Commentary: Causes and Consequences of Male Adult Sexual Assault ================================================================ * Barry W. Wall ## Abstract Bullock and Beckson add to a growing body of literature on the negative consequences of adult sexual assault on male victims. There are similarities as well as important differences between male sexual assault victims and their female counterparts. Their analyses of societal contributions and myths about adult male sexual assault and of the difficulties that male victims experience in accessing and interacting with the medical and legal systems improve professional understanding of this complex subject. Bullock and Beckson1 add to a growing body of literature on the prevalence and consequences of adult sexual assault (ASA) of men. The authors review how the ignorance or minimization of the fact that men can be ASA victims, a misunderstanding of the male physiologic sexual response, and overt and covert homophobia can deter or prevent some male victims from reporting ASA or seeking treatment. Such factors impede the prosecution of perpetrators and attribute blame to victims. The authors also note that, although the same basic power and control dynamics of ASA of female victims apply to male victims, feminist-based groups contribute to limitations in service provision for male victims of ASA, and the larger medical community is often ill equipped to meet the needs of male victims. Until recently, research on male victims of ASA usually addressed its incidence and consequences in institutional settings, such as prisons and the military. It is true that some feminist-based treatment groups can be ideologically at odds with the idea of males as ASA victims, because such acknowledgement could take away treatment resources from female ASA victims and because they are ideologically at odds with the idea that males can be ASA victims. However, much is owed to feminist theory for advancing the understanding of this topic outside of institutions. In the 1990s, pro-feminist elements of the men's movement provided the opportunity for better consideration of the health and emotional needs of men. Legitimizing such concerns came from the feminist and gay liberation movements.2 Not all feminist theories are ideologically opposed to the view that men can be victimized. For example, some postmodern feminists seek to eradicate inequality by challenging the binary construct of male and female that subordinates women to men. Some feminists therefore advocate restructuring society's understanding of available gender roles.3 This feminist goal is consistent with the aim of BGLTQ (bisexual, gay, lesbian, transgendered, and queer) advocacy groups to eliminate homophobia, which, along with gender role, factors heavily into understanding the obstacles that male ASA victims face. Homophobia stems from the cultural generalization that certain properties possessed by a group are universal and non-context dependent. As such, maleness-masculinity and femaleness-femininity complete themselves, perfect each other, and maintain superiority to other complements. Homophobia results in biased attitudes and allows for discrimination in favor of opposite-sex sexuality and relationships.4 Bullock and Beckson do not support the idea that homophobia is solely a moral issue beyond the province of medicine. Instead, they discuss how homophobic attitudes directly impede access to care for male victims of ASA and create interface problems with the legal system, regardless of the male victim's sexual orientation. Understanding and being responsive to such concerns is therefore part and parcel of professional standards crucial to patient care. The decision to seek treatment for any ASA survivor can be difficult. Male victims of ASA experience adverse sexual, psychological, interpersonal, and physical consequences similar to those of female victims and can present with many of the same clinical factors. In addition, Bullock and Beckson discuss differences in topic areas covered in treatment in male victims and female victims. Of note, in one study, men who reported that they were penetrated were less likely, not more, than other male victims to seek counseling.5 This finding further highlights the inhibiting power of shame in seeking treatment. For heterosexual men, ASA can lead to confusion over sex roles and sexual orientation. A heterosexual victim may erroneously believe that he must be gay or that he will become gay as a result of the assault. In contrast, heterosexual men assaulted by women often have less confusion regarding sexual orientation, yet may grapple with gender stereotypes of power and control in treatment. Male victims may believe the myths that male rape is not as serious as female rape or that they cannot be raped, which can be an additional focus of treatment. Misinterpretation of penile physiologic response can worsen concerns regarding complicity. For gay men, ASA can lead to feelings of self-blame and self-loathing that are attached to internalized homophobia. The gay ASA victim may erroneously conclude that he deserves the abuse on some level because of his sexual orientation. Self-blame can be reinforced by the ignorance or intolerance of others who think that a gay victim