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Article 28

Understanding Male Childhood Sexual Abuse

Consequences and Considerations

Caleb P. Turmel and Robin Guill Liles

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Introduction

Childhood Sexual Abuse (CSA) significantly impacts individual development related to sexuality, attachment, and psychological functioning (Hunter, 2006; Kia- Keating, Sorsoli, & Grossman, 2011). Yancey, Hansen, and Naufel (2011) estimated 13– 16% of men are survivors of CSA. Within another community sample, it was reported that 4–9% of males have been sexually abused (Bhandari, Winter, Messer, & Metcalfe, 2011; Etherington, 1995; McPherson, Scribano, & Stevens, 2012). Still, a clear statistical picture of CSA prevalence rates is difficult to obtain. Male survivors of CSA often fear stigmatization (King, Coxell, & Mezey, 2000) and are reluctant to discuss past abuse experiences with healthcare providers (Alaggia & Millington, 2008). Springer, Sheridan, Kuo, and Carnes (2007) reported that CSA is sometimes only one of several sources of childhood trauma. Separating the effects of CSA from other childhood adversity confounds data collection (Bhandari et al., 2011; Thomas, DiLillio, Walsh, & Polusny, 2011). Evidence-based research for counseling male survivors of CSA is less available than are strategies for working with female CSA survivors (Alaggia & Millington, 2008; Gallo-Silver, Anderson, & Romo, 2014). The traumatizing effects of CSA can reach across the lifespan; and from a therapeutic point of view, these aftereffects can prove challenging. Operating from a strengths-based perspective, counseling professionals are uniquely poised to help male survivors of childhood sexual abuse (Hunter, 2006). Expanding our understanding of how to work with this population is addressed in this article (Adamsons, 2013; Barrett, 2009; Simon, Feiring, & McElroy, 2010).

Though each male survivor’s narrative is unique to his personal experiences and worldview, research suggests that there are some shared symptoms resulting from the CSA (e.g., distrust, distancing behaviors, substance abuse; Barrett, 2009; Hovey, Stalker, Schachter, Teram, & Lasiuk, 2011). These men may struggle to form and maintain close relationships, to feel safe with others, and to establish intimate partnerships. Even more worrisome, some people believe that men who survived CSA will become abusers. These preconceptions may be all the more wounding in view of research suggesting that male survivors of CSA are no more likely to become perpetrators of abuse, especially when they negatively view their own abusive experience (Salter et al., 2003). Male CSA survivors typically resolve to be different from their abuser because the experience was so traumatic for them. Still, CSA is unique in ways in which it traumatizes individuals and creates relational isolation (Hovey et al., 2011).

Many survivors express fears that they will not be able to sustain the role of loving caretaker and intimate partner with another adult. Whereas it is common for most men to describe the roles of partner and father as emotionally, mentally, and physically taxing, male survivors of CSA often live with the heightened dread that they will turn out to be inadequate partners and fathers due to their traumatic experiences. Etherington (1995) stated that men who have survived CSA are fearful of becoming parents because they do not want to abuse their own children and because they feel insecure discussing sexuality with their children, unsure of what would be helpful and what might be harmful for their children to hear.

From a developmental point of view, it seems theoretically correct to assume that healing must take place in order for individuals to recover from CSA and to move forward in establishing close and intimate relationships (Berk, 2010). Insecurity surrounding masculinity and personal identity, as well as the inability to trust others, are all significant issues which must be addressed. Relational health is particularly valuable for individuals who are preparing to have children; and when children arrive, the father’s ability to foster healthy relationships with children is crucial to child development (Summers, Boller, Schiffman, & Raikes, 2006). Male survivors of CSA may struggle to develop long-term intimate relationships, and these struggles can directly and negatively impact the positive development of other relationships, particularly when these relationships require an ongoing emotional and physical presence (e.g., father/child; Etherington, 1995). How CSA impacts identity formation and relational health is an important consideration when working with male survivors of CSA (Alaggia & Millington, 2008; Barrett, 2009).

