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Abstract

Although violence affects everyone, men’s health is disproportionately affected. To better understand the etiology of men’s violence, it is essential to comprehensively examine the factors influencing the development and trajectories of violence perpetration and victimization. This review offers a broad perspective on the burden of violence for men and the characteristics of individuals, relationships, communities, and society that combine to influence men’s experience with interpersonal violence, including child maltreatment, youth violence, intimate partner violence, and sexual violence. Men’s experience with violence is influenced by physiological, emotional, and behavioral factors; relationships with family and peers; and social norms. In collaboration with professionals from other sectors, health professionals can help prevent or intervene in male’s perpetration of violence across the lifespan through identification of factors that place men at risk and referral of male patients to evidence-based prevention and intervention resources.

Keywords

violence men’s health sex differences prevention

Violence is one of the most significant sources of mortality and morbidity in the United States. Homicide and suicide consistently rank among the top 10 leading causes of death for persons aged 1 to 44 years and are responsible for the loss of many years of productive life.¹ Violence is the source of a staggering number of injuries that require use of medical services such as those offered in hospital emergency departments, inpatient care units, and physical or occupational rehabilitation centers. An even larger number of injuries are not documented because persons sustaining them may not seek formal medical care. In both instances, violence exerts long-lasting, far-reaching physical and psychosocial impacts, altering the lives of victims and perpetrators; affecting their families, peer, and community groups; and increasing the weight of the financial and social burdens that society must shoulder.

“Although violence affects everyone, men’s health is disproportionately affected. Men are often the perpetrators of violence, but they also carry a heavy burden of violence victimization.”

As described by the World Health Organization, violence can be self-directed (inflicted on oneself), interpersonal (inflicted by another individual), or collective (inflicted by large groups such as states or organized political groups).² In this article, we focus on men’s experience with interpersonal violence that can be further categorized into 2 types: (a) violence that occurs primarily among family members and between intimate partners, mostly in the home, such as child maltreatment and intimate partner violence, and (b) violence that occurs generally outside the home between unrelated individuals who may or may not know one another, such as youth violence and sexual violence by strangers. The nature of interpersonal violence can be physical, sexual, psychological, or involve deprivation or neglect. Information about men’s experience with self-directed violence, including suicide, may be sought from the article by Crosby and colleagues³ in this journal special issue on violence.

Although violence affects everyone, men’s health is disproportionately affected. Men are often the perpetrators of violence, but they also carry a heavy burden of violence victimization. Sex differences in perpetration and victimization vary by the type of violence considered. In this article, we review the prevalence and trajectories of interpersonal violence for men, making comparisons with women’s experiences to highlight how violence uniquely influences men’s health. The individual, family, community, and societal factors that influence men’s risk for experiencing violence compared with women are presented, providing insight into the factors underlying sex differences in violent experiences. Finally, we detail how health professionals can intervene with these factors to reduce men’s perpetration of violence.

Men’s Interpersonal Violence Perpetration and Victimization

Prevalence of Perpetration and Victimization

Men commit a larger number of violent crimes than do women. In 2009, men accounted for 81% of persons arrested for violent crime and 66% of homicide perpetrators.⁴ These sex differences are evident in adolescence as well, with boys accounting for 83% of violent crime index arrests in 2008.⁵ A greater number of high school age male youth report being in a physical fight compared with female youth (39.3% vs 22.9%), and boys are more likely to carry weapons, including firearms.⁶ Although girls can also be aggressive and violent, boys and girls perpetrate different forms of aggression. While boys are more likely to engage in overtly, physically aggressive behaviors, girls are more likely to engage in covertly, relationally aggressive behaviors (eg, through social exclusion).⁷

Young men aged 10 to 24 years also carry a disproportionate burden of violence victimization. In 2007, 4973 male youth in this age group were victims of homicide (rate of 15.3 per 100 000), compared with 791 female youth (rate of 2.6 per 100 000), making homicide the second leading cause of death for male youth (most of these boys and young men, 84%, were killed with a firearm, for a rate of 13.3 per 100 000).¹ The rate of nonfatal assault-related injuries seen in hospital emergency departments is approximately 40% higher for young men compared with young women.¹ Self- and parent-report surveys of children and youth 17 years and younger also reveal that a greater percentage of boys than girls are victims of physical assaults with and without injury, assaults with weapons, and assaults by gangs.⁸

Compared with adult women, adult men are much less likely to be victims and more likely to be perpetrators of physical and sexual intimate partner violence (IPV) and stalking. For example, in the National Violence Against Women Survey (NVAWS),⁹ 22.1% of women and 7.4% of men reported being physical assaulted by an intimate partner in their lifetime. Adult men are less likely to die from intimate partner homicide than are women.¹⁰ Men are also at lower risk for stalking victimization compared with women, such as fearing safety as a result of receiving unwanted phone calls or e-mails or being spied upon.¹¹ In adolescence, however, rates of physical violence victimization by a dating partner are more equal among the sexes. For example, findings from the Youth Risk Behavior Surveillance System revealed that 10.3% of males and 9.3% of females reported being hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend in the previous year. Yet females sustain more injuries than do males from teen dating violence.¹² (For more details on the prevalence and consequences of intimate partner violence, see Black, this issue.¹³)

