Audio transcript: The long-term effects of child sexual abuse

CFCA webinar - 5 August 2013

Robinson

Good afternoon, and welcome to the CFCA Webinar: The long term effects of child sexual abuse. We're most honoured to have Associate Professor Judy Cashmore from the University of Sydney here with us today as our presenter. My name is Elly Robinson, and I am the manager of the Child Family Community Australia information exchange. I would like to begin today by acknowledging the traditional custodians of the land of which we are meeting. I pay my respects to their Elders past and present, and to the Elders from other communities who may be participating today.

Our Webinar today is based on a CFCA publication that can be found on our website at www.aifs.gov.au/cfca, which was written by Associate Professor Cashmore, and Dr Rita Shackel. You will be able to submit questions via the chat box during the Webinar. There will be a limited amount of time in which Associate Professor Cashmore can respond to your questions. That way we'll try to get through as many as possible. It's now my pleasure to introduce today's speaker.

Judy Cashmore has a PhD in Developmental Psychology, and a Master's Degree in Education. She has worked as a consultant to various government agencies, and been involved in numerous state and federal government committees concerning children and families. Judy has been an appointed member of the Judicial Commission of New South Wales since 2004, and is Adjunct Professor at Southern Cross University. She and her colleague and co-researcher, Professor Patrick Parkinson, have been jointly awarded the 2013 Stanley Cohen Distinguished Research Award by the Association of Family and Conciliation Courts for outstanding research and/or research achievements in the field of family law. Please give Judy a very warm and virtual welcome.

Cashmore

Thanks very much, Elly, and welcome to the Webinar. I'm new to this process, I don't know whether you are, but I hope that it goes smoothly. Look, as Elly pointed out, this is a paper that was co-written with Rita Shackel, and it was an update on an earlier paper by the AIFS on the long term effects of child sexual abuse. I'm trying to get down to the next slide - there we go. Right, so what I'd like to talk about today is look at some of the research issues, and the findings, and then talk, and perhaps get some questions from you, too, on the policy and practice implications. The other material that I'll be drawing on in talking about this is a postgraduate course that Rita and I co-teach at the Sydney Law School on child sexual abuse.

AIFS was - actually Elly, in particular - was very prescient in selecting this as a paper to be updated, because this was on the books before the calling of the Royal Commission last year. So to put this in some context, there was a Four Corners last year, called, "Unholy silence", and a lot of this material, in terms of historical sexual assault - that's the reporting of sexual assault - of child sexual assault, some time after it had happened, and particularly in the context of institutions and church organisations - agencies. That announcement was made towards the ends of last year, and the Royal Commission is now well underway.

At the same time, in June 2012, the Victorian inquiry was set up, and that inquiry has now finished its hearings, and so also has an inquiry in the Maitland Hunter area dealing with the child sexual assault within the Catholic Church, and particularly the allegations of the lack of progress of any of those cases to the criminal justice system. What I'd like to start today - and I hope this doesn't immediately turn you off, and you may not share my enthusiasm for research methodology and so on, but the aim of the first part actually is to assist in the intelligent reading of research in this area.

So, particularly an understanding of the basis of research methodology. What does the research say? And making sense of it, a critical evaluation of the findings. What does it say - how do you make sense of the fact that you might get different findings, and particularly different prevalence rates from different studies. And also to address to some extent what the boundaries are between research and advocacy, and the importance of not going beyond your data. Not reaching that precipice where you're no longer solidly grounded in the research base.

Of course what I'll be talking about is a series of research studies, and the issues associated with that, but there will be people who are listening to this and - perhaps, I think - and also those who are listening to the stories of those who are talking to the Royal Commission, and who have their own lived experience of this, and I hope that the sorts of findings that you hear in this make sense to you, but also allow for an emotional response to the materials. We can't hear this sort of material without having some sort of emotional response, if we have any humanity. But we should not just be driven by that. We also need to be solidly based in the research in order to have good groundings for policy and practice.

So what are the big research issues? Well, I guess the main ones are about teasing out the effects of child sexual assault from other adverse experiences that occur in childhood. And that's not straightforward. So there are lots of things that happen to children in the course of their lives between the time that they might be sexually abused, and the outcomes, and we're talking in the research paper and in this talk today about the long term effects. The other aspects that are quite difficult are actually estimating the prevalence of child sexual assault, and I'll come to that in a little more detail later.

