Intervention and Treatment Issues
By completing this course the healthcare professional will be able to:
1. Identify the physical changes that are associated with sexual abuse.
2. Describe common psychological disorders found in abuse survivors.
3. Identify signs of childhood sexual abuse.
4. Describe the types of treatment available.
6. Describe intervention techniques that minimize the trauma to sexual abuse survivors and their families.
Definitions, Scope, and Effects of Child Sexual Abuse
Most professionals are fairly certain they know what child sexual abuse is, and there is a fair amount of agreement about this. For example, today very few people would question the inclusion of sexual acts that do not involve penetration. Despite this level of consensus, it is important to define what sexual abuse is because there are variations in definitions across professional disciplines.
Child sexual abuse can be defined from legal and clinical perspectives. Both are important for appropriate and effective intervention. There is considerable overlap between these two types of definitions.
There are two types of statutes in which definitions of sexual abuse can be found – child protection (civil) and criminal.
The purposes of these laws differ. Child protection statutes are concerned with sexual abuse as a condition from which children need to be protected. Thus, these laws include child sexual abuse as one of the forms of maltreatment that must be reported by designated professionals and investigated by child protection agencies. Courts may remove children from their homes in order to protect them from sexual abuse. Generally, child protection statutes apply only to situations in which offenders are the children's caretakers.
Criminal statutes prohibit certain sexual acts and specify the penalties. Generally, these laws include child sexual abuse as one of several sex crimes. Criminal statutes prohibit sex with a child, regardless of the adult's relationship to the child, although incest may be dealt with in a separate statute.
Definitions in child protection statutes are quite brief and often refer to State criminal laws for more elaborate definitions. In contrast, criminal statutes are frequently quite lengthy.
Child Protection Definitions
The Federal definition of child maltreatment is included in the Child Abuse Prevention and Treatment Act. Sexual abuse and exploitation is a subcategory of child abuse and neglect. The statute does not apply the maximum age of 18 for other types of maltreatment, but rather indicates that the age limit in the State law shall apply. Sexual abuse is further defined to include:
"(A) the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or
(B) the rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children;..."
In order for States to qualify for funds allocated by the Federal Government, they must have child protection systems that meet certain criteria, including a definition of child maltreatment specifying sexual abuse.
With the exception of situations involving Native American children, crimes committed on Federal property, interstate transport of minors for sexual purposes, and the shipment or possession of child pornography, State criminal statutes regulate child sexual abuse. Generally, the definitions of sexual abuse found in criminal statutes are very detailed. The penalties vary depending on:
the age of the child, crimes against younger children being regarded as worse;
the level of force, force making the crime more severe;
the relationship between victim and offender, an act against a relative or household member being considered more serious; and
the type of sexual act, acts of penetration receiving longer sentences.
Often types of sexual abuse are classified in terms of their degree (of severity), first degree being the most serious and fourth degree the least, and class (of felony), a class A felony being more serious than a class B or C, etc.
Although clinical definitions of sexual abuse are related to statutes, the guiding principle is whether the encounter has a traumatic impact on the child. Not all sexual encounters experienced by children do. Traumatic impact is generally affected by the meaning of the act(s) to the child, which may change as the child progresses through developmental stages. The sexual abuse may not be "traumatic" but still leave the child with cognitive distortions or problematic beliefs; that is, it is "ok" to touch others because it feels good.
Differentiating Abusive From Nonabusive Sexual Acts
There are three factors that are useful in clinically differentiating abusive from nonabusive acts – power differential; knowledge differential; and gratification differential.
These three factors are likely to be interrelated. However, the presence of any one of these factors should raise concerns that the sexual encounter was abusive.
Power differential The existence of a power differential implies that one party (the offender) controls the other (the victim) and that the sexual encounter is not mutually conceived and undertaken. Power can derive from the role relationship between offender and victim. For example, if the offender is the victim's father, the victim will usually feel obligated to do as the offender says. Similarly, persons in authority positions, such as a teacher, minister, or Boy Scout leader, are in roles that connote power. Thus, sexual activities between these individuals and their charges are abusive.
- Power can also derive from the larger size or more advanced capability of the offender, in which case the victim may be manipulated, physically intimidated, or forced to comply with the sexual activity. Power may also arise out of the offender's superior capability to psychologically manipulate the victim (which in turn may be related to the offender's role or superior size). The offender may bribe, cajole, or trick the victim into cooperation.
Knowledge differential The act is considered abusive when one party (the offender) has a more sophisticated understanding of the significance and implications of the sexual encounter. Knowledge differential implies that the offender is either older, more developmentally advanced, or more intelligent than the victim. Generally, clinicians expect the offender to be at least 5 years older than the victim for the act to be deemed predatory. When the victim is an adolescent, some persons define the encounter as abusive only if the offender is at least 10 years older. Thus, a consensual sexual relationship between a 15-year-old and a 22-year-old would not be regarded as abusive, if other case factors supported that conclusion.
- Generally, the younger the child, the less able she/he is to appreciate the meaning and potential consequences of a sexual relationship, especially one with an adult. Usually, the maximum age for the person to be considered a victim (as opposed to a participant) is 16 or 18, but some researchers have used an age cutoff of 13 for boy victims. Apparently, the researchers felt that boys at age 13, perhaps unlike girls, were able to resist encounters with significantly older people and were, by then, involved in consensual sexual acts with significantly older people. However, clinicians report situations in which boys victimized after age 13 experience significant trauma from these sexual contacts.
- Situations in which retarded or emotionally disturbed persons participate in or are persuaded into sexual activity may well be exploitive, even though the victim is the same age or even older than the perpetrator.
Gratification differential Finally, in most but not all sexual victimization, the offender is attempting to sexually gratify him/herself. The goal of the encounter is not mutual sexual gratification, although perpetrators may attempt to arouse their victims because such a situation is arousing to them. Alternatively, they may delude themselves into believing that their goal is to sexually satisfy their victims. Nevertheless, the primary purpose of the sexual activity is to obtain gratification for the perpetrator.
- In this regard, some activities that involve children in which there is not a 5-year age differential may nevertheless be abusive. For example, an 11-year-old girl is instructed to fellate her 13-year-old brother. (This activity might also be abusive because there was a power differential between the two children based on his superior size.)
The sexual acts that will be described in this section are abusive clinically when the factors discussed in the previous section are present as the examples illustrate. The sexual acts will be listed in order of severity and intrusiveness, the least severe and intrusive being discussed first.
Offender making sexual comments to the child
- Example: A coach told a team member he had a fine body, and they should find a time to explore one another's bodies. He told the boy he has done this with other team members, and they had enjoyed it.
Offender exposing intimate parts to the child, sometimes accompanied by masturbation.
- Example: A grandfather required that his 6-year-old granddaughter kneel in front of him and watch while he masturbated naked.
- Example: A stepfather made a hole in the bathroom wall. He watched his stepdaughter when she was toileting (and instructed her to watch him).
Offender showing child pornographic materials, such as pictures, books, or movies.
- Example: Mother and father had their 6- and 8-year-old daughters accompany them to viewings of adult pornographic movies at a neighbor's house.
Offender induces child to undress and/or masturbate self.
- Example: Neighbor paid a 13-year-old emotionally disturbed girl $5 to undress and parade naked in front of him.
Offender touching the child's intimate parts (genitals, buttocks, breasts).
- Example: A father put his hand in his 4-year-old daughter's panties and fondled her vagina while the two of them watched "Sesame Street."
Offender inducing the child to touch his/her intimate parts.
- Example: A mother encouraged her 10-year-old son to fondle her breasts while they were in bed together.
Frottage (rubbing genitals against the victim's body or clothing).
- Example: A father, lying in bed, had his clothed daughter sit on him and play "ride the horse."
Digital or object penetration
Offender placing finger(s) in child's vagina or anus.
- Example: A father used digital penetration with his daughter to "teach" her about sex.
Offender inducing child to place finger(s) in offender's vagina or anus.
- Example: An adolescent boy required a 10-year-old boy to put Vaseline on his finger and insert it into the adolescent's anus as initiation into a club.
Offender placing instrument in child's vagina or anus.
- Example: A psychotic mother placed a candle in her daughter's vagina.
Offender inducing child to place instrument in offender's vagina or anus.
- Example: A babysitter had a 6-year-old boy penetrate her vaginally with a mop handle.
- Example: Several children who had attended the same day care center attempted to French kiss with their parents. They said that Miss Sally taught them to do this.
Breast sucking, kissing, licking, biting.
- Example: A mother required her 6-year-old daughter to suck her breasts (in the course of mutual genital fondling).**
Cunnilingus (licking, kissing, sucking, biting the vagina or placing the tongue in the vaginal opening).
- Example: A father's girlfriend who was high on cocaine made the father's son lick her vagina as she sat on the toilet.
Fellatio (licking, kissing, sucking, biting the penis).
- Example: An adolescent, who had been reading pornography, told his 7-year-old cousin to close her eyes and open her mouth. She did and he put his penis in her mouth.
Anilingus (licking, kissing the anal opening).
- Example: A mother overheard her son and a friend referring to their camp counselor as a "butt lick." The boys affirmed that the counselor had licked the anuses of two of their friends (and engaged in other sexual acts with them).** An investigation substantiated this account.
Example: A 7-year-old girl was placed in foster care by her father because she was incorrigible. She was observed numerous times "humping" her stuffed animals. In therapy she revealed that her father "humped" her. There was medical evidence of vaginal penetration.
- Example: Upon medical exam an 8-year-old boy was found to have evidence of chronic anal penetration. He reported that his father "put his dingdong in there" and allowed two of his friends to do likewise.
Intercourse with animals.
Circumstances of Sexual Acts
Professionals need to be aware that sexual acts with children can occur in a variety of circumstances. In this section, dyads, group sex, sex rings, sexual exploitation, and ritual abuse will be discussed. These circumstances do not necessarily represent discrete and separate phenomena.
Dyadic sexual abuse. The most common circumstance of sexual abuse is a dyadic relationship, that is, a situation involving one victim and one offender. Because dyadic sex is the prevalent mode for all kinds of sexual encounters, not merely abusive ones, it is not surprising that it is the most common.
Group sex. Circumstances involving group sex are found as well. These may comprise several victims and a single perpetrator, several perpetrators and a single victim, or multiple victims and multiple offenders. Such configurations may be intrafamilial (e.g., in cases of polyincest) or extrafamilial. Examples of extrafamilial group victimization include some instances of sexual abuse in day care, in recreational programs, and in institutional care.
Sex rings. Children are also abused in sex rings; often this is group sex. Sex rings generally are organized by pedophiles (persons whose primary sexual orientation is to children), so that they will have ready access to children for sexual purposes and, in some instances, for profit. Victims are bribed or seduced by the pedophile into becoming part of the ring, although he may also employ existing members of the ring as recruiters. Rings vary in their sophistication from situations involving a single offender, whose only motivation is sexual gratification, to very complex rings involving multiple offenders as well as children, child pornography, and prostitution.
Sexual exploitation of children. The use of children in pornography and for prostitution is yet another circumstance in which children may be sexually abused.
