/ Ch,UP,ychol Piychitti Vol 33. No. 1. pp. 197-248.

1992 0021 9530/92 $5,00 + 0,00

Primed in Crcai Britain. Ptrgamon Press pic
1992 Associalion for Child Psychology and Psychialry

The Sexual Abuse of Male Children and

Adolescents: A Review of Current Research

Bill Watkins and Arnon Bentovim

Introduction
Childhood sexual abuse is inherently difficult to research, because of the secrecy and
shame which surround it. Despite these difficulties, research on sexually abused boys
has clearly lagged behind that of girls, partly because it has been seen as an uncommon,
if not rare, problem and partly because it was doubted that sexuaJ abuse had significant
effects on boys, or their subsequent development. The purposes of this paper are
to provide a broad overview on all aspects of the sexual abuse of boys, to emphasize
how little we know, and to suggest some future research directions.
If stringent research design criteria had been used to select studies for inclusion
within this review, it would have been brief indeed. However, in a field which is
only just beginning to develop, it was decided many weaker studies should be included,
as they often did have something useful to contribute. Many of these studies suffer
from one or other of the following limitations: being anecdotal; having biased samples;
samples being too small in size; a lack of comparison groups; having no or insufficient
objective measures; being retrospective; and, most relevantly, failing to undertake
gender analysis. Throughout, there has been considerable reliance on clinical reports.
All of these limitations restrict the generalizability of the findings.

Definition
Schechter and Roberge (1976) have provided one of the most widely accepted
definitions of sexual abuse. They defined sexual abuse as "The involvement of
dependent developmentally immature children or adolescents in sexuaJ activities they
do not truly comprehend, and to which they are unable to give informed consent

Keywords: Childhood sexual abuse, boys, perpetrators

Accepted manuscript received 20 May 1991

Department of Psychological Medicine, The Hospitals for Sick Children, London. U.K.
Requests for reprints to: Dr William G. A. Watkins, Department of Psychological Medicine, Christchurch
School of Medicine, Christchurch Hospital, Christchurch, New Zealand.

197
198 ^- Watkins and A. Bentovim

and that violate the sexual taboos of family roles". The last part of this definition
is unnecessary for extrafamilial abuse. In addition, researchers usually include an
age differential between abuser and victim of 5 years or more. However, with the
recent concern over younger perpetrators, Johnson (1988, 1989) has advocated setting
an age differential of only 2 years, along with other criteria, to define interchild sexual
activities which are clearly abusive. Cantwell (1988) goes further and advocates a
definition of abuse between children focused entirely on the behaviour, thus dispensing
with an age criterion. For example, oral-genital contact or penetration of the
vaginal/anal opening with fingers or objects would be regarded as abnormal. These
recent descriptions of children as abusers complete the spectrum of sexually abusive
behaviour first described between adults and children, then adolescents and children,
and now children with other children. Interchild abuse will be discussed further in
the section on under-reporting.
Whoever might be involved in the abuse, the problem of distinguishing abusive
from non-abusive sexual contact with children remains. Sexualized attention has been
put forward as a term to describe the boundary between clearly abusive and clearly
acceptable behaviour (Haynes-Seman & Krugman, 1989). Obvious abusive behaviour
of a boy would be masturbating the boy, anal fingering or intercourse, but caressing
and stroking a baby's buttocks persistently, or poking fingers in the mouth, which
were arousing to the father, would be examples of what was considered as sexualized
attention. Whether such contact is sexualizing depends on the affective state of parent
and child, and whether the child has a sexual response to it. This clearly fades into
the normal cuddling, vigorous bouncing and rough-housing, which is the normal
approach to boys by fathers in particular.
Chasnoff d al. 's (1986) study of maternal-neonatal incest describes the impact of
activities between mothers and infants which are clearly sexual, e.g. sucking penises,
and the subsequent powerful sexualizing effect this has on the baby boy's behaviour
at a very young age. Yates (1982) also describes the eroticization of slightly older
children by incestuous contact. Sroufe and Ward's (1980) interesting observation of
the ways mothers control their children, indicated a relationship between the mothers'
unconscious eroticized forms of control of their children (directed almost exclusively
at the sons) and the fact that these mothers had often been sexually abused themselves.
Sexuaiized attention connects to some other important questions. What effect at
different ages, if any, does modelling of sexual behaviours have? What constitutes
abusive modelling? Faller (1989a), Seghorn, Prentky and Boucher (1987), and Smith
and Israel (1987) assert it is an important factor, but the ethical, accessibility,
multifactorial research design problems inherent in answering such questions are
formidable and as yet have not been met.
Besides a few pioneering studies on selected parent self-repoit groups (e.g. Rosenfeld,
Bailey, Siegel & Bailey, 1986; Rosenfeld, Siegal & Bailey, 1987), we have little reliable
information on community patterns of genital contact between parents and children,
particularly in bathing or toileting situations. Obviously infants and toddlers are subject
to close physical contact during care-taking functions. However, it is of interest to
note in Rosenfeld et al 's (1986) study that more than 50% of 8-10-year old daughters
were reported as touching their mother's breasts and genitals, and more than 30%
to be touching their father's genitals, while more than 40% of 8-10-year old sons
 Sexual abuse of male children and adolescents 1 yy

were reported as touching their mother's genitals and about 20% their father's genitals.
Current research (Smith & Crocke, 1990) based on direct interviewing of children
will help improve our knowledge about how non-abused children gain awareness of
sexual issues and whether there are differences between these children and those who
have been sexually abused.

Prevalence
It is well recognized that the defmition of sexual abuse used, sample selection and
method of asking questions regarding sexual abuse strongly influence the prevalence
rates found. Peters, Wyatt and Finkelhor (1986) have carried out a wide ranging
review of the prevalence of child sexual abuse comparing males to females. They
have examined volunteer samples (Hamilton, 1929; Kinsey, Pomeroy, Martin &
Gebhard, 1953; handis et ai, 1940); college student samples (Finkelhor, 1979; Fritz,
Ston& Wagner, 1981; Fromuth, 1983; Landis, 1956; Seidner & Calhoun 1984); and
community samples (Badgley et al., 1984; Bagley & Ramsay, 1986; Burnam, 1985;
Finkelhor, 1984d; Keckley Market Research, 1983; Kercher & McShane, 1984;
Lewis, 1985; Miller, 1976; Murphy, 1985; Russell, 1983; Wyatt, 1985). Their
conclusion from these North American studies was that there is considerable variation
in the prevalence rates for child sexual abuse derived from these studies. Reported
ranges were from 6% to 62% for females and from 3% to 31% for males. They
comment that even the lower rates indicate that child sexual abuse is far from an
uncommon experience for either girls or boys and that the higher reported rates would
point to a problem of epidemic proportions.
The resource implications of these figures are immense and, as Zeidin (1987) points
out, thought must be given to the impact sexual abuse has before proposing any
intervention which might itself have long-term harmful effects. This is not to condone
less harmful variants of sexual abuse or to miss the risk that such variants may progress
to more harmful forms of abuse. Two American studies (Fritz et ai, 1981; Fromuth
& Burkhart, 1989) and one British study (Baker & Duncan, 1985) illustrate the issue
clearly. All were retrospective. Baker and Duncan (1985) found, with a carefully
selected community sample using a non-contact definition of abuse, a rate for men
of 8 % . Fritz et al. (1981) in contrast used a contact defmition of abuse in their college
student sample and found a rate of 4.8% in men. When Fromuth and Burkhart (1989)
included a non-contact definition of abuse in college men the rate trebled to 15%
in one group and 13% in another. Half of both Fromuth and Burkhart's groups had
a single abusive experience, while the Baker and Duncan (1985) finding is even
higher59%. Fritz et al. (1981) give no such breakdown. All report that the effect
on men was either minimal or less than in sexually abused women. Regrettably, Baker
and Duncan (1985) do not separate gender, or discuss how denial might confound
their fmding that the same proportion of adults who were abused just once (43%)
as those who were repeatedly abused by multiple abusers (42%) report no effect.
Future surveys need to address the problem of separating denial of adverse effects
from valid negative answers.
Overall, Finkelhor (1984b) concluded in his Review Boys as Victims that estimates
from surveys of men in the general population would indicate that perhaps 2.5-8.7%
 200 B. Watkins and A. Ben(ovim

of men are sexually victimized as children. Further, the discrepancy between the
general survey and clinical study samples, along with the differences within these
samples between the male and female abuse ratios, strongly suggests that abused boys
have not been coming to public attention to the same extent as sexually abused girls.
The issue of under-reporting will be returned to later.
Much of the epidemiological work discussed so far has been undertaken in the
U.S.A., but studies in the U.K., e.g. Mrazek, Lynch and Bentovim's (1981) study
of professionals' reports of abuse. Baker and Duncan's (1985) study of a large
community sample, Bentovim, Boston and Van Elburg's (1987) study of cases referred
to a sexual abuse programme, Creighton's (1985) study of cases placed on case registers
along with recent NSPCC figures and a summary by Markowe (1988) for the
Department of Health and Social Security, all indicate the high U.K. prevalence and
the increasing recognition of sexual abuse in the community, and an associated
recognition of boys as victims. The Hobbs and Wynne (1987) report is important
because it shows a clearly rising annual trend in the number of confirmed or probable
cases of abused boys in the same service in the same area.

Ratio of abuse: boys to girls

It was commonly believed 15 years ago that girls were abused in excess of boys
in a ratio of about 9 to 1, but contemporary studies now indicate that the ratio of
girls to boys abused has narrowed remarkably.
Although several community studies have found prevalence rates of abuse in girls
which are only a little higher than in boys (e.g. Baker & Duncan, 1985; Keckley
Market Research, 1983; Lewis, 1985), all of which found ratios of about 5 to 3, the
majority of community studies suggest a higher ratio than this, in the order of 2-4
girls to 1 boy (Badgley et al., 1984; Burnam, 1985; Finkelhor, 1984d; Kercher
& McShane, 1984; Murphy, 1985).
Clinical studies are not so uniform. The highest reported ratio is 2.2 girls to 1 boy
in 1986 (Hobbs & Wynne, 1987). Most reports show 4 girls abused to 1 boy (e.g.
Adams-Tucker, 1984; Bentovim f/iz/., 1987; Gale, Thompson, Moran & Sack, 1988;
Mian, Wehrspann, Klajner-Diamond, Le Baron & Winder, 1986; Tong, Oates &
McDowell, 1987), but other large series are much more in keeping with the 9 to 1
ratio previously believed to be true (e.g. Cupoli & Sewell, 1988; Dube & Hebert,
1988). The continuing discrepancy between community and clinical study ratios
demands further exploration and explanation.

Prevalence of sexual abuse in special populations

Space does not permit full consideration of the prevalence of sexual abuse within
certain populations; however, they are important and clinically relevant. These are:
(1) runaway populations; (2) male prostitutes; (3) male only children's institutions;
and (4) inpatient psychiatric populations.
Generally, firm conclusions cannot be reached regarding these populations, either
because there are insufficient studies, or because the information is very difficult to
obtain. Many of the studies which are available omit gender comparisons.
 Sexual abuse of male children and adolescents

In the U.S.A. the estimated number of runaways is huge (Shane, 1989) and in
one series 38% (34/89) of the boy runaways had been sexually abused when a broad
definition of sexual abuse was utilized (McCormack, Janus & Burgess, 1986). It is
premature to conclude how important sexual abuse is in these boys' decisions to run
away or whether concurrent physical abuse, as a factor, was more important. Nor
can we yet say whether sexual abuse is a relatively stronger influence on the decision
of girls to run away, although this seems probable.
It is also believed that runaways are more prone to be drawn into male prostitution,
including becoming 'rent boys'. Preliminary information suggests no differences
between male and female child prostitutes. Both are very likely to have experienced
preceeding sexual abuse.
Child prostitution merges into the issue of sex rings, over which there is great secrecy
(Christopherson, 1990). For more information readers are referred to Burgess
(1984a,b), Dawson (1989), Finkelhor (1988) and Wild and Wynne (1986). While
sex rings may involve boys and girls (sometimes exclusively either), it is too soon
to say whether there are significant gender differences in the patterns. It is worth
noting that the boundaries of what constitutes a sex ring become blurred with those
of large chaotic families (Dawson, 1989; Porter, 1984). Finally, no gender differences
are apparent in those groups which have sprung up in various countries to advocate
for child sex. Admittedly one in the U.S.A. does call itself the North American
Man/Boy Love Association, de Young (1988) has identified very well their methods
of self-justification.
Closely related, but not the same as prostitution, is the sexual exploitation which
occurs, typically, within male-dominated institutions. There is a widespread anecdotal
reporting of sexual activities within residential schools between older boys and younger,
within juvenile offender contexts, and within children's homes, but no helpful studies
to indicate the incidence or prevalence of such abuse.
There is uniform recent evidence accumulating to show there is a high incidence
of sexual abuse being reported amongst children admitted to child psychiatric inpatient
settings. Individual setting reports (Emslie & Rosenfeld, 1983; Husain & Chapel,
1983; Kolko, Moser & Weldy, 1988; Livingston, 1987; Sansonnett-Hayden, Haley,
Marriage & Fine, 1987; Singer, Petchers & Hussey, 1989) mirror the results of Kohan,
Pothier and Norbeck's (1987) survey of 110 child psychiatric inpatient settings, which
obtained sexual abuse history rates of 16% for boys and 48% for girls. This suggests
that sexually abused children are concentrated into treatment settings for whatever
reason, but, because of the excess of boys admitted, the actual numbers will be very
similar. Thus, for every abused girl (n = 172) admitted in their survey, an abused
boy {n = 172) was admitted as well.

Under-Reporting Factors Relevant to Boys

It is very clear from the prevalence data cited above, despite its variability, that
under-reporting of sexual abuse is consistent and universal. The 8% figure for boys
reported by Baker and Duncan (1985) is in stark contrast to the total population
prevalence figure of 0.3% derived by Peake (1990a) from a projection of cases reported
to professionals (Mrazek et al, 1981).
202 B. Watkins and A. Bentovim

Putting aside explanations which are applicable to both girls and boys, such as
immaturity, insufficient mastery of language, inhibition over the possible consequences
of disclosing and confusion over any pleasurable aspect of the sexually abusive
experiences, the question remains, are there different factors operating in the under-
reporting of boys compared to girls?
In essence, possible factors leading to the under-reporting of sexual abuse in boys
can be conceptualized as either coming from within the boy himself or due to a lack
of response by those around him.

