Sexual abuse of children
A survey of current knowledge
Translation: Roger G. Tanner

Contents
Preface
Summary
Introduction
General points of departure
Investigation
Police complaints
Information
Documentation
Co-operation and interaction
Organisation and support in the handling of cases
The state of knowledge today
Definition of sexual abuse
Occurrence of complaints, abuse and legal process
Causes, risk factors and consequences
Assessing suspicions of sexual abuse
Consultation groups
Treatment measures for children and families in suspected cases of sexual abuse
Treatment models
Treatment outcomes
Children and young persons committing sexual abuse
Legal proceedings
Talking to children
The experiences of social services
Discussion of a suspected case of intrafamilial abuse
Discussion concerning a suspected offender in voluntary leisure activity
Summary of essentials
Concluding remarks
References
Statutory texts

Preface
One of the tasks of the National Board of Health and Welfare is to support the scientific development of social services. As part of this assignment, the Board has compiled a survey of current knowledge and experience regarding, among other things, causes, occurrence, response and various types of remedial action with regard to children and young persons who have been sexually abused, as well as compiling facts about certain neighbouring fields.

The Board has published fifteen expert reports on sexual abuse of children. These are summarised in the present publication, from the perspective of social services. No attempt has been made to cover the entire field, and several aspects are omitted altogether, e.g. medical examination in connection with suspected abuse.

This is a many-faceted subject, and some parts of it have been researched more intensively than others, at the same time as research findings are liable to be incomplete, contradictory or uncertain. Knowledge in the context of personal relations is not definitive but is a permanently ongoing process of interaction between practice, theory and research. The manifold light shed by these reports on the subject brings out the need for knowledge and perspectives based both on proven experience and on research, and on a variety of disciplines and fields of study.

Through this conspectus, the National Board of Health and Welfare seeks to convey a summary of present-day research and experience concerning sexual abuse of children, for the guidance of social services when dealing with such cases. Management and senior handling officers are the main target groups. Essentially, this report is concerned with the demands which children should be entitled to make in terms of protection, support, knowledge and response.

The authors of the expert reports have been given the opportunity of communicating viewpoints on the use made of their texts in the present report. In addition, this report has been examined by the Scientific Council of the National Board of Health and Welfare for Child and Youth Psychiatry, and by Dr Frank Lindblad, Senior Consultant at the Institute of Psychosocial Medicine (IPM).

The task of gathering and synthesising knowledge and experience concerning sexual abuse was conducted within the Social Services Division by Elisabet Svedberg, Project Leader, Björn Hedquist and Merike Lidholm under the direction of Monica Norrman. Marita Minell took part in the introductory phase.

Kerstin Wigzell

Several persons have been involved in compiling the material. Work has been observed and viewpoints communicated by a reference group, known as the Priorities Group, comprising representatives of the Swedish Association of Local Authorities, the Federation of Swedish County Councils, professional associations and the research community. The main observers of work relating to sexual abuse of children were:

Anita Sundin, The Swedish Association of Local Authorities
Carin Lyckéus, The Swedish Association of Health Officers (SHSTF)
Ann Hedberg, The National Association of Nursing Operational Managers
Björn Sundström, The Swedish Association of Heads of Social Services
Sture Henriksson, The Swedish Association of Heads of Social Services
Titti Fränkel, The Swedish Association of Graduates in Social Science, Personal and Public Administration, Economics and Social Work (SSR)
Leif Holmström, Umeå University
Karin Tengvald, The National Board of Health and Welfare/CUS
Eva Sahlin, The National Board of Health and Welfare, HS

Summary
The handling by social services of suspected cases of sexual abuse of children does not differ essentially from the handling of other cases where it is suspected that children are faring badly. An investigation has to be launched as soon as anything comes to the knowledge of the social welfare committee which may require it to take action. The task of investigating, treating and supporting children and families makes heavy demands on the knowledge, competence and preparedness of those concerned. In all cases the guiding principle must be an understanding of each individual's unique personality and situation.

There are no patent solutions for the handling of these cases by social services, but, in the light of the knowledge presented in this report, the task of the social services when a suspected case of sexual abuse is reported can be summarised as follows: carrying out a swift initial investigation of the suspicion, assessing and providing for the child's need of protection and remedial measures, assessing and providing for the family's need of care and support, deciding whether or not to file a complaint with the police, assessing the possible need for information to those concerned, liaising with other authorities and consulting child and youth psychiatric services. A rule in derogation of secrecy empowers, but does not oblige, social services to report suspected cases of sexual abuse to the police.

The documentation of a case must show decisions and measures taken, actual circumstances and material events. The documentation must be drawn up with due respect for the privacy of the individual.

Section 9 of the Social Services Act requires allowance to be made for the child's wishes, "having regard to its age and maturity". This rule derives from the UN Convention on the Rights of the Child. In cases where sexual abuse comes to be suspected, it is often the child itself who relates the matter to an adult in whom it has confidence. The child's story plays a central part in the investigation.

Competent handling of cases concerning sexual abuse requires a knowledge of the symptoms, reactive patterns and effects of traumatic experiences on individuals of different ages, in the short and long term, and also a knowledge of family dynamics. Knowledge concerning normal and deviant sexuality in children and young persons is important, as well as a knowledge of problems other than sexual abuse which may underlie any symptoms. There are, however, no mental symptoms which can be unambiguously construed as indicating that a child has been sexually abused. Certain symptoms, however, may corroborate a child's story.

In order to arrive at a complete assessment of a case where it is feared that a child is faring badly, and in order to offer the child and its family the requisite support, social services are dependent on co-operation and interaction with other agencies. In suspected cases of sexual abuse, close co-operation is needed with the police, with child and youth psychiatric services, possibly with paediatric medicine and with other agencies. The Board's study of consultation groups has shown their work to be seriously undertaken, impartial and dedicated. Consultation groups confer co-ordination benefits, raise the standard of competence and enhance the security of handling procedures.

Every year in Sweden, the police receive between one and two reports of suspected sexual abuse per 1,000 children aged under 15. Swedish studies indicate that approximately seven or eight per cent of women and between one and three per cent of men have at some time during their childhood or adolescence been sexually abused.

According to international research and Swedish statistics, roughly one-third of all sexual offences are committed by young persons. About half of all adult sexual offenders have shown sexually deviant behaviour at an early age, and have committed their first offence before the age of 18.

A complex interaction of many different factors can help to explain the occurrence of sexual abuse of children. One prerequisite is the existence of a potential offender who is sexually and emotionally motivated, has deficient social competence and has little control over his or her sexual impulses. In addition there has to be a child who attracts the offender, is inadequately supervised and is incapable of warding off a sexual approach. Thus there are several obstacles which the offender has to overcome in order for an offence to take place - inward, personal barriers and safety mechanisms, outward obstacles in the situation surrounding the child, and also the child's own resistance.

Most commonly, the offender is known to the child and is part of the child's immediate surroundings. Girls run between two and five times as much risk as boys of being sexually abused. International studies show the average age of the abused children to be between about eight and ten years, but boys, generally speaking, are somewhat older than girls when sexually abused. Family factors such as substance abuse and violence in the family or failure of parental care distinctly augment the risk of vulnerability to sexual abuse.

The treatment of children and young persons who have been sexually abused is based on many different theories and employs a variety of therapeutic methods. The consensus of international research is that children who have been enabled to process their experiences in therapy generally feel better than those who have not had the opportunity of doing so.

Although research into different aspects of sexual abuse has intensified in recent decades, this is a field of study in which a great deal still remains to be accomplished. Hidden statistics make it hard, for example, to gauge the true extent and character of the problem. More research is needed in this field, not least with reference to conditions in Sweden.

The social services possess an extensive and coherent knowledge of the handling of cases of suspected sexual abuse of children, knowledge which needs to be summarised and systematised. There is also a need for development work and for a follow-up and evaluation of the different measures undertaken by social services, especially with regard to their responsibility for children in families where suspicions of sexual abuse exist but have not been confirmed.

Introduction
The former General Recommendations of the National Board of Health and Welfare on sexual abuse of children were repealed in 1999, the reason being that, compared with present-day requirements, the instrument was unclear regarding the distinction between the exercise of statutory powers and scientifically based actions, added to which, it contained a number of General Recommendations on matters requiring a more nuanced approach and several different solutions. New knowledge has now been generated both by research and by professional practice.

This publication describes the current state of knowledge in the field. It is based primarily on the 15 expert reports compiled by the National Board of Health and Welfare to shed light on various aspects of problems connected with sexual abuse of children. The summaries presented below focus on those parts of the reports which are specially relevant to the handling of these cases by social services. Accordingly, some reports are presented quite briefly, others at greater length.

The expert reports themselves are a summary of knowledge emanating from current research and professional practice and, for a deeper understanding and more comprehensive review of the field, should be read in their entirety. The references are numbered 1-31 in the text, and the titles will be found in the list of references. The statutory text commented on is also appended.

Compilation of the expert reports conforms to a special working model. Following an inventory of the problem field, the National Board of Health and Welfare commissioned a number of experts to give an account of the state of knowledge on each particular issue. Every expert report was then examined by an opponent, an expert in the field, and discussed and assessed by a Priorities Group made up of representatives of the Swedish Association of Local Authorities, the Federation of Swedish County Councils, professional associations and social research. The experts alone, however, are responsible for the content of the expert reports and the conclusions presented in them.

