INTERNALIZATION OF DOMESTIC VIOLENCE: EXAMPLE OF SELF-BURNING

Women and Health Learning Package Developed by The Network: TUFH Women and Health Taskforce Second edition, September 2006
Support for the production of the Women and Health Learning Package (WHLP) has been provided by The Network: Towards Unity for Health (The Network: TUFH), Global Health through Education, Training and Service (GHETS), and the Global Knowledge Partnership. Copies of this and other WHLP modules and related materials are available on The Network: TUFH website at http://www.the-networktufh.org/publications_resources/trainingmodules.asp or by contacting GHETS by email at info@ghets.org, or by fax at +1 (508) 448-8346.

About the author Marzieh Moattari, MS, PhD Faculty of Nursing and Midwifery, Shiraz University of Medical Sciences Shiraz, Iran Marzieh Moattari was born in Kazeroon, Iran, in 1956. She graduated from Shiraz Medical Sciences University with degrees in nursing (B A, 1981; MS, 1990) and from Tabriz Medical Scienc es University with a PhD degree in nursing education. She also has a degree (MS, 1998) in medical education. She has many years of teaching experience as a nurse educator. As the director of the masters and postgraduate program in the faculty of nursing and midwifery at Shiraz University, she has played a key role in conducting the program and has supervised many theses and projects since 1990. She is interested in womens health and has conducted qualitative research in this field. She is a member of the Women and Health Taskforce of The Network: Towards Unity for Health.

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INTERNALIZATION OF DOMESTIC VIOLENCE: EXAMPLE OF SELF-BURNING Global Overview Violence against women is not the problem of a particular area, race, relig ion or socioeconomic level. It is a worldwide phenomenon in need of global attention. Victims of violence are vulnerable to many health problems, ranging from those that are simply identified and resolved, to those such as suicide that are more complex. Suicide is a multifaceted problem, to which domestic violence is often a contributing factor. The expression of in ternalized violence in the form of suicide is tied up with the sociocultural context of different societies. In certain parts of the world, self -burning is a common method of suicide. The Importance of Womens Health Women are one of the most important human resources in any country, playing a critical role in societys multilateral development (2). Women live an average of seven years longer than men, and their life expectancy is expected to increase. Because women tend to live longer, their health has a greater impact on themselves and everyone around them, including their children, parents, and anyone else for whom they provide care. In addition, despite recent gains in equality, women are still typically the primary caregivers when family members become ill. In order for women to continue in this vital care giving role, they must maintain their own level of health and wellness. To do so, they need accurate and timely hea lth information, access to resource s, and support from health professionals so they can understand the significance of health in their own lives and take important steps towards living longer and in healthier ways. (10) Violence: A Global Problem In most countries today, women are exposed to gender-based violence. Physical injuries and emotional damage caused by violence have profound effects on the victims, and also on their families and social lives. (11) Domestic violence can severely impair parents abilities to nurture the development of their children. Mothers who are abused may be depressed or preoccupied with the violence. They may be emotionally withdrawn, numb, or irritable , or have feelings of hopelessness. The result can be a parent who is less emotionally available to her children or una ble to care for their basic needs. Abusive fathers are less affectionate, less available and less rational in dealing with their children. Studies even suggest that battered women may use more punitive child-rearing strategies or exhibit aggression toward their children.(12) The Declaration on the Elimination of Violence against Women (1993) defines violence against women as any act of gender-based violence that results in physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivation of liberty, whether occurring in public or in private life. (13)

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Forms of domestic abuse are categorized by Matteson (2001) as: Physical abuse Inflicting or attempting to inflict physical injury and/or illness Withholding access to resources necessary to maintain health Forcing alcohol or other drug use

Sexual abuse Coercing or attempting to coerce any sexual contact without consent Attempting to undermine the victims sexuality

Psychological abuse Instilling or attempting to instill fear Isolating or attempting to isolate victim the from friends, family, school, and/or work

Emotional abuse Undermining or attempting to undermine the victims self of self-worth

Economic abuse Making or attempting to make the victim financially dependent (14) According to Heise, Raikes, Watts and Zwi (1994) some factors that make sexual and other forms of violence persistent include the following: Cultural: Sexually-specific social training Cultural definitions of subservient sexual roles Role expectations in relationships Belief in masculine superiority Values giving men property rights over women Concept of the family as a private domain under mens supervision Marriage traditions (gift to a brides mother, trousseau, etc. ) Acceptance of violence as a tool to end disputes

Economic: Womens economic dependency on men Limited access to credit and cash Discriminative rules for legacies, ownership rights, and using communal lands, making it difficult to make a living after a divorce or becoming a widow Limited access to formal or informal employment Limited access to education and training courses for women 3

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Legal: Womens low rank and position, both in both written and common law Laws related to divorce, guardianship of children, inheritance , and legacy Legal definitions of sexual abuse and domestic be havior Low level of legal knowledge and literacy among women Lack of supportive/facilitative behavior of police and judicial systems toward women

Political: Few women in executive positions, politics, mass media, and medical professions A society that ig nores domestic violence Assumptions about the privacy of family, and thinking that it is not within governments supervisory domain Perceived d anger in objecting to some religious laws that may support the present situation Limited organization of women as a political power Limited cooperation of women in the organized political system (15)

The following world statistics illustrate the seriousness of violence against women: One in three women worldwide is exposed to violence. One in four women is exposed to domestic violence. Being beaten at home is one of the most important causes of disability and death for women. Four million women are sold into forced marriages, obscene acts, or slavery every year. 5000 women become the victims of murders related to traditional beliefs every year. 700,000 poor women are brought to Europe for white slavery. 30- 60% of women experience verbal or physical sexual abuse while they are 13-19 years old (2).

