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Hispanics are disproportionately affected by intimate partner violence. Most of the research describing factors associated with intimate partner violence among Hispanics has focused on Hispanic women or Hispanics in heterosexual relationships. The purpose of this study was to explore the relationship between sexual orientation (heterosexual, homosexual, and bisexual), and demographic, cultural and psychological factors and intimate partner violence among Hispanic men. A cross sectional questionnaire was administered to 160 Hispanic heterosexual and men who have sex with men. Demographic factors (age, education and income), acculturation, depressive symptoms and self-esteem were assessed using standardized instruments. Data was analyzed using ANOVA and simple and multiple logistical regression. Differences in education, income and self-esteem were noted across participants identifying as heterosexual, homosexual and bisexual. Bisexual Hispanic men were almost at 4 times greater odds of reporting the perpetration of IPV than homosexual Hispanic men, even when differences in education, income and self-esteem were controlled for (AOR = 3.92, 95%CI = 1.11, 14.19). This study suggest the importance of specifically targeting bisexual Hispanic men in IPV research and services.
Intimate partner violence (IPV), the most common form of violence against women worldwide, may include physical, psychological, and sexual violence as well as control, coercion, and isolation from family and support systems (World Health Organization [WHO], 2002). In the United States about 4.8 million women and 2.9 million men experience IPV annually (Tjaden & Thonnes, 2000). Of those experiencing IPV, 1,544 deaths were attributed to IPV in 2004, with 75% of these deaths being among women (Department of Justice, 2006). Given the high morbidity and mortality rates associated with IPV in the U.S., the goals of Health People 2020 include attention to the elimination of violence (including IPV) in the U.S. (U.S. Department of Health and Human Services, 2010). Knowledge about the epidemiology of IPV is key to the development of prevention strategies that will help achieve this goal.
Although women disproportionately bear the burden of IPV, IPV is also experienced by men and occurs in same-sex relationships (World Health Organization [WHO], 2002). In fact, 28.8% of men in the U.S. report being a victim of IPV over their lifetime (Reid et al., 2008). These rates appear to be higher among men who have sex with men (MSM) than heterosexual men (Greenwood, Relf, Huang, Pollack, Canchola et al., 2002; Tjaden, Thoennes & Allison, 1999). Although the consequences of IPV have been noted to be more severe among women than male victims, male victims of IPV also experience a number of associated health effects, including injuries, chronic diseases, alcohol use, depressive symptoms, and poor general health (Coker et al., 2002; Reid et al., 2008). Consequently, IPV prevention also needs to consider the needs of men, both as victims and as perpetrators.
Hispanics in the U.S. are disproportionately affected by IPV. Researchers exploring the course of IPV over a 5 year period among a national sample of cohabitating heterosexual couples noted that Hispanics were 2.5 times more likely to initiate IPV and four times more likely to report the recurrence of IPV than non-Hispanic White couples (Caetano, Field, Ramisetty-Mikler & McGrath, 2005). Unique predictors of IPV among Hispanic have also been noted by researchers examining the epidemiology of IPV across racial and ethnic groups (Caetano, Schafer & Cunradi, 2001), underscoring the importance of developing knowledge about racial and ethnic specific predictors of IPV among Hispanics as well as developing culturally-specific prevention intervention to address these. The purpose of this paper is to explore the factors that are associated with both the perpetration and victimization of IPV among a community sample of Hispanic heterosexual and men who have sex with men (MSM), identifying as homosexual or bisexual.
The theoretical basis for the current study is the Syndemic Model for Substance Abuse, Violence, HIV risk behaviors and Depression among Hispanics (Gonzalez-Guarda, Florom-Smith, Thomas, 2011). The Syndemic orientation is concerned with the study of the processes by which syndemics emerge and how they collaborate to produce morbidity and mortality both among individuals and populations (Singer & Clair, 2003). The underlying assumption of this model is that health conditions or illnesses are influenced by social conditions (Singer et al., 2006). These social conditions that influence health and illness include culture, poverty, discrimination, inequality, substandard living conditions, and oppressive relationships. In addition to the relationship of these social conditions with health and illness, the Syndemic Model is based on a biosocial conceptualization of disease that emphasizes the interrelatedness of health conditions and coexisting social conditions.
