Child Sexual Abuse

A Handbook For Health Care And Legal Professions

Diane H. Schetky, Arthur H. Green

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317772637
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

First published in 1988. Child sexual abuse involves the exploitation of a child for the sexual gratification of an adult. A narrower form of child sexual abuse is incest, which refers to the sexual exploitation of the child by another family member. This book provides us a comprehensive and comprehensible current account of what is known and what is not known on the subject of child sexual abuse. Drs. Schetky and Green, both highly skilled and talented child psychiatrists, have a wealth of information and experience that they share in an admirably straightforward and sensible way. They pull no punches, providing the available data, and where no adequate scientific data are available, they draw on their considerable practical knowledge. Each problem area is faced directly and forthrightly, making this book the single-most useful volume for all health care and legal professionals who work with sexually abused children and their families.

Section II

Evaluation

4

The Clinical Evaluation of Child Sexual Abuse

Diane H. Schetky

This chapter discusses the early stages of clinical intervention and outlines objectives for conducting the initial clinical evaluation of the sexually abused child and her family. Practical suggestions to the clinician are provided for interviewing the child. Formulating recommendations for treatment is also considered.

Recognition of Child Sexual Abuse

“Recognition of sexual molestation in a child is entirely dependent on the individual’s inherent willingness to entertain the possibility that the condition may exist” (Sgroi, 1975, p. 18). This means opening our minds to the fact that sexual abuse may occur in nice upper-middle-class families who are pillars of the community, as well as in multi-problem lower-class families. Further, it is important to bear in mind that children of all ages may be victimized and that boys are also at risk.

Discovering sexual abuse involves asking the right questions. This point was made to the author by a resident who always seemed to have an inordinately high number of patients in her caseload who had been sexually abused. When asked for possible reasons for this, she replied, “It’s very simple. I routinely ask about sexual abuse.” Such questions may be put to the new patient or older child while taking a history in the context of the review of systems. Questions such as, “How did you first learn about sex?” “Do you have any concerns about your body?” “Do you know of anyone who has ever experienced sexual abuse?” or “Has anyone ever touched you in a way that made you feel uncomfortable?” give the patient permission to talk about these concerns and signal that the clinician considers them important.

Sexual abuse may present itself in a variety of ways. The child may blow the whistle but is usually unlikely to do so until she approaches adolescence, at which time she is physically and emotionally less dependent upon the abuser if the abuse is within the family. Teenagers may also expose the family secret in response to a father’s or stepfather’s attempting intercourse or when he attempts to curtail their heterosexual activities. In one study (Sauzier, 1986), only 55% of victims revealed their sexual abuse. Those who never told either viewed the experience as insignificant or were involved in a complex relationship with the offender who was likely to be a family member.

When children do choose to talk about sexual abuse they are least likely to turn to a physician or nurse; rather, they are apt to confide in a neighbor, teacher, or trusted relative. Hence, it is most important to educate the public about how to respond in such situations. Sadly, one still hears of cases in which children are not believed or are told “Uncle Joe would never do a thing like that” and that they must have imagined it.

Sexual abuse may be discovered incidentally when a child displays a behavioral or physical problem (Table 1). Apart from gonorrhea in a child under age 14 (other than in a newborn), there are no absolute indicators of sexual abuse (Sgroi, 1977). Many physical findings are highly suggestive and will be discussed further in the chapter that follows. Behavioral manifestations are nonspecific and cover a wide spectrum from the withdrawing child to the more acting-out child (Table 1). Several studies suggest that sexually abused children fall between normal and emotionally disturbed children in terms of the psycho-pathology seen (Conte, 1985; Gomes-Schwartz, Horowitz, & Sauzier, 1985). How important the relationship with the offender was to the child and the mother’s response to disclosure seemed to have bearing on the child’s ensuing psychopathology.

Table 1
Nonspecific Symptoms of Child Sexual Abuse

Physical Symptoms	Behavioral Symptoms
Pregnancy	Withdrawal
Genital lacerations	Anxiety, fearfulness
Rectal tears	Sleep disturbance
Inflamed genitalia	Somatic complaints
Discharge	Eroticization, increased sex play
Stomach aches	Self-destructive behaviors
Blood in stools	Acting-out behaviors
Bruising near genitals	School problems
	Depression, low self-esteem
	Poor peer relations

Someone outside the family may suspect sexual abuse, as is becoming increasingly common given all the media attention to the problem. Such allegations require careful investigation to rule out the possibility of vindictiveness or projection. In many incestuous families, it is unusual for parents to make allegations of sexual abuse as the mother is often passive and feels at a loss to do anything about the situation, or her own dependency needs cause her to fear disruption of the family.

Fathers involved in incestuous relationships are usually loath to come forth because of shame, fear of incarceration, and job loss. Recently, there has been a proliferation of allegations of sexual abuse arising in the context of child custody and visitation disputes. Such charges may arise prior to separation or afterwards, at a point where the mother or child feels safe in lodging them. A parent may bring about false allegations in an attempt to prevent the other parent from having access to the child, or possibly out of dissatisfaction with a custody decree. The complex issues in these cases will be discussed further in Chapter 6.

Clinicians need to be alert to factors that put a child at risk for sexual abuse. Among these are a stepfather in the home (Finkelhor, 1980; Russell, 1984) or living with a single mother (Sauzier, 1986). The latter puts a child at risk by exposing her to more caretakers and more of the mother’s boyfriends.

