Men’s Experiences of Self-Conscious Emotions Following Childhood Sexual Abuse

ABSTRACT Rates of detection and disclosure of childhood sexual abuse (CSA) are believed to be lower in males due to gender socialization fears. The experience of CSA is thought to increase negative self-conscious emotions (shame, guilt, embarrassment, anger, and fear). Such self-conscious emotions have been associated with a range of mental and public health issues. As there has been no research to date that has explored the experience of shame and guilt within the wider context of self-conscious emotional states for males, this research aimed to explore men’s experiences of self-conscious emotions following CSA. Nine semi-structured interviews with males were completed. Interpretative Phenomenological Analysis identified three themes: “Invisible In This World” captures participants’ isolating circumstances surrounding their CSA, and how this impacted their perception of not being protected or able to speak out; “The Emotional Fallout” describes the overwhelming emotions experienced as a result of the CSA and how such emotions have impacted participants lives, and “Learning To Live With The Wound That May Never Heal” addresses how participants have spent their lives living with the abuse and how it’s a process to learn how to adapt and live with the abuse. Findings suggest there is a clear need to recognize the role and power of self-conscious emotions in male CSA, especially for healthcare professionals and services supporting males with CSA. Without addressing such self-conscious emotions, males who have experienced CSA are at risk of enduring the emotional fallout throughout their lives.


Introduction
Self-conscious emotions are a family of emotional states evoked by implicit or explicit self-evaluation and self-reflection (Tangney et al., 2007). Such emotions typically include shame, embarrassment, and pride (Tangney, 1999), along with other more basic emotional states such as anger, fear, and joy (Tracy & Robins, 2007). These states are typically interlinked and are believed to be important to healthy psychological functioning. Self-conscious emotions often manifest in various ways outside the consciousness of the individual and those around them (Tangney & Dearing, 2011). Such emotions may be expressed indirectly through intrapersonal coping skills (substance misuse; Zhu et al., 2019), experienced as isolation or powerlessness (Brown, 2006), or expressed through withdrawal or aggression (Nathanson, 1992). Shame is a global negative self-assessment or judgment "I am bad," whereas guilt is a self-assessment of behavior "I have done something bad" (MacGinley et al., 2019). Like shame and guilt, embarrassment requires a self-appraisal, however it can only occur when attentional focus is directed toward the public self, activating corresponding public self-representations (Tracy & Robins, 2007). The aim of this article is to explore men's experiences of self-conscious emotions arising from childhood sexual abuse (CSA).
HM Government (2018) report, Working Together to Safeguard Children, defines CSA and exploitation as forcing children (under 16 years old) to take part in sexual activities regardless of whether the child knows what is happening. Women are three times more likely to have experienced CSA when compared to men (Office for National Statistics [ONS], 2020). As a result, the research focus has been predominantly on women. However, rates of detection and disclosure may only appear to be low in men (Lillywhite & Skidmore, 2006) due to disclosure barriers relating to gender socialization (fear of homophobia and/or stigma; Homma et al., 2012). Furthermore, CSA is known to increase negative self-conscious emotions (Herman, 2011), which have been associated with a range of mental and public health issues such as depression, addiction, and suicide (Brown, 2006). Impact on psychological symptoms, relationships, disclosure, self-concept, and recovery is also well documented (MacGinley et al., 2019). Research on self-conscious emotions is therefore likely to have clinical relevance in informing psychotherapeutic processes and clinical services for CSA survivors and their support systems (MacGinley et al., 2019).
A scoping review of 28 studies exploring adult survivors of CSA experiences of shame identified five themes demonstrating the impact of shame following CSA: 1)Psychological effects and trauma symptoms, 2)Relationships and social connections and disconnections, 3)Disclosure, 4)Self-concept, and 5)Process of recovery (MacGinley et al., 2019). Pettersen (2013) conducted focus groups with 19 (16 females, 3 males) adults who had experienced shame relating to CSA. Pettersen (2013) identified that shame manifests in seven areas: family, emotions, body, food, self-image, sex, and therapy; and focusing on these areas would be purposeful in the healing process for survivors of CSA. Dorahy and Clearwater (2012) explored the lived experiences of shame and guilt in seven males with a history of CSA. Using Integrative Phenomenological Analysis (IPA) the researchers generated four superordinate themes: Self-As-Shame, Pervasiveness and Power of Doubt and Denial, Uncontrollability, and Dissociation and concluded that shame was not only experienced from the abuse, but also had a "psychological aftermath" throughout the life course (Dorahy & Clearwater, 2012). Alexander et al. (1999) were amongst the first to explore quantitatively the proneness of shame and guilt in 86 (57 females and 29 males) adult survivors of CSA with a diagnosis of moderate to severe depression. They concluded that there was no evidence that self-conscious emotions were prominent in survivors of CSA, although also noted that self-report measures were inadequate at detecting internalized aspects of shame and guilt.

