Forms and Contexts of Child Sexual Abuse in Taiwan: Associations With Adverse Childhood Experiences,Mental Health Outcomes,and Revictimization

Abstract

Child sexual abuse (CSA) in non-Western contexts remains understudied, particularly with respect to how different forms and perpetrator–victim relationships are connected to other adverse childhood experiences (ACEs) and how they shape mental health and revictimization risk over time. This study examines the prevalence of CSA among Taiwanese children and its associations with other ACEs, psychiatric symptoms, and subsequent revictimization, with attention to both the form of sexual abuse and the perpetrator–victim relationship. Data were drawn from a nationally representative, longitudinal survey of children in the 4th and 8th grades (n = 2,599). CSA was assessed across contact (unwanted sexual touching or being forced to touch another person’s private parts) and non-contact forms (forced exposure to sexual images or videos), as well as by perpetrator relationship (parent/caregiver, sibling, or peer). Results indicated that 9.81% of 4th-grade children reported experiencing at least one form of CSA in the past 12 months. Distinct ACEs were differentially associated with specific CSA forms and perpetrator relationships, revealing patterned pathways of interpersonal risk. Parental physical violence was associated with a higher likelihood of parent/caregiver-facilitated CSA, whereas parental psychological neglect and bullying victimization were linked to increased risk of peer-facilitated CSA. All forms of CSA were associated with elevated concurrent psychiatric symptoms. Longitudinal analyses further demonstrated that sibling- and peer-facilitated contact CSA predicted greater psychiatric symptoms 4 years later. Additionally, parent/caregiver- and sibling-facilitated non-contact CSA, as well as peer-facilitated contact CSA, were associated with increased risk of revictimization at follow-up. These findings highlight the importance of distinguishing CSA by both form and perpetrator relationship to better understand the interpersonal contexts in which sexual abuse occurs and its lasting consequences. Implications for targeted prevention, early identification, and intervention strategies are discussed.

Keywords

child sexual abuse sexual abuse adverse childhood experiences mental health revictimization

Introduction

Child sexual abuse (CSA) is a major global issue that can lead to poor mental health throughout life, including depression, self-injury, and posttraumatic stress disorder (Hébert et al., 2021; Li et al., 2020; Liu et al., 2021; Stoltenborgh et al., 2015). CSA is defined as the involvement of children in sexual activity that they do not fully understand, do not or cannot give informed consent to, or are not developmentally ready for (World Health Organization, 1999). CSA can happen through contact (e.g., sexual intercourse, inappropriate touching, fondling) or non-contact (e.g., verbal sexual harassment, indecent exposure, exposure to pornography), and the perpetrator can be a parent, caregiver, sibling, peer, or others (Mathews & Collin-Vézina, 2017; Russell et al., 2020; World Health Organization, 2003). While there is clearer evidence about the risk factors and negative effects of childhood sexual victimization, it is less clear whether these factors and effects differ based on the form of abuse and the relationship between perpetrator and victim. Additionally, most research on this subject has been done in Western countries, with fewer studies exploring this in non-Western settings (Russell et al., 2020). The current study aims to fill some of these gaps by examining the prevalence, correlates, and mental health impacts of CSA, focusing on its forms (non-contact and contact) and the relationship between perpetrator and victim (parent/caregiver, sibling, and peer), using a probability-based sample of 4th graders in Taiwan and following up 4 years later (8th grade; n = 2,599). This research adds to the limited literature on CSA in non-Western contexts and broadens the understanding of its forms and the nature of perpetrator–victim relationships.

CSA: A Critical Global Issue

CSA is a major problem with lasting negative effects. Its harmful impacts are well documented. Research shows that experiencing sexual abuse in childhood is linked to a wide range of physical and mental health issues that can persist into adolescence and adulthood, including reproductive health disorders (Irish et al., 2010), depression (Hébert et al., 2021; Li et al., 2020), self-injury (Liu et al., 2021; Miller et al., 2013; Rodante et al., 2019), posttraumatic stress disorder (Engstrom et al., 2008; O’Brien et al., 2016), victimization from interpersonal violence (Scoglio et al., 2021), and sexual deviance (Levenson & Grady, 2016). Studies also indicate that CSA is widespread among children worldwide. A meta-analysis of global studies reported that the overall estimated prevalence of sexual abuse based on self-report was 12.7% (7.6% for boys and 18% for girls; Stoltenborgh et al., 2015). Another meta-analysis focused on China found prevalence rates of 15.3% for girls and 13.8% for boys (Ji et al., 2013). Similarly, a population-based study with 5,276 children aged 12 to 18 years in Taiwan found high past-year (17.4% for boys and 12.5% for girls) and lifetime (21.8% for boys and 17.7% for girls) prevalence rates for CSA (Feng et al., 2015).

Research has explored the risk factors of CSA, especially within the broader context of adverse childhood experiences (ACEs). The landmark ACEs study (Felitti et al., 1998), originally designed to evaluate the cumulative effects of various ACEs on adult physical health, found that these adversities frequently occur together. By examining different ACEs, Felitti et al. (1998) found significant relationships across exposure categories; individuals who reported any single ACE were more likely than those with no exposure to report additional ACEs, with probabilities ranging from 65% to 93%. Similarly, the poly-victimization framework (Finkelhor et al., 2007) indicates the clustering of victimizations, underscoring the importance of assessing a broad range of victimizations. These studies shed light on the risk factors associated with CSA. For instance, the ACEs study (Felitti et al., 1998) identified significant correlations between sexual abuse and other forms of child maltreatment, such as psychological and physical abuse, as well as factors indicating household dysfunction, including witnessing intimate partner violence (IPV), living with household members who have substance use issues, mental illnesses, or engage in criminal behaviors. Moreover, analyzing the National Survey of Children’s Exposure to Violence through a poly-victimization lens, Finkelhor et al. (2015) found that children who experienced sexual assault were at a significantly higher risk of experiencing physical assault, maltreatment, property crimes, and witnessing violence. Similar findings have emerged from research in other contexts on how ACEs are interconnected. For example, a meta-analysis on risk factors for CSA victimization in Western countries (the United States, Canada, Australia, New Zealand, and Europe) identified several key risks, such as previous CSA victimization, other forms of abuse occurring simultaneously or beforehand, and parental issues like IPV (Assink et al., 2019). Likewise, a population-based study of Australian children revealed that multi-type maltreatment is more common than single-type maltreatment, with nearly two in five children (39.4%) experiencing multiple types and a smaller portion (22.8%) reporting only one type (Higgins et al., 2023).

