Prevalence of Intimate Partner Violence and Associated Factors Among Men Who Have Sex with Men in China

Abstract

Intimate partner violence (IPV) in the heterosexual population has gained increasing public concern in China, but little is known about it among men who have sex with men (MSM).¹ This study aimed to investigate the prevalence of IPV and associated factors among MSM in Chengdu, China. Participants were recruited from a local MSM-friendly health consulting center. This study used the adjusted Intimate Partner Violence Scale among Gay and Bisexual Men (IPV-GBM scale) to capture lifetime IPV experiences including physical, sexual and emotional violence, monitoring, and controlling behaviors. Among 431 participants, 153 (35.5%) reported any IPV experiences, and 119 (27.6%) reported themselves as being the perpetrator. Adjusted logistic regression models revealed that having been engaged in transactional sex was positively associated with victimization through monitoring behaviors (adjusted odds ratio [ORa] = 2.7, 95% confidence interval CI = [1.7, 7.4]) and perpetration of monitoring behaviors (ORa = 3.9, 95% CI = [1.5, 13.3]); drug use was positively associated with victimization through controlling behaviors (unadjusted odds ratio [ORu] = 2.5, 95% CI = [1.2, 5.0]) and emotional violence (ORa = 1.9, 95% CI = [1.0, 3.5]); older age (≥18 years) of first homosexual intercourse was negatively associated with perpetration of physical violence (ORu = 0.3, 95% CI = [0.2, 0.7]) and sexual violence (ORu = 0.4, 95% CI = [0.2, 1.0]); higher self-esteem was negatively associated with both victimization and perpetration of sexual and emotional violence. We found that victimization and perpetration experiences were correlated in all dimensions of IPV. Violence was prevalent among MSM and merits public attention. This study provides more evidence about IPV among Chinese MSM and identifies two significant factors contributing to IPV (self-esteem and age of first homosexual intercourse), which have been overlooked in previous studies. Researchers should take these factors into consideration for interventions developments.

Keywords

intimate partner violence men who have sex with men self-esteem IPV-GBM scale China

Introduction

Intimate partner violence (IPV) among men who have sex with men (MSM) is a significant international health problem that has been raising great concern (Buller et al., 2014). According to the World Health Organization (WHO), IPV refers to any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship (World Health Organization & Pan American Health Organization, 2012). Existing global reviews have already indicated that IPV occurs in male–male relationships at a very high rate (29.7%–78.0%), which is comparable to the rate for heterosexual females, but substantially higher than that rate for heterosexual males (Finneran & Stephenson, 2013; Greenwood et al., 2002; Longobardi & Badenes-Ribera, 2017; Stephenson et al., 2010, 2011). Few studies focus on IPV or domestic violence (DV) among the general heterosexual population in China, and studies among the homosexual population are even rarer. In 2015, China passed its first law against DV, which calls for additional protection for minors, the elderly, people with disabilities, pregnant and lactating women, and seriously ill patients who suffer violence, but it ignores homosexual couples including MSM (Standing Committee of the National People’s Congress, 2015). As a population experiencing a high incidence of violence, MSM have not received sufficient attention. In addition to receiving reduced legal protections against DV compared to heterosexual peers, MSM in China continue to experience stigma and discrimination and do not have the same legal rights as the heterosexual people (Feng et al., 2010; Zhang & Chu, 2005). This may lead to different relationship dynamics with different dimensions of IPV, including forms of IPV that are not consistent with the experience of heterosexual couples (e.g., the threat of being “outed” to colleagues or family). Within this context, understanding the risk factors for IPV among MSM specifically is important to developing interventions and also to maintaining continued efforts for legal reform in the Chinese context.

Published works of literature have pointed out that besides direct physical harm, adverse health outcomes among IPV victims include posttraumatic stress disorder, anxiety, depression, and sexual and reproductive health problems. Moreover, studies have also found that Chinese MSM who are IPV victims are at increased risk of human immunodeficiency virus (HIV) infection (Coker, 2007; Davis et al., 2015; Liu et al., 2018; Wang et al., 2018). In fact, HIV infection via same-sex transmission has increased by 15% from 2007 to 2015 (National Health and Family Planning Commission of the People’s Republic of China, 2015). As one of the determinants of contracting HIV, IPV has gradually attracted the attention of both domestic and international scholars. Current literature on this topic mainly observes the prevalence of IPV among MSM and its associations with HIV-related risk behaviors such as condom-less anal intercourse (Duncan et al., 2018; Starks et al., 2016; Stephenson & Finneran, 2017; Stephenson et al., 2016), substance use (Duncan et al., 2018; Miltz et al., 2019; Stults et al., 2015; E. Wu et al., 2015), and alcohol use (Davis et al., 2016; Peitzmeier et al., 2015). Furthermore, among these factors, several studies outside of China revealed the associations between low self-esteem (Finneran & Stephenson, 2013; McKenry et al., 2006; Nieves-Rosa et al., 2000), depression (Buller et al., 2014; Finneran & Stephenson, 2013; Miltz et al., 2019; Wang et al., 2018), and IPV. However, evidence is far from sufficient about IPV and its associated factors in China, especially among Chinese MSM.

In addition, some research does not define “intimate partner” specifically. Thus, some studies may have included violence experienced in the context of a casual partner, and what they captured were not IPV but violence against men in general. Meanwhile, IPV-relevant studies also often focus on victimization while the perpetration of partner violence is rarely measured globally. Without this knowledge, interventions will be less able to identify risk populations for IPV perpetration or re-perpetration. Simultaneously, to understand IPV among MSM specifically, we must comprehensively explore different types of IPV between couples, which is important to promote a better understanding of IPV and develop interventions against IPV in MSM.

