Abstract
Research investigating intimate partner violence (IPV) among sexual minorities is limited. The research that does exist has found that rates of IPV are similar to or higher than the rates found for heterosexual women, the most commonly studied population in this area. This limited research has resulted in a dearth of prevention/intervention programs targeted for these populations. While some may argue that existing IPV programs can be used for these populations, this review presents an argument for more targeted work with sexual minority populations, using young men who have sex with men (YMSM) as an example. Drawing on the framework of intersectionality, this article argues that the intersectionality of age, sexual identity, and gender combines to create a spectrum of unique factors that require specific attention. This framework allows for the identification of known correlates for IPV as well as factors that may be unique to YMSM or other sexual minority populations. The article presents a conceptual model that suggests new areas of research as well as a foundation for the topics and issues that should be addressed in an intervention.
It is estimated that more than 1 in 3 women (36.5%) and more than 1 in 4 men (28.5%) have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime (Black et al., 2011). An intimate partner, as defined by the Centers for Disease Control and Prevention, is a person with whom one has a close personal relationship including emotional connectedness, regular contract, identity as a couple, and/or ongoing physical contact and sexual behavior. Research investigating intimate partner violence (IPV) as a social and public health issue began in earnest over 50 years ago. Since that time, we have learned that IPV is a public health issue that crosses economic, ethnic/racial, and cultural boundaries. We have also learned that IPV contributes to a number of physical and mental health problems such as depression, post-traumatic stress disorder, cardiovascular disease, and obesity (Campbell, 2002). A number of interventions have been developed and evaluated to address both the primary and secondary prevention of IPV among heterosexual couples. However, in spite of the fact that IPV has been called the third biggest health problem facing gay men, just after HIV/AIDS and substance use (Island & Letellier, 1991), to date, no interventions or programs have been developed for and evaluated with sexual minority populations.
While it could be argued that one of the existing educational group- or dyadic-level interventions designed for heterosexual individuals could adequately address IPV in same-sex relationships, we argue that the psychosocial and cultural context surrounding sexual minority groups require their own targeted interventions to address the unique factors related to IPV found in these groups. Using young men who have sex with men (YMSM) as an example, we argue that the intersectionality of age, sexual identity, and gender combines to create a spectrum of unique factors that require specific attention for this population. Other sexual minority groups (e.g., older men, lesbians, bisexual men) would require similar reviews. In this review, we consider YMSM to include emerging adults (ages 18–25) and young men who may or may not identify as gay or bisexual. 1
The work over the past years has provided us with an initial foundation to better understand the complexities of same-sex relationships. Societal perceptions of same-sex relationships have changed dramatically during this same time, and the U.S. Supreme Court ruled that same-sex marriages must be performed and recognized across the country in June 2015. As society becomes more accepting overall of same-sex relationships, we need to also consider how our current programs and policies that support and intervene in violent relationships address the needs of both heterosexual and homosexual relationships.
This article seeks to provide a framework for the development of targeted interventions for YMSM. We briefly review the literature on prevalence and correlates of IPV among men who have sex with men (MSM); we then move on to explore issues of the intersectionality of age, sexual identity, and gender—drawing from examples specific to YMSM when available and from other populations as needed. After this discussion of the literature, we present a conceptual model that can be used to set a research agenda and a framework for interventions at both the interpersonal and societal levels to address issues of IPV among YMSM. While specific to YMSM, this framework could be further adapted to address other sexual minority populations including lesbians, transgender, and bisexual men and women.
Dating Violence Prevention Programs in the Literature
A relatively recent review of existing dating violence prevention programs identified 12 programs that have published some outcome data indicating changes in knowledge, attitudes, intentions, and/or behaviors related to IPV among adolescents and young adults (Whitaker et al., 2006). Only two programs provided longitudinal data that indicated more long-term positive outcomes among participants (Foshee et al., 1998; Wolfe et al., 2003). The review found that these programs are provided almost exclusively in schools, either classroom-based lessons during health classes or larger assemblies in the school auditorium to provide a briefer overview of IPV and its risks to a larger audience. The programs in this review focus on a number of factors related to IPV including power and control as well as general attitudes about dating violence and gender roles/expectations.
These concepts are relatively universal in relation to perpetration and victimization of IPV across populations. However, supplemental materials in these programs generally include scenarios with a female victim and male perpetrator, films that are also heterocentric in nature, and/or printed materials that present the typical victim/survivor of IPV as a young girl. Missing from these programs are factors that may be relevant for YMSM and other sexual minority groups such as internalized homophobia, the relationship between societal discrimination and violence, positive role models relevant to sexual minorities, negotiating power in same-sex relationships, and a greater emphasis on services available for male victims (with the exception of Foshee et al.’s Safe Dates and Wolfe et al.’s Youth Relationships Project).
IPV Among Adult and YMSM
Epidemiology of IPV Among MSM and YMSM
Research estimating the prevalence of IPV in adult MSM relationships indicates rates similar to heterosexual women, ranging from 12% to 78%, depending on type of abuse, whether one is the victim or perpetrator of violence, sampling techniques, and measurement of IPV (Finneran & Stephenson, 2013; Greenwood et al., 2002a, 2002b; Houston & McKirnan, 2007; Nieves-Rosa, Carballo-Dieguez, & Dolezal, 2000; Pantalone, Schneider, Valentine, & Simoni, 2012; Tjaden, Thoennes, & Allison, 1999; Waldner-Haugrud, Gratch, & Magruder, 1997; Waterman, Dawson, & Bologna, 1989). These studies share several limitations, as suggested by the wide range in estimated rates. First, there is a lack of uniformity as to how one defines IPV and whether it includes only physical violence or also emotional/psychological and sexual. For this review, we define IPV broadly to include instances of emotional psychological, physical, and sexual violence or aggression. Second, this prior body of work relies heavily on convenience samples at community events or clinics. However, more recent research using population-based samples has further validated IPV as a problem among MSM. For example, a recent study using the population-based California Health Interview Survey found that lifetime and 1-year IPV prevalence was higher among gay men compared to heterosexual individuals (Goldberg & Meyer, 2013).