Experiences of child maltreatment victimization also differ between boys and girls. Data from the National Child Abuse and Neglect Data System reveal that boys have a slightly higher fatality rate from child maltreatment than do girls (2.3 compared to 2.1 per 100 000). In substantiated or indicated child maltreatment reports (ie, where maltreatment of a child 0-17 years of age was determined to have occurred), 48.2% are boys and 51.1% are girls.¹⁴ Data from self-report surveys reveal that patterns of abuse differ for boys and girls. Prevalence of sexual abuse and emotional abuse are higher for girls than for boys, but prevalence of physical abuse and neglect are similar for boys and girls.¹⁵ Although rates of sexual abuse are lower for boys than for girls, it is critical for health professionals to understand that sexual abuse of boys does occur, remains a health concern, has serious health consequences, and often is underrecognized and goes untreated.¹⁶ Compared with females, males are more likely to suffer sexual violence victimization when they are 12 years and younger.¹⁷ For more details on the prevalence and consequences of child maltreatment, including sexual abuse, see Leeb and colleagues,¹⁸ this issue.

Although men do experience sexual violence victimization, with nationally representative surveys estimating that 2% to 3% of men have experienced force sex in their lifetime, the burden of sexual violence victimization is felt mostly by women. NVAWS estimated that 1 in every 6 women has been raped at some time in their lifetime, and each year more than 300 000 women are raped. Nearly all rape victims, whether male or female, are raped by a male (in the NVAWS study, 99.6% of women victims and 85.8% of male victims reported being raped by a male).¹⁷ For more details on the prevalence of sexual violence, see Basile and Smith, this issue.¹⁹

Health Outcomes of Violent Victimization

Violent victimization is associated with numerous physical and mental health outcomes that directly affect psychological development, social adjustment, and overall quality of life. Victimization impairs functioning by producing varying levels of physical injury and generating stress levels that exceed individual coping capacities or trigger maladaptive forms of coping. Early victimization experiences are particularly significant because they affect faculties needed to successfully complete developmental tasks in other life stages.²⁰

The health consequences of violence vary by type of violent victimization experienced and can be extensive and severe. For example, victimization by peers in childhood and adolescence may result in attention problems,²¹ internalizing problems (eg, depression, anxiety, or somatic complaints),^22,23 and body mass reductions later in adolescence.²⁴ Outcomes of a specific form of peer victimization—bullying—have been found to include self-harm,²⁵ anxiety disorders, antisocial personality disorders,²⁶ and depression in adolescence.^27,28 Poor health outcomes are more pronounced when boys perpetrate bullying, as well as experience bullying victimization.^29,30

Sexual violence victimization, although occurring at a lower rate for men than for women, can have devastating effects on men. Sexual maltreatment in childhood is associated with negative health outcomes in adolescence and adulthood, including poor emotional well-being and self-esteem,³¹ psychological disturbances (such as posttraumatic stress disorder),³²mental health impairment,^33,34 sexual dysfunction,³⁵ unhealthy eating (eg, binge eating, diet pill use, and laxative use),^31,36,37 self-harm behaviors,³⁸ and alcohol use and abuse.^39,40 Sexual violence victimization at any point in development has been associated with high-risk sexual behaviors that may increase risk for contracting HIV, such as inconsistent condom use.⁴¹ Compared with nonvictims, men who have experienced unwanted attempted intercourse and unwanted completed intercourse in adulthood are more likely to report activity limitations, poor mental health, poor life satisfaction, and lower emotional and social support.^42-44

Men also experience negative physical and mental consequences from IPV victimization—many of which are similar to those consequences experienced by women (as reviewed by Black, this issue¹³). Health consequences include increased risks for injury, current poor health, chronic disease, chronic mental illness, depressive symptoms, and substance use.^45-49

Finally, one of the most prevalent outcomes of violent victimization is later perpetration of interpersonal violence. One of the ways in which violent victimization is related to later perpetration is through adverse victimization experiences in childhood, such as child maltreatment or exposure to violence between caregivers. Such adverse experiences significantly increase perpetration risk by, in part, increasing toxic stress, changing brain structure and function, and instilling or reinforcing predispositions toward violent behavior.^50,51 Victimization can change the way individuals view the world, leading to cognitive schemas that anticipate hostility from others and view violence as a way to resolve conflicts and achieve results, which, in turn may increase the likelihood of violence perpetration for self-preservation and goal attainment. Other factors that increase the risk for violence perpetration are detailed later.

