The Relationship Between Child Sexual Abuse and Sexual Dysfunction in Adults: A Meta-Analysis

Abstract

Child sexual abuse (CSA) has been recognized as a risk factor for sexual dysfunction and has attracted increasing attention. However, controversies remain regarding related research. The aim is to calculate the pooled effect size estimate for the correlation between CSA and sexual dysfunction in adults by meta-analysis. Five bibliographic databases (PubMed, Cochrane Library, Web of Science, Embase, and PsycINFO) were comprehensively searched to clarify the association between CSA and sexual dysfunction in adults. We used a fixed-effects model to determine the total pooled effect size estimate and reported odds ratios (ORs) and the corresponding 95% confidence intervals (CIs). Subgroup analysis, publication bias analysis, and sensitivity analysis were conducted. Adults who had a history of CSA experienced a higher proportion of sexual dysfunction than adults with no history of CSA (OR = 1.68, 95% CI [1.49, 1.87]). Subgroup analysis showed that women with a history of CSA reported a higher proportion of sexual dysfunction than men with a history of CSA (men: OR = 1.45, 95% CI [1.05, 1.84]; women: OR = 1.62, 95% CI [1.42, 1.83]). The estimates of the effect sizes differed substantially depending on the CSA and sexual dysfunction instruments that were used in each study and the region of each sample. This meta-analysis provides conclusive evidence of an association between CSA and sexual dysfunction in adults. Currently known interventions for the treatment of sexual dysfunction after CSA have only been evaluated in women, so specific interventions should be designed for men CSA survivors who experience sexual impairment.

Keywords

child child sexual abuse sexual function sexual dysfunction meta-analysis

Introduction

Currently, child sexual abuse (CSA) is a widespread and serious public social problem that involves children of all sexes, races, and socioeconomic statuses. In general, CSA is an activity that is sexual in nature that occurs between a child and an adult or another child, where the two parties differ in age and developmental status and one party use this unequal relationship of responsibility, trust, or power to satisfy their needs (Gewirtz-Meydan & Opuda, 2022; World Health Organization, 1999). Furthermore, CSA includes all forms of sexual behavior, both those with physical contact, such as rape, fondling, and kissing of the abused party, and those without physical contact, such as exhibitionism, voyeurism, viewing pornography, and verbal sexual harassment (Gewirtz-Meydan & Opuda, 2022; Landolt et al., 2016). A systematic review (Moody et al., 2018) showed that in the three continents (North America, Asia, and Europe), the prevalence of CSA was 20.4%, 9.0%, and 14.3% for girls and 14.1%, 6.7%, and 6.2% for boys, respectively. A meta-analysis from 24 regions (Barth et al., 2013) showed that the prevalence of CSA was between 8% and 31% for girls and 3% and 17% for boys, with 9% of girls and 3% of boys having been forced to engage in sexual intercourse. Another study showed that the worldwide prevalence of CSA is estimated to be 12%, with a prevalence of 18% in girls and 7.6% in boys (Stoltenborgh et al., 2011).

Previous findings have shown that the prevalence of CSA in men might be lower than that in women, men might be more reluctant to disclose their CSA experiences, or both factors might play a role in the differences in the CSA incidence between the sexes (Fromuth, 1986; Luo et al., 2008; O’Leary & Barber, 2008). In most relevant studies, women participants outnumbered men participants and the ratio of women to men was not representative, which might be an indication that men victims are more likely to delay disclosing their CSA experiences, resulting in the underrepresentation of men disclosure in child and adolescent samples (Hébert et al., 2009; Ungar et al., 2009). Men may be less likely to disclose their experiences during childhood/adolescence, most notably because they fear being perceived as homosexual when they are sexually assaulted by men and as abusers when they are sexually assaulted by women—this fear is not considered to have an effect on women (Alaggia, 2005; Alaggia et al., 2019). The result of a review also indicated that the social environment led men to hide their doubts, weaknesses, and fears as much as possible (Paine & Hansen, 2002). In addition to sex, the region of the study sample also influences the prevalence of CSA. Different geographic regions are associated with different values and cultural beliefs, and these differences may influence variations in CSA among countries and continents (Kenny & McEachern, 2000). For example, Asians often have cultural taboos regarding children and adolescents that prohibit the discussion of sexual issues and the display of sexual knowledge (Kenny & McEachern, 2000).

