The Impact of Childhood Sexual Abuse on Adult Female Sexual Function and Sexual Distress: A Systematic Review and Meta-Analysis

ABSTRACT

Objective:

In this study, it was aimed to examine the impacts of exposure to childhood sexual abuse (CSA) on women’s sexual function and sexual distress.

Method:

In this systematic review and meta-analysis study, eight international (EBSCO, Psyc-Info, Proquest, PubMed, Science Direct, Scopus, Ovid, Web of Science) and two national electronic databases (Dergipark and Thesis Database of the Turkish Council of Higher Education) were searched. Studies reporting outcomes of sexual function and sexual distress in women with and without a history of CSA were included. The data were synthesized by meta-analysis and narrative methods.

Results:

Two dissertations and five research articles published between 2010 and 2021 were included in the study. In some studies that were not included in the meta-analysis, it was reported that there was no difference in the prevalence of sexual dysfunction, and sexual satisfaction in women with and without a history of CSA. Meta-analysis results demonstrated lower sexual function (sexual arousal, MD: -0.83, p<0.001; sexual desire, MD: -0.55, p<0.001; lubrication, MD: -0.78, p<0.01; pain, MD: -0.52, p<0.001) and more sexual distress (SMD: -0.79, p<0.05) in women with CSA history.

Conclusion:

This study showed that CSA negatively affects female sexual function and increases sexual distress. Healthcare professionals should be aware that women with a CSA history may have worse sexual functions and more sexual distress. More research is needed on the role of CSA in the etiology of sexual function problems and its possible mechanisms of action.

INTRODUCTION

Childhood sexual abuse (CSA) is generally defined as forcing or persuading a child or young person under the age of 18 to participate in contact (such as touching genital organs or penetrating) or non-contact (such as exhibitionism, watching pornography) sexual acts (Fisher et al. 2017). CSA, a global problem, affects the physical and mental health of victims throughout their lives (World Health Organization 2006). Studies have found that the prevalence of CSA worldwide varies between 8-31% in women and 3-17% in men (Barth et al. 2013). Systematic reviews and meta-analysis studies have indicated that CSA victims are at risk for various physical and psychological problems (Hailes et al. 2019). These risks are schizophrenia, post-traumatic stress disorder, substance use, increase in chronic pain complaints, obesity, and recurrent sexual victimization (Hailes et al. 2019, Irish et al. 2010, Maniglio 2009). In addition, although the underlying mechanisms are not yet fully understood, it is reported that CSA has a high risk of adversely affecting sexual health (Kilimnik et al. 2018, Lacelle et al. 2012, Pulverman et al. 2018, Seehuus et al. 2015). CSA affects sexual health more than other childhood traumas in adulthood, since it usually occurs in relationships with which the child establishes close bonds, abuses the child’s trust, and includes sexual acts (Bigras et al. 2021).

Sexual function is the individual’s ability to respond to or enjoy sexuality (Seehuus et al. 2015). Sexual dysfunction is considered in the presence of a problem (such as orgasm disorder) that causes personal and/or interpersonal distress in a sexual function-related dimension (such as sexual desire, sexual arousal, and sexual satisfaction) (Basson et al. 2010, Bigras et al. 2021).

As a mental disorder category, the International Classification of Diseases and Related Health Problems (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are often used to diagnose female sexual dysfunctions (ICD-11 for Mortality and Morbidity Statistics 2022, IsHak and Tobia 2013). In both DSM-5 and ICD-11, sexual dysfunction must be associated with a clinically evident distress in order to establish the diagnosis of sexual dysfunction (ICD-11 for Mortality and Morbidity Statistics 2022, IsHak and Tobia 2013). In this context, sexual distress, which refers to feelings such as frustration and anxiety related to the sexual act, is considered an important component of sexual dysfunction (Santos-Iglesias et al. 2018).

