INTRODUCTION

Violence against women is defined as any type of behaviors depending on the gender identity, which may result in physical, sexual, or psychological harming or hurting, and it may cause pressure in the social life or in her personal life, and arbitral limitations of her freedom (1). Violence is a universal condition that every woman from each social level may be exposed to, despite ethnic background, religion, culture, education level, whatever her condition in the society or her socioeconomic status is. Factors such as pregnancy, being divorced, or living separately from her partner increase the risk of violence. According to study results of World Health Organization 2002, domestic violence rate was reported as 10-69% by their spouses or partners (2). Although the rates change from country to country, exposure rate of life-long violence for women in the literature have been reported as 38.6% in Nepal, 41% in India, 35% in Pakistan, and 23.8% in the United Kingdom (3-6). In a study conducted on 24048 married women in 2009 in our country by Family and Social Policy Ministry, it was determined that physical violence rate was 39%, sexual violence rate was 15%, emotional violence rate was 44%, and economical violence rate was 23% (7). It is known for a long-time that women who are confronted with domestic violence have high risks high risks for developing psychological disorders. Women whose self-esteem is deteriorated, and feel worthlessness as the result of violence, health problems such as anxiety, depression, and nervousness may occur. If these problems are untreated, they become chronic causing decreased life quality, and deteriorating social and occupational functionality. The most commonly encountered conditions observed in women who are confronted with violence may develop mental diseases such as post-traumatic stress disorder, and depression as well as suicide attempts, alcohol and drug abuse, and hostile behaviors to their children (1).

In the present study, we aimed to determine relationship between dometstic violence rate, violence confrontation and anxiety or depression levels among married women who applied to psychiatry outpatient clinic.

METHOD

The study was initiated after obtaining approval from the local ethics committee. A total of 100 consequent married female patients out of 137 patients who were aged between 18 and 65 years, and applied to psychiatry outpatient clinic in January 2016 were included in the study. Patients who were married, and without physical and mental diseases which prevent responding questions were included in the study. Singles and subjects with communication disorders were excluded from the study. Each case filled up a sociodemographic and clinical data form which were prepared according to information obtained from clinical experience, and reviewed sources. After information was given about violence types at the initial phase of interview, then all participants were requested to fill up a questionnaire inquiring some information such as whether there was any violence (economical, physical, sexual, and psychological); if present, the frequency and duration of violence; and whether spouses applying violence were ever confronted with violence during their childhood. Since verbal violence was the reflection of emotional violence, both of them were inquired under the title of emotional violence. In the same questionnaire, some questions about smoking, alcohol use, economical condition, occupation, and education level were also asked. Illiterate patients were requested to respond questionnaire questions read by the interviewer. Beck Depression Inventory, and Beck Anxiety Inventory were applied to every participants.

Measures

Beck Anxiety Inventory (BDI): It measures frequency of anxiety symptoms that an individual experiences. It is made up of a total of 21 questions. Each item is scored between 0-3 points. The higher the total score, the higher the anxiety level of the patient. Turkish validity and reliability study of the scale was performed by Ulusoy et al. (8).

Beck Depression Inventory (BAI): It is performed to determine depression risk and levels and severity of depressive symptoms in patients. It consists of a total of 21 questions. Each item is scored increasingly between 0 and 3 points, and total score, which ranges between 0 and 63 points, is obtained by summation of these scores. Turkish validity and reliability study of the scale was performed by Hisli et al. (9).

Questionnaire for Severity Evaluation: In the questionnaire, information about physical or sexual violence during childhood, type of marriage between partners, duration of marriage, presence of physical and/or sexual and/or economical and verbal violence (if present, duration, frequency, and type of it), presence of physical violence during pregnancy, application of violence to children at home, suicidal attempt, sociodemographic information about the spouse (education level, occupation, alcohol and/or substance abuse, presence of violence in his childhood) were collected.

Statistical Analysis

Data were analyzed by using SPSS for Windows 22.0 (SPSS Inc., Chicago, IL, USA) computer package program. Chi-square test was used in categorical comparisons. The obtained data were presented as mean±SD, and if measured data were normally distributed, Student t test; if not, Mann-Whitney U test was used intergroup comparisons. The level of significance was accepted at p<0.05.

RESULTS

Sociodemographic Characteristics: The mean age of patients was determined as 44.04±10.3 years. Of patients, 87% were living in city centrums. The family income was low in 23%, moderate in 71%, and high in 6% of the patients. While 63% of patients were graduated from the primary school (primary and secondary school), 17% were graduated from high school, 6% were graduated from the university, and 14% were illiterate. Of the participants, 92% were house-wives, 3% were officers, 2% were students, 1% were workers, and 2% were self-employed. Of the patients, 74% were married to their husbands through match-makers, and 31% reported that they married younger than 18 years of age. Comorbidity diagnosis was present in 52% of participants, and 26% had suicide history. Distribution of psychiatric diagnoses were depression in 39%, anxiety disorder in 40%, conversion disorder in 10%, delusional disorder in 4%, bipolar disorder in 5%, and obsessive-compulsive disorder in 2%. Of the participants, 78% were married longer than 10 years.