Increasing evidence shows that CSA is relevant to many psychological and physical problems, such as psychosocial problems, mental disorders, physical health, and AIDS due to risky sexual behaviors (Arriola et al., 2005; Chen et al., 2010; Lloyd & Operario, 2012; Maniglio, 2009; Varese et al., 2012). Specifically, CSA tends to be more damaging in adulthood than other forms of adverse childhood experiences (Downing et al., 2021), especially with regard to its impact on sexual dysfunction (Bigras et al., 2021; Witting et al., 2008). Sexual dysfunction includes female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, delayed ejaculation, male hyposexual desire disorder, erectile disorder, and premature (early) ejaculation (American Psychiatric Association, 2013). Approximately 46% of women and 33% of men in the general population report sexual difficulties (Briken et al., 2020), and clinically significant sexual dysfunction was reported by 12% of the respondents (Shifren et al., 2008). Another meta-analysis indicated that the incidence of sexual dysfunction among premenopausal women was 40.9% (McCool et al., 2016). For women, the most common form of sexual dysfunction is sexual desire and arousal dysfunction, while the most common form of sexual dysfunction in men are premature ejaculation and erectile dysfunction (McCabe et al., 2016).

Notably, while the association between CSA and sexual dysfunction has been established (Pulverman et al., 2018; Steel & Herlitz, 2007), clear mechanisms between them have not been identified. Compared to normal individuals, the survivors of CSA are probably more likely to suffer from Post-Traumatic Stress Disorder (PTSD), experience attachment-trauma, develop negative perceptions of cognitive associations with sex, have high levels of sympathetic nervous system activity, have poor body image and self-esteem, experience feelings of shame and guilt, and report negative sexual self-schemas (Bornefeld-Ettmann et al., 2018; Gewirtz-Meydan & Lahav, 2020; Gewirtz-Meydan & Ofir-Lavee, 2021; Pulverman et al., 2018; Rellini & Meston, 2011; Seehuus et al., 2015). These undefined mechanisms may all potentially play key roles in CSA and sexual dysfunction. Furthermore, there are sex differences regarding the possible pathways from CSA to sexual dysfunction. For example, with regard to sexual self-schemas, women with a history of CSA experienced more negative affect prior to sexual stimuli, which mediated the association between negative sexual self-schemas and poorer quality of sexual life, indicating that more negative sexual self-schemas could contribute to negative affect prior to sexual experiences and decrease the quality of sexual life (Pulverman et al., 2018; Rellini & Meston, 2011; Seehuus et al., 2015). For men, sexual self-schemas could predict sexual response but not sexual behavior or sexual satisfaction (Aarestad, 2000).

While there is a large body of research suggesting that CSA is a risk factor for sexual dysfunction, the majority of samples comprise women survivors, and relatively little information is available for men survivors (Alami & Kadri, 2004; Gewirtz-Meydan & Opuda, 2022; Lalchandani et al., 2020; Sarwer & Durlak, 1996). Few studies have focused on the relationship between CSA and sexual dysfunction in men (Kamnerdsiri et al., 2020; Sarwer et al., 1997). In fact, men survivors of CSA also have very serious problems with sexual function. For example, Jessica Turchik’s study showed that among the many adverse health outcomes for men college students who suffered CSA, health risk behaviors and sexual functioning problems were the most severe (Turchik, 2012). In terms of specific diagnoses, erectile dysfunction, hypogonadism, and premature ejaculation were the most common (Gewirtz-Meydan & Opuda, 2022).

Numerous studies have shown an association between CSA and sexual dysfunction (Agachanli et al., 2018; Pulverman et al., 2018; Seehuus et al., 2015; Stephenson et al., 2014), but some studies have found no apparent association between CSA and sexual dysfunction (Bigras et al., 2015; Rind & Tromovitch, 1997). The main reason for these differences may be due to the different definitions of CSA (Rellini & Meston, 2007), the different racial/ethnic compositions of the study samples, and the small sample size for a single study (Lombardi et al., 2021). Therefore, the purpose of this meta-analysis was to derive a more precise estimation of the association between CSA and sexual dysfunction in adults of both sexes by means of a meta-analysis.

Methods

Eligibility Criteria

The reviewed studies were included in the meta-analysis if they met the following criteria: (a) the participants were adults, and men and women were included as separate samples; (b) the studies were population-based observational quantitative studies; (c) the studies included CSA and sexual dysfunction as separate variables (rather than integrating them with other forms of abuse and physical dysfunction); (d) the studies reported relative odds ratios (ORs) and 95% confidence intervals (CIs) or had sufficient data for calculation; and (e) the studies had sufficient sample sizes (n ≥ 50).

Search Strategy

In February 2022, a structured and scientific literature search was implemented in four selected databases: PubMed, Cochrane Library, Web of Science, Embase, and PsycINFO. We customized our search strategy for resources that used MeSH topics and related free words. Additionally, we hand-searched reference lists for similar studies and used the cited literature function in the databases to retrieve articles that were available for inclusion. The detailed search strategies are shown in Appendix A.

Study Selection

Using Endnote, duplicate results were excluded. Then, we divided the remaining results and filtered the titles and abstracts to remove articles and books or reviews that did not fall within the scope of the research question. Initially, screened articles were further carefully scrutinized by two researchers based on the inclusion and exclusion criteria. In cases of disagreement, an additional researcher was available to support the determination (Figure 1).

