Starting base

“Men have been sexually abused in childhood have been bumping into services, homelessness, drug and alcohol, mental health services, for years. We are only now starting to ask the question and to develop service response to address their trauma histories” (Counsellor at Service Assisting Male Survivors of Sexual Assault Canberra).

Development of a trauma informed, gender and culturally appropriate recovery oriented service response to address impacts and difficulties and enhance personal and relational well-being of men who have been sexually abused in childhood is a work in progress.

The importance of developing practice responses to better support those subjected to sexual violence was initially taken up by the women's movement in the 1970s and 1980s, resulting in the creation of specialist sexual assault services for women. Since then, there has been an ongoing focus on developing research and practice knowledge to improve the quality of counselling and support to women and men who have been sexually victimised, which has included the development of sexual assault service standards of practice (e.g. VCASA, 2014; NASASV, 2015).

Whilst initially, The National Association of Services Against Sexual Violence (NASASV, 1998) Standards of Practice Manual were developed specifically to enhance service responses to women, the current NASASV Standards have been designed to be more gender inclusive.

The current Standards of Practice Manual (NASASV, 2015) provides valuable orienting principles for practitioners and services responding to adults subjected to childhood sexual abuse or sexual assault (whether the service is a designated 'sexual assault service' or not).

Trauma

The Royal commission defines 'trauma' as referring to:

“an event that is extremely harmful or distressing, such as experiencing or being threatened with sexual violence. The word also refers to a person’s psychological response to the distressing event, immediately and over the medium and long term. In reference to child sexual abuse, we use ‘trauma’ to describe experiences of abuse and institutional responses to it, as well as the ongoing impact they have on the survivors’ psychological wellbeing. Traumatic events ‘involve threats to life or bodily integrity, or a close encounter with violence and death’ which can ‘overwhelm the ordinary human adaptations to life’ and ‘confront human beings with the extremities of helplessness and terror’”.
p. 24, The Royal Commission Vol 9: Advocacy, support, and therapeutic treatment services

The Standards of Practice Manual aligns with the Royal Commission's definition of 'trauma' as referring to both "the actual traumatic event/s and the trauma response/s experienced by the person" and notes:

“that each person’s experience and expression of trauma is personal, unique and not only a function of the particulars of the assault (two people may respond differently to a shared experience), but also the person’s history and trauma history, relationship with the perpetrator, stage of life, support networks, cultural context and socialisation” (NASASV, 2015, p. 17).

In noting this complex interplay of factors that influence the experience, impact and expression of trauma for each person, the Standards of Practice highlights and emphasises the importance of developing a service response that is person/client centred, supports victim's rights and is sensitive to gender and power relations.

Key principles of client centred practice:

• Validating the client's experience of the sexual assault and trauma.
• Not judging the client, or making assumptions about what she/he needs.
• Being guided by the client and addressing the client's stated priorities.
• Offering choices/alternatives to the client, and seeking informed consent.
• Prioritising safety, dignity and respect.
• Providing sufficient time for the client to respond.
• Working together to demonstrate the client's own power and resources.
• Being open, honest and respectful.
• Involving clients in service design and evaluation.

Service delivery consistent with the United Nations Declaration of Victim's Rights:

• The right to be treated with respect and recognition.
• The right to be referred to adequate support services.
• The right to receive information about the progress of the case.
• The right to be present and give input to the decision-making.
• The right to counsel.
• The right to protection of physical safety and privacy.
• The right of compensation, from both the offender and the State.

(United Nations Department of Public Information, February 2000 in NASASV, 2015, p. 18).

The NASASV Standards emphasis on victim's rights is significant, and highlighted here as a key element of developing trauma informed practice with men who have been sexually abused. An important aspect of the work involves an acknowledgement of the fact that a crime has been committed against them, often producing psychological, physical, relational and social effects. In working with men who have been sexually abused in childhood, practitioners have a responsibility to inform the men of the options and support available if they choose to engage with the criminal justice system.

Sensitivity to power relations

As well as emphasising client centred service delivery that support victim's rights, the NASASV Standards of Practice highlights the importance of maintaining a sensitivity to power relations:

“Two central features of psychological trauma are disempowerment and disconnection from others and self. Recovery therefore, must be based within empowerment, new connections and in the context of relationships. Attention to power imbalance are critical elements across all aspects of service delivery” (Herman, 1992 in NASASV, 2015, p. 17).

This ongoing attention to addressing power relations is not surprising given that sexual assault is an interpersonal abuse of power that produces a sensitivity to unequal power dynamics. The Standards of Practice emphasise an activist approach:

“The practitioner should pro-actively address the inherent power differential between them self and their client. There will also be elements of consciousness-raising, social and gender-role analysis, re-socialisation and, to varying degrees, social activism” (Israeli, A & Santor D, 2000)” (NASASV 2015, pp. 17-18).

