Domestic Violence Among Women Attending to Psychiatric Outpatient Clinic

Abstract

Objective:

Domestic violence (DV) is defined as all kinds of abusive behaviors between spouses or relatives living in the same house. Domestic violence is most commonly directed towards women and children. This study aims to review the extent of domestic violence among women consulting to psychiatric outpatient clinic, and to identify its relation with sociodemographic risk factors and psychological symptoms.

Method:

Self-reported Domestic Violence Questionnaire and Symptom Checklist-90-R (SCL-90-R) information was collected from women who admitted to psychiatric outpatient clinic at Marmara University Research and Educational Hospital, and accepted to participate in the study.

Results:

300 women participated in the study. Mean age of participants was 36.24±10.88, 75.7% of them were married, and mostly live within nuclear families. 70.1% of the participants reported verbal violence, and 49.0% reported physical violence. 65.3% of those who have experienced verbal violence have also experienced physical violence. 26.1% of them reported as not having experienced domestic violence before. The nature and extent of domestic violence, women’s attitudes towards it, and its relation with experience of domestic violence during childhood have been explored. Participants’ educational levels, current age and age of marriage, style of marriage, educational level and age of spouse were not found to be associated with experiencing of domestic violence. Both verbal and physical domestic violence were significantly associated with the economic status of women (p<0.05). The mean SCL-90-R score was 1.40±0.68 with the highest mean subgroup score under depressive symptoms category (1.80±0.79). Mean SCL-90-R score showed significant association with the experience of domestic violence (p≤0.001).

Conclusion:

Most of the women participated in the study have experienced domestic violence. Both verbal and physical violence increased with lower economic status. Psychiatric symptoms increased with the experience of domestic violence. Considering its high prevalence and detrimental psychological effects, domestic violence should be inquired by clinicians as part of the psychiatric interview.

INTRODUCTION

Violence is a universal issue in today’s World. According to World Health Organization (WHO), violence is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation (1). ‘Violence against women’ is a term used to define all types of harmful behaviour towards women because of their gender (2). Violence against women is different than interpersonal violence, as women compared to men are more likely to be victim of the violence coming from their family members or partners (2). The most common type of violence against women is the violence inflicted by her spouse or partner (2). Studies carried out in recent years started to distinguish violence towards women as domestic violence (DV), and violence of spouse or partner. DV is all types of aggressive behaviours of a person directed to his spouse, children, parents, siblings, and close relatives (3). All types of gender based actions occurring within the family or household that causes emotional, economical, or physical harm which consist threat, force, or control is defined as domestic violence against women (3). In this study, the violence women were subjected during their childhood by their family members or by their spouses during their marriage as well as violence they use on their own children were questioned. Thereby, the term DV was preferred instead of spousal/partner violence in this article. DV affects negatively the subjected party, witnesses as well as those who use it (4).

Violence is split into separate types as verbal, physical, sexual, and economical violence. According to the 2012 report published by WHO on global spousal violence, 30% of women are subjected to violence by their spouses throughout their lives (5). Also, according to WHO’s 2002 data, 10–69% of all women in the world are subjected to physical violence by their spouses one time or other during their lifetime (1). This prevalence of violence reaches the highest numbers in Africa, Eastern Mediterranean, and Southeast Asia regions of the globe; the lifelong spousal violence in these areas were found to be at about 37% (1). Within the first report carried out in this context covering European Union, it has been discovered that one in every three women (33%) is subjected to physical and/or sexual abuse from the age 15 onwards, 22% were subjected to violence either from their past or present spouses (6). The report states that violence is far more prevalent than it is being reported, however, women cannot share this situation owing to difficulties with concerns of receiving insufficient benefit from the legal system, protecting their rights and supplying their needs (6).

