**Abstract**

This chapter explores the lasting impact of 1987 Cleveland child abuse crisis in the UK in which 127 children were diagnosed by two paediatricians as having been sexually abused. It highlights how this resulted in tensions, misunderstandings and stresses in the interface between the public and the child protection system, and persistent challenges of creating and sustaining a successful multidisciplinary approach to intervention and protection. It argues that the experience in Cleveland provided unique information about the effects of intervening in child sexual abuse, especially where children are trapped in silence and only come to light by way of a proactive intervention. These children remain difficult to help and the best way of intervening remains contentious. The authors challenge the ethos that leaves sexually abused children vulnerable in the face of investigative and evidential hurdles and suggest ways forward.

**Keywords:** Child sexual abuse, Cleveland, medical diagnosis, child protection, dilemmas of intervention

### **1. Introduction**

*'We have learned during the Inquiry that sexual abuse occurs in children of all ages, including the very young, to boys as well as girls, in all classes of society and frequently within the privacy of the family. The sexual abuse can be very serious and on occasions includes vaginal, anal and oral intercourse' ([1], p.243).*

The lasting legacy of the 1987 Cleveland child abuse crisis, in which a medical diagnosis of sexual abuse was made in 127 children, is that Cleveland became a shorthand for difficult issues in child protection, with widely differing meanings, often informed by media rather than professional debate. It was a pivotal point, which has influenced attitudes, policies and politics ever since. The subsequent Butler-Sloss Inquiry [1] left unresolved issues in child protection and had the effect of stifling debate about the dilemmas facing professionals in the field and the communities in which they work. The key issues from Cleveland remain relevant to child protection today. We argue that after Cleveland, what had been a proactive approach to protecting children who were being sexually abused became reactive, focusing only on those children who can disclose abuse, rather than the majority who are trapped in silence, especially the very young whose abuse can only come to light via an adult advocating in their behalf. The critical role of medical diagnosis in advocating for the latter group was effectively ended in the furore which led to the Butler-Sloss Inquiry. The Inquiry failed to grasp the nettle of the problems of protecting these most vulnerable children.

Because the professionals involved in Cleveland were unable to speak publicly, this created an information gap, and powerful myths were generated, influencing both public and professional perceptions; for example that all children seen by the paediatricians were screened for abuse; that a diagnosis of sexual abuse was made on the basis of a single sign (anal dilatation); that the diagnoses were discredited and that children were removed from home for the flimsiest of reasons. Although Butler-Sloss refuted them all, the myths became solidified and entrenched and continue to profoundly affect our society's approach to tackling the reality of child sexual abuse. In 1987, despite the context of increasing awareness and increased willingness to intervene, the management of child sexual abuse was based on a limited understanding of its dynamics and what would happen when attempts were made to bring it to light. There is now a much stronger evidence base, which should inform politicians, professionals and others responsible for making decisions and taking the field forward.

Although the very complex issues involved are now better understood, intervening remains difficult and professionals have inevitably become more anxious and more aware of the risks they take when entering this field. The Butler-Sloss Inquiry addressed but unwittingly increased this struggle. One of the legacies of Cleveland has been professional anxiety, creating a risk-averse climate which has contributed directly to subsequent child abuse tragedies [2]. Professionals, too, are affected by conflict between the need to know and the distress of hearing unspeakable truths.

We argue that the knowledge and understanding gained in Cleveland could have produced positive changes and greater continuity in child protection practice and that this opportunity was lost. The tensions created left an eternal argument about the facts of Cleveland, and continuing failure by the child protection system to tackle the real scale of the problem. The subsequent clampdown on accurate information about the crisis made it difficult for other practitioners to verify the real issues and led many to question whether authoritative interventions based on advocacy for the child are tenable in a social climate which unconsciously supports the denial of the extent of child abuse.

### **2. Background: the Cleveland crisis and the inquiry process**

The Cleveland child abuse crisis had its origins in a seminal paper by Leeds paediatricians Drs Hobbs and Wynne [3], which identified anal abuse as a potentially common childhood syndrome. The medical diagnosis by Drs Higgs and Wyatt of sexual abuse in 127 children in Cleveland placed unprecedented pressure on the resources of police and social services and inter-agency co–operation was stressed to breaking point. A public outcry of disbelief, fuelled by the media and one local MP, led to a major public inquiry [1]. Of the 121 children reviewed by the Inquiry, 27 were under the age of 3 with the youngest under a year old, presenting a uniquely difficult investigative challenge. In the absence at that time of any agreed procedures for intervention into child sexual abuse, procedures designed for other forms of abuse were followed: this involved removing some children from home. This action fuelled the controversy.

The Inquiry's remit did not include establishing whether or not the children had in fact been abused, which was addressed in a parallel process in the High Court. An independent expert panel set up by the Regional Health Authority concluded that in at least 75% the diagnosis of CSA had been correct. The Inquiry had access to the report of this panel but chose not to publish this conclusion. In consequence the public perception, led by a small group of aggrieved parents, a local MP and

#### *Why Cleveland Still Matters: Connections with a New Era DOI: http://dx.doi.org/10.5772/intechopen.97368*

consistently biased reporting in the media, was that the diagnoses were incorrect and the cause of the crisis was overzealous intervention by professionals.

