Overall strategy

The aim of the systematic review was to understand the help-seeking experiences of male victims of DVA. Our objectives were to systematically identify qualitative and mixed-method studies that reported qualitative data of men’s experiences of help-seeking, particularly with regard to services, and to thematically synthesise their findings.

Eligibility criteria of studies

Quality of studies

Assessed with CASP criteria, the studies were generally well conducted. However two studies were predominantly quantitative in design,14 19 three studies had potentially inadequate recruitment strategies,14 19 21 only three studies considered the relationship between the researcher and participant11 13 15 and while eight of the studies described obtaining ethical approval for their research, in four studies there was no mention of ethical approval which could either mean they did not consider seeking approval but more likely they have not reported it (online supplementary file 3).13 16 17 21 Overall, ethical approval details were brief and ethical considerations were not elaborated on within all of the included studies. We know from the wider literature in the field that ethical considerations relating to the safety of potential participants and researchers is important.23 Therefore it is disappointing that these studies did not clarify how safety, confidentiality (and its limits) and signposting to services where appropriate, was administered during the research.

Characteristics of study population

Seven studies recruited men via DVA or social and community services,12–16 19 21 one study recruited from the criminal justice system,17 two recruited from sexual health/HIV clinics11 22 and two from primary healthcare (table 1).18 20

Three studies recruited MSM (gay, bisexual and transgender men),11 13 22 five studies recruited heterosexual men,14–18 and four studies recruited men of diverse sexuality or did not specify sexuality.12 18 20 21

The majority of studies recruited men with a mean age between 40 and 60 years; four studies did not give any details although some specified an age range for recruitment.12 13 19 20 Ethnicity was recorded in six studies11 13–15 21 22 with most studies recruiting a majority of white men although Frierson focused on African-American men.13

The currency of the abusive relationship(s) was not well recorded, with the exception of three studies.14 15 19 Equally most studies included participants who self-reported having experienced DVA with little detail of duration, frequency or type of abuse experienced, although in one study the male victims were taking criminal proceedings against their former partner suggesting prolonged serious abuse.17

We described the themes over two phases (1) barriers to help-seeking and (2) experiences of interventions and support (figure 2) (table 2).

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

Thematic analysis.

Phase 1: barriers to help-seeking

We derived five themes on the barriers to initial disclosure and help-seeking by male victims of DVA. Three themes were closely related: fear of disclosure, challenge to masculinity and commitment to relationship in addition to the themes of diminished confidence/despondency and the invisibility/perception of services (figure 2).

Theme 1: fear of disclosure

This important theme emerged from ten of the twelve included studies of which two were focused exclusively on MSM (table 2).

There was a strong theme across the studies of difficult emotions experienced by male victims: internal fears, ambivalence related to shame and denial.13 15 20 21 This was expressed by both MSM and heterosexual men in the studies. In the study by Frierson13 in which gay African-American men were interviewed the author comments that ‘As the abuse continued, participants described being embarrassed to discuss the various aspects of their abuse outside of their personal networks. For some men they describe feeling as if they are less of a man if they report the abuse.’

One of the participants describes the internal struggle

Is this really going on? Am I in an alternate dimension? It was just that confusing… (Arelle) (Frierson, 2014).

This is also discussed by Tsui et al, ‘Men who have been assaulted by their intimate partners, either in same sex partner or heterosexual relationships, do not want to disclose their problems, in part because they wish to avoid additional problems. Although some may relate abuse to their own weaknesses, others blame their injuries on their own mistakes such as a careless fall or other accidents.’21 Self-perception and societal perception of masculinity is also an important factor in these fears. This is described in more detail in the theme of ‘challenge to masculinity’.

The external pressures surrounding the fear of disclosing DVA are significant and a multifaceted barrier for men discussing their situation with others. This related to perceptions about not being believed by informal or formal potential support.14 15 17 20 Seeking and receiving support from family and friends was generally perceived as beneficial. In Machado et al, 16 in which the authors interviewed male heterosexual victims of DVA, they reported how informal help-seeking leads on to formal help-seeking, but they also say ‘However, the overwhelming majority of participants rated formal sources as unhelpful, especially the services of the judicial system. Conversely, men reported that they had received valuable support from friends, family and colleagues at work.’

The other day, my neighbor saw me, and I was really down; she made me an appointment and took me to the doctor. (F., 43 years) (Machado, 2017)

A heterosexual participant when interviewed alluded to a fear of not being believed and the impact this can have on wider systems responses.17 This fear of not being believed by professionals was coupled with the fear of being falsely accused of being the perpetrator.

