The unheard victims

Last year saw much discussion in The Psychologist over gender and mental health. In February, Daniel and Jason Freeman claimed that women are more likely than men to develop a range of mental health disorders. Their article was countered in the March issue by Martin Seager and colleagues, who (in our view correctly) claimed that mental health problems in men are woefully underreported, resulting in the hidden mental pain of large numbers of men. We would like to add to this debate by considering one particular issue – the sexual victimisation of men and boys.

We pose some broad questions. What do we currently understand about the needs of male sexual abuse survivors? What can service providers offer as potential positive outcomes for males who have experienced sexual abuse across the lifespan? And what part does psychology as a profession have to play in helping to support such outcomes?

What we know

Historically, sexual crimes against males were considered impossible or at best rare with the result that service provision for male survivors has been considered unnecessary. Indeed, the publicity that sexual crime received as a feminist issue contributed to the isolation experienced by male survivors (Davies, 2002), although of course Lew (2004) is correct that without women's activism there would be even less support for males than already exists. In recent years the scarcity of information and lack of publicity about male sexual victimisation has slowly begun to change. In parallel there has been a shift toward increased rates of reporting of sexual offences against males. In 2002, for instance, only 4096 sexual assaults and 852 rapes were recorded as being committed against men in the UK (Davies & Rutland, 2007). In 2010/11 however, whilst police recorded rapes upon women had increased by five per cent from 2009/10 to 2010/11, recorded rapes committed upon men rose by 12 per cent during the same timescale (Osborne, 2011).

Whilst the above reporting figures may highlight efforts that legal services have taken to increase the recording of sexual crimes against males, we know that reported sexual crimes only scratch the surface of actual offences, and that there are still biases in the way that some crimes are recorded but others are not. The facts are simply that the majority of sexual abuse cases are never reported, and many survivors live with their hidden pain for life, without seeking help or professional support.  

Let's look at some figures. In a study of 40 UK male rape survivors, Walker et al. (2005a) showed that only five out of the 40 men had ever reported their rape to the police. Of the five, four claimed their dealings with the police were wholly negative, and only one case out of the five resulted in a conviction. Furthermore, post-rape medical services were utilised by only 14 out of the 40, with only five of the 14 revealing the sexual context of the assault (the others only disclosing their physical injuries). This means that most male rape survivors do not receive testing for sexually transmitted diseases that they may have contracted during their rape, and receive no follow-up support from psychological services to deal with the aftermath of their assault. Even if they do, the support they receive may be inadequate (see Burrowes & Hovarth, 2013; Foster et al., 2012; Lew, 2004; Mathews, 1996; Somerset, 2014).

In a follow-up study, Walker et al. (2005b) investigated the psychological functioning of these 40 male rape survivors compared with 40 matched controls, and found that the rape group experienced lower psychological functioning than the control sample. The average time of assault compared to time of study was 10 years, clearly showing the long-term negative psychological effects of rape upon men. Alarmingly, 19 out of this group of 40 men had attempted suicide after their rape.

Despite these long-lasting and profound psychological effects, men in general find it incredibly difficult to seek support due to their lack of willingness to approach a suitable service, or because the services available are inappropriate. Societal myths and victim-blaming attitudes, prevalent in society (see Davies, 2011, and Davies & Rogers, 2006, for reviews), significantly contribute to the stigma surrounding this type of offence and serve to act as a wall between the survivor and possible help and support.

In a recent Australian investigation O'Leary (2009) and O'Leary and Gould (2009) showed similar findings to Walker et al (2005a; 2005b), namely that sexually abused men (in this study, men abused as children) suffered a range of mental health difficulties, substance abuse and suicidality. When compared with matched controls, men sexually abused in childhood appeared four times more likely to qualify for a clinical mental health diagnosis, and 10 times more likely to qualify for a diagnosis of post-traumatic stress disorder (PTSD).

For male survivors, societal expectations about the male gender role and the concept of male (hetero-) sexuality impacts significantly on men's understanding of what sexual victimisation means to them. This results in many male survivors questioning their gender identity after sexual abuse (Walker et al., 2005a; see also Davies et al., 2010). Males blame themselves both for not stopping the abuse from happening and for struggling with the aftermath, because 'as men they should be able to cope'. The sense of not living up to the masculine ideal of being strong, tough and able to protect oneself from adversity makes men who have been sexually abused unlikely to seek help due to their fear of ridicule and blame (Dorahi & Clearwater, 2012; Lee & James, 2012; Lisak, 2005).

