eISSN: 1989-9742 © SIPS.
DOI: https://doi.org/10.7179/PSRI_2025.47.10

http://recyt.fecyt.es/index.php/PSRI/

Gender-based violence in the pathways of incarcerated
women in Spain

La violencia de género en las trayectorias de las mujeres privadas
de libertad en España

A violência de género nas trajectórias das mulheres privadas
de liberdade em Espanha

Anaïs QUIROGA-CARRILLO https://orcid.org/0000-0002-0705-8921

Mar LORENZO-MOLEDO https://orcid.org/0000-0002-2768-3329

University of Santiago de Compostela

Received date: 12.III.2024

Reviewed date: 02.V.2024

Accepted date: 03.V.2025

CONTACT WITH THE AUTHORS

Anaïs Quiroga-Carrillo: Universidade de Santiago de Compostela, Facultade de Ciencias da Educación (Campus Vida), Xosé María Suárez Núñez, s/n, 15782 Santiago de Compostela, A Coruña. E-mail: anais.quiroga.carrillo@usc.es

1. Introduction

Female delinquency has been an overlooked issue in the social sciences for decades (Lorenzo-Moledo, 2002). Theories of delinquency that emerged in the late 19th and much of the 20th century deliberately ignored female offenders or depicted them through biased and sexist stereotypes (Belknap, 2014).

It was not until the emergence of feminist criminology in the 1970s that studies began to deconstruct this ‘gender blindness’ (Cecil, 2006) and challenge explanations of human behavior that were, in reality, explanations of male behavior (Leonard, 1982). During this period, a growing number of international studies, rooted in different feminist perspectives, sought to address the existing gap in the literature. Initially, these works introduced new perspectives and theories on female delinquency (Adler, 1975; Heidensohn, 1968; Naffine, 1987), but empirical research soon followed, demonstrating the relationship between this phenomenon and women’s economic marginalization, adverse childhood experiences, and social exclusion (Carlen, 1985; Chesney-Lind, 1989; Daly, 1992).

Currently, there are studies from various disciplines that examine female delinquency, both at the international (Brennan et al., 2012; Broidy et al., 2018; Salisbury & Van Voorhis, 2009; Wright et al., 2012) and national context (Almeda, 2003; Añaños-Bedriñana, 2010; Caravaca-Sánchez et al., 2022; Lorenzo-Moledo, 2002; Mapelli et al., 2013; Quiroga-Carrillo, 2022). These studies analyze the unique profiles of female offenders, delve into the etiology of their antisocial behavior, and explore the ways in which their pathways are shaped. Research has highlighted that many of these women exist at the intersection of multiple forms of marginalization, which are connected to factors such as social class, ethnicity, and gender—elements that shape their criminal careers (Crenshaw, 1989; Potter, 2013).

It has been demonstrated that these women come from contexts of poverty and socioeconomic marginalization (Chesney-Lind & Pasko, 2013), as well as from families where violence, neglect, or substance abuse are frequently present (Melendro, 2017). This intrafamilial situation explains why some have been placed in child protection systems, such as foster or residential care (Añaños-Bedriñana et al., 2019; Igareda, 2007). Additionally, their educational attainment is generally low (De Miguel, 2014; Wright et al., 2012), often leading to unemployment or temporary and precarious employment in low-skilled, feminized sectors (Cruells & Igareda, 2005; Wright et al., 2012).

Evidence also points to high rates of alcoholism, substance abuse (Añaños-Bedriñana, 2010; Fazel et al., 2017), and mental illnesses, with the most common diagnoses being depression, anxiety disorders, and post-traumatic stress disorder (PTSD; Caravaca-Sánchez et al., 2022; Tyler et al., 2019). In this regard, while personality disorders are more prevalent among men (Coolidge et al., 2011), self-harming behaviors and the risk of suicide are significantly higher among women (Favril et al., 2020).

However, if there is one factor that stands out in their criminal careers, it is victimization (Salisbury & Van Voorhis, 2009; Wright et al., 2012). Child maltreatment and sexual abuse, as well as gender-based violence in adulthood, have been established in the scientific literature as two of the primary catalysts of female delinquency (Chesney-Lind & Pasko, 2013). Research has shown that both forms of victimization —especially gender-based violence— are disproportionately common among incarcerated women (Brennan et al., 2012; De Miguel, 2014; Radatz & Wright, 2017) and have a greater prevalence in this population compared to their male counterparts (Brown et al., 2021).

