Screening for intimate partner violence should form part of sexual health services to reach vulnerable gay men.
Newly analysed data from the PROUD trial reveals high rates of intimate partner violence (IPV) among gay, bisexual and other men who have sex with men taking pre-exposure prophylaxis (PrEP) in the United Kingdom.
Intimate partner violence (IPV) is defined as physical, sexual, or psychological harm by a current or former partner or spouse. The study looked at both experiences of perpetration and victimisation. In the United States, a body of evidence is building about minority population stress and how this is impacting partner violence in men who have sex with men. But little is known about the impact among men in the UK.
PROUD was a real-world, randomised control trial looking at PrEP efficacy among men who have sex with men in the UK. As part of the PROUD study, data was collected on IPV and whether the trial had influenced experiences of IPV. This was included after initial concerns that PrEP use could have a negative effect with men coming under increased pressure to have sex without a condom. Data was not collected at baseline but was incorporated into general PROUD 12- and 24-month questionnaires.
Ten questions queried experiences of lifetime IPV or IPV in the last year, and IPV with a current or former partner in the last year. Questions focusing on victimisation included asking if they feared their partner’s behaviour, if they needed permission to do certain activities, if they’d been physically abused, if they’d been forced to engage in sexual activity, or if they’d been forced to not wear a condom. The reverse questions were asked to assess perpetration.
Other data collected and analysed in relation to IPV included, clinically significant depressive symptoms, sexual behaviour measures, drug use during sex, age at first anal sex and measures of internalised homophobia.
The completed analysis was based on 436 men who completed either a 12- or 24-month questionnaire. In total answers from 743 questionnaires were analysed. The large majority (96%) of the men identified as gay and white ethnicity (82%), while the median age of the participants was 37 years.
The prevalence of IPV was very high in this group of men, with 44.9% experiencing lifetime IPV victimisation and 15.6% in the last year. Perpetration was also high, at 19.5% for lifetime perpetration and 7.8% in the last year. The results revealed that IPV was strongly associated with sexualized drug use, internalized homophobia, and current symptoms of depression, but not with measures of condomless anal sex.
Lifetime and past year measures of IPV perpetration were strongly associated with younger age and sexualized drug use. Having been a victim of IPV was also strongly associated with IPV perpetration. Lifetime IPV perpetration was more than eight times higher in men who reported also being a victim, and the prevalence of past year IPV perpetration was almost 14 times higher in men who reported victimisation compared to men who did not.
Prevalence of depressive symptoms was almost twice as high among men who had experienced being victims of IPV, compared to those with no experience of IPV. While for men who had experienced both victimisation and perpetration depressive symptoms were almost three times as high.
The overall data is higher than estimates from a cross-sectional survey among London GUM clinics – which estimated 34% and 16.3% for lifetime victimisation and perpetration respectively. However, following interviews conducted after the survey, researchers suspected that IPV was underestimated in this population. Another online survey of men who have sex with men estimated 36% for lifetime victimisation.
The authors hypothesised that the elevated rates in the current study may be the result of men feeling more comfortable disclosing IPV within the clinical trial environment and because they had regular contact with clinic staff. They also note that differences could be the result of the unique behavioural profile of the men participating in the trial. High rates of sexually transmitted infections (STIs), recreational drug use and condomless anal sex at baseline may have all been linked to experience of IPV. It is for this reason that the authors cannot say that the results are generalizable for the rest of the UK.
But there are questions, given this current study and data from elsewhere, about the impact of sexual minority stress and what impact this may have on IPV. The authors commented, “The impact of homophobia not only on one’s mental health but also on dynamics within intimate partnerships needs to be highlighted… The stress associated with social pressure to conform to heteronormative behaviours may play some role in IPV perpetration among gay and plurisexual identified men.”
The investigators call for better awareness of IPV in men who have sex with men and for UK GUM clinic staff to be aware of the common indicators, enquire sensitively about violence, and be able to refer patients to further support where necessary.