Domestic violence (DV) is defined by the World Health Organization [1] as “the range of sexually, psychologically, and physically coercive acts used against adult and adolescent women by current or former male intimate partners.” It represents a unique aspect of the wider set of problems faced by women in most societies worldwide.

Much qualitative evidence and analysis demonstrate that DV has a deleterious effect on the physical and mental health of women [2]. An estimated 35% of women visit emergency departments as a result of DV, and abused women are reported to have a 50-70% increase in gynecological, central nervous system, and chronic stress-related problems compared with non-abused women [3]. Gynecological problems may include sexually transmitted diseases, fibroids, pelvic pain, vaginal bleeding, or infection. Chronic stress-related problems that have been reported include functional gastrointestinal disorders, appetite loss, and colds [3]. There are also reports, including those of a meta-analysis of 14 studies, that women exposed to abuse during pregnancy had an increased risk of miscarriage, abortion, and stillbirth [4,5].

Population-based data on the prevalence and effects of DV are limited in Arab countries and are only available from few countries in the region. The prevalence of DV in Arab countries ranges between 23 and 35%, similar to internationally reported data [6,7]. In a conservative country such as Saudi Arabia, there are no official reports on the prevalence of DV, and only a few hospital-based studies [8,9] have focused on the prevalence and health consequences of DV. In a study conducted among married women in Al-Ahsa, Saudi Arabia [9], the prevalence of lifetime DV was 39.3% (35.9% for mental, 17.9% for physical, and 6.9% for sexual violence). To the best of our knowledge, no population- or hospital-based study has been conducted in Jeddah to assess the prevalence of DV among women. In this paper, we explore DV in women who lived in Jeddah, with the aim of estimating its prevalence and the common health problems reported by abused women.

Participants

This was a cross-sectional survey conducted from December 15^th, 2011 to March 30^th, 2012 at King Abdulaziz University Hospital, King Abdulaziz Oncology Medical Center, and King Fahd General Hospital, which are three leading tertiary care hospitals in the western region of Saudi Arabia.

The target population included a convenience outpatient and inpatient sample of women (patients, caregivers, and visitors) aged 15-70 years who were willing to participate in this study. We could not include participants from women’s gathering groups because our approach was hampered by resistance from the administration owing to the relatively sensitive nature of our theme.

A total of 2301 women were included from the outpatient and inpatient departments of the above-mentioned hospitals. Of these, 2072 respondents completed the full interview, representing an overall response rate of 90.0%. Of the total number of non-responders (n=229), 10.0% provided partial or incomplete information. A followup study of non-responders was not performed, as the survey was conducted in a public place.

A psychologist and a professional health assistant explained the purpose of the research to all the women who consented to participate in the survey. The women were then asked to fill a 50 item questionnaire that comprised questions to identify ever exposure to DV. Special assistance was provided to the illiterate and in cases where further explanation was required. All questionnaires were collected immediately after they were filled.

Instrument

We used a questionnaire that was available in English and Arabic. The questionnaire was developed by selecting items from two validated questionnaires: the NorVold Domestic Abuse Questionnaire [10] and the Kansas Marital Satisfaction Scale [11].

Items assessed

Violence

The questionnaire was composed of five sections:

• Eleven items on the personal data of the women

• Twenty-five items on violence, namely two items for general violence, ten items for physical violence, six items for psychological or emotional violence, and seven items for sexual violence

• Five items that explored the respondents’ options to ask for help

• Five items that assessed the damaging effect of DV on the victims

• Four items that evaluated sexual dysfunction and three items that scored the level of happiness, extracted from the Kansas Marital Satisfaction Scale [12].

For the purpose of this study, physical violence was defined as having ever been pushed, beaten, slapped, kicked, hit with a fist or object, pulled by the hair, dragged, burned, or threatened or attacked with a knife or gun by a spouse or family member.

Psychological abuse was defined as having ever been threatened by a spouse or family member, prevented from visiting or calling family members and friends, or insulted. Sexual violence was defined as having ever been forced by a spouse or family member to have unwanted sexual intercourse.

Marital satisfaction

Marital satisfaction was categorized into the following: extremely dissatisfied, very dissatisfied, somewhat dissatisfied, mixed feelings, somewhat satisfied, very satisfied, and extremely satisfied.

Health problems

Closed-ended questions on general well-being, including body selfimage and perception of self and others, were asked to document health problems experienced by the participants.

Statistical analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS IBM Inc., New York, US), version 18. The independent t-test was used for equal variance and Welch’s t-test for unequal variance. The chi-square test was used to determine the relationship between variables. Differences were considered statistically significant at a p-value of <0.05. Results are expressed as mean ± standard deviation (SD) and frequency (%).

The Biomedical Ethics Research Committee of King Abdulaziz University provided ethical review and approval for the survey, including voluntary recruitment, rigorous confidentiality provisions, and written informed consent.