The Importance of Analyzing CSA Characteristics

Current literature highlights the importance of analyzing the characteristics of sexual abuse. Studies show variations in risk factors and negative psychosocial outcomes among individuals who have experienced CSA. For example, dividing CSA into intrafamilial and extrafamilial categories, a meta-analysis found that victims of intrafamilial abuse tend to start experiencing abuse earlier, face it more often, and endure it for a longer time (Ventus et al., 2017). Other research indicates that certain abuse characteristics are associated with more severe negative outcomes. One study reported that children with multiple reports of sexual abuse and those who experienced severe abuse, such as penetration and sexual injury, are more likely than those with a single report and who did not experience severe abuse to face problematic substance use, arrests, or suicide attempts later in life (Oshima et al., 2014). Another investigation linked complex victimization—defined as sexual abuse committed by a family member, involving penetration, physical injury, or intense fear—to higher levels of posttraumatic stress disorder symptoms, substance use, and risky sexual behavior in adulthood (Boroughs et al., 2015). Similarly, a study of adult women survivors of CSA found that those who experienced sexual abuse along with other forms of maltreatment (including physical or emotional abuse and neglect) and those who did not know their perpetrator were more likely to report self-injury (Steine et al., 2020). These findings suggest that multiple types of maltreatment and sexual abuse involving family members or physical contact tend to produce more serious effects, highlighting the importance of examining both the form of abuse and the perpetrator–victim relationship.

Current Study

Taken together, research to date shows that the ACEs and poly-victimization frameworks are helpful for understanding children’s victimization and the cumulative effects of abuse. It also highlights the importance of considering characteristics of sexual abuse, such as the form of abuse and the perpetrator–victim relationship, when examining the impact of CSA. It is still unclear how prevalence varies by abuse form and the relationship between victim and perpetrator, and which risk factors are linked to CSA when it is broken down by form (e.g., contact, non-contact) and the perpetrator–victim relationship. Addressing these questions is essential given their clinical significance, as it may help service providers develop prevention and intervention strategies better suited to different forms and contexts of abuse. Additionally, most research in this area is conducted in Western countries and often relies on retrospective methods that ask participants to recall their childhood experiences. However, seeking the child’s perspective matters because it may offer a more immediate and developmentally appropriate view, reducing recall bias from retrospective reports.

This study aims to fill some of these gaps by examining the prevalence of CSA, factors associated with its occurrence, and its mental health consequences, with particular attention to the forms of abuse and perpetrator–victim relationships. Using the ACEs framework, we examined the following questions with a sample of Taiwanese children (n = 2,599):

Q1: What is the prevalence of CSA among Taiwanese children, broken down by form (non-contact and contact) and the perpetrator–victim relationship (parent/caregiver, sibling, and peer)?

Q2: Which ACEs are associated with CSA, considering the form and perpetrator–victim relationship?

Q3: How does CSA, categorized by form and relationship, predict negative mental health outcomes and sexual revictimization?

Following the ACEs and poly-victimization models (Felitti et al., 1998; Finkelhor et al., 2007, 2015), we expected that CSA would be connected to ACEs. We didn’t set specific hypotheses about which ACEs are associated with CSA, broken down by form and relationship, because the existing research is limited in distinguishing between contact and non-contact CSA and in accounting for variations in perpetrator–victim relationships. Based on previous studies showing the harmful effects of CSA (Hébert et al., 2021; Li et al., 2020; Liu et al., 2021), we predicted that children who experienced CSA would have more mental health symptoms. Also, considering research indicating that more invasive or family-related abuse (e.g., penetration, physical injuries, family-perpetrated abuse) leads to worse outcomes (Boroughs et al., 2015; Oshima et al., 2014), we hypothesized that children experiencing contact and family-perpetrated CSA would report more severe mental health problems.

Methods

This study draws data from the Longitudinal Study of Children’s and Adolescents’ Family and Social Experiences, a longitudinal project that follows individuals from childhood through adolescence. We analyzed data collected in 2014 (T1: ages 10–11, 4th graders) and 2018 (T2: ages 14–15, 8th graders) from a sample of Taiwanese children (n = 2,599) followed over a 5-year period to assess CSA in middle childhood and adolescence.

Participants

Data were collected from the same cohort of students in 2014 and 2018. The sample was proportionally stratified by county and city in Taiwan (19 counties and cities in total, excluding outlying islands). First, counties and cities were classified as urban or rural, and districts within each category were randomly selected. In the 2013 to 2014 academic year, there were 2,583 primary schools in Taiwan, and the study sampled 25% of these schools. After identifying the sample schools, we contacted school principals to obtain their agreement to participate in the study. Schools whose principals agreed were asked to distribute an introductory letter and consent form to parents or guardians for their signatures. The introductory letter emphasizes that research participation is voluntary, that data collected will remain confidential, and that the data will be used solely for research. We then invited students whose parents provided consent to participate. Of the sampled schools, 314 (49%) principals agreed to participate in this study. Among children whose parents provided consent, almost all (99.9%) assented and completed the questionnaires, resulting in a total of 6,290 completed questionnaires in 2014. Of these, 57 were invalid and excluded from the study due to incomplete signatures from either parents or children, resulting in a sample of 6,233 participants in 2014 (T1). There were significant geographical differences between participating and non-participating schools: the average school-participation rate in Northern Taiwan was lower than the national average, while that in Eastern Taiwan was higher (Shen et al., 2019). Participants were reached again in 2018 (T2), with 2,661 children continuing to participate in the study. For the purposes of this paper, analyses were conducted with the 2,599 children who responded to the questions assessing sexual victimization in both T1 and T2. Of the 2,599 children, approximately half were boys (50.90%), and the majority (84.65%) reported that their parents were married or living together at T1. All respondents were 4th graders at T1, with a mean age of 10.37 years (SD = 0.51).

