Emotional Abuse Against Women in the Context of Intimate Relationships: A Concept Analysis
Abstract
Background: Emotional abuse of women is common and has significant health and social consequences. Emotional abuse often precedes physical and sexual abuse. Research centered on emotional abuse is limited when compared with other forms of abuse, such as sexual and physical abuse. A lack of understanding of emotional abuse in women can lead to negative health complications and failure to provide the most effective care. A close examination of the attributes of emotional abuse is needed to inform interventions that improve women’s health outcomes.
Purpose: The purpose of this concept analysis is to explore the critical components of emotional abuse against women in the context of intimate relationships.
Method: The Walker and Avant (2011) process was used to analyze the concept of emotional abuse. This analysis utilized quantitative and qualitative research studies. Studies in English from 2013 to 2023 were included. Evidence was reviewed to clarify the attributes, antecedents, consequences, and model cases of emotional abuse in women.
Results: One hundred and two studies met the inclusion criteria. Four attributes of emotional abuse were identified, including humiliation, indifference, control, threat, and intimidation. Emotional abuse as a phenomenon is associated with women’s and partners’ influences, unhealthy relationships, the normalization of emotional abuse in society, and the lack of social support. Emotional abuse in women leads to poor psychological, perinatal, and intimate relationship problems.
Conclusion: Nurses should understand the attributes, causes, and consequences of emotional abuse in women to help them recognize and address this issue in the clinical setting. Further studies are needed to increase nursing’s understanding of the experience of emotional abuse in women.
1. Introduction
Intimate partner violence (IPV) is a violation of human rights and a public health and global health problem [1]. IPV can take on different forms, including physical, sexual, emotional, psychological, and economic abuse [2]. According to global statistics from the World Health Organization (WHO), 30% of women are survivors of physical and/or sexual violence, 27% of women aged between 15 and 49 and are in a relationship have experienced physical and/or sexual violence, and 38% of homicide cases resulted from violence against women (VAW) (2021). In a survey conducted in the U.S., 48.4% of women had suffered at least one form of psychological aggression from their partners [3]. VAW leads to the use of multiple healthcare systems, such as medical and mental healthcare seeking [4]. The economic cost of violence is $1.5 trillion worldwide [5], meaning that violence in the lives of women has both a significant human and economic cost. It is, therefore, crucial to determine how to minimize these cost burdens.
Emotional abuse is a nonphysical technique that those who cause harm use to intentionally harm the victim’s psychological wellbeing [6]. According to the National Domestic Violence Hotline [7] in the U.S., emotional abuse consists of the following: domination, separation, humiliation, intimidation, and stalking. There is a lack of literature focused on the forms of emotional abuse and its consequences as outcomes. Resultantly, emotional abuse is less understood [8]. Yet, women perceive emotional abuse as more damaging and injurious in comparison with other forms [9]. Women across the world also report that emotional abuse is the most prevalent form of abuse they encounter [10]. This is likely because emotional abuse can be undetectable and, therefore, hard for women to articulate or describe and, therefore, more difficult to address. Eighty percent of Jordanian women, for example, reported experiencing emotional abuse [11]. Over 50 percent of Ethiopian (57.8%; [10]) and Ecuadorian (56.9%; [12]) women reported that emotional abuse was the most common form of abuse they experienced. Emotional abuse was the most prevalent form of abuse in Zimbabwe and several other Sub-Saharan African countries [13].
Emotional abuse is a complex concept, and previous research has demonstrated challenges in operationalizing and measuring it [14]. Operationalizing some aspects of emotional abuse is complicated, as some women may not consider emotional abuse as violence and thus may not endorse that they are currently experiencing violence or abuse [15]. The prevalence of emotional abuse was assessed using a survey conducted in 15 sites across 10 countries (Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia, Montenegro, Thailand, and the United Republic of Tanzania) [16]. One limitation of the study conducted by Garcia-Moreno et al. [16] was the difficulty in measuring the concept of emotional abuse across different cultures. Due to this difficulty, the number of emotionally abusive behaviors was reported rather than the general prevalence [16]. Another study about the impact of violence against women did not include emotional abuse due to differences in cross-cultural definitions of emotional abuse [17]. Relatedly, forms of emotional abuse and perceptions vary across cultures [18]. Others have recommended a more exact definition of emotional abuse to develop more effective interventions [19].
IPV is the term that is more commonly used in Jordan and the U.S., where the coauthors are based. As such, we have opted to use the term IPV. However, we acknowledge that our colleagues who are scholars in this area also use the term intimate partner abuse (IPA). We also chose to use the term IPV because it covers a broad range of forms of violence, and it is also a term widely used in literature, making it a comprehensive term that aligns with the intricate nature of intimate relationships. The term IPV also captures a spectrum of abusive behaviors, including emotional abuse, which is the main focus of this paper.
Nurses play a critical and distinct role in recognizing and addressing VAW [20, 21]; however, many healthcare providers, including nurses, may focus on physical injuries and ignore psychological and emotional traumas [22]. To our knowledge, there is no concept analysis previously published focusing on emotional abuse in the lives of women within the context of intimate partner relationships. The results of this concept analysis will help generate important knowledge that can be used by healthcare providers, advocates, and researchers who interact with women who have survived emotional abuse. The results will provide nurses, educators, and scholars with a clear, comprehensive view of emotional abuse in the context of intimate partner relationships. The purpose of this concept analysis is to create an understanding of emotional abuse against women in the context of intimate partner relationships.
