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Every day, men are victims of sexual abuse or rape, abused by people who hold power over them. But this experience is directly at odds with the message they grow up with that 鈥榖eing a victim is impossible for men鈥�. So what happens when the potentially catastrophic experience of sexual abuse happens?

I have run recovery groups in London and Glasgow for men, teenage boys and trans and non-binary people who have survived abuse. In my private practice, I see people of all genders who are survivors.

When sitting with these clients I hear about the damaging societal ideas about men and sexual abuse 鈥� men should be able to defend themselves; men can鈥檛 be sexually abused; men always want sex and must have enjoyed it; men can鈥檛 be abused by a woman. I hear how these myths impact the lives of male survivors. One client, Adrian,* told me: 鈥業t was three days after [the rape] and I finally got the courage to go to the hospital, because of the pain. Then, the nurse turns around and says, 鈥淵ou don鈥檛 have any bruises, that鈥檚 unusual, are you sure you were forced?鈥濃��

Adrian鈥檚 experience is shocking but it鈥檚 not unusual. Many of my clients report being on the receiving end of these false social misconceptions from the people meant to look after them, both loved ones and in wider society. Men are already reluctant to seek help 鈥� men see their GP 32% less than women and only eight per cent of men with a common mental disorder are likely to access NHS Improving Access to Psychological Therapies (IAPT) services.^1,2 These barriers become even more significant for men who suffer the catastrophic trauma of sexual abuse or rape 鈥� one of the many reasons that more men die by suicide than women, with the greatest number being men aged 45-50.³

If society refuses to acknowledge male survivors, how do we expect men to acknowledge their own pain? We know one in six men are sexually abused, although this is widely considered to be a conservative figure.⁴ An internal survey conducted of service users at Survivors UK, a men鈥檚 rape and sexual abuse charity, found that men take on average 26 years to disclose an abuse to anyone, if they disclose it at all. Even less data exist about marginalised groups such as transgender or disabled men.

Society and stigma can rob men of permission to be victims of sexual abuse and thus rob them of the first step to healing.

Ego states

If men can鈥檛 access victimhood, what does society and their own sense of masculinity allow them to be? I find it useful to use Karpman鈥檚 drama triangle to help answer that question.⁵

The drama triangle was first created to illustrate the way in which complex interactions occur between people who are enmeshed in conflict or relationships with an imbalance of power. People can be drawn into different roles, feeding off energy that the conflict creates and getting trapped in a particular way of being with certain people.

The three roles in the drama triangle, also known as ego states, are victim, rescuer and persecutor. They are set in an inverse triangle 鈥� rescuer and persecutor on top, and victim at the bottom point. A person is not put into their role within the triangle by another person 鈥� rather, they are actively but subconsciously putting themselves there because of how they relate to another person. People can move around the triangle, inhabiting different ego states depending on the relationship they have with the people around them.

When sadness is met with 鈥榤an up鈥�, pain is met with 鈥榞et over it鈥�, male survivors can fear being labelled or feeling like a victim and 鈥� in fighting to distance themselves from this position 鈥� find themselves instead in persecutor and rescuer mode. It is important to note here that persecutor is an ego state that comes with complexity and nuance.

A particularly damaging myth is that male survivors of sexual abuse will go on to sexually abuse others and it is not one I wish to perpetuate. I am not suggesting an experience of sexual abuse predetermines any behaviour in a person, especially abusive or violent behaviour.

Rescuer

When thinking about my male survivor clients who embody the rescuer ego state, I often adapt this definition to rescuer/protector. These rescuer/ protector survivors often fuss and worry about everyone around them. This may manifest as protectiveness over family, community, identity or gender 鈥� and at its extreme becoming 鈥榰s versus them鈥�. Although the behaviour of the rescuer can be aggressive, it serves to keep him in the rescuer state by creating persecutors, rather than becoming a persecutor himself. A hero is still a hero, even when involved in a fight.

