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Incest Survivors

Abstract and Keywords

Incest is recognized as a societal taboo in many cultures. Despite customs, laws, and moral edicts that forbid sex between familial adults and children or minors and adults, incest continues to occur. Although incidence rates have generally declined over the last three decades, incest is still a prevalent problem in society. The primary focus of this article is incest between adults and children, between siblings, and between children in the United States. The article provides content on the complex interplay of individual, family, and cultural structures that shape survivors’ lives using an ecological, person-in-environment perspective and an examination of the clinical and empirical forces that drive assessment, evaluation, and treatment approaches in support of culturally informed trauma recovery and healing.

Keywords: incest, child sexual abuse, victim-survivor, sexual offender, disclosure, indicators, prevalence and incidence, victimization, healing, resilience, culturally specific treatment and recovery

Definitions

In the United States, the term incest is defined as a type of child sexual abuse (CSA) that occurs within the family system involving “sexually abusive acts toward children” (Murray, Nguyen, & Cohen, 2014, p. 1). More research is also recognizing sibling incest as a form of incest with harmful effects on children (Beard et al., 2013; Strobel et al., 2013). The terms family and sexual abuse have been further scrutinized by researchers, practitioners, policymakers, and lawmakers to assess the context and dynamics within which incest can occur, to identify and hold accountable those who commit incest, to recommend effective prevention and intervention methods, and to develop treatments. Historically, the term incest is rooted in the incest taboo, which reflects social, cultural, and religious customs and laws that forbid sexual relations and marriage among blood relatives, including between adults, between adults and children, between siblings, and between children (Crosson-Tower, 2008). Incest is a crime in all fifty states and sex between a child and an adult is considered nonconsensual and illegal, despite the fact that the legal or statutory definition of incest may vary by state.

In spite of variations in legal definitions across states, the family system and social customs have remained the yardsticks for categorizing and understanding types of incest that occur. In most definitions of incest, the blood-relative criterion has been expanded to include close relationships (such as non-blood-relative adoptive family or friends; marital ties, such as stepparent, stepchild; or a surrogate parental or caregiver role) in a child’s life on a permanent or temporary basis (Crosson-Tower, 2008; Leeb et al., 2008). Another measure found in definitions of CSA is the idea of consent. In most definitions of incest, children cannot give implicit or explicit consent to the sexual activity in word or deed; therefore, another distinguishing feature of the definition of incest is that incest involves forced or coerced sexual behavior imposed on a child (Collin-Vézina, Daigneault, & Hébert, 2013; Stoltenborgh, Van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011; Wodarski, Holosko, & Feit, 2015). Most scholarship also recognizes incest as harmful to the psychological, emotional, and physical well-being of children and adults with a history of CSA (Easton, & Kong, 2016; Hérbert, Langevin, & Daigneault, 2016; Maniglio, 2009; Seto, Babchishin, Pullman, & McPhail, 2015). Research also notes that children and adults may not necessarily experience negative outcomes from experiences of CSA (Lalor & McElvaney, 2010). The primary focus of this article is incest between adults and children, between siblings, and between children in the United States. Healing and recovery from incest are possible; hence, the use of the hyphenated construction victim-survivor is appropriate. The individual terms victim and survivor are also used synonymously.

Scholars sometimes use the term intrafamilial CSA instead of incest to describe sexual abuse occurring within the nuclear and extended family system or perpetrated by someone assuming a surrogate parental or caregiver role for an extended period (Crosson-Tower, 2008; Seto et al., 2015). Extrafamilial abuse is used to describe CSA committed by someone outside of the child’s family system or in a temporary caregiver role, including friends, authority figures, and acquaintances (Crosson-Tower, 2008; Leeb et al., 2008; Johnson, Underwood, Baum, & Newmeyer, 2016). Clinicians and scholars have used the intrafamilial and extrafamilial distinction to assess differences in family and cultural risk and protective factors associated with incest, and its differential effects and treatment for victim- survivors and types of offenders (Johnson et al., 2016; Lestrade, Talbot, Ward, & Cort, 2013; Murray et al., 2014; Seto et al., 2015). Thus, incest is recognized as a form of CSA occurring within family systems, while CSA is an all-encompassing term that can include both intra- and extrafamilial sexual abuse. Another term referenced in the literature on incest and CSA is child molestation. According to Lanning (2010), child molestation is used more interchangeably with legal definitions of sexual molestation, and a child molester refers to “a significantly older individual who engages in any type of sexual activity with individuals legally defined as children” (p. 18), with victimization occurring within or outside the family home. The variations, similarities, and overlap in the terms intrafamilial sexual abuse, extrafamilial sexual abuse, child molestation, and incest fall, varyingly, under the umbrella term CSA. Therefore, in the interest of readability, the terms child molestation, incest, and CSA are used interchangeably to mean the sexual victimization of children, and specific terms (incest, intrafamilial, extrafamilial) are used to distinguish specific contexts, effects, offender characteristics, behavior, or treatment related to the sexual victimization of children.

Prevalence and Incidence

Scholars credit the work of Hamilton (1929) as the beginning of research on the prevalence of CSA (Finkelhor, 1986; Wyatt & Peters, 1986). Prevalence research endeavors to determine the scope of the problem or, more precisely, the proportion of a population that has experienced CSA, while incidence studies attempt to estimate the number of new case occurrences (which may involve more than one child) in a specific period, typically a year (Finkelhor, 1986; Wyatt & Peters, 1986). According to Peters, Wyatt, and Finkelhor (1986), it wasn’t until the late 1970s that prevalence studies became of public interest. During this period, the scope of CSA was estimated at 1 in 4 girls and 1 in 9 boys, an estimate that circulated throughout prevalence literature for about a decade (Peters et al., 1986).

As interest in the safety of children from sexual abuse and other forms of abuse and neglect began to grow in the United States, estimates of the incidence (new cases reported to state agencies) of CSA increased almost tenfold, from 7,559 reported cases in 1976 to 71,961 by 1983 (Peters et al., 1986). Furthermore, in response to the public’s interest in CSA, there was a dramatic increase in wide-ranging prevalence studies and in methodological and definitional challenges that faced researchers interested in assessing the prevalence of CSA (Wyatt & Peters, 1986). Between 1979 and 1985, for example, prevalence studies reported CSA rates ranging from as low as 6% to as high as 62% for females and from between 3% and 31% for males (Peters et al., 1986). Similarly, in a comparison of four representative CSA prevalence studies between 1979 and 1984 in the Northeast and West Coast of North America, Wyatt and Peters (1986) found prevalence rates ranging from 15% to 62% for females. In addition to the variability in prevalence rates, many studies relied on retrospective accounts of CSA provided by adult survivors, which raised questions about the accuracy or validity of information provided (Peters et al., 1986). Thus, authors highlighted a series of factors that must be considered in CSA prevalence research, including the definitions of CSA used by researchers, methodological differences associated with their sampling techniques and data-collection methods, and variability in the population and geographical region sampled (Peters et al., 1986; Wyatt & Peters, 1986).

