Intimate partner violence and its psychosocial correlates among male survivors: The socio-ecological implications

Previous research on the psychosocial correlates of intimate partner violence (IPV) among men has predominantly focused on clinical disorders such as depression and posttraumatic stress disorder. Little is known about the socio-ecological implications of IPV on male survivors. This article examines how nonclinical stressors, such as expectations to perform masculinity and shame of non-performance, intersect with clinical disorders to cause profound suffering in male survivors. Consequently, the article argues that socio-ecological interactions facilitate stressors, culminating in detrimental consequences of IPV for male survivors’ psychosocial well-being. By examining the qualitative experiences of 25 African male survivors of IPV and the perspectives of five key informants working with IPV victims in Johannesburg, this article emphasizes the importance of considering both clinical and nonclinical factors in understanding the psychosocial impacts of IPV on male survivors. The findings support the need for appropriate interventions that address pervasive societal ideologies that further facilitate stress on male survivors’ well-being.


Introduction
Intimate partner violence (IPV) is recognized as one of the most pervasive and harmful forms of interpersonal violence worldwide.IPV occurs when one partner in a romantic relationship engages in destructive behaviours to cause physical, psychological, and sexual harm to the other partner.These behaviours encompass acts of physical aggression, emotional aggression, sexual coercion, and controlling behaviours aimed at dominating the other partner [1] .IPV can occur in various types of partnerships, including marriage, cohabitation, or dating relationships, and can involve both heterosexual and same-sex couples [2,3] .According to the World Health Organisation [4] , approximately one in three women have suffered profound psychosocial effects of physical and sexual IPV worldwide.IPV remains a prevalent issue for women, showing an upward trend in low-and middle-income countries such as Sierra Leone, Timor Leste, and The Gambia.This poses a significant challenge to achieving target 5.2 of the Sustainable Development Goals [5] .The arrival of the global coronavirus pandemic and subsequent harsh lockdown measures significantly exacerbated the psychosocial impact of IPV on women [6,7] .
Although the understanding of IPV against men remains limited due to concerns about underreporting and a lack of research focusing on male victims, evidence suggests its widespread occurrence globally.For instance, in Europe, reciprocal victimization is evident in cities like Athens, Budapest, Porto, Östersund, Stuttgart, and London, with men experiencing physical IPV at a rate of 9.7% compared to 8.5% for women [8] .Instances of sexual violence ranged from 5.4% for men to 8.9% for women [8] .Furthermore, emerging studies have begun exploring the qualitative perceptions and experiences of male IPV, although with limited sample sizes [9,10] .However, research on IPV against men is scarce in Sub-Saharan Africa due to misconceptions surrounding male experiences, perceptions of manhood, and power dynamics, which can be fluid across different contexts [11] .Despite this, surveys have indicated varying rates of male victimization, ranging from as high as 32% in Zambia to as low as 9% in Mozambique [12] .Furthermore, there are documented cases of IPV where women scold their partners with hot water, stab them while they are asleep, and subject them to emotional and physical abuse [13,14] .A study carried out with women serving prison sentences in South Africa has recorded fatalities resulting from IPV among men [15] .
