Psychopathology in Women: Incorporating Gender Perspective into Descriptive Psychopathology

This book examines sex and gender differences in the causes and expression of medical conditions, including mental health disorders.

Sex differences are variations attributable to individual reproductive organs and the XX or XY chromosomal complement. Gender differences are variations that result from biological sex as well as individual self-representation which include psychological, behavioural, and social consequences of an individual’s perceived gender.

Gender is still a neglected field in psychopathology, and gender differences is often incorrectly used as a synonym of sex differences. A reconsideration of the definition of gender, as the term that subsumes masculinity and femininity, could shed some light on this misperception and could have an effect in the study of health and disease.

This second edition of Psychopathology clarifies the anthropological, cultural and social aspects of gender and their impact on mental health disorders. It focuses ongender perspective as a paradigm not only in psychopathology but also in mental health disorders. As such it promotes open mindedness in the definition and perception of symptoms, as well as assumptions about those symptoms, and raises awareness of mental health.

• Language: English
• Publisher: Springer
• Release date: Jul 15, 2019
• ISBN: 9783030151799

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Editor

Margarita Sáenz-Herrero

Psychopathology in WomenIncorporating Gender Perspective into Descriptive Psychopathology2nd ed. 2019

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Editor

Margarita Sáenz-Herrero

Cruces University Hospital, University of the Basque Country, Barakaldo, Vizcaya, Spain

ISBN 978-3-030-15178-2e-ISBN 978-3-030-15179-9

https://doi.org/10.1007/978-3-030-15179-9

© Springer Nature Switzerland AG 2019

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Introduction

Marta B. Rondon

I am honored to write the Introduction to this beautifully edited second edition of Psychopathology and Gender. Prof. Margarita Sáenz-Herrero and her team have successfully collated a comprehensive array of articles that elucidate the difficult and not well-known gender-related and gender-dependent differences in the epidemiology, course, and prognosis of mental disorders.

Gender, which is the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men or girls and women, [1] has been recognized as a powerful social determinant of health. The power relations between the genders are at the root of gender inequality. As Sen et al. put it, gender inequality determines whether people’s health needs are acknowledged, whether they have voice or a modicum of control over their lives and health, whether they can realize their rights [2].

A gender perspective looks at the impact of gender and gender relation on people’s opportunities, social roles, and interactions. A perspective that acknowledges and analyzes the impact of the uneven distribution of resources and unequal access to services (such as education and healthcare) is indispensable for clear conceptualization of the current status of women’s (and girls’) health [3]. Gender relations determine access to resources and to power, with pervasive implications for everyday life, including the way technology and science are advanced and who has access to the development, the control, and the enjoyment of such advances.

A central self-evident concern is women’s lack of control over resources, and even over her own body: in most medical, health (including mental health), and prevention issues related to women the core problem is male-female power relations—including physical, psychological, and sexual violence—and not the lack or inadequacy of services, technology, or information [4].

Depression is the second cause of years lived with disability in the Western Hemisphere [5]. Because it is recognized as a disease that afflicts women twice as often as men, services to recognize and treat it do not receive the highest priority in terms of budgetary allocation.

The distribution of mental disorders in the European Union shows that in most countries women suffer more from lifetime mental health disorders than men, and that this difference is higher in the Southern European countries. Income however is not related to a higher prevalence of mental health disorders, but age is and so is family composition. Married men show fewer mental health problems, but widowed and divorced women have the higher risk among females. Distress is more common in women than in men, but the differences are small in Northern European countries, as well as in Latvia and Slovakia [6]. What do they have in common? They all belong to Group 1 of the Gender Inequities Index (except Latvia). Group 1 comprises countries with high equality in HDI achievements between women and men (absolute deviation of less than 2.5 percent) [7].

Clearly, women’s health, and in our discussion mental health, needs to be appraised and understood in terms of the patriarchist nature of our societies, as Doyal posited in 1994 [8].

Literature on health sciences has a role mostly in health science education and research. This volume will certainly make a great contribution to diminish the sexist orientation of medical training. Gaps and biases have been described in undergraduate, graduate, and continuing education as well as in research.

The biological determinism that reigns in undergraduate medical education, even in a context where most students are women, has precluded awareness and discussion of the social determinants of health (one of which is gender) [9], and the curriculum in general does not address women’s health concerns from a comprehensive perspective: maternal mortality—preventable death—is still a major cause of premature death and important issues as human rights, legislation to protect women from violence, or ethical issues arising from new reproductive technologies are not included.

There are many problems with the choice of topics for research and the barriers for women to advance in academic careers where published research is an integral important expected outcome. In psychopharmacology, even as perinatal depressive disorders are recognized and frequent and powerful determinants of the future welfare of both mother and child, the management is done with scant evidence as no clinical trials are conducted in pregnant women. This is a very serious issue.

Gender-sensitive care is well informed and considers the asymmetrical power relations the woman comes from and does not shy away from looking at the probable violence she endures and considering its on her well-being [10]. It also acknowledges that the practitioner also plays a role in widening the power gap or narrowing it to allow the woman to become a partner in her care. This requires that the user receive all the information that she needs to feel safe and confident.

This book contributes valuable state-of-the-art information about sex and gender as multidimensional concepts; corporality: how important the body, body image, and its distortions are for women; the interface between mind and hormones and the disorders related to the periods of hormonal change; how gender introduces nuances in the most common mental disorders; a very exciting chapter on psychopathology, art, and gender; and a discussion of gender bias in research.

The quality of the contributions is assured by the first-rate choice of authors, who are well-known researchers, academics, and practitioners from various parts of the world. I am sure this editorial effort will bring a lot of intellectual pleasure to the reader.

References

1.

American Psychological Association. Answers to your questions about transgender people, gender identity, and gender expression. 2011.  http://​www.​apa.​org/​topics/​lgbt/​transgender.​aspx .

2.

Sen G, Ostlin P. Unequal, unfair, ineffective and inefficient gender inequity in health: why it exists and how we can change it. Final Report to the WHO Commission on Social Determinants of Health September 2007 Women and Gender Equity Knowledge Network, p. 12.

3.

Rondon MB. A gender perspective is fundamental to improve women's health. J Women’s Health. 2010;(11):1949–50. Epub Sep 16, 2010. https://doi.org/10.1089=jwh.2010.2402.

4.

Fee E, Krieger N, editors. Women’s health, politics, and power: essays on sex/gender, medicine, and public health. New York: Baywood Publishing; 1994.

5.

Murray JL, Lopez AD. Measuring the global burden of disease. N Engl J Med. 2013;369:448–57. https://​doi.​org/​10.​1056/​NEJMra1201534

6.