Individual Factors
(A) Fear of homosexuality
Boys are usually enculturated into an ethos where self-reliance, independence and
sexual prowess are valued, while showing hurt or homosexuality are denigrated.
Finkelhor (1986), Nasjleti (1980) and Peake (1990a), as well as others, have commented
on these issues and Finkelhor and Browne (1986), in particular, have drawn attention
to the 'male monopoly' amongst sexual abusers. This 'male monopoly', it is postulated,
promotes an intense fear of homosexuality, or being labelled homosexual. Since fears
and confusion about sexual identity are already so widespread within the general
community, subsequent sexual victimization may well have the effect of confirming
and possibly fixing such preoccupations and fears. This may then lead to powerful
repression or deletion of the experience, with a failure to report. It is a common clinical
experience for boys to feel that because they responded, it must mean that whoever
victimized them knew they would react and had therefore picked them out because
of some 'sign' of homosexuality. Nathanson (1989) believes shame is a powerful factor
in preventing disclosure. Research substantiating the importance of these clinical
observations is lacking, but needed.
Even after discovery, Nasjleti (1980) has been struck by the extreme reluctance
of adolescent boys to talk about their abuse in therapy, whether this be individual
or group therapy and irrespective of the therapist's gender.
It is tempting to link such an overall reluctance to talk with the clinically described
intense fears of homosexuality. It may partially explain the failure of adolescents to
report their abuse. Certainly Cupoli and Sewell's (1988) and Rimsza and Niggemann's
(1982) age of referral analyses show a dramatic divergence in referrals for boys and
girls in adolescence, with the referral of boys dropping strongly away. An alternative,
but in our view less likely, explanation for this change is that the rate of abuse in
adolescent boys truly decreases.

(B) Differential emotional response

It can be postulated that boys might generally react differently than girls to sexual
abuse and in some way, which makes them less likely to tell about their abuse. The
effects of sexual abuse will be discussed in greater detail below, but broadly speaking
we are referring to whether boys are more likely to 'act out' (externalize) or 'act in'
(internalize) than girls. Within the Diagnostic and Statistical Manual of Menial Disorders
 Sexual abuse of male children and adolescents

(DSMTII-R) American Psychiatric Association, 1987, framework, disruptive

behaviour disorders (externalized) are much more common amongst boys than girls,
whilst anxiety and depressive disorders (internalized) are either equally likely or more
common amongst girls. There is insufficient information to determine gender
differences in regard to post-traumatic stress disorder and adjustment disorders.
Distressed responses tend to elicit more sympathetic and concerned inquiry than do
'acting out' responses.
We simply do not know whether children are more or less likely to talk about
traumatic abusive experiences depending on how they have reacted, and whether
there are gender differences. Kiser et al. (1988) provide a little evidence against such
a notion. In their small preschool sample, both boys (n = 5) and girls {n = 5) were
extremely reluctant to talk about their abuse. They linked this finding to the very
high incidence of post-traumatic stress disorder in the groupout of 10 present.
Kaufman (1984) and Kaufman, Divasto, Jackson, Voorhees and Christy (1980) have
provided some support for the notion that boys may indeed be reluctant to acknowledge
their abuse, through their studies on the effects of rape on men. A proportion of their
subjects were adolescents. They noted that when women are raped, about half show
what is described as an 'expressive' rape trauma syndrome and about half a highly
'controlled' rape trauma syndrome. Kaufman's observations were that only 20% of
males showed an 'expressive' response, whereas 80% showed a 'controlled' response.
It was observed that the male rape victims tended to go to casualty departments
complaining of other injuries and it was only the alertness of the professionals present
which enabled them to share that they had indeed been raped.
Contrary to expectations, the effects literature on sexually abused boys does not,
as yet, provide support for the hypothesis that externalizing responses occur more
commonly in boys. This will be discussed further below.

Lack of Response
(A) Lack of supervision
One proposition which has been put forward is that the lack of supervision in the
community of older boys increases their vulnerability to extrafamilial sexual abuse
(Budin & Johnson, 1989), but that this fails to show up in child protection or even
clinical reports from e.g. hospitals, because such children are not referred on by the
police, who usually receive most reports about what is characterized as extrafamilial
abuse (Finkelhor, 1984a,b,c). Peake (1990a) has drawn attention to the significant
social standing of some recently convicted abusers in what should be trusted
relationships. They included a principal educational psychologist, a paediatrician and
senior staff within UNICEF.
Most of the reported evidence does indeed suggest extrafamilial abuse is more
common in boys (Baker & Duncan, 1985; Faller, 1986b; Finkelhor, 1984b; Rogers
& Terry, 1984; Vander Mey, 1988), but is divided over whether boys are more prone
to abuse by strangers, with some studies supporting this proposition (De Jong, Emmett
& Hervada, 1982; Dube & Hebert, 1988; Ellerstein & Canavan, 1980; Finkelhor,
1984b, Spencer & Dunkler, 1986; Tong et al, 1987); and a similar number not doing
204 B. Watkins and A. Bcniovim

SO (Baker & Duncan, 1985; Bentovim et al, 1987; Faller, 1989b; Friedrich, 1988;
Hobbs & Wynne, 1987; Reinhart, 1987; Rimsza & Niggemann, 1982).

(B) Blaming the boy

Pierce and Pierce (1985) express concern that under-reporting is linked to boys
being seen as not needing protection. Whereas girls have been blamed for their own
abuse via the 'seductive child' notion (discussed in Meiselman, 1978), boys are expected
to be 'tough' and it is their own fault if they put themselves at risk. They thus need
punishment rather than help. While this is a plausible explanation for under-reporting
it is as yet unsubstantiated by research. Finkelhor's (1979) finding shows that,
irrespective of the child's gender, over 90% of abusive acts were initiated by the adult
abuser, not the child, and that even if the blaming mechanisms differ for boys and
girls it remains false to blame the child.
In an interesting recent well designed study, indirect evidence to support such a
blaming hypothesis was found amongst a college undergraduate sample. Written
vignettes involving a 15-year old were presented to the college students, but varied
by sex of perpetrator, sex of victim, and whether the child was encouraging, passive,
resistant, or upset. Broussard and Wagner (1988) found significant differences. Male
respondents rated perpetrators less responsible whenever the victim was male (rather
than female), and least responsible when the male victim was encouraging. They
concluded male victims were penalized more by male respondents.
Whatever the explanation, it seems likely that the relative absence of male adolescent
presentations, as noted by Cupoli and Sewell (1988) and Rimsza and Niggeman (1982),
would help explain the remarkably consistent child protection and clinical studies
reporting that boys are abused at a younger mean age than girls (Bentovim et al,
1987; De Jong et al, 1982; Ellerstein & Canavan, 1980; Finkelhor, 1984b; Pierce
& Pierce, 1985; Rimsza & Niggeman, 1982; Rogers & Terry, 1984; Singer, 1989).
In contrast, Baker and Duncan's (1985) carefully selected sample community finding
(admittedly based on self-report and employing a broad definition of abuse) was that
the onset of abuse age for boys was older than that for girls. This is consistent with
Finkelhor's (1979) college student finding and the results from three studies of
incarcerated sex offenders (Frisbie, 1969; Gebhard, Gagnon, Pomeroy & Christenson,
1965; Mohr, Turner & Gerry, 1964). Reconciliation of these differences through
further research is clearly required. It will need to pay attention to year-by-year analysis
of abuse presentations for both boys and girls. Simple calculation of age means will
mask differing age trends.

(C) Missing alertors more pertinent to boys

A great deal has been written on the topic of mode of presentation or 'indicators'
of sexual abuse, for example in the special report. Child Sexual Abuse: Principles of Good
Practice {\9%Q). A major difficulty in assessing indicators is that they have been compiled
retrospectively. Even so, the necessity of undertaking gender analysis has seldom been
realized. Sebold (1987) has been one of the first to draw attention to the need to become
 SexuaJ abuse of male children and adolescents

aware of possible differential 'indicators' (or alertors) of abuse fcr boys. From clinical
experience he suggests homophobic behaviour, exhibitionism and sexual offending
in preadolescent or adolescent boys should be considered as possible indications that
the boys have been abused.
The available evidence points to the increased possibility of boys being abused in
conjunction with their sisters, rather than in isolation (Bentovim et al., 1987; Faller,
1989b; Finkelhor, 1984b; Pierce & Pierce, 1985; Vander May, 1988), so it is
not surprising that Reinhart (1987) reports a trend towards the abuse of boys being
more often disclosed by a third party. Sexual abuse of a sister is a clear indication
to interview brothers. If this is not done there will be under diagnosing.

(D) Denial of abuse by females

Abuse by women, particularly mothers, has been an especially difficult issue for
the community to contemplate. Even professionals find it extremely hard to make
the leap to being aware that women can abuse as well as men, although in various
series (e.g. Bentovim et al, 1987; Faller, 1989b) the rate of abuse by women either
jointly, in polyincestuous activities, or alone is between 5% and 15% of cases coming
to professional notice. In Dimock's (1988) series of 25 men, 28% were abused by
women20% if only those acting in isolation are considered. Sons vvere abused in
43% of McCarty's (1986) series of mother-child incest, while Fehrenbach and
Monastersky (1988) found 40% of the children abused by female adolescent
perpetrators were male. Finally, Johnson (1989) reports that in her small series of
female child perpetrators, boys were the victims in a ratio of 2 to every 1 girl.
The largest series of female abusers reported is in Fromuth and Burkhart's (1989)
study of college men. Sixty-one (over 70% of those reporting sexual abuse) were abused
by women. This report is almost unique in finding an excess of female over male
perpetrators. Fritz et al.'s (1981) study is the only other one, again with a college
sample, we have found which reports similar findings60% of the perpetrators were
female. Neither study questions the high number of female perpetrators. Instead,
it is suggested that it is clinic samples which have been biased towards male
perpetrators. Replication is obviously required.
McCarty (1986), when considering some of these difficulties, notes an attitude of
"women being viewed as sexually harmless to children: what harm can be done without
a penis?". Obviously abuse covers a much wider range of acts besides penile-vaginal
intercourse.
Fear of disbelief of abuse by females has also played a part in under-reporting,
which is reflected in Krug (1989) and Singer (1989) both finding only one man, in
their respective series of eight and 12, who reported the abuse by their mothers or
other female relatives. Thus, while Faller (1989b) found boys 10 times more likely
than girls to be victimized by a woman alone, it is worth noting Russell and Finkelhor's
(1984) conclusion that in absolute numbers more girls than boys are victimized by
female perpetrators. In view of the latest reports cited above, some doubt about the
firmness of such a conclusion regarding female perpetrators needs to be expressed.
Lastly, evidence suggests that the community tends to employ a double standard,
in which attitudes towards male socialization risk permitting the re-defmition of female-
206 B. Watkins and A. Bentovim

male abuse as simply a normative sexualization experience (Dimock, 1988), or of

no consequence because the abuse was frequently regarded positively (Fromuth &
Burkhart, 1989), or rated by the men retrospectively as having no effect (Baker &
Duncan, 1985). Culturally, women are permitted a much freer range of sexual contact
with their children than are men. Women usually bathe, change and dress their
children. Society accepts mothers taking their sons to bed and may only question
this in terms of overdependency. It does not accord the same indulgence to fathers
taking their daughters to bed (Banning, 1989).
Originally, the 'men-only are perpetrators' belief was so powerful that it was
maintained that any woman who could abuse her son must be psychotic. As recently
as 1979 Rosenfeld claimed that "in mother-son incest one or both parties is usually
psychotic". This clearly is not so, and current clinical experience negates such views.
Krug (1989) noted no psychotic mothers in his series of mother-son abuse cases, as
judged by reports from the sons. In her study McCarty (1986) found only two of
the eight women who molested only male children had documented emotional
disturbances. Our own clinical experience would indicate that the majority of women
who are sexually abusing their sons may well have had a serious sexually abusive
experience themselvesand indeed may well be continuing to be abusedthe abuse,
therefore, is occurring in the context of a polyincestuous situation rather than frank
psychiatric disorder.
Denial of abuse by female perpetrators and fear of disbelief is thus contributing
to under-reporting of both boys and girls, but more so to boys, if the initial trend
towards female perpetrators abusing boys more frequently is confirmed by future
research. The need for doctors in particular to suspend their disbelief was recently
stressed (Wilkins, 1990).

(E) Denial of father-son abuse

In contrast to the number of publications about mother-son abuse, there is an
astonishing relative lack of reports about father-son abuse, even though fathers are
cited as amongst the most frequent, if not the most frequent, abusers of boys, including
sons (Faller, 1989b; Hobbs & Wynne, 1987; Pierce & Pierce, 1985; Reinhart, 1987;
Spencer & Dunklee, 1986; Vander Mey, 1988). Stepfathers, as noted by these authors,
tend to be the alternative most frequently cited perpetrators. Yet there are only sporadic
case reports (Langsley, Schwartz & Fairbaim, 1968; Raybin, 1969; Steele & Alexander,
1981) or small series of five to six cases (Dixon, Arnold & Calestro, 1978; Justice
& Justice, 1979) which have started to look at father-son abuse in any detail. Justice
and Justice (1979) explain this striking denial in terms of "two moral codes: the one
against incest and the one that has previously existed against homosexuality". There
are a few exceptions to the clinical finding that fathers/stepfathers are the most frequent
abusers of boys (e.g. Dejong^^a/. 1982; Ellerstein & Canavan, 1980), the samples
of which appear strongly slanted towards stranger abuse. Paradoxically, one of the
largest series is contained in Johnson's (1988) report on boy perpetratorsseven (30%)
had been abused by their fathers. Langsley et al. 's (1968) assertion that "father-son
incest is the least common (sexually abusive) combination", even with the meagre
information available, is clearly unsustainable.
 Sexual abuse of male chUdren and adolescents

There is some suggestion of there being an association between the physical and
sexual abuse of boys (Cavaiola & Schiff, 1989; Finkelhor, 1984b; Kolko et ai,
1988; Sansonnett-Hayden et ai, 1987; Spencer & Dunklee, 1986), particularly with
father-son incest (Dixon et ai, 1978), which, if sustained, has practical implications
regarding awareness and detection. In this regard it is important to maintain a
distinction between the kind of ongoing repetitive physical abuse, which occurs within
the family, and the kind of force which is used during abductions. The latter is
correlated with older boys, stranger abuse and oral/perianal trauma (De Jong et al.,
1982; Ellerstein & Canavan, 1980; Rimsza & Niggemann, 1982; Spencer & Dunklee
1986).
Pierce (1987), in her survey of the literature, could find only 52 instances of
father/stepfather sexual abuse reports. It is doubtful whether a recent case history
(Halpern, 1987) should be added to this number, as it involved the late adoption
of a 12-year old boy by a homosexual couple, where the abuser had an extensive
paedophile history. In the main paedophiles indicate a preference for boys (Righton,
1981) and Finkelhor (1984b) concluded that victimized boys are more likely than
girls to come from impoverished and single-parent families, so it may well be that
boys are more at risk from older paedophiles seeking such a single-parent family with
children of their specific orientation. It needs to be recognized that a proportion of
all abusers choose their families, their jobs and their friends with a view to gaining
access to children (Peake, 1990a).
As with mother-son abuse, abhorence of father-son abuse is leading to under-
detection and under-reporting. In contrast to mother-son abuse, there may be an
increased likelihood of concurrent physical abuse in father-son abuse. Future research
needs to focus more selectively on perpetrator-victim dyads, such as father-son or
mother-son abuse, to determine whether there are significant differences in the pattems
of abuse and outcomes.

