Masculine Gender Ideologies,Intimate Partner Violence,and Alcohol Use Increase Risk for Genital Tract Infections Among Men

Abstract

Masculine gender ideologies are thought to underlie alcohol use, intimate partner violence (IPV) perpetration, and sexual risk of HIV and other sexually transmitted infections (STIs). We extend on studies in the Indian context by examining the roles of masculine gender ideologies, alcohol use, and IPV on three outcomes of HIV risk (condom use, genital tract infection [GTI] symptoms, and GTI diagnosis). We applied logistic regression models to cross-sectional data of men and their wives in rural Maharashtra, India (n = 1,080 couples). We found that men with less masculine gender ideologies demonstrated greater odds of condom use (i.e., lower odds no condom use, odds ratio [OR] = 0.96, 95% confidence interval [CI] = [0.93, 0.98]). IPV perpetration was associated with increased odds of reporting ≥1 GTI symptom (adjusted OR [AOR] = 1.56, 95% CI = [1.07, 2.26]) and decreased GTI diagnosis (AOR = 0.28, 95% CI = [0.08, 0.97]). Moderate alcohol consumption was associated with increased odds of reporting ≥1 GTI symptom (AOR = 1.51, 95% CI = [1.01, 2.25]). Our findings have direct implications for men’s and women’s health in rural India, including targeted GTI diagnosis and treatment, integrated violence prevention in STI clinics, and targeted intervention on masculine gender ideologies.

Keywords

gender men India genital tract infections

Introduction

India has the third largest HIV epidemic in the world, with 2.1 million people living with HIV (UNAIDS, 2014). More than 80% of new HIV infections in India occur from heterosexual transmission (NACO, 2006), and 40% of new infections occur among married women of reproductive age (15-49 years; Decker et al., 2009). Growing evidence suggests that being married is the greatest risk factor for HIV transmission among women in India (Silverman, Decker, Saggurti, Balaiah, & Raj, 2008). Married women are thought to be exposed to HIV through their husbands’ risk behaviors, including sexual violence and intimate partner violence (IPV), having multiple sex partners, and risky alcohol drinking (Ghosh et al., 2011; Silverman et al., 2008). Indian wives typically have less sexual decision making power than husbands in the marital context (Santhya & Jejeebhoy, 2005), which can exacerbate sexual risk and decrease chances of condom use (Dasgupta et al., 2015). Although the marital context has been identified as high HIV risk for Indian women, much less is known about the risk factors for husbands.

Literature Review

A growing body of work with men in India focuses on the importance of traditional masculine gender ideologies in shaping men’s HIV risk behaviors and the HIV risk of their partners. Traditional gender norms define and reinforce ideals of femininity and masculinity. From childhood to adulthood, boys and girls are exposed to societal messages of how men and women are supposed to behave, which are passed onward from their families, social networks, media, and social institutions (Pulerwitz, Michaelis, Verma, & Weiss, 2010). Masculine gender ideologies are an individual’s attitudes about the appropriate roles, responsibilities, and behaviors for men in their society. In the traditional Indian context, men are expected to be dominant and are “entitled to exercise power and, if needed, be violent towards women who do not adhere” (p. 3) to gender roles and expectations, especially in the marital context (Nanda et al., 2014). IPV is often “rationalized to protect the honor of the family” or to “display their manhood,” whereas women are expected to endure violence to sustain their family and household (Nanda et al., 2014). Research suggests that men who adhere to traditional norms of masculinity, and endorse inequitable gender beliefs, have greater odds of using violence (Barker, 2005), engaging in risky sexual behaviors (Santana, Raj, Decker, La Marche, & Silverman, 2006), and perpetrating sexual violence and IPV against women (Santana et al., 2006). Such findings place a growing emphasis on the importance of gender equity for both men’s and women’s health.

Alcohol use may furthermore exacerbate the associations between masculine gender ideologies, IPV, and sexually transmitted infection (STI) risk for men. There is a consistent gender disparity in which men are more likely to drink alcohol, consume larger quantities of alcohol, and experience alcohol-related behavioral problems than woman (Wilsnack et al., 2009); this is likely because alcohol consumption is gendered as a masculine behavior (Nolen-Hoeksema & Hilt, 2006). Although alcohol consumption has been found to exacerbate IPV perpetration as well as other risky sexual behaviors (Jewkes, 2002), including extramarital sex and STI diagnoses among married Indian men (Saggurti, Schensul, & Singh, 2010), the association between masculine gender ideologies and alcohol use has not yet been examined in Indian men.