The variables included in this study were selected to be consistent with syndemic theory. The psychological variables (depression, substance abuse, high risk sex, and low self-esteem) have been noted to constitute a syndemic among Hispanics (De Santis et al., in press; Gonzalez-Guarda, McCabe, Florom-Smith, Cianelli, & Peragallo, 2011). The results of these two studies provide some evidence that Hispanics are at risk for multiple co-occurring health disparities that are influenced by social factors. The social factors that are included as variables in this study include demographic variables (age, education, income), cultural factors (acculturation), and sexual orientation. With the inclusion of these social factors, the relationship and influence of the social factors on IPV among Hispanic men can be investigated.
A substantial body of research investigating factors associated with IPV among Hispanics has emerged in the last 15 years. This research has primarily focused on describing IPV using Hispanic female samples, or Hispanic couples in heterosexual relationship. A number of demographic, cultural and psychosocial factors have been noted to be closely related to IPV.
Researchers have noted the role that age, education and income play in predicting risk for IPV among Hispanics. Cunradi (2009) studied the role that these demographic factors played in predicting both the victimization and perpetration of partner violence in a probability sample of co-habitating couples. He found that lower age was a predictor of IPV victimization for both Hispanic women and men and a predictor of perpetrating violence among Hispanic women, but not men. Education on the other hand, was a predictor of perpetration and victimization among Hispanic men, but not women. Lower income predicted victimization for both Hispanic women and men, and perpetration among women (Cunradi, 2009). Age, education and income are demographic variables that have emerged consistently in the Hispanic research literature as predictors of IPV victimization and perpetration in heterosexual literature (Cunradi, Caetano & Schafer, 2002; Bell et al., 2006; Caetano, Cunradi, Clark & Schafer, 2002). However, little is known about the role that these play in homosexual or bisexual relationships.
Various Hispanic cultural factors have been associated with IPV in this population. Gender inequalities, machismo, infidelity, immigration, and trans-generational violence were identified as causes of IPV among heterosexual Hispanic women and men (Gonzalez-Guarda, Ortega, Vasquez & DeSantis, 2010; Gonzalez-Guarda, Vasquez, Urrutia, Villaruel & Peragallo, 2011). However, most of the research in this area has been qualitative. Other quantitative studies have explored how acculturation may influence IPV among Hispanics. One study including a probability sample of Hispanic couples noted that lower levels of acculturation among Hispanic males is associated with higher levels of stress, which increases the risk of violence perpetration (Caetano, Ramisetty-Mikler, Caetano Vaeth, & Harris, 2007). However, other researchers that have focused on specific Hispanic subgroups have noted the opposite. Among Puerto Rican women, U.S.-born women and those with a preference for English, women whom were presumambly more acculturated to the U.S. culture, were at greater risk for IPV (Moreno, Morrill, & El-Bassel, 2011). Higher levels of acculturation were also associated with greater risk for IPV in a study with a largely Mexican-American sample (Garcia, Hurwitz & Kraus, 2005). The contradictory nature of these findings support the need for more research in this area.
Some evidence suggests that IPV is related to a number of overlapping or related health disparities among Hispanic women and men. Gonzalez-Guarda and colleagues (2011) noted that IPV, substance abuse, HIV risk, and depression represent a syndemic factor, or interrelated and inseparable conditions, among Hispanic women. Qualitative data with Hispanic heterosexual men suggest that this syndemic may also be experienced by men (Gonzalez-Guarda et al., 2010). Depression and self-esteem are two psychological constructs that have been studied in the IPV Hispanic research. In one study exploring vulnerability among a community sample of Hispanic women, a bidirectional relationship was found between depression and risk for IPV, so that women with IPV were more likely to report more depressive symptoms and women with more depressive symptoms were more likely to report IPV. Lower levels of self-esteem were also associated with IPV, indicating that a similar bidirectional relationship could exist (Gonzalez-Guarda, Peragallo, Vasquez, Urrutia & Mitrani, 2009).
