This study found that measures of IPV were associated with younger age (perpetration only), sexualized drug use, internalized homophobia, group sex, and were strongly associated with depressive symptoms. IPV was not consistently associated with CAS measures among this study population.
The prevalence of IPV in the PROUD trial of GBMSM was very high: 44.9% (95% CI: 40.1, 49.7%) for lifetime IPV victimization and 15.6% (95% CI: 12.4, 19.5%) in the last year, and 19.5% (95% CI: 15.9, 23.7%) for lifetime IPV perpetration, and 7.8% (95% CI: 5.6, 10.8%) in the last year, at the 12-month questionnaire. There was some inconsistency of reporting of lifetime IPV between month-12 and 24 in PROUD. However, among those who reported IPV at month-12 but not 24, a common pattern of response was for men to report being frightened of the behaviour of a partner/having behaved in a manner that frightened a partner at month-12 and to respond ‘Never’ at month-24. Possibly, individuals may forget a single instance of IPV of this nature, view such an occurrence with less significance after a period of time, or ascribe a different meaning to it in the light of changes in the relationship or other circumstances.
The prevalence of IPV in PROUD is high when compared to the Crime Survey for England and Wales (2016) and the UK population-based Adult Psychiatric Morbidity Survey (2007, physical and/or emotional IPV only) whereby lifetime prevalence of IPV victimization was 10.1% (95% CI: 9.5, 10.7%) and 18.7% (95% CI: 17.1, 20.4%) for men respectively in the two studies, and 23.0% (95% CI: 22.2, 23.8%) and 27.8% (95% CI: 26.2, 29.4%) for women [9, 10]. However, both of these studies used a different assessment of IPV and did not present data separately for GBMSM. Estimates from PROUD are more in line with, although still higher than, those from a London GUM clinic cross-sectional study of gay- and bisexual-identified men (2010–2011, N = 519), which used the same measure of IPV (excluding ‘forced to have sex without a condom’): 33.9% (95% CI: 29.4, 37.9%) for lifetime IPV victimization and 16.3% (95% CI: 13.0, 19.8%) for lifetime IPV perpetration . However, a qualitative study with 19 of these men, suggested that the survey results underestimated the prevalence of IPV . PROUD estimates of lifetime IPV and IPV in the last year were also somewhat similar compared to those reported in two UK online samples of GBMSM that used different assessments of IPV. In one online study of 398 GBMSM , past year estimates of IPV were 8.5% (95% CI: 6.0, 11.7%) for physical IPV victimization, 3.3% (95% CI: 1.8, 5.5%) for physical IPV perpetration, 4.5% (95% CI: 2.7, 7.1%) for sexual IPV victimization, and 0.8% (95% CI: 0.2, 2.2%) for sexual IPV perpetration. In the other online study of 258 GBMSM , the prevalence of lifetime IPV victimization was 36.4% (95% CI: 30.6, 42.6%). Men may have been more likely to disclose IPV within the PROUD clinical trial setting, given more frequent contact with healthcare professionals and therefore opportunities for support and referral. Differences observed may also be attributed to the unique behavioural profile of the PROUD sample: there was a very high proportion who reported STIs and recreational drug use at baseline, very high levels of CAS at baseline and follow-up, and an exceptionally high incidence of HIV in the control group [15, 16], factors which may be associated with IPV. Therefore, IPV prevalence in PROUD may differ from other samples of GBMSM, and is not generalizable to the general GBMSM population in England.
In the current study, a trend was found with younger age and increasing prevalence of IPV perpetration, as has been found in other samples of GBMSM [38, 39]. Although no associations were found of sexual identity or ethnicity with lifetime and past year measures of IPV, the vast majority of the PROUD sample were gay identified and of white ethnicity. Furthermore, findings from a recent qualitative study suggest that dyadic inequalities including education and income differentials may serve as a means by which to establish power dynamics in same-sex male couples, and increase the risk of experiencing control and abuse from a partner . The PROUD study sample likely lacked the statistical power to investigate these associations.
Having been a victim of IPV was very strongly associated with IPV perpetration in PROUD. It has been posited, across psychoanalytic theories, that exposure to/experiences of violence, abuse, and neglect, precede the perpetration of violence in future relationships [41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56]. The association between IPV victimization and IPV perpetration may be bidirectional. The very strong relationship observed in this study, may also reflect the phenomena of reciprocal IPV. In Johnson’s categorizations of IPV in opposite-sex partnerships, abuse may take one of four forms: (i) intimate terrorism, whereby one partner carries out abuse via a range of control tactics that are likely to escalate over time in a cyclical pattern of abuse, remorse, pursuit, and tension build-up, (ii) mutual violent control, whereby both partners are abusive and controlling, (iii) violent resistance, whereby one partner is violent and the other responds in violent self-defense, or (iv) situational couple violence, whereby one or both partners are abusive but the abuse is not attached to a pattern of escalating control . In the current study, 16.8% of men reported lifetime experiences of IPV both as a victim and a perpetrator, although it was not possible to distinguish abuse carried out with the same or different partner. Further research is needed to examine whether the dynamics of IPV among same-sex male couples fit within Johnson’s four categories, and what processes are involved in the manifestation of these dynamics.
