Prevalence of Substance Use and Intimate Partner Violence in a Sample of A/PI MSM

Abstract

This study evaluates the prevalence of three forms of intimate partner violence (IPV) (i.e., experience of physical, psychological/symbolic, and sexual battering) among a national sample of Asian/Pacific Islander (A/PI) men who have sex with men (MSM) in the United States and identifies their characteristics. The study also reports the differences of substance use behavior between MSM with and without a previous history of IPV. Our sample was recruited through venue-based sampling from seven metropolitan cities as part of the national Men of Asia Testing for HIV (MATH) study. Among 412 MSM, 29.1% experienced IPV perpetrated from a boyfriend or same-gender partner in the past 5 years. Within the previous 5 years, 62.5%, 78.3%, and 40.8% of participants experienced physical, psychological/symbolic, and sexual battering, respectively. Collectively, 35.8% of participants reported that they have experienced at least one type of victimization and 64.2% have experienced multiple victimizations (two or three types of battering victimization). Overall, 21.2% of our sample reported any substance use within the past 12 months. The present findings suggest that individuals with a history of IPV in the past 5 years were more likely to report substance use (33.6%) compared to those without a history of IPV experience (16.1%).

Keywords

substance use intimate partner violence (IPV)battering men who have sex with men (MSM)

Introduction

Intimate partner violence (IPV) is a serious public health problem nationwide. According to the National Intimate Partner and Sexual Violence Survey Report in 2010, 35.6% of women and 28.5% of men in the United States have experienced rape, physical violence, and/or have been stalked by an intimate partner at least once in their lifetime (Balsam, Rothblum, & Beauchaine, 2005; Black et al., 2011; Carvalho, Lewis, Derlega, Winstead, & Viggiano, 2011; Messinger, 2011; Rhodes, McCoy, Wilkin, & Wolfson, 2009). The U.S. Centers for Disease Control and Prevention (2012) defines IPV as “physical, sexual, or psychological harm by a current or former partner or spouse.” IPV, however, is not limited to sexual intimacy nor does it only occur among heterosexual couples—it can also exist within same-sex relationships.

Although many studies have examined the impact of IPV among heterosexuals, very few have explored its impact among same-sex relationships, particularly among men who have sex with men (MSM; Burke & Follingstad, 1999; Coleman, 1994; Greenwood et al., 2002; Houston & McKirnan, 2007; Letellier, 1994; Seelau, Seelau, & Poorman, 2003). While limited, research has found various forms of IPV among gay and MSM populations. For instance, a past survey of nearly 3,000 MSM discovered 5-year rates of abuse to be 34% (psychological), 22% (physical), and 5.1% sexual (Greenwood et al., 2002). Previous prevalence estimates of IPV among MSM range from 12% to 36% (Tjaden, Thoennes, & Allison, 1999; Waldner-Haugrud, Gratch, & Magruder, 1997; Waterman, Dawson, & Bologna, 1989), and other studies have shown that rates of physical IPV are higher among gay men than heterosexual men (Greenwood et al., 2002; Tjaden et al., 1999). Compared to heterosexual couples, a knowledge gap regarding the overall impact of MSM experiencing IPV still exists.

IPV research among MSM, however, is even more limited when considering populations of racial and ethnic minorities. For example, previous IPV studies (Houston & McKirnan, 2007) were limited to mostly white MSM and contained very few Asian and Pacific Islanders (A/PI) though reports of current and past IPV did not vary by ethnic groups. Past research has identified disparities among racial and ethnic MSM minority groups concerning rates of human immunodeficiency virus (Bochow, 2012; Raymond et al., 2007), but the toll of IPV on minority MSM is still unclear.

The toll of substance use among MSM individuals with previous IPV experience is also lacking. Though past studies suggest that recent and frequent use of marijuana, cocaine, crack, heroine, and illicit tranquilizers are associated with experience of IPV among women (Brewer, Fleming, Haggerty, & Catalano, 1998; El-Bassel, Gilbert, Rajah, Foleno, & Frye, 2001; El-Bassel, Gilbert, Schilling, & Wada, 2000), the relationship between IPV experience and substance use among MSM remains unclear. Nevertheless, studies suggest the prevalence of substance use among MSM populations is high. For example, in a survey of urban MSM from four large American cities, researchers found a high prevalence (52%) of recreational drug use as well as frequent drug use (19%) (Stall et al., 2001). Others found that individuals with same-sex partners were more likely to use substances than those with opposite-sex partners (Cochran & Mays, 2000). Most studies, however, show a relationship between substance use and increased sexual risk among MSM (McCusker et al., 1990; Stall, McKusick, Wiley, Coates, & Ostrow, 1986; Woody et al., 1999). To the best of our knowledge, no previous study has examined the relationship between substance use and experience of IPV among a sample of A/PI MSM.