Historically, studies examining the psychosocial impact of IPV on survivors have primarily focused on the clinical significance and the psychological well-being of women survivors.Wessells and Kostelny [16] have noted that the emphasis on the individual's psychological aspect has led to a significant oversight of the broader social context that profoundly influences the entire socio-ecological environment of survivors.This limited perspective fails to capture the full complexity of the experiences and needs of survivors in diverse cultural settings.Similarly, research discourses on male survivors, predominantly conducted in Western nations, have also been guilty of disregarding the impact of social and cultural aspects on shaping men's perceptions of their psychosocial identities and relationships.Instead, these studies have primarily focused on the physical and psychological harm experienced by men [3,[17][18][19] , neglecting the broader socio-ecological and even economic context of male IPV survivors.The outcome of this article offers insights that could inform the development of regulations, policies, and interventions aimed at addressing nonclinical stressors among male IPV survivors. [16]point out that the symptomatology of psychological and mental disorders alone does not adequately capture the full impact of IPV on survivors' mental health.Although disorders such as posttraumatic stress disorder (PTSD), depression and suicidal ideation can be debilitating, male IPV survivors may experience multiple interacting disorders, further exacerbating their challenges.Other nonclinical stressors include challenges accessing legal and medical services, poverty [16,20] , and the inability to articulate normative masculinity [21] .To comprehensively understand the impact of IPV on men, it is crucial to incorporate these perceptions into the analytical framework, as psychosocial difficulties are intricately connected to men's understanding and expression of their identities and normative values.This article draws on a more extensive study that examines the experiences of IPV victimization in a sample of heterosexual African men in Johannesburg [14] .The focus here is to contribute to the understanding of a social-ecological analysis of the psychosocial effects of IPV on male survivors, complementing existing clinical analyses in the global IPV literature.By adopting Dahlberg and Krug's social-ecological model, this article seeks to understand how interactions at different levels of the survivor's socio-ecology facilitate multifaceted stressors on the psychosocial well-being of the male survivor [22] .This article elucidates IPV's clinical and social toll on these male survivors, illustrating its effects across individual socio-ecological levels and dimensions.The study concludes with a discussion on the implications of this understanding for IPV awareness and practices concerning male survivors.

Mental health and psychosocial effects of IPV
The broader discourse surrounding mental health and psychosocial disorders has often failed to fully address the social and cultural implications of IPV.According to Wessells and Kostelny [16] , one potential explanation for this oversight lies in the divergent interpretations of the term "psychosocial" across different disciplines.For instance, within humanitarian practice, psychosocial signifies the utilization of local cultures and community resources to facilitate healing and well-being [23] .On the other hand, in public health discussions, psychosocial is associated with mitigating the effects of clinical conditions such as depression and stress disorders [16,24] .From a more holistic view, Perez [25] defines psychosocial as the "dynamic relationship between psychological and social effects".This characterization underscores the reciprocal implication of these two aspects, where each factor perpetually shapes the other.This definition emphasizes the interplay between mental health conditions and societal issues and how individuals construct personal significance in response to their lived experiences.Consequently, acknowledging the intricate interconnection between IPV's psychological and social dimensions can profoundly enhance our comprehension of its far-reaching impact on survivors.
Several studies have underscored the profound clinical repercussions of IPV on men, encompassing physical harm and substantial negative psychological aftermaths.Considering concerns suggesting that women may exhibit emotional aggression towards their male partners at higher rates [8,26,27] , men subjected to IPV often grapple with severe mental afflictions like posttraumatic stress disorder (PTSD), depression, and complex trauma and anxiety disorders [3,19] .For instance, Hines's [17] investigation unveils that men enduring IPV are prone to develop PTSD symptoms across diverse cultural contexts.This study scrutinizes the prevalence of PTSD and levels of violence, and animosities directed towards men.The research cohort, composed of 3,461 men recruited from 60 university and college campuses spanning the U.S., Canada, Europe, and Asia, highlights an intriguing finding.The study notes that societies characterized by lower levels of entrenched violence are less inclined to acknowledge the substantial impact of female partners' hostility and aggression towards their male counterparts.These insights corroborate earlier conclusions suggesting that IPV is often accompanied by PTSD and severe depressive disorders, prevalent as co-occurring maladies among both abused males and females [2,28,29] .
