Child sexual abuse (CSA) has received considerable attention over the last two decades by the media, the lay public, mental health care professionals, the legislature, law enforcement personnel, and the judiciary. Much of this attention has concerned the possible psychological consequences of this experience, as is shown by the surge in recent scientific and popular publications (Pope & Hudson, 1995). Our purpose in the current research was to examine these possible consequences by reviewing an important body of literature that has not been systematically examined in previous literature reviews on the psychological correlates of CSA.

First, it is important to discuss definitions. 

Kilpatrick (1987) argued that, in scientific discussions, abuse (i.e., harm) is something to be established as a conclusion, not to be accepted as a premise. Although we are in agreement with this position, because the term child sexual abuse is used pervasively in the literature under consideration, we have retained this term as a matter of convenience. 

Based on the manner of use of this term in the studies to be reviewed, CSA is generally defined in the current article as a sexual interaction involving either physical contact or no contact (e.g., exhibitionism) between either a nonadult (i.e., child or adolescent) and someone significantly older (e.g., an older adolescent or an adult), or between two nonadults in which coercion is employed.

Empirical investigations into the psychological correlates of CSA began in earnest during the late 1970s and grew rapidly during the 1980s. Given the emerging literature on correlates, a number of researchers began conducting literature reviews (e.g., 

Among the literature reviews just cited, the authors typically have concluded that CSA is associated with a wide range of psychological problems, including 

among others. 

Additionally, the typical literature review has asserted or implied that 

Next we discuss these four fundamental claims in more detail.

Four Basic Conclusions or Implications about CSA 

Causality 

Conclusions or implications that CSA causes psychological problems have been indicated in the literature reviews by the consistent use of terms such as effects and impact and by a failure to qualify discussions of symptoms associated with CSA by considering alternative explanations for this association 

(e.g., Black & DeBlassie, 1993; Briere & Elliot, 1994; Browne & Finkelhor, 1986; Kendall-Tackett et al., 1993; Mendel, 1995; Watkins & Bentovim, 1992). 

Conclusions of causality have also appeared in several reviews in which the authors briefly discussed the methodological principle that correlation is not causation but then argued or implied that the evidence supports causality 

(e.g., Briere & Runtz, 1993; Glod, 1993; Urquiza & Capra, 1990). 

In only a minority of the reviews have the authors argued or acknowledged that causality cannot be inferred from the studies they reviewed because of problems such as the presence of confounding variables 

(e.g., Beitchman et al., 1991; Beitchman et al., 1992; Constantine, 1981; Kilpatrick, 1987; Neumann et al., 1996).

Pervasiveness

In addition to concluding or implying that CSA causes later maladjustment, authors of the typical literature review have implied that these negative "consequences" are pervasive throughout the population of persons with these early sexual experiences. 

For example, several authors started out with the claim that they were conducting a "comprehensive" review of the literature 

(e.g., Briere & Runtz, 1993; Glod, 1993; Urquiza & Capra, 1990) 

or were summarizing "what is currently known" 

(e.g., Briere & Elliot, 1994; Watkins & Bentovim, 1992).

Despite claims of comprehensiveness, these authors examined only a small portion or available studies, ones that were mainly based on clinical or legal samples. 

After listing symptom after symptom to demonstrate the harm "caused" by CSA, these authors then failed to discuss limitations on the generalizability of these findings that were based on highly unrepresentative samples, thereby implying that their findings of harm characterize the population of persons who have experienced CSA.

Other authors, although not explicitly claiming to have conducted a comprehensive review, nevertheless also implied that their findings of harm, based mostly on clinical and legal samples, apply to the entire population by similarly failing to qualify the generalizability of these findings 

(e.g., Beitchman et al., 1992; Black & DeBlassie, 1993; Kendall-Tackett et al., 1993; Mendel, 1995). 

A number of authors reported that sizable minorities of persons who experienced CSA are asymptomatic 

(e.g., Briere & Elliot, 1994; Kendall-Tackett et al., 1993). 