In this regard, gender-based violence emerges as a key factor in victimization and vulnerability, as it represents one of the clearest manifestations of inequality, subordination, and power dynamics exerted by men over women. According to the United Nations Declaration on the Elimination of Violence against Women (United Nations, 1993), gender-based violence encompasses any act of violence based on gender that results in, or has the potential to result in, physical, sexual, or psychological harm, also including threats of such acts, coercion, or arbitrary deprivation of liberty, whether in public or private life.

Studies framed within the pathways to crime theory have found that victimization represents a significant risk factor for women in the development of criminal behavior, incarceration (Daly, 1992; Salisbury & Van Voorhis, 2009), recidivism (Fazel et al., 2016; Lynch et al., 2014), and revictimization (Abajobir et al., 2017). In short, the experiences of oppression and abuse these women endure place them on a pathway where crime becomes a means of survival and coping with adversity, which, in turn, makes them more vulnerable to future forms of maltreatment (Chesney-Lind & Pasko, 2013; Jones et al., 2021).

Moreover, these experiences place victims at risk of developing mental illnesses (trauma) and drug-related disorders (Caravaca-Sánchez et al., 2022; Fazel et al., 2016; Jones et al., 2021; Radatz & Wright, 2017). The relationship between victimization, substance abuse, and mental illness is complex, and various hypotheses have been developed to understand it (McKee & Hilton, 2017). The most widely accepted explanation argues that women who have experienced maltreatment and subsequently developed trauma turn to substance abuse as a means of alleviating the symptoms of mental illnesses such as PTSD (Saxena et al., 2014; van Dam et al., 2012).

On the other hand, previous research has shown that gender-based violence is strongly associated with different conditions of vulnerability, such as low educational attainment (Spencer et al., 2019), exposure to child maltreatment (Abajobir et al., 2017), substance use (Cyrus et al., 2021), and offense type (Brennan et al., 2012). This phenomenon cannot be understood in isolation but rather as part of a broader process of social exclusion that shapes the life trajectories of many incarcerated women. This process is characterized by the intersection of multiple risk factors and continued exposure to violence at different stages of life (Salisbury & Van Voorhis, 2009; Wright et al., 2012). In this context, research has highlighted the need to incorporate a socio-educational approach in prisons to ensure women’s successful reentry into society, addressing their trajectories of vulnerability (Añaños-Bedriñana & Yagüe, 2013).

Certainly, the Spanish penitentiary intervention has increasingly prioritized awareness and prevention programs focused on gender-based violence, such as ‘Ser mujer.eS’ (Secretaría General de Instituciones Penitenciarias [SGIP], 2010). While the penitentiary administration offers other socio-educational programs to address needs related to mental health, substance dependence, violent behavior, and disabilities, among others, ‘Ser mujer.eS’ remains the only program specifically designed and implemented for female inmates.

Likewise, within the national context, research on victimization and incarcerated women is still in its early stages. Most studies originate from the Anglophone sphere, which limits our understanding of how these experiences intersect with other characteristics and issues that this population may face.

This study aims to identify the incidence of gender-based violence in a sample of incarcerated women in Spain and to analyze, from a quantitative perspective, the association between having been a victim of gender-based violence and certain sociodemographic and criminological variables. Based on this main objective, the following specific goals are set:

1. Determine the prevalence of gender-based violence in a sample of incarcerated women in Spanish prisons.

2. Analyze the relationship between having been a victim of gender-based violence and diverse sociodemographic variables, such as educational attainment.

3. Examine the association between gender-based violence and criminological variables, including having been in foster or residential care during childhood, juvenile justice measures, substance use, recidivism, and offense type.

4. Identify associations of multiple victimization by assessing whether gender-based violence experienced in adulthood is related to prior child maltreatment.

In this regard, we also aim to reflect on the socio-educational implications of these findings, emphasizing the need to raise awareness of this reality so that prisons can design, implement, and assess programs aimed at addressing the victimization of incarcerated women from a gender-sensitive perspective.