Procedures

This study received approval from the Research Ethics Committee of National Taiwan University Hospital. Paper-and-pencil self-report questionnaires were used. Trained research staff conducted on-site data collection with children in group sessions, scheduled either during or outside regular class hours at each school’s discretion, taking about 45 to 60 min. Before distributing the questionnaire, the study’s purpose and procedures were explained to the participants, and their written assent was obtained. The study aims to understand children and youths’ family and social experiences, particularly the factors that contribute to their long-term well-being. Staff described the questionnaire process and emphasized that participation is voluntary and confidential, and that participants can refuse or withdraw at any time. Participating children were encouraged to respond honestly and told their responses would remain confidential and would be used solely for research.

To ensure privacy and minimize response bias, students sat in individual seats so others could not see their responses. Each student received a questionnaire booklet with a cover and was instructed to close it after completing it. Staff collected all completed questionnaires and sealed them in envelopes to guarantee secure handling and return for analysis. The questionnaires were anonymous and contained no identifying information. The contact details from the informed consent forms collected with the questionnaires were used for contact purposes and to assign each participant a unique identifier, enabling longitudinal data linkage. The consent forms were stored separately from the questionnaires to improve data protection. To thank participants for their time and effort, each completed survey was rewarded with a small gift (a set of stationery in a pencil case). Participants also received government flyers about preventing child maltreatment, offering information on self-protection, government resources on children’s rights, and family violence helplines. The data collection procedure was largely consistent across T1 and T2, with a few exceptions for completing the survey outside the school at parents’ request (Hsieh et al., 2021).

Measures

Table 1 presents descriptive statistics for variables used in the analyses and indicates which variables were measured at T1 (4th grade) and T2 (8th grade). Below, we describe how these variables were measured and report coefficient alphas for the variables analyzed. Because most analyzed variables were measured at T1, the coefficient alphas for their T2 counterparts were not reported.

Table 1.

Descriptive Statistics of CSA, ACEs, and Psychosocial Characteristics (n = 2,599).

T1 variable	n (%) or M (SD)	Range
Any CSA	255 (9.81)	NA
Non-contact CSA	87 (3.35)	NA
Parent/caregiver-facilitated (e.g., parent, stepparent, grandparent)	28 (1.08)	NA
Sibling-facilitated	19 (0.73)	NA
Peer-facilitated	38 (1.46)	NA
Other-facilitated (e.g., stranger, family friend, did not specify)	7 (0.27)	NA
Contact CSA	211 (8.12)	NA
Parent/caregiver-facilitated (e.g., parent, stepparent, grandparent)	51 (1.96)	NA
Sibling-facilitated	41 (1.58)	NA
Peer-facilitated	104 (4.00)	NA
Other-facilitated (e.g., stranger, family friend, did not specify)	24 (0.92)	NA
Demographics
Gender
Boys/males	1,323 (50.90)	NA
Girls/females	1,274 (49.02)	NA
Parental marital status
Married or living together	2,200 (84.65)	NA
Divorced or not living together	367 (14.12)	NA
ACEs
Parental substance misuse	222 (8.54)	NA
Parental physical violence	M = 0.24 (SD = 0.43)	0-4
Parental psychological violence	M = 0.22 (SD = 0.44)	0-4
Parental physical neglect	M = 0.56 (SD = 0.69)	0-4
Parental psychological neglect	M = 0.93 (SD = 0.95)	0-4
Peer bullying victimization	M = 0.57 (SD = 0.72)	0-4
Exposure to psychological IPV	M = 0.42 (SD = 0.88)	0-4
Mental health
Psychiatric symptoms	M = 3.65 (SD = 3.71)	0-20
T2 variable
Mental health
Psychiatric symptoms	M = 4.31 (SD = 4.31)	0-20
Revictimization
Any CSA	107 (4.12)	NA

Note. T1 and T2 data were collected when the participating children were in 4th and 8th grade, respectively. Due to missing responses, the sample sizes for some variables did not total 2,599. Most variables had either no missing data or less than 1% missing. Variables with more than 1% missing data included T1 psychiatric symptoms (n = 33, 1.27%) and T1 parental marital status (n = 32, 1.23%). CSA = child sexual abuse; ACEs = adverse childhood experiences; IPV = intimate partner violence; NA = not applicable.

Sociodemographic Characteristics

Respondents reported their sex (male/female) and their parents’ marital status (married or living together/divorced or not living together).

Adverse Childhood Experiences

ACEs measured included sexual violence victimization, parental substance misuse, parental violence and neglect, peer bullying, and exposure to psychological IPV. The items were adapted from established instruments (Furlong et al., 2005; Runyan et al., 1998; Walsh et al., 2008; Zolotor et al., 2009) and were simplified to align with participants’ developmental and cognitive capacities. Questionnaire development also drew on findings from a 2013 pilot study, which informed item refinement and supported the psychometric quality of the adapted scales (Shen et al., 2019).

