A child can be abused in a wide array of different ways. One of the most serious ones that brings devastating effects to a child’s mental and emotional development is a child’s sexual abuse. People are struggling to put children’s rights in every government’s agenda. The 1989 United Nations Convention on the Rights of the Child states that children should be protected “from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation” (Art.19). The term ‘child abuse’ refers to physical, emotional or sexual acts committed against a child by parent or caregiver (McCoy & Keen, 2009).
In a recent national study conducted in the USA, the prevalence of child sexual abuse was 10.14%, of them 24.8% male victims and 75.2% female victims (Perez-Fuentez et al., 2013). Historically, female victims of incest by male perpetrators have been the primary focus of studies, though over the past few decades there has been a growing awareness of male victimization by either females or males. An additional reason for the seemingly low prevalence of male victims can be the fact that most of the information regarding prevalence and numbers emanates from government agencies, mainly concerned with protecting the child from abuse within the family; it has been consistently shown that while females tend to be abused by family members, males are abused by perpetrators outside the home (Coulborn, 1989).
Child sexual abuse is associated with 47% of all psychiatric disorders appearing in childhood and 26%-32% of psychiatric disorders in adulthood. Some studies have found that it accounts for reason for treatment-seeking among 30% of females in therapy and 50% of male patients (Perez-Fuentez et al., 2013). This disparity is interesting, mainly with regard to the topic of the current essay.
Several theories suggest possible gender differences in the vulnerability to long term outcomes following child abuse (Cutler & Nolen-Hoeksema, 1991). Some reports on the short term impact of childhood adversities indicated that boys are more prone to develop externalizing behaviors such as aggression, impulsivity and defiance in response to abuse, whereas girls are at risk for internalizing problems, including depression, low self-confidence, somatic complains and social withdrawal (Darves-Bornoz et al., 1998).
A study conducted on a college sample in the United States found that female students reported more significant sexual abuse severity and prevalence. They reported more distress and self-blame following the abuse and reliance on coping mechanisms of withdrawal and attempts to forget the incident(s) than males. Nevertheless, there was no difference in the likelihood of receiving negative reactions upon disclosure (Ullman& Filipas, 2005). Thus, while it may seem likely that males would face negative reactions to disclosing abuse, mainly in light of the scarce research and general sentiment according to which such abuse is rare and usually difficult to grasp.
A recent cohort study conducted in Canada found that males reported more physical than sexual abuse, and females reported a more significant prevalence of sexual rather than physical abuse (MacMillan et al., 2013).
The following essay will explore the treatment of males who have been sexually abused as children, comparing and contrasting treatment goals and methods in childhood as opposed to adulthood. I will first refer to the impact of sexual abuse during childhood on male victims- as a child and later on in life.
Impact of Child Sexual Abuse on male children and adults
Numerous reviews over the course of the past few decades have all found a distinct association between childhood victimization and increased rates of mental disorder and adjustment problems in adulthood, including depression, anxiety, anti-social behaviors, substance abuse, Post Traumatic Stress Disorder and suicide attempts (Fergusson et al., 2008).
CSA negatively impacts a number of adult developmental outcomes, including mental disorders, psychological well-being and physical health (Fergusson et al., 2013).
According to the Center for Sexual Assault and Traumatic Stress, natural responses to trauma vary between children and adults. Adults who were exposed to a traumatic event may experience fear, a loss of control; they may experience flashbacks, find it hard to concentrate, feel guilt, foster a negative self-image, feel depressed and experience a disruption in his or her relationships (MacMillan et al., 2013).
Children, on the other hand, may experience fear or anxiety, and may even display psychotic-like symptoms including bizarre behavior, dissociation, hallucinations or flashbacks. In addition, their behavior may tend to be avoidant or aggressive. Some children may exhibit sexualized behavior or make inappropriate sexual gestures. Lastly, children exposed to trauma may experience difficulty relating to others- children and adults alike (MacMillan et al., 2013).
It is important to note that the term ‘adult CSA victims/ survivors’ refers to adults who have been sexually abused as children, and may therefore display symptoms that are different than those displayed by adults exposed to traumatic experiences in adulthood.
The literature on the long-term impact of CSA in adulthood indicates that while adult survivors may exhibit symptoms that resemble a certain disorder (such as Depression or PTSD), more often than not they do not meet all clinical criteria, and exhibit a mixture of symptoms corresponding to several diagnoses. Therefore, one should not rely on one diagnostic system, nor should one course of treatment be employed alone. For instance, the ‘classical’ PTSD model cannot account for the entirety of CSA survivors’ symptoms, as reflected in the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association (DSM). Moreover, it seems that CSA does not fit with the theoretical formulation of PTSD, since it does not take into account the interpersonal nature of the abuse. To address this issue, several theoreticians and clinicians prefer to perceive the impact of CSA in four ‘traumagenic dynamics’: traumatic sexualization, betrayal, powerlessness and stigmatization (Davis& Petretic-Jackson, 2000). Therefore, treatment must be wary of these issues and their implications, and could benefit from a multi-modal approach.
