Women’s Health Reports Volume 4.1, 2023 DOI: 10.1089/whr.2023.0019 Accepted July 19, 2023 Open camera or QR reader and scan code to access this article and other resources online. ORIGINAL ARTICLE Open Access Clinical Neuropsychological Profile and Quality of Life in Women Who Have Suffered Gender-Based Violence Alexandra Yakeline Meneses Meneses,1–3 Sol Fernandez-Gonzalo,3–5 and Mercè Jodar Vicente3–6,* Abstract Background: This research characterizes the clinical and neuropsychological profiles and the quality of life in a group of Ecuadorian women who suffered physical violence, psychological violence, or sexual violence, explor- ing their relationships with sociodemographic factors. Methods: A battery of tests were used to explore the clinical and neuropsychological functions and quality of life in 120 participants who were selected from a population affected by violence. Results: Sixty percent of the participants showed clinical anxiety, 26.7% clinical depression, 40% post-traumatic stress disorder symptoms, 15% moderate personality disorder, and 51.7% a low quality-of-life index. Their Z-scores in the neuropsychological domains evaluated were verbal memory (Rey Auditory Verbal Learning Test = 1.35), working memory (Digits = 1.67), attention (D2 = 1.24), processing speed (Coding = 1.33; Trail Making Test A = 1.81), and executive function (Trail Making Test B = 1.15; Stroop = 0.20; verbal-semantic fluency test = 0.05; verbal fluency test = 1.23). Conclusions: The majority of women who suffered gender-based violence presented clinical levels of anxiety, depression, and post-traumatic symptoms. The cognitive functions with lower scores (Z < 1.5) were working memory and processing speed, mediated by education factor. Keywords: gender-based violence, battered women, violence against women 1 Arts and Humanities Area, Psychology, Israel Technological University of Ecuador, Ecuador. 2 Department of Psychology, Health District 17D10, Cayambe - Pedro Moncayo, Ecuador. 3 Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Barcelona, Spain. 4 Instituto de Investigación e Innovación Parc Tauli-I3PT, Sabadell, Spain. 5 CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain. 6 Neurology Service, Hospital Universitario Parc Tauli, Sabadell, Spain. *Address correspondence to: Mercè Jodar Vicente, Department of Clinical and Health Psychology, Universitat Autonoma de Barcelona, Campus de Bellaterra, Edifici B, Bellaterra 08193, Barcelona, Spain, E-mail: merce.jodar@uab.cat ª Alexandra Yakeline Meneses Meneses et al., 2023; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License [CC-BY] (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 448 Meneses, et al.; Women’s Health Reports 2023, 4.1 449 http://online.liebertpub.com/doi/10.1089/whr.2023.0019 Background Few studies have comprehensively evaluated the Violence against women, especially violence by their impact of violence, differentiating between the type of partners and sexual violence, constitutes a serious pub- violence to which the victims have been exposed. lic health problem and a violation of the human rights That is why our research aims to examine the clinical of women. According to the World Health Organiza- and neuropsychological profile and the quality of life tion,1 one in three women in the world has suffered in Ecuadorian women who suffered different types physical and/or sexual violence by her partner or sexual of violence (physical, psychological, and sexual). We violence by third parties at some point in their lives. hypothesized that women who suffered gender violence There has been a recent increase in studies of how vio- would present high levels of anxiety, depression, post- lence against women affects their health in different traumatic stress symptoms, alterations in the person- areas, including the mental,2–4 cognitive,5,6 physical,7,8 ality profile, and low performance on standardized sexual,9,10 and social dimensions.11–13 Studies conduc- cognitive tests; and that sociodemographic characteris- ted in Ecuador indicate that 64.9% of women are vic- tics, such as level of education, marital status, type of tims of some type of violence,14 the most frequent violence, and time of exposure to violence, would be being physical violence, psychological violence, and correlated with the presence and severity of psycho- sexual violence.15 pathological and cognitive effects. Authors, such as Kaur and Kumar16 and Bichard et al.,17 have pointed out that these violent actions Methods can have permanent physical sequelae such as motor Participants disorders, burns, and scars, reaching high levels of The study population was identified in the Communities severity and leading to loss of consciousness or mild