World Mental Health Surveys Initiative (WMH-EU) Mental health in Europe: a gender perspective. http://​www.​eu-wmh.​org/​PDF/​FactSheet_​Gender.​pdf .

7.

United Nations Development Program. Human development reports. Table 4: Gender Development Index at http://​hdr.​undp.​org/​en/​composite/​GDI .

8.

Doyal L. Women, health, and the sexual division of labour: a case study of the women’s health movement in Britain. In: Fee E, Krieger N, editors. Women’s health, politics, and power: essays on sex/gender, medicine, and public health. New York: Baywood Publishing; 1994.

9.

Johnson J, Stewart DE. DSM-V: toward a gender sensitive approach to psychiatric diagnosis. Arch Womens Ment Health. 2010;13(1):17–9. https://doi.org/10.1007/s00737-009-0115-0.

10.

From Marianism to Terrorism: the many faces of violence against women in Latin America. Arch Womens Ment Health. 2003;6:157–63.

Contents

Part I General Aspects

1 Women Mental Health All over the World:​ Sociopolitical Aspects of Gender Discrimination and Violence:​ Immigration and Transnational Motherhood 3

Magdalena Marino and Kristina Jausoro

2 What Is Human Resilience and Why Does It Matter?​ 27

Paula Silva-Villanueva

3 Intimate Partner Violence Against Women:​ Impact on Mental Health 55

Andrés Felipe Correa Palacio, Elisa Delgado Fuente, Rocío Paricio del Castillo and Cristina Polo Usaola

4 Sexual Violence:​ Effects on Women’s Identity and Mental Health 81

Adela San Vicente Cano, Marta Niño-Laina, Sandra Muñoz Sánchez and Cristina Polo-Usaola

5 Traumatic Life Events and High Risk for the Development of Psychopathology 109

María Recio-Barbero, Margarita Sáenz-Herrero, Paloma Navarro and Inmaculada Hurtado

Part II Sex and Gender as a Multidimensional Concept

6 Improving Our Science in Research with Sex- and Gender-Based Analysis 139

Maria Haarmans

7 Transgenderism and Mental Health from a Non-pathologizing Perspective 169

Marina De La Hermosa and Elvire Agossou

8 Gender and Psychological Differences:​ Gender and Subjectivity 189

María Dolores Avia and Mª. Luisa Sánchez-Bernardos

9 Self-Identity and Gender Differences 207

Miguel Angel González-Torres and Aranzazu Fernandez-Rivas

10 Psychosexual Development, Intersex States, and Sexual Dysfunctions 225

Rafael Segarra-Echebarría, Clara Isern-Tena, Silvia Cañas-Jiménez and Gabriela González-Rodriguez

Part III Gender and Psychopathology

11 Gender, Corporality, and Body Image 265

Margarita Sáenz-Herrero, Janire Cabezas-Garduño and Cristina Díez-Alegría Galvez

12 Body and Hysteria:​ Dissociated Body 295

Agueda Rojo-Pantoja

13 Dysmorphophobia:​ From Neuroticism to Psychoticism 315

María Recio-Barbero, Margarita Sáenz-Herrero, Batirtze Artaraz-Ocerinjauregui, Leire Celaya-Viguera and Eider Zuaitz-Iztueta

14 Eating Disorders 337

Margarita Sáenz-Herrero, Sara Fuertes-Soriano and Mayte López-Atanes

15 Desire and Submission 377

Miguel Ángel González-Torres and Aranzazu Fernandez-Rivas

16 Life Instinct and Gender 391

Olatz Napal-Fernandez

17 Use, Misuse and Gender Differences 433

Carmen Meneses and Iñaki Markez

18 Everything You Always Wanted to Know About Sex (and Gender) in Psychosis But Were Afraid to Ask:​ A Narrative Review 453

Maria Haarmans

Part IV Mental Health Disorders Related to Hormonal Aspects

19 Adolescent Depression 483

Sandra Gómez-Vallejo, Beatriz Paya-Gonzalez, Ernesto J. Verdura Vizcaino and Emma Noval-Aldaco

20 Premenstrual Experience, Premenstrual Syndrome, and Dysphoric Disorder 495

Margarita Sáenz-Herrero, Aida Sanchez-Palacios, Miriam Santamaria and Irantzu Lago-Santos

21 Abortion and Mental Health 525

Marta B. Rondon

22 Pregnancy Depression from a Gender Perspective 533

Mayte Martinez-Cengotitabengoa, Maria Jose Diaz-Gutierrez, Araminta-Elizabeth Peters-Corbett and Monica Martínez-Cengotitabengoa

23 Perinatal Depression 555

Carmen Martín-Requena, Saioa López-Zurbano, Iñaki Zorrilla-Martínez, Amaia Ugarte-Ugarte and Miryam Fernández-Hernandez

24 Puerperal Psychosis 581

Jaime del Corral Serrano

25 Psychological Symptoms and Treatment in the Menopause 595

Sara Barbeito, Patricia Vega and Sonia Ruiz de Azúa

Part V Gender in Psychiatric Disorders

26 Affective Disorders and Gender Differences 611

Patricia Pérez Martinez de Arrieta and Jon Gaviña Arenaza

27 Anxiety Disorders 639

Margarita Sáenz-Herrero, Álvar Peña-Rotella, Ane Eizaguirre-Garcia and Karim Haidar

28 Gender Differences in Posttraumatic Stress Disorder 671

Ana Villamor-García and Estibaliz Sáez de Adana

29 Gender and First Psychotic Episodes in Adolescence 701

Álvaro Andreu, Maria Juncal Ruiz, Ernesto José Verdura Vizcaino and Beatriz Payá-González

30 Schizophrenia and Gender 715

Ana Isabel Cano-Baena, Laura García-Ayala, Marta Zubía-Martín, Iñaki Zorrilla-Martínez and Ana González-Pinto Arrillaga

31 Gender Differences in Bipolar Disorder 739

Saioa López-Zurbano and Ana González-Pinto

32 Mixed Forms in Bipolar Disorder and Relation to Gender 765

Ana González-Pinto, Maddi Laborde Zufiaurre, Beatriz González Hernández, Purificación López Peña, Ana Isabel Cano and Saioa López-Zurbano

33 Borderline Personality Spectrum 783

Olatz Napal-Fernández

34 Somatoform and Factitious Disorders 813

Julia García-Albea, Pedro García-Parajuá and Marta Navas-Tejedor

35 Pathological Gambling:​ Clinical Gender Differences 825

Itxaso González-Ortega, Enrique Echeburúa, Paz de Corral and Rocío Polo-López

Part VI Psychopathology, Art, and Gender

36 Art Therapy and Gender 841

Belén Sanz-Aránguez Ávila and María del Río Diéguez

Part VII Gender Bias in Research. How Does It affect to Mental Health?

