Cindy Tarczon, a Research Officer at ACSSA, interviews Helen Kambouridis from the Royal Children's Hopsital, Gatehouse Centre.

In recent years, therapy in the sexual assault sector has expanded to include working with the perpetrators of sexual violence. The proclamation of the Children, Youth and Family Act 2005 in Victoria, saw the implementation of Therapeutic Treatment Orders¹ legislation. Helen Kambouridis is a Senior Psychologist at the Royal Children's Hospital, Gatehouse Centre for the Assessment & Treatment of Child Abuse, where for the last 15 years she has worked with children who are victim/survivors of sexual assault. In that time, Kambouridis' work with child victim/survivors has expanded to include young people, aged from 10 to 15 years, with problem sexual behaviours and their families.

This interview discusses the changes to the treatment of young adolescent people who sexually perpetrate against their siblings and the impacts and challenges that face their families.

What led you into this field at the Gatehouse Centre?

I came from a teaching and disability sector background, where I had done some family training, before moving into the sexual assault sector. Working in the sexual assault sector, I wanted to have a family type focus. When I first started in this role, the focus was still very much about advocacy for the victim, so more of a traditional CASA² type role. The aim of that type of intervention was predominantly more around making sure the child knew they were not to blame; that it wasn't their fault; that they were not responsible. There is, of course, still a real push around that, but the focus has broadened to stepping back and having a clear assessment about what this child understands about what happened to them and how that's impacted them - more of a clinical assessment. I think that's developed a lot more over the years. It's not so much that the advocacy has gone away, but I don't think it's as primary as what it was before. It actually broadened our role, I think.

What led to the broadening of that role?

I think in the time I've been here, in the broader sector, there's been much more understanding about trauma and the impact of trauma, that's informed our work a whole lot more. So it wasn't just understood as a social justice issue we were addressing; we were looking at children who had been traumatised and their reactions to that trauma.

Understanding the impact of trauma actually gave us something a lot more concrete to work with. Along with that came people finally saying, "Look, maybe we need to put some developmental frameworks in here because we're not just talking about trauma with adults, we're talking about trauma with children". Then people started to look at attachment theory and it's been built upon from there.

How have the outcomes changed for the children that you're seeing now by taking a broader clinical approach?

I'd hope we've been able to give them better skills for managing and understanding their experience and making sense of it. Because we've started to think more broadly, we've made it easier to look more at the family context as well and incorporate that into treatment and not just do the individual work.

A more holistic approach is now undertaken in treating child survivors of sibling sexual assault their families and the siblings that engage in sexually abusive behaviours. What has been the impetus for this change?

A couple of things. Certainly when we started seeing that we were getting more and more sibling cases, we were very strongly advocating that if that sibling was still in the home, the victim/child survivor wasn't safe and if they weren't safe you couldn't do the work. There was certainly that really rigid position right at the beginning and CPS [Children's Protection Society] had done some work around having the predominantly young boys removed from the home and how that might have been a really difficult decision for families. In fact, I think a lot of families resisted.

The families were turning around after a while and saying, "You know what, it's probably a good idea [that their son had been removed]", but then there were also a lot of families who snuck around behind the department's back and still had contact with their sons. And why wouldn't they? So there was a really mixed response to taking that really rigid position.

Somewhere along the line we started to see so much of the angst that the parents were experiencing about having to make that decision, "Who do I side with?" That's effectively what we were making them do. It was bad enough that they were in that position anyway and they would have felt they had to take sides, but when we [as agencies] took that rigid stance, it forced their hand. Of course it's going to be a difficult situation. I wouldn't want to do it. I can't imagine what I would do.

I don't know whether that was the same for other people, but I know I found myself one day sitting with a couple of parents, listening to them condemn their sons who had done some pretty awful stuff to their 6 year-old sister. All I wanted to do was tell these people to stop, because their sons were in a really awful position too. They'd suffered as well and I thought to myself, "Oh my, I'm taking their side. How could I possibly be doing that?"

So I think somewhere along the line, obviously not just me but other people as well, started seeing this wasn't an all or nothing situation. It wasn't black and white. It wasn't good child/bad child. These are kids in one family. They don't sexually assault their siblings because they were born bad. It would be really easy if that was the reason. But that's not it. There's stuff that's happened to all of these kids for one reason or another and, unfortunately, they've taken this line of behaviour. It would be nice if they hadn't, but what's more important is that we actually understand the young person's experiences of life so far, rather than demonise them and buy into that same dynamic that often then happens within the families. That's not helpful. Nor is this about blaming families. Seeking someone to blame, even focusing too hard on why a young person has sexually harmed a sibling, is not the most helpful thing to do. What we need to do is understand and hopefully create some space for change.

