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. Author manuscript; available in PMC: 2023 Aug 1.
Published in final edited form as: J Interpers Violence. 2022 Jun 2;38(3-4):3321–3343. doi: 10.1177/08862605221106145

Psychosocial Risk Pathways from Childhood Sexual Abuse to Intimate Partner Violence among Sexual Minority Men: A Test of the Psychological Mediation Framework of Minority Stress

Danielle S Berke 1,2, Raymond L Moody 2, Christian Grov 3, H Jonathon Rendina 1,2
PMCID: PMC9841749  NIHMSID: NIHMS1856289  PMID: 35652430

Abstract

Although sexual minority men experience elevated rates of childhood sexual abuse (CSA) and equal or greater rates of intimate partner violence (IPV) victimization compared to heterosexual individuals, little research has examined mechanisms linking these forms of victimization in this high-need population. We examined general (i.e., emotion regulation difficulties) and sexual minority specific (i.e., internalized homophobia) mediational pathways between CSA and IPV victimization in a longitudinal sample of 940 sexual minority men. Path analyses revealed significant associations between CSA and internalized homophobia, between internalized homophobia and emotion regulation difficulties, and between emotion regulation difficulties and IPV victimization. No indirect effects of CSA on IPV via general or minority specific pathways were observed. Findings suggest that minority stress specific (i.e., internalized homophobia) and general psychological risk factors (i.e., emotion regulation difficulties) co-occur and may function along independent pathways to link CSA to IPV revictimization. Future work is needed to investigate how mitigation of these modifiable pathways may be targeted to inform violence prevention interventions for sexual minority men.

Keywords: sexual minority men, childhood sexual abuse, internalized homophobia, intimate partner violence, emotion regulation, minority stress

Childhood sexual abuse (CSA), defined as any completed or attempted sexual act, sexual contact with, or exploitation (i.e., noncontact sexual interaction) of a child (Leeb et al., 2008) is a widespread public health problem in the United States. Evidence suggests that sexual minority men experience higher CSA rates than the general male population (Institute of Medicine, 2011; Roberts et al., 2012). In a national epidemiologic survey, bisexual men and gay men had 12.8 and 9.5 times-odds (respectively) of CSA compared to with heterosexual men (Sweet & Welles, 2012). Given the wide range of adverse physical, psychological, and interpersonal consequences associated with CSA demonstrated in both the general population (Amado et al., 2015; Maniglio, 2010) and among sexual minority men (Brennan et al., 2007; Kalichman et al., 2004; Lloyd & Operario, 2012), elucidating and intervening to address the downstream consequences of CSA among sexual minority men is a public health imperative.

One serious potential consequence of early victimization is later exposure to intimate partner violence (IPV). IPV itself is a heterogenous construct which may encompass physical, psychological, and sexual abuse by an individual toward a current or former romantic or sexual partner (Niolon et al., 2017). Numerous studies among presumably heterosexual CSA survivors document a relationship between CSA and increased risk for victimization in adult relationships (for reviews, see Capaldi et al., 2012; Scoglio et al., 2019). A growing body of literature among sexual minority individuals has revealed associations between CSA exposure and physical, sexual, and psychological IPV victimization risk that parallel findings established among heterosexual samples ((Langenderfer-Magruder et al., 2015) Martin-Storey, 2015; Martin-Storey & Fromme, 2017; (Welles et al., 2011)).

Research suggests that the consequences of IPV victimization may be more severe for sexual minority victims compared to their heterosexual counter-parts. IPV victims in same-sex couples have been shown to face greater risk of physical injury due to IPV than heterosexual victims (Graham et al., 2019), are at greater risk of contracting a sexually transmitted infection, including HIV, when involved in an abusive relationship (Beymer et al., 2017), and may more frequently suffer mental health consequences (e.g., anxiety and depression) of IPV (Edwards et al., 2015; Reuter et al., 2017), even when controlling for other sociodemographic variables (Miller & Irvin, 2017). To interrupt these disparities in health outcomes for sexual minority men, empirical research must move beyond testing whether CSA confers risk for IPV victimization and documenting disparity in this high-need population, to identifying mechanisms of risk that may be targeted in intervention and prevention programming.

Research on mechanisms of sexual minority health disparities has largely been guided by two theoretical models: (1) the Minority Stress Model (Meyers, 2003) states that physical, interpersonal, and behavioral health disparities among stigmatized populations emerge through a host of unique (i.e., not experienced by nonstigmatized populations) inter- and intrapersonal mechanisms; and (2) Hatzenbuehler’s (2009) Psychological Mediation Framework extends the Minority Stress Model by suggesting that enacted stigma (i.e., distal minority stress) may give rise to population-level health disparities, not only through elevations in mechanisms of health risk unique to a stigmatized group, but also through their deleterious impact on general psychological coping. Despite the influence of these theories on health disparity research, their empirical application to understanding psychosocial risk pathways from CSA to IPV among sexual minority men has been limited.

The current study aimed to fill this gap by testing a multiple mediation model of IPV victimization in a large sample of sexual minority men. Specifically, we focus on internalized homophobia and emotion regulation difficulties as key psychosocial risk pathways. Internalized homophobia is defined as the internalization of societal negative regard of sexual minority identity into one’s own values and self-perception (Meyer & Dean, 1998). This construct is specified in Meyer’s (2003) Minority Stress Model as a group-specific proximal stressor (i.e., an endogenous psychological consequence of distal stress experiences) which may explain or account for the relation between exogenous stressors (e.g., discrimination, violence, CSA) and disparities in behavioral health outcomes among stigmatized groups (Hatzenbuehler, 2009; Meyer, 2003). Internalized homophobia has been associated with IPV victimization in numerous samples of sexual minority groups (e.g., lesbian and bisexual women; Balsam & Szymanski, 2005; LGBTQ youth; Edwards et al., 2015; sexual minority men; Stephenson & Finneran, 2017).