The real difficulty here is that there are - there is what we call a, "Dark figure", that's people in the community who've been sexually abused as children, who've never told anyone. So they won't appear in any research studies, they won't appear in official statistics, and so their story, and the impact of their experience, doesn't appear in what we're talking about today, although it will, I would expect, be reflected, if it's - if the studies that we're talking about are representative of those experiences.

The other big issue in looking at the research in this area is who do we get these accounts of abuse, and the accounts of what the outcomes are for people, from? Who is telling us, who's giving us that information? And what difference does that make? The other big issue is that researchers and people who do different studies in different areas and different countries at different times, don't make it easy by using different definitions of what constitutes child sexual abuse. That's important because it means that making any comparisons between them is very difficult.

And then the last big issue is that about different research methodologies. And as I said, I'm not sure that many people share my enthusiasm for research methodology. I think it's really exciting and it's important in terms of understanding what these studies mean, but the good news is that as things have progressed over the decades, we now have more rigorous research studies than we had ten, 15, 20, and certainly 50 years ago. And that's important because that means we can have more confidence in the findings.

So let's start by looking at teasing out the effects. What does it mean - we often talk about things like the impact of child sexual assault, or the impact of intervention studies, or the effect of, but how do we actually know that we've got what we'd call a causal relationship? How do we know that x leads to y, for example? Well the first thing you need, it's pretty obvious, is you need to have some association between X and Y. In other words, in terms of what we're talking about today, an association between the abuse and how someone functions, and their outcomes later. And that means that the abuse actually - we need to know that the abuse occurs before the effects. So if the sort of effects we're talking about happen at - beforehand, then we can't say that they're due to the abuse.

The other thing that's really quite critical, is making sure that any association we have between X and Y isn't due to Z, or ABCD, and so on. That is actually is, if we can hold all other things equal, that we know that the association that we're talking about is due to the association between x and y, not due to some other factor. And that is tricky, because we know that child sexual assault sometimes occurs without any other adverse childhood experiences for children in those families, but very often it occurs in families where there are other things that are happening that are difficult for children, and I'll talk about the (indistinct) of this source's reports when we get to that.

So estimating the prevalence. This is where it gets tricky, because we've got research that gives us all sorts of different estimates of how many children, how many girls and how many boys in the community are estimated to have been sexually abused in their childhood, and that varied according to when the reports are made, and of course it's made difficult by the fact that there are many people out there, we think, certainly an unknown dark figure of people who never tell anyone. The reason that's important is that if we don't know, and we're making comparisons between those who we think or know have been sexually abused, and those we think or know haven't, but we get it wrong in terms of the fact that there are people in the non-abused group who actually have been abused, then that compromises that comparison, and it actually will dampen the impact, make the effect look less than it otherwise would. If we could put them without error into the correct categories of abused and non-abused.

OK, the other factor that is important in terms of understanding the research and how it's changed over the years as well, is that a lot of the earlier research came from very specialised populations. So they may have been populations where people were seeking services for some reason. That they weren't doing well and they needed counselling, they needed support and so on, and that's very similar to some of the issues that we find in family law research as well, and of course in the good old psychology days of research undergraduate students were a prime source of research participants, because they were convenient samples, they were people who were around, and easy for researchers working in universities to access. And they often were required to do it as part of their studies.

But we now have a number of studies that are much larger scale, nationally representative, and where we can have more confidence that the people involved actually have, if they have said that they've been sexually abused, or there are records that indicate that. Going on to the next issue, that's about, "What's the source of reports?" Does it matter whether it's the child who tells you that they've been sexually abused and they're the same person who tells you what the outcomes. There is some strength in that because you're getting the account firsthand from the people, from the people involved, who can tell you what's going on, and of course that's critical.

It might also be useful, too, though, to have some verification, not that this is accusations of lying in any sense, but are there records that say that this person reported at that time, and are there differences between those who reported, officially, earlier, and those who didn't? And what does seem to matter, as well, is are we asking people who are now adults, to tell us about their experiences as children, or are these accounts that are coming from children at the time? And how - if it is retrospective, if it's an account as an adult - how long ago was that? Because what we do know from the research is that people in their 60's and 70's are less likely to indicate that they were sexually abused as children, which could indicate that they - that the incidence was less, but it could also indicate that it's something you don't talk about, or something that they have repressed, don't want to think about anymore.