Identifying the ways in which masculine gender ideologies influence HIV risk is particularly important in India, where 35% of Indian women report experiencing marital IPV (Silverman et al., 2008), and IPV is associated with increased risk for HIV (Silverman et al., 2008). Although masculine gender ideologies have been associated with sexual risk behaviors in other national contexts (Fleming, DiClemente, & Barrington, 2016), less work has considered the effects of masculine gender ideologies on the risk for STIs. STIs have been found to facilitate HIV infection and transmission. Even less research has examined the effects of masculine gender ideologies on biomarkers of STIs, such as symptoms of genital tract infection (GTI) which encompass both STIs (e.g., chlamydia, gonorrhea) as well as other infections (e.g., candidiasis, bacterial vaginosis). Studies in the Indian context have demonstrated strong associations between inequitable gender ideologies and IPV, but there has been limited examination of whether masculine gender ideologies and IPV perpetration are associated with STI risk among married men in rural contexts (Nanda et al., 2014). This study examines the roles of masculine gender ideologies, alcohol use, and IPV on three outcomes related to HIV risk: (a) condom use, (b) GTI symptoms, and (c) GTI diagnosis among married men in rural India. We hypothesize that men with less support of equitable masculine gender ideologies (i.e., lower score on Gender Equitable Men [GEM]), who report more frequent alcohol use, and/or whose wives report IPV victimization will have greater odds of using condoms, reporting at least one GTI symptom, and reporting greater odds of ever being diagnosed with a GTI, are associated than their respective comparison groups.

Materials and Methods

This study involved cross-sectional analysis of baseline data from couples (N = 1,081) participating in the Counseling Husbands to Achieve Reproductive Health and Marital Equity (CHARM) study, a family planning evaluation study conducted in the rural Thane District of Maharashtra, India, between March 1 and December 31, 2012. Details on the larger intervention evaluation study can be found elsewhere (Yore et al., 2016).

Sample Design

Sampling efforts were led by scientific leadership in India using geographic maps of rural Maharashtra developed by local primary health centers. Sixty-two geographic clusters were identified on the basis of having comparable population density (approximately 300 households or 1,000 population), geographic size, and makeup of public and private health sector facilities, community resources, and business areas. Of those 62 geographic clusters, 50 were selected based on accessibility. Up to 25 eligible households were recruited per cluster. Trained research staff approached households to identify young married men and their wives for CHARM study participation. Households were eligible for participation if there was a married couple with a husband between the ages of 18 and 30 years, neither husband nor wife was surgically sterilized, both were fluent in Marathi (the native language of Maharashtra), neither had a serious cognitive or health impairment, and they resided together for the past 3 months with no intent to relocate in the next 2 years. Once the household was screened as eligible, research staff provided details regarding the CHARM intervention. If the couple indicated interest, research staff would conduct informed consent with the couple in a private space in the house. Research staff screened 1,881 couples, 1,143 were eligible to participate in the study (60.8% eligibility rate), and 1,081 eligible couples chose to participate (94.6% participation rate). The present analyses are based on data from the baseline survey assessment of husbands and wives (n = 1,080). One participant had missing data on the GTI outcome measures.

Eligible and interested participants completed a 60-min paper survey (distinct surveys for husbands/wives) conducted by a sex-matched researcher. Survey items covered a broad range of topics including demographics, contraception, marital communication, violence, alcohol use, sexual history, and masculine gender ideologies. No monetary incentive was provided for participation. All research study procedures were approved by the institutional review boards at the University of California, San Diego and the National Institute for Research in Reproductive Health (Indian Council of Medical Research), Mumbai.

Measures

Measures for this study were taken from the National Family Health Survey–3 (NFHS-3; International Institute for Population Sciences [IIPS], 2007), India’s version of the Demographic and Health Survey. Sociodemographic measures included age, caste, and receipt of formal education; age and education were assessed for both husbands and wives. Length of marriage was calculated by subtracting age at marriage from current age. Parity assessed number of live births.

Our primary independent variables were masculine gender ideologies, alcohol use, and IPV victimization by wives. Masculine gender ideologies measured men’s gender attitudes related to men’s and women’s roles in relationships and the household (i.e., masculine gender ideology), using the 24-item GEM Scale (Pulerwitz & Barker, 2008). Sample items include the following: “A man should have the final word about decisions in his home,” “It is important that a father is present in the lives of his children, even if he is no longer with the mother,” “A man needs other women, even if things with his wife are fine,” “Men are always ready to have sex,” and “I would be outraged if my wife asked me to use a condom.” Responses were on a 3-point scale: 1 (don’t agree), 2 (partially agree), and 3 (agree). The Cronbach’s alpha was .71 for these 24 items, indicating moderate reliability. A summation score was created, reversing items as appropriate, so that a higher score indicates greater support of gender equitable norms. There is no standard application of the GEM Scale; however, the scale was designed and validated as a continuous measure, therefore we apply it as a continuous measure in our analyses. Frequency of alcohol use was assessed in husbands—daily, once a week, less than once per week, or never. Husband’s perpetration of IPV was asked of wives using items from the NFHS-3. Physical IPV was categorized based on whether or not respondents reported any of the following: “husband slapped you”; “husband twisted your arm or pulled your hair”; “husband pushed you, shook you, or threw something at you”; “husband kicked you, dragged you or beat you up”; “husband choked you or tried to burn you on purpose”; or “husband threatened to attack you with a knife, gun or any other weapon.” Sexual IPV was categorized based on whether or not respondents reported any of the following: “husband physically forced you to have sexual intercourse with him even when you did not want to,” and “husband forced you to perform any sexual acts when you did not want to.” IPV was dichotomized (yes/no).

