Childhood Sexual Abuse and Adult Sexual Risk

Journal of Child Sexual Abuse
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Childhood Sexual Abuse and Adult Sexual Risk

Behavior: A Review and Critique
Amy Dana Ménard & Heather Beth MacIntosh
To cite this article: Amy Dana Ménard & Heather Beth MacIntosh (2021): Childhood Sexual Abuse
and Adult Sexual Risk Behavior: A Review and Critique, Journal of Child Sexual Abuse, DOI:
10.1080/10538712.2020.1869878
To link to this article: https://doi.org/10.1080/10538712.2020.1869878
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JOURNAL OF CHILD SEXUAL ABUSE
https://doi.org/10.1080/10538712.2020.1869878
Childhood Sexual Abuse and Adult Sexual Risk Behavior: A

Review and Critique
a
Amy Dana Ménard and Heather Beth MacIntoshb
a
University of Windsor, Windsor, Ontario, Canada; bMcGill University, Québec, Canada
ABSTRACT ARTICLE HISTORY

Childhood sexual abuse (CSA) is a global problem with serious Received 15 January 2020
repercussions for survivors in various domains of adult interper Revised 14 September 2020
sonal functioning, including sexual risk behavior. This review Accepted 11 December 2020
aimed to summarize findings from the recent literature on the KEYWORDS
connections between CSA and later adult sexual risk behaviors Child sexual abuse; sexual
(e.g., unprotected intercourse, sexually transmitted infection risk behavior; sexually
[STSI] diagnosis). The sexual risk behaviors consistently asso transmitted infections; HIV/
ciated with CSA were having sex under the influence of alco AIDs; review
hol/substances and reports of concurrent sexual partners/
infidelity. Notably, studies investigating the links between CSA
and history of STI diagnosis and CSA and reports of unprotected
sex (with the exception of samples comprised men who have
sex with men) produced inconsistent findings. The methodolo
gical limitations of existing studies are considered and sugges
tions for future research are offered.
Childhood sexual abuse (CSA) is a worldwide problem with serious repercus

sions for the adult functioning of survivors in a variety of domains including
physical and mental health, education, employment, marital quality, parent
ing, and sexual functioning. The prevalence of CSA victimization, depending
on how abuse is defined and measured, may affect up to 36% of girls and 23%
of boys (Kloppen et al., 2016), with women being victimized two to three times
more often than men (Stoltenborgh et al., 2011). The disproportionate vulner
ability of CSA survivors to increased sexual risk behaviors and potentially to
increased risk of sexually transmitted infections and to HIV/AIDS is therefore
of crucial importance. The goal of this manuscript is to review recent research
examining the impact of CSA on adult sexual risk behavior.
CSA and sexual risk behaviors
Reviews focused on the impact of CSA on sexual risk behaviors have found
associations with earlier age at first voluntary intercourse, higher rate of
diagnosis with STIs/HIV, increased involvement in transactional sex (i.e.,
CONTACT Amy Dana Ménard admenard@uwindsor.ca Department of Psychology, University of Windsor,

Windsor, Ontario ON N9B 3P4, Canada.
Supplemental data for this paper can be accessed on the publisher’s website.
© 2021 Taylor & Francis
2 A. D. MÉNARD AND H. B. MACINTOSH
trading sex for money, drugs/alcohol, or shelter), inconsistent use of condoms,

higher number of partners or choosing risky partners, having sex under the
influence of drugs/alcohol and “compulsive” or “hypersexual” behavior
(Abajobir et al., 2017; Aaron, 2012; Arriola et al., 2005; Lloyd & Operario,
2012; Loeb et al., 2002; Metzger & Plankey, 2012; Nielsen et al., 2018; Paolucci
et al., 2001; Relf, 2001; Rooney et al., 2018); all of these associations may vary
by gender and sexual orientation.
In the largest review to date on the subject, Senn et al. (2008) summarized
the findings of 73 articles published between 1970 and 2006. For every
population group, CSA was reliably related to reporting a higher number of
sexual partners, increased involvement in sex trading, more unprotected sex
and greater incidence of STI diagnosis. In addition, female victims and mixed
samples of male/female victims of CSA were more likely to report early sexual
début, and men who have sex with men (MSM) survivors of CSA were more
likely to report positive HIV serostatus.
The current review

An updated review of the impact of CSA on adult sexual risk behavior is
required. Existing reviews have focused only specific populations (e.g., Arriola
et al., 2005; Lloyd & Operario, 2012; Metzger & Plankey, 2012), do not provide
sufficient information with regards to their methodology (e.g., Aaron, 2012),
include only a limited number of sexual risk variables (e.g., Aaron, 2012) or are
simply out of date (e.g., Arriola et al., 2005; Senn et al., 2008). The goal of this
review is to provide a comprehensive update on the recent research investigat
ing the links between history of CSA and a wide-ranging set of sexual risk
variables for male and female victims, inclusive of sexual orientation.
Methods
Searches were conducted in five databases (PsycINFO, MEDLINE, EMBASE,
Web of Science and ERIC) (Bramer et al., 2017) using combinations of the
terms used in previous reviews on the subject: “child* sex* abuse” and first
intercourse, sexual début, infidelity, number of partners, lifetime sexual part
ners, sexually transmitted infection or STI, sexually transmitted disease or
STD, sexual risk, or sexual risk behavior, sex for money, transactional sex,
compulsive/compulsivity, sex addict*, hypersexual*. Inclusion criteria for stu
dies in this review were the following: 1) English-language, 2) publication in
a peer-reviewed journal, 3) included participants who were sexually abused as
children, 4) outcome measure was some aspect of sexual risk, and 5) published
between 2007 and 2019. Given that Senn et al. (2008) published the last
comprehensive review of CSA in both male and female victims, focusing on
studies appearing 1990 and 2006, the decision was made to restrict this review
JOURNAL OF CHILD SEXUAL ABUSE 3
to more recent publications. Exclusion criteria for this review were: 1) articles
with incidental findings related to CSA (e.g., an article focused on the char
acteristics of individuals involved in transactional sex), 2) articles focused on
treatment or intervention.
All titles and abstracts were reviewed (n = 844) and a smaller subset of
records was selected for further reading (n = 115). Relevant articles were read
and summarized, and relevant data were extracted; after reading, 74 were
retained for inclusion in the review. The reference lists of relevant articles
were searched, and further articles were added (n = 8), for a total of 82 studies
(see Table 1).
Results
Younger age at sexual début
The impact of CSA on age of sexual début appears to vary by sex, with a more
consistent connection observed for men than for women. [Note: Age at first
voluntary sexual activity is commonly referred to as “sexual début” in this
research area.] Some studies have found a positive correlation between CSA
and early sexual début with samples of women (Lin et al., 2011; Stroebel et al.,
2012; Wilson & Widom, 2008) but others have shown no significant difference
(Brown et al., 2017; Pahl et al., 2019; Schacht et al., 2010). Studies with samples
of heterosexual men tend to show an association between CSA and younger
age at first voluntary intercourse (Brown et al., 2017; Schraufnagel et al., 2010;
Wilson & Widom, 2008), a connection that may depend on the relationship
with the perpetrator (O’Keefe et al., 2014). One study involving a mixed
sample of men and women found that CSA survivors were more likely to
engage in first consensual intercourse before 14 (Tang et al., 2018).
Higher number of partners
The results of studies investigating the connection between history of CSA and
higher number of recent and/or lifetime sexual partners show a consistent
connection for heterosexual men but inconsistent findings for heterosexual
women and for MSM samples. A positive correlation between CSA history and
number of recent/lifetime sexual partners has been observed for heterosexual
women in some studies (Littleton et al., 2014; Luo et al., 2008; Pahl et al., 2019;
Senn & Carey, 2010; Senn et al., 2011; Stroebel et al., 2012) but not others
(Dodd & Littleton, 2017; Peltzer et al., 2013; Schacht et al., 2010; Scheidell
et al., 2017; Stroebel et al., 2013; Wilson & Widom, 2008). This relationship
may be mediated by cognitive schemas (Niehaus et al., 2010; Roemmele &
Messman-Moore, 2011) or higher levels of traumatic sexualization and sex
guilt (Senn et al., 2012). The results from a longitudinal investigation (London
et al., 2017) suggests that CSA survivors may report a higher number of recent
partners when they are younger; another longitudinal investigation found that
number of partners decreased over time for female CSA survivors but
increased for male CSA survivors (Van Roode et al., 2009). For heterosexual
men, several studies have shown that CSA history is associated with a higher
number of lifetime/recent partners in most investigations (Artime & Peterson,
2012; Holmes, 2008; London et al., 2017; Luo et al., 2008; Scheidell et al., 2017;
Schraufnagel et al., 2010) though not all (Peltzer et al., 2013; Wilson & Widom,
2008). Mediators may include alcohol use (Schraufnagel et al., 2010) or use of
emotion regulation strategies (Artime & Peterson, 2012), and the relationship
may depend on participant age (Van Roode et al., 2009) or relationship with
perpetrator (O’Keefe et al., 2014). Studies with mixed samples of men and
women have tended to find a positive association between history of CSA and
higher number of sexual partners (Markowitz et al., 2011; Peltzer & Pengpid,
2016; Senn et al., 2007; Tang et al., 2018). Investigations with MSM partici
pants also tend to show a positive correlation between CSA and higher
number of partners (Heusser & Elkonin, 2014; Levine et al., 2018; Tomori
et al., 2016) that may depend on the type of contact (e.g., touch vs. penetration)
(Boroughs et al., 2015) or characteristics of the abuse (J. K. Williams et al.,
2015).
Higher rates of infidelity/concurrent partners
Regardless of the population sample, most studies seem to demonstrate