An increasing amount of research is beginning to offer a global over view of the extent of violence against women (16). Violence is documented in all different nations and cultures and can be seen as a worldwide phenomenon. It can be argued that globalization has influenced the scope and the nature of violence against women, bringing different and more opportunities for violence , and making poor women and girls especially vulnerable to entrapment, exploitation, abuse , and enslavement (17). Below are some examples of the incidence of violence: Based on the research findings, one-third to one-fourth of women in differe nt countries have reported an experience of physical or mental domestic violence. In a study conducted in Mexico, the incidence and history of battering among women seeking general medical care was sought, and potential risk factors and associations with presenting symptoms were investigated. C urrent physical and/or sexual abuse was reported by 9% of
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women in Mexico. Lifetime prevalence of abuse was 41%. Pelvic pain, depression, headaches, and substance abuse were frequent among abused women (18). Prevalence of present and past violence among women attending social and health services was the subject of another study conducted in Trieste, Italy, which found that 10.2% of participants reported physical or sexual violence in the last 12 months (regardless of perpetrator) (19). A study in Egypt found associations between wife-beating and contraceptive use, pregnancy management, and reports of other health problems. Thirty-four percent of women in the sample had be en beaten by their current husbands; and 16% had been beaten in the past year. Women who had been beaten at any time in their lives were more likely to report health problems necessitating medical attention (20). A cross-sectional study implemented in Sanandaj in the west of Iran revealed that 38% of the respondents had been assaulted by their husbands at some point during their marriage (21). In a research study performed in Orumie , a city in the northwest of Iran, it was found that women between 17 and 32 were most likely to experience violence. Sixty percent of women who experienced violence from their husbands had only primary education, and 25% of them were illiterate. T he most common kind of violence was physical (50%). Husbands were the most likely to be the perpetrators of violence against women (82.4%). Sexual violence had the lowest rates in this study; one probable reason is the cultural condition of Iranian women that results in such violence being rarely reported (11). According to reports of the WHO and the World Bank, injuries from violence cause 14.5% of diseases in developed countries and 15.2% of diseases in developing countries. The rates of deliberate violence in developed and developing countries are 4.2% and 4.1% respectively. Global estimates indicate that violence is a serious cause of womens disability and mortality. Considering the fact that most of the cases in families are not reported, such figures may be the indicator of a shocking condition. Because of the cultural and religious texture of the society in the Islamic Republic of Iran, violence is seen less in the streets, work and public places. The most common form of violence is domestic violence. (2) Muslim teaching specifically prohibits abuse of wives by their husbands, by the very words of the prophet Mohammed, who in his last sermon exhorted men to be kind to womenyou have rights over your wives, and they have rights over you and to treat your women well, and be kind to them, for they are your partners and committed helpers Alkahateeb, 1991 p.54) (22). According to a survey done in 1993 by the North American Council for Muslim Women, domestic physical violence against Muslim women and children occurred in 10% of the Muslim population. If verbal and psychological abus e were added to this, the figure would rise considerably. One study in Denver, the United States, found that 4% of the victims of domestic violence served in that community were Jewish. Clearly religious communities are not immune from domestic violence (23).

