THE LONG-TERM IMPACT OF THE PHYSICAL, EMOTIONAL, AND SEXUAL ABUSE OF CHILDREN- A COMMUNITY STUDY

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Pergamon 
Child Abuse & Neglect, Vol 20, No. I, pp. 7-21, 1996 
Copynght© 1995 Elsevier Science Ltd 
Printed in the USA. All rights reserved 
0145-2134/96 $15 00 + .00 
0145-2134(95)00112-3 
THE LONG-TERM IMPACT OF THE PHYSICAL, 
EMOTIONAL, AND SEXUAL ABUSE OF CHILDREN: 
A COMMUNITY STUDY 
P. E. MULLEN, J. L. MARTIN, J. C. ANDERSON, S. E. ROMANS, 
AND G. P. HERBISON 
Departments of Psychological Medicine and Preventive and Social Medicine, University of Otago, New Zealand 
and Department of Psychological Medicine, Monash University, Australia 
Abs t rac t - -The associations between giving a history of physical, emotional, and sexual abuse in children and a range 
of mental health, interpersonal, and sexual problems in adult life were examined in a community sample of women. 
Abuse was defined to establish groups giving histories of unequivocal victimization. A history of any form of abuse 
was associated with increased rates of psychopathology, sexual difficulties, decreased self-esteem, and interpersonal 
problems. The similarities between the three forms of abuse in terms of their association with negative adult outcomes 
was more apparent than any differences, though there was a trend for sexual abuse to be particularly associated to 
sexual problems, emotional abuse to low self-esteem, and physical abuse to marital breakdown. Abuse of all types 
was more frequent in those from disturbed and disrupted family backgrounds. The background factors associated with 
reports of abuse were themselves often associated to the same range of negative adult outcomes as for abuse. Logistic 
regressions indicated that some, though not all, of the apparent associations between abuse and adult problems was 
accounted for by this matrix of childhood disadvantage from which abuse so often emerged. 
Key Words---Sexual abuse, Physical abuse, Emotional abuse. 
INTRODUCTION 
THE EXPERIENCE OF abuse during childhood not only generates distress and disturbance 
at the time but may produce long-term deleterious effects on the victims' health and functioning 
(Beitchman, Zucker, Hood, DaCosta, Akman, & Cassavia, 1992; Browne & Finkelhor, 1986; 
Kendell-Tackett, Williams, & Finkelhor, 1993; Reiss, Richters, & Radke-Yarrow, 1993). The 
role of child sexual abuse (CSA) in the genesis of adult disorders has been the focus of most 
research with the physical, and in particular the emotional, abuse of children attracting less 
attention (Claussen & Crittenden, 1991; Rosenberg, 1987). There are suggestions that the 
impact of different types of abuse can produce overlapping patterns of adverse sequelae in 
adult life (Briere & Runtz, 1988; Bryer, Nelson, Miller, & Kroll, 1987; Chu & Dill, 1990; 
Kiser, Heston, Millsap, & Pruitt, 1991; Moeller, Bachmann, & Moeller, 1993; Mullen, Romans- 
Clarkson, Walton, & Herbison, 1988; Muenzenmaier, Meyer, Strnening, & Ferber, 1993). 
Briere and Runtz (1990) produced data indicating abuse specific outcomes, with physical abuse 
linked to aggression towards others, emotional abuse to low self-esteem, and sexual abuse to 
maladaptive sexual behavior. Rieker and Carmen (1986) hypothesized that child sexual abuse 
was particularly damaging to the sense of self which heightened the risks of self-destructive 
Received for publication February 17, 1995; final revision received July 10, 1995; accepted July 1 I, 1995. 
Requests for reprints should be addressed to Professor P. E. Mullen, Forensic Psychiatry Service, P.O. Box 266, 
Rosanna, Victoria 3084, Australia. 
P. E. Muilen, J. L. Martin, J. C. Anderson, S. E. Romans, and G. P. Herbison 
and suicidal behaviors, with physical abuse in childhood producing similar though less severe 
damage to adult functioning. In a study focussing on bulimia nervosa a somewhat different 
hierarchy emerged with emotional abuse in childhood having the strongest association, to adult 
eating disorder, physical abuse a significant but weaker association and sexual abuse only 
contributing in combination with the other forms of abuse (Rorty, Yager, & Rossotto, 1994). 
Thus though there is general agreement that child abuse is associated to a range of problems 
in adult life, the extent to which sexual, physical, and emotional abuse each generate either 
common or specific patterns of damage remains an open question. 