(F) Denial of child-child abuse

Recent research has begun to focus on the need to recognize both the significance
and the efects of sibling and cousin incest, of child-child and adolescent-child sexual
abuse (e.g. Cantwell, 1988; Chasnoff ^/a/., 1986; Dejong, 1989; Friedrich, Beilke
& Urquiza, 1988; Johnson, 1988, 1989; Smith & Israel, 1987). These reports, which
involve over 150 examples, show there is an overlap between these various forms
of abuse. They challenge further acceptance of sibling incest, in which there has been
little interest, because it has not been perceived as being harmful (Dejong, 1989).
Despite the lack of documentation, sibling incest is thought to be the commonest form
of incest (Dejong, 1989). In one centre child perpetrators are presenting at the rate
of three to four each week (Cantwell, 1988). Amongst the male child/adolescent
perpetrators preceeding sexual abuse is common, whilst the sole report on female
child perpetrators found it to be universal (Johnson, 1989). It is these experiences
which are leading authors to challenge the age differential criterion discussed in the
Definition section. The key questions are: (1) how young can a child be and still be
regarded as a perpetrator?; (2) is there a greater likelihood that female adolescent
perpetrators will abuse boys?; and (3) is there a greater likelihood that male adolescent
208 B. Watkins and A. Bentovim

perpetrators will abuse boys? Currently there is insufficient information on which

to base conclusions.
Depending on the laws in different countries, there usually is no legal toe-hold
on children below a particular age, often 10, who abuse, so information from police
or welfare sources is lacking. The youngest perpetrator age found varies, as expected,
with the series described9 years old by De Jong (1989) and Smith and Israel (1987),
6 by Cantwell (1988) and 4 in both of Johnson's samples (1988, 1989). Chasnoff ^f
al. (1986) describe a boy, whose abuse stopped by the age of 9 months, who, at 25
months, was demonstrating "sexual aggressiveness" towards other children. At what
point do we relabel 'sexualization' or 'acting out' abuse? Should we? The implications
of even single case reports like this one are relevant to adult self-reports of abuse.
Within community samples and even offender series such events are beyond recall.
As mentioned in the section on female abusers, 13 girl perpetrators in Johnson's
(1989) series molested two boys for every girl. From the data presented, it is not possible
in Johnson's (1988) parallel series of boy perpetrators to calculate a comparable ratio.
Nevertheless, of the 47 boy perpetrators, 23 cases involved sibling incest, in which
52% abused young brothers. Again, insufficient data makes comparison with Smith
and Israel's (1987) series difficult. There were five female and 20 male perpetrators,
including both children and adolescents. Their victims were overwhelmingly
female89%. Cantwell's (1988) interest was on cycles of abuse between
adolescents/children and other children. It is difficult to unravel the figures, but many
boys were involved as victim-perpetrators. De Jong's (1989) series is also not
comparable as the perpetrators, presumably all males, range up to 40 years of age,
with an adolescent mean. Victims are again overwhelmingly girls and, while cousins
are twice as likely to abuse a boy relative as brothers are, this does not reach statistical
significance. Clearly, it is premature to reach overall conclusions on the basis of such
data, and the questions are best left as hypotheses to be tested.
The questions can, however, be approached from another perspective, that ol
offender reports. Evidence is accumulating to indicate that a majority of offenders
begin their 'careers' in adolescence (Longo & Groth, 1983). In another study of 561
adult sexual offenders, 59% reported the onset of their paraphilic behaviour during
adolescence (Abel et al., 1987). The uncertainty is over how typical or generalizable
are the recent rapidly rising number ofstudies on adolescent perpetrators (e.g. Becker,
1988; Fehrenbach, Smith, Monastersky & Deisher, 1986; Kavoussi, Kaplan & Becker,
1988; Lewis, Shankok & Pincus, 1979; Shoor, Speed & Bartlett, 1966). Becker (1988)
reported that of 27 adolescent perpetrators with their own sexual abuse history, 55%
abused boys; Fehrenbach et al. (1986) reported that of 297 adolescent perpetrators,
28% abused males, mostly boys, nearly all of whom had hands-on offences committed
against them; the frequency of boys abused rose to be almost equal to that of girls
for children aged 6 or less; Kavoussi et al. (1988) found in an outpatient sample oi
37 adolescent offenders, 38% had abused boys aged 11 or less; Lewis et al. (1979)
found in a group of 17 drawn from a secure unit for violent juvenile offenders, that
12% had abused males; lastly, Shoor et al. (1966) found 45% of their Juvenile Probation
Department sample (n = 80) had abused boys aged 10 or less. These results are in
keeping with those from an adult community-based, specialized sex offender treatment
programme (Conte, Wolf & Smith, 1989). Of the 20 men, selected to maximize the
 Sexua] abuse of male children and adolescents 209

amount of information available, 35% had abused boys. It is noteworthy that Budin
and Johnson (1989) found an almost identical number of their 72 incarcerated
offenders37.5%had abused boys.
For those who deal with adolescent perpetrators, it seems reasonable to conclude
that the chances that they will have abused a boy are fairly high. On the face of it
these figures also bolster the case for an apparent under-reporting of boy victims.
Some caution is required, though, because in Conte etal. 's (1989) series it is possible
to calculate the total proportions of the victimsthe 20 men abused 146 children,
of which 34 were boys, which represents 23%, not 35%, of the total. Pierce and Pierce
(1985) think there may be a bias towards imprisoning abusers of boys, which would
distort the above findings, but the actual number of cases proceeding to prosecution,
whether boys or girls, was very low. Obviously these factors are important and they
only emphasize how difficult it is to interpret the data.
In summary, the poor recognition of child-child abuse has contributed to the under-
reporting of sexual abuse of both boys and girls. Amongst boys, the frequency with
which perpetration begins in adolescence, and now it seems preadolescence, with a
preceeding history of abuse, raises the question, "does previous sexual abuse contribute
to the probability of becoming a perpetrator?" This will be returned to after the section
on effects.

Circumstances Regarding the Sexual Abuse of Boys

Common sense suggests there would be very few absolute differences between the
sexual abuse of boys and girls. Clearly, anatomy dictates the nature of ihe abuse
and only girls may have their abuse discovered through an adolescent pregnancy.
Virtually all the hypothesized differences concern probability associations and very
few can be regarded as substantiated. Many are discussed in the body of the text.
For ease of reference they are now listed (see Table 1).

Nature of abuse
Clinical reports, some uncontrolled, are unanimous in finding that boys are more
likely than girls to be subjected to anal abuse (Bentovim et al., 1987; Cupoli & Sewell,
1988; Dejong et al., 1982; Ellerstein & Canavan, 1980; Hobbs & Wynne, 1989,
Reinhart, 1987; Rimsza & Niggemann, 1982; Rogers & Terry, 1984; Spencer &.
Dunklee, 1986). Indeed, if anal intercourse was equated with vaginal intercourse,
then Baker and Duncan (1985) found boys and girls to seem equally at risk. Hobbs
and Wynne (1989) point out that the type of abuse varies by age. Girls are most
likely to be anally abused when young, with a crossover to vaginal abuse around
the age of 10 years. Boys are anally abused approximately equally at all ages. These
findings clearly relate to the anatomical factsanal abuse is more possible in younger
children than is vaginal abuse. Even so, and not surprisingly, there is a greater
likelihood that anal physical findings will be more evident in younger children (Hobbs
& Wynne, 1989; Reinhart, 1987).
In total, the above studies involve over 800 boys. They report extremely high
frequencies of penile-anal intercourse. Bentovim et al. (1987) found a rate of 53%
210
Hypothesis
1. Patterns of abuse. Boys compared to girls are:
Younger
Least likely to
present as adolescents
More likely to
have physical abuse
associated
More likely to be
abused forcefully
More likely to be older
when forcefully abused
Less often firstborn
Less often solo
2. Patterns of discovery. Boys compared to girls are:
Less willing to tell
Discovered more via
third parties/sisters
B. Watkins and A, Benlovim
Table 1
Supported Unsupported
Bentovim et al. (1987); Baker & Duncan (1985);
D e j o n g et al. (1982); Briere et al. (1988);
Ellerstein & Canavan (1980); Dube &i Hebert (1988);
Finkelhor (1984b) (if solo); Faller (1989b);
Pierce & Pierce (1985);
Rimsza & Niggemann (1982);
Rogers & Terry (1984);
Singer (1989)
Cupoli & Sewell (1988);
Johnson & Shrier (1987);
Rimsza & Niggemann (1982)
Bruckner & Johnson (1987);
Cavaiola & Schiff (1989);
Dimock (1988); Dixon et ai (1978);
Finkelhor (1984b);
Kolko et at. (1988);
Sansonnett-Hayden et al. (1987);
Seghorn et al. (1987);
Spencer & Dunklee (1986)
Budin & Johnson (1989); Rogers & Terr>' (1984)
D e j o n g et al. (1982);
Ellerstein & Canavan (1980);
Pierce & Pierce (1985)
D e j o n g et al. (1982);
Fehrenbach et al. (1986)
Bentovim et aL (1987) Dixon et al. (1978)
(father-son abuse);
Faller (1989h) (if
intrafamilial)
Bentovim et al. (1987);
Dixon et al. (1978);
Faller (1989b) (if extrafamilial);
Finkelhor (1984a,b,c);
Pierce & Pierce (1985);
Vander Mey (1988)
Bruckner & Johnson (1987);
Dimock (1988); Finkelhor
(1984b);
Fritz et al. (1981);
Johnson & Shrier (1987);
Krug (1989); Singer (1989)
Reinhart (1987); Sebold (1987);
Vander Mey & Noff (1984)
 Sexual abuse of male children and adolescents
Table I (continued)
Hypothesis
3. Nature of abuse. Boys compared to girls have:
More physical findings
Less non-contact abuse
Less fondling
More masturbatory abuse
More orogenital abuse
More anal abuse
Insufficient recognition
of male child rape
Greater seventy of abuse
More repetitive abuse
4. Perpetrators who abuse boys are:
More often extrafamilial
More often strangers
211
Supported Unsupported
Ellerstein & Canavan (1980);
Spencer & Dunklee (1986)
Baker & Duncan (1985);
Fehrenbach et ai (1986)
Pierce & Pierce (1985); Friedrich et al. (1988)
Rimsza & Niggemann (1982)
Pierce & Pierce (1985);
Cupoli & Sewell (1988)
D e j o n g et ai (1982);
Ellerstein & Canavan (1980);
Pierce & Pierce (1985);
Spencer & Dunklee (1986)
Bentovim et ai (1987);
Cupoli & Sewell (1988);
D e j o n g et al. (1982);
Ellerstein & Canavan (1980);
Friedrich et al. (1988);
Hobbs & Wynne (1989);
Reinhart (1987);
Rimsza & Niggemann (1982);
Rogers & Terry (1984);
Spencer & Dunklee (1986)
Ellerstein & Canavan (1980);
Kaufman (1980);
Vander Mey (1988)
Bentovim et ai (1987); Briere et ai (1988)
Dube & Hebert (1988)
Baker & Duncan (1985)
Baker & Duncan (1985); Dube & Hebert (1988);
Failer (1989b); Friedrich et ai (1988)
Finkelhor (1984b); (boys aged less than 8);
Pierce & Pierce (1985); Mian et ai (1986);
Rogers & Terry (1984); (if aged < 6);
Vander Mey (1988) Tong et ai (1987)
D e j o n g et ai (1982); Baker & Duncan (1985);
Dube & Hebert (1988); Bentovim et ai (1987);
Ellerstein & Canavan (1980); Faller (1989b);
Finkelhor (19B4b) (if solo); Friedrich (1988);
Fisher & Howell (1970) Hobbs & Wynne (1987);
(il homosexual paedophiles); Reinhart (1987);
Spencer & Dunklee (1986); Rimsza &Niggemann(l982)
Tong et ai (1987)
212
Table 1 (continued)
Hypothesis
More often adolescents
More often multiple
More likely to be
involved in a sex ring
Fathers more often
than stepfathers
More often unemployed fathers
Most likely to be professionals
More likely to be imprisoned
Proportionately more
likely to abuse boys
if female
5. Families of abused boys are:
Lower SES
More often fatherless
More likely to have an
emotionally ill
(non-perpetrating) mother
More likely to be black
More likely to blame
boys than girls
More likely to deny impact
B. Watkins and A. Bentovim
Supported Unsupported
Finkelhor (1984b)
(if solo victim);
Reinhart (1987);
Rogers & Terry (1984);
Spencer & Dunklee (1986)
Rogers & Terry (1984); Baker & Duncan (1985);
Faller (1989b) (if extrafamilial) Reinhart (1987)
Vander Mey (1988) Christopherson (1990)
Faller (1989b); Pierce & Pierce (1985)
Friedrich et ai (1988);
Hobbs & Wynne (1987);
Reinhart (1987);
Spencer & Dunklee (1986)
Pierce & Pierce (1985)
Faller (1989b)
Pierce & Pierce (1985)
Becker (1988); Dimock (1988);
Faller (1989b); McCarty (1986)
(only if co-perpetrator)
Finkelhor (1984a,b,c) Faller (1989b)
Pierce & Pierce (1985);
McCarty (1986)
(if mother-son abuse)
Pierce & Pierce (1985)
Becker (1988) Budin & Johnson (1989);
Faller (1989b);
Pierce & Pierce (1985);
Reinhart (1987);
Stiffman (1989)
Rogers & Terry (1984)
Rogers & Terry (1984)
 Sexual abuse of male children and adolescents 2.1 J

Table 1 (continued)

Hypothesis Supported Unsupported

6. Service response to boys:

Involves police more often Finkelhor (1984b)

Perceives less need for Pierce & Pierce (1985)

protection

Perceives less need Pierce & Pierce (1985)

for removal from family

Provides less treatment Adams-Tucker (1984)