of ASA somehow wanted it or was less harmed by it. Gay men may also hesitate to report ASA because of fears of blame, disbelief, or intolerance by police or medical personnel. Such concerns are often amplified by transgendered victims who fear institutional intolerance. As a result, gay and transgendered victims may be deprived of legal protections and medical care following an assault. As with heterosexual male victims, misinterpretation of penile physiologic response can also worsen concerns regarding complicity. Treatment models must therefore recognize both the overlapping and different treatment obstacles that male victims of ASA cope with compared with their female counterparts. The circumstances of their victimization and the victim's own sexual orientation and gender identity must be taken into account. How service providers can use the information reviewed by Bullock and Beckson, as well as research regarding penetration, in treating male ASA victims merits further research. Bullock and Beckson note that there are generally fewer treatment services available for male victims of ASA, regardless of the victim's sexual orientation. It is important to add to their review that ASA is not commonly discussed in the BGLTQ community. Bias and misunderstanding toward the BGLTQ community and well-known gaps and barriers in services for BGLTQ persons impede changes in the system. Further, lack of acknowledgement of ASA can be reinforced in the BGLTQ community because of its need to protect itself from additional discrimination.6 In the broader community, BGLTQ victims cannot assume that services are safe, friendly, or properly tailored for them. Like their female counterparts, adult male victims of ASA can also be traumatized by the criminal process. Critogenic harm can come from recounting intimate details of an assault to historically patriarchal structures, such as police departments and the judicial system. Being subject to inquiry, including cross-examination by defense counsel whose role it is to discredit the alleged victim's account, interferes with the victim's recovery.7 In light of the review by Bullock and Beckson, the forensic examination of male ASA victims warrants discussion. Assessing cases of male ASA victims requires consideration of heterosexism, patriarchy, and gender domination as a part of the overall case analysis. Lack of such consideration may color perceptions, inappropriately misattribute motivation, or otherwise distort assessment of responsibility in civil and criminal proceedings. While as forensic examiners, we must endeavor to avoid our own culture-bound biases, I do not suggest relying solely on cultural, sociologic, or other nonpsychiatric constructs in assessments. However, there are times when such factors provide a relevant context for understanding the victim and perpetrator.8 Forensic professionals performing evaluations of male ASA victims must be able to assess whether the above-noted concerns are relevant to the legal issue at hand and should be able to articulate how the context is relevant to the medicolegal analysis. Society has moved from an exclusive focus on institution-based male ASA to the recognition that such assault is complex and layered and occurs within the society at large. Male ASA, like all acts of violence, is ultimately about the violation of personal integrity. At present, BGLTQ persons continue to be a target of discrimination by most government, religious, and social institutions. Such discrimination has a direct relationship to the reluctance of all types of male victims of ASA to seek treatment or report such abuse. It contributes to the development of clinical conditions similar to female ASA victims, but it also raises challenges in treatment, based in no small part on the very homophobia that drives such reporting underground. As society moves toward full granting of civil rights to BGLTQ individuals, it is possible that the myths about male ASA will abate and thus reduce the frequency of this type of victimization. In the meantime, however, the experience of such victims conflicts with certain dominant notions of masculinity in patriarchal societies, which are characterized by sexism and homophobia. Neither homophobia, nor gender domination, nor patriarchy, nor physiology alone explains all elements of this type of victimization, but they are all important considerations for forensic examiners to take into account. Addressing this area of sexual assault must be a part of a larger agenda to increase understanding of the needs of all ASA victims and how best to serve them. ## Footnotes * Disclosures of financial or other potential conflicts of interest: None. * American Academy of Psychiatry and the Law ## References 1. Bullock CM, Beckson M: Male victims of sexual assault: phenomenology, psychology, physiology. J Am Acad Psychiatry Law 39:197–205, 2011 [Abstract/FREE Full Text](http://jaapl.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFhcGwiO3M6NToicmVzaWQiO3M6ODoiMzkvMi8xOTciO3M6NDoiYXRvbSI7czoyMDoiL2phYXBsLzM5LzIvMjA2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 2. Plumm KM, Terrance CA, Henderson VR, *et al*: Victim blame in a hate crime motivated by sexual orientation. 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