Our dependent variables included men’s recent condom use, history of GTI symptoms, and ever been diagnosed with a GTI. Male participants were assessed on condom use with their wife in the previous 3 months (yes/no). GTI symptoms (yes/no) were based on the men’s reporting ever having had at least one of the following symptoms: (a) pain/burning when urinating, (b) urethral discharge, and (c) genital ulcers. Men were also asked whether they had ever received a GTI diagnosis (yes/no).

Data Analysis

Data analysis began with sample descriptive statistics and bivariate analyses (chi-square, t test, and ANOVA F statistics) to assess associations between covariates (e.g., sociodemographics, IPV, and alcohol use) and GEM score. We checked for multicollinearity via correlations and variance inflation factors (VIF), assuming multicollinearity for variables indicating correlations >.8 or a VIF ≥10. No variables met this standard for any of our outcomes of focus, and thus all covariates were retained in final models (Piegorsch, 2015).

Simple and adjusted logistic regression models and 95% confidence intervals (CIs) were used to assess associations between primary independent variables (e.g., GEM, alcohol use, IPV) and each study outcome (e.g., condom use, history of GTI symptoms, and GTI diagnosis). All analyses were conducted using STATA Version 13.1.

Results

Table 1 reports the characteristics of the full sample of married men living in rural Maharashtra, India. Men were on average 26 years old (SD = 2.68 years, range = 18-30 years), had wives an average age of 23 years old (SD = 2.52 years, range = 17-32 years), had 1.14 children (SD = 0.88, range = 0-5 children), were married for an average of 4 years (SD = 2.68 years, range = 0-14 years), and the mean on the GEM Scale was 47 (SD = 5.41, range = 35-67). Most men (91%) and their wives (83%) had received formal education, were part of a scheduled caste/tribal group (72%), and reported drinking alcohol never (49%) or less than once a week (36%), and one in three men had perpetrated physical or sexual violence against their wives (33%).

Table 1.

Characteristics of Married Men Living in Rural Maharashtra, India.

Continuous Variables	Total		GEM Score
	(n = 1,080)		(n = 1,080)
	M	SD	r	Significance
GEM	47.31	5.41	—
Husband’s age	26.18	2.68	.15	***
Wife’s age	22.57	2.52	.05
Parity	1.14	0.88	−.12	***
Length of marriage	3.90	2.68	−.12	***
Categorical Variables	n	%	M ^a	SD
Husband’s alcohol use			***
Never	536	49	47.88	0.26
Less than once a week	385	36	46.99	0.25
Once a week	139	13	46.59	0.39
Almost everyday	30	3	44.77	0.92
IPV perpetration
No	722	67	47.18	0.20
Yes	358	33	47.57	0.29
Husband’s education			***
Received formal education	988	91	47.50	0.17
Never received formal education	92	9	45.24	0.45
Wife’s education			***
Attended some school	891	83	47.70	0.19
Never attended school	189	18	45.49	0.31
Caste			***
Scheduled caste/tribal	775	72	46.46	0.18
Other backward caste/none	305	28	49.48	0.33
Total	1,080	100.0	1,080	100.0

Note. GEM = Gender Equitable Men; r = correlation; IPV = intimate partner violence (both physical and sexual).

ANOVA for husband’s alcohol use and t test for remaining variables.

p < .05. **p < .01. ***p < .001 (significant association using r for continuous variables, ANOVA for categorical variables with > 2 categories, and t test for categorical variable with 2 categories).

Table 1 also provides mean GEM scores for various subcategories of men. Greater (more equitable) mean GEM score was significantly positively correlated with husband’s age and significantly negatively correlated with parity and length of marriage. Comparing categories of men on their alcohol use, men who drank everyday had the lowest mean GEM score and men who never drank had the highest mean GEM score. Husband’s higher level of education, wife’s higher level of education, and being part of other backward castes or no caste were significantly associated with greater mean GEM score. GEM score was not significantly associated with IPV perpetration.

Table 2 reports the frequency and un/adjusted odds ratios (ORs/AORs) from logistic regression models comparing three dependent variables (no condom use, GTI symptoms, GTI diagnosis) with GEM score, IPV perpetration, alcohol use, and sociodemographic factors. Eighty-one percent of men report not recently using condoms with their wives, 13% had ever experienced a GTI symptom, and 2% reported being diagnosed with a GTI. For recent condom use, greater GEM score was associated with greater odds of recent condom use (i.e., lower odds no condom was used, OR = 0.96, 95% CI = [0.93, 0.98]) in unadjusted models, although this was nonsignificant in the adjusted model (AOR = 0.98, 95% CI = [0.95, 1.01]). Husband’s alcohol use and IPV perpetration were not significantly associated with no condom use in un/adjusted models. For GTI symptoms, in adjusted models, GEM score was not significantly associated with having ≥1 GTI symptom (AOR = 1.00, 95% CI = [0.97, 1.04]), whereas drinking alcohol less than once a week (AOR = 1.51, 95% CI = [1.01, 2.25]) and having ever perpetrated IPV (AOR = 1.56, 95% CI = [1.07, 2.26]) were associated with greater odds of having ≥1 GTI symptom. For GTI diagnosis, in adjusted models, GEM score was not significantly associated with having ever been diagnosed with a GTI, whereas having ever perpetrated IPV (AOR = 0.28, 95% CI = [0.08, 0.97]) was associated with lower odds of having been diagnosed with a GTI.

