Characteristics of participants
Most of the women were in marriages arranged by their families and the majority were separated or divorced. The husband was identified as the main perpetrator by all the interviewed women. Three women also identified in-laws as secondary perpetrators. Further details are given in Table 1.
Table 1
Socio-demographic characteristics of the study participants (N = 20)
Characteristics | n |
Age (years) | |
20–29 | 8 |
30–39 | 8 |
40–49 | 3 |
50–59 | 1 |
Educational status | |
Primary | 3 |
Secondary | 7 |
University | 5 |
Vocational education | 5 |
Employment status | |
Currently employed | 3 |
Unemployed | 17 |
Marital status | |
Separated* | 10 |
Divorced | 7 |
Married | 3 |
Type of marriage | |
Traditional** | 18 |
Modern | 2 |
Length of marriage | |
Less than 10 years | 12 |
More than 10 years | 8 |
*Separated: not officially divorced, **Traditional: family arrangement |
Barriers to survivors disclosing VAW to health care providers
Eleven out of the twenty interviewed survivors said that they had disclosed violence to HCPs at some point. However, all the women encountered multiple barriers to talking to HCPs about their experiences that either prevented disclosure or made it difficult. Themes were identified by the authors that reflect the cultural barriers to talking about VAW that pervade all areas of women’s lives and experiences.
Survivors’ individual level barriers
Two key individual barriers that were identified were women’s sense of dependence on their husband and their fear of the consequences of disclosure.
Dependence on their husband
Women described their dependence on their husbands, both financially and in terms of cultural expectations about how a married woman should behave. They were reluctant to talk about relationship difficulties, matters considered to be ‘too personal’, and likely to result in them being be blamed, shamed or embarrassed.
“I felt like I would be blamed for it and people might say; look, she let out secrets between her and husband. Why would she say that? So that would make me shy, embarrassed to talk about it” [39 year old woman, Hebron].
“Because I don’t want to expose the secrets of my home and I want to stay protected (under husband) and live in comfort” [23 year old woman, Hebron].
Feeling ‘protected’ by marriage was also financial. Exposing violence in the home might lead to separation and divorce, with no guarantee of financial support for the woman or her children. Fear of living apart from their children was a major barrier for women to disclosure.
“Because my family, if I divorced, don’t want me to keep his children and I don’t want to lose my daughters. If I lose the children I will suffer” [34 year old woman, Hebron].
The data highlighted the cultural taboo about women speaking out against their husbands and the stigma attached to those who do so, especially if they are separated or divorced. Most women found it hard to talk about VAW to family members or friends, as well as to HCPs, and they often hid their injuries, or their cause, from them, as well as from HCPs.
“They asked me what happened. I didn’t say it was done by my husband, I said it happened while I was cutting a piece of wood” [34 year old woman, Hebron].
Staying in the abusive relationship and keeping quiet about the violence can be seen as active, calculated choices to protect themselves and their children, expressing agency in difficult circumstances, until an opportunity arose to take action.
Fear
Women talked about their fear of escalation of the violence should they disclose.
“because the violence would get worse and the problems would increase. The problems between my family and his would become worse and God forbid, if it got to the point where they might hurt each other, someone might get killed…that’s not a little issue.” [41 year old woman, Ramallah].
Fear of what might happen if they left the house by themselves to seek help or if they talked about the violence, kept women at home, unable to access HCPs or other forms of help.
“Researcher: you didn’t tell the doctor that you couldn’t go out? SW20: no. Researcher: why? SW20: honestly, I was very, very scared of him … Researcher: you were scared of him? SW20: yes. My husband used to put his key in the door, and when I’d hear it, when I’d hear the key enter the door, I’d start shaking” [32 year old woman, Ramallah].
Women were also reluctant to seek help, especially for psychological distress, for fear of being labelled ‘mentally ill’. Losing their credibility as a competent wife or mother might lead to them losing custody of their children.
“Researcher: so you would like to see a psychologist but you're worried your husband will find out and… SW14: he'd say, for example, ‘she's mentally sick!’ He won't say, ‘she wants to change her behaviour’, he'd say ‘this woman is mentally sick. I want to take the kids’.” [39 year old woman, Ramallah].
