The feminist movement in the 1970’s served as a major catalyst in moving the issue of domestic abuse into the conscious of mainstream America (Ammerman and Hersen 1991; Kiselica and Morrill-Richards 2007; Morrill-Richards and Leierer 2010). Since that time, there has been tremendous advance in the study of abuse in the family. Today, professionals recognize childhood sexual abuse within the family as a significant and widespread problem with consequences lasting long into adulthood (Adler and Schutz 1995; Finkelhor et al. 1990). Despite this progression, the research related to intrafamilial incest conducted by social science researchers over the past three decades has focused primarily on father to daughter incest; largely ignoring the experience of sibling sexual assault (Bess and Janssen 1982; Caspi 2011; Kiselica and Morrill-Richards 2007; Kreinert and Walsh 2011; Phillips-Green 2002; Rudd and Herzberger 1999).

Sibling sexual assault is more common than parental incest. Caffaro and Conn-Caffaro (1998) concluded that sibling incest and assault occur more frequently than parent–child incest and assault, even though sibling incest is one of the most under reported forms of abuse. Bess and Janssen (1982) found 60 % of psychiatric outpatients had experienced some form of sibling incest. A study by Rudd & Herzberger (1999) indicated that 23 % of incest survivors are sibling incest survivors. Clearly, sibling incest is a pandemic problem that requires more attention from mental health professionals.

Understanding why sibling sexual abuse occurs is complex. One of the main factors contributing to this phenomenon is the family environment. Maladaptive parental behavior and dysfunctional family structures have an impact on the sibling relationship. When the family structure supports power imbalances, rigid gender roles, differential treatment of siblings, and lack of parental supervision, the risk for sibling sexual abuse increases (Bank and Kahn 1982; Caspi 2011; Leder 1993; Morrill-Richards and Leierer 2010). Rowntree (2007) conducted a qualitative study of 19 adult female survivors of sibling sexual abuse in which it was found that the minimization of the abuse when disclosed had an impact on the severity and perception of the abuse. In a study conducted by Wiehe (1997), the normalization of abuse by parents was found to be a critical element in the severity and frequency of abuse among siblings. When parents either model inappropriate sexual interaction or are unable to acknowledge inappropriate sexual interactions in their children, it is likely that one child will begin or continue to inflict sexual abuse on a sibling because he or she is modeling the actions of his or her parents (Caspi 2011; Wiehe 1998; Glaser 1986).

Sibling Sexual Abuse

In spite of lack of empirical research on the topic, it is likely that sexual abuse among siblings occurs more frequently than any other form of sexual abuse (Caffaro and Conn-Caffaro 1998; Caspi 2011; Kreinert and Walsh 2011; Wiehe 1998). Defining the specifics of sibling sexual abuse has lacked consistency and clarity in previous research, which has been a hindrance in terms of moving forward with needed empirical analysis (Kreinert and Walsh 2011). As such, this study offers a clear and detailed definition of sibling sexual abuse. Sibling sexual abuse is defined as sexual behavior between siblings that is not age appropriate, not transitory and not motivated by developmentally appropriate curiosity. Some examples of this behavior include inappropriate fondling, touching, sexual contact, groping indecent exposure, masturbation, exposure to pornography, oral sex, anal sex, digital penetration and intercourse (Caspi 2011; Phillips-Green 2002; Wiehe 1990).

While there has been debate as to whether or not non-physical aspects of sibling sexual abuse, such as forced exposure to pornography or sexual leering, are as harmful as physical sexual assault, this study supports the notion that all acts of sibling sexual abuse hold the potential to be equally harmful. Ybarra and Mitchell (2005) found that exposure to pornography as a child, which is not self-seeking or developmentally appropriate, results in a high correlation with substance abuse, depression, attachment issues, and delinquent behavior. Seto (2010) conducted a meta-analysis of 59 studies in which the results suggest forced exposure to pornography (particularly in which sexually violent acts occur) can lead to significantly higher rates of anxiety, low self-esteem, and social isolation. Additionally, it has been shown that unwanted sexual advances, sexual leers, and being forced to view pornographic material can have as much of a psychological impact as physical intercourse (Flood 2007; Leibowitz 2012; Whelan 2003).

