 2007 Adult Psychiatric Morbidity Survey of
England (APMS 2007) to quantify links between CSA and a range of psychiatric conditions.
Method. The prevalence of psychiatric disorder was established in a random sample of the English household
population (n=7403), which also provided sociodemographic and experiential information.
Results. We analyzed six types of common mental disorder, alcohol abuse and drug abuse, and people who screened
positively for post-traumatic stress disorder (PTSD) and eating disorders. All were strongly and highly significantly
associated with CSA, particularly if non-consensual sexual intercourse was involved, for which odds ratios (ORs)
ranged from 3.7 to 12.1. These disorders were also related to adult sexual abuse (ASA), although the likelihood of
reverse causality is then increased. Revictimization in adulthood was common, and increased the association of CSA
with disorder. For several disorders, the relative odds were higher in females but formal tests for moderation by
gender were significant only for common mental disorders and only in relation to non-consensual sexual intercourse.
The population attributable fraction (PAF) was higher in females in all cases.
Conclusions. The detailed and high-quality data in APMS 2007 provided important confirmation both of the
strength of association of CSA with psychiatric disorder and of its relative non-specificity. Our results have major
implications at the public health level and the individual level, in particular the need for better recognition and
treatment of the sequelae of CSA.
Received 12 January 2010; Revised 30 April 2010; Accepted 4 May 2010
Key words: Common mental disorders, revictimization, sexual abuse, substance abuse.
Bebbington et al. 2004; May-Chahal & Cawson, 2005;
Pereda et al. 2009). There is consistent evidence of
deleterious but relatively non-specific psychiatric
sequelae in adulthood. Enhanced risks of depression,
personality disorder, post-traumatic stress disorder
(PTSD), psychosis, drug and alcohol abuse, bulimia
and suicidality have been reported (Coxell et al. 1999;
Dinwiddie et al. 2000; Kendler et al. 2000; King et al.
al. 2002; etFriedman
2002; Putnam, 2003; Bebbington et al. 2004, 2009;
Janssen et al. 2004; Read et al. 2005; Nelson et al. 2006).
The effects seem to be proportionate to the severity
and persistence of the abuse (Bulik et al. 2001; Molnar
et al. 2001), and a history of CSA is more prevalent, and
may have greater impact, in women (MacMillan et al.
2001; Molnar et al. 2001).
The third national Adult Psychiatric Morbidity
Survey (APMS 2007; McManus et al. 2009; www.ic.
nhs.uk/pubs/psychiatricmorbidity07) provides major
advantages for quantifying the association of CSA and
adult sexual abuse (ASA) with a range of psychiatric
disorders. It was based on a large random sample of
the English household population, and used standard-
ized methods to establish the diagnosis of specific
psychiatric conditions. Moreover, detailed infor-
mation about CSA and ASA was obtained using a
* Address for correspondence: Professor P. Bebbington,
Department of Mental Health Sciences, UCL, Charles Bell House,
67–73 Riding House Street, London W1W 7EJ, UK.
Psychological Medicine, Page 1 of 11.
f Cambridge University Press 2010
computer-assisted self-completion interview (CASI),
which offers significant benefits for eliciting poten-
tially sensitive information.
Our analyses cover common mental disorders,
alcohol and drug dependence, and symptoms associ-
ated with two disorders in which sexual abuse may
have particular significance: PTSD and eating dis-
orders. We predicted that severe forms of abuse would
show particularly strong associations with disorder,
as would revictimization, defined here as the rep-
etition in adulthood of abuse in childhood. We also
hypothesized that the effects of sexual abuse would
be moderated by gender, reflecting a greater impact
in females. Associations with psychosis, and with
borderline and antisocial personality disorder, will be
investigated in detail elsewhere.
The data used in these analyses were acquired from a
random sample of household residents aged o16
years. Unlike the previous surveys in this program
(Meltzer et al. 1995; Singleton et al. 2001; Jenkins et al.