of Tabacundo and Cayambe, by the psychology service of head trauma. Cognitive functioning, including func- the Tabacundo Health Center—Ecuador. It should be tions such as attention and executive functions, may noted that these are populations that show high rates be secondarily affected.18–20 Sugg,21 reported other of gender violence14; most of the families are dedicated clinical symptoms associated with victims of violence: to floriculture, and they come from indigenous commu- chronic pain, gastrointestinal disorders, obesity, chro- nities. As part of the strategy for the prevention and erad- nic diseases, symptoms of insomnia, fatigue, and geni- ication of violence against Ecuadorian women, the staff tourinary infections. Sexually transmitted infections of the Psychology service of the Tabacundo Health may appear, as well as serious consequences in the sex- Center—Ecuador, identified the users who declared hav- ual and reproductive health of women as a result of the ing been exposed to violence in the automated system of violent act.22,23 consultations and outpatient care RDACAA—WEB, Another of the consequences observed is psychopath- during the study period 2018 to 2019, reaching a total ological alterations. The Pan American Health Organi- of 120 women exposed to gender-based violence, namely zation (PAHO),24 mentions that the disorders with the physical, psychological, and sexual.41 highest incidence are affective mood disorders and Within its sociodemographic characteristics we have those related to stress, as well as anxiety disorders,25–27 the sample that corresponds to women from the com- depression,28–30 personality disorders,31–33 and post- munities of Cayambe and Pedro Moncayo in the Prov- traumatic stress.34,35 Factors, such as age, marital status, ince of Pichincha—Ecuador, with an average age of level of education, and economic status, have been cor- (mean [M]: 34.3; standard deviation [SD]: 0.7), most related with the severity of psychological symptoms of whom are under common law partnership, living and the increase in reported cognitive difficulties.36–38 with a male partner (59%). Despite the aforementioned seriousness of the effects Their average level of years of schooling is (M: 8.3; of gender-based violence on women, social support ser- SD: 0.3), and with an average intelligence coefficient vices, access to health services, accompaniment, and (M: 81.1; SD: 0.8); all of them have a history of expo- judicial protection have not shown efficiency and sure to gender-based violence, at least once, at any have not guaranteed the redignification of women stage of their lives, whose typology reported as the and the rights of these victims, so the rapid and timely most recurrent was physical (46%), psychological response of these services can have important implica- (43.33%), or sexual (10%). The average time of having tions on the recovery and well-being of women within been exposed to violence was (M: 6.6; SD: 0.5). The their communities.39,40 inclusion criteria were as follows: (1) exposure to Meneses, et al.; Women’s Health Reports 2023, 4.1 450 http://online.liebertpub.com/doi/10.1089/whr.2023.0019 gender violence (physical, psychological, and/or sexu- Psychopathological/clinical measures al); (2) age between 18 and 50 years; and (3) agree- Hospital Anxiety and Depression Scale. It allows to ment to voluntarily participate and having signed the assess the levels of anxiety and depression that the sub- informed consent form. The exclusion criteria were ject presents.45 It consists of seven items related to anx- as follows: (1) intelligence quotient (IQ) less than 70; iety symptoms and seven items related to depressive (2) history of acquired brain damage; (3) history of symptoms, and each item is valued on a scale of 0 to severe neurological or psychiatric illness; (4) history 3 points. The cut point is 7. Subscale scores for anxiety: of toxic consumption habits; and (5) presence of sen- 0–7: No anxiety; 8–10: Minimal anxiety; and 11–21: sory alterations that impede the performance of the Clinical anxiety. Subscale scores for depression: 0–7: tests. No depression; 8–10: Minimum depression; 11–21: Clinical depression. Cronbach’s alpha coefficient of Procedure validity is 0.76. The research was approved by the health committee of District 17D10, Cayambe—Pedro Moncayo, and by the Post-traumatic Stress Disorder Checklist for The Ethics and Research Committee of the UTE University. Diagnostic and Statistical Manual of Mental Disorders, The Mental Health staff of the Tabacundo Health Cen- Fifth Edition. It is an instrument updated to the The ter and external collaborating researchers of the Parc Diagnostic and Statistical Manual of Mental Disorders, Taulı́ Hospital in Barcelona participated. The women Fifth Edition (DSM-5), to evaluate post-traumatic symp- were selected to be part of the study under inclusion toms.46,47 Respondents indicate how much each post and exclusion criteria. All participants were previously traumatic stress disorder (PTSD) symptom has disturbed informed of the characteristics and procedures of the them in the past week (as opposed to the past month), study and of the voluntary nature of their participation using a 5-point scale ranging from 0 = not at all, 1 = a lit- and signed the informed consent form. Women who tle, 2 = moderately, 3 = quite a bit, and 4 = extremely. The agreed to participate in the study were first adminis- cut point is 31. Note 1: The patient must previously tered the National Adult Reading Test NART test42 meet Criterion A. Note 2: A total score of 31 to 33 to rule out intellectual disability. All women who met points is optimal to determine probable PTSD. Note the inclusion criteria met with the study psychologist 3: To determine whether or not it meets the Criterion for the assessment of their psychopathological and cog- for a Provisional Diagnosis PTSD, we will only con- nitive status. The evaluation lasted at most 2 hours and sider symptoms with scores of 2, 3, or 4. Cronbach’s consisted of the application of a wide battery of tests alpha coefficient of validity is 90 to 0.97. and questionnaires to evaluate the psychoaffective, cog- nitive, and quality-of-life dimensions. Millon Clinical Multiaxial Inventory—IV. The scales corresponding to Axis 2 (Clinical Patterns of Personal- Instruments ity and severe personality pathology) were consid- Survey on gender violence. The survey on gender vio- ered.48 Base Rate Profile is as follows: Validity scales: lence was based on the Technical Standard for Com- 0–35: low; 36–74: medium; and 75–100: high. Clinical prehensive Attention to Gender Violence. It allows patterns of personality: 0–60: no risk; 61–74: style; collecting data associated with sociodemographic vari- 75–84: type; and 85–115: personality disorder. Clinical ables, age, gender, marital status, and economic status, syndromes: 0–74: absent; 75–84: present; and 85–115: as well as the type of reported violence and the time of prominent. Cronbach’s alpha coefficient of validity is exposure to violence. 0.72 to 0.82. National adult reading test NART. This is a test for GENCAT Quality of Life Scale. It evaluates the quality- reading unstressed words, which correlates with the of-life index of the users, in the dimensions: emotional QI index of the WAIS intelligence test42–44 and allows well-being, interpersonal relationships, material well- estimating the level of QI. The premorbid IQ is scored being, personal development, physical well-being, according to direct form of 0/30, a score of 10 on self-determination, social inclusion, and rights.49 The NART equals 31 on WAIS-IV, and a score of 30 equals items of each dimension are stated using a frequ- 136 on WAIS-IV. Cronbach’s alpha coefficient of valid- ency scale of four options. Standard scores (M = 10; ity is 0.84.44 SD = 3) of each Quality dimension of Life; percentiles Meneses, et al.; Women’s Health Reports 2023, 4.1 451 http://online.liebertpub.com/doi/10.1089/whr.2023.0019 and Quality of Life Index; Quality of life index of 52 < 1 scores obtained in Overall Test Efficiency (M: 430.71; percentile; and Quality of life index of 138 > 99 percen- SD: 99.75), concentration index (M: 172.64; SD: tile. Cronbach’s alpha coefficient of validity is 0.91. 48.30), and variation index (M: 14.57; SD: 6.13) were considered, according to reference population. Cron- Neuropsychological measures bach’s alpha coefficient of validity is 0.80–0.97. The Rey Auditory Verbal Learning Test. It measures verbal learning ability and short- and long-term reten- Trail Making Test, part A and part B. This test allows tion. A target list of 15 words is read to the patient, who assessing visual motor speed and cognitive flexibility.53 must try to remember it during 5 consecutive trials. Part A consists of executing a task, joining, without Subsequently, a distracting list is presented, and the releasing the line, numbers in chronological order short-term memory of the target list is counted. After from 1 to 25. Part B consists of executing another 30 minutes, long-term memory of the words on the more complex task, in which numbers and letters list is collected. The adaptation of Ferreira for the must be joined in order of alternate increasing (1 a, Latin American population was applied.50 The maxi- 2 b . 