The role of childhood sexual abuse sequelae in the sexual revictimization of women

The role of childhood sexual abuse sequelae in the sexual

revictimization of women

An empirical review and theoretical reformulation

Terri L. Messman-Moorea,*, Patricia J. Longb

aDepartment of Psychology, Benton Hall, Miami University, Oxford, OH 45056-1601, USAbDepartment of Psychology, Oklahoma State University, Stillwater, Oklahoma, USA

Received 1 March 2002; received in revised form 21 June 2002; accepted 22 July 2002

Abstract

There is now widespread empirical evidence that child sexual abuse (CSA) survivors are at greater

risk for sexual revictimization in adulthood, but less is known of the mechanisms underlying this

relationship. Despite the lack of a conceptual framework to guide research, there has been a recent

influx of studies examining explanatory variables, with most focusing on the psychological sequelae of

CSA: alcohol and drug use, sexual behavior, dissociation, posttraumatic symptomatology, poor risk

recognition, and interpersonal difficulties. With the exception of sexual behavior, the studies reviewed

here provide limited or mixed support for the role of intrapersonal factors in revictimization. Future

research may benefit from a focus on the function of psychological distress that is expressed as

psychological vulnerability, as opposed to individual forms of psychopathology or maladaptive

behavior. An ecological framework may be useful as a guide to future investigations, as this model

focuses on factors outside of the victim, including childhood factors such as family environment,

contextual factors including the behavior of the perpetrator, and societal and cultural factors that

impact revictimization. Future investigations should focus on the interaction between victim

vulnerability and perpetrator behavior. Implications for prevention programming, clinical intervention,

and future research are discussed.

D 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Revictimization; Child sexual abuse; Rape; Review; PTSD; Alcohol abuse; Risk recognition;

Interpersonal functioning

0272-7358/02/$ – see front matter D 2002 Elsevier Science Ltd. All rights reserved.

doi:10.1016/S0272-7358(02)00203-9

* Corresponding author. Tel.: +1-513-529-2403; fax: +1-513-529-2420.

E-mail address: [email protected] (T.L. Messman-Moore).

Clinical Psychology Review 23 (2003) 537–571

1. Introduction

Sexual revictimization occurs when a survivor of sexual abuse or rape during childhood is

victimized again (i.e., revictimized) during adulthood (Messman & Long, 1996). Evidence of

the revictimization of child sexual abuse (CSA) survivors has been found among different

populations of women, including college samples (Gidycz, Coble, Latham, & Layman, 1993;

Gidycz, Hanson, & Layman, 1995; Mayall & Gold, 1995; Messman-Moore & Long, 2000;

Urquiza & Goodlin-Jones, 1994), clinical samples (Briere & Runtz, 1987; Bryer et al., 1987;

Shields & Hanneke, 1988), military samples (Merrill et al., 1999), and community samples

(Fergusson, Horwood, & Linskey, 1997; Messman-Moore & Long, 2002; Wyatt et al., 1992).

CSA survivors are between 2 and 11 times more likely to experience adult assault as compared

to nonvictims (Fergusson et al., 1997; Wyatt, Guthrie, & Notgrass, 1992). A recent meta-

analysis (Roodman & Clum, 2001) found that between 15% and 79% of women with histories

of CSAwere raped as adults and reported an overall moderate effect size for revictimization.

It is important to recognize and understand revictimization because sexual victimization

experiences often involve significant, negative psychological, and interpersonal distress that

is frequently long lasting. Traumatic sexual experiences, such as CSA and rape, are associated

with numerous acute and chronic psychological difficulties, including PTSD, depression,

suicidality and self-harm behaviors, anxiety, substance abuse, dissociation, interpersonal

difficulties, low self-esteem, and feelings of guilt and self-blame (for reviews, see Goodman,

Koss, & Russo, 1993; Polusny & Follette, 1995; Resick, 1993). Women with histories of

victimization are also likely to suffer from physical difficulties related to victimization such as

chronic pelvic pain (Goodman et al., 1993) and serious reproductive and sexual health

problems (Bohn & Holz, 1996). Further, repeated traumatic experiences, such as revictim-

ization, may be more likely than a single traumatic incident to involve such negative

psychological sequelae, as there is growing evidence that the psychological effects of

interpersonal violence are cumulative in nature (Follette, Polusny, Bechtle, & Naugle,

1996; Messman-Moore, Long, & Siegfried, 2000).

Now that the vast majority of recent empirical studies are in agreement concluding that

revictimization does occur, researchers are turning their attention toward attempts to explain

the CSA survivor’s increased vulnerability for future sexual assault. Answers to the question

‘‘Why?’’ are important because such information can be used to develop well-informed rape

prevention programming that effectively reduces rates of sexual assault for all women and for

CSA survivors in particular. Further, it is known that prevention and risk reduction programs,

although efficacious for women without histories of assault, are not always helpful for

revictimized women (Breitenbecher & Gidycz, 1998; Hanson & Gidycz, 1993; Marx,

Calhoun, Wilson, & Meyerson, 2001). Therefore, it is imperative that mechanisms leading

to revictimization be identified and understood, as such information will inform programming

tailored specifically to this population.

Several factors, mostly of an intrapersonal nature (e.g., alcohol problems, dissociation, and

sexual behavior) have been investigated as factors contributing to the CSA-revictimization

relationship. Other factors have been investigated as well, including characteristics and severity

of CSA (Wind & Silvern, 1992), negative or dysfunctional childhood family environment

T.L. Messman-Moore, P.J. Long / Clinical Psychology Review 23 (2003) 537–571538

(Fergusson et al., 1997; Koverola, Proulx, Battle, & Hanna, 1996), and other forms of

childhood abuse such as physical abuse or combined physical and sexual abuse (Cloitre,

Tardiff, Marzuk, Leon, & Portera, 1996; Schaaf & McCanne, 1998). Recently, two reviews on

this subject critiqued the empirical literature. Breitenbecher (2001) conducted a narrative

review of empirical investigations and briefly addressed numerous possible causes of

revictimization. Roodman and Clum’s (2001) quantitative review and meta-analysis discussed

methodological considerations relevant to this topic. However, neither review discussed at

length overarching theoretical models nor underlying causal mechanisms (as opposed to

numerous individual factors) that may address the possible interrelationship between causal

factors. Given the recent increase in research on this topic, and because of the important

preventive and clinical implications of identifying and understanding the underlying mecha-

nisms related to revictimization, another review of the recent literature appears necessary. In

contrast to these two recent reviews (see Breitenbecher, 2001; Roodman & Clum, 2001), this is

not an exhaustive review of all investigations that study revictimization; rather, there are two

areas of focus. First, the empirical literature focusing on the role of intrapersonal psychological

factors in sexual revictimization is presented. This focus on intrapersonal factors will allow for

greater detail and depth in the discussion of empirical studies. Theoretical explanations for

sexual revictimization are then examined and an overarching model is identified that would

encompass many of the causal factors discussed previously by Breitenbecher. This model could

serve as a conceptual framework to guide future investigations.

Despite a recent influx of empirical examinations focusing on sexual revictimization, there

continues to be a variety of definitions for this phenomenon (e.g., multiple incidents of abuse in

childhood, multiple incidents in adulthood, at least one incident of abuse in childhood and

adulthood). Discussion of how methodology influences the study of revictimization is beyond

the scope of this article and has been covered elsewhere (Roodman & Clum, 2001). However,

we must recognize that definitions of revictimization impact the investigation of what causes

revictimization. Although we acknowledge other definitions, for purposes of this review, revic-

timization is limited to the experience of sexual abuse in childhood (or adolescence) and sexual

assault or rape in adulthood, with the caveat that definitions of childhood and adulthood vary.

2. Review of the empirical literature

Despite absence of an overarching theoretical framework, research examining contrib-

uting or explanatory factors regarding the CSA survivor’s increased vulnerability has

moved forward. The majority of factors investigated thus far appear to be the psycho-

logical sequelae of the earlier sexual trauma,1 indicating that negative psychological effects

1 It is important to note that much of what is considered to be the negative sequelae of CSA is in fact a

‘‘correlate’’ of CSA (for discussion, see Polusny & Follette, 1995); due to the nature of this topic, the causal

effects of such factors can never be proven. However, it is widely accepted that the experience of childhood sexual

abuse plays an important role in the development of psychopathology and maladaptive behavior patterns. This is

assumed here as well.

T.L. Messman-Moore, P.J. Long / Clinical Psychology Review 23 (2003) 537–571 539

Table 1

Summary of studies examining the psychological sequelae of CSA as risk factors for sexual revictimization

Authors Population n Abuse definition Design Variables Findings

Retrospective

Arata (1999) College women with

histories of CSA

and revictimization;

mean age = 24; 71%

Caucasian 76% single

41 CSA: < 14 years

(Finkelhor, 1979).

Adult: � 14 years.

Unwanted contact (SES;

Koss & Oros, 1982)

Retrospective PTSD: Structured Clinical

Interview for DSM-III-R;

Posttraumatic Stress

Disorder (SCL-90-R;

Crime-Related PTSD Scale)

RV women more likely

than non-RV women to have

lifetime diagnosis of PTSD;

not more likely to have

current diagnosis

Classen, Field,

Koopman,

Nevill-Manning,

and Spiegel (2001)

Treatment-seeking CSA

survivors with PTSD;

mean age = 38; 66%

Caucasian, 54% married;

moderate to low SES

52 CSA: < 16 years, >5 years

age difference b/t

perpetrator and victim;

>2 events b/t ages 3 and

15, genital contact.

Adult: >18 years in past 6

months; coercion, attempted

rape or rape (SES;

Koss & Gidycz, 1985)

Retrospective Interpersonal problems:

Interpersonal problems

(Inventory of Interpersonal

Problems, IIP); PTSD

(Clinician Administered

PTSD Scale for DSM-IV)

RV greater interpersonal

diff. than non-RV;

RV greater difference

with assertive behavior,

overly nurturing behavior,

and social avoidance

Cloitre, Cohen,

and Scarvalone

(2002)

Treatment-seeking

rape survivors and

non-assaulted

community women;

70% Caucasian,

53% b/t ages 31 and 50;

50% low SES;

58% some college or

college graduate

69 CSA: < 18 years; contact

abuse by family or trusted

adult; coerced or forced or

� 5 years age difference b/t

victim and perpetrator (Child

Maltreatment Interview

Schedule; Briere, 1992).

