Review

Abstract

Objective
To address the best available scienti?c evidence on the role of child sexual abuse in the etiology of
suicide and non-suicidal self-injury.

Method
Seven databases were searched, supplemented with hand-search of reference lists from retrieved
papers. The author and a psychiatrist independently evaluated the eligibility of all studies identi?ed, abstracted data, and assessed study quality. Disagreements were resolved by consensus.

Results
Four reviews, including about 65 851 subjects from 177 studies, were analyzed. 

There is evidence that child sexual abuse is a statistically signi?cant, although general and non-speci?c, risk factor for suicide and non-suicidal self-injury. 

The relationship ranges from small to medium in magnitude and is moderated by sample source and size. Certain biological and psychosocial variables, such as

• serotonin hypoactivity and
• genes,
• family dysfunction,
• other forms of maltreatment, and
• some personality traits and psychiatric disorders,

may either act independently or interact with child sexual abuse to promote suicide and non-suicidal self-injury in abuse victims, with child sexual abuse conferring additional risk, either as a ‘distal’ and
indirect cause or as a proximal and direct cause.

Conclusion

Child sexual abuse should be considered one of the several risk factors for suicide and non-suicidal self-injury and included in multifactorial models. 

Discussion (Start of - )

Main results from the studies

1. Across methodologies, samples, and measures, there is a statistically signi?cant association betweenchild sexual abuse and suicidal and non-suicidal self-injurious behaviour or ideation.
2. The magnitude of the relationship between child sexual abuse and suicide and non-suicidal self-injury ranges from small to medium.
3. Child sexual abuse is signi?cantly related also to several other psychological and behavioural problems.
4. Sample source and sample size account, in part, for effect size variance, with studies with smaller samples and subject samples drawn from clinical populations reporting larger effect sizes.
5. All the other moderators generate con?icting or non-signi?cant results:

• more severe and traumatic forms of sexual victimization such as those involving
  • force,
  •  violence,
  • penetration,
  • longer duration, and
  • high frequency of sexual contact 

do not increase the likelihood of suicide and non-suicidal self-injury in people who have been
sexually victimized as children.

In conclusion, ... 

... the results of this systematic review reveal that the role of child sexual abuse in the etiology of suicide and non-suicidal self-injury is complex. 

Being a victim of child sexual abuse is a signi?cant, although general and non-speci?c, risk factor for
suicidal and non-suicidal self-injurious behaviour and ideation. 

However, child sexual abuse is not the only important risk factor for suicide and non-suicidal self-
injuiy. Evidence to date suggests that, in many cases, child sexual abuse has not a primary role in the
etiology of suicidal and non-suicidal self-injurious behaviour. 

Additional biological, psychological, and social risk factors, such as

• serotonin hypoactivity and
• genes,
• family dysfunction,
• co-occurring forms of child maltreatment, and
• certain personality traits and psychiatric disorders

may, in some cases, be directly responsible for suicide and non-suicidal self-injury, or, in other cases,
contribute to the risk of self-in?icted injuries by mediating the relationship between child sexual
abuse and suicide and non-suicidal self-injury. 

However, it is apparent that being a victim of child sexual abuse may sometimes confer additional
risk of suicidal and non-suicidal self-injurious behaviour either as a ‘distal’ and indirect cause or, as a
‘proximal’ and direct cause. 

Thus, child sexual abuse should be considered one of the several risk factors for suicide and non-
suicidal self-injury and included in multi-factorial etiological models to elucidate the mechanisms that
contribute to self-injury in survivors of child abuse. 

To achieve this goal, several methodological advances in research in this area are required, such as 

• use of longitudinal designs,
• control for confounders,
• employment of study samples representative of the general population and
• matched comparison groups,
• and, for literature reviews, assessment of data quality and validity.

Summations

• Child sexual abuse is a statistically significant, but modest, risk factor for suicidal and non-suicidal
  self-injurious behavior and ideation.
• Child sexual abuse may not have a psrimary role in the etiology of suicide and non-suicidal self-injury.
• Additional biological and psychological risk factors may, in some cases, be directly responsible for,
  or, in other cases, contribute to the risk of suicidal en on-suicidal self-injurious behavior by
  mediating the relationship between child sexual abuse and self-injurious behavior. 

Considerations

• The role of child sexual abuse in the etiology of suicide and non-suicidal self-injury is complex.
• The presence of confounding variables and the poor quality of the studies do not allow for causalinferences to be made.
• All studies included in this review did not assess data quality and validity and aggregated differentstudy findings, particulary those with different levels of methodological quality.

Article

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