This work is licensed under a Creative Commons Attribution 4.0 International License. Male Survivors of Sexual Abuse: Becoming Gender-Responsive and Trauma- Informed Jennifer Elkins Katherine Crawford Harold E. Briggs Abstract: While there is a wide body of literature examining the behavioral, emotional, and social consequences associated with being sexually abused, comparatively few studies have focused on males. Sexual abuse victimization among males remains largely under- reported, under-treated, and under-recognized by researchers, practitioners, and the public. Researchers trying to clarify why sexual abuse in males has been overlooked point to prevailing cultural norms, myths, assumptions, stigma, and biases about masculinity. Consequently, there is often an assumption that males are not negatively affected by sexual abuse. Drawing extensively from the literature, this article provides a critical review of: (1) the nature, experience and impact of sexual abuse victimization for males; and (2) the multidimensional processes that promote and inhibit resilient outcomes. It concludes with a discussion of trauma-informed and gender-responsive recommendations and future directions for social work practice, policy, and research. Keywords: Sexual abuse; males; gender; trauma-informed care Over the past 20 years a growing body of literature has documented the enduring behavioral, emotional, and social consequences associated with being sexually abused. Despite this increased attention to sexual abuse, males are significantly less likely to disclose sexual abuse victimization, less likely to seek help, less likely to be suspected of being a victim, less likely to be believed upon disclosure, more likely to be blamed, and more likely to be perceived negatively when they do disclose sexual abuse than their female counterparts (Banyard, Williams, & Siegal, 2004; Holmes & Slap, 1999; O’Leary & Barber, 2008; Paul & Paul, 2016; Speigel, 2003). Researchers trying to clarify why sexual abuse in males has been overlooked have pointed to prevailing cultural norms, myths, assumptions, stigma and biases about victimization of males in general and sexual abuse of males in particular. As a result of these traditional notions of masculinity, there is often an assumption that males are not negatively affected by sexual abuse (Heru, 2001; Kia- Keating, Grossman, Sorsoli & Epstein, 2005; McGuffey, 2005; Teram, Stalker, Hovey, Schachter, & Lasiuk, 2006). Sexually abused males report significantly higher rates of posttraumatic stress disorder (Spataro, Mullen, Burgess, Wells, & Moss, 2004; Wolfe, Francis, & Straatman, 2006), depression (Gover, 2004), substance abuse (Bergen, Martin, Richardson, Allison & Roeger, 2004; DiLorio, Hartwell, & Hansen, 2002) and suicidality (Bergen, Martin, Richardson, Allison, & Roeger, 2003; Easton, Renner, & O’Leary, 2013; Miller, Esposito- Smythers, Wismoore, & Renshaw, 2013). Other internalizing and externalizing problem behaviors are also common. For example, using a population-based sample of 136,549 ______________________ Jennifer Elkins, PhD, MSSW is an Associate Professor, School of Social Work, University of Georgia, Athens, GA 30602. Katherine Crawford, PhD, LMSW is an Instructor, School of Social Work, University of Georgia, Athens, GA 30602. Harold E. Briggs, PhD is a Professor, School of Social Work, University of Georgia, Athens, GA 30602. Copyright © 2017 Authors, Vol. 18 No. 1 (Spring 2017), 116-130, DOI: 10.18060/21301 https://creativecommons.org/licenses/by/4.0/ ADVANCES IN SOCIAL WORK, Spring 2017, 18(1) 117 students in Minnesota, Duke, Pettingell, McMorris, and Borowsky (2010) found that for males, sexual abuse victimization was associated with a 45-fold increase in dating violence, a 4.5-fold increase in fighting, and a 6 to 15-fold increase in self-harm and suicidality. High risk sexual behavior is also more common (Homma, Wang, Saewyc, & Kishor, 2012; Jones et al., 2013). In a meta-analysis, Homma et al. (2012) found that sexually abused boys were significantly more likely than non-abused boys to father a child, to have multiple sexual partners, and were more likely to have unprotected sexual intercourse. Great strides have been made in advancing research approaches that reflect the reality of sexually abused males’ experiences and also tackle the challenges and complexities endemic to high quality research in this field. Nevertheless, there remains a great deal of work to be done. Drawing extensively from existing research, this critical review: (1) examines the nature, experience and impact of sexual abuse victimization for males; and (2) identifies key multilevel risk and protective factors influencing the