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Intimate Partner Violence Among Men
Intimate Partner Violence Among Men Prevalence, Chronicity, and Health Effects Robert J. Reid, MD, PhD, Amy E. Bonomi, PhD, MPH, Frederick P. Rivara, MD, MPH, Melissa L. Anderson, MS, Paul A. Fishman, PhD, David S. Carrell, PhD, Robert S. Thompson, MD Context:
The breadth and depth of intimate partner violence (IPV) experienced by men have not been fully documented.
Objectives:
To describe the prevalence, chronicity, and severity of IPV, and the health outcomes associated with IPV, in adult men with healthcare insurance.
Design:
A retrospective telephone cohort study conducted from 2003 to 2005. The setting was an integrated healthcare system in Washington State and Idaho.
Participants: English-speaking men aged 18 and older (N⫽420) enrolled in the healthcare system for 3 or more years. Main Outcome Measures:
Physical, psychological, and sexual IPV were assessed using five questions from the Behavioral Risk Factor Surveillance Survey. Health was measured using the Short Form-36, version 2 (SF-36v2) survey, the Center for Epidemiological Studies Depression Scale, and the National Institute of Mental Health Presence of Symptoms Survey.
Results:
Men experienced IPV at a rate of 4.6% in the past year, 10.4% in the past 5 years, and 28.8% over their lifetimes. While overall rates of physical and nonphysical IPV were similar, men aged 18 –55 were twice as likely to be recently abused (14.2%, SE⫽2.6%) than were men aged 55 and older (5.3%, SE⫽1.6%). Abuse was typically nonviolent or mildly violent, occurred on multiple occasions, and was initiated by only one intimate partner. Compared to men with no IPV, older men who experienced IPV had more depressive symptoms (prevalence ratios⫽2.61 and 2.80 for nonphysical and physical abuse) and had lower SF-36v2 mental health subscales (range⫽⫺3.21 to ⫺5.86).
Conclusions: Men experience IPV at moderate rates, and poor mental health outcomes are associated with such experiences. (Am J Prev Med 2008;34(6):478 – 485) © 2008 American Journal of Preventive Medicine
Background
A
substantial body of epidemiologic and health services research has focused attention on intimate partner violence (IPV) perpetrated against women. U.S. national surveys show that 25%–29% of women experience some form of IPV in their adult lifetimes.1,2 More detailed population-based surveys reveal that women often experience multiple overlapping types of IPV, rate it as severe, and experience IPV over many years.3 Additionally, strong associations exist between women’s experience of IPV and poor mental, From the Group Health Cooperative Center for Health Studies (Reid, Bonomi, Anderson, Fishman, Carrell, Thompson), the Harborview Injury Prevention and Research Center (Rivara), the Departments of Pediatrics and Epidemiology (Rivara), University of Washington, Seattle, Washington; and the College of Education and Human Ecology, The Ohio State University (Bonomi), Columbus, Ohio Address correspondence and reprint requests to: Robert J. Reid, MD, PhD, Group Health Cooperative, Center for Health Studies, 1730 Minor Avenue, Suite 1600, Seattle WA 98101. E-mail: reid. [email protected].
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physical, and social health.4 –7 The most pronounced health deficits were observed for those women who experienced both sexual and physical violence, those who experienced recent violence, and those reporting 10 or more years of IPV.4,6 Other epidemiologic research has established a relationship between women’s exposure to IPV and hospital admissions,8 healthcare utilization, and costs.9 However, less research has focused on the IPV experienced by men. Some have argued that men’s experience of IPV represents the self-protective behaviors used by abused women or the manifestations of bidirectional violence within a couple rather than the systematic, chronic use of power and control that has been associated traditionally with men’s violence against women.10 –12 National surveys suggest that the lifetime prevalence of IPV in men ranges from 8% to 23%.1,13 Coker and colleagues found lower rates of physical and sexual IPV experienced by men (5.9%) compared to women (17.6%).13 Several statewide and local prevalence sur-
Am J Prev Med 2008;34(6) © 2008 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/08/$–see front matter doi:10.1016/j.amepre.2008.01.029
veys from the U.S. indicate that 4.7%–16.4% of men report having been physically abused by an intimate partner in the past year, and 3.3%– 4.7% of those men say that the violence was severe.14 –17 Although less studied, psychological abuse also appears to be common, with estimates ranging from 17.3% of a national sample of men reporting lifetime verbal abuse or abuse of power and control13 to 30% of rural men reporting threats or controlling behavior in the past year.17 Other research on IPV in men comes from heterosexual couple studies, which suggest equivalent rates of maleto-female and female-to-male abuse,18,19 but women are more likely to suffer physical IPV and injuries.18 –20 There is a paucity of research on the relationship between IPV and health status in men. Coker and colleagues13 found that men who experienced physical IPV or psychological-abuse IPV alone (in the absence of physical violence) disclosed poorer self-reported general health and higher rates of depressive symptoms, drug and alcohol use, chronic mental illness, and injury compared to men who did not experience abuse. The present investigation provides new information on IPV directed toward men. It examines the period prevalence of different types of IPV, the number of abuse occurrences and abusive partners, and the severity and duration of the IPV in an age-stratified sample of men insured by a large, integrated healthcare system. The relationship between IPV and health status is also explored, using well-validated health measures to add to the previous findings of such a relationship. This study builds on prior studies of IPV prevalence and health consequences among 3429 women aged 18 – 643,4 and 370 women aged 65 and older21 insured by the same health plan at the same time.
Methods Study Setting The setting was Group Health, a nonprofit, integrated healthcare system in the northwest U.S. serving an insured population of approximately 530,000 patients. Study procedures were approved by Group Health’s IRB. Analyses were conducted in 2007.
Study Design, Subject Selection, and Data Collection A random sample of English-speaking men aged ⱖ18 was interviewed by telephone between December 2003 and August 2005 about their health and adult experiences with IPV. English-speaking men who had been enrolled at Group Health for at least 3 years were randomly sampled without replacement from enrollment files and were invited to participate. The 3-year enrollment criterion was necessary to compare healthcare utilization and costs between people with and without IPV experiences.9 After a potential participant received an introductory letter describing the study as a general wellness study, he was called on the telephone by study staff who described the study procedures and, if the
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man was interested, obtained his informed consent to participate. Respondents were paid $25 for their participation. Preliminary analysis of an initial random sample of 200 men who completed the survey suggested that approximately 15% of men aged 18 –54 had experienced IPV in the prior 5 years, compared to 2% of men aged 55 and older. Because of this disparity in age-specific prevalence, the remaining sample was age-stratified, oversampling the older group to increase the precision in the 5-year prevalence estimate to within 2% of the point estimate. The analysis was limited to the 440 Group Health patients (204 men aged 18 –54 and 216 men aged 55 and older) who completed the survey.
