Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Perspectives of Victims of Gender Violence

Deborah Atance-Pereira, PhD, RN; María Luisa Zamarro-Arranz, PhD, MD; Juan Francisco Velarde-García, PhD, RN; Elisabeth Huertas-Hoyas, PhD, OT; Jose Miguel Cachón-Pérez, RN; Paula Parás-Bravo, PhD, RN; Domingo Palacios-Ceña, PhD, RN

Abstract

The purpose of the current study was to explore the experiences of women who have been affected by violence and received mental health care. A qualitative phenomenological design was used with in-depth interviews and personal letters in a sample of 29 women from a public mental health center of Madrid, Spain, who were affected by physical, mental, and/or sexual abuse. The analysis revealed three themes: (1) Living With Fear; (2) Feeling Guilty; and (3) Experiencing the Imposition of So-Called “Womanly Duties” (i.e., being a maid, babysitter, and/or sexual slave). The current study highlights the importance of developing educational programs for the prevention of abuse. [Journal of Psychosocial Nursing and Mental Health Services, 58(6), 30–39.]

Abstract

The purpose of the current study was to explore the experiences of women who have been affected by violence and received mental health care. A qualitative phenomenological design was used with in-depth interviews and personal letters in a sample of 29 women from a public mental health center of Madrid, Spain, who were affected by physical, mental, and/or sexual abuse. The analysis revealed three themes: (1) Living With Fear; (2) Feeling Guilty; and (3) Experiencing the Imposition of So-Called “Womanly Duties” (i.e., being a maid, babysitter, and/or sexual slave). The current study highlights the importance of developing educational programs for the prevention of abuse. [Journal of Psychosocial Nursing and Mental Health Services, 58(6), 30–39.]

Gender-based violence is a major global public health problem that affects one third of women worldwide (World Health Organization, 2013). One in five women age 15 and older has experienced this type of violence in Europe (European Union Agency for Fundamental Rights, 2014). The concept of gender-based violence is associated with different terminologies, such as violence against women (VAW), intimate partner violence (IPV), or domestic violence (DV) (Dardis et al., 2015).

IPV can be defined as physical or sexual violence, stalking, or psychological aggression (including coercive acts) by a current or former intimate partner, whether or not the partner is a spouse (Huecker & Smock, 2019; Miller & McCaw, 2019). In addition, DV encompasses a range of abuse, including economic, physical, sexual, emotional, and psychological abuse toward children, adults, and older adults (Huecker & Smock, 2019). Previous estimates indicate that 20% to 30% of women in the United States have experienced IPV in their lifetime (Dicola & Spaar, 2016). In addition, approximately one in three women age 18 and older experience DV, and at least 5 million acts of DV occur annually among women age 18 and older (Huecker & Smock, 2019). IPV and DV tend to be repetitive, with an escalation in frequency and severity over time among women (Dicola & Spaar, 2016). Although IPV or DV are terms that can be applied to violence against women and men of heterosexual or homosexual orientation, outside or within the home (Rollè et al., 2018), the term VAW is specific to women in any context or situation (Korstjens & Moser, 2017). VAW is defined as male aggression toward a female partner (Krahé, 2018). This type of violence entails any act or omission, which being gender-based, causes death; physical, sexual, or psychological injuries; and moral damage to women (Krahé, 2018). VAW is a problem that affects women independent of their age, ethnicity, religion, nationality, sexual orientation, or social conditions (Dardis et al., 2015).

