Childhood sexual abuse and its impact on adult well-being

Abstract

The main aim of this study was to explain the possible effect of childhood sexual abuse (before the age of 18) on the current well-being of those who have suffered it, based on the analysis of a survey conducted in 2018 by the Fundación para la Confianza in the Metropolitan Region in Chile. The sample consisted of 641 participants who were administered a self-report questionnaire. The responses were grouped into three types of sexual abuse: rape, abuse with physical contact, and abuse without physical contact, they were related to sociodemographic variables, perceived impact, and subjective well-being. The results showed a clear relationship between the socioeconomic level, the type of abuse and the evaluation of the impact of the event on subjective well-being. The need to develop more comprehensive definitions of abuse is discussed.

Keywords: childhood sexual abuse, subjective well-being, protective factors, risk factors

Introduction

What is childhood sexual abuse?

The World Health Organization (WHO, 1999) states that “child sexual abuse is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person”. Other proposed definitions (Barudy, 1998; Finkelhor et al., 2015; Pereda et al., 2009) point in the same direction as this one, clearly establishing the existence of an asymmetry of power, lack of consent, early adversity and the public health problem. The most recent definitions (Royal Commission, 2014) go beyond sexual abuse involving physical contact and include the strategies that precede the abuse.

For this research we will consider childhood sexual abuse according to the following definition by Murillo (2020, p. 436):

Types of sexual abuse

The Third National Incidence Study of Child Abuse and Neglect (NIS-3; Sedlak & Broadhurst, 1996) classifies sexual abuse into three types, according to the transgression of bodily limits. They are: a) sexual abuse with penetration/rape (oral, anal or genital penile penetration, or anal, genital, digital or other penetration); b) abuse with physical contact and without penetration (acts in which some form of genital contact has occurred, but with no specific indication of penetration); and c) sexual abuse without genital physical contact (unspecified acts without genital contact, such as fondling or exposure, as well as reports concerning inadequate or inappropriate supervision of a child’s voluntary sexual activities).

Although some situations may fall outside this classification, such as the commercial sexual exploitation of children, the present study understands abuse according to these categories because they have been validated in other contexts. Because of its configuration and its consequences, the commercial sexual exploitation of children belongs to a different set of sexual violations, under-represented in this survey, and will therefore be considered in future research.

Consequences of childhood sexual abuse for well-being

Individual well-being is closely related to a wide range of emotional, physical and social indicators, which are linked to people’s social integration and health (Jiang et al., 2013). For this reason its study has been based on two broad perspectives: the eudaimonic and the hedonic. The first refers to the search for transcendence through living a full experience (Vázquez et al., 2009), while the second focuses on the evaluations people make of their lives using affect and cognition (Diener, 2009). Hedonic well-being includes life satisfaction, understood as the judgements individuals make about different aspects of their own life.

The consequences of sexual abuse in childhood have been widely studied, showing its impact on health and on different variables associated with well-being, such as post-traumatic stress disorder, anxiety, depression, schizophrenia, substance abuse, behavioural and interpersonal problems, difficulties in the sphere of sexuality, or further re-victimisation (Lamoureux et al., 2012). Likewise, different studies report a relationship between the number of adversities experienced in childhood and the severity of a wide range of psychopathological symptoms and disorders in adult life (Clark et al., 2010; Koskenvuo et al., 2010; Turner et al., 2010).

With regard to physical and mental health, the review by Hailes et al. (2019) found that this experience is related to elevated risks of long-term psychosocial, psychiatric and physical health problems, with strong associations with schizophrenia, post-traumatic stress disorder and substance abuse in adulthood.

At the socioeconomic level, childhood sexual abuse is associated in part with poverty and with the socioeconomic conditions of the victims (Font & Maguire-Jack, 2016; Klest, 2012), as well as with a lower likelihood of working in adulthood because of physical or mental health problems, greater financial difficulties and lower income (Barrett et al., 2014; Curie & Widom, 2011; Hamby et al., 2018).

