Domestic Violence : What’s love got to do with it?

• Main Authors: Samir Al-Adawi, Sabah Al-Bahlani
• Format: Article
• Language: English
• Published: Sultan Qaboos University 2007-04-01
• Series: Sultan Qaboos University Medical Journal
• Subjects: na
• Online Access: https://journals.squ.edu.om/index.php/squmj/article/view/1271

SURVEYS FROM DIFFERENT PARTS OF THE world have shown that a woman is more likely to be injured, raped or killed by an intimate partner than by any other person. There are a myriad of subtle but debilitating forms of violence directed towards women: dowry-related or son preference that leads to abortion of female fetuses, female infanticide and bride-burning homicides. The list also includes misdemeanours such as rape, sexual abuse, forced prostitution, female circumcision or genital mutilation.1, 2 Although males are also abused by their female partners and intimate partner violence is not exclusively a male domain,3 for the present purpose, this paper will focus on violence directed at women; that is, women assaulted or harmed physically, psychologically or emotionally by their partner. The rationale for focusing on women is based on the widely established opinion that a female is more likely than the male to bear the adverse effect of intimate partner violence. The saying, ‘‘A hungry man is a hungry man, but a hungry women is a hungry world”, may be relevant a metaphor in coming to grips with the ill effects of abused women. Despite its global occurrence, there is no standard classification for domestic violence in medical literature. The most widely used term for violence between husband and wife is ‘intimate partner violence’. The word ‘intimate’ is misleading since there is no intimacy in such tumultuous circumstances. Other terms that encapsulate partner violence include domestic abuse, domestic violence, spouse abuse, courtship violence, battering, marital rape, and date rape or simply wife beating. For the present purposes, an abusive relationship between husband and wife occurs when a husband tries to harm his wife or to exert control that will harm her either immediately or eventually if repeated over the time. Although data from elsewhere have suggested that women are more likely to experience lack of empowerment and be trapped on the margins of society than their male counterparts,4 in the past decades Oman has begun to close this gender gap. In higher education, approximately 48 per cent of all students enrolled in tertiary education are males, suggesting that female enrollment rate in post secondary education has surpassed that of males.5 Complementing their recent enrollment in education, one of major benefits of the recent literacy campaign is the entrance of women into the labour force. Approximately 30% of the workforce in the Omani civil service is female.6 An interrelated aim of the present discourse is to highlight the role of aggression in human nature with theoretical input from psychoanalytic, ethological, biological and social learning theories. The article will also synthesize the components of domestic violence  such as the role of emotions like jealousy, the roles of hormones and substance abuse as well as consider the role of culture in the expression of domestic violence. Awareness among health professionals of domestic violence is paramount as women experiencing intimate partner violence are at increased risk of various medical and psychosocial problems. It should be highlighted at the outset that, to our knowledge, there are no studies from Oman in the public domain on domestic violence. Therefore, the present discourse is inferential from evidence emerging from elsewhere that may not have direct bearing on the situation in Oman. Consistent with cultural teaching in Oman that the only accepted intimate relationship is a conjugal one, the present focus will be on married couples but, in reviewing literature from other parts of the world, reference will be made to other types of intimate partner violence. I M P A C T  A N D  T Y P E S  O F  D O M E S T I C  V I O L E N C E In addition to overt physical harm, there are other enormous ill effects of domestic violence. The most common is emotional and psychological harm. Women who have been the victims of persistent and unremitting domestic violence tend to experience somatic and psychological distress similar to those experienced by soldiers in war zones and victims of torture or natural disasters.7 These subjective feelings are accompanied by biological markers of distress such as elevated levels of cortisol.8 Sequelae of domestic violence, whether manifest as psychological or as somatic distress, sometimes become chronic even after the abusive relationship has ended. While there are cases where even after separation the abusing husband may find ways to intimidate his ex-wife, some ‘pathological memory’ may persist as ‘flashbacks’ of traumatic experience to haunt and distress the victim. The form and content of intimate partner abuse is varied. The first