Evidence is accumulating which suggests that among UK (N = 398 ), U.S. (N = 1575 , N = 750 ), and Canadian (N = 186 ) samples of GBMSM, markers of internalized homophobia are strongly associated with measures IPV perpetration, including physical, [6, 58], emotional/psychological  and sexual [4, 5], in unadjusted analysis [4, 58], and after adjusting for socio-demographic and lifestyles factors [5, 6]. Associations have also been found with measures of IPV victimization in the U.S., including physical and sexual [5, 6]. In the current study, a marker of internalized homophobia was strongly associated with experiences of IPV victimization and IPV perpetration.
For sexual minority individuals, the internalization of anti-gay attitudes leads to feelings of worthlessness and negativity about the self, and may be linked to pervasive expectations of rejection, and non-disclosure of one’s sexual orientation. The link between internalized homophobia and IPV may be explained by exosystem factor theory and psychoanalytic theories. In exosystem factor theory, stress that is associated with exosystem level factors, the cultural or sub-cultural context in which development occurs, and is perceived to exceed one’s financial/emotional resources, is thought to be an important trigger for the perpetration of violence. This may occur in particular, against the backdrop of exposure to abuse/violence in childhood or early adolescence and lack of social support [59, 60]. Sexual identity is an exosystem level factor if an individual affiliates with a sexual minority population in a community. The stress associated with social pressure to conform to heteronormative behaviours may play some role in IPV perpetration among gay and plurisexual identified men. Enacting hegemonic masculinity via violent domination of one’s partner, may be used as a way of reconstructing a contested masculinity . In psychoanalytic theories, abuse from significant individuals during formative years can manifest in persistent feelings of unworthiness, and an inability to regulate emotional responses and recognize/avoid abuse in adult intimate partnerships. Some individuals develop complex psychological defences necessary for survival, which become highly integrated into one’s personality structure [43, 46]. Although not possible in the current study, an understanding of the degree of exposure to abuse in childhood/adolescence, and emotional ties formed with primary caregivers, as well as levels of social support, may provide insight into why some men who experience internalized homophobia have violent partnerships while others do not.
In a UK study of GBMSM, IPV victimization in the last year was associated with past year use of ecstasy, LSD, cocaine, crack, heroin, or injected amphetamines (OR 1.7 95% CI: 1.16, 2.47, p = 0.006), after adjusting for socio-demographics . Findings from PROUD suggest that sexualized drug use, which to a large extent may encompass the practice of chemsex, may be important in the context of IPV among GBMSM. Sexualized drug use (chemsex) may occur in group sexual settings. In this study, men who reported group sex were more likely to report IPV victimization in the last year, and there was some suggestion of a link with lifetime IPV perpetration. Group sex environments may leave some individuals vulnerable to mistreatment particularly if drugs are used, given their impact on inhibition and self-regulation [29, 62]. The relationship between recreational drug use and IPV may be bidirectional such that drugs are used as a form of self-medication and/or in order to induce a state of cognitive release .
Strong associations were found between IPV and depressive symptoms in the PROUD trial. This is in line with evidence from a recent meta-analysis of GBMSM , and suggests that experiences of IPV may have a lasting adverse impact on mental health. In PROUD, the association with depression was particularly strong for IPV perpetration, including men who both experienced and perpetrated abuse. Similarly, in the only UK study to have examined the link between IPV and depression among GBMSM, the prevalence of depression (HADS≥8) was significantly elevated among men reporting IPV perpetration in the past year versus those who hadn’t (20.7% vs. 11.5%), but not among men reporting victimization (past year or lifetime) . In that study, after adjusting for socio-demographic factors, the association between IPV perpetration and depression was attenuated to borderline significance (OR 3.7 95% CI: 1.0, 14.6; p = 0.060). However, income was adjusted for, which may be highly correlated with both IPV and depression. When comparing these survey study findings to those provided during an interview, there was evidence to suggest that some men who abuse a partner do not report it on a survey questionnaire . It is possible that for those men who do, the experience of IPV may have had a greater psychological impact. IPV perpetration is highly correlated with abusive experiences in childhood [43, 46, 59, 60, 64,65,66]. It is possible that a greater degree of exposure to violence during formative years may also explain a higher prevalence of depression among individuals who have carried out IPV. The relationship between depression and IPV may be bidirectional such that depressive symptoms heighten vulnerability to dysfunctional relationship dynamics, as adaptive coping mechanisms are distorted [67, 68].
