Carey S. Pulverman, Chelsea D. Kilimnik, & Cindy M. Meston

How Common is Childhood Sexual Abuse?

Childhood sexual abuse (CSA) is generally defined as unwanted sexual contact between a child and an adult, and may include oral, vaginal, and/or anal penetration with a penis, digits, or foreign objects, as well as forced sexual touching and non-contact sexual abuse (e.g., exposure to another’s genitals). Experiencing sexual abuse in childhood has been identified as one of the most salient risk factors for the development of sexual dysfunction in adulthood, including problems with sexual desire, arousal, orgasm, and sexual pain (Leonard & Follette, 2002; Loeb et al., 2002). Unfortunately, CSA is a common experience for women. According to a recent meta-analysis of studies from 22 countries, that defined CSA as contact and non-contact sexual abuse before age 18, approximately 20% of women have experienced CSA (Pereda, Guilera, Forns, & Gómez-Benito, 2009b). In studies from the United States, using the same definition of CSA, 17-51% of women reported CSA histories (Pereda, Guilera, Forns, & Gómez-Benito, 2009a). Although adulthood sexual abuse has also been associated with sexual problems (Lutfey, Link, Rosen, Wiegel, & McKinlay, 2009), CSA has more empirical support for a connection to later life sexual dysfunction, (Lemieux & Byers, 2008; Stephenson et al., 2012), therefore the current review focuses on sexual abuse in childhood. 

Sexual Dysfunction among Women with CSA Histories

Sexual abuse has been identified as an important risk factor for sexual dysfunction in adulthood, because the rates of sexual dysfunction among this population are significantly higher than the rates of dysfunction among non-abused women (Leonard & Follette, 2002; Loeb et al., 2002; Polusny & Follette, 1995). Using data from the National Health and Life Survey of 1,749 women, Laumann and colleagues found that 17% reported CSA histories, and that 59% of those women reported sexual difficulties (Laumann, Gagnon, Michael, & Michaels, 1994). Mullen and colleagues surveyed 1,376 women and found a CSA prevalence of 32%, and 47% of the women with abuse histories reported at least one sexual problem (Mullen, Martin, Anderson, Romans, & Herbison, 1994). In a study with 898 women the prevalence of CSA was 35%, and 25% of women with non-penetrative CSA histories developed sexual problems while 32% of women with penetrative CSA histories developed sexual problems (Najman, Dunne, Purdie, Boyle, & Coxeter, 2005). In summary, the rates of sexual dysfunction among women with CSA histories in random probability studies ranged from 25-59%.

While random probability samples provide the most representative and generalizable estimates, the prevalence of sexual dysfunction has also been examined in clinical, community, and college samples of women with CSA histories. Clinical samples, typically composed of women seeking treatment for sexual or mental health concerns, tend to show the highest rates of sexual dysfunction. In studies of women with CSA histories presenting for sex therapy at a sexual health clinic, 63-94% of women reported sexual dysfunction (Jehu, 1988; Sarwer & Durlak, 1996). In another clinical sample of women with abuse histories, 84% reported sexual dysfunction (Westerlund, 1992). Similar rates of sexual problems have been observed in community samples. Community studies tend to recruit a sample of women with abuse histories and a comparison sample of non-abused women, matched on age and other demographic characteristics to compare the sexual health of these two groups. In community studies, 26-85% of women with CSA histories reported sexual dysfunction (Gorcey, Santiago, & McCall-Perez, 1986; Saunders, Villeponteaux, Lipovsky, Kilpatrick, & Veronen, 1992; Swaby & Morgan, 2009). Additionally, some community studies identified higher rates of sexual dysfunction among women with CSA histories compared to non-abused women, but did not report the individual rates for each group (Gold, 1986; Lacelle, Hébert, Lavoie, Vitaro, & Tremblay, 2012). One study of community women did not find any differences in sexual function between those with and without CSA histories, yet noted they had a low participation response rate in their study (Greenwald, Leitenberg, Cado, & Tarran, 1990). In clinical and community samples of women with CSA histories, the rates of sexual dysfunction ranged from 26-94%.

