Prim Care Clin Office Pract

33 (2006) 187–197

Violence and Men’s Health

Peter Stringham, MD, SMBoston University Medical School, Department of Pediatrics and Adolescent Medicine, East

Boston Neighborhood Health Center, 10 Grove Street, East Boston, MA 02118, USA

A combination of biology and culture makes men more susceptible todeath and injuries from violence, and makes them more likely to committhe violence that causes death and injury in others. In the United States,the 2002 murder rate was 9/100,000 for men compared with 3/100,000 forwomen. Seventy-five percent of all homicide victims are men as are 90%of all offenders. Men ages 18–24 have the highest crime and murder rate:100/100,000 for black men; 13/100,000 for white men; 11/100,000 for blackwomen; and 3/100,000 for white women. In other violent crimes, exceptrape, men are also much more likely to be victims and offenders [1].

Practitioners can ask men about violence in their lives by identifying riskfactors for violence, and health care professionals can promote strategiesthat protect men from violence. Factors that protect men from violenceare protective families, higher education, supportive communities, satisfyingwork, a hopeful future, ability to enjoy life, friendship, connections to otherpeople, feeling connected to a positive force that is bigger than they are (na-ture, humanity, the universe or God), and a past history of nonviolence.Risk factors for violence are unsupportive families, poor education, disorga-nized communities, unsatisfying or no work, no hope for the future, inabil-ity to enjoy life, lack of or unhealthy friendships, substance abuse, poorconnections, and a past history of violence. Gun ownership can make vio-lence more lethal [2–6].

As medical practitioners become more comfortable addressing behavioralissues in their patients’ lives, they can also address violence. In the office,documenting a behavioral history that includes violence makes it possiblefor a practitioner to assess the patient’s risk for future violence, to determineappropriate interventions, and to counsel for prevention. Out of the office,practitioners can help decrease communities’ tolerance for violence as amethod to resolve disputes.

E-mail address: stringhp@ebnhc.org

0095-4543/06/$ - see front matter � 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.pop.2005.11.006 primarycare.theclinics.com

188 STRINGHAM

Box 1. Taking a history for teenagers and adult men

� How much education do you have?� Tell me about your work.� What are your future plans?� What things do you do that you really enjoy and make you glad

to be alive?� Tell me about your friends.� Tell me about who and what you love.� Do you have a history of alcohol and drug use?� How many times in a month do you get depressed or really

frustrated? What brings it on and what gets rid of it?� Have you ever been so depressed that you wished you were

not alive?� What about yourself are you the most proud? What are your

best qualities?Follow-up questions

� What is the most upsetting thing that has ever happened toyou?

� How many pushing or shoving fights have you had in the lastyear?

� (If any) Tell me about them: what were they about, were thereany injuries, are the fights resolved? (Try to assess for howwilling the patient is to fight.)

� Generally how do you get out of fights? (Look for nonviolentattitude and skills.)

� Have you ever been threatened with a weapon?� (Sometimes) Are gangs a problem where you live? (If so)

How do you deal with gangs?� Have you ever carried a weapon for self protection? (Virtually

all men who carry weapons believe they carry weapons onlyfor self protection. Also, pocket jack knives are generally notconsidered weapons.)

� Have you ever had a pushing or shoving fight in a dating orlove relationship? (If yes) Tell me about that.

� Is there a gun in your home? What is it for and how is it stored?(Especially ask about this for depressed patients.)

� Has any one hit you at home in the last year?� (As part of a sexual history) Have you ever been forced to have

sex against your will?� (Sometimes) Have you ever had trouble with the police?� When it comes to feeling connected to nature, how connected

do you feel? Not that close, a little bit close, or very close?

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Taking a history

A comprehensive medical and social history is designed to establish rap-port and a relationship between patient and practitioner that highlights thepatient’s strengths. Sample interview questions that can be used to obtaina history for teenagers or adult men are outlined in Box 1 [7,8].

Diagnosis

Most frequently, violence is a consciously chosen tool that some men useto solve conflicts. Sometimes violence is a symptom of underlying disease,psychological disorder, or situational problem. In the latter cases the under-lying problem needs to be addressed. If a patient has attention deficit/hy-peractivity disorder (ADHD) and violent tendencies, treat the ADHD.Similarly, if a patient has substance abuse problems, address substanceabuse. If an extremely frustrated man is unemployed, refer him to a jobprogram.