Measures of Intimate Partner Violence Intimate partner violence was defined as actual or threatened physical, psychological, and sexual violence used by an intimate partner to cause harm or trauma.22 Intimate partners included present or past, heterosexual or homosexual, marital or nonmarital partners. Consistent with the definition used by the CDC, intimate partnerships did not have to include sexual activity.22 For each respondent, a partnership history since he was aged 18 was constructed by asking about the beginning and ending year of each relationship. Each respondent was also asked to estimate the total number of intimate partners in his adult lifetime. To minimize respondent burden, the men were asked detailed information only about their three most recent relationships. Using those three, a complete relationship history for the prior 5 years was constructed for 98.2% of the respondent men. The occurrence of IPV was assessed by using five questions from the U.S. Behavioral Risk Factor Surveillance System (BRFSS) survey14 –16,23,24 (Table 1). The BRFSS questions assess exposure to abusive behavioral tactics, including physical violence (hitting, kicking, and slapping [one question]); sexual violence (forced intercourse and other unwanted sexual contact [two questions]); and psychological— nonphysical—violence (threats and anger [one question], and controlling behavior, name calling, and put downs [one question]). Reports of IPV events using the BRFSS were categorized by their time of occurrence (past year, past 5 years, or adult lifetime) and abuse type (physical, sexual, or
Table 1. Intimate partner violence questions from the BRFSS survey Measure/Content Physical (three questions) Physical: Has an intimate partner ever hit, slapped, shoved, choked, kicked, shaken, or otherwise physically hurt you? Sexual: Has an intimate partner ever forced you to participate in a sex act against your will? Sexual: Has an intimate partner ever threatened, coerced, or physically forced you into any sexual contact that did not result in intercourse or penetration? Nonphysical (two questions) Threats: Have you ever been frightened for your safety, or that of your family or friends, because of anger or threats of an intimate partner? Controlling behavior: Has an intimate partner ever put you down, or called you names repeatedly, or controlled your behavior? BRFSS, Behavioral Risk Factor Surveillance System
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psychological). For each BRFSS abuse type, the men reported the number of abusive partners, the total number of abuse events, and the abuse duration. Respondents rated the severity of each abuse type (across all events and partners) on a 4-point ordinal scale from 1 (did not consider it violent) to 4 (considered it extremely violent).25
Health Status and Social Connectedness Twenty questions from the Short Form-36 Health Survey, version 2 (SF-36v2) were used to assess the men’s perceptions of their health status, including general health, vitality, mental health, emotional health, and social functioning.26 The survey was limited to 20 of the original 36 questions to minimize respondent burden. A subset of these questions was aggregated and standardized (with M⫽50, SD⫽10) to form the physical component summary and mental component summary scores as described by the survey developers.26 General health status was dichotomized into poor/fair and good/very good/excellent health.4 Depression was assessed, using five questions (scored from 0 to 3) from the Center for Epidemiological Studies-Depression (CES-D) scale.27 Item scores were totaled, with a sum of 4 – 6 or 7–15 indicating minor and severe depressive symptoms, respectively.27 The men’s responses to questions about 14 physical symptoms were scored on a 5-point Likert scale, and the total number of symptoms bothering them at least some of the time during the past 6 months was calculated.28 Social connectedness was assessed by asking the men to indicate their involvement in voluntary groups (not active versus somewhat/very active) and their trust of people in their residential communities (not/a little trusting versus quite a bit/very trusting).29 –31
Other Variables Each respondent was asked about his race, ethnicity, income, employment, education, household composition, and residence. Because research has established a link between IPV and a history of childhood abuse32 or the witnessing of IPV as a child,33,34 respondents were also asked about experiences before they were aged 18 of either physical or sexual abuse or of witnessing IPV between their parents or guardians.
Analysis Period prevalence of IPV in the past year, the past 5 years, and the adult lifetime among insured men was estimated using the BRFSS questions. The BRFSS abuse tactics were classified by type as physical (hitting, kicking, slapping, forced intercourse, or unwanted sexual contact) or nonphysical (threats, anger or controlling behavior, or both). Frequencies and measures of central tendency were used to summarize IPV frequency, duration, and severity. Because men aged 55 and older were oversampled to provide more precise periodprevalence estimates, both age-stratified and overall prevalence estimates were calculated. To compute the overall prevalence rates, sampling weights were used in the analysis to weight the surveyed sample to match the age distribution of the insured population of adult males at Group Health. In addition, because of the low response rate in this population (43.5%), additional IRB approval was obtained to collect a limited set of automated sociodemographic and pharmacy data for both respondents and nonrespondents to
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assess and adjust for potential nonresponse bias. Using the total sample (respondents and nonrespondents), multivariate logistic regression was used to estimate the probability that an individual would choose to participate (propensity score35) based on his age, enrollment length at Group Health, and chronic disease burden, using the RxRisk system.36 RxRisk is a validated, resource-based, case-mix model that uses automated, ambulatory pharmacy data to identify and weight select chronic conditions. RxRisk scores were calculated for the study sample using prescription drug profiles during the 6 months prior to subject sampling. The estimated probability of study participation did not differ significantly by IPV exposure status (0.441 in men reporting IPV vs 0.43 in men reporting no IPV; p⫽0.57). Nonetheless, all analyses were propensity-score adjusted to reduce potential bias in the study results due to nonresponse. Prevalence estimates with relative standard errors (RSE) over 30% may be unreliable. Estimates with RSE⬎30% are marked with an asterisk (Table 5) and should be used with caution. Weighted ordinary least-squares regression was used to examine differences in the SF-36v2 subscales and in the number of symptoms reported by men exposed to lifetime physical and nonphysical IPV according to the BRFSS questions compared to men with no IPV exposure since they were aged 18 (reference group). Regression models were run separately for men aged 18 –54 and men aged 55 and older, and were adjusted for age, income, and abuse as a child. Multivariate logistic regression models were used to test for differences in depression symptomatology and social connectedness by IPV exposure groups.
Findings A total of 1094 men meeting the eligibility criteria were sampled from the Group Health enrollment files. Sixty men were excluded because of sampling error (25), death (4), language and hearing problems (22), and severe illness (9). Of the remainder, 349 men (33.8%) refused to participate, 38 (3.7%) were located but not interviewed, and 197 (19.1%) were not able to be interviewed after eight phone attempts made at different times of the day. Informed consent was obtained to undertake telephone interviews with 450 men (participation rate⫽43.5%). Five participants were excluded (1.1%) because they did not complete the entire interview. Complete interviews were collected on 445 men. An additional 25 men (5.6%) were excluded because they had not had an intimate partner since they were aged 18 and thus were not eligible for IPV exposure, resulting in an analytic sample of 420 men. Respondents had relatively high income and educational levels (Table 2). The study population was 81.6% white and 3.6% (reported) Hispanic ethnicity, which is comparable to the adult population in Washington State, at 83.9% and 6.0%, respectively.37 The mean number of household members (2.69; SD⫽⫺1.33) is similar to national estimates (M⫽2.59). A total of 85.2% of the sample reported having a current intimate
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Table 2. Characteristics of the study sample Age group
Age, M (SD) Race (%) Caucasian African American Asian/Pacific Islander American Indian/Alaska native Multiracial or other Hispanic ethnicity Household income ($; %) ⬍25,000 25,000–49,999 50,000–74,999 ⬎75,000 Employment (%) Full-time Part-time Retired Unemployed or other Education: high school graduate or less (%) In a current intimate partner relationship (%) Children in home for whom respondent is guardian (%) Number in household, M (SD) Urban residence (%) Gender of current partner/most recent partner (%) Male Female Did not specify Experienced childhood abuse (physical or sexual) (%) Witnessed IPV as a child (%)
18–54 nⴝ204
55ⴙ nⴝ216
Total Nⴝ420
40.9 (10.9)
65.9 (8.5)
53.8 (15.9)
82.2 5.9 3.5 2.0 4.5 4.9
89.8 0.9 3.7 1.9 1.4 2.3
86.1 3.4 3.6 1.9 5.0 3.6
10.5 18.4 22.9 48.3
12.8 36.0 24.2 27.0
11.7 27.4 23.5 37.4
85.8 6.9 0.5 6.8 10.8 85.8 41.9 3.2 (1.4) 93.0
34.3 14.4 48.2 3.1 11.6 84.7 6.0 2.2 (1.0) 88.5
59.3 10.7 25.0 5.0 11.2 85.2 23.4 2.7 (1.3) 90.7
3.4 94.6 2.0 19.7 14.4
2.3 96.3 1.4 17.2 14.6
2.9 95.5 1.7 18.4 14.5
IPV, intimate partner violence
Period Prevalence of Intimate Partner Violence
partner, of which 95.5% were women. A total of 18.4% of the men reported a history of childhood physical or sexual abuse, and 14.5% had witnessed IPV as children.