Table 2.

Logistic Regression of GEM on Condom Use, at Least One GTI Symptom, and GTI Diagnosis Among Married Men Living in Rural Maharashtra (n = 1,080).

Independent Variables	No Condom Use 81% (n = 874)		≥1 GTI Symptom 13% (n = 141)		GTI Diagnosis^a 2% (n = 24)
Independent Variables	OR (95% CI)	AOR^b (95% CI)	OR (95% CI)	AOR^b (95% CI)	OR (95% CI)	AOR^b (95% CI)
GEM	0.96**	0.98	1.00	0.99	0.99	0.98
GEM	[0.93, 0.98]	[0.95, 1.01]	[0.97, 1.04]	[0.95, 1.02]	[0.92, 1.07]	[0.90, 1.06]
Husband’s alcohol use
Never	Ref.	Ref.	Ref.	Ref.
Less than once a week	0.95	0.88	1.43	1.51*	—	—
Less than once a week	[0.69, 1.33]	[0.62, 1.25]	[0.97, 2.11]	[1.01, 2.25]
Once a week	0.97	0.77	1.44	1.51	—	—
Once a week	[0.61, 1.56]	[0.47, 1.27]	[0.84, 2.46]	[0.86, 2.65]
Almost everyday	2.11	1.57	1.24	1.51	—	—
Almost everyday	[0.63, 7.10]	[0.45, 5.47]	[0.42, 3.68]	[0.49, 4.66]
IPV perpetration
No	ref.	ref.	ref.	ref.	ref.	ref.
Yes	0.93	0.89	1.54*	1.56*	0.28*	0.28*
Yes	[0.67, 1.28]	[0.64, 1.25]	[1.07, 2.21]	[1.07, 2.26]	[0.08, 0.95]	[0.08, 0.97]
Husband’s age	0.93**	0.95	0.97	0.97	1.10	0.87
Husband’s age	[0.87, 0.9]	[0.87, 1.03]	[0.91, 1.03]	[0.88, 1.07]	[0.94, 1.30]	[0.68, 1.10]
Wife’s age	0.97	1.00	0.95	1.00	1.22*	1.21
Wife’s age	[0.91, 1.03]	[0.91, 1.11]	[0.88, 1.02]	[0.89, 1.12]	[1.04, 1.42]	[0.95, 1.54]
Other backward caste/none	0.47***	0.60**	1.83***	2.02**	2.19	2.43
Other backward caste/none	[0.34, 0.64]	[0.42, 0.86]	[1.26, 2.64]	[1.32, 3.08]	[0.97, 4.95]	[0.94, 6.25]
Husband not formally educated	3.64**	2.61*	0.80	0.93	0.46	0.59
Husband not formally educated	[1.57, 8.44]	[1.09, 6.26]	[0.40, 1.58]	[0.45, 1.93]	[0.06, 3.45]	[0.07, 4.83]
Wife not formally educated	2.93***	2.15**	0.85	1.13	0.67	0.68
Wife not formally educated	[1.71, 5.01]	[1.21, 3.83]	[0.53, 1.39]	[0.66, 1.94]	[0.20, 2.26]	[0.18, 2.57]
Parity	0.90	0.59***	0.83	1.04	1.09	0.69
Parity	[0.76, 1.07]	[0.44, 0.77]	[0.68, 1.03]	[0.75, 1.43]	[0.69, 1.71]	[0.35, 1.37]
Length of marriage	1.04	1.15**	0.92*	0.91	1.13	1.23
Length of marriage	[0.98, 1.11]	[1.04, 1.29]	[0.85, 0.98]	[0.81, 1.03]	[0.98, 1.30]	[0.97, 1.56]

Note. GEM = Gender Equitable Men; GTI = genital tract infection; OR = odds ratio; CI = confidence interval; AOR = adjusted OR; IPV = intimate partner violence.

Alcohol omitted due to low cell count.

Adjusted models controlled for by all other variables.

p < .05. **p < .01. ***p < .001.

Discussion

This study described gender role ideologies among married men in rural India and indicated several novel ways in which masculine gender ideologies, IPV perpetration, and alcohol use increased men’s risk for contracting and transmitting STI. We found that men with inequitable masculine gender ideologies may demonstrate more risky sexual behavior with lower condom use than their more gender equitable counterparts. In addition, we find a high level of IPV perpetration among married men in rural India, with approximately one in three men reporting perpetration of physical or sexual violence against their wives. Furthermore, our findings indicate a link between IPV perpetration and GTI symptoms and nondiagnosis, suggesting that men who perpetrate IPV may not seek testing or receive care for their GTIs. The findings also provide insight into potential mechanisms of increased GTI symptoms among IPV perpetrators as alcohol consumption was also associated with increased odds of GTI symptoms. We discuss these key findings in context of extant literature below.