Women who have experienced VAW present with physical symptoms (e.g., injuries, fractures, bruising); substance use (tobacco, alcohol, and other drugs); sexually transmitted diseases; elective abortions (Ferrari et al., 2016); and mental disorders (e.g., depression, anxiety, posttraumatic stress, suicide) (Tarzia et al., 2016) that require treatment and assistance by mental health services. Women using these mental health services receive continued follow up to support their recovery process during their stay at health centers, in the community, and within their social environment (Ministry of Health, Social Services and Equality, 2015). Researchers have shown that mental health professionals help in the prevention and intervention of abuse (McGarry, 2017) via: (a) the detection of risk factors (Gupta et al., 2017) and early detection based on home or prenatal screening (Bradbury-Jones et al., 2017); (b) leading community intervention programs (Gupta et al., 2017); (c) interventions through cognitive-behavioral, trauma-informed care (Arroyo et al., 2017; Taft et al., 2016); and (d) continued support and follow-up interventions for women working toward mental health recovery and social integration (Snyder, 2016).

Furthermore, researchers have shown that there are certain cultural, ethnic, and social factors (e.g., a patriarchal society, machoism, inequality, the distribution of gender-based roles, inequity in women's social opportunities) that perpetuate VAW (Francis et al., 2017). These factors influence the responses of women regarding the abuse (e.g., seeking help, acknowledging the abuse, walking away from the abuser) and the process of recovery. Snyder (2016), in a systematic review on the experiences of abused women, describes how providing a safe and confidential environment facilitates the recovery of women's autonomy and their ability to make decisions. In addition, the presence of feelings such as shame, guilt, and fear; the existence of stereotypes on the role of women in marriage (Francis et al., 2017; Heward-Belle, 2017; Tonsing & Barn, 2017); and women's perspectives in relation to their abusers (McGinn et al., 2016), warrant further study.

In Spain, VAW continues to be a reality that influences the life and health of women, independent of their socioeconomic status, culture, ethnicity, or country of origin (Government Office for Gender-Based Violence, 2019; Ministry of The Presidency, Relations with Parliament and Equality, 2017). Certain factors inhibit the ability of women in Spain to react when seeking professional help to put an early end to abuse and violence. These factors include social and family dynamics (e.g., women age 35 and older, with children, economic dependency toward the abuser, lack of economic resources, physical disability, living with the abuser, not acknowledging being a victim of gender violence), psychological aspects (e.g., fear of the abuser, retaliation involving their children, fear of their family's reaction upon learning that they are a victim of violence, believing that the situation of abuse can be resolved, negation of reality and justification of violence, embarrassment, shame, and feeling sorry for the abuser), and other factors (e.g., lack of knowledge of and fear for court and police procedures) (Government Office for Gender-Based Violence, 2019). Thus, it is relevant to analyze the experiences of Spanish women who have been victims of VAW.

In 2017, the Ministry of The Presidency, Relations with Parliament and Equality identified new forms of VAW, such as female genital mutilation, forced marriages, sexual exploitation, trafficking of women, and violence against one's children as a form of VAW. In Spain, the pact against violence, as well as the various official studies performed by the Government Office for Gender-Based Violence (2015, 2018), express the need to perform follow up with victims of VAW to examine their perspectives and experiences for the purposes of violence prevention and the building of programs based on the needs of women. The purpose of the current study was to describe the experiences of women who have experienced VAW and received mental health care using qualitative methods.

Method

The current study used the guidelines for conducting qualitative studies established by the consolidated criteria for reporting qualitative research (COREQ) (Tong et al., 2007) and the Standards for Reporting Qualitative Research (SRQR) (O'Brien et al., 2014). Qualitative methods are useful for understanding the beliefs, values, and motivations that underlie individual health behaviors (Creswell & Poth, 2018).

Design

A qualitative phenomenological study was conducted, following Husserl's framework (Dowling, 2007), addressing the experiences of women who have experienced VAW and received mental health care. In the field of qualitative studies, phenomenology research is designed to explore the meaning of a phenomenon through specific human experiences via rich descriptions (Creswell & Poth, 2018; Korstjens & Moser, 2017; Moser & Korstjens, 2018). Phenomenology attempts to identify the essence of participants' lived experiences (Giorgi, 2005; Korstjens & Moser, 2017), which is a subjective reflection on human beings when taking part in events in a specific space and time (Creswell & Poth, 2018). For Husserl, the aim of phenomenology is the study of phenomena as they appear to reach an essential understanding of human experience (Dowling, 2007). To consider subjective experiences, the researcher assumes a certain attitude of attentive openness and readiness for a proper understanding of the unique meaning of participants' lived experiences (Carpenter & Suto, 2008).