A parallel strand of evidence emerges from Masho and Anderson's [30] population-based inquiry conducted in Virginia, which delves into the lifetime prevalence and ramifications of sexual assault among males.Beyond the evident physical health consequences such as insomnia, their study establishes that male survivors of sexual assault are 3.4 times more susceptible to psychosomatic symptoms, depression, stress, and suicidal ideation than non-abused men.These findings harmonize with research by Chan et al. [31] that explored the interplay between dating violence, depressive tendencies, and suicidal ideation.The study examines a cohort of 16,000 university students across 21 countries.It unveils a marked correlation between frequent experiences of depression, instances of physical and sexual assault, and suicidal ideation.Notably, 30% and 20% of male and female students reported being victims and perpetrators of physical violence, while 20% and 24% had been involved in sexual coercion, respectively.Suicidal thoughts were prevalent across 32% of sites in median nations such as India, New Zealand, Greece, Russia, and the United Kingdom, with prevalence rates ranging from 8% to 48% [31] .In Uganda, Kinyanda et al. [18] post-conflict cross-sectional survey explored the prevalence, risk factors, and mental health repercussions of IPV victimization across genders.The study revealed similar rates of IPV victimization among men (41.8%) and women (44.9%), encompassing experiences of physical, sexual, and psychological abuse.Significant factors associated with IPV victimization included poverty, alcohol use, and exposure to physical and sexual torture during wartime.Individuals who experienced IPV were more likely to report mental health issues such as probable problem drinking, attempted suicide, and probable major depressive disorder [18] .Furthermore, research in South Africa spotlights the perilous consequences of severe forms of IPV for men, exemplified by distressing cases, where women have enlisted hitmen and witch doctors (sangomas) to murder their partners due to various motivations, including greed, infidelity, and dissatisfaction within the relationship [15] .Despite studies shedding light on the significant clinical aftermath of IPV on males, there is limited literature addressing how social stressors, such as shame, loss of social capital, and challenges related to the construction of patriarchal ideals of manhood, interact within the socio-ecological environment to impact male survivors.It's crucial to recognize the prevalent practices of male domination over women, which profoundly shape masculine identities globally [32,33] , including across African countries [34][35][36] .In South Africa, the broader social context for male victims is entrenched in patriarchal discourses, where men are pressured to conform to norms of power, toughness, and hyper-masculinity to maintain dominance over women and gain respect within their communities [21,[37][38][39] .Therefore, investigating the experiences of men who, unable to assert dominance over their partners, become victims and survivors, and examining how they navigate the interaction between their clinical conditions and their failures to enact social expectations, constitutes a crucial aspect explored in this article.
The socio-ecological model, pioneered by psychologist Urie Bronfenbrenner in the late 1970s, offers a framework to understand the complex interplay between individuals and their social environment.It highlights how people are influenced by multiple layers of social factors and environmental contexts.This model recognizes that these influences can cut across different levels and impact individuals in diverse ways, shaped by their cumulative and intersecting experiences [40] .Dahlberg and Krug [22] have identified psychosocial interconnections in relation to IPV within the socio-ecological framework at various levels.This encompasses the mesosystem level, which involves family, peers, and friends; the ecosystem community level, encompassing elements like neighbourhood, work, and school; and the macro society level, which involves gender norms, regulations, and policies.These interconnected levels have significant implications for the wellbeing of IPV survivors.
While the socio-ecological framework has predominantly been applied to understand influences on male violent behaviour and the effects of IPV on women survivors [16,23,41] , there are indications that non-conformity to societal gender norms such as being strong and dominant at the broader societal level may exacerbate the challenges faced by male victims of IPV who express depressive symptoms and seeking treatment for depression [42][43][44] .Therefore, a comprehensive understanding of the impact of IPV on male survivors' wellbeing requires assessing how stressors across all levels of their socio-ecological context interact and potentially contribute to the development of severe clinical disorders.These considerations underscore the necessity for a more inclusive, relational approach, as adopted in this article, to comprehend male survivors' mental health and psychosocial effects on their well-being.