Of men aged 18 –54, 14.2% reported experiencing IPV in the past 5 years, and 6.1% reported IPV in the past
Table 3. Period prevalence of IPV by type as delineated by the BRFSS Physical IPV Time Period Past 12 months
Age group
N
Est.a
n
b
18–54 55⫹
204 216
6 0
2.9 0.0
Past 5 years
All 18–54 55⫹
420 204 216
6 17 2
1.6b 8.8 1.0b
Adult lifetime
All 18–54 55⫹
420 204 216
19 42 28
All
420
70
95% CI 0.5–5.2 —
Nonphysical IPV RSE
Est.a
n
b
95% CI
Any BRFSS IPV RSE
Est.a
n
41 —
8 5
4.1 2.4b
1.3–7.0 0.3–4.6
37 46
12 5
0.3–3.0 4.7–12.9 0.0–2.3
44 24 70
13 16 9
3.4 8.0 4.3b
1.5–5.3 4.1–11.8 1.5–7.1
29 25 33
17 28 11
5.5 20.8 13.3
3.0–7.9 15.0–26.5 8.7–17.9
22 14 17
25 40 40
6.4 18.6 18.9
3.9–8.9 13.2–24.0 13.6–24.3
20 15 14
17.6
13.7–21.4
11
80
18.7
14.9–22.5
10
6.1 2.4b
95% CI
RSE
2.7–9.6 0.3–4.6
28 46
4.6 14.2 5.3
2.4–6.7 9.2–19.3 2.2–8.4
24 18 30
39 63 56
10.4 30.5 26.5
7.2–13.6 23.9–37.0 20.5–32.5
15 11 11
119
28.8
24.3–33.3
8
a
Estimated percentage adjusted for propensity scores and sampling weights This estimate should be used with caution. Estimates with RSE ⬎30% may be unreliable. BRFSS, Behavioral Risk Factor Surveillance System; IPV, intimate partner violence; RSE, relative standard error.
b
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Table 4. Frequency, severity, and duration of IPV over the adult lifetime (N⫽120) Aged 18–54 Physical IPV
Nonphysical IPV
Physical IPV
Nonphysical IPV
nⴝ42
nⴝ40
nⴝ28
nⴝ40
n Number of different abusive partners One Two or more Number of different occurrences of abuse One 2–5 ⱖ6 Severity of abuse Not violent Slightly violent Moderately violent Extremely violent Years encompassed by IPV ⬍1 1–2 3–5 6–10 ⬎10 Years of abuse M (SD) 25th percentile 50th percentile 75th percentile
Aged 55ⴙ
%
%
n
%
n
n
%
37 5
88.1 36 11.9 4
90.0 10.0
25 2
92.6 7.4
33 7
82.5 17.5
12 22 8
28.6 3 52.4 12 19.0 24
7.7 30.8 61.5
10 10 7
37.0 37.0 25.9
3 10 27
7.5 25.0 67.5
19 14 7 2
45.2 22 33.3 10 16.7 6 4.8 2
55.0 25.0 15.0 5.0
8 8 8 3
29.6 29.6 29.6 11.1
16 8 11 5
40.0 20.0 27.5 12.5
19 8 4 4 5
47.5 7 20.0 13 10.0 10 10.0 3 12.5 6
18.0 33.3 25.6 7.7 15.4
15 2 5 1 3
57.7 7.7 19.2 3.9 11.5
11 4 7 7 11
27.5 10.0 17.5 17.5 27.5
4.1 (7.6) ⬍1 1 3
5.1 (7.0) 1 2 5
3.2 (5.8) ⬍1 ⬍1 4.25
9.3 (11.5) ⬍1 5 14.75
IPV, intimate partner violence
year (Table 3). Among men aged 55 and older, 5.3% and 2.4% reported IPV in the past 5 years and past 1 year, respectively. A total of 28.8% of the men (30.5% of men aged 18 –54 and 26.5% of men aged 55 and older) reported physical and nonphysical IPV in their adult lifetimes. Because none of the survey respondents reported sexual IPV (forced intercourse or unwanted sexual contact) in the past 5 years, and only two men (0.5%) reported sexual IPV in their adult lifetimes, violence was divided into two broad types: physical IPV (hitting, kicking, slapping, and forced intercourse or unwanted sexual contact) and nonphysical IPV (threats, anger or controlling behavior, or both). In the past 5 years, 5.5% of the men reported physical IPV, and 6.4% reported nonphysical IPV. In the past year, 1.6% and 3.4% reported physical and nonphysical IPV, respectively. Men aged 18 –54 were more likely to have experienced abuse in the past 5 years (14.2%) compared to men aged 55 years or older (5.3%; p⬍0.01) When prevalence was compared for men of different ages by IPV type, differences were found for physical IPV (8.8% of men aged 18 –54 versus 1.1% of men aged 55 or older; p⬍0.01) but not nonphysical IPV (8.0% versus 4.3%; p⫽0.13). 482
Characteristics of Intimate Partner Violence Fewer than 15% of the men had experienced IPV by multiple partners during their lifetimes, and no differences were seen by type of abuse according to age (Table 4). Overall, most abused men reported multiple IPV occurrences; 68.1% of men with physical IPV and 92.4% of men with nonphysical IPV reported more than one episode. Across all respondents, 39.1% who reported physical IPV said that it was nonviolent, 31.9% reported that it was mildly violent, and 29% reported that it was moderately or extremely violent. Younger men were less likely than older men to report violent experiences for physical IPV (21.4% versus 40.7%; p⫽0.08) and nonphysical IPV (20% versus 40%; p⫽0.05). Most physical IPV lasted less than a year in duration. Nonphysical IPV was more persistent, with only 18.0% (aged 18 –54) and 27.5% (aged 55 and older) of the men reporting durations of less than 1 year (p⫽0.31).
Health Outcomes and Intimate Partner Violence Of men aged 55 and older, those who had experienced physical IPV in their lifetimes had lower adjusted mean SF-36v2 scores for mental health (⫺5.86), vitality
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Table 5. Health status, symptoms, and social connectedness by IPV type compared to men with no IPV Aged 18–54
Aged 55ⴙ
Physical IPV vs Nonphysical IPV vs Physical IPV vs Nonphysical IPV vs no IPV ever no IPV ever no IPV ever no IPV ever Differencea,b (95% CI) Differencea,b (95% CI) Differencea,b (95% CI) Differencea,b (95% CI) SF-36v2 subscale Role-emotional Vitality Mental health Social functioning Physical component summary Mental component summary Number of symptom in past 6 monthsc
ⴚ2.76 (ⴚ5.30,ⴚ0.23) ⫺1.34 (⫺4.46,1.79) ⫺2.28 (⫺4.83,0.25) ⴚ2.53 (ⴚ4.99,ⴚ0.06) 0.00 (⫺2.78,2.79)
⫺1.79 (⫺4.47,0.89) ⫺0.93 (⫺4.33,2.47) ⫺0.95 (⫺3.39,1.50) ⴚ2.51 (ⴚ4.91,ⴚ0.11) 1.67 (⫺1.18,4.53)
⫺2.49 (⫺5.67,0.69) ⴚ3.48 (ⴚ6.48,ⴚ0.48) ⴚ5.86 (ⴚ9.33,ⴚ2.40) ⫺0.40 (⫺3.17,2.37) ⫺0.75 (⫺4.63,3.14)
⫺1.25 (⫺4.01,1.52) ⫺1.54 (⫺4.52,1.44) ⴚ3.21 (ⴚ5.92,ⴚ0.50) 0.35 (⫺2.33,3.06) 1.13 (⫺2.26,4.52)
⫺2.74 (⫺5.52,0.04)
⫺3.03 (⫺6.15,0.09)
ⴚ4.70 (ⴚ7.91,ⴚ1.48)
⫺1.83 (⫺4.54,0.87)
0.21 (⫺0.55,0.98)
0.11 (⫺0.64,0.87)
⬎PRa (95% CI) General health Fair/Poor Depression (CES-D) Depressive symptoms Severely depressed Social connectedness Not active in voluntary groups Do not trust people in community
PRa (95% CI)
0.68 (⫺0.03,1.38) PRa (95% CI)
0.44 (⫺0.31,1.19) PRa (95% CI)
0.70 (0.22,2.23)
0.66 (0.19,2.33)
1.91 (0.94,3.90)
1.08 (0.51,2.28)
1.20 (0.54,2.64) 1.15 (0.31,4.27)
0.62 (0.18,2.18) 0.55 (0.08,3.79)
2.80 (1.23,6.34) 3.14 (1.06,9.32)
2.61 (1.28,5.34) 2.22 (0.74,6.73)
0.94 (0.60,1.49)
0.72 (0.37,1.40)
1.17 (0.78,1.75)
1.20 (0.85,1.70)
1.31 (0.73,2.34)
1.64 (0.93,2.89)
1.26 (0.54,2.96)
1.33 (0.61,2.92)
Note: Bolded values are statistically significant. a Adjusted for age, income, any abuse as a child, and propensity scores and sampling weights b Difference⫽difference in means, compared to no-IPV-ever group c 14 possible symptoms: joint pain, back pain, insomnia, fatigue, abdominal pain, severe headache, numbness in hands or feet, diarrhea, constipation, shortness of breath, facial or jaw pain, dizziness, nausea or vomiting, and chest pain CES-D, Center for Epidemiological Studies-Depression scale; PR, prevalence ratio.