Studies of college women tend to report the lowest rates of sexual problems for women with CSA histories. Multiple studies cite no differences in sexual function between college women with and without histories of CSA (Alexander & Lupfer, 1987; Bartoi & Kinder, 1998; Meston, Heiman, & Trapnell, 1999; Rellini & Meston, 2007); however, one study found lower sexual function among the college women with abuse histories than their non-abused counterparts (Lemieux & Byers, 2008). College samples inherently select for high functioning individuals with a particular demographic make-up (i.e., generally greater education and higher socioeconomic status), which may in part explain the lower rates of sexual problems for women with CSA histories observed in these samples in comparison to other samples. Notably, one study of college women found that 55% of their sample had CSA histories, and that 65% of those women reported sexual dysfunction (Jackson, Calhoun, Amick, Maddever, & Habif, 1990).

Sexual dysfunction is clearly a concern for women with CSA histories; however, it is important to note that early experiences of sexual abuse do not necessarily lead to sexual problems for all women. The majority of research studies described in the prevalence section assessed sexual dysfunction with self-report instruments or structured interviews based on the Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III; American Psychiatric Association, 1980) criteria for sexual dysfunction, which did not yet include the “distress criterion” that was added to later editions of the DSM. This discrepancy in the assessment of sexual dysfunction between studies complicates the comparison of prevalence rates for sexual dysfunction between women with CSA histories and the general population of women. Keeping this methodical concern in mind, it appears that in the general population of women, approximately 43% report sexual difficulties (Laumann et al., 1999; Shifren et al., 2008), and 12% report clinically significant sexual dysfunction (Shifren et al., 2008), yet in women with CSA histories 25-94% report sexual difficulties (with unknown rates of distress), suggesting that women with abuse histories show an elevated risk for sexual dysfunction compared to the general population of women. For details on the operationalization and assessment of CSA and sexual function in the prevalence studies examined, please see Table 1.

Abuse Characteristics and Sexual Dysfunction

Certain characteristics of the abuse experience can increase the risk of sexual dysfunction. For example, abuse that was repeated (Briere & Elliott, 2003; Kinzl, Traweger, & Biebl, 1995), included multiple abusers (Briere & Elliott, 2003; Easton, Coohey, O’leary, Zhang, & Hua, 2011), was of longer duration (Beitchman et al., 1992), included threat or force (Beitchman et al., 1992; Sarwer & Durlak, 1996), and in which the father was the abuser (Beitchman et al., 1992; Noll, Trickett, & Putnam, 2003) have been related to greater rates of sexual dysfunction in adulthood. In relation to the impact of abuse that included penetration or attempted penetration on sexual health, mixed findings have been recorded. Multiple studies have indicated that CSA that included penetration or attempted penetration increased the risk for sexual difficulties (Davis, Petretic-Jackson, & Ting, 2001; Lemieux & Byers, 2008; Mullen et al., 1994; Sarwer & Durlak, 1996). Other studies, however, noted that penetrative and non-penetrative abuse experiences were equally associated with risk for sexual dysfunction (Najman et al., 2005; Rellini & Meston, 2007), and one study found that non-penetrative CSA experiences conferred a higher risk for sexual dysfunction than penetrative experiences (Lacelle et al., 2012). The age of the child when CSA first occurs has also been examined as an abuse characteristic related to sexual dysfunction. In one study, an older age at onset of abuse was associated with greater sexual difficulties (Easton et al., 2011). In summary, CSA that included threat or force, was chronic, and committed by the father or multiple perpetrators, and first occurred at an older age, appears to increase the risk for subsequent sexual concerns. Given the mixed findings observed for the impact of penetration on risk for sexual difficulties, more research is needed to clarify the potential importance of that abuse characteristic. 

