Abstract
Background and aims:
Child sexual abuse is a condition that can affect the victim’s life in every period and is closely related to physical and mental problems. One of the important consequences of child sexual abuse is suicide. The idea that there is a close relationship between child sexual abuse and suicidal ideation and attempts is widely accepted in the literature, but this relationship is quite complex. In this study, we investigated the factors associated with suicide risk in children and adolescents who were victims of sexual abuse.
Methods:
Two groups were formed: participants who were sexually abused and attempted suicide, and participants who were sexually abused and did not attempt suicide. They were evaluated in terms of anxiety, depression, posttraumatic stress disorder, borderline personality traits, impulsivity, traumatic experiences, and perceived social support using scales.
Results:
The total scores of anxiety-depression, posttraumatic-stress-disorder, impulsivity, traumatic experiences, and borderline personality traits scales were found to be significantly higher, while the perceived social support scale score was found to be significantly lower in the group who attempted suicide.
Conclusion:
Our findings revealed factors associated with suicide attempts in child and adolescent who were sexual abuse victims. Taking these factors into account when evaluating victims of sexual abuse will provide early intervention to high risk patients.
Keywords
Introduction
The term ‘child sexual abuse’ is defined by the World Health Organization (WHO) as sexual activity in which the child does not fully understand, does not consent to, is not developmentally ready for, or violates the laws and social taboos of society (WHO, 1999). Although the prevalence of child sexual abuse varies from region to region, it has become an increasing public health problem worldwide in recent years (Bursztein & Apter, 2009). A review of more than 200 meta-analyses reported that the prevalence of child sexual abuse reached 18% (Stoltenborgh et al., 2015). Child sexual abuse is a global public health problem with a significant prevalence and can lead to physical, social, and psychological problems that may continue into adulthood (Soylu et al., 2022). Studies have indicated that the psychiatric disorders most significantly associated with child sexual abuse are posttraumatic stress disorder, anxiety disorders, and major depressive disorder (Silverman et al., 1996). Moreover, many studies have repeatedly revealed that there is a relationship between child sexual abuse and suicidal ideation and attempts (Cantón-Cortés et al., 2020; Devries et al., 2014; Soylu et al., 2022).
According to the WHO’s 2015 report, it is estimated that 788,000 people lost their lives as a result of suicide (WHO, 2014). In addition to all age groups, suicide is among the leading causes of death in adolescents, and the rates of suicidal ideation and suicide attempts have increased significantly in recent years (Bursztein & Apter, 2009). Suicide is a preventable problem, and the WHO states that reducing suicide-related deaths is a global imperative (WHO, 2014). The most important way to prevent suicide is to closely monitor individuals who have risky environmental factors for suicide and/or have high individual susceptibility to suicide (Klonsky et al., 2016). Studies examining the etiology and risk factors for suicide have revealed that genetic predispositions, unpleasant life events and psychiatric disorders are effective for suicidal behavior. Studies have shown that psychiatric disorders such as bipolar disorder, posttraumatic stress disorder and major depressive disorder; personality variables, especially aggression and impulsivity; low problem-solving skills; exposure to bullying; and low family cohesion are factors that increase the risk of suicide (Amado et al., 2015; Kalin, 2023; O’Connor & Portzky, 2018).
In addition to these well-known factors, being a victim of sexual abuse is also considered a risk factor for suicidal ideation and attempts (Maniglio, 2011; Plunkett et al., 2001; Soylu et al., 2022). A study conducted with female participants reported that 20% to 22% of finalized suicides and suicide attempts may be related to sexual abuse (Devries et al., 2014). It is thought that abuse directly or through some factors increases the risk of suicidal ideation and suicide attempts in sexually abused individuals (Cantón-Cortés et al., 2020; Maniglio, 2011). Attachment style, a sense of trust in the family system, and age at the time of abuse were found to be individual factors associated with suicidal ideation in individuals who were victims of sexual abuse (Cantón-Cortés et al., 2020). It is thought that exposure to child sexual abuse and thus traumatic stress may increase the risk of suicide through physical and psychological effects (Kendall-Tackett, 2002). On the other hand, opinions in the literature indicate that the relationship between sexual abuse and suicide is minimal or negligible. For example, in the meta-analysis conducted by Klonsky and Moyer (2008), after controlling for borderline personality disorder and family atmosphere, the relationship between child sexual abuse and self-harming behavior was found to be negligible. Another meta-analysis suggested that the relationships between family variables (social support, conflict, and psychopathology) and suicidal ideation and behavior were stronger than those between family variables and child sexual abuse (Rind et al., 1998).