(especially black boys);
Pierce & Pierce (1985)

in boys (vs 18% for the total sample), Cupoli and Sewell (1988) a rate of 61% (vs
5.5% for girls), DG Jon^ et al. (1982) a rate of 78%. Ellerstein and Canavan (1980)
found anal physical findings in 44% (rate for reported anal intercourse not given),
Hobbs and Wynne (1989) report anal intercourse rates of 83% for boys and 29%
for girls, Reinhart (1987) reports rates of both anal intercourse and physical findings
in 29%, Rimsza and Niggemann (1982) rates of 58% for attempted/actual anal
intercourse (vs 7 % for girls) and Spencer and Dunklee (1986) a rate of 53 % . If finger-
anal penetration and object-anal penetration are included then the percentages are
even higher. It appears, for these boys at least, to be something of a myth that there
will be no physical findings, as in those papers providing such information, rates are
described of between 29% and 44% (Ellerstein & Canavan, 1980; Dejong et ai,
1982; Reinhart, 1987). After a single acute episode of sexual abuse, there were physical
findings in 86% of those boys in whom physical findings would have been expected
by the history (Spencer & Dunklee, 1986). Despite the exception of Pierce and Pierce
(1985), who report no anal intercourse in their series, it seems reasonable to conclude
that not only is anal intercourse higher in boys than girls, but it is relatively common.
Finally, in a substantial minority of cases, physical findings can be expected.
However, once more, caution is required in interpreting these findings, unequivocal
as they apparently are. An alternative explanation is that they supply strong evidence
of under-reporting. It is to be expected that, as the community grapples with the
acknowledgement of the extent of the sexual abuse of boys, the most severe clear-cut
cases will be recognized first. It is plausible that those children who have been taken,
to predominantly paediatric settings, for examination are those whom their workers
feel most confident have been abused. Baker and Duncan (1985), in their community
sample, found a ratio of contact abuse to intercourse of 8-10:1 (with a slight excess
of contact abuse for boys over girls), with a community prevalence rate for intercourse
of 0.7%. None of the above reports are describing ratios in this order, hence the
implication of under-reporting. Fritz et al. (1981) and Fromuth and Burkhart (1989)
give no indication whether any of the men in their college samples were subjected
 B. Watkins and A. Bentovim

to anal intercourse, although Fromuth and Burkhart appear to have asked their
respondents about this possibility.
What constitutes a significant physical finding has recently been intensely debated.
The Cleveland Inquiry (Butler-Sloss, 1988) has, in particular, focused controversy
over the significance of anal findings, including refiex anal dilatation (pp. 186-193).
The report concluded ''we are satisfied from the evidence that the consensus is that
the sign of anal dilatation is abnormal and suspicious and requires further investigation.
It is not in itself evidence of anal abuse".
It is beyond the scope of this review to cover in detail the nature of the physical
findings associated with anal abuse. The reader is referred to the Cleveland Report
(Butler-Stoss, 1988, pp. 186-193) and several recent papers (Hanson et ai, 1989;
Hobbs & Wynne, 1989; Paul, 1986; Spencer & Dunklee, 1986) for further information.
Nevertheless, it is worth drawing attention to McCann, Voris, Simon and Wells's
(1989) pioneering study designed to collect normative data on anogenital findings
in 267 prepubertal children (2-11 yrs). In essence, they found in their sample perianal
redness (41 %), increased pigmentation (30%), venous engorgement (52%), and anal
dilatation (49%) occurred commonly. Evaluation of physical findings clearly remains
a complex task and as Hobbs and Wynne (1989) say, "there is no single physical
sign that is in itself uniquely diagnostic of abuse*', and physical findings gain most
significance in association with a child's explicit history of anal penetration.
Reinhart (1987) regards anal sphincter laxity as by far the most likely finding in
keeping with chronic injury. Similarly, eversion of the anal canal (Hobbs & Wynne,
1989) or rectal prolapse (Butler-Sloss, 1988) raise serious questions.
Lastly, the finding of a sexually transmitted disease, even though uncommon,
remains strong grounds for suspecting sexual abuse irrespective of gender (Bentovim,
Elton, Hildebrand, Tranter & Vizard, 1988; Ellerstein & Canavan, 1980; Rimsza
& Niggemann, 1982; Spencer & Dunklee, 1986). Hanson et al. (1989) point to the
apparent increase in anogenital warts in children and challenge those physicians who
still ascribe non-sexual modes of transmission to such warts as failing both to recognize
the evidence and to confront the issue of sexual abuse.
There is weak evidence, due to the small number of reports available, that boys
experience less non-contact abuse (Baker & Duncan, 1985; Fehrenbach et ai, 1986)
and more masturbatory (Pierce & Pierce, 1985; Cupoli & Sewell, 1988) and orogenital
abuse (De Jong ^/fl/,, 1982; Ellerstein & Canavan, 1980; Pierce & Pierce, 1985; Spencer
& Dunklee, 1986).
In summary, all the available evidence indicates that boys are more likely than
girls to be subjected to anal abuse. It would appear that only the most severely sexually
abused boys are being detected and referred, because clinically based samples show
a distribution of abuse pattern which is widely divergent from that found in community
or college student surveys. It is probable that such a referral bias, if confirmed, would
partially explain the reported impression that boys are more severely abused than
girls, and at a younger age. When a medical examination is indicated it must include
anal inspection.
Such a medical examination will frequently be necessary because of physical abuse.
Clinical reports universally link sexual abuse of boys, disproportionately compared
to girls, with concurrent physical abuse (Bruckner & Johnson, 1987; Cavaiola & Schiff,
 Sexual abuse of male children and adolescents

1989; Dimock, 1988; Dixon et ai, 1978; Finkelhor, 1984b; Kolko et ai, 1988;
Sansonnett-Hayden et ai, 1987; Seghorn et ai, 1987; Spencer & Dunklee, 1986).
The well known lower social class bias towards physical abuse may well in turn explain
the lower social class skew for sexually abused boys suggested by Finkelhor (1984b).

The Effects of Sexual Abuse

The under-reporting of the incidence and prevalence of sexual abuse in boys has
led to paucity of information about the effects on boys of sexual abuse, in distinction
to girls. In fact, the question of whether there might be differential effects has yet
to be seriously researched and we are left to rely on scattered impressions from clinical
settings, usually involving small samples.
It is customary to consider the effects of sexual abuse from both childhood (initial
effects) and adult (longer term effects) perspectives. As has been observed with children
experiencing the divorce of their parents, age makes a difference. The cognitive,
emotional and experiential immaturity of the younger child makes regressive responses,
following sexual abuse, more likely. In contrast, an older child might run away or
take drugs. How the family responds to the revelation of sexual abuse is also thought
to be a strong influence on the subsequent course of any reaction.
Both Friedrich et ai (1988) and Rogers and Terry (1984) have suggested that greater
initial symptomatology is associated with greater severity of abuse. Wyatt and Powell
(1988) have been more specific and reach the general conclusions that the most negative
consequences for children are associated with abuse by (a) fathers, (b) genital contact
and (c) the use of force, the latter two being aspects of 'severity'. In similar vein,
but also without gender analysis, Sides, Smith and Kusama (1989) report that the
presence ofan Axis I, DSM-III diagnosis is related to older victims, a closer relationship
of the offender to the child, greater frequency and longer duration of abuse.
In the sections following, general and specific initial effects will be considered.

General initial effects

Prerequisites for comparative outcome research between girls and boys will be not
only that the groups are matched demographically, but also that they are matched
for the kind of abuse and abuser.
Tong et al. (1987) are alert to this problem and in their study (which is almost unique
in trying to objectively assess and compare effects on girls and boys, after a mean
follow-up interval of 2.6 years from initial assessment) express caution over too readily
accepting the gender differences they found. Nearly three times as many boys were
abused by strangers as were girls. Even so, their findings, that abused girls showed
more problem behaviour than abused boys and that the boys' self-esteem was no
lower than that of controls, remain challenging. This finds an echo in the self-reports
of less harm from adult men, which is discussed more fully in the subsection on longer
term effects.
The unusual circumstances of purported abuse in a church-related day-care centre,
involving five boys and five girls, aged 2-6, provided a special opportunity to compare
216 B. Watkins and A. Bentovim

children where there was control for many factors, such as timing of the abuse, place
of abuse, kind of abuse and abuser (KisGr et ai, 1988). Various measures, including
the Minnesota Child Development Inventory (Ireton & Thwing, 1974) and the Child
Behaviour Checklist (Achenbach & Edelbrock, 1983), were used, and while initially
the boys presented more clinically significant symptoms than did the girls, preliminary
follow-up suggested girls were more symptomatic 1 year later.

Specific effects
Rogers and Terry (1984) describe behavioural responses which they saw as more
or less unique to male victims, and which appeared to be directly related to the homo-
erotic implications of the sexual contact, in conjunction with differential cultural
expectations of behaviour for boys. Specifically, the common reactions noted in boy
victims were: (1) confusion/anxiety over sexual identity; (2) inappropriate attempts
to reassert masculinity; and (3) recapitulation of the victimizing experience.

Gonfusion over sexual identity

Undoubtedly, from clinical experience, initial anxiety about sexuality and sexual
identity is common. However, there are surprisingly few reports evaluating such
concerns. Rogers and Terry (1984) have been impressed by the frequency with which
parents of molested boys anxiously ask about the probable impact on subsequent sexual
development. Sebold (1987) interviewed 22 therapists working with sexually abused
boys. They reported considerable preoccupation with sexual identity, which became
manifest as homophobic concerns (hence its suggested value as an indicator of abuse).
Direct reports are limited to a few isolated case histories.
In a highly selected adolescent inpatient sample, Sansonnett-Hayden et ai (1987)
describe histories of cross-dressing in five out of their series of six sexually abused
boys. Unfortunately it is not possible to correlate this finding with the identity of
the perpetrators. However, Zucker & Kuksis (1990) describe a case of an 11-year
old boy whose gender dysphoria appeared related to 2-3 years of coercive sexual abuse
by his 16-year old brother. Two of the four male adolescents in Dixon et ai 's (1978)
series are reported as having concerns about their sexuality. Homosexual anxieties
are an aspect of the detailed father-son case history reported by Langsley et ai (1968).
Pierce (1987), in her review of case reports of father-son incest, cites some cases where
anxiety over being homosexual occurs, but is unable to form an opinion about its
general incidence.
A distinction needs to be made between a fear of homosexuality and the development
of a homosexual preference. Indeed, an associated question is, does child sexual abuse
contribute to the expression of a homosexual preference? Finkelhor (1984c) notes
it is a traditional mythology that molestation leads to homosexuality, but at the same
time he found, in his college study, that boys victimized by older men were over
four times more likely to be currently engaged in homosexual activity than were non-
victims. The finding applied to nearly half the boys who had had such an experience.
Causality is not inferred by this finding. It is supported by Johnson and Shrier (1987),
who reported a significantly greater likelihood that boys molested by males would
 Sexual abuse of male children and adolescents Z1 7

identify themselves as homosexual in contrast to those molested by females. Further,

the adolescents themselves often linked their homosexuality to their sexual victimization
experiences.
It is striking that all the adult clinical reports we could find (Bruckner & Johnson,
1987; Dimock, 1988; Krug, 1989; Singer, 1989), involving 57 sexually abused men,
report sexual preference concerns in a significant minority of each group. Krug's
(1989) sample is exceptional, because it involves abuse by mothers.
Two further points need to be made in relation to this topic. Firstly, it is clear
from work with homosexuals that, predominantly, they have not had inappropriate
experiences in childhood themselves, and secondly, only a minority of homosexuals
have a sexual interest in children. (Finkelhor, 1984c; Newton, 1978). It is dangerous
to equate a homosexual abusive act with an assumption that the perpetrator is
homosexually orientated.
Fromuth and Burkhart (1989) looked closely at sexual adjustment and behaviour
in their two large samples of college men and noted that sexually abused men were
no more likely to report a homosexual experience occurring after age 12 than were
non-abused men. But, as they commented, the lack of relationship might be
attributable to the majority of the perpetrators being female. Indeed, it would be
extraordinary if a single, non-contact abusive experience with a woman were to have
such profound effect on sexual identity.
Briere and Runtz (1989) have indicated, in a recent assessment of male sexual
interest in children, a very unexpectedly high rate of sexual interest in children, in
a non-forensic, university male undergraduate population. Twenty-one per cent of
subjects reported sexual attraction to some small children, 9% described sexual
fantasies involving children, 5% admitted to having masturbated to such fantasies
and 7% indicated some likelihood of having sex with a child if they could avoid
detection and punishment. Unfortunately, there was no gender breakdown regarding
the sex of the children towards whom these men were attracted.
As mentioned in the section on under-reporting, it is believed that fear of being
seen as homosexual contributes significantly to non-disclosure. Our clinical experience
is that boys perceive their selection for abuse as a sign of their homosexuality, a feeling
which is intensified if they did not resist, and compounded by any sexual arousal
which occurred.
Questions which it would be valuable to research, are as follows. How common
are homosexual anxieties in boys following abuse? Does the form of abuse make any
difference? (it seems probable that a boy who has been repeatedly sodomized will
have greater homosexual anxieties than one who was not). Does the perpetrator's
identity make a difference? (here it is being postulated that abuse by a male with
whom the boy has an identificatory relationship, such as a father, will have a greater
impact than abuse by a stranger). Of interest in this last regard are Mrazek and
Kempe's (1981) and Raybin's (1969) descriptions of homosexual intergenerational
incest cases.
Inappropriate attempts to reassert masculinity
The emergence of inappropriately expressed attempts to reassert masculinity is
perhaps, in Rogers and Terry's (1984) view, the most common behavioural reaction
218 B. Watkins and A. Bentovim

of boy victims. Preabuse passivity or unassertiveness is followed by postabuse

aggression, such as picking fights, destructiveness, marked disobedience, and a
generally hostile or confrontative attitude. Summit (1983) shares this view too'The
male victim of sexual abuse is more likely to turn his rage outward in aggressive and
antisocial behaviour. He is even more intolerant of his helplessness than the female
victim . . . child molestation and rape seem to be part of the legacy of rage endowed
in the sexually abused boy".
In an interesting and admirable attempt to quantify the likelihood of various
reactions following abuse, Conte and Schuerman (1988) developed a Symptom
Checklist and compared 369 sexually abused children with a community comparison
group. Unfortunately, we are left to assume that both groups included boys and girls.
When rank ordered the top six symptoms of the 38 enquired about were: low self-
esteem (33%), fearful (of) abuse stimuli (31%), emotional upset (237o),
nightmares/sleep disorders (20%), repressed anger or hostility (19%), and depression
(19%). In contrast, aggressive behaviour was ranked 12th (14%), minor problems
with police 26th (3%), shoplifting/stealing 28th (2%), and sexually victimizing others
31st (2%). Clearly we need to know if the rank ordering differs for boys and girls.
It is puzzling why Conte and Schuerman did not do this; perhaps the number of
boys was insufficient. Future studies need to rank order symptoms according to the
gender of the victims.
Another approach has been to evaluate the effects on and clinicad course of sexually
abused children using an established instrument such as the Child Behavior Checklist
(CBCL) ofAchenbach and Edelbrock (1983) (Friedrich, 1988; Friedrich ^^ a/., 1988;
Kiseretai, 1988; McLeer, Deblinger, Atkins, Foa&Ralphe, 1988; Stiffman, 1989;
Tong et ai, 1987). This instrument subsumes child psychopathology within two broad
factorsinternalizing and externalizing. It is reasonable to predict, a priori, that
externalizing responses will be demonstrated more frequently by boys rather than
girls. So far, at least as measured by the CBCL, this is not being borne out. Instead.
the following tentative conclusions have been reached from the above studies. Sexually
abused children are (1) significantly more likely to score in the clinical range of the
CBCL compared to community controls; (2) likely to have total scores in the same
range as other psychiatrically referred, but non-abused children; (3) likely to have
significant elevations of both broad band factors, internalizing and externalizing; (4)
when young boys, reliably discriminated from conduct disordered boys by the presence
of sex problems and a lower degree of aggression (Friedrich et ai, 1988); (5) unlikely
to show clear gender differences regarding either internalizing or externalizing factors
(with the exception that severely abused girls, aged less than six, show more
internalizing than similarly aged and abused boys; Friedrich, 1988); (6) likely to have
significantly elevated CBCL scores when suffering from post-traumatic stress disorder
(McLeer et ai, 1988); (7) strongly infiuenced by family variables whether showing
internalized or externalized behaviour problems (Friedrich, 1988).
A further perspective on this question of externalizing versus internalizing can be
obtained from the Los Angeles Epidemiologic Catchment Area Study, involving a
randomly selected community sample (Stein, Golding, Siegel, Burnam & Sorensen,
1988). Gender comparisons revealed sexually abused men as having "acting out"
lifetime and current psychiatric diagnoses, such as drug abuse or dependence. Abused
 Sexual abuse of male children and adolescents

women, in contrast, had a higher prevalence of all lifetime disorders except antisocial
personality, and higher current prevalence of any disorder, major depression and
anxiety. In this study, at least, the normally expected gender differences regarding
'internalizing' or 'externalizing' diagnoses were being found. More research along
these lines is clearly warranted.

