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Sibling incest: An exploration of trauma, impact, and treatment

ProQuest Dissertations and Theses, 2011
Author: Maria N Panagakis
Sibling incest is the most common form of childhood sexual trauma in the United States (Brand & Alexander, 2003), with traumatic psychological, relational, and sexual sequelae. The findings of this critical literature review highlight the need for more research in this area. Studies on the exact prevalence of sibling incest in the United States were highly limited and emphasized the difficulty in obtaining statistics for this type of trauma. The variations in prevalence rates and reporting numbers were attributed to a variety of variables including the type of survey used to assess the presence of sibling incest, the precise language used to inquire about sibling incest, the gender of the participants surveyed, the setting in which participants were recruited, the types of sexual acts involved, and the age of the participants. Sibling incest was found to be a traumatic circumstance with both short-term and long-term emotional, psychological, and relational effects on the victim. These effects included low self-esteem, anxiety, depression, relationship dysfunction, sexual dissatisfaction, promiscuity, substance abuse and body image disturbances. The most widely accepted treatment for the trauma associated with sibling incest is cognitive behavioral therapy.

TABLE OF CONTENTS Abstract hi Chapter Page 1. Statement of the Problem and Search Strategies 1 Search Strategies 4 Definitions of Key Terms 4 Sexual Offender 4 Incest 5 Sibling Incest 6 Coping 7 Conclusion 8 2. Review of the Literature 10 Childhood Sexual Abuse and Gender 12 Sibling Incest and Gender 13 Dynamics of Sibling Incest 15 Factors That Facilitate Sibling Incest 23 Disclosure of Sibling Incest 25 Impact of Sibling Incest 35 Effects on Parenting 35 Effects on Social Functioning and Self Development 41 v

Chapter Page Effects on Sexual Orientation 48 Conclusion 50 3. Clinical Issues and Treatment 51 Rapport 52 Treatment 52 Spirituality 61 Conclusion 62 4. Critique and Conclusions 63 References 67 Appendix Page A: Manuscript 74 B: Curriculum Vitae 105 VI

CHAPTER 1 STATEMENT OF THE PROBLEM AND SEARCH STRATEGIES "What I want to happen is for them to say sorry to me...I will forgive them...and I would hope that the officer would say yes...now is now and then is then." These are the words of Antonio, a child who was sexually abused by two of his brothers when all three of the children were in junior high school. Despite the trauma that occurred, Antonio's family spoke about each other in loving ways; and the sibling incest, though damaging, was often placed aside by the eagerness of family members to forgive one another for mistakes that were made and the pain that was caused by these mistakes. Individual, family, and societal responses to sibling incest are complex and have lasting implications for the victim, the perpetrator, and the overarching family system (Bass, Taylor, Knudson-Martin, & Huenergardt, 2006). Victims of any form of childhood sexual abuse experience long-term difficulties including psychological, sexual, and relationship problems. While the exact rates of prevalence vary, sibling incest is the most common form of childhood sexual trauma in the United States (Brand & Alexander, 2003; Hardy, 2001). It is the purpose of this literature review to examine the research on the trauma associated with sibling incest, to consider the impact of this abuse on psychological and general functioning, and to explore the variety of clinical treatment responses and clinical issues associated with this form of trauma. 1

The term sibling incest can itself make identifying the magnitude of trauma difficult for researchers and clinicians. The term encompasses an array of behaviors including non-contact offenses, sexual maltreatment, and sexual intrusiveness (Wurtele, 2009). It can be difficult to identify sibling incest in children because it is by nature very secretive and frequently leaves no physical manifestations. The complex feelings associated with the trauma often make it very difficult to disclose (Wurtele, 2009). When sibling incest is discovered or disclosed, it can have a devastating effect on the family system; and it may be tempting to ignore the trauma rather than to report or address it. The incidence of sibling incest is higher than other forms of childhood sexual trauma, and it is more difficult to identify than other forms of childhood abuse because the taboo against sibling sexual activity is weaker than other forms of sexual behavior (Meiselman, 1981). For instance, a certain degree of sexual play among children is considered a normal part of human sexual development (Finkelhor, 1980); and it can be difficult for researchers and even parents to distinguish where normal sexual exploration among children ends and where sexual abuse or sibling incest begins. Another element that makes identifying the prevalence of sibling incest difficult is that the victims of incest can range in age from birth to adulthood. They are at varying stages of cognitive and language development and may therefore be unable to comprehend or disclose the trauma that has occurred. Because sexual abuse is a type of child maltreatment that, of course, involves sex, it can be a particularly difficult topic for society to address (Wurtele, 2009). Thus, it is thought that the cases of child sexual abuse and incest are far more prolific than prevalence rates suggest. 2

