Intimate Partner Violence in Tunisia: Emotional Abuse and Dependency, Alexithymia, and Self-Esteem in Female Victims

Abstract

Despite legislative advances in Tunisia, intimate partner violence (IPV) remains a widespread issue where cultural norms and systems often reinforce silence and male authority over women. This study aims to explore the characteristics of IPV and assess the emotional abuse, emotional dependency, alexithymia, and self-esteem among female victims. We conducted a cross-sectional observational study, involving 120 female victims of IPV who sought expertise at the Psychiatric Emergency Department in Sfax, Tunisia. The data were collected through individual medical visits using the Emotional Abuse Scale (EAS), the Emotional Dependence Questionnaire (EDQ), the Toronto Alexithymia Scale (TAS-20), and the Rosenberg Self-Esteem Scale (RSES). Of the 120 women who agreed to participate in this study, 75.8% were affected by severe emotional violence, 38.3% were emotionally dependent on their spouses, 59.2% were alexithymic, and 83.3% had low self-esteem. The emotional abuse scores were positively correlated with emotional dependency scores (p = 0.026; rho = 0.204). The presence of alexithymia among the victims was significantly correlated with their emotional dependency on their husbands (p = 0.004). Our findings confirm that considering women’s emotional profiles can have important implications for designing both preventive and effective interventions.

1. Introduction

Intimate partner violence (IPV) against women is a serious universal social problem that violates fundamental human rights and is by far the most widespread form of violence and discrimination against women (García-Moreno et al. 2005; OFFICE NATIONAL DE LA FAMILLE ET DE LA POPULATION and AGENCE ESPAGNOLE DE COOPCOOPÉ 2010). According to a recent estimate by the World Health Organization, globally 31% of women who have been in a relationship have experienced some form of violence from their intimate partner, underlining the significance of IPV as a global problem and public health issue (Sardinha et al. 2022; World Health Organisation 2018; S. J. White et al. 2024; Stöckl and Sorenson 2024).

The prevalence, severity, and the associated factors of IPV may vary according to cultural-specific contexts (Peterman et al. 2015). In the Arab region, IPV against women, a phenomenon that thrives in a culture of silence in which norms and systems reinforce typically male authority over women, is particularly prevalent and has a particular impact on the health and well-being of victims (Mojahed et al. 2022; Elghossain et al. 2019).

Like many other countries, Tunisia seems to be experiencing an amplification of this phenomenon, with a steady rise in the number of victims since the revolution, despite the new legislation to combat this violence (La Loi Organique N° 2017-58 Du 11 Aout 2017, Relative à l’élimination de La Violence à l’égard Des Femmes 2017; Klibi et al. 2022). A national survey on violence against Tunisian women (OFFICE NATIONAL DE LA FAMILLE ET DE LA POPULATION and AGENCE ESPAGNOLE DE COOPCOOPÉ 2010), carried out in 2010 by the National Office for Family and Population, first drew attention to the frequency of this phenomenon. According to the National Observatory for Combating Violence Against Women, until 2020, 71% of cases of violence reported to the authorities were IPV (Klibi et al. 2022). Around 20–30% of women in Tunisia hold accepting attitudes toward IPV (Mojahed et al. 2022).

The Tunisian Organic Act N. 2017-58 of 11 August 2017 on violence against women (La Loi Organique N° 2017-58 Du 11 Aout 2017, Relative à l’élimination de La Violence à l’égard Des Femmes 2017; Klibi et al. 2022) reflects a broad understanding of violence in order to ensure equality and respect for human dignity. It creates a new “crime of aggression against the intimate partner” that harms the dignity or physical or psychological safety of the victim, which is punishable with 6 months to 1 year of prison. It adopts a comprehensive approach based on the prosecution of perpetrators of such violence, as well as the protection and support of victims (Voorhoeve 2021). This new Tunisian law of 2017-58 includes reform to key articles of the Penal Code and provides a description of violence against women and its various forms:

Psychological abuse: any verbal aggression or other acts or words detrimental to human dignity or intended to intimidate or dominate a woman.

Physical abuse: any harmful act or abuse affecting the woman’s physical integrity or safety, or her life, such as beating, kicking, wounding, pushing, disfigurement, mutilation of certain parts of the body, confinement, torture, and homicide

Sexual abuse: any act or word intended by the perpetrator to subject a woman to his own sexual desires or to the sexual desires of others, through the use of coercion, deceit, pressure, or other means that are likely to weaken or undermine her will

Economic abuse: any act or omission likely to exploit women or deprive them of economic resources, whatever their origins, such as the deprivation of funds, wages, or income, the control of wages or income, and the prohibition to work or the coercion to work.

