Child Abuse & Neglect 89 (2019) 192–202

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Therapeutic interventions with child survivors of sibling sexual

T
abuse: The professionals’ perspective
⁎
Dafna Tenera,b, , Michal Silbersteinc
a
The Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, Mt Scopus, Jerusalem 91905, Israel
b
The Haruv Institute, Jerusalem, Israel
c
The Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, Israel

A R T IC LE I N F O ABS TRA CT

Keywords: Background: Sibling sexual abuse (SSA) is a continuum of childhood sexual behaviors that do not
Sibling sexual abuse (SSA) fit age-appropriate curiosity. SSA may be the most prevalent, longest lasting form of intrafamilial
Sibling incest sexual abuse – and the least reported, studied and treated.
Survivors of sexual abuse Objective: This exploratory qualitative study examined the experience of intervention with SSA
Professional intervention
survivors from the perspective of mental health professionals, and explored their major ther-
Qualitative thematic analysis
apeutic challenges.
Participants and setting: The sample consisted of 20 Jewish Israeli mental health professionals
working in private clinics or public social welfare services who had experience with SSA.
Methods: Semi-structured interviews focusing on the characteristics of SSA events, perceptions
about the effects of abuse, intervention priorities and therapeutic challenges compared to other
types of child abuse.
Results: Professionals working with SSA survivors are preoccupied with the need to provide them
with physical and emotional protection, as well as to help them process the abuse narrative. They
also find themselves dealing with survivors who do not experience themselves as victims despite
external evidence of abuse, or with the need to reconcile their perception of the sexual re-
lationship as mutual, as opposed to the formal requirement to differentiate between “offender”
and “victim”. In either case, the reality of these survivors can be just as painful as in other SSA
cases.
Conclusions: The complexity of SSA calls for unique intervention skills, including working with
survivor narratives that do not fit the victim/offender dichotomy on one hand and that do not
minimize the potentially harsh consequences of SSA on the other.

1. Introduction

Professionals working with families that have experienced sibling sexual abuse (SSA) are often required to deal with narratives of
abuse characterized by ambiguity and uncertainty regarding the course of events, which can challenge the construction of a strategy
to prevent further harm. Compared to other types of intrafamilial sexual abuse, and despite being one of the most prevalent, SSA is
the least reported to welfare or law enforcement authority, perhaps because it is often seen as playacting or a form of age-appropriate
curiosity (Ballantine, 2012; Bass, Taylor, Knudson-Martin, & Huenergardt, 2006; Cyr, Wright, McDuff, & Perron, 2002; McNevin,

⁎
Corresponding author at: Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Mt Scopus, Jerusalem
91905, Israel.
E-mail address: dtener@gmail.com (D. Tener).

https://doi.org/10.1016/j.chiabu.2019.01.010
Received 19 May 2018; Received in revised form 21 November 2018; Accepted 14 January 2019
0145-2134/ © 2019 Elsevier Ltd. All rights reserved.
D. Tener, M. Silberstein Child Abuse & Neglect 89 (2019) 192–202

2010; Rayment-McHugh & Nisbet, 2003). Self-disclosure is rare, whether within or outside the family. The abuse ends usually not due
to disclosure, but rather because the perpetrator matures and leaves the family home, which is why SSA tends to continue longer than
other forms of intrafamilial sexual abuse (Caffaro & Conn-Caffaro, 2005; Finkelhor, 1980). SSA also involves consequences at least as
severe as intrafamilial sexual abuse between a parent and a child (Carlson, Maciol, & Schneider, 2006). Finally, our knowledge
regarding it suffers from the lack of clear and well-established literature and lack of specific therapy models, leaving professionals to
find solutions by themselves. This study seeks to develop the existing body of knowledge further by examining the therapeutic
challenges faced by mental health professionals treating SSA survivors.