Acutely violent patients

Medical crises cause anxiety, and some patients or family members reactto anxiety and uncertainty with violence [9]. Medical staff, patients, andfamilies need to be protected. A calm, respectful staff will help prevent pa-tient anxiety, and a calm, respectful security system can settle down anxiouspatients and families who might resort to violence.

Sometimes the violence is a sign of an underlying medical condition. TheWHIMPS pneumonic can help assess for medical diseases: (W) withdrawal,Wernicke’s encephalopathy; (H) hypoxia, hypertensive crisis, hyperthyroid-ism, hypoglycemia, hyper or hypothermia; (I) Intracranial bleed or mass, in-toxication; (M) meningitis; (P) poisoning; (S) status epilepticus. Psychiatriccauses may be delirium, posttraumatic stress disorder (PTSD), mania, para-noia, or other psychosis.

The visual presence of several quiet, preferably large, men can often quietdown an agitated patient. Keep dangerous equipment out of the patientsreach and allow both the patient and the clinician an escape route froman examining room.

� When it comes to people, those you know and those you don’tknow that well, do you feel not that close, a little bit close, orvery close?

� When it comes to the whole universedsome people call itGodddo you feel not that close, a little bit close, or veryclose?

Try to end the interview on a positive note.

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When patients or family members are potentially violent and do not haveunderlying medical or psychiatric diagnoses, clinicians can ask them to ex-plainwhy they are upset and address those issues.Apologies and compromisesmay be appropriate and reasonable. One can respond to agitated and abusivetalk with respect, assess why the patient is upset, and address those issues.

Generally, agitated people can feel threatened if they are touched, so talkto them, offer them water or coffee, but give them some physical space.Guide potentially violent people out of a large public space to talk, butkeep doors open so the upset person or the clinician can exit, and have vis-ible security guards within sight and ear shot.

Sometimes it helps to explain, ‘‘You are scaring everyone.’’ If the clini-cian feels afraid, it is a signal to leave the room and get help. If the securityguards are not enough, get help from the police.

A history of increased violence

All people are on a continuum for violence, and the patient history isa tool that practitioners use to assess where on the continuum each patientlies. Most people are below the high violence extremes described here [10].

Men who fit the low violence profile (school or career is going well, gener-ally feels happy, nohistory of fights in last year, has friends, feels connected, notrouble with police or gangs) have different beliefs, skills, and impulses com-pared with men that fit the high violence profile. Low-violence men believethe world to be a neutral or positive place; they believe that talking is thebest way to resolve conflicts. They have many skills for solving conflicts with-out violence. They ask for information, they explain their side of a conflict,they offer compromises, and they have a non-impulsive approach to conflicts.They connect and make an alliance with their adversaries to resolve conflicts.

Men who fit the high violence profile (school or career is going poorly,feels depressed or frustrated a lot, history of fights in last year [the greaterthe past number and more serious the fights, the greater the future risk], so-cially isolated, does not feel connected, trouble with police, in a gang) be-lieve that life is filled with adversity and conflict, that other people are outto get them, and that fighting is the only effective way to resolve conflict.These men have very few skills for solving conflicts nonviolently and havean impulsive, act-before-thinking, style to conflict resolution.

Treatment plans

With all teenagers, and with men who have trouble with street fighting,we can try to change behavior. Office interventions are based on a relation-ship between provider and patient that acknowledges the patient’s strengths,basic decency, and health. All young men need to be admired. After a com-prehensive history that includes their wishes and skills, most doctors canadmire their patients.

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Changes around violence follow the classic behavior change model usedin smoking, drugs, or alcohol [11].

� Precontemplationd(patient sees no problem with the behavior). Youhave told me that you get into fights in bars. I am worried about this.Have you ever thought of doing something different?

� Contemplationd(patient acknowledges some discomfort with behaviorand might consider a change). You have told me that you didn’t like allthe fighting in your neighborhood. I know a lot of guys from your neigh-borhood who don’t fight with anyone and who aren’t wimps. I can tellyou the strategies they use.

