Child Abuse & Neglect 66 (2017) 64–72

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Child Abuse & Neglect

The relationship between childhood sexual abuse and mental

health outcomes among males: Results from a nationally
representative United States sample
Sarah Turner a,b , Tamara Taillieu c , Kristene Cheung d , Tracie O. Afifi a,b,∗
a
Department of Community Health Sciences, University of Manitoba, Canada
b
Department of Psychiatry, University of Manitoba, Canada
c
Applied Health Sciences Program, University of Manitoba, Canada
d
Department of Psychology, University of Manitoba, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: Few studies have examined the associations between childhood sexual abuse
Received 4 August 2016 (CSA), co-occurrence with other types of maltreatment and adult mental health outcomes,
Received in revised form specifically among males. The objectives of this study were to: 1) determine the prevalence
26 November 2016
of males who have experienced a) childhood maltreatment without CSA; b) CSA without
Accepted 23 January 2017
Available online 6 February 2017
other forms of childhood maltreatment; and c) CSA along with other forms of childhood
maltreatment; and 2) determine the relationship between CSA among males and mood,
anxiety, substance and personality disorders and suicide attempts.
Keywords:
Methods: Data were drawn from the 2004–2005 National Epidemiological Survey on Alco-
Child sexual abuse
Males hol and Related Conditions (NESARC) and limited to males age 20 years old and older
Mental disorders (n = 14,564). Child maltreatment included harsh physical punishment, physical abuse, sex-
Child maltreatment ual abuse, emotional abuse, emotional neglect, physical neglect and exposure to intimate
Co-occurrence partner violence (IPV).
Results: Emotional abuse, physical abuse, and exposure to IPV were the most common
forms of maltreatment that co-occurred with CSA among males. A history of CSA only, and
CSA co-occurring with other types of child maltreatment, resulted in higher odds for many
mental disorders and suicide attempts compared to a history of child maltreatment without
CSA.
Conclusions: Child maltreatment is associated with increased odds of mental disorders
among males. Larger effects were noted for many mental disorders and suicide attempts
for males who experienced CSA with or without other child maltreatment types compared
to those who did not experience CSA. These results are important for understanding the
significant long-term effects of CSA among males.
© 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ Corresponding author at: S113-750 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W5, Canada.
E-mail addresses: sarah.turner@umanitoba.ca (S. Turner), umtailli@myumanitoba.ca (T. Taillieu), umcheu46@myumanitoba.ca (K. Cheung),
tracie.afifi@umanitoba.ca (T.O. Afifi).

http://dx.doi.org/10.1016/j.chiabu.2017.01.018
0145-2134/© 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
 S. Turner et al. / Child Abuse & Neglect 66 (2017) 64–72 65

1. Introduction

Child sexual abuse (CSA) is common in the United States (U.S.) with an estimated prevalence between 2.5%–7.8% in
males and 11.4%–13.5% in females (Finkelhor, Turner, Shattuck, & Hamby, 2013; Molnar, Buka, & Kessler, 2001). The long-
term consequences of experiencing CSA can be devastating and have been well documented in the literature. Those who
experience CSA are more likely to be diagnosed with mental disorders, (Afifi et al., 2011, 2014; Afifi, Henriksen, Asmundson,
& Sareen, 2012; MacMillan, Tanaka, Duku, Vaillancourt, & Boyle, 2013; Molnar, Buka et al., 2001; Pérez-Fuentes et al., 2013;
Walker, Carey, Mohr, Stein, & Seedat, 2004) have suicide-related behaviour (Afifi et al., 2014; Devries et al., 2014; Easton,
Renner, & O’Leary, 2013; Holmes & Slap, 1998), and be at increased likelihood for experiencing adult victimization (Afifi
et al., 2009; Desai, Arias, Thompson, & Basile, 2002).
