Wednesday, August 21, 2019

The Jeffrey Epstein case and why language matters


 A statement from the Association for the Treatment of Sexual Abusers

The country has understandably been shocked and appalled by the heinous actions, both confirmed and alleged, involving the sexual abuse and trafficking of children perpetrated by Jeffrey Epstein. However, high-profile cases such as Mr. Epstein’s also bring much-needed attention to a complex public health issue facing not only our country, but all communities worldwide – sexual abuse.

Sexual violence affects millions of people each year in the United States, with more than 1 in 3 women and nearly 1 in 4 men having experienced sexual violence involving physical contact at some point in their lives. International research focused on violence against women has estimated that 35% of women worldwide have experienced either physical and/or sexual intimate partner violence or sexual violence by a non-partner (not including sexual harassment) at some point in their lives. The prevalence of child sexual abuse can be difficult to determine because it is often not reported, but it is estimated that one in four girls and one in six boys will be victims of sexual abuse before age 18.

Sexual abuse is a complex public health issue that requires accurate information in order to support prevention efforts, and the media plays an integral role in information dissemination. However, the media does a disservice to prevention efforts by using terminology such as “pedophile” and “child rapist” interchangeably, as seen in the many articles about Mr. Epstein.

Pedophilia is an attraction to children who have not yet reached puberty. A person with pedophilic interests may or may not act on those desires. In contrast, a child molester is a person who has chosen to sexually abuse a child. In the latter case, even though the abuse is sexual in nature, the motivations for the behavior may not be driven by sexual interest. Other motivations for sexual abuse include but are not limited to, a desire for power and control, general antisocial thinking/beliefs, and intimacy deficits and loneliness. Hence, not everyone who sexually abuses a child has pedophilic interests and not everyone with pedophilic interests will sexually abuse a child. Attraction is not action and action is not attraction.

Whatever Mr. Epstein’s motives may have been, he chose to act on those desires and abuse minors. Unfortunately, his personal wealth allowed him to act with relative impunity. This was exacerbated by those around him either not recognizing what they were seeing due to a lack of awareness about sexual abuse, supporting and benefiting from his behavior, being indifferent to it, or being afraid to report his actions. People who knew him may have minimized his behavior and dismissed their concerns because, with his status and prestige, Mr. Epstein couldn’t be “that guy.”

Mr. Epstein’s case, as well as the cases of Jerry Sandusky, Larry Nassar, and Bill Cosby, are stark reminders that anyone can be “that guy.” Those who commit sexual harm come from all walks of life. They can be people we admire, people we like, people we trust, or people we despise. They cross all socioeconomic, educational, gender, age, and cultural lines.

But another misuse of language – using terms such as “predator,” “monster,” “pedophile,” and “pervert” – to describe individuals who sexually abuse others artificially separates those who cause sexual harm from the rest of us, and does nothing to help the public understand who may perpetrate sexual abuse or develop effective strategies to prevent those actions. Instead, using this kind of language makes it harder to accept that even people we know and trust could be at risk to sexually abuse others.

We must embrace the harsh realities of who commits sexual harm:
·       -  93% of sexual abuse involving minors is perpetrated by someone known to the minor, not a stranger.
·        - 73% of rapes against females age 12 and older are perpetrated by someone known to the victim.

Those who commit sexual harm are those we know and even love, trust, and admire much more often than they are strangers. Effectively preventing sexual abuse requires we all learn about the complexities of sexual abuse, how to protect our children, and how to provide them with the necessary skills to protect themselves across their lifespan. It also requires us to recognize that sexual abuse is not perpetrated by the “monster” other, but by everyday people, famous people, and sometimes even those closest to us.

Accurate information and a shared approach to prevention are the keys to ending sexual abuse. Focusing on sexual abuse as a public health issue provides us with the correct lens to adequately tackle this pervasive issue by moving us beyond ensuring the health of individuals to the health and safety of an entire population. Through education, collaboration, and the involvement of everyone – community members, violence prevention professionals, victim advocates, law enforcement professionals, those who provide treatment to victims/survivors of sexual abuse, and those who provide treatment to persons who have perpetrated sexual abuse – the prevention of sexual abuse can become a reality.

