Best practice guidelines for health service professionals who receive initial disclosures of sibling sexual abuse

Abstract

Sibling sexual abuse is one of the more common forms of child abuse and involves a number of unique complexities. A gap in the literature exists with regards to the appropriate response to an initial disclosure of sibling sexual abuse and the values underlying such a response. This article employs a power and control analysis to consider the definition, prevalence and outcome of such abuse and presents best practice guidelines for health care professionals. The guidelines aim to promote ethical and respectful responses to disclosures of sibling sexual abuse. They reflect an explicit value stance, detailing appropriate responses to disclosure including interagency collaboration, parental notification and consideration of the special status of the abuser as a young person.

Keywords:

• incest
• sexual abuse
• disclosure
• intrafamilial
• sibling

Introduction

Sibling sexual abuse (SSA) is one of the more common forms of child sexual abuse (Lindzey 1967; Canavan et al. 1992); however, it has received relatively little attention in the broader child abuse literature. Most research on intrafamilial abuse focuses on father-daughter abuse (Laviola 1992), possibly reflecting a belief that SSA is less damaging than other forms of child sexual abuse, or the difficulty involved when dealing with a young abuser (Canavan et al. 1992).

While there exists a body of literature addressing the appropriate verbal response for health professionals who receive a disclosure of sexual abuse from a young person, there is little information addressing the specific complexities of SSA, providing a weak empirical base for professional practice (Rayment-McHugh & Nisbet 2003). This review will provide an overview of SSA including prevalence rates, a clear definition, and the outcomes of such abuse. It will explore a power and control analysis of the dynamics and characteristics of SSA, finishing with suggestions for best practice guidelines for health care workers who receive disclosures, including an appropriate and explicit value stance underpinning immediate responses and interventions, details regarding the most appropriate response to disclosure including parental notification and interagency collaboration, and consideration of the special status of the abuser as a young person.

Prevalence of sibling sexual abuse

Sadly, sexual abuse is a relatively common experience for children and adolescents in New Zealand. Reported prevalence rates vary, with sexual abuse thought to be widely underreported (Finkelhor 1980; Wiehe 1997; London et al. 2005; Smallbone 2006). Due to underreporting, prevalence rates may more accurately represent conservative estimates. Fleming and colleagues (Fleming et al. 2007) found that disclosure was rare, with only 10% of males and 18% of females reporting unwanted sexual contact, most to friends rather than parents or teachers (in the following report, the term ‘parents’ is inclusive of all primary caregivers). A study of women in Dunedin and provincial Otago areas (Anderson et al. 1993) found that disclosure was made within one year following sexual abuse by only 37% of victims. The Otago Women's Health Survey (Martin et al. 1991) found that 26% of women reported experiencing sexual abuse before the age of 16, with another 7% reporting non-contact incidents. Of these women, only 40% disclosed the abuse at the time it occurred. New Zealand studies have estimated that 3–6% of males and 17–30% of females have experienced childhood sexual abuse (Fergusson et al. 1996; Fergusson et al. 2000) while Fleming and colleagues (2007) reported rates of 26% and 14% respectively for female and male secondary school students. A retrospective study of child sexual abuse among New Zealand women found rates of 23.5% for women in Auckland and 28.2% in Waikato, reporting that Māori women were approximately twice as likely to have been sexually abused (Fanslow et al. 2007). Anderson and colleagues (1993) found that 32% of women surveyed had experienced unwanted sexual experiences before the age of 16. The discrepancy between reported rates of child sexual abuse and the number of confirmed cases lends further support to the assertion that this type of abuse is widely underreported. Child, Youth and Family (CYF) confirmed 1171 cases in 2010 (Ministry of Social Development 2011a)—a low figure given that there were an estimated 894,400 people aged 14 years and under in New Zealand in 2010 (Statistics New Zealand 2010). Between 85% (Fanslow et al. 2007) and 94.9% of abusers are male (McGregor 2003) and are frequently related to the victim (Anderson et al. 1993; New Zealand Children and Young Persons Service 1996; McGregor 2003).