Based on nationwide telephone surveys of adults and youth (Black et al., 2011), national sexual violence prevalence rates, including lifetime and past year estimates, have emerged over the last two decades and measure multiple types of sexual victimization. In a nationally representative community study involving face-to-face interviews with over 34,000 adults, Pérez-Fuentes and her colleagues (2013) found that 10% of respondents (25% men and 75% women) reported experiencing CSA before the age of 18 years. Finkelhor, Shattuck, Turner, and Hamby (2014) note that national prevalence rates are also fraught with methodological challenges, which make comparisons problematic, including definitions of what constitutes sexual abuse and by whom, and differing actual starting ages for populations used in estimating lifetime exposure. Therefore, since the early 1990s, some scholars have relied more readily on incidence statistics released by the National Child Abuse and Neglect Data System (NCANDS), which aggregates substantiated cases of child abuse and neglect reported to state child protection agencies primarily by parents and caregivers (Finkelhor, Jones, & Shattuck, 2010). NCANDS statistics are readily available and may be useful when assessing within-state trends of substantiated reports of CSA. However, it is not clear whether changes in the occurrence of reported cases of CSA are due to procedural changes or real changes in the incidence of abuse (Jones, Finkelhor, & Kopiec, 2001). Therefore, other confirmatory reporting sources are used in conjunction with NCANDS, such as the National Incidence Study of Child Abuse and Neglect (NIS). The NIS uses standardized and consistent definitions of child abuse and is mandated by Congress, has been conducted about every 10 years since 1974, and provides a broader estimate of the incidence of child abuse in the United States, in that it includes cases reported to state officials as well as community professionals (Sedlak et al., 2010).

Reports from NCANDS (and confirmed by NIS-3 and NIS-4) showed a 58% decline in known and confirmed cases of CSA from 1992 to 2008, a decline that most analysts consider to be a true decline based on similar trends found in victim self-report surveys conducted during a similar time frame (U.S. Department of Health and Human Services, 2010). There is ongoing debate in the child abuse field about several factors attributed to the long-term decline in reported cases. The factors include increased public awareness of CSA as a growing problem, an increase in the number of child protection and law enforcement employees, more aggressive prosecution leading to imprisonment of child sex offenders, improvements in treatment options for survivors, and a prolonged improvement in the economy (Finkelhor et al., 2010).

Current trends in prevalence research reflect an increased interest in disaggregating the experiences of child survivors from early infancy to adolescence. The work of Finkelhor and his colleagues (2014) is notable in delineating trends in childhood sexual abuse exposure. Using national survey data, the authors examined the experiences of children 2 to 17 years old (Finkelhor et al., 2010) and lifetime prevalence rates of victimization exposure among adolescents 12 to17 years old (Finkelhor et al., 2014). Based on evidence from two national surveys of children aged 2 to 17 years in 2003 (2,030 children) and 2008 (4,046 children), Finkelhor and his associates (2010) found the annual prevalence of any sexual victimization of children dropped from 3.3% to 2.0%; however, sexual abuse by known and unknown adults was not significantly different in the two surveys. Lifetime prevalence rates of sexual abuse among adolescents (12- to 17-year-olds) for the period 2003 to 2010 were reported at 1 in 9 girls and 1 in 53 boys abused by adults and 1 in 4 girls and 1 in 20 boys victimized by juvenile offenders (Finkelhor et al., 2014). These findings led the researchers to conclude that “the experience of sexual abuse/assault in childhood and adolescence is very prevalent” (Finkelhor et al., 2014, p. 332). However, they also cautioned readers to avoid comparisons between lifetime and annual prevalence studies during the same period and suggested that the latter are a more sensitive measure for assessing childhood exposure to sexual abuse. Leung, Curtis, and Mapp (2010) also studied the prevalence of CSA among children age 11 or younger using data from the National Health and Social Life Survey, a national representative community sample of 3,432 adults 18 to 59 years old. The researchers found that children’s exposure to sexual abuse was 1.6 times higher in families experiencing parental divorce when the child was age 14, and it was 2 times higher in homes were one or both parents were incarcerated or institutionalized (Leung et al., 2010). Methodological variability across studies with respect to definitions of sexual abusive acts toward children, reporting sources (e.g., substantiated reports, adult retrospective recall), sample populations and selection (e.g., clinical, community, convenience, probability), and survey methods (e.g., telephone, face-to-face interview, self-report questionnaire) creates difficulties in accurately measuring the prevalence of CSA (Murray et al., 2014). Despite these limitations and the underreporting of CSA given the stigma and hidden nature of this crime, prevalence and incidence rates likely provide conservative estimates for assessing and understanding the scope of incest with the body of knowledge available at this time. Research examining incest indicators and effects provides a sense of the magnitude and impact it has in the lives of victim-survivors.

Incest Indicators and Effects

The indicators of incest are identified through child disclosures, clinical diagnostic assessments and observations, medical examinations, forensic assessments, and empirical studies (Everson & Faller, 2012; Kellogg, 2005). Clinical observations, retrospective recall, and standardized or objective measures are discussed variably throughout the literature examining the impact of CSA. Through these methods, initial and long-term symptoms and effects of CSA are identified among victim-survivors ranging from infants to adults as well as specialized populations (e.g., female college students, incarcerated populations, HIV-exposed victim-survivors, court cases, and adolescents in treatment). A great deal more research and clinical assessments focus on female victims, but the field is growing in its acknowledgment and understanding of the effects of CSA on male survivors as well (Easton & Kong, 2016; Wodarski et al., 2015).

Incest is recognized as a form of chronic traumatic stress, with symptoms classified as primary or acute, secondary, and tertiary response patterns, with variability depending on the severity and frequency of abuse, age and gender of offender, victim-survivor age, onset of the abuse, and age difference between the victim-survivor and offender (Cicchetti & Carlson, 1989; Courtois, 1988). Other variables that may affect symptomology include the disclosure process, adult reactions to the child abuse, the child’s response to others’ knowing about the abuse, and the child’s age-specific ability to understand and process the experience (Cicchetti & Carlson, 1989; Elliott & Briere, 1994). In the last decade, there has been greater recognition of a broader array of contextual and structural factors that can influence biopsychosocial and emotional health outcomes experienced by children and adolescent victim-survivors of CSA and later adult psychopathology. Such factors include exposure to multiple and co-occurring victimization, poverty, witnessing domestic violence, family structure and environment, and cultural norms and values (Fontes & Plummer, 2010; Gold, Hyman, & Andrés-Hyman, 2004; Turner, Finkelhor, & Ormrod, 2006). Overall, experts in the field recognize that the effects of sexual victimization in childhood can have severe short- and long-term psychological, physical, and emotional health outcomes during childhood, adolescence, and adulthood (Easton & Kong, 2016; Hillberg, Hamilton-Giachritsis, & Dixon, 2011; Maniglio, 2009, 2013).

Signs and Symptoms

The indicators of incest are typically identified as a range of individual behavioral, physical, emotional/mental/psychological, and sexual and nonsexual signs and symptoms experienced differentially by victim-survivors across the life span, with immediate and long-term effects (Maltz, 2012, Sagatun & Edwards, 1995). Some practitioners also include familial characteristics and interpersonal symptoms among the indicators and risk factors and recognize potential warning signs of incest to be as unique and variable in their manifestation as are victim-survivors themselves (Gold, Hyman, & Andrés-Hyman, 2004; Wodarski et al., 2015). Thus, qualifiers commonly accompany descriptions of the effects of CSA, along with caveats that symptoms and signs may be associated with nonsexual abuse stressors and that CSA is a significant but nonspecific risk factor for biopsychosocial challenges (Hillberg et al., 2011; Maltz, 2012; Turner et al., 2006). Despite the variability in victim-survivors’ experiences and the caveats and qualifiers used to provide a contextual backdrop for understanding and interpreting indicators, researchers and clinicians often identify a similar range of symptoms and signs that may raise suspicion about the occurrence of incest. Additionally, behavioral, physical, and familial symptomology can serve an evidentiary purpose in cases in which the victim-survivor has no conscious memory of the experience for whatever reason—repression, dissociation, denial, etc. (Courtois, 1988).