2. Methods
2.1. Concept Analysis Method
Concept analysis is a strategy used to assess the fundamental components of a concept by carefully breaking it down into elements to determine its internal structure [23]. The concept analysis method is helpful in eliminating vague concepts and obtaining accurate operational definitions to achieve construct validity [23]. Walker and Avant’s [23] method for concept analysis includes eight steps as follows: (1) selecting a concept, (2) determining the purpose of analysis, (3) identifying all uses of the concept, (4) identifying the defining attributes, (5) identifying a model case, (6) identifying borderline, related, and contrary cases, (7) identifying antecedents and consequences, and (8) defining empirical referents. Walker and Avant’s [23] concept analysis method can be utilized to determine the antecedents, attributes, and consequences of emotional abuse in the context of intimate partner relationships. The first two steps of concept analysis were elaborated above in the introduction section.
2.2. Search Method
A systematic literature search was conducted in January 2023. The databases searched were APA PsycInfo, CINAHL, PubMed, and Web of Science. An advanced search was performed using MeSH terms. Table 1 shows the keywords used for this concept analysis. An expert librarian facilitated this advanced search, and two independent researchers selected the articles based on the eligibility criteria. Inclusion criteria for the studies were (1) women who were in a heterosexual relationship or women who experienced emotional abuse from their husband or partner, (2) articles with women who self-reported emotional abuse, (3) articles were published in English and peer-reviewed, and (4) the search was limited to the last 10 years from 2013 to 2023. Table 1 shows the search terms that were used during the literature search.
| Concept | Keywords |
|---|---|
| Emotional abuse | (“Emotional Abuse”[MeSH] OR “emotional abuse ∗”[Title/Abstract] OR “emotional neglect”[Title/Abstract] OR “emotional violence”[Title/Abstract] OR “psychological abuse ∗”[Title/Abstract] OR “psychological neglect”[Title/Abstract] OR “psychological violence”[Title/Abstract] OR “emotional maltreatment”[Title/Abstract] OR “psychological maltreatment”[Title/Abstract] OR “emotional trauma”[Title/Abstract] OR “psychological trauma”[Title/Abstract]) |
| Women | (“Female”[MeSH] OR female[Title/Abstract] OR women[Title/Abstract] OR wife[Title/Abstract] OR wives ∗[Title/Abstract]) |
The total number of studies found in the selected databases was 2640. After removing 131 duplicated studies, 2509 remained. After conducting the initial screening of the title and abstract, 669 studies were included in the second screening by reading more details of the studies’ characteristics. The second screening included 102 studies counted in this analysis. The reason for excluding a number of the articles is that most study findings focused on IPV in general; emotional abuse was not from a partner but was from relatives such as fathers, brothers, and at workplaces; many articles focused on children maltreatment and neglect; and several studies involved women and men, and the findings were not separated based on gender. Figure 1 represents the process of selection studies based on the PRISMA flowchart [24].
3. Results
3.1. Identify All Uses of the Concept
The third step in Walker and Avant’s concept analysis is identifying all uses of the selected concept (2011). The WHO defines emotional abuse as “emotional abuse includes the restriction of movement; patterns of belittling, blaming, threatening, frightening, discriminating against, or ridiculing; and other nonphysical forms of rejection or hostile treatment” [25]. According to the American Psychological Association, emotional abuse is defined as “a pattern of behavior in which one person deliberately and repeatedly subjects another to nonphysical acts that are detrimental to behavioral and affective functioning and overall mental wellbeing… emotional abuse may take, including verbal abuse; intimidation and terrorization; humiliation and degradation; exploitation; harassment; rejection and withholding of affection; isolation; and excessive control” [26]. The European Institute for Gender Equality defines emotional abuse as “belittling, humiliating, or undermining an individual’s sense of self-worth/self-esteem (e.g., constant criticism, verbal insults, and name-calling)’ [27]. The Cambridge Dictionary only defines abuse in general; abuse as a noun is “bad or cruel treatment of a person or animal, or the use of something in an unsuitable or wrong way” while as a verb means “to treat a person or animal badly or cruelly, or to use something in the wrong way” [28].
Emotional abuse is often represented in different terms, including psychological abuse, psychological violence, psychological maltreatment, emotional maltreatment, controlling behaviors, mental violence, mental abuse, mental violence, nonphysical abuse, or psychological aggression. Emotional abuse has been a focus in different disciplines, including sociology, social science, psychology, psych-traumatology, health sciences, public health, nursing, and medicine. The term “emotional abuse,” as used in this paper, encompasses these similar terms. Table 2 delineates the definitions of emotional abuse as defined across the empirical literature included here. Detailed characteristics and findings of each study can be found in the Supporting table (available here).
