Prevalence and Sociodemographic Predictors of Intimate Partner Violence Against Women in El Salvador

Abstract

Violence against women is currently one of the major problems in El Salvador. However, the country lacks existing data to address this issue. The recent coming into effect of the Ley Especial Integral para una Vida Libre de Violencia para las Mujeres (LEIV) [Comprehensive Law for a Life Free of Violence Against Women] urgently calls for the dimensions of the problem to be understood. The aim of this study is to determine the prevalence of physical, sexual, emotional, and controlling violence, which Salvadoran women aged 15 to 64 years suffer at the hands of their current partners or ex-partners, and the association of such violence with sociodemographic factors. The target population of the study is composed of Salvadoran women aged 15 to 64, from which a representative sample of 1,274 women was obtained. The results reveal that 54.4% of Salvadoran women reported having suffered some type of physical, sexual, or psychological violence during their lives. Psychological control (41.2%) was the most frequent form of violence, followed by emotional violence (39%), physical violence (22.5%), and sexual violence (13.3%). Women’s number of children, marital status, and age were the main factors associated with violence. This study provides information needed to develop victim care measures and training programs for professionals. The study also provides evidence of the impact of public policies and prevention programs already in place.

Keywords

intimate partner violence population-based surveys prevalence physical violence sexual violence psychological violence WHO methodology

Violence against women is an important human rights and public health problem, as well as a barrier to economic development affecting all countries and cultures worldwide (Bott, Guedes, Goodwin, & Mendoza, 2012; Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Heise, 1996). This work aims to conduct a detailed study of the prevalence of violence against women in El Salvador, one of the countries with the highest levels of such violence in the world.

Studies funded by the World Health Organization (WHO) show that nearly one third of women in the world will suffer physical and/or sexual violence at some time in their lives. In addition, such violence will primarily be perpetrated by their partners (Devries et al., 2014; García-Moreno et al., 2013). A recent report published in relation to countries in the European Union reveals that 22% of European women have suffered physical and/or sexual violence from their partners at some point in their lives (European Union Agency for Fundamental Rights, 2014). In the case of Latin America, the prevalence of these types of violence ranges between 53.3% in Bolivia and 17% in the Dominican Republic. When focusing on violence that occurred during the year prior to the survey, Bolivia, 2008, is the country with the highest prevalence at 25.5%, and El Salvador, 2008, and Jamaica, 2008/2009, are those with the lowest prevalence, both with 7.7% (Bott et al., 2012).

It is estimated that approximately 1,500 women in El Salvador were murdered between 2000 and 2005. Since then, this number has multiplied, increasing from 390 women murdered in 2005 to 630 registered murders in 2011, making the country one of the leaders worldwide in femicide rates (Organization of Salvadoran Women for Peace, 2016). In the first trimester of 2016, a 140.24% increase of femicides over the same trimester in 2015 was registered. The situation has become so alarming that the WHO has declared femicide in El Salvador to be an “epidemic” (Aguiñada Deras & Molina Ciriani, 2014).

Since the peace agreements in 1992 ended a long civil war in El Salvador, numerous attempts have been made by feminist movements to denounce the violence against women. However, these attempts have not translated into an improvement in the situation of women (Ramisetty & Muriu, 2013). The cultural bases that support rigid gender roles and the normalization of violence in the country are considered causal factors of the high rates of violence against women in El Salvador (Hume, 2004). The family and the community are the contexts in which gender identities are formed and where there is a greater risk of violence (Hume, 2008). In Salvadoran society, the domestic violence suffered by women is considered a “private” affair and, therefore, requires silence that contributes to impunity for this crime. In addition, a wide range of social and political structures reinforce gender inequalities and the practice of violence against women. According to Hume (2008), the symbolic violence in El Salvador provides a powerful framework for understanding how violence is internalized and replicated in Salvadoran society.

Certain figures may illustrate the general situation faced by women in El Salvador. The gender gap in life expectancy is 69 years old for men and 78 for women (WHO, 2017). Adolescent pregnancy is one of the most serious problems in El Salvador. One out of three women between the ages of 20 and 49 has had a pregnancy before the age of 18, with the fertility rate of 1.91 children per woman in 2015. One out of four Salvadoran women between the ages of 20 and 49 have cohabited without being married before the age of 18 (United Nations Population Fund, 2017). Regarding economic resources, women’s wages are on average 15.5% lower than men’s wages in El Salvador. Women are the majority of people working in the informal sector, which denies them access to social security and provides lower average incomes, reducing their opportunities for development (United Nations Development Program, 2017).

However, despite the magnitude of the problem, research into determining the real prevalence of intimate partner violence against women in El Salvador has been extremely scarce. The only available data were obtained in 2007 by the Encuesta Nacional de Salud Familiar [National Family Health Survey] (FESAL, 2008), which revealed that 44% of Salvadoran women aged 15 to 49 years who had ever been married or in an intimate relationship had suffered psychological or verbal abuse, 24% had suffered physical violence, and 12% had suffered sexual violence. Overall, more than half of women in that age group had suffered some type of violence during their lives. However, this national survey presents several shortcomings. The FESAL study was designed to analyze general family health and was not focused on violence against women. Therefore, the design of the measurement instrument and addressing the appropriate ethical considerations regarding research on violence against women (M. Ellsberg & Heise, 2007) were not core aspects of the FESAL’s methodology. This study’s information about violence experienced within the family was only gathered from those women who were willing to provide such information and for whom minimal privacy conditions were met. Finally, these data were collected in 2007 and are therefore outdated.

For these reasons, we carried out a population-based study with the general objective of providing updated and more complete information on the prevalence of physical, emotional, controlling, and sexual violence against women by their partners in El Salvador; the study also sought to provide some associated sociodemographic risk factors.

