Men, masculinity and violence: a study in primary health care services

Abstracts

Há poucos estudos sobre homens abordando violência como evento não fatal. Contribuindo nessa direção, descrevem-se as prevalências da violência psicológica, física e/ou sexual sofridas por homens, detalhando-se nestes tipos a perpetrada contra parceiras. Trata-se de estudo transversal realizado com 789 homens de 18 a 60 anos, dos quais 775 com alguma parceria íntima na vida, selecionados por ordem de chegada em dois serviços de atenção primária na cidade de São Paulo. Foram investigadas as características sociodemográficas e as violências mencionadas, examinadas ainda quanto a sobreposições e à percepção de havê-las sofrido ou perpetrado. As prevalências de violências sofridas na vida foram de 79% para qualquer tipo e por qualquer agressor; 63,9%, 52,8% e 6,1% respectivamente para psicológica, física e sexual. Para violências perpetradas contra a parceira na vida, temos 52,1% qualquer tipo e 40%, 31,9% e 3,9%, respectivamente, para violência psicológica, física e sexual. Nas sofridas e nas perpetradas, a psicológica é a de maior taxa exclusiva, seguida da física. Quanto aos agressores, conhecidos é o principal agressor, seguido de familiar, estranhos e parceira íntima. Na relação entre sofrer por suas parceiras e perpetrar, 14,2% dos casos são sobrepostos e 81,2% somente perpetraram. Conclui-se que, embora nas violências relativas às parceiras íntimas os homens sofram muito menos do que perpetrem, os dados mostram que eles se envolvem em muitas situações de violência, de grandes magnitudes e sobreposições, quer como vitimas ou agressores, reiterando estudos sobre masculinidade. Este conjunto complexo de situações também deve ser considerado nos serviços básicos de saúde.

Homens; Masculinidade; Gênero; Violência; Serviços de saúde; Atenção Primária

ORIGINAL ARTICLE

Men, masculinity and violence: a study in primary health care services

Lilia Blima Schraiber; Claudia Renata dos Santos Barros; Márcia Thereza Couto; Wagner Santos Figueiredo; Fernando Pessoa de Albuquerque

Medicine Department of the São Paulo University School of Medicine - FMUSP

Correspondence to

ABSTRACT

There are few studies on men dealing with violence as a non-fatal event. As a contribution, the prevalences of psychological, physical and/or sexual violence suffered by men and the perpetrated intimate partner violence (IPV) are described. This was a cross-sectional study on 789 men aged 18 to 60 years, of whom 775 ever partnered. Men were selected in order of arrival at two primary healthcare clinics in the city of São Paulo. Sociodemographic characteristics and reported violence were investigated, along with the violence overlapping and perceptions of having suffered or perpetrated violence. The lifetime prevalence of suffered violence was 79% for any type and any aggressor; 63.9%, 52.8% and 6.1% respectively for psychological, physical and sexual violence. For lifetime IPV, the rates were 52.1% for any type and 40%, 31.9% and 3.9% respectively for psychological, physical and sexual violence. For both suffered and perpetrated violence, the psychological type had the highest exclusive rate, followed by physical. Acquaintances were the main aggressors, followed by family members, strangers and female intimate partners. Between suffering and perpetrating IPV, 14.2% of the cases overlapped and 81.2% consisted only of perpetrated violence. It was concluded that although in relation to intimate partner violence, men suffered much less than they perpetrated, the data showed that they were involved in many situations of violence of large magnitude and overlapping situations, both as victims and as aggressors, thus echoing studies on masculinity. This complex set of situations should also be taken into consideration in primary healthcare services.

Keywords: Men. Masculinity. Gender. Violence. Health services. Primary Care.

Introduction

The links between violence and health have been studied since the 1970's, with increasing efforts toward theoretical and methodological improvements and, equally, toward political effort oriented toward the visibility of harm to health and to formulation of policies to face it¹. The revision of scientific studies on violence in the health field² shows the important role played by those who have measured the magnitude of the different types of violence, such as prevalence studies.

