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Victimization from Three Types of Intimate Partner Aggression and Mental Health Concomitants among Women in Pakistan

The aim of the study was to compare associations between three types of female victimization from intimate partner aggression (IPA) and their mental health concomitants. A questionnaire was completed by 569 relatively well-educated women in Pakistan (97.3% had at least a Bachelor’s degree). The mean age was 31.4 years (SD 9.1), and the age range was between 18 and 70 years. The questionnaire included scales for measuring victimization from physical aggression, verbal aggression, and indirect aggressive social manipulation perpetrated by the husband against the wife, and four subscales from the Brief Symptom Inventory (BSI): depression, anxiety, obsessive compulsive symptoms, and somatization. Victimization from verbal aggression was the most common type, followed by indirect aggression, while physical aggression was the least common. All three types of IPA were significantly associated with all four BSI subscales and most strongly with indirect aggression, while physical aggression showed the weakest associations.


Introduction
The aim of the study was to compare associations between victimization from three types of intimate partner aggression and psychological distress in a sample of Pakistani women. The choice of the word 'aggression' instead of 'violence' is here deliberate, since aggression is a wider concept than violence, with the latter being a subset of the former. All violence is aggression, but not all aggressive acts are violent. If aggression is seen as intentional harmdoing, then the harm aimed at in violent behavior is physical rather than psychological. Accordingly, the term intimate partner aggression (IPA), is preferred rather than the more

Indirect and Psychological Aggression versus Physical Aggression
A few studies have shown that psychological/emotional aggression can in some samples even be more detrimental than physical aggression. In a study where psychological aggression was operationalized to include threats, isolation of the victim, and humiliation, it was found that the psychological component was the main contributor for the development of post traumatic stress disorder (Pico-Alfonso, 2005). In another study, it was found that victimization from psychological intimate partner aggression was as detrimental as victimization from physical aggression on all concomitants except for suicidality (Pico-Alfonso et al., 2006). It has also been shown that victimization from psychological intimate partner aggression was more strongly associated with negative health outcomes than physical aggression (Coker et al., 2002). When the relationship between emotional abuse and physical abuse was subjectively assessed, psychological abuse had a greater adverse effect than physical abuse (Follingstad, Rutledge, Berg, Hause, & Polek, 1990).
There are similarities between the concepts psychological/emotional aggression and indirect aggressive social manipulation. Items measuring indirect aggression have by some researchers been included in scales measuring psychological/emotional aggression. The difference between the concepts lies, however, in the fact that psychological/emotional aggression can be both direct and indirect. Due to this, in the present study, the concept of indirect aggressive social manipulation has been adopted. Indirect aggressive social manipulation in intimate partner relations differs from direct forms of physical and verbal aggression by being more subtle and manipulative and is often carried out behind the back of the partner. Typical indirect behaviours are e.g. to try to influence someone, such as children or relatives, to dislike the partner, to ridicule the partner in her/his absence, or to try to exclude the partner from social situations. Indirect IPA has previously been studied in South Sudan (Ndoromo, Österman, & Björkqvist, 2017;Ndoromo, Österman, & Björkqvist, 2018), in Ghana (Darko, Björkqvist, & Österman, 2019), and in Finland and Mexico (Österman, Toldos, & Björkqvist, 2014).

The Cultural Context of the Study
In Pakistan, the prevalent male dominated feudal culture is considered to be the main cause of gender inequality (Taga, 2012). Although Islam emphasizes gender equality, Pakistan remains severely engulfed in inequality (ibid.). Since birth, women are considered subordinate to men, be it in the realm of physical health, education, politics, or the labor market (Nasrullah, Zakar, & Zakar, 2014;Taga, 2012). Early marriages make women vulnerable to societal pressure, since it leads to lack of education and social freedom. It has been found that early marriages, especially child marriages, are linked to domestic aggression (Nasrullah et al., 2014). Moreover, it was also shown that child marriages had long term negative effects on both the emotional and the physical health of the women. The divorce rate is very low in Pakistan since divorce is considered a stigma in most social classes (Ali, 2011); therefore, domestic aggression and conflicts are commonly considered a private matter. In 1998, there were 282 reported cases of burning of women connected to domestic aggression in Pakistan; of these women, 65% died due to the severity of their burns (Ali & Gavino, 2008).