1.1. SSA: definition, prevalence and reporting

SSA is defined as sexual behavior between two or more siblings of the same family that is age inappropriate, intransient, and not
motivated by developmental or appropriate curiosity (Finkelhor, 1980). It may include a range of behaviors, from non-contact abuse,
e.g. exposing genitalia or viewing pornography in front of another sibling, through physical contact over or under the clothes, to oral
or genital penetration (Caffaro & Conn-Caffaro, 2005). This definition is not uniformly accepted, due to the poor state of knowledge
and the difficulty of researchers and clinicians to create a comprehensive framework for this complex phenomenon.
Siblings' sexual behaviors may range from developmentally inappropriate to problematic or abusive behavior. Developmentally
inappropriate behaviors range from obsessive sexual curiosity to full intercourse at an early age, before attaining physical and
emotional maturity (Hatch, 2005; McVeigh, 2003). Problematic or sexually abusive behaviors involve the use of force, manipulation,
threat or coercion (McVeigh, 2003). Nevertheless, these behaviors are not necessarily mutually exclusive, and many families ex-
perience a broad range of sexual behaviors by one sibling or more (Carlson et al., 2006). Hitherto, there have been no universally
agreed-upon criteria for differentiating harmful from harmless sibling sexual behavior (Caffaro, 2014).
Welfare (2010) suggests that the lack of a clear definition for SSA, as well as lack of consensus among scholars and policymakers
regarding its characteristics, make it difficult to estimate the phenomenon’s prevalence. Indeed, different studies present limited data
regarding its extent. Finkelhor (1980) found that among 796 American students, 15% of women and 10% of men were engaged in a
sexual activity with a sibling during childhood. In another study, also among US students, 7% reported sexual activity with a brother
or sister during childhood (Hardy, 2001). In a retrospective study, researchers found that SSA was one of the most common types of
intrafamilial sexual abuse in a British sample of 2869 adults, with twice the rate of parental abuse (Cawson, Wattam, Brooker, &
Kelly, 2000). Another study found that nearly 5% of a sample of 2885 computer-interviewed students reported involvement in SSA
(Griffee et al., 2016). In Israel, 5.2% of abused, neglected or at-risk children reported that a sibling abused them (National Council for
the Child, 2013). Finally, several studies estimated that SSA was the commonest type of intrafamilial sexual abuse (Carlson et al.,
2006; Cole, 1982; Finkelhor, 1980; Tapara, 2012).
The difficulty in identifying the nature of the phenomenon also affects reporting rates: SSA is characterized by high levels of
underreporting, even compared to other sexual assaults (Canavan, Meyer, & Higgs, 1992; Carlson et al., 2006). It is estimated that
only 20% of all SSA cases are reported and are eventually treated professionally (Welfare, 2010). The social myth that sexual acts
between siblings are mutual, harmless, and innocent and that they represent natural age-appropriate curiosity is one possible cause
for the low rates of reporting and detection. The fact that the age gap between the survivor and perpetrator is relatively small might
contribute to this myth (Ballantine, 2012; Kiselica & Morrill-Richards, 2007; Tapara, 2012).
In fact, however, SSA has a traumatic potential with consequences that may be damaging and long lasting at least as much as the
abuse of a child by an adult (Cyr et al., 2002; Haskins, 2003; Russell, 1986). The gap between how the phenomenon is perceived, even
by professionals, and its actual harmful consequences creates a difficult situation for both the survivors and their families, in terms of
receiving the appropriate recognition for their suffering, as well as appropriate professional response (Rowntree, 2007).

1.2. SSA: characteristics and dynamics

Several studies report the age gap between siblings involved in SSA. The age of the perpetrators ranges between 12 to 20 years,
and the age of the survivors (mostly younger sisters) ranges from 3 to 12 (Adler & Schutz, 1995; O'Brien, 1991). In one study, for
example, the average perpetrator-survivor age gap was 4.18 years and it ranged from one to six years (Welfare, 2010). It has been
claimed that the age gap is a significant factor in defining the sexual acts between siblings as abusive: it enables exploitation of power
and authority and at times involves the role of older siblings in caring for younger siblings, giving them opportunities for abuse
(McDonald & Martinez, 2017; McVeigh, 2003; Tener, Tarshish, & Turgeman, 2017). Some researchers emphasize, however, that the
age gap is not a crucial factor and point out cases in which the perpetrator is the same age as or even younger than is the survivor
(Allardyce & Yates, 2013; McVeigh, 2003) – for example, when the perpetrator is younger but physically stronger or when the
survivor has mental or physical disabilities. Hatch and Hayman-White (2001) claim outright that the age gap is insignificant: the
survivor is selected because he or she are vulnerable, whether due to isolation, parental neglect, small physical size, or disability.
Allardyce and Yates (2013) add that cases of SSA not characterized by significant age gaps or by the use of force require further
examination of the dynamics of the sibling relationship.
SSA usually occurs over several years and is rarely a one-time event (Carlson et al., 2006; Daie, Witzum, & Eleff, 1989; McVeigh,
2003). Long-lasting abuse is possible due to the relative accessibility of siblings, and studies have found that often, abuses end only
when the perpetrator leaves the parental home (Carlson et al., 2006; Welfare, 2010). Accordingly, several studies emphasized the
ever-changing dynamics of SSA due to two main factors. First, the family structure alters as the siblings experience cognitive,
emotional, social and physical changes, as part of their natural development. This development shapes the abuse and the dynamics of

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the secret and potential disclosure (Ballantine, 2012). Second, in long-lasting abuses there is a constant tendency by the perpetrator to
escalate the severity of the sexual acts (Caffaro & Conn-Caffaro, 2005; McVeigh, 2003), which may be exacerbated by the siblings'
constant physical accessibility. Indeed, Carlson et al. (2006) describe a pattern whereby SSA is initially motivated by warmth and
affection, and subsequently becomes aggressive and forceful when the survivor tries to resist, but is forced to cooperate due to
increasing pressure by the perpetrator. Another issue of concern is that the perpetrators themselves may also suffer from sexual abuse,
either within or outside the family (Latzman, Viljoen, Scalora, & Ullman, 2011; Tidefors, Arvidsson, Ingevaldson, & Larsson, 2010),
which may also affect the dynamics. Note that the literature that describes the patterns of sibling relationships in cases of sexual
abuse is relatively scarce, and does not meet the need to understand this complex and multidimensional relationship.

