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Cumulative trauma: The

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adult sexual assault, and
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Article in Journal of Traumatic Stress · January 1996

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Journal of Traumatic Stress, Vol. 9, No. L 1996

Cumulative Trauma: The Impact of Child

Sexual Abuse, Adult Sexual Assault, and
Spouse Abuse
Victoria M. Follette, t Melissa A. Polusn~ 1 Anne E. Bechtle, 1 and
Amy E. Naugle 1

The present study investigated the relationship between trauma symptoms and
a history of child sexual abuse, adult sexual assault, and physical abuse by a
partner as an adult. While there has been some research examining the
correlation between individual victimization experiences and traumatic stress,
the cumulative impact of multiple victimization experiences has not been
addressed. Subjects were recruited from psychological clinics and community
advocacy agencies. Additionally, a nonclinical undergraduate student sample
was evaluated. The results of this study indicate not only that victimization
and revictimization experiences are frequent, but also that the level of trauma
specific symptoms are significantly related to the number of different types of
reported victimization experiences. The research and clinical implications of
these findings are discussed.
KEY WORDS: c u m u l a t i v e trauma; sexual abuse; partner abuse; sexual assault.

The frequent occurrence of interpersonal violence perpetrated against

women has long been noted by advocates working in community agencies
that offer victim services. Moreover, there is evidence that this violence
has a serious negative impact on women's psychological functioning
(Browne & Finkelhor, 1986; Goodman, Koss, & Russo, 1993; Polusny &
Follette, 1995). Research investigators have documented posttraumatic
stress symptoms in women reporting experiences of childhood sexual abuse
(Briere & Runtz, 1987), adult sexual assault (Kramer & Green, 1991; Roth-

1Department of Psychology/Mail Stop 298, University of Nevada, Reno, Reno, Nevada 89557.

25
0894-9867/96/0100-0025509.50/1© 1996InternationalSocietyfor Traumatic Stress Studies
26 Follette et al.

baum, Foa, Riggs, Murdock, & Walsh, 1992), and physical abuse by a
spouse or partner (Houskamp & Foy, 1991; Kemp, Rawlings, & Green,
1991; Walker, 1991). Although there is some data on the prevalence of
revictimization experiences, empirical evidence demonstrating both the
presence of revictimization and the cumulative impact of those experiences
is limited.
A number of empirical studies examining violence against women
have supported the hypothesis that women who were sexually abused as
children show an increased likelihood of being revictimized later in life. A
history of childhood sexual abuse has been associated with subsequent sex-
ual assault or rape as an adult, as welt as physical abuse by a partner (Briere
& Runtz, 1987). Gorcey, Santiago, and McCall-Perez (1986) found that
37% of their sample of child sexual abuse survivors reported being raped
as teenagers or adults. In a study investigating revictimization experiences
in sexual abuse survivors, Wyatt, Guthrie, and Notgrass (1992) found that
56% of abuse survivors compared to 21% of nonsexually abused women
experienced adult sexual assault. Briere and Runtz (1987) found that 49%
of sexually abused women compared to 18% of nonabused women reported
being battered by a partner. Additionally, Russell (1984), interviewing a
group of victims disclosing rape or attempted rape, found that more than
fifty percent indicated prior sexual assault experiences. Dutton, Burghardt,
Pert'in, Chrestman, and Halle (1994) found that 49% of battered women
in their sample reported a history of sexual victimization before the age of
17. Kemp et al. (1991) similarly indicated that 66% of their sample of bat-
tered women reported a history of prior physical or sexual abuse during
childhood or as adults.
Thus, while research has investigated the prevalence of revictimiTation
in women, the cumulative impact of these different types of victimization
experiences has not been sufficiently addressed. Gold, Milan, Mayall, and
Johnson (1994) found that women sexually abused as children and sexually
revictimized as adults reported higher ~ a u m a Symptom Checklist (TSC)
scores than women sexually abused as children or adults only. While the
findings of this study suggested a cumulative impact for sexual trauma, the
effect of physical abuse by a partner on reported levels of trauma was not
investigated.
Research investigating the effects of domestic violence has examined
variables that contribute to the development of trauma related symptoms
in battered women. Houskamp and Foy (1991) reported that "a primary
etiological variable for the development of PTSD in battered women may
be the intensity of their exposure to violence" (p. 373). In a study investi-
gating posttraumatic stress disorder (PTSD) symptoms in battered women,
Kemp et al. (1991) reported that the frequency and severity of battering
Cumulative Trauma 27