GEM Scale

This study finds that married men in rural India with equitable masculine gender ideologies had significantly lower odds of no condom use than men with less equitable ideologies, but this did not hold up in adjusted models. This finding aligns with equitable gender role ideologies that support the need for couple coordination of male condom use and the shared responsibility of contraception and disease prevention. However, we did not find any statistical association between the GEM Scale and GTI symptoms or diagnosis. We speculate that a potential explanation for our null findings related to the GEM Scale may be due to our sample in rural India. The GEM Scale, although originally developed to measure masculine gender ideologies in Brazil, has been translated and reliably adapted for use in six other countries including in India (Verma et al., 2006). Although this study utilized the Indian GEM Scale, this was the first application in the rural context of India, where ideals of masculinity differ from those captured with the current Indian GEM Scale. Nevertheless, men’s endorsement of masculine gender ideologies would align with qualitative research that Indian men generally view their relationships through a lens of entitlement and dominance over their female partners (Verma et al., 2006).

Alcohol Use

This study also links occasional alcohol use (less than once a week) to greater adjusted odds of having at least one GTI symptom, with the OR trending in the same direction for more frequent drinking. This finding is supported by other research in India connecting alcohol consumption with HIV/STI risk through increased sexual risk behavior (Dandona et al., 2008; Pai et al., 2009; Saggurti et al., 2010; Singh et al., 2010) and IPV perpetration (Jewkes, 2002; Nanda et al., 2014). One study in particular found that alcohol consumption before sex was significantly associated with being HIV positive among married (but not single) men (Pai et al., 2009). A few studies suggest that moderate to heavy male drinkers may have more nonspousal sexual partners (Saggurti et al., 2010; Singh et al., 2010), not use condoms in these relations (Singh et al., 2010), and have greater likelihood of a current STI diagnosis (Saggurti et al., 2010). HIV prevention interventions in the Indian context should critically focus on alcohol consumption prior to sex among married men (Dandona et al., 2008), as well as reducing alcohol-related sexual risk in this population. In addition, alcohol consumption is a normalized male behavior in rural India. Although almost half of our sample reported never drinking alcohol, findings from rural Maharashtra indicate that rates of alcohol consumption among the tribal populations are higher, and norms around alcohol are different, compared with nontribal populations (IIPS & Macro International, 2008). Alcohol use in tribal settings often includes nontraditional types of alcohol that are homemade, and men may have difficulty quantifying one alcoholic serving and tallying rate of alcohol consumption for discriminant periods of time (Schensul, Singh, Gupta, Bryant, & Verma, 2010).

IPV

A key finding is that married Indian men whose wives report IPV victimization have greater adjusted odds of having a history of at least one GTI symptom. This finding is consistent with prior research linking IPV perpetration to increased STI diagnosis (Decker et al., 2009; Raj, Reed, Welles, Santana, & Silverman, 2008; Silverman, Decker, Kapur, Gupta, & Raj, 2007; Silverman et al., 2008). Although only two studies have addressed IPV and HIV risk among married Indian men (Decker et al., 2009; Saggurti et al., 2010), this is the first time to demonstrate the association among rural Indian men. Previous research has shown that IPV may facilitate HIV transmission from an infected partner via STI infection which have been found to facilitate HIV infection and transmission (Centers for Disease Control and Prevention [CDC], 2014). Thus, our findings lend additional support that IPV is a significant risk factor for poor sexual and reproductive health for both men and women. The link between IPV perpetration and increased GTI symptoms is posited to be behavioral, with data suggesting that male perpetrators of violence are more likely to report multiple sex partnering, inconsistent condom use, injection drug use, and anal sex than non-IPV perpetrators (Decker et al., 2009; Dunkle et al., 2006; Raj et al., 2008). The fact that the association between IPV and GTI symptoms remains in adjusted models (after controlling for sociodemographic factors and masculine gender ideologies), indicates that IPV perpetration constitutes a marker for risky HIV/GTI behavior above and beyond these sociodemographic and masculine gender ideology indicators.

Extramarital sexual infidelity, defined as concurrent undisclosed sexual partnerships such as transactional sex partners, poses additional HIV/GTI risks for married men and their wives. Findings from urban India suggest that most men who have extramarital sex do so with nonformal sex workers within or near their communities of residence (Saggurti et al., 2010). Upon further investigation of our data, we found lower reports of risky sexual behavior (e.g., multiple sex partnering, transactional sex) among married men than expected given that 13% of our sample reported experiencing at least one GTI symptom. Our sample reported 1.1 lifetime sexual partners (SD = 0.41, range = 1-6), with 92% reporting having only one lifetime sexual partner and 6% reporting two. Moreover, only 0.7% reported having an extramarital sexual partner in the previous 6 months. Reliance on self-reported sexual risk behaviors increases the risk of social desirability bias. Given that our study took place in a rural context, it is possible that men underreported extramarital affairs due to the increased stigma attached to living in a rural area with smaller communities and tighter social networks. Nevertheless, intervention research among married men in India should address marital fidelity, negotiated safety, and risk reduction to decrease HIV/GTI risk through risky sexual behavior.

