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Working In The Field Of Child Sexual Abuse
Emotional reactions to child sexual abuse* are to be expected and are normal. However, it is important to recognize them and to prevent them from impairing our professional judgment or interfering with our role performance. This chapter examines the following issues: universal emotional reactions to child sexual abuse, the impact of the professional's gender, the role of socioeconomic and professional status, the effect of personal experiences, and coping with personal issues. In addition, this chapter describes how to incorporate a victim-centered approach into our work when there are competing case concerns.
The Professional as a Person
Despite education and training, which specifies how to perform our professional roles, each of us has personal reactions to our work. Child sexual abuse probably arouses more personal reactions than many of the problems we encounter. Although these may become less intense over time, they do not disappear. Nevertheless, they should not be regarded as a sign of inadequate role performance. After all, if we had no emotional reaction to the plight of a sexually abused child or a father facing a life sentence in prison, something would be wrong with us.
Universal Emotional Reactions
Initially, the enormity of sexual abuse is likely to engender one of two opposing responses—disbelief or belief accompanied by an intense desire for retribution. Such responses can cloud the most important issues— concern for the child and the child's safety.
Disbelief has a lengthy history. When Freud proposed that the etiology of the hysteria he was treating in middle class Viennese women was to be found in childhood experiences of sexual abuse, his theory was roundly rejected as preposterous by his colleagues. Ultimately he retracted this theory because he simply could not believe that so many and such worthy men could have committed incest. The theory he proposed instead was one that put responsibility on the victim, who was regarded as fantasizing about having the sexual relationship with the paternal figure in question.1 2 3 The implication was that the sexual relationship was desired by the child. For 50 years, professionals were comfortable with the belief that sexual abuse, particularly incest, was quite rare, and when it did occur, it quite likely was the consequence of the child's seductive behavior and was not particularly harmful.4 5
This position could not be sustained in the 1970's. The Child Abuse Prevention and Treatment Act required that States mandate professionals to report suspected child maltreatment, including child sexual abuse, in order to qualify for specific Federal funding. The result of this provision was a dramatic increase in the number of cases of sexual abuse reported. These referrals were investigated by child protective services (CPS) caseworkers and law enforcement personnel. As a rule, a believable account of sexual abuse was assumed to be true,6 7 and reports of sexual abuse were substantiated at approximately the same rate as other types of child maltreatment.
However, very soon, new doubts emerged in what is now called the "backlash." Claims are being made by those accused, their lawyers, and a small number of professionals who serve as experts on their behalf that many accusations of sexual abuse are untrue. Although research indicates that false allegations are rare,8 the credibility and integrity of children and the competence of professionals who believe them are being challenged. More problematic is the fact that the backlash gains its strength from well-meaning professionals and lay persons who have a great deal of difficulty believing that an adult could sexually abuse a child. In addition, among those individuals who acknowledge the possibility, there is the strong tendency to minimize its traumatic impact on the victim.
The tendency to disbelieve is reinforced by the troubling emotional reactions that many people have if they conclude that in fact the child has been sexually abused—a sense of anger or rage at the offender. Professionals may believe that the offender should be jailed or that emasculation is suitable punishment. On the other hand, often professionals experience anger and helplessness when a disbelieving family court judge gives custody of a child to an alleged offender or criminal prosecution is unsuccessful.
The rather universal tendencies to want to explain away or minimize the sexual abuse or to desire "a pound of flesh" are also reflected in reactions specific to gender, to socioeconomic and professional status, and to personal experiences, which are described below.
The Impact of Gender
The gender of the professional is likely to influence reactions to cases of child sexual abuse. The major issue is gender identification. The impact of gender identification is complex and varied. At a specific level, it causes the professional to see a person of the same sex, whether offender, victim, or mother of victim, as "like me." At a more general level, the professional may regard the behavior or circumstance of a person of the same sex as reflecting upon not only the professional, her/himself, but also upon others of the same sex. Gender identification can result in either greater empathy or greater rejection of the person of the same sex. On the other hand, the fact that the child, alleged offender, or mother is of the opposite sex may render the professional relatively impervious to the plight of that person.