Child Sexual Abuse

Two forms of sexual victimization were assessed with one question each: non-contact sexual abuse (“I was forced to view sexual photos or videos”) and contact sexual abuse (“Someone touched my private parts when I did not want them to, or made me touch their private parts”). Follow-up questions regarding who committed the abuse—parent/caregiver (e.g., parent, stepparent, grandparent), sibling, peer (e.g., classmate, friend), and other (e.g., someone else)—were asked of those who reported victimization. Four pairs of dichotomous variables indicated whether the respondent had experienced any, parent/caregiver-facilitated, sibling-facilitated, and peer-facilitated non-contact and contact sexual abuse (Y/N).

Physical and Psychological Violence

Parental physical violence and psychological violence were assessed with eight paired items measuring physical violence and four paired items measuring psychological violence perpetrated by both parents in the past year. Example items included “My mom/dad intended to harm me by kicking, grabbing, or shoving me” (physical violence) and “My mom/dad threatened to send me away or kick me out of the house” (psychological violence). Participants rated the frequency of these experiences on a 5-point scale (0 = “Never” to 4 = “More than 10 times”). The average frequency scores were computed and used. The scales of parental physical (α = .88) and psychological (α = .81) violence demonstrated good reliability with the 4th graders.

Physical and Psychological Neglect

Physical and psychological neglect were assessed using four items each. Example items included “No one took me to a doctor or gave me medicine when I was sick or injured” (physical neglect) and “I felt that my family did not care about me” (psychological neglect). Children reported the frequency of these experiences in the past year on a 5-point scale (0 = “Never” to 4 = “More than 10 times”), and average frequency scores were computed. The internal consistency statistics were acceptable for the physical neglect (α = .59) and psychological neglect (α = .66) scales at T1.

Parental Substance Misuse

Parental substance misuse was assessed using two paired items for each parent: “Does your mom/dad drink often?” (Y/N) and “Has your mom/dad ever used an illegal drug, such as methamphetamine, marijuana, or heroin?” (Y/N). Given the low prevalence of reported substance misuse, responses were combined into a single variable indicating parental substance misuse if the child reported that either parent drinks often or has ever used an illegal drug.

Bullying Victimization

Peer bullying victimization was assessed using eight items (e.g., “My classmate had threatened to harm me”). Participants rated how often they had been bullied in the past year on a 5-point scale (0 = “Never” to 4 = “More than 10 times”). The average frequency scores were computed and used. The scale exhibited good internal reliability at T1 (α = .85).

Exposure to Psychological IPV

Child exposure to psychological IPV was assessed with a single item (“I saw or heard my parents insult each other using swear words or profane language”) on a 5-point scale (0 = “Never” to 4 = “More than 10 times”).

Psychiatric Symptoms

The Brief Symptom Rating Scale (BSRS-5; Lee et al., 2003), a commonly used screening tool in Taiwan, was used to assess psychiatric symptoms experienced in the past week. The scale includes five items measuring anxiety, hostility, depression, inferiority, and insomnia (e.g., “I feel down and very unhappy”). Each item was rated on a scale from 0 (“Not at all”) to 4 (“Constantly”), and the total score was the sum of all item responses. The BSRS-5 scale demonstrated excellent reliability with our sample at T1 (α = .91) and acceptable reliability at T2 (α = .76).

Data Analyses

The study conducted analyses with the 2,599 children who participated in both T1 (4th grade) and T2 (8th grade) and responded to questions assessing sexual victimization. Univariate and multivariate analyses were conducted to answer the research questions. Descriptive and multivariate logistic regression analyses were used to examine the prevalence and correlates of sexual victimization. We examined whether demographic factors (gender, parental marital status) and ACEs variables (parental substance misuse, parental physical and psychological violence, parental physical and psychological neglect, peer bullying victimization, and child exposure to psychological IPV) predicted CSA variables, categorized by perpetrator (parent/caregiver, sibling, and peer) and form (non-contact and contact). Furthermore, regression analyses were used to examine whether T1 CSA (categorized by perpetrator and form) was associated with psychiatric symptoms at T1 and psychiatric symptoms and any revictimization of sexual abuse at T2, controlling for demographic variables (gender, parental marital status). Logistic regression analysis was conducted for T2 any CSA, as they were dichotomous. OLS regression analysis was conducted for T1 and T2 psychiatric symptoms, as they were continuous variables. Common logistic regression analyses that use maximum likelihood estimation can be biased due to the rare-event nature of CSA as the dependent variable; therefore, all logistic regression models were estimated using penalized maximum likelihood with the firthlogit command in Stata (Firth, 1993; Heinze & Schemper, 2002). Analysis was conducted with Stata 18.

Results

Prevalence of CSA

Table 1 shows the sample characteristics, including the rates of sexual abuse and other victimization. As shown, nearly one-tenth of the children (9.81%) reported experiencing some form of sexual abuse at T1 (4th grade). Specifically, 8.12% reported someone touching their private parts or being forced to touch someone else’s private parts (contact CSA), while 3.35% said they were forced to view sexual photos or videos (non-contact CSA). More children reported that a classmate or friend had done this to them (peer-facilitated non-contact CSA: 1.46%; contact CSA: 4.00%), followed by a parent, stepparent, or grandparent (parent/caregiver-facilitated non-contact CSA: 1.08%; contact CSA: 1.96%), a sibling (sibling-facilitated non-contact CSA: 0.73%; contact CSA: 1.58%), and someone else, such as a family friend or stranger (other-facilitated non-contact CSA: 0.27%; contact CSA: 0.92%).

Correlates of CSA

Table 2 presents the results of multivariate logistic regression predicting sexual abuse by its forms and the perpetrator–victim relationship.

Table 2.

Correlates of CSA (n = 2,599).

