Improving policy and practice responses for men sexually abused in childhood

Overview

A significant number of men in Australia are victim/survivors of child sexual abuse. While a growing number of services offer therapeutic support and counselling for men, the issue of men's sexual victimisation has not become a public policy issue. It is suggested that conceptualising and responding to male sexual victimisation as a public health issue, will help to improve community responses to men and their families.

Key messages

Although there is a growing body of evidence and research on male victim/survivors of child sexual abuse and its impacts, it has not yet become the subject of a considered public policy interventions.
A public health approach that taps into learning from work with female victim/survivors and recent men's health strategies offers a framework for action that has the potential to assist male victim/survivors of child sexual abuse.
Male victim/survivors of sexual victimisation are a diverse group with diverse needs. Evidence suggests that in order to support healing and recovery it is necessary to create gender appropriate services and interventions that:

reach out and engage men;
address barriers to men's help seeking;
assist men and their families to build supportive relationships;
provide opportunities for group support; and
develop public discussions that offer hope for an improved future.

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Introduction

Child sexual abuse is a well-recognised problem, with substantial evidence indicating many of those victimised experience deleterious effects as adults. It is recognised as a gendered crime, with girls more likely to be subjected to sexual abuse than boys and men representing the overwhelming majority of those perpetrating abuse. Acceptance of the extent and veracity of this problem, as well as awareness of the long-term impacts of sexual trauma, has primarily arisen because of the political and social action by the women's movement over the last 30 or more years. Consequently, most practice and policy initiatives have reflected a primary focus on responding to women as survivors of sexual abuse. Nevertheless, there is now a growing research and knowledge base on both the long-term impacts on men of childhood sexual abuse and on the importance of developing ways to moderate these negative outcomes.

In this Wrap, we discuss improving policy and practice responses to men sexually abused in childhood. A gender analysis is utilised in presenting key aspects of the current research knowledge on the extent and impact of child sexual abuse on men, on barriers to disclosure and on men's preferred methods of coping. In examining service development, we suggest the issue benefits from being conceptualised at a macro level as a public health concern, drawing upon the learning of women's initiatives and recent men's health strategies in ways that attend to diversity. This public health approach is useful in that it emphasises the importance of creating comprehensive and targeted awareness campaigns, supported by the enhancement of practitioner knowledge and skill to ensure appropriate responses at first contact, and at specialist and mainstream services. In noting current interest in improving service responses to men in Australia, we present evidence that highlights the importance of building connections, of actively reaching out and engaging men, of encouraging group work options, of supporting partners and enhancing relationships, and prioritising hope.

Reflexive gender analysis

Our interest is in developing a reflexive style of enquiry, acknowledging that the process of researching and recounting is not a mere account of what is already there, but plays a part in shaping understanding, options, identity, and life possibilities (Marcus, 1992). In focusing on developing gender appropriate services for men sexually abused in childhood we avoid the use of identity categories (e.g., victim/survivor, heterosexual/homosexual) with their propensity to become labels that invisibilise gender and produce singular constraining accounts of people's lives (Alcoff & Gray, 1993; Jagoes, 1996). We do not presume to speak here for all men sexually abused in childhood, to suggest an essential masculine quality, or to suggest homogeneity amongst men in relation to lived experiences and access to resources (Connell, 2002). A gender analysis is adopted in recognition that in our society gender influences who is subjected to sexual abuse and assault, where and in what ways; how sexual abuse is experienced; what are a person's likely responses; ways of managing and subsequent impact on self and a person's help seeking behaviour; and the support available to them and what responses are effective. This gender analysis accepts and goes beyond identifying sexual assault as a "gendered crime", where an emphasis is primarily on acknowledging the reality that sexual violence is a crime overwhelmingly committed by men against women and children. In adopting a gender analysis there is a deliberate avoidance of a gender rights position that advocates services for men in ways that can accentuate the gender divide and create an unnecessary competitive approach towards services development. Whereas, a gender analysis acknowledges there are both similarities and differences in men's and women's experiences of sexual violence and that there is a need to create responsive, evidence-based policy initiatives and service provision that recognises, but does not amplify these, given we know that:

Many of the experiences of re-traumatization which adult survivors encounter with services are the result of misrecognition of their experience or needs, and both denial of the relevance of gender and exaggeration (through reliance on stereotypes). (Hooper & Warwick, 2006, p.473)

Male child sexual abuse

Prevalence and effects

Basic statistics

In 2002, Davies identified that research into the sexual assault of males and its subsequent impacts was over 20 years behind research that examined the sexual assault of females, however there is now a developing body of knowledge that can be drawn upon to inform service provision. Research suggests that:

between 1 in 6-10 males are sexually abused whilst under the age of 16 years (Dube et al., 2005; Dunne, Purdie, Cook, Boyle, & Najman, 2003);
over 30% of confirmed reports of child sexual abuse involve male victims (Fergusson & Mullen, 1999);
most sexual abuse of males happens when adolescent or pre-adolescent (Gonsiorek, Bera, & Le Tourneau, 1994);
80% of childhood sexual abuse of males is perpetrated by males (Dube et al., 2005);
males are more likely than females to be subjected to clergy abuse as children and prison based sexual violence as adults (Heilpern, 1998; John Jay College of Criminal Justice, 2004; Mariner, 2001; Parkinson, Oates, & Jayakody, 2009; Yap et al., 2011); and
the risk of sexual assault declines for adult men relative to adult women (Australian Bureau of Statistics [ABS], 2006; Dal Grande et al., 1999).