nature, experience and impact of sexual abuse for males. The review concludes by offering trauma-informed and gender-responsive recommendations for social work practice, policy, and research. Multidimensional Risk and Protective Factors Abuse-Related Factors Timing (e.g., onset, frequency, duration) is an important source of variability in outcomes (Manly, 2005). Though the research is preliminary, some studies suggest that males are more likely to report an earlier onset (Ompad et al., 2005; Stevens, Ruggiero, Kilpatrick, Resnick, & Saunders, 2005; Walrath et al., 2003) and shorter duration of sexual abuse (Ullman & Filipas, 2005). There is some evidence to suggest that sexually abused males have worse outcomes if they report co-occurring physical abuse (Dong, Anda, Dube, Giles, & Felitti, 2003) or an earlier onset of sexual abuse (Ohene, Halcon, Ireland, Carr, & McNeely, 2005; Ompad et al., 2005; Stevens et al., 2005; Walrath et al., 2003). Frequency, duration and severity of sexual abuse have also been associated with worse outcomes for male youth (Banyard et al., 2004). Characteristics of the perpetrator have emerged as an important factor influencing the impact of sexual abuse. Several studies have found that male survivors are more likely to have extrafamilial perpetrators (Banyard et al., 2004; Feiring, Taska, & Lewis, 1999), and female perpetrators (Briere & Elliott, 2003; Dube et al., 2005; Newcomb, Munoz, & Carmona, 2009). Our knowledge in this area is complicated by the underrepresentation of female perpetrators in the literature (McLeod, 2015) and the underreporting of female-perpetrated sexual abuse. Regardless of the gender of the perpetrator, males experience a unique double stigma that impacts self-definition and self-disclosure of the abuse: with male perpetrators they often face misconceptions, stereotypes and assumptions regarding their sexual orientation; whereas female- perpetrated sexual abuse is often regarded as benign, normative, or a rite of passage that is something to be bragged about. Intrapsychic Factors Because physical evidence of sexual abuse is rare (Heger, Tison, Velasquez, & Bernier, 2002; Kelly, Koh, & Thompson, 2006), self-disclosure takes on increased importance in Elkins et al./MALE SURVIVORS OF SEXUAL ABUSE 118 the identification of sexual abuse. However disclosure is a complex and lifelong process happening mostly in adulthood (Gagnier & Collin-Vézina, 2016; Hunter, 2011). A victim’s cognitive appraisal and self-definition of the sexual abuse experience contributes to the probability of self-disclosure. This is particularly true for males. Stander, Olsen, and Merrill (2002) found that females were nearly 6 times more likely than males to self-define being sexually abused. Of the 2,010 participants who met the behavioral definition for childhood sexual abuse, only 15% of the men identified as sexual abuse survivors in comparison to 49% of the women. Males were more likely to acknowledge and define their experience as sexual abuse if deviated from accepted societal norms. For example, men were 17 times more likely to define themselves as sexually abused if their perpetrator was a family member. This illustrates the difficulty in obtaining an accurate picture of the scope and impact of sexual abuse among males. Other intrapsychic factors such as cognitive appraisal, self-esteem and self-worth, spirituality and/or religion, coping strategies, and attribution style (i.e., locus of control; self-blame) also play a central role in interrupting the pathway between sexual abuse and later adaptive or maladaptive outcomes (Bal, Van Oost, De Bourdeaudhuij, & Crombez., 2003; Crete & Singh, 2015; Feiring, Taska, & Chen, 2002; Hebert, Parent, Daignault, & Tourigny, 2006; Quas, Goodman, & Jones, 2003; Holmes, 2008). The coping strategies (Simon, Feiring, & McElroy, 2010) and cognitive appraisals (Lab & Moore, 2005; Stander et al., 2002) sexual abuse survivors use are critical ingredients in how men and boys understand, define, and experience victimization. Avoidant coping strategies, which are associated with worse outcomes, are more common among sexually abused boys (Simon et al., 2010). However, problem behaviors can also be a successful, adaptive, coping strategy. For example, a complex trauma framework classifies these self-protective responses as tension-reduction behaviors (Briere & Lanktree, 2013; Masten et al., 2005; Richardson, Henry, Black-Pond, & Sloane, 2008). Family, School and Sociocultural Factors Sexually abused males frequently face very real and entrenched problems both inside and outside of the home—including poverty, domestic violence, community violence and racial discrimination—that place