Laws Concerning Domestic Aggression in Pakistan
In Pakistan, state laws follow Shariah laws, and they are intended to protect the rights of women against domestic aggression; yet the laws are not applied to the fullest for political and societal reasons (Pakeeza, 2015). The Pakistan Penal Court does not cover the whole spectrum of domestic aggression against women, but focuses on only a few issues, like miscarriages, and the abandonment of prepubescent children. Under the Domestic Violence Prevention and Protection Act (Act of the Legislature of Sindh, 2013), all types of physical, psychological, and gender-based harm directed at minors in the domestic environment are considered as acts of domestic violence. Despite efforts to legally banish violence against women, violations continue to take place (Pakeeza, 2015).

Prevalence of Domestic Aggression in Pakistan
Even though domestic aggression is common in Pakistan, there is no proper record of it (Rabbani, Qureshi, & Rizvi, 2008), and the number of studies conducted on the issue is relatively low (Ali, Naylor, Croot, & O'Cathain, 2015). It has been estimated that between 30% to 79% of all cases of IPV in Pakistan are reported to the authorities, but action is taken only in a handful of them (Khan, Ali, & Khuwaja, 2009). In a study on a sample of 150 Pakistani women, 34% were found to have sometimes been physically abused (Fikree & Bhatti, 1999).
In a study on domestic violence against wives and working women in the city of Bahawalpur, 90% of the women reported that they had been victimised by a family member; the perpetrators were usually the husband, the father or the brother (Haq, 2017). Besides more traditional forms of domestic violence, cases of kidnapping, murder, rape, honour killing, acid throwing or bride burning have been reported (Ashraf & Abrar-ul-Haq, 2017).
A study in urban areas of Karachi assessed the level of physical, sexual, and psychological IPV. The prevalence of lifetime physical IPV was 57.6%, the prevalence of lifetime sexual abuse was 54.5%, and of lifetime psychological abuse it was 83.6% (Ali, Asad, Mogren, & Krantz, 2011). Poor socioeconomic status contributed to psychological, sexual, and physical abuse. Moreover, statistics show that a low level of education of the husband is a major risk factor for IPV (Khan, et al., 2009).
A study examined the inter-generational cycle of violence and the predictors for perpetration of physical abuse among Pakistani males (Fikree, Razzak, & Durocher, 2005).
The lifetime prevalence of the perpetration of intimate partner physical abuse was 49.4%. Of males, 65% had, as children, witnessed when their mother was beaten, and 46.0% of the males accepted the idea that a man has the right to hit his wife.
A systematic review was made of 21 quantitative studies on IPV in Pakistan, of these 15 were conducted in different hospital environments (Ali et al., 2015). Four different forms of IPV were identified in the studies: verbal, emotional, physical, sexual, and economic. It was concluded that studies on physical violence were the most common types of studies although other forms of IPV such as verbal, psychological, sexual, and economical were also investigated. Health effects, predictors, and reasons for different types of IPV were also reported. In another review 60% of the respondents reported that financial constraints were the main reason for IPV, while 15.3% reported that the joint family system was the prime issue (Khan et al., 2009).

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IPV has been reported to occur during 3-13% of pregnancies in the world, leading to injuries and health risks for both mothers and infants (Campbell, 2002). In a study from Pakistan it was shown that 15% of the female respondents were abused while being pregnant (Fikree& Bhatti, 1999). Another study, made in Karachi showed that 44% of the pregnant women in the sample had been physically or emotionally abused; however, social support diminished the abuse (Farid, Saleem, Karim, & Hatcher, 2008).

Mental Health Concomitants of Intimate Partner Aggression in Pakistan
Several studies conducted in Pakistan has linked IPA to serious mental health problems. It has been found that domestic violence was positively associated with psychiatric distress and low self-esteem (Naeem, Irfan, Zaidi, Kingdon, &Ayub, 2008). In another study, it was found that the self-esteem of psychologically and physically abused women in Pakistan was lower than for women who were not abused (Tariq, 2013). Anxiety and depression have also been found to prevail in 72% of a sample of abused Pakistani women (Fikree & Bhatti, 1999). reported that the main problem for them was IPA (80%) and conflicts with in-laws (43%) (Niaz, 1994).

Originality of the Study
The number of studies conducted on IPA in Pakistan is relatively low (Ali, Nayloretal., 2015).
The present study is aimed at adding to the research on IPA in Pakistan. Outof 21 previous quantitative studies, 15 were conducted in hospital environments (Ali etal., 2015), while the present study includes respondents who were not hospitalized. Studies on physical violence have so far been the most common types of studies in Pakistan (Ali etal., 2015), but the present study includes also measurements for victimization from in direct aggressive social manipulation which have not previously been reported in studies conducted in Pakistan.

