Information for therapists and counsellors

“The path to recovery winds straight through masculinity’s forbidden territory: the conscious experience of those intense, overwhelming emotional states of fear, vulnerability, and helplessness” (Lisak, 1995, p. 262)

Introduction

When the topic of sexual violence arises with male* clients or patients, this can sometimes trigger uncertainty and bring challenges for those working in psychosocial and psychotherapeutic settings. This may be even more the case if experiences of sexual violence are only suspected, but the man* concerned does not come up with it himself and does not signal that he wants to talk about it.

The extent to which the topic should be explored by you as a therapist or counselor depends to a large extent on the patient's/client's counseling or treatment concerns, his prospects of staying within reach, and his current life situation. Due to the diversity of individual conditions, we can only give a few concrete instructions to guide the diagnostic process. At this point, we summarize some information that we consider helpful. (For the sake of linguistic simplification, we refer to survivors in the following, even if the affectedness is initially only assumed).

Basics

Reporting experiences of sexual violence is associated with many barriers, and it touches on aspects of great intimacy. In order to talk about it at all, some basic prerequisites are needed:

  • The survivor must feel safe and be able to trust his counterpart. The obligation of the counselor/therapist to maintain confidentiality is of great importance.
  • The survivor needs to know that he will not be blamed, laughed at, or shamed for what happened.
  • The survivor must be sure that his counterpart is empathetic to him and believes him.
  • The survivor must know that his counterpart will not reduce him to his experience of sexual violence, but will recognize him as a whole person.
Affectedness and disclosure in men

Men are also affected by sexual violence. The consequences manifest in many ways. Those affected often seek support in counseling or treatment contexts due to subsequent stress and health problems, but the sexual violence is not necessarily recognized or named as a (co-)trigger.
 

  • Even those affected men who seek counseling or treatment sometimes do not disclose their experiences or do so very late in the process.
     
  • Speaking about potentially traumatic experiences can trigger distressing memories and feelings, up to the experience of flashbacks and dissociative states. However, disclosure enables the delivery of proper care, and it might help survivors to be given their right to asylum.
     
  • Survivors rarely spontaneously report the sexual violence they have experienced.In most cases, a thorough anamnesis and repeated offers on the part of the counselor/therapist are required.
     
  • The gender of the counselor/therapist may be relevant for disclosure. Some men are very uncomfortable talking about intimate or sexual topics in front of women. For others, this is taboo in front of men from their own (religious or cultural) community. Preference results from an interplay of cultural and biographical factors. As a rule of thumb, most men initially seem to find it easier to talk to a woman.
     
  • The age of the counselor/therapist may also play a role. There are indications that older persons may be preferred.
     
  • If possible, the individual's preferences should be included when referring him to a counselor/therapist.
     
  • Male stereotypes and role concepts, as well as concrete role expectations expressed by the survivor’s family or community, often contradict the survivor’s experiences of vulnerability and helplessness in the context of violence. His self-concept can therefore be shaken by the experience of violence.
     
  • Family changes resulting from migration and acculturation processes can also challenge previous self-concepts.
     
  • The counselor/therapist should be sensitive to these challenges faced by their male clients/patients. Counselors/therapists should be willing to bring these topics up, signal understanding, and thereby provide some relief.
Language mediation

In the context of transcultural counseling and treatment, language mediators are often crucial members of the setting. Working with interpreters involves a number of challenges, only some of which we will address here in reference to the target group:

  • The interpreter should not be a family member of the survivor, as survivors may be inhibited to report openly or family members may not want to translate everything due to feelings of shame.
     
  • If the survivor and the interpreter are members of the same community, the survivor may be worried about the confidentiality of the information.
     
  • The gender of the interpreter is relevant. If possible, the survivor’s preference should be included in choosing an interpreter.
     
  • Desirably, the language mediator does not directly belong to the community of the person concerned, but has a connection to it and can therefore also translate in a culturally sensitive manner.
     
  • The interpreter should be prepared to verbalize content relating to sexuality. It can be helpful to develop suggestions for a sensitive vocabulary in collaboration with the interpreter, which can be offered to the survivor for verbalization.
     
  • If the counselor/therapist is planning to address the topic of sexual violence with the survivor, it is desirable to inform the translator in advance.
     
  • The interpreter is not only a "speaking tube", but plays a significant role in shaping the interaction within the treatment/counselling setting. He/she is also directly confronted with the survivor’s report. Regular supervision can therefore both improve communication in the triad and counteract possible experiences of distress by interpreters.
The importance of context and life situations

Remembering and reporting biographical events represents a confrontation with possibly traumatic experiences, which can trigger strong emotions. Whether the exploration of (suspected) sexual violence experiences is helpful and meaningful for the survivor depends on a number of individual conditions:

  • The reporting of experiences of sexual violence can affect the outcome of the asylum process. When supporting survivors during their asylum process, it can be important to explore their experiences and to practice the verbalization of what they have experienced – at least in its rough outlines. The survivor should be supported with stabilizing techniques during this process.
     
  • It is recommended to make disclosure offers as part of a thorough anamnesis if the survivor has permission to stay in the reception country and if a stable relationship can be established in the counseling/therapy context. It may be necessary to repeat disclosure offers over a period of time. A cautious step-by-step approach is appropriate, based on the person's readiness to disclose and his preferred vocabulary.
     