Different studies in the literature have investigated the relationship between sexual abuse and suicide, but the lack of control groups in these studies or the fact that the control groups consisted of healthy individuals caused limitations in clearly demonstrating this relationship (DeCou & Lynch, 2019; Soylu & Alpaslan, 2013; Soylu et al., 2022; Unlu & Cakaloz, 2016). In light of this information, our study aimed to investigate the factors associated with suicide probability and attempt in children and adolescents exposed to sexual abuse.
Materials and methods
Subjects
This study was designed as a cross-sectional, case-control study to investigate factors associated with suicide attempts among children and adolescents who were victims of sexual abuse. Children and adolescents aged 8 to 18 years who applied to Necmettin Erbakan University Meram Faculty of Medicine, Department of Child and Adolescent Mental Health and Diseases and Dr. Ali Kemal Belviranlı Obstetrics, Gynecology and Pediatrics Hospital Child and Adolescent Mental Health and Diseases outpatient clinics due to sexual abuse or complaints related to sexual abuse were included in the study. Participants were divided into two groups: Group 1, which consisted of participants with suicide attempts after sexual abuse, and Group 2, which consisted of participants without suicide attempts after sexual abuse. Participants who did not have the intellectual capacity to complete the scales, who had psychiatric disorders such as active psychosis and mania that could prevent them from completing the scales correctly, and who did not complete all scales were excluded from the study.
In group-1, 30 participants (27 girls and 3 boys) were recruited by excluding 3 of the 33 sexually abused and suicide attempters (1 did not consent to participate in the study and 2 did not complete the scales), and in group-2, 43 participants (39 girls and 4 boys) were recruited by excluding 7 of 50 participants who had been sexually abused and did not attempt suicide (3 did not consent to participate in the study and 4 filled out the scales incompletely).
Diagnosis/symptom assessment and data collection tools
All participants were assessed via direct face-to-face interviews conducted by experienced clinicians, and Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime Version (K-SADS-PL) was administered by experienced clinicians during the examination of the participants and all psychiatric diagnoses were made according to DSM-5 diagnostic criteria (Kaufman et al., 1997). After the interview and psychological examination, a sociodemographic data form, a sexual abuse information form and a sexual abuse severity score were completed by the clinician. After the participants provided both verbal and written consent, they completed the Child Anxiety and Depression Scale, Post-Traumatic Stress Disorder Scale for Children and Adolescents, Borderline Personality Features Scale for Children-Short Form, Barratt Impulsivity Scale (BIS), Multidimensional Scale of Perceived Social Support, Childhood Abuse Experiences Scale, and Suicide Probability Scale in a quiet and bright environment.
Sexual Abuse Severity Score (SASS)
The scoring system developed by Zink et al. (2009) aims to measure the severity of abuse in sexually abused individuals via retrospective assessment. This scoring includes the age of the victim at the time of the first abuse, the number of times the victim was abused, the nature of the abuse, the number of abusers, and the severity of (physical or psychological) coercion. Each of these parameters is graded, and the total sexual abuse severity score is calculated.
Child Anxiety and Depression Scale-Revised (CADS)
It is a 47-item scale developed to screen for DSM-IV-based anxiety disorders and depression in children and adolescents. Each item is scored between 0 and 3. Turkish validity and reliability study was conducted by Gormez et al. (2017).
Posttraumatic Stress Disorder Scale for Children and Adolescents (PTSDS)
This scale, which is used to measure the level of posttraumatic stress in children, was first used by Pynoos et al. (Pynoos et al., 1987). This scale consists of 20 items. An increase in the total score indicates an increase in symptom severity. A Turkish validity study of the scale was conducted by Erden et al. (1999).
Borderline Personality Features Scale for Children-Short Form (BPFSC)
The scale was developed by Sharp et al. (2014) to detect borderline personality traits. The scale consists of 10 items. A study of validity and reliability was conducted by Coskun et al. (2022).
