Although different, incest, child abuse and child sexual abuse are frequently related in practice. Obviously, not all cases of incest involve children and not all instances of child sexual abuse involve a blood relation. Neither are children subject to abuse necessarily also involved in child sexual abuse but all these can be conveniently considered together for our purposes since all represent a breakdown of family harmony, social taboos and, except in cases of adult incest, a failure of child care.
Incest means intercourse between family members considered legally too close to marry. Child abuse, as defined by the World Health Organisation, is any intended or unintended act or omission which adversely affects a child’s health, growth or psychosocial development, whether or not regarded as abusive by the child or adult. The most commonly used definition of child sexual abuse is the involvement of dependent, immature children or adolescents in sexual activities they do not fully comprehend, to which they are unable to give valid consent and which violate the social taboos of family roles. Child sexual abuse is regarded as existing in one of four forms. First, exposure such as being allowed to view sexual acts, seeing pornography or witnessing exhibitionism; second, molestation or fondling of the child’s or adult’s genitals; third, sexual intercourse – an ongoing activity which involves the child’s mouth, vagina or anus; and finally, sexual intercourse in which the child is obviously assaulted – rape.
Incest, child abuse and child sexual abuse all cause social outrage and can all lead to court proceedings and imprisonment. In consequence they are often difficult to detect and can be hard to prove; the cases which do come to light are thought to be a minority and all three offences are said to be more widespread than popularly believed. Estimates of child sexual abuse in some parts of the world range up to i child in 3. In all child sexual abuse surveys women are twice or more as likely to say they have been sexually abused in childhood than are men and the same holds true of incest surveys where in one, for example, 5 per cent of women but only 2 per cent of men reported this experience. Child abuse, especially in the forms of neglect, non-accidental injury and emotional deprivation, is even more widespread and is most likely to occur in families in which the couple are young and immature; in which pregnancies are unplanned; or in which the mother is young and unsupported. In Western countries the perpetrators of both child abuse and child sexual abuse are parents or step-parents in 70 to 90 per cent of cases.
Since all three conditions are thought to be widespread and detection is difficult, some professionals, such as social workers and doctors, have become carried away with their enthusiasm to root out such problems. Several enquiries have condemned social workers for incompetence or slothfulness in instances of child abuse where the child has eventually died, thus illustrating, yet again, how easy it is to be wise after the event. The purpose of such enquiries is to avoid repetition but one consequence seems to be that in their eagerness not to err again social workers have now become over-zealous to the extent that their departments are so overwhelmed with cases they have identified as being possible abuse that real abusers are even less likely to be detected and helped.
Again, some hospital paediatric departments are fully examining, including genital and anal examination, all children brought to them for whatever reason (such as, for example, an eye examination) in their keenness to detect child sexual abuse. This may upset children, may be a form of abuse in itself, may deter parents from seeking medical help for children and may make it less likely that a sexually abused child will ever be brought to them. Whatever the justifications and they are cogent, it is ill-advised for the medical profession to risk forfeiting public trust by using blundering methods of unnecessary examinations.
Yet again, over-zealousness has misled some doctors into diagnosing abuse or sexual abuse when the signs and symptoms in the child were caused by some other medical condition or were even normal, thus undermining public confidence. Worst of all, some professionals when interviewing children suspected of child sexual abuse have used extremely unwise methods, language and techniques which draw their own motivations into question and deprive the alleged perpetrator of any right to innocence.
Yet all this zeal, which involves only a minority of professionals, is justified by such individuals on the grounds that children are defenceless and must be protected. However, all parents must now face up to the fact that a new hazard of parenthood is that they may be, justly or unjustly, accused of abusing or sexually abusing their children and their innocent explanations of illness or injury may not be instantly accepted. This is a heavy price to pay for the protection of children but it may be worth it if it really leads to the detection of children in danger.
Relevant points to consider mentioned elsewhere include the tendency of love and sex to go together but the need to suppress sex in inappropriate relationships; the tendency of alcohol to diminish inhibitions; the attractiveness of children; the intensity of the heterosexual love for the opposite sex parent in the Oedipal stage which can colour the subsequent recall of events when interviewed as an adult; bad or frightening memories being repressed into the unconscious and thus unavailable for recall; the normal curiosity about genitals between brothers and sisters (and other children); the fact that not all marriages are between mature people and such marriages often produce children early; and that not all children are wanted. Important too are the points that children who have been exposed to violence and sexual abuse, later, as adults tend to become similarly involved; one partner in a marriage may become over-involved emotionally with a child because of defects in the marital relationship; and not all marriages are sexually well-adjusted, leaving one partner frustrated.
Further points to consider are that older children and adolescents may tell lies for their own ends and several accusations of sexual abuse have been shown to be fabrications. Mothers may unconsciously collude in sexual abuse or are sometimes the perpetrator or assist the perpetrator.
