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Curr Addict Rep. Author manuscript; available in PMC 2021 March 01.
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Published in final edited form as:

Curr Addict Rep. 2020 March ; 7(1): 76–88. doi:10.1007/s40429-020-00298-9.

Child Sexual Abuse and Compulsive Sexual Behavior: A

Systematic Literature Review
Melissa N. Slavin, PhD1, Arielle A. J. Scoglio, MPH2, Gretchen R. Blycker, MA3,4,5, Marc N.
Potenza, MD, PhD5,6,7,8, Shane W. Kraus, PhD9
1Columbia University, School of Social Work, New York, NY
2Northeastern University, Institute of Health Equity & Social Justice Research, Boston, MA
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3College of Nursing, University of Rhode Island, Kingston, RI

4HäIsosam Therapy, Jamestown, RI
5Yale University School of Medicine, Department of Psychiatry, New Haven, CT
6Yale University Department of Neuroscience and Child Study Center, New Haven, CT
7Connecticut Council on Problem Gambling, New Haven, CT
8Connecticut Mental Health Center, New Haven, CT
9University of Nevada, Las Vegas, Department of Psychology, Las Vegas, NV

Abstract
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Purpose of review: Information on potential risk factors and clinical correlates of compulsive
sexual behavior (CSB) may help inform more effective prevention and treatment measures. Sexual
victimization, specifically, child sexual abuse (CSA), has been associated with CSB.

Recent findings: This systematic review describes 21 studies on the relationship between CSA
and CSB. Most studies identified a significant association between CSA and CSB. However,
variability in measurements, potential differences in links among community versus clinical
samples, relevance of research among college samples, lack of support for gender-related
differences, and the need for more longitudinal designs were identified.

Summary: Research would benefit from more formalized assessments of CSB across different
populations. Prevention efforts should be aimed toward individuals who experienced CSA and/or
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Correspondence concerning this article should be addressed to Melissa N. Slavin, Columbia, University School of Social Work, New
York, NY 10027. Contact: [email protected].
Compliance With Ethical Guidelines
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Conflict of Interest
The authors report that they have no financial conflicts of interest with respect to the content of this manuscript.
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been
accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept
up to date and so may therefore differ from this version.
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other abuse, particularly if they report engaging in risky sexual behavior. Individuals with CSB
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who have experienced sexual abuse may benefit from trauma-focused treatment.

Keywords
compulsive sexual behavior; child sexual abuse

INTRODUCTION
Compulsive sexual behavior (CSB; also termed sexual compulsivity, sexual impulsivity,
hypersexuality, out-of-control sexual behavior, problematic sexual behavior, or sexual
addiction) consists of persistent failure to control intense, recurrent sexual impulses or urges,
resulting in repetitive sexual behavior over an extended period that generates marked distress
or impairment in functioning (Kraus et al., 2018). The sexual behaviors may be considered
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“socially acceptable”, or “normophilic”, including masturbation, pornography use, and sex

with multiple anonymous partners, but they are typically extreme in frequency and/or
intensity in a manner leading to distress or interference with personal, interpersonal, or
vocational pursuits (Kuzma & Black, 2008). When the 11th revision of the International
Classification of Diseases (ICD-11; World Health Organization, 2018) was officially
adopted at the World Health Assembly in May 2019, Compulsive Sexual Behavior Disorder
(CSBD) was included and classified as an impulse-control disorder. This recognition is an
important first step for furthering discussion of compulsive/problematic sexual behaviors/
disorders. Nevertheless, questions remain regarding appropriate categorization of the
disorder, as it shares many underlying features with addiction (Kowalewska et al., 2018;
Kraus, Voon, & Potenza, 2016; Stark, Klucken, Potenza, Brand, & Strahler, 2018). Estimates
of CSB have been reported to range from approximately 3–6% of U.S. adults (Garcia &
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Thibaut, 2010), including 3% of men and 1% of women (Odlaug et al., 2013). However,
“clinically relevant levels of distress and/or impairment associated with difficulty controlling
sexual feelings, urges, and behaviors” was estimated at 8.6% (10.3% of men and 7.0% of
women) in a nationally representative sample of U.S. adults (Dickenson, Gleason, Coleman,
& Miner, 2018). In a separate nationally representative U.S. adult sample, sexual impulsivity
was acknowledged by 14.7% of individuals (18.9% of men and 10.9% of women; Erez,
Pilver, & Potenza, 2014). As such, precise rates of CSB remain unclear (Kraus et al., 2016),
partly due to differences in criteria and measurement (Womack, Hook, Ramos, Davis, &
Penberthy, 2013). CSB is associated with a range of problematic behaviors and outcomes,
including risky sexual behaviors, unwanted pregnancies, sexually transmitted infections
(STIs) including the human immunodeficiency virus (HIV), and experiencing nonsexual
attacks or robberies (Chemezov, Petrova, & Kraus, 2019; Griffee et al., 2012; Kalichman &
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Cain, 2004; Schneider & Irons, 2001).