Just as protective factors against childhood sexual abuse and its consequences have been identified, such as living in a safe neighbourhood and attending a safe school (Moore & Ramírez, 2015), it has also been found that gender, socioeconomic level and the absence of a healthy emotional bond with at least one significant adult are risk factors for suffering sexual abuse (Cantón & Cortés, 2015; Franco & Ramírez, 2016; Runarsdottir et al., 2019).

The life-course approach is possibly the best way to understand the consequences of cumulative stress for health, because it provides a theoretical framework from which the impact of experiences of early adversity can be understood (Hajat et al., 2020). Along these lines, research has shown that those who suffered childhood sexual abuse are more likely to suffer interpersonal victimisation as adults and sexual re-victimisation in adulthood (Hajat et al., 2020; Montalvo-Liendo et al., 2015). Papalia et al. (2017) observed that sexual abuse occurring between the ages of 12 and 16 emerged as a significant risk factor for belonging to the emerging or chronic re-victimisation trajectories.

This is consistent with research supporting an association between sexual abuse during adolescence and a greater risk of re-victimisation in adult life (Ogloff et al., 2012). In this regard, Steine et al. (2017) note that the evidence suggests these factors may lead to a more severe long-term trajectory of post-traumatic stress disorder, and that victims on the trajectory with the highest symptoms reported that they currently perceive less social support and more relationship problems.

In Chile, some studies have been carried out to better understand this trajectory and its later consequences, highlighting the mediating role of attributions of blame (towards oneself, others and the perpetrator) and of an avoidant coping style in the development of post-traumatic stress disorder associated with childhood sexual abuse (Cantón-Cortés et al., 2011). Villarroel et al. (2014) found that variables such as social support (especially from the family), gender, the victim’s developmental stage, the existence of more intrusive and/or frequent victimisation, a greater degree of familiarity between perpetrator and victim, and harassment strategies on the part of the perpetrator would have an impact on the victim’s cognition and later development.

Prevalence studies worldwide and in Chile

Different prevalence studies worldwide conclude that around 12% of the child population has been sexually victimised (Stoltenborgh et al., 2011). An analysis of 65 studies with information on 21 countries showed a mean prevalence in the general population of 19.2% for girls and 7.4% for boys (Pereda et al., 2009), similar to what Stoltenborgh et al. (2011) observed, who reported higher levels of occurrence for girls (18%) than for boys (7.6%).

Between 2000 and 2019, five surveys were carried out in Chile to gather data on the prevalence and characteristics of childhood sexual abuse (see Table 1). In addition, data have been compiled from state bodies such as the Ministry of Health and the National Human Rights Institute, whose findings have been analysed in the Second Report on Sexual Health, Reproductive Health and Human Rights in Chile (Dides Castillo et al., 2018). There are also alternative sources, such as the Student Well-being Survey (Lehrer et al., 2009), which has also reported information on experiences of sexual violence before the age of 14 in the Chilean population.

Table 1 Surveys on sexual abuse of children and adolescents in Chile

There is agreement that the sexual abuse of children and adolescents is a highly prevalent phenomenon in Chile, that the perpetrator is usually a man known to the victim (often a family member) and that victims are more likely to be women. However, information is still lacking on the perspective that survivors of sexual abuse have on these variables (for example, their own perception of how it affected them), as well as on the after-effects these experiences have on their current well-being, since most of these studies focus on children and young people, analysing the more immediate symptoms and consequences of the phenomenon.

For these reasons, this study seeks to broaden the understanding of childhood sexual abuse, contributing a focus on socioeconomic level, type of abuse and, especially, its possible perceived consequences and well-being in adult life. Specifically, and based on the literature reviewed, current well-being is expected to be lower in people who report having been victims of abuse (hypothesis 1), especially in the case of those with lower socioeconomic access (hypothesis 2). Likewise, the more severe the type of abuse, the lower the well-being is expected to be (hypothesis 3), and people who report a greater impact of the event on their lives are expected to show lower well-being (hypothesis 4).