experienced by women was significantly associated with the presence and

level of PTSD symptoms. The length of the battering relationship was less
strongly related to PTSD outcome variables. However, in both of these
studies the authors did not report analyses that also examined the cumu-
lative impact of other victimization experiences (such as rape and childhood
sexual abuse). Another limitation of these studies is that the focus on PTSD
may not be the most useful conceptual model for understanding the se-
quelae of certain trauma experiences, especially sexual traumas (Finkelhor,
1990).
The present study provides an empirical investigation of the prevalence
of a broad range of victimization experiences in a sample of women seeking
psychological and advocacy services from a number of community agencies.
While previous studies have investigated the impact of trauma using the
TSC with undergraduate students, this study examines a more ecologically
valid sample in that it assesses women seeking services in the community.
Data from a group of women who were not seeking services was also col-
lected in order to explore differences in trauma histories in a nonclinical
sample. In order to evaluate the impact of these trauma experiences, this
study employed the "l]:auma Symptom Checklist (TSC-40; Briere & Runtz,
1989). The use of this measure represents a more precise appraisal of the
presence of trauma related symptoms that is tailored to assess the specific
sequelae of sexual abuse trauma. We hypothesized that a community sample
of women seeking psychological and advocacy services would report more
types of victimization experiences and higher levels of trauma symptoms
than a nonclinical sample of female undergraduate students. We further hy-
pothesized that multiple trauma experiences would lead to increased trauma
symptoms, and that as the number of different types of traumatic experi-
ences increased, subjects would demonstrate a cumulative impact of trauma.

Method

Subjects
The total sample consisted of 210 female subjects. Clinical/community
participants were recruited from psychological clinics (n = 28) and com-
munity advocacy agencies (n = 44). Community agencies included local
domestic violence shelters and the domestic violence advocacy service cen-
ter at the city attorney's office (n = 37) as well as the local rape crisis
center (n = 7). Eighty-one percent of the clinical/community sample re-
ported participating in some form of psychological treatment. Nonclinical
subjects (n = 138) were recruited from the undergraduate subject pool at
28 Follette et al.

a western state university. Thirty-seven percent of students reported a his-

tory of previous psychological treatment. Students received course credit
in exchange for their research participation.
The mean age of the women in the study was 23.5 years (SD = 7.3)
with a range of 17 to 52. The majority of women were Caucasian (86%).
Seven percent were Asian/Pacific Islander, 3% were Hispanic/Latino, 2%
were Native American, and 1% were African American. The majority of
the women also indicated at least some college education (67%). Approxi-
mately 66% of subjects were single, 20% were married or cohabiting, and
14% were separated or divorced.

