Childhood Sexual Abuse: A Narrative Review

Positionality

As authors, we acknowledge that our identities, professional backgrounds, and lived experiences shape the perspectives we bring to this work on childhood sexual abuse (CSA). The first author identifies as a South Asian woman, immigrant, and former international student whose personal and academic experiences inform a deep awareness of cultural stigma, gendered expectations, and structural barriers that influence disclosure, help-seeking, and well-being among marginalized communities. Her scholarship centers intersectionality, trauma-informed pedagogy, and the health of culturally diverse populations, which informs the equity-focused lens applied throughout this review. The second and third authors are public health researchers and faculty members with extensive experience in adolescent health, behavioral health, violence prevention, and school- and community-based public health programming. Their work is grounded in decades of research with youth, families, and community organizations, and is shaped by a commitment to evidence-based prevention, health promotion, and the reduction of health disparities. They recognize that their positionality as researchers working within predominantly Western academic and public health systems influences how they interpret and synthesize existing literature.

Introduction

Despite numerous public health efforts and interventions, childhood sexual abuse (CSA) continues to afflict innumerable individuals throughout the US. Approximately one in seven children have been sexually abused, with one in four girls and one in 20 boys.^1–5 Globally, over 1 billion children are estimated to experience some form of sexual violence during childhood.⁶ Despite growing awareness and research, CSA continues to be severely underreported, particularly in communities where cultural stigma, fear of retaliation, and systemic barriers inhibit disclosure of such events. In many societies, notions of family honor, gender roles, and religious expectations contribute to a culture of silence, leaving victims without support or recourse, which may often result in self-doubt and guilt.⁷ CSA is the most under-reported type of abuse, especially among boys, due to social stigma associated with it from different cultures.⁸ CSA is a form of adverse childhood experiences (ACEs) and places survivors at elevated risk for involvement in risky health behaviors and mental health problems. Extensive research has linked CSA to poor health outcomes, including substance misuse, depression, post-traumatic stress, and other long-term consequences.^9–16

The body of research on the consequences of CSA is extensive but often siloed, with individual studies focusing on specific domains such as psychological health, substance abuse, re-victimization, or sexual offending. This fragmentation can obscure the full, interconnected scope of the damage caused by CSA. As the issue is inherently multifactorial and multidisciplinary, a comprehensive synthesis of literature is crucial for clinicians, researchers, and policymakers to grasp the complexity of the problem and develop practical, holistic interventions. Therefore, the primary aim of this review is to consolidate and summarize the current state of knowledge regarding the multifaceted consequences of CSA.

Methods

The present narrative review synthesizes peer-reviewed literature across multidisciplinary fields of psychology, public health, behavioral health, and social sciences. Relevant studies were identified through searches of major academic databases, including PubMed, PsycINFO, Google Scholar, and Web of Science, using terms related to childhood sexual abuse, mental health, risky sexual behavior, substance use, revictimization, and sexual offending. Reference lists of key articles, meta-analyses, and national surveillance reports were also reviewed to identify additional sources. Priority was given to recent empirical studies, longitudinal research, meta-analyses, and national or international surveillance data. Earlier foundational studies were included when they provided essential theoretical or historical context.

Results

Research has identified a myriad of negative health outcomes associated with CSA, involving physical, emotional, and mental health dimensions.^1,17 CSA can result in disruptions to behavior, emotions, and child development.^18,19 Moreover, CSA is linked to poor psychological functioning, including depression, anxiety, post-traumatic stress disorder (PTSD), and suicidality^4,20–24 as well as aggressive behavior, interpersonal problems, substance abuse, sexual offending, possible re-victimization, and risky sexual behaviors.^25–27 CSA survivors’ racial and gender characteristics may potentially moderate the magnitude of negative health outcomes.^28,29

Racial and Gender Differences

Gender and racial differences exist regarding childhood sexual abuse. Females consistently have higher prevalence rates than males with CSA.^30–32 Cultural norms around masculinity and fear of being labeled and stigmatized may prevent boys from reporting the abuse.^25,29,33 In addition, females are more likely to suffer penetrative abuse by a family member than males.^33,34 Studies have demonstrated that CSA increases the risk for later sexual aggression perpetration in men.^35,36 Evidence also shows that CSA can predict sexual aggression in women.^37,38 A 23-year longitudinal study by Trickett and colleagues²⁴ demonstrated that female CSA survivors report multi-dimensional adverse health outcomes such as the earlier onset of puberty, cognitive deficits, hypothalamic-pituitary-adrenal attenuation, asymmetrical stress responses, and high rates of obesity. Moreover, female survivors in the study also reported lower education, self-mutilation, physical/sexual re-victimization, premature deliveries, and teen motherhood.^18,24