| Author/year/Country | Discipline | Definition |
|---|---|---|
|
Health Sciences | “Emotional intimate partner violence (IPV), also known as psychological or mental abuse, is defined as any behavior that threatens, intimidates, or undermines the victim’s self-worth or self-esteem or controls the victim’s freedom” (p. e206) |
|
Sociology | “Psychological IPV refers to a wide range of emotionally abusive behavior, which may involve threats, ridicule, isolation, or public humiliation [31]” (p. 349) |
|
Public Health | “Emotional violence was defined as a positive response to ever having been insulted, publicly humiliated, intimidated, or threatened or had a partner who threatened to hurt the respondent herself or someone she cared about” (p. 3) |
|
Health Sciences | “Psychological abuse in this study is defined as the domineering actions exerted by a perpetrator with the intention of exerting control over the victim’s actions and behavior by means of restricting contact with family and friends, the use of false accusations, jealousy, the continuous suspicion of unfaithfulness, and the use of financial control” (p. 9) |
|
Public Health | “Psychological violence included those acts causing psychological harm such as insulting, threatening, humiliating, or controlling on unnecessary activities” (p. 3) |
|
Psych-traumatology | “Psychological violence as any act or behavior which causes psychological harm to the partner or former partner. Psychological violence can take the form of, among others, coercion, defamation, a verbal insult or harassment” (p. 3) |
|
Medicine/Gynecology and Obstetric | “Emotional violence was defined as being insulted or made to feel bad about one-self, humiliated or be little in front of others, intimidated or scared on purpose (for example, by a partner yelling and smashing things), or threatened with harm (directly or indirectly in the form of a threat to hurt someone the respondent cares about)” (p. 3) |
|
Public Health | “Emotional abuse: lifetime experience of one or more of the following acts: insulted, made to feel bad about self; belittled humiliated in front of other people; scare tactics/intimidation; threats” (p. 528–529) |
|
Medicine | “Emotional violence (E.V.) is defined as when a woman reported she had been repeatedly insulted, belittled, intimidated, or threatened to be hurt by her partner” (p. NP2580) |
|
Social Science | “Psychological violence includes behaviors such as “control, denigration, deprivation, intimidation, threats, the abdication of responsibility, manipulation, blame, harassment, the negation of reality, indifference, making the wife feel guilty, sulking, and infantilization” ([39], p. 3)” (p. 903) |
|
Psychology | “Psychological violence is a behavior directed to a woman’s psychological control and includes seven categories: humiliations, terrorizing, cognitive disorientation (trying to convince the woman to be insane, weak, and stupid), emotional blackmail, deprivation of basic needs such as economic resources and social contacts, deprivation of valued objects, and corruption or exploitation” (p. N4636) |
|
Nursing | “Psychological violence… if her partner had sworn at her, called her names, insulted her, treated her disrespectfully, or threatened her with violence” (p. 1062) |
3.2. Identify the Defining Attributes
The fourth step of concept analysis is to define the attributes of the concept. This step covers the characteristics of the concept, which helps to distinguish the concept from other concepts [23]. Based on the included studies, the attributes of emotional abuse in the context of an intimate relationship are humiliation, indifference, controlling behaviors, and threats and intimidation.
3.2.1. Humiliation
Humiliation consists of emotional abuse in the forms of belittling or insulting, making women feel bad about themselves, and putting a woman down in front of others or privately [34, 35, 42–45]. Humiliation may include undervaluing [46, 47], ridicule [48], accusing, yelling [47], dehumanizing a woman [49], or sexual humiliation [50]. It includes treating women disrespectfully [51], purposefully saying offensive words, swearing at the woman [41], criticizing her for what she does, telling her that she is not good enough or inadequate, insulting a woman’s appearance such as talking about her in a disrespectful way [29, 52], saying that she is ugly [53], or belittling her on account of the color of her skin [52]. Furthermore, humiliation may encompass accusing a woman that she is dishonest, unfaithful [54, 55], or cognitively disabled, such as being insane or stupid [40]. In addition, women who have been emotionally abused report their partner raising their voice [56], calling her names, or telling her that she is a bad mother [55]. Partners may express disappointment, such as expressing annoyance and blaming a woman because the meal or housework was not completed to their satisfaction [29], or blame her because of his problems [57].
3.2.2. Indifference
Indifference may include ignoring a woman by not giving her enough attention [50, 53], not spending time with her [46], not talking or listening to her [52], or refusing to communicate with her [58]. Other attributes of indifference may include refusal to eat the food she cooks or attend important family events [58]. Men may also ignore responsibilities toward child rearing [47]. Partners may also refuse to engage in sexual activities and ignore a woman’s sexual needs [53], mocking her needs [50], withholding affection [53], and depriving her of love and care [47]. Finally, other examples of indifference include a lack of emotional support during important life stages, e.g., during pregnancy, and a lack of practical support, e.g., not providing transportation to perinatal healthcare or other appointments [52].
3.2.3. Controlling Behaviors
Another attribute of emotional abuse is controlling behaviors. Controlling behaviors include restricting relationships and social life, such as preventing women from connecting with others, isolating women’s friends, and family [59], or imprisoning or confining women in the home [60]. Women experiencing controlling behaviors may need to receive permission from partners before meeting with family or friends [54], obtaining healthcare [50, 61], and leaving the house [54]. In addition, women may be restricted in what they wear, prohibited from watching television [47], and refused basic needs, including food, shelter [50], and financial resources [47, 62].
