Domestic Violence Against Men— Prevalence and Risk Factors

Background: According to the World Health Organization (WHO), intimate partner violence is among the major risks to women’s health around the world. Men, too, can be victims of domestic violence; like female victims, they tend to present initially with their injuries to a family physician or an emergency room. Domestic violence against men is thus a relevant issue for physicians of all specialties.

Methods: This review is based on publications retrieved by a comprehensive, selective search in the PubMed database and with the Google Scholar search service, as well as on a retrospective analysis of data on the injured persons, the aggressors, and the nature of the violence that was experienced and the injuries that were sustained.

Results: The studies identified by the search yielded prevalence rates of 3.4% to 20.3% for domestic physical violence against men. Most of the affected men had been violent toward their partners themselves. 10.6–40% of them reported having been abused or maltreated as children. Alcohol abuse, jealousy, mental illness, physical impairment, and short relationship duration are all associated with a higher risk of being a victim of domestic violence. The reported consequences of violence include mostly minor physical injuries, impaired physical health, mental health problems such as anxiety or a disruptive disorder, and increased consumption of alcohol and/or illegal drugs.

Conclusion: The prevalence of violence against men and the risk factors for it have been little studied to date. It would be desirable for preventive measures to be further developed and for special help to be made available to the affected men.

Intimate partner violence is one of the main health risks for women, according to the World Health Organization (WHO) (1). According to the definition of the convention on preventing and combating violence against women and domestic violence (Istanbul Convention), which came into force on 1 August 2014, committing violence against women includes all acts of physical, sexual, psychological, and economic harm or suffering within the family, the household, or between current or former partners (2).

According to analyses by the German Federal Criminal Police Office, nationwide in 2018, 114 393 women and 26 362 men experienced intimate partner violence, but nothing had been documented about the severity of possible injuries (3). In Mecklenburg–Western Pomerania, the police crime statistics indicate that in the same year, 4317 persons were victims of domestic violence (3978 in 2017), but this number had not been differentiated by sex (4). It should be borne in mind that these statistical data only document reported crimes.

A representative survey of the EU’s Fundamental Rights Agency (FRA) into the extent of sexual and domestic violence included 42 000 women from 28 EU member states and found that one in four or five women has been subjected to physical intimate partner violence since her 15^th year of life. For Germany, a moderate to high prevalence of violence was noted compared with other European countries (5).

A 2004 pilot study investigating the general experiences of violence among men from childhood into adulthood showed after 266 quantitative interviews had been analyzed that one in four men had experienced physical violence at the hands of their female partners at least once (6).

The German Health Interview and Examination Survey for Adults (DEGS1) found that 1.2% of women and 0.9% of men who participated in the survey had been the victims of physical partner violence in the preceding 12 months, although the study method is not uncontroversial (7, 8). A Swiss study found that 2.9% of the 1503 participants had been victims of physical partner violence (9).

German-language medical or forensic technical contributions regarding affected men currently barely exist; consequently we will evaluate the international literature and our own data collection in order to provide a fundamental review of the subject.

The consequences of physical violence

Domestic violence against women has been comprehensively researched and acknowledged as a complex event, with the aim of gaining control and power over one’s partner (5). In addition to—potentially fatal—physical injuries, the harms caused may be (psycho)somatic and psychological in nature or they may consist of behaviors that pose a risk to health (10, 11). 70–80% of children who witness violence against a parent require special help for diverse behavioral problems or emotional disorders (12, 13).

It is well known that women affected by violence have greater problems in securing and maintaining gainful employment (14). According to estimates from the US Centers of Disease Control and Prevention (CDC), affected persons in the US incur a loss of 8 million paid working days as well as 5.6 million working days in the home or family (15). Such unfitness for work leads to higher morbidity and therefore increased use of healthcare services (16).

Although this article focuses on men affected by domestic violence we wish to point out that for women/girls affected by violence—particularly sexual violence—established recommendations for action exist (17, 18, 19, 20).