The number of studies in this context are few in Turkey. According to a research carried out in 1993–1994 among families in 4287 households, it was established that 34% used physical violence, and more than 53% resorted to verbal violence (7). In a survey done in a community clinic in İstanbul, it was established 40.4% of 146 consulting women were subjected to physical violence by their spouses (8). In a psychiatry clinic in Sivas, it was determined that out of the referring women, 57% were abused physically, 36% mistreated emotionally, 32% were forced economically, 30.7% were subjected to sexual abuse, 29.3% experienced verbal violence, and that most of them were trying to hide the violence they endure (9). It was stated that 62% of women referring to the psychiatry clinic were experiencing physical violence in their marriages (10). Besides the single centred researches, countrywide field surveys carried out over the past ten years present serious findings on the scale of violence. In a study done by Arat and Altinay (2007) with the sample group of Turkey, out of 1520 women interviewed, 35% stated that they have been subjected to physical violence by their spouses at least once in their lives, and that 14% were forced to have unconsented sex at least once (11). In the Domestic Violence Against Women in Turkey Research done in 2013–2014, it was demonstrated that among women who have married at least once, 36% of them have been subjected to physical violence, and 14% were subjected to sexual violence once in their lifetime. The same study also reveals that the ratio for women subjected to emotional violence or abuse anytime in their lifetime is 44% (12). It is women who are often targeted in DV, therefore it is important to study the mental effects of violence on women. It has been indicated that DV may have medical, behavioural and mental repercussions, and that typical diagnoses include post-traumatic stress disorder (PTSD) and chronic depression, and that such affects like anger, despair and hopelessness are often experienced by those who have experienced violence (13). Depression, anxiety disorders, PTSD and psycho-somatic disorders are among the mental illnesses associated with violence (10, 14, 15).

This study, carried out on women over the 18 years of age reporting to psychiatry clinic, aims to determine;

1. The scale of DV they have been subjected, and its possibly related socio-demographical characteristics;

2. Correlation between violence and their psychiatric complaints; and

3. Women’s attitude towards DV.

METHOD

Participants consisted of women over the 18 years of age referring to Marmara University Education and Research Hospital psychiatry polyclinic between the dates of 15.06.2012–15.08.2012 who consented to take part in the study. Participants were requested to answer Family Life Survey (FLS) and Symptom Check List (Symptom Check List-90-Revised, SCL-90-R) given by the clinician. Surveys of illiterate participants were filled with the help of the clinician. An approval was requested and given by the Marmara University Medical School Ethics Committee. Participants were informed about the study, and their written consent was obtained.

In the analysis of the sample group, where all women who accepted to participate the study between the stated dates, SPSS 18.0 statistics package software was used to test the normal distribution, for groups over 30 Kolmogorov-Smirnov test, and for groups below 30 Shapiro-Wilk test were employed; chi-square test was used for the binary analyses’ categorical variables; for the continuous variables, t-test was used for those demonstrating normal distribution, and Mann-Whitney U test was used for those who do not. Predictors of variables which are thought to be associated with verbal and physical violence are examined by using multiple logistical regression analysis.

Family Life Survey (FLS): FLS was prepared by taking reference from the clinical interview form, recommended by Vahip and Doğanavşargil (2007) to determine the severity of spousal violence (16). The developed survey was titled FLS since it questions violence in marriage and childhood, and participants’ own approach towards their children. Extra care was taken to ensure the questions were plain and comprehensible. Taking into consideration the difficulty of the victim’s talking about the violence, the recommended questions in the clinician’s related interview form were preferred to be posed without making any amendments. In FLS sociodemographic characteristics, general information about marriage, experience of verbal or physical violence in marriage, experience of verbal or physical violence during childhood, physical violence women direct to their own children, severity of exposure to violence during marriage and childhood as well as their view and attitude towards violence are posed respectively. Formats of questions posed in the survey are as these samples: ‘How would you describe your marriage?’; ‘There are difficult aspects of marriage as well as good. Has any verbal violence ever taken place between you and your spouse during a disagreement or moment of aggression in your marriage? (i.e. insult, swearing, contempt, etc.)’; ‘There are difficult aspects of marriage as well as good. Has any physical violence ever taken place between you and your spouse during a disagreement or moment of aggression in your marriage? (i.e. slapping, hitting, manhandling, etc.)’; ‘In our society it is quite common to beat up, pulling the ear, pinching or resorting to other forms of heavy handedness while bringing up children. Have you experienced these during your childhood?’; ‘Was there anyone in your family who was subjected to heavy handedness?’; ‘People who have been subjected to heavy handedness sometimes think that they deserved it. If you have ever been exposed to brute force, have you ever thought that you deserved it?’ Survey consists of 43 questions.