Method
This article draws from the perspective of individuals' psychosocial meaning and understanding of their lived experiences of IPV.Participants were selected through convenience and purposive sampling techniques.The study recruited male participants aged 18 and above who presented as IPV victims seeking medical care at the Referral Health Facility (RHF) in Johannesburg.This facility offers medico-legal services to all survivors of domestic and sexual violence.The choice of this age range was influenced by African laws determining the age of manhood/maturity to be 18 years and above [45][46][47] .Furthermore, individuals in this age group are more likely to be involved in intimate relationships and have a cultural understanding of their identities as men.Participants selected for the study were men age between 23 to 58 years old, involved in marital, cohabiting, and dating heterosexual relationships spanning from eight months to 10 years.The sample comprised 25 men, including Zimbabweans, South Africans, Congolese, Nigerians, Mozambicans, Malawians, and Eswatinis, who received help at the RHF after experiencing abuse.(see Appendix A).Additionally, the study included five key informants: two medical doctors, one nurse, one police captain, and one police constable, all with extensive experience in assisting male survivors of IPV.For example, one of the medical doctors had practiced clinical forensic medicine for 31 years, while the police captain had served in the SAPS for 20 years and acted as the social crime coordinator at the police station, handling cases of abuse, including IPV, for the past decade (see Appendix B).Valuable insights from these key informants were utilized to enrich the data and gain a deeper understanding of the profound influence of IPV on the psychosocial perception of masculinity.This research employed individual, semi-structured, in-depth interviews to delve into the experiences of men in heterosexual relationships who had encountered IPV.This approach facilitated open discussions about abusive encounters while guiding participants to focus on various aspects of IPV, including physical, emotional, economic, and sexual dimensions [48] .In addition to individual interviews, key informants were also interviewed to leverage their professional expertise and practical knowledge in working with IPV victims.Data analysis followed Braun and Clarke's [49] step-by-step thematic analysis process.The researcher transcribed and manually coded the verbal data in a single-blind manner to ensure familiarity with the data and minimise potential bias.Themes were then identified, reviewed, defined, and named.To grant the participants' voice and to ensure authenticity and transparency, verbatim responses were integrated into the outcome of this document.
Ethical considerations were paramount, given the sensitivity of the subject matter.Ethical clearance was obtained from the Faculty of Humanities at the University of Johannesburg and the Research Committee of Johannesburg's Health District.The study aligns with ethical guidelines outlined by the World Health Organisation [50] for domestic violence research and the conditions set by the Johannesburg Health District Research Committee.An emphasis on maintaining participants' rights, anonymity, and confidentiality was paramount to ensure their safety.Participants were well-informed about the research purpose and provided comprehensive ethical information in the form of an information sheet.This sheet delineated their rights to participate or decline and the voluntary nature of their involvement in the study.An informed consent agreement was signed to affirm their willingness to participate.Participants received assurances of confidentiality and ongoing psychosocial support during the study.They were briefed on the question topics in advance and reminded of their right to refrain from answering any questions that made them uncomfortable.Sample questions included: "Could you describe how your experience with IPV has affected you?" and "Have you noticed any changes in how you perceive your masculinity?".These questions usually impacted their emotions as they began to express the psychosocial impact of IPV on themselves.
Throughout the process, participants were guaranteed confidentiality through pseudonyms, and the recorded data was solely intended for academic purposes.It was explained that the information may be presented at conferences or published in journals.Interviews were conducted within private and secure settings, respecting the emotional well-being of participants.Good communication, interpersonal skills, empathy, and non-judgmental attitudes were consistently maintained during the interviews [51,52] .The analysis in this article is constrained solely to the psychosocial interpretations and understanding derived from men's narratives.

Mental and psychosocial dimensional effects of IPV on African male survivors
This section explores the complex web of mental and psychosocial effects that follow the occurrence of IPV against the men under examination.Across the sample, the African men explain the repercussions of IPV they endure in diverse ways, including the interactional effects of their socio-ecological environment that exacerbate their conditions.The outcomes are organized into four main categories: depression and emasculation, post-traumatic stress disorder (PTSD), suicidal thoughts and social isolation, and health-risk behaviours experienced by male survivors.

Depression and emasculation
Among the African men, the aftermath of surviving IPV is marked by a distressing array of mental health challenges, including depression.The narratives of men like Ndlovu vividly illuminate IPV's profound mental and societal ramifications on men's well-being.
Ndlovu: "She tells me, 'I am not feeling you; you are not a man for me'.Sometimes, she tells me, 'Come and put your 'd' here with the clothes on'.You will not even feel like going there when someone does that.She keeps doing these things to depress me.Besides (denying me) sex, I am emotionally hurt, and sometimes I regret why I met her.I feel undermined".
