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The Global Prevalence of Sexual Assault: A Systematic Review of International Research Since 2010

Emily r dworkin, barbara krahé, heidi zinzow.

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We present a review of peer-reviewed English-language studies conducted outside the United States and Canada on the prevalence of sexual assault victimization in adolescence and adulthood published since 2010.

A systematic literature search yielded 32 articles reporting on 45 studies from 29 countries. Studies that only provided prevalence estimates for sexual assault in intimate relationships or did not present separate rates for men and women were excluded. All studies were coded by two coders, and a risk of bias score was calculated for each study. Both past-year and prevalence rates covering longer periods were extracted.

The largest number of studies came from Europe ( n =21), followed by Africa ( n =11), Asia and Latin America ( n =6 each). One study came from the Middle East and no studies were found from Oceania. Across the 22 studies that reported past-year prevalence rates, figures ranged from 0% to 59.2% for women, 0.3% to 55.5% for men, and 1.5% to 18.2% for LGBT samples. The average risk of bias score was 5.7 out of 10. Studies varied widely in methodology.

Conclusion:

Despite regional variation, most studies indicate that sexual assault is widespread. More sustained, systematic, and coordinated research efforts are needed to gauge the scale of sexual assault in different parts of the world and to develop prevention measures.

Keywords: Sexual assault, rape, international, review, sexual minority

Sexual assault against adolescents and adults is a global public health problem. Sexual assault encompasses a broad spectrum of behaviors and is generally defined as any attempted or completed sexual act, ranging from unwanted sexual touch to rape, that is committed against someone without a person’s freely given consent ( Basile et al., 2014 ; World Health Organization, 2017 ). These include acts that are committed by force, threat of force, or verbal coercion, as well as acts that are committed against someone who is unable to consent due to age, disability, or impairment (e.g., substance use). Sexual assault is associated with a wide range of mental and physical health outcomes, including posttraumatic stress disorder (PTSD), depression, substance use disorders, somatic complaints, and negative reproductive health outcomes ( Dworkin et al., 2017 ; Weaver, 2009 ). In light of these consequences, it is important to understand the global prevalence of adolescent and adult sexual assault in order to appropriately allocate resources and develop effective prevention and intervention strategies.

There is evidence of differences in the prevalence of sexual assault in various world regions ( World Health Organization, 2013 ). Applying an ecological perspective, various sociocultural factors that may differ across countries—such as cultural norms supporting violence generally and patriarchal norms—may affect these prevalence rates ( Krug et al., 2002 ). However, most of the research on sexual assault has been conducted in the United States (US) and Canada. This limits the understanding of the public health burden of adolescent and adult sexual assault worldwide. Thus, the purpose of this review was to summarize the global prevalence of sexual assault in adolescence and/or adulthood for men and women outside of the US and Canada. The review includes both general population prevalence data and specific estimates for the lesbian, gay, bisexual, and transgender (LGBT) population, given evidence for the disproportionate burden of sexual assault on LGBT individuals ( Canan et al., 2019 ; Walters et al., 2013 ).

Prior Research on the Prevalence of Sexual Assault Victimization

Epidemiological studies..

Data obtained since 2010 from the National Intimate Partner and Sexual Violence Survey—an epidemiological study conducted annually in the US—indicates that 18.0–21.3% of women and 1.0–7.1% of men had a lifetime history of attempted or completed rape, and 1.2–1.6% of women and 0.7% of men had experienced attempted or completed rape in the prior 12 months ( Breiding et al., 2014 ; Black et al., 2011 ; Smith et al., 2018 ). In addition, 13.0–43.9% of women and 6.0–23.4% of men had experienced lifetime sexual coercion, and 5.5% of women and 5.1% of men had experienced sexual coercion in the prior 12 months ( Breiding et al., 2014 ; Black et al., 2011 ; Smith et al., 2018 ). Fewer epidemiological studies of the prevalence of sexual assault have been conducted internationally. An exception to this is the World Health Organization World Mental Health surveys, which were conducted from 2001 to 2012 in 24 countries ( Scott et al., 2018 ). These surveys assessed lifetime experiences of sexual assault and other traumas as part of assessing posttraumatic stress disorder. Among women in high-income countries, the lifetime prevalence of sexual assault ranged from 1.8% (Spain) to 26.1% (United States) ( Scott et al., 2018 ). Among women in low- or middle-income countries, the lifetime prevalence ranged from 0.6% (South Africa) to 1.5% (Columbia-Medellin).

Literature Reviews.

Several reviews have been conducted that address the prevalence of sexual assault victimization around the world. We next summarize these reviews, with an emphasis on reviews that include studies of the international prevalence of sexual assault victimization when available. These reviews, in some cases, reflect wide ranges of prevalence estimates, which may be due to methodological differences in primary studies (e.g., sampling strategy, operational definition of sexual assault, measures).

Reviews of Prevalence Among Women.

Several prior reviews have synthesized data on the worldwide prevalence of sexual assault among women. Most recently, a review of worldwide nonpartner sexual assault among women reported data from studies prior to 2011 ( Abrahams et al., 2014 ). This review reported a worldwide estimate of 7.2% lifetime prevalence. Lifetime prevalence was estimated at 3.3–12.2% for Asia, 16.4% for Australasia, 6.9–11.5% for Europe, 5.8–15.3% for Latin America, 4.5%−21.0% for Africa, and 13.0% for North America. In addition to this study’s limitations of focusing only on women and nonpartner violence, the authors noted that most of the reviewed studies used a single broad item to assess sexual assault and only reported lifetime prevalence. An older report by the World Health Organization (WHO) summarized national surveys from regions around the world and reported 5-year sexual assault prevalence estimates among adult women of 0.3–8.0% ( Krug et al., 2002 ). A more recent WHO report described lifetime prevalence among women, with a 30% estimated global prevalence of physical and/or sexual partner violence among ever-partnered women and a 7% estimated global prevalence of nonpartner sexual assault ( World Health Organization, 2013 ). The prevalence of partner violence was highest in African, Eastern Mediterranean and South-East Asia regions and the prevalence of nonpartner sexual assault was highest in Africa and the Americas.

Reviews of Prevalence Among Men.

Fewer reviews have summarized the global prevalence of sexual assault among men. In a review of adult sexual assault among men that included US, Canadian, and international studies, lifetime prevalence estimates ranged from 1% for forcible rape to 30% for any form of coercive sexual contact ( Peterson et al., 2011 ). However, this review highlighted that the only epidemiological studies of sexual assault against men had been conducted in the US.

Reviews of Prevalence Among LGBT Individuals.

Studies indicate that the risk for sexual assault is elevated among LGBT populations in comparison to heterosexual populations. A review of 75 studies from the US indicated that the prevalence of adult sexual assault against people identifying as gay, lesbian, or was 11.3– 53.2% for women and 10.8–44.7% for men ( Rothman, Exner, & Baughman, 2011 ). A more recent epidemiological study reported rates of adult sexual assault (ranging from non-penetrative behavior to completed rape) to be 63% in lesbian women, 80% in bisexual women, and 44% in heterosexual women ( Canan et al., 2019 ). In a study of undergraduates from 120 institutions, past-year sexual assault was reported by 10% of gay men, 10% of bisexual men, 6% of heterosexual men, 9% of lesbian women, and 17% of bisexual women, 8% of heterosexual women, and 11–33% of transgender persons ( Coulter et al., 2017 ). This evidence indicates that higher rates of sexual assault among sexual minority groups represent an important health disparity ( Canan et al., 2019 ). However, no review to our knowledge has summarized the prevalence of sexual assault against LGBT individuals outside of the US.

Reviews of Prevalence Among College Students.

In a review of US-based studies of sexual assault that occurred among women since starting college, prevalence estimates were 0.5–8% for forcible rape, 2–34% for unwanted sexual contact, 2–14% for incapacitated rape, and 2–32% for sexual coercion ( Fedina, Holmes, & Backes, 2018 ). A second US-based review found that the prevalence of completed sexual assault that occurred among women since starting college ranged from 14.2%−23.1% (Muehlenhard et al., 2017). To our knowledge, there has been no review of the prevalence of sexual assault among college students outside of the US.

The Current Study

The purpose of the current study was to update these prior reviews with recent worldwide findings on the prevalence of sexual assault. Due to the large number of studies focusing on US and Canadian samples and the underrepresentation of other world regions in the literature base, we decided to limit the scope of the current review to world regions outside the US and Canada. In contrast to the Abrahams et al. (2014) study, we chose to expand the focus to women and men, as well as to studies that included both partner and nonpartner violence. Because many non-US studies have primarily focused on partner violence and were already described in the review by Abrahams and colleagues (2014) , and in light of evidence that partner and nonpartner violence have distinct mental health effects ( Temple et al., 2007 ), we did not include studies in our review if they only examined sexual assault in intimate relationships. We furthermore focused on prevalence estimates for sexual assault that took place after childhood in order to separate these experiences from child sexual abuse. Many prior reviews and studies have solely reported lifetime prevalence rates, making it difficult to obtain accurate estimates of assaults taking place in adolescence and adulthood. It is important to develop a fine-grained understanding of adolescent/adult assaults specifically, which are likely associated with different consequences ( Messman-Moore, Long, & Siegfried, 2000 ) and contextual factors (e.g., greater likelihood of a non-family perpetrator) ( Smith et al., 2017 ) than child sexual abuse, and thus suggest different implications for intervention. In addition, we systematically evaluated each study using an assessment tool to estimate risk of bias.

Eligibility Criteria

We sought peer-reviewed studies published in English since 2010 that assessed the prevalence of adolescent or adult sexual assault in a country other than the US or Canada. Studies including general population and college student samples were included to reflect the predominant samples in studies from North America, as well as the greatest generalizability to the broader population. Student samples in particular were included given that they are a frequently-studied group found to experience particularly high risk in studies in the US ( Fedina et al., 2018 ), but the extent to which they experience elevated risk globally is unknown. We excluded studies that (1) only reported the prevalence of sexual assault in the context of intimate relationships; (2) only reported the prevalence of sexual assault among a narrow, special population (e.g., sex workers, pregnant women), with the exception of studies of LGBT individuals; (3) only reported the prevalence of sexual assault among a combined sample of men and women; and (4) only reported the prevalence of childhood or lifetime (i.e., where it was not clear that child sexual abuse was excluded) sexual assault.

Study Identification

We searched PsycInfo and PubMed on August 30th, 2019 for peer-reviewed journal articles published in English since 2010. We used Boolean operators for terms related to sexual assault (“sexual assault” OR “forced sex” OR “sexual coercion” OR “sexual victimization” OR rape OR “violence against women” OR “sexual violence” OR “sexual aggression” OR “sex offenses” OR victimization) and prevalence (prevalence OR scale OR incidence). Because this returned a large number of articles about scale development, we excluded studies with related terms (“psychometrics” OR “test validity” OR “test construction” OR “validity” OR “reliability”) in the title, Medical Subject Heading, or abstract. To exclude studies of children, we excluded studies with the words “childhood,” “child,” or “children” in the title, and in PsycInfo, selected Adolescence (13–17 years) and Adulthood (18 years & older) in the Age Group search option. To exclude qualitative studies, we excluded studies with qualitative in the title, and, in PsycInfo, narrowed the results by methodology to quantitative studies. Finally, to exclude studies conducted in the US, we excluded studies with “US” or “United States” in the title, and in PsycInfo, used the Location search term function to exclude studies conducted in the US or Canada. This yielded 549 results from PsycInfo and 414 results from PubMed, for a total of 869 unique articles reviewed for eligibility. Each article was reviewed by two authors for eligibility. Articles identified as potentially eligible by at least one author were re-reviewed for eligibility in reference to exclusion criteria by the first author in consultation with the second and third authors. Of 177 articles reviewed in more depth, 74 articles were excluded because they focused only on sexual assault in the context of intimate partner violence, 30 articles were excluded because they focused on childhood or lifetime sexual assault (i.e., not adolescent or adult sexual assault), and 26 were excluded because they focused on a special population, 9 were excluded that did not measure prevalence, 5 were excluded because they were duplicates, and 1 was excluded because relevant information could not be extracted. Ultimately, 32 articles were determined to be eligible.