Although research focusing on CSA has increased dramatically in the last three decades (Fergusson, McLeod, & Horwood,
2013), much of this literature considers only females, or uses samples that combine males and females. Only a small portion
of literature has focused on CSA specifically among males, with many of these studies using small or non-representative
samples (Dhaliwal, Gauzas, Antonowicz, & Ross, 1996; Dimok, 1988; Easton et al., 2013; Ellerstein & Canavan, 1980; Fromuth
& Burkhart, 1989; Holmes & Slap, 1998; Nalavany, Ryan, & Hinterlong, 2009; Valente, 2005). Results from these studies are
further limited by restricted measures of other types of child maltreatment, most often only including physical abuse as a
co-occurring type of abuse.
Experiencing CSA can result in negative outcomes in childhood, but can also result in long-term conditions that persist
into adulthood. Research examining the long-term mental health sequelae following CSA has focused on comparing males
to females or using non-stratified samples. These methodologies shift attention away from the relationship between CSA in
males and long-term mental health sequelae, and towards the relative difference or similarities in mental health sequelae
between males and females (Dhaliwal et al., 1996; Dube et al., 2005; Fergusson et al., 2013; Spataro, Mullen, Burgess, Wells,
& Moss, 2004). Although it is understood that CSA is related to long-term mental disorders, it is currently unknown how
CSA is linked to anxiety, substance use, mood, and personality disorders as well as suicide attempts in adulthood specifically
among males using a representative general population sample.
The co-occurrence of different types of child maltreatment is common (Dong, Anda, Dube, Giles, & Felitti, 2003; Higgins &
McCabe, 2001). However, it is unknown how often CSA among males occurs on its own and with other types of maltreatment.
A previous study using a non-stratified sample of males and females showed that physical abuse, physical maltreatment, and
physical neglect were significantly more prevalent among individuals with CSA than among those who did not experience
CSA (Pérez-Fuentes et al., 2013). Experiencing more than one type of child maltreatment and/or childhood adversity can
have cumulative effects and has been shown to increase the likelihood of emotional harm (De Marco, Tonmyr, Fallon, &
Trocmé, 2007), suicidality (Afifi et al., 2014; Bryant & Range, 1996), and mental disorders (Afifi et al., 2014). It is unknown to
what extent child maltreatment without CSA, CSA only, and CSA with other experiences of child maltreatment may increase
the likelihood of long-term mental health sequelae. Additionally, most studies do not look at the co-occurrence of six types
of child abuse and neglect (i.e., harsh physical punishment, physical abuse physical neglect, emotional abuse, emotional
neglect, and exposure to intimate partner violence (IPV)) with the experience of CSA, which does not provide a complete
picture of the relationship between CSA alone and in combination with other types of maltreatment and later mental health
outcomes.
This study fills several important gaps in the literature by using a large, representative sample of males from the U.S.,
using a widely used and validated measure of CSA, examining the co-occurrence between six types of child maltreatment
and CSA, and measuring the relationship between child maltreatment and mental disorders and suicide attempts using
an additive child maltreatment variable that includes experiences of child maltreatment with and without CSA and CSA
alone. The objectives of this study were to: 1) determine the prevalence of males who have experienced a) childhood
maltreatment without CSA; b) CSA without other forms of childhood maltreatment and; c) CSA along with other forms
of childhood maltreatment and; 2) determine the relationship between CSA among males and mood, anxiety, substance,
personality disorders, and suicide attempts while adjusting for sociodemographic factors and history of family dysfunction.

