Review

The role of child sexual abuse in the etiology
of suicide and non-suicidal self-injury

Maniglio R. The role of child sexual abuse in the etiology of suicide and
non-suicidal self-injury.

Objective: To address the best available scientific evidence on the role
of child sexual abuse in the etiology of suicide and non-suicidal self-
injury.
Method: Seven databases were searched, supplemented with hand-
search of reference lists from retrieved papers. The author and a
psychiatrist independently evaluated the eligibility of all studies
identified, abstracted data, and assessed study quality. Disagreements
were resolved by consensus.
Results: Four reviews, including about 65 851 subjects from 177
studies, were analyzed. There is evidence that child sexual abuse is a
statistically significant, although general and non-specific, risk factor
for suicide and non-suicidal self-injury. The relationship ranges from
small to medium in magnitude and is moderated by sample source and
size. Certain biological and psychosocial variables, such as serotonin
hypoactivity and genes, family dysfunction, other forms of
maltreatment, and some personality traits and psychiatric disorders,
may either act independently or interact with child sexual abuse to
promote suicide and non-suicidal self-injury in abuse victims, with
child sexual abuse conferring additional risk, either as a distal and
indirect cause or as a proximal and direct cause.
Conclusion: Child sexual abuse should be considered one of the several
risk factors for suicide and non-suicidal self-injury and included in
multifactorial etiological models.

R. Maniglio

Department of Pedagogic, Psychological, and Didactic
Sciences, University of Salento, Lecce, Italy

Key words: self-injury; suicide; child abuse; sexual
abuse; etiology; review

Roberto Maniglio, Department of Pedagogic, Psycho-
logical, and Didactic Sciences, University of Salento, Via
Stampacchia 45

⁄ 47, 73100 Lecce, Italy.

E-mail: [e-mail]

Accepted for publication September 7, 2010

Summations

• Child sexual abuse is a statistically significant, but modest, risk factor for suicidal and non-suicidal

self-injurious behaviour and ideation.

• Child sexual abuse may not have a primary role in the etiology of suicide and non-suicidal self-injury.
• Additional biological and psychosocial risk factors may, in some cases, be directly responsible for, or,

in other cases, contribute to the risk of suicidal and non-suicidal self-injurious behaviour by
mediating the relationship between child sexual abuse and self-injurious behaviour.

Considerations

• The role of child sexual abuse in the etiology of suicide and non-suicidal self-injury is complex.
• The presence of confounding variables and the poor quality of the studies do not allow for causal

inferences to be made.

• All studies included in this review did not assess data quality and validity and aggregated different

study findings, particularly those with different levels of methodological quality.

Acta Psychiatr Scand 2011: 124: 30–41
All rights reserved
DOI: 10.1111/j.1600-0447.2010.01612.x

2010 John Wiley & Sons A/S

ACTA PSYCHIATRICA

SCANDINAVICA

30

Introduction

Lethal and non-lethal self-inflicted injuries, includ-
ing completed and attempted suicide as well as non-
suicidal self-injury (i.e., intentional and direct self-
damaging acts causing bodily harm, without the
intent to die), are a serious public health problem
throughout the world (1–6) and present severe
repercussions on individuals, families, and society
at large (7), including direct and indirect economic
costs (8).

Given the seriousness of self-inflicted injuries,

much literature has attempted to investigate the
factors that promote suicidal and non-suicidal self-
injurious behaviours, with many clinicians and
researchers focusing on child sexual abuse as a
primary etiological factor. In fact, a growing
number of studies addressing the potential associ-
ation between sexual victimization in childhood
and suicide or non-suicidal self-injury in adoles-
cence or adulthood have been published over the
past 20 years. Efforts to summarize the findings of
these studies have resulted in several qualitative
and quantitative reviews.

It should be noted here that although extensive

evidence supports important distinctions between
suicidal and non-suicidal self-injurious behaviours
in terms of base rates, frequency, correlates,
lethality, and treatment outcomes (see 9), in the
literature on the sequelae of child abuse, suicidal
and non-suicidal forms of self-injury have been
often considered together as a common outcome
in survivors of child abuse (10, 11). For instance,
both

suicidal

behaviour

and

non-suicidal

self-injurious

behaviour

have

been

seen

as

deliberate self-damaging acts in which abuse
victims engage to reduce abuse-related distress
(see e.g., 12).