Fewer studies have been conducted that focused on IPV among Hispanic men in same-sex relationships. Some of these have focused on studying IPV within the context of risky sexual behaviors and HIV. In one study, the prevalence of IPV among Hispanic men who have sex with men (MSM) (n = 912) was 52%. A higher incidence of IPV was found among those with HIV infection. When HIV and immigrant status and age were controlled, IPV was associated with participation in high risk sexual behaviors with non-primary sexual partners (Feldman, Diaz, Ream & El-Bassel, 2007). Nieves-Rosa and colleagues (2000) surveyed 273 Latin American MSM in New York City and found that the lifetime prevalence of IPV was 51%. Nearly 12% had experienced sexual abuse, 33% verbal/psychological abuse, and 35% reported physical abuse. Again, IPV was associated with high risk sexual behaviors with non-primary partners.
Other studies have identified factors that contribute to IPV among Hispanic MSM. Hispanic MSM most at risk for IPV included those who had witnessed violence in their family of origin. In addition, HIV risk behaviors, substance abuse, and higher levels of acculturation were found to be associated with IPV among Puerto Rican MSM (Rodriguez-Madera & Toro-Alfonso, 2005). Poor conflict resolution skills were also associated with an increased risk of IPV among Puerto Rican MSM (Toro-Alfonso & Rodriguez-Madera, 2004). In terms of sexual violence, the risk was increased when Puerto Rican MSM had a family history of addictive behaviors and sexual violence (Rodriguez-Madera & Toro-Alfonso, 1999).
A synthesis of the available literature on IPV among Hispanic men, both heterosexual and MSM, revealed a few gaps in the research knowledge base. First, few studies have addressed IPV from the perspective of Hispanic males, as the majority of the literature has focused on factors associated with IPV among Hispanic women or Hispanic heterosexual relationships. Second, few studies have included measures to assess both the victimization and perpetration of IPV. Third, among Hispanic MSM, no studies could be located that compared the influence or effect of sexual orientation on the risk of IPV or examined differences between MSM identifying as homosexual or bisexual. Based on these identified gaps, this study aims to: 1) explore the effect that sexual orientation (heterosexual, homosexual, and bisexual) has on the perpetration and victimization of IPV among a community sample of Hispanic men in South Florida; and 2) explore factors such as demographics, acculturation, depression and self-esteem that may account for differences noted across groups according to sexual orientation.
This study is part of a larger study that explored substance abuse, HIV risk and IPV among Hispanic men using a mixed method approach. The qualitative findings, as well as the results regarding factors associated substance abuse and HIV risk factors among this sample are reported elsewhere (citations removed for peer-review). This study used cross-sectional, standardized questionnaires that were administered to a convenience and community sample of 160 Hispanic men in Miami, FL (80 heterosexual and 80 MSM) through a face-to-face standardized interview format. The questionnaire assessed for the perpetration and victimization of IPV as well as demographic and cultural factors that were hypothesized to be related.
Eligibility criteria for the study included self-identifying as Hispanic or Latino, English or Spanish speaking, between the ages of 18 and 55, and residing in South Florida. Tourist and residents planning to move away from South Florida within one year where excluded. Recruitment efforts included handing out and posting flyers at community and social events, local businesses, community-based organizations and clinics throughout Miami-Dade County, as well as approaching candidates in these settings to inform them about the study. The flyer encouraged Hispanic men from anywhere in the Americas (both the U.S. and Latin America) to participate in the study and described the study as involving an interview about drugs, violence and intimate relationships. Snowball sampling methods, whereby participants were encouraged to inform their family and friends about the study were also used. All data collection was completed in a private study office in a centralized area of Miami that was easily accessible through public transportation.