Method

The research design was non-experimental. The survey falls within cross-sectional descriptive and correlational studies.

Sampling procedure

Participants were invited to take part in two ways. The first method of administration was through a paid platform for obtaining online panels. Through this platform, participants were sent the study link and were compensated for their participation. The compensation consisted of points awarded by the platform, which could later be exchanged for products. Participants who did not wish to take part in the survey or who stated that they had not been victims also received points, which possibly helped to avoid false responses. On opening the study link, participants were presented with an informed consent form with the details of the study and the contact details of the researchers in charge. If they agreed to participate, they were directed to a page to complete their demographic data and then take the survey.

For the online sample, the provider stratified the survey mailings by sex (approximately 50% men and 50% women) and by socioeconomic levels ABC1, C2, C3 and D (9.0%, 19.3%, 28.1% and 43.6%, respectively). The socioeconomic level categories used in the study’s analyses were calculated a posteriori on the basis of two questions detailed in the instruments section.

The second method of administration was through paper surveys. In this case, a volunteer interviewer visited homes in different municipalities (comunas) selected at random. The selection was based on the maps and information on the Metropolitan Region available on the website www.mientorno.cl. On the basis of these maps, blocks were selected with the aim of achieving heterogeneity in socioeconomic level. Once at the homes, the interviewer asked to speak with a person over 18, to whom the aim of the survey and the ethical elements related to it were explained. If the person agreed to participate, it was explained that they would be given the paper survey together with an envelope, and that both would be collected the following day. In this way, the aim was to ensure participants’ confidentiality and anonymity.

No compensation for participants was considered in the paper administration. Considering that this could produce differences in responses between the two formats, the proportion of people who reported being victims or not was compared in each. No association was observed between the type of administration and being a victim (χ²(1)=0.193; p=.660) or the type of abuse reported (χ²(1)=0.161; p=.923). This can be interpreted as evidence that neither method of administration facilitated, for example, socially desirable responses.

Ethical considerations

With regard to ethical considerations, before the study began the survey and the administration design were presented to an ad hoc committee of the Fundación para la Confianza, made up of five professionals. After their comments, adjustments were made to the final instrument and to the mode of administration. Also, since administration was by self-report, the survey provided contact information for the Fundación para la Confianza. This information included an emergency number, an address and an email address, which were available to attend to any participants who needed them. All participants were left a sheet with the contact details, in case they felt they needed to turn, free of charge, to the organisation’s specialised care area. However, no participant made use of it, at least explicitly, during the period in which the survey was administered.

Procedure for administering the instrument

The instrument answered by participants in both formats consisted of four sections, intended to present the study’s informed consent, complete demographic data (sex, age and questions to assess socioeconomic level), assess well-being, and inquire into possible sexual abuse and its characteristics.

The last section presented a list of 14 different types of sexual abuse and the question “During your childhood or adolescence (before turning 18), were you the victim of any of the following situations, being manipulated, deceived, subjugated or forced by another person?”. The options were the following: sexual interactions in exchange for money, protection, material goods or other things; participation in pornographic material; insertion of objects or fingers into the anus, vagina or mouth; oral sex; rape (carnal, anal and/or vaginal penetration); exposing one’s own genitals, masturbating another person; being touched or groped, touching or groping another person, French kissing, being incited to watch sexual intercourse, being incited to look at another person’s genitals, exposure to pornography, and receiving verbal sexual propositions.

Those who answered “No” to the question were thanked and told that they did not need to continue. Those who answered “Yes” were given the option of marking the situations of which they had been victims. Of all the people who reported having been victims, 83.1% (n=167) specified the type of abuse. After this, the questions about the experience of abuse continued.

Finally, on completing the survey in either format, and knowing that a survey like this can trigger traumatic processes, the contact information of the Fundación para la Confianza was presented, in case anyone wished to seek support or help on the subject. To protect confidentiality and anonymity, people who approach or contact the Foundation are not asked to state how they came to it, so it is not possible to determine whether any participant later sought information.