Individuals with a history of CSA have more negative cognitive and affective problems related to sexuality, which may lead to negative sexual health outcomes (Pulverman et al. 2018). In the literature, it is stated that CSA may be associated with sexual dysfunction, decreased sexual desire and satisfaction, and risky sexual behaviors (Kilimnik et al. 2018, Lacelle et al. 2012, Pulverman et al. 2018, Rellini 2008). Some studies have reported that the risk of contracting a sexually transmitted disease increases due to reasons such as the early onset of voluntary sexual intercourse, increase in the number of sexual partners and unprotected sexual intercourse, and the use of drugs or alcohol during sexual intercourse after CSA (Abajobir et al. 2017). A recent study suggested that CSA is not related to all areas of sexuality, contrary to what was predicted (Bigras et al. 2021). Although CSA is strongly associated with increased sexual dysfunction, sexual functions have not been adequately investigated in individuals with a history of CSA. In addition, the study has stated that the wide variety and methodological differences in the definition of CSA lead to inconsistent and complex results (Bigras et al. 2021, Gewirtz-Meydan and Lahav 2020b, Kilimnik et al. 2018, Lacelle et al. 2012). For this reason, healthcare professionals may have difficulty in accessing credible information about sexual problems they frequently encounter (Bigras et al. 2021).

Sexual function is an important determinant of an individual’s quality of life (Carreiro et al. 2016, Flynn et al. 2016). Evaluation of the effect of CSA on sexual function and sexual distress may be beneficial in determining the ways of increasing the quality of life of individuals who have been abused (Carreiro et al. 2016). In addition, it is recommended to confirm the negative health outcomes caused by CSA with quality studies for planning post-abuse health services (Hailes et al. 2019).

In the literature, the effect of CSA on sexual health outcomes has been investigated relatively more in women than in men (Bigras et al. 2021, Gewirtz-Meydan and Opuda 2022). On the other hand, there are no recent studies that systematically reviewed and synthesized the results of studies evaluating the effect of CSA on female sexual function and sexual distress. Studies in the nature of traditional literature reviews reported the results of previous studies (Kilimnik et al. 2018, Pulverman et al. 2018), and in some parts of these studies, the methodological differences of existing studies were discussed. In a systematic review study dealing with some results related to sexual well-being in men and women, CSA and sexual functions were found to be associated in individuals with psychiatric problems and therefore high potential for sexual problems, and adolescents (Bigras et al. 2021). In addition, there are systematic reviews and meta-analysis studies that address the relationship between gynecological diseases, including sexual dysfunction and a history of sexual assault in women (Hassam et al. 2020). However, considering sexual assault in adulthood and childhood together in these studies makes it difficult to understand the effects of CSA on sexual function. The purpose of this systematic review and meta-analysis is to determine the effect of CSA on female sexual function and sexual distress, based on the above-mentioned information. The questions aimed to be answered in the study are as follows;

1. What is the effect of CSA exposure on sexual function of adult women?

2. What is the effect of CSA exposure on sexual distress in adult women?

3. What is the effect of CSA exposure on the prevalence of sexual dysfunction in adult women?

METHOD

This study was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA) Checklist (Moher et al. 2009). Before starting, the study protocol was recorded in the PROSPERO database (CRD42021237119). In order to reduce the risk of possible bias in this study, literature review, study selection, data extraction, and quality assessment of the included studies were performed independently by the first and third researchers, and all these processes were checked by the second researcher. In addition, in order to carry out this study in an appropriate manner and with good quality, pilot studies were carried out with online sessions attended by all researchers, for reviewing, study selection, data extraction and study quality assessment. When there was any difference of opinion among the researchers, the issue was discussed, and consensus was reached in an online meeting attended by all researchers.

Inclusion and Exclusion Criteria

Original research articles and theses published in Turkish or English, which reported the main results on sexual function and sexual distress in women over 18 years of age with and without a history of CSA, were included in this study. Since previous studies on the subject did not include studies published in the last ten years (Kilimnik et al. 2018, Pulverman et al. 2018), this study was limited to studies conducted between 2010-2021.