Gendered behavioral patterns have emerged in a few studies, suggesting that men often engage in hypersexuality and risky sexual behaviors, whereas women engage in internalizing behaviors, such as sexual avoidance or sexual ambivalence.^34,39,40 Some studies suggest women survivors are more likely to engage in risk-taking behaviors than men.⁴¹ However, others suggested that sexual abuse may predict sexually coercive behavior in females but not in men.⁴² In help-seeking populations, men’s hypersexual behaviors often involve pornography and masturbation, whereas women’s are more likely to involve high-risk sexual encounters.^43–45

Regarding differences based on race, according to the US Department of Health and Human Services,³² 20.9% of Hispanic, 20.3% of Black or African American, 8.1% of White, 1.1% of American Indian/Alaska Native, 0.9% of Asian, 4.6% of Native Hawaiian/Pacific Islander, and 10.5% of multiracial children have experienced CSA. There is a paucity of studies with Asian American, Native American, and multi-racial CSA survivors, resulting in disparity among these communities. Moreover, African American females tend to be involved in risky sexual behaviors compared to their male and white counterparts.^28,29

Risky Sexual Behavior

CSA is associated with risky sexual behaviors in adolescence and young adulthood.^{4,15,16,26,27} Risky sexual behaviors are associated with externalizing mechanisms and may involve stress reduction techniques that help CSA survivors regulate their emotions.^46,47 Adolescents with CSA history exhibit low-risk perception,⁴⁸ engage in substance use during sexual activity,⁴⁹ and irregular condom use.^50,51

CSA survivors are more likely than their non-abused peers to initiate sexual activity early (before age 16), have multiple sexual partners, experience teen pregnancy, and report inconsistent condom use.^8,52–56 In addition, youth exposed to CSA are at increased risk of drug use in a sexual relationship⁵⁵ as well as intimate partner violence, rape, and peer violence.^13,14 Although CSA survivors are more vulnerable to hypersexuality than the general population, they tend to develop other sexual concerns as well, such as sexual abuse perpetration, shame, guilt, and anxiety during sexual arousal.^34,57–59 Moreover, they may experience decreased sexual desire, dissociation, orgasm disorders, and arousal disorders

Hypersexuality is a repetitive, high-risk sexual behavior that has been identified as a coping mechanism among CSA survivors.^47,60 Survivors may experience distorted sexual schemas due to traumatic sexualization, leading to re-victimization and interpersonal difficulties.⁶¹ Hypersexuality is linked with adverse health outcomes, including unwanted pregnancies, sexually transmitted infections, and non-sexual attacks.^62–65

Psychologically, hypersexuality is linked to mood disorders, anxiety disorders, substance abuse, gambling issues, and compulsive buying behaviors.^66–69 Studies reveal CSA-related hypersexuality across different groups, including university students, veterans, incarcerated people, and men who have sex with men.^70–77

Psychological Health

Depression is the most frequently reported psychological consequence of CSA.⁷⁸ Research demonstrated that extensive trauma can be caused by CSA such as psychological distress, impaired health, dissociative experiences, anxiety, and depression.^79–83 CSA survivors are also at an elevated risk for somatic illnesses and post-traumatic stress disorder⁸⁴ and depressive disorder. The severity of the abuse may serve as a predictor for long-lasting symptoms with an increased risk of impairment.^31,85,86

CSA survivors tend to exhibit poor self-regulation processes and impulsivity, making them vulnerable to risky health behaviors like substance abuse, unsafe sex, and unhealthy eating behaviors. The relation between impulsivity and CSA has been established through various studies.^87–98 Impulsivity is observed even in the absence of psychiatric disorders such as post-traumatic stress disorder due to CSA.^95–98

The prevalence of traumatic events in schizophrenia patients varies between 45% and 71%, whereas severe and chronic traumatic childhood experiences increase hallucinations among these patients.^99–107 Of these individuals, underreporting is often observed among male patients due to stigma or embarrassment. One study focused on males in a psychiatric hospital receiving treatment for schizophrenia.¹⁰⁸ Self-reports by the patients in this study indicated that the perpetrators of emotional abuse were usually parents, while close relatives were the perpetrators of sexual abuse. More than 63% of the patients reported extreme childhood abuse, while 94% of the patients suffered from some form of traumatic event in their childhood.¹⁰⁸ Hence, a link between CSA and poor psychological health is observed.