a connection between history of CSA and reports of infidelity/concurrent
sexual partners. Studies showed a positive correlation between CSA and
concurrent sexual partners for heterosexual women (Frías et al., 2014; Lin
et al., 2011; NIMH Multisite, 2010; Pahl et al., 2019; Stroebel et al., 2012, 2013;
Vaillancourt-Morel et al., 2015a; Yahaya et al., 2015) and for heterosexual men
(Luo et al., 2008; O’Keefe et al., 2014); this relationship may be mediated by
substance/alcohol/tobacco usage (Icard et al., 2014; Yahaya et al., 2015), sexual
compulsivity (Vaillancourt-Morel et al., 2015a) or avoidance (women only)
(Frías et al., 2014). A study of mixed male and female participants found
a positive association between CSA history and concurrent sexual partnerships
that was both direct and mediated by meth use (Meade et al., 2012).
Higher rates of sex under the influence of drugs or alcohol

Investigations looking at history of CSA and reporting sex under the influence
of drugs or alcohol have tended to show a positive association. Several studies
with heterosexual women have shown a positive relationship between CSA
history and having sex under the influence (Engstrom et al., 2016; Lin et al.,
2011; Littleton et al., 2014). There has been little research on this relationship
in samples of heterosexual men (Holmes, 2008) or mixed samples of men and

women (Peltzer & Pengpid, 2016) but existing studies tend to show a positive
association. For studies involving MSM, CSA survivors were more likely to
report the occurrence of sex under the influence of drugs/alcohol over and
above any association in non-trauma participants (Arreola et al., 2009;
Heusser & Elkonin, 2014; Holmes, 2008; Welles et al., 2009).
Increased likelihood of current/lifetime STI/HIV
Studies investigating the connection between CSA history and either current
or lifetime diagnosis of an STI have produced inconsistent findings for each
population group; a number of mediators and moderators of this association
have been identified. Several studies have found an association between CSA
history and recent/lifetime diagnosis of STI in samples of heterosexual women
(Fix et al., 2019; Haydon et al., 2011; Houston et al., 2013; Luo et al., 2008;
Mosack et al., 2010; NIMH Multisite HIV/STD Prevention Trial for African
American Couples Group, 2010; Olley, 2008; Sutherland, 2011; Sweet et al.,
2013; Sweet & Welles, 2012; Van Roode et al., 2009; C. Williams et al., 2010;
Wilson & Widom, 2009; Yahaya et al., 2015), which may be mediated by
mental health issues (e.g., depression, PTSD or BPD symptoms) (Fix et al.,
2019; Houston et al., 2013; Sutherland, 2011; Sweet et al., 2013), intimate
partner sexual coercion (Sutherland, 2011), substance use (Fix et al., 2019;
Yahaya et al., 2015) or sexual risk behavior (Fix et al., 2019). Other studies have
found no association (Brown et al., 2017; Peltzer et al., 2013; Scheidell et al.,
2017; Wilson & Widom, 2008).
Some research has shown a positive connection between CSA history and
STI diagnosis in heterosexual men (Artime & Peterson, 2012; NIMH Multisite,
2010; Olley, 2008;) that may be mediated by mental health issues (e.g., depres
sion, PTSD) (Brown et al., 2017; Fix et al., 2019), substance use (Brown et al.,
2017; Fix et al., 2019; Sweet et al., 2013) or intimate partner violence [IPV]
perpetration and early sexual début (Brown et al., 2017). The association
between CSA and STI diagnosis in adulthood may also depend on participant
age (Van Roode et al., 2009), characteristics of the abuse (Sweet et al., 2013;
Sweet & Welles, 2012), or self-defining as a victim (Holmes, 2008). Other
research has shown no association (Haydon et al., 2011; Luo et al., 2008;
Peltzer et al., 2013; Scheidell et al., 2017; Wilson & Widom, 2008, 2009).
Studies with mixed samples of men and women have sometimes shown
a correlation between CSA history and STI diagnosis (Latack et al., 2015;
Meade et al., 2012; Peltzer & Pengpid, 2016; Tang et al., 2018) that may be
mediated by meth use (Meade et al., 2012) or symptoms of mental health
issues (Latack et al., 2015) and may also depend on the type of abuse (Senn
et al., 2007). A couple of studies have found no association (Haydon et al.,
2011; London et al., 2017).
6
Table 1. Details of studies reviewed including sample characteristics, CSA prevalence, study design, CSA definition and main findings.
Study design and
Prevalence of assessment
Citation Sample characteristics CSA method CSA definition Main findings on CSA
Ahrens et al. N = 732 men and women 27% contact CSA Longitudinal Victim age unclear, genital contact or + association with transactional sex (women only)
(2012) Adolescents aging out of foster 18% Interviews and penetration
care penetrative CASI
CSA
Arreola et al. N = 912 men 15.8% Cross-sectional Victim<16, no details on sex acts, + association with recent unprotected intercourse
(2009) MSM recruited from social venues Interviews perpetrator 5 years older and
against victim’s will
Artime & N = 320 men 54% Cross-sectional CTQ score + association with lifetime number of partners
Peterson Recruited from urban STI clinics Questionnaires + association with recent and lifetime STI diagnosis
(2012) No association with lifetime unprotected
A. D. MÉNARD AND H. B. MACINTOSH
intercourse
Blain et al. N = 182 men 39% self-defined, Cross sectional Victim<18 + association with score on measure of sexual
(2012) MSM self-reporting difficulty 55% met Interview and compulsivity
controlling their sexual behaviors criteria questionnaires No association with recent number of partners
according to
questionnaire
Boroughs et al. N = 162 men 100% Cross-sectional Victim<12, unwanted sexual contact, CSA with penetration associated with unprotected
(2015) MSM reporting history of CSA and Computer- perpetrator at least 5 years older OR anal intercourse and with a higher number of
inconsistent condom use assisted Victim 13–16, sexual contact, casual sexual partners. CSA by family member
questionnaires perpetrator at least 10 years older or associated with higher risk of STI. CSA with intense
threat of force or harm fear, CSA with physical injury and first CSA in
adolescence not associated with any sexual risk
behaviors.
Brennan et al. N = 936 men 15.5% Cross sectional Child or adolescent, forced and + association with lifetime STI diagnosis
(2007) MSM recruited from pride festivals Questionnaires unwanted sexual activity + association with transactional sex
No association with recent unprotected intercourse
Brown et al. N = 34,391 men and women Not reported Cross sectional Victim<18, sexual touch or penetration + association with lifetime HIV/STI diagnosis (men
(2017) Data from the National Interviews only)
Epidemiologic Survey on Alcohol + association with early sexual début (men only)
and Related Conditions-III
(Continued)
Table 1. (Continued).
Study design and
Catania et al. N = 1,078 men 22–32% Cross sectional Victim<18, unwanted sexual + association with unprotected intercourse
(2008) Data from Urban Men’s Health Questionnaires experiences, use of fear or coercion.
Study III
Cohen et al. N = 214 women 40.2% Cross sectional Victim<14, any sexual contact that was + association with recent unprotected intercourse for
(2009) Enrolled in methadone treatment Interviews and unwanted or against the women reporting stimulant use
program CASI participant’s will, perpetrator was -association with recent unprotected intercourse
an adult for women reporting opiate use
Dodd & N = 646 women 19.7% Cross sectional Victim<14, unwanted sexual No association with recent number of partners
Littleton Low-income women recruited Questionnaires experience, perpetrator was either
(2017) from ob-gyn waiting room relative or older individual/person in
position of authority
Engstrom et al. N = 390 women 55.8% Cross sectional Victim<16, touching, exposure or + association with recent sex under the influence of
(2016) Enrolled in methadone treatment Interviews penetration (with or without force), alcohol/drugs
program perpetrator 5+ years older or No association with recent unprotected intercourse
a relative
Estévez et al. N = 182 women 100% Cross sectional Childhood trauma questionnaire score No association with scores on measure of sexual
(2019) Recruited from associations for Questionnaires impulsivity
victims of CSA
Fix et al. (2019) N = 4,181 men and women 19.8% (women), Cross sectional Victim<18, touched in a sexual way or + association with recent STI diagnosis
Data from the National 8.7% (men) data from forced to engage in sexual activity,
Longitudinal Study of longitudinal perpetrator was parent or caregiver
Adolescent Health (Add Health) survey
Interviews
Frías et al. N = 807 women 14.4% Cross sectional Dichotomous question about + association with extra-dyadic involvement
(2014) Primarily college or university Questionnaires experiencing sexual abuse in
students childhood or adolescence
George et al. N = 436 women 30% Cross-sectional Victim<14, any form of sexual contact, No direct association with intentions to engage in
(2014) Recruited from urban community Experimental perpetrator 3+ years older or risky sex in hypothetical scenario
paradigm perpetrator 1–2+ years under