Sibling incest is a devastating trauma that can have serious physical, psychological, social, sexual, and emotional consequences. Research conducted over the past decade has shown that an array of psychological difficulties is associated with those who have been sexually abused by a sibling compared to those who have not. Emotional difficulties include depression, anxiety, and anger. Psychological difficulties include an impaired sense of self. Sexual difficulties include problems with sexuality and sexual functioning. Cognitive impairments may ensue, including lack of focus, inattention, dissociation, and poor concentration. Physical problems may include sexually transmitted diseases, urinary tract infections, or pregnancy. Interpersonal dysfunction or distress have also been noted such as low social competence, increases in aggression, an inability to trust, and a tendency to become more socially withdrawn than those who have not suffered childhood sexual trauma (Paolucci, Genuis, & Violato, 2001). Child abuse, including sibling incest, has lasting effects not only on the victim but also on the family and surrounding communities. Friesen, Woodward, Horwood, and Fergusson (2010) found that children exposed to early childhood sexual abuse reported substance abuse problems and lower self-esteem. These victims also reported higher rates of perpetrated interpersonal partner violence, early parenthood, and lower relationship satisfaction and overall investment. It is clear that child sexual abuse not only impacts the victims but also affects offenders, their families, and the communities that surround them. It is one of the aims of this literature review to explore the research regarding the impact of childhood sibling incest on victims and their families. 3

Search Strategies To locate the relevant literature, this researcher used the following data collection resources: Academic Search Premier, AHSearch, ArticleFirst, Directory of Open Access Journals, Ebrary, Encyclopedia Britannica, FirstSearch Databases, General Science Full Text, Humanities Full Text, LexisNexis Academic, NetLibrary, Oxford English Dictionary, ProQuest Databases, ProQuest Research Library, PsycARTICLES, PsycEXTRA, PsycFIRST, PsycINFO, and Social Sciences Full Text. Most of the articles were available for download in their full text form. However, one was obtained through Link+, and one was obtained through the Canyon Hills Public Library. The searches were conducted from March to June of 2008, July to December of 2009, and September to November 2010. Key words used in the searches included: coping, sexual abuse, incest, sibling relationships, sibling incest, sex offender, abuse characteristics, sexual violence, shame, sexual development, male sexual abuse, male incest, pedophilia, criminal behavior, recidivism, sex abuse prevalence, partner abuse, victimization, attachment, parental neglect, child maltreatment, parent child relations, perpetrator, and adolescent sexual behavior. Definitions of Key Terms Sexual Offender A sex offender is one who knowingly causes another person to engage in an unwanted sexual act by force, threat, or coercion (Carich, Newbauer, & Stone, 2001). Sex offenders have been categorized by type of sexual arousal and deviant behavior, motivation, personality dysfunction, frequency and chronicity of deviant patterns, social skills and social competence, age and gender of victims, age of perpetrators, and the 4

presence/type of violence employed. There are two general types of sex offenders: regressed and fixated (Carich et al., 2001). Regressed offenders are more often attracted to people within their own age categories and tend to lead relatively normal lives until middle or late adulthood at which point, the sexual transgressions begin. It is postulated that the sexual deviancy is an attempt to maladaptively cope with stressors. Fixated offenders are primarily attracted to children or, in the instance of adolescent or child sex offenders, the victim is of an age or level of psychological or emotional development that is inferior to that of the offender. These types of sex offenders begin deviant sexual activities in adolescence and normally continue throughout adulthood. Their lifestyles involve a pattern of sexually offending against children rather than employing deviant behaviors as a response to stress or to a particular environmental or situational event (Carich et al., 2001). Incest One type of sexual offender is the person who engages in incest. There are a variety of definitions for the term incest, including those with both social and legal implications (Wurtele, 2009). Many legal definitions of the term describe the degree of blood relation at which marriage is not permitted. However, marriage laws can vary from state to state. For the purposes of this dissertation, incest will be used as a social term. Sibling incest is a category of sexual acts initiated by one member of a family toward another without the other's consent, by use of force or coercion, or where there is a power differential between the family members (Shaw, Lewis, Loeb, Rosado, & Rodriguez, 2000). 5

