Helping Small Voices to Speak

by Laurie M. Brandt, Psy.D.

Childhood sexual abuse or incest is a widespread phenomenon that can pervade all aspects of a survivor's functioning. It almost always is a profoundly disruptive, disorienting and destructive experience that can interfere with boundary formation, trust and the meeting of normal developmental tasks. Because of the profound shame associated with sexual abuse, in addition to the very real threats of physical harm to oneself or to members of one's family that often accompany abuse, many victims do not disclose for decades, if at all. The effects of this prolonged secrecy and shame have profound and devastating consequences. It is therefore essential for clinicians who come in contact with young victims to provide as comprehensive, sensitive and unbiased evaluations as possible so that these children can receive the help and the safety they deserve and avoid what often amounts to years of isolation and psychological damage.

To begin to put into perspective the enormity of this problem, some understanding of prevalence seems essential. Many studies suggest that:

• 20-33 percent of all American women have experienced some type of childhood sexual encounter with an adult male¹, with this figure much higher in mental health populations (as high as 66 percent in one report).
• 4-12 percent of all women have had a sexual experience with a relative, and 1 percent with a father or stepfather. Even this latter lower statistic is considered to be in epidemiological proportions, as high as schizophrenia or diabetes. Estimates may actually be low, as they are based almost entirely on reports from white, middle class women.
• Most victims are female with male offenders, and 80 percent of these girls are under 13 years of age, with an average age of 9. A typical pattern is for the abuse to proceed from fondling, to masturbation, to oral-genital contact, with intercourse introduced at puberty, although there are certainly many cases in which this begins much earlier. In incest, a common pattern is for the abuser to begin with the oldest daughter and move down the line, and at least one-half of fathers who abuse one child will abuse another as well.
• Finally, sexually abused children are more symptomatic in later life when the abuse takes place after age 12 than before, or when it continues into puberty. This is because the child feels greater responsibility, is more aware of social norms, and because of the turmoil and struggle with sex that is normally associated with puberty. The frequency and duration of the abuse also are significant factors, as is violence. Non-incest sexual abuse is generally somewhat less traumatic than incest, though the dynamic is virtually the same if the abuse is by someone in a parenting position (e.g.: teacher, babysitter, priest), with the element of betrayal at play here as well.

Less information is available about the early sexual experiences of boys, but the studies that exist indicate boys are abused less than girls and that most contacts between boys and adults are homosexual. Incest between mother and son is thought rare and often seems to take place under more bizarre circumstances.² Literature appears to underestimate this, however, and it seems less likely that boys will identify inappropriate behavior by women as abuse and report it.

Definition of Sexual Abuse

A sexually abusive relationship is defined as any inappropriate physical contact kept secret, not just intercourse. From a psychological point of view, especially from the child's point of view, the sexual motivation of the contact and the fact that it must remain secret are far more significant than the exact nature of the act itself. In addition, any sexual relationship between an adult and a child must be considered coercive. Even though the adult may use positive enticements rather than force to establish the relationship, as is usually the case, one must remember that a child is always powerless in relation to an adult, and he or she is not truly free to refuse a sexual advance.

The legal definition of incest, however, is often quite different from the psychological definition. The law in every state forbids sexual relationships between adults and children. However, most incestuous relationships between father and daughter, for example, do not meet the statutory definitions of incest, but rather fall under the definition of somewhat lesser crimes (e.g.: carnal abuse of a child, indecent liberties with children, corrupting the morals of a minor). This is because many incest provisions only cover vaginal intercourse; or only include blood relations, thus absolving stepfathers; or are only strict for girls under age 13, etc. In practice, these crimes are rarely prosecuted and even more rarely punished, although the landscape of the law is changing, in part as a result of media attention and increased public awareness over the past several years.

As more and more of these cases enter the legal system, the need for sexual abuse evaluations that are at once sensitive to the needs of the child and attuned to legal standards and the needs of the court becomes greater than ever before. With the pressure from "false memory" groups and the controversy surrounding some of the celebrated child sexual abuse cases in recent years, it behooves the investigator now more than ever to provide uncontaminated and accurate interviews, free of leading questions and attempting as much objectivity and impartiality as possible.