The studies eligible for this systematic review and meta-analysis conformed to the following PECOS components;

Participant (P): Adult women over 18 years old

Exposure (E): History of CSA

Comparison (C): No history of CSA

Outcomes (O): Sexual arousal, physiological and subjective sexual response to sexual stimuli, sexual desire, lubrication, orgasm, pain, sexual dysfunction, sexual satisfaction, and sexual distress

Study Design (S): Cross-sectional, experimental, or quasi-experimental studies that provide an opportunity to compare results in women with and without CSA

Qualitative studies and letters to the editor, case reports, systematic reviews, and traditional literature reviews were excluded from this study. Since it is known that sexual difficulties increase in high-risk samples (adolescents, alcohol abusers, patient groups diagnosed with posttraumatic stress disorder) (Bigras et al. 2021), studies conducted with these sample groups were excluded. Studies that did not define CSA separately from other trauma types, did not report male and female participant outcomes by gender, and did not examine the sexual health outcomes considered in this study were excluded. It was planned to include studies that evaluated sexual function and sexual distress outcomes with a scale and/or clinical interview. In studies that met PECOS criteria and were included in this study, outcome variables were evaluated with a scale.

Literature Review

In this study, the literature review was carried out between March 2021 and March 2022. Research articles were sought through EBSCO, Psyc-Info, Proquest, PubMed, Science Direct, Scopus, Ovid, Web of Science and Dergipark. “EBSCO Open Dissertations” and “ProQuest Dissertation” were used to screen international theses, and “The Council of Higher Education National Theses Center” was used to screen national theses. The review was limited to studies published in Turkish and English between 2010 and 2021. In the review, the keywords “child sexual abuse, child molestation, sexual violence, sexual health, sexual (dys)function, sexual satisfaction, sexual distress, and abused women” in accordance with the Medical Subject Headings (MeSH) to access studies in English were used. The keywords “çocuk, ergen, cinsel istismar, cinsel işlev, cinsel sıkıntı, cinsel memnuniyet, and cinsel işlev bozukluğu” were used when searching national databases. In order to reach additional studies, the reference lists of the literature reviews on CSA and women sexual function, which were obtained as a result of the database search, were examined.

Study Selection

All studies obtained from databases were uploaded to a free computer application called Rayyan (Ouzzani et al. 2016). Duplicate studies were removed from the reviews using this application. Then, two researchers, blinded to each other’s selection decisions through the application, selected the studies to be examined according to the title and abstract text. After the selection process was completed by two researchers, the final decision about the study was made with an online meeting attended by all researchers. Then, full texts of the studies were examined according to the inclusion criteria and the studies to be analyzed were determined. Among the studies being conducted within the scope of the same project and having overlapping sample results, the study containing the most comprehensive result was selected. In addition, some studies were excluded due to inconsistent data detected during the data extraction phase. Data were requested by e-mail from the authors of the studies that were not included in the study due to reporting deficiencies. However, due to the lack of feedback, no additional study could be included in this way. Figure 1 shows the selection process of the studies according to the PRISMA flowchart.

Figure 1.

Selection of studies according to the flow chart of Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA)

Data Extraction

A data extraction tool developed by the researchers was used to obtain the data in this study (Table 1). With this data extraction tool, data on the place and year of publication, study design, participant selection, sample size, female average age, CSA definition, measurement technique, and outcome variables of the studies included in the systematic review and meta-analysis were obtained. In studies reporting results by gender or different trauma types, only the data of women with and without CSA were extracted.

Table 1.