This study also extends upon the literature by suggesting that married men who perpetrate IPV are also less likely to receive a diagnosis—and thus prescribed treatment—for their GTI than non-IPV perpetrators in rural India. Upon further investigation of the data, among men who experienced at least one GTI symptom, only 5% of male IPV perpetrators reported GTI diagnosis compared with 22% of male non-IPV perpetrators. This finding highlights a critical area of intervention to prevent the heterosexual transmission of HIV within the marital context in rural India as strong evidence supports that GTI facilitate HIV infection and transmission by increasing both HIV susceptibility and infectiousness (CDC, 2014). Hence, it is critical to detect and treat husbands with GTI as an effective part of HIV prevention strategy. Furthermore, challenges in providing GTI prevention outreach and treatment in rural settings must be addressed. Low GTI diagnosis may also be an artifact of self-treatment with over-the-counter antibiotics. Very high antibiotic misuse, which has been documented in India (Parikh, 2010), could lead to inadequate GTI treatment as well as risk of antibiotic resistance, among other consequences.

Study Limitations

The current findings should be considered in light of several limitations in addition to those already mentioned. First, cross-sectional analysis precludes conclusions of temporality, and prospective research is needed to determine the relative sequencing and impact of alcohol and IPV perpetration on men’s STI acquisition. Second, all data are self-reported and subject to potential biases based on social desirability, recall bias, or intentional underreporting of sensitive or socially undesirable outcomes. Third, reliance on self-reported measures of GTI symptoms and diagnosis, rather than biological assessments, likely provided an underestimate of GTI in our sample (Iritani, Ford, Miller, Hallfors, & Halpern, 2006). Underreporting and truncated variability could have decreased our statistical power to detect a significant association between key variables such as masculine gender ideologies, alcohol, and our outcomes. Finally, although our sample size was reasonably large, the original study aimed to pilot an intervention and did not implement a probability sample. Therefore, our findings are not generalizable to other populations of rural married men in the Indian state of Maharashtra.

The current study indicates a high level of IPV perpetration among married men in rural India, with one in three men reporting perpetration of physical or sexual violence against their wives. Abusive men’s increased risk of reporting GTI symptoms and decreased likelihood of getting a formal GTI diagnosis have direct implications for men and women’s health in rural India, including male GTI intervention and treatment in rural India. These findings bolster the need to integrate violence perpetration prevention within STI clinics and to target men who report inequitable gender ideologies and IPV perpetration. Further work in this population is needed to empirically link and establish temporal sequencing of alcohol consumption, IPV perpetration, sexual risk behavior, and GTI.

Footnotes

Authors’ Note

Anindita Dasgupta is now affiliated to Columbia University, New York, NY. Paul J. Fleming is now affiliated to University of Michigan, Ann Arbor, MI and Saritha Nair is now affiliated to National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi, India

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: This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development under Grants R01HD061115 and R01HD077891-04S1, and the National Institute on Drug Abuse under Grants T32DA023356 and T32DA037801.

Author Biographies

Kiyomi Tsuyuki, PhD, MPH, is an assistant project scientist in the Division of Global Public Health in the University of California, San Diego (UCSD) School of Medicine. As a trained health demographer, Dr. Tsuyuki’s research applies a social justice framework, and a wide range of statistical and qualitative techniques, to elucidate the socio-structural mechanisms responsible for intersecting drug and alcohol misuse, violence, and HIV/STI risk in men and women in the U.S., Latin America, and Asia. Dr. Tsuyuki’s research has been supported by the National Institutes of Health (NIMH, NIDA, NICHD, NIMHD, NIAAA, NIAID), as well as non-federal agencies (World Bank, Sexual Violence Research Initiative).

Balaiah Donta, PhD, MSc, is a scientist ‘G’ in the Department of Statistics at the National Institute for Research in Reproductive Health (Indian Council of Medical Research). Trained in Statistics, Dr. Donta is an expert in sampling techniques and large scale sample surveys and has research interest in enhancing participation of men in sexual and reproductive health, evaluating new contraceptive methods, adolescent reproductive health, gender-based violence, and improving couples’ reproductive health.

Anindita Dasgupta, PhD, MPH, is a postdoctoral research fellow in the Social Intervention Group at the School of Social Work at Columbia University. Dr. Dasgupta’s research focuses on understanding gendered inequities of health as they relate to women’s sexual and reproductive health and substance use in India, Central Asia, and the Middle East.

Paul J. Fleming, PhD, MPH, is an assistant professor in Health Behavior and Health Education at the University of Michigan School of Public Health. He received his PhD in Health Behavior with a graduate minor in Sociology from the University of North Carolina and his MPH in Behavioral Sciences and Health Education from Emory University. His mixed-methods research – primarily carried out in Latin American and sub-Saharan African countries – is focused on developing and evaluating public health interventions that aim to transform gender norms to reduce HIV incidence, improve sexual/reproductive health, and reduce violence perpetration.