However, the initial studies on health from the male population perspective are those based on mortality indicators. The most frequently examined relationship of men with violence is the profile of deaths, in 'external cause' studies, among which are homicide and suicide, defined since 2002 by the World Health Organization (WHO) as violent deaths³. In Brazil, aimed at investigating data from systematic registry of information and still in the category 'external cause', studies on hospital admissions due to these causes also emerge, which can be considered a first proxy to violence as a non-fatal event².

As of the 2000's, when the need to include men in intervention proposals to hinder the violence cycle between genders^4-6, acquiring more knowledge on the male perspective in non-fatal violence, especially domestic violence, was also observed to be necessary. The initial, qualitative studies analyzed the representations of men on exercising power in affective-conjugal relations and their links with violence, discussing them as part of the hegemonic male social identity construct: masculinity, culturally as a reference^7-11.

There are in general few studies estimating the prevalence of the several situations of non-fatal violence in which men are involved. American studies^12,13 show that such situations occur mainly in public locations and men alternate in perpetrator or perpetrated positions, in that physical violence characterizes the most common kind of violence they suffer^14,15.

Less explored and more recent, contrasting with violence against women, are studies conducted with men and that focus, in addition to violence suffered, to domestic violence^16,17.

We held a study from 2002-2004, with men, health service users, with ages ranging from 18 to 60 years, aimed at expanding the knowledge on these two types of scenarios in men, whether violence suffered or perpetrated, especially aimed at estimating violence perpetrated against their intimate partners. Initial results have been published in gender analyses¹⁸, discussing men's violent behaviors such as exercising several forms of masculinity, in the domains of public and private life.

From the complete study, the present article presents: prevalence of psychological, physical and sexual violence suffered by men and classified by aggressors; and the prevalence of these same types of violence perpetrated by them especially against their current or previous partner(s). Violence perpetrated against other individuals that not their partners was also studied, but in this case, only physical violence was approached. Overlapping violence was also taken into account, whether violence suffered or perpetrated, and the relationship between both forms. And, given that the term violence has been appointed as polysemic, the perception of violence suffered or practiced was also studied.

Methods

A cross-sectional study selecting a convenience sample at two primary care services was performed using the following criteria: significant population demand; existing multi-professional team with ability to receive cases possibly activated by the study; quality of medical notes in patient charts; appropriate physical conditions for the development of study activities; perception of the violence problem as a health need by head and teams; and having belonged to studies with same design and method, approaching women users aimed at a future comparative study regarding violence perpetrated by men against their intimate partners (current wife/companion, or any other companion or boy(girl)friend, with a affective-sexual relationship).

The sample selection was consecutive, recruiting participants by order of arrival to the service, with a division of the sample proportional to service volumes per day of the week and service period. All those who went for care at the unit spontaneously, and those who belonged to the population covered by the service as potential users, and were accompanying other individuals to the unit were electable; everyone, as long as they were in physical and mental conditions to be interviewed. Violence was not a criterion for recruiting interviewees and, therefore, there was no selection bias as to that variable. For each refusal, another user was approached until completion of sample size.

The sample was calculated based on data from two studies performed with women in the city of São Paulo, one at primary health units¹⁹ and another population based²⁰. We observed that it would be possible to attain a sample of 786 users: estimates of the prevalence of different forms of current conjugal violence and, consequently, the identification of the percentage of potential "aggressors" and their sociodemographic characteristics, with an accuracy of 5% between the estimated prevalence and the real population value and with a 95% confidence interval; minimum ratio estimates, which would be reached with an 80% test power, that is, with an 80% likelihood to detect differences between 'aggressor' and 'non-aggressor' users at a 5% significance level, as to potential risk factors to which they are subject.

