**4. Acknowledgment**

ALK-Abello supported this study by providing immunotherapy extract. MM is ALK Abellò employee.

### **5. References**

304 Atopic Dermatitis – Disease Etiology and Clinical Management

treatment was very well tolerated. Treatment with SLIT, furthermore, has allowed a gradual and relevant reduction of concomitant therapies with corticosteroids and immunosuppressants. SLIT can modulate the immuno-system in patients with AD and HDM sensitivity. In conclusion the data available from different trials suggest that SIT (both SCIT and SLIT) could be a relevant therapeutic option in the management of AD.

Fig. 2. Modification of specific anti HDM IgE serum levels at baseline and after1 year of SLIT

Atopic Dermatitis (AD) is a common inflammatory itching skin disease affectings a large number of children and adults. Symptoms commonly could vary from person to person. The most common symptoms are dry, itchy skin and rashes on the face, inside the elbows and behind the knees, and on the hands and feet. Itching is the most relevant and common symptom of atopic dermatitis. Scratching and rubbing in response to itching irritates the skin, increases inflammation, and actually increases itchiness. The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic and environmental factors. Children are more likely to develop this disorder if one or both parents have had it or have had other allergic conditions like asthma or allergic rhinitis. While some people outgrow skin symptoms, approximately three-fourths of children with atopic dermatitis go on to develop hay fever or asthma. AD frequently is associated with allergic respiratory disease and often is the first manifestation of allergic disease. Patients suffering from AD will develop allergic rhinitis and asthma. The inflammatory process in the skin of patients with AD initiates with the allergen uptake by epidermal dendritic cells which share in their surface the IgE-receptor. These cells, after the contact with the allergens, start the homing process of T cells. This process plays a

treatment (n = 96); p = 0.0001 paired t-test.

**3. Conclusion**

Thinking Atopic Dermatitis Treatment Differently: Specific Immunotherapy as an Option 307

[26] Novak N, Kruse S, Potreck J, Weidinger S, Fimmers R, Bieber T. Single nucleotide

[27] Adinoff AD. Atopic dermatitis and aeroallergen contact sensitivity. *J Allergy Clin*

[28] Novak N, Valenta R, Bohle B, Laffer S, Haberstok J, Kraft S et al. Fcepsilon RI

[29] Scalabrin DM, Bavbek S, Perzanowski MS,.Use of specific IgE in assessing the relevance

and non asthmatic control subjects. *J Allergy Clin Immunol* 1999;104: 1273-9. [30] Maintz L, Novak N. Getting more and more complex: the pathophysiology of atopic

[31] Werfel T, Kapp A. Environmental and other major provocation factors in atopic

[32] Tan BB, Weald D, Strickland I, et al. Double-blind controlled trial of effect of house dust

[33] Subramanyan K. Role of mild cleansing in the management of patient skin. *Dermatol*

[34] Loden M. Role of topical emollients and moisturizers in the treatment of dry skin

[35] McHenry PM, Williams HC, Bingham EA. Management of atopic eczema: Joint

[36] Korting HC, Kerscher MJ, Schafer- Korting M. Topical glucocorticoids with improved

[37] Wahn U, Bos JD, Goodfield M, Caputo R, Papp K, Manjra A et al. Efficacy and safety of

[38] Mastrandrea F. The potential role of allergen-specific sublingual immunotherapy in

[40] Novak N, Simon Atopic dermatitis - from new pathophysiologic insights to individualized therapy. *Allergy*. 2011 Mar 3. doi: 10.1111/j.1398-9995.2011.02571.x [41] Bussmann C, Bockenhoff A, Henke H, et al. Does allergen-specific immunotherapy

[42] Werfel T, Breuer K, Rueff F, Przybilla B, Worm M, Grewe M et al. Usefulness of specific

Workshop of the British Association of Dermatologists and the Research Unit of the

pimecrolimus cream in the longterm management of atopic dermatitis in children*.*

represent a therapeutic option for patients with atopic dermatitis? *J Allergy Clin*

immunotherapy in patients with atopic dermatitis and allergic sensitization to house dust mites: a multicentre, randomized, dose–response study. *Allergy*

mite allergen avoidance on atopic dermatitis. *Lancet* 1996;347:15–8.

phenotypes in vitro. *J Allergy Clin Immunol* 2004;113:949–57.

eczema. Eur J Dermatol 2007; 17:267–283.

barrier disorders. *Am J Clin Dermatol* 2003;4:771–88

atopic dermatitis*. Am J Clin Dermatol* 2004;5:281–94. [39] Bousquet J. Sublingual immunotherapy: validated. *Allergy* 2006;61:5-6

Royal College of Physicians of London. BMJ 1995;310:843–7.

benefit/risk ratio: do they exist? *J Am Acad Dermatol* 1992;27:87–92.

dermatitis. *Allergy* 1998;53:731-9.

*Ther* 2004;17:26–34.

*Pediatrics* 2002;110:e2.

*Immunol* 2006; 118:1292–1298

2006;61:202–5.

*Immunol* 2005;115:828–33.

*Immunol* 1988;81:736-42

polymorphisms of the IL18 gene are associated with atopic eczema. *J Allergy Clin*

engagement of Langerhans cell-like dendritic cells and inflammatory dendritic epidermal cell-like dendritic cells induces chemotactic signals and different T-cell

of fungal and dust mite allergens to atopic dermatitis: a comparison with asthmatic

[7] Boguniewicz M, Leung DYM. Atopic dermatitis. *J Allergy Clin Immunol* 2006;

[8] Leung DYM, Bhan AK, Schneeberger EE, Geha RS. Characterization of the mononuclear

[9] Leung DY, Boguniewicz M, Howell MD, Nomura I, Hamid QA. New insights into atopic

[11] Novak N, Valenta R, Bohle B, et al. Fcepsilon RI engagement of Langerhans cell-like

[13] Proksch E, Folster-Holst R, Jensen JM. Skin barrier function, epidermal proliferation

[15] Cork MJ, Robinson DA, Vasilopoulos Y, et al. New perspectives on epidermal barrier

[16] Williams H, Flohr C. How epidemiology has challenged 3 prevailing concepts about

[17] Anonymous. Worldwide variation in prevalence of symptoms of asthma, allergic

[18] Hoffjan S, Epplen JT. The genetics of atopic dermatitis: recent findings and future

[19] Bradley M, Soderhall C, Luthman H, Wahlgren CF, Kockum I, Nordenskjold M.

[20] Williams HC, Strachan DP. The natural history of childhood eczema: observations from

[21] Gustafsson D, Sjoberg O, Foucard T. Development of allergies and asthma in infants

[22] Novak N, Bieber T, Leung DY. Immune mechanisms leading to atopic dermatitis. *J*

[24] Purvis DJ, Thompson JM, Clark PM, Robinson E, Black PN, Wild CJ et al. Risk factors

[10] Novak N, Kraft S, Bieber T. IgE receptors. *Curr Opin Immunol* 2001;13:721–6.

and differentiation in eczema. *J Dermatol Sci* 2006;43:159-69. [14] Hudson TJ. Skin barrier function and allergic risk. *Nat Genet* 2006;38:399-400.

atopic dermatitis. J Allergy Clin Immunol 2006;118:209-13.

Swedish population. HumMol Genet 2002;11:1539–48.

*Allergy Clin Immunol* 2003;112(suppl):S128–39.

the British 1958 birth cohort study. *Br J Dermatol* 1998;139:834–9.

[23] Strachan DP. Hay fever, hygiene, and household size. *BMJ* 1989;299:1259-60.

[25] Ozkaya E. Adult-onset atopic dermatitis. *J Am Acad Dermatol* 2005;52:579–82.

cell infiltrate in atopic dermatitis using monoclonal antibodies. *J Allergy Clin*

dendritic cells and inflammatory dendritic epidermal cell-like dendritic cells induces chemotactic signals and different T-cell phenotypes in vitro. *J Allergy Clin*

dysfunction in atopic dermatitis: gene-environment interactions. *J Allergy Clin*

rhinoconjunctivitis, and atopic eczema: ISAAC. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. *Lancet*

Susceptibility loci for atopic dermatitis on chromosomes 3, 13, 15, 17 and 18 in a

and young children with atopic dermatitis—a prospective follow-up to 7 years of

for atopic dermatitis in New Zealand children at 3.5 years of age. *Br J Dermatol*

117(suppl):S475-80.

*Immunol* 1983;71:47–56

*Immunol* 2004;113:949–57.

*Immunol* 2006;118:3-21

1998;351:1225–32.

options. *J Mol Med* 2005;83:682–92.

age. *Allergy* 2000;55:240–5.

2005;152:742–9.

dermatitis. *J Clin Invest* 2004;113:651–7.

[12] Leung DY, Bieber T. Atopic dermatitis. *Lancet* 2003;361:151-60.