What leads some young people to engage in sexually abusive behaviour?

There is a huge range of dynamics that are repeated. A lot of the young people we see have some sort of major loss or trauma or attachment disruption somewhere. Not all of them, but it's not uncommon. A lot of them would have had exposure to pornography or some sort of inappropriate exposure to sexual activity, for example. The literature in this field examines some of the predisposing factors and dynamics, such as the possible impacts of overly sexualised and overly repressed sexualised environments; punitive discipline, which, when particularly focused on that young person, can place them in a dynamic in the family that sees them grow into a position where they become a scapegoat. Then you've got the "princess sister" who is perceived as being the one who can do no wrong, who is loved in preference to her brother and whose status in the family her sibling may feel he can never attain. I mean what better way to get back at your parent and your sister at the same time than to sexually abuse her? "See how mad I am at you, both of you!".

So sometimes there's that dynamic, but then equally there are the kids that have been given power in terms of absent parents or distant parents or parents that somehow aren't connected to their kids. They then have responsibility for looking after a little brother or a little sister. Within that they've got responsibility for punishing a little brother or a little sister and responsibility for pretty much everything to do with their little brother or sister. On top of that there's no supervision, no boundaries. The home is completely chaotic and the young person is left with excessive power and control and they don't know how to deal with it. On top of that chaos and responsibility, they're angry. They're not getting their own nurturing and consequently it all unravels.

A few people talk about siblings seeking nurturance amongst each other. Whether it is because they feel abandoned because their parents aren't connected or whether they're quite actively neglected or physically abused, which leads them to seek a sense of nurturance with each other. One theory is that the nurturing relationship starts to go off track - maybe because the older sibling hits puberty and the next thing you know it becomes sexual. But what particularly makes it become sexual, I don't think we really understand. And again, this is not about blaming the family, as not all families with such dynamics experience sibling sexual abuse. These young people do not have to abuse their sibling. Exactly what trips them into that behaviour is not necessarily clear.

I'm not sure that there's anything more confusing or more muddled than sibling sexual abuse because we talk generally about sexual abuse, boundaries and ambivalence in terms of adult perpetration. But one of the layers, the complexity with sibling sexual abuse, is that there aren't the cross-generational boundaries to begin with. There's also the ambivalence around "He's my brother. I love my brother, I look up to my brother." I don't think we always acknowledge the ambivalence, or the spectrum of feelings in sibling relationships. People would very much find that the expectation is that if your sibling has sexually assaulted you, then you should hate them. There isn't much understanding, except perhaps from people who have experienced this, that especially within our interpersonal relationships, how emotions and reactions all cross over and interrelate. You can love someone and hate them and be angry at them and then feel very sad for them. And most of the children and young people with whom I've worked have told me they still feel confused about this.

Not only have you got that at that sort of sibling, peer generation level, but then there can be a track of thinking that goes down the lines of, "I hate him for what he did. But if I hate him, then where does that leave mum and dad? I don't want to upset mum and dad. Or I'm angry at mum and dad." Whatever reaction that child's having to their parents and their reaction.

The young people that you include in family-based therapy, do they exercise any insight into that? Are they able to articulate that?

I've never particularly worked with anyone who's been able to explain it to me, why they chose that particular behaviour. You can give them words and talk about how they maybe saw something and they wanted to try it out. That's about the most I've got out of a young person: "I saw it on a video and I thought 'Well, I'll give this a shot.'" Jo Hatch's³ research very clearly says these young people have access to their siblings and that's why they can do it - which is a bit disturbing. But I don't think they necessarily know. Even if they did, the shame about what they have done, about perpetrating this type of abuse against a sibling is so huge it is difficult for them to get past the shame a lot of the time.

When employing family-based therapy for sibling sexual assault cases, is there a particular age group you work with?

Most of the families that are coming through are sort of 13, 14-year-old boys and some of the younger ones are between about 6 and 9. So there's quite an age range. In terms of treating kids with problem sexual behaviour, the program is for children under 15. If they've started here before they turn 15 they stay with the centre. Otherwise they may be referred to the Children's Protection Society for example.

What kind of conditions need to be present for you to undertake this kind of family-based therapy?

We have to be able to engage that family somehow and they need to see this as something that's going to be useful to them. So we have to sell it. It's a big ask to get families in here week after week. The Therapeutic Treatment Orders legislation has young people on orders for 12 months, but it is really difficult to do that work in a 12-month period. I think the disconnection that has occurred somewhere along the line is probably one of the most significant factors that we see in these families. There's either disconnection with each other, disconnection between parents and the children, disconnection between the children as to who they are in their behaviour or their feelings. It's just rife. They can't connect with each other and yet we ask them to connect with us as workers. That's a huge job.

