Domestic Violence in Married Couples: From the Viewpoint of Women

Background: Domestic violence is one of the most common problems of public health that can be occurred in families and can lead to physical, psychological, and economic consequences individually, family, and social level. The present study was aimed to determine domestic violence of married couples from the Viewpoint of women. Methods: In this descriptive cross-sectional study 547 women referring to health centers of Marand in 2018 were participated. Sampling method was the convenience sampling method. For data collection, Socio-demographic and the Revised Conict Tactics Scale (CTS2) questionnaires were used. Descriptive (mean, standard deviation, frequency, and percentage of frequency) and inferential statistics, including t-test were used to analyze the data. Results: Results showed that domestic violence against men (98.3%) and women (98.5%) has a high prevalence. Women have experienced more violence in the psychological, physical, and sexual dimensions and men have experienced more violence in the negotiation and injury dimensions. Conclusions: The most important message of study beyond the comparison of the numbers and the operative or the victim of violence is the insecurity of the family environment for women, men, and children, which can have serious consequences for the family and society in the future. According to the importance of family as one of the essential elements of a healthy society, a preventative proceeding is required.


Introduction
Violence is a human rights contravention [1] and appears in a widespread manner in domestic violence form [2,3]. Domestic violence may be applied to children, spouses, parents, siblings, and elders through sexual, physical, mental, neglect /economic (economic deprivation) types [4].
According to the de nition of the WHO, any kind of behavior conducted by individuals with marital transplant and may lead to physical, psychological, or sexual harm will be considered domestic violence.
Some of these behaviors such as physical aggression, psychological abuse, forced intercourse, sexual abuse, and control behavior such as separation from family and friends, supervision and control of socializing, and deprived of basic needs [5][6][7].
Gender-based violence is a serious public health problem that involved nations, cultures, religions, and different classes [4]. Although violence can be happened by men or women, men have committed more than women and women are more prone to harm than men [5,8]. In the United States survey, the prevalence of domestic violence and sexual violence is reported of 36% for women and 29% for men [1]. In another study, 18.7% of men and 27.8% of women reported domestic violence. 12% of men and 22% of women experienced physical violence, 6.3% of women, and 5.6% of men experienced emotional violence [9]. Domestic violence is a hidden problem that causes many health disorders [10]. According to the World Psychiatric Association, domestic violence is a major factor of mental distress and psychiatric illness. It is diagnosed by examining and encountering psychological symptoms [1]. Increasing the intensity of domestic violence has a strong correlation with the deterioration of mental health [11]. Besides physical violence causes physical health problems also cause psychological disorders, such as depression, anxiety, sleep problems, abortion, pain, and hypertension [10,12]. Psychological violence is signi cantly associated with common psychiatric disorders in both women and men [9]. Studies have shown that 20% of psychiatric patients have been victims of domestic violence in a past recent years [13]. Depression and anxiety among victims of violence are 5 times higher [10]. Studies have shown that is a reciprocal and causal relationship between the experience of violence and increased mental illness [8,11].
A review of the empirical literature on domestic violence indicates more attention to violence against women [3]. National statistics show that the domestic violence against women is prevalent but there are limited literature which examined domestic violence in couples. The aim of the present study is to examine domestic violence in married couples from the viewpoint of women referred to health centers.

Study design & Participants
This is a descriptive cross-sectional study. The research population was all married women referring to Health Centers of Marand (one of the largest cities in East Azerbaijan province of Iran) between November 2017 and February 2018. Considering that the prevalence of domestic violence against women in Iran is 66% [14][15][16], the sample size is considered by considering d = 0.04 and α = 0.05, and Z = 1.96, 547 was calculated. Sampling method was proportionate random sampling. At rst the number of married women of each health Centers was received and then the number of sample of each center was determined. The participants received a brief explanation of the objectives, study method, and con dentiality of information. Questionnaires were completed using a convenient (accessible) sampling method. The criteria for inclusion in the research were determined based on interested participation and being married (at least one year at the time of the study). The exclusion criterion was the dissuasion of women for any reason.

Measures
The data collection tools were a socio-demographic questionnaire and the Revised Con ict Tactics Scale (CTS2). The demographic questionnaire was included 19 questions about the current age of couples, marriage duration, age at marriage, marital satisfaction, having children, number and gender of children, current pregnancy, type of dating, type of marriage, premarital dating, education of spouse, marital occupations, family income adequacy, type of insurance and place of residence. The Revised Con ict Tactics Scale (CTS2): Dr. Strauss et al. introduced CTS2 in 1990 [17]. It measures the abundance and repeatability of violence in the past year and before it. The validity and reliability of this questionnaire have been con rmed by Behbidi Moghadam et al., and Cronbach's alpha ≥ 90% has been reported [18]. It has 39 items. Each item was designed in pairs; odd question displays the woman's violence against their husbands and the even questions display men's violence against their wives. Using this questionnaire, violence was measured in ve dimensions: negotiation, psychological, physical, sexual, and injury issues in the past year and before.
The negotiation dimension has six questions (3 emotional and 3 cognitive), the psychological dimension has 8 questions (3 mild and 5 severe), the physical dimension has 12 questions (5 mild and 7 severe), sexual dimension has 7 questions (3 mild and 4 severe) and injury has 6 questions (2 mild and 4 severe).
The mild violence does not damage seriously, but severe violence is more intense that the victim is likely to be harm seriously, and may require treatment interventions. All questions, except six questions of negotiation dimension (positive facet) have a negative facet.
To measure the frequency of violence in the past year, each question has eight options (zero − 7) for responding. The choices of the categories are as follows: "Zero = Violence never happened", "1 = once a time", "2 = twice times", "3 = 3 to 5 times", "4 = 6 to 10 times", "5 = 11 to 20 times", "6 = more than 20 times" and "7 = not in the past year but it had occurred before".
To measure the repeatability of violence, the midpoint was used as follows. For options 0, 1, and 2, the midpoint was the same number, for 3, 4, 5, and 6, the midpoints were 4, 8, 15, and 25, respectively. The midpoint of option 7 was considered zero.
Before performing study, the face validity of tools were developed with ten faculty members cooperation and then the reliability of the tools measured by test-retest method, Cronbach's alpha was ≥ 0.7.

