Family Practice Grand Rounds

The Dynamics of Incest: Presentation of One Family in Acute Crisis

Jim L. Wilson, MD, William Clements, PhD, Remi J. Cadoret, MD, James Pease, MD, and Ed Lammer Iowa City, Iowa

DR. JIM WILSON (Family Physician, Assis­ Eventually, the diagnosis of bipolar affective dis­ tant Professor, Department of Family Practice): order was made, but one of the psychiatrists treat­ The discussion for Grand Rounds today deals with ing him felt that there was little clinical evidence the problem of incest. Mr. Lammer will begin by for that diagnosis. The patient never had episodes presenting background medical and social infor­ which could be considered hypermanic. However, mation obtained when he interviewed this family lithium was begun, and his depression improved as an assignment for an undergraduate course in remarkably. J. K. had a history of heavy alcohol family practice. His interview occurred prior to consumption until a few years ago. Significant the recognition of the present problem. Dr. Pease, medical problems include chronic obstructive who is a third-year family practice resident, will pulmonary disease aggravated by smoking two to describe the crisis event which brought the situa­ three packages of cigarettes a day for many years. tion to our attention. Dr. Clements, who is a mar­ He stopped working four years ago, complaining riage and family counsellor, Dr. Cadoret, a psy­ that shortness of breath severely limited his activ­ chiatrist, and I will have some general comments ity. about incest and family dynamics following the L. K. has been in relatively good health. She presentation of the family medical and social pro­ underwent a cholecystectomy several years ago. file. The daughters have no serious or chronic medical MR. ED LAMMER (Second Year Medical problems, but more will be said about that by Dr. Student): The family is presently composed of four Pease later. members living at home; the father, J. K., the The family has experienced severe economic mother, L. K., and the two daughters, A. K. and B. hardships due to the father’s inability to work. K., who are children from the mother’s previous Initially, the father was self-employed. His wife marriage. assisted in the business, and their income was suf­ J. K. has a long history of psychiatric and medi­ ficient to keep the family at a satisfactory eco­ cal problems. He was hospitalized once for de­ nomic level. The business folded at the time of his pression and once due to a medication overdose. hospitalization for depression. Following this, the family subsisted on unemployment and Social Se­ curity benefits. Later, the mother was able to supplement this income by working part time as a waitress. Health care costs have added to the eco­ nomic burden, but the family has been assisted by From the Departments of Family Practice and Psychiatry, and the College of Medicine, University of Iowa, Iowa City, Medicaid. Iowa. Requests for reprints should be addressed to Dr. Jim When I interviewed the family, there seemed to L. Wilson, Department of Family Practice, Family Practice Center, University of Iowa, Iowa City, IA 52242. be no major problems in their relationships with 0094-3509778/0801 -0363$01.25 ® 1978 Appleton-Century-Crofts

THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 2: 363-367, 1978 363 DYNAMICS OF INCEST each other. I was not made aware of the previous DR. WILSON: Incest, according to Dorland’s marriage of L. K., and I did not know that the girls Medical Dictionary, is sexual intercourse between were stepdaughters of J. K. Dr. Pease will present persons too closely related to contract a legal more information about some of the family’s med­ marriage. State laws regarding incest generally ical problems that have been dealt with in the prohibit persons with a degree of consanguinity in Family Practice Center. which marriage is void from having sexual inter­ DR. JAMES PEASE (Third Year Family Prac­ course with each other. Many state laws specific­ tice Resident): Before I talk about the crisis event ally include adopted or stepchildren in this defini­ I would like to review some of our office records tion. of the family. During the four years that we have The incest taboo has existed to some extent in cared for the family, many visits to the office have most societies and cultures that have been studied. been made by the family members. The mother, The nature and rigidity of the taboo have been who is in her mid 30s, has been to the office for 36 found to vary from culture to culture. Only the visits. The following problems have been recorded mother-son incest seems to be universally prohib­ on her problem list: gynecological problems, anx­ ited in every culture.1 iety, depression, marital and sexual problems, and Notable exceptions to the incest taboo have various minor dermatological problems. The hus­ been known throughout history. In ancient Egypt, band in his early 40s has been seen 38 times and pharaohs were permitted to marry a sibling of the his problems are listed as: chronic obstructive same father but were prohibited from marrying a pulmonary disease, chronic prostatitis, rectal sibling of the same mother. Incest has been bleeding, hypertension, and depression. tolerated in some European royal families and has A. K., the older daughter, has been seen 16 been permitted in some primitive tribes during times with problems including menstrual disorder, religious ceremonies. vaginal discharge, school difficulty, and minor Sociologists have tried to relate certain forms of illnesses. B. K., the younger daughter, has been sexual deviance, including incest, to the social role seen ten times in the office with problems includ­ of women. The degree of matriarchy or patriarchy ing anxiety, breast discomfort, and minor ill­ that exists in a culture has been hypothesized to be nesses. the crucial factor.2 In matriarchal societies a more The incest problem was divulged when B. K. and permissive attitude toward sex exists. In such a her mother presented together to the Family Prac­ society, incest is the sexual behavior most feared tice Center with a note which had been written by and condemned, while homosexuality is tolerated. B. K. to her mother. In the note B. K. described Patriarchal societies are characterized by more the relationship she and her stepfather had main­ restrictive attitudes toward sex in general. tained and stated that they had been having inter­ Homosexuality is the deviance most feared, while course over the past several years. B. K. was ex­ incest causes less concern. tremely frightened to relate this to anybody be­ One entire chapter of Leviticus in the Bible dis­ cause she felt her stepfather would harm her if she cusses sexual relationships in the family. The did so. During the interview it was learned that the Greek civilization was also concerned with incest, older daughter had also experienced a similar re­ and many of the terms we associate with incest lationship with the stepfather. were derived from them. Oedipus complex refers Initially, the mother was very angry and ini­ to mother-son relationships; Electra complex is a tiated legal action against the father. Eventually, term applied to father-daughter relationships; and however, this action was dropped and the step­ the Phaedra complex is the term applied to inces­ father was hospitalized in a psychiatric hospital for tuous relationships between children and steppar­ a period of time before being discharged on medi­ ents. cation. Plans were made for the family to begin Anthropologists and sociologists have devel­ treatment with a family counsellor. It has been a oped many theories to explain the existence of the very emotional experience for me dealing with this incest taboo.1 The anthropological viewpoint pos­ family through this crisis. I have felt somewhat tulates that incest was rare and sporadic among inadequate because of my lack of experience treat­ primitive societies because it was socially isolating ing families in which incest has occurred. and destructive. As with the Egyptian pharaohs,

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incest could be institutionalized when it seemed to she grows older.7 Upon discovery of the relation­ benefit the society. From the biological viewpoint, ship, the father frequently offers many reasons to incest was thought to be detrimental to the race. rationalize his behavior. Such fathers have been Primitive man saw a connection between incest noted to experience little personal guilt, except as and human abnormalities and therefore estab­ a reaction to the shame and disgrace that the rela­ lished rules against inbreeding. In Totem and tionship has brought onto the family.5 Taboo Freud postulated that the incest taboo The wife and mother is central to understanding arose to eliminate disruptive and competitive family dynamics. She plays a central role in pro­ forces within the family. Specifically, he thought moting the development of the relationship be­ the incest taboo was set up to prevent fathers and tween the daughter and father. The mother-wife in sons from competing for the females in the fam­ this situation is frequently described as hostile, ily.3 unloving, and frigid.8 The mother-wife has also Valid statistics on the incidence of incest in our been described as passive, submissive, and overly society are difficult to obtain. Part of this comes dependent upon her own mother.5 Frequently from the differences in reporting from state to the mother-wife has subtly or unconsciously en­ state because of differing definitions in state laws. couraged the relationship between her husband Also, it seems likely that a bias in reporting and daughter, but she denies the relationship until episodes of incest may exist, tending to favor re­ it has been discovered in some other manner. porting it when it occurs in families of lower socio­ Usually the mother-wife denies guilt and is unwill­ economic classes and covering it up when it oc­ ing to accept any responsibility for the relationship curs in higher social classes. or her contribution to it. Weinberg’s study of incest in 203 families re­ Many father-daughter incestuous relationships ported an incidence of 1.2 cases per million popu­ endure over many years. This may imply that the lation in 1910, 1.9 cases per million population in daughter passively encourages the continuation of 1920, and 1.1 cases per million population in 1930.4 the relationship. In some reported cases, the Seventy-eight percent of those were father- daughter has actually initiated the incestuous rela­ daughter incest, 18 percent were brother-sister in­ tionship. There is little written about the personal­ cest, three percent involved multiple incestuous ity of daughters because they are frequently pro­ relationships in the family, and there was only one tected by the courts so that indepth study has been percent reported as mother-son incest. In all of the difficult. Daughters from incestuous relationships mother-son relationships, either one or both of the have been found to suffer from depression, participants was psychotic. fatigue, loss of appetite, generalized pains, sleep Father-daughter incest is the most common disturbances, and in many cases have become type, and the type we are dealing with here. The sexually promiscuous after termination of the in­ fathers in such relationships have been described cestuous relationship.5 A disturbed relationship as coming from chaotic families with poor eco­ with her own mother has also been common. nomic backgrounds, and families in which there Dr. Clements will add some comments on the was little affection expressed between the family family dynamics in incestuous families. members.5 It has also been noted that such men, DR. WILLIAM CLEMENTS (Assistant Pro­ more often than not, had a disturbed relationship fessor, Marriage and Family Counselor, Depart­ with their own fathers. Fathers in a father- ment of Family Practice): The acknowledgement daughter incestuous relationship tend to have a of incest is sometimes as traumatic to the family as poor education, are frequently immature in their the actual incest itself. Discovery often brings a sexual orientation, and have a poor sexual adjust­ host of strong emotions such as fear, anger, ment. In one study of father-daughter incest, 19 of humiliation, and guilt out into the open. In addi­ 26 fathers were described as psychopaths, and 4 of tion, the family frequently has to cope with the the 26 were alcoholics.6 In such cases there is additional stress secondary to court proceedings, usually a history of criminal behavior in the father. hospitalization, and the removal of family mem­ In families with more than one daughter, the inces­ bers from the home. Thus, a descriptive analysis tuous activity frequently begins with the older of those family dynamics found in cases of incest daughter and involves each daughter in turn as refers to the situation before discovery took place,

