Certainly, not all childhood sexual abuse survivors are re-victimized. It would be beneficial to understand which characteristics of the child sexual abuse experience increase the probability of being sexually victimized in adulthood. In both a community (Wyatt et al., 1992) and a college sample (Mayall & Gold, 1995), childhood victims of contact sexual abuse, defined as being fondled or experiencing attempted or completed intercourse, reported a higher incidence of revictimization than women who experienced non-contact forms of child sexual abuse such as having a perpetrator expose his genitals. In addition, victims who reported child sexual abuse that involved force or penetration, either vaginal or anal, reported higher rates of revictimization (Collins, 1998; Fergusson, Horwood, & Lynskey, 1997; Koverola, Proulx, Battle, & Hanna, 1996).

However, characteristics of child sexual abuse are frequently intercorrelated. For example, physical force has been associated with penetration and older age at the onset of abuse (Banyard&: Williams, 1996). Therefore, a variety of abuse characteristics including age at onset of abuse, physical force, penetration, and relationship to the perpetrator should be investigated as predictors of sexual revictimization.

Sexual Behavioral Correlates of Adult Sexual Revictimization
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Characteristics of the sexual abuse also can influence sexual behavior, which in turn may be associated with sexual revictimization. For example, women who experienced severe childhood sexual abuse, when compared to their non-abused counterparts, were more likely to engage in consensual sexual activities at younger ages, including petting and intercourse. In addition, they had more sexual partners and briefer relationships (Fergusson et al., 1997; Wyatt et al., 1992). For a substantial percentage of survivors, involvement with multiple partners takes the form of prostitution. In a prospective study of more than 1,000 participants, childhood sexual abuse was a significant predictor of involvement in prostitution (Widom &; Kuhns, 1996). Thus, some victims of childhood sexual abuse may engage in sexual behaviors, such as early sexual activity, involvement with multiple partners, or prostitution, that increase their probability of sexual assaults in adulthood.

When these sexual assaults occur in marital relationships, they are frequently accompanied by wife abuse. Specifically, it is estimated that between 50% and 70% of marital rape victims are battered by their husbands (for a review, see Mahoney & Williams, 1998). This physical violence can range from slapping, kicking, and punching to more serious forms of violence such as beatings and assaults with weapons (Bergen, 1996; Peacock, 1998). This pattern of abuse indicates that women who are sexually re-victimized also arc more likely to be physically battered. The association between revictimization and partner violence warrants further research.

Sexual Health Correlates of Adult Sexual Revictimization
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A literature review indicates that childhood sexual abuse can be associated with a myriad of serious reproductive and sexual health problems including sexually transmitted diseases, unplanned or adolescent pregnancies, spontaneous miscarriages, therapeutic abortions, infertility, menstrual problems, and painful intercourse (Bohn & Holz, 1996). Most studies, however, have not investigated the prevalence of these health problems among sexually re-victimized women. This is an oversight because victims of multiple assaults can be at increased risk for a variety of reproductive symptoms, including painful or irregular menstruation, and sexual symptoms such as painful intercourse (Golding, 1996). In addition, sexually re-victimized women experienced more unintended pregnancies and abortions than women abused in childhood only (Wyatt et al., 1992). These findings suggest that future research should investigate the reproductive and sexual health correlates of sexual revictimization.

ADULT SEXUAL REVICTIMIZATION AMONG BLACK WOMEN

Using a community college sample, researchers discovered that Black child sexual abuse victims, when compared to their White, Latino, and Asian American counterparts, were more likely to be raped as adults (Urquiza & Goodlin-Jones, 1994). However, in a community sample, there were no ethnic differences in the rates of sexual revictimization (Wyatt et al., 1992). Moreover, revictimization among Black women has been linked to the previously discussed sexual behavior correlates including early sexual activity, multiple sexual partners (Wyatt, Notgrass, & Gordon, 1995), and partner violence (Russo, Dcnious, Kcita, & Koss, 1997). Similarly, Black women with histories of multiple sexual assaults, in either childhood or adulthood, reported increased rates of abortion (Russo et al., 1997) and menstrual irregularity (Golding, 1996). Therefore, it appears that the sexual health correlates of revictimization also are similar across racial groups.

Despite the racial similarities, additional research should focus on the abuse experiences of Black women. Specifically, more information is needed on (a) the frequency of Black women who are abused in both childhood and adulthood, (b) which characteristics of the childhood sexual abuse are predictive of adult sexual revictimization, (c) sexual behavior correlates, and (d) sexual health correlates of revictimization. To date, most of this research has been retrospective, which requires participants to accurately recall their childhood sexual abuse. This maybe difficult for some victims; therefore, researchers recommend that prospective studies be conducted (Williams, 1994,1995).