Complex trauma

Although not officially recognised in diagnostic classification by DSM-5, the term 'complex trauma' as used in this article describes a broad-ranging set of disorders, symptoms and social problems that are not captured by a limited diagnostic category of PTSD. The DSM-5 now notes that PTSD 'may be especially severe or long-lasting when the stressor is interpersonal and intentional (e.g. torture, sexual violence)' (APA, 2013, p.275), which goes some way to describing the complexity of the long-lasting traumas that sexual abuse survivors face. It does not, however, cover the broader issues relating to, for example, long-term social problems that many male survivors contend with. We argue that the blaming and disbelief of the male survivor experience deepens trauma of the original abuse experience, whilst serving to isolate him from the world. Sarbin (1986) posits that self-narratives support human identity, and, without a story that is transparent, survivors experience a sense of detachment from the world around them. In short, he is unheard.

For many survivors, sexual abuse was not just a one-off event. Repeated trauma caused by ongoing sexual abuse, or victimisation experiences that occurred at different times through life, create a prolonged and profound set of problems that readily cause multiple social and mental health issues, such as depression, addictive and self-harming behaviour, substance abuse and dissociative and personality disorders (Wall & Quadara, 2014). Further, re-victimisation is likely to compound the effects of prior abuse experiences (e.g. Briere & Jordan, 2004), the strength and complexity of which is not covered in the PTSD diagnosis.

Service provision

Judith Herman, in her seminal work Trauma and Recovery (1997), argued that some violations are too terrible to tell; and for many, the 'unspeakable' is still present and impacting upon their mental well-being. We argue that current service provision has largely failed to address the complex needs of male survivors. All sufferers of complex trauma need a multifaceted, varied and specialist approach. Harvey et al. (in McMackin et al., 2013) note that models of complex PTSD and an ecological approach support recovery in trauma survivor populations. The negative effects on mental health that sexual victimisation can cause are readily acknowledged by professionals, but isolated treatment of particular symptoms may not resolve the underlying and deep-seated issues caused by sexual abuse (Wall & Quadara, 2014). Indeed, some survivors spend years and thousands of pounds in intensive psychotherapy working on issues relating to the complex trauma associated with sexual abuse (Bird, 2014). Although we know current service provision is not meeting the needs of people with complex trauma, up to now in the UK there has been no consistent approach to guiding services to become more responsive to complex trauma.

Whilst current policy in the UK highlights the importance of integrated services for abuse survivors, there is ongoing debate about how these broad policy objectives can be achieved in practice (see Devaney & Spratt, 2009). Improving the effectiveness of service provision for people with multiple needs would create enormous benefits for survivors and also save in economic terms. Recent Social Return on Investment (SROI) research carried out by the Zurich Community Trust with a male survivor-led agency (Survivors Manchester: see Somerset, 2014) clearly evidenced the possible economic, as well as psychological, outcomes from integrated service models. However, this requires the implementation of person-centred – indeed, survivor-centred – systems that provide the array of services necessary to deal with the social and health aspects of complex trauma. In relation to male sexual abuse survivors, this seamless combination of service provision does not exist at the moment. To enable this, services could build on and adapt existing models used with female survivors.

The elephant in the room – gendering of sexual abuse

We began this article by supporting the argument made by Seager and colleagues (2014) that mental health problems in men are woefully underreported, and their effects often not considered, compared with those of women. We see a similar situation in relation to sexual abuse, such that men's abuse is underreported, underresearched, and underprovisioned. Davies (2002) claimed that research and provision for male sexual abuse was, over a decade ago, many years behind that of female sexual abuse, and today, regrettably, the situation appears much the same in many areas.

We are in no way saying that sexual abuse is worse for men than for women, rather that male responses are often different from females ones. For example:
I    in children, boys are less likely to disclose at the time sexual abuse occurs than girls (e.g. O'Leary & Barber, 2008);
I    men typically disclose being sexually abused in childhood 10 years later than women – on average 22 years after the assault (O'Leary & Barber, 2008; O'Leary & Gould, 2009);
I    men are one-and-a-half times less likely than women to report adult sexual assault to the police (Pino & Meier, 1999; although we have seen recent improvements on this situation in the UK); and
I    men make fewer and more selective disclosures than women (Hunter, 2011).

Such differences mean that specific services are needed for men. World Health Organization research (2007) shows that gender-neutral approaches in supporting change in men's health and well-being are less successful than gender-informed ones. Gendered approaches are needed, directly addressing issues relating to men's life, such as how cultural practices influence gender scripts and shape men's and women's experiences.