Symptom CheckList-90-R (SCL-90-R): The list consists of 90 item symptom scanning scale with Likert type 5 choices per item. It is based on self-reporting. Symptoms are classified as somatization, obsessive compulsive, interpersonal sensitivity, depression, anxiety, phobic anxiety, paranoid thought, hostility, psychosis, and comorbidity. Validity and reliability in Turkish has been done (17).

FINDINGS

Three hundred and twenty women took part in the study. Surveys with more than 50% of the questions being answered were considered valid, thereby answers of 300 participants were taken into evaluation. Average age of the participants was 36.24±10.88 (aged between 18–69). Most being primary and secondary school graduates (58%); 18% of them were employed; 69% were housewives (Table 1); 75.7% of the participants were married; and 92.9% of these were maintaining their first marriages. Participants with a partner have refrained from declaring their status as co-habiting instead stated their marital status as married. Most (86.4%) were living as nuclear families. Average age of getting married was 20.72±4.16. Youngest age of marriage was 13, those who got married before the age of 18 were 22.3% (n=56); 39.5% of them were married through arranged marriages, average duration of marriages were 16.79±10.65 years. 82.2% of them have children, number of children was 1.79±1.34. Average age of spouses was 42.03±10.79, half of the spouses were primary and secondary school graduates (50.2%); 93.7% of the participants have migrated to their current location from another city; 30.5% of them have stated that they either barely manage economically or they cannot manage (Table 1); 70.1% of women were subjected to verbal and 49% were subjected to physical violence by their spouses; 65.3% of the women who were subjected to verbal violence are also exposed to physical violence. Ratio of participants, who are not exposed to any violence was 26.1%. Out of the participants who are exposed to violence, 21% of women were subjected to verbal violence every day, and 1.2% of them were subjected to physical violence every day; 85.5% of the physical violence was done manually (pinching, slapping, hitting with fist, kicking, etc.), 8.5% was done with an objects (stick, article, etc.), and 6% with sharp objects (cutlery, hatchet, cleaver, etc.). Exposure to physical violence was at a level of 20.9% affecting one’s daily activities.

Table 1.

Sociodemographic characteristics of women who took part in the study

Characteristic	Number	%
Marital Status
Single	44	14.7
Married	227	75.7
Divorced	8	2.7
Separated	10	3.3
Widow	11	3.7
Total	300	100
Education
Illiterate	11	3.7
Literate	2	0.6
Primary School	120	37.5
Secondary School	54	16.9
High School	70	21.9
College	12	3.8
University	31	9.7
Total	300	100
Employment Status
Employed	54	18
Unemployed	246	82
Total	300	100
Perceived Income Status
“We can’t manage”	7	2.4
“We barely manage”	83	28.1
“We manage”	199	67.5
“We live in luxury”	6	2.0
Total	295	100
Type of marriage
Arranged	101	39.5
Companionate	100	39.1
Consanguineous	23	9.0
Shotgun Wedding	30	11.7
Dowry	2	0.8
Total	256	100

Examining the attitude towards violence, 11.4% of women think they deserved the physical violence they have been subjected to; 12.9% think, the violence others have been exposed to, is deserved and 55.4% think no gender discrimination is involved in physical violence. Average age of marriage of those who think they deserve violence was lower (Table 2). Most of those who think they deserve physical violence (88.5%) have been subjected to violence during their childhood. The correlation between being exposed to violence during childhood and justifying of being subjected to violence was statistically meaningful (p=0.023). A mere 6.8% of those who declared they have been subjected to violence have applied to legal authorities, which are police stations and courts of justice.

Table 2.

