The Prevalence and Characteristics of Physical Violence Against Married Women in Saudi Arabia: A Cross-Sectional National Study

Introduction:

Violence against women is a major public health issue worldwide, and a significant violation of the basic human rights of women.¹ According to the United Nations, the most common type of violence against women internationally is physical violence in which the perpetrator is an intimate partner.² International data found that almost 30% of women in intimate relationships have encountered physical or sexual violence by their partners. According to the WHO, the Eastern Mediterranean region, which includes the Arab countries, has the second-highest prevalence of physical and/ or sexual partner violence against women after South-East Asia.1 37% of women in the Eastern Mediterranean region were subjected to physical or sexual violence.¹ A systemic review among women undergoing healthcare in Arab countries found that 35.5% of women were physically abused.³ Although data from individual Arab countries are limited,1 previous studies found that the prevalence of physical violence among married women reached up to 34% in Egypt,4 31.2% in Jordan,5 and 40.67% in Lebanon.⁶ In a Kuwaiti study among married and divorced women, 71% of the women were abused physically.⁷ Moreover, a study that examined violence-related injuries in the United Arab Emirates found that women were significantly more likely to be injured at home and by a family member.⁸ In Saudi Arabia, there is no previous national study that assessed the prevalence of physical violence among married women. However, previous studies in primary health care centers found a prevalence ranging from 9% to 80.7%.9, 10-13

Domestic violence against women is associated with various negative health effects. Women who are in abusive relationships were found to have an increased risk of anxiety, PTSD, and depression.^{14, 15} Abused women were also found to be eight times more likely to attempt suicide and six times more likely to abuse substances than non-abused women.^{16, 17} Domestic violence is also associated with multiple forms of physical complaints like headache, chronic pain, gastrointestinal symptoms, and fatigue.¹⁴ In addition, domestic violence was found to increase healthcare costs among abused women compared to women who are not abused.¹⁴ It is also associated with increased non-health-related costs like criminal justice services and damaged or lost properties.¹⁸

There are several sociocultural, individual, and relationship factors that can be attributed to domestic violence internationally.¹⁹ Individual factors may include young age, low academic level, low income, and substance-use disorders.¹⁹ Relationship factors include marital conflict and instability, polygamy, and the number of children.^{19, 20} Also, the existence of traditional gender roles and social norms that tolerate domestic violence in a community was found to be a main sociocultural risk factor.¹⁹ This is especially true in some Arab countries, where the belief that husbands are superior to their wives and they have the right to punish them still exists.^{20, 21} It was also suggested that domestic violence will increase in communities where the status of women is changing, and this is the current status of women in Saudi Arabia.²² This is because in communities where women have very low status, violence is not required to establish male authority, and violence is not acceptable in communities where women have already established high status.

The available information in the literature regarding factors influencing the prevalence of domestic violence is based mostly on Western studies, and it may not fully represent other communities.¹⁹ Studies examining domestic violence in Saudi Arabia, which differ in culture and social norms from Western societies, are still limited.²⁰ Thus, this study aims to describe the various forms of physical violence against women in Saudi Arabia, as well as the consequences and reasons for this violence and the victims’ reactions towards it. This national study is one of the first, if not the first, to explore the characteristics of physical violence in Saudi Arabia. national study to explore the characteristics of physical violence in Saudi Arabia. Results from this study may help identify different preventable factors of domestic violence and barriers preventing the victims from reporting, which may provide a basis for policymakers to develop anti-violence rules and policies.

Materials and methods:

Study design:

A cross-sectional study was conducted during the COVID-19 quarantine period in Saudi Arabia, from 23 March until 21 June, 2020. The study included married women, 18 years of age or older, and living in Saudi Arabia during the study period. It used a non-probability convenience sampling technique, and the data were collected using an electronic survey distributed through social media. The optimal sample size for this study was calculated using Raosoft23 with a 5% margin of error, a confidence level of 99%, and a population size of 4,832,830 married Saudi and non-Saudi women in the 15 to 65 year age group, according to Saudi General Authority for Statistics (2011)24. The sample size was calculated as 700 participants, with the final sample size 2254 participants.

Data collection:

This study is a part of a larger research project investigating all types of violence and the associated factors in Saudi Arabia.²⁵ The data-gathering instrument was an adapted and edited Arabic version of the 2006 WHO international self-assessment survey. The questionnaire was retrieved from Abolfotouh and Almuneef.^{26, 27, 28} Further modifications have been made to the questionnaire reflecting our study objectives, taking into account the study’s current state of the COVID-19 pandemic. In addition to demographic data, the questionnaire included questions about the frequency and severity of physical violence, its consequences, risk factors, and the victim’s reaction. The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center. The questionnaire was accompanied by an informed consent form, and the participants completed the questionnaire voluntarily. Participants were informed of the objectives of the study. This study did not obtain any personal or identifying information to ensure privacy and confidentiality. The data were only accessible to the research team.

Statistical analyses:

Data were entered and analyzed with MS Excel and SPSS 24.0 (IBM Inc., Chicago USA) statistical software. Frequency and percentage were used to describe the categorical data and the outcome variables. Data were analyzed with the assistance of an external data-analysis service.