Types of Sexual Dysfunction

Women with CSA histories report the full spectrum of female sexual dysfunction disorders, including disorders of desire, arousal, orgasm, and sexual pain. In this population sexual dysfunctions are often comorbid, with one study noting that 66% of women with abuse histories and sexual dysfunction reported multiple types of dysfunction (Becker, Skinner, Abel, & Cichon, 1986). The sexual dysfunctions most frequently reported by this population are desire and arousal dysfunctions (Leonard & Follette, 2002). In a national probability sample of 1,749 women, sexual abuse histories indicated a greater risk for sexual arousal disorder than any other type of sexual dysfunction (Laumann, Paik, & Rosen, 1999). In a non-treatment seeking clinical sample of women with abuse histories, 84% reported arousal difficulties, and 53% reported desire difficulties (Westerlund, 1992). In clinical samples of women with CSA histories seeking sex therapy, 49-62% reported arousal difficulties (Becker et al., 1986; Becker et al., 1984; Jehu, 1988), and 51-59% reported desire difficulties (Becker et al., 1986; Becker, Skinner, Abel, Axelrod, & Cichon, 1984; Jehu, 1988; Sarwer & Durlak, 1996). Orgasm difficulties and sexual pain were also common in this population (see Table 2 for more information on the rates of orgasm and pain dysfunctions; Kinzl et al., 1995). For the general population of women, low sexual desire is the most commonly reported sexual dysfunction (Laumann et al., 1999; Shifren et al., 2008); therefore, the major difference in types of disorders between women with and without CSA histories appears to be that women with abuse histories report equally elevated rates of arousal and desire dysfunctions. For details on the operationalization and assessment of CSA and sexual function, and the specific rates for the types of sexual dysfunction disorders, please see Table 2.

Mechanisms Contributing to Sexual Dysfunction

Women with CSA histories report elevated rates of sexual dysfunction compared to non-abused women, and show a somewhat unique presentation of sexual dysfunction, with higher rates of arousal difficulties than non-abused women. Additionally, women with CSA histories show a lower response to standardized sex therapy, including both pharmacological (Berman et al., 2001; van der Made et al., 2009) and psychological (Hall, 2008; Maltz, 2002) approaches, compared to their non-abused peers. The differences in prevalence rates, presentation of sexual dysfunction, and lower response to sex therapy, suggest that sexual difficulties may develop via differential pathways for women with and without CSA histories. Researchers have proposed several potential pathways or mechanisms of action to account for these differences, including cognitive associations with sexuality, sexual self-schemas, sympathetic nervous system activation, body image and esteem, and shame and guilt. Research on the mechanisms involved in the sexual dysfunction of women with CSA histories is necessarily limited by the nature of sexual trauma and research ethics, such that it is impossible to conduct a randomized, controlled experiment on CSA (Freeman & Morris, 2001). Studies on the mechanisms underlying the relationship between CSA and sexual dysfunction are, therefore, susceptible to potential confounds and the complex context in which CSA occurs. This inevitably limits the ability to draw directional inferences from research studies (Feiring, Simon, & Cleland, 2009; Meston, Rellini, & Heiman, 2006).  

Cognitive Associations with Sex

A large body of research has indicated that women with histories of CSA process sexual stimuli somewhat differently than their non-abused peers. Women with abuse histories’ cognitive processing of sexual stimuli has been examined in studies focusing on unconscious associations. Meston and Heiman used a card-sort task involving the categorization of positive and negative self-information and sexually-relevant information (2000). The authors found that women with CSA histories were more likely than non-abused women to describe themselves in negative terms, and less likely to attribute positive meaning to the sexual stimuli. Another study evaluating unconscious associations with the Implicit Association Test (IAT) found that for non-abused women sexual pictures were more strongly associated with positive valence than neutral pictures, yet for women with abuse histories there were no differences in valence between the sexual and neutral pictures (Rellini, Ing, & Meston, 2011). Notably, the authors found that for women with histories of CSA, lower positive implicit associations with sexual stimuli were not associated with lower sexual function, but were associated with lower sexual satisfaction. Research on women’s unconscious biases indicate that sexual stimuli are less strongly associated with positive valence for women with abuse histories than non-abused women.