The definition of what constitutes child abuse is fraught with difficulties. Children in our 
societies are all too often subjected to physical violence, emotional deprivation, and inappropri- 
ate sexual behaviors. In research into abuse the delineation of such abuse from the mundane, 
though undesirable, vicissitudes of childhood can present problems. Wide definitions of abuse, 
be it sexual, physical, or emotional, tend to capture large sections of the community. This 
may have educational or rhetorical power but in research it makes it less likely that clear 
correlations will emerge to long-term effects. More restrictive definitions can reasonably be 
criticized for by implication suggesting a range of unpleasant and even criminal acts are 
somehow not abusive. To further complicate the ascertainment of abuse subjectively identifying 
oneself as a victim of abuse produces a significantly lower rate than asking about specific 
experiences and categorizing on the basis of these responses (Carlin, Kemper, Ward, Sowell, 
Gustafson, & Stevens, 1994). In practice the nature of the research question and the data base 
is likely to profoundly influence both the operational definitions applied and the method of 
inquiry. As long as it is clear how abuse is being delineated and ascertained it is possible to 
generate an adequate evaluation and comparison of the results. 
Children who are victims of one form of abuse are more likely to also experience other 
forms of abuse. Focussing exclusively on one form of abuse is to risk giving a spurious 
prominence to the chosen form of victimization. Abuse is not randomly distributed through 
the community but is more likely to be found in disrupted and disturbed families and in those 
families subject to economic and social disadvantage (Bagley & Ramsey, 1985; Finkelhor & 
Baron, 1986). This creates difficulties for the attribution of an association between the abuse 
and any deleterious adult outcome for the risk factors for the abuse may also be risk factors 
for the negative outcomes. There are already suggestions in the literature with regard to sexual 
abuse that problems with adult psychological and sexual adjustment may be due as much to the 
associated factors in the family background as to the abuse (Fromuth, 1986; Kinzl, Traweger, 
Guenther, & Biebl, 1994; Mullen, Martin, Anderson, Romans, & Herbison, 1994; Pribor & 
Dinwiddie, 1992). The prominence accorded CSA as a cause of adult psychopathology is 
misplaced if CSA operates primarily as a marker for a range of coexisting deleterious influences 
rather than itself carrying the weight of causality. 
This paper attempts to examine both the specific associations between histories of sexual, 
physical, or emotional abuse to negative adult outcomes as well as the potential interaction between 
such experiences. The possibility that child abuse may occur more frequently in disturbed and 
disadvantaged home backgrounds necessitates examining family and social factors as potential 
confounders of any putative relationships between abuse and long-term outcomes. 
METHODS 
Subjects and Procedure 
The study, which was approved by the University and Health Boards' Ethics Committee, 
employed a two-stage design. The first involved sending a postal questionnaire to 2,250 women, 
Long-term impact of child abuse 9 
randomly selected from the electoral rolls of Dunedin, a university city with a population of 
130,000. The electoral rolls, used in national Parliamentary elections, list over 95% of the 
population 18 years and above; and adult literacy is over 97% in the New Zealand population. 
The sample derived from a random sampling programwas checked to ensure that it did not 
overlap with an earlier sample used to investigate sexual and physical abuse (Mullen, Romans- 
Clarkson, Walton, & Herbison, 1988). The postal questionnaire included questions on general 
health, mental health, demographics, social support, and experience of sexual and physical 
abuse both as a child and during adult life. Those who did not return the questionnaires were 
followed up by telephone and letter to clarify whether they wished to participate. 
The second stage was an interview phase. All 298 women under the age of 65 years who 
had indicated on their postal returns that they had experienced unwanted sexual advances prior 
to the age of 16 years were invited for interview. A group of the same size was randomly 
selected from the 716 subjects who did not report sexual abuse either as a child or as an adult 
and this group was also invited for interviews. 
The interviews were conducted over 14 months in 1989 and 1990, either in the women's home 
or at the research unit, depending on the women's preference. The interviews were largely con- 
ducted by J. M. and J. A. and took an average of 1 and 1/2 hours. Women were informed that 
there would be inquiries relating to abuse in the last section of the interview and consent was 
obtained once more prior to the onset of questioning. The women were assured that they could 
discontinue the interview at any stage and withdraw from the study. No financial or other induce- 
ment was offered to participants who gave generously of their time and energy. Counselling and 
appropriate referral was offered to those where it was acceptable. The interviewers were blind to 
the subjects' responses to the postal questionnaire when conducting the interviews. (For further 
details see Martin, Anderson, Romans, Mullen, & O'Shea, 1993.) 