Child pornography. This is a Federal crime, and all States have laws against child pornography. Pornography may be produced by family members, acquaintances of the children, or professionals. It may be for personal use, trading, or sale on either a small or large scale. It can also be used to instruct or entice new victims or to blackmail those in the pictures. Production may be national or international, as well as local, and the sale of pornography is potentially very lucrative. Because of the availability of video equipment and Polaroid cameras, pornography is quite easy to produce and difficult to track.
- Child pornography can involve only one child, sometimes in lewd and lascivious poses or engaging in masturbatory behavior; of children together engaging in sexual activity; or of children and adults in sexual activity.
- It is important to remember that pictures that are not pornographic and are not illegally obscene can be very arousing to a pedophile. For example, an apparently innocent picture of a naked child in the bathtub or even a clothed child in a pose can be used by a pedophile for arousal.
Child prostitution. This may be undertaken by parents, other relatives, acquaintances of the child, or persons who make their living pandering children. Older children, often runaways and/or children who have been previously sexually abused, may prostitute themselves independently.
- Situations in which young children are prostituted are usually intrafamilial, although there are reports of child prostitution constituting one aspect of sexual abuse in some day care situations.22 Adolescent prostitution is more likely to occur in a sex ring (as mentioned above), at the hand of a pimp, in a brothel, or with the child operating independently. Boys are more likely to be independent operators, and girls are more likely to be in involved in situations in which others control their contact with clients.
Ritual abuse. This is a circumstance of child sexual abuse that has only recently been identified, is only partially understood, and is quite controversial. The controversy arises out of problems in proving such cases and the difficulty some professionals have in believing in the existence of ritual abuse.
- As best can be determined, ritual sexual abuse is abuse that occurs in the context of a belief system that, among other tenets, involves sex with children. These belief systems are probably quite variable. Some may be highly articulated, others "half-baked." Some ritual abuse appears to involve a version of satanism that supports sex with children. However, it is often difficult to discern how much of a role ideology plays. That is, the offenders may engage in "ritual" acts because they are sadistic, because they are sexually aroused by them, or because they want to prevent disclosure, not because the acts are supported by an ideology. Because very few of these offenders confess, their motivation is virtually unknown.
- Often sexual abuse plays a secondary role in the victimization in ritual abuse, physical and psychological abuse dominating. The following is a nonexhaustive list of characteristics that may be present in cases of ritual abuse:
costumes and robes: animal, witch's, devil's costumes; ecclesiastical robes (black, red, purple, white);
ceremonies: black masses, burials, weddings, sacrifices;
symbols: 666, inverted crosses, pentagrams, and inverted pentagrams;
artifacts: crosses, athames (daggers), skulls, candles, black draping, representations of Satan;
bodily excretions and fluids: blood, urine, feces, semen;
drugs, medicines, injections, potions;
chants and songs;
religious sites: churches, graveyards, graves, altars, coffins; and
torture, tying, confinement, murder.
Most allegations of ritual abuse come from young children, reporting this type of abuse in day care, and from adults, who are often psychiatrically very disturbed and describe ritual abuse during their childhoods. Issues of credibility are raised with both groups. Moreover, accounts of ritual abuse are most disturbing, to both those recounting the abuse and those hearing it.
Scope of the Problem of Child Sexual Abuse
Clinicians and researchers working in sexual abuse believe that the problem is underreported. This belief is based on assumptions about sexual taboos and on research on adults sexually abused as children, the overwhelming majority of whom state that they did not report their victimization at the time of its occurrence. Moreover, it is probably true that situations involving female offenders as well as ones with boy victims are underidentified, in part because of societal perceptions about the gender of offenders and victims.
Estimates of the extent of sexual abuse come from three main sources – research on adults, who recount their experiences of sexual victimization as children; annual summaries of the accumulated reports of sexual abuse filed with child protection agencies; and two federally funded studies of child maltreatment entitled the National Incidence Studies. In addition, anecdotal information is supplied by some convicted/self-acknowledged offenders, who report sexually abusing scores and even hundreds of children before their arrest.
Prevalence of Child Sexual Abuse
Studies of the prevalence of sexual abuse are those involving adults that explore the extent to which persons experience sexual victimization during their childhoods. Findings are somewhat inconsistent for several reasons. First, data are gathered using a variety of methodologies: telephone interviews, face-to-face interviews, and written communications (i.e., questionnaires). Second, a study may focus entirely on sexual abuse, or sexual abuse may be one of many issues covered. Third, some studies are of special populations, such as psychiatric patients, incarcerated sex offenders, and college students, whereas others are surveys of the general population. Finally, the definition of sexual abuse varies from study to study. Dimensions on which definitions may differ are maximum age for a victim, the age difference required between victim and offender, whether or not noncontact acts are included, and whether the act is unwanted.
The factors just mentioned have the following effects on rates of sexual abuse reported. Face-to-face interviews, particularly when the interviewer and interviewee are matched on sex and race, and multiple questions about sexual abuse may result in higher rates of disclosure. However, it cannot be definitively stated that special populations such as prostitutes, drug addicts, or psychiatric populations have higher rates of sexual victimization than the general population, because some studies of the general population report quite high rates. Not surprisingly, when the definition is broader (e.g., inclusion of noncontact behaviors and "wanted" sexual acts) the rates go up.
Rates of victimization for females range from 6 to 62 percent,29 with most professionals estimating that between one in three and one in four women are sexually abused in some way during their childhoods. The rates for men are somewhat lower, ranging from 3 to 24 percent, 30 with most professionals believing that 1 in 10 men and perhaps as many as 1 in 6 are sexually abused as children. As noted earlier, many believe that male victimization is more underreported than female, in part because of societal failure to identify the behavior as abusive. However, the boy himself may not define the behavior as sexual victimization but as sexual experience, especially if it involves a woman offender. Moreover, he may be less likely to disclose than a female victim, because he has been socialized not to talk about his problems. This reticence may be increased if the offender is a male, for he must overcome two taboos, having been the object of a sexual encounter with an adult and a male. Finally, he may not be as readily believed as a female victim.
The Incidence of Child Sexual Abuse
Incidence of a problem is defined as the number of reports during a given time frame, yearly in the case of sexual abuse. From 1976 to 1986, data were available on the number of sexual abuse cases reported per year to child protection agencies, as part of data collection on all types of maltreatment. These cases were registered with the National Center on Child Abuse and Neglect, and data were analyzed by the American Humane Association. Over that 10-year period, there was a dramatic increase in the number of reports of sexual abuse and in the proportion of all maltreatment cases represented by sexual abuse. In 1976, the number of sexual abuse cases was 6,000, which represented a rate of 0.86 per 10,000 children in the United States. By 1986, the number of reported cases was 132,000, a rate of 20.89 per 10,000 children. This represents a 22-fold increase. Moreover, whereas in 1976 sexual abuse cases were only 3 percent of all reports, by 1986, they comprised 15 percent of reports.
Striking though these findings may be, their limitations must be appreciated. First, current data are not available. Second, cases included in this data set are limited to those that would warrant a CPS referral, generally cases in which the abuser is a caretaker or in which a caretaker fails to protect a child from sexual abuse. Thus, cases involving an extrafamilial abuser and a protective parent are not included. Third, the data only refer to reported cases. This means those cases that are unknown to professionals and those known but not reported are not included. Moreover, these are reports, not substantiations of sexual abuse. The national average substantiation rate is generally between 40 and 50 percent. Substantiation rates vary from State to State and among locations.
The National Incidence Studies (NIS-1 and NIS-2) provide additional data on the rates of child maltreatment, including sexual abuse. Information for these studies was collected in 1980 and 1986; thus, they do not provide annual incidence rates, as the Child Protection data do. In addition, these studies project a national rate of child maltreatment based on information from 29 counties, rather than using reports from all States. Nevertheless, these studies do allow for some analysis of trends because data were collected at two different time points. Moreover, one of the most important features of the NIS studies is that they gathered information on unreported as well as reported cases.
Differences between the first and second studies indicate there was a more than threefold increase in the number of identified cases of sexual maltreatment.***** An estimated 42,900 cases were identified by professionals in 1980 compared with 133,600 cases in 1986. These figures represent a rate of 7 cases per 10,000 children in 1980 and 21 cases per 10,000 in 1986. Despite the fact that the 1986 number and rate are quite close to the figures for suspected sexual abuse reported to child protection agencies in 1986, only about 51 percent of cases identified by professionals in the National Incidence Study were reported to child protective services (CPS). Furthermore, the proportion of cases identified but not reported to CPS did not change significantly between 1980 and 1986.
It is clear that available statistics on the prevalence and incidence of sexual abuse do not completely reflect the extent of the problem. However, they do provide a definite indication that the problem of sexual victimization is a significant one that deserves our attention and intervention.
The Effects of Sexual Abuse on its Victim
Concern about sexual abuse derives from more than merely the fact that it violates taboos and statutes. It comes principally from an appreciation of its effects on victims. In this section, the philosophical issue of why society is concerned about sexual abuse and documented effects will be discussed.
The Impact of Sexual Abuse
Regardless of the underlying causes of the impact of sexual abuse, the problems are very real for victims and their families. A number of attempts have been made to conceptualize the effects of sexual abuse. In addition, recent efforts to understand the impact of sexual abuse have gone beyond clinical impressions and case studies. They are based upon research findings, specifically controlled research in which sexually abused children are compared to a normal or nonsexually abused clinical population. There are close to 40 such studies to date.
Finkelhor, whose conceptualization of the traumatogenic effects of sexual abuse is the most widely employed, divides sequelae into four general categories, each having varied psychological and behavioral effects.
Traumatic sexualization. Included in the psychological outcomes of traumatic sexualization are aversive feelings about sex, overvaluing sex, and sexual identity problems. Behavioral manifestations of traumatic sexualization constitute a range of hypersexual behaviors as well as avoidance of or negative sexual encounters.
Stigmatization. Common psychological manifestations of stigmatization are what Sgroi calls "damaged goods syndrome" and feelings of guilt and responsibility for the abuse or the consequences of disclosure. These feelings are likely to be reflected in self-destructive behaviors such as substance abuse, risk-taking acts, self-mutilation, suicidal gestures and acts, and provocative behavior designed to elicit punishment.
Betrayal. Perhaps the most fundamental damage from sexual abuse is its undermining of trust in those people who are supposed to be protectors and nurturers. Other psychological impacts of betrayal include anger and borderline functioning. Behavior that reflects this trauma includes avoidance of investment in others, manipulating others, re-enacting the trauma through subsequent involvement in exploitive and damaging relationships, and engaging in angry and acting-out behaviors.
Powerlessness. The psychological impact of the trauma of powerlessness includes both a perception of vulnerability and victimization and a desire to control or prevail, often by identification with the aggressor. As with the trauma of betrayal, behavioral manifestations may involve aggression and exploitation of others. On the other hand, the vulnerability effect of powerlessness may be avoidant responses, such as dissociation and running away; behavioral manifestations of anxiety, including phobias, sleep problems, elimination problems, and eating problems; and revictimization.
Our understanding of the impact of sexual abuse is frustrated by the wide variety of possible effects and the way research is conducted. Researchers do not necessarily choose to study the same effects, nor do they use the same methodology and instruments. Consequently, a particular symptom, such as substance abuse, may not be studied or may be examined using different techniques. Furthermore, although most studies find significant differences between sexually abused and nonabused children, the percentages of sexually abused children with a given symptom vary from study to study, and there is no symptom universally found in every victim. In addition, often lower proportions of sexually abused children exhibit a particular symptom than do nonabused clinical comparison groups. Finally, although some victims suffer pervasive and debilitating effects, others are found to be asymptomatic.
