Intimate partner violence: a study in men and women from six European countries

Abstract

We aimed to assess intimate partner violence (IPV) among men and women from six cities in six European countries.
Four IPV types were measured in a population-based multicentre study of adults (18-64 years; n = 3,496). Sex- and city-differences in past year prevalence were examined considering victims, perpetrators or both and considering violent acts' severity and repetition.
Male victimization of psychological aggression ranged from 48.8 % (Porto) to 71.8 % (Athens) and female victimization from 46.4 % (Budapest) to 70.5 % (Athens). Male and female victimization of sexual coercion ranged from 5.4 and 8.9 %, respectively, in Budapest to 27.1 and 25.3 % in Stuttgart. Male and female victims of physical assault ranged from 9.7 and 8.5 %, respectively, in Porto, to 31.2 and 23.1 % in Athens. Male victims of injury were 2.7 % in Östersund and 6.3 % in London and female victims were 1.4 % in Östersund and 8.5 % in Stuttgart. IPV differed significantly across cities (p < 0.05). Men and women predominantly experienced IPV as both victims and perpetrators with few significant sex-differences within cities.
Results support the need to consider men and women as both potential victims and perpetrators when approaching IPV.

Full text

ORIGINAL ARTICLE
Intimate partner violence: a study in men and women from six
European countries
Diogo Costa •Joaquim Soares •Jutta Lindert •
Eleni Hatzidimitriadou •O
¨rjan Sundin •Olga Toth •
Elli Ioannidi-Kapolo •Henrique Barros
Received: 30 April 2014 / Revised: 31 January 2015 / Accepted: 3 February 2015
ÓSwiss School of Public Health 2015
Abstract
Objectives We aimed to assess intimate partner violence
(IPV) among men and women from six cities in six Eur-
opean countries.
Methods Four IPV types were measured in a population-
based multicentre study of adults (18–64 years;
n=3,496). Sex- and city-differences in past year preva-
lence were examined considering victims, perpetrators or
both and considering violent acts’ severity and repetition.
Results Male victimization of psychological aggression
ranged from 48.8 % (Porto) to 71.8 % (Athens) and female
victimization from 46.4 % (Budapest) to 70.5 % (Athens).
Male and female victimization of sexual coercion ranged
from 5.4 and 8.9 %, respectively, in Budapest to 27.1 and
25.3 % in Stuttgart. Male and female victims of physical
assault ranged from 9.7 and 8.5 %, respectively, in Porto,
to 31.2 and 23.1 % in Athens. Male victims of injury were
2.7 % in O
¨stersund and 6.3 % in London and female vic-
tims were 1.4 % in O
¨stersund and 8.5 % in Stuttgart. IPV
differed significantly across cities (p\0.05). Men and
women predominantly experienced IPV as both victims
and perpetrators with few significant sex-differences within
cities.
Conclusions Results support the need to consider men
and women as both potential victims and perpetrators when
approaching IPV.
Keywords Intimate partner violence Europe 
Population-based
Electronic supplementary material The online version of this
article (doi:10.1007/s00038-015-0663-1) contains supplementary
material, which is available to authorized users.
D. Costa H. Barros
EPIUnit - Institute of Public Health, University of Porto, Porto,
Portugal
J. Soares
Institution for Health Sciences, Mid Sweden University,
Sundsvall, Sweden
J. Lindert
University of Emden, Emden, Germany
J. Lindert
Brandeis University, Waltham, USA
E. Hatzidimitriadou
Faculty of Health and Social Care Sciences, Kingston
University, London, UK
E. Hatzidimitriadou
St George’s, University of London, London, UK
O
¨. Sundin
Department of Psychology, Mid Sweden University, O
¨stersund,
Sundsvall, Sweden
O. Toth
Institute of Sociology, Hungarian Academy of Sciences,
Budapest, Hungary
E. Ioannidi-Kapolo
National School of Public Health Athens, Athens, Greece
D. Costa H. Barros (&)
Department of Clinical Epidemiology, Predictive Medicine and
Public Health, University of Porto Medical School, Porto,
Portugal
e-mail: hbarros@med.up.pt
Int J Public Health
DOI 10.1007/s00038-015-0663-1
123

Introduction
Intimate partner violence (IPV) is a violation of human
rights and one of the most frequently experienced forms of
violence (Garcia-Moreno et al. 2006). In 2002, the World
Health Organization (WHO)—World Report on Violence
and Health (Krug et al. 2002) described the prevalence of
past year IPV against women as ranging from less than 3 %
in Australia, Canada and the United States (US) to more
than 30 % in Israel, Peru, West Bank and Gaza Strip. A
2013 WHO global systematic review showed that 35 % of
women ever experienced either physical and/or sexual IPV
or non-partner sexual violence (WHO 2013). However,
some countries in Europe such as Hungary, Portugal and
Greece still lack such estimates.