While less extensive than research with their older counterparts, the literature also indicates that YMSM experience IPV at rates similar to those of heterosexual females (Freedner, Freed, Yang, & Ausin, 2002; Halpern, Young, Waller, Martin, & Kupper, 2004; Mustanski, Garofalo, Herrick, & Donenberg, 2007). For example, among younger sexual minority groups, data from the Youth Risk Behavior Survey found that males endorsing a gay or other same-sex identity have 2.2 times greater odds of being involved in IPV than heterosexual males (Tharp, Feijun, & Stone, 2013). The Healthy Young Men’s Study, a study of YMSM using a probability sampling design, found 41% of YMSM experienced emotional abuse, 23% experienced physical abuse, 18% experienced sexual abuse, and 12% perpetrated physical violence within their intimate relationships in the last year (Wong, Weiss, Ayala, & Kipke, 2010).
Correlates of IPV Among MSM and YMSM
The contexts of the underlying psychosocial issues of IPV among YMSM and other sexual minority groups remain largely unexplored. A recent meta-analysis found that MSM who are victims of IPV are more likely to engage in substance use, suffer from depressive symptoms, be HIV positive, and engage in condomless anal sex; MSM who perpetrate IPV are more likely to engage in substance use (Buller, Devries, Howard, & Bacchus, 2014). Substance abuse and mental health issues are also commonly found among heterosexuals involved in IPV.
When considering intervention development, it is critical to identify and understand those variables or behaviors that may be unique to YMSM or other sexual minority populations’ experiences with IPV. It is these factors, in combination with issues related to the intersectionality of age and gender, which speak to the need for more targeted interventions to address the unique set of factors related to IPV among YMSM and other sexual minority populations. Although research is limited, there are some unique elements that have been linked with perpetration and/or victimization of IPV among MSM or YMSM
Relationship power
Relationship power has been described as intimately linked with relationship violence among heterosexual couples and has been identified as one of the primary drivers of IPV (Archer, 1994; McKenry, Serovich, Mason, & Mosack, 2002). Until recently, we had no insights into how power is conceptualized within same-sex relationships; a recent qualitative study gives us some insights into this formerly unexplored area (Kubicek, McNeeley, & Collins, 2014). For example, sexual positioning, or who takes on the insertive or receptive position in anal intercourse, was identified as being related to relationship power. Young men described the receptive or “bottom” in the relationship as being the “female” or “woman” in the relationship; these individuals were seen as more submissive and weaker than the more masculine “tops.” This also suggests that YMSM subscribe to more traditional gender roles as seen in some heterosexual couples. In addition, societal oppression of gay men, the social acceptability of violence between men, as well as internalized homophobia and shame were perceived to influence the power dynamics within young men’s relationships and ultimately both perpetration and victimization of IPV.
Discrimination, homophobia, and internalized homophobia
Due to heterosexism and societal homophobia, same-sex victims of IPV experience situations that are not experienced by heterosexual victims (Brown, 2008; Rohrbaugh, 2006; Sorenson & Thomas, 2009). Many same-sex victims of IPV must also contend with societal beliefs that their lives and relationships are not acceptable (Balsam & Szymanski, 2005; Kubicek, McNeeley, & Collins, 2015). For example, Finneran and Stephenson found that MSM who reported experiencing more sexuality-based discrimination and internalized homophobia were more likely to report experiences of IPV (Finneran & Stephenson, 2014). In addition, in a study of sexual minority college students, Edwards and Sylaska (2013) found that perpetration of sexual and physical dating violence was related to internalized homophobia, which can be defined as the direction of negative social attitudes toward the self, leading to one’s devaluation and resultant internal conflicts.
A qualitative study with young and emerging adult sexual minority men and women found that participants perceived that societal and internalized homophobia influenced IPV (Gillum & DiFulvio, 2012).
Sexual coercion/risk
Several researchers have also identified an association between condomless anal intercourse, the primary mode of HIV transmission among YMSM, and IPV (Buller et al., 2014; Houston & McKirnan, 2007; Nieves-Rosa et al., 2000; Relf, Huang, Campbell, & Catania, 2004; Stall et al., 2003). For example, the Healthy Young Men’s Study found that YMSM who were victims of physical abuse were more likely to report recent drug use and symptoms of depression, which in turn was related to condomless anal intercourse (Wong et al., 2010). Similar results have been found in heterosexual couples, with women victims of IPV feeling disempowered to advocate for protected sex with their abusive partners (Campbell et al., 2008; Gielen et al., 2007).
Mutual perpetration
Mutual perpetration of IPV—for example, individuals in a relationship taking on both the perpetrator and victim roles—may be more common in young people’s relationships, including YMSM’s (Capaldi & Crosby, 1997; Gray & Foshee, 1997; Kubicek & McNeeley, 2015). Labeling these behaviors as “mutual perpetration” can be a controversial idea, with some researchers and advocates identifying that some “perpetration” may actually be self-defense in many cases. However, research does find that there are high rates of YMSM reporting both receiving and perpetrating different acts of IPV (Kubicek & McNeeley, 2015; Wong et al., 2010).
