rsm92

(This paper was also presented by E= sther Mensah at our RSM meeting October 1997)

Youth Support Forum on Adolescent Health and Welfare

&nbs= p;

Twelfth F= orum Meeting 1997 - At The Royal Society of Medicine,= 1 Wimpole Street, London WC1, Thursday 23rd October 1997

Self Harming Behaviours and Eating Disorder=

An Introduction and discussion of general princi= ples - = Dr Diana Birch - Director Youth = Support

SELF HARM or SELF ABUSE may be seen either in terms of&nbs= p; - Depriving self of … Needs and/or - Engaging in harmful behaviour. F= or example

Depriving self of

by

Needs … <= /b>

Behaviour

=

and / or Engaging in:- Harmful behaviours

= Risk taking

= Harmful relationships

= Self Abuse - physical/ chemical

= WHY? - Why do young people self harm? There are often complex multifactorial reasons which are dependant on individual experience - what does it mean for this particular person - for example - Early patterns Abuse and neglect - w= hat is normal - What do I deserve?

Communication - how do I show my pa= in - I can’t tell you what happened - but if you see my pain you may guess= - or ask me. You can tell by the way I look, by th= e way I act … etc

Guilt - The abuse must be my fault = - so I’ll punish myself some more.

=

Concretisation - making the pain vi= sible - reframing it - making it tangible - a cut , bleeding, - the pain is now my wound - not my inner scars of say sexual abu= se.

Release and expression - pent up feelings - I want to scream - I can’t bear this pain -

Avoidance - of people / situations - I’ll make myself unattractive, unwanted, unlovable (on the outside) because that’s the way I feel about myself (on the inside)=

Power and Control - I have control = over my own abuse (scoring a point against perpetrator) . Eating disorder prime example of ‘control’ of fam= ily.

Self Injury - &n= bsp;            = ; Sheena Brown - Senior Therapist - Youth Support House

I should like to talk about self in= jury in the context of survivors of documented sexual abuse. I shall briefly exa= mine this complex phenomenon and its treatment from a psychodynamic perspective. Initially I shall do this in theory and then through a case study that is v= ery representative of the numerous young women who have attended Youth Support exhibiting this behaviour.

During self injury a woman causes physical damage to herself by, most commonly, scratching biting, cutting, gouging or piercing parts of her body. Most women hide the evidence although latter stages this is sometimes not the case. It is a generally held belief that this behaviour is often an attempt to expiate feelings of guilt, shame= and emotional pain. It is also, for some survivors of sexual abuse, the only available way to express feelings of extreme distress. Brienes study of 1984 which is supported by other researches noted that 31% of survivors of child= hood sexual abuse exhibited a desire to hurt themselves as opposed to l9% of a n= on abused group

I should like to consider self inju= ry as an idiom of distress, indeed a somatic response to distress. By this I m= ean a bodily expressed response that has no apparent meaning in words. Bearing = this in mind and noting that a commonly observed feature of surviving abuse is dissociation from the original trauma. This is done to effect psychic survi= val. Self injury can therefore be seen as a way for the survivor to be able to concretely feel that they and their feelings do exist. = In dissociation the mind ‘splits’ from the body in order to avoid = the effects of pain. This is in order to bring a sense of emotional detachment, of unreality and of not feeling the body’s existence. Cutting, therefore, is a way of feeling alive and associated with ones body. Additionally, in abuse, pain and love can become entangled. This, in turn, = may result in the survivor needing to re-experience the pain which is inextrica= bly linked with love that she felt for the abuser particularly if the abuser wa= s a parent.

Self injury is also linked to self punishment. Part of the process of abuse is the internalisation of negative feelings about the self. Survivors self esteem is often very low - they bel= ieve themselves to be worthless, bad etc. and as a result they could be seen, via self injury, to be destroying themselves body and soul. I have long felt and noted the pervasively silent and silencing properties of abuse. Thankfully,= change is happening and abuse is not the taboo it once was. However, for many survivors - especially children - there might have been no acknowledgement = by the parent that abuse was taking place;&nb= sp; so for them self injuring was the bodily expression of the hidden sc= ars, the emotional damage, a concept noted in the work of Dr Diana Birch.

Can I therefore ask you to consider self injury from the perspective of a cry for desperately needed nurturing, that was after the original trauma denied a= nd even, more tragically, withheld?

I should now like to consider this embodiment of distress further via a case study of a young woman I shall ca= ll Anne.

Anne came s a resident to YSH with a long and terrible history of life experiences. Some = of these included 30 or so care placements before the age of l3 years. She had three suicidal experiences, including one where she leapt off a high river bridge when in the fourth month of pregnancy. As a child she had been repeatedly sexually abused by a close family member.

Diagnosed as having a personality disorder, an alcohol addiction, bulimia /anorexia and a disastrous personal life Anne was still only I her early twenties. She was to be assessed for h= er ability to parent her two lovely toddlers.

Originally Anne lived until the age= of sixteen near a market town. She was one of many children, born in great poverty and rural deprivation, to a very much older father and a young vulnerable apparently learning disabled mother. The family life that Anne witnessed was disordered and her visits home were of short duration usually when social services had= run out of funds or placements. Anne described mother as taking “old men = home from the local pub for drink and sex sessions”. Father also a drinker beat her mother on occasions, this whether he was drunk or sober. Anne as a child witnessed much of this. She went on to re-enact unconsciously a lot of her early experiences in her teenage years. She truly had survived abuse but with a lot of damage.