2. Methods

2.1. Data and sample

Data were drawn from the second wave of National Epidemiological Survey on Alcohol and Related Conditions (NESARC)
collected between 2004 and 2005. The second wave of the NESARC is a cross-sectional sample of 34,653 adults aged 20 years
and older living in households and non-institutionalized settings. In this study, analyses were restricted to male respon-
dents, resulting in a final sample of 14,564. Data were weighted to adjust for non-response, the selection of one person per
household, the oversampling of specific groups, and then further adjusted to be representative of the U.S. population based
on 2006 Census data (Grant et al., 2004). Data were collected through face-to-face interviews by trained lay interviewers of
the U.S. Census Bureau. The response rate was 86.7%. Further details on the NESARC have been described elsewhere (Grant
et al., 2003, 2004; Ruan et al., 2008).
66 S. Turner et al. / Child Abuse & Neglect 66 (2017) 64–72

2.2. Measures

2.2.1. Child maltreatment. Several types of child maltreatment, including sexual abuse, harsh physical punishment, physical
abuse, exposure to IPV, physical neglect, emotional abuse, and emotional neglect, were assessed using questions adapted
from the Adverse Childhood Experiences (ACE) survey (Dong et al., 2003; Dube et al., 2003). The original ACE questions
were based on items from valid, psychometrically established measures designed to assess adverse childhood experiences
using a survey methodology, including the Conflict Tactics Scales (Straus, Hamby, Boney-McCoy, & Sugarman, 1996; Straus,
1979), the Childhood Trauma Questionnaire (Bernstein et al., 1994), and childhood sexual abuse items adapted from Wyatt
(1985). All child maltreatment items, with the exception of childhood emotional neglect, were measured on a 5-point ordinal
scale (never, almost never, sometimes, fairly often, and very often), and respondents were asked to report on experiences that
occurred before the age of 18 years. Psychometrically established dichotomous coding was used to indicate the presence or
absence of each type of child maltreatment based on the following criteria.
Sexual abuse was coded as present if the respondent reported having ever (i.e., any response other than never on the
5-point ordinal scale) experienced any unwanted sexual touching or fondling, or any attempted or actual intercourse by
an adult or other person that was unwanted or occurred when the respondent was too young to understand what was
happening.
Harsh physical punishment was coded as present if the respondent reported having sometimes, fairly often, or very often
been pushed, grabbed, shoved, slapped, or hit by their parents or any adult living in their home. Physical abuse was coded as
present if the respondent reported having ever (i.e., any response other than never on the 5-point ordinal scale) been hit so
hard that it left marks, bruises, or caused an injury by a parent or other adult living in the home. Physical neglect was coded
as present if the respondent reported having ever (i.e., any response other than never on the 5-point ordinal scale) been left
alone or unsupervised before age 10; gone without needed things such as clothes, shoes, or school supplies because a parent
or other adult living in the home spent the money on themselves; been made to go hungry or did not have regular meals
prepared; and/or had a parent or other adult living in the home ignore or fail to get the respondent medical treatment.
Exposure to IPV was coded as present if the respondent reported having sometimes, fairly often, or very often witnessed
their mother’s partner (a) push, grab, slap, or throw something at their mother, or (b) kicked, bit or hit their mother with a
fist or something hard, or if the respondent reported having ever (i.e., any response other than never on the 5-point ordinal
scale) witnessed their mother’s partner (c) repeatedly hit their mother for at least a few minutes or (d) threatened her with
a knife or gun, or used a knife or gun to her hurt. Maternal perpetration of IPV was not assessed in the survey.
Emotional abuse was coded as present if the respondent reported having fairly often or very often experienced a parent or
other adult living in the home swear at or insult the respondent; threaten to hit or throw something at the respondent, but
didn’t do it; and/or act in any other way that made the respondent feel afraid. Childhood emotional neglect was assessed
on a similar 5-point ordinal scale (never true, rarely true, sometimes true, and very often true) based on the following five
items: (a) the respondent felt there was someone in the family who wanted them to be a success, (b) someone in the
respondent’s family made them feel special or important, (c) the respondent’s family was a source of strength or support,
(d) the respondent felt part of a close knit family, and (e) someone in the respondent’s family believed in them. Consistent
with past research, these items were reverse-coded and summed; emotional neglect was coded as present if the total score
for the emotional neglect items was 15 or greater (Afifi et al., 2011; Dong et al., 2003; Dube et al., 2003).
A four-category additive child maltreatment variable was also computed based on participant’s responses to all of the indi-
vidual child maltreatment items. For this variable, respondents were placed into one of four mutually exclusive categories:
(1) no child maltreatment, (2) child maltreatment without CSA, (3) CSA only, and (4) CSA with other child maltreatment.

2.2.2. Family history of dysfunction. Family history of dysfunction was also based on items from the ACE study (Dong et al.,
2003; Dube et al., 2003). A family history of dysfunction was coded as present if the respondent reported that a parent or
other adult living in the home had a problem with alcohol or drugs, went to jail or prison, was treated or hospitalized due
to mental illness, and/or attempted or completed suicide before the respondent was 18 years old.

2.2.3. Mental disorders. Lifetime diagnoses of mental disorders were made using a fully structured interview protocol called
the Alcohol Use Disorder and Associated Disabilities Interview Schedule − Fourth Edition (AUDADIS-IV) (Grant et al., 2001;
Ruan et al., 2008), based on DSM-IV criteria. Reliability and validity of the AUDADIS-IV have been established (Grant et al.,
2003, 2004; Ruan et al., 2008). Dichotomous coding was used to assess the presence or absence each individual mental
disorder based on AUDADIS-IV criteria. Mental disorders that were assessed in this study included mood disorders (i.e.,
major depression, dysthymia, mania, and hypomania), anxiety disorders (i.e., panic disorder, social phobia, specific pho-
bia, generalized anxiety disorder, and post-traumatic stress disorder (PTSD)), and substance use disorders (i.e., alcohol
abuse or dependence or illicit drug abuse or dependence). In addition, the personality disorders assessed included Cluster
A personality disorders (i.e., paranoid, schizoid, and schizotypal), Cluster B personality disorders (i.e., antisocial, border-
line, histrionic, and narcissistic), and Cluster C personality disorders (i.e., avoidant, dependent, and obsessive-compulsive).
Composite variables for each of the different mental disorder categories were also created.
 S. Turner et al. / Child Abuse & Neglect 66 (2017) 64–72 67

2.2.4. Suicide attempt. Each respondent was asked if they ever attempted suicide in their lifetime. This item was measured
as a dichotomous yes or no variable.

2.2.5. Sociodemographic covariates. Sociodemographic covariates included age, marital status, race/ethnicity, education, past
year household income, and a proxy indicator of childhood socioeconomic status (SES). Childhood SES was based on partici-
pant’s response to the question: “Before you were 18 years old, was there ever a time when your family received money from
government programs like welfare, food stamps, general assistance, Aid to Families with Dependent Children, or Temporary
Assistance for Needy families?” (yes or no).