2009), the APMS 2007 only covered England, and there
was no upper age limit. The sample was designed to
represent the population living in private households
(that is, people not living in communal establish-
ments). Ethical approval for APMS 2007 was obtained
from one of the Research Ethics Committees of the
National Research Ethics Service appropriate for non-
The survey adopted a multi-stage stratified prob-
ability sampling design. Full details of sampling and
design are provided by McManus et al. (2009). The
sampling frame was the small user Postcode Address
File. One adult aged o16 years was selected for in-
terview in each eligible household using the Kish grid
method (Kish, 1965). Fifty-seven per cent of those eli-
gible agreed to take part in an interview. Full inter-
views were carried out successfully with 7403 people,
of whom 7353 completed the self-completion inter-
view section that covered sexual abuse. Fieldwork was
carried out between October 2006 and December 2007.
The training and briefing of the experienced National
Centre for Social Research interviewers selected to
work on the first phase of the survey is described
elsewhere (McManus et al. 2009; Bebbington et al.,
in press). The phase one interview involved computer-
assisted personal interviewing (CAPI), with answers
entered by the interviewers directly into a laptop.
The laptop was given to the participant for the self-
completion (CASI) element of the first-phase inter-
view. Respondents knew beforehand that interviewers
were unable to see the results of the self-completed
parts of the interview, which included questions about
different levels of sexual abuse:
(1) Has anyone talked you in a sexual way that made
you feel uncomfortable?
(2) Has anyone touched you, or got you to touch
them, in a sexual way without your consent?
(3) Has anyone had sexual intercourse with you
without your consent?
We identified people who had been sexually abused in
childhood (<16 years) or in adulthood (o16 years).
Those who had been abused in both periods were re-
garded as having experienced ‘revictimization’.
Non-psychotic psychiatric disorders were assessed
in relation to the past week, using the Clinical
Interview Schedule – Revised (CIS-R; Lewis et al.
1992). This can be administered by non-clinically
trained interviewers, and formed part of the phase one
interview. It provides diagnoses of six so-called com-
mon mental disorders (CMDs): depressive episode,
mixed anxiety/depressive disorder, generalized anxi-
ety disorder (GAD), panic disorder, phobic disorder,
and obsessive–compulsive disorder (OCD).
Alcohol dependence in relation to the past 6 months
was derived on the basis of responses to two ques-
tionnaires, the Alcohol Use Disorders Identification
Test (AUDIT; Saunders et al. 1993) and the community
version of the Severity of Alcohol Dependence
Question naire (SADQ-C; Stockwell et al. 1994). All
respondents with an AUDIT score of o10 were also
interviewed with the SADQ-C, which consists of 20
items, covering a range of dependence symptoms
scored from 0 to 3 (total score 0–60). A score of o4 is
taken to indicate at least mild dependence, and we
took this as our threshold for dependence.
Questions about drug use were again located in the
CASI part of the interview. Participants who in the
past year had used cannabis, amphetamines, crack,
cocaine, ecstasy, tranquillizers, opiates or volatile sub-
stances were asked five questions designed to assess
drug dependence based on the Diagnostic Interview
Schedule (Malgady et al. 1992). These questions cov-
ered level of use, sense of dependence, inability to
abstain, increased tolerance, and withdrawal symp-
toms. Endorsement of any of the items in the past year
was used to indicate drug dependence.
Screening tests were used to identify possible cases
of current PTSD and eating disorders. For PTSD,
we used the Trauma Screening Questionnaire (TSQ),
a short screening tool (Brewin et al. 2002). The TSQ
covers the re-experiencing and arousal features of
2S. Jonas et al.
PTSD, but not criteria related to avoidance and
numbing. As the questions were themselves poten-
tially distressing, they were located in the CASI part of
the interview. Respondents were first asked whether
they had experienced a traumatic event at some time
in their life after the age of 16. If so, they rated 10 PTSD
items in relation to the past week. Endorsement of six
or more of these was taken to indicate a positive screen
The prevalence of eating disorders was estimated
using the SCOFF questionnaire (Morgan et al. 1999).