Developmental Trajectories of Perpetration

A large percentage of boys and men never engage in serious aggression and violence, yet others become involved in violence perpetration, at times chronically. Longitudinal studies of boys’ offending patterns have led to the identification of multiple trajectories by which perpetration of violent behavior is developed.^52-54 These trajectories can be differentiated by the age of onset of offending, the duration of offending, and seriousness of offending. Most offending is adolescence-limited and episodic; that is, it starts around the age of 13 years, occurs intermittently, and lasts for only a few years during adolescence when boys feel the desire to test social conventions and gain peer approval. Once transition into adult roles occurs in the late teens and early 20s, most boys desist from offending. However, there is a small percentage of boys who are life-course persistent offenders. These offenders initiate serious, aggressive behavior above what is normative in middle childhood (around the age of 8-11 years), commit a disproportionate number of serious violent offenses in adolescence (eg, assault, rape, robbery, homicide), and continue serious violent offending into adulthood. Studies with long-term follow-up of youth into adulthood have estimated that approximately 10% of men can be classified into the life-course persistent trajectory.⁵³

There are many early markers, particularly at the individual level, that indicate propensity for chronic violence throughout development, including difficult temperaments, cognitive and neurological impairments, and hyperactivity in childhood. Across studies, the most critical factor identified that predicts life-course persistent violent offending is consistently high levels of physical aggression in childhood. Markers in adolescence for chronic offending include weak bonds to school and family, impulsivity, and psychopathic personality traits such as callousness.⁵³ More details will be provided on early markers and risk factors for violent behavior in the next section. Given these early markers and the proportion of violence that youth with these markers are responsible for perpetrating, health professionals who encounter young male patients exhibiting these markers need to be particularly attentive to these patients’ needs and intervene early to prevent a lifelong trajectory of violence, as will be discussed later.

Life-course persistent offenders have poor health outcomes in adulthood, including symptoms of mental health disorders such as antisocial personality disorder, substance use disorder, depression, and schizophreniform.⁵² Males who limit their offending to the adolescent years can have poor outcomes similar to the life-course persistent offenders, yet their outcomes are not as consistent or as severe.

Interestingly, research has investigated trajectories of female violence much less than trajectories of male violence. Consistent patterns across studies have not yet emerged to determine whether trajectories of violence are similar or different for females and males.⁵³

Table 1.

Example Key Factors Influencing Men’s Violence Perpetration at Each Level of the Social Ecological Model

Etiological Underpinnings of Men’s Experience With Interpersonal Violence

There may be innate, biological sex differences in violence at the individual level that result from genetic and physiological characteristics.⁵⁵ However, sex differences may be due to the socially constructed roles, behaviors, activities, and attributes that a given culture considers appropriate for men and women.^55-57 There are also social and cultural factors at the relationship, community, and societal levels that may increase men’s propensity to perpetrate violence or become victimized by violence. Next, we review some of the key factors at each level of the social ecology (individual, relationship, community, and society) that may increase risk for violence perpetration among males (see Figure 1). These factors are only a sampling of factors that influence men’s violence perpetration; comprehensive reviews have been conducted by others.^58-60 Many of the factors listed below contribute to risk for females as well; however, to the degree possible we highlight examples that illustrate the importance of these factors for understanding the development of male violence.

Factors at the Individual Level Associated With Men’s Experience With Interpersonal Violence

As highlighted in the previous section, there are key factors at the individual level that increase the likelihood of men’s violence perpetration and have been validated extensively in the empirical literature. These factors include cognitive, emotional, and behavioral problems that emerge primarily in childhood and adolescence, such as deficits in processing social-cognitive information, impulsivity, depressed mood, oppositional behavior, and substance use. Less well understood, there are also physiological and temperament characteristics of individuals that may influence the propensity for violence, including genetic and hormonal influences, and personality traits such as callousness. When these individual-level factors are present in extreme forms, such as in the case of behavioral and mental disorders (eg, attention deficit hyperactivity disorder [ADHD], conduct disorder (CD), depression, substance use disorder), or occur in combination with one another (ie, comorbid conditions), there is a greater likelihood of an individual progressing along a life-course persistent trajectory. Thus, individual-level factors perhaps have the most explanatory power for the small percentage of men who perpetrate severe, chronic violence. Fortunately, as discussed later, many of these individual-level factors are modifiable through prevention and intervention strategies.

