Child Maltreatment

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A Global Perspective on Child Sexual Abuse: Meta-Analysis of Prevalence Around the World
Marije Stoltenborgh, Marinus H. van IJzendoorn, Eveline M. Euser and Marian J. Bakermans-Kranenburg
Child Maltreat 2011 16: 79 originally published online 21 April 2011
DOI: 10.1177/1077559511403920

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 Child Maltreatment
16(2) 79-101
A Global Perspective on Child ª The Author(s) 2011
Reprints and permission:
[Link]/[Link]
Sexual Abuse: Meta-Analysis of DOI: 10.1177/1077559511403920
[Link]
Prevalence Around the World

Marije Stoltenborgh1, Marinus H. van IJzendoorn1,

Eveline M. Euser1, and Marian J. Bakermans-Kranenburg1

Abstract
Our comprehensive meta-analysis combined prevalence figures of childhood sexual abuse (CSA) reported in 217 publications
published between 1980 and 2008, including 331 independent samples with a total of 9,911,748 participants. The overall estimated
CSA prevalence was 127/1000 in self-report studies and 4/1000 in informant studies. Self-reported CSA was more common
among female (180/1000) than among male participants (76/1000). Lowest rates for both girls (113/1000) and boys (41/1000)
were found in Asia, and highest rates were found for girls in Australia (215/1000) and for boys in Africa (193/1000). The results
of our meta-analysis confirm that CSA is a global problem of considerable extent, but also show that methodological issues dras-
tically influence the self-reported prevalence of CSA.

Keywords
child sexual abuse, epidemiology, gender/sex differences, community samples, adult retrospective reports, cultural/ethnic issues

There is no question about the negative effects of child sexual geographical origin of the samples may influence prevalence.
abuse (CSA) on children’s psychological well-being and their Although geographical area and culture are not isomorphic,
development into adulthood. CSA is associated with a variety differences in cultural beliefs and values might be the underlying
of problems in the short and the long term for both male and mechanism affecting the estimated prevalence of CSA across
female victims (Beitchman, Zucker, Hood, Dacosta, & Akman, countries and continents (Kenny & McEachern, 2000b). For
1991; Beitchman et al., 1992; Browne & Finkelhor, 1986; example, in collectivist cultures like the Asians the needs of a
Chapman et al., 2004; Jumper, 1995; Kendall Tackett, Williams, group tend be considered somewhat more important than those
& Finkelhor, 1993; Paolucci, Genuis, & Violato, 2001; Romano of an individual (Hofstede, 2001). This might result in ignoring
& De Luca, 2001; Spatz Widom, Czaja, & Dutton, 2008; Spatz the abuse experiences of an individual family member in order to
Widom, DuMont, & Czaja, 2007). Although there seems to be protect the family from the shame associated with a reported
some consensus on the global and persistent occurrence of CSA, case of abuse (Back et al., 2003). Also, cultural differences with
controversy exists as to the overall prevalence of CSA with rates regard to sexuality and to sexual restraint might influence the
varying from 0.1% (Mackenzie, Blaney, Chivers, & Vincent, prevalence of sexual abuse and/or the willingness of sexual
1993) to 71.0% (Everill & Waller, 1995). We conducted a com- abuse victims to disclose their experiences (Kenny & McEachern,
prehensive meta-analysis of 217 publications on CSA published 2000b; Runyan, 1998). Examples are the taboo around girls losing
from 1982 to 2008, including 331 independent samples with a their virginity before marriage and the taboo on boys’ homosexual
total of 9,911,748 participants, aiming to reveal the extent of the experiences that are often found in Hispanic cultures (Kenny &
problem and to examine the influence of geographical and sam- McEachern, 2000b).
ple characteristics as well as procedural factors on the estimated Despite the fact that the body of international research about
prevalence of CSA. sexual abuse has widely expanded since Finkelhor (1994)

Influence of Geographical and Sample Characteristics 1

Centre for Child and Family Studies, Leiden University, Leiden, The
Higher prevalences of CSA among girls than among boys are Netherlands
consistently found (Finkelhor & Baron, 1986; Finkelhor,
Corresponding Author:
1994; Pereda, Guilera, Forns, & Gomez-Benito, 2009a; Pereda, Marinus H. van IJzendoorn, Centre for Child and Family Studies, Leiden
Guilera, Forns, & Gomez-Benito, 2009b; Putnam, 2003; University, PO Box 9555, 2300 RB Leiden, The Netherlands
Rind, Tromovitch, & Bauserman, 1998). Besides gender, the Email: vanijzen@[Link]

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80 Child Maltreatment 16(2)

