**4. Explorative part: Gender differences**

Gender differences in alexithymia, dissociation, and self have been published in populations other than CSA. The general picture reveals higher alexithymia scores for men on the BVAQ (Vorst & Bermond, 2001). However, reports using the TAS, failed to demonstrate such gender differences in alexithymia (Parker, Taylor & Bagby, 1989). While, in general men were found to be more alexithymic, women tended to be more vulnerable to dissociation (Coons, 1996; Ross, 1996). Many researchers though reported surpassing scores for males on the frequency of dissociative disorders in various populations including children, adolescents, criminal offenders and forensic patients are reported as well (Kluft, 1996; Putnam et al., 1996). These inconclusive findings can be attributed to methodological problems, such as comparing outcomes from classification systems with outcomes from questionnaires, different populations, and different instruments. For self gender outcomes are even more confusing because researchers have a tendency to make a distinction between an interdependent and an independent self-construal. The social, institutional, and cultural environment of the United States for instance promotes development of independence and autonomy in men and interdependence and relatedness in women (Bakan, 1966; Maccoby, 1990; Markus & Oyserman, 1989). Therefore the outcome of the comparison is dependent upon the self-construal chosen which hampers the making of absolute statements on gender differences.

The comparatively few studies that did investigate both male and female CSA victims seem to indicate that the variety of maladaptive psychological behaviours and psychiatric disorders associated with CSA are expressed differently in boys and girls (Walker et al., 2004). In general, girls manifest a tendency to *internalizing* behaviours (Butler & Nolen-Hoeksema, 1994). Boys on the other hand have been found to display a coping style in response to CSA characterized by more *externalizing* behaviours (Garnefski & Arends, 1998; Kuhn et al., 1998). The different expressions of the impact of CSA on gender may be partly explained by the influence of CSA on gender identity. Male victims seem to become more commonly confused about their sexual identity and orientation in heterosexual relationships (Tzeng & Schwarzin, 1990). Such confusion stems from any type of perceived responsiveness to the incident taking place from the same sex abuser and may lead to the assumption that the masculinity of the victim has been compromised (Moody, 1999). In such cases boys may be more prone to acting out aggression and engaging in delinquent activities in an effort to compensate for and re-establish their perceived loss of masculinity (Rogers & Terry, 1984). Girls on the other hand tend to display a more damaged self esteem and self blame, not only because of their tendency to ruminate, but also because in many cases they are often held responsible for the abuse by suggesting that girls seduced and encouraged the perpetrator (Carmen et al., 1984; Herman, 1981; Kohn 1987), with shame and guilt feelings as a consequence. Additionally, fear and distress enhance a maladaptive vulnerability that

Gender Differences in the Impact of Child Sexual Abuse on Alexithymia, Dissociation and Self 81

strangers. Duration related to the numbers of years the abuse had lasted and frequency related to how many times a week the abuse had taken place. In the category coercion misleading meant that the child was told it was perfectly normal for children to be involved in the kind of sexual activities the perpetrator demanded. Giving presents to the victims supposedly was a strategy to consolidate the bond between perpetrator and child and thereby avoiding betrayal. Threatening meant that the child would no longer benefit from all kind of privileges if it refused to cooperate. Giving the child the idea that he/she was responsible for the abuse by seducing the perpetrator was applied to ensure the abuse was kept a secret. The child was bad and should be ashamed. Exerting emotional pressure happened when the perpetrator convinced the child that he acted out of love and that revealing "our secret" would make the perpetrator very sad and would ruin his life. Physical pressure was another way of preventing the child from revealing the abuse. Finally memory recovery was investigated by asking the subjects whether he/she had ever experienced an episode of inability to recall the traumatic events and if so how many

*Bermond-Vorst Alexithymia Questionnaire* (BVAQ, Bermond & Vorst, 1993), consisting of five subscales (Vorst & Bermond, 2001) which relate to a reduced ability to: a) verbalize emotional experiences (Verbalizing), b) differentiate between emotional feelings (Identifying), c) reflect upon emotions (Analyzing), d) fantasize (Fantasizing), and e)

Reliability and validity of the BVAQ are good (Vorst & Bermond, 2001; Bermond et al., 2007). Assessing the prevalence of alexithymia is based on impairment of the cognitive component (sum total of reduced Verbalizing, Identifying, and Analyzing), as an impaired cognitive component (belonging to Type I and Type II alexithymia) appeared to be related to a broad range of psychological disorders (Moormann et al., 2008; see also the 2007 publication of Bailey & Henry for the relation between Type I & II alexithymia and somatization), while an impaired affective component (sum total of reduced Emotionalizing & Fantasizing) primarily related to activities where expressive behaviour and creative imagination were hampered. For both alexithymia components scores ≥ percentile 70 were used as an indication of impairment while scores ≤ percentile 30 were used as an indication of unimpairement. In the Moormann et al. study of 2008 the cut-off scores for the alexithymia types (based on a student population of 354 subjects) were computed as follows: raw scores ≥54.0 related to an impaired cognitive component while raw scores ≤43.0 related to an unimpaired cognitive component. Regarding the affective component raw scores ≥42.0 related to an impaired affective, while raw scores ≤34.0 related to an unimpaired affective component. Using the above cut-off scores for an impaired cognitive BVAQ component as an indication of the prevalence of alexithymia resulted in an incidence of alexithymia of 20.4% in the Netherlands (Moormann et al., 2008) and of 18.2% in Australia (Bailey & Henry, 2007). On the basis of an albeit small clinical sample of 39, Taylor et al. (1997) suggest a cutoff value of 61 and above on the Toronto Alexithymia Scale (TAS-20). Despite the different instrument for alexithymia the statistics given in Finland (21.0%; Honkolampi et al., 2000), using these TAS-20 cut-off scores, are practically the same as the statistics obtained with the BVAQ in Australia and The Netherlands. Older studies using a cut-off on the earlier 26-item TAS have reported rates of 23% for a normal group in France (Loas et al., 1995) and 18.8% in Canada (Parker et al., 1989). Hence, the cut-off scores used in the present research seem a

years this period lasted.

experience emotional feelings (Emotionalizing).

fair indication for the prevalence of alexithymia.

stems from their perception that the world is a dangerous and threatening place (Feiring et al., 1999). The above seems to be confirmed by case studies, where male victims of sexual abuse were found to have low self-esteem as well (Myers, 1989). Expressions were as being flawed, and shame and guilt for participating in the sexual activities were reported as well, which later may become personality traits. Hunter (1990) reports significantly lower selfesteem scores for male victims of sexual abuse as opposed to non-victims. Dhaliwal et al. (1996) report reduced sexual self-esteem as a consequence of sexual abuse.

In contrast with the above studies where gender comparisons are more relative than absolute, in the present research possible differences in symptom reporting between the sexes will be tested using the same constructs and the same instruments.
