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Sexual abuse in male children and adolescents: indicators, effects, and treatments.

INTRODUCTION

Matthew was a frail, shy child who had difficulty relating with peers, boys and girls alike. He was especially fearful of adults, having been raised in a strict and puritanical home. His interpersonal difficulties led to his being a "loner." At about the age of eight, he was lured into a neighborhood garage by two teenagers who raped and sexually abused him. Matthew was thoroughly confused and overcome by this brutal experience. The sexual abuse by the two teenagers continued for three years. By age eleven, Matthew's family moved to another state and the sexual abuse was terminated.

Throughout the period of sexual abuse, Matthew remained silent because of threats made by the perpetrators. Finally, at age 23, Matthew was able to reveal his experiences to a college counselor. The effects of the abuse are still felt by Matthew, who is in the late stages of early adulthood.

This paper focuses on the experiences of Matthew and others like him: the sexual abuse of male children and adolescents.

INCIDENCE

Crimes involving all types of sexual trauma go largely unreported due to the secretive nature of the offense and the implied collusion that is forced upon victims by their perpetrators and passively encouraged by societal denial (Porter, 1986; Summit, 1988). The incidence of sexual abuse of male children and adolescents is especially "invisible"; it is the lowest reported form of child abuse in the United States (Schultz & Jones, 1983). Its prevalence has been reported to range between 3% and 31% (Finkelhor, Araji, Baron, Browne, Peters, & Wyatt, 1986), while the number of new cases occurring each year throughout the U.S. has risen steadily (Dimock, 1988). Finkelhor (1984) estimates that 46,000 to 92,000 male children under the age of 13 are sexually molested each year. Other estimates suggest that 3% to 9% of males in the general population have been sexually victimized as children or adolescents (Briere, Evans, Runtz, & Wall, 1988), and that they comprise from 11% to 47% of all sexual abuse victims (Singer, 1989; Wyatt & Powell, 1988). Actual reports total a small fraction of this number (Schultz & Jones, 1983). Responsibility for this underreporting is shared by both the victims and those in the helping professions, and is supported by societal attitudes. Much that goes unreported is initially a function of the boys' embarrassment or fear of social stigma--a consequence of our homophobic society (Porter, 1986; Sebold, 1987; Singer, 1989)--or results from the victims' use of repression as a coping mechanism (Singer, 1989), which is also in compliance with unspoken societal expectations (Porter, 1986). Helping professionals may unintentionally contribute to the underreporting of cases by not asking direct questions at the right time. Whenever a female child is found to have been sexually molested, not only should her sisters be regarded as potential victims, but also her brothers.

In a comparison of substantiated child sexual abuse cases, Pierce and Pierce (1985) found that young male victims tended to be from larger families, to be abused by their stepfathers, and to have suffered more threats and use of force by their assailants than young female victims. Rogers and Terry (1984) reported that force was used in half of the sexual assault cases in their clinical sample, although boys were 14% more likely to be threatened with physical harm as a means of gaining compliance. Once identified, fewer males than females were removed from their abusive homes, and females were more likely to receive counseling.

Faller (1989) reports that male subjects in her investigation of sexually abused children were older at the onset of the sexual abuse than were female subjects. They were also more likely to have come from a middle-class background than were females (46% versus 20.5%). Proportions of intra- and extrafamilial sexual abuse for both male and female victims in this study mirrored nationally reported estimates, with 23% of the boys and 14% of the girls having been abused outside of the family. Sexual abuse of boys who were victimized in the home began earlier than it did with extrafamilial victims. In a comparative study of eighty men and women, half of whom had suffered abuse, Briere et al. (1988) found that the median age for the onset of sexual abuse had been 9 years for males and 9.6 years for females. Fifty percent of all abuse was incestuous for both sexes (Briere et al., 1988; Faller, 1989).

A significant majority of sexually abused children report multiple occurrences of victimization by a single perpetrator (Stephens, Grinnel, & Krysik, 1988). Fagot, Hagan, Youngblade, and Potter (1989) report that 85% to 97% of the offenders are male for both male and female victims. One study of male offenders revealed that 11% had suffered some sexual abuse as children, 16% had been physically abused, while 7% had been victims of both sexual and physical abuse (Fehrenbach, Smith, Monastersky, & Deisher, 1986).

The majority of all child sexual abuse victims are living with both parents at the time of the abuse (Mannarino & Cohen, 1986; Stephens et al., 1988). Hoagwood and Stewart (1989) compared sexually abused and nonabused children's perceptions of family functioning. Although all of these subjects were classified as emotionally disturbed and lived in a residential treatment facility, their responses on the McMaster Family Assessment Device (FAD) discriminated between the two groups on three dimensions. The families of the sexually abused children were perceived as less capable of problem solving, of establishing and maintaining effective role boundaries, and as more prone to general dysfunction and pathology. These authors also reported significant gender differences indicating greater pathology in the female sample, a function, perhaps, of male subjects' documented reticence to recognize dysfunction (Porter, 1986; Singer, 1989).