1.3. Therapeutic intervention with SSA survivors

Professionals who work with families coping with SSA meet them in a painful moment. These families are required to make
difficult decisions such as how to protect the survivor, and whether to exclude the perpetrator (Lafleur, 2009). There is consensus in
the literature that good therapeutic intervention should be multidisciplinary and integrative and should consider the needs of the
entire family, from the moment of disclosure to the end of therapy. Cases of SSA often requires the involvement of a large number of
health professionals, each working with a different family member (the perpetrator, the survivor, the family as a unit, etc.). When
therapy is conducted by several professionals, this could pose a serious challenge to its integrity (Bass et al., 2006; Caffaro & Conn-
Caffaro, 2005; Tapara, 2012). Considering the needs of the entire family as well as multidisciplinary work, which also involves the
legal authorities as required, has been found to significantly improve the recovery of survivors and perpetrators (Caffaro & Conn-
Caffaro, 2005; Kambouridis, 2010), parents (Lafleur, 2009), and other siblings (Fontana, 2001). Welfare (2010) argues, however, that
the practice suffers from conflicts between agencies that do not always maintain ongoing coordination; some are designated to work
with the perpetrator and others with the survivor, challenging the integrative approach that strives to balance the needs of all family
members.
Cultural and social aspects should also be addressed in therapy: beliefs and perceptions regarding SSA, as well as the best
treatment for those involved, are significantly influenced by the values held by family members (Alaggia, 2001). Various aspects of
SSA, such as authority, control, intrafamilial boundaries, shame and consent, are influenced by the cultural context, social norms and
beliefs (Bass et al., 2006). The therapist is also influenced by the sociocultural context, which may affect the therapeutic relationship,
consciously or unconsciously. The therapist must be aware of his or her preconceptions and let the family comprehend and construct
its own narrative (Kambouridis and Flanagan, 2003). These factors are all obviously affected by ethnicity, but hitherto there have
been only few studies about the unique therapeutic needs of SSA families belonging to different ethnic groups (e.g. Bass et al., 2006;
Lafleur, 2009).
As we have seen, although knowledge regarding the SSA has begun to develop in recent years, the literature on this issue is still
very limited. In particular, professionals' perspectives have rarely been studied (Kambouridis, 2010). This explorative study seeks to
bridge some of this gap by applying a qualitative approach to explore the experience of intervention with SSA survivors from the
perspective of mental health professionals. It is designed to answer the following questions: What are the major therapeutic chal-
lenges professionals face when intervening in SSA cases, and how do they cope with such challenges?

2. Method

The lack of a conceptual and empirical framework on intervention with SSA survivors led to the use of an exploratory qualitative
approach with the aim of generating innovative knowledge regarding the phenomenon under study (Rendle, Abramson, Garrett,
Halley, & Dohan, 2017) – specifically, on the perspective of mental health professionals.

2.1. Sample

The sample consisted of 20 Jewish Israeli mental health professionals: 16 clinical therapists and 4 child protection officers (CPOs),
all working in a variety of public social welfare services such as child advocacy centers, treatment centers for sexually abused children
or mental health clinics (five also worked in private clinics), and who have treated SSA cases in the course of their work. CPOs are
social workers appointed by law to protect minors at risk. Their work includes both legal and therapeutic components. All the CPOs in
this study have had intensive long-term therapeutic relationships with SSA families and survivors. Participants were first recruited
through notices on websites specifically aimed at this group (such as forums for child therapists). Subsequently, candidates were
asked to suggest to colleagues to participate, and these contacted the researchers independently.
The professionals’ ages ranged from 35 to 63. All were females except two male participants. Five participants had an experience
of 10 years or less in working in the field, 13 had 15–30 years’ experience, and two did not specify their experience.

2.2. Procedure

Sixteen face-to-face semi-structured interviews were conducted by the second author, as part of her master thesis in social work;
four interviews were conducted by master’s students as part of a research seminar on SSA. All were specifically trained to conduct
these interviews by the first author, an expert on child sexual abuse and qualitative research. The interviews were conducted in the
participants’ homes or in another location of their choice. The interviews lasted between one-and-a-half and three-and-a-half hours.

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The interview guide covered several content categories, including the professional’s formal background; the characteristics of SSA
events they encounter; perceptions about the short- and long-term effects of the abuse; intervention priorities; therapeutic dilemmas
and challenges compared to other types of child abuse; and ways of dealing them. The interviews were tape-recorded, transcribed,
and analyzed using the Atlas ti.5 software. Originally conducted in Hebrew, the interview transcriptions were professionally
translated into English and double-checked by the authors to ensure their accuracy and that meanings have not changed in the
translation process.
Ethical issues were addressed through the approval process of the Hebrew University’s Ethics Committee: informed consent was
obtained and special attention was paid to issues of confidentiality and dignity. Identifying details were removed from the data, and
pseudonyms were used.