Among males identified as CSA victims, one of the pioneering studies in the field of male CSA had found that these victims are characterized by sexual compulsiveness, masculine identity confusion and relationship dysfunction (Dimock, 1988). Though these results should be examined bearing in mind significant changes occurring over the past three decades since it was published, the study highlights a variety of possible implications in adulthood that may serve as the initial reason for seeking treatment.
Indeed, earlier investigations into adult outcomes of CSA did not include male victims, either assuming that they do not exist, or otherwise assuming that the outcomes would be the same as females (Yancey& Hansen, 2010).
Not only do male victims tend to avoid reporting abuse, but they also tend to deny the impact of such abuse on their lives. In addition, professional underestimate the prevalence of CSA among males and usually will not hypothesize that their patients have been abused, therefore failing to create the conditions enabling disclosure of the abuse (Holmes et al., 1997).
In general, male victims tend to show more aggressive behaviors, conduct problems and substance abuse, as the most common difference is the male victims’ tendency to display externalizing symptoms as opposed to female victims. Among adolescents, male victims displayed more trouble at school, delinquent behavior and conduct problems (Yancey& Hansen, 2010).
Furthermore, a recent study has found that several factors increase the odds of suicidal attempts among male victims of CSA: duration of sexual abuse, abuse severity, use of force during abuse, conformity to masculine norms, level of depressive symptom and suicidal ideation (Easton et al., 2013).
In a study investigating the impact of CSA among male victims and their spouses, participants described suffering emotional intimacy problems during sexually intimate moment. Several spouses have reported partial or full dissociation and detachment. Moreover, participants reported that they did not enjoy some aspects of their sexual intimacy during part or all of their relationship, either because of CSA history or lack of satisfaction. Some referred to their sexual relationship as a chore (Jacob& Veach, 2005).
Treatment of male CSA victims
Treatment of CSA victims varies in regards to its objective and means. The objective differs between age groups, as distance from the time of the abuse plays a crucial role; in essence, treatment in childhood aims to prevent or decrease consequent psychopathology in adulthood. In General, it was found that coping strategies in the immediate aftermath of the abuse consisted of avoidance strategies while coping strategies in adulthood are aimed at attempting to integrate their experiences (Walsh et al., 2009).
In essence, the treatment of children and adults differs; there is a growing tendency to work with children’s parents, families or caretakers as an integral part of therapy, therefore creating a social support network. In addition, when treating trauma, the focus of treating children is to process the trauma and cultivate positive and constructive coping mechanisms, whereas adults have already created these coping mechanisms and they have integrated into their personality and behavioral structures. In addition, adults may lack social support, and it is more difficult to help them create supportive surroundings.
Children
Retrospective studies among CSA victims indicated that in the direct aftermath of the abuse, children tended to use coping strategies such as psychological escape, physical resistance and disclosure (Walsh et al., 2009).
Unlike among adults, children exposed to sexual abuse display a limited cluster of symptoms. These include fear reactions, hyper-vigilance, aggression and dissociation from reality (Cohen et al., 2006).
The most common forms of treatment employed in treating children who have been victims of sexual abuse include several foci. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has been originally developed for children exposed to CSA. It has been superior to all other treatments in improving PTSD and depressive symptoms. Nevertheless, seeing as boys tend to display more problems related to behavior and conduct, this may not be the therapy of choice. The treatment specifically targets trauma related symptoms including PTSD, depression, anxiety, trauma-related shame and trauma-related cognitions such as self-blame. In addition, this treatment includes parent training (for parents who were not perpetrators of the offense) to help the parents help the child. This is a hybrid model integrating principles of cognitive, behavioral, interpersonal and family therapy. The treatment components include psycho-education, trauma narration, in-vivo desensitization, cognitive processing and relaxation skills (Cohen et al., 2006).
Psychodynamic treatment of CSA victims is intended to reduce PTSD symptoms in addition to increasing awareness of unconscious defense mechanisms in order to enhance positive adaptation and possibly eliminate (Trowell et al., 2002).
Child-Parent Psychotherapy is a dyadic relationship model addressing PTSD and similar symptoms among very young children (younger than 6 years). It is a trauma-focused relationship-based treatment model, incorporating cognitive, behavioral and psychodynamic principles. It should be noted that in addition to addressing trauma-related symptoms such as fearfulness, aggression and accident-prone behavior, CPP creates a joint child-parent trauma narrative of the violence experiences, including age-appropriate exploration and correction of cognitive distortions (Lieberman& Van Horn, 2005).
Finally, family interventions are systemic programs focusing on improving parent-child interactions as well as providing parent training. Another version of such treatment is multi-family group therapy (Cohen et al., 2006).
Adults
In general, adult victims of CSA use a variety of coping methods, including cognitive avoidance, in order to keep from being overwhelmed by threatening emotions, and behavioral strategies intended to manage feelings of helplessness, powerlessness and lack of control (Walsh et al., 2009).