INDICATORS

Indicators of child sexual abuse are, in fact, the initial shorter term effects that are manifested by victims. The efficacy of early detection and treatment in helping young victims of sexual abuse highlights the need for professionals and parents to be knowledgeable about, and attentive to, the early warning signs. This is especially critical with male victims, who are often neglected by potential helpers (Porter, 1986).

Early indicators are difficult to assess, as they vary according to the developmental level of the victim and often differ from one child to another. One national estimate indicates that toddlers and preschool children under five years of age comprise 15% to 18% of those sexually victimized each year (National Center on Child Abuse and Neglect, 1978). Toddlers and preschoolers may exhibit extreme behaviors on either end of the withdrawal-aggression continuum, show precocious sexual knowledge, act out sexually with peers, and/or report difficulty sleeping and nightmares, often with violent or sexual content (Salter, 1988; Schultz & Jones, 1983). Somatic complaints (red or swollen genitals, repeated fissures in the anus, bruising, venereal symptoms) must be checked by a physician. A child's regression to incidents of nocturnal enuresis; sudden fear of being hurt during diapering, baths, or dressing; or intense fear of someone whom the child had known without fear (i.e., one particular sex, a noncustodial parent) should also be viewed as potential indicators, especially if there is no alternate explanation, such as changes or trauma within the family or play environment (Salter, 1988). Excessive and compulsive masturbation that is preferred even to play should be seen as an indicator of sexual abuse among toddlers and young children (Salter, 1988; Schultz & Jones, 1983). Soliciting sexual play from peers, especially when these requests involve force, is a sign that the initiator may be an abuse victim himself. These children may even attempt to insert toys into their rectum or that of pets. Sexual abuse of pets and stuffed animals (e.g., "mounting" a stuffed bear) clearly differentiates these abuse victims from their nonabused peers (Salter, 1988).

In their study of play patterns, Fagot et al. (1989) identified the initial effects of abuse in the very young child. In this study, the young children who played passively and alone, unless approached, but who were not aggressive or antisocial were those who had been molested. This tendency to withdraw can also be seen in school-aged children, who may exhibit excessive dependence or fear of specific people (Elwell & Ephross, 1987; Salter, 1988). In older children (Adams-Tucker, 1982; Fagot et al., 1989) and teenagers who have school phobia, higher rates of truancy may be observed (Elwell & Ephross, 1987; Salter, 1988). Female runaways are considered as having been at high risk for sexual abuse (Adams-Tucker, 1982; Schultz & Jones, 1983). The ultimate act of withdrawal--suicide--is seen more often among sexual abuse victims of both sexes (Adams-Tucker, 1982; Briere et al., 1988). Although withdrawal and truancy can be indicators of child sexual abuse, a sudden increase in aggressivity or a pattern of coming to school early and leaving late can also be warning signs of abuse (Salter, 1988; Schultz & Jones, 1983).

Early warning signs of child sexual abuse vary greatly in type, and in seemingly contradictory ways. It is the suddenness of onset and the degree to which they are exhibited by these young victims that are the critical factors in early detection. Helpers are cautioned that the presence of several indicators may be necessary but not sufficient to assume that abuse exists (Salter, 1988).

EFFECTS

Effects differ within the wide range of abuse parameters. The degree of trauma experienced by the victim has been found to be influenced by the sex of the offender (Vander Mey, 1988), the closeness of the child's relationship to the perpetrator (Caffaro-Rouget, Lang, & van Santen, 1989; Hoagwood & Stewart, 1989), the duration of the abuse (a single incident or multiple occurrences), the severity of the abuse (from fondling to penetration accompanied by force or bodily trauma), and the age of the victim at onset.

Elwell and Ephross (1987) observed a higher degree of trauma when sexual abuse was accompanied by the use of force and physical injury. In their study of one male and six female victims, they also found that trauma was related to the severity of the sexual behavior, but not the perpetrator's threats or the frequency of the abusive behavior. The findings of a much larger (N = 240) comparison study by Caffaro-Rouget et al. (1989) noted that victims' mental and emotional disturbance increased when sexual acts were forced. In this study, a lack of protection or recourse for the abused child, such as is experienced in homes where there is parental substance abuse, was also associated with a higher degree of mental and emotional trauma. This trauma was found to be especially acute when the perpetrator was the mother or a sibling (of the same or opposite sex), a finding supported in the current literature (Hoagwood & Stewart, 1989).