2. Method

2.1. Participants

Due to institutional restrictions on accessing the prison population, especially during the COVID-19 pandemic, a non-probabilistic sampling method was employed for this study. First, prisons were selected through purposive non-probabilistic sampling. To ensure a balanced representation of the female prison population in Spain, the only three women-exclusive prisons under state administration at that time were chosen: Madrid I-Mujeres, Brieva (Ávila), and Alcalá de Guadaíra (Sevilla)1. Additionally, four prisons with women’s modules (where the majority of inmates are male) located in Galicia were included: Teixeiro (A Coruña), Bonxe (Lugo), Pereiro de Aguiar (Ourense), and A Lama (Pontevedra). Second, the female participants were selected using accidental sampling, with the only criterion for inclusion being the ability to speak Spanish.

In September 2021 (SGIP, 2021), the female inmate population in the Spanish penitentiary system was 3,969. For this study, 720 women were invited, of whom 384 agreed to participate. After analyzing the questionnaires and excluding incomplete ones, the final data-producing sample consisted of 376 women from seven Spanish prisons: Madrid I-Mujeres (44.4%), Alcalá de Guadaíra (19.4%), Brieva (11.7%), Teixeiro (9.9%), A Lama (9.3%), Pereiro de Aguiar (3.2%), and Bonxe (2.1%).

The average age of the participating inmates is 41.07 years (SD = 10.89), with a range spanning from 18 to 74 years. In this regard, although women of different ages participated, the majority were between 30 and 50 years old (63.6%). Most of them are Spanish (70.5%), but the sample also includes inmates from the Americas (23.1%), particularly Latin America (22.8%), and, to a lesser extent, from other European countries (5.1%), Africa (1.1%), and Australia (0.3%).

2.2. Instrument

This study is part of a broader research on socio-educational intervention with incarcerated women (Quiroga-Carrillo, 2022), in which two ad hoc instruments were used: a questionnaire for female inmates in prisons and a questionnaire for penitentiary professionals. Both instruments underwent an expert review process (Quiroga-Carrillo, 2022), which allowed for improvements in the questions in terms of both format (item placement and order) and content (expansion or elimination of items and degree of intelligibility).

For this study, only the following questions from the questionnaire for incarcerated women are used:

• Sociodemographic variables: age (continuous quantitative variable), children (dichotomous nominal qualitative), marital status (polytomous nominal qualitative), educational attainment (ordinal qualitative), employment status before incarceration (polytomous nominal qualitative), and whether the partner (or ex-partner) is or has been incarcerated (dichotomous nominal qualitative).

• Criminological profile: foster care (dichotomous nominal qualitative variable), residential care (dichotomous nominal qualitative), juvenile justice measures (dichotomous nominal qualitative), health problems due to drug use (dichotomous nominal qualitative), previous imprisonment (dichotomous nominal qualitative), and offense type (polytomous nominal qualitative).

• Victimization: child maltreatment, perpetrator of child maltreatment, gender-based violence, and perpetrator of gender-based violence-all of which are polytomous nominal qualitative variables.

2.3. Procedure

The questionnaire was administered between September and December 2021 in the seven aforementioned prisons. Prior to its implementation, approval was obtained from the Bioethics Committee of the University of Santiago de Compostela, along with the necessary permissions from the SGIP. Following the recommendations of both entities, as well as the ethical principles of the Declaration of Helsinki, the data collected were used exclusively for statistical purposes, ensuring the confidentiality of the information and the anonymity of the participants.

For the administration of the questionnaire, the study was initially introduced to the inmates in a communal area of the prison (usually the library or dining hall) in the presence of a penitentiary professional. The purpose and objectives of the study were explained, and they were invited to participate, being informed that participation was voluntary and anonymous, and that penitentiary staff would not have access to their responses.

Those who agreed to participate were taken in small groups to a designated meeting room where they completed the questionnaires. Upon arrival, they received an informed consent form, which described the project, the instrument, and their rights as participants. After reading the document and addressing any questions they had, those who remained willing to participate were asked to sign the consent form.

Subsequently, the questionnaires were distributed, and each participant completed them individually within a time frame of 20 to 40 minutes. No inmate chose to withdraw from the study after the distribution of the questionnaires had begun. Women who were unable to read and write or had difficulties with concentration or literacy received assistance from a member of the research team.

