by Michael D. Anestis, M.S.
Today's article will be a little different than prior PBB pieces in that it not only discusses a particular study, but also the ensuing public and professional responses to its findings. Dr. Fischer's article on Monday, the Psychotherapy Brown Bag featured article for June 2009, got me thinking about my past readings on childhood sexual abuse (CSA) and I thought that this particular topic would serve as a good vehicle for discussing several important ideas relevant to the core values of this site:
- Delineating empirical findings regarding the relationship between CSA and mental health outcomes
- Discussing the importance of relying on data to understand mental health matters
- Discussing the importance of clarifying data in terms readily understood by individuals who have not experienced intensive training in statistical analysis so as to reduce the power and reach of misinformation
- Discussing the potential consequences of allowing politics to interfere with the scientific process
Clearly, that's a lot to cover in a single article, so hopefully readers will be forgiving of the shortcomings certain to be a part of any article attempting to take on such a broad set of goals in a short space.
Let me begin with a discussion of the study that prompted a such a historically powerful backlash, a meta-analysis by Rind, Tromovitch, and Bauserman (1998) published in the distinguished American Psychological Association (APA) journal, Psychological Bulletin. Meta-analysis is a statistical technique that allows researchers to look at average findings across studies. In other words, whereas most studies take a sample of individual people and report average findings from that entire sample, meta-analyses take a sample of studies and report average findings from the sample of multiple data sets. This particular article examined 59 studies that had looked at childhood sexual abuse (CSA) and mental health outcomes in college students. The authors reported several findings, including the following (Rind, Tromovitch, & Bauserman, 1998):
- College students with a history of CSA were, on average, slightly less well adjusted than were college students with no history of CSA
- The relationship between CSA and later well-being was accounted for by family environment, meaning that CSA was not directly related with later problematic outcomes, but rather that this relationship was better explained by problematic familial dynamics.
- Men had less severe responses to CSA than did women
In addition to these findings, the authors reported that the degree to which the individual felt that the CSA experience had been consentual impacted the degree to which they experienced later maladjustment, thus potentially indicating a reason to use phrases like "adult-child sex" and "adult-adolescent sex" rather than referring to all such encounters as CSA.
Several aspects of these findings resulted in controversy (for a more thorough review of the controversy that ensued, we recommend Garrison & Kobar (2002) and Lilienfeld (2002)). In particular, the notion that terminology should be shifted to more neutral wording caught the attention of several organizations. The North American Man/Boy Love Association (NAMBLA) posted a headline on their website that claimed the study proved that their cause was harmless. Additionally, the National Association for Research and Therapy for Homosexuality (NARTH), an organization that espouses attempts to "cure" homosexuality, made public claims that this study advocates pedophilia and would provide a scientific basis for decriminalizing CSA. Several public figures then seized upon the NARTH claim, the most prominent of whom was Dr.Laura Schlessinger (known as "Dr. Laura").
Dr. Laura berated the study authors and the APA, making several problematic claims. Lilienfeld (2002) summarizes these claims in detail, but to briefly summarize, Dr. Laura pushed two central points. First, she said that meta-analysis is "junk science" and that, as a "real scientist" she had never seen this technique used in reputable work. The first problem with this is that, although she has an MS in marital and family therapy, her doctorate is in physiology, not clinical psychology, so her exposure to this literature is likely limited and her declaration of herself as a real scientist and the study authors as something less seems unfounded. Assuming her qualifications are not an issue, however, another problem remains with this complaint: meta-analyses, while imperfect in many ways, have appeared in many influential studies by respected scientists in prominent journals. Dr. Laura's ignorance regarding this technique has no bearing on its validity. In other words, if a historian has never heard of World War II, this likely reflects a severe gap in his or her education rather than supporting the idea that WWII had no importance.
Dr. Laura's second central accusation was that the authors intended to present findings that would "allow men to rape children." The absurdity of this accusation is best reputed in the words of the authors themselves, who have published several rebuttals to the many critiques of their work (e.g., Rind, Tromovitch, & Bauserman, 2002). The result of these public outcries - the ones listed above represent only a small sample of the many public criticisms or Rind et al (1998) - was a resolution passed in both houses of the United States congress denouncing the findings, the only such resolution in our nation's history.
In addition to the public outcry, many professionals have unleashed strong rebuttals to the Rind et al (1998) findings. Amongst these critiques are the following (see Dallam et al (2001) and Ondersma et al (2001) for a more thorough review of these criticisms):
- The authors used a college sample. Individuals who experience severely problematic mental health outcomes are unlikely to be present in a college sample, which would thus diminish the power of the sample to find a link between CSA and severe pathology. Rind and colleagues (2002) rebutted this by reiterating that their sample exhibited similar rates of CSA and maladjustment as community samples, but this remains a point of contention not unique to this particular study and a legitimate point of concern.
- While the authors included alcohol use, depression, general anxiety, eating disorders, psychotic symptoms, obsessive-compulsive symptoms, phobias, and somatization, they did not include substance use, antisocial personality disorder symptoms, or post-traumatic stress in their outcome variables. As such, several outcomes frequently linked to CSA were not considered.