Participants

653 people were contacted (77.5% online). Of these, 12 (1.84%) decided not to take part in the study after reading the informed consent, so the final number of participants in this study was 641 people (245 [52.9%] women).

The mean age was 33.53 years (SD = 12.31). As for country of origin, 623 (97.2%) people were from Chile, five (0.8%) from Peru, four (0.6%) from Colombia, three (0.5%) from Venezuela, two (0.3%) from Bolivia, two (0.3%) from Cuba, one (0.2%) from the Dominican Republic and one (0.2%) from Argentina.

With regard to socioeconomic level, participants were classified into three groups on the basis of two questions asked in the second section of the survey. Accordingly, 25.0% (n=160) were in the “low” group, 53.0% (n=340) in the “middle” group and 22.0% (n=141) in the “high” group. Table 2 contains descriptive statistics on the number of participants by sex and socioeconomic level according to the type of administration and whether or not they reported having been victims.

Table 2 Number and percentage of participants who report having been or not having been victims of childhood sexual abuse, by sex and socioeconomic level

Instruments

Socioeconomic level

An indicator of participants’ socioeconomic level was used, based on the educational level and occupation of the household’s main earner. On this basis, participants were classified into three levels (low, middle or high).

Personal Wellbeing Index [PWI]

Adapted in Chile by Oyanedel et al., 2015. It measures quality of life through seven dimensions, each assessed with one item answered on a Likert scale ranging from 0 (“Completely dissatisfied”) to 10 (“Completely satisfied”). All items have the structure “How satisfied are you with…?”. For analysis, the arithmetic mean of the seven items is calculated.

Subjective perceptions and evaluations are especially relevant when dealing with this subject, since they are better predictors of well-being than concrete characteristics such as income. For example, Heins et al. (2011) observed that victims who also had chronic fatigue syndrome in adulthood reported greater psychological distress, even when their levels of fatigue were no higher than those of people who had not been victims. Thus, after analysing the literature on the long-term effects of childhood sexual abuse, it was decided to use in this study three of the seven PWI items (satisfaction with health, current safety and interpersonal relationships). This was because most studies and meta-analyses focus on the effects of abuse on mental and physical health, personal relationships and personal safety (e.g. Corcoran & McNulty, 2018; Hailes et al., 2019; Hughes et al., 2017; McCabe & Murphy, 2016; Papalia et al., 2017).

Internal consistency for the three items used, measured with Cronbach’s alpha coefficient, was 0.65 (95% CI=0.60-0.70). Item-test correlations were homogeneous, ranging from 0.44 to 0.48, and the scale mean was 7.22 (SD=1.85).

Categorisation of types of abuse

Participants had to indicate the type of abuse of which they had been victims. To do so, they were shown a list of 14 different types, which were then grouped according to the NIS-3 categorisation, as follows:

a. Rape: sexual interactions in exchange for money, protection, material goods or other things; participation in pornographic material; insertion of objects or fingers into the anus, vagina or mouth; oral sex and rape (carnal, anal and/or vaginal penetration).

b. Abuse with physical contact: exposing one’s own genitals, masturbating another person.

c. Abuse without genital physical contact: being touched or groped, touching or groping another person, French kissing, being incited to watch sexual intercourse, being incited to look at another person’s genitals, exposure to pornography, and receiving verbal sexual propositions.

Evaluation of the impact of the event

Participants were presented with the item “To what extent do you think this experience has affected you negatively?”, which they answered on a five-point scale, where 0 meant “Not at all” and 4 meant “A lot”.

Analysis plan

Hypotheses were tested using the Jamovi software (The Jamovi Project, 2020). Chi-square tests of independence were carried out to examine possible associations between categorical variables in the sample. To test the first, second and third hypotheses, Student’s t-tests, factorial analyses of variance and factorial analyses of covariance were carried out to determine differences between groups and possible interactions of factors on the variables of interest. In these cases, effect size was also calculated using Cohen’s d (d) and partial eta squared (η_p²). Finally, to test the fourth hypothesis, Pearson, Spearman and point-biserial correlation analyses were carried out, as well as a linear regression analysis to assess the relationship of different study variables with current well-being.