The objective of this study is to add to the limited research available that illustrates the impact of IPV on same-sex relationships, particularly among minority MSM. The aims of this study were (1) to evaluate the prevalence of three forms of IPV (i.e., experience of physical, psychological/symbolic, and sexual battering) among a national sample of A/PI MSM and identify the characteristics of these men and (2) to examine the differences of substance use behavior between MSM with and without a previous history of IPV.

Method

Patient Population and Data Collection

The current study analyzed data collected as part of a national study of A/PI MSM known as Men of Asia Testing for HIV (MATH) (Wong et al., 2011; Wong et al., 2012). The MATH study was a community-based participatory research design and recruited men from seven community-based organizations in seven metropolitan cities (Boston, Los Angeles, New York City, Oakland, Philadelphia, San Francisco, and San Jose) from June 2007 to August 2009. Eligible participants included men ages 18 years and older who self-identified as A/PI ethnicity; had sex with another man in the last 12 months; had resided in the targeted city in the last 6 months; were able to provide verbal and written informed consent in English, Chinese, or Vietnamese; and were willing to participate in HIV screening and confirmatory testing.

The MATH study carried out broad-based recruitment strategies to refer participants into the study, including (1) standard outreach, such as distributing study flyers and postcards in gay bars, venues, and other public sex areas; (2) announcements via mainstream (e.g., gay pride) and racial/ethnic-specific gay events; and (3) announcements via the Internet. In short, participants in the MATH study constituted a purposive (i.e., deliberate and nonrandom) convenience sample of men who met the inclusion criteria. Once referred, each of the men scheduled a time to come to the study site in their respective cities. Upon arriving to the study sites, the men were guided through an informed consent process before any data were collected in a private office dedicated to the project.

Measures

Demographics

Participants self-reported their age, age when they first realized their attraction to men, age at first intimate physical contact with another man, age they moved to the United States, nativity, sexual orientation, location, and racial/ethnic group. They were also asked if they had any form of sexual contact with a woman and if they have been previously tested for HIV.

IPV

MATH participants completed a survey that asked them to report any unwanted physical, sexual, or emotional violence from an intimate boyfriend or same-gender partner during the past 5 years. To define IPV, our analysis used three items of victimization base on similar work by Greenwood and colleagues (2002). Physical battering was defined as being hit or having something thrown at him. Sexual battering was defined as having been forced to have sex. Lastly, psychological/symbolic battering was defined as having experienced at least one of the following: being threatened to stop receiving assistance in the form of money or housing, being verbally threatened to be harmed physically or emotionally, being verbally threatened to physically harm someone the participant cares for, having properly destroyed or damaged, or being threatened to expose to others about the participant’s sexuality.

Substance use

All participants were asked about their use of any of the following substances (yes/no response) in the past 12 months: methamphetamine, cocaine, crack, marijuana, poppers, ecstasy, GHB, Special K, LSD, Downers, opium, and heroine.

Statistical analysis

MATH data were exported to PASW Statistics (Version 18.0) for statistical analysis. Descriptive statistics were used to summarize the sociodemographical variables of the sample. Bivariate methods were used to compare demographic characteristics and substance use of MSM by IPV exposure status. The prevalence of all types of IPV, including each item, was reported for the total sample. Lastly, a spearman correlation coefficient was used to assess the relationship between psychosocial characteristics, substance use, and intimate partner violence.

Results

Demographic characteristics of the sample are outlined in Table 1. A total of 457 participants completed the MATH Study. Forty-five participants (9.8%) did not have documented information about IPV on the data form and were excluded. Overall, 29.1% of the 412 participants reported having experienced IPV from a boyfriend or same-gender partner in the past 5 years. Compared with MSM with no IPV ever, MSM who reported any IPV were significantly younger at the time of survey (M = 28.0, SD = 9.0, p = .01) and when they had their first intimate physical contact with another man (M = 16.3, SD = 4.7, p < .01). Those who self-identified as Asian American were significantly more likely to report having experienced IPV (31.6% vs. 25.0%), while those who self-identified as East Asian were significantly less likely to report having experienced IPV (15.4 vs. 31.6, p = .009). MSM with IPV (91.5%) were more likely to have been tested for HIV compared to MSM with no IPV (84.2%, p = .05).

Table 1.

