A central issue in the substance abuse literature is whether a history of childhood sexual abuse (CSA) is a risk factor for poorer treatment outcomes. Although there is a strong belief that CSA is associated with increased substance abuse treatment utilization and relapse among women clients, most empirical evidence does not support this position. This study addresses this conundrum by exploring several possible explanations among a sample of women in substance abuse treatment. Unexpectedly, the results indicate that women with more severe histories of CSA were likely to have received less lifetime substance abuse treatment, although they were likely to have received more mental health treatment. In addition, the expected interaction between posttraumatic stress disorder (PTSD) status and CSA status and increased rates of both types of treatment was not found. However, participants with both PTSD and CSA concentrated on mental health treatment while those with only PTSD focused on substance abuse treatment.