To ensure the comparability of the data with those obtained in other countries, we followed the WHO’s general methodology and used the measurement tools and ethical requirements recommended by that organization (Al-Atrushi, Al-Tawil, Shabila, & Al-Hadithi, 2013; Bott et al., 2012; Devries et al., 2014; M. C. Ellsberg, Jansen, Heise, Watts, & García-Moreno, 2008; García-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). In contrast to the FESAL study, the age range of the study population was expanded to 15 to 64 years, enabling the violence experienced by women who are no longer in their reproductive years to be studied and offering a more representative sample of Salvadoran women.

Method

Participants

A systematic random sampling conducted at a national level provided a representative sample of women aged 15 to 64 years covering both the rural and urban categories as well as each of El Salvador’s 14 departments and 262 municipalities. The Informe Estadístico del VI Censo de Población y V de Vivienda [6th Population Census and 5th Housing Census Statistical Report] (Dirección General de Estadística y Censo, 2008), which addressed census and population in 2007, was used to determine the population and the sample of the study. The population of El Salvador is 5,744,113 inhabitants, of which 3,024,742 are women and 2,719,371 are men. A total of 1,851,182 women are aged 15 to 64 years. Furthermore, 1,521 visits to Salvadoran homes were carried out until a representative sample of 1,274 women was achieved, providing a 95% confidence level and a sampling error of ±3%. The rate of refused to participate in the survey was 4.23%. To assess the prevalence of violence against women by an intimate partner, 1,089 women who at some time had a partner were selected for this study.

Instrument

We adapted version 11 of the questionnaire from the WHO Multi-Country Study on Women’s Health and Domestic Violence Against Women (WHO, 2003). This instrument measures the physical, sexual, emotional, and controlling violence within a common classification that enables standardization and cross-country comparisons. The instrument complies with the WHO’s methodological and ethical guidelines for research on violence against women (M. Ellsberg & Heise, 2007). Therefore, the violence perpetrated by intimate partners was assessed using the definition of the Declaration on the Elimination of Violence Against Women (United Nations, 1994):

Any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. (Art. 1)

The indicators used for estimating the prevalence of violence against women were established by the Division for the Advancement of Women, Economic Commission for Europe, United Nations Statistics Division (2007) and based on the indicators described by the group Friends of the Chair of the United Nations Statistical Commission on Indicators on Violence Against Women; these indicators have also been adopted by the WHO to enable comparisons between countries (Jansen, 2012). Specifically, we used Indicators 5 to 8, which correspond to violence against women perpetrated by a partner or former partner. The four types of violence perpetrated by a partner considered in the study are emotional, controlling, physical, and sexual (see Table 1). Each of these types is defined by specific acts of violence that have occurred in two fixed periods within the last 12 months and throughout the women’s lives. Prevalence indicators are obtained by considering the women who have suffered at least one of the behaviors that are described within each of the four types of violence (see Table 1) and are measured by means of self-reported experiences of one or more acts of violence perpetrated by an intimate partner since the age of 15. The magnitude of violence was measured to indicate whether it was moderate or severe depending on the types of violent acts and their frequency.

Table 1.

Indicators From 5 to 8 of Violence Against Women Perpetrated by an Intimate Partner.

Type of Violence	Violent Acts
Physical violence	Was slapped or had something thrown at her that could hurt her Was pushed or shoved Was hit with fist or something else that could hurt Was kicked, dragged, or beaten up Was choked or burnt on purpose Perpetrator threatened to use or actually used a gun, knife, or other weapon against her
Sexual violence	Was physically forced to have sexual intercourse when she did not want to Had sexual intercourse when she did not want to because she was afraid of what partner might do Was forced to do something sexual that she found degrading or humiliating
Emotional violence	Was insulted, made her feel bad Was belittled or humiliated Was scared or intimidated, threatened to hurt her Ignored her and treated her indifferently Was harassed with messages, phone calls
Control violence	Tried to restrict contact with her family of birth and keep her from seeing friends Insisted on knowing where she was at all times Got angry if she spoke with another man Was often suspicious that she was unfaithful Expected her to ask permission before seeking health care for herself Refuse money Hindered women’s options to study or work^a Hindered or prevented her to participate in social gatherings with other people^a Criticized her way of cooking or dealing with housework^a

New items developed for this study not included in the version 11 of questionnaire by the WHO Multi-Country Study on Women’s Health and Domestic Violence Against Women Questionnaire (WHO, 2003).

Design and Procedure

This was a population-based cross-sectional study based on a probability sampling method and a national representation of the Salvadoran female population. The WHO’s protocol guidelines (2004) were followed in relation to the structure of the working group, the implementation phases of the project, and other methodological aspects of the research, especially the ethical aspects. The working group comprised the research team and an advisory group formed by people who have been involved in similar studies by the WHO. Additional support was provided by a consultative committee, consisting of (non)governmental and (inter)national entities with responsibilities that concern gender violence.

The structured and standardized questionnaire designed for the WHO Multi-Country Study on Women’s Health and Domestic Violence (WHO, 2004) was adapted to the Salvadoran population. In consultation with the advisory group and the consultative committee, some minor changes were made in the wording of some items, and others were added (see Table 1).

The adequate selection and training of the team of female supervisors and interviewers was a fundamental aspect of the study (Jansen, Watts, Ellsberg, Heise, & García-Moreno, 2004). These women were trained to establish empathic communication with the variety of women who compose the true Salvadoran scene in a nonjudgmental manner, to have the necessary maturity to ensure conditions of unconditional acceptance, and to create a positive environment in which to address violence against women. These women also received specialized training following WHO ethical guidelines (García-Moreno et al., 2006) in which they addressed matters of gender, violence, ethics in research, safety in fieldwork, and interview techniques. The field team was composed of four female supervisors, two female psychologists, two female coordinators, and 24 female interviewers. The instrument was then applied to a pilot sample of 50 women with the aim of testing it on the population under study and improving the wording of the items. The WHO/Pan American Health Organization (PAHO) advisory group was consulted regarding all changes.