The professional [from social services] always treated me as if I was an offender. (M., 36 years) (Machado, 2017)

Men also feared the practical implications of disclosure, such as having nowhere to go, as well as the financial and professional impact. One of the most recurrent fears was losing custody of their children.14 15 20 This fear around the breakup of the family with children is related to the theme of victims’ commitment to their relationship.

In the Tsui et al study, in which men completed open-ended questions, men expressed the fear of putting themselves at future risk of harm from their partner by disclosing. The authors concluded that while ‘fear of [the] perpetrator’, and ‘threat of retaliation’, was not as frequently expressed as in abused women’s experience, fear was still regarded a factor blocking help-seeking among men.21

Theme 2: challenge to masculinity

Seven studies, one of which focused on gay African-American men describes the stigma of being a male victim of DVA on both a personal and on a societal level. Masculinity was linked closely in the papers under review with the fear of disclosure and internal pressures. A participant in the Hogan 2016 study said:

They won’t believe me you know, I mean I’m taller than my wife, you know I’m a big built fella you know, if I call up and say this is not, you know they just wouldn’t believe that (Simon). (Hogan, 2016)

This latter quote suggests that some people who may be physically bigger or perceived to be physically stronger than their partner, can feel that no-one would believe their disclosure of abuse. The assumption that abuse is mainly physical likely deters male victims to disclose experience of abuse. Similar experiences were expressed in the Frierson study of gay African-American men in which the authors state that ‘For some men they describe feeling as if they are less of a man if they report the abuse’.13

Theme 3: commitment to relationship

Two of the included studies of heterosexual men discussed commitment to their relationship and concern for the perpetrator of the abuse as both barriers to help-seeking.14 20 The desire voiced by study participants was for everything to be okay and ‘normal’. Men expressed wanting the abuse to stop, but not their relationship in which they were still emotionally invested. In some cases, concern for their female partner’s well-being took priority over their own.

‘For better or for worse,’ and, well, this was worse. I didn’t care that she was too psychologically disturbed to love me back, I didn’t care. I loved her. And I hoped I could get help for her condition before it was too late. (no id.given) (Hines, 2014)

Commitment to the relationship was closely linked to the fear of losing contact with children as described above in relation to fear of disclosure.14 15 20

Theme 4: diminished confidence/despondency

Three studies, one of which focused on MSM, explored diminished confidence.17 21 22 Both McCarrick et al and Valentine et al studies high-lighted the effect of diminished confidence influencing help-seeking behaviours and the potential role of post-traumatic stress disorder.17 22

It’s been 3 years now since I, I eventually got out the house but, them 3 years I might as well have gone to jail, because I’ve lived in a house and I very rarely go out now. (Lee) (McCarrick, 2016)

In the Valentine et al study, interviews with MSM showed that help-seeking was linked to self-realisation and self-preservation, for example, needing to protect one’s mental health.

I got depressed from it. I was starting to get depressed. And I had started seeing a therapist because some of the verbal [abuse], it was making me feel like—why am I, why would someone choose to stay with someone [like that]?’ (African-American/black, aged 44 years) (Valentine, 2013)

Complacency was related to the longevity of abuse in the Tsui et al study, leading older men to report in open-ended survey questions that they were less likely to seek help as abuse had been going on so long that it seemed futile or not worth doing anything about it.21

Theme 5: invisibility/perception of services

Three studies, two were focused on MSM, explored invisibility of male victims within services.11 13 17 These studies found that men were either not aware that services are available for them or that they did not perceive them as appropriate.13

It would have been certainly an out of body experience because it was certainly something, I couldn’t have imagined for myself. Again, especially as a man. A gay man. So, I- probably would have felt a little awkward about it all. I felt like they wouldn’t understand me because I was gay. (Terry) (Frierson, 2014)

The studies highlighted the importance of the ‘shop front’ of services. The need for a DVA gender-aware culture in services was discussed in both practical and policy terms.11 Some of the papers stated that separate services are needed if male perception of service availability is to be improved. The portrayal of DVA services as a space for women survivors was a barrier to help-seeking in the McCarrick et al study:

‘The headquarters of the DV unit has a massive billboard outside its building, ‘he’s a big hit with the ladies’ and it’s a man standing over a woman, hitting the woman.’ (Lee) (McCarrick, 2016)

To summarise barriers to help-seeking, fear of disclosure was an important theme, covering both the internal pressures of shame and denial and the external pressures of fear of not being believed, fear of being labelled the perpetrator and the practical (negative) consequences of disclosure. It overlaps with ideas of help-seeking being perceived as a challenge to masculinity and commitment to the relationship. There were less data from studies on MSM but experiences appeared to be comparable to heterosexual victims. Challenge to masculinity was also an important theme for MSM populations and describes the societal pressure of ‘being a man’ regardless of sexuality, although it should be noted only one study focused on gay men.

