Intimate Partner Violence Predicts Posttraumatic Stress Disorder Severity Independent of Early Life and Deployment-Related Trauma in Deployed Men and Women Veterans

Abstract

Intimate partner violence (IPV) refers to emotional, physical, and/or sexual abuse perpetrated by a current or former partner. IPV affects both genders, though little is known about its effects on men as victims. The aims of this study were to determine if IPV is a factor contributing to posttraumatic stress disorder (PTSD) severity independently of deployment-related trauma, and to determine if there are gender differences in these associations. Participants were 46 female and 471 male post-9/11 veterans. Four sequential regressions were employed to examine the independent contribution of IPV among multiple trauma types on PTSD severity in men and women at two epochs, post-deployment (participants were anchored to deployment-related PTSD symptoms) and current (within the past month). Models were significant for both epochs in men (ps < .001) but not in women (ps > .230). In men, IPV independently predicted PTSD severity in both epochs (β > .093). However, in women, early life trauma (β = .284), but not IPV was a significant and independent predictor for current PTSD. Thus, there are distinct gender differences in how trauma type contributes to PTSD symptom severity. Although the statistical models were not significant in women, we observed similar patterns of results as in men and, in some cases, the β was actually higher in women than in men, suggesting a lack of power in our analyses. More research is clearly needed to follow-up these results; however, our findings indicate that IPV is a contributing factor to PTSD severity in veterans.

Keywords

intimate partner violence gender issues military posttraumatic stress disorder

Intimate partner violence (IPV) includes sexual and physical violence, stalking, and psychological aggression and coercion, and is a pervasive health problem affecting both men and women. While the effects of IPV are well documented in women very little is known about its effects on men as victims, as much of the research concerning men focuses on their role as perpetrators rather than victims (Machisa et al., 2016; Norlander & Eckhardt, 2005; Pegram et al., 2018; Walling et al., 2012). This knowledge gap may be a significant barrier to health status in the veteran population that is both dominated by men and burdened with a high prevalence of psychological distress associated with military deployment, specifically posttraumatic stress disorder (PTSD). Research has shown that the prevalence of IPV is up to three times higher among veterans (Love et al., 2015) than comparable civilian groups. It is critical, therefore, to determine whether a history of IPV influences current PTSD symptom severity in both men and women who have also experienced deployment-related trauma to gain a complete understanding of the contributing factors to PTSD symptom severity to improve and target treatment accordingly.

Our lack of knowledge regarding the influence of IPV on PTSD symptom severity in deployed male veterans poses a significant challenge because little is known on how to even identify victims. Currently, screening processes for IPV are routine for women veterans receiving care at a VA (Dichter et al., 2017); however, to our knowledge, similar screenings are not routinely administered to men. As a result, men are not easily identified for treatment for IPV-related health issues. Reported prevalence most likely do not represent the accurate prevalence of IPV due to underreporting in both military and civilian populations. Victims may not come forth for a number of reasons, including fear of retribution by the perpetrator, shame, or stigma associated with experiencing abuse. This tendency to underreport may be more salient for men, particularly veteran men, because of stigma in seeking help for mental health issues in general, perceived societal norms for masculinity (Seidler et al., 2016), and masculine military culture and fear that it might influence career trajectory (Held & Owens, 2013; Hoge et al., 2004). Not surprisingly, very little research has examined the impact of IPV victimization on men. In a recent meta-analysis of 58 studies of IPV in veterans, only one study focused on men as victims, whereas women veterans were the focus of the remaining 57 studies, even when those studies included both men and women (Sparrow et al., 2020). This meta-analysis found similar prevalence of IPV victims between men and women, which underscores the importance of including male IPV victims in studies of psychological effects. Another study (LaMotte et al., 2014) investigated the relationship between combat exposure and relationship distress in post-9/11 era veterans. Specifically, they compared reports of relationship distress and violence between male veterans and their female partners. Male veterans reported higher levels of intimate partner aggression, which encompassed physical and psychological aggression, than did their female partners. The authors suggested that the underreporting of male veteran’s aggression by female partners was likely the result of the partner trying to protect the veteran from negative consequences such as legal or financial loss. To our knowledge, no study has examined the impact of IPV on PTSD symptom severity in male veteran at two epochs.

As mentioned, the majority of available research on the topic of IPV has focused almost exclusively on its effects on women (Dekel et al., 2020; Valera et al., 2019). This may be because the reported prevalence of IPV is higher for women (2015 National Intimate Partner and Sexual Violence Survey [NISVS] Data Brief Violence Prevention Injury Center CDC, 2018), women are more likely to sustain serious injury as a result of IPV (Hunnicutt et al., 2019; Kivelä et al., 2019), or the greater stigma associated with male IPV reporting. Although it remains underreported in women, it has been well established that women who sustain physical injury resulting from IPV report to emergency department for face, neck, head, and abdominal injuries (George et al., 2019; Wong et al., 2014). Women victims of IPV also experience higher prevalence of PTSD and depression than do women who have not experienced IPV (Lövestad et al., 2017; Miles-McLean et al., 2019). Furthermore, IPV increases utilization of physical and mental health services in women (Dichter et al., 2018; Kothari et al., 2015).

Another important consideration in thinking about the contribution of IPV to current PTSD severity in veterans is that, overall, military populations are at a high risk for developing chronic and severe PTSD due to exposure to multiple types of traumatic events (Frans et al., 2005; Gerber et al., 2018). Trauma exposure is limited to not only military trauma (Amir et al., 1996) and IPV (Coker et al., 2005) but also sexual and interpersonal violence by non-intimate partners (Guina et al., 2019), as well as early life trauma (ELT; Macdonald et al., 2010). Furthermore, studies that have investigated the combination of trauma types suggest a conditional risk for developing PTSD and more severe PTSD symptomatology is associated with interpersonal trauma types (Cougle et al., 2009; Hetzel-Riggin & Roby, 2013). It is important to note that civilians experience ELT and IPV and these experiences lead to a higher risk for and more severe PTSD. However, studies that compare both populations indicate that veterans are more likely to experience ELT (Blosnich et al., 2014) and IPV (Taft et al., 2012). The confluence of multiple trauma exposures puts veterans in a unique situation with greater risk of developing PTSD and poor functional outcomes. Exposure to multiple traumatic events makes it difficult to determine whether experiencing IPV independently contributes to PTSD symptom severity. This co-occurrence of traumatic events in veterans complicates their clinical presentation and has implications for assessment and treatment. Thus, the aim of this study was to investigate the independent and combined contribution of trauma types to PTSD symptom severity in men and women veterans. We were specifically interested in whether a history of IPV contributes to PTSD symptom severity over-and-above other factors common in this population including combat exposure, military-related traumatic brain injury (TBI), and ELT, three significant risk factors for developing PTSD. In addition, because not much is known about how IPV affects men as victims, as well as possible differential gender effects in development of PTSD among IPV survivors, we examined men and women separately. To address how trauma may contribute to PTSD severity over time, we examined PTSD symptom severity at two time epochs: (a) PTSD severity in the past month (current); and (b) PTSD severity at the time the veteran identifies as their “worst” month since deployment (post-deployment).