There are several well-established instruments to screen IPV, including the Conflict Tactics Scale (CTS) (Straus, 1979), the Revised Conflict Tactics Scale (CTS2; Straus et al., 1996), and the Sexual Experiences Survey (SES) for heterosexual populations (Finneran & Stephenson, 2013; Koss & Oros, 1982). Some studies screened IPV by inquiring into specific behaviors (i.e., hitting, threatening, and destroying property) (Davis et al., 2015) or applying unstructured items (Dunkle et al., 2013; Liu et al., 2018; Wang et al., 2018). Stephenson and Finneran noticed that none of these instruments or items was targeted on MSM during development, and these instruments overlooked the distinct differences in relationship dynamics between homosexual and heterosexual couples (Finneran & Stephenson, 2013; Stephenson & Finneran, 2013). Earlier studies have shown that homosexual and heterosexual relationships have distinguishable characteristics. For example, gay couples reported being more independent, having fewer barriers to leaving a violent relationship, and higher risk for divorce/break-up than married heterosexual couples (Kurdek, 1998). In addition, the context of violence is different. In heterosexual couples, men may abuse their partners by threatening children or performing male privilege (Katerndahl et al., 2010), while the threat of exposing homosexual identity to colleagues and/or family members is only seen in homosexual couples. Thus, for a deeper understanding of IPV among MSM, they developed the Intimate Partner Violence Scale among Gay and Bisexual men (IPV-GBM) based on a group of MSM in the United States with excellent internal reliability (Cronbach’s alpha > 0.90) (Stephenson & Finneran, 2013).

In view of the high prevalence of IPV among MSM in China and its importance in HIV transmission, it is necessary to conduct a comprehensive study of the prevalence of different types of IPV among MSM and associated factors. To that end, this study sought to address some of the gaps in the literature by conducting a cross-sectional study in Chengdu, China. Flynn and Kathryn have reported a three-level model to explain reasons and causes of IPV, and the three distinct levels are as follows: (a) background and personal attributes of perpetrator or victim (Level 1), such as personality, an upbringing, or childhood experiences that may make a person generally more likely to be aggressive; (b) current life circumstances (Level 2), such as current alcohol use and drug use, and other life circumstances that might make a person more likely to respond aggressively in intimate conflict because of the effects associated with these life situations or factors; and (c) immediate precursors or precipitators (Level 3), such as acts by the partner seen as provoking or aggressive, communication issues or “Hot button issues,” and other situational factors (Flynn & Graham, 2010). The purposes of this study were to investigate the prevalence of victimization and perpetration of different types of IPV and to examine the associations between several factors and IPV victimization/perpetration. Based on Flynn and Kathryn’ s three-level model of aggression, we identified several potential factors for IPV among MSM, which have also been reported in current studies (Buller et al., 2014; Finneran & Stephenson, 2013), including ever engaging in transactional sex and having had a casual sex partnership in the past month (precipitators in Level 3), drug use history (life circumstances in Level 2), self-esteem (personal attributes in Level 1), and age of first homosexual intercourse (upbringing experience in Level 1). We hypothesize that ever engaging in transactional sex, having had a casual sex partnership in the past month, together with drug use history would be positively associated with IPV victimization/perpetration among Chinese MSM population. We also hypothesize that MSM with higher self-esteem levels and who had first homosexual intercourse at the age of 18 or older would be less likely to engage in victimization/perpetration of IPV.

Methods

Study Design and Participants

Inclusion criteria included the following: (a) aged 18 years or above, (b) Chinese man who had anal sex with at least one man in the last 6 months, (c) living in Chengdu, China, and (d) having had at least one regular intimate partner in their lifetime, defined as a primary male partner whom the participant is currently dating or in an ongoing intimate relationship with (Davis et al., 2016).

The cross-sectional study was conducted in Chengdu, China, from November 2018 to March 2019. Participants were recruited from an MSM-friendly local health consulting service center in Chengdu. Two staff of the center with field study experience implemented the survey. The field workers approached eligible participants, briefed them about the study and logistics, and invited them to participate until the target sample size was met. Participants were assured that refusal would not affect their right to use services and that they could quit any time during the survey without been questioned. Informed consent was sought before the commencement of face-to-face interviews. This study used a structured questionnaire in Chinese which took about 20 minutes to complete and monetary compensation of CNY 50 (about US$6) was provided to the participants. A research assistant was stationed at the center to monitor the process and quality of the investigation. A total of 540 eligible MSM were approached, of whom 431 (response rate: 80%) completed the interview. Ethical approval was obtained from Sun Yat-sen University before project implementation (approval iD. 2018-049).

Measurement

Background characteristics of the participants

Information was collected on participants’ sociodemographic characteristics and behavioral variables, for example, age, ethnicity, residence type, education level, employment status, sexual orientation, marital status, experience of transactional sex, drug use, age of first homosexual intercourse, and casual sexual partnership in the last month.

Intimate partner violence

Presence of IPV was assessed using the IPV-GBM scale, which covered five dimensions: (a) physical violence, that is, “Have any of the following happened in your relationship with your intimate partner: destruction of property, grabbing, restraining, pushing, kicking, slapping, punching, threats of violence or other acts of physical intimidation?”; (b) sexual violence, that is, “Have you ever had compulsive sex with an intimate partner? Examples may include any of the following: oral or anal sex, having sex with others, having sexual partners outside the relationship, or any other sexual activity that made you feel uncomfortable.”; (c) monitoring behaviors, that is, “Have any of the following happened in your relationship with your intimate partner: demanding access to cell phone and email, reading email or text messages without partner knowledge and repeatedly posting on a partner’s social network pages?”; (d) controlling behaviors, that is, “Have any of the following happened in your relationship with your intimate partner: preventing a partner from seeing his family/friends/ colleagues or communicating with them?”; and (e) emotional violence, that is, “Have any of the following happened in your relationship with your intimate partner: insulting a partner (by making insulting comments about him), criticizing him (by criticizing him for being fat, for dressing up, for sexual behaviors, their appearance, etc.), threatening him (by threatening to break off the relationship), yelling at him or demanding that he be more manly?” There are four options for each question: (a) option A, “I have done the above to my partner”; (b) option B, “My partner has done the above to me”; (c) option C, “Both A and B”; and (d) option D, “Neither A nor B.” In this study, participants who endorsed option A or C were defined as perpetrators, and participants who endorsed option B or C were defined as victims. For each type of IPV, we defined three variables: victimization through specific violence (participants who endorsed option A or C); perpetration of specific violence (participants who endorsed option A or C); and any experience of violence (participants who endorsed option A or B or C). Furthermore, to better calculate the prevalence of IPV, we also defined three other variables: any IPV (participants who endorsed either option A or B or C in any of the five questions); any IPV victimization (participants who endorsed either option B or C in any of the five questions); and any IPV perpetration (participants who endorsed either option A or C in any of the five questions). This scale has been used in a number of studies published in English (Stephenson & Finneran, 2017; Stephenson et al., 2013, 2016). The translation from English to Mandarin was conducted by two staff members independently, and the final version was formed after discussion. We conducted a pilot test to ensure that its words are understandable and conform to the habits of Chinese expressions. Cronbach’s alpha was 0.7 in this study.

