Gender identity construction and sexual orientation in sexually abused males.

Male survivors of sexual abuse must struggle with confused emotions, including depression and anger. They react in a different way than females, however, in that the sexual abuse forces men to face issues of gender-role identity and sexual orientation. These are questions at the level of "Who am I?" and "What is the meaning of my life?" Such questions have always been very complex for men but are especially poignant for male survivors of sexual abuse. The authors use their clinical experience and study of gender identity to address the topic, which psychotherapists sometimes find difficult to make part of their work with men. The topic is addressed at four levels: the construction of male gender role identity, sexuality in a setting of hegemonic masculinity, sexual orientation, and psychotherapy with male survivors of sexual abuse.

Keywords: male survivors, sexual abuse, identity, sexual orientation, sexuality, psychotherapy

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What do we mean by identity? The issue forces an individual to look at the most basic existential questions: Who am I? What is the meaning of my life? Where am I going? These are very complex questions for every man, particularly for male survivors of sexual abuse.

The representation of the self must include the gender to which one belongs. Regarding the relation between identity and gender, Chiland (1988, p. 80, authors' translation) states that "the human being is an abstraction, only men and women exist." She adds, "We are not born as men or women, we become men and women" (p. 79). From early on, a child begins to develop a self concept corresponding to his relation with the environment (Winnicott, 1974). The sense of identity begins with internalized representations of others' expectations as to how an individual must think and behave as a sexual being. Identity represents a construct (Kelly, 1955), a synthesis (Erickson, 1957/1972) made by the individual based on what he was, what he is (the actual self), and what he will be or wishes to become (expected self).

L'Ecuyer (1978) considers identity to be the organized configuration of the perception of one's personal characteristics. From that configuration, the individual selects beliefs, values, and standards to form a profile of behaviors and attitudes he uses in different life situations. Identity is established by and establishes perceptions and choices of situations and events that will confirm it (Combs, Avila, & Purker, 1979) and perhaps modify it. Identity is both the product and the producer (Combs et al., 1979), the object and the subject (James, 1946), the actor and the author (Herman et al., 1992), the I and the Me as described by Georges H. Mead (1934). Part of one's identity is the incorporation of gender roles, which are arbitrarily imposed from without rather than developing from within. Gender-role socialization is always a strain on the individual, since gender roles are operationally defined by gender role stereotypes and norms that are often psychologically dysfunctional for the individual (Pleck, 1981).

The process of identity construction goes on throughout an individual's life, but it is marked by two major phases:

* Formation of gender identity, also known as sexual identity (Money & Ehrardt, 1972; Nungesser, 1983; Shively & De Cecco, 1977) and core gender identity (Tyson, 1986). This begins in males at age 2- 2 1/2, the age of toilet training (Roiphe & Galenson, 1981), when the boy becomes aware that he is expected to stand up to urinate since he has a penis like his father and is anatomically different from his mother. Formation of gender identity includes the feeling of belonging to one sex rather than another.

* Formation of gender-role identity (Money & Ehrardt, 1972; Tyson, 1986) or masculinity (Blos, 1988). Blos defines this as a process that occurs during adolescence and is marked by psychological reorganization. For Tyson (1986), however, gender-role identity begins much earlier.

According to Erikson (1957/1972), adolescence is the turning point of identity construction when young people explore a variety of ideological and interpersonal domains in order to establish their gender role, sexual orientation, body image, and coping style.

As contributions from psychoanalysis, social learning theory, and men's studies have shown, boys are psychologically more vulnerable than girls during the process of identity construction (Badinter, 1992; Begouin-Guignard, 1989; Marcelli, 1989; Pittman, 1990; Tremblay, 1999). The process begins early when a baby boy identifies himself with the primary caregiver, who is usually his natural mother. When the baby boy reaches the age of two and is able to represent himself as a male, he ceases to identify with his mother (Badinter, 1992; Pollack, 1998) and rejects many feminine elements of his personality (Klein, 1984; Roiphe & Galenson, 1981) in order to begin to construct his masculinity. Rejection of this early identification requires a break with the mother (Marcelli, 1989), which is particularly difficult for boys; causes what Rowan (1997) calls the male wound; and initiates a mourning process (Begouin-Guignard, 1988). According to these authors, the process of separation from the mother is facilitated by the father but is more difficult when the father is not physically or affectively available. The mother sometimes becomes emotionally distressed by the consequences of the break with her son and reacts strongly against her husband in front of the children or experiences what Osherson (1986) calls internal unvoiced anger. Something similar happens in families where the mother maintains conflicted contact with former partners. In these families how will it be possible for a boy to identify himself with a man who harms his first love object, his mother? This leaves him alone, identifying himself only negatively: I will not be like my mother.