specific conditions
(Continued)
7
8
Study design and
Griffee et al. N = 1,502 women 19.1% Cross sectional Victim<17, non-contact, contact or + association with scores on measure of sexual
(2012) College students CASI penetration, perpetrator could not compulsivity
be father + association with scores on composite measure of
sexual risk behavior
Gwandure N = 80 men and women 50% Cross sectional Victim<14 + association with scores on composite measure of
(2007) Recruited from community Questionnaires sexual risk behavior
Haydon et al. N = 8,922 men and women 7% of women, Cross sectional Victim<18, sexual touch or sexual + association with STI diagnosis (women only)
(2011) Data from the National 2% of men data from relations, perpetrator was parent or
Longitudinal Study of longitudinal other adult caregiver
Adolescent Health (Add Health) survey
Interviews
Hequembourg N = 634 men 15.3% Cross sectional Victim<14, forced or frightened into No association with lifetime diagnosis of STIs/HIV
et al. (2011) MSM recruited from LGBT event Questionnaires doing something sexual + association with score on sexual compulsivity
participants measure
No association with recent sex under the influence
of alcohol/drugs
Heusser & N = 230 men 23.48% Cross sectional Victim<13, unwanted or forced sexual No association with health-protective sexual
Elkonin MSM recruited from gay and Questionnaires activity, perpetrator 5+ years older communication
(2014) bisexual social networking site No association with recent number of male
partners
+ association with recent sex under the influence
of alcohol/drugs
Holmes (2008) N = 197 men 22% Cross-sectional Victim<13 and perpetrator 5+ years + association with lifetime number of female partners
Recruited through random digit Interviews and older or +association for lifetime sex under the influence of
dialing questionnaires Victim 13–17 and perpetrator 10 drugs/alcohol
+ years older or No association with lifetime number of male
coercion occurred partners
or penetration occurred when + association with lifetime STI diagnosis
victim was <12 and perpetrator was
>12 and 2+ years older than victim
(Continued)
Study design and
Houston et al. N = 190 women 58% Cross-sectional Victim<14 + association with lifetime STI/HIV diagnosis
(2013) Single, homeless women in Interviews
New York City
Icard et al. N = 1,181 men 20.9% Cross-sectional Victim<16, sexual contact or + association with having concurrent steady and
(2014) Recruited from geographical CASI penetration casual sexual partners
clusters, public locations + association with recent unprotected sex
Labadie et al. N = 808 men and women 19.8% women, Cross-sectional Victim<16, sexual experience, + association with scores on measure of sexual
(2018) Recruited from social media, 18.8% men Questionnaires perpetrator 5+ years older or in compulsivity
university listserv a position of authority
Lacelle et al. N = 889 women 31% Longitudinal Victim<18, unwanted sexual acts by + association with scores on composite measure of
(2012a) Recruited from kindergartens Interviews, use of bribes, threats, force or sexual risk
questionnaires drugs/alcohol
and CASI
Lacelle et al. N = 889 women 31% Longitudinal Victim<18, unwanted sexual acts by + association with scores on composite measure of
(2012b) Recruited from kindergartens Interviews, use of bribes, threats, force or sexual risk
questionnaires drugs/alcohol
and CASI
Latack et al. N = 34, 653 men and women 11.1% Cross-sectional Victim<18, sexual touch or penetration + association with recent diagnosis of STI/HIV
(2015) Data from the National data from
Epidemiologic Survey on Alcohol longitudinal
and Related Conditions (NESARC) survey
Interviews
Levine et al. N = 176 men 22.16% Cross-sectional Victim<17, forced or coerced sexual + association with recent number of male partners
(2018) MSM recruited from social media, Interviews activity + association with recent unprotected intercourse
community-based organizations
Lin et al. (2011) N = 478 women 16.7% Cross-sectional Victim<16, physical and nonphysical + association with early sexual debut
Rural-to-urban migrant women in Questionnaires contact + association with concurrent sexual partners
Beijing, China + association with having sex under the influence
of alcohol
(Continued)
9
10
Study design and
Littleton et al. N = 1,616 women 13.6% Cross-sectional Victim<14, any sexual contact, + association with recent number of partners
(2014) College students Questionnaires perpetrator was relative or person in + association with having recent sex under the
position of authority influence of alcohol/drugs
London et al. N = 12,288 men and women 8% Longitudinal No victim age, sexual touch, + association with concurrent sexual partnerships for
(2017) Data from The National Interviews perpetrator was a caregiver men and women (ages 18–26), men only (ages
Longitudinal Study of Adolescent 24–32)
to Adult Health + association with transactional sex in young
adulthood
No association with STI diagnosis
Luo et al. N = 2,994 men and women 3.3% women, Cross-sectional Victim<14, “sexual contact”, defined as +association with lifetime STI diagnosis (women only)
(2008) National stratified probability 5.1% men Interviews and vaginal intercourse or contact with +association with recent number of partners
sample CASI breasts/genitals +association with concurrent sexual partners (men