This was administered to all APMS 2007 respondents
in the CASI part of the interview. A SCOFF score of
o2 was taken as a positive screen for eating disorder.
Again, this is a screening tool, not a diagnostic instru-
As with other lay-administered screening tools, the
prevalences obtained overestimate the rates of dis-
order that would be determined by full clinical inves-
tigation. This must be borne in mind: people who are
positive on the screening instruments described above
are therefore referred to as having ‘PTSD symptoms’
or ‘eating disorder symptoms’ respectively. However,
it is always worth investigating screen-positive partici-
pants as they will tend as a group to share the at-
tributes of those with the full syndrome (e.g. Johns
et al. 2004).
The identification of psychiatric disorder related
to time-frames that were not always the same. Thus, as
for CMDs, screening for PTSD related to the past
week, whereas alcohol dependence related to the past
6 months, and eating disorders and drug dependence
to the past year.
Comparisons of the age and sex distribution of the
survey sample with the national English population
are given in the main survey report (Table 13.5;
McManus et al. 2009). However, the survey data were
weighted to take account of survey design and non-
response, such that the results were representative of
the household population of England aged o16 years.
Weighting was necessarily complex, and is described
in detail by McManus et al. (2009). We used the
‘survey’ commands in Stata 10.0 (StataCorp, 2008),
which allow for the use of clustered data modified by
probability weights, and provide robust estimates of
variance. We describe the variables studied using ac-
tual numbers, but proportions and odds ratios (ORs)
We have already provided evidence that sexual
abuse conforms to a meaningful hierarchy of severity
(Bebbington et al., in press). To test our hypothesis that
the association of abuse with individual psychiatric
disorders was proportional to the severity of abuse,
we created a variable whose four levels consisted of:
‘no abuse’; uncomfortable talk only; sexual touching,
whether accompanied by uncomfortable talk or not;
and non-consensual intercourse. By expanding the
variable into its levels during logistic analysis, we
were able to identify the ORs associated with each
level of severity. The results are presented separately
for CSA and ASA.
We used accepted criteria to test our hypothesis that
sexual abuse would be more strongly associated with
disorder in women than in men; that is, the relation-
ship would be moderated by gender (Baron & Kenny,
1986). Moderation is held to occur when there is an
interaction between a factor (here gender) and an in-
dependent variable (here CSA) such that the former
specifies the conditions under which the latter oper-
ates. We provide ORs and population attributable
fractions (PAFs) separately for each sex, in relation
respectively to contact abuse and to non-consensual
sexual intercourse before age 16.
Table 1 lists the weighted prevalence of the chosen
disorders so as to provide context to the subsequent
analyses. Table 2 presents the overall association of
CSA with each disorder, and then the ORs for each
individual level denoting the severity of CSA, with ‘no
abuse’ as the reference category. (Where no p values
are shown, the significance level is <0.0001.) In all
cases, the overall association was highly significant
(p<0.0001). When we distinguished the different lev-
els of severity, the majority of analyses (18 out of 30)
were again significant beyond p<0.0001. In the case of
the most severe form of abuse, non-consensual sexual
intercourse, all associations were highly significant.
The effect of non-consensual touching was non-
significant in two disorders (drug and alcohol
dependence). Even for uncomfortable sexual talk, the
associations were significant for all but depressive
disorder, mixed anxiety/depression, and panic. In
each disorder, the ORs for non-consensual intercourse
were greatest, being particularly large for phobia
and symptoms of PTSD. However, our hypothesized
severity gradient was less clear when we consider
uncomfortable talk and sexual touching. In several
disorders, the associated OR was greater for the former
than for the latter. The smallest overall associations
between abuse and disorder were seen with alcohol
and drug dependency, and with mixed anxiety/
depressive disorder. The latter is a residual category
for cases that do not meet criteria for any other CMD.