Identity formation continues with identification with the father beginning at about age 3-4 years. According to Penot (1988), boys who lack a significant paternal figure may question the salience of their existence. Solid attachment with the father is necessary for a boy to develop a sense of security. Early father absence is reinforced by the scarcity of men in settings such as daycare centers, kindergartens, and elementary schools. Psychologically, father absence can also occur even when the father is physically present but rarely affectionate with his son. Such fathers are often lonely individuals with few friends of their own. They are men without rich experiences of intimacy (Adams & McCormick, 1982).

Empirical studies have demonstrated that boys and men are forced to respect gender-role stereotypes more than girls or women are (Klein, 1984; Maccoby, 1987; Nungesser, 1983) even when these stereotypes have been strongly criticized by society. Violating sexual stereotypes during adulthood brings social condemnation and more severe psychological consequences for men than for women (Pleck 1981). This means that peer pressure is even stronger for teenage boys (Galambos, Almeida, & Patersen, 1990; Rust & McCraw, 1984). Presently, there is no widely recognized alternative masculine model, and therefore, as Hurstel and Delaisi de Parseval (1990) say, boys today have to face a devalued, fallen, wounded masculine model. Most male gender role models proposed to boys in advertising, television, movies, and other media remain negative: aggressive, dominant, racist, and macho or foolish, unintelligent, and stupid (Nathanson & Young, 2001). This produces confusion in boys: What kind of men does society want us to be?

The fragility of the identity construction process in men compels them to make it a task to be repeated daily (Brittan, 1989). Men chronically doubt their masculinity and feel they have to prove to others and themselves that they are real men. Usually, they tend to prove it by complying with the prevailing sexual stereotype or hegemonic masculinity, that is, being strong, stoical, in control of the situation, active, aggressive, and powerful. This attitude compels men to be competitive with each other and distance themselves from other men, resulting in what Pleck (1980) calls the patriarchal oppression of men, which includes the sexualization of male-male relationships and an interpersonal dynamic dominated by issues of power and violence in which men oppress women, themselves, and each other.

We can easily understand that, if this process is difficult for boys and men in general, it is more complex for a boy or a man who has been sexually abused. However, "prevailing myths dictate that victimhood is the province of women and that men cannot be victims" (Gartner, 1999). Therefore since a man is supposed to be strong, a male survivor often feels that he has failed to protect himself against the abuser, that he should have been capable of preventing his victimization even though he was a child, and that he has not behaved like a "real man," especially if the abuse occurred during adolescence (Munro, 2000, 2002). Many authors have reported this confusion about male gender-role identity in male survivors of sexual abuse. It has led to a sense of being inadequate as men and feelings of loss of power, control, and confidence in their manhood (Hopper, 2005). This causes men to attempt to "prove" their masculinity (Forouzan & Van Gijseghem, 2004) by having multiple female sexual partners, sexually victimizing others, or engaging in dangerous or violent behaviors (Bmckner & Johnson, 1987; Lew, 1988, in Hopper, 2005).

Male survivors face an important inner conflict between the psychological consequences of their experience of abuse and the strain of forming and maintaining their male gender role. Sexual abuse has left them feeling vulnerable and helpless while these feelings are proscribed by gender role constraints.

SEXUALITY AND HEGEMONIC MASCULINITY

When a male considers his masculine identity, his penis becomes more than merely anatomical proof that he is a man. It becomes a symbol of that identity and the primary image of hegemonic masculinity. Zilbergeld (1970) caricatures it in this way, "It is two feet long; it is hard as iron and lasts all night long" (p. 23). The penis becomes something separate from the man like an idol or fetish. Reynaud (1981) says, "Real men, provided with real penises, compare themselves with the model [phallus] and they feel pitifully deprived." He calls this psychological situation the phallus complex. Zilbergeld (1970, p. 27) cites a popular poll of 1,000 men in which, except for "rare and very brilliant exceptions," all respondents expressed doubts about their own sexuality in terms of the size of their penis.

