PREDICTORS OF HELP-SEEKING BEHAVIORS OF SEXUALLY VICTIMIZED MALES IN THE UNITED STATES: A SECONDARY DATA ANALYSIS UTILIZING THE NATIONAL INTIMATE PARTNER AND SEXUAL VIOLENCE SURVEY By Cristy Elizabeth Cummings A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Social Work—Doctor of Philosophy 2018 PREDICTORS OF HELP-SEEKING BEHAVIORS OF SEXUALLY VICTIMIZED MALES INT THE UNITED STATES: A SECONDARY DATA ANALYSIS UTILIZING THE NATIONAL INTIMATE PARTNER AND SEXUAL VIOLENCE SURVEY ABSTRACT By Cristy Elizabeth Cummings This study explores three levels of help-seeking behaviors in male victims of sexual violence through analysis of secondary data from the National Intimate Partner and Sexual Violence Survey. The first manuscript reports prevalence of help-seeking among male victims of sexual violence and the relationships of their help-seeking patterns with sociodemographic characteristics. Over sixty percent of male victims of sexual assault in the sample sought some form of help, only about fifteen percent of the whole sample sought any sort of mental health services to cope with their victimization. Seeking any help was more likely if the victim was white, more highly educated, and had, at some point in his life, had sex with men. Men who had sex with men were also more likely to seek help from at least one formal source. The second manuscript focuses on perpetrator characteristics (e.g. gender and race of perpetrator, age difference between perpetrator and victim, and relationship between perpetrator and victim) and victims’ help-seeking behaviors using multilevel logistic regression. Being victimized by another male or an intimate partner was related to seeking help. The third manuscript seeks associations between incident characteristics and outcomes and victims’ help-seeking behaviors using multilevel logistic regression. Those who were injured, had to miss work or school, or felt fear were more likely to seek some form of help. Findings are contextualized in theories of masculinity and implications are discussed for social work. Keywords: men, masculinity, sexual assault, rape, help-seeking, service utilization Copyright by CRISTY ELIZABETH CUMMINGS 2018 This dissertation is dedicated to all people who have experienced sexual victimization, including the 1,577 men whose courage in sharing their experiences in a national survey led to the production of the rich and complicated dataset used for analysis in this dissertation. iv ACKNOWLEDGEMENTS This dissertation would not have been possible without my committee chair, Dr. Sheryl Kubiak. From our first conversation welcoming me to MSU in 2013, you have enthusiastically championed my success and growth. Thank you for the amazing opportunities in research, funding, writing, and travel. Your warm encouragement of my growth as an independent researcher and leader, as well as your generous attention to my work has made me a better writer, thinker, and member of the academic community. Thank you for sharing your inspiring commitment to making the world a more just place through research, advocacy, and education. It has been an honor to be on this journey with your guidance and support. Thank you so much. I am also filled with gratitude toward my committee members for the ways that they have contributed to my endeavors. In addition to the opportunity to work on her research, the support, mentorship, and kindness that Dr. Anne Hughes has shown me has been enormous. Thank you so much for your belief in me and your encouragement in the moments when I struggle with belief in myself. Dr. Deb Bybee has patiently and kindly supported my growth as a researcher and so graciously shared her brilliance with me. I am so thankful to have had the opportunity to learn from you. Dr. Tina Timm has been a supportive and enthusiastic presence since my earliest days in the doctoral program. Thank you for your unwavering support for me and your flexibility and generosity throughout this process. I am so grateful to my chair and committee that each of you were willing to share your expertise with me, as well as for the time we have spent together. Many of the faculty of the MSU School of Social Work have made me feel that they are personally invested in my success, and I would especially like to thank Dr. Angie Kennedy, Dr. John Mooradian, Dr. Amanda Woodward (and the writing group), Dr. Rena Harold, Dr. Joanne Riebschleger, Leisa Fuller (and Devin), and the Community Programs faculty and staff. The v SSW staff has helped me navigate this process, especially Nancy Gray, Amanda Cartter, and Nancy Perkins. I am very grateful to Dr. Debrenna Agbényiga and Dr. Deborah Johnson for their research mentorship. I am deeply grateful to Megan Spedoske, Josselyn Miller, Tricia Sanchez, Jerrad Billington, and Linda Lawrence at the MSU Veterinary Medical Center for the myriad of ways that they have made a positive impact upon my time at the MSU. This work is built on a foundation of support that extends beyond MSU. I am grateful to Dr. April Lidinsky for being the first person to encourage me to go to graduate school, for being an academic lifeline when I needed it the most, and for cheering me on for the last fifteen years. Dr. Jane Barden, thank you for being an advocate and sounding board in times of need, and a role model, mentor, and friend always. If I could choose, I would always put my office next to yours. I am so thankful to Dr. Beth Wahler for her advice, mentorship, writing opportunities, encouragement, and her friendship (and SSWR comradery). Dr. Marilynne Ramsey and Cindy Lemp, thank you for my first experiences in social work research and practice. Dr. Gina Fedock and Katie Darcy, thank you for being dear friends and colleagues. My family and friends have been a constant source of strength, support, and inspiration, especially during the dissertation process. My dad always encouraged me and I deeply wish he was here to see this. I am grateful for my extended family (Uncle T, Amy, Shannon, Ben, Colleen, and Susan), my step-families (Ed and the Donnellys) (Sherry, Danielle, John, Doug, Jason, Liz, Ace, Lou, and Sylvia), and my family in-law (John, Kathy, and the Robbins family). Edita Milanović, thank you for being my first MSU friend and a constant support. Dasha Shamrova, thank you for being my dissertation writing companion, first reader, and dear friend. Debbie Richmond, I feel so lucky to have met you during the relatively short time that we were vi both at MSU and am grateful for your continued friendship and encouragement. Lynn and Tom Bartley, thank you for your kind support, friendship, and game nights. Jessi Sweazy and Kristen Prock, I am so happy to have spent these last few years together, both the good times (Mario Kart, board games, and Friday nights) and the hard times, too. So grateful for the gift of extra time in the same city with the two of you. Miss you already. My dear friend, Cathy Meyer, has been supportive of my all endeavors for over twenty years, including this dissertation. Thank you and Marc (and James and Lucas) for being great friends and enthusiastic encouragers. I am glad our psychic link has maintained its strength. C.J. Major, thank you for celebrating my successes, checking in on me when you knew I was struggling, and for being so generous with your art. Joanna Basile, thank you for your generosity with your time, your brain, your incredible attention to detail, and your friendship. I know that this document is better due to your attention to it. Carey Major, thank you for your unwavering faith in me, your dedication to our friendship while I was writing, for being there at the high points and the low points, and for helping me talk through anything and everything. You are irreplaceable. Can’t wait to be 1,070 miles nearer, I think it will be more fun than we can reasonably expect. To my nieces, thank you for always being ready to cheer me on, for believing in me, and for all of your help along the way. Alix, thank you for being my realtor, for keeping me organized, and for always having time for me no matter how busy your life gets. Jesi, thank you for your cheerfulness (even when you were pretending), for always helping, for being my personality buddy, and being brave over bridges. Sam, thank you for the late nights of job search prep, for vacuuming my floors, for always singing along in the car, and for just doing whatever needed to be done (except picking the restaurant) during our mutual time at MSU. Especially, vii thank you for all of your work, both along the way and at the last minute, that helped make this dissertation come together. To my brother-in-law, Chad, thank you for always making me laugh, for making the new apartment feel like home in no time at all, for loaning me your children and thus causing more work for yourself, and for always making me feel welcome in your home, no matter how much of your dining room table was covered in my writing materials. Mandy, thank you for being the most amazing, motivational, problem-solving sister-in-law and friend that anyone could ask for. Thank you for helping me focus on what is important and helping me see the big picture. I am grateful every day for the Robbins family (and Gus). My Mom has always been my greatest ally, has believed that I can do anything I set my mind to, and has filled my life with unconditional love. Ever since I was a little girl, she has told me that I could be anything I wanted to be and she has supported every decision that led me to this degree and dissertation. I couldn’t ask for a better Mom or friend. Thank you for everything you do for me. I can’t wait to be 15 hours closer to you. I love you so much. I am truly a lucky daughter. xoxo Autumn, thank you for being my most devoted companion, while Simon, Funky, and Oates (thank you, Sheryl) were excellent entertainment and terrible typists. Finally, A.J., thank you for your faith in me, for uprooting your life to go on this adventure, for supporting me, and for loving me at my worst. I eagerly await the next chapter in our journey together. You are my soup snake. I am overwhelmed with gratitude to all of you. Thank you. viii TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES CHAPTER ONE: OVERVIEW OF DISSERTATION TOPIC AND RESEARCH Introduction Purpose of Study Background and Overview of Male Sexual Victimization Defining Sexual Violence Male Victims of Sexual Violence Impacts of Sexual Violence on Male Victims Overview of Help-Seeking Behaviors in the Context of Sexual Victimization Informal sources of help Formal sources of help The Importance of Seeking Help After Sexual Victimization Benefits of seeking help from formal sources Police Medical Mental health services Negative outcomes of seeking help Men and Help-Seeking Behaviors Male victims of sexual violence and help-seeking Theoretical Approaches Tsui, Cheung, & Leung’s (2012) Conceptual Framework for Analyzing Help- Seeking Behaviors Among Male Victims in Heterosexual Intimate Partner Violence (IPV) Masculinity Male rape myths Gender Role Conflict Organization of Dissertation Chapter Two, Manuscript 1 Chapter Three, Manuscript 2 Chapter Four, Manuscript 3 Chapter Five, Discussion, Implications, and Conclusion CHAPTER TWO: INDIVIDUAL-LEVEL CORRELATES OF SEXUALLY VICTIMIZED MALES’ HELP-SEEKING BEHAVIOR Abstract Introduction Background Intersectionality Literature Review Race of Victim ix xv xvii 1 1 2 4 6 8 9 11 12 12 13 13 13 14 14 14 15 15 17 17 19 20 21 21 21 22 22 22 23 23 24 24 26 27 27 Sexual Orientation of Victim Education Level of Victim Income Current Study Research Questions Methods Research Design Data Management Sample Dependent Variables Help-seeking Formal help-seeking Mental health help-seeking Independent Variables Race of victim Sexual orientation/Chosen sexual partners of victim Education level of victim Yearly income Control Variables Data access and storage Number of sexual victimization perpetrators Sexual victimization severity Sub-samples Defining sexual violence for sample selection 28 29 29 30 30 31 31 32 32 33 34 35 35 35 35 36 36 36 36 37 37 37 37 38 38 39 39 Bivariate relationships between help-seeking and explanatory variables 41 41 41 42 42 42 43 43 44 45 47 47 48 49 50 52 54 54 54 Mental health services sought Help-seeking Control variables Formal help-seeking Control variables Control variables Research Question 2: Predictors of Help-Seeking Behavior Research Question 3: Predictors of Seeking Formal Support Research Question 4: Predictors of Seeking Mental Health Services Research Question 1: Prevalence of Help-Seeking Analysis Results Discussion Prevalence Race Education and Income Sexual Orientation Limitations Implications Implications for Clinical Practice Implications for Macro Practice x Implications for Research Conclusion 55 56 Current Study Methods Research Questions Research Design Data Management Abstract Introduction Literature Review Gender of Perpetrator Race of Perpetrator in Relation to the Race of the Victim Age Difference Between Perpetrator and Victim Relationship Between Perpetrator and Victim Stranger versus known individual as perpetrator CHAPTER THREE: PERPETRATOR-LEVEL CORRELATES OF SEXUALLY VICTIMIZED MALES’ HELP-SEEKING BEHAVIOR 57 57 58 59 59 60 61 62 62 64 64 65 65 65 66 67 68 69 69 70 70 70 72 72 73 73 73 73 74 75 75 Bivariate analysis of explanatory variables and help-seeking behavior 75 Multivariate analysis 76 77 Gender of perpetrator Race of perpetrator in relation to race of victim Age difference between perpetrator and victim Relationship with perpetrator Dependent Variables Help-seeking Formal help-seeking Mental health help-seeking Sub-samples Defining sexual violence for sample selection Perpetrator-level cases Research Question 2: Predictors of Seeking Formal Support Research Question 1: Predictors of Seeking Help Analysis Results Data access and storage Sample Independent Variables Research Question 3: Predictors of Seeking Mental Health Services Bivariate analyses of explanatory variables and formal help-seeking behavior Multivariate analysis 77 77 78 Bivariate analyses of explanatory variables and help-seeking behavior 78 Multivariate analysis 79 80 80 Ad Hoc Analyses Discussion xi Gender of Perpetrator Race of Perpetrator in Relation to Race of Victim Age Difference between Victim and Perpetrator Relationship Between Victim and Perpetrator Limitations Implications Implications for Clinical Practice Implications for Macro Practice Implications for Policy Implications for Future Research Conclusion 81 84 85 85 87 88 88 88 88 89 90 CHAPTER FOUR: INCIDENT-LEVEL CORRELATES OF SEXUALLY VICTIMIZED MALES’ HELP-SEEKING BEHAVIOR Results xii Current Study Methods Research Questions Research Design Data Management Sample Abstract Introduction Literature Review Physical Injury Caused by Perpetrator Missed Work or School Fear Type of Assault Child Victims Data access and storage 91 91 92 93 93 94 94 95 96 98 99 99 99 100 100 101 103 104 104 104 104 105 105 106 107 107 107 108 108 108 110 110 Bivariate analysis of explanatory variables and help-seeking behavior 110 Sub-samples Defining sexual violence for sample selection Incident-level cases Independent Variables Injury Missed work or school Fear of concern for safety Type of victimization Child victim Dependent Variables Help-seeking Formal help-seeking Mental health help-seeking Research Question 1: Predictors of Seeking Help Analysis Multivariate analysis Research Question 2: Predictors of Seeking Formal Support 111 112 Research Question 3: Predictors of Seeking Mental Health Services Bivariate analyses of explanatory variables and formal help-seeking behavior Multivariate analysis 112 113 114 Bivariate analyses of explanatory variables and help-seeking behavior 114 Multivariate analysis 114 115 115 116 117 118 119 120 120 122 122 122 123 123 124 Implications for Clinical Practice Implications for Macro Practice Implications for Policy Implications for Future Research Injury Missed Work or School Fear Rape Child Victim Ad Hoc Analyses Discussion Limitations Implications Conclusion CHAPTER FIVE: DISCUSSION, IMPLICATIONS, AND CONCLUSION Overview of Major Findings Themes Across Manuscripts Hegemonic Masculinity, Rape Myths, and Gender Role Conflict Media representation, masculinity, and male sexual victimization Multiple masculinities Limitations of the Study Implications Implications for Theory Implications for Social Work Clinical Practice Implications for Social Work Macro Practice Implications for Social Work Policy Implications for Future Research Conclusion APPENDICES 126 129 130 131 133 133 134 135 135 136 138 139 140 141 142 APPENDIX A Figure 7. A Conceptual Framework for Analyzing Help-seeking Behaviors among Male Victims in Heterosexual Intimate Partner Violence (Tsui, Cheung, & Leung, 2012) APPENDIX B Figure 8. Adapted Model of Tsui et al.’s (2012) Conceptual Framework for Analyzing Help-seeking Behaviors among Male Victims in Heterosexual Intimate Partner Violence (IPV) 143 145 xiii APPENDIX C Table 18. Summary of Demographic Information of Male Victims of Sexual Violence APPENDIX D Table 19. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Help APPENDIX E Table 20. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Formal Help APPENDIX F Table 21. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Mental Health Services APPENDIX G Table 22. NISVS Operationalization of Sexual Violence REFERENCES 147 150 153 156 159 161 xiv LIST OF TABLES 40 40 44 45 46 71 71 71 72 73 77 78 Table 1. Summary of Help-Seeking Variable Frequencies Table 2. Victims’ Sources of Help Sought (non-mutually exclusive) Table 3. Logistic Regression Results Using General Help-Seeking as Dependent Variable Table 4. Logistic Regression Results Using Formal Help Sought as Dependent Variable Table 5. Logistic Regression Results Using General Mental Health Help-Seeking as Dependent Variable Table 6. Perpetrators’ Race as Reported by the Victim Table 7. Victim’s Race as Reported by the Victim Table 8. Perpetrator and Victim Race Combinations Table 9. Large Age Difference between Perpetrator and Victim is 24 Years Old or Less Table 10. Perpetrators’ Relationship with Victim, as Reported by the Victim Table 11. Multilevel Logistic Regression Results Using General Help-seeking as Dependent Variable Table 12. Multilevel Logistic Regression Results Using Formal Help-seeking as Dependent Variable Table 13. Multilevel Logistic Regression Results Using Seeking Mental Health Services as Dependent Variable Table 14. Type of Perpetration Reported by the Victim Table 15. Multilevel Logistic Regression Results Using Binary Help-seeking as Dependent Variable Table 16. Multilevel Logistic Regression Results Using Formal Help-seeking as Dependent Variable Table 17. Multilevel Logistic Regression Results Using Seeking Mental Health Services as Dependent Variable Table 18. Summary of Demographic Information of Male Victims of Sexual Violence 80 106 112 113 115 148 xv Table 19. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Help Table 20. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Formal Help Table 21. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Mental Health Services Table 22. NISVS Operationalization of Sexual Violence 151 154 157 160 xvi LIST OF FIGURES Figure 1. Diagram of sample selection for individual-level analyses (Ch. 2/Manuscript 1) Figure 2. Diagram of individual-level analyses (Chapter Two/Manuscript 1) Figure 3. Diagram of sample selection for perpetrator-level analyses (Ch. 3/Manuscript 2) Figure 4. Diagram of perpetrator-level analyses (Chapter Three/Manuscript 2) Figure 5. Diagram of sample selection for incident-level analyses (Ch. 4/Manuscript 3) Figure 6. Diagram of incident-level analyses (Chapter Four/Manuscript 3) Figure 7. A Conceptual Framework for Analyzing Help-seeking Behaviors among Male Victims 144 in Heterosexual Intimate Partner Violence (Tsui, Cheung, & Leung, 2012) Figure 8. Adapted Model of Tsui et al.’s (2012) Conceptual Framework for Analyzing Help- seeking Behaviors among Male Victims in Heterosexual Intimate Partner Violence (IPV) 102 110 67 75 33 39 146 xvii CHAPTER ONE: OVERVIEW OF DISSERTATION TOPIC AND RESEARCH Introduction Male sexual victimization is an understudied and under-reported issue (Choudhary, Gunzler, Tu, & Bossarte, 2012; Davies, 2002; McLean, 2013; Mezey & King, 2000; Stemple & Meyer, 2014). The National Violence Against Women Survey (NVAW) (Tjaden & Thoennes, 2006) reports that in the United States, 3.0% of men have experienced rape or attempted rape in their lifetime. A lower lifetime prevalence of rape or attempted rape among men (1.5%) is present in the 2010 to 2012 National Intimate Partner and Sexual Violence Surveys (NISVS) (Smith, Chen, Basile, Gilbert, Merrick, Patel, Walling & Jain, 2017). When other forms of sexual violence are included in estimates the number of men affected by sexual victimization, the NISVS survey, when using weighted estimates, found that 17.1% of men, or a little under 20 million men, have experienced some form of sexual victimization over the course of their lifetimes (Smith et al., 2017). Estimates of prevalence are often influenced by the ways that researchers operationalize sexual violence. Additionally, definitions of sexual violence have implications for policy, practice, and research of particular importance to male victims. In particular, not assigning gender to perpetrator and victim roles in policy, creating non-gendered crime codes (FBI, 2014), and balancing definitions of sexual violence between broad and narrow in research may have an impact on men’s access to sexual assault services and the criminal justice system. Though there were historical references to male rape as early as the Roman times, throughout history, sexual assault has been primarily a female concern in the eyes of many. Major advocacy and reform by second-wave feminists (Brownmiller, 1975) brought rape into the public eye, but also may have further cemented sexual victimization as an experience within the 1 purview of women. One of the earliest recognitions of male sexual victimization in modern times was within a prison population (Davis, 1968). Though 50 years have passed since this ground- breaking work, males are still just beginning to be widely recognized as victims instead of solely as perpetrators. Male victims’ physical health, psychological well-being, and sexual functioning may be severely impacted by sexual victimization. Despite these consequences, males are unlikely to engage in help-seeking behavior, such as reporting to the police or seeking sexual assault services (Allen, 2007; Davies, 2002; James & Lee, 2014, Mezey & King, 1989; Mezey & King, 2000; Mitchell, Hirschman, Nagayama & Hall, 1999; Stemple & Meyer, 2014; Walker, Archer & Davies, 2005). Reasons for this include barriers to help-seeking, such as individual reactions and perceptions, concern about service access, and societal perceptions of masculinity and rape myths (Donnelly & Kenyon, 1996; Himmelstein, & Sanchez, 2014; DuMont, MacDonald, White, & Turner, 2013; Monk-Turner & Light, 2010). However, specific characteristics of the victimization experience, perpetrator, and victim are also related to whether help or support is sought. Moreover, these characteristics may shape the victim’s perception of the event and, thus, contribute to the decision to seek help and/or support (Kennedy, Adams, Bybee, Campbell, Kubiak, & Sullivan, 2012; McCart, Smith & Sawyer, 2010; Tsui, Cheung and Leung, 2012) This work seeks to understand the prevalence of help-seeking among male victims of sexual victimization and to explore the relationships between individual-level, perpetrator-level, and incident-level variables and the decision to seek help. Purpose of Study This study focuses on the help-seeking behaviors of males who have experienced sexual violence. While there have been many studies that explore female victims of sexual violence and 2 predictors of help-seeking, more research is needed to understand male victims’ patterns of help- seeking (Donne, DeLuca, Pleskach, Bromson, Mosley, Perez, & Frye, 2017) This study uses data from the NISVS: General Population Survey (2010) to develop an understanding of the prevalence of help-seeking among male victims, as well as what characteristics promote help- seeking among these individuals. Conversely, through these findings, those characteristics and contexts that may indicate that the male victim is less likely to disclose or help-seek will be better understood. These characteristics and contexts will be explored on three levels: sociodemographic characteristics (e.g., race, sexual orientation, income, education, and lifetime number of sexual perpetrators), perpetrator characteristics (e.g., gender and race of perpetrator, age difference between perpetrator and victim, and relationship between perpetrator and victim), and sexual victimization incident-level outcomes and characteristics (e.g., type of assault, age of victim, injury from assault, negative psychological outcomes from victimization, and impact on work/school). The results of this study have numerous potential implications for the field of social work as well as for providers of sexual assault services. Knowing the prevalence of help-seeking behaviors will emphasize the importance of assessing for trauma in all clients among clinical social workers. Through determining which characteristics are more likely to accompany help- seeking, social workers and other providers will be better able to both create outreach programs and campaigns that target individuals and groups less likely to seek their services, as well as craft appropriate interventions. In the case that some forms of formal services are more sought after than others, this information may provide evidence to support networks and referral streams, linking formal supports. By exploring the relationships between help-seeking behaviors and these characteristics and contexts, utilizing a national dataset, this will provide knowledge that 3 will inform future streams of research related to male victims of sexual violence. Finally, this work seeks to provide information that leads toward the promotion of help-seeking and disclosure among this group of males, leading to increased support and services and decreased negative outcomes related to sexual victimization. Background and Overview of Male Sexual Victimization There are indicators that rape, and other forms of sexual violence have been ongoing problems throughout recorded history. However, these issues are primarily addressed in the scope of women as victims, despite recorded occurrences of the sexual victimization of males (Davis, 1968; Jones, 2000). A notable exception to this is the attention paid to male rape in Roman law, which both recognized that men could be raped and cautioned against the stigma associated with victimization in some situations, especially those involving war or robbery (Richlin, A., 1993). Richlin (1993) makes the distinction that this definition of rape extended to men who were not slaves, prostitutes, or seen as “passive,” a male who “likes to be penetrated” (p. 530). The pioneers that fought for recognition of the seriousness of the crime of sexual assault; for the establishment of rape crisis centers; and for the sensitive informed treatment of victims by police, medical professionals, and other service providers, were second-wave feminists in the 1970s who were successful in bringing attention to the plight of women as victims of sexual violence (Kerber, De Hart, Dayton, & Wu, 2015). One notable inclusion of male sexual victimization in a narrative around female sexual victimization during this time period occurs in a manuscript on rape myths. Schwendinger and Schwendinger (1974) note that “although it is not the subject of this article, we should add that rape is also a fear and a reality for certain men” (p. 18). 4 By drawing attention to the act of rape as a crime, as well as redefining rape as more than “stranger rape,” the feminist activists of the 1970s and 1980s in the United States shed light on rape culture, gender power differentials, and the need for societal and legal change (Brownmiller, 1975; Kerber et al., 2000; Estrich, 1987; Tobias, 1997). Through the second-wave of the feminist movement, policy and culture in the United States began to recognize sexual victimization as a legitimate concern. However, these issues are most often dichotomized by thinking of women as victims and men as perpetrators (Schiff, 1973; Stemple & Meyer, 2014). Most of the changes that have occurred to create laws that protect victims and services that help victims seem to be aimed toward female or child victims; even when male victims are included, they may be unmentioned (i.e., federal funding for sexual assault services). This feminization of the experience of sexual victimization may further stigmatize this experience for male victims (Mezey & King, 2000). Though men in prison are not included in the sample of this study, it is important to note that the first group of modern men to be identified as male victims of sexual violence were incarcerated individuals (Davis, 1968). Policy shifts have occurred to protect incarcerated individuals from rape and sexual assault in prison, including the determination that not protecting prisoners from sexual violence from other inmates is cruel and unusual (Farmer v. Brennan, 51 U.S. 825 (1994), the publication of a report on human rights violations associated with the rape of incarcerated males (Human Rights Watch, 2001), and the passage of the creation of the Prison Rape Elimination Act (PREA) (2003) (National Prison Rape Elimination Commission Report, 2009). While there is research dedicated to male victims outside of prison, with some of the earliest academic articles appearing in the early 1980s (Anderson, 1982; Sarrel & Masters, 1982; Schiff, 1980), and a report in the Los Angeles Epidemiologic Catchment Area Project that 7.2% 5 of men reported experiencing adult sexual assault (ASA) in their lifetime (Sorenson, Stein, Siegel, Golding, & Burnam, 1987), the simple fact that men may also be victims of sexual assault is still newsworthy (Grinberg, 2016; Nelson, 2018; Zakaim, 2016). Defining Sexual Violence When considering how to refer to sexual violence and what that term should mean, there are a wide range of possibilities to examine. Some terms often-used in studies include sexual assault, sexual violence, and sexual victimization. Others are specific to a study, author, or policy, including phrases such as criminal sexual conduct (State of Michigan, 2017), adulthood sexual violence victimization (Anderson, Howard, dean, Moren & Khalifeh, 2016), nonconsensual sexual acts (Wolff, Blitz, Shi, Bachman & Siegel, 2006), non-volitional sex (Coxell & King, 2010), and sexual violence victimization (Smith et al., 2017). In this manuscript, sexual assault, sexual victimization, and sexual violence are used interchangeably by the author to describe general experiences of nonconsensual sex as described in the literature, including rape and coercive sex. Specific terms (e.g., rape, coercion, military sexual trauma) are used to reflect a specific finding or body of work. The terms men and male are used interchangeably. What constitutes sexual violence or sexual assault in the existing body of literature consists of a wide range of actions that vary in severity and specificity. Some studies include acts of perpetration that are less severe than rape or penetration, though still sexual, unwelcome, and traumatizing—such as indecent exposure (Anderson et al., 2016; Centers for Disease Control and Prevention [CDC], 2012; Khalifeh et al., 2014), coercive sex (CDC, 2012), and/or feeling pressured (Larimer, Lydum, Anderson & Turner, 1999)—or quite broad definitions such as “anything sexual without your consent” (Fischer, 1992). Another study is quite specific, asking the survey respondent if anyone placed a body part inside of them (Sedlak, McPherson & 6 Basena, 2013). Several studies frame sexual violence in a way that includes nonconsensual oral, vaginal, and anal sex (force, threats of violence, coercion, or incapacitation with drugs and alcohol) and nonconsensual sexual touching (Cantor, Fisher, Chibnall, Townsend & Lee, 2015a, 2015b; CDC, 2012; Ford & Solo-Marquez, 2016; Meade, Kershaw, Hansen & Sikkema, 2009). For the sake of this manuscript, the terms sexual victimization and sexual violence include all acts defined as sexual violence within the National Intimate Partner and Sexual Violence Survey (CDC, 2010), including nonconsensual exposure, kissing, groping, harassment, forcible rape, attempted rape, being made to penetrate, drug- and alcohol-facilitated rape, attempted rape, and being made to penetrate, and coercive sex (Black, Basile, Breiding, Smith, Walters, Merrick, Chen & Stevens, 2011; Breiding, 2014). Severe victimization is operationalized as forcible or alcohol/drug-facilitated rape or being made to penetrate. There are additional challenges around what time frame is appropriate to measure, when seeking to estimate prevalence of male sexual victimization. National data sets often measure as several points, such as lifetime, in the last three years, and within the last twelve months, widely including victims’ retrospective accounts regardless of age of the victim or setting of the victim’s location (Breiding, 2015; Smith et al., 2017; Tjaden & Thoennes, 2006). However, non-federally initiated studies may report on a particular sub-section of the population, such as those victimized as adults (Elliott, Mok, & Briere, 2004), those victimized as children (Easton, Saltzman &Willis, 2013), lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) victims (Ford & Soto-Marquez, 2016) those victimized during college (Ford & Soto-Marquez, 2016; Forsman, 2017), while in prison (Wolff, Shi, Blitz, & Siegel, 2007), or in the military (Turchik, Rafie, Rosen & Kimerling, 2014). These more focused studies are certainly important contributions to the literature but may be less effective when attempting to situate their 7 prevalence findings within studies that measure sexual victimization to estimate lifetime prevalence. Despite the use of the terms victim and survivor interchangeably or in tandem in both popular culture and academic literature (e.g., Gotovac & Towson, 2015; Guerette & Caron, 2007), for the sake of this manuscript, the term victim will be used to describe men who experience sexual violence. The reason for this is twofold. First, there is an implication that one moves from victim to survivor through healing work on the part of the victim (Bolger, 2014; Waddingham, 2010). As this writer seeks to demonstrate, a number of factors prevent males who have experienced sexual violence from seeking help to heal or, perhaps, even identifying as victims, let alone survivors. Second, there is some critique that encouragement to become a survivor places the responsibility on the victimized, rather than the victimizer (Bolger, 2014; Anonymous, 2016). One victim wrote, “I prefer the word ‘victim’ because it places the focus where it belongs on the … rapist who turned me into a victim by raping me” (Anonymous, 2016). However, this choice is not intended to depower the identity of the survivor or the agency and healing that it represents to those who choose to claim it (Florida Council against Sexual Violence, 2016; Mosley, 2010). Male Victims of Sexual Violence Male victims of sexual violence make up a diverse group (Porche, 2005). Many studies agree that male victims are more likely to be young, between 16 and 30 years old (Isely & Gehrenbeck-Shim, 1997; McLean, 2013). However, race demographics tend to vary by study. In some studies, white males make up the majority of those who experienced sexual violence (Frazier, 1993; Light & Monk-Turner, 2008; Pino & Meier, 1999; Sorenson et al., 1987), yet in others, non-white male victims were in the majority (Tewksbury & Mustaine, 2001; Weiss, 8 2010). Some other notable characteristics found in the literature that may suggest increased vulnerability to sexual violence include living with a physical or mental disability (McLean, 2013) and living in poverty (Keown & Sherley, 2002; Pino & Meier, 1999). Additionally, it may be a false construct to assume that adult male victims of sexual violence are an entirely separate group of people than adult survivors of CSA due to sexual revictimization (Coxell & King, 2010; Classen, Palesh, Aggarwal, 2005; Muehlenhard, Highby, Lee, Bryan & Dodrill, 1998). Sexual revictimization is conceptualized in several different ways, including the concept “in which individuals who have experienced [CSA] are at greater risk than others for adolescent or adult sexual victimization” (Muehlenhard et al., 1998, p. 177). One study, using data from the National Violence Against Women Survey found