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Factors Associated with Domestic Violence Violence is an extremely complex phenomenon that has its roots in the interactions of many factors: biological, social, cultural, economic and political. The world report on violence and health uses an ecological model to try to understand the multifaceted nature of violence. The model assists in examining factors that influence behavior, or which increase the risk of committing or being a victim of violence, by dividing them into four levels: individual, relationship , community, and societal. (24) Indian women are believed to be affected by religion, customs, and age -old prejudices which put them in a subservient and exploitable position in many domains of life. Low rates of participation in education, lack of economic independence, value biases operating against them, and so forth, have resulted in women being dependent on men and other institutions of authority like family, neighborhood, and society. They are usually ignorant of their rights, and even if they are not, they do not have easy access to justice (25). A psychological support program executed in Japan worked with rape victims with posttraumatic stress disorder, who had neither reported the assault to the police nor sought treatment in the mainstream healthcare system. V ictims are generally portrayed as being nonassertive, passive and patient. In particular, Japanese society is only mildly tolerant of female victims who react with anger and aggression toward their assailants, or who assert and articulate their rights. (26) A study carried out in Taiwan to investigate the possible correlation between life-threatening situations, post-traumatic responses, and psycho-physiological symptoms revealed that the medium- and high-risk groups of life-threatening situations accounted for 82.6% of all subjects. Furthermore, 93.6% of all subjects were in a high score group of post -traumatic responses. Among the ten symptom dimensions of psycho-physiological symptoms, anxiety had the highest standardized mean score, followed by obsession, depression, and somatization .The life-threatening situations had a significant positive correlation with the overall post-traumatic responses, the responses of intrusion, and the general severity index. (27). Victims of battering may seek counsel from religious leaders. In a study of 350 battered women, the top responses that women received from clergy were 1 ) a reminder of their wifely duty and instructions to forgive and forget; 2) referral to another resource to limit religious community involvement and 3 ) impractical advice based on religious doctrine that was not only insensitive to their needs, but at times dangerous. Victims are often told by clergy to Stay and work things out. God expects that, or H ope for the best. God will change him. Pray. One study showed that only 8% of the clergies felt they were equipped to deal with family violence , and 37% rated themselves as poorly equipped (Nason-C lerk, 1997). This may be due to lack of training on the issue of violence (23). On the other hand, religion itself can be a powerful tool to heal from the abuse, as a method of coping with it or changing it (Adams, 1999). In a study conducted in 1986 on 187 survivors who had been abuse-free for a year or more, 45 out of 187 reported that their religious beliefs gave them courage, hope and strength. Seventeen said their beliefs gave them support and increased their self-esteem. Six claimed that their religion had aided them in getting free from the abuse. Many of these survivors felt that the power s of forgiveness and understanding were real strengths. Perhaps most importantly, eleven of these survivors
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reported that their religious convictions had prevented them from taking their own lives or killing someone else (Horton, Wilkins & Wright, 1998). Religion is the most important thing to 31% of the population, and is very important to another 55% (Marx and Spray, 1969) (23). Long-term effects of domestic violence on women who have been abused may include the following: Anxiety Chr onic depression Chronic pain Death Dehydration Dissociative states Drug and alcohol dependence Eating disorders Emotional overreactions to stimuli General emotional numbing Health problems Malnutrition Panic attacks Poor adherence to medical recommendations Poverty Repeated self-injury Self-neglect Sexual dysfunction Sleep disorders Somatization disorders Strained family relationships Suicide attempts An inability to adequately respond to the needs of their children In a 1999 study from Johns Hopkins University in the United States , it was reported that abused women have a higher risk of miscarriages, stillbirths, and infant deaths, and are more likely to give birth to low birthweight children, a risk factor for neonatal and infant deaths. In addition, children of abused women were more likely to be m alnourished and to have had a recent untreated case of diarrhea, and less likely to have been immunized against childhood diseases (12). The impact of current and past interpersonal violence on womens mental health was researched in one Italian town. In this study, current violence was found to be strongly associated with psychological distress, the use of psychoactive drugs, and a negative evaluation of health (28). Physical violence from an intimate partner was found to be associated with increased risk of current poor health, depressive symptoms, substance use, chronic disease, chronic mental illness, and injury (29). Violence and suicide are logically related because one of the most important effects of domestic violence is depression, and chronic depression is one of the leading causes of suicide. In 2000, an estimated 1.6 million people worldwide lost their lives to violence, a rate

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of nearly 28.8 per 100 000. Around half of these deaths were suicides, nearly one-third were homicides, and about one-fifth were casualties of armed conflict (24). Over 800,000 people killed themselves in 2000, making suicide the thirteenth leading cause of death worldwide. Among those aged 15-44 years, self-inflicted injuries are the fourth leading cause of death and the sixth leading cause of ill-health and disability. Predisposing risk factors include alcohol and drug abuse, a history of abuse during childhood, and social isolation, as well as depression and other psychiatric problems. Other significant factors include having access to the means of self-harm, and a recent history of attempted suicide (24). The following terms are often used in clinical settings to describe the five levels of suicidal thought or action: Suicidal Ideation: Direct or indirect thoughts or fantasies of suicide or self- injury, expressed verbally or through writing or artwork without definite intent of action. May be veiled or expressed symbolically. Suicide Threats: Direct verbal or written expressions of intent to commit suicide , but without action. Suicidal Gestures: Self-directed actions that result in no injury or in a minor injury by persons who neither intended to end their lives nor expected to die as a resultbut done in such a way that others would interpret the act as suicidal in purpose (e.g. minor scratches on the wrist with a plastic knife). Suicide Attempts: Serious self-directed actions that may result in minor or major injury by people who intend to end their lives or cause serious harm to themselves. Gestures and attempts that are unsuccessful and of low lethality are sometimes called parasuicidal behaviour. Completed or Successful Suicides: Deaths of persons who ended their lives by their own mea ns with conscious intent to die. However, it is important to note that some suicides may occur based on unconscious intent to die (e.g. engaging in high-risk activities) (30).

According to a human development report in 1999, the highest rate of suicide for men and women belongs to Poland (16.7 and 50.6 in 100,000 for male s and females respectively). Iran is at the bottom of this table with 3.4 in 100,000 for women and 3.8 in 100,000 for men. (7). This seemingly low rate of suicide in Iran may be due to a lack of accurate statistics. It is believed that suicide in Islamic countries , including Iran, is an underestimated problem. The official statistics , if any exist, are likely to b e lower than the true rates because of religious prohibition and social concerns (31).