Pornography also affects men's sexual imagination. In it, the man is typically presented as the active, dominant element in sexual relations. He must always follow the same sequence: prolonged kisses, genital caresses, erection, oral-genital contacts, vaginal (heterosexual pornography) or anal (homosexual pornography) intercourse, leading to the ultimate objective, ejaculation and orgasm of both partners at the same time. The man's responsibility for giving his sexual partner the highest level of satisfaction in every sexual encounter leads many men to fear not being good enough (Tremblay, 1998). In pornography but also in many popular books on male sexuality, affection and sexuality are separated. It is said that, for most women, making love implies communication and tenderness and sexual intercourse is a moment of emotional meeting. For some men that is also the case, but for most the sex act represents pleasure for its own sake leading to the release of psychological or physiological tension (Tremblay, 1989). Sexuality is a way for men to channel their own feelings without regard for their relationship with a sexual partner. For some men, having sex is the only time the man is allowed to caress and be caressed.

Such dissociation between affection and sexuality can be seen in a man's choice of sexual partner, who fits either the "Madonna" stereotype or the "whore" stereotype. The Madonna stereotype is the wife, who provides a man with stability as well as sexual and emotional security. She is worshipped as though she were the man's mother. The whore stereotype confirms the power of male seduction and allows a man the feeling of being free of dependence on his wife (Durandeax, 1985).

When a boy or a man is sexually abused, he falls into the same role in the sexual fantasy of hegemonic masculinity as women do: submissive, dominated, sometimes being penetrated, and having to give pleasure to the dominant partner. In being forced into this position, he is not only abused sexually but also denied his gender-role identity. Abuse causes a great deal of confusion. The boy or the man needs sexual pleasure and release but not in this way. He needs to be caressed and loved but not this way. "If he got an erection or climaxed during the abuse, his self-blame and the confusion may be even more extreme" (Munro, 2000, p. 3). In order to face the unpleasant emotions caused by the abuse, some boys reformulate it and call it an initiation, "a coming-on-age experience, especially if the abuser is the same sex as the boy's predominant object choice (women for heterosexual boys and men for homosexual boys)" (Gartner, 1999). By doing so, such boys feel they have taken the more sexually active role, as men are expected to do.

THE COMPLEXITY OF SEXUAL ORIENTATION

Not only is sexual abuse of males most often perpetrated by a male, which means having had a same-sex encounter, but it often also represents having taken the female position with respect to hegemonic masculinity, a position that is also associated with homosexuality. Some authors state that male survivors have to struggle with the issue of sexual orientation (Forouzan & Van Gijseghem, 2004; Hopper, 2005), even though being victimized sexually does not at all mean being gay.

Although the Kinsey report with its seven-degree scale (from exclusive heterosexuality to exclusive homosexuality and bisexuality in the middle) dates from 1948, it is only quite recently (within the framework of epidemiological research on HIV/AIDS) that bisexuality has again become a topic for researchers and clinicians. In practice, however, sexual orientation is still most often presented as a dichotomy between homosexuality and heterosexuality with nothing in between. For a long time, male bisexuality was perceived to be transitional, a part of adolescence and related to the absence of an available sexual partner of the other sex. It was sometimes associated with economic motives, as in prostitution (Rise et al., 1992). Only few authors have given it more importance. Among these, Paul (1984, in Berkey, Perelman-Hall, & Kurdek, 1990) proposes that bisexuality can be a sexual position of its own between exclusive homosexuality and exclusive heterosexuality, one that can be assumed, abandoned and resumed, or held simultaneously with either of the other positions. Zinik (1985, in Berkey et al., 1990) uses expressions such as "serial bisexuality" and "current bisexuality" to describe the same phenomenon but adds a category: "simultaneous bisexuality." Most of these studies conflate sexual behavior and sexual orientation.

Other studies are based on self-identification as heterosexual, bisexual, or homosexual but also use scales that consist of mutually exclusive categories (Berkey et al., 1990). By contrast, Klein (1990, 1993) considers sexual orientation to he a dynamic process that takes into consideration a variety of variables including fantasies, behavior, self-identification, and lifestyle or affiliation with a particular sexual group. His more complex, multifaceted framework is more adapted to changes in sexual orientation that may occur during the life cycle.