General characteristics of the study population

A total of 2301 women were recruited. The mean ± SD age of the women was 34.4 ± 10.9 years. Of the 2301 women, 2235 (97.1%) were Muslim, whereas 23 (1.0%) were Christian; 43 women did not specify their religion. Saudi women constituted 58.3% (n=1342) of the sample.

Among the participants, 1516 (65.9%) were married, 606 (26.3%) were divorced, 58 (2.5%) were widowed, and 34 (1.5%) were separated; 87 (3.8%) did not specify their marital status. Most of the participants came from big families where the mean number of siblings was 7.1 ± 3.4.

Abuse

Emotional abuse

The prevalence of abuse (physical, emotional, and sexual) was 34.0%. Emotional or psychological abuse was the most common form of abuse, which was reported by 720 women (31.3%).

Nearly one in five women (n=492, 21.4%) reported divorce threats from their husbands, 340 (14.8%) reported being prevented from visiting or calling their families, 264 (11.5%) reported their husbands had threatened to marry another wife, 183 (8.0%) received threats of getting thrown out of their homes, and 163 (7.1%) had money withheld from them (Table 1).

Table 1: Frequency of responses to questions that assessed emotional abuse (Data presented as frequency (percent).

Physical abuse

A total of 290 women (12.6%) reported physical abuse. Almost one in ten women reported ever experiencing physical violence in the form of beating (n=237, 10.3%), hitting with the fist (n=222, 9.6%), or slapping (n=194, 8.4%).

Of the 2301 women, 88 (3.8%) reported serious injury that required medical intervention or hospital care; 46 (2%) were threatened with a knife or gun.

One hundred and thirty-six women (5.9%) reported severe beating during childhood (Table 2).

Table 2: Frequency of responses to questions that assessed physical abuse (Data are presented as frequency (percent)).

Sexual abuse

One hundred and eleven women (4.8%) reported being sexually abused by a family member. Sixty-six women (2.9%) reported sexual penetration during childhood, and 68 women (3.0%) reported ever experiencing forceful anal intercourse.

Forty-four women (1.9%) reported that their husbands kicked them during intercourse (Table 3).

Table 3: Frequency of responses to questions that assessed sexual abuse(Data are presented as frequency (percent)).

Health problems reported by abused women

The frequency of health problems was higher in abused than nonabused women (Table 4).

Table 4: Most common medical and mental problems reported by abused and non-abused women (Data are presented as frequency (percent)).

These included loss of trust in others (P<0.0001), irritable colon or gastric ulcer (P<0.0001), hopelessness (P<0.0001), body self-hatred (P<0.0001), and food addiction (P<0.0001) (Table 4).

Marital and sexual satisfaction

The proportion of women who were unsatisfied with their marriages was higher in the abused than non-abused group (P≤0.0001 for emotional, physical, and sexual abuse).

One thousand eighty-three women (52.3%) reported they did not enjoy sex with their spouses; 746 women (54.7%) in the non-abused group did not enjoy intercourse as compared with 337 women (47.7%) in the abused group (P=0.003). Two hundred twenty-nine (10.0%) women declined to respond to the question on sexual satisfaction (Table 5).

Table 5: Marital satisfaction scale showing how satisfied the women were with their marriages (Data are presented as frequency (percent)) (*P≤0.0001).

Help-seeking action

A very small proportion of the women sought help from their families (n=72, 3.1%) or husbands’ families (n=73, 3.2%). Only 56 women (2.4%) responded that they planned to see a psychiatrist; 24 women (1.0%) planned to contact social services.

The definition of women abuse varies in different cultures. In fact, the various methods that are used to measure violence can cause wide variations in its assessment, leading to great difficulties in estimating its prevalence. In a conservative society such as Saudi Arabia where male authority is predominant, it is a quite difficult and complicated task to assess abuse against women.

According to some data [13], there is a growing body of evidence pointing to the range of negative health consequences of DV, and women are reportedly victims of violent deaths, which are either a direct (through homicide) or indirect (through suicide) result of DV. In this study, we attempted to explore violence against women living in Jeddah.

Our analysis showed that the lifetime prevalence of DV was 34.0%, which falls within the 23-35% range of prevalence rates for Arab countries [6,7]. Conversely, the prevalence reported in the current study is relatively lower when compared with results from studies conducted in other regions of Saudi Arabia. Afifi et al. [9] reported that the lifetime prevalence of DV among women in the Eastern Province of Saudi Arabia was 39.3%, and Tashkandi and Rahseed [8] reported that the lifetime prevalence of abuse in women who attended primary health centers in Medina was 57.7%. The lower percentage observed in the current study could be explained by the heterogeneous nature of our population, which consisted of women from various cultural backgrounds.

Emotional abuse was the most frequent form of abuse (31.3%) in our study; 12.6% of the participants reported physical abuse, whereas 4.8% reported sexual abuse. Other authors [7,9,14,15] have also cited emotional abuse to be the most common form of abuse, which we believe might be because all forms of abuse have an emotional component. In one report from Sari, Iran [16], it was found that the prevalence of physical, emotional, and sexual abuse was 73.5%, 92.2%, and 49.6%, respectively. In another report from the United States [14], the authors found that up to 97.2% of the women in their study were emotionally abused. Sexual abuse was also the least common form of abuse, reported in 16.5% of the women.