Despite the tragedy of her short li= fe to date Anne had an ebullience, an optimism and = an infectious sense of humour. It is to be noted that her humour was revealing= ly an angry humour with images of pain. She once memorably described a person’s distasteful expression as being “like a rottweiller chewing a wasp”. Helman notes the metaphoric use of pain in our day to day speech, i.e. “she hurt him deeply” or “I was sore with them” etc. We are using pain words to express feelings. Engel says of pain that it is ‘private data - the sufferer has to tell us, we cannot see the pain’. It is generally noted that the prognosis for healing is better for children whose abusive experience is heard and believed by the parents. So what happens to the child who has been allowed no expression of their pain as was the case in this situation?

Anne came from a family where there= was little hope of any distress or pain being heard. Her parents were engulfed = in their own dysfunctions and with many children born virtually one after the other there was nobody to pay attention to the needs of one distressed litt= le girl.

Placements in large old fashioned children’s homes did little to help Anne so as an abuse survivor she = took into herself, she internalised, feelings of guilt, shame, blame and a huge feelings of anger - all of which were destructive. Consequently her feeling= s of lack of self worth emerged. A child who feels unworthy does not believe or = see themselves worthy of being loved and cared for. For them, being nurtured is= an alien feeling.

In an attempt, begun when she was 8= or 9 years old, to try to communicate her anguish Anne cut and gouged her body, particularly her arms and legs. Her arms were a mass of ugly livid scars. S= he was also determined to show these scars to the world,to externalise her feelings and give them expression. She wanted to make her feelings real. One bitter cold day she refused to wear her coat in a public situation and put on a sleeveless T sh= irt instead.

Her cutting had another purpose, she told me, it offered a release. She said that whe= n she was ‘worked up’ she cut to feel a relief. Engel notes that pain= has two components, the original sensation and the reaction to that sensation. Perhaps the original pain of the cut was redolent for her of the pain she f= elt as an abused child and her reaction to the pain was the gratification of ha= ving a tangible sensation to mourn. Perhaps, also the resultant scars were an embodiment of her distress= and suffering that had not been noted before. I also suggest that each cut or g= ouge represented another attempt to understand and conquer the original trauma. = Whatever the reason for this behaviour Ann’s arms had t= o be seen as a communication. When her cries were initially heard at Youth Support Ann found the nurturing response invasive and = confusing,however after a long period of time when Ann w= as supported with her struggles with parenthood, anorexia, harming, bulimia and sobriety, she began to process her childhood abuse and confront her terror.= Her battle with her self destructive demons continued but the embodiment of he childhood pain ceased to have it’s original purpose.

This young man called Kevin who vis= ited Youth Support House&nb= sp; because his girlfriend since l5 had his child and was subject= to an assessment and there was no support from families etc. Because he was the father arrangements were made for hi m to be included in her assessment. My first impressions were that he looked a typical National Front type, had a = bit of a put down look about him and it is important to remember initial impressions. It soon emerged that once you got through his shell he was very approachable. I will briefly go through his background so you can see the connection with the theme of self harm.&nb= sp; He had one brother 2 years younger who seems the only constant in his life when he was growing up, his parents werent= ’ together, his father had left when he was a baby, and when he was 4 and he remembers this vividly, he can’t understand why he had gone to bed and when he awoke his mother had left. He had some contact with her, but he= was left with his stepfather and brother and the stepfather went off to work ea= rly, Kevin looked after his younger brother and got his breakfast and at 9am when the childminder came he went off to school. In the evenings they were alone until the stepfather came back late. Aged 7 he was aware he could not trust anyone, had to look after himself, and was referred to the Maudsley because of his sudden o= utburts of angry feelings towards his stepfather. He also remembers episodes of sex= ual abuse by his uncle without his stepfathers knowledge and was very much alon= e, self sufficient by this time. Aged l5 he had a fight with his father which = was a particularly bad one, and his father ordered him out. As a final blow he = told Kevin he was not his child anyway. From then on until being admitted to hospital at the age of l8 he was very much on his own. He stayed with his <= span class=3DSpellE>nan for a while which did = not work, but was mainly on the streets. He was often part of a group which set= up homosexuals and took money from them. His girlfriend became very important = in his life, we noticed at YSH he was far more inte= rested in his girlfriend than his child. He said she was the only person he could trust, when he met her he was suicidal and she was the only person he could chat to. He did not spend much time at YSH but we felt he was pushing barri= ers all the time, and was often not allowed in.

We looked at the process of what ha= ppened when he was depressed, feeling empty and suddenly he would feel he had to do something to relieve the depression.. He sometimes whilst staying in hostels cleaned= his room twice a day and this would help. At other times he could only get relief by cutting himself and would be fascinated by watching the blood flo= w. He says he felt no pain at this time. The interesting thing was the distanc= ing between himself and his body and he said he rarely experienced pain, he could harm himself and not feel anything. He was seriously cut about the nec= k in one incident and spent 7 days in hospital and still has to go back for chec= kups but had no experience of that pain. Sexually he said he could take it or le= ave it. Taste also, he could not = taste anything. He had an eating disorder because his stepfather would be rushing= him to finish up meals, very impatient, and when he had the bustup and left he didnt eat at all, so a pattern of punishing his stepfather had by not eating had set in by then.<= /span>

He had l5 sessions until he broke up with his girlfriend and disappeared. He seemed to like the opportunity to tal= k, and as it turned out he was intelligent and he said once he understood the pers= on he was talking to wasn’t putting him down he could take off his mask. There was a sense of hostility, he expected rejection and people to let him= down, so there was a self-fulfilling prophecy about his whole life. He had a big tough exterior which he needed, to be on his guard, and had adopted this ve= ry early on so his feelings of pain both physical and ment= al were numbed.