Sexual Abuse Evaluations

The following are a number of facts and guidelines about sexual abuse evaluations with young children. If some guidelines seem a bit rigid, this is because they are for evaluations that will be admissible in court. In purely clinical situations, one can be somewhat more flexible, though one should still take care to avoid making suggestions to the child or leading them in directions that do not come from them.

It must be remembered that only a relatively small percent of abused children come to us with physical evidence or traumata (e.g.:sexually transmitted diseases, sperm, vaginal/labial abrasions, etc.). The material gleaned from the interview, then, becomes particularly important in determining whether or not sexual abuse has occurred.

The following protocol comes largely from that developed by Sue White, et. al. at the Child Guidance Center of Greater Cleveland.³ It is a thorough, comprehensive protocol, making use of anatomically correct dolls when used with young children that is quite objective and has proven to hold up in legal proceedings.

The major guidelines for the interview itself include that one should:

• Have little identifying information, other than the child's name and age, and excluding specific information about the alleged abusive situation.
• See the child first, before seeing the parents, and plan to see her 2-3 times.
• Go through the whole scenario of the child's day, without tunnel visioning into one event.
• Conduct the interview in a consistent, systematic manner, with the same sequence of events each time.
• See the child alone, without the parent, social service worker, etc., particularly for the doll interview.
• When there are siblings involved, see each child alone, starting with the youngest before they hear the questions from older siblings, and realize that they will already be contaminated with each other by the second or third interview.
• Avoid touching children during the interview, unless you absolutely have to, to move them.
• Avoid asking leading questions, only going to such questions if you are fearful about safety.
• Avoid giving reinforcements, including food, drink, other tangibles, or even praise to the child during the formal interview.

Memory

While there has been much controversy recently about memory for abuse, it should be noted that lying is a distinct, willful act, different from a child's believing something happened because of normal, developmental cognitive functioning. Children under age 4 are generally unable to lie successfully.

Also of note is that children are thought to make more errors of omission than commission, as opposed to adults who know what is supposed to be and fill in the blanks. The child's memory for actions is better than that for surroundings, with memory being best for things they do, rather then for things done to them. Research suggests that there is approximately 2 percent suggestibility in 5-year-olds and up to 22 percent in 3-year-olds about general matters, but that it is very difficult to suggest about sexual matters. Anatomical dolls are not seen to influence suggestibility.

Doll Interview

The structured doll interview should begin with free play, with the initial focus on comfort, relaxation, rapport building and an informal developmental assessment before the dolls are introduced. In the doll interview itself, the evaluator's stance should be one of firm yet kind control.

The specific steps would include: doll identification; then identification of body parts and functions with the clothes on and focusing on the non-sexual parts; then with the upper clothes off; then the lower clothes off; then questioning around general body experiences, with more detailed assessment of all positive responses, and a focused attempt to differentiate between hygienic touching and abuse. Specific parts questioning follows after.⁴

Summary

Childhood sexual abuse is an enormous problem of widespread consequences and repercussions. Years of clinical work with survivors who have not disclosed or received help for 20, 30 or more years after the event highlights the value of early identification and treatment of the sexual abuse while the person is still in childhood. It is hoped that the above protocol for evaluation of childhood sexual abuse will be helpful toward this end.

References

1. Finkelhor, David, "Sexually Victimized Children." New York: Free Press, (1979).
2. Herman, Judith L., "Father-Daughter Incest." Cambridge: Harvard University Press, (1981).
3. Study Guide to Accompany "The Young Victims of Sexual Abuse: An Interview Protocol." Cleveland: Child Guidance Center of Greater Cleveland, (1986).
4. White, Sue, et. al. "Guidelines for Interviewing Preschoolers with Sexually Anatomically Detailed Dolls." Cleveland: Case Western Reserve University School of Medicine, (1987).

Laurie M. Brandt is a clinical psychologist. She coordinates child and adolescent services as well as trauma services at the West Roxbury Center of Harvard Community Health Plan. She is in private practice in Newton Center, Mass.