Forensic and medical/clinical relevance

In the first place, physical intimate partner violence in the form of assault falls among the so-called criminal offences prosecuted only on application by the victim, although the prosecution has the option of agreeing that a criminal prosecution is in the public interest. In such cases, the investigating authorities can commission a medical expert to examine a victim of violence (21).

Since female victims of partner violence tend to be reticent in their reporting behavior—study results show that only 8.8% of women report this to the police (22)—we wish to emphasize the importance of the clinical-forensic examination. Independently of potential criminal proceedings, victims are given easy access to having any injuries sustained documented professionally (after surgical care, where required) and in a form that can be used in court, as well as having evidence secured. In particular, injured parties who do initially not want to file a police report depend on qualified and court-safe documentation of findings, in order to enable a legal work-up of their case at a later date (23, 24).

Victims often initially approach their general practitioners or doctors in emergency departments in hospitals (25, 26). It should therefore be among every doctor’s competencies to identify indications of violence, tackle these, and document them accordingly.

Methods

We conducted a selective literature search in the database PubMed and by using the search engine Google Scholar, using the following search terms: “Häusliche Gewalt gegen Männer”, “Partnerschaftsgewalt”, “Männergewalt”, “domestic violence against men”, and “violence in intimate partner relationships”. We restricted our search to the primary scientific literature published between 1990 and 2019.

When scanning abstracts we considered only articles that had defined the use of violence according to the Istanbul Convention. Where inclusion and exclusion criteria could not be determined on the basis of the title and abstract, we analyzed the full text. Only articles containing prevalence rates of medically relevant forms of domestic violence as reported by the injured parties or the perpetrators were considered eligible for inclusion. After scanning the articles and selection according to inclusion and exclusion criteria, we included 17 articles in the present review.

In order to compare the published results with our own data, we retrospectively analyzed the study data of the outpatient department for victims of violence at the Institute for Forensic Medicine at Rostock University Medical Center over a period of five years (2013–2018). The data collection was generated from the study documentation and evaluated in anonymized form by using Microsoft Excel 2003 software.

Results

Study characteristics

In the included studies we also investigated in addition to the three relevant forms of violence—physical, sexual, and psychological violence—associations with alcohol consumption (27, 28, 29, 30) and substance misuse (27, 31), psychiatric disorders (23, 33), sexual orientation (34), and disabilities (33). The sample size of the studies included data from 54 men surveyed (35) and from 220 073 patient files (36). The experiences of violence were collected in six studies by using the Conflict Tactics Scale (CTS, mCTS, or CTS-2) (27, 29, 32, 37, 38, 39). Table 1 includes further study characteristics.

Table 1

Characteristics of studies of domestic violence against men

Prevalence rates and representative data

The included studies reported prevalence rates between 3.4% and 20.3% for physical violence (27, 32), between 7.3% and 37% for psychological violence (39, 40), and between 0.2% and 7% for sexual violence (38, e1) against physically and mentally healthy men.

For men with psychiatric disorders or disabilities, prevalence rates were clearly higher: 31.8% for physical violence and 42.9% for psychological violence (31), and between 4.1% and 8.8% for sexual violence (31, 33).

Four studies investigated whether the men affected had committed violent acts themselves (29, 30, 35, 39). Of note: most of the affected men had themselves been violent against their partners. Muellemann and colleagues reported that more than half of those affected had already spent time in prison because of domestic violence (35). This is consistent with the results of a study reported by Swan et al., which showed that 92% of women who committed domestic violence had previously experienced violence at the hands of their partners (37).

According to the evaluated forensic medical studies, 53.8% (28) and 85% (25) of men and 64% of women presented with mostly minor injuries, such as skin abrasions (25, 27). For both sexes, serious injuries, such as bone fractures, were found in only 5% (25). Table 1 summarizes further prevalence rates.