Results

Descriptive statistics: characterisation of victims and types of abuse

Of all participants, 201 (31.4%) reported having been victims of one of the 14 types of abuse before turning 18. Of these, 141 (70.1%) were women. Table 3 presents the distribution of the sample according to whether or not they reported having been victims, the type of abuse and socioeconomic level.

• 641adults in the Santiago Metropolitan Region answered the survey (2018)
• 31.4%reported having been victims of one of the 14 types of abuse before the age of 18 (201 people)
• 41.6%of women reported it, compared with 19.9% of men
• 70.1%of those who reported having been victims were women (141 of 201)

The association between sex and having been a victim was significant, with χ²(1)=35.023, p<.001, which indicates that women would tend to report more often having been victims. It should be noted that there was no relationship between socioeconomic level and having been a victim or not.

Table 3 Number and percentage of victims/non-victims, overall and by type of abuse, by sex and socioeconomic level

Note: The sum of the types of abuse (234) is greater than the number of people who reported being victims (201) because the same person could report having been a victim of more than one type of abuse.

Considering the three types of abuse, an association was observed between sex and the types of abuse “rape” (χ²(1)=5.959, p=.015), “with physical contact” (χ²(1)=11.130, p=.001) and “without genital physical contact” (χ²(1)=53.670, p<.001). In all cases women were victims in a higher percentage, while none of the three types was associated with socioeconomic level.

Comparison of well-being between victims and non-victims by socioeconomic level

To test the first two hypotheses, a two-way analysis of covariance was carried out, with having or not having been a victim of some type of abuse and socioeconomic level as factors, and sex and age as covariates. The dependent variable was well-being.

A significant interaction between the two factors was observed, F_(2,535) = 4.599, p=.010, η_p² =.017. On this basis, a simple main effects analysis with Bonferroni correction (p<.017) was carried out, which showed differences only in the low socioeconomic group. In this case, people who had been victims had a mean 1.11 points lower than those who had not been victims, p=.001. In addition, victims of low socioeconomic level had a lower mean than the other two groups of victims, 1.06 points lower than victims of middle level and 1.94 points lower than victims of high level (p=.003 and p<.001, respectively). In this respect, it is interesting to note that in the group of people who report not having been victims, there is only a difference of less than 1 point (.74) between the middle and high levels (p=.011), with no other differences indicating any trend (Figure 1).

Types of abuse, socioeconomic level and well-being

With regard to the third hypothesis, which concerned possible differences in current well-being between victims and non-victims of each of the three types of abuse, analyses of covariance were carried out with type of abuse and socioeconomic level as factors, and age and sex as covariates. In this case, for each person who reported being a victim, the most severe type of abuse reported was considered.

No interaction between the two factors was observed (F_(4,152) =.553, p=.697, η_p² =.014), but there was a direct effect of socioeconomic level (F_(2,152) = 11.117, p<.001, η_p² =.178) and of type of abuse (F_(2,152) = 5.113, p=.007, η_p² =.063).

In the case of socioeconomic level, multiple comparisons showed that the low level had a significantly lower mean well-being than the middle (p=.002) and high (p<.001) levels, while the middle level also had a lower mean than the high level (p=.019). The comparison between the different types of abuse showed that people who experienced abuse without physical contact reported higher levels of well-being than those who experienced rape (p=.012) and those who experienced abuse with physical contact (p=.012).

The analysis of main effects showed differences between the different levels of the factors. As can be seen in Figure 2, victims of low socioeconomic level who reported rape and abuse with physical contact showed lower well-being, while victims in the high socioeconomic group who reported having suffered abuse without physical contact reported significantly greater well-being.

