Journal of Consulting and Clinical Psychology Copyright 1997 by the Am n Psychological Association, Inc.

1997, %L 65, No. 1, 53-59 0022-006X/97/$3.QO

Posttraumatic Stress Disorder in Adult Female Survivors

of Childhood Sexual Abuse: A Comparison Study

Ned Rodriguez Susan W. Ryan

University of California, Los Angeles San Fernando Valley Child Guidance Center

Hendrika Vande Kemp David W. Foy

FUller Theological Seminary Pepperdine University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

This study compared symptoms of posttraumatic stress disorder (PTSD) in a group of 45 adult
This document is copyrighted by the American Psychological Association or one of its allied publishers.

women in outpatient treatment for childhood sexual abuse (CSA) and a group of 31 women who
reported no CSA. The comparison group consisted of women in outpatient treatment for problems
in their committed relationships with male living partners. This research also investigated the trau-
matic impact of dual abuse (both childhood sexual and physical abuse). Standardized assessment
instruments were used to measure PTSD, CSA, and childhood physical abuse (CPA). Results indi-
cated that 86.7% of the CSA group met criteria for current PTSD in accordance with the Diagnostic
and Statistical Manual of Mental Disorders (3rd ed., revised; American Psychiatric Association,
1987), compared with 19.4% of the relationship distress group, providing support for CSA as an
etiological agent for PTSD. In addition, 89% of the CSA survivors reported CPA. Multivariate
analysis revealed that both CSA and CPA exposure variables accounted for a significant portion of
the variance in PTSD symptoms in the CSA group.

In a U.S. national epidemiological study (N = 2,626) investi- number of Americans may be at risk for developing PTSD sec-
gating the prevalence of childhood sexual abuse (CSA), Fin- ondary to CSA experiences.
kelhor, Hotaling, Lewis, and Smith (1990) reported that 27% Gelinas (1983) first used a PTSD conceptual model to under-
of women and 16% of men had experienced sexual abuse as stand the effects of CSA. Later researchers have demonstrated
children. In a subsequent community study of the psychological that a significant portion of child and adult CSA survivors de-
sequelae of (CSA) in adult women, B. E. Saunders, Villepon- velop PTSD. Clinical studies have reported that many sexually
teaux, Lipovsky, Kilpatrick, and Veronen (1992) found that abused children experience subsequent PTSD (e.g., McLeer,
33.3% of the survivors who had experienced CSA involving Callaghan, Henry, & Wallen, 1994; Wolfe, Sas, & Wekerle,
physical contact without penetration and 64.1% of those who 1994). Similarly, community and clinical studies have found
had experienced penetration developed posttraumatic stress dis- that adult CSA survivors often suffer from chronic or delayed
order (FTSD) at some time during their lives. Given the high PTSD (e.g., Rowan, Foy, Rodriguez, & Ryan, 1994; B. E. Saun-
national prevalence of CSA and a report of elevated rates of ders et al., 1992). Reports from studies of adult and child survi-
CSA-related PTSD in at least one community study, a sizable vors have demonstrated preliminary support for an association
between the level of CSA exposure and subsequent PTSD symp-
tomatology (Rowan et al., 1994; B. E. Saunders et al., 1992;
Wolfe et al., 1994). Specific aspects of the CSA experience
Ned Rodriguez, Neuropsychiatric Institute, University of California,
found to be associated with PTSD include duration (Rowan et
Los Angeles (UCLA); Susan W. Ryan, San Fernando Valley Child Guid-
al., 1994; Wolfe et al., 1994) and the perpetrator's use of physi-
ance Center, Northridge, California; Hendrika Vande Kemp, Graduate
cal force (Roesler & McKenzie, 1994; Wolfe et al., 1994).
School of Psychology, Fuller Theological Seminary, Pasadena, Califor-
nia; and David W. Foy, Graduate School of Education and Psychology, Rowan and Foy (1993) reviewed the studies investigating
Pepperdine University. CSA and PTSD and concluded that future research would bene-
This research was conducted at the Graduate School of Psychology, fit from improved methodology including use of psychometri-
Fuller Theological Seminary, Pasadena, California. cally evaluated measures of PTSD and CSA. Briere (1992)
We recognize and thank the sexual abuse survivors for their willing- suggested that studies of adult survivors that rely on retrospec-
ness to participate in this research. The courage they displayed in coming tive self-report of CSA should investigate the test-retest relia-
forth to share their experiences and the strength of their conviction
bility of these reports. Only a single available study of PTSD
to help their fellow survivors were deeply moving. We also gratefully
and CSA has reported the test-retest reliability properties of a
acknowledge Suzann Ogland-Hand, Millie Astin, and Esther Coleman
self-report instrument used to measure CSA exposure (Rowan
for their help in the data collection phase of this project.
Correspondence concerning this article should be addressed to Ned et al., 1994). In the present study, we assess CSA exposure
Rodriguez, who is now at the Department of Psychiatry and Behavioral with this standardized instrument.
Sciences, Trauma Psychiatry Services, 300 UCLA Medical Plaza, Suite Although studies of sexually abused children have used non-
2235, Los Angeles, California 90095. sexually abused comparison groups to provide preliminary sup-