Another approach to studying the cognitive processes of women with histories of CSA has been to examine the language used in women’s expressive writing essays on sexuality. One study asked women with and without CSA histories to write a neutral essay on their previous day and an essay on an ambiguous picture of a couple in a bedroom (Rellini & Meston, 2007). In this study, women with CSA histories showed a greater tendency towards a threatening interpretation of the picture, and used significantly more negative affect words, and less sexual words, in the picture essay than the non-abused women. The authors also assessed sexual desire function in their sample and did not find an association between the greater negative word use of women with sexual abuse histories and their sexual desire function. It appears that women with histories of CSA have a tendency towards more negative interpretations of sexually-relevant information, but those interpretations may not necessarily be associated with their sexual desire function. In a similar study, women were asked to write a neutral essay on their previous day, and a sexual essay on their own personal sexual self-schemas (Lorenz & Meston, 2012). Similar to the previous study, women with abuse histories used significantly more negative emotion words in the sexual essay than non-abused women. Across both essays, the women with histories of CSA used less positive-emotion words than the non-abused women, and for both groups of women greater use of positive emotions words was associated with better sexual function. These findings suggest that positive emotions towards sexuality may be more relevant to sexual function than negative emotions. The sample of women with abuse histories from the Lorenz and Meston study also participated in a 5-session expressive writing treatment study that lead to improved mental and sexual health (Meston, Lorenz, & Stephenson, 2013) and then wrote a new set of neutral and sexual essays. At posttreatment, women showed a reduction in their use of negative emotion words and an increase in positive emotion words in the sexual essay. Notably, the reduction in negative emotion words was associated with improvement in sexual function and sexual satisfaction, but the increase in positive emotion words showed no association with these sexual health variables (Pulverman, Lorenz, & Meston, 2015). Across studies on expressive writing, positive affect was related to improved sexual function, with the exception of the treatment study in which only a reduction in negative emotion was related to improved sexual function.

In addition to the implicit associations and language analysis approaches, the cognitive associations with sexuality of women with abuse histories have also been tested with more direct measures. During a sexual psychophysiological study women with CSA histories reported more negative affect prior to the presentation of an erotic film than non-abused women (Rellini & Meston, 2011). Women with abuse histories also retrospectively reported greater fear, anger, and disgust during sexual arousal with a partner than their non-abused counterparts (Meston et al., 2006; Schloredt & Heiman, 2003; Westerlund, 1992). Greater negative affect both prior to, and during, exposure to sexual stimuli could contribute to the development of sexual dysfunction, particularly arousal dysfunction. The evidence suggests that both greater negative appraisals and a deficit of positive appraisals of sexual stimuli are related to sexual function in women with CSA histories. The differences between the responses of women with and without CSA histories to sexual stimuli reviewed here suggest that CSA may impact the way women cognitively process information related to sexuality.

Sexual Self-Schema

The tendency to appraise sexual stimuli more negatively and less positively has also been demonstrated in women’s perceptions of their sexual selves. Sexual self-schemas are deeply held views and attitudes about the self as a sexual being that impact the processing of sexually-relevant cues and inform sexual behavior (Andersen & Cyranowski, 1994). Sexual self-schemas have primarily been studied with a self-report measure, the Sexual Self-Schema Scale, in which women are asked to rate themselves on a series of trait adjectives (e.g., uninhibited, serious, romantic), that are summarized by two positive factors (passion/romance, and openness to experience) and one negative factor (embarrassment/conservatism; Andersen & Cyranowski, 1994). Research using the Sexual Self-Schema Scale has found that women with abuse histories report less positive sexual self-schemas, but no difference in negative sexual self-schemas compared to their non-abused peers, and positive sexual self-schemas were associated with sexual function (Meston et al., 2006; Reissing, Binik, & Khalifé, 2003). Another study found that women with histories of CSA reported lower positive sexual self-schemas, and greater negative sexual self-schemas than non-abused women, and that both types of sexual self-schemas were related to sexual function and sexual satisfaction (Rellini & Meston, 2011). Taken together these studies suggest that lower positive associations with sexuality are more important to the sexual function of women with abuse histories than greater negative associations with sexuality.