Characteristics in relation to women’s attitude towards domestic violence

Characteristic	Thinks she deserves violence (n=21)	Doesn’t think she deserves violence (n=171)
	Avg±SD	Avg±SD	t	p
Age at marriage	13.38±9.45	16.90±10.72	1.906	0.153
Duration of Marriage	22.18±4.83	20.42±3.98	-1.436	0.058
Being subjected to violence during childhood	%	%	χ2	p
Yes	23 (14.4 %)	137 (85.6 %)	5.200	0.023*
No	3 (4.2 %)	69 (95.8 %)

^*: statistically significant, Avg: average, SD: standard deviation

Upon binary analysis of variables, it has been established that both verbal and physical violence have a meaningful correlation with the perceived level of income, hence violence is more prevalent in lower income households (p=0.003, p=0.015 respectively) (Tables 3 and 4). The ratio of being subjected to physical violence was meaningfully higher in working women (p=0.009); being subjected to verbal violence was not found to be associated with being employed (Table 4). No meaningful relation has been established in multiple logistic regression analysis between verbal violence life and age, education, type of marriage, employment status, number of marriages, age of spouse, education of spouse, living under the same roof with greater family and relocating to another city (β=0.76, SH=39.1%, p=0.052). Whereas, being employed was found to be precursory factor in a model that examines physical violence life according to same variables (β=1.032, SH=43.2%; p=0.017). All women (n=51) who described their marriage as “bad”, 81.3% (n=74) and those who described their marriage as “fair” and 53.5% (n=4) of those who described their marriage as “good” have stated that they are being subjected to physical or verbal violence during their marriages; 39.1% of those exposed to verbal violence and 47.6% of those subjected to physical violence have stated that their referral to psychiatry clinic being related to violence. Most participants (69.4%) do wish to speak with their doctor about violence.

Table 3.

Risk factors in relation to being subjected to verbal abuse

	Subjected to verbal abuse n%	Not Subjected to verbal abuse n%	χ2	p
Perceived income status
“We can’t manage/barely”	111 64.5	61 35.5	8.793	0.003*
“We manage/Live in luxury”	64 83.1	13 16.9
Employment Status
Employed	29 76.3	9 23.7	6.787	0.365
Unemployed	147 69.0	66 31.0
Educational Status
Secondary School or less	129 73.3	47 26.7	2.836	0.092
High School or above	47 62.7	28 37.3
Age married
17 or less	44 80.0	11 20.0	3.667	0.055
18 or above	125 66.5	63 33.5

^*: statistically significant

Table 4.

Risk factors regarding being subjected to physical violence

	Subjected to verbal abuse n%	Not Subjected to verbal abuse n%	χ2	p
Perceived income status
“We can’t manage/barely”	74, 43.8	95, 56.2	5.878	0.015*
“We manage/Live in luxury”	46, 60.5	30, 39.5
Employment Status
Employed	26, 68.4	12, 31.6	0.821	0.009*
Unemployed	95, 45.5	114, 54.5
Educational Status
Secondary School or less	86, 47.3	87, 50.3	0.121	0.728
High School or above	35, 47.3	39, 2.7
Age married
17 or less	31, 57.4	23, 42.6	2.198	0.138
18 or above	85, 49.5	100, 54.1

^*: statistically significant

Total SCL-90-R scores of the participants demonstrate normal distribution, their average being 1.40±0.68; the highest average score between the sub-group is the depressive symptoms (1.80±0.79). Out of symptoms scanned with SCL-90-R, except for the phobic symptoms, a meaningful correlation was found in all other sub-groups and total scores, and to exposure to verbal violence; somatic, hostility and phobic symptoms in all other sub-groups and total scores, and to exposure to physical violence. Psychiatric symptom level of women who are subjected to violence is statistically higher at a meaningful level (Table 5).

Table 5.

Correlation of SCL-90-R scores with being subjected to verbal abuse or physical violence.

