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Clinicians work with more male sexual abuse survivors than they may think.
April is Sexual Assault Awareness Month. And while our society is well aware of female victims, often male victims of sexual assault are forgotten or neglected due to shame, stigma, and the like. Indeed, some may find it surprising that at least 1 in 6 boys is sexually abused before their 18th birthday.1 This number rises to 1 in 4 men who experience unwanted sexual events across their lifetime.2 To wrap your head around those numbers, picture a large college football stadium filled with 100,000 seats. If the audience was solely male, that would mean that at least 25,000 men have been or will be sexually assaulted. That number is staggering.
The public and some health care providers may hear the words men and sexual assault and automatically assume that men are the perpetrators. Somehow seeing men as the targets of sexual violence is difficult to comprehend. The truth is it is hard for most men to see themselves as victims or as someone who has been abused. That is one of the reasons why we encourage the men with whom we work to see themselves as survivors-a small but important change in language that connotes resilience and empowerment.
Trauma in men
“Bill” is 45 years old. Married for 20 years, he and his wife have two children. Bill reports that he and his wife are no longer intimate emotionally, and he finds it difficult to talk with his wife, be affectionate, and often finds himself zoning out when his wife is talking to him. Bill works as a retail supervisor; he noted difficulty holding onto jobs for longer than a year, often due to angry outbursts and irritability that are difficult to control.
When directly asked if he has experienced any traumatic events in his life, he reported none. In answering additional intake questions, he noted that some “funny business” had occurred when he was 14 years old when his next-door neighbor touched him inappropriately.
How and why is it so hard for men to recognize and acknowledge the occurrence of this type of trauma and subsequent mental health problems, and how can we help them?
While traumatic events are quite common in the general population, most people do not have long-standing negative mental health consequences as a result. However, with some traumatic events there is higher incidence mental health difficulties. Sexual trauma packs a huge wallop compared with other traumatic experiences. The probability of having negative consequences is much higher with sexual abuse compared with most other traumatic events. Individuals who experience sexual abuse or assault are at risk for a wide range of medical, psychological, behavioral, and sexual disorders.
Men who have experienced sexual abuse and assault may have very prominent psychological symptoms that are not easily captured in any one psychiatric diagnosis. For example, males who have been sexually assaulted often have buckets of seething anger. This never leaves them but especially comes out when they are feeling threatened or betrayed. Another example is difficulties with sexual functioning such as low sex drive or erectile problems, which not only affects self-esteem and sense of manhood but also interferes with intimate relationships. They may also feel unable to give or feel love or happiness, effects that reverberate into every aspect of their life.
Men who have been sexually assaulted may have concerns about their masculinity as well as their sexual orientation; they struggle intensely with shame and self-blame.3 They are less likely to report sexual abuse, to identify experiences they have had as abusive, and to seek support or formal treatment for these experiences.4-6
Boys and men are socialized to see themselves as strong, tough, and self-sufficient. Acknowledging feelings and disclosing vulnerabilities are in some ways antithetical to traditional masculine roles. Men also frequently wear thick coats of shame, having internalized the blame. When they do disclose, they are frequently met with disbelief, such as “That’s impossible. A man can’t be raped.” Or they are met with invalidation and victim-blaming such as, “How could you let that happen?”
Barriers to treatment
All kinds of male rape myths are responsible for delayed treatment seeking and perpetuating stigma (Table 1). The most prominent barriers to receiving mental health services in adult trauma survivors are concerns related to stigma, shame and rejection, low mental health literacy, lack of knowledge and treatment-related doubts, fear of negative social consequences, and limited resources.7 Male survivors typically do not disclose their histories of sexual abuse and assault for 20 to 25 years.8 They may deny, minimize, or fail to see the connection between sexual abuse and subsequent mental health difficulties. Sometimes they dissociate and do not fully register or remember what happened.
Because many patients may not be completely forthcoming about their histories, patients should always be asked about exposure to traumatic events, including sexual abuse. It is also important to provide validation of the occurrence of the experience and to help the patient understand the connection between the trauma and consequent difficulties.
Supporting male survivors
It is important to offer male survivors a safe place where they are believed and accepted. Many male survivors with whom we have worked over the years tell us that having someone who listened and did not question the validity of their story was paramount to their healing.
The therapeutic alliance is predictive of, or associated with, a reduction in various symptoms.9 However, it is not enough to have a kind, caring, non-judgmental therapist. A mental health clinician who works with male sexual abuse survivors should have the knowledge and skills to understand and help patients who have been abused. For example, some well-intentioned providers may discourage their male patients from talking about their traumatic experiences. They may inaccurately think that talking about such experiences will open Pandora’s box or they themselves may be uncomfortable hearing details of the abuse.
While it may be upsetting for the patient, working through the trauma narrative in a process-oriented or more formalized exposure-based manner is tremendously helpful. Many patients tell us that the more they talk about it, the less impact the abuse has on them. And those discussions of the traumatic event, including details no matter how graphic, can allow survivors to understand and process what happened.