Greater knowledge of risk factors and clinical correlates of CSB can help develop more
effective prevention and treatment interventions. Sexual victimization, specifically, child
sexual abuse (CSA), affecting approximately 17% of girls and 8% of boys (Putnam, 2003)
has been implicated as one of many potential precursors to CSB (Kafka, 2010; Kuzma &
Black, 2008). The World Health Organization (WHO) and the United States Center for
Disease Control (CDC) each provide definitions of CSA that includes direct contact with a

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child as well as noncontact sexual abuse that may include exploitation, sexual harassment,
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exposing a child to pornography, and filming or photographing a child in a sexual manner

(Leeb, Paulozzi, Melanson, Simon, & Arias, 2008; World Health Organization, 1999). CSA
is a widespread public health problem (Murray, Nguyen, Cohen, 2014) and population-level
estimates indicate that one in ten children will experience sexual abuse before the age of 18
years (Finkelhor, Shattuck, Turner, & Hamby, 2014; Townsend & Rheingold, 2013). CSA
has been linked with many deleterious health outcomes, including posttraumatic stress
disorder (PTSD), suicide, homelessness, impaired functioning, and revictimization in
adulthood (Courtois, 2004; Greene, Neria, & Gross, 2016; Walsh, Blaustein, Knight,
Spinazzola, & van der Kolk, 2007). Sexual abuse is also associated with multiple other
negative outcomes related to sexuality, including an increased risk of sexual perpetration
(Lisak & Beszterczey, 2007), as well as shame, guilt and anxiety during sexual arousal,
decreased sexual desire, dissociation, and orgasm and arousal disorders among men and
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women (Lisak & Beszterczey, 2007; Loeb, Williams, Vargas, Wyatt, & O’Brien, 2002;
Najman, Dunne, Purdie, Boyle, & Coxeter, 2005; Price, 2007; Walker et al., 1999)
Additionally, two major pathways commonly linked to CSA, sexual avoidance and sexual
compulsivity (Aaron, 2012; Colangelo & Keefe-Cooperman, 2015), may co-occur, leading
to a type of sexual ambivalence (Noll, Trickett, & Putnam, 2003; Vaillancourt-Morel et al.,
2015), and these domains may be differentially prominent over the course of one’s life
(Herman & Hirschman, 1981).

Several mechanisms have been proposed to explain the relationship between CSA and later
CSB. Neurologically, early sexual victimization may “blunt” the right hemisphere of the
brain, impairing insight, emotion regulation, and ability for interpersonal connection, all
characteristics associated with CSB (Katehakis, 2009). The traumagenic dynamics model
(Finkelhor & Browne, 1985) asserts that survivors of CSA may develop problematic “sexual
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scripts” that shape their beliefs and guide their decisions regarding sexual behaviors,
influencing subsequent risky sexual behavior (Castro, Ibáñez, Maté, Esteban, and Barrada,
2019). Attachment theories based on the ideas of Bowlby (1969) and Ainsworth, Blehar,
Waters, & Wall (1978) posit that individuals develop internal working models from early
experience with caretakers that are encoded into their concept of self (Alexander, 2005) and
lead to introjection (Sullivan, 1954). Other theorists have suggested that sex might be used
as a means of attempting to take back control lost in childhood due to sexual abuse (Gold &
Heffner, 1998). In addition, some research suggests that a substantial minority of CSA
survivors may engage in frequent sexual encounters as a means of regulating their distress
and coping with trauma-related symptoms (Stappenbeck et al., 2016).

Some of the earliest works examining links between CSA and CSB are reports of sexual
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victimization among individuals in treatment for sexual addiction. For instance, Carnes
(1991) found that 39% of men and 63% of women in treatment for sexual addiction reported
CSA in comparison to 8% of male and 20% of female healthy controls. Carnes &
Delmonico (1996) found that among 290 men and women in treatment for sexual addiction,
78% reported CSA. Descriptive data on 19 men and 21 women seeking treatment in an
outpatient psychiatric clinic for problematic cybersex involvement found that 57.9% of men
and 76.2% of women reported CSA (Schwartz & Southern, 2000). Importantly, research on
CSB samples has also described other types of maltreatment (e.g., physical and emotional

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abuse, neglect) that commonly occur alongside CSA. Ferree (2002) found that 81% of men
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and women in treatment for sexual addiction in their sample reported CSA, 72% physical
abuse, and 97% emotional abuse. These other forms of abuse have also been linked with
negative long-term health outcomes, including sexual difficulties (Meston, Heiman, &
Trapnell, 1999; Schloredt & Heiman, 2003). The combination of multiple forms of abuse in
childhood may predict CSB, rather than CSA alone (Meston et al., 1999; Schloredt &
Heiman, 2003). Thus, in examining the relationship between CSA and CSB, it is critical to
assess for other types of co-occurring maltreatment.

METHOD
Search Strategy and Study Selection
This systematic literature review examined studies that assessed the relationship between
sexual abuse and CSB. First, we queried electronic databases (PsycINFO, PsycARTICLES
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and MEDLINE) for peer-reviewed journal articles published between January 1, 1985, and
June 30, 2019. Search terms consisted of the following combinations of keywords “(“sex*
abuse” OR “sex* trauma” OR sex* assault) AND (“sex* addiction” OR “hypersexuality”
OR “compulsive sex*” OR “sex* preoccupation”).” In Figure 1, we present the study
identification and selection process including abstract and full review of identified studies.
Articles were excluded if they were in a language other than English, or a meta-analysis,
systematic review, or theoretical paper. Additionally, articles were excluded if they only
provided prevalence estimates, but did not perform analyses to determine statistical
significance of associations between CSA and CSB. Lastly, we excluded papers that focused
on the relationship between CSA and risky sexual behaviors that did not include a measure
of sexual preoccupation. Studies met inclusion criteria if they examined the relationship
between CSA and CSB, were an empirical study, and included measures of both CSA and
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CSB. Following full-text reviews by the first author, key data elements were extracted from
studies included in the final review. These elements included details about study design,
population, sample size, CSB and sexual victimization measures, and relevant findings.
Twenty-one studies were included and used in identifying patterns across publications and
gaps of knowledge worthy of further investigation to best inform prevention and treatment
efforts relating to CSB.