Treatment is not only available to help prevent individuals at risk of abusing children from acting on their thoughts, it is also available to help individuals who have abused refrain from doing so again. The Association for the Treatment of Sexual Abusers offers access to treatment providers who can help individuals receive the assistance they need to avoid sexually abusing children and others. If you are seeking help for yourself, a family member, or a friend, visit www.atsa.com and click on “Referrals” to find a provider near you.



Thursday, August 15, 2019

Understanding and Responding to Pornography Use with Adolescents Who Have Engaged in Harmful Sexual Behavior: Developmental Considerations

By Russ Pratt & Cyra Fernandes

Introduction: ‘Teen rituals’

Fifteen-year-old Mikey* sits in his room, finishing his homework. From time to time, he closes the window on what he is working on, and watches a bit more of his most recent ‘favorite’ pornographic movie, After looking at this for a few minutes, and, becoming aroused, he picks up his phone, and scrolls through the dozen or so pictures of naked and semi-naked young women he goes to school with. All of them sent these ‘pics’ to him after he asked them to do so. They, in turn, have pictures of him, some requested, and some not. He hears his mother coming up the stairs, so quickly returns to his computer and homework. 

Is the above paragraph fantasy, fact, or somewhere between the two? Well, recent research suggests that this scenario is closer to the facts of the matter, rather than any responsible parents’ nightmare scenario. Not only is exposure to, or viewing of, pornography in adolescence now a normative experience, with research indicating that the majority of adolescents have viewed or been exposed to pornography by age 15 years (Lim et al, 2017), but also that the sending and receiving of naked pictures by adolescents has become a normative adolescent experience (Fisher, et. al., 2019; Smith, Mitchell, Barrett & Pitts, 2009; Mitchell et. al., 2014, Lim et. al., 2017).  In an Australian-based study of 2,136 15 to 17-year-olds, over half the sample had received a sexually explicit text message and had been sent a sexually explicit nude or nearly nude photo or video (Mitchell, et al., 2014). Over one-quarter of them had sent a sexually explicit photo to someone else. Thus it seems that sending and receiving sexually explicit (nude) pictures of themselves or others is the current broadly-acceptable, teenage courtship ritual.  

Does pornography influence sexual practices, behaviors, attitudes, and perceptions 

Well, the short answer to this question seems to be “yes” it does. And not only for adults, but clearly for adolescents commencing their sexual-developmental journey. Pornography significantly influences sexual practices, behaviors, and perceptions of both adults and adolescents when it comes to their view of “…what sex looks like. (Pratt & Fernandes, 2015)” In particular, it seems that consuming pornography (Fisher, et. al. 2019; Lim, et. al., 2017; Mitchell, et. al., 2014) is related to more permissive sexual attitudes and gender-stereotypical sexual beliefs, and, for those youths who view pornography at a very young age (pre-pubescent) we see earlier-onset sexual intercourse, higher rates of casual sex by early adulthood, and higher levels of sexual aggression by adults, in terms of both perpetration and victimization (Bridges, et. al., 2010; Wright, Tokunaga & Kraus, 2015),

The ‘young’ consumer

What do these young people who most frequently view pornography look like? As research indicates that the majority of young people have viewed pornography by 15 years of age, it seems more difficult now than ever before to ‘characterize’ what a ‘frequent consumer’ of pornography looks like, as compared to those who are not. As, authors, researchers, therapists, and even parents, we know how quickly the digital and online world is changing, and thus the patterns of usage we saw even ten years ago may not apply right now. This also means that less-recent research might not portray what the current situation is, as much as we would like. Peter and Valkenburg’s (2016) excellent 20-year summary of the research is a case in point. Findings cited by those authors may now relate to findings from before 1996 – well before the ‘digital revolution’. Given that pornography consumption is now ‘normative’ behavior for adolescents, it might be the case that we can only say that; more males than females view pornography; they (males) view it on a more frequent basis than females, and it is likely that the majority of young viewers do so for commonplace reasons, such as learning about sexual behaviors, and to achieve sexual arousal (Pratt & Fernandes, 2015). 