For social work researchers and clinicians, the heavy emphasis that the literature places on individual indicators highlights the importance of using a strengths-based, person-in-environment framework to examine environmental risk and protective factors that may play a role in magnifying and mitigating the symptomology. Ecological, multisystem, and culturally responsive practice frameworks alert social workers to the intersections of individual, familial, community, and cultural dynamics and contexts that shape assessments and interventions with incest survivors.

Nonspecific Pathways and Outcomes

An extensive body of empirical and clinical research over the past three decades suggests a multitude of nonspecific developmental, physical, behavioral, emotional, and, psychological outcomes associated with CSA (Collin-Vézina, Daigneault, & Hébert, 2013; Lewis, McElroy, Harlaar, & Runyan, 2016; Wodarski et al., 2015). Overwhelmingly, research points to the fact that the heterogeneity of definitions, assessments, and circumstances of CSA makes it extremely difficult to pinpoint or agree upon a specific, consistent etiology and symptomology that can be attributed exclusively to the impact of incest specifically or CSA generally (Collin-Vézina et al., 2013; Lewis et al., 2016; Murray et al., 2014). More frequently, experts commonly recognize that victim-survivors of CSA are at increased risk of experiencing guilt, shame, betrayal, anger, powerlessness, stigmatization, post-traumatic stress disorder (PTSD), anxiety, depression, sexual disorders, and suicidal ideation and attempts, as well as dissociation symptoms (Hérbert et al., 2016; Maniglio, 2009, 2013, 2014; Nanni, Uher, & Danese, 2012; Pérez-Fuentes et al., 2013). However, specific pathways leading to the negative effects are diverse and confounded by many other factors (Finkelhor et al., 2015; Lewis et al., 2016; Wodarski et al., 2015).

Polyvictimization and Adversity Effects

Increasingly in contemporary studies, more attention is given to the differential associations of CSA and other forms of child maltreatment, and the impact that different offenders, family structure, and gender may have on the experiences and symptomology of survivors (Easton & Kong, 2016; Finkelhor et al., 2015; Infurna et al., 2016; Lewis et al., 2016; Maniglio, 2009, 2013, 2014). For example, in a meta-analysis examining the associations between depression and childhood experiences of abuse, Infurna and her colleagues (2016) found a stronger association between psychological and physical abuse and depression than CSA and depression. The authors hypothesized that focusing on a wider array of childhood adversities, instead of one form, might be a more effective way to identify early pathways that result in depression later in life.

Consistent with previous studies, a systematic review of the association of CSA and the etiology of anxiety found evidence to support CSA as a significant nonspecific risk factor for anxiety, particularly PTSD; however, several other factors, including biological, psychosocial, familial dysfunction, and other forms of child abuse, were identified as influencing the relation between CSA and anxiety (Maniglio, 2013). Similarly, peer victimization experiences were highly correlated with clinical levels of PTSD and dissociation symptoms experienced in a sample of sexually abused school-age children (Hérbert et al., 2016). Turner and her associates (2006) also found that exposure to cumulative and multiple forms of victimization, including CSA, over a child’s life course increased mental health risks substantially. Meta-analysis studies have consistently confirmed the significance of multiple factors that interact in influencing biopsychosocial health outcomes through childhood, adolescence, and adulthood among survivors of incest. The implications for prevention and intervention suggest a need for the use of assessment tools that measure multiple forms of victimization and delineate interactions between variables to better identify multiple paths for developing specific interventions at intrapersonal, interpersonal, and environmental levels across the life span of victim-survivors.

Physical Health Effects

Clinical and empirical literature identifies physical symptoms as a manifestation of acute or primary traumatic stress responses to sexual abuse in some cases (Cicchetti & Carlson, 1989; Courtois, 1988). A very broad range of physical signs and symptoms have been identified, including gastrointestinal disorders, gynecological and urological problems, sexually transmitted diseases, pregnancy, symptoms of depression and anxiety, hyperactivity (especially in children), and anorexia nervosa or bulimia (Jensen, 2005; Maltz, 2012). Several recent studies, recognizing the complexity of the pathway from CSA to physical health problems, confirm previous research that physical symptoms later in adult life may be linked with a history of CSA (Kobayashi & Delahanty, 2013). In a meta-review of long-term physical health consequences of CSA, Irish and her colleagues (2010) found that males and females with a CSA history reported more complaints of general health problems, gastrointestinal disorders, gynecologic or reproductive disorders, pain, cardiopulmonary symptoms, and obesity. Previous research confirmed a strong correlation between child abuse (physical and sexual) and obesity in a prospective longitudinal sample of girls (Noll et al., 2007; Williamson et al., 2002). Rich-Edwards and her colleagues (2010) found that physical and sexual abuse in childhood and adolescence was highly associated with type 2 diabetes in a large nationally representative sample of women. Adult obesity was found to be a significant factor influencing the association between child abuse and adult diabetes (Rich-Edwards et al., 2010).

Definitive conclusions about the physical health effects of incest, like behavioral indicators, cannot be made. However, the initial and long-term physical health effects on the quality of life for victim-survivors cannot be understated. These findings reinforce the importance of efforts to improve assessment tools, such as the Adverse Childhood Experiences (ACE) scale, which has been found to predict physical and mental health outcomes through the assessment of early childhood experiences of abuse (physical, sexual, neglect; Finkelhor et al., 2015). Physical effects of incest can be treated or managed with varying degrees of healing and recovery based on a multitude of factors. Social work practitioners are in a prime position to support a strengths-based person-first multidisciplinary team approach in working with victim-survivors and other clinical and medical practitioners in the treatment and prevention of the potential physical symptoms and health problems linked to incest.

Maladaptive and Adaptive Coping

Coping with the experience of incest and its effects can involve a host of maladaptive and adaptive behaviors, often linked with efforts to curtail or mitigate emotional and psychological stressor survivors can experience across the life span (Hérbert et al., 2016; Maniglio, 2009, 2013, 2014; Nanni, Uher, & Danese, 2012; Pérez-Fuentes et al., 2013). Common maladaptive coping strategies reported in the literature include alcohol and drug abuse, suicide attempts, self-harm, and engagement in high-risk sexual behaviors (e.g., multiple sexual partners, prostitution, exhibitionism; Allen, 2017; Everson & Faller, 2012; Homma, Wang, Saewyc, & Klshor, 2012; Pérez-Fuentes et al., 2013; Trickett et al., 2011).

In a 23-year multigenerational longitudinal study of the impact of intrafamilial sexual abuse on female development among females 6 to 32 years old and a demographically similar comparison group (n = 82), Trickett and her colleagues (2011) found that females with a history of sexual abuse (n = 84) experienced an extensive array of biopsychosocial problems. Study participants with a history of incest reported higher rates of drug and alcohol abuse, domestic violence, physical and sexual revictimization, depression, anxiety, dissociation symptoms, hypersexuality, cognitive deficits, early onset of puberty, self-mutilation, eating disorders, teenage pregnancy and premature deliveries, persistent PTSD, dropping out of school, and major physical health problems, including higher rates of obesity (Trickett et al., 2011). Similar to other studies examining the effects of CSA, survivors in the longitudinal study were more likely than the comparison group to experience other forms of victimization, including physical abuse and domestic violence, as well as physical and sexual revictimization in adolescence and young adulthood (Trickett et al., 2011).

Resilience Research

A tremendous amount of research has focused on the links between childhood sexual abuse, other forms of child abuse and adversities, and negative biopsychosocial outcomes; however, research also recognizes factors that mitigate risks and promote resilience and protective assets among survivors of childhood trauma (Edwards et al., 2014; Tiapek et al., 2017; Wingo, Ressler, & Bradley, 2014). Scholars examining individual protective assets as buffers to traumatic experiences are increasingly recognizing the influence of context and culture as well (Ungar, 2011).