SCL-90-R base scores	Scores of those subjected to verbal abuse (n=139) Avg±SD	Scores of those not subjected to verbal abuse (n=60) Avg±SD	p	Scores of those subjected to physical violence (n=90) Avg±SS	Scores of those not subjected to physical violence (n=107) Avg±SS	p
Total score	1.50±0.64	1.15±0.65	0.001**	1.60±0.69	1.24±0.58	0.000**
Somatic	1.68±0.79	1.34±0.81	0.005*	1.75±0.86	1.43±0.72	0.025*
Obsessive compulsive	1.70±0.80	1.36±0.73	0.002*	1.79±0.82	1.43±0.73	0.002**
Interpersonal sensitivity	1.62±0.84	1.18±0.82	0.000*	1.72±0.90	1.26±0.76	0.000*
Depression	1.80±0.79	1.45±0.78	0.005**	1.88±0.90	1.69±0.83	0.003*
Anxiety	1.56±0.81	1.21±0.71	0.003*	1.69±0.83	1.26±0.85	0.000**
Hostility	1.44±0.91	1.02±0.83	0.002*	1.44±0.96	1.20±0.85	0.101*
Phobia	0.92±0.72	0.76±0.70	0.123*	0.96±0.77	0.79±0.65	0.167*
Paranoid Thought	1.39±0.84	1.00±0.74	0.002*	1.53±0.87	1.04±0.72	0.000*
Psychosis	1.03±0.72	0.74±0.70	0.003*	1.14±0.78	0.76±0.59	0.001*
Additional item	1.48±0.80	1.48±0.80	0.029*	1.57±0.86	1.24±0.68	0.004*

Avg: Average, SD: Standard Deviation p value lower than 0.05 are considered statistically significant

^*Mann-Whitney U test was used for variables that do not demonstrate normal distribution

^**T test was used for variables that demonstrate normal distribution in independent groups

DISCUSSION

In our study DV (verbal and physical) lives of women, who applied to the psychiatry clinic were examined. It is thought-provoking that most of the participants’ (73.8%) have declared that they have been subjected to verbal and/or physical violence by their spouses at least once in their lives. In our study, 70.1% of women have stated that they were subjected to verbal violence and 49% of them were exposed to physical violence. Widespread surveys regarding violence directed at women were carried out by General Directorate of Women’s Status. Accordingly, women’s ratio of being exposed to physical violence by their spouses throughout their lives was 39% in the year 2009, and 36% in 2014 (3, 12). In two other studies similar to our sample group, physical violence in women’s marriages were 57% and 62% (9, 10), and verbal violence was 29.3% (9). Establishing higher physical violence rates than ours can be explained by employing a different method. In a study that examines physical violence, results obtained through clinical interview were compared with survey method, rates obtained during clinical interview were found to be meaningfully higher a result, which was interpreted by the researchers that DV may be better recognized through clinical interview (16). In studies searching DV towards women carried out by face to face interview method; physical violence in Edirne was 30.4% (18); verbal violence in 583 households in Sivas was 53.2%, and physical violence was 38.3% (19); physical violence in a community health clinic in İstanbul was 40.4% (8), and physical violence in a district in Sivas was 40.7% (20). In these following studies carried out by survey method, it was established that; in Ankara 88.1% of women were subjected to physical, and 43.2% to verbal violence (21); in Manisa, 32.9% of women were exposed to violence, 64.8% of those were subjected to physical, 66.2% to verbal violence (15). It can be seen that findings of DV studies are quite varying from one another upon analysing these results. It is difficult to compare results due to differences in sample groups, and different methods used in researches. However, what is thought-provoking is that rates are significantly high. Even if the lowest rate of violence is considered in these above mentioned studies, it can be stated that a third of the women were exposed to violence during their lives. The research regarding DV, carried out by WHO in 10 countries through face to face interview method, is probably the most extensive research. Lifetime physical violence of spouse varies between 13% and 61%; the lowest rate is in Japan and the highest is in Peru; it is stated that spousal violence is seen in much lower rates in industrialized countries compared to others (22). The rate of physical violence in our work is similar to those in areas of high severity in this WHO study. In another report published by WHO in 2012, the prevalence of global lifelong spousal violence on women who has had a partner at any one time is 30%. Accordingly, the lowest prevalence is in Europe (25.4%) and Western Pacific (24.6%), and the highest is in South-eastern Asia (37.7%) and Eastern Mediterranean (37%) (3). In a report by European Union Agency for Fundamental Rights (FRA), spousal violence exposure of women in Europe is at 22% (6). Lifelong spousal physical violence of women in United States is at (13%) (23). Prevalence of being subjected to violence of women in our sample is much higher than both Europe as well as many Asian countries. Our research revealed that women are being exposed to physical violence mostly manually; by an item at 8.5%, and by sharp objects at 6.0%. These results may also be considered as the indicator of injuries and femicide resulting from increasing violence in our country over the past few years. Sadly, there had been 303 femicides in 2015, and most (43%) of the murdered women were married (24).

