Born of rape: new legislation in the UK

 By Kieran McCartan, Ph.D., Kasia Uzieblo, Ph.D., and David S. Prescott, LICSW

In April in the UK, the media reported that children born of rape, or any form of sexual abuse, would be designated as victims of sexual abuse. This was accompanied by a BBC documentary examining the issue and the challenges involved for those children and their mothers. This designation of children born of rape is potentially a two-edged sword as on one hand it acknowledges the harm that was done to them and their mothers, but at the same time, it potentially labels, and could stigmatize them. Also, it expands the definition of “victim” in ways that could potentially dilute it and draw away from the experiences of those who experience direct victimization. This new legislation, while seeming on the surface to be more proactive and victim-centered, needs to be unpacked more.

Sexual abuse is potentially traumatizing to its victims and the people who surround them; research, policy, and practice have borne this out. The life experiences of children born due to sexual abuse is an under-researched area. Over the years, through work with those who have been victimized, individuals convicted of sexual offenses, and organizations dedicated to preventing abuse, there are anecdotes of the impact of being a child born of sexual abuse; many believe it should be recognized as Adverse Childhood Experience (ACE). The experience is often related to parental separation, growing up in a traumatized household, diminished parental mental health, and substance abuse issues as well as psychological and mental health issues brought about by the disclosure of conception.

In the BBC documentary, victims of rape who went on to have children as a direct consequence of the sexual assault talked about how it impacted them and the relationships that they had with their children, stating that they were traumatized, depressed, and anxious. The mothers felt that the fact that their child was a product of rape directly impacted their relationship with their child with some rejecting the child, others distancing themselves from them, and others being more protective; all of which was driven by the child being a constant reminder of a traumatic event in their lives that they would rather forget. As the child grew and developed, they often found out that they were born of rape, either through their mother telling them or another means (i.e., a family member or friend), resulting in shame, blame, depression, and anxiety. These children often blamed themselves for what happened. The documentary highlights the intense feelings of shame, guilty, self-blame, anger, and resentment that the mother and child feel around the conception and birth of the child. This includes what these children represented; both mothers and children hoping that they would not end up like their fathers. The documentary ends with the mothers and children reaching a common ground and being able to move forward. In many cases, however, this was after a lot of support and soul searching. The documentary finishes with a need to recognize children born of rape as such so that mothers and children could get the early intervention and ongoing support that they needed.

Another consideration is that it is not always only about the children and women who have been victims of the sexual violence. (New) partners of these women and other family members as parents also carry a great burden when faced with such consequences of sexual violence. They see the consequences and are expected to provide adequate support. But this is not always so obvious. They, too, struggle with this and experience the impact of these complex situations on their well-being and their relationships with other family members. However, this group rarely gets a voice in research and practice. We should not forget them and offer them the necessary tools to deal with this situation and support them when needed.

The creation of new legislation will hopefully identify children born of rape more readily and allow them, their mothers, and the broader family system to seek support, but what does that support look like? This is not addressed in the legislation, and additional funding is not referenced in the press release. In the documentary, participants talk about therapy, counseling, social welfare, and family systems therapy as all things that they have used in the past and found helpful; but these are all costly. While it is important to recognize the harm done to people, it is also irresponsible to expose that harm and not support those individuals in processing it. Recognizing the challenges faced by children born of rape and its impact on them, their relationships is important. While it’s important that we recognize the harm we must provide services to help and support these individuals in dealing with that recognition.

 

The key to successful outpatient juvenile treatment: Have the first appointment!

By Norbert Ralph, PhD

The adverse effects of delays in starting mental health treatment for juveniles have been discussed in the literature. Kataoka, Zhang, and Wells (2002) examined the consequences of delays in accessing psychiatric treatment for different ethnic groups and insurance status. Conn et al. (2019) noted the impact of delays for children and teens in accessing appropriate psychiatric treatment through a qualitative study. In California, a large health organization, Kaiser Permanente, was repeatedly fined for delays in treatment for adolescents, resulting in adverse outcomes (Pfeifer & Terhune, 2015). However, there is a lack of studies specifically focusing on delays in treatment for juveniles who sexually offend, including the prevalence, causes, or effects of such delays.

With no directly relevant research, this blog is based on my experiences as a county administrator and consultant for California counties. It aims to highlight the importance of making the first treatment appointment with the fewest steps, while providing positive support to the youth and their families. Delays negatively impact treatment outcomes, as treatment cannot be effective if it does not start, and delays may have toxic effects. For instance, I recently consulted on a case where, due to family moves and changes in probation officers, court-ordered treatment had not started even after a year.

Possible factors contributing to treatment delays include:

•           Absence of policies guiding the implementation of court-ordered outpatient treatment or everyday issues like probation officers being on leave or cases being transferred to new officers or units.

•           Lack of a list of qualified clinicians for probation officers, particularly in rural and urban counties.

•           Availability of prompt, efficient, and respectful acceptance of new patients by qualified clinicians on the list.

