“I always had very low self-esteem, always thinking I’m one of the worst people around – never had any liking for myself whatsoever. Just the idea of hopelessness, and – that word – useless. And that’s been all through my life”, (p. 87, Royal Commission Final Report, Vol. 3: Impacts)

Orienting overview

• Sexual abuse can have profound and extensive impacts on the lives and relationships of those who are victimised and those close to them.
• There is no prescribed way that children and adults are impacted and respond to childhood sexual abuse. Effects and people's responses are diverse.
• Effects of sexual abuse are interlinked with the context and experience of abuse, types and duration of sexual abuse, person's age, relationship to the perpetrator/s, acts of grooming, options and responses to disclosure, and the resources and support available before and afterwards.
• Effects of sexual abuse are best understood from both a complex trauma and life course perspective.
• There are both similarities and difference in how males and females experience and respond to sexual abuse.
• It is important to note that gender and sexuality significantly impact on the way men experience and respond to the effects of child sexual abuse.
• Research with men who have been sexually abused is dominated by clinical samples, rather than population based samples. This limits our knowledge of those who have not come to clinical attention.
• Sexual abuse can produce sleeper effects that present later in life as men develop relationships, become parents, life circumstances change, or physical and mental health is compromised.
• Care needs to be taken, whilst acknowledging and responding to the significant impacts of sexual abuse, not to do so in a way that foregrounds 'damage and pathology' without acknowledging a person's acts of resilience and survival.
• Research on post-traumatic growth offers insight on the multitude of ways people who have been sexually abused are impacted, how they make sense of the abuse and subsequently respond.
• Hope is identified by those who have experienced sexually abused as a valuable aspect of managing and coping with effects.

Differentiating victimisation from traumatisation

When conceptualising the effects or impacts of sexual abuse, some authors differentiate the experience of 'victimisation' from the experience of 'traumatisation' (Preble & Groth, 2002). There is a difference between the experience of 'sexual victimisation', which "refers to a situation in which one is exploited in a sexual manner", and experiencing the effects or impact of 'traumatisation', which refers to"how the victimisation damages individuals’ psychosocial adjustment or development – in other words the consequences of the abuse" (Crome, 2006, p. 4). This differentiation can be useful because it avoids the assumption that each person's experience of sexual victimisation will automatically mean the same consequences in terms of effects, or experiences of traumatisation. It differentiates the incident/s from the effects.

Common problems

Below is a list of common problems reported by men who have been sexually abused or sexually assaulted. In detailing these reported effects, in line with the Practice Standards of that National Association of Services Against Sexual Violence, it is emphasised here "that each person's experience and expression of trauma is personal, unique" (NASASV 2015, p. 10). Hence, in working with someone who has experienced abuse, it is important to engage and listen to their life story, to their struggles, to what is important to them, in a way that does not only see them as a collections of effects and problems.

Common problems reported by men who have been sexually abused include:

• Distrust, sense of betrayal.
• Guilt, shame, self blame.
• Depression, anxiety, hypervigilance.
• Overwhelming emotions, disassociation/numbing, hyper and hypo arousal.
• Post traumatic stress symptoms: intrusive re-experiencing, effortful avoidance of distressing stimuli, alterations in cognitions and mood, arousal and reactivity.
• Flashbacks, nightmares.
• Eating/body image issues (body dysmorphia), weight loss/gain.
• Suicidal ideation/attempts, self harm.
• Relationship difficulties, disorganised attachment.
• Sexual difficulties.
• Sleep difficulties, insomnia.
• Mental health problems, clinical diagnosis.
• Substance abuse, addiction.
• Physical health difficulties.
• Increased risk of re-victimisation (Banyard et al., 2004;  Tewkesburg, 2007).

The above list highlights some of the traumatic impacts that child sexual abuse can have on men's lives and relationships. Whilst research into impacts of sexual abuse on men's lives is less extensive than that relating to women, we are beginning to understand the depth and degree of impact on men's lives. An Australian study (O'Leary 2009) reported that compared to a general population sample, men who have been sexually abused are:

• 4 x more likely to qualify for clinical diagnosis (17.2% of community men qualify for a clinical diagnosis compared to 65.8% of men who were sexually abused).
• 10 x more likely to qualify for a diagnosis of PTSD.
• 5 x more likely to engage in alcohol and drug misuse.
• 10 x more likely to report suicidal ideation.
• 46% of CSA men had attempted suicide at sometime (O'Leary, 2009).

