AIDS 2012Gay and bisexual men who experienced domestic violence were twice as likely to not use condoms during their last sexual encounter, according to research based out of Atlanta and presented Friday, July 27, at the XIX International AIDS Conference (AIDS 2012) in Washington, DC. What's more, the research claims to provide for the first time a definition of domestic violence that is specific to gay and bisexual men, and this definition does include HIV-related violence.

Previous research has suggested a link between domestic violence and unprotected sex in the general population, but much of the literature—information produced by the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC), for example—ignores a population at high risk for HIV: men who have sex with men, or MSM. “We're normally taking [research and data] derived from assumingly heterosexual women and applying it post hoc to MSM without any indication that it's valid,” said Catherine Finneran, MPH, of Emory University, Rollins School of Public Health in Atlanta. As a result, the definitions and prevalence of domestic violence among MSM vary from study to study, which makes it difficult to explore HIV risk in this context.

Finneran and her colleagues—notably Rob Stephenson, PhD—set out to answer the question, “What do gay and bisexual men conceptualize as intimate partner violence?” Specifically, the researchers created the IPV-GBM Scale, which measures intimate partner violence among gay and bisexual and men.

To create the scale, researchers held focus groups with a total of 83 MSM in Atlanta. The men were presented with a list of items—such as “hit you,” “damage your property” and “call you fat”—and were asked, “Would you consider it violent if it happened to you from a male partner?” Many of the items came directly from the widely accepted Conflict Tactic Scale (CTS), but participants added other items, compiling a total of 30. Of note, participants added five HIV-related items; the standardized CTS and the CDC scale did not include HIV items.

Next, researchers surveyed 1,074 gay and bisexual men in Atlanta (51 percent were non-white, 51 percent were college educated, 27 percent were HIV positive, and 10 percent identified as bisexual). The survey asked the men, “If each of these 30 items happened to you from a male partner, would you consider it violence?”

Researchers applied other analyses to their data to look for underlying patterns. The results? An IPV-GBM Scale of 23 items. The items can be broken down to five unique categories (in order of prevalence):

  • Physical and sexual violence, such as hitting and raping, but also damaging property. This accounted for 32 percent of violence.
  • Monitoring, such as demanding access to your cell phone or repeatedly posting on your social networking pages. This accounted for 14 percent of violence.
  • Controlling, such as preventing you from seeing friends. This accounted for 5 percent of violence.
  • HIV-related violence. This included three items: “Lie to you about his status,” “Not tell you he had HIV before you had sex” and “Intentionally transmit HIV to you.” This also accounted for 5 percent of violence.
  • Emotional Violence, such as calling you fat or telling you to “act straight.” This accounted for 4 percent of violence.
To explore how the new scale compares with the standardized CTS and CDC models, researchers asked survey participants if they had experienced or perpetuated each of the 23 items in the past year. It turns out that the CDC model captured 14 percent of those instances, the CTS captured 28 percent, and the IPV-GBM Scale captured 46 percent.

Finally, the researchers looked at the link between IPV and HIV risk, which they measured as having unprotected anal intercourse. “We found that men who reported any experience of IPV in the last year were about twice as likely to have not used a condom the last time they had sex,” Finneran said. She noted that the CTS and CDC definitions of IPV were not associated with unsafe sex among MSM and that, based on other research, such an association is expected to exist.

“The new scale,” she concluded, captures a higher prevalence of domestic violence and “reflects the lived realities of gay and bisexual men.”

But questions remain. After the AIDS 2012 presentation, someone inquired whether researchers asked if the condomless sex occurred between main partners or casual partners—the underlying idea being that unsafe sex between long-term partners isn't as risky. Finneran said they did distinguish between the two but that the results were the same for both categories. Finneran also pointed out that about 60 percent of HIV infections occur from main partners, a statistic that raises questions about the true level of HIV risk among long-term couples.

Another concern voiced from the audience was that defining items such as “calls me fat” as violence would pathologize gay relationships and also maximize the research findings. To which Finneran stressed that the definitions were created by gay men, not the researchers. But, she said, “we wanted to demonstrate that there are multiple forms of violence.”

The biggest issue brought up, though, was the fact that the category of HIV-related violence only included acts that were perpetuated by HIV-positive men, and none that were done to HIV-positive men. In other words, people with HIV were always the aggressors, never the victims. “I share that concern,” Finneran said. “I am uncomfortable with that aspect of the report's conclusions, but I have to respect what the data says.” Other areas of HIV-related violence were brought up but not maintained in the final analysis, she said, adding that perhaps a subanalysis could shed light on the topic, as would surveying MSM outside the Atlanta area. In short, more research is needed.