When confronted with an accused man, a male professional may be more concerned about the impact of an allegation on the man and may have greater difficulty believing the allegation than a female professional. As well, a male professional might be either more understanding of a male offender because he appreciates gender-related temptations or more censorious because the violation of the taboo reflects on all men. A female professional may give much less thought to the circumstance of the accused man and concentrate on the females (i.e., the girl victim and her mother) and their circumstances.
In one possible scenario, a female professional may be more disbelieving of accusations against women than a male professional because, as a woman, she cannot imagine doing such a thing. However, when she concludes, for example, that a mother has sexually abused her children, she may be especially enraged because of her personal experience as a mother. Similarly, a female professional may have more empathy for the mother of a victim having to choose between her child and her husband, because she is or has been in a comparably dependent position with a man. Alternatively, she may perceive the woman who sides with her husband as a "traitor to her sex."
Both male and female professionals have empathy for victims. However, it is possible that gender identification causes each to be more sensitive when the victim is of his/her gender. This may be particularly true for male professionals when boys are victims, since there is less knowledge about the impact on boys, and boy victims are less likely to share their feelings.9 A male professional, because of his experience of having been a boy, may better appreciate the boy victim's trauma or, alternatively, have more difficulty accepting the boy's vulnerability to victimization.
Finally, professional reactions to sexual abuse may differ by gender because men and women experience living in society differently. That is, although men may not condone their position, they are generally dominant. Women are generally in the subservient position and are probably, as professionals, more appreciative than men of the relationship of sexual abuse to general male dominance in society.
The Impact of Socioeconomic and Professional Status
Professionals need to be aware that they may react differently to cases involving middle to upper class individuals and cases involving the poor. Moreover, situations in which the accused is in a sensitive profession may evoke personal reactions that make it especially difficult to maintain professional distance and act without bias. As with gender, the issue of identification and consequent disbelief may play an important role.
Most professionals working in sexual abuse identify themselves as middle class; thus, they may be more aware of the impact on a middle class person of being accused or found guilty of a sex offense. Class bias is reflected in a commonly held assumption that the trauma of being accused or getting caught is greater for someone who has had an economically successful life and a promising future. In addition, professionals may have more difficulty believing abuse of a middle class person because the accused is "like us."
Likewise, the middle or upper class person may seem less likely to be a sex offender because he/she functions well enough in other aspects of living to sustain class status and may deny more convincingly than someone who is poor and undereducated.
Moreover, the affluent accused who are denying are able to mobilize more resources on their behalf than poor people. They can afford competent lawyers and will have funds to hire mental health experts for their defense. They may enlist the assistance of professionals they know personally and professionally. They may have greater capacity to enlist family, including the wife or husband and others, who are financial dependents to support their claims of innocence.
Adding to the difficulty of impartial intervention, an economic argument may be made. It is that cases involving middle and upper class male offenders should be handled differently because, if the offender is arrested or tried, he will lose his job and not be able to support his family. If convicted, he won't be able to practice his profession any more. If he is incarcerated, he won't be able to pay his bills.
In addition, as professionals, we often experience pressure from the accused's advocates as well as from other professionals, including our superiors, to moderate our intervention when the alleged offender has means or is prominent in the community. Such experiences exacerbate existing ambivalence regarding our professional roles.
The most problematic cases are ones in which the alleged offender works with children or is a member of one of the professions that play a role in sexual abuse intervention—a health care professional, a lawyer, a judge, a law enforcement officer, a mental health practitioner, a day care provider, or a teacher. As professionals, we must be involved in the reporting, investigation, treatment, or prosecution of one of "our own." The psychological and pragmatic need to deny or to minimize the wrongdoing of one of "us" may be especially strong. When faced with the knowledge of the sexual abuse, our ability to respond on a solely professional basis may fail.
Moreover, the stakes are extremely high because the accused professional almost certainly will not be able to continue to practice if found guilty. He/she knows this and therefore is very unlikely to admit to the sexual abuse or seek treatment. Because we as professionals can very easily imagine what it would be like to have our livelihood and well-being so jeopardized, we may become immobilized by denial or may perform our duty with great agony. Such responses reflect our overidentification professionally with the accused.