Studies designed to measure the frequency and identify
the determinants of IPV focus mostly on women as victims
(Bonomi et al. 2009; Garcia-Moreno et al. 2006; Thomp-
son et al. 2006; Yoshihama et al. 2007). However, a review
of 91 studies showed that one in five men was a victim of
IPV (Desmarais et al. 2012a) and poor health outcomes
have been associated with male victimization (Reid et al.
2008).
IPV against women tends to be a repetitive act though
with varied frequency. Over 15 % of ever-injured women
in Brazil, Peru or Thailand but only 1 % of Ethiopian
women reported that it happened more than five times in
their life (Ellsberg et al. 2008). Descriptions, interpreta-
tions and international comparisons of IPV may lose
insight without information on repetition of acts. The
chronicity dimension might additionally elucidate any sex-
difference of IPV (Johnson 1995) since one of the criti-
cisms of prevalence surveys is that simple ‘‘counts’’ of acts
might translate into false sex-symmetric rates if not
accounting for systematic patterns or repetition of acts
(Kimmel 2002).
Little is known on reciprocal violence in the general
population (Caetano et al. 2005), defined as simultaneous
involvement in perpetration and victimization. A sample
of 848 blue-collar American couples showed a 14.2 %
prevalence of reciprocal, 6.1 % male-to-female only and
9.3 % female-to-male only violence (Cunradi et al.
2011). In young American couples reciprocal violence
was as common as non-reciprocal, but more likely to
result in injury (Whitaker et al. 2007). In an analysis of
1,046 couples representing married and cohabiting cou-
ples from 48 states in the USA, approximately 8 %
reported reciprocal violence, close to 4 % reported that
there was perpetration of violence by the male partner
only and approximately 2 % reported the perpetration of
violence by the female partner only (Caetano et al.
2008). No information on the magnitude of reciprocal
violence is available for the adult European general
population and cross-cultural comparisons are limited to
physical and sexual IPV against women. Psychological
abuse has been less studied and may further help
explaining other components of male and female IPV
experiences.
The observed geographical differences in IPV against
women can reflect real variability or just different study
designs, making figures not directly comparable. This
paper presents results of the DOVE project—domestic
violence against men/women in Europe, designed to
compare IPV victimization and perpetration in men and
women from the general population using a multi-country
sample and the same IPV definitions.
Methods
DOVE was a cross-sectional multicentre study involving
non-institutionalized adults (18–64 years) from eight Eur-
opean cities: Ghent–Belgium, Stuttgart–Germany, Athens–
Greece, Budapest–Hungary, Porto-Portugal, Granada–
Spain, O
¨stersund–Sweden and London–United Kingdom
(UK). Sites were selected based on previous collaboration
(Lindert et al. 2012; Priebe et al. 2013), and to represent
geographical and cultural diversity across Europe.
Study design and participants
Detailed description of DOVE’s design and participants
characteristics’ is available elsewhere (Costa et al. 2013).
The sample size was established on the basis of required
levels of statistical power to estimate and compare the
prevalence of IPV across sites. Assuming an IPV pre-
valence of 15 % (Breiding et al. 2008) and 3.0 % of
relative precision, samples size was calculated as 544 (272
women) per centre representing a proportionally stratified
age- and sex-distribution of the resident population (2008
national data). Four sampling strategies were used: reg-
istry-based in Stuttgart and O
¨stersund, registry-based and
random-digit-dialling in Porto, registry-based and via-
public approach in London and random-route in Athens
and Budapest. Registries were municipal in Stuttgart,
electoral in Porto and London, and the state person-address
in O
¨stersund. Invitation letters with a concise project
description were sent to participants selected based on
registries. The study was presented by interviewers as part
of the invitation procedure to participants contacted
through telephone or at their houses.