**19**

*Japan*

**Improvement of Atopic Dermatitis**

 **by Human Sebaceous Fatty Acids**

Hiroyuki Araki, Yoshiya Sugai and Hirofumi Takigawa

Our bodies are protected against a variety of external factors such as transient pathogens and can preserve homeostasis. This defense mechanism consists of many components, including antimicrobial lipids such as *cis*-6-hexadecenoic acid (C16:1Δ6) (Wille & Kydonieus, 2003) and sphingosine (Arikawa et al., 2002), as well as antimicrobial peptides such as β-defensins and cathelicidin (Harder et al., 2010; Hsu et al., 2009; Tay et al., 2011). The levels of these antimicrobial components in the skin of atopic dermatitis (AD) patients are lower than those of healthy subjects (Arikawa et al., 2002; Harder et al., 2010; Takigawa et al., 2005). It has been reported that the uncommon lipid C16:1Δ6 is present as a major component of sebaceous lipids in human skin and hair but that it is not generally included in plant or animal oils. We have focused on this very unique unsaturated fatty acid, and have been investigating the relationship between this fatty acid and the resident flora of human skin as well as transient pathogens. In the course of that research, we found a correlation between C16:1Δ6 and AD, and have developed a method for the production of C16:1Δ6 on an industrial-scale (Araki et al., 2007; Koike et al., 2000a, 2000b; Takeuchi et al., 1990). In addition, we have made further progress in antimicrobial research involving C16:1Δ6 (Araki et al., 2005) and have selected fatty acid derivatives (oxa-fatty acids) with higher activity by means of analyses of structure-activity

In this chapter, we introduce our research into fatty acids, and we also review approaches to

Human skin lipids, including sphingosine and C16:1Δ6, provide a defense against external factors and function to maintain homeostasis. It is well established that human skin lipids contribute to the defense mechanism termed "self-sterilization" (Wille & Kydonieus, 2003) and the antimicrobial activities of each lipid component have been evaluated (Arikawa et al., 2002; Harder et al., 2010). A significant difference was found in the fatty acid composition of sebum lipids between AD patients and healthy controls (Takigawa et al.,

**1. Introduction**

relationships (Sugai et al., in preparation).

normalizing AD from a microbiological point of view.

**2. Function of human sebaceous fatty acid "C16:1∆6"**

2005). We describe the results of our investigation in the section below.

 **and Related Lipids**

*Tochigi Research Laboratories, Kao Corporation*


**4.2 Cholesterol**

A 29 nucleotide-log 2′-F pyrimidine modified RNA aptamer was reported to inhibit Hepatitis C virus (HCV) replication *in vitro*. In the follow-up study, this aptamer was derivatized with cholesterol to form cholesterol aptamer conjugate (chol-aptamer). This conjugate entered the cell and inhibited HCV RNA replication in a cell-based system successfully. Systemic administration of chol-aptamer was well tolerated by mice and increased retention time in plasma [14].

## **4.3 Dialkyl lipids**

Willis et al. conjugated diacylglycerol (DAG) to the 5′-end of a nuclease resistant VEGF aptamer [40]. This DAG-aptamer conjugate was then incorporated to a liposome bilayer, which resulted in aptamers with improved anti-VEGF activity *in vitro* and *in vivo*, both. Importantly, this DAG-aptamer-liposome complex had a considerably better residence time in plasma as compared to unmodified aptamer [40].


**Acknowledgements**

The authors acknowledge financial support from the Natural Science Foundation of Jiangsu Province (Grant no. BK20191223), Key Programme of Jiangsu Commission of Health (Grant no. K2019024), Six talent peals project of Jiangsu Province (Grant No.WSW-039), Six for one project of Jiangsu Province (Grant No. LGY2018093), Young medical talents of Jiangsu (Grant No. QNRC2016833), Project of China International Medical Foundation SKY Medical Imaging (Z-2014-2107-1912-1918).


**1. Introduction**

Chronic inflammatory disorders of the female urinary tract are common and often impact negatively on the quality of life of the affected individual. The management of these disorders, which encompass infectious and non-infectious conditions presenting with pain, is evolving as a result of current research. These changes are reflected in recent changes in the commonly used management guidelines.

Pelvic floor biofeedback with electromyography is used as a primary or adjuvant treatment for these disorders. In this chapter we present the experience gathered in our unit with this treatment modality.


**5. Debris input to glacial systems**

To the basic glacial parameters of Figure 1 weathered rock debris needs to be added to the system for there to be traces in the geological record. This complication is rarely considered; not just a morainic marker but to consider where, when and from where the debris addition was made. It may well have a considerable effect on the system as a whole. The total amount may be important. Dead ice preserved at the snout of a glacier long after the debrisfree glacier has melted may give hummocky moraine or even a rock glacier form. Further, the debris flux may have an effect upon the ice extent. For example, a glacier in equilibrium that receives a debris input near the snout (as from a large rockfall) could produce a glacier advance as the ablation area is reduced. The timing of debris input (at the start or end of a glacier advance phase for example) may be significant. Some work has been done on this in the British Isles, eg. (Ballantyne & Kirkbride, 1987). Although dating such events via cosmogenic ratio methods is now becoming easier (Ballantyne & Stone, 2004; Ballantyne et al., 1998) care must be taken in the temporal interpretation.

Figure 2 indicates the potential complexity here, again related to altitude, continentality and temporal input variations. Rock debris can be added to a glacial, permafrost or periglacial system. Unknowns include the relative and absolute amounts of ice/water and debris but also the flux changes in time (Nakawo et al., 2000; Whalley et al., 1996). Even 'simple' glacial systems may show this. For example a large rockslide on or near the snout of a glacier may allow the snout to advance but if away from the snout the glacier may be hardly affected. In the relatively small glacier in the British Isles however, substantial, but largely unknown, effects may be produced.

Figure 3 illustrates possible scenarios produced by the relative additions of weathered debris quantities to snow/ice bodies. This should not be taken to show that certain features *will* form but that they are possible given the relative components at any time. For example, the time element is not considered as part of the formative process. Some features might be form 'rapidly', others take some time. For the most part process studies do not give a good indication of the time needed to produce a feature. If the debris is lacking then there may be no feature formed at all. However, the diagram does suggest that there is a continuum of features and it does help guide interpretation of what is seen or mapped.

Using Discrete Debris Accumulations to Help Interpret

Upland Glaciation of the Younger Dryas in the British Isles 7

Fig. 3. A schema illustrating the relative proportions (and perhaps fluxes) of snow/ice and

Permafrost warming post Younger Dryas may also have had a significant part to play as has been suggested for present-day rockfall production and (Davies et al., 2003; Whalley et al., 1996) have shown that large debris accumulations are often associated with Little Ice Age events. It is not yet clear how substantial and variable was the production of debris in the Younger Dryas, although some attempts have been made (Ballantyne & Kirkbride, 1987). More recently, Jarman (2009) and Wilson (2009) have examined rockfalls and slope failures associated with Younger Dryas slope activity and the production of discrete debris accumulations. What does seem to be the case is that fossil rock glaciers and protalus lobes are relatively rare in the British Isles and Ireland compared with many mountainous regions. This may well be a consequence of the lack of weathering or rockfalls from the Caledonide rocks that comprise much of upland Britain (Harrison et al., 2008). It is perhaps not surprising

rock weathering debris in a 'glacial' geomorphic system. From Whalley (2009).

Fig. 2. An illustration of the weathered rock debris constituent needs to be taken into account when considering 'glacial, proglacial, perglacial or permafrost conditions. Not only may the debris addition be sudden (rock avalanche) or slow and continuous (scree formation); after Whalley (2009).

A further formational aspect not shown in Figure 3 are the possible altitudetemperature/precipitation-continentality controls (Figures 1 and 2). Thus, it is by no means clear where the 'best' analogues for the YD in the British Isles should be taken. For example, it was once thought that rock glaciers were only found in 'continental' mountains until examples from Iceland were found. The answer lay in the relative amounts of debris supplied to small glacier systems. Furthermore, Icelandic rock glaciers are found where there is no (or only sporadic) permafrost. Hence, the inverse interpretation; relict rock glacier = former permafrost, needs to be used carefully. This applies in fact to most of the features here classed as DDAs


*2.5. Identification of Repeat Sequences in P. vulgaris Mitogenome*

Three kinds of repeats—SSRs, tandem repeats and dispersed repeats—were detected in the *P. vulgaris* mitogenome. The SSRs were detected using the web-based microsatellite identification tool MISA-web (https://webblast.ipk-gatersleben.de/misa/) [47] according to the methods of previous studies [9,26] with a motif size of one to six nucleotides and thresholds of eight, four, four, three, three, and three, respectively. Tandem repeats were identified using the online tool Tandem Repeats Finder 4.09 with default settings (http://tandem.bu.edu/trf/trf.html) [48]. AB-BLAST 3.0 was utilized to identify and locate dispersed repeats with the following parameters: M = 1, N = −3, Q = 3, R = 3, kap, span, B = 1 × 109 and W = 7, which have been proven as effective in many studies [8,9,49]. The BLAST hits with e-values < 1 and identities > 80% were considered as disperse repeats. The number of dispersed

repeats was calculated for seven size intervals (30–49, 50–69, 70–99, 100–149, 150–199, 200–999 and ≥1000 bp). Partly or wholly overlapping repeats were considered as a single repeat unit.