I felt he was someone who self harmed= but was a particular example of how problems are complex and multifaceted.=

A Case History - Alcoholism -      =      Sheila Atherley - Senior Nurse - Youth Support.

Alcohol is the most widely used dru= g in Britain. People drink for many reasons; for example- to enhance meals and celebratio= ns,to relax with friends and family,to escape problems, = to block out feelings of guilt, loneliness etc

Alcohol is quickly absorbed into the bloodstream. It does not need to be digested. Alcohol slows down the brain affecting judgement, co-ordination and emotions. The body burns off alcohol= at the rate of about one unit per hour, most removed by the liver. Time is the only thing that can sober you up,not coffee, exe= rcise, fresh air or cold showers.

Background of case study=

Mrs X aged 39 is the mother of six children ages ranging from 3yrs to 20 yrs. Two of the children died at an e= arly age, at four weeks and two weeks because of cot death. Baby k was born prematurely at 34 weeks and was diagnosed as foetal alcohol syndrome and a heart murmur

Mrs x di= vorced her violent husband but became involved in another violent relationship - in addition she had a drink problem. She also spoke of her loss i.e. the death= of her mother, two babies dying at an early age, and a baby being adopted her = self worth has been deeply damaged by her experience of loss and particularly her experience of being judged as a bad mother. The records state that she has a long standing chronic alcohol abuse problem and consequential child neglect, with continual exposure of her daughter to gross incidents of domestic violence.

MrsX revealed no insight at all into the damage her lifestyle had caused to this child and would be likely to ca= use in future. In view of her lack of co-operation and inconsistency working wi= th social workers and the poor school attendance of her daughter social servic= es applied to the courts for a supervision order

The Guardian Ad Litem came to the p= oint where Mrs X was recommended for psychiatric assessment, hence the admission= to our unit (YSH).

Mrs X was admitted to YSH in May 19= 95 for rehabilitation. A six week intensive residential al= cohol treatment programme, to look at personal issues regarding her dependency, relationships and parenting ability. Her programme included attend A.A.meetings; To agree to random bag and room se= arch; Complete abstention - hence no alcohol, no medication,

no tranquillisers, sedatives or mood altering substances such as cannabis or o= ther drugs. Mrs X was a secret drinker as reported by her partner. She was in constant denial of having a drink problem. At times she appeared intoxicated with a strong smell of alcohol on her breath. She was involved in an incident of violence on the street, outside pubs and in the neighbourhood whilst under = the influence of alcohol.

When challenged= Mrs X would deny having taken alcohol but admitted to having the odd glass of bee= r or lager. Sometimes she would leave the house to attend meetings or contact wi= th her children accompanied or escorted by a member of staff, then refused to return with staff. Other times she would go out and exceed the agreed time = to return

On return she would give an alibi s= uch as having met her partner, friend or her dad. More often than not she appea= red intoxicated There was also evidence of facial bruising, black eye or missing broken front teeth indicating she was involv= ed in a violent episode. When confronted, she stated that the injuries were an accident, but more likely they were a result of confrontation with her viol= ent partner. She attended AA meetings initially with a member of staff then requested to go on her own which was short lived because of her compulsion = to drink. In view of her denial, lack of co-operation and inconsistency the tr= eatment programme was unsuccessful on this occasion although she at a later date ha= d a change of attitude which allowed her to accept her alcoholism and she then responded to treatment.

The Role of the Ea= ting Disorders Association - Joanne Seymour - Eating Disorders Association.=

Eating disorders in Young People gi= ves information about eating disorders for young people by young people. We take messages and contact young people at a time which suits them and also run a help line Mondays to Fridays, and an ansafone at all times. We can recall a= nd save them a cost of a phone call. Phone is answered by trained helpers and = in 1996 the Youth Service was further developed by the addition of three information leaflets specifically aimed at young people.<= /p>

Eating Disorders gives information about anorexia, bulimia etc. and examines the various ways young people can= get help, what is available and what to expect. Friends and relatives write about = their experiences and why they get disorders, how they can be helped. The third leaflet explains confidentiality and their rights, the issue which many you= ng people who contact us are worried about, involving their family etc. The leaflet gives information about the Law and rights, suggestions how to get support and gain confidence. = The latest edition has ‘Talkback’ a feature introduced in August 19= 96 with the intention of encouraging young people to express themselves by let= ter or postcard, to share their experiences with others.

