The psychological effects of male rape
This study was invoked following the observation of a male rape case at the local crown court as part of training for CRASAC (Coventry Rape and Sexual Abuse Centre), and aims to review the psychological effects of male rape as a relevant topic for research. In a male-dominated culture, men do not want to accept their role as victims. The study of male rape has been overshadowed by research into the effects of female rape and as a consequence has been ignored to a large extent. Recent changes to the law have brought recognition of male rape to the forefront and it is hoped that this will result in an improvement in the services provided for male victims. This independent study will identify the prevalence of male rape, the factors that prevent reporting, the long-term psychological effects that it has on the victims and the current support services available to them. Aims and objectives The object of the project will be to identify and review studies that have examined the impact of being a male victim of rape and also the resulting difficulties to be considered when providing support for these victims. The review will identify research material by accessing peer-reviewed publications from the library and internet resources and also text publications on this subject. The studies will be critically reviewed and important results and omissions will be highlighted. Literature review The Sexual Offences Act (1956) was updated in 1994 making the rape of a man an equal crime to rape of a woman. Changes to the act in 2003 made further major amendments to the old law. An offender is guilty of rape if he: Intentionally penetrates the victim’s vagina, anus or mouth and the victim does not consent and the offender does not reasonably believe that the victim is consenting. Only a man can carry out rape but both men and women can be victims. Rape now includes oral penetration, and the offender can not offer a defence that he honestly believed that his victim consented unless that belief must be reasonably upheld. Rape is punishable as a maximum by life imprisonment. Assault by penetration is a new offence that can be committed by either men or women against either sex. The offence requires penetration of the vagina or anus with a part of the offender’s body or anything else, and the penetration is sexual in nature. Assault by penetration can be sentenced to a maximum of life imprisonment. Sexual assault replaces indecent assault, and involves touching the victim in a sexual manner without consent. The maximum sentence is 10 years imprisonment. Male rape is more commonly committed by heterosexual men (McMullen 1990) and the sexual orientation of the victims more evenly distributed. Furthermore, 66% of all gang assaults on men are also perpetrated by heterosexuals (Hodge & Canter 1998). Female perpetrators are also involved in up to 40% of sexual assaults on men (Coxell et al 2000). In Europe, there are no robust epidemiological data on the prevalence of rape or other sexual offences on men. Indeed, male rape did not exist in the eyes of UK law until 1994. Before this, male rape was classified as indecent assault. Following the introduction of the new law, in 1995 there were 3142 indecent assaults and 227 rapes against men - an increase of 51% from 1994 (Stationary Office 1996). More recent Home Office Statistics show an increase of 400% in reported cases of male rape between 1995 and 2000. However, for many reasons, the vast majority of incidents of male rape go unreported. In an attempt to measure the lifetime prevalence of non-consensual sex in men, Coxwell (1999) carried out a cross-sectional survey of 2474 men attending one of 18 general practices. The authors chose to conduct the study in the general practice setting as it was felt to provide a confidential setting where patients expect sensitive and intrusive questions. Participants were shown to a private room and completed a computerised questionnaire. The authors devised their own definition of non-consensual sex “where a person uses force or other means so that they can do sexual things to you that you did not want to do” or “made you do things that you did not want to”. There is currently no standardised instrument to assess experiences of sexual molestation and so the questions chosen were based on the investigators' research and clinical experience. The survey was carried out in general practice settings in city, small town and rural areas and the participants had varied ethnic and social backgrounds. There was a high (79%) response rate and just under 3% reported non-consensual sexual experiences as adults. Only two men who had been raped reported the experience to the police. This compares with the only other major British study of 930 homosexual men (Hickson 1994) where just over a quarter reported that during their lifetime they had been subjected to sex without consent and 10% had been raped (cited in Coxwell 1999). It has long been recognised that male rape has been a feature of all male institutions, in particular, the forces and in prisons. Throughout the world, the environments with the highest frequency of same-sex rape are undoubtedly prisons and jails (Scarce 1997). In the United States, it is estimated that an average of 360,000 males are assaulted behind bars each year and at least two-thirds of these are repeatedly raped and often gang raped on an almost daily basis. It is unlikely that the levels of violence in United Kingdom prisons reach these levels, but nonetheless, the predominant belief persists that inmates get what they deserve. In a lecture delivered to Columbia University in 1993 Stephen Donaldson said ‘No one cares what happens to a prisoner. Everyone has the attitude that prisoners complain too much and have unreal expectations in wanting to live as a human being, that we somehow deserve all that happens to us. I know this attitude well because I used to have this view before my incarceration.’ (cited in Scarce 1997 p37). Like so many other aspects relating to male rape, people’s attitudes often change only when they have a close or personal experience that exposes the many myths that exist. Males are less likely to report rape for several reasons. Some do not even realise that male rape is a crime; being male they assume that society expects them to be able to fend for themselves. If in the victim’s eyes, a crime has not been committed, then they will not report the event to the police. Male rape myths, stemming from the traditional view of masculinity that most men are strong, assertive, sexually dominant and usually heterosexual, lead victims to believe that men cannot be raped or that the effect of sexual assault is less severe for a man than it is for a woman (Groth & Burgess 1980). ‘Because most men have internalised the social belief that the sexual assault of men is beyond the realm of possibility…men have trouble accepting their rape experience as real, not only because it happened to them, but that it happened at all’ (Garnets 1990). At present, law enforcement agencies have a tarnished reputation for handling female rape and therefore sensitivity and professionalism in dealing with a male victim is seen as unlikely. Men who do report sexual assault tend to be treated indifferently by the police (Mezey & King 1989) and can find themselves being ignored, questioned as criminals or at worst ridiculed. Those that do report to the police tend to have suffered more severe physical injuries and have greater confidence in their ability to convince others of their heterosexuality. Others may report to medical services for treatment of their injuries but conceal the circumstances in which they arose. Many end up blaming themselves for what has happened. In the first instance, the victims will be as desperate to keep it a secret as his attacker. Many male victims experience sexual arousal, erection or even ejaculation during the assault. Getting the victim to ejaculate is a major strategy for some perpetrators, symbolising the extent of the offenders' control over his victim. These physical responses may be confused by the victim as indications of pleasure or unrecognised consent (Groth & Burgess 1980). As a result, the victim questions his own sexuality and may feel betrayed by his own body. Is my body telling me that I am actually gay? The risk of public humiliation or being labelled gay push the victim towards the option of remaining silent. Homosexual men are more likely to become victims of male rape, possibly because some have several partners or liaise with strangers and in secretive locations. When such an encounter results in rape the victim may take responsibility for part of what had happened, blaming themselves for putting them at risk or behaving in a way that may have “invited” the attack. Similarly, heterosexual victims may wonder if their behaviour had sent out the wrong signals and somehow set themselves up for assault. Homosexuals also may fall victim to homophobic attacks where sexual assault is common (Comstock 1989). Gay male victims may also experience internalised homophobia or interpret the assault as “punishment” for their sexuality (Garnets 1990). This may be a particularly significant response if the victim is not publicly gay or is in the early stages of coming to terms with his sexuality. These views are unfortunately reinforced by the media and particularly the press. There have been several reports on male rape incidents where the physical attributes of the victims are described in a manner that hints at surprise that such a physically capable person should allow himself to be overpowered and abused (McMullen 1990). Finally, its part of the male ethic emphasising self-reliance that leads many victims to decide that they must deal with the encounter themselves. This prevents them from reporting, taking advantage of what support available and finding a way to recovery (Rentoul 1997). Some will finally find a time and place where they can share their ordeal, but this is often a considerable period after the event. “The lack of social awareness of the psychological problems facing male victims of sexual assault, the paucity of empirical research and the lack of information available to the police and healthcare workers all serve to underscore the need for a review of the published literature in this field” (Rentoul 1997 pg 268). The unfortunate outcome is that the initial psychological impact of male rape is that the men are victimised at multiple levels: first they are victimised by their attackers, they are then subjected to rejection and stigmatisation from friends and family