This report is divided into three parts. The first part deals with the handling by social services of suspected cases of sexual abuse of children. This is no different from the handling of other cases relating to children in distress. The second part briefly describes the knowledge emerging from the expert reports.

The third part deals with the experience-based knowledge discussed at a seminar convened by the Board in 1998.16 At this seminar, about 20 social welfare officers who, through long experience, further training and talks with colleagues, had developed a high level of competence in handling cases of sexual abuse of children discussed the handling of various types of cases.

Professional knowledge and competence are valuable but often have been neither systematised nor documented. The summary of the seminar proceedings includes a description of the handling of a couple of notional cases. An account is also given of the discussions of principle which took place, and of the questions of situation concerning which it was agreed that handling or practice could vary.

General points of departure
Every year in Sweden, the police receive one or two reports of suspected sexual abuse per 1,000 children aged under 15. No statistics are kept regarding the source of these reports. In recent decades between 51 and 67 per cent of complaints to the police have concerned suspected sexual abuse within the family. The actual incidence of crimes such as sexual abuse is unknown, partly because these crimes are often committed by next-of-kin etc. in the private sphere against children and young persons in a position of dependence. Consequently there are a number of impediments to discovery and the filing of complains.4

Suspected cases of sexual abuse of children are most often brought to the knowledge of the municipal social welfare committee through some other agency. All employees in activities affecting children and young persons (e.g. child care and schools) and in medical and social services have a statutory duty (under Section 71 of the Social Services Act) of notifying the social welfare committee in the event of it being suspected that children and young persons are in need of assistance from the community.

The handling by social services of suspected cases of sexual abuse of children is not essentially different from the handling of other cases where it is suspected that children are faring badly. Section 50 of the Social Services Act requires an investigation to be opened as soon as anything is brought to the knowledge of the social welfare committee which can occasion action on its part.

On the basis of the knowledge presented in this publication, the task of the social services in connection with a report concerning suspected sexual abuse could be summarised under the following heads:

• Carrying out a swift initial investigation of the suspicion.
• Assessing and providing for the child's need of protection and remedial measures.
• Assessing and providing for the family's need of care and support.
• Deciding whether or not to file a complaint with the police.
• Assessing the possible need for information to those concerned.
• Liaising with other authorities.
• Consulting child and youth psychiatric services.

Investigation
Section 50 of the Social Services Act lays down that the social welfare committee shall "without delay" open an investigation of matters which "by application or otherwise" have been brought to its knowledge and can "occasion action" on its part.

Before the social welfare committee can decide whether a report received may also occasion action of some kind - and an investigation thus has to be opened - an initial assessment of the matter is made, on the basis of the child's situation. This preliminary examination or assessment means the social welfare committee having to find out more facts in the matter than are contained in the actual report.

The Act requires the investigation to be conducted in such a way that no one is unnecessarily exposed to "injury or inconvenience", and the investigation shall not be more extensive than necessary. The person affected by the investigation shall be notified of its commencement. The social welfare committee may resolve to prolong the investigation for a fixed term if there are special reasons for so doing.

In the handling of suspected cases of sexual abuse, there are often conflicting interests which have to be accommodated. The child's position of emotional dependence on its parents means that the needs of child and family are closely intertwined, at the same time as there may also be manifest conflicts of interest between child and parents, especially where sexual abuse in the family is concerned. The starting point must be the child's perspective. The UN Convention on the Rights of the Child (UNCRC) lays down that in all measures affecting children, the child's best interests have to come first.

The investigation by the social welfare committee is aimed at shedding comprehensive light on the measures most beneficial for the child in the current situation - regardless of what can or cannot be made clear concerning the suspicions of sexual abuse. Roughly one-tenth of all allegations of sexual abuse of children lead to prosecution and about one-tenth of the persons indicted are acquitted.3

In most cases, then, the social services have to deal with families where suspicions of sexual abuse are unconfirmed but where, having regard to the child's total situation, there can still be cause to support the child and family or to intervene in order to protect the child. Social services therefore have to be prepared for the contingency of a complaint to the police not leading to a pre-trial investigation or police inquiry or of a police investigation not leading to an indictment or conviction.

Sometimes the suspicion of sexual abuse has been aroused by something a child has related, while in other cases the assessment may be founded on more or less diffuse indications. A symptom or behaviour cannot be taken on its own to indicate that sexual abuse has occurred. The child's story, therefore, plays a central part in the investigation. Interviews with the child and any siblings should be included in the investigation carried out by the social services.14, 16

Section 9(2) of the Social Services Act lays down that "when a measure affects a child, the child's attitude should be clarified as far as possible. Allowance should be made for the child's wishes, having regard to its age and maturity." This rule is rooted in the UNCRC. The child's right of expressing its opinion in matters by which it is personally affected means that its attitude shall be made clear without putting the child in difficult situations of choice. The social services have the task of obtaining a picture of the child and its needs without pressing the child for viewpoints. This also applies in non-investigative contexts and in both everyday and traumatic situations (Government Bill Prop. 1996/97:124). Furthermore, Section 56 of the Social Services Act lays down that children under the age of 15 may be given a hearing if this can benefit the investigation and there is no presumption that it will be harmful to the child. A similar rule is contained in Section 36 of the Care of Young Persons (Special Provisions) Act, LVU.17

Police complaints
A rule in derogation of secrecy empowers, but does not oblige, social services to report suspected cases of sexual abuse to the police. Thus when suspicions of this kind are involved, the social services also have to decide whether or not to file a complaint with the police. A complaint is filed in most cases where sexual abuse of children is suspected 16, the purpose being to protect the child, prevent any further offences and inaugurate a legal process. In the case of young sexual offenders, it is also very important to indicate the setting of limits by society and the gravity of the situation, since, failing a reaction on the part of the community, there may be a danger of the offensive behaviour developing and growing worse.

Part of the purpose of the investigation conducted by the social services is to protect and support the child and, where necessary, to assist the family, while the police investigation is aimed at investigating a suspected criminal offence with a view possibly to bringing the offender to justice. In certain cases there may even have been a conflict of interests between these two investigations, with their differing points of departure, purposes and procedures.18

If a criminal offence is suspected and a police investigation is going to be conducted, the structure and content of interviews conducted by the social services with the child should be discussed with the police. One of the expert reports refers to the importance of the different investigations being co-ordinated.8 It is not the duty of the social services to investigate what has actually happened and where the blame lies, but to provide the child with the protection and support it needs.

Information
It has been increasingly noted in recent years that sexual abuse also occurs outside the home, e.g. in various activities for children, such as day nurseries, foster-homes, sporting activities and so on. When handling cases of suspected sexual abuse outside the family, e.g. involving an unknown offender on a housing estate, suspicions of sexual offences in school, child care or sporting and other activities for children and young persons, the social services are faced with the question of who is to inform which people of the suspicion or of what has happened, and in what way. It may also be unclear who is responsible for assessment and for informing unaffected families, e.g. in connection with unconfirmed suspicions in sporting activities and suchlike.

The way in which suspicions are to be evaluated and the extent to which information is to be supplied are questions of balance to be decided in each individual case. One of the purposes of information is to find out whether more children may possibly have been abused and may be in need of support, and also to prevent any further abuse.

Documentation
Section 51 of the Social Services Act requires the handling of matters relating to individual persons and the implementation of decisions concerning supportive measures, care and treatment to be documented. The documentation shall record "decisions and measures taken" in the matter and "factual circumstances" and "events of importance". Section 52 requires the documentation to be drawn up with respect for the privacy of the individual. The person concerned shall be aware of the notes kept about him or her and if he or she considers any entry in the documentation to be incorrect, a note shall be made to this effect.

One of the reports refers to the importance of the rule that factual data concerning events, measures etc. should always be viewed and commented on from the children's viewpoint, both in the investigation and in the dossier, and that every child shall be made visible in the documentation. Children who are being considered for remedial measures may eventually want to read and observe for themselves what has happened in their cases and what reasons have prompted various decisions.16

Co-operation and interaction
In order to arrive at a complete assessment of a case where it is feared that a child is faring badly, and in order to offer the child and its family the requisite support, social services are dependent on co-operation and interaction with other agencies. In the matter of investigation, the law requires the social welfare committee to consult experts and to establish other contacts as necessary. In cases of suspected sexual abuse, close co-operation is needed with the police, with child and youth psychiatric services and possibly with paediatric services etc. and also, as far as possible and within the limits of the Secrecy Act, feedback to the source of the complaint if, for example, it is a day nursery or school.

Co-ordination of the investigations often conducted simultaneously - within the social services, possibly by the police/prosecutor, by forensic specialists/paediatricians and in child psychiatry - is vital.14 It has to be made clear what different purposes, topics of enquiry, duties and responsibilities apply to the various activities, in order for child and family to be cared for in the best possible way, to avoid unnecessary duplication and to keep the expectations and demands confronting partners in co-operation within reasonable limits. Consultation groups have proved to be an effective support in the assessment and co-ordination of measures by the agencies involved.8

In connection with suspicions of sexual abuse, the child and the family often go through different crises at once. The child's crisis concerns the actual abuse, while that of the non-offending parent involves feelings of having been unable to protect the child and, in cases of intra-familial abuse - feelings of betrayal and distrust. The crisis also has to do with the potential consequences of the disclosure itself; can the family stay together, will the child be placed in care, will the offender go to prison, who is to be told, what is one to say to friends and relatives, and so on.9

In certain cases the capacity of social services themselves for giving advice and support to the child and the child's family in this situation may be sufficient, while in other cases child-psychiatric expertise may have to be called upon. Social services co-operate more or less as a matter of regular practice with child and youth psychiatric services regarding children believed or known to have suffered sexual abuse. The nature of co-operation varies from one case and municipality to another, depending partly on the treatment which child and youth psychiatric services are able to offer.