Barratt Impulsivity Scale (BIS)
It is a 30-item self-assessment scale developed to measure impulsivity. High scores indicate a high level of impulsivity. Turkish adaptation was conducted in 2008 (Güleç et al., 2008).
Multidimensional Scale of Perceived Social Support (MSPSS)
Developed by Zimet et al. (1988), the SPSS is a self-report scale consisting of 12 Likert-type items. A high score indicates a high level of social support. Eker et al. (2001) adapted the scale into Turkish, and reliability and validity studies were conducted.
Childhood Abuse Experiences Scale (CAES)
It was developed by Bernstein et al. (1994). The scale is a 5-point Likert scale consisting of 40 items. The scale was adapted into Turkish by Aslan and Alparslan (1999).
Suicide Probability Scale (SPS)
The Suicide Probability Scale is a 36-item self-report scale developed by Cull and Gill (1988) to assess suicide risk in adolescents and adults. As the score obtained from the scale increases, the probability of suicide increases. A Turkish validity and reliability study was conducted by Atli et al. (2009).
Statistical analysis
Statistical analysis was performed with SPSS version 25.0 (SPSS Inc.,Chicago,USA). The Shapiro–Wilk test was used to determine whether the distribution of all variables was normal. The chi-square test was used to evaluate the differences between the study and control groups in terms of sex distribution and some clinical characteristics. Student’s t test or the Mann–Whitney U test was used to compare the differences between two groups according to their distributions. Correlations between variables were determined via Pearson or Spearman correlation tests, and correlation analyses were performed with all participants regardless of group. Multivariate analysis of covariance (MANCOVA) was performed to avoid type I errors due to multiple testing effects and to control for confounding factors, the effects of age and sex were controlled, and the groups were compared in terms of the scales of the CADS, BPFSC, PTSDS, BIS, CAES, and SPS. After the MANCOVA test revealed a significant difference between the patient and control groups, one-way analysis of covariance (ANCOVA) was performed separately on the outcome variables. Finally, hierarchical regression analysis was performed to reveal the factors predicting suicide probability. In the first step, the effects of age and sex were tested, and then, in the second step, the total scores of the MSPSS and CAES were calculated. In the third step, the total scores of the CADS and PTSDS were added to the analysis. Finally, in the fourth step, the effects of the total scores of the BPFSC and the BIS were tested. Hierarchical regression analysis was conducted with all participants without any group distinction.
Results
There was no significant difference between group-1 and group-2 in terms of sex distribution, mean age, or age of exposure to abuse. Smoking and alcohol use were significantly more common in the group that attempted suicide. A family history of involvement in crime was significantly greater in the group that attempted suicide. The other clinical characteristics did not differ significantly between the groups. The sociodemographic and clinical characteristics of the groups are given in Table 1.
Sociodemographic and clinical characteristics of group 1 and 2.
Note. Group-1: participants with suicide attempt after sexual abuse, Group-2: participants without suicide attempt after sexual abuse.
Chi square test.
Student T test.
Mann-Whitney U test.
While the SASS total score (z = −0.389, p = .697) did not differ significantly between the groups, the number of perpetrators (z = −3.071, p = .002), and the most severe abuse (z = −2.080, p = .038) subscales were significantly greater in the group that attempted suicide. The rate of reporting abuse was significantly lower in the suicide attempt group. Data on the characteristics of abuse are given in Table 2.
Data on sexual abuse characteristics of the groups.
Note. Group-1: participants with suicide attempt after sexual abuse, Group-2: participants without suicide attempt after sexual abuse.
Chi square test.
CADS, PTSDS, BPFSC, BIS, CAES, and SPS total scores were significantly higher in the suicide attempt group. There was no significant difference between the groups in terms of the MSPSS total score, but the MSPSS-Family subscale score (Group-1 = 14.200 ± 7.521, Group-2 = 21.272 ± 14.554; t = 2.440, p = .017) was significantly lower in the suicide attempt group. To avoid type I errors due to multiple testing effects and to control for confounding factors such as age and sex, a MANCOVA test was conducted, and significant differences were found between the groups (Pillai’s trace V = 0.369, F(1, 71) = 5.263, p < .001, ηp2 = .369). One-way analysis of covariance (ANCOVA) was subsequently performed separately on the outcome variables, and in the analyses where age and sex were controlled, the CADS, PTSDS, BPFSC, BIS, CAES, and SPS total scores were significantly higher in the suicide attempt group. MSPSS did not significantly differ between the groups. Data on the scale scores of the groups are given in Table 3.