Ndlovu's perception of his partner's behaviour as emotional abuse and a deliberate attempt to induce a depressive state illustrates the detrimental impact of such abuse on his psychosocial well-being.His partner's use of sexual virility criticism and withholding of intimacy as tools of emotional torment exemplifies the distressing effects of sexual manipulation within intimate relationships.Ndlovu's experiences shed light on the potential for significant emotional distress (feeling 'emotionally hurt') and subsequent feelings of remorse (expressing 'regret'), potentially contributing to depression among male IPV survivors.This resonates with findings that subtle yet profoundly damaging behaviours, including persistent criticism and jealousy, exist as a potent source of psychological distress among men who endure IPV [26] .
The implications of Ndlovu's experiences extend beyond individual psychology, highlighting broader socio-ecological consequences.Specifically, these experiences can lead to a sense of being 'undermined,' as exemplified by the emasculating feeling of being unable to fulfil one's partner's sexual desires ('I am not feeling you').Corroborating Ndlovu's experiences, Dr Menzi, a practicing medical doctor, and a key interviewee, spoke of the importance of recognizing the intricate interplay between emotional distress, depression, sexual dysfunction, and emasculation among male survivors of IPV: Dr Menzi: "The IPV in males ends up making them feel inferior.They become depressed and they become isolated.
Because society sees them as a boss in a relationship, so when women pull them down, they feel small.From a medical point of view, depression ends up giving you sexual dysfunction, which is even worse because a male who has sexual dysfunction knows that with a woman, you do not mean anything.You are not even a man for them".
These circumstances resonate with prevailing discourses surrounding perceptions of masculine inferiority, often rooted in the fear of not meeting partners' sexual expectations.The apprehension of falling short of these expectations can lead to severe judgments of one's masculinity by peers, reinforcing the stigma of being called a "weak man" or "2-minute noodle" by one's partner [33,36,53] .This highlights the significant impact of fear of ridicule from all spheres of the survivor's social ecology due to ideological discourses that shape established norms and standards around masculine practices and hypersexuality performance in South Africa [21,37,38] .Thus, not adhering to structural norms can contribute to the challenges faced by male survivors grappling with depression [42][43][44] .
In essence, Dr. Menzi provides valuable insights into the intricate interplay of clinical and nonclinical factors across various socio-ecological levels, influencing male individuals navigating the aftermath of IPV [22,40] .Her observation that normative discourses on men's collective dominance [37,38] profoundly affect abused men, leading them to feel emasculated "they feel small", and further exacerbating clinical conditions such as depression and sexual dysfunction among male survivors like Ndlovu.This underscores the significant impact of reactions at the eco-community and macro-societal levels on the psychosocial well-being of male survivors [22,40] .However, existing support structures and policies may operate at these levels to address the psychosocial needs of men impacted by IPV [22,40] .The effects of IPV also result in conditions such as posttraumatic stress disorder, suicidal ideation, and social isolation among male survivors.

PTSD, suicidal thoughts, and social isolation
Bafana: "It has affected me very, very much; I am even scared to go to people.I feel like a street kid.Sometimes I even thought of taking poison".
