Previous literature reviews examining the psychological correlates of CSA have generally 

Clinical and legal samples are problematic because they are not representative of the general population, and because findings from these samples are vulnerable to information and selection biases that threaten their validity (Pope & Budson, 1995). Conclusions based on narrative and qualitative reviews are vulnerable to subjectivity and imprecision (Jumper, 1995). 

Therefore, the conclusions and implications presented in most of these literature reviews cannot be accepted as scientifically valid for the entire population of persons with experiences that are labeled as CSA without further scrutiny. 

These conclusions and implications are that, in the general population, 

To evaluate these basic conclusions and implications about population characteristics of CSA, we examined only studies that used national probability samples, because these samples are most appropriate for addressing questions about population characteristics. Further, we evaluated the results from these studies meta-analytically, in the attempt to reduce subjectivity and strengthen precision.

We located seven studies using national probability samples that contained data concerning correlates or effects of CSA. Four of these studies were based on U .S. samples, and one each was based on a Canadian, British, and Spanish sample. Not including two studies in which researchers used overly broad definitions of CSA, we found that prevalence rates for CSA were approximately 11% for males and 19% for females. In the following sections, we evaluate the basic conclusions and implications presented in previous literature reviews by reviewing the findings from the national samples.

Gender Equivalence 

A number of national studies presented data on respondents' self-reported effects from or reactions to their CSA experiences. A consistent finding across these studies was the greater proportion of negative responses by females. Whereas a majority of females (about two thirds) reported negative effects, only a minority of males (about two in five) did so. Across the three studies that provided self-reported effects data, the size of this sex difference was small to medium. 

Data on reactions at the time of the CSA experience, presented in a fourth study (López et al., 1995), further indicated that the CSA experiences of males and females are not equivalent, with a greater proportion of females reacting negatively. This sex difference was medium size. The contrast analysis of CSA-adjustment relations showed a non-significant trend in the direction of poorer adjustment for SA females compared to SA males. 

The more reliable difference between SA females and males in self-reported effects or reactions compared with current adjustment is not contradictory, because effects or reactions may be temporary and therefore may not be reflected in measures of current adjustment, and measures of current adjustment assess correlates of CSA, which mayor may not reflect effects.

Results from several studies reviewed suggest possible reasons for the consistent differences in self-reported effects and reactions. 

Bigler ( 1992) found that fewer than a third of his male respondents reported being coerced in their CSA experience, whereas more than half of his female respondents reported being coerced. 

Baker and Duncan (1985)

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found that female CSA experiences were three to four times more likely to be incestuous than male CSA experiences. They also found that females were younger than males on average when they experienced CSA. These findings imply that, in the population of persons with a history of experiences classifiable as CSA, males and females have different responses to these experiences because they typically do not have the same type of experience. 

The finding of nonequivalence of male and female CSA experiences in the national samples matches findings in college samples in which only one third of SA males reports negative reactions compared to two thirds of SA females (Rind, 1995). This finding of non-equivalence, however, contradicts clinical findings, upon which most researchers have based their conclusions.

Pervasiveness and Intensity

The se1f-reported effects data contradict the conclusions or implications presented in previous literature reviews that harmful effects stemming from CSA are pervasive and intense in the population of persons with this experience. 

Baker and Duncan (1985) found that, although some respondents reported permanent harm stemming from their CSA experiences (4% of males and 13% of females), the overwhelming majority did not (96% of males and 87% of females). Severe or intense harm would be expected to linger into adulthood, but this did not occur for most respondents in this national sample, according to their self-reports, contradicting the conclusion or implication of intense harm stemming from CSA in the typical case.

Meta-analyses of CSA-adjustment relations from the five national studies that reported results of adjustment measures revealed a consistent pattern: SA respondents were less well adjusted than control respondents. Importantly, however, the size of this difference (i.e., effect size) was consistently small in the case of both males and females. 

The unbiased effect size estimate for males and females combined was r_u = .08, which indicates that CSA, assuming that it was responsible for the adjustment difference between SA and control respondents, did not produce intense problems on average. 

This effect size estimate is comparable to the mean effect size estimate for college students (r_u = .07) in Jumper's (1995) meta-analysis, but it is considerably smaller than the effect size estimates for clinical samples in Jumper's (1995) and Neumann et al.'s (1996) meta-analyses, which were r_u = .31 and d = .50 (roughly equivalent to r_u = .30), respectively. 

Thus, whereas CSA accounted for only about one half of 1% of the adjustment variance for respondents in the national and college samples, CSA accounted for nearly 10% of the adjustment variance in the clinical samples. This substantial difference implies that clinical samples cannot be used to make valid estimates of psychological correlates of CSA in the general population. 