Comparison of scale scores of groups 1 and 2.
Note. Group-1: participants with suicide attempt after sexual abuse, Group-2: participants without suicide attempt after sexual abuse. CADS = Child Anxiety and Depression Scale; PTSDS = Post Traumatic Stress Disorder Scale for Children and Adolescents; BPFSC = Borderline Personality Features Scale for Children-Short Form; BIS = Barratt Impulsivity Scale; MSPSS = Multidimensional Scale of Perceived Social Support; CAES = Childhood Abuse Experiences Scale.
Student T test.
Cohen’s d.
Correlation analyses revealed a positive correlation between age at sexual abuse, CADS, BPFSC, PTSDS, BIS, CAES total scores, and SPS-total score, whereas a negative correlation was found between MSPSS total score and family subscale score and SPS-total score. The correlation analysis results are given in Table 4.
Correlation of scale scores of sexually abused participants.
Note. SA = sexual abuse; SASS = Sexual Abuse Severity Scale; CADS = Child Anxiety and Depression Scale; PTSDS = Post Traumatic Stress Disorder Scale for Children and Adolescents; BPFSC = Borderline Personality Features Scale for Children-Short Form; BIS = Barratt Impulsivity Scale; MSPSS-T/F = Multidimensional Scale of Perceived Social Support-Total/Family; CAES = Childhood Abuse Experiences Scale; SPS = Suicide Probability Scale.
p < .05. **p < .001.
Hierarchical regression analysis was performed to determine the factors predicting the probability of suicide. In the first step of the hierarchical regression analysis, age and sex were added to the model, and no significant relationships were found. In the second step, scales evaluating environmental experiences such as the MSPSS and CAES were included in the analysis, and a significant relationship was found at both scales. In the third step, scales evaluating psychiatric disorders, such as the CADS and PTSDS, were added, and a significant relationship was found between the MSPSS and PTSDS scales, while the CAES did not maintain a significant relationship. Finally, scales evaluating structural factors such as the BPFSC and BIS were added. As a result of the hierarchical regression analysis in which the SPS-total score was determined as the dependent variable, the BPFSC and PTSDS total scores were found to predict a greater suicide probability. Suicide probability was not predicted by any of the other scale scores. The results of the hierarchical regression analysis are given in Table 5.
Factors predicting SPS-total score in hierarchical regression analysis.
Note. SPS = Suicide Probability Scale; CADS = Child Anxiety and Depression Scale; PTSDS = Post Traumatic Stress Disorder Scale for Children and Adolescents; BPFSC = Borderline Personality Features Scale for Children-Short Form; BIS = Barratt Impulsivity Scale; MSPSS-T/F = Multidimensional Scale of Perceived Social Support-Total/Family; CAES = Childhood Abuse Experiences Scale.
Discussion
In our study, we investigated the relationship between the consequences of child sexual abuse and suicide. First, we found that participants who had been sexually abused and attempted suicide used alcohol and cigarettes significantly more often than those who did not attempt suicide. Similar to our results, a study by Soylu et al. (2022) reported that smoking and alcohol use were associated with a greater probability of suicide. Studies indicate that smoking and alcohol use are associated with suicide risk in individuals without any psychopathology and that smoking is associated with suicidal ideation, planning, attempts, and deaths and that there is a dose–response relationship between the number of cigarettes smoked per day and suicide (Berardelli et al., 2018; Echeverria et al., 2021). Smoking and alcohol use are more common in individuals with mental disorders such as depression and PTSD, and it is well known that these psychiatric disorders increase the risk of suicide. Although our results do not indicate that smoking and alcohol use are directly related to suicide, they suggest that smoking and alcohol use in victims of sexual abuse should be carefully monitored in terms of suicide risk in addition to affecting general health status (Echeverria et al., 2021). Our results revealed that the rate of family involvement in crime (defined as at least one first-degree relative being imprisoned at least once) was significantly greater in the suicide attempt group. In a study conducted with adolescents who were victims of sexual abuse, it was reported that extraverted personality traits were associated with hostility and impulsivity and were predictors of suicide attempt (Harford et al., 2014). The source of the impulsive characteristics of the participants who attempted suicide that may be associated with suicide attempts may be the genetic transmission of personality traits such as impulsivity and hostility in their parents, which may explain the high rate of involvement in crime among first-degree relatives.