that the experience of CSA among men was related to increased experiences of adult sexual victimization, in both the context of an intimate-partner and non-intimate-partner victimization (Desai, Arias, Thompson & Basile, 2002). While the literature on sexual revictimization seems more robust when discussing female victims (Black et al., 2011; West, Williams & Siegel, 2000), this phenomenon may still help to explain, in part, the relevance of this manuscript to those males who are adult survivors of CSA. Impacts of Sexual Violence on Male Victims Sexual violence has severe and persistent impacts on male victims’ psychological health (Davies et al., 2012) that, in many ways, parallel those experiences by female victims, including depression (Dickinson, deGruy, Dickinson & Candib, 1999; Frank & Anderson, 1987; Frazier, 1993; Golding, 1996; Kilpatrick & Acierno, 2003; National Sexual Violence Resource Center (NSVRC), 2010; Winfield, George, Swartz & Blazer, 1990), suicidality (Bryan, McNaugton- Cassill, Osman & Hernandez, 2013; Struckman-Johnson & Struckman-Johnson, 2006), shame 9 (National Alliance to End Sexual Alliance [NAESV], 2016; NSVRC, 2010; Weiss, 2010), self- blame (Campbell, Dworikin & Cabral, 2009; Davies, 2002; NSVRC, 2010), PTSD (Abbas & Macfie, 2013; Clum, Calhoun & Kimerling, 2000; Huckle, 1995; NSVRC, 2010; Pimlott-Kubiak & Cortina, 2003; Rentoul & Appleboom, 1997; Ullman & Peter-Hagene, 2014), substance abuse (Coxell et al., 1999; Frank & Anderson, 1987; Porche, 2015; Ullman, 2007; Ullman & Brecklin, 2002) and denial/difficulty accepting that they were victimized (McLean, 2013; Monk-Turner & Light, 2010). There are some reports that men experience even more severe symptoms of certain kinds of mental health issues, including distress (Elliott, Mok & Briere, 2004), hostility (Frazier, 1993), depression (Frazier, 1993), suicidality (Struckman-Johnson & Struckman-Johnson, 2006), and other psychological symptoms (Kimerling, Rellini, Kelly, Judson & Learman, 2002). However, some of this increased symptomology may be related to male help-seeking patterns, such as enduring symptoms for a longer period of time before seeking help and only reporting when symptoms are quite severe (Doherty & Kartalova-O'Doherty, 2010). Male victims of sexual violence may experience confusion over their sexual orientation (Walker, Archer & Davies, 2005; Mezey & King, 1989), concern about arousal during the assault (Bullock & Beckson, 2011; Huckle, 1995; Mezey & King, 2000) concern about their masculinity (Walker, Archer & Davies, 2005) sexual dysfunction (Mezey & King, 1989; Monk-Turner & Light, 2010; Peterson et al., 2011; Sarrel & Masters, 1982; Tewksbury, 2007), and abstinence from sexual activity since their victimization (King & Woollett, 1997). Physical injury is common in sexual assault of adults; 31.5% of female victims and 16.1% of male victims reported injury during their assault (Tjaden & Thoennes, 2006). Though studies have shown that women are more likely to be injured and need medical attention in a 10 incident of sexual violence (Weiss, 2010), others indicate that male victims who are sexually assaulted by a stranger are more likely to experience physical violence (Stermac, Del Bove & Addison, 2004). Pesola, Westfal & Kuffner (1999) recommend that HIV screenings, counseling, and, when appropriate, preventive measures should be available to male victims who seek services at emergency rooms, as rape by a male perpetrator puts the victim at risk for the transmission of HIV and other sexually transmitted diseases (STDs) (Scarce, 1997). While injuries are not present in the majority of cases, male victims are more likely to experience injuries to the anal area (McLean, 2013, Porche, 2005) than female victims of sexual violence. Overview of Help-Seeking Behaviors in the Context of Sexual Victimization The exact type of help that the term help-seeking is referring to may vary within the literature, but it may refer to seeking medical, legal, criminal justice, sexual assault service advocacy, and/or mental health services in relation to victims of sexual violence (Clement, Schauman, Graham, Maggioni, Evans-Lacko, Bezborodovs, & Thornicroft, 2015; Kennedy et al., 2012; Kubiak, Brenner, Bybee, Campbell & Fedock, 2016; Yousaf, Grunfeld, Hunter & 2015). Campbell, Greeson, Fehler-Cabral & Kennedy (2015) make the distinction between disclosure and help-seeking, while Ullman & Filipas (2001) include informal disclosure as part of help-seeking. Liang, Goodman, Tummala-Narra, and Weintraub (2005) refer to seeking “formal support” and “informal support” (p. 72) in relation to female survivors of intimate partner violence. Guadalupe-Diaz and Yglesias (2013) define “informal help-seeking” as including both friends and family and “formal help-seeking” as “shelters, organizations, law enforcement, and mental health” services (p.24–25). Both McCart et al., (2010) and Tsui, Cheung and Leung’s (2012) Conceptual Framework for Analyzing Help-seeking Behaviors Among Male Victims in Heterosexual Intimate Partner Violence (IPV) (p. 13) (Appendix A) 11 differentiate between formal and informal sources of support. In the context of this study, disclosure, seeking informal support, and informal help-seeking are used interchangeably and refer to accessing informal sources of support (e.g., friends, family, intimate partners, and others). Formal help-seeking, seeking formal services, or seeking formal supports refer to seeking services and support from formal sources, specifically law enforcement, medical and mental health professionals, and support hotlines. Help-seeking, help-seeking behaviors, and seeking services and support are more generalized terms that will be used to refer to the actions of reaching out to any individual or service and encompass both formal and informal help- seeking behaviors. Informal sources of help. Generally, informal disclosure is more common than formal help-seeking in victims of sexual violence (Coker, Derrick, Lumpkin, Aldrich & Oldendick, 2000; Dutton, Orloff & Aguilar Hass, 2000; McCart et al., 2010; Ullman, 2007). In this manuscript, sources of informal support are family, friends, intimate partners, and others. In the analyses throughout this work, informal help-seeking is measured as part of general help-seeking behavior. Formal sources of help. Relevant sources of formal support may vary based on the needs of the victim (Guadelupe-Diaz, 2013; McCart et al., 2010; Tsui, Cheung & Leung, 2012). Three types of professional services accessed through formal help-seeking that are particularly relevant to sexual victimization are reporting to law enforcement/police, seeking medical care, and seeking mental health treatment. Other services not included the operationalization of formal support in this manuscript, but that may be relevant, include legal aid or housing assistance, especially in cases of perpetration by an intimate partner or family member. 12 The Importance of Seeking Help After Sexual Victimization Victims of violent crimes’ coping and psychological well-being are improved through services to victims (Mayhew & Reilly, 2008; Ringham & Salisbury, 2004). Navigating and overcoming barriers to help-seeking may be an important step in the coping process (Schreiber, Maercker & Renneberg, 2010; Stige, Træen & Rosenvinge, 2013). Informal help-seeking may lead to more positive outcomes in the victim’s recovery post-victimization, as well as higher rates of satisfaction with support than services utilized as a result of formal help-seeking (Coker, Derrick, Lumpkin, Aldrich, & Oldendick, 2000; Dutton, Orloff, & Aguilar Hass, 2000; Ullman, 2007). Some of the ways that informal supports may help a victim include temporary housing, child care, monetary assistance, and general support (Du Mont et al., 2005; Goodman, Dutton, Weinfurt, & Cook, 2003). However, in addition to informal help-seeking being an effective way to gain support on its own, some studies point to the connection between informal disclosure and formal help-seeking, suggesting that disclosure or informal help-seeking is a facilitator to help- seeking (Guerette & Caron, 2007; Konradi, 2007; Patterson & Campbell, 2010; Ullman & Brecklin, 2002). Benefits of seeking help from formal sources. In female victims of violence, professional services accessed through formal help-seeking may lead to improved psychological well-being following victimization (McCart et al., 2010). Among victims of sexual violence, interventions that occur soon after victimization may be particularly helpful (Kearns, Ressler, Zatzick, & Rothbaum, 2012; Price, Davidson, Ruggiero, Acierno & Resnick, 2014). Police. Reporting to the police can be challenging, especially for male victims (Hammond, Ioannou, & Fewster, 2017), however, several positive outcomes stem from this act of formal help-seeking. Involving law enforcement not only opens the opportunity for criminal 13 punishment for the perpetrator of sexual violence but also increases awareness and statistics about sexual violence (Bosick, Rennison, Gover, & Dodge, 2012; Rennison, Gover, Bosick, & Dodge, 2011). This increased awareness and accurate record-keeping are especially important in the case of male sexual violence victimization, an area in which outreach and awareness are greatly needed. Medical. Seeking help from a medical professional after sexual victimization is important, especially in cases where injury is an outcome of the assault, emergency birth control is needed, or the collection of evidence would be helpful in legal matters. For victims of violent crime, seeking help from a medical professional has a generally low rate, ranging from 7% and 30% (El-Khoury Dutton, Goodman, Engel, Belamaric, & Murphy, 2004; Kaukinen, 2004; Mahoney, 1999). Mental health services. Mental health services are considered to be important to the recovery of an individual who has experienced trauma or violence, including sexual victimization. In many cases, victims display high levels of need of mental health services due to the experience of trauma in the form of sexual violence, such as for post-traumatic stress disorder or depression (Davis, Schraufnagel, George & Norris, 2008). In one survey of adult males who experienced childhood sexual abuse, the respondents characterized the conversations that they had with mental health providers to be among the most beneficial (Easton, 2014). Despite these needs and the efficacy of services for victims of violence (Kearns, Ressler, Zatzick, & Rothbaum, 2012), male victims display low levels of use (Gavrilovic et al., 2005; Sayer, Friedemann-Sanchez, Spoont, Murdoch, Parker, Chiros, & Rosenheck, 2009). Negative outcomes of seeking help. Despite findings that disclosure and seeking help are beneficial to a victim of sexual violence, there is also evidence to the contrary. In some cases, 14 disclosure to friends and family may provoke negative responses from the people who are disclosed to (Ahrens & Campbell, 2000). When seeking formal help, some victims report being further traumatized or experiencing secondary victimization (Campbell, 2008; Campbell et al., 2009; Campbell & Raja, 1999; Kenney, 2002; Klein & Milardo, 2000). Men and Help-Seeking Behaviors Much of what is known about males and their help-seeking behaviors stems from the fields of physical health and mental health and, in recent years, the study of males who experience IPV and other violent crime. Generally, males are less likely to seek medical or mental health help from a professional (Addis & Mahalik, 2003; Corney, 1990; Galdas, Cheater, & Marshall, 2005; McKay Rutherford, Cacciola, & Kabasakalian-McKay, 1996; Möller- Leimkühler, 2002; Padesky & Hammen, 1981; Yousaf, Grunfeld, & Hunter, 2015) or to seek support in a group setting (Barnett, 2005; Krizek, Roberts, Ragan, Ferrara, & Lord, 1999). In IPV literature on male victims, they are noted as less likely to seek to disclose to informal sources of support than female victims (Ansara & Hindin, 2010; Arnocky & Vaillancourt, 2014; Williamson et al., 2015) and are more likely to disclose to informal sources than to seek help from formal sources. This pattern of low levels of help-seeking continue in the context of sexual violence. Male victims of sexual violence and help-seeking. Literature exploring male victims of sexual violence and their help-seeking behaviors, as well as barriers to help-seeking behaviors is limited. Though this topic is gaining attention—leading to an increased number of empirical articles—there are still gaps in the understanding of what prompts help-seeking behavior among these men. However, literature involving male help-seeking behaviors related to IPV, violent crime, and physical and mental health needs, as well as the vast literature related to female 15 victims of IPV and sexual violence, also contains helpful insight into patterns and predictors of formal and informal help-seeking among male victims of sexual violence. While help-seeking and disclosure of sexual victimization are challenging for all victims of sexual violence, victimized males may be even less likely to report sexual victimization than female victims of sexual assault (Allen, 2007; Davies, 2002; James & Lee, 2014, Mezey & King, 1989; Mezey & King, 2000; Mitchell et al., 1999; Stemple & Meyer, 2014; Walker et al., 2005). This lack of help-seeking is apparent in adult victims of sexual violence. Additionally, male victims of sexual violence are less likely to seek help or disclose when in college (Ullman & Filipas, 2005) or as an adult survivor of childhood sexual abuse (CSA) (Easton, 2013; Finkelhor, Hotaling, Lewis, & Smith, 1990). In Tjaden and Thoennes’ (2006) study, only 12.9% of male victims reported their victimization to the police. Masho & Alvanzo (2009), in a study of 91 male victims of sexual assault, found that only 17.6% sought professional help, with physical injury of victimization by a friend or family member greatly increasing likelihood of seeking help. In another measure of males seeking help from formal sources, Zaykowski (2014) utilized data from the National Crime Victim Survey from between 2008 and 2011 to determine who sought help from some form of victim services. Of the 4,746 victims of violent crime (including, but not limited to, sexual violence), 372 individuals accessed some service for victims outside of the police. Of that group, about 25% (n=95) were men. In King and Woollett’s (1997) sample of male victims of sexual assault (n=115), only 17 reported their victimization. Only five male victims of sexual violence in a group of 40 in Walker, Archer & Davies’ (2005) reported their victimization. There are a number of reasons that men do not formally help-seek or disclose in relation to sexual victimization. Some of these potential barriers include: not identifying their 16 victimization as sexual violence (Artime, McCallum, Peterson; 2014); the belief that the victimization was not severe enough to warrant reporting or help (Hammond et al., 2017); embarrassment, fear, or stigma (Weiss, 2010); belief in rape myths (Chapleau et al., 2008; Fisher & Pina, 2013); or the fear that they will not be taken seriously (Jamel, Bull, & Sheridan, 2008). These concerns are not unfounded; there is evidence of revictimization in some cases when victims seek services (Campbell, Sefl, Barnes, Ahrens, Wasco, & Zaragoza-Diesfeld, 1999; Clark, 1987; Kenney, 2002; Klein & Milardo, 2000; Patterson, Greeson, Campbell, 2009) or informally disclose (Ahrens & Campbell, 2000). However, despite these experiences of increased trauma, there is evidence to suggest that, generally, help-seeking and disclosure increase psychological well-being and should be encouraged. Theoretical Approaches Tsui, Cheung, & Leung’s (2012) Conceptual Framework for Analyzing Help-Seeking Behaviors Among Male Victims in Heterosexual Intimate Partner Violence (IPV) Tsui, Cheung & Leung’s (2012) Conceptual Framework for Analyzing Help-Seeking Behaviors Among Male Victims in Heterosexual Intimate Partner Violence (IPV) is a model designed to explore and explain male help-seeking and disclosure behaviors (Appendix A). This model suggests that there are three factors contributing to help-seeking: theoretical perspective (including masculine gender socialization), sociocultural variables (including masculine gender role conflict), and sociodemographic variables. This model also takes into account that there are three potential types of help-seeking behaviors: not seeking any form of help, informal help, and formal help, and acknowledges that these types of help-seeking are not mutually exclusive and can occur at different points in the help-seeking and disclosure process. 17 In order to utilize this model to explore the help-seeking and disclosure behaviors of male victims of sexual violence, the model must be adapted to account for additional factors related to help-seeking, especially in regard to help-seeking related to sexual victimization (Appendix B). The absence of factors related to perpetrator characteristics may be explained by the model’s intended focus on IPV in heterosexual relationships. If applying the model to males experiencing IPV in heterosexual relationships, then the assumed perpetrator gender is female and the assumed relationship between victim and perpetrator is that of intimate partners. However, when applying this model to the broader group of males who experience sexual violence, such default characteristics cannot be assumed. Among male victims of sexual violence, gender of perpetrator may be related to formal help-seeking and disclosure behavior, and more broadly among victims of sexual violence without regard to gender, the relationship between victim and perpetrator has been well documented to affect choices about help-seeking and disclosure (Gartner & Macmillan, 1995; Jensen & Karpos, 1993; Kaukien, 2002; Koss, 1985; Resnick et al., 2000; Stewart et al., 1987; Ullman & Filipas, 2001). An additional group of variables that is unaddressed by this model is assault outcomes. While Tsui et al. (2012) do not include this in their model, this is an important and well- documented group of variables to consider in the context of sexual violence. This group of variables should include severity of assault, physical injury from assault, psychological outcomes as a result of assault, and negative employment and educational outcomes of assault (Gartner & Macmillan, 1995; Resnick et al., 2000). In order to account for these groups of variables, an adapted model of Tsui et al.’s (2012) Conceptual Framework for Analyzing Help-Seeking Behaviors Among Male Victims in Heterosexual Intimate Partner Violence (IPV) is proposed (Appendix B). This adaptation adds 18 two areas of influence to the existing model: perpetrator characteristics, and assault outcomes and contexts. This addition increases the potential groups of explanatory variable groups to five, three of which will be explored in these manuscripts: sociodemographic variables, perpetrator characteristics, and incident characteristics and outcomes. The two areas in the model that are unaddressed by variables in the dataset used for this study are theoretical perspective (including masculine gender socialization) and sociocultural variables (including masculine gender role conflict). What ties these two areas together is the concept of masculinity or masculinities. While this concept is untested in the statistical analyses within this manuscript, to interpret the results, a theoretical underpinning of the theories of masculinity must be considered. Masculinity The concept of masculinity is particularly relevant to the way that men in the United States perceive themselves. The characteristics of toughness, violent behavior, and emotionlessness are identified as defining features of masculinity (Kimmel, 1987). Because these same characteristics are challenged when an individual is victimized, males may be less inclined to identify with the concept or identity of victimhood (McLean, 2013). Men experience blame and feel shame that they were unable to fight off the perpetrator (Davies et al., 2012). Hegemonic masculinity is comprised of the masculine characteristics of the dominant group (Cheng, 1999; Connell, 1987, 2000, 2005; Connell & Messerschmidt, 2005). Cheng (1999) lists this set of characteristics as “able-bodies, heterosexual, Christian…, first world, and ranging in age from 20 to 40” (p. 298). It is important to note that hegemonic masculinity exists as the top of a hierarchy. Lower in the hierarchy are femininity and alternate masculinities that fall outside of or exist in opposition to the hegemony. For men who value upholding the ideals of hegemonic 19 masculinity, sexual victimization may be particularly challenging, with a male or female perpetrator each presenting their own issues in relation to masculinity. When considering traditional hegemonic masculine gender roles, a model that is often cited is David & Brannon’s (1976) Male Sex Role Identity Model. This model divides the role of a man into four spheres: 1) “The Big Wheel” (i.e., that men should achieve success), 2) “The Sturdy Oak” (i.e., that men should be self-reliant and strong), 3) “Give ‘Em Hell” (i.e., that men should be ready to fight and willing to show aggression and dominance), and 4) “No Sissy Stuff” (i.e., that femininity should be avoided) (David & Brannon, 1976, p.12). Masculine roles related to sex imply that men are heterosexual, want sex with women above most other things (O’Sullivan, Beyers, & Finkelman, 1998), and that sexual assertiveness is a manly attribute (Kimmel, 2003; Messner, 1995). Current male rape myths are built on the societal structures that uphold hegemonic masculinity. In fact, LeMaire, Oswald, and Russell (2016) found that in college students, the more sexist attitudes that were held by an individual, the more rape myths were accepted. Sleath and Bull (2010) found that acceptance of rape myths predicted blaming of the victim. Male rape myths. The three initial male rape myths identified and included in a measure by Struckman-Johnson and Struckman-Johnson (1992) were: 1) male rape does not exist, 2) male rape is the victim’s fault, and 3) male rape is not traumatizing. Chapleau, Oswald, and Russell (2008) list the following rape myths: a) Being raped by a male attacker is synonymous with loss of masculinity; b) men who are sexually assaulted by men must be gay; c) men are incapable of functioning sexually unless they are sexually aroused; d) men cannot be forced to have sex against their will; e) men are less affected by sexual assault than women; f) men are in a constant state of 20 readiness to accept any sexual opportunity; g) a man is expected to be able to defend himself against sexual assault (p. 603). These male rape myths, like those attributed to women, ascribe blame to the wrong party: the victim. These myths may be implicitly or explicitly accepted by victims, victims’ families and friends, police, medical professionals, and even sexual assault service providers, making disclosure, reporting, and help-seeking particularly daunting for the male victim. Gender Role Conflict. Gender Role Conflict (O’Neil, 1981) is a model which connects theories of masculinity to daily life for men. This model is rooted in the male ideal that femininity should be avoided at all costs (O’ Neil, 2008). Studies have linked high levels of Gender Role Conflict (GRC) within an individual to low levels of help-seeking behaviors (Cortese, 2003, Wisch, Mahalik, Hayes & Nutt, 1995) and negative opinions about mental health services (Mendoza & Cummings, 2001). Gender role conflict is defined as a “psychological state in which socialized gender roles have negative consequences on the person or others. Gender role conflict occurs when rigid, sexist, or restrictive gender roles result in personal restrictions, devaluation, or violation of others or self” (O’Neil, 2018). For male victims of sexual assault, not seeking help after victimization may be the type of personal restriction caused by GRC. Organization of Dissertation Chapter Two, Manuscript 1 This chapter will present the prevalence of help-seeking within this group of male victims of sexual violence, followed by information on where they sought help. The relationships between help-seeking variables and the individual-level explanatory variables will be assessed with bivariate analysis and binary logistic regression. Explanatory variables examined in this manuscript are: race of victim, sexual orientation of victim, education level of victim, and yearly 21 income, controlling for number of lifetime sexual perpetrators and an experience of severe sexual victimization. Chapter Three, Manuscript 2 This chapter explores the relationships between help-seeking variables and the perpetrator-level explanatory variables assessed with bivariate analysis and multilevel logistic regression with a Poisson link function. Explanatory variables examined in this manuscript are: gender of perpetrator, if victim and perpetrator are the same or different races, if there is a large age difference between a younger victim and older perpetrator, and relationship with perpetrator, controlling for dual victimization by perpetrator through physical violence by an intimate partner. Chapter Four, Manuscript 3 This chapter explores the relationships between help-seeking variables and the incident- level explanatory variables assessed with bivariate analysis and multilevel logistic regression with a Poisson link function. Explanatory variables examined in this manuscript are: injury caused by perpetrator, if the victim missed work or school due to the perpetrator’s actions, if the perpetrator’s actions caused the victim to be afraid or concerned for safety, if the victim was penetrated, and if the victim was a child (under 10 years old) at the time of the incident. Chapter Five, Discussion, Implications, and Conclusion This chapter summarizes the major findings within this dissertation and discuss themes related to masculinity, victimization, and seeking help across the manuscripts. Implications for social work theory, clinical practice, macro outreach, policy, and future research are discussed. 22 CHAPTER TWO: INDIVIDUAL-LEVEL CORRELATES OF SEXUALLY VICTIMIZED MALES’ HELP-SEEKING BEHAVIOR Abstract Males are less likely than their female counterparts to seek help for medical and mental health needs, including seeking services and support related to sexual victimization, which may lead to decreased social support, medical treatment, and mental health interventions for male victims of sexual violence. Thus, understanding relationships between victim-level characteristics and help-seeking behavior is a step toward increasing access to services for sexually victimized males. This study utilizes data from the National Intimate Partner and Sexual Violence Survey (NISVS), 2010 to explore patterns and prevalence of help-seeking behaviors at three levels (general help-seeking (informal and formal help-seeking), formal help-seeking, and seeking mental health services) among male victims (n=1569), as well as relationships between sociodemographic variables (race, sexual orientation, education, income, lifetime perpetrators of sexual violence) using descriptive and bivariate statistics, as well as binary logistic regression. Over 50% sought help, formal and/or informal. Friends were the most-sought form of informal support, while mental health services were the most commonly sought formal help. White men were more likely to seek help than non-white male victims. Sexual partner gender was positively associated to an increased likelihood to seek help across dependent variables. Increased income was negatively associated with seeking formal help. Number of perpetrators of sexual violence in a victim’s lifetime was positively associated with general help-seeking behavior and seeking formal help. These findings are discussed in relation to theories of masculinity and help-seeking. Keywords: sexual violence, male victims, help-seeking, race, sexual orientation, socioeconomic status, masculinity 23 Introduction Male sexual victimization is a topic that has generated increased attention both among researchers and in the public sphere in recent years. Despite this increased attention, there are many facets of this experience of victimization that remain under- or unexplored, including what prompts men to seek help or support following sexual victimization. Despite negative psychological and physical outcomes associated with sexual violence, men are less likely than female victims of sexual violence to seek support from friends and family, or from organizations such as law enforcement, medical facilities, and/or mental health services. This lack of help- seeking and disclosure behavior is especially potentially detrimental to the victims due to the ameliorating effects of social support and mental health services following the trauma of sexual violence. When considering male help-seeking behaviors, several factors must be taken into account. These include masculinity, male rape myth acceptance, and sociodemographic characteristics that may contribute to a male victim’s decisions to seek or avoid formal and informal help seeking among sexually victimized men. Background Though male sexual victimization is an understudied and under-reported issue (Choudhary et al., 2002; McLean, 2013; Mezey & King, 2000; Stemple & Meyer, 2014), the National Intimate Partner and Sexual Violence Survey (NISVS) has contributed to the accuracy of present estimates of prevalence and, in some cases, confirmed previously existing statistical estimates. For example, a commonly cited statistic is that one in six men will experience sexual violence in their lifetime (1in6.org, 2018); the NISVS weighted data suggests a lifetime sexual victimization prevalence of 17.1% among males, approximately one in six (Smith et al., 2017). Within that group of sexually victimized males, the NISVS weighted data indicates that 1.5% 24 experience rape or attempted rape, 5.9% are made to penetrate, 5.8% experience coercion, 11.0% experience unwanted sexual contact, and 13.2% will have a noncontact unwanted sexual experience. Despite the presence of these statistics, men’s reluctance to report sexual victimization makes it difficult to determine true estimates of male victimization (Dube, Anda, Whitfield, Brown, Felitti, Dong, & Giles, 2005) and these reports of prevalence may still be underestimations. Male victims of sexual violence experience negative outcomes from their victimization in multiple spheres of well-being (Davies et al., 2012). Suicidality, post-traumatic stress disorder (PTSD), substance abuse, and physical injury are among some of the most widely documented impacts of sexual victimization (Abbas & Macfie, 2013; Bryan et al., 2013; Kilpatrick & Acierno, 2003; National Sexual Violence Resource Center (NSVRC), 2010; Pimlott-Kubiak & Cortina, 2003; Porche, 2015; Stermac et al., 2006; Struckman-Johnson & Struckman-Johnson, 2006; Tjaden & Thoennes, 2006; Ullman, 2007; Ullman & Peter-Hagene, 2014) However, despite these outcomes of sexual victimization, male victims have low rates of help-seeking behaviors. Similarly to female victims of sexual violence, male victims are more likely to disclose informally to friends and family than to seek help from formal supports (Coker et al., 2000; Dutton, Orloff, & Aguilar Hass, 2000; McCart et al., 2010; Ullman, 2007), such as law enforcement, medical care, or mental health services. While informal support gained through disclosure is helpful even without formal services (Coker et al., 2000; Dutton et al., 2000; Ullman, 2007), another important aspect of informal support is that friends and family may be able to encourage the victim to connect with formal services (Campbell, 2015; Konradi, 2007; Norris et al., 1990; Patterson & Campbell, 2010; Ullman & Brecklin, 2002). Formal services 25 may be an important part of recovery and coping from sexual victimization, with interventions that occur soon after an individual is victimized often being the most helpful (Kearns, Ressler, Zatzick, & Rothbaum, 2012; McCart et al., 2010; Price et al., 2014). In non-victimization circumstances, males are less likely than females to seek help from professional services, especially in relation to mental and physical health (Addis & Mahalik, 2003; Galdas et al., 2005; Yousaf et al., 2015). These patterns of lack of help-seeking are generally consistent among male victims of sexual victimization across the lifespan (Easton, 2014; Ullman & Filipas, 2005). Some potential factors limiting disclosure and seeking help among male victims of sexual violence include the inability to understand their experience as victimization (Artime et al., 2014), believing that the victimization lacked the severity to require disclosure or help (Hammond et al., 2017), shame (Weiss, 2010), rape-myth acceptance (Chapleau et al., 2008; Fisher & Pina, 2013), or fear that their victimization will not be taken seriously (Jamel et al., 2008). In addition to these factors, as well as characteristics related to the perpetrator and the experience of victimization, there are individual-level or sociodemographic variables that may have relationships to the male victim’s decision to seek help or disclose his sexual victimization. Intersectionality One of the reasons to consider individual-level characteristics is because it is important to note that the concept of male victims cannot be defined simply by gender. While males are privileged in U.S. society, the same gendered structures that give them privilege may also limit or oppress men who fall outside of traditional or dominant male norms (Connell, 2005; Cheng, 1999; Murray, 2015; Ralston, 2012). Identities of individuals are comprised of potentially complex “lines of difference” (Lutz, 2002, as cited in Yuval-Davis, 2006, p. 202) or 26 characteristics that may decrease or increase their vulnerability to oppression (Crenshaw, 1989, 1991; May, 2015; Yuval-Davis, 2006). When considering individual-level characteristics—such as race, class, and sexual orientation—an intersectional approach may be useful in understanding how certain “lines of difference” may interact with gender in the ways that male victims approach help-seeking and interactions with service providers (Murray, 2015; Ralston, 2012). While intersectionality has traditionally been particularly vital to the understanding of disparity and oppression related to women of color (Crenshaw, 1989, 1991; May, 2015; Ralston, 2012), it may still be a useful approach to understanding the complexities among the multiple identities of male victims. Due to the heterogeneity of male victims, an intersectional approach may be employed to understand how identities intersect with gender in ways that may increase vulnerabilities (Murray, 2015; Ralston, 2012). Characteristics such as age, sexual orientation, race, socioeconomic status, and the organizational context of the individual (e.g., prison, military, or university) have been identified to have salience in relation to sexual violence, and, thus, with help-seeking behavior, and service utilization and access. Literature Review Race of Victim Generally, there are racial differences in help-seeking behaviors (Flicker, Cerulli, Zhao, Tang, Watts & Talbot, 2011; Hutchison & Hirschel, 1998; Ingram, 2007; Kaukinen, 2004; Lewis et al., 2005). White women are generally considered the most likely to seek help or disclosure (Amstader, McCauley, Ruggerio, Resnick, & Kilpatrick, 2008; Golding, 1989; New & Berliner, 2000; Starzynski et al., 2007; Ullman & Brecklin, 2002; Ullman, 2007). Additionally, African American and Latina women have been found to be less likely to seek help (Sherbourne, Dwight, Johnson, & Klap, 2001) and, in the case of African American women, are more inclined toward 27 informal disclosure (Chow, Jaffee, & Snowden, 2003; Wyatt, 1992). This difference in help- seeking remains when considering racial differences in seeking help from mental health service providers. Individuals who identify as white are more likely to seek mental health services than racial minorities (Alegria, Canino, Rios, Vera, Calderon, Rusch, & Ortega, 2002; Dobalian & Rivers, 2008). Sexual Orientation of Victim Heterosexuality may be a predictor of formal help-seeking. Gay and bisexual men may feel that they cannot report to the police that they are victims of sexual violence by other men due to the worry that their sexual identity may play a negative role in the report and potential investigation (Rumney, 2009). In fact, Rumney (2009) found that some men who did choose to report victimization to the police were dismissed and/or ridiculed by law enforcement who did not believe that the victims could have been sexually victimized or that their report would be fruitless based on the victims’ sexual identity. In the Langenderfer-Magruder et al. (2016) study, only 18.2% of the cisgendered gay and bisexual males who reported being sexually victimized on the survey had made a police report. For members of the lesbian, gay, bisexual, transgender and queer/questioning (Calton, Cattaneo & Gebhard, (2016) community, a barrier to seeking support services both for sexual victimization and other issues is uncertainty of a service provider’s level of LGBTQ acceptance (King et al.,2008; Kenagy, 2005; Lombardi, 2001; Merrill & Wolfe, 2000; Todahl et al., 2009). Calton, Cattaneo, and Gebhard (2016) identified three major barriers to LGBTQ IPV victims’ interface with service providers: lack of understanding of LGBTQ issues, inequity within systems, and stigma. Previous experiences of discrimination, especially by service providers, may decrease these individuals’ likelihood of seeking services (Kenagy, 2005; Lombardi, 2001; 28 Todahl et al., 2009). However, Jackson, Valentine, Woodward, and Pantalone (2017) found that individuals who had coming out experiences that they perceived as positive found it easier to disclose sexual victimization. Education Level of Victim Generally, having a higher education has been identified as a facilitator to both formal help-seeking (Ullman & Brecklin, 2002) as well as informal disclosure (Lewis et al., 2005). In a study of trauma-exposed adults, Ghafoori, Barragan, and Palinkas (2014) found that those who were not involved in mental health services had a lower level of education and were disproportionately male. Among female victims of IPV, those with higher levels of education predicted increased likelihood to seek mental health services. Kaukinen et al. (2013) explains the positive relationship between higher education and increased help-seeking behaviors related to IPV, with increased education being indicative of a better understanding of the existence and efficacy of available services. Income Like education, higher income is often associated with a higher likelihood to seek help (Asser, 1978). For some types of services, being able to afford them may be an important factor in deciding to access them. For example, Price, Davidson, Ruggiero, Acierno, and Renick (2014) found that access to insurance increases the likelihood of accessing formal sources of support. Similarly, for individuals whose perpetrator is an intimate partner, the perpetrator’s control of funds may decrease the victim’s access to financial resources and, thus, decrease their ability to seek services (Bryant-Davis, Ullman, Tsong, Tillman, & Smith, 2010; McNair & Neville, 1996). Among LGBTQ victims of violence, Guadalupe-Diaz and Yglesias (2013) found statistically significant differences related to class and gender. Not only were lower economic classes 29 associated with fewer help-seeking behaviors, but males from a lower economic class were less likely to seek help overall, and less likely to seek formal help for IPV, than female victims of a lower economic class. For adults exposed to trauma, lower income was related to lower levels of mental health service utilization (Ghafoori, Barragan, Palinkas, 2014). However, not all studies agree that increased income and increased help-seeking behaviors consistently have a positive relationship. In Kaukinen, Meyer, and Akers’ (2013) study lower levels of help-seeking and service utilization were found among female IPV victims with higher incomes. Current Study This study focuses on the help-seeking behaviors of males who have experienced sexual victimization or violence. For the sake of this study, sexual violence is broadly defined in accordance with the variables within the NISVS, including forcible and drug/alcohol-facilitated penetration and being made to penetrate, sexual coercion, unwanted sexual contact (i.e., grabbing and kissing), and unwanted sexual experiences that do not include contact (i.e., exposure, harassment, and being made to watch or participate in sexual media). The men victimized in these ways often do not seek services, and in many cases, do not disclose their victimization even to those closest to them. While there has been attention in recent years focused on female victims of sexual violence and predictors of help-seeking, much less is known about male victims’ patterns of help-seeking. Research Questions RQ1: What is the prevalence of help-seeking behavior among male victims of sexual violence? How many seek help from formal sources and/or disclose their victimization to informal sources? What are preferred sources for services and support among male victims of sexual violence? 