In cases involving children who are suspected of having been sexually abused, medical examination is often appropriate. Cases of this kind necessarily involve co-operation with paediatric expertise.

Organisation and support in the handling of cases
The task of investigating, treating and supporting children and families makes heavy demands on the knowledge, competence and preparedness of the handling officers. The point of departure must be an understanding of each individual's unique personality and situation and an awareness of children's powerlessness and dependence on adults.14

The handling of a case of suspected sexual abuse makes demands on the social welfare officer's capacity for self-expression about sexual matters and receptiveness for communication on the subject. Other potential obstacles to professional handling include, for example, gaps in one's knowledge and/or in ability to apply the knowledge possessed, conflicts within the working group and failure of professional self-confidence.

The exacting task of handling matters of sexual abuse also calls for adequate support within one's own organisation. Both Swedish and international experience confirms that clearly defined goals, effective structures with competent management and an express allocation of responsibilities within the organisation, clear and carefully thought out routines with scope for flexibility, in-service training, supervision and support, a good working climate, continuous follow-ups and good routines for co-operating with other agencies are among the prerequisites of good quality in the handling of suspected cases of sexual abuse of children.

In some communities, cases of this kind are so rare that accumulating in-house competence in the field can be difficult. Much can therefore be gained from inter-municipal co-operation, the availability of professional support from more experienced colleagues and opportunities of consulting other professional expertise outside the social services.

Clarity of objectives and supervision
The responsibilities of supervisory staff in relation to social welfare officers are partly concerned with creating security in the work situation and with promoting development. This is done, for example, through recurrent discussions and elucidations of objectives, tasks, expectations and working routines, as well as good information. Continuous follow-up of activities, feedback and structuring of experience provide greater confidence and security and make possible a further development of knowledge and competence. It is also the task of supervisory staff to observe and underpin the development of knowledge and competence in the field. This duty also includes feeding back operational knowledge to politicians and other decision-makers, so as to facilitate, on reasonable terms, the maintenance of good professional standards.

Contacts with news media are a further question which may crop up. Experience of the course of events connected with sexual abuse of children in a Karlstad day nursery indicated the importance of carefully considered, objective and correct information to the media for the avoidance of misunderstandings and rumour-mongering and so as to show the greatest possible consideration towards the persons involved.15

Responsibility for measures and decisions taken
Principles and a decision-making procedure are needed for handling and documentation, so that no doubts will arise concerning limits of responsibility and working procedures for the handling by social services of questions concerning suspected sexual abuse of children. The question of a possible complaint to the police and the decision-making procedure on this subject are one such example.

At the same time as the complexity of these matters implies a particularly great need for guidance and routines, scope is also necessary for flexible decision-making appropriate to each individual family and its circumstances.19 Autonomy and responsibility mean the social welfare officers being at liberty to work independently and flexibly in pursuit of clearly defined objectives. The realisation that mistakes happen and the possibility of learning from and structuring experience through follow-ups and discussions are conducive to security within the working group, creativity and further development in the professional role.

In difficult decision-making situations which involve delicate balances and assessments, e.g. concerning emergency measures and the alternative of awaiting further developments in a case, the possibility should exist of putting things into perspective by consulting supervisory staff and colleagues.

Good working climate, transparency and sense of belonging
One often reads that in work on complicated cases, "parallel processes" ensue, meaning that the feelings and the dynamic occurring in the handling of the case are also deemed to spread to and to be experienced and repeated by the working team, also in relation to any associates.14 The working team needs security, with a good working climate in which matters of this kind can be discussed, in order to respond competently and consistently to its clients. Supervision and in-service training, opportunity for reflection, encouragement, warmth, empathy, support and affirmation from the supervisory staff and within the working team are fundamental prerequisites for maintaining high quality in the handling of difficult cases. It is very important that the supervisory staff should be capable of accommodating the social welfare officers' need of relief and support at work and that they should respect their working situation and the demands it entails.

Further training on sexual abuse of children
In 1996 the National Board of Health and Welfare initiated an advanced further training programme for professionals on the subject of violence to/sexual abuse of children. BUP-Elefanten in Linköping was commissioned to provide the training, and the syllabus was approved by the Faculty of Health Sciences, Linköping University. The course, which carries 20 credits, extends over three terms and is intended for the professional groups whose work brings them into contact with battered or sexually abused children, e.g. staff of child and youth psychiatric services and social services, paediatricians, police officers and prosecutors.

A multidisciplinary course during the first term provides up-to-date knowledge concerning psychological, paediatric, legal and other aspects of child abuse. The focus of attention in this training is on co-operation between different activities. After the first term, professional groups such as paediatricians, police officers and prosecutors conclude their training.

The second and third terms offer advanced studies in the professional field for social welfare officers/therapy staff.

The state of knowledge today
The question of sexual abuse of children was intensely debated during the 1990s. Some of the main points of contention concern different views on the extent of the problems, the truthfulness of children's stories of abuse and viewpoints concerning the handling of the issue by the judicial system and the expert assessments regarded as most reliable. There still exist widely differing opinions, e.g. concerning the nature of the biggest difficulties and the party which is made to suffer most in the legal proceedings - the putatively abused child or the suspected offender.1

The same period also witnessed a substantial growth of knowledge, resulting both from research and from professional experience of encountering and handling these cases. The difficult balances needing to be struck in assessments of measures to be taken concerning suspected sexual abuse - with the child's best interests as the overriding principle - have to be based on the accumulated fund of knowledge and experience, but also on the situation in the individual case, which in turn rules out any detailed prescriptive models.

Although research, both in Sweden and internationally, has been intensified in recent decades, this is a field of knowledge where much still remains to be accomplished. Hidden statistics make it hard, for example, to gauge the true extent and character of the problem. In cases reported to the police, suspicions of sexual abuse have mostly been directed at a male offender within the family or circle of kinship. More recently there has been discussion as to whether female offenders occur more frequently than has been believed. Knowledge of the commonest form of sexual abuse, namely that occurring within the family or in the child's immediate surroundings, remains limited.

The following review is based on a summary of the main points of the expert reports published by the National Board of Health and Welfare and on supplementary material compiled from the perspective of the social services.

Definition of sexual abuse
Sexual abuse of children can be defined as acts or situations of a sexual nature in which an adult or young person uses a minor for the gratification of his or her own sexual or other needs.4 Sexual abuse can be divided into three different types:

• abuse with no physical contact,
• abuse with physical contact,
  
• sexual exploitation of children and young persons in commercial and suchlike contexts.

Sexual abuse without physical contact can mean exhibitionism, voyeurism, sexual allusions, remarks and proposals and exposure to pornographic material. Acts of this kind correspond as a rule to what Swedish law terms sexual molestation and can lead to imprisonment for up to two years.

Sexual abuse with physical contact can mean touching the breasts, genitals and/or anus, masturbation, oral sex, or insertion of a finger, object or penis in the anus or vagina. It can also mean the child being encouraged or compelled to perform sexual acts with the offender.

The third form of sexual exploitation can involve engaging children and young persons in activities for the production of child pornography or the practice of child prostitution.

Depending on the gravity of these two latter kinds of crime, the abuse ranks as sexual molestation, sexual coercion, sexual exploitation of a minor or rape. Sexual coercion is punishable by up to two years' imprisonment, sexual exploitation by up to four years, while rape can lead to imprisonment for up to four years or for between four and ten years in aggravated cases. Distribution and possession of child pornography is punishable by fines or up to two years' imprisonment.3

If the sexual abuser is under 15 years of age, the prosecutor will as a rule refer the matter to the social welfare authorities. This possibility also exists if the offender is between the ages of 15 and 18.

Occurrence of complaints, abuse and legal process
As mentioned earlier, every year in Sweden the police receive between one and two reports of sexual abuse per 1,000 children aged under 15. The number of sexual offences against children reported to the police declined between the mid-1960s and mid-1970s. Following a period of stability, the number of complaints rose steeply between 1982 and 1993 inclusive, subsiding again until 1997. More than half the complaints to the police during this period concern suspected sexual abuse within the family.4

A Swedish survey of complaints to the police concerning sexual offences against children show roughly one-third to involve one-off occurrences and two-thirds to involve repeated abuse which, on average, had been going on for a year before the complaint was made.21 One abused child in four was a boy and most of the children were of school age. Half the children had been subjected to aggravated abuse. If the abuser was the child's father, the child tended more often to be of pre-school age. One out of every four children abused by a biological father had siblings who had also been abused.

There are many impediments to the discovery and reporting of sexual abuse of children and young persons when the offender is a closely related person on whom they are dependent. Presumably, therefore, a large proportion of these crimes never come to the knowledge of outsiders.