Self-esteem

Participants’ self-esteem levels were measured by the Rosenberg Self-Esteem Scale (RSES), a commonly used self-esteem scale in social science research which has been widely applied to Chinese populations (Ang et al., 2006; C. H. Wu, 2008; Y. Wu et al., 2017). The scale consists of 10 items, five worded positively and five worded negatively, with good reliability and validity. Participants were asked to rate each item on a 4-point Likert-type scale from 1 (Strongly Disagree) to 4 (Strongly agree), and the higher final score corresponded to higher self-esteem level. Cronbach’s alpha was 0.8 in this study.

Statistical Analysis

IPV victimization, IPV perpetration, and any IPV experiences were used as the dependent binary variables. Bivariate logistic regression analyses were used to examine associations between sociodemographic characteristics and the dependent variables. Multiple logistic regression models were then fit to investigate relationships between associated factors and the dependent variables adjusting for the corresponding background variables that were statistically significant (p < .05) or marginally significant (p < .1) in univariate logistic regression analysis. We obtained unadjusted odds ratios (ORu) from univariate logistic regression models, adjusted odds ratios (ORa) from multiple logistic regression models, and their respective 95% confidence intervals (CIs). Correlations among dichotomous variables of victimization by or perpetration of IPV in various dimensions (i.e., physical, sexual, monitoring, controlling, and emotional) were assessed by phi correlation coefficients. Data analyses were performed using SPSS 21.0 (SPSS Inc., Chicago, IL), and p < .05 was considered as statistically significant.

Results

Background and behavioral characteristics are presented in Table 1 with details. Of the 431 participants, 75.6% were less than 30 years old (M = 27.6, SD = 8.2, ranged from 18 to 65); more than half of the participants (58.7%, 253/431) had attended university or above and were employed full-time (65.7%, 283/431); the majority of the participants (77.7%, 335/431) self-reported their sexual orientation as homosexual and 16.2% (70/431) reported as bisexual; 34.3% (148/431) of them were married and 7.7% (22/431) self-reported having boyfriend(s) at the time of the survey; 28.1% (121/431) said they had ever used drugs such as methamphetamine and rush; 5.6% (24/431) said they had ever engaged in transactional sex, and 13.0% (56/431) reported having sex with a casual partner in the past month; 18.3% (79/431) reported their age of first homosexual intercourse was less than 18 years (M = 21.7, SD = 6.3, ranged from 12 to 55).

Table 1.

Demographic Characteristics of MSM in Chengdu, 2018 (N = 431).

Demographic characteristics	Frequency	Percentage (%)
Age
≤30	326	75.6
>30	105	24.4
Ethnicity
Han	419	97.2
Others	12	2.8
Residence
Chengdu	407	94.4
Others	24	5.6
Education level
University or above	253	58.7
Others	178	41.3
Marital status
Single	227	52.7
Married	148	34.3
Self-report having a boyfriend/boyfriends	22	7.7
Divorced/widow/others	23	5.3
Job
Full-time	283	65.7
Others	148	34.3
Sexual orientation
Bisexual	70	16.2
Homosexual	335	77.7
Transactional sex
Yes	24	5.6
No	407	94.4
Drug use
Yes	121	28.1
No	310	71.9
Age of first homosexual intercourse
<18	79	18.3
≥18	352	81.7
Having had a casual sexual partnership in the past month
Yes	56	13.0
No	375	87.0

Note. MSM = men who have sex with men; N = total number of participants.

The prevalence of different types of IPV is presented in Table 2 with details. Among all participants, 190 (44.1%) reported at least one of the five types of lifetime IPV experiences (physical, sexual, monitoring, controlling, and emotional). Specifically, 35.5% reported IPV victimization, and 27.6% reported IPV perpetration. The prevalence of victimization through physical, sexual, monitoring, controlling, and emotional violence was 7.2%, 8.8%, 11.8%, 7.9%, and 12.3% respectively, and the rate of perpetration of each of these five types of violence was 7.4%, 7.2%, 11.4%, 5.8%, and 12.3%, respectively.

Table 2.

Lifetime Prevalence of IPV With Regular Partners (N = 431).

Types of IPV	Frequency	Percentage (%)
Physical violence
Any	43	10.0
Victimization	31	7.2
Perpetration	32	7.4
Sexual violence
Any	48	11.1
Victimization	38	8.8
Perpetration	31	7.2
Monitoring behavior
Any	70	16.2
Victimization	51	11.8
Perpetration	49	11.4
Controlling behavior
Any	40	9.3
Victimization	34	7.9
Perpetration	25	5.8
Emotional violence
Any	70	16.2
Victimization	53	12.3
Perpetration	53	12.3
Any IPV	190	44.1
Any IPV victimization	153	35.5
Any IPV perpetration	119	27.6

Note. IPV= intimate partner violence.

Factors associated with IPV victimization

After adjusting for education background, which was the only significant background factor for victimization through sexual violence (p = .032; Table 3), higher self-esteem (ORa = 0.9; 95% CI = [0.8, 1.0]; p = .006) was negatively associated, and having had casual sex partnership in the past month (ORa = 2.4; 95% CI = [1.1, 5.4]; p = .027) was positively associated with victimization through sexual violence (Table 4). After adjusting for age (p = .031; Table 3), being ever engaged in transactional sex was positively associated with victimization through monitoring behavior (ORa = 2.7; 95% CI = [1.0, 7.4]; p = .045; Table 4). Drug use was positively associated with victimization through controlling behaviors (ORu = 2.5; 95% CI = [1.2, 5.0]; p = .012; Table 3). After adjusting for age and marital status (p < .1), higher self-esteem (ORa = 0.9; 95% CI = [0.8, 1.0]; p = .012; Table 4) was negatively while drug use (ORa = 1.9; 95% CI = [1.0, 3.5]; p = .037; Table 4) was positively associated with victimization through emotional violence.