*Yes. yes. There wasn't a problem in her eyes. Nothing in particular came out of those meetings. We were offered more sessions. I don't remember them having any power or authority to go into anything at all.*

Andreas says that he spoke openly with the family therapist about how the mother of his son refused to allow him to participate in the care of the child, and how in many ways she sabotaged the contact between them. The family therapists stated that they could not offer anything more than advice. We asked if he felt that family protection understood his situation:

*I don't really know if they were able to understand my situation because there were two explanations. Mine and hers. What I experienced was that all the agencies that had anything to do with parents and children worked only as advisors and they could try to steer things in a certain direction, but when one party exerts its power, it's useless. In my case, the mother had all the power.*

The latent threat of sabotage of their role as a father and of the switching of the violence relationship is central to the explanation several men give when telling us why they did not raise the subject of the violence with family therapists. The men's reticence in talking to relevant professionals about the violence must be seen in the light of the social and institutional contexts in which they find themselves. It is important to question whether support professionals have good enough tools to map out the forms of violence that may be perpetrated by women and mothers. There are, of course, limitations in our material when it comes to making generalisations about the various support agencies, but these men's stories can contribute to our understanding of why men remain silent about their experiences of violence.

The experience men have of meeting family protection is that staff either direct their professional and interpersonal focus to strengthening the mother–child relationship or appear to be so neutral that the problem of violence cannot be brought up.

Our interviews reveal that men have the words with which to describe their experiences and feelings. It is the fear of not being believed, or the perceived risk of being regarded as perpetrators themselves, which is why men do not talk to professionals or networks before they are physically injured or have a breakdown because of emotional abuse over time. Our interviews with men who have been helped by the crisis centres show that when these men encounter an environment where there is professional competence in the field of violence against men and where staff are ready to meet men and listen to their stories, men open up and accept help and support.

The men who have children have various experiences of sabotage of contact. Tor's ex-wife broke the contact order, took their daughter and moved far away without telling him. Family protection has no mandate to intervene in such a situation, and the couple ended up in a bitter conflict in the courts.

As previously mentioned, Andreas did not live with his ex-girlfriend, making it possible for her to keep him in a marginal position in relationship to their son. The family therapist he spoke to was nice enough and she went some way to acknowledging his frustrations, but, according to Andreas, she could do nothing to help him in the disempowered situation he found himself in as a father. He describes how he experienced his conversations with the family therapist:

*For me the whole situation was weird. I didn't know what to do.  They will make sure that the mother and child are protected. They aren't geared up to help a father who's a victim. So it's a pretty raw deal, in my opinion. You don't have anyone to go to for help.*

In particular, those fathers who have lost access rights and/or been subjected to the repeated threat of losing contact with their children have experienced family protection as too passive, as having protected the mother and/or adopted a neutral attitude to the experiences of violence they have been told about.

The findings indicate that family protection has difficulty in uncovering women's violence.

As part of a preliminary project for this study, we interviewed three family therapists with extensive experience in working with partner violence. We asked them how they worked with cases of family violence and their experiences with couples where the man was the victim. The two offices with whom we were in contact have a rule: if there is any suspicion that violence is involved in the relationship, they arrange a meeting with each partner separately. One of the challenges to have emerged is the reluctance in men to talk about being the victim of violence. It is generally the woman who presents the problems in the relationship, and who largely controls the dialogue with the therapist. It is her understanding of the situation that dominates this dialogue and the man often remains silent, letting her define the relationship.

Our interviews can give some insight into why men and fathers exposed to different forms of violence do not speak about their problems. Their silence should not be solely linked to norms of masculinity and the notion that men lack the language for their experiences (Kimmel 2002; Seidler 1997). Men's silence can also be related to what is at stake in the family protection office—the risk of losing contact with children and the fear of switching of the violence and the dominating role.

## **The Wrong Sort of Victim**

An experience which may be unique to men is the feeling of being the "wrong" sort of victim in the eyes of the support agencies, and a fear of not being believed when they first talk about their experiences. Men are still regarded as unacceptable victims of violence in intimate relationships (Kimmel 2002; Douglas et al. 2012). We have seen that men have both internal and external barriers to seeking help, and that those men who have been in contact with family protection and child protection find that the system has been set up to support abused women and/or mentally unstable mothers. A similar gender bias in support agencies is found in other interviews of men subjected to intimate partner violence (Machado et al. 2016; Corbally 2015). In a Portuguese survey of men subjected to intimate partner violence, Machado et al. (2016) found that men suffer in silence and that the risk of stigma, gender bias in the relevant agencies, together with strong internalisation of ideals about masculinity prevent them from seeking help. The cultural perception of family violence and masculinity contributes to the self-censorship of feelings and experiences when encountering therapists, but also affects men's relationships with friends and family. When family therapists have no sense of the "social game" (Bourdieu 2001), they risk becoming the co-creators of symbolic violence, in that they misconstrue cultural beliefs about mothers and the position of power that women occupy in this context as both legitimate and natural (Bourdieu and Passeron 1977, pp. 5–6).

Family protection and child welfare are the bearers of hegemonic discourses about violence and parenthood. Fear of switching of the violence and the perpetrator role must be seen in the light of established discourse about family violence both within and outside the institutions the couple find themselves in.

## **Crisis Centres for Men**

In Norway there are 43 crisis centres for men. In 2016 there were 131 men living in Norwegian crisis centres. The numbers of men and nights of stay have remained relatively stable in comparison with the figures for 2014 and 2015, but represent a considerable increase from before 2010, when a law was passed making it mandatory for crisis centres to be made available to men. Prior to 2010 crisis centres were open only to women, just as they usually are across the world. They were organised differently, run by voluntary organisations or by local councils. When the law was passed instituting the right of access to crisis centres, it became gender neutral, as indeed all laws are in Norway, and it was also made mandatory to offer services locally for male victims of violence.

The offer of crisis centres is therefore aimed at all those who are vulnerable to violence in intimate relationships; that is, both women and men, the elderly, children (with their caregivers), young people, disabled people, members of the LGBT community (lesbians, gays, bisexuals and transvestites).

Some crisis centres offer either free and temporary accommodation which is available 24 hours a day, every day of the year, while others have a daytime service offering one-to-one counselling and the opportunity to join support groups. No referral is required to get into a crisis centre and users can remain anonymous if they wish.

#### **Experiences of Help from Crisis Centres**

Most of the men interviewed express huge satisfaction with the help they have received from crisis centres and the centres against incest and sexual assault. Some, however, are less satisfied and have suggestions for improvement, something to which we will return. Nevertheless, the overall picture is that crisis centres have in many ways been crucial to these men's view of themselves, and their understanding of what they have been subjected to and how they can move on in life. Both the Norwegian men and those from minority backgrounds are largely pleased with the offer. This generally tallies with the findings of the report *Menn på krisesenter* (*Men at Crisis Centres*; Grøvdal and Jonassen 2015, p. 73) and differs from findings in previous studies about men's experiences with other services (Machado et al. 2016).

Arild says he is "very pleased" with his stay at the centre. Bashir says that "they were really welcoming, and it was safe too". Deo emphasizes that "they have helped me a lot, and they are very kind". Ali says that "I was looked after really well, it was good to feel that there was someone who could help you in this difficult situation."

When we ask Jonas what he thinks about the help he received, he says:

*I probably wouldn't be here today without their help. Actually, the most important thing they did for me was to help me see what kind of life I'd lived. It took a long time before I could admit that there had been something called violence from her side. They also taught me—they spent a lot of time telling me off, unbelievably, they taught me where my responsibility begins and where it ends. I can't take responsibility for the things she does, least of all the things she does when I'm not there.*

Researcher: They really helped you through then?

*Yes, I don't think I'd have managed this without them, looking back that's what I think—if I'd managed without them, I don't think I'd have been a very good person today, especially towards women. It was really positive because—as I said I know some men in the same situation, I see some of them around. Many of them are real women-haters. I see abused women who are man-haters, and it's very easy to fall into that. But despite everything it was women who welcomed me, and it's women I've talked to.*

Jonas feels that he has a completely different understanding of himself and of what he went through after his stay at the crisis centre. He is glad he went there because it was touch and go, according to him. First his mother almost forced him to make contact, then she drove him down and left him on the steps outside. He met an acquaintance, who already lived there, but he told her he was not thinking of staying, he just wanted to take a look. But then he told her his story and she started pulling him up the steps. Jonas says:

*Then she started to pull me and wanted to drag me up the steps and I held back. I said: you won't get me in there, not at least—I know you live here, you're not going to get me in there. Then she rang the doorbell and a member of staff came out, she pulled me up straight and pushed me in through the door. But I was so sure that this place, that it wasn't for me, I was scared I'd be accused of something and that I'd have to listen to how nice my wife was.*

When he entered the therapy room he was shaking so much that he spilled his coffee. He was terrified. Jonas did not want to talk about the violence and with that show his own vulnerability. He was also afraid he would not be believed. Jonas says that he was afraid that they would say that his wife was sweet and nice and that he was the problem. So deeply engrained is the idea of who the perpetrator of violence is in a relationship between a man and woman that men who are exposed to it assume that they will never be believed. It may also have been the notion of a "sisterhood" that many people connect with crisis centres which increased Jonas's fear.