Mohan Ghule, PhD, is an ex technical officer ‘A’ at the National Institute for Research in Reproductive Health (Indian Council of Medical Research). Professionally qualified as Demographer/Population Scientist from prestigious institutes of India and abroad. Dr. Mohan has been associated with National Institute for Research in Reproductive Health (ICMR, GoI) for more than 3 decades and has been instrumental in touching the untouched area of the Reproductive Health as a Principal and Co-Principal Investigator and represented the Institute at various national and international forums. Dr. Mohan’s rich experience in Research, monitoring and evaluation reflected in his national and international peer reviewed publications and policy guidelines.

Battala Madhusudana, PhD, is a senior program officer at the Population Council in India. Dr. Battala has formal training in population studies and geography and has more than 12 years of research experience in the fields of HIV, STI, GBV and family planning. He has expertise in conducting operational research impact evaluation studies.

Saritha Nair, PhD, is a scientist at the National Institute of Medical Statistics, Indian Council of Medical Research (ICMR), Delhi. Dr Nair is a demographer by training and has over 15 years of experience conducting mixed methods research in the areas of reproductive and child health, male involvement, HIV/STI, gender based violence and use of smokeless tobacco among women.

Jay G. Silverman, PhD, is a director of Research for the Center on Gender Equity and Health and a Professor of Medicine and Global Public Health at the University of California, San Diego. He has led multiple major government, foundation and UN-funded studies of gender-based violence (e.g., IPV, sexual assault, reproductive coercion, gender-based household maltreatment, sex trafficking) across multiple global regions regarding effects on women’s and girls’ reproductive and sexual health and the morbidity and mortality of their children.

Niranjan Saggurti, PhD, is a director of the Population Council’s office in India. Dr. Saggurti provides strategic direction and technical oversight to the Council’s research initiatives on young people’s health and development; sexual and reproductive health; and HIV prevention, care, and treatment in India. A public health researcher with more than twenty years’ experience, Saggurti has conducted diagnostic, experimental, and evaluation studies aimed at preventing HIV infection among high-risk and vulnerable populations, reducing sexual and gender-based violence (SGBV), and expanding maternal and child health for India’s most marginalized women. Saggurti has published widely in peer-reviewed journals and has been on the editorial boards of international journals, including PLoS One, and on technical advisory committees in the field of HIV and family planning.

Anita Raj, PhD, is a director of UCSD’s Center on Gender Equity and Health and is a Professor in the Division of Global Public Health, Department of Medicine. Dr. Raj is a developmental psychologist with over 20 years of experience conducting research on sexual and reproductive health/HIV/STI, gender-based violence, substance misuse and abuse, and the intersection of these issues. She has served as Principal Investigator or Co-Investigator on more than 30 grants from various federal funding agencies including NIH [NIMH, NICHD, NIDA, NIAAA], CDC, SAMHSA, and the Office of Minority Health, as well as foundations including the Lucile and David Packard Foundation and Kaiser Foundation. She has authored or co-authored 100+ peer-reviewed publications from these studies.

References

Barker

G. T.

(2005). Dying to be men: Youth, masculinity and social exclusion. London, UK and New York City, NY: Psychology Press.

Centers for Disease Control and Prevention. (2014, November). CDC Fact Sheet: HIV and AIDS among Latinos. Electronic Publication by U.S. Department of Health and Human Services. Retrieved from https://stacks.cdc.gov/view/cdc/25581/Email

Dandona

Kumar

G. A.

Reddy

G. B.

Ameer

M. A.

Ahmed

G. M.

. . . Lakshmi

(2008). Risk factors associated with HIV in a population-based study in Andhra Pradesh state of India. International Journal of Epidemiology, 37, 1274-1286.

Dasgupta

Saggurti

Donta

Battala

Ghule

Nair

. . . Raj

(2015). Intimate partner violence and condom versus other modern contraception use among married women in rural India. Annals of Global Health, 81, 218-219.

Decker

M. R.

Seage

G. R.

III Hemenway

Raj

Saggurti

Balaiah

Silverman

J. G.

(2009). Intimate partner violence functions as both a risk marker and risk factor for women’s HIV infection: Findings from Indian husband-wife dyads. Journal of Acquired Immune Deficiency Syndromes, 51, 593-600.

Dunkle

K. L.

Jewkes

R. K.

Nduna

Levin

Jama

Khuzwayo

. . . Duvvury

(2006). Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS, 20, 2107-2114.

Fleming

P. J.

DiClemente

R. J.

Barrington

(2016). Masculinity and HIV: Dimensions of masculine norms that contribute to men’s HIV-related sexual behaviors. AIDS and Behavior, 20, 788-798.

Ghosh

Arah

Talukdar

Sur

Babu

Sengupta

Detels

(2011). Factors associated with HIV infection among Indian women. International Journal of STD & AIDS, 22, 140-145.

International Institute for Population Sciences. (2007). India National Family Health Survey (NFHS-3), 2005-06 (Vol. 1). Mumbai, India: Author.

