Anabolic Steroid Use and Intimate Partner Violence Among Sexual Minority Men

Abstract

This study examined the relationship between intimate partner violence (IPV) and use of anabolic-androgenic steroids (AAS), in a relationship context, among men who have sex with men (MSM). The sample was collected online via Prolific.co and consisted of 491 MSM. Data were analyzed using structural equation modeling. While accounting for the influence of factors known to be linked to IPV (adverse childhood experiences and alcohol use), the use of AAS in a relationship context was uniquely linked to greater perpetration of IPV. AAS use was not uniquely linked to IPV victimization. Findings from this study contribute to literature on IPV among MSM by including a group-specific risk factor (AAS use) in modeling risk for IPV. Limitations, implications, and future directions for research are discussed.

Keywords

alcohol and drugs dating violence GLBT

Intimate partner violence (IPV) is a major public health issue. IPV can result in missed work, mental health disturbance, physical injuries, transmission of sexually transmitted infections, and death. The estimated cost of IPV in the United States, in terms of medical care, lost work, criminal justice costs, and other costs is over 3.5 trillion across the lifetime of victims (over $100,000 per female victim, over $23,000 per male victim, across their lifetimes; C. Peterson et al., 2018). Research findings on the prevalence of IPV vary depending on the specific definitions of IPV used in studies, but work has indicated that IPV in men’s same-sex relationships is a pervasive problem.

IPV represents a pervasive risk for mental and physical health. IPV consists of actual or threatened violence within the context of an intimate relationship. Although most work has focused on IPV within the context of other-sex relationships, a growing body of work has examined IPV in the context of same-sex relationships. This work has found many of the same factors (e.g., childhood exposure to violence or abuse, alcohol use) to be linked to IPV victimization and perpetration in same-sex relationships (Bartholomew et al., 2008; Kelley et al., 2014; Wu et al., 2015). However, sexual minorities may also have important unique risk factors for IPV that may not have been examined in work that applies models established in other-sex relationships to same-sex relationships. For sexual minority men, anabolic steroid use may be one unique factor that may contribute to IPV in men’s same-sex relationships.

In one study of 2,881 men who have sex with men (MSM), the prevalence rate of psychological IPV victimization was 34%; physical IPV victimization was 22%; for sexual IPV victimization was 5%; 18% of the participants reported more than one form of victimization (Greenwood et al., 2002). These rates were substantially higher than contemporary estimates of the prevalence of IPV among men in other-sex relationships, though lower than the lifetime rate of IPV among women in other-sex relationships, from contemporary studies (Greenwood et al., 2002). In another study of 175 US MSM, 38% of participants reported being the victim of at least one form of IPV (Duncan et al., 2018). In a systematic review of 28 studies on IPV among MSM, the prevalence of physical victimization among MSM ranged from 12% to 45%; for sexual victimization prevalence ranged from 5% to 31%; for psychological victimization prevalence ranged from 5% to 73%. IPV perpetration was less-often measured, with available data indicating prevalence rates of 4–39% for physical IPV perpetration and 78% for psychological IPV perpetration (Finneran et al., 2012). The wide ranges are due, in a large part, to variations in the specific definitions of IPV across studies. Despite the variations in methods, the overall data indicated that MSM reported a prevalence rate of IPV victimization comparable to that observed among women (Finneran et al., 2012). The authors emphasized the needs for continued attention to IPV within same-sex relationships and examination of correlates of IPV perpetration.

Adverse Childhood Events and IPV

Adverse childhood events (ACEs), in the form of witnessing or experiencing physical or psychological abuse, have been strongly linked to IPV perpetration and victimization in adulthood among heterosexual individuals in large studies (e.g., Coid et al., 2001; Ports et al., 2016; Willie et al., 2021). In one study of over 8,000 US men and women, men reported experiencing physical abuse (28%) or sexual abuse (17%), or witnessing abuse (12%), during their childhood. Among men in that sample, those who experienced abuse during their childhood were 1.9–3.8 times more likely to later perpetrate IPV (Whitfield et al., 2003).