The process of homosexual or bisexual identity formation remains particularly difficult in a society that still stigmatizes both sexual orientations. Bory and Hocqueghem (1977) say, "It is one thing to recognize oneself as homosexual, but to accept oneself as homosexual is quite another" (p. 53). Homosexuals (and perhaps bisexuals, too) interiorize feelings of shame and experiences of oppression socially imposed on them (Tremblay, 1989). Who are such men, they may ask? They are not "real men" because they are attracted to other males. They are not females because they have a penis. Who are they, then? With no clear answer in mind, homosexuality and bisexuality are then often denied and repressed. The individual is afraid to reveal his feelings to others and to himself. Some lead a double life, one at work and with the family and the other in furtive meetings, for example, at bars. As for many young heterosexuals, bars become the primary venue for sexual approach. However, it is usually difficult to find a satisfactory partner in a bar, someone who wishes to take part in one's life. This is more likely to happen among meetings with friends, in the workplace, or while engaged in playing sports. Overall, however, the latter networks remain much more accessible to heterosexuals than to homosexuals or bisexuals.

The process of self-identification as homosexual or bisexual is therefore usually a long one and provokes a radical reevaluation of oneself and one's lifestyle, which may include a stage similar to the mourning process of early separation from the mother. "Culturally," say Falconnet and Lefaucheur (1975, p. 98, authors' translation), "men have more difficulty admitting their homosexuality than women, essentially because their virile image would be questioned." It is the same image of masculinity that prevents many men from expressing tenderness and intimacy toward other men in friendships. They fear being labeled as homosexual or having to face desires that are too threatening. Such homophobia (Weltzer-Lang, 1994) characterizes the exchanges between most heterosexual men, and the result is emotional isolation among men (Tremblay, 1989). Internalizing such homophobia, a homosexual man may feel his homosexuality is something "bad." Bisexual identification may be even more difficult in some respects. The homosexual community has developed a culture of support groups and activities and has acquired a certain degree of social recognition (Lever et al., 1992). This is not true for bisexuals, who are perceived by heterosexuals to be as threatening as homosexuals. Discrimination can stir up feelings of shame, guilt, and ambivalence about concurrent heterosexual and homosexual desires.

Although male survivors of sexual abuse have to deal with the same social constraints regarding sexual orientation as other men do, sexual abuse involves even more complex inner struggles. If the perpetrator of the abuse was a man, the survivor may wonder "Am I gay?" Homosexual survivors of sexual abuse may feel shame about themselves and their homosexuality, not distinguishing the experience of abuse from being gay. "Having sex with another man can bring up frightening feelings and memories" (Munro, 2000, p. 4). The same reaction may occur among heterosexual survivors who have been abused by a female. In general, however, male survivors struggle more often with confusion in regard to their sexual orientation and have greater fear of getting involved in a steady loving relationship than men who have never been sexually abused (Forouzan & Van Gijseghem, 2004).

SOME GUIDELINES FOR PSYCHOTHERAPISTS WORKING WITH MALE SURVIVORS OF SEXUAL ABUSE

How does what we know about gender-role identity construction, hegemonic sexuality, and the complexity of sexual orientation of men affect the way a therapist works with a male survivor of sexual abuse? In this section, we will share some thoughts based on our experience in psychotherapy with men. We will use three clinical cases to propose some therapeutic guidelines.

THE STANCE OF THE THERAPIST

The first patient was referred by a nurse who told us that the client was depressed after having had an affair with another man. He had lost more than 30 pounds in the weeks before the first interview and had problems taking care of himself and difficulties at work. At the first meeting, he insisted he wanted to know if he was gay. He thought that a good professional was supposed to be able to determine such things. Trying to do the best to give him the response he needed, we wondered: What would happen if our answer was wrong? More fundamentally, the main question was: Is a therapist able to determine someone's sexual orientation? The only person who has the answer is the client himself. No one else can answer for him. The therapist can only help the client think and let him find his answer. Perhaps the best advice to any man questioning his sexual orientation is to stay far away from professionals who say they can determine a client's sexual orientation.

Instead of seeing the therapeutic relationship as a hierarchical arrangement, we understand therapy in the context of intersubjectivity (Berzoff & de Lourdes Mattei, 1999). The "other" is no longer the object of an intervention but rather becomes a subject, like the therapist himself. There are then two subjects interacting for the wellness of the person concerned.

The therapist's initial therapeutic "posture" is especially important with sexually abused men, who usually have low self-esteem, think they are worthless, and believe that their voice has little value. When we recognize the value of their voice, we help them affirm themselves.