called for more prevalence studies, not much research Incidence and Prevalence
has compared prevalence rates among countries or conti-
For the difference between studies using self-report measures
nents. One meta-analysis reported that the highest preva-
of CSA and informant studies the distinction between inci-
lence rates were found in Africa and the lowest in Europe
dence and prevalence rates might be of interest. Prevalence
(Pereda et al., 2009b). A clue as to what to expect might also
refers to the number of individuals having experienced sexual
come from studies comparing different ethnic groups in
abuse during childhood (Fallon et al., 2010; Peters, Wyatt, &
predominantly Caucasian countries like the United States.
Finkelhor, 1986). Life-time prevalences are generally assessed
In this type of study, Asian minorities often show lower
in self-report studies, since participants are usually asked to
prevalence rates whereas Hispanic minorities often show
report on their experiences of abuse during their entire child-
higher prevalence rates compared to Caucasians (Kenny &
hood and adolescence. Incidence, on the other hand, refers to
McEachern, 2000b). Findings are not unequivocal, however,
the number of new cases of abuse reported or detected during
and it remains to be seen whether the pattern that is found for
a specific, restricted period of time (Fallon et al., 2010; Peters
immigrant groups also emerges from comparisons among
et al., 1986), often in the context of child protective services.
continents.
Incidence studies may underestimate the occurrence of CSA
(Leventhal, 1998) because only a small proportion of abuse
Procedural Factors cases may be reported to child protective services or other
authorities (Goldman & Padayachi, 2000; Leventhal, 1998;
Sampling has been identified more than once as contributing to
Peters, Wyatt, & Finkelhor, 1986). Moreover, incidence studies
the diversity in CSA prevalence rates (Goldman & Padayachi,
capture fewer CSA experiences than prevalence studies
2000; Wyatt & Peters, 1986). It has been argued that lower pre-
because the time frame of incidence studies is more limited
valence rates are found in convenience samples such as college
than the life-time reports in prevalence studies.
student samples that are widely used for research on CSA, com-
However, with regard to studies of CSA based on informants
pared to random samples representing the wider community
(in combination with child protective services files) the distinc-
(Goldman & Padayachi, 2000). A possible reason for the lower
tion between incidence and prevalence may not be as clear-cut
prevalence in college samples is that they may be a psycholo-
as it seems to be. First, the informants might cover more cases
gically healthier group (Goldman & Padayachi, 2000). CSA
than those that are officially reported to child protective ser-
is found to be related to adverse psychological adjustment
vices, certainly in countries without the legal obligation to report
(Jumper, 1995) and as such, better psychological health may
(Euser, Van IJzendoorn, Prinzie, & Bakermans-Kranenburg,
be associated with lower CSA prevalence. College students
2010). Second, it is impossible to ascertain that the cases
may also be more aware of the study’s aims and thus more
reported by informants in incidence studies are the very first
liable to response biases.
sexual abuse experiences of a child and therefore incidence
Studies on CSA also differ in the method of data
studies of CSA might better be regarded as studies of the
collection. Studies in which children or adults report on their
current prevalence of CSA during a limited period of time
own CSA experiences mainly use interviews and question-
(Van IJzendoorn et al., 2007). Based on the above discussion,
naires. Whether or not differences between these two data
prevalence rates from informant studies might underestimate
collection methods are related to differences in prevalence
the prevalence of CSA whereas rates from self-report studies
rates of CSA remains unclear. Some reviews have noted that
might have a bias toward overestimation (Van IJzendoorn, 2007).
studies using interviews show higher prevalence rates than
those using questionnaires (Pereda et al., 2009a; Wyatt &
Peters, 1986) while others did not report such a difference
(Goldman & Padayachi, 2000; Pereda et al., 2009b; Wyatt
Defining CSA
& Peters, 1986). It should be noted that both interviews and In self-report studies, participants are sometimes asked ques-
questionnaires are based on self-reported retrospective recol- tions about CSA without specification of experiences or beha-
lection (Fergusson & Mullen, 1999), with some uncertainty viors that constitute CSA. The answers to these questions may
about whether the reported experiences actually took place be heavily influenced by the participants’ subjective percep-
(Goldman & Padayachi, 2000), although according to Koss tions and definitions of CSA. An extreme example is ‘‘Have
(1993) it is widely accepted that the underreporting of rape is you been sexually abused?’’ (e.g., Diaz, Simantov, & Rickert,
a greater threat to validity than fabrication. Reports of profes- 2002; Hibbard, Ingersoll, & Orr, 1990). This type of question
sionals, dossier or chart reviews, and informant observations does not include a clear operationalization of CSA as presented
of children such as teachers observing their students in primary by the researcher. How CSA is defined and subsequently oper-
schools, do not rely on potentially biased memories of the ationalized might have an impact on the reported prevalence.
respondents and document child abuse from the view of a trained Of course, this is true for both self-report and informant studies.
observer or expert. A possible drawback of such informant stud- A definition of CSA includes several aspects. Defining the cut-
ies is that CSA may be difficult to be detected by informants off age for childhood is an important factor, as is the decision
because CSA might be less ‘‘visible’’ to outsiders than other whether or not to define a minimum age difference between
types of abuse. victim and perpetrator to rule out sexual activity among peers.

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Stoltenborgh et al. 81

Moreover, the acts that constitute CSA are a crucial criterion Mishandeling van Kinderen en Jeugdigen (NPM; Van IJzendoorn
that could influence the reported CSA prevalence. It is easy et al., 2007) in the Netherlands. We expected prevalence rates
to imagine that including, for example, noncontact abuse such to be higher for self-report studies than for informant studies, in
as sexual propositions and exhibitionism would yield higher which case policy decisions might be based on a possible
prevalence rates than including contact abuse only. However, underestimate of CSA prevalence if we have reason to suspect
Pereda et al. (2009b) found no difference in combined preva- that self-reported prevalences would be closer to the true rate in
lence rates between their broad definition (including noncontact the population.
CSA) and their narrow definition (including contact CSA only). We also expected combined rates to be higher for girls than
According to these authors, this puzzling finding is due to the for boys, and higher for studies using a more inclusive defini-
inclusion of some experiences in both their broad definition and tion of CSA compared to studies using a more exclusive defi-
their narrow definition. Related to this issue, the number of ques- nition of CSA. Since previous results were inconclusive with
tions asked in order to assess CSA may affect the prevalence regard to the influence on CSA prevalence of geographical area
estimates to some extent because multiple questions can include of origin of the sample, the method of sampling, and the
more specific information about the definition of CSA than a sin- method of data collection, analyses on these moderator vari-
gle questions can, and more questions might also cover more ables were exploratory.
aspects of CSA, and thus lead to higher prevalence rates.
Method
This Study Literature Search
The current meta-analysis aims at providing an estimate of the Three search methods were used to identify eligible studies,
world-wide prevalence of CSA by integrating prevalence figures published between January 1980 and January 2008. First, we
from a large body of research on CSA and its correlates. We searched the electronic databases PubMed, Online Contents,
focused on unraveling the substantial variation in prevalence fig- Picarta, ERIC, PsychInfo, and Web of Science for empirical
ures reported in primary studies by analyzing the effects of geo- articles using the terms prevalence and/or incidence
graphical and sample characteristics and of procedural factors on combined with one of the following terms: (child*) (sexual)
combined prevalence rates. It is crucial to know whether design maltreatment, (sexual) abuse, and victimization. Second, we
and measurement differences between prevalence studies partly electronically searched the specialized journals Child Abuse
or largely determine the outcomes. Meta-analyses might help to and Neglect and Child Maltreatment with the same terms as
identify the set of studies with optimal design features for com- mentioned above. Third, the references of the collected arti-
parison across time and cultures. cles, dissertations, and book chapters were searched for rele-
We replicated and extended a previous meta-analysis on the vant studies, as were other reviews and meta-analyses on child
same subject (Pereda et al., 2009b) by including a considerably sexual abuse (CSA). Studies were included if the prevalence
larger number of studies (331 studies in our meta-analysis ver- of CSA was reported (a) in terms of proportions at child level
sus 100 in Pereda et al., 2009b) and a larger number of modera- (excluding studies only reporting estimates of the family
tors. A larger number of studies has several advantages. It level) (b) for victims under the age of 18 years in (c) noncli-
increases the power of the analyses, which is important for the nical samples, and (d) if sufficient data were provided to
detection of smaller effect sizes and imperative in case of meth- determine this proportion as well as the sample size.
odological heterogeneity of the studies included in the analyses If publications reported on the same sample or on
(Valentine, Pigott, & Rothstein, 2010). Furthermore, the larger overlapping samples, the publication providing the maximum
number of studies allows us to test the influence of moderators of information was included in the meta-analysis. Thus, the
on estimates of prevalence rates separately for girls and boys, independence of samples and the inclusion of every participant
which was not done by Pereda et al. (2009b). CSA experiences only once in the pertinent meta-analysis were ascertained.
of boys and girls show considerable divergence in prevalence When possible and necessary, the coding form (Table 1) for
and consequences. the study was supplemented with information from the
Another important difference between Pereda et al. (2009b) other—excluded—publications on the same sample. When a
and our meta-analysis is that Pereda et al. (2009b) included only publication reported the prevalence of CSA for more than one
self-report studies whereas we also included informant studies sample separately, for example, for male and female partici-
using reports of professionals. Exploring potential differences pants or for participants of different ethnicities, these subsam-
in prevalence estimates resulting from these rather different ples were treated as independent studies. This procedure
approaches is important because policy decisions regarding yielded 217 publications, published from 1982 to 2008, cov-
several aspects of (the prevention of) CSA are often based on ering a total of 331 samples.
government initiated informant studies such as the National Inci-
dence Study of Child Abuse and Neglect (NIS; Sedlak, 2001) in
the United States, the Canadian Incidence Study of Reported
Data Extraction
Child Maltreatment (CIS; Trocmé, Tourigny, MacLaurin, & We coded three types of moderators: sample characteristics, pro-
Fallon, 2003) in Canada, and the Nationale Prevalentiestudie cedural moderators, and publication moderators (see Table 1).

