Abstract
This study was conducted to explore the relationship between women’s history of experiencing different types of abuse during childhood and development of mental health problems in adulthood. A convenience sample of 409 women recruited from health care centers in Jordan provided data for the study. One-way between-groups multivariate analysis of variance was implemented. Results indicated absence of statistically significant differences in mental health problems between physically abused and sexually abused women compared to their counterparts. Further, a statistically significant difference in mental health was found between women who experienced emotional abuse and childhood neglect compared to their counterparts (Wilks’ lambda for emotional abuse = .914, p < .0001; Wilks’ lambda for childhood neglect = .83, p < .0001). Between-groups comparisons using Bonferroni adjustment indicated that all dependent variables (depression, anxiety, stress, and self-esteem) differed significantly between emotionally and nonemotionally abused women and between neglected and nonneglected women. It was concluded that not all childhood abuse experiences lead to long-term impacts on women’s mental health. However, mental health consequences of childhood abuse may alter women’s obligations toward family, children, and home. Therefore, efforts directed toward assessing women’s history of childhood abuse are very important especially for those who are starting a marital relationship.
Childhood domestic violence is one of the common types of domestic violence experienced by families worldwide. Recently, increased attention has been given to this issue to explore its prevalence rates as well as the consequences associated with such experience. Beyond such efforts, preventive and treatment services are the focus of some governmental and social parties in communities. Physical abuse, sexual abuse, psychological abuse, and neglect are examples of common types of violence directed toward children.
Childhood abuse is inherited in families. It is mainly confined to the home environment and is rarely disclosed to others outside the home boundaries. History of childhood abuse in women is a crucial experience and a factual problem for three reasons. First, family members are the only witnesses of abuse and the abuse experience mainly remains veiled. Second, the victims are mainly females knowing that females are more vulnerable to certain types of abuse compared to males (Brown et al., 2005). Third, having a history of childhood abuse increases a woman’s likelihood of adult victimization (Al-Modallal, 2016a; Hetzel & McCanne, 2005; Woods et al., 2005). This happens because women will be, at some point, under the control of a male partner who may practice abuse against them.
Several studies have been conducted to assess the prevalence of child abuse history in women. In a cross-sectional study among women admitted to psychiatric services in one county in the south of Sweden, investigators revealed that 51% of the participants reported the experience of abuse in their childhood (Nilsson et al., 2005). The victimization rate was lower in a Jordanian sample where 26.7% of the participating women reported experiences of child abuse (Al-Modallal, 2016a).
Perpetrators of child abuse are mainly the mothers and fathers (Hetzel & McCanne, 2005; Nilsson et al., 2005). In addition, siblings are possible perpetrators of abuse (Hetzel & McCanne, 2005; Noland et al., 2004). Childhood abuse tends to reoccur. In a cross-sectional study, 12% (n = 112) of the participating women reported being beaten more than once during their childhood (Coid et al., 2001). Furthermore, different kinds of childhood abuse tend to co-occur. Nearly 18% of the participants reported experiencing three different types of abuse in their childhood years (Al-Modallal, 2016a).
Experiencing childhood abuse increases women’s physical (McNutt et al., 2002; Woods et al., 2005) and mental health problems (Carlson et al., 2003; Nicolaidis et al., 2004; Woods et al., 2005). It also increases women’s susceptibility to adulthood victimization (Al-Modallal, 2016a; Briere & Elliott, 2003; Hetzel & McCanne, 2005; Lutenbacher et al., 2004; Woods et al., 2005). For more clarification, as the number of violent incidents increases, the odds of occurrence of depressive symptoms increase (Nicolaidis et al., 2004) and the cumulative impact on depression increases as well (Bohn, 2003; Carlson et al., 2003; McGuigan & Middlemiss, 2005). Consequently, a woman’s chances of getting worse physical and mental health problems increase as violence incidents accumulate (Carlson et al., 2003).
Rationale for the Study
Jordan is a developing country in the Middle Eastern region. The percentage of married females represents nearly 56% of the total Jordanian females aged 15 years old and above (Department of Statistics, 2017). In one study targeting Jordanian working women, the prevalence rates of depressive symptoms and stress were 51.2% and 36.7%, respectively (Al-Modallal et al., 2012). We found these rates alarming, urging us to investigate reasons behind such rates. On the other hand, and considering significance of childhood abuse history in women’s lives worldwide, we did not find similar studies in Arab women generally and in Jordanian women specifically. As such, mental health sequelae of this experience remained unknown. Therefore, this study was considered. The purpose of this study was to investigate differences in women’s mental health problems based on the type of childhood abuse experience.
