AMERICAN PSYCHIATRIC ASSOCIATION
1400 K Street, NW
Washington, DC 20005


STATEMENT ON MEMORIES OF SEXUAL ABUSE

This Statement is in response to the growing concern regarding
memories of sexual abuse.  The rise in reports of documented
cases of child sexual abuse has been accompanied by a rise in
reports of sexual abuse that cannot be documented. Members of
the public, as well as members of mental health and other
professions, have debated the validity of some memories of
sexual abuse, as well as some of the therapeutic techniques
which have been used. The American Psychiatric Association has
been concerned that the passionate debates about these issues
have obscured the recognition of a body of scientific evidence
that underlies widespread agreement among psychiatrists
regarding psychiatric treatment in this area.  We are
especially concerned that the public confusion and dismay over
this issue and the possibility of false accusations not
discredit the reports of patients who have indeed been
traumatized by actual previous abuse.  While much more needs
to be known, this Statement summarizes information about this
topic that is important for psychiatrists in their work with
patients for whom sexual abuse is an issue.

Sexual abuse of children and adolescents leads to severe
negative consequences. Child sexual abuse is a risk factor for
many classes of psychiatric disorders, including anxiety
disorders, affective disorders, dissociative disorders and
personality disorders.

Children and adolescents may be abused by family members,
including parents and siblings, and by individuals outside of
their families, including adults in trusted positions (eg,
teachers, clergy, camp counsellors). Abusers come from all
walks of life.  There is no uniform "profile" or other method
to accurately distinguish those who have sexually abused
children from those who have not.

Children and adolescents who have been abused cope with the
trauma by using a variety of psychological mechanisms.  In
some instances, these coping mechanisms result in a lack of
conscious awareness of the abuse for varying periods of time.
Conscious thoughts and feelings stemming from the abuse may
emerge at a later date.

It is not known how to distinguish, with complete accuracy,
memories based on true events from those derived from other
sources.  The following observations have been made:

   Human memory is a complex process about which there is a
   substantial base of scientific knowledge.  Memory can be
   divided into four stages:  input (encoding), storage,
   retrieval, and recounting.  All of these processes can
   be influenced by a variety of factors, including
   developmental stage, expectations and knowledge base
   prior to an event;  stress and bodily sensations
   experienced during an event;  post-event questioning;
   and the experience and context of the recounting of the
   event.  In addition, the retrieval and recounting of a
   memory can modify the form of the memory, which may
   influence the content and the conviction about the
   veracity of the memory in the future.  Scientific
   knowledge is not yet precise enough to predict how a
   certain experience or factor will influence a memory in
   a given person.

   Implicit and explicit memory are two different forms of
   memory that have been identified.  Explicit memory (also
   termed declarative memory) refers to the ability to
   consciously recall facts or events. Implicit memory (also termed
   procedural memory) refers to behavioral knowledge of an
   experience without conscious recall.  A child who demonstrates
   knowledge of a skill (eg, bicycle riding) without recalling how
   he/she learned it, or an adult who has an affective reaction to
   an event without understanding the basis for that reaction (eg,
   a combat veteran who panics when he hears the sound of a
   helicopter, but cannot remember that he was in a helicopter
   crash which killed his best friend) are demonstrating implicit
   memories in the absence of explicit recall.

   This distinction between explicit and implicit memory is
   fundamental because they have been shown to be supported by
   different brain systems, and because their differentiation and
   identification may have important clinical implications.
   Some individuals who have experienced documented traumatic
   events may nevertheless include some false or inconsistent
   elements in their reports.  In addition, hesitancy in making a
   report, and recanting following the report can occur in victims
   of documented abuse. Therefore, these seemingly contradictory
   findings do not exclude the possibility that the report is based
   on a true event.