Social-cognitive information processing

The way in which people perceive the world and cognitively process social information affects interpretation of situations and response to physical and social stimuli. Difficulties in navigating interpersonal relationships occur when there are biases in the way in which people receive social information, interpret that information in context, select appropriate responses, and evaluate the consequences of those responses.⁶¹ For example, youth and adults who have a tendency to interpret others’ neutral behavior as having hostile intent exhibit higher levels of aggressive behavior with others.⁶² Compared with girls, boys are more likely to have this hostile attribution bias, perhaps because of differences in social experiences, such as exposures to appropriate modeling of socially appropriate behavior (eg, those provided by supportive parenting and prosocial peer associations) and exposures to violence. Sex differences in violent behavior can be explained, in part, by sex differences in the hostile attribution bias.^61,63

Emotional and behavioral disorders

There are several emotional and behavioral disorders that emerge in childhood and early adolescence that are strong predictors of violent behavior in adolescence and adulthood. Because boys are at greater risk for these disorders than are girls, and (when present) boys’ symptoms are more severe than girls’ symptoms, boys are at heightened risk for perpetrating interpersonal violence.^64-67 For example, ADHD is characterized by symptoms of inattention and/or hyperactivity/impulsivity that typically emerge within the first 7 years of age.⁶⁸ ADHD symptoms make it more likely that males may initiate negative interactions without considering the broader consequences of their behaviors for themselves and for others, and react hastily when confronted, provoked, or experiencing strong, negative emotions. As a result, symptoms increase the odds of committing assault during adolescence and predict the presence and persistence of aggressive offending into adulthood, as indicated by arrests, convictions, incarcerations,^69,70 chronic violence,⁷¹ and IPV perpetration.^72-74 CD commonly occurs alongside ADHD for boys^75,76 and is characterized by persistent violation of norms that interfere with social, academic, or occupational functioning, including aggression toward people and animals, destruction of property, deceitfulness, theft, and serious rule violations (eg, running away, curfew violations, truancy).⁶⁸ CD has subtypes that may emerge during childhood or adolescence.^77,78 Among males, CD has been associated with an increased likelihood of concealed gun carrying during adulthood and with adult involvement in violence, property offenses, drug charges, IPV, and homicide.^67,74,79-81

Use and abuse of alcohol and drugs in adolescence and adulthood also increases risk for violence perpetration across the lifespan, and the effects of use are seen in multiple ways. Substance use may serve as an immediate, precipitating, situational factor in violence, reducing inhibitory control. Use also may increase the severity of violent incidents, increasing the levels of physical harm inflicted.⁸² Early initiation of substance use (eg, before the age of 13 years) as well as chronic substance use in the form of substance use disorder are predictive of higher rates of perpetration over time. Use of alcohol and drugs may affect the social behaviors of females as well as males, but there is some evidence that alcohol and drug use may increase propensities for aggression more in males than in females.⁸³ Alcohol and drug use by males is associated with perpetration of youth violence, teen dating violence, adult IPV, and sexual violence (including sexual coercion in particular; see Basile and Smith, this issue,¹⁹ for more details).^84-86 For example, some research indicates that 30% to 40% of males who assaulted their partners were intoxicated at the time of the incident.⁸⁷ Other work has shown that males who consume large quantities of alcohol (heavy drinkers) exhibit a risk for involvement in IPV that is significantly higher than risk for men who consume less alcohol and men who abstain from alcohol consumption;⁸⁸ male perpetration of physical aggression against female partners is significantly more likely to occur on days when substances are used versus days when substances are not used;⁸⁹ and compared with men’s nonviolent conflicts, men’s violent conflicts are precipitated by significantly higher levels of alcohol consumption.^90,91 Men who become violent while drinking may also be more likely to injure their intimate partners.⁹²

Finally, depressive symptoms have been linked to increased violence perpetration for males. The risk effects of depression may be linked to some of its underlying symptoms such as irritability or agitation, feeling worthless or being hopeless or pessimistic, having recurrent thoughts of death, and diminished abilities to think or concentrate. These symptoms might make aggressive or violent behavior more likely because of increased sensitivity to life challenges, low or negative expectations about life prospects and ability to reach personal goals, and feelings that life has little value. Among male youth, depressed mood is associated with greater involvement in peer violence and dating violence⁹³ and has a robust effect on violence trajectories: depressed mood is significantly associated with slower declines in levels of delinquent behavior over time.⁹⁴ Although depressive symptoms predict higher rates of violence in both sexes,⁹⁵ significantly higher levels of externalizing problems, including violence, are typically observed among depressed boys versus depressed girls.⁹⁶

Personality traits and disorders

Studies of the most chronic and severe violent offenders (eg, men who have perpetrated severe, repeated IPV) have unveiled certain personality symptoms and traits that are common among this small group of offenders. These include symptom clusters and traits that are associated with antisocial, borderline, paranoiac, schizoid, and narcissistic personality disorders.^97-100 Singular personality traits such as callous-unemotional, narcissistic, and Machiavellian traits have also been identified as a risk factor for serious violent offending, including sexual assault, and seem to have unique explanatory power for violence perpetrated by men compared with women.^{97,98,101-106}