In addition, a variety of factors influence how sexual maltreatment impacts on an individual. These factors include the age of the victim (both at the time of the abuse and the time of assessment), the sex of the victim, the sex of the offender, the extent of the sexual abuse, the relationship between offender and victim, the reaction of others to knowledge of the sexual abuse, other life experiences, and the length of time between the abuse and information gathering. For example, the findings for child victims and adult survivors are somewhat different.
It is important for professionals to appreciate both the incomplete state of knowledge about the consequences of sexual abuse and the variability in effects. Such information can be helpful in recognizing the wide variance in symptoms of sexual abuse and can prevent excessive optimism or pessimism in predicting its impact.
* When children are victims, sexual comments are usually made in person. However obscene remarks may be made on the telephone or in notes and letters.
** Activities in parenthesis are not illustrative of the sexual act being defined.
*** Sexual contact can be either above or beneath clothing.
**** The offender may inflict oral sex upon the child or require the child to perform it on him/her or both.
***** These statistics from the revised second National Incidence Study reflect the revised definition of child abuse and neglect, which includes the combined total children who were demonstrably harmed and threatened with harm.
Indicators Of Child Sexual Abuse
Sexual abuse may result in physical or behavioral manifestations. It is important that professionals and the public know what these are because they signal possible sexual abuse. However, very few manifestations (e.g., gonorrhea of the throat in a young child) are conclusive of sexual abuse. Most manifestations require careful investigation or assessment.
Unfortunately, early efforts at cataloging indicators of sexual abuse were problematic. They included extremely rare findings, such as blood in a child's underpants and signs that could be indicative of many problems or no problem at all, such as "comes early to school and leaves late." Recent efforts to designate signs of sexual abuse are more helpful.
They differentiate between physical indicators and psychosocial indicators. Although physical indicators may be noted by many people, a definitive determination is generally made by a medical professional. Similarly, anyone may observe psychosocial indicators; however, often but not always, a mental health professional is responsible for forming an opinion that the symptoms are indicative of sexual abuse.
A differentiation is made between higher and lower probability indicators. That is, some indicators are diagnostic of sexual abuse, whereas others may be consistent with or suggestive of sexual abuse but could indicate other circumstances or conditions as well.
In this chapter, higher probability findings and lower probability physical indicators are discussed first. A comparable discussion of psychosocial indicators will follow. It should not be surprising that the indicators specified in this chapter are similar to the effects described in the previous chapter since indicators are to a large extent the effects of sexual abuse before disclosure. Therefore, these indicators should become a focus of treatment and not simply used to support or rule out an allegation of sexual abuse.
Medical Indicators of Child Sexual Abuse
Significant progress has been made in the medical field in the determination of sexual abuse. Medical professionals are no longer limited to the presence or absence of a hymen as the indicator of possible sexual abuse. A variety of types of genital findings have been documented. In addition, notable progress has been made in identifying anal findings. Moreover, physicians are able to describe the effects of different kinds of sexual activity, and subtle findings can be documented using magnification (a colposcope or otoscope).
However, this progress is not without its controversies. Knowledgeable and conscientious physicians may differ regarding conclusions about certain physical findings. This difference of opinion is primarily due to the fact that data collection regarding the physical signs of sexual abuse has preceded careful documentation of characteristics of genitalia and anal anatomy of children who have not been sexually abused and of variations among normal children. These legitimate differences of opinion have been augmented by challenges to the medical documentation from defense attorneys, their expert witnesses, and alleged offenders.
It is also important to appreciate that for the majority of sexually abused children there are no physical findings. These findings, particularly vaginal ones, are most useful with prepubertal victims. As children become older, the possibility of consensual sexual activity needs to be considered. Further, changes that occur with puberty render insignificant some symptoms that have great significance in young children.
Two High-Probability Physical Indicators
Despite the progress noted above, the highest probability indicators are ones identified over 10 years ago. They are:
pregnancy in a child and
venereal disease in a child.
The reason these findings are high probability is because there is little dispute over the fact that they require sexual activity.
Some professionals assume that pregnancy in a child less than age 12 signals abuse although others designate the age of 13 or 14. Of course, not all situations in which children of these ages become pregnant are abusive, and pregnancy in older adolescents can be a consequence of sexual abuse.
Venereal disease may be located in the mucosa of the vagina, penis, anus, or mouth. The upper age limits for venereal disease raising concern about sexual abuse are similar to those for pregnancy. In addition, there is a lower age limit, usually of 1 or 2 months, because infants may be born with venereal disease acquired congenitally if the mother has the disease.
Interestingly, variations are found within the medical community regarding the certainty that sexual activity causes particular venereal diseases in children. Specifically, there is consensus that syphilis and gonorrhea cannot be contracted from toilet seats or bed sheets, but some differences of opinion exist about other venereal diseases (genital herpes, condyloma acuminata or venereal warts, trichomonas vaginalitis, and urogenital chlamydia), despite the conclusion that such infections are caused by sexual contact in adults. In a recent review of the research, Smith, Benton, Moore, and Runyan conclude that there is "strong evidence" that all of these venereal diseases are sexually transmitted, except for herpes, for which there is "probable evidence." They also review the evidence on human immunodeficiency virus (HIV) and conclude that there is strong evidence it is sexually transmitted as well, unless contracted pre- or perinatally.
High-probability findings specific to the genitalia include the following:
semen in the vagina of a child,
torn or missing hymen,
other vaginal injury or scarring,
vaginal opening greater than 5 mm, and
injury to the penis or scrotum.
Semen in the vagina is the highest probability finding, but it is uncommon.
Although there is a fair amount of variability among girl children in the extent, shape, and other characteristics of hymens, the complete absence of or a tear in the hymen of a young girl is indicative of sexual abuse. In older girls, it is important to determine whether other sexual activities may account for the absence or the tear. Conditions such as bumps, friability, and clefts in the hymen may be a result of sexual abuse, but they are also found in girls without a reported history of sexual abuse.
Health care professionals document and describe injuries to or bleeding from the vaginal opening by likening it to a clock face, 12 o'clock being the anterior midline and 6 o'clock the posterior. Abrasions, tears, and bruises to the vagina between 3 and 9 o'clock, or to the posterior, are more likely to be the result of penile penetration, whereas injuries between 9 and 3 o'clock, or anteriorly, are more likely the consequence of digital manipulation or penetration.
There is some controversy regarding what transverse diameter to use as a guideline for differentiating between girls with genital evidence consistent with penetration and those with no genital evidence, with measures ranging from 4 to 6 mm being advocated as indicative of sexual abuse. One factor that may affect findings is the age of the child, with the expectation that older girls will have larger vaginal openings. Heger, an expert in physical findings related to sexual abuse, discounts the importance of hymenal transverse diameter, noting that it varies in size depending on the position in which the child is examined. It is also important to note that not all girls who have a reported history of penetration evidence enlarged vaginal openings, tears, abrasions, or bruising.
Absent another explanation for an injury to the penis, which is consistent with the child's account of the abusive incident, the injury should be considered indicative of sexual abuse. Bite marks, abrasions, redness, "hickeys," scratches, or bruises may be found.
Lower probability genital findings are as follows:
chronic urinary tract infections.
Erythema or redness and swelling might be caused by genital manipulation or intrusion perpetrated by a significantly older person. However, it might also be the result of poor hygiene, diaper rash, or perhaps the child's masturbation. Increased vascularity, synechiae, and labial adhesions may be a consequence of sexual abuse, but they are common findings in children with other genital complaints.
Vulvovaginitis and chronic urinary tract infections can be sequelae of sexual abuse but also can be caused by other circumstances, such as poor hygiene, a bubble bath, or, in the case of urinary tract infections, taking antibiotics.
The following are high-probability findings:
destruction of the anal sphincter,
perianal bruising or abrasion,
shortening or eversion of the anal canal,
fissures to the anal opening,
wasting of gluteal fat, and
Very occasionally there will be a finding of total absence of anal sphincter control, indicative of chronic anal penetration. If there has been forceful anal penetration, it may result in bruising and scrapes. A shortening or eversion of the anal canal has been found in very young children who have been chronically anally penetrated. Perianal fissures and scars from fissures are thought to be indicative of sexual abuse except when they occur at 12 o'clock and 6 o'clock,55 in which case they may be the result of a large stool. If the fissure is wider externally and narrows internally, this is consistent with object penetration of the anus. The converse finding is consistent with the passage of a large, firm stool. Funneling and wasting of the gluteal fat around the anal opening can occur from chronic anal penetration. This is a rare finding in children but may be found in male adolescent prostitutes. The following anal findings are lower probability:
increased perianal pigmentation,
perianal venous engorgement, and
reflex anal dilatation.
Perianal erythema, increased pigmentation, and venous engorgement are all physical findings noted in children who have a history of anal penetration. However, these conditions also have been reported in substantial numbers of children with no reported history of sexual abuse, suggesting that they can be caused by other conditions. In the case of the first two findings, these conditions could be a consequence of poor hygiene.
A finding that is in some dispute is reflex anal dilatation, that is, gaping of the anus or the twitching of the anal sphincter at the time of physical exam. Some physicians believe that it is a consequence of anal penetration, but others have noted this finding in children whose lower bowel is full of stool. However, gaping of 20 mm or more is thought to be indicative of anal penetration.
Psychosocial Indicators of Child Sexual Abuse
Comparable efforts to identify the psychosocial indicators of child sexual abuse have been made by mental health professionals. In 1985, 100 national experts in sexual abuse met to develop criteria for the "Sexually Abused Child Disorder," in the hope that it would be included in the Diagnostic and Statistical Manual Three-Revised (DSMIII-R). It was not, but the effort remains important. The criteria of the "Sexually Abused Child Disorder" differentiate three levels of certainty (high, medium, and low) and vary by developmental stage. These criteria include both sexual and nonsexual indicators.
The work of Friedrich focuses on sexualized behavior, indicators unlikely to be found in other traumatized or normal populations. His Child Sexual Behavior Inventory has been field-tested on 260 children between 2 to 12 years of age, who were alleged to have been sexually abused and 880 children not alleged to have been sexually abused. It was found to reliably differentiate the two types of children. However, a substantial proportion of children in Friedrich's research, determined sexually abused, are not reported to engage in sexualized behavior. Moreover, children who learn about sex from nonabusive experiences may engage in sexualized behavior.
Two-category typology of behavioral indicators:
sexual indicators, generally being higher probability indicators; and
nonsexual behavioral indicators, usually considered lower probability.
Sexual indicators vary somewhat depending on the child's age. The discussion of these indicators will be divided into those likely to be found in younger sexually abused children (aged 10 or younger) and those likely to be found in older sexually abused children (older than age 10). However, this distinction is somewhat arbitrary, and within these two groups there are children at very different developmental stages. Finally, indicators that are important for children of all ages are noted.
Sexual Indicators Found in Younger Children
These behaviors are high-probability indicators because they represent sexual knowledge not ordinarily possessed by young children.