30 RQ2: What sociodemographic characteristics are predictive of formal and informal help-seeking (general help-seeking) behaviors among male victims of sexual violence? RQ3: What sociodemographic characteristics are predictive of male victims of sexual violence who seek formal support among those victims who sought some form of informal and/or formal help? RQ4: What sociodemographic characteristics are predictive of seeking help from mental health services among those male victims who sought formal help? Methods Research Design This correlational study uses secondary data from the NISVS: General Population Survey (2010), a nationally representative cross sectional, retrospective telephone (landline and mobile) survey that collected information about experiences of intimate partner violence, sexual violence, and stalking among women and men aged 18 or older in the United States (Black et al., 2011; Smith et al., 2017). Information collected by the survey includes respondent demographic information, detailed information about the respondent’s experiences of different types of intimate partner violence (psychological aggression [PA], coercive control [CC], physical violence [PV]) stalking, and sexual violence, all measured for three timeframes: one year, three years, and lifetime. Lifetime victimization variables are utilized for analysis in this study. Additionally, follow-up information was collected both specific to individual sections and for the whole survey during the original data collection for individual who met the criteria, which included being a victim of sexual violence. These follow-up sections include information on individual perpetrators, the individual perpetrators’ actions, and outcomes and actions related to the reported victimization (e.g., help-seeking). 31 Data Management Within this dataset, a complicating factor is the use of perpetrators to organize the data. Though the individual-level variables used as independent variables in these analyses are linked to the de-identified respondent identification number, most variables in the dataset are linked through the perpetrator. Due to the respondents’ freedom within the survey to list perpetrators in the order that they prefer in each section, the variable names PERP1–PERP94 are not indicative of the specific perpetrator named in the variable name. The Sexual Violence section was restructured, creating a series of 22 binary perpetrator variables, indicating the presence or absence of each sexual violence behavior for each perpetrator listed by the respondent. An additional data management step is needed for the help-seeking variables. Help-seeking variables are found within one of the Follow Up sections in the database and are linked to the perpetrator through the use of a list of qualifying perpetrators for each Follow-Up section. Using this list to restructure the variables, it is possible to link the respondent to their help-seeking behaviors through each perpetrator of sexual violence. Data access and storage. Access to this de-identified dataset (United States Department of Health and Human Services, 2014) has been approved by the University of Michigan Inter‐ university Consortium for Political and Social Research/National Archive of Criminal Justice Data on October 5, 2017. Prior to approval, the request for access was reviewed and approved by the Michigan State University (MSU) Vice President for Research and Graduate Studies and MSU Data Technologies. The data is stored on an external hard drive in a locked cabinet in a locked office and accessed using a computer with ASCOMP Software Secure Eraser 5.001 and Cypherix Cryptainer SE 11.6.0 installed. The research protocol for this study was submitted to the Michigan State University Institutional Review Board (IRB) and was approved as expedited. 32 A letter stating this information was provided to the Dissertation Chair, Dr. Sheryl Kubiak, on August 9, 2017. Sample The information in this dataset was collected between January 2010 and December 2010 from 16,191 adults who completed the survey, including 7,292 men, with 1,577 men reporting at least one experience of sexual violence (Figure 1). Figure 1. Diagram of sample selection for individual-level analyses (Ch. 2/Manuscript 1) A subsample (n=1, 569, 21.5% of male respondents) (Appendix C) selected for this study includes all males who reported at least one perpetrator of one of the 22 types of sexual violence listed in the Sexual Violence section of the NISVS within the first 15 perpetrators listed by the victim in their survey responses. For each type of violence, the survey allows the respondent to list up to 15 perpetrators for each sexual violence behavior, with the potential of 94 individual perpetrators listed for each victim (PERP1 to PERP94). To remove outliers and reduce the amount of variable creation, while still retaining an adequate representation of each respondent’s perpetrator list, the perpetrator variables were truncated after PERP15. Before truncation, the victim’s number of perpetrators during their lifetime ranged 1–19, in variables between PERP1 and PERP38. Truncating the perpetrator variables at PERP15 reduced the sample by 33 eight individuals who listed their first perpetrator of sexual violence as PERP16 or higher in the survey. Incident-level variables (e.g., if there was injury as a result of a perpetrator’s actions) and perpetrator-level variables (e.g., relationship with perpetrator) were not considered in sample selection; however, these variables will be explored in Chapters 3 and 4. Within the sample of male victims of sexual violence (n=1,569), the victims ranged in age between the age group 18–24 (12%) to 55+ (30.8%). The majority of the sample identified their race as white (82.2%), with the remaining 17.8% consisting of individuals who identified as black/African American (9.1%), Asian (2.3%), Native Hawaiian/Pacific Islander (2.3%), American Indian/Native Alaskan (2.0%), and “other” (3.7%). Of the 144 individuals who identified as Hispanic, 54% identify as white and 45% identify as non-white when race is dichotomized for analysis. Among those who identified a sexual orientation, 88.2% are heterosexual, and 10.5% identify as LGBTQ (6% gay men, 4.4% bisexual, and 0.1% transgender). However, the utility and accuracy of this variable is limited due to the large number of missing values (missing n=644). About 88% the men in the sample report exclusively having sex with women and about 12% of the sample has either exclusively had sex with men or with both men and women (MSM). Education level within the sample ranged from “no schooling” (0.1%) to a postgraduate degree (17.3%), with the largest groups in the sample attending some college or getting a four-year degree (44.3%). Yearly income ranged from $10,000 a year or less (5.4%) to more than $70,000 (31%). Almost 88% rated themselves in “good” or better mental health, and almost 80% rated themselves in “good” or better physical health. The males in the sample identified between one and 19 perpetrators of sexual violence (x̅ =2.33, SD=2.31). Sub-samples. In order to answer the third and fourth research questions, sub-samples were drawn from the population of male victims of sexual violence. The first sub-sample (Appendix 34 D), for the third research question in this study, consists of all males who reported they had sought at least one form of support as a response to a perpetrator of sexual violence (n=984). From this sub-sample, a second sub-sample (Appendix E) was drawn consisting of those males who report seeking one form of formal support (e.g., law enforcement, medical, psychological, and/or crisis hotline) as a response to a perpetrator of sexual violence (n=361). Defining sexual violence for sample selection. Within the NISVS, sexual violence has been operationalized into 22 (or 21 survey questions, including one with two parts) separate perpetrator behaviors in five groupings of incident-type categories: rape, made to penetrate, sexual coercion, unwanted sexual contact, and non-contact unwanted sexual experience (Appendix G). For this study, all survey respondents who responded affirmatively to any of the sexual violence questions were included as a male victim of sexual violence. Level of severity of sexual violence was examined as a control variable and will be further addressed in Chapter 4 (Manuscript #3) as an explanatory variable. Independent Variables Race of victim. In this study, race of the victim is operationalized by the survey respondents’ first categorical answer to “What is your race?” This variable was dichotomized into two categories (white and non-white) due to low numbers of individuals who responded with an answer other than white (Guadalupe-Diax, 2013). There are 17 missing values in this variable in the entire sample (n=1,569), nine missing values in the sub-sample of those who sought help (n=984), and three missing in the sub-sample of those who sought formal help (n=361). Sexual orientation/Chosen sexual partners of victim. Due to a large number of missing values for this variable in the dataset (n=644 missing), the Sexual Orientation variable is not used 35 for this analysis. In this study, a proxy variable for sexual orientation of the victim was operationalized as Sexual Partner Choice. This variable was created from the respondents’ answers to “In lifetime, sexual partners have been only men/women or both?” The answers were recoded into two values: 0=sex with women only (or no sexual activity), 1=sex with men or both men and women. There are six missing values in this variable in the entire sample (n=1,569), five missing values in the sub-sample of those who sought help (n=984), and three missing in the sub-sample of those who sought formal help (n=361). Education level of victim. In this study, educational level is operationalized as the survey respondent’s answer question “What is the highest level of education you have completed?” There are eight values ranging from lowest level of education (“No schooling” [1]) to highest level of education (“Postgraduate” [8]). This variable is treated as continuous in the analyses. There are no missing values for this variable. Yearly income. In this survey, yearly income is captured in a series of nine binary variables with a skip pattern. For example, the question series begins asking the respondent if their income is above $25,000 per year. Based on the response, questions are asked to narrow the yearly income value to a range within $5,000 to $25,000. This variable was recoded into nine values ranging from less than 10k (1) to above 75k (9). This variable is treated as continuous in the analyses. There are 74 missing values in this variable in the entire sample (n=1,569), 48 missing values in the sub-sample of those who sought help (n=984), and 20 missing in the sub- sample of those who sought formal help (n=361). Control Variables Number of sexual victimization perpetrators. This continuous variable was calculated by tallying the number of perpetrators of sexual violence that each victim reported during the 36 survey as someone who engaged in one of the 22 sexual violence behaviors. This variable ranges from one to 19 and is treated as continuous in the analyses. There are no missing values for this variable. Sexual victimization severity. A binary variable was created for each victim. If the victim had at least one victimization experience that included rape or being made to penetrate, it was considered more severe. If these types of victimization were absent from the victim’s experience, then their victimization consisted of one or more incident types—coercion, unwanted, or noncontact—and were rated as less severe. Those victims with severe victimization experience=1, no severe victimization experience=0. There are no missing values for this variable. Dependent Variables Help-seeking. This binary variable (0= no help-seeking, 1=help was sought) was calculated by assessing for all help-seeking. Throughout the manuscript, general help-seeking and any help-seeking are used interchangeably to refer to this variable. Then these variables were checked against the list of all perpetrators of sexual violence to remove all instances of help- seeking that are not directly related to a sexual violence perpetrator. For example, some victims reported help-seeking in response to the actions of a perpetrator of IPV or stalking who did not also commit a sexual violence against the victim. These instances of help-seeking were removed from the dataset in order to only reflect help-seeking behaviors as closely related to sexual victimization as possible. Formal help-seeking. This binary variable was calculated to reflect formal help-seeking (0=no formal help sought, 1=formal help sought). This variable reflected if the victim ever reported utilizing one of the formal services/sources of support asked about in the survey: police, 37 medical, psychological/counseling, and crisis hotline. These variables were checked against the list of all perpetrators of sexual violence to ensure that all formal help-seeking reported was related to a sexual violence perpetrator. Mental health help-seeking. This binary variable was calculated by combining and dichotomizing the respondent’s answers to two formal sources of help. The two formal sources combined for this variable are 1) talking to a psychologist or counselor and 2) calling a crisis hotline (0=no mental health services sought, 1=mental health services sought). These variables were checked against the list of all perpetrators of sexual violence to ensure that all mental health help-seeking reported was related to a sexual violence perpetrator. Analysis Descriptive statistics and frequencies were assessed and reported for all explanatory variables and dependent variables. Bivariate relationships between dependent variables and the explanatory variables were assessed for statistically significant relationships (Figure 2). Binary logistic regressions were utilized to identify predictors of help-seeking behavior. Missing data were examined using SPSS 25 Missing Value Analysis. The data were tested using Little’s MCAR (Little, 1988) and were not significant (x2 (df=23) = 20.785, p=.594), thus the missing values are missing completely at random (MCAR). Percentage of missing data ranged from 0% to 4.7%. Due to the assumption of MCAR being satisfied (Kang, 2013) and each variable had less than 5% of its variables missing, listwise deletion was used in analysis (Graham, 2009). Analyses were performed using unweighted data due to a lack of information available on the creation of the weights within the dataset (Rosay, 2016), as well as a lack of agreement in the literature regarding use of survey weights in regression modeling (Gelman, 2007). When results of logistic regression using weighted and unweighted data obtained through complex 38 sampling design were compared by Shin and Hanna (2017) in one set of surveys, the differences were found to be unsubstantial. Additionally, when sampling weights were based only on independent variables (e.g. sex, race, age, and state [in U.S.]) (Rosay, 2016), as was the case with this dataset and analyses, Winship and Radbill (1994) suggest that unweighted analyses are preferred. IBM SPSS Statistics 25 was utilized for all statistical analyses in this manuscript. Figure 2. Diagram of individual-level analyses (Chapter Two/Manuscript 1) Research Question 1: Prevalence of Help-Seeking Results As shown in Table 1, more than half (n=984, 62.7%) of the male victims of sexual violence in the survey sought some form of professional help or informal support. Of this group of individuals who sought help, more than half of them (623 males, 63.3% of the 984 males who sought help) did not engage in any sort of formal help-seeking behavior (seeking the help of a law enforcement, medical, or mental health services). These individuals, instead, chose to disclose their victimization to someone in their informal network, such as a friend, family member, intimate partner, and/or other individual known to the victim. A smaller group (361 males, 36.7% of the 984 males who sought help) sought some form of formal help. 39 Table 1. Summary of Help-Seeking Variable Frequencies (n=1,569) Dependent Variable Did victim seek help? Yes No Level of help sought (n=984) Informal disclosure only Formal services sought Sought mental health services Yes No Frequency 984 585 623 361 253 1,316 Valid Percent 62.7 37.2 63.3 36.7 16.1 83.9 Both formal and informal sources of help and support varied in relation to their utilization prevalence among male victims, as shown in Table 2. Among the informal sources of help and support, disclosure to a friend (a non-intimate partner) was the most popular. Male victims reported this form of informal help-seeking 635 times; thus, 37.2% of informal help sought was from a non-intimate partner. These males also sought help from family members (39.1% of informal help sought), intimate partners (18.7% of informal help sought), and other people in their lives (5.0% of informal help sought). Among the formal sources of help and support, psychological or counseling services were the most popular, utilized 338 times (46.3% of formal help sought) by the male victims in the survey. Other sources for formal help included law enforcement (30.8% of formal help sought), medical (20.0% of formal help sought), or a crisis hotline (2.9% of formal help sought). Table 2. Victims’ Sources of Help Sought (non-mutually exclusive) Variable Formal Police Medical Psych and Crisis Informal Non-IP/friend Family IP Other Frequency 151 98 241 635 668 320 85 Valid Percent 15.3 10.0 24.5 64.5 37.4 32.5 8.6 40 Bivariate relationships between help-seeking and explanatory variables. Bivariate relationships were assessed between each of the explanatory and dependent help-seeking variables. Statistically significant results are reported and discussed in this manuscript. Help-seeking. Explanatory variables were assessed for bivariate relationships with general help-seeking among the whole sample of male victims of sexual violence (n=1,569), using chi-square tests of independence and independent-samples t-tests. General help-seeking was statistically significantly related to race ( x2 (1, 5.71) = 15.24, p=.017), with white male victims of sexual violence (n=819, 64.2%) more likely to seek help than minority male victims (n=156, 56.5%); sexual partner choice (x2 (1, 1563) = 27.87, p<.001), with men who had sex with men or both men and women (n=152, 80%)were more likely to seek help than men who only had sex with women or had never had sex(n=827, 60.2%); and education level (t(1143)=- 2.63, p=.009), with males who sought some form of help reporting higher education levels (M=5.82, SD=1.59) than those who did not seek formal or informal help (M=5.59, SD=1.73). Control variables. Control variables were assessed for bivariate relationships with general help-seeking among the whole sample of male victims of sexual violence (n=1,569), using a chi-square test of independence and an independent-samples t-test. General help-seeking was statistically significantly related to severe sexual victimization (x2 (1, 1,569) = 19.74, p<.001), with men who had experienced severe sexual violence (n=284, 72.1%) were more likely to seek help than men who did not report an experience of severe sexual violence (n=700, 59.6%); and number of perpetrators (t(1310.7)=-4.08, p<.001) with the males who sought some form of help reported higher numbers of perpetrators (M=2.53, SD=2.37) than those who did not seek formal or informal help (M=2.03, SD=2.175). 41 Formal help-seeking. Explanatory variables were assessed for bivariate relationships with formal help-seeking among the male victims who sought some form of help (n=984), using chi-square tests of independence and independent-samples t-tests. Formal help-seeking was statistically significantly related to sexual partner choice (x2 (1, 979) = 47.01, p<.001), with men who had sex with men or both men and women (n=93, 61.2%) were more likely to seek help than men who only had sex with women or had never had sex (n=265, 32.0%); and yearly income (t(645.9)=3.75, p<.001), with males who did not seek formal help reported higher yearly incomes (M=5.97, SD=2.03) than those who sought formal help (M=5.40, SD=2.33). Control variables. Control variables were assessed for bivariate relationships with formal help-seeking among the male victims who sought some form of help (n=984), using a chi-square test of independence and an independent-samples t-test. Formal help-seeking was statistically significantly related to severe sexual victimization (x2 (1, 984) = 14.20, p<.001), with men who had experienced severe sexual violence (n=130, 45.8%) were more likely to seek formal help than men who did not report an experience of severe sexual violence (n=231, 33%); and number of perpetrators (t(589.88)=-3.47, p=.001) with the males who sought formal help reported higher numbers of perpetrators (M=2.88, SD=2.79) than those who did not seek formal or informal help (M=2.30, SD=2.06). Mental health services sought. Explanatory variables were assessed for bivariate relationships with formal help-seeking among the male victims who sought formal help (n=361), using chi-square tests of independence and independent-samples t-tests. Seeking mental health services was statistically significantly related to sexual partner choice (x2 (1, 358) = 9.65, p=.002), with men who had sex with men or both men and women (n=77, 82.8%) were more 42 likely to seek help than men who only had sex with women or had never had sex (n=174, 65.7%). Control variables. Control variables were assessed for bivariate relationships with mental health services among the male victims who sought formal help (n=361), using a chi-square test of independence and an independent-samples t-test. Seeking mental health services was statistically significantly related to severe sexual victimization (x2 (1, 361) = 9.53, p=.002), with men who had experienced severe sexual violence (n=104, 80.0%) were more likely to seek formal help than men who did not report an experience of severe sexual violence (n=149, 65.5%). Research Question 2: Predictors of Help-Seeking Behavior Binary logistic regression analysis was utilized to predict the probability of help-seeking for sexual victimization. The predictor variables were race, sexual partner choice, yearly income, and level of education, with control variables of experience of sexual victimization and number of lifetime perpetrators of sexual violence. A test of the full model, versus a model with intercept only, was statistically significant χ2(6, 1,477)=66.05, p<.001. The model was able to correctly classify an overall percentage of 63.4%. The logistic regression coefficient, standard error, odds ratio, confidence interval (95%), and significance can be found in Table 3. Race, sexual partner choice, education, number of perpetrators, and the experience of severe sexual victimization had statistically significant effects when using .0as the criterion for statistical significance. The odds of seeking help from at least one formal or informal source were 1.35 times higher for those who identified as white than for those who identified as nonwhite. The odds of seeking help are 2.02 times higher for those who have had sex with men at some point in their lives than they are for those who have only had sex 43 with women or who have never had sex. For each additional level of education that the victim reported, the odds of seeking some form of help are increased by 1.10 times. For each additional perpetrator of sexual violence that the victim reported, the odds of seeking some form of help are increased by 1.11 times. The odds of seeking help were 1.62 times higher for those who had experienced severe sexual victimization. The relationship between income and the general help- seeking variable was not statistically significant. Table 3. Logistic Regression Results Using General Help-Seeking as Dependent Variable (n=1477a) B White Men who have sex with men Education Income Number of perpetrators of SV Experience of severe victimization Constant a92 cases missing * p<.05. **p<.01. ***p<.001. 0.303* .704*** 0.095** -0.030 0.103*** 0.482*** -0.513* SE 0.145 0.198 0.037 0.028 0.030 0.138 0.246 Odds Ratio 1.354 2.022 1.100 0.970 1.109 1.619 0.599 CI (95%) 1.020-1.799 1.370-2.983 1.023-1.183 0.917-1.026 1.046-1.175 1.236-2.122 Research Question 3: Predictors of Seeking Formal Support Binary logistic analysis was utilized to predict the probability of formal help-seeking for sexual victimization. The predictor variables were race, sexual partner choice, yearly income, and level of education, with control variables of experience of sexual victimization and number of lifetime perpetrators of sexual violence. A test of the full model, versus a model with intercept only, was statistically significant χ2(6, 926)=73.865, p<.001. The model was able to correctly classify an overall percentage of 68.0%. The logistic regression coefficient, standard error, odds ratio, confidence interval (95%), and significance can be found in Table 4. Sexual partner choice, yearly income, and number of perpetrators had statistically significant effects when using .05 as the criterion for statistical 44 significance. The odds of seeking formal help are 3.05 times higher for those who have had sex with men at some point in their lives than they are for those who have only had sex with women or who have never had sex. For each increase in yearly income level reported by the respondent, the odds that the victim will have sought some form of formal help decrease by .875 times. For each additional perpetrator of sexual violence that the victim reported, the odds of seeking some form of help are increased by 1.07 times. Race, education, and severe victimization experienced were not statistically significant. Table 4. Logistic Regression Results Using Formal Help Sought as Dependent Variable (n=926 a) B White Men who have sex with men Education Income Number of perpetrators of SV Experience of severe victimization Constant a58 cases missing * p<.05. **p<.01. ***p<.001. 0.265 1.12*** 0.082 -0.134*** 0.071* 0.263 -0.919** SE 0.200 0.197 0.050 0.036 0.030 0.161 0.333 Odds Ratio 1.303 3.050 1.086 0.875 1.074 1.301 0.399 CI (95%) 0.881-1.927 2.072-4.490 .985-1.197 0.815-0.938 1.012-1.039 0.950-1.783 Research Question 4: Predictors of Seeking Mental Health Services Binary logistic regression analysis was utilized to predict the probability of seeking mental health services for sexual victimization. The predictor variables were race, sexual partner choice, yearly income, and level of education, with control variables of experience of sexual victimization and number of lifetime perpetrators of sexual violence. A test of the full model, versus a model with intercept only, was statistically significant χ2(6, 342)=20.75, p=.002. The model was able to correctly classify an overall percentage of 69.6%. The logistic regression coefficient, standard error, odds ratio, confidence interval (95%), and significance can be found in Table 5. Sexual partner choice and experience of severe sexual 45 victimization had statistically significant effects when using .05 as the criterion for statistical significance. The odds of seeking help from at least one mental health service provider are 2.66 times higher for those who have had sex with men at some point in their lives than the odds are for those who have only had sex with women or who have never had sex. Race, education, yearly income, number of sexual perpetrators, and severe victimization experienced were not statistically significant. Table 5. Logistic Regression Results Using General Mental Health Help-Seeking as Dependent Variable (n=342a) B White Men who have sex with men Education Income Number of perpetrators of SV Experience of severe victimization Constant a19 cases missing * p<.05. **p<.01. ***p<.001. 0.320 0.980** -0.009 -0.070 -0.024 0.550 0.692 SE 0.336 0.343 0.087 0.060 0.048 0.287 0.575 Odds Ratio 1.377 2.664 0.991 0.932 0.976 1.733 1.998 CI (95%) 0.712-2.662 1.359-5.220 0.836-1.175 0.829-1.049 0.889-1.072 0.987-3.040 Due to the high level of significance and effect size found MSM across all three analyses, ad hoc analysis was performed to assess for differences in the small group of MSM in comparison to the larger group of men who only had sex with women or who had never had sex. The relationship between sexual partner gender and severity of victimization was statistically significant (x2 (1, 1563) = 41.78, p<.001) with MSM were more likely to have reported that they had experienced severe sexual victimization than those who reported only having sex with women. An independent-samples t-test was conducted to compare. The relationship between sexual partner choice and income or sexual partner gender and race was not statistically significant. The relationship between sexual partner gender and education was statistically significant (t(251.93)=-3.89, p<.001), with MSM reporting higher levels of education (M=6.15, SD=1.55) than those who reported only having sex with women (M=5.68, SD=1.65) conditions. 