RESULTS
Overview of Studies
Table 1 includes a summary of data reviewed and descriptions of individual studies. Most
(15) studies employed a cross-sectional survey design. Other designs included four cross-
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sectional analyses of longitudinal data, one cross-sectional case-control study, and one
longitudinal design. Nine studies involved only males, four involved only females, and eight
included both males and females. Two samples included adolescents and the others
consisted of adults. No samples overlapped. Sample sizes ranged from 80 to 2,450
participants. The most commonly used CSB measure was the Sexual Compulsivity Scale
(SCS; Kalichman & Rompa, 1995), which was used in seven studies, followed by the Sexual
Addiction Screening Test (SAST; Carnes, 1989), used in three studies. CSA was defined and

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assessed in multiple ways with ages ranging from before age 12 to before age 18. Among
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the 21 studies, 17 supported some form of relationship between CSA and CSB. In the four
studies that did not support a significant relationship, specific aspects appeared related (e.g.,
CSB related to other types of abuse or CSA related to impulsive behaviors in general).

Variation in Samples
Studies included in this review involved participants from several distinct populations. Six
studies examined general community participants (Långström & Hanson, 2006; Meyer,
Cohn, Robinson, Muse, & Hughes, 2017; Plant, Plant, & Miller, 2005; Skegg, Nada-Raja,
Dickson, & Paul, 2010; Vaillancourt-Morel et al., 2015; Vaillancourt-Morel et al., 2016),
four involved men who have sex with men (MSM; Blain, Muench, Morgenstern, & Parsons,
2012; Parsons, Grov, & Golub, 2012; Parsons et al., 2017; Parsons, Rendina, Moody,
Ventuneac, & Grov, 2015), three examined incarcerated individuals who committed sexual
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offenses (Davis & Knight, 2019; Kingston, Graham, & Knight, 2017; Marshall & Marshall,
2006), three investigated individuals in treatment or seeking treatment for CSB and/or other
addictions (Chatzittofis et al., 2017; McPherson, Clayton, Wood, Hiskey, & Andrews, 2013;
Opitz, Tsytsarev, & Froh, 2009), two involved individuals with sexual trauma (Estévez,
Ozerinjauregi, Herrero-Fernández, & Jauregui, 2019; Noll et al., 2003), two involved mostly
university students (Griffee et al., 2012; Perera, Reece, Monahan, Billingham, & Finn,
2009), and one examined U.S. military Veterans (Smith et al., 2014).

Among the seven studies examining community samples, all contained both men and
women and each supported a relationship between CSA and CSB. Two community studies
indicated differential relationships among the groups compared. For instance, Langstrom
(2006) found a relationship between CSA and hypersexuality for women but not for men.
Vaillancourt-Morel (2016) found that CSA severity predicted CSB in single individuals,
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CSB and sexual avoidance in cohabitating individuals, and sexual avoidance in married
individuals. Among four studies examining MSM, all but one found a statistically significant
relationship between CSA and CSB (Parsons, Rendina, Moody, Ventuneac, & Grov, 2015).
Parsons et al. (2015) organized participants into three groups—negative on two CSB scales,
positive on one, and positive on both. Although there was a trend for CSA history among
individuals positive on both scales than neither, the groups did not significantly differ.

The three studies investigating incarcerated individuals who committed sexual offenses
involved samples consisting only of males, and one focused on juvenile participants. All
indicated some form of a significant relationship between CSA and CSB, and one study
indicated a group difference. Marshall (2006) found participants with scores indicating
sexual addiction across groups did not significantly differ in CSA history. Nevertheless,
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incarcerated individuals with sexual addiction were significantly more likely to have
experienced CSA than non-incarcerated counterparts. Among the three studies of individuals
in treatment or seeking treatment for CSB and/or other addictions, one involved all men, one
all women, and one contained both sexes. The study of women (Opitz et al., 2009) found a
significant correlation between CSA and CSB, but other variables better accounted for CSB.
The two other studies did not support a significant correlation between CSA and CSB,
although there were links between CSB and other forms of abuse and negative family

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dynamics. Among the two studies on individuals with sexual trauma, both focused on
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women, including one sample that queried sexual abuse among children and adolescents.
The study of adults did not support a significant relationship, although CSA was linked to
impulsive behaviors in general (Estévez et al., 2019). Among the two studies of mostly
students, one sample involved all women, and the other involved both men and women. Both
found a significant link between CSA and CSB. Lastly, the veteran sample consisted of all
men and found a significant association between CSA and CSB (Smith et al., 2014).

