Understanding the Complexity of Child Sexual Abuse: A Review of the Literature With Implications for Family Counseling
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Auteurs : Sally V. HunterSource :
- The Family Journal [ 1066-4807 ] ; 2006-10.
Abstract
Working with families in which there have been incidences of child sexual abuse is one of the most challenging assignments for a family counselor. Beyond ethical and legal mandates for reporting such assaults, less is understood about the long-term effects on victims. After reviewing the literature on child sexual abuse and gender differences, this article critically examines the major approaches to understanding and treating such issues in family counseling. Clinicians are cautioned to examine their own assumptions about the meaning of such experiences for their clients. Implications are discussed for the practice of family counseling.
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Beyond ethical and legal mandates for reporting such assaults, less is understood about the long-term effects on victims. After reviewing the literature on child sexual abuse and gender differences, this article critically examines the major approaches to understanding and treating such issues in family counseling. Clinicians are cautioned to examine their own assumptions about the meaning of such experiences for their clients. Implications are discussed for the practice of family counseling.</p></abstract><kwd-group><kwd>family counseling</kwd><kwd>child sexual abuse</kwd><kwd>gender</kwd><kwd>prevalence</kwd></kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Reviews</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value> Working with families in which there have been incidences of child sexual abuse is one of the most challenging assignments for a fam- ily counselor. Beyond ethical and legal mandates for reporting such assaults, less is understood about the long-term effects on vic- tims. After reviewing the literature on child sexual abuse and gen- der differences, this article critically examines the major approaches to understanding and treating such issues in family counseling. Clinicians are cautioned to examine their own assump- tions about the meaning of such experiences for their clients. Implications are discussed for the practice of family counseling. Keywords: family counseling; child sexual abuse; gender; prevalence Most current research that explores the role of counseling with people who, as children, had early sexual expe- riences with adults has been based on clinical samples of "sexual abuse survivors" recruited through clinicians (Cameron, 2000; Carter & Parker, 1991; Darlington, 1996; Etherington, 2000; Gill & Tutty, 1999; Lev-Wiesel, 2000). These studies are based on samples of people who have experienced many years of severe sexual abuse in childhood and many years of therapy in adulthood. Certain assump- tions have been made by these researchers in the recruitment process: People are recruited as survivors to participate in a study, and their childhood sexual experiences with adults are assumed to have had a detrimental effect on them. There is a "human tendency to dichotomize complex phenomena and view them in simplistic, black-and-white terms" (Lindsay & Briere, 1997, p. 632), which can be seen operating in this literature. This article reviews and discusses some of the complexity involved in working with families in which child maltreatment is occurring. The article will present an analysis of recent literature relating to the prevalence of child sexual abuse, its long-term effects, the nature of gender differences, and the theories developed to explain this issue. The underlying assumptions on which many studies are based, and current theories used to explain child sexual abuse, will be examined critically. The implications for family counseling will be discussed, includ- ing the need for counselors to be aware of the dominant dis- course in this field and to avoid the trap of making too many assumptions about the impact of the experience on the child. The Prevalence of Child Sexual Abuse Researchers have repeatedly called for more commonly accepted definitions of terms when discussing child abuse issues (Haugaard, 2000; Rind, Tromovitch, & Bausermen, 1998). Estimates of the prevalence of child sexual abuse vary enormously from 2% to 62%, depending on the definition and the sampling method used. Estimates from meta-analyses also vary considerably from 5% to 40% (Bolen & Scannapieco, 1999; Gorey & Leslie, 2001; Rind et al., 1998). The preva- lence rate for "contact and noncontact" child sexual abuse is higher than that for "contact only" child sexual abuse (Gorey & Leslie, 2001; Putnam, 2003), which is estimated to be between 9% and 11% for women and between 5% and 6% for men, when contact includes fondling and penetration (Gorey & Leslie, 2001, p. 151). A population-based survey conducted in Australia in 2000, based on a randomly selected national sample of 1,784 men and women, produced similar prevalence rates. Approximately 12% of women and 4% of men self- reported at least one occurrence of unwanted penetrative expe- riences