Research Team

Prior to the current study, the research team's positioning was established via two briefing sessions addressing the theoretical framework for the study and the team's beliefs and motivations for the research (Carpenter & Suto, 2008). The results of these sessions are shown in Table 1.

Researcher Reflexivity

Table 1:

Researcher Reflexivity

Seven authors (three male and four female) participated in the current study, four of whom had experience in qualitative designs, six held PhDs in health sciences and were university professors not involved in clinical activity, and two were involved in clinical activity with women.

Setting and Participants

The current study included women who have been victims of episodes of violence by their partners and were treated at a public mental health center (PMHC) of Madrid, Spain. Inclusion criteria were: (a) women experiencing physical, mental, and/or sexual abuse by their partner or ex-partner; (b) women who sought help and disclosed their situation of violence and abuse; (c) women age 18 to 65; and (d) women being treated at the PMHC where the study is to be performed. Exclusion criteria were: (a) women who had not sought help and/or had not reported violence and/or abuse; (b) women who were not being treated at the PMHC where the study is taking place; (c) women who did not wish to participate in the study; and (d) inability to communicate in Spanish or to sign the written informed consent form.

Purposive sampling was used, based on relevance to the research question (not clinical representativeness) (Carpenter & Suto, 2008; Teddlie & Yu, 2007). Sampling and data collection were pursued until data saturation was achieved, at which point no new information emerged from the data analysis (Carpenter & Suto, 2008). In the current study, data saturation occurred after including 29 patients.

Data Collection

Data were collected between January 2014 and March 2015. Based on the phenomenological design, the study team used first-person data collection tools (non-structured and semi-structured interviews and letters) (Carpenter & Suto, 2008; Creswell & Poth, 2018). The purpose of unstructured interviews is to use in-depth, open questions that allow participants to describe their experiences in their own narrative (Ayala & Elder, 2011).

With Participants 1 to 17, the study team opened interviews with the following questions: “What is your experience with intimate partner violence?” and “How did it [intimate partner violence] affect your daily life and your physical and mental status?” Thereafter, the study team listened carefully, noted the key words and topics identified by participants' responses, and used their answers to ask for and clarify the content (Carpenter & Suto, 2008). Through this process, the study team collected relevant information from the perspectives of the participants. In addition, during the interviews, the study team used prompts or probes for the following purposes: (a) to encourage participants to provide more detail (“Can you tell me a bit more about that?”); (b) to encourage participants to keep talking (“Have you experienced the same thing since?”); (c) to resolve confusion (paraphrasing something participants said); and (d) to demonstrate that participants have the full attention of the study team (“That's really interesting, please tell me more”) (Carpenter & Suto, 2008; Creswell & Poth, 2018).

The study team performed a first analysis on the unstructured interviews of Participants 1 to 17. This analysis revealed some relevant topics that required further study, marking the need for inclusion of a second stage of data collection. This second stage (Participants 18 to 29) consisted of semi-structured interviews that were based on a question guide designed to gather information regarding specific topics of interest (Ayala & Elder, 2011; Carpenter & Suto, 2008) such as: (a) the participant's role as a woman (“What do you think is your role in your relationship with your partner, and at home with the rest of the family?” and “Have you felt influenced in any way?”); (b) recognizing herself as a victim (“What does it mean for you to suffer violence on behalf of your partner?” and “How has this situation affected your life?”); and (c) fear and guilt (“How did you feel and think when the abuse began, during the abuse, and when the abuse ended?” and “Did you, at any point, feel somehow responsible at all for the situation?”).

Participants were asked to write personal letters or diaries, which were part of the analyzed data. Solicited diaries and letters were used to obtain information from participants in a non-obstructive manner and to capture ordinary events and observations that might be neglected by single recording methods because participants view these as insignificant, take them for granted, or forget them (Morrell-Scott, 2018; Wildemuth, 2009).

