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Measuring psychological abuse by intimate partners

Constructing a cross-cultural indicator for the Sustainable Development Goals

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Atlas trophy and logoEach month the Elsevier Atlas Award recognizes research that could significantly impact people's lives around the world. October's award goes to Lori Heise, Christina Pallitto, Claudia Garcia-Moreno and Cari Jo Clark for their article in SSM – Population Health:

Measuring psychological abuse by intimate partners: Constructing a cross-cultural indicator for the Sustainable Development Goals

The Sustainable Development Goals (SDGs) to address gender equality and empowerment set out to “eliminate all forms of violence against all women and girls in public and private spheres, including trafficking and sexual and other types of exploitation” by the year 2030. These goals include psychological violence as well as physical forms of violence.  The only trouble is that there hadn’t been a standard way to measure psychological or emotional abuse as needed to make meaningful cross-cultural comparisons. Now, an Atlas award-winning team of researchers has used a sophisticated analysis to come up with a relatively simple and meaningful three-level index to do just that. Their findings appear in the journal SSM – Population Health.

“When you talk to women—and it doesn’t matter where you talk to them, it can be Zambia to Baltimore—frequently women in abusive relationships really talk about the devastating impact of the emotional and psychological element of partner violence,” said Lori Heise of the Johns Hopkins Bloomberg School of Public Health and JHU School of Nursing.  “And, yet, it often gets devalued or is hidden as people concentrate much more on physical aspects of violence. Our ultimate goal is to try to elevate women’s voices and capture that element of women’s experiences.”

The researchers including Heise, Claudia Garcia-Moreno and Christina Pallitto of the World Health Organization, and Cari Jo Clark of the Rollins School of Public Health at Emory University, used a statistical approach called Latent Class Analysis along with psychometric testing to evaluate various methods of measuring psychological partner abuse. To do so, they relied on women’s answers to a series of questions from the first 10 countries and 15 sites of the World Health Organization Multi Country Study on Domestic Violence and Women’s Health. The surveys included nearly 25,000 women.

Those questions include, “In the last 12 months, has your current husband/partner or any other partner:”

  1. Insulted you or made you feel bad about yourself?
  2. Belittled or humiliated you in front of other people?
  3. Done things to scare or intimated you on purpose?
  4. Verbally threatened to hurt you or someone you care about?

In addition to providing a “Yes” or “No” answer to those questions, women also indicated how recently and how often they’d experienced such abuse. Women likewise answered another set of questions about controlling behavior they’d experienced from a husband or partner, such as being restricted from contacting family and/or friends.

Their analyses show wide variation in the frequency of psychological abuse women experience, with 12 percent of women in Samoa, Serbia, and Montenegro experiencing such abuse in the last year compared to 58 percent of women in provincial Ethiopia. Their analysis also confirmed that psychologically abusive behaviors are distinct from controlling behaviors and should be reported separately.

The analysis showed that the data fit a three-class model, in which women’s experiences fell into one of three groups: high-intensity, moderate-intensity, or little or no exposure to psychological abuse. The data show that across the 15 sites of the WHO Multi-country Study, about 14 percent of women had experienced high-intensity psychological abuse and nearly 10 percent moderate abuse. The data also adds to evidence that psychological abuse alone, much like physical or sexual violence, put women at increased risk of poor health and thoughts of suicide.

More work is needed to further define psychological and emotional abuse, taking into account cultural differences, the researchers say. But the attention to psychological abuse already is a sign of progress.

“When we started this work 20 years ago, it was a struggle to even talk about violence against women in the international agenda,” Garcia-Moreno said. “Initially, we focused on physical and sexual violence because even that was challenged. Our understanding and advocacy have yielded fruit in the sense that this issue is now recognized as a problem. We have won that battle. Now we can go on to develop a more in-depth understanding of the patterns of violence and what they mean.

Some women experience all forms of violence; but for others, it may be psychological abuse alone. But emotional abuse alone can have similar health impacts as physical or sexual violence. That’s an important message also. This is an important topic and it’s a good moment for making it more visible.”

A conversation with the authors

Recently I spoke with Drs. Lori Heise, Claudia Garcia-Moreno, and Cari Jo Clark about their approach to measuring psychological abuse by intimate partners.
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What are some examples of psychological violence?

Lori Heise: We looked for a set of emotionally aggressive behaviors that resonate as abusive across settings.  This includes being insulted, being humiliated, being intimidated or threatened. Significantly, these are actions short of physical or sexual violence that can have long-term physical and mental health consequences for women.  Traditionally, researchers have focused on physical and sexual violence; yet women frequently will say that the emotional aspect is more harmful and hurtful than even the physical blows. This article is an effort to elevate a type of violence that women experience all over the world, but that has been less captured by the measures traditionally used in the violence field.

Claudia Garcia-Moreno: Another aspect is that we are trying to measure emotional violence in a way that’s comparable across countries and settings, which is a little bit more challenging for psychological items than it is for physical or sexual violence.

Has there been a means to measure it?

Lori Heise: Questions about women’s experiences of violence in all its forms have been routinely asked since the early days when we started to do prevalence surveys. The questions we analyzed are standard questions that have been asked in, for example, the Demographic and Health Surveys, which are done at routine intervals in low- and middle-income countries. The World Health Organization’s Multi-country Study also uses them. We’ve had the questions; the biggest challenge has been how do we interpret the questions and how do we decide what constitutes a case of emotional abuse? As you can imagine, if someone insults you once you don’t necessarily want to put that in the category of abuse.  In fact, when we do an analysis to look at the health consequences of mental and physical abuse, people with only a few acts of emotional aggression look far more like women who have not experience emotional abuse. The biggest challenge has been: how do we take these questions and analyze them to figure out what the cutoff should be? Where do you go from having a partner who may not be the best partner or may say something in an argument to having a partner that should be counted as abusive? That was the challenge that we took on in this article.