Measures of Family and Social Background 
The interview included a detailed schedule which collected data on variables that have been 
associated with an increased risk of abuse during childhood (copies of the schedule may be 
obtained from the authors). Inquiries were made into family factors such as family structure, 
family and parental relationships, discipline and family violence. At the time of the interview 
subjects also completed the Parental Bonding Instrument (PBI), a questionnaire elucidating 
memories of their relationship to their parents (Parker, 1983; Parker, Tupling, & Brown, 1979). 
This instrument enabled the generation of a measure of emotional deprivation during childhood. 
Measures of Abuse 
1. Childhood sexual abuse (CSA) was explored using a series of direct questions about un- 
wanted sexual advances prior to the age of 16 years which covered noncontact abuse, 
including being exposed to indecent suggestions and exhibitionism; contact abuse, including 
any sexual touching, genital contact, involving either the perpetrators or victims genitals; 
and abuse involving actual penetration. CSA of some form was reported by 32% of our 
sample with 25% describing abuse involving physical contact, 20% contact with the victims 
or perpetrators genitals of which 6% involved actual penetration (for further details see 
Anderson, Martin, Mullen, Romans, & Herbison, 1993). It must be emphasized however 
that for the purposes of this analysis we used a subgroup who reported that prior to the 
age of 16 years they had been subjected to abuse involving actual penetration and or genital 
contact on 10 or more occasions. 
2. Physical abuse was defined as reporting physical punishment or hitting by a parent of a 
severity to produce at least lasting soft tissue injury on a regular basis (i.e., more than two 
10 
. 
P. E. Mullen, J. L. Martin, J. C. Anderson, S. E. Romans, and G. P. Herbison 
times a year) including those incidents of abuse of sufficient severity to require hospitaliza- 
tion. These included injuries caused by hitting with open hands or fists or with a weapon, 
such as a belt or stick. 
Emotional abuse or deprivation was defined using the responses to the Parental Bonding 
Instrument (PBI) (Parker, 1983; Parker, Tupling, & Brown, 1979) which generates two 
dimensions of the subjects memory of their parenting, the first being care and affection 
and the second the degree of controlling behavior. The mean scores on the PBI for our 
sample were virtually identical to those reported by Parker and colleagues (1979) and Parker 
(1983). The emotionally abused subgroup was composed of subjects whose ratings of either 
parent fell at least one standard deviation from our sample mean on both the "ca re" and 
overprotection subscales. 
The Control Group 
The control group employed in this analysis were the 390 interviewees who did not meet 
the criteria used in this particular analysis for any of the three forms of abuse. 
Measures of Adult Outcomes 
Mental health. The short form of the Present State Examination (PSE) (Wing, Cooper, & Sartorius, 
1974; Wing, Nixon, Mann, & Left, 1977), which is a structured interview exploring a range of 
psychopathology, was administered by the interviewers who were trained in its use. Additional 
questions were also asked to generate longitudinal data on psychiatric disorder (McGuffin, Katz, & 
Aldrich, 1986). The PSE generates a total score indicative of the overall level of psychiatric 
symptomatology in the previous month as well as being able to generate diagnostic categories. 
The CATEGO program~was employed to identify from the PSE responses a group whose symptoms 
suggested they would have been identified as "a case" and received a clinical diagnosis and 
treatment had they been seen at a mental health clinic or by a mental health professional. Additional 
questions were also included on eating disorders, drug dependence, and self damaging and suicidal 
behaviors. 
The WHO alcohol questionnaire was employed to explore hazardous and abusive patterns of 
alcohol consumption (Saunders, Aasland, & Grant, 1987). A variable was derived from this data 
to identify those women who drank at a hazardous level defined as more than 14 standard drinks 
(140 gms alcohol) per week. 
Self-esteem. The self-esteem questionnaire of Robson (1989) was employed as a measure of 
this dimension as it covers a wider range of components of self-esteem than other instruments 
such as that of Rosenberg (1965). This instrument attempts to quantify the sense of contentment 
and self-acceptance that result from a persons appraisal of their own worth, significance, 
attractiveness, competence, and ability to satisfy their aspirations. Low self-esteem was defined 
as one standard deviation below the mean score for the entire sample. 