Genetic and hormonal influences

Examples of genetic and hormonal factors associated with higher aggression and a greater likelihood of violent behavior by males are possession of the low-activity MAOA allele (MAOA-L)^107-109 and having testosterone levels that are above or toward the upper end of the normal range. Aggression or violence may be more likely in men with the MAOA-L allelic expression because it is associated with impairments in brain structures involved in regulating perception, aggression, anxiety, and fear responses, as well as emotion, memory, motor, and visiospatial functions. Its effects are most likely to be observed in persons who have been exposed to stressful or traumatic life, such as violent victimization, during the early years of life.^109-111 Among males, higher testosterone levels have been associated with greater verbal and physical aggression^112,113 and with having perpetrated premeditated homicide.¹¹⁴ Testosterone alone is not a sufficient cause of violence in males but may play a facilitative or mediating role in the development of violent behavior because it primes the body for aggressive responses to social and environmental challenges.^115-118

Factors at the Outer Levels of the Social Ecology Associated With Men’s Experience With Interpersonal Violence

It is tempting for health professionals to consider that violence perpetration is driven by factors internal to the individual and that if those individual-level factors are addressed through therapeutic treatment, violent behavior can be prevented or reduced. Although such treatment is important, it is critical for health professionals to understand that men are also affected by family members and significant others in their lives, their community and neighborhood context, and social expectations of men’s behavior. It is essential that prevention and intervention strategies attend to those factors as well. Next, we review the factors at the relationship, community, and societal levels that are important to understanding men’s violence and serve as leveraging points for prevention and intervention.

Parenting

The method by which male children are parented is a critical influence in male perpetration. In particular, the ways in which parents manage their young children’s behavior can affect the development of later aggressive and disruptive behaviors in those children. Coercive methods used by mothers to control boys’ misbehavior in childhood (eg, through scolding and threatening) and withdrawal of positive affection are associated with increasing levels of boys’ aggression over time—an effect not found for girls.¹¹⁹ An authoritarian (strict and unsupportive) parenting style exhibited by fathers in adolescence increases risk for violent behavior initiation, such as assault, weapon carrying, and gang membership, particularly for boys.¹²⁰ Parents may resort to harsh discipline to manage their children’s behavior. Harsh physical discipline during childhood increases the likelihood of males perpetrating violence in adolescence⁵⁸ as well as in adulthood, particularly in the form of IPV in adulthood.¹²¹ Harsh physical discipline may affect the way youth understand social situations (eg, perceive others’ neutral behavior to be hostile), positively value aggression, and react aggressively when responding to frustrating situations.¹²² Harsh discipline may be a stronger risk factor for violence for boys than for girls, as boys are more likely to receive harsh discipline from caregivers than are girls.¹²³ There is evidence to suggest that parental warmth can be protective and can moderate the relationship between harsh physical discipline and child behavior problems.^123,124 Harsh physical discipline in the form of child maltreatment is of particular concern, as child maltreatment is a strong predictor of peer violence and IPV in adolescence and adulthood.^51,125

The degree to which parents monitor and supervise adolescent boys’ activities is also an important predictor of boys’ violence perpetration. Parental monitoring of youth activities, such as knowing where a young man spends his free time, knowing who his friends are, designating curfews, and checking in on activities during the day and evening has been associated with adolescent boys’ lower involvement in violent behavior.⁵⁹ Parents monitor boys’ activities less than they do girls’ activities, and this difference in monitoring has been shown to account for differences in boys’ and girls’ physical aggression.^126,127

Peer relationships

Boys are more likely than girls to associate with peers who engage in problem behavior, and one of the best predictors of engaging in and becoming a victim of violence for boys is association with delinquent peer groups.^59,128,129 For boys, gang affiliation is a specific concern, as affiliation with gangs and gang joining is associated with increases in both violence perpetration and victimization, even more so than when associating with violent peers who are not gang involved.^60,130 Boys are more likely to be involved with gangs than are girls, and while violence perpetration can be strongly attributed to gang involvement for males, this does not seem to be the case for females, as other factors are comparatively more predictive of female violence perpetration (eg, family dynamics¹³¹).

The importance of peer influence extends beyond childhood and adolescence. In adult males, perpetration of IPV and sexual violence is predicted by associations with abusive male peers, exposures to peer attitudes supporting aggressive or violent behavior, and affiliations with friends, family, and coworkers who believe that violence in intimate relationships is normal.^132-134 Such relationships shape attitudes and thoughts about the purpose, acceptability, and outcomes of violence. They also influence beliefs about how often violence should be used to address problems (eg, never, rarely, occasionally, or routinely) and shape thoughts about the level of aggression or force needed to achieve objectives.