Method
Design, Setting, and Participants
The study was approved by the Hashemite University. The study was a cross-sectional investigation targeting women visiting governmental health care centers in three metropolitan cities in Jordan. The participants were women attending these health care centers for the purposes of obtaining medical treatment, vaccination, laboratory investigation, or consultation for themselves or for their children. Included in the study were women who were (1) committed to an intimate relationship with a male husband/fiancé, (2) visiting a health center to obtain one of the services provided by health professionals at the centers, (3) able to read to complete the study questionnaire, and (4) not accompanied by the male intimate partner to limit chances of the reporting bias due to the presence of the partner.
Data Collection
Women attending health care centers were approached in the waiting rooms. The research assistants provided a complete description about the study. Study information included its purpose, target participants, type of information required, and time needed to complete the study questionnaire. Women were asked to become participants in the study. Concurred participants were asked to read and sign the study consent form.
Following the consent form process, women were informed about the following: (1) time needed to complete the questionnaire would not exceed 10 min, (2) participation in the study was totally voluntary, (3) withdrawal from the study was an option with no consequences associated with withdrawal, and (4) anonymous data were needed, meaning that no personal information were required. Then, participants were handed the study questionnaire to complete. Questions addressed by the women concerning required data were answered by the research assistants. Completed questionnaires were collected and placed together in sealed envelopes. When given to the primary investigator, the questionnaires were kept secured and access was only limited to the primary investigator.
Measures
Depressive symptoms were measured using the Center for Epidemiologic Studies–Depression Scale (CES-D; Radloff, 1977). The CES-D is a 20-item measure for depressive symptoms in adults. Items ask respondents to rate on a 4-point scale the frequency of experiencing recent (during the last week) depressive symptoms. Four of the 20 CES-D items do not represent symptoms of depression. Therefore, these items are reverse-scored to obtain the final score that ranges between 0 and 60. Reliability (Zauszniewski & Graham, 2009) and validity (Spijker et al., 2004) of the CES-D were supported. Furthermore, psychometric analysis of the CES-D in Jordanian women supported its reliability and validity. Cronbach’s α in 101 Jordanian working women was .90 (Al-Modallal, 2010).
Stress was measured using the Perceived Stress Scale (PSS; Cohen et al., 1983). The PSS is a 10-item tool measuring perceived psychological stress among adults. Each item was rated using a 5-point scale ranging from never (coded 0) to very often (coded 4). The final score is obtained by summing the scores of the 10 items after score reversing the four positive items (Items 4, 5, 7, and 8). Possible scores range between 0 and 40. Evidences of validity and reliability of the PSS were reported where Cronbach’s α was .84 in college students (Cohen et al., 1983).
Anxiety was measured using the Anxiety subscale; part of the Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond, 1995). The Anxiety subscale is a 7-item scale measuring dimensions of anxiety in adults. Examples of the items representing anxiety are “I was aware of dryness of my mouth” and “I had a feeling of shakiness (e.g., legs going to give way).” Each item was rated on a 4-point severity scale ranging from “did not apply to me at all” to “applied to me very much, or most of the time”. The total anxiety score ranged between 0 and 42 (as the scores were doubled for adequate categorization of severity levels). The Anxiety subscale of the DASS was proved as valid in measuring dimensions of anxiety in male and female adults (Henry & Crawford, 2005).
Self-esteem was measured using the 10-item Rosenberg Self-Esteem Scale (Rosenberg, 1965). Respondents were asked to rate their responses to each item using a 5-point rating scale ranging from “strongly disagree” coded as (1) to “strongly agree” coded as (5). The total score is the summation of the 10 items where higher scores represent higher self-esteem levels.
Four types of childhood abuse were assessed. Women were asked to report whether they were physically abused as children (before the age of 12) by their parents/caretakers. A variety of abuse tactics were adopted from a previous study (Shaw & Krause, 2002) to reflect physical abuse in childhood. Examples of physical abuse tactics include being hit with a fist, hit with something that would hurt, kicked, and burned. Responses to items were summed and then dichotomized where a positive experience was coded (1) and a negative experience was coded (0). Cronbach’s α for the physical abuse items was .86.