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Regional Overview: Iran and the Problem of Self-Burning The incidence, pattern, and trends of suicide differ considerably between Asian and Western countries. They also differ considerably within Asian countries and regions. In different parts of Iran, up to 40% of all suicides and parasuicides have been reported as coming about through self-inflicted burns. Women are the main victims of self-inflicted burns in Iran (32). Results of research performed by the Tehran University of Medical Sciences shows that selfburning accounts for 25% of the total number (670) of cases of burning being referred to medical centres of Tehran. In Ilam, one of the provinces of Iran, women account for 80% of suicides, most of which use self-burning as their method. Thirty to fifty percent of these women are victims of their husbands violence. Eighty-four percent of all reported cases of self-burning leading to death within a year were women, meaning that self -burning is 5.5 times more likely in women than men. Fifty percent of the victims were between the ages of 11 and 20; 57% were married and 66% were illiterate. Most of the victims were housewives and did not work outside the home. Furthermore, 35% of self -burning victims had known cases of mental disorders. All of the self-burnings occurred at home, and most of them were burnt by oil. (33) A three-year study was conducted in Jordan in order to investigate the prevalence of suicide attempts by burning, find out which individuals are most prone to attempt this method, and investigate the outcome of self-inflicted burns. Based on the results, the most common method used by suicidal patients was to pour kerosene over themselves and set it on fire. The highest suicide rate was found among young women. Suicidal burns were found t o have a high total body surface area (TBSA) and a high mortality rate compared with other burns of similar magnitude (34). In a descriptive study using demographic questionnaires, semi-structured interviews, and psychological autopsies , 318 cases of self-burning were examined in Mazandaran, Iran, over the course of three years. The average age of the burning victims was 27, and 83% of them were female. Most of them were housewives with a high school education. Sixty-two percent had an impulsive suicidal intention. The major motive was marital conflict, including verbal abuse, battery, aggression, sexual dysfunction, repeated break of relations, disagreement , infidelity, and jealousy. Ninety-five percent had a psychiatric diagnosis (mostly adjustment disorder) and 30% had a chronic physical illness. The mortality rate was 79%. The high prevalence of self-burning in the young population, the pattern of demographic factors, and their motivations and high prevalence of adjustment disorders, highlights the nee d for taking preventive measures such as improving life style, interpersonal relationships, marital problems and family structure (35). In 2002, 381 cases of self-burning were hospitalized in one of the Shiraz hospitals; 91% of them were women. Most of the m were about 20 years old and came from poor families (33). In another study carried out in the Fars province in the south of Iran, it was found that burn injuries were more frequent and larger with higher mortality in females than in males. Suicide attempts for all the patients aged 11 and older were the cause of 41.3% of the burns involving women and of 10.3% of burns involving men (36). Another study performed in Tabriz in the northwest of Iran revealed that 90% of self- burning cases were female. The major motive was marital conflict, and the mortality rate was 79.6%.The mean surface area burned was 65.5 %. Causes of marital conflict included
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poverty, lack of understanding, addiction and alcohol dependenc e, lack of love, infidelity, conflict about dowry, and lack of children (32). Another study was conducted in Masjid-i-sulaiman, Iran, to investigate the possible effects of chronic exposure to sulfur compounds on suicidal behavior. Self-burning was more than twice as common in women as in men (male /female ratio = 0.45).Furthermore , lethal suicide was nearly three times as common in women as in men (male /female ratio = 0.37). A positive significant correlation coefficient was found between mean values of all reactive sulfur compounds and seasonal frequenc y of suicide (31). An analysis of 1089 burn patients in Kurdistan in the west of Iran showed that self-burning in the population aged 13 and older accounted for 12.7% of all suicide attempts (37). Approaching the problem of violence regardless of its connection to suicide, and envisioning the problem of suicide, especially self-burning, irrespective of its association with violence, leads us to think about the possible ways to prevent these extensive problems at different levels. The cultural, legal, economic , and political context underlying these problems should be scrutinized. All health care providers , especially physicians, nurses and midwives, have great responsibilities regarding how to approach these problems. The role of healthcare providers in responding to violence must include identification, support, and referral of women suffering from violence, as well as manage ment of its consequences (38). The public health approach is suggested as an effective strategy for preventing violence against wome n. This approach is characterized by four steps: 1) definition and measurement; 2) identifying causes of the problem for development of an intervention; 3) evaluation of the intervention; and 4) dissemination, which involves taking the promising prevention and intervention strategies and putting them into place at local, state, and national levels (39). Although the complexity of implementing an intensive intervention that is directed to primary care practice teams to improve identification and assistance for victims of domestic violence has been addressed in the related literature (40), the following interventions have been identified by the university health network womens health program commissioned by the Ontario Ministry of Health Women's Health Counci l as the primary interventions: Educational and policy-related interventions to change social norms Early identification of abuse by health and other professionals Programs and strategies to empower women Safety and supportive resources for victims of abuse Improved laws and access to the criminal justice system (41).

Five main objectives introduced in the program of the International Federation of Gynecology and Obstetrics (FIGO) regarding violence against women are as follows: "First and foremost, we must educate our members. Womens doctors , obstetricians, or gynecologists must become able to recognize violence against women and help victims. Second, we must make policymakers and the public aware of violence and its dire consequences for the health of so many women.