and most common type is emotional abuse that includes using insulting names employing terms that are culturally devalued. An abusing husband may deprive his wife of social contact or can sometimes stalk her. Domestic discord may include the husband withholding mundane things such as her money, jewellery or even her favorite perfumes or makeup. Domestic violence may also be manifested in the husband preventing his wife from getting or keeping a job. Domestic violence can also be seen in a wife being coerced into unwanted or forced sexual activity and/or other unremitting intimidations in matters related to marital intimacy. Most dishearteningly, violence can lead to physical harm, disability or even death. However, there are rare cases in which the abused wife takes revenge and kills the husband. In some hallmark cases, the murder of the husband did not result in the prosecution of the wives. The act was considered as self-defense or ‘battered woman defense’.9 The magnitude of intimate partner violence hinges on which definition of violence is used and the context in which it is measured. As expected, domestic violence is likely to remain largely hidden and, despite its wide occurrence, violence towards wives has been seriously understudied. The studies that have been carried out in different parts of the world suggest that there are complex and interrelated reasons, which prevent battered women from seeking outside assistance.10 For the majority, there is the cultural proscription against breaking up the marriage as well as the strong stigma in many communities around the world attached to divorce. Some women in an abusive relationship tend to be caught up with idea that they will not be able to survive outside the present household and therefore see their situation as unredeemable. Others have pointed out that the wife tends to endure an abusive relationship for fear of the negative effects of a marriage breakup on the children.10 From earliest civilizations, it has been known that certain temperaments are prone to certain predispositions including the tendency for intimate partner violence. Psychologists studying personality types have suggested that people with dissocial temperaments are more likely to be involved in intimate partner violence than the general population.11 In psychiatric literature and classification, dissocial individual tends to be callously unconcerned for the feelings of others and incapable of maintaining enduring relationships, although having no difficulty in establishing them. These individuals tend to be intolerant of frustration, get easily provoked and have a tendency to blame others. An interesting feature of these individuals is their communication style, characterized by a sense of grandiosity and highly persuasive statements of self-importance. There are a significant number of dissocial personality types, with a prevalence of 2-3% in the general population. This rate increases to 60% among males with poor impulse control and those with prison records. The powerful nature of individuals with dissocial personalities means that their abused partners tend to perceive their situation as helpless, a hallmark of the condition known as the ‘battered wife syndrome’.13 The feeling of helplessness and the perceived futility of trying to change such a pathological relationship apparently leads to the abused person behaving as if the soul music lyric that ‘love hurts’ were an inescapable part of married life. Walker14 has depicted the ‘cycle of violence’ as fluctuating in complex ways. According to her studies, there is period of ‘honeymoon’ where the couple cease to be caustic to each other and some element of expression of affection prevails. Sometimes the couple vows not to dwell on the past turmoil and seeks to open a new chapter in their relationship. This is followed by a ‘tension building’ phase, characterized by poor communication and other interpersonal problems. The final phase in the circle is ‘acting-out’, where overt outbursts of violent and abusive incidents occur with all the consequences that this may entail. In addition to the physical, emotional or psychological harm to the female, there are also other ill effects of domestic violence. The most obvious victims of domestic violence are innocent children in the household, as violence is likely to have a detrimental effect on children’s cognitive and emotional development. Studies have shown that infants as young as six months old can experience trauma symptoms as a result of hearing or witnessing intimate partner violence.15 There is also indication that domestic violence during pregnancy increases the risk factor for antepartum hospitalisation, obstetrical complications, low birth weight delivery and infant death. 