If we can keep them engaged, we'll have families in here for 2 years, easily, but that's if you can engage them and there's not a lot of them that can manage that. It's difficult for them to come in and talk about this kind of issue every week.

Even if they do turn up because they're on an order or because they're engaged with child protection, some of the families just turn up because they have to. They don't necessarily engage in the work. But I think that's our job. It's easy to blame the family for that by saying they're resistant, but that's supposed to be our skill; how to engage a family; how to engage a child; how to make them actually want to be here. That's hard to do sometimes.

How do you get a family into treatment or a young person into treatment?

We can make a suggestion to the department [Department of Human Services, Child Protection Unit] if we think that's the only way we can get them in here. Sometimes the department makes that decision and sometimes the police.

The Victorian Therapeutic Treatment Orders legislation's most significant impact is that it has made people a whole lot more aware of sibling sexual abuse. It offers young people with sexually abusive behaviour a way to see their future self and their future behaviour differently, which is far better and much more important than punishing them. If a young person is on an order, they've got some protection in terms of the confidentiality of what they tell their therapist and it can't be used against them if charges have been laid. That may have the benefit of allowing the young person to open up. They may feel some degree of protection in talking about their behaviours.

What do we know about these young people and their subsequent adult relationships?

This is an area we certainly don't know much about because I don't think anyone's particularly done that sort of research here in Australia and there'd be a many reasons why.

Phil Rich⁴ talks about some kids just growing out of this. They just get on with their lives, which may be all very good for them, not so good for the siblings they've abused. If they don't go onto perpetrate further, on one level that's good because we don't want any more victims. But where's the accountability and responsibility there? If they haven't got accountability and responsibility for having sexually abused a sibling, what else do they get away with? I actually think that's quite disempowering for people.

Anne Welfare⁵ is probably the closest to having done any work in this area. Some of the brothers who abused their sisters in her study were married and had children, but there was no evidence that they'd done anything else to anyone else. Which is not to say that it doesn't happen. I think in Welfare's study there were wives who knew of their partner's history and were reasonably careful. I'd be really worried about the quality or the type of relationships they're able to have with anyone really, because even if they grow out of it, so to speak, if they're able to do that sort of stuff to somebody, to anybody, I'd question how that impacts on their capacity to relate with anyone. Does that mean they continue to have abusive or controlling sorts of relationships? I don't know. I can't see that it wouldn't have some impact some way or another, even if they do go on to marry and have children, and a successful career. I can't see that it would have no impact on their sense of who they are and how they relate with others.

If the young people who come through here can get a little jolt of a sense of responsibility and if they can wear that, what an absolute antidote to shame that is. We could really turn it around for them by saying, "Look what you can do. You don't have to be ashamed. Look what you're accepting. Look what you're dealing with."

There's so much power in being able to help a child take responsibility for their behaviour too, but a lot of them don't stay around long enough to do that, because it is so shameful and it is so difficult. Not just for them, for everybody.

Shame shapes much of the personal, community and institutional responses to sexual assault. As far as sibling sexual assault is concerned what is the impact of shame on the perpetrators of this abuse?

The responses are just so varied. If they weren't ashamed by their behaviour at some level, they wouldn't do it in secrecy and they wouldn't set the situation up. They know it's wrong. They know it's not what their friends are doing. Especially as far as kids are concerned, shame shuts them up. The last thing young people want to do is expose themselves to other people and be vulnerable to their judgements. But being ashamed because you can't draw very well or you forgot somebody's birthday, it kind of pales into insignificance compared to sexually assaulting your sibling. Nobody understands that type of behaviour. Nobody gets it. Everybody's going to look at you like you've got two heads. That's what I'm guessing many of these young people think.

Children are very black and white, all or nothing type thinkers. They tend to define everything about "who they are" by this behaviour. Some adolescents perhaps, may have moved to a developmental stage where they can start adopting other perspectives, but they're also at the age where who they are and their identity becomes really crucial. If the defining point of their identity is "I'm someone who sexually abused my sister", that's a significant understanding of themselves to try and overcome.

It is made all the more difficult, because in cases of sibling sexual assault often we find the actual behaviour so inexplicable and so difficult to understand that we feel the need to label it and put it in boxes to help us understand it.

The potential for shame is huge and if that's the only way they can see themselves, as someone who does shameful things, who is shameful, who has no other aspect to them, they're really locked.

If you can shift someone out of that shame and into guilt, which is what we do when we help them take some responsibility, that's a little better. If you can feel a bit of guilt you can feel a bit of responsibility. For me, I understand it as a bit of a passage - shame, guilt, responsibility, accountability. With responsibility and accountability comes actually a little bit more power and legitimate power.