2.4. Data analysis

The study follows a quantitative, non-experimental, and descriptive design. For data analysis, the IBM SPSS v25 statistical package was used. First, we conducted a descriptive analysis of the variables to profile the characteristics of the sample. Subsequently, we examined the association between having experienced gender-based violence and other sociodemographic and criminological variables of the inmates (educational attainment, having been in foster or residential care, having received juvenile justice measures, substance use, recidivism, offense type, and having suffered child maltreatment).

To this end, we conducted a univariate analysis using the Pearson Chi-square test and Fisher’s exact test (α = .05, two-tailed significance). Fisher’s test was used when the assumption of expected frequencies greater than 5 was not met for the Chi-square test. To measure the effect size of the non-square contingency tables, Cramer’s V was employed, following Cohen’s (1988) guidelines for interpretation: the effect is small when V ≥.10, medium when V ≥.30, and large when V ≥.50. According to Field (2018), for 2x2 contingency tables, the Phi coefficient (φ) was used, with interpretation equivalent to Pearson’s correlation: the effect is small when φ ≥.10, medium when φ ≥.30, and large when φ ≥.50.

3. Results

As shown in Table 1, most women in the sample have children (79.3%). 56.7% are in a domestic partnership or married. A significant portion (59.1%) has had or currently has a partner in prison. 43.3% have a low level of education (primary education), 40.4% reached a medium level (compulsory secondary education, intermediate vocational training, or upper secondary education), and a minority (16.3%) have completed higher vocational training or higher education. 52.8% were employed before incarceration.

Table 2 presents their criminological profiles. 6% had been placed in foster care during childhood, more than double that percentage (12.6%) had been in residential care, and 16.7% had undergone juvenile justice measures. The majority (60.8%) report having had or currently having health issues due to substance use. 64.4% are first-time incarcerations, while the remaining 35.6% are recidivists. They have primarily been convicted for thefts, burglaries, or property damage (37.3%) and drug trafficking (29.7%).

Table 3 shows the incidence of victimization among the inmates. As can be seen, 26.9% have experienced some form of maltreatment during childhood (20.3% physical violence and 25.9% psychological violence), and 59.6% have been abused by their ex-partner or current partner in adulthood (53.5% physical violence and 58.7% psychological violence).

Following this, we employed the Chi-square test and Fisher’s exact test to examine the association between having been a victim of gender-based violence and specific sociodemographic and criminological variables.

Regarding educational attainment, we found statistically significant differences, χ2(2, 372) = 7.21, p = .027, V = .139, with a small effect size (see Table 4). Women with a low or medium level of education showed a higher proportion of affirmative responses.

Fisher’s exact test indicates a significant relationship between having been in foster care and having experienced gender-based violence (p = .007, φ = .140), with a small effect size (see Table 5). The percentage of victims is higher among those who experienced a situation of neglect that led them to be placed in foster care (either with a family member or a non-relative).

No differences were found based on whether the inmate had been placed in residential care, χ2(1, 363) = 3.41, p = .065, φ = .097, or whether they had received juvenile justice measures, χ2(1, 364) = 2.96, p = .085, φ = .090.

A significant association is detected between health problems due to substance use and gender-based violence, χ2(1, 373) = 53.67, p < .001, φ = .379, with a medium effect size. As shown in Table 6, the proportion of this abuse is higher among those who have or have had drug-related disorders.

No differences were found based on recidivism, χ2(1, 374) = 1.26, p = .262, φ = .058, but significant differences were observed based on offense type, with a small effect size: χ2(4, 365) = 22.65, p < .001, V = .249. Women who were incarcerated for theft or robbery, homicide and its forms, and other crimes report higher rates of gender-based violence compared to those who committed drug trafficking or white-collar crimes (see Table 7).

Finally, significant differences were observed with child maltreatment, χ2(1, 374) = 3.98, p = .046, φ = .103, although the effect size is small (see Table 8). Inmates who experienced abuse as minors report a higher proportion of victimization in adulthood.

4. Discussion and Conclusions

The results lead us to conclude that a significant proportion of participants (nearly 60%) experienced gender-based violence from their ex-partner or current partner, with 54% reporting physical violence and 59% psychological violence. These figures align with other findings reported in the scientific literature and confirm the need to integrate a gender perspective into the socio-educational interventions developed in the correctional context.

