It is interesting to note that health care professionals are grappling with a phenomenon in the twentieth century that has perplexed and frightened society since early times. Incest has a long and multifaceted history. It is an ever-recurring theme of the mythologies of diverse civilizations.1'2 From the Bible (the stories of Lot and Salome) to Greek mythology (Zeus) to ancient literature (Euripides' Hippo!ytus)t intrafamily sexual relations are described. Kardiner has indicated that the nature and rigidity of the incest taboo varied from culture to culture and only mother-son incest was found to be prohibited universally.2''
The current literature is plagued by insufficient and inaccurate data. This may be attributed to inconsistent definitions of incest, inconsistent reporting requirements across states, the strong need of the victim's family to conceal the relationship due to cultural restrictions, the prevalence of myths about incest families and victims, health care providers* lack of awareness of the problem and providers' reluctance to become involved in difficult psychosocial issues. However, all reports agree on the symptoms and problems experienced by the adolescent incest victim. Adolescence may well be the time when incest can inflict the greatest damage. In some way everyone is touched by incest, not just the family members who are directly involved. Aside from the psychological and emotional effects of incest on participants, it affects society by driving some of the participants to prostitution, drug and alcohol abuse, violence and a variety of other social deviations.
Pediatricians are in the front line of the battle against incest and the rehabilitation of its victims. This article aims to contribute to this task by examining the incidence, signs and symptoms, appropriate medical interventions and dynamics of incest (the focus will be primarily on the most commonly reported form: fatherdaughter incest).
DEFINITION OF INCEST
"Incest11 is a legal rather than a medical concept and is defined as "the carnal copulation of a man and a woman related to each other in any of the degrees within which marriage is prohibited by law."4
The literature consistently confines incest to blood relatives. State laws vary in their definitions bf incest, in terms of perpetrator and activity. Some states are expanding the concept of "relative" to include stepparents, grandparents, and caretakers. The incest activity with a child may range from mild sexual excitement due to fondling in the genital area to severe trauma from assaultive penetration.114'5
INCIDENCE OF INCEST
It is difficult to assess the incidence of incest. There is general agreement that accurate statistics are difficult to obtain and the available figures reflect gross underreporting.1'6"8 Fradkin has estimated that 90% of cases of incest are not reported.1 Studies indicate that there was one case per million population per year from 1910 to J 930 to 5,000 cases per million per year from 1945 to 1965 in the United States.1'6'8
Incest crosses all cultural, socioethnic and educational populations.1'6'8 There is greater reporting among the lower socioeconomic groups but this is attributed to differential reporting of all crimes.1'*
Authorities disagree as to whether brother-sister incest occurs more frequently than father-daughter incest. Sibling incest is less likely to be reported because of its relative transient nature and the lack of lasting, documented, disturbing consequences. i'5'6'B Mother-son incest is considered the most uncommon form with one or both partners assumed to be severely disturbed or psychotic.1'6'9 There is documentation of grandfathergranddaughter, mother-daughter and father-son incest.
SIGNS AND SYMPTOMS OF INCEST
Although there are clients who will present with the chief complaint of "incest," the health care provider cannot assume or expect this to happen. It is incumbent upon the provider to maintain an element of suspicion when cues are present. Cues present themselves in the behavior of the adolescent, mother, father or even siblings.
One of the most obvious indicators is the mood and behavior of the index daughter. She may be depressed, withdrawn, exhibit extreme seductiveness, secretiveness, fears, phobias, precocious sexual behavior and/ or learning problems. Psychosomatic symptoms such as recurrent lower abdominal pain or headaches are extremely common. Physical signs may include genital irritation, lacerations, discharges, bleeding, infection, painful urination, pregnancy and sexually transmitted diseases. It must be stated that none of these are definitive signs but they warrant further investigation taking the possibility of incest into account.
DYNAMICS OF INCEST
A number of theoretical frameworks have been developed to assess and understand the dynamics of the incestuous relationship.
Pittman describes patterns of incest as being either unique or habitual. In the unique pattern, the incest may occur as a single event or be limited to a few times. They may be related to situational crisis or stress. ' ''° The longterm, well established mode of family interaction usually kept a secret is defined as the "habitual" pattern of incest.