Rather than conclude that reactions and outcomes are variable (i.e., positive, neutral, or negative), Kendall-Tackett et al. (1993) argued that an absence of symptoms may be attributable to insensitive measures of trauma, delayed symptoms that have yet to manifest themselves, or less damaging abuse with which highly resilient children in highly supportive environments have been able to cope. 

Briere and Elliot (1994, p. 55) similarly rejected the possibility that lack of symptoms indicates no harm by speculating that studies using clinical or forensic samples of abused children may not be generalizable to all sexually abused children because 

"[ t]hese studies may underestimate the impact of abuse in children who are motivated to deny their abuse or children whose reaction to abuse is significantly delayed" (italics added). 

These lines of argument imply that harm is pervasive. In only a minority of the reviews has it been made clear that findings of harm from the studies examined cannot safely be extended to the entire population of persons who have experienced CSA, implying that harm may not be pervasive in this population 

(e.g.., Beitchman et al.. 1991: Constantine, 1981; Kilpatrick. 1987; Neumann et al.. 1996).

Intensity of harm 

As a group, these literature reviewers have further implied that the harm resulting from CSA is generally intense. By listing long series or symptoms, including such reactions and outcomes as posttraumatic stress. suicide, self-mutilation, and dissociation, many reviewers have implied that effects are severe 

(e.g., Black & DeBlassie, 1993; Briere & Elliot, 1994; Briere & Runtz, 1993; Browne & Finkelhor, 1986; Glod, 1993; Kendall-Tackett et al., 1993; Mendel, 1995; Urquiza & Capra, 1990; Watkins & Bentovim, 1992). 

Only a minority of the reviewers presented findings to show that reactions and outcomes are highly variable, rather than being typically highly negative 

(e.g., Constantine, 1981; Jumper, 1995; . Kilpatrick, 1987; Neumann et. al., 1996). 

Equivalence of male and female CSA experiences  

A fourth implication of the literature reviews is that reactions and outcomes for boys and girls are the same (i.e., highly negative). 

Black and DeBlassie (1993) reviewed studies concerned with outcomes for boys and cited research that indicates that "sexual abuse in childhood has, at the very least, an equivalent impact

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on males and females" (p. 128). 

Watkins and Bentovim (1992), who also limited their review to outcomes for boys, began by listing a number of "prevalent myths about the sexual abuse of male children or adolescents." One of these "myths" was that 

"[w]hen boys are abused they are less psychologically affected than girls, both initially and in the long term" (p. 27). 

Mendel (1995) similarly focused on "consequences" for boys. He was critical of the opinions of other researchers (e.g., Rush, 1980) who maintained that boys are less affected by sexual experiences with adults than girls are. He argued that 

"[i]t appears to be an exercise in futility to attempt to determine whether males or females are affected more adversely by sexual abuse. As most researchers conclude, however, and as the studies reviewed here indicate, child sexual abuse has pronounced deleterious effects on its victims, regardless of their gender" (p. 101).

All other reviews cited previously consisted mostly or exclusively of studies using female participants. Nevertheless, reviewers generally stated or implied that reactions and outcomes are similarly negative for males and females. 

Briere and Runtz (1993, p. 312) stated that 

"[a]lthough most research on long-term effects of sexual abuse has been limited to female samples, it is likely that sexually abused males experience similar problems in psychological functioning." 

Briere and Elliot (1994) equated the sexes in their reactions and outcomes by using expressions such as "he or she" when referring to persons who experienced CSA. These authors, as well as others (e.g., Glod, 1993), have further given the impression of equivalence of outcome between the sexes by failing specifically to discuss sex differences. Typically, after evidence for harm was provided based on female samples, the effects of CSA on "children" were discussed, implying that boys are similarly affected because boys are children, too. 

Kendall-Tackett et al. (1993) noted that their studies indicated an absence of consistent gender differences, although they did speculate that only the most symptomatic boys may have ended up in their samples. 