We also prepare articles for Talkba= ck, each focusing on different topics eg bullying, = self harm, friends, recovery, self esteem - this month looking as aspects of gro= wing up. Because of cutbacks we ha= ve cut the issue to two pages but hopefully we are sending it to the young people = who are signposted as the magazine is sent out. The other main function is telephone calls from young people mainly connected with school projects but later on their own behalf, in desperation and needing an outlet. Ongoing correspondence is often used to encourage and point the girls in the right direction. The telephone lines can be useful when someone wants to talk in confidence, apart from the girls sometimes from friends and youth workers involved in their care. They can often feel hopeless, like the girl despera= tely worried about her parents relationship and did n= ot want to burden them with her own worries, or the friend who could hear her friend being sick in the cloakroom and didn’t know what to do. They often simply unburden themsel= ves and we try to help to show there is more than one way to look at the problems.<= o:p>

I would like to add that callers co= me from all walks of society, not just middle class girls= as is sometimes thought.

Many schoolgirls find themselves ge= tting fat and try to diet quickly - a problem increasingly co= mmon especially teen magazines read by l0 yr. olds which present an ideal fashion figure. Information about healthy eating and aspects of puberty whi= ch many girls know little about is given in our leaflets. A large part of their time is spent in their own rooms at this age with a decline of family mealtimes, possibly with entertainment away from the family and many people find that snacking replaces lunch. Sometimes if they have an eating disorder they may need to know what weight gains are ideal so they do not put too mu= ch weight on too quickly which would be counterproductive<= /span>

We have a netwo= rk of self help groups across = the country which passes on details to its members, they may call a contact for= a chat and also give useful directions to youth counselling services. Young callers who do not want to talk to their parents or teachers may find our leaflets useful.

In the February issue of Talkback we decided to tackle the sensitive issue of self harm. Both Ann and I have been receiving letters about experiences, eating and self harm often go together whereby the girl could hurt herself both inside and out. We thought it important to bring this topic into the open because girls may be suffering = in silence and not know what to do, information on how to get help from an art= icle and several letters from self harming girls. One letter was:

I am Katy Wright, a self harmer,= and I would like to share my experiences with others so they know they are not al= one and can identify with me. I had secondary anorexia for the past sixteen mon= ths and during this time although my weight never dropped severely low my mental state did. Every month I would go through scenes of self hate, so mixed up = and when people asked I could only say I don’t know, very angry and very hurt. I was constantly crying. Soon all this was too much for me. I was confused, I was still trying to starve myself and could not cope with my feelings trying to block them out and become numb to emotions. At first I started constantly digging my nails in and scratching = my hands drawing blood then it became all out cutting my arms, I had to feel t= he pain. Somehow people always found out, a “caring friend” who to= ld teacher who then told my parents and could not understand why I did it. It was just my painful life. Along= with people telling me to eat they were now telling me what to do and how to do = it to my own body. The crunch finally came when I scratched along my ribcage a= nd was threatened with being admitted to the psychiatric unit. No one understo= od that the hurt inside was too bad, I had to get it out. Life is getting easier b= it by bit, I managed to go three months now without hurting myself. My eating is still not regular but I am starting to sort that out t= oo. Things in life can get so bad, the pain and anger so bad, but for anyone out there please hang in because things do get better.

Whilst EDA cannot claim to sort the= se issues out it does seem to be able to provide a balancing role in encouragi= ng those young people to contact those who can help them to recover. Often it = is the first step which is the hardest, once they have opened up to talk about eating habits going on to start treatment is often easier. EDA will go on establishing valuable links with professionals and continue to provide a comprehensive service for our young people.

- International Chapter News= -

News of the International Regional Chapter (IRC) of SAM

(Society for Adolescent Medicine) =

=

Co Ch= airs - Diana Birch Gustavo Girard Treasurer Aric Schi= chor

        &= nbsp; London=       Buenos Aires=             = Connecticut<= span lang=3DEN-GB style=3D'font-family:Courier'>

        &= nbsp; England=      Argentina=             &nb= sp; USA

= Our Chapter Institute at the 1998 SAM meeting (Society for Adoles= cent Medicine) Atlanta - March 4th 1998= was on the subject of ‘Exploitation of Youth - An International Perspective’

Our Youth are our resource for the future - but are we exploiting that resource? Across the world employers know that youth are a source= of low waged labour, from teens working in fast food outlets to primary sch= ool children whose tiny hands can knot high quality carpets. They often work in dangerous and abusive conditions. Adolescent sexuality provides another rich area for exploitation - sexual tourism is on the increase and young prostit= utes of both sexes are a prime attraction. Presentations will look at types of e= xploitation in differing cultures from the USA to the = Far East and raise the ques= tion of where lie our responsibilities and our role in prevention?

This will be reported in full in the next journal and I am sure that those of you who were unable to attend will find the transcript informative and very wide reaching - in fact it is beca= use we covered so much ground that there is no room for the write up in this edition.

The 1999 SAM meeting is taking plac= e in Los Angeles on the theme of family work - we have therefore proposed the following form= at for an institute and hope to hear from the SAM organisers in the very near future as to whether the idea has been accepted.   We would very much like to h= ear from anyone interested in presenting or participating.

SAM 1999 - IRC Ins= titute

“When is a f= amily dysfunctional? - A cross cultural view.”

The family provides the ‘stage’ upon which emotional development ta= kes place and sets the scene for future difficulties, personality problems, and patterns of low self worth, self harm and abuse. Our concept of ‘family’ has changed from the classical view of the nuclear fam= ily to a variety of models including extended family, single parent, adolescent parent - there is no single concept of ‘family’. On a mo= re cosmopolitan level - family structure varies cross culturally and we should perhaps also consider bands of street kids and runaways as developing their= own ‘family’ groups.