(⫺3.48), and mental component summary (⫺4.70) compared to men with no IPV (Table 5). Physically abused older men were also 3.1 times more likely to report severe depressive symptoms and 2.8 times more likely to report minor depressive symptoms than were non-abused older men. Older men with nonphysical IPV were also 2.6 times more likely to report minor depressive symptoms, and had a lower SF-36v2 mental health score (⫺3.21) compared to older men with no IPV. No significant differences were found for the remaining SF-36v2 scores (role-emotional, social functioning, and physical component summary), symptoms, general health status, or degree of social connectedness in men with either physical or nonphysical IPV compared to older men with no IPV. Of men aged 18 –54, those with physical and nonphysical IPV had lower social functioning than neverabused men, with adjusted differences of ⫺2.74 and ⫺2.51, respectively (Table 5). Younger men with physical IPV also had a significantly lower role-emotional score (⫺2.76). As with older men, younger men with IPV did not report compromised physical health compared to non-abused men. June 2008
Interpretation This study provides new data on the prevalence, chronicity, severity, and health implications of IPV in men. Overall, 28.8% of adult men who were insured by a large health plan reported having experienced either physical or nonphysical IPV in their adult lifetimes. This figure is similar to the 23% estimated in a national survey that used a similar abuse definition13 but is approximately 15% lower than the 44% of women aged 18 – 64 insured by the same health plan who reported IPV.3 Among the men studied, 17.6% reported lifetime physical IPV, which falls at the upper end of the range reported in prior studies15 that assessed physical and sexual IPV.38 Of note is the fact that fewer than 1% of the men reported lifetime sexual IPV. This result stands in stark contrast to findings from studies of women, in which sexual violence is more commonly reported and has strong associations with poor health.3,6,13 Confirming prior findings,14,15 this study found that younger men were more likely than older men to report recent IPV, particularly physical IPV, for which there was a more-than-eight-fold difference in 5-year prevalence. Violence for most men was limited to a single Am J Prev Med 2008;34(6)
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partner. However, multiple abuse occurrences over time were the norm. In contrast with the IPV experienced by women,3 the abuse reported by men was much less severe, corroborating prior findings.18,38,39 The study’s results also provide new information on the relationship between IPV and health status for men.40,41 As opposed to the experience of women, for whom adverse health effects were present across physical and mental health domains, the health deficits in (mainly older) men were seen primarily for mental health. It was noted that while men with physical IPV had lower SF-36v2 mental health, vitality, and mental component summary scores compared to non-abused men, the mean scores for abused men were approximately 50 (data not shown)—the mean for the SF-36v2 scores derived from the general U.S. population. Scores for non-abused men were above 50, indicating betterthan-average health. The increased rate of severe depressive symptoms for physically abused older men (prevalence ratio⫽2.8) is higher than previous estimates of 1.9 (adjusted OR) for physically abused men aged 18 – 65.13 In contrast to findings for women in the same health plan,4 the lack of a relationship among physical IPV and the SF-36v2 physical scale and reported symptoms may suggest that the abuse that most men experience does not interfere with their physical well-being. However, it is possible that the small sample size precluded having sufficient power to detect substantial differences between groups. Further research with larger samples is needed to explore this issue. Because the respondents were sampled from a highly educated population with healthcare insurance, the results may not pertain to uninsured populations or those with different demographic mixes. The low response rate (43.5%) could introduce bias in studies such as this, although a low response rate is not necessarily a source of bias.42 However, analyses were adjusted using propensity scores to account for potential response bias based on age, duration of enrollment, and case-mix ascertained from prescription-drug utilization profiles. It is important to note that this method of accounting for response bias is not sufficient when the probability of participation depends on the outcome’s being of interest. In fact, it is plausible that IPV is itself a determinant of participation; however, the estimated probability of study participation did not differ by IPV-exposure status. The sample size also did not permit the examination of the temporal sequencing between IPV exposure and health outcomes. Because the men were asked to remember events that may have occurred long ago, the findings may underrepresent the occurrence of events in the distant past. As such, the estimates of lifetime prevalence may be biased downward for older men compared to younger men, and may explain the lowerreported lifetime prevalence found for older men. Finally, abused men were not asked about the reciproc484
ity of violence with their intimate partners. Because many couples report that violence is bi-directional,32,39 it is possible that a portion of the IPV directed at the men by their partners is self-protective. The study’s findings suggest that men experience IPV at moderate rates and may have poor mental health associated with such experiences. The findings also suggest that the failure of healthcare personnel to ask about and acknowledge men’s experiences of IPV may be shortsighted. Asking men about IPV may open a conversational space about abuse—perhaps bi-directional in nature—that may be occurring in their relationships. However, further research is needed to test the effectiveness of different intervention strategies for men experiencing intimate partner abuse. Authors Reid, Bonomi, Rivara, Thompson, Fishman, and Carrell receive research support from the Agency for Healthcare Research and Quality. Drs. Reid and Thompson also received salary support from the Group Health Permanente medical group during the course of this study. This analysis was supported by the Agency for Healthcare Research and Quality (Grant R01 HS10909) and the Group Health Cooperative Center for Health Studies. The Center for Health Studies was involved in the design and conduct of the study, collection, management, analysis, and interpretation of the data. The authors thank the interviewers from Group Health’s Center for Health Studies who telephoned and interviewed the men.
References 1. Tjaden P, Thoennes N. Full report of the prevalence, incidence and consequences of violence against women: findings from the National Violence Against Women Survey. U.S. Department of Justice/CDC, 2000; No. MCJ-183781. 2. Coker AL, Smith PH, Bethea L, King MR, McKeown RE. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med 2000;9:451–7. 3. Thompson RS, Bonomi AE, Anderson M, et al. Intimate partner violence: prevalence, types, and chronicity in adult women. Am J Prev Med 2006; 30:447–57. 4. Bonomi AE, Thompson RS, Anderson M, et al. Intimate partner violence on women’s physical, mental, and social functioning. Am J Prev Med 2006;30:458 – 66. 5. Coker AL, Smith PH, Bethea L, King MR, McKeown RE. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med 2000;9:451–7. 6. Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health outcomes in women with physical and sexual intimate partner violence exposure. J Womens Health 2007;16:987–97. 7. Coker AL, Pope BO, Smith PH, Sanderson M, Hussey JR. Assessment of clinical partner violence screening tools. J Am Med Womens Assoc 2001;56:19 –23. 8. Kernic MA, Wolf ME, Holt VL. Rates and relative risk of hospital admission among women in violent intimate partner relationships. Am J Public Health 2000;90:1416 –20. 9. Rivara FP, Anderson ML, Fishman P, et al. Healthcare utilization and costs for women with a history of intimate partner violence. Am J Prev Med 2007;32:89 –96. 10. Thornton JE, Brackley M, Swenson-Britt E, et al. Domestic violence. N Engl J Med 2000;342:513– 4. 11. Taft A, Hegarty K, Flood M. Are men and women equally violent to intimate partners? Aust N Z J Public Health 2001;25:498 –500.
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12. Bancroft L, Eisenstat SA. Domestic violence. N Engl J Med 2000; 342:514. 13. Coker AL, Davis KE, Arias I, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med 2002; 23:260 – 8. 14. CDC. Physical violence and injuries in intimate relationships—New York, Behavioral Risk Factor Surveillance System, 1994. MMWR Morb Mortal Wkly Rep 1996;45:765–7. 15. Bensley L, Macdonald S, Van Eenwyk J, Wyncoop Simmons K, Ruggles D. Prevalence of intimate partner violence and injuries—Washington, 1998. MMWR Morb Mortal Wkly Rep 2000;49:589 –92. 16. Harwell TS, Spence MR. Population surveillance for physical violence among adult men and women, Montana 1998. Am J Prev Med 2000; 19:321– 4. 17. Murty SA, Peek-Asa C, Zwerling C, Stromquist AM, Burmeister LF, Merchant JA. Physical and emotional partner abuse reported by men and women in a rural community. Am J Public Health 2003;93:1073–5. 18. Schafer J, Caetano R, Clark C. Rates of intimate partner violence in the U.S. Am J Public Health 1998;88:1702– 4. 19. Sorenson SB, Upchurch DM, Shen H. Violence and injury in marital arguments: risk patterns and gender differences. Am J Public Health 1996;86:35– 40. 20. Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999; 282:468 –74. 21. Bonomi AE, Anderson ML, Reid RJ, et al. Intimate partner violence in older women. Gerontologist 2007;47:34 – 41. 22. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate partner violence surveillance: uniform definitions and recommended data elements. Atlanta GA: National Center for Injury Prevention and Control, CDC, 1999. 23. Vest JR, Catlin TK, Chen JJ, Brownson RC. Multistate analysis of factors associated with intimate partner violence. Am J Prev Med 2002;22: 156 – 64. 24. CDC. Intimate partner violence injuries—Oklahoma, 2002. MMWR Morb Mortal Wkly Rep 2005;54:1041–5. 25. McNutt LA, Carlson BE, Rose IM, Robinson DA. Partner violence intervention in the busy primary care environment. Am J Prev Med 2002;22: 84 –91. 26. Ware JE, Catlin TK, Chen JJ, Brownson RC. How to score version 2 of the SF-36 health survey. Lincoln RI: Quality Metric Inc., 2002.