Variability in Measurement
The 21 studies varied in measurements of CSA and CSB. Definitions of CSA included
contact and sometimes non-contact sexual incidents using a range of age cut-points from
below age 18 (Blain, Muench, Morgenstern, & Parsons, 2012; Långström & Hanson, 2006;
Meyer, Cohn, Robinson, Muse, & Hughes, 2017) to below age 12 (Perera et al., 2009).
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Additionally, there were different versions of the word “contact”, with some researchers
defining only genital contact as CSA (Skegg et al., 2010). Some studies examined CSA as
dichotomous and did not define the term specifically where others examined severity of
CSA by variables such as chronicity, characteristics of the abuse, and relationship to the
perpetrator. Lastly, some findings indicate inclusion of a broader range of early sexual
experiences that may influence the development of problematic sexual behaviors, including
early exposure to pornography (McPherson et al., 2013).

There were also differences in measurement of CSB (see Table 1). Several studies used
multiple scales (either previously existing or created specifically for the study) to ensure
measurement of different aspects of CSB. Some research examined CSB on a spectrum,
while others examined it as dichotomous variable determined by whether individuals met a
certain score on a given scale. Among the seven community samples, one study emphasized
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the frequency of sexual behavior (Långström & Hanson, 2006) while others assessed self-
reported dyscontrol (Skegg et al., 2010) or interference with life activities (Plant et al.,
2005). Among the three studies of individuals seeking treatment for CSB, one (Chatzittofis
et al., 2017) examined hypersexual disorder according to Kafka’s (2010) proposed
diagnostic criteria.

DISCUSSION
This review synthesized and described research related to the relationship between CSA and
CSB. To our knowledge, no systematic review or meta-analysis has focused exclusively on
this association. Our goals were to review study designs, measures, samples, analyses, and
findings to assess patterns and gaps of knowledge. We aimed to inform future research and
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foster insight into prevention and treatment of CSB. We found that most studies supported a
relationship between CSA and CSB, though additional research including more diverse
samples (e.g., women, ethnic and sexual minorities) are needed to fully examine these
associations. Nevertheless, in some studies, other potential risk factors including different
types of childhood maltreatment accounted for more variance in CSB or had a cumulative
impact on CSB along with CSA. The findings establishing a link between CSA and CSB are
consistent with studies indicating positive relationships between CSA and risky sexual

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behaviors (Abajobir, Kisely, Maravilla, Williams, & Najman, 2017; Homma, Wang, Saewyc,
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& Kishor, 2012). Additionally, a 2018 meta-analysis of MSM examining CSA and other
factors as syndemic predictors of sexual compulsivity found a statistically significant small
effect size between CSA and CSB (Rooney, Tulloch, & Blashill, 2018). The following
discussion will focus on pertinent topics noted when reviewing these 21 studies: potential
differences in links between CSA and CSB among community versus clinical samples and
factors that may influence such differences, relevance of research among college samples,
lack of support for biological sex or gender-related differences in the relationships between
CSA and CSB, and the need for more longitudinal research.

In this review, most research was conducted on community samples (7), and these studies
supported some form of relationship between CSA and CSB. Only three of the studies
examined individuals in treatment or seeking treatment for CSB and/or other addictions. As
stated above, two of these studies did not find a significant association, and one found a
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correlation, but it was better accounted for by other variables. Due to the scarce amount of
research on this topic and differences across designs and measures, it is difficult to compare
clinical and community samples. These findings suggest the importance of considering
factors that may account for more of the variance in predicting CSB among clinical
populations, such as co-occurring abuse, psychopathology, stress responsiveness, emotional
regulation, and behavioral control, among others. Additionally, future research should ensure
that CSB is assessed comprehensively, by examining ICD-11 inclusionary criteria (including
distress or impairment) and how they relate to sexual behaviors. Research that merely
examines distress or perceived dyscontrol associated with sexual behavior may not actually
be assessing CSB, in that individuals, particularly those who have experienced CSA, may
have a negative sexual self-concept (Lacelle, Hébert, Lavoie, Vitaro, & Tremblay, 2012) that
may influence their perceptions of their sexual behavior. For instance, in a study of 383
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college women (Fromuth, 1986), a history of CSA was associated with women describing
themselves as “promiscuous.” Nevertheless, there was no relationship between CSA and age
of first (consensual) sexual intercourse, frequency of sexual behavior, number of consensual
partners, or sexual desires. In another community sample of 669 MSM in New York City,
men reporting sexual compulsivity were twice as likely as other men to have experienced
CSA (Parsons et al., 2012). Interestingly though, individuals who reported CSA did not have
differences in the number of sexual partners in the last 90 days compared to non-abused
counterparts. Thus, individuals with CSA may reported higher distress and impairment,
although their actual sexual behavior may be similar to those who denied CSA. However,
aspects of the sexual encounters (e.g., the extent to which the encounters may have involved
blatant or nuanced boundary violations) warrant consideration in these relationships. Having
an accurate conceptualization of the frequency of sexual behavior, in addition to distress,
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clinical impairment and other factors associated with it, could allow for more targeted
treatment approaches. For instance, individuals with a negative sexual self-concept may
benefit from interventions focused on building self-esteem, a positive sexual self-schema,
greater body awareness and connection, or assertiveness rather than managing urges
associated with CSB (Badgley, R., Allard, H., McCormick, N., 1984; Carvalheira, Price, &
Neves, 2017; Rellini & Meston, 2011).