Characteristics of Studies İncluded in Systematic Review and Meta-analysis

Authors, Year, Country	Study design	Participant selection	Sample size	Age (years)	CSA definition	Outcome Variables (Mean or Frequency)			Quality Score *
							CSA	NSA
Bird et al. 2014**, America	Cross-sectional	Community, clinical interview with CTQ	CSA:30-39 NSA:21-24	CSA:30 NSA:28	Forced or persuasive sexual intercourse where touching or penetration of the genitals occurs with someone at least 5 years older before the age of 16	FSFI-Arousal Arousal based on laboratory evaluation: Physiological Subjective	4.42±1.01 35.50±33.47 74.81±28.94	5.06±1.03 40.59±34.95 71.73±27.09	Yes:7 Unclear:1
Camuso and Rellini 2010, America	Cross-sectional	Community, online survey with CSAM	CSA:60 NSA:120	CSA:33 NSA:28	Forced touching or oral/anal/vaginal intercourse by someone at least 5 years of age before the age of 14	FSFI- arousal disorder	17	31	Yes:6 Unclear:2
Gewirtz-Meydan et al. 2020a, Israel	Cross-sectional	Community, online survey with CTQ	CSA:308 NSA:312	-	-	Total ASEX Total FSDS-R***	18.69±5.45 20.49±15.47	20.11±4.67 14.50±13.81	Yes:5 Unclear:3
Khouri 2010, America	Cross-sectional	Community, telephone interview	CSA:70 NSA:30	CSA:32 NSA:33	Unwanted sexual activity before the age of 16 (including oral, anal or vaginal intercourse, penetration into the vagina or anus using objects or fingers, or genital touching or caressing)	Total SSS-W Total FSFI	84.3±22.8 22.1±6.3	105.7±28.3 26.9±4.6	Yes: 5 Unclear:3
Pulverman 2017, America	Cross-sectional	Community, clinical interview with THQ	CSA:59 NSA:46	CSA:28 NSA:26	Unwanted sexual experience before age 16 (including oral, anal or vaginal intercourse, penetration into the vagina or anus using objects or fingers, or genital touching or caressing)	Total FSFI Sexual dysfunction	24.12±5.89 31	26.12±5.07 19	Yes: 7 Unclear:1
Staples et al. 2012, America	Cross-sectional	Community, clinical interview with CTQ	CSA:34 NSA:22	CSA:30 NSA:27	Unwanted sexual experience before the age of 16, including touching or penetrating the genitals with someone 5 years or older	FSFI sub-dimension: Desire Arousal Lubrication Orgasm Satisfaction Pain Arousal based on laboratory evaluation: Physiological Subjective	4.2±1.2 4.5±1.0 5.0±0.9 4.5±1.2 4.0±1.4 5.2±1.1 1.7±2.0 80.5±27.3	4.6±0.9 5.0±1.0 5.5±0.8 4.8±1.1 4.4±1.6 5.6±0.9 2.4±2.0 72.0±27.8	Yes: 7 Unclear:1
Stephenson et al. 2012, America	Cross-sectional	Community, and university students, telephone interview, screening with THQ	CSA:105 NSA:71	CSA:33 NSA:32	Unwanted sexual activity before the age of 16 (including oral, anal or vaginal intercourse, penetration into the vagina or anus using objects or fingers, or genital touching or caressing)	FSFI sub-dimension Desire Arousal Lubrication Orgasm Pain SSS-W Sub dimension: Personal distress	3.83±1.54 3.63±1.48 4.23±1.43 3.03±1.74 4.27±0.56 14.48±5.82	4.45±1.06 4.68±0.84 5.25±0.74 4.36±1.56 4.80±0.65 22.37±7.57	Yes:7 Unclear:1

^*Refers to the total number met out of the eight items on the Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional studies.

^**The sample size reported for this study differs according to the outcome variables. Therefore, the sample size is presented as range. Details about the sample sizes of the study are included in the meta-analysis findings (Figures 2 and 3).

^***For this result, the direction of the scale score was adjusted so that a low score indicates increased sexual distress, then included in the meta-analysis. For this arrangement, the reported score was subtracted from 58, which is the highest score that can be obtained from the FSDS-R scale, without changing the standard deviation. CSA, Women with a history of childhood sexual abuse; NSA, Comparison group without a history of childhood sexual abuse; FSFI, Female Sexual Function Index; SSS-W, Self-Sexual Satisfaction Scale for Women; ASEX, Arizona Sexual Experiences Scale; FSDS-R, Female Sexual Distress Scale-Revised; CTQ, Childhood Trauma Scale; CSAM, Child Sexual Abuse Scale; THQ, Trauma History Questionnaire.