In the evaluation of the sexual abuse severity score, the number of perpetrators and severity of abuse were significantly greater in the suicide attempt group. Studies on this subject have shown that an increase in the number of perpetrators and the severity of abuse are associated with suicide attempts (Plunkett et al., 2001; Soylu et al., 2022). An increase in the number of perpetrators and the severity of abuse may increase the risk of suicide by increasing the possibility of victim trauma, the sense of guilt, the risk of PTSD and depression development, and decreasing self-esteem (Soylu et al., 2022). We believe that questioning the characteristics of abuse and performing risk assessments according to these characteristics in interviews with patients who are victims of sexual abuse would be important for preventive medicine. Another finding was that the rate of reporting abuse to official state authorities (e.g. hospitals, police, and schools) was significantly higher in the group without suicide attempts. In other words, reporting abuse and initiating judicial processes seem to reduce the risk of suicide attempt. Correctly and appropriately used reporting mechanisms give the victim of abuse the chance to receive early and effective intervention, thereby preventing possible psychopathologies and other negative consequences (Mathews et al., 2016). In addition, reporting may reduce the risk of suicide by helping the child eliminate ruminative thought processes about the event by experiencing catharsis, and rumination has been reported as a factor associated with suicide in victims of abuse in studies (Kwok et al., 2013). CADS, PTSDS, BPFSC, BIS, and CAES total scores were higher in the suicide attempt group than in the nonsuicide attempt group. In addition, in our correlation analyses, we found positive correlations between the CADS, PTSDS, BPFSC, BIS, and CAES total scores and the SPS-total score, which is consistent with our previous analysis. Our results showed that suicide risk was greater in patients who developed depression and PTSD, which is consistent with the findings of a previous study (Soylu et al., 2022). One study reported that suicidal behavior in abuse victims may be related to borderline personality traits and family experiences (Klonsky & Moyer, 2008). Similarly, our results suggest that borderline personality traits and experiences of abuse may be associated with suicide attempts. Studies of victims of sexual abuse have shown that personality traits such as impulsivity and aggression may be associated with suicide attempts (Baud, 2005; Soylu et al., 2022). In our study, impulsivity was greater in the group with suicide attempts and can be considered a risk factor for suicide in abuse victims. When these data are considered together, there is a complex relationship between sexual abuse and suicide. The effects of sexual abuse on suicidal behavior may be mediated by variables such as neurobiological alterations, certain personality traits, and psychiatric disorders (Maniglio, 2011). Sexual abuse can lead to negative thoughts about oneself, the outside world and the future and further cognitive distortions. These distortions, in turn, may increase the risk of depression and lead to suicide. Similarly, sexual abuse is a clear cause of PTSD, and the development of PTSD may increase the risk of suicide (Soylu et al., 2022). Sexual abuse is a serious trauma and can cause neurobiological alterations. Childhood sexual abuse may decrease serotonin activity, and serotonin hypoactivity may cause impulsivity and aggression. As a result of these effects, the risk of suicide is hypothesized to increase (Maniglio, 2011; Spirito & Esposito-Smythers, 2006). Similarly, childhood abuse experiences can be considered trauma and may contribute to suicide risk in victims of sexual abuse by altering serotonin activity. We found that the MSPSS family subscale scores were significantly higher in the group without suicide attempts and were negatively correlated with the SPS-total score. Kwok et al. reported that perceived family support is a modulator of abuse and suicide risk and that high perceived family support may reduce suicide risk (Kwok et al., 2013). Not only do dysfunctional family relationships and conflicts within the family increase the risk of suicide, but the fact that decreased family support increases the risk of suicide indicates the importance of this issue. Therefore, it is very important to conduct interviews with the families of abuse victims and to provide the necessary support to families to manage this difficult process correctly. Finally, in our correlation analyses, we found a positive correlation between the age of exposure to sexual abuse and the total SPS score. Increased knowledge of abuse is associated with greater social isolation and lower satisfaction levels (Wright et al., 2007). With age, knowledge about abuse increases, and thus, the ability to make sense of the event increases. All of these factors may increase the possibility of suicide by increasing feelings of guilt, ruminative thoughts and thus the risk of psychiatric disorders.