I remember in one session, a client learned my surname (Sachs) and instantly became irate. He was shouting antisemitic sentiments about how, in his eyes, Jews had taken over the area where he lived. The man I had worked and built a relationship with for two months suddenly filled the therapy room with all the damaging and hurtful stereotypes he could think of about my heritage. My mind was racing 鈥� am I in danger? Is this the end of our therapy? After taking a breath, I realised he wasn鈥檛 verbally attacking me 鈥�
my surname activated something, but his words, while abhorrent, kept coming back to protecting his community. In his mind, he was the community鈥檚 protector.

This is an extreme example. More likely though, people inhabiting this ego state find themselves in caring roles, either informally or in a voluntary or professional capacity. While such a role can be emotionally exhausting, it allows a survivor to focus on caring for another object鈥檚 trauma, rather than their own.

These men can find the therapeutic process challenging. In my male survivor groups, men would often say that they have come not to heal or explore their own feelings, but to help other men who have faced similar experiences. Often these men are among the ones who are most likely to report nightmares or flashbacks. This could be interpreted as an inability to consciously sit with past pain so the traumatic symptoms are experienced in the subconscious. In one-to-one therapy, I鈥檒l often have conversations with men who are loyally protective of their mothers, even if that mother did significant harm or facilitated abuse in some way. The rescuer/protector ego state becomes immovable towards a primary care giver, and to suggest otherwise invites rupture.

鈥業n some ways it feels worse than the abuse itself,鈥� says one client, Jo.* 鈥榊ou spend years coming to terms with the fact that the abuse wasn鈥檛 your fault. You want to believe that your mum was innocent, that she did her best or even that she was a victim too. When you finally figure out she let you down, didn鈥檛 do her job properly, it feels unnatural to be so angry at your mum. It took me almost as long to come to terms with that as it did with the actual abuse.鈥�

Persecutor

The persecutory male is still culturally glorified by our society. Take your pick of films 鈥� a lead male is wronged, he is robbed of his car/dog/girlfriend (or whatever interchangeable and often misogynistically framed object of care) and his only possible recourse is to beat up huge numbers of assailants with his bare hands until he, and we the audience, can feel a cathartic release through vigilante justice. To sit with his loss and victimhood is too much and society doesn鈥檛 want that of him 鈥� he must turn the psychological pain into violence to protect his own vulnerable emotions. This fictional version of masculinity comes very close to the rescuer/protector but it鈥檚 less about 鈥榣et me nurture others so I don鈥檛 dwell on my pain or get hurt again鈥� and more about saying 鈥業 will dominate everything, so I don鈥檛 dwell on my pain or get hurt again鈥�, communicated through an expression of strength.

In reality, this perpetrating form of masculinity looks very different. If we want real examples of the persecutor ego state, all we need to do is look at prisons throughout the UK. Men who have been abused can be seen as violent or have used violence as the only way of either shifting internal pain or claiming agency in the world and end up in the justice system. Female survivors by contrast are more likely to get a controversial diagnosis, such as 鈥榖orderline personality disorder鈥�, and end up enmeshed in health services.

Men who exist in the persecutor ego state have often encountered relational trauma so it鈥檚 often not until a long time into the therapeutic relationship that sexual abuse is uncovered. The persecuting ego state may not come out in therapy as overt confrontation at the therapist themselves, but rather at what the therapist is doing. Interventions never land, the client tells you they are bored or they nearly forgot they had therapy. For the therapist, this might result in feeling deskilled, needing to bring in more psychoeducation to prove how knowledgeable they are. They may even be at risk of being moved into victim mode 鈥� all they want is to do their job and they aren鈥檛 being allowed.