   Memories can be significantly influenced by questioning,
   especially in young children.  Memories also can be
   significantly influenced by a trusted person (eg, therapist,
   parent involved in a custody dispute) who suggests abuse as an
   explanation for symptoms/problems, despite initial lack of
   memory of such abuse. It has also been shown that repeated
   questioning may lead individuals to report "memories" of events
   that never occurred.

It is not known what proportion of adults who report memories
of sexual abuse were actually abused.  Many individuals who
recover memories of abuse have been able to find corroborating
information about their memories. However, no such information
can be found, or is possible to obtain, in some situations.
While aspects of the alleged abuse situation, as well as the
context in which the memories emerge, can contribute to the
assessment, there is no completely accurate way of determining
the validity of reports in the absence of corroborating
information.

Psychiatrists are often consulted in situations in which
memories of sexual abuse are critical issues.  Psychiatrists
may be involved in a variety of capacities, including as the
treating clinician for the alleged victim, for the alleged
abuser, or for other family member(s);  as a school
consultant; or in a forensic capacity.

Basic clinical and ethical principles should guide the
psychiatrist's work in this difficult area.  These include the
need for role clarity.  It is essential that the psychiatrist
and the other involved parties understand and agree on the
psychiatrist's role.

Psychiatrists should maintain an empathic, non-judgmental,
neutral stance towards reported memories of sexual abuse.  As
in the treatment of all patients, care must be taken to avoid
prejudging the cause of the patient's difficulties, or the
veracity of the patient's reports.  A strong prior belief by
the psychiatrist that sexual abuse, or other factors, are or
are not the cause of the patient's problems is likely to
interfere with appropriate assessment and treatment.  Many
individuals who have experienced sexual abuse have a history
of not being believed by their parents, or others in whom they
have put their trust. Expression of disbelief is likely to
cause the patient further pain and decrease his/her
willingness to seek needed psychiatric treatment.  Similarly,
clinicians should not exert pressure on patients to believe in
events that may not have occurred, or to prematurely disrupt
important relationships or make other important decisions
based on these speculations.  Clinicians who have not had the
training necessary to evaluate and treat patients with a broad
range of psychiatric disorders are at risk of causing harm by
providing inadequate care for the patient's psychiatric
problems and by increasing the patient's resistance to
obtaining and responding to appropriate treatment in the
future.  In addition, special knowledge and experience are
necessary to properly evaluate and/or treat patients who
report the emergence of memories during the use of specialized
interview techniques (eg, the use of hypnosis or Amytal), or
during the course of litigation.

The treatment plan should be based on a complete psychiatric
assessment, and should address the full range of the patient's
clinical needs.  In addition to specific treatments for any
primary psychiatric condition, the patient may need help
recognizing and integrating data that informs and defines the
issues related to the memories of abuse.  As in the treatment
of patients with any psychiatric disorder, it may be important
to caution the patient against making major life decisions
during the acute phase of treatment.  During the acute and
later phases of treatment, the issues of breaking off
relationships with important attachment figures, of pursuing
legal actions, and of making public disclosures may need to be
addressed. The psychiatrist should help the patient assess the
likely impact (including emotional) of such decisions, given
the patient's overall clinical and social situation.  Some
patients will be left with unclear memories of abuse and no
corroborating information.  Psychiatric treatment may help
these patients adapt to the uncertainty regarding such
emotionally important issues.

The intensity of public interest and debate about these topics
should not influence psychiatrists to abandon their commitment
to basic principles of ethical practice, delineated in The
Principles of Medical Ethics with Annotations Especially
Applicable to Psychiatry.  The following concerns are of
particular relevance:

  Psychiatrists should refrain from making public  statements about
  the veracity or other features of individual reports of sexual
  abuse.

  Psychiatrists should vigilantly assess the impact of their
  conduct on the boundaries of the doctor/patient relationship.
  This is especially critical when treating patients who are
  seeking care for conditions that are associated with boundary
  violations in their past.

The APA will continue to monitor developments in this area in
an effort to help psychiatrists provide the best possible care
for their patients.