Despite the seriousness and complexity of the issue, many national and international studies primarily focus on the prevalence and the consequences of the phenomenon. Only a limited amount of attention is devoted to the context in which these acts of violence occur, and especially to the psychological profile of the victims. In fact, exposure to violence is a significant contributing factor to the development and exacerbation of mental health conditions. In parallel, existing mental health problems increase vulnerability to IPV, creating a vicious cycle that entraps victims and perpetuates abuse (Mazza et al. 2021). In theoretical models that explain the dynamics of relations in violent relationships, personality traits of victims are quoted as possible predictors of IPV (Mager et al. 2014).

Our research aimed to contribute to filling this gap in the literature and seeking to shed more light on the scourge of IPV in our cultural-specific context. It allows a particular focus on the emotional profile of women victims by assessing three constructs that have not been fully investigated so far: emotional dependency, alexithymia, and self-esteem. These constructs deserve special attention in order to develop targeted interventions and support systems aimed at improving victims’ mental health and overall well-being (Tangney et al. 2007).

To this end, we have used emotion-oriented scales to deepen the understanding of the most common form of IPV. Indeed, although psychological violence may not leave visible marks like other forms of violence, it often has a more profound impact due to the emotional and mental breakdown it causes in victims, a consequence that is still frequently overlooked and neglected (Kadir Shahar et al. 2020). Data from the literature show that several factors can contribute to the occurrence of this type of violence and can even increase its severity.

Emotional dependency in romantic relationships is considered a dysfunctional aspect of a personality trait characterized by a strong need for affective bonding (Ponce-Díaz et al. 2019) manifested by permanent and excessive contact from a partner for affection, love, attention, and closeness. Such relationships are distinguished by suffocating and highly unbalanced dynamics (Momeñe et al. 2022; Kemer et al. 2016; Izquiero Martinez and Gomez-Acosta 2013). Some authors have proposed a potential bidirectional association between emotional dependency and IPV, particularly in the context of maintaining the relationship in the presence of IPV (R. F. Bornstein 2006; Chronister 2007; Smith et al. 2013). This dependency fosters a close bond that makes it difficult, if not impossible, for the victimized woman to accept help and leave the violent relationship no matter how unhealthy it may be (Prud’homme 2011). This puts the victim at increased risk of experiencing and tolerating violence (Leemans and Loas 2016).

On the other side, alexithymia is a multidimensional personality trait marked by deficits in emotion processing and regulation, and verbal expression. Alexithymic individuals are characterized by engagement in dysfunctional interpersonal behaviors that lead to impairments in marital functioning (Gabriel et al. 2016; Epözdemir 2012), which may play an important role in the context of IPV (Kowal et al. 2020; Veggi et al. 2024). However, there is still debate as to whether alexithymia is either a risk factor for IPV or a consequence of trauma in this population, as victims may experience emotional numbness as a result of trauma (Craparo et al. 2014). To date, while alexithymia has been extensively studied in violent perpetrators, little research has established an association between IPV and alexithymia in victims and its impact on the onset of psychiatric morbidities in this group of women (Signorelli et al. 2020). Our study is one of the few to specifically examine the role of alexithymia in abused women, and cautiously supports the hypothesis that alexithymia may be a risk factor for IPV victimization.

According to Rosenberg (Rosenberg 1965), global self-esteem is an overall feeling of self-worth. Data from the literature indicate multi-faceted links between IPV and low self-esteem (Papadakaki et al. 2009; Cherrier et al. 2023; Bigizadeh et al. 2021; Güler et al. 2022; Dibacco 2017; Karakurt et al. 2014; El-Etreby et al. 2024; Costa and Gomes 2018).

Given all these considerations, the current study aimed to describe the sociodemographic, clinical, and relational profiles of female victims of IPV in Tunisia and to assess emotional abuse, emotional dependency, alexithymia, and self-esteem among these women who experienced assault.

2. Materials and Methods

Study design: This was a cross-sectional study, conducted between March and December of 2021, including women who experienced assault filing complaints for IPV and referred to psychiatric emergencies at Hédi Chaker Hospital in Sfax for medical expertise through a judicial requisition.

Study population: Our target population was Tunisian women aged 18 years and over who had filed a complaint for IPV, consulted a psychiatric examination on the basis of a court order, and had given their free and informed oral consent. We excluded from our study women with a major cognitive disorder that prevented them from understanding the questionnaire (deficit schizophrenia, intellectual disability, dementia, etc.) and women who were victims of violence other than IPV.

To ensure a representative sample of the Tunisian female population complaining of IPV, the minimum necessary sample size was 113 patients and was calculated based on a 5% margin of error, a 95% confidence interval, and an IPV prevalence of 25% declared to the official Tunisian authorities in 2017 (Klibi et al. 2022).

Study conduct: After consulting the expert psychiatrist who assessed the psychological harm inflicted by IPV, each participant was contacted by the one trained medical doctor (study author) and received explanations about the scientific purpose of this work and reassurance about their anonymity. They were asked for their consent to participate in this study. Participants’ partners were not present during the assessment.