The crisis centre was also of vital importance to Peter, and he too found it difficult to make the first contact:

*Before I came here, it felt very humiliating, it really did. But on the other hand, when I came here for the first time, and rang on the doorbell, and went up to the conversation room, it was like losing 1000 kilos from off my shoulders. It was such a relief to be able to sit there. They said I could sleep there. It was lovely because then I felt so free. To me it was like sitting in heaven.*

The combination of uncertainty as to what they are going into, their general lack of knowledge about the crisis centre and the fact that they were met with such professionalism and caring is central to these men's interpretation of their encounter with the crisis centre. They have low, or even no, expectations, or in Jonas's case negative expectations. When they are met with support and recognition, it is like arriving in "heaven". In many ways the men we interviewed from the crisis centre see themselves as the lucky ones who found their way there; they are grateful that someone would talk to them at all and take them seriously.

#### **Problems with Separate Accommodation and Inadequate Help**

Carlos (22) is in a slightly unusual situation in that he is an adult, but came to the crisis centre with his mother and brother. The whole family had been subjected to violence by the father and the stepfather. According to the Norwegian Crisis Centre Act, men and women must be accommodated in separate areas of the centre. Carlos's story illustrates challenges in how crisis centres are organised. Since he was over 18, he had to live on his own in the men's section, rather than with his mother and younger brother. The men's section is physically separate from the women's and there were no other men living at the centre during the weeks he spent there, so Carlos was alone. His mother was allowed to visit him in the men's section, while Carlos could not visit his mother in the women's section. This shows how problematic the segregation of men and women can be. Because Carlos was defined as a man, he could not set foot in the women's section and participate in any family activities that were arranged there. Nonetheless, Carlos is very pleased with the professional help he received:

Researcher: You came to the crisis centre as a young adult. Did they take care of you too, or did they only take care of your mother? That's an important question for me.

*Yes, I really felt that when they talked with me, I was the focus, and of course there was talk about the whole situation, but they wanted to take care of me. They came up with some ideas—that perhaps I could live on my own and be more self-reliant because I was going to take some exams and so forth. That wasn't what I wanted, but at least they wanted to safeguard my interests separately to my mother. I felt they were thinking like that.*

Researcher: Yes, because the situations you've been through for years are pretty traumatic?

*Yes.*

Researcher: So it was important to address that too, to look at it. *I felt they helped me with that. Yes. It was amazingly kind that such an offer exists. What would have happened [without it]? What would we have done? It was absolutely amazing. Really.*

The staff at the centre recognised that Carlos had taken a huge amount of responsibility in the situation—for both his mother and his younger siblings—and they encouraged him to take care of his own needs. Their support became extremely important to him. At the same time, genderdivided accommodation meant that he was excluded from his family's everyday life and he had no other men in the same situation to talk to. Several other interviewees also suggested that separate accommodation could have an unfortunate impact on social relationships and eventual rehabilitation. Peter says that the women had a barbecue one evening, which he was not allowed to attend. Instead, the staff came in with some barbecued food for him. Peter thought this was boring and rather a shame, and he did not understand why he could not join in. "We could actually have had something to talk about. They (the women) come here for similar reasons to me," he comments. From the men's perspective— "we're all in the same boat"—the statutory segregation of the sexes can seem inappropriate and a constructed distinction.

Ali also reflects on this difference. He thinks it would be good if the women and men could meet for some hours in the afternoon and if some mealtimes could be shared.  he asks. Ali, too, is far from dissatisfied with his stay, but thinks that improvements could be made. He also says that he feels there are differences in the way women and men are treated: "the women here get help quickly and straight away".

Most of the men who came to the centre lived there alone and had to manage for themselves. The fact that the men are isolated from a larger community at the centre represents a continuation of the loneliness these men experienced before arriving there. Considering the vulnerability of their situation, we consider this to be problematic.

The clearest criticisms of the treatment at the crisis centre come from Zaid and Daniel. When Daniel called the council's crisis centre and asked for help, he was told that "the only offer they had was for women". Although Daniel had nowhere to live, he was not allowed to stay at the centre, nor was he informed that the council had a duty to find him a place. The crisis centre asked him to contact the Red Cross or a similar organisation. Daniel is perhaps one of the men in our research who was subjected to the most extensive violence, and he has no explanation as to why he was turned away by the crisis centre.

The centre also promised to call him back, but failed to do so. Daniel was extremely disappointed about this, but he was fortunate enough to be offered excellent help from Skeiv verden1 when he contacted them. Daniel is also the only interviewee who says that he cannot advise other men to contact the crisis centre.

Zaid was very impressed by the "fantastic" help he was getting at the crisis centre, until, when he had been there for four weeks, he was suddenly informed that he would have to move out the following day. This came as a huge shock to him and his situation worsened substantially as a result. He was told by the crisis centre to approach Norwegian Labour and Welfare Administration (NAV), who would find him a place to stay. The whole experience of being thrown out led him to say in his interview that he is now in a terrible state and "hates everything". Zaid feels that the centre gave him poor information and he does not understand why he could not live there any longer.

The positive feedback we received from these men about their experiences with crisis centres proved to apply equally to men who sought help from incest centres.

## **Centres Against Incest and Sexual Abuse**

In Norway there are 19 centres against incest and sexual abuse. They are all are open to men. One of the centres only offers its services to men. The statistics have always shown that the majority of the users of centres against incest and sexual abuse are women and girls. By 2016, 82 per cent

<sup>1</sup> Skeiv verden is a national organization for LGBT people with minority background in Norway.

of users who had suffered sexual abuse (from both family and non-family members) were women and 18 per cent were men. The distribution of genders has been relatively stable over time. The percentage of men varied from 16 per cent to 20 per cent between 2009 and 2016. Among the male users who were victims the average age was 39 years, as opposed to 34 years for women. Of those users who were aged 50 and above, almost 3 out of 10 were men. The figures show that it usually takes longer for men to get to the stage where seeking help becomes a possibility: 54 per cent of men were subjected to abuse for the first time when they were between 7 and 15 years old. Only 16 per cent of men say that they reported the relationship and 11 per cent of the male victims had applied for criminal injuries compensation. Later in this chapter we investigate men's experience of the help they have received from support centres. We will now turn our focus to the experiences reported by men of talking/conversation therapies and other contact with professionals as well as activities offered by these centres.

#### **Experiences with Conversation Therapies and Other Help**

The experiences reported by the men from the two centres against sexual abuse that participated in our study are overwhelmingly and unambiguously positive. The staff at these two centres are highly valued and appreciated by the men we interviewed. It is not rare for the men to describe their encounter with these centres as a crucial turning point, a moment when their lives began to go in a more positive direction.

Bjørn (48) had never spoken to anyone (not even his former partner) about the abuse to which he had been subjected aged 11, before he contacted one of the centres in 2014. This meant that Bjørn had carried his memories inside him for 35 years without talking to anyone about them. In the end, however, the need to talk about the abuse with someone became so strong that it could no longer be ignored: "It was like something gnawing was at my stomach, and it felt like I was going to faint … I felt nauseous." He searched the internet and found the centre. This was to be a turning point for him: "All honour and glory to those who work here, they are fantastically clever people!" His contact with the support centre has since enabled Bjørn to tell, among other people, his daughter, his doctor and his boss what he went through as a child. He says he was well treated and got various kinds of support, which were all excellent.

Terje claims to have had little or no real help earlier in dealing with the sexual abuse in his childhood. He contacted the centre through his brother and feels he received good treatment there. The continuous contact with the centre has helped Terje to lighten the consequences of his childhood abuse, and even to render his appalling past harmless.

Arne, as mentioned earlier, was subjected to sexual abuse by his football trainer when he was 12. The abuse was discovered and the perpetrator was tried and convicted. Nevertheless, Arne feels that it was only when he came into contact with the centre that he received any real help in dealing with his experiences. Before coming to the centre he was about to give up, since there seemed little chance of getting help anywhere. So this was Arne's last hope (he was referred by his GP). He is full of praise for the treatment he received at the centre and says that the experience has been nothing but positive. He says his female conversation partner is amazing, that his needs have been "totally" met and that his time with the centre represents a turning point in his life. Erlend is also full of praise for the centre and its staff. He describes his contact with the centre as "completely amazing. It was unbelievably good to come here."