So the next aspect is in terms of distinguishing disclosure from official reporting. Interestingly there are people that we know, now, from some research studies, who tell researchers that they've never told anyone that they've been sexually abused, but they're actually telling the researcher, and it may be that they can do this in a CASSIE interview where they can type in information confidentiality and anonymously in some way that gets linked with the other responses, but they don't have to tell anyone exactly who they are. And so we know from research that there are a number of people, and particularly males, who will tell researchers for the first time when they have not told anyone during their childhood, and they certainly haven't reported it officially.

But there are a whole lot of aspects around that that will have an impact on the research findings. Who did they tell? How many times? We know that people try - children have often tried a number of times to tell someone what was happening, and they weren't heard. When did they try this? Was it only when they got to adulthood, and why was that? And what were the consequences of trying to tell, and either being heard or not being heard? And you could expect that those consequences, of course, could be quite different. Are quite different. Having a look at the issue of definitions, again, this might seem like a bit of a dry argument, but why do we care so much how researchers define child sexual abuse? Well as I said before, it matters because it is how we can - if affects how we can compare the results from one study from another, and particularly over years and from one country to another.

A really well known research study, the Christchurch longitudinal study, which involved a cohort of children born - I think - 1970's - in 1971, in 1974 perhaps, in Christchurch. Waited until these young people were 18 before they asked the question, for obvious reasons associated with ethics and so on. And their question was whether anyone before they were 16 had ever engaged them in various types of sexual activity. And they divided it up into various categories, whether it was non-contact, and interestingly it's possible that non-contact could become more of an issue as we have online contact, and photos and, well, perpetrators asking children to take photos of themselves and post them to them online, or in various ways that their parents and so on may not know about. So the non-contact, that wasn't the way that it was understood at the time this study was carried on. Then there was contact, but that was physical contact, and then the final category was where there was actually some form of penetration of the child's body by the perpetrator.

So that's one study, and the definitions that were used. Another well known and large scale study in the US was the ACE study, Adverse Childhood Experiences. The importance of that one is that that talks about an adult or person who's at least five years older than the child was at the time - so if the child was 13, the person must have been at least 18, and beyond, an adult - and asked them about particular forms of sexual activity between them. Then we have other studies that I haven't detailed here, which actually only refer to whether or not the abuse occurred within a family. So the two that we've just referred to here don't restrict it to just family, but they do restrict it to childhood activity.

Why do people use these age range, particularly the age of 16, is because in Australia in all states the age of consent for sexual activity is 16, so if you've got children younger than that, and certainly if there's an age difference between them, then it means that we're talking about something that might involve child sexual abuse. Of course the difficulty here is where you've got, say, a 17 year old boy and - or young person - and a 15 year old girl, and those are not the sort of things that you want to catch up in something unless there was something difficult. If it was consensual, and nothing untoward happened in that relationship, that's not the sort of thing that would generally be included in the definition of child sexual abuse.

The other thing that we know, and this again makes it a bit tricky, is that in the Christchurch study, they asked these young people at the age of 18, and then again at 21, they asked them the same question, whether or not they had been sexually abused. And for 86 per cent of that population, they got the same answer that they had - there was no sexual abuse, and they said that at both times. For just under 5 per cent said that they had been sexually abused when they were asked at 18, and then when they were asked again at 21. But then you've got a mixed group, where one in ten of them said that they'd been sexually abused at 18, but then half of those didn't admit it when they were 21. Now it might be that they have all sorts of reasons, "Why are they asking me again?" It could be associated with some sort of - how they were feeling at the time, whether they even want to go there again, is the issue in terms of wanting to forget an embarrassment.

So, we're nearly there in terms of the methodological issues. What's really important, and becoming more recognised, I think, is in terms of the substantial under-reporting, we've always known there's substantial under-reporting of child sexual assault. What's becoming clearer is that that's greater for males than it is for females. One of the ways that that can be checked in terms of the comparison of what people tell you versus what can be known from official records, is that there are cases in which people are known as children to have been sexually abused from official records to child protection, police and so on, but they haven't reported it when asked in adulthood. And there, again, there are various reasons why that might happen. What we do know, again, and it slightly biases the findings or the results you get, is that if it's abuse by a family member, or understandably if it's abuse by a child who was - when the child was under five, they're less likely to report it. Of course if they're under five, they may actually not remember much about it.