46 The relationship between sexual partner gender and number of perpetrators of sexual violence was statistically significant (t(214.35)=-3.92, p<.001), with MSM having higher numbers of perpetrators (M=3.14, SD=3.14) than those who reported only having sex with women (M=2.22, SD=2.15) conditions. Discussion This study used secondary data from the National Intimate Partner and Sexual Violence Survey to examine choices around seeking help among 1,569 male victims who have experienced sexual violence their lifetimes. Individual-level information was collected for each of victims, including race, choice of sexual partner, education level, and yearly income, and were compared between the groups of males who sought help and those who chose not to seek help. This study adds to the existing literature around male victims of sexual assault and their help- seeking behavior, in addition to increasing the ways that the NISVS dataset has been explored. Implications for clinical and macro social work stem from these findings, as well as suggestions for policy implementation and future areas of research. Increased understanding of this population will lead to better services available to male victim, as well as increased accuracy in estimates of prevalence. Prevalence More than half (63%) of the male victims of sexual violence in this sample sought help from some source, formal or informal. However, this percentage decreases to approximately 23% of the sample of male victims of sexual assault when the respondents report their help- seeking behaviors involving law enforcement, medical services, and mental health services. In comparison to other estimates found in the literature, this number is a little higher, as male victims of sexual violence were reported to have sought help from some formal or professional 47 source at levels ranging from 12.5% to 17.6% (Walker, Archer & Davies, 2005; King & Woollett, 1997; Masho & Alvanzo, 2009; Tjaden and Thoennes, 2006). In the sample, approximately 16% of male victims reported seeking mental health services, which is within the range reported in existing studies. Of the formal help sought, mental health services were sought at the highest rates, above the help of law enforcement, medical care, or crisis hotlines. That men sought help from mental health services at a higher rate than medical services is understandable given that not every act of sexual violence requires medical attention. The lower rate of seeking help from the police, in comparison to mental health services, may be explained by several factors. First, there is some evidence that male victims of sexual violence are treated derisively or dismissed entirely when seeking help from law enforcement (Rumney, 2009). Additionally, male victims tend to minimize their victimization experiences and may not consider their experience of violence to be severe enough to report to the police (McCart et al., 2010). Finally, victims of sexual violence may have privacy concerns or fear of the perpetrator that prevent them from reporting to the police (Cohn, Zinzow, Resnick, & Kilpatrick, 2013). The low rate of crisis hotline use is unexpected, especially because there is some evidence that male victims value anonymity when seeking help (Andalibi, Haimson, De Choudhury, & Forte, 2016). However, as the use of online resources for information and support increases among adults (Smith & Olmstead, 2018), and text and chat online supports are available (Finn & Hughes, 2008), the need for traditional, telephone-based crisis hotlines has decreased. Race Nonwhite male victims of sexual violence were less likely to seek any help, either formal, informal, or both, than their white counterparts. These findings are in line with the literature 48 regarding race, as many studies found that white victimized women are more likely to seek help after sexual violence than African American or Latina female victims (Amstader, McCauley, Ruggerio, Resnick, & Kilpatrick, 2008; Golding, 1989; New & Berliner, 2000; Starzynski et al., 2007; Ullman & Brecklin, 2002; Ullman, 2007). That this racial difference in help-seeking behavior also exists for male victims of sexual violence is less documented but is supported within this study. It is less clear as to why the relationship between race and seeking help diminished for formal seeking and seeking mental health services, though Trimble (2007) suggests that, in some studies, race may become statistically significant due to other variables that remain unexplored. An ad hoc independent-samples t-test was conducted to compare race and income among those who sought help to assess for income and race collinearity; however, the relationship between variables was not statistically significant. More research is needed to understand the relationship between race and male formal help-seeking behaviors. Education and Income A higher level of education was predictive of increased likelihood of help-seeking in general. This finding supports the existing results in the literature related to the relationship between help-seeking behavior and education (Kaukinen et al., 2013; Ullman & Brecklin, 2002). Income was predictive of formal help-seeking behavior; however, education and income variables were not significantly correlated with each other, and income did not predict formal help-seeking in the expected direction. The male victims who reported higher yearly incomes were less likely to engage in formal help-seeking; however, income did not have a statistically significant relationship to general help-seeking or seeking mental health services. Though increased income is generally considered to facilitate help-seeking behaviors (Asser, 1978; Ghafoori, Barragan, Palinkas, 49 2014), there is some explanation as to why the reverse may be true in some cases. For example, Kaukinen, Meyer, and Akers (2013) found that female victims of IPV with higher incomes were less likely to seek formal help than those with lower incomes. Some explanations for this relationship may include the ability to resolve issues outside of standard channels due to wealth, and the desire for privacy and status retention (Kauiken, Meyer, and Akers (2013). This desire for privacy and to not diminish status may be increased in male victims due to masculinity norms, such as wanting to be perceived as strong and associating victimhood with femininity. Sexual Orientation Though most of the literature regarding gay and bisexual men and help-seeking behavior following an incident of sexual violence focuses on the barriers to seeking help, the results of the analyses in this study tell a different story. In fact, MSM in the sample were much more likely to seek all three types of help, any type (informal or formal), formal supports, and mental health services. While this is in distinct contrast to much of the literature, there are some instances of related findings. For instance, Merrill and Wolfe (2000) reported that among gay male victims of IPV 60–85% engaged in seeking informal support from their friends or family, while 75% sought formal help from an individual counselor, and 65% sought formal help from the police. There is evidence to suggest that gay and bisexual men are at a higher risk of sexual violence than their straight-identified male counterparts (Gold, Marx, & Lexington, 2007; Langenderfer-Magruder, Walls, Kattari, Whitfield, & Ramos, 2016; Rothman, Exner & Baughman, 2011). Some differences between the MSM group in the sample and those who reported only having sex with women included increased number of perpetrators of sexual victims and a higher percentage of those who identify as MSM reporting experiencing more severe types of victimization than their heterosexual counterparts, as found in the ad hoc 50 analyses related to sexual orientation and other covariate and control variables. This disparity in victimization may explain some of the difference in help-seeking. Further analysis of incident- level variables’ relationship with help-seeking behaviors will be conducted in Chapter 4. Additionally, the increased seeking of help across all levels of help-seeking may be explained by the aforementioned identified increased prevalence of sexual violence within the LGBTQ community, and thus, perhaps an increased access to formal and informal support within the community and, perhaps, a decreased amount of stigma and shame related to sexual victimization within that community. Unfortunately, at least one study refutes the access to the increased prevalence of sexual victimization resources within the LGBTQ community. Todahl et al. (2009) found that in a survey of LGBTQ individuals (respondents were 63.8% female, 30.8% male, 4.6% transgender/other) in the Pacific Northwest, 72% agreed that there is a problem with sexual violence in the LGBTQ community, and 86.7% thought that LGBTQ-specific sexual violence prevention was needed, as it was not a widely present topic of discussion. In logistic regressions that compared female respondents to male and transgender respondents, females were more likely to have used sexual assault services or know someone who has used them, more likely to be aware of services welcoming to them and, were more likely to identify that sexual violence is a problem in the community. Finally, some gay men may adopt alternate ways of interpreting and performing masculinity. Many of the barriers to help-seeking among men are rooted in the idea that hegemonic masculinity rejects males’ capacity to be victims or to be unable to fight back. For some gay men, the act of engaging in sex with another man was already an act that rejected compulsory heterosexuality (Rich, 1980) as well as other masculine norms (Connell, 2005), thus perhaps lowering Gender Role Conflict (O’Neil, 1981, 2008) when confronted with a decision 51 that challenges masculinity norms, creating room in their individual masculine identities for acknowledgement of their victimization and increasing the likelihood that they will seek out the sources they need to recover from sexual trauma. Limitations Despite the unique opportunity to study male sexual victimization this dataset provides for researchers, it also has some limitations. For example, perpetrator behavior is assessed for a wide number of types of sexual victimization, with a wide range of severity. While this level of specificity may be useful in some analyses, information is more limited in relation to help- seeking. Because the help-seeking variables are attached to the perpetrators, not a specific Eincident, it is not clear in cases where the perpetrator engaged in more than one type of sexual victimization or more than one type of victimization (i.e., IPV or stalking) which action prompted the help-seeking behavior. Despite evidence that informal help-seeking or disclosure is a facilitating factor to formal help-seeking behaviors (Campbell, 2015; Guerette & Caron, 2007; Konradi, 2007; Norris et al., 1990; Patterson & Campbell, 2010; Ullman & Brecklin, 2002), in this particular dataset, help- seeking and disclosure behaviors are not cataloged in the order that they were taken, so it is not possible to assess for causality between these two ways of seeking support. Additionally, there is no variable identifying when help was sought; thus, there is no way to calculate length of time to help-seeking behavior or to calculate the proximity between the date of help-seeking behavior and the date of the survey. The variables identifying income and education were collected to reflect educational level and yearly income at the time of the survey rather than at the time of victimization or help- seeking. Male victims who are victimized after childhood are more likely be younger—between 52 16 and 30 years old (Smith et al., 2017; Isely & Gehrenbeck-Shim, 1997; McLean, 2013)—and the mean age of the survey respondents who experienced sexual victimization is higher (35 to 44 years old at time of survey). However, in considering what is known about patterns of male help- seeking, this may be less of a problem than it seems. Men often delay disclosure and help- seeking. This pattern of delaying and, in many cases, only reporting when symptoms are severe, is present in cases of both physical and mental health issues (Doherty & Kartalova-O'Doherty, 2010; Gladas et al., 2004; Good, Dell, & Mintz, 1989; Moller-Leimkuhler, 2002), as well as in relation to sexual victimization. In a survey of 115 male victims of sexual violence, those who had been victimized prior to the age of 16 waited a mean length of 16.4 years to seek counseling services, while those who were victimized after the age of 16 waited a mean length of 7.3 years. Additionally, in cases of childhood victimization, male victims are more likely to wait longer to disclose, often into adulthood (Alaggia, 2010; McElvaney, Greene, & Hogan, 2012; Gagnier & Collin-Vezina, 2016; O’Leary & Barber, 2008), in one study, men waited an average of 30 years before disclosing (Easton, 2013). Thus, despite a lower age at the time of victimization and a higher age at the time of survey (and report of individual-level variables), the variables of income and education may be more closely related to the victim’s status at the time of help- seeking behavior. An additional limitation to this study is the use of gender of sexual partner as a proxy for the LGBTQ community. In this study, men who report that they have only ever had sex with men or that they have had sex with men and women were combined into one group. While the results of that group in analysis were reported as associations involving MSM or sexual partner gender, much of the discussion is drawn from literature that is primarily focused on sexual orientation, especially gay and bisexual men. Because of this, it is possible that some or all 53 aspects of the results and discussion may not resonate with those who identify as gay or bisexual. Finally, the NISVS does not seek respondents within jail or prison, closed organizations that report high numbers of sexually victimized males. Implications Implications for Clinical Practice Though not assessed in this study, a review of the literature shows that male victims of sexual victimization may experience negative responses from both formal and informal sources, ones who ideally would be sources of support and help (Donne, DeLuca, Pleskach, Bromson, Mosley, Perez, Mathews, Stephenson & Frye, 2018; Donnelly, 1996), in the literature on female victims, this may be defined as “secondary victimization” (Campbell, Wasco, Ahrens, Sefl, Barnes, 2001; Campbell & Raja, 1999). This risk of secondary victimization may be even more pronounced for gay men, as LGBTQ individuals may be more likely to experience less satisfaction with mental health service providers than their heterosexual counterparts due to discrimination (Avery, Hellman & Sudderth, 2001; Rutherford, McIntyre, Daley & Ross, 2012). Further research is needed to assess for satisfaction with and helpfulness of services sought by male victims. Additional training may be needed to sensitize providers on issues of male victims of sexual violence and masculinity. Providers of services (law enforcement, medical, and mental health) should be educated about the needs of sexually victimized LGBTQ or MSM men and their experiences. For mental health providers, including clinical social workers, assessments and intakes should be trauma-informed and sensitive to gender in a way that includes males. Implications for Macro Practice Based on the findings in this manuscript, the implications of this work include a need to normalize and encourage men, especially heterosexual men, to identify when they have been 54 victimized and normalize sexual victimization to minimize shame and increase help-seeking behaviors. Improved service referral systems for non-MSM men who don’t receive mental health services are needed, connecting male victims of sexual violence to other services and support as needed. Macro social workers should advocate for outreach programs that emphasize that incidents of sexual violence can happen to males, regardless of race, sexual orientation, or socioeconomic status. Implications for Research When considering the male victim of sexual violence, it is important to pay attention to the intersection of identities and experiences that differentiate these men from each other, as well as those things that may be similar among them. In this manuscript, individual-level barriers are explored, using race, sexual orientation, income, and education to create an approximation of identities. This work seeks to present how these identities and the intersection of these identities support or create barriers to the victim’s ability to seek help after a sexually traumatic event. What remains unexplored are the many complexities related to identity that are not easily quantified in a national survey. How might a male’s own definition of masculinity; or his identity as someone who has experienced sexual assault; or his status (or lack thereof) as a son, brother, husband, father, or friend; or his own experiences of discrimination as a person of color, or member of the LGBTQ population, or both influence his help-seeking behavior? How do these unmeasured identities diverge and intersect? This work provides new insight into the help- seeking decisions of sexually victimized males, but it also creates avenues for exploration in future research. 55 Conclusion This chapter utilized secondary data to explore the relationships between individual characteristics and help-seeking prevalence and patterns among male victims of sexual violence. Prevalence of help-seeking was explored, while rates of general help-seeking were quite high, over sixty percent, rates of seeking mental health services were much lower, about sixteen percent. White men and those with higher levels of education were more likely to seek general help, while lower income was associated with higher levels of formal help-seeking. Men who have had sex with men, or both men and women, were more likely to seek help across all three levels. These relationships are discussed in relation to the literature and in the context of masculinity theories and hegemonic masculinity. Implications of this study include a need for service providers, including social workers to develop relationships between service providers that serve male victims in order to link victims to needed services, as well as an increased need, especially among macro social workers to work toward decreased blame and stigma around sexual victimization and males seeking help. Finally, future research is needed to understand the intersection of the aspects of identity discussed in this manuscript and beyond. 56 CHAPTER THREE: PERPETRATOR-LEVEL CORRELATES OF SEXUALLY VICTIMIZED MALES’ HELP-SEEKING BEHAVIOR Abstract Men are reluctant to seek services and support, including those related to sexual victimization. This reluctance leads to decreased social support and treatment for male victims. Understanding relationships between perpetrator characteristics and the help-seeking behaviors of their male victims is a step toward increasing access to services for sexually victimized males. This study utilizes data from the National Intimate Partner and Sexual Violence Survey (NISVS) 2010 to explore associations between perpetrator characteristic variables (gender of perpetrator, relationship between victim and perpetrator, large age difference between younger victim and older perpetrator, and race of perpetrator in relation to victim) and help-seeking behaviors at three levels (general help-seeking, formal help-seeking, and seeking mental health services) among male victims (n=1,445) between whom have 3,099 perpetrators, utilizing descriptive and bivariate statistics, as well as multilevel logistic regressions with a Poisson link function. Gender of perpetrator was predictive of general help-seeking and formal help-seeking; those who were victimized by men were more likely to seek these types of help. Similarly, a friend or acquaintance relationship between the victim and perpetrator was predictive of increased mental health service use. Intimate partner perpetrators were predictive of increased use of all levels of help-seeking. A large age difference between a younger victim (24 years old and younger) and an older perpetrator was predictive of increased seeking of formal help. These findings are discussed in relation to theories of masculinity and help-seeking. Keywords: sexual violence, male victims, help-seeking, race, gender, perpetrator relationship, age difference 57 Introduction Though male sexual victimization is an issue that has gained more attention in recent years (Choudhary et al., 2012; Davies, 2002; McLean, 2013; Mezey & King, 2000; Stemple & Meyer, 2014), there are still major gaps in the literature around what prompts men to seek help after sexual victimization, as well as what factors may lead to male victims deciding not to seek help or not to disclose following sexual victimization. Despite negative outcomes of sexual victimization that in many ways mirror the psychological and emotional outcomes of female victims, male victims have low rates of help-seeking behaviors and disclosure. Males are less likely than females to seek help from professional services for general mental and physical health needs (Addis & Mahalik, 2003; Galdas et al., 2005; Yousaf et al., 2015), and this pattern of lack of help-seeking exists among male victims of sexual victimization, as well (Easton, 2014; Ullman & Filipas, 2005). Men’s reluctance to report sexual victimization makes it difficult to determine true estimates of male victimization (Dube et al., 2005). A clear understanding of male victims’ experiences with and reactions to sexual victimization may help move the knowledge base around this issue forward in several ways, including a better understanding of prevalence, increased clinical knowledge, and increased evidence for outreach needs. Because men’s lack of reporting influences the ability to accurately calculate prevalence, understanding the circumstances under which men are less likely to report will create greater understanding of the gaps and under-estimations that may be present in reports of prevalence of male sexual victimization. Some of the factors that may decrease the likelihood of seeking help post-victimization include not labeling their experiences of sexual violence as victimization (Artime et al., 2014), 58 the belief that their experiences were not severe enough to require help (Hammond et al., 2017) rape myth acceptance (Chapleau et al., 2008; Fisher & Pina, 2013), shame (Weiss, 2010), and/or fear that they will not be taken seriously (Jamel et al., 2008). However, in addition to those aspects present in the literature that seem to be particularly associated with male victims, there are individual-level, perpetrator-level, and incident-level characteristics. In this study, perpetrator characteristics will be explored to learn more about how these characteristics may be associated with the decision-making processes of male victims who seek help. Perpetrator characteristics (such as gender, age, race, and relationship with victim) have been found to be related to help-seeking among victims of sexual violence. Though most studies related to sexual assault focus on female victims and perpetrators, it is possible that these explanatory variables are similarly related to help-seeking behavior among male victims. Less explored among the literature surrounding female victimization, the gender of the perpetrator may be particularly salient to male victims’ help-seeking processes, especially when examined through the lenses of masculinity and male rape myths. Explanatory variables examined in relation to help-seeking behavior variables in this manuscript will be: gender of perpetrator, race of perpetrator in relation to victim’s race, large age difference between a younger victim and older perpetrator, and type of relationship between perpetrator and victim. Gender of Perpetrator Literature Review There are challenges associated with sexual violence perpetration by either gender. Men who are victimized by males may experience particular issues related to identity and sexual functioning. Confusion about sexuality is a potential outcome for heterosexual-identified males who are victimized by other men (Mezey & King, 1989; Peterson et al., 2011). Mezey and King 59 (2000), based on their previous research, ranked “non-consensual sex with a man as an adult” (p.10) as more severe than “non-consensual sex with a woman as an adult” (p.10) in their book. In a study involving hypothetical circumstances of sexual victimization, men reported that they would be more likely to report a sexual victimization incident by a male perpetrator to the police rather than an incident involving a female perpetrator. Despite this finding, this group still identified barriers to reporting a male perpetrator, such as fear of not having their report taken seriously and feelings of shame (Hammond et al., 2017). Using data from the National Survey of Family Growth, Cook, Morisky, Williams, Ford, and Gee (2016) found that 6% of the surveyed men reported being forced to have sex by a female perpetrator. When coercion was used in an assault, men reacted less negatively to female perpetrators than to males (Peterson et al., 2011; Struckman-Johnson & Struckman-Johnson, 1994). However, victimization by a female perpetrator carries its own barriers to reporting and seeking help, including embarrassment, belief that the victim would not be taken seriously or that the severity of the incident would be underestimated, and that the victimization would be difficult to prove (Hammond et al., 2017). Race of Perpetrator in Relation to the Race of the Victim The literature on help-seeking behavior and perpetrator race is limited and does not focus on how a certain race of the perpetrator may affect help-seeking behavior among sexually victimized males. The studies that do focus on race of the perpetrator and choosing to seek help explore the relationship between intra- and interracial victim/perpetrator relationships (George & Martinez, 2002). However, these few studies are varied in their findings. In some cases, a victim who experienced sexual violence by a perpetrator of a different race was more likely to report their victimization than those victimized by a perpetrator of the same race, among female college 60 students (Fisher et al., 2003; Gidycz & Koss, 1990). However, some studies’ findings report that race stereotyping may impact reporting sexual violence. Regardless of the race of female victims, sexual violence that happened interracially was subjected to more victim-blaming stereotypes (George & Martinez, 2002), and these incidents were less likely to be reported to the police in some studies (Koch, 1995; Weeler & George, 2001). However, female IPV victims in heterosexual interracial relationships were more likely to report experiences of sexual violence, and males in heterosexual interracial relationships were more likely to have a criminal charge more severe than simple assault than those in intraracial relationships (Lipsky, Cristofalo, Reed, Caetano & Roy-Byrne, 2012). Although the findings of Lipsky et al. (2012) are imbedded among more nuanced results, the increased presence of both reporting of sexual violence and more severe charges (though not related specifically to sexual violence) may suggest some sort of positive association between interracial victimization and willingness to seek help from law enforcement. Age Difference Between Perpetrator and Victim Literature related to perpetrator age is limited and, similarly to race, is situated in the literature in relation to the victim. Thus, in the same way that there is no relationship explored between a particular race of perpetrator and the victim’s decision to seek help, the literature does not point to a certain perpetrator age that increases the likelihood of reporting or seeking help. For example, age of the perpetrator as an absolute number (disregarding the age of the victims) has not shown to be a statistically significant predictor of help-seeking for sexual violence victimization among a mixed gender college student sample (Ameral, Reed & Hines, 2017). Rather, age difference might be an important factor in the victim’s decision-making related to seeking help. Female victims of IPV in heterosexual relationships were more likely to report 61 their victimization to police if their male perpetrator was older (Lipsky et. al., 2012). This study approaches age as related to a power difference that may exist between an older perpetrator and younger victim. Volpe, Hardie, Cerulli, Sommers, and Morrison-Beedy (2013) found that among adolescent girls and their older partners, the age difference was positively statistically significantly related to instances of physical and psychological IPV. Relationship Between Perpetrator and Victim Each type of victim/perpetrator relationship (i.e., stranger, friend/acquaintance, family, intimate partner) carries its own challenges and barriers. For example, Backes (2015) writes about the differences between women who report victimization by an intimate partner, versus victimization by a friend/acquaintance or family member. Female IPV victims were more likely than those victimized by a friend/acquaintance or family member to seek formal services beyond law enforcement (Backes, 2015), such as mental health or medical services. Female victims who experience violence from an intimate partner may be less likely to seek help than those who are victimized by a stranger (Mahoney, 1999; McCart et al., 2010), due to financial dependence, not wanting to disrupt their family, and fear of blame (Flicker, Cerulli, Zhao, Tang, Watts, Xia, & Talbot, 2011; McCart, et al., 2010). Stranger versus known individual as perpetrator. Koss (1985) found that individuals who know the perpetrator may be less likely to identify an incident of sexual violence as sexual assault or victimization. By not naming an act of victimization as sexual assault or sexual violence, this lowers a victim’s ability to be able to identify a need for support, further affecting help-seeking and disclosure behaviors. Stewart et al., (1987) found that victims with known perpetrator are less likely to seek help. When considering the differences between sexual assault by a stranger versus by a known person, Ullmann and Filipas (2001) found that assault by a 62 stranger is more likely to lead to formal help-seeking, while sexual assault by a known person is more likely to lead to informal disclosure. McCart et al. (2010) support this finding, identifying that individuals who are victimized by a stranger are more likely to seek medical attention. However, Masho and Alvanzo (2009) found that, of the 91 male victims of sexual assault in their study, victimization by a friend or family member increased the likelihood of seeking help from a professional source. Crime victims, especially victims of sexual violence, are generally more inclined to report assaults perpetrated by strangers to the police (Gartner & Macmillan, 1995; Jensen & Karpos, 1993; Kaukien, 2002, 2004; Resnick et al., 2000), though Kaukien (2002) found that known perpetrators caused victims to seek help within their personal networks, rather than seeking formal help. Additionally, victims of sexual victimization by a friend or acquaintance may experience increased blame, shaming, and/or scrutiny from providers of formal help, such as law enforcement, medical, and mental health professionals (Backes, 2015; George & Martinez, 2002). Most of the existing literature examines the relationships between female victims and their perpetrators, and many of these studies only examine certain relationships associated with certain types of help-seeking, rather than comparisons across types of relationships or potential avenues for help-seeking. Further attention is needed to understand how relationships with perpetrators may impact male victims’ help-seeking. This study will contribute to this gap in the literature by studying male victims of sexual violence and their help-seeking behaviors associated with different perpetrator relationships (i.e., stranger, acquaintance/friend, family, and intimate partner). 63 Current Study This study focuses on associations between perpetrator characteristics and the help- seeking behaviors of males who have experienced sexual victimization or violence. For the sake of this study, sexual violence is broadly defined in accordance with the variables within the NISVS, including forcible and drug/alcohol-facilitated penetration and being made to penetrate, sexual coercion, unwanted sexual contact (i.e. grabbing and kissing), and unwanted sexual experience that do not include contact (i.e exposure, harassment, and being made to watch or participate in sexual media). The men victimized in these ways often do not seek formal services and in many cases, do not disclose their victimization even to those closest to them. While there has been attention in recent years focused on female victims of sexual violence and predictors of help-seeking, much less is known about male victims’ patterns of help-seeking and disclosure and how the characteristics of the perpetrator of sexual violence impact the victim’s choice to seek help in general, from formal sources (i.e. police, medical, and mental health) and specifically from mental health services. Research Questions RQ1: What perpetrator characteristics are predictive of formal and informal help-seeking (general help-seeking) behaviors among male victims of sexual violence? RQ2: Among those male victims of sexual violence who sought help, what perpetrator characteristics are predictive of seeking formal support? RQ3: Among those male victims of sexual violence who sought formal help, what perpetrator characteristics are predictive of seeking help from mental health services? 64 Research Design Methods This correlational study used secondary data from the NISVS: General Population Survey (2010), a nationally representative cross sectional, retrospective telephone (landline and mobile) survey that collected information about experiences of intimate partner violence, sexual violence, and stalking among women and men aged 18 or older in the United States (Black et al., 2011; Smith et al., 2017). Information collected by the survey included respondent demographic information, detailed information about the respondent’s experiences of different types of intimate partner violence [psychological aggression(PA), coercive control(CC), physical violence (PV)], stalking, and sexual violence, collected based on each perpetrator, all measured for three timeframes: one year, three year, and lifetime. Lifetime victimization variables are utilized for analysis in this study. Additionally, follow-up information was collected both specific to individual sections and for the whole survey during the original data collection for individuals who met the criteria, which included being a victim of sexual assault. These follow-up sections include demographic information on individual perpetrators, the individual perpetrators’ actions and the victims’ reactions to those perpetrators’ actions, as well as outcomes and actions related to the reported victimization (e.g. help-seeking). Data Management Within this dataset, a complicating factor is the use of perpetrators to organize the data. Though the individual-level variables used as independent variables in these analyses are linked to the deidentified respondent identification number, most variables in the dataset are linked through the perpetrator. Due to the respondent’s freedom within the survey to list perpetrators in the order that they prefer in each section, the variable names PERP1-PERP94 are not indicative of 65 the specific perpetrator named in the variable name. The Sexual Violence section was restructured, creating a series of 22 binary perpetrator variables, indicating the presence or absence of each sexual violence behavior for each perpetrator listed by the respondent. An additional data management step is needed for the help-seeking variables. Help-seeking variables are found within one of the Follow Up sections in the database and are linked to the perpetrator through the use of a list of qualifying perpetrators for each Follow-Up section. Using this list to restructure the variables, it is possible to link the respondent to their help-seeking behaviors, perpetrator characteristics, and incident-level characteristics, through each perpetrator of sexual violence. Data access and storage. Access to this de-identified dataset (United States Department of Health and Human Services, 2014) was approved by the University of Michigan Inter‐ university Consortium for Political and Social Research/ National Archive of Criminal Justice Data on October 5, 2017. Prior to approval, the request for access was reviewed and approved by the Michigan State University (MSU) Vice President for Research and Graduate Studies and MSU Data Technologies. The data is stored on an external hard drive in a locked cabinet in a locked office and accessed using a computer with ASCOMP Software Secure Eraser 5.001 and Cypherix Cryptainer SE 11.6.0 installed. The research protocol for this study was submitted to the Michigan State University Institutional Review Board (IRB) and was approved as expedited. A letter stating this information was provided to the Dissertation Chair, Dr. Sheryl Kubiak, on August 9, 2017. 