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Third, we must educate medical students so they are able to understand the implications of violence against women, and become able to talk with their future patients about it. Fourth, we need to sensitize and train doctors, nurse-midwives and other reproductive healthcare providers to respond to violence. Fifth, we also need to develop projects to address violence against women in countries where member societies are ready to act. These would integrate the assessment and care of violence against women into reproductive health services." (42)

Background Information on Iran Population profile on Iran Total population in thousands % Population growth rate Crude birth rate per1000 population Crude death rate per 1000 population Total fertility rate Adult literacy, males (%) Adult literacy, females (%) Unemployment in percent Pregnant women attended by trained personnel (%) Deliveries attended by trained personnel (%) Married women (15-49) using contraceptives (%) Newborns with birth weight at least 2.5 kg (%) Infant mortality rate per 1000 live births Maternal mortality rate per 10000 live births Total life expectancy at birth (years) Male life expectancy at birth (years) Female life expectancy at birth (years) Deaths before age 5 per 1000 live births Key Gains in Womens Health in Iran 1. Esta blishme nt of the Womens Cooperation Affairs Centre, a national project for the elimination of domestic violence against women (2). 2. Establishment of nongovernmental organizations related to womens rights, including Womens Rights Support, the Muslim Women Association, and the Institute of Iranian Womens Rights Support. (3) 3. Establishment of womens job creation centres (4). 4. Formation of a family high council presided over by the president or the first vicepresident (4). 5. Improvement of womens sporting equipment in different provinces (4). 6. Establishment of womens information centres in Iran by cooperation of the Womens Cooperation A ffairs Centre and the United Nations Population Fund (4). 7. Implementation of an information technology teaching program especially for housewives in Tehran (4). 65540 1.2 18.1 4.4 2.0 85 73 13 93 88 74 96 28.6 3.7 69 68 70 36 2002 2002 2002 2002 2000 2002 2002 2002 2000 2000 2000 2001 2000 1996 2000 2000 2000 2000

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8. Signing of an international document in 1993 (along with 170 other countries) saying that womens and girls rights are an inseparable part of the universal declaration of human rights, and any kind of violence against women should be uprooted (2). 9. Paying attention to provision and improvement of womens social insuranc e, especially supporting disabled, vulnerable, poor, and old women (2). 10. Forbidding the smuggling of women and children, on the basis of the voluntary protocol of the United Nations convention of 2003 (2). 11. Conducting research on the quantity and quality of domestic violence, including research conducted by the Womens Cooperation Affairs Centre with the cooperation of the United Nations Development program (UNDP) (2). 12. Formation of crisis lines with the cooperation of disciplinary officers, expanding family consultation centres, teaching law to housewives, and teaching high school boys and girls about law and domestic violence against women (2). 13. Accomplishing the national plan of young couples education in Isfahan, teaching them about the mutual rights of couples in Islam, the importance and advantages of marriage, methods of dealing with family disputes, and methods of effective communication between couples and parents (2). Key Challenges: 1. Debate over whether to join the Removal of Discrimination Against Women Convention (5). 2. Establishment of consultation units in judicial centre s for helping families to reduce the number of divorces (6). 3. Approving a law for hijab (In Islam women must cover their body and hair from other men) (6). 4. No organization, mobilization, or expansion of centres working on social problems. 5. Lack of intervention centres for social crisis. 6. Lack of specialized emergency centres. 7. Lack of safe homes, health homes, and special telephone lines for times of crisis and family consulting centres for social problems. 8. Limited expansion of insurance support for women, the elderly, youth, the unemployed, and other vulnerable people. 9. Not enough job opportunities for Irans youth. (Job creation for Irans young society would be the best way of preventing the expansion of suicide and mental disorders.) 10. Lack of necessary education for parents about interventions for children's spiritual crises. 11. Lack of c onsultation centres for pre-marriage educational courses (7). 12. Unreported domestic violence against women in many countries , including Iran (2). Persistent Issues: 1. Many young people dropping out of school before 16 in deprived regions (9). 2. Lack of congrue ncy of Irans population pyramid with that of other countries. (45% of people in Iran are under 20, compared to 35% worldwide) (8). Emerging Issues: 1. Increasing population of youth (7). 2. An increasing rate of female job seekers (4).
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Priority Issues: 1. 2. 3. 4. Improvement of information technology access for women Improvement of socio-cultural associations for women Job creation for women To make more use of educated women in administrative and other jobs (4).

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REFERENCES 1. Womens cooperation affairs centre (2003). Women Newsletter N o 37. 2. University of Massachusetts (2005). A guide to health promotion and disorder management. Philadelphia.Lippincott Co. pp: 2. 3. Arefi, M. (2003). A descriptive study of domestic violence. Womens Studies , No 2. 4. http://www.therapistfinder.net/domestic-violence/domestic-violence -effects.html 5. http://www.who.int/ mediacentre/fact sheets/f5239/en/. 6. Matteson, SP (2001) . W omen's health during childbearing years: A comprehensive approach. St.Louis. Mosby Co. pp 237. 7. Heise LL ,Raikes A, Watts CH,Zwi AB. Violence against women: A neglected public health issue in less developed countries. Social Science Medicine , 39(9): 1165-1170. 8. Warts, Charlotte, and Zimmerman, Cathy (2002).Violence against women: global scope and magnitude. The Lancet, Vol. 359, pp 1232-1237. 9. Ralford, Lorrain and Tsutsumi, Kaname (2004).Globalization and violence against womeninequalities in risks, responsibilities and blame in UK and Japan. Women's studies international forum 27 pp 1-12. 10. Diaz-Olvarrieta, Claudia, Ellertson, Charlotte, Paz, Francisco. Ponce de Leon, Samuel, and Alarcon-Segvia, Donato (2002). Prevalence of battering among 1780 outpatients at an internal medicine institute in Mexico. Social science and medicine 55, pp 1589-1602. 11. Romito, Patrizia and Gerin, Daniela.(2002).Asking patients about violence: a survey of 510 women attending social and health services in Trieste, Italy. Social science and medicine 54, pp 1813-1824. 12. Diop-sidibe, Nafissatou. Campbell, Jacquelyn C. and Becker, Stan (2005). Domestic violence against women in Egypt-w ife beating and health outcomes. Social Science & Medicine. 13. Ghanimzadeh, A.(2002).Wife battering: A prospective studying an Iranian city. AEP12, pp 525. 14. Alkhateeb, S.(1999). Ending domestic violence in Muslim families. Journal of Religion and Abuse, Vol 1, No. 4, pp 49-59. 15. Hagion, R. and Zepka, C. (2002).Religious views and domestic violence. The Ripple Effect. www.the-ripple -effect.org 16. World report on violence and health summary (2002). World Health Organization Geneva: 6 and 21.