The research of Joseph (2012) offers us one possible point to begin psychological debate in how we might support male victims. Joseph describes a model for self-help called THRIVE, part of which we believe is especially important for survivors: 'Re- Authoring'. This refers to listening to the stories the survivor tells himself in order to find new ways of looking at surviving. This model works especially well when male survivors are given support to explore them which hears and honours them as both male and survivor.

In general, fostering better coping in male survivors is the key here. Coping is a dynamic, complex process (O'Leary & Gould, 2010), and what we already know about men's continued well-being could be used to foster better coping along the lines of Joseph's THRIVE model. Specifically, we know the following factors that are correlated with men's enhanced well-being (see also Foster et al., 2012 for further details):
I    Practical information and assistance. Working to develop concrete life skills that address the impact of sexual abuse, exploring feelings and learning to tolerate emotional distress (O'Leary & Gould, 2010).
I    Talking with someone who is supportive. This may be a work colleague, partner or friend (O'Leary & Gould, 2010).
I    Talking with someone who encountered a similar event. Men's well-being is enhanced not just through receiving support but through having the opportunity to support and help others (Kia-Keating et al., 2010; O'Leary, 2009).
I    Developing a sense of hope, positive reinterpretation and growth. Practising optimism, self-understanding, viewing survival and life accomplishments in a positive manner (O'Leary & Gould, 2010; Joseph, 2012).

The problems men experience after sexual abuse can manifest in all areas of their lives, in interpersonal relationships, parenting, employment, and social and leisure activities, and at different points throughout the life span (O'Leary & Gould, 2009). Consequently, it is important that services are flexible enough to respond to a wide range of issues, not just focused around mental health and sexual assault services.

Where we could go

Current service providers struggle to reach out to men. We now need to strengthen existing resources and open up new pathways to encourage and enable male survivors to seek the help that they have denied themselves previously. Academically and practically we can do more to understand men's reluctance to access services that are currently available. The current raft of sexual violence inquiries and trials sparked by 'Operation Yewtree' offer an opportunity to explore what has previously been 'unspoken'.

There is no doubt that delivering services to male survivors is a major challenge, and with a changing economic and structural climate, such challenges often seem insurmountable. But within change is often the opportunity to innovate. For example, the increasing development of the web has allowed platforms like Big White Wall (www.bigwhitewall.com), and Psychology OnLine (www.psychologyonline.co.uk) to be explored. Such platforms could be adapted to deliver support for male survivors, therefore allowing them to avoid having to enter public spaces to receive therapy and support (Craig, 2010). Internet provision can also be combined with group work within the community. For example, Living Well and 1 in 6 Canada (www.livingwell.org.au and www.1in6.ca) will publish a ground breaking manual on conducting male sexual violence therapy groups this year.

Still underlying the issue of male survivorhood is the cultural belief that men should be strong and resilient and not call out for help – however badly they need it. Psychology is a profession that more than any other holds the possibility in our view of being skilled, open and disciplined enough to focus on supporting sexual violence survivors. The dividends for the profession, society and especially survivors could be profound. But all stories need listeners to make them good ones – the unheard are watching to see if we are ready to hear their stories and help them re-author, not just the endings, but the tone of the story itself.

Michelle Lowe
University of Bolton [email protected]

Bob Balfour
Survivors West Yorkshire Bradford, Yorkshire [email protected]