The data were collected through individual medical visits, led by this study’s author, using a hetero questionnaire developed based on the literature and focused on the social, demographic, clinical, and relational characteristics of female victims of IPV, data on past and current incidents of IPV, and data related to the ongoing psychiatric consultation under judicial requisition. We also used four psychometric scales:

The Emotional Abuse Scale (EAS): This is a 28-item questionnaire developed by Neil Jacobson and John Gottman in 1998 (Jacobson et al. 1996). Each item is rated on a 4-point Likert-type scale (1, never; 2, rarely; 3, occasionally; and 4, very often). Total scores range from 28 (minimum) to 112 (maximum). If the score is between 73 and 94, women are considered victims of emotional abuse. The emotional abuse is considered severe if the score is above 95.

The Emotional Dependence Questionnaire (EDQ): This is a 20-item questionnaire assessing women’s emotionally dependent behavior toward men (Henderson and Cunningham 1993). Subjects were asked to respond to each item on a 7-point Likert-type scale indicating the degree of agreement or disagreement. Possible scores range from 20 (highly independent) to 140 (highly dependent), while the neutral level (undecided) is 80.

The 20-item version of the Toronto Alexithymia Scale (TAS-20): This is the most commonly used scale in alexithymia research (Michael Bagby et al. 1994; Taylor et al. 2000). Each item is rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). A subject is considered alexithymic with a threshold score of 61 or higher (El Abiddine et al. 2017). This scale yields three factors: (F1) difficulty identifying feelings (items 1, 3, 6, 7, 9, 13, and 14); (F2) difficulty describing feelings to others (items 2, 4, 11, 12, and 17); and (F3) externally oriented thinking (items 5, 8, 10, 15, 16, 18, 19, and 20). It was used in its validated Arabic version (El Abiddine et al. 2017).

The Rosenberg Self-Esteem Scale (RSES): This is the most widely used measure of global self-esteem in psychological research (Rosenberg 1965). It comprises 10 items measuring positive or negative perceptions of oneself, using a 4-point Likert scale (Robins et al. 2001). A score lower than 30 suggests low self-esteem.

The data entry and analysis were performed using the Statistical Package for Social Sciences (SPSS) software, version 26. We checked the normality of the distribution using the Kolmogorov–Smirnov test and the Shapiro–Wilk test. Female victims’ characteristics and survey responses were analyzed using descriptive statistics. Qualitative variables were expressed as percentages, while quantitative variables were presented as means (Ms) and standard deviations (SDs) or ranges. To compare two qualitative variables, we used the Chi-square test “χ²” or Fischer’s exact test. The Pearson correlation coefficient was used to study the association between two quantitative variables. All tests were two-tailed at a 95% confidence interval, and the p-value was considered significant if <0.05.

Ethical considerations: Authorization from the head of the psychiatric emergency department at Hedi Chaker Hospital in Sfax was granted before data collection. Patients were informed of the scientific aim of this study and the terms of participation. Their freedom to decide whether or not to take part in this study was clearly stated. The confidentiality of the data obtained, and the anonymity of the participants were respected. All the procedures performed in this study were in accordance with the ethical standards of the “Research Ethics Committee, Faculty of Medicine, University of Sfax, Tunisia” and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This research was approved by the above-mentioned committee (approval number 26/24).

3. Results

Of the 179 women we contacted during the study period and who met the inclusion criteria, 120 women agreed to participate in this study, while 59 declined. We achieved a response rate of around 67%.

3.1. Profile of Women Victims of Violence

The mean age of the 120 women who agreed to participate in this study was 37.27 years (SD = 8.227) with a range from 19 to 57 years. The majority of victims were unemployed (46.7%) and of urban origin (96.7%). All of the sociodemographic and clinical characteristics of the victims are summarized in

Table 1. Sociodemographic and clinical history characteristics of female victims of IPV.

	n	%
Age
-  18–25 years	8	6.7
-  26–35 years	49	40.8
-  36–45 years	38	31.7
-  >45 years	25	20.8
Occupational status
-  Unemployed	56	46.7
-  Daily workers	24	20
-  Employed	40	33.3
Socioeconomic level
-  Low	10	8.3
-  Middle to high	110	91.7
Geographical origin
-  Urban	116	96.7
-  Rural	4	3.3
Educational status
-  Illiterate	4	3.3
-  Primary	30	25
-  Secondary	41	34.2
-  University	45	37.5
Sources of income
-  Her own work	62	51.7
-  Spouse	32	26.7
-  Family assistance	21	17.5
-  Alimony	5	4.2
Conflicts with parents
-  Yes	10	8.3
-  No	110	91.7
Use of psychoactive substances
-  Tobacco	15	12.5
-  Alcohol	0	0
-  Cannabis	0	0
Regular religious practice
-  Yes	59	49.2
-  No	61	50.8
Personal history
-  Medical	51	42.5
-  Chirurgical	38	31.7
-  Psychiatric	23	19.2
-  Suicide attempts	18	15
-  Childhood abuse	12	10
-  Violence in a previous relationship	4	3.3
Family history
-  Psychiatric	9	7.5
-  Domestic violence	17	14.2

.