Establishing a firm prevalence rate for SSA specifically is difficult, with estimates often based on child protection agency reports (Canavan et al. 1992). Despite this difficulty, some researchers suggest that it may be the most common type of childhood sexual abuse (Lindzey 1967; Canavan et al. 1992; Rayment-McHugh & Nisbet 2003) with rates spanning from 23% of female incest survivors (Rudd & Herzberger 1999) to 60% of the psychiatric outpatients reporting incestuous histories (Bess & Janssen 1982). A survey of a New Zealand community sample of women (Anderson et al. 1993) found that brothers were more frequently the perpetrators of sexual abuse than biological fathers or step-fathers. McGregor (2003) found that brothers accounted for 12% of offenders, the second largest group of intrafamilial sexual abusers after fathers. Fanslow and colleagues (Fanslow et al. 2007) found that among male abusers, uncles were most likely to be reported, followed by siblings or step-siblings who represented 14% of cases.

Definitions of sibling sexual abuse

There is no statutory definition of child sex abuse in New Zealand; however, particular acts are prohibited under the Crimes Act 1961 (Dyhrberg 2002) including sexual connection between siblings or half-siblings, and sexual conduct with children under the age of 16 (New Zealand Government 1961). Caffaro and Conn-Caffaro (1998) define traumatic sibling incest as sexual behaviour between siblings that is inappropriate for their age or developmental stage, not transitory, and not motivated by developmentally normative childhood curiosity. SSA involves a range of behaviours from non-contact abuse such as indecent exposure and forcing siblings to watch pornography to contact abuses such as physical touching and rape (Haskins 2003). Canavan et al. (1992, p. 129) define incest as ‘sexually oriented physical contact between family members which must be kept secret’. Although sexual curiosity and exploration is a normal aspect of development (Rayment & Owen 1999; McVeigh 2003) it is clearly differentiated from abusive sexual behaviour. SSA is traumatic (Haskins 2003), non-consensual or unwanted (Carlson et al. 2006), and involves coercion or force (Haskins 2003) that is a manifestation of power and control over a weaker sibling (New Zealand Children and Young Persons Service 1996; Carlson et al. 2006; Child Welfare Information Gateway, 2006).

Outcomes of sibling sexual abuse

SSA is associated with many negative outcomes including feelings of shame and guilt (Kiselica & Morrill-Richards 2007), depression, eating disorders, substance abuse (Rudd & Herzberger 1999), low self-esteem, feelings of worthlessness, distorted views of sex, suicidality (American Academy of Child and Adolescent Psychiatry 2011a), externalising problems including sexualised behaviour, aggression, antisocial behaviour, and hyperactivity (Mortimer et al. 2006), trauma symptoms including post traumatic stress disorder and dissociative disorders (Welfare 2008), developmental disruptions, and numerous diagnosable mental disorders (Phillips-Green 2002). Many of these issues persist into adulthood (Pechtel et al. 2005; Wilson 2010) and disrupt interpersonal relations (Welfare 2008) with symptoms including mistrust, sexual response difficulties and intrusive memories of the abuse (Laviola 1992; Phillips-Green 2000).

The wide range of negative outcomes may be partly attributable to the unique features of SSA, above and beyond the effect of the abuse itself. Worse outcomes for sexual abuse generally occur when the abuse involves a longer duration, a perpetrator known to the young person, and penetrative acts (Rowntree 2007). SSA often meets all these criteria (McVeigh 2003). O'Brien (1991) found that sibling perpetrators admitted to more sexual offending including more intrusive acts over a longer period than non-familial sex offenders and adolescent sex offenders who victimised people the same age or older. Cyr and colleagues (Cyr et al. 2002) noted that penetration was more frequent among sibling abusers—reported in 70.8% of cases—than abusing fathers or step-fathers (34.8% and 27.3% respectively). The duration of the abuse, the use of force and the negative outcomes for women sexually abused by their brothers are equally or more severe than those for women abused by their fathers (Laviola 1992; Rudd & Herzberger 1999). The increased severity of SSA may reflect greater victim access and the high levels of secrecy, guilt, shame and self-blame that accompany the experience of victimisation (O'Brien 1991; Laviola 1992; Wiehe 1997).