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27. Shrout PE, Yager TJ. Reliability and validity of screening scales: effect of reducing scale length. J Clin Epidemiol 1989;42:69 –78. 28. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of Mental Health diagnostic interview schedule: history, characteristics, and validity. Arch Gen Psychiatry 1981;38:381–9. 29. Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality, and mortality. Am J Public Health 1997;87:1491– 8. 30. Veenstra G. Social capital, SES and health: an individual-level analysis. Soc Sci Med 2000;50:619 –29. 31. Donald CA, Ware JE. The measurement of social support. Res Community Ment Health 1984;4:325–70. 32. Schafer J, Caetano R, Cunradi CB. A path model of risk factors for intimate partner violence among couples in the U.S. J Interpers Violence 2004; 19:127– 42. 33. Ernst AA, Weiss SJ, Enright-Smith S. Child witnesses and victims in homes with adult intimate partner violence. Acad Emerg Med 2006;13:696 –9. 34. Kitzmann KM, Gaylord NK, Holt AR, Kenny ED. Child witnesses to domestic violence: a meta-analytic review. J Consult Clin Psychol 2003; 71:339 –52. 35. Huang IC, Frangakis C, Dominici F, Diette GB, Wu AW. Application of a propensity score approach for risk adjustment in profiling multiple physician groups on asthma care. Health Serv Res 2005;40:253–78. 36. Fishman PA, Goodman MJ, Hornbrook MC, Meenan RT, Bachman DJ, O’Keeffe Rosetti MC. Risk adjustment using automated ambulatory pharmacy data: the RxRisk model. Med Care 2003;41:84 –99. 37. U.S. Census Bureau. Census 2000, Summary File. www.census.gov/ Press-Release/www/2001/sumfile1.html. 38. Tjaden P, Theonnes N. Prevalence, incidence and consequences of violence against women: findings from the National Violence Against Women Survey. Atlanta GA: National Institute of Justice, CDC, 1998; NCJ-172837. 39. Cascardi M, Langhinrichsen J, Vivian D. Marital aggression: impact, injury, and health correlates for husbands and wives. Arch Intern Med 1992; 152:1178 – 84. 40. Coker AL, Smith PH, Bethea L, King MR, McKeown RE. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med 2000;9:451–7. 41. Coker AL, Pope BO, Smith PH, Sanderson M, Hussey JR. Assessment of clinical partner violence screening tools. J Am Med Womens Assoc 2001;56:19 –23. 42. Curtin R, Presser S, Singer E. The effects of response rate changes on the index of consumer sentiment. Public Opin Q 2000;64:413–28.
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The breadth and depth of intimate partner violence (IPV) experienced by men have not been fully documented.
Objectives:
To describe the prevalence, chronicity, and severity of IPV, and the health outcomes associated with IPV, in adult men with healthcare insurance.
Design:
A retrospective telephone cohort study conducted from 2003 to 2005. The setting was an integrated healthcare system in Washington State and Idaho.
Participants: English-speaking men aged 18 and older (N⫽420) enrolled in the healthcare system for 3 or more years. Main Outcome Measures:
Physical, psychological, and sexual IPV were assessed using five questions from the Behavioral Risk Factor Surveillance Survey. Health was measured using the Short Form-36, version 2 (SF-36v2) survey, the Center for Epidemiological Studies Depression Scale, and the National Institute of Mental Health Presence of Symptoms Survey.
Results:
Men experienced IPV at a rate of 4.6% in the past year, 10.4% in the past 5 years, and 28.8% over their lifetimes. While overall rates of physical and nonphysical IPV were similar, men aged 18 –55 were twice as likely to be recently abused (14.2%, SE⫽2.6%) than were men aged 55 and older (5.3%, SE⫽1.6%). Abuse was typically nonviolent or mildly violent, occurred on multiple occasions, and was initiated by only one intimate partner. Compared to men with no IPV, older men who experienced IPV had more depressive symptoms (prevalence ratios⫽2.61 and 2.80 for nonphysical and physical abuse) and had lower SF-36v2 mental health subscales (range⫽⫺3.21 to ⫺5.86).
Conclusions: Men experience IPV at moderate rates, and poor mental health outcomes are associated with such experiences. (Am J Prev Med 2008;34(6):478 – 485) © 2008 American Journal of Preventive Medicine
Background
A
substantial body of epidemiologic and health services research has focused attention on intimate partner violence (IPV) perpetrated against women. U.S. national surveys show that 25%–29% of women experience some form of IPV in their adult lifetimes.1,2 More detailed population-based surveys reveal that women often experience multiple overlapping types of IPV, rate it as severe, and experience IPV over many years.3 Additionally, strong associations exist between women’s experience of IPV and poor mental, From the Group Health Cooperative Center for Health Studies (Reid, Bonomi, Anderson, Fishman, Carrell, Thompson), the Harborview Injury Prevention and Research Center (Rivara), the Departments of Pediatrics and Epidemiology (Rivara), University of Washington, Seattle, Washington; and the College of Education and Human Ecology, The Ohio State University (Bonomi), Columbus, Ohio Address correspondence and reprint requests to: Robert J. Reid, MD, PhD, Group Health Cooperative, Center for Health Studies, 1730 Minor Avenue, Suite 1600, Seattle WA 98101. E-mail: reid. [email protected].
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physical, and social health.4 –7 The most pronounced health deficits were observed for those women who experienced both sexual and physical violence, those who experienced recent violence, and those reporting 10 or more years of IPV.4,6 Other epidemiologic research has established a relationship between women’s exposure to IPV and hospital admissions,8 healthcare utilization, and costs.9 However, less research has focused on the IPV experienced by men. Some have argued that men’s experience of IPV represents the self-protective behaviors used by abused women or the manifestations of bidirectional violence within a couple rather than the systematic, chronic use of power and control that has been associated traditionally with men’s violence against women.10 –12 National surveys suggest that the lifetime prevalence of IPV in men ranges from 8% to 23%.1,13 Coker and colleagues found lower rates of physical and sexual IPV experienced by men (5.9%) compared to women (17.6%).13 Several statewide and local prevalence sur-
Am J Prev Med 2008;34(6) © 2008 American Journal of Preventive Medicine • Published by Elsevier Inc.
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veys from the U.S. indicate that 4.7%–16.4% of men report having been physically abused by an intimate partner in the past year, and 3.3%– 4.7% of those men say that the violence was severe.14 –17 Although less studied, psychological abuse also appears to be common, with estimates ranging from 17.3% of a national sample of men reporting lifetime verbal abuse or abuse of power and control13 to 30% of rural men reporting threats or controlling behavior in the past year.17 Other research on IPV in men comes from heterosexual couple studies, which suggest equivalent rates of maleto-female and female-to-male abuse,18,19 but women are more likely to suffer physical IPV and injuries.18 –20 There is a paucity of research on the relationship between IPV and health status in men. Coker and colleagues13 found that men who experienced physical IPV or psychological-abuse IPV alone (in the absence of physical violence) disclosed poorer self-reported general health and higher rates of depressive symptoms, drug and alcohol use, chronic mental illness, and injury compared to men who did not experience abuse. The present investigation provides new information on IPV directed toward men. It examines the period prevalence of different types of IPV, the number of abuse occurrences and abusive partners, and the severity and duration of the IPV in an age-stratified sample of men insured by a large, integrated healthcare system. The relationship between IPV and health status is also explored, using well-validated health measures to add to the previous findings of such a relationship. This study builds on prior studies of IPV prevalence and health consequences among 3429 women aged 18 – 643,4 and 370 women aged 65 and older21 insured by the same health plan at the same time.