IRB approval for the university was obtained prior to initiating the study. During recruitment efforts candidates were given the study phone number that they could call to learn more about the study. Candidates were screened over the phone and asked questions relating to their eligibility. Those who were eligible were scheduled for the assessment. Each assessment took approximately 1.5 to 2 hours to complete. Assessments were administered by research staff through a web-based data collection and study management systems (Velos). Upon the completion of the assessment, the participants were paid $30 to compensate them for their time and travel.
The demographic questions in the assessment asked participant to report their age, the years of education they had completed, and their monthly income. These were all continuous measures. Sexual orientation was also assessed by asking participants to self-identify as heterosexual, homosexual, or bisexual. Responses to these were dummy coded using the homosexual category as the reference since participants identifying as homosexual had the lowest reported rates of IPV.
The Bidemensional Acculturation Scale (BAS) (Marin & Gamba, 1996) was used to measure how acculturated respondents are to the U.S. mainstream culture (non-Hispanic subscale) and how acculturated they are to their Hispanic culture of origin (Hispanic subscale). Each subscale contains 12 questions, for a total of 24 questions, and includes responses that range from 1 (almost never) to 4 (almost always). A mean score to each subscale is calculated. A higher score on the subscales indicates a greater level of acculturation in that domain. A mean score of > 2.5 for both the Hispanic and the non-Hispanic subscales is indicative of biculturalism. In this study the BAS as a whole demonstrated good reliability (Cronbach’s α = .96 for non-Hispanic subscale and Cronbach’s α = .86 for Hispanic subscale).
The Center for Epidemiologic Studies Scale (CES-D; Radloff, 1977), a 20 item scale that measures the frequency of depressive symptoms in the past week, was used to assess depressive symptoms. Responses are summed for a total score that can range from 0 to 40 points, with scores of 16 and above indicating a likelihood of clinical depression. The CES-D demonstrated good internal consistency (Cronbach’s α = .82).
The Rosenberg Self-esteem Scale (RSE) (Rosenberg, 1965), a 10 item scale that asks participants to report their self-perceptions, was used to assess self-esteem. The responses to these items range from 1 (strongly agree) to 4 (strongly disagree). The scores range from 10 (low self-esteem) to 40 (high self-esteem). The self-esteem scale demonstrated good internal consistency in this sample (Cronbach’s α = .84).
The victimization and perpetration of physical, sexual, and psychological abuse was assessed through the Partner Table (Gonzalez-Guarda, Peragallo, Urrutia, Vasquez & Mitrani, 2008). The Partner Table collects detailed demographic and behavioral information regarding the last 3 intimate partners the participants had. There are 6 questions that assess IPV. Three of these questions ask participants to identify if the identified partner physically, sexually or psychologically abused them during the course of their relationship with them (IPV victimization). The remaining questions ask participants if they physically, sexually or psychologically abused their partner during the course of their relationships (IPV perpetration). Specific probes are used to provide participants with examples of what could be considered physical (e.g., being hit or hurt in any way), sexual (e.g., being forced to have sex) or psychological abuse (e.g., scream or yell at you). Participants that reported being a victim of physical, sexual or psychological abuse during their most recent relationship were identified as having a history of IPV victimization. Participants that reported perpetrating physical, sexual or psychological abuse during their most recent relationship were identified as having a history of IPV perpetration. The Partner Table has been used previously with Hispanics in South Florida and has demonstrated to have good predictive validity (Gonzalez-Guarda et al., 2009).