Variable	Non-contact CSA								Contact CSA
	Any non-contact		Parent/caregiver-facilitated		Sibling-facilitated		Peer-facilitated		Any contact		Parent/caregiver-facilitated		Sibling-facilitated		Peer-facilitated
	AOR	p	AOR	p	AOR	p	AOR	p	AOR	p	AOR	p	AOR	p	AOR	p
Demographics
Boys/males (vs. girls/females)	1.76^*	.023	1.16	.736	1.03	.957	4.27^***	.001	2.42^***	.000	2.43^**	.010	1.41	.303	4.21^***	.000
Parents divorced or not living together (vs. married or living together)	1.20	.545	2.23	.109	1.49	.488	0.74	.537	0.76	.236	1.43	.339	0.74	.526	0.48^*	.042
ACEs
Parental substance misuse	2.26^**	.005	4.50^***	.001	2.23	.160	1.29	.591	1.57^*	.044	1.82	.128	1.95	.105	1.26	.458
Parental physical violence	1.72^*	.027	4.31^***	.000	1.67	.347	0.49	.099	1.47^*	.040	1.84^*	.044	1.11	.777	1.07	.807
Parental psychological violence	1.09	.733	0.78	.511	1.35	.552	1.51	.240	1.12	.540	1.13	.676	0.96	.918	0.91	.704
Parental physical neglect	1.54^**	.002	1.46	.147	1.54	.143	1.30	.182	1.28^*	.019	1.59^*	.011	1.27	.267	0.96	.794
Parental psychological neglect	1.32^*	.012	1.22	.329	0.95	.832	1.70^***	.001	1.16	.061	1.03	.847	1.11	.534	1.29^*	.018
Peer bullying victimization	1.69^***	.000	1.51	.089	1.08	.792	2.15^***	.000	1.89^***	.000	1.28	.165	1.73^**	.004	1.88^***	.000
Exposure to psychological IPV	0.95	.663	0.88	.480	1.05	.836	0.99	.959	1.20^*	.015	1.07	.624	1.23	.165	1.25^*	.023
Constant	0.01^***	.000	0.00^***	.000	0.00^***	.000	0.00^***	.000	0.02^***	.000	0.00^***	.000	0.01^***	.000	0.01^***	.000

Note. CSA = child sexual abuse; ACEs = adverse childhood experiences; IPV = intimate partner violence; AOR = adjusted odds ratio.

p < .05. ^**p < .01. ^***p < .001.

Any Non-Contact and Contact CSA

As shown, factors predicting non-contact and contact CSA were similar except for parental psychological neglect and child exposure to psychological IPV. Specifically, 4th graders who identified as boys (non-contact: adjusted odds ratio [AOR] = 1.76, p < .05; contact: AOR = 2.42, p < .001) and who reported parental substance misuse (non-contact: AOR = 2.26, p < .01; contact: AOR = 1.57, p < .05), parental physical violence (non-contact: AOR = 1.72, p < .05; contact: AOR = 1.47, p < .05), parental physical neglect (non-contact: AOR = 1.54, p < .01; contact: AOR = 1.28, p < .05), and peer bullying victimization (non-contact: AOR = 1.69, p < .001; contact: AOR = 1.89, p < .001) were more likely to experience non-contact or contact CSA. Parental psychological neglect (AOR = 1.32, p < .05) was only associated with non-contact CSA. Child exposure to psychological IPV was linked only to contact CSA (AOR = 1.20, p < .05). We did not find a significant association between parental psychological violence and either form of CSA.

Non-Contact CSA by Perpetrator–Victim Relationship

Results showed different risk factors for non-contact CSA depending on the perpetrator–victim relationship. Factors such as parental substance misuse (AOR = 4.50, p < .001) and parental physical violence (AOR = 4.31, p < .001) were associated with parent/caregiver-facilitated non-contact CSA; meanwhile, being a boy (AOR = 4.27, p < .001), experiencing parental psychological neglect (AOR = 1.70, p < .001), and experiencing peer bullying victimization (AOR = 2.15, p < .001) were associated with peer-facilitated non-contact CSA. We did not find significant predictors for sibling-facilitated non-contact CSA.

Contact CSA by Perpetrator–Victim Relationship

Results also revealed differences in the risk factors predicting contact CSA based on the perpetrator–victim relationship. Being a boy (AOR = 2.43, p < .01), experiencing parental physical violence (AOR = 1.84, p < .05), and experiencing parental physical neglect (AOR = 1.59, p < .05) were associated with parent/caregiver-facilitated contact CSA. Being a boy (AOR = 4.21, p < .001), experiencing parental psychological neglect (AOR = 1.29, p < .05), experiencing peer bullying victimization (AOR = 1.88, p < .001), and reporting exposure to psychological IPV (AOR = 1.25, p < .05) were associated with peer-facilitated contact CSA. Peer bullying victimization was the only significant predictor of sibling-facilitated contact CSA (AOR = 1.73, p < .01). Additionally, 4th graders who reported that their parents were divorced or not living together were less likely to report peer-facilitated CSA (AOR = 0.48, p < .05).

Mental Health and Revictimization

Table 3 shows the link between T1 CSA experiences and psychiatric symptoms at T1 and T2, and CSA revictimization at T2. Results indicate that, after controlling for two demographic variables (children’s gender and parental marital status), all CSA variables—regardless of form or perpetrator–victim relationship—were associated with more psychiatric symptoms at T1 (parent/caregiver-facilitated non-contact CSA: b = 4.22, p < .001; sibling-facilitated non-contact CSA: b = 4.06, p < .001; peer-facilitated non-contact CSA: b = 3.30, p < .001; parent/caregiver-facilitated contact CSA: b = 2.02, p < .001; sibling-facilitated contact CSA: b = 3.38, p < .001; peer-facilitated contact CSA: b = 1.84, p < .001).

Table 3.

Mental Health and Sexual Abuse Revictimization (n = 2,599).