The fieldwork was carried out between December 2013 and February 2014. The length of the interviews was approximately 60 min. Health promoters offered their support and accompaniment in both rural and urban areas. The interviews were held in private places with no other people present, including sons and daughters over 2 years of age, as established by WHO ethical guidelines (García-Moreno et al., 2006). Each interviewer carried an additional emergency booklet with questions regarding only health for those cases in which spouses or other people intervened. Resting areas were prepared for the interviewers whenever necessary, as recommended by Ellsberg and Heise’s guide for research on violence against women (2007), which accompanies the WHO’s instrument. In addition, group or individual psychological care groups were provided outside the fieldwork to offer emotional support and to prevent interviewers from developing secondary traumatic stress.

Ethical Considerations

The design of this study was evaluated and approved by the Comité Nacional de Ética de la Investigación Clínica de El Salvador [National Clinical Research Ethics Committee of El Salvador] and the Pan American Health Organization’s Ethics Review Committee (PAHOREC). To this end, the ethical considerations established by the WHO for the study of violence against women were followed. Special attention was paid to aspects regarding the requirement of ethical permission for the study, obtaining individual informed consent and voluntary participation, ensuring confidentiality, avoiding harm, and respecting women’s decisions. In addition, consideration was given to issues such as child abuse, mechanisms to attend to researchers’ and fieldworkers’ needs, psychological attention and crisis intervention for the women interviewed, and the appropriate use of data. Furthermore, the Declaration of Helsinki requirements (2000) were also met.

Data Analysis

The database was created in SQL Server using the same names for the variables as those in the Multi-Country Study on Women’s Health and Domestic Violence (WHO, 2004). SPSS (v. 20; IBM Corp.) was used for all statistical calculations. Descriptive statistics were used for the prevalence of different types of violence. Odds ratios (OR) with a 95% confidence interval (CI) level were used in the bivariate and multivariate analyses to estimate associations between sociodemographic variables and lifetime exposure to all forms of violence. Statistically significant variables in the bivariate analyses were entered into the multivariate model one at a time. The final models are displayed.

Results

Sociodemographic Data

The main sociodemographic data are shown in Table 2. The final sample was composed of the 1,089 women who had an intimate partner at some time in their lives with an age range of 15 to 64 years (M = 38.27; SD = 13.13). Of these women, 65.5% lived in urban areas and 34.5% in rural areas. With regard to age, the sample was heterogeneous, as all age ranges were represented. In addition, 97.8% of the women stated they were living with a partner or family member at the time of the interview.

Table 2.

Sociodemographic Characteristics of Women Who Participated in the Study.

Characteristics	No.	(%)
Age groups
15-24	200	18.4
25-34	260	23.9
35-44	274	25.1
45-54	195	17.9
55-64	160	14.7
Marital status
Currently married	475	43.9
Currently living with a man	290	26.8
Long-term relationship, dating couple, unmarried	67	6.2
Previously married, had partner, or cohabited; separated, divorced	250	23.1
Educational level
Never attended school	100	9.3
Primary education	508	47.1
Secondary education	309	28.7
Higher education	161	14.9
No. of children
No children	148	13.6
1-2	500	45.9
3-4	329	30.2
>5	112	10.3
Religion
Catholic	499	45.8
Evangelic	439	40.3
No religion	118	10.8
Other	33	3.1
Ethnic group
White	97	8.9
Mestizo	670	61.5
Indigenous	30	2.8
Afro-descendant	8	0.7
Others	21	1.9
Does not know/does not remember	263	24.2

Moreover, 9.3% had never attended school, 47.1% received primary education, 28.7% received secondary education, and 14.9% had completed higher education. Of the women interviewed, 60% did not have paid employment at the time of the interview. In addition, 40.8% said they sold things and traded to survive, and only 31.9% stated that they were living on the income of their own work. Only 5.1% declared having a stable job in the public sector. Regarding property ownership, between 60% and 90% of women reported not owning homes, land, cars, animals, harvests, savings, or other valuable objects.

Overall Prevalence of the Different Forms of Violence

The results show that 54.6% of the women who ever had an intimate partner had suffered some type of violence at the hands of their partner at some time in their lives. Self-reported lifetime and past-year prevalence of physical violence were 22.5% and 4.3%, respectively. The corresponding figures for sexual violence were 13.3% and 2.8%; for emotional abuse, they were 39% and 14.1%; and for control violence, they were 41.2% and 13.5%. Overall, lifetime prevalence of physical violence, sexual violence, or both was 26.2%, and past-year prevalence was 5.9%.

Prevalence of Psychological Violence (Emotional and Controlling)

Table 3 shows the prevalence of each of the behaviors of controlling violence. The most common controlling behaviors in women’s lives are those related to jealousy, such as insisting on knowing where the woman is at all times (25%) or constantly keeping a watchful eye on her (23.8%). This pattern remains constant in the controlling violence reported during the past year; being suspicious that she was unfaithful is also registered as one of the most frequent behaviors within the last year. An economic indicator (he refuses to give her money) was included among the controlling violence indicators, and 13.3% of women answered in the affirmative to this item when referring to their entire life; 2.5% answered affirmatively with regard to the previous year.

Table 3.

Prevalence of Different Forms of Control Violence by the Intimate Partner Referring to Their Lifetime, and With Regard to the Previous Year.