3.2. Relational Profile of Couple

The mean age difference between partners (men and women) was 6.22 ± 4.85 years. The level of education was lower in men in 42.5% of cases. The marriage was arranged in 58.3% of cases. The average duration of the marriage was 12.34 years, exceeding 10 years in 44.2% of cases. With regard to current marital status, 70% were still in a marital alliance among whom 15.9% were in legal separation (see

Table 2. Relational characteristics of the couple.

	n	%
Difference in education level between partners
-  Similar education levels	57	47.5
-  Men with a higher education level	12	10
-  Women with a higher education level	51	42.5
Type of marital engagement
-  Family arrangement	70	58.3
-  Romantic relationship	50	41.7
Lifestyle of the couple
-  At the marital home	51	42.5
-  At the in-law’s house	9	7.5
-  At the parental home	34	28.3
-  Alone in an independent household	26	21.7
Current marital status
-  Still married	84	70
-  Pending divorce	36	30
Marital duration
-  <5 years	24	20
-  5–10 years	43	35.8
-  >10 years	53	44.2
Children
-  Yes	112	93.3
-  No	8	6.7

). Marital conflicts had existed since the very beginning of the relationship in 91.7% of cases.

3.3. Data Related to the Incidents of Intimate Partner Violence

Almost all women surveyed (99.2%) reported the existence of at least one previous incident of IPV (see

Table 3. Data related to incidents of intimate partner violence.

	n	%
Previous incident(s) of IPV
Previous incidents of IPV
-  Yes	119	99.2
-  No	1	0.8
Early onset of IPV *
-  Yes	100	91.7
-  No	10	8.3
Forms
-  Psychological	119	99.2
-  Physical	105	88.3
-  Financial	52	43.3
-  Sexual	17	14.2
Daily frequency
-  Yes	72	60.5
-  No	48	39.5
Revelation of violence after the first incident
-  Yes	4	3.4
-  No	116	96.6
Previous legal complaint
-  Yes	39	32.8
-  No	81	67.2
Current incidents of IPV
-  Forms
-  Psychological	120	100
-  Physical	105	88.3
-  Economic	19	15.8
-  Sexual	5	4.2
Circumstances or trigger factors
-  Financial problems	40	33.3
-  Substance abuse by the aggressor	30	25
-  Family issues	26	21.7
-  Legal separation	24	20
-  Infidelity and jealousy	18	15
-  Recent unemployment of the partner	9	7.5
-  Not identified by the victim	3	2.5
-  Sexual problems	2	1.7
-  Decompensation of a mental illness in the aggressor	1	0.8
Location of occurrence
-  Marital home	89	74.2
-  Outside of the marital home	31	25.8
Presence of witnesses
-  Yes	86	76.8
-  No	34	23.2
Repercussions
-  Psychological	120	100
-  Familial	116	96.7
-  Social	77	64.2
-  Physical	59	49.2
-  Professional	42	35
Victims’ attitudes
-  Filing a legal complaint	120	100
-  Revealing and seeking help from the surroundings	91	75.8
-  Leaving the marital home	82	68.3
-  Seeking a divorce	67	55.8

IPV: Intimate partner violence; early onset * (before marriage or during the first year after marriage).

). Almost a third of these women (n = 39; 32.5%) had reported that the same causes and circumstances triggered or facilitated IPV each time. Among the women who experienced assault, 18.5% (n = 22) reported that they had chosen not to disclose the violence to those around them, out of fear of being assaulted again (54.5%).

For the current incident prompting the current legal complaint, 74.2% of women had simultaneously endured two forms of IPV and 16.7% had experienced three forms. All surveyed women (100%) had reported psychological violence. The most frequent trigger factors of this violence were financial distress (33.3%) followed by substance abuse by the aggressor (25%). The characteristics of the current incidents of IPV are presented in Table 3.

3.4. Emotional Abuse

Referring to the EAS scale, almost all surveyed women (n = 113; 94.2%) were victims of emotional abuse (scores ≥ 73). This violence was severe in 75.8% of women (scores ≥ 95).

Higher EAS scores were significantly associated with the age group of 26–35 years (p = 0.012), being still married without any divorce pending (p = 0.024), marriage duration exceeding 10 years (p = 0.048), and daily violence (p = 0.005).

3.5. Data Pertaining to the Psychiatric Evaluation Conducted under Judicial Requisition

The current evaluation represents the first psychiatric consultation under judicial requisition in 54.2% of surveyed abused women. An evaluation by a forensic specialist was associated with psychiatric evaluation in 72.5% of cases. The delay between the consultation and the assault ranged from zero to 180 days, with an average of 12.31 days. In 70% of cases, the consultation took place within a week of the assault.