Variable	T1 Psychiatric symptoms		T2 Psychiatric symptoms		T2 Any CSA
Variable	b	p	b	p	AOR	p
Non-contact CSA
Parent/caregiver-facilitated	4.22^***	.000	0.24	.766	4.13^**	.007
Sibling-facilitated	4.06^***	.000	0.50	.610	4.85^**	.009
Peer-facilitated	3.30^***	.000	1.34	.061	1.22	.767
Contact CSA
Parent/caregiver-facilitated	2.02^***	.000	0.08	.898	1.33	.617
Sibling-facilitated	3.38^***	.000	2.04^**	.002	2.65	.059
Peer-facilitated	1.84^***	.000	1.47^***	.001	2.94^***	.001

Note. T1 and T2 data were collected when the participating children were in 4th and 8th grade, respectively. Results were obtained from regression models that included a single CSA variable and two demographic control variables—gender and parental marital status. Results for the demographic variables and model constants were not reported. CSA = child sexual abuse; AOR = adjusted odds ratio.

p < .01. ***p < .001.

In terms of T2 revictimization and mental health outcomes, 4th graders who reported sibling-facilitated contact CSA (b = 2.04, p < .01) and peer-facilitated contact CSA (b = 1.47, p < .001) showed more psychiatric symptoms in 8th grade. Three of six CSA variables predicted revictimization later on. Specifically, 4th graders who experienced parent/caregiver-facilitated non-contact CSA (AOR = 4.13, p < .01), sibling-facilitated non-contact CSA (AOR = 4.85, p < .01), and peer-facilitated contact CSA (AOR = 2.94, p < .001) were more likely to experience revictimization in 8th grade.

Discussion

This study examines the prevalence of CSA among Taiwanese children by abuse form and perpetrator–victim relationship, identifies associated ACEs, and investigates how CSA across these dimensions predicts adverse mental health outcomes and sexual revictimization. Using a longitudinal design with a sample of Taiwanese children assessed in their 4th and 8th grades in 2014 and 2018, this study yields several key findings. First, our results showed that a significant number of 4th graders experienced some form of sexual abuse, with nearly 1 in 10 (9.81%) reporting either contact (unwanted sexual touching or being forced to touch another person’s private parts) or non-contact CSA (forced exposure to sexual images or videos) in the past 12 months. This rate was slightly lower than previous studies on CSA prevalence, such as 12.7% in a meta-analysis of global studies (Stoltenborgh et al., 2015) and 15.3% for girls and 13.8% for boys in a meta-analysis of Chinese studies (Ji et al., 2013). This difference may be due to our study’s use of a single-question approach to measure non-contact and contact CSA, which may undercount abuse that occurs in forms not measured. The finding that more children reported contact CSA (unwanted sexual touching or being forced to touch another person’s private parts; 8.12%) than non-contact CSA (forced exposure to sexual images or videos; 3.35%) was alarming, given that it is suggested that more invasive forms of sexual abuse can cause more harm to children (Boroughs et al., 2015; Oshima et al., 2014). It is also worth noting that in this sample, more children reported that a classmate or friend had done such an act to them than a parent, caregiver, sibling, or someone else. This finding provides new insight, as peer-initiated sexual misconduct or abuse remains relatively understudied.

Furthermore, consistent with our research hypothesis, multiple ACEs were found to be significantly associated with CSA. Among the seven ACEs examined in this study, all but parental psychological violence against the child were significantly linked to either non-contact CSA or contact CSA. This finding supports our hypothesis and aligns with research on ACEs and poly-victimization (Felitti et al., 1998; Finkelhor et al., 2007, 2015). It affirms the usefulness of the poly-victimization perspective in the Taiwanese context, emphasizing the importance of examining multiple ACEs when analyzing sexual abuse experience. The current study additionally contributes to the literature by identifying distinct patterns of association between ACEs and CSA, based on the form and nature of the relationship between the perpetrator and victim. For instance, parental physical violence was linked to parent/caregiver-facilitated sexual abuse in both non-contact and contact forms, but it did not show a significant association with sibling- or peer-facilitated sexual abuse. Likewise, peer bullying victimization predicted peer-facilitated sexual abuse in both forms and sibling-facilitated contact sexual abuse, but not parent/caregiver-facilitated sexual abuse. Three patterns emerged from the results: first, parental physical violence predicted parent/caregiver-facilitated sexual abuse (in both forms); second, parental psychological neglect and peer bullying victimization predicted peer-facilitated sexual abuse (in both forms); and third, fewer examined ACEs were found to be associated with sibling-facilitated sexual abuse, with peer bullying victimization being the only significant predictor, specifically predicting sibling-facilitated contact sexual abuse. These findings were novel and contributed to the field by highlighting nuances in risk factors for CSA.

Moreover, the current study found that CSA was significantly associated with more psychiatric symptoms and revictimization; the findings are in line with previous research on how sexual abuse affects children negatively (Engstrom et al., 2008; Hébert et al., 2021; Li et al., 2020; Liu et al., 2021; Miller et al., 2013; O’Brien et al., 2016; Rodante et al., 2019). For instance, the study found that the association between CSA and concurrent psychiatric symptoms was significant across all CSA variables—regardless of form or perpetrator–victim relationship. In addition, two CSA variables, sibling- and peer-facilitated contact sexual abuse, predicted more psychiatric symptoms 4 years later. Three CSA variables, parent/caregiver- and sibling-facilitated contact sexual abuse, and peer-facilitated non-contact sexual abuse, predicted a higher likelihood of revictimization 4 years later. These findings underscore the importance of researching less-studied CSA, particularly those initiated by peers and siblings. While sexual curiosity in late childhood and preadolescence is developmentally expected and normal, children in this stage are still developing an understanding of boundaries and healthy relationships, and may experiment with coercion, force, and manipulation to engage another child in sexual behavior or to act prudently (McPherson et al., 2024; Wurtele & Kenny, 2011). Our results showed that when such behavior occurred, it had negative mental health consequences for the affected children, despite being initiated by non-adults such as peers or siblings.

