COLUMBIA SOCIAL WORK REVIEW, VOL. VIII | 1 FACTORS THAT CONTRIBUTE TO INTIMATE PARTNER VIOLENCE IN SAME-SEX RELATIONSHIPS WITH HIV/AIDS JASON FREEMAN SAMUEL GILBERT AVIVA RASKIN DARWIN RODRIGUEZ The proposed study is designed to begin research into the impact of HIV/AIDS status on intimate partner violence (IPV) in same-sex couples. By comparing IPV in gay men’s relationships in which HIV/AIDS is present and relationships in which it is not, the proposal asserts that this research is necessary to further research and create prevention interventions in the LGBTQIA communities that take intersectionality into account. The proposal theorizes that HIV/AIDS status should be looked at as a correlate to IPV, in addition to the factors previously identified as correlates such as: socioeconomic status, substance use, relationship history, and other psychological and emotional factors. INTRODUCTION The primary goal of this proposed study is to explore the impact of Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome (HIV/AIDS) status on intimate partner violence (IPV) in same sex couples. By comparing IPV in gay men’s relationships in which HIV/AIDS is present to relationships in which it is not, we wish to set the stage for more research into IPV in the greater LGBTQ community. Doing so will allow professionals - including social workers, clinicians, and physicians - to create specific interventions that are uniquely targeted to serve these marginalized and underserved community. Research on IPV in same-sex relationships is usually neglected, in contrast to research on heterosexual relationships (Houston & McKirnan, 2007; Merrill & Wolfe, 2000). According to the Center for Disease Control’s 2010 National Intimate Partner and Sexual Violence Survey, the lifetime prevalence of rape, physical violence, or stalking by an intimate partner for men who engage in intercourse with men was 26 percent for gay men and 37.3 percent for bisexual men versus 29 percent for heterosexual men. These numbers indicate a pressing need for IPV prevention and intervention in the gay male community, especially as stigma often leads to under reporting. At present, the unique characteristics and impacts of IPV in same-sex couples and the particular needs of these couples are still relatively unknown (McClennen, 2005). Perpetrators of IPV may use their own or their partner’s HIV/AIDS status as a weapon of coercion. They may also fake illness or threaten to reveal the victim’s HIV/AIDS status (“Domestic Violence and HIV/AIDS - NYS OPDV”, 2017). Little is known about the prevalence and clinical associations between HIV/AIDs and IPV; this intersection needs to be thoroughly examined. The National Coalition of Anti-Violence Program’s (2015) report indicates that 44 percent of LGBTQ and HIV-affected survivors of IPV who requested shelter services were rejected; 71 percent attributed the reason to gender identity. Members of the LGBTQ community experience minority stress in addition to relationship stress, which can manifest in various forms of abuse and violence when there is a high level of emotional dependency between intimate partners. When this dependency is present and there is also emotional enmeshment between partners in a relationship, violent behaviors can become a way to compensate for emotional imbalances (Balsam & Szymanski, 2005). LITERATURE REVIEW IPV is a relatively new area of research, and the major focus is on heterosexual relationships. Prior to the 1970s, IPV was deemed a private matter that should be kept at home; it was not considered a federal crime until 1975 (Hoyle & Sanders, 2000). IPV gained visibility through the feminist movement in the 1970s, which helped many heterosexual women. The movement, however, largely left out the gay1 population. It is only recently that the campaign against IPV became more inclusive of such relationships. In 2002, an extensive study was done on the relationship dynamics of gay relationships in which domestic violence was present (McClennen, Summers & Vaughan, 2002).. This study suggested that regardless of sexual orientation or gender, survivors chose not to leave their relationships because they loved their abusers. According to the findings, dependency, jealousy, power imbalances, and substance use are all factors correlated with IPV in the gay male population. From this discovery, one may conclude that IPV can affect anyone, no matter their gender or sexual orientation. This study broadened the scope of what was considered to be IPV and allowed the movement against IPV to start focusing on the pattern of power and control within a relationship rather than the person’s gender or sexual orientation (McClennen, Summers & Vaughan, 2002). In 2005 and 2007, two studies looked at psychosocial factors in same-sex relationships. In the first study, researchers investigated minority stress as it affected relationship quality, as well as both lifetime and recent experiences of IPV. Researchers found that sexual orientation and where one falls on the gender spectrum did not play a role in relationship 1 We are using this term to predominately refer to men who have sex with men, however it is generally inclusive of all same-sex relationships in this paper. 