Statistically significant differences shown in the figure

Comparison	p
Rape, low — Rape, high	<.001
Rape, low — With physical contact, high	<.001
With physical contact, low — Without physical contact, middle	<.001
With physical contact, middle — Without physical contact, high	<.001
Without physical contact, middle — Without physical contact, high	<.001
Rape, low — Without physical contact, middle	<.01
Rape, low — Without physical contact, high	<.01
Rape, middle — Without physical contact, high	<.01
With physical contact, low — Without physical contact, high	<.01
Without physical contact, low — Without physical contact, high	<.01
Rape, low — Rape, middle	<.05
Rape, low — With physical contact, low	<.05
Rape, low — With physical contact, middle	<.05
Rape, high — With physical contact, low	<.05
With physical contact, low — With physical contact, high	<.05

Evaluation of the impact of the event and well-being

To test the fourth hypothesis, the study variables were first correlated, in order to observe the possible relationships between the evaluation of impact and each of them. Then, considering the variables that were significantly related, a multiple linear regression was carried out with well-being as the dependent variable. As shown in Table 4, well-being correlated negatively and statistically significantly with the evaluation of impact, and positively with socioeconomic level.

Table 4 Correlations (Pearson, Spearman and point-biserial) between evaluation of impact, well-being, sex and socioeconomic level

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

Given the correlations observed between the study variables, a linear regression analysis was carried out, with the evaluation of impact and socioeconomic level as predictors of well-being. The model was significant, with F_(3,183)=10.787, p<.001, and explained 15.0% of the variance. Both the evaluation of impact (B= -0.256; p=.01) and socioeconomic level (B= 0.911; p<.001) entered significantly. In other words, the higher the socioeconomic level and the lower the evaluation of impact, the greater the well-being observed.

1. Hypothesis 1

   ExpectedLower current well-being among those who report having been victims of abuse.

   ObservedDifferences only at the low socioeconomic level: 1.11 points lower than those who had not been victims (p=.001).

2. Hypothesis 2

   ExpectedThat the difference would be greater among those with lower socioeconomic access.

   ObservedVictims of low level had 1.06 points less than those of middle level and 1.94 less than those of high level.

3. Hypothesis 3

   ExpectedThe more severe the type of abuse, the lower the well-being.

   ObservedThose who experienced abuse without physical contact reported greater well-being than those who experienced rape or abuse with physical contact (p=.012 in both cases).

4. Hypothesis 4

   ExpectedThe greater the reported impact of the event, the lower the well-being.

   ObservedWell-being correlated negatively with the evaluation of impact (-.20). Together with socioeconomic level, the model explained 15.0% of the variance.

Discussion and conclusions

This research sought to answer the question of whether childhood sexual abuse can have correlates with subjective well-being in adult life. According to the results obtained, it can be concluded that there are associations that allow us to assume that this is indeed the case.

At the descriptive level, the results show a relationship between being a woman and having been a victim of sexual abuse before turning 18. This is consistent with the studies reviewed, according to which women are, in general, the main victims of these acts. This may be compounded if we also consider that in Chilean society there is still great inequality between men and women in terms of working conditions and access to education or health, given that sexual abuse is a type of abuse of power. Even so, it is important to bear in mind that men tend to report less often the sexual assaults they have suffered, so the figure may reflect under-reporting.

Considering the possible effects of sexual abuse on well-being, one variable that the literature review suggested needed to be taken into account was socioeconomic level. Although there was a relationship between this and having been a victim, it was observed that subjective well-being was lower among victims who belonged to the low socioeconomic level. If we consider that in this research the socioeconomic level assessed is the current one and not the one to which people belonged when they were victims, we can think of two explanations derived from the literature review.

On the one hand, lower well-being may be an effect of the abuse that was compounded by a context of lower socioeconomic access during childhood; on the other hand, it may also be that current socioeconomic conditions compound the possible effect. In both cases, it can be thought that socioeconomic level may be a protective or a risk factor for well-being in people of lower socioeconomic level. Finally, although other studies of the general Chilean adult population also show a positive correlation between income and well-being, this research observed that specifically the victims of low socioeconomic level reported lower levels of well-being.