ACEs have been linked with perpetration of physical IPV and sexual coercion, and sexual coercion victimization (Ports et al., 2016; Willie et al., 2021; Zinzow & Thompson, 2015). One study of 186 Canadian men recruited from phone surveys of an urban area with a predominantly sexual minority population also examined ACEs and IPV. ACEs were linked with both physical and psychological IPV perpetration and victimization in that sample (Bartholomew et al., 2008). Although literature on ACEs and IPV among MSM is scant, the extant work indicates support for the same link between ACEs and adult IPV perpetration and victimization as has been observed for heterosexual individuals (Charak et al., 2019).

Alcohol Use and IPV

Alcohol use is strongly associated with IPV (Foran & O’Leary, 2008). In one longitudinal study of over 900 New Zealanders, increasing alcohol use problems were linked with progressively worse IPV perpetration across time (Boden et al., 2012). Qualitative research among other-sex couples has also supported the alcohol as a precipitating factor in IPV perpetration (Murphy et al., 2005) and findings from qualitative, cross-sectional, longitudinal, and experimental research are consistent in linking alcohol use to aggression (Chermack & Giancola, 1997). The link between alcohol and IPV is posited to be due to alcohol’s disruption of cognitive processing systems, resulting in a decreased salience of long-term consequences and increased salience of situational factors such as provocation (Massa et al., 2019). The context of relationships can also play an important role in the relationship between alcohol use and aggression (Chermack & Giancola, 1997).

Alcohol use is a relevant risk factor for IPV among MSM, as MSM have elevated rates of alcohol use compared to their heterosexual counterparts. In one study of 252 MSM in San Francisco, the prevalence of weekly binge drinking was 25% in the sample (Santos et al., 2018). An analysis of over 8,000 MSM recruited from 20 US cities indicated that, among those who drank alcohol, 59% engaged in binge drinking with an average of 6.3 episodes of binge drinking per month (Hess et al., 2015). These elevations in alcohol use are posited to be due to a combination of minority stress processes that can spur on problematic coping, such as alcohol use (Livingston et al., 2016), as well as the potential influence of more permissive peer norms with relation to alcohol use among MSM (Keogh et al., 2009). Due to elevated rates of alcohol use, MSM may be at elevated risk for alcohol use-related problems, such as IPV.

The link between alcohol use and aggression in the form of IPV has been supported among MSM. In a study of 107 US MSM who were or had recently been in a relationship, alcohol use was linked with IPV (Kelley et al., 2014). In another study of 192 Canadian MSM, alcohol use was linked to perpetration of physical and psychological IPV, as well as physical IPV victimization (Bartholomew et al., 2008). Drinking was also linked with both IPV perpetration and victimization among a sample of 37 US Black MSM couples (Wu et al., 2015). Although the use of other illicit drugs has also been linked to IPV including within same-sex male relationships (Cafferky et al., 2018; Duncan et al., 2018; Stults et al., 2015), the role of anabolic-androgenic steroids (AAS) has been under-examined especially in light of the potential relevance of AAS to IPV among MSM.

AAS Use

AAS are schedule II controlled substances that allow for increased development of muscularity, including to levels far beyond normal human capabilities (Cellotti & Cesi, 1992; Kicman, 2008; Ostojic et al., 2011). The vast majority of people who use AAS are not professional athletes or bodybuilders, but are men who simply want to become more muscular (Parkinson & Evans, 2006).

The use of AAS has often been linked to increased aggression (Pope et al., 2000), though recent work has brought the strength and directness of this relationship into question. A meta-analysis of randomized controlled trials on AAS use and aggression found only a small relationship (g = 0.17) between AAS use and self-reported aggression, and no significant link between AAS use and observer-reported aggression (Chegeni et al., 2021). Animal models in more controlled environments may provide more information. In studies of rats, administration of testosterone does not increase motivation for aggression, but may enhance impulsivity and aggressive responses when provocation cues are provided (Cunningham & McGinnis, 2006; Cunningham et al., 2013; Wood et al., 2013); over-focus on provocation cues is also linked with IPV perpetration among men (Clements & Schumacher, 2010; Sprunger & Eckhardt, 2017).