Effects can be viewed as falling into two groups: internalizing and externalizing factors (Achenbach & Edelbrock, 1978). Friedrich, Urquiza, and Beilke (1986) administered the Child Behavior Checklist (CBC; Achenbach & Edelbrock, 1983) to a sample of sexually abused children to determine how severe and to what degree their behaviors were internalized or externalized. They found that 35% of the males and 46% of the females were significantly elevated on the internalizing scales, while 36% of the males and 39% of the females were elevated on the externalizing scales of the CBC.

Internalizing and externalizing scores correlate, however, with a wide range of childhood stressors and do not discriminate as to the source of the stress (i.e., sexual abuse). Salter (1988) cites behaviors that tend to correlate more specifically with child sexual abuse. Those that pertain to male victims include somatic complaints and physical symptoms that are sexual in nature, and verbal reports of sexual abuse, although boys are more reticent than girls to report the abuse. Taking this reticence into consideration, verbal references to ongoing abuse by male victims must always be taken seriously. In a study by Jones and McGraw (1987) of child sexual abuse victims, false allegations, reported in 8% of the cases, broke down to 6% that had been alleged by adults in the children's behalf, with all but one of the remaining cases having been alleged by disturbed adolescents who had been sexually abused in the past. Findings that false claims of child sexual abuse generally occur in less than 2% of the cases support Jones and McGraw's (1987) research.

Male Children and Adolescents

A study by Briere et al. (1988) compared adult males and females who had been sexually victimized as children with a control group who had not suffered abuse. They found that sexual abuse in childhood has, at the very least, an equivalent impact on males and females. They purport that sexual molestation may be even more traumatic for young male victims than for females, since reportedly lower levels of abuse for the former resulted in similar symptomatology. Among the effects that distinguished victims from nonvictims were a greater incidence of suicide attempts and higher levels of anxiety and depression. The effects of child sexual abuse reported by others include depression, suicidal gestures (Mandell & Damon, 1989), anxiety, somatic complaints (Elwell & Ephross, 1987; Mandell & Damon, 1989), disturbed interpersonal relations due largely to the inability to trust others (Mandell & Damon, 1989), school difficulties (Elwell & Ephross, 1987), a decrease in the level of social functioning (Mandell & Damon, 1989), heightened sexual activity/preoccupation that often includes compulsive masturbation (Friedrich, Beilke, & Urquiza, 1988; Friedrich & Reams, 1987; Salter, 1988; Sebold, 1987), homophobic concerns (Everstine & Everstine, 1989; Mandell & Damon, 1989; Porter, 1986; Sebold, 1987), infantile behavior (Friedrich & Reams, 1987), paranoic or phobic behavior (Sebold, 1987), and poor body image or changes in bodily functions (Sebold, 1987). A male's sense of powerlessness may even be channeled into aggressive sexual behavior wherein the victim becomes an offender (Porter, 1986; Rogers & Terry, 1984). No single effect, however, has been found to be universal.

Abuse Victims as Adult Males

Reported characteristics of adult males who were sexually abused as children include sexual preoccupation or compulsiveness (Singer, 1989), gender identity confusion (Dimock, 1988; Krug, 1989), sexual orientation confusion (Bruckner & Johnson, 1987; Dimock, 1988; Myers, 1989; Singer, 1989), difficulty establishing stable, trusting relationships (Dimock, 1988; Krug, 1989; Myers, 1989; Singer, 1989; Strean, 1988), depression, substance abuse (Bruckner & Johnson, 1987; Krug, 1989; Singer, 1989), disturbances in self-esteem and body image (Myers, 1989; Singer, 1989; Strean, 1988), and symptoms of chronic posttraumatic stress disorder (Myers, 1989). Repression, denial, or normalization of the trauma is often manifested by adult male clients (Myers, 1989; Schultz & Jones, 1983).

The relationship between homosexual behavior and sexual abuse is not necessarily causal. Men who engage in same-sex behaviors are not necessarily gay, and gay males may be more vulnerable to a variety of victimization experiences, including sexual abuse (Dimock, 1988). Not all male children and adolescents who suffer sexual abuse become sexual offenders. Strean (1988) asserts that only about 30% of sex abuse victims actually repeat this cycle of abuse with their own families.

TREATMENT

There are many similarities in treatment guidelines for male and female victims of child sexual abuse. However, there are some unique differences for helpers who deal with young male victims. Helpers are no more immune to the effects of socialization than are the victims and their families. Helpers must not only become aware of their own biases, but also the interplay of their biases and those exerted by societal denial on both victims and their families in the domain of sexuality--especially in regard to male sex role identity. Porter (1986) urges all those who counsel male victims of sexual abuse to explore their own feelings about victimization and sex roles. Unconditional acceptance of the victim and his chosen sexual orientation (as an adolescent or adult male) is basic to the therapeutic relationship.