Adult: � 18 years; forced

completed/attempted oral –

genital contact, intercourse, or

penetration (Sexual Assault

History Initial Interview

Schedule; Resick, 1987)

Retrospective Interpersonal Schemas:

Beck Depression

Inventory; Brief

Symptom Inventory;

Interpersonal Schema

Questionnaire (ISQ)

RV generalize from

childhood to adult schemas;

schemas generally negative,

portray parents as hostile

and controlling. RV showed

more limited range of

interpersonal expectations,

tended to expect others to

be hostile and dominant;

non-RV also generalize from

childhood to adult schemas;

schemas generally positive,

portray parents as warm

and noncontrolling;

Non-RV CSAS didn’t

generalize schemas

from childhood.

Cloitre, Scarvalone,

and Difede (1997)

Treatment-seeking

rape victims and

nonvictimized

control group;

mean age = 33.5;

76% Caucasian,

92% employed,

92% educated

56 CSA: < 18 years; contact by

family or trusted adult;

coerced or unwanted

experiences by perpetrator

5 years older than victim.

Adult: � 18 years; completed

or attempted intercourse,

oral – genital contact

Retrospective PTSD and dissociation:

Structured Clinical

Interview for DSM-II-R;

Dissociative Experiences

Scale (DES); Inventory for

Interpersonal Problems (IIP)

RV more likely to meet

criteria for a dissociative

disorder. RV reported more

difficulties interpersonal

functioning. No differences

between RV and single adult

assault for levels of PTSD

symptomatology.

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Fergusson, Horwood,

and Lynskey (1997)

Birth cohort of New

Zealand born young

women; demographics

not described

520 CSA: < 16 years;

noncontact and contact;

attempted or completed acts.

Adult: � 16 years; any

unwanted sexual attention,

violent sexual relationships,

or sexual assault

Mixed:

longitudinal:

family and

other factors;

retrospective:

CSA and adult/

adolescent

abuse

Sexual behavior:

demographic factors

(e.g., SES);

family and parental factors;

childhood sexual abuse;

adolescent/adult sexual

victimization;

sexual behaviors

(e.g., onset of sexual

activity, teenage

pregnancy, unprotected

intercourse, etc.)

Severity of CSA related to RV.

CSA as attempted/completed

intercourse had highest rates

of RV and teenage pregnancy,

earliest onset of sexual activity,

unprotected intercourse, and

sexually transmitted diseases.

Relationship b/t CSA and

sexual behaviors reduced but

not eliminated when controlled

for family factors and SES.

When age at first intercourse

is controlled, rel. b/t CSA

and multiple partners is NS,

but relationship b/t CSA and

RV remains.

Kessler and

Bieschke (1999)

Undergraduate

and graduate

level college

women; mean

age = 21;

92% Caucasian


contact abuse.

Adult: >18 years; unwanted

contact to rape (SES;

Koss & Gidycz, 1985)

Retrospective Dissociation: Internalized

Shame Scale (ISS);

Trauma Symptom Inventory

(TSI)—Dissociation subscale

Dissociation did not mediate

relationship between CSA and

adult sexual victimization. RV

women reported higher levels

of shame.

Krahe,

Scheinberger-Olwig,

Waizenhofer, and

Kolpin (1999)

German female

adolescents

between ages

17 and 20 years;

mean age = 18.6

281 CSA: age cut-off not stated.

Asked, ‘‘Have you ever been

sexually abused as a child or

young adolescent?’’

Adult: age cut-off not stated.

Unwanted intercourse (SES;

Koss & Oros, 1982)

Retrospective Sexual behavior: childhood

sexual and physical abuse;

feelings of worthlessness;

sexual behavior; adult

sexual victimization

Relationship b/t physical abuse

and RV is NS. CSAS more

consensual partners than

nonabused girls (5.6 vs. 2.9),

number of partners mediated

relationship b/t CSA and RV.

Mayall and Gold

(1995)

College women;

mean age = 18.95;

74% Caucasian,

15.1% African

American; 97%

single

654 CSA: < 15 years; sexual

contact by perpetrator

>5 years older (mod.

Finkelhor, 1979). Adult:

� 16 years; sexual contact

due to threat/use of force

(mod. CSE; Finkelhor, 1979)

Retrospective Alcohol use and

sexual behavior: alcohol

consumption (method of

assessment was not

described); sexual

behavior (Heterosexual

Behavior Scale, HBI)

No difference in alcohol

consumption b/t RV and

non-RV.

Alcohol consumption

predicted sexual experiences,

which predicted ASA.

Relationship b/t CSA and

alcohol consumption not

reported. CSA and sexual

experiences both discriminate

ASA. CSAS had more sexual

experiences. Interaction b/t

CSA and sexual experiences

to predict ASA not tested.

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Table 1 (continued)


Retrospective

Merrill et al. (1999) US Navy recruits;

mean age = 21;

63% Caucasian,

22% Black,

8% Hispanic,

84% single, 53% HS,

40% some college

1093 CSA: < 14 years;

contact with perpetrator

� 5 years older (mod.

Finkelhor, 1979).


Rape—intercourse,

oral – genital contact

by force, threats,

or use of alcohol/drugs.

Attempted rape—

attempted unwanted

intercourse (SES;

Koss & Woodruff, 1991)

Retrospective Alcohol use and

sexual behavior:

Alcohol Abuse—

Michigan Alcoholism

Screening Test;

Childhood Physical

Abuse—Conflict;

Tactics Scale Parent –

Child Version; number

of sexual partners

CSA, alcohol problems,

and number of sexual

partners predicted adult

rape (controlling for

child physical abuse).

No significant interaction

between alcohol problems,

number of sexual partners,

or CSA in predicting

adult rape.

Messman-Moore

and Long (2002)

Community women;

mean age = 37;

92% Caucasian,

52% married


contact by relative,

person � 5 years older,

or due to threat/

force (Finkelhor, 1979;

Wyatt, Lawrence,

Vodounon, & Mickey, 1992).


Rape—intercourse by

force or use of alcohol/

drugs. Coerced

intercourse—unwanted

intercourse due to

verbal coercion, misuse

of authority (mod. SES;

Koss & Oros, 1982)

Retrospective Alcohol/drug use

diagnosis: Lifetime

Alcohol Abuse/

Dependence, Substance

Abuse/Dependence—

Structured Clinical

Interview for Diagnosis

(SCID-IV-NP)

CSA, alcohol-related

diagnoses and

substance-related

diagnoses each

predicted rape and

coerced intercourse.

No significant

interaction between

CSA and either

diagnostic status

in predicting rape or

coerced intercourse.

Wyatt, Notgrass,

and Gordon (1995)

African American

community sample;

46% age 18–26,

54% age 27–36,

42% never married,

34% HS educ.,

37% some college


noncontact and contact,

unwanted or coercive

incidents (Wyatt, 1985).

Adult: >18 years;

noncontact, attempted

and completed rape

Retrospective Sexual behavior:

frequency of sexual

behavior; frequency

of unintended and

aborted pregnancies;

number of sex

partners and brief

relationships (WSHQ;

Wyatt et al., 1992)

RV and women victimized

during adulthood more

likely to report multiple

partners and brief

relationships compared to

CSA only or nonabused.

RV women more likely than

others to report unintended

pregnancies or abortions.

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Gidycz, Hanson,

and Layman

(1995)

College women;

mean age = 18–19;

92% Caucasian,

39% moderate

to high SES,

18% low to

moderate SES

N = 796,

T1 = 667

(85%)*,

T2 = 178

(75%),

T3 = 65

(85%);

* percent

return-rate

CSA: < 14 years

(Finkelhor, 1979);

noncontact, fondling,

rape, or attempted rape.

Adolescent: � 14 years

prior to participation;

unwanted fondling,

verbally coerced

intercourse, rape, or

attempted rape

(SES; Koss &

Oros, 1982). Both

CSA and adolescent

victimization ranked

according to severity,

moderate to severe

Prospective

9 months

Alcohol use, sexual

behavior, and

interpersonal

problems: previous

sexual victimization;

number of sexual

partners; alcohol use

(typical use);

psychological

adjustment (Beck

Depression Inventory,

Beck Anxiety

Inventory);

interpersonal

functioning (IIP)

CSA correlated

with adolescent

victimization,

adolescent victimization

correlated with RV

at 3, 6, and 9 months.

Alcohol use to

intoxication predicted


but not RV. CSA and


correlated with

interpersonal problems.

Interpersonal problems

did not predict RV.

Number of sex partners

at Time 1 predicted

RV at Time 3

(9 months). Number

of partners did not

mediate b/t CSA and

RV. CSA correlated

with number of partners

during adolescent

and at Time 1;


correlated with number

of sexual partners at

Times 1, 2, and 3.

Greene and

Navarro (1998)

College women;

95% Caucasian,

40% high SES,

31% moderate

SES, 69%

first-year students

T1 = 274,

T2 = 88,

T3 = 105

CSA: < 14 years

(Finkelhor, 1979).

Adolescent:

age 14 until

beginning of

study (SES;

Koss &

Gidycz, 1985).

Adult: (SES)

Prospective

9 months

Alcohol use and

sexual behavior:

alcohol consumption;

level of sexual

activity; psychological

adjustment (Beck

Depression Inventory

and Beck Anxiety

Inventory)

Prior victimization

most consistent

predictor of future

victimization; alcohol

use correlated

with victimization

at all intervals, but

did not predict RV.

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Table 1 (continued)


Prospective

Himelein (1995) College women; mean

age: T1 = 18.4 years,

T2 = 21.0 years; 73%

Caucasian, 24%

Black, 4% other

minority

T1 = 330,

T2 = 100

CSA: < 16 years;

noncontact and

contact experiences

with anyone except

dating partner (mod.

Finkelhor, 1979).