Taken together, we see a number of correlates of IPV commonly identified across populations such as substance use, mental health, and power dynamics. Importantly, as we further delineate below, sexual minority populations, particularly YMSM, experience these same behaviors at higher rates than their heterosexual peers. Additionally, understanding how power is constructed in YMSM relationships, the context of mutual perpetration and societal discrimination and oppression of sexual minority populations should all be considered in the development of interventions for YMSM. These are unique issues that existing IPV interventions (typically developed with a heteronormative perspective) do not fully address nor consider in their theoretical base.
Intersectionality of Age, Sexual Identity, and Gender
Given the limitations with current prevention/intervention programming, the objective here is to outline the unique factors that may influence involvement in IPV among YMSM with the recommendation that future programming integrates these factors into existing programs and/or new more universal group or dyadic-based programs are developed. Intersectionality is a framework that considers the intersections between forms or systems of oppression, domination, or discrimination. The literature on intersectionality has contributed a great deal to our understanding of the disparities that exist among different populations such as African American women and sexual minorities (Bowleg, 2008; Crenshaw, 1989). With regard to YMSM, we would argue that the experiences of being a nonheterosexual young man cannot be understood in terms of gender, sexual identity, and age individually; rather these dimensions must be understood collectively and how they may interact or reinforce each other. Figure 1 provides a depiction of the factors within each of these areas that may influence IPV; we include those that are unique to YMSM and those that may be common in the more general population. As Figure 1 indicates, there are a number of factors that overlap across these dimensions. We note this to explain that we recognize these factors are not isolated within one dimension of YMSM’s lives. Rather, these factors are fluid and may move into and out of these dimensions at various times across the life course.
Intersectionality of age, sexual identity, and gender: Key factors related to intimate partner violence among young men who have sex with men.
Age: The Developmental Stage of Emerging Adulthood
YMSM ages 18–25 occupy a unique developmental phase called “emerging adulthood,” which warrants special attention. Distinct from adolescence, emerging adulthood is a time of greater independence when young people may explore different life goals and opportunities in school, work, and peer and romantic relationships (Arnett, 2000). This is a time when young people are typically moving out of their family home for the first time and exploring educational and career opportunities (Arnett, 1998). Research shows that risk behaviors such as alcohol and drug use as well as partner violence are at their highest during this time period (Chassin, Pitts, & Prost, 2002; King, Nguyen, Kosterman, Bailey, & Hawkins, 2012; Lohman, Neppl, Senia, & Schofield, 2013; Thompson, Swartout, & Koss, 2013; Walsh, Latzman, & Latzman, 2014). The desire for exploration, experimentation, and greater independence may also contribute to this increased frequency of risk behaviors (Arnett, 2005; Bachman, Wadsworth, O’Malley, Johnston, & Schulenberg, 1997; Tucker, Ellickson, Orlando, Martino, & Klein, 2005).
Cognitive Development
We now know that brain development does not stop in adolescence; rather, it continues to full maturation into one’s mid-20s during this emerging adulthood phase. This final stage of brain development allows for greater processing of emotions and social information; the areas of the brain used for planning and processing risk and rewards also undergo important developments during this stage (Beck, 2012). These developments related to emotional processes and risk analysis may hamper clear decision-making and impulse control. It is this last stage of cognitive development that has been identified to partially explain the high rates of risk behaviors during this period. This later development also indicates that individuals may be more able to change behaviors during this time period, given that risk behaviors are not fully ingrained. Thus, interventions prior to or during this period may be more likely to impact risk behaviors than interventions later in life.
YMSM and Emerging Adulthood: Period of Increased Risk Behaviors
While this time period includes some of the highest rates of risk behaviors for youth generally, sexual minority youth, including YMSM, are at even greater risk, reporting higher levels of alcohol use and misuse compared to their heterosexual peers (Talley, Sher, & Littlefield, 2010; Wong, Schrager, Chou, Weiss, & Kipke, 2013). A meta-analysis of 18 studies found that the odds of sexual minority youth using substances (i.e., cigarette, alcohol, illicit drugs) were 190% higher than for heterosexual youth (Marshal et al., 2008).
It is during this time period that YMSM typically begin to explore and define intimate relationships. Therefore, interventions during this period, when YMSM are perhaps first exploring their intimate relationships and defining what they want and desire from them, are critical to curtail not only IPV and related negative health outcomes among YMSM but to also prevent such occurrences at later life stages.
Dating Violence During Emerging Adulthood
Among the general population, national studies have identified that the rates of IPV are at their highest during emerging and young adulthood. For example, in the National Survey of Families and Households, higher rates of partner violence were found among respondents younger than 30 years (Sorenson, Upchurch, & Shen, 1996). Similarly, in the longitudinal National Youth Survey, the past-year prevalence of physical violence decreased as the cohort aged, from a high of 55% when respondents were aged 18–24 years to a low of 32% when they were aged 27–33 years (Morse, 1995).
One important distinction that should be made when comparing IPV between young adults and older adults is that prior work on dating violence among adolescents and emerging adults has suggested that the rate of victimization by an intimate partner during this developmental stage is similar for males and females (Avery-Leaf, Cascardi, O’Leary, & Cano, 1997; Foshee, 1996; Malik, Sorenson, & Aneshensel, 1997; Roberts & Klein, 2004). This indicates a greater general propensity for violence at this age than their older counterparts.