Types of Control Violence	Lifetime Prevalence(n = 1,089)		Past-Year Prevalence(n = 1,089)
Types of Control Violence	No.	(%)	No.	(%)
He tries to keep you from seeing your friends	201	18.4	65	6.0
He tries to restrict contact with your family of birth	143	13.1	34	3.1
He insists on knowing where you are at all times	273	25	100	9.2
He is constantly jealous	259	23.8	91	8.4
He is often suspicious that you are unfaithful	144	13.2	50	4.6
He expects you to ask his permission before seeking health care for yourself	94	8.6	24	2.2
He refuses to give you enough money for household expenses, even when he has money for other things	144	13.3	27	2.5
He hinders or prevent her to study or work	147	13.5	39	3.6
He hinders or prevents her to participate in gatherings	104	9.6	24	2.2
He criticizes her way of cooking or dealing with housework	83	7.6	26	2.4

In relation to emotional violence, as seen on Table 4, the most frequent behaviors were insults both during women’s lifetime and within the previous year with a prevalence of 35% and 11.9%, respectively. This behavior was followed by humiliation (21.7% and 6.3%). With regard to the relative frequency with which these behaviors occur, more than half of the women who had suffered them before the previous year reported that they had occurred many times. However, this pattern changes in the case of the past year, during which most victims report that they have suffered these behaviors on a few occasions (see Table 5).

Table 4.

Prevalence of Different Forms of Emotional Violence by the Intimate Partner Referring to Their Lifetime, and With Regard to the Previous Year.

Type of Emotional Violence	Lifetime Prevalence(n = 1,089)		Past-Year Prevalence(n = 1,089)
Type of Emotional Violence	No.	(%)	No.	(%)
Insulted you or made you feel bad about yourself	382	35	130	11.9
Belittled or humiliated	237	21.7	69	6.3
Done things to scare or intimidate you on purpose	160	14.7	44	4.0
Verbally threatened to hurt you or someone you care about	173	15.9	44	4.0
He ignores you and treats you indifferently	172	15.9	52	4.8
He harasses her	80	7.4	24	2.2

Table 5.

Relative Frequency of Different Forms of Emotional Violence by the Intimate Partner Before Past Year and in the Last 12 Months.

Type of Violence	Frequency
	Once		A Few Times		Many Times
	No.	(%)	No.	(%)	No.	(%)
Before past year
Insulted you or made you feel bad about yourself	48	18	115	43.1	104	39
Belittled or humiliated	19	11.6	63	38.4	82	50
Done things to scare or intimidate you on purpose	11	9.8	32	28.6	69	61.6
Verbally threatened to hurt you or someone you care about	19	14.3	39	29.3	75	56.4
He ignores you and treats you indifferently	10	9.2	41	37.6	58	53.2
He harasses her	6	10.7	15	26.8	35	62.5
In the last 12 months
Insulted you or made you feel bad about yourself	16	13	73	59.3	34	27.6
Belittled or humiliated	4	6.3	34	53.1	26	40.6
Done things to scare or intimidate you on purpose	5	12.5	17	42.5	18	45
Verbally threatened to hurt you or someone you care about	1	2.4	23	56.1	17	41.5
He ignores you and treats you indifferently	3	7	27	62.8	13	30.2
He harasses her	3	14.3	9	42.9	9	42.9

Prevalence of Physical Violence

The most common physically violent behaviors suffered by women (see Table 6), both during their lives and within the previous year, were being pushed and cornered or having their hair pulled (18.6% and 3.9%, respectively), followed by being slapped or having something thrown at them that could hurt them (16.9% during their lives and 2.8% within the past year). Unlike emotional violence, women who are victims of physical violence stated that these acts occurred mostly with a frequency of many times both before the past year and within the last 12 months. For example, before the past year, 60% of women who had been kicked stated that they experienced this with a frequency of many times. Similarly, 59.2% of women who experienced episodes of attempted choking or burning and 59.3% of those who had been threatened with a gun said that they experienced this many times. This pattern was very similar to the violence reported within the past year, during which 55.6% of the women who reported attempts of choking, burning, and threats with a gun reported that these forms of violence occurred many times (see Table 7).

Table 6.

Prevalence of Different Forms of Physical Violence by the Intimate Partner Referring to Their Lifetime, and With Regard to the Past Year.

Types of Violence	Lifetime Prevalence(n = 1,089)		Past-Year Prevalence(n = 1,089)
Types of Violence	No.	(%)	No.	(%)
Slapped you or thrown something at you that could hurt you	184	16.9	31	2.8
Pushed you or shoved you or pulled your hair	202	18.6	42	3.9
Hit you with his fist or with anything else that could hurt you	143	13.2	22	2.0
Kicked you, dragged you, or beat you up	95	8.7	13	1.2
Choked or burnt you on purpose	66	6.1	10	0.9
Threatened with or actually used a gun, knife, or other weapon against you	75	6.9	10	0.9

Table 7.

Relative Frequency of Different Forms of Physical Violence by the Intimate Partner Before Past Year and in the Last 12 Months.

Type of Violence	Frequency
	Once		Few Times		Many Times
	No.	(%)	No.	(%)	No.	(%)
Before last year
Slapped you or thrown something at you that could hurt you	21	15.4	48	35.3	67	49.3
Pushed you or shoved you or pulled your hair	22	14.8	55	36.9	72	48.3
Hit you with his fist or with anything else that could hurt you	9	8.8	35	34.3	58	56.9
Kicked you, dragged you, or beat you up	7	9.6	22	30.1	44	60.3
Choked or burnt you on purpose	8	16.3	12	24.5	29	59.2
Threatened with or actually used a gun, knife, or other weapon against you	10	16.9	14	23.7	35	59.3
In the last 12 months
Slapped you or thrown something at you that could hurt you	5	16.7	13	43.3	12	40
Pushed you or shoved you or pulled your hair	5	12.8	19	48.7	15	38.5
Hit you with his fist or with anything else that could hurt you	4	19	6	28.6	11	52.4
Kicked you, dragged you, or beat you up	3	25	3	25	6	50
Choked or burnt you on purpose	2	22.2	2	22.2	5	55.6
Threatened with or actually used a gun, knife, or other weapon against you	1	11.1	3	33.3	5	55.6

Prevalence of Sexual Violence

With regard to sexual violence perpetrated by an intimate partner (see Table 8), one of the most prevalent behaviors was forcing women to have sexual intercourse against their will. This occurred in 9.6% of women at some time in their lives and to 2.1% within the last year. Of the former, 48.8% stated that this form of violence had occurred many times (see Table 9). Furthermore, 11% of women admitted that at some point in their lives, they had consented to having sex out of fear (1.8% within the last year); 41.7% of those victims (50% of those in the last year) also reported that it had occurred many times.