A power and control analysis of sibling sexual abuse

A power and control analysis can be used to understand how abuse occurs within relationships in which power differentials are operating. Power and control analyses have been more commonly applied to intimate partner violence (Yllö 2005; Gage & Hutchinson 2006; Hann 2007; Kelly & Johnson 2008) and are based on a feminist model that positions ‘unfair hierarchies of value’ (Brown 2004, p. 465) and inequalities in power and authority as central to the occurrence of abuse (Brickman 1984). A feminist perspective of incest centres around gender oppression and gender roles that serve to privilege males over females (Dominelli 1989; Thompson 2009). Within both intimate partnerships and sibling relationships, inequitable power and control both underpins and is maintained by abuse with acts of abuse used intentionally by the more powerful person in the relationship to dominate the less powerful person (Russell 1986). Because ‘the feminist model depicts incest as occurring between an active, resistant but powerless victim and a powerful, intrusive, self-serving offender’ (Brickman 1984, p. 66), it is appropriate to extend a power and control analysis to SSA. Sibling relationships frequently involve clear power imbalances based on gender and birth order (Russell 1986; Caffaro & Conn-Caffaro 1998;), with SSA occurring within the dynamics of this power relationship (Brickman 1984; Russell 1986).

The myths associated with SSA mark a point of difference from other forms of child sexual abuse. A lack of clarity may be experienced around issues of consent, responsibility and participation due to myths such as the normalisation of sexual abuse as harmless exploratory behaviour; an assumption of mutuality and willing participation; and the belief that a specific age difference is necessary for abuse to occur. A power and control analysis is important to dispel the myths surrounding SSA, firmly positioning it in the realm of abuse rather than normal exploratory behaviour, and guiding professionals to respond in an appropriate and sensitive manner.

As generational boundaries are not crossed, and there is generally a smaller age difference between siblings than between an adult perpetrator and a child victim, confusion can arise regarding whether SSA is indeed abuse (Canavan et al. 1992; Ballantine 2012). As the individuals involved are either children or youths, abusive behaviour may be inaccurately perceived as benign exploratory sexual behaviour (Ballantine 2012); however, within a power and control analysis SSA does constitute a form of child sexual abuse. SSA involves the misuse of power and control by one person to exploit another person for sexual gratification (Dyhrberg 2002) and enforce secrecy surrounding the abuse (Phillips-Green 2002). This definition focuses on the experience and perception of the victim regardless of chronological age.

SSA often involves the use of coercion, force and threat to create and maintain secrecy around the abuse (DeJong 1989; James & MacKinnon 1990; Canavan et al. 1992; Laviola 1992; Adler & Schutz 1995; Rudd & Herzberger 1999; Hardy 2001; Carlson et al. 2006; Ballantine 2012), the use of which precludes genuine consent being given by the victim. A greater level of verbal threat and physical force is employed by brothers who sexually abuse their sisters compared to other intrafamilial abusers (Adler & Schutz 1995; Rudd & Herzberger 1999), with some girls reluctant to fight back against physical force due to the fear of further physical abuse (Laviola 1992). Furthermore, victims may erroneously believe that they were willing participants (Canavan et al. 1992) or that they could have stopped the abuse (Wiehe 1997; Caffaro & Conn-Caffaro 1998). This is supported by Hardy (2001) who found that victims of SSA were more likely to view the behaviour as abusive when they were adults than at the time the abuse occurred, possibly reflecting a lack of knowledge about appropriate sibling relationships during childhood.

An awareness of the fundamental importance of power and control to SSA allows practitioners to recognise the vulnerability of children disclosing abuse, who are most likely to be younger than their abusers (Hardy 2001; McVeigh 2003) and female (DeJong 1989; Hardy 2001; Carlson et al. 2006). Russell (1986) suggested that a lack of awareness regarding the power differentials posed by gender may contribute to the perception that SSA is less serious than other forms of child abuse and contribute to an assumption of mutuality. An analysis of power inequality dispels this particular myth. Wiehe (1997) suggested that the differential socialisation of males and females may contribute to the belief that females should submit to superior males and that this belief underpins the abuse of power and control characteristic of SSA. Families in which child sexual abuse occurs frequently ascribe to patriarchal values (Haskins 2003). This view of the relative positions of males and females provides males with a greater degree of power in both the family and societal context (Cole 1982; Canavan et al. 1992). A patriarchal nuclear family structure places females in a subordinate position, creating an environment that enables abuse to occur (James & McKinnon 1990; Laviola 1992; Caffaro & Conn-Caffaro 1998) and reduces the likelihood of reporting for all types of sexual abuse (Alaggia & Kirshenbaum 2005). A female youth may be vulnerable to SSA by a same age or even a somewhat younger sibling in a family in which male needs and desires are given primacy and isolation is experienced (James & MacKinnon 1990; Conn-Caffaro & Caffaro 1993).