In general, literature reviews (e.g., 10, 11, 13–

35) have found high rates of suicidal and non-
suicidal self-injurious behaviours among victims
of child sexual abuse. However, there are funda-
mental questions concerning the nature and the
specific pathways of the association between child
sexual abuse and suicide and non-suicidal self-
injury that remain unanswered. Much of this
uncertainty might be attributable, in part, to the
methodological limitations of the literature on
child abuse. Most reviews of the empirical liter-
ature are characterized by imprecision and sub-
jectivity (see 31, 36). In fact, many reviews have
specified neither the data sources that were
searched nor the criteria used for including
studies. Furthermore, the majority of these liter-
ature reviews have not assessed data quality and
validity and have aggregated different study find-

ings, paying more attention to findings suggesting
harmful effects. As a result, causal inferences
cannot be made and conclusions cannot be drawn.
Thus, the role of sexual victimization in childhood
as a causal factor for suicide and non-suicidal self-
injury in adolescence or adulthood is not well
understood (11).

Aims of the study

To understand how and why some victims of early
sexual victimization self-injury in later life, this
paper provides a qualitative and semi-quantitative
analysis of the findings of the several reviews that
have addressed the literature on the association
between child sexual abuse and suicide and non-
suicidal self-injury. Given the severity of self-
inflicted injuries and with the current high levels
of public and scientific interest in child abuse, an
analysis of what is currently known about the
potential role of child sexual abuse in the etiology
of suicide and non-suicidal self-injury is required to
implement research and prevention efforts.

Material and methods

Given that this systematic review is part of a more
comprehensive review of the literature on child
sexual abuse, the methods are illustrated in detail
elsewhere (37, 38) and are only briefly described
here.

To obtain relevant studies, seven internet-based

databases (AMED, Cochrane Reviews, EBSCO,
ERIC, MEDLINE, PsycINFO, and ScienceDi-
rect) were searched for articles published between
January 1966 and December 2008. Separate
searches were conducted for the keywords child
(hood) sexual abuse and child(hood) sexual mal-
treatment. Further articles were identified by a
manual search of reference lists from retrieved
papers.

Studies were included whether they (i) appeared

in peer-reviewed journals; (ii) were published in
full; (iii) were critical reviews of the literature; (iv)
were not dissertation papers, editorials, letters,
conference proceedings, books, and book chapters;
(v) reviewed studies sampling human subjects; (vi)
investigated medical, neurobiological, psychologi-
cal, behavioural, sexual, or other health problems
following

childhood

sexual

abuse;

(vii)

had

primary and sufficient data derived from longitu-
dinal, cross-sectional, case–control, or cohort stud-
ies. For the purposes of the present systematic
review, only reviews that examined suicidal and
non-suicidal forms of self-injury following child
sexual abuse were included.

Child sexual abuse and self-injury

31

In accordance with guidelines for systematic

reviews (39–44), data were abstracted and study
quality was assessed on the basis of the following
criteria: (i) evidence identification, i.e., the data
sources (e.g., computerized databases, key jour-
nals, or reference lists from pertinent articles and
books) used to identify studies, including years
searched, keywords, and constraints; (ii) study
selection, i.e., the criteria used to select studies for
inclusion in the review; (iii) data extraction, i.e., the
process by which researchers obtained the neces-
sary information about study characteristics and
findings from the included studies; (iv) quality
assessment, i.e., the criteria or guidelines used for
assessing data quality and validity; (v) data syn-
thesis and analysis, i.e., the methods used to
analyze the results and the strength of evidence
as well as the description of the main results in an
objective, rigorous, and transparent fashion, with
the highest quality evidence available receiving the
greatest emphasis. Based on these criteria, each
study was assigned one of the following ratings:
good (study meets all criteria well), fair (study
does not meet one criterion), or poor (study does
not meet more than one criterion). Those studies
which were judged poor were rejected, because
they had important methodological limitations
that could invalidate their results.

Given that the assessment of all the papers by at

least two researchers working independently may
limit biases, minimize errors, improve reliability of
findings, reduce the possibility that relevant reports
will be discarded, and ensure that decisions and
judgments are reproducible (39, 41), the author,
R. M., and a psychiatrist, professor of Criminol-
ogy, independently evaluated the eligibility of all
studies identified, abstracted data, and assessed
study quality. Disagreements among authors were
discussed and resolved by consensus after review of
the article and the review protocol.

Results

A total of 20 535 articles were identified. The
internet-based search identified 20 502 articles, 0
from AMED, 9 from Cochrane, 1550 from EBSCO,
1154 from ERIC, 2514 from MEDLINE, 7956 from
PsycINFO, and 7319 from ScienceDirect. Thirty-
three articles were identified by the manual search of
reference lists. Two hundred and forty-four full-text
articles were retrieved for more detailed evaluation
and 39 fulfilled all inclusion criteria. Of these, 35 did
not meet more than one of the quality criteria. For
these reasons, these studies were judged poor and
were rejected. Four reviews were judged fair,
because they did not meet the fourth criterion (i.e.,

they lacked a formal quality assessment) and were
included in this systematic review. A summary of
the study selection process is illustrated in Fig. 1.