Data Extraction

All three authors coded studies. To increase reliability, all three authors first coded five articles (two of which were ultimately excluded due to insufficient data) independently, using a draft codebook, and then reviewed discrepancies as a group and revised the codebook. Each author then coded 2/3 of the remaining articles such that all articles were double-coded. Discrepancies were tracked and resolved as a group. We coded the following variables:

Prevalence of sexual assault.

We coded any prevalence estimates provided reflecting sexual assault in adolescence, adulthood, and/or the past year separately for women (unselected for sexual orientation), men (unselected for sexual orientation), and LGBT individuals. When studies reported multiple subtypes of sexual assault (i.e., partner and nonpartner), we recorded these subtypes only when a combined prevalence rate was not provided. We also recorded the number of individuals who provided data on sexual assault (i.e., the denominator of prevalence estimates) and the number of people exposed to sexual assault (i.e., the numerator of prevalence estimates).

Study methodology.

We coded study characteristics including year of publication, year of data collection, country name, and world region. In terms of sample characteristics, we coded minimum, maximum, and mean age of the sample; whether the sample was limited to women; and whether the sample was limited to university students given evidence from the US that risk for sexual assault is especially high on college campuses ( Fedina et al., 2018 ). We also coded characteristics of the instrument used to assess sexual assault, including the instrument name; whether the instrument consisted of one item only; whether the definition of sexual assault was limited to penile-vaginal intercourse and/or nonpartner perpetrators; and whether incapacitated, coerced, non-penetrative, and/or attempted sexual assault were explicitly included in the definition of violence provided to participants or instrument items.

Risk of bias.

We adapted Hoy and colleagues’ (2012) 10-item tool for assessing risk of bias in prevalence studies. We coded whether studies’ target population closely matched the national adolescent/adult population in terms of relevant variables (e.g., age, sex, occupation) (item 1); whether studies’ sampling frame was representative of their identified target population (item 2); whether studies either conducted a census or used random sampling to select participants from the sampling frame (item 3); whether the response rate was >= 70% and whether responders and nonresponders were compared, and if so, whether significant differences were identified (item 4); whether studies collected data directly from participants, rather than a proxy (item 5); whether studies used behaviorally-specific questions about sexual acts (e.g., fondling, penile penetration) and/or tactics (e.g., force, coercion) to assess the acceptability of the specificity of case definition (item 6); whether studies presented evidence of the reliability and/or validity of the instrument used to assess sexual assault (item 7); whether studies used the same mode of data collection for all participants (item 8); whether studies reported at least one prevalence estimate reflecting a recall period of an acceptably short length (i.e., within 12 months, as defined by Hoy and colleagues 1 ; item 9); and whether an appropriate and accurate numerator and denominator were presented that corresponded to the reported prevalence estimates (item 10). Thus, each study received a bias score ranging from 0 to 10.

LGBT sample characteristics.

We recorded the percent of women in the LGBT sample and the study definition of the LGBT group sampled.

Summary of Included Studies

Ultimately, 32 English-language articles from 29 countries reflecting 45 country-specific studies were included (see Table 1 for study characteristics by region). The most represented regions were Europe (21 studies; 11 of which were conducted by the same research group) and Africa (11 studies), and the least represented regions were the Middle East (1 study) and Oceania (i.e., New Zealand and Australia; 0 studies). Most studies assessed sexual assault in both men and women; only 31.1% of studies were limited to women. About a quarter (26.7%) of studies were limited to university students. Eight studies provided prevalence information for LGBT individuals, including five studies that presented prevalence information for LGBT individuals only and three that presented prevalence information for both an overall sample and LGBT individuals specifically. In general, survey questions were administered in the local language. For the few studies that did not state this explicitly, none indicated that a language other than the local language was used.

Study Characteristics by Region

Note . No studies were found for Oceania.

54.1% of those with a lifetime SA history were assaulted in the past year.

Assessments of sexual assault.

Sexual assault was assessed via interview for all participants in 15 (33.3%) studies, and via self-administered survey in 30 studies. A single-item measure was used in 11 (25.6%) studies. 2 Thirty (68.2%) studies presented behaviorally-specific descriptions of sex acts to participants, and 32 (71.1%) presented behaviorally-specific descriptions of tactics (e.g., force, coercion) to participants. In terms of the definition of sexual assault used, 5 (11.4%) studies limited their definition to penile-vaginal penetration, 2 (4.5%) explicitly included drug/alcohol-facilitated sexual assault but not other forms of incapacitated violence, 17 (38.6%) explicitly included any incapacitated sexual assault, 27 (61.4%) explicitly included coerced sexual assault, 26 (59.1%) explicitly included non-penetrative sexual assault, 24 (54.5%) explicitly included attempted sexual assault, and 1 (2.2%) only assessed sexual assault committed by nonpartner perpetrators.

The average risk of bias across studies was 5.7 out of 10, in which 10 indicates maximum bias. Importantly, these studies could have been unbiased for their study goals; risk of bias instead reflects the degree of bias for the goal of characterizing country-level prevalence of sexual assault (which, in most cases, was not the study goal). Nevertheless, we next describe the risk of bias in assessing prevalence to contextualize study findings and highlight research needs, consistent with best practices for conducting systematic reviews ( Petticrew & Roberts, 2008 ; Sanderson, Tatt, & Higgins, 2007 ). In 80.0% (n = 36) of studies, the target population did not closely match the national adolescent/adult population in terms of relevant variables. In 71.1% (n = 32) of studies, the sampling frame was not representative of its identified target population. For 55.6% (n = 25) of studies, we found that they did not either conduct a census or use random sampling to select participants from the sampling frame. In 75.6% (n = 34) of studies, the authors did not demonstrate that their prevalence estimates were at minimal risk of nonresponse bias (either via reporting a response rate of >= 75% or demonstrating no significant differences between responders and nonresponders). No studies failed to collect data directly from participants, rather than a proxy. Almost half (46.6%; n = 21) of studies did not use an acceptably specific case definition (defined as using behaviorally-specific questions about both sexual acts and coercive tactics). In 88.9% (n = 40) of studies, no evidence of the reliability and/or validity of the instrument used to assess sexual assault was presented, and 2.2% (n = 1) of studies did not use the same mode of data collection for all participants. In 60.0% (n = 27) of studies, the length of the shortest prevalence period assessed was not appropriate (an appropriate recall period was defined as 12 months or less, consistent with the risk of bias instrument). Finally, 86.7% (n = 39) of studies did not present numerators and/or denominators corresponding to the reported prevalence estimates or presented numerators and/or denominators that did not match the reported prevalence estimates.

Region-Specific Prevalence

Next, we present prevalence findings by region, first separated for women, men, and LGBT individuals, and then separated into past-year prevalence and prevalence for other recall periods (e.g., since age 18). When possible, we present comparisons as a function of nationally representative sampling designs vs. other sampling designs, student vs. nonstudent samples, assessment of sexual assault by interview vs. self-report, and/or study definitions of sexual assault. When such comparisons were not possible due to a small number of studies, we instead present a descriptive summary of each study.

Summary information by region is presented in Table 1 . Details of study methodology can be found in Supplemental Table 1 . Prevalence rates are presented in Supplemental Table 2 (women), Supplemental Table 3 (men), and Supplemental Table 4 (LGBT individuals).

Eleven studies reflected countries in Africa, including Botswana (1 study), Burundi (1 study), Cameroon (1 studies), Ethiopia (2 studies), Malawi (1 study), Nigeria (3 studies), South Africa (1 study), and Swaziland (1 study).

Nine studies reported on past-year prevalence among women. The two studies using nationally-representative sampling designs to assess past-year prevalence found rates of 4.7% (Swaziland; Tsai et al., 2011 ) and 14.1% (Malawi; Fan et al., 2016 ). In comparison, somewhat higher rates—14.6% (Nigeria; Adejemi et al., 2016 ) and 24.4% (Ethiopia; Adinew & Hagos, 2017 )—were identified in the two studies of past-year prevalence among students, and a wider range of past-year prevalence rates—4.6% (Botswana; Tsai et al., 2011 ) to 38.3% ( Parmar et al., 2012 )—in the five studies using non-student and non-nationally-representative samples. In the five studies that assessed sexual assault by interview, past-year prevalence ranged from 4.6% (Botswana; Tsai et al., 2011 ) to 38.3% ( Parmar et al., 2012 ), as compared to a somewhat narrower range of 5.1% (Nigeria; Decker et al., 2014 ) to 24.4% (Ethiopia; Adinew & Hagos, 2017 ) for the four studies using self-report assessments. The study using the most restrictive definition of sexual assault (including only completed, forced, penile/vaginal penetration) found a past-year prevalence rate of 11.3% (Burundi; Elouard et al., 2018 ), whereas the study using the most inclusive definition of sexual assault (including incapacitated, coerced, non-penetrative, and/or attempted assaults) found a relatively higher past-year prevalence rate of 24.4% (Ethiopia; Adinew & Hagos, 2017 ).

Three studies reported on prevalence during other periods of time for women. Two separate studies of Ethiopian students at the same university reported rates of sexual assault during college: Adinew and Hagos (2017) used a broad definition of sexual assault and reported a sexual assault prevalence rate of sexual 8.0% since starting university and 2.4% in the current academic year, and Tora (2013) reported that the prevalence of completed rape was 2.4% during the first year of university and 0.8% in the 2nd year of university and above. Ibanga (2011) reported a prevalence rate of 16.5% since age 16 (Nigeria).

Two studies reported prevalence rates for men unselected for sexual orientation. Both were conducted in Nigeria. The past-year prevalence of sexual assault was reported to be 9.4% among undergraduate students ( Adejimi et al., 2016 ), and the prevalence of sexual assault since age 16 was reported to be 15.0% among randomly-sampled individuals in the North-Central and South-South regions of Nigeria ( Ibanga, 2011 ).

LGBT individuals.

Adejimi and colleagues (2016) reported that the past-year prevalence of sexual assault was 14.8% among bisexual individuals (51% of whom were women) and 18.2% among “homosexual” individuals (27% of whom were women).

Seven studies contributed information from four countries in Asia: China (3 studies; 2 Hong Kong and 1 mainland), India (2 studies), Mongolia (1 study), and Turkey (1 study).

Four studies reported past-year prevalence rates for women unselected for sexual orientation. All of these studies used self-report assessments of sexual assault 3 , and none used a nationally-representative sampling design. The one study of past-year prevalence among college students found a rate of 59.2% (Turkey; Schuster et al., 2016), whereas the past-year prevalence range was lower—0.0% (Hong Kong; Zhang et al., 2016 ) to 7.2% (India; Decker et al., 2014 )—for non-student samples. Of the studies assessing past-year prevalence, the two studies with the most restrictive definition of sexual assault (including only completed, coerced or forced penile/vaginal penetration) found past-year prevalence rates for non-partner sexual assault of 1.0% (China) and 1.6% (India). In comparison, the study using the most inclusive definition of sexual assault (including incapacitated, coerced, non-penetrative, and/or attempted assaults) found a relatively higher past-year prevalence rate of 59.2% (Turkey; Schuster et al., 2016).

Two studies reported on prevalence during other periods of time for women. In a representative sample of Hong Kong Chinese women, 0.6% reported nonpartner sexual assault since age 18. In a study of students at four universities in Turkey, the prevalence since age 15 was 77.6%.

Two studies reported prevalence rates for men unselected for sexual orientation. One study reported a past-year prevalence of 0.3% among unmarried young men in Hong Kong ( Zhang et al., 2016 ). In a representative sample of Hong Kong Chinese men, 0.8% reported nonpartner sexual assault since age 18. In a study of students at four universities in Turkey, the past-year prevalence of sexual assault was 55.5%, and the prevalence since age 15 was 65.5%.

Two studies reported prevalence for LGBT individuals. Shaw and colleagues (2012) reported a past-year prevalence of sexual assault of 17.5% among men who have sex with men and transgender individuals in 4 districts in southern India. Peitzmeier and colleagues (2015) reported a past-3-year prevalence rate of 16.0% (crude) and 14.7% (weighted) among people assigned male sex at birth who had had anal sex with a man in the past 12 months.