2.3. Statistical methods

Statistical weights were applied in all analyses to ensure that the NESARC data were representative of the general U.S.
population. To account for the complex sampling design of the NESARC, Taylor series linearization was used as a variance
estimation technique using Stata software. First, descriptive statistics were computed using cross tabulations and logistic
regression models to examine the distribution of sociodemographic characteristics by CSA. Second, descriptive statistics
using cross tabulations were computed to examine the co-occurrence of CSA with other types of childhood maltreatment
and a family history of dysfunction. Logistic regression models were also computed to examine the association between
CSA and other types of child maltreatment and a family history of dysfunction. Models were first run unadjusted (OR), and
then adjusted for sociodemographic covariates (AOR). Third, descriptive statistics using cross tabulations were computed
to examine the distribution of mental disorders by the four-level childhood maltreatment variable (i.e., no maltreatment;
child maltreatment without CSA; CSA only; and CSA with other types of child maltreatment). Finally, multivariable logistic
regression models were computed to examine the association of the four-level childhood maltreatment variable by mental
disorders. Multivariable logistic models were adjusted for sociodemographic covariates and a family history of dysfunction.
Additive effects of the four-category child maltreatment variable were tested by changing the reference groups in the
multivariable logistic regression models. Significant differences between the child maltreatment groups are indicated by
differing superscripts in the tables. Results at p ≤ 0.05 were considered statistically significant and 95% confidence intervals
are reported for all models. To account for the multiple comparisons, P values of p ≤ 0.01 and p ≤ 0.001 are also provided to
interpret the models at a stricter statistical level for the more conservative reader.

3. Results

The prevalence of CSA among males was 5.3%. The four-category child maltreatment variable indicated that 58.1% of
males experienced no child maltreatment, 36.7% experienced child maltreatment without CSA, 1.3% experienced CSA only,
and 4.0% experienced CSA with other forms of maltreatment. The distribution of CSA by sociodemographic characteristics
is provided in Table 1. The prevalence of CSA was significantly higher among respondents aged 40–69 years (vs. 70 years
and older), those who were currently separated or divorced (vs. married or common-law), respondents self-identifying as
American Indian or Alaskan Native, Black, and Hispanic (vs. White), and among respondents with both lower childhood SES
and past-year total household incomes.
The presence of other forms of child maltreatment and a family history of dysfunction were strongly associated with CSA
(Table 2). That is, the odds of experiencing CSA were significantly elevated in homes where other forms of child maltreatment
or a family history of dysfunction were also present (odds ratios (ORs) range from 2.98 to 5.84, all p ≤ 0.001). These relation-
ships were attenuated, but remained statistically significant, after adjustment for sociodemographic covariates (adjusted
odds ratios (AORs) ranged from 2.71 to 5.22, all p < 0.001).
The association between the four-level categorical child maltreatment variable and mood, anxiety, and substance disor-
ders and suicide attempts is provided in Table 3. Child maltreatment increased the odds of all mental disorders and suicide
attempts. With the exception of hypomania, alcohol abuse/dependence, and any substance use disorder, experiencing CSA
only was significantly related to an increased odds of all mental disorders and suicide attempts compared to not expe-
riencing child maltreatment after controlling for sociodemographic variables and a family history of dysfunction (AORs
range from 1.77 to 8.57, p ≤ 0.05). Examination of the differences across the child maltreatment categories indicated that
CSA only and CSA with other types of maltreatment had significantly higher odds of major depression, dysthymia, mania,
any mood disorder, panic disorder, generalized anxiety disorder, any anxiety disorder, and suicide attempts compared to
child maltreatment without CSA. The strength of the association between CSA only was not statistically different from child
maltreatment without CSA and was significantly lower compared to CSA with other types of child maltreatment for PTSD,
alcohol abuse/dependence, and any substance use disorders.
The association between CSA, based on the four-category child maltreatment variable, and personality disorders is pro-
vided in Table 4. With the exception of schizoid personality disorder and borderline personality disorder, experiencing CSA
only was associated with all personality disorders after adjusting for sociodemographic factors and family history of dysfunc-
tion (AORs ranged from 2.46 to 5.96 p ≤ 0.05). Examination of the differences across child maltreatment categories indicated
that CSA only and CSA with other types of maltreatment categories had significantly higher odds of schizotypal personality
disorder, any Cluster A personality disorder, borderline personality disorder, narcissistic personality disorder, any Cluster
B personality disorder, any Cluster C personality disorder, and any personality disorder compared to child maltreatment
68 S. Turner et al. / Child Abuse & Neglect 66 (2017) 64–72

Table 1
Sociodemographic Characteristics by Childhood Sexual Abuse History in a Nationally Representative Sample of Adult Males from the United States.

Sociodemographic Covariate No Sexual Abuse % (n) Sexual Abuse % (n) OR (95% CI)

Age (years)
20–29 95.7 (2020) 4.3 (96) 1.04 (0.72, 1.49)
30–39 94.4 (2492) 5.6 (161) 1.36 (0.98, 1.89)
40–49 94.3 (3067) 5.7 (217) 1.41 (1.05, 1.89)*
50–59 94.2 (2502) 5.8 (175) 1.44 (1.03, 2.00)*
60–69 94.2 (1691) 5.8 (103) 1.43 (1.04, 1.96)*
70 or older 95.9 (1814) 4.1 (93) 1.00

Marital Status
Single (never married) 94.3 (2876) 5.7 (187) 1.22 (0.98, 1.52)
Separated/Divorced 91.8 (1869) 8.2 (166) 1.81 (1.42, 2.29)***
Widowed 94.6 (588) 5.4 (31) 1.16 (0.69, 1.94)
Married/Common-law 95.3 (8250) 4.7 (461) 1.00