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Additionally, only two studies focused on college students. A larger body of work has
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examined relationships between CSA and risky sexual behaviors among this population
(e.g., Fromuth, 1986; Krahé & Berger, 2017; Meston et al., 1999). For instance, Meston,
Heiman, & Trapnell (1999) found that among 1032 undergraduate students, after adjusting
for physical and emotional abuse, neglect, and demographic variables, frequency of sexual
abuse among young women was positively related to more permissive sexual attitudes and
fantasies, frequency of masturbation, unrestricted sexual behavior, and frequency of
intercourse. Because college students may be at elevated risk for developing sexual problems
due to easy access to multiple sexual partners and openness to various sexual experiences
(Dodge, Reece, Cole, & Sandfort, 2004), prevention efforts should be aimed toward students
with CSA histories reporting risky sexual behaviors or CSB, including problematic
pornography use.

Third, significant findings in this review did not appear to be influenced by an individual’s
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biological sex or self-reported gender. In the two studies that did indicate gende-rrelated
differences, one found that CSA predicted hypersexuality only in women (Långström &
Hanson, 2006) and the other only in men (Skegg et al., 2010). Some researchers have
postulated that gender-related differences in CSB exist for individuals with CSA histories,
with more men experiencing CSB and more women experiencing sexual avoidance (Aaron,
2012). More research is needed to further examine these relationships and consider potential
confounds. For instance, CSA may lead to different behaviors in men and women in part
based on traditional gender norms and socially acceptable gendered behaviors. Additionally,
some research has found that women are more likely than men to report penetrative abuse
and abuse by a family member (Najman et al., 2005; Rind & Tromovitch, 1997). As
described by Noll et al. (2003), abuse perpetuated by one’s biological father is often
conducted in the absence of physical force or violence, which may prevent the child from
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understanding the very real power differential that exists between the child and adult. This
misperception may lead the child to engage in more self-blame than someone whom can
more clearly decipher blame, which may contribute to confusion about issues concerning
sexual arousal, leading to sexual ambivalence. Additionally, some research has hypothesized
that any gender differences may be an artifact of more studies having been conducted on
CSB among men (Blain et al., 2012;. Forouzan & Van Gijseghem, 2005; Parsons et al.,
2012).

Lastly, the study design most often used for research studies was cross-sectional. More
developmental longitudinal outcome studies are needed to examine how CSA may impact
children, adolescents, and adults’ sexual functioning over time and influence the
manifestation of particular behaviors in adulthood (e.g., problematic pornography use,
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engagement in frequent anonymous sex). For instance, individuals abused in adolescence

may be more likely to respond by withdrawing while preschoolers and younger children
may display more externalizing sexualized behavior (Kendall-Tackett, Williams, &
Finkelhor, 1993). Consistently, men who experienced sexual abuse as adolescents or adults
appeared to experience more erectile dysfunction than other men (Tucker, Harris, Simpson,
& McKinlay, 2004). Large, contemporary, longitudinal, and nationally representative studies
of U.S. adults can help elucidate many of the current questions that surround the links
between CSA and CSB.

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Limitations
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The studies that were reviewed included samples that were racially and ethnically diverse.
However, specific considerations relating to race and ethnicity (including discrimination and
stress that may be experienced disproportionately among specific racial/ethnic groups)
warrant additional investigation in studies of CSA and CSB. Furthermore, a number of
measurements and scoring thresholds were used to assess CSB, complicating comparisons
across studies. Several studies created scales to assess CSB, which may limit
generalizability. As only three studies specifically examined samples reporting symptoms of
CSB and/or other addictions, it is unclear how many people met full diagnostic criteria for
CSBD. Similarly, assessment of CSA also varied, consistent with findings in another recent
review (Scoglio, Kraus, Saczynski, Jooma, & Molnar, 2019), complicating cross-study
comparisons. Relatedly, not all studies considered other types of co-occurring maltreatment.
Studies that accounted for other abuse often showed these variables to explain major
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variance on CSB or have a cumulative impact in addition to CSA. Additionally, it is

important to consider possible differences in findings across distinct populations. For
instance, given that three studies focused on sex-offender populations, each with differing
characteristics (adolescents in inpatient treatment, adults either incarcerated or committed to
treatment, and incarcerated adults), these findings may differ from studies of non-sex-
offending participants. For example, differentiating coercive sexual behaviors (that may
involve exhibitionism, voyeurism, frotteurism, pedophilia, and sexual assault) from
noncoercive ones may be important for diagnostic and treatment purposes and have legal
implications. Lastly, as the most prevalent design was a cross-sectional, retrospective
assessment of the impact of CSA on adult sexuality, causal conclusions on how sexual abuse
may differentially impact people over time are limited.
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Conclusions and Future Directions