Description of studies

The four reviews included in this systematic review
are described in Table 1. All the meta-analyses
were published between 1996 and 2008 and
reviewed a total of 177 studies (including 222
different subject samples, with 65 851 subjects). Six
(3.38%) of these studies were analyzed by more
than one review. The following sample types were
investigated: both young and adult subjects, only
adults, both males and females, and only females.

One of these meta-analyses focused on non-

suicidal self-injurious behaviour. All the other
reviews assessed suicide or non-suicidal self-injury
along with several other psychological or behavio-
ural sequelae of child sexual abuse. In the studies
included in each review, suicidal and non-suicidal
self-injurious behaviours were usually measured by
suicide and non-suicidal self-injury inventories,
scales, or questionnaires, investigator-authored
items or questions, or suicide and non-suicidal
self-injury-related items, or subscales from clinical
questionnaires, scales, and inventories.

All these reviews detailed the data sources used

to identify studies, the criteria used to select studies
for inclusion in the review, and the process by
which researchers acquired the necessary informa-
tion concerning study characteristics and findings
from the included studies. All the reviews under-
took a quantitative analysis of the data (i.e., meta-
analysis) to infer whether child sexual abuse was
significantly related to suicidal and non-suicidal
self-injurious behaviours and to estimate the
strength of this relationship. All the meta-analyses
described the main results in an objective fashion,
specified the methods that were employed to obtain
these results, took into account the strength of
evidence, investigated whether any observed effects
were consistent across studies, explored possible
reasons for any inconsistencies, and outlined how
heterogeneity was explored and quantified.

The following moderator variables were ana-

lyzed: form and date of publication of the study,
site of the study, size and source of the samples,
gender, socioeconomic status, and age of the
subjects at the time of assessment, sampling
strategy, method of assessment of abuse (e.g.,
questionnaire list), type of statistic used, definition
of child sexual abuse based on the maximum age of
victim, level of contact, consent, force, frequency,
and duration of abuse, relationship to the perpe-
trator (e.g., parent), age when abused. Multiple

Maniglio

32

regression, analysis of variance, and test of cate-
gorical models were used to determine whether
moderator variables accounted for significant
heterogeneity in effect sizes.

The main findings of the four meta-analyses

included in this systematic review are qualitatively
and semi-quantitatively analyzed in an evidence-
based, objective, and balanced fashion, with the
highest quality evidence available receiving the
greatest emphasis (45). To represent the degree of
the relationship between child sexual abuse and
suicide and non-suicidal self-injury, the effect size
estimators d and r were used. Positive d and r
values indicate higher levels of symptomatology for
sexually abused participants compared with con-
trol participants. According to Cohen (46), d of
0.20, 0.50, and 0.80, and r of 0.10, 0.30, and 0.50
correspond to small, medium, and large effect
sizes.

Strength of the association between child sexual abuse and
suicidal and non-suicidal self-injurious behaviour

In their review, Klonsky and Moyer (24) under-
took a meta-analysis of 45 samples from 43 studies,
with a total of 13 687 subjects, to address the
relationship between child sexual abuse and non-
suicidal self-injurious behaviour. Results showed

that child sexual abuse was significantly related to
non-suicidal self-injury. Such association was small
in magnitude.

Neuman et al. (26) provided 15 meta-analyses to

address the relationship of child sexual abuse with
a variety of psychological, behavioural, and sexual
problems, including self-mutilation and suicidal
ideation or behaviour. Three studies were used in
the non-suicidal self-injury meta-analysis and eight
in the suicidal ideation or behaviour meta-analysis.
Results indicated that child sexual abuse was
significantly related to suicidal and non-suicidal
self-injurious behaviour. The magnitudes of such
relationships were small to medium. Child sexual
abuse was significantly related also to all the other
problems, with magnitudes ranging from small to
medium.

In the review by Paolucci et al. (28), six meta-

analyses were undertaken to address the associa-
tion of child sexual abuse with a number of
psychological, behavioural, and sexual outcomes,
including suicidal ideation or behaviour. Ten
studies, with a total of 4008 subjects, were used
in the suicidal ideation or behaviour meta-analysis.
Results indicated a significant association between
child sexual abuse and suicidal ideation or behav-
iour. Such relationship was nearly medium in
magnitude. Child sexual abuse was significantly

AMED (n = 0)

Cochrane

(n = 9)

EBSCO

(n = 1550)

ERIC

(n = 1154)

Articles identified and

screened for retrieval

(n = 20 502)

Articles retrieved for

more detailed

evaluation (n = 211)

Articles excluded on title /

abstract review (n = 20 291):

editorials, letters, or conference

proceedings; no critical review

of the literature; no focus on
effects of child sexual abuse

Articles excluded on full-text

review (n = 205): no critical

review of the literature; no

focus on depression; no

sufficient data from

longitudinal, cross-sectional,

case-control, or cohort studies

Articles identified from

reference lists of

retrieved articles and
retrieved for detailed

evaluation (n = 33)

Articles included for

quality assessment

(n = 39)

MEDLINE
(n = 2514)

PsycINFO
(n = 7956)

Sciencedirect

(n = 7319)

Articles included

(n = 4)

Articles rejected on quality

assessment (n = 35)

Fig. 1.