Surveys suggest that only one-tenth of all reported cases of suspected sexual abuse of children lead to prosecution, but there are great regional variations here, and many prosecutors have had no experience of handling this type of case. Of the cases taken to court, roughly one-tenth end in acquittal - the same proportion as for other crimes of the same gravity.3

According to various surveys, between seven and eight per cent of women and between one and three per cent of men in Sweden are estimated to have been sexually abused at some time or other during their childhood or adolescence.4

Most sexual abuse is committed by men. Women are believed, according to various surveys, to commit between five and 15 per cent of all such offences.11 These figures are uncertain, and it is believed that the hidden statistics can be higher where female offenders are concerned. Clinical experience suggests that traumatisation can be graver in the case of children sexually abused by their mothers.22

Causes, risk factors and consequences
One of the expert reports describes factors on the part of the offender, combined with matters having to do with the child and the situation, which make it possible for abuse to be committed.11 Another report describes the short-term and long-term consequences for children who have been sexually abused.12 These reports are based on a review of international research. The summary below is also based on a report by the National Council for Crime Prevention and on experience presented in a report published by Swedish Save the Children.

A complex interaction of many different factors can help to explain the occurrence of sexual abuse of children. One prerequisite is the existence of a potential offender who is sexually and emotionally motivated, has deficient social competence and has little control over his or her sexual impulses. In addition there has to be a child who attracts the offender, is inadequately supervised and is incapable of warding off a sexual approach. Thus there are several obstacles which the offender has to overcome in order for an offence to take place - inward, personal barriers and safety mechanisms, outward obstacles in the situation surrounding the child, and also the child's own resistance. Powerful sexual motivation is needed in order to commit a sexual offence against a child which is taboo and which will have severe consequences if discovered.

The offender and the process of abuse
Most sexual abusers are men. As mentioned earlier, women comprise between five and 15 per cent of offenders in known cases of sexual abuse. Probably, as already remarked, the hidden statistics for these crimes are even greater where female offenders are concerned.

According to the expert report, four preconditions have to be met in the offender in order for abuse to materialise. The potential offender must experience an emotional benefit from children, must be sexually attracted to children, must feel impeded from developing a profound and lasting relationship with an adult partner and must overcome his or her inward compunctions about engaging in sexual contacts with children.11

Research concerning sexual offenders has mainly focused on paedophilia, and above all on adult men whose principal sexual interest and activity involves children. There are various nuances of paedophilia. In international literature, the proportion of adults with a paedophile disposition in a population is estimated at less than one per cent. Estimates of this kind, however, are highly uncertain. Not all people with paedophile inclinations give vent to their deviant sexual desires.21 It is a moot point whether parents sexually abusing their children are of a paedophile disposition or not.

Children's possibilities of warding off sexual abuse are smallest within the family. Abuse of this kind often continues for a long time before it is discovered, if indeed it ever comes to the knowledge of a third party.

Sexual abuse within the family (incest) has traditionally been associated with a transient inclination in which the events have mainly been triggered by a crisis in life. This view has been challenged in recent years.11

Certain offenders most often abuse the children whom they are acquainted with only superficially or not at all, though this does not preclude abuse of their own children as well. Paedophiles are often described as being fond of children and as having a talent for responding to and associating with children and a good hand with them. This orientation towards children contrasts with difficulties in establishing and maintaining adult relations. These offenders observe and look for passing children, e.g. in playgrounds, swimming baths and sports grounds or school playgrounds. Strategies can vary from surprising solitary, unknown children to cultivating an acquaintance, exploiting one's professional role (e.g. as a teacher), becoming a good friend of a child's parents, making advances to the children in one's own family or moving in with or marrying a single mother.

Planned abuse has been described as the offender slowly creating a relation of trust with the child who gradually becomes emotionally attached to the offender. The offender becomes the child's best friend and confidant, and pressurisation, threats and force rarely occur during this phase. After a time, often a longer period than is believed (from months to years), the adult introduces sexuality into the relationship by gradually shifting the limits, so that the child will barely notice the difference from one occasion to the next. Any resistance by the child is broken down by the adult's authority through the emotional ties which exist (the child wants to oblige) or by the adult normalising the sexual act (all adults and children do this).

Often what detains the child in these relationships of abuse is the child's devotion to the abuser and belief in the adult authority's normalisation of the acts. The child trusts the adult and in several cases it is not until after a disclosure that the child realises that the adult has been lying and that sexuality between children and adults is neither normal nor permissible. Only in exceptional cases do express threats form part of the picture. Threats are most often committed with preserving the shared secret.

According, however, to experience of abuse situations within the family, it is common for the abused child to be enjoined by threats to secretiveness and silence.22

Female sexual abusers
Up till now, the knowledge resulting from research and debate and from clinical experience has mainly concerned sexual abuse of children by men. Women have been traditionally regarded as "naturally" caring, which of course makes the idea of women as abusers particularly upsetting and prompts greater opposition to the insight that women too can be guilty of sexual abuse. More recently, in both Swedish and, for example, British debate, indications have been presented that the number of female abusers may in fact be greater than has been believed.23

As regards young women who commit sexual abuse, one study remarks that they commit serious abuse and do so most often in a situation where they are responsible for a child.10

Women convicted in Sweden of sexual abuse of children at the beginning of the 1990s generally received a different type of sentence from men, due to their being judged mentally ill in the legal sense. Between 1990 and 1994, a total of 110 women were reported for sexual offences against children, and 17 of them were convicted and sentenced mainly to probation and care. The accused women were suspected of having abused boys and girls to equal extents.24

A British researcher has proposed a division of female sexual abusers into the following categories: Those abusing infant children, mostly their own, those abusing teenage boys within their circle of acquaintance, and those submitting to an authoritarian man and abetting his abuse. According to certain international studies, it is more common for women than for men committing sexual abuse to have been sexually abused themselves as children.23

Risk factors of child abuse
Most commonly the offender is known to the child and is present in the child's immediate surroundings. Girls are more liable than boys to be subjected to sexual abuse: recent studies indicate that between two and five times more girls than boys are abused.11 International studies put the average age of the abused children at between about eight and ten years, but boys are generally somewhat older than girls when subjected to abuse.

The children more liable than others to be abused, according to the surveys, are children who do not believe or do not know that they are allowed to say No to adults, children who are afraid of being punished and children who are looking for affection because they are denied it from adults who are close to them. A greater risk is also incurred by children who are seen by other people as behaving in a sexualised manner or who are inadequately supervised by their parents or other adults.

Sexual abuse can entail sexual traumatisation, it can imply betrayal and a feeling of stigmatisation, and it can induce a sense of powerlessness. This in turn can have psychological consequences in the form of impaired self-esteem and sexual confusion, which can make a child more vulnerable to further abuse.

The question has been discussed and investigated whether children with functional impairment are at greater risk of being sexually abused, e.g. because they have more difficulty in defending themselves, making themselves understood or, in the case of children with intellectual disabilities, understanding the implications of what they are subjected to, and also because they are more dependent on numerous care providers. In a major American survey, the risk of a child with functional impairment meeting with sexual abuse was judged to be 1.7 times greater than for a child with no functional impairment.

Some children with neurological functional impairments can run a greater risk of being sexually abused.13 Certain neuro-psychiatric disturbances in children can, for example, be manifested by an obsession with sexuality or by uninhibited sexual expressions and overtures. This is instanced by children and young persons in whom Tourette's syndrome has been diagnosed; they can be obsessed with compulsive sexual acts, such as compulsive touching of their own private parts or other people's, exposure, obsession with pornography, sexual thoughts, words and actions. Through their sexually provocative and obtrusive behaviour, they expose themselves to a greater risk of being sexually abused.

Family factors such as substance abuse and violence in the family or failure of care by parents also augment the risk of exposure to sexual abuse.11

Research indicates that previous experience of abuse on the part of a member of the family has a bearing on the risk of being sexually abused. In an American study of 67 women whose children had been sexually abused, 34 per cent of the women themselves had been abused as children, as against 12 per cent of a control group. In a Swedish clinical study of women who had been sexually abused during their childhood or adolescence, 18 per cent of their children had also been sexually abused.

Sexual abuse of children in day care attracts a great deal of attention, not only because it occurs in a setting which is meant to be secure for the children but also because more children are liable to be affected. International research, however, has come to the conclusion that the risk of sexual abuse in a day nursery is generally smaller than the corresponding risk in the child's own home.

What is particularly serious is the indication by international research that children placed in institutions or foster-homes are liable to be sexually abused.11 A report published by the National Board of Health and Welfare shows that between 1988 and 1993 there were 86 reports of suspected sexual abuse of children in Swedish foster-homes ("family homes") and that in 70 per cent of these cases the suspected offender was the father of the family.25

Consequences of sexual abuse
The potential consequences of sexual abuse during childhood and adolescence have begun to be increasingly studied and documented.12

Certain researchers believe the short-term effects to be dependent on the nature of the abuse, e.g. whether or not penetration occurred, the relation between the offender and the child, how often and during how long a period the abuse occurred, whether or not physical violence occurred, and the degree of erotisation. In addition, factors on the child's part such as its development and maturity, and its capacity for processing its experiences, together with the family's capacity for coping with what has happened, are also considered of importance.

The symptoms which the child may develop after abuse may in themselves become stress factors for the child and its family. Researchers also maintain that the occurrence of other stress factors, e.g. conflicts in the home, alcoholism etc., probably also makes an important difference to the child's reaction following sexual abuse. Thus being subjected to sexual abuse can imply a wide variety of experiences.

Researchers describe a model of the potential impact on the child, based on four factors inherent in the abuse itself - betrayal by the adult, the child's powerlessness, stigmatisation and sexual traumatisation.