Regarding the psychological assessment, all women surveyed exhibited symptoms related to the psychological impact of the violence they had suffered. These various symptoms included sleep disturbances (85%), anxiety symptoms (81.7%), depressive symptoms (38.3%), and avoidance and reliving symptoms (11.7%). Psychiatric follow-up was deemed necessary in 40% of cases, while 10.8% had been referred to the psychiatric emergency department for immediate care.

3.6. Emotional Dependency

Regarding emotional dependency, the mean score of the QDE was 79.38 (SD = 14.8), indicating a mild level of dependency. More than a third of women surveyed (38.3%, n = 46) were emotionally dependent on their spouses (score range of 80–140).

Higher QDE scores were correlated with the age group of 26–35 years (p = 0.016), absence of childhood violence (p = 0.028), tobacco consumption (p = 0.049), early onset of IPV (p < 0.001), and a personal history of psychiatric issues (p = 0.02).

3.7. Alexithymia

The mean score of TAS-20 was 63.33 (SD = 8.920) with a range from 45 to 88. According to this scale, 59.2% of women were alexithymic (n = 71). The average scores for the different factors, F1, F2, and F3, were 12.9 (SD = 4.75), 13.69 (SD = 3.42), and 30.57 (SD = 2.90), respectively.

The presence of alexithymia was significantly associated with having children (p = 0.008), the absence of suicide attempts (p = 0.005), and a longer duration of marriage (p = 0.011).

3.8. Self-Esteem

The mean score on the RSES was 28.68 (SD = 2.87). Among the women surveyed, 83.3% (n = 100) had low self-esteem.

Low self-esteem was correlated with older age (p = 0.002), longer marriage duration (p = 0.012), conflicts with parents (p = 0.03), attempted suicide (p = 0.024), significant social repercussions of IPV (p = 0.008), and anxiety symptoms (p = 0.011).

3.9. Associations between Different Measuring Instruments

The presence of alexithymia among the victims was correlated with emotional dependency on their husbands (p = 0.004) according to the categorical approach (see

Table 4. Correlations between the different scales.

		TAS-20			EAS			EDQ			ESES
		A+	A−	p	EAS+	EAS−	p	ED+	ED−	p	Low	High	p
TAS-20	A+	_	_	_	68%	4.2%	0.442	50%	77.5%	0.004	84.5%	15.5%	0.678
	A-	_	_		91.8%	8.2%		50%	22.5%		81.6%	18.4%
EAS	EAS+	_	_	_	_	_	_	92.5%	97.5%	0.422	82.3%	17.7%	0.599
	EAS−	_	_		_	_		7.5%	2.5%		100%	0%
EDQ	ED+	_	_	_	_	_	_	_	_	_	81.3%	18.8%	0.386
	ED-	_	_		_	_		_	_		87.5%	12.5%
ESES	Low	_	_	_	_	_	_	_	_	_	_	_	_
	High	_	_		_	_		_	_		_	_

TAS 20: Toronto Alexithymia Scale; EAS: Emotional Abuse Scale; EDQ: Emotional Dependence Questionnaire; ESES: Rosenberg Self-Esteem Scale; A⁺: alexithymic; A⁻: not alexithymic; ED⁺: emotional dependency; ED⁻: no emotional dependency; EAS⁺: emotional abuse; and EAS⁻: no emotional abuse.

).

According to the dimensional approach, only emotional abuse scores were positively correlated with emotional dependency scores (p = 0.026; rho = 0.204).

4. Discussion

The response rate to our survey was around 67%. Other studies (Boyer 2017; Lamy et al. 2009) also reported high initial refusal rates, likely due to the early assessment of women still under psychological stress. This type of survey may be perceived as delicate and intrusive, with privacy concerns. Some women may feel insecure about disclosing violent acts to an unknown third party for fear of losing anonymity, facing reprisals, or having their spouse identified as the aggressor. Additionally, some participants may have experienced high levels of marital control, leading them to withdraw from this study. In this context, it is challenging to assess the psychological impact of IPV on the same victim on two consecutive occasions and by two different investigators.

4.1. Participants’ Profile

The sociodemographic and clinical characteristics of victims of IPV show that there is no typical profile. Based on the existing literature, women from diverse socioeconomic backgrounds can be victims of IPV. Serious psychiatric or somatic sequelae are more common in survivors of IPV than in the general population (Popa-Velea et al. 2020; Kadir Shahar et al. 2020). Our findings align closely with a recent systematic review of IPV risk factors in Arab countries, which revealed a complex structure of overlapping psychological, demographic, societal, and legal factors (Mojahed et al. 2022)

Nevertheless, some characteristics of the couple have been found to be more important in initiating and reinforcing violence. Several studies have found that women with higher social status may be at increased risk of IPV, possibly because they are more likely to challenge male authority (Mojahed et al. 2022). An increasing age difference between the victim and the perpetrator, as found in our population, is considered a factor that could facilitate IPV by giving the perpetrator a dominant position within the couple (Balci and Ayranci 2005). In addition, other authors have confirmed that the difference in educational level is the main factor that could increase the risk of any type of IPV by generating frustration among men regarding their belief in their socially dominant role (Klibi et al. 2022; Abramsky et al. 2011).