Rationale and research question
Previous literature in this subject area presents three primary limitations. Firstly, of the 28 peer reviewed studies in the scoping review by MacGinley et al. (2019), only three specifically explored adult survivors' lived experiences of shame. The researchers proposed that insights into shame, and other selfconscious emotions, are constrained by quantitative research, rendering the responses to shame for survivors, clinicians, and communities unknown (MacGinley et al., 2019). Further qualitative research to capture lived experiences and inform responses to self-conscious emotions are required to address this gap.
Secondly, out of the three qualitative studies only one employed a male sample (i.e., Dorahy & Clearwater, 2012). This is illustrative of the literature as CSA in men has received less attention when compared to women, despite prevalence deemed to be higher than generally perceived (Dorahy & Clearwater, 2012).
Finally, the studies outlined above explored shame and/or guilt and often termed these emotions as "self-conscious", despite it being well referenced in the literature that self-conscious emotions also extend to embarrassment along with other more basic emotional states such as anger, fear, and joy (Tangney, 1999). There has been no research to date that has explored the experience of shame and guilt within the context of these wider range of self-conscious emotional states. Thus, the current research will attempt to overcome these limitations by addressing the following research question: What are men's experiences of self-conscious emotions following childhood sexual abuse?

Research design
This research adopted an interpretivist epistemological position. An interpretivist researcher seeks to access meaning that participants bring to experiences, which includes the broad cultural and experiential worlds, from which individual perspectives and beliefs are formed (Greene, 2010). It is also recognized the researcher has an active involvement as they too bring their own beliefs and experiences to the interpretive process (Greene, 2010).
In line with this position, this research employed IPA to explore the experiences of self-conscious emotions for male survivors of CSA. IPA (Smith et al., 2009), through its three main characteristics of phenomenology, hermeneutics, and ideography, allows for detailed exploration of how participants make sense of their personal and social world. IPA is committed to the analysis of each case; only then common experiences amongst participants are considered.

Sampling design
A non-probability sampling design was utilized to recruit a purposive sample of adult male CSA survivors. Purposive sampling is suited to IPA as it helps to ensure the sample is homogenous with regards to the inclusion criteria identified as important to the study (Smith et al., 2009). The extent of homogeneity varies depending on the research, for this project, the specific experience of CSA defined the homogeneity of the sample. As this was a phenomenological study, fewer participants were recruited in favor of gathering a large amount of data per participant (Smith et al., 2009). This is in line with the IPA approach which is committed to the detailed interpretative account of participants experiences, which can only be realistically conducted with a small sample size (Smith et al., 2009).
Fourteen men were initially recruited via two United Kingdom (UK) based charities with nine men meeting the inclusion criteria of the study. All participants provided their demographic details ( Table 1).

Methods of data collection and analysis
In-depth interviews are suited to IPA as they allow for collection of rich data (Smith et al., 2009). Data was therefore collected through one-to-one semistructured interviews to allow participants to provide a specific narrative or examples of experience. An interview schedule was developed to explore the experiences of self-conscious emotions in relation to CSA. All interviews took place via video call due to COVID-19 pandemic restrictions; they were all audiorecorded and transcribed verbatim. Interviews lasted between an hour to two hours (M = 97 mins), with the option for participants to take a break when required. An established step-by-step analytic approach for IPA described by Smith et al. (2009) was followed using the updated terminology (Smith et al., 2021). Thus, personal experiential themes (PETs), relating directly to the participant, and group experiential themes (GETs), reflecting the group of participants, were developed following the coding of the transcripts by the lead researcher. Each stage of the analysis process was discussed in research supervision. All participants were contacted to engage in respondent validation to validate, verify, and enhance the trustworthiness of the findings (Doyle, 2007). Two participants took part in respondent validation and provided positive agreement with the findings.

Ethical considerations
Ethical approval was granted by Coventry University (CU) Ethics Committee (P115107). The research was planned and undertaken in line with the British Psychological Society (BPS) Code of Human Research Ethics (British Psychological Society, 2021b) and Code of Ethics and Conduct (British Psychological Society, 2021a). All documents used in the research have been prepared with an Expert by Experience. 1 The researcher followed a distress protocol to manage any participant distress that may arise during a research interview (Haigh & Witham, 2015). Participants' identity was protected by providing pseudonyms in place of real names with all personal/identifiable information removed in the reporting of the findings. Only the immediate research team had access to the interview data.