The use of AAS is elevated among sexual minority men. Estimates of AAS use prevalence among sexual minority men range from approximately 10% to 20% (Halkitis et al., 2008; Ip et al., 2019; Parent & Bradstreet, 2018). Muscularity is, broadly, indicative of attractiveness (Swami & Tovée, 2008; Varangis et al., 2012) and masculinity (Edwards et al., 2017) for many sexual minority men, and is rated as broadly desirable in partners among sexual minority men (Bailey et al., 1997; Sánchez & Vilain, 2012). Thus, social pressure may compel many sexual minority men to use AAS to attain a body that is more likely to be perceived as desirable by potential partners.

AAS and IPV

As mentioned above, AAS have long been implicated as resulting in increases in dispositional aggression. Yet, this link is more tenuous than it may appear to be. For example, one study of over 10,000 Swedish adult twins indicated that AAS use was linked with violent crime—but so was use of other drugs, and once other substance use was controlled for, the unique link between AAS use and violent crime was no longer significant (Lundholm et al., 2015). Other work has suggested that antisocial personality traits link AAS use and violence (Hauger et al., 2021) and that individuals interested in AAS use may already have elevated levels of aggression before initiation of use (Sagoe et al., 2016). Nevertheless, the animal model research reviewed above suggests that AAS use may promote aggression in response to perceived provocation. Such perceived provocation is a risk factor for IPV (Massa et al., 2019), and as AAS use is elevated among sexual minority men, AAS use may be a unique risk factor for IPV perpetration among sexual minority men.

Current Study

The aim of this study was to examine whether AAS use within a dating context (i.e., use by either oneself or one’s partner) was linked with IPV, after accounting for the influence of adverse childhood experiences and alcohol use. To this end, we had the following hypotheses:

Hypothesis 1: ACEs and alcohol use would be positively linked with IPV perpetration.

Hypothesis 2: After accounting for the influence of adverse childhood experiences and alcohol use, AAS use in a dating context would be positively linked with IPV perpetration.

In addition, we also conducted an exploratory analysis of the link between AAS use in a dating context and IPV victimization, given previously reported links between use of other substances, such as alcohol, and IPV victimization (e.g., Devries et al., 2014).

Method

Participants

Participants were 491 cisgender men. The participants ranged in age from 18 to 79 (M = 31.35, SD = 11.60). Demographic data are presented in Table 1.

Table 1.

Participant Demographics.

Characteristic	N (%) or Mean (SD)
Age	31.35 (11.60)
Race/ethnicity
White	329 (67%)
Asian/Asian American	38 (8%)
Hispanic/Latino	32 (7%)
Black/African American	31 (6%)
Multiracial	4 (1%)
Another identity	3 (1%)
American Indian/Native American	2 (<1%)

Measures

Adverse childhood experiences

Adverse childhood experiences (ACEs) were based on items from Felitti et al. (1998). All items asked about experiences had the question stem “When you were growing up, at age 18 or before that. . .” Four domains of ACEs were assessed in this study. Psychological abuse was measured with two items (sample item: “Did a parent or other adult in the household, often or very often swear at, insult, or put you down?”), physical abuse was measured with two items (sample item: “Did a parent or other adult in the household often or very often push, grab, shove, or slap you?”), sexual abuse was measured using four items (sample item: “Did an adult or person at least 5 years older ever touch or fondle you in a sexual way?”), and witnessing abuse was measured with four items (sample item: “Was someone other than you in your household sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at them?”). Responses were made on a dichotomous response scale (1 = no, 2 = yes). Responses were averaged, with higher scores indicating more exposure to childhood abuse. Composite reliability (R. A. Peterson & Kim, 2013; Raykov, 1997) for responses to items on the ACEs items were .94, .82, .99, and .84 for psychological abuse, physical abuse, sexual abuse, and witnessing abuse, respectively.

Alcohol use

Alcohol use was assessed using the AUDIT-C (Bush et al., 1998). The AUDIT-C contains three items pertaining to alcohol use (sample item: “How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?”) each with five response choices scored as 0–4. The AUDIT-C was scored continuously as a measure of alcohol use consumption rather than scored based on the clinical cutoff scores, consistent with past research on alcohol use severity when continuous severity and not diagnostic assessment was the goal of using the AUDIT-C (Rubinsky et al., 2013). In prior research using samples of gay and bisexual men, AUDIT-C scores were linked with frequency of IPV victimization (Bacchus et al., 2017). Composite reliability for responses to the AUDIT-C items in this study was .80.