As I said, the good news is that we actually have more rigorous research methodologies now. Larger scale studies. We've got more prospective studies, so catching the data as it's happening, and following the same people through forward in a longitudinal study. More nationally representative samples. Some interesting co-twin comparisons, where one twin, one of the members of the twins, were sexually abused, and the other wasn't, which allows you, of course, to have a comparison group. And that's the other difference, that studies now are much more likely to have comparison groups than they were earlier on. And also to use standardised measures.

And once you've got a certain bulk of studies, and they're more rigorous and so on, what we now have available to us are things called meta analyses. And that's a technique where you can take the effect size across a series of studies, and pull them together, taking accounts of the strengths of the studies and what the findings were, and what did they take account of in terms of coming to their results, and pooling that, and coming up with something that's stronger in terms of looking at the results across studies. And again, the reason for good measures is that that makes those comparisons, pulling things together, simpler. Well, more robust.

So, just to - let's have a quick look at the issue about what are the consequences of child sexual abuse? I think probably - and if you read the stories of what people tell you and I'm thinking here, too, of, you know, books like Chrissie Foster's book, "Hell on the Way to Heaven", and so on, what the really terrible thing about child sexual abuse is that it distorts relationships, and not just the relationship between the perpetrator, who's very often someone trusted by both the child and the family, but also the child and their family members, because why didn't they know what was going on? And that leads to all the issues around betrayal of trust, and how come I wasn't protected? Why was it me who was picked on by this person? Why was I groomed, and not somebody else in the family? Or why was it me and not my twin?

The other aspect that it does, is it causes sexualisation of children's behaviours, so that they come to understand and believe that this is the way in which the world works for them in terms of what they get in return for their sexualised encounters. But it has all sorts of aspects in terms of the stress response, and people talking more about trauma these days, and so on, and we can talk about that at some stage, and what that term actually means. But the impact on brain development, particularly for younger children, and also for adolescents, where brain development is - that's where they're learning about their identity of who they are, what their sexual identity is, and a whole lot of the pruning and the relationships that are so critical at that time of their life.

The consequences of disclosure are the other thing - and reporting - the other things that we really need to take into account in understanding what's the impact of long term - or what's the long term impact of sexual abuse on children. Well what we do know is that being believed is quite critical. Whether it happens when they're children, which of course is preferable, or whether it happens at some stage of their life, that somebody actually believes, and that they're not alone. Ideally, if that's - they're believed, and that powerless feeling can stop, and the abuse can stop, if it happens early enough and in their childhood. And before it goes on to being more
- longer duration and more harmful. The betrayal of trust aspect is quite critical.

But there are also the consequences that come with reporting to child protection agencies. Those who've tried to go to the church and get some sort of response - or the institution involved, whether or not that was satisfactory, and what we're hearing from a number of these inquiries is that it's way from satisfactory. Whether any report was made to police, and what about criminal prosecutions. Did it ever eventuate? And if so, what were the outcomes? Did that make it better, or not? Did it make it worse? Interestingly, a very recently released study by Jodi Death, and is a study, "They didn't believe me", which is talking to 81 survivors of child sexual abuse by church personnel.

And one of the things that was interesting about this is when these people were asked, "Why did you believe somebody knew?" and they gave a whole series of reasons here, that they thought that somebody else in the family must have known what was going on, because either it happened in bedrooms, where doors were closed, there were consequences for the person, there were other people present when it happened, or that somebody told, or that their reaction to the perpetrator was such that they didn't believe that their family members couldn't have understood what was going on, or didn't know. But children can often have understandings and expect that adults are more all seeing than they actually are, and sometimes it can be very difficult to see things like that, that are going on either in the family or in trusted institutions.

The other piece of data that Jodi has presented is a figure here which shows you who did they - if they reported, and of the people that she talked to, 44 of them actually made an official report. And the main people that they reported to were actually the police. And also, for these, because they were church related, somebody associated with the church was very high in - if you added up all of those bottom bars, you'd see how high that number is. So the police were pretty much up there. What was interesting in her study is that police
- they got a more satisfactory response from the police than they did from the church - anyone that they told within the church.