Method

Participants

Participants were women (n = 49) and men (n = 479) consecutively enrolled post-9/11 veterans from the longitudinal cohort study at the Translational Research Center for TBI and Stress Disorders (TRACTS) at VA Boston Healthcare System, a TBI National Netword Research Center. Exclusion criteria included prior serious medical and/or neurological illnesses unrelated to TBI, active suicidal and/or homicidal ideation requiring intervention, or a current diagnosis of bipolar disorder or psychotic disorder (except psychosis not otherwise specified due to trauma-related hallucinations) according to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000).

As such, eight men and one woman were excluded for factors that could substantially impact neurological, cognitive, and psychiatric function, such as low premorbid IQ, possible personality disorder or psychotic diagnoses, and congenital neurological irregularities, respectively. Data for ELT and IPV were missing for two men and two women, two men were missing data for the Clinician Administered PTSD Scale (CAPS), and five women and 33 men were missing data for combat experiences, leaving data from 430 men and 41 women available for data analysis resulting in a final total n = 471. Participants with missing data were excluded from regression analyses.

All participants completed around 10 hr of biological, psychiatric, neuropsychological, and neuroimaging assessment. The study was approved by the VA Boston Healthcare System Institutional Review Board and all participants provided written informed consent. Participants were provided $210 for their time and travel costs.

Clinical Measures

Demographics, combat exposure, and TBI

A demographics questionnaire was used to collect information pertaining to gender, race/ethnicity, education, and health history. Combat exposure and experiences were assessed using the Deployment Risk and Resilience Inventory (DRRI): Combat Experience Scale (King et al., 2006). The DRRI is composed of 17 subscales that focus on risk and resilience factors related to deployment. This study used only the Deployment Experience subscale, which consists of 16 questions that ask if an individual experienced certain combat-related events. Answer options range from 0 (never) to 4 (daily or almost daily). In our sample, the DRRI had good reliability (Cronbach’s α = .89).

The Boston Assessment of TBI-Lifetime (BAT-L; Fortier et al., 2014), a validated, semi-structured clinical interview, was used to assess participants’ history of TBI that occurred during deployment. The BAT-L provides information on the number of TBIs, severity, and nature of TBI (e.g., blunt and blast-related mechanism of injury).

PTSD

A doctoral-level psychologist assessed PTSD symptoms using the CAPS for the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994; Blake et al., 1995). The CAPS is a structured clinical interview during which participants are asked to rate the frequency and intensity of symptoms related to PTSD on a scale ranging from 0 to 4. Higher scores on the CAPS reflect more severe PTSD symptomatology. In our sample, the CAPS had excellent reliability (Cronbach’s α = .96). The CAPS was used to assess PTSD diagnoses and symptom severity at two time epochs, worst month post-deployment and in the past month (current). Post-deployment refers to the time period occurring after any deployment throughout their military career during which participants reported that their PTSD symptoms were the worst. Current refers to the 1-month time period prior to the assessment. The psychologist-administered interviews (BAT-L, CAPS) were reviewed for diagnostic agreement during weekly consensus meetings including at least three doctoral-level psychologists.

IPV

Three questions from the Traumatic Life Events Questionnaire (TLEQ; Kubany et al., 2000) were used to identify participants with a lifetime history of IPV. The TLEQ is a 22 question self-report measure of exposure to 22 distinct traumatic events. Each question asks participants how many times they have been exposed to a particular traumatic event on a scale from “Once” to “>5 Times.” Participants are also asked to include the age the event started and ended, if physical injury occurred, and, if appropriate, who perpetrated the (acquaintance/friend, stranger, family member, and intimate partner). These questions were as follows: Item 9 “Has anyone threatened to kill you or cause you serious physical harm” and Item 17 “Has anyone stalked you-in other words: followed you or kept track of your activities-causing you to feel intimidated or concerned for your safety?” being committed by an intimate partner, as well as Item 12 “Have you ever been slapped, punched, kicked, beaten up, or otherwise physically hurt by your spouse (or former spouse), a boy/girlfriend, or some other intimate partner?” Because the TLEQ frequency variable is limited by the maximum of “>5 Times” for the scale cut-off, a dichotomous variable was created by coding the endorsement of at least one of the three IPV questions, where participants were coded as 1 (having experienced IPV) or 0 (not).

ELT

An ELT frequency variable was computed using the TLEQ (Kubany et al., 2000) for items endorsed as having been experienced prior to the age of 18 years. For example, participants were asked “While growing up: Did you witness family violence?” and “While growing up: Were you physically punished in a way that resulted in bruises, burns, cuts, or broken bones?” This variable was coded with 0 (never experienced) to 6 (experienced 5 or more events) for each question on the TLEQ. Response frequencies were summed for each traumatic event that occurred before the age of 18 for each participant. A dichotomous variable was also computed for ELT, where individuals who had a score of 0 on the frequency variable were coded as 0 (no ELT) and if at least one ELT event was endorsed, participants were coded as 1 (having experienced ELT).

Statistical Analyses

Chi-square analyses were used to compare differences between groups (IPV–/IPV+ men and IPV–/IPV+ women) for all dichotomous variables. To examine mean differences between groups, we conducted univariate analyses of variance (ANOVAs) for continuous variables. The Benjamini and Hochberg method was used to control for the false discovery rate where appropriate (Benjamini & Hochberg, 1995). Four hierarchical regression models were used to determine if the addition of information regarding IPV improved prediction of PTSD symptom severity beyond that of ELT, TBI, and combat exposure in men and women separately. Each model was evaluated to ensure that the assumptions of homogeneity of variance, linearity, and normality of the residuals were met. Furthermore, we used a variable inflation factor (VIF) of < 2.5 to ensure the absence of multicollinearity. For each model, PTSD symptom severity, at post-deployment and current (within the last month) was the dependent variable and factors related to traumatic events were used as predictor variables. Variables were entered into the model sequentially. In the first step, for each model, time since deployment, age, and education were entered. All trauma variables, with the exception of IPV, were entered in the second step and IPV was entered in the third and final step.