Often reports of non-physical sibling sexual abuse are dismissed or minimized which intensifies the feelings of shame, guilt, and hopelessness related to the abuse (Walker-Descartes et al. 2011). It is crucial not to minimize this type of sexual abuse as this form tends to happen more frequently and occur over a longer period of time than physical types of sexual abuse. Further, there is a growing trend of using non-physical types of sexual abuse with increased access to computers and other technology (Flood 2009; Sears et al. 2006).

When compared with child sexual abuse in which an adult is the perpetrator, the impact and prevalence of sibling incest is often underestimated by society. This may be a result of the challenges related to establishing the victim and offender roles. Determining if coercion was a factor in the abuse may be another obstacle when dealing with siblings. Another difference between adult and sibling sexual abuse is that no generational boundary has been violated, which makes sexual abuse easier to hide. An exaggerated sexual climate in the family or a rigidly repressive sexual family environment increases the risk of sibling sexual abuse. These environments may also contain multiple offenders of sexual abuse within the family, thus increasing the challenge of detecting and dealing with sibling sexual abuse specifically (Caffaro and Conn-Caffaro 2005; Caspi 2011). Each offender may use denial as a means to protect himself or herself from experiencing shame and to maintain the abuse; therefore, the likelihood of any one member of the family reporting the incest is reduced.

Implications for Self-Esteem

Several studies support the notion that self-esteem is one construct of well-being closely associated with the quality of the sibling relationship. Raver and Volling (2007) surveyed 200 adults between the ages of 18 and 25 and found a significant correlation between family experiences, in particular, positive sibling interactions, and the ability to engage in healthy romantic relationship functioning as an adult. Using a convenience sample of 98 college students, Daniel (1999) found a strong, positive correlation between how one believed a sibling perceived him or her and the development of self-esteem as an adult. Caya and Liem (1998) administered a survey to 194 university students between the ages of 16 and 55 to study how the sibling relationship is used as a buffer from parental conflict. The results indicated the sibling relationship has a strong enough impact on the development of self-esteem that a positive sibling relationship can promote the development of positive self-esteem in the face of severe conflict outside of the sibling relationship (Caya and Liem 1998). While these studies highlight the importance of focusing attention on self-esteem when studying sibling relationships, none of the above studies address how abusive sibling relationships may interfere with the development of positive self-esteem. The research presented in this paper attempts to address the gap in the literature and use an empirical analysis to address how any experience with sibling sexual abuse may impact the development of self-esteem.

Consequences

Sibling sexual abuse tends to last over a longer period of time and uses more force than any other form of child sexual abuse (Rudd and Herzberger 1999). The severity and frequency of this type of sexual assault creates a situation in which long-term and devastating consequences exist. While some believe that sexual contact with a sibling can be positive, the reality is that there is no type of sibling sexual violation that promotes healthy individual development (Canavan et al. 1992; Carlson 2011; Caspi 2011). Survivors do not report sibling sexual abuse experiences as positive; in fact, the overwhelming majority of these survivors report having negative emotional, physical and mental reactions to the abuse (Carlson 2011; Kiselica and Morrill-Richards 2007; Morrill-Richards and Leierer 2010). Suffering sexual victimization from a sibling leads to negative and often life-long consequences (Phillips-Green 2002).

Consequences for Children

The developmental consequences for children who have experienced sibling sexual abuse are tremendous. Because of the unique longevity and severity that accompanies sibling molestation; survivors usually experience the disruption of 2-3 developmental stages of life (Rudd and Herzberger 1999; Wiehe 1990). During the time of abuse, energy normally used for developmental tasks is used instead for survival. Some of the consequences for this disruption include premature sexualization, difficulty with peer relationships, confusion about sexuality, aggression, and a distorted sense of self (Rudd and Herzberger 1999).

Snyder et al. (2005) found that risk related behaviors in child survivors of sibling sexual assault are uniquely severe. As a group, these children exhibit the most severe forms of mental distress and antisocial behavior. Sibling molestation survivors are unlikely to receive professional intervention, which indicates most of these children will carry their problems into adulthood (Snyder et al. 2005).