13. in sequential order) under time pressure, mum value is 15 and the minimum value is 0. Means and the number of mistakes made is counted. A stan- of references by age and schooling were controlled, dardized version for the Latin population was used.53 based on the reference population. Verbal learning The direct scores obtained in seconds were considered, and memory are assessed by the learning curve, the according to the means obtained in the reference pop- total acquisition or total learning (SI–V) and trials V ulation, under control of age and schooling. Cron- (final acquisition level), VII (delayed recall), and VIII bach’s alpha coefficient of validity is 0.70 to 0.90. (recognition). Cronbach’s alpha coefficient of validity is 0.80. Stroop test. It is an instrument that assesses complex Digits-WAIS-IV. It is used to measure immediate attention, through the ability to inhibit verbal inter- memory and working memory capacity.51 It consists ference, or faster automatic response, so it is a good of repeating a series of numbers from less to greater measure of selective attention.54 The level of interfer- complexity, it starts in a sequential order, then in ence was obtained, based on the scores obtained that reverse order and finally in increasing order. WAIS-IV mark a typical score of 20 to 80. The results were scales were used, according to age. A score below 7 rep- interpreted, according to the means obtained in the resents limited cognitive function. Cronbach’s alpha reference population. Cronbach’s alpha coefficient of coefficient of validity is 0.94. validity is 0.89. Coding—subtest WAIS-IV. The task consists of com- Phonological verbal fluency test. It consists of a con- pleting with the appropriate symbols, some squares trolled and programmed verbal production test, in that have a digit in their upper part.51 It evaluates, which the subject must produce words that begin the speed and visual motor skills. WAIS-IV scales with a letter pre-established by the examiner for 1 min- were used, according to age. A score below 7 represents ute (example: P—M—R).55 The scores were obtained limited cognitive function. Cronbach’s alpha coefficient directly, and were analyzed based on the means obtai- of validity is 0.94. ned in the reference population. Cronbach’s alpha coefficient of validity is 0.82. Test D2. It measures selective and sustained atten- tion.52 The test contains 14 lines with 47 characters, totalizing 658 items. These stimuli contain the letters Semantic verbal fluency test. It assesses the ability to ‘‘d’’ or ‘‘p’’ that can be accompanied by one or two retrieve stored semantic information.55 It is related to small lines located, individually or in pairs, at the top the speed to organize the thought and the strategies or bottom of each letter. The subject’s task consists of used for the fast search of words, in a time of 60 sec- carefully reviewing the content of each line from left onds. The scores were obtained directly, and were to right, then marking every letter ‘‘d’’ that has the analyzed based on the means obtained in the reference assigned consignment or key, discriminating the rele- population. Cronbach’s alpha coefficient of validity is vant elements from the irrelevant ones. The direct 0.82. Meneses, et al.; Women’s Health Reports 2023, 4.1 452 http://online.liebertpub.com/doi/10.1089/whr.2023.0019 Statistical analysis 15.0% had a moderate risk of pathology or personality SPSS v24.0.0 and R v3.6.2 were used for data process- disorder, and 51.7% had a low quality-of-life index ing. A descriptive analysis of the data was performed (GENCAT) (Fig. 1). to present the sociodemographic profile, reporting the When comparing the values obtained on the differ- mean and SD. The direct scores of the cognitive tests ent tests applied, divided by type of violence suffered, were transformed to z scores to place the women studied those women who suffered sexual violence more with respect to the standard averages that are offered by often had clinical anxiety (66.7%), clinical depression the scales of each test and that consider sex, age, and (41.7%), post-traumatic stress (58%), moderate-risk schooling. Z < 1.5 was set as the cutoff point to deter- personality disorder (42.9%), and low quality of life mine the cognitive impairment of clinical relevance in (50%) than those women who reported physical and the cognitive tests.56 Analysis of variance and Kruskal psychological violence (Fig. 2). No correlations were Wallis tests were used, according to the fulfillment of found between the clinical malady and the type of vio- the statistical test requirements, to analyze the differences lence, except that post-traumatic stress was more com- between types of violence (physical, psychological, and mon in the group of women who suffered sexual sexual violence) according to disaggregation groups violence ( p = 0.003) (Table 2). This nonsignificant dif- (sociodemographic factors); to demonstrate or not the ference was confirmed with the post hoc tests carried existence of a significant difference, multiple contrast out, presenting some of them in confidence interval tests ( post hoc) were constructed. In addition, the type graphs for means (Appendix 3). of tests used in the data analysis plan for multiple com- Regarding the neuropsychological variables, a clini- parisons are added as shown in the Supplementary cally significant decrease was only observed in the Material (Appendix A2). working memory variable (Digits = 1.67) and in the processing speed variable (Trail Making Test part A Results [TMT-A] = 1.81). It is important to mention that, No differences in sociodemographic variables were although no clinically significant results were observed observed between the groups who suffered physical, in the rest of the averages, there was a tendency to pres- psychological, and sexual violence, except that the ent values lower than the average for their age and cul- group with sexual violence showed a higher IQ than tural level of verbal memory (Rey Auditory Verbal the group with sexual, physical, or psychological vio- Learning Test = 1.35), attention (D2 = 1.24), visual lence (F = 4, 40; p = 0.014) (Table 1). motor speed (Coding = 1.33), and executive function The general results of the clinical tests administered tasks (Trail Making Test part B [TMT-B] = 1.15, indicate that 60.0% of women who suffered vio- Stroop = 0.20, phonetic verbal fluency with phonetic lence presented clinical anxiety (Hospital Anxiety and instruction = 0.05, and verbal fluency with semantic Depression Scale [HADS]-A), 36.7% reported clini- command = 1.23) (Fig. 3). cal depression (HADS-D), and 40.8% of the women Comparing the means of the scores on the neuropsy- evaluated presented post-traumatic stress symptoms chological tests between the groups of physical, psycho- (Post-Traumatic Stress Disorder Checklist for DSM-5 logical, and sexual violence, the group of women who (PCL-5). Regarding the personality profile (Million-III), suffered sexual violence had clinically significant scores Table 1. Sociodemographic Characteristics of the Participants Variables Total Physical violence Psychological violence Sexual violence p-valor N 120 56 52 12 Age, M: SD 34.3: 0.7 35.4: 1.1 33.6: 1.1 32.3: 2.9 0.341 Years of schooling, M: SD 8.3: 0.3 7.8: 0.4 8.7: 0.5 8.8: 0.9 0.301 Violence exposure time, M: SD 6.6: 0.5 7.2: 0.8 6.2: 0.7 5.7: 1.3 0.583 IQ, M: SD 81.1: 0.8 81: 0.9 80: 1.1 88: 4.0 0.014* Marital status, n (%) Single 16 (100) 6 (37.5) 7 (43.8) 3 (18.8) 0.504 Married 38 (100) 19 (50.0) 15 (39.5) 4 (10.5) 0.504 Divorced 7 (100) 5 (71.4) 1 (14.3) 1 (14.3) 0.504 Free union 59 (100) 26 (44.1) 29 (49.2) 4 (6.8) 0.504 *p = < 0.05 Differences in the averages obtained in the estimated IQ in the groups by types of violence. IQ, intelligence quotient; M, mean; SD, standard deviation. Meneses, et al.; Women’s Health Reports 2023, 4.1 453 http://online.liebertpub.com/doi/10.1089/whr.2023.0019 FIG. 1. Percentages obtained in the tests that indicate the presence or absence of clinical/psychopathological alterations in the global simple. Millon: Millon Clinical Multiaxial Inventory-IV; GENCAT: GENCAT Quality of Life Scale; DSM-5, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; HADS-Anxiety, Hospital Anxiety and Depression Scale (Anxiety); HADS Depression, Hospital Anxiety and Depression Scale (Depression); PCL-5, Post-traumatic Stress Disorder Checklist for DSM-5. (Z < 1.5) on the screening tests (TMT-A and TMT-B) Women who lived with their romantic partner showed and in the attention test (D2) compared with the aver- greater anxiety than women who did not live with a ages among the physical and psychological violence partner (HADS-A, p = 0.012) (Table 2). Weak correla- groups, which were slightly but not significantly tions were found between the scores on the neuropsy- below the average for their age and schooling level chological tests and the clinical variables (Table 3). (Fig. 4). The differences in the scores between the groups that Discussion differed by cognitive and clinical variables were medi- To the best of our knowledge, this is the first study that ated by the sociodemographic factor. Women with evaluates the impact of violence against women, in the cog- <8 years of schooling showed lower scores on the atten- nitive, psychoaffective, and social dimensions, and ex- tional tests than women with >8 years of schooling (D2, plores its association with sociodemographic factors. As p = 0.02). The Kruskal–Wallis test showed that women main results of the study, it was found that women exposed who suffered