THE DISCOMFORT OF SEXUALLY ABUSED MEN SEEKING HELP

Like many men requesting assistance, sexually abused men tend to hide or deny their symptoms over a long period of time (Charmaz, 1994). In fact, like men (and women) in general, they tend to free from their problems to avoid uncomfortable feelings (Dulac, 1997). They wait for a crisis or pressure from their social network before consulting a therapist (Dulac, 1997; Tremblay, 1989). For Dulac (1997, p. 16, authors' translation), "men act downstream--after a crisis." The pressure becomes so strong that they tend to act out with aggressive behavior, sometimes directed toward their families and friends (Lynch & Kilmartin, 1999).

Some authors (Brooks, 1998; Dulac, 1999) conclude that the therapeutic process as such acts in opposition to the constraints of traditional masculinity (see Table 1). Asking for help then implies that a man positions himself against the social norms of masculinity. Seeking psychotherapy is like "not being a real man." The price paid for admitting to being powerless to solve his own problems is feeling stigmatized and rejected by his fellow community of men (Dulac, 1997). Like physical illness, psychological distress marginalizes men by destabilizing their conception of masculinity. Although it is easier to seek help for someone who has succeeded in differentiating himself from stereotypes of masculinity, it is very difficult for most men.

We can now understand why a male survivor of sexual abuse can be uncomfortable asking for help. He feels as though he has been placed in a nonmasculine situation by the abuse and may be trying to restore his masculinity, but the helping process is perceived as yet another situation that puts him in a nonmasculine stance.

COUNTERTRANSFERENCE REACTIONS

Most traditional men seek help in unconventional ways, sometimes even aggressively (Dulac, 1997, 1999). They risk being perceived as violent and therefore not appropriate for gaining access to public health services. The suffering hidden behind such aggressive attitudes will probably not be identified at first, and the therapist may fail to establish a therapeutic bond in order to communicate with the person behind the behavior. Even though distinguishing the person from his behavior is recognized as a basic principle in psychotherapeutic interventions, in working with men often the therapist does not relate in the first place to a human being but rather to a behavior to be controlled and suppressed. More accurately, the therapist's discomfort dominates the relationship, and he protects himself by keeping emotional distance from his male client or hiding behind intervention norms and protocols. It is important to welcome men despite the nature of their help-seeking behaviors, to decode the suffering behind aggressive behavior, and to give particular attention to the first contact.

Another possible countertransference reaction that occurs when working with abused men is reacting to the abuse as if it were the therapist's own struggle, not the client's. It is important to talk openly about the abuse and help the client deal with the perpetrator (if he wants to do that) by referring him to a good attorney, but if he does not wish to go pursue the matter legally, this is also acceptable. In fact, he may continue to love the perpetrator. The therapist has to support the client's choice regarding what to do about the perpetrator without judging.

WILLINGNESS TO TALK OPENLY ABOUT ABUSE

One client was sexually abused by his older brother from age five to 15. This was the fourth therapist he had consulted. The first therapist was his doctor who detected the abuse by treating some important related physical problems the client presented. A psychiatrist then offered him therapy but, as the client told us, never addressed the abuse as an issue in therapy. According to the client, after two years of therapy, the psychiatrist concluded that he was unable to help the client and referred him to a female therapist, thinking that it would be easier for the client to talk to a woman. The new therapy lasted one year but again without addressing the abuse as an issue. According to the client, the female therapist referred him to someone else who uses "body work" as a therapeutic approach. That therapy lasted another year again but without addressing the issue of sexual abuse. This client needed someone willing to hear what happened without overreacting, someone who could give him faith in his capacities to face reality, someone who could help him deal with his current sexuality.

Helping male survivors of sexual abuse involves a special difficulty when the client is himself also a sex offender. Freeman-Longo (1986) notes that an offender often finds it difficult to disclose his own abuse. The offender generally has more trouble disclosing his victimization than discussing what he has done to others. Freeman-Longo explains that victimized offenders lack empathy for others. They easily discuss what they consider the positive part of the experience and repress the traumatic aspects. We infer from this study that the impact of sexual victimization on males seems to be like Lacan's forclusion, a psychic mechanism that rejects unbearable representations before they have been integrated in the person's unconscious. This psychic mechanism would explain why male survivors are so reluctant to disclose their victimization and therefore why it is so difficult to address the issue with them. The therapist has to maintain faith in his clients' capacities and always emphasize their strengths, not their deficits. He has to respect the timing of the clients' openness.