Although there are no exclusive circumstances in which boys are abused, research indicates that boys are more likely than girls to be abused outside the home, subjected to extra-familial abuse (Ogloff, Cutajar, Mann, & Mullen, 2012), abused around witnesses, and be abused by strangers (ABS, 2006; Crome, 2006). The developing body of knowledge emphasises the situational and contextual nature of sexual abuse where some boys and men, more than others, are targets of sexual abuse or sexual assault. Vulnerability is situational, it should not just be seen as a personal characteristic. Risk of sexual abuse escalates if a boy is homeless, has a learning or physical disability, is subjected to other forms of maltreatment in the home, comes from an impoverished and/or single-parent family, is same-sex attracted, or has spent time in a hospital or institutional setting (Crome, 2006; Mitra, Mouradian, & Diamand, 2011).

Effects

Sexual abuse is something done to someone, not a diagnosis, characteristic, essence or something a person is. (Anderson, 2008, p. 56)

There is no prescribed way that people are affected by sexual abuse or assault; everyone is different. However, we do know childhood sexual abuse can have profound effects. In comparison with men in general, men who have experienced childhood sexual abuse disproportionately report:

depression/anxiety;
intense emotions/anger;
flashbacks/nightmares;
overwhelming shame/guilt;
decreased appetite and weight loss;
suicidality/self harm;
sexual difficulties;
relationship difficulties;
sleep difficulties; and
mental health problems (Banyard, Williams, & Siegel, 2004; Tewkesburg, 2007).

There is a growing consensus that the effects of childhood sexual abuse are best understood as characteristic of complex trauma. Identifying the impacts of childhood sexual abuse as complex trauma is important, because, whilst having many similarities to acute trauma (e.g., natural disasters), the occurrence of trauma at a critical developmental period can significantly impact on sense of self, safety, and trust in adult life - especially when perpetrated by a trusted caregiver or family member (Curtois & Ford 2009, van der Kolk 2005). Understanding the complexity of the effects of this trauma is important to enable professionals to respond appropriately.

The most comprehensive Australian study to date (O'Leary, 2009; O'Leary & Gould, 2009) identified that men who have been subjected to child sexual abuse are vulnerable to a range of mental health difficulties, increased substance abuse, and suicidality. When compared to a community comparison group, men sexually abused in childhood are four times more likely to qualify for a clinical diagnosis, and some 10 times more likely to qualify for a diagnosis of post-traumatic stress disorder (PTSD). These findings are consistent with numerous studies showing a significant over-representation of adults with histories of childhood sexual abuse amongst clinical mental health populations (Nurcombe, 2000; Olgoff & Cutajar, 2009). In addition, in amongst clinical populations, there is some evidence to suggest that men subjected to sexual abuse exhibit a greater propensity for externalising behaviours (e.g., aggression and excessive risk taking), whereas women who have been sexually abused exhibit internalising behaviours (e.g., guilt and depression) (Romano & De Luca, 2001).

Suicide

We know that whilst Australian men are significantly more likely than women to commit suicide, both women and men who have been subjected to childhood sexual abuse report higher rates of suicidality than the general population (Spokas, Wenzel, Stirman, Brown, & Beck. 2009). Evidence suggests that men sexually abused in childhood are particularly vulnerable to suicide, reporting suicidal ideation at 10 times the rate of a community sample of Australian men; 46% of these men reporting at least one attempted suicide (O'Leary, 2009; O'Leary & Gould, 2009). Recent publicity (McKenzie, Baker, & Lee, 2012) detailing the death by suicide of 34 men sexually abused as schoolboys by two men in Victoria, graphically highlights the impact of sexual abuse on men's lives, as does the below comment from a 25 year old man:

I tried to knock myself off about three times … OD'd twice, slashed my wrists once, yeah, woke up in hospital and all that sort of sh_t … f_ck, can't even get that right! So it's the first thing I thought - can't even do this f_ckin' right - so that was a bit of a spin-out. (O'Leary, 2010, p. 959)

Although steps are being taken to address the problem of men and suicide - with initiatives such as Promoting Good Practice in Suicide Prevention: Activities Targeting Men (Department of Health and Ageing [DoHA], 2008) - men sexually abused in childhood are not recognised as a group requiring specifically targeted interventions (Department of Health, 2010). Factors that have been shown to increase the suicidality of these men and that can inform development of future targeted initiatives are: feeling isolated and alone; acting violently and aggressively; blaming themselves for the abuse; using alcohol and drugs; feeling fearful and anxious; along with a loss of hope (O'Leary & Gould, 2009; Spokas et al., 2009).

Barriers to men's disclosure

Considerable efforts are required in Australia to educate men to come forward after sexual assault, with "more publicity is needed to dispel the myths about male sexual assault". (KPMG, 2009, p. 37)

A particular challenge in seeking to provide helpful information to men and support more helpful ways of coping is that men are very reluctant to disclose child sexual abuse (or adult sexual assault). Research indicates that:

a majority of men who have experienced childhood sexual abuse have not told anyone (Holmes & Slap, 1998);
boys are less likely to disclose at the time sexual abuse occurs than girls (O'Leary & Barber, 2008; Paine & Hansen, 2002);
men typically disclose being sexually abused in childhood 10 years later than women - on average 22 years after the assault (Holmes & Slap, 1998; O'Leary & Barber, 2008; O'Leary & Gould, 2009);
men are one-and-a-half times less likely than women to report adult sexual assault to police (Pino & Meier, 1999); and
men make fewer and more selective disclosures than women (Hunter, 2011).