For the present study 3,496 (women =2,026) partici-
pants from six centres were considered (Supplementary
Table 1). Data from Ghent (n=245) and Granada
(n=138) were excluded since the target sample size was
not achieved.
D. Costa et al.
123

Socio-demographic characteristics included sex, age,
education (categorized in secondary level or less and uni-
versity degree), marital status (single, cohabiting, married
or separated/divorced) and migrant background (partici-
pants indicating another place of birth than the country they
lived in or another nationality). These were collected by
face-to-face interview in Athens, Budapest, Porto and
London. In O
¨stersund, as per ethics demand, questionnaires
were mailed and returned using a pre-paid envelope. In
Stuttgart, a number of face-to-face interviews were con-
ducted but most questionnaires were mailed (74.5 %). Also
in Porto (14.0 %) and London (3.5 %), a small proportion
of participants opted for participation by post. In all sites,
the IPV section was self-administered. Data collection took
9 months and was completed in May 2011.
Outcome measures
The same standardized and validated questionnaire was self-
administered by participants in all centres to assess IPV,
ensuring that the definition of IPV types assessed was the same.
Past year prevalence of IPV against men and against women
was assessed using validated versions of the Revised Conflict
Tactics Scales (CTS2) (Straus et al. 2003), originally developed
in English, available in Portuguese, German and Swedish
(Straus 2004; Straus and Mickey 2012). Translations to Greek
and Hungarian followed a standard protocol: forward transla-
tion, expert panel revision, back-translation, new expert panel
revision and piloting. The CTS2’s act-specific type of ques-
tioning was used in cross-cultural research on IPV against
women, namely in the WHO multi-country study (Garcia-
Moreno et al. 2006) or the Demographic Health Surveys (DHS)
(Palermo et al. 2013) and in the study of elder abuse (Lindert
et al. 2013). The CTS2 allows to measure psychological
aggression (8 items), physical assault (12 items), sexual coer-
cion (7 items) and injury (6 items). For each act, the participant
answers two questions: the frequency of the act by a current or
former partner (victimization) and the frequency by the parti-
cipant (perpetration), i.e. each participant responded from both
perspectives: as a victim and as a perpetrator.
Participants were asked ‘‘How often did this happen in
the past year?’’, and eight frequency options given: once in
the past year, twice, 3–5 times, 6–10 times, 11–20 times,
more than 20 times, not in the past year but ever happened,
and never happened.
The questions covered acts of ‘‘minor’’ or ‘‘severe’’ vio-
lence according to risk of injury that would require medical
attention (Straus et al. 2003). Even though ‘‘moderate’’ and
‘‘severe’’ may be considered more appropriate terms, we
followed the original scales’ author terminology.
The frequency of abuse was categorized as once, 2–5 and
more than 5 times,and was considered a measure of chronicity
instead of the mean number of acts to overcome the skewed
sample distribution (Straus et al. 1996). Participants were
characterized as victims or perpetrators of ‘‘minor’’ or
‘‘severe’’ violence according the severity of the reported act.
Ethical considerations
The WHO ethical and safety guidelines (Ellsberg and
Heise 2002) were taken account in the fieldwork design
and the study protocol was approved by local Research
Ethic Committees, ensuring that the principles of anon-
ymity and informed consent were upheld.
Interviewers received instructions for conducting inter-
views in the presence of the participant alone. If privacy
was not ensured, the interviewer would kindly apologize
and stop the questioning. When there was face-to-face
contact, participants were given an envelope where to put
the self-administered violence-module of the questionnaire,
that was sealed and returned to the interviewer. The
training of interviewers followed a standardized protocol,
previously created by the research team. It included pre-
sentation of the project aims, role-playing involving
scenarios related to introducing the interview, dealing with
difficult participants and sensitive situations during the
interview, research ethics and safety of participants and
researchers during field work including handling of
reported/witnessed IPV incidents, and a crisis-intervention
protocol. The voluntary character of participation was
emphasized and although written informed consent was
asked to all face-to-face interviewed participants, no link
between signed consents and questionnaires existed.