Demographic Characteristics of Asian/Pacific Islander MSM by IPV Status.

	Overall	IPV	No IPV
Variables	(N = 412)	(n = 120)	(n = 292)	Significance
Age in years: M (SD)
Age at time of survey	30.0 (10.2)	28.0 (9.0)	30.8 (10.5)	F = 6.75, p = .01
Age when first realized attraction to men	11.5 (4.5)	11.7 (4.5)	11.4 (4.5)	F = 0.37, p = .54
Age at first intimate physical contact/physical sex with another man	17.6 (5.4)	16.3 (4.7)	18.2 (5.6)	F = 9.77, p = .002
Age when moved to the United States	14.7 (9.9)	12.7 (8.6)	15.5 (10.3)	F = 3.22, p = .074
Nativity: n (%)
U.S. born	194 (47.7)	59 (50.0)	135 (46.7)	χ²(1) = 0.36, p = .547
Non-U.S. born	213 (52.3)	59 (50.0)	154 (53.3)
Sexual orientation: n (%)
Gay	345 (84.4)	97 (80.8)	248 (85.8)	χ²(3) = 6.74, p = .081
Bisexual	53 (13.0)	22 (18.3)	31 (10.7)
Straight	6 (1.5)	0 (0.0)	6 (2.1)
Other	5 (1.2)	1 (0.8)	4 (1.4)
Location: n (%)
East Coast	59 (15.1)	17 (14.5)	42 (15.3)	χ²(1) = 0.035, p = .85
West Coast	333 (84.9)	100 (85.5)	233 (84.7)
Race: n (%)
Asian American	109 (26.9)	37 (31.6)	72 (25.0)	χ²(5) = 15.38, p = .009
Southeast Asian	147 (36.3)	45 (38.5)	102 (35.4)
East Asian	109 (26.9)	18 (15.4)	91 (31.6)
South Asian	3 (0.7)	1 (0.9)	2 (0.7)
Mixed	26 (6.4)	13 (11.1)	13 (4.5)
Hawaiian and Pacific Islander	11 (2.7)	3 (2.6)	8 (2.8)
Other variable: Yes: n (%)
Ever had any form of sexual/intimate contact with another man in your life	398 (97.3)	119 (99.2)	279 (96.5)	χ²(1) = 2.24, p = .14
Ever had any form of sexual/intimate contact with a woman	163 (40.0)	53 (44.2)	110 (38.2)	χ²(1) = 1.26, p = .26
Ever been tested for HIV	353 (86.3)	108 (91.5)	245 (84.2)	χ²(1) = 3.82, p = .05

Note. MSM = men who have sex with men; IPV = intimate partner violence.

Table 2 summarizes the prevalence rates for each form of battering, and the individual items defining them. During the previous 5 years, 62.5%, 78.3%, and 40.8% of participants experienced physical, psychological/symbolic, and sexual battering, respectively. The most common form of psychological/symbolic battering experienced by participants was being verbally threatened to be physically or emotionally harmed (55.8%). Collectively, 35.8% of participants reported that they have experienced at least one type of victimization and 64.2% have experienced multiple victimizations (two or three types of battering victimization).

Table 2.

Prevalence of IPV Victimization During the Past 5 Years (n = 120).

Variables	n (%) Yes
Physical
Being hit or having something thrown at him	75 (62.5)
Psychological/symbolic
Being threatened to stop helping him with money or with housing	22 (18.3)
Being verbally threatened to harm him physically or emotionally	67 (55.8)
Being verbally threatened to physically harm someone he cares for	20 (16.7)
Having property destroyed or damaged	48 (40.0)
Being threatened to tell others about his sexuality	20 (16.7)
Sexual
Having been forced to have sex	49 (40.8)
Any victimization (experience at least one type of victimization)	43 (35.8)
Multiple victimization (experience two or three types of victimization)	77 (64.2)

Note. IPV = intimate partner violence.

Table 3 outlines the prevalence of substance use in the past 12 months. Overall, 21.2% of our sample reported any substance use within the past 12 months. Participants with a history of IPV in the past 5 years were more likely to report substance use (33.6%) compared to those without IPV experience (16.1%). Although marijuana use had the highest prevalence (16.2%) among other substances, we did not find a significant difference in its usage between participants with and without IPV experience. Compared to those without IPV experience, however, participants with IPV experience were significantly more likely to report using the following substances in the past 12 months: ecstasy (18.5%, p < .001), cocaine (11.8%, p = .002), methamphetamine (9.5%, p = .002), GHB (5.7%, p = .003), LSD (4.8%, p = .003), downers (4.9%, p < .001), opium (3.8%, p = .009), and heroin (1.9%, p = .025). There was a statistically significant positive relationship between substance use and intimate partner violence (r = .20, p < .001).