Results
Most of the women (85.8%) were housekeepers and (84.2%) had children. Most women were married in the traditional manner (80.9%).The mean duration of marriage was 10.41 years. About half of the participants (55.7%) were satis ed with their marriage. Most women (72.9%) had partly income su ciency. Less than half of the women (49.6%) lived in their own houses. Other socio-demographic characteristics of participants are shown in Table 1. In terms of prevalence of domestic violence among couples, women have experienced more violence in the psychological, physical, and sexual dimensions and men have experienced more violence in the negotiation and injury dimensions. (Fig. 1).
Over the past year, 98.5% of women and 98.3% of men had experienced violence at least in one dimension. About 7% of women and 7.3% of men experienced violence in all ve dimensions during the past year.
Also, results showed that the repeatability of negotiation and injury dimension are higher in women (against men). However, the use of the T-test showed that this difference is signi cant only in the negotiation dimension. The mean of repeatability of psychological, physical, and sexual violence was higher in men than in women, and this difference was statistically signi cant. The mean (standard deviation) of repeatability for total domestic violence against women and men was obtained 94.43 (80.66), and 87.29 (72.20) respectively, but this difference was not signi cant statistically (Table 2). The results of the sub-dimensions of violence were obtained according to Table 3. According to this table, in the severe sub-dimension, maximum violence against men and women is psychological (in both genders) and the minimum is in sexual and injury respectively.
In the mild sub-dimension, the maximum and minimum of violence against men and women are psychological and injury respectively in both genders. Overpassing the time and the approval of women's protection laws seems that physical violence has diminished, and negotiation and psychological violence had increased [19].
The prevalence of violence against men in our study in the dimension of the negotiation, psychological, physical, sexual, the injury was 97.3%, 74.5%, 29.5%, 26.1%, and 18.7% respectively and in the study of Mohammad Khani, was 77.8%, 59%, 26.5%, 19.1%, 13.5% respectively. The results of these two studies have consistency [19]. On the other, in study reported prevalence rates between 3.4% and 20.3% for physical violence between 7.3% and 37% for psychological violence, and between 0.2% and 7% for sexual violence, against physically and mentally healthy men [20].
In the present study, the distribution of the domestic violence prevalence against women is negotiation, psychological, physical, sexual, and injury, but in Mohammad Khani's study, they were negotiation, psychological, physical, injury, and sexual respectively. However, the distribution of domestic violence prevalence against men has consistent in both studies [19].
A comparison of the prevalence of violence against women and men suggests women more than men have been perpetrated the negotiation and injury, but men more than women have been perpetrated psychological, physical, and sexual violence. Comparison of the prevalence of dimensions of domestic violence against women shows, women have less sexual than physical, in other words, sexual violence in women's ranked in third and in men in fourth place. Although the tools of the two studies are different, the results are consistent.
Comparison of the repeatability of domestic violence against women and men suggests that women have committed negotiation and injury than men repeatedly, but men have committed psychological, physical, and sexual than women repeatedly. However, these differences had a statistical signi cance in all dimensions except injury.
Determining the extent of intimate partner violence against men may be di cult due to socio-cultural issues such as fear of disclosure, being judged by male peers, or undermining their masculinity [21,22].
Women's violence against men is also a serious social issue that can lead to increase male violence against women [19]. This issue is much important to consider because, by the in uence of modernity, the beliefs and values of women and men about marriage and family life are changing constantly [3].
Domestic violence against men will have irreparable consequences such as divorce, addiction, criminal, and other problems, which, like other complications of domestic violence, can be considered individually and socially [3].
The World Health Organization, the World Psychiatrists' Association, and the Centers for Disease Control in America introduce the prevention and intervention for intimate partner violence as a major and important goal [1].
According to Watts and Zimmerman, globally the report of domestic violence is less and it may be due to the sensitive nature of the issue [23]. The problem with conducting studies that want to describe violence in terms of gender is the amount of silence, fear, and embarrassment. That is why domestic violence against men is not reported [4]. To prevent the adverse effects of this issue on the results of the study, after mutual trust development with the participants, preparing a private room and a safe environment with intimacy were used for women interviews. The existence of different subcultures is a limitation to generalizing results to other cultures. Another limitation was the lack of access to studies that reported women and men's violence against each other simultaneously. Another limitation of the study was the lack of access to men and the completion of questionnaires only by women, and the results were related to their viewpoint.

Conclusion
The ndings show that the prevalence of domestic violence against couples is high. Domestic violence against both couples in each of the ve dimensions is almost uniform in terms of arranging, prevalence, and repeatability. Domestic Violence seems to be reciprocal and initially begins with negotiation and extends to other dimensions. The most important message of study beyond the comparison of the numbers and the operative or the victim of violence is the insecurity of the family environment for women, men, and children, which can have serious consequences for the family and society in the future.
According to the importance of family as one of the essential elements of a healthy society, a preventative proceeding is required.

Declarations
Ethics approval and consent to participate Prevalence of domestic violence in married couples n= 547