Despite international efforts, violence against women (VAW) continues to be frighteningly common and tolerated within many societies in developing countries in general and Arab countries in particular under the garb of cultural norms, or through misinterpretation of religious rules 1,2 1,2. VAW may not only compromise the quality of life of women and children but also be a hidden obstacle in the economic and social development of countries 3.
The most common forms of VAW include the following: intimate partner violence and other forms of family violence; sexual violence; female genital mutilation; femicide, including honor and dowry-related killings; human trafficking; and VAW in humanitarian and conflict settings 4. Rates varying from 15 to 71% were reported by the WHO multicountry study (2005) in 10 countries 5. More recently, the first global systematic review (2013) on the prevalence of two most common forms of VAW, intimate partner violence and nonpartner sexual violence, shows striking findings; almost one-third (30%) of all women who have been in a relationship have experienced physical and/or sexual violence by their intimate partner, whereas 7% of women have been sexually assaulted by someone other than the partner. The prevalence was highest in the WHO African, Eastern Mediterranean, and South East Asia regions (∼37%) 6. Real prevalence may be higher in the Arab world, as under-reporting of spousal violence in particular is common as a result of shame, fear of retaliation, lack of information about legal rights, lack of confidence in, or fear of, the legal system, and the legal costs involved. Under-reporting is highest in case of sexual violence as it remains highly stigmatized in all settings 7.
There is evidence that, in the Arab world, many of the specific sociocultural and economic factors that foster a culture of VAW are behind the alarming magnitude of the problem 1. Most importantly are the social norms that support male authority, control over women, and approve or tolerate VAW 2,8 2,8. Sex inequalities in access to formal employment and secondary education, discriminatory family laws, and childhood exposures to violence are also important risk factors 6.
In the Middle East, specific types of domestic violence (DV) are common, including honor-related violence directed at both unmarried and married women, abuse by other family members (such as in-laws, parents, and brothers), early, forced, and/or temporary marriages, sexual harassment, violence against girls and women in school, work, and healthcare settings, female genital cutting/mutilation, sexual abuse of female children in the household, violence perpetrated against domestic workers, and other forms of exploitation 1. Although honor violence was extensively researched 9, relatively little attention was paid to violence that takes place outside families, such as sexual harassment and violence against girls and women in work and healthcare settings 10. Sexual harassment in public and work places is extremely prevalent in Egypt. A United Nations’ study 11 showed that 99.3% of Egyptian women ever experienced sexual harassment. In the current issue, a study that investigated harassment in a large University Hospital in Gharbeya, Egypt, reported very high level of workplace harassment (70.2%). Most of the harassed nurses, despite claiming adverse psychological effects due to harassment situations, did not take action or lodge an official complaint for fear of being dismissed, losing their reputation, or facing social stigma in the workplace.
Two studies addressing DV in this issue were conducted in clinical settings in Kingdom of Saudi Arabia and Egypt. They revealed much higher rates than those cited by community-based studies 1,6,12 1,6,12 1,6,12. These high rates cannot be interpreted without special focus on the context, and methods followed to ensure higher disclosure. It is worth mentioning that studies conducted in health settings tend to yield higher prevalence rates. In addition, both studies share common features; they reflect the role of culture in fostering a violent environment as compared with the role of education, a social factor which had a protective effect against violence. The study conducted in the Northern Border, Kingdom of Saudi Arabia, where an Islamic conservative culture prevails, reported a very high rate of violence against wives (80.7% for physical and 100.0% for psychological violence), but the rate was significantly lower when the husband was highly educated. Authors explained that, besides the effect of culture, this high rate was also due to strict assurance of confidentiality, privacy, and using women for data collection; all encouraged women to disclose more information to the primary care physician. Nevertheless, considerable percentages of wives refrained from disclosing the real causes of violence, as the social norms in this culture forbid disclosure of intramarital conflicts. This highlights the important role of the primary care physician in detecting violence and providing a culturally sensitive service to the survivors of DV 13.