2.3. Data analysis

The qualitative thematic analysis (Braun & Clarke, 2006) included several interrelated stages. Before beginning the analysis, the
interviews were read several times in order for the authors to become familiar with the data and to identify initial ideas. In the first
stage the researchers entered each interview transcript as a case into the Atlas ti.5 software and performed open coding, which
yielded initial categories. More precisely, the cases were broken down into small segments of text, representing discrete “units of
meaning,” and each unit was labeled according to its content.
In the second stage, the codes were grouped together as initial themes. As the authors read the cases, some of the themes were
removed or changed and additional codes and categories were added. For example, several codes were defined as "keeping the
survivor safe from further abuse," whereas others were defined as "working with survivors’ feelings of shame."
In the third stage, the themes and subthemes were reviewed and classified by their dimensions and properties (Strauss & Corbin,
1998). For example, the various perceptions related to physical protection for survivors were merged and separated from all other
perceptions concerning emotional component of the treatment.
In the fourth and final stage, themes were refined, named, and interrelationships between them were suggested (Braun & Clarke,
2006). For example, the previously identified theme was further classified into “ensuring physical and emotional safety". At this
stage, the authors referred back to the transcripts when necessary to retrieve additional information needed to develop the categories
(Maykut & Morehouse, 1994).
Trustworthiness (Guba & Lincoln, 1985; Morse, 2015) was achieved by member checking, peer debriefing, and audit trails.
Member checking was first conducted during the data collection process, when participants were asked to clarify and elaborate, and
give examples of their perceptions, and to respond during the interview to issues raised in previous interviews (Morse, 2015). For
example, after conducting a couple of interviews it became clear that professionals felt less certain about SSA cases than about other
sexual abuse cases. As a result, interviewees were asked directly in the following interviews: "Other therapists discussed the un-
certainty that is typical to these cases. What is your perception about that?” Second, after the data analysis, the findings were emailed
to participants. Three chose to reply, and expressed their agreement with the findings.
Peer debriefing took place throughout several stages of the thematic data analysis process (Nowell, Norris, White, & Moules,
2017). During the initial coding process, it took place by having the two authors analyze each interview with weekly meetings held
throughout the coding process to ensure the work was systematic and to ensure the uniformity and accuracy of the coding system. In
the following stages, when themes emerged, the researchers continued to hold regular meeting. During this peer debriefing, personal
thoughts were discussed and the researchers ensured systematic analysis of all data. Finally, it was verified that each theme and
subtheme had a coherent pattern (Nowell et al., 2017). The researchers also discussed their work with colleagues, experts in the fields
of child sexual abuse and qualitative research, in order to ensure the quality of the researchers work (Henry, 2015). The audit trail
consisted of detailed documentation maintained throughout the research, to show how the raw data were collected and analyzed.
Excerpts from the raw data were attached to all interpretations and the peer debriefing process was documented in writing (Bowen,
2009).
In order to guard against personal or professional assumptions that could have biased the coding, reflexive writing accompanied
the entire process, with the authors reviewing and documenting their own personal and professional assumptions, values, thoughts
and experiences as they evolved during the interviews and analysis (Cope, 2014; Nowell et al., 2017). To this end, reflective journals
were kept by the authors in order to raise awareness of influences on their interpretation of the data and their relationship to the
research topic and participants (Jootun, McGhee, & Marland, 2009).

3. Findings

Data analysis yielded three themes: (1) Ensuring SSA survivors’ physical and emotional safety; (2) Creating a new survivor
narrative; (3) Dealing with the “grey cases”, which include two subthemes: (a) When the survivors do not perceive themselves as
abuse victims; and (b) When professionals cannot clearly label one of the siblings as “perpetrator”. Note that as further elaborated
below, the terms “survivors” and “perpetrators” refer to external definitions, but do not necessarily represent the professionals’
perceptions, or the siblings’ for that matter. Note, moreover, that although the focus here is on the survivor, interventions in SSA
cases include treatment of all family members. Accordingly, the therapists’ perceptions range from focusing on the individual's unique
needs to looking at the family as a whole. All the themes were supported by the majority of participants.

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3.1. Ensuring the survivors’ physical and emotional safety

After SSA is disclosed, the first task for the family and professionals accompanying it is to stop the abuse and to ensure that the
survivor and other siblings are protected. The interviews indicate that often, this family reorganization requires mental resources that
are not always available at an emotionally turbulent time when the family is forced to make difficult decisions. In particular, the
family is torn between the immediate need to protect the survivor and other siblings and the need to take the time to come to terms
with the event. Hamutal, a clinical social worker and CPO, described one such family:
The parents were broken… We tried to build a protection program with them, but there was a feeling that they did not understand
the urgency, and that they did not have the wherewithal to implement it. I actually remember the father explaining to me that…
sometimes [the abusive brother] stays with one of [the little siblings] and he would not hurt them, because they talked to him
about it and now it’s OK.… I don’t blame them – even before they had the chance to come to terms with the meaning of things we
were already expecting them to pull themselves together and to actually change everything they thought about their children....
There was no time for them to digest… but as far as I'm concerned, there's what I call "child's time" here, and you have to act
quickly to provide protection.
The protection that must be provided is not only physical, but also psychological, that is, creating a supportive and emotionally
safe environment. The participants emphasize that the survivor must feel trusted, loved and supported. As described by Ruthie, a
clinical psychologist and family therapist at a center for treating child sexual abuse,
The survivor must know that her parents are behind her, believe her and do everything to support her. It is always a challenge
when the abuse is in the family, and certainly when it is about abuse between siblings. And that's… more important than
everything. I have seen girls who broke down because of an abuse that was disclosed only because they did not receive support in
this terrible situation. On the other hand, I also saw amazing parents who really managed to support and be there for their
daughters, and there is no comparison between the ability of these girls to cope.
According to Ruthie and other participants, in order to enable mental integrity, there must first be recognition by the family and
the parents in particular, of the severity and consequences of the abuse. Such recognition does not always occur: often, the family
responds by minimizing or even denying the abuse. Hanna, a social worker and family therapist, describes a girl she treated in an
addiction treatment center:
I had one girl, cute girl, not even fourteen, and she kept trying to escape home. I didn’t get it – what was the point?… It took her a
long time to tell me that she was running away because she knew that if she would not be home, the brother who abused her
would turn on to her sister.… Against all odds, we somehow managed to obtain a court order and get the brother out of the house.
After the brother left, I encouraged her to call her mother, and with her full permission, I listened in…. the mother did not say to
her, "My sweet girl, my poor thing, what you've been through, how hard it is for you”, and all that. Rather, she said, "How dare you
break up our family? I'll make sure they chase you all your life!"… I sat and cried with her… And I have to tell you, reflecting back,
I don’t know if I did the right thing… I think her mother’s bad words were worse than what her brother had done to her.
Unsupportive familial responses to SSA disclosure were perceived by the professionals as devastating for the survivor. At the same
time, participants also described families that were immediately able to provide emotional and physical support for survivors. Orit, a
clinical social worker who once ran an emergency center for abused children, describes what she calls an “exemplary family”:
The parents were extremely upset when they arrived. It turned out that their son had been abusing their daughter… for many
years. He abused one daughter, and when he started abusing the second daughter, it was disclosed. [The welfare authorities]
wanted to send the daughter to an emergency center. And then I sat with them and evaluated their ability to take responsibility for
her protection, and it turned out that the child had already been moved to her grandparents, and without consulting they began to
see how to protect her. Their ability to see her, not to deny and repress… Then I recommended not placing her in the center, but
leaving her at home, believing that this family could be trusted …

