بهداشت جنسی در زنان با گزارش سابقه سوء استفاده جنسی از کودکان

Objective The present study examined the association between child sexual abuse (CSA) and sexual health outcomes in young adult women. Maladaptive coping strategies and optimism were investigated as possible mediators and moderators of this relationship. Method Data regarding sexual abuse, coping, optimism and various sexual health outcomes were collected using self-report and computerized questionnaires with a sample of 889 young adult women from the province of Quebec aged 20–23 years old. Results A total of 31% of adult women reported a history of CSA. Women reporting a severe CSA were more likely to report more adverse sexual health outcomes including suffering from sexual problems and engaging in more high-risk sexual behaviors. CSA survivors involving touching only were at greater risk of reporting more negative sexual self-concept such as experiencing negative feelings during sex than were non-abused participants. Results indicated that emotion-oriented coping mediated outcomes related to negative sexual self-concept while optimism mediated outcomes related to both, negative sexual self-concept and high-risk sexual behaviors. No support was found for any of the proposed moderation models. Conclusions Survivors of more severe CSA are more likely to engage in high-risk sexual behaviors that are potentially harmful to their health as well as to experience more sexual problems than women without a history of sexual victimization. Personal factors, namely emotion-oriented coping and optimism, mediated some sexual health outcomes in sexually abused women. The results suggest that maladaptive coping strategies and optimism regarding the future may be important targets for interventions optimizing sexual health and sexual well-being in CSA survivors.

This manuscript was submitted as part of the doctoral dissertation in psychology of the first author. This research was made possible by a grant from the Canadian Institutes of Health Research (CIHR). The authors thank Hélène Beauchesne and Lyse Desmarais-Gervais for project administration and data collection coordination, Manon Robichaud for data management and Pierre McDuff for statistical consultation. We also wish to thank the young adults who participated in the study. While the exact prevalence of childhood sexual abuse (CSA) remains difficult to establish because of the different definitions of CSA and methodologies used in empirical reports (Senn, Carey, & Vanable, 2008), current studies suggest that between 15% and 30% of North American women experienced childhood sexual victimization (Pereda, Guilera, Forns, & Gómez-Benito, 2009). Several studies have indicated that exposure to CSA is associated with a variety of short- and long-term negative outcomes including depression, anxiety, low self-esteem, suicidality, substance abuse, and sexual revictimization (Barnes et al., 2009, Briere and Elliott, 2003 and Filipas and Ullman, 2006). The experience of CSA has also been linked to adverse physical health including greater health risk behaviors such as substance abuse (Rodgers et al., 2004). More recently, authors have suggested that CSA survivors may also face important issues related to their sexual health (Lemieux and Byers, 2008 and Senn et al., 2008). According to Hansen, Mann, McMahon, and Wong (2004), sexual health is not merely the absence of disease but represents a core and essential part of being human. The concept of sexual health thus refers to numerous aspects of human sexuality including sexual functioning, satisfaction, and behavior that go beyond the mere absence of diseases such as sexually transmitted infections (STIs) or sexual dysfunctions (Coker, 2007, Lemieux and Byers, 2008 and van Roode et al., 2009). In order to fully grasp the extent to which CSA may compromise women's sexual health, attention must therefore be given to various indicators of women's sexual health as well as to possible adverse effects on women's sexual well-being. Problems regarding sexual health are generally operationalized as high-risk sexual behaviors such as: younger age at first consensual intercourse, large number of both lifetime and recent sexual partners, high frequency of unprotected sex, use of drug or alcohol during sexual activities and a greater likelihood of contracting a STI (Lemieux and Byers, 2008 and Senn et al., 2008). Data from several studies seem to indicate that women with a history of CSA are more likely to engage in high-risk sexual behaviors than women without such history (for reviews see: Arriola et al., 2005 and Senn et al., 2008). Furthermore, research indicates that CSA survivors may also experience difficulties in sexual functioning including a greater risk of experiencing sexual dysfunctions, sexual anxiety, and fear of sexual activities (Luo et al., 2008, Meston et al., 2006, Najman et al., 2005, Noll et al., 2003a, Noll et al., 2003b, Schloredt and Heiman, 2003 and Zwickl and Merriman, 2011). However, other studies have failed to find any association between CSA and a variety of high-risk sexual behavior (Bartoi and Kinder, 1998 and Medrano et al., 1999) and sexual