Results

Participants

First, we examined group differences for all variables included in our regression models, data are presented in Table 1. Groups did not differ in age, F(3, 513) = 1.43, p = .143, $η_{p}^{2} = . 011$ ; education, F(3, 470) = 2.34, p = .073, $η_{p}^{2} = . 015$ ; or time since deployment, F(3, 448) = 1.98, p = .115, $η_{p}^{2} = . 013$ However, groups did differ in combat exposure, F(3, 436) = 9.12, p < .001, $η_{p}^{2} = . 059$ , where men reported greater combat experiences overall than women. When examining differences between groups on dichotomous trauma variables, groups differed in military TBI, χ²(3, n = 517) = 10.11, p = .018, such that a higher proportion of men and women with a history of IPV and men without a history of IPV experienced military TBIs than women without a history of IPV. Next, men and women with a history of IPV had a higher proportion of ELT than men and women without, χ²(3, n = 517) = 9.95, p = .019. There were no differences in the incidence of IPV between men and women, χ²(1, n = 517) = 2.85, p = .092. Furthermore, IPV did not differ by military rank, χ²(2, n = 504) = 4.94, p = .088, or branch of service, χ²(4, n = 501) = 4.03, p = .421. However, branch of service did differ between the sexes. Specifically, 23.91% of women were Air force veterans compared with 3.92% of men, and 21.35% of men were Marine veterans compared with 0% of women. Men and women did not differ in military rank, χ²(2, n = 508) = 1.43, p = .489.

Table 1.

Demographics.

Demographic Variables	IPV‒				IPV+
	Men		Women		Men		Women
	(n = 386)		(n = 33)		(n = 85)		(n = 13)
	M	SD	M	SD	M	SD	M	SD
Age	32.32	8.82	35.42	16.99	32.45	7.77	36.21	10.93
	n	%	n	%	n	%	n	%
Race/ethnicity
African American/Black	26	6.73	5	15.15	10	11.76	4	30.77
American Indian/Alaskan	2	0.52	0	0.00	1	1.17	0	0.00
Asian	10	2.60	1	3.03	0	0.00	0	0.00
Hawaiian/Pacific Islander	1	0.26	0	0.00	0	0.00	0	0.00
Caucasian/White	291	75.38	19	57.57	63	74.12	5	38.46
Hispanic	56	14.50	8	24.24	12	14.20	4	30.77
Education
High school or less	143	37.04	3	9.10	25	29.57	2	15.38
Bachelor’s or some college	207	53.62	25	75.75	52	61.20	11	84.62
Graduate school	36	9.32	5	15.15	8	9.41	0	0.00
	M	SD	M	SD	M	SD	M	SD
Deployment history
Number of deployments	1.56	0.90	1.18	0.77	1.72	1.07	1.31	0.48
Duration (months)	15.31	9.92	11.06	7.61	14.71	8.87	14.15	5.96
Time since (months)	43.46	35.43	38.00	29.97	53.53	38.05	44.46	36.94
Combat exposure	17.43	11.74	8.63	8.51	20.29	12.87	8.18	6.57
	n	%	n	%	n	%	n	%
Marital status
Married	168	43.63	10	31.25	22	25.88	3	23.07
Widowed	3	0.78	0	0.00	0	0.00	0	0.00
Divorced	35	9.10	8	25.00	18	21.17	3	23.07
Separated	18	4.67	2	6.25	6	7.05	0	0.00
Never married/single	135	35.06	8	25.00	34	40.00	6	46.15
Not married but cohabitating	26	6.75	4	12.50	4	4.71	1	7.69
Clinical characteristics
Military TBI	175	45.34	8	24.24	48	56.47	6	46.15
Post-deployment PTSD diagnosis	245	64.47	22	66.67	69	82.14	13	100.00
Current PTSD diagnoses	260	67.35	26	78.78	70	82.35	11	84.61
Early life trauma	220	57.17	18	54.54	65	76.47	10	76.92

Note. Bolded values indicate p < .05. Dichotomous variables are reported as n and % and continuous variables are reported as M and SD. IPV = intimate partner violence; TBI = traumatic brain injury; PTSD = posttraumatic stress disorder.

When considering differences in PTSD diagnoses between groups, men and women with a history of IPV were more likely to meet criteria for post-deployment PTSD, notably 100% of women with IPV experience met the criteria, χ²(3, n = 510) = 16.11, p = .001. Men with a history of IPV and women (IPV+/IPV‒) were more likely to meet criteria for a current diagnosis of PTSD, χ²(3, n = 516) = 12.86, p = .005. Univariate ANOVAs revealed a significant difference in post-deployment PTSD symptom severity between groups, F(3, 484) = 8.33, p < .001, $η_{p}^{2} = . 049$ , where pairwise comparisons showed that men (M = 83.37, SD = 31.26) and women (M = 86.23, SD = 25.83) with a history of IPV had more severe PTSD symptoms than men (M = 65.27, SD = 33.05) without a history of IPV. Similarly, there was a statistically significant difference in current PTSD symptom severity between groups, F(3, 511) = 6.68, p < .001, $η_{p}^{2} = . 038$ , where pairwise comparisons showed that men (M = 62.20, SD = 29.90) and women (M = 68.77, SD = 26.32) with a history of IPV had more severe PTSD symptoms than men (M = 48.51, SD = 29.90) without a history of IPV.

Table 2 displays full model statistics for each model at each of the three steps. Briefly, in Model 1: Current PTSD in men, the addition of IPV to trauma variables explains about one third of the variability in the prediction of post-deployment PTSD symptom severity. This addition of IPV at Step 3 increased the reliability of the prediction of current PTSD symptoms beyond military TBI, combat and ELT, albeit only slightly. In Model 2: Post-deployment PTSD in women, the addition of IPV at Step 3 did not increase the reliability of the prediction of the current PTSD symptoms over and above the other trauma types.

Table 2.

Regression Models for IPV Duration and Frequency.

