Sexual abuse and mental ill health in boys and men: what we do and don't know.

The spectrum of adverse mental health trajectories caused by sexual abuse, broadly defined as exposure to rape and unwanted physical sexual contact, is well-known. Few studies have systematically appraised the epidemiology and impact of sexual abuse among boys and men. New meta-analytic insights (k = 44; n = 45 172) reported by Zarchev and colleagues challenge assumptions that men experiencing mental ill health rarely report sexual abuse exposure. Adult-onset sexual abuse rates of 1-7% are observed in the general population, but for men experiencing mental ill health, adult lifetime prevalence was 14.1% (95% CI 7.3-22.4%), with past-year exposure 5.3% (95% CI 1.6-12.8%). We note that these rates are certainly underestimates, as childhood sexual abuse exposures were excluded. Boys and men with a sexual abuse history experience substantial disclosure and treatment barriers. We draw attention to population health gains that could be achieved via implementation of gender-sensitive assessment and intervention approaches for this at-risk population.

Social taboos related to male sexual victimisation, coupled with significant disclosure barriers faced by boys and men exposed to sexual abuse, catalyse societal and self-stigma, in addition to perceived inadequacy and shame.[1] Collectively, these factors adversely affect the mental health and well-being of boys and men with sexual abuse histories. Relative to girls and women, boys and men are less likely to: disclose sexual abuse at the time, accurately label experiences as sexual abuse and receive acknowledgement or validation of sexual abuse experiences from clinicians and/or parents.[2] It is commonplace for men to defer initial disclosure for upwards of three decades.[3] Best estimates regarding the latency of sexual abuse disclosure among men reasonably suggest a proportion of these men never experience sufficient safety[4] to speak of their abuse experience(s), with the psychosocial impacts silently concealed and suffered or self-managed.

Compelling data show that at the population health level, exposure to traumatic events such as childhood and adult-onset sexual abuse can have a powerful impact on the mental ill health trajectories of boys and men. This includes elevated risk for suicide attempts and death by suicide,[5] as well as engaging in maladaptive male-specific coping behaviours, influenced by gender norms especially among younger males,[6] including aggression, substance misuse and risk-taking.[7] The knowledge base related to sexual abuse among boys and men is underdeveloped.[8]

New prevalence data

Zarchev and colleagues[9] present compelling meta-analytic prevalence data on adult-onset sexual abuse (defined as exposure to rape and unwanted physical sexual contact at ≥18 years of age) among men with a history of mental ill health. As the authors correctly state, scant research exists on the male experience of sexual abuse[8] (including epidemiological data), and in their review (k = 44; n = 45 172) using Bayesian multi-level models, important contributions are offered to advance the field. First, Zarchev and colleagues differentiated sexual abuse exposure according to abuse perpetrated within familial or intimate relationships versus non-familial/partner perpetrators. Second, analyses examined disorder- and comorbidity-specific effects. Third, meta-regression techniques were used to investigate effects according to study characteristics (e.g. age, year of data collection, screening instrument, sampling design, implementation of instrument).

Findings indicated that for men experiencing mental ill health, adult lifetime sexual abuse prevalence was 14.1% (95% CI 7.3–22.4%) and past-year exposure was 5.3% (95% CI 1.6–12.8%). There was little change to the adulthood lifetime rate when studies at higher risk of bias were omitted from analysis. Men with mental illness were not at higher risk of sexual abuse perpetrated by an intimate partner than men in the general population; however, the key finding indicated that the prevalence of adult-onset lifetime abuse for men diagnosed with a mental disorder was potentially three times higher relative to the general population (1–7%). This underscores the need for research to sensitively screen for and assess sexual abuse exposure among men attending clinical settings (including those presenting for care in later life[10]) and to develop trauma-informed care mindful of masculine norms, some of which are known barriers to disclosure and treatment engagement.[1] We applaud the data-driven insights provided by Zarchev and colleagues and offer reflections for driving the field forward.

Suggestions for future research

Improved data collection

Over 50% of the included studies used convenience sampling, with a similar proportion failing to report response rates. Nonetheless, the reported adult lifetime and past-year rates reported by Zarchev and colleagues are certain to be underestimates of prevalence among men experiencing mental ill health, owing to the known latency of male sexual abuse disclosure (e.g. including those who potentially deny true exposure in clinical interview) and the exclusion of studies reporting childhood sexual abuse (onset at <18 years of age). Furthermore, all but one of the included studies involved a clinician or trained specialist assigning psychiatric classification. Although this approach is considered gold standard for enhancing validity of coded diagnostic impressions, the lack of anonymity may have resulted in a proportion of men denying true abuse exposure because of shame and other factors.[4]

Zarchev and colleagues[9] highlight that reported lifetime prevalence rates would be markedly higher if childhood sexual abuse studies were included in the analysis, with the true prevalence of male childhood sexual abuse in men with mental illness yet to be determined. Prior meta-analysis in the general population (<18 years of age) indicates that 8% (95% CI 4–16%) of men have experienced childhood sexual abuse broadly defined,[11] and a recent self-report study adopting convenience sampling among 1277 young men (≤30 years of age) seeking mental health help yielded a childhood sexual abuse prevalence rate of 21.9%.[7] This rate is remarkably similar to the 21.1% self-reported prevalence in the Zarchev review, which was notably 11.5% higher than the 9.6% prevalence reported in face-to-face studies.