Recently the sexual self-schemas of women with abuse histories have also been explored with text analysis approaches that extract common themes, or schemas, from natural language. In contrast to self-report questionnaires, this text analysis approach enables schemas to arise organically from the data itself. The first study to employ this approach examined sexual essays written by women with and without abuse histories, and identified seven unique sexual self-schemas including family and development, virginity, abuse, relationship, sexual activity, attraction, and existentialism (Stanton, Boyd, Pulverman, & Meston, 2015). When comparing the essays of women with and without abuse histories, it was noted that non-abused women used the virginity and relationship schemas more than the women with abuse histories, and the women with CSA histories used the abuse and attraction schemas more than the non-abused women. The authors posited that while the loss of virginity may be a highly salient event in the sexual development of non-abused women, this may not apply to the women with CSA histories. For women with CSA histories, it is likely that abuse experiences were more salient to their early psychosexual development than the loss of virginity.

Meston and colleagues conducted a randomized clinical trial of a 5-session expressive writing treatment for women with histories of CSA and current sexual dysfunction (Meston et al., 2013). The study included two treatment conditions, that asked women to write about either their trauma history or their sexual self-schemas. Women in the sexual self-schemas condition showed significant improvement in sexual function and greater improvement than women in the trauma condition, reiterating the importance of sexual self-schemas to the sexual function of women with abuse histories. In further support of the impact of sexual self-schemas on study outcomes, women’s posttreatment essays were examined with the text analysis approach described here, and women with CSA histories showed reductions in their use of the abuse, family and development, virginity, and attraction schemas, and an increase in their use of the existentialism schema (Pulverman, Boyd, Stanton, & Meston, 2016). Expressive writing on sexual self-schemas may aid women with histories of CSA to process their abuse experiences and thus diminish the prominence of abuse in their sexual self-schemas.

Sympathetic Nervous System Activation

One posttraumatic symptom commonly observed among women with a history of CSA is chronic elevated sympathetic nervous system (SNS) activity or physiological hyperarousal. Symptoms of elevated SNS activity can include increased heartrate, increased respiration, muscle tension, perspiration, exaggerated startle response, and difficulty sleeping (American Psychiatric Association, 2013). Although this physiological response is common to all major traumas, in childhood trauma the elevated SNS activity begins so early in life it can fundamentally alter the individual’s overall physiological functioning and put them at elevated risk for stress-related disorders (Hulme, 2011).