10.

International Institute for Population Sciences (IIPS) & Macro International. (2007). National Family Health Survey (NFHS-3), 2005-06 (Vol. 1) Mumbai, India: IIPS.

11.

Iritani

B. J.

Ford

C. A.

Miller

W. C.

Hallfors

D. D.

Halpern

C. T.

(2006). Comparison of self-reported and test-identified chlamydial infections among young adults in the United States of America. Sexual Health, 3, 245-251.

12.

Jewkes

(2002). Intimate partner violence: Causes and prevention. The Lancet, 359, 1423-1429.

13.

National AIDS Control Organization (NACO) and National Institute of Medical Sciences. (2006). Technical report: India HIV estimates 2006. New Delhi, India.

14.

Nanda

Gautam

Verma

Khanna

Khan

Brahme

. . . Kumar

(2014). Masculinity, intimate partner violence and son preference in India. Washington, DC: International Center for Research on Women.

15.

Nolen-Hoeksema

Hilt

(2006). Possible contributors to the gender differences in alcohol use and problems. The Journal of General Psychology, 133, 357-374.

16.

Pai

N. P.

Joshi

Moodie

E. E.

Taksande

Kalantri

Pai

. . . Reingold

(2009). Profile of adults seeking voluntary HIV testing and counseling in rural Central India: Results from a hospital-based study. AIDS Care, 21, 294-300.

17.

Parikh

(2010). Status of antibiotic use in India. Journal of the Association of Physicians of India (JAPI), 58, 7.

18.

Piegorsch

W. W.

(2015). Statistical data analytics: Foundations for data mining, informatics, and knowledge discovery. West Sussex, United Kingdom: John Wiley.

19.

Pulerwitz

Barker

(2008). Measuring attitudes toward gender norms among young men in Brazil development and psychometric evaluation of the GEM scale. Men and Masculinities, 10, 322-338.

20.

Pulerwitz

Michaelis

Verma

Weiss

(2010). Addressing gender dynamics and engaging men in HIV programs: Lessons learned from Horizons research. Public Health Reports, 125, 282-292.

21.

Raj

Reed

Welles

S. L.

Santana

M. C.

Silverman

J. G.

(2008). Intimate partner violence perpetration, risky sexual behavior, and STI/HIV diagnosis among heterosexual African American men. American Journal of Men’s Health, 2, 291-295.

22.

Saggurti

Schensul

S. L.

Singh

(2010). Alcohol use, sexual risk behavior and STIs among married men in Mumbai, India. AIDS and Behavior, 14, 40-47.

23.

Santana

M. C.

Raj

Decker

M. R.

La Marche

Silverman

J. G.

(2006). Masculine gender roles associated with increased sexual risk and intimate partner violence perpetration among young adult men. Journal of Urban Health, 83, 575-585.

24.

Santhya

Jejeebhoy

S. J.

(2005). Young women’s experiences of forced sex within marriage: Evidence from India. In Jejeebhoy

S. J.

Shah

I. H.

Thapa

(Eds.), Sex without consent: Young people in developing countries (pp. 59-73). London, England: Zed Books.

25.

Schensul

J. J.

Singh

Gupta

Bryant

Verma

(2010). Alcohol and HIV in India: A review of current research and intervention. AIDS and Behavior, 14, 1-7.

26.

Silverman

J. G.

Decker

M. R.

Kapur

N. A.

Gupta

Raj

(2007). Violence against wives, sexual risk and sexually transmitted infection among Bangladeshi men. Sexually Transmitted Infections, 83, 211-215.

27.

Silverman

J. G.

Decker

M. R.

Saggurti

Balaiah

Raj

(2008). Intimate partner violence and HIV infection among married Indian women. Journal of the American Medical Association, 300, 703-710.

28.

Singh

Schensul

J. J.

Gupta

Maharana

Kremelberg

Berg

(2010). Determinants of alcohol use, risky sexual behavior and sexual health problems among men in low income communities of Mumbai, India. AIDS and Behavior, 14, 48-60.

29.

Joint United Nations Programme on HIV/AIDS (UNAIDS). (2014). The gap report: Joint United Nations programme on HIV/AIDS. Retrieved from http://files.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2014/UNAIDS_Gap_report_en.pdf (accessed 22 March 2017).

30.

Verma

R. K.

Pulerwitz

Mahendra

Khandekar

Barker

Fulpagare

Singh

S. K.

(2006). Challenging and changing gender attitudes among young men in Mumbai, India. Reproductive Health Matters, 14, 135-143.

31.

Wilsnack

R. W.

Wilsnack

S. C.

Kristjanson

A. F.

Vogeltanz-Holm

N. D.

Gmel

(2009). Gender and alcohol consumption: Patterns from the multinational GENACIS project. Addiction, 104, 1487-1500.

32.

Yore

Dasgupta

Ghule

Battala

Nair

Silverman

. . . Raj

(2016). CHARM, a gender equity and family planning intervention for men and couples in rural India: Protocol for the cluster randomized controlled trial evaluation. Reproductive Health, 13, Article 14.