Measures

Personal Data Survey. The Personal Data Survey (PDS) is a self-report

inventory that was developed by the investigators to assess standard demo-
graphic information, such as marital status, ethnicity, socioeconomic status,
and use of psychotherapy services. Additionally, the PDS assessed subjects'
history of childhood sexual abuse and adult sexual assault. Sexual victimi-
zation experiences were assessed using multiple behaviorally specific ques-
tions as suggested by Russell (1986). Characteristics of the abuse, including
type of sexual contact, age of onset, duration of abuse and relationship to
perpetrator were assessed. Child sexual abuse was defined as follows: any
forced or pressured sexual contact between the subject and someone older
before the age of 18. Sexual contact included kissing in a sexual way, touch-
ing in a sexual way without involving sexual intercourse, and sexual inter-
course of any type (oral, anal, or vaginal). Adult sexual assault was defined
as forced or pressured sexual contact involving penetration (e.g., sexual in-
tercourse of any type including oral, anal, or vaginal) that occurred after
the subject's 18th birthday.
Physical abuse by a past or current partner was assessed using the
violence subscale of the Conflict "Ihctics Scales (CTS; Straus, 1990). The
CTS is a measure frequently used to assess conflict management strategies.
Alpha coefficients for the physical aggression scale of the CTS are reason-
ably high, ranging from .69 to .88 for husband to wife abuse. Evidence
from a broad range of studies also suggests that the CTS is a valid measure
of conflict within families (Straus, 1990). Behaviorally specific items ranging
from "threw something at you" to "used a knife or a gun" were coded
dichotomously. That is, the subject endorsed whether these behaviors had
ever occurred with either a current or past partner. The following CTS
items were used to define physical aggression: "pushed, grabbed or
shoved," "slapped," "kicked, bit, or hit with a fist," "hit or tried to hit with
Cumulative T r a u m a 29

an object," "beat up, .... threatened with a knife or gun," and "used a knife
or gun." Current or past physical violence by a partner was defined as the
presence of at least one incident of physical aggression by a partner as
measured by the CTS.
Trauma Symptom Checklist-40 (TSC-40). The TSC-40 (Briere &
Runtz, 1989) is a 40-item self-report instrument designed to identify the
nature and extent of trauma-related symptoms on six subscales (Anxiety,
Depression, Dissociation, Sexual Abuse ~ a u m a Index, Sexual Problems,
and Sleep Disturbance). Research has supported the reliability and validity
of the TSC-40 as a measure of the long-term correlates of childhood sexual
abuse (Elliott & Briere, 1991, 1992). TSC-40 total scores yield an alpha of
.90, and the mean internal consistency for the subscales is .69 (Elliott &
Briere, 1992). Additionally, the TSC-40 has been used to distinguish an
adult sample of childhood sexual abuse survivors from a nonabused clinical
sample (Briere & Runtz, 1989). The TSC-40 has empirically demonstrated
differences in symptoms between adults with different child abuse histories,
such as physical, sexual, and emotional abuse (Briere & Runtz, 1990).

Procedures

All participants were given a description of the study and a packet

of materials to complete, including the PDS and the TSC-40. Subjects seek-
ing services from psychological clinics and community agencies completed
materials at the time of their initial intake. Upon completion, packets were
placed in a collection box or mailed to the experimenters. All responses
were anonymous to ensure confidentiality.

Results

Victimization Experiences

The frequencies of various types of victimization experiences for clini-

cal/community and nonclinical samples are reported in Table 1. Overall,
73% of women in this sample reported at least one type of victimization
during childhood or as an adult. Forty nine percent of the women indicated
a history of child sexual abuse, 17% reported adult sexual assault, and 55%
reported physical abuse by a partner.
30 FoHette et al.

Table 1. Percentage of Subjects Reporting Different Types of Victimization

Experiences
Clinical/Community Nonclinical/Student
n ffi 72 n = 138
Child sexual abuse 65 40
Adult sexual assault 40 5
Physical partner abuse 79 43

Table 2. Mean Composite and Subseale Scores on the Trauma Symptom Checklist-40
Clinical/Community Nonclinical/Student
(n = 72) (n = 138)
M SD M SD t

TSC Total score 48.3 20.3 29.4 16.8 7.20*

Anxiety 9.5 4.8 6.1 3.9 5.47*
Depression 12.7 5.5 7.0 4.5 8.01'
Dissociation 6.6 4.6 4.4 3.5 3.94*
Sexual Abuse Trauma Index 7.6 4.7 3.8 3.5 6.58*
Sexual Problems 7,8 5.6 4.2 4.3 5.15"
Sleep disturbance 10.5 4.5 6.5 4.1 6.49*
•io < .0001.

