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. Author manuscript; available in PMC: 2021 May 1.
Published in final edited form as: J Trauma Dissociation. 2020 Jan 28;21(3):365–375. doi: 10.1080/15299732.2020.1719263

Correlates of Resilience After Childhood Sexual Abuse among Men Who Have Sex with Men

Sannisha K Dale 1, Jasmyn Sanders 1, Steven A Safren 1, Gail Ironson 1, Conall O’Cleirigh 2,3
PMCID: PMC7199796  NIHMSID: NIHMS1556434  PMID: 31986997

Abstract

Men who have sex with men (MSM) are at high risk for physical and mental health conditions and are often discussed in the health literature as “at risk” versus “at promise”. However, there is an ongoing need to examine factors that place MSM “at promise” for optimal well-being. This manuscript examines correlates of resilience, the ability to “bounce back” and function adaptively after adversities, among MSM. One hundred and five MSM with a history of childhood sexual abuse, who were enrolled in a randomized control trial were recruited for a supplemental study assessing resilience and other psychosocial factors. Participants completed measures assessing resilient trait and coping (i.e. “I am able to adapt” and “I tend to bounce back”), symptoms of trauma, trauma-related thoughts, and distress tolerance (ability to regulate unpleasant feelings). Findings from multivariable linear regressions controlling for covariates (age, education, race/ethnicity, and income) indicated that higher resilience was associated with (a) lower trauma scores on re-experiencing severity (b = −1.41, SE = .53, p = .01) and avoidance severity (b = −1.61, SE = .67, p = .02), (b) lower post traumatic cognitions (b = −11.39, SE = 5.08, p = .03) especially negative cognitions about the self (b = −.44, SE = .16, p = .007), and (c) higher distress tolerance (b = .26, SE = .10, p = .01). Our preliminary findings suggest that resilient coping/traits are important to research after childhood sexual abuse among MSM, potentially assess in clinical settings, and address in interventions.

Keywords: Resilience, men who have sex with men (MSM), childhood sexual abuse

Introduction

Men who have sex with men are at higher risk for negative physical and mental health conditions compared to men who do not have sex with men, and as such MSM are often discussed in the health literature in terms of being “at risk” versus “at promise”. For instance, the highest number of new HIV diagnoses occurs among MSM, despite MSM representing a small fraction of the U.S. population (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, 2016; Song, Hall, Green, Szwarcwald, & Pantazis, 2017). This disproportional burden of the HIV epidemic has been linked to both structural (e.g. oppression, marginalization) and psychosocial factors (e.g. substance use, sexual abuse) that may place MSM at greater risk for HIV contraction (Beyrer et al., 2012; Koblin et al., 2006). However, while a focus on “risk” may help researchers to understand the factors that need to be ameliorated, a focus on what factors place MSM “at promise” for healthy and fulfilling lives is necessary to know what factors need to be amplified and promoted in intervention efforts. Thus in recent years, scholars have begun to explore factors that may be associated with positive outcomes among MSM (Emlet, Shiu, Kim, & Fredriksen-Goldsen, 2017; McNair et al., 2018; White Hughto, Hidalgo, Bazzi, Reisner, & Mimiaga, 2016). The present manuscript adds to this burgeoning literature by examining correlates of resilience (the ability to “bounce back” and function adaptively following adversity) after childhood sexual abuse (CSA) among MSM (Dale et al., 2014, 2015).

In prior literature resilience has been conceptualized as a trait, coping strategies, genetic predispositions, environmental factors, interpersonal resources, and the process by which an individual functions adaptively following adverse life events (Bonanno, Galea, Bucciarelli, & Vlahov, 2007; Caspi et al., 2003; Charney, 2004; Connor & Davidson, 2003; Emlet et al., 2017; Jacelon, 1997; Masten, Best, & Garmezy, 1990; Waaktaar & Torgersen, 2012; Wells, 2009). A recent review defined resilience as “positive psychological, behavioral, and/or social adaptation in the face of stressors and adversities that draws upon an individual’s capacity, combined with families’ and communities’ resources to overcome serious threats to development and health” (Dulin et al., 2018, p. S7). Research investigating resilient traits and coping among MSM living with HIV, has linked higher resilience (e.g. tendency to bounce back after hard times) with higher psychological health-related quality of life (Emlet et al., 2017). Higher resilience (e.g. ability to adapt to change) among MSM has also been associated with lower rates of condomless anal sex (McNair et al., 2018).