The term family member is not limited to those individuals with kinship relationships but includes individuals who have taken on kinship roles. For example, in some households, adults have chosen to not legally marry but nonetheless occupy husband/wife roles within the family system. In many studies on family dynamics, the absence of legal marriage is common. This absence does not necessarily alter the dynamic of the system nor does it negate the fundamental order and hierarchy of domestic relationships. For instance, the legal distinction between stepfather and mother's boyfriend does not, for the purposes of this review, translate into a social- relational difference (Gordon & O'Keefe, 1984). Sibling Incest In the case of sibling incest, sexual acts are initiated by one sibling toward another. Sibling incest can involve a brother and sister, two sisters, or two brothers. It seems that brother-sister incest initiated by the brother is the most common combination (Caffaro & Conn-Caffaro, 1998). This form of sexual abuse may be more difficult to define, as the parties involved may be age-peers. Factors that distinguish developmentally normal sexual play between siblings from sibling incest include (a) the age difference between the individuals involved; (b) the types of sexual behaviors (and in particular, the presence of penetration), the frequency of the acts, the duration of the acts, and the relevance and appropriateness of the acts with respect to the child's developmental stage; (c) the motivation behind the acts (be it curiosity and exploration vs. the exploitation of one party over another or the sexual gratification of one party at the expense of the other); and, (d) the level of mutuality or the degree to which the sexual 6

activity was voluntary to each of the parties involved (Caffaro & Conn-Caffaro, 1998; Finkelhor, 1980; Wiehe & Herring, 1991). It is difficult to concretely operationalize the age difference (if any) that is required for a sexual act among siblings to constitute incest. The element of age is further confounded by gender differences and the presence of a power differential or other manipulations. For example, Russell (1986) reported that a brother close in age may effectively coerce a sister into sexual behavior due to a socially constructed role of authority, especially within the context of a traditional or patriarchal family where males are deemed to have greater power. It is possible that even a 1 -year age difference among siblings, given all of the mediating factors that are inherently present amidst familial relationships, may have enormous power implications for both siblings (Russell, 1986). For the purposes of this review, there is no minimum age difference required to define an act as constituting incest or childhood sexual abuse. Coping Coping is defined as the cognitive and behavioral efforts allocated to manage specific external and internal demands appraised as taxing or exceeding the resources of the individual (Lazarus & Folkman, 1984). The choice of coping strategies is influenced by the degree of perceived control the individual has over the situation and the degree of threat the individual perceives being posed by the stressor. Within the definition of coping are the subcategories of emotion-focused coping and problem-focused active coping. Emotion-focused coping is the attempt individuals make to regulate their emotions as a response to managing a stressor. This may be further categorized as employing strategies of either avoidance (i.e., wished the situation would go away, 7

slept/ate/drank/used drugs more), distancing (i.e., refused to think about the problem too much), self-blame, controlling one's feelings (i.e., tried to keep feelings private), or some combination of these (Lazarus & Folkman, 1984). Problem-focused active coping is divided into the behaviors of confrontation (i.e., tried to get the person responsible to change his or her behavior), seeking social support (i.e., talked to someone who thought could help), and planning how to actively respond to the environmental stressor (i.e., what next steps might be). These responses (i.e., problem-focused active coping) tend to be employed more frequently when the stressor is thought to be within the individual's control and, thus, be influenced and solved, to some degree, by the individual. Lazarus and Folkman (1984) suggested that situations that are perceived by the individual to be outside of his or her control are more likely to produce a response of emotion-focused coping. In this way, it is likely that victims of incest are more likely to employ emotion-focused coping rather than problem-focused active coping. Conclusion Sibling incest may result in long-ranging psychological, emotional, and social difficulties (Alpert, 1997; Cole, 1982; Forward & Buck, 1978; Gilbert, 1992; Loredo, 1982). There is considerably little known about sibling incest and about the specific treatment options available. The dearth of research is attributed to the sensitive nature of the subject, the difficulty of identifying victims, and the propensity of victims and families to keep the matter private and hidden. It is the purpose of this literature review to explore the available literature on the topic of sibling incest and to identify the specific areas in which more research may be helpful. This literature review will examine the 8

research on the trauma associated with sibling incest, the impact of this abuse on psychological and general functioning, and the variety of clinical and treatment issues involved. 9

