Mental health in women abused by their partners. A study with samples from Mexico and Spain.
Violence against women is internationally recognized as a social phenomenon which represents a public health and a human rights problem. (1) Partner violence is the most common form of violence against women, and around 30% of the female population in a relationship suffers from it worldwide. It affects women from all areas, social classes, and levels of education. (2,3) Partner violence affects the physical and mental health of victims in both the short and long term, (4) it breaks down their social functioning, and it has an economic cost for the population, given that as well as the costs derived from treating the victims and their aggressors, women who experience abuse may end up unable to work, losing their income, ceasing to participate in social activities, and depleting their strength to protect themselves and their children. (3,4)
Although the rates differ between studies, the most common mental health problems in women abused by their partners are post-traumatic stress disorder and depression, (5) followed by somatic-type symptomatology and anxiety. (6) It is also associated with suicidal thoughts and behaviors. (5,7) It has been proposed that partner violence generates a relationship of dependency and submission of the woman towards her partner, which implies low self-esteem. (8) Where there is psychological violence, as well as leaving her defenseless, it also has consequences of sleep disorders, loss of appetite, fear, confusion, and misery. (9)
At the root of this complex phenomenon are gender stereotypes and inequalities that lead to inequalities in the state of women's mental health. (10) There is evidence that women abused by their partners perceive that they have less power than their aggressors, (11) while other factors, such as an elevated socioeconomic level or a higher level of education, act as protectors. (1) Gender inequality and structural socioeconomic conditions are factors that condition violent contexts for women. (12)
The sociocultural factors most commonly related to partner violence indicate that it is greater when used as the normal form of conflict resolution in the relationship; (13) when in their relationship, women seek to comply with traditional or socially-expected gender roles, (13) and when they lack social and institutional support. (9)
In terms of the social perception of partner violence among the general population, (14,15) it has been found that sociocultural anchors based on gender violence stereotypes, as well as public attitudes of tolerance or intolerance of the phenomenon, have important implications for understanding it, particularly in the application of prevention programs which emphasize the relevance of transforming attitudes and gender norms. (1)
Although there is evidence of the relevance of sociocultural factors in the risk of violence against women, (1) and its effect on their mental health, (16) there remain many questions to be resolved. (17) Furthermore, the majority of studies with victims have been carried out on clinical samples, which usually only include the most serious cases. (18) As such, the general objective of the present study is to analyze abuse of women by their partners in the general population via a comparative study of Spanish and Mexican women. To do this, the relationship between partner violence and the women's mental health was studied, as well as the relevance of sociocultural factors associated with this phenomenon.
The study used a sample of convenience formed of 202 women from the general population; half residing in Mexico and the other half in Spain. All of these women had a current or recent male-gendered partner. Their ages comprised 18-65 years, the mean age of the Spanish women being 33.39 (DT=12.20) and the Mexican women being 32.50 (DT=12.75); a difference that was not statistically significant (t 200)=0.51, p=.89. Table 1 shows data about the primary sociodemographic characteristics of the women and their lives with their partners. It can be seen that a little over a third of the participants from each country were married, and only a minority were separated or divorced. Although in women from both countries, diverse levels of education were seen, statistically significant differences were found in the percentages of academic level. A university education was more prevalent in the Mexican women than the Spanish, whereas the opposite was true of middle school studies. Statistically significant differences were also found in the occupations of women in both countries: Mexican women were more likely to be professionals or homemakers, whereas the Spanish women were more likely to have manual type jobs.
Inventario de Evaluation del Maltrato a la Mujer por su Pareja [Inventory to Assess Partner Abuse Against Women - APCM for its Spanish acronym]. (19) It consists of 57 questions which recognize the most common forms of abuse of women by their partner on a response scale of five options. These behaviors are grouped into three scales: 1. Psychological abuse, made up of 38 questions whose internal consistency (Cronbach's alpha) in the present sample is .94. 2. Physical abuse, including a total of 15 questions with an internal consistency of .83. 3. Sexual abuse, made up of four questions with an internal consistency of .84. The internal consistency of the inventory's 57 questions is .94.
Goldberg's General Health Questionnaire (GHQ-28). (20) This is a test designed to detect psychic disorders in a community setting. It is made up of four subscales, each with seven questions, called somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression. In the present sample, the internal consistency of each scale was .83, .87, .75, and .90, respectively.
