Intimate Partner Violence in Same-Sex Relationships: Are We Aware of the Implications?

Abstract

Intimate partner violence (IPV) has been a significant public health problem in same-sex relationships. However, health policies across the globe do not address IPV causing a massive gap in health and economic burden. In the last decade, crucial missing links have been established, and researchers tried to connect the dots of this severe health disparity. This intersectionality has found the impact of race, gender, class, physical ability, and legal framework of IPV in lesbian, gay, and bisexual (LGB) relationships. However, preventive strategies, training programs, and dialogues in the clinical field about IPV are from heteronormative lenses. This particular bias can perpetuate the issue and will remain one of the leading causes of health burden in the LGB population. This article reviews the lacunae in health policies regarding same-sex IPV, highlights its impact on minority mental health, and calls for attention to train health-care professionals regarding the same.

Introduction

Intimate partner violence (IPV) is defined as violence against a partner of any gender in the form of physical aggression, verbal aggression, and sexual violence executed by a current or former legal partner, cohabitating partner, or dating partner. IPV has been a significant public health problem in same-sex relationships. However, global health policies do not address the same issue, causing a massive gap in health and economic burden. In the last decade, crucial missing links have been established, and researchers tried to connect the dots of this severe health disparity. This intersectionality has found the impact of race, gender, class, physical ability, and legal framework of IPV in lesbian, gay, and bisexual (LGB) relationships. Surprisingly, prevention and awareness of the same revolve only around cisgender heterosexual couples. A recent study on media representation of same-sex IPV (SSIPV) pointed out ¹ the resource concerns, police involvement, and heteronormativity and heterosexism in media coverage of the same. Most preventive strategies, training programs, and dialogues in the clinical field about IPV are from the heteronormative lenses. Such bias can, however, perpetuate the issue, and it will remain one of the leading causes of health burden in the LGB population. ² This article reviews the lacunae in health policies regarding same-sex IPV, highlights its impact on minority mental health, and calls for attention toward the same.

Prevalence of IPV

Since 1980, multiple studies have been conducted to determine the prevalence of IPV in same-sex relationships. Around 61.1% of bisexual women, 43.8% of lesbians, 37.3% of bisexual men, and 26.0% of gay men experienced IPV during their life. ³ A meta-analysis of 14 studies in self-identified lesbian couples found that the prevalence of IPV over a lifespan is greater than that of heterosexual intimate partner relationships. ⁴ Finneran and Stephenson ⁵ highlighted that rate of IPV in male-male partnerships was similar to or higher than the rates of IPV observed in populations of women in a systematic review. ⁵ A study found that young same-sex couples have greater odds of experiencing IPV perpetration and victimization, resulting in physical injury after comparing mixed-sex couples across 8 potentially confounding variables. ⁶ Messinger ⁷ pointed out that all forms of abuse were more likely to occur in gay and bisexual couples than in heterosexual ones. ⁷ Finneran and their colleagues ⁸ estimated the similar prevalence rates of same-sex IPV in the United States, Canada, Australia, United Kingdom, South Africa, Brazil, Nigeria, Kenya, and India.

Broadly, IPV can be physical violence, stalking, and psychological aggression. Finneran et al ⁸ found that the most common form of IPV is physical violence from more than 2,000 self-reported gay men. A 2017 systematic review showed that the rate of physical IPV ranged from 19.9% to 39% for gay and bisexual men. ⁹ A scoping review of IPV among gay and bisexual men noted that despite the predominant focus on physical abuse in the studies reviewed, same-sex couples experience more psychological abuse than physical abuse. ¹⁰ Examples of psychologically aggressive behaviors are being called ugly, fat, crazy, or stupid by their partners, witnessing their partners act in an angry manner that seemed dangerous, and being insulted, or humiliated. ¹¹ A qualitative study, through in-depth interviews with men having same gender attraction, revealed that for survivors of IPV, emotional and verbal was the most common form of abuse, again more frequently reported than physical violence. Stalking was also identified as the most common form of IPV in sexual minority relationships than in heterosexual relationships. A study revealed that 66.27% of gay men and 60.38% of bisexual men reported victimization of intimate stalking as a form of IPV. ¹² Nearly one-half of heterosexual women (47.5%), 7 in 10 bisexual women (76.2%), and 6 in 10 lesbians (63.0%) experienced this form of aggression.^{12, 13} However, many systematic reviews and studies have reported that sexual violence is the most diminutive form of IPV in same-sex couples and heterosexism can influence these partnerships.^14–16

Risk Factors

Sexual minorities share some risk factors with the heterosexual population; however, they present with unique vulnerabilities and require targeted population-based research and intervention.