A prerequisite for treatment of the male sexual abuse victim is the disclosure of the experience (Porter, 1986). However, such disclosure is hampered by denial. Damon, Todd, and MacFarlane (1987) note that the use of denial and repression is especially strong in children aged three to six, who are cognitively preoperational. Denial reflects a boy's strong need not only to protect himself from the specific trauma, but also to spare himself the social sanctions and isolation he imagines would be forthcoming if others were to know (Everstine & Everstine, 1989). In this way, sexually abused males often become victims of another kind as well--victims of societal denial (Porter, 1986; Summit, 1988). Denial can manifest itself to different degrees, from extreme conditions such as the development of multiple personalities and amnesia to definitional and impact denial wherein the victim redefines the abuse or denies any emotional effects (Porter, 1986).

Experienced helpers who are comfortable with their own sexuality preface their therapeutic interviews by providing information concerning the prevalence of sexual abuse of males and some feelings and attitudes boys are likely to have about such abuse (Porter, 1986; Salter, 1988). Since the amount of sex

education varies greatly from one age group to another and from one child to another, some basic explanations may be necessary in order for the helper and the child client to communicate. Rather than using specific terms that are assumed to have a definitional consensus (e.g., "molestation"), helpers should ask young clients for more general accounts of their sexual "experiences." Many younger males would deny having been molested, for example, if a woman had forced them to perform sexual acts (Porter, 1986; Salter, 1988; Wheeler & Berliner, 1988).

Among group, family, and individual therapy modalities, individual therapy, especially with a male helper, can be the most difficult and intimidating for the male sexual abuse victim (Porter, 1986). In all but extreme cases in which group therapy is precluded, individual work should be done concurrently in support of group treatment.

Group psychotherapy can be highly beneficial to male victims of sexual abuse in strengthening impulse control, enhancing self-esteem, and providing opportunities to participate in reality testing (Mandell & Damon, 1989). During group treatment for adult males who were sexually abused as children, Bruckner and Johnson (1987) reported the emergence of the following themes: disclosure, dealing with anger, sexuality education, the victim as offender, and intimacy and truth building in relationships. Although the majority of group interventions involve unstructured group therapy, Sturkie (1983) found that she had greater success by implementing a model of structured group treatment with female latency-aged sexual abuse victims. The eight themes used for this model (believability; guilt and responsibility; body integrity and protection; secrecy and sharing; anger; powerlessness; other life crises, tasks, and symptoms; and court attendance) could be modified to serve the specific needs of young male victims.

A peer group of four to ten (preferably six to eight) members co-led by a male and a female therapist has been found to be the most effective model for group treatment (Mandell & Damon, 1989; Porter, 1986). Age spacing among members should be closer for younger children, with three to six sessions, lasting from one to one and one-half hours, conducted once a week (Friedrich, Berliner, Urquiza, & Beilke, 1988). Once the group is guided toward supportive interaction, the members' fear of being ostracized is diminished and they come to view the group as a haven of security and acceptance (Porter, 1986).

In family therapy, the nonoffender father's presence is crucial from the beginning. Fathers are more likely to collude with the victim in wishing to minimize the abuse and/or to deny a need for treatment (Porter, 1986). An essential element of the therapist's role is that of creating a firm alliance with the parents so that they can maintain their parental roles with a sense of self-respect. Elton, Bentovim, and Tranter (1987) identified four stages common to family intervention: disclosure of abuse, family disruption, movement toward rehabilitation, and the creation of "a new family."

General suggestions to helpers working with the sexually abused child include empowering the young victim with the knowledge that he is not bad, although, due to his inexperience, he may have made some poor choices. Control is returned to the child-victim once he realizes that choices can be renegotiated whenever new information becomes available (Lamb, 1986; Porter, 1986). Normalizing the child's fears and guilt, and demystifying the subject matter by modeling an appropriate way of talking about the abuse with moderate emotional involvement, can serve to validate the positive and negative feelings created by the abuse experience (Porter, 1986). General goals of therapy may include ventilation of affect (Porter, 1986; Wheeler & Berliner, 1988), learning specific anxiety-reducing techniques (Friedrich, Berliner, et al., 1988; Wheeler & Berliner, 1988), increasing self-esteem, enhancing social support and empathy, improving awareness of interpersonal boundaries and relationships with others (Friedrich, Berliner, et al., 1988), altering attributions of responsibility (Friedrich, Berliner, et al., 1988; Wheeler & Berliner, 1988), explaining the offender's behavior or understanding the abuse, especially through structured role-playing (Friedrich, Berliner, et al., 1988; Wheeler & Berliner, 1988; Damon et al., 1987), restoring expectations of self-efficacy (Wheeler & Berliner, 1988), and exploring the significance of the abuse to the victim's sense of sexuality and sexual orientation (Wheeler & Berliner, 1988).

Cheryl Ann Black, doctoral candidate, New Mexico State University.

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Author:Black, Cheryl Ann; DeBlassie, Richard R.
Publication:Adolescence
Date:Mar 22, 1993
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