Table 3.

Prevalence of Substance Use in the Past 12 Months by IPV Status.

	Overall	IPV	No IPV
Variables	(N = 396)	(n = 116)	(n = 280)	Significance
Substance use	84 (21.2)	39 (33.6)	45 (16.1)	χ²(1) = 15.12, p < .001
Marijuana	43 (16.2)	17 (22.7)	26 (13.6)	χ²(1) = 3.26, p = .071
Ecstasy	28 (8.5)	17 (18.5)	11 (4.7)	χ²(1) = 16.19, p < .001
Poppers	26 (8.0)	11 (11.6)	15 (6.6)	χ²(1) = 2.30, p = .13
Cocaine	19 (5.5)	11 (11.8)	8 (3.2)	χ²(1) = 9.64, p = .002
Methamphetamine	14 (4.1)	9 (9.5)	5 (2.0)	χ²(1) = 9.88, p = .002
Crack	10 (2.6)	5 (4.5)	5 (1.9)	χ²(1) = 2.18, p = .14
GHB	8 (2.2)	6 (5.7)	2 (0.8)	χ²(1) = 8.57, p = .003
Special K	6 (1.6)	2 (2.0)	4 (1.5)	χ²(1) = 0.12, p = .73
LSD	6 (1.6)	5 (4.8)	1 (0.4)	χ²(1) = 9.13, p = .003
Downers	5 (1.3)	5 (4.9)	0 (0.0)	χ²(1) = 13.24, p < .001
Opium	5 (1.3)	4 (3.8)	1 (0.4)	χ²(1) = 6.84, p = .009
Heroin	2 (0.5)	2 (1.9)	0 (0.0)	χ²(1) = 5.05, p = .025

Note. IPV = intimate partner violence; GHB = Gamma hydroxybutyrate; LSD = lysergic acid diethylamide.

Discussion

We aimed to bridge the current knowledge gap regarding IPV in same-sex relationships, particularly among racial/ethnic minority MSM. Our findings indicated that our diverse sample of A/PI MSM had a high prevalence of IPV (29.1%). Approximately two out of five MSM (35.8%) reported experiencing at least one type of IPV victimization and more than half experienced multiple victimizations. This discovery of a high IPV prevalence in our sample is consistent with findings from previous studies (Balsam et al., 2005; Carvalho et al., 2011; Greenwood et al., 2002; Messinger, 2011; Rhodes et al., 2009; Waldner-Haugrud et al., 1997).

Our second objective—to examine the differences of substance use behavior between people with and without IPV experience—found that MSM who experienced any IPV in the past 5 years were more likely to report substance use in the last 12 months compared to their counterparts. Our finding of a high prevalence of substance use among MSM is consistent with previous research (Stall et al., 2001), yet adds to the available literature as we exclusively studied A/PI MSM.

Additionally, our study has several weaknesses that deserve to be mentioned. First, members of our sample population were recruited via purposive sampling, and thus limit our ability to generalize the findings to the broader MSM population. Specifically, it is possible that our prevalence estimates of IPV may be underreported as MSM individuals who are homeless, less likely to attend the areas of recruitment, or are not actively engaged in social media may have been excluded and under-sampled. In addition, self-reported IPV victimization among East Asians may have been underreported due to the stigma associated with mental and physical health challenges. Fear of being stigmatized for having such conditions, for instance, may impede individuals from help-seeking behaviors (Leong & Lau, 2001).

Second, our study’s employment of a cross-sectional design limited our ability to establish causality. For example, although our findings suggest a stronger prevalence of substance use among those who reported a history of IPV victimization, our analyses do not prove that victimization leads to the use of such substances. It is possible that substance use may have been present prior to or concurrent with IPV victimization.

Last, our attempt to measure the prevalence of IPV victimization did not utilize standard items or a standard recall period. This limitation may potentially reduce the ability to compare our findings with national data.

Despite these limitations, this study’s results have several implications. First, our findings highlight and support previous studies that suggest IPV as a problem impacting not only heterosexual relationships but also same-sex couples, particularly MSM. Past IPV research have focused primarily on women as victims of IPV (Cohen et al., 2000; Coker, Smith, McKeown, & King, 2000) even though later studies have revealed comparable prevalence rates among men (Tjaden et al., 1999; Waldner-Haugrud et al., 1997). Thus, based on our own findings, we agree with Greenwood et al. (2002) who have argued that society needs to accept and understand that men are victims as well as perpetrators of violence (Letellier, 1994).