Social class. Subjects' socioeconomic class (SES) was estimated from the current occupation 
and, where relevant, that of the partner using the standard New Zealand tables (Elley & Irving, 
1985). Educational status was assessed as a separate variable according to the highest formal 
qualification gained. A variable employed in this analysis was a decline in SES from that of 
the woman's family of origin to that of her current family. 
Sexual history. The history was obtained of the age at first voluntary intercourse, and any 
premarital pregnancies and their outcomes. Previous marriages and cohabitations and their 
Long-term impact of child abuse 11 
outcome were also recorded. A measure of current sexual functioning was developed specifi- 
cally for this study and included inquiries about the frequency of sexual activity, levels of 
satisfaction with their current sex lives, and present and past sexual difficulties together with 
their perceived origins. A mixture of direct questions, open-ended questions, and Likert scales 
were employed. The variables employed in this analysis were the current marital status and 
reported sexual problems which were attributed to their own attitude to sexuality rather than 
to medical problems, partner shortcomings, or other practical difficulties. The quality of the 
women's currentrelationships was also explored using the Intimate Bond Measure (Wilhelm & 
Parker, 1988). 
Measures of Family and Social Background 
The interview included a detailed schedule exploring the structure and relationships within the 
family of origin, the mental and physical health of the parents during the subjects childhood and 
the quality of the relationships during childhood with other family members and peers. The factors 
derived from these problems were employed to construct potential risk factors which have been 
claimed to be associated with increased risks of abuse (Finkelhor & Baron, 1986). 
Statistical Analysis 
Data was entered on the University's mainframe computer and analyzed using the SPSSX 
statistical program. Control subjects, as defined for the purposes of this analysis, were compared 
for all analysis with the three forms of abuse separately and those three in combination. 
Continuous variables were transformed, where appropriate, for non-normality and analyzed 
using student's t-test, while categorical variables were tested for significance by X 2 and odds 
ratio tests. 
Logistic regression carried out on the SPSSX was used to test the importance of sexual, 
emotional, and physical abuse in combination with a range of other variables relating to the 
subjects childhoods which have been suggested as increasing the risk of being abused. The 
result of these models are expressed in terms of adjusted odds ratios. The percentage of the 
deviance accounted for in the models by the relevant factors are quoted as a measure of the 
variance in the outcome explained. 
In analyzing an extensive database problems may arise from multiple analysis (Jones & 
Rushton, 1982). In reporting odds ratios, the usual convention of providing 95% confidence 
limits has been adhered to, but when the lower limit approaches unity the results should be 
treated with reservation. This caveat does not apply to the results of logistic regression where 
multiple analysis is not an issue. 
RESULTS 
Sample 
The number of women who returned usable questionnaires was 1,376, which was 61% of 
the whole sample and 71% of the women under 65 with whom we were concerned in this 
study. Information available from the electoral role suggested that our nonresponders did not 
differ from respondents in socioeconomic status. The sample employed in this study was drawn 
from the 610 women invited for subsequent interview, 497 (80%) of whom completed the 
interview (for further details see Anderson, Martin, Mullen, Romans, & Herbison, 1993; and 
Martin, Anderson, Romans, Mullen, & O'Shea, 1993). 
There were 107 (21.5%) women in the interview sample who reported experiencing some 
12 P. E. Mullen, J. L. Martin, J. C. Anderson, S. E. Romans, and G. P. Herbison 
form of abuse during childhood which fell within our criteria for this analysis. The sexually 
abused group consisted of 53 (10.7%) women, 32 of whom had during childhood been subjected 
to penetration and 21 to repeated genital contact. The physically abused group contained 39 
women (7.8%) and the emotionally abused 57 (11.5%). (The pattern of overlap between the 
three types of abuse is presented in Table I.) The physical and emotional abuse was all at the 
hands of parents or primary caregivers but fathers or stepfathers accounted for 23.1% of sexual 
abuse, and in 45.8% of such abuse the perpetrator was outside of the immediate family. Those 
reporting physical abuse identified the mother as sole abuser in 15 cases, the father in 15 
cases, and 9 subjects were physically abused by both. Emotional abuse was associated primarily 
with the father in 23 cases, the mother in 24 cases, and both father and mother in 10 instances. 