Table 3.

Association Between IPV Victimization and Background Variables.

Variables	Types of IPV victimization
	Physical			Sexual			Monitoring			Controlling			Emotional			Any IPV
	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value
Demographic characteristics
Age
≤30	7.4	1.0		9.5	1.0		13.8	1.0		8.3	1.0		14.7	1.0		39.0	1.0
>30	6.7	0.9 [0.4, 2.2]	.811	6.7	0.7 [0.3, 1.6]	.374	5.7	0.4 [0.2, 0.9]	.031	6.7	0.8 [0.3, 1.9]	.594	4.8	0.3 [0.1, 0.7]	.10	24.8	0.5 [0.3, 0.8]	.009
Ethnicity
Han	7.2	0.8 [0.1, 6.8]	.877	8.6	0.5 [0.1, 2.2]	.342	11.9	1.5 [0.2, 11.8]	.705	7.9	0.9 [0.1, 7.5]	.954	12.4	1.6 [0.2, 12.3]	.674	35.8	1.7 [0.4, 6.3]	.445
Others	8.3	1.0		16.7	1.0		8.3	1.0		8.3	1.0		8.3	1.0		25.0	1.0
Education level
University or above	7.9	1.3 [0.6, 2.8]	.496	6.3	0.5 [0.2, 0.9]	.032	13.0	1.3 [0.7, 2.5]	.355	6.3	0.6 [0.3, 1.2]	.154	13.0	1.2 [0.7, 2.1]	.574	39.1	1.5 [1.0, 2.2]	.061
Others	6.2	1.0		12.4	1.0		10.1	1.0		10.1	1.0		11.2	1.0		30.3	1.0
Marital status
Single	6.2	1.0		9.7	1.0		10.6	1.0		9.7	1.0		11.0	1.0		34.4	1.0
Married	0.0	0.0	.998	6.1	0.6 [0.01, 2.7]	.505	3.0	0.3 [0.0, 2.0]	.200	0.0	0.0	.998	0.0	0.0	.998	12.1	0.3 [0.1, 0.8]	.016
Having boyfriend(s)	10.1	1.7 [0.8, 3.7]	.164	8.8	0.9 [0.04,1.8]	.768	16.2	1.6 [0.9, 3.0]	.112	6.8	0.7 [0.3, 1.5]	.323	18.2	1.8 [1.0, 3.2]	.050	43.2	1.5 [1.0, 2.2]	.084
Others	8.7	1.4 [0.3, 6.8]	.639	4.3	0.4 [0.1, 3.3]	.412	8.7	0.8 [0.2, 3.7]	.779	8.7	0.9 [0.2, 4.0]	.877	4.3	0.4 [0.0, 2.8]	.337	30.4	0.8 [0.3, 2.1]	.7
Job
Full-time	9.2	2.9 [1.1, 7.7]	.033	8.1	0.8 [0.4, 1.5]	.486	11.7	1.0 [0.5, 1.8]	.953	8.1	1.1 [0.5, 2.3]	.799	11.3	0.8 [0.4, 1.4]	.388	33.2	0.8 [0.5, 1.1]	.171
Others	3.4	1.0		10.1	1.0		12.2	1.0		7.4	1.0		14.2	1.0		39.9	1.0
Sexual orientation
Bisexual	4.3	1.0		7.1	1.0		10.0	1.0		7.1	1.0		8.6	1.0		31.4	1.0
Homosexual	8.4	2.0 [0.6, 6.9]	.253	9.6	1.4 [0.5, 3.7]	.526	12.2	1.3 [0.5, 2.9]	.599	8.7	1.2 [0.5, 3.3]	.678	14.0	1.7 [0.7, 4.2]	.223	36.7	1.3 [0.7, 2.2]	.401
Not sure/others	0.0	0.0	.998	3.8	0.5 [0.1, 4.7]	.559	11.5	1.2 [0.3, 4.9]	.827	0.0	0.0	.998	0.0	0.0	.998	30.8	1.0 [0.4, 2.6]	.970
Transactional sex
Yes	4.2	0.5 [0.1, 4.2]	.561	12.5	1.5 [0.4, 5.3]	.515	25.0	2.7 [1.0, 7.1]	.047	12.5	1.7 [0.5, 6.1]	.394	8.3	0.6 [0.1, 2.8]	.546	45.8	1.6 [0.7, 3.6]	.280
No	7.4	1.0		8.6	1.0		11.1	1.0		7.6	1.0		12.5	1.0		34.9	1.0
Drug use
Yes	9.1	1.5 [0.7, 3.1]	.343	11.6	1.6 [0.8, 3.1]	.211	14.9	1.5 [0.8, 2.7]	.224	13.2	2.5 [1.2, 5.0]	.012	19.0	2.2 [1.2, 4.0]	.009	42.1	1.5 [1.0, 2.3]	.072
No	6.5	1.0		7.7	1.0		10.6	1.0		5.8	1.0		9.7	1.0		32.9	1.0
Age of first homosexual intercourse
<18	6.8	1.0		12.7	1.0		16.5	1.0		8.9	1.0		19.0	1.0		45.6	1.0
≥18	8.9	0.8 [0.3, 1.8]	.527	8.0	0.6 [0.3, 1.3]	.187	10.8	0.6 [0.3, 1.2]	.162	7.7	0.9 [0.4, 2.0]	.723	10.8	0.5 [0.3, 1.0]	.048	33.2	0.6 [0.4, 1.0]	.040
Self-esteem		0.9 [0.8, 1.0]	.055		0.9 [0.8, 0.9]	.002		1.0 [0.9, 1.1]	.798		0.9 [0.8, 1.0]	.067		0.9 [0.8, 1.0]	.032		1.0 [0.9, 1.0]	.202
Having had a casual sexual partnership in the past month
Yes	12.5	2.1 [0.9, 5.1]	.106	17.9	2.7 [1.2, 5.9]	.013	12.5	1.1 [0.5, 2.5]	.868	10.7	1.5 [0.6, 3.8]	.403	3.6	0.2 [0.1, 1.0]	.049	41.1	1.3 [0.7, 2.3]	.351
No	6.4	1.0		7.5	1.0		11.7	1.0		7.5	1.0		13.6	1.0		34.7	1.0

Note. Statistically significant results with p value < .05 are in bold font. OR = odds ratio; CI = confidence interval; IPV = Intimate partner violence; Row (%) Indicates the proportion of people with different types of IPV victimization among participants with different characteristics. For example, 7.4% represents the proportion of people with physical violence victimization among participants who are aged 30 or less.