Surprisingly, our analysis showed that boys were more likely than girls to report sexual abuse, including any non-contact CSA, any contact CSA, peer-facilitated non-contact and contact CSA, and parent/caregiver-facilitated contact CSA. This finding contrasts with prior meta-analyses by Stoltenborgh et al. (2015) and Ji et al. (2013), who reported higher prevalence among girls than boys in global samples (primarily from North America and Europe) and in Chinese populations (mainland China, Taiwan, and Hong Kong), respectively. It also diverges from official reports of child sexual assault cases in Taiwan, which indicate higher reporting rates among girls (Minister of Health and Welfare, 2025). However, our finding is consistent with a population-based study in Taiwan that found a higher prevalence of sexual abuse among teen boys aged 12 to 18 (Feng et al., 2015). This pattern may reflect measurement limitations, as our study relied on a single item to assess both non-contact and contact sexual abuse. Alternatively, boys may be more willing to self-report sexual abuse or may be more likely to experience certain forms of peer-related sexual victimization, such as nonconsensual sexual touching or forced exposure to sexual content. Some peer interactions—such as the commonly reported schoolyard behavior a-ru-ba (阿魯巴), in which peers unexpectedly touch or strike another child’s genitals as a form of play—may be more frequently experienced or reported by boys.

Limitations

The study findings should be interpreted with caution, given their limitations. First, the data were collected in 2014 and 2018 using self-report surveys. The age of the data underscores the need for more recent evidence, and reliance on self-report raises the possibility of differential interpretation of survey items, particularly those that may be difficult for children to accurately report (e.g., parental substance misuse). We conducted a pilot test to assess the psychometric properties of the measures and to confirm that school-age children could reliably report their health status and experiences of violence victimization. However, questions about ACEs and sexual abuse may be underreported because of the shame perceived (Dufour & Nadeau, 2001). Relatedly, we used only two items to measure sexual abuse; therefore, the harmful sexual behaviors captured in the current study were limited to the items we assessed. Furthermore, while we label sexual behaviors as sexual abuse because of their coercive nature, the actual interaction between the child and the actor can complicate the definition (McCartan et al., 2024). For instance, when a peer or similarly aged sibling asks a child to view sexual images, the meaning and implications differ substantially from when this behavior is carried out by a parent or caregiver. This study was unable to capture such nuances using self-report surveys. Moreover, the CSA measured in the current study did not include duration and frequency, which limits our understanding of potential dose responses. In addition, children’s gender was measured by self-report with only “girl” and “boy” as response options, which prevented us from examining how queer identities and non-gender-conforming temperaments may interact with the study findings. Finally, the findings indicate a concerning prevalence of ACEs, including sexual victimization. In this study, we did not have specific protocols in place to respond when children reported any form of ACEs. The consent and assent materials emphasized that data would remain confidential and would be used solely for research purposes. In addition, privacy protections were implemented by separating identifiable consent information from de‑identified questionnaire data. While these measures were essential for protecting participants’ confidentiality, they limited our ability to take direct action on behalf of children who reported ACEs. Nonetheless, participants were provided with child protection resources, and future research should consider approaches that offer additional support without compromising privacy, such as making counseling services available upon request.

Implications for Research and Practice

The study has several implications for research and practice. First, given the limitations of the current study and our findings regarding the perpetrator–victim relationship, future research should use a more comprehensive set of items to measure CSA and continue to examine the nuances of the perpetrator–victim relationship. In this way, research can expand the capture of harmful sexual behaviors and simultaneously enhance understanding of the potentially differing impacts of CSA across perpetrator–victim relationships. For instance, future research can use a CSA measure validated in the Chinese context (Chen et al., 2004) and add questions to investigate relationships with the perpetrator, as well as the duration and frequency of these experiences. Furthermore, future research should include questions that assess children’s gender identity and examine how queer and non-gender-conforming identities may affect their experiences of CSA.

Findings on the different patterns of association between ACEs and CSA, based on the form and nature of the relationship between the perpetrator and victim, indicate distinct risk factors for CSA facilitated by a parent/caregiver, sibling, or peers, suggesting the need to tailor intervention and prevention strategies. For example, the significant association between bullying victimization and peer-facilitated sexual abuse, and between parental psychological neglect and peer-facilitated sexual abuse, suggests that problematic sexual behaviors among peers are likely to occur within bullying dynamics and may go unnoticed and unaddressed because of parental neglect. The concerning prevalence of peer-facilitated sexual abuse, especially contact one (4.00%), suggests a need for evidence-based sexual health education in Taiwanese primary schools to help children develop healthy body boundaries, identify problematic situations, and know what to do if past or ongoing abuse occurs. For example, the school-based “Who Do You Tell?” program has demonstrated improvements in children’s knowledge of sexual abuse prevention and their self-protection skills (Tutty et al., 2020). Taiwanese schools should consider integrating such curricula and tailoring them to the local cultural context, such as addressing harmful interactions involving touching others’ private parts among boys.

The significant associations between parental physical violence and both contact and non-contact parent/caregiver-facilitated CSA, as well as between parental substance misuse and non-contact parent/caregiver-facilitated CSA, underscore the importance of heightened vigilance for sexual abuse among children who report these family risk factors. Disclosure of sexual abuse in Taiwanese children may be constrained by shame, collectivist values, or filial piety (孝, xiao)—a Confucian virtue emphasizing respect, obedience, and care for one’s parents (Dufour & Nadeau, 2001; Latiff et al., 2024). Teachers and social workers should attend closely to these indicators and consider the possibility of sexual abuse. The finding also suggests a need for further research on sibling-facilitated sexual abuse, given that we identified only one significant ACEs risk factor for sibling-facilitated sexual abuse (i.e., peer bullying victimization).

