Table Of ContentCHILD SEXUAL ABUSE
Child Sexual Abuse
AN INTERDISCIPLINARY MANUAL
FOR DIAGNOSIS, CASE MANAGEMENT,
AND TREATMENT
Kathleen Coulborn Faller
M
MACMILLAN
© Columbia University Press 1988
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First published in the USA in 1988 by Columbia University Press
First published in the UK in 1989 by
MACMILLAN EDUCATION LTD
Houndmills, Basingstoke, Hampshire RG21 2XS
and London
Companies and representatives
throughout the world
Chapter 9 was written by Mary Westhoff, M.D. and Mary Steinberg.
Dr Westhoff is in private pediatric practice and Dr Steinberg
is Assistant Professor of Pediatrics, Oregon Health Services
University in Portland, Oregon. She was formerly Clinical
Instructor of Pediatrics, University of Michigan.
Chapter 15 was written by Donald N. Duquette, Professor of Law,
University of Michigan.
British Library Cataloguing in Publication Data
Faller, Kathleen Coulbourn
Child sex abuse: an interdisciplinary
manual for diagnosis, case management and
treatment.
1. Children. Sexua l abuse by adults.
Treatment
I. Title
362.7'044
ISBN 978-0-333-49890-3 ISB N 978-1-349-11047-6 (eBook)
DOI 10.1007/978-1-349-11047-6
Contents
Preface by Alan Gilmour vii
Introduction to the Macmillan edition X
ACKNOWLEDGEMENTS
XV
PART 1. THE CHARACTERISTICS OF CHILD SEXUAL ABUSE
1. The Parameters of the Problem for Professionals 3
2. The Sample: 190 Victim-Perpetrator Dyads 22
PART II. UNDERSTANDING CHILD SEXUAL ABUSE
3. Differential Diagnosis of Sexual Abuse 49
4. The Causes of Sexual Abuse 89
PART Ill. EVALUATION OF SEXUAL ABUSE
5. An Overview of the Assessment Process 119
6. Interviewing the Child 156
7. Interviewing the Perpetrator 191
8. Interviewing the Mother 225
9. Behavioral Characteristics and Physical Findings:
A Medical Perspective,
Mary Steinberg and Mary Westhoff 244
PART IV. INTERVENTION IN CHILD SEXUAL ABUSE
10. Case Management 265
11. Treatment of the Victim 281
12. An Overview of Treatment and Individual
Treatment Issues 321
13. Treating Dyadic Relationships 343
14. Family Treatment and the Use of Groups 369
15. Legal Interventions
Donald N. Duquette 392
MEDICAL GLOSSARY 405
REFERENCES 407
INDEX 417
Preface
Alan Gilmour
Director, NSPCC
During the 1980s child sexual abuse has emerged as a major social
problem, placing new and heavy demands on community services at a
time coinciding with a marked increase in the notification of cases of
physical abuse; a period of retrenchment in public expenditure by
central and local government; and a climate of mounting public disquiet
and alarm, fuelled by a continuing series of highly publicized child abuse
inquiries. How important at such a time that a balanced, considered and
reasoned approach to the problem should come from those who are in a
position to guide us through the complex issues which must be faced.
That is the great merit of this book, it distils hard-won practice, wisdom
and research into an eminently readable and usable practice manual.
The book loses nothing in its translation from the American practice
context to that of the United Kingdom. Even the chapter on legal
intervention (Chapter 15) is of value, demonstrating as it does what can
be achieved in a system which is less uniform and more open to
innovation than our own. In particular, approaches dealing with
offenders - and, in some states, the interaction between the legal
system and the multidisciplinary system - provide stimulating ideas for
Area Child Protection Committees (ACPCs) to consider. Kathleen
Coulborn Faller and her associates have provided us with invaluable
help, and there is much to learn from this book.
Child sexual abuse is presenting practitioners with many new
challenges; not least of these is to their personal functioning. The reality
of sexual abuse and the lasting trauma it inflicts do not find expression
only in the minds and lives of victims and perpetrators but also reach
deeply into the internal world of the helper. Distant echoes from the
past can stir up feelings for the helper, and their needs are no less
important than those to whom they reach out. This work is not for
everyone, and there is no shame in facing up to the fact, but those who
can reach out to the victim and perpetrator need to be cared for as well.
vii
viii PREFACE
Staff care is an essential piece in the jigsaw. It is important that there is
opportunity for resolving personal feelings which may otherwise impede
the reasoned and compassionate approach to the problem which is so
well demonstrated in this book.
We have made a great deal of progress, building on the sound
foundation of multidisciplinary work which has been developed in
response to physical abuse and neglect. The NSPCC has built a national
network of Child Protection Teams (CPTs) which have developed much
innovative practice and provided extensive training and consultative
services, and will shortly open a National Training Centre to carry
forward this work. The British Association for the Study and Prevention
of Child Abuse and Neglect has promoted interprofessional awareness
and understanding of child sexual abuse. Arnon Bentovim and his
co-workers have expanded our knowledge of family therapy. The
Bexley project showed the way forward with joint police and social
work investigation, now many others are following their example.
Esther Rantzen understood the need for children to seek help in their
own right when she pioneered ChildLine, and gave such impetus to the
work other helplines had begun in this field.