Sexual Identity: Health and Mental Health of YMSM
Adolescence and young adulthood is a time of relatively good health for the general population. However, there is growing evidence to suggest that sexual minority youth are at increased risk for a wide range of physical and mental health problems compared to their heterosexual peers (Lock & Steiner, 1999). These include physical abuse (Freedner et al., 2002; Hunter, 1990; Tharp et al., 2013), sexual violence and victimization (Balsam & Szymanski, 2005), school problems (Gonsiorek, 1988; Remafedi, 1987, 1990; Savin-Williams, 1994), homelessness (Gibson, 1989; Kipke, Weiss, & Wong, 2007; Remafedi, 1987; Savin-Williams, 1994), and depression and suicide (Allen & Glicken, 1996; Bontempo & D’Augelli, 2002; Garcia, Adams, Friedman, & East, 2002; Gibson, 1989; Kipke, Kubicek, et al., 2007; Koblin et al., 2006; Mustanski, Garofalo, & Emerson, 2010).
Also, while YMSM share many of the same developmental tasks as heterosexual youth, the struggle to develop and integrate a positive adult identity (a primary developmental task for all adolescents and young adults) is made more challenging for YMSM, given the disapproval, discrimination, and homophobia many of them experience from their families, peers, racial/ethnic community, and/or faith community (D’Augelli & Herschberger, 1993; Kubicek, McDavitt, Weiss, Iverson, & Kipke, 2009; Ryan & Futterman, 1997; Savin-Williams, 1989; Uribe & Harbeck, 1992). This social and emotional isolation may in turn contribute to internalized homophobia and thereby increase YMSM’s vulnerability and risk for experiencing a range of poor health and mental health outcomes (Savin-Williams, 1990). Sexual minority youth themselves have identified that internalized homophobia contributes to violence in their lives.
Collectively, these studies suggest disparities in substance use, mental health, and victimization/abuse among YMSM. Issues related to mental health and child maltreatment are especially important when considering involvement in partner violence, as they are strongly associated with both perpetration and victimization of IPV in both heterosexual and sexual minority populations (Buller et al., 2014; Campbell, 2002; Finneran & Stephenson, 2013; Jewkes, 2002; Mason et al., 2014; Wong et al., 2010).
HIV, IPV, and YMSM
Finally, when thinking about YMSM, it is almost impossible to not consider how a public health issue such as IPV may affect the most pressing health concern in this population, HIV/AIDS. From 2008 to 2011, YMSM aged 13–24 years had the greatest percentage increase (26%) in diagnosed HIV infections across populations (Centers for Disease Control and Prevention, 2012). Moreover, research indicates that men who are HIV positive are more likely to be victims of IPV than HIV negative individuals (Craft & Serovich, 2005; Feldman, Diaz, Ream, & El-Bassel, 2007). As mentioned previously, IPV is highly correlated with HIV risk behaviors—specifically unprotected anal intercourse, suggesting a complicated relationship between IPV and HIV with causal associations somewhat unclear.
Additionally, research indicates that IPV and other psychosocial health problems such as depression, substance use, and child maltreatment increase one’s vulnerability for HIV/AIDS. These issues tend to co-occur with each other and data indicate that the number of psychosocial health problems additively increases risk for HIV among YMSM (Mustanski et al., 2007). These findings suggest that addressing one of these issues—for example, IPV—would potentially also address HIV risk within this population.
In sum, we know that in spite of the fact that this developmental stage generally represents the healthiest time in one’s life—the “young invincibles” as they are commonly referred to today—issues such as depression, low self-esteem, substance use, and child maltreatment are more common among this population. These issues are also identified as being important correlates and drivers of IPV across populations. This indicates that the “foundation” for IPV is potentially higher for YMSM—further indicating a great need for interventions.
Gender: Gender Roles and Masculinity
Ideas of Masculinity
When examining adolescent male ideas about masculinity, Marsiglio (1988) proposed a conceptual model of heterosexual masculinity with a focus on cultural scenarios and influences that promote competitiveness, aggressiveness, independence, emotional coolness, dominance, and assertiveness. Importantly, issues of gender identity are an integral part of the foundation of sexual scripts, which develop during adolescence and emerging adulthood (Marsiglio, 1988).
It should be noted that masculinity, while associated with toughness, status, and assertiveness, is often also associated with what it is not; that is, not being feminine and not homosexual. Being a man requires not being compliant, dependent, or submissive to their partners and not being a “sissy” in physical appearance or behaviors (Herek, 1986). In fact, some authors have asserted that to “be a man” in contemporary American society can be equated with homophobia (Noar & Morokoff, 2002). While this point of view is changing in some societies, with ideas of gender hybridization and men being encouraged to find their “feminine sides,” these masculine ideals and social roles are still dominant today.
Learned gender roles and expectations inform men’s beliefs and perception about their roles and responsibilities within their relationships. Research has shown that men who harm women often do so when their sense of traditional manhood—such as being a breadwinner or having women meet their needs—is threatened (K. L. Anderson & Umberson, 2001; Atkinson, Greenstein, & Lang, 2005). Feminist theory has been the foundation for this argument, emphasizing gender and power inequality in heterosexual relationships and how societal messages may sanction a male’s use of violence and aggression, and the proscribed gender roles that dictate how men and women behave in their intimate relationships (Pence & Paymar, 1993).