Data Extraction and Quality Assessment

One researcher independently examined each article using a self-designed data extraction form which was double-checked by a second researcher. Disagreements were resolved by discussion and, if necessary, referred to a third researcher for a final decision. The following data were extracted from the selected articles: (1) the first author; (2) the publication year; (3) the country and region investigated; (4) the age of the study subjects; (5) the study design; (6) the sample size; (7) the CSA and sexual dysfunction instruments used; and (8) the effect sizes (ORs and 95% CIs). The quality of the cross-sectional studies was evaluated using a modified version of the Newcastle–Ottawa scale (NOS) (Jarde et al., 2016), and the quality assessment of the cohort studies was performed using the NOS in this meta-analysis (Stang, 2010).

Statistical Analyses

Considering that most of the selected articles were cross-sectional studies, we extracted the effect size for one outcome from each study, and we used 95% CIs and ORs. The heterogeneity of the studies was assessed using Higgins I-squared (I²) statistic and p values. An I² value of 0–24% indicates low heterogeneity, 25–49% indicates moderate heterogeneity, and over 50% indicates considerable heterogeneity (Guyatt et al., 2011). Regarding the origin of heterogeneity, we performed subgroup analyses by sex, geographic region, and assessment instrument. In addition, we performed a sensitivity analysis to estimate the effect of an independent study on the pooled results. Publication bias was tested statistically by Begg’s tests (Higgins & Thompson, 2002) and Egger’s tests (Egger et al., 1997) and viewed graphically by funnel plots (Higgins et al., 2011). All statistical analyses were conducted using Stata version 15.1.

Results

Study Characteristics

We initially identified 6215 potentially eligible records from the electronic database. Then, we reviewed the titles and abstracts of the articles and removed duplicates, resulting in a final selection of 97 articles. Three additional articles were identified from the reference lists. Finally, the full texts were then reviewed according to the eligibility criteria, and 15 eligible articles were identified. Table 1 shows the overall characteristics of the 15 included studies, including one retrospective cohort study and 14 cross-sectional studies (Alami & Kadri, 2004; Bendixen et al., 1994; Dunlop et al., 2015; Fleming et al., 1999; Kamnerdsiri et al., 2020; Kinzl et al., 1995; Lalchandani et al., 2020; López et al., 2017; Luo et al., 2008; Mullen et al., 1994; Najman et al., 2005; Pulverman et al., 2019; Sarwer et al., 1997; Sarwer & Durlak, 1996; Steel & Herlitz, 2007). The included studies surveyed 14,619 participants, mostly between the ages of 18 and 80 years. Furthermore, the included studies were published between 1994 and 2020, and the subjects were from five continents (Africa, Europe, North America, Asia, and Oceania). The majority of studies were conducted in North America (k = 5; 33.3%), Europe (k = 5; 33.3%), and Oceania (k = 3; 20.0%).

Table 1.

Overview of Studies.

Study	Country (region)	Age (years)	study design	Sample size (M/F)	CSA assessment	Sexual dysfunction assessment	Odds ratio (95% CI)
Alami and Kadri (2004)	Morocco (Africa)	20–80	CS	728 (0/728)	Self-report	Self-report	F: 1.39 (0.73, 2.65)
Dunlop et al. (2015)	United States (North America)	18–75	CS	740 (337/403)	CTQ	ASEX	1.55 (1.15, 2.08) M: 1.11 (0.67, 1.84) F: 1.25 (0.83, 1.87)
Kamnerdsiri et al. (2020)	Czech (Europe)	15–85	CS	1,004 (1004/0)	Self-report	IIEF-5	M: 5.00 (2.22, 11.24)
Kinzl et al. (1995)	Austria (Europe)	18–30	CS	202 (0/202)	SASC	DSM-III-R	F: 4.36 (2.08, 9.10)
Lalchandani et al. (2020)	United States (North America)	≥50	CS	1,745 (0/1745)	NHSLS	NHSLS	F: 1.79 (1.14, 2.82)
López et al. (2017)	Spain (Europe)	≥18	CS	766 (0/766)	SHQ	FSFI	F: 1.76 (1.28, 2.41)
Najman et al. (2005)	Australia (Oceania)	18–59	CS	1,544 (773/771)	Self-report	Self-report	1.74 (0.93, 1.45) M: 1.65 (1.11, 2.46) F: 1.73 (1.27, 2.35)
Sarwer et al. (1997)	United States (North America)	42.95 ± 10.00	CS	359 (359/0)	Self-report	DSM	M: 1.33 (3.36, 19.49)
Sarwer and Durlak (1996)	United States (North America)	40.52 ± 9.04	CS	359 (0/359)	Self-report	DSM	F: 1.88 (1.11, 3.19)
Luo et al. (2008)	China (Asia)	20–64	CS	3,005 (1479/1526)	NHSLS	NHSLS	1.85 (0.74, 3.57) M: 2 (1.09, 3.65) F: 2.4 (1.33, 4.33)
Steel and Herlitz (2007)	Swedish (Europe)	31–45	CS	1,300 (0/1300)	Self-report	DSM	F: 1.21 (1.01, 1.92)
Mullen et al. (1994)	New Zealand (Oceania)	Unknown	CS	492 (0/492)	Self-report	Self-report	F: 2.44 (1.49, 4.00)
Bendixen et al. (1994)	Norway (Europe)	16–58	CS	964 (476/488)	Self-report	Self-report	3.62 (2.38, 5.48) M: 4.33 (1.52, 12.37) F: 2.65 (1.66, 4.24)
Fleming et al. (1999)	Australia (Oceania)	CSA: 18–74 No CSA: 17–79	CS	611 (0/611)	Self-report	Self-report	F: 1.95 (1.29, 2.94)
Pulverman et al. (2019)	United States (North America)	20–52	RCS	800 (0/800)	Self-report	Self-report	M: 1.75 (1.12, 2.72)