Long-term Impact of Abuse 
Sexual abuse in childhood. Those reporting child sexual abuse had significantly poorer mental 
health. They were more likely to be identified as cases on the PSE (35.8% vs. 9.5% X 2 = 
30.32 pfrom 12.1% for any single form of abuse to 40.0% for all three types of 
abuse (X 2 38.202 df 3 pto below together with the drop in deviance, which is a measure of the 
percentage of possible variance explained by each model. A decline in SES was no longer 
significantly related to abuse after logistic regression. Separation and divorce remained signifi- 
cantly associated to physical abuse [O.R. 1.87 (95% C.L 1.2--2.89)] as well as having experi- 
enced frequent shifts in residence during childhood [O.R. 1.53 (95% C.I. 1.06--2.23)] but 
not to sexual or emotional abuse (drop in deviance 1.8%). Sexual problems remained associated 
with both sexual [O.R. 1.52 (C.I. 1.09--2.07)] and emotional abuse [O.R. 1.46 (95% C.I. 
1.02--2.05)], as well as with violence in the parental relationship [O.R. = 1.42 (95% C.I. 
1.05--1.92)] and frequent shifts in childhood [O.R. = 1.31 (95% C.I. 1.02--1.68)]. These 
four factors together accounted for 2.2% of the drop in deviance. Low self-esteem continued 
to be significantly related to sexual abuse [O.R. 1.53 (95% C.L 1.08--2.14)] and emotional 
abuse [O.R. 1.56 (95% C.I. 1.11 - -2 .22)] together with having described oneself as a shy child 
[O.R. 1.38 (95% C.L 1.07--1.77)] and to having had an invalid or chronically physically ill 
mother (O.R. = 1.46 95% C.L 1.09--1.95). These four factors accounted for 3.4% of the 
drop in deviance. Being identified as a psychiatric case on the PSE continued to be significantly 
associated with sexual abuse [O.R. = 2.02 (95% 1.40--2.94)] and emotional abuse [O.R.= 
1.75 (95% C.L 1.19--2.56)] as well as with having grown up in a family where the parents 
frequently moved (O.R. = 2.09 95% C.I. 1.46--2.72) and having had a physically sick mother 
16 P. E. Mullen, J L. Martin, J. C. Anderson, S. E. Romans, and G. P. Herbison 
Table 4. The Odds Ratios Following Logistic Regression for Negative Adult Outcomes in Those with 
Histories of Abuse 
Emotional 
Negative Outcome Sexual Abuse Physical Abuse Abuse 
Decline m SES NS NS NS 
Separation or Divorce NS 1.87 ( 1.20-2.89) NS 
Pregnant Prior to 19 years 1.64 (I.43-2.36) NS 1.83 (1.30-2.61) 
Sexual Problems 1.52 (1.09-2.07) NS 1.46 (1.02-2.05) 
Low Esteem 1.53 (1.08-2.14) NS 1.56 (1.1 ! -2.22) 
PSE Case 2.02 (1.40-2.94) NS 1.75 (1.19-2.59) 
Eating Disorder 1.75 (1.15-2.59) NS 1.76 (I.17-2.61) 
Ever Suicide Attempt 3.57 (2.11-5.99) NS 2.42 (1.34-4.39) 
Heavy Drinker 1.77 (1 22-2.56) NS NS 
Ever Depressed 1.80 (1.29-2.51) NS 1.45 (1.03-2.03) 
Ever Inpatient 2.46 ( 1.41-4.10) NS 1.77 (1.05-2.97) 
(O.R. = 1.56 95% C.L 1.09--2.20). The drop in deviance associated with these in combination 
was 7.7%. Ever having had a depressive disorder continued to be significantly associated with 
sexual abuse [O.R. = 1.80 (95% C.I. 1.29--2.51)] and emotional abuse [O.R. = 1.45 (95% 
C.L 1 . 0 3 - - 2 . 0 3 ) ] as well as with a history of domestic violence in the parental relationship 
(O.R. = 1.45 95% C.L 1.11--1.90), though these three variables together only accounted for 
1.2% of the deviance. Eating disorders were associated with sexual [O.R. = 1.75 (95% C.L 
1.15--2.59)] and emotional abuse [O.R.= 1.76 (95% C.I. 1.17--2.61)] as well as one 's 
parents separating during one's childhood (O.R. = 1.86 95% C.L 1.17--2.94) and these three 
factors produced a 2.5% drop in the deviance. Heavy drinking was associated only with sexual 
abuse (drop in deviance 3.3%). Suicidal behavior continued to be associated with sexual 
[O.R.= 3.57 (95% C.I. 2.11--5.99)] and emotional abuse [O.R. = 2.42 (95% C.I. 1 .34- - 
4.39)] together with frequent parental rows (O.R. = 2.03 95% C.I. 1.19--3.49). These three 
variables accounted for 9.3% of the deviance. Having been admitted to a psychiatric hospital 
was associated with both sexual [O.R. = 2.46 (95% C.L 1.41--4.10)] and emotional abuse 
[O.R. = 1.77 (95% C.I. 1.05--2.97)] as well as to having had a physically ill mother (O.R. 