Assessment of the Quality of Studies

By following the steps suggested for systematic review studies (Karaçam 2013), the quality of the studies included in this study was evaluated. In this way, it was ensured that studies of low quality were not included in the meta-analysis. Quality assessment tools of the Joanna Briggs Institute were used for quality assessment. Since all included studies were conducted in accordance with the cross-sectional study design, the eight-question quality assessment tool (JBI Critical Appraisal checklist for Analytical Cross-Sectional Studies) used for this design was chosen (Moola et al. 2017). Every item in this tool is rated with “Yes, No, Uncertain and Not Applicable” options. In this context, the evaluation results of each study were presented as “Quality score” in Table 1.

Data Synthesis

The studies included in this study had different measurement methods and outcome variables. Meta-analysis was performed if there were at least two study results related to the outcome variables examined in this study and obtained with similar measurement methods (Ryan 2016). Data that were not included in the meta-analysis were tabulated and presented in the form of narrative synthesis.

Meta-analysis was performed using Review Manager 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark). The effect size was calculated using the mean difference (MD) in outcomes of sexual function and sexual distress obtained with similar measures, and the standardized mean difference (SMD) in outcomes obtained with different measures. In the included studies, sexual distress was assessed with different scales which has scoring differences. Therefore, low scores in some results and high scores in others indicated increased sexual distress. In order to combine the results of studies using different measurement methods for the same outcome measurement, the differences in direction between the scales were corrected by subtracting the reported average value from the highest possible value for the scale without changing the standard deviation (Higgins and Green 2011).

Q test and Higgins I² value are frequently used to evaluate heterogeneity in meta-analysis. In case of few studies, the Q test has lower power and does not provide information about the extent of heterogeneity when compared to I² (Melsen et al. 2014). Since the number of studies included in the meta-analysis was small in this study, heterogeneity was evaluated using I². A value greater than 50% for I² indicates significant heterogeneity. In cases where heterogeneity is high, the random effects model was used to estimate the difference between the means. Fixed effect model was used for I² values less than 50% (Higgins and Green 2011, Melsen et al. 2014). In this way, the effect of heterogeneity on the strength of the evidence obtained was controlled (Higgins and Green 2011). All tests were calculated in two ways and p<0.05 value was considered as statistically significant.

RESULTS

Systematic Review Findings

Screening Findings

As a result of the screening, 7718 articles and 349 theses were reached from the databases. As a result of removing the repetitive records and examining according to the title and abstract, respectively, 69 studies that could be examined in full text were obtained. As a result of the analysis on the full text, a total of 7 studies, including 2 theses and 5 research articles, that met the inclusion criteria were identified (Figure 1). No published articles of thesis studies were found in the screenings.

Characteristics of the Studies

All included studies were cross-sectional studies conducted in community samples and published in English. The sample consisted of American women in six of the studies and Israeli women in one. In the studies, the age ranged from 28-32 in American women with and without a history of CSA and 26-33 in their Israeli female counterparts. The total sample size of the studies ranged between 30 and 308 individuals in women with a history of CSA, and between 21 and 312 individuals in women without a history of CSA. CSA was defined as an unwanted/forced/persuasive contact sexual encounter/activity/experience before the age of 16 in five studies and before the age of 14 in one study. In one study, the diagnosis way of CSA was not reported, but CSA was evaluated with the ‘Childhood Trauma Scale’, which is a valid and reliable scale (Gewirtz-Meydan and Lahav 2020a). Therefore, although no clear definition of CSA was made, this study was not excluded.