Data analysis
Sex-specific, age-standardized (European standard popu-
lation) past year period-prevalence (and 95 % confidence
intervals) of victimization and perpetration was calculated.
For each violence type and sex, the frequency of uni-
directional and bidirectional/reciprocal [being victims and
perpetrators of the same type of violence (Whitaker et al.
2007)] was computed. Chi-square and Fisher exact tests
were used to compare prevalence by sex, city and violence
type. SPSS v20 was used for analysis.
Results
Victimization
Psychological aggression
The prevalence of women victims of psychological
aggression ranged from 46.4 % (41.3–51.6 %) in Budapest
to 70.5 % (65.1–75.8 %) in Athens (Fig. 1). Porto (48.8,
IPV from 6 European countries
123

Fig. 1 Past year age-
standardized prevalence of acts
of victimization (any severity),
(conducted in six European
cities during 2010–2011).
*p\0.05 for sex comparison of
past year estimates within
country; all other site
comparisons for past year
estimates were statistically
significant, p\0.05; error bars
illustrate 95 % confidence
intervals
D. Costa et al.
123

42.3–55.3 %) presented the lowest and Athens (71.8,
66.5–77.2 %) the highest prevalence of male victims.
Severe acts were reported by 37.4 % (31.6–43.2 %) of men
and 30.0 % (24.6–35.4 %) of women in Athens and by
9.7 % (5.8–13.6 %) and 8.0 % (5.2–10.8 %), respectively,
in O
¨stersund (Fig. 2).
The prevalence of psychological aggression of both
sexes was similar in every city except Budapest, where
men reported more often being victims (58.8 vs. 46.4 %,
p=0.04), either of minor (31.6 vs. 26.3 %) or severe acts
(27.0 vs. 19.9 %, p=0.01).
Sexual coercion
Sexual coercion was reported by 9.2 % (6.2–12.1 %) of
women in O
¨stersund and 8.9 % (6.0–11.9 %) in Budapest,
being over 20 % in the remaining cities (Fig. 1). In men,
estimates ranged from 5.4 % (2.6–8.2 %) in Budapest to
27.1 % (21.3–32.9 %) in Stuttgart. In women, the fre-
quency of severe acts was lower in O
¨stersund (1.7,
0.4–3.0 %) and higher in London (9.2, 5.9–12.5 %), with
no male cases in O
¨stersund and 5.5 % (2.8–8.2 %) in
Athens men (Fig. 2).
Physical assault
Porto presented the lowest rates of physical assault (women:
8.5, 5.8–11.2 %; men: 9.7, 5.9–13.6 %) and Athens the
highest (women: 23.1, 18.1–28.1 %; men: 31.2, 25.7–36.7 %,
p=0.040) (Fig. 1). Severe acts in women ranged from
3.0 % (1.1–4.9 %) in Stuttgart to 14.7 % (10.5–18.9 %) in
Athens and in men from 3.5 % (1.1–5.9 %) in Stuttgart to
19.6 % (14.9–24.3 %) in Athens (Fig. 2).
Injury
Women from O
¨stersund reported the lowest prevalence of
injury (1.4, 0.2–2.6 %) while the highest was in Stuttgart
(8.5, 5.5–11.6 %) (Fig. 1). In men, estimates ranged from
2.7 % (0.6–4.9 %) in O
¨stersund to 6.3 % (3.4–9.2 %) in
London. Severe acts in women ranged from 0.3 %
(0.0–0.9 %) in O
¨stersund to 3.6 % (1.5–5.7 %) in London
(Fig. 2). No severe cases were observed in O
¨stersund while
in London the prevalence was 3.7 % (1.5–5.9 %).