And these are the reasons that they said that they were finally reporting, and a number of these people were reporting many years after they'd actually been abused. And top on the list was to protect children. To get this person, this perpetrator, out of the system. Wanting the church to accept responsibility, and wanting to be heard, and wanting something to be done about what had happened. And again, some sort of resolution of the process of what they'd experienced. If we look, again, at what the experience is, for those who go in - who do get to the point of the criminal justice system, where it proceeds beyond the police to a criminal prosecution, and that's actually a very small proportion of cases. Getting a good estimate of what that proportion is is very difficult, but we know that it, you know, various estimates are one in ten, or less than that. And again, the issue here is being believed by someone through the process.

But the experience of those who go through it is that it's a very unequal playing field for the victim witness and those who are on the defence side. And that many people go into this feeling very unprepared, and they then can often feel very betrayed by results that - outcomes like acquittals or aborted trials that they were hoping not to get, and maybe not expecting. And the way in which they're treated by people in the system, by the police, by the prosecution lawyers, by the defence lawyers - and we should also have the judges and judicial officers there - is very important in terms of how they walk away from that regardless of the result.

The sorts of things that they talk about that make that experience difficult is being able to tell their story, and having that in their own voice, and not being distorted by the process. Not being told just to answer the question, "Yes", or, "No", being able to answer questions in a way that is true to their experience, and that is usually not their experience, that they are able to do that. The adversarial system with the form of cross-examination which is deliberately to attack the credibility, leads many of the people going through this to feel as though what comes out of it is a twisted defence narrative, and a comment by Caroline Taylor in her book about legal fictions and so on, or one of them, is that the very peripheral become central. So the tiny details that the - that mean nothing, but how their credibility is attacked. It's not what actually happened and whether they can tell a story that makes sense, but it's actually attacking it on the things that don't matter.

And there are also all sorts of ways in which delayed disclosures, and a continuing relationship with the perpetrator can be exploited and misunderstood within the court process, and that's not helped by the multitude of warnings that a jury is given, given case law and the way that's built up. And the other thing that makes that difficult is the problem of separate trials. That if there's more than one perpetrator, they can be treated separately, and if there's more than one victim, you can end up with multiple trials, none of which tell the full story. And it also means that people have to go through this process over and over again, and it makes no sense to those who are involved. Again, it feels like a legal fiction.

So, to cut to the chase in terms of what the main findings are, I'm not going to go through these in detail because the report is available online, this is the report CFCA with reader, and myself, so you can see all the references, but I just wanted to highlight some of the real issues here. The big issue is that there's a range of adverse outcomes for children who were sexually abused during childhood, and those outcomes can show themselves in adolescence - can show themselves in childhood, in adolescence, and in later adulthood, but I'll be focussing on what we know about what happens later in adulthood, and in adolescence. The main point that I'd really like to emphasise here is that abuse is not destiny. Not all who experience child sexual abuse are necessarily harmed by it, or harmed in a way that is reported in these sorts of findings, and the timing of the difficulties varies. So it's not universal, and it's not inevitable. There is hope, and if there have been problems, they can be overcome. Often with quite a lot of work to get around that.

But there's lots of aspects of the abuse that can have an impact on the experience of a child who's been sexually abused. Who was the abuser? How much trust did they have? How close were they to the family? How did they destroy the relationships within the family and the trust involved. How old was the child? Whether they're male or female, we're coming to see, does make some difference. What forms of manipulation were used, and how did people react if they tried to tell anyone about it? Those sorts of things are quite critical in the way in which children experience the consequences of child sexual abuse beyond the abuse itself.

This gives you a summary of this side of the consistent findings of behavioural and mental health functioning. And with the more rigorous studies, these are the findings that are coming through time and time again with a substantial amount of confidence in their findings, and that is that there are elevated risks, greater likelihood of anxiety, depression, and suicidality. People who try to commit suicide, and those who attempt. Those who actually have fatal accidental overdoses, for example. Alcohol and substance abuse. Risky behaviours that include sexual behaviours, and those that - all of those have implications for interpersonal relationships, and how you deal with and trust others in your life after you've been betrayed in trust in this way. And particularly quite insidious and very unfair is the greater risk of re-victimisation for those who've been victimised as children. And it's not just mental health, it's also - increasingly we're seeing a range of physical health problems that are stress response related. And I'll talk a little bit later, just about gender differences.