Another controlling technique involves a partner displaying jealous acts or behaviors [54]. The abusive partner may prevent the woman from talking with other men or women [51] and get angry when she talks with other men. In some instances, the partner insists on knowing where she is all of the time, which can include forms of harassment or stalking. Harassment or stalking behaviors may include always checking up on where the woman is, who she is with, and listening to her phone calls [59]. Other similar behaviors include checking the mileage when a woman uses a car [59], continuously calling her at work [59], or demanding to know where a woman goes and who she wants to meet [51]. Finally, controlling behaviors also include marital rape and sexual coercion without physical power. The partner uses their control to make the woman feel guilty and shame her if she refuses to engage in sexual acts [49].
3.2.4. Threats and Intimidation
The final attributes of emotional abuse are threats and intimidation. Partners may directly or indirectly threaten to harm or hurt [42, 45, 63] and intimidate a woman. Verbal threats may include threats of divorce or separation [29, 64], threats that they will marry another woman [64], threats to harm the children [65], or take custody of children, threats to take away economic support [66], and threats to hurt relatives or close friends of the woman [42, 43, 67].
Other forms of intimidation include intentionally scaring women [64, 68] or causing concern for their family’s safety [62], e.g., staring, shouting, or yelling [62, 69], destroying the woman’s belongings or property, or threatening to throw something at her [49, 51, 59]. In addition, partners may make threats to physically harm or murder her, refuse to let her leave the house [47], threats to abandon her [50], or threats to domineer, harass, or stalk her. Some partners use animals as property and intentionally threaten to harm [30] or abuse the animal in front of a woman to intimidate her [49, 51]. Finally, partners may intimidate women by saying that something bad may occur to the partner or threatening to commit suicide [59].
3.3. Identifying a Model Case
According to Walker and Avant [23], the fifth step of concept analysis is recognizing a model case. A model case provides an example of the selected concept. It includes the defining attributes of the concept and serves as an example to portray the concept to others.
3.3.1. Model Case
Jane is a 32-year-old woman who married her 42-year-old husband, Mike, after she graduated high school. They have four children, ages 14, 10, 6, and 2, and a cat. Jane is unemployed, and Mike works as an automobile mechanic. Jane’s husband frequently calls her stupid, ugly, and undesirable. He always criticizes her appearance, saying that she is fat and short. One day, she told him that she planned to attend a community event downtown when the kids were at school. Her husband said, “No, you will not!” She tried to explain why she wanted to go, but he yelled, “No way! Are you going to meet other men? You will not leave this house. If you sneak out, I won’t let you see your family next month. Do you remember the time that I broke your gold bracelet? Well, this time, I will destroy the watch that your mother bought for you. If you disobey me, I will take your cat for a ride and throw it out of my car as I drive down the highway.” Jane started crying. Her husband remarked as he left the room, “You disgust me. You are so dramatic and sensitive.” This is an example of a model case of emotional abuse in the context of intimate relationships.
3.4. Identifying Borderline, Related, and Contrary Cases
The sixth step of concept analysis is to examine additional cases, including borderline, related, and contrary cases. Borderline cases are examples that consist of most of the defining attributes of the concept but not all the defining attributes. Related cases are examples that are related to a concept but do not have all the defined attributes. Contrary cases are examples that are completely different from the model cases, and all defining attributes of the model case are missing [23].
3.4.1. Borderline Case
Amy is a teacher and has been married to Adam for 20 years. Adam belittles Amy by blaming her for not being able to get pregnant and have children, even though Adam’s low sperm count is the primary reason why they struggle with infertility. Recently, a slender woman walked past them when they were outside. Adam told Amy that thinner women are more beautiful than her. Adam frequently ignores Amy and does not pay attention to her when she talks and when she asks him for something she needs. This example has some attributes of emotional abuse in intimate relationships, such as humiliation and indifference. However, there are no controlling behaviors, threats, and intimidation.
3.4.2. Related Case
Valerie, a 28-year-old woman, presents to primary care clinic 6 months after the birth of her third child. She has been married to Emmanuel, age 38, for the last 10 years. She has three children and does not want any more; however, her husband wants a “large family.” Upon further discussion, the nurse practitioner learns that Emmanuel does not know she is at the clinic. He frequently accuses her of infidelity if she leaves the house without him. He is always suspicious of her and has limited her contact with her family and friends. She is requesting a birth control method that he will not be able to detect, as she is afraid of him being even more controlling if he finds out. This example has some attributes of emotional abuse in intimate relationships, such as controlling behaviors and limiting social support. However, there are no threats, humiliation, or indifference.
3.4.3. Contrary Case
Suzanne is a businesswoman who married Jake, a businessman, and they have two children. Suzanne’s mother is dependent on Suzanne since she is bedridden, has dementia, and has no other family support. Jake is a supportive husband. He supports Suzanne by bathing their children, helping to cook meals, and completing most household chores. Jake also provides her verbal and moral support and encouragement since he recognizes that she is often frustrated. When Suzanne feels stressed, she goes to her husband to get support and share her feelings. Jake often encourages Suzanne to go outside for a walk or have lunch with her friends as he knows she is less stressed when she takes breaks from home. Jake frequently compliments Suzanne in front of people during social gatherings, praising her for how well she cares for her mother and their children. Suzanne and Jake talk about their intimate desires, and they mutually agree on the actions they are comfortable with. This contrary case contradicts the model case. In this case, the examples are elevating, caring, supportive, harmless, and complementary, none of which are attributes of the defined model case.