Finally, as a result of the hierarchical regression analysis we conducted to determine the factors that predict the SPS-total score, we found that the BPFSC and PTSDS total scores predict a high SPS-total score and that the other scale scores have no predictive properties. Borderline personality disorder is characterized by a pervasive pattern of instability in emotional regulation, interpersonal relationships, self-image, and impulse control. It is reported to result from the interaction between biological (e.g. temperament) and psychosocial factors (e.g. unfavorable childhood events) and has been shown to be associated with severe impairment in an individual’s functioning, high rates of comorbid mental disorders, self-harm, and suicidal behavior (de Aquino Ferreira et al., 2018). Borderline personality traits are clearly associated with being a victim of sexual abuse and suicide risk, but the direction of this relationship is not yet clear (Berardelli et al., 2018; de Aquino Ferreira et al., 2018). On the one hand, an individual with borderline personality traits has a high risk of being abused and attempting suicide; on the other hand, the reverse relationship is also possible. Childhood sexual abuse may cause activation of the hypothalamo-hypophyseal axis and affect the cortex, amygdala, and hippocampus through an increase in cortisol and may lead to the production of behavioral patterns observed in borderline personality disorder (Balbernie, 2001). Our results cannot provide clear information about the direction of this relationship, but it is clear that borderline personality traits in children and adolescents who are victims of sexual abuse predict the possibility of suicide, and it is important for experts to consider this information when evaluating victims of abuse to better analyze suicide risk. Another factor predicting the likelihood of suicide was the PTSDS total score. PTSD is one of the possible consequences of sexual abuse (Hartman & Burgess, 1989). PTSD may increase the possibility of suicide in sexual abuse victims directly and/or by causing depression. PTSD is one of the most common psychiatric disorders in sexual abuse victims; therefore, PTSD symptoms should be carefully evaluated and monitored while sexual abuse victims are interviewed.
Although our study provides important results in terms of determining the risk of suicide and revealing the factors associated with suicide in children and adolescents who are victims of sexual abuse, there are several limitations. First, it cannot present a cause–effect relationship because of its cross-sectional design. Therefore, longitudinal studies in the field are needed. Another limitation is that it was conducted in a single center with participants admitted to the hospital. Therefore, it cannot be used to evaluate the whole society. Community-based and multicenter studies will reveal valuable results in this regard. The strengths of our study include the fact that our control group consisted of abused individuals and therefore more clearly revealed the relationship between abuse and suicide, face-to-face interviews and psychiatric evaluations were conducted with all patients, and many factors affecting the risk and probability of suicide were evaluated together.
Conclusions
Our research underscores the intricate and multifaceted association between childhood sexual abuse and suicide attempts. Our findings demonstrates that elements such as the intensity and frequency of abuse, coexisting psychiatric conditions like PTSD and depression, borderline personality characteristics, impulsivity, and insufficient familial support substantially elevate suicide risk. Reporting the abuse to official authorities serves as a protective factor, highlighting the significance of early intervention and systemic assistance. These findings highlight the imperative for thorough clinical assessments that encompass not just trauma history but also relevant psychological and environmental aspects to enhance the evaluation and management of suicide risk in sexually abused adolescents. Future longitudinal and multicenter investigations are essential to elucidate causality and formulate targeted therapies.
Footnotes
Acknowledgements
The authors acknowledge that the language editing of the whole article was done by Curie.
Ethical approval and consent to participate
Ethics committee approval was obtained from Necmettin Erbakan University Ethics Committee (2022/4085) and all procedures were in accordance with the Declaration of Helsinki and local laws and regulations. Written and verbal consent was obtained from all participants.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Data availability statement
Data will be made available on request.