The results of the current meta-analyses and those of previous meta-analyses (Jumper, 1995; Neumann et al., 1996) taken together imply that clinical samples overestimate the adjustment variance accounted for by CSA in the general population by a factor of 15 and thereby substantially exaggerate the intensity of CSA correlates in the general population. Researchers' reliance on clinical samples in most previous literature reviews to estimate CSA-adjustment relations is therefore problematic.

The effect size estimates obtained from the national studies (r_u = .07 for males and r_u = .10 for females) cannot be interpreted as estimates of the effects of CSA on adjustment for several reasons.

First, these values estimate correlates, of which only a portion is likely to be effects. Therefore, the actual effects of CSA on adjustment in the general population are likely to be lower than the obtained effect size estimates, implying that the intensity of CSA effects in the population of persons who have experienced CSA is of very small magnitude. 

Second, the effect sizes from Boney-McCoy and Finkelhor's (1995) study should not be combined with the effect sizes from the other studies because these researchers restricted the SA population to persons with unwanted experiences. If the goal is to estimate CSA psychological correlates in the population, then the sample of SA respondents obtained must accurately reflect the population of SA persons, which Boney-McCoy and Finkelhor's sample did not. Thus, the lower unbiased effect size estimates obtained without Boney-McCoy and Finkelhor's effect sizes (r_u = .06 for males and r_u = .07 for females) are likely to be more precise population estimates.

Bigler (1992) provided information on the distributions of his participants' responses, which are relevant to examining whether CSA produces intense and pervasive effects. The distributions were positively skewed for both sexual dysfunction and level of trauma, with most scores falling in the non-problematic range. 

This information suggests that, assuming a causal role for CSA, CSA affects a small portion of individuals in an intensely negative way but has a much smaller negative effect, if any, on most individuals. 

This finding is consistent with Baker and Duncan's (1985) data on self-reported effects, in which only a small minority of SA individuals reported permanent harm. Clinical and legal samples are the sample types that are mostly likely to consist of these extreme negative cases (Okami, 1991). This bias highlights the problem of focusing on clinical and legal samples to describe the correlates of CSA-a focus that has characterized nearly all previous literature reviews.

Causality

The results of several studies reviewed in this article are relevant to the issue of the role of CSA in causing harm. 

Laumann et al. (1994) found that, although SA respondents consistently reported more sexuality-related problems than control respondents, they were also consistently more sexually active and had consistently

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experienced more diverse types of sex than control respondents. This confounding variable of extent and type of sexual experience renders the difference in adjustment between the SA and control respondents un-interpretable in terms of cause and effect. Laumann et al. argued that greater sexual activity may have subjected SA respondents to more untoward outcomes, which may then have led to poorer adjustment.

Two studies used statistical control in assessing the relationship between CSA and current adjustment in an attempt to overcome problems of confounding variables (Boney-McCoy & Finkelhor, 1995; Finkelhor et al., 1989). 

Boney-McCoy and Finkelhor controlled for a variety of demographic variables as well as an index of parent-child relations and found that CSA respondents remained statistically significantly more poorly adjusted than controls. They argued that this result strengthens the assertion that CSA, and not some other variable, caused the poorer adjustment.

However, several considerations suggest that their control variables may not have been adequate to support this assertion. 

First, demographic variables have been found not to be important correlates of CSA in other national probability samples (Ageton, 1988; Laumann et al., 1994). 
Second, the parent-child index excluded nonsexual abusive experiences, which may have weakened its effect in statistical control. 
This possibility is suggested by recent research that has shown that CSA often occurs along with physical abuse or emotional neglect (Ney et al., 1994), and that when these other experiences are held constant, CSA-symptom relations frequently disappear 

(e.g., Cole, 1987; Eckenrode, Laird, & Doris, 1993; Higgins & McCabe, 1994; Ney et al., 1994; Wisruewski, 1989). 

For example, Wisruewski (1989), who used path analysis to examine CSA-adjustment relations among female students from 32 U.S. colleges and universities, chosen to be representative of all institutions of higher leaming in the U.S., concluded that the 

"data do not support child sexual abuse as a specific explanation of current emotional distress. The data are best interpreted as supportive of other factors such as family violence ... as having the greatest impact on current emotional adjustment" (p. 258). 

Finkelhor et al.'s (1989) control variables were similar to those of Boney-McCoy and Finkelhor (1995), and hence their conclusion that a causal link between CSA and adjustment was supported because most CSA-adjustment relations remained statistically significant after statistical control is subject to the same criticisms.