Summary of study selection process.

Child sexual abuse and self-injury

33

Table

1.

Description

and

results

of

the

included

reviews

Source

Main

methods

Subjects

Outcome

variables

Moderator

variables

Significant

outcomes

(effect

sizes

or

odds

ratios

[95%

confidence

interval];

homogeneity)

Significant

moderators

(between-group

homogeneity)

Klonsky

&

Moyer

(24)

Systematic

search;

study

selection;

meta-analysis

Male

&

female

young

&

adult

patients

&

non-patients

(43

studies,

45

samples,

13

687

subjects)

Self-injurious

behaviour

Sample

size

and

source,

gender

and

age

of

the

subjects

at

the

time

of

assessment

Self-injurious

behaviour

(u

=

0.23

[0.20–0.26],

P

<

0.001;

Q

=

90.47,

P

<

0.001)

Sample

source

(Q

=

5.34,

P

<

0.001),

sample

size

(N

>

125:

u

=

0.21)

Neuman

et

al.

(26)

Systematic

search;

study

selection;

meta-analysis

Female

adult

patients

or

non-patients

(38

studies,

11

162

subjects)

Suicidal

ideation

or

behaviour

,

self-mutilation,

overall

psychopathology

,

anger

,

anxiety

,

depression,

revictimization,

sex

problems,

substance

abuse,

self-concept,

interpersonal

problems,

dissociation,

obsessions

or

compulsions,

somatization,

posttraumatic

stress,

general

symptoms

Publication

date

and

form,

sample

size

and

source,

age

of

subjects

at

the

time

of

assessment,

assessment

of

abuse,

type

of

statistic,

relationship

to

the

perpetrator

Suicidal

ideation

or

behaviour

(d

=

0.34

[0.24–0.44]),

self-mutilation

(d

=

0.42

[0.19–0.64]),

overall

psychopathology

(d

=

0.37

[0.33–0.41];

Q

=

62.36,

P

<

0.01),

anger

(d

=

0.39

[0.25–0.51]),

anxiety

(d

=

0.40

[0.34–0.47]),

depression

(d

=

0.41

[0.36–0.46]),

revictimization

(d

=

0.67

[0.50–0.84]),

sex

problems

(d

=

0.36

[0.30–0.42]),

substance

abuse

(d

=

0.41

[0.31–0.51]),

self-concept

(d

=

0.32

[0.32–0.47]),

interpersonal

problems

(d

=

0.39

[0.22–0.46]),

dissociation

(d

=

0.39

[0.32–0.47]),

obsessions

⁄

compulsions

(d

=

0.34

[0.22–0.46]),

somatization

(d

=

0.34

[0.24–0.45]),

posttraumatic

stress

(d

=

0.52

[0.44–0.59]),

general

symptoms

(d

=

0.46

[0.40–0.52])

Overall

impairment:

sample

source

(Q

B

=

9.40,

P

<

0.01)

Paolucci

et

al.

(28)

Systematic

search;

study

selection;

meta-analysis

Male

&

female

young

&

adult

patients

&

non-patients

(37

studies,

88

samples,

25

367

subjects)

Suicidal

ideation

or

behaviour

,

depression,

posttraumatic

stress,

early

sex

or

prostitution,

sex

perpetration,

intelligence

or

learning

Gender

and

socioeconomic

status

of

subjects

at

the

time

of

assessment,

level

of

contact

and

frequency

of

abuse,

relationship

to

the

perpetrator

,

age

when

abused

Suicidal

ideation

or

behaviour

(d

=

0.44

[0.40–0.48]),

depression

(d

=

0.44

[0.41–0.47]),

posttraumatic

stress

(d

=

0.40

[0.37–0.43]),

early

sex

⁄

prostitution

(d

=

0.29

[0.25–0.32]),

sex

perpetration

(d

=

0.16

[0.11–0.21]),

intelligence

⁄learning

(d

=

0.19

[0.12–0.26])

Maniglio

34

Table

1.