In the studies, sexual function was evaluated using the Female Sexual Functioning Index (FSFI), Arizona Sexual Experiences Scale (ASEX) and The Sexual Satisfaction Scale for Women (SSS-W). In the studies, the “The Female Sexual Distress Scale-Revised (FSDS-R)” and “The Sexual Satisfaction Scale for Women (SSS-W)” personal distress subscale were used in the evaluation of sexual distress. The decrease in FSFI total and subscale scores and total ASEX scores indicates a lower level of sexual function and an increased risk of sexual dysfunction (McGahuey et al. 2000, Wiegel et al. 2005). The decrease in total SSS-W scores indicates that sexual satisfaction is lower (Meston and Trapnell 2005). The increase in total FSDS-R scores (Derogatis et al. 2008) and the decrease in SSS-W personal distress subscale scores represent less sexual distress (more well-being) (Meston and Trapnell 2005). Table 1 shows the general characteristics and main findings of the included studies.

Quality Evaluation of the Studies

Eight items of the quality assessment tool were answered as ‘Yes’ with 7 for four studies, 6 for one study, and 5 for two studies (Table 1). Study subject, setting, and confounding/contributing factors were unclear in 71.4% (n=5) of the studies. In addition, methods used to cope with confounding factors in two studies (28.5%), inclusion criteria in one study (14.2%) and the assessment method of exposure in one study (14.2%) were not defined.

The Effect of Childhood Sexual Abuse on Sexual Function and Sexual Distress

The Study Findings That Could Not Be Included in the Meta-analysis

In studies with results that could not be included in the meta-analysis, there was no significant difference in sexual satisfaction (Staples et al. 2012), prevalence of sexual arousal disorder (Camuso and Rellini 2010), and prevalence of sexual dysfunction (Pulverman 2017) in women with and without a history of CSA (Table 1). One study reported that women with a history of CSA generally had lower sexual satisfaction (Khouri 2010).

Meta-analysis Findings

In a meta-analysis conducted based on the results of three studies included in this study (Bird et al. 2014, Staples et al. 2012, Stephenson et al. 2012), the level of sexual arousal was found to be lower in women with a history of CSA compared to their counterparts (MD: -0.83, p<0.001). In a meta-analysis based on two studies (Staples et al. 2012, Stephenson et al. 2012), it was determined that women with a history of CSA experienced less sexual desire (MD: -0.55, p<0.001) and lubrication (MD: -0.78, p<0.01) and more pain during sexual intercourse (MD: -0.52, p<0.001). There was no significant difference in orgasmic function in women with and without a history of CSA (MD: -0.83, p>0.05). A meta-analysis conducted based on three studies reporting results on the effect of CSA on overall sexual function (Gewirtz-Meydan and Lahav 2020a, Khouri 2010, Pulverman 2017) revealed that the level of sexual function was significantly lower in women with a history of CSA compared to their counterparts (Figure 2 SMD: -0.43, p<0.01). In addition, two studies reported the results of physiological and subjective sexual arousal elicited by visual erotic stimuli in the laboratory environment in women with and without a history of CSA (Bird et al. 2014, Staples et al. 2012). In the meta-analysis based on these studies, it was determined that the physiological (SMD: -0.24, p=0.21) and subjective (SMD: -0.21, p=0.29) sexual responses of women with and without a history of CSA to erotic videos in the laboratory environment were similar (Figure 3; p>0.05).

Figure 2.

Meta-analysis results on sexual functions of women with and without a history of childhood sexual abuse

SD, Standard deviation; CI, Confidence Interval; CSA, Women with a history of childhood sexual abuse; NSA, Comparison group with no history of childhood sexual abuse

Figure 3.

Meta-analysis results of subjective and physiological sexual responses to visual erotic stimuli in the laboratory setting of women with and without a history of childhood sexual abuse

SD, Standard deviation; CI, Confidence Interval; CSA, Women with a history of childhood sexual abuse; NSA, Comparison group with no history of childhood sexual abuse

Results regarding the effect of CSA on sexual distress were reported in two studies. In the meta-analysis based on the results of these studies, sexual distress was found to be higher in women with a history of CSA compared to those without a history of CSA (Figure 4; SMD: -0.79; p<0.05).

Figure 4.