Masculinity Among MSM
There is limited work examining ideas of masculinity among homosexual men. One study found that gay men’s sexual identity was related to a lack of “heterosexual” masculinity (Connell, 1992). However, while these men formed what they termed a more “homosexual” masculinity, they were socialized within the same cultural scripts that form traditional gender roles. As a result, this homosexual masculinity maintained some of the societal ideals of masculinity such as a sense of toughness and independence commonly associated with the traditional ideas of masculinity.
Others have found that gay men oftentimes compensate for their societal subordination and signify their masculine selves by emphasizing larger bodies and muscularity (Hennen, 2005), athletic ability (E. Anderson, 2002), sexual risk-taking (Collins, 2009; Green & Halkitis, 2006), and brotherhood and the devaluation of women (Yeung & Stombler, 2000; Yeung, Stombler, & Wharton, 2006). Similarly, Wolkomir (2009) showed how gay men in “mixed-orientation marriages” emphasized their ability to provide for their wives and children in spite of their sexual orientation and perceived masculinity—indicating that taking care of one’s family was an integral factor in being a man. Whether they stressed physical, sexual, or paternal prowess, gay men in each of these studies emphasized elements of the masculine ideal to signify creditable masculine selves.
In recent qualitative studies with YMSM, researchers reported that the participants tended to hold traditional beliefs about gender norms and behaviors. One study reported that young men defined masculinity as “taking care” of one’s partner, being “independent” and mature (Kubicek et al., 2015). Conversely, femininity was described as being “catty,” “soft spoken,” and sweet and doing things a “normal” man would not such as being a bottom. In this study, young men felt that boys were socialized to be more aggressive than girls, making it hard to be submissive in a relationship; they found that participants reported commonly working out problems with brothers or friends through physical fights. Young men felt that social norms tend to condone violent behavior between men and this may also contribute to the high rates of IPV in this population.
Taking this into consideration, it should not be surprising that additional challenges may result from the negotiations and communications that occur within gay men’s intimate relationships. When both partners are exhibiting aspects of the traditional ideas of masculinity including aggression, dominance, and a desire for sexual prowess, identifying the power dynamics within the relationships is a challenge and ever evolving. It is within these dynamics that we must examine experiences of IPV within YMSM’s relationships.
Conceptual Model: Intersectionality of Age, Sexual Identity, and Gender and the Effect on IPV Among YMSM
A conceptual model that outlines the factors discussed here in each dimension of age, sexual identity, and gender and how they intersect and combine to impact victimization and perpetration of IPV among YMSM is presented in Figure 2. The model conveys the idea that IPV cannot be explained or intervened on by a single factor, nor can it be explained by the factors identified within heterosexual couples alone. Rather, IPV is the result of a number of complicated factors that exist within these dimensions.
Conceptual model of the intersectionality of age, sexual identity, and gender: Their role in intimate partner violence among young men who have sex with men.
People experience different forms of privilege and subordination, depending on their race, class, gender, sexuality, and nationality. YMSM as a group reside within at least three areas 2 of intersectionality: (1) their developmental period of emerging adulthood which includes some of the highest rates of risk behaviors and violence; (2) a minority sexual identity (e.g., gay, bisexual, queer, questioning) which includes societal discrimination and health disparities; and (3) masculine gender, which typically offers a sense of privilege and power while promoting a sense of toughness and status.
These dimensions combine to inform the development of dating and sexual scripts of YMSM, which are the logical intervention point in this model. Providing young men the tools needed to develop and support healthy and satisfying sexual/dating scripts is likely the key to addressing violent relationships.
Sexual Scripts, Masculinity, and Violence
Sexual scripts, like gender roles, are learned through socialization and can be seen as providing guidelines for “appropriate” sexual behavior and sexual encounters. The traditional sexual script (TSS) is the most commonly described script in American societies and includes different expectations for men and women. Is sum, the TSS describes men as “oversexed,” having strong sexual needs, being highly aggressive in their pursuit of sexual interactions and the initiators of sexual behaviors (Byers, 1996). Women on the other hand are seen as “undersexed,” passive, being sexually reluctant yet appearing interested and sexy and the recipients of sexual initiations. The factors included in the TSS have been used to explain the prevalence of sexual coercion and rape in Western cultures (Byers, 1996; Murnen, Wright, & Kaluzny, 2002; Santana, Raj, Decker, La Marche, & Silverman, 2006).
Although the TSS is the most widely described dating/sexual script in the literature, because it was developed based on heterosexual couples’ experiences, its relevance for YMSM or other sexual minority populations is limited. Our knowledge of how sexual minorities develop and practice dating/sexual scripts is much more limited.
The majority of the research that considers sexual scripts of MSM typically focuses on scripts as they relate to safer sex and HIV prevention (Parsons et al., 2004). While important, the result is that we know little about the sexual scripts of MSM and YMSM more generally. One study that focused on understanding the sexual scripts of young gay men identified a number of different sexual scripts that young men may use in their intimate relationships (Mutchler, 2000). These scripts include romantic love, which occurs within monogamous relationships; “adventure,” which includes a number of casual and single encounters; sexual coercion; safe sex; and unsafe sex. The type of script was largely dependent upon setting, roles, and situation, with young men adopting different scripts dependent on the location (e.g., public sex venue, home) and relationship type.