them at higher risk for maladaptive developmental outcomes. Focusing on school can serve as a protective mechanism for sexually abused children living in chaotic, stressful, and unstable home environments. However, the array of characteristics, problems, and consequences associated with sexual abuse victimization can also translate into problems in academic achievement (Avery, Massat, & Lundy, 2000; Buckle, Lancaster, Powell, & Higgins, 2005) and social skills (Bal et al., 2003; Feiring, Rosenthal, & Taska, 2000; Hebert et al., 2006). Family-level risk and protective factors that potentially play a role influencing resilient adaptation include parental substance abuse, maternal education, parent-child relationship, family functioning, and parental support and belief (Kim & Cicchetti, 2004; Pintello & Zuravin, 2001; Rosenthal, Feiring, & Taska, 2003; Stevens et al., 2005). However, the parent-child relationship is a particularly critical protective factor considering it is typically tied into the parent’s belief in and support of their child subsequent to the disclosure of the abuse. ADVANCES IN SOCIAL WORK, Spring 2017, 18(1) 119 Given the individual and society level stigma, prejudice, stereotypes, and taboos surrounding homosexuality in the United States, many male survivors experience unique issues related to fears of becoming or being seen as a potential perpetrator, fear of being perceived or labeled as gay, and confusion about sexual identity that can lead to hypermasculinity and attempts to reassert masculinity (Alaggia & Millington, 2008; Dhaliwal, Gauzas, Antonowicz, & Ross, 1996; Teram et al., 2006). In addition to sexual identity and gender role stereotypes and norms surrounding masculinity, many sexually abused males also contend with the interlocking influences of racial socialization, racial stress, and racial appraisals (Hughes et al., 2006; McGuffey, 2008; Yasui & Dishion, 2007). Racial appraisal refers to the process of “how and why trauma victims construct their interpretations of trauma when there is already an excess of stigma due to their racially marginalized positions in the social order” (McGuffey, 2008, p. 219). Comparatively little research has focused on sexual abuse victimization for males who are members of racial, ethnic, cultural, religious and sexual minority populations (Kenny & McEachern, 2000). Still fewer studies have examined intragroup differences and how multiple identities intersect, particularly for males. For example, what does it mean to be a gay, African American male victim of sexual abuse? While the racial, ethnic, cultural and religious meanings ascribed to sexual abuse can be a potent risk or protective factor, little research to date has focused on sexually abused males. Trauma-Informed and Gender-Responsive Care A trauma-informed care approach is an essential component in service provision. In traditional systems of care, trauma is not well understood or taken into consideration, which leads client problems or behaviors to be viewed as separate, discrete, and unrelated to past trauma experiences (Clervil & DeCandia, 2013; Harris & Fallot, 2001) With a trauma- informed approach individuals are viewed through a ‘trauma lens’ that views behaviors, emotions, responses, and attitudes as an accumulation of survival skills created in response to trauma experiences (Clervil & DeCandia, 2013). Hopper, Bassuk, and Olivet (2010) describe a consensus-based definition of trauma-informed care as: a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment. (p.82) Although males and females may experience the same kinds of trauma, how they process and respond to these experiences may present differently based on the social expectations of each gender role (Crable, Underwood, Parks-Savage, & Maclin, 2013; Fallot & Bebout, 2012). Thus, there is also a need for trauma-informed and gender- responsive care (Crable et al., 2013; Fallot & Bebout, 2012). Given the low rates of self- disclosure, this overarching framework is imperative in creating a safe and supportive environment for male survivors being served in the various public systems (Corbin et al., 2011; Fallot & Bebout, 2012; Harris & Fallot, 2001). Difficulty can also arise when working with male survivors because the social expectations of men to be strong and independent can influence and restrict the range of emotions men are allowed to express in public and even recognize privately (Fallot & Bebout, 2012). This is especially pronounced Elkins et al./MALE SURVIVORS OF SEXUAL ABUSE 120 for African American and Hispanic/Latino males. However, ultimately there is a need for vulnerability and the ability to process a range of emotions when recovering from