On a scale of one to ten, Odd gives the centre he visits a ten. Here he meets understanding, is accepted as he is and is given the help he needs to think more clearly and in new ways about himself and his difficult experiences. Odd is emphatic when he says that the help he received there made it possible for him to go on with his life and gave him back a sense of joy.

At first Sølve was sceptical and reticent about the activities and opportunities he was offered, but has become increasingly positive over time: "The centre works for me 100 per cent. Yes."

Many men mention the importance of talking to another man about their experiences of abuse.  One or two men suggest that the gender of the person they meet to talk about their experiences is irrelevant or, indeed, that they feel more comfortable talking to a woman. Most, however, prefer to talk to a man and also emphasise the importance of this being a man with similar experiences to their own. This contributes to the sense of being heard, seen and understood. In contrast to the formal support available, Odd (63) insists that "the guys here have [hands-on] knowledge, they know [about it] from their own experience". Joar (28) says that "it's amazingly good to have someone to talk to as an adult, especially a man who might also have experienced stuff". Joar says he would have come to the centre earlier if he had known the quality of the help he would get there.

The importance of being received quickly after you have taken the very difficult step of ringing or visiting the centre is also highlighted. It is essential that the men are not left to stand in a queue or made to wait their turn. The unbureaucratic organisation and spirit of these centres appear therefore to be as important as the experience of being really understood and respected. The importance of being seen quickly and easily, and received with open arms without any expectation or judgement, is also crucial to the positive experience offered at these centres.

Given the positive impact these centres have had, and continue to have, on the lives of our interviewees, it is important to identify how they found out about the centres' activities and how they came into contact with them. Most of them seem to have had only the vaguest knowledge, or no knowledge at all, of the various activities run by the centres. They have quite simply been driven to attend by the overwhelming need to talk about the sexual assaults to which they have been exposed, often in childhood: difficult and/or painful experiences that they have never previously shared with anyone or, for that matter, received any professional help in processing. Often it is a current crisis in life, such as a divorce or other marital problem, which is the trigger. But it can also be the accumulated weight of painful experiences, which eventually becomes impossible to bear. Sometimes it can be a small, yet significant incident that triggers memories and symptoms linked to the abuse.

In three cases, it was someone close (partner, sibling) who tipped the men off about the centres' existence and the chance of their getting help there. Three were referred by other professional agencies or persons (staff members of other crisis centres, e.g. doctors). Three others found information after looking on the internet, while one found out about it in a short article.

# **Summary and Recommendations for an Improved Support System**

Earlier studies indicate that negative childhood experiences are one of the main causes of ill health in adulthood (Felitti et al. 1998; Felitti 2003). These studies also indicate that various types of difficulties accumulate and increase the risk. Factors that contribute to an increased vulnerability are, among other things, physical and sexual violence, emotional neglect, the divorce of parents, and parents suffering with mental illness and/or alcohol problems. Previous studies have, as mentioned earlier, also shown that people who have experienced violence from others are at increased risk of partner violence (Haaland et al. 2005, p. 54).

In this study we find that many of the men who have been in contact with the centres against incest and sexual abuse because of their childhood experiences of violence and sexual abuse have also experienced violence in adulthood. Those men who have been subjected to sexual assault have generally also been subjected to other forms of physical violence, bullying, psychological violence or neglect. Of the men in our study subjected to partner violence, there are several who say they were also subjected to bullying and other violence as children and/or teenagers; this is particularly true in the case of men from immigrant backgrounds. However, several of the men describe a stable and secure childhood.

The consequences of violence vary in gravity and depend on its extent and duration. But the consequences of sexual abuse and other forms of violence are very often wide reaching and profound: shame, guilt and fear are common, as are low self-esteem, suicidal thoughts and alcohol or drug abuse. Other common reactions and symptoms in men, which can more specifically be linked to trauma, are anxiety, panic attacks, depression, sleeping difficulties, phobias, avoidance of situations reminiscent of the abuse, elevated stress levels, hyper-vigilance and dissociation.

For many of the men in our study, abuse and violence have also had social consequences, including lack of confidence, loneliness, tendencies towards isolation and problems with close or intimate relationships. The men who have been subjected to violence and abuse have often taken time before being able to acknowledge and deal with the violence of which they have been a victim. Years have frequently gone by before these men reached out to any support agencies. Interviews we have conducted with staff within family protection, crisis centres and centres against incest and sexual abuse reflect the findings of prevalence studies—that most men wait a long time to approach healthcare services, the police or other professionals when they experience violence. By the time they seek help, the violence has generally been going on for a long time.

Nordic and international studies have found that men who are exposed to physical and mental abuse by a partner suffer similar physical and psychological damage to that experienced by women (Grøvdal and Jonassen 2015; Helweg-Larsen and Frederiksen 2008; Sogn and Hjemdal 2009; Hines and Douglas 2011, 2015; Hines et al. 2001; Coker et al. 2002). The right kind of help from support agencies can help reduce the negative health effects of violence in intimate relationships and contribute to helping both victims and their children. Being believed is essential to receiving help. Our interviews with men who have experienced partner violence perpetrated by women suggest that women/mothers have a privileged position within the system: that they can sabotage contact, threaten court action and/or the switching of the violence and power relationship. Those offering help must understand that men who are the main providers and in full-time employment can live with serious violence from women.

Encounters with various professional bodies—such as the DPS (local psychiatric units), medical profession, psychologists, police or schools are often described in these interviews as inadequate or negative. Despite examples to the contrary, the men in our sample have often felt that they have not been listened to; they have even been ignored and occasionally misdiagnosed.

A common experience among most of the fathers in our study is that they feel that family protection and other organisations spend more time supporting mentally unstable mothers than assessing the father's resources and ability to offer care. The men find that parts of the government support system, such as family protection, have a gender bias and that staff subject them to indirect abuse by taking the side of violent mothers. Several of our interviewees say they have had no legal protection as fathers. However, our sample is not large enough for us to claim that these men's experiences represent a widespread trend among men who are in contact with family protection in Norway.

It is also important to point out that the majority of our interviewees who have been users of family protection had no contact with family therapists until late in the process—that is, in situations of high-level conflict and relationship breakdown. We have found that men often feel that support agencies are oriented towards traditional gendered beliefs about men and women. This is in line with other studies. In a Norwegian interview study of minority men's encounters with family protection, it was found that the views of staff were coloured by just such traditional assumptions about men and women, and that such prejudices almost automatically led staff to take the side of the woman (Lopez 2007, pp. 10–11). Looking at these studies in context, we can infer that the official support system has difficulty in addressing men's vulnerability and their need for help in these difficult situations in their lives, and that this must be seen in the light of dominant gendered ideas and understanding of "violence" and "victims".

Surveys carried out in the present study have also documented that the support system appears to be lacking in knowledge about the services available to men subjected to violence in intimate relationships. These findings may indicate that the system has problems identifying male victims and/or not recognizing when men require help.

A pilot study on violence against men in intimate relationships (Sogn and Hjemdal 2009) revealed that despite the goodwill of the support system, only a few organisations actively disseminated information about the services on offer to male victims of violence. As we have shown in Chap. 3, few people know that family protection also offers help to men who are experiencing violence in intimate relationships.

As mentioned before, most of the men in this study who have used a crisis centre report benefiting greatly from its services. This applies to both Norwegian and foreign men. A challenge that many men face in other parts of the system is that staff have not taken them seriously, have failed to recognise their role as fathers or have been suspicious of them. Seidler (1994) writes that men are educated to be careful about what they say because words can easily be used against them. As we have seen, the fathers in this part of the study spent a lot of time and thought finding strategies to avoid the switching of the violence relationship. A common strategy is not to talk about the violence to which they are being subjected.

For decades in Norway, there has been a strong political will to achieve gender equality. This has been expressed in the establishment of fathers' rights to paternity leave, and in proactively making moves to prevent violence and abuse against women. Norway is one of the countries in the world in which most women are in work or education, and where it is taken for granted in most areas of society that both parents will participate in the care and education of their children. The men we interviewed who have children express a strong desire to be actively involved as fathers. The majority have taken a long paternity leave and say they have taken considerable responsibility for housework and care of the children. As we have seen, we also have some dramatic examples of fathers who have been deprived of the opportunity to be a significant caregiver to their children. Our sample consists of modern fathers who are the main breadwinners and also victims of violence. Their stories have been silent thus far in the discourse about violence in intimate relationships. Gender-biased understandings in and outside the support agencies (who should ideally be helping children and both parents) can contribute to those agencies becoming co-agents in the reproduction of a stereotypical gendered bias about violence in close relationships.