Goals of the Study
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The present study is a prospective investigation of the frequency of adult sexual revictimization in a sample of Black women with documented histories of childhood sexual abuse. It is expected that a substantial percentage of these women will experience adult sexual revictimization. Another goal is to investigate which childhood sexual abuse characteristics are predictive of adult sexual revictimization. It is expected that younger age at onset of abuse, physical force, penetration, and abuse by a family member will predict subsequent revictimization. The final goal is to investigate the link between sexual behavior and sexual health correlates and revictimization. Specifically, sexually revictimized women, when compared to those sexually abused in childhood only, are expected to report earlier consensual sex, more sexual partners, more involvement in prostitution, and partner violence. It is also expected that re-victimized women will report more reproductive and sexual health problems including pregnancies, abortions, sexually transmitted diseases, and menstrual problems.

METHOD

Participants
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Participants were drawn from a sample of 206 victims of child sexual abuse who were examined in the emergency room of a large city hospital in 1973 to 1975. They and/or their family members were interviewed at the time as part of a larger study on the consequences of sexual assault (McCahill, Meyer, & Tischman, 1979). The sample was composed primarily of African American girls (84%) ranging in age from 10 months to 12 years at the time of the abuse. The reported sexual abuse involved sexual contact by force, threat of force, misuse of authority, or by a person who may or may not have used force but who was 5 or more years older than the child.

The abuse ranged from genital fondling to sexual intercourse and was perpetrated by a wide range of individuals—fathers, stepfathers, other family members, friends, acquaintances, and strangers (all males). Soon after each girl was seen in the hospital, consent to participate in the study was obtained from the children and/or their care-givers, and the child and care giver were interviewed. Institutional review board procedures were followed for obtaining consent.

In 1990 and 1991, an average of 17 years after the abuse, 153 of these girls, now adults, were located and asked to participate in the current study. Ten women refused to participate, 7 consented but did not show up for their interviews. A total of 136 women were reinterviewed in 1990 and 1991 (66% of the original sample) as part of a follow-up study of the consequences of child sexual abuse. Legally effective informed consent, including a description of the sensitive nature of some of the material that would be involved, was obtained before each interview. Participants were advised that they could stop the interview at any time and still receive payment (\$30) for their involvement.

Analyses in this article focused on the 113 Black participants (86% of the reinterviewed sample). There were no significant differences between interviewed and non-interviewed Black women on demographic variables or characteristics of the abuse that brought them to the attention of the hospital in the first place. The mean age for this sample at time of reinterview was 25.2 years (SD = 3.20), with a range from 19 to 31 years old. Most (61%) of the participants never had been married. Fifty percent had a high school diploma or GED equivalent. Although 29% were working full- or part-time, a majority were unemployed (64%). The median personal income was less than \$8,000 in the last year prior to interview.

Procedures
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Relying on phone directories, official and government records, and neighborhood canvassing, the women were located in 1990 or 1991 and re-inter-viewed face-to-face. There were no follow-up interviews of the care-givers who were interviewed in the early 1970s. Although a few participants were interviewed in their own homes, almost all were interviewed in a private office. The interviewers were two women, one White and one African American, who had received training and supervision to ensure that they were able to establish rapport with the women and conduct interviews on sensitive and potentially upsetting personal topics. Interviewers were blind to the details of the women's histories of victimization, although they knew the purpose of the study. Each interview began with questions about more neutral aspects of the woman's life such as her education and employment status. After sufficient rapport had been established, questions about other topics such as relationships in her family of origin, drug and alcohol use, sexual history, psychological functioning, and detailed questions about sexual victimization were asked. The interview averaged 3 hours and was followed by debriefing when the woman's questions were answered. There also was a discussion of how she was feeling about the interview. Interviews were suspended if the inter viewer judged that the participant was in any distress, and crisis intervention services from a local sexual abuse treatment center were made available at no cost to all participants if they were interested. Only 3 women used these resources.

Measures

Child sexual abuse. As previously discussed, all the participants in this study experienced documented forms of child sexual abuse ranging from genital fondling to intercourse. Medical records from the visit to the city hospital in the 1970s, as well as data from the 1970s interview with the child and care giver, were used as an indicator of the abuse suffered in the index event The 1990 follow-up interview that gathered data on sexual abuse included 14 questions (patterned after Russell's 1984 questions) about various sexual experiences. Ten of these questions were designed to elicit reports of all the sexual abuse the women suffered in childhood. Answers to these questions have resulted in high rates of disclosure of child sexual abuse when used with other samples (Williams & Finkelhor, 1989). Specific description of these variables are attached in an appendix.