53
 54 RODRIGUEZ, RX\N, VANDE KEMP, AND FOY

port for CSA as an etiological agent in the development of PTSD search project contacted researchers by phone, at which time they were
(e.g., McLeer et al., 1994), only a single major PTSD study of briefed regarding the general contents of the instrument packet and again
adult survivors has used a nonsexually abused comparison group informed of confidentiality. Researchers scheduled appointments at that
time.
(Albach & Everaerd, 1992). However Albach and Everaerd did
The comparison group consisted of 31 help-seeking women. This
not assess for PTSD with standardized diagnostics. In the present
group was used to control for CSA and for the help-seeking status of
study, we use a standardized PTSD interview instrument to com-
the CSA survivors. The requirements for inclusion in the relationship-
pare PTSD in a group of help-seeking adult women who report distress group were the same as for the CSA group, except that partici-
CSA with a similar group who report no CSA. pants were to be in outpatient psychological treatment addressing rela-
Nonclinical and clinical studies have reported that many sexu- tional problems for at least 6 months. This group consisted of women
ally abused children also experience physical abuse (e.g., Moeller, who sought treatment to address problems in committed heterosexual
Bachman, & Moeller, 1993; Surrey, Swett, Michaels, & Levin, relationships. Although these relational problems had sometimes resulted
1990). Although some studies have found higher PTSD rates in in separation of the couple, all women reported continued significant
involvement with their partner. As with the CSA group, a network of
children who experienced both sexual and physical abuse (e.g.,
therapists and support groups and a research flyer were used to recruit
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Kiser, Heston, Milsap, & Pruitt, 1991), other researchers have

prospective comparison group participants. Relationally distressed
This document is copyrighted by the American Psychological Association or one of its allied publishers.

reported that dual abuse did not elevate PTSD rates (e.g., Adam,
women were assessed for CSA experiences with the Sexual Abuse Expo-
Everett, & O'Neal, 1992), No studies that diagnosed PTSD in
sure Questionnaire (SAEQ; see below). Only those participants who
adult survivors have examined the impact of dual abuse. However, did not meet the definitional criteria for CSA (i.e., relationally distressed
Wind and Silvern (1992) found that adult survivors of dual child- women who did not report CSA experiences) were included in the
hood abuse did have elevated levels of trauma-related symptoms comparison group.
when compared with survivors who had experienced only one Table 1 compares the demographic characteristics of the CSA and
form of abuse or nonabused controls. None of the studies investi- the nonsexually abused comparison groups. With the exception of mari-
gating PTSD in CSA survivors who also experienced CPA used tal status, the demographic characteristics of the groups were not sig-
a standardized instrument to assess CPA exposure. In addition, nificantly different. In terms of marital status, a greater proportion of
CSA survivors had never been married, and a greater proportion of
no current studies of adult CSA survivors have used standardized
the comparison group was separated. Neither group reported current
PTSD diagnostics to investigate the impact of dual abuse on
problematic alcohol or drug usage.
PTSD symptoms. In the present study, we use standardized mea-
sures of PTSD and CPA to explore the effect of dual abuse on
PTSD symptoms in adult CSA survivors. Measures
Specific hypotheses for the present study were that (a) PTSD
rates and the levels of PTSD symptoms (PTSD intensity) will Demographic and history questionnaire. A modified version of the
be significantly higher in the CSA group than in the nonsexually Vietnam Veterans History Questionnaire (Foy, Sipprelle, Rueger, & Car-