  • If the survivor will likely not obtain the right to stay in the reception country, and if contact could be interrupted unexpectedly at any time, it is not advisable for the counselor/therapist to explore the issue on his or her own initiative.
     
  • If the survivor wants to talk about the experience, the counselor should however be ready to listen, to respond empathetically, and to offer adequate support.
     
  • At times, disclosure events may adopt a ‘flooding’ character in which survivors disclose a lot of distressing information in a short time. However, emotions may not be experienced in coherence with the report, but may occur with delay and cause severe distress. Here, a limiting co-regulation from the outside can support a beneficial pace of disclosure.
     
  • If the survivor clearly signals that he does not wish to open up this topic, this should be respected.
Early detection

The signs of experiences of sexual violence are manifold, and are usually not unambiguous. From direct care practice, the following indications are known to suggest experiences of sexual violence:

 

Verbal cues

  • Reports of or evidence of physiologic impairment in the genital or rectal area (e.g., urologic pretreatment, incontinence, pain with urination, pain with sitting).
  • Implications or reports of difficulties in sexual life
  • Paraphrased or indirect allusions to violent experiences
  • Statements with references to a perceived loss of honor or great embarrassment
  • Desire for an examiner/counselor/clinician of a particular gender, or statements that certain topics cannot be discussed because of the gender of the other person
  • Desire for a language or culture mediating person with certain characteristics (regarding gender, country of origin, age).

General cues in symptomatology

  • Post-traumatic stress symptoms
  • Depressive symptoms
  • Suicidality
  • Symptoms of anxiety
  • Somatoform symptoms
  • Pronounced pain symptomatology without recognizable physiological cause

General behavioral cues

  • Curved seating position
  • Avoidance of eye and body contact
  • Recognizable isolation in everyday life
  • Sleep disturbances
  • Aggressive behavior, impulsivity
  • Anomalies in personal hygiene (overpronunciation of personal hygiene, lack of hygiene)
Triage Tool by Keygnaert & Linthout (2020)

The Belgian researchers Ines Keygnaert and Leni Linthout have developed a Triage Tool to help identify refugees and migrants who experienced sexual violence more quickly. The two ‘Triage identification sheets’ (pages 27-37) are aimed at persons working with refugees in a general reception context (e.g. in housing facilities, educational institutions, offices) as well as persons working in health care for refugees. The tool is currently only available in English.

Disclosure offers

Disclosure offers ideally approach the topic from the general to the specific.

  • If a patient/client is suspected of having experienced sexual violence, e.g., due to a reported incarceration, it is possible to start from general information and pose increasingly more specific questions. For example:
     
    • ‘We know from reports from these prisons that there is a lot of violence there. [...] Sometimes this violence also refers to the sexuality of a person. [If appropriate, give examples of what this could mean] Have you heard about this, too? […] Have you also witnessed/seen something like that there? [...] Have you experienced something like that yourself? [...]’
       
  • If the person concerned reports physical experiences of violence, it could be asked:
     
    • ‘You have told me about experiences of violence that relate to your body. Have you also experienced something that relates directly to your sexual organs?’
       
  • It may be useful to announce awareness of the potential transgression of norms in advance, and to normalize or contextualize the topic:
     
    • ‘I am going to ask you a question that you may find very inappropriate. But I want to assure you that this topic here is a very normal topic that we can talk about, and that it is very important for me as your [therapist/counselor] to ask you this question. [...]’
Culturally sensitive diagnostics and anamnesis

Here we provide you with material to support the promotion of cultural sensitivity in anamnestic and diagnostic processes.

  1. Information at a glance: In our ‘Pockets’ in German, we have compiled the most important information on diagnostics and anamnesis in transcultural settings. At the end of each pocket, you will find references for further reading.
  2. Screening procedures tested for cultural sensitivity: On the Q-Cultural website [https://www.q-cultural.de], many standard screening procedures are available in psychometrically reviewed translations.

References / Further Reading:

Keygnaert, I., & Linthout, L. (2021). Triage Tool for identification, care and referral of victims of sexual violence at European asylum reception and accommodation initiatives. Ghent, Belgium: Ghent University - International Centre for Reproductive Health (ICRH).

Lisak, D. (1995). Integrating a critique of gender in the treatment of male survivors of childhood abuse. Psychotherapy, 32, 258 -269.

Nesterko, Y., & Glaesmer, H. (2020). Sexualized violence against men in the context of war and displacement. Trauma & Violence, 14(3), 182-196.

Russell, W., Hilton, A., & Peel, M. (2010). Care and Support of Male Survivors of Conflict-Related Sexual Violence: Background Paper.

Schönenberg, K. H., Glaesmer, H. & Nesterko, Y. (2022). Dimensional assessment of the individual experience of war- and displacement-related sexual violence and its consequences among male victims: A Narrative Literature Review [Assessment of the Individual Experience of Sexual Violence in War and Forced Displacement and its Consequences Among Male Victims: A Narrative Literature Review]. Psychotherapy, Psychosomatics, Medical Psychology.

Vorab-Onlinepublikation. doi.org/10.1055/a-1806-3313