Results
Through the process of IPA, three GETs were identified: "Invisible In This World". "The Emotional Fallout" and "Learning To Live With The Wound That May Never Heal". All participants contributed to the three GETs.

Invisible in this world
This GET captures participants' circumstances surrounding their CSA, and the impact this had on participants' perception of not being protected or able 1 The Expert by Experience was a male member of staff from Survivors UK, with an experience of CSA.
to speak out. It includes two sub-themes: Left to fend for myself and Having no voice.

Left to fend for myself
Many participants described a childhood which was characterized by physical and/or emotional neglect, which left them feeling alone and isolated in their childhood and teenage years. For some participants, this meant they were left to make sense of the world and fend for themselves: "From the age of nine I used to run away from home because it used to be safer on the streets then at home" (Alex, lines 7-9). Ben, Ashley, and Andy described feeling as though their parents did not have the time for them and how this "increased the vulnerability" (Ben, line 104) to be abused: We went to school on Saturdays even, so six days a week. And there's no social life at home. So I guess I was probably very lonely. So I'm painting a picture of urm here's the perfect opportunity for somebody to zoom in and what we now call groom this child. (Andy, While the level and extent of the neglect varied amongst participants, all participants described feeling alone and isolated when the abuse started.

Tom shared "[he] didn't know what to do at the time about it [abuse]
(pause)" (lines 109-110), the pause may indicate how Tom felt alone and confused; while Charlie "had decided from the very first time it happened, [he] wasn't telling anybody. For a while [he] thought it was just [him] that it was happening to" (lines 127-129). Participants seemed unable to tell others because they felt confused, different and like the only one.
Moreover, participants also felt let down by services as when the authorities were aware of the abuse/r they were unwilling to do anything to protect the individuals: But the fact that the people that he was associated with were the people who were supposed to be protecting me . . . And so I think the fact that I feel really let down by a lot of people urm in authority, because they should have done something about it and it seems to have been no duty of care back in those days and anybody that did have an inkling or insight into what he was doing rather than telling the police they just moved him. (Charlie, Thus, participants felt their needs were invisible or unimportant. As a result, many participants developed an "absence" of trust (Carl, line 729) in others, which further exacerbated a need to fend for themselves as they could not trust or rely on others for safety and protection.

Having no voice
Participants' experiences of CSA were internalized. Many felt controlled by their abuser and powerless to speak out: He [the abuser] got me to swear on the Bible that I wouldn't tell anyone so (pause) he said, "this is our special secret", you know "never tell anyone" and he physically got the Bible out. Looking back on it, I just, well at the time thought, well, yeah, that that, obviously, religion was really important to me and erm I just thought well obviously I can't tell anyone about it. (Tom, The power of using Tom's religion to ensure his silence created a belief such behavior was the norm, and he would be chastised by God if he spoke out. It is likely that Tom felt controlled by his secrecy and powerless to have a voice against the abuser. Carl lost his faith after he disclosed the abuse to the Church pastor and learnt the response to the abuser was "you obviously like children so why don't you become a Sunday school teacher" (line 302). Sam also described an invalidating experience whereby he disclosed to his local church and was told "[he] was using [his] past as an excuse not to take responsibility for [his] life, . . . that's when really everything just kind of just hit the fan" (lines 148-150). In this instance Carl and Sam had the courage to have a voice, which was denied and invalidated by authority, likely leaving them feeling powerless with nowhere to turn.
Some participants highlighted the abuser used physical and/or emotional domination/force over them: "I felt that he was actually or potentially could physically hurt me because the way he would hold me, he would hold me down" (Charlie, lines 137-138), and "so I became very aware of the amount of psychological control that [the abuser] was seeking to continue to exert over my life" (Ashley, lines 36-37). Sam's abuser was seen as a "pillar in society" (line 90) which meant that nobody questioned what was happening. This suggests that the experience of CSA can leave the individual feeling controlled in a multitude of ways, leaving them powerless. Such experiences often left participants feeling fearful: "I didn't say anything because I knew what was gonna happen and I knew what was going on" (Ben, lines 264-265), which took away their ability to speak out. Carl, Dean, and Ben described a belief where they needed to be "complicit" (Dean, line 651) for fear of being hurt.
Many participants also described a confusion about what was happening "as it went against everything I knew" (Ben, lines 518-519) and caused Charlie, Ashley, Alex, and Tom to "question . . . [their] sexuality" (Alex line 312): All the boys that I mingled with were all trying to be quite macho because we were into football and everybody was chasing girls in school and, you know, kinda like that and so from the get go there was nobody that I wanted to know that another man was touching me . . . so I had no desire to be associated with being gay or what you call a puff back in those days. (Charlie, The fear and confusion of being associated with a different sexuality led to an increased silence and secrecy. For Charlie there was an intense fear of others rejecting him, whereas Alex internalized this confusion, "you know, is there something wrong with me?" (line 528), emphasizing he felt alone and unable to speak to others due to fear of rejection. There was also a sense of confusion and a silencing for some participants due to sexual gratification: Looking back why I didn't tell my parents that's the strange thing and I've got (pause) I mean, the the big thing about it, I think, is because I was aware that I was enjoying it, because it it did turn me on and that's something I've sort of, it's quite difficult to come to terms with. (Tom, It is likely that any sexual gratification was not only confusing for participants, but the associated guilt and embarrassment maintained their silence.