Research examining the role of resilience in moderating negative biopsychosocial outcomes of CSA and other forms of childhood adversities defines resiliency in multiple ways. Resilience is conceptualized in some studies as a multidimensional adaptable developmental process that emerges and shifts over the life course (Cicchetti, 2013; Klika & Herrenkohl, 2013). Masten (2011) uses a systems framework to conceptualize resilience as the ability of a system to withstand, respond, or recover from threats to its safety, security, viability, and development. In the context of CSA, using a systems framework of resilience as a form of interdependent interacting systems alerts clinicians to the influence of family, social, community, and cultural sources of resilience in addressing the needs of survivors (Southwick et al., 2014). Resilience is also constructed as an individual trait or characteristic that acts as a protective factor in promoting successful coping with hardship and as an outcome of adversity (Edwards et al., 2014; Southwick et al., 2014). Salient individual traits characteristically used to describe resilience include hopefulness, ego strength, hardiness, adaptive coping styles, cognitive flexibility, and perseverance (Cicchetti, 2013; Southwick et al., 2014).

Many definitions and methods are used to conceptualize and study resilience. Several researchers have recognized resilience as a significant moderator in studies examining its effect on the biopsychosocial outcomes associated with experiences of child maltreatment across a variety of survivor populations. Cross-sectional research studies have operationalized resilience characteristics in a variety of ways using the self-rated 10-item Connor-Davidson Resilience Scale (Campbell-Sills & Stein, 2007), the 14-item Resilience Scale (RS-14; Wagnild & Young, 1993), and the 25-item Connor Davidson Resilience Scale (Connor & Davidson, 2003). For example, in a cross-sectional study of 237 adolescent girls in the child welfare system with substantiated cases of physical, sexual, and emotional abuse, the role of resilience, as defined by interpersonal traits, was examined as a moderator of negative behavioral and mental health outcomes (Tiapek et al., 2017). Consistent with findings of previous research (Edwards et al., 2014; Wingo et al., 2010), Tiapek and her colleagues (2017) found that resiliency was a significant moderator of the relationship between CSA and emotional abuse and PTSD, depression, and revictimization. Edwards et al. (2014) tested resiliency characteristics as a moderator of psychological distress in a sample of female college students (n = 765) with a history of multiple child maltreatment (sexual abuse, physical abuse, verbal abuse, and witnessing intimate partner violence). The researchers found that while there was no evidence of moderation for physical or interpersonal distress, resilience was a significant moderator of the multiplicity of child maltreatment and psychological distress (Edwards et al., 2014).

Wingo and her colleagues (2010, 2014) examined resilience characteristics in two urban settings with adult men and women with a history of childhood victimization and other forms of trauma exposure. In the 2010 study, Wingo and associates found that resilience mitigated depressive symptom severity in an urban population of predominately African American adult females and males (n = 792) with a history of childhood abuse and trauma exposure. The researchers (Wingo et al., 2014) also tested the moderating effects of resilience characteristics in a low-income, high-stress, and trauma-exposed population of inner-city adults (n = 2,024) with history of child abuse (physical, emotional, sexual) and other trauma events (e.g., sudden life-threatening illness, military combat, witnessing violence and murder of close friends and family, natural disaster). They found that resilience characteristics mitigated the tendency for harmful alcohol and illicit drug use the study population.

Cross-sectional research designs, self-report scales, and retrospective recall are limitations that preclude causal inferences when interpreting the results of these studies. In a review of longitudinal studies examining resilience in maltreated children, Klika and Herrenkohl (2013) found some consistency in the domains of resilience measured (e.g., social, emotional, behavioral); however, similar to the cross-sectional studies, the great variability in measures used limits comparability across studies. Nevertheless, resilience research holds promise and potential regarding implications for treatment and prevention of CSA.

Current resilience research, although fraught with limitations, supports and extends previous research in recognizing that learned helpfulness and positive adjustment to traumatic life experiences is possible for incest survivors (Himelein & McElrath, 1996; Wright, Crawford, & Sebastian, 2007). Positive resolution of incest experiences is linked with meaning-making and benefit-finding for some survivors, as well as the development of healthy coping responses and the successful integration of the traumatic experience in the survivor’s life (Sewell & Williams, 2001; Wright et al., 2007). Wright and her associates (2007) found that effective resolution of the trauma and effects of incest were linked with cognitive restructuring, recognizing the pain and suffering, and engaging in prosocial behaviors to rebuild the self-concept. These findings are consistent with an approach to social work practice that involves the use of strength-based and empowerment models that support biopsychosocial-cultural dimensions of development related to chronic after-effects.

Disclosure Process

Disclosure of incest is also a complex process. Key factors affecting the impact of disclosure are related to the time frame and manner in which disclosure occurs, and the person to whom the experience is disclosed. Therefore, many scholars (Alaggia, 2004; Sjoberg & Lindblad, 2002) define disclosure broadly, whether the disclosure is accidental, purposeful, or prompted, as a process by which a person tells another about the sexual abuse they have experienced. Disclosure can be formal (for example, the official reporting of abuse to the authorities) or informal (such as telling a peer, parent, or siblings). Delays in disclosure are also frequently seen (Alaggia, 2004; Sjoberg & Lindblad, 2002). Some of the factors that influence disclosure include age at time of abuse, length of abuse, type of abuse, relationship to perpetrator, familial support, and cultural norms (Fontes & Plummer, 2010; Goodman-Brown, Edelstein, Goodman, Jones, & Gordon, 2003; Esposito, 2014).

Accidental and Purposeful

Accidental disclosure occurs when sexual abuse is revealed in any way other than by purposeful telling. Accidental disclosure might occur through verbal expression, physical or emotional symptoms, or witnessed behaviors (Alaggia, 2004; Esposito, 2014). Abuse of children less than 6 years old is frequently discovered accidentally (Alaggia, 2004; Goodman-Brown et al., 2003). Young children are frequently less inhibited when discussing events that might be embarrassing to older children (Goodman-Brown et al., 2003). Purposeful disclosure is the intentional telling of the sexual abuse that has occurred. Much of the research indicates age as the primary factor in determining whether a disclosure is intentional or accidental. Purposeful disclosure is more likely to occur in children more than 5 years old because older children have greater cognitive ability, understand the norms of society, and have knowledge about right and wrong behaviors (Alaggia, 2004; Goodman-Brown et al., 2003). For these reasons, purposeful disclosure is also less likely in children who are developmentally delayed (Paine & Hansen, 2002).

Cultural and familial factors and the child’s perceptions of family support can also influence a victim’s willingness to disclose sexual abuse in a purposeful manner. Children whose caregivers were supportive (defined as “willing to accept the possibility that their child may have been sexually victimized and the absence of evidence of punishing or pressuring the child to deny abuse”) disclosed at 3.5 times the rate of those whose caregivers were not supportive (Paine & Hansen, 2002, p. 280).

Delayed

Frequent delays between the time of abuse onset and the time of disclosure are supported in most of the research, with fewer than 1 in 4 victims of childhood sexual abuse immediately disclosing its occurrence (Paine & Hansen, 2002). Delays can be anywhere from a few months to many years, with many survivors not disclosing the abuse until they reach adulthood (Goodman-Brown et al., 2003; Sjoberg & Lindblad, 2002).

Several factors have been identified as affecting the length of time between initial abuse and disclosure. They include age at time of abuse, severity of abuse, developmental factors, gender, relationship with perpetrator, fear of negative consequences, sense of responsibility for the abuse, and familial support (Goodman-Brown et al., 2003; Paine & Hansen, 2002; Sjoberg & Lindblad, 2002; Somer & Szwarcberg, 2001). Children who are young at the onset of abuse are likely to delay disclosure until they can understand the wrongness of it (Goodman-Brown et al., 2003). Young children also may not yet have the knowledge or skills to verbalize their experiences (Paine & Hansen, 2002).