37 Gender Bias in Research:​ How Does It Affect Mental Health?​ 865

Maria Recio-Barbero and Isidro Pérez-Fernandez

About the Editor

Margarita Sáenz-Herrero

was awarded a degree in medicine at the University of Valladolid. She received her PhD in medicine in 2004 from Complutense University in Madrid. She is a specialist in Psychoanalytic Psychotherapy at Comillas University and a specialist in Integrative Psychotherapy at Alcalá University. In 2009, she received a Specialization in Forensic Psychiatry.

She has been an Associate Professor at Complutense University until 2005 where she taught undergraduate and postgraduate students. Since 2009, she is teaching medical students at Basque University in Vitoria. She has also been a tutor of psychiatric residents since 2009 at Alava University Hospital, and she is currently tutoring medical residents in psychiatry at Cruces University Hospital in Bilbao.

She has worked with Professor López-Ibor at San Carlos University Hospital in Madrid. During this period she received a grant to attend the Eating Disorders Program with Professor Katherine Halmi at New York Hospital, USA.

She has worked in different hospitals such as Sant Boi Psychiatric Hospital in Barcelona and Alava University Hospital until 2015 when she started working at Cruces University Hospital in Bilbao.

As an author, she has published more than 20 international posters and communications both nationally and internationally. She has contributed as speaker more than 50 presentations in national and international congress. She has contributed several articles in magazines worldwide and 20 chapters in books. She has edited several books. In 2015, she edited Psychopathology in Women, a Gender Perspective with Springer.

Her recent research focuses on Gender Perspective as a Paradigm in Clinical Psychopathology, in the use of psychotherapeutic approaches in daily clinical practice. She has actively participated in several research projects and has led different projects. She collaborates as a researcher at Cibersam, led by Ana González-Pinto, and she is interested in promoting research projects that include the gender dimension, not included into scientific research so far.

She has participated in the organization and has been part of scientific committees of different congresses and conferences in the Spanish Society of Psychiatry. She is a member of the Neuropsychiatry Association of Euskadi and vice president of the Society of History and Philosophy of Psychiatry. She is a vocal member of the Spanish Society of Psychiatry. At present, she is an advisory board member at IAWMH.

Since 2014, she coordinates and participates in the Equality Conferences in Bilbao, promoting equality in psychiatry in Álava Hospital and Cruces University Hospital. She has contributed to Gender Violence Basic Course for health workers in Osakidetza, and she is included in a Preventing Gender Violence Group.

She is nowadays participating in the standards applicable worldwide to services for Victims of Violence against Women, with Emakunde and Basque Government, through a collaboration agreement with the United Nations Project.

Part IGeneral Aspects

© Springer Nature Switzerland AG 2019

Margarita Sáenz-Herrero (ed.)Psychopathology in Womenhttps://doi.org/10.1007/978-3-030-15179-9_1

1. Women Mental Health All over the World: Sociopolitical Aspects of Gender Discrimination and Violence: Immigration and Transnational Motherhood

Magdalena Marino¹   and Kristina Jausoro²  

(1)

Roberto Clemente Center, New York, NY, USA

(2)

Department of Education, Social Services Berritzegune, Vitoria-Gasteiz, Spain

Magdalena Marino (Corresponding author)

Email: [e-mail]

Kristina Jausoro

Abstract

Along the next chapter, we will discuss the specific challenges that women face in the health system, including the lack of access that suffer much of the world’s female population. We will defend a change of approach to the women’s health issues whenever they need to use the health system.

To thereby, we will describe some gender inequalities that appear from the family microsystems to social and political macrostructures of power and world organization that are some causes behind the female pathology. We refer here to some of them that particularly affect women: gender violence in all its forms, including poverty, human trafficking, and violence used against women during armed conflicts. In conclusion, we talk about lack of justice.

Since we are talking about women mental health around the world, we review the feminization of migration, analyzing the positive and negative aspects of it, and with special emphasis on transnational motherhood and its impact of women.

After analyzing these aspects, we suggest some recommendations to mental health professionals for possible lines of work from the health system, with the objective of making a change possible, a change based in the empowerment of women, considering health professionals as active agents and enablers of that empowerment.

Keywords

Gender violencePovertyMigrationTransnational motherhoodEmpowerment

All symptom is, in essence, a precipitate of meanings related to different dimensions of human life: childhood history, psychic suffering, intersubjective conflicts (couple or family), social failure, situations of helplessness, conceptual breaks with reality, and are presented as manifestations of a malaise that cannot be reduced to an absolute determinism, whether biological, psychic or cultural. Epidemiological studies reveal a female, general and mental, excess morbidity in adulthood, which highlights the need to reflect on this situation.(Tubert, 2001)

There is no society or community in the world where women are treated equally as men, having inevitable consequences in their health. Thus, women’s mental health can only be understood if their life’s context is taken into consideration; biological, sociocultural and the person [1].

The World Federation of Mental Health announced in 1996 that often psychological stress in women has social origins; discrimination against women in employment, education, food distribution, health access, and the resources to economic development turn them vulnerable to physical and sexual violence, psychiatric disorders, and psychological stress.

According to the World Health Organization (WHO) report Women and Health 2009, women and men face many similar health problems; nevertheless, the differences are so great that women’s health requires special attention [2]. Taking into account the same report, it is fair to say that some disorders affect to the same extent men and women, only women face more difficulties obtaining the health assistance that they need. Gender inequalities in education, freedom, or income, for example, are the ones that limit girls and women to protect their own health.

Health problems faced by women share common features worldwide, but also many great differences are observed, determined by different living conditions. Girls and women’s health is influenced by social and economic factors such as access to education, family, wealth, and place of residency. These differences are established not only in developing countries but also in the developed ones.

The differential prevalence of psychological disorders has led to investigate more accurate differential diagnosis that take into consideration the importance of culture in the construction of subjectivity. Defending the need to work with differential diagnosis does not imply establishing differences and defending unequal illnesses but presupposes taking into consideration living conditions and different risk factors affecting men and women. We need to develop approaches that consider the range of discrimination suffered by women, and these approaches must include the effect caused by poverty, lack of cultural resources, violence, and social devaluation [3].

To achieve that approach work is needed to shed the gender bias underlying theoretical models and health practice. The gender biases, as pointed out by Carmen Valls, are [4]:

Extrapolate to general population (meaning women) research results obtain with male population. Assuming that risks factors and health protectors are the same to everyone makes us suppress the gender differential morbidity and mortality.