66 Sample The information in this dataset was collected between January 2010 and December 2010 from 16,191 adults who completed the survey, including 7,292 men (Figure 3), with 1,577 men reporting at least one experience of sexual violence. Figure 3. Diagram of sample selection for perpetrator-level analyses (Ch. 3/Manuscript 2) A subsample (n=1, 569, 21.5% of male respondents) selected for this study includes all males who reported at least one perpetrator of one of the 22 types of sexual violence listed in the Sexual Violence section of the NISVS (see below) within the first fifteen perpetrators listed by the victim in their survey responses. For each type of violence, the survey allows the respondent to list up to 15 perpetrators for each sexual violence behavior, with the potential of 94 individual perpetrators listed for each victim (PERP1 to PERP94). To remove outliers and reduce amount of variable creation, while still retaining an adequate representation of each respondent’s perpetrator list, the perpetrator variables were truncated after PERP15. Before truncation, the victim’s number of perpetrators during their life time ranged from (1-19), in variables between PERP1 and PERP38. Truncating the perpetrator variables at PERP15 reduced the sample by eight individuals who listed their first perpetrator of sexual violence as PERP16 or 67 higher in the survey. Incident-level (e.g. if there was injury as a result of perpetrator’s actions) (discussed in Chapter 4) and perpetrator-level variables (e.g. relationship with perpetrator) (discussed in this chapter) were not considered in sample selection, however perpetrators of sexual violence who were also perpetrators of IPV were removed from the sample, thus reducing the number of victims from 1,569 to 1,445. Within the sample of male victims of sexual violence(n=1,445), the victims ranged between the age group 18-24 (11.4%) to 55+ (31.9%). The majority of the sample identified their race as White (82.4%), with the remaining 17.6% consisting of individuals who identified as Black/African American (8.0%), Asian (2.5), Native Hawaiian/Pacific Islander (0.1%), American Indian/Native Alaskan (2.5%), and Other (3.5%). of the 131 individuals who identified as Hispanic, 55.6% identify as White and 44.4% identify as non-White when race is dichotomized. Among those who identified a sexual orientation, 88.6% are heterosexual, 10.1% identify as LGBTQ (6% gay men, 4% bisexual, and 0.1% transgender). However, the utility and accuracy of this variable is limited due to the large number of missing values (missing n=589). About 88% the men in the sample report exclusively having sex with women and about 12% of the sample has either exclusively had sex with men, or with both men and women. Education level within the sample ranged from “no schooling” (0.1%) to a post graduate degree (18.1%), with the largest groups in the sample attending some college or getting a four year degree (45%). Yearly income ranged from $10,000 a year or less (5.4%) to over $75,000 (31%). Almost 88% rated themselves in “Good” or better mental health and almost 80% rated themselves as having “Good” or better physical health. Sub-samples. In order to answer the second and third research questions, sub-samples were drawn from the population of male victims of sexual violence. The first sub-sample consists of all 68 males who reported that they had sought any sort of help as a response to a perpetrator of sexual violence (n=846). This group was used for analysis for research question two (who sought at least one type of formal help). From this sub-sample, a second sub-sample was drawn, consisting of those males who reported seeking at least one form of formal support (i.e. law enforcement, medical, psychological, and/or crisis hotline) as a response to a perpetrator of sexual violence (n=271). Analysis for research question three (who sought mental health services) was conducted using this sub-sample. Defining sexual violence for sample selection. Within the NISVS, sexual violence has been operationalized into 22 (or 21 survey questions, including one with two parts) separate perpetrator behaviors in five groupings: Rape, Made to Penetrate, Sexual Coercion, Unwanted Sexual Contact, and Non-Contact Unwanted Sexual Experience (Appendix G). For this study, all survey respondents who responded affirmatively to any of the sexual violence questions were included as a male victim of sexual violence. Level of severity of sexual violence was examined as a control variable in Chapter 2 and will be further addressed in Chapter 4 (Manuscript #3) as an explanatory variable. Perpetrator-level cases. Within this manuscript, perpetrator-level variables are utilized for analysis. While Chapter 2 explored the relationship between victim characteristics and the acts of seeking help, seeking formal help, and seeking mental health services, in Chapters 3 and 4 the choice to seek help and the type of help sought may vary among the victim’s decisions in response to different perpetrators’ victimization. Thus, within one victim, there may be perpetrators of sexual violence for whose behaviors the victim sought some form of help, some form of formal help, mental health services, all of those types of help, or no help at all. For the 1569 males in the sample who were sexually victimized, there are 3,545 perpetrators. The 69 victims have an average of 2.33 perpetrators, ranging from 1-15 perpetrators in this sample. Among the 984 victims who sought some form of help, there are 1700 perpetrators. The group of 361 men who sought help from at least one formal source (i.e., police, health care, and/or mental health) had 540 perpetrators among them. Because of the nature of the dataset, it is possible that each of perpetrators could have committed more than one act of assault toward the victim. It is due to this non-specificity of incident outcomes that perpetrators of IPV physical violence (in addition to the required sexual victimization behavior(s) were removed from the sample for this set of analyses. Independent Variables Gender of perpetrator. In this study, gender of perpetrator was operationalized as the gender reported by the survey respondent for each perpetrator. This variable has been dichotomized as male perpetrator (1) or female/non-male perpetrator (0). There were no missing values. Almost forty seven percent (n=1451) of the perpetrators in the overall sample (n=3099) were male. Race of perpetrator in relation to race of victim. Because the literature suggests that the relationship between help-seeking and race is not race itself, but rather the sameness or difference between the victim and perpetrator (Fisher et al., 2003; Lipsky, Cristofalo, Reed, Caetano & Roy-Byrne, 2012), race of perpetrator was operationalized in relation to the victim. This variable was created utilizing the first race category reported by the survey respondent for each perpetrator (Table 6) and for the victims (Table 7). The variables were them merged to identify combinations of victim/perpetrator races (Table 8) and dichotomized to creating a binary variable with categories of Same Race (1) or Different Race (0). There are 9 missing victim race values, 34 victims who listed their race as “Other,” (Table 6) 119 missing perpetrator race 70 values, and 166 perpetrators listed as “Other”. Due to the number of missing and unable to be categorized values, there are 376 missing values in the dichotomous variable used in the multivariate analysis. Because this variable was created based on the literature to be tested in the multivariate analyses, it was kept in the analyses, despite a 12.1% missing data. Table 6. Perpetrators’ Race as Reported by the Victim (n=2,980a) Variable White African American Asian Native Hawaiian or Pacific Islander American Indian or Alaskan Native Other a 2294 362 55 21 82 166 Frequency 119 classified as missing (14 refused, 105 did not know). Frequency Table 7. Victim’s Race as Reported by the Victim (n=1,445a) Variable White African American Asian Native Hawaiian or Pacific Islander American Indian or Alaskan Native Other a 15 missing. Table 8. Perpetrator and Victim Race Combinations (n=3,099a) 1190 115 36 2 36 51 Valid Percent 77.0 12.1 1.8 0.7 2.8 5.6 Valid Percent 83.2 8.0 2.5 0.1 2.5 3.6 Variable Frequency Valid Percent Same Race White African American Asian Native Hawaiian American Indian Different Racesa White/African American White/Asian White/Native Hawaiian White/American Indian African American/Asian African American/Native Hawaiian African American/American Indian Asian/Native Hawaiian a 2277 2077 162 19 1 18 446 258 65 17 78 6 1 18 3 73.4 67.0 5.2 0.6 0.0 0.6 14.5 8.3 2.1 0.5 2.5 0.2 0.0 0.6 0.1 No distinction is made between victims’ and perpetrators’ races. If race was unknow for victim or perpetrator, treated at missing (n=376). 71 Age difference between perpetrator and victim. Age was operationalized as the difference in age between the victim and perpetrator, estimated based on calculations using the categorical ordinal age categories for victim and perpetrator reported by the respondent. Perpetrators were coded as being meaningfully older than their victims if there was at least one full ordinal category between themselves and a victim under the age of 24 (Table 9). Thus, this variable consists of perpetrators who were at or above 18 years old who victimized someone 10 years of age or younger, perpetrators who were 25 years old who victimized someone 17 years old or younger, and perpetrators over 35 years old who victimized someone 24 years old or younger. The age differences between victim and perpetrator were dichotomized into one variable reflecting the presence of a large age difference, which will be utilized in the regression instead of perpetrator age. Table 9. Large Age Difference between Perpetrator and Victim is 24 Years Old or Less (n=3,099) Variable Large age difference exists Victim’s age ≤10/ Perp’s age ≥ 18 Victim’s age ≤ 17/ Perp’s age ≥ 25 Victim’s age ≤ 24/Perp’s age ≥ 35 No large age difference 6.0 2.4 2.3 1.3 94.0 Valid Percent Frequency 187 74 72 39 2914 Relationship with perpetrator. In this study, the relationship between the perpetrator and the victim is operationalized utilizing the answer to categorical survey question “What was your relationship to {initials} the first time this/any of these things happened?” This variable was categorized into four values: friend/acquaintance, family, intimate partner, stranger (Table 10). There were 30 missing values. For multivariate analysis, two dummy variables were created: 1) intimate partner, and 2) friend/acquaintance/family, with stranger as an omitted reference category. 72 Frequency Valid Percent Table 10. Perpetrators’ Relationship with Victim, as Reported by the Victim (n=3,069a) Variable Intimate Partner Family Friend/Acquaintance Stranger a 30 missing. Dependent Variables 494 130 1448 997 24.1 3.7 43.6 28.5 Help-seeking. This binary variable (0= no help-seeking, 1=help was sought) was calculated by assessing for all help-seeking. Throughout the manuscript, general help-seeking and any help-seeking were used interchangeably to refer to this variable. Then these variables were checked against the list of all perpetrators of sexual violence to remove all instances of help-seeking that are not directly related to a sexual violence perpetrator. For example, some victims reported help-seeking in response to the actions of a perpetrator of IPV or stalking who did not also commit a sexual violence against the victim. These instances of help-seeking were removed from the dataset in order to only reflect help-seeking behaviors as closely related to sexual victimization as possible. Formal help-seeking. This binary variable was calculated to reflect formal help-seeking (0=no formal help sought, 1=formal help sought). This variable reflected if the victim ever reported utilizing one of the formal services/sources of support asked about in the survey: police, medical, psychological/counseling, and crisis hotline. These variables were checked against the list of all perpetrators of sexual violence to ensure that all formal help-seeking reported was related to a sexual violence perpetrator. Mental health help-seeking. This binary variable was calculated by combining and dichotomizing the respondent’s answers to two formal sources of help. The two formal sources combined for this variable are 1) talking to a psychologist or counselor and 2) calling a crisis hotline (0=no mental health services sought, 1=mental health services sought). These variables 73 were checked against the list of all perpetrators of sexual violence to ensure that all mental health help-seeking reported was related to a sexual violence perpetrator. Analysis Descriptive statistics and frequencies were assessed and reported for all explanatory variables, as well as the dependent variables. Bivariate relationships between dependent variables and the explanatory variables were assessed for statistically significant relationships (Figure 4). Missing data were examined using SPSS 25 Missing Value Analysis. The data were tested using Little’s MCAR (Little, 1988) and were not significant (x2 (df=2) = 1.489, p=.475), thus the missing values are missing completely at random (MCAR). Percentage of missing data ranged from 0% to 12.1%1. Due to the assumption of MCAR being satisfied (Kang, 2013) and all variables, besides the combined race variable had less than 5% of its variables missing, listwise deletion was used in analysis (Graham, 2009). Multilevel analyses were necessary because there were multiple perpetrators nested within each victim and help-seeking behaviors for each perpetrator were not likely to be independent decisions within the same victim2. Multilevel logistic regressions with a Poisson link function were utilized to identify predictors of help-seeking behavior. This multivariate analytic strategy estimates risk ratios, rather than odds ratios, which are typically inflated when the phenomenon under study is common rather than rare (i.e., approaching 50% occurrence); this is a particular concern in multilevel analysis, where the estimated proportions of occurrence vary across individuals (Katz, 2006; McNutt, Wu, Xue, & 1 For more information, see the Race of Perpetrator in Relation to Race of Victim sub-section of Independent Variables in the Methods section for further explanation and description of this variable. 2 For more information, see the Perpetrator-level cases sub-section of Sample in the Methods section. 74 Hafner, 2003; Zhang & Kai, 1998). Risk ratios are interpreted as effects on the probability of occurrence of the dependent variable rather than the odds of occurrence, as with odds ratios. Analyses were performed using unweighted data due to a lack of information available on the creation of the weights within the dataset (Rosay, 2016), as well as a lack of agreement in the literature regarding use of survey weights in regression modeling (Gelman, 2007). When results of logistic regression using weighted and unweighted data obtained through complex sampling design were compared by Shin and Hanna (2017) in one set of surveys, the differences were found to be unsubstantial. Additionally, when sampling weights were based only on independent variables (e.g. sex, race, age, and state [in U.S.]) (Rosay, 2016), as was the case with this dataset and analyses, Winship and Radbill (1994) suggest that unweighted analyses are preferred. IBM SPSS Statistics 25 was utilized for all descriptive and bivariate statistical analyses and Stata 15 was utilized for multivariate analyses in this manuscript. Figure 4. Diagram of perpetrator-level analyses (Chapter Three/Manuscript 2) Research Question 1: Predictors of Seeking Help Results Bivariate analysis of explanatory variables and help-seeking behavior. Explanatory variables were assessed for associations with general help-seeking among the whole sample of 75 male victims of sexual violence (n=1,445) and their perpetrators (n=3,099). General help-seeking had a statistically significant association with gender of perpetrator (x2 (1, 3,099) = 29.56, p<.001) with males who had been victimized by a male (n=742, 52.1%) more likely to seek help for incidents involving that perpetrator than males victimized by a female (n=682, 47.9%); and large age difference between victim and perpetrator(, x2 (1, 2,723) = 6.683, p=.010) with victims much younger than their perpetrator (n=102, 55.1%) seeking help at higher rates for incidents involving that perpetrator than those males victimized at a later age or by someone closer in age to the victim (n=1322, 45.4%). An association between relationship and general help-seeking was observed, χ2(3, 3,069) = 11.78, p = 0.008), significant at p< .05, Bonferroni-adjusted for 4 comparisons. Multivariate analysis. Multilevel logistic regression with a Poisson link function analysis was utilized to predict the probability of help-seeking for sexual victimization. The predictor variables were perpetrator gender, perpetrator’s race in relation to victim, age difference, if perpetrator was an acquaintance/friend or family, and if the perpetrator an intimate partner. The coefficient, robust standard error, relative risk, confidence interval (95%), and significance can be found in Table 11. The likelihood ratio is significant x2 (5, 2,723) = 19.96, p=.0013). Gender of perpetrator had statistically significant effects when using .05 as the criterion for statistical significance. Having been victimized by a male perpetrator is associated with a 31% increase in the proportion of individuals seeking help for incidents involving that perpetrator. Victimization by an intimate partner is associated with a 24% increase in the proportion of individuals seeking help for incidents involving that perpetrator. 76 Table 11. Multilevel Logistic Regression Results Using General Help-seeking as Dependent Variable (n=2,723 perpetratorsa, 1,316 victimsb) Robust RR Gender Race Age Difference Intimate Partner Acquaintance/Friend or Family Constant Variance a438 cases missing b136 victims/groups * p<.05 **,p<.01. ***,p<.001. Coefficient 0.272*** 0.050 0.135 0.217* 0.005 -1.061*** 0.143 SE 0.848 0.076 0.097 0.114 0.665 0.034 0.029 1.312 1.052 1.145 1.242 1.005 0.346 0.143 CI (95%) 1.157-1.490 0.912-1.213 0.969-1.352 1.037-1.489 0.883-1.144 0.285-0.420 0.097-0.212 Research Question 2: Predictors of Seeking Formal Support Bivariate analyses of explanatory variables and formal help-seeking behavior. Explanatory variables were assessed for associations with formal help-seeking among the sub- sample of male victims of sexual violence who sought some form of help (n=846) and their perpetrators (n=1,420). In examining relationships between formal help-seeking and exploratory variables, gender of perpetrator is statistically significant (x2 (1, 1,420) = 26.32, p<.001) with victims of male perpetrators (n=253, 62.9%) seeking formal help at a higher rate for incidents involving that perpetrator than victims of female perpetrators (n=149, 37.1%); and large age difference between a younger victim and adult perpetrator was also significant in relation to formal help-seeking (x2 (1, 1,420) = 27.83, p<.001) with individuals who had a large age differences between themselves and their perpetrator seeking (n=52, 51%) seek formal help at a higher rate than others (n=350, 26.6) for incidents involving that perpetrator. An association between relationships and formal help-seeking was observed, χ2(3, 1,412) = 54.29, p <.001), significant at p< .05, Bonferroni-adjusted for 4 comparisons. Multivariate analysis. Multilevel logistic regression with a Poisson link function analysis was utilized to predict the likelihood of formal help-seeking for sexual victimization. The predictor variables were perpetrator gender, perpetrator’s race in relation to victim, age 77 difference, if perpetrator was an acquaintance/friend or family, and if the perpetrator an intimate partner. The coefficient, robust standard error, relative risk, confidence interval (95%), and significance can be found in Table 12. The likelihood ratio is x2 (5, 1,246) = 52.22, p <.001). Gender of perpetrator, presence of age difference, and if the perpetrator was an intimate partner, had statistically significant effects when using .05 as the criterion for statistical significance. Having been victimized by a male perpetrator is associated with an 86% increase in the proportion of individuals seeking formal help for incidents involving that perpetrator. The presence of a large age difference between a younger victim and an older perpetrator is associated with an 74% increase in the proportion of individuals seeking formal help for incidents involving that perpetrator. Being victimized by an intimate partner is associated with a 117% increase in the proportion of individuals seeking formal help for incidents involving that perpetrator. Table 12. Multilevel Logistic Regression Results Using Formal Help-seeking as Dependent Variable (n=1,246 perpetratorsa, 770 victimsb) Robust RR Coefficient 0.625*** SE 0.100 0.556*** 0.777*** Gender Race Age Difference Intimate Partner Acquaintance/Friend or Family Constant Variance a214 cases missing b91 victims/groups * p<.05. **p<.01. ***p<.001. Research Question 3: Predictors of Seeking Mental Health Services 0.252 0.163 0.232 0.386 0.141 0.025 0.075 1.868 1.106 1.743 2.176 1.108 0.124 0.287 -2.090*** 0.103 0.287 CI (95%) 1.435-2.432 0.828-1.476 1.342-2.263 1.536-3.080 0.864-1.423 0.083-0.184 0.172-0.478 Bivariate analyses of explanatory variables and help-seeking behavior. Explanatory variables were assessed for associations with seeking mental health services among the sub- sample of male victims of sexual violence who sought mental health services (n=271) and their 78 perpetrators (n=402). The relationship between gender of perpetrator and seeking mental health services was statistically significant, (x2 (402) = 12.75, p <.001), with those victimized by males (n=165, 57.5%) seeking mental health services at a higher rate for incidents involving that perpetrator than those males who were victimized by a female (n=122, 42.5%). Additionally, the race combination variable was significant in relation to seeking mental health services (x2 (357) = 9.39, p =.002) with victims whose race matched their perpetrator (n=229, 74.4%) seeking mental health services at a higher rate for incidents involving that perpetrator than those whose race differed from their perpetrator (n=26, 10.2%). A large age difference between a younger victim and adult perpetrator was also significant in relation to formal help-seeking (x2 (1, 402) = 8.52, p=.004) with individuals who had a large age differences between themselves and their perpetrator seeking (n=46, 88.5%) seek formal help at a higher rate for incidents involving that perpetrator than others (n=241, 68.9%). An association between relationship and formal help- seeking was observed, χ2(3, 398) = 52.54, p <.001), significant at p< .05, Bonferroni-adjusted for 4 comparisons. Multivariate analysis. Multilevel logistic regression with a Poisson link function analysis was utilized to predict the likelihood of seeking mental health services for sexual victimization. The predictor variables were perpetrator gender, perpetrator’s race in relation to victim, age difference, if perpetrator was an acquaintance/friend or family, and if the perpetrator an intimate partner. The coefficient, robust standard error, relative risk, confidence interval (95%), and significance can be found in Table 13. The likelihood ratio is x2 (5, 357) = 22.27, p <.001). Gender of perpetrator, presence of age difference, and if the perpetrator was a friend/acquaintance had statistically significant effects when using .05 as the criterion for statistical significance. Being victimized by a friend/acquaintance/family member is associated 79 with an 81% increase in the proportion of individuals seeking mental health services for incidents involving that perpetrator, while victimization by an intimate partner is associated with a 63% increase in proportion of individuals seeking mental health services for incidents involving that perpetrator. Table 13. Multilevel Logistic Regression Results Using Seeking Mental Health Services as Dependent Variable (n=357 perpetratorsa, 247 victimsb) Robust RR Gender Race Age Difference Intimate Partner Acquaintance/Friend or Family Constant Variance a65 cases missing b33 victims/groups * p<.05. **p<.01. ***p<.001. Ad Hoc Analyses Coefficient -0.130 0.136 0.094 0.494** 0.593*** -0.825*** 5.34e-36 SE 0.071 0.181 0.082 0.302 0.306 0.093 0.878 1.146 1.098 1.639 1.810 0.438 CI (95%) 0.750-1.029 0.840-1.563 0.947-1.272 1.141-2.352 1.300-2.522 0.289-0.664 1.46e-34 5.34e-36 2.96e-59 – 9.66e-13 Additional bivariate analyses were conducted in an attempt to further explore some of the results of the multivariate analyses. Crosstabs were utilized to assess for bivariate relationships between same race and acquaintance and between gender of perpetrator and severity of victimization (used in Chapter 2 analyses). In both cases the associations were not statistically significant. Discussion This study employed secondary data analysis to examine choices around seeking help among 1,445 male victims who have experienced sexual violence perpetrated by 3,099 individuals over the course of the victims’ collective lifetimes. Perpetrator-level variables, including gender of perpetrator, race of perpetrator in relation to the victim, whether there was a large age difference with a younger victim and older perpetrator, and relationship between victim and perpetrator, were compared at the perpetrator level between the males who sought help for 80 incidents involving that perpetrator and those perpetrators for whom the males chose not to seek help to better understand under which circumstances male victims of sexual violence are more likely to utilize general support, including from informal sources, formal services, and mental health services. Not only does this study further explore the National Intimate Partner and Sexual Violence dataset through the examination of this sample and these variables, but these findings add to the knowledge around male victims of sexual assault and their help-seeking behavior. Additionally, this work has implications for social work in both clinical and macro capacities and will inform future streams of research involving this group of victims. Gender of Perpetrator Being sexually victimized by a perpetrator of either gender creates unique challenges for the male victim. Gender of perpetrator was predictive of help-seeking behavior in general help- seeking and formal help-seeking. Those who were victimized by a male perpetrator were more likely to seek help for incidents involving that perpetrator, however, gender was not significant in the final model. In order to contextualize these results, the first thing to acknowledge is that men have a difficult time accepting the identity or label of victim regardless of the gender of the perpetrator. Not only does our society generally assume that a victim of sexual violence is female or a child (Lisak, 1993), but men are socialized in the same way —to believe that based on their gender, they are not able to be victims. This concept is supported by the way that gender is socialized, creating a dichotomy in which women are victims (Javaid, 2014; Sundaram, Helweg-Larsen, Laursen, & Bjerregaard, 2004); thus, men must be the opposite. Deviation from this indicates a departure from traditional or hegemonic masculinity (Åkerström, Burcar, & Wästerfors, 2011; David & Brannon, 1976; Connell, 2005; Javaid, 2015; Kimmel, 2003). This false belief about the 81 nature of victimization, specifically male sexual victimization, is a rape myth (Chapleau, Oswald, & Russell, 2008; Struckman-Johnson & Struckman-Johnson, 1992). Certain rape myths negate the very idea that a man could be a victim of sexual violence. For example, the idea that a man cannot be raped (Davies & Rogers, 2006; Javaid, 2017; Stermac, Del Bove, & Addison, 2004) or as Chapleau et al. (2008) state, that “men cannot be forced to have sex against their will” (p. 603). If a male victim has internalized this rape myth, regardless of the gender of the perpetrator, then it may be difficult for him to identify himself as a victim. It is due to these norms related to masculinity and male rape myths that a man may have a difficult time acknowledging his victimization experience or seeking help, regardless of the gender of his perpetrator. However, this concept sets the stage for a deeper understanding of the nuances related to experiencing and reporting sexual victimization experienced by male victims and to perhaps explain why men were more likely to seek help for victimizations by male perpetrators in this study. The results of this study indicate that men who are victimized by another male are more likely to seek some form of help, as well as to specifically seek formal sources of support. This finding is consistent with the literature, which suggests that male victims would be more likely to report a male perpetrator to the police (Hammond et al., 2017). Additionally, the literature around help-seeking, for non-sexual-assault-related needs indicates that, among men, increased severity of symptoms is related to an increased likelihood of seeking help at times delaying even when symptoms are quite severe (O’Brien, Hunt, & Hart, 2005). Among male victims of sexual violence, one of the barriers to reporting or seeking help is the concern that their victimization was not severe enough to warrant reporting or help (Hammond et al., 2017). 82 Some studies suggest that male sexual violence committed by a male perpetrator could be considered to be more severe, and have more severe outcomes, than a similar act of sexual violence committed by a female perpetrator (Mezey & King, 2000; Peterson et al., 2011; Struckman-Johnson & Struckman-Johnson, 1994). Thus, it follows this logic that the victims may be more inclined to report violence that they perceive to be more severe, and therefore, may be taken more seriously by friends, law enforcement, medical personnel, and mental health service providers. In this study, these severity factors may supersede the barriers associated with seeking help for victimization by a male perpetrator, despite concerns that they will be perceived as less masculine (Groth & Burgess, 1980) or that people will think they are not heterosexual (Sivakumaran, 2005). In the same way that masculinity is constructed in opposition to victimhood, femininity is not associated with the perpetration of violence, including sexual violence (Levy & Adam, 2018). Females are not only more likely to be perceived as victims (Howard, 1984), they are expected to be passive and non-violent (Kelland, 2011), and more likely to identify themselves as victims when compared to their male counterparts (Heru, 2001). This labeling of females as victims places them in opposition to the label of perpetrator creates a false narrative that characterizes men as perpetrators and women as victims. This false dichotomy creates a situation in which a male who has been victimized by a female is doubly subverting the socially accepted narrative. First, he must accept his identity as a victim, which places him in a feminine role. Then, he must recognize the incident as victimization, which is less likely when a male’s sexual perpetrator is female (Artime et al., 2014). A rape myth associated with male victims and female perpetrators suggests that “it is impossible for a woman to rape a man” (Turchik & Edwards, 2012, p. 212) or that “women cannot rape or sexually assault men” (Javaid, 2017, p. 7) and that 83 men are always willing and ready to engage in sexual activity (Chapleau, Oswald, & Russell, 2008; Clements-Schreiber & Rempel, 1995). Acceptance of these rape myths may mean that the victim is experiencing Gender Role Conflict, which leads to making choices that are not to the males benefit (such as not seeking help) to follow perceived gender expectations (O’Neil, 1981, 2008). Male sexual victimization by a female perpetrator is generally perceived to be less psychologically and physically traumatic (Chapleau, Oswald, & Russell, 2008; Levy & Adam, 2018; Struckman-Johnson & Struckman-Johnson, 1992), less likely to be intervened upon by a bystander (Rosenstein & Carroll, 2015), and more likely to be made into a joke in the media (Baer, 2011; Blay, 2016). These perceptions of female-perpetrated sexual violence understandably create barriers to formal help-seeking and informal disclosure by the victims. These barriers include embarrassment, worry that they will be dismissed or not taken seriously, concern that the severity of the incident would be underestimated, and that the victimization would be difficult to prove (Hammond et al., 2017). Race of Perpetrator in Relation to Race of Victim Though there were no statistically significant associations between help-seeking and race in any of the final models in the multivariate analyses, in bivariate analysis, victims of sexual violence with perpetrators of the same race sought mental health services for incidents involving that perpetrator at a higher rate than those who had a perpetrator of a different race but did not seek general help or formal help at a statistically significant higher rate. One study found that victims are more likely to report their victimization if the perpetrator is of a different race rather than the same race (Fisher et al., 2003). This may be because in cases of the same race, especially among minorities, the victim feels that he or she must protect the perpetrator, as 84 presented by Pagelow (1984) in regard to IPV, especially due to distrust of the police (Davis & Henderson, 2003; Reisig & Parks, 2000). Though this theory of racial solidarity in the face of institutional racism is less likely in this study due to a small number of non-white, same-race victim/perpetrator pairings (6.5% of the total perpetrators who were the same race as their victims), it is worth considering beyond this study, especially when applied to cases in which the perpetrator of sexual violence is not a stranger. Age Difference between Victim and Perpetrator In this study, a large age difference between a younger victim (24 years old and younger) and an older perpetrator was predictive of increased seeking of formal help and mental services for incidents involving that perpetrator. While this association and direction is supported by the existing literature, the relationship between age difference and help-seeking and reporting in the literature has primarily been explored among female victims of IPV. One possible explanation of this association exists in the knowledge that male victims have a difficult time interpreting incidents of sexual victimization as victimization (Artime et al., 2014). Perhaps in cases in which the perpetrator is quite a bit older than the victim, the male victim is more likely to recognize the loss of control that he has over the situation, thus leading to increased identification and reporting of the victimization. Relationship Between Victim and Perpetrator Because the existing literature on the association between help-seeking and the relationship between victim and perpetrator is varied in its conclusions, this study supports some aspects of the current knowledge base, while also challenging some of the underlying premises associated with victims of sexual violence and their help-seeking behaviors. There were two interesting findings within this study: 1) the associations between perpetrator acquaintance/friend 85 relationship and the dependent help-seeking variables in the multivariate analyses, and 2) the associations between the perpetrators being a stranger and the dependent help-seeking variables in bivariate analyses. While the association between a friend or acquaintance as perpetrator seems to support previous studies, findings related to a stranger perpetrator were somewhat unexpected. A friend/acquaintance or family relationship between the victim and perpetrator was predictive of increased-mental health seeking for incidents involving that perpetrator, despite not being predictive of increased seeking of general or formal mental health services for incidents involving that perpetrator. As previously discussed, regarding gender of perpetrator and age difference, victims of sexual violence, especially men, may struggle to identify sexual victimization as victimization. Those who are victimized by a known person are less likely to be able to identify if the incident was victimization (Artime et al., 2014; Koss, 1985) and are less likely to seek help (Stewart et al., 1987). Not identifying an incident of victimization as such naturally leads to decreased help-seeking. This study found that the association between victims with known non-IPV perpetrators, such as friends or acquaintances, and general or formal help- seeking was not significant. However male victims of acquaintance/friend perpetrators were more likely to seek out mental health services for incidents involving that perpetrator than other victims. This could be that with the increased privacy associated with the confidential nature of mental health services, the male victim feels more comfortable in discussing the impact of victimization by a friend or acquaintance. Ullmann and Filipas (2001) found that assault by a stranger is more likely to lead to formal help-seeking, while sexual assault by a known person is more likely to lead to informal disclosure. In this study, bivariate analyses suggest a negative relationship between having a 86 stranger as a perpetrator and seeking formal or mental health services. This association is surprising, especially due to the idea of the “real” or “normal” victim/rape playing a role in how victims are perceived (Estrich, 1987). Certain characteristics, such as female victims, injury during incident, perpetrator had a weapon, and perpetrator was a stranger (DuMont, Miller, Myhr; 2003; Hayes, Lorenz, & Bell, 2013; Patterson, D., Greeson, M., & Campbell, 2009; Rader & Rhineberger-Dunn, 2010), are considered to be signifiers of sexual violence that more people take seriously. While there was some expectation at the start of this study that the increased level (of stranger perpetrator towards a “normal” rape) might increase a male victim’s likelihood to seek help, it is not the case with this data. Limitations Limitations of the dataset have been discussed previously in this manuscript, focusing on the wide range of behaviors identified as sexual violence by the NISVS, the lack of temporality among the help-seeking variables, and the lack of respondents in prison. For further discussion of these limitations, see Chapter 2 limitations in this manuscript. A limitation of this dataset that impacted this manuscript is the mechanism of linking the victim to help-seeking behaviors through the perpetrator, rather than through an individual incident or behavior. For instance, we may know that a victim sought help due to the action of a particular perpetrator, and that the perpetrator committed sexual violence, as specified by the NISVS. However, if the perpetrator also engaged in another kind of victimizing behavior against the victim, for example IPV physical violence, there is no way to determine which victimization incident prompted the victim to seek which kind of help. This issue was addressed in the analyses by controlling for the presence of IPV physical violence, the type of victimization most likely to, along with sexual victimization, prompt the victim to seek various forms of help. 87 Implications for Clinical Practice Implications For clinical social workers, this increased understanding may help in assessment and treatment of sexual victimization of clients, as well as lead to an increased cognizance of their clients’ barriers in seeking their services. Increased clinical knowledge about the ways in which male clients may be feeling shame and judgement as a result of perpetrator-level characteristics, especially gender of and relationship with the perpetrator, are particularly important. Acknowledgement of the disenfranchised victimhood that male victims of female perpetrators may be experiencing and rejection of the concept that these victims experience less severe or impactful outcomes is particularly important. Implications for Macro Practice For macro social workers, understanding the predictors for seeking help may lead to an increased ability to accurately target groups of victims who may be more in need of outreach. This outreach could be in the form of advertisements in a community, informing community members of the true scope of sexual violence, or even increased media presence of different kinds of victims. Ideally, this outreach and advocacy would normalize perpetrator-level characteristics that cause victims to avoid seeking help, especially any of the areas that the victim perceives as potential blame inducing characteristics. Implications for Policy While United States classification of rape includes any kind of penetration, this is a recent change in the law. The Federal Bureau of Investigation (FBI) currently defines rape as “Penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim" (FBI, 2014). 