Respondents
A questionnaire was completed by 569 women in Pakistan. The mean age was 31.4 years (SD 9.1), and the age range was between 18 and 70 years. Of the respondents, 96.7% (550) were married, 2.3% divorced (13), 0.9% widowed (5), and 0.2% (1) separated. Eighty-seven were pregnant, and 19 did not know whether they were pregnant or not. Two-point seven percent had a high school education or less, 45.4% had a Bachelors' level, and 51.9% a Masters' level of education or higher; the last group included 29 female medical doctors.

Instrument
A questionnaire was constructed in order to investigate female victimization from domestic aggression perpetrated by the husband, and its psychological concomitants. The following types of aggressive behavior perpetrated against the wife were measured: physical aggression, verbal aggression, and indirect aggressive social manipulation. Verbal and physical aggression were measured with the Direct Indirect Aggression Scale for Adults (Österman & Björkqvist, 2009). Two items (bit, scratch) were removed since they did not fit in with a husband's behaviors. Items specifically suited for Pakistan were added (see below). The items in the scale measuring aggressive indirect social manipulation were all new and created to fit in with the culture in Pakistan. All items of the scales started with the question: "How often has your husband done the following?" Responses were given on a five-point scale (0 = never, 1= seldom, 2 = sometimes, 3 = often, 4 = very often).

Victimization from Three Types of Intimate Partner Aggression
Verbal aggression was the most commonly type of aggression perpetrated by the husbands (58 % of the total victimization scores), followed by indirect aggression (27%), and physical aggression was the least common (15%) [F (2, 567) = 335.69, p < .001, η p 2 = 0.542] (Fig. 1). The most common single behaviors of verbal aggression were quarreled with me, interrupted me when I was talking, and yelled at me. For indirect aggression, the most common single items were tried to make me feel guilty, made a negative comparison between me and his sisters and/or mother, and made socially fun of my intellect. For physical aggression, the most common behaviors were has thrown objects in anger, damaged something that was mine, and pushed me back in order to prevent me from standing in front of him in different situations.  A multivariate analysis of variance (MANOVA) revealed that there were no significant differences in victimization between pregnant and non-pregnant women. Accordingly, pregnant respondents were equally much victimized from all three types of IPA as nonpregnant ones.
The age of the respondents did not correlate with any of the three types of victimization.
Neither was there a difference in degree of victimization between respondents at different educational levels.

Mental Health Concomitants of Victimization from Three Types of Intimate Partner Aggression
The respondents were divided into two groups, one with respondents who had experienced more than the mean of physical victimization (high), and one with less than average victimization from physical aggression (low). The same procedure was followed for verbal and indirect aggression. Three separate multivariate analyses of variance (MANOVA) were then conducted, one for each type of victimization, with the three types of victimization as independent variables and four psychological concomitants as dependent variables. All three multivariate analyses were significant (Tables 2−4).
The univariate analyses showed that women who had been more than average victimized from physical aggression scored significantly higher on anxiety, depression, obsessive compulsive symptoms, and somatization than women who had been less victimized (Table   2). For victimization from verbal aggression (Table 3) and indirect aggression (Table 4)

Concomitants
All three types of victimization from intimate partner aggression, physical, verbal and indirect aggression, correlated significantly with the four psychological concomitants anxiety, depression, obsessive compulsive symptoms, and somatization. For indirect aggression, the correlational coefficients were all above .50 (Table 5). In order to compare the correlational coefficients between the three types of victimization and the four psychological concomitants, Fisher's r to z transformation was used: z = -(z r1z r2 ) / √(1/( 1-3) + 1/( 2 − 3)) in which z r = ½ ln ((1+r) / (1-r)). A z-value ≥ 1.96 indicates p< .05. It was found that the correlational coefficients between indirect aggression and the four psychological concomitants (r = .51-.57) were all significantly larger than the correlations between victimizations from physical aggression and the same concomitants (r = .33 -.41) (z ≥ 3.07 for all, p< .05) ( Table 5). The correlational coefficients between victimization from verbal aggression and depression and obsessive compulsive symptoms (both r = .48) were also both significantly higher than the correlations between victimization from physical aggression and the same two concomitants (r = .33, 37) (z > 2.27 for both, p< .05). There was no significant difference between the correlational coefficients for physical and verbal aggression with anxiety or somatization. For depression, the correlational coefficient was significantly lower with physical aggression (.37) than with verbal aggression (.48). The same was the case for obsessive compulsive symptoms; the correlational coefficient was significantly lower with victimization from physical (.33) than with verbal aggression (.48). No significant differences were found between the correlational coefficients for verbal aggression and indirect aggression with any of the psychological concomitants.
Four linear multiple regression analyses (method Enter) were conducted with the four types of IPA predicting anxiety, depression, obsessive compulsive symptoms, and somatisation (Table 6). Indirect aggression predicted all four psychological concomitants, while verbal aggression predicted all but somatisation. Physical aggression predicted only obsessive compulsive symptoms, however negatively. The β-values were highest for indirect aggression (between .42 and .49); for the other types of aggression, they were below .26.