and potentially humiliated at the hands of the law. These factors serve to reinforce the internalisation of self-blame and denial of the need for help that inhibits recovery from the assault. The psychological consequences of male rape impact in the immediate & long-term and can be emotional, behavioural and somatic. There have been few studies looking at the impact of male rape in comparison to female rape, but it is reasonable to assume that some features are common to both. Based on several studies into the effects of rape trauma in females, the responses have been classified into anticipatory, impact, reconstitution and resolution (Koss & Harvey 1991). The anticipatory phase immediately precedes the sexual assault. Realising that they are potentially in danger the victim deploys various defence mechanisms including rationalisation in order to preserve safety and avoid escalation of violence. Many men will freeze or submit in order to minimise injury as a result of primitive responses for self-preservation and will therefore put up minimal resistance. The definition of a real man Stanko (1990) ‘ a strong heterosexual male protector, capable of taking care of himself and, if necessary, guarding his and other’s safety aggressively’ (cited in Petrak & Hedge 2002 p52) is not supported in a UK study of 119 cases of male sexual assault where freezing was the victim response in 60% of heterosexuals, bisexuals and homosexuals (Hodge & Canter 1998). The impact phase includes the duration of the assault and the immediate aftermath. The intense fear of death or bodily harm gives rise to an inability to appraise or respond to the situation. This may give rise to overwhelming psychological arousals such as shock, numbness, disbelief and helplessness. Males tend to conceal their emotions and adopt the need to deal with the situation as they would expect the masculine stereotype to do. The reconstitution phase encompasses the weeks and months following the rape during which time the victim attends to basic needs and may make efforts to reduce vulnerability by changing telephone numbers or moving house. It is during this phase that the differences between male and female victims probably become more apparent with the male victims struggling with sexual and gender identity, anger and self-denial. The resolution phase is characterised by anger despair and shame. In males particularly hostility and desire for revenge may well feature. There are a number of important differences in the impact of rape on men and women but in addition, the many parallels are acknowledged. As mentioned, the response of submission for self-preservation when threatened is associated with shame, guilt and humiliation. Men are more likely to be the victims of greater physical trauma, held in captivity for longer and raped by multiple assailants, sometimes more than once. Men are more frequently attacked by strangers (Groth 1980) and the offender more likely to use and display weapons (Donaldson 1990). Male coping strategies differ significantly from females. In one comparative study the majority of female victims reported responding in an expressive emotional style, crying, sobbing and restless, whilst most males remained calm, composed and subdued. The male coping strategy characterised by denial and control renders them more prone to later psychiatric problems and reduces the likelihood of seeking help (Mezey 1987). In addition, the help and support for male victims of rape is estimated to be 20 years behind that for females (Rogers 1998). A questionnaire survey investigating the effects of rape on men attracted only 52 responses after advertising in one national newspaper, several free and gay orientated magazines and posters in 5 genito-urinary treatment centres, asking for victims of male rape to take part in the study (Walker 2005 a). Of these, 40 returned completed forms. Over half of the respondents (63%) considered themselves either bisexual or gay. The survey consisted of five questionnaires, one specifically asking about experiences of male rape, the others being standardised questionnaires relating to wellbeing and self-esteem. 60% of respondents had first reported the incident to someone that they knew, 27.5% first revealed their ordeal to a professional, of that only 12.5 % informed the police and the remaining 12.5% had not told anyone before completing the questionnaire. Of those who informed the police only one person reported a positive reaction, the remaining four regretted their decision to tell the police. Only one perpetrator was convicted and sentenced to 10 years imprisonment. All of the victims experienced long-term negative psychological and behavioural effects after the assault. In almost all cases these included depression, flashbacks, fantasies about revenge, anxiety, loss of self-respect and an increased sense of vulnerability. The symptoms persisted in many cases for several years after the rape. Associated with fantasies about revenge against the assailant were feelings of anger and difficulty in controlling emotions. The loss of self-respect made several victims feel uneasy in the company of males and in some cases lead to self-destructive behaviour including self-harm, alcohol and drug abuse and suicidal ideation or attempts. Around 70% of the victims experienced crises