16, 17 It was noted that even mature adolescents, who witnessed inter-parental violence, tend to suffer emotional and psychological distress as well as an increased rate of aggression, delinquency and poor academic performance.18 This echoes a famous African proverb that “When elephants fight, the reeds get hurt”. There is also indication of ‘triangulation’ whereby the simmering tension between the pair diverts the conflict on to a child, therefore stabilizing the relationship between the original pair. In the atmosphere of triangulation, the child may resort to attention seeking behaviour such as adopting a sick role to defuse conflict between the father and mother. The sick role as a result of triangulation has been shown to heighten the frequency of seeking medical help which, in turn, leads to a large number of consultations and iatrogenic illnesses in triangulated children.19 O V E R V I E W  O F  A G G R E S S I V E  B E H AV I O U R  I N  H U M A N S By any definition, violence towards an intimate partner is a manifestation of aggressive behaviour. It is therefore pertinent to consider emerging views on aggression. Aggression is defined as violence, the technical term being a behaviour that intends to injure - physically and psychologically – another person using corporal or verbal means.20 For the present purpose, theories of aggression will be reviewed, though not exhaustively, from those that put forward the view that aggression is an instinct to those that posit aggression as learned behaviour. The first and foremost theory of aggression in humans suggests that our tendency for violence is innate or instinctive. One of the first persons to paint a pessimistic view of human nature and aggression was Sigmund Freud, 21 who famously said that ‘man is wolf to man’, ‘Homo homini lupus’. Aggression, violence and our propensity to harm others and ourselves is an inevitable predicament and at the heart of the human psyche, according to Freud’s classic book, Civilization and its Discontents.21 As a basic part of human emotion, aggression can manifest itself inwardly as self-destructive behaviour. According to this view, reckless driving or puffing cigarettes encapsulates the internal channeling of aggression. According to Freud,21 in order to harness such instincts, society should devise and encourage mechanisms to channel violence into more acceptable and less brutal activities. The natural extension of this view is to explore anthropological studies that have compared the rate of violence in human societies in order to test whether aggression is inevitable. The societies were classified as either ‘low conflict’ or with ‘high conflict’. It has been found that those societies that socialize to minimize interpersonal confrontation, in other words, operate to encourage ‘low-conflict’ paradoxically have higher rates of violent death. On the other hand, in societies that operate to have ‘high conflict’, whereby children are encouraged to be brave and bullying others is expected behaviour, the rate of violence is generally relative low.22 This seemingly counter-intuitive view appears to support the instinctual model of aggression. In this model, aggression is an instinct that cannot be ‘suppressed’ by any agent of socialization. It also implies that the atmosphere of violence paradoxically serves as catharsis for the aggressive instinct. Otherwise, as has been observed in low conflict societies, attempts to harness aggressive behaviour are in fact counterproductive. While the view that human nature is inscribed in our genes has received some support, 23 there is also empirical evidence that aggression is a learned behaviour rather than an innate temperament. According to the seminal work of Bandura,24 aggression is learned through observation. Mass media have been known to instigate violence in real life, including the self-destructive type known as copycat suicide.25 Preference for viewing violent programs among youngsters is disproportionally related to aggressive behaviour during adolescence. Watching aggressive role models (either live or on film) significantly heightens the amount of aggressive behaviour displayed by children, compared to youngsters viewing a non-aggressive role model or not having access to violence scenes. Interestingly, observation of live role models results in imitation of more specific aggressive acts, whereas observation of filmed (either real or cartoon) role models sets off more aggressive responses of all kinds.26, 27 In addition to longitudinal observation, there are psychological studies suggesting that those who commit violence have been themselves victim of violence, a phenomenon known as ‘identification with an aggressor”, where the victim takes the role of perpetrator. It is possible that an individual who sustains mistreatment in childhood is likely to internalize the view that violence is a means to conflict resolution. There is a strong link between currently experienced domestic violence and violence experienced as either a child or an adult.28 As the abused are likely to become abusers, then, by implication, violence begets violence and therefore it is a learnt behaviour.1 In support of this view, childhood experiences of abuse or witnessing family violence are independent