Perpetration
Psychological aggression
Women perpetration ranged from 48.9 % (43.7–54.1 %) in
Budapest to 74.7 % (69.6–79.9 %) in Athens while in men
it ranged from 51.5 % (45.0–58.0 %) in Porto to 71.4 %
(66.9–76.7 %) in Athens (Fig. 3). Sex-differences were
found in Stuttgart (women: 66.6 %; men: 55.8 %,
p=0.019) and Budapest (women: 48.9 %; men: 58.1 %,
p=0.030). Severe acts, in women and men, were less
frequent in O
¨stersund (6.0, 3.6–8.4 %, and 6.3, 3.1–9.5 %,
respectively) and more frequent in Athens (30.0,
24.6–35.4 % and 39.1, 33.3–44.9 %) (Fig. 4).
Significant sex-differences in severity of acts were no-
ticed in Athens (p=0.009) and Stuttgart (p=0.039).
Sexual coercion
Budapest (women: 3.6, 1.7–5.6 %, men: 10.6, 6.8–14.4 %,
p=0.002) and Stuttgart (women: 23.5, 18.8–28.1 %, men:
30.6, 24.6–36.6 %) presented the extreme rates and sig-
nificant sex-differences were observed in all cities, except
Stuttgart (p-values \0.001 in Porto and O
¨stersund,
p=0.001 in Athens and p=0.047 in London, Fig. 3).
Severe acts in women ranged from 0.3 % (0.0–0.9 %) in
O
¨stersund to 2.8 % (0.9–4.7 %) in London (Fig. 4). No
male cases were recorded in Stuttgart and O
¨stersund, the
prevalence in London being 5.0 % (2.4–7.6 %).
Significant sex-differences in severity of acts were ob-
served in Porto (p=0.001), Athens (p=0.004),
O
¨stersund (p=0.001) and Budapest (p=0.002).
Physical assault
Women perpetration ranged from 10.0 % (7.1–13.0 %) in
Porto to 21.6 % (16.8–26.5 %) in Athens, and by men from
9.6 % (5.8–13.5 %) in Porto to 33.0 % (27.4–38.6 %) in
Athens (Fig. 3). Severe acts perpetrated by women ranged
from 1.1 % (0.0–2.2 %) in O
¨stersund to 12.1 %
(8.3–15.9 %) in Athens, and by men from 1.0 % (0.0–2.3 %)
in Stuttgart to 21.8 % (16.9–26.7 %) in Athens (Fig. 4).
Significant sex-differences were found in Athens
(p=0.004), with more male perpetration.
Injury
Women that perpetrated injuries ranged from 2.8 %
(1.1–4.5 %) in O
¨stersund to 9.4 % (5.9–12.8 %) in Athens,
and from 1.7 % (0.0–3.4 %) in O
¨stersund to 9.0 %
(5.3–12.7 %) in Stuttgart regarding men, with significant
sex-differences in Athens (women: 9.4 %; men: 3.9 %,
p=0.019) (Fig. 3). Considering women, severe acts ran-
ged from 0.3 % (0.0–0.9 %) in O
¨stersund to 5.0 %
(2.5–7.5 %) in London (Fig. 4). No male cases were
recorded in O
¨stersund, but the prevalence was 4.2 %
(1.8–6.6 %) in London.
In Athens, women significantly more frequently perpe-
trated minor and severe acts (p=0.021).
IPV from 6 European countries
123

Directionality
Bidirectional or reciprocal (being involved as both vic-
tims and perpetrators) was the predominant pattern of
violence (Supplementary Table 4). Significant sex-dif-
ferences in the overall sample were observed for
psychological aggression (only-victims, only-perpetrators
and bidirectional IPV, respectively, were, men:4.1, 3.5
and54.5%vs.women:2.0,5.0,54.4%,p=0.001) and
for sexual coercion (men: 3.0, 7.5 and 12.5 % vs. women:
7.7, 1.6 and 9.7 %, p\0.001).
Chronicity of victimization
Violence was experienced repeatedly (Supplementary
Tables 2, 3). Considering the number of acts of severe
Fig. 2 Past year age-
standardized prevalence of acts
of victimization (minor and
severe acts), (conducted in six
European cities 2010–2011).