abused comparison group; (b) CSA will account for a larger roll, 1984) was used to gather demographic and historical information.
The wording was adapted for usage with female respondents, and addi-
portion of the variance in PTSD symptoms in the sample than
tional screening questions were incorporated regarding childhood adjust-
the level of CPA exposure; (c) within the CSA group, CSA
ment problems (e.g., truancy, psychological treatment, academic diffi-
duration, and use of physical force, will be positively correlated
culties, etc.) and childhood risk factors for later mental illness (e.g.,
with PTSD intensity; and (d) within the CSA group, CPA expo- parental marital discord, extreme poverty, etc.). A screening question
sure will account for a significant portion of the variance in regarding exposure to familial violence was also added. Demographic
PTSD symptomatology after controlling for CSA exposure. variables to be analyzed included gender, ethnicity, age, marital status,
education, employment, family-of-origin socioeconomic status (SES),
and childhood alcohol and drug usage.
Method
The SAEQ. The SAEQ was used to measure CSA exposure. Rowan
(1992) and Rowan et al. (1994) developed the SAEQ as a paper-and-
Participants
pencil retrospective self-report instrument to assess multiple aspects of
Seventy-six help-seeking women recruited through a network of thera- the CSA experience in adult survivors. The SAEQ identifies 10 catego-
pists and self-help groups in the greater Los Angeles area participated ries of increasingly invasive sexual events, ranging from "exposure of
in the study. The CSA group included 45 women currently seeking another's genital area" to "fondling" to "intercourse." The SAEQ
treatment for CSA. Participants were required to be engaged in some also assesses additional salient aspects of the CSA experience including
form of outpatient therapy for at least 6 months to ensure that traumatic duration and use of force. Ryan (1993) and Ryan, Rodriguez, Rowan,
memories and feelings that may surface as a result of their research and Foy (1992) reported that the majority of SAEQ items demonstrated
participation could be addressed within a supportive therapeutic context. adequate test-retest reliability. Specifically, test-retest reliability coef-
Any type of self-reported sexual experience before the age of 16 with ficients for the 10 exposure questions ranged from .73 to .94. Questions
someone 5 or more years older defined sexual abuse. Numerous studies concerning age of abuse onset and termination measured duration and
cited by Peters, Wyatt, and Finkelhor (1986) have used a similar demonstrated reliability coefficients of .88 and .92, respectively. The
definition, dichotomous screening question that assessed for physical force during
Therapists and support-group leaders distributed flyers that described the abuse had a reliability coefficient of .82.
participation requirements for the CSA portion of the study: CSA experi- Assessing Environments HI (AEfll). The AEIII (Berger & Knutson,
ence congruent with the definitional criteria, current involvement in 1984) was used to measure CPA exposure. The AEIII is a standardized
outpatient psychological treatment, willingness to complete self-report retrospective paper-and-pencil self-report measure commonly used by
questionnaires, and willingness to participate in a one-on-one interview child abuse researchers. It consists of 10 demographic questions fol-
regarding the effects of the CSA. The flyer informed prospective partici- lowed by 155 true-false items that inquire regarding numerous aspects
pants of confidentiality. Survivors who elected to participate in the re- of the individual's childhood history, including 10 behaviorally based
 PTSD AND CHILDHOOD SEXUAL ABUSE 55

Table 1
Demographics for Childhood Sexual Abuse and Relationship Distress Groups

Childhood sexual Relationship distress

Variable abuse (n = 45) (n = 31) Statistical test

Mean (and SD) age M = 35.3, SD = 7.6 M = 38.7, SO = 9.5 f(74) = 1.68
n (and %) ethnicity X2 (3, N = 76) = 5.66
Caucasian 38 (84.4) 22 (71.0)
Hispanic 5(11.1) 4 (12.9)
African American 1 (2.2) 5 (16.1)
Asian 1 (2.2) 0(0)
n (and %) marital status X2 (4, N = 16) = 18.07*
Never married 22 (48.9) 3 (9.7)
Divorced 4 (8.9) 2 (6.5)
Separated 3 (6.7) 11 (35.5)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Living together 2 (4.4) 3 (9.7)

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Married 14(31.1) 12 (38.7)

Median level of education Some college Some college r(74) = 1.26
Employment X 2 (4, N= 76) = 1.25
Disabled 2 (4.4) 2 (6.5)
Unemployed 9 (20.0) 6 (19.4)
Student 5(11.1) 2 (6.5)
Part time 10 (22.2) 9 (29.0)
Full time 19 (42.2) 12 (38.7)
SES (family of origin income) -,f (4, N =76) = 8.48
Poor or lower 15 (33.3) 4 (12.9)
Lower middle 9 (20.0) 3 (9.7)
Middle 16 (35.6) 16 (51.6)
Upper middle 5(11.1) 7 (22.6)
Upper 0(0) 1 (3.2)

Note. Statistical test refers to chi-square test, except for continuous variables of age and education, where
it refers to t test. SES = socioeconomic status.
*p < .01.