Twelve percent reported no experiences with child sexual abuse. If the woman did not recall her sexual victimization, she was not informed of this by the interviewer (see Williams, 1994, 1995, for a detailed discussion of the issue of forgetting experiences of child sexual abuse for this sample). Sixty-two percent of the women recalled the child abuse recorded in the records from the 1970s (the index abuse), and 68% reported other experiences of child sexual abuse in addition to the index abuse recorded earlier. The child sexual abuse variable in this study was any sexual abuse prior to age 18 that was reported by the women in the 1990s as well as the index incident from the 1970s interview' (see Banyard & Williams, 1996, for a discussion of correspondence between prospective and retrospective data). Multiple incidents of abuse were categorized as child sexual abuse if they occurred prior to age 18.

Characteristics of the child sexual abuse. The current study used multiple indicators of the women's experiences with childhood sexual abuse. Four characteristics of child sexual abuse were assessed: age at the time of abuse, the use of physical force, the type of sexual act involved, and the relationship of the victim to the perpetrator. These characteristics were assessed at two points in time—in the 1970s, shortly after the index event of sexual abuse that brought the child into the hospital, and during the follow-up interview in the 1990s. The variables were assessed using the same definitions for both interviews. These definitions were based on work by Amir (1971).

Age of onset was measured by the youngest age when first sexually abused. Force was measured by the following specific question that was asked about each reported experience of sexual abuse: "Did the perpetrator use physical force (hitting, pushing, beating, or slapping), choking or gagging, or use a weapon to involve you in the sexual contacts?" Penetration was defined as oral, anal, or vaginal. It encompassed both sexual intercourse and digital penetration. Finally, the authors determined whether a participant had experienced intra-familial or extra-familial abuse by using the following criteria. If the sexual abuse was perpetrated by anyone in the immediate or extended family, including stepfathers, the participant was recorded as having experienced intra-familial abuse. To also take into account non-biologically related father figures such as mother's boyfriends, the authors asked participants about these persons. If the individual was a perpetrator and acted as a father figure to the participant, the participant was considered to have experienced intra-familial abuse.

Adult sexual revictimization. Among the 14 questions about various sexual experiences asked during the 1990 follow-up interview, 4 elicited reports of adult sexual victimization (see Williams, Siegel, & Pomeroy, 2000). Participants were categorized as sexually re-Vic-timized only if they reported one or more of these violent incidents after age 18 (see appendix).

Sexual behavior correlates of revictimization. Consensual sexual activity, involvement in prostitution, and partner violence were investigated as possible correlates of revictimization. Consensual sexual activity was measured by the question, "Have you had consensual or voluntary sexual intercourse with a man, that is where he put his penis in your vagina?" If the response was affirmative, the participant was asked to indicate her age at first consensual sex and number of male sexual partners. Involvement in prostitution was measured by the question, "Have you ever agreed to exchange sex for money or drugs, that is engaged in prostitution?" Participants were categorized as victims of partner violence if they reported various forms of physical assaults in the context of a romantic relationship (see appendix).
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RESULTS Frequency of Adult Sexual Revictimization

Thirty percent of participants reported adult sexual revictimization. The number of sexually abusive incidents that occurred in adulthood ranged from 1 to 6, with the majority of participants reporting 1 (79%) or 2 (18%) such incidents.

Predictors of Adult Sexual Revictimization

The characteristics of the child sexual abuse experienced by the women are presented in Table 1. To determine which characteristics might be associated with the likelihood of sexual revictimization, the authors first conducted bivariate analyses. T^est and chi-square tests of significance were used, as appropriate to the level of measurement, for each characteristic of the abuse by revictimization status. There was one significant difference. More revictimized women experienced child sexual abuse that involved physical force, x(2) (1,N'= 104) = 9.6, p< .001. Age at onset of abuse did not differ by revictimization status, t(110) = 1.58, p = .11. In addition, revictimized women were not more likely than those who were not sexually abused in adulthood to experience child sexual abuse that involved penetration, x(2) (1, N= 105) = 1.59, p = .20; or abuse by a family member x' x(2) (1, N= 110) = 1.27,p=.25.

Sexual Behavior Correlates of Revictimization
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There were two significant differences on variables that were identified as possible correlates of revictimization (see Table 3). Specifically, sexually revictimized women were 3 times more likely to have engaged in prostitution, x(2)(1,N=109) =7.28, p<.005. The participants also experienced substantial rates of partner violence. More than one half (55%) reported being hit or beaten by a partner. Thirteen percent of these physically violent intimate relationships involved the use of an object against the participant and 31% resulted in an injury. The number of physically abusive relationships in adulthood ranged from one to five, with a majority of participants reporting one (71%) or two (17%) violent relationships. As predicted, there were differences in partner violence based on revictimization status, with sexually revictimized- women reporting more physical abuse than women abused in childhood only, X(2) (1, N= 108) = 5.67, p <.01.