Bonding to social institutions: Fatherhood, marriage, and employment

Unemployment has been found to predict higher levels of violence perpetration, particularly against intimate partners.^135,136 Life transitions that foster bonding to social institutions, such as the workforce, may provide an opportunity for males to desist from violence. Although not extensively studied, employment has been identified as a factor associated with desistance of violence and delinquency in adolescence and early adulthood, particularly when employment is of steady, low-intensity duration that limits interaction with delinquent peers and offers new skill development.^137,138 Fatherhood and marriage as social institutions can be potential turning points in young males’ violence perpetration and may be due to increased access to social support and networks, routines that focus on family life, and a renewed sense of self.^139,140 Having the responsibility of supporting a spouse and serving as a role model for a child may be key motivators for desistance; however, qualitative research suggests that young men feel that they can only desist from violence when they have the ability to access the labor market to support the family.^141,142

Social capital and neighborhood disadvantage

Neighborhoods differ in the degree to which residents know one another and are perceived to be counted on to intervene when there is disruption in the neighborhood that might lead to violent behavior, such as when young men are seen skipping school, hanging out in groups on street corners, and starting fights. Such neighborhood social capital has been termed “collective efficacy.” Collective efficacy has been found to be an informal means of social control, as low collective efficacy correlates with and predicts violent crime in neighborhoods.^143,144 In one study, lower social cohesion and informal social control and a greater number of residents with attitudes supporting nonintervention in family violence were associated with higher rates of nonlethal IPV against women.¹⁴⁵ Low collective efficacy is associated with antisocial behavior as early as school entry and is particularly influential in disadvantaged neighborhoods compared with more economically advantaged neighborhoods.^143,144,146 Little research has examined differential effects of collective efficacy by sex; that is, whether it influences men’s and women’s violence differently. However, it might be predicted that collective efficacy is a more critical influence of male violence than female violence, particularly in adolescence, as the effects of collective efficacy are thought to be due to enhanced social norms about the unacceptability of behaviors and neighborhood conditions associated with violence, reduced association with delinquent peers, and greater social supports for parental supervision and authoritative parenting—all factors that are strong predictors of men’s violence.^147,148

Social norms and gender roles

Men’s engagement in violent behavior can be in part explained by cultural concepts of masculinity and masculine gender norms and roles corresponding to these concepts. Traditional conceptions of masculinity include toughness, status, independence, and power as key indicators of a male’s position relative to cultural standards for maleness. In many cases, aggression is used as a means of satisfying or demonstrating the possession of these masculine characteristics. Exposure to norms about men’s engagement in aggressive and violent behavior begins at an early age. In childhood, boys are more likely to be taught via conditioning and social learning that behaving aggressively is normative, acceptable, and a natural part of male gender roles. Research has shown that compared with girls, boys hold more normative beliefs about aggression and that these normative beliefs, in turn, predict aggressive behavior. This effect is greater for boys than for girls.¹⁴⁹

Notions about behaviors expected of boys may lessen the likelihood that early childhood problem behaviors will be interpreted as signs of conditions that influence the potential for violence across the life course. Early expressions of aggression may be ignored or reframed and the significance of the behaviors may be underestimated. In some cases, the behaviors may receive positive reinforcement as they may be considered examples of “boys being boys.” In others, such expressions may be met with harsh sanctions or punishments that may increase the likelihood of violence at later points in life (eg, harsh parental discipline).

Sex differences in the effects of normative beliefs about aggression and aggression-related gender roles extend into adolescence and adulthood. For example, in adolescence, normative beliefs about the acceptability of violence against dating partners (eg, that it is okay to hit a dating partner or that a dating partner can behave in a way to deserve violence) predict dating violence perpetration.^136,150 Particularly relevant to adult men’s violence against women, studies show that men’s normative beliefs about women fulfilling traditional gender roles, male dominance in the family, and possession of traditional masculine gender role ideologies are predictive of male perpetration against female intimate partners.^136,151

Gender norms and roles specify how males are expected to respond when challenged, confronted, or offended. They may dictate that certain behaviors should be displayed as evidence of masculinity and constrain the response actions perceived as culturally viable. In certain cultures, prescriptive norms may dictate that males respond to certain offenses in a manner that is aggressive or violent. Moreover, proscriptive norms discouraging aggression and violence may be less rigidly enforced among males versus females because a certain level of aggression is expected or tolerated as a sign of traditional masculinity.

Gender roles and social norms also affect health maintenance and help-seeking behavior among males. Traditional gender roles based on rigid conceptions of masculinity make it less likely that men will seek external help in addressing problems with physical, mental, or social health. Notions of toughness, beliefs that help seeking signals weakness, and ideas that men solve their own problems may prevent men from using relevant services or influence them to use such services inconsistently or when circumstances have become extremely urgent. These conditions make it less likely that problem areas will be detected and addressed and increase the likelihood that men will use less effective means of addressing health and social concerns.

