Building gender appropriate and transformative services

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). Gender, and in particular 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 and policy development in the 1970s, 1980s, 1990s, and in some cases into the 2000s, emphasised support for the ‘female victim,’ as the identified client, whether sexually abused in childhood or sexually assaulted as an adult.

The attached image, part of the forensic medical examination tool kit in Queensland until 2003, graphically demonstrates this early focus on the female victim.

It is only in the 1990s and 2000s that the importance of developing gender appropriate services for men subjected to child sexual abuse started to become emphasised — often by women practitioner/researchers (Crome, 2006; Davies, 2002; Donnelly & Foster, 2005; Kenyon, 1996; O’Leary, 2001; Washington, 1999; Worth, 2003).

In 1998 the Australian National Standards of Practice Manual for Services Against Sexual Violence (National Association of Services Against Sexual Violence [NASASV]) 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.” (NASASV, 1998, p. vii).

In 2009 a Review of Queensland Health Response to Adult Victims of Sexual Assault continued to note 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).

The reality is that service development to assist men sexually abused in childhood has up until now been fragmented, with service access and quality determined by which state or territory you are in, where you are in that jurisdiction, and often influenced by whether a particular practitioner or identity has taken an interest in the issue. For example, in Victoria since the 1990s, a number of the Centres Against Sexual Assault (CASA) 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, despite the fact that funding for non-government sexual assault service was provided only to support women aged 15 and over until 2012, many services provided some sexual assault counselling to men.

Awareness of this historical context is important for practitioners to remember when talking with men who have been sexually abused, in that men will often berate themselves for failing to come forward and access support earlier, when the reality is that in the majority of jurisdictions awareness of sexual abused of males, and the need for organised service responses for men, did not exist. The Royal Commission into Institutional Responses to Child Sexual Abuse has rightly placed a spotlight on the past (and present) institutional, service, and individual failures to respond appropriately to men and women subjected to child sexual abuse.

Understanding and drawing upon men’s health initiatives

In 2010, the Australian 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 (Department of Health and Ageing, 2010). 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.

A focus on men’s health and wellbeing in general is valuable, in that it situates the problems of the sexual abuse of boys and 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.” (p. 19).

Reference to men’s health literatures is also useful, in that it allows us to work through how gender and sexual abuse interact and impact on men’s health and wellbeing, and to identify effective intervention strategies that do not over or under emphasise either the influence of gender or sexual abuse in men’s lives.

When working with men who have been sexually abused it is useful to note that they live within a culture where men in general have:

• Less knowledge and awareness of health issues.
• Lower likelihood to access GP, health care practitioners.
• Lower mental health literacy.
• Less likelihood to ask questions when they do seek help.
• Poorer diet and nutrition.
• Higher consumption of alcohol and illicit drugs.
• Higher use of tobacco.
• Increased negative impact of unemployment.
• Greater likelihood of being a victim of assault, robbery, and homicide.
• Greater likelihood of perpetrating violence.
• Greater likelihood of committing suicide.
• Reduced life expectancy compared to women (living on average 6 years less).

In working with men, it is useful to maintain an awareness that:

“Many of the tasks associated with seeking help from a health professional, such as relying on others, admitting a need for help, or recognizing and labeling an emotional problem, conflict with the messages men receive about the importance of self-reliance, physical toughness, and emotional control.”

— Addis & Mahalik 2003, p.7.

One of the values of presenting men’s health information, and how ‘masculine norms’ shape men’s lives and help seeking, is that it means making change and improving well-being is not solely centred on resolving the legacy of sexual abuse. It highlights how difficulties that men face and their reluctance in accessing support is very much shaped by growing up and living in our culture as ‘a man.’ It places the lens on and problematises dominant masculinity, and in the process creates space to challenge the sense of failure men can experience in not measuring up to the masculine ideal. The individual man lives and acts within a cultural constructions of masculinity which itself significantly shapes his lives and help seeking. Making explicit and unpacking the ‘straight jacket’ of limited masculine norms can assist men who have been sexually abused to put aside self judgement and sense of personal failure for ‘not coping’.

Gender appropriate and transformative services

The creation of gender appropriate/transformative service responses for men who have been sexually abused benefits from consulting with both women and men to reference and draw upon knowledge, skills, and initiatives. In 2015, the National Association of Services Against Sexual Violence produced the 2nd edition of its Standards of Practice Manual, with a primary aim of “defining and describing an expected quality of services for the sexual assault sector across Australia” (2015, p.6). The manual emphasises the importance of practitioners taking “gender issues into account” in developing service responses (NASAV 2015, p.51). 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 gender 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.
• Centralised monitoring, evaluations, and support for the implementation of policy and practice guidelines (Australian Women’s Coalition, 2010).

 

Building connections

Engaging services

Given that we know that 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 a developing model of service delivery that is especially relevant for men subjected to child sexual abuse. This is particularly true 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, as well as their partners and families, should have access to:

• Comprehensive information and practical resources, including web based material.
• 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. Another challenge is to understand that men’s reluctance to access services sits within a culture where men, in general, visit health care professionals 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. 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, 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 has decided that ‘now’ is the time to sort this out. Making time for a phone conversation or an initial meeting is critical — or some men may never call 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 rooms, 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 men friendly environment, and this can often lead to further disengagement.
• Providing associated, relevant services — like relationship and couple’s 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.