Note. ASEX = Arizona Sexual Experiences Scale; CI = confidence interval; CS = cross-sectional study; CTQ = Childhood Trauma Questionnaire; DSM = Diagnostic and Statistical Manual of Mental Disorders; F = Female; FSFI = Female Sexual Function Index; IIEF-5 = International Index of Erectile Function 5-item version; M =Male; NHSLS = National Health and Social Life Survey; RCS = retrospective cohort study; SASC = Sexual Abuse Screening Checklist; SHQ = Sex History Questionnaire.

As shown in Table 1, five assessment tools were used to evaluate CSA, and six assessment tools were used to evaluate sexual dysfunction in 15 studies. Most of the studies were conducted by using participants’ self-reports, four studies (Kinzl et al., 1995; Sarwer & Durlak, 1996; Sarwer et al., 1997; Steel & Herlitz, 2007) used the Diagnostic and Statistical Manual of Mental Disorders (DSM) to assess sexual function, and two studies (Lalchandani et al., 2020; Luo et al., 2008) used assessment instruments were from the National Health and Social Life Survey Of American (Carpenter et al., 2009). Definitions of CSA and sexual functioning also varied among the included studies. This variation in definitions poses a challenge for the consistent analysis and clarification of CSA and sexual dysfunction. Table 2 shows the definitions of CSA used in the studies, as well as the relevant indicators used to assess sexual function.

Table 2.

Operative Definitions and Measures.