Statements indicating precocious sexual knowledge, often made inadvertently.
- A child observes a couple kissing on television and says that "the man is going to put his finger in her wee wee."
Sexually explicit drawings (not open to interpretation).
- A child draws a picture of fellatio.
Sexual interaction with other people.
- Sexual aggression toward younger or more naive children (represents an identification with the abuser).
- Sexual activity with peers (indicates the child probably experienced a degree of pleasure from the abusive activity).
- Sexual invitations or gestures to older persons (suggests the child expects and accepts sexual activity as a way of relating to adults).
Sexual interactions involving animals or toys.
- A child makes "Barbie™* dolls" engage in oral sex.
The reason sexual knowledge is more compelling when demonstrated by younger children than older ones is that the latter may acquire sexual knowledge from other sources, for example, from classes on sex education or from discussions with peers or older children. Even younger children may obtain knowledge from sources other than abuse. However, children are not likely to learn the intimate details of sexual activity nor for example, what semen tastes like and penetration feels like without direct experience.
Another indicator often cited is excessive masturbation. A limitation of this as an index of sexual abuse is that most children (and adults) masturbate at some time. Thus, it is developmentally normal behavior, which is only considered indicative of sexual abuse when "excessive." However, a determination that the masturbation is excessive may be highly subjective. The following guidelines may be helpful.
Masturbation is indicative of possible sexual abuse if:
- Child masturbates to the point of injury.
- Child masturbates numerous times a day.
- Child cannot stop masturbating.
- Child inserts objects into vagina or anus.
- Child makes groaning or moaning sounds while masturbating.
- Child engages in thrusting motions while masturbating.
Sexual Indicators Found in Older Children
As children mature, they become aware of societal responses to their sexual activity, and therefore overt sexual interactions of the type cited above are less common. Moreover, some level of sexual activity is considered normal for adolescents. However, there are three sexual indicators that may signal sexual abuse.
sexual promiscuity among girls,
being sexually victimized by peers or nonfamily members among girls, and
Of these three indicators, the last is most compelling. One study found that 90 percent of female adolescent prostitutes were sexually abused. Although there has not been comparable research on male adolescent prostitutes, there are clinical observations that they become involved in prostitution because of sexual abuse.
A High-Probability Sexual Indicator for All Children
Finally, when children report to anyone they are being or have been sexually abused, there is a high probability they are telling the truth. Only in rare circumstances do children have any interest in making false accusations. False allegations by children represent between 1 and 5 percent of reports. Therefore, unless there is substantial evidence that the statement is false, it should be interpreted as a good indication that the child has, in fact, been sexually abused.
Nonsexual Behavioral Indicators of Possible Sexual Abuse
The reason that nonsexual behavioral symptoms are lower probability indicators of sexual abuse is because they can also be indicators of other types of trauma. For example, these symptoms can be a consequence of physical maltreatment, marital discord, emotional maltreatment, or familial substance abuse. Nonsexual behavioral indicators can arise because of the birth of a sibling, the death of a loved one, or parental loss of employment. Moreover, natural disasters such as floods or earthquakes can result in such symptomatic behavior.
As with sexual behaviors, it is useful to divide symptoms into those more characteristic of younger children and those found primarily in older children. However, there are also some symptoms found in both age groups.
Nonsexual Behavioral Indicators in Young Children
The following symptoms may be found in younger children:
other regressive behavior (e.g., needing to take transitional object to school);
self-destructive or risk-taking behavior;
impulsivity, distractibility, difficulty concentrating (without a history of nonabusive etiology);
refusal to be left alone;
fear of the alleged offender;
fear of people of a specific type or gender;
firesetting (more characteristic of boy victims);
cruelty to animals (more characteristic of boy victims); and
role reversal in the family or pseudomaturity.
Nonsexual Behavioral Indicators in Older Children
eating disturbances (bulimia and anorexia);
self-destructive behavior, e.g.,
- suicidal gestures, attempts, and successes and
criminal activity; and
depression and social withdrawal.
Nonsexual Behavioral Indicators in All Children
Three types of problems may be found in children of all ages:
problems relating to peers,
school difficulties, and
sudden noticeable changes in behavior.
Sexually abused children may manifest a range of symptoms, which reflect the specifics of their abuse and how they are coping with it.
Suspicion is heightened when the child presents with several indicators, particularly when there is a combination of sexual and nonsexual indicators. For example, a common configuration in female adolescent victims is promiscuity, substance abuse, and suicidal behavior. Similarly, the presence of both behavioral and physical symptoms increases concern. However, the absence of a history of such indicators does not signal the absence of sexual abuse.
An Emotional Reaction Consistent With the Abuse Being Described
Children may have a variety of emotional reactions to sexual abuse, depending on the characteristics of the child and the abuse. The following are common emotional reactions and associated child or abuse characteristics:
reluctance to disclose: characteristic of most children except possibly for very disturbed or very young children;
embarrassment: a rather mild response often found in disturbed and young children;
anger: more characteristic of boy victims (but not always evident);
anxiety: noted frequently in adolescent girls;
disgust: a typical reaction to oral sex;
depression: often present in victims who care for the abuser or feel they are responsible;
fear: typical of cases in which the child has been injured or threatened during the course of the victimization; and
sexual arousal: another response sometimes found in disturbed and young children.
Situations In Which the Clinical Criteria May Not Be Found
The small number of studies that examine clinical criteria in proven cases (which are usually substantiated with offender confession) find that a substantial number of children's accounts lack the expected criteria. For example, in Faller's study, only 68 percent of accounts contained all three criteria. Young age of the victim and being a boy were associated with not satisfying the expected criteria. Younger children were less likely to provide contextual detail and to evidence an emotional response consistent with the account. Similarly, boy victims were less likely to describe the abuse and to exhibit affect.
There can be other good reasons why children fail to manifest the expected clinical criteria. Affect may be absent because the child dissociates, the child has told about the abuse many times, or the trauma has already been addressed in treatment. In addition, emotionally disturbed children, who have suffered many other traumas, may not become upset about sexual abuse because, compared to their other life experiences, it is not as bad. Detail may be absent because the abuse has been repressed or because it happened long ago and has been forgotten.
It is legitimate to substantiate a case with only a description of the sexual abuse.
Moreover, it is important for interviewers to appreciate that a child's inability to describe sexual abuse does not mean it did not happen. It means that sexual abuse cannot be confirmed, but that is different from it not having happened. Research on adult survivors indicates that many victims never tell.
Criteria for Confirming an Allegation From Other Sources
There are other sources of information that can support a finding of child sexual abuse.
The most definitive finding is the suspect's confession. Unfortunately it is uncommon, particularly at the point of investigation, when the alleged offender may be very frightened and concerned primarily with his own well-being.CEU
An operational definition of a full confession is that the alleged offender admits to all or more sexual activity described by the child. As a partial confession, the suspect may make "incriminating" statements by admitting to some but not all of the child's allegations. Alleged offenders may minimize their behavior by admitting to "just touching," may deny acts involving severe penalties, or may not admit to certain behavior they find particularly shameful. These incriminating statements deserve attention because they may be found in cases in which the suspects are frightened to admit. There appear to be several types:
The alleged offender may claim diminished capacity.
"I don't remember what I do when I've been drinking."
The suspect admits to the behavior but says it was not intended to be sexually abusive. There are actually two types of cases that fall within this category, those in which the suspect says the mistake was on his part and those in which he insists his behavior has been misinterpreted. Examples follow:
"I forgot my daughter was in the bed with me. I thought she was my wife."
"I was only trying to show her the difference between men's privates and little girls'."
The evaluator must use common sense in assessing the probability that the alleged offenders' explanations are likely and feasible. There will be cases, especially those involving child care activities, where this is quite difficult.
In addition, the suspect may admonish professionals to attend to the accounts of others.
"My daughter would never lie about a thing like that." CEU
Finally, the alleged offender may say that he didn't abuse the child, but he is confessing to it to get on with treatment or to keep his daughter from having to testify against him in court.
As noted in the previous chapter, there has been considerable progress in the documentation of physical findings from sexual abuse.
Other Physical Evidence
In some cases, the police and sometimes others will have obtained physical evidence such as pornography or instruments used in the abuse.
Occasionally, there will be eyewitnesses to sexual abuse. These may be other children who were also abused or who observed abuse. They may also be adult eyewitnesses, sometimes the spouse of the offender.
Forming a Conclusion About Sexual Abuse
In order to arrive at a conclusion about the likelihood of sexual abuse, the professional weighs the clinical findings from the child's interview as well as confirming evidence from other sources. Rarely is the professional 100-percent sure that the abuse occurred as described, with absolutely no room whatsoever for doubt. On the other hand, it is extremely difficult to determine without any doubt that the sexual abuse did not occur. In this regard, Jones has developed a useful concept, a continuum of certainty. Cases fall somewhere along a continuum from very likely to very unlikely. child abuse ceus, child abuse continuing education courses, child abuse ceus credit, child abuse reporting ceus, continuing education in child abuse, online ceus child abuse laws and ceus. online ceus for social workers, lmft, counselors and all medical professionals.
Treatment Of Child Sexual Abuse
Treatment of child sexual abuse is a complex process. Orchestration of treatment in the child's best interest is a genuine challenge. Moreover, it is often difficult to know how to proceed because there are so few outcome studies of treatment effectiveness.
In this chapter, case management issues are discussed; a model for understanding why adults sexually abuse children is proposed; treatment modalities are described; and treatment issues are examined. The focus of the discussion is primarily on intrafamilial abuse.
Case Management Considerations
One of the reasons sexual abuse treatment is such a challenge is that it occurs in a larger context of intervention. Therefore, coordination is of utmost importance and ideally is provided by a multidisciplinary team. Treatment issues are then handled by the team as part of overall intervention.
The team usually consists of the various professionals directly involved in the case and their consultants and, as noted earlier, begins its activity at the time of case investigation. The composition and functioning of teams vary by locality, and the level of participation of team members often varies depending on the stage of the intervention. In an intrafamilial case, the members active at the treatment stage will ordinarily include the Child Protective Services (CPS) and/or foster care workers, the therapists treating various family members, professionals providing other services (e.g., homemaker, parenting guidance), a representative from the prosecutor's office, and relevant consultants. The frequency of meetings will depend on the needs of the case and how the team is structured.
The following issues are the most important of those the team should consider at this stage of intervention: separation of the child and/or the offender from the family, the role of the juvenile court, the role of the criminal court, the treatment plan for the family, visitation, and family reunification.
Case management decisions are often provisional; that is, they are based on what information about the family members and their functioning is available when decisions are made. Treatment is often a diagnostic process. The positive or negative responses of family members to treatment determine future case decisions. Outcomes of court proceedings can impinge upon and alter case management decisions and treatment.
The team meets periodically to assess progress and make future plans. Because of the complexity of case management decisions and the fact that a decision in one realm can have an impact on other aspects of the case, especially on treatment progress and outcome, multidisciplinary decision making is crucial. In the absence of a multidisciplinary team, such decisions should be made in consultation with other relevant professionals.
Before the implementation of the treatment plan, the following case management decisions should be addressed:
Should the child remain a part of the family?
Do the courts have a role in the case?
Is there a question of visitation?
Guidelines for making these decisions will be discussed.
Should the Child Live With the Family?
