My office moved three months ago, and I am now on “the social work hallway” where people pass my door (or wait outside of it) on the way to meet with our medical social workers. There is a constant stream of people, sometime in singles or couplets, other times in small groups.
The other day, one of my social worker colleagues came up the hall, stopped at my door and exclaimed, “People have to stop molesting our kids! Don’t they realize the damage they are doing?”
Her obvious distress and frustration was the result of yet another session with an adult woman suffering from sequelae from childhood abuse. We know that there is a dose response relationship between the number of reported adverse childhood experiences (ACE) and poor health outcomes. This applies to both organic diseases such as heart disease, COPD, lung cancer and others, as well as mental illness. Many of our patients are afflicted with both.
Child maltreatment is unfortunately more prevalent than one might think. A 2016 Health and Human Service report estimated there were 676,000 victims of abuse and neglect in that year alone. Three-quarters (74.8 percent) of victims were neglected, 18.2 percent were physically abused, and 8.5 percent were sexually abused, while 14 percent experience a combination of maltreatments. Cumulatively, the toll is great with estimates of one in three adult women and one in six men having been abused sexually as children.
There has been significant media coverage over the past year reporting on episodes of differing forms of abuse. These stories would otherwise have remained untold except for the fact that someone was brave enough to open the discussion. Once opened, a flood of victims streams forward as, in each case, one perpetrator has abused multiple victims. Listeners wonder how so many children could have been abused and yet people around them at the time not be aware that the abuse was occurring.
In reality, this is often the case. Pedophiles are masters at manipulation, as the following case illustrates.
It was a cold, clear day, the kind that made the inside of her nose tingle and the tops of her ears burn. It was a school day and the little girl walked her usual route to her friend’s house where together they would continue their walk to the school playground, chatting along the way. On this particular day, the little girl’s friend was running late. The friend’s mother invited the little girl inside to get out of the bitter cold. Although the little girl was grateful for the warmth, she worried that she would have to walk very quickly and maybe even run part of the way in order to get to school before the bell. There would be no playground time today — but it was too cold, anyway.
An older couple lived next door and had a car, and so the friend’s mother called to see if the girls might get a ride. The mother sent the little girl next door while her own child finished getting ready. That was fine by the little girl, as that meant she might be able to play with the couple’s little white dog while waiting. Sometimes the man let the girls feed the little dog treats after school. Other times the girls got the treats — usually a hard candy, but in the summer if they were out back running through the sprinkler they sometimes got an ice cream cone! The neighbor and his wife were in the kitchen finishing breakfast and welcomed the little girl in.
As the neighbor’s wife was clearing the dishes, the neighbor offered, “Would you like to see the Christmas tree?”
Really? What child doesn’t want to see sparkling lights and ornaments? The smiling wife nodded agreement but cautioned, “Make it a quick visit. You don’t want to be late for school.”
The tree was in the basement. It was dark and the stairs were steep. The little girl couldn’t see any sparkling lights. “Where’s the tree?” the little girl asked. The man left the girl in the dark, walked ahead and plugged in the tree. “Come closer to see the ornaments,” the man advised. The little girl stepped closer to the light-filled tree.
“Don’t you want to give me a Christmas kiss?” the man asked.
“No,” replied the little girl.
“But you’re standing under the mistletoe. Didn’t you notice? You have to give me a kiss now,” said the man.
The little girl had no idea what mistletoe was and was very confused. She got a funny feeling in her tummy like something wasn’t right.
“Just a little one,” the man urged.
Now the little girl was even more confused as the man leaned in for his kiss. Instead of brushing the little girl’s cheek, he placed his kiss firmly on her mouth. He then made it clear that he wanted more.
The little girl froze. At that moment, the air in the basement became colder than the air outside.
The next minute the little girl heard a door open and a women’s voice calling down the stairs. The little girl scampered up the stairs and into the warmth of the kitchen where her friend now waited for her.
The man did drive the girls to school that day, but the little girl never walked in front of his house again. She choose instead to walk on the opposite side of the street. She didn’t tell anyone what happened — not even her friend.
The above story has many classic features. The perpetrator was a neighbor, known to the victim and the friend’s mother and felt to be “safe.” He had prior contact, ingratiated himself to the children by providing special treatment, made himself available to the mother for “errands,” moved from public to private interaction with the children, and in the end made intimate physical contact. This process is called "grooming.” It involves intentional actions and behaviors that allow the perpetrator to build a relationship of trust with the child, and often the parents, as well.
Grooming occurs over a period of time and is specifically designed to lower a child’s inhibitions toward touch. The first physical contact between predator and victim is often nonsexual, may appear accidental or innocent, and is designed to desensitize the child. Offenders may “test” the victim’s reaction. If the victim reacts negatively, the offender can apologize, explain it was an accident and move on. If the victim does not react negatively, the testing continues and escalates.
The relationships between the abuser and their victims is often quite complex. The more powerful abuser will try and make the child think they were complicit in the abuse, making reporting the abuse unlikely. Other times the child is dependent on the services provided by the abuser, as was seen in the case of the U.S. gymnastic team. Knowing the above, explains in part how perpetrators “get away” with their abuse on the scale that they do.
So what can we as individuals do to help?
If a person, particularly a child, discloses abuse, the most important thing you can do is to believe the person. It is actually more common for a child to deny that abuse has occurred than to confirm abuse. Believing a person’s story validates the person, and their experience and is the first step in promoting healing. Although what is shared is likely to be alarming and upsetting, it is important to remain calm and to continue to listen, reassuring the person that the abuse is/was not their fault.
As health care professionals, we are required to report all suspected cases of juvenile abuse or neglect to the Department of Social Services in the county in which the child resides, but any private citizen has that same opportunity. We owe this to our children and to the adults they will become, and we owe this to ourselves as a society.
If you would like more information and examples of how to support a person through disclosure, the Metropolitan Organization to Counter Sexual Assault (MOCSA) website is a great resource.
Donna Tuccero is core faculty with the Duke Family Medicine Residency Program and a health care provider in the Duke Family Medicine Center. Email donna.tuccero@duke.edu with questions.
Editor’s note: A member of the Duke Family Medicine faculty guest blogs every month. Blogs represent the opinion of the author, not the Department of Community and Family Medicine or Duke University.