What family structures work for the individual and why? What is a dysfunctional family? How can we and when should we intervene? By working with families we hope to break cycles of dysfunctional patterns and enable children to grow = into happy effective adults and future parents themselves. This institute will explore the ab= ove issues on a cross cultural basis and attempt to draw common lessons from our joint experiences.

=

Sexual Ab= use and the Girl Child

Sheila Campbell-Forrester Senior Medical Officer of Heal= th - Jamaica

Child sexual abuse especially in the girl child has been with us for centuries and has become an important Public health problem over the past decade. Sexual abuse in the girl child accounts for approximately a third of all child abuse cases. Sexual abuse is defined= as the exploitation of a child through violent or non violent molestation. This includes a spectrum of behaviour ranging from violent rape to inappropriate touching of the genitals or seduction. Data from the STD Control Programme = of the Ministry of Health revealed a decreasing trend in the cases of Gonorrho= ea seen in the 0-14 age group between 1991 and 1992, 9.2% and 4.6% cases respectively but the trend of more females than males continues to be seen. That is 8% of cases and 4.3% in 1991 and 1992 were females. The data sugges= ts that 80 - 90% of sexual abuse occurs in the girl child which is corroborate= d by data from the Child Guidance Clinics. Similar findings are also reported fr= om the United States where 90% of sexual abuse is to the girl child.

In a study done at the University Hospital in 1984 the youngest child was 9 months of age with a mean of age of 8 year= s. Children in this study were seen with a range of STD’s i.e.genital warts, trichomonas, herpes, all evidenced through sexual molestation. There appears to be an association between stability of home environment and sexual molestation wi= th 60% mothers unemployed, one third having no stable residence and the highest incidence occurring during school holidays when supervision is minimal.

Characteristics of offenders vary a= nd research has not been able to show any difference between the make up of a perpetrator and an ordinary man and sometimes sexual abuse is seen as an extension of male sexuality. A study of sexual abused cases seen at the chi= ld guidance clinic in 1987-88 showed that in 32% of cases sexual abusers were strangers, 25% were neighbours, 22% were male relatives, 11% were stepfathe= rs and 2% fathers. A wide range of physical and behavioural consequences may o= ccur as a result of sexual abuse in the girl child, although not confined to the girl child alone. In the study previously referred to done at the child guidance clinic the most common presentations were emotional - that of the child being sad and weepy, followed by physical problems (vaginal discharge) and then sleep disturbances, aggression, headaches and promiscuous or seduc= tive behaviour. The history and medical evaluation is therefore of utmost import= ance and may be the only evidence available for the courts.

Current laws are grossly inadequate= in the protection of children from sexual abuse particularly as it relates to exploitation of the young girl. The present age of consent is 14 years and should be raised to l6 years. The measure of punishment needs to be reviewed and the Justice Act needs to include proprietors of night clubs who employ = girls under l7 years. Reformations of the law is neces= sary and needs to be more “friendly” in enabling the justice process= in sexual abuse in any child.

Child sexual abuse especially in the girl child has been with us for centuries and has become an important Public health problem. It is quite common for newspapers to print letters or to re= port on some aspect of child sexual abuse (eg child hookers in Ocho Rios, Daily Gleaner May l4,1995= ) This is probably so because more persons are becoming more willing to report chi= ld sexual abuse and to share their experiences. This is further borne out by t= he increase in visits to institutions allowing the Central Registry and Child Guidance Clinics to record and report invaluable information on the child abuse.

Child sexual abuse has been defined= as the exploitation of a child through violent or non violent molestation. This includes a spectrum of behaviour ranging from violent rape to inappropriate touching of the genitals or seduction. (Milourn= 1993 p.1) It also includes the use of the child for pornographic purposes, prostitution, exhibitionism and exposure to erotic material for the purpose= of stimulation of the child and gratification of the abuser (Horsham 1989,p.4)

EPIDEMIOLOGY

Between 1987 and 1988 the Child Guidance Clinic at the Comprehensive Health Centre saw 55 cases of sexual abused children, 51 or 93% of which were females and 4 (7%) were males. At = the child abuse clinic at the University Hospital 424 girls were seen with a vaginal discharge I 1984, 80 girls (14%) were confirmed as having gonorrhoe= a, which is considered to be evidence of sexual abuse. The age of youngest chi= ld was 9 months and the mean age was 8 years. Children were seen with genital warts, trichomonas, herpes,= all evidence of sexual molestation (Task Force report April 1993, p.2) The = 1993 data from the central registry which represents island wide data reported 2= 43 cases of sexual abuse which was 60% of all child abuse cases. Sexual abuse = was the most frequently reported type of abuse. Of the 243 cases, 237 or 97.3% = were females and 6 were males which confirms the mark= ed predominance of females in this kind of abuse. Child Guidance Clinic report 1994

= Type of abuse No   %

Sexual        243   60

Physical     120   30

Emotional     22 = 5

Neglect       19   5

The national data on sexually transmitted disease showed the following trend in gonorrhoea in the under fourteen age group; sexual abuse should always be considered in the girl ch= ild with an STD.Gonorrhoea cases in the girl child = are therefore a sensitive indicator of sexual abuse although the data would not reflect whether or not the transmission may have been sexual or non sexual. Between 1991 and 1994 an average of 229 cases of gonorrhoea were reported in both males and females in the under 14 age group, 80% of which were femal

