by Dr Brad Hillier, Consultant Forensic Psychiatrist
This article appears in our latest newsletter (Spring 2024) which can be downloaded here.
There are many different types of “violence” that can be conceptualised as occurring towards LGBTQI+ people. If it is accepted that LGBTQI+ rights are human rights, then any organisation, institution or state that does not recognise them and protect them are arguably carrying out violence against this group; state-sanctioned violence in the form of the death penalty and corporal punishments exist in a number of countries globally and obviously have extremely deleterious effects on the health and wellbeing of sexual minorities in these places.
More insidious forms of discrimination and stigma, even in societies where LGBTQI+ rights are enshrined in law and actively protected, still occur. They form the basis of “minority stress”, an established transtheoretical model describing the acute and chronic impact of these forces on minority individuals – in this case sexual minorities – who have to hide their true identities, including consciously and unconsciously from themselves. Associated with this is the internalisation of homophobic narratives which add to the internal psychological conflict that is thought to underpin the significantly increased prevalence of many mental disorders and substance use in sexual minorities. These conflicts are not resolved by “coming out”, and if anything have the potential to be both reinforced by actual discrimination (as opposed to the fear of it resolved by secrecy) and associated stigma and shame.
LGBTQI+ relationships exist within this context of minority stress, societal discrimination and in some cases active persecution, which clearly range from shame and stigma, to realistic fear of physical violence and the death penalty in some places.
Perhaps unsurprisingly, LGBTQI+ relationships have significantly higher rates of intimate partner violence than heterosexual relationships, depending on how this violence is defined. For example, in a study of men who have sex with other men (MSM) in Nigeria in 2020, up to 55% of respondents reported “monitoring behaviour” as a feature of their relationship, with emotional violence in 45%, physical violence in 31% and sexual violence in 20%. Recourse to justice is also extremely limited owing to the criminalisation of same-sex activity.
The addition of substance use, increasingly evident particularly through the phenomenon of “Chemsex”. This is a specific form of sexualised drug use (SDU) involving primarily the stimulant methamphetamine and/or gamma-hydroxybutyrate (GHB; a disinhibiting depressant) facilitated by geolocation dating or “sex meet” apps for MSM, and is also shown to increase risk of IPV. A recent longitudinal cohort study of 557 men in Los Angeles, followed between 2014 and 2020 demonstrated both high rates of both physical and sexual IPV (up to 22% of people) which was significantly associated with stimulant use in the preceding 6 months (IPV group 68% vs Non-IPV group 42.1%; P<0.001). Similar associations were also found with regards to being HIV+, adding further weight to the emerging syndemic association between violence, HIV+ status, stimulant use (and mental health problems).
A challenge that Chemsex poses to definitions of IPV includes that of what constitutes an “intimate partner”. It is not uncommon for such individuals to have met before, so having no form of pre-existing relationship. This contrasts with the more traditional terminology in heteronormative parlance, whereby a longer, possibly marital, relationship is often assumed. Clinical assessment and future research does need to consider this important difference and attempt to characterise it in methodology. What is very clear is that men who have sex with men have significant risks of IPV (and other forms of violence) in association with a range of other substance use, mental, and physical health problems, which may present in a wide variety of settings within health, social care and justice. It is crucial that these opportunities are not missed to ask about IPV and safeguard these individuals, who may otherwise not disclose through fear, shame and stigma. All such settings will require a minority stress and sexual minority-informed approach in order to ensure this.
Research can transform lives. We want to support discoveries about what helps people with mental disorder who have been victims of criminal behaviour, or perpetrators of criminal behaviour, and their families, and the clinicians and others who treat them and, indeed, the wider community when its members are in contact with these problems. More effective prevention is the ideal, when this is not possible, we need more effective, evidenced interventions for recovery and restoration of safety.
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