CHAPTER 2 REVIEW OF THE LITERATURE Sexual trauma of any kind can have long-reaching and long-lasting implications on social and psychological functioning (Briere & Elliott, 1994). However, there are differences in the impact and trauma associated with non-familial sexual assault, such as date rape, and sexual trauma inflicted upon one family member by another (incest). In France, Darves-Bornoz, Berger, Degiovanni, Gaillard, and Lepine (1999) followed 121 victims of incestuous and non-incestuous sexual assault to note the frequencies in each group of mental disorders during the 6 months following rape and the frequencies of psychosocial impairments in personality functioning. Participants were clinically assessed using the Structured Clinical Interview for DSM-IV for Dissociative Disorders (SCID-D) and the Anxiety Disorder Interview Schedule, which was also used to assess for social phobias. Interviews were conducted using a population entering a sexual abuse treatment center found in a university hospital. Participants were assessed during their initial visit to the center and again 1 month, 3 months, and 6 months following the initial interview. The results indicated many similarities in the incest and non-incest groups. Both groups noted self-blame, desire for revenge, humiliation, nightmares, sleep disturbances, phobias, guilt, irritability, decreased daily functioning, and sexual problems. Dissociative disorders, social phobia, somatoform disorders, and low self- esteem were more prevalent in the incest group. Psychotic disorders were more common 10

in the non-incest group, but researchers hypothesized that this was a factor more associated with the elevated mean age of the non-incest group participants. The incest group also experienced more negative effects on development, especially in the realms of personality and social functioning. Researchers discovered that although any type of sexual assault may be traumatic on victims, incest has unique implications on psychosocial functioning (Darves-Bornoz et al., 1999). The limitations to this study were that only two relatively short measures were used to assess a wide array of psychological impairment, and the sample population was ethnically uniform. Therefore, results may not be generally applicable. Cyr, Wright, McDuff, and Perron (2002) sought to determine if the relationship of the perpetrator to the victim had an effect on incest impact. The participants in this study were 72 girls sexually abused by their fathers, stepfathers, or brothers. The girls were between the ages of 5 and 16 years and were separated into groups based on incest perpetrator and age of the victim. The purpose was to identify the differing characteristics of the abuse, the family environments, and the psychosocial distress of these young girls. Data was collected from the victims, their mothers, and professionals in the departments of child protective services who had been working with the victims. The participants completed measures of traumatic stress; their mothers completed the Child Behavior Checklist-Parent Report Form (CBCL) and other self-report questionnaires on family characteristics. Workers in child protective services completed information regarding the nature and severity of the abuse. Results suggested few differences in the characteristics of sexual abuse between the three groups. However, penetration was more frequent in the sibling incest group (70.8%) than in the stepfather 11

incest (27.3%) or father incest (34.8%) groups. Ninety percent of the victims of fathers and brothers manifested clinically-significant distress on at least one measure, whereas 63.6% of stepfather victims did. Compared with father and stepfather perpetrators, brothers were raised in families with more children and more alcohol abuse (Cyr et al., 2002). Some researchers believe that incest between siblings who are close in age is less harmful than other types of incest and that violence and physical coercion rarely occur in sibling incest or have fewer negative effects on the victim due to the social context within which the violence occurs. However, in the older brother-younger sister incestuous category, sisters more often report negative reactions, while brothers more often report positive reactions to the experience; therefore, much like other violent or sexual crimes, the victim views the circumstance in a much different way than the perpetrator (Cole, 1982). One of the major limitations of this study describing the harmful effects of incest is the assumption that the sisters were the victims and, therefore, viewed the events negatively, while the brothers were perceived as the perpetrators. However, men and boys can also be victims of sibling incest, and victims of any other type of sexual assault (Ray, 2001). Much of the research on sibling incest focuses on the female victims, and most studies examining the long-term consequences of abuse have focused on women. However, sexual abuse of both boys and girls is an area of concern. Childhood Sexual Abuse and Gender While most studies have focused on women, the prevalence of childhood sexual abuse in men is quite significant. An early study conducted by Finkelhor (1980) found an 8.3% prevalence rate in college men. This study surveyed 266 male college students and 12