- Several constructs discussed in the Rind et al (1998) study were not directly measured. In particular, "consent" was not measured, thus making their controversial conclusions regarding the victim's perception of the experience more difficult to interpret.
- The authors did not clearly define CSA and included studies that measured different forms of CSA, confusing the findings. Additionally, the authors did not include multiple studies that involved incest because they believed the large effect sizes in those studies were outliers rather than true representations of the magnitude of the relationship between the variables of interest.
Given all of the controversy and complaints, it becomes pivotal to ensure that there is a clear understanding of what the authors were actually attempting to say in their original article. Put simply, they found that many college students with a history of CSA do not have problematic mental health outcomes and that, for those who do, this can in large part be attributed to problematic family environments. Quite honestly, it's unclear why this is controversial. To me, it seems like welcome news and a source of hope to hear that many individuals walk away from such a horrific experience without consequences and it seems like an inspiration for future research into why certain individuals are so resilient and how to improve family environments so as to mitigate the effects of CSA. Additionally, despite the comments made by several media personalities regarding the aims of the authors, the following text appeared in the original article:
"Finally, it is important to consider implications of the current review for moral and legal positions on CSA. If it is true that wrongfulness in sexual matters does not imply harmfulness, then it is also true that lack of harmfulness does not imply lack of wrongfulness. Moral codes of a society with respect to sexual behavior need not be, and often have not been, based on considerations of psychological harmfulness or health...Similarly, legal codes may be, and have often been, unconnected to such considerations...In this sense, the findings of the current review do not imply that moral or legal definitions of or views on behaviors currently classified as CSA should be abandoned or even altered. The current findings are relevant to moral and legal positions only to th extent that these positions are based on the presumption of psychological harm."
In other words, the authors were not making any attempt to alter the moral views of CSA. They were simply attempting to empirically test an assumption that has been firmly held for generations: that CSA has a direct and powerful link to problematic mental health outcomes. Finding that this link might not be as strong as presumed, therefore, has no bearing on whether or not the action should occur. The authors themselves acknowledge that individuals with a history of CSA do, in fact, have higher rates of mental illness. The findings simply clarify the point that victims of CSA are not doomed to mental illness and, in treating mental illness in victims of CSA, there are other variables (e.g., family environment) that might be highly important to consider.
Quite obviously, this article does not cover all of the research on this topic and the findings of Rind et al (1998) are not universally consistent with other findings. Despite the controversy and the focus on this one particular review, however, there have been several follow-up studies that have reported similar findings. For example, in a prospective study of CSA victims first interviewed in 1970 and follow-ed up with 20 years later, Horwitz, Widom, McLaughlin, and White (2001) found that, after controlling for overall stressful events, childhood victimization had little direct relationship to mental health outcomes. Similarly, Klonsky and Moyer (2008) reviewed the literature on CSA and self-injury and found that the relationship between these two variables is quite small. The point of these findings is not that CSA is not harmful and disgusting, but rather that the connection between these variables is better explained by other variables (e.g., environmental stress, family support, personality variables) that would serve as highly effective points of therapeutic intervention.
I want to conclude this article by addressing one of the aims I mentioned at the beginning of this text. First and foremost, while I support the use of data without intervention by third parties with political aims, it is beholden upon researchers to discuss their findings in a way that makes their point clear. Without training in meta-analysis, it is difficult to read and understand studies like Rind et al (1998). As such, it is easy for the message of an article to get lost in translation and misinformation to take a firm grip on the public's understanding of an important topic. Peer-reviewed scientific articles are highly valuable, but researchers need to understand the limitation of their reach and to realize that, if they do not translate them themselves, somebody else will (or nobody will, and the findings will remain largely unknown). It is a major leap of faith to assume that the translation will be accurate, particularly for controversial and surprising findings. PBB aims to make this very type of translation and we are highly trained in reading and interpreting empirical research, but without question, an author will certainly disagree with our interpretations of their findings from time to time. When the only people talking publicly about psychological research are people not involved in the field of psychology, the public is left without an informed source of information. In this particular case, influencial public figures such as Dr. Laura were able to take advantage of the disconnect between researchers and the general public to fuel a controversy that was truly inconsistent with the point of the article.
Many lessons can be learned from the saga of the Rind et al (1998) review. How we interpret data, how we explain our findings, how we understand the link between CSA and mental health, who we listen to when learning about mental health phenomena, and several other ideas are impacted by these events. At this point, nothing can conclusively be determined about the relationship between CSA and mental health, but we do know this: our assumptions are not always accurate and, as such, we need to systematically study vulnerabilities and resilience in CSA victims in order to ensure the best possible outcome for the greatest number of people.
In the meantime, I invite your comments and questions on this important topic. There have been many subsequent studies both supportive and contradictory to Rind et al (1998) and I'd love to hear how you think those studies factor into our understanding of this relationship. Before signing off, however, I'd like to carefully reiterate an important point. Those of us at PBB believe that CSA is a highly dangerous and problematic phenomenon. If there is a small direct link between CSA and mental health outcomes, this does not mean CSA is unimportant or acceptable, but rather that something else explains the indirect relationship between these variables and we need to more fully understand that entire picture in order to develop the best possible treatments.
If you are interested in learning more about the use of science in clinical psychology, we recommend the following products, all of which are available in our online store:
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
