Handbook of Child and Adolescent Sexuality

Developmental and Forensic Psychology

Daniel S. Bromberg, William T. O'Donohue

• Publisher: Academic Press
• Year: 2013
• Print ISBN: 9780123877598
• eBook ISBN: 9780123877642
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Adolescent and child sexuality is studied by developmental psychologists from a research perspective and is of interest to forensic psychologists dealing with abuse and custody issues as well as rape cases. In many cases, it is of interest whether the child in question was sexually active to understand the extent to which an underage minor might have voluntarily participated in sexual activity as opposed to having been coerced. Previously, researchers interested in the applications of their research needed to look to separate books, and forensic specialists needed to look to development books to find the information they may have needed. This handbook provides both audiences with the related information they need.- Encompasses normative behavior and clinical disorders in one source- Applies the information on development and behavior to forensic issues- Provides treatment information on sexual disorders in children- Provides information on children and adolescents in one volume

Part One

Ethical Issues Pertaining to the Sexuality of Minors

Chapter 1 Choosing for Children

Chapter 1

Choosing for Children

Michael Lavin, San Antonio, Texas¹

The Rudiments of Consent

When clinicians treat a child because of a sexual disorder or behavior, they must manage difficulties that have to do with treating any child and also difficulties that have to do with salience of sex in American culture. Let us begin with the general difficulties.

Everybody now concedes that children are not miniature adults. Because children are not adults, two central principles that govern the treatment of adults have their importance reversed. For competent adults, their liberty interests take precedence over their welfare interests. Competent adults are at liberty to refuse standard treatments and even lifesaving treatments. An adult’s refusal of a low-risk, beneficial treatment may raise clinical eyebrows and result in an assessment of that adult’s competence, but the general rule is that competent adults get to decide to what they will submit. They must consent to their treatments. Young children have no such right, though the older children get, the harder it becomes to overrule their wishes, as they have the capacity to consent. Still, the importance of liberty has its day in America. Even young children do get asked to assent to treatments, but minor children lacking decisional capacity have no veto power over beneficial treatments.

Clinicians do, on standard accounts, have a duty, barring emergencies, to obtain permission before treating a child; however, the child’s mother or father, the persons who, unless disqualified or absent, do consent to treatment, have grave constraints placed on their deciding. These constraints may not apply when deciding for an incompetent adult. In particular, a parent has a legal obligation to make treatment decisions for their children based on what is in the child’s best interest. When a person other than the patient must decide what treatments to accept or reject, the custom is to call him a proxy. Parents are proxies for their children. Their duty is to decide what is in the child’s “best interest.” When a proxy decides for somebody other than a child, the proxy may sometimes have a duty or permission to ignore what is in the patient’s best interests, and decide as the patient would decide if he were competent to decide. For example, a man may need a blood transfusion. If he is a Jehovah’s Witness, his wife may refuse the transfusion, even if it is likely to save his life. She may rely on her reasonable beliefs of what he would wish done in this situation, rather than the best interest standard. In practice, some parents may make treatment decisions based on their understanding of what their child wants, but the ordinary understanding is that they are to rely on what is in the child’s best interests to make a decision.

The Best Interest Standard is in fact misnamed. Despite the name, few parents can make decisions based on a literal reading of this standard. Often nobody knows what is in the best interest of the child. The remote consequences of a decision may be unknowable. There may be disagreements about what to include in the calculation of a child’s best interest, or even what weight to assign different factors. One parent may think a child in a persistent vegetative state should receive aggressive treatment to keep him alive in that state, whilst other parents would opt for minimal care. Whatever the law says about cases of this kind, and that may vary from jurisdiction to jurisdiction, there is no definitive answer to what is in the child’s best interest in many cases.

What then must proxies relying on the Best Interest Standard do? They must do what all parents do. They must agree to good enough care. A parent must consent to have a child examined after a rape, but may decline a recommendation for psychoanalysis to help the child cope with its sequelae, though they would have an obligation to agree to a briefer form of psychotherapy if the child needed it. There need be no agreement in many cases about what assessments and treatments a parent must accept, as reasonable people for any number of reasons could disagree about what the child needs. If the best interest standard were literally true, the same facts should yield the same decision in each case.

As a matter of law, parents do provide consent to the treatment of their children, and barring legally carved out circumstances—for example a daughter need not obtain permission from her father for treatment, if the father has raped her—parents do in most instances have to consent for a clinician to provide treatment to their children.

Why? Tradition is part of it. It is the done thing. Money is a part of it. In many instances where consent matters, children lack a means of paying for the services. But perhaps there are deeper reasons than either tradition or money.

Consent derives from a Latin word that means “with knowledge.” When somebody consents to something, he does more than just agree to it. People consent in situations that have gravity. Consent fits best in contexts where something that matters is at stake. The moral idea is rooted in simultaneous respect of a person’s liberty and welfare. When persons consent to an assessment or treatment, they are to know what is at stake for them. One might think of the consent as requiring an informed mind and a free will. What is involved? There are at least two general requirements:

1. A conveyance of information that

1. is understood; and

2. is complete and relevant to the choices.

