Co-occurrence subgroups of child sexual abuse, health risk behaviors and their associations among secondary school students in China

Child Sexual Abuse (CSA) means 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 [1]. CSA has spread throughout countries, continents, and socioeconomic classes in recent decades [2] and attracted increasing attention from the public, the media, and the academia. WHO [3] estimated in 2006 that 150 million girls and boys under the age of 18 have experienced CSA. Some meta-analyses estimated the average global prevalence of CSA to be around 11.8%, although it varies from 2 to 62% among different studies as well as types of CSA [4‐6].

CSA is regarded as a type of Adverse Childhood Experiences. Studies, particularly among youth, have shown CSA victims are more likely to engage in behaviors that can place them at risk for negative outcomes, which are in general referred to as youth Health Risk Behavior (HRB), such as alcoholism, drug abuse, anxiety, violence, and suicidal ideation [7, 8], and has long been concerned with short-term and long-term negative sequelae [9‐16]. Even a single form of abuse can be associated with risk in different HRB domains [17‐19]. CSA is however a multi-indicator measurement, which indicates that experiencing CSA often means experiencing more than one form of CSA [20, 21] i.e. multiple victimization [22, 23]. While the consequence of CSA may not be measurably apparent for some youth, other youth report HRBs}{suicidal ideation [24, 25]. Different forms of abuse items may overlap and interact with each other, and the combination of different forms may modify specific social and psychological consequences [23, 26, 27]. CSA’s covert nature may prevent victims from expressing themselves and seeking help. Without considering the nature of co-occurrence, the estimation of the association between CSA and HRB may be biased [28]. The lack of research on multi-victimization hinders our understanding of the impact of multiple CSA victimization [29]. Insights into different subgroups of CSA and the association patterns with HRBs could help service providers and decision makers identify adolescents at risk that need help, and design specific inventions according to victims’ characteristics and demands [30‐32].

China has the largest youth population in the world, with more than 200 million students in primary and secondary schools, accounting for 20% of the national population in total. CSA has attracted public attention in China, while researches in this field are still insufficient, with scarcely any on multiple victimization. Existing Chinese researches on the association between child victimization and health behaviors often focused on single form of the adolescent adverse experiences from small samples or limited study sites [33‐35]. It is thought that the cultures and traditions of Asian societies may lead to different CSA patterns and their associations with behaviors, but there is little research on CSA patterns [36] in China. There is need to examine the heterogeneity and patterns of multi-victimization in teens to help optimize prevention and intervention programs on a national scale.

Across the globe, the self-report prevalence of CSA varies greatly among different studies ranging from 2 to 62% [4‐6], and the average is estimated to be 12% [4]. According to a meta-analysis that synthesized CSA prevalence of Chinese studies [39], prevalence of CSA showed large variation from 2%(Yen, 2008)to 35.2%(Zhao&Li, 2006)of self-reported at least one form of CSA experiences in China [41]. Different studies have used different CSA items to define CSA, which largely affects the estimated prevalence [42]. Estimates from broad definitions of CSA that includes non-contact CSA yield higher prevalence compared with estimates from narrow definition of CSA that merely include contact CSA (Chen et al., 2010). According to Ji’s review about CSA studies in China, the prevalence of contact CSA varied from 3.3% (Ye, Tao, Fang, Huang, & Sun, 2006) to 14.5% (Chen, Dunne, & Han, 2004), and that of penetrative CSA varied from 0.4% (Chen, Dunne, et al., 2004; Li, 2008) to 2.9% (Chen, Dunne, & Han, 2006) in females. The prevalence of contact CSA varied from 3% (So-kum Tang, 2002) to 15% (Chen, Wang, & Dunne, 2003), and that of penetrative CSA varied from 0 (Li, 2008) to 2.9% (Xia et al., 2009) in males. Our research has produced consistent results. The prevalence of experiencing at least one form of CSAs is 12.9% among the participated students in China. The prevalence of each measured sexual abuse item varies from 1.0 to 4.4%. Non-contact CSAs are the most common forms. Some current studies have shown that the majority of victims were under 14 years old when they encountered CSA [43], and the least age difference between the perpetrator and the victim was 5 years [44]; while in some other studies, the age cut-off point is set as 16 years old [45‐47] or 18 years old [48, 49]. The discrepancy in study population is also one of the reasons for the difference, as the research objects in Sun’s research are adults [48], while those in Chen’s research [50] are college students in selected areas. Variations of prevalence from different studies are mainly due to different definition of CSA experiences, different constrains to the age of the victim/the perpetrator, different situations in which CSA occurs, and different recruitments of respondents as well. The direct comparison should be done with caution.