Data analysis was conducted in three steps. First, simple logistic regression was conducted to determine of the odds of reporting IPV victimization or perpetration according to sexual orientation. Separate crude odds ratios and 95% confidence intervals were calculated for regressions predicting IPV victimization and IPV perpetration. Then, ANOVA was conducted to determine if there were differences in demographic, cultural and psychological factors according to sexual orientation. Finally, multiple logistic regression was used to test the hypothesized relationships and calculate adjusted odds ratios (AORs) and 95% confidence intervals. Only the factors that were significantly associated with IPV in the ANOVA were included in this last step. Separate regressions were conducted for the two IPV outcomes, IPV victimization and IPV perpetration. All data was analyzed using SPSS, version 17.
Participants were between the ages of 20 and 56 (M = 41.25, SD = 9.03) and reported completing a mean of 12.49 years of education (SD = 3.65). The majority of participant reported earning less than $1,000 a month (62%). Only 5.8% reporting a monthly income of $3,000 or more. More detailed demographic information is reported elsewhere (citation removed for peer-review). The sample was almost equally divided into heterosexual and MSM, with 48.1% (n = 77) reporting being heterosexual, 39.4% (n = 63) reporting being homosexual and 12.5% (n = 20) reporting being bisexual. An equal proportion of participants reported being a victim or perpetrator of IPV (20.1%, n = 33 for both categories) in their most recent relationship. A more detailed description of the types of abuse that were reported is provided in Table 1.
When compared to those identifying as homosexual, heterosexual participants were not at an increased odds of reporting IPV victimization (OR = 2.10, 95%CI = 0.84, 5.21) or IPV perpetration (OR = 2.44, 95%CI = 0.95, 6.29). However, participants reporting being bisexual were at increased odds of reporting both IPV victimization (OR = 3.70, 95%CI = 1.14, 12.06) and IPV perpetration (OR = 5.33, 95%CI = 1.62, 17.54).
The was no relationship between sexual orientation and age [F(2,157) = 2.05, p = .132]. Nevertheless, relationships between sexual orientation and education [F(2,157) = 9.76, p <.001] and income [F(2,157) = 10.77, p <.001] were found. There were no significant relationships between sexual orientation and Hispanic acculturation [F(2,157) = .44, p = .65], non-Hispanic acculturation [F(2,157) = 1.72, p = .18], and depression [F(2,157) = 2.23, p = .11]. However, a significant relationship between sexual orientation and self-esteem were noted [F(2,157) = 6.18, p = .003].
The results from the final logistic regression models predicting IPV victimization and perpetration are presented in Tables 2 and and33 respectively. When controlled for the effects of each other, sexual orientation, education, income and self-esteem did not predict IPV victimization. Nevertheless, participants who identified as being bisexual were almost 4 times at greater odds of reporting having perpetrated IPV in their most recent relationship, even when differences in the education, income and self-esteem between groups were considered (AOR = 3.97, 95%CI = 1.12, 14,19).
This study is the first to explore the relationship between sexual orientation and risk for IPV victimization and perpetration among Hispanic men. Important differences between groups were noted. Contradictory to what has been reported in other studies examining IPV in heterosexual and same-sex relationships (Greenwood, Relf, Huang et al., 2002; Tjaden, Thoennes & Allison, 1999), a smaller proportion of homosexual participants reported IPV victimization and perpetration in their most recent relationships than heterosexual participants. There are several possibilities for these differences. One of these may be due to confounding. When compared to the heterosexual group, participants self-identifying as homosexual had less previously established risk factors for IPV, including being older and reporting higher levels of education and income (Cunradi, Caetano & Schafer, 2002; Bell et al., 2006; Caetano, Cunradi, Clark & Schafer, 2002). This may be why the multiple logistic regression model which controlled for these demographic factors yielded no differences between those identifying as homosexual versus heterosexual in regards to their risk for IPV victimization and perpetration.