CSA is a widespread public health problem and has been implicated as one of many
potential precursors to CSB. This review synthesized and described research on the
relationship between these two variables. Most studies supported a significant association;
patterns and limitations across findings should be considered when conducting future
research and informing prevention and treatment measures. In Table 2, we summarize
knowledge gaps and recommend future directions in research and practice. More formalized
assessments of sexual behavior and related distress and impairment could help determine
whether individuals meet diagnostic criteria for CSBD to better facilitate comparisons across
studies (Kraus et al., 2018). Additionally, thorough assessment of CSA characteristics can
allow for both dichotomous and continuous measurements of CSA to assist in more nuanced
analyses. Given the prevalence of the use of digital devices and engagement in digital media,
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assessment of sexual abuse should also consider image-based sexual abuse, non-consensual
image sharing, and sexting behaviors (DeKeseredy & Schwartz, 2016; Johnson, M., Mishna,
F., Okumu, M., Daciuk, 2018) Other mediators and moderators of the relationship between
CSA and CSB should also be considered, such as co-occurring types of maltreatment,
personality and psychiatric characteristics, and gender roles. Furthermore, large,
contemporary, and nationally representative studies of U.S. adults are needed that include
diverse groups, such as women, sexual minorities, racial/ethnic minorities, disadvantaged
sociodemographic groups, and individuals with disabilities. Research that considers gender

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beyond binary designations should be conducted to understand relationships between

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gender, CSA and CSB. Longitudinal studies using a cohort design could help assess the
trajectory of sexually related responses (i.e., sexual avoidance, compulsivity, and
ambivalence) across the life-span. Prevention efforts should be aimed toward individuals
who have experienced CSA and/or other types of abuse, particularly if they report engaging
in risky sexual behavior in young adulthood. Information on warning signs of CSB should
be distributed at sexual abuse treatment centers and online support groups. In treatment
settings, thorough trauma-informed assessments are indicated to help identify CSA and
other related exposures. Individuals with CSB who have experienced sexual abuse may
benefit from trauma-focused treatments that include education about the impacts of abuse
and focus on developing healthy sexual scripts. CSB can have multiple detrimental impacts
on daily life. Understanding potential risk factors, such as sexual abuse, may permit more
targeted and effective methods of prevention and treatment.
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Acknowledgements:
Research reported in this publication was supported by the National Institute on Drug Abuse of the National
Institutes of Health under Award Number T32DA037801. The content is solely the responsibility of the authors and
does not necessarily represent the official views of the National Institutes of Health.

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Figure 1.
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Table 1.

Summary of Study Characteristics and Findings

First Author, Study Design Study Population Sample Size CSB Measure Sexual Trauma Measure Relevant Findings
Year
Slavin et al.

Blain et al., 2012 Cross-sectional Gay and bisexual men 182 men 1 2 Men who endorsed CSA reported
interview and reporting CSB symptoms in CSBI CTQ : CSA subscale significantly higher CSB than those who
survey NYC area assessing unwanted touching denied CSA. CSA severity statistically
to more severe forms of predicted CSB above child physical and
sexual abuse before age 18 emotional abuse, depression, anxiety, and
PTSD.

Chatzittofis et Cross-sectional Male patients with 107 men (67 Patients met four or 4 Patients who met criteria for HD did not
al., 2017 case control hypersexual disorder (HD) patients and 40 more of five of CTQ-SF (Swedish endorse higher scores on CSA subscale
and healthy male volunteers healthy 3 5 compared to healthy volunteers, although
Kafka’s proposed version ): CSA subscale
volunteers) they did endorse higher CTQ scores in
diagnostic criteria general. HD patients with (versus without)
suicide attempts reported higher scores on
the CSA subscale.

Davis et al., Cross-sectional Male juveniles who had 307 juvenile Three scales derived Four scales to assess CSA CSA and male caregiver psychological
2019 survey sexually offended sampled males for current study to severity before age 17: abuse were significantly associated with
from inpatient treatment estimate latent trait of number of sexual abusers, “normophilic excessive sexualization.”
centers “normophilic excessive frequency of sexual abuse,
sexualization”: degree of penetration, and
hypersexuality, sexual degree of force
compulsivity, and
sexual preoccupation

Estévez et al., Cross-sectional Spanish women who had 182 women MULTICAGE 3 7 CSA was not significantly correlated with
2019 survey suffered CSA mostly referred 6 CTQ-SF (Spanish version ) sexual addiction, although it was related to
by associations for treatment CAD-4 impulsive behaviors in general.
of childhood abuse and
maltreatment

Griffee et al., Cross-sectional Female undergraduate and 1502 women Hypersexuality and 16 statistical predictors Mean scores for Hypersexuality and Risky
2012 survey graduate college students in Risky Sexual Behavior involving sexual behaviors Sexual Behavior Scale and both of its
addition to university faculty Scale (created for coerced by male partners and subscales were significantly higher among
and staff and individuals from current study) 14 predictors involving those with CSA than those without.

Curr Addict Rep. Author manuscript; available in PMC 2021 March 01.
the same general population sexual behaviors coerced by However, none of the 30 CSA items were
female partners -Excluded among most powerful of 101
women who endorsed father- developmental statistical predictors of
daughter incest CSB.

Kingston et al., Cross-sectional Adult male sexual offenders 529 men Three scales derived Assessed sexual abuse before Significant correlations between different
2017 survey who were either incarcerated for current study to age 17 by degree of types of CSA and hypersexuality. Dose-
or committed to treatment at measure latent trait of penetration, amount of force, response relationship between cumulative
time of assessment hypersexuality: sexual frequency, and exposure to effects of sexual, emotional, physical
compulsivity, sexual pornography prior to age 13 abuse, and neglect with hypersexuality.
preoccupation, and
sexual drive.