Asterisk difference between
men and women is statistically
significant (p\0.05); severe
counts participants who suffered
at least one act of severe
violence in the past year; minor
only counts participants who
declared being victims of only
minor acts of violence in the
past year; all site comparisons
for past year estimates were
statistically significant,
p\0.05; error bars illustrate
95 % confidence intervals for
severe acts
D. Costa et al.
123

psychological aggression victimization, significant sex-
differences were found in O
¨stersund (3.8 % of women
sustained at least one severe act 2–5 times and 4.1 % of
men sustained only once) and in London (12.4 % of
women were victims of a severe act more than 5 times
while 13.2 % of men 2–5 times).
For minor physical assault, significant sex-differences
were found in Athens (10.1 % of women were victims of
one act more than 5 times and 11.4 % of men only once).
Also in Budapest men and women differed (3.9 % and
3.1 % of women being victims 2–5 times and more than 5
times, respectively, while men 4.8 % once and 5.2 %, 2–5
times). Sex-differences were also observed for severe
physical assault in Stuttgart (2.2 % of women were victims
once and 2.2 % of men 2–5 times). Significant sex-differ-
ence was found for minor injury in Athens (2.5 % of
women reported at least one act more than 5 times and
1.8 % of men reported only once).
Fig. 3 Past year age-
standardized prevalence of acts
of perpetration (any severity),
(conducted in six European
cities during 2010–2011).
*p\0.05 for sex comparison of
past year estimates within
country; all other site
comparisons for past year
estimates were statistically
significant, p\0.05; error bars
illustrate 95 % confidence
intervals
IPV from 6 European countries
123

Fig. 4 Past year age-
standardized prevalence of acts
of perpetration (minor and
severe acts), (conducted in six
European cities during
2010–2011). Asterisk difference
between men and women is
statistically significant
(p\0.05); severe counts
participants who suffered at
least one act of severe violence
in the past year; minor only
counts participants who
declared being victims of only
minor acts of violence in the
past year; all site comparisons
for past year estimates were
statistically significant,
p\0.05; error bars illustrate
95 % confidence intervals for
severe acts
D. Costa et al.
123

Chronicity of perpetration
With few exceptions, chronicity of perpetration was similar
within each city according to sex (Supplementary Table 3):
in Budapest, more than 5 minor psychological aggression
acts were declared by 18.3 % of women and 2–5 times by
27.8 % of men. In Porto, 20.3 and 16.4 % of women
reported minor acts of psychological aggression 2–5 times
and more than 5 times, respectively, while 28.6 % of men
reported them 2–5 times. Also in Porto, more than 5 acts of
minor sexual coercion were declared by 15.0 % of men and
8.1 % of women.
In Athens, men and women differed by minor physical
assault (14.7 % of men reported once and 5.8 % of women)
and severe injury (7 women reported to perpetrate one act
once, while no men did).
Discussion
This study suggests that IPV is a frequent plight among
men and women living in these European urban centres,
and that its prevalence and relative proportion of types
present large geographical variation. However, within each
city, men and women presented equivalent prevalence of
victimization and perpetration except for sexual coercion,
more often perpetrated by men. Men and women experi-
enced repeated episodes of IPV, be it ‘‘minor’’ or ‘‘severe’’,
and reciprocal IPV was preponderant in all sites.
Intimate partner violence prevalence
Our prevalence estimates for physical IPV are similar to those
reported in the US for the past 10 years (Desmarais et al.
2012a,b). However, we found higher estimates compared to
those documented for the settings with higher incomes pre-
sent in the WHO multi-country study (Garcia-Moreno et al.
2006), which were Japan (3.1 % for physical IPV against
women and 1.3 % for sexual IPV) and Serbia and Mon-
tenegro (3.2 % physical IPV and 1.1 % sexual IPV). Our
estimates were also higher when compared to those observed
in the International Violence Against Women Surveys
(IVAWS) European sites (Johnson et al. 2008), for which past
year physical IPV against womenrangedfrom1%inDen-
mark and Switzerland to 8 % in Czech Republic.