Emotion regulation is a multidimensional, general psychological coping process that involves awareness, understanding, and acceptance of emotional states; the ability to control behaviors when experiencing distress; and the ability to use contextually appropriate emotion regulation strategies to flexibly modulate emotions (Gratz & Roemer, 2004). Independent lines of empirical research have demonstrated associations between (1) exposure to CSA and emotion regulation difficulties in the general population (e.g., Cloitre et al., 2005; D’Andrea, et al., 2012); (2) exposure to discrimination/enacted minority stigma and emotion regulation difficulties among sexual minority adults (Hatzenbuehler, 2009; Pachankis, Redina, et al., 2015; Rogers et al., 2017) and; (3) emotion regulation difficulties and IPV victimization risk in the general population (Berzenski & Yates, 2010; Gratz et al., 2009). Emotion regulation difficulties have also been shown to predict sexual revictimization among college women survivors of CSA (Messman-Moore et al., 2010). However, we know of no existing studies that simultaneously assess the unique contributions of emotionregulation difficulties and internalized homophobia on associations between CSA and IPV victimization.

Current Study and Hypotheses

The current study leverages the One Thousand Strong cohort, a longitudinal study cohort of sexual minority men (see Methods), to test a psychological mediation minority stress model of IPV victimization. We hypothesized that we would replicate previous research identifying a positive temporal association between CSA and IPV victimization (Hypothesis 1). Consistent with Hatzenbueler’s Psychological Mediation Framework (2009), we also hypothesized that this association would be mediated by general and group-specific risk factors such that longitudinal associations between CSA and IPV victimization would emerge via internalized homophobia (Hypothesis 2) and emotion regulation difficulties (Hypothesis 3). Given the lack of studies in this area, a priori hypotheses about pathways to IPV revictimization via specific emotion regulation difficulties were not advanced, and instead were deemed exploratory

Method

Data analyzed were derived from One Thousand Strong, a longitudinal study of a cohort of HIV-negative sexual minority men from across the United States. The primary goal of the One Thousand Strong cohort was to examine risk and resilience factors associated with HIV transmission risk. As such, sexual minority men reported on experiences of victimization and psychosocial stressors including internalized homophobia and emotion regulation difficulties. The college’s Institutional Review Board approved all study procedures.

Participants and Procedures

We have previously published a more detailed description of recruitment and enrollment efforts for the One Thousand Strong cohort ((Grov et al., 2015)). In brief, we identified participants through a panel of LGBT-individuals provided by a marketing firm, Community Marketing and Insights. Community Marketing and Insights draw their panelists from a variety of LGBT-specific and non-LGBT specific sources; approximately 50% of their panel is drawn from LGBT-specific sources. Participants were targeted based on matched estimates of the distribution of same-sex couples across the United States. Community Marketing and Insights identified participants deemed to be preliminarily eligible and shared information of these individuals with our research team, who independently reached out to these participants to verify eligibility, enroll, and follow them longitudinally from 2014 to 2017.

Criteria for eligibility were (a) reside in the United States, (b) be assigned male sex at birth, (c) identify as male, (d) identify as gay or bisexual, (e) report having sex with a man in the past year, (f) self-identify as HIV-negative, (g) be willing to complete an at-home self-administered rapid HIV antibody test, (h) be willing to complete self-administered testing for urethral and rectal chlamydia/gonorrhea, (i) be able to complete assessments in English, (j) have access to the internet to complete at-home online assessments, (k) have access to a device that was capable of taking a digital photo, (l) have an address to receive mail that was not a P.O. Box, and (m) report residential stability (i.e., had not moved twice in previous 6 months). We excluded participants if they tested HIV-positive on the rapid HIV antibody test. Of the 1375 eligible men, 1071 (77.9%) completed all of the baseline assessment requirements and were enrolled.

Eligible participants were contacted for reassessment at 12-month, 24-month, and 36-months after completing baseline assessments. At each assessment, participants completed at-home online surveys via Qualtrics that contained the measures used in the present analyses. The average time for completion of the baseline assessment was 78 minutes and participants were compensated $25 for the completion of each survey. Of the 1071 men enrolled in baseline, 1017 completed the 12-month assessment, 985 (92%) completed the 24-month assessment and 966 (90.2%) completed the 36-month assessment. In total, 940 participants (87.8%) provided complete data at all examined time points and were included in the analyses for this paper. Of note, participants who were excluded from analyses for non-completion tended to have lower education and lower income.

At baseline, the average age of the sample was 40.23 (SD = 13.67, range 18–79). Overall, a majority of participants identified as White, non-Hispanic (70.8%) and gay (95.3%). Most reported having a 4-year college degree or more (58.3%), having full-time employment (67.8%), and earning an annual income more than $50,000 (47.8%). A small majority of participants reported being partnered at the 24-month (52.2%) and 36-month assessment (53.3%).

Measures

Childhood sexual abuse.

CSA was operationalized using pre-established criteria derived through iterative field testing in a large-scale probability-based sample of sexual minority men (Paul et al., 2001). Criteria consisted of two questions asking if the participant: (a) had experienced sexual activity in which they felt forced or scared into having sex with someone who was older than them and (b) were age 16 or younger at the time. Participants who indicated they had been forced or scared into having sex with someone who was older than them prior to the age of 17 were considered to have experienced childhood sexual abuse (0 = No, 1 = Yes). Previous research supports the predictive validity of these CSA criteria; this measure of CSA has been associated with depression, sexual compulsivity, substance use, and sexual risk behavior in samples of sexual minority men (Parsons et al., 2012, 2017).

Internalized homophobia.

The Internalized Homophobia Scale (IHS, Martin & Dean, 1988) is a 9-item scale that measures the internalization of gay-related stigma (e.g., I feel that being gay/bisexual is a personal short-coming for me; I have tried to stop being attracted to men in general). Participants responded to each of the nine items using a Likert-type scale ranging from 1 (Strongly Disagree) to 4 (Strongly Agree) and these items were averaged with higher scores indicating greater internalized homophobia (α = .883).

Emotion regulation difficulties.