Witnessing domestic violence at a young age and learning that aggression and violence are ways to achieve the desired are likely to make a person perpetrate violence with their partners in future and result in the intergenerational transfer of violence. ¹⁷ IPV in the LGB population also operates based on syndemics or synergistic epidemics where multiple health problems cluster in a population fueled by biological interactions, thus increasing the overall effect of the illness. Thus, psychosocial, mental, and physical health issues exacerbate vulnerable populations. ¹⁸ IPV is associated with multiple mental health problems such as depression, posttraumatic stress disorder, and substance use disorder. Devries et al ¹⁹ found that IPV was often a harbinger of depression and depression often predisposed to IPV. The symptoms of depression, such as lack of initiative and interaction, self-blame, guilt, and hopelessness, also limit help-seeking behavior. Studies done by Filson et al ²⁰ also demonstrated that learned helplessness is associated with IPV among heterosexual women. Hypothetically, this can also be the truth amongst lesbians, considering the heteronormative society we live in. Reingle et al ²¹ and Temple and Freeman ²² showed a strong association between substance use disorders and IPV in adolescent men and women. Stults et al ²³ hypothesize that substance use may cause disinhibition and increase impulsivity, particularly in intoxicated states leading to a more frequent occurrence of IPV. Substance use also might be a way to cope with the stress of ongoing IPV. It was pointed out by Fortunata and Kohn ²⁴ that in lesbian couples, perpetrators abuse substances more than the IPV survivors, and the intensity of alcohol use was associated with the amount of violence in the relationship. Substance abuse was found to be one of the strongest correlates of male and female same-sex IPV.^{25, 26} Traditional gender roles can both be a cause and a maintaining factor of IPV. Most traditional value systems operate on binarity—black/white, yin/yang, and men/women. ²⁷ In same-sex relationships, there often is a sub-conscious struggle to conform to traditional male and female gender roles. Society dictates that masculinity should entail characteristics of aggression, dominance, and emotional repression. ²⁸ Men are likely to resort to violence to prevent emotional vulnerability exposure or avoid appearing weak or “unmanly.” ²⁹ Gay or bisexual men conforming to traditional male roles may feel insecure about their “masculinity” and use violence to exert dominance and control their partner. On the other hand, women are perceived as nonviolent creatures with caring nature, conceiving the notion of a so-called egalitarian lesbian utopia. ³⁰ This makes it hard for a lesbian to identify IPV in their relationship, often dismissing it as “cat fights” or defending the acts of violence by “girls do not hurt girls.” ³¹

Moreover, the radical feminist culture of 1970, to normalize lesbian relationships, portrayed only men as the perpetrator of aggression. ³² Recognition of female same-sex IPV challenges the sanctity of lesbian relationships. ³³ In cultures where same-sex relationships are yet to be accepted, IPV among same-sex couples remains ignored and under-reported for fear of self-stigmatization. ³⁴ Due to a strong sense of heteronormativity in certain cultures and a low acceptance rate of homosexual relationships, talking about IPV itself was considered “doubly closeted” as the stigma was twice as much: first surrounding the sexual orientation and second, surrounding the domestic violence. ³⁵

Power dynamics, that is, power imbalance, has played a significant role in both opposite and same-sex IPV. ³⁶ Another factor unique to IPV in the LGB population is internalized homophobia. Like Freudian “anger turned inward,” societal homophobia gets converted into internalized homophobia. Internalized homophobia induces negative self-concept, devalued self, and internal conflicts between expected stereotyped gender role and current role. A negative self-concept sometimes is a justification for the ongoing IPV; from a survivor’s perspective, they deserve abuse because of their sexual identity, while perpetrators with internalized homophobia might project their negative feelings on their partners and commit violence toward them. ³⁷ In societies with low acceptance of same-sex relationships, an ill-formed support system and more dependence on partners lead to higher rates of IPV.^38–40 Meyer ⁴¹ observed that in minorities, apart from the general stressors, there is unique and chronic stress arising from social processes. Minority stressors exist on a continuum of proximity to the self, ranging from internalized stigma to various discriminatory social laws and policies. This concept is now applied for the intersectionality in research on health disparities experienced by LGB people. This excess stress, sometimes referred to as minority stress, is due to them belonging to a minority group. Few studies have examined the alleged relationship between minority stress and IPV.^{42, 43} Furthermore, a study has confirmed a significant association between perpetration of IPV and minority stressors, with most types of IPV perpetration linked to internalized homophobia. ⁴⁴

Sexual script theory suggests that how to behave with an intimate partner is a learned behavior. Growing up by observing cultural norms generates one’s sexual script. ⁴⁵ LGB adolescents grow up by observing the sexual script between traditional gender roles prescribed by the society. Thus, there is lack of sexual script and healthy sexual role models for LGB adolescents and young adults.