In seeking to better understand and address men's limited disclosure and help seeking we are required to look beyond the stigma associated with sexual abuse itself and the power exercised through threats, coercion, blame etc., and the "silencing" effects of fear, confusion and shame (Dorahi & Clearwater 2012). Interviews with men identify a reluctance to disclose sexual abuse out of concern that they will be treated differently, and will receive limited or inadequate responses (O'Leary & Barber, 2008). Men report that their disclosure of abuse is heavily influenced by dominant masculine stereotypes, questions related to sexuality, and uncritical acceptance of the idea that male victims will become perpetrators of abuse (Sorsoli, Kia-Keating, & Grossman, 2008; Washington, 1999).

Masculinities

I'm not telling nobody that it happened to me, because that makes me weak. That makes me less than a man. (Sorsoli et al., 2008, p. 341)

We know that dissonance between male role expectation and the experience of victimisation impacts significantly on men's understanding and can have men questioning their whole gender identity (O'Leary, 2001, p. 84). Limited ideals of manhood compound problems for men, in that men both blame themselves 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 "failure as a man" that sexual abuse can feed into makes men less likely seek help, leading to increased isolation and its accompanying problems (Lisak, 2005).

Men may (often correctly) assume that to disclose sexual abuse would be to open him to ridicule or stigmatisation (Yarrow & Churchill, 2009). In this scenario, keeping quiet becomes configured as a way of looking after oneself. It also fits with the gender training men receive growing up to put up with discomfort and wait until difficulties impact on day-to-day functioning before acting (White & Johnson, 2000; Wilhelm, 2009). Our experience working with men sexually abused in childhood, and evidence from Kia-Keating, Grossman, Sorsoli, and Epstein (2005), suggests that in order to come forward and speak up about sexual abuse, men need reassurance that they will be believed, taken seriously, and not evaluated against normative masculine expectations. Unless these expectations are actively challenged, men have little reason to think they will receive a supportive response.

Sexuality

Homophobia (personal and public) acts as a major inhibitor of men disclosing child sexual abuse and seeking any form of assistance (KPMG, 2009). Questions relating to sexual identity produce unnecessary confusion and move attention away from the use of violence, manipulation, coercion and the offensive nature of the crime of sexual abuse. If a man was sexually abused by a man he may be concerned that people will think he is gay, and discriminate against him, or if he was abused by a woman that people will not take his complaints seriously, and think he should be okay about it (Teram, Stalker, Hovey, Schachter, & Lasiuk 2006). Personal concerns with questions of sexuality often trouble men, even if they have never previously experienced sexual interest in another man (Foster, 2005). Individual men themselves may not have negative attitudes towards homosexuality, but are aware that men identified as anything other than heterosexual, face discrimination, harassment and abuse.

Gay-identifying and same-sex attracted men face the doubly silencing effects of stigma surrounding child sexual abuse and homophobia (Lew, 2004). Here, difficulties become compounded by societal denigration of same-sex relationships. Personal distress and reluctance to speak about abuse is only added to by suggestion of a supposed link between sexual abuse and "damaged" sexuality (O'Dell, 2003). Unfortunately, there is insufficient room to detail in anything but a cursory way, the extent to which questions of sexuality produce distress and silence men subjected to sexual abuse.

Uncritical promotion of the idea that male sexual victimisation leads automatically to perpetration

A significant barrier to men seeking support and accessing services is the suggestion that a boy who experiences child sexual abuse is likely to go on to perpetrate abuse. Unfortunately the "automatic" route from victim to perpetrator is often uncritically reproduced in the media cited in the context of working to prevent sexual abuse. Whilst recognising it is always important to intervene to stop abuse, it is also important to be aware that research has found that most males sexually abused in childhood (95%) do not become sexual offenders (Ogloff et al., 2012), but particular experiences and patterns of childhood behaviour additional to sexual abuse are associated with an increased risk of offending (Richards, 2011; Salter et al., 2003).

Despite the fact that there is no straight forward, causal pathway from victimisation to offending, the "cycle myth" continues to circulate and has a profound impact on men's lives, leading to men monitoring and viewing themselves in negative ways, stopping men from participating in relationships, parenting or working with children (Ouellette, 2009). Greater education would assist service providers to put this concern into perspective and help remove this complex barrier to disclosure and help seeking (See Boyd & Bromfield, 2006; Living Well, 2012).

Methods of coping

Men are tough. Men are macho. Men don't need help. All we have to do is "get over it - be a man!" You know, men don't cry, men don't eat quiche either! [laughs] It's sad, very sad. (Teram et al., 2006, p. 509)

Men adopt a variety of methods of coping with sexual abuse, some of which have been identified as helpful, some unhelpful. Coping is best understood as a dynamic, often complex process, not simply a static pathway from not coping through to coping well (O'Leary & Gould, 2010). The following quote from a gay-identifying man highlights the complexity of this process:

I don't always use protection, and that's just like, oh well, I want to feel the whole thing and I don't give a damn what the repercussions are. But in actual fact, if I'm not in that frame of mind, I do give a damn, but because of the abuse … It almost feels like I'm a bit of a perpetrator on myself in a way - who gives a f_ck about me? … And I relate this to the abuse, definitely. (O'Leary & Gould, 2010, p. 2674).