Predictor	Post-Deployment PTSD			Current PTSD
Predictor	Adj. R²	R²/ΔR²	p	Adj. R²	R²/ΔR²	p
Men
Step 1: Age, education, time since deployment	.093	.099	<.001	.082	.089	<.001
Step 2: Combat experience, military TBI, ELT	.315	.325/.225	<.001	.260	.270/.181	<.001
Step 3: IPV	.326	.337/.013	<.001	.267	.279/.008	<.001
Women
Step 1: Age, education, time since deployment	.157	.225	.032	.045	.123	.211
Step 2: Combat experience, military TBI, ELT	.105	.250/.025	.148	.062	.214/.091	.244
Step 3: IPV	.075	.250/.000	.230	.037	.219/.005	.333

Note. ELT = early life trauma; IPV = intimate partner violence; PTSD = posttraumatic stress disorder; TBI = traumatic brain injury.

Next, in Model 3: Current PTSD in men, the predictors accounted for about one third of the variability in current PTSD symptom severity. Again, the addition of IPV at Step 3 slightly increased the reliability of the prediction of the current PTSD symptoms beyond military TBI, combat, and ELT. Finally, in Model 4: Current PTSD in women, IPV did not add to the prediction of PTSD severity.

Descriptive analysis of standardized beta contributions

None of the regression models predicting PTSD symptom severity in women were statistically significant, although they all followed the same pattern as the models in men. We suggest that this is likely due to the relatively small sample size resulting an underpowered analysis. However, given the fact that the prevalence in the population of women veterans is similarly low and to obtain a sample large enough to gain statistical significance would require tremendous resources, we offer a descriptive approach to comparing the beta coefficients between men and women. Standardized beta coefficients for each model are presented in Figure 1. When considering differences between genders in post-deployment PTSD symptom severity, the trauma exposure variables contribute more toward the prediction of PTSD in men than in women, as evidenced by the higher standardized beta values. However, when examining differences between the genders in current PTSD severity, the beta for ELT in women is over double that of men, indicating that ELT is a more salient predictor of current PTSD severity for women. Importantly, when examining the contribution of IPV, the standardized beta values are higher (and statistically significant) in men than in women.

Figure 1.

Patterns of standardized beta contributions by sex.

Discussion

The primary finding of this study was that IPV exposure was differentially predictive of PTSD severity based on gender, though the overall contribution was moderate. This difference was observed although overall prevalence of PTSD diagnosis and severity were similar in men and women. In women, ELT and time since deployment were the only significant predictors of current PTSD severity (and not for worst month post-deployment). We suggest that the lack of statistical significance in our regression models for women is likely due to being underpowered as a result of a small sample size. Thus, we qualitatively examined the differences in standardized beta contributions in women. Altogether, a little less than a quarter of the variance in both post-deployment and current PTSD severity was accounted for by our trauma variables in women, suggesting that we are missing traumatic event(s) or other variables that are impacting PTSD severity in women. Indeed, military sexual trauma (MST), a factor that we did not consider in this analyses because data were unavailable, is associated with a higher prevalence of PTSD and more severe symptomatology than other traumas alone or in combination in female veterans (for a review, see Suris & Lind, 2008; Yaeger et al., 2006). It is possible that the inclusion of the measure would have improved the predictive power of our models for women.

While the contribution of IPV to PTSD symptom severity at both epochs was modest, it is an important clinical consideration. Interpersonal violence is a predictor of severe and chronic PTSD (Forbes et al., 2014; Nishith et al., 2000). It should be noted that we used a lifetime approach instead of assessing trauma exposure within the past year. Cumulative trauma exposure is associated with more severe and chronic PTSD (Jakob et al., 2017; Yehuda et al., 1995). Furthermore, men are rarely screened for IPV and IPV-related injuries. Thus, even though the contribution of IPV is minimal, if unaddressed, it could have serious detrimental effects on mental health and future functional outcomes in this generation of veterans.

We also see a shift in trauma contribution between the two epochs, where in men, at worst month post-deployment, traumatic events contributed more strongly to the prediction of PTSD, as evident by larger standardized beta coefficients. Overall, current PTSD severity scores are lower than worst month post-deployment PTSD scores, thus the lower standardized beta coefficients likely reflect recovery over time. Furthermore, the individual trauma types contribute to PTSD severity differently at different time points: In men, ELT contributes most strongly to PTSD severity post-deployment but military TBI is the greatest contributor to current PTSD severity. The evolution of trauma contributors at post-deployment and current epochs is an important indicator that PTSD is not a static disorder and, for veterans who have experienced multiple traumatic events across the lifespan, focusing on each trauma type collectively or the lifetime burden of trauma instead of a unitary event may be a more effective approach to treatment. Finally and importantly, IPV remains a significant predictor of PTSD severity at both time points, indicating a greater need to include both genders in the examination of IPV-related pathology.

Both men and women with IPV had a higher proportion of PTSD diagnoses and more severe post-deployment and current PTSD symptoms. The distinct gender differences found in PTSD diagnoses and symptom severity is well established (Carmassi et al., 2014; Haskell et al., 2010; Hourani et al., 2015; Irish et al., 2011). Women are more than three times more likely to develop PTSD after trauma exposure, even when controlling for trauma type (Breslau et al., 1999), and are more likely to have more severe symptoms (Hourani et al., 2015; Norris et al., 2001). Thus, it is interesting that these gender differences were not observed in our sample of veterans with IPV. This finding may be explained by the greater frequency of ELT experienced by men and women with a lifetime history of IPV in our sample. It is also well established that individuals who experience ELT are more likely to experience greater mental health problems including PTSD (Ehlers et al., 2013; Lanius et al., 2010), mood, and anxiety disorders (Carr et al., 2013; Chu et al., 2013). Taken together, these results may indicate that men with IPV are a more vulnerable population than men who have not experienced IPV.

Social support following traumatic experiences, like combat, is important in resilience to and recovery from PTSD (Andrews et al., 2003; Woodward et al., 2015) and other related psychopathologies (Asberg & Renk, 2014). It may be possible that veterans experiencing IPV do not have as supportive environment as those who do not and this may exacerbate PTSD symptoms. The lack of social support at home, may explain in part why IPV predicts PTSD severity in men. Social support has been found to mitigate the effects of IPV in women in several studies (Cheng & Chan, 2004; Matud et al., 2003); however these effects have not been examined in men. Moreover, IPV may decrease social support for victims, particularly in the event of emotional or psychological IPV, where the perpetrator isolates their partner or threatens the partner’s support system (Beeble et al., 2009). Thus, social support may play a substantial role in the damaging effects associated with IPV experiences on mental health in our sample. However, because women are more likely than men to seek social support through interpersonal interactions (Ashton & Fuehrer, 1993; Coker et al., 2002), outside of an intimate relationship, the diminished partner support may lead to more detrimental effects in men. It must be noted though, because we did not directly examine social support in our sample, these interpretations are speculative. Future studies should include a measure of perceived social support to examine the role of social support in risk and resilience following IPV.