The emotional fallout
This GET describes participants' overwhelming emotions arising from their CSA and how such emotions have impacted participants' lives. It includes three subthemes: It's my fault, The power of emotion, and Uncontrollable rage.

It's my fault
This sub-theme describes how participants were left consumed with the belief that they were to blame: "I think that one of the longest longest feelings that I have is the guilt is the guilt that it was my fault" (Tom, lines 802-802). The repetition of "longest" emphasizes how this has stayed with Tom throughout his life and consumed his emotional wellbeing.
The fact that after that time, when you are the minor that is being abused. If the disclosure is not made immediately then one feels complicit and therefore that feeling of being complicit makes it impossible to, to to, to disclose without in those days being accused of well it must [be] your fault, it must be something you did blah blah. (Andy, Andy describes how he took on a level of responsibility that he was to blame for being complicit and how this blame prevented him from disclosing. This was also a similar experience for Dean, "it always felt to me that I was to blame that I was complicit in some way, because I let it go ahead" (lines 651-652). Participants were therefore likely consumed with the belief it was their fault and were holding onto a "guilt that I allowed it to continue and it's my fault that he carried on abusing people" (Tom, line 803). Most participants held onto this belief throughout their life course and were left questioning "Did I show some signs or something? You know, was it me? Did I lead them on?" (Alex, lines 257-258).
This often manifested into participants carrying an intense "self-loathing, you know I really hated, and I mean, detested myself" (Sam, line 214). The level of self-loathing was so high for Sam, Alex, Ben, and Dean it accumulated in a suicide attempt, "the things I used to do, like hanging myself, you know, I used to try and hang myself with my tie with my school tie and all sorts I've tried just to get out of this world" (Alex, lines 490-492). This illustrates how participants internalized their experiences and held onto this shame and blame, which became so oppressive they felt a "lack of self-acceptance" (Ashley, line 282) so strong they were unable to live with their powerful selfconscious emotions.
All participants described living with shame which dictated and ruled their life, "oh god the power of shame, the toxic power of shame, which I would say has been particularly evident and crops up a lot" (Ashley, lines 285-286). For Tom, Dean, and Andy the shame and guilt were perpetual; "I guess every time one thought about it" (Andy, line 467). However, all participants in their later years recognized that shame and blame did not belong to them: "I grew up thinking, if I feel something, it must be true but actually the guilt and shame is true it's just where it went was false" (Sam, lines 668-670). Ben also adopted this perspective: "it's not your fault, you're not to blame" (line 464). Whilst there may be some shift in the level of blame and shame, these emotions can remain all-consuming, and did not dissipate for all participants.

The power of emotion
Participants described their emotions being so powerful they had to develop strategies to cope. For some participants, "alcohol played a big part . . . and all the different drugs" (Alex, line 64) as their lives were on a "collision course" (Sam, line 171). For Carl, Tom, Sam, Charlie, and Alex alcohol was used as a "method of self-medication" (Carl, line 410) and a means of "escape" (Tom, line 530). It is likely this strategy prevented participants from processing their own emotions as their "emotional part was damaged" (Charlie, line 681) and too raw and tender to acknowledge and accept. Many participants also spoke about the need to hide their emotions from others: I'm no Jekyll and Hyde either, but a lot of the time, publicly, I am very positive and I think that's part of my job is part to do that, on my own I live with a lot of self-doubt, and sorrow and sadness and depression. (Sam, This illustrates how Sam continues to experience powerful emotions but does not feel able to be honest with others, therefore masking how he really feels. Some participants described "a role I was operating under" (Andy, line 41) and a "temporary armor" (Charlie, line 437) as a way of hiding their true self. Tom, Alex, and Dean manage this intense emotion by keeping themselves "selfcontained and shut off" (Dean, line 322): I was very on my own, it was a very alone job and I was in a very on my own, you know? I love that seven years of just on my own, there again on my own and that's part of how my life's been that's been on my own and even to this day. (Alex, Alex's fear of rejection manifests in isolating himself to prevent being hurt or let down, like he was in childhood. For other participants there was a longing for social connection and acceptance as a way of managing the intense fear of rejection often resulting in "allowing people I guess to tread over me a bit a times" (line 155) and Tom's ways to avoid rejection is "trying to please" (line 775).