The Difficulties with Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) is a 36-item scale measuring difficulties with emotion regulation and includes six subscales: (1) Clarity (i.e., extent to which individuals know the emotions they are experiencing); (2) Nonacceptance (i.e., lack of acceptance of emotions); (3) Goals (i.e., an inability to engage in goal-directed behavior when distressed); (4) Impulse (i.e., impulse control difficulties when experiencing negative affect); (5) Awareness (i.e., difficulties attending to ongoing emotional experiences); and (6) Strategies (i.e., limited access to strategies for effective regulation of emotions). Participants rated each item using a Likert-type scale ranging from 1 (Almost never) to 5 (Almost always). Higher scores indicate greater difficulties in emotion regulation. The DERS has demonstrated adequate convergent validity with established measures of emotionregulation difficulties and emotional avoidance, has been associated of IPV in an undergraduate sample (Gratz & Roemer, 2004), and has been previously used in samples of sexual minority men (Pachankis, Rendina et al., 2015). Cronbach’s alphas across subscales in the present sample ranged from .827 (Clarity) to .927 (Nonacceptance).

Intimate Partner Violence.

An adaptation of the Revised Conflict Tactics Scale (Straus, et al., 1996) was used to assess IPV victimization. Consistent with prior research (Greenwood et al., 2002), the introduction and measure items were modified to be culturally specific to sexual minority men. Participants were asked to report how many times in the previous 12-months they experienced each form of IPV assessed with a boyfriend or partner. In total, 12 different forms of IPV were assessed, including six physical violence items (hit with fist or open hand; throwing something; pushed or shoved; forced to get drunk or high; kicked; hit with object), five items assessing psychological violence (verbally threatened; verbally demeaned in front of others; made fun of appearance; damaged or destroyed property; stalked), and one sexual violence item (e.g., forced to have sex). We created an overall IPV victimization frequency variable by summing the number of times the participant experienced each of the 12 different forms of IPV victimization. This variable was treated as a count outcome in our analyses to capture the chronicity of IPV victimization in this sample. The validity of counting acts of IPV victimization as an indicator of this outcome is well-supported by previous research (Straus & Douglas, 2017).

Analytic Plan

First, we examined each of our continuous variables for normality and determined that the distribution of internalized homophobia was positively skewed. As such, we log-transformed this variable before standardizing the distribution of our continuous variables. We calculated descriptive statistics and bivariate correlations in SPSS (version 25). Chi-square difference tests were calculated comparing CSA and IPV at baseline and 36 months.

Primary analyses entailed calculating a zero-inflated Poisson multiple mediation path model using Mplus (8.0). Zero-inflated Poisson modeling is appropriate when the dependent variable is a count variable with a large proportion of zero values. As our measure of IPV was administered to all participants at each timepoint, regardless of relationship status, we assumed an excess of zero values. Participants who were not in a relationship within the time period assessed were expected to always report zero instances of IPV; participants in a relationship who did not experience IPV within the time period assessed would also report zero. Zero-inflated Poisson regression differentiates these distinct population distributions into two components: a logit distribution component, which models the “true zeros” (the zero-inflation), and a Poisson distribution component, which models the count data (i.e., the number of IPV events that occurred during the assessed interval). We report results of the count component of the model which yields a regression coefficient in log odds (Atkins & Gallop, 2007).

In our model (Figure 1), IPV victimization at 36 months was regressed on CSA (assessed at baseline), internalized homophobia (assessed at 24 months), and each emotion regulation difficulties subscale (each assessed at 24 months). Indirect effects were estimated for the effect of CSA on IPV at 36 months via internalized homophobia and each of the emotion regulation difficulties subscales. The model used maximum likelihood estimation with robust standard errors adjusted for age, baseline IPV, and 24-month and 36-month relationship status. This analytic plan allowed for a test of systematic changes in instances of IPV victimization as a function of emotion regulation difficulties, internalized homophobia, and the indirect effects of CSA through these psychosocial risk processes.

Figure 1.

Figure 1.

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Conceptual diagram. Note. Not depicted in the conceptual model but a part of the statistical model are age, baseline IPV, 24-month relationship status, and 36-month relationship status which were included in the analysis to statistically adjust for their potential confounding influences on the paths in the model.

Results

Preliminary Analyses

Table 1 presents means, standard deviations, and bivariate correlations for each of the variables we used in the path analyses. At the bivariate level, CSA was positively associated with internalized homophobia assessed at 24 months (r = 0.07, p = .024) but was not associated with any of the emotion regulation difficulties subscales assessed at 24 months or with IPV assessed at 36 months (rho = 0.03, p = .356). However, CSA was positively associated with IPV assessed at baseline (rho = 0.10, p = .002). Internalized homophobia at 24 months was positively associated with all emotion regulation difficulties subscales assessed at 24 months (r = 0.21–0.35, p < .001) and IPV assessed at 36 months (rho= 0.07, p = .047). The emotion regulation difficulties subscales at 24 months and IPV assessed at 36 months were also positively correlated and all reached statistical significance (rho = 0.13–0.20, p < .001) with the exception of the Awareness subscale (rho = 0.06, p = .066).

Table 1.

Correlation Coefficients, Means, and Standard Deviations Among Key Variables.

1 2 3 4 5 6 7 8 9 10 11
1. CSA (baseline)
2. Internalized homophobia (24-month) 0.07* —
3. Nonacceptance (24-month) 0.05 0.32** —
4. Goals (24-month) 0.00 0.24** 0.60** —
5. Impulses (24-month) 0.05 0.31** 0.63** 0.64** —
6. Awareness (24-month) −0.01 0.21** 0.21** 0.15** 0.28** —
7. Strategies (24-month) 0.02 0.35** 0.72** 0.74** 0.74** 0.32** —
8. Clarity (24-month) 0.02 0.30** 0.52** 0.49** 0.59** 0.62** 0.63** —
9. IPV (36-month) 0.03 0.07* 0.20** 0.13** 0.17** 0.06 0.14** 0.14** —
10. IPV (baseline) 0.10** 0.11** 0.16** 0.15** 0.16** 0.01 0.15** 0.12** 0.26** —
11. Age 0.01 −0.11** −0.13** −0.19** −0.17** −0.04 −0.18** −0.19** −0.03 −0.18** —
Mean 0.20 1.38 11.23 11.43 9.81 14.02 15.06 9.90 1.56 5.53 40.27
Standard deviation 0.40 0.62 5.51 4.29 4.33 5.23 6.51 3.83 11.15 17.55 13.66
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Note. CSA = childhood sexual abuse; IPV = intimate partner violence victimization.