Results:

Socio-demographic characteristics:

2254 married women have answered the electronic questionnaire. The majority of them were Saudi (94.6%), 31 to 40 years-old (45.3%), government employees (72.3%), and with a college education (65.7%). Most of the women also had alive parents (70.4% fathers; 88.4% mothers) and 3-5 children (35.2%), and about 75% of women had mentioned that they were part of 1 to 5 male and female siblings in their respective families. Similarly, the husbands were predominantly 31-40 years old (46.3%), government employees (42.8%), and with a college education (53.4%) (Table 1).

Frequency and severity of physical violence:

Of 2254 women who participated in this study, only 352 (15.6%) reported that they have been subjected to physical violence from their husbands. 93% of the women who were subjected to violence have ever been slapped/ punched on any part of their bodies by their husbands (10.4% always; 9.2% most of the time; 73.4% sometimes), 65.4% have been kicked/pushed or thrown on the floor (7.1% always; 9.4% most of the time; 48.9% sometimes), 11.4% have been threatened with a handgun or knife (1.1% always; 2.3% most of the time; 8.0% sometimes), 33.1% have been subjected to chocking (2.6% always; 5.1% most of the time; 25.4% sometimes), 60.7% have had house items thrown at them (7.4% always; 12.0% most of the time; 41.3% sometimes), and 59.9% have been subjected to other forms of physical violence like bites, pulling, or burning (5.7% always; 8.6% most of the time; 45.6% sometimes) (Table 2).

Characteristics and consequences of physical violence

The majority of violence victims in this study were abused in the absence of others (49.1%) and did not remember the last time their husbands hit them (71.4%) or how many times in the last year (89.1%). 39.1% of women who were victims of violence have been beaten by their husbands while pregnant. The vast majority of abused women have said that their husbands’ violence affected their physical or mental health (92.4%). 45.5% have sustained injury secondary to physical violence, and 20.6% have lost consciousness as a result of the violence. Approximately half of the women (51.6%) were hurt badly enough to need healthcare, and the types of injuries that necessitated treatment were Bruises (76.6%), Wounds (31.2%), Eye/ear injury (28.6%), Abortion (16.9%), Broken bones (13.0%), Broken teeth (5.2%), and burns (2.6%).

Reasons of physical violence among married women and their reactions towards it.

According to the women who were subjected to violence in this study, their husbands hit them mostly for no specific reason (39.7%), if they disobeyed (34.8%), and due to problems with his or her family (32.1%). The women reacted to the violence by their husbands by crying (57%), defending themselves (54.3%), asking for divorce (21%), leaving the house (16.8%), and asking for help (11.3%). Approximately half of the women subjected to physical violence told their siblings (51.2%) or parents (50.8%); 31.4% of the women told no one about the violence. 81% of violence victims did not ask for help from the police, social protection, court, hospitals, or counselors. The most common reasons for not asking for help were because they were afraid that they will lose their children (38.3%), bring bad name to the family (28.2%), or afraid of divorce (24.3%) (Table 4).

Discussion:

In this study, physical violence among married women in Saudi Arabia was found to be 15.6%. This is lower than the prevalence that was reported worldwide (30%) or in the Eastern Mediterranean region 37%.1 This study is among the first Saudi studies to address physical violence on a national level. Previous Saudi studies have assessed physical violence only in clinical settings (e.g., primary health care centers) or in a single city. Studies that were conducted in primary health care centers in Saudi Arabia found the prevalence of physical violence among married women to be 17.9% in Al-Ahsa,29 20% in Riyadh,11 25% in Medina,12 44.5% in Jeddah,13 and 80.7% in Arar.⁹ Also, A previous study in multiple teaching, governmental, and primary health care institutions in Riyadh found that the prevalence of physical violence among married women was 9%.10 These discrepancies between the prevalence found in Saudi studies may be attributed to multiple reasons related to their methodologies such as variations in study design, study duration, the setting, or the data collection method (survey-based vs. interview). It was noticed that the studies with a lower sample size had a higher prevalence of physical violence. For example, the study conducted in Arar among 208 participants had an 80.7% prevalence of physical violence,9 and the study conducted in Jeddah resulted in a 44.5% prevalence of physical violence had 200 participants.¹³ On the other hand, this study had 2254 participants and resulted in a 15% prevalence of violence. Another reason to explain the variation of the prevalence between local studies is the sociodemographic profile of the participants. Women from different cities may have different cultural backgrounds, which may influence their experience of violence.