The problems men experience can manifest in all areas of their lives, in interpersonal relationships, parenting, employment, social and leisure activities and at different points throughout the life span (Alaggia & Millington, 2008; O'Leary & Gould, 2009). Consequently, it is important that knowledge about men's experiences of sexual abuse and ways of responding is available in a range of service settings, not just mental health and sexual assault services. For example, it is useful that human service professionals are aware that drug and alcohol misuse is the most preferred method of coping amongst men sexually abused in childhood, in order to develop appropriate referral processes and support strategies (O'Leary, 2009).

Factors that have been found to impact on men's coping is the severity of sexual abuse (physical injuries, number of incidents, duration, number of perpetrators, and relationship to perpetrator) and how disclosure is handled by family or friends (O'Leary, Coohey, & Easton, 2010; O'Leary & Gould, 2009). Although we might hypothesise that disclosure is more likely to be associated with a better outcome, if the response is inappropriate or not protective it can result in increased difficulties (O'Leary et al., 2010). Coping strategies that have been identified as unhelpful and predictive of clinical diagnosis are suppression, withdrawal, anger, denial and acceptance (that "this is my lot in life") (O'Leary, 2009). Factors that are correlated with men's enhanced wellbeing are:

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).
Talking with someone who is supportive. This may be a work colleague, partner or friend (O'Leary & Gould, 2010).
Talking with someone who encountered a similar event. Men's wellbeing is enhanced not just through receiving support but through having the opportunity to support and help others (Grossman, Sorsoli, & Kia-Keating, 2006; Kia-Keating, Sorsoli, & Grossman, 2010; O'Leary, 2009).
Developing a sense of hope, positive re-interpretation and growth. Practicing optimism, self-understanding, viewing survival and life accomplishments in a positive manner (O'Leary & Gould, 2010; Wolin & Wolin, 1993).

Service development

Development of services for men sexually abused in childhood

It is now accepted that "services for victim/survivors of sexual assault form an essential component of the effort to provide an adequate response to sexual violence in Australia" (Astbury, 2006, p. 1) and that gender is a significant factor influencing models of intervention and service provision (World Health Organization [WHO], 2004). Women's experiences of sexual abuse and sexual assault have been central to the development of service responses since the 1970s, when rape became the focus of the feminist movement and services were initiated, developed and run by women for women (initially with no or little government funding). It is understandable therefore that service development in the 1980s and early 1990s emphasised support for the "female victim", as the identified client, whether sexually abused in childhood or sexually assaulted as an adult. In more recent times these efforts have coalesced into advocating a cross-government fully coordinated public health approach to addressing problems of sexual violence (See National Framework for Sexual Assault Prevention, Office for the Status of Women, 2004), culminating in The National Plan to Reduce Violence Against Women and Their Children (Council of Australian Governments [COAG], 2010). The National Plan outlined a comprehensive framework for support and assistance, emphasising the following strategies:

Strategy 4.1: Enhance the first point of contact to identify and respond to needs.
Strategy 4.2: Support specialist domestic violence and sexual assault services to deliver responses that meet needs.
Strategy 4.3: Support mainstream services to identify and respond to needs.

Whilst these strategies would provide an excellent framework for improving responses to men sexually abused in childhood, to date, initiatives to assist these men have not been the subject of such focused policy considerations or political activism. Men sexually abused in childhood are in a policy limbo. On occasions they are identified as a group requiring assistance, however as a specific group requiring recognition and support, they are absent from many policy documents and initiatives responding to sexual abuse and sexual assault (COAG, 2010; Foster, 2005).

In naming the current policy gaps, we do not suggest that the need to recognise male sexual victimisation and develop gender appropriate services for men subjected to child sexual abuse has not been the subject of considerable comment - often by women practitioner/researchers (Crome, 2006; Davies, 2002; Donnelly & Foster, 2005; Kenyon, 1996; O'Leary, 2001; Washington, 1999; Worth, 2003). The National Standards of Practice Manual for Services Against Sexual Violence (National Association of Services Against Sexual Violence, 1998) clearly identified a "need for more detailed standards for working with male victim/survivors" and that "such standards would need to address some unique issues faced by male victims and the implications for practice" (p. vii). The Review of Queensland Health Response to Adult Victims of Sexual Assault also noted that: "nationally sexual assault services for males are not comprehensive, and service access by males is very poor" (KPMG, 2009, p. 37). Internationally, "compared with females, recognition of male victims is seen as a relatively new discovery, and attitudes to service delivery needs and other responses can be uninformed and indifferent" (Hooper & Warwick, 2006, p. 473).

Availability of services to assist men sexually abused in childhood is currently fragmented, with service access determined by which state or territory you are in, where you are in that state, and often influenced by whether a particular practitioner or "champion" has taken an interest in the issue. For example, in Victoria, since the 1970s, South Eastern Centre Against Sexual Assault (SECASA)¹ have provided support to men as well as women. In the ACT, in 2000, Canberra Rape Crisis supported the development of Service Assisting Male Survivors of Sexual Assault (SAMSSA), now operating out of the same premises. In Queensland, funding for non-government sexual assault services is at present focused on supporting women aged 15 and over, with some sexual assault services in regional areas offering counselling for men.

To date, the process of including men in established sexual assault services that were originally designed to assist women (sexually assaulted as an adult or child) has produced tension and concern that the realities of sexual violence being a "gendered crime", requiring a gender appropriate response, will be lost through adoption of a gender neutral approach (Worth, 2003). However, adoption of a gender neutral approach would be counter to recent policy initiatives and research that highlight the importance of considering the role of gender in health outcomes and developing more responsive and effective services.