trauma experiences. A safe and supportive environment is a necessary component in this process. Future Directions and Recommendations Despite the increased attention to sexual abuse, victimization of males continues to be overlooked. Consequently, it is crucial that practitioners and researchers incorporate a developmentally and contextually-sensitive focus on: (1) the nature, experience, and impact of sexual abuse for males, (2) the multidimensional processes that promote and inhibit resilient outcomes, and (3) trauma-informed and gender-responsive approaches to care. One of the most straightforward ways to do this is for researchers to be intentional in including males in studies focusing on sexual abuse and testing for gender as an effect moderator. Researchers and practitioners working with specialized populations of males with appreciably higher rates of sexual abuse victimization should also be aware of the higher likelihood for sexual abuse and include this as part of the initial and ongoing screening and assessment process. Recognizing some of the unique issues males experience, and taking this into account in study designs, may increase the chances for larger samples and/or subsamples of sexually abused males. This includes: (1) increased attention to sexual abuse victimization for males who are members of racial, ethnic cultural, religious, and sexual minority populations, and (2) awareness of and sensitivity to how questions about sexual abuse are constructed. Questions should be gender-neutral and avoid labels and instead use behavioral definitions of the sexual abuse. Finally, more research is needed to better understand the impact of sexual abuse on males across multiple domains of functioning. Accounting for the influence of confounding factors in the family, peer, school, and neighborhood environment is also critical given that sexual abuse rarely occurs apart from other risk factors. Micro-level Implications for Trauma-Informed Care Practitioners and service providers should use a trauma-informed and gender- responsive framework as a guide in practice and service provision (Crable et al., 2013; Fallot & Bebout, 2012). Gender role expectations impact the initial trauma experience as well as the narrative explanation and reactions of the survivor (Crable et al., 2013; Fallot & Bebout, 2012). For male survivors it is essential that providers take into consideration the influence of male gender role socialization on their experience (Fallot & Bebout, 2012; Foster, Boyd, & O’Leary, 2012; Sorsoli, Kia-Keating, & Grossman, 2008). Issues and expectations based on gender role socialization regarding sexuality should be addressed directly, and normative male expectations should be actively examined and challenged (Fallot & Bebout, 2012; Foster et al., 2012; Sorsoli et al., 2008). Social workers should explore prevalent messages that boys and men learn about how “real” men think, act, and feel (Fallot & Bebout, 2012; Foster et al., 2012; Sorsoli et al., 2008). These messages and expectations need to be discussed openly, so males are able to learn how to integrate all parts of self (Fallot & Bebout, 2012). By acknowledging these gendered messages, social workers communicate that they are not blaming the victim and create a sense of safety and ADVANCES IN SOCIAL WORK, Spring 2017, 18(1) 121 trustworthiness for the male client (Fallot & Bebout, 2012; Foster et al., 2012; Sorsoli et al., 2008). It is important males be asked about a history of exposure to violence as soon as possible in the intake process, with sensitivity to using labels that denote victimization (Fallot & Bebout, 2012). There is, however, also a need to directly ask questions related to sexual abuse (Sorsoli et al., 2008). If specific questions regarding sexual abuse are not asked, it is unlikely these experiences will be disclosed (Sorsoli et al., 2008). These questions may need to be raised several times over the course of service provision (Fallot & Bebout, 2012; Sorsoli et al., 2008). Social workers should also be careful not to push for details prior to establishing a safe and supportive therapeutic relationship (Fallot & Bebout, 2012; Foster et al., 2012; Sorsoli et al., 2008). For example, if a man is receptive to responding to broad questions regarding discussion of a trauma history, it would make sense for a service provider to move forward with a more comprehensive trauma assessment, which should include a recovery plan and referral to specific trauma services (Fallot & Bebout, 2012). However, if the social worker is met with a negative response to initial questions regarding a trauma history, more emphasis should be placed on forming rapport and a collaborative