Most abused women in this study reported that their partner’s abuse had affected them a lot physically or mentally, and approximately half of them have been hurt badly enough to need healthcare. Negative health effects of domestic violence have been reported internationally1 and among the Arab population.³⁰ A previous systemic review among Arab clinical populations found that domestic violence significantly increased the odds of sleep problems, depression, pain, abortion, and hypertension.³⁰ Despite the health effects, 81% of abused women in this study did not go to any specialized service for help. Similarly, data from the USA suggest that 85% to 97.5% of abused women do not report domestic violence.³¹ In local studies among primary healthcare visitors, 40% of abused women In Riyadh10 and 41.4% of abused women in Al-Ahsa29 did not seek any help. These numbers suggest that the true prevalence of domestic violence, whether physical or otherwise, might be much higher than the reported prevalence because many cases are not reported. Most of the abused women in this study did not remember the last time their husbands hit them or how many times in the last year. This could indicate that the violence could be infrequent in some cases, so some women do not remember it. For example, the majority of the women answered “sometimes” when asked if they have ever been slapped (73.4%) or kicked (48.9%) by their husbands. Another explanation for this forgetfulness could be psychological repression of the event by the victims due to its traumatizing nature.

In our study, women did not report the violence mostly because of fear of losing children, fear of bringing shame to their families, and fear of divorce. It was suggested that the reasons for not reporting domestic violence could be personal or cultural.³¹ Personal reasons may include financial dependency of the victim on her abuser, fear of revenge, or simply embarrassment, while cultural reasons include an imbalance of women and men in society, victim-blaming, and family’s privacy.³¹ Due to the traditional culture of Saudi society, these reasons may affect Saudi women’s decision to report to a greater extent than Western women. Unlike western culture which values individuality, the Saudi society is a collectivist society that puts the needs and desires of the large group, like the family, over the individual’s best interest.³² Another reason for not reporting domestic violence in Saudi Arabia could be that some women think it is an acceptable, and even justifiable, way of solving marital conflict. For example, 51% of women who participated in a cross-sectional study in Southern Saudi Arabia thought it is acceptable for the husband to beat the wife in case she insulted him or disobeyed him.³³ In another Saudi study, 52.7% of men and 36% of women thought that violence is appropriate in case of women’s misconduct.³⁴ Saudi Arabia has an existing law of protection from abuse, and the country is currently modifying rules and regulations to allow more independence for women as part of it is 2030 vision.³⁵ However, there is still a role for policymakers to ensure that the laws are implanted correctly (i.e., abusers are getting persecuted, and victims are getting helped).³⁵ Also, there is a need for awareness campaigns to spread awareness that domestic violence is not acceptable in any case, under any circumstances, and it is actually a crime.

There was a high number of women who were physically abused during pregnancy in this study (39.1%). Data regarding the prevalence of physical violence among pregnant women in Saudi Arabia is limited; however, two studies in Eastern Saudi Arabia addressed the topic and found that the prevalence was 22%-69.5%.36, 37 According to the WHO, physical intimate partner violence during pregnancy ranged between 1% in Japan and 28% in Peru.³⁸ In Arab countries, Hawcroft et al. found that physical violence during pregnancy ranged from 10.4% to 54%.30 The Saudi prevalence of physical abuse during pregnancy found by this study and two other studies^{36, 37} appears to be on the higher side when compared to the international prevalence and is closer to the prevalence found by other Arab studies,30 perhaps due to the cultural similarities between Saudi Arabia and other Arab countries. Indeed, this high prevalence indicates a need for domestic violence screening in prenatal clinics.

Approximately half (45.9%) of the women in this study were abused in front of their children. This finding was similar to a study in Riyadh in which 65.3% of women have been abused while their children witnessed it.¹¹ Previous international studies also found that children from families who deal with domestic violence could be three to nine times more likely to experience injury or abuse, whether directly or when trying to protect a parent.³³ Children from abusive families were also found to be more likely involved in bullying, playground violence, and juvenile crime.³³ These findings indicate that interventions focusing on violence against women would also be helpful to the whole family. Moreover, exploring domestic violence against mothers in children who have behavioral or unexplained medical symptoms may be beneficial.

This study has multiple limitations. One is that the data were collected using an electronic survey distributed by social media, which may affect the accuracy and the reliability of the results and result in self-reporting bias. For example, this study may not reflect the nature of physical violence among Saudi women who do not use social media, do not use it frequently, or do not use the app that was used to collect the data for this study. Also, women who have never experienced physical violence may not be eager to participate in the survey due to less interest in the subject than physical-violence victims. Moreover, the sample size included may not accurately reflect the prevalence for the females suffering from domestic violence due to fears of identifying the responders’ identity, which may be a cause for social embarrassment and further violence.

In conclusion, in this study, 15% of women were subjected to physical abuse, and most of them were impacted negatively as a result of this experience. Despite the negative effects, 81% of the women did not report the violence, and 31.4% of the women did not even tell their family or friends. There was a high prevalence of women who were abused while pregnant or in front of their children, 39.1% and 45.9%, respectively. Findings from this study suggest an urgent need for policymakers to facilitate reporting domestic violence and helping the victims. Also, domestic violence awareness campaigns in the community would be beneficial. Moreover, domestic screening programs should be implanted in healthcare settings to identify possible victims.

Acknowledgments

We would like to thank and acknowledge all the anonymous participants who partook in our study. Moreover, we would like to thank King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center for their support and resources that were available to us during our study. Lastly, in following ethical guidelines, we would like to disclose the use of an external data analysis service, which helped in writing the results section of our paper.

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