Långström et al., Cross-sectional Swedish adult men and 2,450 adults Upper 10% of 1 item: “Were you ever Sexual abuse both before and after age 18
2006 survey and women from a 1996 national (1,279 men, 1,171 population on sexual involved in a sexual activity differentiated between low and high
interviews women) behaviors including without wanting it yourself?” hypersexuality groups for women, with
Page 17
 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

First Author, Study Design Study Population Sample Size CSB Measure Sexual Trauma Measure Relevant Findings
Year
survey of sexuality and health number of sexual Separate variable if abuse sexual abuse associated with high
in Sweden partners, frequency of happened before age 18 hypersexuality. Only sexual abuse after 18
pornography use, differentiated between these groups for
masturbation, etc. men.
Slavin et al.

Marshall et al., Cross-sectional Adult men incarcerated for 80 men (40 8 8 Participants with scores indicating sexual
2006 survey sexual offenses compared to incarcerated men SAST 1 item from SAST : Were addiction across groups did not
community comparisons in and 40 you sexually abused as a significantly differ in CSA. Incarcerated
Canada community men) child or adolescent? men with sex addiction were more likely
to have experienced CSA than non-
incarcerated men.

McPherson et Cross-sectional Adult users of support 348 adults (195 9 10 CSA did not correlate with CSB, although
al., 2013 survey websites relating to drug, women, 153 men) SCS ETISF SA subscale childhood emotional abuse, youth
alcohol, gambling, and sexual assessing unwanted touching exposure to pornography, and parental sex
addictions to forced sex before age 18. addiction were statistical predictors.
Five additional items
assessing exposure to sexual
material before age 18

Meyer et al., Cross-sectional Geographically diverse U.S. 812 adults (504 8 1 item: “Before the age of CSA, attachment anxiety, and emotion
2017 survey adults women, 308 men) SAST 18, were you sexually regulation were statistical predictors of
abused?” CSB.
Noll et al., 2003 10-year Girls with history of SA 166 girls (77 girls Scale derived for Child Protective Services Women who endorsed CSA 10 years
prospective study between ages 6–16, compared with SA history current study: substantiated report of sexual earlier were more preoccupied with sex,
of survey data to non-abused girls of same and 89 non-abuse 11 abuse by a family member younger at first voluntary intercourse, and,
age group and assessed 10 comparisons) SAAQ : sexual involving genital contact/ more likely to have been teen mothers
years later preoccupation subscale penetration before age 16 than comparison participants, adjusting for
mental health and demographics. Less
severe forms of abuse associated with
higher sexual preoccupation.
Opitz et al., 2009 Cross-sectional Women with self-identified 99 women 12 2 Although there was a significant positive
survey sexual addiction; 56.6% of W-SAST CTQ correlation between sex addiction and
whom participated in a CSA, only depression, family adaptability,
treatment program for sexual and drug abuse statistically predicted
addiction sexual addiction in a regression analysis.

Parsons et al., Cross-sectional Men who have sex with men 669 men 9 Two items assessing if Men with CSB were 2.2 times as likely as
SCS

Curr Addict Rep. Author manuscript; available in PMC 2021 March 01.
2012 survey (MSM) in New York city participants reported ever other men to have experienced CSA.
taken from the Sex and Love been forced or frightened by Among MSM with high levels of polydrug
study someone into doing use, depression, and partner violence,
something sexually before CSA did not relate to CSB.
age 16 or with partner at
least 10 years older

Parsons et al., Cross-sectional “Highly sexually active” gay 368 men 9 13 See Parsons, 2012 Participants were organized into three
2015 analysis of and bisexual men in NYC SCS HDSI requirement groups—negative on both SCS and HDSI,
longitudinal taken from the Pillow Talk positive on the SCS only, and positive on
cohort survey study both. Although there was a trend for
and interview greater CSA among both SCS and HDSI
data than neither, the groups did not
significantly differ.
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First Author, Study Design Study Population Sample Size CSB Measure Sexual Trauma Measure Relevant Findings
Year
Parsons et al., Cross-sectional HIV-negative gay and bisexual 1071 men 9 See Parsons, 2012 Adjusting for demographics and partner
2017 analysis of men from the One Thousand SCS requirement violence, polydrug use and depression,
longitudinal Strong cohort CSA was associated with 1.87 times the
cohort survey odds of reporting CSB.
Slavin et al.

data

Perera et al., Cross-sectional College students 539 adults (166 9 4-item scale by Aalsma et al. CSA and poor family environmental
2009 survey men and 373 SCS Sexual Sensation 15 conditions statistically predicted CSB and
women) 14 examining severity of sexual sensation-seeking, with CSA
Seeking Scale CSA before age 12 explaining the most variance for both.

Plant et al., 2005 Cross-sectional UK men and women drawn 2,027 adults 1 item: “During the 3 items taken from CSA was significantly associated with
survey and 16 (1,052 women, last 12 months has 16 problematic sexual activity in both men
interview from the GENACIS 975 men) sexual activity GENASIS assessing CSA and women.
interview schedule interfered with your before age 16
everyday life?”

Skegg et al., Cross-sectional Men and women (aged 32) in 940 adults (474 1 item: “In the past 12 1 item: “Before you turned Men who defined their sexual behavior as
2010 analysis of New Zealand from the men and 466 months, have you had 16, did someone touch your “out of control” were significantly more
longitudinal Dunedin Multidisciplinary women) sexual fantasies, urges genitals when you didn’t likely than those who denied these
cohort survey Health and Development or behavior that you want them to?” behaviors to endorse CSA queried 6 years
data Study felt were out of earlier (23% versus 6.1%). There was no
control?” significant difference among females.