While some authors propose that sexual behaviour between siblings is abusive when it is unwanted, exploitative or involves a specified age difference (Finkelhor 1980; Russell 1986), others assert that sexual contact between a same age or older brother and his sister is always abusive due to the greater power given to males in society, suggesting that female gender constitutes a greater vulnerability than age (Cole 1982; Brickman 1984), and that power inequalities reduce the possibility of mutual consent (Cole 1982; Canavan et al. 1992). Laviola (1992) noted that half of the women interviewed were abused by brothers less than five years older than them and, as Russell (1986) explained, even an age difference of one year can have significant power implications. Other authors propose that sexual activity between siblings may be an aspect of normative development within certain limits (Russell 1986; Canavan et al. 1992). A succinct summary of the literature supporting this position was provided by Canavan and colleagues (1992, p. 131) who wrote ‘prevailing notions suggest that if the experience occurs between young age-mates, if there is no betrayal of trust between the children, if it is a result of natural curiosity and experimentation, and if children are not traumatised by disapproving adults who discover their activity’ then sexual behaviour between siblings may be considered part of normal development.

It is important that professionals consider SSA within the framework of a power and control analysis to raise awareness of the power and control they hold as recipients of a disclosure of SSA. As with adult survivors of sexual abuse, children may experience feelings of guilt, embarrassment, shame, self-blame or concern about their disclosure being believed; additional stressors which render them particularly vulnerable to inappropriate practice (Kambouridis & Flanagan 2003; McGregor et al. 2010). Survivors of SSA frequently experience emotional conflict when considering whether to disclose the abuse (Wiehe 1997), fearing negative reactions including punishment, blame, misunderstanding and family breakdown (Canavan et al. 1992; Laviola 1992; Grant et al. 2006;). Kelley (1990) emphasised that the negative long-term effects of child sexual abuse may be intensified by strongly negative reactions from adults following disclosure.

Important values

Health service professionals receiving disclosures of SSA are faced with additional complexities compared to disclosures of sexual abuse by adult perpetrators, including the special status of the abuser as a young person, the response of the children's parents and the impact of both these factors on the safety of the victim. Ethical navigation of these complexities requires a clear value stance on which to base immediate and subsequent responses and actions following the disclosure. Important values include an understanding that SSA is different to normative exploratory behaviour, is never the fault of the victim, involves acts that are always inappropriate, constitutes a betrayal of trust, and that maintaining the safety and integrity of the victim is paramount. These values are informed by the power and control analysis discussed, recognising the frequent use of force, threat and coercion during SSA and the power imbalances between siblings due to age and gender that allow one sibling to abuse another.

SSA is a different experience to the normative curiosity and exploratory behaviour that is a normal part of childhood. Developmentally appropriate sexual behaviour typically involves children of a similar age, is unlikely to involve penetration, is motivated by curiosity rather than a desire for gratification or exploitation, and is transient and mutual (Carlson et al. 2006). This is in contrast to SSA, which is generally more intrusive and of a longer duration as previously mentioned (O'Brien 1991; Rudd & Herzberger 1999), involving an abusive condition such as an age differential or coercion that diminishes the ability to give consent (Carlson et al. 2006). Furthermore, non-abusive childhood interactions are not usually experienced as aversive. SSA is associated with feelings of guilt, shame, helplessness, fear and divided loyalties, with a young person often simultaneously desiring to stop the abuse and protect their abuser and family from the consequences of disclosure (Summit 1983; McCarthy 1986; Finkelhor & Browne 1988; Rudd & Herzberger 1999; Caffaro & Conn-Caffaro 2005; Kluft 2010). It is then, in part, the perception of the victim and their experience of coercion and disempowerment that define SSA.