Uncontrollable rage
The experience of anger was a prominent emotion for most participants. Ashley described how he feels "frightened by the way the anger can trigger off that fight reaction rather than a flight one" (line 482). Alex expressed his anger being so powerful it changes who he is, "my anger could be really angry and I'm not an angry person" (Alex, line 551) and Tom described how his anger is "out of character for me in general (laughs)" (lines 617-618); the laugh implies that Tom is uncomfortable with the power of his anger. Dean described his anger as "bottled up in sort of a cage . . . and I keep it down in the dungeon and put bricks on it to stop it from escaping" (lines 833-834) illustrating how he tries to control it.
Most participants felt their anger had "intensified" (Dean, line 896) across the life course, with Tom, Ben, Ashley, and Charlie becoming "very antiestablishment, very anti authority" (Charlie, line 260). Ben spoke of feeling angry that "society has put so much effort into focusing on men being perpetrators not victims" (lines 663-665), highlighting the narrative around male CSA remains unchanged. Many participants viewed their anger toward authority as a way of advocating for their "lack of voice as a child, and indeed as an adult" (Ashley, line 525).
I can only think of it as being a way of getting back at somebody. So yeah, the interesting thing is, it's never, I'd like to think it's never somebody who is vulnerable, it would be normally somebody in authority. So I'd like to be confrontational to people in authority, because of how somebody in authority did it to me, so I do tend to have a what's the word? Not disrespect, no distrust, I probably distrust the people in authority. (Tom, It is likely anger in adulthood is a way for participants to regain the power and control taken away from them in childhood. It does leave . . . does change the way your brain develops and, you know, genetically it can affect you (pause) so again that does anger me or that I mean rage but I do have some sense of anger that you know, again, what would what could I have achieved. (Sam, Sam's anger is directed toward the abuser for disrupting his life trajectory, leaving Sam ruminating "if I hadn't had that abuse experience? How much further would I have been along the road?" (lines 314-315) further exasperating Sam's anger.

Learning to live with the wound that may never heal
This GET describes how participants have spent their lives living with their CSA and the process of learning how to adapt and live after the abuse. It is comprised of three sub-themes: Eternal torment, De-shaming process and History not repeating itself.

Eternal torment
All participants described how the abuse continues to live within them. Andy voiced "it's always there" (line 225) like a "gnawing maggot" (line 500) illustrating how there is a physical manifestation of the abuse which he can never escape. The memories of the abuse remain so prominent; for Tom "lots of things really sort of stick in my mind" (line 157), and Charlie can "still recall these memories so clearly all these years later" (line 233). Carl manages the intensity of the abuse by having "a lot of blocked memories" (line 234), and Alex stated, "I can't turn that clock back and yes it is about moving forward but you know that's always gonna be in my head" (line 585-587) suggesting the experience of CSA will always feature in the participants' lives.
I would see it like a dry stone wall and so I've got to re build myself but some of the stones were too heavy for me to lift because I've got a disability and so there would be gaps in that wall and sort of, I think last time, I was shown how to fill those gaps I didn't need to fill it with a big stone I could use a few smaller stones to and that's the best way I get I can really I can really describe it. (Dean, This analogy captures how Dean's CSA left him having to rebuild himself in adulthood, and how this has been an ongoing process, learning skills and gaining insight throughout his life. Many participants articulated how they were still living with the consequences of the abuse. Andy described "experiencing the kind of dreams which you end up screaming out in the night and waking yourself" (lines 421-422), and Carl spoke about "a night disturbance of dreams of waking up, tooth grinding and kicking around" (lines 399-400) suggesting how the experience of CSA remains unprocessed and present in the body. Charlie, Sam, and Alex described a multitude of ways that CSA manifests today, including "flashbacks" (Charlie, line 331), being triggered by the media and, "[suffering] a lot with . . . eating" (Alex, line 391). Sam stated: "every relationship I've had has had some kind of echo of my abuse" (line 230) illustrating how prominent and powerful CSA is, and continues to be, for participants.