Twenty-one studies reflected European countries, including Austria (1 study), Belgium (1 study), Cyprus (1 study), Germany (3 studies), Greece (1 study), Lithuania (1 study), Netherlands (3 studies), Norway (1 study), Poland (2 studies), Portugal (1 study), Slovakia (1 study), Spain (2 studies), Sweden (1 study), and the United Kingdom (2 studies). Eleven of these studies were conducted by Krahé and colleagues.

Four studies reported past-year prevalence rates for women unselected for sexual orientation. Among the studies using nationally-representative designs, the past-year prevalence of sexual assault ranged from 0.6% (Spain; Domenech Del Rio et al., 2017 ) to 1.7% (Netherlands; de Haas et al., 2012 ), whereas the highest past-year prevalence rate (1.9%) was identified in the one study of past-year prevalence among students (United Kingdom; Holloway & Bennett, 2018 ). Two studies of past-year prevalence used interviews to assess sexual assault and found rates of 0.6% (Spain; Domenech Del Rio et al., 2017 ) and 1.2% (Germany; Allroggen et al., 2016 ). In comparison, similar but somewhat higher rates were identified in the two studies using self-report measures: 1.7% (Netherlands; de Haas et al., 2012 ) and 1.9% (Wales; Holloway & Bennett, 2018 ). In terms of study definitions, the study assessing past-year prevalence with the most restrictive definition (which referenced both completed forced penetration and “sexual assault” generally) found a prevalence rate of 1.2% (Germany; Allrogen et al., 2012). In comparison, the two studies with the most inclusive definitions (explicitly including coerced, non-penetrative, and/or attempted assaults) found that past-year prevalence was 0.6% (Spain; Domenech Del Rio et al., 2017 ) and 1.7% (Netherlands; de Haas et al., 2012 ).

Fifteen studies assessed the prevalence of sexual assault since adolescence or adulthood among women. In the three studies using a nationally-representative design, the past-5-year prevalence was 2.5% (Germany; Hellmann et al., 2018 ), the prevalence since age 13 was 9.8% for completed sexual assault (Britain; Macdowall et al., 2013 ), and the prevalence since age 18 was 6.2% (Norway; Thoresen et al., 2015 ). In college samples, the prevalence since the (country-specific) age of majority was higher, ranging from 30.8% (Spain; Krahé et al., 2015 ) to 45.5% (Greece; Krahé et al., 2015 ), and the range of prevalence estimates in non-college samples was wider, from 6.2% (Norway; Thoresen et al., 2015 ) to 52.2% (Netherlands; Krahé et al., 2015 ). The prevalence since the age of majority was assessed by interview in one study and was found to be 6.2% (Norway; Thoresen et al., 2015 ), whereas the prevalence as assessed by self-report measures was higher, ranging from 9.8% ( Macdowall et al., 2013 ) to 52.2% (Netherlands; Krahé et al., 2015 ). The study with the most restrictive definition of sexual assault (including only forced completed penetration) found a prevalence of 6.2% (Norway; Thoresen et al., 2015 ), whereas the prevalence in studies with the most inclusive definition (including incapacitated, coerced, non-penetrative, and/or attempted assaults) was higher, ranging from 19.7% (Lithuania; Krahé et al., 2015 ) to 52.2% (Netherlands; Krahé et al., 2015 ).

Four studies reported past-year prevalence rates for men unselected for sexual orientation. Among the studies using nationally-representative designs, the past-year prevalence of sexual assault was 0.6% (Germany; Allroggen et al., 2016 ) and 0.7% (Netherlands; de Haas et al., 2012 ). In comparison, among the studies not using nationally-representative designs, the past-year prevalence was similar at 0.5% (Sweden; Swahnberg et al., 2012 ) and, in the only study to assess past-year prevalence in a sample of college students, past-year prevalence was 0.6% (United Kingdom; Holloway & Bennett, 2018 ). In the study with the most restrictive definition (which referenced both completed forced penetration and “sexual assault” generally), past-year prevalence was 0.6% (Germany; Allroggen et al., 2016 ), whereas in the study using the most inclusive definition (including coerced, non-penetrative, and/or attempted assaults), past-year prevalence was similar, at 0.7% (Netherlands; de Haas et al., 2012 ).

Sixteen studies assessed the prevalence of sexual assault since adolescence or adulthood among men; all studies used a self-report measure to assess sexual assault. Among the two studies using nationally-representative designs, the prevalence of completed sexual assault since the age of majority was 0.3% (Norway; Thoresen et al., 2015 ) and 1.4% (Britain; Macdowall et al., 2013 ). In comparison, the range of prevalence estimates since the age of majority was relatively higher—from 19.4% (Germany; Krahé & Berger, 2013 ) to 55.8% (Greece; Krahé et al., 2015 )—in four studies of college students, and wider—from 1.5% (Sweden; Swahnberg et al., 2012 ) to 49.0% (Cyprus; Krahé et al., 2015 )—in nine studies using non-student and non-nationally-representative samples). The study with the most restrictive definition of sexual assault (including only forced completed penetration) found that prevalence since the age of majority was 0.3% (Norway; Thoresen et al., 2015 ), whereas rates were higher—ranging from 10.1% (Belgium; Krahé et al., 2015 ) to 55.8% (Greece; Krahé et al., 2015 )—in the studies using a more inclusive definition of sexual assault (including incapacitated, coerced, non-penetrative, and/or attempted assaults).

Three studies reported prevalence rates for LGBT individuals. In a study of university students in Germany, Krahé and Berger (2013) reported prevalence rates since the age of consent (14 years) of 8.7% for women and 26.3% for men with a history of same-sex contact only, and 47.4% for women and 37.0% for men with a history of both same- and opposite-sex contact. In a study of alcohol-related sexual assault among university students in Wales, Holloway and Bennett (2018) reported past-year prevalence rates of 3.0% among individuals identifying as lesbian or gay, 2.0% among individuals identifying as bisexual, and 2.8% among individuals identifying as “other.” Bos and colleagues (2019) studied cisgender individuals in the Netherlands attracted to people of the same sex, and found that the prevalence of sexual assault since age 16 was 10.9% for men and 23.9% for women.

No identified studies reported on the prevalence of sexual assault in Oceania.

Latin America

Six studies reported on the prevalence of sexual assault in Brazil (3 studies), Chile (2 studies), and Mexico (1 study).

Four studies reported prevalence rates for women. The past-year prevalence of sexual assault was assessed by one study as 4.7% (Brazil; da Silva et al., 2010 ). Three studies reported on the prevalence of sexual assault since age 14, and yielded rates ranging from 29% (Brazil; D’Abreu et al., 2013 ) to 51.9% (Chile; Schuster et al., 2016b ).

Three studies reported prevalence rates for men unselected for sexual orientation. These studies reported on the prevalence of sexual assault since age 14 and yielded rates ranging from 20.4% (Chile; Lehrer et al., 2013 ) to 48.0% (Chile; Schuster et al., 2016b ).

Three studies reported prevalence rates for LGBT individuals. In a study of cisgender men in Brazil who had sex with a man or transgender person in the past 12 months, 54.1% of those with a lifetime sexual assault history reported past-year sexual assault ( Sabidó et al., 2015 ). Among college students in Brazil, the prevalence of rape since age 14 was 11.8% for bisexual men, 14.3% for bisexual women, 14.3% for “homosexual” men, and 0% for “homosexual” women ( D’Abreu et al., 2013 ). In a study of cisgender men who have sex with men (defined as individuals who reported anal or oral sex with a male partner in the last year) in Tijuana, Mexico, a past-year prevalence rate of 1.5% was identified ( Semple et al., 2017 ).

The aim of this paper was to offer an updated review of English-language studies published since 2010 that examined the prevalence of adolescent and/or adult sexual assault in countries other than the US and Canada. Knowledge about the worldwide scale of sexual aggression is scarce compared to the broad research literature that has built up in North America. A systematic search of the relevant databases yielded a total of 32 articles with 45 studies from 30 countries that met the inclusion criteria for our review (i.e., peer-reviewed studies published in English since 2010 that assessed the prevalence of adolescent or adult sexual assault in a country other than the US or Canada in general population or student samples of different sexual orientations). The majority of studies in this review found that sexual assault was endemic in the country studied. The prevalence of past-year sexual assault against women ranged from 0% (China) to 59.2% (Turkey). The prevalence of past-year sexual assault against men ranged from 0.3% (China) to 55.5% (Turkey). Among LGBT individuals, the prevalence of past-year sexual assault against ranged from 1.5% (Mexico) to 54.1% (among those with a lifetime sexual assault history; Brazil). As expected, prevalence rates based on longer time periods were higher, but due to variations in the periods covered, they cannot be presented in a summary fashion. These differences may reflect variation in study methodology. In addition, sociocultural variables (e.g., presence of patriarchal, heterosexist, or violence-supportive norms) that differ across countries may affect risk for sexual assault ( Krug et al., 2002 ) and explain these differences.

Differences in Prevalence Estimates by Study Methodology

Study methodology varied widely, which likely impacted the magnitude of obtained prevalence estimates. Comparisons for all of these aspects of study methodology are limited by a small number of studies using the same type of methods; indeed, in many regions, we were unable to conduct any comparisons. Nevertheless, some notable differences were observed.

First, some patterns in prevalence rates as a function of sample were noted. In particular, past-year prevalence estimates tended to be higher in college student samples (for past-year prevalence among women in Africa, Asia, and Europe, but not for men in Europe) as compared to nationally-representative samples. Although research in the US has also documented high rates of sexual assault in college samples ( Fedina et al., 2018 ), there is some indication that higher rates of sexual assault observed in college samples may be due to the younger age of these samples rather than college attendance per se ( Mumford et al., 2020 ). Indeed, there is evidence that rates of sexual assault may in fact be higher among college-aged women who do not attend college ( Sinozich & Langton, 2014 ), potentially because college attendance may be a marker of certain protective factors against victimization risk (e.g., economic and housing stability). Yet other studies did not find differences between students and nonstudents in the prevalence of sexual assault ( Coker et al., 2016 ; Mumford et al., 2020 ). Therefore, additional research is needed to examine a potentially increased risk of sexual assault among young adults globally, and to understand regional risk and protective factors for victimization. In addition, as compared to nationally-representative samples, the range of prevalence estimates tended to be wider in samples that were neither nationally representative nor composed of college students (for past-year prevalence among women in Africa; for prevalence since adolescence/adulthood among both women and men in Europe), suggesting less precision in reflecting the true country-level prevalence of sexual assault in these studies.

Second, study definitions of sexual assault appeared to affect observed prevalence estimates. In most cases where we were able to make comparisons, prevalence was higher when using explicitly inclusive definitions of sexual assault—including, for example, coerced, attempted, and/or non-penetrative assaults—and lower when studies used more restrictive definitions. This suggests that researchers should be thoughtful in how they define sexual assault, and assessing and reporting the prevalence of specific types of assaults (e.g., coerced vs. force) would be helpful to increase the comparability of global studies on this topic.

Less clear patterns emerged as a function of whether sexual assault was assessed by interview or self-report. Whereas the range of past-year prevalence estimates among women in Africa was wider for interview studies versus self-report studies, higher rates of sexual assault (both past-year and in adolescence/adulthood) were identified in self-report studies as compared to interview studies among women in Europe. This is perhaps unsurprising, given that research has found no differences in rates of disclosure of sensitive information (including sexual assault) as a function of interview versus self-report methods ( Rosenbaum et al., 2006 ). However, there may be cross-cultural differences in comfort with disclosure in interview versus self-report measures, and more research on this topic is needed to clarify this issue.