The study carried out on pregnant women attending the largest University Hospital in Egypt also revealed a very high rate of exposure to violence during pregnancy (30.6%) and, similar to the study conducted in Kingdom of Saudi Arabia, the rates were significantly lower among participants whose husbands were highly educated. Generally, the prevalence of DV in Egypt across various Demographic and Health Survey (DHS) (DHS 1995, 2005, 2014) does not appear to have changed over these two decades; nearly one-third of married women ever experienced a form of physical violence by their husband 12,14 12,14. Small surveys, however, consistently reported higher rates 15–17 15–17 15–17. However, this rate of violence during pregnancy is alarming; it is about four-folds the rate reported by the Egypt’s DHS, 2014 (7%) 12. The facts that most participants in this study expressed characteristics suggestive of social disadvantage and that the tool used for measuring DV was not comparable to the standardized questionnaire used in DHS may partly explain this high difference. Violence in this critical period have serious reproductive consequences and such high rates could influence health workers to screen women for DV and lead to effective referrals and interventions.
Early marriage of girls is another common type of VAW in the Arab world, but mostly not perceived as such by people. Findings documented in the Egypt’s DHS 2014 12 indicate that the overall level of teenage childbearing is 11%. The interesting study carried out among adolescent girls and boys in rural Upper Egypt showed that, although early marriage of girls was not universally recognized by adolescents as a form of gender-based violence (GBV), yet they demonstrated a satisfactory knowledge about the legal age of marriage as well as tendency to abandon the practice. Findings of this study reflect a growing awareness on the issue of GBV among adolescents and emphasize the importance of measuring participants’ perception of the concept of GBV rather than directly measuring the mere accuracy of knowledge about the terms used to describe it.
Conflicts of interest
There are no conflicts of interest.
1. Boy A, Kulczycki A. What we know about intimate partner violence in the Middle East and North Africa. Violence Against Women 2008; 14:53–70.
2. Khawaja M, Linos N, El-Roueiheb Z. Attitudes of men and women towards wife beating: findings from Palestinian Refugee Camps in Jordan. J Fam Viol 2008; 23:211–218.
5. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts C. WHO multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. Geneva, Switzerland: World Health Organization; 2005.
6. World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva, Switzerland: WHO, The Department of Reproductive Health and Research (RHR); 2013.
7. UNICEF. Domestic violence against women and girls. Italy: Innocenti Research Center. Innocenti Digest; 2000; 6:1–30.
8. Kaplan RL, Khawaja M, Linos N. Husband’s control and sexual coercion within marriage: findings from a population-based survey in Egypt. Violence Against Women 2011; 17:1465–1479.
9. Kulczycki A, Windle S. Honor killings in the Middle East and North Africa: a systematic review of the literature. Violence Against Women 2011; 17:1442–1464.
10. Abbas MAF, Fiala LA, Abdel Rahman AGE, Fahim AE. Epidemiology of workplace violence against nursing staff in Ismailia Governorate, Egypt. J Egypt Public Health Assoc 2010; 85 (1–2):29–43.
11. UN Women, Cairo Demographic Center. Study on ways and methods to eliminate sexual harassment in Egypt: results/outcomes and recommendation. New York: UN; 2013.
12. Ministry of Health and Population [Egypt], El-Zanaty and Associates [Egypt], and ICF International. Egypt Demographic and Health Survey 2014. Cairo, Egypt and Rockville, MD, USA: Ministry of Health and Population and ICF International; 2015.
13. Usta J, Taleb R. Addressing domestic violence in primary care: what the physician needs to know. Libyan J Med 2014; 9:23527.
14. Ambrosetti E, Abu Amara N, Condon S. Gender-based violence in Egypt: analyzing impacts of political reforms, social, and demographic change. Violence Against Women 2013; 19:400–421.
15. Bakr I, Ismail N. Domestic violence among women attending out-patient clinics in Ain Shams University Hospitals, Cairo, Egypt. J Egypt Public Health Assoc 2005; 80 (5–6):629–650.
16. Afifi M. Physical violence and some reproductive health variables among currently married Egyptian women. J Egypt Public Health Assoc 2008; 83 (1–2):49–66.
17. Fahmy HH, Abd El-Rahman SI. Determinants and health consequences of domestic violence among women in reproductive age at Zagazig district, Egypt. J Egypt Public Health Assoc 2008; 83 (1–2):87–106.