On several occasions, Bafana's partner used weapons such as a knife, stick, and a steel bar to inflict violence on him.His most memorable episode of abuse was when his partner scalded him with hot water, which left scars of superficial burns from his face to his left arm.His illustration above further suggests that male survivors of IPV are significantly likely to be at risk of experiencing PTSD.Bafana exhibited profound fear, stress, and trauma because of his partner's brutal and life-threatening violence.The fear of potential continued assault has contributed to his development of social anxiety disorder, leading him to express, "I am even scared to go to people [4] ."IPV is generally considered a traumatic experience [26] , and many of the examined African men indicated their posttraumatic experiences after intermittent episodes of abuse.PTSD is a debilitating mental health condition after a traumatic event [4,26,54] .Symptoms of PTSD include, among others, persistent mental stress, unwanted memories of the traumatic events, persistent anticipation of a possible repetition of the traumatic event, persistent thoughts, and feelings of fear [20,54] .The general and dominant notion in literature is that female victims of IPV are more likely to experience PTSD [16,55] ; however, research has documented that male victims are also likely to experience PTSD after episodes of abuse perpetrated by women [17,26,27] .In agreement with the later studies, the men under examination suffered profound experiences of PTSD experiences, as discussed above.These experiences also culminate in situations where some of the men contemplated suicidal actions or excluded themselves from social networks.Bafana's ordeal profoundly underscores the severe and enduring ramifications of IPV, encompassing the dire presence of suicidal thoughts ("sometimes I even thought of taking poison") and social withdrawal ("I am even scared to go to people").Bafana's withdrawal into social self-isolation speaks volumes about the profound impact of IPV on one's sense of self and interpersonal relationships with peer's friends and neighbours.His experience points to how trauma endured by male survivors may not only fracture their connection with their abuser but also extend to their broader social network.The toxic aftermath of IPV leaves Bafana grappling with feelings of shame, fear, and a profound sense of isolation, which further exacerbates the weight of emotional distress endured and leads to contemplating an escape from pain by suicide [31] .Research indicates that suicide rates among South African men are approximately five times higher than those among women [56,57] .On average, the annual Years of Potential Life Lost (YPLL) due to suicide were 9559 in men and 2612 in women [57] .This underscore the significant contribution of suicide to premature death, particularly among young men in South Africa.Moreover, the evidence suggests that besides poisoning and injuries, other specific causes of suicide among men remain unclear [56,57] .Impressions indicate that abused men often internalize their masculine anxieties and fears to maintain their cultural and public image, resulting in self-organisation and, as in Bafana's case above, suicidal attempts [58,59] .Consequently, a nexus exists between societal expectations of masculinity, experiences of abuse, and mental health outcomes among men in South Africa.
On the other hand, it appears that the feeling of fear, vulnerability as well as the shame and societal stigma associated with being identified as a victim of female-perpetrated abuse, is significantly likely to inform male victims' decisions not only to exclude themselves from social networks but also contemplate relocating to a new environment away from friends and peers.This was Andile's plan in a cohabiting relationship for five years and with a child.During his reflections on his victimized status, he revealed the following: Andile: Sometimes, when I am alone, I feel like I should travel somewhere where I am going to start a new life because when I go around, people laugh at me, and I feel weak.I plan to go away so I can forget all these things.
Most male victims of IPV are likely to cope with the primary abuse from their partners but are less likely to cope with the secondary victimization from peers and the community [9,60] .This is because, as men, they are generally expected to be in charge and control of their intimate relationships; hence, society considers heterosexual men's IPV experiences as taboo and inconsistent with expected masculine standards [7,60,61] .Hence, Andile contemplates relocation to "start a new life".Andile's expressions are corroborated by Mr. Shaka's view (an informant interviewee): "Some men move away from their places to faraway places and start new lives.They do not even want to be seen by their friends who know they are abuse victims; they are scared that they will be undermined".
Indeed, Andile's narrative vividly illustrates how the shame of ridicule, the quest for a culturally accepted masculine identity, and the trauma of experiencing IPV from women can lead to his withdrawal from social circles as a coping mechanism for his wounded sense of masculinity.This echoes the pervasive gender discourse and realities in South Africa, where men are expected to articulate dominant masculinity, particularly over women to garner respect from both peers and the community, as highlighted by various scholars [21,[37][38][39] .These men's experiences resonate with the broader discourse acknowledging the intricate web of psychosocial stressors spanning multiple levels of socio-ecological influence.At the meso-interpersonal level, Bafana's PTSD profoundly affects his sense of belonging, leading him to withdraw from friends and peers out of shame.However, Bafana's withdrawal from meso-level interactions poses the risk of him losing significant familial support.Interactions at the eco-community level highlight the dynamics of the neighbourhood and local community, where being "laughed at" contributes to the secondary victimization of individuals like Andile and prompts his thoughts of relocation.At the macro societal level, Bafana's struggle to meet societal expectations of masculinity intersects with eco-community level secondary victimization, exacerbating his PTSD condition and contributing to suicidal ideation.This underscores how interactions across different levels of the socio-ecological framework shape the experiences of IPV survivors [22,40] .Moreover, these IPV experiences also manifest in risky health behaviours commonly observed among survivors of IPV.