Studies that assess the prevalence of sexual assault in multiple countries using similar methods can help to identify true differences in prevalence across countries. However, just three studies in our review included data from more than one country ( Decker et al., 2014 , two African and two Asian countries; Krahé et al., 2015 , 10 countries in the European Union; Tsai et al., 2011 , 2 African countries). These studies show clear differences in prevalence rates that cannot be attributed to differences in methodology. For example, in the Decker et al. study, past-year prevalence rates of nonpartner sexual assault of women varied from 2% in China to 18% in South Africa. In the Krahé et al. (2015) study, prevalence rates of sexual assault victimization since the age of consent varied between 20% in Lithuania and 52% in the Netherlands. A qualitative follow-up study did not reveal differences between the countries in the way the items were interpreted ( Krahé et al., 2016 ). However, even when the same design and instruments are used, comparability of prevalence rates between countries may be affected by cultural differences, such as differences in willingness to disclose experiences of violence, or in familiarity with the response format ( Krahé, Bieneck, & Möller, 2005 ). Indeed, it is likely that the prevalence rates identified in this review are biased by underreporting ( Cook et al., 2011 ).

Strengths and Limitations of the Reviewed Literature

The studies included in this review highlight existing research priorities and gaps. We were able to obtain prevalence data obtained for most world regions, even though only English-language studies were included. However, the total number of estimates was small and distributed unevenly across world regions, with Europe ( n =21) and Africa ( n = 11) making up two-thirds of the studies. Although many of studies from Europe were conducted by a single research team and reflected relatively small samples comprised mostly of students, this still represents an uneven distribution., which was also found in the comprehensive review of prevalence studies of nonpartner sexual assault by Abrahams et al. (2014) . In addition, we found no studies from Oceania and only one study from the Middle East from which we could garner prevalence data. Although it is possible that research on this topic was published in languages other than English, it is also possible that this reveals a lack of research on this topic in certain world regions. This could be due to multiple factors, such as less structural support for academic research outside of the US and Canada, relatively less attention to the issue of sexual assault prevalence in some countries, or country-specific difficulties in conducting prevalence research (e.g., ongoing conflict, infrastructure challenges).

More studies examined sexual assault rates for women compared to men, which mirrors the state of the evidence in North America (e.g., Fedina et al., 2018 ; Peterson, et al., 2011 ). However, it was surprising to note that less than a third of studies were limited to women, which perhaps reflects an increase in global attention to the problem of sexual assault against men. The underrepresentation of studies including LGBT participants ( n = 19) (e.g., men who have sex with men) also parallels the North American knowledge base ( Rothman et al., 2011 ). Moreover, it is worth noting that 12 of the 19 LGBT studies came from Europe, reflecting a lack of attention to sexual assault in these groups in many countries outside the Western world.

Assessment of the risk of bias of studies identified a notable strength of this body of literature: the methods used in the current set of studies to assess sexual assault were relatively high-quality. In 32 studies, behaviorally-specific questions presenting different coercive strategies were used to elicit reports of sexual assault, and 30 studies used behaviorally-specific questions about the sexual acts in which victims were made to engage. The use of behaviorally-specific questions is considered superior to the use of broad, single-item questions ( Cook et al., 2011 ), which were used in 11 studies. Using behaviorally-specific questions is particularly relevant for cross-cultural analyses of the prevalence of sexual assault because cultural differences in the social construction of sexual assault are not detected using broad labels, such as rape. The predominance of the gold standard of using behaviorally-specific questions in the current body of studies is in contrast to the review by Abrahams et al. (2014) , who found most of their studies to use broad questions about sexual assault, not specifying coercive strategies and sexual acts. One possible reason for this difference is that our review was restricted to studies published in peer-reviewed journals, whereas over 90 percent of the estimates in the Abrahams et al. review came from grey literature reports that are typically not subjected to the same degree of rigorous quality control. However, it is also possible that this reflects more recent researcher adoption of advancements in the measurement of sexual assault.

In addition to the small overall number of studies, the knowledge about sexual assault generated by the body of evidence covered in our review is limited by several aspects of the studies. The average risk of bias score was 5.7 on a scale from 0 to 10, where 10 indicates maximum bias, indicating that the obtained prevalence rates need to be interpreted with caution with regard to their generalizability to the population as a whole. Specific areas of limitation were identified in this regard. First, fewer than half of the studies ( n = 19) were based on random samples from the target population, one was based on a census, and the remainder were based on convenience samples. Second, sample sizes varied widely, ranging from 22 to over 10,000 across the total set of studies, which creates large differences in terms of statistical power and measurement error. These aspects highlight the challenge of ensuring equivalence in the study of sexual assault across cultures, which needs to be defined at the level of conceptual definitions, operationalizations, sample selection, data collection process, and analyses ( Padilla, Benitez, & Vijver, 2019 ). It is important to note that these methodological issues are by no means specific to the literature covered by this review but also apply to studies of the prevalence of sexual assault more generally, including the evidence from North America ( Cook et al., 2011 ). It is also important to note that the primary goal of these studies was not necessarily to assess the prevalence of sexual assault, so these limitations pertain to the goal of understanding the global prevalence of sexual assault rather than reflecting the quality of the primary studies per se.

Limitations of the Current Review

Although the present set of studies adds important information about the scale of sexual assault worldwide, several limitations have to be noted about our review. First, only studies published in English were accessible to us. It is possible that relevant articles on this topic were published in languages other than English and were missed by our search strategy, although the lack of research on this topic from certain English-speaking countries (e.g., Australia) was notable. Second, the review was limited to studies published in peer-reviewed journals. Given that such studies accounted for less than 10% of the estimates included in the review by Abrahams et al. (2014) , this means that many more prevalence estimates are likely to be available in other outlets, which are not considered in our study. However, the limitation to studies subjected to peer review was deemed appropriate to achieve a similar standard of quality control across the studies, acknowledging that these standards may still vary to some extent between journals. Third, we did not consider studies that focused exclusively on sexual assault by intimate partners. In countries outside North America and Western Europe, intimate partner violence against women has received far more research attention than sexual assault by strangers. Because this literature has been covered comprehensively by Abrahams et al. (2014) , we decided to adopt a broader perspective that also included nonpartner sexual assault. Finally, because we focused on studies that were primarily concerned with identifying the prevalence of sexual assault, we may have missed studies that did not specify “incidence,” “prevalence,” or “scale” among the keywords but reported lifetime or one-year prevalence rates as part of other research questions.

Research Implications

Based on the results of this review, the first priority for a global research agenda on the comparative prevalence of sexual assault across countries should be to assess prevalence in multiple countries using standardized data collection protocols. Realizing this goal is likely beyond the scope of a single study and may require large-scale funding by international agencies for comparative studies in a sufficiently large sample of countries from different regions. Given the uneven geographic distribution of available English-language studies, special attention should be given to regions (e.g., Middle East, Oceania) where few or no previous studies have been conducted. Once a reliable data base has been established, the second task for a cross-cultural research agenda on the prevalence of sexual assault consists of identifying factors that may differentiate countries in terms of their relative scale of sexual assault. A limited body of comparative studies have examined associations between country-level variables, such as gender inequality, overall levels of crime, or religious affiliations, and prevalence rates of sexual aggression (e.g., Coon, 2013; Hines, 2007 ; Krahé et al., 2015 ). A special topic is the problem and significance of sexual assault in regions of conflict, in which sexual assault is more difficult to assess but also more likely to occur ( Krug et al., 2002 ). Third, it will be important to gain an understanding of sexual assault in specific subcultures within countries. Some of the studies in our review examined sexual assault in selected subgroups of the population, such as samples from disadvantaged or high-risk neighborhoods (e.g., Decker et al., 2014 ; Tsai et al., 2011 ). This perspective needs to be extended to identify conditions that precipitate sexual assault within regions. The use of qualitative research methods and an intimate knowledge of the respective culture are essential to address this task. Finally, future systematic reviews should include studies published in a range of languages other than English to address the English-language bias of the current review. Fostering international collaboration between researchers on this topic could help to facilitate such reviews.

Policy Implications

The gaps identified in this review also have implications for the development of policies and prevention measures. One task is to promote the acknowledgement of sexual assault experiences by sexual minorities, especially in countries in which they are discriminated against at the levels of law and societal discourse. Another task is to offer better protection to victims regardless of sex and sexual orientation by appropriate legislation and victim-support provisions. Finally, combining evidence from prevalence studies with knowledge about variables that predict an increased vulnerability to sexual assault is needed to design theory-based programs for the prevention of sexual assault. In the age of globalization and large-scale migration, such efforts need to consider the cultural context in which sexual assault occurs and must be stopped.

Supplementary Material

Acknowledgments.

Author note: Manuscript preparation for this article was supported by National Institute of Alcohol Abuse and Alcoholism (NIAAA) Grant R00AA026317 (PI: Dworkin). The views expressed in this article are those of the authors and do not necessarily reflect the positions or policies of the University of Washington or the NIAAA.

We acknowledge that there is limited and mixed evidence regarding whether 12-month prevalence estimates of sexual assault are necessarily more accurate than those reflecting longer recall periods ( Gibbs et al., 2019 ), but chose to retain this criterion to maximize similarity to the original tool and reflect the likelihood that shorter recall periods produce less biased recall than longer recall periods.

The total number of studies reflects those studies for which we were able to code study characteristics. The number of studies is smaller than 45 when some studies were missing information on a given study characteristic.

Zhang et al. (2016) used face-to-face interviews unless participants requested to complete measures alone, in which case, self-report measures were used.

Contributor Information

Emily R. Dworkin, University of Washington, United States.

Barbara Krahé, University of Potsdam, Germany.

Heidi Zinzow, Clemson University, United States.

* = Studies included in the review

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Examining the short and long-term impacts of child sexual abuse: a review study

• Review Paper
• Open access
• Published: 15 February 2024
• Volume 4 , article number  56 , ( 2024 )

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• Sana Ali   ORCID: orcid.org/0000-0003-3474-000X 1 , 2 ,
• Saadia Anwar Pasha   ORCID: orcid.org/0000-0002-6416-7358 3 ,
• Ann Cox   ORCID: orcid.org/0000-0002-8399-8050 4 &
• Enaam Youssef 5  

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Child sexual abuse is a growing problem, representing an egregious abuse of power, trust, and authority with far-reaching implications for the victims. This review study highlights the intricate psychological impacts of child sexual abuse, addressing both short and long-term consequences. Existing literature highlights the deep impacts on the victims’ psychological health and well-being, necessitating an in-depth examination of the subject. Drawing from a sample of n = 19 research articles selected through stringent inclusion and exclusion criteria and the PRISMA approach, this study synthesizes results from publications spanning 2010 to 2022. The review reveals various detrimental impacts on the victims’ psychological well-being, including short-term consequences, i.e., isolation, bullying, stress, anxiety, and post-traumatic stress disorder (PTSD). Long-term effects encompass PTSD in later life, disrupted intimate relationships, social and emotional health concerns, revictimization, and more. In conclusion, the study emphasizes the lack of a definitive number of impacts, highlighting the need to discuss and raise awareness about child sexual abuse. This increased awareness is important for parents, guardians, and responsible authorities to effectively counteract these crimes against children. Also, providing emotional support to victims is important to mitigate the long-term impacts. The researchers offer implications and discuss limitations, providing an extensive overview and foundation for future research and interventions.

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Introduction

Child sexual abuse is prevalent across class, race, and ethnicity, with both short-term and long-term impacts. It mainly involves an interaction between the abuser and the child, in which the child is the focus of the sexual stimulation of an observer or the offender (Wagenmans et al. 2018 ). Child sexual abuse is anticipated as silencing the minor, and consequently, reporting such incidents is much less. Even without knowing the full ratio of the relevant incidents, experts agree that 500,000 children face sexual abuse yearly (YWCA.org 2017 ). This sexual offence against children has always been an existing phenomenon in all societies and historical eras. For instance, ancient civilizations openly adopted child sexual abuse as a normal, cultural, and social practice aimed at the learning and development of children (Ali 2019 ). Despite the perceptions about child sexual abuse historically varied, we found varying perceptions ranging from acceptance (justifiable) to rejection (children’s rights violation) (DiLillo et al. 2014 ). Child sexual abuse is not limited only to penetration; instead, showing a child pornographic photos, voyeurism, touching a child’s genitals, and even making the child touch or see the perpetrator’s private body parts is also considered sexual abuse (National Sexual Violence Resource Center 2011 ). It is also notable that both boys and girls are strongly susceptible to sexual abuse. However, girls are more vulnerable as they confront sexual abuse three times more than boys, while boys are more likely to be severely injured or die after sexual molestation (National Sexual Violence Resource Center 2011 ). A report by the World Health Organization in 2006 revealed that more than 20% of women and 8% of men in 39 countries reported that they had faced sexual abuse during childhood.