Support System for Same-Sex IPV Survivors

Out of 195 countries across the globe, 31 countries have legalized same-sex union, and 126 countries have legalized same-sex attraction till December 2021.^{46, 47} However, only 3 countries have legal protection for SSIPV. ⁴⁸ A support system for SSIPV survivors is crucial for protecting their mental health and the long-term implications of causing an economic burden. ⁴⁹ The Home Office of the United Kingdom, which protects SSIPV survivors, reports that the cost of domestic abuse is estimated to be over £66 billion. ⁵⁰ The other 2 countries, the United States and New Zealand, provide legal protection to SSIPV under the Violence Against Women Act of 1994 and Domestic Violence Act 1995, respectively. ⁴⁸ However, the help-seeking behavior of the LGB population against IPV is influenced by homonegativity, which may cause them to avoid seeking support. A strong presence of heteronormativity in social contexts and stereotyping of gender roles like a man is always a perpetrator and a woman is always a victim can also be problematic. ³⁵

Santoniccolo and colleagues ³⁵ found in a systematic review of 21 studies that feelings of isolation, low awareness and knowledge of the phenomenon, low awareness of avail-able resources, fear of discrimination, fear of repercussions, and negative feelings about one’s sexual orientation are the major hindrances in the help-seeking process. The moral system of society often influences the support system and social policies, and it also influences the attitudes of LGB toward IPV. ⁵¹ Pagliaro et al ⁵¹ examined gay men and lesbians where their willingness to help a same-sex couple as a bystander was based on the moral evaluation of the survivor, like infidelity. Connel ⁵² mentions, “patriarchal culture has a simple interpretation of gay men: they lack masculinity.” If individuals do not perceive gay males as traditionally masculine, they may not believe the prevalence of violence.

In contrast, the need to prove masculinity can be a triggering factor for violence in relationships. ⁵³ LGB from ethnic minorities face barriers to accessing services due to racism and homophobia in institutions and might struggle to trust the government institutions. ⁵⁴ Consequently, in countries where broad legal protections are available but the same-sex union is not legal, people might not report IPV to their doctors because they have faced discrimination from health-care institutions.^55–57

Guidelines to Approach Same-Sex IPV

Good quality health information, screening, and guidelines for secondary health begin with accurate documentation and coding information by practitioners using sound classification systems. Policymakers and commissioners of health services rely on this crucial step for informing public policy to set public health priorities, monitor and improve the effectiveness of program interventions, and commission and fund services. Previously, ICD 10 codes for IPV were fragmented and had poor reliability and validity. ⁵⁸ From its categorization of violence (T74 Maltreatment syndromes, X and Y Assault, Z63 Problems relating to primary support group), researchers have pointed out that codes qualifying as IPV generally did not fit within a biomedical model.^{58, 59} Thus, a more straightforward nonjudgmental taxonomy of violence which transcends cross-cultural societies was adopted within the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5) ⁶⁰ and International Classification of Diseases, 11th Edition (ICD 11) for improved screening and treatment. The resultant criteria condensed it to 3 items: an act of abuse/neglect, any actual or potential for more than negligible impact, and partner relationship between person and perpetrator.

Although the literature on LGB IPV is generally lacking, there is a need for research specifically on treatment and guidelines. Guidelines for cisgender heterosexual IPV survivors share similarities in some approaches and safety planning but differ on certain crucial needs. These similarities acknowledged include the manipulation of power and control dynamics and tactics of abuse such as physical, sexual, emotional, or economic abuse, use of privilege, and isolation. LGB IPV survivors, however, differ in having a substantial risk of being in isolation from family members and other social support. This critical point requiring specific approaches concerning the fragility of the patient-carer relationship is only acknowledged and not detailed in a few national violence guidelines (North American National Directory of Domestic Violence Programs, NICE 2016 Domestic violence and abuse guidelines). The American Psychiatric Association (APA) has a specific guide for Treating LGB Patients Who Have Experienced IPV. ⁶¹ Most of it emphasizes the importance of an all-inclusive and nonjudgmental use of language in the history-taking of survivors with the acknowledgement of said fragility of the patient-carer relationship in different settings. Such language has been associated with increased disclosure of sexual orientation. ⁶²

As addressed in the APA guidelines, safety planning needs are distinct amongst LGB IPV survivors. When identifying locations to seek safety, the APA guidelines recognize the ongoing history of violence against these communities, especially minorities within minorities (eg, LGB communities of color). ⁶¹ The survivor may not feel safe engaging with the law enforcement or going to the hospital for worry of not being taken seriously or that their requests will be met with homophobia. ⁶³ Interestingly, 2 studies^{64, 65} found that the police are ranked second in preference for heterosexual IPV survivors and last for same-sex IPV survivors.

Finally, the APA guidelines support linking survivors to existing agencies and organizations that work specifically within LGB communities.

Recommendations

As we have discussed the health priorities and vulnerabilities of SSIPV survivors, primary care brings us to this essential question—what can health-care physicians do to address the gaping disparities within our present health-care scenario? What follows are a set of recommendations that seek to address this question and related issues concerning laws and addressing the issue in a clinical setting.

1. Advocacy

   Advocacy is one of the backbones of interventions to support SSIPV survivors. It can be done by: (a) Working with individuals, helping survivors with specific court hearings and processes, and providing safety planning and risk assessment information and (b) advocating for the legalization of same-sex union; putting the SSIPV in domestic violence acts to support survivors.

2. Clinical practice

   In practice, it is crucial not to follow the framework of heterosexual IPV survivors while assisting the SSIPV survivors.

3. Research

4. Ensuring research questions are developed in a way that is sensitive and relevant to meet the study aims and the participants.

5. Researching traumatic experiences could be distressful. Peer support groups and keeping a journal reflecting on feelings and reactions are essential to maintain emotional well-being.