Race/Ethnicity
American Indian/Alaskan Native 89.6 (208) 10.4 (25) 2.32 (1.36, 3.98)**
Asian/Native Hawaiian/Pacific Islander 96.1 (398) 3.9 (20) 0.81 (0.48, 1.39)
Black 92.4 (2137) 7.6 (162) 1.66 (1.29, 2.13)***
Hispanic 93.8 (2504) 6.2 (186) 1.32 (1.02, 1.72)*
White 95.3 (8336) 4.7 (452) 1.00

Education
Less than High School 94.3 (2107) 5.7 (126) 1.17 (0.89, 1.55)
High School 95.0 (3636) 5.0 (221) 1.02 (0.81, 1.28)
Some College/University 93.8 (2816) 6.2 (207) 1.29 (1.01, 1.64)*
Post-Secondary Degree 95.1 (5024) 4.9 (291) 1.00

Past Year Household Income

Less than $20,000 92.8 (2302) 7.2 (173) 1.63 (1.22, 2.18)***
$20,000–$39,999 94.3 (3332) 5.7 (222) 1.28 (1.04, 1.57)*
$40,000–$69,999 95.1 (3752) 4.9 (215) 1.08 (0.85, 1.36)
$70,000 or more 95.5 (4197) 4.5 (235) 1.00

Government Assistance Receipt in Childhood

Yes 90.1 (1740) 9.9 (201) 2.28 (1.86, 2.79)***
No 95.4 (11,723) 4.6 (631) 1.00
*
≤0.05.
**
≤0.01.
***
≤0.001.

Table 2
Co-Occurrence of Childhood Sexual Abuse with Other Forms of Maltreatment and Family History of Dysfunction in a Nationally Representative Sample of
Adult Males from the United States.

Type of Childhood Maltreatment No Sexual Abuse % (N) Sexual Abuse % (N) OR (95% CI) AORa (95% CI)

Harsh Physical Punishment 86.8 (2280) 13.2 (360) 4.02 (3.36, 4.81)*** 3.70 (3.09, 4.43)***
Physical Abuse 81.1 (859) 18.9 (200) 5.18 (4.10, 6.55)*** 4.43 (3.48, 5.63)***
Exposure to IPV 82.1 (1073) 17.9 (252) 5.10 (4.11, 6.32)*** 4.37 (3.48, 5.50)***
Emotional Abuse 79.8 (860) 20.2 (215) 5.84 (4.59, 7.43)*** 5.22 (4.08, 6.68)***
Emotional Neglect 87.4 (1055) 12.6 (173) 2.98 (2.37, 3.74)*** 2.71 (2.13, 3.46)***
Physical Neglect 89.2 (3412) 10.8 (464) 3.57 (2.94, 4.33)*** 3.30 (2.73, 3.98)***
History of Family Dysfunction 89.6 (3259) 10.4 (417) 3.12 (2.59, 3.76)*** 2.77 (2.30, 3.34)***
***
≤0.001.
a
AOR = Odds ratio adjusted for: age, marital status, race/ethnicity, education, income, and government assistance in childhood.

without CSA (AOR range from 2.68 to 7.86 p ≤ 0.001). The odds for CSA only and CSA with other types of child maltreatment
were not significantly different for any of the personality disorders.

4. Discussion

The significant findings from this study are: 1) of the males who experience CSA (5.3%), most experience CSA along
with other types of child maltreatment (4.0%); 2) emotional abuse, physical abuse, and exposure to IPV were the most
common forms of maltreatment that co-occurred with CSA; 3) a history of CSA only and CSA co-occurring with other types
of child maltreatment, resulted in higher odds for many mental disorders and suicide attempts compared to a history of
child maltreatment without CSA.
First, CSA more commonly occurred with other types of maltreatment than on its own. The odds of experiencing CSA
were the largest with emotional abuse, physical abuse, and exposure to IPV after adjusting for sociodemographic variables
 S. Turner et al. / Child Abuse & Neglect 66 (2017) 64–72 69

Table 3
The Association between Childhood Sexual Abuse History and Mood, Substance, Anxiety Disorders and Suicide Attempts in a Nationally Representative
Sample of Adult Males from the United States.

Mental Disorders No Child Maltreatment Child Maltreatment Sexual Abuse Only Sexual Abuse with
without Sexual Abuse Child Maltreatment