Similarly, data from 2012 to 2013 shows that 2% of boys and 4% of girls experience some sexual abuse every year (Chan et al. 2013 ). Another report (UNICEF 2020a ) revealed that more than 120 million individuals worldwide face forced sexual acts during their childhood. Most are females (89%), and 11% are males. Globally, this statistic is much higher as every one out of four girls and one in every six boys during the early years of their lives (YWCA.org 2017 ).

Similarly, sexual abuse of children is possible in almost every social setting and location, i.e., schools, roads, justice institutions, and homes. Also, it is prevalent equally among all socio-economic classes and age groups; children facing sexual abuse sometimes cannot realize their molestation (Selengia et al. 2020 ). Around 92.0 of the reported incidents were linked by acquittances (closed relatives), indicating the prevalence of incestuous abuse (Ali et al. 2021 ). Notably, there are three dynamic factors behind child sexual abuse, i.e., psychological, economic, and social. For instance, social factors involve one’s personal experience of sexual exploitation during childhood (Middleton et al. 2017 ). Economic factors involve poverty. For example, parents may ask their girl child to look for a capable man to take care of her primary needs, which may further lead to engaging in sexual activities in return for monetary support (Simuforosa 2015 , p. 1792).

On the other hand, psychological factors are mainly defined as sexual interest in children due to a mental disorder (Tenbergen et al. 2015 ). However, the economic factors responsible for perpetuating child sexual abuse mainly involve forcibly engaging children in sexual acts, selling or buying children pornography, and all the other relevant factors that lead to the economic benefits for the perpetrators (Ali 2019 ). Notably, the impacts of child sexual use are detrimental from different aspects. For instance, these impacts are immediate yet prolonged, indicating their severity during adulthood. According to (Downing et al. 2021 ), stress-induced variations in the pro-inflammatory substances, i.e., alterations in gene expression and cortisol, mediate these detrimental impacts.

Additionally, risky sexual behaviours against children and the opposite gender are further attributed to the impacts of child sexual abuse (Fisher et al. 2017 , p. 11). Child sexual abuse poses an influential societal challenge, demanding careful examination to understand its complexities fully.

Aim and purpose

This research aims to scrutinize the role of Child Sexual Abuse as a risk factor for causing several psychological concerns among the victims. The researcher has reviewed some studies on Child Sexual Abuse and its impacts. Drawing on the aims of this article, the study aims to examine (1) the short-term psychological impacts of Child Sexual Abuse and (2) the long-term psychological impacts of Child Sexual Abuse according to studies conducted during the past twelve years (2010–2022). The overarching goal is to provide a comprehensive synthesis of existing literature, shedding light on the multifaceted consequences of child sexual abuse over both short and long-term durations. By systematically analyzing and assessing a selected set of articles, this study seeks to contribute to the understanding of prevalent themes, methodologies, and gaps in the existing literature surrounding the psychological impacts of child sexual abuse. The significance of this work extends to informing future research, interventions, and policymaking related to child protection and well-being. Finally, the aim is to facilitate the development of targeted and effective strategies for preventing, intervening, and supporting individuals affected by children.

In response to the urgent need for a comprehensive understanding, this review study uses the PRISMA approach to navigate existing literature. Addressing the CSA in current knowledge, we highlight the major difficulties associated with unravelling the complexities of child sexual abuse. This review not only synthesizes an extensive body of research but also discusses their findings and insights to overcome the inherent challenges in comprehending the short and long-term impacts of child sexual abuse. Our study seeks to make a distinctive contribution by explaining the intercity of this fragile subject matter, thus laying the groundwork for more effective interventions and support systems. It addresses the following research questions based on the aims and purposes of current research.

RQ1. What constitutes Child Sexual Abuse, and how can it be accurately defined within the current literature?

RQ2. How does Child Sexual Abuse affect the mental health and overall well-being of individuals, considering both short-term and long-term impacts?

This study is based on the systematic literature review approach. The review-based studies are a significant part of the existing literature as they closely witness the ongoing trends and complexities in the field under study (Ali and Pasha 2022 ). Besides, the relevant studies also highlight the major findings to further the gap and conduct an in-depth analysis of the other aspects of the same concern.

Assumptions and justifications

In the context of this systematic literature review, certain assumptions were made to facilitate the synthesis and analysis of the selected studies. These assumptions are integral to the nature of the review process. First, it was deemed that the definitions of key terms, i.e., “child sexual abuse” and “psychological impacts,” were relatively consistent across the selected studies. This assumption is grounded in the anticipation that researchers within the field comply with widely accepted definitions and classifications. While variations in terminologies exist, a comprehensive screening process and compliance with inclusion criteria mitigated possible discrepancies. The study focused on articles with clear and relevant definitions, assuring homogeneity in the selected literature.

Further, the decision to include articles published from 2010 onwards was based on the assumption that recent research mirrors current trends and developments in comprehending the psychological impacts of child sexual abuse. The rationale is rooted in the dynamic nature of research, focusing on current perspectives. This assumption allows for analyzing the most recent insights into the subject matter and recognizing the evolving nature of societal attitudes and academic discourse.

Evaluation of assumptions

While these assumptions were important for the systematic review process, it is important to acknowledge their probable impact on the results. A few considerations emphasize how these assumptions may affect the outcomes. For example, despite efforts to ensure consistency, variations in definitions across studies may introduce complexities in interpreting psychological impacts. This could influence the synthesis of results, and readers should be aware of the potential heterogeneity in conceptualizing key terms. Besides, the focus on recent publications assumes that newer research accurately represents the current landscape. However, this may bias contemporary perspectives, potentially bypassing practical insights from earlier studies.

Thus, considering the problem’s complexity and continuous research, the researcher selected three specialized platforms: PubMed, Science Direct, and APA PsycNet. However, the selection criteria were not restricted to any age, gender, race, ethnicity, nationality, and language. The keywords for the search were “impacts of child sexual abuse, child sexual abuse, psychological effects of child sexual abuse, short-term effects of child sexual abuse, and long-term effects of child sexual abuse. Later the researcher tabulated the data using Microsoft Excel, which further helped calculate the included articles’ percentages and frequencies. The researcher used the PRISMA method for systematic review, as suggested by (Page and McKenzie 2021 ). Table  1 summarizes the inclusion and exclusion criteria used in the current study:

Based on the PRISMA method of screening, evaluation and Selection, the researchers gathered a total of 113 records from the selected database. After removing the duplicates, 106 total articles were further screened for full-text availability (93). Finally, the researchers selected n  = 19 articles adhering to the selection criteria (See Fig.  1 ).

PRISMA flow chart for the articles selection process

Table  2 summarizes the frequencies and percentages of the literature according to their database. It is observable that most of the articles were from PubMed (n = 11 or 57.8). APA PsyNet provided n = 7 or 36.8% articles, while n  = 1 (5.2%) article was obtained from Science Direct.

Table  3 summarizes the frequencies and percentages of the selected literature according to their publication years. As visible, most of the studies ( n  = 12, 63.1%) were published from 2015 to 2020, indicating that these years focused mainly on research scholars in psychology, communication, sociology, criminology, and other fields. These results also reflect the prevalence of the relevant concern demanding a strong consideration towards children’s rights and health protection (Ali and Pasha 2022 ). Followed by 04 or 21.0% of studies published between 2010–2015, n  = 03 or 1.7% of studies published until the end of November 2022.

Concerning the frequencies and percentages of the cited literature according to their designs, most studies (09 or 47.3%) were based on a review approach. Followed by experimental design ( n  = 06 or 31.5%), 03 or 15.7% of studies were based on the perspective method. Finally, online n  = 1 (5.2%) of the study was based on the case study method, and the same number of studies ( n  = 1, 5.2%) was categorized as “other” (See Table  4 ). Additionally, n  = 11 or 7.8% of studies were based on a qualitative approach, n = 11 or 57.8% were based on the quantitative approach, and only one study was based on the mixed method approach (See Table  5 ).

The researchers calculated the frequencies and percentages of the cited literature according to the data-gathering approaches used by the relevant researchers (See Table  3 ). Most studies ( n  = 13, 68.4%) were based on the survey method. Besides, the interview approach was preferred in 04% of studies. While n  = 1 (5.2%) study was based on the literature review approach, and the same number of literature ( n  = 1, 5.2%) was categorized as “other”.

Validation of selected methodology

The methodology used in this systematic literature review underwent a thorough validation process to ensure its reliability and comprehensiveness. Key elements of the validation process are.

Adherence to PRISMA Guidelines: The systematic review methodology rigorously adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, as Page and McKenzie ( 2021 ) recommended. PRISMA guidelines are widely recognized and accepted standards for conducting systematic reviews, assuring a systematic and transparent approach to literature synthesis.

Inclusion and Exclusion Criteria: Establishing clear and strict inclusion and exclusion criteria contributed to the robustness of the methodology. These criteria were designed to select studies that specifically addressed the psychological impacts of child sexual abuse, enhancing the relevance and reliability of the synthesized literature.

Search Strategy: The search strategy employed in selecting articles was exhaustive, using three specialized platforms—PubMed, Science Direct, and APA PsycNet. The chosen keywords were carefully selected to encompass diverse dimensions of child sexual abuse and its psychological impacts, minimizing the risk of overlooking pertinent studies.

Data Tabulation and Analysis: Using Microsoft Excel for data tabulation provided a structured and organized approach to handling the extensive information extracted from the selected articles. This facilitated a systematic calculation of frequencies and percentages, assuring accuracy and consistency in reporting.

PRISMA Flow Chart: A PRISMA flow chart (Fig.  1 ) visually represents the systematic article selection, screening, and inclusion process. This chart improves transparency and serves as a visual validation of the methodological stringency applied in the study.

While this systematic review does not involve the same type of validation as experimental or modelling studies, the validation lies in compliance with established guidelines, rigorous criteria for article selection, and transparent reporting of the review process. These elements collectively contribute to the robustness and credibility of the methodology used in this study.

Review of literature

Defining child sexual abuse.

According to (Pulverman et al. 2018 ), the definition of child sexual abuse has been a major concern for many researchers since the 1970s. The prevalent cases and recent concerns indicate that providing and establishing the definition of child sexual abuse is urgent and needs strong consideration. Notably, it is important to keep the complexity and sensitivity of the relevant issue under consideration when providing a potential definition of child sexual abuse (Pulverman et al. 2018 ) theoretically defined child sexual abuse as the unconscionability of the acts, which further indicates four types of activities such as the relationship of power between an adult and child, the child in the lower position facing inequality, the child’s susceptibility is exploited based on their detriment, and truancy of true consent (Table 6 ).

Defining sexual abuse can vary on a different basis. For instance, (Vaillancourt-Morel et al. 2016 ) argue that child sexual abuse mainly relies on the legal definition. Several self-reported cases of child sexual abuse remained affirmed, leading to further legal actions, yet some cases indicate doubtful accusations. As in the empirical study (Vaillancourt-Morel et al. 2016 ), results indicated 21.3% sexual abuse among females and 19.6% among males. At the same time, 7.1% of females and 3.8% remained consistent with self-defined child sexual abuse. However, (Ma 2018 ) stated that the relevant definition could vary according to the prevalence estimation. Besides, this definition is based on five criteria, including the age of the childhood, the age of the perpetrator or the age difference between the victim and the perpetrator, the relationship between the victim and the perpetrator, the type of sexual acts performed by the perpetrator, and the extension of the coercion. According to (Pulverman et al. 2018 ), child sexual abuse can be defined as unwanted sexual activities between an adult and a child, including vaginal, oral, and anal penetration. Besides, online child sexual abuse, including online sex, child pornography, and others, is also considered a vital type of child sexual abuse.