Sexual Health Correlates of Adult Sexual Revictimization
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Four types of sexual health problems were more common among revictimized women (see Table 4). They were almost 3 times more likely than their non-revictimized counterparts to report repeated vaginal infection,x(2) (1, N= 107) = 7.38, p < .005. They also more frequently reported problems conceiving, X(2) (1, N= 107) = 6.22, p< .01; sexually transmitted diseases,x(2) (1 N 107) =5.70, p<. 01; and painful intercourse, x(2) (1,A'N 107) =4.04,/><.05.

Other types of reproductive and sexual health problems were common among revictimized participants as well. For example, approximately one half reported a miscarriage and painful or irregular menstruation. However, when compared to women who were not revictimized, they were not significantly more likely to experience miscarriages,x(2) (1 N 107) = 0.34. p= .55; irregular periods,x(2) (1 N =107)=1.75, p= .18; painful menstrual cramps,x(2) (1 N=107)= 2.01, p= .15; premenstrual syndrome, x(2) (1 N 107)=2.33,p=. 12; or other gynecological problems, x(2) (1 N =107)=0.15,p=.69.

DISCUSSION
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This study is a prospective investigation of adult sexual revictimization among 113 Black women with documented histories of childhood sexual abuse. The goal was to obtain information on the frequency of Black women who were sexually abused in both childhood and adulthood and to determine which characteristics of the child sexual abuse were predictive of revictimization. Thirty percent of the participants were revictimized, which is consistent with the results in other community samples (e.g., Wyatt et al., 1992; Wyatt et al., 1995). Physical force was the only characteristic of the child sexual abuse that predicted subsequent victimization. Although age at onset, penetration, and abuse by a family member were not significant predictors, it should be noted that these characteristics are intercorrelated (Banyard & Williams, 1996).

This study also investigated possible sexual behavior correlates of revictimization. Revictimized women did not have consensual intercourse at younger ages or more male sexual partners. However, they were 3 times more likely than their nonrevictimized counterparts to report a history of prostitution. As previously discussed, childhood sexual abuse has been linked to involvement in prostitution (Simons &: Whitbeck, 1991; Widom & Kuhns, 1996). The results of the present study indicate that sexually revictimized women may be at even greater risk for participation in prostitution.

In addition, partner violence was experienced by a substantial percentage of participants in this study. For example, slightly more than one half were physically assaulted by a partner and approximately one third of the participants reported an injury. Sexually revictimized women were at an even greater risk of being physically abused. This finding is also consistent with prior studies that found that marital rape often occurs in conjunction with physical battering (Mahonev &: Williams, 1998).

Finally, the present study considered the reproductive and sexual health correlates of revictimization. Although multiple sexual assaults have been linked to ;i variety of gynecological problems (Bohn & Holz, 199b, (..Golding, 1996), few studies have investigated the prevalence of reproductive and sexual health problems of women who were sexually abused in both childhood and adulthood. The present study indicates that revictimized women are at increased risk for some types of health problems. When compared to women abused in childhood only, they experienced more problems conceiving, repeated vaginal infections. sexually transmitted diseases, and painful intercourse.

Limitations of the Study
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Because it is difficult to conduct a prospective study using unreopened cases of child sexual abuse, all the cases in this study had been reported to the authorities. Therefore, the findings may not be generalizable to those who never report child sexual abuse. Furthermore, the dichotomous measures of child sexual abuse characteristics and the high correlations between these variables may confound researchers'. understanding of the effect of abuse characteristics on sexual revictimization. It may be useful to replicate this study with a larger sample using continuous variables so that the effects of more specific forms of force and penetration or finer distinctions between victim-offender relationships can be examined (Banvard & Williams. 1996).

Moreover, the authors cannot say if rates of adult sexual assault are higher in this sample without a comparison group of women who were not sexually abused in childhood. Similarly, it is not known if the rates of partner violence found among the women in this sample would differ from a comparable group of young, low-income, urban, Black women with a relatively low level of education. This is an important consideration because demographic factors such as age and social class may account for increased rates of partner violence among African Americans (see West, 1998, for a review). Therefore, caution should be used when generalizing about Black women across income groups. Future research should focus on child sexual abuse and revictimization among educated, middle-class. Black women (Russo et al., 1997).