AAS use

AAS use was assessed using two items. One item asked about the participant’s own use of AAS within the past year while in a relationship, dating, or hooking up with a man, and one asked about whether participants have dated a man who used AAS within the last year. Reponses were dichotomized, with positive answers to either or both items coded as 2 and responses of no use by self or partner coded as 1. Just over 7% of the sample reported use of AAS by self or partner; most (n = 30) were reported use by only a partner, and other reported use by self only (n = 3) and both self and partner (n = 3).

Intimate partner violence

IPV victimization and perpetration were assessed using 10 items from prior research on same-sex IPV (Miltz et al., 2019). Each assessed using parallel sets of five items asking about the past year behaviors with men partners (sample item: “Have you ever been hit, slapped, kicked or otherwise physically hurt by a partner [not including consensual sexual activity]?”/“Have you ever hit, slapped, kicked, or otherwise physically hurt a partner [not including consensual sexual activity]?”). Responses were made on a dichotomous scale (1 = no, 2 = yes). Responses were averaged, and higher scores indicate more IPV victimization or perpetration. The current items were chosen as they were adapted specifically for the assessment of same-sex IPV and were based on the Health and Relationships survey, a large-scale survey focused on lesbian, gay, bisexual, and transgender sexual health (Bacchus et al., 2017; Jonas et al., 2014). Composite reliability for responses to the IPV victimization items was .86, and for IPV perpetration was .83.

Procedure

This study was approved by the institutional review board at The University of Texas at Austin. Participants were recruited from Prolific.co, a crowdsourcing research website. Prolific is similar to other crowdsourcing research sites, such as Mturk (Buhrmester et al., 2011; Goodman et al., 2013). However, Prolific.co users complete detailed screener data upon enrollment, and see only studies for which they are eligible based on their screener data. This approach reduces the risk of potential participants seeing task openings and then impersonating identities to enroll in a study, a notable problem with Mturk (MacInnis et al., 2020; Sharpe Wessling et al., 2017).

The study was made available through Prolific.co only to cisgender men, who identified as gay or bisexual, who lived in the United States at the time of the study, and who had been in a romantic and/or sexual relationship with a man in the past year based on their responses to the screening data they completed upon enrollment. At the time of data collection, 1,481 Prolific.co members were eligible to participate in the study and had been active in the 2 weeks prior to the study; 496 Prolific.co members clicked into the study, with five discontinuing the survey and returning the task on Prolific.co. All eligible participants within the Prolific.co platform were able to view the study’s informed consent page, which explained the purpose of the study and requirements for participating. Interested participants then viewed the informed consent page online and could elect to participate in the study. The study materials were hosted online on Qualtrics. Participants were compensated with $3 credited toward their Prolific.co accounts. Participants completed the measures in an average of 12.2 minutes. Missing data were managed using available item analysis (Parent, 2013); we examined the data set for participants missing more than 20% of data on any measure. The only participants with more than 20% missing data on any measure were the five who did not complete the study and who were excluded from analyses. Remaining individual missing data points were managed by calculating the mean of available items for measures.

Results

Descriptive statistics and variable intercorrelations for mean scores on the measures are reported in Table 2. The model was coded in Mplus version 8 and run using maximum likelihood estimation with robust standard errors (MLR; note that fit indices are not defined for this type of model under MLR and as such fit indices are not presented; the model can be evaluated based on the path coefficients). The ACEs items and AUDIT were manifest variables composed of the means of responses to items for each scale. The two IPV variables (victimization and perpetration) were modeled as latent variables. On the perpetration latent variable, two items (forcing a partner to engage in sexual activity and forcing a partner to have sex without a condom) did not load onto the latent construct at p < .05 and were not included in the modeling. This was likely due to very low endorsement of those items, with only five and four participants reporting “yes,” respectively. Correlations and means for IPV perpetration in Table 1, and alphas in the measures section, also exclude responses to this item.

Table 2.

Descriptive Statistics and Bivariate Correlations.