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82 Child Maltreatment 16(2)

Table 1. Coding System

Variable Coding Description

Sample characteristics
Continent 1 Australia Including New Zealand
2 North America Including USA and Canada
3 Europe
4 Africa
5 South America
6 Asia
Country’s level of economic 1 Developing
development 2 Developed
Ethnicity 1 African American Predominance in sample, based on
reports in the study
2 Caucasian
3 Asian
4 Hispanic
5 African
Age of respondent at assessment Continuous
Gender distribution in sample 1 Male
2 Female
3 Mixed
Procedural moderators
Definition of abuse 1 According to NIS-3 Based on the types of behavior
2 Broader than NIS-3 included in the definition
3 Stricter than NIS-3
Prevalence period 1 0–12 Age criterion that was used to define
2 0–13 CSA; each participant was
3 0–14 included in a single category
4 0–15
5 0–16
6 0–17
7 0–18
8 Limited period: 1 year
9 Limited period > 1 year
Age difference 1 Difference specified The minimum age difference between
2 No difference specified victim and perpetrator in the def-
inition of CSA
Type of instrument 1 Questionnaire
2 Interview face-to-face
3 Telephone interview
4 Computerized interview
5 Observation
6 Reports of professionals
7 Dossier or chart study
Instrument validated 1 No
2 Yes
Number of questions regarding CSA Continuous; if a range was provided,
the minimum number was coded
Respondent 1 Child or adolescent
2 Parent
3 Adult
Response rate Continuous
Sampling procedure 1 Random
2 Modified random
3 Convenience sample
Sample size Continuous
Evidence maltreatment 1 Self-report Self-report was coded when parents
were respondents
2 Informant
Publication moderators
Year of publication Continuous
Publication outlet 1 Journal article
2 Dissertation
3 Book chapter

Note: CSA ¼ childhood sexual abuse.

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Stoltenborgh et al. 83

Sample characteristics comprised the geographical area from 30 publications were coded by two coders. Agreement between
which the sample originated (Australia/New Zealand, North the coders for moderators and outcome variables was satisfac-
America, Europe, Africa, South America, Asia), the level of tory (ks for categorical variables between .52 and 1.00, average
economic development of the sample’s country of origin (high- .78, and agreement between 65 and 100%, average 86%; intra-
resource or low-resource according to the World Economic class correlations for continuous variables between .78 and
Outlook Database [International Monetary Fund, 2010]), the 1.00, average .95; lowest interrater agreement for period of pre-
predominant ethnicity of the sample (only used for the subset valence, complete agreement for continent, economic develop-
of studies originating from the United States and Canada), the ment, ethnicity, age respondent, gender, sample size, evidence,
age of the respondent at the time of assessment (recoded into year of publication, publication outlet).
three categories using the 33rd and 67th percentile scores: <20
years, 20–30 years, >30 years), and the gender distribution in the
sample (100% female, 100% male, or mixed). The coded out-
Meta-Analytic Procedures
come was the proportion of children sexually abused. In order Meta-analytical approaches are well-known in medical sci-
to be able to weight effect sizes, sample size was also coded. ence, for example, to test the effectiveness of an intervention
Procedural moderators included the definition of CSA that on a disease. This type of research question requires methodo-
was coded in accordance with the acts of perpetrators covered logical homogeneity of the studies included that ideally should
by the definition used by the third National Incidence Study be randomized controlled trials. In contrast, our meta-analysis
(Sedlak, 2001; see Appendix). This resulted in three categories included studies that were heterogeneous in their methodology,
ranging from stricter to broader than the NIS-3 definition. and one of our aims was to explore the possible influence of
When the definition of CSA included a smaller set of indicators methodological factors on reported prevalence. This type of
than specified in the Appendix (in most cases, implying indica- approach has been used earlier in other meta-analyses aiming
tors restricted to penetration), ‘‘stricter than NIS-3’’ was coded. at estimating prevalence (e.g., De Sanjose et al., 2007; Pereda
When no more and no less than the perpetrator acts specified in et al., 2009b; Van Os, Linscott, Myin-Germeys, Delespaul, &
the appendix were included in a study’s definition of CSA, Krabbendam, 2009), as well as in many meta-analyses on non-
‘‘according to NIS-3’’ was coded. ‘‘Broader than NIS-3’’ was experimental, correlational studies in human development
coded when noncontact abuse (such as exhibitionism) was (e.g., Barel, Van IJzendoorn, Sagi-Schwartz, & Bakermans-
included in the study’s CSA definition. Kranenburg, 2010; Cyr, Euser, Bakermans-Kranenburg, & Van
Furthermore, procedural moderators included the period of IJzendoorn, 2010; Juffer, & Van IJzendoorn, 2005).
prevalence (0–12, 0–13, 0–14, 0–15, 0–16, 0–17, 0–18, limited The meta-analysis was performed using the Comprehen-
period 1 year, limited period >1 year; each participant was sive Meta-Analysis (CMA) program (Borenstein, Rothstein,
included in a single category), and whether the definition of & Cohen, 2005). For each study, the proportion of abused
CSA in the study included the specification of an age difference children was transformed into a logit event rate effect size and
between victim and perpetrator (difference specified, no differ- the corresponding standard error was calculated (Lipsey &
ence specified). Procedural moderators regarding the measure- Wilson, 2001). After the analyses, the logits were retrans-
ment of CSA were the type of instrument used for the study formed into proportions to facilitate interpretation of the
(questionnaire, face-to-face interview, telephone interview, results. Combined effect sizes were computed using CMA.
computerized interview, observation, reports of professionals, Analyses were carried out both including and excluding
dossier/chart study), whether the instrument was validated (as outlying logit event rates and including and excluding multi-
reported by the studies; yes or no), and the number of questions variate outlying studies. Multivariate outliers were detected
asked (recoded into three categories using the 33rd and 67th after multiple imputation of missing values, using the missing
percentile scores: less than 3, 3–7, 8 or more). Other procedural values analysis in SPSS 17.0. Because no significant differ-
moderators included who the respondent was in the case of self- ences were found between analyses including and excluding
report (children/adolescents, adults, parents), the response rate outliers, results are reported including outliers.
(recoded into three categories using the 33rd and 67th percentile Significance tests and moderator analyses were performed
scores: low [<66.8%], medium [66.8–85.2%], high [>85.2%]), through random effects models (Borenstein, Hedges, &
the sampling procedure (randomized—including random and Rothstein, 2007). Fixed effects models are based on the
modified random samples—, convenience, or other), the sample assumption that effect sizes observed in a study estimate the
size (recoded into three categories using the 33rd and 67th per- corresponding population effect with random error that stems
centile scores: small [<265], medium [265–733], large [>733]), only from the chance factors associated with subject-level sam-
and the kind of evidence used to determine CSA (self-report— pling error in that study (Lipsey & Wilson, 2001; Rosenthal,
scored also when parents reported on abuse of their children— 1991). This assumption is not made in random effects models
vs. informant, based on clinical judgment, medical evaluation, (Hedges & Olkin, 1985). Random effects models allow for the
or jurisprudence). possibility that there are also random differences between stud-
Publication moderators were publication outlet (journal ies that are associated with variations in procedures, measures,
article, dissertation, book chapter, other) and year of publica- or settings that go beyond subject-level sampling error and thus
tion (recoded into decades). To assess intercoder reliability, point to different study populations (Lipsey & Wilson, 2001).