Of all the reported cases of gonorr= hoea in females 8% were in the under l4 age group in 1991, 4.3% in 1992, 6% in 1= 993, and 4.4% in 1994. Less than 1% of cases in this age group were males(STD Control Programme Annual Report 1992, Data 1993/94)

=

The data is corroborated by that reported from the United States where it is estimated that 90% of reported cases involve girls and that only between 2% to 10% of incidents are report= ed (Jong 1990, p.1) The1984 university study suggested a correlation between stability of home environment and sexual molestation as= 60% of mothers of these children were unemployed; over one third had no stable residence and the highest incidence were seen in January and September when= it is presumed that the children were left unprotected during the school holid= ays (Joint Task Force Report p.3) The data of the central registry also noted a seasonal variation in sexual abuse cases with an increase of cases occurrin= g in May and October (Child Guidance Clinic report p.8) It is, however, difficul= t to explain this variation. All of the perpetrators of sexual abuse were men, a= nd this has not changed since 1987/88. It is estimated that approximately a th= ird of perpetrators are in the age group 20-34 years old.

Sexual abuse can occur in any famil= y at any socio-economic level, however in the Jamaican situation one has to cons= ider such factors as the transient union situation where mothers change boyfrien= ds frequently and usually for economic gains. Very often it is the boyfriend w= ho is the perpetrator. Step-parenting, marital breakdown and poor supervision = of children may be other factors to be considered in child sexual abuse. There= are also some fathers who think it is their right to have first intercourse with their girl child and the myth still exists that the cure for gonorrhoea is = to have sexual intercourse with a virgin.

= The perpetrator - psychological, economic and demographic characteristics of offenders vary According to Emily Driver research has failed to find any fundamental difference between the make up = of the child molester and men in general, and sexual abuse of children is seen= by some as an extension of normal male sexuality. Sexual prowess is an importa= nt part of the male self image and by tradition involves conquest, domination = and taking the initiative all of which are easier with children (Emily Driver 1= 989) In Jamaica strangers were 32% of perpetrators, relatives 25% cases and 25% = of children were victimised by other individuals previously known to them(neighbours).(Millbourn 1991) In the child guidance clinic study of 1987/88 the following was found to be= the profile of the sexual abuser:

&nb= sp;    Abuser       No   %

= Complete stranger 18 32.7

= Neighbours       14 25.4<= /p>
= Male relatives    12 21.8<= /p>
= Stepfathers       6<= span style=3D'mso-spacerun:yes'> 10.9<= /p>
= Not stated        3   5.4

= Father            1   1.8

Stepgrandfather    1   1.8

=

Many perpetrators involved in repetitive abuse were usually themselves abused as children. In the case of= the abusive father, he often has unfulfilled needs. Some are often wife abusers,maybe drug or alco= hol abusers, unemployed or paedophilic.

Date rape or acquaintance rape situations in which a male forces or pressures a peer into sexual activity = while others involve misrepresentation of power or authority to engage younger children in sexual contact. = If these acts are not disclosed or reported then the perpetrator will abuse ot= her children.

Case history: Adolescent Date Rape = -15 year old Gem obese female, who has a low self esteem meets boy whom she thi= nks she likes. He invites her to his home. She goes, no one else is home. He te= lls her to take off her clothes, she refuses, he loc= ks her in and rapes her. Afterwards he tells her to leave. Gem cannot tell mother = as mother is very strict and does not allow her to go out with boys. The child guidance clinic study of 1987/88 noted that 7 teenagers were male perpetrat= ors. Three of the group were part of gang rape attacks on three girls. This is a disturbing fact when it is recognised that there is such “disrespect = and disregard for females by boys in our community” (Milbourn 1991, p.7)

= The Victim= -Children are taught to be obedient and obey the requests of adult without questionin= g. They are also vulnerable because they believe in and fear the threats of perpetrators. under 5 years of age they are not = always able to distinguish between right and wrong and their emotional growth and development is hinged on love - i.e. hugging, touching and cuddling. These qualities make them vulnerable to sexual abuse and continuing abuse(Horsham 1989

=

= The Mother= In the Jamaican context it has been observed that mothers whose children have = been sexually abused were seen to be passive, disconnected from their daughters = and accepting the sexual abuse almost as if it were inevitable. They often bow = to pressure from family and neighbours “to drop the case” and pay little attention to follow up of the child (Milbourn 1991, p.7)

Behavioural consequences and perpetrators methods - The initial and long term physic= al and emotional symptoms of sexual abuse vary with the trauma resulting from = the abuse and the age and sex of the child. Infants and toddlers may have gener= al irritability from oral and rectal abrasions that cannot be localised by par= ent or physician. Dysuria from genital trauma may s= uggest a urinary tract infection. Trauma resulting in laceration to the vestibule, anus or hymen should be associated with bleeding; however, an anal fissure = from penetration may be misdiagnosed. Symptoms vary with age and sex of the chil= d. Some may be overt such as fear and avoidance of the perpetrator or general = and non specific.Symptoms may present in adulthood = and can include medical complaints including alcoholism, sexual compulsiveness,= identity and relationship confusion. The older child m= ay be able to relate about the abuse but may be reluctant because of fear of reprisals, guilt associated with the act of acceptance of bribes or fear of dissolution of the family (Garfinkel, Carlson, = Weller 1990)