The two remaining themes in this section are more individual; the fourth theme sums up the hopeless of men in abusive relationship due to degraded confidence and responsibility and the fifth theme describes the perceived availability, and potentially the reality of available services for male victims of DVA both in terms of gender and sexuality.

Phase 2: experiences of interventions and support

Four themes emerged relating to experiences of interventions and support: initial contact, confidentiality, appropriate professional approaches and inappropriate professional approaches. Confidentiality is closely linked to ideas of the appropriateness of professional approaches (figure 2) (table 2).

Theme 6: initial contact—tipping the balance

Four studies explored the importance of the perceived levels of crisis; none of which focused on MSM12 17 18 20 These studies describe that a crisis often needed to happen before a man seeks help. Simmons et al described that ‘a sense of urgency to seek help and feeling ready to talk about one’s victimisation were strong factors that tipped the balance towards a high likelihood of disclosing victimisation, whereas a low perceived need for help tipped the balance towards a low likelihood of disclosure.’20 Family and friends were generally seen as a positive source of support whether that was associated with an initial acknowledgement or support further down the line.12 17 18 20

Had I not spent most of the day that I was arrested with a close friend who was able to identify my wife’s behaviour and advise me, I would have been in a psychologically weak situation when arrested. (Henry) (McCarrick, 2016)

Theme 7: confidentiality

Five studies emphasised the importance of confidentiality for men seeking help, two of the five studies focused on MSM.11 15 17 18 20 This need was expressed generally and in practical ways, such as valuing the provision of an appropriate private space for disclosure within a healthcare setting. Overall men’s primary motive was to keep their situation private. A heterosexual respondent in the Simmons et al study expressed doubt in the confidentiality of the health system within a small town.20 In the Frierson et al study in which gay African-American men were interviewed one participant said

‘I don’t think I would ever seek domestic violence help…’ It’s probably the way that I was raised. Like it’s a black thing. Whatever happens in your house stays in your house. People from the outside don’t need to know. Chuck, (Frierson, 2014)

There was relatively little information on the types of services that men preferred but in the Hogan 2016 study, a heterosexual man described the importance of the anonymity of the telephone.15

Talking to you is alright because we’re on the phone; I don’t know what you’re doing at the other side of the phone, but, if you was like, phew I don’t know, if you was looking at me, I don’t think I’d be looking at you when I’m talking to you (Stuart). (Hogan, 2016)

Religious mentors were described as important resources because they were considered non-judgemental and could be trusted although a participant in the Morgan 2014 study expressed doubts.18

It pains me to say it but I wouldn’t always trust the church’s approach to confidentiality (ID.1220030, aged 59). (Morgan, 2014)

Theme 8: appropriate professional approaches

Five studies explored the professional approach, one of studies focused on MSM.11 15 16 18 20 A preference for receiving help from a female professional was a consistent theme across studies and settings.11 15 18 20 Conversely there was little or no discussion around male professional support.

Studies in the healthcare settings suggested that continuity of contact (care) was favoured by men.11 18 20 Simmons et al proposed that in the caring encounter confidence could be built in just one session for some, whereas others required a longer term relationship for disclosure.20 According to Morgan et al a pre-existing relationship with the general practitioner facilitates disclosures by men.18 This was echoed by a MSM participant in the Bacchus et al study.11

When I come here I just want to get the job done and go. I probably may not have met that person before; I don’t want to start spluttering out all the things that have been going on. I now have a very good relationship with my HIV consultant and if he were to ask me that question, I would probably be much more open about discussing it with him. (Gabe, 33 years) (Bacchus, 2016)

The primary healthcare setting was regarded as a suitable and safe place to talk about violence by some, suggesting an overlap with the theme of confidentiality. Discussions with primary healthcare professionals around common physical and mental health symptoms associated with DVA seemed to facilitate disclosure. In the Simmons 2016 study the author described how a supportive, empathetic attitude from a professional opens ‘the door’ for disclosure.20 A heterosexual participant in the Morgan et al study speculated:

I think it’d probably be a good thing because I bet there’s a load of it going on all the time. Maybe people don’t even consider it abuse until they really question it like that. […]. [ID.1150023 aged 25] (Morgan, 2014)

Other views were at odds with this, with the suggestion by a man that non-medical professionals were more suitable to trigger and respond to potential disclosures.