Health-risk behaviours
Many of these African men find it challenging to cope with experiences of depression and PTSD.Some of these men resort to health-risk behaviours as a survival strategy to navigate around their socio-ecological environment.Ndlovu shares his struggle: Ndlovu: "I cannot handle it as a man.My colleagues keep telling me to return to being the person I used to be.I cannot even perform well at work without drinking beer.Sometimes, I have to drink before heading to work.I am on my way to becoming addicted to beer."Ndlovu's expressions of his inability to "handle it as a man" echo the cultural narratives in some African societies that promote masculine stoicism, where enduring pain and suffering is seen as a hallmark of traditional masculinity [21,60] .In this context, Ndlovu's traumatic conditions have resulted in a noticeable shift in his masculine behaviour, extending to his performance at work.Ndlovu's narrative underscores a clear link between traumatic experiences, alcohol abuse, and decreased productivity at work, highlighting the detrimental consequences of IPV on male survivors' economic well-being.This impact is further evidenced by the experiences of other men in the study; for instance, sustaining superficial burns led to the mandatory loss of work hours for Simba, he expressed, "Now I'm not working because of this burn," while Lukah lamented, "So, I don't have money to pay rent and I have nothing at all, So, this is painful for me."In many African cultures, men typically perceive themselves as providers for their families, and their ability to secure paid employment is intricately linked to their sense of identity and self-worth [14,[36][37][38] .Consequently, the loss of work hours and financial setbacks pose significant risks to men's sense of masculinity and work.Thus, men like Ndlovu may resort to alcohol abuse as a coping mechanism in the workplace, as he mentioned, "I have to drink before heading to work."Alcohol abuse as a coping strategy mirrors the methods commonly associated with female survivors of IPV who experience PTSD [62] .Research has shown that IPV contributes to alcohol and substance abuse for male survivors [3,17,27] .However, as noted by Mr. Mabaso, a key informant in this study, using alcohol as a coping strategy can lead to other significant consequences for men: "I believe this is also when they start seeking other partners.If you are unhappy in your current relationship, especially when you have experienced physical abuse, you begin to look elsewhere.This puts them at risk of contracting sexually transmitted diseases, HIV/AIDS, and unplanned pregnancies." In his expert view, it becomes apparent that male survivors of IPV may exhibit a complex response, with some turning to infidelity as a means of seeking solace outside the abusive relationship.This hazardous behaviour, perceived as a coping mechanism to alleviate distress, poses significant risks, including exposure to STDs, including HIV/AIDS, and unintended pregnancies.Indeed, prior studies have underscored hazardous sexual activity as a prevalent risk factor for STDs and HIV in certain South African communities [63][64][65] .
In effect, clinical PTSD and depression intersect with nonclinical stressors across different socioecological levels, further complicating conditions for men like Ndlovu [22,40] .At the meso-interpersonal level, his depressive state is reinforced as his drinking habit becomes a point of scrutiny by his friends.Additionally, Ndlovu's inability to sustain productivity at work highlights the profound economic repercussions of IPV that play out in eco-community-level interactions.Finally, the entrenched societal expectations around work and masculinity at the macro societal level play a pivotal role in compelling Ndlovu to resort to alcohol as a coping mechanism.This observation underscores broader societal and peer group factors interacting and compelling abused men to engage in health-risky behaviours to cope with the pain of their experiences.
In conclusion, recognizing and addressing these multi-level dynamics is essential for providing comprehensive support to survivors of IPV.By understanding the interconnectedness of clinical factors and health-risk stressors across socio-ecological levels, interventions can be tailored to effectively address the diverse needs of survivors and promote their overall well-being and recovery.