Methods Study Setting The setting was Group Health, a nonprofit, integrated healthcare system in the northwest U.S. serving an insured population of approximately 530,000 patients. Study procedures were approved by Group Health’s IRB. Analyses were conducted in 2007.
Study Design, Subject Selection, and Data Collection A random sample of English-speaking men aged ⱖ18 was interviewed by telephone between December 2003 and August 2005 about their health and adult experiences with IPV. English-speaking men who had been enrolled at Group Health for at least 3 years were randomly sampled without replacement from enrollment files and were invited to participate. The 3-year enrollment criterion was necessary to compare healthcare utilization and costs between people with and without IPV experiences.9 After a potential participant received an introductory letter describing the study as a general wellness study, he was called on the telephone by study staff who described the study procedures and, if the
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man was interested, obtained his informed consent to participate. Respondents were paid $25 for their participation. Preliminary analysis of an initial random sample of 200 men who completed the survey suggested that approximately 15% of men aged 18 –54 had experienced IPV in the prior 5 years, compared to 2% of men aged 55 and older. Because of this disparity in age-specific prevalence, the remaining sample was age-stratified, oversampling the older group to increase the precision in the 5-year prevalence estimate to within 2% of the point estimate. The analysis was limited to the 440 Group Health patients (204 men aged 18 –54 and 216 men aged 55 and older) who completed the survey.
Measures of Intimate Partner Violence Intimate partner violence was defined as actual or threatened physical, psychological, and sexual violence used by an intimate partner to cause harm or trauma.22 Intimate partners included present or past, heterosexual or homosexual, marital or nonmarital partners. Consistent with the definition used by the CDC, intimate partnerships did not have to include sexual activity.22 For each respondent, a partnership history since he was aged 18 was constructed by asking about the beginning and ending year of each relationship. Each respondent was also asked to estimate the total number of intimate partners in his adult lifetime. To minimize respondent burden, the men were asked detailed information only about their three most recent relationships. Using those three, a complete relationship history for the prior 5 years was constructed for 98.2% of the respondent men. The occurrence of IPV was assessed by using five questions from the U.S. Behavioral Risk Factor Surveillance System (BRFSS) survey14 –16,23,24 (Table 1). The BRFSS questions assess exposure to abusive behavioral tactics, including physical violence (hitting, kicking, and slapping [one question]); sexual violence (forced intercourse and other unwanted sexual contact [two questions]); and psychological— nonphysical—violence (threats and anger [one question], and controlling behavior, name calling, and put downs [one question]). Reports of IPV events using the BRFSS were categorized by their time of occurrence (past year, past 5 years, or adult lifetime) and abuse type (physical, sexual, or
Table 1. Intimate partner violence questions from the BRFSS survey Measure/Content Physical (three questions) Physical: Has an intimate partner ever hit, slapped, shoved, choked, kicked, shaken, or otherwise physically hurt you? Sexual: Has an intimate partner ever forced you to participate in a sex act against your will? Sexual: Has an intimate partner ever threatened, coerced, or physically forced you into any sexual contact that did not result in intercourse or penetration? Nonphysical (two questions) Threats: Have you ever been frightened for your safety, or that of your family or friends, because of anger or threats of an intimate partner? Controlling behavior: Has an intimate partner ever put you down, or called you names repeatedly, or controlled your behavior? BRFSS, Behavioral Risk Factor Surveillance System
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psychological). For each BRFSS abuse type, the men reported the number of abusive partners, the total number of abuse events, and the abuse duration. Respondents rated the severity of each abuse type (across all events and partners) on a 4-point ordinal scale from 1 (did not consider it violent) to 4 (considered it extremely violent).25
Health Status and Social Connectedness Twenty questions from the Short Form-36 Health Survey, version 2 (SF-36v2) were used to assess the men’s perceptions of their health status, including general health, vitality, mental health, emotional health, and social functioning.26 The survey was limited to 20 of the original 36 questions to minimize respondent burden. A subset of these questions was aggregated and standardized (with M⫽50, SD⫽10) to form the physical component summary and mental component summary scores as described by the survey developers.26 General health status was dichotomized into poor/fair and good/very good/excellent health.4 Depression was assessed, using five questions (scored from 0 to 3) from the Center for Epidemiological Studies-Depression (CES-D) scale.27 Item scores were totaled, with a sum of 4 – 6 or 7–15 indicating minor and severe depressive symptoms, respectively.27 The men’s responses to questions about 14 physical symptoms were scored on a 5-point Likert scale, and the total number of symptoms bothering them at least some of the time during the past 6 months was calculated.28 Social connectedness was assessed by asking the men to indicate their involvement in voluntary groups (not active versus somewhat/very active) and their trust of people in their residential communities (not/a little trusting versus quite a bit/very trusting).29 –31
Other Variables Each respondent was asked about his race, ethnicity, income, employment, education, household composition, and residence. Because research has established a link between IPV and a history of childhood abuse32 or the witnessing of IPV as a child,33,34 respondents were also asked about experiences before they were aged 18 of either physical or sexual abuse or of witnessing IPV between their parents or guardians.
Analysis Period prevalence of IPV in the past year, the past 5 years, and the adult lifetime among insured men was estimated using the BRFSS questions. The BRFSS abuse tactics were classified by type as physical (hitting, kicking, slapping, forced intercourse, or unwanted sexual contact) or nonphysical (threats, anger or controlling behavior, or both). Frequencies and measures of central tendency were used to summarize IPV frequency, duration, and severity. Because men aged 55 and older were oversampled to provide more precise periodprevalence estimates, both age-stratified and overall prevalence estimates were calculated. To compute the overall prevalence rates, sampling weights were used in the analysis to weight the surveyed sample to match the age distribution of the insured population of adult males at Group Health. In addition, because of the low response rate in this population (43.5%), additional IRB approval was obtained to collect a limited set of automated sociodemographic and pharmacy data for both respondents and nonrespondents to
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assess and adjust for potential nonresponse bias. Using the total sample (respondents and nonrespondents), multivariate logistic regression was used to estimate the probability that an individual would choose to participate (propensity score35) based on his age, enrollment length at Group Health, and chronic disease burden, using the RxRisk system.36 RxRisk is a validated, resource-based, case-mix model that uses automated, ambulatory pharmacy data to identify and weight select chronic conditions. RxRisk scores were calculated for the study sample using prescription drug profiles during the 6 months prior to subject sampling. The estimated probability of study participation did not differ significantly by IPV exposure status (0.441 in men reporting IPV vs 0.43 in men reporting no IPV; p⫽0.57). Nonetheless, all analyses were propensity-score adjusted to reduce potential bias in the study results due to nonresponse. Prevalence estimates with relative standard errors (RSE) over 30% may be unreliable. Estimates with RSE⬎30% are marked with an asterisk (Table 5) and should be used with caution. Weighted ordinary least-squares regression was used to examine differences in the SF-36v2 subscales and in the number of symptoms reported by men exposed to lifetime physical and nonphysical IPV according to the BRFSS questions compared to men with no IPV exposure since they were aged 18 (reference group). Regression models were run separately for men aged 18 –54 and men aged 55 and older, and were adjusted for age, income, and abuse as a child. Multivariate logistic regression models were used to test for differences in depression symptomatology and social connectedness by IPV exposure groups.
