Cleveland

Among the people who almost certainly took comfort from the tone of the national discussion of events in Cleveland in the summer of 1987 were three middle-aged men from a housing estate in Congleton, Cheshire. As emerged in their trials earlier this year, these men had repeatedly been making sexual assaults of the most extreme sort on very young members of their families, sometimes in a spirit of revolting cruelty. One man had raped his sobbing five-year-old daughter, as she was held down by her mother, and buggered his three-year-old son. The other two had indecently assaulted and buggered children between the ages of five and nine. It is reasonable to suppose that these men would have applied the Cleveland affair to their own situation quite thoroughly. While sexual assaults on children are no doubt sometimes unpremeditated, the literature is full of cases where the activity is a highly conscious project, often the project of a lifetime, even when the behaviour that is planned is of the most cruel and selfish variety. Men do, in real life, get married in the spirit of Humbert Humbert – sometimes with much younger and more defenceless targets in view than Lolita. They do – pace the incredulity expressed about certain diagnoses of Dr Marietta Higgs – deliberately get themselves accredited as fit to foster children with the intention of abusing their charges. In the case of Congleton it appears that some fifteen other adults may also have been involved in child sex: it was a ‘sex ring’ – a vague expression which is nevertheless surely correct in its implication of group commitment to a particular sexual practice.

It is also reasonable to suppose that the signals reaching Congleton from Cleveland via the media would have been encouraging. There was the general incredulity that, in a population of over half a million, there could be as many, or even remotely as many, as 121 children who had been sexually asaulted in a way that left clinical signs. There was the persistent invitation to sympathise with the parents of these children, to envisage your own distress and outrage if you, as an innocent parent, had your own children detained in hospital against your wishes (an invitation which was extremely compelling – but only appropriate where the parents were not responsible for the venereal disease and injuries of the genitalia and anus with which most of their children were presenting). There was authoritative support for the protesting parents, in the sense that the local MP, the local Police up to the highest level, and the chief police surgeon of the district, all said that the pediatricians and social workers involved were wilfully irresponsible. There was almost no perception, it seemed, that these people were in a very difficult moral predicament in which they deserved understanding – and practical support. In Congleton it must all have looked like another buggers’ charter. Happily the Police and social services in Cheshire were not so inhibited by Cleveland that they failed to achieve exposure and conviction (indeed, they said they had been helped by the mistakes of Cleveland – but the value of criminal prosecution as a goal where child sex abuse is concerned was one of the issues which divided the parties at Cleveland). And the report of the Butler-Sloss inquiry, for all its reticences about names and numbers, brought in a verdict on Cleveland very antagonistic to the hitherto prevailing one: by far its harshest judgments are reserved for MP Stuart Bell, the Police, and the doctors who supported the Police in their hostility to Drs Higgs and Wyatt.

That human nature – or, probably more exactly, male human nature – has the capacity to perform deliberately and persistently the acts performed at Congleton is for most of us very disorienting, and incomprehensible. The fact, however, is stark (since Congleton, two more sex rings involving very young children, in Nottingham and South London, have come before the courts), and police, social workers and doctors have a duty to keep it in mind, grotesque and dismaying though it is. To remember that a father or stepfather who looks like other fathers and stepfathers may be an abuser of children in this sense, and sometimes deduce that he is, will indeed have an air of witch-hunting – the leading metaphor in Stuart Bell’s version of the Cleveland affair, When Salem came to the Boro – but this is in the nature of the case. At Cleveland it seems that the social workers and doctors were much more mindful of possibilities than the Police. Before the appointment of Marietta Higgs early in 1987, the social services in Cleveland had been creating machinery for coping with the physical child-abuse, including sexual, which they knew at least in theory that they might encounter. For Dr Higgs, theory was brutally confirmed in July 1986, in her previous post at Newcastle, when she saw the startling phenomenon of anal dilatation in a two-year-old girl: the finding was confirmed by a woman police surgeon and the parents arrested. For Dr Wyatt, a pediatrician with an enormous case-load who seems to have been oppressed by the scale of general child ill-health in his district, the emotional impact of the physical signs of sexual abuse was enhanced by the thought that much of the ‘failure to thrive’ which he had found distressingly intractable might have such abuse in its aetiology. The Butler-Sloss report notes that he had been ‘obviously affected ... deeply’ by a dramatic example of anal dilatation shown to him by Dr Higgs, his first acquaintance with the sign. He also remembered his first distressing encounter, in 1983, with child sex-abuse in any form at Middlesbrough, a six-week-old girl with a torn vulva; he had failed to diagnose abuse and had been surprised when the Police told him that the girl’s father had confessed to yielding to ‘a sudden sexual urge’.