Table 4.

Adjusted Logistic Regression of IPV Victimization and Risk Factors.

Variables	IPV victimization
	Sexual		Monitoring		Controlling		Emotional		Any IPV
	ORa (95% CI)	p value	ORa (95% CI)	p value	ORa (95% CI)	p value	ORa (95% CI)	p value	ORa (95% CI)	p value
Transactional sex
Yes	NA	NA	2.7 [1.0, 7.4]	.045	NA	NA	NA	NA	NA	NA
No	NA	NA	1.0	NA	NA	NA	NA	NA	NA	NA
Drug use
Yes	NA	NA	NA	NA	2.5 [1.2, 5.0]	.012	1.9 [1.0, 3.5]	.037	NA	NA
No	NA	NA	NA	NA	1.0	NA	1.0	NA	NA	NA
Age of first homosexual intercourse
<18	NA	NA	NA	NA	NA	NA	1.0	NA	1.0	NA
>=18	NA	NA	NA	NA	NA	NA	0.6 [0.3, 1.1]	.112	0.6 [0.4, 1.0]	.067
Self-esteem	0.9 [0.8, 1.0]	.006	NA	NA	NA	NA	0.9 [0.8, 1.0]	.012	NA	NA
Having had a casual sexual partnership in the past month
Yes	2.4 [1.1, 5.4]	.027	NA	NA	NA	NA	0.3 [0.1, 1.3]	.097	NA	NA
No	1.0	NA	NA	NA	NA	NA	1.0	NA	NA	NA

Note. Statistically significant results with p value < .05 are in bold font. ORa = adjusted odds ratio; CI = confidence interval; IPV= Intimate partner violence.

Factors associated with IPV perpetration

There were no background variables that were significantly or marginally significantly associated with perpetration of physical/sexual violence. Age of first homosexual intercourse of 18 or older was negatively associated with perpetration of both physical (ORu = 0.3; 95% CI = [0.2, 0.7]; p = .005) and sexual violence (ORu = 0.4; 95% CI = [0.2, 1.0]; p = .042). Higher self-esteem was negatively associated with perpetration of sexual violence (OR = 0.9; 95% CI = [0.8, 1.0]; p = .038; Table 5). After adjusting for age, marital status, and sexual orientation, being ever engaged in transactional sex (ORa = 3.9; 95% CI = [1.5, 10.4]; p = .006) remained positively associated with perpetration of monitoring behaviors. Similarly, associations between higher self-esteem (ORa = 0.9; 95% CI = [0.8, 1.0]; p = .007) and perpetration of emotional violence remained significant after adjusting for age and marital status (Table 6).

Table 5.

Association Between IPV Perpetration and Background Variables.