before the age of 16 (Dunne, Purdie, Cook, Boyle, & Najam, 2003). To a certain extent, these figures may reflect a greater reluctance on the part of men to share their stories for fear of stigmatization (King, Coxell, & Mezey, 2000). Understanding the Complexity of Child Sexual Abuse: A Review of the Literature With Implications for Family Counseling Sally V. Hunter University of New England, Armidale, New South Wales, Australia THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES, Vol. 14 No. 4, October 2006 349-358 DOI: 10.1177/1066480706291092 © 2006 Sage Publications Author's Note: This literature review included studies from Australia, Canada, Great Britain, and the United States. Although some findings may apply to survivors without regard to nationality, readers should note that conclusions based on data from particular countries may not generalize to all survivors. Correspondence con- cerning this article should be addressed to Sally V. Hunter, School of Health, University of New England, Armidale, NSW 2351 Australia; e-mail: sally.hunter@une.edu.au. 349 In a large-scale study of men in the United Kingdom visiting their local doctors, 5% reported having nonconsensual sex before the age of 16, of which 80% were sexual assaults by men and 20% by women (King et al., 2000). In addition, more than 7% reported having consensual sex before the age of 16 with a person at least 5 years older; 90% of these early sexual experiences involved women. This study reveals some of the complexities involved in this issue and suggests that child sexual abuse of boys by older women may be more common than child sexual abuse of boys by older men. Second, many incidences between boys and older women are not reported (King et al., 2000; West, 1998), partly because boys do not necessarily define these early sexual experi- ences as abusive (Etherington, 1997; Little & Hamby, 1999; Rencken, 2000). The idea of a woman committing a sexual assault on a young boy confronts our assumptions about masculinity and femininity. It flouts conventional beliefs in the "natural order of things" and is part of the reason that a man may feel so stigmatized and find it so difficult to report that he has been the victim of non-consensual sex with a woman. (King et al., 2000, p. 12) This is only one of the barriers preventing men from dis- closing child sexual abuse. Men are also reluctant to admit to having been sexually abused by other men for somewhat different reasons. There is often a sense of stigma and shame attached to such events (Briggs, 1995a; Dhaliwal, Gauzas, Antonowicz, & Ross, 1996; Etherington, 1997; G. R. Holmes, Offen, & Waller, 1997; King et al., 2000; Noll, Trickett, & Putnam, 2003). The boy is often afraid of being labeled as a homosexual or deviant (Cohen, 2001; Gill & Tutty, 1997; Little & Hamby, 1999; Rencken, 2000). In a recent qualitative study of boys sexually abused by men, the author describes the difficulty of disclosing abuse, particularly within the family. The closer the boy's relationship to the perpetrator, the more distressing, the more risky the abuse: hence the more improbable sounding when denounced and the more diffi- cult the task of convincing other adults in the family of what is really going on. (Dorais, 2002, p. 27) As a result, prevalence rates among men may well be considerably underestimated in much current research. For many men "the consequences of disclosure are perceived as worse than the consequences of non-disclosure" (G. R. Holmes et al., 1997, p. 77). Coupled with the cultural belief that women are sexually passive, harmless, and unlikely to be sexual aggressors (Boroughs, 2004; Denov, 2003a), these stereotypical gender scripts may lead to the incidence of child sexual abuse among boys being significantly unrecog- nized and untreated (W. C. Holmes & Slap, 1998). An Australian population-based study (Dunne et al., 2003) showed that although the incidence of penetrative experiences for both men and women has not varied much over time, the incidence of nonpenetrative abuse among younger men was lower than for older men. A similar decline in offi- cially recognized cases of sexual abuse in the United States has also been reported (Jones, Finkelhor, & Kopiec, 2001). However, this evidence needs to be treated with cautious optimism (Jones & Finkelhor, 2003) because of the possibility that younger men are less willing to disclose sexual abuse than are older men (Dunne et al., 2003). The Long-Term Effects of Child Sexual Abuse There is a great deal of qualitative evidence, based on research studies conducted among clinical populations of vic- tims, that shows the potentially devastating impact that child sexual abuse can have on the lives of men and women (Briggs, 1995b; Cameron, 2000; Darlington, 1996; Dolezal & Carballo-Dieguez, 2002; Etherington, 1997, 2000; Fater & Mullaney, 2000; Gill & Tutty, 1999; Hall, 2000; Lev-Wiesel, 2000; Ray, 1996, 2001). This is supported by evidence from large-scale studies that have identified correlations between child sexual abuse and psychological distress (de Visser, Smith, Rissel, Richters, & Grulich, 2003; Edwards, Holden, Felitti, & Anda, 2003; W. C. Holmes & Slap, 1998; Neumann, Houskamp, Pollock, & Briere, 1996), adult psy- chopathology including depression (Horwitz, Widom, McLaughlin, & White, 2001), alcohol abuse (Horwitz et al., 2001; MacMillan et al., 2001), antisocial behavior (Horwitz et al., 2001; MacMillan et al., 2001; Putnam, 2003), suicide risk (Dube et al., 2001), anxiety about sex (de Visser et al., 2003), and personal problems such as increased numbers of divorces and increased likelihood of unfaithfulness within relation- ships (Colman & Widom, 2004) among men and women. There is also evidence of low self-esteem and depression in women (Cecil & Matson, 2001), increased risk of revictim- ization in women (Coid et al., 2001) and men (King et al., 2000), and problems related to intimate relationships and sex- ual functioning (Dhaliwal et al., 1996; W. C. Holmes & Slap, 1998; Watkins & Bentovim, 2000) among men. The experience of child sexual abuse itself varies in terms of its severity, according to a large number of complex and interwoven factors (Putnam, 2003). These variables include the age of the child (Putnam, 2003), the sex of the child (Colton & Vanstone, 1996), the nature of the relationship between the adult and the child (Colton & Vanstone, 1996; W. C. Holmes & Slap, 1998), the severity of the abuse and the use of force or coercion (Colton & Vanstone, 1996), other forms of maltreatment experienced by the child (Edwards et al., 2003), the frequency and duration of the abuse (Cecil & Matson, 2001), whether or not the child has a disability (Putnam, 2003), the child's sexual orientation (de Visser et al., 2003; Tomeo, Templer, Anderson, & Kotler, 2001), the family environment (Colton & Vanstone, 1996; Putnam, 2003; Rind et al., 1998), and the perceived level of social support from family and friends at the time (Reyes, Kotovic, & Cosden, 1996). This makes it very difficult to 350 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2006 predict the effects, outcomes, and long-term consequences of child sexual abuse because these factors are rarely controlled for (Dhaliwal et al., 1996). Another reason for the difficulty assessing impact of sex- ual abuse is that the experience is often compounded by other associated dysfunctional behaviors and dynamics within the family system. It is thus often hard to differenti- ate the effects of sexual abuse from those of the associated chronic psychosocial adversities (Rutter, Giller, & Hagell, 1998). One prospective study suggested that children who had experienced child sexual abuse often grew up in impov- erished environments, with poverty, inadequate parenting, parents who were unemployed, or parents using drugs or alcohol (Horwitz et al., 2001). Another survey suggested that such children had often experienced other forms of child maltreatment such as emotional abuse, neglect, physical abuse, and witnessing of domestic violence in the home (Coid et al., 2001). About one third of adults self-report that they have experienced more than one form of child maltreatment (Edwards et al., 2003). Recent large-scale studies have demonstrated that other forms of child maltreatment such as child physical abuse, witnessing domestic violence in the home, emotional abuse, and neglect also correlate with negative outcomes in adult life. A "dose-related" effect has been demonstrated between the number of different types of maltreatment reported and poor outcome in terms of mental health (Edwards et al., 2003) and suicide risk (Dube et al., 2001). One study of Native Americans showed that physical and emotional abuse was more highly correlated with depression and anger than child sexual abuse (Hobfoll et al., 2002). Another study of adults with substantiated histories of child abuse suggested that other forms of child maltreatment had an equal impact on people's ability to establish intimate relationships (Colman & Widom, 2004). Unfortunately, other forms of child maltreatment and family dysfunction often form the context within which child sexual abuse occurs. There is some disagreement in the literature (and among practitioners) as to whether family dysfunction is caused by child sexual abuse or vice versa. Some feminist authors rightly point out the possibility that discussion of family dysfunction can "obscure the operation of power relation- ships implicit in incest, and serve to protect the perpetrator and de-emphasize his responsibility" (Kamsler, 1990, p. 13). Other researchers see family dysfunction as contribut- ing to the adult symptomatology of abuse survivors inde- pendently of the abuse itself. One reason for this is that the conflicted and overcontrolling family environment creates an atmosphere of hostility and chaos that makes it difficult for a child to make a healthy adaptation, even in the absence of sexual abuse. Recently, there has been a debate in the literature over the long-term effects of child sexual abuse. In 1998, a contro- versial meta-analysis concluded that "CSA does not cause intense harm on a pervasive basis regardless of gender in the college population" (Rind et al., 1998, p. 46). The authors also recommended the introduction of the term adult-child sex to describe "a