The fact that gross sexual assaults are performed on very young children is the crucial background to the events at Cleveland in 1987. The whole ethical issue about the behaviour of the social workers and doctors comes down to this: how should they have used their powers in dealing with the children and parents they saw, given the knowledge that sexual abuse of children, sometimes very brutal, does occur? For example, the father of three young girls diagnosed as showing signs consistent with sexual abuse complained to the inquiry in written evidence about the running of the case conference on his children: ‘Came in at the end. Was informed about what the situation was – very little said. I complained at not being allowed to put my point of view across.’ Another father tried to resist bringing his son to the hospital for examination after his daughter had been diagnosed as sexually abused, and was warned by Drs Higgs and Wyatt that ‘he may be placed in the care of the Local Authority if we did not have him examined.’ The Butler-Sloss report goes on: ‘His wife told of returning to the hospital next morning and of Dr Wyatt saying: “If you dare to take your child out of the hospital she will be placed straight into care.” A place of safety order was obtained this day and the mother said: “[that evening] I arrived home and opened the door to find a place of safety order on my doormat.” ’

This is the kind of material which above all incensed the British public against the pediatric and social services of Cleveland last summer. When set beside the reality of child sex-abuse, it tells of a very complex moral issue, to which mere indignation about doctors and social workers is an inadequate response. One element in this difficult moral calculation which must be measured at the outset is the disruption of families. It was by the use of place of safety orders such as are referred to in the second episode that separation of children and parents initially occurred at Cleveland, and it was these orders which were chiefly at issue in the complaints about separation. It is important to realise that place of safety orders are only valid for a maximum of 28 days. Until the number of cases judged to be needing attention by a limited staff had built up to a very high level, in the summer of 1987, it was the conscious policy of the Cleveland social services always to seek a minimum period for these orders, of seven days at the outside. A place of safety committal to a hospital ward of this extent, with visiting or even living-in permitted to the parents (which seems to have been the usual arrangement at Cleveland), is not more onerous to a family than a normal medical admission. Sustained separation from the family may start when a care order from the Juvenile Court to this effect follows on the place of safety order. Unfortunately, it is not apparent from the literature on the affair how often this second step was taken: certainly it followed in many cases. It is to be noted, incidentally, that the total number of place of safety orders taken out on the grounds of abuse in Cleveland in the first half of 1987 was not much greater than in the same period in 1986: it is probable that many cases which would previously have been labelled ‘physical’ were labelled ‘sexual’ in 1987 because in the new circumstances it was this feature of the abuse, among a cluster of signs, which was first noted.

Some commentators have suggested that the professionals could have separated the children from the suspected abuser, but not from their families, by taking the father or stepfather away from the home, but this was not a feasible option. Only the High Court, acting for a child warded to it, has the power to order this sort of arrangement; place of safety orders granted by the magistrate, or care orders emanating from the Juvenile Court, the two expeditious instruments for protecting an endangered child designed for the use of the professional agencies, and routinely employed by them, do not give the power to remove a father or stepfather. It was probably to the good that the professionals at Cleveland did not have the power to bring about the isolation of particular individuals from the children they were suspected of abusing. As I mention shortly, the social workers and doctors may have been too ready to locate sexual abusers among the immediate families of the children – especially the male parents. The place of safety order, with its sequels, does not make assumptions about the identity of the abuser and concentrates on the matter of protecting the child.