Pre-college/adolescent

victimization: no age

stated; unwanted

contact with dating

partner regardless of

age (mod. SES; Koss &

Gidycz, 1985). Sexual

victimization: no age

stated; unwanted contact

since beginning

college (mod. SES)

Longitudinal

32 months

Alcohol use and

sexual behavior:

consensual sexual

experiences; alcohol

use in dating;

assertiveness; attitudes

towards rape

CSA correlated with

adolescent victimization;


correlated with adult

victimization, CSA not

correlated with adult

victimization; adolescent

victimization correlated

with consensual sexual

experiences, alcohol use in

dating, and sexual victimization

during college; adolescent

victimization strongest

predictor of college victimization.

Sandberg,

Matorin, and

Lynn (1999)

College women;

*mean age� 18.5;

* predominantly

Caucasian

*(demographic

information not collected)

T1 = 349,

T2 = 338

CSA: < 16 years;

contact only

(Finkelhor, 1979).

Adult: � 16 years;

unwanted contact

(SES; Koss & Oros, 1982)

Prospective

10 weeks

PTSD and dissociation:

Dissociative Experiences

Scale (DES); Impact

of Events

Scale—Revised (IES-R)

All variables were related.

Dissociation and PTSD did

not mediate RV. PTSD

moderated RV.

Siegel and

Williams

(2001)a

Community females;

93% African American;

low SES; age: T1 = 8.4

T1 = 206,

T2 = 411,

T3 = 249;

206 CSAS

and controls

CSA: < 18 years;

documented by

hospital records

or contact by force

or by perpetrator

� 5 years older.

Adult: not described

Longitudinal

20 years;

wave 1—

1973–1975,

wave 2—1990–

1991, wave 3—

1996–1997

Alcohol use and

sexual behavior:

Michigan Alcohol

Screening Test (MAST;

Selzer, 1971); sexual

behavior and beliefs

(Belief Inventory;

Jehu, 1988)

CSA did not predict RV,

but CSA prior to and after

age 13 did predict RV.

Multiple sexual partners

and alcohol abuse predicted

ASA, only alcohol abuse

predicted ASA when all factors

considered together.

West, Williams,

and Siegel

(2000)a

Black women with

documented histories

of CSA; mean

age = 25.2; 61%

never married,

50% HS educ., low SES

113 CSA: see Siegel

and Williams (2001)

above. Adult: >18 years;

any unwanted sexual

experience (Russell, 1984)

Prospective Sexual behavior:

age at first consensual

intercourse; number of

consensual partners;

prostitution

No difference b/t RV and non-RV

for age at first intercourse or

number of partners. RV more

likely than non-RV to report

engaging in prostitution.

Summary of abbreviations: CSA= child sexual abuse, CSAS=CSA survivors, b/t = between, rel = relationship, adol = adolescent, vic = victimization, NS = nonsignificant.a These studies utilized the same sample.

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of the earlier abusive experience may actually create or increase vulnerability for later

victimization.

Given this, the role of several psychological correlates of CSA, including posttraumatic

stress disorder (PTSD), dissociation, alcohol and drug use, sexual behavior, risk recognition

difficulties, and interpersonal difficulties, will be examined. Only studies designed specif-

ically to examine revictimization are included. To ease comparison of studies, specific

information as definitions of CSA, adolescent and adult sexual assault, and rape are included

if available. Although investigations of single variables will be insufficient to fully explain

the CSA survivor’s vulnerability, the majority of studies discussed examine only one or a few

variables. To date, no studies that examine large, complex models are available. A brief

summary of all the studies reviewed can be found in Table 1.

2.1. Posttraumatic symptomatology, dissociation, and revictimization

PTSD and dissociation may contribute to revictimization because these problems are not

uncommon chronic reactions for survivors of CSA (Polusny & Follette, 1995), and such

difficulties can interfere with information processing of relevant danger cues (Sandberg,

Matorin, & Lynn, 1999). Rates of PTSD among CSA survivors in clinical samples range from

33% to 86% (Polusny & Follette, 1995). In a community sample, Saunders et al. (1992) found

that between 8.8% and 17.9% of CSA survivors met criteria for PTSD. Further, likelihood of

developing PTSD appears related to severity of the childhood abuse, with higher rates among

those experiencing contact sexual abuse and childhood rape (Saunders et al., 1992).

Several aspects of PTSD may be important with regard to revictimization. Re-

experiencing symptoms, such as intrusive thoughts (and the emotional distress accom-

panying those symptoms), may interfere with the ability to perceive or act upon potential

risk or danger when a situation contains cues that remind the CSA survivor of prior

abuse. Chu (1992) has proposed that during the numbing phase of PTSD, an individual

may be more vulnerable due to decreased awareness of potential danger. Arousal

symptoms, such as sustained hypervigilance and exaggerated startle response, can

generalize from the CSA scenario to ‘‘safer’’ situations in the survivor’s everyday life

and create within the abuse survivor a constant state of ‘‘being on alert.’’ However, while

hyperarousal is sometimes positively correlated with threat perception (Wilson, Calhoun,

& Bernat, 1999), continual arousal symptoms may actually desensitize the survivor to real

threat and decrease the likelihood that she will respond to perceived danger. A survivor

who frequently feels afraid in situations that she labels ‘‘intellectually’’ as safe may learn

to cope with overwhelming affect by ignoring her emotional response if it involves fear.

This may result in increasing difficulty distinguishing between true alarms and learned

alarms (Barlow, 2002). The perpetrator, in turn, may recognize her inability to accurately

assess risk and act upon this vulnerability. Dissociation affects information processing in a

similar capacity. Dissociation may also increase risk for revictimization because sexual

predators may learn to recognize such confusion or distractibility as signs of a woman’s

vulnerability and be more likely to attack such women (Cloitre, Scarvalone, & Difede,

1997).


2.1.1. Empirical studies

Despite the theoretical links between PTSD, dissociation, and revictimization, few studies

that examine these relationships are available. Four studies were located which were designed

specifically to examine the role of PTSD and/or dissociation in relation to sexual revictim-

ization. Arata (1999) proposed that PTSD would be a precursor to, and a possible risk factor

for, revictimization among college women. She found that although revictimized women

were significantly more likely to have a lifetime diagnosis of PTSD than women with a

history of CSA only, they were not significantly more likely to have a current diagnosis.

However, PTSD was generally identified as having begun following the CSA experience

(63% of revictimized women reported a childhood onset, while 38% reported an adult onset).

Although not statistically significant, differences between these two groups regarding onset of

PTSD approached statistical significance (P < .07), indicating that PTSD is a precursor and

possible risk factor for revictimization. Kessler and Bieschke (1999) examined dissociation

and revictimization in a large retrospective investigation of college women. While approx-

imately 70% of CSA survivors were revictimized, dissociation was not statistically related to

adult victimization, thus precluding any mediating effects. Sandberg et al. (1999) conducted

the most methodologically rigorous study to date, which examined the role of dissociation

and posttraumatic symptomatology in relation to sexual revictimization in a 10-week

prospective study of college women. While dissociation and PTSD were related to

victimization both in childhood and adulthood, neither dissociation nor PTSD symptoms

mediated the relationship between CSA and adult sexual assault. However, while dissociation

also failed to moderate this relationship, PTSD symptoms did have a significant moderating

effect. Previous sexual victimization was more strongly associated with subsequent sexual

victimization in the context of high levels of posttraumatic symptomatology.

Only one study is available that examines these issues with a clinical sample (Cloitre et al.,

1997). Rates of PTSD were high in the revictimized (75%) and adult sexual assault only

(70%) groups. However, a significantly larger number of revictimized women met criteria for

a dissociative disorder (46%) as compared to the women who reported adult assault only

(13%). The lack of differences between groups regarding PTSD symptomatology may be due

to ceiling effects and the high level of psychological distress exhibited by all of the

participants who were seeking treatment.

2.1.2. Summary

Conclusions drawn from such a small and diverse group of studies are tentative at best.

Although revictimization is associated with PTSD and related symptomatology, given that

most studies are retrospective, it is still unknown if PTSD operates as an underlying causal

mechanism rather than an outcome of revictimization. One prospective study (Sandberg et

al., 1999) did find that revictimization is more likely for CSA survivors who suffer from

PTSD and related symptoms, implying that PTSD may play a causal role. The role of

dissociation in relation to revictimization is unclear given that a clinical sample found

dissociation to be important, while college studies did not. This may due to an interaction

between the nature of the sample (e.g., college students) and level of psychological distress

(e.g., nonclinical levels). More information is needed to conclude that dissociation might


create risk for revictimization among women who experience clinically significant

psychological distress. Because these studies are comprised of predominantly Caucasian,

educated, young women from college samples, additional investigations are needed with

large diverse community samples focusing on PTSD and related symptomatology such as

dissociation and dissociative disorders with prospective, and ideally longitudinal designs.

Further, the discrepancy in findings between different types of samples may indicate that

studies of psychological distress would be most appropriate with community or clinical

samples, rather than college samples, given the level of functioning of women in these

groups.

2.2. Alcohol and substance abuse and revictimization

Alcohol abuse and substance abuse as factors in revictimization have also been studied. It

is known that women with a history of CSA are more likely to have problems with alcohol

and other substances as compared to women with no history of CSA (Briere & Runtz, 1987;

Mullen et al., 1996; Silverman, Reinherz, & Giaconia, 1996; Wilsnack et al., 1997). It has

been hypothesized that increased use of alcohol and other drugs by survivors may help

alleviate the distress associated with victimization experiences. Many researchers have

conceptualized substance abuse by survivors as a form of emotional or experiential avoidance

(e.g., Briere, 1992; Briere & Runtz, 1993; Follette, 1994; Polusny & Follette, 1995). Use of

alcohol or other substances may help CSAS to numb negative feelings associated with CSA,

to forget the abuse experience, and to avoid abuse-specific memories and affective responses

characteristic of PTSD (Briere & Runtz, 1993; Follette, 1994). Briere and Runtz (1987, p.

374) have suggested that alcohol and drug intoxication function as forms of ‘‘chemically

induced dissociation, invoked as a chronic coping response to aversive affects, memories, and

situations.’’