DECONSTRUCTION OF HEGEMONIC MASCULINITY

The therapeutic process with male survivors of sexual abuse includes not only working on the trauma but also confronting the client's socialization as a man (Lisak, 2001). The first goal depends on whether the second has been achieved. To work on the trauma, we must encourage the expression of emotions, the recognition of negative feelings, and the acceptance of having been victimized as well as other aspects of the man's experience that are denied or unacceptable in the ideology of hegemonic masculinity. The therapist must be prepared to challenge this ideology and its rigid prescriptions (Brooks, 1998; Lisak, 2001).

It is interesting that some boys do not put a stop to the abuse they are suffering even though they are physically able to do so (at age 13 or even later). How can we understand this? We have already mentioned a client abused by his older brother from age five to fifteen. Another client was sexually abused by his godfather until age 17 but revealed the abuse only at this age. In these two cases and probably in many others, the perpetrator is the only man (again, in most reported cases the perpetrator is a man) paying attention to the boy. Often the perpetrator offers the boy affection he has not received from his father. It is therefore not surprising that many perpetrators are men in supportive positions in the social network of boys (uncles, teachers, and coaches) (Dorais, 1997). If the perpetrator is the father or a brother, the episodes of abuse are often the only occasions when the boy can feel close to his father or his brother. Otherwise, the father or brother remains distant, often also violent (Dorais, 1997).

Boys need male identification figures, and they need to feel affection from these figure in order to use them as models, but boys do not need to have such men as sexual partners. Needing attention and closeness from other men, however, it is not surprising that sometimes abused boys do not stop the abuse while they are physically able to do so. By acknowledging male hegemonic ideology, the therapist allows the boy or man to have a better understanding of his needs and how having seemed not to react "like a man" is part of that ideology.

Some clients talk about the abuse as a sort of initiation, which is often how the perpetrator has characterized the abuse (Mathews, 1995). This ruse may be exposed as a way to resolve the inner conflict of having been placed in a "non-masculine" position.

EXPERIENCING A NONSEXUAL INTIMATE BOND

In order to talk about the experience of having been abused, the sexual trauma, and his feelings about men and women, the client needs to feel close to the therapist. Therapy is a very intimate relationship. For a sexually abused man facing a male therapist, this is a major issue, for two reasons. If the perpetrator was a man, the client may have to deal with the fact that previous confidence in a man led him to being abused, so his first reaction to the male therapist is distrust, and for such men intimate relationships are associated with abuse, and they avoid a connection with the therapist as a protection against another episode of abuse. In other cases, the client may act in a seductive way with the therapist. It is important for the therapist to be aware of those possibilities and always be clear with him about the countertransferences involved.

DEALING WITH SHAME

Counseling men is often based entirely on the client's overt behavior and emphasizes his deficits. The "capitalization" hypothesis offers another orientation for counselors (Good & Sherrod, 2001). It suggests that, to be efficient, a therapist must use the client's strengths rather than first pointing out his deficits. For example, instead of criticizing a man who rationalizes his victimization, the capitalization hypothesis, which indicates capitalizing on the client's strengths, prescribes helping him recover his desire to understand himself and his ability to reason in order to help him develop emotional competence.

Capitalizing on the client's strengths also offers the advantage of thwarting a feeling that is dominant in most men: shame (Krugman, 1998; Osherson & Krugman, 1990). Most men who have experienced abuse evaluate themselves as inadequate, wrong, bad, sick, or guilty (Hopper, 2005). Guilt has the following underlying meaning: I did something wrong. Though closely related, shame is quite different from guilt. Shame is defined as a "painful feeling of inferiority, unworthiness, or being ridiculed by somebody else, of being low in other's opinion." In contrast to guilt, shame implies that I am wrong. Shame bears the fear of being judged and socially disapproved of. It causes the man to question his right to exist at the level of his basic identity (De Gaulejac, 1989).

Dealing with shame in therapy helps the client feel that he is "all right" and that he is not responsible for the abuse, even though there were times it seemed as though he initiated the abuse in an understandable honest quest for closeness. He learns that it was the adult's responsibility to adequately respond to his needs at that time, not the boy's. In those cases, what the male victim really wanted at that time was intimacy, not sex. Dealing with shame also helps him to recognize that he is a good man, a "real man."