relationship with the individual so questions regarding trauma can be revisited (Fallot & Bebout, 2012). Prefacing with the prevalence and widespread occurrence of exposure to violence can validate and normalize male survivors’ experiences and feelings (Fallot & Bebout, 2012; Knight, 2015). Once past sexual abuse has been disclosed, it is essential it be taken seriously. This includes responding calmly and empathetically, with affirmation and attentiveness (Foster et al., 2012; Knight, 2015; Sorsoli et al., 2008). This initial response to the disclosure can serve as an initial boundary-setting activity and can provide an emotionally restorative experience that aids in counteracting a client’s previous vulnerability in relationships (Sorsoli et al., 2008). If the response to initial disclosures are inappropriate or not protective, there can be increased difficulties (Foster et al., 2012; Knight, 2015). This includes: avoiding addressing the trauma entirely, probing for too much detail too soon, pushing for expression of feelings when it is not appropriate, and minimizing the impact of the trauma (Knight, 2015). It is also necessary for males to gain support and security in growing their emotional vocabulary and to be assisted in cultivating the necessary skills to identify, label, and describe emotions that may sometimes be perceived as more stereotypically feminine (Fallot & Bebout, 2012). Male survivors should be assisted in developing a wider range of options when expressing emotions (Corbin et al., 2011; Fallot & Bebout, 2012). For example, men may be reluctant to discuss emotions or relationships and this should not be viewed as a lack of engagement in services. Instead, service providers should enhance the client’s sense of safety by slowing the rate of expectation in regards to open communication and level of disclosure (Fallot & Bebout, 2012). Furthermore, male trauma survivors often encounter a dilemma related to the conflict between the identity of being a man and the experience of being powerless and a victim. These two identities can be in direct contradiction with one another and can lead to the display of all-or-nothing responses (Corbin et al., 2011; Fallot & Bebout, 2012). It is Elkins et al./MALE SURVIVORS OF SEXUAL ABUSE 122 important for service providers to recognize that these all-or-nothing responses can come in the form of overt aggression or withdrawal (Fallot & Bebout, 2012; Foster et al., 2012). If a male client is engaging in aggressive behavior, it needs to be understood in the context of survival skills and adaptive behaviors that have protected the individual when they felt threatened in the past (Fallot & Bebout, 2012). This understanding can help reduce a counterproductive response by service providers (Fallot & Bebout, 2012). The extent to which male survivors participate meaningfully in clinical treatment is often dependent on the extent to which the social worker addresses the manifestations of the legacy of sexual abuse, explores the degree of internalization of the abuse experience, and the impact of the abuse on relationships with others. In furthering the change process with male survivors, the social worker can explore the meanings male survivors attach to their abuse experiences and change the narrative they have internalized about themselves, others, and the world. The following capacity-building practice recommendations are ways social workers can help clients identify how sexual abuse experiences manifest in relational themes and patterns across relationships:  Learning to operationalize the practice of self-acceptance, emotional awareness and regulation by establishing and defining personal boundaries.  Engaging in self-acceptance through daily self-affirmations and cognitive restructuring of negative self-talk.  Aiding clients in thinking through places and times in their schedule to inventory, nourish and care for emotional, physical, social, and psychological well-being. (Fallot & Bebout, 2012). The strengths and skills of trauma survivors should also be emphasized and used as a way of promoting hope and empowerment and highlighting resilience (Fallot & Bebout, 2012). Offering choices throughout service provision should be made a top priority in decreasing issues of power within the therapeutic relationship (Fallot & Bebout 2012; Foster et al., 2012; Sorsoli et al., 2008). For example, offering the male client a choice of practitioner, such as having a male or female, can increase the client’s comfort and help decrease power dynamics (Foster et al., 2012). Clients must be included in decision-making and should work collaboratively with the service provider in the development of any