Risk factors

Between 10.6% and 40% of affected men themselves had experienced abuse or cruelty in childhood (32, 36). Alcohol misuse, jealousy, mental disorders, disabilities, and short relationship duration were identified as further risk factors (30, 31, 32, 33, 39). The described consequences of violence included in addition to physical injuries (25) a 2.5-fold reduction in wellbeing (odds ratio [OR]:1.95) as well as (in 24.2% of cases) psychiatric sequelae, such as anxiety or other mood disorders (13.6% and 8%), disruptive disorders (11.2%), and raised alcohol consumption or substance misuse (7.1%) (27, 32). Further aspects are listed in Table 1.

In our own data collection, a total of 867 persons in the outpatient department for victims of violence were examined over the study period, of which 455 were adults (52.5%). Of these, 190 were men, of whom 16 reported being victims of intimate partner violence. The study included all examined men who presented to the outpatient department for victims of violence in the absence of an official order according to § 81 of the German code of criminal procedure. None of those examined refused to participate in the data collection. Of note is the number of male victims in 2018, which in that study year accounted for 5.2% of total examinations and 10.3% of examined adults. Table 2 summarizes the main results from the data survey.

Table 2

Retrospective evaluation of examinations undertaken between January 2013 and December 2018 in the Rostock outpatient department for victims of domestic violence (documentation of injuries in 16 men after intimate partner violence)

The male victims of intimate partner violence who were examined were exclusively middle aged or older. Eight men were aged between 31 and 50, eight were older than 50. Altogether eight of the men were local, four were from the neighboring rural district of Rostock. Only four men presented from the further away cities of Schwerin and Wismar or the rural district of Ludwigslust-Parchim.

All of the men in the study were living in heterosexual relationships. Six reported that their partners had mental disorders, in equal proportions alcohol dependency, depression, and paranoid schizophrenia. Of these men, two reported being alcohol dependent or having borderline personality disorder themselves.

The violence was committed mainly by wives, in four cases by life partners. In two cases violence was committed by former partners; in these cases contact had remained close because the couple had children together. It should not be discounted that violence can be committed on a mutual basis (35): in two cases the wives of the injured men also presented to the outpatient department for victims of violence.

Participants named as triggers mainly accusations of unfaithfulness, financial worries, or the already mentioned underlying mental disorders. The reported frequency of incidents was “once” and “repeatedly in the past three years.”

The men mainly reported having been struck open-handedly and scratched. In most cases, however, combinations of different methods of blunt violence were applied (Table 2); two men reported being struck with items such as a barbell/dumbbell and shoehorn. The men under study showed the effects of low grade to higher grade intensive blunt violence. The main injuries seen were scratch-like skin defects, hematomas, erythema, but no patterned injuries. Penetrating trauma, compression of the neck, or sexual violence were not reported, but it should be borne in mind that the study population was small. In two cases, inpatient admission was required; four men received outpatient medical treatment. We present two example findings from selected cases.

Case 1

A 38-year-old man reported how after an initially verbal argument with his former partner, she had struck him with her fist and threatened him with a knife. Subsequently she had splashed him with hot water from a kettle (Figure 1). He then shoved her. Both parties reported contacting the police in parallel. The man reported two earlier incidences of domestic violence against him by his partner.

Figure 1

Case 1, patchy scald injuries on the front of the right shoulder

Case 2

A 35-year-old man reported having got into an argument with his long-term life partner regarding him using his mobile phone. When he wanted to leave the flat, the argument escalated. She knocked the mobile out of his hands, struck his back with her fists, and scratched him (Figure 2). He reported several prior incidents of a similar nature; she often “lost it.”

Figure 2

Case 2, streaky skin hemorrhages on the right acromion

Discussion

Intimate partner violence continues to be considered the most common form of violence against women and can result in serious injuries. In Germany in 2018, a total of 324 women and 97 men fell victim to attempted or completed killing at the hands of their (former) partners (3). In Western societies it seems that the ongoing move towards equality of the sexes is associated with an increase in domestic violence against men (3, e2).