Variables	Types of IPV perpetration
	Physical			Sexual			Monitoring			Controlling			Emotional			Any IPV
	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value	ROW (%)	OR (95% CI)	p value
Age
≤30	6.7	1.0		8.0	1.0		12.9	1.0		6.4	1.0		14.1	1.0		30.7	1.0
>30	9.5	1.5 [0.7, 3.2]	.348	4.8	0.6 [0.2, 1.5]	.273	6.7	0.5 [0.2, 1.1]	.087	3.8	0.6 [0.2, 1.7]	.321	6.7	0.4 [0.2, 1.0]	.049	18.1	0.5 [0.3, 0.9]	.013
Ethnicity
Han	7.6	133,579,333.2	.999	7.2	0.8 [0.1, 6.8]	.877	11.7	213,941,289	.999	6.0	102,504,744	.999	12.6	233,934,996	.999	27.7	1.1 [0.3 4.3]	.838
Others	0.0	1.0		8.3	1.0		0.0	1.0		0.0	1.0		0.0	1.0		25.0	1.0
Education level
University or above	7.5	1.0 [0.5, 2.1]	.936	6.3	0.7 [0.4, 1.5]	.407	13.4	1.7 [0.9, 3.2]	.109	5.1	0.7 [0.3, 1.7]	.485	13.4	1.3 [0.7, 2.4]	.390	28.5	1.1 [0.7, 1.7]	.639
Others	7.3	1.0		8.4	1.0		8.4	1.0		6.7	1.0		10.7	1.0		26.4	1.0
Marital status
Single	6.6	1.0		7.9	1.0		9.7	1.0		7.9	1.0		10.6	1.0		26.9	1.0
Married	3.0	0.4 [0.1, 3.5]	.442	3.0	0.4 [0.0, 2.8]	.332	3.0	0.3 [0.0, 2.2]	.235	0.0	0.0	.998	0.0	0.0	.998	9.1	0.3 [0.1, 0.9]	.037
Having boyfriend(s)	8.8	1.4 [0.6, 2.9]	.435	7.4	0.9 [0.4, 2.0]	.932	16.9	1.9 [1.0, 3.5]	.042	3.4	0.4 [0.1, 1.1]	.081	18.2	1.9 [1.0, 3.4]	.036	33.8	1.4 [0.9, 2.2]	.153
Others	13.0	2.1 [0.6, 7.9]	.265	4.3	0.5 [0.1, 4.1]	.543	4.3	0.4 [0.1, 3.3]	.412	8.7	1.1 [0.2, 5.1]	.897	8.7	0.8 [0.2, 3.7]	.779	21.7	0.8 [0.3, 2.1]	.596
Job
Full-time	8.1	1.4 [0.6, 3.0]	.443	6.0	0.6 [0.3, 1.3]	.191	10.6	0.8 [0.4, 1.5]	.488	5.7	0.9 [0.4, 2.1]	.857	12.7	1.1 [0.6, 2.1]	.711	26.9	0.9 [0.6, 1.4]	.628
Others	6.1	1.0		9.5	1.0		12.8	1.0		6.1	1.0		11.5	1.0		29.1	1.0
Sexual orientation
Bisexual	8.6	1.0		4.3	1.0		5.7	1.0		4.3	1.0		7.1	1.0		25.7	1.0
Homosexual	7.5	0.9 [0.3, 2.2]	.751	8.1	2.0 [0.6, 6.6]	.281	13.1	2.5 [0.9, 7.2]	.090	6.3	1.5 [0.4, 5.2]	.525	13.7	2.1 [0.8, 5.4]	.138	29.0	1.2 [0.7, 2.1]	.585
Not sure/others	3.8	0.4 [0.0, 3.7]	.441	3.8	0.9 [0.1, 9.0]	.924	3.8	0.7 [0.1, 6.2]	.716	3.8	0.9 [0.1, 9.0]	.924	7.7	1.1 [0.2, 6.0]	.927	15.4	0.5 [0.2, 1.7]	.290
Transactional sex
Yes	8.3	1.1 [0.3, 5.1]	.861	16.7	2.8 [0.9, 8.8]	.076	29.2	3.6 [1.4, 9.1]	.008	12.5	2.5 [0.7, 9.0]	.162	20.8	2.0 [0.7, 5.5]	.198	25.0	0.9 [0.3, 2.2]	.769
No	7.4	1.0		6.6	1.0		10.3	1.0		5.4	1.0		11.8	1.0		27.8	1.0
Drug use
Yes	9.1	1.4 [0.6, 2.9]	.411	9.9	1.7 [0.8, 3.6]	.175	13.2	1.3 [0.7, 2.4]	.450	5.8	1.0 [0.4, 2.4]	.993	13.2	1.1 [0.6, 2.1]	.715	35.5	1.7 [1.1, 2.7]	.022
No	6.8	1.0		6.1	1.0		10.6	1.0		5.8	1.0		11.9	1.0		24.5	1.0
Age of first homosexual intercourse
<18	15.2	1.0		12.7	1.0		13.9	1.0		8.9	1.0		17.7	1.0		35.4	1.0
≥18	5.7	0.3 [0.2, 0.7]	.005	6.0	0.4 [0.2, 1.0]	.042	10.8	0.7 [0.4,1.5]	.430	5.1	0.6 [0.2, 1.4]	.204	11.1	0.6 [0.3, 1.1]	.108	25.9	0.6 [0.4, 1.1]	.086
Self-esteem		1.0 [0.9, 1.1]	.737		0.9 [0.8, 1.0]	.038		1.0 [0.9, 1.1]	.527		1.0 [0.8,1.0]	.116		0.9 [0.8, 1.0]	.021		0.9 [0.9, 1.0]	.089
Having had a casual sexual partnership in the past month
Yes	10.7	1.6 [0.6, 4.1]	.318	12.5	2.1 [0.9, 5.1]	.106	12.5	1.1 [0.5, 2.7]	.775	7.1	1.3 [0.4, 3.9]	.646	5.4	0.4 [0.1, 1.2]	.103	33.9	1.4 [0.8, 2.6]	.259
No	6.9	1.0		6.4	1.0		11.2	1.0		5.6	1.0		13.3	1.0		26.7	1.0

Note. Statistically significant results with p value < .05 are in bold font. OR = odds ratio; CI = confidence interval; IPV = intimate partner violence; Row (%) Indicates the proportion of people with different types of IPV perpetration among participants with different characteristics. For example, 6.7% represents the proportion of people with physical violence perpetration among participants who are aged 30 or less.

Table 6.

Adjusted Logistic Regression of IPV Perpetration and Risk Factors.

Variables	IPV perpetration
	Physical		Sexual		Monitoring		Emotional		Any IPV
	ORa (95% CI)	p value	ORa (95% CI)	p value	ORa (95% CI)	p value	ORa (95% CI)	p value	ORa (95% CI)	p value
Transactional sex
Yes	NA	NA	NA	NA	3.9 [1.5, 10.4]	.006	NA	NA	NA	NA
No	NA	NA	NA	NA	1.0	NA	NA	NA	NA	NA
Drug use
Yes	NA	NA	NA	NA	NA	NA	NA	NA	1.6 [1.0, 2.5]	.056
No	NA	NA	NA	NA	NA	NA	NA	NA	1.0	NA
Age of first homosexual intercourse
<18	1.0	NA	1.0	NA	NA	NA	NA	NA	NA	NA
≥18	0.3 [0.2,0.7]	.005	0.4 [0.2, 1.0]	.042	NA	NA	NA	NA	NA	NA
Self-esteem	NA	NA	0.9 [0.8, 1.0]	.038	NA	NA	0.9 [0.8, 1.0]	.007	NA	NA

Note: Statistically significant results with p value < .05 are in bold font. ORa = adjusted odds ratio; CI = confidence interval; IPV= Intimate partner violence.

Correlations among different types of IPV

The correlations among different types of IPV victimization and perpetration are presented in Tables 7 to 9. Table 7 shows that all five dimensions of IPV victimization experiences were correlated (p < .001). This meant that people who had experienced one type of IPV were more likely to be victims of other types of IPV. The associations among different IPV perpetrations were only found to be significant between physical and monitoring, physical and emotional, sexual and controlling, sexual and emotional, monitoring and emotional violence (Table 8). The associations between IPV victimization and perpetration were also found to be significant (Table 9). Overall, any lifetime IPV victimization was strongly associated with any lifetime IPV perpetration (phi = 0.832, p < .001).

Table 7.

Correlations Among Different Types of IPV Victimization.