3.5. Identifying Antecedents and Consequences
The seventh step of concept analysis is to identify antecedents and consequences. Antecedents are situations that precede the concept, which serve to clarify how it operates and make assumptions about the concept. Consequences are the events that result from the occurrence of the concept, which helps to identify ideas that are not considered [23]. Figure 2 delineates the conceptual map of emotional abuse against women in the context of intimate relationships.
3.5.1. Antecedents
The concept of emotional abuse has several crucial elements that trigger it, including a history of child maltreatment, women’s and partners’ factors, unhealthy relationships, normalized emotional abuse in communities, and lack of social support. Each of these elements will be explained in detail in the following.
3.5.1.1. History of Childhood Maltreatment
Experiencing childhood maltreatment is linked to emotional abuse [29, 40, 70–76]. Women who have been neglected or physically and emotionally abused in childhood are likely to report emotional abuse by their partners later in life [70]. Specifically, childhood maltreatment that is characterized by neglect, physical abuse, and antipathy significantly predicts emotional abuse [40]. It is important to note that not only a woman’s experience of child abuse is correlated with emotional abuse but also her partner’s history of childhood maltreatment is a significant factor [29]. A history of family violence in women’s lives is associated with exposure to emotional abuse [69]. Women who experience abuse before pregnancy also have a high likelihood of exposure to emotional abuse during pregnancy and postpartum [68]. History of IPV [62, 77], women who witness parental violence [78, 79], and maternal IPV [72] are also all significantly correlated with emotional abuse.
3.5.1.2. Women Factors
There are many women-centric factors that increase the likelihood of experiencing emotional abuse. Age is correlated with experiencing emotional abuse, but the age range varies across studies. Many researchers report that women between 15 and 34 years report a higher prevalence of emotional abuse compared to those who are 35 and older [12, 33, 49, 62, 69, 76, 77, 80–84]. However, other researchers found that older women report more emotional abuse, and specifically, that emotional abuse increases with age [34, 38, 65, 85, 86]. In addition, being younger when married [87], including women who are married between 18 and 24 years [79], and early sexual debut [84, 88] increase the likelihood of emotional abuse.
Women’s educational attainment is another factor related to emotional abuse; however, the effect is inconsistent across studies. In most studies, low levels of education in women lead to an increased risk of being exposed to emotional abuse [12, 30, 33, 34, 56, 69, 81, 82, 86, 89–93]. However, other studies found that increased education was correlated with increased vulnerability to emotional abuse [29, 87].
Women’s employment and socioeconomic status are factors associated with emotional abuse. Regardless of women’s socioeconomic status, women are at increased risk of emotional abuse. Being employed decreases the risk of facing emotional abuse [33, 94]. Women who are economically disadvantaged [80, 95, 96], have low income [72, 76, 84], and who have lost their jobs or are underemployed [62, 83] have an increased likelihood of experiencing emotional abuse. In comparison, women who own land have an increased probability of experiencing emotional abuse [80]. Earning a similar salary to [38] or more than [29, 38] their husbands is also associated with exposure to emotional abuse. In addition, women who work have a likelihood of exposure to emotional abuse [54, 97].
Women’s health status is the final factor to consider. Experiencing emotional abuse is associated with women who have poorer health status [69], including having two or more health issues during pregnancy [33, 84]. Women with low self-esteem and loneliness report increased experiences of emotional abuse [41]. Furthermore, women who are diagnosed with depression [41, 98], substance use [62, 72, 98], alcohol use, and smoking [56, 84, 96] increased the likelihood of experiencing emotional abuse.
3.5.1.3. Partners’ Factors
The husband’s age, employment status, socioeconomic status, and educational attainment are also linked to emotional abuse in women. Having an older husband is significantly correlated with an increase in women suffering emotional abuse [92, 96]. Husbands who are unemployed [33, 89, 92, 99] or have low socioeconomic status [92] are associated with being perpetrators of emotional abuse toward their spouse. Women whose husbands have a low educational level [34, 79, 89, 92, 93, 99] or have limited formal education [90] increase the probability of women’s exposure to emotional abuse. If husbands have a higher social class than their wives, this also increases the risk of women experiencing emotional abuse [29]. Husbands who earn more money [65] increase the risk of women experiencing emotional abuse.
Health-related behaviors are another characteristic to examine in men. Women whose husbands consume alcohol [34, 54, 65, 67–69, 78–80, 89, 92, 96, 99–102], gamble [69], have a substance use disorder [68, 82], or smoke [99] are also significantly more likely to emotionally abuse their wives. Husbands who have violent behaviors outside of intimate relationships [65] are more likely to emotionally abuse their wives.
3.5.1.4. Unhealthy Relationships
Women’s autonomy in the household correlates with emotional abuse. Women who have low autonomy [81] and unequal marital power [38], such as independence regarding professional issues [88], economics [34, 87], decision-making [88, 96], and uncooperative husband [38], are more likely to experience emotional abuse.