OVERCOMING EMOTIONAL ISOLATION

Although men usually are in contact with many people, they develop very few affective bonds. Their social networks are public, based on concrete activities where expressing emotions and intimacy is discouraged or forbidden (Dulac, 2001). Too often, the only confidante they have is their wife (Tremblay, 1989). According to Rubin (1986), 85 percent of men limit their intimate relationships to their wife. It is therefore not surprising that many men feel isolated after a separation or divorce.

It is extremely important to relieve a man's affective isolation. This implies that he learn how to fully use his social network and participate in the life of the greater community. Without being a panacea, therapeutic groups are often helpful (Dulac, 2001). The group encourages exchanges between men in a secure atmosphere that is different from the competitive environment typical of their previous relationships with men. Participating in a self-help group of other abused men helps the client see that he is not the only one who has been abused. It is "a powerful tool for healing and change" (Munro, 2000, p. 3). He can appreciate the experiences of other participants and feel that they appreciate his. Groups are also good to help a man reconstruct a more adapted masculinity--men caring for other men, men expressing themselves, men being intimate without sexual contacts, men showing vulnerabilities as well as strengths. Clients learn different ways to "be a man" and find alternatives to the model of hegemonic masculinity. The fact of being heard and validated by other males "secures" them and encourages self-questioning while promoting emotional relationships and friendships with other men that are more than instrumental.

DEALING WITH SEXUALITY

As the trauma of the abuse is sexual, it is obviously important to include sexuality as an issue dealt with in the therapeutic process (Gartner, 1999; Hopper, 2005; Munro, 2000). Without forcing any discussion, the therapist may let the client know that sexuality will probably become a topic. In the same way we often have to deconstruct hegemonic masculinity, we may have to deconstruct the conception of sexual orientation. The man has to develop the ability to deal with sexuality not only by responding to another's needs but also to his own needs. In order to do so, however, he has to become more aware of himself and put aside certain social constraints he has learned. Therapy must also often deal with internalized homophobia, since in many cases homophobia is a way for men to avoid facing their own sexual feelings (Munro, 2000).

OTHER ISSUES

Recently, some good papers have been written on working with men in therapy. Some of these papers indicate that most therapeutic models were created to work with a normative clientele (Tremblay, 1989, 1996). These models are based on talking and expressing emotions, both of which are often difficult for traditional men, who are centered on doing and acting. These men want to feel that the help they receive will bring practical and concrete changes. This is less threatening than being at the center of a dialogue. The use of structured exercises between or during the session is recommended by some therapists (Cadsky et al., 1996; Tremblay, 1989, 1996; Tremblay & L'Heureux, 2002). Cadsky et al. (1996) recommend limiting use of evaluation means such as questionnaires, even though they can sometimes be helpful for gaining self-awareness. More dynamic or kinesthetic techniques can help bring about self-disclosure, which is compatible with keeping the focus on emotions (Tremblay & L'Heureux, 2002). Levant (2001) calls traditional men's difficulties in verbally expressing their feelings as alexithymia. He argues that it is important in therapy to help men enhance their emotional vocabulary to develop mechanisms for identifying emotions as they appear.

CONCLUSION

Working with sexually abused men in a therapeutic setting is not a straightforward process involving the routine application of a few techniques. Men who have been sexually abused have to face questions regarding their identity, especially their gender role identity, and their sexual orientation. Working on identity issues and sexual orientation is helpful in the process of recovering from the effects of sexual abuse. We hope this paper will have contributed to a better understanding of some aspects of the therapeutic process with sexually abused men.

Correspondence concerning this article should be addressed to Gilles Tremblay, School of Social Work, Universite Laval, Quebec, QC G1K 7P4. Electronic mail: [e-mail].

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GILLES TREMBLAY PIERRE TURCOTTE

UNIVERSITE LAVAL (QUEBEC)

Table 1
Some Paradoxes of the Therapeutic Procee (Brooks, 1998, p. 44)

Typical psychotherapy demands       Masculinity demands

Self-disclosure                     Hiding private life
Renouncing to control               Maintaining control
Non-sexual intimity                 Sexualizing intimity
Showing weaknesses                  Showing strenghts
Feeling shame                       Expressing pride
Acting vulnerable                   Acting invincible
Seeking help                        Being self-reliant
Expressing emotions                 Being stoic
Being introspective                 Taking action
Addressing relationship conflicts   Avoiding conflicts
Confronting pain and suffering      Denying pain and suffering
Acknowledging failure               Endlessly persisting
Admiting being ignorant             Feigning omniscience