Goodman-Brown and associates (2003) found that boys are more likely than girls to delay disclosure, and fears of negative consequences, such as being labeled a homosexual, are a contributing factor. Cultural influences on gender can impact whether a victim discloses or not as well. Girls are more likely to be held to cultural standards of purity and virginity, which may lead to delayed disclosure or nondisclosure to avoid being stigmatized or labeled in a negative manner (Paine & Hansen, 2002). Boys whose perpetrators are women have to contend with the societal view that relationships between older women and younger boys are not considered abuse and may even be glorified (Paine & Hansen, 2002).

Another factor that contributes to delays in disclosure is whether the abuse was intrafamilial or extrafamilial. Children are less likely to disclose abuse the more closely they are related to the abuser. Eighty-nine percent of intrafamilial abuse was either disclosed after a delay or not disclosed at all, versus 54% of extrafamilial abuse (Goodman-Brown et al., 2003). This delay in disclosure may be related to fears of betraying a parent, punishment for telling a family secret, or feelings of self-blame for the abuse (Somer & Szwarcberg, 2001).

Types of Sexual Offenders

Common Risk Factors and Characteristics

Although the characteristics of individual perpetrators of incest vary, common risk factors have been identified. Some risk factors include a family history of alcohol misuse, violence, unemployment, and/or marital problems, and other sexual deviations or dysfunctions (Falshaw et al., 1996; Glasser et al., 2001). Individual perpetrators of extrafamilial incest tend toward sexual deviations and antisocial personality characteristics, while perpetrators of intrafamilial incest do not typically have those characteristics, although victims of intrafamilial incest tend to be younger at onset and have longer abuse histories (Seto, Babchishin, Pullman, & McPhail, 2015). Furthermore, according to Simon-Roper (1996), families in which incest occurs can be classified as chaotic. Another factor believed to contribute to intrafamilial sexual abuse is parental loss or absence (Thomas & Fremouw, 2009). These factors can lead to unhealthy attachment patterns and contribute to the likelihood of becoming a perpetrator of sexual abuse of children (Simon-Roper, 1996; Thomas & Fremouw, 2009). In adulthood, perpetrators of incest are more likely to have had a significant relationship (married, cohabiting, separated, or divorced) with nonperpetrators. In addition, on average, perpetrators have lower educational levels than nonperpetrators, although they are slightly more likely to maintain steady employment than nonperpetrators (Glasser et al., 2001).

Child and adolescent offenders also vary as individuals; however, certain personal, familial, and experiential characteristics have been identified as being common to them (Silovsky, Swisher, Widdlifield, & Turner, 2013). Personal characteristics, such as other nonsexual behavioral problems, developmental delays, and impulse-control problems, commonly co-occur with sexual behavior problems. Familial issues that diminish parents’ ability to supervise and/or guide their child, such as single-parent homes, parental stress and/or personal trauma, parental mental illness, and substance use, can contribute to an environment supportive of sexual offending. Experiences of sexual abuse, exposure to pornography or inappropriate sexual behaviors in others, and experiences of violence, such as physical abuse, domestic violence, and community violence, lead some children to repeat the learned behaviors. The strongest indicators are the experiences of violence and learning to use force to achieve goals (Silovsky et al., 2013).

Pedophiles

The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) defines pedophilia as the sexual attraction to prepubescent children, characterized by recurrent, intense sexually arousing fantasies or urges or behavior involving sexual activity with a child. The individual must have acted on the urges or the urges must be causing significant distress. Pedophiles must be at least 16 years old and at least 5 years older than the child involved. Attraction may be exclusive to children or can include both children and adults. The attraction may be to males, females, or both, and the attraction can be limited to only familial relationships.

The number of males with pedophilia is estimated to be 3% to 9% of the population; the prevalence of pedophilia in females is believed to be lower (American Psychiatric Association, 2013; Houtepen et al., 2016). Recent evidence suggests that similar processes are involved in pedophilic attraction to children and sexual attraction to others (Houtepen et al., 2016).

Several comorbid psychiatric disorders, such as substance use disorders, depression, bipolar and anxiety disorders, antisocial personality disorders, and other disorders of sexual arousal, are seen in individuals, especially males, convicted of sexual offenses (American Psychiatric Association, 2013).

Female Offenders

The topic of female perpetrators has only just begun to be researched because of a long-standing belief among scholars that women did not sexually abuse children, or that, when they were involved in abuse, it was because a male had coerced them into being involved (Elliott, 1994). It is estimated that females perpetrated 5% of abuse of girls and 20% of abuse of boys (Elliott, 1994), but this estimate could be low due to underreporting; in fact, one report estimated rates of 25% for both groups (Lipshires, 1994). Women who perpetrate sexual abuse of children are more likely to be related to, or in another close relationship with, the child. Most frequently, the mother is the offender, but other offenders include grandmothers, sisters, aunts, and other female caregivers, such as teachers or babysitters (Lipshires, 1994; Sanghani, 2015). Researchers suggest that although there are women who fit the criteria for pedophilia, most women are more likely to be motivated by a desire for closeness with someone (Sanghani, 2015). It is believed that women in this group want to fulfill their idealized version of a romantic relationship but choose children or adolescents because they are less threatening than adults (Lipshires, 1994; Sanghani, 2015). Finally, there are women who offend as part of a partnership, usually with a male partner, but sometimes with another female (Elliott, 1994; Sanghani, 2015).

Child and Adolescent Offenders

As with female offenders, child and adolescent offenders have been dismissed as not occurring frequently or not being harmful. However, some researchers have concluded that sibling sexual abuse is more common than any other form of incest or family violence (Morrill, 2014; Tucker et al., 2014). Five percent of perpetrators are less than 9 years old, 16% are less than 12 years old, 38% are between 12 and 14 years old, and 46% are between 15 and 17 years old (Finkelhor et al., 2009). Juvenile offenders account for almost one-third of those identified by police as having committed offenses against minors, whether inside or outside the family (Finkelhor et al., 2009; Grubin, 1998). Other characteristics of juvenile offenders that make them distinct from adult offenders are that they are more likely to offend in groups (24%, vs. 14% of adults), carry out their abuse in schools (12%, vs. 2% of adults), have younger victims (59%, vs. 39% of adults), and have more male victims (25%, vs. 13% of adults; Finkelhor et al., 2009). One other difference between child and adolescent offenders and adult offenders is that youth have lower rates of recidivism (approximately 7% to 10%, vs. up to 52% in adult offenders against minors; Association for the Treatment of Sexual Abusers, 2012; Lobanov-Rostovsky, 2015; Przybylski, 2015). The majority of youth perpetrators are male, with only 7% female (Finkelhor et al., 2009). Female offenders are more likely to be younger than males (31% less than 12 years old, vs. 14% of males). Female offenders are more likely to offend with others (36% offending with another juvenile, vs. 23% of males; 13% offending with an adult, vs. 5% of males). They were also more likely than males to have multiple victims (23%, vs. 12% of males; Finkelhor et al., 2009). Offender age ranges from 12 to 17 years old, with the peak age for incidents against younger children occurring between 12 and 14 years of age, and offenses against other teenagers beginning in mid to late adolescence, while offenses against those less than 12 years old decline (Finkelhor et al., 2009; Hunter, 1999).