Men's health strategies

In 2010, the Federal Government introduced the National Male Health Policy and the National Women's Health Policy that clearly identified gender as a primary consideration in understanding health and wellbeing and the importance of developing effective, appropriately targeted service responses (DoHA, 2010). We suggest the knowledge and intervention strategies developing in relation to men's health can be drawn upon to enhance services for men subjected to child sexual abuse, forming an essential piece of the jigsaw to better understand men's responses to child sexual abuse. Reference to men's health strategies allows us to work through how gender and sexual abuse interact to impact on men's health and wellbeing, and to identify effective intervention strategies.

The focus on men's health and wellbeing in general is valuable in that it situates the problems of sexual abuse of boys/young males within the broader community context and creates the opportunity for more expansive and effective targeting of responses. Although the National Men's Health Policy does not recognise the health costs of men's experiences of sexual abuse, Priority Area 3 emphasises the importance of a life course approach and to adapt services to different populations: to "develop and deliver health related initiatives and services taking into consideration the needs of Australian males and different population groups of males, in different age groups and during key transition points in the life course" (DoHA, 2010, p. 19). Similarly, while The Victorian Men's Health Strategy 2010-2014 (Department of Health, 2010) does not prioritise initiatives to address childhood sexual abuse or recognise it as a possible risk factor for suicidality, it does foreground a need to: "ensure services typically oriented towards females in areas such as parenthood, sexual assault and intimate partner violence are also able to meet the needs of male clients" (p. 38).

Attending to diversity

In developing service provision, it is a mistake to see men subjected to sexual victimisation as an homogenous group. There is considerable diversity in experience and access to resources and as National Men's Health Policy Priority Area 3 (DoHA, 2010) stated, developing initiatives will need to be adapted to reach out, engage and assist different groups of men. As Connell (2005) noted:

… gender is a way of structuring social practice in general, not a special type of practice, it is unavoidably involved with other social structures. It is now common to say that gender ‘intersects' - better, interacts - with race and class. (p. 75)

The necessity to pay attention to and design responses that consider the intersectionality of gender, race, class ability, sexuality, age, geographical location was emphasised in relation to women in the National Standards of Practice Manual for Services Against Sexual Violence (National Association of Services Against Sexual Violence, 1998, p. vii) and is equally applicable to men - especially given that the men who most likely to have experienced child sexual abuse and to face difficulties in accessing support are men who are socially disadvantaged. That is:

men with a disability (French 2007; Mitra et al., 2011; Murray & Powell 2008; Sobsey, 1994);
men experiencing a mental illness (O'Leary & Gould, 2009);
same-sex attracted men (Davies, 2002; Fenaughty et al., 2006; Pitts, Smith, Mitchell, & Patel, 2007; Schwarzkoff, Wilczynski, Ross, Smith, & Mason, 2003);
Indigenous men (Office for Status of Women, 2004; Aboriginal Child Sexual Assault Taskforce, 2006; KPMG 2009);
men from culturally and linguistically diverse communities (Grossman et al., 2006; Sorsoli et al., 2008);
men in prison (Heilpern, 1998; Yap et al., 2011);
men in the military (Rumble, Mckean, & Pearce, 2011; DLA Piper, 2012);
rural and regional men (Neame & Heenan, 2004);
young men (Tylee, Haller, Graham, Churchill, & Sanci 2007); and
male sex workers (McMullen, 1990; Office for the Status of Women, 2004).

We know from men's health research that engaging marginalised and disadvantaged groups of men requires something more than opening the door and expecting them to walk in (Hardy, 2007). Our difficulty is that we are only beginning to consider how to respond to men subjected to child sexual abuse, as an identifiable group, let alone refine approaches to particular groups of these men.

Trauma

A major development of sexual assault services has been the inclusion of a trauma-informed framework when assisting clients sexually abused in childhood. The language of trauma-informed care is now arguably the dominant means through which service providers understand the impacts of sexual abuse and sexual assault. Judith Herman's work in this area, Trauma and Recovery (Herman, 2004), foregrounds the role of gender and is particularly influential, as is the excellent work of John Briere and colleagues who stated:

Although there is little doubt that men and women undergo many of the same traumatic events and suffer in many of the same ways, it is clear that (1) some traumas are more common in one sex than the other, and (2) sex role socialisation affects how such injuries are experienced and expressed. These differences, in turn have significant impact on the content and process of trauma- focussed therapy. (Briere & Scott, 2006, p. 78).

What is absent, however, from Briere and Scott's Principles of Trauma Therapy and much of the current trauma-informed literature is a detailed articulation of how to adapt the content and process of the trauma-focused therapeutic work in relation to working with men who have experienced child sexual abuse. In seeking to further refine and improve trauma-informed interventions, there will be opportunities to draw upon World Health Organization research which has identified "gender transformative" approaches as more effective than "gender neutral" or "gender sensitive" approaches in supporting change in men's health and wellbeing, sexual and reproductive health, ending violence against women and other men, and promoting health seeking behaviours (WHO, 2007). Gender transformative approaches directly address power relations, review how cultural practices influence gender scripts and shape men's and women's lives, and how these can be enabling and constraining in different contexts at different times. What these approaches offer is an understanding of how gender is produced and reproduced whilst encouraging involvement in transformative change at individual and societal levels.

