A history of childhood sexual abuse (CSA) is a risk factor for adult emotional distress, including symptoms of depression, anxiety, dissociation, and trauma. However, CSA is likely associated with adult distress indirectly through an impact on mediating variables. In a review of the empirical literature, the authors found support for the roles of shame or self-blame, interpersonal difficulties, and avoidant coping strategies as mediators. In addition, emotional distress appears to mediate links between CSA and other adverse outcomes, such as alcohol abuse and revictimization. The authors conclude with a number of methodological and conceptual recommendations.