willing encounter with positive reactions" (p. 46). This study created a controversy in the U.S. media, and the findings were subsequently severely criticized (Dallam et al., 2001; Lilienfeld, 2002). Since the publication of this provocative study, other authors have cautiously stated that early sexual experiences do not necessarily have a devastating impact on the children involved (Colman & Widom, 2004; Dallam et al., 2001; Haaken & Lamb, 2000; Horwitz et al., 2001; Oellerich, 2000; Putnam, 2003; Stanley, Bartholomew, & Oram, 2004). These researchers have pointed out the vari- ability of the effect on children and, in this way, offer a mes- sage of hope to many families. In many respects, the Rind et al. (1998) findings were not new. As long ago as 1995, it was acknowledged that about 40% of children experiencing child sexual abuse have few or no symptoms on standard measurements (Finkelhor & Berliner, 1995). Another study concluded that after control- ling for stressful life events "childhood victimization had lit- tle direct impact on any lifetime mental health outcome" (Horwitz et al., 2001, p. 184). In other words, even in very severe cases, it is very difficult to demonstrate conclusively a causal link between early sexual experiences and adult psychopathology. As a group, these children develop a par- ticular pattern of problems in adulthood but do not neces- sarily develop severe psychopathology (Putnam, 2003) or become dysfunctional interpersonally (Colman & Widom, 2004). Later, I will discuss implications for these findings related to counselor expectations and assumptions about effects of sexual abuse and how those can affect treatment outcomes. The Nature of Gender Differences Understandably, much of the research in this field focuses on one gender or the other. Initially, researchers focused on the sexual abuse of girls, but more recently, researchers have focused on the sexual abuse of boys (Dhaliwal et al., 1996; Dolezal & Carballo-Dieguez, 2002; Dorais, 2002; W. C. Holmes & Slap, 1998; Rencken, 2000; Valente, 2005; West, 1998) and female perpetrators (Boroughs, 2004; Denov, 2003b; King et al., 2000; Watkins & Bentovim, 2000). Researchers are also beginning to focus on the difference between homosexuals' and heterosexuals' early sexual experiences with adults (Kalichman et al., 2001; Stanley et al., 2004; Tomeo et al., 2001), issues for male sex workers (Leary & Minichiello, in press), and the taboo subject of motherdaughter incest (Fitzroy, 1997). As has been mentioned, there is considerable evidence of gender differences in response to child sexual abuse. Most studies suggest that women suffer more than men from depression, anxiety, posttraumatic stress disorder (PTSD) symptoms, and adjustment problems (Feiring, Taska, & Lewis, 2002; Horwitz et al., 2001; MacMillan et al., 2001; Rind et al., 1998; Sigmon, Greene, Rohan, & Nichols, 1996). Women Hunter / CHILD SEXUAL ABUSE 351 therapistsurvivors also report more problems with self- esteem, relationships, trust, sex, and work than do their male counterparts (Little & Hamby, 1999). This supports the idea that child sexual abuse has a more profound effect on women than on men; however, other data suggest that this may be an oversimplification. In most of the studies quoted above, the women had experienced more recent or more severe forms of abuse, including physical contact, than the men in the sample (Feiring et al., 2002; Rind et al., 1998; Sigmon et al., 1996). When the symptoms experienced by men who have been sexually abused were compared with a matched, normative sample of men, the abused men tended to exhibit more symptoms of depression, anxiety, antisocial personality dis- order, and alcohol problems (Gold, Lucenko, Elhai, Swingle, & Sellers, 1999; Horwitz et al., 2001). In other words, some men also experience mental health problems following early sexual experiences, although this may not be a universal or an inevitable outcome for either sex. As discussed earlier, it is likely that the sexual abuse of boys is underreported, especially among homosexual men (Kalichman et al., 2001; Stanley et al., 2004; Tomeo et al., 2001). One study among Latino male abuse victims found that more than half did not consider their early sexual expe- riences with an older man (on average 9 years older) to be sexual abuse, and several felt that they had been the one to initiate the experience (Dolezal & Carballo-Dieguez, 2002). One explanation put forward to explain a similar result was that it was safer for a gay adolescent to make a sexual advance toward an older man than toward another adoles- cent and risk aggression, outing, or rejection (Stanley et al., 2004). The authors argue that "the standard convention of defining age-based childhood sexual abuse as uniformly negative, harmful and coercive may not accurately represent gay and bisexual men's sexual experiences" (Stanley et al., 2004, p. 388). Differential Coping Strategies In a study of sexually abused children and adolescents, it was found that shame and attribution of blame were better indicators of recovery than the characteristics and severity of the abuse itself (Feiring et al., 2002). Those