Male Survivors of Childhood Sexual Abuse: Implications for Counseling Development and Mental Health

Successful completion of Erikson’s stages of psychosocial development is important for forming healthy adult relationships and raising children effectively (Berk, 2010). Traumatic experiences can disrupt positive progression through Erikson’s stages of development (Simon et al., 2010). In most cases, CSA is profoundly traumatizing and at a minimum typically translates into post-traumatic stress symptomatology, distrust of others, and externalizing behaviors (e.g., substance abuse, violence, etc.; Simon et al., 2010). When a young boy is sexually abused, his psychosocial development is likely challenged, which can impact both short- and long-term emotional, social, and psychological functioning (Kia-Keating et al., 2010; Thimm, 2010).

Coxell and King (2010) reported that successful adult development is difficult for CSA male survivors because they are hesitant to trust others or express their personal needs and vulnerabilities. These men are prone to “shutting down” and may desire to isolate themselves in order to feel safe (Kia-Keating et al., 2010). When people survive maltreatment, they are likely to develop cognitive schemas in order to try to make sense of their experience. These schemas offer “protection,” and they possibly help individuals avoid further abuse (Thimm, 2010). Although isolation and “shutting down” could have been important for protection in childhood, these behaviors are counterproductive to adult development and relational health (Etherington, 1995; Kia-Keating et al., 2010; Schuetze & Eiden, 2005). The manifested symptoms of CSA (e.g., distancing, withdrawal, isolation) can be difficult to understand and accept, further threatening the already tenuous nature of relationship development (Martsolf & Draucker, 2008; Roberts, O’Connor, Dunn, Golding, & the ALSPAC Study Team, 2004).

There is research to show that mental health symptoms are related to an abuse history (Kia-Keating et al., 2010). According to Alaggia and Millington (2008), men who were sexually abused as children have a higher risk for developing major depression, anxiety, suicidal ideation, and substance abuse issues. Attempting to repress memories of the abuse is common among survivors of CSA and is a contributing factor in the development of anxiety and depression (Alaggia & Millington, 2008). Post-traumatic stress symptomatology is also common among male survivors of CSA (Hovey et al., 2011).

Relationships

The correlation between male childhood sexual abuse and relational difficulty appears well established (Alaggia & Millington, 2008; Etherington, 1995; Hovey et al., 2011; Kia-Keating et al., 2010). Someone whom they thought they could love and trust abused them, and this event may understandably shape the survivor’s perspective surrounding intimacy (Etherington, 1995; Kia-Keating, et al., 2010). When survivors of CSA enter into adult relationships, it can be difficult for them to express emotional needs and to be physically close with partners (Kia-Keating et al., 2010). Many male survivors have difficulty with physical contact, and this can impact both intimate partner relationships, as well as father/child relationships. (Robertson, 2012).

Frequently, men who have survived CSA worry that they will not be good fathers. They may even fear that they will hurt or brutalize their children. These men understand that fathers are important to child development (Cabrera, Shannon, & Tamis-Lemonda, 2007). Fathers facilitate child cognitive and emotional growth, and a loving father/child relationship can positively influence a child’s social interaction with peers (Cabrera et al., 2007). Some men are extremely protective of their children, fearful of an external threat of abuse (Robertson, 2012). For other men, becoming a father acts as a trigger, causing repressed and denied emotions to resurface (Robertson, 2012). This response is understandable due to the frequency with which so many men deny the existence of abuse in the first place (Kia-Keating et al., 2010). Although vulnerable emotions are difficult to express, Kia-Keating et al. (2010) found that, sadly, anger is more easily expressed.

There are many factors necessary for relationships to succeed, including clear communication, a healthy sense of self, openness to change, and willingness to be emotionally intimate. Male survivors of CSA can struggle with many of these factors, yet male survivors who engage in positive healthy relationships often experience “relational recovery” (Kia-Keating et al., 2010). Male survivors of CSA who can negotiate the perceived threats to relationship building (e.g., distrust) and establish a loving, caring, and intimate relationship with another person, may significantly benefit from that relationship. Indeed, the fact that these men perceive long-term commitment and fatherhood as a positive experience suggests that they may also be capable of framing their CSA as a meaningful albeit tragic experience (Wright, Crawford, & Sebastian, 2007).