= 2.01 95% C.L 1.20--3.39), and these three factors accounted for 4.8% of the deviance. 
The interactions between the three forms of abuse and other negative developmental factors 
was further examined using logistic regression. This added little to the original logistic regres- 
sion for sexual and emotional abuse but demonstrated that physical abuse became a significant 
association to a number of negative adult outcomes when combined with other developmental 
variables. Physical abuse in combination with parental separation was significantly associated 
with low self-esteem (O.R. 1.54 95% C.L 1.11--2.14), ,in combination with frequent shifts in 
childhood to sexual problems (O.R. = 1.37 95% C.I. 1/08--1.75), and to being a case on the 
PSE in combination with parental rows (O./~. = 1.55 95% C.I. 1.08--2.23). Sexual abuse 
became a significant contributor to current separation and divorce when combined with frequent 
parental rows (O.R. 1.51 95% C.I. = 1.08--2.10). 
Relationship to Gender of Abuser 
Those subjects who report being abused physically or emotionally by both maternal and 
paternal caregivers tended to have higher rates/of all negative outcomes measured than those 
who nominated only one of the primary ~aCegivers as abusive. Emotional abuse by male 
caregivers, as against that by females, was l~articularly associated with difficulties with regard 
to sexuality in adult life (X 2 33.4 df3 pminimized in a community sample such as this in which 
no obvious advantage accrued to those reporting abuse and in which only four subjects had 
discovered or "clarified" their memories of abuse as a result of participating in therapy or abuse 
groups. It should be noted that the sexually abused women made relatively few attributions of 
long-term problems to these childhood experiences and that our. analysis suggests a greater degree 
of association between the reported abuse and current difficulties than their subjective assessments 
of its impact (see Mullen et al., 1994). This is against an exaggeration by our subjects of the role, 
at least of sexual abuse, in any current difficulties. In the final analysis, however, this remains a 
study of histories of abuse provided by adults. Alternative research strategies which are based on 
following up children known to have been victimized provide important insights into abuse, but 
they also have to contend with the ascertainment problem as less than 10% of even the most 
serious forms of abuse come to official or medical notice at the time (Anderson et al., 1993; 
Green, 1988). Methodologically ideal studies in this area may always escape us, but good enough 
studies will, when taken together, illuminate the central theoretical and clinical issues. 
Those women who reported having been exposed to some form of abuse in childhood, be 
it sexual, physical, or emotional were in adult life more likely to have mental health, interper- 
sonal, and sexual difficulties. The current psychopathology revealed by the PSE in those 
reporting abuse fell almost exclusively in the area of depressive and anxiety symptoms. It was 
similarly histories of previous depressive disorders which were so prominent among the abused. 
18 P. E. Mullen, J. L. Martin, J C. Anderson, S. E. Romans, and G. P. Herbison 
Eating disorders were increased in all three forms of reported abuse, though most obviously 
in those with histories of emotional and sexual abuse rather physical abuse as suggested by 
Rorty, Yager, and Rossotto (1994). The elevated rates of prior psychiatric treatment in those 
reporting abuse of any type is consistent with studies on those with mental illness which have 
demonstrated very high rates of reporting childhood abuse and neglect (Meuenzenmaier, Meyer, 
Struening, & Ferber, 1993). 
There was some support for previously reported differences between the long-term impact of 
differing categories of abuse. Those with histories of sexual abuse, as opposed to the physically 
abused, were more likely to report sexual problems, but the emotionally abused group had very 
similar levels of sexual difficulties. The emotionally abused group had somewhat worse self-esteem 
than the physically or sexually abused but the differences were modest. Though these subtle 
differences are discernible in the pattern of adult problems associated with particular forms of 
abuse, the most striking finding is the similarity in the pattern of difficulties and disabilities. The 
postulated association between physical abuse and emotional neglect and later aggressive and 
criminal behavior (Widom, 1989) unfortunately could not be investigated, as no adequate measure 
of violent or irresponsible conduct had been included in the study design. The failure to find a 
clear separation between the associations to different types of abuse could simply reflect an 
inadequate sample size or a failure to address the specific correlates of such abuse. Conversely, 
it could be that any serious form of abuse in childhood produces a generalized, and largely 
nonspecific, disruption in the child's development. Even if subtle distinctions do exist, the hypothe- 
sis that there are highly specific long-term post abuse syndromes is difficult to accommodate to 
both such a diverse range of potential long-term sequelae and to such an extensive overlap between 
the types of abuse. As might be expected those reporting more than one form of abuse in childhood 
fared even worse than those reporting single types of abuse. Given the frequency of multiple 
abuse, this is of potential clinical importance. 
