(In this post I have followed my usual practice of disguising the patients.)
Incest is defined by Webster’s as sexual intercourse between persons so closely related that they are forbidden by law to marry. But religious and secular law has varied from time to time and place to place. What is forbidden at one time may not be at another. For instance, in some places marriage between an uncle and niece is forbidden. At other times and places it is not. Marriage even between brother and sister has at times been condoned, even encouraged– in Egyptian royalty, for instance, around the time of Caesar. However, the term incest has come to be used much more loosely today. Different kinds of sexual encounters among family members have merged in many people’s minds with sexual abuse in general. Not surprisingly. Child sexual abuse often takes place between family members.
There is a consensus that sexual experience below a certain age is inappropriate and likely to be harmful. Certainly harmful, most people would probably say. There is not universal agreement, however, of just what age is too young. Children in some cultures can technically marry even before puberty, although the marriage may not be consummated for some time. In this country the age of consent is different from state to state. As a matter of fact, every sort of sexual interaction between adults and young people, even children, occurs regularly, including rape. The effect of these behaviors is strikingly different depending on how coercive they are and on the relationship of the people involved. Adults who run afoul of the law because of committing one of these criminal acts should not be treated all the same, because their acts are not all the same.
At one extreme: A young woman who was a patient of mine had serious sexual difficulties. Whenever she was at the point of reaching a climax, a picture of her father would flash to her mind. For this reason she was to a considerable extent sexually incapacitated. When she had been a teen-ager, and for some years before, her father had raped her at intervals, not always out of sight of her mother. When I asked what reaction her mother had had, she told me her mother would wave her hands impatiently and tell them “to stop all that fooling around.”
It was hard to know just what aspect of these experiences was most traumatic: her father’s viciousness, her mother’s indifference, or the unmitigated physical violence, itself. The emotional consequences affected every aspect of her self-esteem and social competence, and plainly was an important factor in her chronic anxiety and depression. She trusted no one.
At the other extreme are many cases of cousins, or even siblings, playing some version of “doctor,” that is mutual looking, and, perhaps, touching of genitals. Usually, neither child is injured, or even discomfited, by this experience. I only find out about these incidents years later when they are reported to me in passing. If there was an emotional consequence to them, it was not apparent to me—except, perhaps, for someone expressing a vague sense of embarrassment and guilt. Those guilt feelings seem to have grown up when these young people grew up and discovered that the sexual behaviors in which they had engaged are condemned by everyone—and if not condemned, exactly, at least discouraged by everyone.
When I started practicing psychiatry, I had not thought very much about these matters. I knew that Freud had regarded sexual feelings as universal among children and central to the development of different neurotic problems; but I did not see very much overt expression of such feelings, so I was inclined to think that Freud’s emphasis on childhood sexuality might have been an odd expression of the Victorian times in which he lived, or, perhaps, some idiosyncrasy of Freud’s point of view. Incest, itself, was completely outside of my training and experience. I knew there were good genetic reasons for the incest taboo, and I knew that taboo was manifest in many different animal species because of those reasons. I was, consequently, unprepared when I ran into my first case of actual incest.
One of my first patients was a young, grossly overweight woman who had a variety of social difficulties. She tended to be impulsive and provocative. She fought with her friends and with her previous psychiatrists. She showed up at their houses at odd times asking to use their bathroom. As a consequence, she was told she was not welcome to continue treatment. She had made a number of unconvincing suicide attempts, including one in my office. Besides these self-defeating behaviors which could be considered aspects of a personality disorder, she had some checking behaviors and other symptoms of a mild OCD. Like most patients—in fact, like most people—various diagnoses could be made to describe her; but they tended to overlap and did not particularly call for one sort of treatment over another. I did not think she needed to be on medication.
One day she mentioned to me that she had not had any sexual encounters recently except with her brother, who was a twenty-four year old divinity student. It took some animated conversation back and forth for me to learn that she had been having sexual relations with her brother for a number of years. It took a number of subsequent conversations for me to come to believe what she was telling me. I pointed out what I thought was obvious, that continuing this incestuous relationship was a terrible idea; and she ought to stop.
“Why?” she asked me.
“What do you mean, ‘why?’ I think you know why. Incest is condemned by everyone. And you’re both adults!”
“Well, but why exactly should we stop?”
Like most things that seem obvious, I had never stopped to ask myself exactly why incest between adults was wrong. “You know,” I said, finally, “if you and your brother were to have a child, there would be a high probability that child would be abnormal.”
She laughed. “Of course, we make sure I can’t get pregnant.”
