Speaking about the unthinkable

For almost a decade I have researched and worked with sexual harm, with child and adult victims of sexual abuse and those who have engaged in sexual harm towards others. This has included working within and alongside charities, public health services, governmental departments and initiatives. And yet, I continue to be struck by how we, as professionals and as a society, struggle to engage with this topic.

I am passionate about supporting and safeguarding current victims and working preventatively to protect potential future victims of child sexual abuse. I am a trainee clinical psychologist, at the University of Surrey and Surrey and Borders NHS Trust. My roles to date have involved direct clinical work, consultation, training, as well as supporting domestic and international research and practice-based policy changes within charity and governmental initiatives. 

There are a multitude of factors which mean we often don't attend to issues relating to child sexual abuse in the way we do with other presentations, such as other aspects of risk or mental health experiences. With the scenarios below, I aim to highlight some of those often seen in clinical practice. Let me talk you through a couple I've seen. Although fictional the scenarios are based on real clinical cases. 

Cases to consider

Imagine you're sitting in a multi-disciplinary meeting reviewing new referrals and you read a referral relating to a young boy (CS, aged 5). Try to read it as you genuinely would in a meeting, and not be swayed by the topic of this article. 

CS is reported to have sexually touched a peer. The referral says CS has previously made repeated false allegations of sexual and physical abuse by his father. The referral says these allegations are being manufactured and coached to CS and his sibling by their mother, due to parental conflict. 

What are your initial thoughts? How would you talk about this case with a colleague?

Okay, what about this version:

Again, you're sitting in a multi-disciplinary meeting reviewing new referrals and you read a referral which also relates to a 5-year-old boy (CS) who is reported to have sexually touched a peer. 

CS has several ongoing physical health concerns, including sudden onset of bedwetting, persistent tummy ache, fear and avoidance of spending time with his father and uncle. Significantly, CS has made repeated, consistent and detailed disclosures of sexual, physical and emotional abuse by his father, of him and his sister. The way they have communicated these makes it unlikely these are false. CS has also engaged in numerous incidents of harmful sexual behaviour towards peers and shown some coercive behaviours to prevent disclosure by the victims. Additionally, CS's mother experienced domestic abuse by CS's father, including physical, emotional and financial abuse. Reports of maternal 'coaching' of the children are by CS's father and his legal team.

Whilst you're considering these different referrals it might be helpful to consider what various statistics tell us about child sexual abuse:

For example, reports from the Centre of Expertise on Child Sexual abuse predict around 500,000 children in the UK are sexually abused every year. 1,370 children per day. Additionally, false allegations of sexual abuse are very rare (London et al., 2008; O'Donohue et al., 2018). 

Additionally, it is not developmentally typical for a child to possess the level of knowledge about sex and sexual behaviours necessary to make false disclosures as detailed as those provided by CS and their sibling, suggesting this knowledge is likely to have been gained through exposure to and/or experience of these sexual behaviours. This is especially consistent when the child-like interpretation of their disclosures of sexual abuse are considered, for example when the abuse is described using child-like terminology or understanding. 

The referrals are based on the same fictional case. You'll notice the second referral provides much more information; I wonder if you had a different opinion reading the second referral to the first? What do you notice about how the information is presented in each one? What we know is that there continue to be significant difficulties in identifying and responding to sexual abuse. The above scenarios highlight some of these. 

You may have noticed that you were less curious about potential sexual abuse, and the role this might have played in the harmful sexual behaviours showed by CS, after the first scenario. This is likely due to something called 'confirmation bias'. This is a form of bias whereby we tend to attend to information which fits an existing hypothesis (in this case, the 'coaching' by mum) than consider alternative hypotheses. This is particularly the case when this understanding is presented by fellow professionals, especially if we feel less knowledgeable or confident in this area. 

It is also important to consider how our emotional response can impact our interpretation of this information. Both scenarios are understandably upsetting, but which one is more so? I imagine it's the one where two children have repeatedly been unsafe, experienced significant trauma from those who should keep them safe, as well as been exposed to domestic abuse. It is understandably incredibly difficult to 'sit with' the details of the second scenario, and this commonly leads to a form of cognitive avoidance where we are biased to the version of events which feels less distressing. These are just a few of the factors we are noticing in research, that are having a key role in impacting how we respond to child sexual abuse.

My research

As part of my training, I am researching child sexual abuse. Whilst it's an incredibly challenging and emotive topic to discuss and think about, it's important not to shy away from it. 

In one of these projects, I review what we know about the ways in which children communicate their experiences of sexual abuse. One of the difficulties we face in identifying and responding to child sexual abuse is that we rely on children to 'disclose', to verbally tell us, that they are being abused. Unfortunately, although the case described above is an exception, this just doesn't map on to what happens in real life. Children are much more likely to show us through their behaviour, by showing distress or even sexualised behaviours which are developmentally inappropriate. 