Gender analysis

Sensitivity to developing a gender appropriate service response to men who have been sexually abused in childhood is the focus of this elearning package. The Standards of Practice Manual (NASASV 2015, p. 17) foreground feminist and gendered frameworks that:

“also recognise that men are subject to stereotypes and the dominating social expectations around traditional models of masculinity; and that both sexes can experience detrimental consequences resulting from these gender expectations and the violent use of power.”

The gender analysis adopted here recognises that, in our society, gender influences who is subjected to sexual abuse and assault, where, and in what ways; how sexual abuse is experienced; what are a person's likely responses; ways of managing and subsequent impact on self and a person's help seeking behaviour; and the support available to them and what responses are effective (Briere & Scott, 2006, p. 78; Covington, Griffin & Dauer, 2011; Foster, Boyd & O'Leary, 2012). In seeking to develop gender appropriate responses, it is recognised that there are both similarities and differences in men's and women's experiences of sexual violence (and heterogeneity amongst men and women) and that there is a need to create evidence-based service provision that recognises, but does not amplify these (Hooper & Warwick, 2006, p. 473).

In foregrounding practice principles of a client centred, victim's rights based framework that is sensitive to and addresses gender and power relations, it is recognised that there is a growing emphasis amongst government, not for profit and for profit service providers and practitioners on utilising and implementing trauma informed care and practice.

Trauma informed care and practice

“‘Trauma-informed approaches’ refers to ‘frameworks and strategies to ensure that the practices, policies and culture of an organisation, and its staff, understand, recognise and respond to the effects of trauma on client wellbeing and behaviour’.The key principles of a trauma-informed system of care include:

• ‘having a sound understanding of the prevalence and nature of trauma arising from interpersonal violence and its impacts on other areas of life and people’s functioning
  
• ensuring that organisational, operational and direct service-provision practices and procedures promote, not undermine, the physical, psychological and emotional safety of consumers and survivors
  
• adopting service cultures and practices that empower consumers in their recovery by emphasising autonomy, collaboration and strength-based approaches recognising and being responsive to the lived, social and cultural contexts of consumers (for example, recognising gender, race, culture and ethnicity), which shape their needs as well as recovery and healing pathways
  
• recognising the relational nature of both trauma and healing’.”
  p. 25, Royal Commission Final Report Vol 9: Advocacy, support, and therapeutic services 

Key principles of trauma informed care and practice are presented here as they overlap and compliment the practice principles and framework outlined in the Standards of Practice Manual (NASASV, 2015), and support practitioners in developing a more comprehensive and effective service response to men subjected to sexual violence.

Key principles of trauma informed care and practice:

• Creating a safe supportive environment.
• Prioritising individual choice and self determination.
• Developing understanding and awareness of common impacts and triggers.
• Enhancing individual resources and support to better manage impacts.
• Foregrounding a recovery oriented, empowering, strengths based approach.
• Developing trusting, collaborative, respectful relationships (MHCC, 2013).

In identifying key principles, it is important to note that trauma informed practice is conceptualised as more than an individual practice response. Quaderia and Hunter emphasise in a discussion paper examining "Principles of Trauma-informed approaches to child sexual abuse" (2016, p. 5) for the Royal Commission into Institutional Responses to Child Sexual Abuse, that trauma informed care is "envisaged as a systemic change approach that is reflected at all levels of the service system". A whole of organisation trauma informed approach involves:

• Having a sound understanding of the prevalence and nature of trauma arising from interpersonal violence and its impacts on other areas of life and people's functioning (see Prevalence and Characteristics and Effects Module).
• Ensuring that organisational, operational and direct service–provision practices and procedures promote, not undermine, the physical, psychological and emotional safety of consumers and survivors.
• Adopting service cultures and practices that empower consumers in their recovery by emphasising autonomy, collaboration and strength-based approaches.
• Recognising and being responsive to the lived, social and cultural contexts of consumers (for example, recognising gender, race, culture and ethnicity), which shape their needs as well as recovery and healing pathways.
• Recognising the relational nature of both trauma and healing (Quaderia and Hunter, 2016, pp. 5-6).

The development and implementation of trauma informed care and practice is presented here as a priority, in recognition that "non trauma – informed services often mirror the power and control experienced in the abusive relationships that caused the past trauma making recovery difficult and the risk of re-traumatisation real" (MHCC, 2013, p. 9). The deleterious impacts of inadequate or ineffective service responses to women and men subjected to sexual violence, commonly referred to as the 'second assault', has been highlighted since the 1980s, (Williams & Holmes 1981; Madigan & Gamble 1991; Donnelly & Kenyon 1996; Scarce 1997; Washington 1999; Davies 2002, Foster, Boyd & O'Leary 2012).