Resilience is especially important to understand among MSM after CSA because CSA has been associated with numerous negative mental, physical, and sexual health outcomes among MSM (Boudewyn & Liem, 1995; Browne & Finkelhor, 1986; Mimiaga et al., 2009; Paul, Catania, Pollack, & Stall, 2001). For instance, Levine and colleagues (2018) found that compared to MSM without a history of CSA, MSM with a history of CSA had a higher number of male partners, instances of condomless anal sex, alcohol use, and depressive symptoms. Further, studies have noted higher symptoms of post-traumatic stress disorder and negative thoughts about one-self among persons with histories of abuse/trauma compared to persons without trauma histories (Batchelder et al., 2017; Boroughs et al., 2015; Browne & Finkelhor, 1986; Karatzias et al., 2018; Maniglio, 2010; Reisner, Mimiaga, Safren, & Mayer, 2009). However, higher resilience may relate to lower negative mental health symptoms among MSM after CSA. Among MSM after CSA, the present manuscript examines the association between resilient trait and coping and symptoms of trauma, trauma-related thoughts, and distress tolerance (ability to regulate unpleasant feelings).

Methods

Participants

Participants who were enrolled in an existing randomized control trial were recruited for a supplemental study assessing resilience and other psychosocial factors. The multi-site randomized clinical trial ( NCT01395979) was of HIV-uninfected MSM who reported sexual risk and had a history of CSA before age 17. Recruitment procedures for the RCT consisted of posting ads on online dating sites and distributing flyers at bars, clubs, cruising areas, and community venues. Once interested participants contacted study research assistants they were screened and scheduled for a baseline assessment. The baseline assessment included computer-based psychosocial assessments, a psychiatric evaluation, and HIV and other STI testing. Participants had to meet the following inclusion criteria to be enrolled in the RCT: (1) report sexual contact before the age of 13 with an adult or a person 5 years older, or sexual contact between the ages of 13 and 16 inclusive with a person 10 years older (or any age with the threat of force or harm), (2) report more than one episode of unprotected anal or vaginal intercourse within the past three months, and (3) be HIV-uninfected. Procedures were approved by institutional review boards at X and X (removed for blind review).

Measures

Socio-demographic Characteristics.

Participants provided socio-demographic information via self-report measures including age, race (American Indian/Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Highlander, White, or unknown/not reported), education (some high school, high school graduate or GED, some college/associate degree/ technical school, college graduate/bachelors degree, some graduate school, masters degree, or doctoral degree), and income (0 = $10,000 or less, 1 = 10,001 to $20,000, 2 = $20,000 to $40,000, 3 = $40,001 to $60,000, 4 = 60,001 to $80,000, 5 = over $80,000).

Resilience.

The CD-RISC2 is a 2-item self-report assessing the ability to thrive despite adversity using both personality traits and coping (Vaishnavi, Connor, & Davidson, 2007). The items are “I am able to adapt when changes occur” and “I tend to bounce back after illness, injury, or other hardships.” Response options range from 0 (not true at all) to 4 (true nearly all the time). The CD-RISC2 has shown good construct validity (e.g.) and good convergent validity with the 23-item CDRISC from which the two items of the CD-RISC2 were taken (Connor & Davidson, 2003; Vaishnavi et al., 2007). For instance, higher scores on the CDRISC2 predicted lower PTSD symptom severity among firefighters, and the model with the CD-RISC 2-item predicting PTSD symptom severity was not improved when the remaining items of the 23-item CD-RISC were included (Jeong et al., 2015). The CD-RISC2 Cronbach’s alpha in the present study was .79.