88 This definition can be applied to any victim regardless of their biological sex characteristics. However, prior to January 1, 2013, the FBI’s Uniform Crime Reporting (UCR) code defined “forcible rape” as “the carnal knowledge of a female forcibly and against her will” (FBI, 2014, p. 1). This definition clearly limited the scope of rape to female victims, and in some cases may have limited the interpretation of the UCR code to exclude other types of sexual violence outside of penile penetration of a vagina (FBI, 2014, p. 1). While the definition of rape in the United Kingdom does contain the potential for male victims to be included, it assumes that the perpetrator is male and requires penetration with a penis to be distinguished as rape. The Sexual Offences Act of 2003 defines rape as committed by a person who “intentionally penetrates the vagina, anus or mouth of another person with his penis” (UK, 2003; Javaid, 2014). This definition should be broadened to acknowledge the possibility that female perpetrators may be capable of rape. Finally, while the United Nations has a very broad definition of sexual violence (WHO, 2012) and the organization has turned its focus to the plight of male sexual violence victims in Syria (Chynoweth, 2017), a more comprehensive position acknowledging the victimization of males in a more robust way is necessary to spread the need for international attention for this group of individuals in need of services and support. Implications for Future Research Additional inquiry is needed to explore the differences in gender of perpetrators within this dataset. Assessment of provider-level knowledge about ways in which perpetrator-level characteristics impact their clients would be an interesting step at either a community or national level to assess needs for additional training and outreach. A qualitative study that builds off the findings of this chapter would be particularly useful to assess the intricacies of the relationships between variables. 89 This chapter utilized secondary data to explore the relationship between perpetrator Conclusion characteristics and the decision of male victims of sexual violence to seek help at different levels. Relationships between three levels of help-seeking behavior and perpetrator variables including gender of perpetrator, race of perpetrator in relation to the victim’s race, age difference between victim and perpetrator, and relationship between victim and perpetrator were examined. The three levels of help-seeking behavior were: 1) any informal or formal support (general help- seeking); 2) formal support (i.e. medical, law enforcement, and mental health services); and 3) mental health services. If a perpetrator was male or was an intimate partner, the victim was more likely to seek general help for incidents involving that perpetrator. If the perpetrator was male, if there was a large age difference involving an older perpetrator, or if the perpetrator was an intimate partner, the victim was more likely to seek formal help for incidents involving that perpetrator. If the perpetrator was not a stranger, the victim was more likely to seek mental health services for incidents involving that perpetrator. Some recommendations that stem from this chapter include increased awareness among clinicians and increased outreach by macro social workers that both victims and perpetrators may be any gender. Additionally, acknowledgement of the unique barriers to seeking help for male victims based on gender of perpetrator and relationship to the perpetrator and understanding how these barriers may be related to theories of masculinity may be useful to clinicians. 90 CHAPTER FOUR: INCIDENT-LEVEL CORRELATES OF SEXUALLY VICTIMIZED MALES’ HELP-SEEKING BEHAVIOR Abstract Generally, males are less likely to seek help. This decreased likelihood is present in the comparison between male and female victims of sexual violence and their choices to seek services and support related to sexual victimization. This reluctance may lead to decreased social support, medical treatment, and mental health interventions for male victims of sexual violence. Data from the National Intimate Partner and Sexual Violence Survey (NISVS) 2010 is used to explore associations between incident-level variables (injury, missing work or school, fear of perpetrator, penetrative assault, and victim was a child at the time of the incident) and help-seeking behaviors at three levels (general help-seeking (both informal and formal help-seeking), formal help-seeking, and seeking mental health services) among male victims (n=1,445) and nested incidents/perpetrators (n=3,099) utilizing bivariate statistics, as well as multilevel logistic regressions with a Poisson link function. Although there may be many individual and perpetrator characteristics that influence this help-seeking decision, it is important to understand the characteristics and outcomes of the incident itself. Injury, missing school or work, and fear of perpetrator were positively associated with general help-seeking behavior and seeking formal help, however, fear of perpetrator was negatively related to seeking help from mental health services. Penetrative assault predicted increased use of formal sources of help, specifically mental health services. Victims who were ten years old or under at the time of victimization had increased likelihood of seeking help from formal sources. These findings are discussed in relation to theories of masculinity and help-seeking. Keywords: sexual violence, male victims, help-seeking, race, gender, perpetrator relationship, age 91 Introduction Despite recent increased attention to male sexual victimization in the empirical literature, (Choudhary et al., 2012; Davies, 2002; McLean, 2013; Mezey & King, 2000; Stemple & Meyer, 2014), there are still areas in need of further inquiry and attention, including the area of barriers and facilitators to seeking help among this population. Though the existing literature indicates that male victims of sexual assault experience negative psychological and emotional outcomes, male victims are reluctant to seek help, in part due to concerns related to their personal perceptions of masculinity. For needs unrelated to sexual assault, such as general mental and physical health needs, males are less likely than their female counterparts to seek help from professional services (Addis & Mahalik, 2003; Galdas et al., 2005; Yousaf et al., 2015), and this decreased likelihood of seeking help also seems to exist among male victims of sexual violence (Easton, 2014; Ullman & Filipas, 2005). There are a number of barriers to seeking help from formal sources, many of which are exacerbated by or specifically exist or are exacerbated due to societal norms of masculinity, and thus, may be more relevant to male victims. These include not characterizing the experience of sexual violence as victimization (Artime et al., 2014), thinking that the victimization experience was not severe enough to warrant help or attention (Hammond et al., 2017), rape myth acceptance (Chapleau et al., 2008; Fisher & Pina, 2013), shame (Weiss, 2010), and/or fear of not being taken seriously by the individuals or organizations (Jamel, Bull, & Sheridan, 2008). In addition to these barriers, there are incident-level characteristics and outcomes, individual-level, and perpetrator-level characteristics that have associations to female victims’ decisions to seek help or disclose their sexual victimization and may play similar roles in the decision-making processes of male victims choosing to seek help. 92 Literature Review Incident-level characteristics of sexual assault have been shown to play a role in victims’ decision-making processes related to seeking help, though less is known about the ways these variables may impact male victims of sexual violence. This section draws from help-seeking and victimization literature related to male victims of sexual violence when available, but most associations are explored through literature involving female victims of sexual assault or victims of non-sexually based incidents. The incident-level variables reviewed for this manuscript include characteristics, such as type of assault and if victim was a child at the time of victimization, and outcomes of assault, such as injury caused by perpetrator, work or school missed because of victimization, and victim felt fear because of the perpetrator’s actions. Physical Injury Caused by Perpetrator Physical injury during victimization is a predictor of help-seeking behavior among victims (Backes, 2015; McCart et al., 2010; Resnick et al., 2000; Starzynski et al., 2005; Ullman & Filipas, 2001). Masho & Alvanzo (2009), in a study of 91 male victims of sexual assault, found that only 17.6% sought professional help, with physical injury greatly increasing the likelihood of seeking help. In a study of 323 female sexual assault victims, Ullman & Filipas (2001) found that injury during assault predicted a higher rate of help-seeking from formal sources. In fact, there may be a link to physical injury and type of help-seeking or disclosure. Those injured are more likely to seek formal supports, while a lack of injuries would more likely encourage informal disclosure (Fisher, Daigle, Cullen & Turner, 2003). Among victims of violent crime, including non-sexual incidents, those who were injured were more likely to be willing to meet with victim support services (Lowe, Wilan, Khan, Brooks, Robinson, Graham-Kevan…& Bryce, 2015). In particular, medical services are often the type or 93 one of the types of formal help sought in these cases, due to the nature of the injuries (McCart et al., 2010); however, a distinction must be made between seeking help for injuries and disclosing victimization to medical professionals. Tewksbury (2007) found that male victims would seek medical, and even mental health, services for their symptoms without disclosing the nature of their victimization (Lowe & Rogers, 2017). Additionally, those who report their victimization to law enforcement are more likely to receive medical care, including a SANE exam (McCart et al., 2010; Resnick et al., 2000). Among Kilpatrick, Resnick, Ruggierio, Conoscenti, and McCauley’s (2007) survey of 3,001 women in the United States, they found that one of the variables associated with increased reporting of rape to the police was injury during the incident. Missed Work or School Sexual victimization, as well as domestic violence, can lead to the victim’s decreased ability to maintain employment that was routine prior to their victimization. Tjaden & Thoennes (2006) found that 19% of female victims of sexual assault needed to miss work following their victimization. This may be for a number of reasons, including appointments with formal services (i.e medical, legal, or mental health) or because psychological outcomes from the sexual victimization may lead to the victim’s decreased capacity for the work that they were doing prior to victimization (Loya, 2015). Bouffard, Nobles, Goodson, Koeppel, Marchbanks, and Chaudhuri (2017) identify that victims of crimes may need legal assistance to help them both get and keep employment, and that this population may have increased attendance issues, leading to lower wages and decreased job security (Tolman & Wang, 2005). Fear Within the literature, fear is often defined as fear of perpetrator during the assault, or fear of injury or death during assault. Some studies have found connections between this experience 94 of emotional distress experienced during or after victimization and increased formal help-seeking behavior (Amstadter et al., 2008; Kilpatrick et al., 2007; Starzynski et al., 2007). Amstader et al. (2008) reports a positive relationship between fear of perpetrator during the assault and seeking mental health services, in a study involving 556 women with sexual assault histories however, this variable was not found to be statistically significant in the final model. Conversely, other studies found that fear of the perpetrator decreased the likelihood of seeking help, especially from the police (Cohn et al., 2013; Logan et al., 2005; McCart et al., 2010). Specifically, female victims in rural areas characterized fear of perpetrator as a barrier to reporting their victimization (Logan et al., 2005; McCart, et al., 2010). In cases of sexual victimization during childhood, threats by the perpetrator and the power that the perpetrator has over the victim can lead to fear that delays disclosure for years (Easton, Saltzman & Willis, 2013). Type of Assault Type of assault is characterized in a number of different ways in the literature. The association between type of assault and help-seeking behavior remains largely unexplored, especially for male victims. In one study, Monk-Turner and Light (2010) found that of 219 male victims of sexual assault, the only predictive factor was that if penetration occurred, men were less likely to seek services. However, other studies suggest that likelihood of seeking services increases with the severity of the incident (Kilpatrick et al., 2017; Resnick et al., 2000; Starzynski et al., 2005). Among female victims of sexual assault, there are differences in the severity of psychological impact based on type of penetration (i.e. vaginal vs. anal vs. oral) with oral and anal being more severe (Pinsky, Shepard, Bird, Gilmore, Norris, Davis & George, 2017). It is not clear how these differences impact male victims of penetrative assault or how this increased 95 severity impacts female help-seeking behavior. Ullman and Filipas (2001), found that among a sample of 323 women who had been sexually assaulted, help-seeking differed based on whether an incident was alcohol facilitated; women who experienced alcohol-facilitated assaults were more likely to seek help from a mental health provider, while women who did not experience an alcohol-facilitated sexual assault were more likely to seek help outside of mental health services. Kilpatrick et al. (2007) found that among a sample of college women and a sample of women in the general population, use of force during rape by the perpetrator was associated with increased likelihood of formal help-seeking, specifically reporting to the police, when compared to alcohol or drug facilitated rape. In one study of a mixed gender group of victims who sought help, the type of incident most common for males to seek help in response to varied by age (Green, Ramelli, & Mizumoto, 2002). For males over the age of 18, anal penetration was the most common type of incident. For adolescent males between 12 and 17, oral sex performed on the victim was most commonly the type of incident. Among male children, boys ranging in age from zero to 11, the most common incident type for which they sought help was groping of the genitals (Green et al., 2002). Child Victims3 Among child victims, the gender differences seen in adult help-seeking behavior remain. Even at early ages, male victims are less likely to disclose their abuse and tend to wait longer before reporting sexual assault or seeking help for their victimization than their female counterparts (Alaggia, 2010; Gagnier & Collin-Vezina, 2016; McElvaney, Greene, & Hogan, 3 Child victim is included as an incident-level due to the way that this data set is structured. Though at first glance this variable may seem to be individual-level, and suited best for Manuscript #1, this variable was capture at the time of first victimization by each perpetrator. So, a single victim who has experienced victimization by multiple perpetrators will have multiple variables indicating whether he was a child at the time of that victimization. Additionally, many of the individual-level variables reflect conditions at the time of the survey (e.g., yearly income, education level), while this variable is reflective of conditions at the time of the incident. 96 2012; O’ Leary & Barber, 2008; Priebe & Svedin, 2008). Easton (2013), in a survey of 487 male victims of childhood sexual abuse, found that the males waited approximately 30 years before their first instance of disclosure or formal help-seeking behavior. However, the direction of the relationship between age and likelihood of help-seeking behavior is disagreed upon in the literature. Paine and Hansen (2002) suggest that tendency to disclose victimization decreases as children get older, while Finkelhor, Wolak, and Berliner (2001) found that victims who are children are less likely to report a crime to law enforcement than adult victims. This lack of child reporting is credited to the concept that children must access law enforcement through their parent (Finkelhor et al., 2001) and that parents generally want to handle issues, including sexual victimization of their child, on their own (Finklehor, 1984). This reporting pattern may impact formal help-seeking (police, medical) and bias the estimate of child sexual victimization. When children sought formal help, gender differences were also observed. Boys were more than two times more likely to seek mental health advice from a doctor than girls did in a sample of sexually victimized children, however, girls were more than two times more likely ask a doctor for advice about a physical problem (Daigneault, Vézina-Gagnon, Bourgeois, Esposito, & Hébert, 2017). For adolescents or older boys, help-seeking patterns may be different, with higher levels of disclosure or formal help-seeking. Lahtinen, Laitila, Korkman, and Ellonen (2018) found that disclosure rates were at about 80% for this older group of minors. Almost half the disclosures among this group were to their peers, rather than to an adult. However, this group may face some of the same barriers as adult male victims. Studies about attitudes towards victims have shown that, even in childhood, societal perceptions of male victims of blame for being sexually victimized are present. Older boys who were sexually victimized by a female perpetrator are 97 seen as more culpable due to a perceived lack of resistance involved in the incident and the increased responsibility that comes with puberty (Broussard & Wagner, 1988; Davies & Rogers, 2006; Eisenberg, Owens & Dewey, 1987). This negative perception might prevent boys from disclosure or seeking help. Current Study This study focuses on the associations between incident characteristics and outcomes and the help-seeking behaviors of males who have experienced sexual victimization or violence. For the sake of this study, sexual violence is broadly defined in accordance with the variables within the NISVS, including forcible and drug/alcohol-facilitated penetration and being made to penetrate, sexual coercion, unwanted sexual contact (i.e., grabbing and kissing), and unwanted sexual experience that do not include contact (i.e., exposure, harassment, and being made to watch or participate in sexual media). The men victimized in these ways often do not seek services, and in many cases, do not disclose their victimization even to those closest to them. While there has been attention in recent years focused on female victims of sexual violence and predictors of help-seeking, much less is known about male victims’ patterns of help-seeking and how the characteristics (i.e., type of assault, age of victim at time of incident) and outcomes of sexual violence (i.e., injury, fear, missed school or work) impact the victim’s choice to seek help in general, from formal sources (i.e. police, medical, and mental health), and specifically from mental health services. It is important to note that though the independent variables are referenced as incident-level throughout the manuscript to denote the difference between characteristics of the perpetrators themselves and characteristics associated with the perpetrators’ behaviors and resulting outcomes, both perpetrator-level and incident-level variables are linked through each victims’ list of perpetrators. For example, the data may indicate that the perpetrator 98 cause an injury to the victim and that the perpetrator raped the victim, however there is no way of ascertaining if the injury took place during that particular victimization or another less severe or non-sexual violence. It is due to this non-specificity of incident outcomes that perpetrators of IPV physical violence (in addition to the required sexual victimization behavior(s)) were removed from the sample for this set of analyses. Research Questions RQ1: What incident-level characteristics are predictive of formal and informal help-seeking (general help-seeking) behaviors among male victims of sexual violence? RQ2: Among those male victims of sexual violence who sought help, what incident-level characteristics are predictive of seeking formal support? RQ3: Among those male victims of sexual violence who sought formal help, what incident-level characteristics are predictive of seeking help from mental health services? Research Design Methods This correlational study uses secondary data from the NISVS: General Population Survey (2010), a nationally representative cross sectional, retrospective telephone (landline and mobile) survey that collected information about experiences of intimate partner violence, sexual violence, and stalking among women and men aged 18 or older in the United States (Black et al., 2011; Smith et al., 2017). Information collected by the survey includes respondent demographic information, detailed information about the respondent’s experiences of different types of intimate partner violence [psychological aggression(PA), coercive control(CC), physical violence (PV)], stalking, and sexual violence, collected based on each perpetrator, all measured for three timeframes: one year, three year, and lifetime. Lifetime victimization variables are utilized for 99 analysis in this study. Additionally, follow-up information was collected both specific to individual sections and for the whole survey during the original data collection for individual who met the criteria, which included being a victim of sexual assault. These follow-up sections include demographic information on individual perpetrators, the individual perpetrators’ actions and the victims’ reactions to those perpetrators’ actions, as well as outcomes and actions related to the reported victimization (e.g. help-seeking). Data Management Within this dataset, a complicating factor is the use of perpetrators to organize the data. Though the individual-level variables used as independent variables in these analyses are linked to the deidentified respondent identification number, most variables in the dataset are linked through the perpetrator. Due to the respondent’s freedom within the survey to list perpetrators in the order that they prefer in each section, the variable names PERP1-PERP94 are not indicative of the specific perpetrator named in the variable name. The Sexual Violence section was restructured, creating a series of 22 binary perpetrator variables, indicating the presence or absence of each sexual violence behavior for each perpetrator listed by the respondent. An additional data management step is needed for the help-seeking variables. Help-seeking variables are found within one of the Follow Up sections in the database and are linked to the perpetrator through the use of a list of qualifying perpetrators for each Follow-Up section. Using this list to restructure the variables, it is possible to link the respondent to their help-seeking behaviors, perpetrator characteristics, and incident-level characteristics, through each perpetrator of sexual violence. Data access and storage. Access to this de-identified dataset (United States Department of Health and Human Services, 2014) has been approved by the University of Michigan Inter‐ 100 university Consortium for Political and Social Research/ National Archive of Criminal Justice Data on October 5, 2017. Prior to approval, the request for access was reviewed and approved by the Michigan State University (MSU) Vice President for Research and Graduate Studies and MSU Data Technologies. The data is stored on an external hard drive in a locked cabinet in a locked office and accessed using a computer with ASCOMP Software Secure Eraser 5.001 and Cypherix Cryptainer SE 11.6.0 installed. The research protocol for this study was submitted to the Michigan State University Institutional Review Board (IRB) and was approved as expedited. A letter stating this information was provided to the Dissertation Chair, Dr. Sheryl Kubiak, on August 9, 2017. Sample The information in this dataset was collected between January 2010 and December 2010 from 16,191 adults who completed the survey, including 7,292 men (Figure 5), with 1,577 men reporting at least one experience of sexual violence. A subsample (n=1,445, 21.5% of male respondents) selected for this study includes all males who reported at least one perpetrator of one of the 22 types of sexual violence listed in the Sexual Violence section of the NISVS (see below) within the first fifteen perpetrators listed by the victim in their survey responses. For each type of sexual violence, the survey allows the respondent to list up to 15 perpetrators for each sexual violence behavior, with the potential of 94 individual perpetrators listed for each victim (PERP1 to PERP94). To remove outliers and reduce amount of variable creation, while still retaining an adequate representation of each respondent’s perpetrator list, the perpetrator variables were truncated after PERP15. Before truncation, the victim’s number of perpetrators during their life time ranged from (1-19), in variables between PERP1 and PERP38. Truncating the perpetrator variables at PERP15 reduced the sample by eight individuals who listed their first 101 perpetrator of sexual violence as PERP16 or higher in the survey. Incident-level (e.g. if there was injury as a result of perpetrator’s actions) (discussed in this) and perpetrator-level variables (e.g. relationship with perpetrator) (discussed in Chapter 3) were not considered in sample selection. However, due to the structure of the dataset and the inability to determine if injury, missed days of work, or fear were related to sexual victimization or another perpetrator behavior, such as physical violence. Thus, perpetrators who also committed IPV physical victimization against the victim were removed from the sample. Figure 5. Diagram of sample selection for incident-level analyses (Ch. 4/Manuscript 3) While this removed 124 (7.9% of sample) victims and 446 perpetrators/incidents (12.6%) from the analyses, this slightly reduced sample allows for the clear assessment of the associations between incident outcome variables and the dependent variables. Within the sample of male victims of sexual violence(n=1,445), the victims ranged between the age group 18-24 (11.4%) to 55+ (31.9%). The majority of the sample identified their race as White (82.4%), with the remaining 17.6% consisting of individuals who identified as Black/African American (8.0%), Asian (2.5), Native Hawaiian/Pacific Islander (0.1%), American Indian/Native Alaskan (2.5%), and 102 Other (3.5%). of the 131 individuals who identified as Hispanic, 55.6% identify as White and 44.4% identify as non-White when race is dichotomized. Among those who identified a sexual orientation, 88.6% are heterosexual, 10.1% identify as LGBTQ (6% gay men, 4% bisexual, and 0.1% transgender). However, the utility and accuracy of this variable is limited due to the large number of missing values (missing n=589). About 88% of the men in the sample report exclusively having sex with women and about 12% of the sample has either exclusively had sex with men, or with both men and women. Education level within the sample ranged from “no schooling” (0.1%) to a post graduate degree (18.1%), with the largest groups in the sample attending some college or getting a 4 year degree (45%). Yearly income ranged from $10,000 a year or less (5.4%) to over $70,000 (31%). Almost 88% rated themselves in “Good” or better mental health and almost 80% rated themselves as having “Good” or better physical health. Analysis for research question one (who sought some form of help/general help-seeking) was conducted using this group of male victims. Sub-samples. In order to answer the second and third research questions, sub-samples were drawn from the population of male victims of sexual violence. The first sub-sample consists of all males who reported that they had sought any sort of help as a response to a perpetrator of sexual violence (n=846). This group was used for analysis for research question two (who sought at least one type of formal help). From this sub-sample, a second sub-sample was drawn, consisting of those males who reported seeking at least one form of formal support (i.e. law enforcement, medical, psychological, and/or crisis hotline) as a response to a perpetrator of sexual violence (n=271). Analysis for research question three (who sought mental health services) was conducted using this sub-sample. 103 Defining sexual violence for sample selection. Within the NISVS, sexual violence has been operationalized into 22 (or 21 survey questions, including one with two parts) separate perpetrator behaviors in five groupings: Rape, Made to Penetrate, Sexual Coercion, Unwanted Sexual Contact, and Non-Contact Unwanted Sexual Experience (Appendix G). For this study, all survey respondents who responded affirmatively to any of the sexual violence questions were included as a male victim of sexual violence. Level of severity of sexual violence was examined as a control variable in Chapter 2 and will be further addressed in this manuscript as an explanatory variable. Incident-level cases. Within this manuscript, incident-level variables are utilized for analysis. While Chapter 2 explored the associations between victim characteristics and the acts of seeking help, seeking formal help, and seeking mental health services, in Chapters 3 and 4 the choice to seek help and the type of help sought may vary among the victim’s decisions in response to different perpetrators’ victimization. Thus, within one victim, there may be perpetrators of sexual violence for whose behaviors the victim sought some form of help, some form of formal help, mental health services, all of those types of help, or no help at all. For the 1,445 males in the sample who report sexual victimization, there are 3,099 perpetrators. Among the 846 victims who sought help, there are 1,420 perpetrators. The group of 271 men who sought help from at least one formal support had 402 perpetrators among them. Independent Variables Injury. This binary variable (1=victim was injured by perpetrator, 0=victim did not report injury by perpetrator in survey), was constructed from the follow-up question related to injury sustained from perpetrator’s actions that was asked for each perpetrator that the victim had identified as committing sexual violence (among other types of behaviors) against the victim. 