Betrayal by the adult can mean that the child's expectation of receiving care and protection is violated, the consequences of which can include, for example, deficient capacity for trust, increased vulnerability in close relationships, anxiety, fear, grief and depression. Sexual abuse can also give the child feelings of guilt, shame, impaired self-esteem and an experience of being different.

The child can experience powerlessness and feel incapable of protecting itself and putting an end to the abuse and also of making others believe his or her story. This can, for example, give rise to anxiety, fear, nightmares, depression and aggressive behaviour.

If the offender puts the blame for the abuse on the child and puts pressure on the child to keep quiet, the child may draw the conclusion that the activities have been shameful, which can give rise to feelings of guilt, shame, grief and depression. This stigmatisation can result in the child becoming more vulnerable to subsequent abuse and exploitation. The child may react, for example, with lack of trust and feelings of discomfort in close relationships. More long-term effects can include aggressive behaviour and substance abuse.

With regard to sexual traumatisation, factors have been observed such as the encouragement in the child of sexual behaviour inappropriate to its age, which can lead to a preoccupation with sexuality and compulsive sexual behaviour. Sexual activity and arousal can come to be associated with negative feelings and memories, which later are believed capable of causing sexual dysfunction.

As regards the long-term effects, researchers find the likelihood of developing various psychosocial difficulties in the long term to be between two and four times greater for persons who have been sexually abused than for others. Thus studies in this field have identified an increased occurrence of depressive symptoms, anxiety syndromes, anti-social behaviour, substance abuse, eating disturbances, suicidal behaviour and self-injuring behaviour, post-traumatic stress syndrome and sexual problems.

Assessing suspicions of sexual abuse
Competent handling of matters relating to sexual abuse requires a knowledge of the symptoms, reactive patterns and effects which traumatic experiences produce in individuals of different ages, in the short and long term, as well as a knowledge of family dynamics. Knowledge of normal and deviant sexuality in children and young persons and of other problems than sexual abuse which may underlie possible symptoms is also important.

In cases where sexual abuse comes to be suspected, it is often the child concerned who describes more or less clearly to an adult whom it trusts, often the mother, what has happened.22 The child's own narrative is central to the investigation.

Suspicion can also be aroused more indirectly, e.g. through the child showing signs of not being in good shape or through sexualised behaviour.14 Swedish and American studies have shown that less than half of all children who are sexually abused relate or reveal anything closely connected with the abuse.12

Children who through sexual behavioural deviations, mental symptoms or physical injuries, show signs of possible abuse are a heterogeneous group and a difficult one to assess. It may be that other persons have misinterpreted age-adequate sexual behaviour, but the children may have a variety of child-psychiatric and psychosocial problems and in some cases may actually have been abused. Others may have difficulties which are due to various functional impairments and medical problems.14

Children's ability to remember and describe
The debate concerning the way in which sexually abused children can recall and describe such occurrences and the age at which they can do so has led to an intensification of research into children's powers of recall. Current knowledge concerning children's ability to remember and to recall memories, and the implications this holds for interviews with children, is dealt with in one of the expert reports, based on Swedish and international research on the subject.5

Children's spontaneous relations of sexual abuse have, according to researchers, seldom proved to be invented. Children most often speak the truth to begin with but can be led astray by leading questions or by a long delay between occurrence and interview. This is especially true of pre-school children. Younger children do not readily assent to leading questions about activities and occurrences of a sexual nature which they have not been involved in. If anything the problem is getting the children to tell in the first place. They can, however, deliberately choose not to tell the truth if, for example, they feel frightened or threatened or believe that they will be punished.

The expert report includes a schematic description of memory. Long-term memory can be basically described as three different kinds of memory process: storage of what we can do (procedural memory), of what we know (semantic memory) and of what we have experienced (episodic memory).

Research has demonstrated lasting episodic memories in children from the age of about two years. Storage is facilitated by the child's development of a more pronounced ego concept, which is established at roughly the age of two years, and by the linguistic capacity which helps the child to structure its memories. Memories from the pre-linguistic period are probably stored in the form of implicit of procedural information, which is very hard to access consciously. These memories tend more to be recalled on a non-conscious plane, through specifically situational or emotionally charged clues, and they can be expressed in physiological reactions and behaviours.

Children can keep traumatic and highly negative emotional events, such as sexual abuse, out of their consciousness, especially when these things have happened at an early age, been perpetrated by someone close to the child, been repeated and been denied by others who are close to the child. This can be understood as a survival mechanism for fending off memories which arouse powerful negative feelings. The memory information is not lost for good but is prevented for as long as possible from entering the focus of conscious attention.

Reviving memories of emotionally charged events is more dependent on effective clues than if the case was more neutral, everyday occurrences. Mood is one such clue - re-enactment of one's own emotional experience makes it easier to remember the event which evoked it. Outward surroundings, sounds, smells etc. are other such clues which can also involuntarily evoke memories of traumatic events. Sensory impressions in connection with a trauma seem, according to Swedish research, to be retained regardless of a person's age at the time of the experience. The expert report states that there are good grounds for supposing that powerful feelings in connection with an event facilitate the encoding and storage of a memory of the event, while stress in the retrieval of the memory can impair access.

In many cases it can be fruitful to regard the disclosure as a process over time. It is not uncommon for children to retract the stories they have told about abuse. Retraction frequencies vary in different surveys between four and 22 per cent. Research has also shown that direct questions make a difference to whether or not children describe sexual abuse. In one study of children and young persons in out-patient psychiatric care, the proportion of cases was found to rise from six to 31 per cent if the children were specifically asked by experienced staff whether they had been sexually abused.12

Children's sexuality
Suspicions of sexual abuse of children are often assessed in the light of information from surrounding adults about the child's behaviour, among other things, together with the child's own narrative. Sexual behaviour which is palpable and problematic to the child itself and/or others around it can be a sign that something is wrong, apart from the child's general behaviour perhaps having been affected. To be able to assess what is to be considered problematic, sexualised behaviour in children, adults need to know what forms of sexual behaviour are common and to be expected in different phases of development. One of the expert reports compiled in this field therefore deals with children's sexuality, in the light of current research, including both what we in our society can regard as normal and accepted sexual behaviour in children and characteristics of behaviour looked on as deviant.7

Fears of children having been sexually abused are sometimes aroused by professional categories encountering children in the course of their work, by reason of symptoms and sexual behaviour which are regarded as problematic and inappropriate to the children's ages. The expert report points out that the meaning of "normal" or "deviant" with regard to children's sexuality is to a great extent socially and culturally conditioned and therefore liable to change with the passing of time. Adult values and interpretations influence the way in which children perceive their sexuality and their bodies, and also the way in which adults are influenced by their own experiences and knowledge. Sexuality could be said to emanate from the physiological functions of the body but to acquire its meaning as a result of children being gradually socialised into the values and norms existing at various levels of the surrounding community. Systematised knowledge of children's sexuality and behaviour is therefore important with a view to making assessments less arbitrary.

"Normal" sexual development in children has been far less explored than behaviour which is termed problematic in one or other respect. This, of course, can make it hard to judge what kinds of behaviour ought to give cause for concern. Researchers are, however, unanimous regarding the results of studies of sexual behaviour in children. In the expert report, the conclusions arrived at in international and Swedish studies are summarised as follows. Children are naturally inquisitive about their own bodies and other people's. Sexual play and exploration of this kind is often engaged in out of curiosity and is spontaneous, light-hearted and reciprocal by nature. Sexual interaction between children and sexual behaviour in an individual child, e.g. as a reaction to experience of abuse, is on the other hand frequently characterised by anxiety and has elements of coercion, threat, dominance, aggression and violence. Behaviour resembling adult sexuality (e.g. acts bearing a direct relation to sexual intercourse) are very uncommon in observations of children generally, but they do occur among children who have been sexually abused. Studies have also shown, however, that one-third of sexually abused children do not display any symptoms at all in the form of sexual or general behaviour.

Thus a child's sexual behaviour, if regarded by others as disturbing and problematic, may signal a warning that something is wrong in the child's existence. If so it is important to assess the whole of the child's living situation. Sexual behaviour may also be an expression of a healthy exploration of one's own sexuality and may proceed through reciprocal games with other children of the same age and at the same level of development. The expert report points out that assessment and interpretation of children's sexual behaviour demands a knowledge of girls' and boys' development, both biological and psychological, a knowledge of social and cultural norms, and an awareness of one's own attitude to sexuality.

Signs of sexual abuse
One of the expert reports describes the discovery and consequences of sexual abuse on the basis of a review of research.12

Children find it very difficult to describe sexual abuse, both when it is happening and later. The disclosure of abuse is a process which can sometimes take a long time, and it is not uncommon for the child to retract its narrative. Observation and ability to evaluate symptoms is therefore important for the discovery of sexual abuse of children. Things are complicated by the many-faceted nature of the symptoms and - as mentioned earlier - by the fact of not all sexually abused children displaying any symptoms at all.

The way in which children react to sexual abuse is affected by several different factors: the trauma as such, the child's ability to cope with difficult experiences, and its disposition and ability to expel the occurrence from its memory. Factors of importance include the following:

• the character of the abuse (on an isolated or repeated occasions, its duration, the occurrence or otherwise of violence, whether the
• child's body has been violated or the child has witnessed sexual acts),
  
• relationship to the offender (close relative, position of dependence or, on the other hand, a more distant relative or an unknown offender),
  
• the child's personality, its innate resources and its reactions to stresses,
  
• the support which parents are capable of providing.