Drs Higgs and Wyatt were confident in their diagnoses of sexual abuse, and the social workers in turn – partly because they naturally respected the views of qualified pediatricians and partly because they were so instructed by the County Director – acted on these diagnoses unquestioningly. Before the fundamental questions are opened up – how justified was this pediatric confidence, and has justified should it have been before the doctors acted on it? – it is worth considering the complaints from parents cited above through the eyes of a professional who had good reason to think that a child had been assaulted, and was charged to protect this child (always bearing in mind that only a minority of parents registered such complaints, and that even on the showing of Mr Bell’s account the two doctors were often perfectly communicative and courteous with the parents). Particularly difficult to stomach, one imagines, might have been the father who had a ‘point of view’ to express. There were definitely fathers in Cleveland who were abusing their children and yet quite cynically putting on the mask of aggrieved, decent parenthood: quite a number of them, in fact, sought the protective wing of Stuart Bell with their sob-stories, and were embraced by it (in one case Bell refused to accept the mother’s version of events in the face of the father’s denial). The briskness, perhaps amounting to brusqueness, with which the children were legally removed flowed from another perception about the fathers: that they would continue to assault their children and, even more to the point, would coerce their children into denying that they had been abused, or into withdrawing earlier descriptions of abuse. At Cleveland one father, against whom there were well-founded allegations of abuse, removed his children from the hospital and secreted them before a place of safety order could be sought. On top of all this, the professionals perhaps had a personal dislike for the fathers they believed to be abusers because of disgust for their actions. Such feelings suggest a third fundamental question: how much does the sexual abuse of children matter?

These points on behalf of the doctors and social workers as they sometimes behaved at a particularly publicised phase of their handling of abuse need some qualification, however. To start with, the professionals often made an assumption that families were the site of abuse, with fathers or stepfathers the most likely offenders within the family. As a judgment of probability this may be just about defensible, in the light of what statistics of abuse there are: but it could presumably have been checked for individual families at Cleveland much more than was attempted. Cleveland County, in fact, seems to have been in something of a muddle as to what it did think of the family, with even the vilified Sue Richardson originally backing regular inclusion of families in case conferences, while Butler-Sloss found that parents were not admitted to any of the conferences on suspected cases of sex-abuse conducted between April and August 1987 (and Sue Richardson later told the enquiry that she thought the utility of ‘family co-operation’ was ‘a bit of a myth’). The doctors, while distressed and angry about abuse, may have conceived the fact of family responsibility for abuse in a somewhat abstract and passive light, rather as one might feel about bacteria or viruses. They were criticised by the Police for being tardy in providing written evidence that could assist the prosecution of abusers; more seriously (since one can see that they could have regarded the securing of criminal convictions as peripheral to the main business of protecting children), they are accused in the Butler-Sloss report of frequently failing to communicate with GPs, even in the way of a standard letter about their findings in the outpatients’ clinic. Here again, however, When Salem came to the Boro tends to put them in a rather better light. It also makes it hard to get a clear idea of the attitude of Dr Higgs, in particular, to families – since she emerges as a real enthusiast for ‘family assessment’ from her Newcastle days, who routinely did a family tree as part of her case notes.

How justified were the doctors in their diagnoses? Drs Higgs and Wyatt were not vicious cranks who looked for sexual abuse where it was not suggested, and found it in a preposterously high proportion of their patients. Butler-Sloss acquits them of ever having looked for signs of abuse when there was not a reason to. Many children passed through their out-patient clinics without being examined for abuse, and many of those in whom abuse was suspected were cleared after examination. Take the facts concerning Dr Wyatt. He saw 2246 children as out-patients at Middlesbrough General between January and July 1987. Fifty-three had been referred for abuse of some sort and were examined accordingly. Dr Wyatt looked for sexual abuse in 55 children in all, however they came to him, in the whole period. Of these he was able to clear eight. The picture is rather different for Dr Higgs. A higher proportion of her smaller outpatients load were referrals for abuse, no doubt because of her known interest in the condition (45 referrals out of 560 patients). In all, she examined 102 children for sexual abuse in the first half of 1987; she cleared 22 of them. The figures are consistent with what is generally accepted about serious child sex-abuse (abuse which could leave clinical signs): that it is more common than the general rate of detection would suggest, perhaps being experienced by between 1 per cent and 3 per cent of children at some stage (incidence will obviously be much lower than prevalence, but may be expected to be high when there is a backlog of undetected cases). Even Dr Irvine, the police surgeon so critical of Higgs and Wyatt, saw 161 children in two years in Cleveland on suspicion of sexual abuse and made 58 positive findings.