items related to the occurrence of physical punishment that form a PTSD diagnosis, we used the SCID to assess the the current and lifetime
Physical Punishment (PP) scale (Berger, Knutson, Mehm, & Perkins, level of PTSD symptoms (PTSD intensity). Consistent with previous
1988). The score on the PP scale could range from 0 to 10. Endorsement research (Astin, Ogland-Hand, Coleman, & Foy, 1995; E. A. Saunders,
of four or more PP scale items identified children who experienced 1991), we created a PTSD intensity score by summing the total number
severe physical punishment (Zaidi, Knutson, & Mehm, 1989). The of DSM-HI-R SCID symptoms experienced by the participant. Scores
scales of the AEm have been standardized, demonstrating excellent ranged from 0 to 17. A number of standardized PTSD instruments mea-
test-retest reliability, and validity established by the measure's ability sure PTSD intensity by summing the number of PTSD symptoms (e.g.,
to discriminate abused and nonabused adolescents (Berger et al., 1988; PTSD Symptom Scale Self-Report; Foa, Riggs, Dancu, & Rothbaum,
Zaidi etal., 1989). 1993). The rationale for summing symptoms is that the number of
Structured Clinical Interview for DSM-UI-R <SCfD). The SCID symptoms-experienced is an indicator of the intensity of the PTSD.
(Spitzer, Williams, Gibbon, & First, 1990) is a structured clinical inter-
view designed to assess for the diagnostic criteria for a variety of disor- Procedure
ders from the revised third edition of the Diagnostic and Statistical
Participants met with researchers for approximately 2 hr. They re-
Manual of Mental Disorders (DSM-III-R; American Psychiatric Asso-
viewed and signed forms documenting their informed consent to partici-
ciation, 1987). In the present study, we used only the PTSD module.
pate in the research study. Participants completed a packet of written
Keane, Weathers, and Kaloupek (1992) reported that the SCID PTSD
materials containing the demographic questionnaire, the SAEQ, the AE-
module demonstrates high interrater reliability and validity through
III, and several other instruments used in another research project. Parti-
strong correlation with other PTSD measures. The SCID has been used
cipants were then interviewed with the SCID. An unstructured portion
to assess for PTSD in CSA survivors in previous research (e.g., Rowan
of the interview followed, during which interviewers debriefed partici-
et al., 1994). The CSA group was interviewed with the SCID regarding
pants and were available to explore any concerns or feelings that may
PTSD symptoms associated with CSA experiences. The comparison
have surfaced as a result of the participants completion of the study.
group was interviewed using the SCID regarding PTSD symptoms con-
Participants were paid $20.
nected with relationship distress, although relational distress does not
meet the DSM criteria "A" standard for a traumatic stressor. The SCID
contains an initial screening question inquiring regarding the partici-
Results
pant's life experiences of various types of traumas. We used this question Description of CSA, CPA, and Exposure to Other
to determine whether the relational distress experienced by members of
Traumas
the control included domestic violence (DV), a traumatic stressor. Be-
fore administration of the research protocol, the investigators were CSA, In terms of abuse severity, 23% reported experiencing
trained in the administration of the SCID. In addition to establishing a contact sexual events but not penetration; 33% reported digital
 56 RODRIGUEZ, RYAN, VANDE KEMP, AND FOY

or object penetration but not penile penetration; and 44% re- their abuse in therapy and those who remembered before therapy
ported penile penetration. The mean age of CSA onset was 5 or those who never forgot their abuse.
(SD = 4). The mean age of CSA termination was 13 (SD = Regarding the level of PTSD symptoms, the mean SCID cur-
4). The mean duration of CSA was 7 years (SD = 6). Forty- rent PTSD intensity was 12.0 (SD = 3.3) in the CSA group
seven percent indicated that a perpetrator used physical force and 4.6 (SD = 3.7) in the comparison group. A t test revealed
during the abuse. that this difference was significant, r(74) = 9.21, p < .001.
Additional aspects of the CSA were also assessed. Forty-two The mean SCID lifetime PTSD intensity was 14.2 (SD = 2.4)
percent felt their life was in danger during the abuse. Twenty- in the CSA group and 6.0 (SD = 3.7) in the comparison group.
nine percent indicated that they had been molested by a single A t test found that this difference was significant, t(74) = 11.77,
perpetrator, 27% by two perpetrators, 22% by three perpetrators, p < .001. No significant relationships were identified between
and 22% by four or more perpetrators. Survivors identified 50% any demographic variables and current or lifetime PTSD inten-
of the perpetrators as nuclear family members, 20% as extended sity scores. Correlational analyses between the trauma exposure
family members, and 30% as nonfamily members. In regard to variables and PTSD intensity scores identified significant posi-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

memories of CSA, 44% indicated that they had always remem- tive relationships between AEIH-PP Scale score and current
This document is copyrighted by the American Psychological Association or one of its allied publishers.