Deficient emotional ties between the parents and the child augment the risk of the child being abused. This also implies a risk of the child not meeting with an understanding response from people who are close to it, response which could otherwise alleviate the harmful effects of a trauma.

There are no mental symptoms which can be unambiguously construed as signs of a child having been sexually abused. Certain symptoms may, however, corroborate the child's narrative.

Physical symptoms which can prompt suspicion of sexual abuse are recurrent infections of the urinary tract, discharges, injuries to the external genitals, with inflammation, swelling and bleeding or injuries to inward parts, injuries in the anal area such as inflammation, fissures, faecal or urinary incontinence, and bruises on the insides of the thighs. In the great majority of cases, though, medical examination, if any, at the time of a complaint being filed fails to yield any medical evidence.

Certain neurological disturbances in children can be manifested for example, through an obsession with sexuality or uninhibited sexual expression and approaches. This is raised in the expert report describing experience from research and clinical activity with regard to children and young persons with neuro-psychiatric disturbances.13

Many neuro-psychiatric disorders in children, especially Tourette's syndrome, autism and Asperger's syndrome, entail symptoms which can prompt suspicions that the children have been sexually abused. Deviations with regard to capacity for relationships, empathy, communication and, sometimes, obsession with sexuality can create problems and risks of misunderstanding. In certain cases, functional disturbances of these kinds and their expressions may also conceivably aggravate the risk of the young person actually being sexually abused and abusing others, which further complicates the assessment of these cases.

If children and young persons with the above mentioned and closely related functional impairments are suspected of having been involved in situations of sexual abuse - whether as victims or offenders - the expert report states that an assessment has to be made by a neuropsychiatrist and a neuropsychologist.

Consultation groups
During the 1980s both the social services and the police experienced a growth in the number of cases concerning sexual abuse of children. At the same time, efficient routines of co-operation between different authorities were lacking. In its former General Recommendations on Sexual Abuse (issued in 1991 and repealed in 1999), the National Board of Health and Welfare advocated wider formal co-operation between social services and other authorities in this field, through the setting up of "consultation groups" made up of representatives of the authorities charged with handling these cases.

The aim was to achieve better co-ordination and a higher level of competence in this, a complex working field which sometimes involves conflicting interests and differing considerations with regard both to families and to the different remits and working procedures of different authorities.

It was thought that, through the anonymous discussion of current cases in the consultation groups, each authority could contribute its particular kind of knowledge and competence without infringing the bounds of secrecy. In the light of the consultation, each authority would then make its own decision and take action accordingly. The consultation group could also serve as a body to which, for example, child care and school staff could turn for support in the assessment of any suspicions of sexual abuse and for advice when deciding whether or not to file a complaint with the social services.Current rules of secrecy are unaffected by several authorities co-operating through consultation groups or by other means.17

A study of consultation groups in three counties
Consultation groups concerning suspected sexual abuse of children and young persons exist in all counties of Sweden and in most municipalities. Their membership varies, comprising representatives of the social services, police, child and youth psychiatric services (BUP/PBU) and, possibly, child health care, paediatric medicine, adult psychiatry, the prosecution service and, in certain cases, other agencies.

The National Board of Health and Welfare has commissioned a study aimed at shedding light on the activities of consultation groups.8 Topics of enquiry included the dilemmas and difficulties confronting these groups, the benefit which the official representatives taking part feel that they derive from the consultation groups, and ways in which the work of the groups can improve handling procedures from the children's point of view. The study was based on questionnaires and interviews involving consultation groups in three counties: Norrbotten, Uppsala and the former County of Skaraborg. In these counties, consultation groups include representatives of the prosecution authority, adult psychiatry, child health care, paediatric medicine, gynaecology, primary care and schools, as well as the social services, police and child and youth psychiatric services, which are represented in all groups.

Discussions in the consultation groups
One of the main purposes of consultations, according to the consultation groups investigated, is to discuss the measures to be taken by each authority and the order in which they are to be taken.

Most of the cases discussed by the consultation groups during the period investigated were raised by the social services. Child and youth psychiatric services initiated less than one-fifth of cases, and only a few were raised by the police. Some cases were also initiated by an authority outside the consultation group, such as a child care authority, a school or a child habilitation body.

The consultation groups only supply viewpoints - they do not take decisions - and discussions continue until the party taking the initiative feels able to proceed on the basis of the viewpoints and perspective which other authorities contribute from their particular fields of competence. Questions discussed by the consultation groups in the cases concerned have been whether the social services are to start an investigation, whether parents are to be contacted, the filing of complaints with the police, interviews with the child, placement of children, referral to child psychiatry, medical examination etc.

Development of the consultation groups
From several of the consultation groups it is reported that the handling of business concerning suspected sexual abuse has changed during the decade or more for which the groups have existed, in favour of a more open-minded approach to the question, better preparedness for canvassing the viewpoints of other professional groups, and more professional handling of all contacts, based on consideration of the child's best interests. Individual response to all concerned and joint planning of co-ordination between the authorities are discussed in the consultation groups. The police can for the most part provide questioning at short notice where necessary, at the same time as the social services launch an investigation and offer support to children and parents, more independently of the outcome of the question of guilt than used to be the case. Response to the suspected offender and the possible need for crisis support are also discussed and observed.

The groups investigated stressed that co-ordination between the authorities concerned is invaluable, as are the different viewpoints and knowledge which the various kinds of expertise are able to contribute. Another aspect is that the level of knowledge and vigilance concerning sexual abuse, response to children etc. is raised within activities which otherwise do not come into contact with the problem.

All those interviewed feel that they have been helped and have felt strengthened for further dealing with the case involved, knowing who to contact next, who should do what and so on. They have felt more calm and collected when meeting the child and its parents. In addition it has been made clear who should talk to the children and about what, and in this way unnecessary repetition has been avoided. They have perceived the advantage to the child or young person of his or her situation being taken seriously and illuminated from various angles through the discussions in the consultation group. In this way deadlock has been avoided, both between the professionals and within the family and circle of kinship. An open. multi-professional discussion, according to the consultation groups, can increase the possibility of providing the child and its network with adequate support.

Intermittently during the debate the consultation groups have been criticised for not complying with secrecy provisions or on the grounds that standpoints adopted by individual officials in cases have been unduly influenced by the joint discussions. In the groups investigated, the feeling is that handling and discussion are based on each profession and on official responsibility, and that great importance is attached to secrecy. In cases where prosecutors take part, the case, if it comes before the prosecution authority, is handled by another prosecutor, not by the one taking part in the consultation group.

Several of the consultation groups have devoted themselves to supplying comprehensive information about sexual abuse to the professional categories coming into contact with the problem and are duty-bound to observe it, e.g. in child care and schools and in other activities to do with children and young persons. Members of consultation groups can also be contacted for telephone counselling in anonymous cases of suspicion of sexual abuse and in order to discuss the filing of a complaint with the social services.

Consultation groups create co-ordination benefits
Summing up, the study shows that serious, impartial and dedicated work is done by the consultation groups. According to the expert report, these groups confer co-ordination benefits, improved competence and provide greater security in the handling of cases of suspected sexual abuse.

Treatment measures for children and families in suspected cases of sexual abuse
Sexually abused children and young persons need to be able to process their feelings and experiences relating to the abuse, so as to make further, positive progress in their development. Knowledge and experience concerning sexually abused children and young persons have increased substantially in recent decades but are still at the build-up stage. One of the expert reports describes various types of treatment which have been devised abroad and in Sweden, for both victims and offenders. The description is based on a review of international research and of Swedish and international clinical experience.9

Treatment models
There are a number of common themes which are included in the treatment of sexually abused children, whatever the methods and structure otherwise employed. Provision for the child's need of protection, and the creation of trust and confidence are ingredients, to all types of treatment. In addition, the treatments are aimed at processing fear, desolation, sense of loss and feelings of guilt, and also of providing opportunities for the expression of feelings. By giving the child an opportunity of telling its story, the experience is processed. Strengthening the sense of identity and self-esteem, and repairing the child's body image, sensitivity and expressions of sexuality are other vital elements of treatment.

Child and youth psychiatric services in Sweden have knowledge and experience of treatment both individually and within the family with reference to sexual and other forms of abuse, but there are also a number of programmes in Sweden which have been specially designed for the treatment of sexually abused children. Examples are given below of a number of amply documented therapeutic activities. This description is not exhaustive. Knowledge and experience in this field have been developed in several places throughout Sweden, both in child and youth psychiatric services and in social services.

BUP-Elefanten
BUP-Elefanten is a specialised psychotherapeutic unit for children and young persons who it is suspected have been sexually abused or have themselves subjected others to sexual abuse, and also for their families. In addition, the unit engages in methods development, research and teaching in this field. BUP-Elefanten offers the families individual treatment programmes with many different ingredients. The emphasis is on individual response to each child and family, early crisis interviews in connection with the disclosure of abuse, and highlighting of the ties and relationship between child and parents. Individual therapy is provided through counselling, play, symbol drama, picture therapy or a technique, known as EMDR (eye movement desensitisation and reprocessing) for processing traumas by means of eye movements. Family therapy, parental therapy, group therapy and network therapy are also offered. The treatment focuses mainly on the trauma in question and its consequences for the child's mental health and development, the child's adjustment and ability to function, and the child's relationships. The overriding aim is for the child to be able to protect itself and set limits, to be able to identify and manage its feelings, thoughts and behaviour, to be able to trust others, build up a stronger self-esteem and clear self-image, to develop social skills, not to sexualise of adopt a "victim role" in relationships, and to find its own sources of gratification and happiness. Evaluation of the therapy is in progress.