The acts involved in SSA are always inappropriate. Children are not psychologically or physiologically prepared to cope with the sexual stimulation or negative emotional aspects involved in SSA (American Academy of Child and Adolescent Psychiatry 2011a), and although older adolescents often explore sexual behaviour in the context of dating relationships, this developmentally appropriate interest is still very distinct from SSA. It is important to remain aware that SSA is always inappropriate, regardless of whether negative outcomes for the child are apparent or not. While up to one-third of victims are reported to be asymptomatic following sexual abuse (Mannarino & Cohen 1986; Conte & Schuerman 1987), a sleeper effect may be operating, whereby problems only become apparent later in life when intimate relationships are explored (Beitchman et al. 1992; Kendall-Tackett et al. 1993). While longitudinal data is limited, Putnam (2003) suggested that between 10% and 20% of asymptomatic children will deteriorate during the 12 to 18 months following evaluation. The exploitative nature of SSA is the factor that make the acts harmful, rather than the outcome alone.

An awareness of the betrayal of trust represented by SSA is also important for those receiving disclosures of abuse. Finkelhor and Browne's (1988) model of traumagenic dynamics explains that intrafamilial sexual abuse involves a significant violation of the trust and care that young people have a right to expect from family members. Mortimer and colleagues (2006) explain that the experience of sexual abuse includes the context in which the abuse is disclosed and the family and judicial outcomes that follow, in addition to the abuse itself. Disclosure is not a discrete experience, rather it is part of a process (Sorensen & Snow 1991; Petronio et al. 1996; Ungar et al. 2009) that may be distressing itself and does not instantly end the young person's suffering (Berliner & Conte 1995). In order to disclose SSA, the young person must overcome a number of obstacles, such as threats of harm, retribution or withdrawal of love from the abuser, fear of blame and fear of others’ negative reactions (Berliner & Conte 1995; DeVoe & Coulborn 1999; Palmer et al. 1999; American Academy of Child and Adolescent Psychiatry 2011a). Disclosing SSA is a significant act of trust for an individual who has had their trust betrayed in a highly traumatic way. An inappropriate response to the disclosure would create secondary victimisation, exacerbating the effects of the abuse and contributing to possible iatrogenic effects and the adoption of a stable identity as a victim (McCarthy 1986; Kelley 1990).

The trust implicit in a disclosure of SSA and the position of power held by the professional involved highlights the importance of recognising that at the point of disclosure, the professional's primary responsibility is to the young person disclosing. The main focus is to promote their safety via contact with CYF and/or the police to ensure that the abuse stops and that they receive the protection and assistance they require. Although secondary to the immediate safety of the victim, it also needs to be recognised that the safety and integrity of the abuser needs to be managed carefully throughout the disclosure process, particularly when they are also a young person who potentially has their own history of abuse. Higher rates of sexual abuse have been found among adolescents who offended against siblings than those who offended against non-family members (Worling 1995; Rayment-McHugh & Nisbet 2003). O'Brien (1991) found a higher rate of prior sexual victimisation among sibling incest offenders (42%) than either those who offended against extrafamilial (40%) or non-child victims (29%). Furthermore, adolescents who perpetrate sexual abuse against their siblings may be more likely to have been victims of physical abuse than those whose victims are not siblings (O'Brien 1991; Worling 1995; Latzman, et al. 2011) with studies reporting physical abuse rates of up to 92% (Adler & Schutz 1995). When SSA has occurred, it is certain that the abuser and their family require help to address the behaviour and the unhealthy family dynamics that have contributed to an environment in which SSA was able to occur. While these factors are of considerable importance, the needs of the victim must not be subordinate to those of the abuser or family.

Characteristics of the immediate response

Regarding the immediate disclosure situation, there are five important characteristics of an appropriate response including taking the child's disclosure seriously, affirming their decision to disclose, assuring them that they are not to blame and that steps will be taken to stop the abuse, and following up with appropriate action. These responses are congruent with the values outlined—that SSA constitutes a serious breach of trust, involves inappropriate and harmful behaviour, and is never the fault of the victim.

