Introduction

Intimate partner violence (IPV) such as domestic violence and abuse, battering, or family violence is a pattern of assaultive and bullying behavior by a spouse or a partner against another in an intimate domestic relationship.¹ IPV may have any pattern of relationship exploitation (physical, threats, emotional or psychological, verbal, economic, and sexual abuse). It can affect any member of the family including spouse, older people, and children.¹,²

Physical abuse is the use of any form of physical bullying (punching, pulling hair, slapping, shoving, biting, twisting arms, kicking, choking, hitting, and pushing down),² whereas threat is by carrying out something, which might hurt the partner emotionally (threatening to commit suicide, taking away children from partner, or to report partner to a governmental agency or betraying other important secrets).² However, emotional abuse is impassive behavior to the partner and is carried out by putting partner down, making partner feel crazy or bad about self, prohibiting the partner from seeing family and friends, ongoing degradation or threats) although, economic abuse is performed by preventing the partner from working or repossessing earnings.² On the other hand, verbal abuse is giving a bad partner naming or use harsh and insulting language to the partner.² However, economic abuse is keeping partner in financial shortage (inhibit any job opportunity, taking partner’s money, making partner ask for money).² And, sexual abuse is by making partner do sexual things against her will or physically attacking the sexual parts of partner’s body.²

IPV against women is a prevalent problem, which reached to 42% in the Kingdom of Bahrain³ , and is extended to 58.5% women in Saudi Arabia.⁴ Globally, one in three women has a history of IPV.⁵ It is commonly underreported as a public health problem with serious adverse health outcomes, which threatens women’s mental and physical well-being.⁶ The global prevalence rate of physical and sexual IPV against women varies from 15% to 71%, depending on the instrument used to measure IPV.⁷

The barriers to disclosure and/or seek professional help are different, such as cultural or traditional differences, confusion state, fear of retaliation or fear of family dysfunction, and shame.⁸,⁹

Case study

A 34-year-old Bahraini woman presented with a chief complaint of worsening depression symptoms—insomnia, loss of appetite, thoughts of guilt feelings, low self-esteem, and low-energy. She had multiple injuries all over the right side of her body such as contusion and abrasion with many longitudinal band lacerations. She claimed that she fell down during her household work. The patient had been taking antidepressant medications with psychotherapy in a psychiatric clinic. While, on using abuse screening questionnaire, she revealed that her husband was verbally threatened to harm her, then he abused her physically, emotionally on many occasions.

She did not call the police or asked any help from any agencies. Also, she was beaten by her father from preschool age until she was 13 years of age; and her parents were divorced. 

Case discussion

The patient’s history suggested very high-risk factors for IPV. She was from the lower socioeconomic state, with a history of child maltreatment and witness for family violence. Her husband had antisocial personality disorder, with alcohol abuse and history of infidelity. The victim was accepting her husband violence and gender inequality. Both the couple had experienced family disruption and mental illness in their caregiver providers. Also, she was accepting her social isolation and was very hesitant to give history. However, she was open with the help of validation statement and IPV Screening Tool (IPV-ST; Tables 1 and 2).¹⁰

Then, the physician should follow mnemonic RADAR—Routinely screen for IPV, Ask direct questions, Document your findings, Assess patient’s safety, Review options and referrals.

She had the various medical complication of both acute and chronic squeal for being a victim of IPV. There were different contusion and laceration and blunt abdominal trauma; however, there was no fracture and concussion. The patient was frequent attender for many psychosomatic disorders, chronic pain syndrome, negative health behavior, besides the history of chronic depression, and anxiety.¹¹,¹² Consequently, the physician should be enough alert to suspect IPV by having high suspicions of affirmative clinical indicators (Table 3).¹¹

Once physician had a patient-centered approach and used open-ended question in the supportive, nonjudgmental, welcoming, and nonthreatening environment, the patient declared all her painful scars in her relationship. Also, the physician was alert to her acute and chronic signs of abuse. Correspondingly, the physician assured her about consultation privacy, safety, and confidentiality issues.⁹ As well, the physician addressed her social/psychological needs and assessed her safety concerns for her family. Lastly, the physician offered her referral to mental health, social worker, and Batelco Centre for Family Violence Victims (women’s shelters, support groups, and legal advocacy). Finally, the physician discussed with her about the importance of the legal tools and he agreed with her about a safety plan for violent partner.¹²,¹³

The physician asked the patients the following questions at the consultation: If you decided to leave, where could you go? Can you keep clothes, money, and copies of keys and important papers in a safe place? Where could you go in an emergency? How would you get there? Many women call a women’s shelter to learn more about it. and Would you like to use our office phone? Moreover, the physician validated patient’s strengths and documented the observation, assessment, and her future plans. To finish, the physician offered regular follow-up appointment and assessed her barriers to contact him.^12,13

Conclusion

IPV is a common and serious primary health problem, which compromises the social and family fabric of Bahrain’s society. IPV is not limited to physical violence but also includes different types of violent and controlling behavior. Thus, general physicians need to have a high index of suspicion and to have a proper approach the victims of violence in a sensitive and nonjudgmental way. Recognizing the women’s autonomy is the primary focus in the process of supporting them to accomplish safer and healthier lives.

Recommendation

1. Promote gender equality and women’s human rights to reject gender disparity in basic education.
2. Encourage women to have a paid job and be independent financially.
3. Inspire women to have a role in political dimension and share of parliamentary seats.
4. Create an action plan for the political empowerment of women by having active Supreme Council of Women.
5. Establish, implement, and screen action plans to address violence against women by developing and monitoring legislation and other related actions.
6. Forced marriage is an abuse of human rights and cannot be justified by any religious or cultural basis.
7. Stop honor killings, when women are murder in the name of the family honor.
8. Enlist social, political, religious, and other leaders in speaking out against violence in the family.
9. Establish systems for data collection and screen violence against women.
10. Support research on the causes, consequences, and costs of violence against women and on
effective prevention measures.

Conflicts of interest

None