As it stands, the current literature conceptualizes IPV differently for men and women. The current literature focus on women as victims and men as perpetrators may be driven by reporting bias, as men are less likely to report physical victimization (de Waal et al., 2017) and are not likely to be routinely screened for IPV victimization. By dichotomizing gender in the exploration of IPV, we are missing a vulnerable population of men for whom no treatment or prevention efforts have been developed. Veterans with a lifetime history of IPV in our study also experienced multiple traumatic events, starting early in life and culminating in deployment-related trauma, which is among the most severe types of traumas. The chronicity, severity, and multiple trauma types of male veterans’ lifetime history of trauma may lead to difficulties in trust and communication, which in turn may lead to disruptions in romantic relationships. Future studies should examine the prevalence of psychological versus physical IPV and how these different categories of IPV differentially affect psychological outcomes in civilian and veteran men and women. This is particularly important because there has been no substantial research on men as victims of IPV. Understanding the negative impacts on IPV on men will be important in identifying men that may be in need of treatment or resources. Most importantly, addressing the specific and unique needs of men victims will help to destigmatize IPV for both genders.

Limitations

Several limitations to the present study should be considered in the interpretation of our results. First, the sample sizes of our groups were discrepant. This is largely unavoidable when examining gender differences within military populations. Women makeup around 11% of currently deployed troops and this is reflected in our study sample. We did our best to match groups on all demographic variables and found no significant differences on these between our four groups. Furthermore, our analyses were not in gross violation of the tests used despite discrepant sample size and as such the results are robust and likely generalizable. Furthermore, the prevalence of IPV in men and women in our sample maps on to the currently reported prevalence from the National Intimate Partner and Sexual Violence Survey (2015 NISVS Data Brief Violence Prevention Injury Center CDC, 2018) and other studies (for a review, see Sparrow et al., 2020).

Another caveat to our study is that it did not examine perpetration and as such, we cannot determine if men or women were also perpetrators. Houry and colleagues (2008) examined differences in IPV perpetration and victimization in a sample of civilians and found comparable proportion of victimization between the genders (around 20%). However, men and women differed on combined perpetration and victimization, where men (13%) were more likely to be both a perpetrator and a victim than were women (2%). Thus, it is possible that men and women with a lifetime history of IPV have also been perpetrators and this fact may have had a differential influence on PTSD severity across gender. However, because these numbers are likely low, we are unable to determine the impact of perpetration on our sample. Future studies should examine the impact of perpetration on the experience of psychological distress evident in men and women veterans with a lifetime history of IPV.

Finally, while the TLEQ is a highly reliable and valid measure for examining trauma exposure throughout the lifespan, it does have limitations for use as a continuous measure. First, the TLEQ does not provide an accurate measure of frequency or severity for any of the traumatic events included in the questionnaire. Each item on the measure only allows for the endorsement of “>5” exposures to any one event. This creates a critically low ceiling for a frequency variable. Furthermore, the TLEQ has three questions that pertain to psychical and psychological IPV but does not include a question for sexual IPV. For this reason, we were unable to include sexual IPV in our IPV variables.

Conclusion

The current literature conceptualizes IPV differently for men and women. The current literature focus on women as victims and men as perpetrators is largely driven by reporting bias. Therefore, we are missing a vulnerable population of men for whom no treatment or prevention efforts have been developed. Veterans with a longer duration of IPV in our study also experienced multiple traumatic events, starting early in life, including deployment-related trauma, which is among the most severe types of traumas. The chronicity, severity, and multiple trauma types of male veterans’ lifetime history of trauma may lead to difficulties in trust and communication, which in turn may lead to disruptions in romantic relationships. Future studies should examine the rates of psychological versus physical IPV and how these different categories of IPV differentially affect psychological outcomes in civilian and veteran men and women. This is particularly important because there has been no substantial research on men as victims of IPV. Understanding the negative impacts of IPV on men will be important in identifying men that may be in need of treatment or resources. Most importantly, addressing the specific and unique needs of men victims will help to destigmatize IPV for both sexes.

Footnotes

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 research was supported in part by the Department of Veterans Affairs by the Translational Research Center for TBI and Stress Disorders (TRACTS), a VA Rehabilitation Research and Development Traumatic Brain Injury Center of Excellence (B9254-C). M.E.P. is supported by the Polytrauma and Traumatic Brain Injury Rehabilitation Research Program, Office of Academic Affiliations, Rehabilitation Research and Development, VA Boston Healthcare System.

ORCID iD

Meghan E. Pierce

Author Biographies

Meghan E. Pierce, PhD, is an instructor in Psychiatry at Harvard Medical School and an advanced fellow in Polytrauma and TBI Rehabilitation Research at Boston VA Healthcare System and the Translational Research Center for TBI and Stress Disorders. Her research interests include alterations in the neurobiological response to stress related to posttraumatic stress disorder and comorbid deployment-related pathologies and how this relationship differs between the sexes.

Catherine Fortier, PhD, is an investigator and clinical director at the Translational Research Center for TBI and Stress Disorders and an assistant professor at Harvard Medical School. Her research involves investigating the cognitive neuroscience of alcohol use, cerebrovascular risk, and traumatic brain injury through integration of multiple experimental and clinical techniques.

Jennifer R. Fonda, PhD, is an assistant professor at Boston University School of Medicine, lecturer at Harvard Medical School, and the epidemiologist for Translational Research Center for TBI and Stress Disorders. Her primary research interests focus on the epidemiology of psychiatric and neurologic disorders.

William Milberg, PhD, is professor of Psychology at Harvard Medical School and Co-Director of the Translational Research Center for TBI and Stress Disorders. His research focuses on how neurological and psychiatric diseases interact with aging to provide insights into brain organization.

Regina McGlinchey, PhD, is a professor of Psychiatry in the Department of Psychiatry at Harvard Medical School and the Director of the Translational Research Center for TBI and Stress Disorders. Her research interests focus on deployment-related comorbidities in Veterans, particularly, intimate partner violence, chronic alcohol use, binge drinking, and aging.