There are of course significant challenges in collecting accurate childhood sexual abuse prevalence data among boys and men, and research on trauma history assessment that avoids causing harm is needed. Improved prevalence data matter for a number of important reasons. Recent longitudinal research has shown that, after controlling for sociodemographic, health and background factors, childhood sexual abuse undermines men's mental health across the life course well into men's sixth, seventh and eighth decades of life.[10] Hence, there is a rationale for reducing the duration of untreated (or unacknowledged) sexual abuse among boys and men, with the aim of offsetting subsequent distress or illness. That said, it is acknowledged that humans have extraordinary reservoirs of, and capacity for, resilience in the aftermath of trauma exposures. Formal psychological intervention may not be necessary for many men with a sexual abuse history – indeed sexual abuse exposure need not consign boys and men to lives of misery. Many men articulately reflect on experiences of post-traumatic growth[12] and positive identity development after abuse exposure.

Intervention studies: how and when to intervene

Previous studies have called for an urgent focus on intervention-based research for males with histories of sexual abuse, including the roles of formal and informal support groups, psychoeducation and awareness campaigns, and refinement of clinical treatment modalities.[8] This may extend to case conceptualisation, assessment and diagnosis, inclusive of older men who may be presenting to mental healthcare services for the first time. Following exposure to traumatic events, including sexual abuse, males are known to be less likely to experience threshold post-traumatic stress disorder (PTSD) compared with females, but report comparatively higher rates of externalising symptoms, including alcohol and drug use, irritability, anger and violent behaviour.[13] Of note, DSM-5-TR acknowledges that this constellation of externalising symptoms are particularly likely to co-occur with major depressive disorder in men.[14] Traumatic events may exacerbate underlying socially influenced gender differences in response to distress, resulting in alternative constellations of post-traumatic symptom patterns among boys and men.[13]

Clinicians reticent to ask about men's sexual abuse experiences may inadvertently add to the harms experienced by men seeking care. Poor treatment experiences among male sexual abuse populations can reinforce a sense of shame and secrecy, perpetuate rejection and prohibit the development of therapeutic trust, acceptance, connection and honest disclosure with treating therapists.[2] Future research should examine differential outcomes for boys and men based on whether disclosure (and treatment access) is provided proximally to exposure, and the types of supportive approaches and interventions that boys and men experience as acceptable, engaging and safe. Emerging evidence suggests that (a) early disclosure (within 1 year) of sexual abuse, (b) the nature of the response to abuse disclosure and (c) having in-depth discussions about abuse experiences are each protective for men's mental distress.[8] These factors do, however, raise complexities, including safety implications for those less than 18 years of age, the readiness, confidence and willingness of clinicians, peers and family to appropriately listen to and validate sexual abuse disclosure, and the extremely limited availability of appropriately sensitive services for boys and men. These are areas requiring urgent research and practice advances.

Implications for population health

Adequately addressing the mental health needs of boys and men who have experienced sexual abuse is certain to spur major advances in population health. It is increasingly clear from the meta-analysis of Zarchev et al[9] and others[11] that sexual abuse among boys and men is massively underrecognised and undertreated. The associated burden of disease, comorbidity and suffering, both for the individual and that imposed on others, is immense. Attention to this problem would likely reduce rates of suicide among men, which globally eclipse suicide rates among women by a factor of two to four.[15] When extrapolating conservative prevalence rates of undetected and untreated sexual abuse, maladaptive coping strategies (e.g. substance use, aggression, risk-taking) that risk harm to self and others could be reduced in hundreds of millions of boys and men globally. There is growing attention to the ways in which gender norms affect the social and emotional development of boys and men[15] and future tailored interventions and programme development for boys and men affected by sexual abuse must be cognisant and transformative of such norms. This extends to initial disclosure and help-seeking, tailoring of specialised services and clinical trials to improve long-term psychosocial functioning. Too often ignored and hidden in plain sight, boys and men with sexual abuse histories require focused attention to address their unmet mental health needs. Doing so will improve not only the mental health of affected individuals, but extend health benefits to the families and communities where these men live.