used a self-report survey comprising descriptive sexual behaviors rather than asking participants to categorize their experiences. Finkelhor differed from Risin and Koss's (1987) study by including non-contact experiences (i.e., having the genitals of the perpetrator flashed at the victim and also defined specific age criteria). In the Finkelhor study, participants must have been under the age of 14 years at the time of the incident or incidents; and the perpetrator of the sexual act must have been at least 5 years older than the victim. If the participant was older than 14 years old at the time of the incident, then the perpetrator had to be at least 10 years older for that participant to be included (Finkelhor, 1980). Sibling Incest and Gender Sibling incest is a particularly damaging type of childhood sexual abuse. A study examining 17,337 adult HMO members in California sought to provide a comparison of the long-term effects of childhood sexual abuse (including sibling incest) by gender of the victim (Dube et al., 2005). The study aimed to identify current trends in prevalence, provide perspective on the need for future research, discuss prevention activities, and explore effective treatment options for survivors. The participants completed a survey about abuse and dysfunction in their childhood households. They also answered survey questions about other health-related and lifestyle issues. The researchers then statistically controlled exposure to other forms of negative childhood experiences that commonly co- occur with sexual abuse. They completed a multivariate logistic regression analysis to examine the relationship between the severity of the incest based on dimensions such as the presence or absence of intercourse and the long-term health and social problems suffered by the participants. These problems included substance abuse, mental illness, or 13

marriage and family discord. The results were then categorized based on the gender of the victim. For male victims, the relationships between the gender of the incest perpetrator and the outcome variables were also analyzed (Dube et al., 2005). Dube et al.'s (2005) survey indicated that the prevalence of sibling incest among participants was 16% of all males surveyed and 25% of all females. Of the men who reported being sexually abused, participants indicated that 40% of the incidents of incest involved female perpetrators. Of the women who described being sexually abused, 6% indicated the involvement of female perpetrators. The participants who reported a history of childhood sibling incest were significantly more likely to report detrimental mental health outcomes as well. For instance, a history of suicide attempts was twice as likely among both men and women who experienced childhood incest. Also, the victims of childhood sibling incest had a 40% higher probability of marrying an alcoholic when compared with those who did not have a sexual abuse history. The incest victims were more likely to report current marital discord or discontent (Dube et al., 2005). Dube et al. (2005) had several significant findings on the negative effects of childhood incest on later adult mental health functioning. These results are discussed in greater detail in the following sections. However, it is relevant to discuss the gender rates found in this survey of 17,337 adults. Male victims comprised 16%> of the total survey population. This figure is thought to be somewhat underestimated given factors such as the mental and social stigma perceived by men when reporting sexual victimization, the incidence of forgotten or repressed traumatic memories, and issues related to the self- report survey method. However, the risk of negative outcomes for adult male victims of sibling incest was similar when the genders of the perpetrator and the victim were 14

controlled. Although prior reports suggested that male victims of childhood sexual abuse and, more specifically, sibling incest are rare compared to the reported female victims, this study indicated that male victimization is common among the population studied and is also associated with negative mental health and psychosocial outcomes in later life (Dube et al., 2005). Studies estimating the rates of male victims of childhood sibling incest ranged from 4.8% to 10%. The prevalence of male victims of sibling incest varies partially based on the sample population and survey method. For example, a study of male college students conducted by Fritz, Stroll, and Wagner (1981) in which 412 participants were given a self-report questionnaire and asked to report incidents of abusive sexual experiences in childhood reported incest at the lower end of the prevalence spectrum. Fritz et al. found rates to be 4.8% of the surveyed population. Researchers suspect that participants were reluctant to view or to label their experiences as abusive. In another survey of male college students, a national sample of 2,972 participants was given eight self-report behavioral descriptions of sexual behaviors that they witnessed or experienced within their families of origin before the age of 14 years (Risin & Koss, 1987). The surveys attempted to simply describe, in an objective format, the behaviors rather than to label them as abusive or traumatic. Risin and Koss found a prevalence rate of 7.8%. This is almost twice the rate of the Fritz et al. survey in which the sexual behaviors were categorized as abusive. Dynamics of Sibling Incest Sibling incest is widely accepted by researchers and clinicians as being the most common type of incest, having an even higher prevalence than adult-to-child incest 15