Recovery oriented practice

An additional framework that many practitioners will be familiar with, and can guide them in developing more comprehensive service response to men subjected to sexual violence, is the Recovery-Oriented Mental Health Services. The National Framework for Recovery-Oriented Mental Health Services presents a number of key domains of practice:

Domain 1

Promoting a culture and language of hope and optimism. A service culture and language that makes a person feel valued, important, welcome and safe, communicates positive expectations and promotes hope and optimism — this is central to recovery-oriented practice and service delivery.

Domain 2

Person 1st and holistic: Putting people who experience mental health issues first and at the centre of practice and service delivery; viewing a person's life situation holistically.

Domain 3

Supporting personal recovery: Personally defined and led recovery at the heart of practice rather than an additional task.

Domain 4

Organisational commitment and workforce development: Service and work environments and an organisational culture that are conducive to recovery and to building a workforce that is appropriately skilled, equipped, supported and resourced for recovery-oriented practice.

Domain 5

Action on social inclusion and the social determinants of health, mental health and wellbeing: Upholding the human rights of people experiencing mental health issues and challenging stigma and discrimination; advocating to address the poor and unequal living circumstances that adversely impact on recovery.

Development of trauma informed practice

The Trauma Informed Care and Practice Framework and the National Framework for Recovery-Oriented Mental Health Services are presented here as frameworks that overlap, compliment, and can support practice and service delivery outlined in the NASASV Standards of Practice Manual. However, the Trauma Informed Care and Recovery Oriented Frameworks are best understood as providing a valuable starting base that benefit from refinement to include knowledge and practice elements that are of specific relevance when working with men who have been sexually abused in childhood.

Trauma informed practice with men who have been sexually abused in childhood involves providing information and support (psycho-education) about the specific impacts, physiological and interpersonal challenges of sexual violence, on addressing common difficulties, isolation, self blame, shame, guilt, fractured sense of self, questions of masculinity and sexuality. And, as highlighted earlier, doing so in a way that acknowledges that these struggles and difficulties are the result of a criminal offence being committed against them. In 2016, Blue Knot Foundation authored Trauma and the Law: Applying Trauma-informed Practice to Legal and Judicial Contexts, which identified a key principle of trauma informed practice is a:

“(4) Consistent emphasis on what may have happened to a client, rather than what is ‘wrong’ with client/s” (Blue Knot Foundation, 2016, p. 6).

Without such a 'consistent emphasis', men who have been sexually abused can be quick to 'beat up on themselves' and see struggles and difficulties as another example of their 'personal failure', rather than the 'effect' of a sexual offence was committed against them as a child.

In addition to the above, practitioners working with men sexually abused in childhood benefit from adopting a life course approach that recognises there are key moments for intervention and support, an awareness of common difficulties that men can face and their preferred coping strategies.

Life course approach

In seeking to develop trauma informed practice, men who have been sexually abused report that there are moments throughout their life when impacts and difficulties are triggered and surface and that these critical moments are opportunities for intervention and support. These include:

• Discovery or disclosure of sexual abuse or sexual assault.
• At times of crisis or distress, when triggered, flashback, returned memories.
• Engagement with service system, health, mental health, drug and alcohol, addiction, homelessness.
• Exposure to media discussions, information, support, education, sex education.
• Imprisonment, arrest, probation or parole.
• When making a police statement or attending court as complainant/witness.
• Starting a relationship, ending a relationship, leaving home or institution, birth of child, child turning the age they were when abused, seeing the perpetrator or hearing of their death, death of parent or significant other.
• When experiencing workplace difficulties or stress, time of significant life change.
• Health check up, vasectomy, colonoscopy, prostate check, dental work, operations.
• Entering residential or aged care facilities.

Practitioners, social workers, psychologists, health workers, GPs, support workers, carers, etc. do not need to be experts in how to respond, but have awareness how people who have been sexually abused may be impacted and what may be critical moments that offer opportunities for intervention and support and where appropriate referral.

Common effects

As outlined above, a key element of service development is an awareness of common impacts, triggers and difficulties that men subjected to sexual violence can experience. Whist there is no prescribed way that people are impacted, or respond to sexual abuse or assault (everyone is different), we do know childhood sexual abuse can have a profound effect on a person's physical and mental health and relational well-being. In brief, men who have experienced childhood sexual abuse report experiencing:

• Guilt, shame, self blame.
• Lack of trust, sense of betrayal.
• PTSD, depression/anxiety, clinical diagnosis.
• Overwhelming emotions/anger.
• Flashbacks/nightmares.
• Weight loss, weight gain, body dysmorphia.
• Suicidality/self harm.
• Relationship difficulties.
• Sexual difficulties.
• Sleep difficulties, insomnia.
• Mental health problems.
• Abuse of drink and drugs.
• Physical health difficulties.
• Increased risk of homelessness and involvement with criminal justice system.
• Increased risk of re-victimisation (Banyard, Williams, & Siegel, 2004; Briere & Scott, 2006; Tewkesburg, 2007).