In terms of the characteristics of IPV incidents, our study shows, consistent with prior literature, that psychological violence is the most common, followed by physical violence, then economic violence, and finally sexual violence (Argentel et al. 2021; Yalch and Rickman 2021). Moreover, as other studies have shown (OFFICE NATIONAL DE LA FAMILLE ET DE LA POPULATION and AGENCE ESPAGNOLE DE COOPCOOPÉ 2010; Klibi et al. 2022), victims of IPV generally do not experience only one form of abuse. The authors have clearly demonstrated that different forms of violence are, often, interrelated, as they can occur, persist, intensify, and cease simultaneously or independently. The variety and the accumulation of the different types of violence are used to gain and maintain power and control over the partner, and thus appear to be the most detrimental to women’s overall mental health (Ali et al. 2013; Zakar et al. 2013; Patard et al. 2020).

Moreover, IPV is a widespread issue that crosses cultural boundaries, affecting both Western and Eastern societies, although the contextual factors may differ. Its manifestations and the societal responses to it differ significantly across cultures, shaped by local norms, laws, and values. In Eastern cultures, IPV is frequently linked to patriarchal structures, where traditional gender roles and societal norms dictate male dominance and the acceptable use of violence as a means of conflict resolution. Legal frameworks in many of these societies often reinforce this dynamic, favoring male authority and limiting women’s rights, thus perpetuating the cycle of violence (Abdel-Salam et al. 2022; Elghossain et al. 2019). Conversely, in Western societies, IPV is more often associated with family breakdown and underlying aggressive behaviors. It is often examined from the perspective of mental health and social issues, with an emphasis on the impact of such violence on family dynamics and individual well-being (Karamitanha et al. 2024; M. E. White and Satyen 2015).

4.2. Emotional Abuse

In order to gain a more objective understanding of the most common form of violence found in our population, we elected to assess psychological abuse, using a psychometric measurement tool (EAS). We confirmed that 94.1% of the women surveyed had experienced emotional abuse. Of these women, 75.8% were seriously assaulted. Worldwide, the data are consistent with our findings (Trevillion et al. 2012; Mazza et al. 2021).

Data from the literature, as well as our own, show that a number of factors can contribute to the occurrence of this type of violence and can even increase its severity. Firstly, we found that living in close proximity to the aggressor during periods of conflict may increase the risk of experiencing more emotional abuse (p = 0.011). This is a crucial component of the perpetrator’s strategy to maintain authority and control over their partners. Furthermore, the presence of this type of violence was associated with daily repetition of violent incidents (p < 10⁻³), especially those of a physical nature (p < 10⁻³). According to some authors (Hegarty et al. 2013), severe physical abuse is systematically associated with psychological mistreatment maltreatment. The consequences are frequent, with long-term deterioration of mental health and quality of life for victims. Finally, emotional abuse was associated with significant social impact (p = 0.03). As a psychological manipulation tactic used by the abuser, some women find themselves increasingly isolated without even realizing it. This is a means used by the abuser to increase his level of control and create a vacuum around his victim that can exacerbate the experience of violence and hinder his strategies for dealing with the violence or leaving the relationship (Akyazi et al. 2018; Costa and Gomes 2018).

4.3. Emotional Dependency

The average total score of the QDE was 79.38, indicating a mild level of emotional dependency of these women on their partners. Our results were consistent with the study conducted by St-Arnaud in 2017 among women victims of IPV admitted to shelters (St-Arnaud 2017). More recent studies have mentioned a greater emotional dependency in people experiencing IPV (Momeñe et al. 2022; Martín and Moral 2019).

Myriad factors have been linked to this emotional dependency in the context of IPV. There is some support in the prior literature for a negative association between emotional dependency on men and age (Henderson and Cunningham 1993). Consistent with our results, younger women, particularly the age group between 26 and 35 years, were correlated with emotional dependency (p = 0.016). Indeed, the socialization of girls in Eastern societies leads them to perceive having a man to share their life with as the single biggest determinant of their status and life satisfaction. These cultural and social beliefs about the sanctity of marital life could contribute to the development of high levels of pathological dependency on male partners, making women vulnerable and easy targets for IPV perpetrators, particularly since they are younger and have limited life experience (Henderson and Cunningham 1993).

Further data suggest that the likelihood of the abused woman leaving the relationship is reduced by high levels of emotional dependence (Bornstein 2006). This hypothesis could be confirmed in our population, given the low rate of filing for divorce despite the early onset of conflict even before marriage (p < 10⁻³). In fact, the fear of living alone and not being able to find another partner, and the priority given to the relationship, above all else, are indicators of pathological dependency that could explain submissive and subordinate behaviors and the tolerance of abusive marital situations (Kemer et al. 2016).