(Carlson, Maciol, & Schneider, 2006). Sibling incest can include a variety of sexual behaviors. The frequency of these acts can vary. Studies based on agency records estimate frequencies of reported sibling sexual behavior to include fondling (25%-100%), genital contact (19-94%), vaginal intercourse or attempted vaginal intercourse (12.5- 53%), oral sex (53%), and anal intercourse (6.2%). In one study, 71% of the sibling incest cases involved intercourse (Cyr et al., 2002). Perhaps one of the most important factors in the subject of sibling incest is the issue of consent. Sexual acts upon which both parties have agreed are less likely to be defined as incest than are behaviors that are forced on one sibling by another (Carlson et al., 2006). Some studies require coercion or physical force to be involved in the sexual act for the case to be considered incest. This may require threats of violence, bribery, intimidation, physical aggression, or other forms of coercion. However, these types of force were only found in 9% of the reported cases of sibling incest (Cyr et al., 2002). According to Cyr et al., a common scenario of sibling incest begins as mutually agreed upon sexual behaviors; the degree to which both parties consent may change over time until one individual (now labeled the victim) is no longer a willing participant in the sexual acts. This scenario, in which siblings consent to the engaging of sexual behavior, may be seen in the context of a dysfunctional family categorized by parental neglect. The sexual activity begins as a way for the siblings to express and receive nurturance and affection that are unavailable from the parental figures or as a way for the children to cope with family stress and unmet emotional needs (Carlson et al., 2006). These acts are 16

categorized as sibling incest because eventually, one of the parties involved is not able to or no longer chooses to consent in the sexual acts; and the behaviors become coercive. The age of the parties involved is often a large factor in distinguishing incest from developmentally appropriate sexual play; yet, it is a factor that is difficult to definitively describe. Several authors have attempted to operationally define an age difference of 2 to 5 years as necessary to categorize sibling-to-sibling sexual acts as incest (Gilbert, 1992). A study of 100 individuals who reported experiences of sibling incest found that the earliest memories of the abuse were reported as having occurred when the victim was between the ages of 5 and 7 years. In this study, the perpetrator was averaged in age to be 3 to 10 years older than the victim or between the ages of 8 and 17 years (Wiehe & Herring, 1991). Another study stated the average age difference between the victim and the perpetrator to be 7 years but found that 40% of the cases of brother-sister incest involved less than a 5-year age difference. In yet another study, almost one-third of victims were below the age of 10 years, and just over half were between the ages of 10 and 13 years (Russell, 1986). A more recent study estimated that the average age difference between the victim sibling and the perpetrating sibling was 5.3 years (Cyr et al, 2002). The dynamics of sibling incest are not well understood due to limitations in the amount and variety of research available in the field about the subject. Carlson et al. (2006) explored the dynamics and rates of sibling incest in a population of adults. They used a retrospective survey design on a convenience sample of 41 adults. Of this sample, 35 (82.9%) were women and 8 (17.1%) were men. The mean age of the respondents was 38.5 years. Most of the sample were Caucasian individuals. Ninety percent of the sample 17

Full document contains 114 pages
Abstract: Sibling incest is the most common form of childhood sexual trauma in the United States (Brand & Alexander, 2003), with traumatic psychological, relational, and sexual sequelae. The findings of this critical literature review highlight the need for more research in this area. Studies on the exact prevalence of sibling incest in the United States were highly limited and emphasized the difficulty in obtaining statistics for this type of trauma. The variations in prevalence rates and reporting numbers were attributed to a variety of variables including the type of survey used to assess the presence of sibling incest, the precise language used to inquire about sibling incest, the gender of the participants surveyed, the setting in which participants were recruited, the types of sexual acts involved, and the age of the participants. Sibling incest was found to be a traumatic circumstance with both short-term and long-term emotional, psychological, and relational effects on the victim. These effects included low self-esteem, anxiety, depression, relationship dysfunction, sexual dissatisfaction, promiscuity, substance abuse and body image disturbances. The most widely accepted treatment for the trauma associated with sibling incest is cognitive behavioral therapy.