Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London
Academic Centre, West London Mental Health NHS Trust
Section of Forensic Psychiatry, St George's Hospital Medical School, London
Correspondence: Michael King, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK. E-mail: m.king{at}rfc.ucl.ac.uk
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ABSTRACT |
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Aims To investigate whether sexual molestation in males is a significant predictor of psychological disturbance.
Method We recruited men attending general practice and genitourinary medicine services. Participants took part in a computerised interview about sexual molestation as children or adults. We ranked reported sexual experiences into three categories of decreasing severity. Each category was treated as an independent predictor in a multivariate analysis predicting different types of psychological disturbance.
Results Men who reported child sexual abuse were more likely to report any type of psychological disturbance. Men who reported sexual molestation in adulthood were 1.7 (1.0-2.8) times more likely to have experienced a psychological disorder, but self-harm was the single most likely problem to occur (odds ratio=2.6, range=1.3-5.2). Men reporting consenting sexual experiences when aged under 16 years also were more likely to report acts of self-harm (odds ratio=1.7, range=0-2.8).
Conclusions Sexual abuse as a child or adult is associated with later psychological problems. All forms of sexual molestation were predictive of deliberate self-harming behaviour in men.
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INTRODUCTION |
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METHOD |
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In the GP survey we approached over 300 practices in England, of which 18 eventually took part. These consisted of nine practices in London, two in Manchester, three in small towns and four in rural areas. The commonest reasons for refusal were lack of space or time for the study. One GUM clinic in central London took part in the study.
We asked men aged 18 years and over who were consecutive attendees to the general practices or GUM clinics to take part in anonymous and confidential research on men and their sexual experiences. We explained that we wished to ask participants questions about non-consensual sexual experiences. Men who consented were taken to a private room and shown how to operate the computerised interview. We used a computerised interview because of evidence that this mode of presentation increases the reporting of sensitive material (Millsten & Irwin, 1983; Turner et al, 1998). Little was said to the participants once the interview was under way. The researcher was present to guide the participant should he encounter difficulty with the computer program. Participant's responses were not visible to the researcher.
We asked men their age, ethnicity and current or most recent occupation, and to report their sexual orientation on a sevenpoint scale modelled on the Kinsey scale (Kinsey et al, 1948). No standardised instrument exists to assess the nature of experiences of sexual molestation of men and their possible psychological sequelae. Thus, we generated items for the computerised interview from a literature search, and our previous research (Mezey & King, 1992, 2000; King & Woollett, 1997) and clinical experience. As reported elsewhere (Coxell et al, 1999), we defined non-consensual sex as where a person(s) uses force or other means so that they can do sexual things to you that you did not want them to do or where a person(s) uses force or other means to make you do sexual things that you did not want to do. However, as sexual experiences before age 16 years may be predictors of later sexual experience, we also asked about sexual molestation before age 16 years. We used the same definition for non-consensual sexual experiences before and after the age of 16 years. Participants were also questioned about whether, before the age of 16 years, they had done sexual things that they had wanted to do with a person(s) who was at least 5 years older. In English law, any person under 16 years is incapable, either legally or practically (because of a lack of appreciation of the significance or consequence of the act), of giving consent to sexual activity (West, 1987). However, offences where the child apparently consents are treated differently, depending upon the age of the perpetrator. Although the nature of the behaviour and the developmental level of the child are important in defining the seriousness of the abuse (Cantwell, 1988), a 5-year age difference between the perpetrator and the child has been used to define sexual abuse where no force is involved (Finkelhor, 1986). If men are asked only about non-consensual experiences in childhood, such abusive experiences may be missed.
Men who reported any of the above were asked in some detail about the sexual experience(s) and disclosure to others. We then asked all participants, regardless of their replies to questions about sexual molestation as an adult or child, whether they had experienced any of the following since the age of 16 years:
Data analysis
We analysed the data using the Statistical Package for the Social Sciences
(Version 6). Not all men answered every question posed. We give denominators
in each instance where there are missing data.