The role of pornography

So, what is the role of pornography in the development and maintenance of adolescent harmful sexual behavior? The answer is frustratingly unclear. While it is neither possible nor accurate to state that adolescent pornography use leads to harmful sexual behavior, it may be the case that repeated exposure to pornography might lead to desensitization and contribute to distorted views of what are normative, acceptable, or desired sexual behaviors and relationships. For some children and adolescents, this exposure could provide such a “skewed template” for the “how-to” and “what” of sexual behavior, and, more importantly, provide information and images that are so inappropriate for their developmental stage (Pratt & Fernandes, 2015) that it cannot be decoded nor understood; 

Young people who engage in sexually abusive behavior often present with deficits in important psychosocial skills (Peter & Valkenburg, 2016), and may lack the developmental maturity to both understand the explicit sexual content of pornography, and that it may not represent ‘real-life’ sexual relationships and behaviors and what people seek in sexual relationships (Pratt & Fernandes, 2015). 
In addition, due to sexual inexperience, learning disorders, intellectual disabilities and autism spectrum disorders, some youth may be even less able to critique and comprehend that what they see in pornography is not what “real-world” sex looks like. They may also be either reluctant or unable to seek support from adults to help them make sense of what they saw in pornography.

Conclusion

To conclude (and there is so much more to say), educating adolescents about healthy sexuality is a key component of treatment. For adolescents who have engaged in harmful or sexually abusive behaviors, the development of healthy sexual practices is key. Whilst sex education should include a focus on the relational aspects and boundaries of sexual behavior, more is needed. The authors have created a developmentally focused, “savvy consumer” model for youth which advocates ‘zero-tolerance’ for pornography viewing for very young children, combined with a ‘harm-minimization’ model for older adolescents. The model has, at its heart, the belief that the ability to both critique the falseness of pornography, and highlight positive, real-world sexual health practices will ensure that the qualities of healthy, safe, and desired sexual practices remain in-focus during treatment. 
In particular:
Respect,
Mutual consent,
Equality and partnership, 
The freedom to say no, and;
The freedom to negotiate equally regarding healthy, respectful sexual pleasure and activity.

References

Bridges, A J.,Wosnitzer, R., Scharrer, E., Sun, C., & Liberman, R. (2010). Aggression and Sexual Behavior in Best-Selling Pornography Videos: A Content Analysis Update, Violence Against Women 16(10), 1065-1085.

Fisher, C. M., Waling, A., Kerr, L., Bellamy, R., Ezer, P., Mikolajczak, G., Brown, G., Carman, M. & Lucke, J. (2019). 6th National Survey of Australian Secondary Students and Sexual Health 2018, (ARCSHS Monograph Series No. 113), Bundoora: Australian Research Centre in Sex, Health & Society, La Trobe University. 

Lim, M.S.C., Agius, P.A., Carrotte, E.R., Vella, A.M., & Hellard, M.E. (2017). Young Australian’s use of pornography and associations with sexual risk behaviours, Australian and New Zealand Journal of Public Health, 2017 online, doi: 10.1111/1753-6405.12678.

Mitchell, A., Patrick. K., Heywood, W., Blackman, P., & Pitts, M. (2014). 5th National survey of Australian secondary students and sexual health 2013. ARCSHS Monograph Series No. 97,  Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia.

Peter, J., & Valkenburg, P. M. (2016) Adolescents and pornography: A Review of 20 Years of Research, The Journal of Sex Research, 53:4-5, 509-531.

Pratt, R., & Fernandes, C. (2015). How Pornography May Distort Risk Assessment of Children and Adolescents Who Sexually Harm. Children Australia, 40, pp 232-241 doi:10.1017/cha.2015.2.