Meta-analysis results on sexual distress in women with and without a history of childhood sexual abuse

SD, Standard deviation; CI, Confidence Interval; CSA, Women with a history of childhood sexual abuse; NSA, Comparison group with no history of childhood sexual abuse

In these meta-analyses, the I² value for sexual arousal, sexual desire, pain, subjective and physiological sexual arousal results was below 50%. For lubrication, orgasm and general sexual function results, the I² value varied between 60% and 94%.

DISCUSSION

The findings of this systematic review and meta-analysis study, which aimed to examine how childhood sexual abuse affects female sexual function and sexual distress, supported that CSA negatively affected female sexual function and increases sexual distress in adulthood and CSA could be an important risk factor for sexual dysfunctions (Kilimnik et al. 2018, Pulverman et al. 2018). In the studies included in this study, the FSFI scores reported for women with history of CSA were below 26.55, which is considered as a clinical cut-off value for sexual dysfunction (Wiegel et al. 2005). Numerous researchers used this value to determine the risk of sexual dysfunction in samples including women with a history of CSA (Witting et al. 2008). In addition, meta-analysis findings in this study showed that women with a history of CSA generally had worse sexual functions, had more problems related to sexual desire, arousal and pain, and increased sexual distress. These findings are compatible with the literature (Loeb et al. 2002, Pulverman et al. 2018). However, the results of some studies included in this study on the prevalence of sexual arousal disorder and sexual dysfunction in women with and without a history of CSA (Camuso and Rellini 2010, Pulverman 2017) were similar differently from the meta-analysis findings. It was thought that the reason for this difference between the related studies (Camuso and Rellini 2010; Pulverman 2017) and the literature and this meta-analysis might be associated with a real effect or sampling error due to the sample characteristics of the studies, or to overlooked confounding/contributing factors.

In a previous study, it was found that 23-62% of women with a history of CSA had arousal disorders and 18-45% had orgasmic disorders (Pulverman et al. 2018). It has been stated that women with a history of CSA may ignore the pleasurable aspect of sexual experience due to their tendency to avoid negative emotional experiences, and therefore may have difficulty in sexual arousal or reaching orgasm (Lacelle et al. 2012, Pulverman et al. 2018). Contrary to the literature (Klimnik et al. 2018, Loeb et al. 2002, Pulverman et al. 2018), no significant difference was found in orgasm in women with and without a history of CSA in this study. This difference may be associated with the fact that findings of the present study were based on studies conducted in community samples and did not include the results of studies conducted on women with sexual problems.

Sexual arousal in women consists of two components, physiological and subjective. Physiological genital arousal includes genital vasocongestion and other physiological changes that occur in response to sexual stimuli. Subjective arousal represents mental preoccupation in sexual acts (Meston and Stanton 2019). It has been reported that only two therapeutic approaches (mindfulness-based therapy and impressive writing therapy) have been empirically validated for treating sexual problems, including sexual arousal disorders, in women with a history of CSA (Gewirtz-Meydan 2020). There is a need for further studies on the subject. Figuring out the subjective and physiological arousal processes of women with a history of CSA can guide the development of effective treatments (Gewirtz-Meydan 2020, Meston and Stanton 2019). This study showed that the results of sexual arousal evaluated by FSFI and measured in the laboratory were not compatible with each other in women with history of CSA. Physiological and subjective arousal components can be evaluated together with FSFI. However, due to its structure, FSFI cannot separate the physiological component of arousal from its subjective component. For this reason, it may be more limited in evaluating sexual arousal when compared to laboratory measurements (Meston and Stanton 2019). The findings of this study revealed that although women with and without CSA history displayed similar physiological and subjective sexual arousal results against visual erotic stimuli, they were less aroused when they evaluated their own sexual functions. Due to a limited number of studies addressing the effects of CSA exposure on psychophysiological, emotional, and cognitive sexual response, it is difficult to interpret the present study’s findings on sexual arousal. It is thought that the history of sexual abuse or negative sexual experience may cause low subjective sexual arousal in women by affecting beliefs and attitudes towards sexuality and sexual acts. The time of abuse may affect subjective sexual arousal and increase sexual shame and conservatism. It has been reported that abuses which occur after menarche or before the person’s consensual sexual experience may affect women’s ability to engage in satisfactory sexual interaction (Meston and Stanton 2019). In a study, it was found that some women with a history of CSA may exhibit a learned stress response when they encounter erotic stimuli, which may negatively affect their physiological sexual arousal (Rellini et al. 2009). In another study, it was found that most women with a history of CSA were able to avoid close sexual interactions and had less common and compatible perceptions of sexuality with a sexual partner (Rellini 2008). In different studies, it has been reported that sexual avoidance, negative attitudes towards sexuality and sexual intimacy, difficulty in establishing satisfactory sexual relations, and feelings of anger, shame and guilt about sexuality were higher in women with a history of abuse (Berlo and Ensinck 2000, DiLillo 2001). Mechanisms proposed to explain the correlation between CSA and sexual dysfunctions include sexual cognitive status, sexual self-schemas, sympathetic nervous system activation, body image and esteem, shame, and guilt (Pulverman et al. 2018). However, there is a need for further studies on the effects of CSA history features on sexual arousal.