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while treatment occurs ex post facto after every­ sample referred for psychiatric care gave a history thing is more or less out in the open. of incest. A number of interesting features from Let’s talk about three patterns of father- these families were followed up, and it was dis­ daughter incest. First, there is the pattern of indis­ covered that 14 of the 26 fathers in the sample criminate promiscuity in which incest between the were described as inadequate-psychopath.6 father and daughter is just one component of the Inadequate-psychopaths are people who have dif­ total pattern. Another pattern of incest is ficulty responding to life stresses. Other people in pedophilia where the father has a sexual interest in the study were described as aggressive young girls, including his own daughter. Another psychopaths, a type of personality that usually pattern of incest is familial incest in which the sex­ ends up in jail. Four of the men in the study were ual contact of the father is restricted solely to alcoholics. The father in this family certainly had members of the family. severe personality problems, including alco­ With the latter pattern of incest, which I think holism. About half of the fathers in this study had describes the family discussed today, the family served jail sentences for various crimes. maintains a facade of a happy family. However, In another recent review in a psychiatric journal there is noted almost always a disturbance in the in which 14 cases of incest were studied, it was sexual relationship between the parents. In addi­ reported that the father or stepfather was usually tion, the mother tends to divest herself of maternal violent, alcoholic, or both.9 In that study, the responsibilities in the home and promotes the mothers were described as chronically depressed. daughter into a role of nurturing or taking care of Depression in mothers was not discussed in the the family. This type of behavior represents a Northern Ireland study, but it was mentioned that massive denial on the part of the mother. Leading ten of the mothers were fully aware of what was up to the discovery and at the point of discovery going on and chose to remain quiet about it. Both itself, extreme guilt and anxiety are often ex­ studies stressed the patterns of the daughter as­ perienced by the daughter. This guilt is not so suming many of the mother’s responsibilities. Of much because of the existence of the sexual rela­ course, every family that exhibits this pattern of tionship, but because of the daughter’s fears of behavior is not necessarily an incestuous family. harming the family and causing it ridicule and We ought to be concerned about outcome for humiliation. individual family members and the family as a In light of these characteristics, the treatment whole. In the American study, 12 out of 14 mar­ from a counseling viewpoint would consist of: (1) riages ended in divorce or separation. In the Irish marriage counseling for the parents to restore their study 2 out of 26 marriages were ended, and in relationship; (2) therapy for the father in an at­ both the divorce occurred after the father was tempt to condition him not to be attracted to his prosecuted and jailed. There seems to be some daughter; (3) counseling for the daughter to allow difference in outcome depending on the way the her to ventilate whatever feelings she might have situation is handled. In terms of treatment, it is in regard to the incident(s) and the relationship important to consider the family unit. Will it be with her father; and (4) a meeting(s) of the entire broken up? Who is the patient under these cir­ family together to talk about the family relation­ cumstances? How will the news be broken to the ships. In summary, the family ideally has the need rest of the family? I suspect that the way the to get involved in four different types of counsel­ physician responds to these questions may de­ ing, which might take place concurrently. termine how the family will react. Will it be taken DR. REMI CADORET {Professor, Depart­ to court or will the family members seek counsel­ ments o f Family Practice and Psychiatry)-. Briefly, ing? I would like to comment on a pattern that may What happens to the daughters after this type of point to a high-risk family, which I think is present experience? One of the problems in dealing with in this situation. If one is aware of the high risk of incest is our lack of knowledge concerning long­ certain patterns, one can be a little more sensitive term outcome. We don’t know whether the out­ in picking it up. In a recent study from Northern come is better for the girls if they stay with their Ireland representing a fairly large sample of the families or whether divorce and separation is bet­ population, four percent of women and girls in the ter because they are away from the influence. In