Smith et al., Longitudinal Male Veterans of Operations 258 men CSB portion (2 items) Single item at baseline taken Individuals with a history of CSA had
2014 interviews at Iraqi Freedom, Enduring 17 18 more than 3 times greater odds of CSB
baseline, 3, and 6 Freedom, or New Dawn from MIDI from the DRRI assessing than did those without such trauma,
months unwanted sexual activity adjusting for other childhood abuse and
before age 18 mental health factors.

Vaillancourt- Cross-sectional French-Canadian adults 686 adults (529 French version of the 12-item measure to For both men and women, CSA was
Morel et al., survey currently involved in a close women, 157 men) 9 determine CSA before age positively associated with sexual
2015 relationship SCS 16. Severity determined by compulsivity and sexual avoidance.
chronicity, type of act,
relationship with perpetrator

Vaillancourt- Cross-sectional French-speaking Canadian 1033 adults (760 French version of the 10-item measure to CSA severity was associated with higher
Morel et al., survey adults from the community women, 273 men) 9 determine CSA before age sexual compulsivity in single individuals,
2016 and universities SCS 16. Specifiers: with or higher sexual avoidance and compulsivity

Curr Addict Rep. Author manuscript; available in PMC 2021 March 01.
without presence of physical in cohabiting individuals, and sexual
force or violence, and with or avoidance in married individuals.
without “consent” of child

Note.
1
Compulsive Sexual Behavior Inventory (CSBI), Coleman, Miner, Ohlerking, & Raymond, 2001
2
Childhood Trauma Questionnaire (CTQ), Bernstein & Fink, 1998
3
Kafka, 2010
4
Childhood Trauma Questionnaire- Short Form (CTQ-SF), Bernstein et al., 2003
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5
Gerdner & Allgulander, 2009
6
MULTICAGE CAD-4, Pedrero Pérez et al., 2007
7
Hernandez et al., 2013
8
Sexual Addiction Screening Test (SAST), Carnes, 1989
Slavin et al.

9
Sexual Compulsivity Scale (SCS), Kalichman & Rompa, 1995
10
Early Trauma Inventory Self Report-Short Form (ETISF), Bremner, Bolus, & Mayer, 2007
11
Sexual Activities and Attitudes Questionnaire (SAAQ), Noll, Trickett, & Putnam, 2003
12
Women’s Sexual Addiction Screening Test (W-SAST), Carnes & O’Hara, 1994
13
Hypersexual Disorder Screening Inventory (HDSI), Kafka, 2010
14
Sexual Sensation Seeking Scale, Kalichman et al., 1994
15
Aalsma, Zimet, Fortenberry, Blythe, & Orr, 2002
16
Gender, Alcohol and Culture: An International Study, World Health Organization, 2003
17
Minnesota Impulsive Disorder Inventory (MIDI), Grant, 2008
18
Deployment Risk and Resilience Inventory (DRRI), King, King, Vogt, Knight, & Samper, 2006.

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Table 2.

Knowledge gaps relating to CSB and CSA and approaches for addressing the gaps.

Current Gaps Future Directions

Slavin et al.

Assessment of CSB Assess CSBD by ICD-11 inclusionary criteria (including distress or impairment) and how these symptoms relate to sexual behaviors. Develop standardized screening
assessment to reflect this definition and update language according to new developments in conceptualization (e.g., impulse-control vs. addictive disorder)

Assessment of CSA Use thorough measurement tools for CSA, including assessments of age of onset of abuse, and characteristics of the abuse/perpetrator. Assess CSA both dichotomously and
continuously for more nuanced analyses of CSA and CSB.

Mediators and Examine mediators and moderators of the relationship between CSA and CSB, including CSA characteristics, co-occurring types of maltreatment, personality and psychiatric
Moderators characteristics, race/ethnicity and gender roles. Consider these characteristics in comparisons of links across sample types, including clinical, community, and college settings.

Prevalence Data Conduct large, contemporary, and nationally representative studies of U.S. adults. Examine links between CSA and CSB among diverse groups such as women, sexual
minorities, different racial/ethnic groups, disadvantaged sociodemographic populations, and individuals with disabilities.

Longitudinal designs Conduct naturalistic longitudinal studies using a cohort design to assess the trajectory of sexually related responses (i.e., sexual avoidance, compulsivity, and ambivalence)
across the life-span.

Prevention Prevention efforts should be aimed toward individuals who have experienced CSA and/or other types of maltreatment, particularly if they report engaging in risky sexual
behavior. Information on warning signs of CSB should be distributed in health care settings, including sexual abuse treatment centers, and online support groups. Public
campaigns aimed at reducing stigma and shame are recommended.

Treatment Clinical interviews examining CSB should assess for CSA and other types of abuse. Trauma-informed psychotherapy and pharmacotherapy may help individuals understand the
impacts of abuse on problematic sexual scripts and develop new patterns of behavior. Expansion of treatments to address CSB and CSA-related sequelae are warranted as CSA
and CSB often co-occur with psychiatric disorders.

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