This paper has two objectives: to review some aspects of the law of confidentiality in the health care field and to evaluate how the law of confidentiality impacts on the processes of child protection.

The true incidence and prevalence of sexual abuse against children is difficult to ascertain. Differing sampling methods, definitions of sexual abuse and methods of information-gathering have a significant effect on the rates reported. General population studies (Morrison et al, 1994) in the USA and Europe reveal a rate between 0.7 and 1.83 per 1000 children. Data from prevalence studies (Morrison et al, 1994) highlight large differences, with rates varying from 7 to 62%; meanwhile, only between 2 and 17% of sexual assaults are reported to the police. Many of the reported offenders are not prosecuted because of difficulties with the child's statement. Some offenders are cautioned, others are charged with specimen charges or have their charges downgraded. Despite an increase in the reporting of sexual offences since the 1970s, they account for only approximately 3% of all offenders on probation and 8% of male offenders in prison even though the number and length of prison sentences for sex offenders has increased since the 1970s. Convicted female offenders remain a very small group with only 23 convicted female sex offenders in custody in 1989.

Victims of child and other forms of sexual abuse receive increasing attention and resources but it is often difficult to extend the same kind of understanding and possibilities of treatment to their perpetrators. Many of the perpetrators have been victims themselves, which is often a major reason for their having developed in such a way; sometimes the offenders are virtually children themselves (Royal College of Psychiatrists, 1994b).

Abuse is an inter-generational problem. Abusers have been damaged in childhood by abusive action perpetrated on them, usually by their parents but sometimes by other significant adults. At times, in becoming adults, the early emotional damage can manifest into psychopathological features, including perversions or paraphilias and perpetration of abuse against children.

This paper examines the complex relationship between the process of investigation and the provision of treatment in cases of child sexual abuse. Child sexual abuse is now a well-recognised and documented phenomenon, the deleterious sequelae of which have been studied, initially in survivors presenting in adulthood (Wyatt & Powell, 1989) and (more recently) during childhood (Briere, 1992; Kendall-Tackett et al, 1993). Following the recognition of sexual abuse from the accounts of adult survivors, and in order to reduce the harm caused to sexually abused children by providing earlier protection and treatment, attention began to be directed to the earlier recognition of child sexual abuse, during childhood.

The experience of sexual abuse in childhood is very common (Jehu, 1988). The highest estimate from the USA (Wyatt & Peters, 1986) suggests that 42% of girls up to the age of 17 have experienced abuse, and the best estimate from Britain (Baker & Duncan, 1985) would give a prevalence of between 12 and 20%. Mullen et al (1993) found in a general population of women in New Zealand an overall prevalence of abuse before the age of 16 of 32%, with 20% reporting genital contact and 3% penetrative sex. In the American series half of those abused (21% of the respondents) reported that the abuse was by a family member: the figure for intra-familial abuse in the British series was 14% of those reporting abuse, and thus about 3–5% of all the women who responded. There may be many explanations for the large international variations, including differences in definition, sampling and other aspects of methodology, but it is also possible that abuse is indeed more common in some countries than others.

Irrespective of whether one considers official statistics, the proliferation of clinical referrals, research initiatives, review articles or even media attention, the problem of children and adolescents who sexually abuse other children has become a subject of increased attention. Given the proportion of young abusers who are themselves victims of sexual abuse, understanding the continuities between sexual victimisation and sexually abusive behaviour has been important. Despite the paucity of reliable evidence, it is clear that the majority of children who are sexually abused do not become abusers. Moreover, we know that around half of all young abusers have not themselves been victims of abuse. This paper sets out to consider these issues and highlight potentially important factors in understanding the origins and development of sexually abusive behaviour at an early age.

This study is presented to encourage recognition and early intervention with cycles of physical, sexual and emotional abuse, both within institutions (whether the family, hospital, residential care, residential schools or penal institutions) or within the community at large.

The key messages emerging from this paper are the need for early intervention in all cases of known or suspected child abuse, and the necessity for practitioners to remain alert to the possible early traumatic origins of adult symptomatology. These clear messages are amply supported by research (Lindberg & Distad, 1985; Browne & Finklehor, 1986; Briere, 1992; Mendel, 1995; Styron & Janoff-Bulman, 1997). The paper suggests that services for both victims and perpetrators could be identified and provided much sooner if the process is started with an ‘overall statement of risk’ or risk assessment. Given the connections between child abuse, family violence and various physical, psychosomatic and emotional problems presenting to doctors in all specialities, it is clear that “The likelihood of a clinician encountering past or current abuse is overwhelming” (p. 109). The message here is that all doctors, not just psychiatrists, should be alert to the possibility of abuse in the past history or present symptomatology of their patients.

Workers in the field of learning disability drew attention to the problem of sexual abuse and learning-disabled children and adults only a decade ago (Sinason, 1986; Cooke, 1989), at the same time that British society first tolerated the knowledge that non-disabled children were being abused. Although guidelines have been produced and voluntary organisations such as the National Association for the Protection from Sexual Abuse of Adults and Children with Learning Disabilies (NAPSAC), the Association for Residential Care (ARC) and Voice UK have made vital contributions, psychiatric involvement and provision is uneven (ARC & NAPSAC, 1993).