Primary health care

Future efforts to improve practitioners' ability to respond appropriately to men sexually abused in childhood will be able to draw upon already established resources and recent advocacy for improved responses to women. Enhancing the skill and knowledge of practitioners to respond more effectively at first contact with women and men sexually abused in childhood is the focus of the excellent Canadian Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse (Schachter, Stalker, Teram, Lasiuk, & Danilkewich, 2009). Similarly, a more informed, structured and proactive approach was recently advocated by Happy Healthy Women: Not Just Survivors: A Consultation Report Advocating for a Long-Term Model of Care for Survivors of Sexual Violence (Australian Women's Coalition, 2010). Although, the Happy Healthy Women report focused on women, the recommendations seek to address a gap in the national agenda that would similarly benefit men who have survived childhood sexual abuse. The recommendations include:

clear pathways for victim/survivors of recent and historical sexual assault to access non-crisis counselling and health services and link into other services;
single-service locations for providing comprehensive, holistic, victim-centred services to victim/survivors of both recent and historical sexual assault (short, medium, and long-term interventions);
protocols (interagency guidelines) to clarify role responsibilities and processes;
evidence-based standardised common assessment and planning tools and interventions, and associated practice standards (for short, medium and long-term work);
a professional development framework to guide training;
provision of services by appropriately qualified professionals both within the public sector and the community and voluntary sector; and
centralised monitoring, evaluations, and support for the implementation of policy and practice guidelines (Australian Women's Coalition, 2010).

1 All Victorian CASAs work with male victim/survivors, accounting for 20% of the clientele accessing counselling and support services.

Building connections

In noting that support for men sexually abused in childhood has received limited attention at a policy level and that service development has been fragmented, we are aware of a growing interest in accessing specialist training and the adaptation of services to better engage and respond to these men (Foster, 2010). The final section of this Wrap looks at some ways of building connections, of actively engaging men, at the value of encouraging group work, of supporting partners and enhancing relationships, and of prioritising hope.

Engaging services

Given that we know men will work assiduously to not become identified as a man who has been sexually abused as a child, the first steps to engage with a service are often tentative and involve careful checking out. It is useful therefore to ensure that there are not excessive requests for personal information up front. Confidential and anonymous sources of information such as telephone help lines and websites are well used by men and can be used as "stepping stones" to accessing services (Wilkins & Baker, 2004). Websites operate not just as sources of information, they are developing sites of service delivery that are especially relevant for men subjected to child sexual abuse, given the limited services in rural and regional areas and men's reluctance to publicly identify as having been subjected to sexual violence (Craig, 2010; Foster, 2011). Ideally men sexually abused in childhood, their partners and families should have access to:

comprehensive information and practical resources, including web based material; and
counselling and support - face-to-face, telephone, email, live chat and group programs.

Services are challenged to reach out to men, to build the pathways and help men step through the door, and to understand men's reluctance to access services sits within a culture where men in general visit health care professional less than women, often only seeking help at a time of crisis (DoHA, 2008). "First contact" and "no wrong door" policy initiatives require all services to understand that men will seldom name their experience of sexual abuse as a factor in current health or relationship crises, and also that life crises present crucial "windows of opportunity" for child sexual abuse to be named in a context that enables referrals and connections to appropriate support.

In seeking to design a service that responds to men, we can draw on some of the learnings from the development of Men and Family Relationships Services (Department of Families, Housing, Community Services and Indigenous Affairs [FaHCSIA], 2009) and men's health initiatives, that point to a number of useful strategies:

Designing, developing and marketing services specifically to men who have experienced child sexual abuse. Men's health initiatives have identified that for information provision to be effective, it has to be gender specific, directly addressing men and the difficulties they experience: generic impersonal, not man-friendly language simply does not do the job (Hardy, 2007; Worth, 2003).
Acknowledging and adapting services to meet the differences in men's cultural and sexual identities - not presuming one size fits all. For example, services are confronted by the particular dilemma of needing to be pro-actively gay and queer friendly whilst not excluding those men who have become overtly homophobic as a reaction to being sexually abused.
Reduced waiting times for consultations. There is often a short window period when men seek assistance, quite often a man might be in crisis or decided that "now" is the time to sort this out. Making time for a phone conversation or an initial meeting is valuable - or some men may never ring back.
Flexible appointment times, offering evening appointments in particular. Men are often more reluctant than women to take time off from work for health appointments and are unlikely to tell someone they are attending counselling.
Creating a more male-friendly entrance and waiting room using posters and relevant information (note this does not mean only having stereotypical car or footy magazines: a newspaper is a good start). Macdonald, Brown, and Gethin (2009) suggested that many generic health and community services do not provide a male friendly environment and this can often lead to further disengagement.
Providing associated, relevant services - like relationship and couple counselling, a men's group, parenting support, or health check-ups - which can be bridges to identifying and obtaining assistance to address sexual abuse.
Developing genuine partnerships with local service providers that support warm referrals and avoid unnecessary repetition of personal information.
Demonstrating a professional, competent approach to men - in personal interactions and written material - that is concise, direct and matter-of-fact, uses humour thoughtfully and facilitates a "laid back" and friendly environment that is proactive and sensitive (Smith, Braunack-Mayer, Wittert, & Warin 2008).
Offering a choice of service provider, in particular priortising an option to see either a woman or man (Denov, 2004).

Given that the majority of boys are sexually abused by men, it is not surprising that men often report a preference for talking with a woman (Chowdhury-Hawkins, Mclean, Winterholler, & Welch, 2008). Choice is key, recognising that some sexually abused men "feel safer working with women, especially in the context of emotional repression and relationship struggles", whilst also appreciating the "opportunity to explore issues of sexuality, masculinity/vulnerability and social behaviour with men" (KPMG, 2009, p. 37). This again highlights the importance of attention to gender in working with men and developing an analysis that does not collapse sex with gender and sexuality, and understands the complexities of gender and sexual relations.