3.2. Creating a new narrative

Recreating the survivors’ abuse narrative is described by professionals as a key aspect of SSA interventions. It aims to enable the
expression of painful memories that preoccupy the survivor and try to conceptualize the abuse events, which until then have not been
spoken. The creation of this narrative is made possible by processing the abuse, according to the age and developmental level of the
survivor, and constitutes a process that invites renewed contact with the complex emotional contents, now mediated by the pro-
fessional. In the process, emphasis is placed on the abandoning of non-constructive beliefs and on the survivor's unique strengths.
Apart from conversation therapy, therapists interviewed for this study presented a wealth of tools including play therapy, art
therapy, bibliotherapy, and psychodrama. More specifically, participants describe attempts to integrate survivor’s thoughts and
feelings and to address survivors’ self-blame and self-hatred, while transferring the responsibility for the abuse to the perpetrator.
Moving out of the cycle of self-blame is perceived by professionals not only as an internal process but as one related to the family's
ability to convey the message that the survivor is not responsible. Na'ama, a clinical social worker working in a center for child sexual
abuse survivors, describes such a therapeutic process with a 13-year-old girl:

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One of the most significant moments in the treatment was when we read the letter written by the brother together… He described
the things he had done to her in detail… for example, how the whole family went to the beach and he followed her into the water,
pulling her behind a breakwater, and there he actually raped her without anyone noticing. When they returned to the beach, he
laughed at her for having scratches on her back and called her clumsy; he said that she had slipped… And her mother suddenly
began crying that she remembered that time, the scratches on her back! She said to her in tears, “You were not clumsy! You were
not!” It was as if she was saying, "you're not guilty, not guilty of what happened."
Several participants suggest that feelings of self-blame may also result from mixed feelings towards the perpetrator and the sexual
acts. From the survivor’s point of view, the sexual relationship may involve fear, disgust, intrusiveness and threat, but also warmth,
enjoinment and sexual pleasure. These feelings of pleasure may obviously exacerbate feelings of self-blame and shame, leaving the
survivor confused and torn. Moreover, the everyday relationship between the siblings may also include normative or even warm
aspects. Accordingly, the participants believe that in order for the renewed narrative to contain these contradictory and confusing
aspects, the therapist must adopt a flexible position and be able to expand his or her spectrum beyond the dichotomy of a benevolent
vs. malevolent sibling. Ruthie illustrates how difficult it is to maintain such a position when describing how the girl she was treating
awaited her abusive brother’s first visit from prison:
She says excitedly that he's coming for the holiday and she's almost euphoric… And all I can think of is God, how can you be
happy? This was the brother who abused her… causing her to cut herself, and starve herself…. I was irrationally afraid that her
longing for him… would bring her back to a situation where she could be abused once again. As if I would [somehow] enable it, if
I would be happy for her….
Finally, one of the major aspects of creating a new narrative was the need to address the survivors’ sense of their parents’ absence
when the abuse took place. Participants described how parents could be experienced by the survivor as indifferent, absent, and
inaccessible in such a way as to be seen as equally abusive. The survivors’ need to express their longing for the parents’ protection,
along with the disappointment or anger experienced in its absence, has been described as essential to the process:
I think there is nothing harder than for [such] a child to emotionally face his parents, the disappointment [of the fact] they could
not protect him, the anger or the sadness. The craving for unconditional love, for a mom or dad that you can trust is so powerful,
even if it has never been experienced… It is a craving that continues to exist and sometimes even gets stronger when the abuse
stops. I believe that therapy can and should translate these pleas into real life. To mediate for parents this existential need… There
is a potential here to actually transform this very difficult experience of absence. (Na’ama)