Smith, A. P., Mitchell, A., Barrett, C., & Pitts, M. (2009) Secondary Students and Sexual Health 2008: Results of the 4th National Survey of Australian Secondary Students, HIV/AIDS and Sexual Health, Australian Research Centre in Sex, Health and Society (Latrobe).

Wright, P.J, Tokunaga, R.S., & Kraus, A., (2015), ‘A meta-analysis of pornography consumption and actual acts of sexual aggression in general population studies’, Journal of Communication, 66(1), 183-205.

Wednesday, August 7, 2019

When we become the barriers to progress


By David S. Prescott, LICSW, & Kieran McCartan, Ph.D.

At first, it all seems so easy. The large institution or agency decides they are going to get serious about professional development and quality improvement. “I’ve done some research on evidence-based practices and have concluded that we need to implement the Forensic Version of the XYZ-PSB model. It has all the qualities that we’re looking for, combining elements of all the popular models that are available, and even has some mindfulness. The fact that there are some deep breathing exercises at the start of some sessions qualifies it as a biopsychosocial approach.”

We’re kidding, of course. It often seems to us that the latest/greatest models make the largest promises until the implementation effort begins. The history of psychotherapy is certainly replete with examples of fad treatments, each one appearing to be bigger, better, faster, or just plain more. Many a well-intended agency and director (including the first author, David) have sought training in a particular method because it had worked in some other setting or been proven in a study or two, only to find out that the old adage is true: All too often what is new is not what makes a treatment approach effective. At the same time, what makes the same treatment effective is not new.

The above example of the fictitious XYZ-PSB: FV is ironic because there is a chance that it will work if implemented with diligence, confidence, and a shared belief between therapists and clients that it will work (Wampold & Imel, 2015). In other words, the belief that something will work very often contributes to its success. This is one reason why we have science: to understand not only what works, but how and in what ways.

The rest of the picture may not be so pleasant, however. The unfortunate reality at the front lines, often not reported in research, is that there are any number of ways that good treatment can go bad under the wrong conditions. Let’s take the above director’s plan for implementing XYZ-PSB: FV. Even before implementation, what kinds of exploration of the agency’s needs and staff attitudes takes place? Are the staff excited for the opportunity or feeling beleaguered that they are having to learn yet another approach at high risk of passing into history like the others?

Other questions follow. Will the director participate in the training? The absence of key decision-makers from the process itself can have a significant effect on staff, even though it is not mentioned in any manuals. Likewise, does the agency or institution bring in an outside trainer who trains, perhaps does some consult calls, and leaves without a succession plan? Some way to keep the spirit and practice of the treatment alive? And then during the initial phases of this implementation, what other barriers occur, such as the director getting a new job, or another influential actor going out on medical leave?

Of course, the picture can become even more pernicious. Are there other challenges competing with the meaningful implementation of a high-quality approach? For example, many agencies experience severe pressure to ensure complete adherence to complicated licensing requirements or accreditation. At what point is the search for excellence – that burning desire to become more effective – compromised by the need to ensure timely documentation? Does adherence to regulations end up compromising adherence to a new model? Do we then expend so much effort pursuing fidelity to the model that we then forget to maintain fidelity to the actual client and his or her individual characteristics?

These are questions too often omitted from any manual or introductory training, but they threaten treatment integrity nonetheless. This is why collaboration between researchers, trainers and professionals is so important in the creation of evidence-based practice that is fit for purpose in the real world (see another blog by Kieran on the importance of co-creation).  One of the sadder outcomes of implementation efforts, in our view, is when professionals work treatment jargon into case notes as a signal to auditors and licensors that they were using a model when in fact they really weren’t.

We (David and Kieran, along with our collaborator Danielle Harris) have argued in our training, and in a recent paper, that we can learn a lot about improving services by listening to the voices of the service user. Yet, most treatment providers work in environments where the same service user has little or no voice in their treatment planning.

Out hope is that by raising these questions we may better inspire dialog among professionals, researchers, and trainers as to how we might better anchor our practice in the evidence. All too often the enemy to successful implementation is ourselves.