The study team recorded and transcribed all interviews, recording 2,123 minutes of interviews overall. The first 17 interviews ranged in length from 33 to 128 minutes (mean = 82.9; SD = 29.29), and the second set of interviews ranged in length from 41 to 102 minutes (mean = 59.5; SD = 18.86). A personal letter was obtained during the second stage of data collection from Participant 2. No other letters were gathered, as the remaining participants stated that they did not wish to add anything to their declarations. The interviews were held at the participant's home (n = 1) or in a private room at the PMHC (n = 28), depending on the participant's preference. The interviews were conducted by two female researchers (D.A.P., M.L.Z.A.) to avoid a masculine presence during the data collection process. The interviews were conducted in Spanish; however, data were ultimately presented in English. To ensure the accuracy of the information derived from the study, a translation protocol was used, as presented in Table 2 (Chen & Boore, 2010; van Nes et al., 2010).

Translation Protocol

Table 2:

Translation Protocol

Data Analysis

Full transcriptions of each interview, researchers' field notes, and participants' documents were produced. The study team collated texts to allow qualitative analysis, after which a thematic analysis of the data was conducted (Saldaña, 2012). Analysis began by pinpointing the most descriptive content to obtain meaningful units. This initial analysis was followed by a deeper analysis to reduce and identify the most common meaningful groups (Carpenter & Suto, 2008). Thus, groups of meaningful units were formed based on similar points or content. These units facilitated emergence of topics describing participants' experiences. The study team conducted this process of thematic analysis separately for each interview. Coding was conducted separately for each interview by three authors (D.A.P., J.F.V.G., D.P.C.). Later, the results of the analysis were combined during team meetings (Saldaña, 2012). In case of differences, final themes were identified by consensus. No data analysis software was used.

Rigor

The current study followed the COREQ (Tong et al., 2007) and SRQR guidelines (O'Brien et al., 2014). Criteria by Lincoln and Guba (1985) were used for establishing the trustworthiness of data by reviewing issues concerning the credibility, transferability, dependability, and confirmability of the data. Credibility was addressed via researcher triangulation (each interview was analyzed by two researchers). Thereafter, the study team had meetings during which these analyses were compared. Triangulation of data collection tools was also sought (unstructured and semi-structured interviews were conducted, and researcher field notes were kept), and member checking was used (by asking participants to confirm data obtained at the stages of data collection and analysis). For transferability, the study team provided in-depth descriptions of the study (providing details of the characteristics of researchers, participants, contexts, sampling strategies, and the data collection and analysis procedures). For dependability, an audit trail was developed by an external researcher (including an assessment of the study research protocol, focusing on aspects concerning the methods applied and the study design). Finally, confirmability was encouraged via the performance of researcher triangulation, data collection tools triangulation, and author reflexivity (performance of reflexive reports and by describing the rationale behind the study) (Moser & Korstjens, 2018).

Ethics

The current study was approved by the Ethical Research Committee of the Universidad Rey Juan Carlos. Research was performed in accordance with the Declaration of Helsinki (World Medical Association, 2013). Informed consent, verbal and written, was sought from participants. All participants granted permission to record their interviews. Protection of participants was ensured throughout the study. The study team adhered to the tenets of protection of anonymity and confidentiality at all times during personal data collection and data processing; therefore, said data was only accessible by the study team (Paavilainen et al., 2014). Moreover, personal data and information that might identify participants were replaced with numerical codes (Btoush & Campbell, 2009). In addition, several measures were implemented to ensure minimal risk (danger from the abuser) and avoid potential harm (emotional responses). To ensure minimal risk, direct contact was made between the study team and participants, thus, no contact existed with people other than participants (Langford, 2000). To prevent emotional responses arising during interviews, the study team made interview questions supportive, non-judgmental, and free from blaming or stigmatizing language. Participants were also offered the possibility of either suspending the interview or withdrawing from the study (Btoush & Campbell, 2009). All participants were contacted by telephone within 24 to 48 hours after data collection to assess their emotional status and their need for assistance.