Escala de Gravedad de Sintomas del Trastorno de Estres Postraumatico [Scale for Severity of Symptoms of Post-Traumatic Stress Disorder]. (21) This is a heteroapplicable assessment scale made up of 17 questions with four response options. Five of the questions assess flashbacks, seven assess avoidance, and five assess an increase in activation. In the present sample, the internal consistency of each scale was .79, .75, and .81 respectively, and that of the total score was .89.
Self-Esteem Questionnaire (SEQ-RM). * This instrument is made up of 25 questions which correspond to the shortened and validated version of the Self Esteem Questionnaire for women abused by their partners. The response format is four points and the questions are grouped into two factors: Self-confidence, made up of 11 questions whose internal consistency in the present sample is .88. Low self-esteem and insecurity, made up of 14 questions, with an internal consistency of .92.
Cuestionario de Actitudes hacia los Roles de Genero [Attitudes Towards Gender Roles Questionnaire]. * This is made up of 22 questions with Likert-type responses of seven points which assess the extent to which people have traditional attitudes and beliefs about the roles of men and women. Its internal consistency in the present sample was .93.
Escala de Apoyo Social [Social Support Scale]. (22) This is formed of 12 questions which gather information about perceptions of practical and emotional support. In the present sample, the seven questions which make up the scale of emotional support had an internal consistency of .87, and the five questions which measured instrumental social support had an internal consistency of .83.
Escala de Sexismo Antiguo y Moderno [Old-Fashioned and Modern Sexism Scale].23 This scale is made up of 13 questions with Likert-type responses, five of which assess old-fashioned sexism with an internal consistency of .63, and the remaining eight of which assess modern sexism with an internal consistency of .73.
Given that all of the tests had been previously used and validated in Spain, the first step was to adapt the language used in some of the questions to terms more commonly used in the Mexican context. All of the women gave their informed consent and their anonymity was totally guaranteed. Furthermore, they all participated voluntarily, and did not receive any monetary compensation for their collaboration. The women were accessed via municipal social services, where psychology students individually interviewed women who attended these services, and via people who were known to the students. In the latter case, the students gave the women an envelope containing the tests and the informed consent letter, they were advised how to fill in the forms, and they were asked to return the questionnaires in the sealed envelope once they had completed them, such that the students would not be able to see their answers and the researchers did not know the identities of the participants. This investigation was approved by the Ethics and Animal Welfare Committee of the University of La Laguna, Spain.
To understand whether there are differences between the two countries in terms of the intensity of partner abuse, a variance analysis was performed. The MANOVA in which the factor was the country of residence and the dependent variables were the scores in the three scales on abuse showed that there were statistically significant differences: F(3,98)=4.99, p=.002. Table 2 shows the means and typical deviations, as well as the main results of the variance analyses for each type of abuse. It can be seen that Mexican women had significantly higher scores than Spanish women in terms of physical and psychological abuse by their partners.
Given the high diversity in the scores on partner abuse, that the majority of women experienced only psychological abuse, and that some advised only occasionally experiencing harmful behaviors by their partners, it was decided to establish categories of abuse based on the scores in the APCM. Women whose scores on the psychological abuse scale were lower than six and who scored zero for physical and sexual abuse were included in the "no abuse" category. In other words, this category was for women who did not and had not suffered physical or sexual violence from their partners, even if they had occasionally been called a demeaning name. The category of "psychological abuse" includes women who scored more than five for psychological abuse, zero for physical abuse, and zero for sexual abuse. In other words, this category was for women who, despite not experiencing or having experienced physical or sexual violence from their partners, were abused psychologically. A third category was formed entitled "psychological and physical and/or sexual abuse" which included women who scored more than five for psychological abuse and more than zero for physical or sexual abuse (or both). As can be seen in Table 3, there are statistically significant differences between Mexican and Spanish women in the frequency with which they experience violence from their partners. Practically a quarter of Mexican women and 45.5% of Spanish women were classified in the category of "no partner abuse"; 42.6% of women from both countries only suffered psychological abuse from their partners, and 31.7% of the Mexican women and 11.9% of the Spanish women also experienced physical and/or sexual abuse.
Table 4 shows the coefficients of correlation for the women from each country between the intensity of the partner abuse with mental symptomatology as assessed by the GHQ-28, post-traumatic stress disorder, and the two factors in the self-esteem questionnaire. It can be seen that in Mexican women, psychological partner abuse is statistically significantly associated with greater somatic symptomatology, anxiety and insomnia, greater social dysfunction, PTSD symptomatology, flashbacks, avoidance, lower self-esteem, and less self-assurance. In Spanish women, psychological partner abuse was associated with greater social dysfunction and avoidance symptomatology. Furthermore, physical abuse was associated with severe depressive symptomatology in Spanish women and with lower self-confidence in Mexican women.