The belief that men and women get ill in different ways. The weight of this belief is so great that many of the women’s problems are sent from primary care or women’s health centers, narrowing women’s health in reproductive health. Other symptoms are usually ignored, and after repeated demands of medical attention, analgesics or anxiolytics are prescribed, as a result the demand is psychologized and medicalized.

The clinical approach, especially biomedical and pharmacological, derives in framing the claim as pathology.

In this context, the increased use of psychotropic drugs for women can be a source of self-regulation of the exogenous elements in order to reduce discomfort [5].

It is true that in the last decades, the health sciences have evolved allowing visualizing some of the problems of women but much work remains. To contribute in breaking gender bias, professor Valls (2000) brings forward five proposals:

1.

Democratize knowledge production. Health research should consider experimental subjects both men and women.

2.

The research designs in addition to the biological differences between sexes must also consider gender and the positions and social roles they each play.

3.

To achieve better diagnosis, family life and work conditions should be taken under consideration.

4.

Sex is a demographic control variable, and gender should be considered a relational analytic variable.

5.

Innovative designs should be implemented to detect the attitudes of health workers during their clinical practice in order to detect any inequalities.

From the conviction of the universal right of all people to a public health system that ensures their welfare, this system should work in all scopes incorporating the gender perspective transversely. This involves two main axes of action:

Enhance the participation and role of women as active agents in the production of her own health.

The incorporation of interdisciplinary teams (physicians, psychologists, social workers, social educators) trained in addressing health issues from the perspective of gender. It would have to boost the collective empowerment of health system workers, with the objective to introduce the gender perspective in their daily practice, training them and stripping them of the gender bias aforementioned.

Interdisciplinary work is not only essential in the field of health but also the answer to many of the problems that arise in the health of women. Women’s health should be addressed from the social health space where different institutions (health, justice, social services, education, employment, etc.) are involved.

1.1 The Social Health Approach

The traditional structure of health and social services is not well suited to the mixed nature of women’s needs. Between the health and social services scopes, confluence zones are especially confusing and present difficulties of coordination because they are dependent on various government agencies. These difficulties might have a negative impact in people’s quality of life.

There are elements that are considered fundamental and defining in terms of social health approach:

It is a response to complex needs that require mixed interventions, social and health, simultaneously or sequentially, but always complementary.

It has the objective to guarantee the continuity of care avoiding mismatches, gaps, or waiting time between the different services.

It rules by the interdisciplinary principle.

It is based on an integral intervention approach focused in the person and oriented to guarantee the maximum level of quality of life and autonomy.

The principal objective of social health approach is a response to complex needs. There are certain populations for whom, because of their nature and their health and social characteristics, it is required a maximum coordination between both areas. Among these population groups are the elderly dependent and people with chronic disease (major disabilities, mental disorders, etc.). To these groups we can add those whose diagnoses are conditioned to their gender role, highlighting the urgent need of coordination regarding gender violence.

Much are the advantages of social health approach; we emphasize the main ones:

Introduces greater facilities in the articulation of services of different nature in the context of community action, therefore responding better to new social demands

Favors the permanence in the community, articulating the means to prevent hospitalization or long-term residencies

Offers greater possibilities of developing an interdisciplinary approach which enriches professional practice

Facilitates access to the most vulnerable population groups that other ways present significant barriers in access to care due to social isolation

Favors a more rational use of resources and higher levels of efficiency and effectiveness in its use

Promotes continuity of care

Favors detention of dysfunctions at different levels and scopes of care

If we consider that women’s health is conditioned from childhood by gender role imposed, treatment and approach must come from the social health scope and with the incorporation of the several disciplines in the both work teams primary and specialized care.

1.2 Gender Violence: A Public Health Problem Around the World

The United Nations defines violence against women as any act of gender-based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. [6]

The Declaration of Violence against Women as a social problem has been accompanied by the recognition by the health sector of violence against women as a public health problem.

In 1996, WHO declared gender-based violence as an international priority for health services, due to its grave consequences on health and to its magnitude and the significant economic impact involved.

In most of the literature on the subject, there is agreement that violence against women takes three main forms: physical, psychological, and sexual violence [7].

However, and although this is the most common differentiation, based on the proposal of the Expert Report on Combating Violence Against Women of the Council of Europe [8], there frequently are other forms of violence, giving rise to the description of the following types:

Physical violence: all action carried out voluntarily which causes or may cause damage and personal injury to women. It includes the use of physical force or objects to attempt against their physical integrity.

Sexual violence: any attempt against the sexual freedom of women by which they are obliged to bear or carry out acts of sexual nature. It includes any act or sexual expression carried out against their will that violates their physical or emotional integrity such as jokes, rude expressions, unpleasant comments, obscene phone calls, undesirable sexual proposals, forcing them to watch pornography, any act or sexual intercourse not consented to by women (harassment, rape, incest), any relationship or sexual act deemed by women to be humiliating or painful, or the obligation to prostitute themselves.

Psychological violence: any action, generally of verbal or economic nature, that causes or may cause psychological damage in women. It includes the use of mechanisms of control and communication that threaten women’s psychological integrity, well-being, self-esteem or consideration of, in both public and private, in front of other people, such as to denigrate them, to despise what they do, to make them feel guilty, to treat them as if they were slaves, to make unpleasant comments about their physique, to humiliate them in public or in private, to create a bad reputation about them, to force them to be accountable for their relationships and contacts with other people, to force them to break off with friends, to prohibit them from talking to people of the opposite sex, to show jealousy of friendships, to limit them in their living space or not to respect it, to make jokes (sexist jokes of denigrating nature), and to undervalue their contributions or executions, insults made in public or in private, threats and intimidation, emotional blackmail, threats of suicide if the couple expressed their desire to separate, etc.

Economic violence: inequality in access to common resources. It includes denying or controlling women the access to shared sources of money, to generate their economic dependence; to impede their access to employment, education, or health, denying their rights of property; etc.

Structural violence: intangible and invisible barriers that impede women’s access to basic rights. It includes the denial of information to their fundamental rights, the relations of power in schools or at work, or discriminatory legislation in all social spheres.

Spiritual violence: the destruction of women’s cultural or religious beliefs through punishment, ridicule, or the imposition of a system of beliefs that are alien to their own. It includes the submission and invisibility of women’s cultural or religious beliefs or analyzing them from an ethnocentric perspective.