Physical Violence in the Marriage: One or more than one types of violence was determined in 76% of the patients. The physical violence was determined as 45% in the marriage. Women aged between 18-25 years were more commonly exposed to physical violence (53%). It was reported that physical violence was determined in 46% of women living in cities, and 63% living in villages. Of the patients who were exposed to physical violence, 96% (n=43) were exposed to verbal violence, 53% (n=24) were exposed to economic violence, 20% (n=9) were exposed to sexual violence, 38% (n=17) were exposed to physical violence during pregnancy, 40% (n=18) were exposed to physical violence during childhood, and 8% (n=4) were exposed to sexual violence during childhood. Of the patients who were exposed to physical violence, 73% were married through a matchmaker. Forty percent of the participants reported that they were exposed to physical violence during their childhood. It was determined that 24% of the patients had poor economic conditions. In the overall patient group who were working (n=8), 6 of them (75%) were exposed to physical violence. Fifteen percent of patients who were exposed to physical violence reported that they attempted suicide. It was reported that slapping was the most common form of physical violence application (87%). It was determined that rates of physical violence during marriage were 29% among illiterate women, 44% among primary school graduates, 53% among high school graduates, and 67% among university graduates. The higher the education level, the higher rate of physical violence exposure. Forty percent of women (n= 18) who were exposed to violence, were applying violence to their children.

Physical violence during pregnancy: Of the 100 participants, 20 women (20%) who children and completed pregnancies had reported that they were exposed to physical violence during their pregnancies, and 35% of them reported that they applied violence to their children after the birth.

Violence to children: Twenty-two patients (24%) with children, and 18 patients (40%) who were exposed to violence in the marriage reported that they applied violence to their children. It was determined that women who were exposed to violence in the marriage, applied more commonly violence to their children. Of patients who applied violence to their children, 8 were exposed to physical violence during their childhood, and 7 were exposed to physical violence during their pregnancies.

Physical violence to children: Among 24 patients who were physically abused during their childhood, 18 (75%) were exposed to domestic violence, and 8 (30%) of them were applying violence to their own children.

Emotional (verbal) violence in the marriage: Emotional violence rate was determined as 68% in the marriage. Exposure rates of emotional violence in the marriage of women were determined as 50% among illiterate women, 67% among primary school graduates, 76% among high school graduates, and 100% among university graduates. The higher the education level of women, the higher rate of emotional violence exposure. Suicide attempt was determined as 29% among patients who were exposed to emotional violence in the marriage.

Economical violence in the marriage: Rate of economical violence exposure was determined as 39% among women during the marriage. The rate of economic violence exposure among women were determined as 15% among illiterate women, 59% among primary school graduates, 23% among high school graduates, and 3% among university graduates. No significant relationship was determined between education level and rate of economic violence exposure among women. It was determined that 67% of women who were exposed to economic violence had moderate or good economic level.

Sexual violence in the marriage: Sexual violence exposure rate was determined as 11% among participants in the marriage, and 18% (n=2) had sexual abuse history during their childhood, and 6 of them were married at young age (younger than 18 years of age), 91% made their marriages through a matchmaker. Ninety-one percent of individuals exposed to sexual violence were married longer than 10 years. In this patient group, 3 were exposed to physical violence during their pregnancy, and 9 were exposed to physical violence during sometime of their marriages. Of the patients, 6 attempted suicide during their marriages.

Men engaged in violence: Out of the 30 men who had no job, 11 men were applying physical violence to their wives. All of the men using substance (n=13) were applying verbal violence to their spouses, and 9 of these men (69%) applied physical violence, 8 of them (62%) applied economic violence, 4 (31%) applied sexual violence, and 3 males (23%) applied physical violence during their pregnancies.

Severity and scale scores: When compared with scale scores, depression and anxiety scores of women were exposed to violence (physical, emotional, economic, and sexual violence) were higher than women who were not exposed to violence (Table 1 and 2). The highest depression scores (31.9±14.8) were determined in women who were exposed to sexual abuse in the marriage, whereas the highest anxiety scores (27.0±9.7) were determined in women who were exposed to physical violence during pregnancy. Among women who were exposed to physical violence, the highest anxiety and depression scores were determined in individuals who were exposed violence every day (BAI=32.3±13.1, and BDI=33.5±11.1). Depression scores according to severity types are shown in Table 1, and anxiety scores are shown in Table 2. Depression and anxiety scores of the women who reported that they were exposed no type of violence were 16.0±10.3, and 17.6±11.2, respectively. There was statistically significant differences in anxiety and depression scores between women who were not exposed to violence, and who were exposed to one or more types of violence (p<0.05). Anxiety and depression scores were determined much higher in the women who were exposed to all types of violence than who were exposed to 1, 2, or 3 types of violence (BAI=34.8±14.7, BDI=36.0±15.9). We determined that patients diagnosed with depressive disorder and anxiety disorder were most commonly exposed to emotional violence, and to physical violence in the second line (Table 3).

DISCUSSION

In our study, domestic violence rates, factors affecting the violence, and anxiety and depression levels of married women who were exposed to the violence and applied to the psychiatry outpatient clinic were investigated.