Table 8.

Prevalence of Different Forms of Sexual Violence by the Intimate Partner Referring to Their Lifetime, and With Regard to the Past Year.

Type of Violence	Lifetime Prevalence(n = 1,089)		Past-Year Prevalence(n = 1,089)
Type of Violence	No.	(%)	No.	(%)
Did your husband/partner ever force you to have sexual intercourse when you did not want to	107	9.6	23	2.1
Did you ever have sexual intercourse you did not want to because you were afraid of what your husband/partner might do	120	11	20	1.8
Did your husband/partner ever force you to do something else sexual that you did not want or that you found degrading or humiliating	62	5.7	8	0.7

Table 9.

Relative Frequency of Different Forms of Sexual Violence by the Intimate Partner Before Last Year and in the Last 12 Months.

Type of Violence	Frequency
	Once		Few Times		Many Times
	No.	(%)	No.	(%)	No.	(%)
Before last year
Did your husband/partner ever force you to have sexual intercourse when you did not want to	10	12.2	32	39	40	48.8
Did you ever have sexual intercourse you did not want to because you were afraid of what your husband/partner might do	10	11.8	35	41.2	40	41.7
Did your husband/partner ever force you to do something else sexual that you did not want or that you found degrading or humiliating	6	13.3	18	40	21	46.7
In the last 12 months
Did your husband/partner ever force you to have sexual intercourse when you did not want to	5	21.7	11	47.8	7	30.4
Did you ever have sexual intercourse you did not want to because you were afraid of what your husband/partner might do	2	11.1	7	38.9	9	50
Did your husband/partner ever force you to do something else sexual that you did not want or that you found degrading or humiliating	2	25	3	37.5	3	37.5

Injuries or Harm Resulting From Physical Violence

Women who reported having been victims of physical violence at the hands of their intimate partners at some time in their lives were also asked whether they had suffered injuries or harm as a result of this violence. Of the victims of physical violence, 34.6% of women suffered injuries, usually on more than one occasion. These injuries even led to a loss of consciousness in 10% of the cases and required medical attention in 28.2% of the cases (61 women).

Table 10 shows the relative frequency of these injuries. The most frequent types of injury were scratches, abrasions, or bruises, which occurred in approximately 74.4% of the injured women. However, it is especially notable that other more severe injuries were also reported by a high percentage of women, including cases of cuts, punctures, or bites (34.4%) as well as deep cuts and stabbings (21.1%). The occurrence of internal injuries as a consequence of physical violence was also present in 18.9% of the women who had been physically hurt by their partners.

Table 10.

Injuries or Harm Consequence of Physical Violence by an Intimate Partner Referring to the Lifetime Among Women Victims of Physical Violence (N = 284).

Type of Injuries	Percentage of Injuries(n = 284)
Type of Injuries	No.	(%)
Cuts, punctures, or bites	31	34.4
Cuts, scratches, bruises, or aches	67	74.4
Sprains or dislocations	9	10
Burns	5	5.6
Deep wounds	19	21.1
Injuries to eye or ear	9	10
Broken bones	86	8.9
Broken teeth	6	6.7
Internal injuries	17	18.9
Other similar injury	6	6.7

Relation With Sociodemographic Factors

At the bivariate level, women’s age, number of children, educational level, and marital status constituted the main risk factors for all forms of lifetime violence (Table 11: OR columns). Older women were more at risk of physical, sexual, and emotional violence than were their younger counterparts. Women with more children were also more at risk of all forms of lifetime violence. A woman’s lack of formal education was associated with physical, sexual, and emotional violence, and being previously married/separated was also associated with all forms of violence. The educational level of the last/current partner had a statistically significant association with physical and emotional violence over the lifetime.

Table 11.

Associations Between Sociodemographic Factors and Life Time Experience of Physical, Sexual, Emotional, and Control Violence (n = 1,089).