How did you go about taking the answers to those questions and coming up with ways to make meaningful comparisons and categories?

Cari Jo Clark: In the literature, there are lots of ways these questions and answers have been used. So the question for us was: How do we make the most out of the data available without over interpreting it. Many would say if any of these were mentioned once, then that’s a case of abuse. But is a single act the same as someone who has endured many types of violence or who has endured any of them at high frequency? The answer is probably not. Any psychological violence is bad, but we need a way to differentiate.

One technique we used is a method called Latent Class Analysis. Using this method, we assume psychological abuse is a construct and we’re measuring it with discrete items based on real lived experiences. We take this latent model and look for patterns and whether they are the same across countries--that’s one of the advantages this method offers. We want to identify patterns that seem consistent so we can identify the variables that hold together to create distinct typologies of experience. We tried to identify a reliable pattern where we could begin to say—and this is just the beginning of a conversation—but we tried to arrive at a consistent pattern where a reasonable person could look at a cluster of items and their frequencies and say that looks like severe abuse vs. moderate abuse vs. low or no abuse.

Claudia Garcia-Moreno: As Cari said, this is part of a larger conversation we are having because the Sustainable Development Goals indicators include the elimination of violence against women including psychological violence. Countries are now being asked to report on this. What we see at the moment is countries are reporting very differently. They use different measures or even if they use the same questions they don’t have a consistent way of reporting them. So, this work is feeding into analysis we are doing of larger datasets to see if we can find a consistent way to report emotional violence, as a way to facilitate the work of countries and our ability to make comparisons across them.

Are there things you’ve already learned using this approach to measuring psychological abuse?

Lori Heise: One of the things we face as a field is that people were defining emotional abuse in all sorts of ways. Based on the same answers to the same questions, some were saying it’s emotional abuse based on entirely different cutoffs. Another big question was around controlling behaviors. When men control a woman’s movement or other aspects of her life: is that a type of emotional abuse or is it something else? Do those questions tap this underlying construct we call emotional abuse or is it a separate phenomenon? In the literature, some are combining controlling behaviors with emotional violence.

Our analysis made two things clear. Controlling behaviors should be conceptualized and reported separately. They aren’t the same as emotional abuse. We recognize also there are different intensities of emotional abuse. So, we’ve created a way with existing data to differentiate high intensity and moderate intensity and low or no emotional violence. The “low or no” has in it the possibility that women were insulted once or may have experienced low-grade actions. But it doesn’t rise to the level of violence. Countries are now asked to report on the levels of physical violence women experience, sexual violence they experience, and for the first time emotional violence they experience. And now, what this new formula gives countries is guidance about how to do that.

The other thing that’s intriguing—though not surprising to those who work with survivors—is many who experience physical and sexual violence also experience emotional abuse. It’s rare to have one without the other, and the more severe the physical and sexual violence the more severe the emotional violence is. So, actually by identifying women experiencing either sexual or physical violence, we capture a lot of the emotional violence that women experience.  What we have not been capturing is women who may experience moderate or severe emotional abuse without physical or sexual violence. What our analysis shows is that those women also experience some of the same mental and physical health consequences as women who experience physical or sexual violence.  This new formula allows countries to capture women experiencing psychological violence alone.

Cari Jo Clark: The other piece that’s importance is trying to understand and begin a conversation about thresholds. If it’s all or nothing, it doesn’t give us much guidance about change over time or how to intervene if everyone is classed similarly despite different levels of severity. The classification allows us to begin validating different typologies and to see if they relate to other health issues. We identify the pattern and then show the pattern has some merit.

What’s next for you and this method of measurement?

Claudia Garcia-Moreno: We have been gathering prevalence data from all the surveys we can lay our hands on and now have data for 139 countries from the year 2000 onwards. We have this database and we’ve been extracting physical, sexual, and psychological violence and we’re looking at different things. First, what are the questions people or countries are using in their surveys and are they similar? By and large they are similar, but there are small differences. Next, we will look to see if we can do a similar analysis as we’ve done here in a much larger dataset, which as Cari said will be a way of validating the pattern. Not all studies will have other health data, but some will. So, this is the next step to apply the analysis to a much larger dataset and to provide clear recommendations for countries on how to collect, analyze, and report this data.

Cari Jo Clark: I think that’s really important. In this paper, we did a sophisticated set of analyses, but we are not asking countries to do the same. The goal of the paper and the work is to provide straightforward guidance to countries so they don’t have to go to academics or need special programming or software to get these patterns down. They can use basic statistics and generate reliable information for tracking their progress toward the Sustainable Development Goals.

Related resources

About SSM-Population Health

SSM - Population Health shares the same Editors-in Chief and general approach to manuscripts as its sister journal, Social Science & Medicine. The journal takes a broad approach to the field especially welcoming interdisciplinary papers from across the Social Sciences and allied areas.


Written by

Kendall Morgan, PhD

Written by

Kendall Morgan, PhD

Kendall Morgan, PhD, is a scientist turned science writer via the Science Communication Program at the University of California, Santa Cruz. Her work has been featured in publications including Big Science Media's Genome, Cancer Today, The Scientist, Science News, Science Now, and by organizations including Addgene and the Life Sciences Foundation. She lives in Durham, NC.


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