� Early changed(patient is trying to change behaviors). Talking to somegang members about pulling back from gang activity is good. You can stillkeep on good terms with individuals in a gang as friends without being in-volved in the gang activities. (or) Staying away from those guys completelyfor a while and making new friends completely is a good plan.

� Relapsed(patient falls back into poor behavior after vowing to quit).You changed before and you can do the same thing again. There are coun-selors who can help you.

Teaching conflict resolution

Intervention to teach young men how to resolve conflicts without vio-lence involves helping to change attitudes about violence and when to fight,and simultaneously teaching nonviolent skills to resolve conflicts withoutlooking weak. This is a 1–2 minute intervention.

I talk with a lot of guys around here. Most of them don’t fight and theydon’t get harassed. I’ve asked them what they do, and this is what they tellme.

� They say the most important tool to keep out of fights is a good attitude.They treat everyone like he is a cousin. You might have a cousin who isupset and may even want to fight. You probably won’t fight him; you’lltry to find out why he is upset. You ask, ‘‘Why are you saying that?’’and go from there. If you did something wrong, you could apologize andtry to make it right. If you didn’t do anything wrong you could explainthat. Essentially you are treating your cousin with respect and yourselfwith respect. Guys who get along with everyone treat everyone theymeet like they are a cousin. You can be a guy that anyone can talk toand work out any kind of problem that comes up. You essentially tellyour cousin,’’ You can talk to me about anything and I will work it outwith you, but I won’t fight you.’’

� When someone is upset and very angry, they sometimes are a little para-noid and afraid of you, so it is important to stand at least arms length awayfrom a person who wants to fight you. You don’t want make them moreafraid and attack you.

192 STRINGHAM

� Treating people with respect, like a cousin, will prevent 90% of all streetfights right up front. There will be some situations where this doesn’twork. The non fighting guys say that they leave conflicts if any of thesefollowing things happen:

� If you feel genuine fear leave. We rarely feel afraid in real life except inmovies. If you walk into a club or any other place and feel real fear,know that your body is telling you something important. You might notbe able to say what is wrong, but your body is sensing that something isdangerous and you should get out of there as quickly as you can. (Alcohol,cocaine and weapon carrying are associated with increased fightingpossibly because they numb a person’s self protective fear. Similarlyteenagers who carry guns say they keep going deeper into conflicts be-cause they don’t feel afraid.)

� If you think you are going to lose your temper leave. Men cannot thinkwell when they lose their tempers. You need to think clearly to talk tosomeone who is upset. If you think you are beginning to lose your temperyou can say, ‘‘I am beginning to lose my temper, so I have to leave. I willtalk to you another time when I have calmed down.’’

� You can also leave if a person wants to fight you and they are acting ob-viously drunk or high or acting crazy. If a guy can’t listen to you just leave.

� This last one is hardest. You may see someone hurting another person, butyou alone would not be able to stop it. Leave and then get help to stop it.We feel bad if we let an injustice go uncorrected so we sometimes need toget outside help. (As a doctor you can get a relationship with the local po-lice, particularly the officers in charge of community and youth policing.Then you can refer people to that person if you think they are sensible.)

� Does this make sense to you? (If not.) What kinds of things work for peo-ple around here? (You may learn other good ways to peacefully resolveconflicts in your particular neighborhood.)If your patient is in a lot of fights and is at all worried about his behavior,

an in-office intervention may not be enough. You can suggest a counsel-or who can help him with whatever combination of depression, careerproblems, substance use, and violence he has. Even very violent, trou-bled youth can turn their lives around when they are motivated. Somecities have created programs for youth who have trouble with multipleareas of poor behavior.

Gun ownership

Guns increase the lethality of a violent act whether it is defensive or ag-gressive. Murder rates are generally higher in countries and states withhigher gun ownership rates. Southern states have a higher murder ratethan northern, western, or midwestern states. The 2002 annual murderrate in the United States was 5.6/100,000; the most frequent cause was

193VIOLENCE AND MEN’S HEALTH

fights, followed by robberies. Most of the murders (7176/14,054) were com-mitted with handguns [1].

Children enjoy playing with everything, and many children will play withguns if they are around. In a study of Boston and Pittsburgh teenagers, 19%had handled a gun without their parents’ knowledge or permission [12].