Results

In total, 29 women participated in the current study, with a mean age of 46.27 years (range = 24 to 64), and 2.13 children on average. No participants withdrew from the study. Regarding their country of origin, 22 participants were from Spain and seven were of a foreign nationality, including Morocco (n = 2), Yemen (n = 1), Venezuela (n = 1), Santo Domingo (n = 1), Argentina (n = 1), and Ecuador (n = 1). Participants had diagnoses of depression (n = 10), anxiety combined with posttraumatic stress (n = 5), anxiety (n = 10), posttraumatic stress (n = 2), and schizophrenia (n = 2). Six participants held university degrees, 13 finished their secondary education, and the remaining 10 participants had no studies. Regarding work status, nine participants were employed, 16 were unemployed, and four described themselves as housewives. No participants were living with their abuser in the same home. In addition, 22 participants had previously reported the abuse, whereas seven participants had not made the abuse known to the authorities.

Three main themes were identified: (1) Living With Fear; (2) Feeling Guilty; and (3) Experiencing the Imposition of So-Called “Womanly Duties.”Table 3 reports participants' narratives, taken directly from interviews and personal letters, regarding the three emerging themes.

Narratives from Women who have Experienced Domestic Violence

Table 3:

Narratives from Women who have Experienced Domestic Violence

Living With Fear

The narratives collected by the study team described fear as a constant part of participants' everyday life because of the real danger they faced. The uncertainty of when and where they might experience violence, and what type of violence they were going to be affected by worsened the fear. Most participants described feeling unable to react, and that their fear was used by their abuser to gain control over them. The presence of the abuser and the threat or memory of past abuse was enough to block and control some of the women. Fear remains even when the woman no longer lives with the abuser, making her modify certain behaviors, such as not leaving the house, closing all the windows and entrances, and being on a continuous state of alert. Battered women felt marked for their lives.

Feeling Guilty

Participants' narratives showed how they felt responsible for the violence inflicted upon them, for not having taken measures against the abuser, for having taken measures too late, or for having triggered the violence. Frequently, participants described how their abuser used guilt as an instrument of control. On the other hand, guilt reappears in women when filing a report and/or after separating from the abuser. On other occasions, participants described feeling guilty for not fulfilling their “expected duties” as a wife/woman.

Experiencing the Imposition of So-Called “Womanly Duties”

Participants' narratives described how their abusers imposed certain obligations upon them as women. The non-fulfilment of these obligations justified the violence. Participants described how the obligations of the wife/woman consisted of fulfilling the role of maid, babysitter, and/or sexual slave. Although not all of these roles were shared by participants, there is an “ideal” vision regarding what the woman should and should not do in the home. These obligations included cooking, cleaning the house, taking care of children, preparing meals, having drinks on supply in the house, ironing clothes, managing house matters, and performing novel sexual acts. Furthermore, participants interviewed acknowledged that their abusers forced them to perform unpleasant sexual acts that affected their self-esteem, which resulted in avoidance of sex. Most participants avoided using the term “rape,” but they did describe situations where they were forced or coerced into sex. For some women, the concept of “obligation” was linked to being a “good wife.” Having performed the expected functions of a wife/woman provided a certain reassurance.