Variables	Physical Violence		Sexual Violence		Emotional Violence		Control Violence
Variables	OR(95% CI)	AOR(95% CI)	OR(95% CI)	AOR(95% CI)	OR(95% CI)	AOR(95% CI)	OR(95% CI)	AOR(95% CI)
Age groups
15-24	1	1	1	1	1	1	1	1
25-34	1.48 [0.87, 2.51]	1.18 [0.64, 2.16]	1.82 [0.87, 3.80]	1.23 [0.53, 2.83]	1.38 [0.93, 2.01]	1.07 [0.67, 1.71]	0.91 [0.62, 1.33]	0.84 [0.54, 1.32]
35-44	2.18** [1.28, 3.51]	1.72 [0.93, 3.20]	2.98** [1.49, 5.97]	1.90 [0.83, 4.38]	1.67** [1.13, 2.46]	1.14 [0.70, 1.86]	1.31 [0.90, 1.90]	1.29 [0.81, 2.05]
45-54	2.44** [1.44, 4.13]	2.04* [1.04, 4.00]	2.70** [1.30, 5.62]	1.50 [0.60, 3.72]	1.78** [1.17, 2.70]	1.11 [0.64, 1.92]	0.92 [0.61, 1.38]	0.85 [0.50, 1.45]
55-64	3.91** [2.30, 6.64]	3.00** [1.46, 6.05]	5.61** [2.77, 11.35]	3.11* [1.24, 7.78]	2.11** [1.37, 3.27]	1.19 [0.66, 2.16]	1.26 [0.83, 1.93]	1.08 [0.61, 1.92]
Marital status
Currently married	1	1	1	1	1	1	1	1
Cohabiting but not married	1.50* [1.05, 2.13]	1.63* [1.01, 2.43]	1.38 [0.89, 2.12]	1.62* [1.00, 2.63]	1.40* [1.03, 1.89]	1.41* [1.01, 1.98]	1.45* [1.07, 1.96]	1.53* [1.10, 2.14]
Dating couple, unmarried	0.88 [0.44, 1.75]	2.85* [1.23, 6.65]	0.37 [0.11, 1.22]	0.90 [0.20, 4.08]	0.80 [0.46, 1.41]	1.78 [0.90, 3.52]	1.55 [0.92, 2.60]	2.60** [1.39, 4.85]
Previously married, separated, divorced	1.87** [1.30, 2.68]	2.31** [1.53, 3.48]	1.77** [1.15, 2.72]	1.88* [1.15, 3.06]	2.11** [1.54, 2.89]	2.50** [1.73, 3.61]	2.49** [1.81, 3.41]	3.00** [2.08, 4.29]
Education
Never attended school	2.96** [1.57, 5.58]	1.11 [0.50, 2.44]	2.52** [1.25, 5.08]	1.41 [0.57, 3.45]	1.69* [1.01, 2.85]	0.70 [0.36, 1.37]	1.54 [0.91, 2.60]	1.45 [0.74, 2.82]
Primary education	2.32** [1.39, 3.86]	1.21 [0.66, 2.22]	1.50 [0.85, 2.67]	1.00 [0.50, 2.02]	1.61* [1.10, 2.36]	0.89 [0.55, 1.43]	1.72** [1.17, 2.52]	1.60 [0.99, 2.57]
Secondary education	1.80* [1.05, 311]	1.44 [0.80, 2.61]	1.10 [0.58, 2.06]	0.99 [0.20, 4.08]	1.30 [0.86, 1.96]	1.05 [0.66, 1.67]	1.73** [1.15, 2.61]	1.62* [1.03, 2.55]
Higher education	1	1	1	1	1	1	1	1
No. of children
No children	1	1	1	1	1	1	1	1
1-2	3.91** [1.93, 7.95]	4.32** [1.84, 10.13]	6.07** [1.87, 19.69]	6.95* [1.55, 31.15]	2.10** [1.35, 3.29]	2.71** [1.54, 4.79]	1.38 [0.93, 2.05]	1.88* [1.13, 3.13]
3-4	5.61** [2.74, 11.50]	4.73** [1.89, 11.79]	9.99** [3.07, 32.45]	9.57** [2.03, 45.06]	3.84** [2.42, 6.08]	4.75** [2.51, 9.00]	1.73** [1.15, 2.61]	2.23** [1.24, 4.00]
>5	8.21** [3.77, 17.87]	5.18** [1.91, 14.03]	14.11** [4.14, 48.02]	11.33** [2.25, 56.92]	4.07** [2.35, 7.07]	4.30** [2.04, 9.04]	1.44 [0.86, 2.42]	1.60 [0.79, 3.24]
Last/current partner education
Never attended school	2.39* [1.20, 4.79]	1.46 [0.65, 3.27]	1.56 [0.72, 3.38]	0.67 [0.27, 1.68]	2.23** [1.24, 4.00]	1.84 [0.92, 3.69]	1.05 [0.58, 1.89]	0.74 [0.37, 1.47]
Primary education	2.33** [1.44, 3.78]	1.77* [1.01, 3.12]	1.09 [0.64, 1.85]	0.70 [0.37, 1.33]	1.75** [1.20, 2.54]	1.56 [0.98, 2.46]	1.17 [0.81, 1.68]	0.88 [0.56, 1.37]
Secondary education	1.51 [0.91, 2.51]	1.56 [0.89, 2.71]	0.83 [0.48, 1.47]	0.85 [0.46, 1.60]	1.21 [0.82, 1.78]	1.25 [0.81, 1.94]	1.17 [0.80, 1.70]	1.01 [0.66, 1.53]
Higher education	1	1	1	1	1	1	1	1

Note. OR = non-adjusted odds ratios; 95% CI = confidence interval; AOR = adjusted odds ratios.

p < .05. **p < .01.

Multivariate analyses were also performed to test for possible confounding factors (Table 11: AOR columns). Women’s marital status and number of children remained significant for all forms of lifetime violence. Compared with being currently married, women cohabiting but not married and those previously married/separated were more at risk of physical, sexual, emotional, and control violence. Women’s age remained associated with physical and sexual violence but not with emotional violence. After controlling for all confounding factors, last/current partner education was associated only with physical violence, and women’s educational level was associated only with control violence.

Discussion

The main results of this study demonstrate that violence against women in El Salvador continues to be a fundamental problem that directly affects the lives of half of the female Salvadoran population, as 54.4% of the women who were interviewed stated having suffered some type of violence (physical, sexual, or psychological) throughout their lives at the hands of a current or former intimate partner. The most prevalent form of violence was psychological violence. Following WHO guidelines, in our study, we distinguished between controlling psychological violence and emotional psychological violence. Controlling violence was registered through acts directed at women that went against their dignity and capability to exert their freedom and make decisions concerning their own lives. The most frequent controlling behaviors suffered by women were related to jealousy and their partners being suspicious of them being unfaithful, followed by restricting women’s freedom to go out and have contact with other people. The most frequent forms of aggression with regard to emotional violence were insults, humiliation, threats, or harassment.

If we compare the results of our work with the prevalence figures of violence against women in El Salvador registered by the FESAL study (2008), considering with caution the differences in the age ranges of the studied populations and the methodological differences mentioned above, a considerable coincidence may be found in relation to the overall prevalence of violence experienced throughout women’s lives (psychological, physical, or sexual). In both cases, approximately half of Salvadoran women were found to have suffered some type of violence at some time in their lives. After breaking down the results in terms of types of violence, a slight decline can be observed in psychological and physical violence, whereas a slight increase can be noted in sexual violence. Unfortunately, this confirms that this major social problem has not been mitigated in any way in recent years.