3.3. The grey areas

3.3.1. When the survivors do not perceive themselves as abuse victims

The first subtheme of the “grey areas” theme involves cases perceived by professionals as offensive and abusive, in which the
perpetrator sibling clearly initiated the abuse for such negative motivations as sexual gratification or control over the other sibling.
What makes these cases “grey” in the eyes of the participants is the fact that in the course of their intervention, they realize that the
survivors do not consider themselves victims. This may be because they are too young or immature to be aware of the deviancy of the
acts, or because the sexual acts took place while they were asleep. In other cases, the survivors seem to perceive the sexual acts as
beneficial or enjoyable. These cases raise difficult questions concerning how ethical and therapeutic it would be to "force" the survivor
into a “victim” narrative. Hamutal elaborates on this critical dilemma:
I had a case of a four-year-old girl whose brother would sit her on his knees and masturbate on her while she was naked before
taking a shower, because it was his chore to wash her…. For her, it was a game. I spoke with the teacher, talked to the parents, met
the girl – and nothing. The girl was happy and joyful… she was reallyunaware of the sexual abusive acts behind these seemingly
innocent games… I was really in a dilemma – should I refer her to the unit?… Why should I take her out of her pleasant and safe
childhood world?… Eventually… we decided to refer the parents to parental guidance and to keep an eye on her.… I even argued
with my supervisor about this case… She did not understand how I could leave a girl who had been abused without treatment.
Na’ama refers to a 10 year-old sexually abused by her 17-year-old brother, similarly describing the sharp differences between her
professional view and the perception of her client:
She was referred here by a CPO… And the information that comes with her tells of several years of acts [performed by her
brother]…. You find that things do not add up in the story…. Because you expect to find a girl who is anxious or at least confused,
but when I begin she stares at me… like what is your problem? … For her, the story is different: she tells me she is her brother's
model and one day she will be famous… And she really had fun with him, and for her it really was a game…. There was nothing
coercive, he would ask her if she wanted to play “models” and photograph her on a cellphone…
The intervention in her case is very complex. What should I say? That she was sexually abused? Not for her, not at all! Would she
feel the same in a few years from now? … Maybe yes and maybe no, I have no answers…
These cases, with abusive sexual acts on one hand and lack of perceived victimization on the other, clearly illustrate the gap that
sometimes exists between the survivors’ and the professionals’ perception. What defines these cases as grey is the uncertainty pro-
fessionals feel when having to make therapeutic decisions and the need to address the gap between external and internal perception

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of the sexual acts. This also applies to the second gap arising from the interviews.

3.3.2. When professionals cannot clearly label one of the siblings as “perpetrator”
Unlike the first, the second “grey area” type includes cases perceived by processionals as mutual and reciprocal, with both siblings
described as taking part in initiating the sexual acts. Here, too, the siblings involved do not feel victimized, but whereas in the first
type, professionals clearly define these cases as abusive, here professionals cannot label the siblings as “perpetrator” or “victim” –
which is often required by the welfare and legal systems. This is described by Sharon, a clinical social worker and family therapist:
I had a patient, a gentle, nine-year-old boy who suffered from a social anxiety. He came because of difficulties at home and mainly
social problems that have made life very difficult for him. During the therapy, after two or three months, he incidentally told me
that his sister, who was two years older than him, goes to his bed every day before sunrise, kisses him and rubs herself on him
without clothes. When more was revealed about this case, it turned out that it was not so sexual, not strictly sexual…. How to
describe it?… That's how they spent their time in the morning, when they would talk and laugh and just be together in such
intimacy. Kind of like a routine, something that was even normal for them.… For him, it was an hour of magic, in which he felt
close to his sister. A secret intimacy. The sexual acts with his sister were in no way forced upon him.
The professionals in this study ask themselves whether it is appropriate to associate such relationship with sexual abuse. Is the
term at all applicable to the experience of those involved? These questions are further sharpened by Ariela, a social worker and
psychotherapist who treated a 20-year-old who had been sexually abused by her cousin and later had sexual relations with her
younger brother and cousin. Ariela distinguishes between the sexual acts with the cousins, which she defines as abusive, and the
sexual relationship with the brother, which she considers more mutual, normative and routine:
I have to say that I do not consider her relationship with her brother abusive, but rather a kind haven. In this crazy family system,
there was no room for her, and no recognition, and nobody saw anything good about her…. I think that the relationship between
them was experienced as a place where you could lay back, relax and enjoy – not even sexual gratification, but rather intimacy,
calm, comfort and relief from anxieties.… She told me once, "You know when you're small and cute and everyone likes to pinch
you in your vagina”…. I think, what a reality… a five- or seven-year-old girl and anyone can see, touch or pinch her vagina.… So
in this crazy family reality… where she is laughed at for having a “fat vagina”, how fun it must be for your brother to love your
vagina, to enjoy it and there can be something pleasant between them. So I think calling it abuse is irrelevant for this family, it's
like not understanding where she lives. Because when you use the word “abuse” you assume intent, you assume there is a
perpetrator, and that is not the case here: she did not “hurt” her brother – it was a kind of rescue.
Instead of the common terminology of "perpetrator", "victim", and "sexual abuse" which she considers irrelevant, Ariela associates
different meanings with the incest relationship, based on the insider definition of her patient, and chooses different words for them,
which better reflect the young woman’s narrative, such as comfort, haven, intimacy, or rescue.
More generally, the interviews reveal that working on “grey” cases raises complexities that require professionals to abandon
familiar and “convenient” frames of mind and look for the unique experience and meaning given to the intrafamilial sexual abuse
relationship by the siblings involved, and consider the unique context of each case. In some of these cases, the context of the family
environment is emphasized more strongly, as the sexual acts are perceived by the professionals as meeting emotional needs not met
by the parents. In such cases in particular, rather than labeling them as (only) “perpetrator” or “victim”, both siblings are perceived
by the professionals as survivors of the family circumstances rather than each other.