Clinical Work

Entering into a counseling relationship with a male survivor of CSA can be murky waters for many counselors. This article hopes to make working with this population less tenuous for counselors and helping professionals. The following clinical suggestions focus upon three main areas: (a) instilling hope in the client, (b) developing a sense of self, and (c) establishing personal meaning making (Flaskas, 2007; Simon, 2009; Wright, et al., 2007). These are broad topics; and in many cases as the client begins to heal, he may develop these characteristics as a by-product of clinical help (i.e., working through his past trauma and experiencing healing). Discussions surrounding these topics, and contextualized through the client’s abuse experiences, allow clients psychologically to approach this anguished part of their histories and hopefully to become less sensitized to the correspondingly painful memories. Hope, sense of self, and meaning or purpose in life are essentially existential concepts, but it is theorized that they can also invoke long- lasting change and healing in male survivors of CSA (Wright et al., 2007).

Instilling Hope

Hope can act as a means of therapeutic change within any individual, and someone who has survived CSA will benefit from feeling hopeful in the moment, as well as from feeling hopeful about the future. It is important to approach a discussion of hope with a sense of openness, acknowledging that hope and the absence of hope are both significant for an individual’s progress in therapy. According to Flaskas (2007), hope does not necessarily have to be diametrically opposed to hopelessness; rather, both can exist within a client and indeed are necessarily present in all of us to varying degrees. As an individual experiences change, he establishes a healthy balance between hope and hopelessness and accepts these feelings as a constant within his life (Flaskas, 2007).

So how does one actually instill hope in a male survivor of childhood sexual abuse? As with any therapy, an important starting place is developing a strong therapeutic relationship. The therapeutic relationship provides the foundation for potential disclosure of CSA and can also act as a platform for the client to learn how to be in a trusting and safe relationship with someone else. It is theorized that as the relationship between therapist and client grows, the client will become more open to taking risks and more willing to discuss difficult subjects. As with any therapeutic relationship, there will be issues of transference, miscommunication, and shared emotional intimacy. What is important is that the client begins to get a sense of the (a) possibility for growth within the therapeutic relationship, (b) potential for future healing as therapy continues, and (c) hope for replicating these positive experiences in other relationships (Arnd-Caddigan, 2012).

Trust is important in any therapeutic relationship, and developing trust is most important for a survivor of CSA (Kia-Keating et al., 2010). Demonstrating to the client that you are a trustworthy individual is paramount to succeeding in developing a therapeutic relationship and establishing hope (Arnd-Caddigan, 2012; Kia-Keating et al., 2010). Trust for a survivor of CSA may look different than trust with someone that does not have a history of CSA. Emotional vulnerability can be difficult for survivors because in many cases they were abused by someone whom they loved and trusted (Alaggia & Millington, 2008). Affirming the individual’s subjective experience by acknowledging the pain, confusion, and fear that they felt (and feel) in relation to their abuse experience will help establish the counselor as a trustworthy individual (Alaggia & Millington, 2008). Open and honest communication, combined with clear explanations regarding counseling techniques—particularly the intentions which underlie the techniques—can be helpful. Of course, fundamental ethical guidelines such as confidentiality and the limitations of the counseling relationship must prevail throughout the counseling relationship. If the counseling professional believes he or she has overstepped or violated the therapeutic alliance, then it is important to acknowledge these mistakes. When appropriate, self-disclosure can go far in demonstrating the counselor’s humanity and corresponding vulnerability, as well as diminishing the power differential between client and counselor (Alaggia & Millington, 2008).

As trust develops between the counselor and the client, it is important to move in a direction of positive change as defined by the client (Thimm, 2010). Measurable and tangible results are superior to abstract theories and concepts for providing the client a sense of hope for the future. Framing each session within the context of client-defined goals and objectives provides the client with a sense of progress and accomplishment. Change for the sake of change is not the goal. Rather, empowering the client to recognize that indeed change can occur and is occurring allows for the instillation of hope. Setting goals may seem like a simple and rudimentary technique for counseling male survivors, but it is a valuable starting place and should not be discounted for its seeming simplicity. As goals are achieved, the counselor relates these accomplishments to the client’s self-efficacy and to his ability to succeed, reminding the client that such successes are not only possible but highly probable outside the therapeutic relationship.