Substance Abuse

CSA survivors are more likely to abuse substances as a coping mechanism involving trauma.^109,110 Academic and social performance is linked to poor mental health (depression, ADHD), higher substance abuse (smoking, marijuana, alcohol consumption), and poor lifestyle habits (low intake of fruits and vegetables, higher BMI, less sleep) among college students who reported CSA.¹¹¹ CSA survivors are at increased risk for alcohol problems.^12,112–122 Several studies have revealed a link between problematic alcohol consumption and childhood abuse.¹²³Alcohol abuse might be mediated by a desire to dissociate in CSA survivors.¹²⁴

CSA may be associated with the use of narcotics,¹²⁵ severe and extreme drug use,¹²⁶ and high prevalence of drug abuse or dependency.^127,128 Furthermore, CSA survivors tend to initiate smoking at an early age^129,130 and indulge in frequent and regular smoking during adolescence.^{125,129–134} The higher prevalence of smoking among CSA survivors can be explained by nicotine use disorder.¹³⁵ In addition, CSA survivors are at elevated risk for marijuana abuse, cannabis dependency, and a higher prevalence of cannabis use.^136–138 A 2023 meta-analysis of 102 studies (N = 902,000) reported significant pooled associations between ACEs and smoking, problematic and heavy alcohol use, cannabis use, and illicit drug use.¹³⁹ A youth-focused 2024 systematic review and meta-analysis likewise found that CSA predicted substance use/misuse among adolescents and young adults.¹⁴⁰ Contemporary CDC surveillance of US high school students further links cumulative ACEs to higher prevalence of current alcohol use, vaping, and prescription opioid misuse.¹⁴¹

Re-victimization post CSA

CSA survivors are at increased risk of future sexual victimization both in adolescence and adulthood.^{9–11,142–148} Such re-victimization can also include subsequent interpersonal trauma such as sexual assault or intimate partner violence.¹⁴⁴ In a recent meta-analysis, the mean prevalence of sexual re-victimization across 80 studies was 47.9%, suggesting that nearly half of CSA survivors face sexual victimization in adulthood.¹⁴⁹ Recent reviews confirm elevated revictimization risk following childhood maltreatment and highlight psychological mechanisms, including PTSD symptoms, dissociation, emotion dysregulation, alcohol misuse, and risky sexual behavior as contributors.^144,150,151 Prospective and population studies also underscore that greater cumulative adversity predicts higher risk for subsequent victimization and related health harms.¹⁴¹ Importantly, protective factors exist; parental bonding/support and positive social support have been identified as potential buffers against revictimization.¹⁵²

Attachment Issues

Secure attachment may have the ability to protect the CSA victim against the damaging trauma on the psychological adjustments associated with the abuse.^153,154 Similarly, attachment insecurity explains the association between sexual trauma and adjustment difficulties later in life.^155,156 Preschool-aged CSA victims perpetrated by a family member tend to display signs of disorganized attachment compared to non- abused children.¹⁵⁷ In contrast, other studies suggest that more than half (57%) of preschool-aged children who suffered from penetrative CSA were securely attached.¹⁵⁸ CSA survivors may develop a unique internal working model due to their childhood experiences shaping their self-concept and sexual behavior.¹⁵⁹

Secure attachment with parents may reduce risky internalizing and externalizing behaviors portrayed by young CSA victims, minimizing the risk of HIV/STIs, drinking problems, hypersexuality, and risky sexual behaviors.¹⁶⁰ In contrast, disorganized attachment may form a relationship between internalizing and externalizing behavior problems one year after CSA.¹⁶¹ Adolescents who experience CSA may develop insecure and disorganized attachments with their parents, which in turn can result in sexually risky behaviors as coping mechanisms towards CSA and parental dismay.^161,162

Sexual Offending

Although multiple research studies have reported that the CSA contributes towards sexual offending,^163–169 few studies have argued that CSA is not a precursor for sexual recidivism.¹⁷⁰ CSA may have a strong correlation with adolescent sexual offending^37,77 and adult sexual offending.¹⁷¹ Furthermore, a CSA may be associated with an individual’s psychological and criminological problems.^{23,164,172,173} Criminal offenders are more likely to have experienced exponential trauma due to CSA than the general population.^174–176

Over time, various studies have attempted to understand the associations between CSA and sexual offending,^177,178 male juvenile sexual offenders,¹⁷⁹ longitudinal sexual offending,¹⁸⁰ and prevalence of CSA among sexual offenders.¹⁸¹ Such studies have indicated that CSA significantly affects offending and sexual offending during adulthood. CSA survivors may suffer from emotional dysregulation, resulting in their experimental personality, hence engaging in risky and pervasive sexual behaviors.¹⁸¹