Men in the persecutor ego state often find themselves not just experiencing relational trauma but also in conflict with statutory organisations, such as healthcare, the criminal justice system or local councils. This conflict inevitably takes its toll and can be a continuous losing battle. 鈥業 just hurt people in my life,鈥� says Jack,* 鈥榓nd if they said to me, 鈥渓ook, we love you and we know what you鈥檝e been through, but you can鈥檛 behave like this鈥�, I would ignore them or shout at them or tell them how stupid they were being. Someone made a complaint about me at work for being pushy and angry. This was mad to me because I always enjoyed work, I liked helping or advising people. I didn鈥檛 see it as pushy and angry. I almost lost my job, not because they were going to fire me, but because I thought, 鈥淔**k you! I鈥檓 going to leave, then you鈥檒l see how stupid you鈥檙e all being鈥�.鈥�

Victim

Unlike the other ego states, in the victim ego state, a person seeks to relate to other people in a way that elicits help. Often those around them are unable to help in a way that relationally connects 鈥� ego states are ways of being in the world that can feel immovable. Someone in this ego state can be caught in a cycle of behaviour that constantly reinforces victimhood: 鈥榃hy do I always date terrible people, they always find me!鈥� The difference between this ego state and the other two, however, is that the premise that victimisation took place is agreed 鈥� and this can be hard for some male survivors.

People are rarely locked into one ego state; they flux and change depending on who or what the person is in relation with. Relating to anyone as a victim, however, can be simply too psychically dangerous for some survivors 鈥� and therein lies the challenge for us as therapists.

Being self-aware

The work that is required to support male survivors should start before the client steps into the therapy room. We need to acknowledge the societal ideas about masculinity and how it prevents men from seeking help. We also need to examine ourselves and our own beliefs that could uphold damaging ideas about men. Sexual abuse is just one barrier that men face to accessing help. I often say in therapy groups and presentations that sexual abuse rarely happens in a vacuum 鈥� often men are faced with other challenges such as different forms of abuse, poverty or structural oppression. We must do what we can to be accessible in a meaningful way, communicating to men who face barriers that we are inclusive in a more than tokenistic way. In our personal lives, we need to be aware of when harmful myths about masculinity affect our decisions or behaviour, and challenge those around us who knowingly or unknowingly perpetuate these myths.

Once men are in therapy, we need to be aware that male clients will resist the victim ego state, holding onto the rescuer or persecutor positions instead and, as a result, resisting the therapeutic process. Bion describes this as 鈥榓ttacks on linking鈥�, where a therapist may try to link the pain a client is feeling in the present to objects in their past, often a parent or caregiver.⁶ But rather than accepting this link, the client attacks the therapist and thus avoids the pain of making psychic links. This can present in multiple ways 鈥� the therapy can feel stuck, or the client can feel foggy or bored. They may be late for sessions or withhold payment. The pain of surviving sexual trauma can be acted out in every transaction between the client and the therapist, requiring us to work hard to tune in to what is going on.

Different modalities will use different techniques to create space for the client to examine their ego state, relationships and feelings. Cognitive behavioural therapists may want to focus on deconstructing some of the cognitive distortions that keep clients stuck in ego states, to rebuild a more balanced world view that allows men to need support and help. A personcentred therapist may work to accept and understand the clients鈥� feelings to help them connect or reconnect with a sense of inner value, taking the power out of external ego states and unhelpful relationships. Whatever modality, therapy needs to create enough space so that the client can simultaneously step away from ego states and the relationships that maintain them, as well as unlearn some of the damage that societal ideas of masculinity have caused.

All ego states are a prison, but they can become a familiar, even comforting one. The goal is not for men to move from a familiar ego state into a more challenging one but to move away from the drama triangle altogether. How therapists support this will depend on modality, the therapeutic setting and how the therapist builds relational trust with the client.

From a place of trust the therapist can interrogate ego states and investigate the evidence that maintains them. This can be a delicate process 鈥� challenging a world view held by someone deeply entrenched in an ego state can serve to compound a set of unhelpful beliefs. But over time, the therapist works to build a trusting and nonjudgmental relationship, allowing the client to move around the drama triangle. The goal here is to allow men to sit with their own sense of victimhood and not be held hostage by societal beliefs. And, through accepting that they were a victim, allow themselves to seek the support they need in the therapy room and beyond.

*Client names and identifiable details have been changed.