The Impact of Personal Experiences
Many life experiences can intrude upon professional practice, and working in sexual abuse can intrude upon a professional's personal life. Three personal issues that seem particularly salient are discussed below: having been sexually victimized, being a parent, and sexuality.
A professional who has been sexually abused her/himself or who is part of a family in which there has been sexual abuse must cope with this personal issue as well as with the other stresses of work with sexual abuse. It is both infeasible and inappropriate to consider excluding such persons from working in this area. First, an estimated one-fourth to one-third of women are sexually victimized as children.10 11 12 The current estimates for men are lower, around 10 per cent.13 However, the majority of professionals who work in the field of sexual abuse are women. Second, persons who have sexual victimization in their background bring a special sensitivity and experience that can be of great value in their work. There is no research on professional motivation to work in sexual abuse. However, based on knowledge of what in general draws persons to help others, it is safe to assume that for a fair proportion of professionals, it has to do with some direct or personal knowledge about the problem.
Nevertheless, professionals who have personal experiences of sexual abuse need to have addressed these in therapy, be especially aware of countertransference issues, and be alert to the importance of protecting their own mental health.
Warning signs that the professional's own victimization is impeding performance include feeling so overwhelmed by fear, anxiety, disgust, or anger that the victimization interferes with sound decision making or intervention or evokes the strong desire for retribution; experiencing intrusive thoughts or having flashbacks at work; recalling previously repressed memories of victimization when involved in cases of sexual abuse; and displaying overly punitive responses to the nonoffending parent or offender. These signs certainly indicate the need for additional, skilled treatment and clinical supervision, but they should not automatically lead to a conclusion that the professional must cease her/his work in the field.
Being a Parent
The experience of parenthood can impact on one's reaction to a case of sexual abuse, and working with sexual abuse can influence parenting.
Parenthood can make the professional more appreciative of the risks as well as more appalled at the transgressions of the parenting role. Parents are confronted with many situations in which the child's behavior (e.g., wanting to sleep in the bed between the parents) and parenting responsibilities (the need to assist the child in bathing, toileting, and understanding differences between male and female anatomy) can present risks for sexual activity. Sometimes, professionals who are parents are less willing to label client behaviors as sexually inappropriate because of their overidentification with the client as another parent. For example, a professional who is a father may minimize genital contact between an alleged offending father and his daughter, accepting the explanation that the daughter was being helped to learn about "wiping herself."
Conversely, certain biological drives and normative proscriptions inhibit sexual activity with children for parents. Because of these personal experiences, parents may be more censorious than nonparents when these boundaries are crossed.
In terms of work influencing parenting, a common impact of professional involvement with sexual abuse is for the parent to become quite concerned about the risk of his/her own child being sexually abused. Parents may become suspicious of family members, babysitters, friends of the family, neighbors, day care providers, and school personnel. Parents may also be hyperalert to behavioral and physical indicators, such as urinary tract infections, masturbation, enuresis, and sleep disturbances. Generally, vigilance about a child's contacts with others and concern about symptoms are positive parental responses. However, they should result in a considered investigation of suspicions, rather than an immediate conclusion that something terrible has happened.
Being familiar and comfortable with all aspects of sexuality is essential in working in the field of child sexual abuse. For the professional, this means being able to talk freely about all types of sexual issues.
Professional involvement with cases of sexual abuse very frequently has an impact on personal sexuality. There are at least three ways in which this occurs. First, when the professional engages in sexual activity, recollection of the sexual acts in a recent case may intrude into the sexual experience. Generally this has an inhibitory effect, that is, images of sexual activity or the particular sexual acts of the case diminish desire. However, a more troubling reaction is one in which the recollections stimulate arousal. They may become the stimulus for masturbatory activity or fantasies during sexual activity with a partner. When this happens, the professional should seek counseling.