De-shaming process
Many participants spoke about how they have undergone a process whereby they now understand and accept what happened, however this does not mean that their experience is "cured" (Sam, line 345).
But by the same token, urm it's not part of me that I am afraid to take ownership of (pause) the acknowledgement that the abuse happened to me, not by me, not for me but to me, was a very powerful acceptance, which allowed me to move forward . . . it, it frames, it frames part of who I am, I guess, in some odd sort of way, to the point that I, I don't feel the shame that I have to hide away from it. (Andy, The understanding that "it's not my blame to hold, it's not my shame, it was his shame and he manipulated and used me, and you know, that's unacceptable" (Dean, lines 772-773) highlights how the shame and guilt becomes less prominent once participants have adopted this view.
Sam described normalizing his emotions which "takes the steam out of them, I think by understanding where they come from, I think we depower them, so understanding where the sadness comes from, takes away [the abuser's] power in my life" (lines 614-616). Carl, Tom, and Ashley described how this de-shaming process enables them to connect with their emotions creating a sense of "personal power" (Ashley, line 555), often experienced for the first time in their lives. Additionally, Charlie, Alex, and Sam manage the power of their emotions by adopting a mentality of "keeping going" (Charlie, line 505) and "pushing through" (Alex, line 167), feeling as though "I've got to carry on because what's the alternative?" (Sam, line 601).
It's not even about a journey. It's about actually just sort of saying that I can be perfectly comfortable, I don't need to get healed to get better, I have a, I have a lifestyle, if you like, which works. (Carl, lines 1010(Carl, lines -1012 This captures that there is a wound, which all participants still feel the effects of, however they adapted to get the best out of their lives as they "don't want to revel in victimhood" (Ben, lines 390-391).

History not repeating itself
All participants spoke passionately about "wanting to look outwards, . . . to support other men, especially, who have experienced sexual abuse" (Ashley, lines 14-16). Alex described wanting to help others because "it keeps me strong . . . focused" (line 627), with Dean sharing "I just want to make a difference" (line 51). Most participants wanted to share their experiences to support men, because "most men can't put their heads above the parapet" (Dean, line 42), as men' CSA remains a "taboo" (Carl, line 366). This is echoed by Ben, who describes wanting to "shine a spotlight" (line 57) as "men are often left in the dark" (line 73), illustrating how males with CSA may feel devalued by society.
Carl, Tom, Sam, and Charlie spoke about wanting to change the narrative for men due to their own experiences with "abysmal" (Sam, line 41) services. For Carl, "the services available for men are frankly appalling. They really are appalling" (lines 90-92); Carl's repetition of appalling highlights his anger toward services and the fundamental problem that services are not designed to support males with CSA. This was also captured by Andy who felt "there's a very small number of people who are qualified to deal with male victims of sexual abuse" (lines 130-131), which often means that males do not receive the support they need.
Additionally, Sam shared his belief that the problem is maintained by the medical model: "child abuse isn't a medical condition and it's really unhelpful to kind of try and medicalize it" (Sam, lines 778-779), suggesting the focus for support should be to "learn to manage, rather than be cured of" (lines 344-345) CSA. Finally, all participants hoped "lessons can be learned" (Tom, line 77) because "unless we stand up and say something, nothing will actually change" (Carl, line 105).