Victims Who Offend

Many researchers have concluded that 50% to 80% of adult perpetrators were victims of sexual abuse themselves (Falshaw et al., 1996; Glasser et al., 2001; Tardif & Gijseghem, 2005). Some researchers even assert that it is very unlikely that any offenders have not experienced sexual trauma (Rasmussen et al., 1992). In the literature, several theories of abuse are used to explain what may lead victims to become perpetrators. The process is sometimes referred to as trauma learning (Burgess et al., 1988; Falshaw et al., 1996), a term that refers to the changes seen in behavior as a result of victimization. Trauma learning occurs when victims demonstrate behaviors that are a repetition of their trauma experiences. In these repetitions, the victim shows behaviors associated with being both a victim and a perpetrator (Falshaw et al., 1996; Tardif & Gijseghem, 2005). Social learning theory (Bandura, 1977; Burton et al., 2002; Jespersen et al., 2009) is used to explain the transition from victim to perpetrator as a process in which maladaptive behaviors are reinforced by the witnessing of them. This transition is often seen intergenerationally, when an adult family member sexually abuses a child and the child victim becomes a perpetrator against a younger sibling (Falshaw et al., 1996). The family environment can model for a child how aggressive behavior can lead to needs being met (Bandura, 1973; Falshaw et al., 1996). A similar theory, differential association-reinforcement (Akers et al., 1979), allows for the impact of family and also how interactions with reinforcing groups can aid in acquisition of antisocial behaviors.

The literature also shows one major difference in characteristics among victims who transition to perpetrators. This difference is in how the males and females react to their own abuse. Generally, males are socialized to demonstrate aggression, while females are more likely to internalize their reactions to abuse (Falshaw et al., 1996). The percentage of males who become offenders after being victimized is higher than the percentage of women who become offenders (Falshaw et al., 1996; Glasser et al., 2001). There is also some research that indicates that males who were abused by females, in particular mothers, are more likely to become offenders than those who are abused by males (Glasser et al., 2001; Thomas & Fremouw, 2009).

Types of Victimization

Sexual abuse can be categorized into primary and secondary victimization. Primary victimization includes all touching and nontouching behaviors the offender directs toward the victim. Family, friends, partners, and society inflict secondary victimization on victims.

Primary Victimization

The primary way in which children are sexually victimized is through the direct actions of offenders, including both contact and noncontact behaviors. Primary victimization also includes the grooming process offenders engage in prior to the actual abuse (Bennett & O’Donohue, 2014; Knoll, 2010; Williams et al., 2013). Grooming has been defined as “the process by which sex offenders carefully initiate and maintain sexually abusive relationships with children. Grooming is a conscious, deliberate, and carefully orchestrated approach used by the offender” (Knoll, 2010, p. 374). There is some variation between offenders in specific grooming behaviors used, but researchers have identified common goals. The goals include gaining the child’s trust and compliance, securing access to the child, and ensuring that the child keeps the abuse secret (Bennett & O’Donohue, 2014; McAlinden, 2006; Williams et al., 2013).

An offender will offer attention and friendship to gain a child’s trust and to encourage the child to confide information. To make the relationship seem more special, the offender may give gifts or take the child to the movies or an amusement park. This behavior allows the offender to get the child away from caregivers who might be protectors of the child, and allows the offender to manipulate behavior by the giving or withholding of rewards (Bennett & O’Donohue, 2014; McAlinden, 2006; Williams et al., 2013). Other behaviors the offender may use include “accidentally” touching the child in order to gauge the child’s reaction or engaging in behaviors that could be considered normal caregiving, such as giving the child a bath or a backrub (Lang & Frenzel, 1988). Some offenders try to confuse or manipulate children by blurring moral standards or by giving them misinformation about sexual behaviors (Lang & Frenzel, 1988). Force, which includes explicit and implicit threats, grabbing, pushing, slapping, punching, choking, and spanking, is also frequently used (Lang & Frenzel, 1988).

To maintain secrecy, sexual abuse predators will use the children’s desire to feel special and loved combined with their confusion and guilt. This complex combination of feelings can increase a sense of responsibility in children, which, in turn, makes them less likely to disclose the abuse (Bennett & O’Donohue, 2014; Lang & Frenzel, 1988). The literature also explores a process of grooming focused not on the child but on the environment around the child. Sometimes seeking out single mothers, offenders work to gain the trust of the whole family in order to have access to the child (Bennett & O’Donohue, 2014). Offenders also frequently demonstrate responsible and caring behavior while in public. They work to create a perception that they are kind people who like helping out with children (McAlinden, 2006).

Touching and Nontouching Behaviors

Many types of behaviors are considered abusive. Some forms of abuse, such as pornography, exhibitionism, voyeurism, and obscene interactions via phone or computer, do not involve physical contact (RAINN, 2009). More invasive forms of sexual abuse include fondling, oral-genital contact, mutual masturbation, and vaginal, anal, or object penetration (Finkelhor, 1994; Lang & Frenzel, 1988). Abuse that includes penetration tends to happen most frequently with postpubescent victims and in abusive relationships that extend over time (Finkelhor, 1994). Law enforcement tends to place more emphasis on sexual crimes involving penetration because of how the criminal code is written. However, research has shown that nonpenetrative acts can have as much of an impact on the victim as penetrative acts (Finkelhor, 1994).

Secondary Victimization

An emerging area of research in CSA is the secondary victimization that is sometimes experienced by victims after the initial trauma (Campbell & Raja, 1999; Campbell et al., 2001; Hopson, 2010; Tavkar, 2010; Williams, 1984). Secondary victimization results from negative attitudes or behaviors directed toward the victim, frequently demonstrated as victim blaming, which can result in additional stress and trauma (Campbell & Raja, 1999; Williams, 1984). Victim blaming can lead to disregard for the victim’s needs, a lack of support, and the victim’s feelings of condemnation and/or alienation (Campbell & Raja, 1999; Williams, 1984).

The sources of secondary victimization can be family, friends, partners, and community members and organizations. Secondary victimization frequently occurs when a CSA survivor discloses the abuse to someone and is met with expressions of disbelief, blame, minimization, rejection, hostility, punishment, demands for secrecy, and complacency regarding protecting the victim and preventing further abuse (Campbell et al., 2001). There is evidence suggesting that these negative social reactions are more important in determining psychological symptoms than the abuse characteristics themselves (Lange et al., 1999; Ullman, 2003). Negative parental reactions, particularly from the mother, appear to be more strongly associated with negative behavioral outcomes than other sources of secondary victimization (Browne & Finkelhor, 1986).

When victims seek services in the community, they can also experience secondary victimization. The ideal treatment model would prioritize victims’ needs and avoid victim blaming, but this model is not the norm (Campbell & Raja, 1999). Police officers and medical staff are frequently focused on their own needs, and victims are given minimal care or even denied services (Campbell & Raja, 1999). Survivors of sexual violence want to be believed and treated with kindness, respect, and understanding (Battaglia, Finley, & Liebschutz, 2003), but when law enforcement is focused on conviction and medical staff on quick, efficient treatment, the needs of the victims are not likely to be met, leaving them feeling revictimized (Campbell et al., 2001).

Cultural Considerations

Sociocultural Context

The sexual abuse of children is a common phenomenon that occurs in all families regardless of family structure, geography, race, class, gender, ability, and sexual orientation distinctions. However, scholars continue to explore the ways in which CSA is defined, perceived, experienced, disclosed, presented, reported, and responded to can be uniquely embedded in cultural norms, scripts, and values (Alaggia, 2001; Cromer & Goldsmith, 2010; Fontes & Plummer, 2010; Lestrade, Talbot, Ward, & Cort, 2013; Lowe, Pavkov, Casanova, & Wetchler, 2005; Tyagi, 2001). Noting the mixed and conflicting scholarship on the relevance of cultural context in CSA situations, Fontes and Plummer (2010) took the definitive position, based on their research and clinical experience, that “cultural values and families’ position within society impact the likelihood of disclosure and also impact the steps professionals need to take to support disclosures” (p. 496). Cultural values and norms with the potential to silence disclosure of CSA identified by Fontes and Plummer (2010) include patriarchy, sexual scripts regarding taboos and modesty, virginity, women’s status, honor, respect, and shame. They make the important and relevant observation that “children and families are influenced by the awareness that others─both within and beyond their culture and social networks─are watching, judging, encouraging, and demanding certain responses” (p. 496).