treatment plans or service referrals. For example, a social worker might ask the client “How can we work together to meet your goals?” (Fallot & Bebout, 2012). Although there are several trauma-informed strategies and techniques that social workers can use with male sexual abuse survivors, an underlying sense of safety in the environment and therapeutic relationship is an essential first step (Fallot & Bebout, 2012; Foster et al., 2012; Knight, 2015). A focus on the male survivor’s strength and resilience and the awareness of how gender socialization impacts recovery are central components of all service provision. It is also important for social workers to understand the differences in how men access and utilize services, as well as the best techniques and strategies to begin and maintain this engagement (Foster et al., 2012). Because men can be hesitant about accessing services, sometimes life crises present an opening or opportunity for sexual abuse to be identified in a context that can lead to referrals and linkage to appropriate support. Another important factor that should be considered is to create a male-friendly ADVANCES IN SOCIAL WORK, Spring 2017, 18(1) 123 environment in the entrance or waiting room, which may include relevant posters or information (Foster et al., 2012). Macro-level Implications for Trauma-Informed Care Effective male-specific sexual abuse advocacy, outreach, and training can influence more proximal factors related to the prevention and amelioration of maladaptive outcomes for male survivors. This includes challenging and confronting the homophobia and traditional gender role norms that frequently silence male survivors. Social media, the internet and web-based technology are increasingly critical tools. Mandated reporting policies, requirements, and training are another area that needs greater attention. In the wake of the Penn State sexual abuse scandal (Chappell, 2012), many states began to re- examine and revise existing mandatory reporting requirements (Persky, 2012; Kelly, 2012), which vary from state to state (Child Welfare Information Gateway, 2012; Pietrantonio et al., 2013). While this stricter legislation is well-intentioned, it often neglects two components integral to achieving its goal: (1) adequate mandated reporter training; and (2) funding to ensure proper investigation of these reports in already understaffed, underfunded, and overburdened child welfare agencies. Emerging evidence suggests that the majority of mandated reporters do not receive adequate training regarding how to identify the signs of abuse and neglect (Pietrantonio et al., 2013; Wekerle, 2013). One way to address this is through minimum training requirements for all mandated reporters using a standardized, evidence-informed curriculum that all states are required to adopt (Kenny & Abreu, 2015). This is one way to ensure that mandated reporters are more knowledgeable and comfortable about recognizing sexual abuse in general, and sexual abuse in males in particular. Because school-aged male youth are surrounded all day by peers and non-relative adults, it is an ideal location for individual and group treatment aimed at enhancing social support and building positive relationships. For these reasons, the school context in particular represents a unique and potentially crucial entry point for trauma-informed support, prevention, and intervention throughout the disclosure and recovery process. Faith-based and youth-serving organizations also have the opportunity to play a similarly important role, particularly for outreach and engagement within historically marginalized communities. Religion/spirituality can provide a sense of community, meaning and purpose that can be helpful in coping with trauma (Bryant-Davis et al., 2012). At the same time, traumatic events often shatter core assumptions and beliefs about the world in ways that can lead to religious/spiritual discontent, disillusionment, and rejection. 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Clinical Child and Family Psychology Review, 10(2), 137-179. doi: https://doi.org/10.1007/s10567-007-0021-9 Author note: Address correspondence to: Jennifer Elkins, School of Social Work, University of Georgia, 279 Williams Street, Athens, GA 30602, 706-542-5473, jelkins@uga.edu https://doi.org/10.1192/bjp.184.5.416 https://doi.org/10.1037/0022-006X.70.2.369 https://doi.org/10.1177/1077559505274675 https://doi.org/10.1080/01612840600599994 https://doi.org/10.1016/j.chiabu.2005.01.005 https://doi.org/10.1016/S0145-2134(03)00035-8 https://doi.org/10.1016/j.chiabu.2012.11.005 https://doi.org/10.1016/j.chiabu.2005.08.015 https://doi.org/10.1007/s10567-007-0021-9 mailto:jelkins@uga.edu