Only one review was explicit in not equating the experiences of boys and girls, concluding that sex differences are unclear because they have not been adequately addressed in studies (Beitchman et al., 1991).

Problems with Conclusions and Implications of the Literature Reviews

Sampling biases

These literature reviews have predominantly consisted of studies conducted on clinical or legal samples. In a sizable minority of these reviews, the studies that were included were restricted entirely to those using clinical or legal samples 

(e.g., Beitchman et al., 1991; Black & DeBlassie, 1993; Glod, 1993; Kendall-Tackett et al., 1993; Watkins & Bentovim, 1992). 

Studies sampling from other populations were much less frequently included, despite the fact that a large literature exists on psychological correlates of CSA based on college samples. At least 60 such college studies are currently available, locatable through databases such as PsycLIT or Dissertation Abstracts International, most of which were available to researchers who conducted literature reviews in the 1990s.

Clinical and legal samples are highly problematic because they cannot be assumed to be representative of the general population of persons who have experienced CSA (Okami, 1991; Rind, 1995), and because data coming from these samples are vulnerable to a number of biases that threaten their validity (Pope & Hudson, 1995). 

Okami (1991) examined a group of adults who had experienced CSA as negative, neutral, or positive. Negative responders included both clinical and nonclinical participants. He found that clinical participants evidenced a variety of adjustment problems that were substantially more pronounced compared to other participants, including nonclinical negative responders. He concluded that clinical patients with adverse CSA experiences appear to constitute the negative polar extreme of reactions and outcomes. 

Rind (1995) reviewed the results of a large number of studies based on college samples from which researchers examined the psychological correlates of CSA. He reported that most researchers either found no adjustment differences between sexually abused (SA) students and control students or found only a few differences among many measures of adjustment -- differences that were small in terms of effect size. Rind also reported that, as a group, the college samples showed that females and males react differently to CSA, with about two thirds of females reacting negatively compared to only one third of males. 

These results are important in terms of trying to understand correlates of CSA in the population of persons with this experience, because about half of U.S. adults have some college exposure 

(Fritz, Stoll, & Wagner, 1981; U.S. Bureau of the Census, 1995). 

These findings suggest that clinical samples are not representative of the general population.

Pope and Hudson (1995) argued that clinical samples are not only unrepresentative of the general population but are also unrepresentative of nonclinical persons suffering from the same presenting symptoms because of selection bias. These researchers were critical of the validity of results from CSA research using clinical samples because of a number of methodological considerations. They pointed to information bias as a major threat to the internal validity of the findings from these samples. 
Aside from possible investigator biasing effects (cf. Rosenthal, 1977), they argued that participant effects posed serious problems for making causal inferences concerning the relation between CSA and later maladjustment. 
Patients searching for causes of their problems (termed effort after meaning) are more likely to recall CSA experiences than are controls, thereby inflating the correlation between CSA and maladjustment, they argued.

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Further, they were critical of the general failure of CSA researchers to take into account confounding variables that could be responsible for the CSA-maladjustment link. 
They concluded their methodological critique by commenting that many of these studies 

"are so severely vulnerable to selection bias, information bias, and lack of consideration of confounding variables that they are rendered almost valueless" 
(p. 378).

Pope and Hudson's (1995) methodological argument that maladjustment in general cannot safely be attributed to past CSA experiences because of confounding variables has received support from recent empirical research, which has demonstrated that CSA tends to be confounded with other factors that are likely to affect later psychological adjustment 

 Researchers who have statistically controlled for confounding variables such as 

have tended to find that the relationship between CSA and maladjustment disappears 

(e.g., Cole, 1987; Fromuth, 1986; Harter et al., 1988; Higgins & McCabe, 1994; Nash et al., 1993a; Pallotta, 1991).

Subjectivity and imprecision  

Another shortcomig of previous literature reviews is that most have been narrative and qualitative. 

Jumper (1995) argued that conclusions drawn from this method of review are vulnerable to being subjective and imprecise. In an attempt to be more objective and precise, Jumper (1995) and Neumann et al. (1996) recently conducted meta-analyses of CSA studies. 