104 Among the 3,099 perpetrators in the total sample, 5.4% (n=166) caused injury. Among the 1,420 perpetrators who engaged in behaviors that prompted some form help-seeking behavior from the victim, 9.4% (n=9.4%) caused injury. Among those 402 perpetrators whose victimization behavior cause the victim to seek formal services, 22.4% (n=90) caused some injury. There were no missing values. Missed work or school. This binary variable (1=victim missed work or school due to perpetrator behavior, 0=victim did not report missing work or school in the survey), was created from the follow-up question asking if the perpetrator’s actions ever caused them to miss work or school. This question was asked for each perpetrator that the victim had identified as committing sexual violence (among other types of behaviors) against the victim. Among the 3,099 perpetrators in the total sample, 3.3% (n=101) caused the victim to miss work or school. Among the 1,420 perpetrators who engaged in behaviors that prompted some form help-seeking behavior from the victim, 6.1% (n=9.4%) caused the victim to miss work or school. Among those 402 perpetrators whose victimization behavior caused the victim to seek formal services, 15.2% (n=61) caused the victim to miss work or school. There were no missing values. Fear of concern for safety. Due to issues within the dataset (discussed further in Limitations), this variable is the only emotional/psychological response variable available for accurate inclusion into the analysis. This binary variable was constructed utilizing the responses to two questions in the NISVS, one asking which perpetrators caused the victim to be concerned for their safety and which perpetrators made the victim feel fearful. Due to collinearity of these two variables and little clarity in operational distinction between the variables, these two variables were combined and dichotomized (1=victim was afraid or concerned for safety due to perpetrator, 0=victim was not concerned for safety or afraid of perpetrator). While temporality is 105 not addressed in several ways throughout the NISVS, this variable was included as an incident- level variable, rather than a perpetrator-level variable due to the skip patterns of the survey. Answering yes to either of the above-mentioned questions prompted the survey giver to ask a series of questions about the victim’s reaction to the perpetrator’s behaviors, including questions about nightmares, avoidance, numbness, and feelings of detachment. Among the 3,099 perpetrators in the total sample, 21.8% (n=667) caused the victim to feel fear of concern for safety. Among the 1,420 perpetrators who engaged in behaviors that prompted some form help- seeking behavior by the victim, 34.3% (n=489) caused the victim to feel fear of concern for safety. Among those 402 perpetrators whose victimization behavior caused the victim to seek formal services, 52.2% (n=210) caused the victim to feel fear of concern for safety. There were no missing values. Type of victimization. This series of binary variables dichotomizes the presence or absence of each Incident Type Category (found in Appendix 9) for each perpetrator based on the victims’ reports of perpetrators’ behaviors within the Sexual Victimization section of the NISVS (Appendix 9). These variables are not mutually exclusive (Amstader et al., 2008; Cohn et al., 2013). While each of these variables are assessed for association with the dependent variables, Rape (1=perpetrator physically penetrated victim, 0=victim did not report being penetrated by perpetrator), despite having the lowest incidence of occurrence, was selected for use in multivariate analyses due to the strong presence of an association between being penetrated and help-seeking behaviors in the existing literature. Table 14. Type of Perpetration Reported by the Victim (n=3,099, of 1,445 victims) Variable Rape Made to Penetrate Coercion Unwanted 156 304 368 1196 5.0 9.8 11.9 38.6 Frequency Valid Percent 106 Table 14. (cont’d) Non-Contact aNon-mutually exclusive Among the 3,099 perpetrators in the total sample, 5% (n=156) physically penetrated the victim 1718 55.4 anally or orally (Table 14), using force or drug/alcohol facilitated assault. Among the 1,420 perpetrators who engaged in behaviors that prompted some form help-seeking behavior from the victim, 5.7% (n=81) physically penetrated the victim. Among those 402 perpetrators whose victimization behavior caused the victim to seek formal services, 12.4% (n=50) physically penetrated the victim. There were no missing values. Child victim. Age of the victim at the time of victimization was determined based on the follow-up question asking how old the victim was at the age of the first incident with each perpetrator. Within the dataset, this information is presented as categorical, with the first category as 10 years old or under. This variable was dichotomized to represent victims who were in this youngest age group at the time of victimization (1=victim was 10 years old or younger, 0=victim was older than 10 years old). Among the 3,099 perpetrators in the total sample, 7.6% (n=235) sexually victimized males that were ten years of age or younger. Among the 1,420 perpetrators who engaged in behaviors that prompted some form help-seeking behavior from the victim, 9.6% (n=136) sexually victimized males that were ten years of age or younger. Among those 402 perpetrators whose victimization behavior caused the victim to seek formal services, 17.2% (n=69) sexually victimized males that were ten years of age or younger. There were no missing values. Dependent Variables Help-seeking. This binary variable (0= no help-seeking, 1=help was sought) was calculated by assessing for all help-seeking. Throughout the manuscript, general help-seeking and any help-seeking are used interchangeably to refer to this variable. Then these variables 107 were checked against the list of all perpetrators of sexual violence to remove all instances of help-seeking that are not directly related to a sexual violence perpetrator. For example, some victims reported help-seeking in response to the actions of a perpetrator of IPV or stalking who did not also commit a sexual violence against the victim. These instances of help-seeking were removed from the dataset in order to only reflect help-seeking behaviors as closely related to sexual victimization as possible. Formal help-seeking. This binary variable was calculated to reflect formal help-seeking (0=no formal help sought, 1=formal help sought). This variable reflected if the victim ever reported utilizing one of the formal services/sources of support asked about in the survey: police, medical, psychological/counseling, and crisis hotline. These variables were checked against the list of all perpetrators of sexual violence to ensure that all formal help-seeking reported was related to a sexual violence perpetrator. Mental health help-seeking. This binary variable was calculated by combining and dichotomizing the respondent’s answers to two formal sources of help. The two formal sources combined for this variable are 1) talking to a psychologist or counselor and 2) calling a crisis hotline (0=no mental health services sought, 1=mental health services sought). These variables were checked against the list of all perpetrators of sexual violence to ensure that all mental health help-seeking reported was related to a sexual violence perpetrator. Analysis Descriptive statistics and frequencies were assessed and reported for all explanatory variables, as well as the dependent variables. Bivariate relationships between dependent variables and the explanatory variables were assessed for statistically significant relationships (Figure 6). Multilevel analyses were necessary because there were multiple perpetrators nested 108 within each victim and help-seeking behaviors for each perpetrator were not likely to be independent decisions within the same victim4. The likelihood ratio is x2 (5, 3,099) = 278.23, p<.001). Multilevel logistic regressions with a Poisson link function were utilized to identify predictors of help-seeking behavior. This multivariate analytic strategy estimates risk ratios, rather than odds ratios, which are typically inflated when the phenomenon under study is common rather than rare (i.e., approaching 50% occurrence); this is a particular concern in multilevel analysis, where the estimated proportions of occurrence vary across individuals (Katz, 2006; McNutt, Wu, Xue, & Hafner, 2003; Zhang & Kai, 1998). Risk ratios are interpreted as effects on the probability of occurrence of the dependent variable rather than the odds of occurrence, as with odds ratios. Analyses were performed using unweighted data due to a lack of information available on the creation of the weights within the dataset (Rosay, 2016), as well as a lack of agreement in the literature regarding use of survey weights in regression modeling (Gelman, 2007). When results of logistic regression using weighted and unweighted data obtained through complex sampling design were compared by Shin and Hanna (2017) in one set of surveys, the differences were found to be unsubstantial. Additionally, when sampling weights were based only on independent variables (e.g. sex, race, age, and state [in U.S.]) (Rosay, 2016), as was the case with this dataset and analyses, Winship and Radbill (1994) suggest that unweighted analyses are preferred. IBM SPSS Statistics 25 was utilized for all statistical analyses in this manuscript. 4 For more information, see the Perpetrator-level cases sub-section of Sample in the Methods section 109 Figure 6. Diagram of incident-level analyses (Chapter Four/Manuscript 3) Research Question 1: Predictors of Seeking Help Results Bivariate analysis of explanatory variables and help-seeking behavior. Explanatory variables were assessed for associations with general help-seeking among the whole sample of male victims of sexual violence (n=1,445) and their perpetrators (n=3,099), using chi-square tests of independence and independent-samples t-tests. General help-seeking was statistically significantly related to perpetrators who caused injury ( x2 (1, 3,099) = 85.39, p<.001), with victims who were injured during sexual victimization (n=134, 80.7%) were more likely to seek some form of help for incidents involving that perpetrator than those who were not injured (n=1290, 44.0%); perpetrators who cause victims to miss work or school (x2 (1, 3,099) = 67.89, p<.001), with those who missed work or school (n=87, 86.1%) more likely to seek help for incidents involving that perpetrator than those who did not miss work or school(n=1,337, 44.6%); fear (x2 (1, 3,099) =240.9, p<.001) with the presence of fear or concern for safety caused by perpetrator (n=498, 72.2%) related positively to increased general help-seeking behavior for 110 incidents involving that perpetrator in comparison to those who did not report fear (n=935, 38.6%). Victims for whom an incident occurred under ten years of age (n=136, 57.9%) were positively associated with increased help-seeking for incidents involving that perpetrator in comparison to older victims (n=1288, 45.0%), (x2 (1, 3,099) =14.55, p<.001). If a perpetrator committed coercion (x2 (1, 3,099) = 32.03, p<.001), and non-contact unwanted sexual experience, (x2 (1, 3,099) = 1.46, p=.004), were associated with increased help-seeking behavior for incidents involving that perpetrator, however penetrative assault was not statistically significantly related to help-seeking behavior. Multivariate analysis. Multilevel logistic regression with a Poisson link function analysis was utilized to predict the likelihood of formal help-seeking for sexual victimization. The predictor variables were injury, missing work or school, fear of perpetrator, rape, and victim was a child. The likelihood ratio is statistically significant x2 (5, 1,420) = 199.69, p<.001). The coefficient, robust standard error, relative risk, confidence interval (95%), and significance can be found in Table 15. Presence of injury, missing work or school, and fear of the perpetrator had significant effects when using .05 as the criterion for statistical significance. A perpetrator of sexual violence causing an injury is associated with a 25% increase in the proportion of individuals seeking help for incidents involving that perpetrator. A victim who needed to miss work or school due to victimization is associated with a 37% increase in the proportion of individuals seeking help for incidents involving that perpetrator. Fear of the perpetrator is associated with an 80% increase in the proportion of individuals seeking help for incidents involving that perpetrator. 111 Table 15. Multilevel Logistic Regression Results Using Binary Help-seeking as Dependent Variable (n=3,099 perpetrators, 1,445 victims) Robust RR Injury Missed work or school Perpetrator’s actions caused fear Penetrative assault Victim was under 10 years old Constant Variance * p<.05. **p<.01. ***p<.001. Coefficient 0.224** 0.317*** 0.582*** -0.118 0.112 -1.033 0.142 SE 0.091 0.094 0.093 0.088 0.082 0.017 0.028 1.251 1.373 1.789 0.889 1.119 0.356 0.142 CI (95%) 1.085-1.442 1.200-1.571 1.615-1.981 0.731-1.080 0.970-1.291 0-0 0-0 Research Question 2: Predictors of Seeking Formal Support Bivariate analyses of explanatory variables and formal help-seeking behavior. Explanatory variables were assessed for associations with formal help-seeking among the sub- sample of male victims of sexual violence who sought some form of help (n=846) and their perpetrators (n=1,420). Formal help-seeking was statistically significantly related to a perpetrator who caused injury, ( x2 (1, 1,420) = 114.0, p<.001); with victims who were injured (n=90, 68.2%) during victimization were more likely to seek formal help for incidents involving that perpetrator than those who were uninjured(n=312, 24.2%); a perpetrator who caused the victim to miss work or school (x2 (1, 1,420) = 84.12, p<.001) with those who missed work or school (n=61, 71.8%) more likely to seek formal services for incidents involving that perpetrator compared to those who did not miss (n=341, 25.5%); fear of the perpetrator, (x2 (1, 1,420) = 79.41, p<.001), with those who reported feeling fear (n=210, 43.0%) positively related to formal help-seeking behavior for incidents involving that perpetrator when compared with those who were not afraid (n=192, 20.6%). Rape, x2 (1, 1,420) = 50.44, p<.001, being made to penetrate, x2 (1, 1,420) = 14.05, p<.001, coercion, x2 (1, 1,420) = 25.13, p<.001, and non-contact unwanted 112 sexual experiences x2 (1, 1,420) = 27.02, p= p<.001, were related to increased formal help- seeking for incidents involving that perpetrator. Multivariate analysis. Multilevel logistic regression with a Poisson link function analysis was utilized to predict the likelihood of formal help-seeking for sexual victimization. The predictor variables were injury, missing work or school, fear of perpetrator, rape, and victim was a child. The coefficient, robust standard error, relative risk, confidence interval (95%), and significance can be found in Table 16. The likelihood ratio is x2 (5, 1,402) = 11.58, p=.041). Presence of injury, missing work or school, fear of the perpetrator, rape, and a child as victim had significant effects when using .05 as the criterion for statistical significance. A perpetrator of sexual violence causing an injury is associated with a 67% increase in the proportion of individuals seeking formal help for incidents involving that perpetrator. Missing work or school due to victimization is associated with a 70% increase in the proportion of individuals seeking formal help for incidents involving that perpetrator. Fear of the perpetrator is associated with 61% increase in the proportion of individuals seeking formal help for incidents involving that perpetrator. Penetrative assault by a perpetrator is associated with a 44% increase in the proportion of individuals seeking formal help for incidents involving that perpetrator. Victimization at the age of ten years old or younger is associated with a 65% increase in the proportion of individuals seeking formal help for incidents involving that perpetrator. Table 16. Multilevel Logistic Regression Results Using Formal Help-seeking as Dependent Variable (n=1,420 perpetrators, 846 victims) Robust RR Injury Missed work or school Perpetrator’s actions caused fear Penetrative assault Victim was under 10 years old Constant Coefficient 0.511*** 0.530*** 0.478*** 0.363** 0.503*** -1.846 SE 0.208 0.208 0.177 0.167 0.204 0.156 1.667 1.698 1.612 1.438 1.654 0.158 CI (95%) 1.305-2.130 1.336-2.159 1.299-2.000 1.146-1.806 1.300-2.106 0-0 113 Table 16. (cont’d) Variance * p<.05. **p<.01. ***p<.001. 0.299 0.797 0.299 0-0 Research Question 3: Predictors of Seeking Mental Health Services Bivariate analyses of explanatory variables and help-seeking behavior. Explanatory variables were assessed for associations with seeking mental health services among the sub- sample of male victims of sexual violence who sought mental health services (n=271) and their perpetrators (n=402). Seeking mental health services and fear of the perpetrator have a statistically significant relationship, (x2 (1, 402) = 9.47, p=.002), with fear of the perpetrator (n=136, 64.8%) having a negative association with seeking help from mental health services for incidents involving that perpetrator when compared with those without fear (n=151, 78.6%. Rape, x2 (1, 402) = 4.44, p=.035, being made to penetrate, x2 (1, 402) = 8.45, p=.004, coercion, x2 (1, 402) = 17.38, p<.001, unwanted sexual contact x2 (1, 402) = 29.16, p<.001, and non- contact unwanted sexual experiences x2 (1, 402) = 18.43, p<.001), were related to increased seeking help from mental health services for incidents involving that perpetrator. Multivariate analysis. Multilevel logistic regression with a Poisson link function analysis was utilized to predict the likelihood of mental health services-seeking for sexual victimization. The predictor variables were injury, missing work or school, fear of perpetrator, rape, and victim was a child. The coefficient, robust standard error, relative risk, confidence interval (95%), and significance can be found in Table 17. Fear of the perpetrator and penetrative assault had significant effects when using .05 as the criterion for statistical significance. Fear of the perpetrator is associated with 21% decrease in the proportion of individuals seeking mental health services for incidents involving that perpetrator. Penetrative assault by a perpetrator is 114 associated with a 26% increase in the proportion of individuals seeking mental health services for incidents involving that perpetrator. Table 17. Multilevel Logistic Regression Results Using Seeking Mental Health Services as Dependent Variable (n=402 perpetrators, 271 victims) Robust RR Injury Missed work or school Perpetrator’s actions caused fear Penetrative assault Victim was under 10 years old Constant Variance * p<.05. **p<.01. ***p<.001. Ad Hoc Analyses Coefficient 0.045 -0.049 -0.230** 0.235** 0.084 -0.272 4.19e-34 SE 0.113 0.108 0.074 0.116 0.104 0.039 4.91e- 33 1.046 0.952 0.794 1.264 1.088 0.762 4.19e-34 CI (95%) 0.847-1.293 0.762-1.189 0.662-0.953 1.056-1.514 0.902-1.312 0.689-0.843 4.34e-44 – 4.04e-24 Additional bivariate analyses were conducted in an attempt to further explore some of the results of the multivariate analyses. Crosstabs were utilized to assess for bivariate relationships between same race and acquaintance and between gender of perpetrator and severity of victimization (used in Chapter 2 analyses). In both cases the associations were not statistically significant. Discussion This study used secondary data from the National Intimate Partner and Sexual Violence Survey to examine choices around seeking help among 1,445 male victims who have experienced sexual violence perpetrated by 3,099 individuals over the course of the victims’ collective lifetimes. Incident-level information was collected for each of the perpetrators from the victims’ perspective. Incident-level variables, including if the assault caused injury, if the victim missed work or school during the assault, if the perpetrator’s actions caused fear, if penetration of the victim was part of the assault, and if the victim was a child at the time of 115 assault, were compared between the perpetrators of incidents for whom males sought help and those who chose not to seek help. This analysis to helps us to better understand under which circumstances male victims of sexual violence are more likely to utilize general support including from informal sources, formal services, and mental health services. These findings add to what is known about male victims of sexual assault and their help-seeking behavior, in addition to increasing the ways that this dataset has been explored. Macro and clinical social work implications stem from these findings, as well as suggestions for policy implementation and future areas of research. This work begins to open the door to our understanding of how men who are victimized make decisions about whether or not to seek help, and the types of help they do access. With this increased understanding, providers of formal services can more successfully meet the needs of this population. Injury In this study, injury during an assault was related to both increased general help-seeking and increased formal help-seeking. This result is in line with the existing literature, which suggests that injury during any sort of victimization increases the likelihood that help will be sought for incidents involving that perpetrator (Backes, 2015; McCart et al., 2010; Resnick et al., 2000; Starzynski et al., 2005; Ullman & Filipas, 2001). Presumably, in some cases this increased help-seeking in the case of injury may be associated with a specific medical need stemming from the injury. However, this relationship may be more nuanced than this, due to the victim’s masculine identity and rape myth acceptance. It has been suggested that incurring an injury during a sexual assault, especially one which occurs during resisting the assault is an indicator of a “perfect”, “worthy”, or “real” victim. In sum, this concept is associated with young, usually female, victims with limited sexual 116 history who are forcibly penetrated by a stranger, who may injure the victim during the assault and may have a weapon (DuMont, Miller, Myhr; 2003; Hayes, Lorenz, & Bell, 2013; Patterson, D., Greeson, M., & Campbell, 2009; Rader & Rhineberger-Dunn, 2010) This conceptual identity of “real victim” stems from the similarly constructed concept of “real rape” (Estrich, 1987). While this concept is generally considered in relation to female victims, similar standards can be (and are) applied to male victims (Chapleau, Oswald, & Russell, 2008). In fact, some of the constraints of hegemonic masculinity may enhance the association between the concept of acceptable victimhood and injury. If injury is present, this may be a signifier that the victim fought against the perpetrator, fulfilling a prominent masculine role. Not only do traditional masculinity norms, such as David & Brannon’s (1976) “Give ‘Em Hell” area of masculinity (that men should be aggressive and ready to fight) support the idea that male victims should have tried to defend themselves. This masculine ideal is supported in the rape myth, “a man is expected to be able to defend himself against sexual assault (Chapleau, Oswald, & Russell, 2008, p. 603), thus experiencing an injury associated with sexual assault may be interpreted by the victim as some small endorsement of masculinity that creates a safe space for seeking help. Missed Work or School In this study, missed work or school due to a sexual assault was related to both increased general help-seeking and increased formal help-seeking related to the perpetrator of those incidents causing the missed work or school. While the connection between sexual assault and increased likelihood of missed work is clear in the existing literature, most of the findings are specific to female victims, and little is known about the relationship between missing work or school after experiencing sexual violence and the likelihood of seeking help for either gender. In 117 a study about stalking victims, Reyns & Englebrecht (2014) found that having to miss work increased informal help-seeking among the whole group in their study, as well as among victims who chose to not report to the police. This study also found that missing work was related to formal help-seeking, though it was only statistically significant for female victims. Ad hoc bivariate analysis to determine the relationship between “Missed work” and “Severe victimization” (created from penetration and made to penetrate variables) to ensure that missing work is not a proxy for incident severity in the analysis. The relationship is statistically significant, however, only 9% (n=36) of 398 severe incidents involved missed work. However further ad hoc analysis shows a positive association between missing work and stalking, similarly to Reyns and Englebrecht’s (2014) finding among victims of stalking. Future analysis should address this. Outside of possible interference from stalking incidents by the same perpetrator or increased severity of incident, there are some practical explanations for the positive relationships between general help-seeking and missing work or school and formal help- seeking and missing work or school. For instance, general help-seeking in relation to missing work or school may be in the form of disclosure to a supervisor at work or teacher at school to explain the victim’s absence. A positive relationship between formal help-seeking and missed work or school may be explained by a need to attend an appointment with a formal source of help, or that the victim needed to get some formal documentation of the incident, such as a police report. Fear Fear was related to help-seeking behavior in all three analyses, though the direction changed based on the type of help that was sought. Fear of the perpetrator led to increased likelihood of general and formal help-seeking for incidents involving that perpetrator, however 118 fear of the perpetrator led to decreased likelihood of utilizing mental health services for incidents involving that perpetrator. Though most of the available studies focus on women, there is an overall indication that a victim’s emotional distress, including fear, is predictive of seeking help (Fanslow & Robinson, 2010; Kilpatrick et al., 2007). In a study that did include male victims (of stalking), fear was positively related to seeking both formal and informal help among victims of stalking. When this sample was split by gender, fear was a statistically significant predictor of informal help-seeking for men, but not for women (Reyns & Englebrecht, 2014). This finding, when considered alongside the studies involving female victims of IPV and/or sexual assault gives us some indication of what patterns of help-seeking to expect for male victims of sexual assault. However, a surprising outcome of this manuscript is the negative relationship between fear and seeking help from mental health services. It can be speculated that sexually victimized males who felt fearful of their perpetrators were looking for formal services that would offer them some sort of protection (ex. police and medical) and mental health services were not viewed as a means to protection from the perpetrator. Rape If the male victim experienced rape/ penetrative assault by a perpetrator, he was more likely to seek formal sources of help and mental health services for incidents involving that perpetrator. The existing literature on how penetrative assault impacts male victims’ help- seeking behaviors is split. Some researchers have found that penetration decreases the likelihood of seeking help (Monk-Turner & Light, 2010), while other studies indicate that more severe victimization leads to increased likelihood of help-seeking behavior (Kilpatrick et al., 2017; Resnick et al., 2000; Starzynski et al., 2005). One point to consider is that the literature suggests that male victims may have a difficult time identifying an incident as sexual victimization (Koss, 119 1985). When an incident is a penetrative assault, a non-consensual penetration of a male victim’s mouth by a penis, or anus by a penis, fingers, or object (NISVS, 2010), it seems as though the victim would be more likely to identify this assault as sexual victimization, as opposed to an incident of lesser severity. Rape was not a significant predictor of general help-seeking. It might be the case that informal disclosure of a penetrative assault experience to friends, family, or intimate partners may be avoided due to shame. Child Victim Those who were victimized as children were more likely to seek formal help for incidents involving that perpetrator than those who were first victimized by a perpetrator at adolescent and adulthood. Though we know that some of the literature reports that children, especially male children, have low rates of disclosure and reporting (O’ Leary & Barber, 2008), because of the probable large amount of time between victimization and help-seeking, many of these child victims most likely looked for formal help for their victimization as adults (Easton, 2013) (though this is not testable in the current dataset). This statistically significant relationship between age of the victim at the time of the incident and increased formal help-seeking is not immediately explainable. Limitations There are several limitations associated with incident-level analyses utilizing this dataset. First, all incident-level data is linked to the victim through the perpetrator, so rather than being able to assess for help-seeking related to individual incidents, one may only assess for help- seeking due to actions and outcomes associated with the perpetrator’s behaviors. Additionally, there is no way to assess if the incident-level variables related to incident outcome (e.g. injury, missed work or school, victim’s fear of perpetrator) are directly related to sexual victimization or 120 another type of perpetrator behavior within the same perpetrator. This limitation was managed by removing perpetrators from the sample who had behaviors in both the IPV physical victimization and sexual violence sections of the NISVS. While this decreased sample size, it provided a clearer picture of the incidents that led to help-seeking by removing the perpetrators most likely to cause injury, fear, or missed school or work outside of sexual victimization. An issue of note is the lack of information collected about the nature of disclosure when formal sources of help are accessed. Victims of sexual violence may seek medical help for an injury without disclosing the nature of the incident which caused the injury (Lowe & Rogers, 2017; Tewksbury, 2007), so though the relationship between injury and help-seeking behavior is examined through the lens of masculinity, disclosure of sexual victimization cannot be assumed. An additional limitation is the lack of clarity in perpetrator reference among the section of questions in the NISVS that may have provided information on post-traumatic stress disorder among male victims of sexual violence in this dataset. Though questions related to nightmares, avoidance, numbness, and feeling detached were asked of the survey respondents for any perpetrator who the respondent identified as causing fear or concern for safety, the order that the perpetrators were presented to the respondent for these questions is unclear (Rosay, 2016). The inability to link these outcomes of victimization to separate perpetrators does not allow for analysis in the current data structure. This limitation could possibly be overcome through assigning these variables to the victim at the individual-level, creating separate variables or a composite score representing trauma responses to lifetime victimization. Alternately, a researcher would need to seek further clarification on “how perpetrators are ordered in FU3 data” (Rosay, 2016, p. 258). 121 Implications for Clinical Practice Implications This research suggests several implications for clinical social workers. First, when assessing for trauma in a client of any age, it is important to understand how trauma may have impacted a victim at varying points in the victim’s lifespan. When working with adults, it may be that a client has been hiding a childhood victimization for many years. This study’s results suggest that males who were victimized at the age of ten or younger are more may be more likely to seek or have sought help formal help, but the association to formal help-seeking does not maintain its significance when assessed for solely seeking mental health services. Thus, even though an adult male victim may have sought some formal help at some point following a victimization, this does not ensure that he has received the mental health services that he may need. For men who have been sexually violated, it was found that injury is predictive of help- seeking behaviors. We need to consider that, conversely, lack of injury may indicate a decrease in likelihood that the victim will seek help. This decreased likelihood may indicate that victims who are not injured are in increased danger of being undiagnosed or treated for medical or mental health issues stemming from the assault, such as sexually transmitted diseases and trauma. Clinicians should be prepared to link clients with appropriate resources, including medical services or lawyers. Implications for Macro Practice Macro social workers should develop outreach to encourage non-physically injured victims of sexual assault to seek medical attention, for evidence collection, sexually transmitted disease testing and treatment, and additional resources. Public education and outreach around 122 what constitutes sexual assault (not just penetrative assault) is necessary to increase seeking of help among more victims of all genders, as well as helping male victims more readily being able to identify an incident of sexual assault as such. Outreach to teachers and school social workers to assist in recognizing that sexual assault can happen early in childhood and help to understand early signs of victimization in children. Finally, programs such as Workplaces Respond to Domestic and Sexual Violence (2018) from Futures Without Violence should be implemented to safeguard the rights of victims, as well as educate employers about how to respond appropriately to victims who are also employees and to make the place of employment a safe place to disclose victimization and a place safe from victimization. Implications for Policy A policy implication resulting from the findings in this manuscript is that increased attention should be paid to the ability of victims of sexual assault to retain employment and school enrollment following an incident of sexual victimization. Legal support for job related matters for victims of sexual violence should be available, and nation-wide policy granting further job-related protections to victims of sexual violence should be implemented, rather than laws at the state level. This policy change could be enacted through federally mandated flexible leave or as an amendment to the Family Medical Leave Act of 1993. If implemented federally, at state-level, or just within certain businesses, special attention should be paid to ensure that the use of this policy by an employee does not force more disclosure of circumstances than strictly necessary. Implications for Future Research This manuscript presents exploratory findings related to help-seeking behaviors in male victims of sexual assault. Through these results, avenues for future research have become 123 apparent. This manuscript operationalizes presence of injury as binary; further analyses should incorporate injury severity into analyses. The literature and bivariate analyses suggest that there may be a relationship between missed work or school and stalking by perpetrators of sexual violence, this relationship needs to be further explored. Future analysis using the NISVS should include exploring associations between help-seeking choices among male victims of sexual assault and PTSD symptoms at the victim level. One of the findings in this chapter was related to missing work due to sexual victimization. Future research should investigate state-level differences in laws protecting the employment of victims of sexual assault who need to miss work. Follow-up research should seek to assess businesses’ understanding and implementation of these laws in states that have these protections. Conclusion This chapter seeks to explore the relationship between help-seeking behaviors of male victims of sexual assault and incident-level characteristics using secondary data from the NISVS. Three levels of help-seeking include general help-seeking (both formal and informal help- seeking), formal help-seeking, and seeking mental health services and associations were explored between these dependent variables and incident-level variables: if victim was injured by perpetrator, if victim missed work or school due to the perpetrator’s actions, if the perpetrator’s actions caused the victim to be afraid, if the incident included penetration, and if the victim was the age of ten or under at the time of the victimization. Presence of injury, missed work or school, and fear were predictive of general help-seeking. Formal help-seeking behavior was predicted by presence of injury, missed work or school, fear, penetrative assault, and victim age of ten or younger at the time of victimization. Seeking help from mental health services was predicted by the presence of penetrative assault. Decreased fear by victim was predictive of 124 increased seeking of mental health service. Implications for social workers include increased understanding of appropriate referrals and linkages to make between a male victim of sexual violence and additional community providers, as well as the need for outreach in the form of public education around how sexual violence is defined. Finally, policy changes are necessary at the national level to ensure that no victim loses his or her employment due to the repercussions of sexual violence. 125 CHAPTER 5: DISCUSSION, IMPLICATIONS, AND CONCLUSION Generally, males are less likely to seek help when they need it for physical or psychological issues (Addis & Mahalik, 2003; Galdas et al., 2005; Yousaf, Grunfeld, & Hunter, 2015). These decreased help-seeking patterns are also present among male victims of sexual victimization, despite the negative psychological, emotional, and sometimes physical outcomes associated with sexual victimization (Easton, 2014; Gavrilovic et al., 2005; Sayer et al., 2009; Ullman & Filipas, 2005). Though more researchers are turning their attention to the topic of male victims of sexual violence, (Choudhary et al., 2012; Davies, 2002; McLean, 2013; Mezey & King, 2000; Stemple & Meyer, 2014), the attention to this group of victims is relatively recent and the mechanisms that encourage and discourage male victims from seeking help remain unexplored in a systematic way. Encouraging male victims to seek help following an incident of victimization is vital to the victim’s well-being. Not only is there evidence that the act of seeking help and overcoming barriers encourages victims’ healing (Schreiber, Maercker & Renneberg, 2010; Stige et al., 2013), but receiving services from formal sources, such as law enforcement, medical professionals, and mental health providers improves coping and psychological well-being among victims (Easton, 2014; Kearns et al., 2012; Mayhew & Reilly, 2008; Ringham & Salisbury, 2004). The lack of help seeking for sexual victimization has repercussions beyond the victim’s well-being, including creating challenges in prevalence measurement and inaccurate estimations of the problem (Dube et al., 2005). Without an accurate understanding of the prevalence of the problem of male sexual victimization, it is impossible to allot appropriate resources to address the problem and treat the victims. An important component of reporting sexual victimization, 126 especially to the police, is that statistics and through those statistics, public awareness of the issue is created (Bosick et al., 2012; Rennison et al., 2011). However, reporting to the police comes with its own pitfalls. The response to male victims of sexual violence by the police has historically and even recently been unpleasant, homophobic, mocking, and dismissive (Javaid, 2015). Additionally, the ways in which members of the legal system as a whole think about masculinity and how it should be enacted may be barriers to male victims of sexual assault who are seeking legal recourse (Small, 2015). The aim of this dissertation is to increase knowledge around male victims’ prevalence and patterns of help-seeking behavior, especially regarding what characteristics influence their decisions to seek help after an incident of sexual victimization through bivariate and multivariate analysis of secondary data in the National Intimate Partner and Sexual Violence Survey (2010) data set. By exploring characteristics (i.e., individual, perpetrator, and incident) and types of help-seeking (i.e., any help sought, formal help-sought, mental health services sought) on three levels, this work creates a comprehensive snapshot of which male victims might be more likely to seek services, as well as which victims might be more likely to avoid seeking help. A more complex understanding of these patterns of help-seeking behavior will increase the accuracy of prevalence estimates by allowing researchers to be more aware of the potential gaps in reporting, as well as create increased knowledge that has practice implications for social workers in clinical and macro practice. The adapted theoretical framework guiding this dissertation’s inquiry is Tsui, Cheung, and Leung’s (2012) Conceptual Framework for Analyzing Help-seeking Behaviors among Male Victims in Heterosexual Intimate Partner Violence (IPV) (Appendix A). This model includes varied help-seeking outcomes: no help-seeking, informal help-seeking, and formal help-seeking. 