How women may cope with their partners is another factor related to emotional abuse. Women’s coping mechanisms, such as elevating their voices in the presence of their husbands, leaving home without seeking permission from their husbands, speaking with other men, putting off household chores, and refusing to sleep with their husbands [29] increase the risk for women experiencing emotional abuse.
An imbalance in power is also associated with emotional abuse [88]. Education and income imbalances between couples increase the risk of wives experiencing emotional abuse [103], including wives who make more money and have a higher educational level [103]. The nature of the relationship between partners is also associated with emotional abuse. For example, continuous disagreement with husbands [62, 87], uncommitted intimate relationships [94], and women whose husbands support controlling behaviors [86] are more vulnerable to emotional abuse.
The marriage type is also associated with emotional abuse. Polygamous marriages expose women to emotional abuse [54, 67, 100]. Women whose husbands have other wives and women who do not know about the marital status of their husbands [102] report more emotional abuse, and women who are economically dependent on their husbands [34] are also more likely to experience emotional abuse.
Women who have more children reported they experience higher levels of emotional abuse [34, 79, 80, 95]. Unplanned pregnancies [33, 105], unwanted pregnancies [62, 105], women who are more likely to negotiate for safer sex [86], women who give birth before age 25 [106], and terminated pregnancy [84] also make women more vulnerable to emotional abuse from their partners.
3.5.1.5. Normalized Emotional Abuse in Communities
Residing in communities that accept IPV and justify the imbalance of power in decision-making and autonomy in the household can elevate the likelihood of women facing emotional abuse. Communities characterized by economic inequality and criminality can increase the probability of women experiencing emotional abuse [88]. Some communities do not recognize nonphysical violence as abuse [60]. Women report that cultural norms that support disempowering women and justify violence elevate patriarchal power dynamics in a relationship [53]. Some women may also believe that men can do whatever they want because their husbands paid a dowry or bridal price2 [53]. In contrast, women’s empowerment in societies is considered a protective factor from abuse. Women’s empowerment, including financial (e.g., employment), social (e.g., being able to move without restriction), and cultural (e.g., attitudes toward domestic violence), are associated with lower exposure to emotional abuse [101]. Women who have patriarchal beliefs [80] and accept abuse by men have been directly linked with increased emotional abuse by partners [80, 81, 102]. Women lacking knowledge of emotional abuse, its consequences, and their rights have increased vulnerability to emotional abuse [34, 53].
3.5.1.6. Lack of Social Support
Women who receive low social support are more likely to experience emotional abuse [91, 108]. Women who receive ineffective social support [68] or low family support [94] are associated with a high prevalence of emotional abuse. Women who are emotionally abused and report loneliness are also less likely to receive social support [48].
Emergency events and crises in societies are associated with emotional abuse. For example, the COVID-19 pandemic increased the risk of abuse including emotional abuse [109]. Lockdown restrictions prevent women from receiving help and support from agencies. During the lockdown, women trapped in their homes with their partners reported exposure to emotional abuse [109].
Other factors to consider regarding the availability of social support include immigrant status or location of residence. Being an immigrant [38, 73] increases the possibility of women experiencing emotional abuse. Place of residence is associated with exposure to emotional abuse [110]. For example, women who live in rural areas [76, 92] and live in poor communities have reported higher levels of emotional abuse compared with their urban-living peers [89]. However, women who live in urban areas [81] reported emotional abuse. These are unique factors to consider when trying to mitigate exposure to emotional abuse via social support.
3.5.2. Consequences
The consequences of emotional abuse affect women include poor outcomes in psychological health, perinatal health, and intimate relationship problems.
3.5.2.1. Psychosocial Health
Emotional abuse is associated with several mental health problems [36], such as somatic symptoms, anxiety, and depression [41, 111, 112]. In addition, psychiatric morbidity, including depression or depressive symptoms [53, 57, 66, 106, 109, 112–119], anxiety [57, 66, 106, 109, 113, 115, 117, 118, 120], somatization symptoms [35, 113], poor body image and dissatisfaction [106], eating disorders [53], psychogenic seizure [66], irritability, lapse of memory, and difficulty concentrating and somatic conditions [118] are all linked to experiencing emotional abuse.
Women who experience emotional abuse report increases in self-objectification, body surveillance, and body shame [59, 106, 121]. After experiencing emotional abuse, women may cope by using substances and illicit drugs [33, 114]. Several studies show that women may have suicidal ideation due to emotional abuse [36, 52, 53, 58, 112, 116, 120, 122]. Women reported experiencing post-traumatic stress symptoms (PTSSs) [57, 71], post-traumatic stress disorder (PTSD) [35, 46, 115], complex PTSD, negative affect, and dissociation [35] due to experiencing emotional abuse from their partners.
Emotional abuse can also affect women’s psychological wellbeing. For example, emotional abuse can lead to negative psychological outcomes [123], including sadness [43, 52], crying, and less interest in engaging in social activities that one normally enjoys [52] and distress symptoms [41, 124]. Emotional abuse is related to sleep disturbance [58] and insomnia [118]. Other comorbidities associated with emotional abuse include lower psychosocial health [117], low self-esteem [41, 53, 117], feelings of worthlessness [43], feeling of hopelessness [53], and loneliness [41].