2 | COLUMBIA SOCIAL WORK REVIEW, VOL. VIII quality or experiences of IPV in gay relationships (Balsam & Szymanski, 2005). The second study found a significant relationship between unsafe sex and IPV. Researchers theorized that IPV impacted psychosocial characteristics and health issues among gay and bisexual men (Houston & McKirnan, 2007). These studies show that a homosexual identity is critical to a person’s psychosocial development, and both argue that societal homophobia and heterosexism paired with internalized homophobia play a key role in IPV in homosexual relationships (Balsam & Szymanski, 2005; Houston & McKirnan, 2007). Additional studies have explored the prevalence, clinical associations, and impact of IPV on the gay male population. These studies sought to explain associations between IPV and available sociodemographic and psychological factors, clinical status, and both HIV/AIDS-related and unrelated hospitalizations. They found that, given the prevalence of IPV within the gay population, there is a demonstrated need for targeted services and intervention. In addition, when patients reported past and/or present IPV, they had significantly worse health-related quality of life outcomes (Siemieniuk, et al., 2013). IPV was also associated with an increased progression rate from HIV to AIDS (Siemieniuk, et al., 2013). The impact of IPV on people living with HIV/AIDS was clinically relevant due to the increased frequency of interruptions in care (Houston & McKiernan, 2007). The study conducted by Siemieniuk, et al. (2013) brought HIV/AIDS status into the conversation in a quantitative manner and showed that it needed to be further examined as a contributing factor toward IPV. CONCEPTUAL FRAMEWORK Disempowerment theory examines IPV from the perpetrator’s perspective and considers a broad range of characteristics that relate to the patterns of abuse in a relationship. The current research proposal will utilize disempowerment theory and three of its major domains – economic, psychological, and social – to explain the association between risk factors and IPV in same-sex relationships with HIV/AIDS. In line with Disempowerment Theory, individual characteristics, intimate relationship characteristics, and family of origin factors place individuals at risk for perpetration of IPV (Mason et al., 2006). When an abusive partner feels as if their control is threatened, they may use violence or other abusive tactics to impose their will upon their partner (Archer, 1994). See Figure 1 as follows: FIGURE 1 - CONCEPTUAL FRAMEWORK OF THE STUDY OF HIV/AIDS STATUS AND THE FACTORS THAT CONTRIBUTE TO INTIMATE PARTNER VIOLENCE (IPV) IN SAME-SEX RELATIONSHIPS. METHODOLOGY RESEARCH DESIGN AND SAMPLING The populations of interest for this proposal are self-identified Black, Caucasian, and Latino men living with HIV/AIDS and attend an HIV/AIDS clinic in NYC. All participants must meet the aforementioned criteria We will utilize a cross-sectional study approach for our research. The sampling frame will be obtained by handing out surveys in HIV/AIDS clinics in New York City. COLUMBIA SOCIAL WORK REVIEW, VOL. VIII | 3 This study will use cross-sectional methodologies to provide a comprehensive picture of the present environment. Our data analysis will include 300 participants: 100 Caucasian, 100 Black, and 100 Latino. Examining three different groups allows us to see any patterns that exist within the groups as well as compare any that emerge. DATA COLLECTION METHODS AND MEASURES The survey will be offered at clinic check-in to all patients, not just the target population to provide additional privacy, during routine visits. Patients will be given a voluntary informed consent form to read and sign. Both the survey and consent form will be subject to Institutional Review Board approval. Patients who voluntarily complete the survey will be offered consultation services by a social worker with IPV and HIV/AIDS