Where are the benefits to families dealing with this issue through family-based therapy?

If they can get through the can of worms that this opens up for them, in relation to disconnection and past trauma for example, then it can lead to a positive change.

I've only ever seen one family come out of this intact, that is, with the siblings both back at home, with behaviours changed for the better and the trauma resolved. That's sad, but that's the reality when you look at real relationships in terms of everything that we're asking them to do; what we're asking them to face; what we're asking them to unpack. I count it as a good outcome if I see one positive change in the relationship somewhere. It may not be that everything's fixed or resolved, but if there's a positive change somewhere that's a good outcome. And I have seen many of those.

What is the benefit of family-based therapy for the victim/survivor?

I think for the most part by opening it up and having the whole family exposed to intervention takes a little bit of the heat off that identified victim/child. However the abused child still needs to be identified as the victim. It allows for a little bit more room to talk about some of the ambivalent issues that centre around why the perpetrator is receiving help as well.

Some of the abused siblings just want their brother to be punished, which is fair enough. They want to know why their brother gets to come and play with things and talk. Family-based therapy allows you to have those conversations, whereas when that young person wasn't participating - they were being treated somewhere else or they weren't being treated at all, that conversation wasn't brought into our faces, so we didn't have to have to deal with it. I actually think that makes a bit of a difference. If that's the first sort of conversation about ambivalence you can have with the abused child then there's probably a whole lot more that's going to lead to.

It is something that they need to talk about because they won't offer it again. That's usually because they get an idea somewhere, as I've mentioned previously, that they shouldn't let anybody know that they really do like their brother, or that it was kind of nice when he gave me a cuddle. The same sort of shame issues that you get, I suppose, from people who have been abused by somebody else. If there's been the slightest bit of positive in the relationship it's hard for them to admit because everyone around them has made such a huge deal about how "It was wrong. It wasn't right. You were hurt. You were traumatised." That all needs to be acknowledged but so does the fact that they may have felt something positive there too.

What about for parents in this situation?

Ultimately I don't think we could blame the parents any more than they blame themselves. You'll get some parents who blame themselves and are just drowning in that sense of guilt. You'll get others who really defend against it and start attacking their children, either the young person displaying the behaviour, "It's him, he's a monster!" Or they blame the recipient of the behaviour, "It's her! She always was a precocious little thing." I've had parents say those sorts of things about their kids.

But for most parents, if they ever had the slightest lack of confidence in themselves as parents, having one child that sexually assaults another completely devastates them. But if they can somehow manage that disclosure, that process through intervention or treatment, then they've got something they can achieve through that as well. While we might talk about young men regaining a sense of appropriate agency and power through taking responsibility, maybe parents can feel a better sense of who they are as parents through the way they come to look at the situation. The sibling who's been the victim of it all can also get a sense of validation of who they are and that they are not just someone to be abused.

So each part of the family can get something positive out of it, but if they don't get the opportunity, don't take the opportunity, or engage in the opportunity to work through some of this stuff in therapy, then I don't know how they can change things for the better. The temptation to close in or close down must be so strong for families who have experienced sibling sexual abuse. The shame, again, is so palpable. And it's not as if these families can easily refer to other families who have experienced the same thing. What gets reported in the media, what gets talked about tends to be child sexual abuse perpetrated by adults, in and out of the family, but adults. And if you look at how sibling sexual abuse is represented in literature and film - and it's there a lot more than you might realise - it's often romanticised or minimised. So it's not as if these families have an obvious reference point or that they can take any sort of "solace" - so to speak - in the fact that this happens in other families. I know it happens in other families because of my work, but these families and most of society just are not aware of the depth of this type of abuse. Family therapy opens up the conversations, helps to challenge secrecy and shame - for the parents as well as the children.

What are the types of conversations that need to be had about sibling sexual assault?

I think there needs to be broader acknowledgement that it does happen. It's not only about how much older a sibling is, because there's some argument that if there's only a couple of years age difference between siblings, then it can be dismissed as "doctors and nurses". But it's not about age difference.

The way we need to approach it is to understand how the abused child, the child who engaged in the abusive behaviour, the parents and then the whole lot of them together, make sense of it. Because if we don't start there, we're putting our assumptions and our sort of understanding that's based on all the current discourses about sibling abuse on them. If we don't start from their position or understanding we're not going to get anywhere near the job done of moving any of them to a place where they can somehow reconcile what's happened and try to move forward with it.

Further reading

• Children with problem sexual behaviours and their families
• Adolescents with sexually abusive behaviours
• Young offenders and sexual assault bibliography