Continued

Source

Main

methods

Subjects

Outcome

variables

Moderator

variables

Significant

outcomes

(effect

sizes

or

odds

ratios

[95%

confidence

interval];

homogeneity)

Significant

moderators

(between-group

homogeneity)

Rind

et

al.

(31)

Systematic

search;

study

selection;

meta-analysis

Male

&

female

adult

non-patients

(59

studies,

51

samples,

15

635

subjects)

Suicidal

ideation

or

behaviour

,

overall

psychopathology

,

alcohol,

anxiety

,

depression,

dissociation,

eating

disorders,

hostility

,

interpersonal

sensitivity

,

locus

of

control,

obsessions

or

compulsions,

paranoia,

phobia,

psychosis,

self-esteem,

sex

problems,

social

impairment,

somatization,

general

symptoms

Publication

form,

study

site,

sampling

strategy

,

gender

and

age

of

the

subjects

at

the

time

of

assessment,

sampling

strategy

,

assessment

of

abuse,

age

of

victim

in

abuse

definition,

level

of

contact,

consent,

force,

frequency

,

and

duration

of

abuse,

relationship

to

the

perpetrator

Suicidal

ideation

or

behaviour

(r

=

0.09

[0.06–0.12];

v

2

=

10.94),

overall

psychopathology

(r

=

0.09

[0.08–0.11];

v

2

=

49.19,

P

>

0.50),

alcohol

(r

=

0.07

[0.02–0.12];

v

2

=

2.97),

anxiety

(r

=

0.13

[0.10–0.15];

v

2

=

4.62),

depression

(r

=

0.12

[0.10–0.14];

v

2

=

25.71),

dissociation

(r

=

0.09

[0.04–0.15];

v

2

=

1.86),

eating

disorders

(r

=

0.06

[0.02–0.10];

v

2

=

9.92),

hostility

(r

=

0.11

[0.06–0.16];

v

2

=

11.22,

P

<

0.05),

interpersonal

sensitivity

(r

=

0.10

[0.06–0.15];

v

2

=

11.78),

obsessions

⁄

compulsions

(r

=

0.10

[0.06–0.15];

v

2

=

5.01),

paranoia

(r

=

0.11

[0.07–0.16];

v

2

=

10.34),

phobia

(r

=

0.12

[0.07–0.17];

v

2

=

8.08),

psychosis

(r

=

0.11

[0.06–0.15];

v

2

=

10.13),

self-esteem

(r

=

0.04

[0.01–0.07];

v

2

=

51.31,

P

<

0.05),

sex

problems

(r

=

0.09

[0.07–0.11];

v

2

=

39.49,

P

<

0.05),

social

impairment

(r

=

0.07

[0.04–0.10];

v

2

=

20.37),

somatization

(r

=

0.09

[0.06–0.12];

v

2

=

15.20),

general

symptoms

(r

=

0.12

[0.08–0.15];

v

2

=

18.77)

Overall

impairment:

incest

(r

=

0.09),

gender

⁄consent

interaction

(z

=

2.51,

P

>

0.02;

females,

r

=

0.11

[0.09–0.13];

v

2

=

14.50)

Child sexual abuse and self-injury

35

related also to all the other outcomes, with
magnitudes ranging from small to medium.

Rind et al. (31) provided 18 meta-analyses to

address the relationship of child sexual abuse with
a variety of psychological, behavioural, and sexual
problems, including suicidal ideation or behaviour.
Nine samples, with a total of 5425 subjects,
were used in the suicidal ideation or behaviour
meta-analysis. Results showed that child sexual
abuse was significantly related to suicidal ideation
or behaviour. The magnitude of such relationship
was of small size. Child sexual abuse was signifi-
cantly related to several other outcomes, with
magnitudes of small size.

Moderators of the relationship between child sexual abuse and
suicidal and non-suicidal self-injurious behaviour

Klonsky and Moyer (24) found that the distribu-
tion of effect size estimates exhibited significant
heterogeneity. An analog of an analysis of variance
procedure appropriate for effect size data showed
that sample type was a significant moderator of the
relationship between abuse and non-suicidal self-
injury. This relationship was stronger for the
clinical samples than for the non-clinical samples.
Further analysis of effect sizes revealed that some
explanation of effect size variance was also
accounted for by sample size. Studies with larger
samples (N > 125) reported smaller effect sizes.
According to the authors, this result suggested the
possibility of a bias toward publishing studies with
statistically significant results, because studies with
smaller sample sizes required larger effect sizes to
achieve statistical significance. Indeed, formal
analyses found evidence of publication bias, sug-
gesting that smaller studies with positive findings
were more likely to be published than smaller
studies with null or negative findings.