4. Discussion

This qualitative study explored central issues in interventions with survivors of sibling sexual abuse (SSA) from the perspective of
professionals. Qualitative analysis revealed that the main themes raised by professionals related to physical and mental protection for
the survivor, the creation of a new narrative for the abuse, and the need to deal with “grey areas”, cases in which the sexual acts were
not perceived as abusive by survivors and cases perceived by professionals as mutual.
Disclosing intrafamilial child sexual abuse of any kind often places survivors in a sensitive and vulnerable position, with a crucial
need to know that they are safe and protected (Draucker & Martsolf, 2008). Accordingly, ensuring SSA survivors’ physical and
emotional safety was perceived by the professionals interviewed for this study as the crucial starting point for any intervention,
assuming that no treatment was valuable as long as the survivor was not safe. While physical protection was perceived as easier to
apply and could often be achieved by at least temporary separation of the offending sibling from the rest of the family (Harper, 2012),
emotional protection was experienced by professionals as more complex. While some studies found that after SSA, professionals were
more concentrated on immediate physical safety rather than on attending to the child’s emotional needs (Yates, 2017), the parti-
cipants in the current study were extremely concerned with their clients’ emotional state. Indeed, they emphasized the crucial role of
the survivors’ parents in providing the emotional needs of the survivor sibling.
Emotional protection is described by several researchers as mostly depending on the family’s ability to recognize the abuse and its
severe consequences for the survivor, to provide unconditional support and to place the responsibility for the abuse on the shoulders
of the perpetrator (Caffaro & Conn-Caffaro, 2006; Charuvastra & Cloitre, 2008; Heiman, 1988). Such support is presented in the
literature as essential for the survivor to deal with the abuse and its consequences (Fletcher, 2004). Supportive responses serve as a
healing factor, and unresponsive, accusing, minimizing or denying responses tend to aggravate the impact of the abuse; in fact, the
latter may be experienced by the survivor as even more offensive than the abuse itself (Charuvastra & Cloitre, 2008).

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Yet studies also emphasize the emotional complexity parents face when they are expected to adopt an unequivocal position in
favor of the survivor when the perpetrator is also their child and absolute support for the survivor may be perceived as coming at the
expense of supporting him as well (Caffaro & Conn-Caffaro, 2013; Welfare, 2010). At times families may choose, for various reasons,
to support the perpetrator sibling, and as a result, the survivor may paradoxically become the object of blame, when her or his version
of the story is being questioned and he or she do not receive the recognition and support they need for recovery. Indeed, studies
focusing on parents’ responses to their children’s disclosure of SSA stress that they are often experienced by the children as un-
available (Katz & Hamama, 2017) and that as perceived by professionals, they tend to disbelieve the survivors or minimize their
experience (Rowntree, 2007; Tener, Luski, Tarshish & Turgeman, 2018).
Similar results arise from the general CSA literature, which indicates that sexually abused children do not tend to tell their parents
they have been abused, and feel they cannot share their feelings with their parents even after the initial disclosure (Søftestad,
Toverud, & Jensen, 2013). It was also found that children avoided disclosing to parents out of concern that their experiences would be
minimized or disbelieved, or that their family members would be hurt (Jensen et al., 2005). Indeed, parents of sexually abused
children may experience and express anger, blame, isolation, and disbelief after disclosure of CSA (McCourt, Peel, & O’Carroll, 1998).
Nevertheless, Lafleur (2009), who interviewed mothers after their children had been involved in SSA, suggested that even when
the parents did not firmly support the survivor, they could still protect her in different ways such as seeking professional help or
removing the offending sibling from their house. Moreover, parental support in the aftermath of sexual abuse has a healing effect for
child survivors of CSA (Godbout, Briere, Sabourin, & Lussier, 2014).
The second theme, reconstructing the narrative of the SSA survivors, was described by therapists as a lengthy process. Many
similarities can be seen between the therapists’ experience and the literature on the treatment of adult women sexually abused in
childhood. Herman (1992) and Zeligman & Solomon (2004) argue that through the therapeutic process, the contents that have been
so fragmented in a dissociative and inaccessible state become visible, and receive a name, context and renewed meaning. The
formulation of the narrative provides an opportunity to reconstruct meaning wile transferring the responsibility to the offending
sibling. This process, however, is fraught with challenges. Fontana (2001), for example, studied children's perspectives following the
disclosure of SSA, and found that in some cases, the survivors would rather take responsibility and blame for the actions, because
shifting the responsibility to the offending sibling might deprive her of the ability to continue perceiving him as benevolent.
This dilemma is closely related to the third theme. The difficulty involved in creating a new narrative that would enable the
survivor to recognize the abuse and to place responsibility for the actions on the perpetrator stems also from complex meanings of the
relationship. One of the unique findings in this study is that many of the professionals emphasized the grey areas in treating SSA,
where strict definitions of "victim" and "perpetrator" did not necessarily reflect the experience of the abused siblings as well as their
own perceptions of the acts. The literature on definitions of SSA emphasizes elements such as differences in power (age and gender)
between perpetrator and survivor, and the use of authority, coercion and manipulation as indicators (Carlson et al., 2006; Griffee
et al., 2016). There is almost no reference in the literature, however, to cases that do not meet such criteria, and if so, they are often
mentioned in the context of sexual behaviors among very young children of similar age, which are then attributed to natural curiosity
(Caffaro & Conn-Caffaro, 2013).
Perceived reciprocity between the siblings is sometimes interpreted by researchers as stemming from the internalization of the
unequal power relations with their older siblings, which makes the younger ones easier to exploit (Owen, 1998). Even if such
explanations were applicable to some cases, the almost complete absence of narratives of mutuality or references to the lack of clear
distinction between perpetrator and survivor is somewhat baffling given the emphasis on the “grey areas” described in this study and
others (see below). Although clarifying the issue obviously requires further study, it appears that this lacuna stems from an attempt to
avoid the prior conservative tendency to define sexual behavior among children as reciprocal, harmless natural curiosity, part of
normative development, or even romantic (Rowntree, 2007; Russell, 1986), while ignoring its potential long-term negative effects on
survivors’ lives (Cyr et al., 2002; Haskins, 2003; Russell, 1986).
The findings of the current study also suggest that sexual relations between siblings may become part of their daily life, without
necessarily being perceived as deviant or abusive. In some cases, they were even described by participants as a source of comfort in a
dysfunctional family. In their study of the Child Advocacy Center in Jerusalem, Tener et al. (2017) described several cases where it
was impossible to distinguish between perpetrators and survivors and where the same sibling played both parts, as well as others
where the survivor did not perceive the sexual relations as traumatic, but rather as part of their daily lives. According to Katz and
Hamama (2017), after each incident, the children in their study would watch TV or play computer games with their sibling, resuming
their daily routine. In Yates’ (2017) study, when social workers needed to make decisions concerning cases of SSA, they were
sometimes struggling to decide who the survivor was and who the perpetrator was in the family. In such cases, they tended to
recommend keeping the siblings under the same roof. Morrill and Bachman (2013) suggested further that one of the facets that need
to be taken under consideration when defining sibling abuse is how each sibling frames the interaction: the societal construction of
their sexual contact as necessarily traumatic can be harmful and may precipitate an additional crisis.
Nevertheless, the findings of the current study suggest an even more complicated picture, whereby reciprocity when initiating of
the relationship or lack of self-definition as victim do not necessarily make the reality of these siblings simpler or less painful. Indeed
Johnson (1991, 2003) distinguishes between siblings’ sexual behaviors that fall out with developmental norm, and yet are not forced,
and abusive behaviors characterized by exploitation and power relations. The first variation is often mutually initiated and may
include acts equivalent to adult sexual activity that are kept secret. They can also be perceived as a way for siblings to seek comfort in
cases of a harmful family atmosphere. Despite the absence of the coercive component, however, Johnson suggests that such behavior
may cause a significant damage when children rely on sexual behaviors as a way of coping, at the expense of their ability to perform
developmentally important tasks.