Domestic violence is known to affect women’s health and well-being seriously [17-20]. In the current study, loss of trust, body self-hatred, food addiction, and irritable bowel syndrome or gastric ulcers were significantly more common among abused women. This finding might be related to the fact that psychological or emotional abuse, which was the most common form of abuse in our study, is positively related to negative health perceptions [21]. Furthermore, our finding of poor sexual fulfilment, which was more common among abused women, is not surprising because sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable sex experiences, free of coercion, and violence [22].

Many women in our study declined to make comments on their spouses or marital fulfilment; however, the level of marital satisfaction was high in the respondent group. Most women (79.9%) were satisfied to extremely satisfy although over half of them (52.3%) reported they did not enjoy sex with their husbands. In Saudi Arabia, interpretations of the local culture and traditions, as well as social peer pressure, have been reported to have a negative impact on women’s well-being [23]. As a result, women tend to tolerate their husbands and thus feel they are satisfied with their marital lives, or they decline to talk about their spouses for fear that it is socially improper to do so. More so, because sex is generally a subject of taboo in Saudi Arabia like in many Arab countries [24,25], most women tend to ignore the importance of sexual satisfaction in marriage or judge that it is not important.

We found that only 1% of DV victims planned to seek help from social services. Few participants left their contact numbers with the prospect that we could help them gain access to social services since personal efforts were unsuccessful, and the limited available services were only accessible to local citizens. It is plausible that some women do not report cases of DV because social services are underdeveloped in Saudi Arabia or because of the poor perception of social services by the local population [25]. In addition, Arab women are in general expected to balance their needs and well-being against loyalty to their spouses and preservation of family reputation [26]. Besides, fear of retaliation by the spouse has also been reported to be more common among Arab women, whose concerns are not only limited to increasing violence, but also to being separated from their children, a technique that is commonly applied by violent spouses [7]. However, this may be more of a cultural than a religious issue, as Prophet Muhammad (10 A.H.) in his last sermon said: “Do treat your women well and be kind to them for they are your partners and committed helpers.”

Approximately 90% of countries have ratified international conventions specifically banning discriminations against women, including the Convention on the Elimination of All Forms of Discrimination against Women [27] and the Declaration on the Elimination of Violence against Women [28]. In Africa, human rights groups such as the Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa [29] stipulates that “States Parties shall prohibit and condemn all forms of harmful practices which negatively affect the human rights of women and which are contrary to recognized international standards. States Parties shall take all necessary legislative and other measures to eliminate such practices.”

This study has several limitations. First, because women were recruited from hospitals, the results may not be representative of the local population in Jeddah. Second, the use of close-ended questions in the questionnaire probably introduced bias since women with no opinion were constrained to respond. Third, we could not obtain information from some participants due to barriers associated with fear of breach of privacy, tensions about limited confidentiality, and frustration linked to feelings of unsafety after releasing information to strangers. Fourth, our use of questionnaires implied that we relied on the participants’ honesty and memories thereby increasing the risk of bias during data analysis. Finally, the interpretation of happiness and satisfaction is purely subjective and cannot be accurately assessed.

However, our study highlights the magnitude of DV among women who were interviewed at three of the largest hospitals in Jeddah. We recommend that social service policy makers make their facilities available to victims of DV by encouraging women to disclose their abuse, changing the perception of social services in our society, and providing victims of abuse with mandatory prevention, counselling, and support. Furthermore, the role of care managers (specially trained nurses) should be explored in abused women needing medical attention. A previous model that incorporated care managers to support general practitioners and specialists in managing patients showed that patients were more satisfied with health care services due to their strong partnership with care managers who collaborated effectively with physicians [30].

Domestic violence affects 34.0% of women attending the outpatient and inpatient clinics of three of the main tertiary hospitals in Jeddah. Mental and medical disorders are more frequent among victims of DV. Furthermore, only a small proportion of abused women seeks or plans to seek help either from family members or social security services. Policy makers should, therefore, improve the social support services to encourage and cater for the needs of abused women. It is necessary for health policy decision-makers to set rules and regulations to carefully assess this problem, which can be done by improving the level of awareness about violence against women and developing social support services to cater for the needs of abused women. In addition, health care providers should consider developing a valid and culturally appropriate violence screening method in pregnant women to enable health professional’s screen and estimate suffering, and hence provide victims of DV with adequate care and support.

This work did not receive any specific grant from any funding agency in the public, commercial, or non-profit sector.

The author wishes to thank Mr. Kalvin Balucanag for his help in analyzing the data. The author would like to thank the staff at King Abdulaziz University Hospital, King Abdulaziz Oncology Medical Center, and King Fahd General Hospital for their help in collecting data.

As the sole author, Wafa M.K. Fageeh wrote and approved the manuscript for submission. She warrants that this article is her original work and it has not received prior publication nor is it under consideration for publication elsewhere.

The author has no competing interests.