In the United States, where significant progress has been made in this line of research, Jones et al. (2021) found that 69% of incarcerated women had experienced physical assault, 31% sexual abuse, and 72% psychological abuse in the 12 months prior to their most recent relationship before their arrest. In the study by Leone & Beeble (2024), the figures for physical abuse rise to 99% and for psychological violence to 100%. St. Cyr et al. (2021) present similar figures, with 91% reporting some form of gender-based violence in the 12 months before being incarcerated. Of these, 64% reported psychological abuse, 57% physical violence, 50% stalking, and 51% combined violence (physical, emotional, and sexual).

In Peru, Cyrus et al. (2021) found that 69% had experienced threats of violence, 61% physical violence, and 28% sexual assault. In Spain, the study by Fernández-Iglesias (2017) indicates that 26% had suffered physical abuse, 30% psychological and emotional abuse, and 13% sexual abuse, all at the hands of their partners. A few years before, Mapelli et al. (2013) established that 51% had been victims of gender-based violence prior to incarceration.

On the other hand, our data indicate a relationship between educational level and gender-based violence victimization. The literature has shown that higher educational attainment in women acts as a protective factor against gender-based violence, while lack of education is a risk factor (Damonti, 2019; Spencer et al., 2019; Vives-Cases et al., 2010). However, few studies analyze this relationship with a sample of incarcerated women. In the study by St. Cyr et al. (2021), educational attainment was not associated with any form of gender-based violence. For Jones et al. (2021), a low level of education was significantly associated with adverse childhood experiences, but not with gender-based violence in adulthood. Although the results in this population are inconclusive, it is clear that strengthening the education and training of these women is crucial, not only to enhance their reintegration opportunities but also as a strategy to prevent future victimizations.

In our study, we also found a relationship between having been in foster care and having been a victim of gender-based violence. Again, the literature addressing the relationship between these two variables is limited. The research by Katz et al. (2023) reports a high prevalence of emotional abuse and bidirectional violence among adult women who had been in foster care. Jonson-Reid et al. (2007) concluded that a significant proportion of adolescents in foster care reported experiencing violence in intimate relationships. To our knowledge, there are no studies that examine this issue with a sample of women who are or have been incarcerated.

Overall, and in an attempt to explain our results, it can be hypothesized that child abuse and neglect were established as one of the triggering factors for delinquent behavior (Broidy et al., 2018; Cernkovich et al., 2008; Chesney-Lind & Pasko, 2013), placing these women at risk for revictimization (Abajobir et al., 2017; Caravaca-Sánchez & Wolff, 2016). It remains to be analyzed whether foster care can offer these women an opportunity to promote healthy relationships or, conversely, represents an additional risk factor (Ball et al., 2023). In any case, our results highlight the importance of developing early socio-educational interventions that address the consequences of child maltreatment and emotional vulnerability in women at risk of social exclusion.

Another relevant finding is the relationship between health problems due to substance use and gender-based violence, a topic widely addressed in the literature. High prevalence rates of alcoholism and drug use have been documented among women who are victims (Ataiants et al., 2020; Stone & Rothman, 2019), including those who entered the criminal justice system (Cyrus et al., 2021; McKee & Hilton, 2017). It is worth noting that, while it is common for abuse to precede substance dependence (Ahmadabadi et al., 2019; Cernkovich et al., 2008; Saxena et al., 2014), it has also been shown that drug use represents a risk factor for future victimization (Cafferky et al., 2018). Therefore, programs for female inmates must focus on trauma, substance abuse, and the dynamics of violence, adopting a holistic approach that addresses their interrelationship rather than treating them as isolated problems.

Women who entered prison for crimes such as theft, homicide, and other violent offenses are the ones who most report having suffered gender-based violence. Studies framed within the pathways to crime theory suggest the existence of a group of women with high rates of victimization (both in childhood and adulthood) who have committed serious and violent crimes (Brennan et al., 2012; Daly, 1992; DeHart, 2018), as well as property offenses (Richie, 1996; Simpson et al., 2008). Regarding the latter offense type, it is important to highlight that theft and robbery are crimes where women often participate alongside their partners (McNeeley, 2019; Simpson et al., 2008). It has been shown that some abusive partners coerce women into committing crimes, covering them up, or even taking the blame for them (Barlow, 2016; Nuytiens & Christiaens, 2015). These findings highlight the need to prioritize the rehabilitative dimension of imprisonment, analyzing within the criminal justice system the biographical factors and the structural conditions that lead these women to offend. The justice system needs to consider not only the criminal behavior itself but also the impact of gender-based violence, coercion to commit crimes, and social exclusion as factors that may underlie many female criminal careers. Within the prison context, it is crucial to design and implement programs that address the specific needs of incarcerated women, arising from their recurrent experiences of violence.