Table 3 presents corresponding analyses for the
different forms of ASA. Again the overall associations
Sexual abuse and psychiatric disorder in England3
were all significant beyond p<0.0001. All ORs for
non-consensual sexual intercourse were significant
at a similar level, except for panic (p=0.02) and al-
cohol dependence (p=0.007). Non-consensual sexual
intercourse was associated with the greatest ORs,
for all disorders except panic. In most disorders, the
association with uncomfortable talk was less than that
with sexual touching.
Table 1. Frequency of psychiatric morbidity in the sample (weighted percentages, true
Type of psychiatric disorderReference period Frequency, % (n)
Common mental disorders (CMDs)
Mixed anxiety and depression
Past 6 months
Disorders established from screening
GAD, Generalized anxiety disorder; OCD, obsessive–compulsive disorder; PTSD,
post-traumatic stress disorder.
Table 2. The effect of different forms of child sexual abuse (CSA) on adult psychiatric disorder (ORs and 95% confidence intervals)
Overall effect of
Common mental disorders (CMDs)
Depressive disorder1.74 (1.5–2.0) 1.82 (0.9–3.8)
3.08 (2.0–4.8)5.07 (2.7–9.6)
Mixed anxiety/depression1.46 (1.3–1.6)1.88 (1.4–2.5) 3.72 (2.5–5.6)
GAD1.64 (1.4–1.9) 2.56 (1.8–3.6)4.51 (2.6–7.9)
Panic 1.60 (1.3–2.0)2.78 (1.3–5.8)
12.12 (6.4–23.0)Phobia 2.07 (1.7–2.5)
OCD 1.84 (1.5–2.3) 4.53 (2.1–9.7) 7.01 (2.9–17.2)
Drug dependence1.51 (1.3–1.8)2.37 (1.4–4.0)1.26 (0.7–2.3)
Alcohol dependence1.38 (1.2–1.6)1.71 (1.0–2.9)
Disorders established from screening
OR, Odds ratio; GAD, generalized anxiety disorder; OCD, obsessive–compulsive disorder; PTSD, post-traumatic stress
Reference category: no sexual abuse. p values shown only where they are >0.0001; that is, all others are p<0.0001.
4S. Jonas et al.
The ORs varied less with the severity of ASA than in
CSA. The association of abuse with alcohol and drug
dependence was again the weakest. However, the
overall association of abuse with the various disorders
was relatively consistent for both CSA and ASA,
ranging from 1.35 to 2.1.
We then analyzed the effects of revictimization
(Table 4). We used two definitions of this: in the first,
non-consensual sexual intercourse in childhood was
repeated in adulthood, whereas the second involved
the repetition of childhood contact abuse in adult-
hood. Whatever the definition, for CMD, and for
symptoms of PTSD and eating disorder, the ORs
associated with revictimization are approximately
double those derived just from childhood abuse. In
relation to alcohol dependence, this was only true of
abuse involving non-consensual sexual intercourse,
and there was relatively little increase in the ORs
for contact abuse. There was an anomalous finding in
relation to drug dependence: revictimization involv-
ing sexual intercourse was in fact associated with a
reduction in the OR.
In Table 5 we present the effect of gender on the
association between CSA and adult psychiatric dis-
order. To reduce the number of analyses, we grouped
CMDs together, but drug and alcohol abuse, and
symptoms of PTSD and eating disorders were ana-
lyzed separately. In relation to non-consensual sexual
Table 3. Adult sexual abuse (ASA) correlates of adult psychiatric disorder (ORs and 95% confidence intervals)
Overall effect of
Common mental disorders (CMDs)
5.65 (2.9–10.9) Phobia1.89 (1.6–2.2)3.04 (1.4–6.6)
OCD 1.77 (1.4–2.2) 2.62 (1.3 –5.3)
Drug dependence 1.41 (1.2–1.7)2.08 (1.3–3.2)1.01 (0.4–2.4)
Alcohol dependence1.35 (1.2–1.5) 1.93 (1.4–2.7) 2.01 (1.2–3.3)
Disorders established from screening instruments
OR, Odds ratio; GAD, generalized anxiety disorder; OCD, obsessive–compulsive disorder; PTSD, post-traumatic stress
p values shown only where they are >0.0001; that is, all others are p<0.0001.