Types of IPV	IPV victimization
Types of IPV	Physical	Sexual	Monitoring	Controlling	Emotional	Any IPV
Physical	NA	0.262*	0.315*	0.318*	0.306*	0.375*
Sexual	0.262*	NA	0.241*	0.334*	0.207*	0.419*
Monitoring	0.315*	0.241*	NA	0.372*	0.344*	0.494*
Controlling	0.318*	0.334*	0.372*	NA	0.336*	0.394*
Emotional	0.306*	0.207*	0.344*	0.336*	NA	0.505*
Any IPV	0.375*	0.419*	0.494*	0.394*	0.505*	NA

Note. Phi correlation coefficients were reported. IPV = intimate partner violence.

p < .001.

Table 8.

Correlations Among Different Types of IPV Perpetration.

Types of IPV	IPV perpetration
Types of IPV	Physical	Sexual	Monitoring	Controlling	Emotional	Any IPV
Physical	NA	0.092	0.177*	0.081	0.271*	0.320*
Sexual	0.092	NA	0.127	0.200*	0.224*	0.330*
Monitoring	0.177*	0.127	NA	0.161	0.289*	0.351*
Controlling	0.081	0.200*	0.161	NA	0.149	0.335*
Emotional	0.271*	0.224*	0.289*	0.149	NA	0.401*
Any IPV	0.320*	0.330*	0.351*	0.335*	0.401*	NA

Note. Phi correlation coefficients were reported. IPV = intimate partner violence.

p < .001.

Table 9.

Correlations Among IPV Victimization and Perpetration.

IPV victimIPV perpetrator	Physical	Sexual	Monitoring	Controlling	Emotional	Any IPV
Physical	0.606*	0.099	0.280*	0.213*	0.163	0.382*
Sexual	0.131	0.579*	0.204*	0.285*	0.224*	0.375*
Monitoring	0.127	0.121	0.548*	0.221*	0.267*	0.483*
Controlling	0.085	0.238*	0.124	0.627*	0.179*	0.334*
Emotional	0.197*	0.133	0.300*	0.205*	0.634*	0.505*
Any IPV	0.451*	0.503	0.593*	0.474*	0.606*	0.832*

Note. Phi correlation coefficients were reported. IPV = intimate partner violence.

p < .001.

Discussion

Although the current attention to IPV among MSM in China is insufficient, some researchers who engaged in this field had already reported the prevalence of IPV among MSM in some regions, mainly Shenyang and Shanghai (Braitstein et al., 2006; Davis et al., 2016; Liu et al., 2018; Wang et al., 2018). Despite the use of different scales and recall periods (ranging from the past 3 months to the lifetime) in previous research, the prevalence of IPV in the Chinese MSM population is consistently high. This study reported a lifetime prevalence of any IPV experiences of 44.1%, which is very close to a study conducted by Dunkle et al. (2013) (44.8%) and is higher than some earlier published reports in China (Davis et al., 2015; Liu et al., 2018; Wang et al., 2018). Part of the difference may stem from different study locations and measurements. Earlier domestic studies in this area tended to use the definition of IPV from the Centers for Disease Control (CDC) or their own definitions to estimate the IPV experience among MSM (Davis et al., 2015; Dunkle et al., 2013; Liu et al., 2018).

This is the first time that the IPV-GBM scale was applied in China. Although the scale was translated with minor adaptive modifications, the overall items are consistent with the original scale. In addition, some of our results are similar to those from previous studies, for instance, emotional violence is the most common type of IPV (28.3%–38.6%) (Davis et al., 2016; Stephenson & Finneran, 2017). To the best of our knowledge, this scale is the only measurement developed specifically for IPV among MSM (Buller et al., 2014; Dunkle et al., 2013; Stephenson & Finneran, 2013); hence, a further evaluation of its applicability in the Chinese MSM population is recommended.

This study reported the associations between IPV and a history of having transactional sex or having sex with a casual partner(s) in the Chinese MSM population, which is consistent with previous studies (Davis et al., 2015; Liu et al., 2018). According to previous studies, these risky sexual behaviors could result in IPV experiences, and IPV experience may also result in risk behaviors (Wheeler et al., 2014). To discern the mechanism underlying this complex association is difficult because risky sexual behaviors and associated factors may occur and intensify simultaneously within complicated social and psychosocial contexts (Jie et al., 2012).

We also reported an association between drug use and IPV, which is also consistent with previous studies (Chong et al., 2013; Houston & McKirnan, 2007; Ibragimov et al., 2017; Li et al., 2012; Nehl et al., 2015; Stults et al., 2015; Wheeler et al., 2014; E. Wu et al., 2015). Some researchers suggest that there is a reciprocal feedback loop between drug use and IPV (Kilpatrick et al., 1997; Stults et al., 2015). The victim of IPV may face multiple forms of interpersonal trauma throughout their lives, and drug use or addiction may be used as their coping mechanism for such trauma; meanwhile, drug use could also trigger violence (Rivera et al., 2015). In general, the bidirectional relationships between IPV and drug use remain obscure. We encourage further research to fully untangle the latent causal relationship.

It is worth mentioning some new findings from this study. The association between the age of first homosexual intercourse, self-esteem, and IPV is a novel finding from this research. This study found that being 18 or older for first homosexual intercourse is negatively associated with perpetration of physical and sexual violence. To our knowledge, there is no existing research that reported a significant association between the ages of first sexual behavior and IPV in Chinese MSM populations. Based on the nature of this study, the underlying causal relationship cannot be explained, but the findings shed new light on the development of interventions. For example, very young people might be lacking in both romantic and sexual experiences, or may have not learnt methods to guarantee their safety during their first homosexual intercourse as well as during interpersonal conflicts. Thus, education on sexual health and coping strategies for interpersonal conflicts among adolescents may help to reduce the probability of IPV experiences.