Sexual abuse was assessed by asking women to report whether they were sexually abused by an adult during childhood. Responses were coded as (1) for the “yes” response and (0) for the “no” response. Emotional abuse and neglect were assessed by three questions for each. The three questions representing childhood emotional abuse were if the woman (as a child) was called names she did not like, hurled with hurtful words, and reported hearing the guardian wishing that she had not been born into the family. Items representing child neglect included a woman’s report of not having a person who loved and cared for her as a child, (often) unavailability of ready meals, and (often) unavailability of someone who took care of her and looked to ensure she had clean clothes, good personal hygiene, and cared for her general appearance. Women’s positive report, coded as (1), to any of these tactics indicated their victimization with emotional abuse or neglect as children. The code (0) was for women’s negative reports of emotional abuse and neglect. Since emotional abuse and child neglect are somehow related, reliability coefficient was examined for the total items. The resultant Cronbach’s α for the emotional abuse items and child neglect items together was .74.
Analysis Strategy
Data analysis was performed using SPSS statistical analysis software (Version 17.0). Frequencies were used to explore the dichotomized independent variables (physical abuse, sexual abuse, emotional abuse, and neglect). Means and standard deviations were used to present continuous dependent variables (depression, anxiety, stress, and self-esteem). One-way between-groups multivariate analysis of variance (MANOVA) was implemented to explore differences in mental health consequences based on women’s abuse experiences. Significance level of .05 was set for the analysis. α levels were adjusted where applicable to limit Type I error.
Results
Four hundred and nine women participated in the study. A little less than half of the women (n = 167; 42.4%) were between the ages of 31 and 40. All but 8.9% of the women had children as a result of a marriage relationship. A university degree was earned by 36.3% and nearly a similar percentage of women (35.9%) earned high school diploma or less. Medium socioeconomic status based on women’s family income was reported by 63.3%. The majority (84.2%) declared living in a city and a quarter (25.2%) possessed a job/career for living.
Regarding women’s history of childhood abuse, emotional abuse and physical abuse were the most frequently reported types of abuse experienced during childhood (n for emotional abuse = 190 [47.1%] and n for physical abuse = 180 [46.5%]). Descriptive statistics (M ± SD) for the dependent continuous variables are presented in Table 1.
Descriptive Statistics of the Study Variables.
Note. N = 409.
Examination of mean scores of mental health problems based on women’s history of emotional abuse and childhood neglect indicated that abused women have, on average, higher mean scores of depression, anxiety, and stress and lower mean scores of self-esteem when compared to nonabused women (see Table 2).
Description of Mental Health Problems Based on Women’s History of Childhood Abuse.
One-way between-groups MANOVA was implemented to explore differences in mental health problems based on the type of childhood abuse experience. There were no statistically significant differences between physically abused and nonphysically abused women and between sexually abused and nonsexually abused women on the combined dependent variables (depression, stress, anxiety, and self-esteem; Wilks’ lambda for physical abuse = .982, p = .42; Wilks’ lambda for sexual abuse = .98, p = .36).
Examining effects of emotional abuse and childhood neglect on women’s mental health indicated that there was a statistically significant difference in mental health between abused and nonabused women (Wilks’ lambda for emotional abuse = .914, p < .0001; Wilks’ lambda for childhood neglect = .83, p < .0001). Levene’s test indicated that equality of variances was violated for the depression and anxiety variables. Therefore, a more conservative α level of .025 was set for these variables. Between-groups comparisons were considered using Bonferroni adjusted α of .013 for stress and self-esteem and an α level of .006 for depression and anxiety (α levels of .05 and .025 were divided by the number of independent variables [four] to control for Type I error). Between-groups comparisons indicated that all dependent variables (depression, anxiety, stress, and self-esteem) differed significantly between emotionally and nonemotionally abused women and between neglected and nonneglected women (see Table 3, for details).
Results of MANOVA Test for the Differences in Mental Health Based on History of Childhood Abuse.
Note. MANOVA = multivariate analysis of variance.
*p Value < .013 using Bonferroni adjustment for Type I error. **p Value < .006 using Bonferroni adjustment for Type I error.
Discussion
Two types of childhood abuse were relatively high in this study. Childhood emotional abuse was the mostly reported by the participants (47.1%). This prevalence rate is an indicator for the significance of this type of abuse in women’s lives. Unfortunately, some family members in the community use hurtful words and verbally assault their children. They pay no attention to the psychological harm that would happen to these children (when they grow up) as a result of such experience. Hurtful words directed toward females as children are unforgettable and women can recall such an experience several years after victimization. This was evident in the relatively high-reported prevalence rate of emotional abuse.
Physical abuse was prevalent as well where its rate reached 46.5%. There are probable reasons that would explain this high rate. One of these reasons is that some people may think that physical punishment is an effective way of disciplining children. Another reason is that physical punishment that does not leave the child bruised could be culturally acceptable.