The extraordinary events which led to the Cleveland Inquiry and the
report of Lord Butler Sloss, 1 throw into sharp relief many of the issues
we have to tackle. The Department of Health Circular Working
Together, 2 and the Assessment Practice Guide, 3 and other related
circulars and the imminent changes in child care law provide the basis
for further progress. What is clear is the need for a real commitment to
provide the vital resources and training which all the involved
professions need. Good training is the key to good practice, which
should be free from dogma. We must guard against dogmatism in our
therapeutic work - there is far too much we do not know and have yet
to learn. Fashions change and the flavor of this month can quickly
become the discarded practice of tomorrow. That is why this book is
important. Mature experience and professional judgement is brought to
bear on a wide range of theories, research findings and practice
methods, which are intelligently and eclectically applied in searching for
a way forward in helping each unique family, so well illustrated in the
Case Examples. Such standards of practice are not beyond our ability
and for the sake of the children we must strive to achieve those
standards.
PREFACE IX
References
1. Report of the Inquiry into Child Abuse in Cleveland, I987 (London:
HMSO, 1988).
2. Working Together: A Guide to Arrangements for Inter-Agency
Co-operation for the Protection of Children from Abuse (London:
HMSO, 1988).
3. Protecting Children: A Guide for Social Workers Undertaking a
Comprehensive Assessment (London, HMSO, 1988).
Introduction to the Macmillan
Edition
The problem of child sexual victimization is a universal one. Issues
Americans face in dealing with sexual abuse are also found in the
United Kingdom and other countries. Therefore, although Child Sexual
Abuse: An Interdisciplinary Manual for Diagnosis, Case Management,
and Treatment was originally written with an American audience in
mind, its applicability is much broader. However, in order to make this
book more useful to British (and, incidentally, to other non-American
readers) this introduction will highlight similarities and differences in
the problem of child sexual abuse and how it is handled in the United
States and the United Kingdom.
In both countries, sexual victimization of children is a rapidly
emerging issue of concern in the child welfare field. Beginning in the
1970s, because of increased knowledge about child maltreatment in
general and changes in the structure of service delivery, professionals
and the public in the United States and the United Kingdom became
aware of sexual abuse as a serious social problem. In the United States
(as a consequence of mandatory reporting of child maltreatment by
professionals) and in the United Kingdom (because of the creation of
registers of maltreating parents) large numbers of sexual abuse cases
came to be formally identified. Moreover, in both countries, the
proportion of children who have been sexually abused requiring
protection is increasing. Caseloads of workers providing child welfare
services thus contain larger numbers of sexual abuse cases than ever
before.
Therefore, although the statistics cited in Chapter 1 on the number of
reported cases and the percentage of persons sexually abused in the
general population reflect findings in the American population, the
reader can find comparable patterns in the United Kingdom. The
definitions of sexual abuse offered in the chapter are as applicable to
sexual abuse in Britain as in the United States. The purpose of Chapter
2 is to acquaint the American reader with the clinical sample that
formed the basis for the book, so that the reader can compare it to the
population he or she is serving and thereby judge the relevance of the
information in the book. The British reader will also want to make this
comparison.
X
INTRODUCTION xi
There have been parallel improvements in the United States and the
United Kingdom in the areas of identification and diagnosis of sexual
abuse. In addition, much cross-fertilization has taken place between
professionals in the two countries. Chapters 6 through 9, which describe
diagnostic interviewing of victims, offenders, and mothers of victims
and medical identification of sexual abuse, are therefore as applicable to
provision of service in Britiain as in the United States. However,
guidelines regarding the medical identification of anal findings found in
Chapter 9 need to be slightly modified based upon new research. Anal
gaping and focalliponecrosis of the anal ring (seep. 260) may be found
in some children who have not been sexually abused (Steinberg, 1989).
Recently both countries have experienced comparable dilemmas
related to the issue of false allegations, which makes the material found
in Chapter 5 related to the process of validating an allegation and
characteristics of true and false accounts of sexual victimization
pertinent in both countries.
In both the United States and the United Kingdom the capabilities for
investigating cases and protecting children are more highly developed
than mental health intervention to ameliorate the causes and effects of
sexual abuse. Chapters 10 through 14, which are concerned with case
management and treatment of sexual abuse, are therefore consistent
with the state of knowledge in both countries. As a result, they should
serve as useful guides to British mental health practitioners and others
involved in providing therapy to individuals and families coping with
sexual abuse.
Chapter 3, which offers frameworks for differential diagnosis of
sexual abuse, approaching the problem from three different
perspectives - the proximity of the relationship between victim and
offender, the role relationship between victim and offender, and
offender psychopathology - should be as applicable to sexual abuse in
the United Kingdom as in the United States. However, because there
are social structural differences between the two countries, the
proportion of cases falling into some categories will differ. For example,
divorce is much more common in the United States, occurring in almost
half of marriages as compared with one-fifth in Great Britain (Byrne
and Padfield, 1985). Moreover, most divorced American women
remarry. Therefore, it is likely that in Great Britain a relatively larger
proportion of incest cases will involve biological fathers in intact
families, and a smaller proportion stepfathers and non-custodial fathers
(Mrazek, Lynch, and Bentovim, 1981). Similarly, since on the whole
British families maintain closer ties with their extended families than
American families, cases involving grandfathers and uncles may be
found in relatively larger proportions in the United Kingdom.