Study	Definition of CSA	Measures used to examine sexual function
Alami and Kadri (2004)	In the current study, the authors defined sexual abuse as the participation of a child or a teenager in sexual activities enforced by violence or seduction or that transgressing the social taboo.	A questionnaire made available by the authors inquiring about sociodemographic status, sexual abuse during childhood, and the potentially traumatic impact (mental illness, prostitution, and sexual dysfunction) was used.
Dunlop et al. (2015)	A history of CSA was ascertained from the five-item sexual abuse sub-scale of the CTQ-SA. This self-report measure asks about the frequency of sexual abuse on a 1–5 scale, representing the range of “never true” to “very often true” (range 5–25). Categorical ratings of abuse severity are based on the scores: 5 = No abuse; 6–7 = Low; 8–12 = Moderate; ≥13 = Severe.	The ASEX was used to measure sexual functioning. This 5-item self-report instrument gathers information on physiological and on subjective arousal. The ASEX asks patients to report on core elements of sexual function, including sexual drive, arousal, penile erection/vaginal lubrication, ability to reach orgasm, and satisfaction with orgasm.
Kamnerdsiri et al. (2020)	Were you ever sexually abused (harassed by an adult) during your childhood (up to the age of 15)?	The IIEF, a self-administered sexual function questionnaire with 15 items, has demonstrated high specificity and sensitivity for detecting changes in erectile function (EF) associated with treatment
Kinzl et al. (1995)	Sexual Abuse Screening Checklist was designed for the current study. Sexual abuse was elicited from responses to 10 questions.	A 7-item measure was used to evaluate the prevalence of sexual dysfunction experienced by all subjects. This measure was designed for this study and is based on DSM-III-R list of female sexual dysfunctions (American Psychiatric Association, 1987) including sexual desire disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders.
Lalchandani et al. (2020)	Childhood sexual abuse was assessed with a question from the National Health and Social Life Survey (1992): “Before you were 12 or 13 years old, did anyone touch you sexually?”; women responding yes were considered to have been exposed to childhood sexual abuse.	Sexual problems in the past 12 months were assessed using interviewer-administered questionnaire measures adapted from the National Health and Social Life Survey, including trouble lubricating, not finding sex pleasurable, and experiencing physical pain during intercourse.
López et al. (2017)	Defined as sexual contact or manipulation by someone, without the victim’s consent, before the age of 18, and type of abuse (having suffered touching, having been forced to touch, having suffered attempted penetration, having suffered penetration)	Women who have suffered sexual abuse in childhood and adolescence present more frequently sexual dysfunctions, defined as disorders of desire, arousal, orgasm, pain disorders (vaginismus or dyspareunia), and sexual rejection.
Najman et al. (2005)	Women who said they had had sexual experiences before age 16 were asked about the sexual experience, including information on the type of abuse; age at the time of abuse; relationship to the abuser; age of the abuser; and frequency and period of the abuse (the period being obtained by subtracting the age at first episode from age when the abuse stopped); whether coercion was used; whether the abuse was disclosed to anyone; and the self-perceived short-and long-term effects of the abuse.	Eight questions relating to sexual dysfunction were derived from a major U.S. survey (Laumann et al., 1999). These questions asked respondents to report whether they have had any of the listed experiences for a period of several months or more over the last 12 months. Six questions (lack of interest in sex, unable to orgasm, orgasm too quickly, painful intercourse, not finding sex pleasurable, and anxiety about sexual performance) are common to males and females. In addition, males responded to two questions concerning achieving and maintaining an erection, while females had two questions about difficulties becoming lubricated and trouble reaching orgasm.
Sarwer et al. (1997)	CSA was defined as unwanted physical sexual contact, while the victim was considered a child (14 or younger). The contact had to be considered abusive by the victim.	Men were diagnosed at the time of treatment using DSM-III-R criteria: male erectile disorder, hypoactive sexual desire disorder, and premature ejaculation.
Sarwer and Durlak (1996)	Sexual abuse was operationalized as unwanted, physical sexual contact (ranging from genital touching to penetration) while the victim was considered a child by legal definition (age 14 or younger).	The diagnosis of sexual dysfunction followed DSM-III-R criteria: female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder
Luo et al. (2008)	The respondents were asked: “Did someone have sexual contact with you before you turned age 14? ‘Sexual contact’ here includes vaginal intercourse (sleeping with someone or making love), caressing as well as other ways of stimulating genitals/female breasts.”	“Sexual dysfunction(s)” was based on four items asking whether the respondent had ever encountered during sex in the past 12 months: (i) could not get any pleasure (uncomfortable, unaroused); (ii) any genital pain; (iii) vaginal dryness and insufficient lubrication (for women), or trouble in achieving or maintaining erection when having sex (for men); and (iv) unable to achieve an orgasm.
Steel and Herlitz (2007)	Sexual abuse was defined as “unwanted” or “forced” sexual contact during childhood or adolescence. The contact must have occurred before age 18	Sexual dysfunction was measured according to the DSM-IV of the American Psychiatric Association, with the exception of lubrication problems. For males, items included assessment of hypoactive sexual desire, pain, male erectile dysfunction, retarded ejaculation, and premature ejaculation within 12 months.
Mullen et al. (1994)	Child sexual abuse was investigated, both at the postal and interview phases, by a series of questions relating to aspects of abuse.	A measure of current sexual functioning was developed specifically for this study, and included inquiries about the frequency of sexual activity, levels of satisfaction with their current sex lives, and present and past sexual difficulties. A mixture of direct questions, open-ended questions, and Likert scales was employed.
Bendixen et al. (1994)	A definition of sexual abuse was given in parenthesis “By sexual abuse we mean events in which you were forced, coerced or tricked into sexual acts against your will or acts which adults ought not do with children.”	None provided
Fleming et al. (1999)	CSA was defined as all experiences of sexual contact occurring before the age of 12 with a person 5 or more years older, irrespective of consent, and all experiences of sexual contact occurring between 12 and 16 years with a person 5 or more years older, unless wanted or not distressing at the time	Sexual problems were measured by a series of questions which were later combined to form a single scale (Cronbach’s alpha 5.71). The scale consisted of the following variables: pain or discomfort during intercourse; lack of orgasm; lack of sexual arousal; lack of sexual interest; lack of pleasure in sexual activity; lack of lubrication; and partner’s lack of interest
Pulverman et al. (2019)	Lifetime sexual assault was defined as any sexual act that occurred without a woman’s consent and involved the use of threat or force, and included attempted and completed penetration of the vagina, mouth, or rectum. Childhood sexual assault was before 18 years of age.	Sexual pain was assessed with one item based on the sexual function items from the Study of Women’s Health Across the Nation, a large epidemiologic study of health in women during the middle years. Current female sexual pain was assessed with the following dichotomous item: “Does it hurt you to have sexual intercourse or penetration (yes/no)?”

Note. ASEX = Arizona Sexual Experiences Scale; CSA = child sexual abuse; CTQ-SA = Childhood Trauma Questionnaire-short form; DSM = Diagnostic and Statistical Manual of Mental Disorders; IIED = International Index of Erectile Function.