European nation-wide studies of IPV in both genders
have been conducted in the UK, Denmark and Sweden,
although differences in study design and IPV definitions
hinder comparisons. Nevertheless, the British Crime Sur-
vey (Khalifeh et al. 2013) points to past year estimates of
physical IPV against men of 1.3 % and of 2.0 % against
women, whereas in Denmark (Sorensen et al. 2012) these
were 6.4 % in men and 5.0 % in women, lower than our
results. Two studies conducted in Sweden (through post),
one using the WHO tool (Nybergh et al. 2013) and another
using the CTS2 (Lovestad and Krantz 2012) showed that
past year physical IPV against men was 7.6 and 11 %,
respectively, and against women it was 8.1 and 8 %, while
sexual IPV male victims were 2.3 and 0.6 % and female
victims were 3.0 and 3.2 %. Also a study conducted among
women living in Germany (Stockl et al. 2011) showed that
15 % ever experienced physical violence and 17 %
experienced physical or sexual violence.
We considered acts of physical and sexual IPV,
regardless of severity, which might partially explain our
higher estimates. When we considered only ‘‘severe’’ acts
of physical assault victimization, our results lay in the same
range as those cited (Fig. 2), except in Athens, showing a
significantly higher prevalence.
No further recent comparable data were available for the
other countries concerned and psychological IPV against
men and women has been much less studied, mainly
because of lack of agreement on standard measures and
definitions (WHO 2013).
Previous cross-cultural research on violence against
women has suggested that societal factors such as attitudes
towards IPV (cultural acceptance of violence as normative
behaviour) (Uthman et al. 2010) and country-level socio-
economic features (Uthman et al. 2009), may explain
country differences observed in the status of women and
men in society and thus relate to the cross-country variation
in prevalence. Such factors might also explain the variation
observed in our study, although the city-differences seemed
specific to the type of violence: for example, physical
assault was more reported by participants in Athens and
less so in Porto, but this difference was reversed when
reporting sexual coercion. This may be an interesting dif-
ference considering that Portugal and Greece present worse
socioeconomic indicators and the lowest level of gender
equality (EIGE 2013) compared to the other sites in the
study. Other cultural specificities should be explored for
each violence type in these industrialized settings.
Differences between sexes
Within each city, the frequency of victimization and per-
petration of psychological aggression, physical assault and
injury was similar between men and women. A meta-ana-
lysis of 82 studies assessing aggression suggested that
women were more likely than men to practice physical
aggression acts and to do it more frequently while men were
more likely to inflict injury (Archer 2000). Our findings
appear to confirm this, favouring theories of social roles that
explain similarities in male and female IPV as a result of the
evolving gender equality of western societies (Archer
2009).
IPV from 6 European countries
123

Additionally, sexual coercion perpetration was different
between men and women. In the Swedish general popula-
tion more past year sexual coercion victimization was also
found in women [3.2 vs. 0.6 % with the use of the CTS2
(Lovestad and Krantz 2012) and 3.0 vs. 2.3 % with the
WHO tool (Nybergh et al. 2013)] while perpetration was
declared by 5.2 % of men and 0.8 % of women. As with
other self-reported sensitive and private issues, gender and
country-specific stigma about IPV perpetration may impact
on self-disclosure, although if this was the case, we would
expect larger within-country differences than those noted.
Likewise, using the CTS2 individual data (compared to
couple data) to assess IPV may lead to underreporting, both
in men and women, but even more in men (Archer 1999;
Chan 2011). However, such information pertains mainly to
physical assault and if male reporting of sexual coercion
was affected, the observed sex-difference would be wider.
Recent studies have reported that sex-differences might
be only found in lifetime victimization and perpetration
estimates when compared to past year estimates, reflecting
women’s more severe experiences (Lovestad and Krantz
2012; Nybergh et al. 2013). However, an analysis of life-
time prevalence for the four types of IPV assessed
(Supplementary Tables 5, 6) revealed the same cross-
country differences as noted for past year estimates and
sex-differences within each site also followed the same
pattern found for past year estimates.
Chronicity
The chronicity of abusive acts helps to explain sex-differ-
ences according to the type of IPV. For instance, the
construct of intimate terrorism describes a type of abuse
repeatedly perpetrated by men against women, whereas
common couple violence, suggested as typical of the
general population, tends to be less severe and less frequent
(Johnson and Ferraro 2000). As presented in Supplemen-
tary Tables 2 and 3, the frequencies of abusive acts of
victimization or perpetration were similar in men and
women for all IPV types, supporting a gender equivalence
in IPV that favours social theories associating women’s
empowerment to the traditional profile assumed with their
partners (Hines 2007). However, our chronicity analysis
pertains only to the abuse experienced during the previous
year, not allowing to clearly test the presence of intimate
terrorism, which might be underestimated in population-
based studies with this type of approach (Johnson et al.