References

2015 NISVS Data Brief | Violence Prevention | Injury Center | CDC. (2018, November27). https://www.cdc.gov/violenceprevention/nisvs/2015NISVSdatabrief.html

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

Amir

Kaplan

Kotler

(1996). Type of trauma, severity of posttraumatic stress disorder core symptoms, and associated features. The Journal of General Psychology, 123(4), 341–351. https://doi.org/10.1080/00221309.1996.9921286

Andrews

Brewin

C. R.

Rose

(2003). Gender, social support, and PTSD in victims of violent crime. Journal of Traumatic Stress, 16(4), 421–427. https://doi.org/10.1023/A:1024478305142

Asberg

Renk

(2014). Perceived stress, external locus of control, and social support as predictors of psychological adjustment among female inmates with or without a history of sexual abuse. International Journal of Offender Therapy and Comparative Criminology, 58(1), 59–84. https://doi.org/10.1177/0306624X12461477

Ashton

W. A.

Fuehrer

(1993). Effects of gender and gender role identification of participant and type of social support resource on support seeking. Sex Roles, 28(7), 461–476. https://doi.org/10.1007/BF00289608

Beeble

M. L.

Bybee

Sullivan

C. M.

Adams

A. E.

(2009). Main, mediating, and moderating effects of social support on the well-being of survivors of intimate partner violence across 2 years. Journal of Consulting and Clinical Psychology, 77(4), 718–729. https://doi.org/10.1037/a0016140

Benjamini

Hochberg

(1995). Controlling the false discovery rate: A practical and powerful approach to multiple testing. Journal of the Royal Statistical Society, Series B: Methodological, 57(1), 289–300.

Blake

D. D.

Weathers

F. W.

Nagy

L. M.

Kaloupek

D. G.

Gusman

F. D.

Charney

D. S.

Keane

T. M.

(1995). The development of a clinician-administered PTSD Scale. Journal of Traumatic Stress, 8(1), 75–90. https://doi.org/10.1007/BF02105408

10.

Blosnich

J. R.

Dichter

M. E.

Cerulli

Batten

S. V.

Bossarte

R. M.

(2014). Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry, 71(9), 1041–1048. https://doi.org/10.1001/jamapsychiatry.2014.724

11.

Breslau

Chilcoat

H. D.

Kessler

R. C.

Peterson

E. L.

Lucia

V. C.

(1999). Vulnerability to assaultive violence: Further specification of the sex difference in post-traumatic stress disorder. Psychological Medicine, 29(4), 813–821. https://doi.org/10.1017/S0033291799008612

12.

Carmassi

Akiskal

H. S.

Bessonov

Massimetti

Calderani

Stratta

Rossi

Dell’Osso

(2014). Gender differences in DSM-5 versus DSM-IV-TR PTSD prevalence and criteria comparison among 512 survivors to the L’Aquila earthquake. Journal of Affective Disorders, 160, 55–61. https://doi.org/10.1016/j.jad.2014.02.028

13.

Carr

C. P.

Martins

C. M. S.

Stingel

A. M.

Lemgruber

V. B.

Juruena

M. F.

(2013). The role of early life stress in adult psychiatric disorders: A systematic review according to childhood trauma subtypes. The Journal of Nervous and Mental Disease, 201(12), 1007. https://doi.org/10.1097/NMD.0000000000000049

14.

Cheng

S.-T.

Chan

A. C. M.

(2004). The multidimensional scale of perceived social support: Dimensionality and age and gender differences in adolescents. Personality and Individual Differences, 37(7), 1359–1369. https://doi.org/10.1016/j.paid.2004.01.006

15.

Chu

D. A.

Williams

L. M.

Harris

A. W. F.

Bryant

R. A.

Gatt

J. M.

(2013). Early life trauma predicts self-reported levels of depressive and anxiety symptoms in nonclinical community adults: Relative contributions of early life stressor types and adult trauma exposure. Journal of Psychiatric Research, 47(1), 23–32. https://doi.org/10.1016/j.jpsychires.2012.08.006

16.

Coker

A. L.

Smith

P. H.

Thompson

M. P.

McKeown

R. E.

Bethea

Davis

K. E.

(2002). Social support protects against the negative effects of partner violence on mental health. Journal of Women’s Health & Gender-Based Medicine, 11(5), 465–476. https://doi.org/10.1089/15246090260137644

17.

Coker

A. L.

Weston

Creson

D. L.

Justice

Blakeney

(2005). PTSD symptoms among men and women survivors of intimate partner violence: The role of risk and protective factors. Violence and Victims, 20(6), 625–643. https://doi.org/10.1891/0886-6708.20.6.625

18.

Cougle

J. R.

Resnick

Kilpatrick

D. G.

(2009). Does prior exposure to interpersonal violence increase risk of PTSD following subsequent exposure?Behavior Research and Therapy, 47(12), 1012–1017. https://doi.org/10.1016/j.brat.2009.07.014

19.

de Waal

M. M.

Dekker

J. J. M.

Kikkert

M. J.

Kleinhesselink

M. D.

Goudriaan

A. E.

(2017). Gender differences in characteristics of physical and sexual victimization in patients with dual diagnosis: A cross-sectional study. BMC Psychiatry, 17(1), Article 270. https://doi.org/10.1186/s12888-017-1413-0

20.

Dekel

Shaked

Ben-Porat

Itzhaky

(2020). The interrelations of physical and mental health: Self-rated health, depression, and PTSD among female IPV survivors. Violence Against Women, 26, 379–394. https://doi.org/10.1177/1077801219832916

21.

Dichter

M. E.

Haywood

T. N.

Butler

A. E.

Bellamy

S. L.

Iverson

K. M.

(2017). Intimate partner violence screening in the veterans health administration: Demographic and military service characteristics. American Journal of Preventive Medicine, 52(6), 761–768. https://doi.org/10.1016/j.amepre.2017.01.003

22.

Dichter

M. E.

Sorrentino

A. E.

Haywood

T. N.

Bellamy

S. L.

Medvedeva

Roberts

C. B.

Iverson

K. M.

(2018). Women’s healthcare utilization following routine screening for past-year intimate partner violence in the veterans health administration. Journal of General Internal Medicine, 33(6), 936–941. https://doi.org/10.1007/s11606-018-4321-1

23.

Ehlers

C. L.

Gizer

I. R.

Gilder

D. A.

Yehuda

(2013). Lifetime history of traumatic events in an American Indian community sample: Heritability and relation to substance dependence, affective disorder, conduct disorder and PTSD. Journal of Psychiatric Research, 47(2), 155–161. https://doi.org/10.1016/j.jpsychires.2012.10.002

24.