A script focused on sexual coercion within YMSM relationships is particularly relevant for public health interventions, given that unprotected sex continues to be the main mode of transmission for HIV/AIDS. Research indicates that there are high rates of sexual coercion in men’s relationships. One community survey found that 55% of gay men reported unwanted penetration or genital fondling with the most commonly reported tactics including persistent touching, guilt-tripping, telling lies, and alcohol or drugs (Waldner-Haugrud & Gratch, 1997). Another study with YMSM found that 37% reported their partner “insisted” on sex without a condom in the last year (Kubicek & McNeeley, 2015).
While research describing sexual scripts of sexual minorities is limited, important inferences from the above discussions can be made. One, research shows that MSM and YMSM often incorporate aspects of traditional masculinity to assert their independence and power in their relationships. Two, in the absence of more relevant role models, YMSM tend to take on the traditional gender roles in their relationships that they learned from their parents or other role models growing up. These scripts may include one partner being the more “masculine” and the other more feminine. With these in mind, YMSM and other sexual minority groups likely utilize aspects of the TSS that fit their situations and sexual ideals. Thus, these aspects of masculinity and power are important to consider for IPV prevention for sexual minority men, especially sexual and physical abuse. Third, YMSM may integrate a number of different dating scripts based on specific partners and time and space. These scripts can include a variety of risks associated with sexual coercion and condomless sex.
Conceptual model for IPV prevention among YMSM
Many of the factors presented in Figure 2 are identified as correlates of IPV among heterosexual couples; however, there are some unique factors that should once again be highlighted. First, the overarching sociocultural factors that YMSM must navigate on a daily basis cannot be overlooked. While change is occurring rapidly in this area, with public opinion supporting gay marriage changing dramatically over the last 10 years (Daniels, 2014), inequality and social discrimination remain as evidenced by “religious freedom” laws being proposed and enacted in several states. YMSM themselves perceive that this inequality has a deep effect on their relationships, as they have been conditioned to defend themselves as a result of these societal views (Díaz & Ayala, 2001; Diaz, Ayala, & Bein, 2004; Wilson & Yoshikawa, 2004). This places violence in a more prominent place in their lives, resulting in using violence as a reflex when facing conflict and challenges in their lives. Also, while society generally sees violence against women as wrong, it is often hard for people to see males as a victim in IPV. Coupled with a greater endorsement of violence between men and boys—“boys will be boys”—the acceptability of IPV within YMSM relationships appears to be much greater.
It should also be noted that the deleterious effects of societal, familial, and community homophobia have been linked to poorer mental health, substance misuse, unprotected sexual intercourse, and other negative health outcomes for YMSM (Choi, Han, Paul, & Ayala, 2011; Díaz & Ayala, 2001; Finneran & Stephenson, 2014; Harper & Schneider, 2003; Mays & Cochran, 2001; Mustanski et al., 2007; Wong et al., 2010). Thus, the cycle of negative societal influences contributing to poorer health outcomes for YMSM continues.
Second, the developmental stage of emerging adulthood is an interesting juxtaposition. While the time period typically represents the healthiest time of one’s life, it is also a time period with heightened risk behaviors such as substance use, violence, and sexual risk. As described, YMSM typically have higher rates of these risk behaviors than their heterosexual peers. As YMSM begin to assert their independence and develop a sense of identity, they often find themselves exploring gay communities. Historically, these communities have often been defined as bars and clubs in the “gay ghetto.” While these communities can offer YMSM a place to freely express their sexual and individual identities, they are also situated in high-risk settings where alcohol, drug use, and public sexual encounters are common (Holloway, Rice, & Kipke, 2014). Thus, this time period for YMSM is particularly risky—pointing to the need for ongoing intervention efforts.
Third, YMSM as a group endorse a sexual identity other than straight or heterosexual. Certainly, there are different issues to examine depending on whether one identifies as gay, queer, or bisexual, or eschews any such label while seeking sexual partners of the same gender. However, as a group, YMSM experience a number of health disparities related to mental health, physical health, and substance use. They are also more likely to experience child maltreatment and limited familial support. All of these issues are related to both perpetration and victimization of IPV.
YMSM have limited role models for healthy and satisfying intimate relationships (Kubicek, Beyer, Weiss, & Kipke, 2012). In the absence of such role models, they often model their relationships after their parents’ or other adults in their lives, which are generally not fully relevant and at times may not be the healthiest images. Additionally, relationship power is determined by some unique factors such as sexual positioning, comfort level with one’s sexuality, relationship experiences, and attractiveness (Kubicek et al., 2014).
Finally, the issue of gender roles and masculinity cannot be ignored. The masculine ideal is something that men often strive to achieve. Research shows that YMSM endorse common masculine ideals such as athletic ability, sexual prowess, and being aggressive. Even those values not endorsed by YMSM such as a tendency to be antifeminine and antihomosexual may exist in YMSM’s perceptions and contribute to higher levels of internalized homophobia and diminished self-esteem. Social learning of gender roles teaches young men to be assertive, powerful, and to achieve status. For YMSM, this places two young men, whose brains are still developing their ability to assess risks and rewards and fully comprehend emotional and social cues, in a relationship in which both parties are endorsing these masculine ideals. The opportunities for YMSM to be at odds with each other as they struggle to achieve status in their relationship are numerous and may increase the risk for IPV.
Dating and sexual scripts: A modifiable point of intervention
The proposed model suggests that young men’s dating and sexual scripts mediate these factors and their relationship to IPV. While we have limited information about these scripts, we do know that they provide a structure for young men to use when negotiating their intimate relationships. Given the lack of relevant role models to inform these scripts, young men likely draw from what they see from their parents, their friends, the media, and other gay men they may interact within their communities. A fuller understanding of these scripts and how young men integrate them into their relationships is greatly needed to flesh out the dynamics within young men’s relationships.