Major Depression
% (n) 12.1 (1022) 18.7 (1037) 30.5 (56) 39.1 (228)
AOR1 (95% CI) 1.00 1.52a (1.34, 1.71)*** 3.22b (2.13, 4.85)*** 3.54b (2.82, 4.45)***
Dysthymia
% (n) 2.3 (192) 4.7 (274) 8.4 (18) 10.9 (74)
AOR (95% CI) 1.00 1.90a (1.46, 2.48)*** 3.80b (2.08, 6.94)*** 3.70b (2.54, 5.41)***
Mania
% (n) 2.9 (234) 6.5 (345) 13.4 (23) 16.0 (94)
AOR (95% CI) 1.00 2.01a (1.59, 2.54)*** 5.51b (3.14, 9.68)*** 4.15b (2.84, 6.08)***
Hypomania
% (n) 3.2 (266) 4.3 (236) 4.4 (8) 9.2 (51)
AOR (95% CI) 1.00 1.34a (1.08, 1.67)** 1.46a,b (0.64, 3.35) 2.76b (1.80, 4.25)***
Any Mood Disorder
% (n) 15.6 (1297) 24.0 (1336) 35.7 (68) 47.0 (282)
AOR (95% CI) 1.00 1.56a (1.41, 1.74)*** 3.09b (2.08, 4.59)*** 3.66b (2.89, 4.64)***
Panic Disorder
% (n) 3.5 (295) 5.6 (296) 13.3 (24) 15.9 (84)
AOR (95% CI) 1.00 1.47a (1.19, 1.82)*** 4.18b (2.45, 7.13)*** 3.81b (2.57, 5.65)***
Social Phobia
% (n) 4.4 (363) 7.2 (398) 7.7 (18) 15.2 (95)
AOR (95% CI) 1.00 1.58a (1.30, 1.92)*** 1.81a,b (1.04, 3.17)* 2.91b (2.09, 4.05)***
Specific Phobia
% (n) 8.5 (714) 11.6 (652) 15.0 (32) 18.9 (109)
AOR (95% CI) 1.00 1.35a (1.18, 1.56)*** 1.87a,b (1.12, 3.11)* 2.09b (1.52, 2.86)***
GAD2
% (n) 3.6 (305) 5.7 (308) 10.8 (22) 16.2 (97)
AOR (95% CI) 1.00 1.39a (1.14, 1.69)** 3.09b (1.72, 5.56)*** 3.53b (2.56, 4.85)***
PTSD
% (n) 2.3 (213) 6.0 (350) 5.5 (16) 13.5 (87)
AOR (95% CI) 1.00 2.33a (1.84, 2.94)*** 2.33a (1.25, 4.37)** 4.66b (3.34, 6.52)***
Any Anxiety Disorder
% (n) 16.6 (1389) 24.6 (1340) 35.6 (71) 42.8 (266)
AOR (95% CI) 1.00 1.53a (1.38, 1.70)*** 2.78b (1.89, 4.10)*** 3.00b (2.36, 3.81)***
Alcohol Abuse/Dependence
% (n) 43.8 (3537) 52.6 (2840) 46.8 (97) 60.9 (385)
AOR (95% CI) 1.00 1.40a,b (1.27, 1.54)*** 1.13a (0.80, 1.61) 1.72b (1.37, 2.15)***
Drug Abuse/Dependence
% (n) 12.5 (976) 19.6 (1031) 23.4 (44) 32.5 (205)
AOR (95% CI) 1.00 1.59a (1.41, 1.78)*** 2.32a,b (1.47, 3.65)*** 2.53b (1.92, 3.34)***
Any Substance Use Disorder
% (n) 45.8 (3677) 55.5 (2990) 49.1 (104) 64.3 (407)
AOR (95% CI) 1.00 1.45a,b (1.32, 1.59)*** 1.15a (0.82, 1.63) 1.80b (1.44, 2.26)***
Any Mood, Anxiety, or Substance Use Disorder
% (n) 55.7 (4511) 67.2 (3670) 68.2 (140) 80.8 (511)
AOR (95% CI) 1.00 1.59a (1.45, 1.73)*** 1.77a,b (1.23, 2.55)** 2.80b (2.00, 3.91)***
Suicide Attempt (Lifetime)
% (n) 0.9 (79) 3.1 (191) 7.0 (13) 12.7 (76)
AOR (95% CI) 1.00 2.82a (1.93, 4.11)*** 8.57b (3.81, 19.26) *** 9.27b (5.73, 15.00)***

Adjusted AOR with different superscripts indicate that the odds ratios were statistically significantly different at p ≤ 0.05 (i.e., the same superscript letter
indicates that the odds ratios were not statistically different from each other).
*
≤0.05.
**
≤0.01.
***
≤0.001.
1
AOR = Odds ratio adjusted for: age, marital status, race/ethnicity, education, income, government assistance in childhood and history of family dysfunc-
tion.
2
GAD = generalized anxiety disorder.

(AORs = 5.22, 4.43 and 4.37, respectively). This finding is important for health care practitioners so that inquiries about CSA
are made when other types of maltreatment are disclosed. This may be especially important for discovering CSA among
males, because it is an underreported type of abuse (Holmes & Slap, 1998). Stigma, confusion, and fear associated with CSA
among males strongly contributes to secrecy and non-disclosure (Spataro, Moss, & Wells, 2001), therefore, normalizing and
increasing the conversation around CSA among males in health care settings may facilitate higher disclosure rates. Without
disclosure, the individual will not receive services, which may increase the likelihood of better mental health outcomes
following experiences of CSA. Health care professionals should recognize the commonality of co-occurrence between other
70 S. Turner et al. / Child Abuse & Neglect 66 (2017) 64–72

Table 4
The Association between Childhood Sexual Abuse History and Personality Disorders in a Nationally Representative Sample of Adult Males from the United
States.