When talking about gender violence, there is a tendency to equate it to the most common and proxime to our context: intimate partner violence and sexual violence in the social environment. WHO estimates that almost one third of all women have experienced intimate partner violence or sexual violence [9]. Globally, 38% of murders of women are committed by their intimate partner, this number does not include the amount of women that commit suicide as a result of abusive relationships. From our experiences as workers, family members, friends, and members of society, and with emerging powerful movements like #MeToo, these two forms of gender violence are well known and described.

However, intimate partner violence is only one of multiple forms of violence against women. Socio-economic inequalities and traditional and patriarchal systems create and perpetuate other perverse social and structural forms of violence against women. Unfortunately, there are multiple forms and examples of social and structural violence against women around the world that we could discuss, but we will focus on three that we find extremely perverse and distressful: poverty, slavery and human trafficking, and use of women as weapon in wars.

1.2.1 Defining Poverty and Its Gender Distribution

Poverty is the worst form of violence—Mahatma Gandhi

Overcoming poverty is not a task of charity, it is an act of justice—Nelson Mandela

The association between poverty and mental disorders appears to be strong and universal, occurring in all societies irrespective of their levels of development of the country [10]. Traditionally, poverty has been defined in pure economic terms of amount of income per day. Thus, poverty means much more than income.

Poverty was defined in the UN’s Human Development Report (1997) as the denial of the opportunities and choices most basic to human life—the opportunity to lead a long, healthy, and creative life and to enjoy a decent standard of living, freedom, dignity, self-esteem, and respect from others [11]. The lack of opportunities and choices for women and girls due to gender are innumerable. In terms of education, women continue having less access to basic education and even less access to higher education [11]. In the labor market, women in all levels face daily salary inequality, exploitation, discrimination, and lack of equal and fair opportunities. Only 22% of the world’s parliament is women, and in general, the presence of women in positions of power and decision-making shows that sadly the glass ceiling remains a reality [12]. These factors, among other structural and legitimated gender discrimination forms, have contributed to feminization of poverty [13].

Poverty and its structural causes limit women’s ability to be active and productive members of society, to realize their potential and ultimately to be mentally as well as physically healthy [10]. The negative social and economic factors associated with poverty furthermore act as a barrier to health and mental health-care services. Similarly, restrictions in women’s ability to participate fully and actively in the community, be part of the decision-making process on issues affecting one’s life, or have the opportunity to improve one’s social and economic situation and status also adversely affect the mental health of women. Mental health professionals have the responsibility to acknowledge the challenges and external barriers that poverty—in its broad definition—brings to women. As well, an approach focused on strengths and resilience, instead of just psychopathological personality traits that further stigmatize women.

The eradication of global poverty requires a strong change on the deep-seated structural causes of poverty that requires extensive discussion, outside of the scope of this chapter. However, it is important to demand special attention to structural violence and discrimination against women, a solid compromise with the promotion of women’s human rights, from the basic one of education, and the incorporation of gender equality and mainstreaming into all legislation to decrease gender-related poverty.

1.2.2 Human Trafficking

Trafficking demonstrates the weaknesses of global capitalism and the disparity caused by the economic rules of the countries most powerful; but mostly reveals normalization of human cruelty and cultural processes that have strengthened—Esclavas del poder, Lidia Cacho, [14]

Human trafficking is defined as the recruitment and movement of persons by threat, force, coercion, or deception for the purpose of exploitation (sexual exploitation, forced labor, or slavery) [15]. Due to its underground nature, statistics on the scale of the problem are unreliable; however, the International Labour Organization (ILO) estimates that globally 2.5 million persons are currently in situations of exploitation as a result of trafficking and that another 1.2 million are trafficked annually [16]. Human trafficking is a particularly abusive form of migration and one of the most severe human rights violations in the world. Reports from around the world include descriptions of the extreme forms of physical, psychological, and sexual abuse experienced by persons who are trafficked in the sex industry and exploited in multitude of labor settings, including construction, agriculture, and domestic servitude [17].

While trafficking affects both men and women, it is not a gender-neutral phenomenon. Up to 80% of trafficked persons are disproportionately women and girls [18]. Women are particularly vulnerable to trafficking due to their social and economic position, as well their position in the migratory process. Poverty, unemployment, a high demand (and low regulation) for cheap labor and services in female-designated sectors of work, discriminatory immigration laws, and a cultural context in which violence against women is tolerated are the most important and recognized causes of women trafficking [13]. These causes have a common root, gender inequality, and the lack of rights afforded to women. By failing to protect and promote women’s civil, political, economic, and social rights, governments create situations in which trafficking arise. A real political response and compromise with the respect, protection, and promotion of women’s human rights in all the arenas (social, economic, political, educational, and health) is the first step to ensure an end to trafficking in women.

Until a solution is found, the United Nations requires governments to implement measures to promote the physical, physiological, and social recovery of human trafficking victims, including medical and psychological responses to trafficked people’s health needs [15]. For meeting these international agreements, countries will have to provide psychological support services for trafficked persons. Yet, the health and mental health consequences and potential public health implications of human trafficking have generally received little attention; the mental health community is just beginning to respond to these persons’ needs [17].

Human trafficking victims enter in a circle of terror, violence, and cruelty that denies them their right to safety, dignity, freedom, equality, health care, work, and education, among others. Often, victims come from a previous history of gender-based violence and are revictimized. As a result of such exposure—and re-exposure—to trauma, the limited research on the mental health consequences of trafficking consistently report high levels of symptoms indicative of anxiety (48–97.7%), depression (54.9–100%), and post-traumatic stress disorder (PTSD) (19.5–77%) [17]. It is also common the comorbidity among these disorders [19]. The literature describes a broad range of reactions related to trauma: fear, guilt, rage, sense of betrayal, distrust, helplessness, shock, suspicion, feeling lost, sense of apathy and resignation, extreme forms of submissiveness to authority, maladaptation in social situation, and loss of personal autonomy [20]. The length of time spent being exploited and the level of violence and injuries sustained while trafficked increase the risk of suffering anxiety, depression, and PTSD symptoms [17, 19, 21]. Women who were trafficked for sexual exploitation had a higher prevalence of PTSD in comparison to women that were trafficked for labor exploitation [22].

When authorities encounter trafficked women, they often suffer physical pain and exhaustion, confusion, disorientation, amnesia, strong emotional reactions, and inability to recall events or to communicate that may affect their ability to obtain assistance [23]. Even after being liberated from a trafficking experience, women and girls face huge stressors, including entering in a complicated legal system in order to obtain assistance, possible participation in criminal proceedings, immigration and asylum procedures, stigma associated with sex work, and being reunited with families who may be unaware of their experience—and when they are aware often reject them. Similarly, women may experience the same concerns about poverty and unemployment that caused them to leave their home in the first place [19]. Subsequently, the lack of social support and additional life stress upon their return may affect the symptoms severity.