Emotional abuse can affect women’s physical health. Women mention that emotional abuse affects their health and sense of wellbeing. For instance, emotional abuse leads women to self-harm [52], poor general physical health and pain during sex [106], fatigue [118], increased likelihood of being physically abused [125], leads to lack of appetite [52], and impairs overall quality of life and daily functioning [112, 115].
3.5.2.2. Perinatal Health
Emotional abuse during the perinatal period can also contribute to poor maternal and infant outcomes. Women who experience emotional abuse have an increased risk for elevated perinatal depressive symptoms and perinatal depression [120, 126] and postpartum depressive symptoms [32, 108, 120, 127, 128]. Emotional abuse can affect the continuity of pregnancy and increase negative birth outcomes such as preterm birth, termination of pregnancy [105, 110], and stillbirth [126, 129]. Pregnant women exposed to emotional abuse are also at risk for abortion [71, 129], repeat abortions [130], and miscarriage [129]. Emotional abuse can also lead to unwanted pregnancy and lower utilization of maternal healthcare services, including antenatal care, delivery assistance by skilled health providers, and postnatal care [105, 131, 132]. Infants born to women exposed to emotional abuse are at risk of compromised fetal and infant growth [114], low birth weight [56, 126], birth defects, and asphyxia [126].
3.5.2.3. Intimate Relationship Problems
Emotional abuse can break down the quality of intimate relationships. Increased relationship dissatisfaction, being anxious or avoidant, and sexual dissatisfaction, dysfunction, or decreased levels of sexual communication are related to experiencing emotional abuse [48]. Women also report fearing their partners [58]. Emotional abuse led women in one study to engage in risky behaviors because they have a desire to engage in sexual relations but their husbands refuse to have sex [53]. The self-development of women who experience emotional abuse is hindered, lowering their self-esteem, and making them feel hopeless for love and tenderness in the context of intimate relationships [60].
3.6. Define Empirical Referents
The last step of Walker and Avant’s concept analysis is defining empirical referents (2011). In this step, we show how the concept exists in the real world by measuring the concept. The attributes and empirical referents are frequently the same [23]. In our analysis, no previous investigators used tools to embrace all attributes of emotional abuse. In addition, there are no tools to cover all characteristics of each attribute, including humiliation, control, threats, and intimidation. Table 3 represents the previous tools that were used in the included studies for this concept analysis and the attributes that are covered in the tools.
| Tool’s name | Humiliation | Indifference | Controlling | Threaten and intimidation | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Attributes | Insulting | Blaming | Accusation suspicion | Ignoring/Careless | Isolation/Restriction | Jealous | Stalking | Take permission | Sex coercion | Verbal threats | Scaring acts | Destroy items |
| The revised composite abuse scale | √ | √ | √ | √ | √ | |||||||
| The WHO multi-country | √ | √ | √ | |||||||||
| A revised conflict tactics scale (CTS2) | √ | √ | √ | √ | √ | √ | ||||||
| The composite abuse scale (CAS) | √ | √ | √ | √ | √ | √ | √ | √ | ||||
| The abuse assessment screen (AAS) | √ | √ | ||||||||||
| The NorVold domestic abuse questionnaire (NORAQ) | √ | √ | √ | √ | ||||||||
| Index of spouse abuse (ISA) | √ | √ | √ | √ | √ | √ | ||||||
| The psychological maltreatment of women inventory (PMWI-short) | √ | √ | √ | √ | √ | √ | √ | √ | ||||
| Measure of psychologically abusive behaviors (MPABs) | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | ||
| Emotional abuse questionnaire (EAQ) | √ | √ | √ | √ | √ | √ | √ | √ | √ | |||
| The multidimensional measure of emotional abuse | √ | √ | √ | √ | √ | √ | √ | √ | ||||
| The HITS (hurt, insulted, threatened with harm, and screamed) screening tool. | √ | √ | ||||||||||
| A modified version of the abusive behavior inventory | √ | √ | √ | √ | √ | |||||||
4. Discussion
Researchers report that most people identify physical or sexual abuse as a type of IPV. Often, people do not identify emotional abuse as a form of IPV, as it can be difficult to recognize when it is occurring due to its subtleties [7]. However, it is a form of violence with serious short- and long-term negative effects on women’s physical, mental, sexual, and reproductive health. It also has an impact on the health and happiness of their children. Emotional abuse has significant social and financial costs, affecting families and societies [133].
Concepts are important components of theories. Concept analysis is an important step in building nursing theories by breaking down the concepts and getting a basic comprehension of the attributes, antecedents, and consequences that underlie the concepts [23]. Exploring a concept may provide a clear linkage to solutions within the discipline of nursing [134]. The continued advancement of nursing science is dependent on the development of nursing theories that successfully portray phenomena of interest by forecasting and managing them [135]. The concept analysis of emotional abuse within the context of intimate relationships shows attributes, antecedents, consequences, a model case, and empirical referents. Some antecedents and consequences of this concept are previously explored in the empirical literature but focused more on other forms of abuse, such as physical and sexual abuse; however, this concept analysis demonstrates that emotional abuse has similar adverse implications for women’s health outcomes. In addition, because emotional abuse worsens women’s health, women with various health conditions are more vulnerable to emotional abuse.