Activity of the SNS naturally increases during sexual arousal. Studies on the relationship between SNS arousal and sexual arousal in women have identified an optimal level of SNS arousal for facilitating genital sexual arousal (Meston & Gorzalka, 1996). Research using both exercise and ephedrine to increase SNS arousal prior to viewing an erotic film showed that, in sexually functional women, increases in SNS arousal provided a jumpstart to genital sexual arousal, resulting in enhanced levels of genital sexual arousal to an erotic film (Meston & Gorzalka, 1995, 1996b; Meston & Heiman, 1998). The enhancement to genital sexual arousal provided by exercise has also been demonstrated in (non-abused) sexually-dysfunctional women (Lorenz & Meston, 2012; Meston & Gorzalka, 1996a). However, in an exercise study comparing women with CSA histories, both with and without posttraumatic stress disorder (PTSD; a disorder that includes elevated SNS activity; American Psychiatric Association, 2013), to non-abused women, the women with abuse histories did not show an increase in genital sexual arousal in the exercise condition, in contrast to their non-abused peers who did show an increase (Rellini & Meston, 2006). In fact, the authors found an inverse relationship between PTSD symptoms and genital arousal, such that women with CSA histories and greater symptoms of PTSD showed lower levels of genital sexual arousal after exercise. The authors of this study concluded that, for women with CSA histories SNS arousal may already be so elevated that the increase in SNS arousal that occurs naturally during sexual activity may push their SNS activation beyond the optimal range, leading to impaired sexual function. Alternate methods of assessing SNS activation including measurement of the stress hormone cortisol, have also revealed different profiles between women with and without CSA histories, and these differences were also related to sexual function (Meston & Lorenz, 2013; Rellini, Hamilton, Delville, & Meston, 2009; Rellini & Meston, 2006).

Body Image and Esteem

Research has also suggested that the body image or body esteem of women with CSA histories may account for the elevated rates of sexual dysfunction reported by this group. Body esteem refers to cognitive and affective appraisals of one’s own body that are influenced by experiences and socialization (Young, 1992). In the general population of women, higher body image is associated with better sexual function. Specifically, negative appraisals of the body during sexual activity negatively impact sexual function (for review, see Woertman & van den Brink, 2012). Women with abuse histories report lower overall body esteem than their non-abused peers (Kilimnik & Meston, 2016; Sack, Boroske-Leiner, & Lahmann, 2010; Wenninger & Heiman, 1998), particularly for the sexual attractiveness element of body image (Kilimnik & Meston, 2016; Wenninger & Heiman, 1998). Two studies have linked body image to the sexual function of women with abuse histories. Wenninger and Heiman found that a lower evaluation of the sexual attractiveness element of body esteem was associated with poorer sexual function for women with abuse histories (1998). Kilimnik and Meston found that abuse history moderated the relationship between both overall body esteem and sexual excitation (defined as brain processes related to approaching seuxal stimuli; Bancroft & Janssen, 2000), and the sexual attractiveness element of body esteem and sexual excitation (2016). In other words, decreases in body esteem were associated with decreases in sexual excitation, but only for women with histories of CSA. The authors suggested that during CSA a child may learn to associate her body with the abuse, thereby leading to negative appraisals of her body that continue into adulthood and impair sexual function.

Research on the treatment of eating disorders also sheds light on the relationship between CSA and body esteem. The rates of eating disorders are elevated among women with histories of CSA compared to non-abused women, and a relationship between a history of CSA and low body image has also been noted in the eating disorder literature (Smolak & Murnen, 2002; Wonderlich, Brewerton, Jocic, Dansky, & Abbott, 1997). A treatment study for women with anorexia nervosa and bulimia nervosa identified a differential treatment response between participants with and without histories of abuse. Specifically, the authors found that women with CSA histories reported less improvement in sexual function after treatment compared to their non-abused counterparts (Castellini et al., 2013). Although body image improved significantly among the non-abused women, there was no change in body image for the women with abuse histories. This treatment study suggests an important association between low body image and sexual function and indicates that the low body image of women with CSA histories may be particularly intractable.

Shame and Guilt

The emotions of guilt, shame, and self-blame related to CSA have also been identified as potential mechanisms underlying the development of sexual dysfunction in women with CSA histories. In a prospective longitudinal study of CSA survivors, beginning immediately after the abuse was reported to authorities, greater shame and self-blame at one year post-abuse predicted greater sexual difficulties at six years post-abuse (Feiring et al., 2009). Notably, shame and self-blame predicted sexual difficulties over and above abuse severity (defined as presence of penetration, use of force, duration of abuse, number of events, familial or non-familial perpetrator, and living or not living with perpetrator), suggesting that emotional reactions to CSA may be more relevant to the development of later sexual problems than characteristics of the abuse itself. The authors suggested that shame and self-blame may negatively impact women’s sexual self-schemas (Feiring et al., 2009), although to date no empirical studies have examined the relationship between those two constructs. In another study, women with abuse histories reported higher rates of sex guilt (defined as expectations of punishment for “improper” sexual behavior) than non-abused women; however, this study did not assess sexual function (Walser & Kern, 1996). These studies provide preliminary evidence that negative emotions of guilt, shame, and self-blame, may serve as one of the pathways through which early abuse impacts women’s later sexual function. 