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84 Child Maltreatment 16(2)

To test the homogeneity of the overall set and specific sets Moderator Analyses
of effect sizes, we computed Q-statistics (Borenstein et al.,
The results of all moderator analyses on the set of self-report
2005). In addition, we computed 95% confidence intervals
prevalence studies are presented in Table 2, in the left-hand
(CIs), again based on random estimates, around the point esti-
column for girls and in the right-hand column for boys. The
mate of each set of effect sizes. Q-statistics and p-values were
results of the moderator analyses using gender are presented
also computed to assess differences between combined effect
separately in the next paragraph.
sizes for specific subsets of studies grouped by moderators.
Sample characteristics. The result of the moderator analysis
Again, the more conservative random effects model tests were
for gender (female, male, mixed) was significant, Q(2) ¼
used. Contrasts were only tested when at least two of the sub-
105.33; p < .01, as was the result of the analysis contrasting
sets consisted of at least four studies (Bakermans-Kranenburg,
studies with female and male samples, Q(1) ¼ 92.63; p <
van IJzendoorn, & Juffer, 2003).
.01. The combined prevalence for female samples was 18.0%
We used the ‘‘trim and fill’’ method (Duval & Tweedie,
(95% CI: 16.4–19.7%; p < .01), for male samples 7.6% (95%
2000a, 2000b) to calculate the effect of potential publication
CI: 6.6–8.8%; p < .01), and for samples with mixed gender
bias on the outcomes of the meta-analyses. Using this method,
8.7% (95% CI: 6.5–11.6%; p < .01). Because the confidence
a funnel plot is constructed of each study’s effect size against
intervals of female and male samples did not overlap, we
its precision (usually plotted as 1/SE). These plots should be
decided to conduct further moderator analyses separately for
shaped like a funnel if no publication bias is present. However,
female and male samples (see Table 2).
since smaller studies and studies with nonsignificant results are
Significant differences were found between the continents
less likely to be published, studies in the bottom left-hand cor-
of origin of the sample for girls as well as for boys. The highest
ner are often omitted (Duval & Tweedie, 2000b; Sutton, Duval,
combined prevalence was found in Australia for girls and in
Tweedie, Abrams, & Jones, 2000). We used the logit of the
Africa for boys whereas the lowest combined prevalence was
reported prevalence as effect size. The k right-most studies con-
found in Asia for both genders. This can also be seen in
sidered to be symmetrically unmatched were trimmed. The
Figure 1, representing the results of moderator analyses using
trimmed studies can be replaced and their missing counterparts
gender, carried out separately for each continent. Significant
imputed or ‘‘filled’’ as mirror images of the trimmed outcomes.
gender differences were found in Asia, Australia, Europe, and
This then allows for the computation of adjusted overall effect
United States/Canada, with girls showing a higher combined
sizes and confidence intervals (Gilbody, Song, Eastwood, &
prevalence than boys. With respect to the level of economic
Sutton, 2000; Sutton et al., 2000).
development of the sample’s country of origin, significant
differences were found for boys but not for girls. For boys, the
Results combined prevalence was higher in low-resource countries
than in high-resource countries. When ethnicity was used as a
Combined Prevalence moderator on the subsample of studies with samples originating
The combined prevalence for the total set of studies (k ¼ 331, from the United States and Canada, differences between ethnic
N ¼ 9,911,748) was 11.8% (95% CI: 10.0–13.8%; p < .01). groups were found for boys but not for girls. For boys only, the
The set of studies was heterogeneous, Q(330) ¼ 269,244.78; combined prevalence for African American samples was higher
p < .01, indicating that differences among the effect sizes than for Caucasian samples. No significant differences were
existed within this set of studies that originate from another found related to the age of the respondent at the time of the
source than sampling error. We conducted a moderator analysis study, indicating a comparable combined prevalence for studies
contrasting self–report studies with studies based on informants, using respondents younger than 20-years-old, 20–30-years-old,
which was significant, Q(1) ¼ 30.03; p < .01, reflecting a differ- and older than 30 years.
ence in combined prevalence between studies using informants Procedural moderators. Figure 2 shows the procedural
and studies using self-report measures of CSA. The combined moderator analyses resulting in significant effects for girls,
prevalence was 0.4% (95% CI: 0.1–1.5%) for informant studies boys, or both genders. Regarding the definition of CSA, signif-
(k ¼ 8, N ¼ 9,500,797) and 12.7% (95% CI: 10.7–15.0%) for icant differences were found for girls only, with the studies
self-report studies (k ¼ 323, N ¼ 410,951). The confidence using the NIS-3 definition yielding the highest combined pre-
intervals of informant and self-report studies did not overlap. valence, followed by studies using a broader definition. Studies
Therefore, these sets of studies were treated as representing using a stricter definition reported the lowest combined preva-
separate populations of studies. We report the results of the lence. For girls, the combined prevalence differed according to
moderator analyses for the set of self-report studies only because the period of prevalence used in studies in order to assess the
moderator analyses were not possible within the set of informant occurrence of CSA. The combined prevalence was highest in
studies due to the small number of studies. studies using a 0–14 year period, followed by 0–16 and 0–18
Duval and Tweedie’s (2000a, 2000b) trim and fill method periods and by 0–17 and 0–15 periods. The lowest combined
revealed no asymmetry in the funnel plots for self-report and prevalence was reported in studies using a 0–13 period. For
informant studies. The absence of unmatched studies on the right girls and boys, the reported prevalence was significantly influ-
side suggests that asymmetrical publication bias is unlikely. enced by the inclusion or exclusion of an age difference