Differences in the way males and females are socialized, for example, are recognized as a factor in the expression and range of symptoms and disclosure presentations among incest victim-survivors (Gonsioreh, Berr, & LeTourneau, 1994; Sebold, 1987). Gender-based cultural stereotypes and societal norms and expectations of masculinity create challenges for male victim-survivors of incest, who may not present as dominant, powerful, and aggressive, but instead as vulnerable and passive─stereotypes attributed more to females (Dorahy & Clearwater, 2012; Gagnier & Collin-Vézina, 2016). Being a male victim in itself challenges traditional male gender norms, such as heterosexuality, emotional control, and dominance, which can conflict with feelings of shame and stigma experienced by male victim-survivors (Easton, Saltzman, & Willis, 2014), making it harder for some male victims to disclose experiences of CSA and seek help (Alaggia, 2010; Anderson, 2011). Additionally, societal myths about female offender behaviors being less harmful to victims, particularly male victims, had the effect of emotionally and psychologically emasculating and silencing some male victim-survivors of CSA (Denov, 2004; Spiegel, 2003).

Studies examining the relationship between gender norms and mental health among male survivors of CSA have also found that high conformity to traditional constructs of masculinity is associated with mental distress (Easton et al., 2014). Cultural and religious factors are identified as salient issues affecting disclosure patterns, help seeking, and expressed symptomology among culturally diverse populations (Alaggia, 2001; Clear, Vincent, & Harris, 2006; Cromer & Goldsmith; 2010; Fontes & Plummer, 2010; Ullman & Filipas, 2005).

The sociocultural context of incest, treatment, and recovery has relevance for social work practitioners and researchers. It provides a culturally specific lens for understanding incest-related dynamics associated with the connections between family, community, and culture, and child-specific demographics associated with the intersections of race, gender, class, sexual orientation, ability, and religion, for example. It is largely recognized that incest occurs in all sectors of society and cultures. However, intra- and cross-cultural factors, including structures of domination and oppression (i.e., racism, sexism, classism, heterosexism), can collide in ways that differentially shape trauma experiences, disclosure processes, help seeking, and recovery needs of specific victim-survivor groups (Alaggia, 2001; Bryant-Davis, 2005; Fontes & Plummer, 2010; Ruiz, 2016). Fontes (1995, p. xvi) reasoned that culturally tailored “interventions will be more effective than interventions that are ‘generic’ (that is, based on the lives of heterosexual, middle-class, White, European American, Christian, female clients).” Bryant-Davis (2005, p. 7) echoed a similar sentiment, asserting, “When we ignore the cultural heritage of survivors, we are being incompetent clinicians at best and discriminatory at worst.”

Empirical studies have found that cultural factors, including structural barriers associated with race, class, gender, language, and immigration status, influence patterns of disclosure and nondisclosure among culturally diverse child survivors of incest (Fontes & Plummer, 2010; Jacques-Tiura, Tkatch, Abbey, & Wegner, 2010; Valandra, 2007; Washington, 2001). For example, research has found culturally specific barriers related to the strong black woman myth (Singleton, 2003; Wilson, 1994). In addition, cultural mandates regarding racial loyalty compound disclosure considerations for African American female survivors identifying black men as sex offenders in a racially biased legal and judicial system (Bryant-Davis & Ocampo, 2005; Robinson, 2002; Rose, 2003; Tillman, Bryant-Davis, Smith, & Marks, 2010). Cultural edicts related to modesty, shame, and embarrassment were found to influence disclosure of incest in Arab cultures, as did the cultural environment of sexuality suppression among a community sample of Latina women (Fontes & Plummer, 2010; Gilligan & Akhtar, 2006). Clear, Vincent, & Harris (2006) also found ethnic differences in the presentation of incest symptomology among African American, Latina, and white incest survivors. The CSA literature continues to evolve and provides some understanding about the influence of cultural considerations on survivors’ decisions to speak out about their experiences of sexual abuse in childhood and later revictimization as adults (Tillman et al., 2010; Tyagi, 2001; Valandra, 2005).

Gender and Sexual Orientation

Another cultural factor that can strongly influence incest-related experiences is gender.

Nationally representative data of lifetime exposure to sexual violence based on nationwide random telephone surveys of adults and youth indicate that more than one-quarter of male victims of rape (27.8%) experienced the first rape when they were 10 years old or younger (Black et al., 2011). However, female victim-survivors garnered much more attention in incest literature until the 1980s (Ray, 1996). The title of Hunter’s (1990) book, Abused Boys: The Neglected Victims of Sexual Abuse, indicates the pervasive cultural misapprehension that boys are almost exclusively sexual offenders, rather than victims. On the other hand, patriarchal, sexist cultural norms have placed female children at greater risk for victimization.

Cross-cultural gender-biased myths and assumptions regarding the rarity of incest among males are influenced, in part, by stereotypical cultural norms of males as a strong protectors and females as weak and in need of protection, placing both genders differentially at risk. Culturally constructed gendered norms shape the reporting, disclosure, treatment, and recovery processes for male victim-survivors (Gonsioreh, Berr, & LeTourneau, 1994; Hunter, 1990). Empirical and clinical studies of male and female survivors of incest indicate that they are more likely to be abused by males than females (Finkelhor, 1994; Ray, 1996; Russell, 1986). These gendered dynamics in the experiences of male and female incest survivors often intersect with homophobic and heterosexist stereotypes and myths about lesbian, gay, bisexual, and transgender (LGBT) individuals and contribute to the presence of homophobic concerns among males and females (Courtois, 1988; Sebold, 1987). Additionally, cultural myths and stereotypes based in homophobia and heterosexist norms intersect with incest myths and often lead to the erroneous assumption that same-sex and opposite-sex contact in the context of sexual abuse is reflective of one’s sexual orientation, instead of a reflection of sexual abuse (Hunter, 1990).

In the final analysis, what is needed are practitioners and scholars who understand the oppression that LGBT survivors experience, are willing to learn about the cultural norms that continue to evolve in LGBT communities, and are equipped to use culturally sensitive approaches to researching, understanding, and supporting the recovery of LGBT survivors of incest (Arey, 1995; Butke, 1995).

Treatment Models and Goals

Best practices in the field of incest recovery require attention to the cultural context of trauma recovery and the use of culturally informed interventions for CSA. Conceptually, to engage in culturally informed practice with survivors, clinicians must embrace an intersectional approach to understanding survivor experiences and critically and reflectively assess how structural and interpersonal forms of oppression shape trauma and recovery across the survivor’s life span. Fontes (1995) and Bryant-Davis (2005) offer culturally specific frameworks that can be used to guide practice and self-care in supporting the recovery needs of incest survivors. What follows are some of the specific CSA assessment tools commonly used in the field. Each assessment and treatment model should be evaluated by clinicians regarding its utility and appropriateness with diverse groups and its potential to promote culturally engaged healing and recovery or to perpetuate systems of oppression in the lives of diverse cultural groups. The survivor assessment tools are organized in Table 1 for ease of readability. The commonly used assessment tools in the table are used by clinicians to identify and assess trauma exposure, and to identify sexual behaviors and psychopathology symptoms experienced by victim-survivors. Specific assessment tools are identified for children, adolescents, and adults.