In the Child Guidance Study 1987-88= the presenting characteristics of sexual abuse were:

PHYSICAL& BEHAVIORAL OBSERVATIO= NS

= ASSOCIATED WITH SEXUAL ABUSE

Characteristics    No  =     %

Sad and weepy      23=       25

Physical symptoms

(vaginal discharge) 19      21.1

Sleep disturbance 13&= nbsp;    14.1

Aggressive         9       9.7<= /p>
Somatic symptoms   8       8.6<= /p>
Seductive promiscuous7     7.6<= /p>
Enuresis encop= resis 5 &= nbsp;     5.4<= /p>
Runaway behaviour 3&= nbsp;     3.2<= /p>
Stealing           3       3.2<= /p>
Suicidal thoughts=

and behaviour        3     3.2<= /p>
(Milbourn 1991 p.16)

Powerlessness or disempowerment res= ults because the girl child’s needs and will are made subservient to the <= span class=3DGramE>perpetrator’s. The sense of powerlessness and hopelessness is associated anxiety, fear, phobias, hyper-vigilance, perception of self as victim, somatic complaints school problems, vulnerability to future abuse or becoming an abuser.

Stigmatisation occurs because the c= hild is given a message of being responsible or to blame for the abuse. This results in feelings of guilt, shame, isolation, l= owered self esteem, suicidal ideation, criminal behaviour and self injuring behavi= our such as drug or alcohol abuse.

Masked presentations of sexual abuse are common. These cases are characterised by initial physical or behaviour complaints other than sexual abuse. Masked presentation may make up approximately 19-60% of diagnosed sexual abuse cases. Typical masked compla= ints are genital symptoms, abdominal pain, constipation or rectal bleeding, stra= ddle injury, pregnancy and other somatic and behavioural problems (De Jong 1990,p.4)<= /span>

= MEDICAL EVALUATION OF SEXUALLY ABUSED CHILD History of sexual abuse Sexual abuse of children usually follows a predictable sequence of events. Histori= cal details corroborated by specific physical findings provide the strongest ev= idence of sexual abuse. Statements made to the physician may be particularly impor= tant in validating the allegations and may be admissable in court as an exception to the hearsay rule. The child’s statements = are important as they may be the only evidence that abuse has occurred and it is critical that the interview be carried out with the same attention to detai= l as with collecting forensic evidence.

A sensitive, no= n threatening, non leading, unhurried approach is essential. It is usually painful for children to discuss their experiences and can be quite difficult for professionals to listen. Children are extremely sensitive to the reacti= ons of those to whom they disclose the abuse. The interviewer must be open and objective and not presume that the child was psychologically damaged, embarrassed or hurt. Nor should the interviewer presuppose the child’s feelings about his or her abuser; such feelings may be complex and ambivale= nt.

When conducting the interview, the physician should: 1. Inform the child of what will happen during the interv= iew and physical examination. 2  &nbs= p; Acknowledge how difficult it is for the child to talk, give support but not promise what cannot be delivered 3. Encourage the child to ask questions 4. Determine child’s name for bo= dy parts and names and nicknames of family members, use these terms during the interview. 5.Obtain a medical history particular= ly of the gentio-urinary system or gastro-intestinal complaints 6.Reassure child that she is not to blame 7.Avoid using negative words. 8.Be non judgmental, matter of fact or ca= sual. 9.Supplement a direct questioning approach with the us= e of communication aids such as drawing activity, puppets or anatomically detail= ed dolls.

The child is often best interviewed= in the absence of the parents although this is not always possible. When taking the child’s history the physical should obtain answers to the followi= ng questions. Who is the perpetrator? Is he or she a stranger or known to the child? How did the alleged perpetrator gain access to the child, have opportunity for private interaction and how were the activities presented to the child? Was this a single episode or recurrent abuse? Was there a progression of increase in intimacy of contact? How did the child describe his or her feelings during the activities? What were the circumstances surrounding the disclosure and was = it accidental or purposeful? When was the last abuse? What has happened since = the last episode? What type of sexual contact was attempted? (DeJong 1990,p.5-6)

= SEXUALLY TRANSMITTED DISEASES -The sexually abused girl child or a= ny other abused child is at risk of an STD. This may be the only physical evid= ence of sexual contact and sexual abuse. The matter of STDs has to be handled wi= th care to determine non sexual or sexual transmission. HI= V disease poses a challenge i= n the case of the sexually abused girl child. Testing for HIV disease is indicate= d in all cases especially where the perpetrator is a known case or there is no baseline knowledge about the perpetrator. In acute molestation recognition = of the window period requires that baseline testing be done and the test repea= ted in three months. The HIV positive child in addition to facing the stresses = of abuse has to face new challenges of stigmatisation and of becoming an outca= st on society.

Case: <= span lang=3DEN-GB style=3D'font-family:"Courier New";mso-bidi-font-family:"Tim= es New Roman"'>Marina aged 7 was sexually abused. She tested positive for HiV and the perpetrator apprehended. Marina had to be removed from the area in which she lived because she would not ha= ve been accepted by the community and school. Father wanted to have nothing to= do with her and mother was left to support her. This is only one tragedy of an= HIV infected child who has been abused.