bered their abuse, whereas 56% reported that they had been PTSD intensity, r(76) = .43, p < .01; and lifetime PTSD inten-
amnesic for their abuse. Sixteen percent of the CSA group re- sity, r(76) = .46, p < .001, for the entire sample. In addition,
ported remembering their abuse in the context of psychotherapy. within the CSA group, no significant differences in PTSD inten-
CPA. The mean score on the 10-item AEin PP Scale was sity levels were found between survivors who remembered their
3.3 (SD = 2.5) for the CSA group and 1.1 (SD = 1.6)forthe abuse in therapy and those who remembered before therapy or
comparison group. A t test determined that this difference was those who never forgot their abuse. The lifetime PTSD intensity
significant, ?(74) = 4.63 p < .001. Eleven percent of the CSA score was used in the following analyses as it was reasoned
group and 54.8% of the comparison group endorsed no PP scale to be a more accurate reflection of PTSD symptom levels for
items, indicating they had not experienced CPA. Thus, 89% of participants who were asymptomatic at the time of the study
the CSA group and 45.2% of the comparison group reported but reported a past history of PTSD symptomatology.
CPA experiences. In addition, 44.4% of the CSA group and
19.4% of the comparison group endorsed four or more items
CSA, CPA, and PTSD Intensity
on the PP scale, indicating an experience of severe physical
abuse. This difference was significant, x2 O> N = 76) = 5.13, Although the groups differed in terms of marital status, expo-
p < .05. sure to DV, and witnessing childhood violence, these variables
Other trauma exposure. In terms of witnessing familial vio- were not significantly related to PTSD intensity, so they were
lence in childhood, 77.8% of the CSA group reported this expe- not included in the multiple regression analysis investigating
rience, compared with 32.2% of the relationship distress group, PTSD intensity scores across groups. A stepwise multiple re-
X2 (1, N = 76) = 15.75, p < .001. Only 4.4% of CSA survivors gression analysis was used to investigate the relative impact of
reported adult domestic violence experiences compared with CSA and CPA exposure on the lifetime level of PTSD symp-
54.8% of the comparison group, x 2 (1, N = 76) = 24.86, p toms. Lifetime SCID PTSD intensity score served as the depen-
< .001. dent variable and exposure to CSA (defined by membership in
the CSA group or the nonsexually abused comparison group)
and AEni PP Scale score served as the independent variables.
PTSD Prevalence and Intensity Only CSA exposure entered the regression equation, accounting
for 65% of the variance in lifetime SCID PTSD intensity scores
Descriptive statistics based on the SCID data indicated that in the sample. For CSA exposure, B = 4.09 (SE - .35), and
86.7% of the CSA group met full DSM-III-R criteria for CSA- 0 = .81, p < .001 ; f f 2 = .65, p < .001.
related PTSD at the time of the study, whereas 19.4% of the
comparison group met PTSD criteria for relationship distress,
CSA, CPA, and PTSD Intensity in CSA survivors
which involved domestic violence. A chi-square analysis indi-
cated that the difference in current PTSD rates between groups Zero-order correlation. A correlational analysis was con-
was significant, x 2 U > N = 76) = 34.43, p < .001. In addition, ducted to investigate the relationships between the CSA expo-
97.8% of the CSA group met full DSM-III-R criteria for PTSD sure variables of duration and force and lifetime SCID PTSD
at some point during their lives, compared with 25.8% of the intensity scores. Both variables were significantly positively cor-
comparison group. A chi-square analysis found that this differ- related with PTSD intensity; duration r(45) = .33, p < .01;
ence was significant, x 2 (1, N = 76) = 44.00, p < .001. No force, r(45) = .32, p < .05. A significant positive correlation
significant relationships between current or lifetime PTSD diag- was also found between CPA (AEIII PP scale score) and PTSD
nostic status and any demographic variables were identified. intensity, r(45) = .35, p < .01. Further analysis indicated that
Although the groups differed in marital status, marital status these three variables were not significantly intercorrelated.
was not associated with a PTSD diagnosis. No significant rela- Multiple correlation. A hierarchical multiple regression
tionships were found between the trauma exposure variables of analysis explored the impact of CPA on CSA-related PTSD
witnessing familial violence, CPA, or DV, and PTSD diagnosis. symptoms. Lifetime SCID PTSD intensity score served as the
In addition, within the CSA group, there were no significant dependent variable. Independent variables included the CSA
differences in PTSD rates between survivors who remembered exposure characteristics of force and duration, which were
 PTSD AND CHILDHOOD SEXUAL ABUSE 57

Table 2 sample, and the experience of multiple types of trauma in child-

Summary of Hierarchical Regression Analysis for Variables hood (e.g., CSA, CPA, witnessing familial violence), and later
Accounting for Lifetime PTSD Intensity Scores (n = 45) adulthood (e.g., DV, rape) has been linked to higher PTSD
levels (e.g., Astin et al., 1995; Graham-Howard, 1993), future
Variable B SEB ft studies must assess for multiple trauma exposure, especially in
Step 1 help-seeking populations. Using standardized instruments mea-
Duration .11 .06 .27* suring exposure to different types of traumas and standardized
Force 1.26 .63 .27* PTSD diagnostics, additional studies should investigate the im-
Step 2 pact of the experience of multiple forms of trauma on PTSD
CPA .26 .13 .29*
symptoms.
Note. PTSD = posttraumatic stress disorder; CPA = childhood physi- The present study reported high rates of current (86.7%)
cal abuse. R2 = .19 for Step 1; Afl2 = .08 for Step 2 (ps < .01). and lifetime (97.8%) PTSD in a sample of help-seeking adults
V < .05. reporting CSA experiences. Two other studies that used the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

SCID to assess PTSD in outpatient samples found similarly

This document is copyrighted by the American Psychological Association or one of its allied publishers.