Table 4. The effect of sexual revictimization on psychiatric disorder (ORs and 95% confidence intervals)
Non-consensual sexual intercourseContact abuse
In childhood onlyWith revictimizationIn childhood onlyWith revictimization
Common mental disorder
OR, Odds ratio; PTSD, post-traumatic stress disorder.
Sexual abuse and psychiatric disorder in England5
intercourse, the ORs in females were very consider-
ably greater than in males for every condition except
eating disorder. Indeed, in males the ORs are non-
significant in relation to non-consensual sexual inter-
course for CMD, drug dependence and PTSD. For
PTSD, this was also the case for contact abuse. There
was generally much less effect of gender in relation to
However, despite the suggestive ORs, formal test-
ing for moderation suggested that gender moderates
the impact of CSA only in relation to CMDs, and then
only for non-consensual sexual intercourse.
Values for the PAF are also presented in Table 5.
This measure effectively combines the frequency of
sexual abuse with its impact at the individual level to
represent the relationship between sexual abuse and
psychiatric disorder at the population level. Because
CSA is less frequent in males, and the ORs are smaller,
PAF values generally increase the discrimination be-
tween males and females. In fact, non-consensual
sexual intercourse accounts for little attributable risk
in males for any of the disorders, and the PAF is many
times greater in females. Because contact abuse is
more common than non-consensual sexual inter-
course, it is associated with higher PAFs. Indeed,
nearly a quarter of cases of PTSD in females can be
attributed to the experience of contact abuse in child-
hood. The highest PAF in males is for eating disorder,
whether in relation to non-consensual intercourse or
to contact abuse.
It should be noted that our primary presentation
is of results unadjusted for sociodemographic at-
tributes. This is because the prevalence of our sexual
abuse measures did not vary significantly with socio-
demographic status, apart from gender and age
(Bebbington et al., in press). Adjustment should there-
fore be unnecessary. However, to ensure that this as-
sumption was valid, we reran the analyses presented
here after adjusting for social class, educational level,
ethnicity, and level of household income. This adjust-
ment made no difference to the results: sexual abuse
remained a strong determinant of these disorders.
Because reports of sexual abuse decrease significantly
with the age of the respondent (Bebbington et al., in
press), we conducted separate analyses controlling
just for age. Again, this had no effect on the strength of
the association between sexual abuse and any of the
psychiatric disorders analyzed.
This is the third household survey in the British
National Psychiatric Morbidity program (Jenkins et al.
2009). Over the 14 years separating these surveys, the
response rate has declined progressively from 80% to
57%. This reduction has been found in other popu-
lation surveys (e.g. Kessler et al. 1994, 2005; Tolonen
et al. 2006). It leads to concerns that samples may be
increasingly unrepresentative of the populations from
which they are drawn. However, both risk estimates
and the associations of disorder with predictors are,
at least sometimes, relatively insensitive to response
rates that would have until recently been regarded as
poor (Batty & Gale 2009; Bergman et al. 2010). In re-
sponse to these potential worries, we conducted a
sensitivity analysis of the effect of response rate on the
prevalence of sexual abuse. We divided the whole
sample into two by the response rate seen in individ-
ual regions. We then compared the ‘any sexual abuse’
CAPI question by this new locational variable, both
weighted and unweighted. There was no significant
association between location and prevalence. Nor
was this due to lack of statistical power: the un-
weighted prevalences of abuse were close in lower
and higher responding areas (5.5% and 4.9%, respect-
Sexual abuse is a sensitive topic, and concerns about
the accuracy of reportage, in particular under-
reporting, must be taken seriously. Fergusson et al.