So, in terms of the behavioural effects, these are - and you can see these with the slide later - what's important, I think, is the last point there, and that's about the cumulative and additive synergistic effects. And what that means is that child sexual abuse often doesn't occur just by itself. It often happens in concert with other forms of maltreatment. If families where there may not be good parenting capacity, and that actually makes the child vulnerable to the approaches and grooming of a perpetrator. And also that there may be parental alcohol abuse and so on, and also impacts. And of course the things that then occur for the child as a later person in terms of alcohol and substance dependence also have impact on the way in which they live their lives, unless things can be turned around.

Just wanted to pull out here the issues around alcohol and substance abuse, and look at lifetime alcohol dependence rates, and the findings here, these are comparative rates. So for women there's a study, and we have a number of studies that have consistent results. This is a doubling of the rate of alcohol dependence for women who were sexually abused as children compared with those who weren't. And the same with men, but the rates for men, both the non-abuse and the abuse rate, are significantly higher. As I indicated earlier, what's important is not just finding a relationship, but also understanding how that occurs. And we're now learning more about what happens in the brain, what happens in people's behaviour that might cause someone who's been sexually abused to actually seek - use alcohol and substances.

Partly it's about pilling the pain, deadening the memories, but there's - and that's particularly in relation to dampening of post-traumatic stress symptoms, and the hyperarousal that's associated with that early abuse, and the impact that it has on their views of themselves. But what we see here, also, is parental alcohol problems that actually feed into this and make it worse. And the same occurs in terms of looking at the link between childhood abuse and cannabis use. Particularly the level of psychosis in adolescence. People are becoming increasingly concerned about the interaction of cannabis use for already vulnerable adolescents.

And this study in Psychological Medicine, and a journal I'd recommend, shows that there's greater than additive interaction. Just to show you, the diagram here - not huge sample size, but look at that last bar. That is showing you where you've got children who've had some form of childhood maltreatment, and cannabis use, and what it does to the rates of psychosis in adolescence, and that is a concern. An interactive synergistic effect. There area number of those that go on in this area, and I'll just highlight a couple of them as we go through. One of the things - another aspect in terms of - you find in the paper, is about the increased likelihood of risky, harmful behaviours, particularly in adolescents, who tend to have more of a propensity than other age groups for this, but it means that the rate of accidental fatal overdoses with drugs and alcohol - drugs in particular, is higher.

Gambling is also becoming more evident in this group, and sexual behaviour with early onset, and sexual activity. Multiple partners and unprotected intercourse leading to STDs and unwanted pregnancies. And again, to look at some of the linkages between that, what are the mechanisms? Well the other factors that are involved here are things like how do people feel about themselves when they've been sexually abused? What sort of concerns do they have about why was I chosen? Why was it me? Why couldn't I get out of this situation, or why did I get into it? Feelings of learned helplessness. Issues around early risky - use of drug and alcohol again, and early risky sexual behaviours, which then play into other things later on.

Just to talk a little bit about the issues of interpersonal difficulties, again, that issue of betrayal of trust, and the invasion of personal boundaries. And the difficulty for sexual abuse in particular is that it has the secrecy around it. "Our little secret." But it implicates children and they feel responsible for being involved in that, and the confusion that that results in, and feelings of self blame, guilt, shame, social isolation, "Why me?" And what we do know, is that there also seem to be some differences in the impact for those who go on to be mothers and fathers. Particularly if there are other aspects involved. For mothers, things like poor choice of a partner, social isolation, role of violent partners, and of course that leads to parental stress.

For fathers, there are a number of issues that are often going on here, and that's around anxiety, those who feel really over protective about their children, would never let them go and stay overnight anywhere, and - or be alone with a male anywhere, because they don't trust that anyone wouldn't abuse if they had the opportunity. Those who are concerned about the victim to offender pathway, could I do this because I was abused, and having heard the stories? And I'll talk about that briefly in a moment, but there's also the positive aspect here, that fathering can be a healing experience for those who've been sexually abused as children, and they would never let it happen to their own children, and treasure their children.