At the very point at which professionals were trying to get to grips with dealing with the new phenomenon of children presenting via a medical route, the situation went beyond their control. The local MP made allegations in the House of Commons of 'collusion and conspiracy' (subsequently dismissed by Butler-Sloss) and the Inquiry effectively interrupted all ongoing work. The method of the Inquiry, which, despite its statement to the contrary, was adversarial rather than inquisitorial, was unsuited to the elucidation of a highly complex and sensitive issue such as CSA. This resulted in polarisation and a lack of balance, and encouraged the media to represent the professionals as being wholly wrong and the parents as being entirely innocent, creating a public misconception that has endured ever since.

#### **3. A unique opportunity at the heart of the matter**

Professionals in Cleveland were presented with a new opportunity to intervene protectively where children were experiencing the most serious forms of child sexual abuse. Some of the children were able to disclose. For some, disclosure was prompted by the medical examination. Others were identified as having been abused but were unable to say anything about what was happening to them. These children, who were trapped in the silence inherent in the dynamics of the abuse, came to attention through a medical 'window', a diagnosis based on previously unrecognised signs and symptoms. The two paediatricians Drs Higgs and Wyatt have analysed the children's presentation and medical findings and described dilemmas for the doctor [4]. The children who came to attention in this way, via an adult or alerting signs and symptoms rather than purposeful disclosure, then posed an enormous challenge for the professionals as to how to intervene to protect them. We term them 'Group B', in contrast to those who can make a disclosure and assist in an investigation, whom we term Group A.

In the case of children in Group B the identity of the perpetrator is likely to be unknown. Butler-Sloss identified but did not resolve this key dilemma and its relation to the question of removal from home. Removal from home, though fraught and controversial, facilitated disclosure for some children. Paediatricians in Leeds reported a similar pattern, commenting 'We know many children never describe their abuse, others only after months in the safety of a foster home. Children left at home may be threatened and never feel able to disclose, and without some sort of admission from the child professionals are increasingly anxious about taking any action. Yet it may be only by removal of the child from the abuser that the child can develop the confidence to tell' [5].

A theme of the Butler-Sloss Inquiry [1] is that children would normally disclose except for 'rare occasions when an abused child does not choose to tell' (p.207). The tenor of the report equates non-disclosure with no abuse. Rather than recognising how difficult and unlikely any disclosure is, particularly for young children, the report emphasised the risks of trying to assist children by interviewing them in more facilitative ways, such as asking them directly. Expert evidence to the inquiry warned that interviewers can create bias, interviews themselves could be abusive, and that children can lie and fantasise about abuse.

The importance of the medical diagnosis for such children was overridden by the idea that the 'gold standard' for the diagnosis of child sexual abuse was disclosure by the child. This reliance on disclosure as the prime route to diagnosis was accompanied by the discrediting of the medical diagnosis, which was based

on a constellation of signs including reflex anal dilatation (RAD). At this time the evidence base for medical findings in child sexual abuse was small, allowing scope for wide disagreement between professionals, which then deterred paediatricians elsewhere from working with child sexual abuse. More recent research [6] suggests that medical findings can in fact make a very important contribution to the diagnosis of child sexual abuse and that anal dilatation is a highly significant sign. The Inquiry missed this unique opportunity to evaluate this vital issue at the heart of the crisis.

The way the Cleveland crisis was handled had long term negative effects over the succeeding decades, and we believe that knowledge and experience about children in Group B has been lost. Such children have become largely invisible, and even when they do come to light, they remain difficult to help because the best way of intervening remains contentious.

#### **4. The medical diagnosis: was it mistaken?**

Since 1987 more research has been carried out into the medical signs that the Cleveland paediatricians described [7]. Despite this, the diagnosis of child sexual abuse has become more complex and uncertain. Very little has been added to the evidence base about anal abuse in children, few cases are documented, and paediatricians are still not all in complete agreement about some of the signs that were detailed by Hobbs and Wynne [3].

Although there is still not a complete consensus on this matter the current evidence- based guidelines for doctors [7] conclude that the so called 'controversial' sign of anal abuse used in Cleveland is one of the most statistically significant findings that can be relied upon in the diagnosis, along with most of the other signs and symptoms that the Cleveland paediatricians found.

After Cleveland the changed perceptions of the medical diagnosis soon became apparent. The Social Services response changed and although there were the same number of child protection case conferences, fewer children were placed on the register, fewer taken into care, and there were fewer criminal convictions. Campbell [2] explores the way in which the expert medical consensus that there was no wholesale error of diagnosis was kept from view, and how it was known that scapegoating the Cleveland paediatricians would undermine the paediatric role elsewhere.

## **5. The resulting backlash**

Since 1987 society has tried to come to terms with the nature and extent of what can now be understood as an 'iceberg' of child sexual abuse. Ongoing secrecy and denial creates a backlash that can be driven by perpetrators, victims, professionals, politicians and the wider society which hampers the best efforts to understand and intervene effectively to help child victims. At the same time, it can be argued that there is far greater acceptance among the wider public of the reality of child sexual abuse, influenced by the courage and integrity of survivors who have come forward to bear witness to their experiences. In our opinion, a Cleveland-type crisis was an inevitable stage of a process whereby professional awareness advanced; but we argue that this took place in a context of impunity for perpetrators and public ignorance of the reality, and the Inquiry was an exercise in containment of the problem. We can now see how the media backlash used the disagreements between professionals to discredit them.