Based on current knowledge, we ranked reported sexual experiences in three categories. Psychological disturbance is most common in men who report sexual abuse as children, the effects of which are severe and last into adulthood (Kendall-Tackett et al, 1993). Thus, we regarded this experience as having potentially the greatest impact. So-called consensual sexual experience as a child was our last category. Even where the child considers sexual contacts with adults positive, such sexual experiences may be associated with various forms of negative affect at the time of the sexual contact. For example, in one study of 37 male and 26 female participants who reported engaging in sexual contact with an adult or older child, many reported feeling guilty (41%), frightened (35%) and/or ashamed (29%) at the time of the contact (Okami, 1991). Thus a priori we derived three categories of sexual abuse of decreasing severity:
Each category was treated as an independent predictor in a series of one-step, multivariate, logistic regressions predicting different types of psychological disturbance. We included in the regression other risk factors and confounders of the potential association between sexual molestation and psychological disturbance. These were: age in years; social class (non-manual v. manual); ethnicity (White v. non-White); interview site (GUM v. GP) and sexual behaviour (reporting/non-reporting of consensual sex with men). There is evidence that people who report same-sex partners are more likely to report psychiatric disorders than those who report opposite-sex partners (Sandfort et al, 2001). Our data had also already shown that men who reported male sexual partners were significantly more likely to report sexual molestation in adulthood (Coxell et al, 1999, 2000). Thus, we decided to include same-sex behaviour in the regressions. Reported psychological disturbance was grouped into five categories for use as dependent variables in five regression analyses: psychological disturbance (anxiety, depression and/or sleep disturbance); sexual problems; self-harm; drug and/or alcohol misuse; and any of these difficulties.
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RESULTS |
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Prevalence of sexual molestation
In the GP sample 71 (2.9%; 95% CI 2.2-3.6) men reported non-consensual
sexual experiences after age 16 years, 128 (5.3%; 95% CI 4.4-6.3) before age
16 years and 185 (7.7%; 95% CI 6.5-8.8) reported consensual
experiences under age 16 years. In the GUM sample, 40 (18%; 95% CI 13-23) men
reported non-consensual sexual experiences after age 16 years, 25 (12%; 95% CI
8-17) before age 16 years and 55 (27%; 95% CI 21-33) reported
consensual experiences under age 16 years.
Prevalence of reported psychological disturbance
Reported psychological disturbance that had been present for at least 2
weeks since the age of 16 years was relatively common in these populations of
men (Table 1).
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Multivariate analysis
After controlling for age, social class, ethnicity, sexual behaviour and
the site of the survey (general practice or GUM clinic), men who had
experienced sexual molestation as children had significantly increased odds
for reporting each particular type of psychological or behavioural disturbance
(Table 2). Men who reported
sexual molestation in adulthood were more likely to have suffered any
psychological disorder, but self-harm was the only behaviour that was more
likely to be reported than others. Men who reported consenting
sexual experiences when aged under 16 years were also more likely to report
committing acts of self-harm.
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DISCUSSION |
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Strengths and weaknesses of the data
The main advantage of our study is that sufficient numbers of men reporting
sexual molestation at different ages were directly compared with a large
comparison group who gave no history of sexual molestation. This means that we
had greater power to assess whether differences observed between groups
remained significant after demographic and other confounding factors are
controlled. A univariate analysis of data from a recent survey of adolescents
suggested that although boys who had experienced a sexual assault were more
likely than girls experiencing such assaults to consult a psychiatrist or
psychologist, this gender difference was no longer significant once the age of
the victims was controlled (Darves-Bornoz
et al, 1998). Our sample size also means that the
confidence intervals of our estimates are relatively narrow. One important
limitation to our study, however, is our inability to make a temporal link
between the reported problems and the sexual molestation. Thus, we can only
report associations and cannot conclude that the links are causal. A second
limitation is that our study lacks power to examine associations between the
nature and circumstances of particular sexual acts and reported psychological
difficulties. Third, the fact that the GP sample was limited to a number of
volunteer practices and our GUM sample to one inner-city clinic may limit the
external validity of our results. Finally, and largely because of the length
of the interview, standardised assessments of past psychological disorder were
not applied, except in the case of alcohol misuse.