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the Irish study, 11 of the 26 girls seemed to develop the family made many visits to the Family Practice character disorders, mainly sexual promiscuity. Center. Should the diagnosis have been made ear­ Four of them became prostitutes. All of those who lier? developed character disorders came from very dis­ DR. PEASE: All along the way it is very inter­ turbed homes with alcoholic, psychopathic fathers esting to look at the notes. There were comments and promiscuous mothers. Therefore, I don’t like, “We have to watch this family. There is think it can be said that the daughters’ problems something going on that we don’t know about.” were caused by the incestuous relationship with From my contact with the family, particularly with their father. Five girls developed frigidity and aver­ the girls and the mother, they seemed to be very sion to sexual relations after they were married. close, and it has been difficult to get information Three of them showed symptoms of hysterical from them regarding their personal relationships. personality, and frigidity and aversion to sexual DR. CLEMENTS: That is one of the char­ relations are classical symptoms of hysterical per­ acteristics of this kind of family. There is an im­ sonality. Therefore, I suspect many of them may plosion with the family energy spent back on have had hysterical personalities all along. In six the members. By way of contrast, in adolescence girls, there was no apparent long-term effect at all. one typically observes an explosion with adoles­ DR. ROBERT RAKEL (Family physician, Pro­ cents leaving the home, yet bringing all sorts of fessor and Head, Department of Family Practice)-. friends in. But in this family there is more of an Did they deal with the relationship happening implosion, with the energy directed into the fam­ again? ily. No friends are in and out of the home. The DR. CADORET: No, they didn’t deal with re­ family is isolated, and gratification takes place al­ cidivism, which is quite high and which I think most solely within the family unit. demonstrates the need for treatment for the DR. WILSON: I would like to thank our pre­ fathers and the mothers. senters and discussants for their participation, and DR. RICHARD COOK (Third Year Family thank you, the audience, for your contributions. I Practice Resident): It seems to me that the legal am distributing a list of references used in prepar­ classification of this problem is crucial to the ing our discussion and a list of articles suggested treatment. Is this really child abuse or is it a crimi­ for further reading. nal sexual offense? Which classification is more optimal for the family, and which classification is References more optimal for treatment? 1. Henderson DJ: Incest: A synthesis of data. Can Psychol Assoc J 17:299, 1972 DR. CLEMENTS: My response is that it de­ 2. Taylor GR: Sex in History. New York, Ballantine, 1954 pends on the family. If the daughter experiences a 3. Messer AA: The "Phaedra Complex." Arch Gen Psy- chiatr 21:213, 1969 lot of humiliation and degradation and has physical 4. Weinberg SK: Incest Behavior. New York, Citadel abuse connected with it, that is one thing. How­ Press, 1955 5. Sarles RM: Incest. Pediatr Clin North Am 22:633, ever, if the daughter experiences it as a time of 1975 6. Lukianowicz N: Incest I: Paternal incest. Br J Psychi- closeness, a pleasurable experience, that is, atr 120:301, 1972 perhaps, something else. Interestingly enough, the 7. Molner G, Camerson P: Incest syndromes: Observa­ tions in a general hospital psychiatric unit. Can Psychiatr studies that I have read report that the daughters Assoc J 20:373, 1975 who had the least problems were those who were 8. Cormier BM, Kennedy M, Sangowicz J: involved at the earlier ages. Those who had the Psychodynamics of father-daughter incest. Can Psychiatr Assoc J 7:203, 1962 most problems were those who experienced the 9. Browning D, Boatman B: Incest: Children at risk. Am incest near or during adolescence.1 J Psychiatr 134:69, 1977 DR. WILSON: Sometimes the mothers are really quite reluctant to press charges, especially if Additional Reading there is a threat that the father will be jailed, since Boekelheide PD: Incest and the fam ily physician. J Fam Pract 6:87, 1978 this may possibly leave the family without the Weitzel WD, Powell BJ, Penick EC: Clinical management of bread winner. The mother may prefer to see the father-daughter incest. Am J Dis Child 132:127, 1978 Kennedy M, Cormier BM: Father-daughter incest: Treat­ daughter leave the home rather than the father. ment of the family. Laval Med 40:946, 1969 DR. FORREST DEAN (Third Year Family Henderson DJ: Incest. In Sadock BJ, Kaplan HI, Freedman AM (eds): The Sexual Experience. Baltimore, Williams and Practice Resident): In retrospect, it is obvious that Wilkins, 1976

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