Forbes

Lockwood

Phelps

Wade

Creamer

Bryant

R. A.

McFarlane

Silove

Rees

Chapman

Slade

Mills

Teesson

O’Donnell

(2014). Trauma at the hands of another: Distinguishing PTSD patterns following intimate and nonintimate interpersonal and noninterpersonal trauma in a nationally representative sample. The Journal of Clinical Psychiatry, 75(2), 147–153. https://doi.org/10.4088/JCP.13m08374

25.

Fortier

C. B.

Amick

M. M.

Grande

McGlynn

Kenna

Morra

Clark

Milberg

W. P.

McGlinchey

R. E.

(2014). The Boston Assessment of Traumatic Brain Injury-Lifetime (BAT-L) semi-structured interview: Evidence of research utility and validity. The Journal of Head Trauma Rehabilitation, 29(1), 89–98. https://doi.org/10.1097/HTR.0b013e3182865859

26.

Frans

Ö.

Rimmö

P.-A.

Åberg

Fredrikson

(2005). Trauma exposure and post-traumatic stress disorder in the general population. Acta Psychiatrica Scandinavica, 111(4), 291–290. https://doi.org/10.1111/j.1600-0447.2004.00463.x

27.

George

Phillips

C. H.

Shah

Lewis-O’Connor

Rosner

Stoklosa

H. M.

Khurana

(2019). Radiologic findings in intimate partner violence. Radiology, 291(1), 62–69. https://doi.org/10.1148/radiol.2019180801

28.

Gerber

M. M.

Frankfurt

S. B.

Contractor

A. A.

Oudshoorn

Dranger

Brown

L. A.

(2018). Influence of multiple traumatic event types on mental health outcomes: Does count matter?Journal of Psychopathology and Behavioral Assessment, 40(4), 645–654. https://doi.org/10.1007/s10862-018-9682-6

29.

Guina

Nahhas

R. W.

Kawalec

Farnsworth

(2019). Are gender differences in DSM-5 PTSD symptomatology explained by sexual trauma?Journal of Interpersonal Violence, 34, 4713–4740. https://doi.org/10.1177/0886260516677290

30.

Haskell

S. G.

Gordon

K. S.

Mattocks

Duggal

Erdos

Justice

Brandt

C. A.

(2010). Gender differences in rates of depression, PTSD, pain, obesity, and military sexual trauma among Connecticut war veterans of Iraq and Afghanistan. Journal of Women’s Health, 19(2), 267–271. https://doi.org/10.1089/jwh.2008.1262

31.

Held

Owens

G. P.

(2013). Stigmas and attitudes toward seeking mental health treatment in a sample of veterans and active duty service members. Traumatology, 19(2), 136–143. https://doi.org/10.1177/1534765612455227

32.

Hetzel-Riggin

M. D.

Roby

R. P.

(2013). Trauma type and gender effects on PTSD, general distress, and peritraumatic dissociation. Journal of Loss and Trauma, 18(1), 41–53. https://doi.org/10.1080/15325024.2012.679119

33.

Hoge

C. W.

Castro

C. A.

Messer

S. C.

McGurk

Cotting

D. I.

Koffman

R. L.

(2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13–22. https://doi.org/10.1056/NEJMoa040603

34.

Hourani

Williams

Bray

Kandel

(2015). Gender differences in the expression of PTSD symptoms among active duty military personnel. Journal of Anxiety Disorders, 29, 101–108. https://doi.org/10.1016/j.janxdis.2014.11.007

35.

Houry

Rhodes

K. V.

Kemball

R. S.

Click

Cerulli

McNutt

L. A.

Kaslow

N. J.

(2008). Differences in female and male victims and perpetrators of partner violence with respect to WEB scores. Journal of Interpersonal Violence, 23(8), 1041–1055. https://doi.org/10.1177/0886260507313969

36.

Hunnicutt

Murray

Lundgren

Crowe

Olson

(2019). Exploring correlates of probable traumatic brain injury among intimate partner violence survivors. Journal of Aggression, Maltreatment & Trauma, 28(6), 677–694. https://doi.org/10.1080/10926771.2019.1587656

37.

Irish

L. A.

Fischer

Fallon

Spoonster

Sledjeski

E. M.

Delahanty

D. L.

(2011). Gender differences in PTSD symptoms: An exploration of peritraumatic mechanisms. Journal of Anxiety Disorders, 25(2), 209–216. https://doi.org/10.1016/j.janxdis.2010.09.004

38.

Jakob

J. M. D.

Lamp

Rauch

S. A. M.

Smith

E. R.

Buchholz

K. R.

(2017). The impact of trauma type or number of traumatic events on PTSD diagnosis and symptom severity in treatment seeking veterans. The Journal of Nervous and Mental Disease, 205(2), 83. https://doi.org/10.1097/NMD.0000000000000581

39.

King

L. A.

King

D. W.

Vogt

D. S.

Knight

Samper

R. E.

(2006). Deployment risk and resilience inventory: A collection of measures for studying deployment-related experiences of military personnel and veterans. Military Psychology, 18(2), 89–120. https://doi.org/10.1207/s15327876mp1802_1

40.

Kivelä

Leppäkoski

Ruohoniemi

Puolijoki

Paavilainen

(2019). The documentation and characteristics of hospitalized IPV patients using electronic medical records data: A follow-up descriptive study. Journal of Family Violence. 34(7), 611–619. https://doi.org/10.1007/s10896-019-00081-z

41.

Kothari

C. L.

Rohs

Davidson

Kothari

R. U.

Klein

Koestner

DeBoer

Cox

Kutzko

(2015). Emergency department visits and injury hospitalizations for female and male victims and perpetrators of intimate partner violence. Advances in Emergency Medicine, 2015, Article 502703. https://doi.org/10.1155/2015/502703

42.

Kubany

E. S.

Haynes

S. N.

Leisen

M. B.

Owens

J. A.

Kaplan

A. S.

Watson

S. B.

Burns

(2000). Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: The traumatic life events questionnaire. Psychological Assessment, 12(2), 210–224.

43.

LaMotte

A. D.

Taft

C. T.

Reardon

A. F.

Miller

M. W.

(2014). Agreement between veteran and partner reports of intimate partner agression. Psychological Asssessment, 26(4), 1369–1374.