Finally, we include health outcomes that may result from victimization of IPV including HIV as well as the potential negative outcomes of perpetrating IPV including criminal justice consequences and mental health. While the factors related to HIV infection and other negative health outcomes are beyond the scope of this review, it should be noted that these health outcomes are a part of the picture. Certainly, some young men are resilient and are able to extricate themselves from negative situations and maintain good health. However, for those young men who remain in violent relationships, whether they be emotional, psychological, physical, or sexual violence, the likelihood of having mental or physical health issues increases. Thus, intervening in YMSM’s violent relationships has the possibility of addressing other important health disparities.
Taken as a whole, it is clear that IPV within YMSM’s relationships is the result of a number of independent and interdependent variables. The model provides a framework for the issues that should be addressed in a comprehensive IPV prevention/intervention program that is relevant to YMSM. Developing appropriate interventions that address each of these factors and provide YMSM the tools needed to develop healthy and satisfying intimate relationships is necessary to curb this public health issue.
Public health and medical professionals should pay particular attention to this issue, as addressing and reducing the prevalence of IPV among YMSM may be one way to address the other public health issues facing this vulnerable population. Specifically, in the United States, the only demographic group that has seen a rise in the incidence of HIV/AIDS in the last 15 years is YMSM. Because we know IPV is related to coercive and/or unprotected sex, successful interventions that address IPV may also address HIV in this high-risk population. Given that we have had limited success in addressing HIV among YMSM in the last 30 years, an approach that provides YMSM the basic tools for developing healthy intimate relationships may be a novel method to curb this epidemic.
Research Implications and Conclusions
This article serves to provide a framework for researchers and practitioners to begin to consider IPV within YMSM’s relationships. Identifying correlates and drivers of IPV within the different dimensions of YMSM’s lives is crucial for effectively addressing this public health issue. This model also suggests a number of avenues for empirical research and hypotheses to be tested.
One result of the HIV/AIDS epidemic is that it paved the way for researchers to better understand the risk and protective behaviors of high-risk populations such as YMSM. However, the singular focus on HIV has oftentimes ignored other aspects of YMSM’s lives. YMSM and other sexual minority groups should be viewed as whole beings with full lives outside the HIV epidemic. Understanding these lives will ultimately lead to programs and services that can promote the overall health and well-being of YMSM. IPV, like HIV, is not the result of a single factor. Collectively, researchers including sociologists, anthropologists, social workers, psychologists, and public health professionals need to begin to look at YMSM’s lives more holistically to better understand the health disparities and risks that they encounter.
For example, we know very little about YMSM’s sexual scripts outside of condom negotiations. More empirical research investigating the power dynamics, gender roles, and sexual negotiations (e.g., bottom vs. top, vs. versatile) is needed to understand conflicts and compromises in young men’s relationships. For instance, at what point does a young man change his sexual script from one of adventure to “romantic love” and how do those scripts impact sexual negotiations/scripts and conflict resolution? While we propose that the correlates of IPV are mediated by young men’s dating and sexual scripts, the lack of information about these scripts limits the utility of this model. Additionally, we have limited information about how MSM and YMSM conceptualize and consider the role of masculinity in their lives and relationships. As our world changes and ideas about masculinity change with it, more rigorous studies that explore what it means to be a man in today’s society and how that is characterized and negotiated in same-sex relationships is integral to our understanding of IPV.
Given that the cognitive development of YMSM is ongoing, more longitudinal studies that integrate these concepts of masculinity, sexual negotiations, and risk behaviors are needed. As young men mature and develop new intimate relationships, it is likely that their views on masculinity and gender will also change. Longitudinal investigations of these issues will provide us a better foundation to understand the life course of YMSM and how the correlates and drivers of IPV change over time. For example, we need to better understand to what extent do YMSM’S perspectives on masculinity change over time and how that may affect their involvement in partner violence.
Additional studies that rigorously document the types of violence (e.g., physical, emotional, financial, sexual) that YMSM and other sexual minorities experience are also necessary. This requires a more stringent operationalization of IPV and measures that can capture the range of behaviors. These are necessary in order to better document the negative health outcomes in these populations, so that providers are better able to address the needs of victims and survivors of IPV.
Additionally, while we are in the third decade of HIV/AIDS, we continue to see high rates of HIV among YMSM of all backgrounds. This suggests that our past and current efforts have not been fully successful and new approaches need to be developed. The relationship between IPV, sexual coercion, and HIV is not well understood. Research that empirically tests these relationships with more population-based studies are needed to assess to what extent intervening with IPV will also intervene on the HIV epidemic among YMSM.
Intervention Opportunities
IPV has been a concern in our country for nearly 50 years, but only in the past 15 or so have we focused any attention on this public health concern in nonheterosexual relationships. Universal IPV prevention interventions do not address some of the factors outlined in this framework. For example, current programs using a heteronormative lens typically assume there is a female victim and a male perpetrator (Foshee et al., 1998; Wolfe et al., 2003). As a result, providers are woefully untrained in dealing with male victims. In addition, current programs do not take into account internalized homophobia, societal perspectives on same-sex relationships, and the discrimination that many sexual minorities face on a daily basis. They also do not take into account how power and conflicts are negotiated when two males are involved in an intimate relationship.