Second, professional involvement in cases of sexual abuse may raise concerns about the professional's own sexual role performance. For example, men may wonder if they are subtly coercing or manipulating their partners. Women may become concerned that their compliance with sexual activity is not entirely voluntary, or they may worry that they are using sexual favors as a way of controlling their partners.
Third, professionals may have sexual reactions to their clients. Such reactions may be of attraction or disgust. In either case, professionals must be sensitive to these feelings and not let them influence professional responses.
Coping With Personal Issues
Dealing With Personal Feelings in Professional Practice
The best way to prevent personal reactions from undermining the quality of professional work is to be aware of their existence. In fact, the reason for describing possible sources of personal reactions and typical emotions is to encourage reflection by the reader. For many professionals, self-talk, in which the professional reminds him/herself of personal biases and reactions, should be undertaken regularly.
Second, as much as possible, the professional's intervention should be guided by practice principles, policies, guidelines, and research. For example, most communities have protocols for CPS and law enforcement collaboration. Similarly, there are practice guidelines for when to remove a sexually abused child from the home. Additionally, research on offender recidivism can assist a judge in sentencing. Nevertheless, despite the existence of these aids, because knowledge about sexual abuse is incomplete, there will be many situations in which the professional has to use his/her judgment. Sometimes, protocols and other guides actually interfere with gathering evidence or "proving" a case, engendering feelings of frustration and anger toward the system. In such instances, it is important for professionals to be able to process their feelings.
There is no denying that work in the field of sexual abuse is extremely stressful and may lead to burnout. There are four characteristics of cases that make the work potentially debilitating. First, the acts themselves are terrible and terribly harmful. Sexual abuse violates fundamental social norms, and the lives of some victims dramatically attest to its devastating effects. Second, cases are fraught with uncertainty. In many instances, it is not possible to determine whether the abuse occurred. Likewise, it is very difficult to determine the risk of future sexual abuse. Third, often as professionals, we do harm while attempting to do good. Victims are sometimes retraumatized by repeated interviews, intrusive medical exams, court testimony, and separation from their families. Fourth, often we are unsuccessful. Victims are not made safe, and offenders may not be prosecuted or held accountable for their actions.
Negative experiences working in the field of sexual abuse can result in frustration, rage, a sense of helplessness, and then giving up. A process of burnout eventually leads to insensitivity toward clients and disengagement in the helping relationship. Burnout is harmful for clients and professionals alike.
The best preventive measure and remedy for burnout is collaborative work. This can mean working with a partner, for example, as police officers often do. Having adequate supervision as a mental health professional is another way of working collaboratively. Sharing the treatment of an incestuous family with a colleague can prevent the sense of isolation and overwhelming responsibility that leads to burnout. Consulting with a more experienced person either within one's own agency or outside can be helpful in all professions. Interdisciplinary collaboration is also quite helpful—teams of CPS caseworkers and police or lawyers and mental health experts can enhance the quality of work as well as alleviate stress. Finally, working as part of a multidisciplinary team, which includes the range of professionals involved in child sexual abuse cases, is the most desirable way of handling these cases. Teamwork minimizes some of the problems that lead to burnout (e.g., the dilemma of uncertainty regarding whether the child was sexually abused, iatrogenic effects of intervention, and unsuccessful intervention). In addition, teamwork allows an opportunity for sharing the pain and distress that many cases cause professionals.
A Victim-Centered Approach
Professionals often feel pulled in several directions in their work on child sexual abuse cases. Although most professionals want to help the victim, potentially competing concerns include the feeling that sex offenders should be punished, a concern that the offender may be dangerous to others, a belief that sexual abuse is a mental health problem, a concern about the impact of disclosure upon the mother, a belief that the mother is partly responsible for the abuse, an awareness of the effect of sexual abuse and intervention on nonvictim siblings, and a feeling that everyone in the family needs help.
Taking a victim-centered approach is a way of dealing with conflicting goals in sexual abuse intervention. A victim-centered approach is one in which considerations of what is in the victim's best interest override competing concerns.