high rates. Rowan et al. (1994) reported a current PTSD rate

treated as a block variable, and the AEIII PP scale score. To of 69%, and O'Neill and Gupta (1991) reported a 73.1% current
control for the effects of CSA exposure, the CSA exposure PTSD rate. Seventy-seven percent of the survivors in the present
block variable was entered in the first step, accounting for 19% study reported experiencing penetration, compared with 77%
of the variance in PTSD intensity scores. In the second step, of O'Neill and Gupta's sample and at least 68% of Rowan et
the AEIII PP Scale score was entered, accounting for an addi- al.'s sample. High rates of PTSD in help-seeking CSA survivors
tional 8% of the variance. Table 2 summarizes the results of the probably relate to the generally higher levels of distress and
regression analysis. CSA exposure reported in clinical samples (Herman, Russell, &
Trocki, 1986). B. E. Saunders et al. (1992) found lower rates
of lifetime PTSD for CSA survivors in their community sample
Discussion
who had experienced noncontact (11.4%) or contact CSA in-
The finding of higher PTSD rates and higher levels of PTSD volving no penetration (33.3%). Compared with the high life-
symptoms in the CSA group supported the hypothesis that time PTSD rates in the current study, these lower rates likely
symptoms of PTSD would be more common in participants who reflect the lower levels of CSA exposure in these two groups.
reported CSA experiences than in participants who reported no However, B. E. Saunders et al. (1992) did report a higher life-
CSA. These results are consistent with similar findings from time PTSD rate for survivors who experienced penetration
two other studies of adult CSA survivors that compared PTSD (64.1%). Although additional clinical studies that use random
symptoms in sexually abused and nonsexually abused groups. selection are necessary to further support the generalizability of
Using nonstandardized PTSD diagnostics and a sample of 97 the finding of a high rate of PTSD in clinical adult survivors,
incest survivors and 65 matched controls, Albach and Everaerd the results of the present study provide support for Rowan et
(1992) reported a 62% PTSD rate in the incest group and a 0% al.'s suggestion that a diagnosis of PTSD should be considered
PTSD rate in the control group. In a small subsample of inpa- whenever an adult survivor presents for treatment.
tient participants with a diagnosis of borderline personality dis- As predicted, within the sexually abused group, results dem-
order, E. A. Saunders (1991) used the SCID to demonstrate onstrated a positive relationship between the CSA exposure vari-
higher PTSD intensity in a group of CSA survivors (n = 12) ables of force and duration and the level of PTSD symptoms.
than in controls (n = 10). Two controlled studies of child Previous studies have reported similar relationships for the CSA
CSA survivors reported higher PTSD rates in sexually abused variables of force (Roesler & McKenzie, 1994; Wolfe et al.,
children than in nonabused children (McLeer et al., 1994; Sa- 1994) and duration (Rowan et al., 1994; Wolfe et al., 1994).
deh, Hayden, McGuire, Sachs, & Clivita, 1994). The results of Multivariate analysis revealed that together these variables ac-
the present study contribute to a growing body of controlled counted for a significant portion of the variance in PTSD symp-
research studies demonstrating preliminary support for CSA as toms. Relationships between CSA variables and PTSD intensity
an etiological agent for PTSD. Future studies using random provide support for the notion that a higher level of exposure
selection, standardized measures of PTSD, and nonsexually to CSA results in a higher level of PTSD symptoms. Research
abused comparison groups are necessary to provide further sup- has demonstrated similar exposure-distress relationships in sur-
port for the notion that the experience of CSA can lead to PTSD. vivors of other types of traumas including combat (e.g., Foy et
CSA exposure accounted for a significant portion of the vari- al., 1984), rape (e.g., Neumann, Gallers, & Foy, 1989), and
ance in PTSD intensity levels in the sample. Although partici- DV (e.g., Astin et al., 1995). Future CSA studies that use stan-
pants in both groups reported CPA experiences, CPA exposure dardized measures of CSA and PTSD and random selection are
did not account for a significant portion of the variance in PTSD necessary to investigate which aspects of the CSA experience
intensity after controlling for CSA exposure. These results were are traumagenic.
expected, given that the SCID assessed for PTSD symptoms The majority of CSA survivors acknowledged experiences of
tied to CSA or relationship distress and not CPA. A sizeable CPA (89%), with 44.4% experiencing severe physical abuse.
portion of the comparison group indicated that their relational This finding supports previous research (e.g., Moeller et al.,
distress included instances of domestic violence. Because expo- 1993; Surrey et al., 1990) reporting a high prevalence of CPA
sure to traumas other than CSA was common in the overall in CSA survivors. As predicted, after controlling for the level of
 58 RODRIGUEZ, RYW, VANDE KEMP, AND FOY