expertise. Sociodemographic and clinical variables including age at IPV screen, location of original diagnosis, self-reported ethnicity, income level, living arrangements, housing, and history of incarceration will be recorded at the initial visit and updated as appropriate. Sections of the standard IPV screening tool WAST (Woman Abuse Screening Tool, see Appendix I) will be adapted for the survey. The WAST is a series of eight questions that screens for emotional, physical, and financial abuse. A screening tool developed in 2013 for gay and bisexual men (see Appendix II) will also be incorporated into the survey, however whether it has ever been implemented widely is unknown (Stephenson, Hall, Williams, Sato, & Finneran, 2013). We will analyze the data per the criteria laid out in our sampling methods, based on how the participants self-identify on the survey. The data collection will take one to two years and require six participating HIV/AIDS clinics. Clinics will be recruited by invitation. We will analyze IPV in same-sex relationships among individuals living with HIV/AIDS via univariate, bivariate, and multivariate statistical procedures and compare it to data for those living without HIV/AIDS. First, we will conduct descriptive analyses to produce the profile of the 300 participants in the study sample. Second, we will use bivariate analyses to examine HIV/AIDS status and IPV among the participants. Third, we will employ multivariate analyses to identify factors associated with IPV among same-sex couples with HIV/AIDS. TABLE 1 – MEASURE OF VARIABLES Independent Variables Measures Socio-Demographics & History of Participant Gender Identity Female = 0; Male = 1 ; Non-binary = 2 Age Age of person Income Level Tiered levels of income 0-10,000 = 0; 10,000-30,000 = 1; 30,000-50,000 = 2; 50,000-75,000 = 3; 75,000-100,000 = 4; 100,000-250,000 =5; 250,000+ = 6 Ethnicity White/Caucasian = 0; African Amer- ican/Black = 1; Hispanic/Latino = 2; Asian Pacific Islander = 3; Other = 4 Sexual Preference Female = 0; Male = 1; Either = 2; Other = 3 Receiving public assistance No = 0; Yes = 1 Living arrangement Alone = 1; Cohabitating with partner or others = 2 Housing Homeless = 0; Supported Temporarily= 1; Stable = 2 History of Incarceration No = 0; Yes = 1 History of Childhood Abuse No = 0; Yes = 1 Frequency of Social Calls (support) In a month: Never = 0; Rarely = 1; Sometimes = 2; Often = 3; Frequently; 4; Everyday = 5 4 | COLUMBIA SOCIAL WORK REVIEW, VOL. VIII Mental and Physical Health HIV/AIDS Diagnosis No = 0; Yes = 1 Location of Original Diagnosis Variable Depression prior to HIV diagnosis No = 0; Yes = 1 HIV psychiatry appointment in past year? No = 0; Yes = 1 Psychiatry appointment ever? No = 0; Yes = 1 Other mental health diagnosis No = 0; Yes = 1 Substance Use Alcohol Use Never = 0; Rarely = 1; Infrequently = 2; Sometimes = 3; Often = 4; Almost day = 5; Everyday = 6 Illicit Substance Use (including mar- ijuana in locations where it has been legalized) No = 0; Yes = 1 Smoker Current = 0; Former = 1; Never = 2 Socio-Demographics of Participant’s Partner Sex Female = 0; Male = 1 Age Variable Income Level Tiered levels of income 0-10,000 = 0; 10,000-30,000 = 1; 30,000-50,000 = 2; 50,000-75,000 = 3; 75,000-100,000 = 4; 100,000-250,000 =5; 250,000+ = 6 Ethnicity White/Caucasian = 0; African-Amer- ican/Black = 1; Hispanic/Latino = 2; Asian Pacific Islander = 3; Other = 4 Living arrangement Alone = 1; Cohabitating with participant = 2 Illicit Substance Use No = 0; Yes = 1 Alcohol Use No = 0; Light Drinker = 1; Moderate Drinker = 2; Heavy Drinker = 3 Frequency of Social Calls In a month: Never = 0; Rarely = 1; Sometimes = 2; Often = 3; Frequently; 4; Everyday = 5 Dependent Variables Measures Intimate Partner Violence *”Yes” or “No” responses were collected. Relationship (IPV experienced within)* only current = 0; only previous = 1; both current and previous = 2 COLUMBIA SOCIAL WORK REVIEW, VOL. VIII | 5 Type of abuse* Emotional = 0; Physical = 1; Sexual = 2; Intimidation (using HIV) = 3; Financial = 4; Isolation = 5; Neglect = 6 Number of Abuse Types Experienced * One = 0; Two = 1; Three = 2; Four = 3; Five = 4; Six = 5; Seven = 6 DISCUSSION & CONCLUSION Several limitations of this study should be taken into consideration. First, using a cross-sectional method will not allow us to determine causality (Balsam & Szymanski, 2005; Houston & McKiernan, 2007). Because our participants will be actively engaged in services through HIV/AIDS clinics, the study sample cannot be considered representative of the entire population of interest, as one of the hallmarks