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 Table 2. Results of Moderator Analyses for Self-Report Studies: Number of Studies and Participants, and Combined Prevalence Including 95% Confidence Intervals (CI)

Female Samples Male Samples

Combined Combined
kc N Prevalence (%) 95% CI Contrast Qa kc N Prevalence (%) 95% CI Contrast Qa

Sample characteristics
Continent 19.28** 10.59*
Africa 8 13,318 20.2** 13.1–29.7 5 1,403 19.3* 8.9–37.0
Asia 11 5,466 11.3** 7.5–16.6 8 3,888 4.1** 2.0–8.3
Australia 12 16,372 21.5** 15.3–29.3 8 10,775 7.5** 3.8–14.2
Europe 39 35,468 13.5** 11.0–16.5 24 26,513 5.6** 3.8–8.4
South America 3 1,564 13.4** 6.2–26.5 2 415 13.8* 3.7–40.0
USA/Canada 120 143,883 20.1** 18.1–22.4 57 99,681 8.0** 6.2–10.2
Economic development 0.89 7.02**
High-resource 174 196,830 18.3** 16.7–20.0 91 138,398 6.8** 5.5–8.2
Low-resource 19 19,241 15.9** 11.9–20.9 13 4,277 14.0** 8.5–22.2
Ethnicityb 5.15 3.90*
African American 12 3,332 26.3** 19.9–33.9 6 1,588 16.5** 7.6–32.1
Asian 1 278 25.0 9.0–53.0 1 192 11.0* 1.5–49.5
Caucasian 71 121,455 18.7** 16.6–21.0 34 88,096 7.2** 5.1–9.9
Hispanic 6 2,427 22.2** 14.7–32.2 3 1,864 7.7** 2.3–23.2
Age of respondent 2.61 2.92
Under 20 years 40 18,586 19.8** 16.4–23.8 19 9,020 6.6** 4.2–10.1
20–30 years 34 15,949 21.0** 17.1–25.5 25 15,344 10.4** 7.2–14.7
Over 30 years 40 47,346 16.8** 13.8–20.4 15 23,194 7.2** 4.4–11.4
Procedural moderators
Definition CSA 8.72** 2.57
Broader than NIS-3 59 44,365 19.1** 16.3–22.2 38 70,949 7.0** 5.0–9.7
Stricter than NIS-3 61 82,403 15.1** 12.9–17.7 38 51,320 6.9** 5.0–9.5
According to NIS-3 47 71,117 21.2** 17.8–25.0 17 11,906 10.7** 6.6–16.8
Period of prevalenced 24.32** 4.26
0–12 3 2,248 6.6** 3.0–13.9 2 287 11.2* 3.0–34.0

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0–13 8 2,562 6.6** 4.0–10.7 7 2,120 10.0** 5.0–19.1
0–14 7 2,623 28.8* 19.2–40.8 4 4,030 9.4** 3.7–21.7
0–15 14 20,390 16.4** 11.9–22.3 5 4,073 12.8** 5.8–26.0
0–16 43 36,657 19.0** 15.9–22.5 27 24,667 7.0** 4.9–9.9
0–17 14 11,045 16.2** 11.7–21.9 10 39,949 5.5** 3.1–9.8
0–18 94 135,778 18.7** 16.6–21.0 46 56,566 6.8** 5.1–9.0
Age difference 8.29** 11.8**
Difference specified 54 31,689 22.0** 18.8–25.6 25 18,935 12.9** 9.0–18.1
No difference specified 139 184,382 16.7** 15.0–18.4 79 123,740 6.2** 5.0–7.7

Type of instrument 10.52* 3.75

Interview face-to-face 41 21,889 17.4** 14.4–20.9 11 8,645 6.5** 3.5–11.6
Interview telephone 14 33,727 13.8** 9.9–18.8 12 21,149 5.4** 3.0–9.4
Questionnaire 127 139,125 19.7** 17.8–21.8 71 98,008 8.2** 6.5–10.3
Questionnaire computer 5 10,082 9.7** 5.4–16.9 6 12,252 4.5** 2.0–9.7

85
(continued)
 86
Table 2 (continued)
Female Samples Male Samples

Combined Combined
kc N Prevalence (%) 95% CI Contrast Qa kc N Prevalence (%) 95% CI Contrast Qa

Instrument validated 0.07 1.82

No 112 142,622 17.6** 15.7–19.8 72 110,655 6.6** 5.2–8.4
Yes 69 68,899 18.1** 15.6–20.8 26 29,124 9.0** 6.1–13.0
Number of questions 30.11** 5.95
under 3 43 94,548 12.0** 10.0–14.3 28 73,051 4.8** 3.3–7.0
3–7 49 60,761 19.9** 17.0–23.1 28 33,808 10.4** 6.2–12.7
8 and over 47 26,807 22.5** 19.2–26.1 21 14,425 7.9** 5.2–11.8
Respondent 0.30 6.84*
Adult 156 124,449 18.4** 16.7–20.2 78 99,769 8.6** 7.0–10.7
Child 36 90,889 17.3** 14.2–21.0 24 42,017 4.7** 3.2–7.1
Response rate 6.40* 10.09**
Low 51 59,139 20.4** 17.2–24.1 25 70,781 6.1** 4.1–9.0
Moderate 48 65,601 14.9** 12.4–17.9 32 50,039 5.0** 3.5–7.1
High 45 72,091 18.8** 15.6–22.5 27 15,852 11.1** 7.7–15.8
Sampling procedure 1.93 12.31**
Convenience 106 60,308 19.1** 17.0–21.3 53 76,953 10.3* 7.9–13.3
Randomized 86 155,711 16.9** 14.8–19.2 51 65,722 5.2* 3.9–6.8
Sample size 25.50** 12.35**
Small 54 9,733 22.0** 18.8–25.4 29 4,760 12.0** 8.6–16.5
Medium 51 34,215 19.8** 17.5–22.3 39 13,804 7.2** 5.4–9.7
Large 55 172,123 13.0** 11.1–15.2 36 124,111 5.4** 4.0–7.2
Background moderators
Year of publication 4.10 1.48