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17. Sharma , B.R.(2005).Social etiology of violence against women in India. Social Science Journal. 42, pp 375-389. 18. Konishi, Takako (2000).Cultural aspects of violence against women in Japan. The Lancet 355:1810. 19. Hou Wen-Li.Wang Hsiu-Hung.and Chhung,Hsin-Hsin( 2005).Domestic violence against women in Taiwan: their life-threatening situations, post-traumatic responses, and psychophysiological symptoms: an interview study. International Journal of Nursing Studies 42 pp 629-636. 20. Romito, Patrizia. Turan, Janet Molzan and De Marchi, Margherita (2005). The impact of current and past interpersonal violence on women's mental health. Social Science & Medicine 60, pp 1717-1727. 21. Coker, Ann L. Davis, Keith, E et al (2002). Physical and mental health effects of intimate partner violence. American Journal of Preventive Medicine, 23 (4) pp 260-268. 22. Marcus Pamela E. Suicide. In Fortinash, K.M. and Holoday Worret, Patricia A.(2004). Psychiatric Mental Health N ursing.3rd edition San Diego. Mosby Co. 23. Suicide, escape from reality (2003). Mehr News Service. Available at: http://www.mehrnews.com/fa/News Detail.aspx?.NewsID=3353 24. Saadat,Mostafa. Bahaoddini, Aminolla, Mohabatkar, Hassan and Noemani, Koorosh (2004). High incidence of suicide by burning in Masjid -i-Sulaiman (southwest of Iran), a polluted area with natural sour gas leakage. Burns 30: 829-832. 25. Maghsoudi, Hemmat.Garadagi, Abbas.Jafary, Golam Ali.Azarmir, Gila.Aali, Nahid Karimian, Bahram and Tabrizi, Mahnaz.(2004).Women victim s of self-inflicted burns in Tabriz ,Iran. Burns 30: 217-220. 26. Mahdavi, B. (2004). Burning destiny of women who seek death in fire. Sina news service. Available at http://www.iransocialforum.org/public/04063002.htm. 27. Haddad, S.Y, Haddadin, K.J.,Abu-samen, M.et al.(1998).Suicide attempted by burning: a three year study. Annals of Burns and Fire Disaster, Vol 11, No 4. 28. Zarghami,M.Khalilian,A (2002).Deliberate self-burning in Mazandaran, Iran. Burns,Vol 28, No 2, pp115-9. 29. Panjeshahin, M.R.Rastegar Lari,A.Talei, AR. Shamsnia, J.Alaghehbandan, R. (2001) . Epidemiology and mortality of burns in the southwest of Iran. Burns 27, pp 219-26. 30. Groohi Bahran, Alaghehbandan, Reza.Rastegar Lari, Abdolaziz. (2002). Analysis of 1089 burn patients in province of Kurdistan, Iran. Burns (28): 569-74. 31. Garcia-Moreno,C.(2002).Violence against Women: What is the World Health Organization doing? International Journal of Gynecology and Obstetrics 78, Suppl.1 S119-122.
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32. Saltzman, Linda E, Green, Yvonne T. and Thacker, Stephen B. (2000).Violence against wome n as a public health issue comments from the CDC. Am J Preventive Med 19(4):325-329. 33. Pearlman,Deborath N .(2000).Violence against women Charting the impact on health policy, health care delivery, and law. American Journal of Preventive Medicine. 19(4) pp 212-213. 34. Hyman, Ilene.Guruge, Sepali. Stewart, Donna and Ahmad, Farah. (2000).Primary prevention of violence against women. Women's Health Issues.10:288-293. 35. Benagiano,G.(2002).The role FIGO in addressing violence against women International Journal of Gynecology and Obstetrics. 78 Suppl.1 S125-127. 36. http://www.emro.who.int/emrinfo/country profiles-ira.htm. 37. Womens cooperation affairs centre (2003). Women Newsletter. No39. 38. Womens cooperation affairs centre (2004). Women Newsletter. No 42. 39. Ebrahimi, Z. (2003). Womens rights and difficult route of joining to the removal of discrimination against womens convention. Womens Journal. Available at http://www.zanan.co.ir/social/. 40. Ebrahimi, Z. (2003). There was just one female opponent. Women's Journal. Available at http://www.zanan.co.ir/social/ 41. Shojaii, M.(2004). Iranian women are still hope ful and waiting. Womens Journal. Available at http://www.zanan.co.ir/social/. 42. Social harms will grow without finding the root. (2003). Mehr News Service. Available at http://www.mehrnews.com/fa/News Detil.aspx? News ID=1469.