The impact of emotional abuse varied with the gender of the abuser. Those emotionally 
abused by their female caregivers were more prone to psychiatric difficulties in adult life, 
whereas such abuse from the male parent figure was particularly deleterious to adult sexuality, 
thus suggesting that in this culture there are still some gender specific roles with regard to the 
developing child. The predicted greater impact of a physically abusive male caregiver was not 
found. Sexual abuse is almost exclusively perpetrated by males, and with only two female 
sexual abusers in this series no analysis by gender was possible. 
Abuse was not randomly distributed through our population but occurred more often in 
those from disturbed and disrupted home backgrounds. Those who had grown up in intact 
nuclear families were significantly less likely to report any form of abuse. Similarly, having 
a close and confiding relationship with the mother seemed to confer a degree of protection. 
Those from socially and economically privileged backgrounds were also less likely to report 
any form of abuse. Intact families do not guarantee stability and those children exposed to an 
environment of severe parental discord, with or without overt violence, were also at high risk. 
In physical and emotional abuse, the perpetrators of the abuse are usually also responsible for 
the disrupted and violent home backgrounds, whereas in the sexually abused the abuse is often 
at the hands of men outside of the immediate family. A lack of effective protection and a 
child drawn to seek affection and caring outside of the family probably mediates the connection 
between sexual abuse and a disrupted home life. 
Those elements in the child's background that could reasonably be assumed to have been 
operative prior to the abuse constitute potential risk factors. Obtaining reliable chronologies 
of childhood experiences is plagued with difficulties. We counted as risk factors those elements 
which certainly predated abuse, such as parental social class, but also included factors where 
the history gave rise to a reasonable supposition of precedence. In factors such as having a 
confidante as a child or confiding in the mother, a degree of skepticism is appropriate for these 
Long-term impact of chdd abuse 19 
could have followed the abuse or the abuse could have led to an understandable reappraisal 
and adjustment of memories. 
The risk factors for abuse were broadly similar for all three forms of abuse though physical 
abuse was particularly strongly related to violence in the parental relationship, and to alcoholism 
or other mental disorder in one of the primary caregivers. Emotional abuse tended to go 
together with a lack of a confident among one's childhood peers and, not surprisingly, with a 
lack of a confiding relationship with the mother. 
The risk factors which were associated with higher levels of abuse were themselves associ- 
ated in many instances with the same negative outcomes in adult life as were the different 
types of abuse. This raised the possibility that the associations between abuse and adult 
difficulties could have been accounted for not by the abuse itself, but by those factors connected 
to the increased risks of abuse. Logistic regression was used in an attempt to disentangle the 
impact of the three forms of abuse both from each other and from the potentially confounding 
influences of problematic family and social backgrounds. The logistic regression suggests that 
although part of the apparent relationship between abuse and problems in adult life is accounted 
for by such risk factors, there remains in most instances an independent association between 
sexual and emotional abuse and problems in the areas of mental health, sexuality, and social 
functioning. In those reporting sexual abuse the risksof suicidal behavior remains three times 
higher, and the chances of being a case on the PSE was still over twice that of nonabused 
subjects. Similarly, in emotional abuse the risks of suicidal behavior and psychopathology are 
in the region of twice as high. Physical abuse appeared, however, to disappear following 
logistic regression as a contributor to all outcomes except separation and divorce. This could 
be the result of a lack of malignancy in the long-term effects of physical abuse or could reflect 
variance stealing in which the effects of physical abuse are obscured by its close relationship 
to alternative pathogens in the developmental history. That this is indeed the case is supported 
by the logistic regression which looked at the effects of the three types of abuse in combination 
with a range of other childhood risk factors. Physical abuse was once more a significant 
contributor to the associations with lowered self-esteem, sexual problems, and being a case 
on the PSE when studied in combination with such factors as parental rows and those frequent 
shift of residency in childhood suggestive of family and social instability. 