Findings A total of 1094 men meeting the eligibility criteria were sampled from the Group Health enrollment files. Sixty men were excluded because of sampling error (25), death (4), language and hearing problems (22), and severe illness (9). Of the remainder, 349 men (33.8%) refused to participate, 38 (3.7%) were located but not interviewed, and 197 (19.1%) were not able to be interviewed after eight phone attempts made at different times of the day. Informed consent was obtained to undertake telephone interviews with 450 men (participation rate⫽43.5%). Five participants were excluded (1.1%) because they did not complete the entire interview. Complete interviews were collected on 445 men. An additional 25 men (5.6%) were excluded because they had not had an intimate partner since they were aged 18 and thus were not eligible for IPV exposure, resulting in an analytic sample of 420 men. Respondents had relatively high income and educational levels (Table 2). The study population was 81.6% white and 3.6% (reported) Hispanic ethnicity, which is comparable to the adult population in Washington State, at 83.9% and 6.0%, respectively.37 The mean number of household members (2.69; SD⫽⫺1.33) is similar to national estimates (M⫽2.59). A total of 85.2% of the sample reported having a current intimate
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Table 2. Characteristics of the study sample Age group
Age, M (SD) Race (%) Caucasian African American Asian/Pacific Islander American Indian/Alaska native Multiracial or other Hispanic ethnicity Household income ($; %) ⬍25,000 25,000–49,999 50,000–74,999 ⬎75,000 Employment (%) Full-time Part-time Retired Unemployed or other Education: high school graduate or less (%) In a current intimate partner relationship (%) Children in home for whom respondent is guardian (%) Number in household, M (SD) Urban residence (%) Gender of current partner/most recent partner (%) Male Female Did not specify Experienced childhood abuse (physical or sexual) (%) Witnessed IPV as a child (%)
18–54 nⴝ204
55ⴙ nⴝ216
Total Nⴝ420
40.9 (10.9)
65.9 (8.5)
53.8 (15.9)
82.2 5.9 3.5 2.0 4.5 4.9
89.8 0.9 3.7 1.9 1.4 2.3
86.1 3.4 3.6 1.9 5.0 3.6
10.5 18.4 22.9 48.3
12.8 36.0 24.2 27.0
11.7 27.4 23.5 37.4
85.8 6.9 0.5 6.8 10.8 85.8 41.9 3.2 (1.4) 93.0
34.3 14.4 48.2 3.1 11.6 84.7 6.0 2.2 (1.0) 88.5
59.3 10.7 25.0 5.0 11.2 85.2 23.4 2.7 (1.3) 90.7
3.4 94.6 2.0 19.7 14.4
2.3 96.3 1.4 17.2 14.6
2.9 95.5 1.7 18.4 14.5
IPV, intimate partner violence
Period Prevalence of Intimate Partner Violence
partner, of which 95.5% were women. A total of 18.4% of the men reported a history of childhood physical or sexual abuse, and 14.5% had witnessed IPV as children.
Of men aged 18 –54, 14.2% reported experiencing IPV in the past 5 years, and 6.1% reported IPV in the past
Table 3. Period prevalence of IPV by type as delineated by the BRFSS Physical IPV Time Period Past 12 months
Age group
N
Est.a
n
b
18–54 55⫹
204 216
6 0
2.9 0.0
Past 5 years
All 18–54 55⫹
420 204 216
6 17 2
1.6b 8.8 1.0b
Adult lifetime
All 18–54 55⫹
420 204 216
19 42 28
All
420
70
95% CI 0.5–5.2 —
Nonphysical IPV RSE
Est.a
n
b
95% CI
Any BRFSS IPV RSE
Est.a
n
41 —
8 5
4.1 2.4b
1.3–7.0 0.3–4.6
37 46
12 5
0.3–3.0 4.7–12.9 0.0–2.3
44 24 70
13 16 9
3.4 8.0 4.3b
1.5–5.3 4.1–11.8 1.5–7.1
29 25 33
17 28 11
5.5 20.8 13.3
3.0–7.9 15.0–26.5 8.7–17.9
22 14 17
25 40 40
6.4 18.6 18.9
3.9–8.9 13.2–24.0 13.6–24.3
20 15 14
17.6
13.7–21.4
11
80
18.7
14.9–22.5
10
6.1 2.4b
95% CI
RSE
2.7–9.6 0.3–4.6
28 46
4.6 14.2 5.3
2.4–6.7 9.2–19.3 2.2–8.4
24 18 30
39 63 56
10.4 30.5 26.5
7.2–13.6 23.9–37.0 20.5–32.5
15 11 11
119
28.8
24.3–33.3
8
a
Estimated percentage adjusted for propensity scores and sampling weights This estimate should be used with caution. Estimates with RSE ⬎30% may be unreliable. BRFSS, Behavioral Risk Factor Surveillance System; IPV, intimate partner violence; RSE, relative standard error.
b
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Table 4. Frequency, severity, and duration of IPV over the adult lifetime (N⫽120) Aged 18–54 Physical IPV
Nonphysical IPV
Physical IPV
Nonphysical IPV
nⴝ42
nⴝ40
nⴝ28
nⴝ40
n Number of different abusive partners One Two or more Number of different occurrences of abuse One 2–5 ⱖ6 Severity of abuse Not violent Slightly violent Moderately violent Extremely violent Years encompassed by IPV ⬍1 1–2 3–5 6–10 ⬎10 Years of abuse M (SD) 25th percentile 50th percentile 75th percentile
Aged 55ⴙ
%
%
n
%
n
n
%
37 5
88.1 36 11.9 4
90.0 10.0
25 2
92.6 7.4
33 7
82.5 17.5
12 22 8
28.6 3 52.4 12 19.0 24
7.7 30.8 61.5
10 10 7
37.0 37.0 25.9
3 10 27
7.5 25.0 67.5
19 14 7 2
45.2 22 33.3 10 16.7 6 4.8 2
55.0 25.0 15.0 5.0
8 8 8 3
29.6 29.6 29.6 11.1
16 8 11 5
40.0 20.0 27.5 12.5
19 8 4 4 5
47.5 7 20.0 13 10.0 10 10.0 3 12.5 6
18.0 33.3 25.6 7.7 15.4
15 2 5 1 3
57.7 7.7 19.2 3.9 11.5
11 4 7 7 11
27.5 10.0 17.5 17.5 27.5
4.1 (7.6) ⬍1 1 3
5.1 (7.0) 1 2 5
3.2 (5.8) ⬍1 ⬍1 4.25
9.3 (11.5) ⬍1 5 14.75
IPV, intimate partner violence
year (Table 3). Among men aged 55 and older, 5.3% and 2.4% reported IPV in the past 5 years and past 1 year, respectively. A total of 28.8% of the men (30.5% of men aged 18 –54 and 26.5% of men aged 55 and older) reported physical and nonphysical IPV in their adult lifetimes. Because none of the survey respondents reported sexual IPV (forced intercourse or unwanted sexual contact) in the past 5 years, and only two men (0.5%) reported sexual IPV in their adult lifetimes, violence was divided into two broad types: physical IPV (hitting, kicking, slapping, and forced intercourse or unwanted sexual contact) and nonphysical IPV (threats, anger or controlling behavior, or both). In the past 5 years, 5.5% of the men reported physical IPV, and 6.4% reported nonphysical IPV. In the past year, 1.6% and 3.4% reported physical and nonphysical IPV, respectively. Men aged 18 –54 were more likely to have experienced abuse in the past 5 years (14.2%) compared to men aged 55 years or older (5.3%; p⬍0.01) When prevalence was compared for men of different ages by IPV type, differences were found for physical IPV (8.8% of men aged 18 –54 versus 1.1% of men aged 55 or older; p⬍0.01) but not nonphysical IPV (8.0% versus 4.3%; p⫽0.13). 482
Characteristics of Intimate Partner Violence Fewer than 15% of the men had experienced IPV by multiple partners during their lifetimes, and no differences were seen by type of abuse according to age (Table 4). Overall, most abused men reported multiple IPV occurrences; 68.1% of men with physical IPV and 92.4% of men with nonphysical IPV reported more than one episode. Across all respondents, 39.1% who reported physical IPV said that it was nonviolent, 31.9% reported that it was mildly violent, and 29% reported that it was moderately or extremely violent. Younger men were less likely than older men to report violent experiences for physical IPV (21.4% versus 40.7%; p⫽0.08) and nonphysical IPV (20% versus 40%; p⫽0.05). Most physical IPV lasted less than a year in duration. Nonphysical IPV was more persistent, with only 18.0% (aged 18 –54) and 27.5% (aged 55 and older) of the men reporting durations of less than 1 year (p⫽0.31).