Discussion

Researchers have reported that VAW is associated with depressive symptoms, suicidal ideation, posttraumatic stress disorder, generalized anxiety disorder, and substance use (Chmielowska & Fuhr, 2017; Park et al., 2017). The experience of VAW and mental disorders among abused women are linked and exacerbated by prior abuse or attributed to past or present relationships (Masci & Sanderson, 2017), poverty, discrimination (Chmielowska & Fuhr, 2017), and conflict with traditional gender roles (Park et al., 2017). The effects of VAW on the mental health of women explains the referral of abused women to mental health and psychiatry services. Perhaps a problem that has a large cultural and social component has been medicalized in an attempt to cover for the lack of social and community resources for the prevention of violence and the care of women experiencing abuse (Taft & Colombini, 2017). The authors of the current study agree that implementing programs of care, support, and follow up by health organizations and institutions is essential to helping abused women (Miller & McCaw, 2019); however, it is necessary to approach VAW at its origin and to consider the construction of gender and the cultural and social perspectives of women (Krahé, 2018). This approach cannot be achieved through health care alone.

Fear was a constant element in the narratives of participants. This constant fear is experienced as a terrifying and uncontrollable situation that lingers despite the abusive relationship having been interrupted (Keeling et al., 2016), or the abuser not being physically present (Souto et al., 2015). Fear is not associated only with the threat of physical abuse to the woman, it is also associated with other circumstances, such as kidnapping or violence directed at children (Gregory et al., 2017).

Participants in the current study acknowledged feeling like they had been “marked.” Similarly, McCleary-Sills et al. (2016) showed that women who have experienced abuse often feel stigmatized due to the shame felt by the abused women and their families. This shame is based on the misguided belief that violence is only a temporary marital problem, and that help is intrusive and unnecessary (Othman et al., 2017). The consequence of this belief is a delayed provision of appropriate services (Francis et al., 2017).

Participants' narratives describe how guilt appears in abused women, who consider themselves responsible for the abuse. In that direction, Othman et al. (2014) described how some women associate the violence with their own mistakes, with the understanding that their abusers were the ones in charge of correcting them. This belief entails a high risk for women, from a social perspective, as violence can become accepted as a corrective instrument to be wielded by the man/husband (McCleary-Sills et al., 2016), or which can be minimized or accepted by the victim (Othman et al., 2014).

The idea that abused women might feel guilt for their own abuse may also be related to the guilt felt by victims regarding the fulfillment of so-called “duties or obligations as a woman.” The study authors believe that this relation may be explained when considering that these womanly obligations are based on roles established by a patriarchal society. Researchers have described how abused women become labeled within the home, and thus take on the role of raising children and are not allowed to work outside the home (Mannell et al., 2016; Roush & Kurth, 2016). Heward-Belle (2017) also reported that abusers use the social representation of a “good mother” to coerce women and exercise control over them.

To the knowledge of the current study team, no prior research has identified the roles of maid, babysitter, or sexual slave in studies concerning abused women. Moreover, current participants experienced sexual relations as something unpleasant that they felt forced to undergo. Researchers define these situations as rape, which in these women generates a rejection of sex (Roush & Kurth, 2016; Stern et al., 2016) and can lead to sexual health disorders (e.g., AIDS, HIV, other sexually transmitted diseases) and female sexual dysfunction (e.g., dyspareunia, vaginal injuries) as a result of the abuse (Bo et al., 2017; Krahé, 2018). Surprisingly, there are certain situations where sexual relations are considered obligatory for women and men believe that they have the authority to maintain these obligations (Cardoso et al., 2016).

Implications

The current study team believes that the results of this study have implications for practice, and that health care professionals must provide help to abused women: (a) in the community, by developing educational programs for promoting gender equality, explaining the social and cultural factors that help perpetuate the abuse, and eliminating stereotypes and myths regarding women, their role in marriage and the family, and their so-called “duties” in the home; and (b) in health centers, where “safe zones” should be created to encourage a therapeutic environment and entrance to the facility is made easy for abused women. By providing a safe environment, promoting confidence and empathy, and encouraging abused women to verbalize emotions (e.g., fear, guilt), health care providers can work toward the empowerment of women and help them with decision making (Evans & Feder, 2016; Snyder, 2016; Wilson et al., 2016).