In the review by Neuman et al. (26), a significant

heterogeneity among effect sizes was found. Focus-
ing on the sample-level rather than symptom-level
effect sizes, the authors found that the variability in
sample-level effect sizes could be accounted for by
sample source. Clinical samples generated larger
effect sizes. There was a tendency for studies with
smaller samples (N < 50) to yield comparatively
high mean effect sizes, compared to studies that
examined larger numbers of subjects.

In the review by Paolucci et al. (28), a series of

analyses of variance revealed that none of the
moderators was statistically significant.

Rind et al. (31) found that the effect sizes were

generally homogeneous. Further analysis of the
sample-level effect sizes indicated that larger effect
size estimates were significantly linked to intra-

familial abuse and definition of abuse including
both willing and unwanted sex (only for women).
Importantly, certain family variables (i.e., physical
or emotional abuse and neglect, adaptability, con-
flict or pathology, family structure, support or
bonding, and traditionalism) were confounded with
child sexual abuse. The confounding of child sexual
abuse and family environment raised the possibility
that child sexual abuse was not causally related to
outcomes or was related in a smaller way than
uncontrolled analyses had indicated. To address
this issue, the relationship between family variables
and symptoms was examined. Thus, 18 further
meta-analyses were provided. Two samples, includ-
ing 634 subjects, were used in the suicidal ideation
or behaviour meta-analysis. Results showed that
family environment was significantly related to
suicidal ideation or behaviour (r = 0.26; 95%
confidence interval: [

)0.18 to 0.33]). The magnitude

of such relationship was medium to large, and, thus,
larger than that of the association between child
sexual abuse and suicidal ideation or behaviour.

Discussion

Main results from the studies

i) Across methodologies, samples, and mea-

sures, there is a statistically significant
association between child sexual abuse and
suicidal

and

non-suicidal

self-injurious

behaviour or ideation.

ii) The magnitude of the relationship between

child sexual abuse and suicide and non-
suicidal self-injury ranges from small to
medium.

iii) Child sexual abuse is significantly related

also to several other psychological and
behavioural problems.

iv) Sample source and sample size account, in

part, for effect size variance, with studies
with smaller samples and subject samples
drawn from clinical populations reporting
larger effect sizes.

v) All the other moderators generate conflicting

or non-significant results: more severe and
traumatic forms of sexual victimization such
as those involving force, violence, penetra-
tion, longer duration, and high frequency of
sexual contact do not increase the likelihood
of suicide and non-suicidal self-injury in
people who have been sexually victimized
as children.

The results of the four meta-analyses included

in

this

systematic

review

show

that

across

Maniglio

36

methodologies, samples, and measures, survivors
of child sexual abuse are significantly at risk of
suicide and non-suicidal self-injury. However, child
sexual abuse was significantly related also to
several other psychological and behavioural prob-
lems. Therefore, child sexual abuse should be
considered a general, non-specific risk factor for
suicidal and non-suicidal self-injurious behaviours.

The magnitude of the relationship between child

sexual abuse and suicide and non-suicidal self-
injury ranged from small to medium. Moderator
analyses revealed that sample source and sample
size accounted, in part, for effect size variance.
More specifically, studies with smaller samples
reported larger effect sizes. This result suggests the
possibility of publication bias, with smaller studies
with positive findings being more likely to be
published than smaller studies with null or negative
findings (24). Furthermore, subject samples drawn
from clinical populations yielded larger effect sizes
than did subject samples drawn from non-clinical
samples. This result suggests that psychiatric sam-
ples tend to exclude well-adjusted survivors of
sexual abuse because these samples are likely to
constitute the negative extreme of abuse outcomes
(31). In contrast, community and student samples
tend to include more well-adjusted abuse survivors,
because a certain level of wellness is required to
perform daily activities, such as occupational tasks,
school

obligations,

family

responsibilities,

or

household activities.

All the other moderators generated conflicting or

non-significant

results.

Many

clinicians

and

researchers (see, e.g., 11, 14, 15) have suggested
that the relationship between child sexual abuse
and suicide and non-suicidal self-injury may be
greater for more severe and traumatic forms of
sexual victimization, such as those involving force,
violence, penetration, longer duration, and high
frequency of sexual contact. Nevertheless, the
results of this systematic review do not confirm
suspicions that such factors concerning aspects of
the abuse experience increase the likelihood of
suicide and non-suicidal self-injury in people who
have been sexually victimized as children.