predictors of that person becoming the abuser himself. This type of detrimental childhood experience has been shown to render its victims vulnerable to a multitude of longterm negative emotional, behavioral and academic outcomes, as well as poor physical health, in addition to perpetuating the circle of violence.2 If aggression is inevitable or otherwise, then it should be expressed more saliently in animals since animal are more driven by their instincts than humans are. Ethological research notably by Lorenz30 and Goodall31 have shown that aggression is, in their term, ‘species-specific behaviour’ and therefore is a more complex phenomenon than that depicted by psychoanalysts such as Sigmund Freud. Unlike humans, animals have evolved mechanisms to control aggression and, moreover, animals have not invented weapons, nor do they have the faculty for premeditated murder and violence. The incidence of intra-species violence and warfare is lower or largely nonexistent in animals compared to humans. Interestingly, a study conducted on wild primates called bonobo (Pan paniscus) suggests that there are few tendencies for intra-species aggression.32 It has been speculated that the largely peaceful life among bonobos might be related to strong bonds - affinitive behaviors - between males and females.33 Bonobos’ social organization is based on the female lineage. The question here arises why apes have apparently succeeded while humans have pitifully failed. Could it be that the gender imbalance that exists in human society that is to blame? Countering such a view, there is indication that aggression is present on a wide scale even in human matrilineal societies where women are perceived to be endowed with some symbolic power.34 F A C T O R S  I N  D O M E S T I C  V I O L E N C E While the debate lingers on as to whether aggression in humans is a learnt behaviour or neurogenetically determined, 35 it is relevant here to examine empirical data indicating the correlates of intimate partner violence. It should be said at the outset that there is no unitary profile of a violent husband or uniform socio-demographic background of the perpetrator of domestic violence.36 In the present context, the roles of emotions like jealousy, endogenous and exogenous substances that impact on mood and subsequently the tendency for domestic violence will be reviewed. Finally, more consonant to Oman, the role of cultural patterning in moderating or otherwise violence in the family will also be considered. THE ROLE OF JEALOUSY IN DOMESTIC VIOLENCE Among the repertoires of varied human emotional predispositions, jealousy has been largely ignored in the medical literature. Jealousy is defined as an emotion experienced by one who perceives that another person is giving attention, love, or affection to a third party. As should be expected, jealousy is likely to play a significant role in intimate partner violence. It is difficult to demarcate between ‘healthy jealousy’, which translates to a lay person as part of the concept of love, and ‘unhealthy’ jealousy. There is evidence that social customs define how jealousy should be perceived. According to Mengali, Mungai and Rucci, 37 some societies embrace jealousy as acceptable social behaviour while other societies may view some expression of jealousy as abnormal, in particular when it exceeds a certain level of possessiveness. Although genetic tests have shown that 20% of women had children by men other than their husbands,38, 39 jealousy, sometimes labeled obsessional jealousy, occurs without any shred of evidence of infidelity. Such ideation appears to exist in 10% of the population.37 In the psychiatric fraternity, an extreme aberration or form of jealousy is known as ‘pathological jealousy’ or the ‘Othello syndrome’.40 Individuals afflicted with such an emotion tend to be preoccupied with unrelenting thoughts of the infidelity of their spouses. Overt attempts to confirm these suspicions are common. For example, a husband may constantly check the whereabouts of his wife. One classical manifestation of pathological jealousy is when a husband seeks to discover all the phone calls his wife has made. In the extreme form, not only are the relationship and partner damaged, but the quality of life for the sufferers of pathological jealousy themselves is also severely compromised by the presence of obsessive and unremittingly distressing thoughts of their partner’s infidelity. The factors associated with pathological jealousy have not been widely documented though some single case reports have implicated the roles of coffee, hazardous and chronic abuse of alcohol and even overt brain injury.41, 42 There are some psychosocial correlates of pathological jealousy including perceived imbalance in the attributes of the couples. The perceived asymmetry that may threaten a partner can include education levels or, for that matter, even standards of beauty. It is suggested that spouses who perceive their partner as ‘attractive’ are vulnerable to fall pray to