Trauma Symptoms

Table 2 illustrates the TSC-40 composite and subscale scores for clini-
cal/community and nonclinical/student subjects. Women seeking psychologi-
cal and advocacy services reported higher levels of trauma symptoms than
nonclinical, undergraduate females. In a follow-up analysis, subjects were
partitioned into groups by the number of different types of trauma expe-
riences reported. ~ a u m a symptoms, according to TSC-40 subscale scores,
for these groups are presented in Table 3.
The TSC has undergone some revisions and data directly analogous
to our clinical sample is not currently available. However, when examining
a clinical sample of subjects completing the TSC-33, Elliott and Briere
(1991) reported that abused women showed a mean score of 41.4 and non-
abused women had a mean score of 27.7. National standardization data
for the TSC-40 has been recently reported by Elliott and Briere (1992).
Based on a community sample of 2,963 professional women, the mean total
TSC-40 scores were 26.0 and 20.9 for abused and nonabused women re-
 ¢3

gJ
W
Table 3. Mean Subscale Scores on the Trauma Symptom Checldist-40 for Women Reporting Different Levels of Trauma a
No trauma One t ~ e Two types Three types
Subscale M SD M SD M SD M SD F
Anxiety 4.9 2.7 6.7 4.0 8.6 5.0 12.0 4.3 20.1"
Depression 5.4 3.5 8.7 4.9 10.6 5.4 14.9 5.9 24.1"
Dissodation 3.6 3.0 4.5 3.4 6.2 4.2 8.4 5.3 11.5"
Sexual Abuse Trauma Index 2.7 2.3 4.6 3.8 6.3 4.4 9.7 5.2 21.1"
Sexual Problems 3.0 2.8 5.0 4.8 7.0 5.4 9.5 5.6 13.6"
Sleep Disturbance 5.3 3.1 7.7 4.6 9.0 4.2 12.0 4.9 16.8"
aNote. Groups were based on the number of different types of trauma experiences reported including childhood sexual abuse, sexual
assault as an adult, and physical violence by a partner.
*p< .0001.
32 FoUette et al.

spectively. Thus, our TSC scores appear comparable to what has been ob-
served in other studies.
An analysis of variance (ANOVA) was conducted between subjects
who reported zero, one, two or three different types of trauma, with the
dependent variable being the total TSC-40 score. The ANOVA results in-
dicated a significant overall effect for the number of different types of
trauma (F(3, 209) = 26.2, p < .0001). Scheff6 post hoe analyses indicated
that all groups (0, 1, 2, and 3 different types of trauma) differed significantly
from each other in the level of trauma symptoms (t9 < .05). Thus, a cu-
mulative impact for multiple types of trauma experiences was shown, as
measured by the TSC-40. Figure 1 shows the group means for subjects
reporting 0, 1, 2, and 3 types of trauma experiences.

Discussion

The results of this study indicate that both clinical/community and

nonclinical samples reported high rates of child sexual abuse and physical
abuse by a partner. Women seeking services at clinical/community agencies
reported multiple types of victimization experiences, including high rates
of adult sexual assault. These results empirically validate the anecdotal evi-

TOTAL TSC-40 SCORES BY NUMBER OF TRAUMAS

xt

!
1

No TroJma OneType TwoTypes ThreeTypes

NUMBER OF DIFFERENTTYPES OF TI~AUMA REPOI~TED

Figure 1. Cumulative ~'auma in women reporting different levels of trauma. Note: p <
.05; number of different types of trauma reported by women included childhood sexual
abuse, sexual assault as an adult, and physical violence by partner.
Cumulative Trauma 33