Lastly, the study corroborates well-documented links between sexual abuse and adverse mental health outcomes in children and extends prior research by demonstrating that heightened psychiatric symptoms were evident across all CSA variables examined—regardless of the form of abuse or the child’s relationship to the perpetrator. These findings imply a need to closely examine the pathways through which sexual abuse affects children’s well-being and the potential mechanisms to mitigate the adverse effects of sexual abuse, including preventing revictimization. They also emphasize the importance of comprehensive prevention and intervention efforts, using a systematic approach that supports victimized children and effectively engages individuals who engage in harmful sexual behaviors.

Conclusions

This study enhances understanding of CSA in Taiwan by examining its prevalence, correlates, and mental health effects through a nuanced approach that considers both the form of abuse (non-contact and contact) and the relationship between perpetrator and victim (parent/caregiver, sibling, and peer). Findings reveal a concerning prevalence: nearly 10% of 4th graders report recent experiences of CSA. Importantly, results show distinct pathways linking ACEs to CSA. Parental physical violence is associated with a higher risk of parent/caregiver-facilitated sexual abuse, while parental psychological neglect and bullying victimization are linked to greater risk of peer-facilitated sexual abuse. These varied patterns highlight the interconnectedness of family- and school-based adversities in influencing children’s vulnerability to sexual victimization. By illustrating how interpersonal contexts shape both risk and impact, this study moves beyond prevalence estimates and underscores the importance of prevention and intervention strategies tailored to specific relationships and settings. Efforts to prevent CSA and address its mental health impacts should include family violence prevention, school-based anti-bullying programs, and early detection of children exposed to multiple adversities.

Footnotes

Acknowledgements

We sincerely thank the schools, parents, and students who took part in this study. Special thanks to Guang-Yi Liu and Chia-Hsin Ariel Chiang for their technical support and literature search.

ORCID iDs

Shih-Ying Cheng

April Chiung-Tao Shen

Ching-Yu Huang

Hsi-Sheng Wei

Ethical Considerations

The study received Institutional Review Board (IRB) approval from the National Taiwan University Hospital.

Authors’ Contributions

The authors’ contributions to the paper are as follows: study conception and design: Shih-Ying Cheng and April Chiung-Tao Shen; data collection: April Chiung-Tao Shen, Hsiao-Lin Hwa, Ching-Yu Huang, Jui-Ying Feng, Yi-Ping Hsieh, Hsi-Sheng Wei; analysis and interpretation of results: Shih-Ying Cheng, April Chiung-Tao Shen, Ching-Yu Huang; draft manuscript preparation: Shih-Ying Cheng, April Chiung-Tao Shen, Ching-Yu Huang. Funding acquisition: April Chiung-Tao Shen. All authors reviewed the results and approved the final version of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research and/or authorship of this article: This study was funded by the National Taiwan University Children and Family Research Center Sponsored by CTBC Charity Foundation (grant number: FR012).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Data Availability Statement

The authors do not have permission to share data.

Author Biographies

Shih-Ying Cheng, MSW, PhD, is an assistant professor at the Jane Addams College of Social Work, University of Illinois Chicago. Her research focuses on gender-based violence, particularly severe violence, and its impact on vulnerable populations. She examines the effects of violence on survivors, their healing processes, and the implementation of evidence-based assessments and interventions. Additionally, her work explores gender-based violence among Asian immigrants to the United States, including their help-seeking behaviors and the cultural adaptation of evidence-supported interventions and assessments for this population.

April Chiung-Tao Shen, PhD, is a distinguished professor in the Department of Social Work at National Taiwan University (NTU). Her research interests include family violence, intimate partner violence (IPV), child maltreatment, children exposed to IPV, and family relationships. Professor Shen has received multiple awards for outstanding research and service from NTU, professional academic societies, and the Ministry of Education. She was awarded the Fulbright Senior Research Award in 2014. In 2021, she was elected President of the Taiwan Association of Social Work Education. Since 2022, she has served as Director of the NTU Children and Family Research Center.

Ching-Yu Huang, PhD, is an assistant professor in the Department of Psychology and a research associate at the Children and Family Research Center at National Taiwan University. She is the co-director of the Mendez Asia-Pacific Centre for Investigative Interviewing. Her interdisciplinary research focuses on the intersection of child development and contextual vulnerabilities that may hinder individuals’ access to justice. Her areas of expertise include parenting, child maltreatment, sexual violence, investigative interviewing, and cultural contexts as vulnerabilities.

Jui-Ying Feng, DNS, RN, is a professor in the Department of Nursing at National Cheng Kung University, Taiwan. Her research interests and professional expertise focus on child maltreatment and protection. She has published a number of articles on child maltreatment in Taiwan. She is also a director in the Department of Nursing at National Cheng Kung University Hospital.

Yi-Ping Hsieh, PhD, is an associate professor of Social Work at the University of North Dakota. Her research focuses on technology use and well-being, online victimization, resilience, child maltreatment, and family dynamics across cultural contexts. She has published extensively in high-impact journals on the intersections of online behavior and experiences, youth mental health, and family risk and protective factors. Dr. Hsieh’s interdisciplinary work integrates advanced quantitative and mixed methods approaches to inform interventions that enhance the well-being and safety of vulnerable children, families, and older adults.

Hsi-Sheng Wei, PhD, is a professor in the Department of Social Work at National Taipei University, Taiwan. His research interests include school bullying, juvenile delinquency, and evaluations of youth services. He has published a number of articles on the topic of peer victimization and bullying in Taiwan. He has served on the editorial boards of several academic journals and is currently conducting survey projects on the life conditions and school adjustment of local adolescents.

Hsiao-Lin Hwa, MD, PhD, is a professor in the Department and Graduate Institute of Forensic Medicine at NTU, Taiwan. She is an experienced gynecologist and a well-known forensic examiner for sexual assault survivors. Her research interests include domestic violence, sexual assault injuries, and DNA analysis. She has published a number of articles on sexual assault injuries and forensic DNA analysis in Taiwan. She is a division leader at the NTU Children and Family Research Center.

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