Not only are alcohol and drug use associated with CSA, but they have also been identified

as factors involved in adult sexual assault (for review, see Testa and Parks, 1996). Use of

alcohol by the rape victim as well as the perpetrator has been identified as a situational

variable that may increase the likelihood of rape and other forms of sexual assault (Marx, Van

Wie, & Gross, 1996), and some studies have found that more than half of female rape

survivors report using alcohol before their assault (Frinter & Rubinson, 1993; Harrington &

Leitenberg, 1994; Muehlenhard & Linton, 1987). Fewer studies are available examining the

use of substances (other than alcohol) and rape, although theoretically effects of substance use

and related problems would be similar to those of alcohol. Burnam et al. (1988) found that

sexually assaulted individuals were 1.8 times more likely to report a history of alcohol abuse

or dependence and 2.6 times more likely to report a history drug abuse or dependence prior to

the assault as compared to a control group. The risk for sexual assault likely increases for

intoxicated women because this condition impairs problem solving and escape behaviors.

Further, women who drink may be more likely to encounter potential perpetrators in the

setting in which alcohol is consumed (e.g., bars, fraternity parties, etc.) and may be at

increased risk for sexual victimization because of the way they are perceived by men (Testa &

Parks, 1996). Men perceive women who are drinking as more sexually responsive (George et


al., 1995) and are less likely to view forced or coerced sex with an intoxicated woman as rape

(Norris & Cubbins, 1992).


There are seven studies available which focus on the role of alcohol or substance use as

factors in revictimization. Three studies utilizing a retrospective design examine these issues.

Messman-Moore and Long (2002) examined the role of both alcohol and substance use

disorders in relation to revictimization of CSA survivors in a community sample. Both CSA

and diagnostic status (DSM-IV diagnoses of alcohol/substance abuse/dependence) predicted

rape and coerced intercourse, but there was no significant interaction between CSA and

diagnostic status. Merrill et al. (1999) investigated the relationship between childhood abuse

(physical and sexual) and sexual revictimization, as well as two mediating factors, number of

sexual partners, and alcohol problems, in a sample of US Navy recruits. CSA was a

significant predictor of adult rape (even when controlling for childhood physical abuse).

Alcohol problems and number of sexual partners also predicted adult rape even when

considered with the childhood abuse variables. Although CSA survivors had a higher

number of sexual partners, controlling for this factor did not eliminate the association

between CSA and adult rape, suggesting that the number of sexual partners does not mediate

revictimization. Further, there was no significant interaction between CSA and alcohol

problems in relation to adult rape (revictimization), indicating that CSA and alcohol

problems constitute two independent risk factors for adult rape (as in the Messman-Moore

and Long study). Mayall and Gold (1995) examined the relationship among adult sexual

assault, CSA, sexual activity, and alcohol use in a large college sample. There was a

significant relationship between contact CSA and adult sexual assault, but there was no

evidence for a direct relationship between alcohol consumption and adult sexual assault.

Sexual experience was the strongest predictor in the model that discriminated between

women who were and were not assaulted during adulthood. Further, sexual experience was

significantly but weakly correlated with CSA. Women with histories of CSA reported more

sexual experiences during adulthood than women without a history of CSA. The association

between alcohol consumption and adult sexual assault was mediated by amount of adult

sexual experience.

Four studies are available that use a longitudinal or prospective design to examine the role

of alcohol use in revictimization. Siegel and Williams (2001) examined drinking and sexual

behavior in relation to revictimization risk in a longitudinal study following girls with

documented CSA and a matched control group for approximately 20 years. They found that a

history of problem drinking significantly increased the odds of revictimization. When

considered together, presence of CSA and adolescent sexual abuse together (abuse both

before and after age 13) increased the likelihood of adult victimization by almost five times,

while alcohol problems increased risk 2.5 times. Although the number of sexual partners was

positively correlated with revictimization, such behavior did not increase risk of assault

substantially. In another longitudinal study, Himelein (1995) followed college women over a

period of 32 months and examined both alcohol use and sexual behavior as risk factors for

sexual victimization. She found evidence of revictimization from adolescence to adulthood


(but not from childhood to adulthood). Later victimization was positively correlated with

number of sexual partners, and women were more likely to be victimized in college dating

situations if they reported greater use of alcohol in dating situations. However, prior

victimization in dating was the strongest predictor of subsequent sexual victimization, and

alcohol use was no longer related to later victimization in a multivariate model. Greene and

Navarro (1998) investigated alcohol consumption and sexual behavior in relation to

revictimization in a prospective study of female college students. Results supported existence

of revictimization, but alcohol use did not mediate the effects of previous victimization.

Alcohol use was a significant predictor in the path analysis in relation to prior victimization

but not revictimization. However, the number of sexual partners was positively correlated

with adolescent and later victimization. Sexual behavior accounted for almost 13% of the

variance predicting later victimization, but did not consistently predict sexual revictimization.

Gidycz et al. (1995) examined alcohol use, sexual behavior, and interpersonal difficulties in

relation to revictimization among college women with a prospective design. Typical alcohol

use was related to adolescent victimization only, and was not a significant predictor of sexual

revictimization. Number of sexual partners at the initial assessment was related to CSA,

adolescent and later victimization at a 3-month follow-up period, but was not related to

victimization assessed at 6 and 9 months. Initial interpersonal functioning was correlated with

CSA and adolescent victimization, but was not correlated with subsequent victimization at 3,

6, and 9 months. Later interpersonal functioning was not correlated with subsequent

victimization either.

2.2.2. Summary

The role of alcohol-related problems in revictimization is still obscure despite seven

studies available examining these problems. What is clear is that alcohol related factors are

related to sexual victimization, regardless of how alcohol-related factors are assessed (i.e.,

measures of consumption vs. psychological diagnosis) and regardless of the population

surveyed (i.e., college vs. community samples). However, despite these findings, it does not

appear that alcohol-related factors consistently explain the relationship between prior and

subsequent victimization. The one study (Mayall & Gold, 1995) that tested for mediation did

not find that alcohol use mediated the relationship between CSA and revictimization. The

failure of some studies to find interactions between CSA and alcohol-related factors (Merrill

et al., 1999; Messman-Moore & Long, 2002) does not support the idea that alcohol moderates

the CSA-revictimization relationship. Results of all prospective studies indicate that prior

victimization is the strongest predictor of later victimization. Further, with the exception of

Siegel and Williams (2001), most prospective studies indicate that alcohol use is not a

significant predictor of later victimization when in a model containing multiple factors

(Gidycz et al., 1995; Greene & Navarro, 1998; Himelein, 1995). These inconsistencies across

studies may be due to an interaction between type of sample and severity of psychological

problems, which may impact nonsignificant findings. However, it may be that there are no

mediating effects for alcohol or drug-related problems, but because CSA survivors are more

likely than nonsurvivors to have such problems, they continue to be at increased risk for

revictimization.


2.3. Risk recognition and revictimization

Some researchers have discussed the possibility that revictimization occurs because

revictimized women may have deficits in their abilities to perceive or act upon threat in

potentially dangerous situations (Chu, 1992; Kluft, 1990; Nurius & Norris, 1996). Failure

to engage in self-protective behavior may be related to several factors including low self-

esteem, assertiveness deficits, or lack of skill in avoiding or escaping risky situations.

Impediments to accurate risk recognition or responses should be considered within an

interpersonal and social context, however. Nurius (2000) emphasizes that risk perception

also includes the application of such knowledge to the self, which means that a woman

might identify a risky scenario but discount this information if she beliefs these risk

factors do not apply to her for one reason or another. A second important issue is that

with each appraisal a woman must consider both the possible positive and negative

consequences of a self-protective response. Risky scenarios are often the very same

situations in which women are pursuing the goals of entertainment, friendship, or

intimacy, which may take precedence over concerns for safety and self-protection

(Nurius, 2000). A woman may not engage in self-protective behavior if she has concerns

about how she might be viewed or perceived by her partner (as well as her peer group)

if she rejects the sexual advances. When compared to women without a history of sexual

abuse, CSA survivors might be more concerned about being rejected by a person they

care about, or conversely, from potential embarrassment that could occur in reaction to

public resistance, or be more likely to have a general fear of being stigmatized or judged

by others.

Research conducted thus far on risk recognition or perception has focused on repeated

adult sexual victimization, rather than child to adult sexual revictimization. Several studies

examined the relationship between adult sexual assault and identification of threat cues in a

dating situation using an analogue design. Neither retrospective designs (e.g., Cue, George, &

Norris, 1996) nor prospective designs (e.g., Breitenbecher, 1999) found a relationship

between threat perception and prior adult sexual victimization, while Breitenbecher (1999)

also found no relationship between threat perception and adult victimization during a 5-month

follow-up period.

Most studies, including those reviewed above, focus on recognition of risk and less on how

women respond to perceived risk. However, Meadows, Jaycox, Orsillo, and Foa (1997)

conducted a study of college students that differentiated between recognizing and acting on

potential risk. While no differences were found between previously victimized and non-

victimized women (physical or sexual assault at any age) for risk recognition, individuals

with histories of assault reported that they would leave a hypothetical scenario significantly

later than did individuals without a history of sexual assault, even when controlling for

severity of dissociation. Scenes with an acquaintance or someone known to the subject (rather

than a stranger) were ‘‘left’’ significantly later by subjects with a history of assault. Further,

subjects without a history of assault also endorsed leaving the scene prior to physical contact,

in contrast to previously abused subjects who usually did not endorse leaving until after

physical contact had been made.



While the topic of risk recognition in relation to repeated victimization has received some

attention, there is relatively little known about risk recognition in relation to revictimization

that occurs for CSA survivors. Meadows, Jaycox, Stafford, Hembree, and Foa (1995)

examined the relationship between childhood abuse (either physical or sexual), risk

recognition, and adult revictimization (physical or sexual assault) with a sample of

treatment-seeking women diagnosed with PTSD and found that women who reported only

a single assault had significantly better risk recognition than revictimized women. However,

poor risk recognition was not associated with child sexual or physical abuse.

While not limiting revictimization to only CSA survivors, Wilson et al. (1999) did include

women with child to adult revictimization as well as women who reported repeated adult

sexual victimization. They investigated revictimization, PTSD, and perceptions of risk

among college women with an analogue study utilizing an audiotaped date rape vignette.