Mechanisms Suggested by Treatment Research

Given that the impact of CSA on sexual health cannot ethically be studied with randomized controlled experiments, treatment research provides an alternative method for examining mechanisms that may be involved in the development of sexual dysfunction. Women with histories of CSA show a lower response to standardized sex therapy treatments than non-abused women (Hall, 2008; Maltz, 2002). In a study on sildenafil citrate (Viagra) including women both with and without histories of CSA, women with CSA histories showed a significantly lower response to the drug in terms of genital arousal, lubrication, and orgasm, than non-abused women. Of the women who responded to the drug, 70% of the non-abused women reported that the enhanced arousal made intercourse more pleasant and satisfying, yet only 14% of the women with CSA histories reported that the drug made intercourse more pleasant and satisfying, while another 14% of the women with CSA histories reported that the enhanced arousal made intercourse unpleasant or disturbing (Berman et al., 2001). In a study of testosterone and vardenafil (Levitra) for treating female sexual dysfunction, non-abused women responded with enhanced genital sexual arousal to the drugs, yet women with histories of CSA did not show any change in genital sexual arousal response (van der Made et al., 2009). Clinical experts have posited that treatments that directly enhance genital sexual arousal may move too quickly and be too explicitly sexual for women with histories of sexual abuse who may hold chronic negative associations with sexuality, their sexual self, and their own bodies (Hall, 2007; Maltz, 2002).

In contrast to the pharmacological studies just reviewed, women with abuse histories responded better than their non-abused peers to mindfulness-based sex therapy (Brotto, Basson, & Luria, 2008). To further explore this notable finding, a follow-up study compared group cognitive behavioral sex therapy (CBT) to group mindfulness-based sex therapy for women with CSA histories and sexual dysfunction (Brotto, Seal, & Rellini, 2012). The mindfulness treatment included training on present moment focus during non-sexual and sexual activities and body scanning for physical sensations with a focus on sensations in the genital region (Brotto, Basson, Luria, Seal, & Woo, unpublished manual). At post-treatment, women in the mindfulness condition showed an increase in subjective sexual arousal to an erotic film in the laboratory compared to their pretreatment responses, and compared to the responses of women in the CBT condition. Notably, this increase in subjective arousal was not accompanied by an increase in genital sexual arousal. Although treatment did not affect women’s genital arousal, it appeared to affect the relationship between their genital and subjective sexual arousal, such that they were more aware or more responsive to their genital arousal at posttreatment. The authors speculated that the mindfulness orientation of the treatment may have enabled the women to disconnect from negative cognitions such as memories of the abuse, and fully attend to the sexual stimulus in the present moment (Brotto et al., 2012). Although several active mechanisms have been proposed to account for the improvements in sexual function conferred by mindfulness-based sex therapy treatments (Stephenson, 2017), it is unclear whether a unique mechanism is at work when these treatments are applied to women with histories of CSA.