Traditional studies recommended CSA to be classified into four types, namely (1) non-contact, (2) genital touching, (3) attempted vaginal or anal insertion, and (4) vaginal or anal penetration. Empirical opinions showed that CSA involving types (2), (3), and (4) are more likely to have significant negative consequences. Other studies suggested to group CSA into two types, one being body-contact CSA and the other being non-contact CSA. However, in real life, victims often encounter more than one type of CSA [51]. Traditional classification methods set empirical cut-off values for classification, dividing children into mutually exclusive categories. One advantage of these methods is that the classification is easy to create and compare. The disadvantage is that they required priori assumptions about the adverse impact, and often took into account only one type of the most serious sexual abuse experience that an individual had experienced. They cannot extract how and to what extent various types of abuse coexist in the target population. Thus, some other studies tried cluster analysis to explore more reasonable CSA classification. For example, a study conducted on 303 teenagers in Denmark resulted in a model of four latent classes, namely, multiple CSA latent class, high language/low contact latent class, high sexual contact latent class and nonvictim latent class [52].

The results of our study are consistent with the literatures highlighting subgroups of CSA by latent class analysis rather than the traditional empirical approach. Compared with the categories obtained according to the traditional classification, the latent class of CSA obtained in our study has taken into account both heterogeneity and co-occurrence. Based on the conditional probability and local independence, this study obtained a three-class latent variable to characterize the latent categorical profiles behind CSA experience as “Low CSAs “, “Verbal or exhibitionism CSA”, and “High Multiple CSAs”. The results of our study and the Danish study found similar latent class subgroups of CSA victims, characterized by high language/low contact latent class, high multiple CSA class and low CSA latent class, which reflected that the LCA method is helpful and stable in detecting latent CSA subgroups. In another study trying using LCA, a sample of 657 young people recruited from high schools and colleges was examined to identify latent class of sexually abusive perpetrators [53]. In this analysis, latent classes of kissing/caressing, attempting sexual intercourse, and completed sexual intercourse were established based on CSA items, which were then found to be related to the abusive behaviors of verbal coercion, material seduction, and violent coercion of the perpetrators. It can be seen that LCA can help to find homogeneous subgroups and the association between the groups and some certain distal variables.

Our study also fits a three-category latent class variable according to the heterogeneity of HRBs. The result is consistent with the results of some other researches. Zlotnick [54] believed that some characteristics of complex posttraumatic stress disorder(PTSD) should coexist with internalized indicators (for example, ineffectiveness, shame, depression/ despair, social withdrawal, and physical discomfort), while other characteristics should be more related to externalization indicators (for example, self-destructive behavior, impulsive actions, and hostility). Miller’s research [55] indicated internalization and externalization show higher scores on complex PTSD rather than simple PTSD in a series of scales measuring the core concept of PTSD. These findings highlight the heterogeneous of patients with complex adverse experiences. The practice of the LCA method in these researches suggests that the latent category method can better take into account the consistency within group and the difference between groups. The attempts of these studies using the LCA method suggest that the LCA method has great potential in the field of exploring adolescent behavior co-occurrence and heterogeneity.