(2000) assessed the stability of reports of CSA over a
3-year gap. They concluded that people who had not
been abused did not falsely report that they had been,
but that people who had been abused did not report it
every time they were asked. As a result, false negatives
may reach 50%. However, this did not materially af-
fect estimates of the relative risk of associated psychi-
atric disorders (Fergusson et al. 2000).
Nevertheless, sensitivity is likely to vary with time,
and possibly with age. In addition, not everyone is
equally subject to embarrassment or discomfiture.
Some of the more minor forms of abuse might be
forgotten, discounted or repressed with increasing
age and changing perspective. Our category of un-
comfortable sexual talk might be an example of this.
By contrast, non-consensual sexual intercourse is
clearly abuse, and an almost universally illegal one. It
is thus more likely to be under-reported than forgot-
ten, and its acknowledgement will depend to an extent
on the method of enquiry. The 2007 APMS involved
deliberate and strenuous efforts to maintain the qual-
ity of information in sensitive areas of the interview,
including stressing confidentiality and interviewing
participants alone where feasible. In addition, there
are particular advantages to CASI. Thus, getting
people to complete the questionnaire themselves on
6 S. Jonas et al.
Table 5. The effect of gender on the association between child sexual abuse (CSA) and adult psychiatric disorder
Non-consensual sexual intercourseContact abuse
OverallMale Female OverallMale Female
Common mental disorderOR (95% CI)
2.7 (0.8–5.8 )
Interaction term OR 1.0 (95% CI 0.6–1.6), p=0.96
1.97 (1.3–3.1) 2.10 (1.1–4.1 )
Interaction term OR 1.2 (95% CI 0.5–2.9), p=0.68
1.80 (1.3–2.5) 2.14 (1.4–3.3 )
Interaction term OR 1.1 (95% CI 0.6–2.2), p=0.69
3.53 (2.4–5.2)2.30 (0.98–5.4)
Interaction term OR 1.8 95% (CI 0.7–4.6)
3.28 (2.5–4.3) 3.48 (1.8–6.8)
Interaction term OR 0.9 (95% CI 0.4–1.8), p=0.71
2.79 (1.9–4.2 )
Interaction term OR 2.9 (95% CI 1.0–8.2), p=0.043
5.09 (2.8–9.2) 2.95 (0.8–11.5)
Interaction term OR 3.0 (95% CI 0.7–13.5), p=0.15
3.50 (2.0–6.0) 4.08 (1.5–11.5 )
Interaction term OR 1.4 (95% CI 0.4–4.6), p=0.57
6.57 (3.7–11.8)1.73 (0.2–13.1)
Interaction term OR 4.4 (95% CI 0.5–36.3), p=0.16
5.23 (3.3–8.3)5.54 (1.8–17.5)
Interaction term OR 0.8 (95% CI 0.2–2.7), p=0.72
Drug dependence OR (95% CI)
Alcohol dependenceOR (95% CI)
PTSD OR (95% CI)
Eating disorderOR (95% CI)
OR, Odds ratio; CI, confidence interval; PAF, population attributable fraction (%); PTSD, post-traumatic stress disorder.
Sexual abuse and psychiatric disorder in England
a laptop computer and making them aware that the
interviewer would have no access to the answer was
intended to encourage frankness.
Although the information about abuse and disorder
was obtained at a single point in time, in the over-
whelming majority of cases CSA ostensibly predates
what are, after all, current disorders. For CSA, a causal
inference is therefore more defensible than for ASA. It
is still subject to the caveat of systematic distortion
of reportage, in whatever direction, by people with
mental disorders. However, as we pointed out above,
they are generally reliable informants.