This diagram is simply to show you, again, some of the linkages coming out of the Christchurch longitudinal study. This is looking at the impact on what sort of partnerships do these young people - do these people have at age 30, and what are the linkages, and what does - where one thing leads to another, and that's what that diagram leads to, and some of the things that we've already been talking about. So in terms of - the picture that this gives, and the reason for showing that - and again, it's a fairly simplified view in one sense, but again, indicated what a complex interplay there is between various factors, and how one thing can have an impact on others, starting with child sexual abuse in childhood. And as I said, the irony and the difficulty is about sexually abused children and the propensity, or the greater likelihood they have, to be re-victimised as adolescents, and, again, as adults. And it's not just sexual victimisation, but certainly sexually abused children are more likely to be sexually assaulted as adults.

Again, we need to think about what are the mechanisms. And there have been various theories put forward, but again, self esteem comes in. If you don't think well of yourself, you don't think that maybe you're worth protecting, in various ways, or that your hyperarousal levels mean that you are not very good, perhaps, at discriminating actual threats from false alarms. So some of the issues around that are the sorts of explanations that people are looking for to understand why is it that children who have been sexually abused are more likely to be sexually assaulted later, and victimised in other ways? And again, sexualised behaviours may have something to do with that.

The involvement in the criminal justice system is a really important issue, and one that we need to be very clear about because of the risk of stigma, and a false understanding of the victim to offender cycle, which people talk about as though it's a given, but it's not. Yes, there's an increased risk, but there's a vast majority of those - the vast majority of those who have been sexually abused as children don't go on to offend. And again, we need to be careful when we look at the studies in this area, if you're wanting to understand this more. What sorts of studies have been conducted here, what's their population base, what's the starting point? If you start from children who've been sexually abused you'll get one picture. If you start from those who are offenders in prison, in juvenile detention centres and so on, again, you'll get a different picture.

So let's start where we've got sexually abused children. What happens if they're our starting point and we follow them through? Well, first we need to understand - again, look at what some of the mechanisms might be. We know that children who've been sexually abused are more likely to have behaviour problems. There are issues of trust, et cetera. They may run away, that puts them at risk in terms of, you know, how are they going to survive out there if they don't have means of support, and are they choosing safe means of support? And who are they getting involved with, and what do they have to do in order to meet their needs for survival. We also know that there is a greater risk of juvenile offending for that group of children.

But in terms of sexual offending, quite mixed results, and certainly for those who were under 12 at the time that they were sexually abused, one study actually by Widom actually shows that they're less likely to be sexual offenders of they were abused under the age of 11. But there's an interesting study, an Australian study, by Ogloff and his colleagues, which looked at a whole lot of records, so this is a different style of study, which looked at official records, child protection records, inquiry records, police records, morgue records, all sorts of things about death rates and so on, and found that in fact sexual offending by males was higher, but still quite low - well, it was - if it was 9 per cent, in other words 91 per cent of those who'd been sexually abused now didn't go on to sexually abuse. But if they were over 12 at the time that they were abused, then they were three times more likely than those who were not abused to sexually offend. And that's the - than those who were younger than that age, sorry.

Let's then take a look at - because what we often hear here is that you start form those who are in prison and say, well, yes, that a lot of those are in prison for sexual offending and they were sexually abused when they were children, so, look, it means that one - if you were abused as a child it goes on to mean you're abusive as an adult. That's not true. What we do know is if you go to prisons and you look at the inmates there that there's a high proportion of those who've had a history of maltreatment, and other adverse childhood experiences. And across a number of studies, that's pretty high. We're talking about 41 to 43 per cent. And a good study in New South Wales looking at juvenile justice detainees shows, you know, high levels of those who were involved in juvenile detention centres, who, having committed other offences - and we're not talking about sexual offences alone here, in fact it's the minority - had actually experienced some form of abuse as a child.

If we have a look at this graph, I think it's pretty sobering. And particularly for young women, but look at how many of those young people in juvenile detention centres had some form of childhood abuse or neglect, or reported it. We're talking about 80 per cent of young women, and around - you know, very high proportions. So those who were actually in juvenile detention centres have that sort of history. It's one of the reasons they ended up there, rather than in some other places, but it's not the abuse alone, it's how they were treated beyond that that would have had a serious impact. What sort of support did they get? Did they have anyone who believed them? Did they have anyone around who loved and could provide the sort of support that they needed?