Heterogeneity, Effect Size, and Sensitivity Analyses

Figure 2 shows that the heterogeneity of the included studies was low (I² = 21.2%, p = 0.218), so the effect sizes were pooled using a fixed-effects model. The result of the meta-analysis of the average effect size indicated that the odds of developing sexual dysfunction increased by 68% when people had experienced CSA (OR = 1.68, 95% CI [1.49, 1.87]). The result of the sensitivity analysis (Figure 3) indicated that the pooled effect size did not obviously vary after the exclusion of any study; therefore, the result was regarded as steady.

Subgroup Analyses

Subgroup analyses were conducted according to sex, region, and the instruments used to assess CSA and sexual dysfunction. According to the results of the subgroup analysis by sex (Figure 4), six studies with men participants produced a considerable mean effect size (OR = 1.45, 95% CI [1.05, 1.84]) with low heterogeneity (I² = 14.4%, p = 0.322), and 13 studies with women participants produced a considerable mean effect size (OR = 1.62, 95% CI [1.42, 1.83]) with low heterogeneity (I² = 15.9%, p = 0.284). For subgroup analysis by different regions (Figure 5), the highest mean effect was observed in Asia (OR = 1.85, 95% CI [1.10, 2.60]), followed by Oceania (OR = 1.84, 95% CI [1.48, 2.20]), and North America (OR = 1.64, 95% CI [1.31, 1.97]). Mean effect size estimates varied across studies depending on the tools used to assess CSA and sexual dysfunction. According to the results of the subgroup analysis using five CSA assessment tools for CSA (Figure 6), 10 studies that used self-reports produced a considerable mean effect size (OR = 1.66, 95% CI [1.42, 1.90]) with moderate heterogeneity (I² = 39.5%, p = 0.095). According to the results of the subgroup analysis using seven assessment tools for sexual dysfunction (Figure 7), six studies that used self-reports produced a considerable mean effect size (OR = 1.85, 95% CI [1.54, 2.15]) with moderate heterogeneity (I² = 29.8%, p = 0.212), and four studies that used the DSM produced a considerable mean effect size (OR = 1.36, 95% CI [0.96, 21.75]) with moderate heterogeneity (I² = 28.3%, p = 0.242).

Assessment of Publication Bias

The results from the funnel plot (Figure 8) indicated fundamental symmetry in terms of the effect size estimates, which signaled no publication bias. The results of Begg’s test (p = 0.113) and Egger’s test (p = 0.097) also indicated that there was no publication bias.

Discussion

To the best of our knowledge, our study is the first to investigate the association between CSA and sexual dysfunction using a meta-analysis. The examination of 15 studies produced considerable evidence of a critical association between CSA and sexual dysfunction. In particular, we found that adults who had a history of CSA experienced a higher proportion of sexual dysfunction than adults with no history of CSA.

The results of the meta-analysis suggest that CSA survivors are at higher risk for sexual dysfunction. For women, our findings are consistent with those of other studies (Alami & Kadri, 2004; Lalchandani et al., 2020; Pulverman et al., 2018; Steel & Herlitz, 2007) that have found that the experience of CSA puts women at greater risk for sexual function problems. However, for men, while previous studies did not clearly show an association between CSA and sexual dysfunction (Gewirtz-Meydan & Opuda, 2022; Steel & Herlitz, 2007), the meta-analysis clearly quantitatively showed that the experience of CSA also put men at greater risk for sexual dysfunction, which demonstrates that the role of CSA in the development of men sexual dysfunction should also receive more attention.

Our results also showed that the experience of CSA had a more significant influence on sexual dysfunction in women than in men, as confirmed in several studies (Kinzl et al., 1996; Najman et al., 2005; Rind & Tromovitch, 1997). However, this result may occur because of the lower rate of CSA disclosure and reporting of sexual dysfunction for men. In the psychosocial context of masculinity, the experience of CSA violates gender norms and expectations of boys and men, and victims and gay men are often stigmatized (Mahalik et al., 2003; Spataro et al., 2001). When sexually assaulted by men, many men survivors of CSA fear being perceived as homosexual and victimized and therefore are not forthcoming in disclosing CSA or seeking help after CSA (Easton et al., 2014). It is a general societal belief that women are victims of CSA and men are perpetrators of CSA, and that women sexual predators may be perceived as well-meaning “teachers” who provide sexual “education” to boys (Denov, 2001). Under the influence of this perception, men may conceal CSA even when they have been sexually abused by women (Denov, 2001). In addition, under the cultural influence of society, when starting a new sexual relationship, men need to show strong sexual interest and behavior to prove their masculinity, sexuality, and virility (Wiederman, 2005), and this may explain why reports of men sexual dysfunction are underestimated.