In the "classic" incestuous family, the pathology is confined within the family and within the home. There are apparent role reversals between the mother and daughters). On the superficial level, the family appears stable and well, with the problems concealed from the community.1
Tonnes identified some of the characteristics of classic incest families. Often the parents are involved in early marriages of long duration with many children. There are no acting-out behaviors by the children and no extramarital affairs by the parents. The father maintains rigid, restrictive control of the female children and their social activities. There are limited contacts with the outside world by family members.2'" Homeostasis is maintained in the dysfunctional family by the incestuous activity. The activity also serves several purposes; 1) it forms a defense for the parents against feelings of sexual inadequacy; 2) it serves as a revenge for the daughter against the mother for her lack of nurturance; 3) it decreases separation anxiety for all members of the triad; and 4) it serves as a method for keeping up a facade of role competence for both parents.
In "mult iproblem" families, the sexual abuse may be incidental or a minor component to chronic disorganization in a chaotic environment. ' There are many problems recognizable to the community. Often the family is known to social service agencies because of difficulties with drugs, alcohol, arson, theft, school truancy, etc.
Studies have identified characteristics of individuals in both classic and multiproblem incest families. It should be noted how consistent the data is from study to study.
Typically, the father is in his late 30s when the relationship begins. Generally, the relationship involves the oldest daughter.1'2'6''3 Incest occurs in intact homes and major factors are sexual difficulties, maladjustment and estrangement between husband and wife.2 There is an avoidance and/or cessation of activities between spouses.6 The father is domineering, patriarchal and was raised in a chaotic family where divorce, instability and little emotional warmth prevailed.6 The incestuous relationship is generally prolonged and may be terminated by the daughter getting married or leaving home. The activity often continues with each younger daughter in succession. Little guilt is experienced by the father and rationalization and denial are defense mechanisms utilized in order to cope with the strong social disapproval.
The most striking finding about the mother is her knowledge of and collusion in the incestuous affair. Sarles states that in almost every case, the wife promoted the incestuous relationship by abandoning or frustrating the husband sexually or by actively altering the living arrangements to foster incest.6 Once the relationship has commenced, the wife reacts in one of two ways: either by tolerating the incest with little or only token protest or by blinding herself to the incest by obvious use of denial. :'5X"n The mother tends to be passive, dependent, immature and strongly attached to her own mother.1,2,5,6,12 Not only does the mother deprive her daughter of protection from the father but also deprives the daughter from developing sufficient personality strengths to resist the incestuous relationship.5'6 The mother is away from home or at work or arranges to leave father and daughter alone.
The daughter is usually a passive participant who seldom complains or resists. She may accept the sexual advances as an expression of affection. She is hungry for attention and willing to rescue the father from his unhappiness. Many victims experience guilt and depression, stemming from disruption of the home, social stigma, and feelings of hostility and revenge toward the mother.6
The generational boundaries between family members are often blurred, with family members not having strong, clear individual identities. ' The father is able to pursue the daughter as a substitute for the wife. He may behave impulsively, irrationally, and immaturely. The mother may become the child and rival to the daughters. The siblings feel excluded and may express jealousy as they do not receive the attention or the privileges of the "special" daughter.
The fears of family disintegration are shared by all family members. The threat of family break-up creates extreme stress. The fears are associated with the revelation of the incest, the reactions of the community and the possible consequences.''2'"'14
MEDICAL INTERVENTION WITH THE ADOLESCENT INCEST VICTIM
Incest occurs in the privacy of the home and is maintained by secrecy. This makes detection difficult for relatives, school officials, neighbors and health professionals. Incestuous relationships may continue in the absence of overt symptoms.
The health care provider may encounter incest in the form of conversion symptoms, masked depression, suicidal behavior, or genitourinary complaints.6 In general, there will be few, if any, physical signs of abuse, especially in ongoing situations or those with no force involved.
The disclosure may occur in the medical setting. Nakashima cites three responsibilities of the professional in dealing with the situation: I) to help the family deal with their reactions to the stress of the crisis; 2) to begin to evaluate the need for and kind of treatment services that will be ultimately required; and 3) to prepare the family for the necessary steps in the process, including mandatory reporting, court involvement and child welfare referrals.1 In addition, the health care provider must care for any acute medical problems of the victim, to safeguard the adolescent from any threat of further sexual abuse and to comply with the established legal requirements.15
It is essential that the provider maintain a relaxed, reassuring tactful demeanor while interacting with the victim and family. The only way to document incest is by the history. It is recommended that the health care provider interview the adolescent without the parents present. Not only does this offer support and reassurance to the adolescent but encourages her to give a complete history of the abuse. The client must know that the interview cannot remain confidential in order to protect her rights.
