In this sample of women with MDD and sexual abuse histories, having a parent or parent figure as the perpetrator was associated with dramatically increased odds of multiple suicide attempts. This finding is consistent with a prior study,22
which demonstrated a relation between the kinship to the perpetrator and the number of suicide attempts in a community sample. Our study, in contrast, focuses on a clinical sample of women at high risk for suicidal behaviour and seeks to inform the clinical assessment of suicide risk, apart from psychiatric diagnoses of BPD and PTSD. We have demonstrated that perpetrator status has a strong and independent relation to suicide attempt histories. PTSD was associated with having ever attempted suicide, but not with multiple attempts. Although we observed an association between BPD and multiple-attempter status in univariate analyses, that relation is confounded by one or more variables in the multivariate analysis. It may also be that certain features of BPD, such as impulsivity,41
rather than the diagnosis per se, are related to propensity to multiple suicidal behaviour attempts.
According to our findings, women with MDD who have been sexually abused by a parent or parent figure may be at a higher risk for multiple suicide attempts, and close monitoring for suicide risk may be warranted. Prior studies have indicated a higher risk for future suicidal behaviour with increasing numbers of suicide attempts.23–25
Sexual assault by a parent or parent figure is typically accompanied by other family adversities, including parental conflict21
and parental psychopathology.10
Joiner et al20
has described a person’s suicide attempts as a response to perceived burdensomeness, thwarted belonging, and acquired capacity for self-harm. The pain, shame, and alienation of the abused child growing up in such profoundly troubled families may be the bellwether for interpersonal risk factors in adulthood.
Several limitations in these data should be acknowledged. First, the study’s cross-sectional design precludes causal conclusions. Longitudinal studies are warranted to address hypotheses regarding causal pathways. Second, findings may not be generalizable to men and to women with sexual abuse histories not seeking mental health treatment,42
and to those diagnosed with psychosis, schizophrenia, bipolar disorder, mental retardation, and active substance abuse or dependence. Although our sample is limited to women with MDD and childhood sexual abuse histories, our research43
has found that this group represents about 15% to 20% of treatment-seeking women in community mental health care. Third, biases in retrospective reporting of abuse and suicide attempt histories are possible. However, empirical evidence supports the reliability and validity of retrospective reports of suicide attempts.30
A recent large-scale study44
found that a self-report measure of childhood sexual abuse had long-term stability, construct validity, and evidence of familial corroboration. Reviews of the validity of retrospective reporting of childhood abuse have concluded that false positives are rare, whereas false negative are not rare.45,46
In our study, false negatives (that is, denying sexual abuse by a parent when it did occur) would mitigate against finding between-group (parent abuse, compared with no parent abuse) differences. Further, studies have shown that the presence of psychiatric diagnoses, including depression, do not affect the reliability of childhood abuse reports.5,47
Fourth, we acknowledge that the age of abuse onset dichotomization (that is, onset before the age of 6 years, compared with abuse onset after the age of 6 years) can be construed as arbitrary, yet some type of categorization is necessary for scientific communication, and this one had been used effectively in prior research.19
Fifth, associations between sexual abuse characteristics other than parent figure or parent perpetrator and suicide attempt history may be attenuated by the sample size. Finally, adult exposure to IPV or sexual assault was assessed through single-item questions from the TLEQ.39
Other forms of childhood abuse or trauma, which are frequently co-occurring with sexual abuse, could have an effect on suicidal behaviours, as has been shown in several studies.48
Data on PTSD chronicity, which could be associated with multiple-attempter status, were not available.