Some parents now report that they are limiting their physical contact with their children so as to avoid possible accusations of abuse and say they have stopped undertaking activities which could be misreported or misunderstood, such as allowing children to see them in the bath or dressing. Even loving displays between some couples are now being curtailed in the presence of their children. This is unreasonable and probably harmful to children. Whatever is done, provided the presence or participation of the child is not an additional erotic gratification for the adult, then sexual abuse is unlikely to be occurring. Wise parents should heed the possibility that their children may let sex-play reach the point of incest and should reduce the opportunities for it to occur. They should also consider whether others in contact with their children might sexually abuse them and take steps to reduce opportunities for this to happen. Grandparents, baby sitters of both sexes, teachers, neighbours, older children and so on have all been perpetrators.
The cultural tendency of parents to exercise more control over the movements of girls seems to be justified by their greater likelihood of being sexually abused. If parents detect in themselves any tendency to abuse their child, sexually or in other ways, they should discuss it with a professional and together try to devise ways of controlling the situation. Once abuse is discovered professional help must be sought because it is almost always impossible to deal with it in the family alone. Confidentiality when approaching a professional is obviously a major concern and this may be refused but obviously if the parents are trying to help themselves and there is no immediate danger to the child most professionals will be only too willing to do everything in their power, including obtaining assistance from other professionals, to help and are most unlikely to take steps which could harm the parents. Virtually everyone would regard this as an ideal outcome to a potentially harmful situation.
The political response to child sexual abuse is to set up teams of paediatricians, GPs, police surgeons, psychiatrists, gynaecologists, psychologists and social workers so as to take a broad view of possible cases and also to curb the zealots. Whether a committee of this type is the right way to go is open to question but we shall see. The most fundamental means of prevention is to carry out research on cases and families so as to devise preventive strategies, advise parents and generally become better at case detection. The involvement of psychiatrists, family therapists and psychotherapists is therefore to be welcomed.
Although the child or its mother may report abuse, as may family friends, GPs, social services and so on, teachers rarely report it. Nevertheless they, along with sensible parents, have a role to play in teaching children to be wary, to say no, to scream and get away if abused, and not to feel bound by promises of secrecy where wrongdoing is involved but to tell an adult they trust at once. Obviously, too, teachers and the school medical service are in a good position to detect neglect and abuse in schoolchildren whereas health visitors can help with its detection in younger ones. Since child abuse can be inadvertent this is an area where parents might see intervention as being helpful and be glad of it if the situation is creatively handled.
Just as child abuse may come to light through fractures, burns and bruises so incest may be revealed by pregnancy, and sexual abuse through pregnancy, genital warts or VD. Genital signs, such as an enlarged hole in the hymen may show the presence of vaginal intercourse in incest and child sexual abuse and damage to the anus may indicate that anal intercourse is occurring. Most sexual abuse starts at around 8 years of age and incest perhaps even later. In both these and in emotional forms of child abuse psychological symptoms may predominate. The child may be ashamed, sad, guilty, depressed, withdrawn, regressed, isolated, untrusting, failing to thrive and have eating problems or academic problems at school. His or her behaviour may be sexually precocious or show other abnormalities.
Long term consequences for the child are related in some degree to the amount of trouble which results from the situation. In girls long continued sexual abuse by the father seems to be particularly harmful id an introduction to homosexuality in a boy may fix his sexual preferences, perhaps for life. Psychiatric illness or sex and relationship problems later in life may all follow from childhood abuse. Difficulties in relating to the opposite sex and a difficulty in obtaining a partner are often seen later in cases of brother-sister incest. A report from Australia on the examination of victims of child abuse several years later showed they had fewer friends, were less ambitious, had poor self-esteem and more behaviour problems than non-abused children.
Once detected the treatment of all three conditions must be to stop the incest, child abuse or sexual abuse, to prevent a recurrence and to repair the damage. Medical treatment may be necessary, especially in child abuse but individual, group and family therapy are most used to cope with other aspects. Strengthening the marital relationship and improving the parents’
sex-life can bring child sexual abuse to an end with a degree of ease. Psychotherapy to promote maturity, including psychosexual maturity in the parents, can also work wonders in child abuse as well as child sexual abuse. Helping the victims of incest, child abuse and child sexual abuse to deal with what has happened and particularly to help them deal with the guilt many of them feel seems to limit the chance of future distress.
Where repair of the situation seems to be unlikely, impossible or has failed, or where the gravity of the offences is thought to demand punishment, the professionals and courts may, unhappily, put children into care and perpetrators into prison. Since few parents, or even
step-parents, set out with the intent to harm children, it is a sad outcome to be avoided if possible because children may end up worse off than before.
The subject of child sexual abuse is vast and the reader is referred to specialist books on the subject aimed at parents, for further information.
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