The preferred outcome in cases of sexual abuse, as in other types of child maltreatment, is that after intervention the family will be intact.
Generally at the time of disclosure of the sexual abuse, the offender is not separated from the family. The victim may be removed if the mother is unable or unwilling to protect and support the victim or if the victim wishes to be removed. Many professionals advocate the removal of the offender even in circumstances in which the victim is removed.CEU
After these initial decisions, a longer term plan must be made about whether the child should be a part of the family and, if so, whether or not that family should include both parents. This plan will be based on an assessment of each parent.
Aspects of the functioning of both parents outlined previously in the discussion of risk assessment should be examined in deciding about the child's future living situation. These include the following factors for the offender:
the extent of the offender's sexually abusive behavior;
the degree to which the offender takes responsibility for the sexual abuse;
the number and severity of the offender's other problems, for example;
- substance abuse,
- violent behavior,
- mental illness, and
- mental retardation.
Regarding the nonoffending parent, the following factors should be assessed:
reaction to knowledge about the sexual abuse,
quality of relationship with the victim,
level of dependency on the offender, and
the number and severity of other problems.
Other possible problems are similar for the nonoffending parent and the offender.
Although these factors are universally useful to consider, in specific cases other factors may be important or even overriding.
Offenders who have engaged in a small number of sexual acts, have taken responsibility for their behavior, and have few other problems are judged to have positive findings in these key areas and are usually treatable. Negative findings in these three areas mean that the prognosis for positive treatment outcome is quite guarded. When mothers are protective of victims when they discover the sexual abuse, have good relationships with victims, are not unduly dependent on the offender, and do not have other significant problems, their treatment prognosis is positive. Again negative findings mean that the treatment prognosis is poor.
These proposed variations in parental functioning suggest four possible combinations: both parents may have positive findings, indicating a good treatment prognosis (case type 1); the nonoffending parent may have positive findings, and the offender negative ones (case type 2); the offender may have positive findings and the nonoffending parent negative ones (case type 3); and finally, both parents may have negative findings (case type 4).
Different combinations argue for different intervention plans and long-term goals.
This matrix suggests how professionals hope to be able to make decisions. However, the parents are usually more complex than the matrix suggests. Probably in the majority of cases, the parents present a mixed picture, rather than appearing to have either a very good or bad prognosis. Moreover, as already suggested, there may be gaps in information about the family when treatment planning is undertaken and parental functioning is not static. Progress or lack of progress in treatment may result in reconsideration of the initial placement and treatment plan. Because of these complexities, most sexually abusive families should and do receive a trial of treatment. This generally entails individual treatment for all parties and the appropriate use of groups. Initial case decisions are periodically evaluated based on treatment outcome and reassessed accordingly. In addition to being useful in placement and treatment planning decisions, the matrix may offer guidance in terms of court intervention. Most professionals would agree that the Juvenile Court should be involved in all four types of cases, perhaps with the exception of a small number of those falling into case type 1. These might be cases in which the offender confesses to his wife or family, the family seeks treatment, and the abuse is then reported to CPS by their therapist. CEU
There is also increasing consensus that criminal charges should be filed, even though the offender appears treatable. Some professionals feel that even treatable offenders should do some jail time, while others see the criminal process as a means of ensuring that the treatable offender will take responsibility for his behavior and/or enter into treatment. However, criminal prosecution is especially important in cases categorized as case types 2 and 4 to offer some protection to both the family and society from the offender.
In addition, factors related to the child should also be considered. These include the child's wishes. To be more precise, if the child does not wish for a reunified family, that desire should be given a great deal of weight. A child's wish for the offender not to leave the home, however, should generally not be granted. In addition, some sexually abused children are so damaged, because of the abuse and other conditions, that they require specialized care outside the home.
The same assumption is made here as in earlier chapters, that there is a single offender, usually a father figure, and a nonoffending parent, usually a mother figure. If that is not the case, and there is more than one offender, especially within the family, prognosis is much poorer. Even more problematic are cases in which both parents are offenders; in such instances, family reunification is extremely unlikely to be in the child's best interest.
The Role of the Courts
Two or three courts are potentially involved in a sexual abuse case—the Juvenile Court, responsible for child protection; the Criminal Court, responsible for offender prosecution; and the Divorce Court, if either parent decides to pursue divorce.
Court involvement can be either a help or a hindrance to therapeutic goals. The challenge is to integrate court involvement into the overall intervention. Early decisions about the role of the court can facilitate its role in the therapeutic process.
The court can be helpful in compelling family members, especially offenders, into treatment; in protecting victims and families from offenders; and in effecting alternative living situations for offenders (or victims, if necessary).
Court involvement can be problematic because legal safeguards for the defendant may prevent certain evidence from being admitted; because the adversarial process may interfere with the therapeutic process, including disruption of offender treatment by incarceration; and because it allows procedural delays that may prevent timely intervention.
Finally, testifying in court may have a positive or negative effect on the child. The effect, in part, depends on its outcome. That is, if the case is won, the impact of court testimony is more likely to be positive.
Victims may gain a sense of mastery over the sexual abuse from testifying. If they are believed, they may derive a degree of vindication when they see that the offender has to pay for what he did. Completing the court process may also engender a sense of closure for the victim.
On the other hand, victims may experience court testimony as additional trauma. Some are required to confront their abusers, endure lengthy cross-examination, and reveal shameful experiences to an audience. If possible, the courtroom should be cleared during the child's appearance. Testifying in court, which rarely entails a single appearance, may enhance the child's perception of him/herself as a victim, rather than a normal child. Moreover, because the court process tends to be protracted, it may delay resolution of the victim's treatment issues. For more detailed information on the role of the court in child abuse and neglect cases, the reader is referred to another manual in this series entitled Working With the Courts in Child Protection.
As noted previously, in most cases it is appropriate for the offender to leave the home and for the victim to remain. In other cases, the victim should be removed to protect her/him from further sexual abuse and/or emotional abuse. (In a very small number of cases, it will be appropriate to leave the family intact after disclosure.) Obviously what constitutes visitation will vary depending on the living arrangements.
However, there are some guidelines to be used by the court and the professionals in making decisions about visitation. Many professionals recommend no contact between the victim and the offender, if the child is to appear in court, until after her/his testimony. If the mother and/or other family members are unsupportive of her/his testifying, they may be prohibited from seeing her/him until after her/his testimony.
If the child genuinely does not wish visitation, there should be none. There should be no unsupervised visitation until the child feels she/he will be safe and the offender has been assessed and found not at risk to re-offend. In some cases, the child may want visitation or unsupervised visitation when it is not deemed in her/his interest by the professionals. In such a circumstance, professional opinion should prevail.
Assuming all parties want visitation, as the offender (and other family members) make progress in treatment, visitation is initiated and becomes progressively more liberal (i.e., more frequent, for longer time periods, and with less supervision). As successive steps are taken to make visitation more liberal, it is important to make sure the victim (and her/his caretaker) want this change. The multidisciplinary team or the child's therapist needs to make these decisions.
Causal Models of Sexual Abuse
Before developing a treatment plan, it is important to have an understanding of why the sexual abuse occurs, both generally and in the particular case under consideration.
It is useful to briefly examine the history of causal theories of sexual abuse before a discussion of the current level of professional understanding. Historically there have been two rather separate efforts to understand the phenomenon of sexual abuse, its causes, and its resolution. These can be conceptualized as the family-focused perspective and the offender-focused perspective.
The Family-Focused Perspective
Those taking a family perspective focused their attention on incest and developed hypotheses that family dynamics are at the root of sexual abuse. Specifically, clinicians taking this perspective described the collusive mother, who has estranged herself from the father, as the "cornerstone" of the incestuous triad and the victim as a parental child who has replaced her mother as sexual partner to the father.
The implications of this model in terms of treatment are that the mother and the daughter must change, but the offender is not necessarily required to take responsibility for his behavior and develop strategies to control it. Most professionals working in the sexual abuse field recognize the limitations of a perspective that focuses purely on family dynamics.
This perspective does not help very much in explaining extrafamilial sexual victimization and, taken to its extreme, represents the offender as the hapless victim of family dynamics. Moreover, recent research, which finds that a substantial proportion of incest offenders begin their sexual victimization as adolescents and experience arousal to children before they become fathers, calls into question assumptions about the pivotal role of family dynamics in incest.
The Offender-Focused Perspective
Those who work primarily with perpetrators have historically been located in institutions for adjudicated offenders. Most of these clinicians/researchers appreciate that their clientele do not represent the full spectrum of sex offenders. Their focus has been on understanding the etiology of sexual abuse by examining the physiological and psychological functioning of offenders. They typically do not have access to families to understand any role they might have played in the victimization, nor its impact on the families. Moreover, as these clinicians develop and implement treatment strategies, they may have to do so in a vacuum and in an artificial environment. There are frequently both problems translating what is learned in treatment in the institution to the offender's normal environment and failure to continue needed treatment when the offender returns to the community.
An Integrated Model
Efforts to integrate the family and offender perspectives to the causes of sexual abuse began in the mid-1980's. Finkelhor examined the spectrum of clinical literature and research into the causes of sexual abuse and developed a model of causation that incorporates both the family-, and offender-focused perspectives. He posits four preconditions that must obtain for sexual abuse to occur: factors related to the offender's motivation to sexually abuse; factors predisposing the offender to overcoming internal inhibitors; factors predisposing to overcoming external inhibitors (e.g., absence of environmental obstacles); and factors predisposing to overcoming child's resistance (e.g., a vulnerable child or the use of coercion). Finkelhor applied this model on both the individual (case) level and the socio-cultural level.
The model presented here is somewhat different and more practice-focused. It proposes that there are some causal factors that are prerequisites for sexual abuse and there are others that play a contributing role. Prerequisite factors – sexual arousal to children and a propensity to act on arousal – are to be found within the offender, whereas contributing factors may come from the culture, from the family system (including the marital relationship), from his current life situation, from his personality, or from his past life experience.
An Integrated Model of the Casual Factors of Sexual Abuse
The presence of the two prerequisite factors (sexual arousal to children and propensity to act on arousal) is both necessary and sufficient to result in sexual abuse. This is not the case for the contributing factors. For example, a man does not sexually abuse his daughter because his marriage is unhappy. More than half of American marriages end in divorce, suggesting that a substantial number of marriages are unhappy. But only a very small number of men in unhappy marriages sexually abuse their children.
Contributing factors may enhance the prerequisite factors or they may, independent of an effect on the prerequisites, increase risk. An example of the former dynamics is found in the role of alcohol abuse. It usually leads to diminished capacity to control behavior, which may increase the propensity to act on sexual arousal to children. (Chemicals are also used by some offenders to cope with guilt related to their abuse behavior.) An example of the latter dynamic is that found in situations of unsupervised access to children. It may enhance risk because it provides opportunity for an offender who is aroused to children and prone to act on that arousal. This model will be referred to again in the discussion of treatment issues.
In this section, the role of various treatment modalities is described. An approach to treatment that addresses prerequisite and contributing causes of sexual abuse and meets the treatment needs of victim, family, and offender must be multimodal. Ideally, individual, dyadic, family, and group treatment modalities should be available, especially if reintegration of the offender and/or the victim into the family is planned. However, therapists and programs without this full spectrum of services can be successful in treatment.