Personality Disorders No Child Maltreatment Child Maltreatment Sexual Abuse Only Sexual Abuse with
without Sexual Abuse Child Maltreatment

Paranoid PD1
% (n) 2.4 (191) 4.7 (283) 7.2 (18) 11.4 (76)
AOR2 (95% CI) 1.00 1.81a (1.40, 2.34)*** 3.21a,b (1.60, 6.41)*** 3.58b (2.56, 5.01)***
Schizoid PD
% (n) 2.3 (185) 3.9 (223) 4.4 (9) 7.1 (44)
AOR (95% CI) 1.00 1.56a (1.19, 2.05)** 1.94a (0.85, 4.41) 2.26a (1.38, 3.69)**
Schizotypal PD
% (n) 2.0 (188) 5.8 (340) 10.4 (23) 19.4 (114)
AOR (95% CI) 1.00 2.63a (2.02, 3.43)*** 5.59b (3.29, 9.50)*** 7.86b (5.32, 11.63)***
Any Cluster A PD
% (n) 5.7 (488) 11.5 (675) 16.5 (39) 27.5 (171)
AOR (95% CI) 1.00 1.93a (1.61, 2.31)*** 3.32b (2.10, 5.25)*** 4.54b (3.31, 6.24)***
Antisocial PD
% (n) 3.5 (258) 8.2 (428) 9.2 (17) 19.9 (106)
AOR (95% CI) 1.00 2.26a (1.82, 2.80)*** 3.09a,b (1.62, 5.90)*** 5.10b (3.61, 7.20)***
Borderline PD
% (n) 3.1 (265) 7.5 (443) 15.3 (30) 21.1 (140)
AOR (95% CI) 1.00 2.16a (1.75, 2.67)*** 5.96b (3.68, 9.64)*** 5.25b (3.84, 7.18)***
Histrionic PD
% (n) 1.0 (80) 2.6 (133) 4.0 (8) 6.3 (44)
AOR (95% CI) 1.00 2.47a (1.72, 3.55)*** 4.34a,b (1.63, 11.61)** 4.83b (2.80, 8.33)***
Narcissistic PD
% (n) 5.0 (429) 10.2 (605) 16.4 (31) 20.3 (142)
AOR (95% CI) 1.00 2.00a (1.68, 2.39)*** 3.60b (2.19, 5.90)*** 3.76b (2.88, 4.92)***
Any Cluster B PD
% (n) 10.2 (826) 20.8 (1170) 28.2 (58) 43.4 (271)
AOR (95% CI) 1.00 2.14a (1.87, 2.45)*** 3.67b (2.51, 5.38)*** 5.17b (4.06, 6.59)***
Avoidant PD
% (n) 1.3 (96) 2.3 (125) 2.9 (8) 5.2 (34)
AOR (95% CI) 1.00 1.65a (1.15, 2.36)** 2.46a,b (1.15, 5.24)* 2.85b (1.70, 4.79)***
Dependent PD
% (n) 0.2 (14) 0.3 (16) 0.3 (1) 1.6 (9)
AOR (95% CI) 1.00 1.03a (0.36, 2.99) 1.11a,b (0.11, 11.17) 3.73b (1.003, 13.87)*
Obsessive-Compulsive PD
% (n) 6.3 (498) 9.6 (521) 15.1 (25) 17.8 (113)
AOR (95% CI) 1.00 1.50a (1.28, 1.75)*** 2.57a,b (1.49, 4.24)*** 2.72b (2.00, 3.70)***
Any Cluster C PD
% (n) 7.1 (557) 10.8 (586) 17.0 (30) 19.8 (126)
AOR (95% CI) 1.00 1.49a (1.28, 1.73)*** 2.68b (1.62, 4.34)*** 2.66b (2.00, 3.55)***
Any PD, n (%)
% (n) 17.0 (1392) 29.2 (1636) 37.1 (80) 53.6 (335)
AOR (95% CI) 1.00 1.83a (1.65, 2.04)*** 2.94b (2.06, 4.19)*** 4.29b (3.37, 5.46)***

Adjusted AOR with different superscripts indicate that the odds ratios were statistically significantly different at p ≤ 0.05 (i.e., the same superscript letter
indicates that the odds ratios were not statistically different from each other).
*
≤ 0.05.
**
≤0.01.
***
≤0.001.
1
PD = personality disorder.
2
AOR = Odds ratio adjusted for: age, marital status, race/ethnicity, education, income, government assistance in childhood and history of family dysfunc-
tion.