Recapitulation of the victimizing experience

Although less common than confusion over sexual identity or compensatory
aggression, there is a tendency among boy victims to recapitulate their own
victimization, only this time with themselves in the role of perpetrator and someone
else the victim (Rogers & Terry, 1984; Cantwell, 1988). One mechanism which would
appear to facilitate the transition from victim to victimizer is 'identification with the
aggressor'. Since perpetrators are usually male it can be posited that boys are more
likely to identify in this manner than girls. Friedrich (1988) describes a compelling
example where an 8-year old sexually abused boy is directly taught by his stepfather
to abuse his sisters. Obviously, mechanisms besides 'identification with the aggressor'
are operating in such a situation, e.g. coercion and modelling.
Conte and Schuerman's (1988) work supports the assertion that victimizing others
is uncommon, subject to the reservation that there is no gender breakdown on the
symptom checklist. While sexually victimizing others ranks 31st (2%) out of 38
symptoms, it still ranked ahead of suicide attempts (32nd) and other forms of self-
harm (33rd). This 2% prevalence of sexually victimizing others, which in actual
numbers meant seven children, can be starkly contrasted to the rates found in reference
to boys alone. Sansonnett-Hayden et ai (1987) report three (50%) out of six abused
adolescent boys became perpetrators, while Friedrich et al. (1988) found four (13%)
out of 31 boy victims had become perpetrators by the age of 8. The most extraordinary
report in this regard is that of Chasnoff ^/a/. (1986), where of three baby boys, whose
abuse stopped at 4, 9 and 18 months respectively, two had begun, before the age
of 3 years, to sexually molest other children. The pooled prevalence of sexual
victimization of others by boys in these three studies is thus 22% (9/40). As a finding
it may not be sustained, but if rank ordered with Conre and Schuerman's (1988)
symptom list, it would then become the fourth most common symptom. Obviously,
the above information has been gathered in very disparate ways and such a
transposition is of dubious validity. Nevertheless, it suggests a fmding of grave concern
and of great practical importance. Should it be replicated, then sexually abused boys
need to have included in their therapy programmes a component which targets
perpetrator prevention strategies. A problem arises as to which boys. Should it be
all or only a selected group?
Finkelhor (1986) has argued cogently about the dangers of a single-factor theory
whereby victims become victimizersthat it is exaggerated, that it ignores sociological
aspects, that it will strike terror into the hearts of victims and that, worst, it might
become a self-fulfilling prophesy. Further, it is quite clear that not all abusers were
themselves abused. We agree with and share these concerns, but also believe if the
evidence continues to support such a hypothesis then it cannot be ignored, particularly
if it offers a potentially valid preventative strategy.
220 B. Watkins and A. Bentovim

Adult patients tend to affirm the concern by spontaneously expressing doubts over
their abusive potential. There are now at least three reports on group work with men
who were sexually abused as childrenall describe having to confront this problem.
Singer's (1989) group included four men who acknowledged sexual feelings towards
their own and others' children, but denied ever acting on them. Bruckner and Johnson
(1987) reported their group members, too, were concerned about their potential for
sexual behaviour with children, while Dimock (1988) found a number of individuals
who revealed perpetrating sexual abuse on younger children during adolescence, and,
in one instance, a man who revealed incest with his daughter. It is imperative, as
Dimock stresses, that such issues are not dealt with by inappropriate use of
confidentiality, when children may be at risk within the community. It is essential
to establish compassionate approaches to offending behaviour if the cycle of abuse
and perpetration is to be broken.
It is clear that those who work with perpetrators, particularly adolescent offenders,
think the victim-abuser cycle is relevant (Becker, 1988; Cantwell, 1988; Faller, 1989a;
Freeman-Longo, 1986; Ryan, Lane, Davis & Isaac, 1987; Ryan, 1989). Kaufman
and Zigler (1987) have warned of the impact experimental design has on perceptions
of the strength of associations. They cite a study, of physical abuse and neglect, where
retrospective analysis indicated a 90% rate of intergenerational transmission, while
prospective analysis indicated a rate of only 18%. With this caution in mind a review
of the prevalence of sexual abuse in the histories of sexual offenders/perpetrators is
undertaken.
Researchers who have reported on child/adolescent perpetrator series described
widely divergent prevalence rates in the backgrounds of those they have studied. Jones,
Gruber and Timbers (1981) found none of their 24 offending adolescents gave self-
reports of abuse. Pomeroy, Behar and Stewart (1981) found one (16%) of six
perpetrating boys and adolescents had been sexually abused, although the details of
how they assessed the boys for sexual abuse were not given. They may have been
premature in ascribing a 'constitutional' explanation for the 'precocious and persistent
interest in sex play' which these children exhibited. Indeed, several of the case histories
presented suggest as assessment for sexual abuse would have been warranted. Other
earlier reports show that the question of prior sexual abuse was not even being
considered regarding adolescent perpetrators (Lewis et ai, 1979; Shoor et ai, 1966),
which probably reflects the understanding of the time.
Recent reports concerning boys and adolescents give a different picture. Both Becker
(1988) and Fehrenbach et ai (1986) found rates of 19% prior sexual abuse in a
combined total of 422 adolescent offenders. The most striking results are those of
Smith and Israel (1987), where 52% of their sibling perpetrators sample had previously
been abused, and Johnson (1988) where 49% of her male child perpetrators had been
previously abused. Longo (1982) reported that 47% of the adolescent sex offenders
in his treatment programme had been sexually abused. Finally, Katz (1990) found
61 7o of 31 molesters in a residential treatment programme for molesting adolescents
reported previous molestation of themselves.
The findings for girls and women are even more dramatic. Half (14) of the adolescent
girl perpetrators had been sexually abused in Fehrenbach and Monastersky's (1988)
series and all of Johnson's (1989) sample of 13. Of the 21 abusing mothers in McCarty's
 Sexual abuse of male children and adolescents

(1986) group, 76% experienced sexual abuse and an additional 12% were suspected
of being abused.
The findings with adults complement what is being described with children. Of
106 child molesters 32% reported some form of sexual trauma in their early
development (Groth & Burgess, 1979). The University of Michigan Interdisciplinary
Project on Child Abuse and Neglect found, in those where information was available,
27% of the intrafamilial perpetrating fathers or stepfathers had been abused (Faller,
1989a), while Seghorn et ai (1987) studied the entire population of the Massachusetts
Treatment Centre for Sexually Dangerous Persons and found 57% of the 54 child
molesters had been victims of childhood sexual assaults (rapists had less than half
this prevalence23%). An even greater divergence was found by Pithers, Kashima,
Cumming and Beal (1988), where 56% of 135 paedophiles and only 5% of 64 rapists
had histories of childhood sexual victimization. In the view of Freeman-Longo (1986)
and Friedrich et ai (1986), the probability of perpetrator outcome is increased by
repeated abuse of long duration or abuse by multiple abusers. Russell and Finkelhor
(1984) associated the risk with more severe, more unusual and more disturbing abuse.
In summary, current evidence supports the conclusion that the sexual abuse of
boys in childhood is an important contributory, but not a necessary, factor in the
development of a perpetrator. For girls, although there is less evidence, abuse may
be a necessary perpetrator developmental factor. Any child who is referred because
of concerns about sexually abusive behaviour towards other children should be assessed
for possible abuse of themselves.

Long-Term Effects
Our discussion so far has focused on the initial general responses reported in boys,
as well as those regarded as more specific, such as sexual identity confusion, attempts
to reassert masculinity and recapitulation behaviours. For ease of reference various
hypotheses regarding long-term effects are now listed (see Table 2).
The assessment of long-term effects raises a number of key questions as follows.
(I) Is there a demonstrable association between childhood sexual abuse and later
psychological disorder, which significantly exceeds that of non-abused males? (2) If
there is, has disorder been continuously present or has onset occurred later on in
life? (3) What proportion of sexually abused males have an associated disorder, and
does the proportion for each disorder differ betwen men and women? (4) Does the
pattern of disorder/difficulty seen differ between men and women?
There are now a few studies appearing which permit at least a preliminary evaluation
of these questions. A major problem to date in many of the retrospective
epidemiological studies which include men (e.g. Finkelhor, 1979; Fritz et ai, 1981;
Fromuth & Burkhart, 1989; Stein et ai , 1988) is how effectively they identify subjects
who have been anally abused. From the information available in these studies, few,
if any, questions regarding abuse have covered this possibility, yet it seems reasonable
to assume that anal abuse would be the kind of abuse adult men will be most reluctant
to spontaneously admit. Such omissions will not only contribute to under-reporting,
but may also skew efforts to analyse associated long-term effects, given our belief
222
Hypothesis
1. Initial effects
Boys, like girls, commonly
respond to abuse with
sexualization
2. Longer term effects
Male child/adolescent
perpetrators have a frequent
history of previous sexual
abuse
Adult sex offenders have a
frequent history of previous
sexual abuse
Sexually abused boys later
have greater sexual identity
confusion and an increased
likelihood of a homosexual
preference
3. Sexually abused adolescents/men
Have lower sexual self-esteem
and/or greater sexual
dysfunction
Have an increased tendency
towards compulsive sexuality
Self-report less psychological
harm
B. Watkins and A. Bentovim
Table 2
Supported Unsupported
Friedrich et ai (1988);
Gale et ai (1988);
Y^olko etai (1988);
Mian et ai (1986);
Rogers & Terry (1984);
Sebold (1987);
Tufts' New England Medical
Center (1984);
Yates (1982)
Becker (1988); Jones et ai (1981);
Cantwell (1988); Pomeroy et ai (1981)
Fehrenbach et ai (1986);
Friedrich (1988);
Johnson (1988); Katz (1990);
Rogers & Terry (1984);
Sansonnet-Hayden et ai (1987)
Faller (1989a);
Russell & Finkelhor (1984);
Freeman-Longo (1986);
Croth & Burgess (1979);
Longo (1982); Seghorn et ai (1987)
Bruckner & Johnson (1987); Becker (1988);
Finkelhor (1984c); Fromuth (1989)
Johnson & Shrier (1987);
Justice & Justice (1979);
Krug (1989); Singer (1989)
Finkelhor (1984c); Fritz et at. (1981);
Fromuth & Burkhart (1989) Fromuth (1983);
(premature ejaculation and Stein et ai (1988)
erectile difficulty only);
Johnson & Shrier (1987)
Dimock (1988); Krug (1989) Fromuth & Burkhart (1989)
Baker & Duncan (1985); Johnson & Shrier (1987)
Catanzarite (1980);
Fritz et ai (1981);
Fromuth (1983)
 Sexual abuse of male children and adolescents 2.2.O

Table 1 (continued)

Hypothesis Supported Unsupported

Have a greater prevalence of Briere et al. (1988); Fromuth (1983)
depression compared to non- Dimock (1988); Krug (1989);
abused males Stein et ai (1988); Stiffman (1989);
Swett et ai (1990)

Have increased suicidal feelings Briere et al. (1988);

or behaviour McCormack et ai (1986);
Singer (1989)

Have lower self-esteem than non-Cavaiola & Schiff (1989); Fromuth (1983);
abused males Singer (1989) Stiffman (1989)

Have an increased prevalence of Briere et ai (1988); Fromuth (1983)

anxiety disorders McCormack et ai (1986);
Stein et ai (1988);
Swett et ai (1990)

Have increased relationship Bruckner & Johnson (1987);

difficulties Dimock (1988); Krug (1989);
McCormack et al. (1986);
Singer (1989)

that the worst effects are linked to the severest abuse. Baker and Duncan (1985) are
an exception, in that anal abuse was clearly revealed to them in their one-to-one
interviews, leading to the finding of equal intercourse rates of abuse for males and
females. However, despite equal rates of contact sexual abuse, males reported
themselves as being significantly less damaged by their abusive experiences than did
females. The researchers were puzzled by this finding and hypothesized that boys
might more readily dissociate from the experience on the basis that it was incongruent
with expected adult sex role behaviour. In children, Rogers and Terry (1984) and
others reach the opposite conclusionit is that very aspect, i.e. the homosexual nature
of the act, which they consider leads to the most psychological conflict. How can these
views be reconciled?
Certainly there is consistency in men's self-report of less harm. Besides Baker and
Duncan's (1985) study a number of others describe similar findings, notably Fritz
et ai (1981) and Fromuth and Burkhart (1989). What distinguishes these latter two
studies is the fact that they both describe very atypical excesses of female abusers
in college samples of men. Fromuth and Burkhart (1989) were concerned that their
results might be attributable to an excess of female perpetrators, but did not discuss
differing effects relating to contact/non-contact or frequency of abuse. Lastly, there
are also anecdotal case reports of less harm (Catanzarite, 1980).
The only opposing report (Johnson & Shrier, 1987) notes that, on direct interviewing
of their outpatient medical clinic adolescents, "intense traumatic impact on their lives
at the time of the experience and at the time of reporting several years afterward"
was experienced.
224 B. Watkins and A. Bentovim