The findings of this concept analysis provide us with basic knowledge in the literature about emotional abuse against women within the context of intimate relationships. The findings will help researchers and investigators develop new conceptual frameworks and theories that will inform the early detection of IPV, including emotional abuse, to better promote women’s health. The promotion of better women’s health also needs to consider the consequences of emotional abuse on women and their offspring. The psychological and perinatal implications of emotional abuse can create generational trauma and poor health. Nurse scientists and healthcare providers have an important role to play in the development of innovative interventions across multiple levels based on the generation of new knowledge that leads to theory building.
Furthermore, this concept analysis may improve women’s health outcomes as concept analysis helps to advance nursing science and practice by providing conceptual clarity [136]. Emotional abuse is associated with a range of poor health outcomes. According to a recent study by Dye [137], there are negative long-term health consequences from experiencing emotional abuse during childhood. Adult participants who experienced emotional abuse, reported “higher rates of depression, anxiety, and stress compared to those who reported only physical, only sexual, or combined physical and sexual abuse” ([137], p. 404). Therefore, understanding the antecedents and consequences of emotional abuse has several clinical implications. First, clinicians can screen for emotional abuse attributes during the clinical assessment to detect and provide interventions that address the emotional abuse consequences. Second, identifying explicit attributes and consequences will provide the evidence base for the development of prevention programs and treatment plans. Third, conceptual clarity promotes appropriate consultation or referral for mental health support. Future interventions include those that would address childhood abuse to avert adult experiences of emotional abuse. Our findings suggest that the amendment of current policies to add a focus on violence in the lives of women that encompasses emotional abuse is also worthy of consideration.
The findings of our analysis clarify the antecedents, attributes, and consequences of emotional abuse in the lives of women. This concept analysis of emotional abuse in the context of IPV addresses the gap in knowledge regarding this form of abuse. We used a systematic search strategy, adhered to the PRISMA guidelines and independently screened the articles that supported the validity of our findings. The included studies were published in many different countries, which give a broad spectrum of understanding of emotional abuse in the context of intimate relationships from different cultures and perspectives. There are, however, some limitations that should be mentioned. We included studies published only in the last 10 years, which may have led to us missing some of the historical underpinnings of the concept of emotional abuse.
Future reviews should include older literature to further investigate the historical development of emotional abuse across the decades. Since this is the first write-up to analyze the concept of emotional abuse in the lives of women, it would be difficult to consider a comparison with other empirical findings. This concept analysis also only includes studies focused on intimate partner relationships and does not account for emotional abuse experienced by other relatives such as brothers, fathers, or mothers-in-law, which may be significant in many societies around the world. Future research is recommended to help us understand emotional abuse more broadly and to develop knowledge that would allow for the development of targeted interventions that would meet women’s unique needs following experiences of emotional abuse from various other family members. Future studies focusing on the relationship between women’s age and exposure to emotional abuse are recommended.
5. Conclusion
This concept analysis represents the attributes, antecedents, and consequences of emotional abuse in the lives of women. Our analysis shows how this concept is complex and multifaceted, caused by different factors, with various impacts on women’s health. More research on this concept is needed if we are to develop effective multilevel interventions that address emotional abuse in the lives of women within the context of intimate partner relationships. In this paper, we highlighted the urgent need for increased recognition of the problem of emotional abuse as a form of IPV. This recognition is needed not only in research and healthcare practice but also when it comes to social support systems and legal and therapeutic settings where the goal is to enhance healthy intimate partner relationships and also to promote women’s health and wellbeing. Considering emotional abuse as a legitimate form of harm is important for developing prevention and intervention programs. Further research is recommended to help us comprehend the nuances of emotional abuse and to increase awareness among community members about emotional abuse and its consequences. Emotional abuse is often a precursor to other forms of violence that could be detrimental to women’s health, including homicide. All forms of violence in the lives of women, therefore, need to be urgently addressed.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
No funding was received for this research.
Acknowledgments
We thank Dr. Jeanne M Erickson for providing guidance on conducting a concept analysis. We thank the librarian for facilitating the search by providing the search terms in the literature for this concept analysis. The first author, Hanan Abusbaitan, is a Research Coordinator on an ongoing study being conducted in the Upper Midwest. This ongoing study was funded by the National Institute on Minority Health and Health Disparities (R01 MD016388) and aims to understand the impact of the COVID-19 pandemic on the help-seeking of American Indian and Black women experiencing intimate partner violence. Intimate partner emotional abuse is an important form of violence identified in the lives of women participating in this study that has important implications for women’s health and wellbeing. This finding necessitated the current concept analysis, so we could gain an understanding of the concept of emotional abuse to better inform our analyses for this ongoing study. We appreciate all the women participating in this study and the information they have taken the time to share that will inform future interventions and policies to improve health outcomes for women experiencing violence.
Endnotes
1A committed relationship means a serious and long-term intimate relationship with a partner [104].
2Bridal price means the gifts or money from the bridegroom or his family are given to the bride’s family [107].
Supporting Information
The supporting file consists of an evidence table for the eligible articles included in this concept analysis. The evidence table delineates deep details about where the studies were conducted, the definition of emotional abuse, its attributes, antecedents, and consequences, and the tools used to measure emotional abuse.
Open Research
Data Availability Statement
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.