Recent reviews emphasize dynamic, changeable factors such as emotion regulation difficulties, antisocial tendencies, deviant sexual interests, substance misuse, and social isolation as relevant to risk, alongside empirically supported protective factors such as prosocial supports, goal-directed living, and adaptive sexuality.¹⁸² In justice-involved samples, CSA has been associated with heightened odds of sexual offending, in part via emotion dysregulation.¹⁸¹ Together, these findings support trauma-informed assessment and strengths-based rehabilitation that target modifiable risk and promote protective factors.

Discussion

Despite decades of effort and vigilance, significant gaps still hinder prevention, detection, and survivor-centered care for CSA survivors. Measurement and surveillance remain inconsistent across different types of studies, which may act as a barrier to comparability and likely lead to an underestimation of the true scope.^3,6 Clinical research also demands more in-depth research as CSA survivors often report PTSD, poor mental health outcomes, chronic pain, and somatic or persistent psychosomatic symptoms.¹⁸³ Yet the pathways and gold-standard care models remain inconsistently defined. Understanding the mechanisms linking CSA to risky sexual behavior and substance use involving emotion dysregulation, coping through alcohol/drugs, and re-victimization risk may require longitudinal studies and causal research to go beyond cross-sectional analysis.^{75,76,140,152,184} Equity gaps persist among boys and men, transgender and gender-diverse CSA survivors. Racial or ethnic diversity and underserved populations are underrepresented in existing research samples, limiting the generalizability of findings and obscuring disparities across different determinants of health domains.^11,28,184 Lastly, implementation evidence remains limited as only a few studies examine the effectiveness, scalability, or costs of prevention standards in youth-serving organizations or integrated, cross-sector responses.¹⁸⁵

Technology and social media have introduced additional pathways through which CSA may occur, be concealed, or be repeated. Technology-facilitated CSA may include online grooming, sexual solicitation, image-based sexual abuse, sexual extortion, livestreamed abuse, and the creation or circulation of child sexual abuse material.^{3,92,185–187} These forms of abuse are particularly concerning among adolescents, who frequently use social media, messaging applications, gaming platforms, and other digital spaces for social connection, communication, and identity development.^3,185,186 Recent research suggests that when online sexual abuse is included in prevalence measurement, overall CSA estimates increase, underscoring the need to incorporate technology-facilitated abuse into surveillance, prevention, and intervention frameworks.³ Prevention efforts should therefore extend beyond traditional in-person risk environments and include digital safety education, caregiver engagement, youth-serving organizational policies, reporting pathways, staff training, and trauma-informed responses to online victimization.^92,185–187

Future research should center on health equity by strengthening the ways CSA is defined, measured, and addressed. This includes creating standardized definitions and measures, especially for technology-facilitated abuse, so surveillance systems and cohort studies can capture the full range of experiences. Longitudinal, multi-site cohorts and pragmatic trials are needed to test mechanisms such as how emotional dysregulation contributes to substance use, sexual risk, and revictimization. Furthermore, these studies may also help evaluate trauma-informed, attachment-informed, and culturally responsive interventions. An intersectional lens may serve as an essential canvas for understanding how overlapping identities such as gender, race, disability, immigration history, and LGBTQ+ status shape both exposure to CSA and access to protective resources. Equity perspective may require intentionally oversampling and tailoring analyses for groups historically overlooked in CSA research, including boys and men, transgender and gender-diverse youth, survivors with disabilities, non-citizens, and racially and ethnically marginalized communities. Research should also rigorously assess youth-serving organizations’ policies and school and community-level prevention strategies, such as staff training, boundary policies, reporting pathways, caregiver engagement, and digital safety approaches, to determine their effectiveness and identify unintended consequences. Finally, implementation science should be used to examine adoption, fidelity, workforce capacity, and cost-effectiveness across child welfare, education, healthcare, and justice systems to ensure interventions are feasible, sustainable, and equitable in real-world settings.^6,185