Anal dilatation (a dilatation of the inner sphincter – which is not under voluntary muscular control – when the buttocks are parted that becomes visible when the external sphincter – which is under voluntary control but cannot remain closed for more than a few seconds on its own – has to relax) was the only physical sign of abuse in 18 of the 121 diagnoses made by the doctors. But there was no case in which it was not accompanied by other evidence, and it was never the sole ground for the diagnosis. It is correct to call anal dilatation a ‘controversial’ sign in the sense that doctors disagree about its significance in a child: but no plausible explanation for it other than that of buggery has been discovered (and historically, in adults, it has been taken by doctors as indicative of chronic buggery). In the Butler-Sloss report the doctors who most directly attacked the use of anal dilatation by Higgs and Wyatt are criticised as almost unethically slipshod in their claims about its real significance and their own acquaintance with it. (It needs to be said also that the stories of painful anal examinations by Higgs and Wyatt were unfounded: doctors examining for the Police, who generally insisted on inserting one or more fingers into the anus, caused more discomfort.) Even if anal dilatation does indicate abuse, it is not known how likely it is to manifest itself, even when present, in any particular examination, or how long it persists. These uncertainties make any diagnosis of renewed abuse, beyond the first fact, impossible, and at Cleveland Dr Higgs, who knew the problems, was certainly too ready to assert that further assaults had been made on some of her patients.

Though fairly novel in their belief that clinical signs on their own could indicate sexual abuse, and in counting among these signs the fairly novel one of anal dilatation, Drs Higgs and Wyatt made many correct diagnoses. Their success-rate is of course a burning issue, which the Butler-Sloss report does not comment on directly. There are three sets of figures in the report which imply something about the reliability of the doctors. A Second Opinion Panel was set up in June 1987 to review a number of their disputed diagnoses (the membership of this panel was accused by some of being biased in favour of Higgs and Wyatt): it judged from medical, psychiatric and social evidence (the medical being sometimes rather out of date) that the doctors had made wrong diagnoses in four out of 29 cases. At the same time a Regional Reference Group was created to look at all new findings of sexual abuse by Higgs and Wyatt (this panel could be suspected of the opposite kind of bias, for a Cleveland police surgeon usually took part in each review): it found eight wrong diagnoses out of 22. Finally, of the original cohort of 121 children, 67 became wards of court because diagnoses of sexual abuse had been contested in the Juvenile Court, and 27 of these were judged not to need protection and were returned to their homes.

This is not much to go on, but it does look – making allowance for possible bias in the review panels’ figures, and assuming that the cases not contested in the Juvenile Court were mostly correctly diagnosed – as if the Higgs-Wyatt scoring rate might have been about 75 per cent, or three to one. Was this good or bad? Do you say that the doctors unearthed a commendably large number of suffering children, or that they inflicted suffering on a disgracefully large number of innocent families? This raises the second fundamental question about the doctors at Cleveland: were they justified in causing place of safety orders to be taken out, and probably in most cases then supporting care applications in court, if there was a one-in-four chance that their diagnosis of sexual abuse was wrong? One aspect of this issue is the balance of evidence which it was reasonable, or even obligatory, for them to act on. Stuart Bell, who is a lawyer, should know better when he wrings his hands over the abandoning at Cleveland of the ‘Anglo-Saxon concept of justice’, whereby a man is innocent until proved guilty. The standard of proof required in the Juvenile Court, because it is a civil court, is that of the balance of probability; moreover, the local authority has an obligation (certainly more acutely sensed by local authorities everywhere in England after events such as the Jasmine Beckford affair) to apply to the court on behalf of children whom they think will be found to be abused. The evidential requirements concerning wards of court are less certain, but the most recent judges’ opinions, as quoted by Butler-Sloss, are that the standard of proof should be even weaker than in the Juvenile Court: not even a ‘balance of probability’ but a ‘real possibility’. Interestingly, Butler-Sloss is clear that the Police have a duty to act in support of the local authority as it seeks to secure a care order, and hence should accept a lower threshold of evidence before they investigate child sex-abuse than if the only outcome could be a successful prosecution of the abuser. In Cleveland, she says, the Police thought just in criminal terms – or even just in terms of discrediting the hated Dr Higgs and hence, supererogatorily, of exonerating suspected abusers.