Children disclosing sexual abuse experience disclosure as less distressing if they are treated respectfully, informed about the process that will occur, are not discounted or pressured and are acknowledged for their ability to disclose the abuse (Berliner & Conte 1995). It is important that young people who disclose SSA are responded to in a non-judgemental manner to allow them to speak freely (American Academy of Child and Adolescent Psychiatry 2011b), talking as long and in as much detail as they want to (McKenzie 1999). A supportive, caring response may, in a small way, counteract the damage to their ability to trust (American Academy of Child and Adolescent Psychiatry 2011b). It is important that young people see they are being taken seriously and their efforts to stop the abuse by disclosing are not futile (American Academy of Child and Adolescent Psychiatry 2011b). The same serious consideration should be given to disclosures from children and adolescents of all ages. A number of studies have demonstrated that disclosures of sexual abuse by adolescent victims are perceived as being less credible than those made by younger children (Waterman & Foss-Goodman 1984; Back & Lips 1998; Hicks & Tite 1998; Rogers & Davies 2007); however, as established previously, age does not affect the validity of the experience of SSA.

The young person should be explicitly affirmed for doing the right thing (McKenzie 1999; American Academy of Child and Adolescent Psychiatry 2011b), a message that may encourage them to be open about the abuse during later investigations (McKenzie 1999). Due to the coercion and manipulation involved in SSA, it is also vital to state explicitly that the young person is not to blame for the abuse (American Academy of Child and Adolescent Psychiatry 2011b). They may have been told by their abuser that they are directly responsible for the abuse (Ministry of Health 2002), or believe that the abuse is punishment for wrongdoing (American Academy of Child and Adolescent Psychiatry 2011b). Interestingly, Lamb (1986) offers a contrasting view, suggesting that telling victims that the abuse was not their fault may emphasise their victim status and further reduce their feelings of control.

Young people who disclose SSA should be told that prompt steps will be taken to protect them and ensure that the abuse stops (American Academy of Child and Adolescent Psychiatry 2011b). This assurance is one of the most powerful interventions able to be provided by health care professionals (Ministry of Health 2002). An essential part of this step is documentation. Details of when and where the disclosure occurred and details of the abuse provided by the young person should be recorded in writing, verbatim if possible (New Zealand Children and Young Persons Service 1996). It is never appropriate to interview the child or ask leading questions (New Zealand Children and Young Persons Service 1996) as investigation occurs in the context of an evidential interview conducted by the police or CYF staff (New Zealand Children and Young Persons Service 1996; Mortimer et al. 2006). It may reassure the young person to indicate that help will also be sought for the abuser and wider family as victims are often concerned about the impact of their disclosure on others (Ministry of Health 2002; Kluft 2010). It is important to be honest about the flow of information and that others will need to be told; however, the child should be assured that information will remain as confidential as is possible (New Zealand Children and Young Persons Service 1996; McKenzie 1999).

Discussions with the victim's parents regarding the protective actions to be taken should be conducted with caution and discussed with supervisory staff prior to the occasion if possible (Ministry of Health 2002). Potential problems that may arise include placing the child or health care provider in danger, and the family avoiding protection staff or closing ranks to reduce the possibility of intervention (Ministry of Health 2002). Due to these risks, it is advisable to let specialist child protection staff broach this topic with families. If the discussion does occur, it is important to sensitively promote a collaborative approach with the goal of keeping the child safe and supporting parents in their parenting role, keeping them informed and supporting them to make their own decisions when possible (Ministry of Health 2002). Regardless of the level of interaction with the family, it is vital to keep in mind that the safety and needs of the child are of primary importance.

If a discussion with parents occurs, they may benefit from direct suggestions or referrals for further assistance to help manage symptoms of the abuse, such as nightmares, oppositional behaviour, angry outbursts and specific fears, as these are most likely to manifest in the family environment (Mortimer et al. 2006). Discovering that their child has been a victim of SSA can cause parents to experience uncertainty, guilt and self-blame, or feel overwhelmed (Rickerby et al. 2003; Plummer & Eastin 2007). Contact with parents needs to be sensitive to these potential negative reactions as they will impact on the parental response to the disclosing child; it can be helpful to present avenues through which parents can access help to cope with their own responses (Rickerby et al. 2003; Lovett 2004) and trauma to the family unit (Phillips-Green 2000).