Discussion
IPA was utilized in this research to explore men's experiences of self-conscious emotions following CSA. Three GETs were identified. The first GET "Invisible In This World", captures participants' isolating circumstances surrounding their CSA, and how this impacted their perception of not being protected and silenced. The second GET, "The Emotional Fallout", describes the overwhelming emotions experienced as a result of the CSA and how such emotions have impacted participants' lives. The third GET, "Learning To Live With The Wound That May Never Heal", addresses how participants have spent their lives living with the abuse and how it is a process to learn how to adapt and live with the abuse.
Participants described their shame, blame and guilt associated with the abuse. This is in line with previous findings that the experience of CSA increases negative self-conscious emotions (Herman, 2011), especially shame and guilt (Dorahy & Clearwater, 2012). Specifically, Dorahy and Clearwater (2012) proposed that males experience a "self-as-shame" construct. Indeed, this was captured in the current findings with participants describing an intense self-loathing and lack of self-acceptance. Such findings contribute to the well-documented strong influence of shame on the self for both males (Dorahy & Clearwater, 2012;Pettersen, 2013) and females (Chouliara et al., 2014;Saha et al., 2011). This refutes Alexander et al. (1999) conclusion of selfconscious emotions not being prominent in survivors of CSA. Instead, it highlights the importance of not relying on self-report measures to capture self-conscious emotions, with findings from this research and Dorahy and Clearwater's (2012) emphasizing that males manage their shame through avoidance and internalization to protect themselves from further shame. Dorahy and Clearwater (2012) who explored how shame and guilt is experienced by men concluded that shame is experienced as internal ("I am the cause"), stable ("I will always be responsible") and global ("it was me who caused it, not just my behavior"), which is in line with previous constructs of shame in CSA (Lewis, 1992;Van Vliet, 2009). Whilst it was striking that the participants internalized their shame and adopted the global belief that it was their fault, many of the current participants were able to distance themselves from the stable belief of shame to recognize that "it's not my blame to hold, it's not my shame" (Dean, line 772). This meant that across the life course there is some shift in how shame is perceived, although it was often the process of therapy and self-seeking support which enabled participants to shift this relationship with their shame.
Guilt typically manifested in feeling guilty for having any sexual gratification during the abuse, for letting it happen, and for not disclosing sooner (and thus not "saving" others from abuse). In line with Dorahy and Clearwater's (2012) findings, participants saw themselves, not their actions as responsible for the CSA. Dorahy and Clearwater (2012) described this as a "categorical shame" whereby the whole self is tarnished with shame. Thus, it appears there is a complex, overlapping relationship between shame and guilt, as participants took on the responsibility for the abuse and began to blame themselves which in turn generates further shame about who they are as a person (Lisak, 1994).
The aim of this research was to explore the experience of shame and guilt within the context of a wider range of self-conscious emotional states such as anger, fear, and joy. The "uncontrollable rage" experienced by participants, predominately in their later life, was striking. This research is the first to explore anger in detail and it is evident that this emotion is so powerful and prominent. Additionally, this research found participants' anger was directed toward authority/organisations/services for not protecting them and thus changing their life trajectory, and at society for the attitudes and stigma toward male CSA. The current study builds on previous research (Dorahy & Clearwater, 2012) by extending our knowledge that anger is a prominent and pervasive selfconscious emotion, often directed externally in males, and likely represents the lost voice of the child seeking a way to exert the control and power they did not have in childhood. Anger should therefore be considered a self-conscious emotion associated with CSA, which likely increases self-loathing and shame toward the self, and not just be seen as simply aggression.
Fear of homophobia and/or stigma of male CSA is well-documented in the research literature (Homma et al., 2012). Yet the experience of fear in general for male survivors of CSA has not been specifically researched. Dorahy and Clearwater (2012) noted participants feared being perceived as gay or weak. Building on their findings, this research suggests that fear is not just tied to one's sexuality, but that fear is experienced at the time of CSA, and throughout the life course. For participants the fear manifested in feeling powerless, with no voice to advocate for themselves, dreading the consequences and not being believed. Fear was often carried into adolescent and adulthood, with participants describing how they were "plagued with fears around sexuality" (Ashley, line 300). It was also evident in relationships, often fueling overcompensating in relationships, due to an intense fear of rejection. Combined, fear was often internalized increasing participants' sense of shame and guilt, maintaining their silence and eternal torment.

Implications for policy and clinical practice
The Independent Inquiry Child Sexual Abuse (IICSA) explored the significant institutional failings to care and protect children in the UK (2022). The IICSA (2022) inquiry highlighted that there are still significant limitations in data collection methods, and that the number of CSA cases is likely to be much higher than the numbers recorded. This is especially relevant for boys (ONS, 2020), and given how difficult and painful participants in this research found the disclosure process, it is likely that the outdated attitudes and myths held by society often perpetuate lower reporting and maintains the taboo (Independent Inquiry Child Sexual Abuse, 2022). More therefore needs to be done to tackle the attitudes within society relating to CSA and its implications across the life course. Thus, societal norms need to be challenged by teaching programmes and storylines to break down the barriers to disclosing CSA, so survivors feel able to seek support at the time. This is in line with the participants' passion for ensuring history does not repeat itself by wanting to advocate and encourage males to come forward to tackle the stigma and social narrative associated with male CSA.
Given that all participants in this research did not disclose their abuse until adulthood means that child and adult services should incorporate the importance of modeling safety, utilizing safe spaces, and highlighting the value of sensitive questions and showing concern (Morrison et al., 2018). All healthcare professionals should therefore be more equipped at building and providing a trusting and safe relationship. It will also be crucial, through increased training, that healthcare professionals working with CSA have an awareness and acknowledgment of the implication of shame, guilt and fear in the therapy setting (McElvaney et al., 2022;Plante et al., 2022).
Adopting the principles from the Power Threat Meaning Framework (PTMF; Johnstone et al., 2018) may be fundamental in how CSA is approached within services. The PTMF advocates for alternative approaches to understanding distress with an emphasis on the personal meaning individuals attribute to their experiences and what they had to do to survive the power and threat in their lives (Johnstone et al., 2018). If clinicians shaped how questions are phrased and moved away from the traditional medical model approach "What is wrong with you" and instead adopted a curious "What happened to you?, How did it affect you, What sense did you make of it? and What did you have to do to survive?" (Johnstone et al., 2018, p. 190), individuals may feel more comfortable and able to share their experiences. This may also reduce some of the self-conscious emotions, such as shame and guilt, which are so strongly associated with CSA (Herman, 2011).