Recommendations for practice and policy should directly address the gaps identified in the current evidence base. Public health and clinical systems should adopt survivor-centered, trauma-informed approaches that include routine screening for common comorbidities such as PTSD, depression, substance use, and chronic pain, paired with warm-handoff referral pathways. Multidisciplinary care for CSA survivors should also include evidence-based, trauma-informed, and skills-based treatment approaches. Dialectical Behavior Therapy (DBT) and DBT-informed models may be particularly useful for survivors experiencing emotion dysregulation, self-harm, suicidality, dissociation, interpersonal instability, shame, and complex or recurrent trauma symptoms. DBT for posttraumatic stress disorder has shown benefit among women with PTSD related to childhood abuse, with evidence of significant reductions in PTSD severity in randomized clinical research.^188,189 Youth-serving organizations should implement nationally aligned standards such as CDC guidelines and recommendations to strengthen early prevention and reduce opportunities for harm. These may include staff training, boundary and reporting policies, caregiver engagement, and digital safety protocols. Public schools are also critical settings for CSA prevention and early identification. School-based prevention efforts should include developmentally appropriate sexual health education, consent education, healthy relationship curricula, digital safety education, and clear reporting pathways for students. School social workers, counselors, nurses, health educators, and teachers can play important roles in recognizing warning signs, responding to disclosures, supporting mandated reporting processes, and connecting students with appropriate services. Quality sexual health education should be medically accurate, age-appropriate, culturally responsive, trauma-informed, and inclusive of skills that help students recognize unsafe situations, seek help, understand bodily autonomy, and identify trusted adults.^190,191 Advancing equity requires investing in culturally and linguistically responsive services for underrepresented and historically marginalized groups, ensuring they are accessible, affirming, and community-grounded. Social workers are central to CSA prevention, identification, response, and long-term survivor care. Within child welfare, schools, health care, behavioral health, and community-based settings, social workers often serve as mandated reporters, trauma-informed assessors, advocates, case managers, and care coordinators. Their professional role is particularly important for connecting survivors and families to child protection systems, mental health services, legal supports, culturally responsive resources, and ongoing community-based care. The social work profession also contributes to the development and implementation of abuse reporting standards, survivor-centered practice models, interdisciplinary collaboration, and policies that prioritize safety, confidentiality, equity, and continuity of care.¹⁹² Finally, cross-system data-sharing frameworks that protect privacy while improving coordination among the child welfare, education, healthcare, and justice systems are essential for timely identification, continuity of care, and the prevention of revictimization.^152,185

Conclusion

CSA remains an evolving public health challenge, with harm that echoes across the lifespan. Survivors face higher risks for mental and physical health problems, substance use, and revictimization, and they often encounter stigma and structural barriers when seeking help. Addressing CSA effectively, therefore, requires more than awareness; it calls for survivor-centered, trauma-informed, and culturally responsive care; modernized prevention that includes technology-facilitated abuse; and coordinated action across healthcare, education, child welfare, justice, and community organizations. Moving forward, progress hinges on standardized definitions and surveillance; early identification and timely referral; evidence-based treatment that integrates behavioral health and family support; and the adoption of safety standards in youth-serving organizations (e.g., training, supervision, reporting pathways, and digital safety policies). Equitable access to services, especially for underrepresented survivors (boys and men, transgender and gender-diverse youth, youth with disabilities, and racially/ethnically diverse communities), is essential. With sustained investment in prevention, rigorous evaluation, and cross-sector collaboration, incidence may be reduced, affecting lifelong consequences, and strengthening protective relationships that may help survivors heal and thrive.

Acknowledgments

None

Disclosure Statement

The author(s) have no relevant financial disclosures or conflicts of interest.

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The authors used Grammarly Software (v1.2.262.1891) for grammar and language editing of the discussion section. All edits were reviewed and accepted by the corresponding author. No substantive content was generated by AI

About the Author(s)

Dr. Kruti S. Chaliawala, PhD, CHES is an Assistant Professor within the School of Public and Population Health at Boise State University. Her primary research interests are psychosocial determinants of health among international students, mental health, sexual health, and minority health. ORCID: https://orcid.org/0000-0002-4048-5052 Email: krutichaliawala@boisestate.edu

Dr. Keith A. King, PhD, MCHES is a Professor and Director of the Center for Prevention Science in the Department of Health Promotion and Education at University of Cincinnati. His research emphasizes adolescent health promotion, suicide, violence and substance abuse prevention, mental health promotion, sexual health, survey development, and program evaluation.

Dr. Rebecca A. Vidourek, PhD, CHES is a Professor of Health Promotion and Education at the University of Cincinnati. She also serves as the Graduate Program Coordinator for HPE and the Health Education Health Promotion Concentration Director for the Master of Public Health program. Her research emphasizes child/adolescent health promotion, substance abuse prevention, suicide prevention, positive youth development, school health education, and violence prevention.