•           Collaboration between probation officers and clinicians to address potential complications related to transportation, afterschool activities, working hours of parents, or language.

•           Availability of telehealth options.

•           Payment for treatment by the county.

•           Realistic and supportive addressing of the client's concerns and motivation for treatment.

•           Lengthy litigation delaying the resolution of the issue.

This list is not exhaustive but serves as examples of potential problems.

Consequences of delayed treatment initiation include:

•           Longer time on probation due to delays.

•           Increased stress for clients, including prolonged worry, adverse effects, limitations of probation, and uncertainty.

•           Impaired development of trust and working alliance with probation and clinicians due to issues with timeliness, support, and treatment initiation efficiency.

•           Decreased client motivation for treatment with prolonged delays.

•           Delayed treatment for the underlying problem, increasing the likelihood of recidivism or further problematic sexual behaviors in youth and problematic of "enabling" family or individual belief systems.

Solutions to avoid delays involve a systems perspective, which is often overlooked. The goal is to minimize steps, reduce barriers, and increase the likelihood of successful progression. These initial contacts also shape the client's first experience with the therapeutic process. Starting off with support, collaboration, and efficiency is crucial for establishing a productive treatment alliance. Sustaining the administrative and collaborative framework behind the scenes requires focused effort.

One approach employed in several California counties is establishing an "in-house" mental health team with a coordinator to oversee and facilitate the process. Having the team located alongside probation is advantageous. Alternatively, maintaining a list of external providers who can collaborate may serve as an effective alternative or complement. Establishing policies and protocols streamlines the process, benefitting probation officers and their supervisors. Providing informative and supportive guidance to clients, akin to medical procedures, is essential for reducing anxiety. Close collaboration and problem-solving between probation officers and clinicians regarding obstacles contribute to successful outcomes. These initial administrative contacts are integral to the therapeutic process and set the tone for facilitating a working alliance with clients.

An analogy from basketball illustrates some of these issues. If someone makes free throws approximately 80% of the time, the chance of them making five in a row is 33%. However, if their success rate increases to 95%, the likelihood of making three in a row jumps to 86%. Similarly, in treatment planning, having the first appointment with the fewest steps and a high probability of success, delivered in a warm and friendly manner, enhances the chances of successful treatment.

To summarize, for outpatient juvenile treatment to be more successful, the first appointment should be scheduled promptly, supportively, and with minimal obstacles. Delays and barriers to treatment initiation are likely to decrease treatment effectiveness, increase client distress, and erode trust in the probation system.

References:

Conn, A. M., Szilagyi, P. G., Nadeem, E., Wang, H., Sterling, E. W., & Franke, T. M. (2019). The mental health system failed our child: Qualitative insights from families of children with serious emotional disturbance. Psychiatric Services, 70(10), 885-890.

 

Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among U.S. children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159(9), 1548-1555.

 

Pfeifer, S., & Terhune, C. (2015). California again slams Kaiser for delays in mental health treatment. Los Angeles Times. Retrieved from https://www.latimes.com/business/la-fi-kaiser-mental-health-20150225-story.html

 

The importance and challenge of the service user voice in sexual abuse research, policy, and practice

By Kieran McCartan, PhD

This week, I attended a workshop as part of a research project that I am working on related to evaluating trauma informed practice with young people across the Bristol, South Gloucester, and North Somerset area (Project Vanguard). For those who may not be aware, “service user” or “a person with lived experience” are the preferred terms in the UK; the most common term in the North America would probably be “client.”

The well-run event was developed by a leading UK-based child-protection charity and was led by two ex-service users who talked about their experiences of being in the child protection system and the impact that this had on them at the time as well as afterwards. The aim of the workshop was to invite professionals and researchers to hear the voices and lived experiences of service users and to think about how these influence the attendees’ daily work and the feed into the ongoing research project that the event was linked to. The research project in question, which the workshop was designed to support, focuses on young people, trauma, informed practice, and professional engagement; so not sexual abuse specifically, but it raised some consideration and challenges for the sexual abuse field. 

The UK’s increasing multi-disciplinary and cross-agency approach to understanding, preventing, and responding to sexual abuse is resulting in interesting conversations about what evidence looks like and how we conduct and implement that research. Nowhere is this approach more prominent than in the growing intersection between public health, health, and criminal justice. In many ways, health and justice agencies are miles apart, as discussed below, especially in terms of data, data collection, and outcomes. This presents an opportunity to collaborate and expand our evidence portfolio. 

Currently, there is work taking place that looks at health outcomes for criminal justice programs and interventions. This includes how health outcomes are measured and what this means in terms of prevention of offending behavior, especially in the context of a changing police and criminal justice environment (i.e., the move to preventive policing and better police training).  Among the most important, and sometimes challenging, research tools starting to be incorporated in health outcomes, the service user voice. 