Consequences for Adults

Both survivors and offenders of sibling sexual abuse experience the lasting impact of the abuse as they become adults. In adulthood, the consequences often become more severe and have an effect on social interactions, school, work and family life (Monahan 2010; Phillips-Green 2002). Mental illness related to the abuse also begins to surface at this time with many survivors and offenders reporting symptoms of posttraumatic stress disorder, anxiety disorders, depression, dissociative disorder, eating disorders, angry outbursts, self-injury, somatic complaints, and suicidal ideation (Wiehe 1990; Wiehe 1998). Carlson (2011) interviewed 35 adult female survivors of sibling sexual abuse and found there to be significant lingering emotional and psychological effects of this childhood experience. Monahan (2010) found that, without intervention to deal with the abuse trauma, the emotional impact of sibling sexual abuse reemerged later in life as other life issues emerged such as a terminal illness or caring for a dying parent. Clearly, ignoring the problem of sibling sexual abuse does not foster a sense of well-being.

Adult survivors may be overly dependent on maladaptive coping strategies and are not familiar with adaptive coping mechanisms. It is common that adult survivors of sibling sexual abuse will begin to seek help for these maladaptive behaviors in college. College is an extraordinarily stressful time in development, often bringing an already present sense of distress to a level of dysfunction not previously experienced (Gipple et al. 2006). College students that have a sexually abusive history with a sibling report greater levels of anxiety and depression as well as lower levels of self-esteem and self-efficacy. This group also demonstrates a strong belief in luck and very little trust in the benevolence of others (Graham-Bermann et al. 1994).

Adult survivors are in tremendous danger of re-victimization in interpersonal relationships. Having a history of sibling sexual abuse may result in an altered risk appraisal process in which the adult survivor has difficulty identifying potentially harmful outcomes (Combs-Lane and Smith 2002). Often, survivors of sibling incest are not able to recognize and respond in a protective manner to threats. As a result, adults who have experienced traumatic sexual victimization from a sibling are likely to engage in at- risk behaviors throughout life (Finkelhor and Browne 1988). Some of the most common at-risk behavior college student survivors of sibling sexual abuse engage in include unprotected sex, self medication with alcohol and drugs, and confusion about sexuality ranging from extreme frigidity to extreme promiscuity (Combs-Lane and Smith 2002). A study conducted by Noland et al. (2004) found both men and women who experience sibling molestation are at high risk of dating violence in college.

Hypothesis

The normalization of sibling sexual abuse by the family structure and society creates a layer of shame and complication that can have devastating results for both the survivor and offender. It is crucial that mental health workers learn more about the serious problem of sibling sexual abuse (Kiselica and Morrill-Richards 2007; Morrill-Richards and Leierer 2010; Wiehe 1998). This study attempts to address one consequence of experiencing sibling sexual abuse with the following hypothesis:

Experiencing sibling sexual abuse as a child inversely impacts level of self-esteem in adulthood.

The hypothesis above addresses a specific aspect of the gap in research on sibling sexual abuse. The study design is an exploratory survey based on an altered version of the Conflict Tactics Scale (Straus 1979) and the Rosenberg Self-Esteem Scale (Rosenberg 1965). The survey is self-report and each section is in a Likert scale format.

Perhaps the main barrier to understanding sibling sexual abuse is an absence of current empirical research. While virtually every other type of research related to family violence has received steady funding since the early 1980’s, funding for the study of sibling abuse has sharply decreased during the same time period (Haskins 2003; Kiselica and Morrill-Richards 2007). The dearth of current research that addresses the complexity and unique circumstances surrounding sibling sexual abuse and the consequences that linger into adulthood is a source of concern (Ammerman and Hersen 1991; Caspi 2011; Phillips-Green 2002). This study marks an effort to promote and expand much needed research on this topic.

Method

Descriptive Information of Participants

Participants in this study consisted of both undergraduate and graduate college students enrolled at a public urban university in the mid-south of the United States. The sample was one of convenience in that surveys were distributed directly by the primary investigator to classes. The age of students ranged from 15 to 59, with a median age of 20 and a mean age of 23. Females comprised 67.1 % of the sample, men comprised 32.6 % of the sample, students identifying as transgendered comprised 0 % of the sample, and students identifying as something other than female, male, or transgendered comprised 0.3 % of the sample. Students identifying as African American/Black represented 32.3 % of the sample, students identifying as Asian represented 1.7 % of the sample, students identifying as Caucasian/White represented 55.5 % of the sample, students identifying as Hispanic/Latino represented 1.7 % of the sample, and students identifying as other represented 3.9 % of the sample. It is important to consider the limitations of age, gender, and ethnic/cultural identity demonstrated with this sample.