Previous researchers may have found higher levels of IPV among MSM than men in heterosexual relationships because there were no differentiation between individuals identifying as homosexual or bisexual (Greenwood, Relf, Huang et al., 2002; Tjaden, Thoennes & Allison, 1999). In this study, the MSM category was separated into the self-defining “homosexual” and “bisexual” categories. Significant differences in both IPV victimization and perpetration were found between the bisexual group when compared to the homosexual group, even when demographic and psychological factors were controlled for. This may be a result of an increased vulnerability to IPV that may results from a societal or provider view that bisexuality is a transitional stage (i.e., from heterosexual to homosexual or vice versa) or a pathology, rather than a valid sexual orientation (Eady, Dobinson & Ross, 2010). More research is needed to understand the differences between the experiences of men identifying as exclusively homosexual and bisexual men, and how these related to their behavioral risks.
Results from the focus group component of the parent study identified discrimination as potential risk factor for maladaptive health behaviors such as the perpetration of violence (citation removed for peer review). In fact, participants of the MSM focus groups described how their intersecting identities, such as being “gay” and Hispanic, interacted to make them a particularly vulnerable group that suffered from discrimination as a result of their sexual orientation and racial/ethnic minority status. It may be that bisexual Hispanic men suffer additional discrimination that results from being a sexual minority (i.e., bisexual) within a sexual minority group (i.e., MSM). This additional minority status may also limit the amount of social support and resources bisexual Hispanic men have access to. However, the differentiation in risk for IPV between bisexual and homosexual participants and why these may exist need to be further explored in future research as this is the first study to suggest this difference. The syndemic model, which identifies potential individual, cultural, relationship and socio-environmental factors associated with health and behaviors among Hispanics, can be used to further guide the exploration of potential risk and protective factors for IPV among this group (Gonzalez-Guarda, Florom-Smith and Thomas, 2011).
This study has several limitations. First, the design was cross-sectional. Consequently, cause and effect relationships cannot be established. Although predictors of IPV were explored statistically, because the data on the independent and dependent variables were collected at the same time, these predictions are only theoretical. Second, data about IPV victimization and perpetration were collected from only one member of the intimate relationship. It is unknown if different findings may have resulted if data was collected from both members of the relationship. Lastly, the sample consisted of a relatively small convenience sample of Hispanic men in South Florida. This limits the generalizability of finding to both the broader South Florida Hispanic male community, as well as the broader Hispanic male community in the U.S. Additionally, the small sample size limited ability to explore other potential factors associated with IPV that may have explained the differences noted between the participants identifying as bisexual versus those identifying as homosexual.
This study has important implications for IPV related services and research. This study suggests that bisexual Hispanic men are at an increase risk for IPV, especially as perpetrators. Researchers have documented the negative experiences that bisexual men have with mental health providers (Eady, Dobinson & Ross, 2011). Consequently, strategies need to be implemented to provide competencies for health care providers that will enable them to deliver more culturally appropriate services to victims and perpetrators of IPV who identify as bisexual. Culturally specific prevention strategies that address the unique risk and protective factors associated IPV among bisexual and MSM Hispanic men should also be developed. Nevertheless, more information about the risk and protective factors associated with IPV among bisexual Hispanic men is needed to inform these prevention strategies. This study also supports the bolstering of IPV related services and programs targeting Hispanic men more broadly. As noted in this study, both the victimization and perpetration of IPV is relatively common among Hispanic men. Nevertheless, Hispanic males are often not screened for IPV, forgoing an opportunity to identify victims or perpetrators and render services that may prevent the cycle of abuse in the Hispanic community. Health care providers should regularly screen for IPV among this population and develop protocols to address both the victimization and perpetration of IPV in culturally appropriate ways.
This study was funded by the National Institute of Minority Health and Health Disparities (NIMHD) at the National Institutes of Health (NIH) Grant 1P60 MD002266 to Nilda Peragallo, PI.
Rosa M. Gonzalez-Guarda, University of Miami, School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL. Email: ude.imaim@zelaznogasor; Office: 305-284-8374.
Joseph P. De Santis, University of Miami, School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, Email: ude.imaim@sitnasedj; Office: 305-284-5039.
Elias P. Vasquez, University of Texas at El Paso, El Paso, Email: ude.petu@zeuqsavoicnevorpeXT.