Studies have suggested that the effects of CSA are cumulative. Exposure to high levels or multiple forms of CSA experiences may have more harmful and more reversible effects [23]. In our study, the results of association analysis showed that, adolescents presented diverse patterns of HRBs according to different patterns of CSA experience. Compared to the students classified as “Low HRBs”, those classified as “externalizing HRBs” were associated with a high probability of “Verbal or exhibitionism CSA”, and a similar association was evident among those in “internalizing HRBs”. Meanwhile, compared with “Low CSAs”, those in “high multiple CSAs”, have the strongest association with both “externalizing HRBs” and “internalizing HRBs”. All these associated directions were positive and statistically significant, which are consistent with the research hypothesis. Existing studies suggest that children with CSA experiences show higher risk of engaging in health-risk behaviors, such as drinking, smoking, gambling, and suicidal ideation [38, 49, 56, 57], or being less ambitious, having fewer friends, and having lower self-esteem [10, 58], and then their lives may have been traumatically disrupted by these behaviors [12‐16, 59]. Compared with those who have received low or no abuse, multiple victimization are associated with an increased risk of externalization problems [60] or internalizing problems [61‐65]. Our results not only confirmed the relation between CSA and risk behaviors, but also showed a dose-response association between the amount of ACE and behavioral and health issues, which were consistent with some of the few current studies, which means multiple victims are more likely to have behavioral or psychological problems. Sexual assault or forced penetrated abuse is more likely to associate with more negative long-term consequences [66‐68] compared with non-forced or non-penetrated sexual abuse. More severe forms of sexual abuse are more destructive because they reinforce feelings of helplessness, powerlessness and self-blame [69]. Our study supports previous studies that multiple CSA experiences may lead to a decrease in the overall perception of one’s health [70] and an increase in negative health behaviors [71]. Abuse prevalence are believed to undermine the ability of adolescents to complete key developmental tasks, promoting them to use ineffective or even harmful coping strategies. The difference in population patterns can help researchers understand the homogeneity and heterogeneity between individuals, so as to provide a basis for the design and implementation of targeted intervention measures for different subtypes of victimization.

Previous studies showed that boys and girls who experienced CSA may have similar physical and mental health sequelae [24, 72, 73]. Our study showed that some of the association strength differed between genders. The associations were nearly twice as strong in girls as it was in boys (male OR = 3.08, 95%CI 1.48–6.40 vs female OR = 6.05, 95%CI 3.73–9.80). The results suggest that boys and girls may differ in how they respond to negative events [74, 75]. Females tend to internalize stress into shyness, shame, guilt, sadness, and self-hostility [76], while males are more likely to respond with externalizing behaviors such as problematic alcohol use or committing violent acts [77]. However, there are controversies in existing studies on the impact of gender on the associations of CSA and HRB. Coohey [78] suggested that sexually abused boys were more likely than girls to have an internalizing behavior problem using a clinical sample, while Maikovich-Fong [61, 72] claimed that sex did not moderate the relation between abuse characteristics and youth emotional and behavioral problems. These findings highlight the importance of gender in the field of CSA research.

Notwithstanding the limitations, our study contributes to the scarce literature on exploring prevalence and co-occurrence subgroups of Chinese school teens reporting sexual abuse and examines the association between CSA and HRB patterns. The prevalence of experiencing at least one form of CSAs is 12.9%. Non-contact CSAs are the most common forms. The co-occurrence and heterogeneity of the experiences play a role in the association of CSA and HRB. Students who have experienced multiple-victimization of CSA have a higher probability of HRB risk, especially “depression, despair, or extreme anxiety”, “suicidal ideation” and “suicidal behavior”. The findings emphasize the importance of considering heterogeneity and co-occurrence in studies of adverse childhood experiences. The analysis could improve understandings of the potential vulnerabilities. Although contact or non-contact CSA are considered public health problems, multi-victimization has more significantly negative effects. Children with multiple abuse experiences should be paid more attention to for risk behavior interventions. The results could provide new evidence and research directions for association between CSA and HRB, and help revise the interventions for different subgroups of victims.