Interventions against violence (Gupta et al., 2017; McGarry, 2017), based on trauma-informed care (Arroyo et al., 2017; Reeves, 2015; Taft et al., 2016), should focus on detecting trauma and should make clear the power imbalances in relationships between health care professionals and abused women, thus maximizing autonomy, minimizing anguish, and promoting multidisciplinary care. For the detection of trauma, it is necessary to provide abused women with an environment that guarantees privacy, is free from prejudice or pressure, and which supports a sense of safety (Ali & McGarry, 2018). Fear, blame, shame, and stigmatization can act as barriers to the communication of abuse (Reeves, 2015). Likewise, it is necessary to eliminate power imbalances between the abused woman and the health care professional, promoting a more direct relationship, thus avoiding relationships of superiority and inferiority. It is also necessary to designate specific health care professionals who will be in charge of caring for these women, helping create relationships of trust to discuss traumatic experiences and to avoid the perception that staff are detached or occupied and/or that they cannot or do not want to actively listen to affected women (Ali & McGarry, 2018).

The study team believes that the fear experienced by participants was used by their abusers for coercive control, decreasing their autonomy. To maximize women's autonomy and minimize anguish, health care should be individualized, minimizing unnecessary procedures and facilitating women in the process of decision making (Reeves, 2015).

Currently in Spain, aside from the previously mentioned recommendations, a pact against VAW has been signed by all political representatives in the Spanish parliament (Ministry of The Presidency, Relations with Parliament and Equality, 2017). This pact extends beyond the health level, as it includes interventions against VAW across all sectors (e.g., educational, health, legal) and within all institutions (national, regional, and local entities). The pact takes special care for the protection of children and minors, acting against any form of VAW within or outside partner relations, with a special focus on sexual violence, trafficking in women and young girls, sexual exploitation, female genital mutilation, and forced marriages.

Limitations

There are limitations to the current study, which is based on the narratives of abused women who have experienced a considerable mental health impact and were referred to the PMHC. The current study did not include women who had experienced other means of abuse. In addition, two of the current authors work with these women; however, due to their personal contact with participants, they did not participate in data collection. Finally, only one personal letter was obtained from participants.

Conclusion

Fear is part of the daily lives of abused women. Fear controls and paralyzes their lives and lingers even if the abuser disappears. In turn, abused women feel guilty for not knowing how to stop the mistreatment and for separating from the abuser. Abused women feel that their duty is to fulfill their role as maid, babysitter, and/or sexual slave. Failure to comply with their prescribed roles triggers episodes of violence. The results of the current study can help spread awareness and understanding of the experiences of women who experience VAW. Experiencing fear and guilt and feeling subjected to certain obligations associated with their gender, are all factors that mark the experiences of the women who participated in the current study.

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Researcher Reflexivity

ThemeBeliefs/Motivations
Theoretical FrameworkThe theoretical framework was interpretivist. From this perspective, human actions are meaningful and the goal of interpretive inquiry is the understanding of how people interpret the meaning of this social phenomenon.
Researcher Beliefs and PositionalityGender-based violence involving social and cultural factors, which both originate and perpetuate the abuse. Not only does abuse affect women's physical and mental health, it also affects self-perception, relationships, habits, and ways of living, as well as the roles adopted by women, even toward their abuser.
Reciprocity and Interaction with ParticipantsResearchers provided participants with information regarding their affiliation, place of work, telephone number, and e-mail, so that participants were able to contact them at any time. Researchers explained to participants the considerations for handling any emotional responses occurring during data collection (see Ethics section), and explained that the most important aspect of the study was the participants, not the data collection.

Translation Protocol

PhaseDescription
First StepVerbatim transcription of the interview data in Spanish, followed by thematic analysis.
Second StepTranslation of the themes and selected narratives into English by two bilingual translators, and subsequent consensus between both translators.
Third StepBack-translation of the themes and selected narratives by an independent translator.
Fourth StepFinal agreement on the translation in a meeting held by researchers and translators. Conceptual equivalence was achieved by selecting the terms that most native speakers would understand.