I thought about all of this after our session was over. The real reason she should stop, I realized only after thinking about it for a while, was tied up with the reason she was engaging in this behavior in the first place. She resented her brother for being a “goody-two-shoes” and was determined to prove he was just as morally defective as she was. She wanted to drag him down to her level. The reason she ought to stop was to salvage her relationship with her brother—and to stop her systematic attempt to injure him. It was not a small matter, also, that anyone finding out about her being involved in incest would regard her as unnatural. She knew all this, of course. Sometime later, she agreed to stop. She chose to do this by having me speak to her parents– who had an interesting response, when I spoke to them finally.
“Thank goodness,” her mother said. “I thought you were going to tell us she was on drugs.”
But, at that point, the incestuous relationship did stop.
I have not sought to study these matters systematically; but as I ran into these sexual behaviors—or misbehaviors—over the years, certain facts have come to my attention:
1. Memories that people report about sexual experiences (abuse) during childhood are not reliable. Certain clinicians have built a world view about early sexual encounters in which they feel that these experiences are the cause of every sort of emotional problem in adulthood. Therefore, they go to great lengths to elicit these stories. Under the influence of a committed therapist, patients will, indeed, remember such experiences even when those experiences did not, and sometimes could not, have happened. I will not go into length here about the “false memory syndrome,” but these memories are believed in sincerely by patients—sometimes causing the dissolution of families since various family members are accused falsely by the patient of child abuse.
2. However, sexual encounters are common in childhood. In fact, sexual abuse and frank incest are more common than recognized and can occur at any age—from infancy to old age.
When I was a senior staff member at a psychiatric hospital, it came to my attention that the daughter of a patient was discovered engaging in a sexual act with her father who was in a hospital bed at the time. She was 70 years old. I asked her why did she did this, and she told me, “I thought that was what he wanted.” I did not think to ask how old her father was or how long the sexual aspect of that relationship had gone on. I think I was feeling world-weary that day.
Sometimes it is possible to independently verify these accounts of sexual abuse in childhood, but usually not. I take the position that memories that were always there are likely to be accurate, and memories that were “recovered” are not. Any sort of memory recovered under hypnosis, in particular, is likely to be false.
3. Just as some people are more vulnerable to post-traumatic stress disorder than others who find themselves in the same traumatic situation, the effect of illicit sexual behavior—incest and/or sexual abuse—in childhood is different from one person to the next. I have seen two women (not counting the woman reported above) who reported that they had had frank sexual intercourse with their older brothers until they had reached puberty, or even after, and were not troubled in any way as a result—in their opinion, anyway. They did not feel as if they had been exploited, and they were not angry at their brothers. I have seen others in that situation who were, indeed, angry at their brothers and resentful.
Sexual behavior is likely to occur, especially in childhood, when a young person is being supervised by an older male. The older male does not have to be someone who is obviously disturbed or perverted. Some situations invite sexual acting out—for young men who might otherwise never think of committing such acts. For this reason I do not think children should be baby-sat by older boys, including brothers. Usually, I am in the position of suggesting to my patients that they should not be worrying about particular dangers they imagine; but this is one situation in which I warn them against a practice they would not otherwise think is potentially dangerous.
4. The principal long-term effects of childhood sexual abuse is on self-esteem and not on future sexual adjustment—at least, this has proven true in my experience. Often these children, usually girls, grow up feeling somewhat guilty. Everyone says these encounters were not their fault; but they may not feel deep down that that is true. They may feel complicit.
Recently, a Catholic bishop was scolded for saying that children sometimes encourage these sexual experiences. His remarks were interpreted as suggesting the responsibility—and guilt—of the adult who was involved was, therefore, lessened. Although the idea of children initiating a sexual interaction with an adult is repugnant, and , perhaps, unbelievable; it does happen. Of course, the fact that a child is willing to have sex in no way mitigates the responsibility of the adult.
Child abuse is so repellant, it is treated harshly under the law. Some states make a distinction between certain kinds of acts that take place within a family, and are, therefore, less of a threat to the rest of society, and acts with a stranger. Sometimes these distinctions are ignored. Instances of sexual abuse vary—as does human behavior in general. Violent acts are especially destructive and threatening to everyone. I wonder, though, whether some of the laws that track sexual offenders and require their entering into treatment actually do prevent further acts of this sort. There may be some satisfaction in harassing these individuals, as they have abused others; but I am not sure whether or not they are helped, or society protected, by these laws. In particular, I am not sure forcing sexual offenders into psychotherapy is of much help. Some of what passes for group psychotherapy is not therapeutic at all. Probation can be made conditional on their “confessing” to further crimes that on one or two occasions, at least, I knew they had not committed. Therapy is general does not work well when it is compulsory. (c) Fredric Neuman 2012