Data was collected using a questionnaire that identified sociodemographic characteristics, aspects of reproductive and sexual health, violence suffered and practiced as to physical, psychological and/or sexual types. For violence practiced, given the main interest of the study as a whole, a priority was given in terms of details on the types of violence perpetrated against intimate partner or spouse (current or previous), asking men who were in or had been in any conjugal or affective-sexual relationship. For each one of the questions and in the three types of violence studied, we also asked if episodes occurred once, a few or many times (recurrence or repetition of violence). Questions did not include the term violence and were adapted from the questionnaire validated²¹ for use in women. They began by: "Could you tell me if you ever treated your current spouse/companion, or any other companion or boy (girl) friend in the following way", complemented by: 1) for psychological violence (1 item) - "Insulted, belittled, humiliated or made her (him) feel bad"; 2) for physical violence (5 items) - "1. Slapped her or threw something that could hurt her? 2. Shoved her or shook her? 3. Hurt her with a punch or with an object? 4. Kicked her, dragged or beat her? 5. Strangled her or burned her on purpose? 5. Threatened using or actually used a fire weapon, knife or another weapon against her?" 3) for sexual violence (2 items) - " 1. Forced your partner have sexual intercourse when she did not want to? 2. Forced your partner practice certain sexual practices that she did not like?"

Questions with more than one item (physical and sexual violence) were considered positive as long as at least one of the items was answered affirmatively. Such questions showed themselves to be consistent with a 0.89 Cronbach Alpha for each physical type question and 0.86 for the sexual type.

Men were also asked about practicing violence during adult life against people. However, in this case, only physical violence was investigated, as follows: "After you became 18, did you ever hit or physically assault anyone that was not your companion?" As to individuals assaulted, answers were classified as: another family member that was not your partner; acquaintance (friend, neighbor or work colleague); stranger.

In the case of being a victim of violence, questions also tried to differentiate acts of psychological, physical and sexual violence, but without differentiating their internal items. Violence suffered was also explored as to recurrence of episodes.

Questions asked were: 1. For psychological violence - "did anyone ever (on the street, at a bar, at work or at home) insult, belittle you, or make you feel devalued?"; 2. for physical violence - "did anyone, ever (on the street, at a bar, at work or at home) physically abuse you (slap, push, punch, kick, etc.)?"; and 3. for sexual violence - "did anyone at any time force you to have sexual intercourse against your will?".

As to aggressors, answers were classified as follows: intimate partner; another family member other than the partner; acquaintance (friend, neighbor or work colleague); stranger.

Last, aimed at investigating the perception of involvement in violence settings by users interviewed, two questions were asked at the end of the questionnaire that referred for the first time to the word violence: 1) "do you consider having suffered violence from anyone in your lifetime?"; 2) do you think you have ever been violent with anyone in your lifetime?"

Data analysis was descriptive, with variables described using means, standard deviations, frequency, proportions and confidence intervals, and aimed to analyze the prevalence of violence suffered or perpetrated. Overlapping physical, sexual and psychological violence, in the case of violence suffered or in the case of violence perpetrated against an intimate partner, was also analyzed. The relationship between those who suffered and those who perpetrated violence, in the intimate partner segment was also examined. Analyses were done on Stata 10.0.

The study was approved by the institution's Ethics Committee on 12/11/2002. Questionnaires were applied to all study participants by male interviewers, in interviews at private locations of the services after reading and signing the consent form (TCLE). This and other ethical procedures in relation to men participating in the study were adopted based on recommendations for studies on sensitive themes²³, such as anticipation of care support and special care in the choice, training and supervision of field researchers.

Results

We interviewed 789 users, 775 of which having had an affective sexual partner during their lifetime. The mean age of the total sample was 35.8 years (SD = 11.0). The general mean for schooling was 7.6 years (SD = 3.9), which is the equivalent to incomplete elementary school. One third of men were between 25 and 34 years, and the highest frequency of schooling was between 5 and 11 years (Table 1).