The severity of symptoms and the risks and challenges victims face after their trafficking experience indicate that treatment services should be available immediately [21]. However, some victims are quickly deported to their country of origin, finding the same context of poverty and discrimination that they had left and where assistance is inexistent, or they are forced to participate in criminal investigations as a condition to assistance. As consequence of the abuse of power suffered and intensity of trauma, the engagement and creation of a therapeutic relationship may be challenging. In the first period after trafficking, a sensitive approach is required to address problems of memory, the lack of trust, and the fear to talk about their experience. It is essential to assure trafficking survivors a period of recovery and reflection before making decisions about their future and well-being (like coming back with their family or participating in criminal investigations).

If multidisciplinary teams are usually important, they are crucial in this field. These interdisciplinary teams should involve law enforcement personnel and social agencies that provide legal, educational, vocational, economic, and other vital life resources. However, this collaboration should not liberate clinicians for a general awareness of immigration policies.

Mental health professionals working with trafficking survivors must have specific training in trauma, especially sexual and interpersonal trauma [20]. Most present-day treatments currently follow the direction of trauma-approach treatments for victims of domestic violence, sexual assault, torture, and immigrants and refugees. In addition, clinicians need a culturally sensitive approach and multicultural competence required to work with immigrants for providing appropriate care to these women.

We cannot forget that human trafficking is not only a personal experience but also a community and global matter that goes against social justice and human rights, and we as professional and as human beings have a responsibility to combat it.

1.2.3 Women in Armed Conflicts

Since 1945, there have been an estimated 150 wars in the world [24]. Despite the new techniques of warfare, the sophistication and precision of weapons, and international conventions that forbid civilians as targets, civilians die in greater numbers than soldiers do. Children and women are the most vulnerable and the first victims of these wars. Even when conflicts officially end, violence against women continues and often worsens [25].

Violence against women during wartime is recognized by international humanitarian organizations as a fundamental violation of human rights, a primary public concern, and a major impediment to peacemaking, reconstruction, and development of war-torn countries [25]. The United Nations passed in 2000 the Resolution 1325 on women and peace and security. This historic resolution calls for the equal participation and full involvement in all steps of conflict resolution and peace building, as well on promotion and maintenance of peace and security. It also demands to all parties in conflict to take special measures to protect women and girls from gender-based violence, particularly rape and other forms of sexual abuse, in situations of armed conflict [26]. This resolution seeks to give a voice to the silenced women survivors and to include the perspective of women in the construction of peace, but sadly it had (and still has) a very limited impact.

Historically, sexual violence against women during war can be tracked from the eleventh century until these days. For centuries, sexual violence against women has been rarely prosecuted and often even considered an unfortunate product of war [27]. In the Resolution 1325, it is still considered gender-based violence. In June 2008 the United Nations in its Resolution 1820 denounces that women and girls are particularly targeted by the use of sexual violence, including as a tactic of war to humiliate, dominate, instill fear in, disperse and/or forcibly relocate civilian members of a community or ethnic group [28]. This means, in the context of a war, sexual violence is a deliberate (and effective) military weapon to tear apart individuals, families, and communities.

In 2009 the UN Security Council openly recognized, in the voices of Hillary Clinton and Ban Ki-moon, that violence against women had not diminished but even increased in some places, being used as a brutal weapon in armed conflicts with total impunity. Two new resolutions (S/RES/1888 and S/RES/1889) were approved asked for the immediate cessation of all acts of sexual violence and reiterating the importance of women’s participation in peace processes and promoting women’s leadership, respectively [29, 30]. These resolutions, along with the S/RES/1960 on 2010, repeat and strength same petitions.

In 2013 two new resolutions in women and peace and security were adopted. In June 24, 2013, the Council adopted the Resolution 2106 defining sexual violence as a crime against humanity and encouraging member states to adopt a national penal legislation to prosecute them [31]. In October 18, S/RES/2122 supports the petition of women’s leadership and request from the UN a more active involvement in protecting human rights and pursuing gender equality and empower of women in conflict areas [32]. The Secretary has reported some advance in this fight but still far away from an, at least, gender-equilibrium respect of women and girls’ human rights.

If we do not have the capacity to prevent war, we have a collective responsibility to better understand and treat its psychiatry, medical, and social consequencesMichael Hollifield (Hollifield, 2005, p. 1284) [33]

Hagen (2010) describes five characteristics that distinguish war sexual violence against women from other kinds of sexual violence during peacetime [34]:

1.

Used at a massive scale.

2.

Approximately 90% occur in the presence of other women to infuse fear, in front of other soldiers to promote solidarity, and other community members to show power and total suppression.

3.

Has an extreme level of brutality.

4.

Often includes slavery.

5.

Serves as ethnic cleansing.

The consequences of these brutal attacks against women are felt in multiple levels. In the individual level, women that survive war rape suffer multiple and severe forms of physical and psychological trauma. From severe and permanent physical damage and disabilities, AIDS, to post-traumatic stress disorder, depression, anxiety, sense of helplessness, and a total destruction of self-identity and sense of belonging, the wounds of war rape in an individual are atrocious [27]. Adding to these wounds and to the personal shame and humiliation that public, brutal, and massive rapes bring, many women suffer the rejection of their own family and the community due to sociocultural values regarding sexuality [25]. In a macro level, these women face a destroyed society that does not have the economic, political, socio-cultural, and health-care infrastructure to assist them, and they are forced to migrate into refugees’ camps where education, work, and recovery opportunities are limited. Displaced and removed from their community, they are condemned to a life of extreme poverty and complete dependence that places them at risk of further victimization [34].

As the consequences are felt in all dimensions of a person’s life, interventions should also address the full impact in all areas. Refugees and war survivors in destroyed societies have multiple physical and psychiatric symptoms, cultural individualities, language barriers, and poli-trauma that complicate illness experience and diagnosis from a traditional western perspective [33]. Biomedical models of trauma are too limited to attend the reality of these survivors [24]. These complex realities need a holistic model that understands the peculiar experience of women in a society in war, and the women’s voices should be the guide for it.

In the absence of that holistic model until these days, some recommendations are appearing clearly in the literature:

Disempowerment, gender inequality, stigmatization of sexual violence, self-identity, and body objectification are some of the central themes to work on the therapeutic space [34].