127 In addition, this model identifies three factors contributing to help-seeking: 1) theoretical perspective (including masculine gender socialization), 2) sociocultural variables (including masculine gender role conflict), and 3) sociodemographic variables. The adaptation of the theoretical framework (Appendix B) is informed by the existing literature around help-seeking, especially studies that reported that certain potential variables may act as barriers or facilitators to seeking help. While research around male victims of sexual assault was closely examined, due to a lack of empirical literature, especially quantitative studies with a large sample, additional literature around help-seeking behavior was included. The literature that this work is built upon includes studies that focused on female victims of sexual violence and male or female victims of violent crime, especially intimate partner violence. It is through the review of this literature that two additional factor areas: 1) perpetrator-level characteristics and 2) incident-level characteristics were included in the adapted version of Tsui, Cheung and Leung’s (2012) conceptual framework (Appendix A). Though variables related to theoretical perspective and sociocultural orientation are not present within the NISVS, the results of the analyses are interpreted through a theoretical lens informed by masculinity theory (David & Brannon, 1976; Connell, 1987, 2000, 2005; Connell & Messerschmidt, 2005; Kimmel, 1987, 2003), including gender role conflict (O’Neil, 1981, 2008) and male rape myth acceptance (Chapleau et al., 2008; Struckman-Johnson & Struckman-Johnson, 1992). The questions this dissertation answers are: 1) What is the prevalence of help-seeking behavior among male victims of sexual violence? How many seek help from formal sources and/or disclose their victimization to informal sources? What are preferred sources for services and support among male victims of sexual violence?; 2) What sociodemographic characteristics are predictive of help-seeking in general, formal help-seeking, and seeking mental health 128 services among male victims of sexual violence?; 3) What perpetrator characteristics are predictive of help-seeking in general, formal help-seeking, and seeking mental health services among male victims of sexual violence?; and 4) What incident characteristics are predictive of help-seeking in general, formal help-seeking, and seeking mental health services among male victims of sexual violence? Overview of Major Findings The first manuscript explored prevalence of help-seeking among male victims of sexual violence and their help-seeking patterns relationships with sociodemographic characteristics (e.g. race, sexual orientation, income, education). Though over sixty percent of the male victims of sexual assault in the sample sought some form of help, only thirty percent of the sample chose to seek help from a formal source. Only a little over fifteen percent of the whole sample sought any sort of mental health services to cope with their victimization. Associations between sociodemographic characteristics and help-seeking behavior were assessed using logistic regression. Seeking any help was more likely if the victim was white, and had, at some point in his life, had sex with men. Those with higher levels of education were more likely seek some sort of help. Men who had sex with men at some point in their lifetime were also more likely to seek help from at least one formal source, as well as those with lower income. Only being a man who has had male sexual partners was predictive of seeking mental health services. The second manuscript explored associations between perpetrator characteristics (e.g. gender and race of perpetrator, age difference between perpetrator and victim, and relationship between perpetrator and victim) and victims’ help-seeking behaviors using multilevel logistic regression. Men who were victimized by another male or an intimate partner were likely to seek 129 some form of help for incidents involving that perpetrator. Formal help was more likely to be sought by those who had been victimized by another male, an intimate partner, or by someone much older than the victim for incidents involving that perpetrator. Mental health services for incidents involving a particular perpetrator were more likely to be sought by those who knew their perpetrator. The third manuscript explored incident characteristics (e.g. type of assault, age of victim ) and outcomes (e.g., injury from assault, fear caused by incident, impact on missing work/school) and their associations with victims’ help-seeking behaviors using multilevel logistic regression. Those who were injured, had to miss work, or felt fear were more likely to seek some form of help for incidents involving the perpetrator involved in the incident causing injury, missed work/school, or fear. Formal help was more likely to be sought by those male victims who were injured, missed work, felt fear, experienced penetrative assault, or were ten years of age or younger at the time of the incident for incidents involving that perpetrator. The experience of a penetrative assault led a victim to be more likely to seek mental health services for incidents involving that perpetrator. Despite the presence of fear being predictive of help-seeking in general and formal help seeking for incidents involving that perpetrator, those who reported that they felt fear were less likely to seek mental health service for incidents involving that perpetrator. Themes Across Manuscripts However, it is only speculative that with more comprehensive data, social change would appear around male victimization. In the last few years there have been news articles devoted to informing the public of the phenomena of adult male sexual victimization(Grinberg, 2016; Zakaim, 2016), fictional television shows, such as Outlander, Coronation Street, and 13 130 Reasons Why that depict sympathetic male victims experiencing horrific sexual victimization, and well-known celebrities, such as Anthony Rapp, Terry Crews, James Van Der Beek, and Brendan Fraser (Baron, 2018; McKenzie & Fisher, 2017), have spoken out about their victimization. The climate, in the sense of public awareness, for society to care and invest in male victims is quite good, yet the social narrative remains situated around male rape myths that both blame male victims for their victimization, while also negating the severity of male sexual assault. It is only by shifting the narrative, and changing the way we, as a society think about what it means to be male, will men ever really feel free to get the support that they need. Hegemonic Masculinity, Rape Myths, and Gender Role Conflict Throughout these manuscripts, the lens of masculinity was used to interpret the results in a way that utilized Tsui, Cheung & Leung’s (2012) conceptual framework. Hegemonic masculinity and the way that the enactment of this form of masculinity impacts rape myth acceptance and the enactment of gender role conflict was present throughout. In Manuscript #1/Chapter 2, gay men’s rejection of compulsory heterosexuality (Rich, 1980) and hegemonic masculinity (Connell, 2005) places them in a role in which help-seeking is more plausible. If masculine norms (Mahalik et al., 2003) dictate that men avoid all things feminine and having sex with men is considered feminine, then experiences of being sexually assaulted by a male may lead a heterosexual male victim to worry about perceptions of feminization. “Victimization by sexual assault is perceived as a feminized state” (Small, 2015, p. 153). However, if masculinity is situated opposite to victimization, then femininity is opposite of perpetration. Thus, in Manuscript #2/Chapter 3 male victims were more likely to seek help if their perpetrator was a male. This can be explained by the males’ acceptance of the rape myth that women cannot rape men (Turchik & Edwards, 2012), and through the understanding of the 131 masculine/feminine divide. If a man reports that he was sexually victimized, not only is he enacting his gender “wrong” by being a victim, he is doubly subverting the narrative by admitting that his perpetrator was a woman. In Manuscript #3/Chapter 4 if injury or penetrative assault were elements of a sexual victimization, the male victim was more likely to seek help. Part of this can be explained through the acceptance of the rape myth that men cannot be raped (Struckman-Johnson & Struckman- Johnson, 1992), if a man has accepted this myth, it makes it much more difficult for him to recognize the incident as victimization. It takes more severe victimizations, such as injury, penetration, or being assaulted by a man (Man. 2/Ch. 3) for the victimization to be recognized as such. Another layer to injury is the way that it may possibly represent the male victim’s masculinity. If the injury signifies that the male victim fought his attacker, then he may be enacting masculinity through an aggressive response to sexual violence (David & Brannon, 1976; Chapleau et al., 2008; Kimmel, 1987) These components of the study are more concrete examples of the many ways that male victimhood, especially around sexual victimization, when contextualized within the expectations of traditional masculinity can be a barrier to seeking help. The absorption of hegemonic masculinity, when coupled with sexual victimization, creates a situation for a male victim in which he experiences gender role conflict (O’Neil, 1981). The victim is forced to choose between an action which conflicts with his masculinity (seeking help) and an action that may cause him further harm (not seeking help). Despite the individual negative implications of hegemonic masculinity, this is not just an individual problem, but rather a societal one. A major challenge in overcoming masculinity norms is that the concept is pervasive throughout society and reinforced in subtle (and less than subtle ways). 132 Media representation, masculinity, and male sexual victimization. Societal perceptions of men as victims of sexual assault present a major challenge for male victims. Not only is hegemonic masculinity enacted and rewarded in daily life, media representations of men are often larger than life, and impossible to embody for most men. Beyond the way that masculinity is represented, media and cultural representations of male sexual victimization are referenced in a comedic context (Cohen; 2014; Small, 2015; Stemple & Meyer, 2014). Despite some movement towards the treatment of male sexual victimization as a serious subject in the media on television (e.g. Criminal Minds, American Crime), in comic books (e.g. Invincible), and novels (e.g. Outlander), there are many more recent instances in which male sexual victimization is portrayed for humor (e.g. Wedding Crashers, 40 Days and 40 Nights) or shock value (e.g. American Horror Story) (Doyle, 2016). These attitudes towards male victimization stem from the societal construction of gender and the ways that masculinities inform male rape myth acceptance and create barriers to male help-seeking behaviors. Changing the landscape of media to reduce the occurrences of male sexual assault as a joke or horror plot point may reduce some of the stigma associated with victimization. Additionally, increasing the ways in which maleness is portrayed in the media to exhibit other ways of being masculine beyond traditional hegemonic masculinity may increase society’s capacity to shift towards a view of men and maleness that creates a safe space for male victims. Multiple masculinities. Despite the overarching hegemonic masculinity (Connell, 1987, 2000, 2005; Connell & Messerschmidt, 2005), the concept of multiple masculinities (Lusher & Robins, 2009) has developed, which may simultaneously subvert some aspects of traditional gender norms while also supporting or reconstructing other aspects. These may be related to race or ethnicity, sexuality, class, or an alternative core identity intersecting with multiple identities 133 and backgrounds. In considering rape culture and its relation to masculinity, Kimmel (2010, 2012) and Connell (2005) urge society to embrace new masculinities that would both create a safe space for male victims to exist and heal. Movement away from hegemonic masculinity, towards the recognition of masculinities which allow men to act outside of traditional gender roles is imperative for the long-term support of male victims. Limitations of the Study A limitation, related to both this study and the larger sphere of gender-based research, is the increasing number of gender non-conforming individuals. While the majority of individuals in the United States and internationally identify as male or female, the number of individuals who identify outside of the gender binary of male and female (e.g., gender fluid, genderqueer, agender, gender neutrois, bigender, third gender, or gender non-conforming [GNC]) is increasing (Bockting, 2008; Killerman, 2013; Richards, Bouman, Seal, Barker, Nieder, and T’Sjoen , 2016), as is the acceptance of identities outside of the male/female binary (Fusion.net, 2015). Doan (2016) reports that the 2014 United States (U.S.) census data, when estimates are calculated with expanded counts, suggests that there were over 4.8 million genderfluid adults living in the U.S. in 2014. While this does not diminish the need for services and outreach focused on male victims, it is important to note that the number of individuals who identify outside of the gender binary is increasing and may be in need of services. Transgender individuals are especially vulnerable to sexual violence, (Grant, 2011; Langenderfer-Magruder et al., 2016; Testa, Sciacca, Wang, Hendricks, Goldblum, Bradford & Bongar, 2012) and even mental health or sexual assault-specific services that serve both male and female individuals effectively may not be welcoming to or appropriate for those who do not identify with gender in a binary way (Markman, 2011). 134 Some limitations of this study involve the survey. First, the retrospective design of the survey may decrease accuracy, due to the reliance on the memories of the participants (Eisenhower, Mathiowetz & Morganstein, 1991; Finney, 1981; Van der Vaart, Van Der Zouwen & Dijkstra,1995). Second, though the victim’s gender socialization, views of masculinity, and rape myth acceptance seem to play an important role in his choice to seek help or not, both in the theoretical model (Tsui, Cheung and Leung’s (2012) and the interpretation of this study’s results, there are no variables in the data set that allow for the testing of these theories. Third, this retrospective, cross-sectional survey does not measure the time between victimization and seeking help. Men tend to delay seeking help (Doherty & Kartalova- O'Doherty, 2010; Yousaf et al., 2015), despite interventions being most effective shortly after victimization (Kearns et al., 2012; Price et al., 2014). The implications of understanding the relationship between the variables in this manuscript and time to help-seeking could have powerful implications for social work clinical and macro practice. Finally, a limitation of this study is the very problem that it seeks to address—the decreased likelihood of reporting sexual victimization by men. Not only are survey takers less likely to answer sensitive questions about victimization (Aday & Cornelius, 2006) and measuring sexual violence is challenging regardless of the victim’s gender (Fisher, 2009), but the same barriers that stand in the way of a man seeking help or disclosing victimization may stand in the way of discussing his sexual victimization to an unknown party over the phone. Implications Implications for Theory This dissertation makes three contributions to theory, through the use of Tsui, Cheung and Leung’s (2012) Conceptual Framework for Analyzing Help-seeking Behaviors among Male 135 Victims in Heterosexual Intimate Partner Violence. First, the adaptation of adding two factors to the model: perpetrator-level characteristics and incident-level characteristics was a successful addition to the model. This is suggested through the statistically significant relationships between help-seeking variables and variables associated with these two added factors in this study. Second, though this model was designed to explain the relationship between male victims and help-seeking for heterosexual IPV victimization, with the adaptation, not only does this conceptual model apply to male victims of sexual violence, it seems to retain its utility outside of intimate partner perpetration and with perpetrators of either gender. Finally, though the findings of this dissertation are in agreement with the conceptual model that theoretical perspective (e.g., masculine gender socialization) and sociocultural variables (e.g., masculine gender role conflict) are integral to a male victim’s choices around help seeking, it seems as though they may not function in the same way. While there is a negative relationship between hegemonic masculinity and help-seeking for male sexual victimization, in the literature (Davies et al., 2012; McLean, 2013), less is known about how this mechanism works. It seems possible, based on the interpretation of the results in this study, that theoretical perspective and sociocultural positioning, especially related to masculinity, may act as a filter or lens through which characteristics of the incident are viewed or pass through—allowing the male victim to judge the suitability of sharing his victimization with others. Implications for Social Work Clinical Practice The most obvious group of clinicians for which this dissertation has implications is clinical staff of sexual assault service agencies and other clinical social workers in direct practice. The National Alliance to End Sexual Violence (n.d.) recommends that staff training, outreach/advertising, and services focus on male victims, as well as female victims. This 136 recommendation is promising for male victims and hopefully indicates both that male victims are aware of service through provider outreach and that the time when male victims would be turned away from service providers (Donnelly & Kenyon, 1996) has passed. The clinical implications include potential areas for additional training, new approaches to assessments and interventions, and increased networks for referrals. Broadly, training may be needed to help providers of clinical treatment become aware of the prevalence rates of male victims versus the rates of help-seeking. Clinicians should be aware of training opportunities which help them to learn how to work with male victims in individual or group settings, as well as to identify and address any biases against male victims or male rape myth acceptance. Movement towards trauma-informed, gender-responsive practice for males should be encouraged. One example of this is the addiction recovery program, Helping Men Recover (Covington, Griffin, & Dauer, 2011). Clinicians should focus on preservation of existing women’s safe spaces, while also creating space for male victims at the organizational level, including exploration of alternative sources of support for male victims. Creating services that “make seeking and receiving help less traumatic” is important for both male and female victims of sexual assault (Allen, Ridgeway, & Swan, 2015, p. 105). Developing a gender sensitive assessment that does not stigmatize or retraumatize the victim while assessing for trauma would be a good first step. Assessments should not assume the gender of the perpetrator, the nature of the sexual violence, or the age of the victim at the time of the assault, though assessments for trauma should include childhood. Based on the findings of this study, the inclusion of childhood in a trauma assessment may lead to male victims who are more likely to talk about their previous victimization. 137 Due to the increased help-seeking found in men who have sex with men in this study, providers should be educated on the needs of LGBTQ individuals and men who have sex with men (MSM). This is especially important, as LGBTQ individuals may have increased difficulty finding a service provider that is accepting of them (Calton et al., 2016) and a bad experience with a service provider may cause a victim to not seek help the next time they are in need (Kenagy, 2005; Lombardi, 2001; Todahl et al., 2009). However, this need for sensitivity does not extend only to LGBTQ men, based on the findings in Manuscript #1/Chapter 2, men who have only had sex with women are even less likely to report than their LGBTQ counterparts. Injury was found to be a predictor of formal help-seeking, which includes medical care. However, there are important steps that can be taken in a medical setting for victims of sexual assault of either gender. For example, STDs can be tested for and treated, post-exposure prophylaxis can be administered for possible HIV exposure (HIV.gov, 2015), even Plan B, an emergency contraceptive can be administered in cases when the victim is male, but has a uterus, such as in the case of transmen. Often the hospital is the conduit for evidence collection, allowing the victim to have the option to work with the police. Clinicians should be prepared to provide referrals and resources to clients including medical services for a or lawyers. Implications for Social Work Macro Practice There are a number of ways that macro social workers could use this work to inform their practice. Outreach is needed to encourage victims of sexual assault who are not injured to still seek medical attention for possible exposure to HIV and STDs, as well as evidence collection. Outreach to teachers and school social workers to assist in recognizing that sexual assault can happen early in childhood and help to understand early signs of victimization in children. Concerning missed employment, programs such as Workplaces Respond to Domestic and Sexual 138 Violence (2018) from Futures Without Violence should be implemented to safeguard the rights of victims, as well as educate employers about how to respond appropriately to victims who are also employees and to make the place of employment a safe place to disclose victimization and a place safe from victimization. The most important implication for this work may be an increased spotlight on the need for more public knowledge about this very serious issue. Macro social workers should advocate for outreach programs that emphasize that sexual assault can happen to males, regardless of race, sexual orientation, or socioeconomic status. It is not surprising that almost forty percent of the sample of victimized males in this study chose to never seek help or disclose to anyone, in their whole lifetime until they were approached to participate in the NISVS survey and were asked directly about their victimization experience. Outreach is needed to educate males and clinicians about what exactly could be considered sexual violence, to remove the stigmatized connection between victimhood and femininity, and to sensitize community members to this issue so that male rape is no longer a punchline. By empowering men to share their stories, their similarities, and difference, and putting a face to this underrecognized population, macro social workers have the opportunity to slightly shift the culture away from hegemonic masculinity and towards the multiple masculinities Kimmel (2010, 2012) and Connell (2005) urge us to embrace. Implications for Social Work Policy Implications for policy in this dissertation focus on advocacy and attention. First, social workers should advocate for laws that broadly define sexual assault in a way that includes the possibility that men may be victims of sexual assault and that women may be perpetrators. Social workers should advocate for policies that ensure that even if victims of violence miss work or school, that their place as a student or employee is protected. Additionally, national and 139 international human rights and sexual assault advocacy groups should devote some portion of their attention to male victims of sexual assault. Finally, laws, services, and budgets are often planned with adult female and child victims in mind, including federal funding for research and treatment (Mezey & King, 2000). Policy work should be done to ensure that male victims have the same access to the tools. Implications for Future Research Implications for future research include ideas that have emerged from the findings, as well as next steps with the NISVS (2010) data set. There are a number of future explorations with this dataset that stem from this work. Most predominant is the next step of creating one model to better understand the associations between explanatory and dependent variables through multilevel analysis. Other future analyses would explore variable associations, including gender of perpetrator, injury severity, and post-traumatic stress disorder proxy variables at the individual-level. Qualitative work that explores the male victim’s relationship with identity and masculinity would contribute to the question of the role that these concepts play in help-seeking would further inform this work, as well as the role of masculinity in the conceptual model (Tsui, Leung & Chen; 2010). As we know that men in the LGBTQ community may be more likely to seek help, thus research that assesses knowledge of providers related to male victims of sexual assault, and especially the needs of the LGBTQ community would be especially appropriate. Finally, some broader social questions that are relevant to this work. Studies on the impact of societal representation of male sexual assault on males would be appropriate as an extension of this topic. Another potential avenue of research related to this topic would involve implementing a survey which asked questions similar to the NISVS, but also included seeking 140 Gender Role Conflict Scale (O’Neil, 1981) and Male Rape Myth Scale (Struckman-Johnson & Struckman-Johnson, 1992) to test how gender role conflict and rape myth acceptance interact. Conclusion Through the use of secondary data in the NISVS (2010) this dissertation seeks to systematically explore a broad range of aspects of the experience of male victims of sexual violence and their association with the victim’s decision to seek help, including characteristics of the victim, the perpetrator, and the incident. Through a better understanding of the associations between these characteristics and the victim’s choice to seek help, we can create knowledge around barriers and facilitators of help-seeking after an incident of sexual violence. These findings serve to increase understanding of existing gaps in prevalence estimates, advance clinical knowledge for more through assessments for trauma in male clients, provide increased evidence related to outreach needs, and set the stage for future research about male victims of sexual assault and their help-seeking behaviors. 141 APPENDICES 142 APPENDIX A Figure 7. A Conceptual Framework for Analyzing Help-seeking Behaviors among Male Victims in Heterosexual Intimate Partner Violence (Tsui, Cheung, & Leung, 2012) 143 Appendix A. Figure 7. A Conceptual Framework for Analyzing Help-seeking Behaviors among Male Victims in Heterosexual Intimate Partner Violence (Tsui, Cheung, & Leung, 2012) Reprinted with from: International Journal of Psychology Research, Vol. 7, Male victims in heterosexual intimate partner violence: A framework explaining help-seeking reluctance, p. 13, 2010, Tsui, V., Cheung, M., & Leung, with permission from Nova Science Publishers, Inc. 144 APPENDIX B Figure 8. Adapted Model of Tsui et al.’s (2012) Conceptual Framework for Analyzing Help- seeking Behaviors among Male Victims in Heterosexual Intimate Partner Violence (IPV) 145 Appendix B Figure 8. Adapted Model of Tsui et al.’s (2012) Conceptual Framework for Analyzing Help-seeking Behaviors among Male Victims in Heterosexual Intimate Partner Violence (IPV) 146 APPENDIX C Table 18. Summary of Demographic Information of Male Victims of Sexual Violence 147 Appendix C Table 18. Summary of Demographic Information of Male Victims of Sexual Violence (n=1569) Variable Frequency Valid Agea 18–24 25–34 35–44 45–54 55 or older Raceb White Non-white Black Asian Native Hawaiian/ Pacific Islander American Indian/ Alaskan Native Other Hispanicc Sexual Partnerd Women Only MSM Sexual Orientatione Heterosexual Gay Bisexual Transgendered Education No schooling 1st–8th grade Some high school High school Technical Some college Four-year college Postgraduate 189 262 294 337 484 1,276 276 141 36 3 39 57 144 1373 190 827 56 41 1 1 21 107 390 84 380 315 271 Percentage 12.0 16.7 18.7 21.5 30.8 82.2 17.8 9.1 2.3 2.0 2.5 3.7 9.2 87.8 12.2 88.2 6.0 4.4 0.1 0.1 1.3 6.8 24.9 5.4 24.2 20.1 17.3 148 Table 18. (cont’d) Variable Frequency Valid Percentage 80 87 103 129 188 202 243 463 5.4 5.8 6.9 8.6 12.6 13.5 16.3 31.0 Yearly Incomef Less than 10K 10K–15K 15K–20K 20K–25K 25K–35K 35K–50K 50K–75K 75K+ Mental Health (self-rating)h Excellent Very good Good Fair Poor Physical Health (self-rating)i Excellent Very good Good Fair Poor Number of SV Perps (max–min) Number of SV Perps (mean) a 3 missing, b 17 missing, c 7 missing, d 6 missing, e 644 missing, f 74 missing, g 2 missing, h 2 missing, i 2 missing 30.4 31.0 26.0 10.3 2.4 15.3 32.9 31.3 15.3 5.2 2.33 (SD=2.309) 476 486 407 161 37 240 515 491 240 81 1–19 149 APPENDIX D Table 19. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Help 150 Appendix D Table 19. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Help (n=984) Variable Frequency Valid Agea 18–24 25–34 35–44 45–54 55 or older Raceb White Nonwhite Black Asian Native Hawaiian/ Pacific Islander American Indian/ Alaskan Native Other Hispanicc Sexual Partnerd Women Only MSM Sexual Orientatione Heterosexual Gay Bisexual Transgender Education 1st–8th grade Some high school High school Technical Some college Four-year college Postgraduate 141 166 184 218 273 819 156 83 18 1 20 34 80 827 152 526 47 35 1 7 57 236 53 256 203 172 Percentage 14.3 16.9 18.7 22.2 27.7 83.2 15.9 8.4 1.8 0.1 2.0 3.5 8.1 84.0 15.4 85.8 4.8 3.6 0.1 0.7 5.8 24.0 5.4 26.0 20.6 17.5 151 Table 19. (cont’d) Variable Frequency Valid Percentage 48 58 63 80 128 121 154 284 4.9 5.9 6.4 8.1 13.0 12.3 15.7 28.9 Yearly Incomef Less than 10K 10K–15K 15K–20K 20K–25K 25K–35K 35K–50K 50K–75K 75K+ Mental Health (self-rating)g Excellent Very good Good Fair Poor Physical Health (self-rating)h Excellent Very good Good Fair Poor Experience of Severe Victimization Number of SV Perps (max–min) Number of SV Perps (mean) a 2 missing, b 9 missing, c 3 missing, d 5 missing, e 371 missing, f 48 missing, g 1 missing, h 1 missing, 15.9 33.1 30.5 15.2 5.2 28.9 156 326 300 150 51 284 300 313 239 105 26 30.5 31.8 24.3 10.7 2.6 1–19 2.51 (SD=2.51) 152 APPENDIX E Table 20. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Formal Help 153 Appendix E Table 20. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Formal Help (n=361) Variable Frequency Valid Agea 18-24 25-34 35-44 45-54 55 or older Raceb White Nonwhite Black Asian American Indian/ Alaskan Native Other Hispanicc Sexual Partnerd Women Only MSM Sexual Orientatione Heterosexual Gay Bisexual Education 1st-8th grade Some high school High school Technical Some college 4-year college Postgraduate Yearly Incomef Less than 10K 10K-15K 15K-20K 20K-25K 25K-35K 35K-50K 50K-75K 75K+ 28 48 74 97 113 304 54 26 2 11 15 31 265 93 200 26 18 2 22 78 19 105 66 69 25 35 25 33 40 38 61 89 Percentage 7.8 13.3 20.5 26.9 31.3 84.2 15.0 7.2 0.6 3.0 4.2 8.6 73.4 25.8 81.0 10.5 5.0 0.6 6.1 21.6 5.3 29.1 18.3 18.3 7.2 10.1 7.2 9.5 11.6 11.0 17.6 25.7 154 Table 20. (cont’d) Variable Frequency Valid Percentage 86 103 102 53 17 23.8 28.5 28.3 14.7 4.7 Mental Health (self-rating) Excellent, Very good, Good, Fair, or Poor Physical Health (self-rating)g Excellent, Very good, Good, Fair, or Poor Experience of Severe Victimization Number of SV Perps (max-min) Number of SV Perps (mean) a 1 missing, b 3 missing, c 1 missing, d 3 missing, e 160 missing, f 20 missing, g 2 missing, h 1 missing 11.9 27.4 32.7 20.2 7.5 36.0 43 99 118 73 27 130 2.88 (SD=2.79) 1-19 155 APPENDIX F Table 21. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Mental Health Services 156 Appendix F Table 21. Summary of Demographic Information of Male Victims of Sexual Violence Who Sought Mental Health Services (n=253) Variable Frequency Valid Agea 18-24 25-34 35-44 45-54 55 or older Raceb White Nonwhite Black Asian American Indian/ Alaskan Native Other Hispanicc Sexual Partnerd Women Only MSM Sexual Orientatione Heterosexual Gay Bisexual Education 1st-8th grade Some high school High school Technical Some college 4-year college Postgraduate Yearly Incomef Less than 10K 10K-15K 15K-20K 20K-25K 25K-35K 35K-50K 50K-75K 75K+ 20 38 55 68 72 216 35 16 1 8 10 23 174 77 138 19 16 2 15 51 16 81 42 46 19 28 18 28 25 22 43 59 Percentage 7.9 15.0 21.7 26.9 28.5 86.1 13.8 6.3 0.4 3.2 4.0 9.1 69.3 30.7 54.5 10.8 9.1 0.8 5.9 20.2 6.3 32.0 16.6 18.2 7.9 11.6 7.4 11.6 10.3 9.1 17.8 23.3 157 Table 21. (cont’d) Variable Frequency Valid Percentage 46 73 74 46 14 18.2 28.9 29.2 18.2 5.5 Mental Health (self-rating) Excellent, Very good, Good, Fair, or Poor Physical Health (self-rating) Excellent, Very good, Good, Fair, or Poor Experience of Severe Victimization Number of SV Perps (max-min) 2.97 (SD=2.88) Number of SV Perps (mean) a 0 missing, b 2 missing, c 1 missing, d 2 missing, e 110 missing, f 16 missing 11.1 28.1 32.4 20.6 7.9 41.1 28 71 82 52 20 104 1-19 158 APPENDIX G Table 22. NISVS Operationalization of Sexual Violence 159 Appendix G Table 22. NISVS Operationalization of Sexual Violence Incident Type Categories Sexual Violence Behavior Related NISVS Questions Rape Completed Forced Penetration Attempted Forced Penetration Completed Alcohol or Drug Facilitated Penetration Anyone used physical force: make you receive anal sex? Anyone used physical force: make you perform oral sex? Anyone used physical force: put their fingers/ object in your anus? Anyone used physical force: try to have vaginal, oral, or anal sex with you? Anyone made you receive anal sex (alcohol or drug facilitated)? Anyone made you perform oral sex (alcohol or drug facilitated)? Completed Forced Made to Penetrate Anyone used physical force: make you have vaginal sex? Anyone used physical force: make you perform anal sex? Anyone used physical force: make you receive oral sex? Made to Penetrate Attempted Forced Made to Penetrate Completed Alcohol or Drug Facilitated Made to Penetrate Sexual Coercion Unwanted Sexual Contact Non- Contact Unwanted Sexual Experience Anyone used physical force: try to make you have vaginal sex with them? Anyone had vaginal sex with you (alcohol or drug facilitated)? Anyone made you perform anal sex (alcohol or drug facilitated)? Anyone made you receive oral sex (alcohol or drug facilitated)? Anyone coerced sex by: doing things like telling you lies? Anyone coerced sex by: wearing you down by repeatedly asking for sex? 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