In fact, men and women have substantially different attitudes toward CSA. Men are inclined to view these sexual violations as an adventurous and curiosity-satisfying sexual experience with a predominant memory of indifference, possibly tinged with mild fear, or a sense of inexplicable excitement, with the latter more apparent in contacts with the opposite sex, whereas most women view these violations as physically invasive or morally wrong with a predominant memory of fear, discomfort, and embarrassment (Rind et al., 1998). This may be because men and women experience sexual abuse differently in terms of its destructiveness. For example, women are more likely to experience sexual abuse in general (Najman et al., 2005). In fact, gender stereotypes that exist in society may lead men to believe that experiencing sexual intercourse with an adult woman is a demonstration of sexual prowess or masculinity (Coxell et al., 1999), but this perception makes it less likely for those encounters to be recognized as CSA.

It is valid to note that sexual abuse experienced during childhood may have a disproportionate impact on other interpersonal experiences in the adolescent dating experience that is not limited to the sexual health domain. For example, CSA victims reported more physical and psychological dating violence, and sexual dating victimization rates were slightly higher for girls than for boys (Hebert et al., 2017). This might be influenced by certain socialization and gender stereotypes, with boys interpreting coercive behaviors as non-abusive (Walker et al., 2004).

The results of the analysis also suggest that the risk of sexual dysfunction differed among CSA survivors in different geographic areas. In general, CSA and sexual dysfunction can be influenced by a variety of factors among the continents. One explanation is that the differences among continents reflect real differences in CSA (Pereda et al., 2009; Stoltenborgh et al., 2011). Differences among countries are not just due to CSA disclosure issues, but also to real socioeconomic and cultural differences (Mbagaya et al., 2013). For example, a survey from Tanzania and Kenya showed that the main reasons for the increased prevalence of CSA including the following: The loss of traditional values; poverty that led girls to participate in prostitution; the influence of the sex tourism culture; and the fact that women are far less prominent in society than men (Lalor, 2004). It was also shown that on the African continent, adolescents may be encouraged to have sex with older adults as they transition to adulthood (Mbagaya et al., 2013).

We found that for the instruments used to measure CSA and sexual dysfunction, the mean effect size estimates varied across studies. However, because most studies used self-reports and the rest of the studies used different measurement tools, some results varied widely. Positive results in studies using different measurement tools consistently supported the association of CSA with sexual dysfunction. However, the low effect sizes observed in studies measuring CSA using self-reports and the high effect sizes observed in studies measuring sexual dysfunction using self-reports deserve our attention. To assess CSA and sexual dysfunction more accurately, future studies should rely on validated measures or measures derived from clinical diagnostic criteria, such as the use of instruments that are consistent with the DSM to assess sexual dysfunction (American Psychiatric Association, 2013).

Our results suggest that effective interventions for CSA survivors who are experiencing sexual dysfunction are necessary and greatly needed. While traditional sexual treatment programs are intended for the general population, CSA survivors, as a unique group, may require modification of these interventions (Maltz, 1988; Rellini, 2014). Based on the most recent evidence, positive expressive writing (EW) and mindfulness therapy (MBT) have been empirically validated and proven to be effective in the treatment of women sexual dysfunction (Brotto et al., 2008; Meston et al., 2013). Several positive mechanisms have been proposed to explain the improvement in sexual functioning with EW and MBT; for example EW can improve mental health through mechanisms such as exposure and habituation to traumatic memories, reducing the desire to hide traumatic memories, emotional expression, and cognitive reappraisal (Meston et al., 2013). However, we do not yet know if there is a unique mechanism at work when providing these therapies to women with a history of CSA. This is a question that deserves to be explored in future research, and an understanding of the mechanisms can help to develop targeted interventions. In addition, regarding sexual therapy for men survivors of CSA, there is no treatment option that provides guidelines for the treatment of sexual dysfunction including delayed ejaculation, male hypoactive sexual desire disorder, erectile dysfunction, and early ejaculation in men CSA survivors (Gewirtz-Meydan, 2020).

Strengths and Limitations

To better explain our findings, it is essential to be aware of the limitations of the meta-analysis. First, the included studies were mainly cross-sectional studies, with only one cohort study included. Furthermore, the quality scores of the articles were not high, which affects the statistical efficacy of the meta-analysis and reduces the credibility of the results to some extent. Second, most of the studies included unverified self-report questionnaires to assess CSA and sexual dysfunction. The reliability and validity of the questionnaires were questionable, which may cause certain information bias. Future studies should rely on validated measures or measures derived from clinical diagnostic criteria. Third, the small number of included studies in some subgroups may have an impact on the results of the analysis. For example, only one study was available for some regions, which makes the results unconvincing. Fourth, the included studies were observational studies, which could not prove the causal sequence between CSA and sexual dysfunction in adults. Despite these limitations, our study also has several advantages. First, this was the first quantitative study to assess the association between CSA and sexual dysfunction. Second, the heterogeneity of this study was very low, and the results are credible. Finally, this study only selected studies of CSA and excluded the influence of confounding factors from other adverse experiences in childhood (e.g., physical abuse, neglect, emotional abuse). The literature, which selected men and women separately for investigation in this study, was able to clarify that there is a difference in the effect of CSA history on sex.