dence provided by many advocacy center workers who report that a sub-
stantial number of their clients experience multiple types of traumas.
Consistent with previous reports (e.g., Browne & Finkelhor, 1986;
Polusny & FoUette, 1995), this study demonstrated that women seeking psy-
chological or advocacy services from community agencies reported signifi-
cantly higher levels of trauma symptoms than a nonclinical sample of
undergraduate females. More importantly, these results indicated that
trauma of an interpersonal nature does indeed appear to be cumulative in
its impact. Individuals who reported multiple types of victimization experi-
ences showed increasingly higher levels of post-trauma symptomatology, as
measured by an instrument specifically designed to assess the effects of those
experiences. Thus, it does not seem to be the case that women habituate
to repeated violent experiences, but rather that they will show increasing
levels of symptoms such as anxiety, depression, and dissociation. The finding
that the level of exposure to traumatic experiences has a cumulative effect
is consistent with findings on combat related PTSD (Foy, Resnick, Sipprelle,
& Carroll, 1987) and rape (Ruch, Amedo, Leon, & Gartrell, 1991).
The revictimization of trauma survivors has important implications for
subsequent psychological functioning. In studies of rape victims, individuals
with previous sexual assault histories tended to have lower levels of global
functioning, prolonged trauma-related symptoms, and were more likely to
develop substance abuse problems (Ruch et al., 1991). Previous histories
of domestic violence also appear predictive of lower levels of functioning
in adult rape victims (Resick, 1993). One implication of the current study
is the necessity for assessing for multiple victimization experiences in clients
who present at either traditional treatment facilities or at victim assistance
agencies such as rape crisis centers. Symptoms from recent traumas may
not only be distressing in and of themselves, but they may also serve to
exacerbate symptoms related to earlier abusive experiences.
These results have further implications for treatment. Exposure to mul-
tiple types of trauma experiences may affect a client's rate of recovery from
subsequent traumatic events. In addition, multiple trauma experiences may
impact both the nature of current presenting problems and the efficacy of
future treatment. More specific treatment planning for survivors of multiple
victimization experiences is needed. Issues surrounding a client's current
risks for revictimization should be carefully addressed in therapy to aid in
the prevention of additional victimization experiences. Research is needed
to understand the specific processes that may make the client vulnerable to
revictimization, such as the use of chemically or psychologically induced dis-
sociation strategies. Additionally, research aimed at identifying specific skills
deficits that may increase vulnerability to victimization is needed.
34 FoHette et al.

The current study provides ecologically valid data, in its use of clients
seeking services from a variety of sources, including community agencies
that are not often included in empirical studies. Moreover, it adds to the
growing body of literature documenting the high levels of violence perpe-
trated against women in our culture. Given our source of subjects, it is not
particularly surprising that nearly three fourths of our total sample had at
least one victimization experience. An examination of the data indicates
that two thirds of our clinical/community subjects had some history of child
sexual abuse. Even our nonclinical undergraduate sample indicated a high
level of trauma experiences, with almost forty percent of them reporting
childhood sexual abuse experiences and over 40% of them reporting physi-
cal abuse by a partner. These findings are quite consistent with what has
been reported elsewhere (Briere & Runtz, 1987), providing additional evi-
dence for the ubiquity of victimization against women in our society.
While this research provides important evidence for the cumulative
impact of trauma, several limits of the current study should be mentioned.
One limit of this study is that the majority of subjects were Caucasian
(86%). Although the ethnicity demographics of this study are consistent
with those of the TSC-40 validation study reported by Elliott and Briere
(1992), caution should be used when generalizing the results of this study
to other ethnic and cultural minority groups. A second limit of this study
is the retrospective nature of this research. As noted by Briere (1992), the
passage of time and current levels of psychological distress may influence
the accuracy of subjects' recollections of traumatic events. Finally, the re-
suits of this study are limited by the narrow focus on investigating the im-
pact of childhood and adult sexual victimization and adult partner violence
on trauma symptoms. Other life events and stressors as well as potential
mediating variables were not addressed by this study.
It is extremely important that researchers not only continue to docu-
ment the presence of victimization and its consequences, but also that they
work to develop widespread intervention programs. These programs should
target at risk populations, dealing with issues such as substance abuse, skills
deficits, and empowerment strategies. However, the documentation and
treatment of this victimization is not sufficient. As researchers and thera-
pists, we believe that we must also work for sociopolitical changes that will
enhance the lives of all women by decreasing their risk of victimization.

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 Cumulative Trauma 35

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