The issue of repeated abuse is of considerable im-
portance. Because of time constraints on the interview,
we were unable to enquire about repeated abuse
during childhood. Our measures of revictimization are
therefore based on repetition of childhood abuse when
the victim is adult (defined as being o16 years old).
During adulthood, there is an increased likelihood of
reverse causality, as people are at greater risk of sexual
exploitation after they have developed psychiatric
disorders (Romito & Gerin, 2002). This should be
borne in mind.
Finally, a distinction must be made in relation to
PTSD and eating disorders. As described above, these
were based on screening scores. This is likely to in-
crease the prevalence obtained. However, it is reason-
able to assume that the cases identified in this way
share qualities with those that would have been de-
rived from more extended clinical assessment.
Our results confirm that both CSA and ASA are
strongly associated with a wide range of psychiatric
disorders. This relationship is dose related, in two
ways. First, in every psychiatric disorder, the highest
ORs were associated with the group reporting sexual
intercourse without consent, clearly the most trau-
matic form of sexual abuse experience. However,
we expected higher ORs for sexual touching than for
uncomfortable sexual talk. This was sometimes the
case, but with no overall consistency, perhaps because
uncomfortable talk may be just as disturbing to the
victim as the physical intrusion of touching. Others
have found the severity of abuse in childhood in-
creases the risk of adult psychiatric morbidity (Mullen
et al. 1993; Kendler et al. 2000, 2004; Bulik et al. 2001;
Anda et al. 2006).
Second, revictimization was associated with an in-
creased frequency of disorder. The exception was in
the case of repeat non-consensual sexual intercourse in
relation to drug dependence. The combination of non-
consensual sexual intercourse before 16 with later re-
petition generally showed the strongest associations;
this was particularly marked in relation to symptoms
of PTSD and eating disorder, with ORs of 12.6 and 9.2
In general, males are reported to respond less se-
verely than females to given levels of trauma (Tolin &
Foa, 2006; Koenen & Widom, 2009). It might therefore
be expected that the psychiatric disorder/sexual abuse
relationship is moderated by gender. In our data, the
ORs in relation to non-consensual sexual intercourse
were much higher in women in all conditions except
eating disorder. The effect of sexual abuse was par-
ticularly large for symptoms of eating disorder, but, if
anything, the effect of CSA was greater in men than in
women. However, formal tests of moderation were
only significant for CMDs. The failure to demonstrate
moderation elsewhere may represent a Type II error,
as considerable statistical power is required to dem-
onstrate interaction terms.
Although ORs provide a measure of the strength
of the association between abuse and psychiatric dis-
order, the PAF represents the proportion of psychi-
atric disorders that can be ascribed to exposure to
sexual abuse. In theory, the PAF indicates how much
the prevalence of psychiatric disorder would be re-
duced if no sexual abuse occurred in the population.
As such, it is dependent both on the prevalence of
the exposure to sexual abuse in the population and the
strength of the association of sexual abuse with dis-
order. Given that sexual abuse is more common in fe-
males (Bebbington et al., in press), the distinction
between males and females should be enhanced by
using the PAF. This was so for all conditions studied,
including symptoms of eating disorder. In other
words, at a population level, sexual abuse has a much
more important bearing on psychiatric disorder in
women than in men. Perpetrators are usually men,
and the sensitivity of women to abuse may reflect
power relationships between the genders in society at
However, the CSA relationship is remarkably non-
specific. Others have shown associations with multiple
adult psychiatric conditions, including depression,
anxiety disorders, personality and eating disorders,
substance abuse, suicidal behavior, and psychosis
(Polusny & Follette 1995; Dinwiddie et al. 2000;
Kendler et al. 2000; Bulik et al. 2001; Molnar et al. 2001;
Putnam, 2003; Bebbington et al. 2004, 2009; Nelson
et al. 2006; Weich et al. 2009a). We need to explain why
so many different disorders are associated with the
same putative etiological agent. Candidates include
the frequent co-morbidity between the disorders we
studied, and the possibilities that there are multiple
pathways linking sexual abuse to different disorders,
or that the pathways underpinning the increased
risk are operative in many psychiatric conditions.