Although group, individual, dyadic, and family modalities should be available, it does not appear to be necessary to have a rigid progression from individual to dyadic to family therapy. However, it is crucial that progress be made in individual and sometimes dyadic therapy before family therapy is indicated and before individuals can benefit from it. The types of treatment and their uses will be discussed as follows:
Group therapy is generally regarded as the treatment of choice for sexual abuse. However, usually groups are offered concurrent with other treatment modalities, and some clients may need individual treatment before they are ready for group therapy. Furthermore, there will be a few clients who are either too disturbed or too disruptive to be in group treatment.
- Groups are appropriate for victims, siblings of victims, mothers of victims, offenders, and adult survivors of sexual abuse. In addition, "generic" groups that include offenders, parents of victims, and survivors of sexual abuse have been found to be very powerful and effective for all parties involved.
- Groups may be time-limited, long-term, or open-ended. They may deal with specific issues (e.g., relapse prevention, sex education, or protection from future sexual abuse), or they may deal with a range of issues. Some programs have "orientation" groups for new clients, usually with separate groups for children and adults.
- Victim's and offender's groups have been brought together for occasional sessions. Models that have concurrent groups for victims or children and their non-offending parents, where from time to time the two groups join for activities, are very productive.
Individual treatment is appropriate for victim, offender, and mother of victim (as well as for siblings of victims and survivors). As a rule, an initial function and a major one for individual treatment is alliance building. All parties have to learn to trust the therapist and come to believe that change is possible and desirable. The members of this triad may have different levels of commitment to therapy, with the victim usually the most invested and the offender the least.
Dyadic treatment is used to enhance and/or repair damage to the mother-daughter relationship, the husband-wife relationship, and the father-daughter relationship, as well as to deal with issues initially addressed in individual treatment.
Family therapy is the culmination of the treatment process and is usually not undertaken until there has been a determination that reunification is in the victim's best interest.
Multiple therapists can be very helpful. Such a complex series of interventions can rarely be provided by one individual. If possible, two therapists should be involved, even if it is only one person doing the group work and another the individual, dyadic, and family work. However, because each family member will typically participate in a group as well as other treatment modalities, there are usually several clinicians involved with a single family. Moreover, there are reasons other than logistics for involving several clinicians.
- Sexually abusive families are very difficult to work with, and therapists need one another's support. Such families are crisis-ridden and multiproblem, making it very difficult for one person to have total responsibility for the family.
- Assigning a different therapist to the victim and to the offender "recreates," although artificially, a family boundary that was crossed when the sexual abuse occurred. It also enhances a sense of privacy and safety for the victim—two elements violated by the offender.
- In addition, cotherapy, using both a male and female therapist, has considerable therapeutic advantage. It exposes family members to appropriate role models of both sexes. Cotherapy also enhances the ability of clinicians to effect change because of the leverage it allows, particularly in group therapy.
- Finally, decisions that must be made in the course of treatment are very difficult ones, and mistakes are potentially devastating. Two or more heads may be better than one. And as noted earlier, ideally clinicians should be guided in their decisions by the input of a multidisciplinary team.
There are two main objectives in sexual abuse treatment:
dealing with the effects of sexual abuse, and
decreasing risk for future sexual abuse.
Victim treatment tends to focus more on the former; mother's treatment issues are fairly evenly split; and the offender's issues are predominantly in the realm of preventing future victimizing behavior, although the initial stage of treatment may focus on the effects of the abuse disclosure on him/her.
Treatment Issues for the Victim
The saliency of treatment issues discussed in this section will vary for each victim, some possibly being irrelevant. Also, there may be additional treatment issues for victims that are not discussed here. The following issues appear to be the most important:
trust, including patterns in relationships;
emotional reactions to sexual abuse;
behavioral reactions to sexual abuse;
cognitive reactions to sexual abuse; and
protection from future victimization.
These issues are interrelated. As the following discussion illustrates, the categorization is somewhat artificial.
Being a victim of sexual abuse can have a devastating effect on children's object relations, particularly the ability to trust other people. In intrafamilial sexual abuse, the impact may be pervasive because a caretaker, who should be a protector and a limit-setter, exploits the child and violates the boundaries of acceptable behavior. Furthermore, this damage may be exacerbated by an unsupportive nonoffending parent. Moreover, sexual abuse may not be the only way in which the child's trust is undermined. The victim may experience other maltreatment or traumatic experiences in the family.
However, children sexually molested outside the home may also experience problems with trust. This may come about because the person who victimizes the child is someone to whom the child has been entrusted by the parents, as happens, for example, when the abuser is a child care provider. These victims frequently perceive their parents as having given permission for the exploitation. Alternatively, the offender may be a person in a position of authority over the child and she/he feels compelled to comply. Then children may have considerable difficulty trusting persons in positions of authority in the future.
The challenge to the therapist is to create circumstances in which the child has positive experiences with trustworthy adults in order to ameliorate the damage to the child's ability to trust. This may involve rehabilitating the parents and/or creating opportunities for appropriate relationships with adults, for example, with foster parents, mentors, or other relatives. An admonition to therapists is that they must be honest and dependable in order to create an atmosphere of trust.
Emotional Reactions to Sexual Abuse
Three common emotional consequences of sexual victimization are a sense of somehow being responsible and therefore feeling guilty, an altered sense of self and self-esteem because of involvement in sexual abuse, and fears and anxiety.
Feeling responsible. An offender may make the victim feel responsible for the sexual abuse, for the offender's well-being, and/or for the consequences of disclosure. Victims may also feel guilty for not having stopped the sexual abuse as well as for any positive aspects of the abuse, such as physical pleasure, the special attention given by the offender, or an opportunity to have control over other family members because of "the secret."
The role of the clinician is to help the child understand intellectually and accept emotionally that the child was not responsible. The adult sexually abused the child; the child did not sexually abuse the adult. It was the adult's job – not the child's – to stop or prevent the abuse.
Altered sense of self. Guilt feelings as well as the invasive and intrusive nature of the sexual activity impact negatively on the child's sense of self and self-esteem. As Sgroi puts it, victims suffer from "damaged goods" syndrome. The effect is both physical, in that children have an altered sense of their bodies, and psychological, in that children may see themselves as markedly different from their peers.
The task of the therapist is to make victims feel whole and good about themselves again. Work, mentioned above, that addresses the issue of self-blame is helpful. However, so are interventions that help children view themselves as more than merely victims of sexual abuse. Normalizing and ego-enhancing activities, such as doing well in school, participating in sports, getting involved in scouts, or helping a younger victim, can be very important in victim recovery.
Anxiety and fear to be discussed here are related to the traumatic impact of the abuse per se on the child rather than environmental responses to it. The victim develops phobic reactions to the event, the offender, and to other aspects of the abuse. Experiences that evoke recollections of the abuse come to elicit anxiety. In some children this anxiety and phobias become pervasive and crippling because of the level of avoidance they engage in to reduce their stress.
Before treating the child's fears and anxiety, the therapist must be sure the child is not being sexually abused or at risk for sexual abuse. Then the therapist engages the victim in a series of interventions that allow her/him to gradually deal with the abuse and related phobias and anxiety in ways that usually avoid excessive stress and allow mastery. These may include discussions, play therapy, or interventions in the child's environment. For example, the victim may be encouraged to ventilate by talking about the abuse and accompanying feelings, thereby reducing the level of distress related to it. Similarly, a child who is phobic about being left with a babysitter may be left with a relative first for short and then longer time periods, then with a babysitter for brief and then longer periods and thereby be desensitized to babysitting situations.
Additional emotional reactions may be found. Depending on the circumstances of the victimization and the child's personality, she/he may react with regression, anger, depression, revulsion, or posttraumatic stress disorder to sexual abuse. These emotional reactions are likely to manifest themselves in problematic behaviors. These behaviors will be discussed in the next section.
Behavioral Reactions to Sexual Abuse
As suggested in the second chapter, behavioral effects of sexual abuse can include sexualized behavior and other behavior problems.
Sexualized behavior. A serious reaction is sexualized behavior. Children who have been sexually victimized may masturbate excessively and openly or sexually interact with other people. Every act of sexualized behavior has the potential for increasing the probability of future acts. Not only is the activity likely to be physically pleasurable, but it may also enhance the child's view of her/himself as a sexually acting out person. Such acts may also stigmatize the child, which has a negative impact on the child's sense of self.
Clinicians should work to diminish and/or eliminate sexualized behavior through teaching behavioral controls. Sexual acting out may be controlled, for example, by teaching the child to masturbate privately. Behavior management techniques, which can involve rewarding "sex-free" days and using "time-out" for sexual acting out, can be taught to the child's caretaker. In addition, the child's energies that might have gone into sexual behavior can be channeled into more age-appropriate activities by having a caretaker monitor the child, interrupt any sexual acting out, and provide opportunities for positive alternative behaviors. These interventions are conducted with the child's caretaker and/or in dyadic work with child and caretaker.
One of the reasons treatment of sexualized behavior is so essential is because of a recently recognized phenomenon called the victim to offender cycle. Both male and female victims are at risk for this problem. Many offenders begin as victims, whose response to sexual abuse is to identify with the aggressor and to sexually act out in order to cope with their own sense of vulnerability and trauma. Professionals must recognize the potential danger of allowing sexualized behavior to go untreated, which is that the child then is at risk for becoming first an adolescent offender and eventually an adult offender. The child not only damages him/herself, but also may cause grave harm to many other children over the course of time.
Other behavior problems. Other behavioral reactions to sexual abuse include such problems as aggression toward people and animals, running away, self-harm (cutting or burning), criminal activity, substance abuse, suicidal behavior, hyperactivity, sleep problems, eating problems, and toileting problems.
Some of these problems, for example, difficulties with sleep, eating, toileting, and being alone, may be acute after disclosure but diminish over time and eventually disappear. Short-term intervention, labeling the behavioral problems as common reactions, and helping the victim resolve the underlying emotional or cognitive issues is generally helpful. Parents are encouraged to be understanding.
Treatment strategies for all behavioral problems include helping the victim understand the relationship between the behaviors and the sexual abuse and emotional or cognitive reactions to it; helping the child develop insight into the self-destructive nature of some of these behaviors; assisting the victim in more appropriate expression of the emotions, for example, anger; and behavioral interventions to diminish and eliminate problematic behavior. With older children, group therapy is usually very useful in addressing these problems.
Cognitive Reactions to Sexual Abuse
An important part of treatment of victims of sexual abuse is to help them understand the meaning of the abuse. This includes learning what appropriate and inappropriate touching entails; what is wrong about sexual activity between adults and children, if they do not know this; why adults or a particular adult was sexual with them; and in some cases, why they were chosen as targets and what that means to them. How these issues are addressed will vary with the child's developmental stage. They may be more adequately dealt with in group treatment than individual therapy, and sometimes having the offender take full responsibility for the abuse in dyadic therapy with the victim is useful.
Moreover, an adequate explanation for a child at a young age may not be sufficient as she/he grows older. Thus, this particular issue will need to be addressed at a more sophisticated level as the child matures. This may be done by a parent but in some cases will need to be done by a therapist.