Most individuals interviewed were employed, followed by self-employed individuals. We observed a relevant proportion of unemployed individuals. Of these, most defined themselves as married or living with a companion. As to home arrangement, most men lived in homes comprised of a nuclear family (couple with children).

Men and violence suffered

Table 2 shows a quite high prevalence of violence suffered, of any kind or by any perpetrator/aggressor, during lifetime. When psychological, physical and sexual violence suffered were considered, regardless of considering them separately or overlapping, the rates were 63.9% (n = 504), 52.8% (n = 416) and 6.1% (n = 48), respectively.

Regarding recurrence, psychological and physical violence were observed to be characterized by repetition of episodes, if we add few or many events in comparison to one event (once), although the highest magnitude for psychological violence was high frequency (many times) and for physical violence, once. Sexual violence, on the other hand, was characterized by a single event, given its magnitude surpasses the sum of repetitions for a few and many times.

Regarding aggressors (Figure 1), work colleagues, acquaintances and strangers, are, in that order the three main aggressors observed in psychological violence. Physical violence, on the other hand, has another pattern, with family members coming second, along with strangers, in the order of importance of aggressors. These data show a strong presence of work colleagues in psychological violence, but not in physical violence, whose major presence is due to closer relations. Sexual violence has another profile, in that an intimate partner is the second most important category of aggressor. In contrast, the intimate partner is a much less important aggressor in physical and psychological violence.

Men and violence perpetrated

One third of men (n = 247; 31.3%) practiced physical violence against individuals other than their intimate partners or former-partners (data not presented). When classified as individuals assaulted, we observed that the main victims of assault were strangers (44.9%), followed by acquaintances (34.8%).

Regarding violence against an intimate partner (Table 3), we observed a little more than half of men (52.1%) perpetrated some kind of violence (psychological, physical and/or sexual) throughout life. In relation to type of violence perpetrated, we observed that the highest prevalence was for psychological and physical violence together, followed by exclusive psychological violence.

As to recurrence, repetition is the characteristic of psychological violence, different from the remaining types that point toward very near magnitudes between single episode and repeated episodes. The fact that repetition of "a few times" episodes is the most frequent for psychological and for sexual violence, stands out.

Men and overlapping violence

As may be observed in Figure 2, there are several overlaps in situations of violence: those that occur among psychological, physical and sexual, with overlapping of types of violence perpetrated and also suffered. This is also the case for overlapping of suffering and perpetrating violence.

Regarding overlap of violence suffered by men, the highest proportion among cases reported is psychological violence associated with physical violence. The most present exclusive type among cases is psychological violence (30% of cases), in that exclusive sexual violence is a rare situation. Overlap of the three types is proportionally the less frequent situation.

The profile reported for violence suffered approached what was observed for cases of intimate partner violence, and in the latter, the exclusive psychological type is even more present (35.6% of cases of violence). Sexual violence is rarely exclusive, whether suffered or practiced, even if against an intimate partner.

When taking into account the relationship between suffering and perpetrating violence, if we only consider those who suffered or perpetrated violence against intimate partners (n = 775), there is a 14.2% case overlap, and the majority are exclusively perpetrated violence (81.3%).

Men and the perception of having suffered or perpetrated violence

When asked if they considered having suffered violence in life, regardless of appointing aggressors, 67.2% of men interviewed answered no, while 32.8% answered yes. As to the perception of having been violent in a lifetime, regardless of appointing against whom it happened, we observed a similar response pattern, with 69.6% not considering having been violent and 30.4% stating having been violent.

Discussion

The present study is a pioneer in Brazil regarding non-fatal violence suffered or perpetrated by men, simultaneously considering conjugal or partnership relations and others in the private and public setting. It shows high rates of violence in the population surveyed and a very large group of users inside health services, particularly in primary care, comprising cases of violence suffered or cases of men aggressors. Despite the limitation of the convenience sample, surveying only men users and having been designed with a priority for intimate partner violence, the present study allowed collecting reliable information on several situations of suffered or perpetrated violence.