The DEGS1 study, which we mentioned earlier, was criticized—among other reasons—because differentiated study instruments had been applied inexpertly and critical discussions relating to the subject had been disregarded (8). Similarly, we cannot unequivocally say whether the studies presented here included details on context, personal dynamics, or the sociocultural background of the subjects, especially tendencies to denial or taboo.

Most men in our own survey were married to the female perpetrators or had lived with the women for several years. This contradicts the results of Lövestadt and Krantz, who found that if a relationship had existed for less than three years, the risk of becoming a victim of domestic violence was higher (OR: 4.85; 95% confidence interval: [1.94; 12]) (39).

According to the Federal Criminal Police Office, the age group of 30- to 39-year-old men was most commonly affected by domestic violence (3). Even though older men were overrepresented in our own survey, other studies indicate that younger men particularly at risk (e1, e3).

In Mecklenburg–Western Pomerania, a recent study of unreported crimes found that only 3% of cases of intimate partner violence are reported to the police, but the study did not differentiate by sex (e4). The unreported numbers of women and men who are victims of domestic violence is likely to be much higher in view of such a low willingness to make a report (28). Many theories exist of why men in particular may hesitate to report domestic violence. In addition to their own feelings of shame, one reason may be fear that they will not be believed and worry that they will be prohibited from contact with their children. Furthermore, there are the reasons known from female victims of domestic violence: the hope that their partner will change and the desire for an intact family (6).

The well known three phases in the cycle of violence—the tension-building phase, acute or crisis phase, and calm or honeymoon phase—is rarely broken without external intervention; rather, it is likely to gain in intensity (e5). Whether this model is also generalizable to men affected by intimate partner violence should be investigated in future studies.

Our survey of cases in Rostock shows that the range of injuries is similar to that seen in other forensic studies: Todt et al. evaluated studies commissioned by the authorities of 199 female and 17 male victims of domestic violence and described as the most common injuries hematomas, skin abrasions, and erythema, which occurred in greater numbers on the upper limb, head, and trunk of the injured party (e6). Walter and colleagues found that 67% of affected men had not contracted any injuries, but 21% reported hematomas and contusions, 7% reported pain, and 5% reported head injuries (6). These injuries are consistent with those in our own survey as well as those reported in international forensic medical studies (27, 28).

A nationwide prevalence study found that 64% of women who were victims of intimate partner violence reported injuries, and 56–80% reported mental sequelae (e7). Similar effects were also found for men who were victims of intimate partner violence (27, 32), although mental stress or the presence of Munchausen syndrome cannot be studied in a forensic medical setting.

It is already scientifically confirmed that clinical-forensic studies are needed (e8). Data from the local counseling and support network CORA confirm that in 2018, 400 women and 39 men reported having received counseling in specialist advice centers for sexual violence, and 2053 women and 346 men reported having received counseling in intervention centers for domestic violence and stalking (e9).

Conclusion

Dealing with this stigmatized topic in an open and supportive way is a mandatory prerequisite to identifying victims of domestic violence in routine clinical practice. To this end, more training measures for physicians should be made available in order to raise awareness of the subject. Hospital staff in particular have a key role in setting the course, and should thus be supported by targeted training measures (23).

Doctors from all specialties form an interface between medical care, documentation of findings, and the wider support system. Numerous recommendations exist for conducting a forensic-medical examination and relevant documentation of findings in victims of violence; on the basis of these the documentation of injuries of men who are victims of domestic violence in medical practice should not pose any problem (17, 18, 19, e10).

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 17 December 2019, revised version accepted on 8 May 2020.

Corresponding author
Dr. med. Verena Kolbe
Institut für Rechtsmedizin, Universitätsmedizin Rostock
St.-Georg-Str. 108, 18055 Rostock, Germany

Cite this as:
Kolbe V, Büttner A:
Domestic violence against men—prevalence and risk factors.
Dtsch Arztebl Int 2020; 117: 534–41.
DOI: 10.3238/arztebl.2020.0534

►Supplementary material

For eReferences please refer to:
www.aerzteblatt-international.de/ref3120

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