An a priori power analysis was conducted to aid in estimation of accurate sample size. The analysis found the minimum acceptable sample size for this study to be 64, given an alpha of 0.10 and an anticipated effect size of 0.15. After considering sample sizes in related studies in conjunction with the power analysis, a minimum usable sample of 75 was accepted (Caffaro and Conn-Caffaro 1998; Goodwin and Roscoe 1990; Liem and Boudewyn 1999; Simonelli et al. 2002; Steinmetz 1978; Wiehe 1997; Wiehe 2000). With a return rate of 94.1 % a sample of 362 surveys were received. Only students indicating they had at least one sibling were included in the analysis. After extrapolating those indicating experience with sibling sexual abuse as a survivor, perpetrator, or both, the sample size for this study was 87.

Instrumentation

As there is no widely used or validated questionnaire related specifically to sibling abuse, this study utilizes an exploratory survey in which the first section is based on an altered version of the original Conflict Tactics Scale (CTS) (Straus 1979). The CTS has been well established over decades with internal reliability ranging from 0.79 to 0.95 and stable, consistent construct validity demonstrated across hundreds of studies (Straus and Gelles 1990). Additionally, the CTS has been adapted in numerous studies to specifically address issues related to abuse (Morrill-Richards and Leierer 2010; Sugarman and Hotaling 1996; Straus and Gelles 1990). Morrill-Richards & Leierer (2010) adapted the CTS to address all forms of sibling abuse. Building on the work of Morrill-Richards & Leierer (2010), this study exclusively addresses sibling sexual abuse, with items addressing both physical and psychological sexual violations such as vaginal intercourse, touching, fondling, oral sex, and forced exposure to pornography. Responses to the first 36 questions, addressing prevalence and severity of sibling abuse, can be answered in a range from never (0) to always (5). The following are examples of the altered CTS questions in this section of the survey:

A sibling forced me to view pornographic material 0 1 2 3 4 5

I forced a sibling to view pornographic material 0 1 2 3 4 5

A sibling sexually touched me 0 1 2 3 4 5

I sexually touched a sibling 0 1 2 3 4 5

These questions not only measure recollection of presence and severity of sibling abuse, but also provide information regarding the type of experience with sibling abuse, as either the survivor or perpetrator. The general experience with sibling sexual abuse scale (indicating any type of experience with sibling sexual abuse as survivor or perpetrator) reflected a Cronbach’s alpha coefficient of 0.743, with the subscale of perpetrating sibling sexual abuse reflecting a Cronbach’s alpha coefficient of 0.702 and the subscale of surviving sibling sexual abuse reflecting a Cronbach’s alpha of 0.787.

The second section of the survey contains ten self-report questions from the Rosenberg Self-Esteem Scale (Rosenberg 1965). These questions address global self-esteem and are in a four point Likert-type rating scale ranging from strongly agree (3) to strongly disagree (0). A higher score on this scale reflects a higher level of self-esteem. Reliability tests over time for the Rosenberg Self-Esteem Scale (Rosenberg 1965) demonstrate adequate reliability, with average reliability ranging from 0.73 to 0.80 (Kaplan and Pokormy 1969; Hagborg 1993). Over the past four decades, construct validity and convergent validity have been consistently demonstrated in numerous studies (Gray-Little et al. 1997; Hagborg 1993). Additionally, this self-esteem scale has been found to be especially reliable when used with high school and college students (Bagley et al. 1997; Goldsmith 1986). In this study, the test for reliability of this scale reflected a Cronbach’s alpha coefficient of 0.82.

Analysis

Given the nature of this study, an alpha of 0.1 was used. Allowing a more liberal significance level in this research does not place participants in danger, but rather serves to draw attention to an understudied area of sexual abuse. In this case reducing type II error and allowing more room for type I error reduces the likelihood of dismissing the potentially meaningful social phenomenon being researched (Hays 1998; Huck 2007). Additionally, sibling sexual abuse experience has been consistently underreported; thus allowing a more liberal level of significance offsets social desirability phenomena as well as some of the secrecy and minimization which accompanies the issue (Phillips-Green 2002; Simonelli et al. 2002).