Research in health care generally includes a service user or a service user panel, which is a group of people with lived experience (i.e., have the health condition in question or use the service being evaluated) to give their feedback and input about the research. Over time, this has evolved into co-production, whereby the service user or people with lived experience help to design the research together so that it is seen as fit for purpose and responsive to service user needs. Co-production has a rich history in the social sciences, especially in childhood? research. It is seen as both essential and the gold standard in health research. However, in criminal justice research this is not always the case and there are pockets of good practice regarding co-production, but these are often limited to victim’s research, young people’s research and often prison based research. 

In the field of sexual abuse research, we often research people convicted of sexual offenses, but they are not involved in the co-design of the research, they are merely the researched. This poses a question about the validity of the research design and question: are we getting to the core of issue from the person with a lived-experience perspective or are we solely basing our understanding on past evidence and researcher considerations? Our assessments of the needs of these individuals are by no means always accurate. This is illustrated in a recent article on the terms we use for persons who have sexual interests in children (Jahnke, Blagden, & Hill, 2022). This showed that the handling of person-first language received feedback worthy of consideration from minor-attracted persons, feedback that we should take into regard in our research and clinical practice.  If we want to have a solid view of the service-user perspective, then co-production is a serious consideration for our field. Of course, there are challenges, including getting access to people with lived experience who are willing and able to participate, managing risks posed by the research and those with lived experience, research ethics challenges, researcher bias, the capacity of the researcher to be swayed by the person with lived experience, and the impact of broader social contexts. 

In considering co-production, our field has started to look to people in prison, on probation, or in community treatment; however, the question remains as to whether these are always the most representative service users for co-production? After all, many are in need of treatment but have not been impacted by incarceration, treatment, and rehabilitation programs. Research has also used the internet to engage with people with lived experience who may not have been in the criminal justice system or who at risk of committing an offense; but the issue with this approach is that one is often unsure of the validity and representative of comments from generally anonymous participants. 

Currently, there is no easy answer to the debates around co-production in the field of sexual abuse, but there is a recognition that it is important and needed. This means that we should be having the conversation, that research funders should be encouraging it, and that ethics boards should be aware of it. The event that Kieran attended this week really drove home the importance of co-production not only in terms of hearing the service user voice, but also in making sure that the research tackles all the issues at stake and is fit for purpose. Co-production can be a trauma-informed way to engage in research to benefit policy and practice.

What’s the goal with treatments for Pedophilic Disorder?

By David S. Prescott, LICSW

A recent media storm focused on attempts to modernize laws relating to sexuality, including the Take Pride Act in Minnesota (https://tinyurl.com/4sm8jure). Here is the relevant text from the law. It seems to remove attraction to children as part of the definition of sexual orientation.

“Subd. 44. Sexual orientation. "Sexual orientation" means having or being perceived as having an emotional, physical, or sexual attachment to another person without regard to the sex of that person or having or being perceived as having an orientation for such attachment...”

Whatever one thinks about that definition, what was taken out of the law was:

“…or having or being perceived as having a self-image or identity not traditionally associated with one's biological maleness or femaleness. "Sexual orientation" does not include a physical or sexual attachment to children by an adult.”

Where the definition of sexual orientation once excluded a sexual attraction to children, this seems to remove that exclusion, leaving open the possibility that sexual attraction to children could be interpreted as an orientation. Multiple media outlets described this as “normalizing” pedophilia, while others said that it was nothing more than removing language. It’s no wonder media pundits get confused (especially with double-negative language involved).

The predictably polarized media coverage has led to private conversations with some professionals expressing doubts about the scope of their practice in the future. The sponsor(s) of the bill have been vocal that they don’t intend to open the door to pedophilia as an orientation, but the law is not written with our field in mind. At a time when conversion therapy continues to be reviled, is it possible that some providers may be liable for helping their clients with sexual attraction to children? In many ways, this seems completely far-fetched since treatment providers in our field typically try to help people manage their urges and have long recognized that they likely can’t change someone’s innate sexuality. In the absence of any universally agreed-upon definition of “orientation,” perhaps there is a lawsuit waiting to happen.

 On the one hand, we might argue that we are helping people who have consented to treatment manage (not change) their sexual interests and urges. On the other hand, some may argue that the mandated nature of treatment or even the social climate of treating these individuals raises questions about truly informed consent given freely. If anything, though, it seems many professionals will want to be clearer than ever on the aims of treatment.

I believe that lawsuits against professionals or agencies for practicing conversion therapy with clients who are attracted to children would be a losing endeavor under almost all circumstances. Most people can understand the difference between helping clients in treatment manage their behavior and attempting to change their innate sexual orientation. Still, lawsuits are expensive and stressful, and I respect the opinions and concerns of those in our field who want to do the work of helping people build healthier and offense-free lives.

As the saying goes, an ounce of prevention is worth a pound of cure. It might be worthwhile for professionals to revisit their policies and clarify in writing and with their clients that using treatment approaches with people with pedophilic disorders is about managing urges and behaviors and not an attempt to change the innate qualities of someone’s sexual orientation. One colleague aptly referred to treatment approaches in this area as similar to techniques others might use to manage anger. Whatever the case, ongoing attempts to clarify informed consent with clients at every turn will be vital.