As a doctor, it is reasonable to recommend that parents not keep loadedguns around the house. If they believe they need a gun, it should be kept un-loaded and in a locked location, preferably with the ammunition stored sep-arately from the gun. If a child or adult has clinical depression, find out ifthere are guns close by, and if so, recommend their removal.

Aggressiveness in a dating relationship

If a patient indicates that sometimes he hits his girlfriend, and on furtherquestioning the practitioner thinks he may be falling into a controlling rolein a relationship, try to initiate a behavior change using the precontem-plation (This is OK with me and I don’t want to change), contemplation(Maybe there is another way), early change (I’ve tried to stop), and relapse(we’re back in the same pattern) model.

For any of these behavior changes to be effective, the doctor must haveestablished a true working alliance with the man. Preaching and shamingare ineffective. A doctor’s offer to a patient should be: ‘‘If you want to dosomething different I can help you live a happier life.’’

Precontemplationdthe patient feels comfortable controlling hisgirlfriend.

� Your examination shows you are strong and well. You did tell me that youfeel you need to tell your girlfriend how to dress and who her friends canbe, and that you have hit her a couple of times, but that she is not afraid ofyou.

� I am worried about that.� I am really glad you think she is not afraid of you yet. If a woman everbecomes afraid of a man, rather than feeling close to a man she will startto put distance between the two of them. I think in love relationships a mandeserves closeness, trust, respect, support, and love. If fear ever gets intothat, love dies. A man may get obedience, but he loses respect, closeness,friendship, and love. It’s sad. Even sex can become bad, because a womandoesn’t feel close and trusting of the man.

Contemplationdthe patient may want to change.

� When you are upset, say you are upset. When your girlfriend is irritatingyou, say, ‘‘ this is bothering me.’’

� You want someone with you because they choose to be with you, not be-cause they are afraid to leave. Make sure you ask your girlfriend whatshe wants, and see if you want to meet some of those needs.

194 STRINGHAM

� I think a good relationship is one in which: you feel good about yourself,you feel good about your partner, you feel good about what goes on be-tween the two of you, she feels good about herself, she feels good aboutyou, she feels good about what goes on. As you can see this is pretty com-plex, but that is the way it is. If you cannot keep all six things pretty muchin balance over time, consider changing girlfriends.

� If you feel you need to control a particular girl or you feel that you want tohit a girl a lot, consider changing girlfriends to someone who you know willleave you in a minute if you are aggressive with her.

If you feel the patient is actively abusing his partner and has no desire tochange, you can try to talk to him, but know your primary responsibility isto the abused partner.

Feeling connected

A primary prevention strategy to address violence is to promote the op-posite of violence: a more peaceful approach to life. People who feel deeplyconnected to something bigger than they are that is positive are more resil-ient [5,13]. A practitioner can explain the reasoning behind the questionsabout feeling connected to nature, humanity, or the universe, and recom-mend that men increase their feelings of deep connection to a positive forcethey respect. Because of past history and individual personality, differentthings work for different people. One size does not fit all. However, manyinner city and suburban youth in the author’s practice find meditation a use-ful practice. An approach to introducing meditation is outlined in Box 2.

Interventions in the community

Prothrow-Stith and Spivak [3] have outlined a comprehensive communityapproach to decreasing violence and murder by defining violence as a conse-quence of despairing young men who see no future for themselves, who areencouraged in a culture of violence from many sources, and who have easyaccess to handguns.

Leaders can stop agencies from blaming each other for the problem ofviolence. Professionals can acknowledge each profession’s limited powerto solve the problem of violence. By working together, schools, communitygroups, medicine, clergy, police, recreational groups, gang workers, andbusiness leaders can decrease violence in an entire community. Youngmen need to interact in ways that are safe and promote nonviolent waysof resolving conflicts. They need meaningful jobs, they need connections,and they need hope for the future. This hope needs to be available to menof all personality types and all skill levels.

Medical professionals can be influential with community leaders to pro-mote or participate in a coordinated effort. Some community opinion

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makers, like some patients, need to be shown how to promote nonviolenceand still be assertive.

Intervention after a fight

Doctors see men who are injured in fights. One can generalize from self-inflicted injury assessments and interventions to ‘other inflicted’ injuries [14].

Box 2. Introducing the practice of meditation to patients

� Pick a word to help you meditate like ‘‘peace, love, one, or yes’’.Any word will do.