Swedish Save the Children
Swedish Save the Children has since 1990 been operating a psychotherapy reception, the Boys' Reception in Stockholm, for the treatment of boys who have been sexually exploited and also of boys who have themselves committed this kind of abuse.26 One of the basic principles of the treatment is that the abuse must be "clinically verified", even if it has not been legally established. The concept refers to the child's way of expressing personal experience of abuse in a manner judged credible in a psychotherapeutic perspective. The treatment focuses on four central areas: Describing the abuse, Expressing feelings, Speaking out and Accepting (Swedish acronym: BUSA). The abuse can be described in words, in play, by drawing or by demonstrating with dolls, and its purpose is to "make it really real" and to relieve the children of "unhealthy secrets". As an aid to the expression of feelings of all kinds - for example, anger towards the offender, guilt, shame, fear etc. - use is made of cuddly toys of different kinds and sizes, cushions, differently coloured pieces of cloth symbolising different feelings, fairytales, cards with unfinished sentences etc. Speaking out is concerned with re-establishing the limits of one's integrity - spatial, corporeal and emotional territory which has been infringed. This is done, for example, by identifying and expressing feelings about wanting and not wanting and by discussing and marking limits in various ways. Accepting is about being able to move on and not getting trapped in a "victim identity". It is also about highlighting the "normal" and helping the boys to prevent the abuse from overshadowing everything else in their lives.

Other therapeutic activities
Therapeutic activities relating to sexual abuse of children also exist or are being built up in other parts of Sweden. In about 20 different places, group therapy is jointly offered by social services and child and youth psychiatric services, as for example at Vasa PBU in Stockholm. The Köping PBU (Child and Youth Psychiatric Services) and the Liljeholmen PBU in Stockholm have also been engaged for some years in developing methods for working with families and children where sexual abuse is suspected. These activities have not been evaluated.

Scientific evaluations of different forms of treatment, adapted to Swedish conditions, for sexually traumatised children and children who have sexually abused others are urgently needed but, as yet, are for the most part lacking.

Treatment outcomes
The treatment of children and young persons who have been sexually abused is founded on many different theories and therapeutic methods, e.g. psychodynamic therapy, cognitive behavioural therapy, family therapy, picture therapy, symbol drama, play therapy and hypnosis.9

International research into the outcomes of treatment for sexual abuse shows, briefly, that children who have been enabled to process their experiences in therapy generally feel better than those who have not had the opportunity of doing so. On the other hand, no firm differences in outcomes have been demonstrated between different forms of treatment, due among other things to the difficulties involved in making fair comparisons between different therapy methods.

Therapy research still has many deficiencies. Many studies include few children, have high dropout rates and are difficult to compare, owing to great variations in such basic matters as the ages of the children, the balance of the sexes, symptoms, treatment times etc. In control group studies, the groups have not always been fully comparable.

Children and young persons committing sexual abuse
Sexual abuse is not only committed by adults against children, there are also cases of children and young persons abusing younger individuals and coevals. This means young persons committing a sexual act against the wishes of the victim, without consent, in an aggressive, exploitative or threatening manner. In cases where the young person is under 15, no criminal charges are preferred and he or she is instead referred to the social services for remedial action.

Two expert reports describe the current state of knowledge concerning minors committing sexual offences. One of these reports describes therapy in a project targeting this group and summarises current knowledge of the field.10 International and Swedish research concerning young persons subjecting others to sexual abuse is also presented in the other expert report.6 Experience of the treatment of young offenders is also presented in a report from Swedish Save the Children22 and in the proceedings of a conference on this subject.27

According to international research and Swedish statistics, roughly one-third of all sexual offences are committed by young persons.6 About half of all adult sexual offenders have shown sexually deviant behaviour at an early age and committed their first offence before they were 18. There is a certain measure of scientific support for the theory that some of those already displaying sexually abuse behaviour in early years will commit new offences. The extent of sexual crime among young persons is probably greater than the official statistics indicated. Most of these crimes never come to the notice of the authorities, because disposition to report sexual offences to the police is low in itself and, probably, lower still where sexual offences are committed by young persons. In addition, the formal possibilities of investigating and recording these crimes are limited. The low proportion of young persons among all sexual criminals in Sweden, compared with other countries, may be partly due to factors of this kind.

About 95 per cent of young persons subjecting others to sexual abuse are boys.10 Just as with abuse committed by adult sexual offenders, however, researchers presume that the hidden statistics may be higher in the case of young women committing sexual abuse.

The victim of sexual abuse by a young person can suffer harm in the same way as when the offender is an adult. Identifying actions of abuse and responding to the young person's actions with adequate treatment are an important preventive measure both for the individual teenager and for the prevention of further abuse in future.

Studies of young sexual offenders
In a British project for the treatment of young women who had committed sexual offences, it was found that there were more similarities than dissimilarities between young women and men guilty of sexual abuse. The similarities include factors contributing towards abusive behaviour, the abuse procedure and receptivity to treatment. Society and professionals, however, do not appear to react the same when a young woman commits sexual abuse as when a young man does so.

The consequences to the victims are just as serious when the offender is a young woman as when the offence is committed by a young man.

Research findings suggest that there is no single factor or experience leading a young person to develop abusive behaviour. Rather what is involved is a combination of deficient control of impulses, low level of social competence, previous personal experiences of violation, bonding problems, family dynamics, experience of violence in the family etc.6

A Swedish survey of 56 sexual offenders aged between 15 and 20 who had undergone forensic psychiatric examination showed the median age of the offenders to be 18 and that of the victims 14.28 More than half of them committed abuse against someone they knew. 70 per cent used physical coercion or violence to subdue their victim, and 80 per cent committed abuse which involved attempted or completed oral, genital or anal intercourse. More than half the young persons committing sexual offences had previously had dealings with child and youth psychiatric services or adult psychiatry. Two-thirds had received special instruction in schools and nearly half were clearly below-average achievers in school. In connection with the forensic psychiatric examination, 75 per cent were judged to have a personality disturbance (a lasting pattern of comprehensive difficulties, e.g. as regards control of impulses, social relationship, realistic thinking and emotional response). Upwards of a quarter were clearly under the influence of alcohol or drugs when the abuse was committed.

The GRUF project
Children and young persons committing sexual abuse need help appropriate to their age. This can, for example, mean individual or group therapy focusing on sexually accepted behaviour, setting of limits and ways of achieving emotional proximity without sexualised behaviour, combined with trauma-oriented therapy.10

The GRUF project (group therapy for young sexual offenders), which has been in progress in Sweden since between 1996 and 1999, focuses on the need of specific treatment for sexual offenders aged between 13 and 18. In this project, representatives of BUP-Elefanten in Linköping, Vasa PBU in Stockholm, Swedish Save the Children and the Kristianstad Social Welfare Authority have taken part, with a view to exchanging and developing knowledge and experience of this field.

Experience from the GRUF project shows that there are instances of adults - both professionals and families - denying the gravity of sexual abuse committed by a young person, and that consequently a long time may pass before the problems are observed. In nearly all the cases contacted through the project, the victim was acquainted with or related to the young offender.

Young persons with abusive behaviour are sometimes placed, against better knowledge, in foster-homes where there are younger children. Almost one-fifth of the 123 young victims in the project were living in the foster-home (family home) or institution where the young offender was also placed. The abuse to which the young persons in the project subjected other children and youngsters mostly involved advanced sexual acts, very often directed against very young victims. The review of the backgrounds of the young persons concerned showed that most of them had themselves been subjected to emotional violence and neglect and that one-third had had personal experience of sexual abuse in their early years.

The expert report states that when young persons commit sexual offences, it is very important that this should be clearly indicated, instead of - as is often the case - being kept secret, hushed up and denied. In the encounter with the young sexual offender, it is essential to show empathy and to distinguish between the abusive behaviour itself and the young offender as a person. A survey of young sexual offenders can, according to a British model, serve to assess how dangerous the young person is, and how great a risk there is of relapse into crime, as well as identifying the young person's own needs, suitable treatment and placement, and necessary restrictions.

The Swedish Save the Children Boys' Reception
The Swedish Save the Children survey shows that nearly a quarter of the 101 boys who were sexually abused had been abused by other children or young persons - the offences had been committed by a total of 22 young boys.22 As a rule, the youngsters committing the abuse were well known to their victims; seven of them were elder brothers of the victims, three were relatives and one was a step-brother. Ten of the young persons committing abuse were boys in the neighbourhood and one was unknown. The abuse was often aggravated, not infrequently with anal penetration. Physical violence was common, especially when victim and offender where brothers. The average age of the young persons committing sexual abuse was 14 at the time of the abuse. Most of them admitted to the abuse.