Group work

A consistent theme in enhancing men's wellbeing is the importance of easing men's sense of isolation in relation to their experiences of sexual abuse, to build their sense of connection with other men and build supportive family and partner relationships. Like groups for women, groups for men have a role to play in building connection and challenging the sense of personal failure in ways that individual counselling cannot do (e.g., Bruckner & Johnson, 1987; Fisher, Goodwin, & Patton 2008; Friedman, 1994; Lew, 2004; O'Leary, 2009; Singer, 1989; Wilkien, 2009). In Australia, a diverse range of models and styles of groups exist: self help/peer groups, professional facilitated groups, psycho educational groups, workshops, and weekend retreats. While formal evaluation and documentation of group work is limited, there is a growing evidence base to support the benefits of enhancing group options available to men who have experienced childhood sexual abuse (O'Leary & Gould, 2010). An incomplete list of groups in Australia includes: weekend retreats run by regularly visiting US therapist Mike Lew (e.g., Back on Track [DVD] by SECASA, 2010); self-help groups (MARS in Brisbane); time-limited, weekly, structured therapeutic and ongoing semi-structured support groups (Living Well, Northern CASA, NSW Central and South Eastern Sexual Assault Service, Survivors and Mates Support Network [SAMSN]); psycho-education groups (SAMSSA Canberra); and symptom-reduction focused programs adapted from women's groups (Northern Sydney Sexual Assault Service) (see Box 1). The Northern Sydney Sexual Assault Service has evaluated the outcomes of group work for both women and men in The Jacaranda Project (Davidson, 2007; McMaugh, 2001). A key learning from this project was that group-work programs designed for women required considerable modification when working with men. In the future it will be useful to investigate, document and conduct comprehensive evaluations to determine what are key themes, dynamics, processes and content areas that contribute to effective group interventions for men sexually abused in childhood.

Box 1: Group work resources

Back on Track (DVD), SECASA <http://www.secasa.com.au/pages/back-on-track-dvd/watch-back-on-track/>
MARS in Brisbane: Contact: Dr Wendell Rosevear, Phone: (07) 38571222
Living Well
Northern CASA <http://www.casa.org.au/contact-us/>
Eastern and Central Sexual Assault Service, Sydney Health Service <http://www.sswahs.nsw.gov.au/services/communityhealth/ecsas/>
Survivors and Mates Support Service
Service assisting male survivors of sexual assault (SAMSSA) <http://samssa.org.au/about-us/contact-us>
Northern Sydney Sexual Assault Service: Phone (02) 9926 7580 (adults)

Relationships

Recognising that men live their lives in the context of partner and family relationships and that experiences of sexual abuse can profoundly impact on these relationships, there is value in enhancing relationship counselling services, skills and the knowledge base to support men and their families. Especially as we know that supportive, caring partner relationships are positively correlated with men's mental health and wellbeing in general (Breckenridge, Cunningham & Jennings, 2008; Courtenay, 2003). Research has identified that men and women subjected to child sexual abuse:

are 40-50% more likely to report relationship difficulties (Dube et al., 2005); and
experience increased confusion during sexual and emotional intimacy, including "checking out" and becoming emotionally disengaged (Jacob & Veach, 2005).

The current scarcity of information and services that specifically address men's experiences of child sexual abuse has an unfortunate flow-on effect on partners. Partners, female and male, are often the gatekeepers for men's emotional wellbeing and are typically the first person a man will tell about the sexual abuse. An added difficulty and pressure that female partner's experience, different from male partner's of women who have been sexually abused, is that men typically have smaller social support networks than women and are less likely to have a close confidant other than their spouse (Flood, 2005). Unfortunately, the pressure men feel to keep the abuse secret can amplify partners' distress and isolation. This can be further compounded by heterosexism for those men in same-sex relationships: as professionals (in research, clinical and policy contexts) we need to find ways to listen to same-sex couples about how they negotiate these obstacles to establish healthy, satisfying intimate relationships.

While relationships are a place where problems related to a history of abuse can appear, they are also a place where difficulties, including difficulties with trust, intimacy and sexual relations can be worked through and resolved (Jacob & Veach, 2005; Kia-Keating et al., 2010). Although the Introduction to Working With Men and Family Relationships Guide (FaHCSIA, 2009) and Mensline resources such as Renovate Your Relationship do not address the problems experienced by men in relation to child sexual abuse, we suggest that the Federal Government initiatives have created valuable knowledge and community skill in engaging and working with men which might be drawn upon.

Hope

A challenge we face as researchers/practitioners in reporting and responding to sexual abuse, is not to contribute to people's sense of hopelessness and isolation. O'Dell (2003) expressed concern with continuous emphasis on the "harm story", the idea that individuals subjected to sexual violence are irreparably damaged and all the problems they face in life can be attributed to the effects of the abuse (see also Armstrong, 1996; Davis, 2005; Wade, 1997). The issue is complex, and as Anderson (2008) pointed out the "harm story" can be helpful: "… if the harm story relieves a person from the feeling of responsibility, unworthiness and shame, it is a good alternative, provided it functions as a temporary refuge and not a permanent position" (p. 60). While it is clear sexual abuse does cause great harm and distress, we need to know how it is that, despite these harms, many men manage to live satisfying and fulfilling lives, often without recourse to professional assistance (Anderson, 2008; Gonsiorek et al., 1994; Miltenburg & Singer, 2000).

We argue that presenting and circulating research that identifies how men subjected to child sexual abuse do cope, manage and survive is important because it offers hope, and challenges the idea that sexual abuse results in irredeemable damage.