2014).
Bidirectional violence
Previous studies suggested that IPV perpetration by both
partners within a relationship is fairly common, but this
was criticized under the assumption that differences would
be revealed if the severity and repetition of acts was
assessed (Whitaker et al. 2007). In our study, bidirection-
ality (being involved simultaneously as a victim and as a
perpetrator) was accompanied by similar severity and
chronicity confirming previous studies (Riggs et al. 2000).
The focus on the protection of women victims and
restriction of men-perpetrators has to evolve towards a
general victim protection and restriction of perpetrators,
continuing actions to prevent violence against women but
raising awareness to prevent IPV on men.
Study limitations
We cannot rule out bias in prevalence estimates due to
differences in sampling and data collection. We did not
collect information on refusals or response rates. However,
a comparison of participant’s characteristics sampled from
different sources, within the same city (performed in Porto
and London) (Costa et al. 2013), suggests that the sampling
method may not have biased participants’ characteristics
mix.
The CTS2 was self-completed without intervention of
interviewers. Nevertheless, mailed questionnaires may have
resulted in a lower disclosure, particularly if participants
filled the questionnaire without privacy (namely with the
presence of their partner) as opposed to the private setting
ensured in sites where a trained interviewer introduced the
questionnaire. This might explain the lower IPV rates ob-
served in O
¨stersund. However, in Stuttgart, IPV rates were
amongst the highest, therefore, if any underestimation ex-
isted due to low disclosure induced by the post method, we
would expect even higher prevalence estimates.
Regarding the use of telephone, bias might arise if
landlines do not cover specific groups (ex: lower socioe-
conomic position). Only in Porto was this method used for
recruiting and an older than expected population assessed.
Our samples’ age and educational profiles were compared
with the general population characteristics’ as provided by
the respective National Statistics Institutes (five-age
groups, by sex) and Eurostat country estimates (education)
and a slight over-recruitment of older people in Porto,
O
¨stersund and Budapest and of more educated people in all
sites was observed (Costa et al. 2013). Additional stan-
dardization for education did not affect the estimates
(results not shown), and if residual confounding remained
violence prevalence would be underestimated (Bangdiwala
et al. 2004).
The CTS2 has been criticized for not measuring context-
related features of IPV and only counting acts of violence.
Contextual and meaning variables of interest should be the
focus of further research efforts, assessed with separate
valid instruments along with the CTS2 (Straus 2012).
D. Costa et al.
123

Conclusions
This is the first study reporting comparable data on four
IPV types in six cities of six countries, contrasting adult
men and women from the general population and detailing
the perspectives of victims, perpetrators and of those
declaring both. Even though different sampling techniques
were used, all aimed to provide probabilistic samples of
each city resident’s and the remaining procedures that were
taken account during the study design (sample size calcu-
lation allowing appropriate statistical power to determine
IPV prevalence and cross-city comparisons, the use of the
same training and standardized questionnaire in all centres)
ensure the validity of these results.
The high prevalence rates and the variation observed in
these European cities for psychological aggression, physi-
cal assault, sexual coercion and injury as types of IPV,
emphasizes the significance of preventive interventions,
given the well-known consequences to health associated
with IPV. These results also emphasize the need to con-
sider city-level characteristics that influence men’s and
women’s reports of IPV. Similar prevalence estimates
between men and women within the same city and the
bidirectional or reciprocal pattern (being both a victim and
perpetrator) observed in the experiences of psychological
aggression, physical assault and injury must be considered
in the design and the evaluation of preventive
interventions.
Acknowledgments The authors would like to thank all men and
women who generously participated in the DOVE project in the
different cities across Europe. This work was supported by the
Executive Agency for Health and Consumers—European Commis-
sion [contract number: 20081310] and the Fundac¸a
˜o para a Cie
ˆncia e
Tecnologia [SFRH/BD/66388/2009 and PTDC/SAU-SAP/122904/
2010].
Conflicts of interest None declared.
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