relating to their sexuality and masculinity after the rape. Some became sexually promiscuous but others found it difficult or impossible to resume sexual relations either because of reduced libido, impotence or because the whole idea of having sexual intercourse had become repulsive. One heterosexual man who had experienced an erection and ejaculation during the ordeal found it very difficult to equate his body’s physical responses with his own emotions at the time of the rape. Over 80% of the men experienced profound feelings of guilt and self-blame for either putting themselves at risk in some way or failing to prevent or fight back during the attack. This resulted in the men feeling a loss of self-respect and self-worth. At the time of the survey only one man felt that he had recovered from the ordeal, 31 had made some steps towards recovery, but eight felt that they had not recovered at all. This publication was limited in sample size, but by the nature, if its design was able to provide detailed descriptive data providing an insight into the psychological effects that being raped had on the victims. What was missing was the timescale over which these effects were most debilitating and some measure of whether the provision of appropriate support services may have helped to reduce these. Previous reports have suggested that psychological disturbance and health problems could last a decade or more after male rape (Coxell 1996). In a similar sized study (Walker 2005) recruited 40 male rape survivors through national advertising in the British press. Respondents were asked to complete a series of questionnaires and their responses were used to compare psychological functioning with a matched control group. In this study half of the survivors described themselves as gay and 32% as heterosexual. Most were aged between 16 and 25. Four verified questionnaires were used for the assessment: The General Health Questionnaire (GHQ: Goldberg 1978) measures aspects of psychological functioning: somatic symptoms, anxiety, social dysfunction and depression. Compared to the controls survivors displayed high levels of anxiety and depression. Approximately one-third of the survivors also reported somatic symptoms and social dysfunction. None of the controls showed any of these characteristics. The World assumptions scale (WAS: Janoff-Bulman 1989) measures people’s basic assumptions about the world they live in: benevolence, justice, randomness, self-worth, controllability and luck. Surprisingly the only significant difference between survivors and the controls was that survivors showed significantly low scores for self-worth. The State self-esteem scale (Heatherington & Polivy 1991) measures self-esteem in terms of performance, social and appearance. As predicted, the survivors showed significantly lower self-esteem scores across all parameters. The Impact of event scale (IES: Horowitz et al 1979) consists of 15 statements, 7 measuring intrusion of thoughts relating to the event and 8 measuring avoidance of thoughts relating to the event. The majority of survivors suffered from intrusive re-experiencing of the rape and 80% had problems sleeping because of thoughts and images related to the rape. Most also recognised avoidance of certain thoughts, ideas or feelings and situations. Of particular concern was the association between attempting suicide and avoiding psychological help. The presence of three persistent clusters of symptoms: re-experiencing the trauma, avoidance of trauma-related stimuli and symptoms of increased arousal for more than one month fits the current diagnosis of Post-traumatic stress disorder PTSD (American Psychiatric Association 1994). Whilst there has been strong evidence linking PTSD with female rape, the lack of research into the long-term effects of adult male rape, confounded by the reluctance of male victims to report rape and take part in studies leaves a gap in our knowledge in this area (Rogers 1997). The profound effect that PTSD can have on an individual is best illustrated by a case report (Rogers 1997). Richard was raped by three men when he was 21. Ten years later he was still suffering from PTSD. Richard suffered from flashbacks lasting up to one hour seven times a day where it felt as if he was being raped again. He avoided visiting public houses and lavatories, groups of men, and would not read newspapers in case there were any sexual crimes reported. Richard had compulsive rituals of bathing, scrubbing his anal region and hand washing up to 20 times a day. He avoided eating full meals to avoid defecating and would induce vomit after eating. He was depressed and had also developed an alcohol problem. The management of PTSD has focused on reducing depression and suicide risk by medication and cognitive-behavioural therapy. So far this is an area of management that is dependant on experience with treating female survivors. However, the differences between male and female responses to rape may warrant a modified approach when dealing with male victims. ‘Several specific factors distinguish the recovery efforts of male survivors from those of their female counterparts. These factors are all related to the way in which males are socialised to be different from females, and they create a gigantic web that entangles, and frequently traps, male