One study found that positive coping mechanisms differentiated between male victims suffering from psychopathology and those who did not (O’Leary, 2009). Therefore, the main objective in treating adult male survivors would be to create and cultivate positive coping mechanisms such as seeking social support, reframing events and implementing practical strategies for facing the impact of these experiences. In addition, adult survivors may experience intimacy problems and interpersonal dysfunctions that may very well have shaped their entire world view and self-view. Unlike children whose character is in formation, adults come to therapy with life-long experiences, beliefs and cognitions that are harder to alter since they have been present for many years and may have been reinforced.
Research supports the importance of finding meaning in the abuse experiences, as this cognitive coping strategy was associated with less psychological distress, less isolation and better overall adjustment (Walsh et al., 2009).
Literature addressing social dysfunction among adult CSA survivors includes the issues, strategies and treatment processes, but these have yet to be evaluated in clinical trials, as empirical data remains scarce. Moreover, it was found that social support mediated the relationship between child abuse and anxiety or depression in adulthood (Sperry& Spatz-Widom, 2013).
Therefore, it seems that treatment for adult male survivors of CSA should consist of providing social and emotional support, in addition to alleviating emotional distress through psychiatric assistance. The importance of alleviating emotional distress is twofold. First, in order to benefit from therapy, one needs to be in a facilitating frame of mind, able to discuss painful memories or feelings and endure possible distress caused in the course of treatment while the memories and feelings are being worked through. The second reason lies in the prevalence of suicidal attempts among adult male CSA survivors. Many studies have found that psychotherapy alone is not sufficient in preventing suicide; more often than not, psychiatric intervention in conjunction with psychotherapy is the best course of action.
References
Cohen, J. A., Mannarino, A. P., Murray, L. K., & Igelman, R. (2006). Psychosocial Interventions for Maltreated and Violence‐Exposed Children. Journal of Social Issues, 62(4), 737-766.
Cutler, S. E., & Nolen-Hoeksema, S. (1991). Accounting for sex differences in depression through female victimization: Childhood sexual abuse. Sex roles, 24(7-8), 425-438.
Darves-Bornoz, J. M., Choquet, M., Ledoux, S., Gasquet, I., & Manfredi, R. (1998). Gender differences in symptoms of adolescents reporting sexual assault. Social Psychiatry and Psychiatric Epidemiology, 33(3), 111-117.
Davis, J. L., & Petretic-Jackson, P. A. (2000). The impact of child sexual abuse on adult interpersonal functioning: A review and synthesis of the empirical literature. Aggression and violent behavior, 5(3), 291-328.
Easton, S. D., Renner, L. M., & O’Leary, P. (2013). Suicide attempts among men with histories of child sexual abuse: Examining abuse severity, mental health, and masculine norms. Child abuse & neglect.
Fergusson, D. M., Boden, J. M., & Horwood, L. J. (2008). Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child abuse & neglect, 32(6), 607-619.
Fergusson, D. M., McLeod, G. F., & Horwood, L. J. (2013). Childhood sexual abuse and adult developmental outcomes: Findings from a 30-year longitudinal study in New Zealand. Child abuse & neglect.
Jacob, C. M. A., & Veach, P. M. (2005). Intrapersonal and Familial Effects of Child Sexual Abuse on Female Partners of Male Survivors. Journal of Counseling Psychology, 52(3), 284.
Lieberman, A. F., & Van Horn, P. (2004). Don't Hit My Mommy: A Manual For Child-parent Psychotherapy With Young Witnesses Of Family Violence Author: Alicia F. Lie.
MacMillan, H. L., Tanaka, M., Duku, E., Vaillancourt, T., & Boyle, M. H. (2013). Child physical and sexual abuse in a community sample of young adults: Results from the Ontario Child Health Study. Child abuse & neglect.
O’Leary, P. J. (2009). Men who were sexually abused in childhood: Coping strategies and comparisons in psychological functioning. Child abuse & neglect, 33(7), 471-479.
Pérez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S., & Blanco, C. (2012). Prevalence and correlates of child sexual abuse: a national study. Comprehensive psychiatry.
Sperry, D. M., & Widom, C. S. (2013). Child abuse and neglect, social support, and psychopathology in adulthood: A prospective investigation. Child abuse & neglect.
Trowell, J., Kolvin, I., Weeramanthri, T., Sadowski, H., Berelowitz, M., Glasser, D., & Leitch, I. (2002). Psychotherapy for sexually abused girls: psychopathological outcome findings and patterns of change. The British Journal of Psychiatry, 180(3), 234-247.
Ullman, S. E., & Filipas, H. H. (2005). Gender differences in social reactions to abuse disclosures, post-abuse coping, and PTSD of child sexual abuse survivors. Child Abuse & Neglect, 29(7), 767-782.
Walsh, K., Fortier, M. A., & DiLillo, D. (2010). Adult coping with childhood sexual abuse: A theoretical and empirical review. Aggression and violent behavior, 15(1), 1-13.
Yancey, C. T., & Hansen, D. J. (2010). Relationship of personal, familial, and abuse-specific factors with outcome following childhood sexual abuse. Aggression and Violent Behavior, 15(6), 410-421.