Davidson PTSD Scale (DTS; (Davidson et al., 1997; Zlotnick et al., 1996).

The DTS is a 17-item self-report measure, based on the PTSD symptom clusters defined by DSM-IV. Each item is rated from 0 to 4 for both frequency (0 = not at all, 4 = everyday) and severity (0 = not at all, 4 = extremely) during the past week. Items are summed for a total score, and subscales of re-experiencing, avoidance, and hyperarousal. The total scale has demonstrated good test-retest reliability (r=.86) and internal consistency (r=.99) in previous studies and good internal consistency (α=.87) in the present study (Davidson et al., 1997). This scale was administered by a clinician and used to identify posttraumatic symptoms related specifically to CSA.

Post Traumatic Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999).

The PTCI is a measure of trauma-related thoughts and beliefs that consists of 3 factors (Negative Cognitions About Self, Negative Cognitions About the World, and Self-Blame). Item responses range from 0 (totally disagree) to 6 (totally agree) on a 7-point likert scale. These 3 factors have showed great internal consistency (α = .86-.97) and good test-retest reliability (Foa et al., 1999). Researchers also found that the three factors differentiated between traumatized individuals with PTSD from those without (Foa et al., 1999). The three factors of the PTCI were also significantly associated with measures of depression, PTSD severity, and general anxiety (Foa et al., 1999). The Cronbach’s alpha for the PTCI in the present study was .97.

Distress Tolerance Scale (Simons & Gaher, 2005).

Thisis a 15-item questionnaire that assesses 4 domains of distress tolerance – Regulation (e.g., When I feel distressed or upset I must do something about it immediately), Tolerance (e.g., I can’t handle feeling distressed or upset), Appraisal (e.g., My feelings of distress or being upset are not acceptable), and Absorption of one’s time and attention by the distress (e.g., When I feel distressed or upset, I cannot help but concentrate on how bad the distress actually feels). Participants rate the extent to which they agree with each of the questions on a 5-point likert scale (5. strongly disagree to 1. strongly agree). The scale showed good internal reliability (.89) and significant associations with other measures of distress tolerance(Simons & Gaher, 2005). The Cronbach’s alpha in the present study was .92.

Statistical Analyses

SPSS 24 was used to conduct run descriptive statistics (e.g. frequencies, mean) and multivariable linear regressions. In separate linear regressions, resilience scores were entered as the predictor and trauma symptoms, trauma cognitions, and distress tolerance as outcomes. Covariates of age, education, race, and income were controlled for in all linear regressions.

Results

One hundred and five MSM participated in the supplemental study. Detailed sociodemographic information is presented in Table 1, but in short their average age was 37, 67% identified as White, 24% identified as Black or African American, 77% had some college education or above, and 50% earned an annual income of less than $20,000 per year.

Table 1.

Sociodemographics and Characteristics of MSM

Characteristic Mean (SD, range) or n (%)*
Age 37.95 (11.628, 18-62)
Income Less than $10,000 29 (28%)
$10,000 - $20,000 24 (23%)
$20,001 - $40,000 17 (16%)
$40,001 - $60,000 17 (16%)
$60,001 - $80,000 9 (9%)
$80,000 and greater 7 (7%)
Education Some high school 4 (4%)
High school graduate/GED 18 (17%)
Some college/AA/technical school 35 (33%)
College graduate (BA/BS) 17 (16%)
Some graduate school 9 (9%)
Master’s degree 17 (16%)
Doctorate/Medical/Law degree 3 (3%)
Race White 71 (68%)
Black/African-American 26 (25%)
Asian 2 (2%)
Native Hawaiian/Other Pacific Islander 1 (1%)
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*

Note: Percentages do not equal 100% due to rounding and missing values.

The average score on the CDRISC2 was 3.95 (SD = .87, min = 1, max = 5), indicating moderate resilience among the sample. Average scores on the post-traumatic cognitions (M = 81.87, SD = 43.42; min = 5, max = 176), distress tolerance (M = 3.04, SD =.89; min = 1.33, max = 5), and trauma symptoms severity (M = 17.95 SD = 12.52; min = 0, max = 52 and frequency (M = 16.29, SD = 12.23; min = 0, max = 44) suggests moderate levels of post-traumatic cognitions and distress tolerance and mild to moderate levels of trauma symptoms.