Discussion and conclusion
This article highlights the significant psychosocial impact of IPV on African men, highlighting the complex interplay between mental health issues and social stressors among male IPV survivors.Utilizing the socio-ecological framework, it examines how mental health conditions such as depression and PTSD intersect with social stressors including expectations of masculinity and economic well-being, resulting in profound suffering for male IPV survivors.This perspective diverges from previous studies focused on factors facilitating men's use of violence towards women and children within the socio-ecological framework [16,22,23,41] .Instead, it emphasizes how nonclinical socio-ecological stressors exacerbate the conditions of male IPV survivors.
The dataset reveals significant mental health challenges, notably depression, among African male IPV survivors.While existing literature extensively explores the clinical effects of IPV on male survivors predominantly in Northern contexts [42][43][44] , there is a notable lack of representation in Southern literature [18] .However, this analysis not only highlights the profound effects of depression on the clinical well-being of documented Africa male survivors but also elucidates the nonclinical ramifications of pervasive feelings of emasculation experienced by these individuals.Moreover, prevalent discourses regarding perceptions of masculine inferiority, intertwined with community and social dynamics, exacerbate the challenges of navigating feelings of emasculation.This compounds depression and imposes a psychosocial toll on male IPV survivors [21,37,38,66] .Thus, the analysis suggests potential socio-ecological implications of the interplay between emasculation and depression among male IPV survivors.
The findings also underscore the widespread prevalence of PTSD among male IPV survivors.Extant literature has extensively documented the debilitating effects of PTSD, including feelings of fear, stress, and suicidal ideation among male IPV survivors [3,19,20] .However, the narratives of the participants shed light on the intricate interplay of shame, societal stigma, and the pursuit of masculine identity in shaping coping mechanisms for PTSD among African male survivors.This interaction between individual experiences and societal expectations regarding masculinity often leads some men to seek refuge from social ridicule by starting anew in a different environment [14,60] .These struggles manifest at the interpersonal level, disrupting interpersonal relationships and social networks.Additionally, interactions at the community and societal levels underscore the perpetuation of harmful gender norms and the stigma surrounding male victimization, further complicating the challenges faced by the examined African male survivors.The profound interplay of clinical and nonclinical factors within the socio-ecological framework of male IPV survivors is evidenced by the co-occurrence of depression, PTSD, and subsequent health-risk behaviors.The utilization of alcohol as a coping mechanism, as observed in the narratives of the men, not only reflects deep individual distress but also underscores broader cultural narratives promoting stoicism and resilience among men facing victimization [52,59] .However, the potential ramifications of alcohol misuse, including hazardous sexual behaviors and heightened vulnerability to STDs and HIV, underscore the significant public health implications of coping mechanisms adopted by male IPV survivors, particularly within the context of South Africa [63][64][65] .Furthermore, male survivors encounter additional hurdles in adhering to societal ideals of masculinity, particularly concerning the maintenance of productive work lives amid traumatic circumstances [14,[36][37][38] .Given the close association between masculine identities and the ideal of being the primary breadwinner, economic stressors emerge as a noteworthy nonclinical repercussion of IPV, further compounding the challenges faced by male survivors in their path to recovery.This observation suggests a connection between trauma, alcohol abuse, hazardous sexual behavior, diminished work productivity, and financial setbacks interacting within the socio-ecological environment of male IPV survivors.
The analysis presented in this article highlights the invaluable utility of the socio-ecological framework in understanding the clinical and nonclinical impacts of IPV on male survivors.By examining the intricate interactions between mental health conditions such as depression and PTSD and social stressors including masculinity expectations and economic pressures, this framework offers crucial insights into understanding the multifaceted challenges encountered by male IPV survivors in both global and local public health discourse [16,22,41] .In essence, this paper underscores the imperative of embracing a socio-ecological perspective that encompasses layered interactions among individual experiences, peers and familial, social support systems, community dynamics, and societal norms.This holistic approach is essential for effectively addressing the diverse needs of male IPV survivors and guiding the development of targeted interventions aimed at alleviating the enduring consequences of IPV within their socio-ecological contexts.