8 S. Jonas et al.
The considerable co-morbidity in our sample has been
analyzed in detail by Weich et al. (2009b), and its ef-
fects on the relationship between sexual abuse and
psychiatric disorder will be examined elsewhere.
The association between abuse and PTSD in APMS
2007 is a special and interesting case because of the
way it was assessed: PTSD was identified only in re-
lation to adult traumas. Such traumas could, in prin-
ciple, be instances of ASA. However, if there is, as we
demonstrated, a link between CSA and PTSD, this
must arise because the CSA has changed the rate
of exposure to trauma in adulthood, or the level of
response to it in terms of PTSD symptoms. The
symptoms cannot be the persistent consequences of
the childhood trauma.
Sexual abuse in childhood will generally precede
the development of psychiatric conditions identified
in adulthood. Thus there must be some mediator
linking the abuse with the onset of disorder, often at a
considerable remove of time. Likely candidates are
mentally intrusive reminders of the abusive experi-
ence, psychological processes involving attitudes and
beliefs, propensities towards mood disturbance in the
face of subsequent experience, and styles of coping
that may impair the processing of the original abuse.
CSA has extreme adverse effects on self-esteem, self-
blame and psychological well-being (Mannarino &
Cohen, 1996; Kamsner & McCabe, 2000; Banyard et al.
2001; Murthi & Espelage, 2005). People who have been
sexually abused often display avoidant coping, which
then links to the later development of various psychi-
atric disorders (Cortes & Justicia, 2008; O’Leary, 2009).
Abuse may also modulate the physiological stress re-
sponse in deleterious ways (Driessen et al. 2000; Heim
et al. 2000; Read et al. 2005; Spauwen et al. 2006).
Finally, it may create vulnerabilities to later damaging
Our results showed that CSA was followed by a
significant increase in the risk of ASA. Fifty per cent
of those who had experienced abuse under 16 also
reported an episode over the age of 16. This re-
victimization certainly seems to increases the risk of
psychiatric disorder over and above the occurrence
of childhood abuse alone, as others have found (Gold
et al. 1999; Classen et al. 2005). The increased risk
might be the direct effect of the further abuse.
Alternatively, revictimization might merely be a
marker of the severity or impact of the original abuse.
Of interest, the same psychological attributes predic-
tive of disorder following CSA may also be predictive
of revictimization, thus contributing to a malign spiral
(Fortier et al. 2009). Moreover, avoidance of physical
and emotional reminders of trauma may interfere with
learning about safety judgments, and place the abused
person at risk of further victimization (Fortier et al.
2009). Finally, symptoms of PTSD, depression and
anxiety increase vulnerability for revictimization in
prospective studies (Messman-Moore et al. 2005, 2009).
Our findings have important clinical implications,
first from the sheer prevalence of abuse, and second
from the wide range of disorders associated with it. In
ordinary clinical practice, it is not routine to ask de-
tailed questions about sexual abuse. As others argue
(Read et al. 2005), it should be. People who have ex-
perienced sexual abuse are often identified by social
services and through the criminal justice system,
and there is increasing awareness in schools and in
primary care. If mediating psychological processes are
also maintenance factors, targeting them will have
beneficial effects both in treatment and in secondary
prevention. Thus, the psychological consequences of
abuse may be dealt with before psychiatric disorders
emerge, with new treatment developments including
rescripting as part of cognitive behavioral therapy
approaches (Holmes et al. 2007; Linden & Zehner,
E.K. has received funding for some clinical sessions
from the National Institute of Health Research (NIHR)
Biomedical Research Centre for Mental Health at the
South London and Maudsley National Health Service
(NHS) Foundation Trust, and the Institute of Psy-
chiatry, King’s College London.
Declaration of Interest
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