CSA decreases sexual satisfaction in adult women (Kilimnik et al. 2018, Lacelle et al. 2012, Pulverman et al. 2018, Rellini 2008) and some features of CSA (vaginal penetration, fear at the time of abuse, familial bond with the perpetrator, and persistence of abuse) are associated with satisfaction level (Rellini and Meston 2007). In this study, only two studies which evaluated sexual satisfaction in women with and without CSA were found, and the results of these studies were not suitable for meta-analysis. In addition, the findings of this study supported the results of the study, which reports that there is no standard definition of CSA in studies, researchers often focus on the effects of severe CSA, and non-contact experiences are not considered as CSA (Mathews and Collin-Vézina 2019, Pulverman et al. 2018). These findings suggest that further studies are needed to draw consistent conclusions about the effect of CSA on sexual satisfaction.

In our systematic review and meta-analysis, the strengths of this study include using a comprehensive research strategy, revealing the current situation on the subject and determining the analyzed results with reliable methods. The findings of this study are limited to the results of the study with a relatively small sample including young women living in the United States and Israel. A limited number of studies included in this study and the fact that the I² value was above 50% in some of the results included in the meta-analysis suggest that there is a significant heterogeneity in some of the included results (lubrication, orgasm, general sexual function and sexual distress). This may be a factor that may weaken the strength of the evidence. On the other hand, heterogeneity was controlled by using random effects model while performing meta-analysis in this study (Higgins and Green 2011). Since it is known that statistical power does not always increase even if the number of studies increases (Cohn and Becker 2003), it is thought that reliable results can be obtained with a small number of studies in cases where this model is used in meta-analysis. In addition, when the number of studies in the meta-analysis was less than 10, publication bias was not evaluated in this study because the success and power of the tests used to evaluate publication bias were low (Hoffman 2015). However, there is a general tendency to publish studies with significant results in academic journals. The inclusion of theses in this study can be considered as a factor that increases the power of the study in terms of inclusiveness and can reduce publication bias.

CSA is common in almost every society. Strong evidence is needed to demonstrate the association of CSA with adverse health outcomes (Barth et al. 2013, Hailes et al. 2019). This study can be considered as a beginning in understanding the deficiencies in the literature and determining the research needs. When interpreting the findings of this study, it should be taken into account that the characteristics and quality of the included studies and the results of the studies are based on self-reported findings.

CONCLUSION

Further studies are needed to evaluate the correlations between CSA and sexual health outcomes in different cultures and age groups. Healthcare professionals (such as psychiatrists, clinical psychologists, family physicians, nurses, midwives) should definitely question the history of CSA in the evaluation of sexual health and should be aware that women with a history of CSA may have worse sexual functions and higher sexual distress. When planning the diagnosis and treatment of sexual problems in women with a history of CSA, the participation of different disciplines should be ensured, and women should be appropriately supported concerning treatment according to their needs.