The findings from another study using a national sample, not included in the current review because it did not report psychological correlates of CSA and because of its exclusive focus on female respondents, are particularly relevant for interpreting causation in national samples (Ageton, 1985, 1988). 

Ageton reported the results of longitudinal data collected on U.S. respondents aged 11 to 17 at the beginning of the study and found that girls experiencing unwanted sexual contacts differed from those who did not in terms of family, school, and social factors. 

We computed effect sizes for these measures for the last year for which data were taken to obtain estimates of the magnitude of confounding between CSA and social environment. Effect sizes ranged from small-medium to large. 
Some examples were these: 

 These results suggest that the small differences in adjustment between CSA and control respondents observed in other national samples may be attributable to larger differences in social environment, rather than to the CSA.

To address the issue of whether CSA was the result or cause of negative social factors, Ageton (1988) analyzed the longitudinal data prospectively. She investigated whether any social factors measured in earlier years of the study were predictive of CSA that occurred in later years of the study and found that a number of factors were predictive. 
We computed effect sizes for the significant predictors, averaged them over the two years reported for each predictor, and obtained the following: 

These results, with effect sizes of small to medium magnitude, imply that negative social factors predispose children and adolescents to CSA, rather than the reverse. These results are consistent with the possibility that negative social factors lead to poorer adjustment and to CSA and that the relation between CSA and adjustment in the general population is either spurious or of lower magnitude than we estimated.

Qualifications 

Several qualifications of the findings from the national probability samples need to be discussed. 

The first concern involves the measures of effects used in these studies. 
It may be argued that self-reports of effects of CSA are not valid in terms of describing actual effects. For example, it may be argued that persons with CSA experiences are sometimes not aware of the negative impact that these experiences have had on their current

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adjustment, leading them to underreport this impact. This argument is consistent with the recovered memory view (see Loftus & Ketchum, 1994).

Although these false negatives may occur in some cases, their occurrence may be counterbalanced by the occurrence of false positives in other cases. Persons with current adjustment problems who attribute these problems to their CSA experiences may make invalid causal inferences because of their "effort after meaning," in which they have been motivated to explain their current difficulties and have chosen their CSA experience as the causative factor because of the salience of CSA in our culture at the present time as an explanation for maladjustment (Pope & Hudson, 1995). Thus, false negatives and false positives may both occur, with the result that overall bias in measurement may be small and may not necessarily be in the direction of underestimation of negative effects.

Self-reports of harm stemming from CSA experiences are generally accepted by child abuse researchers as valid indicators of harm. This being the case, it seems inappropriate to dismiss self-reports of no harm. 

Baurmann (1983), who examined psychological correlates of CSA using the largest sample ever employed in CSA research of children and youths who experienced CSA, argued for the inclusion of self-reports of effects. One basis for his argument was that self-reported effects corresponded well to standardized measures of adjustment in his study.

Another possible shortcoming of the studies reviewed in the current article is that a number of these researchers did not use standardized measures of adjustment but instead used just a few common sense items. 

Although this criticism applies to two of the five studies with measures of adjustment 

(Finkelhor et al., 1989; Laumann et al., 1994), 

it does not apply to the other three 

(Bigler, 1992; Boney-McCoy & Finkelhor, 1995; López et al., 1995). 

Bigler and López et al. used standardized measures; Boney-McCoy and Finkelhor constructed a measure of PTSD, but its items were taken and modified from the well-established SCL-90-R. 

The results across studies were fairly consistent, regardless of measurement instrument, suggesting the validity of the non=standardized measures.

Another criticism that might be made is that the measures employed were not sensitive to the type of harm that is assumed to result from CSA, because CSA is assumed to have particular effects (Briere & Elliot, 1993). 

Nash, Hulsey, Sexton, Harralson, and Lambert (1993b, p. 290) argued, however, that because "almost every conceivable form of pathology" has been attributed to CSA, any given measure of adjustment should be sufficiently sensitive. 

Furthermore, the majority of studies using measures of adjustment in the current review specifically assessed sexual adjustment, which is one type of adjustment that has been frequently hypothesized by child abuse researchers to be vulnerable to CSA experiences.

Aside from measurement concerns, another possible shortcoming is response rate. 
Bigler (1992) showed the poorest response rate (33%), which casts doubt on the generalizability of his findings. 
In the López et al. (1995) study, although the initial response rate was 82%, only 49% of these respondents returned their questionnaire, which contained the adjustment measure. The validity of the results from this study are suggested, but not demonstrated, by the fact that SA and control respondents returned their questionnaires at approximately the same rate. The validity of López et al.'s (1995) results, as well as those of Bigler (1992), is implied by the consistency of these findings with those of the other studies in which response rates were quite high.