This, again, is another figure looking at the number of young people in juvenile detention centres, and we're talking here where they're talking about serious childhood abuse and neglect. And again the proportions are pretty high. We're talking about, you know, over one in four, certainly - and nearly one in two young women in 2009, who were reporting sexual abuse - sorry, serious form of - some form of abuse. Not necessarily just sexual, but also heavily involved. There are a range of physical health problems, and that's actually coming out more and more in the research, particularly go to Psychological Medicine and have a look at what's there in terms of the range of physical health problems that people have that are associated with child sexual abuse in their childhood. And it's also some in our paper.

Just want to talk briefly now about gender differences. If you look at a range of research papers, predominantly it's girls who we know are sexually abused. And a number of papers talk about it as being 75 per cent, 80 per cent, and so on. But one of the things that makes it difficult here, is that we know that boys are less likely to disclose, and less likely to tell anyone at any stage. So in fact the numbers that we have in terms of relevant to men, are lower than they should be, and proportionately lower than they would be, we suspect, for girls. And there's a whole lot of prevalence issues associated with that. So why would it - why might that be? Well, being a victim isn't being a, "Real man", is it? According to our culture. It - being vulnerable - being a victim means being vulnerable. It's not in line with having male sexual prowess.

There's added impact, or issues around a fear of being labelled or labelling yourself as being homosexual. Does it mean that because I was singled out, and in fact I responded physically, that I'm a homosexual? Does it mean, going back to the victim offender cycle, that I've been abused, I'm likely to go on? So I don't want to tell anyone in case that is what they think. Does it mean that they are more likely to think that I was the instigator, I started this out? Because sexual abuse is - or sexual behaviours are more likely instigated by males than females in the cultural understanding.

The other thing we know about sexual abuse and boys, and particularly abuse by clergy, is that it's more likely to be boys than girls who are sexually abused within church-related institutions by clergy and related people. 75 to 80 per cent in studies that we have access to. And the most common age for boys is between the - you know, early adolescence, 11 to 14 years. And they wait a very long time to tell anyone. The figures we have, on average, 25 years. So you've got a 15 year old, who's waiting until they're, on average, in their 40's, to tell anyone about it. And that's what we're talking about in terms of historical child sexual assault. But what we don't know is if they go into the prosecution system, what are the chances of it getting to prosecution, is that what they want, and will they get the results that they're hoping for?

So what are the main messages? What do we know? Well, we certainly know that it's a complex picture, that's it's multiply determined, and there are multiple pathways leading to multiple outcomes. As I said - talked about the interactive synergistic relationships. There certainly is an increased risk of a number of adverse long term effects. But abuse is not destiny. It's not universal, it's not inevitable. But there might also be sleeper effects. It might happen - be triggered by things like media reports, by things that happen in people's lives, the birth of children, pregnancies and so on. So what don't we know? We don't know what the effect of criminal prosecutions is on those who are survivors. We don't know what the impact of media coverage is. We've got some inklings, we've got some ideas. And we don't know what the effect will be of those coming forward to the Royal Commissioner, and those hearing about it. And how do those who engage feel as a result of doing so? And depending on what factors?

So in terms of being an intelligent consumer, it's about being able to critically evaluate what you read in the findings. Looking at the research rigour, looking at consistent patterns, not just single study findings. Being alert to both quantitative and qualitative studies. And certainly being alert to the quality of the journal, and whether or not they're peer reviewed. Not necessarily fool proof, but a good guide. Taking a good look for systematic reviews and meta analyses. And keeping in mind when did this occur? In what cultural context? And I haven't specifically related this to Aboriginal communities, but that is a whole other story. And being aware of what the confounding factors are. What are the multiple pathways and the interactions?

And then very lastly, intelligent application is what's the gap between what we know already and what we do? And what's the gap between what we know and we don't know? And critically, when there are people out there who are providing services, let's make sure that they're properly evaluated treatments and interventions. What do we know about those services? Who is able to access them? What benefit do they get from them? And what are the long term outcomes of those services?

So I think that's a bit of a romp through the area, taking on some of the issues from the paper, and going a little bit beyond what's in that paper, and I hope it answered some of your questions.

END OF TRANSCRIPT

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