A complete health history should be elicited and documented as well as a full account of the sexual abuse. The client should have a complete general physical examination with particular attention paid to the mouth, anus and external genitals for any signs of trauma. Any evidence of abuse or injury should be documented in detail. This will include close observation of the clothing, fingernails and pubic hairs (dirt in the hair if the assault was recent). The external genitalia should be examined with a determination of whether or not penetration of the vaginal cavity has occurred. 1|6 The condition of the hymenal ring, diameter of the hymenal opening and the introitus should be noted and recorded. In addition, a perianal examination should be conducted for trauma, erythema, decreased sphincter tone, lubrication, lacerations, or foreign bodies.
While performing the physical examination, the health care provider should be cognizant of the need for specimen collection for laboratory examination. Not only do the laboratory results play a significant role in the client's medical management, but also in any legal proceedings." The proper collection of specimens, labeling, handling of specimens (chain of custody) ensures their admissibility in the court in the event of legal prosecution.15
The selection of laboratory tests will be determined in part by the history of the contact, type, time and in part by the findings of the physical examination. The survival of spermatozoa varies with the victim's physical condition and the site of deposit. 16 The Table shows the latest period of spermatozoa detection after sexual penetration of an adult victim.16
If the history indicates recent sexual contact, a Wood's (ultraviolet) lamp can be passed over the clothing and body of the victim. The Wood's lamp will fluoresce bluish-white (in a dark, unlit room) in the presence of semen. Specimens for sperm motility and acid phosphatase should be collected from the sites that fluoresce. Separate specimens can be collected with a sterile cottontipped swab (moistened with saline, if necessary) and gently rubbed across the skin. Each swab is placed into separate test tubes, sealed and labeled. The specimens can be checked for sperm (swab in 1 cc normal saline) and acid phosphatase (swab in 1 cc normal saline or special acid phosphatase solution). The enzyme acid phosphatase is secreted into the seminal fluid by the prostate gland. One milliliter of human ejaculate contains 400 to 8000 King Armstrong units of acid phosphatase activity. Hospital and office laboratories may have access to prepared 5% bovine serum albumin solution that preserves the enzymatic activity of semen longer than water or saline. A value of 50µ or higher is interpreted "semen positive." In addition, a gram stain can indicate the morphology and the presence of sperm (dark blue color).
UPPER LIMITS FOR TIME OF DETECTION OF SPERMATOZOA
When examining the pelvic area, the Wood's lamp should be passed over the perineal region. Secretions from the vaginal cavity and at the fornix of the vagina can be collected, placed in test tubes, sealed and examined for motile sperm and acid phosphatase. It is important to note that the test is valid only if positive. A wet mount (slide) can be prepared to observe for sperm (motile and non-motile).
All adolescents should have a base-line pap smear and pregnancy test performed. If the history reveals vaginal penetration, the menstrual history is unclear, or intercourse occurred midcycte, the possibility of administering diethylstilbestrol or a concentrated course of high dose combination birth control pills should be considered. Other factors to keep in mind are that the risk of becoming pregnant from coitus midcycle is 2% to 30%. Post-coital contraceptives are not 100% effective. The failure rate is .05%. In addition, post-coital contraceptives are contraindica ted if 72 hours or longer have passed since the midcycle sexual assault.
The recommended dosages for post-coital contraceptives are:
1. Diethylstilbestrol (DES): 25 mg (1 tablet), twice a day for five days within 24 to 72 hours after intercourse (taken orally); or
2. High dose combination birth control pills; two tablets every 12 hours for two doses(total four pills, taken orally).
The advantage of the birth control pills is that there is slightly less nausea and vomiting experienced than with the diethylstilbestrol.
The adolescent should be counseled that if post-coital contraceptives are taken and menses has not begun within three weeks, a pregnancy test should be repeated. If the test is positive, a therapeutic abortion is recommended due to the possible teratogenic effects of high-dosage hormones. Abortion is advised because of the increasing risks of genetic and hereditary disorders of offspring of consanguineous relations.
All of the possibilities and alternatives of a pregnancy should be discussed with the adolescent. The health care provider should determine the most appropriate time depending on the client's state of mind at the initial meeting.
Baseline studies for sexually transmitted diseases also should be conducted at this time.
The goals of treatment are the reconstitution of the family with the cessation of the incest and assistance to change to more appropriate and healthier role functioning. ' It is apparent that in working with an incestuous family, any treatment approach must address the variety of complex factors and dynamics.