Finally, it is important to consider Boney-McCoy and Finkelhor's (1995) results more closely, because their effect sizes were larger than those in the other national studies. It is possible that their effect sizes were larger not because they asked only about unwanted CSA, in contrast to the other national studies in the meta-analysis, but because their participants were younger. The effects of CSA might have been more salient and thus detectable for their SA respondents because of the recency of the CSA; these effects may tend to diminish over time, resulting in the smaller effect sizes in the other national samples based on older respondents.

This possibility would suggest that CSA has effects that are more intense, at least initially, than is indicated in the current review. 
Several points, however, argue against this possibility. 

First, when age of participants is held constant (i.e., only college samples are used), unwanted CSA is associated with larger effect sizes (Rind, 1996). 

Second, respondents in Boney-McCoy and Finkelhor's sample who reported CSA were likely to have been unrepresentative of all respondents in their sample who experienced events classified by our society as CSA.
Only 1% of boys and 5.6% of girls aged 16 or less reported contact CSA involving peers or older persons. 
In sharp contrast to this finding, Laumann et al. (1994) found in their national sample that 12% of men and 17% of women reported contact CSA with older persons (peer sex was excluded) before they reached puberty. 
They found further that prevalence rates did not vary as a function of age cohort. 

These findings suggest that many respondents in Boney-McCoy and Finkelhor's sample who experienced contact CSA may not have reported it. Respondents who did report CSA may have tended to have had more negative experiences resulting in parents or guardian being more likely to be aware of the CSA. 
This greater awareness, in turn, may have led these respondent to be more willing to report experiences of CSA. Respondents with CSA whose families were unaware of the experience may have been more reluctant to disclose it, given that their parents or guardians knew about the study and may have been present or 

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nearby while they answered questions over the telephone -- respondents participated only after parents or guardians were informed about the study and gave permission. Therefore, CSA correlates may have been inflated by a bias in willingness to report the CSA. These considerations suggest that CSA does not on average have effects that are more intense, at least initially, than is indicated in the current review.

Summary and Conclusions

Our goal in the current study was to examine whether, in the population of persons with a history of CSA, this experience causes pervasive, intense psychological harm for both genders. Most previous literature reviews have favored this viewpoint. However, their conclusions have generally been based on clinical and legal samples, which are not representative of the general population. 

To address this viewpoint, we examined studies that used national probability samples, because these samples provide the best available estimate of population characteristics. 

Our review does not support the prevailing viewpoint. The self-reported effects data imply that only a small proportion of persons with CSA experiences are permanently harmed and that a substantially greater proportion of females than males perceive harm from these experiences.

Results from psychological adjustment measures imply that, although CSA is related to poorer adjustment in the general population, the magnitude of this relation is small. 

Further, data on confounding variables imply that this small relation cannot safely be assumed to reflect causal effects of the CSA.

Browne and Finkelhor (1986, p. 178) cautioned "advocates not [to] exaggerate or overstate the intensity or inevitability of [ CSA) consequences," because such exaggeration has iatrogenic potential. 
Despite this caution, child abuse researchers have tended to depict CSA as a "special destroyer of adult mental health" (Seligman, 1994, p. 232). McMillen, Zuravin, and Rideout (1995, p. 1037) recently commented that the "experience of child sexual abuse is a traumatic event for which there may be few peers." 

Results of analyses of the national samples show that such characterizations are exaggerated at the population level. 

This exaggeration may stem from our culture's tendency to equate wrongfulness with harmfulness in sexual matters (Money, 1979). CSA is violative of norms and laws in our culture; these facts, however, do not imply its harmfulness in a scientific or psychological sense (Kilpatrick, 1987). 
It is important to add to this discussion of exaggeration that understatement is also problematic. CSA is potentially harmful for young persons because of their vulnerability to being misused. The current findings should thus not be interpreted by lay persons as condoning abusive behavior.

Finally, analysis at the population level may obscure characteristics of particular segments of the population. 
In the current review, the effect size estimate of the relation between CSA and adjustment, which was of low magnitude, cannot be interpreted as applicable to every case. 
When CSA is accompanied by particular dispositional or situational factors, including variables such as 

then CSA might produce intense harm; 
on the other hand, 

then harm may be absent (Constantine, 1981). 

Combining the former and latter types of experiences into one category labeled CSA is problematic, because both negative and neutral effects can become obscured. 

By moving beyond socio-legal definitions of CSA and employing strictly scientific definitions (cf. Ames & Houston, 1990; Rind & Bauserman, 1993), researchers can better describe psychological correlates of the heterogeneous collection of experiences currently labeled as CSA.