Participants were instructed to stop the audiotape ‘‘if and when they believed the man had

gone too far’’ (p. 707). Longer response latencies indicated poorer risk recognition. Overall,

revictimized women had longer response latencies than women who were victimized on a

single occasion. One interesting incidental finding concerns the role of symptomatology in

risk recognition. While overall levels of PTSD symptomatology did not mediate the

relationship between prior victimization and revictimization, symptomatic women, particu-

larly those with high levels of hyperarousal PTSD symptoms, detected risk earlier than

nonsymptomatic women.

2.3.2. Summary

Despite the assumption that risk perception is an important factor in sexual assault, there is

much less known about how this factor may impact child to adult sexual revictimization.

Future research must examine this question in relation to CSA, as only two studies included

CSA survivors (e.g., Meadows et al., 1995; Wilson et al., 1999). Unfortunately, neither of

these studies examined the specific role of childhood sexual abuse, although Meadows et al.

(1995) concluded that childhood abuse (both physical and sexual) did not have an important

role in risk recognition. Further, there are no studies available that examine the relationship

among CSA, risk recognition, behavioral responses, and revictimization. Findings from the

later Meadows et al. (1997) study indicate that behavioral responses, rather than risk

recognition per se, may be an important causal factor in revictimization, but this possibility

remains unexamined in the case of child to adult sexual revictimization. Additional study is

needed to determine if CSA survivors are at risk for revictimization not only because of deficits

in risk recognition, but also because of internal barriers to their escape from this situation.

2.4. Sexual behavior and revictimization

Another factor that may be important in explaining the problem of revictimization is the

sexual behavior pattern of survivors. The current literature suggests that CSA survivors display

different patterns of sexual behavior compared to women with no history of CSA. Sexual

behavior such as precocious and/or coercive sexual behavior (Bonner, Walker, & Berliner,


1999), younger age at first intercourse (Fergusson, et al., 1997; Fiscella, Kitzman, Cole,

Sidora, & Olds, 1998; Stock, Bell, Boyer, & Connell, 1997), and greater number of sexual

partners (Fergusson et al., 1997; Fehrenbach & Long, 2001; Krahe, Scheinberger-Olwig,

Waizenhofer, & Kolpin, 1999) are more common among survivors. There is also some

evidence that women with a history of CSA have more permissive attitudes about participation

in sexual behavior (Miller et al., 1995), are both more accepting of the sexual behavior of

others and themselves (Fehrenbach & Long, 2001), have more negative attitudes towards

sexual behavior (Orr & Downs, 1985), have different reasons for engaging in sexual

intercourse (Fehrenbach & Long, 2001), and may be more likely to label themselves as

promiscuous as compared to peers with similar types and rates of sexual behavior (Fromuth,

1986). Sexual guilt, sexual anxiety, fear of intimacy, and low sexual self-esteem have also been

found among women with a history of CSA (Fehrenbach & Long, 2001; Fromuth, 1986).

Researchers have proposed that CSA survivors may engage in sexual behaviors as a way of

avoiding emotional distress (Briere, 1996). Engaging in sexual behaviors may help survivors

to avoid the negative feelings associated with CSA and to forget the abuse experience and

avoid abuse-specific memories, even temporarily. Increased sexual behavior evident among

CSA survivors may place them at greater risk for revictimization because they are exposed to a

greater number of sexual partners (some of whom may sexually assault them).

Also increasing the risk of revictimization may be the CSA survivor’s self-perception. As

noted previously, women with a history of CSA are more likely to have permissive attitudes

about participation in sexual behavior and are more likely to label themselves as promiscuous

as compared to peers with similar types and rates of sexual behavior. Such self-perceptions

may be apparent to potential perpetrators and may influence the decision to target these

women for sexual coercion. These self-perceptions may also make it more difficult for these

women to leave sexually abusive relationships after an assault has occurred (i.e., in the

context of a marriage or dating relationship). Women with a history of CSA may not perceive

better alternatives as they have come to expect violence in sexual relationships based on their

prior experiences.

Given that there are a number of reasons to believe that revictimization may be related to a

survivor’s sexual behavior, it is not surprising that the relationship between sexual behavior

and revictimization has been studied extensively. Overall, nine studies were found that focus

on some aspect of sexual behavior in relation to revictimization, including five retrospective

and four prospective studies.


Krahe et al. (1999) examined the relationship between adult sexual victimization,

childhood sexual and physical abuse, and sexual behavior in a sample of German female

adolescents. Women with histories of CSA and those who were ‘‘not sure’’ whether they

experienced CSAwere more likely than nonabused to women to report unwanted intercourse.

The number of partners predicted sexual victimization; women who reported CSA had a

significantly higher number of sexual partners (5.6 vs. 2.9 reported by women without

histories of CSA), which was in turn related to higher rates of later victimization. There was

no relationship between age at first intercourse and sexual victimization. When CSA was


considered together with consensual sexual activity, the relationship between CSA and

revictimization was reduced, but not eliminated, indicating that the link the CSA and

subsequent victimization is not exclusively attributable to the mediating effect of sexual

activity.

Fergusson et al. (1997) investigated sexual behaviors in relation to revictimization among a

birth cohort of New Zealand born young women who were studied from birth to the age of 18

(although reports of CSA were retrospective). Those reporting CSA involving attempted or

completed intercourse had the earliest onset of sexual activity and the highest rates of sexual

revictimization after the age of 16. After adjustment for childhood and family factors, the

relationships between CSA and sexual outcomes tended to reduce. Further, it appears that the

direct impact of CSA on sexual risk taking behaviors is mediated by the impact of CSA on

age at first consensual intercourse. CSA is associated with an increased rate of early onset

consensual intercourse that acts to increase the individual’s risk of multiple sexual partners.

However, independent of age at first intercourse and family background, CSA increases

likelihood of sexual revictimization, particularly the risk of rape/attempted rape during late

adolescence.

Two studies are available that examine the role of sexual behavior in sexual revictimization

among more diverse samples including African American women. West, Williams, and Siegel

(2000) investigated the relationship between CSA, sexual behaviors, and sexual revictimiza-

tion among African American women with documented histories of CSA. They failed to find

any differences between revictimized and nonrevictimized CSA survivors for age at first

consensual sexual experience or for number of consensual partners. However, revictimized

survivors were more likely to report engaging in prostitution as compared to nonrevictimized

survivors. In another study focusing on African American women, Wyatt, Notgrass, and

Gordon (1995) found that women who were revictimized or women with only adult

victimization were more likely to have multiple sexual partners and brief sexual relationships

than women who experienced only CSA or who were not abused.

Three prospective studies and one longitudinal study were discussed previously in

regard to alcohol use (Gidycz et al., 1995; Greene & Navarro, 1998; Himelein, 1995;

Siegel & Williams, 2001). Overall, these studies found a relationship between sexual

behavior and later victimization. In prospective studies with college women that spanned

9–32 months, number of sexual partners consistently predicted later victimization (Gidycz

et al., 1995; Greene & Navarro, 1998; Himelein, 1995), although when assessed in shorter

intervals (3, 6, or 9 months), number of sexual partners did not always predict

revictimization (Gidycz et al., 1995; Greene & Navarro, 1998). Further, although number

of sexual partners was positively correlated with revictimization in a 20-year longitudinal

community study, such behavior did not increase risk of assault substantially (Siegel &

Williams, 2001).

2.4.2. Summary

Many studies are available that examine sexual behaviors in relation to the revictimization

of CSA survivors with different populations. Results of most studies presented here support

the idea that sexual behaviors are related to revictimization, but the role of each type of


behavior in relation to revictimization is mixed. In some studies, CSA and adult sexual

victimization appear related to the number of consensual sexual partners, with victimized

women reporting more partners. Some report that the number of sexual partners mediates the

relationship between CSA and revictimization (e.g., Himelein, 1995; Krahe et al., 1999;

Wyatt et al., 1995). Others, however, indicate that additional variables such as age at first

intercourse, mediate the relationship between CSA and number of partners (Fergusson et al.,

1997). While it is logical that women who begin sexual activity at earlier ages will likely have

more sexual partners across their lifespan, it is unknown which of these factors (early

intercourse vs. number of partners) is the more important contributor to revictimization.

Further, several studies find either mixed or no support for the role of sexual behavior in

revictimization (Gidycz et al., 1995; Siegel & Williams, 2001). Nonetheless, overall these

findings suggest that sexual behavior is an important factor in the revictimization of CSA

survivors. Additional studies with more diverse samples are needed to examine multiple

aspects of sexual behavior, including self-perceptions and attitudes regarding sexuality.

2.5. Interpersonal difficulties and revictimization

Another aspect of the traumatic effects of CSA potentially related to revictimization is the

negative impact of CSA on interpersonal relationships. The experience of CSA may

interfere with the development of self-concept and sexual identity, and may distort basic

beliefs about trust, safety, and control in significant relationships (Cole & Putnam, 1992;

Trickett & Putnam, 1993; for review, see DiLillo, 2001). For instance, DiLillo and Long

(1999) found that CSA was associated with less satisfaction, trust, and poorer communica-

tion in couple relationships, and Hunter (1991) found that CSA survivors reported lower

relationship satisfaction with their partners and poorer sexual adjustment. In a clinical

sample, Jehu (1988) found that all of the CSA survivors surveyed reported problems in both

general social relationships and with partners, and half of survivors reported interpersonal

problems with other women. Harter, Alexander, and Neimeyer (1988) also found that CSA

was associated with poor social adjustment among college women. Browne and Finkelhor

(1986) describe the problematic interpersonal relations that can result from four different

traumagenic dynamics—traumatic sexualization, betrayal, stigmatization, and powerless-

ness. Messman and Long (1996) speculate that the traumagenic dynamic of betrayal could

impact judgment regarding the trustworthiness of others. Gelinas (1983) has observed that

survivors of CSA tend to place the needs of others before their own and have difficulty

saying ‘‘no’’ in intimate relationships, perhaps creating risk for revictimization. Further,

revictimization may occur through a variety of mechanisms that impact interpersonal

relatedness including a maladaptive learning history or beliefs regarding interpersonal

relationships that result from the CSA experience, gender role socialization and sex role

stereotypes, poor relationship choices, and learned helplessness (Messman & Long, 1996).

However, there are currently only a few studies available that examine whether certain types

of interpersonal difficulties are associated with revictimization (Classen, Field, Koopman,

Nevill-Manning, & Spiegel, 2001; Cloitre et al., 1997; Cloitre, Cohen, & Scarvalone, 2002;

Gidycz et al., 1995).