Regression analysis was used to address the research hypothesis: Experiencing sibling sexual abuse as a child inversely impacts the level of self-esteem in college students. The independent variable was the indicator of experience with sibling sexual abuse as determined by the altered version of the CTS (Straus 1979), which includes overall experience with sibling sexual abuse as either the perpetrator or survivor or both, perpetrating sibling sexual abuse, and surviving sibling sexual abuse. The dependent variable for this regression was the score students obtained on the Rosenberg Self-Esteem Scale (Rosenberg 1965).

As shown in Table 1, this regression model was significant at the α = .1 level for general experience with sibling sexual abuse as a perpetrator, survivor, or both (β = -.242, t = -2.978, p = .000). The effect size for this model was calculated using Cohen’s d, and is represented in Table 1 as having an effect size of 0.64. These results suggest that any type of experience with sibling sexual abuse as a child negatively influences the self-esteem of college students. Rather, the more experience one has with this form of sibling abuse as a child, the less self-esteem one is likely to have as an adult.

Table 1 General experience with sexual sibling abuse predicting level of self-esteem in college students
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In order to understand these results in greater depth, two additional regressions were run to consider experience as a perpetrator and survivor separately on self-esteem as one enters adulthood. Table 2 shows perpetrating sibling sexual abuse (β = 125, t = -1.548, p = .081), to be significant at the α = .1 level. The effect size for this model was calculated using Cohen’s d, and is represented in Table 2 as having an effect size of 0.47. While not demonstrating as much significance or power as the other two regressions, this analysis still suggests the more experience one has perpetrating sibling sexual abuse as a child, the more likely he or she will be to have lower self-esteem as a college student. The final regression was run to explore the influence of surviving sibling sexual abuse as a child on the self-esteem of adult survivors. As outlined in Table 3, this regression model found that surviving sibling sexual abuse has a significant impact on self-esteem at the α = .1 level (β = -.206, t = -3.382, p = .001). The effect size for this model was calculated using Cohen’s d, and is represented in Table 3 as having an effect size of 0.79. This analysis suggests the more sibling sexual abuse one survives as a child, the more likely he or she is to have a low level of self-esteem as an adult.

Table 2 Experience perpetrating sexual sibling abuse predicting level of self-esteem in college students
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Table 3 Experience surviving sexual sibling abuse predicting level of self-esteem in college students
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Discussion

This study serves to provide some of the only empirical research in support of the likelihood that sibling sexual abuse could be the most common form of child sexual abuse in the United States. In spite of the apparent frequent occurrence of sibling sexual abuse, it is disturbing how little has been done to address the complexity and unique circumstances surrounding this form of abuse (Ammerman and Hersen 1991; Caspi 2011; Phillips-Green 2002). Families and society deny sexual abuse among brothers and sisters and minimize the long-term consequences of experiencing such maltreatment. When siblings who have survived sibling sexual abuse disclose to family members, parents and guardians often handle the report with disbelief and anger, which may enable the abuse to continue. These factors must be taken seriously in order to confront sibling sexual abuse effectively (Ammerman and Hersen 1991; Dunn and Plomin 1991; Johnston and Freeman 1989; Wiehe 1998).

In order to improve treatment approaches and prevention programs, further research needs to be done to improve understanding of the subject. More research related to prevalence and consequences unique to sibling sexual abuse is desperately needed to gain a comprehensive understanding of how deeply rooted the problem is in society. In addition to prevalence and consequences, more research on interaction effects of other types of family violence on sibling sexual abuse as well as studies dedicated to exploring specific types of sibling sexual abuse would be beneficial in gaining insight to some of the complexity surrounding sibling sexual abuse. Study of unique plans for treatment with offenders, survivors and families will offer mental health professionals new options for effectively working with this population (Caffaro and Conn-Caffaro 2005; Phillips-Green 2002; Wiehe 1998).

In addition to research, counselor education as it relates to sibling sexual abuse must also be considered. Counselors must be taught to explore issues of sibling sexual abuse, especially when working with families where other forms of abuse exist. In general, greater study of sibling sexual abuse will improve the abilities of counselors to assist the children and families affected by this problem.