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SUGGESTED READING Mertus J, Flowers N, Dult M (1999). Women and girls human rights education (local action, global change). Published by Unifem and Centre for womens global leadership. pp: 231-2. Bahnassawi ES (1985) Woman between Islam and World Legislation. Trans. Abdul Fattah El-Shaer. Kuwait : Dar ul Qalam. Lemu A, Heeren F (1978). Woman in Islam. England: Islamic COE. Mustafa N (1993). My Body is My Own Business. Shia International Oct, p 29. Nadvi M. Modesty and Chastity in Islam. Kuwait: Islamic Bk, 1982. Takim L. The Islamic and Muslim View of Women. Shia International Oct. p 22. Moinifar Heshmat Sadat. Family Structure and Patriarchy within the Family. Available at : http://www.iranwomen.org/scripts/wwwi32.exe/%5bin=f:/zanan/latin/res/titles.in%5d/?query =Moinifar%20.%20Heshmat%20.%20Sadat RECOMMENDED WEBSITES Amnesty International Stop Violence against Women http://web.amnesty.org/actforwomen/index-eng End Violence against Women http://www.endvaw.org/ Iran Women Womens Information and Statistics Center http://www.iranwomen.org/Zanan/English/home.htm United Nations Fourth World Conference on Women http://www.un.org/womenwatch/daw/beijing/platform/violence.htm World Health Organization Violence against Women http://www.who.int/mediacentre/factsheets/fs239/en/index.html

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Case Studies: Student Notes All the case studies (except one) presented here are real cases admitted to one of the countrys hospitals. The data given in each case study is actually a guide to activate the process of inquiry in your mind and group discussion in your class. You are expected to find links between what you have learned from this module and what you read in each case. You are also expected to find information gaps that may exist. A list of questions is included with each case study to help guide your discussion.

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Case Studies Student Notes

Case Studies Tutors Note s We would request that you guide the process of group discussion and encourage all the students to take pa rt in it. So, it is suggested that you refrain from concentrating just on the presented questions or on giving all the information students may need, since it may block the process of inquiry. The most important aim of these self -directed sessions is to make the problem of violence and suicide (especially self-burning or other forms of self-harm) more tangible for the students. Possible questions fo r students (sample responses are given for you to help guide students if necessary) 1. Create a problem list for each case. For example, in Mrs PGs case: being uneducated poverty cultural problems being too young and uninformed for marriage having no pa ssion toward her husband lack of support addiction, etc.

2. What are some probable factors that may trigger violence against women in each case? For example: environmental noise and climate factors the invasion of personal space personality factors cultural and situational factors including loss of self-esteem, and so forth

3. What are the most important factors that may make the women in these cases vulnerable to suicide? For example: poverty unemployment not having a happy marriage and family life lac k of religious integration

4. What are the roles of cultural, social, economic and religious factors in the occurrence of violence against women? Can be discussed on the basis of the text, case studies, etc. 5. What are the facilities or organizations that mig ht have helped the case studies victims if they had sought help because of domestic violence or suicidal thoughts? judicial centres consultation units religious organizations psychiatry centres
Case Studies Tutors Notes

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6. What are some interventions that communities can do take prevent domestic violence? For example: implementing some policies for victims support, improving job training programs, improving educational programs, improving the economic condition of high-risk families

7. How can health and mental health care systems play a role in decreasing violence against women? For example: improving the awareness of health care providers about violence against women creating some standards and protocols for facing these situations dedicating more health care system budgets to preventing violence against women in each of the three preventive levels, keeping violence victims health records

8. What are the roles and responsibilities of health care providers? For example: identification, support and referral of women suffering from violence management of the consequences of violence

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Case Studies Tutors Notes

Case Study: Mrs PG Mrs PG, now 25, was born in a populous household in Bavanat, a rural area in the south of Iran. Her father was a farmer with low income. She began her elementary education at the age of 12 (four years later than normal), but after only one year of schooling, her family compelle d her to marry. She was neither emotionally attached to her husband nor prepared to live jointly with him, but because of the cultural situation and the poor condition of her family, they forced her to marry. Her husband was 18 years old and had an elementary education. At first he was a farmer, but then he changed jobs to earn more money. After her marriage , Mrs PG continued her education to the fourth grade. She tried to increase the family income through carpet-making. Mrs PG is the mother of two children, aged 4 and 8. Mrs PG used to bring opium to her grandmother , and she eventually became addicted herself. Her husband also become addicted and was irascible and nervous. He considered cooking and housekeeping to be the duties of his wife and never appreciated her. He continually beat Mrs PG without any reason. As she continued to suffer from the verbal abuse and torture, Mrs PG repeatedly thought of suic ide, but she never carried it out. She was an easily-offended person, and in order to escape from her problems with her husband, she used to take refuge in religious places. She shared her suffering with her mother and sought help, but her mother advised her to settle down and endure the difficulties. Despite having no attachment to her husband, Mrs PG made a settlement w ith him and never thought of divorce, if only for her childrens sake. Their altercations lasted, however, until one day a severe verbal and physica l confrontation between Mrs PG and her husband took place. She could not longer endure her husbands rudeness , so in order to scare him, she poured oil on herself. Her husband took the match from her to prevent her suicide, but as soon as he was nt looking, she lit herself on fire. When her husband heard her crying and shouting, he smothered the fire with a blanket and took her to the hospital. Now Mrs PG is suffering from burns over 27% of her body, including her arms, chest, face and neck. She is in her 21st day of hospitalization and is repentant for her behaviour. She had believed that her actions would result in some positive changes in her husbands behaviour, but she has noticed no difference and she still doesnt have any attachment to him. She clings to life only for her children. Questions for students 1. 2. 3. 4. 5. 6. 7. 8. What are the problems faced by Mrs PG? What are some probable factors that may trigger violence against women like her? What are the most important factors that may have made her vulnerable to suicide? What are the roles of cultural, social, economic and religious factors in the occurrence of violence against Mrs PG? What are the facilities or organizations that might have helped Mrs PG, if she had sought help because of domestic violence or suicidal thoughts? What are some interventions that communities can take to prevent domestic violence? How can health and mental health care systems play a role in decreasing violence against women? What are the roles and responsibilities of healt h care providers?
Case Study: Mrs PG