Only the social workers were actually bound by these legal considerations, which go a long way, it may seem, towards justifying their proceedings (it is perhaps harsh of Butler-Sloss to deem that they should have made fewer applications for care orders once the medical evidence from Higgs and Wyatt started to be contested in the Juvenile Court: even in the contested cases the doctors were right more often than they were wrong). The doctors did not have to think legally, and when they recommended a place of safety order they were thinking medically: arranging the best therapy they knew in the light of a diagnosis which had been arrived at by a balancing of probabilities. As it happened, the ordinary diagnostic standard of proof was much the same as that required by the courts involved, for whom a three-to-one probability is more than good enough. But it is, in effect, argued by the doctors’ critics that they should have applied a stricter standard in the diagnosis of sex-abuse than they would for most other conditions, because the therapy – separating children from their families – is so drastic. To which the doctors might reply that the evil of sexual abuse is so great that they were justified in taking a one-in-four chance of causing another evil – that of separating a non-abused child from its family. So at the bottom of the Cleveland controversy there lies the question, how much does the sexual abuse of children matter?

On behalf of the doctors, it must at once be said that they had to weigh against the effects of separation, not just any kind of sexual act by an adult with a child, but acts which were serious in the sense of causing some degree of injury. The new awareness of the extent of child sex-abuse by which they were influenced springs, historically, from the discovery of how widespread is physical cruelty to children in all guises. Dr Higgs first heard about the problem of sexual assaults in the context of hearing about general cruelty, at Newcastle, but even without this background she was bound to encounter the cruel side of child sex-abuse simply because, as a doctor, her concern was the physical body. The same goes for Dr Wyatt, who, in addition, believed that sexual trauma could do significant damage to a child’s general health. As I have mentioned, it looks as if many of the cases categorised as sex-abuse in 1987 would have been labelled physical abuse in 1986. Don’t three children saved from physically-injuring sexual assault outweigh one child separated from its parents?

It is by no means clear that the answer to this question is always yes as far as the assaults revealed at Cleveland are concerned. Anal dilatation, for example, is agreed, even by those who believe it to denote abuse, to be a transient phenomenon. This is not to say that the critics of Drs Higgs and Wyatt are generally to be detected, even in their own minds, in the position of playing down the evils of anal intercourse with a young child. Few of them saw very far at all into the logic of their hostility to the doctors – but some argument to the effect that physically-injuring sexual activity with a child is not an unmitigated evil has to be advanced in any reasonable case against Wyatt and Higgs. There are glimpses of such an attitude in some of the testimony to Butler-Sloss, and in a recent judgment on paternal visiting rights by Butler-Sloss herself. There is possibly a certain minority among doctors who, discreetly, take the view that sexual abuse may have some emotional benefits for its victim. A friend of mine who is a moral philosopher said that he thought ‘sex abuse’ at Cleveland was often a new way of saying ‘incest’. Perhaps incest can be expected sometimes to involve mild injury; even with this proviso, are we all confidently opposed to incest? It starts to look as if Higgs and Wyatt were a little fuddy-duddy, and their enemies rather more up-to-date, rather more in tune with the sexual liberationism of our time.

Again, few in the anti-doctor party saw themselves in this light, but I think their position is essentially a liberationist one – while the difficulty they feel in following it through is an example of the inconsistencies which our modern sexual culture has thrown up, in its own way, just as abundantly as the sexual culture of the 19th century. Our society is enthralled by sexual ‘prowess’; we have almost no place for a notion of undesirable sexual excess, and hence almost no foothold for objections to incest. In the Sun the heroes are the men who ‘bonk’ with the greatest frequency; in the TLS the subject of a biography is interesting in proportion to the amount of secret sexual activity that he can be discovered to have engaged in. Since ordinary humans are not up to these admired standards, our deference towards sex leads to contradictions no less ridiculous than the contradictions of Victorianism, only the other way round. I recently looked into a biography of Liberace where the blurb said that his sexual appetite was ‘insatiable’: it turned out that Liberace, far from never being satiated, never got to first base, and had a silicon implant in his penis because he couldn’t achieve an erection. To make a different historical comparison, this is rather as if some famous desert-dwelling celibate of the second century turned out to be a sexual satyr. It is all hagiography.