These factors include: the relatedness of the participants, the individual pathology, the chronological and emotional age of the child, the quality of the parent-child relationship, the pattern and kind of incestuous activity and the type of family involved.1
There are a number of therapies being utilized in the treatment of incest. These include individual therapy with the alleged offender, removing the victim from the home, psychoanalysis, family therapy, and psychotherapy for the victim.
Browning and Boatman noted depression in the mothers but found these women responsive and receptive to treatment. ''' ' Pittman recognized the need for immediate attention to any acute individual problems before treatment can be taken. In some cases, court ordered treatment may be necessary for the offender to seek treatment.1
It is generally recommended that the child, mother and father receive individual therapy before attempting family therapy. The rationale for the postponed family work is that incestuous families are badly fragmented as a result of the original dysfunctional dynamics, now further exacerbated by disclosure of incest to civil authorities. Giaretto's comprehensive treatment protocol has documented success. It involves individual counseling for the child, father and mother, mother-daughter counseling, marital counseling which becomes a key treatment if the family wishes to be reunited, father-daughter counseling and group counseling.' Although the treatments are not listed in order of importance, usually all are required for family reconstruction.
The family may need assistance in locating community resources for other identified needs. The health care provider is in an ideal position for coordinating the elements of the treatment program and to serve as a liason between providers, agencies and the family.
All health care providers are mandated reporters of suspected sexual abuse. All 50 states consider incest a felony. The reporting agency may vary although it is usually a special branch of the police department or the protective services agencies. It may be necessary for the adolescent to be removed from the home and placed in temporary foster care if other suitable housing arrangements, or arrangements for the alleged offender to leave, cannot be made. It is essential that supportive counseling be initiated immediately (at the moment of disclosure) and continued.
Regardless of the treatment plan selected, specific issues in relation to the adolescent victim must be considered. The developmental tasks of adolescence will serve as a useful reference point in identifying major concerns and issues to be resolved. Keeping in mind the difficulty for nonsexually abused adolescents in achieving these tasks should clearly indicate the need for immediate, consistent and ongoing support and therapy for the sexually abused victim. Commonly the immediate therapy issues are centered around resolving guilt, relinquishing the responsibility for the relationship, despair over the break-up of the family, disloyalty to the father, anger toward the mother and a general sense of depression, helplessness and poor self-image. The therapist should recognize how emotionally charged these issues are and be prepared to deal with the client at various levels with these issues.
A treatment plan consisting of long and short term goals can be established with the input from the client. This will give direction to the therapy sessions as well as encourage the adolescent to begin taking control of her life, making decisions, providing a safe arena to assert herself and shedding the passive victim role. Not only will the client receive help through the initial crisis period but continued support through any legal justice system proceedings.
In time, the adolescent can move through unresolved issues of the incest and begin to achieve the normal developmental tasks.
In conclusion, no health care provider can ignore the possibility of sexual abuse in any patient population. An element of suspicion must arise when a history and physical findings are inconsistent, when a history is vague, incomplete or unreasonable, when the examination reveals unexplained lacerations, genital lacerations, bruising, unexplained bleeding, pregnancy or venereal disease and the demeanor of the adolescent causes one to ponder the rationale for that affect.
The possibility of identifying an incest victim and all the resulting multi-agency, multi-service interventions which will follow is frightening. But the ramifications of not pursuing, not assessing, observing, intervening and evaluating a sexually abused adolescent are severe. A sexually abused adolescent needs support and empathy. The health care provider is in an ideal position to begin any necessary treatment, be it physiological, psychological and/ or social. Networks and teams can be established so that health, legal and social needs are met in a coordinated, comprehensive manner. This may help to ensure that needs are not overlooked and that services are not duplicated. Special teams and programs are becoming more established throughout the country, but the tack of such a resource does not preclude the health care providers' legal and moral responsibility to intervene when necessary. There are gratifications from assisting an incest victim and with more and more providers responding to reporting requirements and acknowledging the need for intervention, the statistics may in time reverse so that fewer adolescents may end up suffering the consequences of repeated malignant sexual and psychological abuse.
Special thanks to Dr. Mireille Kanda, Dr. Tomas Silber and Dr. Kathy Woodward for their assistance and support.
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4. Bcrest J: Medico-legal aspects of incesi. Journal of Sex Research 4(3): 195205.
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15. Pascoe D: Management of sexually abused children. Pediair Ann 1979; 8(5):44-58.
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UPPER LIMITS FOR TIME OF DETECTION OF SPERMATOZOA