In addition, the issue of timing and directionality cannot be addressed in this study. For example, the authors cannot assess whether involvement in prostitution occurred before or after the adult .sexual assault. It is also possible that some of these instances of sexual revictimization occurred when the woman was engaged in prostitution; for example, slit- might be raped by a customer. Relatedly, it is not possible to know if the reproductive and sexual health problems are the result of revictimization, multiple sexual partners, involvement in prostitution, or other factors.

Suggestions for Intervention
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Despite the limitations, this study has the advantage of following a sample of Black women with documented histories of sexual abuse in childhood. Thus, even those who did not recall any child sexual abuse were included. The findings indicate that some Black child sexual abuse survivors, particularly those who are later revictimized, are at greater risk for involvement in prostitution and partner violence. They also had an increased probability of serious reproductive health problems. To develop appropriate intervention strategies, professionals need to be prepared to explore the possible effects of child sexual abuse when they encounter Black women seeking treatment for a variety of problems, including sexually transmitted diseases (N. J. Thompson, Potter, Sanderson, & Maibach, 1997) and partner violence (Russo et al., 1997). Intake interviews could include information about the nature and characteristics of child sexual abuse as well as experiences with sexual assaults and physical battering in adulthood.

Although Black survivors experience negative consequences as a result of their victimization, they may be reluctant to seek assistance. Russo et al. (1997) found that doctors were perceived as condescending and unhelpful. To avoid miscommunication, helping professionals should make a greater effort to establish rapport with their clients. For example, they could enhance the client's sense of safety by explaining therapeutic or medical procedures and asking permission before touching the client (Stalker, Schachter, & Teram, 1999).

Treatment efforts should extend beyond the professional relationship with the victim. Although community members appear to have some awareness of the symptoms associated with child sexual abuse, they could benefit from more information (V. L. Thompson & Smith, 1993). For example, service providers can help victims and family members understand the link between child sexual abuse and future victimization and health problems. Information can be disseminated through community leaders, religious institutions, and ethnic events. A well-drafted, culturally sensitive statement concerning child sexual abuse could also be published in Black newspapers. This technique has been used to successfully raise awareness concerning sexual harassment (Ransby, 1995) and rape (White, 1999) in the Black community.

In conclusion, this study is further documentation that a substantial percentage of women sexually abused in childhood will be sexually abused in adulthood. Understanding the dynamics that place these women at increased risk is an important research priority.

APPENDIX Description of Victimization Variables
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Child Sexual Abuse

During the 1990 follow-up interview, participants were asked if the following experiences occurred anytime when they were a child or adolescent but before age 18:

1. Did anyone, male or female, ever try or succeed in having any kind of sexual relations with you when you didn't want to? (In other words, intercourse or anything else?)

2. Did anyone ever try or succeed in touching your genitals or sex organs or getting you to touch their genitals when you didn't want to?

3. Did anyone ever feel you, grab you, or kiss you in a way you felt was sexually threatening?

4. Did you have any kind of sexual experience with someone who had authority over you, such as a doctor, teacher, employer?

5. Did you have any sexual contact with an uncle, brother, father, grandfather, or sister, mother, or other male or female relative?

6. Did you have any sexual experiences with an older person like a camp counselor, baby sitter, older friend or person who picked you up while hitchhiking?

7. Did you ever have any other unwanted sexual experience with any one, male or female? This could include a boyfriend or other male or female friends.

8. Did someone else who was older than you ever purposely expose their genitals to you in a way that was meant to upset you?

9. Did you have sexual contact or experience with someone else who was 5 or more years older than you, even if you agreed?

10. Did you have any other upsetting sexual experience that you haven't mentioned yet?

Sexual Revictimization
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Participants were categorized as sexually revictimized if they reported one or more of the following violent incidents after age 18:

1. Have you ever had an unwanted sexual experience with any one male or female? This could have been sex forced by a date, a friend, a husband, someone you knew only casually, or a stranger. It could be a boss or a family member.

2. Have you ever been in any (other) situation where there was violence or threat of violence, where you were also afraid of being sexually assaulted?

3. In general, have you narrowly missed being sexually assaulted by someone?

4. Can you think of any (other) unwanted sexual experiences?

Partner Violence

Participants were categorized as victims of partner violence if they answered yes to the following question: "In any romantic relationship there arc likely to be disagreements. There may even be situations where partners hit or slap each other. In any of your romantic relationships has it happened that your partner hit, slapped, punched, cut, or did something like that to you?"

NOTE

1. Because these were reports made by adult women, under provisions of the authors' assurance of confidentiality, no reports of child sexual abuse were made by researchers to authorities.

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