Violence and abuse have major health, social and socio-economic consequences. Violence between parents also affects any children involved. We see the current emphasis on putting resources into the prevention of violence and abuse (including bullying), with a focus on children and young people, as extremely positive. Our study shows that men who were victims of sexual abuse at a young age also experienced physical and mental violence, neglect and, interestingly, bullying at school. With early detection of violence and abuse, and specific intervention and treatment where necessary, a great deal of human suffering can be reduced. We have seen in the Norwegian survey (Chap. 3) that even in the various official support systems whose mandate it is to offer support and help, there is a lack of knowledge about the services available for men who are being subjected to violence and abuse. We also know that several other countries in Europe and the Nordic regions do not have crisis centres or other emergency facilities for men who are experiencing serious violence in intimate relationships.

The Norwegian government's plan against violence and abuse for the period 2016–2021—*Opptrappingsplan mot Vold og overgrep* (Prop. 2016–2017)—provides an overview of possible measures to combat violence in close relationships, as well as violence and abuse against children, and of the main challenges related to the subject. The plan contains both short-term and long-term strategies to meet these challenges and presents a clear understanding of the major health and social consequences of violence and abuse.

Violence and abuse often lead to major physical and psychological problems for those individuals affected, and can also lead to lower educational attainment in school among children and adolescents, and thus poorer career opportunities later in life. For some, the consequences will be a reduced opportunity to participate in working life and a generally lower quality of life. The socio-economic costs, as pointed out in Prop. 2016–2017, are also significant.

The ambition behind this plan is to raise awareness and improve understanding among the wider public, but also to emphasise that the competence to deal with violence and abuse among professional groups appointed to do so (e.g. doctors, nurses, psychologists, police, lawyers) or those whose work puts them in a position to detect suspicious cases (e.g. teachers, staff working in child welfare) is worthwhile and valuable. The interviews with male victims of violence and abuse in our study indicate that such awareness is often lacking or entirely absent. Occasionally the lack of knowledge among various professionals has surfaced in shocking ways. Other studies have also found that discourses of masculinity and partner abuse frequently disadvantage men in identifying partner violence and seeking help (Corbally 2015).

It is crucial to identify violence early in order to prevent revictimisation. Victims of violence must be offered assistance. The public should be aware of the help available. Taken as a whole, our study provides the basis for the following general recommendations to prevent, detect and deal with violence in intimate relationships in Norway and in other countries:

# **References**

Bourdieu, P. (2001). *Masculine Domination*. Cambridge: Polity.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# **8**

# **The Need to Develop the Established Theory of Partner Violence Further**

We started this book by showing that, in line with recent research, we would use Johnson's typology of violence in intimate relationships; that is, the divide between intimate terrorism and situational violence. We find that the violence perpetrated against the men we have interviewed must in the main be characterised as intimate terrorism. This is by no means surprising. Johnson points out that situational violence is largely revealed through population surveys, while intimate terrorism is identified through qualitative studies of particular groups exposed to violence. The reason for this is the significant difference between the extent of situational violence and intimacy terrorism detected through prevalence studies. As we have seen in the review of Nordic surveys in Chap. 2, the gender differences seem relatively small in the case of milder forms of physical partner violence, and several studies show that both men and women are both frequently subjected to control and abuse in partner relationships. We want to focus now, therefore, on intimate terrorism, and only to touch on situational violence.

A central premise for Johnson's concept of intimate terrorism is, as mentioned earlier, an asymmetric power relationship. In all relationships where there is serious and systematic violence, there will be a dominant party. Feminist-oriented scholars have had a vast influence over the research about family violence and have contributed to highlighting women's and children's experiences of serious violence in intimate relationships. Johnson's theoretical perspective on gender and power has had a major impact on the analysis of clinical trials of abused women. Implicit to Johnson's perspective on intimate terrorism is his theory on gender power, which has its basis in the idea that men as a group dominate women as a group, and that systematic physical violence and control are motivated by the desire for dominance and oppression (Johnson 2008). Over the last decade there has been a cultural shift that has led research communities to recognise that men can be subjected to serious and systematic violence from both women and other men.

One reason for disagreement among partner violence researchers is the lack of clarity about what actually constitutes intimate terrorism. If one emphasises the aspect of control, as Johnson does, then any little slap or push could be considered intimate terrorism, as long as we find that the woman exercises control in a relationship. In that case, the number of male and female perpetrators will necessarily be equal. If the emphasis is placed on more systematic and long-term threatening behaviour and serious violence, which may include psychological, physical and sexual violence, the number of victims of violence will be fewer and we will approach what we might more intuitively understand by the term intimate terrorism.

An understanding of partner violence as a phenomenon which was originally based on the experiences of abused women with violent men, and founded on the understanding of a patriarchal society, must now be developed further to throw light on the serious and systematic psychological and physical partner violence perpetrated against men (see also Bell and Naugle 2008), since partner violence can be committed by both men and women (Simmons et al. 2014). Intimate terrorism can be exercised without the partner having physical superiority.

We find men who are in a privileged economic position and who are physically superior, who are nonetheless exposed to serious acts of violence. These events lead to feelings of worthlessness and suicidal ideation in these men. As shown in Chaps. 4 and 5, in such relationships it is not the partner who is physically superior (the man) who dominates, but the woman who exercises psychological control over the man. This book's primary contribution to the international debate on violence in intimate relationships lies perhaps in the fact that we have been able to clearly document the impact of psychological violence against men—what it comprises and how it is experienced. This must also have an impact on our wider understanding of what intimate terrorism entails.

Our research also shows a marked trend that those women who perpetrate violence often have psychological problems and have been both victims and perpetrators. There are strong indications that these women are in need of therapeutic treatment. As mentioned previously, studies of male perpetrators of violence in intimate relationships have shown that six out of ten men undergoing therapy have experienced childhood violence themselves and have major problems with anxiety, depression and substance abuse (Rangul Askeland et al. 2011). In a Norwegian interview study of mothers who inflicted violence on their children, Kruse and Bergman (2014) found that the mothers themselves had had earlier experiences of violence and had also subjected a partner or ex-partner to violence. These women say that the violence often occurred when they found the demands of looking after the children overwhelming. This reflects findings in the international literature on maternal violence (see Kruse and Bergman 2014) and challenges Johnson's (2008) sociological perspective on partner violence, showing the need to supplement it with other theoretical perspectives (see also Bell and Naugle 2008).

In several prevalence studies, Johnson's theory of men's need for dominance over women is used to explain why women are more vulnerable to domestic violence (Dobash and Dobash 1995, 2004; Kimmel 2002). We find it problematic to take the motive behind the violence for granted. Since we have not interviewed the wives and girlfriends (perpetrators) of the men in our survey, we can say nothing about their desire or need to control these men. Future studies should make it a priority to investigate women's motives for exercising violence in the family and to shed light on their experiences. What we can say here is that the men's experiences of being isolated and exposed to this form of violence over long periods erode their self-esteem, their desire to live and their sense of worth.

The psychological violence to which men are subjected, in the form of degradation as fathers, ridicule and humiliation, is not measured in several of the major investigations into violence. The most recent and most important survey in Norway investigating violence in intimate relationships does not include any questions about psychological violence (Thoresen and Hjemdal 2014). This necessarily means that the study fails to offer an adequate picture of the extent of violence against men in intimate relationships.

Both family protection and the crisis centre movement in Norway have been dominated by a biased focus on men's violence against women, which has in part been supported by previous feminist studies and the focus of Johnson and other feminist researchers on men's violence. There is reason to assume that a gender bias in samples and in empirical foundations has hindered the furtherance of knowledge about men's vulnerability and need for help (Douglas and Hines 2011; Fjell 2013; Schei and Bakketeig 2007; Grøvdal and Jonassen 2015).

Our study shows that men are also subjected to systematic violence. We find that male victims need help, but that there is significant resistance which makes it difficult for them to seek and access it. This resistance lies within the men themselves, in the relevant organisations and in society, and clearly has its roots in the established discourse about perpetrators and victims of violence. Additionally, much of our theoretical understanding of violence in intimate relationships supports a one-sided focus on women as the vulnerable party. It is crucial that theories be reassessed if we are to extend our knowledge about, and change our attitudes to, violence against men.

## **Masculinities Studies of Male Violence**

In traditional research into men, the focus has been on men as the perpetrators of violence, and substantially less on them as victims of violence (Connell 1987, 2005; Kimmel 2002, 2006). When, in the late 1980s and early 1990s, men's studies began to establish itself as an independent field, it was strongly influenced by the contemporaneous feminist criticism of patriarchal structures. Historically, women as a group had been oppressed by men, economically, socially and ideologically. When it came to the question of violence, it was presented as a fact that men were the instigators of most violence, both at a collective and social level as well as on an individual level. It is the violence on an individual level that impacts many women and children. Men's violence towards, and general suppression of, women was the dominant social pattern in most societies; a gender-based suppression was in existence. This meant that the question of power became central, even in the emerging feminist-inspired research into men. This was further reinforced by the fact that this research was often fused with Marxist criticism of the capitalist society. Here, gender relations were understood in the same way that Marxism understood the relationship between the social classes: just as the bourgeoisie in a capitalist society was seen to be oppressive and to possess greater resources than the working classes, so too was the relationship between men and women seen as one of oppressor and oppressed. This thinking is apparent in sociologist R. W. Connell's theory of dominant hegemonic masculinity, which remains the most influential theory in this field.