Although violence could be defined in various subgroups, it is known that the exposure to any one type of violence increases both the risk as well as rate to be exposed to others (25). In our study, supporting this information, it was established that most women who were subjected to verbal violence also had physical violence during their lives. It was noted that part of the women subjected to physical violence, have abstained from answering other questions of the survey about violence, and questions relating to the person applying the violence. This may be due to the fact that people refrain from disclosing information about violence as well as a difficulty about the nature of the survey method. Violence could be better reflected in an appropriate and supportive clinical environment (16).

In this study it can be seen that as the income level gets lower, both types of violence occur in a meaningful way and at a higher rate. Sociodemographic characteristics have been analysed in DV studies, and various conclusions have been reached. Akyüz et al. (2002) have established the correlation between education level, education of the spouse, income level, marriage contentment, and violence subgroups (9). Yaman, Efe, and Ayaz (2010) have indicated the association between education level, age gap with the spouse, unemployment of the spouse, economic status, and being subjected to violence (21). Kocacik et al. (2006) have found correlation between type of violence, and education level, annual income and type of family (19). In a community health clinic there was no correlation between being subjected to violence, and education, socioeconomic status and employment in women (8). Vahip and Doğanavşargil (2006) have demonstrated the association between age and living under the same roof with the mother-in-law, and violence in marriage (10). Spousal violence was also demonstrated to be linked with the childhood traumas, education of the spouse, and the age of the wife (26). WHO has established that young age, alcohol dependency issues, not being legally married, man having more than one marriages, being sexually abused during childhood, presence of child neglect either in man’s or woman’s mother, and growing up with DV increase the risk of spousal violence (27). The same publication states that high socioeconomic status, education at high school level, and legal marriage is preventative against spousal violence. In Ethiopia there is a high risk of spousal violence where husband uses alcohol and have history of DV in the family (28). Low level education and being subjected to violence is associated with DV in Pakistan (29). Women share the opinion that insufficient income, disagreements, and use of alcohol increase DV (20). Among the factors defined to be associated with DV, low education level and sub-standard income may be the most valid results. Women in Turkey answered an open ended question about the reasons of male violence as “economic issues” at the highest rate (14%) (11).

A significant determinant of violence toward women is the social gender inequality. Women, who do not have their own economic freedom and have lower education than men are under increasing risk of being subjected to violence (30). In Turkey, 9.4% of women over the age of 25 cannot read and write; this ratio is approximately five times higher than that of men. Participation in labour force is 71.5% in men compared with 30.8% in women. Employment rate increases along with education level (31). It is thought that education and economic resources do not necessarily save women from exposure to violence, however provides them to get away from violence or end it rapidly; thereby, they are subjected to violence at much lower rate (25). We have concluded that women in our study are exposed to physical violence at much higher rates. Women working in an income generating employment, which results in an increase in their income levels, could be foreseen as a decrease in risk of violence. However, women’s working in an income generating job is not necessarily an illustrative factor about whether they shall be exposed to violence or not (11). Difference of status between spouses being in favour of the wife is a factor that increases the possibility of violence (11).