only)
Markowitz N = 119 men and women 47.1% Cross-sectional Victim<12, “sexual experiences”, +association with recent number of partners
et al. (2011) Recruited from methadone/ Questionnaires perpetrator 5+ years older or victim +association with recent unprotected intercourse
substance abuse treatment 13–17 and perpetrator 10+ years
centers, HIV clinics older
Masters et al. N = 436 women 32.1% Cross-sectional Victim<14, any sexual contact, -association with intentions to engage in unprotected
(2014) Recruited online and with print Experimental perpetrator 3+ years older or sex in hypothetical scenario
advertisements paradigm perpetrator 1–2 years older and use
of coercion, force or threats
Mattera et al. N = 148 men 22% Cross-sectional Victim<13, sexual contact, perpetrator +association with recent unprotected intercourse
(2018) Bisexual Latino men recruited Interviews 4+ years older No association with lifetime STI diagnosis
from neutral organizations,
“sexual” venues, bisexually-
oriented venues and clinical sites
Meade et al. N = 3,328 men and women 9.4% women, Cross-sectional No victim age, any sexual contact with + association with recent unprotected sexual
(2012) Recruited from outside local 9.2% men Interviews force intercourse
drinking establishments + association with concurrent sexual partners
+ association with transactional sex
+ association with recent STI diagnosis
(Continued)
Study design and
Meyer et al. N = 812 men and women 16% Cross-sectional Victim<18, self-defined as sexually +association with scores on measure of sexual
(2017) Recruited from local universities, Questionnaires abused compulsivity
university counseling centers, and
community organizations
Mimiaga et al. N = 4,295 men 39.7% Cross-sectional Victim<13, “a sexual experience” and -association with self-efficacy for adopting safer
(2009) Data from a large-scale data from perpetrator 5+ years older or victim sexual behaviors
randomized longitudinal 13–17 and perpetrator 10+ years - association with
HIV prevention trial among MSM study older communication skills regarding safer sex
conducted in 6 US cities, CASI + association with recent unprotected intercourse
+ association with lifetime STI diagnosis
Morokoff et al. N = 473 men and women 62% men, 67% Cross-sectional Victim<14, a sexual experience with an + association with recent unprotected intercourse
(2009) Recruited from substance abuse women data from “older person”
treatment facilities longitudinal
study
Questionnaires
and CASI
Mosack et al. N = 388 women 40.5% Cross-sectional Victim<16, sexual abuse or rape + association with recent unprotected intercourse
(2010) Recruited using street outreach CASI + association with lifetime STIs
near public housing and known No association with transactional sex
drug and sex exchange sites No association with having recent sex under the
influence of drugs/alcohol
Niehaus et al. N = 1,150 women 20.7% Cross-sectional Victim<14, contact or non-contact + association with lifetime number of sexual partners
(2010) College students Questionnaires abuse with force/coercion
NIMH Multisite N = 1,070 men and women 63.6% women, Cross-sectional Victim<18, sexual incidents, + association with unprotected intercourse
(2010) Baseline data from randomized 26.5% men CASI perpetrator was 5+ years older or + association with concurrent sexual partners
controlled intervention trial of HIV >18 or there was use of force/ + association with STI diagnosis
serodiscordant African-American coercion + association with transactional sex
couples from four U.S. cities

(Continued)
11
12
Study design and
O’Keefe et al. N = 1,178 men 12.4% (sister- Cross-sectional Victim<18, perpetrator was adult + association with concurrent partners
(2014) College students brother incest CASI female or sister + association with scores on measure of sexual
and abuse by compulsivity
older female) + association with scores on composite measure of
sexual risk behavior
+ association with lifetime number of sexual
partners
+ association with early age of sexual debut
Olley (2008) N = 583 men and women 55% Cross-sectional Victim<15, sexual intercourse with + association with recent diagnosis of STI
College students Questionnaires force or persuasion + association with recent unprotected intercourse
Pahl et al. N = 343 women Not reported Cross-sectional Not reported + association with lifetime number of partners
(2019) Women in their thirties who data from No association with early sexual debut
identify as Black or Latina longitudinal No association with recent unprotected intercourse
study + association with concurrent sexual partners
Questionnaires + association with score on composite measure of
sexual risk
Parcesepe N = 222 women 55% Cross-sectional No victim age, sexual contact or + association with recent unprotected sex
et al. (2015) Alcohol-using women engaged in CASI penetration, perpetrator 5+ years
sex work in Mongolia older
Peltzer & N = 18,404 men and women 2.6% Cross-sectional Self-defined dichotomously + association with recent number of sexual partners
Pengpid College students Questionnaires + association with recent sex under the influence
(2016) of alcohol/drugs
Peltzer et al. N = 824 men and women 3.8% men, 5.6% Cross-sectional Self-defined dichotomously No association with recent number of sexual partners
(2013) College students women Questionnaires No association with recent unprotected sexual
intercourse
No association with lifetime STI diagnosis
Peterson et al. N = 377 men 52.3% Cross-sectional Score on Childhood trauma + association with score on composite measure of
(2018) Recruited from urban STI clinics Questionnaires questionnaire sexual risk behavior
(Continued)
Study design and
Plotzker et al. N = 113 women 56% Cross-sectional Victim<14, contact, non-contact or + association with score on composite measure of
(2007) Recruited from safe injection sites Questionnaires penetration, perpetrator 18+ sexual risk behavior
Roemmele & N = 653 women 6.0% Cross-sectional Victim<14, sexual contact or + association with score on composite measure of
Messman- College students Questionnaires intercourse, perpetrator 5+ years sexual risk behavior
Moore older or a family member + association with lifetime number of sexual
(2011) partners
Schacht et al. N = 64 women 13% Cross-sectional Victim<14, sexual contact or + association with intentions to engage in
(2010) Recruited from urban community Experimental penetration, perpetrator was 5 unprotected sex in hypothetical scenario
and university paradigm + years older No association with early sexual debut
No association with lifetime number of sexual
partners
Scheidell et al. N = 11,820 men and women 9.8% of women, Cross sectional Victim<18, touched in a sexual way or + association with lifetime number of sexual partners
(2017) Data from National Longitudinal 6.7% of men data from forced to engage in sexual activity, (men only)
Study of Adolescent to Adult longitudinal perpetrator was parent or caregiver + association with transactional sex (men only)
Health survey No association with lifetime STI diagnosis
Interviews
Schraufnagel N = 280 men 20% Cross sectional Victim<14, sexual activities, No association with recent unprotected intercourse
et al. (2010) Recruited from the community Questionnaires perpetrator 5+ years older + association with lifetime number of sexual
partners
+ association with early sexual debut
Senn & Carey N = 414 women 31% Cross sectional Victim<12, oral, anal or vaginal sex, + association with lifetime number of partners
(2010) Recruited from publicly-funded CASI perpetrator 5+ years older or + association with recent unprotected intercourse
STD clinic victim<16 and perpetrator 10+ or
use of threat or force
Senn et al. N = 481 women 43% Cross sectional Victim<12, oral, anal or vaginal sex, + association with lifetime number of partners
(2011) Recruited from publicly-funded Interview, perpetrator 5+ years older or + association with recent unprotected intercourse
STD clinic questionnaires, victim<16 and perpetrator 10+/use + association with transactional sex
CASI of threat or force