Psychiatric disorders
Depression, suicidality, anxiety and substance abuse disorders have all been linked
as outcomes associated with sexual abuse.
Despite the difficulty, recently identified by Surtees and Sashidharan (1986) and
van den Brink et ai (1989), in comparing international studies which use different
diagnostic systems, e.g. the Present State Examination (PSE) or the Diagnostic
Interview Schedule (DIS) (the two systems agreed on only 58% of the depression
and 46% of the anxiety diagnoses), good evidence is accumulating from carefully
selected community samples (Mullen, Romans-Clarkson, Walton & Herbison, 1988;
Stein et ai, 1988) to show depressive and anxiety disorders are significantly more
common current diagnoses in women who were sexually abused in childhood. Later
dysfunction can no longer be dismissed with statements like "research is inconclusive"
(Henderson, 1983.)
In men, the most rigorous information comes from the large-scale Los Angeles
Epidemiologic Catchment Area Study (Stein et ai, 1988). One of the key detailed
questions which was asked related to sexual abuse: "In your lifetime, has anyone
ever tried to pressure or force you to have sexual contact? By sexuad contact I mean
their touching your sexual parts, your touching their sexual parts, or sexucd
intercourse". The study shows that on both the lifetime and 6-month prevalences
of any psychiatric diagnosis, sexually abused men had higher prevalence rates than
women. This brings us to the second interesting finding, namely, that this excess
is entirely accounted for, within the five broad band diagnostic categories (substance
abuse disorders, schizophrenic disorders, affective disorders, anxiety disorders and
antisocial personality disorder) by the greater frequency in men of substance abuse
disorder and, at least on the lifetime prevalence figures, by a greater frequency in
men of antisocial personality disorder. The reverse holds true too, i.e. women had
higher rates of anxiety and depressive disorders than men and these were significandy
more frequent than the non-abused women controls. There were no associations
regarding schizophrenic disorders. Overall, these findings are in keeping with
traditional gender differences regarding psychiatric epidemiology. What is interesting
is that psychosocial stress is thought to play a significant part in these disorders.
Stein et ai 's (1988) evidence suggests sexual abuse may be one of those psychosocial
factors.
In future research it will be very important to match perpetrator gender to outcome
research. This is highlighted by Fromuth and Burkhart's (1989) finding of no increased
depression (as measured by the Beck Depressive InventoryShort Form) in men
predominantly abused by women.
Because of the inherent sample selection difficulties, weaker evidence is emerging
from clinical reports. McCormack et al. (1986) report abused adolescents had more
suicidal feelings than non-abused controls, and Singer's (1989) impression of the men
in his (uncontrolled) group was that suicidal behaviour was relatively common. The
best clinical evidence comes from Briere, Evans, Runtz and Wall (1988) and Swett,
Surrey and Cohen (1990). Briere et ai (1988) looked specifically at the symptomatology
in men who had been sexually abused as boys and who later presented to a crisis
centre. (Thus, by self-definition, they were already individuals with problems.) Their
results showed no gender differences, with the men demonstrating a very similar range
 Sexual abuse of male children and adolescents

of disorders to their abused female counterparts. Both were equally likely to have
made previous suicide attempts and significantly more so than non-abused controls.
Using the Trauma Symptom Checklist (TSC-33), Briere et ai (1988) found both
abused men and women manifested greater symptomatology in all instances
(dissociation, anxiety, depression, anger, sleep disturbance) than their non-abused
controls, with a highly significant main effect of sexual abuse. One gender difference
Briere et ai (1988) did find was that abused men were the most angry group, followed
by abused women and then the control groups.
In the only clinical report of its kind which we could find, Swett et al. (1990), using
a contact definition of sexual abuse, found in a sample {n = 125) drawn from consecutive
new male outpatients that symptom severity was significantly greater in those who
were abused before the age of 18, in contrast to male patients who were not abused.
Abuse (sexual, physical or both) accounted for 15 % of the variance in the SCL-90-R
rating instrument (Derogatis, 1983). Thirteen per cent reported sexual abuse and
half of these had been physically abused as well. With one exception the subscale
scores for the sexually abused or both sexually and physically abused groups were
always higher than the physically abused only (commonest) group. The distribution
of psychiatric diagnoses (DSM-III-R) did not differ between the sexually abused and
physically abused groups.
In summary, the limited available evidence suggests that depressive and anxiety
disorders are more common in sexually abused men, but less so than in abused women.
Further, the severity of symptoms appears greater in sexually abused, in contrast
to non-abused, men, with or without psychiatric disorder.

Substance abuse
As detailed earlier (Stein et ai, 1988), the higher lifetime and 6-month overall
psychiatric disorder prevalence rates, noted in men compared to women, are mainly
accounted for by the frequency of substance abuse disorders.
Uncontrolled clinical reports are unanimous in reporting that substance abuse
problems are associated with sexually abused male subjects (Bruckner & Johnson,
1987; Dimock, 1988; Krug, 1989; Singer, 1989). Two recent papers on adolescents
provide a preliminary insight into how sexual abuse might evolve into substance abuse.
First Cavaiola and Schiff (1989) found, in a residential treatment centre for chemically
dependent adolescents, that sexually abused subjects (male and female) had a
significantly younger age for beginning use of either alcohol or drugs than their control
groups drawn from the same treatment centre and local high schools. Next Singer
et ai (1989) addressed the question of temporal sequence and found 77% of their
adolescent psychiatric inpatients had been sexually abused prior to or concurrently
with their first drink or first drug use. Then they showed that severity of alcohol and
drug misuse, as judged by number of times drunk or high on drugs, was significantly
associated with sexual abuse, and finally they report significant differences in the
pattern of substance abuse. The proportion of sexually abused adolescents regularly
using cocaine and stimulants was greater. Once more, in the absence of a gender
analysis we are left assuming the results apply equally to males and females.
 B. Watkins and A. Bentovim

Sexual functioning
Adverse effects on adult sexual functioning are frequently described in sexually
abused women. Much less is known about men, and the results are confusing. Johnson
and Shrier (1987) reported the most sexual dysfunctions (inhibition of libido, premature
ejaculation, erectile difficulties and failure to ejaculate) in a significantly increased
proportion of abused adolescents. Generally, Fromuth and Burkhart (1989) did not
find such difficulties, with a few exceptions (more premature ejaculation in one group
and erectile difficulties in the other). Pierce (1987) cites three studies where incestuously
abused sons later marry and continue to have sexual problems. Stein et ai (1988)
found a consistent trend where twice as many sexually abused women as sexually
abused men reported fear of sex, lowered libido and less sexual pleasure, on a lifetime
prevalence basis. Their 6-month prevalence figures revealed no abused men describing
fear of sex, lowered libido and less sexual pleasure.
It is worth noting that Stein et al. (1988) only focused on inhibition of sexuality
and did not cover compulsive or disinhibited sexual behaviours, which Dimock (1988)
and Krug (1989) think are important possible consequences. Men are particularly
loathe to admit to feelings of sexual inadequacy or difficulty, which makes
discrimination between 'no' as a genuine answer and 'no' as a reflection of a
psychological denial very difficult.
At a more global level, McCormack et ai (1986) found that, while sexually abused
runaway girls were significantly more likely to have confused feelings about sex than
non-abused girls, there were no such differences in runaway boys. In contrast,
Finkelhor (1984c) developed a "sexual self-esteem" measure and found abused
men had lower sexual self-esteem than abused women and both had lower results
than non-abused controls.
In sum, it is premature to reach any conclusions about the effect sexual abuse has
on later male sexual functioning, although the trend is towards less effect than with
females.
The issue of confused sexual identity has been discussed separately above.
Conceptually, what has most strikingly been omitted from discussion about long-
term effects on male sexuality is the inclusion of perpetrator risk. It is perturbing
to read Rush (1980) saying that boys who identified with the molester suffered no
''loss of masculine esteem" and instead experienced their abuse as "either
inconsequential or positive". Further, as adults Rush expected that they would be
able to dismiss their abuse. We believe perpetrator risk must be included as one of
the possible adverse long-term effects of sexual abuse of boys. So far, no community
study has been able to quantify such an outcome.

Self-esteem
Cavaiola and Schiff (1989) empirically document that low self-esteem is one of the
enduring sequelae to abuse. All subscales of the Tennessee Self-Concept Scale were
scored significantly lower in adolescent runaways than those of non-abused controls.
Stiffman (1989) has not been able to replicate these self-esteem findings using a different
inventory, even though the runaways showed significantly more behaviour problems
(as judged by the Child Behavior Checklist) and depression (as judged by the Beck
 Sexual abuse of male children and adolescents

Depression Inventory). It is difficult to explain such discrepant results, which include

failure to find an association with substance abuse. They may be a reflection of the
sample characteristicsthe adolescents come, by their own assessment, from very
grossly dysfunctional family backgrounds. With regard to lower self-esteem, Fromuth
and Burkhart (1989) obtain no association between such problems and sexually abused
men.

Relationships
The last long-term effect of interest concerns relationships. Uncontrolled clinical
reports with men agree that severe difficulty is experienced in maintaining sustained
and meaningful relationships (Bruckner & Johnson, 1987; Dimock, 1988; Krug, 1989;
Singer, 1989). This is seen as flowing from a mistrust of others, from fearing intimacy,
from making and breaking relationships abruptly, and lastly from recreating abusive
relationships which echo the childhood relationship shortcomings. All of these factors
are likely to spill over into general difficulties with sexual relationships.
It could be expected that difficulties such as these would suggest a diagnosis, in
some, of borderline personality disorder. This question has been raised, but not
answered, in two recent publications. Swett et ai (1990) note an insignificantly
increased rate of borderline personality disorder in a subsample of abused men, while
Ogata ei ai (1990) did not. The numbers are far too small in either study to allow
even a preliminary conclusion to be reached, complicated by the fact that Swett et ai
(1990) did not separate sexually abused from physically abused men in their analysis.
At a younger age, but with controls, McCormack et al. (1986) document in
adolescents trends for sexually abused males to have more difficulty interacting with
friends, to withdraw from friends, to have difficulty with same sex friend relationships,
and difficulty with opposite sex friend relationships. Compared to non-abused controls,
abused adolescents had a significantly greater fear of adult men. There is an obvious
developmental continuity between these findings and the above.
In summary, there is now preliminary evidence available which shows there are
significant adverse long-term associations between sexually abused males and
psychological disorder, particularly when such abuse involves physical contact by other
males. While this is true of both anxiety disorders and depression, it is especially
true of substance disorders. When sexual identity difficulties and perpetrator risk
aspects are added to these problems the cause for concern increases. As yet there
is insufficient information to determine the frequency of these outcomes, but we
anticipate further research will support the gender differences in the pattern of disorder
being described so far.

Identification of Perpetrator Risk in Childhood

Freeman-Longo (1986) has posed two very important questions: (1) "Which
variables in addition to sexual abuse, differentiate outcomes between those victims
of sexual abuse who go on to become sexually abusive and those who do not?" and
(2) "Why do sexual offenders who are not abused sexually or otherwise become
offenders?" It is our intention to concentrate on the first question.
228 B. Watkins and A. Benlovim

Becker (1988) has proposed a broad contextural model, which includes individual,
family and social variables. These variables inevitably interrelate.
(A) IndividualSocial isolation;
Impulse control disorder;
Conduct disorder;
Limited cognitive abilities;
History of physical/sexual abuse.
(B) Family Parent(s) engage in coercive sexual or physical behaviour towards
each other;
Family belief system supportive of coercive sexual behaviours;
Parents have poor interpersonal skills and lack empathy.
(C) Social Society supportive of coercive sexual behaviour;
Society supportive of the sexualization of children;
Peer group behaves in an antisocial behaviour.
As referred to in the Definition section earlier, modefling (Faller, 1989a; Johnson,
1989; Ryan et ai, 1987; Seghorn et ai, 1987; Smith & Israel, 1987) is thought to
play a powerful role in the transmission of sexual values, including abusive ones.
There is some urgency, from a practical point of view, in improving our skills in
the prediction and identification of those children who have become, or are at risk
of becoming, perpetrators. One of the puzzles of child sexual abuse is why so few
girls, in contrast to boys, become abusers following their own abuse. Finkelhor (1986)
has challenged all theorists to explain within their model, the 'male monopoly' on
molestation and the fact that not all victims become victimizers. Continuing on,
Finkelhor proposes a variety of explanations, such as: women are socialized to be
more sexually submissive; boys may have more childhood sexual experiences than
girls; boys may be physiologically aroused more quickly and sexually conditioned
more easily than girls, while girls, through the selective promotion of nurturing roles,
may have more internal inhibitions to overcome.
Clinical opinion is unanimous in considering sexualized behaviour in children,
especially when young, to be one of the most powerful alertors, second only to a direct
disclosure, to sexual abuse (Lusk & Waterman, 1986; Salter, 1988; Vizard & Tranter,
1988). The judgement that the behaviour is indeed 'over-sexualized' or 'inappropriate'
requires a good knowledge of what is regarded as normal sexual behaviour in children
across all ages (Bentovim & Vizard, 1988). Over-sexualized behaviour includes
compulsive masturbation, sexual acting out with animals or toys, a preoccupation
with sexual matters, atypical knowledge of sexual acts, amongst others. Such
behaviours are resistant to sanctions and prohibitions. Sometimes authors use different
terms to describe the same observation, e.g. Yates (1982), who calls the process
'eroticization'. Its relevance lies in the fact that it is thought to be induced by the
abuse and, most importandy, it significantly helps differentiate sexually abused children
from non-abused children. Three studies, using standardized measures, have now
confirmed a relationship exists between inappropriate sexual behaviour and sexual
abuse. In the Tufts (1984) study, which omitted gender analysis, 27% of the abused
4-6-year olds scored significantly above either clinical or general population norms
on a Sexual Behaviour Scale, while 367o of abused 7-12-year olds demonstrated high
levels of sexual disturbance which differentiated them from their general or clinical
 Sexual abuse of male children and adolescents

peers. Friedrich ei ai (1988) found, on the scale measuring sexual problems within
the Child Behavior Checklist (CBCL), 70% ofboysand44% of girls scored at least
one standard deviation above the normal peer population. In a later study, Friedrich
(1988) compared sexually abused boys with conduct disordered boys. On the CBCL
profiles very few differences existed between the conduct disordered and the sexually
abused boys, with the exception that the conduct disordered boys were true to their
diagnosis and significantly more aggressive, while the sexually abused boys were
significantly more sexualized.
The prevalence of sexualization shows considerable across-study variability and,
while it is clear from the reports that the samples include boys, comparison of results
between boys and girls is generally omitted. One exception is Kolko et al.'s (1988)
inpatient sample, where highly significant differences were found between sexually
abused and physically abused children. When predicting abuse status, 49% of the
variance for sexually abused children was explained by the sexual behaviour factor
versus 7% for those who were physically abused. Important gender effects were
foundthe girls scored significantly higher totals for sexual behaviour than the boys.
This is the opposite of Friedrich et ai 's (1988) finding. Other inpatient reports confirm
the relationship between sexual abuse and concerning sexual behaviour (Livingston,
1987; Kohen et ai, 1987).
Community samples are also consistent in finding sexualization. Gcile et ai (1988)
report only two significant symptomatic diflerences between sexually abused, physically
abused and non-abused children aged 7 or less. One was that 41% of the sexually
abused children showed inappropriate sexual behaviour while less than 5% of the
physically or non-abused groups did, i.e. it was powerfully identificatory. Some of
the "marked sexual aggressiveness" described (e.g. coercive fellatio, insertion of objects
into the rectum, and attempted forcible intercourse) seems like child perpetration
by another name. In future it is imperative that studies like this, where boys formed
nearly a quarter of the sample, include analysis by gender. We need to know whether
the rates of sexualization differ for boys and girls and, further, whether the patterns
of such sexualization differ.
The variability in sexualization rates is emphasized by Mian et al. (1986), who
found it manifest in 18% of their young children (aged 6 or less), while Conte and
Schuerman (1988) report only 7% of their sample showed age-inappropriate sexual
behaviour, giving a range in these three studies of 7-41%.
Currently there is intense debate over the merits of separating out a 'sexually abused
child's disorder' (for inclusion within the American Psychiatric Association's Diagnostic
and Statistical Manual) from post-traumatic stress disorder (PTSD) (Corwin, 1988).
The key issues are: should sexualization be regarded as a 're-experiencing'
phenomenon and is victimization part of this sexualization? The findings of Kiser
eiai (1988) and McLeer^/a/. (1988) are that sexualization should indeed be regarded
as 're-experiencing'. However, Finkelhor (1988) points out that not all sexually abused
children develop a post-traumatic stress disorder and that as the notion of PTSD is
broadened, it loses meaning. Terr's (1987) solution has been to propose two types
of disorder: Type I disorders, which follow from a single traumatic event, and Type II
disorders, which result from multiple or long-standing experiences with extreme
distress, such as sexual abuse.
230 B Watkins and A. Bentovim