Causality issues

The results of this systematic review show a
statistically significant, but modest association
between child sexual abuse and suicidal and non-
suicidal self-injurious behaviours. However, it
should be noted that causal inferences cannot be
made, because of the presence of confounding
variables and methodological weaknesses in the
studies included in each review. Many of the

studies investigating the relationship between
child abuse and suicide or non-suicidal self-injury
are characterized by a generally poor methodolog-
ical quality (14). Indeed, most studies have design,
sampling, and measurement problems, such as
poor sampling methods, absence of appropriate
comparison groups, inadequate operationalization
and measurement of abuse histories and outcomes,
insufficient control for effect modifiers and con-
founders, or designs inappropriate to prove cau-
sality. In addition, it should be noted that all the
reviews included in this systematic review did not
assess data quality and validity and aggregated
different study findings, particularly those with
different levels of methodological quality. There-
fore, findings should be interpreted cautiously.

Most importantly, much of the traditional

empirical research on the relationship between
child sexual abuse and suicide or non-suicidal self-
injury has not controlled for the overlap with other
biological, psychological, or social factors that
increase the risk of suicidal and non-suicidal self-
injurious behaviours (see e.g., 11). Thus, it is
unclear whether suicide and non-suicidal self-
injury in subjects who have been sexually abused
in childhood may be attributable to early sexual
abuse or whether suicidal and non-suicidal self-
injurious behaviours may be attributable to other
risk factors that may precede, accompany, or
follow the experience of child sexual abuse.

Several reviews have shown that suicide and

non-suicidal self-injury are related to genetic com-
ponents (47–56), abnormalities in the serotonergic
system (57–60), other forms of child abuse, espe-
cially emotional (61) and physical maltreatment
(21, 62, 63), dysfunctional family relationships and
climate, especially impaired or unsatisfying parent–
adolescent relationships, unsupportive parenting,
high family conflict, low family cohesion, parental
divorce, and ineffective family communication (20,
21, 34, 64), personality variables, especially aggres-
sion (21, 32, 65–67), impulsivity (21, 32, 67),
hopelessness (20, 21, 32, 65, 68, 69), negative
affectivity (see 70), and ineffective problem-solving
ability (21, 32), and psychiatric disorders (20, 21,
65), especially schizophrenia (71, 72) depressive
(73–76), personality (77; see also 78), and sub-
stance-related disorders (79–82), anorexia nervosa
(83, 84), and bipolar (76, 85-87; see also 88),
attention deficit hyperactivity (89), and posttrau-
matic stress disorder (90).

Some of these factors might better account for

the risk of self-injury and suicide in people who
have been sexually victimized as children, rather
than the experience of child sexual abuse itself
having a causal role in the etiology of suicide and

Child sexual abuse and self-injury

37

non-suicidal self-injury. More specifically, there is
evidence that the various forms of child maltreat-
ment are highly prevalent and intercorrelated in
dysfunctional families (13, 63, 91, 92). Speaking
more broadly, it has been noted that, in these
distressed families, it is difficult to determine the
specific effects of child sexual abuse over and above
the effects of dysfunctional environment and
genetic contribution (14, 63, 91, 93), because of
the high prevalence of family problems and co-
occurring forms of child maltreatment as well as
histories of substance abuse, psychiatric disorders,
and suicidal behaviour among parents that may be
transmitted to their offspring (93). For example, in
the meta-analysis by Klonsky and Moyer (24),
those studies that controlled for borderline per-
sonality disorder and family environment revealed
a minimal or negligible relationship between child
sexual abuse and non-suicidal self-injury. In the
meta-analysis by Rind et al. (31), certain family
variables (e.g., family structure, conflict, pathol-
ogy, support or bonding, and traditionalism) were
confounded with child sexual abuse and more
strongly related to suicidal ideation and behaviour
than was child sexual abuse.

In sum, it is possible that, in abusive contexts or

dysfunctional families, both environmental and
biological factors may increase the risk of suicidal
and non-suicidal self-injurious behaviours in off-
spring (93). Multiple risk factors for suicide and
non-suicidal self-injury other than child sexual
abuse, such as a family history of suicidal behav-
iour, mental illness, or substance abuse in parents
and offspring, family conflict or dysfunction, and
other forms of child abuse, might also be present in
these dysfunctional contexts. Some of these factors
may be directly responsible for suicide and non-
suicidal self-injury in the survivors of child sexual
abuse.

In addition, other factors may contribute to the

likelihood of suicidal and non-suicidal self-injuri-
ous behaviours in adolescent or adults who were
sexually abused as children by mediating the
relationship between early sexual victimization
and self-injurious behaviour. In fact, it is possible
that the effects of child sexual abuse on later
suicide and non-suicidal self-injury may operate
through the mediating influences of other vari-
ables, such as neurobiological substrates and
certain personality traits or psychiatric disorders.
In other words, it is possible that child sexual abuse
may promote other biological or psychological
conditions which, in turn, might lead the victim to
engage in suicide and non-suicidal self-injury. In
these cases, child sexual abuse would not have a
direct pathway to suicidal and non-suicidal self-

injurious behaviours but instead would have a
direct relationship with another condition, which,
in turn, would have a direct pathway to self-
injurious behaviour.