	2	3	4	5	6	7	8	M	SD
1. Psychological abuse	.579***	.178***	.490***	.004	.094*	.154**	.113*	1.318	0.421
2. Physical abuse		.159***	.580***	−.014	.133**	.176***	.071	1.133	0.305
3. Sexual abuse			.182***	.112*	.110*	.223***	.198***	1.152	0.323
4. Witness abuse				.002	.073	.157***	.083	1.131	0.272
5. Alcohol use					.049	.178***	.125**	2.727	2.830
6. AAS use						.123**	.143**	1.073	0.261
7. IPV victimization							.473***	1.116	0.205
8. IPV perpetration								1.054	0.140

Note. IPV = intimate partner violence; SD = standard deviation.

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

Model results are displayed in Table 3. For IPV perpetration, sexual abuse and alcohol use were associated with perpetration, supporting hypothesis 1. AAS use was also uniquely associated with IPV perpetration. To examine the benefit to the model of including AAS use, we compared the model with a model that constrained the path between AAS use and IPV perpetration to zero, to examine change in loglikelihood and R² (akin to hierarchical regression in a normal regression). With AAS use included in the model, loglikelihood improved by −29.85 (df = 2), p < .001. R² improved for IPV perpetration, from R² = 0.123 in the constrained model to R² = 0.143 in the model in which the path from AAS use to the IPV variables was estimated. Thus, hypothesis 2 was supported and we found a unique relationship between AAS use in relationships and IPV perpetration.

Table 3.

Path Coefficients for the Model.

Path	Estimate	SE	p
DV: IPV perpetration
Psychological abuse	0.085	0.099	.388
Physical abuse	−0.008	0.101	.938
Sexual abuse	0.197	0.059	.001
Witness abuse	0.059	0.084	.483
Alcohol use	0.196	0.068	.004
AAS use	0.144	0.061	.019
DV: IPV victimization
Psychological abuse	0.056	0.070	.425
Physical abuse	0.102	0.077	.190
Sexual abuse	0.181	0.055	.001
Witness abuse	0.059	0.073	.418
Alcohol use	0.190	0.058	.001
AAS use	0.098	0.054	.071

Note. AAS = anabolic-androgenic steroid; IPV = intimate partner violence; SE = standard error.

We also examined our exploratory hypothesis, that AAS use would be linked with IPV victimization. Sexual abuse and alcohol use were associated with victimization, similar to IPV perpetration. AAS use was not associated with IPV victimization. Comparing the constrained and unconstrained models, the change in R² was smaller for IPV victimization than for perpetration; R² = 0.134 in the constrained model and R² = 0.143 in the model with the AAS use to IPV paths estimated.

Discussion

The goal of this study was to explore the association between AAS use in relationships and IPV, after controlling for the influence of ACEs and alcohol use. Hypothesis 1 was supported; sexual ACEs and alcohol use were linked with IPV perpetration, consistent with prior research on ACEs and alcohol use in relation to IPV (Charak et al., 2019; Coid et al., 2001; Foran & O’Leary, 2008; Hess et al., 2015; Santos et al., 2018). Hypothesis 2 was also supported, in that AAS use within a dating context was uniquely associated with IPV perpetration. The exploratory hypotheses related to IPV victimization indicated that IPV victimization was linked with sexual ACEs and alcohol use, but AAS use was not.

AAS’ proposed relationship with aggression (Cunningham & McGinnis, 2006; Cunningham et al., 2013; Wood et al., 2013), especially in the context of IPV, may explain why AAS use was uniquely associated with IPV perpetration within the current sample, over and above the influence of known predictors of IPV (alcohol use and ACEs). AAS use may increase reactivity to perceived social provocation, similar to such effects observed with alcohol in relation to IPV (Clements & Schumacher, 2010; Eckhardt et al., 2015). As MSM are at elevated risk for use of AAS, AAS use may represent an important, unique risk factor for IPV among this population. We also explored the potential relationship between AAS use and IPV victimization. However, AAS use in a relationship did not emerge as a unique predictor of IPV victimization. Thus, in this study, AAS use did not appear to contribute to both IPV victimization and perpetration, as is observed with other substances such as alcohol (Devries et al., 2014).