Understanding men’s help seeking

Addis and Mahalik, in their 2003 article “Men, Masculinity and the Contexts of Help Seeking,” outline some questions and concerns men are often working through, or seeking to have confirmed or denied, when determining whether to access support. Men often ask themselves:

Is the problem ‘normal’?

If the man perceives the problem as ‘not normal’, he is less likely to seek help. This highlights the importance of raising community awareness and increasing visibility of information and material about the sexual abuse of males.

Is the problem a central part of me?

If the problem is seen as a central part of his identity, or that he will be treated differently because of this, he is less likely to seek help. This highlights the importance of differentiating and disentangling the person from the problem (see the Living Well campaign “Sexual abuse is something that happened to me. It’s not who I am”).

Will I have the opportunity to reciprocate?

If there is an opportunity to reciprocate in some way, the man is more likely to access the service. To reciprocate and contribute fits with masculine ideals of being active (as opposed to being passive recipients of service, which would acknowledge vulnerability and ‘need’ for help). This is why some men value group programs.

How will others react if I seek help?

Men live in relational contexts, and are sensitive to how other men in their circle of friends or community may respond to their help seeking about this problem. This highlights the importance of building a community of support that provides encouragement for men to access assistance to deal with difficulties.

What can I lose if I ask for help?

A concern that others may negatively judge a man, or that acknowledging difficulties and asking for help makes him feel out of control and does not fit with his view of the ‘man he wants to be’, will lessen his likely hood of accessing support. This concern highlights the value of providing a confidential and private service, and also of male role models (local men, famous men) publicly speaking out, acknowledging difficulties, and emphasising the importance of accessing support.

It is particularly important to create a community of support — a welcoming, men friendly service environment with accompanying information and resources that address some of the concerns described above — when we understand that men who have been sexually abused are often starting from the assumption that many of the difficulties are unique to them and that the service won’t be able to help. Evidence suggests that men’s willingness to engage and access support is also influenced by the perceived qualities and skills and the gender of the practitioner.

Practitioner qualities

Qualities men appreciate when communicating in primary health care settings:

• Practitioners being attuned to men’s attitudes and interests, and aware of masculine hang-ups (Harvard Health Letter, 2008; RACGP, 2006b; Richardson, 2004; Wilkins, et al., 2008).
• Adopting a frank approach. Being concise, direct, and matter-of-fact when communicating with men.
• Demonstrating professional competence — keeping abreast of the latest information, and conveying this in a meaningful and helpful way.
• Providing written information.
• Using humour thoughtfully. More than just sharing a joke, it is about facilitating a ‘laid back’ and ‘friendly’ environment in which men feel comfortable to speak about their concerns.
• Showing empathy: The ability to communicate easily, at the same level of the man, listening and understanding his perspective.
• Being proactive and sensitive. Supporting men to resolve health issues promptly with referrals (trusted recommendation) to another professional and/or specialist where appropriate. (Smith JA, et al., Med. J. Aust, 2008; 189:618-21. “Engaging men in primary care settings,” Andrology Australia, 2009).

Given the silencing and shame of men who have been sexually abused, they are unlikely to name abuse or associated difficulties without some evidence that the organisation or practitioners have knowledge and understanding about the issue, and importantly ‘how to help.’ The quality of being able to provide practical support that helps to effect change the man is seeking is important. Men’s interest and investment in solution focused approaches fits with the masculine norm and expectation of ‘engaging in active problem solving.’ To have a clear sense of purpose, and to have a road map for meeting desired outcomes, are an important starting prerequisite for some men — otherwise, what would be the purpose in ‘opening up the can of worms?’

Another key expectation for practitioners and services to be aware of is that for some men the gender of the practitioner is important.

Gender of the practitioner

The gender of the practitioner is important to some men. Ideally, men who have been sexually abused should be offered a choice as to the gender of the practitioner he wishes to work with (Denov, 2004). Given that the majority of boys are sexually abused by males, it is not surprising that a number of men report a preference for talking with a woman (Chowdhury-Hawkins, Mclean, Winterholler, & Welch, 2008). There is no hard and fast rule here, for some men the gender of the practitioner is more important a concern than others.

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). Some men will choose to speak with a female first and then a male, or vice versa. This, again, highlights the importance of practitioners’ awareness of how gender constructs influence the lives of men sexually abused in childhood, both in relation to their own lives, and how they perceive the knowledge, skills, and understanding of practitioners.

Although providing choice as to the gender of practitioner is ideal, for some services and private practitioners, due to funding limitations, geographical location etc., this is not possible. In some instances, initial preferences can be overcome by practitioners actively engaging with the man, building rapport, and demonstrating their sensitivity, knowledge, and understanding of what are his concerns and how they may be addressed. This is more likely if the worker possesses comprehensive gender awareness and analysis themselves, and has done the work to understand how gender intersects and influences men’s experiences of childhood sexual abuse.

In order to properly support men and their loved ones, a practitioner would have access to regular supervision with someone who themselves has a comprehensive gender analysis and understanding of trauma, childhood sexual abuse, and its impacts.

 

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