sexual violence more often had post- to gender violence, domiciled in Cayambe and Pedro Mon- traumatic symptoms than women who suffered phys- cayo, Ecuador, present clinical levels of anxiety, depression ical and psychological violence (PCL-5, p = 0.003). and post-traumatic stress, and a decrease in quality of life. Meneses, et al.; Women’s Health Reports 2023, 4.1 454 http://online.liebertpub.com/doi/10.1089/whr.2023.0019 FIG. 2. Results obtained from the tests applied in the clinical/psychopathological variables by the type of violence. The effects of violence showed an association with ies, sequels for mental health were reported, such as some sociodemographic factors, thus, women who anxiety disorders,25–27 depressive disorders,28–30 affec- live with their sentimental partner presented higher tation in the personality profile,31–33 and post- levels of anxiety, compared with women who live with- traumatic stress.3,4,34,35 out a sentimental partner. In addition, women exposed Our study suggests that violence against women not to sexual violence presented a significantly higher level only affects mental health, but also affects performance of PTSD symptoms and obtained a low cognitive pro- in activities of daily living, which require attention and file, with difficulties in attention tasks and executive concentration, as well as negatively impacts social func- functions. In addition, sociodemographic characteris- tioning, decreasing the quality of life of women.18–20 tics, such as level of education, marital status, type of Therefore, it is based on what has already been men- violence, and length of exposure to violence, are related tioned by the WHO1,24 that violence against women to the presence and severity of psychopathological con- is not only a global social problem, but also a public ditions, especially levels of anxiety and post-traumatic health one. stress. It is also important to highlight in our findings that In this sense, the results obtained in this research sexual violence has greater repercussions compared partially support the initial hypothesis, which had with physical and psychological violence, especially in assumed that the psychological profile of women the presence of post-traumatic symptoms. Previous exposed to violence would be affected. Such affectation studies had already warned about the impact of sex- is repeated in stories of women violated in other cul- ual violence on the physical and mental health of the tural and social settings, where, according to the stud- victims.34,35 Table 2. Differences Among Groups of Cognitive, Clinical, and Sociodemographic Variables Living Living without a with a Age Years of schooling partner partner 18 to 30 31 to 50 with a Physical Psychological Sexual years old years old <8 years old >8 years old partner violence violence violence n 5 37 n 5 83 (n 5 70) (n 5 50) (n 5 23) (n 5 97) (n = 56) (n = 52) (n = 12) Kruskal– Kruskal– Variables Test M;DS M;DS ANOVA M;DS M;DS ANOVA M; DS M; DS Wallis M;DS M; DS M; DS Wallis Verbal memory RAVLT 0.97; 0.68 1.26; 0.58 0.606 1.25; 0.66 1.06; 0.65 0.253 0.88; 0.58 1.31; 0.55 0.354 1.24; 0.56 1.11; 0.55 1.09; 0.55 0.726 Working memory Digits 1.28; 0.60 1.43; 0.66 0.384 1.47; 0.63 1.55; 0.66 0.078 1.58; 0.60 1.47; 0.65 0.599 1.26; 0.63 0.84; 0.64 0.81; 0.63 0.392 Attention D2 1.07; 0.64 1.51; 0.65 0.200 1.54; 0.66 1.14; 0.65 0.002* 1.00; 0.66 1.67; 0.65 0.137 1.17; 0.65 1.47; 0.60 1.96; 0.58 0.082 Processing speed Coding 1.43; 1.68 1.34; 1.55 0.649 1.74; 0.87 0.84; 0.72 0.190 1.54; 0.78 1.28; 0.75 0.836 1.42; 0.75 1.31; 0.70 1.42; 0.65 0.836 Executive TMT-B 1.11; 0.63 1.20; 0.65 0.492 1.80; 0.79 1.38; 0.75 0.749 2.17; 0.60 1.59; 0.66 0.177 1.10; 0.65 1.43; 0.65 2.40; 0.68 0.174 455 functions Stroop 0.85; 0.60 0.60; 0.54 0.812 1.58; 0.64 1.45; 0.65 0.741 1.17; 0.64 1.51; 0.65 0.281 0.21; 0.64 0.28; 0.64 0.23; 0.65 0.279 SVFT 0.03; 0.65 0.02; 0.65 0.292 0.89; 0.58 0.79; 0.55 0.478 0.66; 0.52 0.5; 0.55 0.545 0.13; 0.57 0.16; 0.55 0.19; 0.54 0.737 PVFT 1.04; 0.63 1.23; 0.91 0.366 1.22; 0.57 1.10; 0.60 0.751 1.44; 0.64 0.74; 0.65 0.231 1.28; 0.63 1.03; 0.65 0.98; 0.68 0.501 Anxiety HADS-A 11.70; 4.55 11.3; 4.24 0.309 11.32; 3.82 11.68;4.50 0.346 10.80; 4.52 12.39; 4.40 0.012** 10.86; 4.00 11.9; 3.50 12.5; 3.50 0.335 Depression HADS-D 8.29; 3.63 8.5; 4.03 0.903 8.68; 4.09 8.22; 3.60 0.326 9.06; 3.40 9.18; 3.30 0.125 8.2; 3.20 8.48; 3.30 9.92; 3.60 0.474 Post-traumatic PCL-5 50.12; 5.25 50.4; 5.25 0.162 49.63; 7.89 51.4; 7.77 0.423 31.06; 7.75 30.63; 7.20 0.136 30.6; 7.30 34.0; 6.60 50.8; 6.70 0.003*** stress Personality Millon 46.16; 4.53 45.3; 9.41 0.317 44.78; 3.50 46.7; 4.30 0.428 62.25; 4.30 49.34; 4.10 0.070 45.03; 4.30 48.5; 3.40 54.25; 3.5 0.068 Quality of life GENCAT 