types of maltreatment and CSA, which can lead to greater awareness of the prevalence of CSA and aid with the disclosure of
CSA among males.
Second, for many mental disorders and for suicide attempts, experiencing CSA only or CSA with other types of mal-
treatment resulted in a greater odds ratio compared to experiencing child maltreatment without CSA after adjusting for
sociodemographic factors and family history of dysfunction. The lack of a significant difference between experiencing CSA
only and CSA along with other types of child maltreatment may indicate that CSA has a particularly detrimental impact on
mental health outcomes and suicide attempts compared to other types maltreatment. Other studies have also found that
CSA on its own has a strong relationship with mental disorders; however, these studies only measured one or two other
types of maltreatment, unlike the six other types of maltreatment included in this study (Briere & Elliott, 2003; Molnar, Buka
et al., 2001). Since alcohol abuse/dependence was highly prevalent across all groups in the four-level child maltreatment
variable, there was a lack of variance between the groups which resulted in a non-significant odds ratio for CSA only. This
should not be interpreted to mean that CSA is not associated with alcohol abuse/dependence, but rather that alcohol abuse
is prevalent among all males in the U.S., regardless of experiences of child maltreatment.
 S. Turner et al. / Child Abuse & Neglect 66 (2017) 64–72 71

There was a large and significant increase in the odds ratio associated with suicide attempts and CSA only compared
to maltreatment without CSA (AOR = 2.82 for maltreatment without CSA and AOR = 8.57 for CSA only). Other studies have
confirmed that CSA is associated with increased suicide attempts (Afifi et al., 2008; Molnar, Berkman, & Buka, 2001); how-
ever, no studies have looked at the relative difference in odds ratios between maltreatment without CSA, CSA only, and
maltreatment with CSA. No other mental disorder included in this paper showed such a large difference in odds ratios
between maltreatment without CSA and CSA with or without other types of maltreatment. This shows that CSA specifically
has a significant and strong relationship with suicide attempts. It is important for health care practitioners to understand
the association between CSA in males and suicide attempts so that suicidal behaviours are assessed and monitored in this
population.
There are several factors associated with CSA that may contribute to the strong relationship between CSA and many mental
disorders and suicide attempts. These include stigma, embarrassment, shame, and secrecy. Experiences of CSA among males
challenge current masculine roles endorsed by Western society including dominance, being emotionally stoic, pursuit of
status, winning, and heterosexuality (Easton et al., 2013; Mahalik et al., 2003). Experiences of CSA are often associated
with feelings of fear, vulnerability, helplessness, and confusion which are not consistent with these masculine stereotypes
(Spataro et al., 2001). Some male CSA victims may decide to over-assert their masculinity in attempts to internally reconcile
their compromised masculine roles (Easton et al., 2013). However, strong adherence to masculine roles has been shown to
be associated with greater psychological distress, but less willingness to seek treatment (Mahalik et al., 2003). Men who
uphold the importance of adhering to masculine roles may feel embarrassed or ashamed of their experiences and refrain from
disclosing abuse (Easton et al., 2013; Spataro et al., 2001). Secrecy associated with CSA experiences may lead to reluctance
to seek mental health treatment and increased risk of experiencing mental health impairment including suicide attempts.
Reducing the stigma and secrecy associated with CSA by increasing the frequency of conversation about CSA among males
and understanding the prevalence and co-occurrence with other types of abuse may be an important first step in reducing
the poor health outcomes associated with CSA among males.
There are several strengths of this study including: 1) the use of a large, representative data set from the general U.S.
population; 2) the assessment of seven forms of child abuse and neglect using psychometrically established tools; 3) the
adjustment for a family history of dysfunction; and 4) the examination of numerous mood, anxiety, substance use and
personality disorders along with suicide attempts. There are also several important limitations in this study. First, the
study is retrospective and cross-sectional in nature, resulting in the inability to produce causal inferences. Second, all data
are self-report. Third, although the study adjusted for a family history of dysfunction, it did not adjust for adult stressors
that could affect the presentation of mental disorders. Fourth, PTSD is no longer classified as an anxiety disorder in the
DSM-V criteria, however, these data are based on the DSM-IV criteria, therefore we have included PTSD in our composite
measure of any anxiety disorder. Fifth, there was a low prevalence of some mental disorders including hypomania, schizoid
personality disorder and dependent personality disorder, leading to possibly underpowered analyses and the presentation
of non-significant findings when significant ones may exist.

5. Conclusions

This research contributes to the small, but growing, literature on CSA among males. It is important to recognize the
prevalence of CSA among males and its relationship to long-term mental health outcomes. CSA among males commonly
co-occurs with other types of maltreatment, which is important knowledge for health care providers and to inform effective
intervention strategies. However, it is also important to recognize that CSA can occur on its own. Experiencing CSA is related
to increased odds of many mood, anxiety, substance and personality disorders, as well as suicide attempts. In many cases,
the effect sizes for these poor mental health outcomes are stronger when CSA is experienced compared to other experiences
of child maltreatment that do not include CSA. Focusing on prevention of CSA, intervention strategies to reduce stigma and
secrecy associated with CSA, and promotion of resilience following CSA could potentially mitigate some of the mental health
impairments among males.

Funding

This work was supported by Dr. Afifi’s Research Manitoba Establishment Award, CIHR New Investigator Award, and CIHR
Foundations Scheme Funding Award.

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