With regard to the relative frequency of specific violent behaviors, both physical and sexual violence follow a similar pattern of behavior when comparing their occurrence throughout women’s lifetime and within the last year; they are both revealed as stable forms of abuse against women. In the case of emotional violence, the victims mentioned insults and humiliation as the most frequent behaviors before the past year, while within the last year, other behaviors were noted as more frequent, specifically that their partner did not talk to them or harassed them. This change could be due to the impairment suffered, with time, from the memory of behaviors such as being ignored or harassed, given that such behavior might be considered as less severe than an insult or intentional ridicule. As noted by Devries et al. (2013), the difficulty of assessing psychological violence throughout women’s lifetimes lies mainly in the fact that it is forgotten more easily because it is normally perceived as less severe.

Comparing the Prevalence of Violence Against Women Across Countries

The figures that enable a more reliable comparison with figures from other countries and regions are those related to physical and sexual violence (Al-Atrushi et al., 2013; Bott et al., 2012; Devries et al., 2014; Ellsberg et al., 2008; García-Moreno et al., 2005). In this regard, 26.2% of the respondents declared having suffered physical or sexual violence by their partners at some time in their lives. If we compare the figure from El Salvador with the one offered by studies conducted by the WHO in other Latin American countries before 2005, we see that the Salvadoran one is significantly lower. For example, in Peru, research revealed a prevalence of 56% of physical violence and/or sexual violence in urban areas and 69% rural areas; in Brazil, the figures were 29% in urban areas and 37% in rural areas (García-Moreno et al., 2005). However, the Salvadoran figure is more in line with the updated global indicators informed by Devries et al. (2014) after revising 141 studies with national and subnational samples from 81 countries using a methodology similar to the one used in the present work. These latter studies have been conducted in the period between 1999 and 2010, and they reveal that overall, 30% of women over 15 years have suffered physical violence, sexual violence, or both by their partners at some time in their lives (Devries et al., 2014). However, their prevalence figures vary across regions/countries, being the highest at approximately 65% in Sub-Saharan Africa, and the lowest in East Asia, with an estimation of 16.3%. In Central America, the region in which El Salvador is located, the estimated prevalence index for physical and/or sexual violence is 29.5% (Devries et al., 2014), which is very close to the figure obtained in our study. Other works conducted in the region also offer similar prevalence indexes. For example, Bott et al. (2012) reported a prevalence of 29.3% in Guatemala and 27.3% in Nicaragua.

We also analyzed the injuries or harm that women suffered as a result of physical violence, a clear indicator of the severity of such violence. It was found that 34.6% of women had been injured at some time. These figures are higher than those of the WHO’s Multi-Country Study (García-Moreno et al., 2005) in which 20% of women from different countries who had suffered physical violence had ever been hurt or injured. Other studies based on population samples show indexes between 40% and 72% of women injured or harmed at some point in their lives as a consequence of inflicted physical violence (Tjaden & Thoennes, 2000). For this reason, El Salvador is placed among the countries with highest indexes. Regarding the type of injury, most injuries were not very severe and included scratches or bruises; however, approximately 20% of the victims reported having suffered more severe injuries, such as cuts, deep wounds, stabs, and even internal injuries. It is noteworthy that 6.9% of women who suffered violence had been threatened by their intimate partners with a gun, and in more than 50% of the cases, this occurred many times throughout their lives and within the last year. These data illustrate the situation of vulnerability in which women find themselves and are linked with the femicide index of El Salvador, one of the highest in the world.

Although these data are alarming, they may underestimate the real magnitude of violence against women in El Salvador. In fact, a weakness of the present study is that given the situation of widespread violence and danger in El Salvador, the research team could not access some of the most dangerous neighborhoods under the control of juvenile gangs (maras). In those areas, maras control the community, and State intervention is minimal, which increases impunity regarding violence against women. In addition, women who are related to a mara member are controlled not only by their partner but also by the mara itself. For this reason, most of these women do not report violence (Aguilar Umaña & Rikkers, 2012). It is highly probable that in these neighborhoods, violence against women is not only more prevalent but also more severe.

Sociodemographic Correlates and Prevalence Dynamics of Gender Violence Across Life Span

In our study, we have also shown the relationship of certain sociodemographic factors with the different forms of violence over a lifetime. Specifically, having children appeared to be a risk factor for physical, sexual, and psychological (emotional and control) violence, which was similar to findings in other studies (e.g., Ali, Asad, Mogren, & Krantz, 2011). In countries such as El Salvador where child care rests largely on women, the presence of children in families hinders women’s access to economic resources and employment, diminishing their power in intimate relationships and thus making the occurrence of violence more probable (Pratto & Walker, 2004).

Women’s age has also been identified as a risk factor for physical and sexual violence. One interpretation of this result could be that violence against women in El Salvador is ongoing year-over-year, and older women will therefore be more exposed over their lifetime.

In this study, marital status was also statistically significant for the different forms of violence. Women who had been victims of violence were more likely to be separated or cohabitate with their partners than to be currently married, because they were more likely to have left their abusive partners and to be separated from their husbands, but not necessarily from their current partners. This result coincides with that found in similar research carried out in cultural contexts very different from El Salvador, such as in the U.S. population (e.g., Smith, Thornton, DeVellis, Earp, & Coker, 2002).

