Improved data collection

Over 50% of the included studies used convenience sampling, with a similar proportion failing to report response rates. Nonetheless, the reported adult lifetime and past-year rates reported by Zarchev and colleagues are certain to be underestimates of prevalence among men experiencing mental ill health, owing to the known latency of male sexual abuse disclosure (e.g. including those who potentially deny true exposure in clinical interview) and the exclusion of studies reporting childhood sexual abuse (onset at <18 years of age). Furthermore, all but one of the included studies involved a clinician or trained specialist assigning psychiatric classification. Although this approach is considered gold standard for enhancing validity of coded diagnostic impressions, the lack of anonymity may have resulted in a proportion of men denying true abuse exposure because of shame and other factors.^{Reference Easton, Saltzman and Willis4}

Zarchev and colleagues^{Reference Zarchev and Roos9} highlight that reported lifetime prevalence rates would be markedly higher if childhood sexual abuse studies were included in the analysis, with the true prevalence of male childhood sexual abuse in men with mental illness yet to be determined. Prior meta-analysis in the general population (<18 years of age) indicates that 8% (95% CI 4–16%) of men have experienced childhood sexual abuse broadly defined,^{Reference Barth, Bermetz, Heim, Trelle and Tonia11} and a recent self-report study adopting convenience sampling among 1277 young men (≤30 years of age) seeking mental health help yielded a childhood sexual abuse prevalence rate of 21.9%.^{Reference Rice, Kealy, Seidler, Walton, Oliffe and Ogrodniczuk7} This rate is remarkably similar to the 21.1% self-reported prevalence in the Zarchev review, which was notably 11.5% higher than the 9.6% prevalence reported in face-to-face studies.

There are of course significant challenges in collecting accurate childhood sexual abuse prevalence data among boys and men, and research on trauma history assessment that avoids causing harm is needed. Improved prevalence data matter for a number of important reasons. Recent longitudinal research has shown that, after controlling for sociodemographic, health and background factors, childhood sexual abuse undermines men's mental health across the life course well into men's sixth, seventh and eighth decades of life.^{Reference Easton, Kong, Gregas, Shen and Shafer10} Hence, there is a rationale for reducing the duration of untreated (or unacknowledged) sexual abuse among boys and men, with the aim of offsetting subsequent distress or illness. That said, it is acknowledged that humans have extraordinary reservoirs of, and capacity for, resilience in the aftermath of trauma exposures. Formal psychological intervention may not be necessary for many men with a sexual abuse history – indeed sexual abuse exposure need not consign boys and men to lives of misery. Many men articulately reflect on experiences of post-traumatic growth^{Reference Easton, Coohey, Rhodes and Moorthy12} and positive identity development after abuse exposure.

Intervention studies: how and when to intervene

Previous studies have called for an urgent focus on intervention-based research for males with histories of sexual abuse, including the roles of formal and informal support groups, psychoeducation and awareness campaigns, and refinement of clinical treatment modalities.^{Reference Easton8} This may extend to case conceptualisation, assessment and diagnosis, inclusive of older men who may be presenting to mental healthcare services for the first time. Following exposure to traumatic events, including sexual abuse, males are known to be less likely to experience threshold post-traumatic stress disorder (PTSD) compared with females, but report comparatively higher rates of externalising symptoms, including alcohol and drug use, irritability, anger and violent behaviour.^{Reference Tolin and Foa13} Of note, DSM-5-TR acknowledges that this constellation of externalising symptoms are particularly likely to co-occur with major depressive disorder in men.¹⁴ Traumatic events may exacerbate underlying socially influenced gender differences in response to distress, resulting in alternative constellations of post-traumatic symptom patterns among boys and men.^{Reference Tolin and Foa13}

Clinicians reticent to ask about men's sexual abuse experiences may inadvertently add to the harms experienced by men seeking care. Poor treatment experiences among male sexual abuse populations can reinforce a sense of shame and secrecy, perpetuate rejection and prohibit the development of therapeutic trust, acceptance, connection and honest disclosure with treating therapists.^{Reference Rapsey, Campbell, Clearwater and Patterson2} Future research should examine differential outcomes for boys and men based on whether disclosure (and treatment access) is provided proximally to exposure, and the types of supportive approaches and interventions that boys and men experience as acceptable, engaging and safe. Emerging evidence suggests that (a) early disclosure (within 1 year) of sexual abuse, (b) the nature of the response to abuse disclosure and (c) having in-depth discussions about abuse experiences are each protective for men's mental distress.^{Reference Easton8} These factors do, however, raise complexities, including safety implications for those less than 18 years of age, the readiness, confidence and willingness of clinicians, peers and family to appropriately listen to and validate sexual abuse disclosure, and the extremely limited availability of appropriately sensitive services for boys and men. These are areas requiring urgent research and practice advances.

Implications for population health

Adequately addressing the mental health needs of boys and men who have experienced sexual abuse is certain to spur major advances in population health. It is increasingly clear from the meta-analysis of Zarchev et al^{Reference Zarchev and Roos9} and others^{Reference Barth, Bermetz, Heim, Trelle and Tonia11} that sexual abuse among boys and men is massively underrecognised and undertreated. The associated burden of disease, comorbidity and suffering, both for the individual and that imposed on others, is immense. Attention to this problem would likely reduce rates of suicide among men, which globally eclipse suicide rates among women by a factor of two to four.^{Reference Rice, Oliffe and Seidler15} When extrapolating conservative prevalence rates of undetected and untreated sexual abuse, maladaptive coping strategies (e.g. substance use, aggression, risk-taking) that risk harm to self and others could be reduced in hundreds of millions of boys and men globally. There is growing attention to the ways in which gender norms affect the social and emotional development of boys and men^{Reference Rice, Oliffe and Seidler15} and future tailored interventions and programme development for boys and men affected by sexual abuse must be cognisant and transformative of such norms. This extends to initial disclosure and help-seeking, tailoring of specialised services and clinical trials to improve long-term psychosocial functioning. Too often ignored and hidden in plain sight, boys and men with sexual abuse histories require focused attention to address their unmet mental health needs. Doing so will improve not only the mental health of affected individuals, but extend health benefits to the families and communities where these men live.