problems (Merrill et al., 2003, Meston et al., 1999 and Miner et al., 2006). These inconsistent findings may be due to methodological issues such as a lack of consensus on the definition and measurement of CSA, and the diversity of both sampling and assessment measures used across studies (Senn et al., 2008). Studies may have relied on different operational definitions of CSA; some may include a spectrum of CSA experiences, whereas others may focus only on the most severe forms of CSA (e.g., involving penetration). This renders the task of comparing results across studies difficult and challenging (Senn et al., 2008). Furthermore, the majority of studies have been conducted with clinical samples and high-risk populations; such results may overestimate the link between CSA and adverse sexual outcomes (National Institute of Mental Health Multisite, 2001, Parillo et al., 2001 and Senn et al., 2006). The current literature clearly lacks documentation of the sexual health outcomes in CSA survivors within large community samples (Coker, 2007). Numerous conceptual models exist to explain CSA, however the concept of traumatic sexualization proposed in Finkelhor and Browne's (1985) traumagenic dynamics model seems particularly relevant (Lemieux & Byers, 2008) in understanding sexual health consequences associated with CSA. Traumatic sexualization refers to the development of precocious and negative feelings and attitudes about sexuality that result from a child being rewarded for engaging in sexual activity and sexual behaviors that are inappropriate in regards to his or her developmental level (Finkelhor & Browne, 1985). Clinical and empirical data suggest that CSA may be associated with opposing sexual health outcomes through the process of traumatic sexualization (Merrill et al., 2003 and Simon and Feiring, 2008). Women who have experienced CSA may come to view sex as necessary for affection, and thus engage in high-risk sexual activity with one or many partners resulting in an “oversexualization” of their relationships (Senn et al., 2008 and Simon and Feiring, 2008), whereas some CSA survivors may also have been conditioned to associate sex with negative feelings, leading to problems of diminished sexuality as well as sexual dysfunctions (Merrill et al., 2003 and Simon and Feiring, 2008). Thus, CSA survivors may experience sexual problems related to both heightened and diminished sexuality, which can in turn increase these women's risk of reporting sexual health problems (Briere, 2000 and Simon and Feiring, 2008). Studies therefore need to document various indicators of women's sexual health in order to fully understand the impact of CSA (Lemieux & Byers, 2008). While past studies have provided strong evidence of a relationship between CSA and later sexual health outcomes, little is known about the process through which CSA survivors may experience later adverse outcomes (Merrill, Thomsen, Sinclair, & Milner, 2001). Researchers have proposed models that include coping as a potential mediator of associations between CSA and long-term outcomes (Briere, 2002, Spaccarelli, 1994 and Walsh et al., 2010). Findings from these studies have provided evidence that coping strategies may in fact be among the key mediators by which CSA may influence long-term adjustment (Briere, 2002, Spaccarelli, 1994 and Walsh et al., 2010). More specifically, the experience of CSA may promote particular maladaptive coping strategies that may, in turn, be related to various outcomes (Walsh et al., 2010). Previous research has also identified the use of maladaptive coping strategies including both avoidant (e.g., avoidance, denial, distancing, disengagement) and emotion-oriented coping strategies (strategies aimed at managing negative emotional responses) to be associated with more adverse outcomes in adults sexually abused as children (Long and Jackson, 1993 and Merrill et al., 2003). Nevertheless, some authors have recently stated that coping strategies may serve both a mediating or moderating role (Walsh et al., 2010). Specifically, CSA may lead to the use of a certain type of coping, which in turn, may influence long-term outcomes (mediator model), and the long-term impact of CSA may vary depending on the type of coping strategies employed by CSA survivors (moderator model) (Banyard and Williams, 2007, Banyard et al., 2008, Walsh et al., 2010 and Wright et al., 2007). Thus, coping strategies may in fact serve both functions, which underscores the need to examine coping as both a possible mediator and moderator of later adjustment (Calvete et al., 2008, Merrill et al., 2001 and Walsh et al., 2010). Other personal factors may also represent potential variables influencing adjustment or act as protective factors following abuse (Gall et al., 2007 and Swanston et al., 2003). Optimism, that is the way individuals think and feel about the future (Seligman, 2006), has been associated with later psychological and physical well-being as well as with health promoting behaviors (Nunn, Lewin, Walton, & Carr, 1996). Optimism has been named as a potential factor that can promote resilience among individuals who have experienced traumatic events (Brodhagen & Wise, 2008). Optimism has also been identified as a potential mediator of the relationship between childhood abuse and later adverse outcomes (Brodhagen & Wise, 2008). Brodhagen and Wise's (2008) study of college students revealed that optimism partially mediated distress among participants with a history of childhood physical and emotional abuse, and fully mediated distress among participants who had experienced rape. However, since the experience of CSA was not associated with distress, the predicted mediation role of optimism in the relationship between the experience of CSA and distress could not be tested (Brodhagen & Wise, 2008). Furthermore, the dynamic of powerlessness proposed by Finkelhor and Browne's (1985) model suggests that CSA may lead to feelings of hopelessness (i.e., less optimism) which, in turn, may lead to risky sexual behaviors in adulthood (Quina, Morokoff, Harlow, & Zurbriggen, 2003). Hence, experiencing less optimism regarding the future may be both an outcome of CSA as well as an important predictor of risky sexual behaviors in adulthood (Quina et al., 2003). Thus, optimism may be an important mediator that might explain the relationship between CSA and later adverse sexual health outcomes. However, studies have also provided evidence for the possible moderating role of optimism on later health outcomes since individuals with a greater sense of optimism also seem to engage in fewer health risk behaviors (e.g., smoking) that can lead to illness, as well as in more health promoting behaviors (Mulkana & Hailey, 2001). Since research findings indicate that optimism is related to engaging in health promoting behaviors, it seems likely that optimism could also be associated with healthier sexual activities; i.e., avoiding high-risk sexual behaviors and thus decreasing one's susceptibility to sexual health problems. Thus, optimism may also be an important moderator of the relationship between CSA and sexual health outcomes. Despite its relevance, few studies have specifically explored optimism and the person's view of their future in relation to outcomes among CSA survivors (Swanston, Nunn, Oates, Tebbutt, & O’Toole, 1999). Consequently, it seems necessary to examine both the possible mediating and moderating role of optimism (Wong & Fielding, 2007). Current study. Childhood sexual abuse represents an important public health issue; women who have experienced CSA appear more vulnerable to contracting STIs as well as HIV and AIDS ( Doll, Koenig, & Purcell, 2003). While researchers have recently underlined the importance of relying on more comprehensive measures of sexual health, the existing studies have focussed solely on specific negative markers of sexual functioning such as high-risk sexual behaviors ( Lemieux & Byers, 2008). Researchers have also underscored the importance of identifying potential factors associated with sexual health outcomes ( Senn et al., 2008), but few studies have examined personal factors such as optimism and coping strategies. The present study aims to address some of these limitations. Using a large sample of adult women recruited from a community setting rather than a clinical or high-risk sample of women, this study will document the sexual health outcomes of CSA survivors by including a vast array of indicators of sexual health. Moreover, this study will examine optimism and maladaptive coping strategies (i.e., avoidant and emotion-oriented coping) as potential mediators and moderators between the experience of CSA and the sexual health outcomes. The first hypothesis is that women who experienced more severe CSA (i.e., involving attempted or completed penetration) will report more adverse sexual health outcomes (i.e., greater involvement in high-risk sexual behaviors; more sexual problems; more negative sexual self-concept) than women who have experienced less severe forms of CSA (i.e., involving touching only; exhibitionism only), or who have not experienced CSA. The second hypothesis is that maladaptive coping strategies (i.e., emotion-oriented and avoidant) and optimism will mediate the association between CSA and women's sexual health. More specifically, we anticipate that CSA will be associated with greater use of maladaptive coping strategies as well as with lower levels of optimism and, in turn, greater use of maladaptive coping strategies as well as lower levels of optimism would be related to poorer sexual health outcomes (i.e., greater involvement in high-risk sexual behaviors; more sexual problems; more negative sexual self-concept). The third hypothesis is that maladaptive coping strategies as well as levels of optimism will moderate the relationship between CSA and later sexual health outcomes. We expect that the relationship between CSA and later sexual health outcomes will be qualified (i.e., moderated) by coping strategies and level of optimism. More specifically, higher levels of maladaptive coping strategies and lower levels of optimism are predicted to lead to more adverse sexual health outcomes (i.e., greater involvement in high-risk sexual behaviors; more sexual problems; more negative sexual self-concept) for women reporting CSA.