Discussion
The aim of the study was to investigate associations between three types of victimization from IPA and mental health concomitants. The most common type of victimization was from verbal aggression which constituted 58% of the total victimization. The second most common type was from indirect aggression, which constituted 27% of the total victimization.
Victimization from physical aggression was the least common type, which constituted only 15% of all victimization. A systematic review of studies on IPV in Pakistan (Ali et al., 2015) has concluded that studies on physical violence have so far been the most common ones.
Therefore, the findings from the present study indicate that since other forms of victimization apart from physical ones might be more frequent, these should also be studied.
In comparison with another study on IPA in Pakistan (Ali et al., 2011) the mean values for victimization were relatively low in the current sample. On a scale from zero to four, the summed scores for all types of victimization remained below 1 (= seldom). The score for physical aggression, 0.23, was the lowest one. A study from Pakistan has previously shown that low levels of education of the husband are a risk factor for intimate partner violence (Khan, et al., 2009). Thus, the overall low scores might be explained by the relatively high educational level of the respondents in the sample.
It is notable that pregnant respondents were equally much victimized as non-pregnant ones.
This finding corroborates another study from Pakistan, where 15% of the pregnant females were found to have been abused (Fikree & Bhatti, 1999), and also a third study from Pakistan according to which 44% of the pregnant participants had been both physically and emotionally abused (Farid et al., 2008).
Women who had been more than average victimized from any of the three forms of aggression − physical, verbal, or indirect − scored significantly higher on anxiety, depression, obsessive compulsive symptoms, and somatization than those who had been less victimised.
Furthermore, it was found that the correlational coefficients between victimizations from physical aggression and the four psychological concomitants were all significantly lower than the correlations between victimization from indirect aggression and the same concomitants.
For depression and obsessive compulsive symptoms, the correlations were also lower for physical aggression than for verbal aggression. Indirect aggression usually aims at psychological rather than physical harm. In the present study, all four symptoms of psychological distress showed the highest association with victimization from indirect aggression (β-values varied between .42 and 49), and the lowest association with victimization from physical aggression. This is in line with previous studies, in which psychological/emotional aggression has been shown to be equally detrimental as physical victimization (Pico-Alfonso et al., 2006), or even more detrimental (Coker et al., 2002;Follingstad, Rutledge, Berg, Hause, & Polek, 1990;Pico-Alfonso, 2005).
In this well-educated Pakistani sample, with relatively low scores of victimization from IPA, the strongest predictor for mental health problems was indirect aggressive social manipulation, while victimization from physical aggression did not predict mental health problems. Low levels of victimization in general, and especially of physical aggression, might contribute to these results. However, victimization from IPA and psychological distress associated with it appears to be a serious problem in Pakistan, as strong associations were found even in this well-educated sample. So far, a limited number of studies on IPA have been conducted in Pakistan, and there is a dire need to educate both women and men about the issue.

Conclusion
The most common types of victimization was found to be from verbal and indirect aggression, while physical aggression was the least common type. Furthermore, psychological distress showed the highest association within direct aggression and the lowest with physical aggression.
The low mean values for victimization in the current sample of well-educated respondents suggest that education plays a crucial part. It is noted that the strongest predictor for mental health problems in this sample was indirect aggressive social manipulation, while victimization from physical aggression did not predict mental health problems.
Studies on physical violence have so far been the most commonones in Pakistan (Ali et al., 2015). Future studies would benef it from including also other forms of aggression besides physical forms of IPA. Groups with different levels of education are also needed to be included in studies on IPA in Pakistan.