What is in the victim's best interest? That may vary depending on the case, and it may not always be easily discernible. Ascertaining the victim's best interest usually begins by finding out what the victim wants to happen, the older the child the more weight given to the victim's wishes. Does she want to be removed from the home or have the offender removed? Does she want the offender to be prosecuted or to get some help? Of course, there are times when what the victim wants is not in her best interest, because it risks her safety or psychological well-being. In such cases, the child's best interest should be pursued, but with a developmentally appropriate explanation to the child about why her wishes cannot be granted.
The Potential Iatrogenic Effects of Intervention
For some time professionals have been concerned with iatrogenic or system-induced trauma. One of the reasons that pursuit of the victim's best interest is so important is that a fundamental trauma resulting from sexual abuse is a sense of powerlessness. The victim's body is used by the offender for his gratification; the child is psychologically intimidated by the offender into cooperation with the sexual activity; and the child may be compelled by the offender to keep the sexual abuse a secret. Additionally, out of concern for the impact of disclosure on the family, the victim may feel forced not to disclose or that the consequences of disclosure may be worse than the abuse itself.
The complaint of many victims is that when the sexual abuse is discovered, things get worse rather than better because their lives continue to be controlled by others, and they experience all sorts of additional traumas. These may be repeated, insensitive, and humiliating interviews; a frightening medical exam; a confrontation involving the perpetrator or the victim's family; an unpleasant placement experience; treatment that the child finds unhelpful or traumatic; and court testimony. Often the most problematic aspects of intervention are not knowing what is going to happen and having no say in decisions. It is important that the intervention not exacerbate the child's sense of powerlessness.
Strategies for Minimizing the Trauma of Investigation
There are some fairly universally accepted strategies for diminishing the trauma of investigations of child sexual abuse. The interview process can be made less problematic. First, the number of interviews can be minimized, either by videotaping investigative interviews, having professionals who need to hear the child's account behind a one-way mirror, or having more than one professional in the room, usually with one asking the questions. Second, the use of a skilled and sensitive interviewer can minimize the negative effect of disclosure and even make it a cathartic or empowering experience. Third, allowing a support person to be with the child during part or all of the interview can diminish its traumatic impact. Fourth, conducting the interview in a facility that is private and designed to create comfort can be helpful. The potentially iatrogenic effects of the medical exam can be decreased by obtaining the child's consent to the exam and by using a skilled and sensitive health professional. That person explains that the purpose of the exam is to ensure that the child is "ok;" usually does a complete physical, not just a genital exam, and both informs the child, at each step of the exam, what will happen next and allows the child some control over the process. If the child is resistant to the exam, even when properly undertaken, then serious consideration should be given to not doing it. If it is deemed medically necessary, it might be rescheduled, when the child is less upset, or it might be done under anesthesia.
Children should not be subjected to polygraph exams during the course of investigation. Subjecting children to polygraphs gives the message that they are not to be believed and must "prove" themselves. The efficacy of polygraphs has not even been established for adults, let alone for children.14
Strategies for Ensuring That Intervention Is in the Victim's Best Interest
When an investigation substantiates child sexual abuse, professionals must decide what to do. Basic issues for the child are safety and rehabilitation. In addition, decisions about the use of the courts to protect the child and to prosecute the offender impinge heavily on the child's well-being. Related to these issues are questions about family separation. Does the family remain intact, does the offender leave, or is the child removed? Professionals agree that it is preferable to remove incest offenders from the home. However, there are cases in which, to protect the child, to prevent her/his psychological abuse, or to relieve the victim of the experience of family turmoil, the child needs to be placed outside the family. If the family has been separated, the question of family reunification has to be addressed.
There are two basic strategies that can enhance the probability that case decisions will be made in the child's best interest. The first has already been mentioned: the child should be asked what she/he wants. Second, case decisions should be preceded by a careful assessment and should be made in consultation with a multidisciplinary team, whenever feasible.
* "Sexual abuse" in this manual refers generally to sexual acts involving a child and a person who is significantly older, usually an adult. However, the discussion in this manual focuses primarily on guardian, or person responsible for the child's welfare (see, Child Abuse Prevention and Treatment Act).
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