Violent media exposure

Exposure to violence in the media (eg, television, movies, video games, and the Internet) can have short-term and long-term effects on the perpetration of aggressive and violent behavior. Cross-sectional and longitudinal studies have revealed that children who consume larger amounts of violent media in the form of television, movies, and video games exhibit greater aggression and that these effects persist through adolescence and adulthood. These effects may be due to observational learning (ie, the development of social scripts that indicate aggression is normative and increase perceptions that others’ intent is hostile) and the decrease of emotional response to violence after habitual exposure. Effects of violent media on behavior can be seen immediately after exposure: in experimental studies, children, adolescents, and adults have been found to interact more aggressively with others after viewing television or video games with violent content, an effect that can be explained by priming of aggressive cues, increases in physiological arousal, and social modeling of behavior.^152-155 Violent media exposure is not only associated with higher levels of minor aggression but also higher levels of serious violent behavior.^156,157 In some studies, the strength of the relationship between media exposure and violence for boys and men has been illustrated to be slightly higher than the strength of the relationship for girls and women; in other studies, media violence exposure has been shown to predict different types of violence for males and females (physical aggression for males and indirect aggression for females).^152,155,158 When violent content is integrated with eroticism in media, the effect on aggression is substantially larger¹⁵⁵ and may lead toward greater callousness toward women. Furthermore, exposure to x-rated material in childhood, adolescence, and young adulthood has been linked with an increase in sexually aggressive behavior.^157,159 Thus, exposure to violence in the media, particularly when coupled with sexually suggestive material, is a particular concern for the development of men’s violence.

What Health Professionals Can Do to Prevent and Intervene in Men’s Interpersonal Violence

Identification of Emotional and Behavioral Disorders That Predict Violence Perpetration

Health care professionals are in key positions to identify risk factors for violence among males, including emotional and behavioral disorders. This is especially true during periods such as childhood and adolescence where interactions with health care occur more frequently and are routinely initiated by parents or guardians to assure healthy development. Identifying emotional and behavioral disorders in childhood and adolescence is of critical importance, given that risk factors may be identified early in life, and evidence-based prevention strategies are available to address these risk factors during the child and adolescent developmental periods and, in turn, reduce the likelihood of violence in adulthood. In its 2009 report on preventing mental, emotional, and behavioral disorders among young people, the Institute of Medicine asserted that primary care settings offer a critical opportunity to detect risks for behavioral problems and disorders that increase the likelihood of violent behavior (eg, CD, ADHD, substance use disorder, and depression). When examining children and adolescents, health practitioners should be alert to cognitive and behavioral signs in childhood and adolescence, such as hyperactivity, impulsivity, inattention, defiance, disobedience, aggression, and early substance use. For example, practitioners can engage in conversations with caregivers of young children and with older children and adolescents themselves to develop an understanding of what relationships are like at home and at school, whether there are any challenges in school performance, if there are problems with relationships with peers, when challenges are encountered with the following of rules and routines, and if there are attention difficulties. It is important to acknowledge that there are some barriers to effective identification of disorders (eg, because of lack of consensus on assessment guidelines, stigma associated with the identification of emotional and behavioral disorders, and insufficient reimbursement incentives for conducting preventive assessments). Health professionals should also be aware that some males (or parents, in the case of young children) may be unlikely or less likely to disclose information about behaviors or experiences that are essential to assessing risks for violence due to the influence of social norms around disclosure of emotional or behavioral difficulties. Although there are these limitations and challenges, it still remains important for health practitioners to use the tools and guidance that are available to identify emotional and behavioral problems in children and adolescents.

Assessment of emotional and behavioral disorders is warranted when reliable tools and methods have been identified, training on assessment procedures has been obtained, and preventive, early intervention, and treatment services are available for patient referral and utilization. Assessment may be needed most for high-risk groups of youth, such as boys and young men involved in the child protection and juvenile justice systems, as they are at elevated risk for mental and behavioral disorders that increase violence risk.¹⁶⁰ Helpful tools and guidance are available from the American Association of Pediatrics Bright Futures Initiative in their Performing Preventive Services Bright Futures Handbook (http://brightfutures.aap.org/continuing_education.html) and the California Institute for Mental Health compendium of assessment tools for early childhood social-emotional development (http://www.cimh.org/downloads/IPFMH_Screeningtools.pdf).

Detection of Victimization Experiences

Because one of the strongest predictors of violence perpetration is violent victimization, detecting victimization experiences is also of critical importance. Because males are generally less likely to disclose victimization, they may be less likely to receive compensatory services that could lessen the long-term health effects of victimization. In turn, this may increase the likelihood that they may eventually hurt others. Identifying early violent victimization may afford this subset of boys with opportunities for positive development and chances to live healthy, violence-free lives despite the adverse nature of their early experiences. More information about detecting victimization experiences such as child maltreatment can be found in Leeb et al, this issue.¹⁸ Once victimization experiences are detected, health professionals can refer patients to prevention and intervention services to address the consequences of victimization and to prevent perpetration.