The Royal Commission Final Report on impacts of childhood sexual abuse

Below is a chart developed by the Royal Commission into Institutional Responses to Childhood Sexual Abuse, which details the statistical impacts of the experience of childhood sexual abuse on survivors:

Impacts of Childhood Sexual Abuse from p. 75, Royal Commission Final Report, Vol. 3 Impacts

Impact	Number affected (6,412 survivors)	Proportion (%)
Mental health issues	6,088	94.9
Relationship issues	4,332	67.6
Education and/or economic issues	3,569	55.7
Sexual behaviour issues	1,554	24.2
Involvement in crime	1,456	22.7
Physical health issues	461	7.2
Direct consequences (eg pregnancy, sexually transmitted infection, injury)	440	6.9
Other	32	0.5

PTSD

Many men who have experienced sexual abuse, and those who live with them, are all too familiar with the below symptoms:

• Criterion B: Intrusion Symptoms, whereby the traumatic event is persistently re-experienced.
• Criterion C: Avoidance, involves persistent effortful avoidance of distressing trauma-related stimuli after the event.
• Criterion D: Negative alterations in cognitions and mood.
• Criterion E: Alterations in arousal and reactivity.
• Criterion F: Persistence of symptoms (in Criteria B, C, D and E) for more than one month.

In highlighting that men who have experienced sexual abuse often present with symptoms that meet the criterion for a diagnosis of PTSD, there is a developing acceptance that the cluster of effects of child sexual abuse is better articulated 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).

Complex trauma

Judith Herman (2001), trauma and recovery pioneer and advocate for the acknowledgement of 'complex trauma', notes how child sexual abuse occurs at a critical developmental period in a child's life, significantly impacting on a person's subsequent sense of self, safety, and trust in relationships — especially when perpetrated by a trusted caregiver or family member (Courtois & Ford, 2009; van der Kolk 2005). Different from other forms of trauma, childhood sexual abuse often involves traumatic stressors that:

1. Are repetitive and prolonged.
2. Involve direct harm or neglect, abandonment by caregivers.
3. Occur at developmentally vulnerable times in a victim’s life.
4. Have great potential to severely the child’s development.

If practitioners are going to provide a trauma informed response, it is essential they have a comprehensive understanding of the complex interpersonal and relational difficulties produced by repeated sexual trauma. Different from some other forms of trauma, sexual abuse is an interpersonal crime that occurs at a critical time of a child's development. As such, it can leave a child/adult struggling to self-regulate (i.e. to feel in control of his or her feelings, cognitions, beliefs, intentions and actions), to achieve a sense of self-integrity (i.e. the feeling that one is a unique, whole, coherent, and worthy individual), or to experience relationships as nurturing, and possess reliable resources that support self-regulation and self-integrity (van der Kolk 2005; Courtois & Ford, 2013).

Noticing how an experience of sexual abuse/complex trauma impacts on a sense of self, as a 'unique, whole, coherent, and worthy individual', is pertinent, given that someone who has developed and can call on a strong, robust, resilient sense of self is better able to deal with difficulties and life stressors as they appear.

In foregrounding potential complex traumatic impacts, it is recognised that impacts will often vary and change over time.

The Royal Commission Final Report identified other mental health disorders that were associated with childhood sexual abuse. These included:

• eating disorders;
• mood disorders, such as bipolar disorder;
• psychotic disorders, such as schizophrenia;
• personality disorders, such as borderline personality disorders; and
• dissociative disorders (p. 98, Vol. 3: Impacts)

Initial and long term effects

In one of the earliest reviews of research studies about the effects of child sexual abuse, Browne and Finkelhor (1986) suggested that effects could be divided into initial effects (those occurring within 2 years of the termination of the abuse) and long term effects (which includes persisting initial effects and other effects arising more than two years after the termination of the abuse). Common short term responses include:

• Fears and phobias.
• Anxiety.
• Depression.
• Sexualised behaviours.
• Uncharacteristic changes in behaviour and attitudes.
• Withdrawal and lowered academic performance.

My anxiety was so severe that job interviews were distressing and it took 17 interviews before I was accepted for a position as a social worker. My anxiety causes me severe distress in social situations, and therefore I try to avoid them. Examples of positions I have had to relinquish because of my social anxiety disorder include an Honorary Fellow at a university college in Hobart and a Bench Justice at Hobart Magistrates Court. I also had to cease a doctorate at the University of Tasmania as it required communicating with many people. (Mr Graeme Frazer, p. 95, Royal Commission Final Report, Vol. 3: Impacts)

In a more recent review of research about the long-term effects of child sexual abuse, Cashmore and Shackel (2013) detailed effects in terms of "a range of outcomes" in the following areas:

• The impact of child sexual abuse on mental health.
• Mental health functioning (including: psychiatric conditions, alcohol and substance abuse, risky behaviours and adjustment difficulties).
• Interpersonal outcomes (including: intimate relationships and parenting, re-victimisation, risks of offending).
• Physical health (heart and digestion difficulties) and overall developmental outcomes.
• Gender specific differences.

To read the full article, go to: Cashmore, J., & Shackel, R. (2013). The long term effects of child sexual abuse. Child Family Community Australia Information Exchange, 11.

