Abstract 

When evaluating sexual abuse allegations it is extremely important to differentiate between symptoms that arose prior to disclosure and those that arose afterwards.  Symptoms arising after the disclosure and cessation of abuse can be caused by sexual abuse therapy, multiple interrogations, and other aspects of the legal process.  Therefore, in a sex-abuse examination it is necessary to inquire as to the timing of the development of any claimed symptoms.  Diagrams are presented to facilitate this inquiry.

Article   

Evaluators conducting sex-abuse examinations often fail to make a differentiation between symptoms that arose prior to disclosure and those that arose subsequently.  Such a differentiation can be extremely important when attempting to determine whether the accusation is true or false.  

The effects of sex abuse can range from no effects at all to psychosis and all points in between.  Furthermore, the symptoms that may result from sex abuse are so varied that they do not fall into any specific category.  Sometimes the sex abuse is a traumatic experience and the victim may indeed exhibit symptoms warranting a post-traumatic stress disorder (PTSD) diagnosis.

Some individuals who have been sexually abused do not develop PTSD symptoms, but may develop sexual problems, e.g., sexual inhibition problems, compulsive sexuality, and a wide variety of atypical forms of sexual behavior (paraphilias).  Interestingly, the same kinds of symptoms may be seen in people subjected to a sexualized form of therapy in which they are indoctrinated into the belief that they were sexually abused when there is no good reason to believe that they were.  Such individuals may not only develop sexual symptoms, but symptoms that might warrant a PTSD diagnosis.

For the patient who has been traumatically sexually abused, the PTSD trauma is sexual.

For the PTSD patient who was not sexually abused, the trauma may be the "therapy," i.e., a treatment that is much more educational and programming than a therapeutic process.

I refer to this as "therapy" trauma.  And there are patients — especially children subjected to interrogations by police, "validators," lawyers, prosecutors, judges, juries, psychiatrists, psychologists, social workers, and self-styled "therapists" — who may also develop a wide variety of symptoms derived from this trauma, symptoms that may warrant a PTSD diagnosis, a sexual diagnosis, and/or a wide variety of other diagnoses.  I refer to this as legal process trauma, because for these people the trauma is not sexual but the legal process.

In order to differentiate between pre-disclosure and post-disclosure symptoms, the evaluator should trace carefully the evolution of the sex-abuse accusation.  Such inquiry should be conducted not only with the alleged victim, but the accuser as well.  For children, this will usually involve the alleged child victim and the accusing adult, most often a parent.  

When the accuser and the victim are the same person, such as is seen in situations of belated sexual abuse accusations, then only one person need be interviewed.  

In all cases, however, when it is possible to interview the accuser and the accused together, such interviews should be conducted.  Obviously, this is not always possible, especially in criminal cases when such interviews are rarely permitted.  In civil cases, however, especially child-custody disputes, examiners should conduct such interviews.  After all, the two parties are generally still husband and wife (or ex-husband and ex-wife).

The examiner does well in such an inquiry to begin by asking the accuser a question such as, "I would like you to think back and tell me exactly when was the first time that you thought that you (your child) had been sexually abused."  

This question might be followed by: "Exactly what happened then that made you think that sexual abuse had taken place?"  

The presence of the accused party at that point can often be helpful in such an inquiry.  Differences of opinion can be addressed simultaneously in order to increase the likelihood that the examiner will get as valid a picture as possible of what actually happened.  

Then, the examiner should proceed with questions such as: "And what was the next thing that happened?"  Particular focus should be given to the day of the alleged victim's disclosure and the nature of the interviews conducted.

The examiner should then delineate the various symptomatic effects of the alleged abuse during the time frame of the abuse and subsequently.  Again, these should be traced in detail along a time continuum.

I have found that the diagrams presented in this article facilitate this inquiry and are particularly useful when included in the examiner's report.  I refer to these as The Sex-Abuse Time-Line Diagrams.  

Four diagrams have been prepared, each of which has its own special purpose.  

	Figures 1 and 2 are for the examiner.  They include the information for the examiner to consider during the assessment process.
	Figures 3 and 4 include only the Time-Line element in the figures and are to be presented to the patient in the course of the inquiry.

It would be injudicious to use Figures 1 and 2 for this purpose because they provide information that might contaminate the interview.

Figure 1 is most useful in situations in which there has been a time gap between the time of last possible exposure of the abused to the alleged perpetrator and the time of disclosure. 

This is commonly the case in situations in which an adult woman belatedly accuses an elderly relative of having sexually abused her in childhood.  The time frame of the alleged abuses during childhood would be represented by A-B.  Point C represents the time in therapy when she uncovered alleged memories of her abuse.  Point D represents the time when the examiner conducts the interview.

The graphics at the bottom of Figure 1 represent the symptomatic effects of the aforementioned kinds of abuse.  As can be seen, depicted there is the gradual increase of symptoms over the A-B time frame.  With the discontinuation of the abuse at Point B, one would expect a gradual diminution of the symptomatic effects of the sex abuse.  At Point C they would be less than at Point B and, if there were no disclosures, interrogations, and "therapy," the symptoms would decrease even further by Point D.  If, however, at Point C the patient is subjected to "therapy" and/or legal process trauma, then symptoms would increase progressively by Point D.