Presented above and below is a brief overview of common effects, complex trauma and coping strategies. For a more comprehensive discussion see the Effects Module.

Complex trauma

Whilst men who have been sexually abused report high rates of PTSD (intrusive re-experiencing, effortful avoidance of distressing trauma-related stimuli, alterations in cognitions and mood, arousal and reactivity), it is understood that the complex cluster of difficulties they can face may be better described as Complex PTSD or Complex Trauma (Noting that Complex PTSD is not a diagnosis in DSM-5, but is planned for inclusion in the ICD-11, due for release in 2017/18).

The Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder acknowledge the complex cluster of difficulties ‘beyond the recognised symptoms of PTSD’ that survivors of childhood sexual assault can present with:

Childhood sexual abuse can limit, delay or impair attainment of developmental milestones and interpersonal skills entirely. Therefore, rather than working to recover and re-establish skills and a sense of self, individuals can require support to acquire skills and establish a sense of identity and self separate from the traumatic experience. Trauma informed practitioners recognise that at the time of the sexual abuse and afterwards a person can adopt survival strategies reflective of their developmental age and the resources available to them, which can later become problematic.

Whilst the research and practice knowledge base in relation to improved coping and recovery from childhood sexual abuse is not as comprehensive for men as for women, there is developing evidence of men’s preferred ways of coping and responding and what strategies are most effective.

Methods of coping

“I buried it [the sexual abuse]. Every time it reared its ugly head I buried it. I put more trash on top of it [violence and drugs] and stomped it down and buried it.” (Participant E1, 32 years old).

The development of an effective trauma informed response to men sexually abused in childhood requires not just an understanding of common impacts, but also what ways of coping are typically adopted by men and what coping strategies are 'unproductive' and 'productive' in the long term. As the above quote highlights, some coping strategies might be effective for some people for a while, however, they can outlive their usefulness.

 

Unproductive coping

For men who have experienced childhood sexual abuse or sexual assault, unproductive coping strategies centre on behaviours that reinforce avoidance of trauma related thoughts, feelings and memories. In an attempt to regain control, avoid re-experiencing the trauma, and supress strong emotions, men often adopt strategies that will allow them to push on through in life.

Identified unproductive coping strategies utilised by men:

• Suppression.
• Withdrawal.
• Denial.
• Internalisation.
• Anger.
• Acceptance that this is my lot in life (O'Leary & Gould, 2010).

It is interesting to note that, whilst the above coping strategies are identified by research as unproductive in terms of men's long term mental health, the very same coping strategies are identified as preferred by men who have been sexually abused.

It is also of note that 'seeking social and emotional support' is one of the least preferred coping strategies. It is also identified as contributing to improved coping and overall well-being of men sexually abused in childhood. This highlights the importance of actively reaching out, addressing barriers and creating pathways to enhance men’s seeking support.

Productive coping

The below behaviours have been identified to be associated with productive coping and enhanced well-being for men who have been sexually abused in childhood:

• Accessing information and resources that assist in reducing a sense of isolation and self-blame.
• Seeking practical assistance and developing concrete life skills aimed at addressing the impact of the sexual abuse e.g. learning to tolerate emotional distress and regulate trauma-related symptoms.
• Talking with a supportive person – worker, counsellor, partner, friend.
• Talking with someone who has experienced a similar event. Plus, actively supporting and helping others.
• Developing sense of hope, positive re-interpretation and growth. Practicing optimism and self compassion, viewing survival and life accomplishments in a positive manner. (O'Leary and Gould, 2010; Grossman, Cook, Kepkep, & Koenen, 1999; Wolin and Wolin, 1993).

The Royal Commission Final Report provided information on how cultural connections provided strength for Aboriginal and Torres Strait Islander Survivors, including this quote from Dr Gee of the Victorian Aboriginal Health Service: 

“With my mob of Stolen Generation members in particular, it has been the fact that, despite being institutionalised and experiencing abuse, they’ve somehow managed to maintain a connection to their cultural connections and to their family members and communities. That’s a massive source of resilience that sometimes differentiates between those who have been really damaged and are on really long journeys of recovery”, (p. 59, Vol. 3: Impacts).

It is recognised that group support has a valuable role to play in enhancing men’s well-being and ways of coping, in particular in breaking down the sense of isolation and self blame, see Foundations Module.

Additional useful reading

O'Leary & Gould (2010). Exploring coping factors amongst men who were sexually abused in childhood.

Next section

Introduction to the Three Phase Trauma Framework.