We have also worked with male survivors who have told us that their therapist seemed inappropriately voyeuristic, wanting explicit details of the abuses and appeared excited and eager to hear more, which felt like being abused all over again. Others have told us stories of therapists grimacing in disgust or pain or communicating an inability to hear the patients’ stories, all of which perpetuates shame and silence.
After disclosing the pain of their traumatic experiences, some survivors were met with insensitive, inaccurate, victim-blaming, and dismissive reactions. One patient told us that when he told his therapist that he needed to talk about the sexual abuse he had experienced, the response was, “I hope you are not one of those homosexuals who are going to waste my time telling me about imagined sexual abuse.” By reinforcing the patient’s belief that he was a severely flawed human being, the comment kept him from seeking help for many years.
Treatments for adults
There are numerous guidelines that provide recommendations on psychological and pharmacological treatments for posttraumatic stress disorder in adults (Table 2).10,11 The American Psychiatric Association guidelines strongly recommend the use of cognitive behavioral therapy, cognitive processing therapy, cognitive therapy, and prolonged exposure therapy as part of treament. The use of brief eclectic psychotherapy, eye movement desensitization and reprocessing, and narrative exposure therapy as well as pharmacotherapy with fluoxetine, paroxetine, sertraline, and venlafaxine are conditionally recommended for this patient population.12
The guidelines do not make recommendations for first-line treatment-psychotherapy first or instead of medications-because of insufficient evidence. The assignment of a strong recommendation is based primarily on a harm-to-benefit analysis, with more benefits seen as a result of psychological treatments for these patients.
In a meta-analysis of PTSD treatment for adults, trauma-focused psychotherapies were compared with selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors.13 Only four studies met inclusion criteria; of those, two were deemed at high risk of bias. The unbiased studies showed no difference in PTSD symptom reduction but had wide confidence intervals. The authors concluded that there is insufficient evidence to determine whether medications or trauma-focused psychotherapies are more effective for PTSD symptom reduction.
Guidelines are intended to simplify treatment decision-making and as such, they are not rigid. While we celebrate several effective psychotherapies and pharmacotherapies for PTSD, it is possible that male survivors may refuse to participate or drop out before completing therapy. Moreover, they may engage in these therapies but not experience their full benefit and are thus in need of ongoing care. For example, in one study of interpersonal assault survivors who received an evidence-based psychotherapy for PTSD, women evidenced more rapid gains on global guilt, guilt cognitions, anger/irritability, and dissociation as compared with men.14
Shared decision-making that takes into account the values and preferences of patients is essential as is the consideration of benefits and harms of any intervention. Educating trauma survivors also allows shared decision making. Thus, clinicians should be ready to offer information about evidence-based options. They also should teach coping skills while being sensitive to cultural and socio-demographic differences.
Case Vignette (cont’d)
What are Bill’s treatment options? During Bill’s appointment, the clinicians should elicit his treatment preferences and ask about his current functioning. Following a three-phase model, ensure Bill is safe, stable, and utilizing healthy coping skills before delving into trauma processing. Begin by providing psychoeducation about available treatments specific for trauma processing (eg, prolonged exposure and cognitive processing therapy), as well as treatments that are trauma-informed though not trauma-focused (eg, cognitive behavioral therapy, dialectical behavior therapy) that might help Bill with his impulsivity and anger. Since anger may be a symptom of depression, let Bill know that an SSRI (eg, fluoxetine, paroxetine, sertraline, and venlafaxine) would be a useful adjunct to the psychotherapy.
The characteristics of the abuse as well as male survivors’ responses may be different, which can have an impact on assessment and treatment. For example, the assault may involve a single occurrence of penetration by several perpetrators (ie, a gang rape that occurs while a man is a young adult serving in the military or in a fraternity) or it may involved skilled grooming of a boy by an older and deceptively admirable figure such as a priest, coach, or teacher.
Of course, some men who have experienced sexual abuse or assault may not have significant mental health difficulties or may recover on their own without professional intervention. Similarly, some male survivors may have difficulties that wax and wane across their lifespan, becoming particularly strong with certain triggers (eg, smells) or during particular times of the year (eg, anniversary of the abuse). Others, especially those with severe and prolonged abuse histories, may experience more profound or longer- term problems.
Some patients may prefer a support group rather than one-on-one counseling.15 Peer-based support lets survivors know that they are not alone and removes the element of a power hierarchy or judgment. Regardless of their treatment choice, it is our hope that survivors can work through their traumatic experience and live a healthy and meaningful life.
Dr Cook is Associate Professor, Department of Psychiatry, Yale University School of Medicine, New Haven, CT; Dr Ellis is Assistant Director, Nova Southeastern University Trauma Resolution and Integration Program, Fort Lauderdale, FL. The authors report no conflicts of interest concerning the subject matter of this article.
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