Limitations
The age of the sample ranged between 38 and 72 years, with most participants being in their 50s. The sample did not consist of any males in their twenties or forties which limits the representation of the sample. Given participants described a "de-shaming process" and an intensification of anger across the life course, it would be beneficial to capture the experiences of males from all age categories to ensure the findings are representative and reflective of their experiences. The recruitment of the participants may have resulted in a biased sample. All participants were members of a charity designed to support males with an experience of CSA, thus participants may be more inclined to seek support and have greater insight into their experiences and associated difficulties. The sample therefore does not capture the experiences of males who have not disclosed their abuse or are not yet at the point of affiliation with other survivors or CSA specific organizations. Additionally, whilst participants in the sample may have previously been supported by community mental health teams in the National Health Service (NHS), the sample is not a clinical sample and therefore does not represent individuals who are currently receiving input from the NHS.
Finally, the sample is comprised of White British or White other ethnicities, and therefore lacks ethnic diversity. This is in line with the existing literature that CSA experiences in minority populations are often overlooked (Futa et al., 2001) and underrepresented in research. This is surprising given the ONS (2020) finding that mixed/multiple ethnic groups were the ethnic group with the highest proportion of reported CSA. 2 The "widespread failure" (p.37) to record the ethnicity of victims of CSA means voices from different ethnic backgrounds are not being captured and resources may therefore not be targeted correctly across communities (IICSA, 2022).

Future directions
CSA related shame, and likely all self-conscious emotions, naturally vary between cultures and communities (Wo, 2005). There needs to be further research to explore the role and power of self-conscious emotions in different ethnicities and cultures to determine the social and cultural spheres in which self-conscious emotions unfold (Budden, 2009). Given the finding that shame and guilt was most prominent in adolescent and early adulthood, with anger intensifying in later adulthood, further research would benefit from exploring how self-conscious emotions manifest across the life course, particularly in early adulthood. Exploring self-conscious emotions following CSA in a clinical sample should be the focus of future research to shed light on how such emotions are being processed by individuals who are experiencing the emotional fallout of CSA and receiving the support and input of specialized community or inpatient mental health teams. This could increase awareness of CSA within healthcare services and influence how services are designed to support the emotional response to CSA, opposed to the behavioral and symptom focus often adopted now.

Conclusion
A detailed insight of nine participants' experiences of self-conscious emotions following CSA was provided. The power of emotion experienced by participants and the implications such emotions have had, and continue to have, across the life course is striking. In concordance with previous research, participants captured the toxicity of shame, blame and guilt and how this has been so prominent and destructive in a multitude of ways. This research adds to the literature by exploring all self-conscious emotions, with findings capturing participants' fear and uncontrollable rage. Interestingly, most participants were able to change their relationship with shame and guilt through a de-shaming process. However, anger often intensified, likely acting as a voice for the silenced child. Considering these findings, and how they support previous research, there is a clear need to recognize the role and power of selfconscious emotions in male CSA, especially for healthcare professionals and any individual working with male CSA. Without addressing such selfconscious emotions, males living with CSA are at risk of enduring the emotional fallout throughout their lives.

Declaration
This empirical research was part of a research thesis for a Doctorate in Clinical Psychology at Coventry University and the University of Warwick. Ethical approval was granted by Coventry University Ethics Committee (P115107). There have been no additional funding bodies involved in this research.
We hereby confirm that this manuscript was reviewed by both authors. Neither author of this paper has any financial or other conflicts of interest, that might be interpreted as influencing the research reported in this article.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors
Leah Drewitt-Smith, Doctorate in Clinical Psychology at Coventry University and University of Warwick, Trainee Clinical Psychologist. Specialist interest in a trauma informed approach and focus in adult mental health, with research interests in men's experiences of adverse childhood experiences and how these present in today's society and manifest across the life course.
Magda Marczak, PhD, Lecturer in Clinical Psychology with research interests in encompassing Clinical Health Psychology, Adult and Older Adult mental health and cyberpsychology with regards to the growing influence of technology and the blurring of boundaries between work and non-working life.