who attrib- uted the abuse to the offender's characteristics, rather than to themselves or situational factors, managed to keep their self- esteem more intact (Lev-Wiesel, 2000). It is possible that sexually abused males are more likely to experience shame than are females for the same reasons that they are less likely to report the abuse (Gill & Tutty, 1997; Little & Hamby, 1999; Williams & Banyard, 1997). Men may also employ different coping strategies than women. Concealing the abuse is one strategy that is fre- quently adopted to avoid the "anticipated disbelief, denial, and rejection" if they were to disclose the abuse (Dorais, 2002, p. 19). Men also seem to be more likely to employ a strategy of acceptance and less likely to employ emotion-focused strategies than are women (Sigmon et al., 1996). Even male therapists are "less likely to believe that therapy or working through their abuse is important to their recovery" (Little & Hamby, 1999, p. 384). There is an increasing interest in the literature in the con- cept of resilience and how it can be applied to cases of child sexual abuse. Researchers have called for more studies into adults who experienced child sexual abuse but did not seek treatment to understand how they have coped with, and adjusted to, their experiences (Romans, Martin, & Morris, 1999). One such study showed that "well adjusted" female child sexual abuse survivors had a greater tendency than did "poorly adjusted" female child sexual abuse survivors to use the cognitive strategies of disclosing and discussing the event, minimization, positive reframing, and refusing to dwell on the experience (Himelein & McElrath, 1996). It has also been suggested protective factors such as having an active approach to problem solving, gaining positive attention from others, having an optimistic view in the midst of suffering, having an ability to maintain a positive view of the meaning of life, being autonomous and proactive, and seeking novel experiences are also protective (Rak & Patterson, 1996). Obviously, there are many cultural differences evident in the ways that child sexual abuse may be experienced and processed. Particular cultural factors can bring with them both greater risks and protective features for potential vic- tims (Korbin, 2002). There is a need for professionals to share a transcultural definition of child sexual abuse because of the diverse ways the behavior is labeled and treated by different cultural groups (Chan, Elliott, Chow, & Thomas, 2002). It is beyond the scope of this literature review to explore cultural differences in detail. It is important to acknowledge that men are still far more likely than are women to move from victim to offender (Briggs, 1995b), particularly among those who have been abused by a female relative (Salter et al., 2003). In their lon- gitudinal study of 224 former male victims of sexual abuse, 12% of the sample eventually committed sexual abuse against other children, most as early as 14 years old (Salter et al., 2003). Clearly, there is a need for a great deal more research to explain the complicated dynamics that lead some men (and women) to continue the abuse cycle with the next generation. CONCEPTUAL MODELS FOR WORKING WITH CHILD SEXUAL ABUSE There is a considerable amount of case history and qual- itative data that suggest various methods of treatment for adult survivors of child sexual abuse. Most of these approaches advocate using attachment theory (Stubenbort, Greeno, Mannarino, & Cohen, 2002; Thomas, 2003), trauma theory (Berliner & Briere, 1999; Briere, 1997; Phillips & Daniluk, 352 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2006 2004; Terr, 2003), narrative therapy (Harvey, Mishler, Koenen, & Harney, 2000), or supportive therapy, group work, and 12-step programs (Glaister &Abel, 2001; Palmer, Brown, Rae-Grant, & Loughlin, 2001). There is very little literature relating to evidence-based practice, and there is a great need for more outcome studies in this field (Finkelhor & Berliner, 1995). Many theories have been developed to explain how child sexual abuse affects people as they grow into adulthood. Table 1 summarizes the main psychological, psychosocial, and neu- robiological theories and their originators, the mechanism whereby the child is affected, and the possible effects on adult health. Inevitably, this represents an oversimplification because many researchers and clinicians working in this field now use a combination of theoretical concepts to explain this complex human phenomenon. For example, the self-trauma model (Briere, 1997) uses features of a number of diverse the- ories including trauma theory, self-psychology, cognitive ther- apy, developmental theory, and behavior therapy. Similarly, the model of self-protection (Thomas, 2003) includes ideas from attachment theory, developmental psychopathology, trauma, dissociation, and experiential psychology. The development of theory in this field has mirrored the development of counseling theory in general (Hulme, 2004). Early conceptualizations included Freud's (Breuer & Freud, 1893-1895/1955) theory of repressed trauma, which was later replaced by his seduction