In a prospective study discussed earlier, Gidycz et al. (1995) examined interpersonal

functioning as a potential mediator of revictimization. Initial interpersonal functioning was

correlated with CSA and adolescent victimization, but was not correlated with subsequent

victimization at 3, 6, and 9 months. Later interpersonal functioning was not correlated with

subsequent victimization either. However, in a retrospective study, Classen et al. (2001) found

that treatment-seeking women with histories of CSA and current PTSD and who had also

been sexually revictimized in the previous 6 months reported greater interpersonal problems

than those who were not sexually revictimized during that period. Revictimized women were

more likely to describe themselves as overly responsible and as having greater difficulty

being assertive in interpersonal relationships than those who were not revictimized.

Revictimized women also described themselves as being overly nurturing and socially

avoidant. In another retrospective study discussed earlier, Cloitre et al. (1997) investigated

interpersonal functioning in relation to revictimization among a clinical sample. The

interpersonal functioning of revictimized women differed significantly from women with

only adult assault. Overall, revictimized women exhibited and reported significantly greater

difficulties regarding self- and interpersonal dysfunction as compared to women with a

history of sexual assault only during adulthood. Cloitre et al. (2002) also examined the

interpersonal schemas of revictimized women. Revictimized women had the tendency to

generalize their predominant parental schemas to their current relationships, particularly the

schemas that their parents were hostile and controlling. Women with histories of CSA but

who were not revictimized tended to view their parents in a similar light, but did not

generalize from parental to current schemas. Finally, women who were never abused or

assaulted generalized warm and noncontrolling schemas of their parents to their current

schemas.

2.5.2. Summary

Researchers are only recently beginning to explore the impact of CSA on interpersonal

functioning in relation to revictimization. The studies discussed above provide a starting-

point for further investigations given the consistent finding of disturbed relatedness

among CSA survivors, particularly those who are revictimized. Revictimized women tend

to view themselves in a more negative light, seeing themselves as less assertive and more

likely to provide care for others rather than consider their own needs. Further, these

women also seem to generalize negative interpersonal schemas from childhood to

adulthood, expecting others to treat them in a hostile, controlling and domineering man-

ner, even if there is evidence to the contrary (Cloitre et al., 2002). However, despite

these observations, not all studies find interpersonal functioning related to revictimization

(Gidycz et al., 1995).

2.6. Summary of research on revictimization factors

All studies examined here focused on the psychological problems of CSA survivors as

factors in revictimization. From this review, we can draw several conclusions, but several


limitations should be acknowledged. First, most studies examining these phenomena utilize

college samples that are predominantly Caucasian and middle- to upper-class (e.g., Gidycz

et al., 1995; Greene & Navarro, 1998; Himelein, 1995; Mayall & Gold, 1995). Evidence

of revictimization is stronger among samples that include older women (Roodman &

Clum, 2001), while studies reviewed here tended to include young samples. Because most

studies focus on middle- to upper-class, educated, young, Caucasian, college women,

findings from these studies might not apply to non-Caucasian women, or to women living

in crime-ridden inner cities or within substandard financial means. However, studies of

young, Caucasian, college students are still important because findings indicate that

revictimization does occur within all socioeconomic strata, and protective factors, such

as higher socioeconomic status and education, do not always protect women from

revictimization. Despite the emphasis on college populations, some studies including

noncollege samples were available. Unfortunately, they usually had a much smaller sample

size that might have impacted statistical findings (e.g., Classen et al., 2001; Cloitre et al.,

1997, 2002).

Second, lack of diversity with regard to psychological functioning also creates problems

when examining psychological distress as a factor in revictimization, as individuals from

college samples have on average significantly better psychological adjustment than

individuals from clinical and community samples. The severity of psychological distress

is important to consider because it may be that only clinically significant psychological

problems would be severe enough to interfere with functioning and affect vulnerability. An

overview of findings suggests that, for many studies discussed here, psychological

functioning is confounded with sample type (i.e., college), limiting conclusions regarding

psychological distress variables. For studies reviewed here, the relationship between

psychological problems and revictimization was stronger in clinical (e.g., Cloitre et al.,

1997) or community samples (e.g., Merrill et al., 1999; Siegel & Williams, 2001) rather

than college samples (e.g., Gidycz et al., 1995; Greene & Navarro, 1998; Sandberg et al.,

1999).

Third, and very importantly, the vast majority of research to date consists of retrospective

studies that are unable to determine causality, and findings from retrospective investigations

often differ from prospective or longitudinal studies. For example, two prospective studies

(Gidycz et al., 1995; Greene & Navarro, 1998) reported results from retrospective data that

identified a relationship between alcohol use and revictimization, however, results from

prospective data failed to support this factor as a consistent predictor of later sexual

victimization (i.e., revictimization). This is further complicated because most prospective

studies used college samples. Finally, although many studies discuss possible mediating roles

for these psychological factors, few studies actually tested for mediation. Despite these

problems however, there are several tentative conclusions.

Of all the types of psychological distress reviewed, only one factor, sexual behavior,

predicts revictimization on a fairly consistent basis. Most studies find a relationship between

revictimization and the level of sexual activity (number of partners), and this factor

sometimes mediates the relationship between CSA and revictimization. However, given that

the link between CSA and later victimization is never completely eliminated, sexual behavior


does not fully explain revictimization. These findings indicate that sexual behavior cannot by

itself explain the phenomenon of revictimization.

Evidence for the role of other psychological problems is often mixed, prohibiting strong

conclusions regarding any causal role in revictimization. Although PTSD symptomatology is

associated with revictimization among retrospective studies, its role as a causal mechanism is

still unclear. Arata (1999) found an apparent temporal relationship between CSA and PTSD,

implicating PTSD as possible causal factor, although the retrospective design precludes this

conclusion. However, results from one prospective study (Sandberg et al., 1999) suggest that

PTSD might better be conceptualized as playing a moderating, rather than mediating role.

Given these positive findings, PTSD should likely be examined further as a causal factor in

revictimization. An association between revictimization and dissociative phenomena is not

consistently found. Only retrospective studies using clinical samples (e.g., Cloitre et al.,

1997) find that dissociation and related problems are related to revictimization (as opposed to

college samples), and there have been no tests of mediating models or use of prospective

designs with clinical or community samples.

There is also mixed evidence that alcohol-related factors directly affect revictimization, as

some retrospective studies report independent effects for CSA and alcohol use (e.g., Merrill et

al., 1999; Messman-Moore & Long, 2002), and alcohol use often fails to consistently predict

revictimization in prospective studies (e.g., Gidycz et al., 1995; Himelein, 1995). The one study

examining the role of substance abuse (Messman-Moore & Long, 2002) found no evidence of

an interaction between such problems, and both factors were strong predictors when in the

model together, which suggests that mediation could not have held.More information is needed

to determine if alcohol-or substance-related factors explain the relationship between CSA and

revictimization, or if these factors contribute to revictimization independently.

Analogue studies examining risk recognition find that risk recognition is not consistently

associated with revictimization, but this concept may be important in conjunction with

information about escape behaviors and PTSD symptomatology (see Meadows et al., 1997;

Wilson et al., 1999). Interpersonal difficulties and beliefs about relationships do appear to be

consistently related to revictimization (Classen et al., 2001; Cloitre et al., 1997, 2002), but the

causal role of these factors has not yet been explored. The findings of one study examining

the response to risk recognition (Meadows et al., 1997) and studies focusing on interpersonal

difficulties (Classen et al., 2001; Gelinas, 1983) overlap, indicating that poor assertiveness

within relationships may serve as an internal barrier to acting upon risk. Examining the

intersection between these concepts may prove fruitful.

Although there may be some methodological explanations for inconsistencies among the

findings discussed above, wemust also acknowledge other reasons why intrapersonal problems

do not consistently explain revictimization. It could be that these variables are not critical to the

process of revictimization, but they are correlated with factors that are explanatory. For

instance, alcohol expectancies might be more important than alcohol use itself with regard to

revictimization (Nishith, Bazile, Clum, Messman-Moore, & Resick, 2001). It may be that only

women who abuse alcohol solely because they expect use to enhance sexuality, sociability, etc.,

are at increased risk for revictimization, because they are most likely to abuse alcohol in a

scenario that is risky for acquaintance rape (e.g., parties, fraternity houses, or bars). Other


factors correlated with psychological distress, such as coping strategies or access to social

support, may also be important to explore. Previous studies have found that effective coping

strategies are an important factor in recovery from adult rape and incest, while disengagement

and avoidant methods of coping lead to increased psychological distress (Burt & Katz, 1987;

Drauker, 1989). One study examining revictimization and coping (Gibson & Leitenberg, 2001)

found that revictimized women usedmore disengagement methods to cope with an adult sexual

assault than women without a history of CSA. Reactions to disclosure of abuse and available

social support may also play an important role (Messman-Moore & Resick, 2002).

We must also recognize that it is very possible that the focus should not be on intrapersonal

psychological factors at all. However, to support this conclusion, we need additional research

based upon a guiding theoretical model that captures the complexity of this issue, including

not only victim characteristics, but also perpetrator behavior and societal and cultural factors

that operate to increase risk.

3. Theoretical explanations of revictimization

There is no empirically validated theoretical model of revictimization, although several have

been proposed (e.g., Gold, Sinclair &Balge, 1999; Grauerholz, 2000;Messman&Long, 1996).

Without a guiding theory, the same question continues to be asked: ‘‘Why are these women at

increased risk?’’ The search for an answer to this question has led most researchers to focus on

the victim, i.e., ‘‘Is there something about the CSA survivor as an individual that places her at

greater risk?’’ Some have asked, ‘‘Do these women choose sexually abusive partners as some

unconscious desire for a ‘mastery’ experience?’’ (Chewning-Korpach, 1993; Chu, 1992; van

der Kolk, 1989). It has been proposed that the psychodynamic concept of repetition compulsion

explains revictimization in that ‘‘many traumatized people expose themselves, seemingly

compulsively, to situations reminiscent of the original trauma’’ (van der Kolk, 1989, p. 389).We

argue that the phenomenon of repetition compulsion as an explanation of revictimization is

unsatisfactory because it is difficult to study empirically, and because the theory is often

misinterpreted to blame the victim.