The Crimes Amendment Act 2011 (New Zealand Government 2011) requires adults who are ‘so closely connected that it is reasonable to consider them members of the household’ (Child, Youth and Family 2012) to take reasonable action to protect a young person who is at risk of death, grievous bodily harm, or sexual assault. Despite this requirement, professionals may fail to report disclosures for a number of reasons, including inadequate training in child protection issues, a lack of physical evidence, low confidence in child protection services, fear of family retaliation, concern about disruption to the therapeutic relationship, attributions of blame for sexual abuse to the child (Blaskett & Taylor 2003), concern regarding the additional time and legal requirements, including time spent with the family and testifying, personal doubt about the credibility of the disclosure and concerns about legal liability (Budai 1996). The sharing of information without the consent of the child or family involved is subject to strict criteria that are often unclear to the professionals involved; however, inquiry reports and research and policy documents often identify systemic failures in coordination and communication as primary contributions to negative outcomes for vulnerable children (Ministry of Social Development 2011b).

Due to the legal requirement to protect vulnerable children from suspected abuse, the range of reasons perceived to be valid barriers to reporting, and the negative outcome for the young person if their disclosure is not reported, it is imperative that any health service organisation that provides services to young people develops and implements a policy that recognises the importance of reporting disclosures of abuse and provides a clear set of steps for how to comply with this requirement. Reporting disclosures to CYF and/or the police is recommended as they are specialists and the only agencies with the statutory authority to investigate and take action to prevent future harm in response to the disclosure (New Zealand Children and Young Persons Service 1996; Child, Youth and Family 2001). Numerous organisations and professional bodies have created guidelines for addressing abuse disclosures (for examples, see New Zealand Children and Young Persons Service 1996).

Victim safety and residential placement

For some service professionals, such as social workers, receiving a disclosure may necessitate being involved in the decision-making process surrounding whether either young person needs to be removed from the family home. Following a disclosure of SSA, the abuser should be removed to a residence in which they will not have access to the victim, or any other vulnerable potential victims—a restriction that the receiving caregivers should be made aware of (Costin et al. 2009). This step acknowledges that there may be other victims and prevents the opportunity for future abuse. Most children who experience sexual abuse do not disclose during childhood and, if they do, they do not always disclose the full extent of the abuse (Summit 1983; Sorensen & Snow 1991; Alaggia & Kirshenbaum 2005; London et al. 2005) with victims of young offenders less likely to disclose than those abused by adults (Lamb & Newberger 1989, as in Lamb & Coakley 1993).

Placing the abuser with family members with whom they have an established relationship and who will adhere to these restrictions is preferred (Child Welfare Information Gateway 2006; Costin et al. 2009). The removal of the abuser may protect them from the hostility of other family members and give the family the opportunity to start to deal with the abuse (Grant et al. 2006). Placing the abusive sibling in an alternative residence offers the additional benefit of providing them with a safe living arrangement while their pathway into offending is explored—an important consideration given the high rates of physical and sexual victimisation among sibling sexual abusers. In the event that parents disbelieve the disclosure and are not willing to provide support for or ensure the safety of the victim, the victim may need to be provided with an alternative residence; however, if the victim is able to be supported at home, it is the abuser who should be removed. Favouring the removal of the victim would penalise them for disclosing the abuse, contributing to secondary victimisation (McCarthy 1986), and may reinforce the associated self-blame or guilt.

The response of parents is one of the most important determinants of outcome for the young person (Mortimer et al. 2006), with strong and early support for victims of sexual abuse associated with more positive short-term and long-term adjustment (Elliott & Carnes 2001; Rickerby et al. 2003; Lovett 2004; Plummer & Eastin 2007). The removal of the abuser may validate the experience of the victim and demonstrate family support (Grant et al. 2006). The issue of safety must also be considered. Sexual assault, including SSA, occurs only if there is the opportunity, including the potential abuser, a suitable target and an absence of a guardian able to prevent the crime (Cohen & Felson 1979; Ward & Siegert 2002). Accordingly, consideration of the family dynamics that created the opportunity for SSA to occur will be necessary (Grant et al. 2006). Sexual assaults committed by adolescents tend to occur during times with limited supervision, often immediately after school (White et al. 2006). If SSA has been ongoing, questions must be asked regarding the level of supervision and monitoring in the home, and whether the victim will be safe to remain there, especially if there are other siblings.