In accordance with the literature, a significant correlation was found between emotional dependency and women’s psychiatric history (p = 0.02). On the one hand, pervasive and debilitating emotional dependence may indicate the presence of borderline or dependent personality disorder in which the woman fears separation, feels uncomfortable and helpless when alone, and has an excessive need to create and maintain nurturing relationships. These women view their partner as an object to fulfill their needs and are willing to engage in behavioral strategies that are aimed at accentuating submission and vulnerability, such as supplication and integration (Henderson and Cunningham 1993; Bornstein 2012). On the other hand, dependency on people, much like dependency on substances, could also be a way of adapting to suffering or loss, as well as a way of masking depressive affect and repairing self-esteem impaired by feelings of helplessness and inefficacy (St-Arnaud 2017). Tobacco use, which was correlated with high emotional dependency in our study (p = 0.049), could be used to alleviate this emotional distress.

Furthermore, in our study, we found that an absence of a history of childhood trauma was correlated with emotional dependency (p = 0.028). This result is at odds with the prevailing literature, which typically demonstrates positive correlations showing that having a history of childhood victimization or exposure to family violence is one of the factors contributing to IPV in adulthood (Shechory 2013; Speranza et al. 2022). These findings support the idea that women victims of IPV are more likely to have attachment problems, which are associated with early affective deficiencies that they attempt to cover or compensate for in maladaptive ways through their partner (Estévez et al. 2018; Speranza et al. 2022; González-Jiménez and Hernández-Romera 2014; Momeñe et al. 2022). Our contrasting results can be explained by the self-reported methodology used in this research and the low percentage of childhood abuse reported by our victims (10%) compared to those reported in the literature (51%) (Speranza et al. 2022).

Finally, our study found a significant positive correlation between emotional dependence and emotional abuse (p = 0.026). Our results align with the existing literature, indicating that women with higher levels of emotional dependence are more vulnerable to IPV, particularly psychological violence (Castillo-Gonzáles et al. 2024). These women struggle to establish healthy boundaries and tend to tolerate abusive behavior in hopes of preserving the relationship (Leemans and Loas 2016; Castillo-Gonzáles et al. 2024). A strong emotional bond with the partner causes these women to reinterpret and downplay the emotional abuse. This makes stopping it seem less urgent and may make them more likely targets for additional psychological abuse that further weakens their ability to leave.

4.4. Alexithymia

Based on the TAS-20 scale, it was found that 59.2% of the women met the criteria for alexithymia, suggesting a high incidence of affective regulation difficulties in IPV victims. Our findings were in line with the literature showing that victims of IPV are less aware of their own and others’ emotional experiences and have more difficulty verbalizing their emotions (Pietri and Bonnet 2017).

In our study, alexithymia was correlated with an absence of attempted suicide (p = 0.005). This finding is supported by literature data showing that there is no significant association between alexithymia and suicidality (Taiminen et al. 1996; Iskric et al. 2020). This may be because women with higher levels of alexithymia are likely to have more difficulty understanding and explaining their own distress associated with experiences of violence. As a result, they may not experience negative feelings that could even lead to emotional distress, such as a desire to escape or even a death wish.

Furthermore, alexithymia would be an adaptive process that enables the subject to temporarily or permanently disconnect from intense emotional activation when confronted with a stressful situation. In addition, as a traumatic event, this violence is said to have an anesthetic effect on emotions, leading to a state of sideration that inhibits the victim’s ability to act and allows the violence to recur over time (Pietri and Bonnet 2017). Thus, in our study, we found that the more long-lasting the marriage, the more alexithymic the women became (p = 0.01).

The association between having children and the presence of alexithymia (p = 0.008) was also found in our study. This may be due to the fact that a larger family would place greater burdens and responsibilities on the woman, causing her to be overwhelmed with household and child-rearing responsibilities as well as marital responsibilities, leading to poorer verbal communication and more difficulty in understanding and explaining her own stress, thus leading her to be more submissive and permissive in abusive marital situations.

Another key finding of the present study was the strong correlation between emotional dependence and alexithymia (p = 0.004). This relationship highlights a critical dynamic in the psychological profiles of the victims. Alexithymia, a global impairment in emotional processing, makes it difficult for victims to recognize and express their emotional states, which can increase their dependence on partners for emotional validation (Karukivi 2014; Lumley et al. 2007). In abusive relationships, perpetrators take advantage of this dependency, reinforcing the victims’ reliance on them and perpetuating the cycle of abuse. Victims with alexithymia may struggle to identify abusive behaviors as harmful, and their dependence on the abuser can prevent them from seeking help or attempting to leave the relationship (Lumley et al. 2007; Guilbaud et al. 2002). This dependency is further exacerbated by low self-esteem and insecure attachment styles, which are common among IPV victims (Craparo et al. 2014). Women with insecure attachment styles lack a sense of self-cohesion and the ability to autonomously regulate their emotions. They perceive their relationships as unstable and uncertain and believe that their self-esteem depends on unpredictable conditions set by others (Giannini et al. 2011).