(Continued)
13
14
Study design and
Senn et al. N = 481 women 45% Cross sectional Victim<12, oral, anal or vaginal sex, + association with recent unprotected intercourse
(2012) Recruited from publicly-funded CASI perpetrator 5+ years older or No association with recent number of partners
STD clinic victim<16 and perpetrator 10+/use -association with positive attitudes toward
of threat or force condoms
+ association with HIV knowledge and condom
application skills
Senn et al. N = 1,265 men and women 65% of men, 66% Cross sectional Victim<12, oral, anal or vaginal sex, + association with recent unprotected sex
(2007) Recruited from publicly-funded of women CASI perpetrator 5+ years older or + association with lifetime and recent number of
STD clinic victim<16 and perpetrator 10+/use partners
of threat or force + association with transactional sex
+ association with lifetime STI diagnoses

Sikkema et al. N = 256 men and women 100% Cross sectional Victim<12 or 13–17, sexual touching, For women only, behavioral difficulties and crack/
(2009) Women and MSM recruited from Questionnaires perpetrator was 5+ years older or an cocaine usage were associated with
community organizations, all HIV adult unprotected sex.
+ For men only, marijuana use, less spiritual coping
and behavioral difficulties
were associated with unprotected sex.
For men and women, marijuana use, greater
impact of HIV-related shame on behavior, and less
use of active coping were associated with high
sexual transmission risk behavior.
Stappenbeck N = 436 women 32.3% Cross sectional Victim< 14, sexual contact, perpetrator + association with unprotected sex intentions
et al. (2016) Recruited from online and print Experimental 3+ years older or perpetrator
advertisements paradigm 1–2 years older and use of coercion,
threats or force
Stroebel et al. N = 1,521 women 17.1% (father- Cross sectional Not reported + association with transactional sex
(2012) College students daughter CASI + association with infidelity
incest and CSA + association early sexual debut
by other adult + association with lifetime number of sexual
male) partners
(Continued)
Study design and
Stroebel et al. N = 1,521 women 2.6% (sister-sister Cross sectional Victim<18, contact, non-contact or + association with transactional sex
(2013) College students incest and CSA CASI penetration, perp was sister or adult + association with infidelity
by other adult woman No association with lifetime number of sexual
female) partners
Sutherland N = 197 women 46% Cross sectional Victim<16, any sexual act, perpetrator + association with lifetime STI diagnosis
(2011) Recruited from healthcare sites Questionnaires 5+ years older
and provider referrals
Sweet & Welles N = 34,653 men and women 14.9% of women, Cross sectional Victim<18, unwanted sexual touch or + association with recent STI diagnosis
(2012) Data from the 5.2% of men data from intercourse
National Epidemiologic Survey on longitudinal
Alcohol and Related Conditions survey
CASI
Sweet et al. N = 33,902 men and women Not reported Cross sectional Victim<18, unwanted sexual touch or + association with recent STI diagnosis
(2013) Data from the National data from intercourse
Epidemiologic Survey on Alcohol longitudinal
and Related Conditions survey
CASI
Tang et al. N = 17,966 men and women 27.5% Cross sectional Victim<18, sexual harassment, sexual+ association with recent unprotected sex
(2018) College students Questionnaires touch or intercourse + association with early sexual debut
+ association with lifetime number of partners
+ association with recent STI diagnosis
Tomori et al. N = 11,788 men 22.4% Cross sectional Victim<16, unwanted sexual touching + association with transactional sex
(2016) MSM recruited via respondent Interviews or intercourse + association with recent unprotected sex
driven sampling + association with lifetime number of partners
Vaillancourt- N = 699 men and women 20.0% of women, Cross sectional Victim<16, sexual experience, + association with infidelity
Morel et al. Recruited from the community 18.9% of men Questionnaires perpetrator 5+ years older or in + association with score on measure of sexual
(2015a) and online a position of authority compulsivity
Vaillancourt- N = 686 men and women 20% of women, Cross sectional Victim<16, sexual experience, + association with scores on a measure of sexual
Morel et al. Recruited from the community 19% of men Questionnaires perpetrator 5+ years older or in compulsivity
(2015b) and online a position of authority
(Continued)
15
16
Study design and
Vaillancourt- N = 1,021 men and women 21.3% of women, Cross sectional Victim<16, sexual experience, + association with scores on a measure of sexual
Morel et al. Recruited from the community 19.6% of men Questionnaires perpetrator 5+ years older or in compulsivity
(2016a) and online a position of authority
Vaillancourt- N = 1,033 men and women 21.4% of women, Cross sectional Victim<16, sexual experience, + association with scores on a measure of sexual
Morel et al. Recruited from the community 21.6% of men Questionnaires perpetrator 5+ years older or in compulsivity
(2016b) and online a position of authority
Van Roode N = 936 men and women 30.3% of women, Longitudinal Victim<16, unwanted sexual activities + association with number of partners
et al. (2009) Data from the Dunedin 9.1% of men CASI + association with diagnosis of STIs
Multidisciplinary Health and
Development Study,
Walsh et al. N = 1,169 men and women 32% Cross sectional Cutoff score of 6 on Child Trauma + association with score on composite measure of
(2014) College students Questionnaires Questionnaire sexual risk

Watson et al. N = 556 women Not reported Cross sectional Cutoff score of 6 on Child Trauma + association with score on composite measure of
(2013) College students Questionnaires Questionnaire sexual risk
No association with contraceptive self-efficacy
Weiss et al. N = 212 women 33.6% Cross sectional Child Trauma Questionnaire, cutoff not + association with score on composite measure of
(2019) Women reporting recent intimate CASI specified sexual risk
partner violence
Welles et al. N = 593 men 47% Baseline data from Victim was child or adolescent, + association with score on measure of sexual
(2009) HIV-positive MSM intervention unwanted sexual activities with compulsivity
study older man or woman + association with having recent sex under the
influence of alcohol/drugs
+ association with recent unprotected intercourse
J. K. Williams N = 1,522 men 30% Cross sectional Victim <12, sexual touching or -association with recent unprotected intercourse
et al. (2015) Black MSM recruited from Interview and intercourse and perpetrator 5 + association with number of recent partners
community outreach, medical CASI + years older or victim 12–16,
clinics, unwanted sex and perpetrator 5
provider referrals, + years older
C. Williams N = 309 women 35.3% Cross sectional Victim<18, sexual intercourse with + association with lifetime and recent STI diagnosis
et al. (2010) Recruited from health care Interviews force No association with recent unprotected sex
settings
(Continued)
Study design and
Wilson & N = 1,196 men and women Not reported Longitudinal Victim<12, sexual touching or + association with early sexual debut
Widom Cases of sexual abuse processed (case-matched Interviews intercourse + association with transactional sex (women only)
(2008) in the juvenile or criminal courts prospective No association with lifetime STI diagnosis
of a metropolitan area cohort study) No association with recent number of partners
Wilson & N = 754 men and women 7.4% Longitudinal Victim<12, sexual touching or + association with lifetime STI diagnosis (women
Widom Cases of sexual abuse processed Interviews intercourse only)
(2009) in the juvenile or criminal courts
of a metropolitan area
Yahaya et al. N = 12,800 women 1.7% Cross sectional Victim<18, sexual intercourse or other + association with recent STI diagnosis
(2015) Data from the 2008 Nigerian Interviews sexual acts with force + association with concurrent sexual partners
Demographic and Health Survey + association with recent unprotected sex
(DHS)
17
For MSM samples, some studies have shown that CSA history predicts STI
diagnosis in adulthood (Brennan et al., 2007; Mimiaga et al., 2009; Tomori
et al., 2016) though not all (Hequembourg et al., 2011; Mattera et al., 2018);
this may depend on characteristics of the abuse (Boroughs et al., 2015; Sweet
et al., 2013; Sweet & Welles, 2012).
Decreased condom use/unprotected sex
Studies on condom use/episodes of unprotected sex and CSA history show