The results of this study must be interpreted in light of its limitations. First, this study is cross-sectional and thus causality cannot be inferred from the results. Longitudinal research is needed to explore the links between the variables in this study in more detail. Second, our data collection method relied on obtaining data form a crowdsourced website. Although such data are generally useful for research (Palan & Schitter, 2018), systemic differences between users and non-users of these sites might exist. For example, we were unlikely to obtain data from individuals in extreme poverty, who may not have access to the Internet or compatible devices to complete studies; we were also unlikely to obtain data from wealthier individuals, who would have little need for the small amount of compensation offered on sites such as Prolific.co. Further research on this topic can help to understand these complex intersections, such as IPV among low income MSM. Third, we assessed only some of the range of factors, distal and proximal, that may contribute to IPV in men’s same-sex relationships. Fourth, we assessed alcohol use using the AUDIT-C, which is one possible measure of alcohol use. Future research may employ other assessments of alcohol use, such as a timeline follow-back which would allow for the assessment of the temporal effects of alcohol use on IPV. Fifth, we assessed AAS use as a couple-level variable due to limitations in power that would occur examining it at the individual level, with most of the reported AAS use being by one’s partner only. Future research may assess the differential impact of AAS use by a partner on IPV victimization, and vice versa, as well as the nature of AAS use in long-term relationship IPV versus short-term/hook-up IPV, stalking, or other aggressive behaviors. Finally, we did not assess the temporal concordance of AAS use (or alcohol use) and IPV; future research may use longitudinal or momentary ecological sampling to better understand precise relationships between AAS use and IPV.

Despite these limitations, the results of this study highlight the importance of targeting AAS as a method of prevention and intervention against perpetration of IPV with sexual minority men. This is particularly important given the limited focus on perpetration of IPV, particularly within the sexual minority community. From a prevention perspective, it appears fruitful to develop programming focusing on the prevention of AAS, and substance use more broadly given the impact of alcohol use on IPV. These programs may benefit from highlighting the link between AAS use and aggression and in turn the potential impact of AAS on IPV and other forms of violence. Given the current study’s focus on sexual minority men, this may be a particularly important program within this community and may benefit for specific conversation about the unique risks for AAS use among sexual minority men including the potential social pressure to increase one’s muscularity (Swami & Tovée, 2008; Varangis et al., 2012). In addition, clinicians working with perpetrators of IPV, particularly sexual minority men, would benefit from exploring AAS and targeting AAS within treatment. Clinicians may also benefit from investigating IPV with clients who are struggling with substance use, particularly AAS. Finally, given the potential relationship between AAS use and masculinity (Edwards et al., 2017), feminist approaches to therapy which focus on exploring and understanding cultural norms regarding gender roles may be particularly useful for this population (e.g., Brown, 2018).

In summary, the present findings suggest that the use of AAS, which is elevated among sexual minority men, may be an important factor to include in research on IPV in addition to common risk factors including ACEs and alcohol use. As such, this may be a fruitful area for future prevention and intervention work surrounding IPV among sexual minority men, particularly regarding perpetration. Additional work is needed on how anabolic steroid use influences IPV over time, and methods by which AAS-related IPV can be reduced.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research and/or authorship of this article: This study was funded by a grant from the University of Texas at Austin Office of the Vice President of Research, awarded to Dr. Mike Parent.

ORCID iDs

Mike C. Parent

Nicole L. Johnson

Author Biographies

Mike C. Parent, PhD, is an Associate Professor in the Department of Educational Psychology at the University of Texas at Austin. His work focuses on behavioral health among gender and sexual minority populations. He is interested in substance use and its impact on health, as well as innovative mental health service delivery solutions.

Nicole L. Johnson, PhD is an Associate Professor of Counseling Psychology at Lehigh University. Her research is dedicated to the exploration and implementation of prevention programming for gender-based violence (e.g., rape, intimate partner violence, violence against individuals with marginalized sexual and gender identities) and the understanding and eradication of rape culture. Nic is the coordinator of The Resistance Lab at Lehigh University. She is also a licensed psychologist whose clinical work focuses on the empowerment of survivors of gender-based violence through feminist approaches to counseling.

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