Physical acts of violence directed towards an intimate partner do not often occur in isolation, frequently there is overlap with other forms of violence, including sexual abuse . IPV may lead to a distortion of one’s perception of self-worth and ability to recognize dysfunctional relationship dynamics . It is therefore plausible, that experiences of IPV with a previous partner may also lead to unwanted sex and CAS with other partners. In a recent meta-analysis , exposure to any kind of IPV was associated with CAS (pooled OR: 1.72 95% CI: 1.44, 2.05) and HIV seropositivity (pooled OR: 1.46 95% CI: 1.26, 1.69). In the current study, there was some suggestion of an association between lifetime IPV victimization and receptive CAS with an HIV-positive partner not known to be on antiretroviral treatment. However, measures of IPV were not found to be associated with any other measures of CAS or partner numbers in the PROUD trial. Similarly, no associations were found between depressive symptoms and sexual risk behaviour, despite the evidence for a relationship in other high-income country studies of GBMSM [70, 71]. There was no evidence from PROUD to suggest a synergistic effect of IPV and depression on sexual risk behaviour. The unique nature of the PROUD study population, GBMSM who reported very high levels of CAS, may explain why associations with CAS measures were not seen for depression or IPV. Perhaps IPV and depression do not explain why some men who engage in CAS have a higher number of CAS partners. It may be that other factors, with greater disinhibiting effects, such as higher levels of recreational drug use and/or personality traits associated with sexual compulsivity/sensation seeking, play a greater role in this context.
The role of GUM services in addressing IPV
The UK National Institute for Health and Care Excellence recommends that trained staff in sexual health services ask about IPV as part of good clinical practice, even where there are no indicators of violence and abuse . However, a recent UK survey (2010–2011) found that only 34.7% of 522 gay and bisexual GUM clinic attendees felt that ‘health professionals should ask all patients whether they have been hurt/frightened by a partner’, whereas 62.6% felt only some patients should be asked based on symptoms . Further qualitative exploration revealed that men perceived the busy clinic environment as not conducive to asking all patients about IPV in a manner that would encourage disclosure. Conversely, some men felt that selective enquiry could be stigmatizing. At the very least sexual health services should display information on IPV, as well as train staff to recognize the common indicators, enquire sensitively about violence, and refer patients to further support within and outside of the health care setting. In the UK context this includes referral to domestic and sexual violence advisors (IDSVA) and local IPV services. General IPV support services for men include the ManKind Initiative and the Everyman Project, which offers counseling in London, as well as services specifically tailored to sexual and gender minorities, such as the Respect Phoneline and Galop LGBT Domestic Abuse Helpline, offering information and support. The IRIS ADViSE model, which encompasses training to enhance recognition, enquiry, and referral, has been shown to increase the IPV enquiry and identification rate among female GUM clinic attendees in a UK pilot study , and in a cluster randomized trial of women attending general practitioners in the UK, the identification of IPV and referral to specialist services . In a recent RCT of Project WINGS, which aimed to provide effective IPV victimization screening, brief intervention, and referral to treatment services (SBIRT) for substance using women in New York, identification of IPV and receipt of IPV services was found to increase after 3-months of follow-up .
Information on the number and type of recreational drugs used in the past three months and higher risk alcohol consumption was only collected at the baseline questionnaire. Not being able to investigate other factors, which may be important in the context of IPV such as social support and financial security, was also a limiting factor. It was not possible to investigate data on dysfunctional relationships formed with primary caregivers in childhood/early adolescence. Not all PROUD participants were included in the IPV analysis due to missing questionnaires at months 12 and 24. Participants lost to follow-up may differ in terms of psychosocial factors. However, depression at baseline was not associated with loss-to-follow-up (overall or in each trial arm separately), and there was no difference between men with depressive symptoms and men without symptoms at the 12-month questionnaire in terms of completing the 24-month questionnaire (27.1% vs. 24.8% lost-to-follow-up respectively; p-value = 0.702). There was also no difference between men reporting experiences of lifetime IPV victimization and men who did not at the 12-month questionnaire in terms of completing the 24-month questionnaire (27.2% vs. 23.5% lost-to-follow-up respectively; p-value = 0.387). Even after including repeated observations in GEE models, given the relatively small sample size of the PROUD trial, the analysis may have lacked power to accurately detect the presence of some associations. GEEs were used for data-analysis in this paper, which treat the data as if it were cross-sectional, prohibiting inferences about causality. There is a need to conduct an adequately powered longitudinal study designed to address IPV among sexual minorities.