Existential theory embraces the idea that individuals can and do have the power to make positive changes in their lives (Day, 2009). This knowledge empowers individuals to pursue avenues of personal growth that may have seemed impossible due to their abuse experience. Framing an individual’s change with a realistic view of self is crucial for the individual. According to Simon (2009), survivors of abuse must grieve the person whom they could have become had they been spared the abuse. The grief process will look different for everyone, but beginning with an open discussion on what one has lost or missed in life due to the abuse experience may be a good place to start. Mourning and “letting go” of the person whom the client could have become gives way to increased psychical and emotional space for the client to feel hope for the man he is and is becoming (Flaskas, 2007; Simon, 2009).

Sense of Self

A male survivor of CSA may report feeling dehumanized or inadequate due to the flagrant disregard the perpetrator had towards him (Alaggia & Millington, 2008). Survivors often sense that there is something inherently wrong with them, or that they should have been strong enough to stop the abuse (Alaggia & Millington, 2008). Regardless of how they may feel about themselves, there is generally a deep sense of shame surrounding the survivor’s sense of self (Alaggia & Millington, 2008; Saha, Chung, & Thorne, 2011). These shameful feelings will evolve differently according to an individual’s personal experiences and cultural perspective; nonetheless, helping the client to develop a positive and worthy sense of self seems an important start when working with male survivors of CSA.

An important dialogue to have with a male survivor of CSA, and realistically any male client, is to discuss his beliefs and understanding of masculinity. Personal views on masculinity are often fraught with inaccurate overt and covert rules and roles from families of origin. Male survivors of CSA may hold very strong (and often negative) beliefs about themselves as a result of their abuse. Discovering and then deconstructing these beliefs surrounding masculinity and CSA are important goals for therapy. Discussing perceptual incongruences between themselves and other men and defining their “standards of masculinity” can also be helpful. One method for introducing discussions surrounding masculinity includes client/counselor collaboration in listing and openly exploring activities that define masculinity. The counselors should “meet the client where he is” when discussing masculinity, and counselors must understand that many of the client’s beliefs are most likely profound and deeply held. (Robertson, 2012)

When males share that they were victims of CSA, the responses they receive may be hurtful and invalidating. As the client opens up about something as simple as an emotion or as deep as a painful historical narrative, maintaining an empathetic, accepting, and caring stance validates the client’s sense of self and enhances growth of the counseling relationship (Kia-Keating et al., 2010). Individuals who grow up in an abusive setting may not realize that the abuse was wrong until they are old enough to learn otherwise. Their emotions surrounding the abusive event can be confusing and frustrating (Roberts et al., 2004). Thus, helping the individual recognize and name feelings and emotions that they did not know they possessed prior to therapy can be therapeutic. Concrete exercises such as worksheets with lists of different feeling words are “starting places” for opening a male survivor’s mind to his emotional world.

The counselor and client can also dialogue about different “roles” that the individual fulfills in his daily life. Roles can even be given names such as: adult, partner, father, friend, boss, motivator, judge, child, caretaker, etc. Helping the survivor recognize that he may think, feel, and behave differently in one role from the way he thinks/feels/behaves in another role encourages powerful insights—and may ultimately help him to build toward greater internal congruence. One worry is that an individual may have become emotionally or developmentally trapped in the age during which he was abused (Emmerson, 2013). As theorized by Erik Erikson, if a male was abused at 10 years old, he can still feel like a 10-year-old child in certain situations, even though in reality he is now a 37-year-old man (Berk, 2010). Emotionally-charged interactions (e.g., husband/wife, partner/partner) and/or ones which involve a power differential (e.g.., father/child) will often result in strong reaction to role behavior. Roles can be introduced with a discussion on the different personas the individual may assume in order to complete certain tasks. Counselors must practice acceptance during role discussions, eschewing judgment of roles as positive or negative, good or bad (Emmerson, 2013). Helping clients to recognize the various roles they assume may empower them to embrace all parts of themselves.

With each role comes self-talk specific to that role. The empty chair technique is a powerful intervention, allowing various role persona to interact with one another, and hopefully bring about greater internal congruency within the client. Teaching and practicing mindfulness can help clients draw nearer to different aspects of their personality. Over time and on reflection, clients can learn which elements of their personality are helpful and healing and should accordingly be embraced and nurtured, as well as which elements are hurtful and diminishing and should accordingly be discouraged or even quashed. (Emmerson, 2013).