of IPV is isolation from and lack of engagement in services (Herman, 2015). This study is limited to a single same-sex population in New York City, so the gay male population in rural areas and in other cities will be neglected, in addition to the rest of the LGBTQ community. Additionally, we will look at three generalized racial groups in our study. Other groups and associated communities may show results that differ from those of the groups included in this study. Expanding the scope of the study to include other sexual orientations, identities, or HIV negative couples would add additional insight into the impact of fixed variables on overall IPV. Future potential studies should address these concerns and issues of IPV. There are technical limitations to this study in that there is not a well-established and researched measure for IPV in the LGBTQ communitiy, much less one that takes into account the intersectional nature of human experience. For example, the standard eight-question WAST tool that is used to rapidly assess whether someone is in an abusive relationship is woman centered (Herman, 2015). In addition, many of the studies treat the LGBTQ community as one homogenous group, and sometimes assume that what is applicable for one subset of the population applies to another and not as a diverse population. Individuals in the LBGTQ communities already experience oppression and discrimination in their day-to-day lives (Harper & Schneider, 2003). The lack of services tailored to the unique needs of the survivors of abuse in same-sex couples with HIV/AIDS is a further injustice. Professionals – including social workers, clinicians, and physicians – should be educated about the specific needs of the different populations they serve to provide or advocate for the appropriate resources. Due to the stigmas attached to being gay, having HIV/AIDS status, or being an IPV survivor, clients who have experienced IPV are likely to be reluctant to disclose experiences of abuse (Carvalho et al., 2011; National Sexual Violence Resource Center, 2008). Professionals would benefit from an understanding of the unique factors of IPV in same-sex couples while conducting assessments and interventions so they can design strategies for this population. REFERENCES Balsam, K. F., & Szymanski, D. M. (2005). Relationship quality and domestic violence in women’s same-sex relationships: the role of minority stress. Psychology of Women Quarterly, 29(3), 258-269. doi:10.1111/j.1471-6402.2005.00220.x Brown JB, Lent B, Brett PJ, Sas G, Pederson LL. woman abuse screening tool for use in family practice. Fam Med 1996; 28(6): 422–428. Carvalho, F.A, Lewis, J. R, Derlega, J. V, Winstead, A. B, & Viggiano, C. (2011). Internalized sexual minority stressors and same-sex intimate partner violence. 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NISVS: An overview of 2010 findings on victimization by sexual orientation. Retrieved October 24, 2016, from http://www.cdc.gov/violenceprevention/pdf/cdc_nisvs_victimization_final-a.pdf Waterman, C. K., Dawson, L. J., & Bologna, M. J. (1989). Sexual coercion in gay male and lesbian relationships - predictors and implications for support services. The Journal of Sex Research, 26(1), 118-124. 2015 Report on lesbian, gay, bisexual, transgender, queer, and HIV-affected intimate partner violence - AVP: the anti-violence project. (2015). Retrieved October 14, 2016, from http://avp.org/resources/avp-resources/554 SAMUEL GILBERT Samuel Gilbert is a Columbia University student from Minnesota. As an openly gay man from rural Minnesota, he learned first-hand what it feels like to be oppressed and disenfranchised. This ostracizing feeling fueled his passion to help others like him. In his undergraduate career at St. Cloud State University, he studied applied sociology. Sociology helped him continue to develop his passions for social justice. Samuel began working with the LGBTQ+ community on campus, the intimate partner violence campus program, and undocumented immigrants in the surrounding area. In the future, his goal is to continue doing research that focuses on the intersection between LGBTQ+ relationships and intimate partner violence. JASON FREEMAN Jincong Q. Freeman (Jason) received his Bachelor’s degree in Economics from the University of Minnesota-Twin Cities in 2014. He is currently a first- year graduate student at Columbia University School of Social Work. He focuses on Advanced Clinical Practice with the field of practice in Health, Mental health, and Disabilities. Jason interns at Selfhelp Community Services, where he