Costin et al. (2009) point out that psychological safety must be considered in addition to physical safety to avoid further harm to the victim and to address their reactions, fears and emotional needs. Although highly supervised contact can ensure physical safety, it may not effectively prevent the emotional abuse and subtle tactics of power and control characteristic of SSA (California Professional Society on the Abuse of Children 1997; Costin et al. 2009). The victim may want to maintain contact with the abusive sibling to diminish the anger of the abuser or other family members, to ask forgiveness for making the disclosure, or to gain reassurance the abusive sibling is alright (California Professional Society on the Abuse of Children 1997). However, due to the issues of power and control inherent in SSA, it is more appropriate to address these fears directly rather than allow continued exposure of the victim to their abuser. Failing to separate the victim from their abuser may cause the victim to feel unsupported or disbelieved, or later recant the disclosure (Rieser 1991; Sorensen & Snow 1991; California Professional Society on the Abuse of Children 1997).

During the decision-making process, it is important to consider cultural factors. In the New Zealand context, it is important to acknowledge the effects of colonisation, urbanisation and socio-economic disadvantage on Māori (Ministry of Health 2002). As Māori experience disproportionate socio-economic disadvantage (White et al. 2008), practitioners must be aware of the potential effects of placing children with whānau members who may already be experiencing disadvantage, including exacerbation of financial and emotional strains (Grant et al. 2006). Furthermore, it is important to have an awareness of the way in which colonisation and urbanisation have contributed to the breakdown of traditional social structures in Māori society which traditionally protected children from abuse (Balzer et al. 1997; Jenkins & Harte 2011). However, the strong focus of Māori culture on the importance of extended family may be considered a significant strength in this regard.

Summary

Sexual abuse by siblings is possibly the most common type of sexual abuse and involves the use of tactics of power and control to exploit a weaker sibling for personal gratification. It is as prevalent and harmful as any other type of sexual abuse, if not more so. SSA contributes to a range of negative outcomes that often persist into adulthood. A review of the literature provides a view of the issues that it may be helpful to consider when a young person discloses SSA to a health service professional, including appropriate values to underpin responses and interventions, the characteristics of an appropriate immediate response and consideration of victim safety. It is recommended that all health services that have contact with children have a formal policy to outline the appropriate responses and steps to be taken when disclosures of abuse, including SSA, are received.

Professionals may be equipped to extend more sensitive and appropriate responses when their understanding of SSA is underpinned by the values that are supported by the literature reviewed, including that: SSA involves the use of power and control tactics and inappropriate behaviour that is qualitatively different from normative exploratory behaviour; SSA is never the victim's fault; the abuse constitutes a significant betrayal of trust; and maintaining the safety and integrity of the victim is paramount.

The immediate response may more strongly support the young person disclosing SSA if the delivery and information is consistent with the values outlined. A supportive response affirms the young person's decision to disclose as the right decision, assures them that they are not to blame for the abuse, conveys that their disclosure is being taken seriously and communicates that steps will be taken to stop the abuse, with prompt follow-up action taken, including reporting to CYF and/or the police. If health service providers are involved in decisions regarding the residential placement of the victim or the abuser it is important to consider the safety of both parties. If either youth is able to remain at home safely, the victim should be given priority. It is most appropriate for the abuser to be removed to the care of extended family if a safe placement can be found; however, it must be ensured that they do not have access to their victim or other potential victims. Supervision and monitoring in the family home should also be considered to ensure no further opportunities for abuse of the disclosing youth or other siblings exist. Finally, it is important to consider socio-economic factors that may influence the ability of family members to support abusive youth, with Māori experiencing disproportionate levels of disadvantage.

Of these considerations, the underlying values based on a power and control analysis may be the most important. While the issues surrounding SSA are complex, they are more likely to be navigated in an ethical and positive manner if the adults entrusted with a disclosure act in a manner that is respectful of their experience and supportive of their right to live free of abuse.