There is change from labeling these women as victims to survivors, resilient women that are capable and should participate in their healing process. Women’s resilience needs to be recognized and supported by mental health providers as a way to promote their adequate access to their rights of health care and justice [24].

There is also a change in the focus on psychopathologic manifestation to the focus on resilience, protective factors, and methods of coping for the purpose of developing interventions and services [24].

Health and mental health services for war survivors need to be culturally and gender sensitive.

The complex needs require multiagency coordinated services.

It is necessary to understand the social reality where the services are being displayed, like the political instability, the uncertainty about settlement, migration stressors involved, and the effect of collective trauma [34].

It is important to include the protection and promotion of human rights, the search of social justice, and the empowerment (in the personal and the social level) in the work with female war survivors [24].

Given the complex nature of this their experience and trauma, coordinated multiagency services are suggested [24].

In summary, mental health interventions with war survivors have to take into account the environment and ecological reality of the person and the community. They need to be complemented with individual and collective legal, social, and political actions destined to build or restore the empowerment of women and address all kind of social inequalities and discrimination that exist.

1.3 International Recommendations for the Prevention of Gender-Based Violence

Violence against women is perhaps the most shameful human rights violation. It knows no geographical or cultural limits, or economic position. As long as it continues, we can not say that we have actually made progress towards equality, development and peace.Kofi Annan, Secretary-General of the United Nations

The Declaration on the Elimination of Violence Against Women, adopted by the General Assembly of the United Nations in 1993, shows the international understanding and recognition that violence against women is a violation of human rights and a form of discrimination against women.

The human rights norms that emerge from the Convention on the Elimination of all Forms of Discrimination against Women, subsequently ratified by the World Conference on Human Rights of the United Nations (UN) of 1993 and other international instruments, not only extend the validity of areas that were previously not considered as subjects of rights but also establish differences between formal equality and substantive equality. It is recognized as well that the so-called universal human rights—even when they guarantee in formal terms the legal equality of men and women—were defined from the life and experiences of men and do not take into account the needs and everyday experiences of women.

Therefore, and based on these experiences, the following is recommended:

Expand democracy based on the effective participation of citizens and the full observance of human rights.

Develop a national plan with state guarantees for the compliance of the principle of gender equity.

Create government initiatives to improve the social status of women.

Promote the production of up-to-date statistical information permitting to visualize the gaps and iniquities of gender at all levels.

Penalize the media and professionals involved in cases that through promotional campaigns use women as objects or marginalize women’s social, intellectual, racial, or economic status.

The Platform for Action document adopted at the Fourth World Conference on women, held in Beijing in 1995, defines violence against women as 1 of the 12 critical areas of concern that should be given particular emphasis by governments, the international community, and civil society.

At its 42nd session, in 1998, the Commission on the Social and Legal Status of Women of the United Nations proposed new measures and initiatives that should be applied by the member states and by the international community in order to put an end to violence against women, including the incorporation of a gender perspective in all policies and relevant programs. Among the conclusions agreed upon during the session, there are measures to provide support to the work of nongovernmental organizations; to combat all forms of trafficking in women and girls; to promote and protect the rights of migrant workers, in particular women and children and girls; and to promote the coordinated activities of research on violence against women.

In relation to violence against women in the domestic sphere, WHO multicountry study results on health of women and domestic violence against women underscore the need to take urgent measures on a wide variety of instances, ranging from local health authorities and community leaders to national governments and international agencies [35].

As the study graphically shows, violence against women is a widespread and deeply rooted practice that has serious consequences for the health and well-being of women. Its persistence is morally unacceptable; their costs are immeasurable both for individuals and for health systems and for the society in general. However, until relatively recently, no other relevant public health problems had been so widely neglected and misunderstood.

The wide differences in the prevalence and patterns of violence found from one country to another, and mostly from one context to another within the various countries examined, suggest that there is nothing natural or inevitable about this problem. Attitudes can and must change, the conditions of women can and must be improved, and men and women can and must convince themselves that violence cannot be accepted in human relations.

Reinforcing the idea of violence against women as a critical and preventable public health problem, and insisting on its serious impact on women and their children’s health and mental health, the WHO reminds the health system of its crucial role on this process.

The proposal is a woman-centered health response that actively enhances women’s safety, takes into account women’s perspectives in the designation and delivery of services, responds to women’s need in an humane and holistic way, provides information and support to allow informed choices and decision, and especially empowers women to participate in their own care [36].

The following recommendations have been extracted, primarily from the conclusions of the study, although they are also based on studies and lessons learned from experiences in numerous countries. Specifically, the recommendations corroborate the conclusions and recommendations presented in the WHO’s World Report on Violence and Health [37]. Recommendations are grouped in the following categories:

Strengthen the commitment and action at the national level.

Promote primary prevention responses.

Involve the education sector.

Strengthen the health sector response.

Support women living with violence.

Sensitize those who are part of the criminal justice systems.

Support research and collaboration.

In order to address and prevent violence against women, it is necessary that many sectors (educative, legal, health, economic, etc.) take action in many areas. However, it is important that states take the final responsibility for the security and well-being of its citizens. In this sense, the national governments, in collaboration with nongovernmental organizations and international organizations, must give priority to this issue.

Following international recommendations, each country is called upon to implement prevention programs of gender-based violence, to investigate such acts and prosecute and punish perpetrators, as well as ensure the woman victim her rights of care and assistance.

Various strategies and different models of legislation have been established in different countries, some include educational measures and preventive actions, while others establish specific courts or police offices for the matter. In the best cases, prevention, education, and integrated services for victims (from health to legal assistance in the same agency) conform a comprehensive approach to elimination of gender-based violence. Thus, not all approaches define violence against women in the same way nor act against all of its manifestations.

1.4 Prevention and Response

Further assessment is required to determine the effectiveness of violence prevention measures [38]. Some of the interventions with more promising results are the promotion of education and work opportunities for women and girls, the improvement of their self-esteem and their negotiating skills, and the reduction of the inequalities of gender in communities.

Other efforts which proved to be effective are intervening with adolescents to reduce violence in their relationships, supporting programs for children who have witnessed acts of violence between partners, massive public education campaigns, and adopting measures of collaboration with men and boys to challenge attitudes about gender inequities and the acceptability of violence.

The defense of victims, greater awareness among health workers about violence, and broader knowledge of the resources available for battered women (such as legal assistance and/or accommodation and care of children or other dependents) can mitigate the consequences of violence.

1.5 The Feminization of Immigration

Addressing women’s mental health around the world inevitably means to talk about immigrant women. Due to globalization of economy and its effect on labor market, migration has risen until the point that has almost doubled during the last 50 years. Traditionally, women migrated with men as dependents or as part of the family reunification processes, but recently women are migrating as autonomous breadwinners. Women constitute now the 48% of all international immigrants, approximately about 124 millions of those who migrate, some as highly skilled workers, but mostly running away from poverty and other human rights violations, [39].