Survivor Assessment Tools

Table 1. Commonly Used Survivor Assessment Tools

Author

Assessment Tool

Purpose

Freidrich et al., 1992

The Child Sexual Behavior Inventory

Identifies sexual behaviors

Briere, 1996

Trauma Symptom Checklist for Young Children (TSCYC)

Assessment of trauma-related symptoms

Briere, 2005

Trauma Symptom Checklist for Children (TSCC)

Assessment of trauma-related symptoms

Ribbe, 1996

Traumatic Events Screening Inventory for Children (TESI-C)

Measurement of trauma exposure

Fletcher, 1996

When Bad Things Happen Scale (WBTH)

Measurement of trauma exposure

National Center for Study of Corporal Punishment and Alternatives in School, 1992

My Worst Experiences Survey (MWES)

Measurement of trauma exposure

Pynoos et al., 2015

The Clinician-Administered PTSD Scale for DSM-5─Child/Adolescent Version (CAPS-CA-5)

Measures post-traumatic symptoms and severity level

Steinberg and Brymer, 2008

UCLA PTSD Reaction Index (PTSD-RI)

Assesses posttraumatic stress reactions among children and adolescents across trauma types, sex, age ranges, and cultures

Fletcher, 1996

The Parent Report of Child’s Reaction to Stress

Completed by caregiver—used to assess post-traumatic symptoms and severity level

Survivor Treatment

Several evidence-based treatment models can be used once a thorough assessment has been completed. The treatment models are organized in Table 2 for ease of readability.

Treatment models should be selected based on specific characteristics of the individual survivor, such as age, severity of symptomology, and goals of treatment. Trauma-focused cognitive behavioral therapy (TF-CBT), parent–child interaction therapy (PCIT), and trauma-focused play therapy are aimed at working with children and/or adolescents; however, each approach works differently and other individual and family characteristics, such as family involvement and cognitive ability, need to be considered before selecting a model. Cognitive processing therapy (CPT) is suggested for use with adults who are experiencing PTSD symptoms. Eye movement desensitization and reprocessing (EMDR) can be used with adults, adolescents, and children, but to be used most effectively, it requires special training for the practitioner.

Table 2. Treatment Models

Author

Treatment Models

Purpose & Target Audience

Child Welfare Information Gateway, 2012

Trauma-focused cognitive behavioral therapy (TF-CBT)

  • Psychoeducation

  • Relaxation

  • Affect regulation

  • Cognitive coping and processing

  • Trauma narrative and processing

  • In vivo exposure

Reduction of symptoms of PTSD, depression, and other negative effects of the trauma in children and their caregivers

  • Children age 3 to 18

  • Nonoffending caregivers

Saunders et al., 2004 Funderburk and Eyberg, 2011

Parent-child interaction therapy (PCIT)

Reduction of negative parent/child behavior problems and developmental issues

  • Children age 2 to 7

Saunders et al., 2004

Cognitive processing therapy (CPT),

Treatment of PTSD and PTSD-related depression

Saunders et al., 2004

Trauma-focused play therapy

Identification and validation of feelings, thoughts, and reactions

  • Children

Saunders et al., 2004

Eye movement desensitization and reprocessing (EMDR)

Reduction of PTSD symptoms

  • Children, adolescents, and adults

Offender Assessment and Treatment

Using risk-level needs assessment and knowledge about offender responsivity can be beneficial in establishing treatment type (Andrews & Bonta, 2003). Studies show that offenders of different levels of risk respond best to different types of treatment (Harkins & Beech, 2007). Interventions should address the attitudes, needs, learning style, and ability of individual offenders and take into consideration psychopathy, motivation, and locus of control (Harkins & Beech, 2007). The offender treatment models are organized in Table 3 for ease of readability.

Table 3. Offender Treatment Models

Author

Treatment Model

Purpose

Yates, 2013

Cognitive-behavioral treatment (CBT)

Challenge and alter cognitions

Yates, 2013

Relapse prevention (RP)

To identify, anticipate, and prepare for high-risk relapse situations

Yates, 2013

Thought suppression/self-regulation

  • Combined with CBT

  • Combined with distractors

Self-regulation of thoughts leading to controlled behaviors

Briken, 2012

Testosterone-lowering medication (TLM)—Age dependent

Used when there is a history of:

  • Institutional conditions

  • Treatment failure

  • Multiple victims

  • Multiple paraphilias

  • Deviant sexual interests

  • Psychiatric disorders

Sex Offender Recidivism Assessment

Research supports the use of a few tools for assessing risk of sex offender recidivism. These include the Static-99 (Hanson & Thornton, 2000), Static-2002 (Hanson, Helmus, & Thornton, 2010), MnSOST-R (Epperson et al., 2000), Risk-Matrix 2000-Sex (Kingston et al., 2008), and the SVR-29 (Boer et al., 1997). There are, however, no validated tools to establish recidivism risk for specific subsets of sex offenders, such as female offenders or child pornography offenders (Baldwin, 2015). Understanding and utilizing effective culturally informed sex offender assessment and treatment tools are effective ways to support healing and recovery that benefit offenders and also reduce risks and promote safety for children and the public generally.

Conclusion

Incest is among the numerous terms used to describe the sexual abuse of children by adults, siblings, and other children typically known to a child. Similarly, many conditions and contexts exist in which incest can occur. The variability in the ways scholars and researchers define and describe incest does not dilute the fact that the sexual abuse of children is a pervasive public health and social problem requiring a multidimensional, ecological, culturally responsive, and strength-based approach to effectively assess, intervene, and prevent. Research identifying the signs, symptoms, and effects of incest consistently and overwhelmingly recognizes CSA as a complex traumatic experience with general, nonspecific pathways to short- and long-term negative biopsychosocial outcomes for many victim-survivors and asymptomatic effects for other survivors.

Pathways of both adversity and resilience typify the experiences of many child, adolescent, and adult survivors of incest, solidifying the need for ecological and multidimensional approaches to intervention and prevention efforts. Substantial research alerts scholars to the importance of examining the interplay of a multitude of individual, intrapersonal, interpersonal, and contextual factors that intersect in ways that place children at risk for multiple forms of abuse and adversity, with implications for developing polyvictimization, multisystem, culturally responsive assessment tools and interventions. Given the broad array of variables that shape childhood experiences with, and recovery from, incest, social workers must be prepared to intervene at all levels of practice to mitigate the effects of incest across the life course and to reduce the incidence of incest.

Further Reading

Chew, J. (1998). Women survivors of childhood sexual abuse healing through group work: Beyond survival. Binghamton, NY: Haworth.Find this resource:

    Daro, D. (1988). Confronting child abuse: Research for effective program design. New York: The Free Press.Find this resource:

      De Becker, G. (1999). Protecting the gift: Keeping children and teenagers safe (and parents sane). New York: Dell.Find this resource:

        Foa, E., Hembree, E., & Rothbaum, B. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. New York: Oxford University Press.Find this resource:

          Follette, V. M., & Ruzer, J. (2006). Cognitive-behavioral therapies for trauma. New York: Guilford.Find this resource:

            Mate, G. (2011). When the body says no: Understanding the stress-disease connection. New York: Random House.Find this resource:

              Ogden, P., & Minton, K. (2008). Trauma and the body: A sensorimotor approach to psychotherapy. New York: Norton.Find this resource:

                Terr, L. C. (2011). Working with children to heal interpersonal trauma: The power of play. New York: Guilford.Find this resource:

                  Van der Kolk, B. (2015). The body keeps the score brain, mind, and body in the healing of trauma. New York: Penguin Books.Find this resource:

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