In relation to violence practiced, even against others than the partner, a prevalence of high magnitude was observed, which already points toward the reproduction of the hegemonic cultural pattern of male socialization^{17, 22,24} and reiterates other studies, with population samples beginning at age 18^12,13. In this study, data equally show that this violence occurs in public settings and in relatively anonymous collective environments, given the highest frequency of cases was also against 'strangers'^12,13.

The rate of any type of violence perpetrated against a partner is compatible with data found in a Brazilian revision¹⁷. It refers that Barker and Acosta, in 2003, surveying 749 15 to 60 year-old men, in Rio de Janeiro, found 51.4% of cases of violence perpetrated against a partner in lifetime, equally having psychological violence as the most prevalent¹⁷. This violence against a partner represents, according to Brazilian studies with focus groups with men^10,11, the imposition of authority over women and female submission in affective relationships, reflected in men practicing acts of humiliation, abuse, cursing and threats of other aggressions whenever they are disappointed with domestic tasks, obligations with children or in the couples' relations. Many times it is added with physical violence, as the present study also observed. Regarding physical violence, the rate found is higher than in the literature, whether Brazilian¹⁷, or in a study performed in South Africa²⁵, that verified a prevalence of 28.2% among 15 to 26 year old men. However, this rate is within the prevalence variation range from 18 to 45% found in a population survey with 18 to 65 year old men in India²⁶. On the other hand, sexual violence perpetrated against a lifetime partner, 3.9% in this study, was the least frequent in the literature, ranging between 18% and 40%, in the study from India²⁶ to a rate of 9.3% in the study in South Africa²⁵, and in comparison to another study performed in South Africa, that found 15.3% for the past ten years²⁷.

Regarding violence suffered from any aggressor, the present study also revealed a very high prevalence. However, as the three types of violence were added up, this is not very comparable to international studies, almost always oriented toward physical violence or a physical and/or sexual violence. If we consider the two latter types of violence, the present study, with respectively 52.8% and 55.3%, shows rates of lower magnitude than data presented in a nationwide American study (respectively, 66.4% and 66.8%)¹². However, the rate of sexual violence (6.1%) is twofold the one presented by the American study (3%), explaining the greater difference between physical and/or sexual violence, in relation to physical, when comparing our study to the American study.

On the other hand, regarding the general rate of violence suffered we found, there is an increased relevance of the psychological type in events in the Brazilian setting. Recent studies on masculinity appoint toward a feeling of devaluation that men feel due to subordination in certain situations in terms of class and race²⁸. Others appoint men as the preferred target - in comparison to women - for downgrading by police^29,30. The situation reported of humiliation in the work environment is interesting³¹ and it reiterates the results of the present study as to the aggressors of violence suffered, with rates very near to strangers, which are the main aggressors in Brazil, as well as in the American study by Tjaden and Thoennes¹².

Regarding intimate partner violence when the aggressor is a woman, the prevalence for any type of violence found in our study (10.2%) is practically half of the one found in American studies, such as the Reid et al. study³², with 28.8%, and the one done with health service users over 18 years old; or the population study by Coker et al³³, 22.9%, in 18 to 65 year-old men. Also for each type of violence suffered, in our study, 9.2% psychological, 7.1% physical, 1% sexual and 7.9% physical and/or sexual, these rates are lower than the ones found in the American literature, with 18.7% for psychological and 17.6% for physical and/or sexual, among users³², or 7% for physical for the male population¹². However in all psychological violence studies it persists as of the greatest magnitude. On the other hand, for sexual violence, if the rate we found (1.5%) is higher than the 0.2% of the Tjaden and Thoennes study¹², it is still quite lower than the 5.1% from another Brazilian population study, in the 16 to 65 year old group, for urban Brazil³⁴. This difference may be explained by a major under-revealing of this type of violence by men interviewed, given they were interviewed as users of the service in which the survey was held, or by a regional difference in the São Paulo area, given the same instrument was used.