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4.1. Limitations and future directions

The study has several limitations. First, the interviews were conducted only with professionals; even though their perceptions are
important for understanding the interventions in SSA cases, it is important to better understand the perspectives of the survivor
siblings themselves, as well as those of other family members. Second, the interviews were conducted with two different types of
professionals: child protection officers who are more involved in the initial intervention after disclosure and therapists involved later
in the procedure. Unfortunately, the small sample as well as confidentiality issues made it impossible to compare the groups – an
interesting direction for future study.
In addition, the paper concentrated on interventions with the SSA survivors at the expense of other family members, or the need,
indicated by both clinicians and researchers, to address the family as a whole in SSA cases (Keane, Guest, & Padbury, 2013). The
participants indeed discussed their perceptions of interventions with other family members or in the family as a whole but this was
not part of the present scope.
The study is also limited in that it does not refer to the timing of disclosure relative to the timing of therapy: future studies should
focus on the survivors as well as family experiences in different points in the process (before and during disclosure, during inter-
vention and after the immediate intervention has ended). It also does not specifically address professionals’ work with sibling in
different ages (such as children as opposed to adolescents), as well as different genders – both important distinctions for future
studies.
In addition, as always in qualitative research, generalization should be addressed. This study does not imply that the findings can
be generalized to all professionals dealing with SSA. Instead, it attempts to present voices and subjective perspectives at the expense
of generalization. Relatedly, the current study did not take into account the survivors’ cultural and societal context that may affect
issues concerning intervention and coping.
The current study aimed to promote and expand much-needed research on therapeutic interventions in SSA. Future studies should
focus on identifying critical issues in treating SSA cases, including focusing on specific treatment models and for different types of
clients (Caffaro, 2017), as well as identifying specific needs of other family members during SSA interventions and of the family as a
whole. Future studies should also address the specific treatment component, such as ensuring safety or creating a new narrative, as
well as to examine the role they play in different stages of the intervention. For example, ensuring the survivors’ physical or emo-
tional safety may be relevant in childhood but also in adulthood, especially when the survivor stays in contact with the family of
origin. Future studies should also concentrate on specific cultural factors affecting SSA interventions, such as large family size or the
cultural importance of the family.
Finally, future studies should address what is perhaps the main contribution of the present study: highlighting the grey areas of
SSA, which are rarely discussed in the current literature despite their apparent centrality to the practitioners’ experience. Future
studies should therefore elaborate on the diverse experiences of SSA survivors in order to better understand how to create beneficial
interventions that would not be experienced by survivors as intrusive and traumatizing, on top of their already difficult experiences.
In practical terms, this is related to the critical issue of housing arrangements after disclosure: when the SSA is interpreted as mutual
or at least as not involving clear perpetrator and survivor roles, this may affect practitioners’ decision whether to leave the siblings
under the same roof. This issue should be studied in depth with relation to additional factors such as age gap, characteristics of the
sexual acts, or the family’s ability to create protective home environment.

4.2. Conclusions

This study explored central issues in the perspective of professionals working with SSA survivors. As indicated by the findings,
SSA may occur in a wide variety of dynamics, and involve ambiguity and complexity. Disclosure of the sexual acts and the pro-
fessionals’ intervention with the family sometimes constitute the first encounter of the survivors with external societal perceptions
and definitions of what has previously been their private domain, and is often a turning point in their narrative.
While working with survivors of SSA, as suggested in this study, professionals need to be aware of the gaps that may arise between
the way they perceive the survivors and their story and how they themselves perceive it. Professionals should strive to create a
therapeutic space that recognizes these gaps and does not rush to formulate an interpretation that introduces patterns that are not
necessarily suitable for the survivor. Being unable to acknowledge the survivors’ experience may be hinder treatment.

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