CSA exposure, the level of CPA still accounted for a significant Berger, A. M., Knutson, I. F., Mehm, J. G., & Perkins, K. A. (1988).
portion of the variance in CSA-related PTSD intensity scores The self-report of punitive childhood experiences of young adults and
in multivariate analysis. Thus, when adult survivors of dual adolescents. Child Abuse and Neglect, 12, 251-262.
childhood abuse seek treatment, CPA exposure probably ac- Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Charney,
D. S., &. Keane, T. M. (1995). Clinician-Administered PTSD Scale
counts for a portion of the potential elevation in CSA-related
for DSM-IV. Boston and West Haven, CT: National Center for Post-
PTSD symptom levels. This finding supports the notion that
traumatic Stress Disorder.
exposure to the childhood trauma of physical abuse may potenti-
Briere, J. (1992). Methodological issues in the study of sexual abuse
ate the PTSD response to CSA. As noted in the Introduction,
effects. Journal of Consulting and Clinical Psychology, 60, 196-203.
previous studies have found that the experience of CPA in CSA Finkelhor, D., Hotaling, G., Lewis, I. A., & Smith, C. (1990). Sexual
survivors increases PTSD or trauma-related symptoms. Addi- abuse in a national survey of adult men and women: Prevalence,
tional studies must use standardized measures of CSA, CPA, characteristics, and risk factors. Child Abuse and Neglect, 14, 19-
and PTSD to investigate the traumatic impact of dual abuse. 28.
Future research may consider assessing both CSA-related PTSD Foa, E. B., Riggs, D. S., Dancu, C. B., & Rothbaum, B. O. (1993).
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

and CPA-related PTSD and examining the impact of dual abuse Reliability and validity of a brief instrument for assessing post-trau-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

on each form of PTSD. matic stress disorder. Journal of Traumatic Stress, 6, 459-474.
The present study used the number of symptoms endorsed on Foy, D. W, Sipprelle, R. C., Rueger, D. B., & Carroll, E. M. (1984).
the SCID to measure PTSD intensity. Future studies should use Etiology of posttraumatic stress disorder in Vietnam veterans: Analy-
sis of premilitary, military, and combat-exposure influences. Journal
PTSD instruments that provide a more comprehensive measure-
of Consulting and Clinical Psychology, 52, 79-87.
ment of PTSD intensity involving the assessment of the severity
Gelinas, D. J. (1983). The persisting negative effects of incest. Psychia-
and frequency of each symptom in addition to summing the
try, 46, 312-332.
overall number of symptoms experienced (e.g., The Clinician-
Graham-Howard, M. L. (1993). The relationship between exposure to
Administered PTSD Scale for DSM-IV; Blake et al., 1995).
multiple traumas and the development of PTSD symptoms in boys
In the present study, comprehensive information was unavail- (University Microfilms No. DFA93-23803). Dissertation Abstracts
able for the duration of treatment of both groups. Both groups International, 54(05), 2752B.
had been engaged in treatment for their respective problems for Herman, J., Russell, D., & Trocki, K. (1986). Long-term effects of
at least 6 months. Future clinical studies should determine the incestuous abuse in childhood. American Journal of Psychiatry, 143,
length in treatment as this variable may be an important factor 1293-1296.
in understanding how PTSD symptoms may vary across the Keane, T. M, Weathers, F. W, & Kaloupek, D. G. (1992). Psychological
course of therapy. assessment of post-traumatic stress disorder. The National Center for
Finally, 16% of the CSA group remembered their abuse in Post-Traumatic Stress Disorder: PTSD Research Quarterly, 3, 1-7.
the context of psychotherapy. Some researchers (e.g., Loftus, Riser, L. J., Heston, J., Milsap, P. A., & Pruitt, D. B. (1991). Physical
1993) have set forth the hypothesis that memories of sexual and sexual abuse in childhood: Relationship with post-traumatic stress
disorder. Journal of the American Academy of Child and Adolescent
abuse recovered during psychotherapy may reflect the sugges-
Psychiatry, 30, 776-783.
tion of the therapist rather than actual CSA experiences. It is
Loftus, E. F, (1993). The reality of repressed memories. American
unlikely that the results of this study are confounded by this
Psychologist, 48, 518-537.
hypothesis, because neither the PTSD rates nor PTSD intensity
McLeer, S. V., Callaghan, M., Henry, D., & Wallen, I. (1994). Psychiat-
levels differed between CSA survivors who remembered their
ric disorders in sexually abused children. Journal of the American
abuse during therapy and those who remembered their abuse Academy of Child and Adolescent Psychiatry, 33, 313-319.
before beginning therapy or those who never forgot their abuse. Moeller, T. P., Bachman, G. A., & Moeller, J. R. (1993). The combined
Although firm empirical support has not been provided for the effects of physical, sexual, and emotional abuse during childhood:
hypothesis that some therapists implant "memories" of CSA Long-term health consequences for women. Child Abuse and Neglect,
in their patients, prospective studies have documented that CSA 17, 623-640.
survivors sometimes forget their abuse experiences (e.g., Wil- Neumann, D. A., Callers, J., & Foy, D. (1989, October). Traumatic
liams, 1994). violence and PTSD in rape victims. Poster session presented at the
annual meeting of The Society for Traumatic Stress Studies, San
References Francisco.
O'Neill, K., & Gupta, K. (1991). Post-traumatic stress disorder in
Adam, B. S., Everett, B. L., & O'Neal, E. (1992). PTSD in physically
women who were victims of childhood sexual abuse. Irish Journal
and sexually abused psychiatrically hospitalized children. Child Psy-
of Psychological Medicine, 8, 124-127.
chiatry and Human Development, 23, 3-8.
Peters, S. D., Wyatt, G. E., & Finkelhor, D. (1986). Prevalence. In D.
Albach, K, & Everaerd, W. (1992). Posttraumatic stress symptoms in
Finkelhor (Ed.), A sourcebook on child sexual abuse (pp. 15-59).
victims of childhood incest. Psychotherapy Psychosomatics, 57, 143-
Beverly Hills, CA: Sage.
151.
American Psychiatric Association. (1987). Diagnostic and statistical Roesler, T. A., & McKenzie, N. (1994). Effects of childhood trauma on
manual of mental disorders (3rd ed., rev.) Washington, DC: Author. psychological functioning in adults sexually abused as children. Jour-
Astin, M, Ogland-Hand, S. M., Coleman, E. M, & Foy, D. W. (1995). nal of Nervous and Mental Disease, 182, 145-150.
Posttraumatic stress disorder and childhood abuse in battered women: Rowan, A. B. (1992). Posttraumatic stress disorder in a clinical sample
Comparisons with maritally distressed women. Journal of Consulting of adults sexually abused as children (University Microfilms No.
and Clinical Psychology, 63, 308-312. DEZ92-16856). Dissertation Abstracts International, 53(02),
Berger, A.M., & Knutson, J. F. (1984). Assessing environments HI. 1075B.
Iowa City: Department of Psychology, University of Iowa. Rowan, A. B., & Foy, D. W. (1993). Post-traumatic stress disorder in
 PTSD AND CHILDHOOD SEXUAL ABUSE 59