imagining that their partner is involved in marital infidelity. A woman who has attained higher educational achievement than her husband is likely to attract his jealousy. In polygamous societies, jealous tension may arise if a woman perceives neglect by her husband, usually in favour of a younger and more attractive wife.43 Studies have found that the nature of jealousy is different between sexes.44 Men become particularly jealous when they feel the potential loss of the partner, whereas women are more concerned about the effects of infidelity on the quality of the relationship.44 An in vivo neuro-imaging study supports the dichotomous processing of cues of sexual and emotional infidelity. For example, in a recent study, Takahashi et al.45 have demonstrated that there is gender difference in cerebral perfusion in response to mock situations of infidelity. When exposed to a situation arousing jealousy, males showed greater activation in the amygdala and hypothalamus while women’s increased cerebral blood flow was significantly elevated in the posterior superior temporal sulcus. One of the consequences of an atmosphere of distrust in the household is discord leading to verbal threats and in extreme cases, to violence or even homicide. ROLE OF ENDOGENOUS AND EXOGENOUS SUBSTANCES IN DOMESTIC VIOLENCE It has been long known that biological rhythms do play a part in behaviour and there is increasing evidence that certain phases of biological rhythms do coincide with family discords.46 Hormonal changes have been suggested to lead to the distressing feelings accompanying menstruation on the part of the wife and lack of understanding on the part of the husband. Such a scenario can fuel hostile communication that can heat up into verbal abuse or even trigger violence. On the male side, there is also an indication that the male’s predominant hormones, such as testosterone, may play a crucial role in the expression of violence. Mazur & Booth’s47 review study shows that men with higher levels of testosterone are more likely to divorce, be arrested for offenses other than traffic violations and use a weapon in fights. In animal experiments, castration has been shown to reduce aggression. In contrast, testosterone restores aggression in castrated mice. There is also evidence of the role of other neuromodulaters in violence. Higley et al.48 studied free-ranging rhesus monkeys living on an island. They had the low serotonin metabolite and 5-hydroxyindole acetic acid levels, associated with high risktaking behaviour – such as aggression towards older, larger animals, and taking long leaps between trees. Many died as a result of attacks from mature males. However, the direct link between aggression and violence is not clear. Testosterone or other neuromodulators must be present for organisms to exhibit aggression, but injecting compounds with affinity to these neuromodulators has been shown to be insufficient to turn a previously non-aggressive mouse into an ag gressive one or vice versa.48 As it takes ‘two to tango’, a simplistic association between biological rhythms, hormones and violence may not be adequate to capture the complexity of domestic violence although this link appears to be tantalizingly plausible. One plausible explanation is that rather than neurochemistry having a direct effect on aggression, there ought to be interplay between one’s temperament such as impulsivity, coupled with deranged biological rhythms and the exigent ecological or social milieu for expression of aggression to take place. Among these factors, it appears that poor impulse control plays a critical role in the initiation of domestic violence.49 In addition to endogenous substances, such as the neuromodulators mentioned above, exogenous substances, such as some mind altering substances, have been shown to play significant roles in domestic violence. It has been repeatedly shown that alcohol abuse has a strong influence on the quality of marital life. In some parts of the world where there is a relaxed attitude to the availability of alcohol, the majority of patients attending emergency medical attention are victims of intimate partner violence.50 Alcohol is prohibited in Islam because it is believed to diminish one’s sense of responsibility, cloud the consciousness and challenge the precept of self-restraint accentuated in Islamic teaching.51 More recently, emerging anecdotal reports and impressionistic observations suggest that there is a rise of alcohol-related illnesses and deaths and alcohol-related social problems in Islamic societies, including Oman.51 On the one hand, a husband who has been drinking may be perceived as ‘charming’ or even ‘cute’ when he loses his inhibition and starts to shower his wife with compliments. However, on the other hand, beyond such a convivial period, alcohol does impair judgment and often leads to erratic behaviour and different types of inhibition loss. There are speculations that alcohol intake tends to induce negative mood states as well as impulsiveness