Conclusion

This meta-analysis provides conclusive evidence of an association between CSA and sexual dysfunction in adults. Our results also suggest that the experience of CSA increases the risk of sexual dysfunction not only in women survivors, but also in men survivors. Furthermore, the experience of CSA has a stronger influence on women than on men. Nevertheless, currently known interventions for the treatment of sexual dysfunction after CSA have only been evaluated in women, and specific interventions should be designed for men CSA survivors who experience sexual impairment to address the needs of these men.

Implications for Research, Policy, and Practice

Healthcare professionals should be aware of the association between CSA and sexual dysfunction in the management and treatment of sexual dysfunction.

The current interventions for the treatment of sexual dysfunction after CSA have only been evaluated in women only (Brotto et al., 2012; Meston et al., 2013). Specific interventions should be designed to address the needs of men CSA survivors who experience sexual impairment.

Routine screening for a history of CSA in individuals experiencing sexual dysfunction. Assessing for CSA will help determine whether CSA influences the probability of sexual dysfunction in both sexes.

Future studies should use validated measures or measures derived from clinical diagnostic criteria when assessing the association between CSA and sexual dysfunction.

Future studies should explore clear mechanisms of the association between CSA and sexual dysfunction, thus providing clues for developing targeted interventions.

Critical Findings

To the best of our knowledge, our study is the first to investigate the association between CSA and sexual dysfunction using a meta-analysis. CSA increases the risk of sexual dysfunction in adults (OR = 1.68, 95% CI [1.49, 1.87]), as found in most studies.

Our results also suggest that the experience of CSA increases the risk of sexual dysfunction not only in women survivors, but also in men survivors.

Subgroup analysis showed that women with a history of CSA reported a higher proportion of sexual dysfunction than men with a history of CSA (men: OR = 1.45, 95% CI [1.05, 1.84]; women: OR = 1.62, 95% CI [1.42, 1.83]).

Supplemental Material

sj-docx-1-tva-10.1177_15248380221113780 – Supplemental material for The Relationship Between Child Sexual Abuse and Sexual Dysfunction in Adults: A Meta-Analysis

Supplemental material, sj-docx-1-tva-10.1177_15248380221113780 for The Relationship Between Child Sexual Abuse and Sexual Dysfunction in Adults: A Meta-Analysis by Shao-Jie Wang, Jun-Jie Chang, Lei-Lei Cao, Yong-Han Li, Meng-Yuan Yuan, Geng-Fu Wang and Pu-Yu Su in Trauma, Violence, & Abuse

Supplemental Material

sj-docx-2-tva-10.1177_15248380221113780 – Supplemental material for The Relationship Between Child Sexual Abuse and Sexual Dysfunction in Adults: A Meta-Analysis

Supplemental material, sj-docx-2-tva-10.1177_15248380221113780 for The Relationship Between Child Sexual Abuse and Sexual Dysfunction in Adults: A Meta-Analysis by Shao-Jie Wang, Jun-Jie Chang, Lei-Lei Cao, Yong-Han Li, Meng-Yuan Yuan, Geng-Fu Wang and Pu-Yu Su in Trauma, Violence, & Abuse

Footnotes

Acknowledgements

We thank Professor Haifeng Pan, who provided editing suggestions that greatly assisted the research.

Declaration of Conflicting Interests

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

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the National Nature Science Foundation of China (No 81874268, 82173539).

ORCID iDs

Yong-Han Li

Pu-Yu Su

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Shao-Jie Wang is a postgraduate student at Department of Maternal, Child and Adolescent Health at Anhui Medical University, China. He is interested in juvenile Antisocial behavior.

Jun-Jie Chang is a postgraduate student at Department of Maternal, Child and Adolescent Health at Anhui Medical University, China. He is interested in chronic stress in children.

Lei-Lei Cao is a postgraduate student at Department of Maternal, Child and Adolescent Health at Anhui Medical University, China. He is interested in childhood sexual abuse and adolescent mental health.

Yong-Han Li is a postgraduate student at Department of Maternal, Child and Adolescent Health at Anhui Medical University, China. He is interested in peer bullying and adolescent health.

Meng-Yuan Yuan is a postgraduate student at Department of Maternal, Child and Adolescent Health at Anhui Medical University, China. She is interested in childhood adverse experiences in children.

Geng-Fu Wang is a doctor at Department of Maternal, Child and Adolescent Health at Anhui Medical University, China. He is interested in the development and behavior science in children and adolescent.

Pu-Yu Su is a Professor in Department of Maternal, Child and Adolescent Health at Anhui Medical University, China. Professor Su’s research interests include child and adolescent development and behavior. His research emphasis is the relationship of childhood adverse experience and adolescent physical and mental health.

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