Age at time of molestation
Sexual molestation of boys was associated with more reported psychological
disturbance than sexual molestation of men. This finding has also been
reported in a community survey of 432 men and women who reported sexual abuse
as a child or adult. Burnam et al
(1988) found that child as
opposed to adult sexual assault was a significant predictor of the first onset
of depression, alcohol misuse or dependence, drug dependence and phobia, for
both men and women, as identified by structured clinical interview. Our
findings for general psychological disturbance and substance misuse problems
can be seen as support for these previous findings but our data go further in
identifying child sexual molestation as a predictor of sexual difficulty and
self-harm.
Consensual sexual experiences in childhood
So-called consensual sexual experiences in childhood were
associated with fewer psychiatric disorders than child sexual abuse. There are
a number of possible explanations for this. First, male perpetrators were much
more common in child sexual abuse (GP sample, 82%; GUM clinic sample, 80%)
than in consensual sexual experiences (GP sample, 14%; GUM
clinic sample, 31%). (Percentages refer to occasions on which a male or female
perpetrator was involved and can add up to >100 because both male and
female perpetrators were involved on some occasions.) Sexual activity with a
male perpetrator may involve more penetrative sex (see
Coxell et al, 2000)
and may lead to concerns about sexual function and confusion about sexual
orientation. Furthermore, sex between a teenage boy and an older woman is
popularly regarded in some cultures as an introduction to sexual matters and
to manhood (Bolton et al,
1989). Second, child sexual abuse occurred at a younger mean age
(GP sample, 11 years (s.d.=3); GUM clinic sample, 9.8 years (s.d.=3)) than
consensual sexual experiences (GP sample, 14 years (s.d.=1.9);
GUM clinic sample, 14 years (s.d.=1.8)). These age disparities reflect large
differences in sexual and psychological development. Finally, anxiety and
depression may be associated with differential recall, attribution and/or
labelling of the sexual experiences (Beck,
1976; Derry & Kuiper,
1981). Men who have not developed psychological disturbance as
adults may be less inclined to describe childhood sexual experiences as
unwanted. We note, however, that the rate of consensual
experiences was more than three times greater in the GUM sample (27%) than in
the GP sample (8%). Thus, consensual experiences may also be
associated with subsequent sexual risk-taking behaviour. There is evidence
that (Puerto Rican) men who have sex with men and who have a history of child
sexual abuse are significantly more likely to engage in receptive anal
intercourse and in unprotected anal intercourse than men without such a
history (Carballo-Dieguez & Dolezal,
1995). Men in this study who reported willing sex
with an older partner when aged 13 years or younger were ranked between the
other two groups with respect to these behaviours
(Carballo-Dieguez & Dolezal,
1995).
Type of psychological disturbance
Unwanted sexual experiences in adulthood were principally associated with
reported self-harming behaviour. It is possible, however, that reporting
self-harm is a proxy for other disturbed feelings, such as anxiety and
depression, that have subsequently been forgotten. Self-harming behaviour may
be recalled more easily because of acute pain, possible scarring and/or injury
or medical attention received. There are a number of other reasons why these
unwanted experiences may have failed to be significantly associated with other
psychological disturbances. First, we conflated data from the victims of
experiences perpetrated by men and women. There is some evidence that sexual
assault of men by women is less disturbing than sexual assault by other men
(Struckman-Johnson &
Struckman-Johnson, 1994). We found a trend that confusion about
sexual orientation was more common after sexual molestation by another man
(26%; 13/50) compared with sexual molestation by a woman (11%; 4/35;
2=2.7, 1 d.f., P<0.10). Second, our data analysis
strategy may have an impact on the findings pertaining to adult sexual
molestation. We divided our sample in such a way that men who reported sexual
assault as a child and as an adult were placed in the child sexual assault
group, because we assumed that child sexual abuse was the most serious
category of assault. We did not retain them as a separate group in the
analysis because men reporting both types of assault were relatively uncommon.
Had we placed these men with the group reporting only sexual assault as an
adult, we may have found that adult sexual molestation was a significant
predictor of a wider variety of disturbance. Third, our findings may also have
been affected by the fact that not all persons who reported sexual assault
provided details about what had happened to them or answered questions about
psychological disturbance. For example, 12 of 40 men in the GUM clinic sample
who reported sexual assault in adulthood did not complete the interview.
Acts of self-harm are more common in women than in men and thus such behaviour in men may indicate sexual molestation as an adult or child.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication October 5, 2001. Revision received April 4, 2002. Accepted for publication April 9, 2002.
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