Issues of independence, assertiveness, and dominance are imbued into our societal ideas of masculinity. While society provides young women some positive role models in negotiating issues of masculinity successfully, those same models are not available for young men in same-sex relationships. Thus, in the absence of positive relationship role models, young men are left to their own devices and instincts. Given the impulse control and risk-seeking behaviors of many emerging adults, this is a potentially dangerous situation.
When considering the development or adaptation of programs for sexual minority groups—whether they be group-, dyadic-, individual-, or community-level programs, one must consider the expertise and comfort level of current providers in this area. The only published study examining violence prevention service providers’ experiences and perceptions of working with sexual minority clients indicates that only 17% were required to attend training on working with sexual minority groups; 23% had received no training (Ford, Slavin, Hilton, & Holt, 2013). This study also found that staff felt only minimally prepared to work with lesbian, gay, bisexual, and transgender (LGBT) populations, with respondents feeling less able to work with MSM than same-sex identifying women. This indicates that additional trainings—as well as partnerships with local LGBT service organizations—would be required to ensure that program staff are culturally sensitive and aware of the needs of these different populations. Even advocacy programs and similar endeavors that exist to reduce stigma around IPV and recognize the need to create awareness that violence can happen to anyone regardless of race, class—and yes, sexual orientation—require a shift in thinking about how we portray the “victim” and “perpetrators” in relationship violence to make it more gender neutral or universal.
Another factor that should be noted when considering the utility of universal IPV intervention programs for sexual minorities is that many evidence-based IPV prevention and intervention programs may have had reduced effectiveness because they were developed and evaluated prior to our gaining a full understanding of the etiology and complex dynamics associated with IPV. Moreover, a number of recent empirical findings have challenged some of the widely held beliefs about IPV (McKenry et al., 2002). Researchers have done a commendable job of understanding these complexities within heterosexual relationships and a similar assessment should be done with sexual minority populations.
Finally, current programs also do not take into account the fact that YMSM as a whole experience higher rates of many of the most common covariates of IPV: mental health issues, substance misuse, and child maltreatment. Prevention programs targeting YMSM would ideally provide additional tools for managing substance use, cognitive behavioral, or similar psychoanalytical approaches to address depression and self-efficacy as well as support for those young men who have experienced violence in the past.
Current programs designed for heterosexual dating couples may provide a strong foundation for addressing IPV among YMSM. Reviewing and adapting such programs so that they fully address the array of factors that contribute to IPV should be a research priority for those working with this high-risk population. This will likely require multidisciplinary teams to effectively translate and implement these programs in community settings. While most schools offer programs promoting healthy dating relationships and helping students to recognize “red flags” of violent relationships, these programs are designed with heterosexual students in mind. Prior research has found that YMSM tend to tune out sexual education provided in schools precisely because they do find it relevant to their lives (Kubicek, Beyer, Weiss, Iverson, & Kipke, 2010). Thus, these more targeted interventions should be designed and implemented in settings that can most effectively reach YMSM. This may include online or virtual environments, community or clinic settings, or in classroom settings where multiple approaches to dating violence prevention are explored.
These new programs could be designed at the community, group, dyadic, or individual levels. For example, dyadic interventions could focus on developing mutually satisfying and healthy sexual scripts. To address structural issues such as homophobia and general acceptance of violence between men, school or community-based interventions stressing the importance of inclusion and equality could be implemented. Social marketing that targets our own society’s acceptance of violence is also necessary to make our communities safer for everyone.
The ideal scenario for group-level interventions would be to hold them at LGBT service agencies or similar locations where a more exhaustive discussion of the unique factors that impact YMSM’s relationships can be discussed. Clearly, reaching a broader population of YMSM and other sexual minority groups could be achieved in schools—however, current programming would need to be adapted to be more gender neutral (e.g., using androgynous names in scenarios or lessons) as well as integrating examples of same-sex relationships into the curriculum and introducing how societal views can negatively impact our relationships.
This review provides an initial framework in which practitioners and researchers can begin to address the issue of IPV among YMSM. However, this is just a starting point. As more formative and empirical research is completed to better characterize the lives of YMSM, this model will likely change. New factors may be added and relationships better understood. Also, issues such as ethnicity, race, and culture may also need to be considered when working with YMSM from different communities. Thus, it is our expectation that this model will be amended as needed to reflect our current understanding of the lives of YMSM. In addition, while this model is specific to YMSM, similar issues and approaches can be used for other sexual minority populations. This will provide practitioners guidelines and an initial framework to support the development of more equitable programs and research across populations.
Footnotes
Author’s Note
The content is solely the responsibility of the authors and does not necessarily represent the official views of the California HIV/AIDS Research Program.
Acknowledgments
I would like to thank Adam Leventhal, PhD, and Ricky Bluthenthal, PhD, for their careful review and critique of this work. Finally, the author would also like to acknowledge the insightful and practical commentary of the members of the Community Advisory Board: Noel Alumit, Asian Pacific AIDS Intervention Team; Chi-Wai Au, Los Angeles (LA) County Department of Health Services; Mary Case, LA Gay and Lesbian Center; Matt Harwood, AIDS Project Los Angeles; Susan Holt, LA Gay and Lesbian Center; Dustin Kerrone, LA Gay and Lesbian Center; Miguel Martinez, Division of Adolescent Medicine, CHLA; and Ricki Rosales, City of LA, AIDS Coordinator’s Office.
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 study was partially funded by the California HIV/AIDS Research Program (ID10-CHLA-048).