It was determined in our study that 76% of participants were exposed to at least one of violence types, and the most common ones were verbal and physical violence. Of the patients, 68% were exposed to verbal; 45% were exposed to physical; 39% were exposed to economic; and 11% were exposed to sexual violence. Akyuz et al. (10) reported in their study performed on women who applied to psychiatry outpatient clinic that 36% were exposed to emotional violence, 29.3% were exposed to verbal, 32% were exposed to economic, 57% were exposed to physical, and 30.7% were exposed to sexual violence. Economic violence is defined as using economic sources, and money as a sanction, threat, and controlling tool (11). Although physical, sexual, and verbal violence types are well-known in our society, economic violence type is not a well-known and described concept. When our data were compared with those of Akyuz et al. (10), physical and sexual domestic violence rates were lower, but emotional and economic violence were higher. Also it was determined in our study that the higher the education level of women, the higher the physical and emotional violence rates they would be exposed to. In previous studies, it was reported that the higher the education level of women, the lower the physical violence rates (12-14). Increasing education level with increasing violence in our results might be explained by increased rate of women expressing that they were exposed to violence. Additionally, as the education level is increased, women became more aware of their rights and freedoms, and they tried to defend themselves more which might increase their exposure risk to violence. As a matter of fact, it was reported in the literature according to feedback hypothesis that violence rates were increased among women who had increased freedom and status (15). It is known that women who have been exposed to domestic physical violence, applied physical violence more commonly to their children (16). It was determined in our study that 40% of patients who were exposed to physical violence applied violence to their children. Domestic violence is transferred from generation to generation, and not only psychological condition of individuals who are exposed to violence, but also individual(s) who have witnessed, especially psychosocial development of children, are affected. In the literature, there are studies indicating that individuals who have been exposed to or witnessed domestic violence during childhood, may apply violence even more severely against their family members (17,18). We determined in our study that 53% of males who applied domestic physical violence to their wives experienced violence during their childhood.

Self-respect is decreased in women who are exposed to violence, and they develop feelings of shame, guilt, and regret due to results of the experienced events. Also, as an inevitable outcome of violence, women experience some mental symptoms such as anxiety, depressive mood (19). If these mental problems are untreated, then they may lead to suicidal thoughts in those violence victim women. Previous studies reported that suicidal tendency was increased among women who were exposed to violence (20). In our study, it was determined that 33% of women who were exposed to violence attempted suicide during their marriages.

In a study performed on patients who applied to psychiatry outpatient clinic, it was determined that women who were exposed to violence had suicidal thoughts at 10%, suicide attempt history at 18%, and the frequency of continuous major depression was 68% (21). In a study conducted in Iran, it was reported that 35% of married women were exposed to physical violence, whereas 77% were exposed to non-physical violence during their marriages, and significant rate of women exposed to domestic violence had depression and anxiety symptoms (22). In another study, it was observed that women who were exposed to domestic violence applied to outpatient clinics commonly with somatic, depressive, or anxious complaints (10). It was reported that addition of domestic violence to clinical picture in an individual with an existing psychiatric disease might act as a stressor like other traumas, and intensify the existing psychopathology (23). When scale scores were compared, depression and anxiety scores of women who were exposed to violence (physical, emotional, economic, and sexual violence) were determined higher than the ones without exposure to violence. Anxiety and depression scores of women who were exposed to all violence types were determined quite higher than scores of women who were exposed only to one violence type. Moreover, anxiety and depression scores were determined the highest in women who were exposed to physical violence every day.

Alcohol or substance abuse and presence of mental diseases in men were reported as factors increasing risk for violence exposure (24). Consistently with the literature, more than half of men who applied violence to their wives were exposed to violence during their childhood in our study. All of men who had substance addiction applied verbal violence to their wives, and 69% of men applied also physical violence to their wives.

In our study, it was determined that depression scores were the highest among women who were exposed to sexual violence in their marriages. Considering types of domestic violence, it was defined that the most severe effect was caused on women by concomitant presence of physical and sexual violence (25). Similarly, majority of women who were exposed to sexual violence experienced also physical, emotional, and economic violence in our study, so it might increase depression levels of those individuals.

Small and non-homogenous sample size, and self-reported way of data collection may be encountered as limitations of our study. Besides, information about males such as smoking, alcohol intake, education level, economic level, and whether they had been exposed to violence during their childhood was collected form the wives rather than spouses themselves. Some characteristics of individuals are also important in addition to social, cultural, economic, and psychological factors in the violence action. However, personality characteristics, existing psychiatric states, and the degree of marital relationship have not been evaluated in our study.

In conclusion, it is determined in our study that domestic violence in individuals with psychiatric disease have been correlated with increases in anxiety and depression scores. Also it has been defined that exposure to domestic violence of any type causes increased suicide attempts. Further comprehensive studies are required to determine domestic violence among patients with psychiatric diseases, and the correlation with psychiatric symptomatology.

Conflict of Interest: Authors declared no conflict of interest.

Financial Disclosure: Authors declared no financial support.

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