inconsistent results for women, heterosexual men and mixed samples; how
ever, there seems to be a clear positive association for MSM samples. Studies
have demonstrated that heterosexual women reporting a history of CSA were
less likely to use condoms consistently (Mosack et al., 2010; NIMH Multisite,
2010; Olley, 2008; Senn & Carey, 2010; Senn et al., 2012), a relationship that
may be mediated by alcohol and drug use (Sikkema et al., 2009; Yahaya et al.,
2015), attitudes and beliefs (Morokoff et al., 2009; Senn et al., 2012), and
involvement in sex trade or having sex under the influence (Mosack et al.,
2010). This association may also depend on characteristics of drug use (Cohen
et al., 2009) or type of sexual partner (Parcesepe et al., 2015). However, other
studies have found no association between CSA and condom use for samples
of women (Engstrom et al., 2016; Lin et al., 2011; Pahl et al., 2019; Peltzer et al.,
2013; C. Williams et al., 2010).
In general, research involving heterosexual men has tended to be mixed in
regard to findings on CSA and reports of unprotected sex with some investi
gations showing a positive association (Icard et al., 2014; Olley, 2008)
mediated by type of sexual partner (Icard et al., 2014) or revictimization,
sexual assertiveness and depression (Morokoff et al., 2009). However, other
studies have found no association between CSA and unprotected intercourse
for heterosexual men (Artime & Peterson, 2012; Peltzer et al., 2013;
Schraufnagel et al., 2010). For studies with mixed samples, a few studies
found that CSA history predicted inconsistent condom use (Markowitz
et al., 2011; Senn et al., 2007; Tang et al., 2018), a relationship that may be
mediated by meth use (Meade et al., 2012) or marijuana use, HIV-related
shame and decreased use of active coping strategies (Sikkema et al., 2009).
Another study found no association (Peltzer & Pengpid, 2016).
In studies with MSM, result has often shown a positive association between
CSA history and inconsistent condom usage (Catania et al., 2008; Levine et al.,
2018; Mattera et al., 2018; Tomori et al., 2016), though this relationship may
depend on characteristics of the abuse (Boroughs et al., 2015; Welles et al.,
2009), type of sexual activity (Mattera et al., 2018) and type of sexual partner
(Catania et al., 2008). Mediators of the relationship may include drug use
(Mimiaga et al., 2009; Sikkema et al., 2009), safer sex attitudes, and commu
nication skills (Mimiaga et al., 2009), psychological distress (Arreola et al.,
2009) and coping (Sikkema et al., 2009). However, one study found no
association between CSA and unsafe sex (Brennan et al., 2007) and another
found that CSA history reduced odds of unprotected anal sex (J. K. Williams
et al., 2015).
Increased sexual compulsivity
Studies examining the relationship between scores on measures of sexual

compulsivity and CSA history have tended to show a consistent association
across all samples. Positive correlations have been observed in samples of
heterosexual women (Griffee et al., 2012; Meyer et al., 2017; Vaillancourt-
Morel et al., 2015a), heterosexual men (Icard et al., 2014; Meyer et al., 2017;
O’Keefe et al., 2014; Vaillancourt-Morel et al., 2015a) and MSM samples (Blain
et al., 2012; Hequembourg et al., 2011; Welles et al., 2009). For studies
involving mixed samples of men and women, the correlation depended on
victim self-definition (Vaillancourt-Morel et al., 2016a), victims’ marital status
(Vaillancourt-Morel et al., 2016b) and attachment style (Labadie et al., 2018).
Increased involvement in sex trade/transactional sex

Studies examining the association between CSA history and involvement in
transactional sex have tended to find positive associations for women, mixed
samples, and MSM but inconsistent results for samples of heterosexual men.
Many studies have found that women with a history of CSA are more likely to
be involved in sex trading (Ahrens et al., 2012; Senn et al., 2011; Stroebel et al.,
2012; Wilson & Widom, 2008), depending on participant age (London et al.,
2017; Scheidell et al., 2017) and on type of abuse (Stroebel et al., 2013). For
heterosexual men, some studies have shown an association between CSA
history and involvement in sex trade (Scheidell et al., 2017), depending on
participant age (London et al., 2017), but others have demonstrated no
association (Ahrens et al., 2012; Wilson & Widom, 2008). Research has
generally shown a positive connection between CSA history and involvement
in transactional sex for mixed samples (Ahrens et al., 2012; Meade et al., 2012;
NIMH multisite, 2010; Senn et al., 2007) and for MSM samples (Brennan et al.,
2007; Tomori et al., 2016).
Discussion
Findings on the relationship between CSA and adult sexual risk behavior were
mixed and varied significantly across population samples. For all samples, the
adult sexual risk behaviors most consistently associated with CSA were having
sex under the influence of alcohol or substances and reports of concurrent
sexual partners/infidelity. CSA history was also associated with greater
involvement in transactional sex (heterosexual women, MSM), higher number