= SEXUAL ABUSE - THE GIRL CHILD AND THE LAW -= The Joint Task Force on Child Abuse stated in its report that “Current la= ws do not appear to be adequate in the protection of children from sexual abus= e, particularly from the point of view of exploitation of young girls”.The present age of consent is l6 years h= aving been changed in 1988.There is anomaly between the Incest Act which provides maximum punishment of ten years for a father who abuses his child under 12 years of age and the Offences Against the Person Act which provides a penal= ty of life imprisonment for carnal abuse of a young girl of the same age who is not related. The Task Force recommends equal punishment for abusers of chil= dren under 12 years whether or not they are related plus - 1.Mandatory reporting= of child abuse cases. Medical practitioners, social workers and the police are required by law to report cases to the Registry 2.Mandatory counselling and psychiatric treatment for sexual abusers in a family situation. 3.Empowerment of the court to remove the child or offe= nder from the home in the case of incest involving a girl under l7 years while t= rial is pending, whichever is in the best interest of the child. 4.It is also recommended that provision should be made under the Juvenile Act to prosecute a)the proprietor of a nightclub who employed a girl under l7 b)the owners of premises who knowingly re= nt their premises for use as a brothel where girls aged l7 are used as prostitutes. c)the persons who watch girls perfo= rm indecently or are present at such performances.

Reformation of the law is necessary= and needs to be more “friendly” in enabling the justice process in sexual abuse of any child. The Convention on the Rights of the Child (Art 3= 4,1989) states that the State shall protect children fr= om sexual exploitation and abuse, including prostitution and involvement in pornography. What should be society’s vision of our children? It shou= ld be one where are children are happy, healthy, wholesome, protected, loved a= nd cared for to enable them to achieve their full potential and certainly not abused.

Acknowledgements to Dr Pauline Milbourn, Dr Beryl Irons, Joint Task Force,Dr Alfred Braithwaite, Phylis= Smikle

REFERENCES

1.Horsham Patricia M.D.Practical Guidelines to the assess= ment of the sexually abused child

2.Report= on the Task Force on Child Abuse

3.DeJong= A.R. Child Sexual Abuse, Pediatrics and Nutrition Re= view

Exerpta= Medic vol.4.No2.p 1-8

4.Sexually transmitted disease control programme report 1991-92

5.Emily Driver and Audrey Droisen, Child Sexual Abuse, Feminist perspectives

6.Garfinel, Carlson & Weller Psychiat= ric disorders in children and adolescents, 341-343

7.Child= Abuse in Jamaica - COJ UNICEF Review of Children in extremely difficult circumstances

8.Child Guidance Clinic annual report 1994

9.Unpublished data STD 1992-94

10.Pauline Milbourn, Fernanda DiTullio, Valerie Beckford - Child Abuse in a child guidance clinic setting.

APPLY NOW !!

Youth Support International Confere= nce on Adolescent Health and Welfare - 1998

Royal = College= of Physi= cians - London

October 2= 2^nd and 23^rd 1998

Applicati= on forms from Youth Support

Conference Administration

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OR Visit = our new Website at http://www.youthsupport= .demon.co.uk

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Proceedings of our conference 1996

Youth - Our Resource for the Future <= /span>

Now available from Youth Support

- £5 by mail order -

write to YSH 13 Crescent Ro= ad London BR3 2NF

or FAX 0181 659 3309

or E mail us at Lisa@youthsupport.demon.co.uk

A Framed Childhood Memory

= Josephine Lomax-Simpson

Youth Support Carnival= - Sunday 24^th May 1998

- Eastenders to the rescue! -

Eastender= Italians= - The di Marco Family came to the aid of the ‘real= 217; Italian family of Teresa (Leila Birch) in supp= orting young people’s charity Youth Support.

The Carnival - Attended by Leila Birch (Teres= a) - Louise Jameson (Rosa di Marco) - Leon Lissek (grandfather Bruno) - Michael= Greco (brother Beppe) - Marc Bannerman (brother Gianni) publicised Youth Support and it’s work = and raised money to help run and equip ‘the Bridge’ and our new play therapy unit. Carnival featured costumes , beads= and masks, donkey rides and pet show, games and prizes, clowns, fire eaters and limbo dancers. Music included= live bands and Leila took the stage briefly to sing with her ‘real’ brother’s band ‘Scrummage’.

The Bridge - Official Opening - Performed by <= /i>Leila Birch (Teresa= ) her screen mother (Louise Jameson) ‘The Bridge’ provides accommodation and aftercare in our half way house, w= here individuals, couples or parents with children can be offered a semi- independent lifestyle. They are able to move on to their ‘own flat’ wit= h staff available for support. The e= thos is generally that of an extended family - like having an aunt to call on for support and advice. Clients also have access to the services of therapy, counselling and occupational opportunities run by the charity both in Beckenham and in Penge.

Sport Sponsorship -an award was presented to a promising Basketball player to enable him to attend a special training camp= in the USA. Nathaniel Henry (17) whose family originally hail from Jamaica , was re= commended by the London Towers team and is set to become a basketball star - thanks to Youth Support’s help. He was presented his award by screen brothers Beppe and Gianni.<= /p>
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The Journ= al of Adolescent Health and Welfare

is published by:-   Youth Support,   13, Crescent Road,   = London<= /span> BR3 2NF<= o:p>

Tel No 01= 81 650 6296        =            Charity No 296080                =   Fax No 0181 659 3309

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