survivors (Struve 1990 p36) The support services for the male survivors of rape are very limited and have received little attention. There is a vicious circle whereby men do not report because of the lack of facilities available to them and the stigmatisation of male rape. As a result of under-reporting the issue of male rape does not attract the level of attention that it deserves and this, in turn, makes it difficult to acquire resources. It is a shame that the centres provided to assist female victims of rape are often reluctant to offer advice or the basic courtesy of listening to male victims in crisis, primarily due to a lack of training and awareness. Survivors (Sheffield) is a registered charity and one of the most established providers of support and information for male victims. The principles behind survivors are to recognise that male victims need to be listened to, to be able to express their emotions in a safe environment (BACP Ethical Framework), to be believed not criticised, and to be provided with free information and advice through a service that is aware of and sensitive to issues of sexual orientation, race and disability. In addition to medical attention and appropriate legal advice and support, the victims must have access to the necessary services that will support recovery from the trauma. This may include further medical treatment and a range of therapies including pharmacotherapy and counselling. Men talk a lot but don’t say much. ‘As the number of men coming forward to disclose sexual assault increases it is important that the support offered is appropriate for these men’s needs.’ (Sullivan 2006 p1). Most will benefit from counselling (King 1995) but for many reporting is often late and some do not report at all. Some have suggested that both heterosexual and homosexual victims would prefer a female therapist in order to avoid the mistrust of men, the danger of eroticised transference and loss of control in therapy. (King 1995) argues the lack of evidence to support this and that a male therapist may help to regain trust in men. They may need counselling about potential HIV transmission which is a primary concern for many victims (Laszlo 1991). Principles of care (Ledray 1990) include respect, empathy, recognition of the event and acceptance of the victim. Several treatment strategies have been employed to help victims recover including crisis therapy (Koss & Harvey 1987), hypnotherapy, psychodynamic therapies and cognitive therapy but there is little recognition of the potential for a more person-centred approach. In view of the studies reviewed, it would appear that many of the problems experienced by male victims are as a result of their not meeting the standards that they have associated with being a ‘real man’. These conditions of worth of how society expects them to behave conflict with the primitive responses that were brought into play in order to maximise the chances of survival. As the victims are most commonly not accepting what has happened in the real sense and are denying themselves the opportunity to express themselves, it is unlikely that having some expert explain what has happened will be of much benefit. It is surely much more likely to benefit the individual to provide them with the empathy and respect that they deserve so that they have an opportunity to discover these truths for themselves. Having not been in control at the time of the rape it would be insensitive not to respect the individuals right to take control of their lives in the aftermath. Tempting as it may be to encourage the victim to take part in a counselling relationship, it is important to respect their right to autonomy and self-determination, and to present for help at a time that suits them and when they feel ready (Bond 1993). Another aspect that must be remembered is that many victims will not discuss their ordeal for a considerable time after the event. Therefore the potential that an apparently unrelated presenting complaint may develop months or years after falling victim to male rape must be recognised. Summary To summarise, male rape is an issue that has been distorted by myths and ignorance about the nature of heterosexuality and homosexuality in relation to perpetrators and victims. The study of male rape and its consequences is thwarted by the reluctance of male victims to report their assault and difficulty in recruiting respondents for research purposes. Male rape has not been recognised in law in the United Kingdom until 1994 and as a result, the police and legal serviced are inexperienced in providing for the needs of male victims which further inhibits reporting. This situation is slowly improving. Most perpetrators of male rape are heterosexual and there are a relatively higher proportion of homosexual victims. The effects of male rape are devastating and may persist for many years. The most common response is: non-reporting, denial, anger, depression, low self-esteem, sexual dysfunction and loss of sexual identity. The evidence required to guide best practice in helping victims is severely deficient buy similarities between the needs of male and female victims are recognised. At present, the most basic needs of male survivors are rarely met and this can only be achieved through increased awareness, research and appropriate funding.