Impacts of child sexual abuse

Child sexual abuse is strongly detrimental to children’s physical and psychological health. In this regard, researchers and medical experts claim physical consequences as serious as brain damage and immediate death. Minor injuries are also found in some cases. However, death is the most common physical outcome of child sexual abuse (Habes et al. 2022 ). As noted by (Beltran 2010 ), no single impact patterns exist. Sometimes, a victim does not show any prominent impacts that may impede the development of a psychological syndrome that adversely affects a child’s social, emotional and cognitive abilities. Some researchers claim that only 20–30% of children remain emotionally and physically stable after sexual molestation. However, although they remain normal, internally, they develop latent effects of sexual abuse. The short-term and immediate psychological impacts of sexual abuse may involve painful emotions, Post-traumatic stress disorder, cognitive distortions, and disturbed mood. These victims respond to sexual abuse in diverse ways that can be changed over time. However, the psychological harm is still severe and can result in even adverse consequences. During sexual abuse, victims can feel fear, anxiety, self-blame, guilt, confusion, and anger. They feel self-conscious and humiliated, unable to talk about what happened, which can result in stress and frustration (Pulverman et al. 2018 ). Table  1 below provides a summary of studies witnessing the physical and psychological consequences of child sexual abuse (Table 7 ).

(Batool and Abtahi 2017 ) named short-term effects “initial effects”, as these reactions mainly occur during the first two years of abuse. Previous studies revealed that 66.0% of children were emotionally disturbed due to sexual abuse, 5.2% were mild to moderately disturbed, and 24.0% remained stable after the sexual abuse. Similarly, a study conducted by (Fontes et al. 2017 ) also witnessed the short-term impacts of sexual abuse on the mental health of the victims. Results gathered by using the Propensity Score Matching technique revealed that 13.3% of sexually abused children reported a greater feeling of loneliness, 7.5% were having difficulty in making friends, and 9.5% reported insomnia. Despite these effects differing among male and female children, both were equally confronting to the relevant mental disturbances.

Further, regarding the long-term effects of child sexual abuse, (Petersen et al. 2014 ) stated that it results in both short and long-term effects. A survivor may feel peer rejection, confusion, lack of self-confidence, conduct disorder, oppositional defiant disorder, and aggression. Similarly, in the later years, the survivor may also develop other extreme psychiatric disorders such as depression, low economic productivity, drug addiction and even severe medical illness. According to (Hodder and Gow 2012 ), long-term child sexual abuse can also result in substance abuse, long-term depression, negative attributions, and even eating disorders. Most recently, practitioners also found even more chronic mental disorders such as delusions, schizophrenia, and personality disorders. However, children who have experienced abuse involving penetration are more likely to develop these chronic psychotic and schizophrenic disorders. Likewise, sexually abused children also have low self-esteem and overly sexualized behaviour, which, in many cases, results in teen pregnancy and motherhood and even an increased vulnerability to another victimization (Townsend 2013 ). Besides, socially isolated children with a disability or emotional disorder are comparatively more vulnerable to victimization. Once the abuse has happened, they also face threats to end the relationship if they refuse to perform sex or threats to publicly share their sexual images (UNICEF 2020b ) (Table 8 ).

Wagenmans et al. ( 2018 ) highlighted the occurrence of prolonged and severe psychological disorders among individuals who previously experienced child sexual abuse. As noted, the prolonged effects are more common when there is a repetitive and interpersonal nature of abuse, mostly leading to develop Post-Traumatic Stress Disorder (PTSD) in later years. Those with a history of Child Sexual Abuse risk developing issues in interpersonal relationships, emotional regulation, and self-concept that result in “Complex PTSD” (p. 2). As (Gupta and Garg 2020 ) noted, child sexual abuse indicates an increased self-harming behaviour, fear, depression, impaired brain development, and others that are criteria for developing Post-Traumatic Stress Disorder (PTSD). Notably, this sexual abuse is not limited to physical and sexual harm; it also involves emotional abuse that further indicates the severity of the relevant issue today. It is also worth mentioning that most victims report sexual abuse in their later life. These victims also indicate their revictimization as one of the most consistent outcomes of child sexual abuse (Papalia et al. 2021 ). The term revictimization is also defined as any further victimization even during childhood, adolescence, or adulthood after the first incident of sexual abuse during childhood (P.1). However, there can be different factors, including sex, mental health issues, age at initial abuse, and others as different determinants of revictimization (Papalia et al. 2021 ). (MacIntosh and Ménard 2021 ) synthesized the status of research witnessing the long-term impacts of child sexual abuse over the past thirty years. As noted, different researchers have witnessed different impacts. Disturbed academic functioning, substance abuse and alcoholism in later years, revictimization and developing Post-Traumatic Stress Disorder (PTSD). Besides, sexual disorders, sex-related cognitions, disturbed intimate relationships, and emotional aspects of sexuality remain highlighted, witnessed, and still need much more consideration. Finally, the study by (Schreier et al. 2017 ) highlighted another important dimension regarding the impacts of child sexual abuse, as their focus was on the victims’ siblings as an important factor to determine in post-abuse scenarios. As noted, siblings can confront several emotional responses after disclosing the child’s sexual abuse. Siblings’ reactions are important as negative behaviour can increase the post-abuse stress among the victim and the family. Thus, it is concluded that the siblings should also be provided clinical services to reduce the negative impacts of child sexual abuse. Siblings also indicate symptoms of distress on an average level that needs strong consideration.

The gathered evidence unequivocally highlights the pervasive and profound negative impacts of child sexual abuse on the psychological health, cognitive development, and overall well-being of victims. The complex dynamics of the relationship between the abuser and the child, initially built on trust and affection, morph into a distressing paradigm of power, domination, victimization, and, in some examples, revictimization. The susceptibility of children in such situations places their psychological health at considerable risk, necessitating urgent and effective preventive measures to protect their well-being. This study serves to highlight the enduring and detrimental repercussions of child sexual abuse that can persist throughout a child’s life. The complexities of the psychological toll highlight the need for targeted interventions and support mechanisms. Our findings indicate that discussions and heightened awareness surrounding child sexual abuse are imperative. It is not merely a matter of quantifying impacts but a call to action to proactively empower parents, guardians, and responsible authorities to counteract these blatant crimes against children. Thus, our study affirms the critical importance of providing emotional support to victims, recognizing it as an integral component in mitigating the long-term impacts of child sexual abuse. By shedding light on the deep consequences and supporting awareness, we aim to contribute to the collective efforts toward a safer environment for children, free from the effects of sexual abuse.

Implications

Incidents of child sexual abuse are prevalent, especially since access to vulnerable children is even more feasible due to social media and other digital platforms (Ali et al. 2021 ). Consequently, children are at increased risk of maltreatment, particularly sexual abuse. Consequently, this research has some implications for the service and police departments, parents, and mental healthcare practitioners across the globe.

Families should receive prevention support and guidance through proper risk assessment and multi-level parent education (Tener et al. 2020 ). Parents informing the children about the protection measures can also help them prevent any detrimental incident that may further nullify the impacts of sexual abuse.

Providing mental healthcare services to the victims, their families, and their siblings, as also emphasized by (Schreier et al. 2017 ), also ensures the children’s mental well-being and development, especially among those who have been through any abusive exposure.

Besides psychological impacts, there are other detrimental impacts that child faces after sexual abuse that necessitate the provision of adequate healthcare services. These healthcare services aim to ensure the different consequences of abuse and that the victim may overcome the incident (Rahnavardi et al. 2022 ).

Medical healthcare providers, including staff, should also support and guide the victim and their families. Although exposure to a CSA victim can be traumatizing for healthcare practitioners, their behaviour and support patterns can help the victims cope with the challenges, especially with the psychological impacts (Pérez-Fuentes et al. 2013 ).

A victim can also face other consequences that may further worsen the impact of sexual abuse, including bullying. Schools and teachers can also effectively nullify these impacts by supporting and scrutinizing the victims. The focus should be on avoiding any further outcomes on their mental health (Sawyerr and Bagley 2017 ).

Implementing laws and active consideration towards welfare programs and training sessions for children, parents, and teachers as caregivers can also mitigate the impacts of child sexual abuse (Batool and Abtahi 2017 ).

Limitations and recommendations

Although this study synthesized the findings of recent literature witnessing both short-term and long-term impacts of child sexual abuse, it also contains some primary limitations. First, this study does not involve human subjects or clinical trials that may witness the impacts under study in a particular setting. Second, the Selection of the cited articles was strict and based on only three databases, limiting its scope. Third, the research does not provide any country-specific evidence. Instead, the cited literature is scattered and based on studies from around the world. Finally, although the study empirically witnesses the impacts of child sexual abuse, there are many regions where empirical research on child sexual abuse, its impacts, and causes are understudied. Consequently, this study emphasizes conducting more research on the impacts of child sexual abuse, its prevalence, and causal factors that may further provide strong insights regarding the relevant issue and help propose implications and nullify its impacts.

Data availability

No data is associated with this research project.

Code availability

No codes are available for this study.

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Ali, S., Pasha, S., Cox, A. et al. Examining the short and long-term impacts of child sexual abuse: a review study. SN Soc Sci 4 , 56 (2024). https://doi.org/10.1007/s43545-024-00852-6

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Lessons learned from child sexual abuse research: prevalence, outcomes, and preventive strategies

Delphine collin-vézina, isabelle daigneault, martine hébert.

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Although child sexual abuse (CSA) is recognized as a serious violation of human well-being and of the law, no community has yet developed mechanisms that ensure that none of their youth will be sexually abused. CSA is, sadly, an international problem of great magnitude that can affect children of all ages, sexes, races, ethnicities, and socioeconomic classes. Upon invitation, this current publication aims at providing a brief overview of a few lessons we have learned from CSA scholarly research as to heighten awareness of mental health professionals on this utmost important and widespread social problem. This overview will focus on the prevalence of CSA, the associated mental health outcomes, and the preventive strategies to prevent CSA from happening in the first place.

Keywords: Child sexual abuse, Review, Prevalence, Mental health outcomes, Prevention

Although only recently acknowledged as a concerning social problem, child sexual abuse (CSA) is, in our day, at the forefront of worldwide social policies and practices. Four decades of research has certainly contributed to better our knowledge on the experiences of victims of CSA. With more than 20,000 research papers on CSA listed under the most renowned research databases, child and adolescent mental health practitioners, researchers and decision-makers may find it challenging to keep up with this rapidly increasing literature. In response to this need, the aim of the current paper is to provide a brief overview on CSA to heighten awareness of practitioners on this utmost important and widespread social problem. The content of this paper was first presented at the annual symposium of the Centre for Child Protection , headed by the Institute of Psychology at the Pontifical Gregorian University and scholars of the University of Ulm, to a group of religious leaders responding to the sexual abuse of minors around the world, including Argentina, Ecuador, Germany, Ghana, India, Indonesia, Italy and Kenya. Upon invitation, this current publication is a unique opportunity to highlight a few of the main lessons we have learned from the scholarly literature on CSA, with a focus on its prevalence, mental health outcomes and preventive strategies.

Magnitude: how prevalent is CSA?