The A-B time frame would be the period during which one would expect to have seen symptoms of abuse.  Under such circumstances, one would expect to see residual symptomatology during the B-C time frame as well, especially if the abuse was traumatic.  

When there has been no actual sex abuse, then no symptomatic effects of sex-abuse trauma are to be seen either in the A-B or the B-C time frame.  Under such circumstances we only see symptomatic effects during the C-D time frame and this is depicted in the lowest symptomatic effects rendition in Figure 1.  

Although it is possible (but very improbable) that symptoms arising in the C-D time frame might be the result of uncovered memories of early childhood abuse, it is far more likely that such symptoms are the result of the suggestions and even the indoctrinations of the "therapist."  Of course, this is only one of many factors that one should consider when differentiating between a true and a false accusation, but it is an important factor nonetheless.

The same diagram should prove useful in nursery school situations in which there is a time gap between the child's last possible exposure to the alleged perpetrator and the time of disclosure.  

A common situation is one in which the child was attending the nursery school during a particular school year, represented by time frame A-B.  Many weeks, months, and possibly even years later, word gets around that one or more school personnel was sexually molesting children.  Investigations are conducted and at Point C children disclose their alleged abuses during the A-B time frame.  A series of interrogations then ensue, some of which may be coercive and sexualized.

Symptoms arising during the C-D time frame, symptoms that are the result of legal process trauma, are more likely to be the result of the interrogations.  Often, in such circumstances the children are put into "therapy" at Point C and the symptoms one sees are then the result of the combination of the legal process trauma and the "therapy" trauma.  

Had the children indeed been sexually molested during the A-B time frame, the period of attendance at the school, then one would expect to see symptoms during the A-B time frame and during the B-C time frame.  At point C, the initial evaluator might see residual symptoms of the sexual abuse at that point.  

If the child was then protected from legal process/"therapy" trauma, then one could predict that such symptoms would have reduced themselves in frequency and duration, as depicted by the broken line in the symptomatic effects diagram in Figure 1.  

Figure 1 is also applicable to other situations in which there is a belated accusation, e.g., clergy, scoutmasters, recreation workers, teachers, and even strangers.

Figure 2 is useful in situations in which the time of last exposure to the alleged perpetrator (Point B) coincides very closely with the time of disclosure (Point C).  An example would be a situation in which a mother actually observes her husband, the child's stepfather, to be engaged in a sexual encounter with the child.  She immediately calls the police, obtains a restraining order, and the stepfather is immediately required to live elsewhere. 

Another example would be one in which a separated mother makes inquiries of her daughter on her return home from a visit with the father.  She decides that the father's behavior during the course of bathing the child suggests strongly that he was sexually abusing their daughter.  Immediately she calls the police and obtains a restraining order, which brings about a cessation of visitation.

In both of these cases Figure 2 is applicable.  In both of these cases, as well, legal process/"therapy" trauma can intensify symptoms and/or bring about symptoms that might not have otherwise appeared.  

The upper symptomatic effects depictions at the bottom of Figure 2 depict expected symptomatic effects had there been bona fide sexual abuse.  As seen there, one would expect a gradual increase in symptoms over the A-B time frame.  At Point B, with the removal of the alleged perpetrator, one would then expect a gradual diminution of symptomatic effects of the sex abuse.  These are represented by the broken line from Point B/C to Point D. 

However, if the child is subjected to legal process/"therapy" trauma, the reduction of symptoms does not take place; rather, there is an escalation of symptoms.  And these are represented by the upper B/C-D line in the same graphic.  The lowest graphic depicts the situation when there has been no sexual abuse.  Then, there is a rapid appearance of symptoms at Point B/C with further increase over time as the child is continually subjected to legal process/"therapy" trauma.

These diagrams can also be useful when making inquiries involving what I refer to as retrospective reinterpretation.  This is a phenomenon seen in false sex-abuse accusations in which behaviors which, during the time frame of the abuse were considered to have other causes are, subsequent to disclosure, re-interpreted in such a way that they allegedly provide verification that sexual abuse was taking place.  

The diagrams can also be useful for delineating what I refer to as the pathologizing-the-normal-process by which behaviors that were considered to be normal during the time frame of the abuse are, in hindsight, also considered to be manifestations of sexual abuse.

As mentioned, Figure 3 and Figure 4 are designed for use with parents.  The information above the time line is identical to Figures 1 and 2.  The information below the time line has been deleted in order to ensure that the interviewee is not provided with any information that could contaminate the responses.

Figure 3

Figure 4

I have found it useful to include these diagrams as addenda in my reports in that they provide clarifications that enhance the efficacy of the report.  

Last, I have found the diagrams useful in the courtroom — especially in jury trials.  An enlargement of the diagrams can be made and the examiner and/or attorney can make reference to them in the course of testimony.  Readers who believe these diagrams could prove useful to them have my permission to reproduce them for their own personal use only.

Richard A. Gardner is Clinical Professor of Child Psychiatry, Columbia University, College of Physicians and Surgeons.  This article is adapted from his book: Protocols for the Sex-Abuse Evaluation (Cresskill, New Jersey: Creative Therapeutics, Inc., 1994)