Table 5 shows the coefficients of correlation in the women from each country between the intensity of partner abuse and sociodemographic factors, social support, sexist beliefs, and traditional attitudes towards gender roles. It can be seen that although partner abuse is independent of the sociodemographic characteristics of the Mexican women, the same is not true of the Spanish women, in whom a higher level of psychological and sexual violence was seen with older age, as well as greater psychological violence in those who have more children and in those who have a lower level of education. Although in both countries women who have less social support experienced the most psychological abuse, for Spanish women such support was also seen to be a protective factor against other types of partner violence. At the same time, Mexican women who experienced psychological partner violence scored higher in old-fashioned sexism and had more traditional attitudes towards gender roles. Finally, although for Spanish women, experiencing partner violence is independent of their sexist beliefs, all three types of violence are associated with a more traditional attitude towards gender roles.
DISCUSSION AND CONCLUSION
The results of the present work indicate that partner violence, especially psychological violence, is a common problem in women of the general population. Such violence can be influenced by sociocultural patterns, given that it was more common for the Mexican women to experience partner abuse, especially physical abuse, in comparison with the Spanish women. This coincides with reports on the prevalence of violence against women, where Spain has one of the lowest levels of violence in general, and particularly violence against women, in international classification. Mexico, however, has one of the highest, especially in terms of social violence. (9) In both countries, partner violence was associated with less social support, an association which limited psychological violence in Mexican women, but which also led to other forms of violence in Spanish women. This finding is relevant, because social support and access to general health services and particularly mental health services for victims of violence is recognized the world over as a protective factor against experiencing partner violence. (3)
Even if women in both countries who had more traditional attitudes towards gender roles experienced more partner violence, in Mexican women this association was only present in relation to psychological abuse, whereas in Spanish women it was present for all three types of violence. Furthermore, while partner violence was independent of sociodemographic characteristics in Mexican women, in Spanish women it was associated with older age, a higher number of children, and a lower level of education. This may be associated with wider coverage of institutional and social support, as well as mental health services, which the general population in Spain has access to, given that in recent years, public policies and women's support programs have played a leading role in the legislation and culture of the country. This has led to the opening of a number of specialized institutions, as well as social programs to prevent and treat the phenomenon of gender violence in all its manifestations, unlike in Mexico, where there is still a lack in this area. This information demonstrates the relevance for the mental health of women that involvement in the economic and sociocultural factors which foster a culture of violence against women can have, likewise institutional work directed towards the prevention of violence in the general population.
In terms of the impact of violence on the mental health of women in both countries, an association was made between psychological partner violence and symptomatology of post-traumatic stress disorder, even though the association between this violence and victims' mental health is greater in Mexican women, perhaps because the violence they experience is more intense. Although this is a matter that needs to be analyzed in depth, the present study has not tackled it, as it deals only with a primary approach to the phenomenon. Even if in Spanish women, physical abuse was associated with severe depressive symptomatology, the results of the present study highlight the few associations detected between physical and sexual abuse and the women's mental health; a fact that is perhaps a consequence of there being a minority of women who experienced said violence in this case, especially in Spanish women.
As such, although the results of the present work assume an advancement in knowledge of this subject, the study does have a series of limitations. Firstly, it should be noted that it used a sample of convenience, which limits the generalization of the results in terms of the frequency with which women in the general population experience partner violence. Secondly, it was a cross-sectional study, and therefore it cannot refer to cause-and-effect relationships. In spite of this, the data presented here adds evidence to the knowledge that partner violence, especially psychological violence, is an important threat to the mental health of women who require a treatment model which approaches the sociocultural factors that sustain it.
Conflict of interest
The authors do not declare any conflicts of interest.
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Maria Jose Garcia Oramas,  M. Pilar Matud Aznar 
 Faculty of Psychology, Veracruz University, Xalapa, Ver. Mexico.
 Department of Personality, Assessment, and Psychological Treatment, University of La Laguna, Tenerife, Spain.
Correspondencia: Marfa Jose Garcia Oramas. Privada Circuito Cascada de Naolinco 6, col. Nuevo Xalapa, 91097, Xalapa, Ver., Mexico. E-mail: firstname.lastname@example.org, email@example.com
Received first version: December 9, 2013. Second version: March 26, 2015. Accepted: April 21, 2015.
* Rector NA, Roger D. Self-concept and emotion-control. Paper presented at the 3rd Annual Meeting of the European Congress of Psychology. Helsinki, Finland, 1993.