Finally, the relationship between child maltreatment and gender-based violence in adulthood aligns with the existing literature on persistent victimization trajectories. In recent decades, it has been widely demonstrated that multiple and persistent victimization processes at an early age increase the likelihood of experiencing gender-based violence (Abajobir et al., 2017; Caravaca-Sánchez & Wolff, 2016; Klest, 2012; Jones et al., 2021). Specifically, among victims of child abuse, it is common for complex trauma to develop, leading to the normalization of abuse, emotional dysregulation, insecure attachment, feelings of guilt, and depression—characteristics that make them more vulnerable to future violence (Li et al., 2019; Widom et al., 2014). To break this cycle of victimization, prisons must implement interventions focused on trauma, promoting the emotional well-being of these women. This involves strategies that help them recognize and break patterns of abuse, develop coping skills, build healthy relationships, and access support resources upon their release.

Therefore, we can conclude that among Spanish incarcerated women, certain variables are directly related to experiencing gender-based violence, which reinforces the need for socio-educational interventions within prisons. The literature has highlighted that correctional treatment should incorporate education as a key element for reintegration, ensuring that female inmates have access to training programs, psychological support, and social assistance that address their specific needs stemming from violence and exclusion (Añaños-Bedriñana & Yagüe, 2013).

However, our study has several limitations. First, we did not include in the study any variables related to trauma, so we were unable to examine how this issue is associated with the experiences of violence. Additionally, there are several challenges when working in this context —a total institution— which has protocols and timeframes that are not always aligned with research requirements. Third, the restrictions on access to prisons, especially during the COVID-19 pandemic, forced us to use a purposive non-probability sampling method, which limits the generalization of the results to the entire female prison population in Spain. Finally, the questionnaire used is a self-administered instrument, which can lead to response biases, particularly in terms of social desirability.

Overall, we believe our work has contributed to a deeper understanding of this line of research in the Spanish context, where the analysis of victimization experienced by incarcerated women has been limited, particularly from a quantitative approach and within the field of Education Sciences.

Our results have several implications for the penitentiary system, the most notable of which is the integration of a gender perspective into the socio-educational interventions developed within prisons. International literature has outlined a set of guidelines that ensure the development of gender-responsive practices, including the following:

• The use of assessment instruments adapted to the specificities of female offending.

• The implementation of gender-responsive programs that holistically address the prevention of violence, the development of autonomy, trauma, and substance abuse.

• The reduction of the number of women in male prisons, considering dedicated facilities for female inmates.

• The training of correctional staff in gender perspective and trauma response, ensuring that interventions promote real reintegration.

In this regard, several countries have developed initiatives and programs to address trauma and the prevention of gender-based violence, among other issues (Blanchette & Brown, 2006; Bloom et al., 2003; Gelsthorpe, 2020). In Spain, as previously mentioned, the ‘Ser mujer.eS’ program (SGIP, 2010) stands out as the only program specifically designed for women offered by the penitentiary system. Thus, in our country, there remains a gap in the implementation of prison programs that specifically and comprehensively address the needs of these women. The administration must develop new initiatives that focus on mental health, trauma resulting from previous victimization experiences, substance abuse, motherhood, employability, and support networks, responding with a holistic socio-educational perspective to the complexity of these women’s pathways.

Therefore, the goal is to move towards more inclusive and effective prison models that not only punish but also educate, prevent, and promote the social reintegration of female inmates, many of whom come from complex cycles of social exclusion.

Contributions

Funding

This research was funded by an ‘Aid for University Teacher Training’ (‘Ayuda para la Formación del Profesorado Universitario’) from the Spanish Ministry of Education, Culture, and Sport (FPU17/00373).

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Bioethics Committee of the University of Santiago de Compostela (USC-39/2020) and the General Secretariat of Penitentiary Institutions (Secretaría General de Instituciones Penitenciarias) of the Spanish Government. Informed consent was obtained from all participants involved in the study.

Conflict of interest statement

The authors declare no conflicts of interest.

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