The main thing that helped was talking about it [the child sexual abuse] and knowing that I was believed. He [the counsellor] gave me hope that I can overcome the cards that have been dealt to me, and become something I want to become. (O'Leary, 2010, p. 11)

The media image of guys who have been abused is often that his whole life is wrecked. This doesn't give us hope. Because basically, we need inspirational work and stories to be told, because otherwise we get the sense that we can't deal with things, that we don't have it within ourselves. It's sort of like a constant underestimation of our ability to deal with things, and to find peace in the midst of it all, in the midst of the pain and suffering. (O'Leary, 2010, p. 9)

Small steps are being taken in relation to raising public awareness and supporting media representations of the sexual abuse of males that are affirming and offer hope. For example, see the Living Well and 1in6 poster/visual media competitions and community blog; and the collaborative work between Law and Order SVU, the Joyful Heart Foundation and 1in6to develop scripts and create public service announcements that encourage awareness, understanding and enhanced support.

We now have men speaking out as champions seeking to address men's health, depression, suicidality, prostate cancer, domestic violence, and joining the white ribbon campaign. We would equally benefit from having ambassadors who will champion the provision of support to men subjected to sexual victimisation. What the women's movement has demonstrated is that it is important that responsibility for change is not left to those women and men who have been subjected to childhood sexual abuse or sexual assault. As The National Plan to Reduce Violence Against Women and Their Children highlighted:

Sustainable change must be built on community participation by men and women taking responsibility for the problems and solutions. (COAG, 2010).

Conclusion

Although research with men is considered to be somewhat behind the research for women, it is generally agreed that significant numbers of Australian men have been subjected to sexual abuse in their lifetime and that this often contributes to significant difficulties in these men's lives.

Existing sexual assault services (including those originally intended for women) have shown it is possible to provide an effective service response to men who have been subjected to sexual abuse as children. Their effectiveness has been partly dependent upon recognising men as a group who share some commonalities with women sexually abused in childhood, but who also face gendered challenges as men. It has also been dependent upon the political will of practitioners, services and funding bodies to recognise the support needs of men.

Many men will not consider sexual assault services as a support option. Therefore, greater readiness and awareness among a broader range of health professionals will form an essential component of an effective service response to men into the future. Sexual assault specialist services will continue to play an important role in addressing barriers to men's disclosure, developing information, resources and training that support practitioners to recognise and meet the needs of men sexually abused as children.

Current men's health policies in Australia recognise the importance of many health-related issues faced by men, however, they fail to explicitly acknowledge sexual abuse as a problem faced by significant numbers of men. These problems are manifested in mental health, substance, and correctional services, often with little recognition that this childhood trauma is related to current service utilisation. The implication is that better recognition of child sexual abuse as part of the aetiology of these difficulties potentially has a transformative impact on service delivery and outcomes for many men, their families and the broader community.

Advocates for men sexually abused in childhood might usefully focus on raising the profile of sexual abuse as a public health issue within policy discussions, in order to develop initiatives that reach out and engage men, address identified barriers to men's disclosure, offer practical assistance, support and, most importantly, hope for the future.

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Acknowledgements

Gary Foster PhD is Manager of Anglicare Southern Queensland Sexual Assault Services - Living Well. Cameron Boyd is a Counsellor/Advocate, Northern Centre Against Sexual Assault. Patrick O'Leary PhD is Head of School of Human Services and Social Work, Griffith University.

Publication details

ACSSA Wrap

Published by the Australian Institute of Family Studies, November 2012

20 pp.

ISBN:

978-1-922038-16-6

Suggested citation:

Foster, G., Boyd, C., & O'Leary, P. (2012). Improving policy and practice responses for men sexually abused in childhood (ACSSA Wrap No. 14). Melbourne: Australian Centre for the Study of Sexual Assault, Australian Institute of Family Studies.

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Improving policy and practice responses for men sexually abused in childhood

Improving policy and practice responses for men sexually abused in childhood

Overview

Key messages

Read the publication

Introduction

Reflexive gender analysis

Male child sexual abuse

Prevalence and effects

Basic statistics

Effects

Suicide

Barriers to men's disclosure

Masculinities

Sexuality

Uncritical promotion of the idea that male sexual victimisation leads automatically to perpetration

Methods of coping

Service development

Development of services for men sexually abused in childhood

Men's health strategies

Attending to diversity

Trauma

Primary health care

Building connections

Engaging services

Group work

Box 1: Group work resources

Relationships

Hope

Conclusion

Further reading

References

Acknowledgements

Publication details

Download Publication

Share

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Improving policy and practice responses for men sexually abused in childhood

Improving policy and practice responses for men sexually abused in childhood

Overview

Key messages

Read the publication

Introduction

Reflexive gender analysis

Male child sexual abuse

Prevalence and effects

Basic statistics

Effects

Suicide

Barriers to men's disclosure

Masculinities

Sexuality

Uncritical promotion of the idea that male sexual victimisation leads automatically to perpetration

Methods of coping

Service development

Development of services for men sexually abused in childhood

Men's health strategies

Attending to diversity

Trauma

Primary health care

Building connections

Engaging services

Group work

Box 1: Group work resources

Relationships

Hope

Conclusion

Further reading

References

Acknowledgements

Publication details

Download Publication

Share

Further reading

The nature and extent of sexual assault and abuse in Australia

Sexual revictimisation

Allegations of family violence and child abuse in family law children's proceedings

The exception that proves the rule

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