* Matud MP. Stress investigation and its impact on the health of women in the Canaries. Santa Cruz de Tenerife: Canarian Institute of Women, 1998.
Table 1. Socio-Demographic characteristics of the sample Mexicans Spanish (N = 101) (N = 101) N % N % Partner status Not living together 20 19.8 33 32.7 Married 37 36.6 36 35.6 Common law 42 41.6 29 28.7 Separated or divorced 2 2.0 3 3.0 Children No children 43 43.4 55 54.5 One 11 11.1 14 13.9 Two 23 23.2 23 22.8 More than two 22 22.2 9 8.9 Level of education Basic 24 23.8 28 28.3 Middle 25 24.8 39 39.4 University 52 51.5 32 32.3 Occupation Student 30 30.6 25 24.8 Manual work 4 4.1 35 34.7 Non-manual work 2 2.0 10 9.9 Professional 35 35.7 14 13.9 Homemaker 27 27.6 17 16.8 [chi square] Partner status Not living together Married Common law Separated or divorced 5.78 Children No children One Two More than two 7.26 Level of education Basic Middle University 8.11 * Occupation Student Manual work Non-manual work Professional Homemaker 41.67 *** * p <.05; *** p <.001. Table 2. Means (typical deviations) and comparisons between Mexican and Spanish women in intensity of partner abuse Mexicans Spanish F(1.200) Psychological abuse 20.89 (22.92) 11.31 (13.41) 12.99 *** Physical abuse 1.02 (3.02) 0.13 (0.42) 8.45 ** Sexual abuse 0.52 (1.69) 0.20 (0.83) 3.05 Total abuse 22.43 (25.75) 11.69 (14.06) 13.51 ** [[eta].sup.2] partial Psychological abuse .061 Physical abuse .041 Sexual abuse .015 Total abuse .063 ** p <.01; *** p <.001. Table 3. Comparison between Mexican and Spanish women in frequency of partner abuse Mexicans Spanish [chi square] N % N % No abuse 26 25.7 46 45.5 Psychological abuse 43 42.6 43 42.6 Psychological and 32 31.7 12 11.9 physical and/or sexual abuse 14.64 ** ** p <.001. Table 4. Correlations in Mexican and Spanish women in the intensity of partner abuse with scores on the GHQ-28 scale, PTSD symptomatology, and self-esteem Mexicans Psychological Physical Sexual Somatic .31 ** .18 .16 Anxiety and insomnia .33 ** .07 .17 Severe depression .20 * .01 .05 Social dysfunction .27 ** .04 .12 Flashbacks .23 * .12 .18 Avoidance .27 ** .03 .08 Increased activation .08 -.05 -.03 Low self-esteem, insecurity .31 ** .14 .15 Self-confidence -.37 *** -.22 * -.10 Spanish Psychological Physical Sexual Somatic .09 .07 -.03 Anxiety and insomnia .17 .06 .05 Severe depression .15 .21 * .15 Social dysfunction .20 ** -.03 .07 Flashbacks .11 -.06 -.08 Avoidance .23 * -.01 -.03 Increased activation .14 -.05 .00 Low self-esteem, insecurity .18 .15 .00 Self-confidence -.04 -.12 -.07 * p <.05; ** p <.01; *** p <.001. Table 5. Correlations in Mexican and Spanish women in the intensity of partner abuse with sociodemographic characteristics, social support, and sexist and traditional attitudes towards gender roles Mexicans Psychological Physical Sexual Age -.03 -.08 .00 Number of children .10 .03 .00 Level of -.08 .05 .09 education ([section]) Emotional social support -.24 * -.03 -.02 Practical social support -.28 ** -.07 -.14 Old-fashioned sexism .24 * .12 .12 Modern sexism -.15 -.05 .02 Traditional attitude .23 * -.15 .06 towards gender roles Spanish Psychological Physical Sexual Age .23 * .11 .16 * Number of children .28 ** .19 .18 Level of -.30 ** -.06 -.14 education ([section]) Emotional social support -.37 *** -.28 * -.26 * Practical social support -.23 * -.15 -.23 * Old-fashioned sexism .11 .10 .16 Modern sexism .08 .04 .12 Traditional attitude .31 ** .29 ** .24 * towards gender roles ([section]) Coefficient calculated through Spearman's Rho. * p <.05; ** p <.01; *** p <.001.
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|Title Annotation:||Original article|
|Author:||Oramas, Maria Jose Garcia; Aznar, M. Pilar Matud|
|Date:||Sep 1, 2015|
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