Expressive writing treatments focused on the sexual function of women with histories of CSA have also pointed towards potential mechanisms of action. Meston and colleagues tested a 5-session expressive writing treatment focused on sexual self-schemas and found that both the schema-focused group and the trauma-focused group, evidenced improvements in sexual function and sexual satisfaction (Meston et al., 2013). Expressive writing is proposed to improve mental health through the mechanisms of exposure and habituation to traumatic memories, reduction in the desire to conceal traumatic memories, emotional expression, and cognitive re-evaluation (Pennebaker & Chung, 2011). Given that Meston et al.’s trial was the first study to test expressive writing as a treatment for addressing sexual dysfunction in women with abuse histories, it is unknown exactly which mechanisms may be most salient for this group. The authors suggested that the expressive writing treatment approach may have been especially appropriate for women with abuse histories by providing them with ultimate control over the content of their essays and the pace of treatment (Meston et al., 2013). Indeed, the stigma surrounding sexual abuse has been linked to reluctance to disclose abuse history or seek mental health treatment for abuse-related concerns (Tener & Murphy, 2015), thus the private nature of expressive writing may have improved treatment efficacy for this group of women. 

Conclusion

 Sexual abuse in childhood has been identified as one of the most important risk factors for the development of sexual dysfunction in adulthood. Indeed, our review of prevalence studies revealed that in random probability studies 25-59% of women with CSA histories report sexual dysfunction, a rate that rises to 84-94% in studies on clinical samples. Notable differences emerged between the sexual health of women with and without histories of abuse in terms of the prevalence of dysfunction, types of dysfunctions, and treatment response. Specifically, sexual dysfunction is more prevalent among women with CSA histories than non-abused women. Although desire difficulties are the most common issue for women in general, both desire and arousal difficulties are elevated among women with histories of abuse. In terms of treatment response, women with a history of CSA show a lower response to treatments that directly enhance genital sexual arousal, in comparison to non-abused women, yet show a better treatment response to mindfulness-based sex therapy. Differences between the sexual health of women with and without a history of abuse indicate that the sexual problems of women with CSA histories may develop via distinct mechanisms from the sexual problems of non-abused women. A better understanding of the mechanisms underlying sexual dysfunction among women with CSA histories is vital to developing targeted treatments for sexual dysfunction in this population.

To date researchers have proposed several potential mechanisms to account for the robust relationship between histories of CSA and sexual dysfunction in adulthood. These proposed mechanisms include cognitive associations with sexuality, sexual self-schemas, sympathetic nervous system activation, body image and esteem, and shame and guilt. Our review of the literature suggests that women with a history of CSA appraise sexual stimuli, and even their own sexual identities, as more negative and less positive than non-abused women, with the lower positive appraisals showing a stronger relationship to sexual function. Emotional reactions to the abuse including elevated levels of shame, guilt, and self-blame have also been associated with lower sexual function and may be related to the development of less positive appraisals of sexual stimuli. Further research is warranted on the relationship between these negative emotions and cognitive appraisals of sexual stimuli and sexual self-schemas.

Elements of the physical body have also been linked to the lower sexual function of women with abuse histories. Specifically, women with CSA histories show elevated baseline sympathetic nervous system activation that can impair sexual arousal response, and less positive appraisals of their own body, particularly in regards to perceived sexual attractiveness. Further research on the complex interactions of cognitive appraisals of sexual stimuli, sexual self-schemas, physiological sexual arousal, and negative emotions could help to clarify the unique contribution of each element to the development of sexual dysfunction in women with abuse histories. Prospective longitudinal designs such as those employed by Feiring and colleagues, in which variables are assessed over time, provide the most comprehensive picture of the relationship between early sexual abuse and later adult sexuality (2009).

Treatment studies have also suggested some potential active mechanisms. To date, both mindfulness-based sex therapy and expressive writing therapies have been particularly effective for addressing sexual dysfunction among women with a history of abuse. Several potential mechanisms could account for the efficacy of each of these treatments respectively, thus further research is needed to clarify the active ingredients of these approaches. Assessing a broad range of potential mechanisms in treatment studies would comprise a first step towards a better understanding of the development of sexual dysfunction among women with abuse histories. Once mechanisms have been reliably identified they can serve as the targets for therapeutic change to improve the sexual health of women with abuse histories.