Wheeler and Berliner (1988) have also contributed to the PTSD debate and argue
that the heterogeneity of sexual abuse effects is best accounted for by classical and
social learning theory. As Wheeler and Berliner note, autonomic arousal, such as
occurs during abuse, may have a direct facilitative effect on the acquisition of sexual
behaviours. In our view there is a risk of oversimplification if'sexual aggressiveness'
or interchild perpetration is conceptualized as just a 're-experiencing' phenomenon.
Irrespective of this diagnostic debate the question still remains whether any of these
relevant theoretical models can account for the driven, compulsive quality observed
regarding the post-abuse sexual behaviour of some children. Such behaviour shows
resistance to change in alternative environments and the ineffectiveness of sanctions
and prohibitions is striking. The problem is well recognized by foster parents, who
are frequently at risk and at a loss over how to cope with such behaviour. The very
young age at which this occurs is both distressing and perturbing. Vivid case histories
are provided by Friedrich (1988) and Yates (1982), involving children of 2, 6 and
8 years of age. It is as if these children have been primed. Is a pragmatic knowledge
of such an effect behind the Rene Guyon Society slogan "Sex by year eight or else
it's too late" (de Young, 1988)? We believe it is and that the acquisition of these
behaviours, before the child has the necessary emotional, cognitive or social capabilities
to regulate their own sexuality, plays a part in the victim-perpetrator cycle to which
Cantwell (1988) has so clearly drawn attention.
A relevant associated question is: "What continuity, if any, exists between post-
sexual abuse sexualization and adult behaviours?" It has long been noted that one
possible outcome for abused girls has been 'promiscuity' (Finkelhor, 1986). With
his sexually abused male patients Krug (1989) found six out of eight described having
multiple concurrent sexual partners. Dimock (1988) goes further and considers sexual
compulsiveness to be one of the common characteristics of abused men. He describes
examples of compulsiveness as a "preoccupation with sexual thoughts, compulsive
masturbation . . . sexual acts with other men at pornographic book stores and
restrooms, and frequent and multiple sex partners". He identified such behaviours
in 11 (44%) out of 25 men. Rather than calling women promiscuous and men
compulsive we think the term 'sexual compulsiveness' should be applied equally to
males and females. These studies provide only weak evidence of any continuity between
child and adult sexual behaviour. They are retrospective, involve small, highly selected
samples and are unable to establish whether in fact childhood sexualization existed.
Follow-up studies are required to answer this question.
One of the theoretically important aspects about the emerging literature on child
perpetrators (Cantwell, 1988; ChasnoHetai, 1986; Dejong, 1989; Friedrich, 1988;
Johnson, 1988, 1989; Smith & Israel, 1987) is the way, by definition, it controls for
the biological factors associated with puberty. Whatever biological factors may be
operating within perpetrating boys these reports indicate that they can only be
prepubertal ones.
A recurrent theme in the literature on sexual offenders is an association between
offending and prior physical abuse (Fehrenbach et ai, 1986; Seghom et ai, 1987),
with the notable exception of Pithers ei ai (1988). Saunders and Awad (1988) identify
a number ofstudies which suggest an overlap amongst adolescent sexual offenders,
juvenile delinquents, boys from abusive or neglectful families and socially isolated
 Sexual abuse of male children and adolescents 231

boys. Kavoussi et ai (1988) found, in a male outpatient sample, that by far the most
common diagnosis was conduct disorder, which applied to nearly half their adolescent
sex offenders. Seghorn ei al. (1987) describe a significant association between sexually
abused child molesters and both prior physical abuse or neglect. Of the child molesters,
18% were diagnosed as antisocial personality disorder. It has long been recognized
that developmentally there is an association between physical abuse, conduct disorder
and later antisocial personality disorder. Fehrenbach et ai (1986) write of the
'panimmaturity' seen in offending adolescents. Recently, Katz (1990) provided
empirical support for these assertions and concluded that not only did adolescent child
molesters show evidence of more global social and psychological maladjustment than
normals, but compared to non-sex offending delinquents they appeared more socially
incompetent.
What these intercorellating behaviours and diagnoses have in common is that they
constitute the core of those behaviours which have been seen as 'externalizing'. As
we have noted earlier, there is some evidence to support the proposition that the sexual
abuse of boys in comparison to girls shows a stronger association with both physical
abuse and the use of force during the sexual abuse.
At the start of this section we stated the question framed by Freeman-Longo (1986)
about which variables might contribute to a perpetrator outcome following sexual
abuse. Johnson (1989) has cogently discussed the way factors might interrelate to
produce sexually abusive behaviour in girls; however, much of what she writes is
just as pertinent to boys. Drawing on her work and that of Becker (1988), we would
like to propose the following model.

Perpetrator risk index following child sexual abuse^

Gender Male (possibly hnked to temperamental factors)

Abuser Male
Close relative
Multiple perpetrators

Type of abuse Repeated

Long duration
Creater severity

Age of child Impact greater with younger child (less than 8)

Effects Anxious sexualization (post own CSA)

Externalizing coping adaptation
(potentiated by concurrent physical abuse)
Sexual identity confusion
Identification with the aggressor

Diagnosis Conduct disorder When present

Post traumatic stress disorder
Attention deficit disorder
Learning difficulty
Panimmaturity
the likelihood of
'e.xternalizing' responses
is increased
continued overleaf
232 B. Watkins and A. Bentovim

Perpetrator risk indexcontinued

Treatment Treatment for own CSA not sought/provided

Treatment for early perpetrating behaviour not sought/provided

Family Intergenerational CSA history

Weak sexual boundaries (seen as seductiveness, extramarital liaison, exposure
to pornography, denial of perturbing sexual behaviour in own children)
Prohibition of sexuality
Coercive beliefs and behaviours regarding sexuality

Social Isolation from peers

Socialization into 'male dominance' culture

presence of each factor is seen as adding to the cumulative risk.

CSA = Childhood sexual abuse.

We wish to stress that we see the key factors as being a combination of sexualization
and externalizing responses. Virtually every factor listed has the potential to augment
either one or both of these processes. These are the very kinds of behaviours referred
to by Becker (1988), Cantwell (1988), Friedrich (1988) and Ryan et ai (1987) in
children who have already become child or adolescent perpetrators. The critical
question is do they have predictive value? We regard them as facilitating the
development of the 'emotional congruence' which Finkelhor (1984a) has postulated
as one of the four preconditions to sexual abuse.
The term 'anxious sexualization' is used because, as Johnson (1989) has so accurately
described in girls, there is a dysphoric aspect associated with the sexualization, which
is devoid of affection or caring towards the other child who is targeted for abuse.
By 'externalizing coping adaptation' we mean a habitual way of coping with
frustration or distress by denying, blaming others and acting out in an impulsive
and angry manner on others or the environment. The link with physical abuse is
via anger. Physical abuse generates anger, which tends to be responded to in
maladaptive or externalizing ways. A homophobic response following sexual abuse
would be an example of an externalizing response.
Sexualization and externalizing can be conceptualized as threshold phenomena,
hence their value in partially explaining why some, but not all, boys later become
perpetrators. Triggering is inherently part of this threshold concept. Thus, in a
particular child sexualization may be evoked by a single forceful sodomization, but
a masturbatory experience may not do so; however, repeated masturbatory experiences
might. Resilience varies between children, hence a particularly resilient child may
not become sexualized even after sodomization, while a less resilient one might
following masturbation alone. Ellis, Piersma and Grayson (1990) present a case history
which cogently illustrates the interplay of various factors suggested in the risk index
above. In an interesting review which covers the prediction of sexual aggression in
men, Hall (1990) includes past sexual victimization as one of the posited predictive
variables.
At present such an index has no validity. Some of the factors are quite specific,
others quite general. Nevertheless, we think it has heuristic value and hope it will
 Sexual abuse of male children and adolescents

provide a preliminary framework for selecting certain boys for treatment along
preventative lines. It potentially should assist the development of relevant research
strategies.
It would be premature and dangerous to use the proposed index in a closed predictive
way. Undoubtedly, it would be regrettable if any tone of inevitability was conveyed
to the caregivers of these children. Instead our intention is to provide a framework
whereby a rational basis can be given for assessing concern.
What this model fails to do is to contribute to an understanding of the developmental
track pursued by those boys who have not been sexually abused, yet who have become
abusers. Some of the more general factors could be equcdly applicable, but it is doubtful
that they are sufficient to explain a perpetrator outcome.

Management and Treatment

We know of no published research studies which systematically evaluate the
treatment of sexually abused boys. By way of contrast, Johnson and Berry (1989)
note that in the U.S.A. there were as many as 470 programmes and services available
to the adolescent sexual offender, and a great deal more is known about their treatment
requirements.
The studies which do refer to the treatment of sexually abused boys do so on a
single case basis (Ellis ei ai, 1990), incidentally (Friedrich, 1988; Nasjleti, 1980),
descriptively (Rogers & Terry, 1984; Schacht, Kerlinsky & Carlson, 1990), or focus
on the principles of therapy (Furniss, 1990; Peake, 1990b). In addition, there are
now several descriptive reports of therapy with men who were previously abused as
children (Bruckner & Johnson, 1987; Singer. 1989). This lack of treatment information
and evaluation is hardly surprising and flows logically from the under-recognition
of the prevalence of the sexual abuse of boys and the significance of its effects.
Despite the lack of reports, nearly all of the above authors share the opinion that
group work is invaluable. Thereafter variability, rather than uniformity, marks
opinion.
The process of recognizing, reporting and diagnosing boys who have been sexu2illy
abused has many similarities to that of girls. Differentially Sebold (1987) makes a
case for certain alertors having greater relevance to boys. While some of these have
apparent face vsilidity (abuse of sister, homophobia, child perpetration), others appear
much less significant or even controversial associations (infantile behaviour, paranoid
behaviour, setting fires). Our own experience is that it is unwise to assume, when
abuse of a girl has been disclosed, that any boys in the family have not been abused.
False allegations have recently been discussed in a number of publications (Benedek
& Schetky, 1987a,b; Bresee, Stearns, Bess & Packer, 1986; de Young, 1986; Everson
& Boat, 1989; Klajner-Diamond, Wehrspann & Steinhauer, 1987; Mantell, 1988;
Wehrspann, Steinhauer & Klajner-Diamond, 1987). The questions raised are whether
boys are any more or less truthful than girls when making allegations, and conversely,
whether they are more or less likely to make false allegations. These questions have
hardly begun to be answered, although in one study (Everson & Boat, 1989) which
surveyed 88 Child Protection Service units involving 1249 cases of reported sexual
234 B. Watkins and A. Bentovim

abuse, only one boy was reported as being amongst the 29 false cases. The meaning
of this finding is unclear. It might mean when boys do present to protection services
they are more readily believed or equally it might mean greater disbelief and pressure
to retract is brought to bear on girls. Both might hold. Perhaps, because of the
homosexual stigma involved, boys are less likely to be coached into making allegations
of sexual abuse in a custody dispute situation.
Concern that diagnostic interviewing will, through a generalization effect, be a
traumatic experience in its own right, if conducted by a male interviewer, has led
to a guiding principle that diagnostic work, with both boys and girls, is best undertaken
by women. How strongly this holds for boys has yet to be established. Certainly when
it comes to group therapy, most reports advocate, whether with boys or men, conjoint
male and female therapists (Bruckner & Johnson, 1987; Furniss, 1990; Schacht f/ ai,
1990; Singer, 1989). The advantages and disadvantages of female only, male only,
or both gender cotherapists have been clearly set out by Peake (1990b). The stresses
of such work make it preferable to work conjointly rather than alone.
While Schacht ei ai (1990) provide the greatest detail about the process of their
group therapy work with boys, the most useful information about the basic principles
of such work has been formulated by Furniss (1990). He suggests the following aims
and goals need to be addressed in therapeutic, as contrasted to protection, groups:
(1) adolescent boys need specific help to open up in the group, especially in the presence
of women; (2) sexually abused adolescent boys need to overcome gender stereotypes
and to allow themselves to ask for help in the group; (3) the group needs to address
fears and tendencies of homosexuality as a result of homosexual abuse; (4) the group
needs to address possible ongoing sexual abuse by the boys themselves and the fears
of becoming abusers later in life; (5) the boys need to be able to talk openly about
issues of tension relief (it is crucial to deal with any sexualization of tension relief);
(6) the boys should be encouraged to talk in the group about their sexual fantasies
in order to evaluate abusive tendencies; (7) the group needs to address the relationship
and attitudes towards sisters, mothers and women in general (the ability to relate
emotionally in a non-sexual way to girls and women is crucial for therapy and for
prevention); (8) the group needs to help each boy to think about finding a non-abusing
father figure to whom they can relate, both to talk about their abuse and as someone
with whom they can identify.
The composition of the group raises some difficult questions. Should the group
be single sex? Giarretto (1981) has put forward the possibility of even adolescent boys
and girls working together, but recent opinion (Furniss, 1990; Peake, 1990b) and
our own experience supports the value of separate gender groups, with the possible
exception of younger children. Pragmatic and organizational factors are likely to play
a considerable part in making these decisions, as they will in determining age spread.
Our experience is that groups with a 2-year age difference work well (4-6, 6-8, etc).
In contrast, Schacht ei al. 's (1990) group included boys aged 10-14 years and Nasjleti's
(1980) 12-17-year olds. Differences in group size are also apparentNasjleti's (1980)
group had nine, Schacht ei al.'s (1990) ranged between three and 11, while Furniss
(1990) thinks the optimal number is five to eight boys. The last two studies consider
the groups can be conducted on either a closed or slow open basis, lasting 1 hour.
and meeting on a weekly basis. Strong views have been expressed against including
 Sexual abuse of male children and adolescents

child/adolescent perpetrators within such groups, unless they themselves have also
been sexually abused (Furniss, 1990; Peake, 1990b). Schacht ei ai (1990) did, however,
run just such a mixed victim and abuser group.
Research is needed to determine whether it is feasible to concurrently meet the
needs of victims and victim-perpetrators within the same group. On the one hand
there is the task of helping with the trauma associated with the victimization experiences
and on the other the task of having the boy take responsibility for any perpetrating
behaviour. Furniss (1990) makes the important point that boys must take responsibility
for abusing others before their own victimization can be addressed; however, taking
such responsibility is an ongoing not a one-off process. Nowhere, in our experience,
is this dilemma more painfully demonstrated than in families where an older victimized
child subsequently abuses a younger sibling. In these parents there is tremendous
confusion over expressing sympathy towards the abused sibling, while at the same
time feeling rage towards the son-perpetrator.
Obviously, open groups are of indeterminant duration, while closed groups are
not. Schacht ei ai (1990) found in their open group that the most difficult management
issue they faced was stopping group members from continuing to be abusive in the
context of the group. Limit setting was essential to the extent that it was necessary,
after some months, to remove one boy from the group. In contrast to girls, where
it has proved possible to meet for up to 20 sessions in a closed group, the Great Ormond
Street child sexual abuse project experience with boys aged 12-14 has been that it
is often not possible to go beyond 12 meetings, without the development of significant
disruption and acting out. In general, the project experience has been that as the
age band of the group decreases it is necessary to decrease the number of sessions.
Boys become extremely anxious when faced with having to talk about sexual matters
and readily react by becoming over-excited. It is likely some fears will be projected
onto the peer group, such as fears of being regarded as effeminate or sissy. It is,
therefore, vital for therapists to establish rules such as: boys will talk one at a time,
nobody should leave the room without the leader's permission, and there should be
no hitting out. It is particularly difficult for boys, whose home and neighbourhood
cultures are ones which have discouraged showing feelings, to fully participate in
groups. Marked anxiety, disruptiveness and emotional inhibition argue for smaller
group size. Studies evaluating optimal group size for boys are needed.
Johnson and Berry (1989) also identify the need for groups to be run in a very
stylized and structured manner. Although this is with child perpetrators (who are
mostly victims too), there are clear overlaps with the principles of victim only groups.
Structure can be provided through various techniques, such as: initial sharing of names
and interests; having a 'news game' which updates the group about recent changes
in each member's circumstances; questionnaires; role plays; watching videos and video
feedbacks; card sorts; the use of personal books in which group members write privately
each week and receive responses from the group leaders; and a ritualized snack at
the beginning and/or end of each meeting. It is unreasonable to expect very young
children to sit or concentrate on any one activity for an hour and a variety of age-
appropriate activities are essential to sustain their interest (Vizard, 1986).
Closed groups lend themselves to the development of relatively fixed programmes,
built around important themes or topics (Bentovim f/a/., 1988; Furniss, 1990; Johnson
 B. Watkins and A. Bentovim