My second project explores what factors colleagues working in social care identify as impacting safeguarding decision making. This research is ongoing, but the preliminary results highlight that professionals agree that the taboo around the discussion of sex and sexual abuse amongst professionals frequently impedes how we make best practice safeguarding decisions. Yet this is also a factor professionals identify as having most control to change. 

Given how difficult and emotive the topic of child sexual abuse is, it is understandably one we don't want to think about. Unfortunately by treating this as a 'taboo' we continue to perpetuate a context where child sexual abuse is less spoken about, identified less – thereby impeding how well we can recognise and stop children experiencing sexual harm, provide the appropriate response for perpetrators of sexual abuse, as well as the support victims receive. 

You would be forgiven for thinking 'okay, so if I know that we avoid this topic I can make an effort to consider it'. Sadly, cognitive psychology research suggests that even when we are aware of biases of this nature we don't seem to respond very differently. In fact sometimes it can perpetuate the issue because we feel reassured that we are aware of our biases. 

So, what can we do?

Generally, people who go into working with children have the best intentions, genuinely want to support children and adults, and prevent harm. It's distressing for them to think there might be times when a child is experiencing harm that they aren't aware of or don't effectively safeguard, so we know we're not lacking in motivation to keep children safe. Here, then, are some practical tips.

Address the taboo 

Be the voice to change the taboo around sexual abuse. Be curious about how sex, sexual relationships, sexual abuse is being talked about where you work. If you're in a CAMHS team for example, are the children under the service regularly asked about their experiences of sexual touch, whether these have ever felt scary or confusing? Are there any imbalances of power which haven't been considered, such as characteristics which might make the child more vulnerable to risky adults or other young people, e.g. cognitive abilities, physical size, financial power? Don't underestimate the impact breaking down the taboo around sexual abuse can have. 

Check your thresholds

Research has also highlighted how our approach to concerns about child sexual abuse can be impacted by over-relying on a criminal justice lens, rather than a safeguarding lens. Safeguarding practice guidelines require us to consider whether 'on the balance of probabilities' a child is experiencing harm. Meaning when considering information which makes us concerned a child is being abused, we should ask 'is it more likely than not that this is happening?'. This is a very different threshold to that seen in evidential and criminal justice arenas where information is considered 'beyond a reasonable doubt', and so safeguarding professionals may need to take action where our Police colleagues are allocating the case 'No further action' or 'Insufficient evidence'. The lack of a criminal justice outcome is not the equivalent of the abuse having not taken place. Don't underestimate how powerful it is being the person who believes them. 

What if I compromise evidence?

Another common anxiety is worrying about compromising evidence by speaking to a child about their experiences or taking safeguarding action before Police have concluded their investigation. Whilst in ideal circumstances safeguarding and criminal justice response work in parallel to one another, with a positive symbiotic relationship of information sharing, unfortunately the rates of successful convictions in all cases of sexual harm are extremely low. This means if you are working with a child who is/has experienced sexual abuse, it is already exceedingly unlikely there will be a successful criminal justice outcome. Therefore, changing your safeguarding or therapeutic approach is unlikely to increase the chances of a conviction but may make a very real difference to that child's experience of safety and/or processing of what has happened to them. You might be the only person who has ever given the space for this, and if you are working with this person as a child, you can have a vital role in helping them develop some kind of narrative about what happened to them, that is wasn't their fault and there are safe people out there. 

Be curious

If you haven't already, I would encourage you to listen to Steven Barlett's The Diary of a CEO podcast with Game of Thrones star Maisie Williams. Whilst there are some challenges with the way the podcast approaches discussions of trauma, in the podcast Maisie talks about how she was doing her best to leave red flags for those around her to pick up. Sadly, despite having people who loved her it took a while for someone to ask her directly what she was experiencing. This meant she continued to experience harm.

For me, Maisie's account was such a powerful and emotive capturing of what I have seen in practice – children doing their best to tell us in a variety of ways they aren't okay, both intentionally and unintentionally, but because we're waiting for an eloquent verbal narrative about their experiences, we can miss these cues. Or sometimes, these signs might worry us but the anxiety of 'getting it wrong' is too big and so we wait for some form of 'confirmation'. 

It can also be helpful to reflect on the message we are giving children by staying silent about these topics. If a safe and trusted adult can't name this and the dominant narrative is silence, what does this teach children? There is such importance in using our position of power as adults and clinicians to name the unspoken, this may help a child feel more able to disclose their experiences or provide a sense of safety which is key for them later on. We have nothing to lose by asking a child directly, but that child may have everything to gain from being asked – even if they don't know how to respond yet. 

What if I'm right?

These are just a few things you could think about, do differently, notice within whichever setting you are or will be in. It's an undeniably distressing topic to think about, but if we continue to not talk about it, let it be the elephant in the room, we continue to teach children that it's too awful to think about.

Something a valued colleague often says to the young people we work with is 'There is nothing so big, or so awful, we can't talk about it'. So, ask the questions and don't think 'What if I am wrong?'. Think 'What if I'm right?'.