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Before 1990 24 10,969 18.3** 14.4–23.1 10 7,177 5.6** 2.9–10.7
1990–1999 80 52,202 19.8** 17.4–22.4 44 29,413 6.9** 5.4–9.7
After 1999 89 152,900 16.5** 14.6–18.7 50 106,083 8.3** 4.0–7.2
Publication outlet 5.24* —
Dissertation 5 1,822 31.8* 19.6–47.0 1 213 12.2 1.7–52.7
Journal 186 206,035 17.8** 16.3–19.4 102 135,434 7.4** 6.1–9.0
Note: CSA ¼ childhood sexual abuse.
a
Subgroups with k < 4 or ‘‘other’’ categories are excluded from contrasts.
b
For the subset of studies originating from the United States and Canada.
c
Differences in totals of k are due to the exclusion from the pertinent analysis of studies with missing values.
d
All participants are included in a single category.
*p < .05.
**p < .01.
Stoltenborgh et al. 87

55
Girls Boys
50

45

40
Estimated prevalence (%)

35

30

25
**
20 **
Mean
female
15 **
*
10
Mean
5 male

0
Africa Asia Australia Europe South USA/Canada
Americaa

Figure 1. Estimated combined prevalence for self-report studies of CSA, separated according to geographical area of origin of the sample and
to gender, including the overall combined prevalence for girls and boys. Stars represent a significant difference between girls and boys within
a geographical area of origin of the sample (*p < .05; **p < .01).
a
The significance of the analyses on the South American samples could not be tested, due to k < 4.

criterion between perpetrator and victim. The reported age Publication moderators. No significant differences in
difference was usually 5 years (52 out of 54 studies on girls and combined prevalence existed with regard to the year of
all of the studies on boys), and only twice an age difference of 3 publication, independent of the gender of the sample. For girls
years was used. The combined prevalence of studies including but not for boys, the result of the analysis with publication
such an age-difference criterion was higher than the combined outlet was significant. The combined prevalence of the studies
prevalence of studies without an age-difference criterion. reported in dissertations was significantly higher than the
For girls but not for boys, the combined prevalence differed combined prevalence in studies reported in journals.
between the types of instrument used to assess CSA. The lowest
combined prevalence was found in studies using a computerized
questionnaire, the highest in studies using paper-and-pencil Discussion
questionnaires. The combined prevalence of both types of inter- Using meta-analytical methods, we combined prevalence
views – face-to-face and by telephone – was in between the types figures on CSA reported in 217 publications published
of questionnaires. For both genders, whether studies used a vali- between 1982 and 2008. The global prevalence of CSA was
dated or a non-validated instrument was not a factor of influence estimated to be 11.8% or 118 per 1000 children, based on
on combined prevalence. With respect to number of questions, a 331 independent samples with a total of 9,911,748 partici-
larger number of questions about CSA concurred with a higher pants. As hypothesized, a gap existed between the combined
combined prevalence for girls but not for boys. For boys but prevalence from self-report studies and from informant stud-
not for girls, the respondent used in studies mattered with respect ies. The difference was much larger than expected with self-
to the combined prevalence, with adult men showing a higher report studies yielding a combined rate that was 30 times
combined prevalence than boys. higher than the rate of informant studies (127 per 1000 chil-
Regarding response rate, the lowest combined prevalence dren vs. 4 per 1000 children). Sample characteristics and
was found in the medium range for both genders, the highest methodological aspects of the informant studies might
in the low range for girls and in the high range for boys. The account for part of the difference in reported prevalence. For
results of moderator analyses with sampling procedure were example, four out of eight informant studies were based on
significant for boys only. The combined prevalence reported reports of CSA during the last year whereas most of the
in studies using male convenience samples was approximately self-report studies used an up-to-18 year’s period of preva-
twice the combined prevalence reported in studies using male lence. Reporting CSA over a one year period limits the time
randomized samples. Furthermore, the larger the sample size, frame and reduces the number of persons that experienced
the lower the combined prevalence for both girls and boys. CSA compared to reporting CSA over the entire childhood

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88 Child Maltreatment 16(2)

35 35 35
Estimated prevalence (%)

Estimated prevalence (%)

Estimated prevalence (%)

30 30 30
25 25 25
20 20 20
** **
15 15 **
15
10 10 10
5 5 **
5
0 0 0
Stricter NIS-3 broader 12 13 14 15 16 17 18 Specified Not specified

(a) Definition of CSA (b) Period of prevalence (c) Age difference specified

35 35 35
Estimated prevalence (%)

Estimated prevalence (%)

30

Estimated prevalence (%)

30 30
25 25 25
20 **
20 20
15
15 15
10 *
10 10
5
5
0 5 *
0
Interv f- interv quest quest 0
t-f tel comp <3 3–7 >7
Adult Child
(d) Type of instrument (e) Number of questions
(f) Respondent

35 35 35
Estimated prevalence (%)
Estimated prevalence (%)

Estimated prevalence (%)

30 30 30
25 25 25
20 20 20
*
15 15 15
**
10 ** 10 ** 10
5 5 5 **
0 0 0
Low Medium High Randomized Convenience Small Medium Large

(g) Response rate (h) Sampling procedure (i) Sample size

Girls Boys

Figure 2. The influence on estimated prevalence of self-report studies of CSA of (a) the definition of CSA, (b) the period of prevalence, (c) whether an
age difference was specified in the definition of CSA, (d) the type of instrument, (e) the number of questions that were used to assess CSA, (f) the
respondent, (g) the response rate, (h) the sampling procedure, and (i) the sample size. Dotted lines represent the overall mean estimated
reported prevalence for girls and boys. Stars represent a significant difference between categories within female or male studies (*p < .05;
**p < .01).

period. Also, seven out of eight informant studies used professionals, thus excluding unreported cases of CSA that
randomized samples whereas only about half of the self-report might have been reported had self-report measures been used.
studies did so. In the set of male self-report studies random
sampling resulted in a lower reported prevalence compared
to convenience samples, which points to the possibility that Gender
randomized studies are associated with lower estimates. Last A substantial difference in the prevalence of self-reported CSA
but not least, all informant studies used reports registered by was found between girls and boys. This was true globally and