“Other than that, family, or society rather considers psychiatrists are only for crazy people. That’s their negative views on psychological treatment” [24 year old woman, Ramallah].
Health care service level barriers
Expectations of Health Care Providers’ (HCP) role
Women varied in their views as to whether attending to the issue of VAW was within the remit of HCPs, and they had low expectations of getting help. Women saw the focus on physical health as the normative role of HCPs, and they were unwilling to take up HCPs’ time in busy clinics.
“I don’t know. The idea never came to my mind. I don’t expect that they could help me with the situation” [19 year old woman, Ramallah].
“yes I had the potential to [disclose], but I didn’t feel like the doctor would listen to me if I did … because there were a lot of people waiting for a turn and other than that, she works fast … she doesn’t ask about the person’s state…it was just an exam for the fetus, and that’s it, work is done” [24 year old woman, Ramallah].
Some women expressed personal ambivalence about the idea of HCPs probing into areas of their life they considered ‘private’, even when they had obvious bruising.
“it was normal, anyway, he checked me out, put his stethoscope here. Examined my arms and said alright up, we are done ….. because maybe I want a doctor just to examine me, not to know everything about me” [30 year old woman, Hebron].
“honestly? I don’t like them to get involved in my private life...I consider it my personal life. It’s private" [32 year old woman, Ramallah].
Others, however, said they would prefer HCPs to look beyond their physical health, show concern for women’s psychological well-being and take the initiative to ask about violence.
“maybe they could ask me questions, give me support …” [24 year old woman, Hebron].
“Well, women feel that they don’t care. I don’t feel like they care about these things at all. So at least they should ask those that he feels something might be wrong.” [23 year old woman, Hebron].
Most women were clear that the initiative must come from the HCP asking direct questions, even repeatedly, in order to overcome their initial reluctance to disclose.
“Researcher: in a case where a woman refused to talk about, what should the doctor do? SW03: ask the first time, and second time, third time” [30 year old woman, Hebron].
Women’s direct experiences of disclosure and non-disclosure to HCPs
Missed opportunities for disclosure were described by women who presented with warning signs of abuse including low mood, bruising and poor nourishment, with no questions asked by HCPs.
“There was an apparent thing on my arm, it was obvious that I had. When I get upset it’s obvious, he didn’t ask me about it or anything” [30 year old woman, Hebron].
“I was crying but, its normal, no one asked me about it. About anything!” [23 year old woman, Hebron].
However, in spite of the barriers, just over half of these survivors had disclosed violence to HCPs.
“no, she asked me. she asked me “what's going on? I feel like you're not all right?” I told her “I'm having some problems with my husband.” [32 year old woman, Ramallah].
Many of them, however, reported little benefit. Simply initiating a conversation was felt to be insufficient, some women felt that HCPs should make a full assessment of the violence.
“What happened, why it happened. They should do a proper assessment about anything that looks like a case of abuse. It’s obvious when something is normal and something is strange.” [34 year old woman, Hebron].
Women often said they wanted help to change their husband’s behavior, so that they could preserve their marriage, and their social and financial survival. They did not know who to call on other than involving the police and filing a complaint.
“SW15: yes. If I knew that there was someone that could talk to my husband and influence him to change his temper habits and such, then I would say something, but there is no one” [26 year old woman, Ramallah].
They wanted HCPs to take responsibility for making a report of violence to the police, according to an unwritten and rarely followed mandate from the Ministry of Health.
“[HCPs SHOULD]do what they're supposed to. For example, I reach out to them and they suspect that something is happen, they should immediately call the police. Even if I'm insistent upon not wanting to talk, from their report and their examinations, it’s clear” [21 year old woman, Ramallah].
“They said the results show that nothing is broken there is only fracture. The Doctor asked me: “how this happened”, and I said that it was from my husband”. The Doctor then asked for the police. The police arrived and they asked me everything.” [34 year old woman, Hebron].
Privacy, confidentiality and trust
Lack of personal privacy in health care consultations was another barrier to disclosure for the women, who were often accompanied by their husband or in-laws, making it impossible for them to talk about violence.