The overall contribution of abuse to the variables studied in this population were, however, 
modest; for even if we assume such associations represent causal connections, the drops in 
deviance in the various models indicate the contributions of abuse to lie in the range of 1% 
to 5%. This should caution against overestimating the contribution of childhood abuse in 
general, and sexual abuse in particular, to explaining mental health and interpersonal difficulties 
in our community. The contribution to the overall level of distress and disorder in the commu- 
nity should not, however, be confused with the possible contribution of abuse to difficulties 
and disabilities in an individual victim. 
Child abuse, and sexual abuse in particular, has come to be regarded by many clinicians as 
making a powerful contribution to adult psychopathology. A study such as this on a random 
community sample inevitably examines a wider spectrum of abuse than will be encountered 
in clinics, and is unlikely to include some of the severely abused and distressed victims driven 
by their problems to seek professional assistance. Extrapolation from epidemiological studies 
to the consulting room require caution, but it does potentially provide a useful additional 
dimension, if not necessarily a corrective one, to clinical impression and clinically based 
research. This study once more highlights the close relationships between sexual, emotional, 
and physical abuse reinforcing the findings of previous workers (Briere & Runtz, 1988; Bryer, 
Nelson, Miller, & Kroll, 1987; Moeller et al., 1993; Rorty, Yager, & Rossotto, 1994). A focus 
on sexual abuse should not be allowed to obscure the possible relevance of emotional and 
physical abuse to adult problems. Further, this study places the adverse outcomes associated 
20 P. E. Mullen, J. L. Martin, J. C. Anderson, S. E. Romans, and G. P. Herbison 
wi th his tor ies o f any f o r m o f abuse f i rmly in the con tex t o f a mat r ix o f ch i ldhood d isadvantage , 
f r o m wh ich such abuse so of ten arises and f r o m which some, at least, o f the apparent associa- 
t ions to abuse are l ike ly to be at tr ibutable. Ch i ld abuse is an ev i l to wh ich no ch i ld should be 
exposed . Th is s tudy supports an assoc ia t ion b e t w e e n g iv ing a his tory o f such abuse and an 
increased vu lnerab i l i ty to a range o f menta l heal th, persona l and socia l p r o b l e m s in adult l ife, 
but p laces abuse a longs ide a range o f o ther d e v e l o p m e n t a l t raumas and d i sadvan tages as 
potent ia l causal agents. T h e m e s s a g e for therapists is that w h e n eva lua t ing the r e l evance o f 
ch i ldhood abuse to b e w a r e an exc lus ive , and po ten t ia l ly exagge ra t ed focus on the t raumas o f 
sexual abuse wh ich m a y obscure both the r e l e v a n c e o f o ther fo rms o f abuse and the un fo ld ing 
o f o ther d a m a g i n g d e v e l o p m e n t a l inf luences . 
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R~sum6----French abstract not available at time of publication. 
Resumen---En esta investigaci6n se examinaron, en una muestra comunitaria de mujeres, las asociaciones entre la 
existencia de una historia de maltrato ffsico, maltrato emocional o abuso sexual en la infancia y una serie de problemas 
sexuales, interpersonales y de salud mental en la vida adulta. El maltrato fue definido de forma que se establecieran 
grupos con historias de victimizaci6n inequfvocas. Una historia de cualquier forma de maltrato estaba asociada con 
aumento en las tasas de psicopatologfa, dificultades sexuales y problemas interpersonales y un descenso en la autoes- 
tima. Las semejanzas entre las tres formas de maitrato en cuanto a su asociaci6n con consecuencias negativas en ia 
6poca adulta eran m~is aparentes que cualquier diferencia. Sin embargo, se observaba una tendencia a que el abuso 
sexual estuviera particularmente asociado con problemas sexuales, el maltrato emocional con una baja autoestima y 
el maltrato ffsico con fracaso matrimonial. El maltrato de cualquier tipo se daba de manera mils frecuente en aqueilos 
sujetos con historias familiares alteradas y desorganizadas. Los factores de la historia familiar asociados con los 
informes de maltrato estaban, elms mismos, a menudo asociados con el mismo tango de consecuencias negativas 
adultas que se habfan asociado con el maltrato. Los anfilisis de regresi6n logfstica indicaron que algunas, aunque no 
todas, de las aparentes asociaciones entre maltrato y problemas adultos eran explicadas por dicha matriz de desventaja 
infantil, a partir de la cual emerge el maltrato tan frecuentemente.