Limitations

One major limitation of this study is the reality that sexual abuse is often more difficult to disclose than other forms of abuse (Alaggia 2004; Caffaro and Conn-Caffaro 1998; Wolfe et al. 2006; Wiehe 1997). In cases of sibling molestation, disclosure is usually delayed or happens accidentally when it is discovered by a third party such as through routine medical examination (Alaggia 2004). The average delay of disclosing sibling abuse is 3-18 years, which indicates many children live with the sexual abuse and do not receive treatment until well into adulthood. While it is rare for survivors of every form of sexual abuse to disclose the abuse immediately, survivors of sibling sexual abuse experience the added complication of not wanting to betray a sibling (Alaggia 2004; Finkelhor and Browne 1988; Wolf et al. 2006). When siblings do report sexual abuse, parents and guardians frequently respond with disbelief, which models behavior non-accepting of the abuse that has occurred and leaves the impression reporting sexual abuse is negative (Wiehe 1990). In light of these circumstances, it seems possible students with sibling sexual abuse history may not feel comfortable disclosing on this survey.

The fact that the survey was self-report presents another limitation to this study. In spite of the reality that the survey was anonymous and voluntary, the force of social desirability could have influenced how students chose to respond. It was assumed that students were reporting in a truthful manner; however, there was not an accurate and accessible means for which to test the validity of student responses in this study. Therefore, it is possible that responses were included in the analyses that were not reflective of some students’ reality.

There are two limitations related to the research design of this study. First, as family violence is typically a systemic problem, it is likely that the experience of sibling abuse does not occur in isolation of other forms of abuse. This study did not consider the effect possible interaction of experiencing other forms of abuse in addition to sibling abuse may have on the outcome. Future research modeling this study can modify the survey to include questions addressing other abusive family experiences. The challenge to this will be to maintain a primary focus on sibling abuse and not designate the sibling abuse experience as secondary to other forms of family violence. Second, as explained previously, this study did not disaggregate the measure of sibling sexual abuse into specific types of sibling sexual abuse. Further research can expand this study through examining specific types of sexual abuse based on psychological and physical contact. The difficult task when focusing on the specifics of the sexual abuse interaction in future research will be to avoid minimizing the impact non-physical sexual abuse has on the survivor.

A further limitation is the lack of attention paid to identity variables (such as age, gender, and cultural identity) beyond the basic scope of demographic reporting. It is possible that these variables could prove significant factors in how one responds to the experience of sibling sexual abuse, and in turn, how he or she develops self-esteem. Additionally, cultural implications tied to varied meanings and significance of sexual sibling interactions were not addressed in this study and may be a consideration in future research. Clearly, results of this study should not be generalized to the larger population; rather, the analyses offers a starting point to stimulate further research on the prevalence of and treatment for the consequences of sibling sexual abuse.

Counseling Implications

The results of this study support the possibility that sibling sexual abuse is likely more pervasive than other more commonly treated and studied forms of sexual abuse. While there is no doubt that assumptions can not be made from this study alone, the significance of the results underscore the need for clinicians to begin addressing the issue with more rigor and gravity (Caffaro and Conn-Caffaro 2005; Caspi 2011; Wiehe 1990). Helping this population is complex and requires understanding of the unique implications associated with abuse in sibling relationships. In order to offer the best treatment possible to those connected with sibling sexual abuse, mental health professionals must consider appropriate treatment options and prevention programs (Ammerman and Hersen 1991; Simonelli et al. 2002).

Treatment

One piece of building on this research is to begin considering how to help the survivors and perpetrators of sibling sexual abuse. Over the last several decades, some instruments have been developed to assess the health of sibling relationships. The most comprehensive is the Sibling Abuse Interview (SAI) (Caffaro and Conn-Caffaro 1998). The SAI is a thorough interview used to evaluate individual children, sibling dyads, non-targeted children, parents or adult caregivers, the parental dyad and the family unit. Other clinical tools that may be useful when attempting to assess the presence of sibling sexual assault are the Scale of Negative Family Interactions (Simonelli et al. 2002), Conflict Tactics Scale (Straus et al. 1998), and the Sexual Experiences Survey (Koss and Gidycz 1985). Using these instruments should not be done in isolation, but in conjunction with other therapeutic interventions (Wiehe 1990; Simonelli et al. 2002).