*

p < 0.05.

**

p < 0.01.

Table 2 presents means, standard deviations, and between group comparisons on experiences of CSA and IPV victimization. Participants who experienced CSA were 1.62 times more likely to report any IPV assessed at baseline compared to participants who did not experience CSA, χ2 (1, N = 940) = 8.48, p = .004. No differences were observed between participants who experienced CSA and those who did not in terms of experiencing any IPV assessed at 36 months, χ2 (1, N = 929) = 0.96, p = .329. Participants who reported any IPV at baseline were more 3.94 times more likely to report any IPV at 36 months compared to those who did not report any IPVat baseline, χ2 (1, N = 929) = 46.26, p < .001.

Table 2.

Descriptive Statistics by CSA and IPV.

CSA IPV (36-month)
No Yes No Yes
79.89% (n = 751) 20.11% (n = 189) 88.83% (n = 819) 11.93% (n = 110)
χ2 OR χ2 OR
IPV (baseline) - No 67.38% (n = 506) 56.08% (n = 106) 8.48** 1.62 69.23% (n = 567) 36.36% (n = 40) 46.26** 3.94
IPV (baseline) - yes 32.62% (n = 245) 43.92% (n = 83) 30.77% (n = 252) 63.64% (n = 70)
 IPV (36-month) - No 87.62% (n = 658) 85.19% (n = 161) 0.96 1.27 — —
 IPV (36-month) - yes 11.19% (n = 84) 13.76% (n = 26) — —
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Note. CSA = childhood sexual abuse; IPV = intimate partner violence victimization; OR = odds ratio.

*

p < 0.05.

**

p < 0.01.

Primary Analyses

Results of our zero-inflated Poisson multiple mediation path model are presented in Table 3. In the Poisson component of the model, CSA was positively associated with internalized homophobia at 24 months (β = 0.08, p = .025) but was not significantly associated with any of the emotion regulation subscales at 24 months. Path analyses also revealed significant covariance between internalized homophobia at 24 months and the Nonacceptance (β = 0.13, p < .01), Awareness (β = 0.09, p < .05), and Strategies (β = 0.16, p < .05) emotion regulation subscales assessed at the same timepoint.

Table 3.

Model Coefficients.

Standardized
B SE 95% Cl ARR
Direct effects on mediators
 CSA →nonacceptance 0.05 0.04 −0.02 0.12
 CSA → goals 0.00 0.03 −0.06 0.06
 CSA → impulse 0.05 0.03 −0.02 0.11
 CSA → awareness −0.01 0.03 −0.07 0.05
 CSA → strategies 0.02 0.03 −0.04 0.08
 CSA → clarity 0.02 0.03 −0.04 0.08
 CSA → internalized homophobia 0.08 0.04* 0.01 0.15
Direct effects on IPV
 CSA → IPV 0.06 0.22 −0.36 0.49 1.07
 IPV Events (baseline)→IPV 0.28 0.10** 0.09 0.47 1.32
 Nonacceptance → IPV 0.03 0.19 −0.35 0.41 1.03
 Goals → IPV 0.41 0.15* 0.11 0.71 1.51
 Impulse → IPV 0.28 0.16 −0.04 0.60 1.32
 Awareness → IPV 0.54 0.15* 0.25 0.83 1.72
 Strategies → IPV −0.22 0.19 −0.59 0.15 0.80
 Clarity → IPV −0.52 0.16* −0.83 −0.21 0.60
 Internalized homophobia → IPV 0.07 0.13 −0.20 0.33 1.07
Covariance between mediators
 Internalized homophobia →nonacceptance 0.13 0.05** 0.03 0.23
 Internalized homophobia →goals −0.04 0.05 −0.13 0.05
 Internalized homophobia →impulse 0.09 0.07 −0.04 0.21
 Internalized homophobia →awareness 0.09 0.05* 0.00 0.18
 Internalized homophobia →strategies 0.16 0.06* 0.03 0.28
 Internalized homophobia →clarity 0.04 0.05 −0.06 0.14
Indirect effects on IPV through mediators
 CSA →nonacceptance → IPV 0.00 0.01 −0.02 0.02 1.00
 CSA → goals → IPV 0.00 0.01 −0.02 0.03 1.00
 CSA → impulse → IPV 0.01 0.01 −0.01 0.04 1.01
 CSA → awareness → IPV −0.01 0.02 −0.04 0.03 1.00
 CSA → strategies → IPV 0.00 0.01 −0.02 0.01 1.00
 CSA → clarity → IPV −0.01 0.02 −0.05 0.02 0.99
 CSA → internalized homophobia → IPV 0.01 0.01 −0.02 0.03 1.01
AIC 38247.59
BIC 38606.19
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Note. CSA = childhood sexual abuse; IPV = intimate partner violence victimization; All paths were adjusted for age, 24-month relationship status, and 36-month relationship status.

*

p ≤ .05

**

p ≤ .01.