Protection From Future Victimization
Treatment of victimized children needs to include strategies for future protection. Teaching children to say no and tell someone may be useful, especially if the material is presented in a group setting and there are opportunities to role play resisting sexual advances. Specific protective strategies involving family members and helping professionals need to be developed in intrafamilial sexual abuse situations. Additionally, the therapist must appreciate that placing even partial responsibility for self-protection on the victim is potentially an overwhelming burden.
Treatment Issues for the Mother (Nonoffending Parent)
Although the discussion that follows refers specifically to mothers as nonoffending parents, much of the material is also applicable to nonoffending fathers. Treatment issues for mothers of victims can be categorized under the following four general headings.
issues related to the sexual abuse,
issues related to the mother-victim relationship,
issues related to the offender (spouse), and
other personal issues.
These issues are particularly relevant to cases involving mothers in intrafamilial sexual abuse but also can be important when other persons are the abusers. Like victim treatment issues, they are interrelated, and there may be other issues that are salient in a given case. The relationship of the mother's treatment issues to factors to be assessed in making decisions about victim reunification with the family will become apparent.
Issues Related to the Sexual Abuse
It is difficult for most people, including mothers of victims, to understand why an adult might want to be sexual with a child. This is often the first issue that the clinician must address with the mother. This may be especially difficult for the mother to understand if the offender is her spouse or another close relative.
The therapist may offer professional understanding into the general causes of sexual abuse or those specific to the case. The parent might also be given material to read. However, group involvement, in either a generic sexual abuse or mothers' group, may be the most effective method for addressing this issue.
A related issue is that of believing the victim's disclosure of sexual abuse. Many parents will try to explain it away. As noted in the discussion of assessment of the nonoffending parent, coming to believe a victim is usually a process, rather than instantaneous.
The therapist may describe what in the child's disclosure makes her/him believe the child or speak generally about the conclusion that children rarely make false allegations and the reasons for that belief. However, group treatment, in which the mother is confronted by others who have also struggled with disbelief, is often the most effective mode for dealing with this issue.
Finally, the therapist will want to help the mother understand her role in the abuse, if she has had one. The nonoffending parent is not to blame for the victimization but in some instances may have contributed to risk of abuse or prolonged abuse, for example, by leaving the child for long periods of time with the offender or by discounting the child's early disclosures.
Interestingly, a good prognosis is suggested when a mother feels very guilty and the therapist must work to alleviate her sense of responsibility. Conversely, a poorer prognosis is indicated when the mother sees herself as absolutely blameless and the therapist has to point out things that the mother might have done differently that could have prevented or minimized the abuse. As with other issues related to the abuse, this issue may be best dealt with in group therapy.
Issues Related to the Mother-Victim Relationship
Treatment of intrafamilial sexual abuse that results in successful reunification of the family rests upon the mother's relationship with the victim. This may be a very problematic relationship at the time of disclosure. The offender may have engaged in manipulations that have alienated mother and victim from one another. The victim may have developed problematic behaviors because of the abuse, which have damaged her relationship with the mother. The consequences of disclosure may be blamed on the victim, or the mother may never have related well to the victim (or other people).
This problem appears to be less severe with boy victims. Mothers are more likely to be supportive of them. In part this is because when boys are sexually abused, the offender is more often, than with girls, someone outside the family. Moreover, when victimized within the family, boys tend to be abused along with their sisters, meaning the mother is less likely to regard a single child as to blame or as the source of her frustrations. However, this phenomenon may also relate to differences in role relationships between mothers and daughters and mothers and sons.
The therapist tries to enhance the mother-victim relationship by assisting the mother in developing empathy for the victim; by facilitating their communication; by helping them resolve ongoing problems in their relationship, such as disputes regarding bedtime or chores; and by helping them develop opportunities for mutually enjoyable experiences. Initial work is usually done in individual treatment with the mother, and later within the mother-child dyad.
Improving the mother-child relationship is generally a prerequisite to assisting the mother in being protective of her child in the future. Although interventions are employed to help the offender control his behavior in the future, the major source of protection for the child is the mother.
Intervention to make the mother more protective is implemented in a variety of ways. If the mother has a more positive relationship with the child, she will be more predisposed to protect the child. Treatment to improve the mother-child communication should enhance the likelihood the child will tell mother. Moreover, the therapist usually works with both the child and the mother to encourage communication specifically about the child's safety.
Especially if the family has not been separated or, if separated, as the family is reunited, specific guidance should be given to the mother regarding safety. For example, she may be instructed not to leave the child alone with the offender, not to let the offender bathe the child, not to allow the offender any control over the child's activities, and/or not to give the offender the responsibility for disciplining the child. How long these protections remain in place will depend on the case.
Finally, the therapist usually helps the mother develop a specific plan in case the offender does reoffend. Her plan is communicated to the victim, the offender, and the rest of the family. It can often involve dissolving the marriage.
Issues Related to the Offender (Spouse)
In cases of intrafamilial sexual abuse, the mother must decide whether she wants to sever her relationship with the offender or try to salvage the relationship. Some mothers decide at the time of disclosure to terminate the relationship or, alternatively, to work to preserve it. For others, this decision takes time and observation of the offender's progress or lack thereof in treatment. Still others are indecisive and change their minds more than once.
The clinician may have an opinion about what the mother should do. However, it is wise to allow the mother to make her own decision. This does not preclude sharing opinions about the offender's treatability and the likelihood of the victim remaining or returning home should the mother choose to stay with an untreated or untreatable offender.
In cases in which the offender is the mother's partner, regardless of the decision to leave or to stay, the mother will need to address her relationships with men. The goal is to help her gain some insight into these relationships, including that with the offender, and to understand their problematic aspects. If she intends to stay with the offender, she must be assisted in changing that relationship. If she leaves him, the goal of insight is to help her in future relationships. Group treatment with other mothers is particularly useful in this work. Of course, if her intention is to preserve the relationship with the offender, dyadic work with the offender is necessary.
Often mothers are very dependent on the men who have abused their children. In most instances, it is important to help her become less dependent so that she will be better able to seek what is in her children's and her interest, should there be a conflict between the offender's interest and that of the rest of the family.
Independence may be fostered by involving the mother in activities outside the home, including therapy; enhancing her financial independence; encouraging her to do things without his assistance; and facilitating her assertiveness when they are in conflict. Opportunities for these types of interventions may present themselves quite naturally if the offender must leave the home at the time of disclosure of the sexual abuse. Because of the mother's need to function autonomously in his absence, he may return home to a situation quite different from the one he left
Other Personal Issues
Most mothers must deal with other issues related to current functioning and past experiences in therapy. The most common issue regarding current functioning is low self-esteem. However, other issues, such as substance abuse, experiences of violence, dependency, and emotional problems, often need to be addressed as well.
The most common issue in terms of past trauma is having been sexually victimized themselves. Such an experience can have a variety of implications in terms of the mother's ability to deal with her children's sexual abuse. For example, at the time of disclosure, a mother may be so overwhelmed because of her own abuse that she cannot deal with her child's victimization. In such instances, her abuse may have to be addressed first. Her own victimization may have an impact on her willingness to believe the victim, her ability to discern risky situations (she may not note them), and her choices of partners, playing a role in her choosing someone who is sexual with children. In addition, it may cause her to mistakenly believe her children are being victimized.
Treatment Issues for the Father as the Offender
Although the following discussion will refer to the father as the offender, it is equally applicable to cases involving stepfathers and unmarried partners of mothers who are offenders. It is also relevant to some situations involving other intrafamilial offenders. Treatment issues for the offending fathers can be broadly defined as falling into three categories:
issues related to the father's past sexual victimization of children,
issues related to the father's possible future victimization of children, and
other dysfunctional behaviors and problems.
These broad categories tend to be overlapping.
Issues Related to the Father's Past Sexual Abuse of Children
In many cases, the first challenge for the clinician is obtaining a confession of the sexual offenses. Many fathers are too ashamed to admit what they have done. Others are reluctant to disclose their abuse during litigation because they are afraid of its impact on the outcome. They may be more willing once the court case is resolved. Others are ordered into treatment by the court while continuing to protest their innocence.
Operationally, confession means an admission to all of the acts the child has described. However, it is common for the child not to disclose all of the abuse; therefore, it is important for the offender's therapist to stay in touch with the victim's therapist in case there are additional disclosures. (In treating intrafamilial sexual abuse, it is important for each family member to consent to share information with each therapist treating each family member.) To obtain a confession, the therapist actively confronts the father with the information on his offenses provided by the victim and others. In addition, group treatment, in which the father observes others confessing their victimizing behavior, can facilitate full disclosure.
With confession must come an acceptance of responsibility for the abusive acts. That is, the father must disavow any past excuses, such as his wife was not giving him sex or that he was drunk at the time. He must not minimize the behavior by saying, for example, "it only happened once," "there was no penetration involved," or "I stopped when she asked me to." As is probably apparent, it is extremely difficult to know when the offender has actually accepted responsibility rather than saying what he thinks the therapist wants to hear. Again, the use of group treatment can be especially helpful because other offenders may be more capable of discerning and confronting deception than a therapist.
A related task of treatment is for the father to appreciate the harm the abuse has caused the victim, his partner, and finally himself. There may be others affected as well, for example, siblings of the victim and the extended family. Some sort of communication from the victim and the offender's partner about the effects of the abuse on them can be useful. This may be in the form of a letter, a video or audiotape, or a face-to-face confrontation involving the therapist. Generic groups in which offenders are confronted by adult survivors and mothers of victims, other than the offender's own, can facilitate these insights. Written accounts, by victims, journalists, and professionals, of the impact on victims may be used, and offenders' groups can be the context for this work. As with the issue of responsibility, being sure the father is doing more than saying the right thing is a significant challenge.
At some point in treatment after the offender has confessed, taken responsibility, and come to appreciate the harm he has done, a series of apologies should be made. The offender must apologize to the victim, to his partner, and to the family in intrafamilial cases. There may be others who have been affected and deserve an apology as well. This is a process, not a single act, usually conducted in the context of dyadic or family treatment. The fact that the offender apologizes does not imply that the victim and others need to forgive him. These interventions need to be carefully orchestrated and controlled by the therapist. Only after the offender has completed the process, demonstrating an appreciation of the harm done, should his return home be considered.
A final treatment issue related to past abuse has to do with prevention. In order to prevent future sexual abuse, it is important for the offender and the therapist to understand why the offender sexually abuses children. In this regard, the model presented earlier in this chapter is relevant.
Thus, the treatment process involves coming to understand the offender's arousal pattern and why he acts on the arousal. Then contributing factors are explored.
Sexual arousal to children. Arousal patterns vary. They may be conceptualized as follows:
Child is the offender's primary sexual object. Some offenders' sexual preference, sometimes exclusively, is for children. The term pedophile is generally used to refer to this type of offender. Often pedophiles not only prefer children, but children of a particular age and sex. Pedophiles tend to have multiple victims and actively seek opportunities whereby they can have sexual access to children, by choosing vocations and avocations that afford them contact with children. A contributing factor to this type of arousal pattern is often traumatic childhood sexual experience.