and aggression.52 Individuals with a long-term history of hazardous and harmful alcohol abuse are prone to impaired processing of emotional stimuli and have been found to have ‘disturbed’ serotonin and testosterone activity.35 Both serotonin and testosterone have been critically associated with aggression and impulsivity.35 There is also evidence that men with ‘verbal expressive deficits’ tend to get more frustrated and angry during tense verbal communication.53 This corroborates earlier findings suggesting males, in response to external threats, tend to rely more on ‘primitive’ brain regions to process emotion while females exposed to similar threats tend to show activation in brain areas involving the higher neurocognitive neural substrate controlling planning and rationality.54 The lack of neural apparatus to process emotion in males may explain that why even minor heated arguments may lead to violence in order for the man to ‘get his point across’ or ‘win’ the argument in particular when the situation is marked with social stress and intoxication. Although the evidence appears to support the view that alcohol is an important indicator of domestic violence, it is worthwhile noting that approximately 76% of perpetrators of domestic violence have no apparent history of alcohol abuse. Therefore, other factors should be considered. In a similar way to alcohol abuse, there is also a strong suggestion that the use of many mind altering substances tend to be a strong predictor of family violence, 11 either because they impair judgment or as part and parcel of the unpleasant emotions during withdrawal from the drug. Despite the link between mind altering substances and domestic violence, there are myriad cases where domestic violence is independent of these substances – hence the importance of including other factors in the algorithms , including a history of being physically harmed by parental figures during childhood, certain personality profiles, and substance misuse. C U LT U R A L  F A C T O R S  A N D  D O M E S T I C  V I O L E N C E Finally, although intimate partner violence is distributed throughout the world, there are cultural factors that contribute to its variations. Douki et al. 55 have found that one in three women are likely to experience domestic violence in some countries in the Middle East, but this may be ‘tip of the iceberg’ as the region has been described as being marked by a “culture of silence”.10, 56 Therefore, it is not surprising that the majority of victims of violence studied were afraid, embarrassed or simply did not know where to seek help. Within the constraints of the culture of silence, campaigns against domestic violence are yet to be held; in any case, the impact of such campaigns in other parts of the world leaves much to be desired.10, 57 It would be relevant to reflect on socio-cultural factors that might affect their impact in the Arab/Islamic part of the world. To paint a blanket picture, as if there were a unitary ‘Arab character’, the collective identity of the family is arguably the central cultural patterning in the Middle East. According to Dwairy,58 individuals in the Arab world live in a symbiotic relationship with their family that reinforces social behaviour reflecting group identity. In a traditional, collectivistic Arab society, the intimate details of the household would not go beyond the family circle. Indeed, reliance on the criminal justice system to confront the evil of family violence may be counterproductive.58 When a husband, the only deemed “protector’ for the welfare of the wife and children in these societies, becomes the abuser, outside encroachment into what is perceived as a private family matter may damage the whole family including the victim, as shame and honour have a strong role in the indices of social cohesion and family bonding.58 Other family members may resist the ‘family secret’ being exposed to outsiders because the whole saga will sully the family’s honour. The need to preserve honour and social collectivity may override personal distress, even if it means submission to unremitting and lifelong abuse. Although no formal study has been conducted in Oman, there are two factors that may have moderated as well as perpetuated the incidence and magnitude of family violence. In the traditional setting, it has been commonly accepted that society is paternalistic and collectivistic.59 In such a setting, the norm is an extended family, with family members living in close proximity. Marriage is a bond between the families, as the couple represents a small link in the chain of family ties. Marriage is considered a sacred and unbreachable institution. The family plays a central role in the collectivistic society. If a misunderstanding happens between couples, violence is unlikely to occur as other family members will intervene to calm down the situation. In such a setting, couples are not alone in the household. However, wife beating may occur for two reasons. Firstly, the cultural patterning disco