Due to our study’s limitations, further research aiming to determine the psychosocial predictors of IPV among A/PI MSM is warranted. Since more than half of the participants in our study were foreign-born, research assessing the role of acculturation, defined as the psychological and social changes that individuals experience upon entering a new and different cultural context, may also bridge the current knowledge gap regarding the impact of IPV among diverse groups of MSM. Additionally, future research should investigate the toll of problematic use of various substances among A/PI and other groups of MSM, as our study only assessed limited measures of substance use.

Our findings reinforce the need for intervention programs that aim to relieve the overall burden of IPV among racial/ethnic minority MSM. It may be essential for public health agencies and other organizations to respond to this issue by developing support shelters and programs for MSM who may become potential victims of IPV, especially since domestic violence shelters for MSM are typically limited (Pattavina, Hirschel, Buzawa, Faggiani, & Bentley, 2007). Our findings also warrant the need for ongoing research and surveillance of substance use trends among A/PI MSM, especially among individuals who are victims of IPV perpetration.

Furthermore, training health care providers to effectively screen and provide care for MSM IPV victims in a culturally sensitive manner may be a vital element in addressing this overlooked issue. The American Medical Association (2008), for example, states that physicians should routinely inquire patients about physical, sexual, and psychological abuse as part of their medical history. They add that physicians should also be familiar with current information about cultural variations in response to abuse, public health measures that are effective in preventing violence and abuse, and how to work cooperatively with relevant community services. Since A/PI MSM often face language and cultural barriers when seeking care (Wong et al., 2012), increased training of clinicians to consider and address these issues may strengthen current efforts to screen for and respond to victims of IPV.

Additionally, clinicians must also overcome numerous challenges that prevent them from effectively screening for IPV. The lack of provider education regarding IPV, lack of time spent with patients, and fear of offending patients, for example, have been identified as barriers clinicians face when providing routine screening (Waalen, Goodwin, Spitz, Petersen, & Saltzman, 2000). Thus, interventions designed to overcome these barriers and increase IPV-screening rates in health care settings are warranted.

Footnotes

Authors’ Note

Institutional Review Board Approval: Georgetown University’s Institutional Review Board (#2004-130) approved this study. The Men of Asia Testing for HIV (MATH) Study Consortium consists of the following organizations: AIDS Services in Asian Communities, Philadelphia, Pennsylvania; Asian Americans for Community Involvement, San Jose, California; Asian Health Services, Oakland, California; the Asian & Pacific Islander Coalition on HIV/AIDS, New York, New York; the Asian Pacific AIDS Intervention Team, Los Angeles, California; the Asian and Paci6c Islander American Health Forum, San Francisco, California; the Asian & Pacific Islander Wellness Center, San Francisco; Massachusetts Asians and Pacific Islanders for Health, Boston, Massachusetts; Georgetown University, Washington, D.C.; George Washington University, Washington, D.C.; and Emory University, Atlanta, Georgia.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The preparation of this article was supported in part by grants from the National Institutes of Health (R01HD046354—Frank Wong) and the Emory Center for AIDS Research (P30 AI050409—Eric Nehl and Frank Wong).

Author Biographies

Alvin Tran, MPH, is a doctor of science student in the Department of Nutrition at the Harvard School of Public Health. He received his MPH from Emory University and a BA in Medical Anthropology and a BS in Public Health from the University of Washington.

Lavinia Lin, MPH, is a senior research project coordinator in the Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health in Atlanta, Georgia, USA. She received her MPH from Emory University and BSc in Nutritional Sciences from the University of Toronto.

Eric J. Nehl, PhD, is an assistant research professor in the Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health in Atlanta, Georgia, USA. He received his PhD in Health Behavior from Indiana University, a MS in Community Health and BS in Health Education from Ball State University.

Colin L. Talley, PhD, is an assistant research professor in the Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health in Atlanta, Georgia, USA. He received his PhD in History of Health Sciences from the University of California, San Francisco. His MA in History is from San Diego State University and BA in Political Science from the University of Houston.

Kristin L. Dunkle, MPH, PhD, is an assistant professor in the Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health in Atlanta, Georgia, USA. She received her PhD in Epidemiology and MPH in International Health from the University of Michigan. She completed her undergraduate studies in Biology and English and received a BA from Case Western Reserve University.

Frank Y. Wong, PhD, is an associate professor in the Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health in Atlanta, Georgia, USA. He received his PhD from Texas A&M University.

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