As to recurrence of episodes, no data from other studies were found for comparison to our current results. The fact that the profile of violence perpetrated is quite different from suffered violence draws attention, and this is probably due to the fact that perpetrated violence is the one against partners, a situation of major intimacy. It is a contrast that for physical violence, single and repeated episodes have practically the same proportion, but sexual violence is marked by repetition of episodes. In the case of violence suffered, physical violence is characterized by repetition, while sexual violence is characterized by single event situations.

These results reiterate the trait of gender violence against women, particularly intimate partner violence, in that the contrast of sexual violence against women in comparison to the one against men stands out^2,12,34, showing that men are more perpetrators of sexual violence against women and of physical violence among men peers. These differences however may also be due to difficulty in revealing sexual violence suffered by men and, even more, as repeated violence.

Last, as to psychological, physical and sexual violence overlap, there is a high proportion of combined types, indicating that the combination of types of violence are the standard whether in violence suffered, or perpetrated against a partner. When considering the overlap of violence suffered and practiced, restricted to intimate partner violence, we observe that women are less usual aggressors against their partners than men. This strengthens the Tjaden and Thoennes study¹² that shows men as the main aggressors of women and of other men, not only for intimate partner violence, but in general. These results also indicate that men suffer more violence in public setting and perpetrate more in the household, which is in agreement with the study by Reed et al,³⁵ that found a significant positive association between intimate partner violence and involvement in acts of violence in the community, in a population based study developed with African American men in the US.

Rhodes et al.³⁶ described a 10.8% overlap between suffered and practice intimate partner violence. The rate is near the 14.2% found in our study, although it refers only to violence in the past year.

In the perception of violence, not only is there a quite lower rate of considering having suffered violence in a lifetime (32.8%), but also as to having been violent (30.4%), if we consider the affirmative answers to question on acts practiced or suffered without mentioning the term "violence". The rate of considering having suffered violence being similar to that of being violent also stands out. A possible explanation would be that men conceive as violence only part of the situations experienced and reported of aggressions, abuse and humiliations, given that in general, such acts are seen as tolerable because they are part of building up their masculinity, especially in relations with close individuals or acquaintances. This aspect is strengthened by qualitative studies with men^10,11 that show, particularly in relation to intimate partner violence, that men consider its occurrence commonplace. The term violence, in turn, would designate unusual situations and would mean only public situations or of non-personal and relatively anonymous relations.

Final comments

The characteristics of violence suffered and perpetrated indicate major involvement of men in several situations, reciprocally strengthened and recurrent throughout their lives. They show violence in almost all forms of social relations, although they do not always acknowledge it. Thus, data found confirm and are explained by gender studies, for which violence is part of boys' socialization, resulting in practice in order to exercise their masculinity in daily life in the future. By interiorizing violence in the processes to affirm their identity as men, this gender reference predisposes them to perpetrate against people they consider inferior in the social stratum, such as women, the elderly, homosexuals, or certain class strata or races among their peers²⁴.

If we consider violence of men against women, in which intimate partner violence prevails, the gender approach allows interpreting possibilities that range from a greater association between machism and violence⁵, to the interpretation on internalized beliefs of a greater authority of men in connection with the notion of virility^24,38 , and to the fact that gender violence reacts to expectations and actions of men. This set of features points toward the representation of violence as a practice to educate and acculturate a partner(s) at "home" and on the "street"³⁷.

Therefore, whether in affective-sexual relations, or in public sociability relations, extremely perverse situations are formed and in which using violence is justified and is commonplace, producing major impacts on the health of men and of women and in their demands at health services. It is extremely relevant, therefore, that these situations become the object of future studies and be a target for care and prevention measurements in the Health scenario.

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Publication Dates

• Publication in this collection
  20 Feb 2013
• Date of issue
  Dec 2012

History

• Received
  25 May 2011
• Accepted
  12 Jan 2012
• Reviewed
  14 Dec 2011