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: Fifth edition. DSM- 5. Arlington, VA: American Psychiatric Publishing.
Bird, J. (2014). Rationale for personal growth and education course in prisons: The 'Way Out' course. NAPAC: Unpublished manuscript.
Briere, J. & Jordan, C. (2004). Violence against women: Outcome complexity and implications for assessment and treatment. Journal of Interpersonal Violence, 19(11), 1252–1276.
Burrowes, N. & Hovarth, T. (2013). The rape and sexual assault of men: A review. London: Survivors UK.
Craig, D. (2010). Virtually helping? An exploration of the use of the internet and online resources by adult male survivors of childhood sexual abuse. Unpublished master's dissertation, University of Manchester.
Davies, M. (2002). Male sexual assault victims. Aggression and Violent Behaviour, A Review Journal, 7, 203–214.
Davies, M. (2011). Perceptions of male sexual assault: A review. Forensic Update. 102, 22–29.
Davies, M. & Rogers, P. (2006). Perceptions of male victims in depicted sexual assaults. Aggression and Violent Behaviour, A Review Journal, 11, 357–367.
Davies, M. & Rutland, F. (2007). Male rape: The scope of the problem. Forensic Update, 89, 29–32.
Davies, M., Walker, J., Archer, J. & Pollard, P. (2010). A comparative study of long-term psychological functioning in male survivors of stranger and acquaintance rape. Journal of Aggression, Conflict and Peace Research, 2(4), 25–33.
Devaney, J. & Spratt, T. (2009). Child abuse as a complex and wicked problem: Reflecting on policy developments in the United Kingdom in working with children and families with multiple problems. Child and Youth Services Review, 31(6), 635–641
Dorahi, M.J. & Clearwater, K. (2012). Shame and guilt in men exposed to child sexual abuse: A qualitative investigation. Journal of Child Sexual Abuse, 21, 155–175.
Foster, G., Boyd, C. & O'Leary, P. (2012). Improving policy and practice responses for men sexually abused in childhood. Australian Centre for the Study of Sexual Assault. Retrieved 1 December 2014 from www.aifs.gov.au/
acssa/pubs/wrap/wrap12
Freeman, D. & Freeman, J. (2014). The stressed sex. The Psychologist, 27(2), 84–87.
Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.
Hunter, S.V. (2011). Disclosure of child sexual abuse as a life-long process: Implications for health professionals. Australian and New Zealand Journal of Family Therapy, 32(2), 159–172.
Joseph, S. (2012). What doesn't kill us: The new psychology of post-traumatic growth. Bodmin: Piatkus.
Kia-Keating, M., Sorsoli, L. & Grossman, F.K. (2010). Relational challenges and recovery processes in male survivors of childhood sexual abuse. Journal of Interpersonal Violence, 25(4), 666–683.
Lee, D. & James, S. (2012). The compassionate mind approach to recovering from trauma using compassion focused therapy. London: Robinson.
Lew, M. (2004). Victims no longer: The classic guide for men recovering from sexual child abuse (2nd edn). New York: Harper.
Lisak, D. (2005). Male survivors of trauma In G.E. Good & G.R. Brooks (Eds.) The new book of psychotherapy and counselling with men (Revised & abridged edn) (pp. 47–158). San Francisco: Jossey-Bass.
Mathews, F. (1996). The invisible boy: Revisioning the victimization of male children and teens. Ottawa: National Clearinghouse on Family Violence, Health Canada. Retrieved 1 December 2014 from www.canadiancrc.com/PDFs/
The_Invisible_Boy_Report.pdf
McMackin, R.A., Newman, E., Fogler. J.M. & Keane, T.M. (Eds.) (2012). Trauma therapy in context. Washington, DC: American Psychological Association.
O'Leary, P.J. (2009). Men who were sexually abused in childhood: Coping strategies and comparisons in psychological functioning. Child Abuse & Neglect, 33(7), 471–479.
O'Leary, P.J. & Barber, J. (2008). Gender differences in silencing following childhood sexual abuse. Journal of Child Sexual Abuse, 17(2), 133–143.
O'Leary, P.J. & Gould, N. (2009). Men who were sexually abused in childhood and subsequent suicidal ideation: Community comparison, explanations and practice implications. British Journal of Social Work, 39(5), 950–968.
O'Leary, P.J. & Gould, N. (2010). Exploring coping factors amongst men who were sexually abused in childhood. British Journal of Social Work, 40(8), 2669–2686.
Osborne, S. (2011). Violent and sexual crime. In R. Chaplin, J. Flatley & K. Smith (Eds.) Crime in England and Wales 2010/11: Findings from the British Crime Survey and police recorded crime (2nd edn). Retrieved 1 December 2014 from www.gov.uk/
government/uploads/system/uploads/attachment_data/file/116417/hosb1011.pdf
Pino, N.W. & Meier, R.F. (1999). Gender differences in rape reporting. Sex Roles, 40(11/12), 979–990.
Sarbin, T.R. (Ed.) (1986). Narrative psychology: The storied nature of human conduct. New York: Praeger.
Seager, M., Morison, L., Wilkins, D. et al. (2014). The hidden pain of men. The Psychologist, 27(3), 138–139.
Somerset, A. (2014). Social return on investment. Survivors Manchester. Retrieved 1 December 2014 from tinyurl.com/mhcb7t4.
Walker, J., Archer, J. & Davies, M. (2005a). Effects of rape on male survivors: A descriptive analysis. Archives of Sexual Behavior, 34, 69–80.
Walker, J., Archer, J. & Davies, M. (2005b). Effects of male rape on psychological functioning. British Journal of Clinical Psychology, 44, 445–451.
Wall, L. & Quadara, A. (2014). Acknowledging complexity in the impacts of sexual victimisation trauma. Australian Centre for the Study of Sexual Assault. Number 16.
World Health Organization (2007). Engaging men and boys in changing gender-based inequity in health: Evidence from programme interventions. Geneva: Author.