More specifically, it is possible that child sexual

abuse may influence suicidal and non-suicidal
self-injurious behaviour by negatively affecting
neurobiological or personality development. For
example, it has been hypothesized that sexual
abuse in childhood may set serotonergic function
at a lower level (94). This effect might persist into
adolescence or adulthood, contributing to the
increased risk for suicidal and non-suicidal self-
injurious behaviours. It has been also suggested
that the effects of serotonin hypoactivity and genes
on suicidal behaviour may operate through impul-
sivity and aggression (32, 65). Furthermore, in the
meta-analysis by Klonsky and Moyer (24), those
studies that controlled for hopelessness suggested
that the relationship between child sexual abuse
and non-suicidal self-injury became minimal or
negligible. Therefore, it is possible that the rela-
tionship between child sexual abuse and suicidal
and non-suicidal self-injurious behaviour might be
mediated by neurobiological alterations and some
personality variables, such as impulsivity (95),
aggression (95), poor problem-solving skills (35),
and hopelessness (35).

Most importantly, in many cases, psychological

disturbance, in terms of dysfunctional personality
traits or psychiatric disorders following child
abuse, may lead child sexual abuse survivors to
self-injury to reduce painful abuse-related internal
states. A literature review has shown that most
non-suicidal self-injurers identify the desire to
alleviate negative affect as a reason for self-
injuring and present decreased negative affect
and relief after self-injury (96). It has been
hypothesized that suicidal and non-suicidal self-
injurious behaviours may be seen as emotionally
avoidant coping activities, i.e., behavioural strat-
egies employed to temporarily avoid, reduce,
anesthetize, interrupt, or alleviate unpleasant
internal states, such as, thoughts, memories, feel-
ings, or affects, associated with an abuse history,
to provide survivors with a temporary sense of
calm and relief, at least for some period of time
(10, 12, 16–18, 29, 32, 95–99). In other words, it is
possible that child sexual abuse might lead to
psychic distress, in terms of dysfunctional person-
ality traits, psychiatric disorders, or painful abuse-
related internal states, which, in turn, might lead
child abuse victims to employ emotionally avoi-
dant coping behaviours, such as self-inflicted
injuries, to achieve temporary relief, especially
when these individuals also have concurrent prob-

Maniglio

38

lem-solving deficiencies or poor coping skills (100,
101). Although often effective in the short term,
emotionally avoidant coping strategies are rarely
adaptive in the long term, leading to repeated
cycles of self-inflicted injuries in the presence of
future pain, subsequent calm, the slow building of
further tension, and, ultimately, further self-harm
(16).

In conclusion, the results of this systematic review

reveal that the role of child sexual abuse in the
etiology of suicide and non-suicidal self-injury is
complex. Being a victim of child sexual abuse is a
significant, although general and non-specific, risk
factor for suicidal and non-suicidal self-injurious
behaviour and ideation. However, child sexual abuse
is not the only important risk factor for suicide and
non-suicidal self-injury. Evidence to date suggests
that, in many cases, child sexual abuse has not a
primary role in the etiology of suicidal and non-
suicidal self-injurious behaviour. Additional biolog-
ical, psychological, and social risk factors, such as
serotonin hypoactivity and genes, family dysfunc-
tion, co-occurring forms of child maltreatment, and
certain personality traits and psychiatric disorders
may, in some cases, be directly responsible for suicide
and non-suicidal self-injury, or, in other cases,
contribute to the risk of self-inflicted injuries by
mediating the relationship between child sexual abuse
and suicide and non-suicidal self-injury. However, it
is apparent that being a victim of child sexual abuse
may sometimes confer additional risk of suicidal and
non-suicidal self-injurious behaviour either as a
distal and indirect cause or as a proximal and
direct cause. Thus, child sexual abuse should be
considered one of the several risk factors for suicide
and non-suicidal self-injury and included in multi-
factorial etiological models to elucidate the mecha-
nisms that contribute to self-injury in survivors of
child abuse. To achieve this goal, several methodo-
logical advances in research in this area are required,
such as use of longitudinal designs, control for
confounders, employment of study samples repre-
sentative of the general population and matched
comparison groups, and, for literature reviews,
assessment of data quality and validity.

Acknowledgement

I thank Oronzo Greco, MD, University of Salento, Lecce,
Italy, for his help on study selection, data abstraction, and
quality assessment.

Declaration of interest

This study has no external funding source and was not
financial supported. The author has indicated he has no

financial relationships relevant to this article to disclose. The
author has not other interests in specific in relation to the
pharma industry without any direct connection to this study.

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