4.5. Self-Esteem

In our study, based on the RSES, 83.3% of the surveyed women who experienced assault had low self-esteem. This finding is consistent with many studies that support low self-esteem as a consequence of IPV, but also as an initiating and sustaining cause of abusive relationships and as a mediator of the severity of outcomes (Papadakaki et al. 2009; Cherrier et al. 2023; Bigizadeh et al. 2021; Güler et al. 2022; Dibacco 2017; Karakurt et al. 2014; El-Etreby et al. 2024; Costa and Gomes 2018). It is thus expected that self-esteem will be negatively associated with mental problems and moderate the relation between the woman’s experience of IPV and psychological distress (Matheson et al. 2015; Nathanson et al. 2012; Costa and Gomes 2018; Tariq 2013). The damaged self-esteem developed by the women surveyed in the current study was associated with several mental health outcomes, including anxiety symptoms (p = 0.011), suicidal ideation (p = 0.024), and social isolation (p = 0.008), as shown in the current study. These can be caused by the feelings of helplessness and worthlessness they experience, the isolation they often suffer, and the constant criticism and attacks on their self-identity and self-worth they receive from their aggressor (Quintero et al. 2023).

In our context, the quality of social support has been shown to moderate the relationship between self-esteem and IPV. As a manipulation tactic used by the abuser, some women find themselves increasingly isolated by their partners without even realizing it. This is a means used by the aggressor to increase his level of control and create a vacuum around his victim, which in turn prevents her from feeling safe, lowers her self-esteem, and increases psychological symptoms (Costa and Gomes 2018), which minimizes her chances of fighting back.

Moreover, the lack of a supportive environment further exacerbates the vulnerability of these victimized women. Our study just supports this concept and shows a significant correlation between low self-esteem and the presence of conflicts with parents (p = 0.03). In fact, the development and regulation of self-esteem are shaped by life experiences within the social setting (Cherrier et al. 2023; Gómez et al. 2019). Individuals with low self-esteem often feel worthless and devalued as a result of childhood rejection, criticism, and conflicts with their parents (Rosen 1991).

All of this distress often allows the abuse to continue and intensify in long-term marriages, where emotional and material dependency is greater (Tariq 2013; Güler et al. 2022; Papadakaki et al. 2009). The longer women stay in an abusive relationship, the lower their self-esteem (Güler et al. 2022; Tariq 2013). This relationship was confirmed in our study (p = 0.012).

4.6. Limitations

To the best of our knowledge, our study is the first to assess simultaneously emotional abuse and dependency, alexithymia, and self-esteem among female victims of IPV in Tunisia.

However, some limitations of this study should be taken into account when interpreting the results. The main limitation is the cross-sectional nature of our study, which while having the advantage of being easy to execute, limits the ability to make causal inferences about the relationships found in this study. Furthermore, this study was carried out on women referred to the psychiatric emergency department of the Hedi Chaker Hospital in Sfax. While these women represent a representative sample of Tunisian women filing complaints for IPV, it cannot fully reflect the extent and all aspects of this phenomenon. The monocentric and regional nature of the sample limits the scope of our results.

5. Conclusions and Implications for Practice

IPV is the most widespread form of violence against women in the world and in Tunisia. It is a phenomenon that continues to merit special attention, not only because of the physical damage it causes but also because of its countless psychological repercussions.

In summary, this study expands the knowledge about IPV in our specific understudied population. As such, we turned our attention to a broad but specific assessment of the multifactorial nature of male violence, which highlights a complex and dynamic interaction of individual, relational, and sociocultural factors. Our research has yielded a number of interesting findings mainly focused on the assessment of the relational and emotional profile of female IPV victims, which has yet to be fully explored and taken into account. Indeed, the majority of women surveyed were victims of emotional abuse (94.1%). More than a third of them (38.3%) were emotionally dependent on their spouses and more than half (59.2%) were alexithymic. Low self-esteem was identified in 83.3% of cases. Emotional dependency was associated with both emotional abuse and alexithymia.

In this context, we can suggest that not only is the emotional vulnerability of female victims of IPV a sensitive indicator of IPV revictimization but also that the negative impact of victimization experiences on women’s capacities for emotional regulation may be cumulative. These women have more difficulty managing their distress and coping with the violence.

The results of this study can have important implications for designing both prevention programs and effective interventions for victims of IPV. More psychoeducation and awareness of non-physical forms of abuse may break the silence and be particularly helpful in reducing psychological distress in this population. In addition, it is critical to implement psychological interventions for IPV victims that prioritize emotion regulation, self-affirmation, and empowerment counseling in order to improve the level of emotional independence and relational decision-making (Craparo et al. 2014; Cameron et al. 2014).

Providing legal assistance and advocating for stronger protective laws is also essential. The Tunisian Organic law N° 2017-58 on the elimination of violence against women and children should be more widely known and applied, as should the subject of women’s rights, which should be integrated into educational programs.