For the significant effects of our prospective predictors on IPV victimization at 36 months, adjusted risk ratios (ARR) were obtained by exponentiating the standardized Poisson regression coefficients. CSA and 24-month internalized homophobia were not significantly associated with IPV victimization at 36 months. IPV victimization at baseline was positively associated with IPV victimization at 36 months (β = 0.28, p < .001, ARR = 1.32). For each act of IPV at baseline, the expected number of acts of IPV victimization at 36 months increased by 32%. Similarly, the Goals (β = 0.41, p = .017, ARR = 1.51), Awareness (β = 0.54, p = .027, ARR =1.72), and Clarity (β = −0.52, p = .015, ARR = 0.60) emotion regulation difficulties subscales assessed at 24-months were each associated with IPV victimization at 36 months. With each standard deviation increase in emotion regulation difficulties Goals and Awareness subscales at 24 months the expected number of acts of IPV victimization at 36 months increased by 51% and 72%, respectively. With each standard deviation increase in the Clarity emotion regulation difficulties subscale at 24 months the expected number of acts of IPV victimization at 36 months decreased by 40%. None of the indirect effects of CSA on IPV victimization via assessed emotion regulation difficulties subscales or internalized homophobia at 36 months were significant.

Discussion

To our knowledge this study is the first to test an application of Hatzenbuehler’s (2009) Psychological Mediation Framework of Minority Stress to IPV victimization among sexual minority men. Longitudinal mediation analyses revealed significant associations between CSA and internalized homophobia, between internalized homophobia and emotion regulation difficulties, and between emotion regulation difficulties and IPV victimization. However, no indirect temporal effects of CSA on IPV via these psychosocial risk pathways were observed.

We hypothesized that we would replicate previous research identifying a positive association between CSA and IPV victimization. Consistent with this hypothesis, our results demonstrate that participants who experienced CSA were 1.62 times more likely to report any IPV victimization in our baseline assessment compared to participants who did not experience CSA. These findings add to the limited but growing literature on the victimization experiences of sexual minority men. To date, studies specifically examining pathways linking CSA to IPV have been predominated by investigations of heterosexual women as victims and/or heterosexual men as perpetrators (Desai, et al., 2002; Scoglio et al., 2019). Of note, the effect size of the association between CSA and IPV victimization in this sample of sexual minority men is somewhat smaller than that reflected in samples of presumably heterosexual women (e.g., Engstrom et al., 2008: OR = 3.01). These differences may reflect the role of gender norms and the complexities of self-identifying as a victim in CSA assessment (Boroughs et al., 2015). As CSA victimization is often stigmatized, self-identifying as a victim can be challenging, particularly for men (Vaillancourt-Morel et al., 2016).

Results of multiple mediation analyses also revealed unique temporal associations between CSA and internalized homophobia. Specifically, sexual minority men who reported a history of CSA, prospectively endorsed significantly higher levels of internalized homophobia than those whose early life experiences did not include this form of abuse. Although similar bivariate associations have been reported previously (e.g., McGeough & Sterzing, 2018), the emergence of this significant association in a multiple mediation framework is novel. Our findings indicate the presence of a unique risk pathway from CSA to internalized homophobia, distinct from the consequences of CSA on emotion regulation difficulties and from the shared associations between emotion regulation difficulties and internalized homophobia.

These findings have important clinical implications. Negative beliefs about the self and self-blame are common reactions among CSA survivors (Ullman & Filipas, 2005). Further, self-blaming or other inaccurate causal attributions about CSA may functionally overlap with distorted beliefs about sexual minority identity (e.g., “If I weren’t gay this wouldn’t have happened to me.” “I am gay because of the abuse.”). Negative stereotypes about sexual minority men (e.g., “Gay men are promiscuous.”) may also mirror and reinforce these self-blame attributions, suggesting the potential for numerous cognitive pathways linking CSA to internalized homophobia. Findings from this study suggest a need for greater focus on internalization of such beliefs among sexual minority CSA survivors as a target of clinical intervention.

Consistent with Hatzenbuehler’s (2009) Psychological Mediation Framework, our results revealed that internalized homophobia was uniquely and significantly associated with emotion regulation difficulties. Specifically, difficulties attending to ongoing emotional experiences (Awareness), a tendency to develop secondary emotional responses such as shame or fear to one’s negative emotions (Nonacceptance) and believing that few strategies for coping with strong negative emotion are available (Strategies) were associated with internalized homophobia in our multiple mediation model. These findings indicate that, even when controlling for the effects of CSA on emotion regulation difficulties, internalized homophobia may be uniquely associated with a set of specific emotion regulation difficulties.

Consistent with previous research (e.g., Berke et al., 2019; Gratz & Roemer, 2004), our multiple mediation model also revealed significant temporal associations between emotionregulation difficulties and IPV. Difficulties engaging in goal-directed behavior when distressed (Goals) and difficulty attending to ongoing emotion experiences (Awareness) prospectively predicted IPV risk among sexual minority men in our sample, even when adjusting for CSA history, baseline levels of IPV victimization, and internalized homophobia. To our knowledge, this is the first study to demonstrate longitudinal associations among these psychological risk factors and IPV victimization among sexual minority men.

However, counter to Hypotheses 2 and 3, neither emotion regulation difficulties nor internalized homophobia mediated the temporal relationship between CSA and IPV revictimization (despite being positively associated with both). These findings suggest that, although emotion regulation difficulties and internalized homophobia are correlated experiences, their associations with interpersonal victimization experiences (i.e., CSA and IPV) may operate via direct and independent pathways. The absence of significant indirect effects of CSA on IPV victimization via emotion regulation difficulties and/or internalization homophobia may also reflect characteristics of the study cohort, which was limited to HIV-negative sexual minority men. Given existing evidence linking CSA and IPV victimization with HIV risk (e.g., Edwards et al., 2015) future research is needed to replicate and extend the present pattern of findings observed.

Limitations

This study comprises a number of additional limitations worth noting. First, the current sample was mostly gay, White, and well educated (nearly 60% of the sample had a college or graduate school education), limiting the generalizability of study findings to more ethnically/racially diverse samples and to sexual minority men of varying levels of educational attainment and those who do not identify as gay. For example, bisexual men have been documented to experience psychosocial health disparities including elevated rates of IPV exposure, compared to both heterosexual and gay men (Pathela & Schillinger, 2010). Future research can build on the present study to consider how this model varies among subgroups (e.g., sexual minority men of color; bisexual men; sexual minority men living with HIV), given the considerable variance in sexual minority experiences.