2. A volitional requirement that

1. entails an uncoerced choice;

2. entails practical reason; and

3. results in a public authorization of any chosen intervention for which there has been an adequate conveyance of information.

Readers should avoid literalism in regard to these requirements. Understanding information, for example, is a scalar quality. It admits of degrees. Complete information relevant to a choice is at best aspirational. Rational patients resent consent forms that omit important benefits or side effects of an intervention, as these omissions prevent their choosing wisely. They are not interested in whether their therapist is left-handed. Likewise, “uncoerced” does not mean that the patient has no compelling reasons for making his choice. Few people would agree to prolonged exposure therapy for PTSD, if they were asymptomatic. Having a condition for which one is being treated does not count as coercion; being told you will be gelded in your psychology course unless you agree to doing the assignments does count as coercion. It is sometimes difficult to tell whether choice is coerced, but it is often very clear that a choice was not coerced.

Practical reasoning guides choice. Theoretical reason seeks the truth. Practical reason seeks apt choices. To have practical reason, human beings must have the capacity to make use of what they know and believe. They must also have sane goals (viz., I want to be healthy, I want to stop stealing women’s shoes, etc.), as well as an understanding of how to use what they know to help them get what they want. People differ in how well they can engage in practical reasoning. Adults with disorders that can impair practical reason, as do Alzheimer’s disease or mental disorders in the psychotic spectrum, are sometimes unable to meet the volitional requirement. Some children, for example younger ones, are incapable of meeting it.

These requirements for consent illuminate what happens in an ordinary consent process. It has five elements. Each requirement rests on the conveyance of information, its comprehension, and the employment of practical reason to choose an offered intervention, and the free choice of interventions. After all, if one proposes to impose an intervention, these five features of the consent process are beside the point, even though it is indeed possible to tick through this process with a patient incapable of consent, as would happen with young children, demented, insane, or comatose patients.

1. The proposed intervention is explained.

2. The intervention’s benefits are explained.

3. The intervention’s risks are explained.

4. The same is done for alternatives to proposed intervention, including doing nothing.

5. The patient is invited to ask questions.

Now that the complexities of the consent process are in relief, they pose obstacles to children that will lessen as the children age. With the passage of time, children grow in their ability to understand what clinicians tell them and to use what they are told to make a free choice from alternatives. In philosophical terms, the theoretical and practical reason of children matures and improves with time. For a variety of reasons, legal systems tend to simplify the task of determining when a human being is free to make choices about their medical treatment, by providing an age of majority. So, when a person in the United States reaches particular age milestones, he is left at liberty to make certain decisions for himself, until at the age of 21 there is a presumption in favor of his decisional capacity to make the choices of a fully fledged citizen.

Hot Button Case

Despite the emotion attaching to sexual decisions, it is difficult to discern any ground for thinking that they necessitate a novel theory of informed consent; however, there are reasons why a child may strain to acquire the capacities to make choices about sex whilst still young.

Just as children’s minds evolve towards adulthood, so do their bodies. Changes in the body have an impact on what children desire. Prior to puberty, a child faces a set of “natural” and “social” pressures favoring gender conformity. Girls and boys face expectations having to do with names, etiquette, dress, choice of friends, sexual attraction, play, competition, eating, and self concept. On the list goes.

Perhaps one of the earliest sexual difficulties a child faces involves the embrace or rejection of the alleged implications of its anatomical sex, though other sexual challenges also face a child. Many people report being aware of bisexual, homosexual, or heterosexual partner preferences at an early age. Depending on a child’s overt responses to these early challenges, it may face conflict with parents or other significant adults. As a result, therapists may decide to decline treatment to children whose parents have decided to pursue therapy aimed at producing a child whose sexual behavior is a closer approximation to what the proxies electing treatment desire.

Consider the plight of a transgendered child. Four general grounds for declining to treat a transgendered child are readily discernible. First, a therapist may disapprove of the proposed treatment. Second, the therapist, whether he is approving or disapproving, may believe he is incompetent to achieve the desired results. Third, a therapist may believe that the proposed treatment is something to which no proxy can consent because it is contrary to the good-enough interests of the child. A therapist might reach this conclusion for any number of reasons. If the child dissents from the proposed treatment, the therapist may believe it wrong to impose treatment against the child’s dissent. Even if the child assents to proposed treatment, the therapist might decline because he believes it contrary to the child’s interests. Fourth, a therapist may conclude that, no matter what the law says, a child has the decisional capacity to consent to accept or decline to accept treatment, because the child has the decisional capacity to give informed consent, implying the proxy is the wrong person from whom to accept consent or to let determine what is to be done. If so, a therapist may conclude that he has no right to overrule a competent minor’s decision to decline treatment.