Child is one of multiple sexual objects. Other offenders have multiple paraphilias or aberrant sexual preferences and sometimes normal sexual preferences as well. The behavior of these offenders is characterized by sexual contact with children but may also include rape of adults, promiscuity with adults, exposure, voyeurism, sadomasochism, group sex, bestiality, and other sexual acts. The term sexual addict is often applied to this type of offender. The contributing factors or etiology of this pattern of sexuality appear to be a combination of childhood and adolescent experiences.
Child is a situational sexual object. Finally, there are offenders whose normal sexual orientation is toward peers but who become aroused by children under certain circumstances. Factors that contribute to such arousal may include the absence of other sexual outlets, stresses affecting normal marital and/or peer relations and communications, child pornography, and physical exposure or contact to children that is sexually stimulating. Although initial sexual contact involving this type of offender may be situationally induced, the experience may be very gratifying. Clinical experience indicates this is likely to result in an increased desire for and preference for sex with children.
As may be apparent from the last point, although these three arousal patterns are presented as though they are discrete, they probably are not. For example, it may be inappropriate to classify some offenders as having either a primary orientation to children or to adults.
Understanding the offender's arousal patterns may be done by having the offender describe what he experiences about his victims as arousing, having him discuss in detail his sexually abusive behavior, having him reveal his sexual fantasies, or measuring his erectile responses to various visual and auditory sexual stimuli using the penile plethysmograph.* Treatment prognosis with pedophiles and sexual addicts is much poorer than for those who have situational sexual arousal to children.
The propensity to act on arousal. There is research that suggests that a substantial minority of the male population experiences sexual arousal to children. (Comparable research has not been conducted on women.) However, it appears that a great many more men experience these feelings than act on them. The willingness to act on these feelings appears to be related to one or in most cases more than one of the following deficits:
pervasive superego deficits,
circumscribed superego deficits,
impulse control difficulties, and
Persons whose superego deficits are pervasive have little or no conscience. The term psychopath is often applied to them. This condition is thought to be a result of early traumatic life experiences. Those who have some superego deficits may experience an absence of conscience related specifically to sexual activity or sexual activity with children, or they may generally have a weak or impaired superego. Some combination of early experience, lifestyle, and cultural norms may create this sort of superego. Differing in degree is the offender who has cognitive distortions related to his sexual deviance. He will have persuaded himself that sexual abuse is not bad or not so bad by such rationalizations as "The child won't know what I'm doing so it's not harmful" or "Everyone needs sex; this is my way." After the initial act, distortions may be "The child didn't resist, so she must have liked it," "There was no penetration so it wasn't really sexual abuse," or "It's my wife's fault because she withheld sex from me." Some offenders appreciate that what they do is wrong, but they do it anyway because they have poor impulse control.
Finally, some offenders experience diminished capacity, which enhances propensity to act on arousal. Typically, this is a temporary condition, and its most common cause is substance abuse. Thus, the offender acts on his arousal because alcohol or drugs have decreased his ability to control his behavior. Initial instances of victimization when drunk may occur without a prior plan. However, subsequently, the offender may drink so that he will have an excuse to abuse. Furthermore, after the initial acts, the attraction of the behavior itself may increase and chemicals are less necessary to diminish control. There can be other causes of diminished capacity. Offenders may lack adequate ability in handling stress, depression, anxiety, and/or anger in healthy ways. In addition, some persons suffer from chronic diminished capacity as a result of mental retardation or organic brain syndrome. If they experience arousal to children, it will make them at ongoing risk for sexual abuse.
Contributing factors. Some factors that may enhance arousal or increase the propensity to abuse have been described above. There may be other factors that act on these prerequisites and ones that independently contribute to risk for sexual abuse, for example, child behaviors, mother behaviors, and opportunity to sexually abuse.
It is an important part of the treatment process to understand why the offender has sexually abused children so that he can be empowered to gain control over his arousal and propensity to act on arousal. Some of the intervention that addresses contributing factors may be initiated with the offender alone, but much is done in the treatment of other individuals in the family and in dyadic and family work.
Issues Related to Possible Future Sexual Abuse
As noted in the previous section, preventing future sexual abuse relies on understanding what made the offender abuse in the first place. In this section, interventions that address arousal to children and propensity to act on arousal are discussed.
Sexual arousal to children. It has already been pointed out that sexual and other trauma during childhood may play a role in later sexual arousal to children. However, understanding the relationship of the offender's previous history to his arousal patterns is probably the least useful in prevention of future sexual abuse. In fact, often offenders manipulate the treatment process so that past history becomes an excuse for their offending. In spite of this risk, for some offenders, understanding the origins of previously incomprehensible behavior can render it manageable. Moreover, realizing that what the offender learned about sex roles as a child was wrong can lead to the development of more appropriate definitions of sex role behavior.
When deviant arousal patterns have been defined, the therapist will attempt to change these patterns. That is, the therapist will endeavor to decrease sexual arousal to children and increase arousal to appropriate sex objects. This is done through a variety of behavioral interventions that rely on both respondent and operant conditioning. These techniques include aversive conditioning, covert sensitization, thought stopping, masturbatory satiation, behavioral rehearsal, systematic desensitization, and masturbatory reconditioning. These techniques are often used in conjunction with social skills training, empathy training, and behavioral assignments.
Behavioral interventions are exacting, and some require a laboratory setting. They also require the full cooperation of the client if they are to be successful. Moreover, the changes they create are not assumed to be permanent (nor are those from other types of intervention), and clients may need booster sessions. Many mental health professionals are untrained in and uncomfortable with behavioral interventions. However, to date they are the only therapeutic techniques that have been found, based on empirical evidence, to decrease sexual arousal. It behooves every clinician treating offenders to be familiar with these techniques and use those that can be suitably employed in his/her agency.
The propensity to act on arousal. Two approaches may be used to address propensity to act: techniques that enhance superego functioning by taking responsibility for sexual abuse and relapse prevention. Offenders whose propensity to act is based on pervasive superego deficits will probably not respond to treatment to reduce this propensity. However, those who have circumscribed superego deficits or are engaged in cognitive distortions probably will respond to interventions to address superego deficits. Treatment that is focused on getting the offender to take responsibility for his abusive behavior, to appreciate its harm, to acknowledge the feelings of traumatized parties, and to make amends or reparation is meant to enhance the offender's superego functioning and eliminate cognitive distortions, thus decreasing the probability of his acting on arousal in the future. Making amends or reparation usually involves a physical (e.g., community service) or monetary consequence that may serve to teach empathy and inhibit further abuse. In addition, when an offender lacks a strong internalized superego, the fact that there will be consequences for reoffense, such as prison or his wife leaving him, serves as an external superego. The strength of such interventions is in their deterrent effect.
In recent years, sex offender therapists have experienced success by using relapse prevention strategies, a technique borrowed from addiction treatment, in their intervention. Relapse prevention addresses propensity to act based on impulse control problems, reduced inhibition, and diminished capacity. Relapse prevention assumes that there are emotional states and behaviors on the offender's part that precede and ultimately precipitate the sexually abusive behavior. Often the offender is unaware of these factors and believes that his behavior is out of his control.
The clinician assists the offender in understanding these precursors and helps him develop a plan to manage such situations so that he does not reoffend. The clinician uses disclosures from the offender and others, including the victim, to obtain an accurate understanding of the circumstances that led to offending. Obviously such an intervention requires a candid and cooperative offender.
With some offenders, particularly those with cognitive limitations and difficulty being introspective, the clinician merely teaches the offender to anticipate, identify, and avoid risky situations. Thus, the offender may be instructed that he cannot assist at summer camp anymore or he cannot be left alone with his daughter.
With other offenders, the clinician helps him understand the chain of events, often seemingly unrelated to the sexual abuse, that precedes the victimization. This might include a series of procedures, such as the grooming process an offender may employ in the seduction of his victim, or acts such as getting upset with his wife and getting drunk after she goes to bed as a prelude to going into the daughter's room to molest her. The therapist then teaches the offender to interrupt the chain of events rather early while he still has control of his behavior. Thus, the pedophile is instructed to avoid driving by playgrounds, and the offender whose abuse is precipitated by drunkenness is instructed to abstain completely. If he has a serious substance abuse problem, he is sent to a substance abuse treatment program, either before treatment of his sexually abusive behavior is begun or in conjunction with sexual abuse treatment.
The relapse prevention plan is usually written out, and the offender carries it with him so he can refer to it when he thinks he is in a high-risk situation.
Interventions with the family mentioned earlier, such as not allowing the offender to be alone with the child or to discipline her, are meant to prevent him from being in high-risk situations. Moreover, there are numerous other ways the family and others can be involved in helping the offender prevent a relapse. Because most offenders experience more than one deficit leading to propensity to act, interventions that focus both on his taking responsibility and on relapse prevention are advised.
Other dysfunctional behaviors and problems. The offender may experience many other problems, and often these are contributing factors to the sexual abuse. Examples might be violent behavior, problems with the law, poor parenting skills, marital discord, poor social skills, low self-esteem, lack of education, and unemployment.
These are appropriate foci of treatment, and indeed it may be necessary to treat them because they increase the risk for future sexual abuse. Nevertheless, it is crucial that the clinician not allow him/herself to become sidetracked into only dealing with these other problems. Distraction can occur more easily than one might think if the offender refuses to admit to the sexual abuse or is reluctant to focus on it in treatment, yet is more than willing to work on his other problems. This pitfall is usually avoided if group therapy, which forces the offender to deal with his abuse, is a major component of the intervention and/or if there are several therapists involved in the case.
- The plethysmograph consists of a gauge attached to the offender's penis that can measure and systematically record tumescence.
Impressive progress has been achieved in the child sexual abuse field in the last 10 years. Advances have been made in identification, investigation, intervention, and treatment. Sexual abuse cases, perhaps even more than other types of maltreatment, require multidisciplinary, multiagency collaboration in order for professionals to effectively act in the victim's and family's best interest. Many communities have developed guidelines and protocols for handling these cases.
Yet there is still much work to be done. More progress has been made in the identification and investigation of sexual abuse than in treatment, and resources tend to go into these efforts rather than into preventing and ameliorating the problem. There is a startling paucity of treatment outcome studies. Consequently case management decisions and decisions about what techniques to use in treatment are made by clinicians without empirically tested guidelines.
Moreover, despite the progress in identification, many cases still go undetected. Further, our investigative techniques do not guarantee all victimized children will disclose, and many cases are still inadequately investigated. Moreover, in too many instances children's disclosures are met with skepticism, and the conscientious work of professionals acting on their behalf is challenged.
Although in part professional shortcomings relate to the fact that our abilities to address sexual abuse are still developing, they are largely the result of lack of adequate resources. Caseloads for child protection staff and foster care workers are too large; their training is inadequate; and because of the stresses of the job, their turnover rates are unacceptably high. There are too few trained clinicians who can provide treatment to families and individuals involved in sexual abuse, and when skilled professionals are available, there are often insufficient funds to pay for the necessary treatment. Finally, the funding for research to help us better understand sexual abuse and how to address it is in very short supply.
Nevertheless, professionals in the field of child sexual abuse continue to strive to educate the public and other professionals about this problem and its pervasive effects. Despite the shortage of resources, there is leadership at the Federal and State levels that has played a fundamental role in the substantial progress that has been made. The willingness of adults with prominent roles in the community to identify themselves as former victims and survivors of sexual abuse has added immeasurably to the credibility of child victims and has inspired professionals to continue their work.
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