Until recently, there was much disagreement as to what should be included in the definition of CSA [ 1 ]. In some definitions, only contact abuse was included, such as penetration, fondling, kissing, and touching [ 2 ]. Non-contact sexual abuse, such as exhibitionism and voyeurism, were not always considered abusive. Nowadays, the field is evolving towards a more inclusive understanding of CSA that is broadly defined as any sexual activity perpetrated against a minor by threat, force, intimidation, or manipulation. The array of sexual activities thus includes fondling, inviting a child to touch or be touched sexually, intercourse, rape, incest, sodomy, exhibitionism, involving a child in prostitution or pornography, or online child luring by cyberpredators [ 3 , 4 ]. CSA experiences vary greatly over multiple dimensions including, but not limited to: duration, frequency, intrusiveness of acts perpetrated, and relationship with perpetrator. Although sexual activity between children has long been thought to be harmless, child on child CSA experiences, such as those involving siblings, is increasingly being recognized as detrimental for the emotional well-being of children as adult on child CSA [ 5 - 7 ]. While adult-to-child interactions in which the purpose is sexual gratification are considered abusive, sexual behaviours between children are less clear-cut as there is no universal definition of sexual abuse that differentiates it from normal sex play and exploration [ 8 ]. Although a 2 to 5-year age difference between children was first suggested as necessary to consider sexual behaviours between siblings to be incest [ 9 ], this criterion is being questioned as studies have shown this age difference to be much lower in many substantiated cases of child-to-child abuse [ 10 ]. This formulation of CSA is in keeping with the recommendations from the 1999 World Health Organization Consultation on Child Abuse Prevention, where CSA is defined as any activity of a sexual nature ‘between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person’. That said, some definitional issues have not yet been resolved in the field. First, much disparity exists regarding age for sexual consent, or age for sexual maturity, which has an influence on the extent to which statutory sex offenses are considered CSA. Sexual activities that involve a person below a statutorily designated age fall under the large umbrella of CSA; however, the age of consent varies greatly across countries, from as young as 12 or 13 (e.g. Tonga, Spain) to 17 or 18 years of age (e.g. some states in the US, Australia). In virtually all European jurisdictions, sexual relations are legal from age 16 onwards, but some countries have set the age for sexual consent at 14 or 15 [ 11 ]. In other words, when no coercion or force is used, cases that involve sexual activities between an adult and, for example, a 14-year-old teenager, will be either perceived as a consensual sexual relationship or criminalized and defined as sexual abuse, depending on the legal statutorily designated age of the country where the event occurred. In Canada, a bill was recently adopted to change the age of consent from 14 to 16, a premiere in Canada’s history, which emphasizes the impact governmental decisions can have on definitional issues of CSA in societies over time [ 12 ]. Second, although coerced sexual activities that occur in dating or romantic relationships is recognized as a form of sexual violence by the World Health Association (see for example a WHO multi-country study from Garcia-Moreno and colleagues [ 13 ]), the extent to which this form of interpersonal violence is socially recognized and acknowledged in different legislations around the world is unclear.

In that vein, the exact extent of the problem of CSA is difficult to approximate given the lack of consensus on the definition used in research inquiries, as well as the differences in the data collection systems across areas [ 14 ]. For example, in their review of the current rates of CSA across 55 studies from 24 countries, Barth and colleagues [ 15 ] found much heterogeneity in studies they reviewed and concluded that rates of CSA for females ranged from 8 to 31% and from 3 to 17% for males. Though, despite these methodological challenges, recent systematic reviews and meta-analyses that included studies conducted worldwide across hundreds of different age-cohort samples have consistently shown an alarming rate of CSA, with averages of 18-20% for females and of 8-10% for males [ 16 ], with the lowest rates for both girls (11.3%) and boys (4.1%) found in Asia, and highest rates found for girls in Australia (21.5%) and for boys in Africa (19.3%) [ 17 ]. Research findings do, however, clearly demonstrate a major lack of congruence between the low number of official reports of CSA to authorities, and the high rates of CSA that youth and adults self-report retrospectively. Indeed, the recent comprehensive meta-analysis conducted by Stoltenborgh and colleagues [ 17 ] that combined estimations of CSA in 217 studies published between 1980 and 2008, showed the rates of CSA to be more than 30 times greater in studies relying on self-reports (127 by 1000) than in official-report inquiries, such as those based on data from child protection services and the police (4/1000). In other words, while 1 out of 8 people report having experienced CSA, official incidence estimates center around only 1 per 250 children.

This discrepancy can be explained by the different steps that CSA cases go through before they are substantiated, and thus counted in official-report inquiries. First, victims of CSA or their confidants have to disclose their suspicions to the authorities. Many reports of child abuse are never passed on. In fact, the majority of studies highlight the fact that many victims continue to be unrecognized [ 3 ]. A review of CSA studies by Finkelhor [ 2 ] found that across all studies, only about half of victims had disclosed the abuse to anyone. This problem is often referred to as the phenomenon of the “tip of the iceberg” [ 18 ], where only a fraction of CSA situations are visible and a much higher proportion remain undetected. Disclosure is a delicate and sensitive process that is influenced by several factors, including implicit or explicit pressure for secrecy, feelings of responsibility or blame, feelings of shame or embarrassment, or fear of negative consequences [ 2 , 19 , 20 ]. Ethnic and religious cultures may also influence the way by which the process of disclosure is experienced and can act as either facilitators or barriers to the telling and reporting of CSA [ 21 ], which may explain variations of CSA rates across geographical areas [ 17 ]. Moreover, mandatory reporting regulations that have been adopted over the past decades in several countries, which imply that professionals are obliged to bring their suspicions of CSA to the attention of the authorities, can also impact the official counts of CSA in different countries [ 22 ]. In jurisdictions that have chosen not to enact mandatory reporting, including New Zealand, the United Kingdom, and Germany, a large discrepancy between adult self-reports of CSA and official data is to be expected as more cases may not be divulged to the authorities than in countries where reporting is mandatory. Second, based upon the initial disclosure or reporting, cases are screened in or out for further investigation by child protection workers or the police. Not all sexual abuse cases are considered to fall under the jurisdiction of child protection services, such as those that were assessed to involve no imminent risk to the child with regards to his/her security and development. For instance, cases where the alleged perpetrator is not the child’s caregiver may be less likely to be retained for investigation as it may not be under child welfare responsibilities to investigate these cases [ 23 ]. Finally, in light of evidence gathered in the course of the investigation process, cases are deemed substantiated or not by child protection workers and the police. When the child’s testimony is deemed unreliable or when the proof is perceived as questionable, cases may be considered unfounded and will, as a result, not be counted towards official data. Indeed, there is some evidence that police are less likely to charge sexual offenses than any other type of violent crime [ 24 ]. Other factors, such as the victim’s gender, may also influence substantiation decisions as demonstrated in a recent American study that showed, using the National Survey of Child and Adolescent Well-Being, that workers were less likely to substantiate cases involving male victims [ 25 ]. As improper interviewing techniques may hamper the capacity of victims to report accurately the abusive experience they were subjected to, promoting and sustaining best-practice interviewer techniques, notably among police officers, should be prioritized [ 26 ]. Considering the impact that all these different layers of influence have on cutting down the number of CSA cases that are known to and substantiated by the authorities, victims identified in official-report inquiries are therefore believed to represent only a small fraction of the true occurrence. For all these reasons, relying on official-reports to determine the magnitude of CSA is a method that carries a constant error of underestimation. In other words, children that are identified are only those that were able to disclose, were believed, reported to, and followed up by proper authorities, and those cases that presented enough evidence to be substantiated as CSA.

In terms of risk factors, being female is considered a major risk factor for CSA as girls are about two times more likely to be victims than males [ 16 , 17 ]. Several authors do, however, point out that there is a strong likelihood that boys are more frequently abused than the ratio of reported cases would suggest given their probable reluctance to report the abuse [ 27 ]. A recent Canadian population-based study confirmed this assumption by showing that among CSA survivors, 16% of female victims had never disclosed the abuse, whereas this proportion rose to 30% for male victims [ 28 ]. With respect to age, children who are most vulnerable to CSA are in the school-aged and adolescent stages of development, though about a quarter of CSA survivors report they were first abused before the age of 6 [ 3 ]. In addition, girls are considered to be at high risk for CSA starting at an earlier age and lasting longer, while boys’ victimisation peaks later and for a briefer period of time. The presence of disability is also considered a risk factor for CSA and other forms of maltreatment as the impairments may heighten the vulnerability of the child [ 29 ]. Aside, the absence of one or both parents or the presence of a stepfather, parental conflicts, family adversity, substance abuse and social isolation have also been linked to a higher risk for CSA [ 30 ]. In terms of the presupposed impact of socioeconomic status and ethnic background, the existing literature has many weaknesses and obvious contradictions. Overall, while low family or neighborhood socioeconomic status is a great risk factor for physical abuse and neglect [ 31 , 32 ], its impact on CSA is not as proven. On one hand, CSA could appear to occur more frequently among underprivileged families because of the disproportionate number of CSA cases reported to child protective services that come from lower socioeconomic classes [ 3 ]. In that vein, some populations of children have been overrepresented in research that focuses on vulnerable populations, such as Black American children from low socioeconomic status families, which may create an erroneous belief that race and ethnicity are risk factors for CSA [ 33 ]. On the other hand, some recent population-based studies are showing that, amongst other factors, living in poverty is a predictive factor for children to be subjected to both physical and sexual abusive experiences [ 34 , 35 ].

Mental health outcomes: what are the effects of CSA?

Several models have been developed in an attempt to explain the adverse negative impact of CSA [ 36 ]. Among the most established conceptual frameworks on the impact of CSA is the Four-Factor Traumagenics Model [ 37 ]. This model suggests that CSA alters a child’s cognitive and emotional orientation to the world and causes trauma by distorting their self-concept and affective capacities. This model underscores the issues of trust and intimacy that are particularly pronounced among victims of CSA. The unique nature of CSA as a form of maltreatment is highlighted by the four trauma-causing factors that victims may experience, which are traumatic sexualization, betrayal, powerlessness, and stigmatization. Traumatic sexualization refers to the sexuality of the victims that is shaped and distorted by the sexual abuse. Betrayal is the loss of trust in the perpetrator who shattered the relationship and in other adults who are perceived as not having protected the child from being abused in the first place, or having not supported her upon disclosure. Powerlessness is experienced through power issues at play in CSA, where victims are unable to alter the situation despite feeling the threat of harm and the violation of their personal space. Stigmatization is the incorporation of perceptions, reinforced by the perpetrator’s manipulative discourse or by dominant social negative attitudes towards victims, of being bad or deserving and responsible for the abuse.

Several reviews and meta-analyses published in the 90s and early years of 2000 suggested that a wide range of psychological and behavioral disturbances were associated with the experience of CSA, which led experts in the field to conclude that CSA was a substantial risk factor in the development of a host of negative consequences in both childhood, adolescence and adulthood [ 38 - 41 ]. More recently, systematic reviews have confirmed that, given the vast array of etiological factors that interact in predicting mental health outcomes, CSA is considered a significant, though general and nonspecific, risk factor for psychopathology in children and adolescents [ 42 - 44 ].

Among the wealth of psychopathologies that have been studied among CSA victims, post-traumatic stress and dissociation symptoms have received great attention. Overall, victims have been shown to present significantly more of these symptoms than non-abused children, or than victims of other forms of trauma. In one of our studies that compared 67 sexually abused school-aged girls with a matched group, CSA was found to significantly increase the odds of presenting with a clinical level of dissociation and PTSD symptoms, respectively, by eightfold and fourfold [ 45 ]. These results have echoed previous research conducted among cohorts of sexually abused school-aged children and teenagers where about a third to a half of all victims showed clinical levels of post-traumatic stress symptoms [ 46 - 50 ]. Only a few studies have been conducted with younger cohorts of children, yet high levels of dissociation were documented among sexually abused preschoolers [ 51 , 52 ]. In that vein, results from one of our recent inquiries revealed higher frequencies of dissociative symptoms among a group of 76 sexually abused children aged 4 to 6 than children of the comparison group [ 53 ]. These symptoms were found to persist over a period of a year following disclosure [ 54 ]. In contrast to children who have experienced other forms of trauma, it was also found that CSA victims are more likely to present post-traumatic stress symptoms [ 55 ]. Using a prospective method in which sexually abused children were followed over 36 months, Maikovich, Koenen, and Jaffe [ 25 ] demonstrated that boys were as likely as girls to exhibit post-traumatic stress symptoms.

Aside from post-traumatic stress and dissociation symptoms, a significant number of other mental health and behavioral disturbances have been linked to CSA. High levels of mood disorders, such as major depressive episodes, are found in cohorts of children and teenagers who have been sexually abused [ 56 , 57 ]. Sexually abused children are more likely than their non-abused counterparts to present behavior problems, such as inappropriate sexualized behaviors [ 58 ]. In the teenage years, they are found to more often exhibit conduct problems [ 59 ] and engage in at-risk sexual behaviors [ 60 , 61 ]. Victims are more prone to abusing substances, to engaging in self-harm behaviors, and to attempting or committing suicide [ 62 - 65 ]. Adolescents sexually abused in childhood are five times more likely to report non-clinical psychotic experiences such as delusions and hallucinations than their non-abused counterparts [ 66 ].