theory (Bowers & Farvolden, 1996; Masson, 1992). Developmental theory and attachment theory have influenced later theoreticians (Briere, 1997; Krzowski, 1997; Thomas, 2003). Feminist, systemic, and narrative models for working with families have led to a poststructural style of therapy in which the issues around child sexual abuse are explored within the context of the social and cultural restraining beliefs affecting the whole family (Adams-Westcott & Isenbart, 1990; Barrett, Trepper, & Stone Fish, 1990; Durrant & Kowalski, 1990; Etherington, 2000; Gill & Tutty, 1999; Herman, 1996; Kamsler, 1990; Laing & Kamsler, 1990; White, 1989). In recent years, the trauma model has reemerged in the form of PTSD, with sev- eral researchers arguing that child sexual abuse constitutes a specific type of prolonged trauma that often incorporates the use of coercion (Finkelhor, Hotaling, Lewis, & Smith, 1990; Gold, 2000; Herman, 1995). Working with a family in which a child has disclosed child sexual abuse is a highly complex field that sets in motion a number of safeguards, legal mandates, and specialized interventions. Clinicians need to adjust their approach and treat each family individually, depending on the characteristics of the abused child (male or female, het- erosexual or homosexual) and the offender (male or female, intrafamilial or extrafamilial). The characteristics of the family (level of dysfunction, cultural beliefs, acceptance or denial of the abuse, coping mechanisms used) and issues of shame and blame will also be crucial in determining the treatment plan adopted. Some of the theories shown in the Table 1 can be adapted to working with families more eas- ily than others. For example, narrative (Crossley, 2000) and complex PTSD approaches (Gold, 2000) are suitable for counseling families because they include an exploration of the sociocultural and family dynamic aspects of the issue. IMPLICATIONS FOR WORKING WITH FAMILIES Based on the research and theory that has been presented, it can readily be seen that there is a need for clinicians to become more aware of the possible long-term effects of child sexual abuse. It has been highlighted how factors such as the clinician's theoretical approach and assumptions about child sexual abuse can have significant implications on treatment. Clients need to be treated differently, depending on their early sexual experiences, family backgrounds, gender, and sexual orientation. Based on the literature reviewed, the author offers several practice guidelines for working with families in which one member has experienced child sexual abuse. The Variability of the Impact of Child Sexual Abuse It can be both reassuring and liberating for family coun- selors to realize that early sexual experiences with adults do not necessarily have a profoundly devastating effect on all children. This comment is in no way intended to undermine the suffering experienced by many people as a result of child sexual abuse. It is, however, intended to challenge the notion that early sexual experiences inevitably and necessarily lead to great distress or adult psychopathology. Some children may be more resilient to trauma, perhaps in part because they receive more support from their families (Barbarin, Richter, & deWet, 2001) or from family counselors who rec- ognize their strengths and resources (Durrant & Kowalski, 1990). Being believed is, in itself, a great help to children. The child may also be more able to place responsibility for the sexual behavior where it belongs, onto the adult involved (Feiring et al., 2002; Kessler & Bieschke, 1999; Lev-Wiesel, 2000), or have better cognitive coping mechanisms (Himelein & McElrath, 1996). The Importance of Careful Choice of Language It is all too easy for the counselor to define an experience as abusive when the victim, particularly adolescent boys, may choose to view the experience in a completely different way. This can lead to a form of victimology (McCarthy, 1997; Rind, Tromovitch, & Bausermen, 2001), in which clients feel the need to maintain their sense of normality and self-esteem by wearing "a mask of being the average, normal guy" (Valente, 2005, p. 13). There is a need to draw a dis- tinction here among the legal definition of abuse, regulations Hunter / CHILD SEXUAL ABUSE 353 354 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2006 TABLE 1 Conceptual Models of Child Sexual Abuse Theory Early Theorists Mechanism Possible Effect on Adult Health Psychodynamic theory Seduction theory Developmental trauma theory Attachment theory Family systems theory Feminist theory Recovered memory theory False memory syndrome Learned helplessness and cognitive behavioral theory Child sexual abuse accommodation syndrome Shame and attribution theory Somatization theory Neurobiological theory Narrative theory Posttraumatic stress disorder (PTSD) Traumagenic dynamics theory Breuer and Freud (1895) later retracted Freud (1905/1962), Ferenczi (1909), Klein (1946) Erickson (1963), Finkelhor (1984) Bowlby (1988), Dutton (1998), Thomas (2003) Minuchin and Fishman (1981), Bowen (1978), Finkelhor (1984) Courtois (1997), Herman (1981), Ward (1984) Cameron (2000), Williams (1994) Loftus, Garry, and Feldman (1994), Wakefield and Underwager (1994) Seligman (1994), Briggs (1995a), Bandura (1977) Summit (1983) Kaufman (1989), Lewis (1987) Briere (1992) van der Kolk (1996) White and Epston (1990), Durrant and Kowalski (1990) van der Kolk, McFarlane, and van der Hart (1996), McCann and Pearlman (1990) Finkelhor and Browne (1986) Repression of childhood trauma Oedipal fantasies, identification with aggressor through introjection, damage to ego functioning Disruption to normal childhood development by trauma, leading to poor self-integrity and impulse control Disruption to attachment, leading to anxious attachments Family dysfunction, enmeshed behavior, other forms of child maltreatment Abuse of power by men over children, powerlessness of child Traumatic childhood amnesia, recovery in adulthood False memories produced by suggestive therapy Inappropriate passivity, disrupted cognitive schemata, internalized blame Accommodate to secrecy, helplessness, and entrapment. Delayed disclosure followed by retraction Feelings of shame related to pessimistic attributional style Unexplained physical health problems because of need to minimize original trauma Prolonged stress leading to biochemical, cellular, or structural change (e.g., to information-processing system) Oppression by cultural construct of victim, unhelpful self-narrative Disruption to cognitive schemata and affect because of traumatic event(s) Four traumas--traumatic sexualization, stigmatization, betrayal, and powerlessness-- that alter cognitive schemata and affect Hysteria Neurosis, impact caused by incest taboo Dysfunctional development, drug and alcohol abuse, eating disorders, somatization, depression, anxiety Personality disorders Family pathology leading to multiple problems Reduced competence and efficacy, oppression of women Multiple effects on adult health caused by repression of memories No effect on alleged victim, false memories surfacing Depression, pattern of revictimization Overachievement, or self-harm, drug and alcohol abuse, disruption to trust and intimacy Depression, low self-esteem, maladaptive coping style Depression, anxiety, and sexual problems masked by somatic symptoms or chronic pain Physiological and neurological changes, impulsivity, increased aggression, depression, anxiety, memory problems Lack of empowerment and competence, victim mentality PTSD symptoms of arousal and numbing, dissociation, can present as phobias, drug and alcohol abuse, eating disorders, depression, psychosis, and so on Confusion over sexual identity, problems with intimacy, guilt, shame, grief, depression, dependency, hostility, anxiety, victim mentality, nightmares, and so on (continued) about mandatory reporting, and the language that the family counselor uses in the therapy session. It is particularly important in this field that counselors choose their language deliberately and with great care. Using a Strength-Based Rather Than a Deficit Model of Counseling There is an opportunity in this field for family counselors to work from a strength-based rather than a deficit model by moving away from working with victims to working with a family who has experienced an event, or a series of events, and who is learning to cope in imaginative and creative ways. This is an approach that emphasizes resilience, resources, and strengths rather than focusing exclusively on damage and deficits (Durrant & Kowalski, 1990, p. 70). It offers hope to families and challenges one of the dominant discourses in this field. The Possibility That Men Have Had Early Sexual Experiences With Adults Family counselors need to be open to the possibility that men, who attend therapy for other reasons, may have had early sexual experiences with adults of either sex and feel a great reluctance to disclose these experiences. The use of a narrative therapy approach may be useful in helping men to overcome the cultural restraints in this area. The principal restraining belief is that real men are not victims (Gill & Tutty, 1999), which is an internalization of the social dis- course about masculinity. The child (boy) seems to believe it is in his best interests to keep the information secret. He is all too aware of the taboos pertaining to the abuse of boys by older males: the taboo around the vulnerability of males, the taboo against homo- sexuality, and the taboo against the involvement of minors in sexual behavior. (Dorais, 2002, p. 3) The family counselor working from a narrative perspective would draw out and challenge such societal and cultural beliefs during the counseling session. The Opportunity for Working Creatively With Males Within Families Given that there are significant gender differences in terms of the response to early sexual experiences, family counselors need to accept the challenge of constructing cre- ative, gender-specific methods of intervention in this field. Because men are less likely to report early sexual experi- ences, to view them as abusive, or to see them as experi- ences that require the use of "talking therapy," opens up a particular set of challenges for the family counselor. Some additional suggestions from the