Referral to Prevention, Intervention, and Treatment Services

Programs to prevent violence among young adults and adults have not been evaluated as extensively or as rigorously as programs for children and adolescents. However, advances in science have resulted in the identification of evidence-based programs that address the key risk and protective factors for interpersonal violence perpetration in the childhood and adolescent years. When emotional, behavioral, and social problems are detected in young boys and adolescents, health professionals have a responsibility to refer to prevention, intervention, and treatment services. These services are often located in other sectors, including social services, justice, and education; hence, a collaborative approach to prevention between physicians and these other sectors is strongly encouraged. The ability to properly refer depends heavily on whether one possesses current knowledge regarding available resources, as well as relationships with relevant partners who can collaborate in addressing aggressive and violent behavior. To facilitate the referral process, it is recommended that health professionals become aware and stay abreast of evidence-based programs to prevent the onset or reoccurrence of violence and support services that may address individual-, relationship-, and community-level factors that may affect the likelihood of violence. It may be particularly helpful to have knowledge of effective programs and services that can achieve positive outcomes among males and females, as well as programs and services that address the specific concerns of males and the forms of violence they are more likely to perpetrate.

The most promising prevention strategies in early childhood to prevent aggression and violence include parent management training, parent–child interaction training, and child cognitive problem-solving skills training.^161,162 The Incredible Years Training Series is an example of an effective parent and child skills training strategy that combines child, parent, and teacher programs to prevent and treat conduct problems in early and middle childhood.^163-165 For example, the program teaches nonviolent discipline and communication strategies to parents and social skills and conflict management to children.

The most promising prevention strategies in middle childhood and adolescence to prevent peer, intimate partner, and sexual violence include school-based programs that improve youth social skills and address social norms about the acceptability of violence among peers and dating partners (see Haegerich and Dahlberg,¹⁶⁶ this issue, for more details). Some of these programs, such as curricula that are provided to all students in an elementary or middle school that focus on conflict solving, emotional awareness and control, and social skills and problem solving, have been shown to result in a 15% relative reduction in aggressive and violent behavior.¹⁶⁷

For adolescents already involved in violent offending, health professionals may refer youth to intensive intervention and treatment programs including functional family therapy, multisystemic therapy (MST), and multidimensional treatment foster care.^161,162 MST includes family therapy, behavioral parent training, and cognitive behavior therapy modalities to address youth’s challenges with the family, school, and neighborhood. Strategies are implemented to increase engagement with school, work, and recreational activities; reduce association with delinquent peers; and increase socialization with prosocial role models. MST has been found to be effective in reducing community violence and sexual behavior problems among young men.^168-170

For more information about effective prevention, intervention, and treatment strategies for children and adolescents, health professionals may consult the Blueprints for Violence Prevention Initiative at the Center for the Study and Prevention of Violence at the University of Colorado at Boulder (http://www.colorado.edu/cspv/blueprints/index.html. In addition, other articles in this special issue on violence provide recommendations for primary and secondary prevention strategies across the lifespan in the specific areas of child maltreatment, IPV, sexual violence, and self-directed violence.

Conclusion

Violent victimization and perpetration is acutely experienced by men. To reduce the burden of violence on men’s health and to prevent violence perpetration, it is critical that health care professionals understand the factors that place men at risk for experiencing violence and the prevention strategies available for referral. Factors that increase risk of experience with violence range from those at the individual level, such as mental and behavioral disorders, to those at the societal level, such as social norms, gender roles, and exposure to violent media. Health professionals often do not have the appropriate reach to influence all the factors that influence men’s violence across the social ecology. Violence is a complex problem that cannot be addressed by one sector alone. Health professionals must work with professionals from other sectors, including social services, justice, and education to create environments that are safe and healthy for boys and men and to ensure that comprehensive, evidence-based intervention occurs early to prevent serious violence from occurring. A multisectoral approach to violence prevention can increase all sectors’ overall abilities to address violence comprehensively and effectively and result in improved outcomes for individuals as well as populations.

Footnotes

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Violence and Men’s Health

Abstract

Keywords

Men’s Interpersonal Violence Perpetration and Victimization

Prevalence of Perpetration and Victimization

Health Outcomes of Violent Victimization

Developmental Trajectories of Perpetration

Etiological Underpinnings of Men’s Experience With Interpersonal Violence

Factors at the Individual Level Associated With Men’s Experience With Interpersonal Violence

Social-cognitive information processing

Emotional and behavioral disorders

Personality traits and disorders

Genetic and hormonal influences

Factors at the Outer Levels of the Social Ecology Associated With Men’s Experience With Interpersonal Violence

Parenting

Peer relationships

Bonding to social institutions: Fatherhood, marriage, and employment

Social capital and neighborhood disadvantage

Social norms and gender roles

Violent media exposure

What Health Professionals Can Do to Prevent and Intervene in Men’s Interpersonal Violence

Identification of Emotional and Behavioral Disorders That Predict Violence Perpetration

Detection of Victimization Experiences

Referral to Prevention, Intervention, and Treatment Services

Conclusion

Footnotes

References