Survivors of sibling sexual abuse commonly have a strong need to understand the relationship between the abuse and the familial connection with the offender (Wiehe 1998). Clinicians must develop plans for treatment that address the complexity of the interaction between family life and abusive sibling acts (Phillips-Green 2002). In order to begin addressing such a complicated situation, it may be beneficial to integrate family, individual and group methods of therapy (Caffaro and Conn-Caffaro 2005; Kiselica and Morrill-Richards 2007).

Individual therapy will vary from case to case. The most critical aspect of individual therapy when working with offenders and survivors of sibling sexual abuse is to establish trust (Ross 1996). Establishing trust is particularly difficult with this population because of the intense secrecy and shame that is likely to have accompanied the sexual abuse. The client could believe he or she is abnormal, which will make opening up in the therapy session difficult. As a result, mental health professionals must establish rapport, create a safe environment, and establish collaborative and unique goals for therapy (Patterson 1982; Phillips-Green 2002).

When developing treatment plans with children who are survivors or offenders of sibling sexual abuse, several important considerations must be made. As mentioned previously, sibling sexual abuse often interrupts the developmental stages, which can lead to delayed cognitive and emotional functioning (Rudd and Herzberger 1999). The use of play therapy, art therapy and sand tray therapy are often easier for children to work with, especially if he or she has experienced trauma (Caffaro and Conn-Caffaro 2005; Wiehe 1990).

As this study suggests, treatment with survivors of sibling sexual abuse would likely benefit by including building self-esteem and developing self-confidence. The survivor must be allowed to experience at his or her own pace and be offered the opportunity to confront the offending sibling as well as other family members if so desired (Wiehe 1998). Survivors need help addressing guilt, shame and fear. Another therapeutic goal should be to help the survivor identify healthy support networks (Snyder et al. 2005).

Often, perpetrators are not considered in treatment plans or dismissed as not being in need of healing aspects of well-being such as self-esteem. The significance perpetrating sibling sexual abuse may have on self-esteem as demonstrated in this study suggests a need for considerations regarding the treatment of perpetrators. Individual therapy with sibling sexual offenders will center on issues of denial and taking responsibility. Most offenders have endured the abuse of someone else; however, it is critical that the abuse experienced by the offender not be viewed as an excuse for the abuse that he or she has inflicted on his or her sibling (Rudd and Herzberger 1999; Wiehe 1998; Simonelli et al. 2002). Requiring the offending sibling to take responsibility and acknowledge what has happened may be an especially difficult challenge, as parental figures may not be in support of the offender taking responsibility for what has happened (Caffaro and Conn-Caffaro 2005; Simonelli et al. 2002).

There is no doubt that sibling sexual abuse is connected to issues in the family. While family therapy can be powerful and prove beneficial when dealing with this issue, the therapist has an obligation to ensure that the family does not blame the survivor for what has happened before commencing with family interventions (Phillips-Green 2002). Mental health counselors working with families in which sibling sexual abuse exists must address denial both within the family and in society, and explain the impact societal and family denial of this abuse has on the survivor (Rudd and Herzberger 1999).

Group therapy is an additional component that has proven beneficial in the case of sibling sexual abuse. Survivors and offenders should not be combined in one group, but rather each should be offered a separate group situation. Groups offered to survivors provide a sense of connection and support as well as increase a sense of empowerment and self-esteem (Ammerman and Hersen 1991). Offender groups provide support as well as an opportunity for perpetrators to begin talking about responsibility (Ammerman and Hersen 1991; Phillips-Green 2002).

Prevention

One of the most promising approaches related to prevention involves assisting families with parenting responsibilities. When parents understand how to promote positive parent–child relationships and sibling interactions, the risk of abuse in the entire family tends to be reduced (Donnelly 1999; Wilson 1987). Mental health professionals can help directly through promotion of structured parent education programs to teach parents how to be role models and teachers of prosocial behavior for their children. Indirect prevention efforts can be done through consultation and involvement with national grassroots networks such as Family Support America. Networks such as this are comprised of individuals and institutions that advocate for the development of prevention-oriented and community based programs (Ammerman and Hersen 1991; Kiselica and Morrill-Richards 2007; Noland et al. 2004).