literature include the use of therapeutic rituals (Adams-Westcott & Isenbart, 1990), the use of attachment theory and the concept of attachment injuries in adult romantic relationships (Johnson, Makinen, & Millikin, 2001), the use of conjoint therapy that addresses the relational effects of trauma and secondary trauma (Nelson & Wampler, 2000), and the use of more extroverted healing activities suitable for men, such as physical activi- ties and experiences in nature (Little & Hamby, 1999). SUMMARY Family counselors are challenged to take a more positive, strength-based approach when working with clients who are struggling to come to terms with the early sexual experi- ences of family members. Even when working within the context of an ethical code that requires mandatory reporting of suspected child abuse, it is still possible for family coun- selors to make choices about the approach they adopt and the language they use in session. By avoiding the trap of making assumptions about the inevitable consequences of the sexual experience and labeling or pathologizing the experience, the family counselor will open up a space in which clients can tell their own stories about what has hap- pened and what they experienced, in their own language. In some cases, especially where family members are not directly involved in the sexual incident, this may have a big impact on the level of hope that the family may feel. Using this approach, family counselors do not minimize what has happened but rather help to identify the strengths of the Hunter / CHILD SEXUAL ABUSE 355 TABLE 1 (continued) Theory Early Theorists Mechanism Possible Effect on Adult Health Self-trauma theory Betrayal trauma Complex PTSD Briere (1992) Freyd (1996) Finkelhor, Hotaling, Lewis, and Smith (1990), Herman (1995), Gold (2000) PTSD, cognitive distortions, altered emotionality, dissociation and impaired self-reference PTSD response to betrayal Disruption to cognitive schemata and affect because of prolonged trauma and coercion, compounded by family dysfunction PTSD symptoms, low self- esteem, depression, anxiety, and problems with intimacy and sexual relationships As above PTSD symptoms, dissociation, somatization, changes in identity and relationships, repeated victimization individuals involved. This encourages family members to help each other to overcome what has happened in a creative and life-sustaining way. 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Lindsay</surname></name> (Eds.), <source>Recollections of trauma: Scientific evidence and clinical practice</source> (pp. <fpage>371</fpage>-<lpage>377</lpage>). <publisher-loc>New York</publisher-loc>: <publisher-name>Plenum</publisher-name>.</citation></ref></ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Understanding the Complexity of Child Sexual Abuse: A Review of the Literature With Implications for Family Counseling</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Understanding the Complexity of Child Sexual Abuse: A Review of the Literature With Implications for Family Counseling</title></titleInfo><name type="personal"><namePart type="given">Sally V.</namePart><namePart type="family">Hunter</namePart><affiliation>University of New England, Armidale, New South Wales, Australia</affiliation></name><typeOfResource>text</typeOfResource><genre type="review-article" displayLabel="review-article"></genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">2006-10</dateIssued><copyrightDate encoding="w3cdtf">2006</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">Working with families in which there have been incidences of child sexual abuse is one of the most challenging assignments for a family counselor. Beyond ethical and legal mandates for reporting such assaults, less is understood about the long-term effects on victims. After reviewing the literature on child sexual abuse and gender differences, this article critically examines the major approaches to understanding and treating such issues in family counseling. Clinicians are cautioned to examine their own assumptions about the meaning of such experiences for their clients. Implications are discussed for the practice of family counseling.</abstract><subject><genre>keywords</genre><topic>family counseling</topic><topic>child sexual abuse</topic><topic>gender</topic><topic>prevalence</topic></subject><relatedItem type="host"><titleInfo><title>The Family Journal</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1066-4807</identifier><identifier type="eISSN">1552-3950</identifier><identifier type="PublisherID">TFJ</identifier><identifier type="PublisherID-hwp">sptfj</identifier><part><date>2006</date><detail type="volume"><caption>vol.</caption><number>14</number></detail><detail type="issue"><caption>no.</caption><number>4</number></detail><extent unit="pages"><start>349</start><end>358</end></extent></part></relatedItem><identifier type="istex">5E095271E3D4B46E0D028DBA8B8FFE027F33589F</identifier><identifier type="DOI">10.1177/1066480706291092</identifier><identifier type="ArticleID">10.1177_1066480706291092</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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