A meta-analysis is a quantitative analysis of the statistical findings from a collection of studies. From each study, a statistic is obtained (e.g., a t or an F statistic assessing the difference in adjustment between a CSA and control group). 
All statistics are then converted to a common statistic (e.g., to standard normal deviate zs or Pearson rs). 
The new statistics are then combined into one single overall statistic that can then be used to 

This latter use is a frequent focus of meta-analyses, and the strength of association is referred to as the effect size -- effect size can also be conceptualized as the standardized size of the difference in mean responses (e.g., adjustment) between two groups (e.g., a CSA versus control group). 

Two common measures of effect size are Pearson's r and Cohen's d; the former measure is simply the correlation between group membership and response, whereas the latter represents the number of standard deviations between the means of the responses of two groups. Cohen (1988) suggested that rs of .10, .30, and .50 and ds of .20, .50, and .80 can be interpreted as small, medium, and large effect sizes, respectively. 

[Thus:]

Jumper (1995) meta-analyzed 26 published studies containing 30 samples (5 male and 25 female), of which approximately one fourth were community, clinical, student, and mixed. 
She found that CSA respondents consistently performed more poorly than controls on various measures of psychological adjustment. 
Jumper used Pearson's r to assess the strength of association between CSA and adjustment problems. Averaging her findings across measures revealed a medium effect size in the case of clinical samples (r = .31), but only a small effect size in the case of college samples (r = .07).

Neumann et al. (1996) meta-analyzed 38 studies consisting of 38 female samples, about half of which were clinical and half of which were nonclinical. 
They also found that CSA respondents were more poorly adjusted than controls. 
Using Cohen's d, they found that the size of this difference was medium in the case of clinical samples (d = .50), but small in the case of nonclinical samples (d = .32). 

The results of Jumper's (1995) and Neumann et al.'s (1996) meta-analyses, taken together, imply that clinical samples cannot be assumed to be representative of other populations. 
For example, in the case of Jumper's study, whereas CSA accounted for nearly 10% of the adjustment variance in the clinical samples, it accounted for only one half of 1% of the adjustment variance in the student samples 

(percent variance accounted for is obtained by squaring the effect size r and then multiplying this result by 100; although appropriate for describing percent of variance explained, r² is not currently considered to be a good measure of effect size by leading methodologists because it underestimates this metric, Rosenthal & Rosnow, 1991).

Current Study 

The goal for the current study was to examine the basic conclusions and implications that are contained in many previous literature reviews, which hold that CSA causes pervasive and intense harm, regardless of gender, in the population of persons with a history of CSA. 

The findings of 

as well as the results of the meta-analyses by

suggest that these conclusions and implications, based mainly on findings from clinical and legal samples, may not be valid for the population of persons with a history of CSA, because clinical and legal samples are not representative of this population. 

Most appropriate for addressing 

in the population of persons with a history of CSA would be studies based on samples that are representative of the general population.

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Although it may not be possible to obtain a perfectly representative sample of the general population, good approximations have been made by a number of researchers who have employed national probability samples. National probability samples are selected in such a way so as to be representative of the (usually adult) population in the nation where the sampling is done.

Because response rates are never 100%, and because certain segments of the adult population are generally excluded from the sampling frame (e.g., prisoners or college students living in dormitories), these samples cannot be considered to represent precisely the national population.
Nevertheless, these samples serve as good approximations of the national population and are more representative of this population than any other types of samples that have been selected.

Therefore, to examine whether CSA causes pervasive, intense harm, regardless of gender, in the population of persons with a history of CSA, we attempted to collect and analyze all currently available studies conducted on national probability samples that included data relevant to psychological correlates or effects of CSA.
Relevant data could come from measures of psychological or sexual adjustment or from self-reported effects of the CSA experience. We also employed meta-analytic techniques in an attempt to achieve greater objectivity and precision compared to previous qualitative and narrative reviews.