The Redress and Civil Litigation Report of the Australian Royal Commission into Institutional Responses to Child Sexual Abuse (2015) adds to our understanding in noting that not only can effects be episodic and ongoing, but there are also 'sleeper effects' — problems that 'emerge at later stages in life or be triggered by significant life events' (Redress and Civil Litigation Report, 2015, pp. 185-186):

“Consistently with post-traumatic stress disorder (PTSD) and complex PTSD more generally, survivors often find that symptoms emerge for the first time later in life. For example, survivors may experience anxiety and flashbacks when their own children reach the age they were when they were abused. Similarly, many survivors who have come to private sessions and who are in the older age group have told us they are experiencing symptoms of depression, nightmares and sleep disturbance as they confront impending institutionalisation associated with ageing, increased health needs and possible hospitalisation or residential aged care” (Redress and Civil Litigation Report 2015:186).

Factors that can influence the nature and severity of effects

There is a growing knowledge base of factors associated with the circumstances and experience of sexual abuse that can influence the severity and type of effects people experience. Research has indicated that the impact of child sexual abuse on both genders is likely to be modified by the following variables:

• The age at which the abuse began.
• The duration and frequency of the abuse.
• The type of activities which constituted the abuse.
• The nature of the relationship between the offender and the victim.
• The number of injuries sustained from the abuse.
• The number and sex of offenders involved in the abuse.
• Disclosure or discovery of abuse.
• The manner in which disclosure or discovery of the abuse occurred.
• The quality of responses to disclosure (Condy et al, 1987; Crowder & Myers-Avis, 1993; Hunter, 1990a; O'Leary, Coohey, & Easton, 2010; Pierce, 1987).

In 2017, The Royal Commission Final Report identified additional factors that could impact experiences of abuse, including:

• the social, historical and institutional contexts of the abuse
  
• the victim’s circumstances, experiences and characteristics (such as age, gender, disability, prior maltreatment, and experiences with disclosing the abuse). (p. 10, The Royal Commission Final Report, Vol. 3: Impacts)

Developmental factors

Sexual abuse can impact differently, depending on the physical and developmental age at which it occurs. If abuse occurs at formative periods when the brain is being sculpted "the abuse induces a cascade of molecular and neurobiological effects that alter development" (Sanderson, 2006, p. 44). According to Teicher (2002), maltreatment at an early age can have enduring effects on a child's brain development, function and response to stress. Clinical data and research on dissociative identity disorder (DID) suggests that the younger the child is at the time of onset of CSA, the more likely the child is to dissociate and develop 'psychogenic amnesia' (Putnam, 1985). Effects such as dissociation can be a valuable protective mechanism at the time, when the mind closes down and takes the person away from the painful and distressing reality of what is happening. However, they can become problematic if later on they disassociate, or become absent when confronted by a triggering stimulus or mildly stressful situation.

Furthermore, the Royal Commission notes different implications on one's sense of self, depending on the age that trauma occurs:

Psychiatrist Professor Herman observes that ‘repeated trauma in adulthood erodes the structures of the personality already formed’, whereas repeated trauma in childhood ‘forms and deforms personality’. (p. 79, Royal Commission Final Report, Vol. 3: Impacts)

In an early piece of research, Mullen and Fleming (1998) noted that if a child has to cope with a problematic family background or prior emotional abuse, they will be more vulnerable to additional impact of child sexual abuse. Mullen and Fleming (1998) state that child sexual assault often has a primary impact on the child’s developing capacities for:

• trust,
• intimacy,
• agency, and
• sexuality (Mullen & Fleming, 1998).

Fergusson and Mullen (1999) highlight the role of support, in noting that these adverse psychological and social outcomes may be lessened by appropriate social and emotional support immediately following the assault and later in life. Three factors affecting a child's abilities to recover from sexual abuse were identified in an early study on female victims:

1. the basic constitutional characteristics of the child (for example, temperament, high self-esteem and internal locus of control);
2. a supportive family environment (warmth, nurturance, organization and so on); and
3. a supportive individual or agency that provides a primary support system to assist the child in coping and in developing a positive model for identification.” (Urquiza & Capra, 1990, p. 129).

In 2015, the Royal Commission into Institutional Responses to Child Sexual Abuse Redress and Civil Litigation Report identified similar individual, relational and environmental factors that can influence how men and women are impacted by sexual abuse:

• The child’s individual characteristics and make-up.
• Their care-giving experiences and family and social support.
• The various aspects of their school, community and society that protect them or put them at risk (Redress and Civil Litigation Report, 2015, p. 165).

Awareness of patterns and variables which mediate the effects of sexual abuse can assist men we work with to make sense of the impacts and address sense of personal failure and self blame. For example, if he experienced repeated violent assaults, accompanied by emotional abuse by others, at a young age, and attenuating circumstances did not provide sources of support, the effects are more likely to be profound and complex.

Summary of moderating influences on the effects of sexual abuse:

• Severity and duration of abuse.
• The relationship with the perpetrator, especially in regard to trust and dependence.
• Other traumatic events or circumstances occurring at the time.
• Developmental stage at which abuse occurs.
• Level of support and nurturance.
• Quality of responses to the child following disclosure or discovery of abuse.
• Some personal characteristics and level of self agency.

 

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