Despite the fact that migration is a complex and multi-caused phenomena, there is an agreement on pointing as a principal cause for this change in the gender of migration in the country of origin (push factors) gender-based violence, gender inequality, feminization of poverty, unemployment, human rights violations, war, and discrimination [40]. Even when economic causes are the main reason to move, women often migrate to escape abusive and patriarchal traditions that limit opportunity and freedom [18]. On the other side of the frontiers, the most common pull factors (anticipated benefits on the country of destine) are the increasing demand for women in domestic positions and service and care-related jobs, the opportunity to receive higher wages, and family reunifications.

For many women, migration means a safer place, a new world of more equality, a relief from oppression and the discrimination that limits freedom, and an opportunity to develop their potential. For origin and receiving countries, the contribution of women migrants can transform quality of life. In origin countries, the economic contribution can palliate poverty, provide education and health care, and generally improve the quality of life of their families an even the whole communities. Beyond the economic factors, the social change thought new and renovated ideas, values, knowledge, or skills of women can contribute to promote human rights and gender equality. In receiving countries, they contribute their work and expertise, pay taxes, and support a style of life in developing countries that most take for granted allowing, for example, other women to delegate the traditionally assumed care of children and elderly for incorporating to labor market.

However, while migration is often an empowering experience, some migrants endure severe human right violations, abuse, and discrimination that affect their well-being. During the traveling, they are exposed to severe abuses including kidnapping, extortion, physical violence, and trafficking. In the country of destination, immigrant face with language barriers, culture shock, isolation and loss of support systems, loss of socioeconomic status, unemployment or working in unsafe or unhealthy work conditions, poverty, social exclusion, prejudice and discrimination, lack of knowledge of existing services and barriers in accessing the health system, and feelings of vulnerability due to legal status [41]. In addition to all these stressors that can affect (in different proportion) all migrants, women have the unique experience of sexual and gender-based violence [42]. Due to the status as women and as foreigners (in addition to race, ethnicity, class, or religion), female migrants face disproportionate risk of abuse and violence at home, in the streets, or in the place of work [18].

The international organization worldwide recognized a feminization of migration in 2000 and compromised to promote equal access to project and services for the immigrant women, even to create specific programs to addressing their specific needs [43]. However, despite this acknowledge of challenges and risks of immigrant women, both international and national regulations fail to adequately address their problems. Trafficking and exploitation of domestic worker, two kinds of modern enslavement that affect mostly females, testify the lack of adequate opportunities for women to migrate safely and legally.

As we explain, even when migration can be a positive experience for millions, there are serious risks for female migrants that can compromise their physical and mental health and even their survival. For these women that are mothers, there is also another layer of complexity in their experience: they left their home and children behind to become a domestic worker caring for someone else’s home and children instead of their own. Following, we will describe the transnational motherhood phenomenon, a paradox of the immigration that require from mental health professionals’ especial attention and, even more than ever, a culturally and gender sensitive perspective.

1.5.1 Transnational Motherhood

The feminization of migration changes the structure, organization, and hierarchy of the family and impacts the life cycle of its members. As women are increasingly migrating alone to find work, this has reconfigured the shape of the immigrant family and trans-nationalizing the meaning of motherhood [44]. Hondagneu-Sotelo and Avila were the first to employ the term transnational mother to describe these women that have migrated to another country in order to become the family breadwinner, leaving their country, culture, family, and children behind. In describing the paradox of having to leave their children, they relate the experience as being simultaneously here and there: here as breadwinners and there as caregiver and nurturing mothers. Transnational mothers are in the process of actively, if not voluntarily building alternatives constructions of motherhood [45].

The interpretation of the departure of women and its impact on family structure is connected with the norms and values of their society. In societies with patriarchal values and marked roles of emotional caregivers, women may be questioned, criticized, and denied of support as their migration is perceived as an abandonment instead of a sacrifice. In societies where nurturing and care is shared among extended family and community members, the sacrifice is better recognized and even celebrated. The ideas about the reunification are even more complex, grading from assuming it as the only valid option and not accepting alternative family arrangements, to blaming the mothers for bringing their children to a new country under the premise that they are breaking their roots and disrupting their lives.

Initial literature on transnational families found that the migration of mothers is a traumatic event with devastating consequences for these women and incurs substantial social and psychological negative changes among the family who remains behind [46].

Several studies find devastating psychological effects, such as anxiety, anger, somatic symptoms, depression, guilt, symptoms of posttraumatic stress disorder related to separation from children, and guilt, experienced by women with family fragmentation [44, 47, 48]. Miranda et al. found that the odds of depression for Latinas transnational mothers were 1.52 times greater than those of Latinas whose children were currently living with them [49]. Further, the reunification phase is not as easy and dreamlike as it could seem. It affects the entire functioning of each person of the family in their environment. When reunification occurs in Latino immigrants, families are faced with strong processes of adjustment that can include acculturation challenges, the addition of new family members, missing caretakers in homeland, authority conflicts, depression, anxiety, and behavioral problems. In Suarez-Orozco et al., mothers after reunification verbalized struggle with asserting authority and frustration because their financial and emotional sacrifices are not fully appreciated by their children [50].

On these studies, and especially in their diffusion, the focus tends to be on the devastations and rupture. Women are stigmatized for breaking the family in the first instance and then questioned later when they try to reunite with their children in a new country, because that may be traumatic for the children as well [51]. Also, this perception often assumes the migration as a personal and free election of the women, ignoring the socioeconomic pressures that may have caused it.

After these initial findings, several studies focused on deconstructing the negative conception, presenting alternative definitions of family structure and emphasizing that it is possible to maintain a positive relationship between mothers and children in the distance without severe emotional consequences, especially using new technologies.

These studies focused on the economic benefits, the resilience of the children left behind [52], plasticity of the families and readjustment of roles [53], or the opportunity to create relationship through technology [54].

It is very loable that these models defy the traditional model of nuclear family as the only valid. However, as Lagomarsino [51] notes, these perspectives may subestimate the complexity of motherhood. From these perspectives, the need of proximity and the physical connection that mothers and children claim could be seen only as a product of an excessively traditional or paternalistic culture, without recognizing the immigrant women the right to be (and the right to want to be) with their families and the emotional suffering due to the separation.

It is important to note that there are not the only frontiers but the social inequalities that create the ambiguous loss of separation and provoke emotional