Treatment for young sexual offenders
The purpose of treatment in American and British programmes is summed up in the following objectives: reducing denial and inducing the young offender to accept responsibility for his behaviour, to develop empathy with the victim, to identify his own patterns with regard to what triggers abusive behaviour and how it is underpinned by cognitive distortions and rationalisations, and to learn to break this pattern. Other parts of the treatment involve developing social skills and a positive self-image and to developing family relations. Exploring and processing one's own vulnerability and history, if any, of abuse are regarded as further important but secondary elements in the treatment of young offenders.10, 6

The National Board of Institutional Care (SiS) has two institutions offering treatment of young sexual offenders, namely Garanten, a secure treatment unit at the Bärby approved home29 and a two-year project at the Tunagården residential treatment centre.30 The young persons offered this treatment are aged between 14 and 18. SiS also has an investigation home in Hässleholm which profiles itself by examining young persons with severe psychiatric problems and young persons who have committed sexual offences.27

Both the treatment institutions mentioned above have a wide variety of treatment programmes with many different elements, such as individual therapy, group counselling, environmental therapy, family counselling and school instruction. At Garanten, individual therapy has a confronting, cognitive focus, while at Tunagården it is psychodynamic, with supportive and processing phases. The purpose of the treatment at both institutions is to avoid relapses by achieving a development and change in the young offender and increasing social competence and the capacity for relating to and empathising with others. Treatment at both institutions is based on international experience and focuses heavily on the abusive behaviour, responsibility and self-esteem. Tunagården has planned treatment times of two to three years. At Garanten a continuous, all-round assessment is made of the risk of relapse, and this assessment forms the basis of the degree of control exerted over the young individual. Treatment here proceeds by three stages, with young offenders, if there is considered to be no risk of relapse, moving on to an open exit department and from there to other accommodation while continuing their treatment.

The Swedish Save the Children Boys' Reception, BUP-Elefanten, Vasa PBU, the Kristianstad social services and several other communities in Sweden also offer treatment for young boys who have subjected other children or youngsters to sexual abuse.

Legal proceedings
Legal aspects are also part of the handling of suspected sexual abuse. Often an investigation is needed to see whether a crime has actually been committed; this task devolves on the police. Finding out what has happened when a child may have been subjected to a criminal act entails particular difficulties. The facts emerging from the investigation, and the manner in which they do so, have an important bearing on the outcome of any legal proceedings. There has been discussion concerning the credibility to be ascribed to children's narratives and to symptoms of suspected sexual abuse. Legal proceedings also have to be conducted with due consideration for the best interests of the child. One of the expert reports describes legal procedure and discusses the rights of the child and the possibilities of asserting them in the proceedings.3

Legal process
When a suspected sexual offence is reported to the police, the prosecutor decides whether to open a pre-trial investigation. This can only happen if "there is reason to suppose" that a crime has been committed. No pre-trial investigation is needed if a criminal offence can be rules out or if there are no concrete circumstances to suggest that a crime has been committed. Conversely, a pre-trial investigation is obligatory if concrete circumstances can suggest that a crime has been committed - for example, as regards sexual abuse of children, an observation, statement or symptom of some kind. A pre-trial investigation can, however, be dispensed with if there is a presumption that prosecution would be waived. The prosecutor may also decide to close a pre-trial investigation which is in progress if he/she considers the evidence to be insufficient, but the investigation can be re-opened if new evidence emerges.

When the pre-trial investigation reaches the stage where someone is "suspected on probable cause" of a crime, that person is entitled during questioning to be informed of the suspicion and, subject to certain restrictions, to study what has been deposed against him or her. If there is "probable cause" for suspecting him or her of a crime, the suspect can, during the pre-trial investigation, be arrested, detained and remanded.

After the pre-trial investigation has been completed, the prosecutor decides whether to instigate criminal proceedings. This has to be done if there is sufficient evidence to secure a conviction, which in turn requires the establishment "beyond all reasonable doubt" of the accused having committed the crime in question. In other words, very strong evidence is needed in order for a matter to be taken to court. This means that, due to the evidence being considered insufficient, many cases are closed by the prosecutor discontinuing the pre-trial investigation or refraining from criminal proceedings.

According to the expert report, too many police inquiries concerning suspected sexual abuse of children tend to end in closure, or in the prosecutor deciding not to instigate criminal proceedings, due to excessive caution in the assessment of whether a prosecution could lead to conviction.

The Office of the Prosecutor-General has issued new guidelines on pre-trial investigations of suspected sexual abuse.18 There it is noted that the child's interest in protection and care can entail certain collisions of interest in relation to the purpose of the criminal investigation, namely to clarify the possible crime and who committed it. For example, the investigation may suffer as a result of the custodial parent etc. being informed. Importance is emphasised of prosecutors co-ordinating their actions, e.g. with those of social services and medical care, at the same time as it has to be realised that the authorities have different parts to play and different interests to safeguard. Useful co-operation, therefore, according to the Office of the Prosecutor-General, requires each official representative to act within his or her particular sphere of responsibility and competence.

The expert report already mentioned states that the judicial system and its competence are not adapted to the special conditions applying when complainants are children. There are great difficulties involved in evaluating the child's narrative and safeguarding the child's interests in a manner which at one and the same time accommodates the rights of both child and suspect and is in harmony with the current principles of Swedish justice.

In all cases involving one person's word against another's, there are difficult problems of evidence evaluation. These are made still more difficult when the alleged victim is a child who cannot fully understand and describe what has happened to it. The expert report goes on to say that if, in addition, the suspect is a close relative to whom the child has a relation of dependence, the situation is further complicated by the child's vulnerability and feelings of guilt and shame.

One problem is that the police investigation can be impeded if either of the custodial parents object to the child being questioned and examined. Even though there are formal possibilities of questioning and examination still taking place, in practice this is a problem, especially as regards younger children, who cannot be expected to be willing or able to co-operate without their parents' consent. New legislation effective from 1st January 2000 strengthens the possibilities of asserting the rights of the child when a custodian or close relative is suspected of a criminal offence against the child. A special representative can be appointed for the child and can grant permission for medical examination and attendance for questioning.

Police questioning of children demands special competence and requires the procedure to be adapted to the child's conditions and conducted in such a way that an account is obtainable which can, as far as possible, be deemed reliable. But the experts report calls for an understanding of the great difficulties which are involved in obtaining a legally satisfactory statement by questioning a child who has been sexually abused.

One further procedural difficulty is that, by precedent, the child is not present in court, which in practice weakens its position. The child's statement is presented in a video-recorded interrogation, and this is deemed to have less evidential value than a direct statement in court. The report goes on to say that there is a danger of the court, owing to lack of competence, accepting statements by various experts as verdicts in the actual question of guilt.

Talking to children
Example of a child interview by the police
Particular difficulties arising when children are to be questioned, and especially very young children, are connected with the child's capacity for remembering and reproducing what it has experienced, as compared with the evidential requirements applying to testimony in court. One of the expert reports presents a survey of 193 complaints to the police concerning cases of sexual abuse in a police district between 1986 and 1995.2

The review of police interviews with children suspected of having been the victims of sexual abuse and lawyers' interpretations of these interviews presuppose the narrative emerging from the police interview to be a result of the interaction in the interview situation between the police and the child and of the preconditions accompanying this interaction. Conditioning factors include, for example, the child's age and maturity, previous experiences and general situation in life, the quality of the interaction, the child's understanding and interpretation of the words and concepts used, the environment and degree of stress, and the availability of social support in the interview situation.

In the survey presented, it is observed that the lawyers' assessment of the child's credibility is adapted to the legal outcome of the case. Things which in one case can be regarded as lack of credibility on the part of a child when the suspect is not deemed guilty can, in another case where the suspect is deemed guilty, be justified and formulated as intelligible in view, for example, of the way in which the police interview in itself may have influenced the child concerned.

In the police interviews studied, four different forms of narrative were identified. There were children who, consistently throughout the interview, described abuse or did so fragmentarily, or children who consistently or fragmentarily denied abuse. The survey pointed to the difficulties of conducting police interviews with children in a satisfactory manner. It was noted, for example, that the police in the survey made extensive use of suggestive questions and that the exacting evidential requirements in themselves can lead the police to formulate questions in a way that makes it difficult for the child to furnish a legally tenable narrative. The expert report advocates the method of encouraging the child as far as possible, through open-ended questions, to tell the story in its own words.

Talking to children
As mentioned earlier, talking to children requires special knowledge and competence. These questions are dealt with in one of the expert reports, summarising Swedish and international research and experience in this field.5

Talking to young children about events which they have experienced is made more difficult by their limited vocabulary and their unfamiliarity with putting things into words, understanding adults' questions and concentrating on what is important. Children have a limited capacity for processing, organising and selecting information. They have a different perception of time and in the course of conversation they are in a position of dependence which makes them eager to oblige the adult. Children most often tell the truth to begin with, but younger ones especially can be led astray by leading questions if a long time has elapsed between the occurrence and the interview or, for example, if they feel frightened or threatened or want to avoid punishment. Children answer more correctly if they are given support and feel secure and comfortable in the conversational situation. The expert report states that, given the right questioning technique, even very young children can to some extent compensate their as yet undeveloped linguistic capacity and their lack of chronological organisation.

According to the expert report, there may be reason to have several meetings with a child when talks are concerned with powerful emotional experiences. The above mentioned guidelines from the Office of the Prosecutor-General say the same.18 According to the expert report, contact and trust have to be established, and this can be a painstaking, time-consuming process with several attempts needed to elicit memories. Memories can crop up long after the question has been asked. Telling the story entails a processing which in turn can result in more memories coming to the surface.