Some of the participants of our study reckon that they deserve violence. This finding is meaningfully associated with being subjected to violence during childhood. Violence experienced during childhood may make violence faced during adulthood justifiable hence causing to accept violence; thereby, may result in violence to continue increasingly. In studies carried out in our country, it has been reported that women relate the violence they are being subjected with certain causes or consider it justifiable (8, 32, 33). According to the Turkey Census and Health Survey carried out in 2013, women’s approval rate to be beaten up by their husbands in at least one of such situations like burning the meal, answering back to her husband, spending money unnecessarily, neglecting the care of children, refusing to engage in sex, is at 13.3% taking all the participants into account, and at 11.1% in Istanbul (34). We have not determined according to which causes the participants justified violence. In a recent study done with Turkey sample group, most women (one in every ten people) have stated that violence could not be justified for any reason whatsoever (11). In the end, it may be possible to say that not every woman finds violence justifiable. In our study, although the rate of violence is higher among those who defined marriage as “bad” however, prevalence of violence even among those who defined marriage as “good” could be the result of attitude towards acceptance of violence.

The youngest age of marriage in our study is 13; 22.3% of the participants married before the age of 18, a rate close to the rate of early age marriages in Turkey. Marrying off girls before they complete their development of identity, is preventing them from getting an education, joining the labour force, and keeping them away from social life significantly, inhibiting the development of their self-confidence, thereby leaving them unprotected against all types of violence. Marriages at an early age cause an increase of physical and mental health issues in women, both directly and indirectly resulting from a high rate of exposure to violence. Therefore, in order to prevent marriages at an early age that could be deemed as violation of human rights, legislative amendments, education programs, and permanent systematic changes embracing the social life, are being advised (35).

All kinds of violence could affect mental health. Most common types of lifelong mental illnesses that are detected in women subjected to spousal violence are phobias, depression, dysthymia, and general anxiety disorder; any one type of spousal violence increases mental diagnoses in a meaningful manner (36). The most commonly updated comorbidity in women experiencing DV is PTSD, and the lifelong diagnosis given most often is the major depression (14). In Pakistan, high rates of depression are detected in married women subjected to violence (29). Variables that affect depressive symptoms the most are chronic illness and DV (15). Depression is significantly much higher in Turkey among people who are subjected to DV, and this deteriorates women’s quality of life (25). In a study examining DV in people with mental illness; among women, prevalence of lifelong spousal violence among inpatients were 16–94%, and among outpatients 7–81% (37). Meaningfully higher rate of DV was detected among women with suicide attempt of the psychiatric inpatient group; therefore, researchers suggested questioning DV in suicide attempt (38). Congruous with literature, meaningfully higher symptom levels were detected in women subjected to violence; among a part of the women who were subjected to violence referred to our polyclinic as a result of DV, most participants wished to speak with their doctor about the violence. Women subjected to violence might be abstaining from reporting their injuries or distresses, may not seek help with the fear of being labelled, and may be scared of ending their marriages (39).

In our study, the rate of participants seeking help from legal authorities is very low (6.8%). In a widespread survey carried out in Turkey, 49% of women who were subjected to physical or sexual violence by their spouse or person they lived with, never told their experience to anyone; most of them (91.8%) never sought help from any authority. Moreover, 55% of them have stated that they could not get help from people who witnessed or were aware of the violence (3). Women subjected to violence in rural areas mostly remain silent whereas those in cities either retaliate verbally or leave their husbands. Women in cities apply to legal authorities about violence at a higher rate than women in rural areas (3). Women may be worried about their complaint reporting violence hitting a dead-end and abstain from applying to authorities. Just as people who endured violence experience difficulties in telling their ordeal, mental health professionals also have issues about asking about violence. Mental health professionals may think that they have no role in detecting DV in suspicious cases, hence refrain from questioning (39). Mental health professionals’ perspective and attitude to DV should be handled in pre and post-graduation trainings; also a scanning and intervention guidelines for health workers, containing information about things that can be done to detect spousal violence and DV, should be prepared.

This paper has been presented verbally during 48^th National Psychiatry Congress (Bursa, 2012)