Resilience predicts lower re-experiencing and avoidance severity

In multivariable linear regressions controlling for covariates (age, education, race/ethnicity, and income), resilience score was not significantly related to the total frequency or severity of trauma symptoms on the DTS. However, higher resilience score was significantly associated with lower trauma score on the re-experiencing severity (b = −1.41, SE = .53, p = .01) and avoidance severity (b = −1.61, SE = .67, p = .02) subscales, but not the hyperarousal subscale nor frequency scores of all three subscales.

Resilience predicts lower negative cognitions about the self

In multivariable linear regressions with resilience as the predictor variable and post traumatic cognitions as the outcome variable, while controlling for covariates (age, income, education, race), results showed that higher resilience score was significantly associated with lower post traumatic cognitions (b = −11.39, SE = 5.08, p = .03). When analyses were run for the three post traumatic cognitions subscales separately (negative cognitions about self, negative cognitions about the world, and self-blame), results revealed that only the negative cognitions about the self subscale score was significantly inversely related to resilience (b = −.44, SE = .16, p = .007).

Resilience predicts higher distress tolerance

Multivariable linear regressions with resilience entered as the predictor, distress tolerance as the outcome, and several covariates (age, race, income, and education) found that higher resilience score was significantly related to higher distress tolerance (b = .26, SE = .10, p = .01). A closer examination of how resilience related to the four subscales of tolerance, absorption, regulation and appraisal revealed that resilience was significantly positively related to tolerance (b = .33, SE = .13, p = .01), absorption (b = .31, SE = .13, p = .02), and appraisal (b = .22, SE = .11, p = .04), but not regulation (b = .25, SE = .13, p = .06).A higher absorption score suggests that the participant experiences less absorption and therefore, has greater capacity to deal with their distress.

Discussion

In our sample of MSM who survived CSA, we found moderate levels of resilience and that resilience was significantly associated with lower symptoms of post-traumatic stress disorder, lower trauma-related cognitions, and higher distress tolerance. Our findings coincide with existing literature that has found significant associations between resilience, higher psychological and health-related quality of life, and lower depressive symptoms (Dale et al., 2014; Emlet et al., 2017; Dale et al., 2019). Further, the particular scales/subscales of trauma symptoms, cognitions, and distress tolerance that resilience was associated with suggests interesting nuances. First, resilience was significantly inversely associated to the severity of distress from trauma symptoms, particularly distress linked with avoidance and re-experiencing. However, resilience was not significantly associated with the frequency of the trauma symptoms, suggesting that resilient coping/traits (i.e. “I am able to adapt when changes occur”) does not relate to the number of trauma symptoms experienced, but rather resilience relates to the distress linked to the symptoms. This suggests that resilience coping/traits may be especially useful in helping individuals lower the distress linked to their experience of trauma symptoms. Secondly and in support of the last point, higher resilient coping/traits were significantly associated with higher distress tolerance both in terms of the overall scale and three of four subscales (tolerance, absorption, and appraisal). Perhaps having a resilient outlook (e.g. “I am able to adapt”) may coincide with being able to tolerate negative distress because one anticipates that he can deal with stressful situations. Third, higher resilience was significantly associated with lower total scores on trauma-related cognitions, indicating that overall higher resilient coping/traits are related to lower trauma-related thoughts. Further analyses of subscales, revealed that higher resilience was associated with lower negative cognitions about the self, but resilience was not associated with negative cognitions about the world and self-blame cognitions. In part, this may be due to the fact that the resilience items are positive statements about whether one is able to adapt or bounce back from adversity; therefore, someone in agreement with the resilient statements may also have lower negative thoughts about oneself as assessed by the negative cognitions subscale.