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Stoltenborgh et al. 89

for most continents separately. Women reported CSA more genders in Asia seem to be consistent with the idea that abuse
often than men, which is convergent with the meta-analysis experiences are less often disclosed in a collectivist culture
by Pereda et al. (2009b). The prevalence rates we found were than in individualistic cultures. The highest prevalence for girls
comparable to those reported in Pereda et al. (2009b): 18.0% found in more individualistic countries like Australia and New
for girls and 7.6% for boys (Pereda et al., 2009b: 19.7% and Zealand might partially stem from culturally based willingness
7.9%, respectively). Gender differences for reported preva- to disclose their sexual experiences and the ease with which
lence of CSA may be due to either higher occurrence of CSA they talk about sexuality (Kenny & McEachern, 2000b;
among girls than among boys, or to boys’ more reluctant atti- Runyan, 1998). Values related to taboos on sexuality found
tude toward disclosing their CSA experiences, or both causes in many Hispanic cultures, or shame associated with disclosure
might play a role (Dhaliwal, Gauzas, Antonowicz, & Ross, of CSA, are thought to prevent abused persons from talking
1996; Finkelhor & Baron, 1986; O’Leary & Barber, 2008; about their experiences. In the Hispanic cultures of South
Romano & De Luca, 2001). Men might be reluctant to disclose America one might expect to find fairly low rates of reported
CSA for several reasons, among which feelings of weakness prevalence because of the secrecy around early sexual
and of failure because of society’s traditional view of men as experiences. The high combined rate of 22.2% among the
aggressors rather than as victims (Dhaliwal et al., 1996; female Hispanic American samples is not consistent with this
Romano & De Luca, 2001). expectation. Unfortunately, the number of studies originating
Moreover, boys might be afraid of being considered the from South America was too small to be contrasted with those
instigator of CSA rather than the victim (Dhaliwal et al., of other continents. More studies on the prevalence of CSA
1996), or they may not view their sexual experiences with older research in this geographical area are badly needed.
women as sexual abuse because of sex stereotypes (Coxell, The alternative explanation would be that differences
King, Mezey, & Gordon, 1999). As the majority of CSA perpe- between continents reflect real differences in the prevalence
trators are male, male victims may also fear being regarded as of CSA. Mbagaya (2010), for example, argued that differences
homosexual (Dhaliwal et al., 1996; Romano & De Luca, 2001). in prevalence rates between countries may not (only) be due to
Male victims who disclose their CSA experiences tend to do so disclosure issues but to real socioeconomic and cultural differ-
later than female victims (O’Leary & Barber, 2008). On aver- ences. On the African continent, initiation rites representing the
age, it would take most male CSA victims more than 10 years ‘‘transition into adulthood’’ in early and mid-adolescence may
before they start to discuss their CSA experiences. For women, encourage sexual behaviors with older persons (Mbagaya,
the average period between the CSA experiences and disclo- 2010). Myths associated with HIV cure and avoidance strate-
sure was found to be much shorter (O’Leary & Barber, gies may increase the prevalence of CSA in sub-Saharan Africa
2008). This might contribute to higher rates for girls than for (Lalor, 2008). In addition, young partners are considered less
boys, and explain our finding that for boys the prevalence was likely to have HIV, and are thus preferred as sexual partners
higher in adult samples than in child samples, a finding that was (Madu & Peltzer, 2000). Furthermore, Madu and Peltzer
not replicated for girls. (2000) pointed out that the male dominant society in South
Africa may be responsible for high CSA rates because men
in such societies feel that they have authority over women and
Continent of Origin of the Sample children. The socialization of African children to unquestio-
Continent of origin of the sample influenced the CSA ningly obey older people puts them at risk for sexual abuse
prevalence as well. This converges with the results of the by people to whom they are expected to pay their respects
meta-analysis of Pereda et al. (2009b) but in that meta- (Lalor, 2008; Mbagaya, 2010). Lastly, the rapid social changes
analysis separate prevalences for boys and girls per continent in Africa along with increases in urbanization and individual-
were not reported. It should be noted that most prevalence stud- ism have led to greater isolation of families. In situations where
ies have not been conducted with the explicit goal to compare children are left with biologically unrelated caregivers when
prevalence rates across a variety of cultures. In fact, the cultural parents go to work, the risk of sexually abusive experiences
perspective on prevalence of child maltreatment across cultures increases (Mbagaya, 2010).
is still underdeveloped although recently some progress has
been made (Mbagaya, 2010). Geographical area and culture
may be overlapping but are not necessarily similar, and any
Procedural Moderators
comparison between countries or continents might not be gen- Some procedural factors influenced self-reported prevalence of
eralized to cultural differences. Nevertheless, Hofstede (2001) CSA for boys and girls (e.g., sample size showing the same pat-
proposed some major cultural dimensions that are globally tern of influence for both genders), other factors influenced the
related to countries and geographic areas, and one of the prevalence for only one of the genders (e.g., number of ques-
dimensions is individualism or the emphasis on the collective tions showed a significant effect for girls but not for boys).
(Hofstede, 2001), which might be relevant to child maltreat- Based on the effects on reported prevalence of procedural
ment prevalence estimates. moderators in our set of self-report studies, and the speculation
For example, for girls and boys, we found the lowest com- that the combined prevalence from informant studies might
bined prevalence in Asia. The fairly low CSA rates for both underestimate while the combined prevalence from self-report

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90 Child Maltreatment 16(2)