In an effort to understand revictimization, most theories focus exclusively on the CSA

survivor or characteristics of her abuse. This is problematic, however, because previous

research has found that few, if any, victim characteristics besides previous victimization

predict rape (Koss & Dinero, 1989; Koss & Harvey, 1991). Focusing on the victim and her

behavior is also problematic because there is no consideration of the behavior and motivation

of the perpetrator. While there has been research on the characteristics of sexually aggressive

perpetrators (for review, see Berkowitz, 1992), we must also examine the role of perpetrators’

behaviors and motivations in models of revictimization. Theories of revictimization should

also consider the importance of societal and cultural factors including devaluation of women

and children, patriarchal systems, gender-related social roles, sexual scripts, and cultural

myths as factors potentially contributing to revictimization (Koss et al., 1994).

There is a need for an all encompassing, theoretical framework to guide empirical studies of

revictimization, its causes and effects. This theory should be complex and broad enough to


encompass intrapersonal, interpersonal, and societal issues, should organize the inchoate

literature and explain disparate empirical findings. While we encourage a focus on factors

outside the victim, we are not arguing that theories should not address the circumstances and

context of sexual victimization in relation to the victim.Wemust learn more about the factors or

mechanisms that contribute to the increased vulnerability of CSA survivors. However, instead

of focusing solely on the vulnerability of these women, theories should include the interaction

of two factors: (1) the vulnerability of CSA survivors and (2) the presence of an opportunistic

perpetrator. To date, most theories and empirical research focus on the first half of this formula

without acknowledging the importance of a second necessary factor, the perpetrator.

3.1. An ecological model

Given these criteria, an ecological model may be a good way to understand the relationship

between CSA and revictimization. Grauerholz (2000) discusses such a model, developing

ideas first presented by Bronfenbrenner (1977, 1979) and Heise (1998). This model proposes

that revictimization can be understood within a system of four levels, illustrated as four

concentric circles that consider four levels of factors: ontogenic development factors related

to the initial victimization experience (e.g., personal history of the victim, psychological

sequelae of CSA or early family environment), microsystem factors considering the context

of abuse (e.g., perception by the perpetrator that the victim is an easy target, victim’s

decreased ability to respond assertively and effectively to unwanted sexual advances),

exosystem factors such as lack of resources or alternatives (e.g., low socioeconomic status,

unsafe living conditions, etc.), and macrosystem factors such as cultural norms and

institutions (e.g., cultural tendency to blame victims).2

The ecological model provides an overarching, guiding theory, and is the most inclusive

and far-reaching available, allowing integration of research conducted from various theor-

etical perspectives. The majority of research on revictimization has focused on variables such

as characteristics of the initial CSA experience (e.g., physical force, penetration, relationship

to the perpetrator), other forms of childhood abuse (e.g., physical abuse), and the psycho-

logical sequelae of the childhood abuse (e.g., dissociation), factors which fall within the two

innermost circles of Grauerholz’s model: ontogenic development and microsystem. The

interpersonal, contextual, and cultural factors considered as the exosystem and macrosystem

in this model have not received as much attention. Focusing exclusively on intrapersonal or

2 Those familiar with the Bronfenbrenner model might note that Grauerholz’s definitions of ontogenic

development and microsystem are not consistent with the original ecological model. Grauerholz has grouped

together historical factors including the family environment during childhood as part of ontogenic development,

while Bronfenbrenner’s model would consider the family environment as part of the microsystem. Further,

Grauerholz considers the interaction between the perpetrator and the psychological problems of CSA survivors as

part of the microsystem, which is also not entirely consistent with the original ecological model. Despite these

differences, however, this model may still be a useful heuristic if adapted as a guiding framework because this

model considers the behavior of the perpetrator, the context in which victimization occurs, and the psychological

vulnerability of the CSA survivor.


microsystem factors ignores important information such as perpetrators’ perceptions of

victims, or cultural forces that likely contribute to continued victimization of CSA survivors.

Research focusing on revictimization, and explanatory factors in particular, is clearly in

initial, early stages of development. Utilizing the ecological model as a theoretical or

conceptual framework would provide scholars with a sense of direction, as well as a

framework within which to interpret findings.

Although much research on revictimization focuses on the two innermost circles of the

Grauerholz (2000) model, ontogenic development and microsystem, we believe that the

empirical studies reviewed here would best fit within a single level, the microsystem, the

context in which revictimization occurs. To fully understand the phenomenon of revictimiza-

tion, we must move beyond a focus on the victim’s personal characteristics or history and

widen our perspective to the microsystem, the first level that examines the context of

victimization, including both the perpetrator and the victim. Further, it may be beneficial to

move away from conceptualizing psychological problems of the victim as intrapersonal, to

viewing these problems as interpersonal, when considered in conjunction with revictimiza-

tion. Revictimization is an interpersonal process. Indeed, despite the importance of PTSD,

dissociation, or alcohol abuse, such problems do nothing to increase risk for victimization

unless there is a perpetrator present who will ‘‘take advantage of’’ the victim’s vulnerability.

Further, contextual factors might be more amenable to change. Ontogenic factors, by

definition, occur earlier in the survivor’s life and often cannot be altered. However, we can

change the context in which revictimization is more likely by focusing on the interaction

between victim vulnerability and perpetrator behavior.

We also should consider the possibility that risk for revictimization might vary within

different levels of this model depending on the identity of the perpetrator. For instance, while

macrosystem factors such as patriarchal views would influence revictimization by all types of

perpetrators, exosystem factors such as poverty and unsafe neighborhoods might contribute

more significantly to revictimization by a stranger. Further, certain risk factors may be more

salient than others for revictimization perpetrated by different types of perpetrators (e.g.,

partners vs. acquaintances vs. strangers). Future research should also consider not only

victim-related factors, but perpetrator-related factors as well. The perpetrator can be examined

at each level of the ecological system as well as the victim.

3.2. Underlying causal mechanisms

Although intrapersonal factors such as sexual behavior and alcohol use appear important to

the process of revictimization, we still need a unifying framework to increase our under-

standing of how the interaction between victim characteristics and perpetrator behavior leads

to revictimization. The psychological sequelae of CSA discussed previously can be

conceptualized as two mechanisms within the microsystem that increase vulnerability of

CSA survivors for revictimization (see Fig. 1). These two mechanisms operate in different

ways to increase risk for revictimization, and may help explain why certain factors do not

consistently predict revictimization. The first mechanism operates to increase risk for

revictimization through increased contact with potential rapists. Here, the victim’s sexual


behavior (e.g., number of sexual partners) or problems such as alcohol or drug use increase

the likelihood of revictimization because these behaviors operate to increase contact with

potential perpetrators, or because these behaviors actually create a context where victimiza-

tion is more likely (e.g., in situations where alcohol is consumed by both the victim and

perpetrator). For instance, women who drink may be more likely to encounter potential

perpetrators in settings such as bars or fraternity parties where alcohol is likely to be

consumed (Testa & Parks, 1996). Promiscuous sexual behavior could increase revictimization

risk simply because women who have more sexual partners are more likely to encounter a

potential perpetrator. This mechanism would also explain why women who abuse alcohol or

substances, but whose use occurs only in their own home or in situations where potential

perpetrators are not present, would be at lower risk. For such women, problematic alcohol or

substance use would not increase risk for revictimization.

The second mechanism operates in a different manner to increase risk for revictimization

because it involves factors that increase the likelihood that the perpetrator will choose to act

aggressively. The second mechanism reflects the psychological and social vulnerability

within the victim that potential perpetrators are likely to identify and act upon. According to

this mechanism, women are at increased risk because psychological difficulties (e.g.,

dissociation, frequent intoxication, or risk recognition deficits) decrease awareness or the

ability to respond to dangerous situations, resulting in a vulnerable state to which a

perpetrator might respond with aggression. Risk increases because a potential perpetrator

would identify and act upon the woman’s vulnerability, not just because such problems

increase the likelihood of encountering a perpetrator.

Fig. 1. Microsystem mechanisms within an ecological framework of revictimization.


Because psychological correlates of CSA (e.g., dissociation, PTSD, alcohol abuse, sexual

behavior, risk recognition, interpersonal difficulties) have mostly been examined in isolation,

one could infer that they are considered to be completely separate factors with different

underlying mechanisms, or assume that such factors operate in different ways to create risk

for revictimization. However, such factors probably do not operate independently. For

example, Epstein et al. (1998) found that PTSD mediated the relationship between childhood

rape and alcohol use. Therefore, examination of factors in combination appears to be

important. However, few studies that empirically examine more than a single variable are

available. We propose that these factors are related, not simply because of the high rates of

comorbidity among such problems, but because underlying mechanisms and processes may

operate in very similar ways to increase vulnerability and increase risk for revictimization

among CSA survivors.

For instance, alcohol abuse and dissociation, two distinct phenomena, do have functional

aspects that overlap (e.g., both intoxication and dissociation lead to decreased awareness of

surroundings and ability to respond to danger—both factors serving as vulnerabilities that

potential perpetrators may act upon). Briere and Runtz (1987) identified the functional

similarity between substance intoxication and dissociation when they concluded that alcohol

and drug intoxication function as forms of ‘‘chemically induced dissociation, invoked as a

chronic coping response to aversive affects, memories, and situations’’ (p. 374). Further,

although interpersonal difficulties do not operate in ways similar to PTSD and dissociation,

these sequelae can also serve to increase vulnerability to revictimization because of an

increased possibility that the CSA survivor will be manipulated within an interpersonal

context. In all cases, the psychological sequelae would operate to increase risk because a

perpetrator perceives the victim’s reduced awareness, her inability to respond assertively and

effectively, or both.

Similarly, alcohol use and certain patterns of sexual behaviors may share a common

underlying mechanism that leads to revictimization. Contact with a greater number of sexual

partners may place a woman in contact with more potential perpetrators. Consuming alcohol

and substances in social settings involving others may also serve to increase contact with

sexual perpetrators. Thus, while these two factors may not occur simultaneously within any

one woman, the presence of either factor may increase her risk for revictimization by

increased exposure to perpetrators.

Several different types of psychological difficulties can increase risk for revictimization

because perpetrators identify or recognize this psychological vulnerability and act upon it.