child sexual abuse survivors: A literature review. Journal of Traumatic Spitzer, R. L., Williams, J. B. W, Gibbon, M., & First, M. B. (1990).
Stress, 6, 3-20. The Structured Clinical Interview for DSM-III-R. Washington, DC:
Rowan, A. B., Foy, D. W., Rodriguez, N., & Ryan, S. (1994). Posttrau- American Psychiatric Association.
matic stress disorder in a clinical sample of adults sexually abused Surrey, J., Swett, C., Michaels, A., & Levin, S. (1990). Reported history
as children. Child Abuse and Neglect, 18, 51-61. of physical and sexual abuse and severity of symptomatology in
Ryan, S. W. (1993). Psychometric analysis of the Sexual Abuse Expo- women psychiatric outpatients. American Journal of Orthopsychiatry,
sure Questionnaire (University Microfilms No. DFA93-23808). Dis- 60, 412-417.
sertation Abstracts International, 55(11), 3709A. Williams, L. M. (1994). Recall of childhood trauma: A prospective
Ryan, S. W., Rodriguez, N., Rowan, A., & Foy, D. W. (1992, August). study of women's memories of child sexual abuse. Journal of Con-
Psychometric analysis of the Sexual Abuse Exposure Questionnaire sulting and Clinical Psychology, 62, 1167-1176.
(SAEQ). Poster session presented at the 100th Annual Convention of Wind, T. W., & Silvern, L. (1992). Type and extent of child abuse as
the American Psychological Association, Washington, DC. predictors of adult functioning. Journal of Family Violence, 7, 261-
Sadeh, A., Hayden, R. M, McGuire, J. P. D., Sachs, H., & Clivita, R. 281.
(1994). Somatic, cognitive, and emotional characteristics of abused Wolfe, D. A., Sas, L., &. Wekerle, C. (1994). Factors associated with
children in a psychiatric hospital. Child Psychiatry and Human Devel- the development of posttraumatic stress disorder among child victims
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

of sexual abuse. Child Abuse and Neglect, 18, 37-50.

This document is copyrighted by the American Psychological Association or one of its allied publishers.

opment, 24, 191-200.

Saunders, B. E., Villeponteaux, L. A., Lipovsky, J. A., Kilpatrick, Zaidi, L. J., Knutson, J. E, & Mehm, J. G. (1989). Transgenerational
D. G., & Veronen, L. J. (1992). Child sexual assault as a risk factor patterns of abusive parenting: Analog and clinical tests. Aggressive
for mental disorders among women. Journal of Interpersonal Vio- Behavior, 15, 137-152.
lence, 7, 189-204.
Saunders, E. A. (1991). Rorschach indicators of chronic childhood sex- Received September 6, 1995
ual abuse in female borderline patients. Bulletin ofMenninger Clinic, Revision received January 11, 1996
55, 48-71. Accepted January 17, 1996 •