& Berry, 1989; Peake, 1990b), such as defining who is responsible for child sexual
abuse, discovering all the different names used for the sexual parts of bodies,
appropriate body contact in families, how to be assertive, how to cope with sexual
confrontations, specific ways of dealing with flashbacks, sexual arousal to others, coping
with fears, how to say 'no' and how, in practical ways, to seek help.
Furniss (1990) makes the very important point that, while all sexually abused
children need some protection work, not all need therapy to the same extent. This
echoes the opinion of Zeitlin (1987) whereby intervention needs to be matched with
perceived effects.
In summary, preliminary reports suggest that the older the children the greater
the need to separate the groups by gender; further, in comparison to girls, it may
be necessary in group therapy with boys, certainly with older boys, to have smaller
groups which run for fewer sessions. Lastly, the content requires some focus on
homosexual fears, gender stereotyping and sexism, as well as abusing urges and
inclinations.

Other treatment components

Complementing the group work with boys is group work with caregivers,
perpetrating parents and couples, as well as counselling for individuals and families
(Bentovim ei ai, 1988; Ellis et ai, 1990; Giarretto, 1981).
Rogers and Terry (1984) identify three harmful parental reactions, which appear
particularly common in cases involving male victims. These are denial or minimization,
blaming the victim, and unrealistic fears regarding the impact of the event. They
link denial of the impact of abuse to parents harbouring strong feelings of disgust
or revulsion regarding homosexuality or homosexual behaviour. Further, the parents
of the self-identified homosexual child frequently choose to blame the assault on tbe
child's homosexuality rather than on the offender. When the child is of latency (middle)
age marked parental anxieties or fears are commonly expressed regarding future sexual
development and the likelihood of becoming homosexual. Such anxiety can lead to
very distorted perceptions of both normal and routine child behaviour. Parents with
these fears may implicitly or explicitly reinforce aggressive antisocial behaviour on
the part of their sons. Less commonly, the child may internalize the parental
projections, thereby generating a self-fulfilling prophecy. To counter these reactions,
Rogers and Terry (1984) advocate therapy with the parents which focuses on education
regarding abuse dynamics, promoting understanding from the boy's rather than the
parent's perspective and allowing parents to identify their own projections through
exploration and discussion of feelings regarding homosexuality.
With intrafamilial abuse the basic principles of management are the same for boys
and girls. The abuser needs to take responsibility for the abuse, which may lead to
living apart from the family, separation, or imprisonment. The degree of support
as opposed to denial, blaming or scapegoating by the non-abusing parent will play
a major part in determining whether the boy remains within his family or lives
separately, preferably with foster parents or in a residential setting. Even when mothers,
since they are usually the non-offending parent, are supportive, Furniss (1990) notes
 Sexual abuse of male children and adolescents 237

adolescent boys usually find it impossible to turn to them to talk about issues of sexuality
and, especiadly, homosexual abuse.
If living apart from the family is necessary for the boy, then the potentiality or
actuality of abusive behaviour towards other children takes on special importance.
Johnson (1990) has set out extremely useful guidelines for adoptive parents faced
with the responsibility of a sexually acting out or perpetrating child. These include
adequate preparation about the child's history, about the likelihood of other
problems, an ability to talk about sexuaJity, yet to limit sexually acting out behaviour,
privatizing masturbation, reducing sexual stimuli (which may be acceptable for
non-traumatized children), knowing whether the adoptive parent has had an abusive
childhood experience of their own, etc. These guidelines apply equally to foster
parents.
Those children who are in a transition from victim to victimizer may need placement
in a therapeutic community setting, which can contain, whilst still protecting, other
children, and yet continue to work intensively with the boy who is beginning an abusive
pattern.
O'Mahoney (1990) emphasizes the need for residential units tc have written policies
on the limits on sexuality for young people in their care, on the limits of the unit's
responsibility for intervention when abuse is suspected, and means whereby staff can
disclose abuse or victimization by other staff. The place of restraint needs careful
thought, because of its potential abusive connotations.
Future research evaluating the outcomes of abused boys placed in fostering versus
residential settings and the circumstances when one or the other is preferable is much
needed. In the U.K. these outcomes are relatively common. Bentovim ei al. (1987)
report in their follow-up study that over a quarter of those children referred (180
in 120 families) were either fostered (10%) or placed in residential situations (17%).
Only a small percentage (14%) were able to live with both parents, while about a
third of the children continued living with their mother alone. Whether these outcomes
are equally likely for boys and girls is not known. Results such as these show that
rehabilitation of treatment families is a difficult task, although some stardingly different
results, again undifferentiated by gender, have been reported in the U.S.A., e.g.
by Giarretto, Giarretto and Sgroi (1978), where family reunion is claimed for 90%
of families.

Therapy wiih men

It is beyond the scope of this review to cover therapy with sexually abused men.
Diversity of opinion is apparent regarding duration of groups (short vs long), length
of session (1 hour vs several hours), and the place of individual therapy (preceeding
vs concurrent) (Bruckner & Johnson, 1987; Singer, 1989). In addition, a number
of books have recently been published which aim at facilitating general and personal
understanding. They outline the authors' therapeutic experience and include many
individual accounts by men of their own childhood sexual abuse (Grubman-Black,
1990; Hunter, 1990; Lew, 1990; Thomas, 1989).
238 B. Watkins and A. Bcntnvim

Therapy wiih adolescent perpetrators

The work of Johnson (1988, 1989, 1990) and Johnson and Berry (1989) regarding
child perpetrators has already been referred to several times in this paper. There is
much greater awareness of, and experience with, adolescent perpetrators (Becker,
1988; Ryan etai, 1987; Ryan, 1989see also the section on child-child perpetration).
The important question is whether parts of these treatment programmes could
useiully be adapted to become part of an effective preventative strategy for those
sexually abused boys who are identified as being at 'high risk' of future perpetration.
There are some obvious parallel work areas between boys who are victims and those
who are perpetrators of sexual abuse. Examination of adolescent perpetrator
programmes shows that they identify emotioned, cognitive and behavioural sequences
which lead to the kind of responses that have been termed 'externalizing' in this paper.
Rogers and Terry (1984), without directly relating it to prevention, comment, in
their intervention guidelines with abused boys, on the importance of therapy directed
at correcting cognitive misunderstandings, such as 'it's my own fault, I wasn't man
enough to protect myself; 'there must be something about memy looks or voice
which shows I'm gay and that's why I was abused'. Externalizing occurs when the boy
resolves T i l show them I'm a man' and escalates aggressive behaviour. They also
identify a need for reciprocal work with parents to counter parallel misunderstandings
(see above). Such reciprocal work makes sense from a preventative perspective; indeed,
it is probable that most children will be unable to maintain correction of their cognitive
distortions if those same distortions are still believed by other powerful members of
the family, e.g. 'he's bound to become a rapist now'.
The goal of treatment would be to reduce or at least forestall sexualizing and
externalizing responses. The advice set out for adoptive parents by Johnson (1990)
is clearly a step in this direction.
Adolescent perpetrator treatment programmes aim to interrupt dysfunctional cycles
of abusive activity and sexual arousal by heightening awareness and then teaching
avoidance of triggers which evoke feelings of helplessness, lack of control and loss
of trust (Becker, 1988; Kysin etai, 1987; Ryan, 1989). While aversive conditioning
and sexual satiation techniques would not be appropriate strategies with 'at risk of
perpetrating' boys, other more general aspects of their programmes, such as anger
management, social skills training and self-esteem promotion, may well be capable
of adaptation for prevention purposes.
Salter's (1988) practical guide for treating child sex offenders and victims provides
a detailed account of every aspect of the treatment programmes mentioned above,
but needs adaptation for working with adolescent perpetrators (Bentovim & Kinston,
1990).
Summary
Inevitably, in a wide ranging review, there will be some important omissions. The
main difficulties in assessing the available information have been the lack, in so many
studies of analysis along gender lines, the lack of control groups, and, m many
instances too small sample size. Despite these limitations there has, over the past
decade been an upsurge of interest in and awareness of the significance oi the sexual
 Sexual abuse of male children and adolescents

abuse of boys. It permits us to identify a number of important trends and to draw

certain conclusions.
Firstly, the scale of the sexual abuse of boys is much greater than was believed
10 years ago. There is no reason to think this is simply an artifact of definition, or
information gathering, or indeed of an increased willingness to recognize abusive
behaviour between children, even though these will all have an effect. Whilst the
trend is clear, the actual prevalence rate is difficult to determine, with a reported
range of between 3% and 31%. A current 'best guess' suggests contact abuse in the
range of 2-5% in the male population. As each study controls for its own definition
of abuse, the narrowing in the ratio of boys to girls abused can be accepted as quite
reliable, and additional evidence of a delayed recognition effect. Retrospective
community evidence shows 1 boy is abused for every 2-4 girls abused. In contrast,
the highest clinical ratios are for 1 boy to every 4 girls. Those who work with runaways,
male child prostitutes, or child and adolescent psychiatric inpatient units appear
particularly likely to encounter abused boys.
Secondly, a variety of explanations have been advanced to explain the apparent
under-reporting or underdetection of the sexual abuse of boys. Prominent among
them have been the boy's fears of disbelief and of being labelled homosexual. Police
pattems of reporting extrafamilial abuse may mask its extent from protection or health
agencies, which is important because extrafamilial abuse does appear to be more
common in boys, especially older boys, than girls. Although there has been some
dimunition of the cultural denial that girls can be abused, a parallel decrease of denial
regarding boys has lagged behind. This is particularly true of father-son and of the
much less common mother-son abuse. It is plausible that certain 'alertors' are more
relevant for boys. The recent development of aggressive behaviour, homophobic
anxiety, co-abuse of a sibling and abusing behaviour in particular deserve
consideration.
Thirdly, regarding the pattern of abuse, there is strong evidence indicating boys
are more frequently subjected to anal abuse than are girls. However, the clinical
impressions that boys are more severely abused and at a younger age are probably
erroneous and due to only the most seriously abused boys being referred at present.
Compared to girls, there is considerable clinical evidence to suggest concurrent physical
abuse occurs with boys.
Fourthly, clinical reports convincingly demonstrate that the initial effects of abuse
on boys are deleterious and it is no longer sustainable to state otherwise. What is
less clear is what proportion of boys develop adverse effects in response to what kind
and what degree of sexual abuse by which kind of abuser. It is doubtful whether
outcome studies have controlled sufficiently for the compounding effect of concurrent
physical abuse. Indeed, the common sense expectation that the worst outcomes are
associated with increasing severity, frequency and duration of abuse, requires further
substantiation. Responses which are seen as more specific to boys are greater sexual
identity confusion and an inappropriate reassertion of masculinity. Even so, and
contrary to expectations, attempts to reliably measure externalization-internalization
differences (as reflected in the CBCL) between boys and girls have not been very
successful. Both genders tend to show a mixed pattern of response. Insufficient credence
has been placed in the possibility that sexually abused boys may, in the near term.
240 B. Watkins and A. Bentovim

become perpetrators. They undoubtedly do and much more frequently than girls.
The significance of adolescent perpetration has been seriously underestimated.
Fifthly, adverse longer term effects, similar to those in women, are now being
reported in men. So far, the limited evidence available suggests abused men present
less frequently with depressive and anxiety disorders, and more frequently with
substance abuse disorders than do women, despite college and community self-report
surveys of less harm to men than women. Suicidality, lowered self-esteem and increased
relationship difficulties are also being reported in abused men. The initial responses
in boys of sexual identity confusion, inappropriate reassertion of masculinity and
recapitulation of the victimizing experience demonstrate a developmental continuity
with adult outcomes, such as a greater than expected but small proportion of men
having a homosexual preference, an increased prevalence of substance abuse, antisocial
personality disorders and an increased risk of becoming a perpetrator. However, the
evidence, besides that for the perpetrator risk, is weak and prospective studies are
required to show good evidence of such continuities.
Conceptually, the risk of becoming a perpetrator, as an outcome, has not been
included in the assessment of adverse long-term effects. The mounting evidence for
a developmental continuity between child, adolescent and adult perpetration, following
preceding childhood sexual abuse, suggests that an increased risk of perpetrator
outcome should now be included as one of the potential long-term effects. In parallel
with the above statement it needs to be recognized that the development of a perpetrator
may not include an experience of prior personal sexual abuse. Recent evidence with
college men suggests sexual interest in children is commonly present. Whether, or
how, this interest evolves into actual abuse is not known.
Lastly, there is a dearth of information about the effectiveness of differing treatment
modalities or treatment outcomes in sexually abused boys. Clinical opinion and
description favours the use of peer group therapy, usually in closed groups, in
conjunction with individual, family, and parent group work. Developmental immunity,
inhibition about talking and the propensity of boys who 'act out' indicate, especially
with adolescents, the need for separate gender groups which are highly structured
organizationally, limit setting and regard to the content of each session. In therapy
which goes further than sharing, educating and promoting self-protection skills, some
focusing on homosexual fears, compensatory aggression, and fears about becoming
an abuser is valuable.
Should future research continue to support the proposition that childhood sexual
abuse of boys significantly increases the probability of becoming a perpetrator, then
identification of those boys who are significantly at risk would permit the development
of preventative strategies. One possible model for identifying such 'at risk' boys is
proposed within this paper.
We have now reached a point where all future child sexual abuse research, whether
epidemiological, effects or treatment orientated, should include gender analysis.

AcknowledgementsWil\ Watkins would like to express his gratitude to the University of Otago Medical
School, whose granting of study leave made participation in this review possible.
 Sexual abuse of male children and adolescents 241

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