Different types of psychological difficulties can also increase risk for revictimization because

they increase contact with potential perpetrators. Focusing on the function or outcome of this

symptomatology (e.g., decreased awareness and ability to respond to danger leading to

vulnerability to a potential perpetrator or increased contact with potential perpetrators), rather

than the distinct symptomatology itself (i.e., dissociation vs. drug abuse vs. interpersonal

dysfunction vs. sexual behaviors) may help explain contradictory findings. Some women may

be more vulnerable because they abuse alcohol or drugs, and others may be more vulnerable

because of their tendency to dissociate, but neither alcohol abuse nor dissociation will fully

explain revictimization for all women. Further, increased numbers of sexual partners or


greater use of alcohol, often in social settings, may increase contact with perpetrators. Neither

one alone will explain this increased potential for victimization, and these factors must be

considered in the context of increased vulnerability as well.

The state of the current literature on this subject could be compared to the story of the blind

men and the elephant. As researchers, some of us are focusing on the trunk, some of us are

focusing on the tail, and others are focusing on the leg of the elephant, without realizing that

in actuality we are all studying different parts of the same beast. Rather than construing that

the entire elephant is a rope (as did the blind man examining the tail), the blind man must

communicate with his peers about their experiences. Here, rather than concluding, for

example, that alcohol abuse is the only important explanatory factor (or conversely, that it

is not important because it is not consistently related to revictimization), we must also

consider that sexual behavior, interpersonal problems, and each of the other correlates of CSA

are part of this problem. Alcohol abuse, dissociation, PTSD, risk recognition, and interper-

sonal problems may simply be different ways in which vulnerability is expressed, but are

actually different aspects of the same mechanism that increases risk for revictimization:

psychological vulnerability. Increased numbers of sexual partners and alcohol or substance

use in social settings may similarly be different aspects of the second mechanism: increased

risk through contact with perpetrators. These variables may not consistently predict

revictimization if they are examined separately or in isolation (i.e., alcohol abuse or PTSD,

alcohol use or sexual behavior patterns), rather than as the concept of psychological

vulnerability. Given this, we propose a shift from examining individual types of psycho-

logical distress to a focus on the function or outcome of such problems: increased contact with

potential perpetrators and psychological vulnerability acted upon by perpetrators. Such

mechanisms may be best examined as a composite of several other individual factors.

It is necessary to assess not only the individual contribution of each risk factor, but also

the importance of a composite variable that reflects the functional aspects of these factors

that increase risk and vulnerability. This composite variable may be comprised of an

accumulation of different types of risk (e.g., engaging in high risk sexual behavior and

abusing alcohol), or may be comprised of an severity index of problems, with more severe

problems creating risk regardless of the type of problem (e.g., engaging in high risk sexual

behavior is sufficient to increase risk by itself if such behavior reaches a certain threshold).

Assessing increased risk and psychological vulnerability is important because it is very

likely that this risk and vulnerability, rather than the psychological problems from which

these mechanisms are derived, are the essential factors with regard to increased likelihood of

revictimization.

While not an attempt to explain revictimization, one study (Koss & Dinero, 1989) utilized

this approach to examine risk for sexual victimization among college women. Risk was

operationalized according to three vulnerability-enhancing mechanisms: vulnerability-cre-

ating traumatic experiences (e.g., family violence, family instability, CSA), social–psycho-

logical vulnerability (e.g., sexual attitudes, rape myth acceptance), and situational

vulnerability (e.g., alcohol use, sexual activity). Although these three mechanisms failed to

predict victimization (only vulnerability-creating experiences such as CSA appeared import-

ant in this model), this may still be a valuable approach. These mechanisms may have been


unable to predict victimization simply because the wrong risk factors were selected for

inclusion.

Future attempts to quantify psychological vulnerability as a composite variable may

benefit from an ‘‘in depth case study approach,’’ utilizing qualitative analysis to identify

salient risk factors. A qualitative examination could focus on the presence and intensity of

different factors, identify common patterns or combinations of factors, and consider the

context of victimization in relation to revictimization. Qualitative analyses can also examine

the relative importance or frequency of many ‘‘subclinical’’ problems as opposed to the

presence of a single ‘‘clinically significant’’ problem, as well as provide data for formulating

profiles of revictimized women, and future studies may determine whether certain patterns

emerge as more prevalent. Qualitative findings may ultimately impact which factors are the

focus of future investigations.

4. Conclusion

The negative long-term impact of childhood sexual abuse is irrefutable. Most mental

health professionals agree that such experiences are related to acute and chronic psycho-

logical (and physical) difficulties, and that such difficulties often continue into adulthood.

Those searching for an explanation of the CSA survivor’s increased vulnerability for later

victimization have sought answers in several realms, most recently focusing on the

psychological sequelae of CSA as a possible contributor to the increased vulnerability for

revictimization. However, although the focus of current empirical research intuitively ‘‘makes

sense,’’ the area continues to suffer from lack of a guiding theoretical model. What has

resulted is a disconnected literature. Although attention focused on this topic has grown

considerably in the past several years, little has been accomplished by way of identifying

overarching explanatory models.

We are beginning to discover important factors contributing to revictimization. The

research conducted so far has provided us with some limited information, but also with

clues for the direction of future research. The ecological framework provides an appropriate

setting for the study of revictimization, and future investigations should include a focus on the

microsystem level of this model, which emphasizes the interaction of attributes, behaviors,

and beliefs of the victim and the perpetrator. We must focus less on individual factors and

instead examine mechanisms that increase vulnerability and risk within the context of the

microsystem. In all studies of revictimization, we must recognize the importance of factors

besides the victim and her behavior. We hope that a general acceptance of an ecological

model will spur interest in factors outside the victim and her behavior, including the behavior

of the perpetrator and our society’s response to the sexual victimization of children and

women. However, we also must not shy away from the study of victims’ characteristics or

behaviors (which are targeted by perpetrators) for fear of blaming the victim. This, too, would

impede progress in the development of effective risk reduction programming and treatment

for survivors. Focusing on how abuse affects victims to make them more vulnerable does not

mean that we believe victims intentionally place themselves in dangerous situations.


Furthermore, while important, focusing on women’s behaviors and risk reduction program-

ming will only help some individual women some of the time (i.e., those who participated in

such programs, and then only under some sets of circumstances) to reduce their risk.

However, to truly reduce the incidence of sexual victimization for all women, global change

can only occur through prevention programming with men. Effective risk reduction

programming for women does not equal rape prevention.

Much of the current research seeking to explain revictimization focuses on the victim and

the psychological effects of CSA. The function of the psychological effects of CSA can be

described by two separate mechanisms at the microsystem level. The first mechanism—

exposure risk—includes factors that increase contact with potential perpetrators, such as

engaging in high-risk sexual behaviors, or using alcohol or other substances in situations

where perpetrators are likely to be present. The second mechanism increases vulnerability to

potential perpetrators because such factors increase the likelihood that a perpetrator will act

aggressively. PTSD, dissociation, alcohol use, risk recognition, or interpersonal difficulties

can all function to increase the likelihood that a perpetrator will view the victim as ‘‘an easy

target.’’ Although these two mechanisms are promising as potential explanations, we should

recognize that they are just two of many mechanisms underlying the process of revictimiza-

tion. Research on revictimization must also address the macrosystem and exosystem because

these systems encapsulate our society’s devalued view of women and children; such

devaluation may increase sexual aggression and the acceptability of violence towards women

and children. Research on macrosystem and exosystem factors might benefit from the

inclusion of theories such as routine activities theory (Finkelhor & Asdigian, 1996; Schwartz

& Pitts, 1995), and other ideas from disciplines such as victimology, sociology, and

criminology. For instance, according to routine activities theory, (Finkelhor & Asdigian,

1996) certain aspects of the victim, including victim vulnerability, increase risk because such

characteristics are ‘‘congruent’’ with the motives or needs of offenders. This idea seems

particularly relevant to the study of revictimization.

Conclusions of studies examining mediating and moderating factors in revictimization

are important to development of effective risk reduction programs. If future research

would utilize the ecological model to focus on the perpetrator as well as the victim,

information gleaned from such studies might contribute positively to the development of

effective prevention programs for men. Risk reduction programming may need to extend

programs designed for all women, to include components tailored to women with histories

of CSA. Programs for women with histories of victimization may benefit from focusing

on the victim’s personal attributes and skill deficits as well as focusing on reduction in the

psychological sequelae of CSA such as dissociative tendencies. Clinicians are in a unique

position to ameliorate the effects of, or even reduce the likelihood of, victimization. If

revictimization is related to vulnerability created by the psychological sequelae of previous

victimization experiences, mental health providers will be able to decrease risk for

revictimization if therapy successfully resolves such issues. Psychotherapy may decrease

vulnerability if the survivor’s psychological symptoms of PTSD or dissociation are

decreased or eliminated, if a survivor’s self-esteem improves, or if self-protective

behaviors are modeled and learned (for example, see Messman-Moore & Resick, 2002).


Psychotherapy could also help survivors develop safer, more appropriate repertoires of

sexual behavior, to examine beliefs about interpersonal relationships, particularly intimate

relationships, and to examine the impact of interpersonal dynamics in relation to

revictimization.

Finally, scholars must recognize the impact of our work and accept responsibility for

where our questions, and the answers to those questions, lead us. Our theories of

revictimization will shape what we will find empirically. If we focus on the victim, we

will find within her and her behavior explanations for revictimization. However, we must

recognize the interpersonal context in which revictimization takes place, and choose to also

focus on the perpetrator and cultural factors within our society. The study of revictimiza-

tion should focus on the intersection between the victim and the perpetrator. We will never

fully understand revictimization while the microscope remains focused solely on the

victim.

Acknowledgements

This research was supported by a grant awarded to the first author from the College of

Arts and Sciences at Miami University. Earlier versions of this article were presented at the

7th International Family Violence Research Conference, July 2001, in Portsmouth, NH and

the 35th Annual Meeting of the Association for Advancement of Behavior Therapy,

November 2001, in Philadelphia, PA. The authors would like to thank Margaret

O’Dougherty Wright and Sarah Ullman for comments and suggestions on earlier versions

of this manuscript.

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