works with senior adults in applying government benefits. He is also a research assistant for Dr. Elwin Wu at Social Intervention Group, where he studies HIV prevention and intervention among Black/ African American men who have sex with men. Jason expects to graduate in May 2018 and plans to apply for Ph.D. programs after graduation, so he can continue to pursue research in population health and HIV/AIDS prevention intervention related topics. AVIVA RASKIN Aviva F. B. Raskin received her Bachelor’s degree in Linguistics from Reed College in 2009. She is a dual- degree MSW/MPH candidate at Columbia’s Mailman School of Public Health and School of Social Work. She conducted original research for her B.A. on Japanese Women’s Language. This lead her to investigate IPV in Japanese society. Her interest in HIV/AIDS came from growing-up in the Bay Area in the early 1990s where she watched her favorite teacher pass away from AIDS. Prior to graduate school Aviva volunteered in DV shelters as a peer/community advocate, worked on DV hotlines, and as a CASA. Aviva is currently working with Dr. Elwin Wu on HIV prevention and intervention among Black/ African American men who have sex with men. DARWIN RODRIGUEZ Darwin earned a BA in International Business (2005) and a MS in International Management (2013), but his passion for helping people led him to transition into Social Work. He is currently a first-year student at Columbia School of Social Work (CSSW). However, his involvement with social justice started in his native Venezuela at the age of nine when he was a UNICEF ambassador for his community. He is concentrating in advanced clinical practice and is interested in counseling survivors of trauma within the LGBTQIA community. Darwin is currently working at Year Up (New York City) where he contributes to a program aspiring to empower low-income young adults to go from poverty to professional careers. APPENDIX I Woman Abuse Screening Tool (WAST) COLUMBIA SOCIAL WORK REVIEW, VOL. VIII | 7 1 In general, how would you describe your relationship? a lot of tension, some tension, none 2 Do you and your partner work out arguments with great difficulty, some difficulty, or no difficulty? often, never, sometimes 3 Do arguments ever result in you feeling down or bad about yourself ? often, never, sometimes 4 Do arguments ever result in hitting, kicking, or push- ing? often, never, sometimes 5 Do you ever feel frightened by what your partner says or does? often, never, sometimes 6 Has your partner ever abused you physically? often, never, sometimes 7 Has your partner ever abused you emotionally? often, never, sometimes 8 Has your partner ever abused you sexually? yes, no Rabin, R. F., Jennings, J. M., Campbell, J. C., & Bair-Merritt, M. H. (2009). Intimate partner violence screening tools. 36(5). APPENDIX II Screening Tool for Gay and Bisexual Men 1 Have arguments in your relationship escalated into any of the following: destruction of property, grabbing, restraining, pushing, kicking, slapping, punching, threats of violence or other acts of physical intimidation? yes, no 2 Has your partner pressured or forced you to do something sexual that you didn’t want to do? Examples may include any of the following: oral or anal sex, having sex with others, having sexual partners outside the relationship, or any other sexual activity that made you feel uncomfortable. yes, no 3 Has your partner pressured you to have sex without a condom after you asked to use a condom? Or do you suspect that your partner has lied to you about their HIV status, or intentionally tried to transmit HIV to you? yes, no 4 Has your partner insulted, criticized, threatened or yelled at you in any way? Examples may include the following: using slurs, calling you names, calling you fat, criticizing your sexual performance, criticizing your clothing, asking you to act more masculine or threatening to out you yes, no 5 Has your partner prevented you from communicating with or seeing your friends/family/coworkers? Or monitored or demanded access to your cell phone, email, social networking sites, finances or spending? yes, no 6 Have you ever felt afraid, threatened, isolated, trapped or like you were walking on eggshells within your relationship? Or have your friends or family raised concerns about your safety within your rela- tionship? yes, no Stephenson, R., Hall, C., Williams, W., Sato, K., & Finneran, C. (2013). Towards the development of an intimate partner violence screening tool for gay and bisexual men. Western Journal of Emergency Medicine, 14(4), 391-401. doi:10.5811/westjem.3.2013.15.