Taken with caution, comparing the prevalence rates of violence throughout women’s lifetime with the prevalence rates of violence within the last year, a rough estimation can be made of how many women may have succeeded in leaving violence behind in terms of managing to live 12 months without violence. In the case of controlling behavior, 41.2% of women who had ever had a partner had suffered such behavior at some time in their lives, while 13.5% had suffered that form of violence within the last year. Therefore, it could be said that 27.7% of the interviewed women had managed to escape controlling violence. With regard to emotional violence, the prevalence of 39% throughout women’s lives was reduced to 14.1% within the last year. Therefore, 24.9% of women are no longer victims of emotional violence. In the case of physical violence, the rates were 22.5% throughout women’s lives and 4.3% within the last year. Hence, 18.2% of women stopped suffering this type of violence. In addition, in the case of sexual violence, that same comparison revealed 10.5% of women who were no longer experiencing such violence. In conclusion, in all forms of analyzed violence, a significant percentage of women managed to leave violence behind. This fact, which is in itself positive, could reflect the visible effect of the different public policy initiatives carried out in El Salvador within recent years. For example, the Ley Especial Integral para una vida Libre de Violencia para las Mujeres [Comprehensive Law for a Life Free of Violence against Women] (LEIV, 2012) and the Ley de Igualdad, Equidad, y Erradicación de la Discriminación de la Mujer [Law of Equality, Fairness, and the Elimination of Discrimination against Women] (LIE, 2011) were approved to eliminate violence and promote equality. In addition, the government and women’s organizations have promoted diverse awareness-raising campaigns. However, these seemingly positive results need to be cautiously interpreted, as they could instead be due to the tendency of women to report recent violence less reliably than violence that occurred further in the past. This underreporting can occur because recent violence generates a greater fear to disclose or because women believe that reporting it might entail some type of consequence.

Analysis of the Situation and Policy Making Recommendations

Given the demonstration of the high prevalence of partner violence against women in El Salvador, the first and most important recommendations that follow must be not only to urgently prioritize primary prevention measures but also to prioritize care services for victims with relation to the health, social, and legal sectors, as well as other support services. It must be acknowledged that during recent years in El Salvador, significant progress has been achieved with regard to legislation, raising awareness and political measures designed to eliminate violence against women. One example, without doubt, was the approval of the LEIV on November 25, 2010, which not only safeguards the best interests and well-being of women victims of violence but also addressed for the first time the development of prevention policies (e.g., de Lemus, Navarro, Megías, Velásquez, & Ryan, 2014). In addition to this law, which came into force on January 1, 2012, the LIE was approved in March of the previous year. As a consequence of these legal advancements, important information about gender violence has become publicly salient as social campaigns have been conducted to raise social awareness. Furthermore, the Salvadoran government, through the Secretaría de Inclusión Social [Secretariat of Social Inclusion], has founded organizational units called Ciudad Mujer, which seek to guarantee the fundamental rights of Salvadoran women through specialized services that cover their needs with respect to sexual and reproductive health, comprehensive attention addressing gender violence, financial empowerment, and the promotion of their rights. Finally, other awareness-raising initiatives promoted by the Instituto Salvadoreño para el Desarrollo de la Mujer (ISDEMU) [Salvadoran Institute for Women’s Development] and other non-governmental organizations have made highly valuable efforts in the interest of Salvadoran women’s rights, as has the support offered by international cooperation agencies through training and specialization of personnel in charge of attending women victims of violence and imposing sentences.

However, in many ways, the impact of such initiatives has not been sufficient to ensure a correct application of the law and a significant decrease of the prevalence of partner violence against women in El Salvador. In fact, other research carried out in the country has shown, for example, that not all forms of violence are correctly identified by the population, with emotional violence, controlling behavior, and sexual violence being the most difficult to recognize (de Lemus et al., 2014; Navarro-Mantas, 2009). In perceiving violence, as Hume (2004, 2008) noted, gender stereotypes have a strong influence. Cantera and Blanch (2010) found greater acceptance of traditional female and male stereotypes in El Salvador than in other countries such as Spain, with violence being mainly identified with traditional male stereotypes. This greater acceptance of gender stereotypes and the relationship between masculinity and violence in El Salvador should be investigated in future studies to better contextualize the prevalence figures.

This evidence urgently calls for gender violence in El Salvador to be firmly addressed as a major social, economic, and health problem. First, it is imperative to ensure the appropriate support and safety for the victims. Despite the country’s lack of resources, first investing in training programs aimed at the justice sector to ensure enforcement of the law would be highly recommended. This sector is especially resistant to acknowledging the problem from a critical analysis of the social and cultural factors that sustain it. Therefore, the justice sector requires special attention, considering the message of impunity that is being broadcast to the society as well as the lack of victim support. It is also important to strengthen the care systems, which involves taking action at a psychosocial level and within the health care system to reinforce the detection of violence in primary care. To this end, specialized protocols and specific training are required. Furthermore, it is necessary to continue the development of campaigns to increase the social awareness and social education promoted by the government in cooperation with feminist organizations. Finally, addressing the problem at its roots requires investing in primary prevention and implementing that prevention by introducing content focused on equality between men and women across the entire educational system.

To sum up, partner violence against women in El Salvador constitutes one of the major urgent challenges the country must face and manage, as the high prevalence verified in this population-based study shows.

Footnotes

Acknowledgments

The authors would like to thank WHO for the use of the Women’s Health and Life Events Questionnaire; and Alessandra Guedes, Claudia García-Moreno, and Henriette Jansen for their advice and responding to all of our methodological questions. Thanks to the fieldwork supervisor group, Mariely E. Campos, Diana Y. Barrera, Nancy C. Cortez, and Miriam Guardado, and to all interviewers team. Finally, they thank all women who shared their stories with them.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financially supported by CICODE (Centre for Development Cooperation Initiatives, University of Granada. Spain).

ORCID iD

Laura Navarro-Mantas

Author Biographies

Laura Navarro-Mantas is a researcher at the University of Granada (Spain) and has worked as a visiting professor and researcher at Universidad Tecnológica de El Salvador. Her research interests are oriented to gender violence, focusing on national surveys and prevention.

Marta J. Velásquez is a lecturer in psychology at the Universidad Tecnológica de El Salvador where she runs the gender professorial chair.

Soledad de Lemus is an assistant professor of social psychology at the University of Granada (Spain). Her main research interests are social psychology of gender, prejudice, and intergroup relations more broadly.

Jesús L. Megías is a professor in experimental psychology at the University of Granada (Spain). His main research interests concern intimate partner violence and social perception of sexual aggression against women.

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