The Investigation of Child Sexual Abuse

The investigation of sexual abuse spans many disciplines including pediatrics, psychiatry, psychology, social work, guidance counselors, protective service workers, police, and attorneys. Often there will be duplication of efforts and the child is subjected to repeated interviews, some by skilled and others by less skilled persons. When not handled optimally, the process may be confusing to all the participants and traumatic to the child. Ideally, the investigation should be streamlined, with one mental health professional doing a videotaped interview of the child to be made available for others to see. Interviewers need to be skilled at evaluating and building rapport with young children and must possess a solid knowledge of child development, as well as an understanding of the dynamics of child sexual abuse. They need to be comfortable discussing sex with children and be aware of their own feelings and how they impact on the interview process. It is essential that they have access to the child and his family on several occasions.

The question of whether to undertake sexual abuse evaluations alone or as a team is largely academic and a function of the context of the clinician’s practice. Obviously, if one is in solo practice in a rural area one may not have the luxury of a team approach. The advantage of doing the entire evaluation is that one has direct access to all parties and can prepare a report based on direct observations. One must be aware of countertransference issues and the attempts of various parties to manipulate. In contrast, the team approach offers more opportunity to discuss one’s feelings about the case and provide support to one another. Potential pitfalls exist however, as when team members take sides or cannot arrive at a consensus of opinion and end up making conflicting recommendations.

Strategies for Initial Intervention

Some clinicians may be reluctant to become involved in cases of sexual abuse because they dislike dealing with crises or are uncertain how to proceed. The following guidelines are offered to alleviate some of these anxieties involved in dealing with incestuous families. Many of the principles are applicable to extrafamilial abuse as well.

1. Make the most of the crisis. The Chinese character for crisis combines the symbols for danger and opportunity. In crisis there is the opportunity for change in the family structure and inserting oneself into an otherwise closed system.

2. Report and support Reporting of child sexual abuse cases or any suspicion thereof is mandated in all states. Some well-intended professionals fear that reporting will only add to the family’s stress. Although this is a valid concern, it is at the same time naive to assume that one can manage these cases single-handedly. The authoritarian backup of the legal system is often critical to ensuring that incestuous families remain in treatment. It is easiest to report sexual abuse immediately, since the longer one waits the more likely one is to get dragged into the family’s pact of silence. The physician has an ethical obligation to inform the parents that a report will be filed. Racusin and Felsman (1986) point out that any deception undermines the possibilities for therapeutic work and that informing parents serves to facilitate empathy and render intervention more effective. Support means preparing the family members for what lies ahead, being available to them, and encouraging them to be responsive to the needs of the victim and other children at risk.

3. Give the most support and authoritarian protection to the family member who blew the whistle. Family members may turn on the child or pressure her to recant her allegations. Rather than deal with their own guilt, they may try to view the child making the allegations as the source of the problem. In one such case, parents accused their daughter of being a witch and physically and emotionally banished her from the family.

4. Talk explicitly about what happened. This diffuses the emotional impact of sexual abuse, avoids denial, and gives family members permission to talk about it.

5. Monitor one’s own feelings and nonverbal behavior and strive for a nonjudgmental stance. For example, Chris, age 10, was asked why she had not been able to tell her caseworker about ongoing sexual abuse, and she replied, “Every time I tried to tell her, she got this weird expression on her face.”

6. Talk with family members individually.

The Victim

In speaking with the victim, it is important to avoid overidentifying. One should not presuppose that the experience was all bad or painful for her or that she is necessarily angry with the offender, nor should one try to be angry for the victim. When the child is seen initially, the child’s anger toward her mother over the issue of lack of protection and role reversal may be much closer to the surface than anger with the father. It is equally important not to view the child as the seductress or imply that she could have put a stop to the relationship, had she really wanted to. When the male therapist is confronted with a seductive child, he may be tempted to handle his own discomfort by casting the blame on the child. It is helpful to remember that seductive behavior is a learned behavior often reinforced by the offender.

It is important to take time to establish rapport with the child but not to “beat around the bush.” If sexual abuse has already been uncovered, the child is likely to know why the clinician is seeing her. It is necessary to allow her to express her feelings in her own words and to avoid asking so many questions that she does not have a chance to give her view of what happened. The clinician can use the child’s vocabulary but should clarify what the child means by specific terms.

It is useful to give the child an intellectual understanding of what occurred and reassure her that she did the right thing in telling about the sexual abuse. Two rationales that have proven helpful to child victims are that telling is the first step toward getting help for the offender and that it is a means of protecting other children at risk, such as younger siblings. Further, the child may be told that the secret is really the offender’s secret, not hers. MacFarlane (1986) reassures the child by telling her that sharing a secret is like getting rid of a painful splinter.

The Nonoffender

The nonoffender will usually be the mother who may or may not have been aware of the ongoing sexual abuse. Anger toward her over her role in the abuse is not helpful; rather, one needs to look at her as a victim in need of support during a time of crisis. Common responses are shame, guilt, loss of self-esteem and family support, and feelings of helplessness. Some mothers may harbor intense anger toward men, which may make a male clinician uneasy. Typically, these women are passive and need to be helped to assume a more protective role toward their daughters ...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Foreword
• Contents
• Acknowledgments
• Introduction
• Child Sexual Abuse A Handbook for Health Care and Legal Professionals
• Section I Overview
• Section II Evaluation
• Section III Legal Issues
• Section IV Treatment and Prevention
• Appendix
• Name Index
• Subject Index