Second, measurement of CSA and IPV present complexities that may limit the generalizability of study findings. Our use of a dichotomous measurement of CSA that included the use of words such as “forced “and “scared” limits our ability to assess within-group heterogeneity of CSA experiences and may have introduced social desirably demands. Similarly, variability exists across IPV measurement and conceptualization regarding who is considered to be an “intimate partner,” what types of actions constitute violence, and the role of power and control in violent interactions (Nicolaidis & Paranjape, 2009). Relatedly, given the longitudinal design of our study, we were unable to reliably determine if participants were with the same partner from one time point to the next. Although, we adjusted for relationship status at 24-month and 36-month assessments in our primary analyses, the current study is limited in its ability to differentiate between violence occurring in the same relationship versus violence across multiple relationships. Finally, evidence suggests that a significant portion of IPV is bidirectional (Langhinrichsen-Rohling et al., 2012); however, the current study focused only on IPV victimization. Although this study addresses important gaps in the literature on psychosocial pathways linking CSA to IPV victimization in sexual minority men, more research designed to measure and integrate risk pathways to IPV perpetration as they operate alongside IPV victimization pathways are needed.

Research and Clinical Implications

Limitations notwithstanding, there are several important implications of our findings. The model tested here suggests that both minority stress specific (i.e., internalized homophobia) and general psychological risk factors (i.e., emotion regulation difficulties) may be independently associated with interpersonal victimization experiences among sexual minority men. Given evidence for disproportionate rates of CSA and disproportionate consequences of IPV among sexual minority individuals relative to hetersexual individuals, including greater risk for injury (Graham et al., 2019), HIV infection, (Beymer et al., 2017), and protracted psychological distress (Edwards et al., 2015; Reuter et al., 2017), greater clarity in the specification of risk pathways among the interrelated experiences of CSA and IPV victimization is crucial to the development and identification of effective violence prevention and other behavioral and mental health intervention programs for this high need population. Given its longitudinal design, the current study advances the strength of casual inferences that can be drawn from evidence of associations among CSA, psychosocial risk factors (i.e., emotion regulation difficulties; internalized homophobia), and IPV victimization.

The present model suggests that, in addition to interventions that target emotion regulation deficits that may emerge following CSA, reductions in internalized homophobia might at least partially reduce associations between early life boundary violations and future violent victimization experiences in the adult intimate partnerships of sexual minority men. Future research that uses intervention evaluation or experimental designs is needed to establish the unique impact and efficacy of programs that apply trauma-informed and minority stress approaches to reduce IPV risk and its associated consequences. However, results of the current study suggest that programs that integrate intervention strategies for targeting both general emotion regulation difficulties concomitant with CSA with intervention content to specifically address the unique consequences of minority stress such as internalized homophobia, represent promising future directions for IPV prevention and intervention research.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The One Thousand Strong study was funded by NIH/NIDA (R01 DA 036466: Christian Grov). Jonathon Rendina’s effort was supported by a NIH/NIDA grant (K01-DA039030). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. At the time of the study, the first author was a Scholar/Affiliate Scholar with the HIV/AIDS, Substance Abuse, and Trauma Training Program (HA-STTP), at the University of California, Los Angeles; supported through an award from the National Institute on Drug Abuse (R25DA035692).

Author Biographies

Danielle Berke, Ph.D. is a Clinical Psychologist, Assistant Professor of Psychology at Hunter College, City University of New York (CUNY), and a member of the doctoral faculty of the CUNY Graduate Center. Her clinical research broadly focuses on identifying risk and resilience factors associated with victimization and adaptation to traumatic harm, particularly among women and sexual and gender minorities.

Raymond L. Moody, Ph.D. is a graduate of the Health Psychology and Clinical Science (HPCS) doctoral program and is currently completing a postdoctoral fellowship in the Substance Abuse Epidemiology Training Program (SAETP) at Columbia University. His research examines the impact of social and psychological stress on substance use and sexual behavior among sexual and gender minorities.

Christian Grov, Ph.D., MPH is a professor and chair of the Department of Community Health and Social Sciences of the CUNY School of Public Health. His research centers on the sexual health of sexual minority individuals, particularly gay and bisexual men.

H. Jonathon Rendina, Ph.D., MPH is currently an Associate Research Professor, in the Department of Epidemiology at the Milken Institute School of Public Health at George Washington University and the Senior Director of Research at Whitman-Walker Health. His research focuses on social stress and health, with an emphasis on the role of intersectional sexual minority stress in driving LGBT health disparities and the impact of stigma on the health of people living with HIV.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