� Sit with your feet on the floor and your hands in your lap. Closeyour eyes.

� As you breathe out think the word.Think the word.� If an idea comes into your head, think, ‘‘Oh well, I’ll think about

that later’’ and go back to the word. Imagine ideas as paperboats floating on the river. You are in the river. Just let yourselfsink deeper and deeper into the quiet peacefulness of the river.Let the paper boats float by.

� After a while you will begin to feel you are in a quiet safe place.You will feel perfectly safe, perfectly calm and perfectlyloved.This is meditation. .

� If you do this every day for 5 to 20 minutes once or twice a day,you may be able to feel this same peaceful quiet feeling manytimes a day when you are not meditating. When you wake upyou will see your clothes and your food and you’ll feel thisfeeling. When you see your friends or family, you will feelthis feeling. When you see the trees or the sky, you will feel thisfeeling.

� The idea is just to hang out in the quiet place and rememberhow to get there.

� I will teach you one more thing while you are here in this quietplace. Maybe you have a problemda little problem or a bigproblem. Think, ‘‘I want a helper,’’ and a helper will appear toyou. You can ask the helper for advice about the problem,and you will probably get good advice. If it is a very bigproblem ask the helper to take some of it away from you. .

� What you have learned today is that you have a place withinyou where you can go whenever you want to feel safe, calm,and loved, and you have a place within you where you can goto get good advice.

� Now whenever you want to, open your eyes.

196 STRINGHAM

An acute assessment is designed to answer the question, Is the patientsafe to leave here after the injury is stable and is there anyone else who isin danger after this patient leaves?

� Stabilize the patient medically and deal with the injury.� If medically stable, find out the circumstances of the injury. If you don’tunderstand the dynamic, say, ‘‘I don’t understand that. Explain that tome.’’

� Assess to see if the patient is safe when he leaves your office. ‘‘Is this con-flict settled?’’ (Is the patient still a target?)

� Assess to see if anyone else is in danger. ‘‘What will happen after youleave here?’’ (Will anyone take revenge?)

� If the conflict is not settled, see if there is a mediator to settle theconflict without violence. ‘‘Is there someone who can settle this peace-fully?’’ Most conflicts occur between people who know each otherand most communities have natural peacemakers who know everyoneand can sometimes calm down these conflicts. Some hospital emer-gency rooms have hired community peacemakers to perform thisfunction.

� Sometimes a police department needs to be involved because the patientfeels afraid or because they will feel they personally need to take revengeif the police are not involved.

� Just as in suicide attempts, do not let the patient leave your office untilyou feel that the violence has ceased.

A subacute assessment is designed to determine if the injured patientneeds a long-term plan to prevent further injuries. The acute assessmentcan give the circumstances of the inflicted injury. A modified version ofthe previous routine assessment questionnaire will help give a man’s overallsusceptibility to violence. The subacute diagnoses can be a mixture of thefollowing:

� Innocent injurydpatient was fooling with a friend and injury is more ofan accident. Low overall risk on routine assessment. No intervention

� Victim of a crimedmay need post traumatic stress counseling or policeintervention.

� Depressiondpatient recklessly put self in dangerous situation. May in-dicate need for therapy for posttraumatic stress disorder, depression,alcohol or other substance abuse, or attention deficit disorder.

� Flirting with violencedpatient is on the edge of a culture of violence.May need a referral for career counseling or substance abuse. Needshelp with the steps for behavioral change.

� Deeply committed to violence as a life styledalthough few people havegood answers here, if a clinician can make a connection with this man,he may be able to help him consider changing in the future. Even veryviolent men are ambivalent about their own violence.

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Summary

As practitioners gain more skill regarding how to address behaviorchange in their male patients, they can add violence to the list of changeablebehaviors that create misery for many men. Nonviolent street-smart menknow how to make empathic connections with other men who may be upset.When doctors themselves can establish empathic alliances, know where pa-tients are coming from, and know alternative beliefs and skills for assertivebehavior that work for other men, they can offer hope and concrete skills formen who suffer from violence. Practitioners also need to develop a referralnetwork of mental health and educational counselors who are skilled in be-havioral change. Medical professionals can help to make their communitiesmore connected and nurturing places to live.

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