The mental health outcomes of CSA victims are likely to continue into adulthood as the link of CSA to lifetime psychopathology has been demonstrated [ 67 - 72 ]. Even more worrisome is the fact that CSA victims are more at risk than non-CSA youth to experience violence in their early romantic relationships [ 73 , 74 ] and that they are 2–5 times more at risk of being sexually revictimized in adulthood than women not sexually abused in childhood [ 75 - 77 ]. In adulthood, CSA survivors are more likely to experience difficulties in their psychosexual functioning [ 78 , 79 ]. A 23-year longitudinal study of the impact of intrafamilial sexual abuse on female development confirmed the deleterious impact of CSA across stages of life, including all of the mental health issues mentioned above, but also hypothalamic–pituitary–adrenal attenuation in victims, as well as asymmetrical stress responses, high rates of obesity, and healthcare utilization [ 80 ]. The impact of CSA as a predictor of major illnesses is garnering increasing attention, including gastrointestinal disorders, gynecologic or reproductive health problems, pain, cardiopulmonary symptoms, and diabetes [ 81 - 83 ]. In all cases, early assessment and intervention to offset the exacerbation and continuation of negative outcomes is highlighted, according to several studies [ 84 ], as symptoms can develop at a later age [ 3 ] or may not be apparent at first [ 85 ].

Indeed, despite overwhelming evidence of deleterious outcomes of CSA, it is commonly agreed that the impact of CSA is highly variable and that a significant portion of victims do not exhibit clinical levels of symptoms [ 86 ]. Some authors have suggested that about a third of victims may not manifest any clinical symptoms at the time the abuse is disclosed [ 87 ]. This can be explained, in part, by the extremely diverse characteristics of CSA which lead to a wide range of potential outcomes [ 86 ]. Other common reasons thought to account for asymptomatic survivors of sexual abuse include: (1) insufficient severity of abuse, (2) the fact that symptoms may not be detected by practitioners, (3) development of avoidant coping styles that mask victims’ distress, (4) or that asymptomatic survivors may be more resilient than the survivors who show symptoms [ 88 ]. Related to this latter explanation, among an array of variables potentially influencing the resilience capacities of CSA victims, children who receive support from their non-offending parents [ 89 ] and those who have not experienced prior abuse [ 90 ] seem to fare better in spite of the sexual abuse adversity. Among other personal and relational factors that promote resilience in victims are: less reliance on avoidant coping strategies to deal with the traumatic event [ 91 - 93 ], higher emotional self-control [ 94 ], interpersonal trust and feelings of empowerment [ 85 ], less personal attributions of blame and of stigmatization [ 95 , 96 ], and high family functioning and secure attachment relationships [ 97 , 98 ]. This scholarship points to the importance of using a broad ecological framework when researching and intervening on the factors that promote resilience in victims of CSA [ 88 ].

Three promising lines of research have recently emerged that shed new light on the relationships between CSA and psychopathology. First, results from the growing field of polyvictimization, which is the study of the impact of multiple types of victimization (from peers, family, crime, community violence, physical assaults, and sexual assaults), call for a de-compartmentalization of violence research by pointing out that cumulative experiences of victimizations are more detrimental to the child’s well-being than are any single experiences, including those of a sexual nature [ 99 ]. This suggests that measuring the impact of all forms of victimization alongside CSA is warranted in order to fully capture the influence of violence and abuse on the development of children and youth mental health outcomes. Second, recognizing the great diversity of symptom presentations in sexually abused cohorts, several scholars have attempted to identify the different profiles or sub-categories of victims. For example, Trickett and colleagues [ 100 ] found distinct profiles in their sample of girls sexually abused by family members, including victims of multiple perpetrators, characterized by significantly higher levels of dissociation, and victims of father-daughter incest who presented higher levels of disturbances across domains, including internalized (e.g. depression) and externalized (e.g. delinquency) behaviors. Hébert and colleagues [ 101 ] further contributed to this scholarship by identifying four different profiles among a sample of sexually abused children: (1) the chronically abused children displaying anxiety symptoms, (2) the severely abused children presenting a host of both internalized and externalized problems, (3) the less severely abused children displaying fewer symptoms, (4) and the less severely impaired children despite severe experiences of CSA, which the authors referred to as the resilient group. As a whole, these studies call for a better tailoring of the services offered to sexually abused children, so that services can well match the mental health needs of victims [ 102 ]. Third, drawing from epigenetics [ 103 ], cutting-edge inquiries are developing in CSA research on the interaction of CSA with other environmental factors and with genetic factors to predict mental health and behavioral outcomes, for example, violent behavior [ 104 ], or suicidal gesture [ 105 ]. These inquiries confirm the relevance of studying the psychobiology of child maltreatment [ 106 ] as a promising route to better our understanding of the unique contribution of CSA to mental health disturbances, relative to other factors, as well as of the complex nature of the interactions at play. This knowledge could eventually benefit the elaboration of effective intervention programs.

Preventive strategies: how can we prevent CSA from happening in the first place?

In light of the high prevalence of CSA and the wealth of deleterious outcomes associated with this abusive experience, it stands to reason that research attention must turn toward preventing CSA. Two widespread forms of sexual assault prevention efforts have been extensively studied and disseminated, namely, offender “management” and educational programs delivered, for the most part, in school settings. Offender management is the approach that aims to control known offenders, for example, registries, background employment checks, longer prison sentences and various intervention programs. It is a tertiary prevention initiative that acts mostly in the individual sphere and, as such, presents certain inherent limitations in regards to preventing CSA from happening in the first place [ 107 ]. Indeed, although the public generally approves of so-called punitive legal practices, such as longer sentences, they are based on a misconception of sexual abusers as pedophiles, “guileful strangers” who prey on children in public places, when in actual fact the child sex offender population is more varied, includes individuals known to the victim and is comprised of juveniles in almost a third of cases [ 107 ].

The second most frequent approach, primary prevention, involves universal educational programs generally delivered in schools and aimed at potential victims. In the majority of cases, these universal programs also intervene in the individual preventive sphere and more infrequently in the family or societal sphere. Regarding children attending elementary school, meta-analyses by Zwi and colleagues [ 108 ], covering 15 studies, and by Davis and Gydicz [ 109 ], covering 27 studies, revealed that programs are effective at building children’s knowledge about sexual abuse and their preventive skills. The second of those two meta-analyses further demonstrated that programs are more effective if they are longer in duration (four sessions or more), if they repeat important concepts, if they provide children with multiple opportunities to actively practice the taught notions and skills, and if they are based on concrete concepts (what is forbidden) rather than abstract notions (rights or feelings). Some programs have proven effective for building knowledge and skills among children in an average socio-economic environment [ 110 ], but presented mitigated results in a multi-ethnic and underprivileged urban environment, indicating that the program may need to be adapted in order to optimize its effects with specific clientele [ 111 ]. As per adolescents or young adults attending high school or college, a meta-analysis of 69 studies involving close to 20,000 participants revealed that programs are effective for improving participants’ knowledge and attitudes [ 112 ]. However, changes in terms of behaviours or intentions to act were too low to be clinically significant. Also, factors related to the clientele, the facilitator, the setting and the format of the program have all been shown to impact the effectiveness of sexual violence prevention programs in college or university settings [ 113 ]. For some of the above programs, data are available to suggest that they are associated with a reduction of the incidence of child sexual assault [ 114 ] and sexual victimization in teenage romantic relationships [ 115 ]. However, too few studies are available to draw a firm conclusion as to the efficacy of prevention efforts, introduced since the 1970s, to reduce the true incidence of CSA observed by authorities in some countries, most notably the US [ 116 - 119 ].

The advantages of the universal approach are numerous: these programs can be offered at low cost, they are fairly easy to implement widely, and they allow to reach a maximum number of children while avoiding the stigmatization of a particular population. Yet, this approach has also been criticized since it places the responsibility of prevention in the hands of children. Consequently, this approach should not be considered as the only answer to a social problem as complex as CSA. A multi-factorial approach may indeed constitute a more promising solution to solve the problem of sexual abuse. A multi-factorial conceptualization of sexual assault suggests that only the development of global preventive approaches, targeting personal, family as well as societal norms that influence the risk of assault, may substantially reduce incidence and prevalence rates [ 119 , 120 ]. Those actions may take a variety of forms, such as awareness campaigns, efforts to provide the proper training to all persons who may work with children and adolescents, including sexual abuse and trauma themes in academic programs of future practitioners, or even the development of up to date and comprehensive kits to help the media provide information free of sexism, prejudices and sensationalism when reporting on sexual assault cases. In addition, parents’ participation is a fundamental element for a successful prevention initiative as this may increase the acquisition of preventive abilities in children [ 110 ], thus, future endeavors will need to tackle the challenges to foster a greater participation of parents. While most prevention initiatives have favoured a universal approach, targeting at-risk groups may also ensure optimal efficacy of prevention efforts. Integrating new technologies and using social medias (web site, applications for cell phones, online interactive games) may be particularly relevant for prevention efforts targeting teenagers. If such approaches were implemented and coordinated on a broad scale, they may have a greater impact on the number of sexual assault victims.

The sexual abuse of children is a form of maltreatment that provokes reactions of indignation and incomprehensibility in all cultures. Yet, CSA is, unfortunately, a widespread problem that affects more than 1 out of 5 women and one out of 10 men worldwide. This alarming rate clearly calls for extensive and powerful policy and practice efforts. While the effects of CSA may not always be initially visible, survivors of CSA still carry the threat to their well-being. The traumatic experience of CSA is one major risk factor in the development of mental health problems affecting both the current and future well-being of victims. Considering that many victims continue to be undetected, the roots of these mental health problems may also be unrecognized. In an effort to provide effective services to all victims, we should prioritize the development of strategies to address the barriers to disclosure and reporting. Although the taboo of CSA might not be as prominent as a few decades ago when CSA was rarely spoken of, veiled issues may still prevent victims from reaching out to authorities to reveal the abuse they suffer. To effectively prevent CSA, global preventive approaches, targeting personal, family and societal conditions, need to be explored and validated so to protect the next generations of children and youth from sexual victimization.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

The project was initiated by Prof. Dr. Collin-Vézina who wrote the sections on prevalence and mental health outcomes of CSA. Prof. Dr. Daigneault and Prof. Dr. Hébert led the writing on CSA prevention strategies. All authors read and approved the final manuscript.

Author’s information

Prof. Dr. Delphine Collin-Vézina is the Tier II Canada Research Chair in Child Welfare. She is a clinical psychologist by profession and a researcher in the area of child sexual abuse. She is an Associate Professor at the McGill University School of Social Work (Canada). Her proposed research program aims at promoting societal recognition of sexual abuse, and at implementing and evaluating promising practices to help victims of abuse heal from their trauma.

Prof. Dr. Isabelle Daigneault is a clinical psychologist and an Associate Professor in the Department of Psychology at the Université de Montréal (Canada). She has a particular interest in the areas of resilience and mental health of young sexual assault victims, as well as in the processes influencing the life trajectories of young victims. Her projects also relate to the efficacy of treatments offered to victims and sexual assault prevention programs.

Prof. Dr. Martine Hébert has training in child development and child clinical psychology. She is Full Professor at the Department of Sexology at the Université du Québec à Montréal (Canada) and director of the Research Team on interpersonal trauma. Her research interests focus on the diversity of profiles in sexually abused victims and factors related to resilience trajectories. Current projects also center on the evaluation of prevention and intervention programs.

Contributor Information

Delphine Collin-Vézina, Email: [email protected].

Isabelle Daigneault, Email: [email protected].

Martine Hébert, Email: [email protected].

Acknowledgements

The Article processing charge (APC) of this manuscript has been funded by the Deutsche Forschungsgemeinschaft (DFG).

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