Emotional abuse: a neglected dimension of partner violence.

Emotional abuse is well recognised as a form of intimate partner violence that is widespread in abusive and dysfunctional relationships. It is often overshadowed by physical and sexual partner violence, which are closely related. The prevalence of exposure to emotional abuse in women can range from 9% to 70%. Ana Ludermir and colleagues report in The Lancet today that emotional abuse during pregnancy might be more important than are physical and sexual violence in determining the development of postnatal depression. Today’s fi nding supports a population-based study from Japan, in which women who experienced only emotional abuse had poorer self-reported health status, suicidal ideation, diffi culty in daily activities, increased use of health services in the previous month, and symptoms of distress. Such fi ndings suggest that a radical reevaluation of the importance of emotional abuse in women’s mental health is necessary. Emotional abuse is more diverse than physical and sexual abuse because it takes many diff erent forms, including verbal abuse, threats of violence, engendering fear, humiliation, destruction of property, enforcement of social isolation, taking or withholding earnings, and fl aunting other sexual partners. There is variation in acts between diff erent cultures, and the way the victim perceives the emotional abuse also infl uences the eff ect of the act. In violent relationships, women often experience pervasive emotional abuse compared with the more discrete acts of physical and sexual violence; at times, emotional abuse might be the only form of abuse. The association of emotional abuse with ill-health has been hard to assess because of strong overlaps with physical and sexual violence, especially in settings with a high overall prevalence of partner violence. Emotional abuse generates fear and anxiety, removes social support, impoverishes, and undermines self-esteem; it is therefore unsurprising that such abuse is important in postnatal depression. Emotional abuse probably has a greater importance in women’s mental ill-health than originally thought, and should therefore receive more attention from researchers and health services. Ludermir and colleagues’ study has important implications for health services. Postnatal depression is an important and prevalent health problem in women worldwide and aff ects both mother and baby. Today’s fi ndings suggest that 10% of postnatal depression could be prevented if partner violence was eliminated, and that a substantial proportion of women at risk of postnatal depression could be identifi ed during antenatal care if midwives or doctors inquired about partner violence, including emotional abuse. Women at risk need psychological support and mental health services, which are often inadequate in low-income and middle-income countries and so compound the problems for female victims. The high prevalence of postnatal depression reported in today’s report shows the great need for improved mental health care. Emotional abuse has not been part of many screening recommendations to identify women who experience abuse during prenatal care, such as those from the American Congress of Obstetricians and Gynecologists. However, there is mounting evidence that guidelines I declare that I have no confl icts of interest.