Connell (1987, 2005) challenges the tendency in early feminist research to observe and describe men as one unique and homogeneous group. Connell points out that there are significant variations between men's circumstances and attitudes, which require us to talk about masculinities in the plural (Connell 2005). There are, for example, groups of oppressed men whose access to economic and political resources is more restricted than that of more influential men. Other groups of men are marginalised and largely powerless, for instance because of their ethnicity or other reasons. However, Connell only sees this oppression or marginalisation in relation to other men—these men are never seen as oppressed or marginalised in relation to women (Connell 2005).

Despite the fact that Connell demonstrates that there are various types of masculinities in any given society, with varying access to power, influence and resources, he upholds the original feminist premise that men as a group are always oppressive to women. Certain men can of course oppress other men, make them victims of violence, exploit them economically or marginalise them, yet these male victims nonetheless occupy a superior position to women (Connell 2005). The inner logic of this theory makes it virtually impossible to see women as anything but subordinate to men, and as victims of men's power and violence.

Although Connell's relatively influential theory is largely used within the field of social science, the same logic has also influenced major sections of men's studies, including historical research on men (Rotundo 1993; Kimmel 2002, 2006; Tjeder 2003). Despite various attempts at offering greater nuance, the feminist gender-power perspective on male dominance and female subordination prevails.

## **The Need for Alternative Theoretical Perspectives**

As Jennifer Lawson (2012) points out, we must now work to bridge gaps between the polarised theories of violence and gender. The field of research on violence is still largely shaped by a sociological gender-power perspective and an oppressed/oppressor model. Not only is this problematic in the understanding of women, it is also highly problematic in the understanding of men. Nor does the gender-power model make sense in the analysis of violence in gay relationships.

From a historical perspective, it easy to understand why theoretical analyses have emphasised men's power. This is also understandable from a global perspective. The problem is that it has closed the way for a more phenomenological and realistic understanding of violence in intimate relationships, where both men and women are perpetrators of violence and power. There is not just *one* truth about serious partner violence and there cannot therefore be *one* theory to explain it: neither the causes of violence nor the reasons why some people are exposed to serious and systematic violence in intimate relationships. There is good reason to question physical superiority as a "natural" explanation of systematic partner violence, and of the fear of (more) violence. An uncritical acceptance of the discourse about the female victim and the myth of the good mother can contribute to acceptance of the violence perpetrated by women and mothers in intimate relationships, but also to the concealment of the violence that exists in gay relationships.

Established narratives of partner violence set limits on how men can talk about their experiences of violence. Foucault describes how discourses create "truth effects" (Foucault 1977). As we saw in the chapter on partner violence (Chap. 5), fathers feel that they must avoid bringing up the subject of women's violence in any discussion relating to children and their care, because they are afraid they might be suspected themselves. The accepted thinking within family protection appears to be characterised by the belief that the mother is best for the child and that men are perpetrators of partner violence, not the victims of it.

In Scandinavian men's studies, there has been a desire to show that many men in this part of the world have been positive in their attitude to more egalitarian relationships between the sexes; and that they have distanced themselves from the negative traits traditionally attached to the notion of manliness, such as violence or unwillingness to take responsibility for children and family (Holter 2007; Aarseth 2011). Using the concepts of unmanliness/manliness, some scholars have attempted to demonstrate the wide variations that characterise different forms of masculinity, where forms of manliness are almost always created and defined in direct relation to forms of unmanliness—which are marginalised and repudiated (Liliequist 1999; Andersson 2004; Lorentzen 2004; Ekenstam 2006; Lorentzen and Ekenstam 2006). Unmanliness, just like manliness, is dependent on historical context. At times unmanliness has been linked with a derisive view of femininity (Connell 1987; Kimmel 2002), but by no means always.

With this theoretical approach it has been possible to get closer to a more real and complex picture of manliness in all its diversity. This is a picture that shows vast differences in access to power and status among men, and recognises that many men are, or have been, subjected to oppression in similar ways to women. There was a desire to make clear the sense of emotional loss and powerlessness that exists in many ordinary men's lives. In several of the studies that look at the play between manliness and unmanliness, a need has been identified for a more phenomenological perspective; that is, we must listen to men's own voices and take their personal experiences seriously (Lorentzen 2004; Ekenstam 2006; Lorentzen and Ekenstam 2006).

Although we see that these attempts offer a more phenomenological picture of men's actual experiences, and of the variety and complexity that exist, we find, based on our present study, that this perspective has also been limited. Firstly, it seems from many of our interviews that some men who occupy the position of victim do not perceive themselves as unmanly, but on the contrary as manly. Secondly, it seems that it is not only other men, as previously believed, who define men as unmanly, but also the women with whom they have relationships. There is also the question of how important the matter of womanliness/manliness/unmanliness actually is to men's self-image, or, indeed, to our analysis of their relationships.

### **Some Problems with Structuralist Theory**

A prominent voice in men's studies which has long criticised the biased focus on structural power relationships and the lack of a phenomenological perspective is that of sociologist Victor Seidler (1994, 1997, 2004). Seidler maintains that one problem with a structuralist theory is its universalism: it is a rationalist theory with generalisable claims. The variables are given beforehand, which means that many of the more selfcontradictory features of reality are squeezed into overly narrow conceptual frameworks. In line with a western (generally masculine) scientific tradition, it reduces cultural variations, personal experiences and feelings to a minimum. Feelings such as grief, fear and vulnerability are acknowledged as little in this research as they are within the dominant male culture. This biased focus on structural relationships is even accompanied by the dismissal of what we can call the "personal", "emotional" or "therapeutic", particularly here, where power is presented as the most relevant question. Although there is a significant link between the concepts of manliness and power (and violence), manliness cannot always be reduced to power. As Ekenstam (2006) argues, the diversity of male identities, as well as the relationships between men and women, is too complex and the contradictions too many.

Seidler points out that an understanding of the power relationship between the genders, and the various social structures, must be the starting point of our analysis, not the end point. The biased structuralist approach to research on masculinity has meant that we actually know very little about how men think or perceive themselves. The neglect, abuse and violence they have experienced as children, as well as the disempowerment they may also have experienced, tend to be rendered invisible when masculinities are only seen in terms of power relationships. We lack insight into the fear, pain, suffering and sense of insecurity that many boys and men (also) experience throughout their lives.

Seidler believes it is necessary to develop new methods for interviewing men about their personal relationships. The researcher must be prepared to build a personal relationship and to allow men's own voices to be heard. It was just such an approach that inspired our work with this book.

In our study we have wanted to let the men tell their own stories and to allow their voices to come through. This study shows a complex picture of the violence to which men are subjected. Violence can be systematic over a period of time, it is psychological and physical, and it is threatening and dangerous. According to accounts given by the men who are experiencing partner violence, female perpetrators often (strategically) use society's assumption that men are assumed to be the violent partner. The challenge has been to meet these male voices with a theoretical understanding of the relationship between gender and family dynamics, and the relationship between each individual's history and their present situation.

In our interviews we talked to men about feelings of unmanliness associated with being exposed to violence, based on theories of unmanliness. We found, however, that men rarely define themselves as or see themselves as unmanly because they are victims of violence, or because they do not retaliate. On the contrary, many of them emphasise that they see it as an expression of manliness when they do *not* hit back. Additionally, both those who have/had male or female partners express that they had no intention or desire to use violence against their partner. This differs from the findings of several other interview studies, which have found that male victims of partner violence perceive themselves as unmanly (Bjerkeseth 2010; Morgan and Wells 2016).

Seidler (1994, 1997) criticizes structural perspectives that take their starting point in (male) physical and economic supremacy. Our study shows that men who are subjected to violence can in fact be socially and/ or economically dominant, and that they see their strategy of nonviolence as an expression of manliness. When, despite these factors, men are subjected to systematic violence, it seems obvious that a structural perspective is inadequate in seeking to understand violence towards men.

We need to include the dimension of *psychological dominance* if we are to explain psychological/physical violence against men. A position of psychological dominance is as easy for a woman to occupy as it is a man, and thus the analysis of violence will not be so strongly linked to the man. Such a theory will mean that gender itself will become less relevant to the understanding of violence in intimate relationships (see McHugh et al. 2013).

Our interviews show that these men have felt enormous caring and empathy for their partners. Despite being subjected to systematic and serious violence, they try to understand their violent partners and are concerned for the partners' care needs. These men find coping strategies in order to live with the violence, and for many of them this involves trivialising or under-communicating it. Meanwhile, some do not perceive themselves as being the victims of violence before a substantial amount of time has passed. One reason for this may be that men, like society and institutions in general, have internalised the understanding that women, not men, are exposed to violence. Thus, they lack the concepts for the violence to which they are exposed, until the violence has escalated to the point that it represents a real threat.