studies might overestimate the CSA prevalence rate, we suggest as ‘‘During the past week, when being undressed, how often did
some recommendations aiming at the reduction of possible your baby cry?’’ (Infant Behavior Questionnaire; Rothbart,
biases in estimations of CSA prevalence in self-report studies. 1981) provide more precise information than broad questions
The use of sufficiently large population-based randomized such as ‘‘How much does your baby fuss/cry in general?’’
samples is indicated, and this not only because of the formal (Infant Characteristics Questionnaire; Bates, Bennett Freeland,
aspect of generalizability to the general population of a coun- & Lounsbury, 1979). In this study, the use of one or two ques-
try. In our meta-analysis, a lower combined prevalence for tions was associated with a stricter definition of CSA whereas a
self-report studies was found in male randomized samples broader definition of CSA was reflected in the use of more
compared to male convenience samples, and self-report stud- questions. The use of behaviorally specific questions about
ies with larger sample sizes resulted in a lower combined pre- CSA would also eliminate a possible drawback of self-report
valence compared to studies with medium or small sample studies that leave the interpretation of the global term ‘‘sexual
sizes for both genders. The findings indicate that studies with abuse’’ to the participants’ subjective perceptions and defini-
better methodological qualities yield lower estimated preva- tions. Developing an instrument including behaviorally specific
lence rates. Tentatively, this could be seen as evidence that questions based on the rather broad, non behaviorally specific
lower prevalence estimates could be more accurate compared definitions of CSA provided by international organizations
to higher prevalence estimates. might prove to be quite challenging, especially if one would like
the instrument to be universally applicable. The development of
such an instrument might be preceded by a clearer specification
Limitations and Future Research of the acts that constitute CSA according to international organi-
The heterogeneity in the subsets of studies, despite the mod- zations and across a wide variety of cultures. An empirical con-
erators that were taken into account, indicates that the sample ceptual analysis focusing at more concrete and precise
characteristics and methodological factors included in this operationalizations of CSA might be especially useful. Such
meta-analysis did not yet fully explain the vast variation in an approach has, for example, been successful in the area of
self-reported rates of CSA. Unfortunately, the small number attachment and sensitivity research (De Wolff & Van IJzendoorn,
of informant studies did not allow for examining the influence 1997; Posada et al., 2008).
of sample characteristics and methodological factors on the In our opinion, the large costs to society of (the conse-
estimated prevalence. Comparing moderators of prevalence quences of) CSA would warrant the investment in a study using
estimates for informant and self-report studies could add to both informant and self-report measures including multiple
our understanding of the strengths and weaknesses of both behaviorally specific questions in the same large, randomized,
types of studies. population-based sample, as such a study could provide the
Studies using both informants and self-report data within a most accurate estimate of CSA prevalence as a basis for pre-
single, nationally representative randomized sample could ventive policy measures.
contribute to clarifying the large difference in reported preva-
lence between these two study types. To ensure comparability
of the prevalence rates it would be imperative that identical,
clearly operationalized criteria for CSA are used for both the
Conclusion
informant and the self-report measurements. We would rec- The current meta-analysis shows that CSA is a global problem
ommend using CSA criteria that correspond to the legal def- of considerable extent, even though methodological differences
inition of CSA in the specific country, so that the results of between studies have an impact on the reported prevalence of
studies will be useful for local policymakers. Alternatively, CSA. The prevalence rates contrast sharply with the United
the criteria for CSA could be derived from official interna- Nations’ Convention on the Rights of the Child (1989) in which
tional organizations, for example, the definition provided by the 194 ratifying countries (November 2009) explicitly state
the Consultation on Child Abuse Prevention of the World that they shall take all appropriate legislative, administrative,
Health Organization (1999). This would ensure the compar- social, and educational measures, either nationally, bilaterally,
ability of prevalence among countries. or multilaterally, in order to protect children from sexual abuse.
With regard to the measurement of CSA, the results of this The results of our meta-analysis show a lower limit estimate of
meta-analysis emphasize the recommendation of the use of self-reported CSA prevalence in girls of 164/1000 and an upper
multiple behaviorally specific questions instead of a single- limit estimate of 197/1000. For boys, the lower limit is 66/1000
item label question, in line with Koss’ (1993) recommendation and the upper limit is 88/1000. Even the lower bound estimates
with regard to rape. By analogy with the measurement of infant are alarming in their demonstration that CSA is a global phe-
temperament, answers on behaviorally specific questions such nomenon affecting the lives of millions of children.

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Stoltenborgh et al. 91

Appendix A
NIS-3 Definitions of Child Sexual Abusea

Specific Form of Maltreatment (NIS–3 code) Acts/Omissions Included

Penile intrusion (01.0) Sexually assaulting or exploiting a child or permitting sexual assault or exploitation of a
child where acts involving penile penetration of or by child have occurred. Such acts
include oral (fellatio), anal (sodomy), or genital intercourse, whether heterosexual
or homosexual. Category includes cases where sexual exploitation (involving
intrusion) by other persons was knowingly permitted by a person responsible for the
child (e.g., child’s prostitution, child’s involvement in pornography with intrusion,
child’s nonvoluntary involvement in intrusion sex). Category does not include sexual
abuse of an unknown nature, situations encompassed by categories in 02 or 03, nor
inadequate supervision of child’s voluntary sexual activities. The mere presence of
venereal disease does not constitute adequate evidence to support that this form of
maltreatment occurred.
Intrusion by finger or any object (01.1) Sexually assaulting or exploiting a child or permitting sexual assault or exploitation of a
child where acts involving penetration with fingers or any object, of or by child, have
occurred.
Molestation with genital contact (02.0) Sexually assaulting or exploiting a child or permitting sexual assault or exploitation of
a child where acts involving genital contact of or by child—but not involving
(specific indications of) actual intrusion—have occurred. Such acts would include
penile or vaginal fondling or stimulation of or by child, whether heterosexual or
homosexual.
Other or unknown sexual abuse (03.0) Committing or permitting sexual assault, exploitation, maltreatment, or abuse other
than categories 01 and 02, above. This could include: sexual assault or exploitation
where acts did not involve actual intrusion or genital contact (e.g., exposure, inap-
propriate kissing, hugging, fondling of breasts, buttocks, or other nongenital areas,
etc.); and sexual assault or molestation where acts were of unknown or unspecified
nature (i.e., no specific indication that intrusion or genital contact had occurred).
Category includes all allegations involving child’s voluntary sexual activities, such as
allegations concerning inadequate or inappropriate supervision of child’s voluntary
sexual activities. Category does not include attempted, threatened, or potential
sexual assault or exploitation if no actual sexual contact was indicated to have
occurred. When no physical contact appears to have occurred, allegation should be
coded elsewhere (see categories 06b and 07c).
a
Extracted from Sedlak (2001).
b
Emotional abuse, category verbal or emotional assault.
c
Emotional abuse, category other or unknown abuse.

Declaration of Conflicting Interests *Akyuz, G., Sar, V., Kugu, N., & Dogan, O. (2005). Reported child-
The author(s) declared no potential conflicts of interests with respect hood trauma, attempted suicide and self-mutilative behavior
to the authorship and/or publication of this article. among women in the general population. European Psychiatry,
20, 268-273. doi: 10.1016/[Link].2005.01.002.
*Alexander, P. C., & Lupfer, S. L. (1987). Family characteristics and
Funding
long-term consequences associated with sexual abuse. Archives of
MJBK and MHvIJ were supported by awards from the Netherlands
Sexual Behavior, 16, 235-245. doi: 10.1007/BF01541611..
Organization for Scientific Research (MJBK: VIDI grant no. 452-
*Amodeo, M., Griffin, M. L., Fassler, I. R., Clay, C. M., & Ellis, M. A.
04-306; MHvIJ: SPINOZA prize).
(2006). Childhood sexual abuse among black women and white
women from two-parent families. Child Maltreatment, 11,
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