of sexual partners (heterosexual men), early sexual début (heterosexual men
and women) and reports of unprotected intercourse (MSM). Notably, studies
investigating the association of CSA with STI diagnosis or unprotected sex
(with the exception of MSM samples) produced inconsistent findings. The
results of this review are discrepant from those of previous reviews and meta-
analyses (e.g., Abajobir et al., 2017; Aaron, 2012; Arriola et al., 2005; Lloyd &
Operario, 2012; Loeb et al., 2002; Metzger & Plankey, 2012; Paolucci et al.,
2001; Relf, 2001; Senn et al., 2008). For example, while many previous reviews
have identified an association between CSA history and higher number of
sexual partners for heterosexual women (e.g., Arriola et al., 2005; Loeb et al.,
2002; Senn et al., 2008), findings in this area were inconsistent in the current
review.
Given the similarities between the methodology employed for this review and
those of previous reviews, there appear to be two main explanations for the
discrepancies observed: 1) the findings reviewed here reflect real social changes
in sexual behavior that have occurred in the last decade (i.e., decreases in unpro
tected sex, decreases in number of sexual partners), and/or 2) methodological
issues in the design of studies related to CSA and sexual risk behavior have
produced inconsistent findings. It seems unlikely that worldwide public health
initiatives (e.g., Burns et al., 2016; Widman et al., 2018) would disproportionately
affect the sexual risk behaviors of CSA survivors, nor have most of these inter
ventions been designed with that group in mind. There is also no evidence to
suggest that interventions created to address mediators of sexual risk behavior
factors have been successful on a wider scale (e.g., treatments for depression,
alcohol/substance use, assertiveness for safer sex) or that they would be particu
larly effective for CSA survivors. The more plausible explanation for these findings
is that serious methodological issues continue to plague this area of research.
One of the most fundamental issues that have not been resolved in this area
is how to define and conceptualize sexual “risk” as it relates to sexual health. In
this review, some researchers focused primarily on the risk variables them
selves without relating them to a particular outcome. This is problematic in so
far as authors may be implying that some sexual activities are inherently
dysfunctional (e.g., having a higher number of sexual partners, involvement
in transactional sex) without providing evidence of the deleterious conse
quences of these behaviors. Others looked at the connection of CSA to HIV,
with some distinguishing between STIs and HIV and others classifying STIs
and HIV together. Again, it is problematic to categorize curable and incurable,
one-time diagnoses and regular occurrences together, for both theoretical and
statistical reasons. If the connection to an objective, quantifiable risk is not
made, studies in this area run the risk of moralizing and judging the sexual
behavior of CSA survivors and furthering the sex-negative discourse that
characterizes this domain of inquiry.
Methodological issues related to predictor variables and study design
One of the most fundamental issues in the field, and one that has been
repeatedly noted by other reviewers (Finkelhor, 1979; Metzger & Plankey,
2012; Senn et al., 2008), is extreme inconsistency in the measurement and
definition of CSA. In this review, the definition of CSA varied widely based on
victim age (from under 12 to 18), nature of the abuse (e.g., harassment, non-
contact abuse, penetrative abuse, inclusion of force or coercion), relationship
to the perpetrator, and frequency of abuse (from one lifetime occurrence to
regular occurrence over many years). Several studies have shown different
impacts on adult functioning based on age at victimization (J. K. Williams
et al., 2015; Markowitz et al., 2011), level of contact (Boroughs et al., 2015;
Lacelle et al., 2012b), relationship with perpetrator (Engstrom et al., 2016) and
frequency of victimization (Sweet & Welles, 2012). Each of these issues is likely
to account for some of the discrepancies observed in relationships with out
come variables.
In many instances, researchers did not gather data about other experiences
of child maltreatment (e.g., child physical abuse, neglect) or failed to take this
information into account statistically. This is a significant, ongoing issue in the
field (Senn et al., 2008) given the pervasive overlap between various forms of
child maltreatment; in retrospective studies of adults, up to 40% of CSA
victims report other forms of maltreatment (Higgins & McCabe, 2001).
Compared to CSA, other types of abuse or neglect may account for more
variance and offer better explanations for adult sexual risk behavior.
The means by which CSA was measured also varied significantly between
investigations. Some studies asked participants a yes/no question as to whether
they had experienced sexual abuse as children. This approach is problematic
given that several studies have shown that individuals who do not self-define
as having been abused but who do meet legal criteria tend to show many of the
same effects as other victims (Senn et al., 2011; Vaillancourt-Morel et al.,
2016a). Other studies have used questions developed by the researchers them
selves (with insufficient details about these questions) and some used pub
lished measures but did not specify cutoff values. The means of gathering data
about experiences of CSA varied from self-report questionnaires to face-to-
face interviews to computer-assisted approaches despite research results show
ing significant differences in results based on these methods, due to a variety of
factors including stigma and recall bias (Schroder et al., 2003). Differences in
measurement are likely to result in the identification of a heterogeneous pool
of CSA survivors and therefore significant differences in scores on outcome
variables.
Studies on CSA and sexual risk behavior have often failed to appropriately
stratify findings by demographic variables (e.g., sexual orientation, sex). Given
how frequently differences are found in the literature based on survivor
demographics, it is imperative to test these associations and present subse

quent analyses on this basis. Although many studies excluded participation
from sexual minority group members (or indeed, failed to assess sexual
orientation altogether), some studies seem to have included both heterosexual
and non-heterosexual participants in their statistical analyses, potentially
clouding important differences. Very few studies have considered the mediat
ing role of participant ethnicity; however, those investigations that have
investigated the association have sometimes found differences in the connec
tions between CSA and sexual risk behavior based on ethnic groups (e.g., Fix
et al., 2019; Wilson & Widom, 2009). Future investigations in this area must
stratify results by demographic group membership and type of abuse in order
to clarify associations between CSA and sexual risk.
Methodological issues related to outcome variables

The connections between CSA and sexual risk outcome variables are often
confounded by wide variation within the categories of risk. Participants were
often asked about having sex under the influence of alcohol or substances and
classified dichotomously, where this could mean a couple of alcoholic drinks
before sex or regular use of cocaine or heroin, implying that these behaviors
were treated as equivalent in analyses. This is a concern as research has shown
that different substances incur different effects on sexual decision-making,
with some substances actually decreased risk-taking (Berry & Johnson, 2018).
STI diagnosis was also often coded dichotomously despite studies demonstrat
ing differences in relationship to CSA history based on how STI history is
categorized (Haydon et al., 2011). Research looking at CSA history and
involvement in sex trade/transactional sex has often coded this variable
dichotomously as well despite significant heterogeneity within this group,
and likely different risk profiles. Although many researchers do make clearer
distinctions within the category of unprotected sex, some investigators have
not parsed this category based on insertive and receptive behaviors or vaginal
and anal intercourse, a significant omission as the probability of contracting
HIV with each of these sex acts varies significantly, from 138/10,000 (expo
sures to receptive anal intercourse) to 4/10,000 (exposures to insertive vaginal
intercourse) (Centre for Disease Control, 2019). To further obscure the rela
tionship between CSA and sexual risk behavior, some investigators coded
exposure to sexual risk of any kind dichotomously, meaning that any engage
ment at any time during the lifespan to any of the behaviors described above
would be coded and analyzed together. Given the heterogeneity in how sexual
risk has been defined and measured in these investigations, it is perhaps
surprising that any associations have been founded with CSA.
Some of the issues pertaining to definitions and measurements of sexual risk
variables carry significant moral judgment. For example, many recent studies
still use the term “promiscuity”, implying that sexual relationships are under
taken indiscriminately or that casual sexual relationships are inherently pro
blematic. Other studies have conflated reports of multiple or concurrent sexual
partnerships with infidelity, without appearing to verify whether or not parti
cipants’ non-monogamy might be consensual and whether this might have
a differential impact on sexual risk. Cutoffs in defining sexual risk behaviors
have been chosen with no basis in empirical data; for example, reporting more
than 10 lifetime sexual partners or more than two partners in the past year.
These choices by investigators have muddied the results of research on CSA
and have also contributed to pathologization and stigmatization of survivors.
In some cases, the connection between CSA and a given sexual risk variable
seems likely to be confounded by other more salient aspects of sexual risk.
Earlier sexual debut and involvement in transactional sex may only be relevant
to sexual risk if they are associated with higher number of partners and
increased likelihood of unprotected sex. Johnson et al. (2016) found that
having sex under the influence of the alcohol was only related to decreased
likelihood of condom use when condoms were not readily available. Well-
planned mediation analyses will allow for the identification of the most salient
sexual risk variables.
Implications for clinicians and educators