94.24; 16.07 94.9;15.07 0.156 93.27; 15.78 96.8; 15.76 0.423 96.33; 14.50 92.97; 13.70 0.289 95.13; 14.30 94.5;13, 7 93.9; 14.1 0.916 Digits: WAIS-IV Digits subtest; D2: Test D2; Coding: WAIS-IV Coding subtest; Stroop: Stroop Test; Millon: Millon Clinical Multiaxial Inventory-IV. *p-Value calculated using ANOVA (analysis of variance) to compare differences between groups by years of schooling, in the averages estimated in clinical and neuropsychological tests. **p-Value calculated using Kruskal Wallis to compare differences between groups by marital status, in the averages estimated in clinical and neuropsychological tests. ***p-Value calculated using Kruskal Wallis to compare differences between groups by type of violence, in the averages estimated in clinical and neuropsychological tests. ANOVA, analysis of variance; DSM-5, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; GENCAT: GENCAT Quality of Life Scale; HADS-Anxiety, Hospital Anxiety and Depres- sion Scale (Anxiety); HADS Depression, Hospital Anxiety and Depression Scale (Depression); PCL-5, Post-Traumatic Stress Disorder Checklist for DSM-5; PVFT, phonetic verbal fluency test; RAVLT, The Rey Auditory Verbal Learning Test; SVFT, semantic verbal fluency test; TMT-B, Trail Making Test Part B. FIG. 3. Z score distribution of the tests that assess neuropsychological functions. Digits: WAIS-IV Digits subtest; D2: Test D2; Coding: WAIS-IV Coding subtest; Stroop: Stroop Test; RAVLT, The Rey Auditory Verbal Learning Test; PVFT, phonetic verbal fluency test (TFVF: Spanish version); TMT-B, Trail Making Test Part B; SVFT, semantic verbal fluency test; (TFVS: Spanish versión). FIG. 4. Differences among the groups of physical, psychological, and sexual violence studied, regarding the reported neuropsychological performance. 456 Meneses, et al.; Women’s Health Reports 2023, 4.1 457 http://online.liebertpub.com/doi/10.1089/whr.2023.0019 Table 3. Relationship Between Cognitive and Clinical Variables HADS-A HADS-D PCL-5 MILLON GENCAT Variable Test Pearson’s R p Pearson’s R p Pearson’s R p Pearson’s R p Pearson’s R p Verbal memory RAVLT 0.045 0.625 0.18 0.849 0.104 0.258 0.072 0.436 0.104 0.258 Working memory Digits 0.162 0.078 0.126 0.169 0.108 0.241 0.048 0.599 0.108 0.241 Attention D2 0.024 0.794 0.156 0.088 0.063 0.497 0.143 0.118 0.063 0.497 Processing speed Coding 0.010 0.914 0.162 0.076 0.038 0.681 0.001 0.988 0.038 0.681 TMT-A 0.067 0.465 0.066 0.477 0.133 0.148 0.145 0.115 0.133 0.148 Executive functions TMT-B 0.129 0.162 0.037 0.690 0.002 0.980 0.057 0.535 0.002 0.980 Stroop 0.004 0.963 0.074 0.423 0.036 0.699 0.008 0.935 0.036 0.699 PVFT 0.101 0.273 0.028 0.757 0.033 0.721 0.056 0.540 0.033 0.721 SVFT 0.052 0.575 0.095 0.303 0.074 0.419 0.047 0.611 0.074 0.419 Also, it was observed that the group of women Women with a history of cranioencephalic trauma exposed to sexual violence presented clinically signifi- and toxic consumption habits were excluded from cant scores (z < 1.5) in the tasks of sustained this study, due to the fact that a neuropsychological attention, processing speed, and executive functions. battery was used, which is not adapted for these popu- This finding is consistent with other populations of lations. Therefore, the rates of psychopathology rep- sexually abused women, who showed greater impair- orted in this article may have been underestimated. ment in verbal memory, executive functions, and atten- Finally, exposure to trauma can be ongoing and mul- tion, compared with women who had not been tifaceted, so the categorization of trauma in the study subjected to sexual violence.10,56 problem presented examines only one episode of care As it has already been shown that health is a deter- (exposure to events related to gender-based physical, minant of quality of life, in this sense, this study was psychological, and sexual violence). Therefore, there able to verify that more than 50% of women exposed are limitations in capturing the complexity of the possi- to violence presented a low level of quality of life. ble psychological consequences and effects on the qual- These findings are consistent with data reported in ity of the victims, since the reported symptoms could, in other contexts, both in developed and developing addition to the traumatic event of exposure to gender- countries. This risk pattern seems to be characteristic based violence, also derive from many different traumas among our women, regardless of their nationality and/or early traumas that persisted over time. and/or cultural group they belong to.11–13,57–60 Conclusions These findings are important for organizations that design support programs for victims of violence, for a In general, the majority of women exposed to