  1. Amado BG, Arce R, & Herraiz A. (2015). Psychological injury in victims of child sexual abuse: A meta-analytic review. Psychosocial Intervention, 24(1), 49–62. 10.1016/j.psi.2015.03.002 [DOI] [Google Scholar]
  2. Atkins D, & Gallop R. (2007). Rethinking how family researchers model infrequent outcomes: A tutorial on count regression and zero-inflated models. Journal of Family Psychology, 21(4), 726–735. 10.1037/0893-3200.21.4.726 [DOI] [PubMed] [Google Scholar]
  3. Balsam K, & Szymanski D. (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. 10.1111/j.1471-6402.2005.00220.x [DOI] [Google Scholar]
  4. Berke DS, Reidy DE, Gentile B, & Zeichner A. (2019). Masculine discrepancy stress, emotion-regulation difficulties, and intimate partner violence. Journal of Interpersonal Violence, 34(6), 1163–1182, 10.1177/0886260516650967 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Berzenski SR, & Yates TM (2010). Research on intimate partner violence: A developmental process analysis of the contribution of childhood emotional abuse to relationship violence. Journal of Aggression, Maltreatment & Trauma, 19(2), 180–203. 10.1080/10926770903539474 [DOI] [Google Scholar]
  6. Beymer M, Harawa N, Weiss R, Shover C, Toynes B, Meanley S, & Bolan R. (2017). Are partner race and intimate partner violence associated with incident and newly diagnosed HIV infection in African-American men who have sex with men? Journal of Urban Health, 94(5), 666–675. 10.1007/s11524-017-0169-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Boroughs MS, Valentine SE, Ironson GH, Shipherd JC, Safren SA, Taylor SW, Dale SK, Baker JS, Wilner JG, & O’Cleirigh C. (2015) Complexity of childhood sexual abuse: Predictors of current post-traumatic stress disorder, mood disorders, substance use, and sexual risk behavior among adult men who have sex with men. Archives of Sexual Behavior, 44(7), 1891–1902. 10.1007/s10508-015-0546-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Brennan DJ, Hellerstedt WL, Ross MW, & Welles SL (2007). History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men. American Journal of Public Health, 97(6), 1107–1112. 10.2105/AJPH.2005.071423 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Capaldi DM, Knoble NB, Shortt JW, & Kim HK (2012). A systematic review of risk factors for intimate partner violence. Partner Abuse, 3(2), 231–280. 10.1891/1946-6560.3.2.e4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. D’Andrea W, Ford J, Stolbach B, Spinazzola J, & van der Kolk B. (2012). Understanding interpersonal trauma in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82(2), 187–200. 10.1111/j.1939-0025.2012.01154.x [DOI] [PubMed] [Google Scholar]
  11. Desai S, Arias I, Thompson MP, & Basile KC (2002). Childhood victimization and subsequent adult revictimization assessed in a nationally representative sample of women and men. Violence and Victims, 17(6), 639–653. 10.1891/vivi.17.6.639.33725 [DOI] [PubMed] [Google Scholar]
  12. Edwards K, Sylaska K, & Neal A. (2015). Intimate partner violence among sexual minority populations: A critical review of the literature and agenda for future research. Psychology of Violence, 5(2), 112–121. 10.1037/a0038656 [DOI] [Google Scholar]
  13. Engstrom M, El-Bassel N, Go H, & Gilbert L. (2008). Childhood sexual abuse and intimate partner violence among women in methadone treatment: A direct or mediated relationship? Journal of Family Violence, 23(7), 605–617. 10.1007/s10896-008-9183-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Graham LM, Jensen TM, Givens AD, Bowen GL, & Rizo CF (2019). Intimate partner violence among same-sex couples in college: A propensity score analysis. Journal of Interpersonal Violence, 34(8), 1583–1610. 10.1177/0886260516651628 [DOI] [PubMed] [Google Scholar]
  15. Gratz K, & Roemer L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. 10.1023/b:joba.0000007455.08539.94 [DOI] [Google Scholar]
  16. Greenwood GL, Relf MV, Huang B, Pollack LM, Canchola JA, & Catania JA (2002). Battering victimization among a probability-based sample of men who have sex with men. American Journal of Public Health, 92(12), 1964–1969, 10.2105/ajph.92.12.1964 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Grov C, Cain D, Whitfield T, Rendina H, Pawson M, Ventuneac A, & Parsons J. (2015). Recruiting a US national sample of HIV-negative gay and bisexual men to complete at-home self-administered HIV/STI testing and surveys: Challenges and opportunities. Sexuality Research and Social Policy, 13(1), 1–21. 10.1007/s13178-015-0212-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Hatzenbuehler M. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707–730. 10.1037/a0016441 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Institute of Medicine (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. National Academies Press. [PubMed] [Google Scholar]
  20. Kalichman SC, Gore-Felton C, Benotsch E, Cage M, & Rompa D. (2004). Trauma symptoms, sexual behaviors, and substance abuse: Correlates of childhood sexual abuse and HIV risks among men who have sex with men. Journal of Child Sexual Abuse, 13(1), 1–15. 10.1300/J070v13n01_01 [DOI] [PubMed] [Google Scholar]
  21. Langenderfer-Magruder L, Walls NE, Whitfield DL, Brown SM, & Barrett CM (2015). Partner violence victimization among lesbian, gay, bisexual, transgender, and queer youth: Associations among risk factors. Child and Adolescent Social Work Journal, 33(1), 55–68. 10.1007/s105-60-015-0402-8 [DOI] [Google Scholar]
  22. Langhinrichsen-Rohling J, Misra TA, Selwyn C, & Rohling ML (2012). Rates of bidirectional versus unidirectional intimate partner violence across samples, sexual orientations, and race/ethnicities: A comprehensive review. Partner Abuse, 3(2), 199–230. 10.1891/1946-6560.3.2.199 [DOI] [Google Scholar]
  23. Leeb RT, Paulozzi L, Melanson C, Simon T, & Arias I. (2008). Child maltreatment [Google Scholar]
  24. Lloyd S, & Operario D. (2012). HIV risk among men who have sex with men who have experienced childhood sexual abuse: Systematic review and meta-analysis. AIDS Education and Prevention, 24(3), 228–241. 10.1521/aeap.2012.24.3.228 [DOI] [PubMed] [Google Scholar]
  25. Maniglio R. (2010). Child sexual abuse in the etiology of depression: A systematic review of reviews. Depression and Anxiety, 27(7), 631–642. 10.1002/da.20687 [DOI] [PubMed] [Google Scholar]
  26. Martin JL, & Dean LL (1988). The impact of AIDS on gay men: A research instrument [Unpublished Technical Report]. Columbia University. [Google Scholar]