Although additional research is needed, taken together, our preliminary findings suggest that interventions promoting two resilient coping/traits (“I am able to adapt when changes occur” and “I tend to bounce back after illness, injury, or other hardships”) may show promise in lowering trauma symptoms (especially trauma-linked distress), lowering negative cognitions about the self, and improving distress tolerance. Given the cross-sectional nature of this study, it may also be that interventions addressing negative self-cognitions, distress tolerance, and trauma symptoms may boost resilience. Researchers should investigate whether an intervention focused on improving resilience among MSM after trauma would have these positive outcomes. In addition, given the brevity of the CD-RISC2, it may be beneficial as a brief psychometric screening tool in health systems that serve MSM to indicate men who may need further resources to enhance coping/resilience. However, additional research is needed to determine score cut-offs and the utility of the CD-RISC2 as a screening tool.

Despite these interesting findings and potential implications, there were a few limitations. First, this study consisted of MSM recruited and enrolled in two major cities in the northeast and southeast U.S. and therefore findings may not be generalizable to other geographic locations. Second, this study examined cross-sectional variables and therefore causal conclusions are not possible. A future paper in this sample should examine how resilience impacted how well participants did in the clinical trial. Third, to prevent excessive participant burden with multiple long measures, in measuring resilience we utilized the two-item Connor Davidson Resilience Scale, which has good evidence of reliability and validity in the literature. However, the 10- or 25- item Connor Davidson Resilience Scales may have provided additional findings or insights (Connor & Davidson, 2003). Fourth, we utilized the Davidson PTSD Scale (Davidson et al., 1997) DSM-IV scale, which captures symptom frequency and distress, but lacks some symptomology on PTSD cognitions captured in the DSM-V PTSD diagnosis. However, to offset this limitation we measured PTSD cognitions using the PTCI (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999).

In conclusion, among a sample of men (who have sex with men) with histories of CSA, we report novel findings that higher resilient coping/traits were associated with lower trauma symptoms and cognitions and higher distress tolerance. Our findings echo that resilient coping and traits (i.e. “I am able to adapt” and “I tend to bounce back”) are important to research after trauma among MSM, potentially assess in clinical settings, and address in interventions.

Table 2.

Multivariable Regressions of Resilience Predicting Outcome Variables

Dependent
Variables		 B SE β t p
Davidson total frequency −.288 1.450 −.020 −.198 .843
 Davidson frequency intrusive re-experiencing subscale −.514 .373 −.139 −1.376 .172
 Davidson frequency avoidance and numbness subscale −.412 .710 −.060 −.580 .563
 Davidson frequency hyperarousal subscale .638 .599 .109 1.066 .289
Davidson total severity −2.534 1.482 −.177 −1.710 .091
 Davidson severity intrusive re-experiencing subscale −1.410 .529 −.318 −2.666 .010
 Davidson severity avoidance and numbness subscale −1.611 .670 −.270 −2.405 .019
 Davidson severity hyperarousal subscale −.081 .558 −.016 −.145 .885
PTC total −11.385 5.077 −.227 −2.242 .027
 PTC Negative Cognitions about Self subscale −.437 .157 −.278 −2.781 .007
 PTC Negative Cognitions about the World subscale −.110 .161 −.070 −.682 .497
 PTC Self-Blame subscale −.080 .176 −.046 −.452 .652
DTS Total .265 .104 .255 2.555 .012
 DTS Tolerance Subscale .329 .130 .254 2.541 .013
 DTS Absorption Subscale .310 .129 .240 2.399 .018
 DTS Regulation Subscale .246 .130 .191 1.897 .061
 DTS Appraisal Subscale .219 .107 .208 2.059 .042
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Acknowledgments

Research reported in this publication was supported by the National Institute of Mental Health (R01MH095624, P.I. Conall O’Cleirigh, Second Site P.I. Gail Ironson). Dr. Dale was funded by R01MH095624-03S1, K23MH108439 (P.I. Sannisha Dale), and R56MH121194 (P.I. Sannisha Dale) from the National Institute of Mental Health. Steven Safren was funded by grant K24 DA040489. The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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