With regard to type of abuse, lower well-being was observed among those who suffered rape. This could be due not only to the greater level of physical and psychological intrusion of this type of abuse, but also to the fact that abuse involving any type of penetration is usually the result of longer processes and may, therefore, prolong its effects on subjectivity. That is to say, rape often occurs in the advanced phases of an abusive process, which has already been under way for some time.

Similarly to what was observed in the comparison between victims and non-victims, both rape and abuse with physical contact imply lower well-being in the case of the low socioeconomic level.

Considering that subjective well-being corresponds to a cognitive evaluation of living conditions, it is possible to think that the lower well-being observed in some groups was related to the evaluation made of the event. In this respect, our results showed that this last variable does indeed have a negative explanatory effect on well-being, and that socioeconomic level has a positive one. In this regard, it is possible to think that greater economic access may also allow greater access to recovery and reparation processes (such as psychological therapy) that help give new meaning to what happened.

It should be pointed out that one of the first challenges when carrying out research and interventions related to childhood sexual abuse is its definition. A clear and comprehensive definition can make it possible to carry out epidemiological research that comes closer to the real prevalence, or can become a tool for giving a clearer account of the experience of those who have been victims but are unable to define it clearly. Conversely, unclear definitions can facilitate re-victimisation or silencing (Dupret & Unda, 2013; Mantilla, 2015).

For these reasons, this research established some necessary elements for a complete definition that would allow not only its understanding at the level of academic research, but would also contribute to a comprehensive understanding of the phenomenon. These elements are the processual consideration of strategies and actions, and not only the act; the symbolic asymmetry of power; the exploitation of vulnerability and of trust; the manipulation of consent; the sexually abusive acts; and the preparation strategies prior to the physical abuse (Barudy, 1998; Finkelhor et al., 2015; WHO, 1999; Pereda et al., 2009; Perrone & Nannini, 1997; Royal Commission, 2014).

However, we believe this definition can be improved. For example, we think it necessary to add to it the strategies that follow the sexually abusive acts and that tend to silence the victim and those around them. It is also important to stress that there are people without full capacity for understanding (sexual understanding in particular), such as infants, children and people with different types of intellectual disability, among others. For this reason, we also believe that a complete definition must consider and distinguish between lack of understanding due to intellectual capacity and lack of understanding of sexuality.

A complete definition of childhood sexual abuse considers

• Strategies and actions as a process, and not only the act
• The symbolic asymmetry of power
• The exploitation of vulnerability and of trust
• The manipulation of consent
• The sexually abusive acts
• The preparation strategies prior to the physical abuse
• What the authors propose adding: the later strategies that tend to silence the victim and those around them
• What the authors propose adding: distinguishing between lack of understanding due to intellectual capacity and lack of understanding of sexuality

Despite the contribution and novelty of this research, it has some elements and limitations that must be considered. First, at the methodological level, the prevalence of abuse was high compared with other research on the subject. In this respect, this study also considered sexual abuse without genital physical contact. Although this contributed to the higher prevalence, it was a methodological and operational decision since, being a broad definition of abuse, it made it possible to analyse the results in a segmented way, differentiated by levels.

Second, one of the clearest limitations is the lack of depth in the questions addressing the support perceived by victims. In this respect, it would be interesting for future research to address, for example, how victims understand the support they received, which coping mechanisms they consider most effective and what the perceived impact of other people’s support is on their experience of sexual abuse.

As for the life trajectories of adults who were victims of sexual abuse in childhood, it should be made explicit that this was a challenge and a significant limitation, mainly because it was not part of the stated aim of the present research. Bearing in mind that it is often not known what happened in those trajectories, this point is a limitation of the study because it is treated as a retrospective aspect and not as a present one. In this sense, better knowledge of the mediating variables related to the experience of childhood sexual abuse will allow a greater understanding of it.

This research faced various challenges, both theoretical and methodological, and its results also constitute new challenges for future inquiry. We believe that the way of defining abuse conceptually and operationally can help shed light on future research and give an account of the phenomenon of childhood sexual abuse from a more comprehensive perspective, one that fully takes in the process of victimisation.

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