  27. Martin-Storey A. (2015). Prevalence of dating violence among sexual minority youth: Variation across gender, sexual minority identity and gender of sexual partners. Journal of Youth and Adolescence, 44(1), 211–224. 10.1007/s10964-013-0089-0 [DOI] [PubMed] [Google Scholar]
  28. Martin-Storey A, & Fromme K. (2017). Mediating factors explaining the association between sexual minority status and dating violence. Journal of Interpersonal Violence, 36(1–2), 1–28. 10.1177/0886260517726971 [DOI] [PubMed] [Google Scholar]
  29. McGeough BL, & Sterzing PR (2018). A systematic review of family victimization experiences among sexual minority youth. Journal of Primary Prevention, 39(5), 491–528. 10.1007/s10935-018-0523-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Messman-Moore T, Walsh K, & DiLillo D. (2010). Emotion dysregulation and risky sexual behavior in revictimization. Child Abuse & Neglect, 34(12), 967–976. 10.1016/j.chiabu.2010.06.004 [DOI] [PubMed] [Google Scholar]
  31. Meyer I. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Meyer IH, & Dean L. (1998). Internalized homophobia, intimacy, and sexual behavior among gay and bisexual men. In Herek GM (Ed.), Stigma and sexual orientation: Understanding prejudice against lesbians, gay men, and bisexuals. (pp. 160–186). Sage Publications, Inc. https://doi.org.proxy.wexler.hunter.cuny.edu/10.4135/9781452243818.n8 [Google Scholar]
  33. Miller B, & Irvin J. (2017). Invisible scars: Comparing the mental health of LGB and heterosexual intimate partner violence survivors. Journal of Homosexuality, 64(9), 1180–1195. 10.1080/00918369.2016.1242334 [DOI] [PubMed] [Google Scholar]
  34. Nicolaidis C, & Paranjape A. (2009). Defining intimate partner violence: Contro-versies and implications. In Mitchell C. & Anglin D. (Eds.), Intimate partner violence: A health-based perspective (pp. 19–29). Oxford University Press [Google Scholar]
  35. Niolon PH, Kearns M, Dills J, Rambo K, Irving S, Armstead T, & Gilbert L. (2017). Preventing intimate partner violence across the lifespan: A technical package of programs, policies, and practices. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. [Google Scholar]
  36. Pachankis JE, Rendina HJ, Restar A, Ventuneac A, Grov C, & Parsons JT (2015). A minority stress – emotion regulation model of sexual compulsivity among highly sexually active gay and bisexual men. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 34(8), 829–840. 10.1037/hea0000180 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Parsons JT, Grov C, & Golub SA (2012). Sexual compulsivity, co-occurring psychosocial health problems, and HIVrisk among gay and bisexual men: Further evidence of a syndemic. American Journal of Public Health, 102(1), 156–162. 10.2105/ajph.2011.300284 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Parsons JT, Millar BM, Moody RL, Starks TJ, Rendina HJ, & Grov C. (2017). Syndemic conditions and HIV transmission risk behavior among HIV-negative gay and bisexual men in a U.S. national sample. Health Psychology, 36(7), 695–703. 10.1037/hea0000509 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Pathela P, & Schillinger JA (2010). Sexual behaviors and sexual violence: Adolescents with opposite-, same-, or both-sex partners. Pediatrics, 126(5), 879–886. 10.1542/peds.2010-0396 [DOI] [PubMed] [Google Scholar]
  40. Paul JP, Catania J, Pollack L, & Stall R. (2001). Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect, 25(4), 557–584. 10.1016/s0145-2134(01)00226-5 [DOI] [PubMed] [Google Scholar]
  41. Reuter TR, Newcomb ME, Whitton SW, & Mustanski B. (2017). Intimate partner violence victimization in LGBT young adults: Demographic differences and associations with health behaviors. Psychology of Violence, 7(1), 101–109. 10.1037/vio0000031 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Roberts AL, Rosario M, Corliss HL, Koenen KC, & Austin SB (2012). Elevated risk of posttraumatic stress in sexual minority youths: Mediation by childhood abuse and gender nonconformity. American Journal of Public Health, 102(8), 1587–1593. 10.2105/ajph.2011.300530 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Rogers AH, Seager I, Haines N, Hahn H, Aldao A, & Ahn W. (2017). The indirect effect of emotion regulation on Minority Stress and problematic substance use in lesbian, gay, and bisexual individuals. Frontiers in Psychology, 8(25). 10.3389/fpsyg.2017.01881. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Scoglio AAJ, Kraus SW, Saczynski J, Jooma S, & Molnar BE (2019). Systematic review of risk and protective factors for revictimization after child sexual abuse, Trauma, Violence, & Abuse, 22(1), 41–53. 10.1177/1524838018823274 [DOI] [PubMed] [Google Scholar]
  45. Stephenson R, & Finneran C. (2017). Receipt and perpetration of intimate partner violence and condomless anal intercourse among gay and bisexual men in Atlanta. AIDS and Behavior, 21(8), 2253–2260. 10.1007/s10461-017-1709-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Straus MA, & Douglas EM (2017). Eight new developments, uses, and clarifications of the Conflict Tactics Scales. Journal of Family Issues, 38(14), 1953–1973, 10.1177/0192513×17729720 [DOI] [Google Scholar]
  47. Straus MA, Hamby SL, Boney-McCoy S, & Sugarman DB (1996). The revised Conflict Tactics Scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17(3), 283–316. 10.1177/019251396017003001 [DOI] [Google Scholar]
  48. Sweet T, & Welles SL (2012). Associations of sexual identity or same-sex behaviors with history of childhood sexual abuse and HIV/STI risk in the United States. JAIDS Journal of Acquired Immune Deficiency Syndromes, 59(4), 400–408. 10.1097/qai.0b013e3182400e75 [DOI] [PubMed] [Google Scholar]
  49. Ullman SE, & Filipas HH (2005). Gender differences in social reactions to abuse disclosures, post-abuse coping, and PTSD in child sexual abuse survivors. Child Abuse & Neglect, 29(7), 767–782. 10.1016/j.chiabu.2005.01.005 [DOI] [PubMed] [Google Scholar]
  50. Vaillancourt-Morel MP, Godbout N, Germain Bédard M, Charest E, Briere J, & Sabourin S. (2016). Emotional and sexual correlates of child sexual abuse as a function of self-definition status. Child Maltreatment, 21(3), 228–238. 10.1177/1077559516656069 [DOI] [PubMed] [Google Scholar]
  51. Welles SL, Corbin TJ, Rich JA, Reed E, & Raj A. (2011). Intimate partner violence among men having sex with men, women, or both: Early-life sexual and physical abuse as antecedents. Journal of Community Health, 36(3), 477–485. 10.1007/s10900-010-9331-9 [DOI] [PubMed] [Google Scholar]

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