Given the inconsistencies noted in the associations between CSA history and
vulnerability to sexual risk behavior, it is difficult to make consistently useful
recommendations for clinicians and educators who work with CSA survivors.
Vulnerability to sexual health risks is likely to depend on survivors’ demo
graphic characteristics (e.g., gender, sexual orientation, ethnicity), with several
longitudinal studies demonstrating change in risk behaviors over time (e.g.,
London et al., 2017; Scheidell et al., 2017; Van Roode et al., 2009). It may also
depend on characteristics of the CSA experience and the presence of other
types of child maltreatment (e.g., neglect, physical abuse), which may affect up
to 40% of CSA victims (Higgins & McCabe, 2001). In addition, it is unclear
how other well-established negative consequences of CSA (e.g., adult sexual
assault) might interact with and heighten victims’ vulnerability to issues of
sexual risk. Finally, research on mediators that may serve to decrease risk
among CSA survivors (e.g., social support, psychotherapy, sex education) has
lagged.
In the studies reviewed for this manuscript, CSA was consistently associated
with having sex under the influence of alcohol or substances and reports of
concurrent sexual partners/infidelity. For certain groups, CSA history was also
associated with greater involvement in transactional sex, higher number of
sexual partners, earlier sexual début and greater frequency of unprotected
intercourse. These findings may provide a starting point for a careful and
detailed assessment; however, the details are likely to provide a fuller picture
and a better basis for intervention. Abramovich (2005) argued that involve
ment in transactional sex is often a means by which CSA victims can leave
chaotic home environments; this contextualizes research findings that CSA
survivors are more likely to be involved in transactional sex in late adoles
cence/early adulthood but not as they get older (London et al., 2017; Scheidell
et al., 2017). The impact on sexual risk of consuming substances during sex is
likely to depend on the type of substance (Berry & Johnson, 2018) and on the
availability of condoms (Johnson et al., 2016). Reporting a higher number of
partners or concurrent sexual partners may only be problematic insofar as
participants are also reporting more unprotected sex, which is not always the
case (Ashenhurst et al., 2017). Clinicians would be advised to engage in a fine-
grained analysis of their clients’ sexual risk behaviors.
Clinicians and educators would be encouraged to keep these conflicting and
sometimes pathologizing findings in mind as they work with survivors; how
ever, they will also need to take an objective stance about the potential
connections between risk behaviors and increased likelihood of STI/HIV
contraction without moralizing or judging to avoid alienating or stigmatizing
survivors. The clinical literature on the impacts of trauma on development and
interpersonal relationships may be of greater use in guiding clinicians (e.g.,
Maltz, 2001; MacIntosh, 2019; MacIntosh & Johnson, 2008) to help survivors
address, explore and manage the underlying issues around risk. This may
include trauma responses that impede boundary-setting and appropriate sex
ual assertiveness (e.g., to say no, to ask for a condom to be used). Risk
reduction strategies may be beneficial with CSA survivors, especially those
that address sexual and ethnic minority status (Williams et al., 2008; Wyatt
et al., 2004).
Future directions
To date, researchers examining the connections between CSA and sexual risk
have omitted entire populations; some of the excluded groups include trans
gender individuals, women-who-have-sex-with-women (WSW), and older
individuals. In the vast majority of studies included in this review, the only
occasions on which the existence of trans* individuals were acknowledged was
when they were specifically excluded as participants; however, population
health data suggests that the risk of HIV is disproportionately high in this
group, especially for transgender people of color (Centre for Disease Control,
2019). WSW have often been excluded from research on sexual risk, although
studies have established that WSW may also have sex with non-female part
ners or may have a history of engaging in behaviors that could compromise
their health (Lemp et al., 1995). Few studies have looked at the impact of CSA
on the sexual risk behaviors of individuals over 40; this is a serious concern as
older individuals may be disproportionately vulnerable to contracting STIs

(Schick et al., 2010) and make up almost 20% of new HIV cases (Centre for
Disease Control, 2019). Groups that have historically been marginalized must
be included in research on CSA and sexual risk lest their omission contribute
further to their disempowerment.
Gathering data about other mediators of the relationship between CSA and
sexual risk will be an important step in the evolution of this area of research.
Improvements in medicine and pharmacology suggest that researchers should
be collecting data on the use of pre-exposure prophylaxis (PrEP), which may
relate to individuals’ sexual risk decision-making; none of the studies included in
this review explicitly asked participants if they were using PrEP. With few
exceptions (Sikkema et al., 2009), researchers have often failed to take into
account the effects of protective factors that mediate the relationship between
CSA and adult functioning. For example, the vast majority of studies do not
gather data on whether participants have sought psychotherapy for symptoms
related to childhood victimization or other important protective factors identi
fied in reviews of resilience in CSA survivors (e.g., education, active coping,
social support) (Domhardt et al., 2015). The result of this omission has been the
pathologization of victims and a sense of fatalistic inevitability for this group.
Conclusion
Previous reviews on CSA have found reliable correlations with various aspects
of adult sexual risk behavior, including STI history, involvement in transac
tional sex, higher number of sexual partners, earlier sexual début, having sex
under the influence of alcohol/substances and inconsistent use of condoms.
Despite the use of similar methodological practices, this review found incon
sistent associations with these dimensions of sexual risk that varied across the
populations sampled. Across all groups, a history of CSA appeared to be
reliably associated with having sex under the influence of alcohol/substances
and reports of concurrent sexual partners/infidelity but did not show consis
tent associations with STI history or unprotected intercourse (with the excep
tion of MSM samples). The discrepancies noted between the findings of this
review and previous reviews relate to methodological problems that have
plagued this area of research. Future studies must include different demo
graphic groups, a standardized definition of CSA and gold-standard assess
ment techniques, clearly defined and non-judgmental outcome variables and
appropriate mediation analyses.
Disclosure of Interest
The authors disclose no conflict of interest.
Notes on contributors
Amy Dana Ménard is a clinical psychologist and assistant professor in the department of
psychology at the University of Windsor. She is coauthor of “Magnificent sex: Lessons from
extraordinary lovers” by Rutledge, winner of the 2021 consumer book award from the Society
for Sex Therapy and Research.
Heather Beth MacIntosh Ph.D.is a clinical psychologist and Associate Professor in the MScA
Couple and Family Therapy Programme at McGill University where she is the recipient of the
H. Noel Fieldhouse Award for Distinguished Teaching. She is the author of the recently
released book: Developmental Couple Therapy for Complex Trauma a Manual for
Therapists by Routledge Press.
ORCID
Amy Dana Ménard http://orcid.org/0000-0002-3503-5559
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Journal of Child Sexual Abuse

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wcsa20

Childhood Sexual Abuse and Adult Sexual Risk

Amy Dana Ménard & Heather Beth MacIntosh

To link to this article: https://doi.org/10.1080/10538712.2020.1869878

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Childhood Sexual Abuse and Adult Sexual Risk Behavior: A

ABSTRACT ARTICLE HISTORY

Childhood sexual abuse (CSA) is a worldwide problem with serious repercus­

CSA and sexual risk behaviors

CONTACT Amy Dana Ménard admenard@uwindsor.ca Department of Psychology, University of Windsor,

trading sex for money, drugs/alcohol, or shelter), inconsistent use of condoms,

The current review

Higher number of partners

Higher rates of infidelity/concurrent partners

Regardless of the population sample, most studies seem to demonstrate

Higher rates of sex under the influence of drugs or alcohol

in samples of heterosexual men (Holmes, 2008) or mixed samples of men and

Increased likelihood of current/lifetime STI/HIV

paradigm perpetrator 1–2+ years under

sample CASI breasts/genitals +association with concurrent sexual partners (men

couples from four U.S. cities

CASI of threat or force

+ association with lifetime STI diagnoses

(2014) College students Questionnaires Questionnaire sexual risk

Decreased condom use/unprotected sex

Studies on condom use/episodes of unprotected sex and CSA history show

Increased sexual compulsivity

Studies examining the relationship between scores on measures of sexual

Increased involvement in sex trade/transactional sex

involvement in transactional sex (heterosexual women, MSM), higher number

Methodological issues related to predictor variables and study design

demographics, it is imperative to test these associations and present subse­

Methodological issues related to outcome variables

Implications for clinicians and educators

older individuals may be disproportionately vulnerable to contracting STIs

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Childhood sexual abuse (CSA) is a worldwide problem with serious repercus

demographics, it is imperative to test these associations and present subse