If the parents wish their transgendered child’s treatment to aim at producing behaviors congruent with the behaviors of conventional heterosexual children, these four grounds may produce conflict with the parents. The same kind of conflict arises in the more frequently discussed case of parents wishing a gay child to receive treatment aimed at making him straight. The conflict is unavoidable, even if at first glance it appears avoidable by, for example, citing incompetence to achieve the aim as the reason for declining the treatment request. For even if, as is arguably likely, nobody possesses a reliable therapy for making a transgendered child or gay child conform to the gender and sexual behavior preferences of his parents, the therapist declining therapy has to decide what to tell the parents.

The American Psychological Association (APA) does have guidelines and resolutions regarding the treatment of gays, lesbians, and bisexuals, and also has a resolution condemning discrimination against transgendered, gender variant, or gender nonconforming persons (APA, 2011); however, neither the guidelines nor resolutions are standards that bind members, under threat of sanctions, to a particular stance towards the GBLT population. Psychologists might dissent from either the guidelines or the resolution without making themselves vulnerable to formal sanctions, as would be the case for violations of APA ethics code standards (APA, 2010).

The relevant guidelines and resolutions regarding treatment of gays, lesbians, and bisexuals do argue that any efforts aimed at changing the sexual orientation of a gay person should include a warning that no effective treatments to accomplish this goal are known to exist, despite the existence of organizations claiming otherwise. The resolution on transgendered people does call for improved treatments for gender variance, but the context of the document makes clear that the goal is not to bring a transgendered person into alignment with the regnant gender expectations for a transgendered person’s anatomical sex. Instead, the treatment mentioned aims at making it easier for transgendered persons to live in the gender role of their choice. Provisions of medical, legal, and social services furthering this goal are endorsed, rather than enforcement of gender norms.

Given the stance of the APA, there is ground for asserting a duty of psychologists declining to treat, whether they approve of what the parents are proposing or not, to inform them that the “official” position of the leading psychological association is that there is no reason to believe there exists, in the present state of knowledge, treatment that will work to achieve their goal. If a therapist rejects the APA’s reading of the effectiveness of efforts to change a person’s sexual orientation or gender nonconformance, he has a duty to explain why he disagrees. To omit this information would constitute a deception, and limit a proxy’s ability to make informed choices on behalf of the gay or transgendered child. In the language of informed consent explained in the prior section, the conveyance of information for obtaining consent is defective.

Now if a therapist disapproves of the proxy’s choice for a child, that fact does not justify withholding information from a proxy, so the duty to inform the patient of the relevant information, even if a therapist disapproves of it, stands; however, aside from life-threatening emergencies, therapists have no duty to provide services that they disapprove of. Even if it were possible to “cure” a gender variant child, a therapist has no duty to do so, any more than he would have a duty to “cure” a left-handed child, if he could do so. There are many reasons for this view. In non-emergencies, a therapist is, just as is the patient or his proxy, an autonomous agent. His professional duties may constrain how he provides or does not provide elective procedures, but he has the option of deciding whether to provide them. For example, a psychologist might refuse to provide services designed to assist a gay child in coming out because, for example, her religious convictions forbid her to do so.

Serious moral difficulties emerge if a therapist believes that, for example, no proxy has a right to impose a particular treatment on a child. Treatments to realign sexual orientation or align gender to identify with sexual identity count as examples. Given the guidelines of the APA and its resolutions on transgendered human beings, a psychologist has the makings of an argument for the conclusion that it is contrary to a proxy’s duty to make treatment decisions in accordance with the best interest standard to seek to “cure” a transgendered child or gay child. Underlying this argument is the notion that the therapist or the APA is the true upholder in these cases of a child’s good-enough interests; the idea being that treatment in these cases of the kind desired by the parents always is contrary to the good-enough interests of the child.

A clear example of this kind of case arises when the secular perspective of what counts as being in a child’s best interests, as represented by the APA, collides with parents’ religiously informed perspective on what counts as being in a child’s best interests. These disputes arising from assertions about what is a spiritual benefit are slippery. Few Americans would be willing to agree that it is permissible for Somali parents to infibulate their daughters on the ground that it is their time-honored custom in parts of east Africa, has religious benefits and sanctions, and is a boon to chastity, even if some of these claims turn out to be true. On the other hand, many people are willing to permit Amish parents to decline customary medical procedures and treatments, or to permit secular parents to circumcise their sons. The moral terrain in these disputes is treacherous for many reasons. A central difficulty is the weight, if any, to assign to certain kinds of interests, and who is to assign the weight, especially in the absence of a consensus. For example, as a matter of law, parents must assign the education of their children a high weight. In the United States, a parent may no longer refuse to school a daughter on the ground that, in this parent’...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Preface
• Acknowledgements
• Part One: Ethical Issues Pertaining to the Sexuality of Minors
• Part Two: Research Strategies: How Do We “Know” What We “Know?”
• Part Three: Child and Adolescent Development
• Part Four: Children and Adolescents as Sexual Abuse Victims
• Part Five: Children with Sexual Behavior Problems and Adolescent Sexual Offenders
• Index