The contradictions in our sex-admiring culture about children and sex are less amusing. While there is a great reluctance to condone sex between adults and young children, I think many people would have difficulty in squaring this attitude with their own sexual code, except in the case of activity which causes painful injury. When the sexual acts involve no injury at all (though here we leave the domain of the Cleveland events), or the child is relatively mature, say at least twelve, what grounds are available, in the codes of most of us, for condemning the adult abuser? One of the recent books about Cleveland is called The Last Taboo, an ambiguous title with contradictory implications. It can refer to child sex-abuse as a forbidden topic, a secret in our society, or to child sex-abuse as a forbidden activity. For the first of these senses ‘taboo’ is the right kind of word nowadays: we pride ourselves on our superiority to taboos, and the author of the book, Gay Search, certainly wants to expose the reality of sexual abuse. But should we be equally valiant against the taboo which forbids the activity itself? Why not, when we have disposed of so many other dusty old prohibitions? Gay Search does not intend this implication, but her title stumbles across it, and her text cannot avoid it either. She writes of the child abuser: ‘the key question to which everyone wants an answer ... is: why do they do it?’ Then a number of psychoanalytic and psycho-social explanations are canvassed. If she were discussing homosexuality (an activity from which the taboos have been lifted), this procedure would nowadays be ridiculed, and probably rightly. Child abusers are not deficient or unwell, and if this is the only argument available against them, there will soon be a thriving Incest-Lib movement. The answer to ‘why do they do it?’ is that our sexual culture doesn’t offer any reason why they shouldn’t, and in some ways offers them inducements. They have been ahead of us in breaking yet another taboo. When there are lots of magazines on sale with pictures of women’s buttocks thrust towards the camera, sometimes parted, it is to be expected that a couple of busy pediatricians in a general hospital will encounter some dilated anuses.

It is of course possible to seek to extend the scope of consequentialist arguments (in an older terminology, utilitarian arguments) against child sex-abuse beyond the area of physical injury. There are studies which claim that victims of sex-abuse tend to experience various kinds of psychological and social disturbance in adult life. But these outcomes are not inevitable, being more in the way of statistical tendencies, and the notions of disturbance involved (though it is interesting to learn that the Hungerford gunman, Michael Ryan, may have been an abused child) can be unsatisfactory: ‘failure to form stable relationships’, for instance, is perhaps a trait which few of us would be confident in disavowing. Also, some of these damaging outcomes arise simply because of other people’s attitudes to sex-abuse (when a wife cannot tell a husband about her incestuous past, for instance); in a society tolerant of such experiences (which is no more unthinkable than lesbian parenthood was thirty years ago) these effects could be avoided. Consequentialist arguments might also be met by pointing out that children ‘enjoy’ sex with adults, in the sense that some boys and girls do have orgasms in these acts. Whether they enhance the quality of a child’s life (as an adult might claim about his or her pleasure in sex) is more doubtful. There is perhaps a stronger case to be made for the emotional satisfactions of a sexual bond with an adult – though the test here would be whether these are greater than those afforded by ordinary intimacy, a test which I think it would be hard to pass.

Arguing about child sex-abuse in the utilitarian way does not lead to clear solutions, and the case against it is probably better rested on arguments about autonomy, about an individual’s right not to be made to perform acts he or she cannot understand the meaning of, and not to be treated as an instrument. If such arguments weighed really strongly in our society, the utilitarian considerations invoked at Cleveland – of the suffering caused by the separation of families – would not command the mass response they commanded in 1987, which is perhaps improbable. The feminist movement is one of the few sectors of opinion in our culture which has set its face against the general deference to sex, and in the feminist comment on Cleveland there has been more rights-minded argument than in other quarters, less patience with the thought that a man may be entitled to bugger his child if this causes less suffering than taking the child from the family. Unfortunately, even the feminists have shown some tendency to do what Butler-Sloss admirably criticises right at the start of her report: to turn what must be at its heart a matter of children’s experiences into something ‘centred upon adult perceptions and concerns’. Beatrix Campbell’s book, for instance, is disfigured by too much fast footwork with the paradoxes of our sexual culture, and by some offensive witticisms (‘anal dilatation is apparently ... rather like an orgasm, or a sneeze, or a duck-billed platypus – there’s nothing else quite like it’). There’s not as much here to trouble the men of Congleton as there should have been.