We suggest that new theoretical understandings of violence are urgently needed. Such a theorising must take into account the findings in this study. That is to say, it must be acknowledged that men also experience intimate terrorism in close relationships. One can no longer claim, as Johnson has done a number of times, that intimate terrorism is "almost exclusively" perpetrated by men. We have no basis on which to discuss the extent of violence towards men in comparison to the same form of violence towards women. Nor, perhaps, is this the most important factor in developing theoretical perspectives further. We need to adapt our research in order to get a better picture of the extent and nature of the intimate terrorism directed at men. A theoretical understanding that includes men who are exposed to serious violence necessarily implies that the traditional gender-power discourse must be modified and supplemented (see Bell and Naugle 2008). Violence in intimate relationships is a complex phenomenon that requires a variety of theoretical approaches (Bell and Naugle 2008; Lawson 2012). Perspectives and theoretical models must acknowledge that violence is perpetrated in same-sex relationships and by both sexes in heterosexual relationships; that ethnic background/nationality/residence status can further complicate matters; and finally that both the perpetrator's and the victim's personal histories are of importance. Our empirical findings also indicate that violence can have a basis in psychological dominance, and is therefore less linked to womanliness or manliness than previously thought. As we have touched upon, social backgrounds are relevant too in our understanding of people's vulnerability in a partner relationship.

## **Future Research on Violence in Intimate Relationships**

Our study shows that there is a need for a more nuanced understanding of power relationships with regard to family violence, sexual abuse and intimate terrorism. It is not enough to investigate physical/economic superiority (structural power relationships) in order to understand violence in intimate relationships. As Russel Dobash and Emerson Dobash (2004) have pointed out, further research on violence in intimate relationships must include in-depth research about women's violence to male partners. We find that the structuralist understanding of violence must be supplemented with an understanding of how psychological dominance can provide a basis for power and coercion. As already outlined, it is necessary to have a new theoretical understanding of violence in intimate relationships which includes violence against men. Such an understanding implies that Johnson's concept of intimate terrorism also includes women's violence against men. Kimmel (2002) has suggested methods to reconcile the disparate data of gender symmetry and gender asymmetry, and encourages researchers and practitioners to acknowledge women's use of violence, while simultaneously understanding why this violence tends to be different from that perpetrated by men towards their female partners.

Our proposals for future research on violence in intimate relationships are as follows:

# **References**

*Call It Anything Else Than Violence": A Research Review and Interview Study of Mothers' Violence Against Children)* (Vol. 4/2014, Report) Nasjonalt kunnskapssenter om vold og traumatisk stress (The Norwegian Centre for Violence and Traumatic Stress Studies). Oslo: Nasjonalt kunnskapssenter om vold og traumatisk stress. Retrieved from https://www.nkvts.no/rapport/jeg-kanjo-ikke-kalle-det-noe-annet-enn-vold-en-forskningsoversikt-og-enintervjustudie-om-modres-vold-mot-barn/.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.


**3.2 Wood decaying fungi**

Wood decaying or xylophagous fungi are those fungi that decompose wood dead or alive. These fungi in nature break down complex molecules of deadwood and branches and return their nutrients to the soil [2, 28]. Wood decaying fungi cause brown rot, soft rot, and white rot, with a different set of enzymes, and

#### **Table 1.**

*White-rot fungi and lignin degradation enzyme produced by them.*

based on the type of decay they cause they are classified as brown-rot fungi, softrot fungi, and white-rot fungi [29]. Brown-rot fungi produce hydrogen peroxide that breaks down cellulose and due to this the fungus removes all the cellulose compound from the wood and left the wood brown in color. Soft-rot fungi secrete the cellulolytic enzyme and break down the cellulose of the wood, these fungi are less aggressive than the white-rot fungi, whereas the white-rot fungi break both lignin and cellulose of the wood [5]. White-rot fungi produce laccase enzyme in higher concentrations and therefore they have been investigated for various use in mycoremediation, biofuel production, medical industries [5]. Fungi belonging to ascomycetes and basidiomycetes are generally white rot-fungi and have the potential to produce numerous enzymes of economic importance and hence white-rot fungi are extensively investigated to support the human lifestyle [29], however, these fungi also have adverse effects on our household wooden gadgets.

The wood and the leaf litter biomass have mostly lignocelluloses as the major components produced by the plant photosynthesis and represent the most abundant renewable resource in the soil [11]. Lignocellulose is consists of three types of polymers, cellulose, hemicellulose, and lignin which are strongly linked together by chemical bonds like non-covalent forces and by covalent cross-linkage, very small amount of lignocellulose produced by-product in agriculture or used in industries, and the remaining are considered as residue [11, 30]. Different microorganism degrades residue for the carbon as a source of energy, however, filamentous fungi evolved with the ability to degrade lignin to CO2 and other compounds as discussed in the above paragraph [31]. Some other lignocelluloses degrading fungi like brownrot and soft-rot fungi rapidly modify the lignin content and these fungi collectively play an important role in the carbon cycle [1, 11]. Apart from degrading lignin the white-rot fungi also degrade a variety of persistent environmental pollutants [30, 32, 33] like aromatic hydrocarbon, aliphatics hydrocarbon, cyanide compound, pesticides, fungicides, etc. This ability of white-rot fungi is only due to the strong oxidative activity and low substrate specificity of their ligninolytic enzyme (**Table 1**). As discussed above the white-rot fungi most commonly the macrofungi belongings to ascomycetes and basidiomycetes served as the integrated part in an ecosystem service as they produce various enzymatic mechanisms that degrade the wood and helps in maintaining the forest soil healths. Many fungi are the source of food for invertebrates in the forest, the organisms that feed on the fungi are termed as the fungivore. The ecological function of the fungi is strongly linked with the wood decay dynamics in the forest ecosystem [37], in **Table 1** the fungus listed with the enzymes are some most common enzymes produced by these fungi when come in contact with the woods and forest debris to degrade the recalcitrants forest wood and debris, the listed fungi in **Table 1** is mostly common in the forest ecosystem that acts as the decomposers.

#### **4. Role of fungi in human nutrition**

Fungi degrade different biomass and obtain nutrition for their growth and development. Fungi occur in diverse climates under different challenging conditions, and therefore they synthesized secondary metabolites to pace with the challenging threats of their life and the secondary metabolites have a broad range from antibiotic to mycotoxin. Fungi mainly use three pathways to synthesized metabolites: i. the mevalonic acid pathway (synthesize terpenoids, steroids, etc), ii. the shikimic acid pathway (synthesize aromatic amino acids, alkaloids, etc), and iii. The acetate pathway (synthesize polyketides, fatty acids, etc). Metabolites have

beneficial effects on human health like antioxidants, antibiotics, immunity booster, potent anticancer agents, and reduce stress, etc.

Mushrooms (filamentous fungi) with fruiting bodies show a huge number of pharmacological aspects in human health. Macrofungus like *Ganoderma sp.* and *Cordyceps sp.* used in the traditional medicines, *Ganoderma* (Reishi) mushroom has also been commonly referred to as the "mushroom of immortality", "tenthousand-year mushroom", "mushroom of spiritual potency", and "spirit plant by the Chinese monk [38, 39]. Generally, Mushrooms seemed to be used for food, medicine, poison, and in spiritual mushroom practices in religious rituals across the world since at least 5000 BC [40]. Gordon Wasson (father of modern Ethno mycology) supposed that the Soma plant used in religious ceremonies, over 4000 years ago, before the beginning of the Christian era, by the people who called themselves "Aryans" was a mushroom [41, 42]. The Vedic juice called "soma rasa" is said to bestow divine qualities on the soul of the consumer,

#### **Table 2.**

*Nutraceutical value of some edible mushrooms.*

even immortality [40, 42]. Mushrooms are considered one of the delicious foods and are commonly produced worldwide. They have been an essential part of the human diet and are used as both food and medicine for centuries. As shown in **Table 2**, they are a rich source of nutrients and bioactive compounds such as carbohydrates, fibers, proteins, vitamins, minerals, and have enormous medicinal attributes such as antibacterial, antiviral, antioxidant, anticancerous, and hypocholesterolemic which are valuable for human health [43]. The mushrooms are rich in protein and carbohydrate content, whereas low in lipid content. They contain essential amino acids, which help in meeting the needs of amino acids in the human body (**Figure 3**). They are also rich in many essential unsaturated fatty acids, such as linoleic and oleic acids, which are necessary for the proper functioning of the body. Apart from this, they contain many essential minerals, which are responsible for the proper metabolism of many pathways. Mushrooms being achlorophyllous therefore, they grow on decayed organic matters, rich in lignin, cellulose, and other important carbohydrates. It is economical, rich in pharmacological properties, easy to cultivate, requires low resources and area, and can be grown all over the world. Nutritional, medicinal, bioremediation, and biodegradation aspects of mushrooms are increasing day by day and have got strong focused in investigation for their hidden metabolic compounds [44, 45].