44.

Lanius

R. A.

Frewen

P. A.

Vermetten

Yehuda

(2010). Fear conditioning and early life vulnerabilities: Two distinct pathways of emotional dysregulation and brain dysfunction in PTSD. European Journal of Psychotraumatology, 1(1), Article 5467. https://doi.org/10.3402/ejpt.v1i0.5467

45.

Love

A. R.

Morland

L. A.

Menez

Taft

MacDonald

Mackintosh

M.-A.

(2015). “Strength at home” intervention for male veterans perpetrating intimate partner aggression: Perceived needs survey of therapists and pilot effectiveness study. Journal of Interpersonal Violence, 30(13), 2344–2362. https://doi.org/10.1177/0886260514552445

46.

Lövestad

Löve

Vaez

Krantz

(2017). Prevalence of intimate partner violence and its association with symptoms of depression; a cross-sectional study based on a female population sample in Sweden. BMC Public Health, 17(1), Article 335. https://doi.org/10.1186/s12889-017-4222-y

47.

Macdonald

Danielson

C. K.

Resnick

H. S.

Saunders

B. E.

Kilpatrick

D. G.

(2010). PTSD and comorbid disorders in a representative sample of adolescents: The risk associated with multiple exposures to potentially traumatic events. Child Abuse & Neglect, 34(10), 773–783. https://doi.org/10.1016/j.chiabu.2010.03.006

48.

Machisa

M. T.

Christofides

Jewkes

(2016). Structural pathways between child abuse, poor mental health outcomes and male-perpetrated intimate partner violence (IPV). PLOS ONE, 11(3), Article e0150986. https://doi.org/10.1371/journal.pone.0150986

49.

Matud

M. P.

Ibáñez

Bethencourt

J. M.

Marrero

Carballeira

(2003). Structural gender differences in perceived social support. Personality and Individual Differences, 35(8), 1919–1929. https://doi.org/10.1016/S0191-8869(03)00041-2

50.

Miles-McLean

H. A.

LaMotte

A. D.

Williams

M. R.

Murphy

C. M.

(2019). Trauma exposure and PTSD among women receiving treatment for intimate partner violence perpetration. Journal of Interpersonal Violence. Advance online publication. https://doi.org/10.1177/0886260518820634

51.

Nishith

Mechanic

M. B.

Resick

P. A.

(2000). Prior interpersonal trauma: The contribution to current PTSD symptoms in female rape victims. Journal of Abnormal Psychology, 109(1), 20–25.

52.

Norlander

Eckhardt

(2005). Anger, hostility, and male perpetrators of intimate partner violence: A meta-analytic review. Clinical Psychology Review, 25(2), 119–152. https://doi.org/10.1016/j.cpr.2004.10.001

53.

Norris

F. H.

Perilla

J. L.

Ibañez

G. E.

Murphy

A. D.

(2001). Sex differences in symptoms of posttraumatic stress: Does culture play a role?Journal of Traumatic Stress, 14(1), 7–28. https://doi.org/10.1023/A:1007851413867

54.

Pegram

S. E.

Abbey

Woerner

Helmers

B. R.

(2018). Partner type matters: Differences in cross-sectional predictors of men’s sexual aggression in casual and steady relationships. Violence and Victims, 33(5), 902–917. https://doi.org/10.1891/0886-6708.VV-D-17-00080

55.

Seidler

Z. E.

Dawes

A. J.

Rice

S. M.

Oliffe

J. L.

Dhillon

H. M.

(2016). The role of masculinity in men’s help-seeking for depression: A systematic review. Clinical Psychology Review, 49, 106–118. https://doi.org/10.1016/j.cpr.2016.09.002

56.

Sparrow

Dickson

Kwan

Howard

Fear

MacManus

(2020). Prevalence of self-reported intimate partner violence victimization among military personnel: A systematic review and meta-analysis. Trauma, Violence & Abuse, 21(3), 586–609. https://doi.org/10.1177/1524838018782206

57.

Suris

Lind

(2008). Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma, Violence, & Abuse, 9(4), 250–269. https://doi.org/10.1177/1524838008324419

58.

Taft

C. T.

Suvak

M. K.

Kachadourian

L. K.

Pinto

L. A.

Miller

M. M.

Knight

Marx

B. P.

(2012). Examining impelling and disinhibiting factors for intimate partner violence in veterans. Journal of Family Psychology, 26(2), 285. https://doi.org/10.1037/a0027424

59.

Valera

E. M.

Campbell

Gill

Iverson

K. M.

(2019). Correlates of brain injuries in women subjected to intimate partner violence: Identifying the dangers and raising awareness. Journal of Aggression, Maltreatment & Trauma, 28, 695–713. https://doi.org/10.1080/10926771.2019.1581864

60.

Walling

S. M.

Meehan

J. C.

Marshall

A. D.

Holtzworth-Munroe

Taft

C. T.

(2012). The relationship of intimate partner aggression to head injury, executive functioning, and intelligence. Journal of Marital and Family Therapy, 38(3), 471–485. https://doi.org/10.1111/j.1752-0606.2011.00226.x

61.

Wong

J. Y.-H.

Choi

A. W.-M.

Fong

D. Y.-T.

Wong

J. K.-S.

Lau

C.-L.

Kam

C.-W.

(2014). Patterns, aetiology and risk factors of intimate partner violence-related injuries to head, neck and face in Chinese women. BMC Women’s Health, 14, Article 6. https://doi.org/10.1186/1472-6874-14-6

62.

Woodward

M. J.

Eddinger

Henschel

A. V.

Dodson

T. S.

Tran

H. N.

Beck

J. G.

(2015). Social support, posttraumatic cognitions, and PTSD: The influence of family, friends, and a close other in an interpersonal and non-interpersonal trauma group. Journal of Anxiety Disorders, 35, 60–67. https://doi.org/10.1016/j.janxdis.2015.09.002

63.

Yaeger

Himmelfarb

Cammack

Mintz

(2006). DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. Journal of General Internal Medicine, 21(3), S65–S69. https://doi.org/10.1111/j.1525-1497.2006.00377.x

64.

Yehuda

Kahana

Schmeidler

Southwick

S. M.

Wilson

Giller

E. L.

(1995). Impact of cumulative lifetime trauma and recent stress on current posttraumatic stress disorder symptoms in holocaust survivors. The American Journal of Psychiatry, 152(12), 1815–1818. https://doi.org/10.1176/ajp.152.12.1815