These two reasons shed light on some people’s views about raising children. Some people may consider children as their own property and give themselves the right to manage children’s lives and discipline them the way they think is correct. Due to lack of studies conducted in this field, there are no strong evidences available explaining reasons behind the use of physical violence during childhood years in the Jordanian and Middle Eastern society. However, our knowledge of the culture of our participants supports our explanation in this regard. Future studies in this field are highly recommended.
Results of MANOVA indicated presence of significant differences on the combined mental health variable (in terms of depression, stress, anxiety, and low self-esteem) between victims and nonvictims of both emotional abuse and child neglect. Victims of both types of abuse were significantly more depressed, stressed, and anxious and possessed lower self-esteem mean scores when compared to nonvictims.
This finding has two important considerations. The first one is that not all types of childhood abuse impact mental health in adulthood. For instance, we found that childhood physical abuse and childhood sexual abuse did not affect mental health of the victims as emotional abuse and childhood neglect did. This finding was congruent with previous findings where no any type of childhood violence (including physical, sexual, and psychological violence as well as witnessing parental violence) provided significant association with depressive symptoms in college women (Al-Modallal, 2016b). The second consideration is that types of abuse that do not leave the victim bruised or traumatized (such as emotional abuse and neglect) are more influential in terms of mental health sequelae in adulthood, when compared to physical and sexual abuse that are mainly associated with visible physical trauma.
Lack of significant relationship between physical and sexual abuse with mental health in adulthood was incongruent with results of a previous investigation. In one study, significant bivariate relationships were found between childhood physical abuse with depression and anxiety and between childhood sexual abuse with depression and anxiety (all p values < .05; Ramos et al., 2004). In the current study, only five (1.3%) women reported sexual abuse in childhood. This very low frequency is a quite enough reason for the lack of significant association between sexual abuse and mental health problems.
Regarding physical abuse, absence of significant relationship between physical abuse and mental health problems in adulthood may have one of the two explanations. The first one is that physical abuse doesn’t affect victims’ mental health in any way. The second explanation is that mental health problems (if they occur) do not last long after the initial physical abuse incidents. This means that victims of physical abuse recover from mental health sequelae of abuse shortly after victimization or after recovery from the trauma (such as scratches and bruises) that occurred as a result of physical abuse. Follow-up studies are recommended in this regard to explain our assumptions.
Socioeconomic factors of our participants indicated that the majority were from the middle class. Nevertheless, these factors were not effective in buffering the negative impacts of neglect and emotional abuse on women’s mental health status. Jordanian women can be characterized as women of high tolerance. They can tolerate duties associated with household demands, work demands (if working outside home), and family demands (Al-Modallal et al., 2010). Yet it seems that this tolerance falls short in front of childhood abuse experiences such as emotional abuse and childhood neglect. This result, in turn, signifies the conclusion that emotional abuse and neglect can be more harmful and more damaging to women’s mental well-being compared to physical and sexual abuse. This conclusion is partially supported in earlier research (Rich et al., 2005).
Mental health consequences of childhood abuse last to adulthood. Women with poor mental health status are prone to poor family functioning in terms of child care, ability to perform household chores, and meeting social obligations of the husband and the family in-law. Poor family functioning could rationalize adulthood victimization by the husband because of unmet family needs. In addition, poor mental health status could be a reason for violence by the intimate partner (Lehrer et al., 2006; Stith et al., 2004). Put differently, two antecedents (poor family functioning and poor mental health status) are likely to exist in victims of childhood abuse and their presence would explain future victimization in adulthood.
It’s been empirically supported that child abuse is significantly associated with adult victimization by the partner (Al-Modallal, 2016a; Briere & Elliott, 2003; Hetzel & McCanne, 2005; Lutenbacher et al., 2004; McNutt et al., 2002). If adulthood victimization occurs, it is expected that victims of childhood abuse will suffer the cumulative impact of such experiences that can be exhibited in the form of poor mental health status.
Conclusion
This study contributed to broaden our understanding about mental health well-being in Jordanian victims of childhood abuse. Mental health consequences of childhood abuse are not yet well explored in Jordanian society. International studies indicate the high prevalence rates of this problem. It has been empirically reported that types of childhood abuse co-occur, which magnifies the problem and necessitates collaborative efforts to address it. Childhood abuse negatively impacts victims’ mental health even after years of victimization. This impact in turn influences survivor’s general health and family function.
Efforts to address history of childhood abuse and the associated mental health status among young women who are in the very beginning of their marital relationship are necessary. Collaborative efforts are needed to come up with comprehensive plans to overcome negative impacts of domestic violence. Such efforts would reveal better mental health status and a more successful family function for women.
Footnotes
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: The study was supported by the Hashemite University, Zarqa-Jordan.