“At the hospital they asked me what was wrong. My mother in law told me “if you tell them ‘he hit me’ we’ll divorce you. Don’t say that. We don’t have women who complain about their husbands here.” The doctor told me “I know you’ve been hit. I know it, but if you don’t want to say something, I can't do anything.” I went back home…” [24 year old woman, Ramallah]
“Researcher: did you have privacy when the doctor came to examine you? Were you by yourself with him, for example? I mean, could you have told him “honestly, doctor, I… SW11: No my mother in law was with me…. there’s no privacy pause and even if I told him, the doctor how could he benefit me? He won’t help me with anything” [23 year old woman, Hebron].
Women did not trust patient confidentiality, and were anxious about disclosing in case ‘domestic violence’ appeared in writing in their medical report. They described overlapping social and professional networks in their communities. HCPs may know other family members, social ties and loyalties might outweigh concepts of confidentiality, and disclosure may not remain a private matter. For women, this risked an escalation of violence and other repercussions.
“SW10: yes I was very scared. Researcher: why, what's he going to do to you? SW10: what do you mean? if he finds out that I told the doctor, I'm sure he wouldn’t stay quiet. I mean, [the doctor] is going to say something. He's going to say “this girl gets hit while pregnant” and [word of] that gets to him, then he would have hit me even more if my husband found out that I talked to the doctor about him.” [21 year old woman, Hebron].
“For example, if my medical record was with you, and your colleagues came along she’ll read the file and know about my life” [30 year old woman, Hebron].
“I didn’t want to make any problem. The Doctor is our family doctor and I was ashamed to talk about this” [34 year old woman, Hebron].
“No. I wouldn’t have trusted him because I'm living with people I don’t trust; he might be one of them. I mean, he'll always side with them; he is still from their town. I wouldn’t have trusted him or told him. I’d be scared to go tell my husband, then he’d tell me why did you go tell him and the situation would be flipped against me.” [20 year old woman, Hebron].
Societal level barriers to disclosure
Normalization of violence
Women described the cultural expectation that a wife should tolerate her husbands’ behavior, that it is ‘normal’ to be hit by him. An abusive husband should be given a ‘chance to change’.
“Yes, we are afraid of the society, we always give a chance that maybe things will change. Unfortunately, it is the opposite, it will carry on and on until it becomes serious.” [34 year old woman, Hebron].
“Listen, a divorced woman is always the one blamed. No matter what. They don’t say that the man was no good, no it’s the woman fault. You should have been patient. You should have tolerated it. What am I supposing to tolerate more than I have endured?” [20 year old woman, Hebron].
Expectations of women’s role
Women described their society as ‘repressive’ and they were fearful of being judged if they talked about VAW or left their husbands.
“Honestly no, because I never thought I’d ever file a complaint against him in my life. Firstly, for the sake of my kids and then because women are always violated. No matter what you say, your name and subject is going to be on the tip of everyone’s tongues” [36 year old woman, Hebron].
One woman whose husband was in prison for violence felt she was being watched by the community and always had to be on her best behavior, as if she were the guilty party. Others echoed this experience of being abandoned by society for speaking out. Fear of being blamed and being seen as a ‘home-wrecker’ stopped some women from filing for divorce.
“I think it’s more the nature of our society. Our society abandons a woman who speaks out about her circumstances, even when they are bad” [36 year old woman, Hebron].
“Like I said before they put all the blame on the woman and it’s because of you, like how they’ve already put all the blame on me. The closest people to you; you’re the reason, you’re the home wrecker” [30 year old woman, Hebron].
One woman regretted not having spoken out sooner, since she now recognized how her rights had been taken away since marriage.
“no, now I would have talked. I would have talked then because I’ve given up so many things in my life, from the day I married [perpetrator] until now, there are a lot of rights that he’s denied me from” [36 year old woman, Hebron].
Stigma
Women’s fear of being stigmatized for their actions was a strong theme in their accounts. They described their fear of the stigma of a ‘mental health label’ or of being a ‘home-wrecker’, and of being ostracized by society for speaking out against their husband, separating from or divorcing him. After leaving a violent relationship, women continued to feel stigmatized and faced barriers to getting support for themselves or their children, such as attending counselling sessions alone or getting psychological help for themselves or their children.
“Even for my son and his sessions, in the beginning I told her even if you need to put two sessions a week, do it. I wanted my son to get better, but I felt that it was unaccepted” [45 year old woman, Hebron].