Personal Meaning

Even more significant than hope or a sense of self, and indeed a more universal human need, is personal meaning-making. As Victor Frankl emphasized: “Ultimately, man should not ask what the meaning of his life is, but rather he must recognize that it is he who is asked” (Frankl, 1946, p. 131). This concept nudges individuals to pursue opportunities, activities, and interests which are personally meaningful. Clients can learn that they are empowered—even compelled—to take responsibility for personal meaning- making (Bagathai & Stoica, 2012). As a male survivor of CSA begins to pursue healing, experiencing personal responsibility and meaning in the healing process is critical for establishing purposeful living and hope for the future (Bagathai & Stoica, 2012).

Finding meaning and purpose for one’s past, current, and future life is an important counseling goal for anyone; and this is no different for a male survivor of CSA. Although it is a process requiring time and hard work, finding meaning in one’s past CSA experience can be a redemptive experience (Kia-Keating et al., 2010). Attributing meaning to an individual’s past abuse can empower individuals to move forward with their lives (Kia-Keating et al., 2010). A simple technique for starting the process of meaning attribution could be as simple as asking the client to develop a timeline of his life, including the period of time during which the abuse occurred. With caring counselor support, survivors can examine how emotionally painful the abuse was, and clients can also attest to how emotionally strong they are for having survived the abuse and carrying on. Counselors can illuminate positive client attributes and characteristics that may somehow be related to the abuse, and counselors can allow clients to tell their stories and to adopt a tolerable lens through which they can come to view their abuse (Day, 2009). This process of developing a narrative by which to view their abuse will add continuity to their history and help survivors to ascribe meaning to who they are, who they were, and who they hope to be (Day, 2009).

Developing a narrative with male survivors of CSA can have multiple positive outcomes. When a client shares his story with a counselor, this process can be cathartic and provide new perspectives (Day, 2009). As they heal, men may feel the courage to share their abuse stories with other individuals in their lives. Such sharing can evolve into greater intimacy with important others in their lives, thus creating a feeling of knowing and being known. In addition and if the individual has the opportunity to hear stories of other CSA survivors, this can also be an affirming and positive experience. Finding relatable elements in their own stories with the stories of other men can give clients a sense of community and of helping others in that community (Day, 2009). Indeed, a sense of meaning can often be derived from helping others, connecting with others, and sharing stories (Bagathai & Stoica, 2012; Day, 2009). Giving clients a directive “to share your story” or to go volunteer somewhere may or may not be effective, but encouraging them to find personally meaningful ways to give back to their community can be helpful in the therapeutic process.

The work of finding meaning and purpose is often a spiritual process (Eliason, Samide, Williams, & Lepore, 2010). Clients who seek meaning-making through a higher power can experience positive healing. Receiving and feeling acceptance from a higher power may also provide the impetus for an individual to practice self-acceptance and to strive for higher moral ideals (Eliason et al., 2010). This kind of altruistic motivation may be ideal for helping an individual to attribute meaning to his life. That said, some male survivors of CSA may have suffered their abuse from authority figures within a religious or spiritual setting, and as such, this topic must be approached with care, if at all (Eliason et al., 2010; Robertson, 2012). Learning and practicing mindfulness and paced breathing are simple techniques which often resonate with the deeper spiritual parts in all of us, without overtly involving a higher power or religious themes (Cukor, Spitalnick, Difede, Rizzo, & Rothbaum, 2009).

Summary

As male survivors of childhood sexual abuse progress through their treatment and begin to develop hope for the future, a stronger sense of self, and personal life meaning, they are likely to develop the capacity for moving towards others with openness to emotional intimacy (Cukor et al., 2009; Flaskas, 2007). Knowing this is particularly poignant in view of the many survivors of CSA who express their heartfelt desire to have long-lasting and loving relationships and to become warm and loving fathers. Healing from childhood sexual abuse is a journey that requires commitment from both the therapist and the client. It is hoped that implementing techniques and theories described here will enable the individuals to have long-lasting change in their lives and to develop deeply loving relationships with their partners and children.