Narratives from Women who have Experienced Domestic Violence

ThemesNarratives
Living With FearFear of facing a real danger: “…when he came back from work, even the sound of the keys when he came through the door made me shake…it was an unsupportable state of anxiety.” (P24, Spanish) Uncertainty about violence: “…always with fear, just seeing him breath a certain way or opening the door a certain way, made me panic.” (P3, Spanish) Reaction disability: “… I had no courage, I had more fear than bravery, it was as if I froze…” (P29, Spanish) Behavioral changes: “…I don't dare to open the window, not even in the summer, even if I amsuffocating” (P2, Spanish); “…it was panic, I spent nine months locked up at my parents' house.” (P10, Spanish) Be marked: “…for me, being a victim is going through all I have gone through and continuing to experience it…it's like having a cross marked on my forehead” (P8, Spanish); “…however many years pass, it is like a wound that cures, but the scar lasts your whole life.” (P27, not Spanish)
Feeling GuiltyFeel responsible: “…I have always felt guilty, thinking that I had provoked that situation” (P27,not Spanish); “…I am to blame for everything…I regret not having done anything to stop it.” (P9, Spanish) Guilt as instrument for control: “…I was always guilty, he twisted things in a way that you are the only one responsible and I felt responsible, and he used that against me.” (P24, Spanish) Guilt for reporting: “…filing a report was the time I felt most guilty. It was either him or myself, he was going to kill me…but when I looked into my children's eyes, I had my doubts” (P13, Spanish); “…I felt peace, but at the same time, a feeling of guilt, a tremendous confusion in the mind.” (P3, Spanish) Guilty for not fulfilling their “duties” as a woman: “…he hit me again, while pregnant, he kept blaming me for not feeling like having [sexual] relations, it was what I had to do when he wanted and as he wanted.” (P4, Spanish)
Experiencing the Imposition of So-Called “Womanly Duties”Fulfilling the role of maid, babysitter, and/or sexual slave: “…he was well at ease, because he had a babysitter, a maid, and a sexual slave with whom he could do whatever he wanted…” (P2, Spanish) “Ideal” vision the woman in the home: “…I had to make his meals, clean him, do everything for him…” (P1, not Spanish) Unpleasant sexual acts: “…when we had sexual relations, he started doing unpleasant things to me, I felt bad regarding my body, and regarding my person, your self-esteem becomes trodden on” (P24, Spanish); “…I have a trauma with sex that you wouldn't imagine… I am disgusted by it.” (P2, Spanish) Forced relations: “…when I did not want to have relations, because I was exhausted…he forced me…then I felt awful.” (P4, Spanish) Be reassured for fulfilling your obligation as a woman: “…I have a clear conscience…I have been a good wife to him, I have behaved well, I have given him everything I could and everything I know, I feel hurt that he has not valued any of this.” (P2, Spanish)
Authors

Dr. Atance-Pereira is RN, Emergency Medical Service of Madrid, Madrid; Dr. Zamarro-Arranz is Associate Professor, Department of Medicine, Universidad Complutense de Madrid, Madrid; Dr. Velarde-García is Professor, Department of Nursing, Spanish Red Cross, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Autonoma de Madrid, Madrid; Dr. Huertas-Hoyas is Professor, and Dr. Palacios-Ceña is Professor and Director, Research Group of Humanities and Qualitative Research in Health Science Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid; Dr. Miguel Cachón-Pérez is Professor, Department of Nursing, Universidad Europea de Madrid, Madrid; and Dr. Parás-Bravo is Professor, Department of Nursing, Universidad de Cantabria, Santander, Spain.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors are grateful to the women who participated in this study.

Address correspondence to Juan Francisco Velarde-García, PhD, RN, Department of Nursing, Spanish Red Cross, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Autonoma de Madrid, Avenida Reina Victoria 28, 4a planta, 28003, Madrid, Spain; e-mail: jvg@cruzroja.es.

Received: December 24, 2019
Accepted: February 07, 2020
Posted Online: April 14, 2020

10.3928/02793695-20200319-01

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