gender- timely global intervention and rehabilitation that can based violence who participated in this study, showed generate an impact on the maximum possible number considerable levels of anxiety, depression, and post- of women, in accordance with the objectives of sustain- traumatic symptoms, as well as poor performance in able development. The results of this study support the the functions of verbal memory, attention, processing need for a comprehensive assessment, not only physi- speed and executive function, in addition to a low cal but psychological and social in victims of violence, level of quality of life. encouraging a rethinking of reception and intervention Regarding the differences between the groups of protocols, with special focus on care for women victims cognitive and clinical variables, mediated by the socio- of sexual violence. demographic factor, it was found that the group of women exposed to sexual violence presented a higher Limitations level of post-traumatic stress, and clinically significant This study is not without limitations. First, it was not negative scores on attention tests sustained, process- possible to include a control group of women not expo- ing speed and executive capacity, compared with the sed to violence to study the differences from women groups of women exposed to physical and psychologi- who suffered violence. Second, the low level of educa- cal violence. Also, the women who live with their sen- tion of the women in this study and the fact that they timental partner showed a higher level of anxiety, all belonged to the same floriculture community does compared with those who live without a partner. not allow the results to be generalized to other popula- The integration of the results presented a closer tions of women with other socioeconomic levels. picture of the physical, psychological, and social Meneses, et al.; Women’s Health Reports 2023, 4.1 458 http://online.liebertpub.com/doi/10.1089/whr.2023.0019 damage in the victims of violence, and suggests a re- Author Disclosure Statement consideration of the reception and intervention proto- No competing financial interests exist. cols, integrating the sociodemographic factor that accompanies each affected population, and prioritizing Funding Information women victims of sexual violence. This research did not receive any specific grant from funding agencies in the public, commercial, or not- Acknowledgments for-profit sectors. The research presented in this article contributes to the doctoral thesis project, ‘‘Clinical, neuropsychological Supplementary Material profile, and quality of life in women affected by gender- Supplementary Material based violence, and effectiveness of EMDR Therapy,’’ supported by the main author, Alexandra Meneses, in References the Autonomous University of Barcelona. 1. World Health Organization. Violence against women [Internet]. www.who.int. 2021. Available from: https://www.who.int/es/news-room/ The authors would like to thank Health District fact-sheets/detail/violence-against-women [Last accessed: January 2, 2021]. 17D10—Cayambe Pedro Moncayo, Ecuador for 2. Oram S, Khalifeh H, Howard L. Violence against women and mental health. Lancet Psychiatry 2017;4(2):159–170; doi: 10.1016/S2215- their extensive support. 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Association between of Mental Disorders, Fifth Edition domestic violence and women’s quality of life. Rev Latino Am Enferma- GENCAT ¼ GENCAT Quality of Life Scale gem 2017;25(0):2901; doi: 10.1590/1518-8345.1535.2901 HADS-Anxiety ¼ Hospital Anxiety and Depression Scale (Anxiety) 60. Soleimani R, Ahmadi R, Yosefnezhad A. Health consequences of intimate HADS Depression ¼ Hospital Anxiety and Depression Scale (Depression) partner violence against married women: A population-based study in IQ ¼ intelligence quotient Northern Iran. Psychol Health Med 2016;22(7):845–850; doi: 10.1080/ M ¼ mean 13548506.2016.1263755 NART ¼ National Adult Reading Test PCL-5 ¼ Post-Traumatic Stress Disorder Checklist for DSM-5 PVFT ¼ phonetic verbal fluency test (TFVF: Spanish version) Cite this article as: Meneses Meneses AY, Fernandez-Gonzalo S, RAVLT ¼ Rey Auditory Verbal Learning Test Jodar Vicente M (2023) Clinical-neuropsychological profile and quality SD ¼ standard deviation of life in women who have suffered gender-based violence, Women’s SVFT ¼ semantic verbal fluency test (TFVS: Spanish versión) Health Reports 4:1, 448–460, DOI: 10.1089/whr.2023.0019. TMT ¼ Trail Making Test Publish in Women’s Health Reports - Immediate, unrestricted online access - Rigorous peer review - Compliance with open access mandates - Authors retain copyright - Highly indexed - Targeted email marketing liebertpub.com/whr