…Definitely health advisor cos they are much more likely to have an empathic approach. And the doctors would be like ‘I don’t know which pill to give you for that. (Shaun, 52 years) (Bacchus, 2016)

While there was little content in the studies suggesting which interventions were preferred by men, Hogan 2016 suggested that counselling was acceptable to most men who had been victims of female-perpetrated violence.15 In the Machado et al study, two heterosexual men talked about the usefulness of being signposted to a psychologist from DVA services.

…I consulted a psychologist and it was good (…) It changed the way that I think and understand what was happening to me. (B., 35 years) (Machado, 2017)

Theme 9: inappropriate professional approaches

Six studies explored inappropriate professional approaches; one of which focused on gay men.12 13 15–17 19 Some negative comments were made regarding interactions with professional support. In the Hogan study, the authors described some men experiences as a ‘wall of silence’ from health professionals and ‘a lack of sensitivity and compassion’.15

Some participants described a lack of understanding from professionals towards lesbian, gay, bisexual, and transgender (LGBT) help-seekers, with a general feeling that services were ‘heterosexual-orientated’ with ‘gender stereotyped treatment’. One participant in the Frierson 2014 study talked about how a therapist had normalised abuse with in a gay relationship.

Something radiates off of a person’s body when they are uncomfortable around gay people. And that’s the feeling I get when I am the only gay person in a room. Even if people don’t know and I tell them that hey I date guys, they kind of just like eww. It could be me. (Chuck) (Frierson, 2014)

The men’s accounts of interaction with the police were polarised, with both positive and negative encounters.12 13 15 16 18 19

Hogan commented ‘a few (LGBT men) who did report to the police got a mixed response. Some had a sympathetic response but no follow through in terms of applying the law to the abusive partner. A small number had very unhelpful responses from the police though these said this had happened a long time ago.

When I did speak to the police they were like basically you’re two men, work it out. That it’s an abusive relationship but you know basically like why are y’all doing this? (Quin) (Frierson, 2014)

In the Morgan et al study, one man described how although the initial response from the police was supportive, there was no follow-up or signposting to further services.

Yes the police did arrive, they did take me seriously, they did follow-up etcetera etcetera but there was no, you know there was no, offer of on-going [support] to have a talk to the support line. They said what I had to do was call my lawyer up. (Participant 5) (Morgan, 2016)

Summarising the experiences of interventions and support; the theme of initial contact describes how many men get to a tipping point, generally a crisis or low point which leads to disclosure. It is unfortunate that none of the contributing studies include the views of MSM. Confidentiality is an important theme, describing the various forms it can take and relates to participants experiences of interaction with professionals.

A consistent element of appropriate professional response is that men appear to prefer to disclose and discuss DVA with a female professional. Primary healthcare professionals appear to be acceptable to male victims of DVA, but the study of gay African-American men suggests other professionals may be preferred. Participant’s descriptions of the criminal justice system are mixed but suggest that at best the police support is short term.

Strengths and limitations

The search for studies was systematic and exhaustive without language limitations and including the grey literature. We used prespecified inclusion and exclusion criteria and independent reviewers for inclusion and data extraction review was conducted. The critical appraisal and thematic synthesis followed established methodology.8–10 This is the first evidence synthesis of qualitative studies on the experience of help-seeking by male victims of DVA and our thematic findings on the interaction with professional services adds to the evidence base.

The limitations of this review are that not all dimensions of the topic are covered by these qualitative studies, for example, ethnicity and cultural barriers to help-seeking by men. Throughout this systematic review we have used the term men who have sex with men (MSM) as we recognise that some men may not identify as gay or as in a same-sex relationship even when they do have sex with men. However, in the Frierson study which clearly defines its participants as gay men we have kept this description. We acknowledge however that MSM is a contentious term and that further refinement of terms is needed.37 It is also important to point out that these qualitative studies have captured the voices of those who were willing to come and speak to someone, whereas more anonymous methods might have yielded some different findings. While we do not have empirical evidence this could have an impact on disclosure figures.