This study reports that MSM with higher self-esteem levels are less likely to be either victims or perpetrators of sexual and emotional violence. Previous studies among heterosexual population have revealed that low self-esteem is associated with IPV (Donnellan et al., 2005; Kataoka et al., 2003; Pflieger & Vazsonyi, 2006; Vagi et al., 2015). According to these studies, individuals with low self-esteem are at increased risk of violent, aggressive, and criminal behaviors in adulthood and are also prone to partner violence (Donnellan et al., 2005; Kataoka et al., 2003; Pflieger & Vazsonyi, 2006; Vagi et al., 2015). Possible explanations may be that low self-evaluation and insensitivity to violence would lead to nonresistance to and/or connivance with partner violence. Meanwhile, individuals with low self-esteem may respond to violent behaviors with aggression and violence due to emotional outbursts and loss of control caused by self-injury (Hickman et al., 2004; Saunders et al., 1993). Few studies have explored self-esteem and IPV among MSM populations globally, and they show that MSM who experienced victimization by or perpetrated domestic abuse were likely to have lower self-esteem, which is consistent with our finding (McKenry et al., 2006; Nieves-Rosa et al., 2000). The role of high self-esteem in reducing violent events warrants further investigation and may be particularly important for designing interventions in settings like China, where full legal protections for MSM are not present.

This study has some advantages including innovatively using targeted scales and measuring different types of IPV victimization/perpetration comprehensively. Compared with previous studies, which mainly discussed the impact of IPV experiences on risky sex and HIV transmission (Buller et al., 2014; Davis et al., 2015, 2016; Dunkle et al., 2013; Finneran & Stephenson, 2013; R. Stephenson & Finneran, 2017; Wang et al., 2018; Wheeler et al., 2014), this study focuses on the factors affecting the occurrence of IPV, which enriches the domestic research in this field.

This study also has some limitations. First, the study explored the lifetime prevalence of IPV experiences, which could result in recall and misclassification bias, especially for older participants. Second, IPV is a sensitive topic, so the social desirability bias from self-reporting measurements might exist. In addition, the frequency or severity of IPV experiences has not yet been explored, nor did we distinguish the roles of victims from perpetrators. Further research should more rigorously measure the experiences of IPV. Third, due to the venue-based recruitment strategy, these results may not be generalizable to all MSM populations in China or globally. Last, the cross-sectional nature of this study made it impossible to draw causal inferences from the study findings. We encourage future studies to employ longitudinal methods to determine causal correlations between these variables.

Conclusions

This study quantified the experience of IPV among MSM in China and explored some factors associated with IPV experiences such as self-esteem and the age of first homosexual intercourse, which were seldom examined in previous studies. Particular attention should also be given to the risk factors for IPV including drug use and risky sexual behaviors. Given the high prevalence of IPV found among the population that is overlooked by the law against violence in China, it is important to understand key factors that are desperately needed in developing public services toward prevention and intervention before legal aids are available. From our understanding, the key factors for targeted interventions specific to MSM include improving self-esteem, decreasing drug use, strengthening education on safe sex, and prioritizing MSM who started having homosexual sex at earlier ages. Based on the correlations between victimization and perpetration of different types of IPV, the establishment of social support for MSM has to cope with the co-occurrence of IPV experiences.

Footnotes

Acknowledgements

The authors would like to thank all participants who have taken part in this study and all field workers for their support on data collection.

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 study was supported by the National Natural Science Foundation of China (grant numbers 81803334, 71774178, and 71974212), the Natural Science Foundation of Guangdong Province (grant no. 2017A030310561), a Major Infectious Disease Prevention and Control of the National Science and Technique Major Project (grant no. 2018ZX10715004), Science and Technology Planning Project of Guangdong Province (grant no. 2017A020212006), Science and Technology Research Project of Guangzhou (grant nos. 201504291407178 and 201607010368), and the China Medical Board (grant no. 18-301).

ORCID iDs

Fengsu Hou

Wangnan Cao

Jinghua Li

Notes

Author Biographies

Dannuo Wei is currently a master student majoring in social medicine and health service management in School of Public Health, Sun Yat-sen University. She received her bachelor’s degree from Xiamen University. She has an active interest in intimate partner violence among men who have sex with men and its potential related factors. She is also interested in the possible negative mental health effects associated with violence experience among MSM in China.

Fengsu Hou is now a research associated professor with the Department of Public Mental Health, Shenzhen Kangning Hospital, and also an adjunct assistant professor at the Department of Psychiatry, University of Rochester Medical Center. His research interests include IPV, depression, and suicide prevention among women and LGB population in China.

Stuart Gilmour is now a professor at St. Luke’s International University. His current research areas include mental health, society medicine, epidemiology and statistics, quantitative health system assessment, and health inequality.

Chun Hao is a deputy director at the Sun Yat-sen Global Health Institute (SGHI). As a Takemi Fellow at Harvard School of Public Health, the project she participated in include the policy and practice of integrating HIV and sexual/reproductive health services in Mexico and the health promotion project for tobacco workers in Southern Brazil to improve their asthma symptoms.

Jing Gu is a professor and head of the Department of Medical Statistics of School of Public Health, Sun Yat-sen University. Her research interests include behavioral health, health intervention, and evaluation in vulnerable populations. Her studies were supported by China National Science Foundation, NIH, and other regional grants. She has published over 80 papers in peer-reviewed international journals.

Rubee Dev is a postdoctoral fellow at the Sun Yat-sen Global Health Institute, Sun Yat-sen University. Her area of research interest is maternal and child health and adolescent sexual and reproductive health. In particular, much of her work entails extensive research to identify the data gaps and opportunities for action in meeting the needs of adolescent girls and adult women.

Wangnan Cao is a visiting scholar at the School of Public Health, Brown University. Her research focuses on behavior change interventions with a focus on men who have sex with men and women. She has a particular interest in disclosure of HIV serostatus and sexual orientation to social network members.

Liping Peng is currently a master student trained in Medical Statistics and Epidemiology in school of public health, Sun Yat-sen University. She received her bachelor’s degree from Sun Yat-sen University. Her areas of research interests include sexual behaviors among men who have sex with men, HIV biomedical interventions and mathematical modeling of infectious diseases.

Keru Wang is a master of public health at the school of public health, Sun Yat-sen University. He received his bachelor’s degree from Guangdong Medical University. He is working on projects about dynamic model of HIV among men who have sex with men in China.

Jinghua Li is an associate professor in School of Public Health, Sun Yat-sen University. She received her PhD degree from the Chinese University of Hong Kong, Master’s degree from the University of Tokyo, and Bachelor’s degree from Tsinghua University. Her research interests include behavioral health, epidemiological modeling, economic evaluation, and mental health among LGBT population in China.

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