Health Outcomes and Intimate Partner Violence Of men aged 55 and older, those who had experienced physical IPV in their lifetimes had lower adjusted mean SF-36v2 scores for mental health (⫺5.86), vitality
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Table 5. Health status, symptoms, and social connectedness by IPV type compared to men with no IPV Aged 18–54
Aged 55ⴙ
Physical IPV vs Nonphysical IPV vs Physical IPV vs Nonphysical IPV vs no IPV ever no IPV ever no IPV ever no IPV ever Differencea,b (95% CI) Differencea,b (95% CI) Differencea,b (95% CI) Differencea,b (95% CI) SF-36v2 subscale Role-emotional Vitality Mental health Social functioning Physical component summary Mental component summary Number of symptom in past 6 monthsc
ⴚ2.76 (ⴚ5.30,ⴚ0.23) ⫺1.34 (⫺4.46,1.79) ⫺2.28 (⫺4.83,0.25) ⴚ2.53 (ⴚ4.99,ⴚ0.06) 0.00 (⫺2.78,2.79)
⫺1.79 (⫺4.47,0.89) ⫺0.93 (⫺4.33,2.47) ⫺0.95 (⫺3.39,1.50) ⴚ2.51 (ⴚ4.91,ⴚ0.11) 1.67 (⫺1.18,4.53)
⫺2.49 (⫺5.67,0.69) ⴚ3.48 (ⴚ6.48,ⴚ0.48) ⴚ5.86 (ⴚ9.33,ⴚ2.40) ⫺0.40 (⫺3.17,2.37) ⫺0.75 (⫺4.63,3.14)
⫺1.25 (⫺4.01,1.52) ⫺1.54 (⫺4.52,1.44) ⴚ3.21 (ⴚ5.92,ⴚ0.50) 0.35 (⫺2.33,3.06) 1.13 (⫺2.26,4.52)
⫺2.74 (⫺5.52,0.04)
⫺3.03 (⫺6.15,0.09)
ⴚ4.70 (ⴚ7.91,ⴚ1.48)
⫺1.83 (⫺4.54,0.87)
0.21 (⫺0.55,0.98)
0.11 (⫺0.64,0.87)
⬎PRa (95% CI) General health Fair/Poor Depression (CES-D) Depressive symptoms Severely depressed Social connectedness Not active in voluntary groups Do not trust people in community
PRa (95% CI)
0.68 (⫺0.03,1.38) PRa (95% CI)
0.44 (⫺0.31,1.19) PRa (95% CI)
0.70 (0.22,2.23)
0.66 (0.19,2.33)
1.91 (0.94,3.90)
1.08 (0.51,2.28)
1.20 (0.54,2.64) 1.15 (0.31,4.27)
0.62 (0.18,2.18) 0.55 (0.08,3.79)
2.80 (1.23,6.34) 3.14 (1.06,9.32)
2.61 (1.28,5.34) 2.22 (0.74,6.73)
0.94 (0.60,1.49)
0.72 (0.37,1.40)
1.17 (0.78,1.75)
1.20 (0.85,1.70)
1.31 (0.73,2.34)
1.64 (0.93,2.89)
1.26 (0.54,2.96)
1.33 (0.61,2.92)
Note: Bolded values are statistically significant. a Adjusted for age, income, any abuse as a child, and propensity scores and sampling weights b Difference⫽difference in means, compared to no-IPV-ever group c 14 possible symptoms: joint pain, back pain, insomnia, fatigue, abdominal pain, severe headache, numbness in hands or feet, diarrhea, constipation, shortness of breath, facial or jaw pain, dizziness, nausea or vomiting, and chest pain CES-D, Center for Epidemiological Studies-Depression scale; PR, prevalence ratio.
(⫺3.48), and mental component summary (⫺4.70) compared to men with no IPV (Table 5). Physically abused older men were also 3.1 times more likely to report severe depressive symptoms and 2.8 times more likely to report minor depressive symptoms than were non-abused older men. Older men with nonphysical IPV were also 2.6 times more likely to report minor depressive symptoms, and had a lower SF-36v2 mental health score (⫺3.21) compared to older men with no IPV. No significant differences were found for the remaining SF-36v2 scores (role-emotional, social functioning, and physical component summary), symptoms, general health status, or degree of social connectedness in men with either physical or nonphysical IPV compared to older men with no IPV. Of men aged 18 –54, those with physical and nonphysical IPV had lower social functioning than neverabused men, with adjusted differences of ⫺2.74 and ⫺2.51, respectively (Table 5). Younger men with physical IPV also had a significantly lower role-emotional score (⫺2.76). As with older men, younger men with IPV did not report compromised physical health compared to non-abused men. June 2008
Interpretation This study provides new data on the prevalence, chronicity, severity, and health implications of IPV in men. Overall, 28.8% of adult men who were insured by a large health plan reported having experienced either physical or nonphysical IPV in their adult lifetimes. This figure is similar to the 23% estimated in a national survey that used a similar abuse definition13 but is approximately 15% lower than the 44% of women aged 18 – 64 insured by the same health plan who reported IPV.3 Among the men studied, 17.6% reported lifetime physical IPV, which falls at the upper end of the range reported in prior studies15 that assessed physical and sexual IPV.38 Of note is the fact that fewer than 1% of the men reported lifetime sexual IPV. This result stands in stark contrast to findings from studies of women, in which sexual violence is more commonly reported and has strong associations with poor health.3,6,13 Confirming prior findings,14,15 this study found that younger men were more likely than older men to report recent IPV, particularly physical IPV, for which there was a more-than-eight-fold difference in 5-year prevalence. Violence for most men was limited to a single Am J Prev Med 2008;34(6)
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partner. However, multiple abuse occurrences over time were the norm. In contrast with the IPV experienced by women,3 the abuse reported by men was much less severe, corroborating prior findings.18,38,39 The study’s results also provide new information on the relationship between IPV and health status for men.40,41 As opposed to the experience of women, for whom adverse health effects were present across physical and mental health domains, the health deficits in (mainly older) men were seen primarily for mental health. It was noted that while men with physical IPV had lower SF-36v2 mental health, vitality, and mental component summary scores compared to non-abused men, the mean scores for abused men were approximately 50 (data not shown)—the mean for the SF-36v2 scores derived from the general U.S. population. Scores for non-abused men were above 50, indicating betterthan-average health. The increased rate of severe depressive symptoms for physically abused older men (prevalence ratio⫽2.8) is higher than previous estimates of 1.9 (adjusted OR) for physically abused men aged 18 – 65.13 In contrast to findings for women in the same health plan,4 the lack of a relationship among physical IPV and the SF-36v2 physical scale and reported symptoms may suggest that the abuse that most men experience does not interfere with their physical well-being. However, it is possible that the small sample size precluded having sufficient power to detect substantial differences between groups. Further research with larger samples is needed to explore this issue. Because the respondents were sampled from a highly educated population with healthcare insurance, the results may not pertain to uninsured populations or those with different demographic mixes. The low response rate (43.5%) could introduce bias in studies such as this, although a low response rate is not necessarily a source of bias.42 However, analyses were adjusted using propensity scores to account for potential response bias based on age, duration of enrollment, and case-mix ascertained from prescription-drug utilization profiles. It is important to note that this method of accounting for response bias is not sufficient when the probability of participation depends on the outcome’s being of interest. In fact, it is plausible that IPV is itself a determinant of participation; however, the estimated probability of study participation did not differ by IPV-exposure status. The sample size also did not permit the examination of the temporal sequencing between IPV exposure and health outcomes. Because the men were asked to remember events that may have occurred long ago, the findings may underrepresent the occurrence of events in the distant past. As such, the estimates of lifetime prevalence may be biased downward for older men compared to younger men, and may explain the lowerreported lifetime prevalence found for older men. Finally, abused men were not asked about the reciproc484
ity of violence with their intimate partners. Because many couples report that violence is bi-directional,32,39 it is possible that a portion of the IPV directed at the men by their partners is self-protective. The study’s findings suggest that men experience IPV at moderate rates and may have poor mental health associated with such experiences. The findings also suggest that the failure of healthcare personnel to ask about and acknowledge men’s experiences of IPV may be shortsighted. Asking men about IPV may open a conversational space about abuse—perhaps bi-directional in nature—that may be occurring in their relationships. However, further research is needed to test the effectiveness of different intervention strategies for men experiencing intimate partner abuse. Authors Reid, Bonomi, Rivara, Thompson, Fishman, and Carrell receive research support from the Agency for Healthcare Research and Quality. Drs. Reid and Thompson also received salary support from the Group Health Permanente medical group during the course of this study. This analysis was supported by the Agency for Healthcare Research and Quality (Grant R01 HS10909) and the Group Health Cooperative Center for Health Studies. The Center for Health Studies was involved in the design and conduct of the study, collection, management, analysis, and interpretation of the data. The authors thank the interviewers from Group Health’s Center for Health Studies who telephoned and interviewed the men.
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