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Case Study: Mrs MJ Mrs MJ had finished her elementary education, and despite ha ving many suitors, married a man who was too aggressive and bad -tempered. Her husband had an elementary education, an addiction, and poor vision, and was unable to work to support their costs of living. T hese problems caused suffering for his helpless wife. Mrs MJs father indirectly found out everything. He was rich and left his garden and home to live with his daughter and work to support her and her husband. He began providing for all of Mrs MJs needs. Although he was aware of the torture that his daughter was tolerating from her husband, he ne ver encouraged her to seek a divorce, because he felt it would shame their family to have a divorced daughter. But Mrs MJ finally got tired of her husband and one day burned herself. Her husband closed all the doors to the house, instead of seeking help. He thought it would bring shame on a man if his wife had burned herself. He quenched the fire with water and tr ansferred her to the hospital. The poor woman was so afraid of her husband that she did not confess to selfburning until the end of her life; perhaps she was sure that she was going to die and didnt want to make the situation worse. Many family members and relatives never knew what had happened. Until the last days of her life, Mrs. M.J. pretended that an unintentional fire caused her burns. But she was burned over 30% of her body, on her neck, chest and hands, and she die d of respiratory failure.

Questions for students 1. 2. 3. 4. 5. 6. 7. 8. What are the problems faced by Mrs MJ? What are some probable factors that may trigger violence against women like her? What are the most important factors that may have made her vulnerable to suicide? What are the roles of cultural, social, economic and religious factors in the occurrence of violence against women? What are the facilities or organizations that might have helped the victim in this case, if she had sought help because of domestic violence or suicidal thoughts? What are some interventions that communities can take to prevent domestic violence? How can health and mental health care systems play a role in decreasing violence against women? What are the roles and responsibilities of health care providers?

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Case Study: Mrs MJ

Case Study: Mrs RM Mrs RM is a married nursing student at the graduate level. She belongs to an ethnic group in Iran in which the incidence of violence against women is reported to be high. She is in her second semester and has failed 6 credits out of 12 in her first course of study. She was referred to the director of the graduate program , who asked her to drop her present course and postpone her study. T he reason she gave for her poor performance was that she had help her father with the farming, as she was responsible for supporting her parents economically. The director of the program was not convinced, and advised her to solve her p roblem in another way. She tried to help Mrs RM understand the limitations of the program and the consequences of such a decision; the same courses would not be offered in the next semester, for example, resulting in prolongation of her study. Mrs RM was not satisfied with the suggestion, but showed her willingness to think about alternative ways of solving the problem. After a short period of time she returned to the director and restated her previous decision. At this time she had some scars on her face and some dark areas around her eyes. She cried and again asked to be allowed to drop her present course. Finding a warm atmosphere, she expressed her feelings towards her husbands violent behaviour. She admitted that the real reason she wanted to drop the present course was that she did not feelsafe staying with her husband in a city far from her relatives. After the problem had been explored, the student was allowed to leave the school but not her studies, as she was identified as a talented student. The teachers allowed her to not attend class but be in touch with them to get the necessary information regarding the materia l and resources of study. She was also introduced to a consultant to receive special advice and support. Questions for students 1. 2. 3. 4. 5. 6. 7. 8. What are the problems faced by Mrs RM? What are some probable factors that may trigger violence against women like her? What are the most important factors that may make Mrs RM vulnerable to suicide? What are the roles of cultural, social, economic and religious factors in the occurrence of violence against women? What are the facilities or organizations that might helpthe victim in this case, now that she has sought help? What are some interventions that communities can take to prevent domestic violence? How can health and mental health care systems play a role in decreasing violence against women? What are the roles and responsibilities of health care providers?

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Case Study: Mrs RM

Case Study 4 Mrs F is a twenty-year-old woman living in a rural area near Shiraz, Iran. She has a known case of diabetes mellitus. Despite being smart and studious , she had to discontinue her studies when she had just finished her guidance (lower secondary) school because h er family had decided to arrange her marriage. At the time of her marriage , she was 14 years old, and she was used to helping her mother do the daily chores, like going to the spring to wash clothes. Most of the boys in that region wished to be her husband as she was a young and beautiful girl. But the decision had already been made, and her cousin had been chosen by her family to be her husband. T he girl showed her unwillingness toward this marriage. After some time, the families began to quarrel with each other about her, until finally the unwanted marriage took place. Mrs F began her new life with her husband in a small room. After the marriage ceremony, she became a maid for her new family and was unhappy. She was subjected to her husbands humiliations. Her husband continuously threatened to marry again. Furthermore , she was blamed by her husbands family for her having diabetes , even though she had informed them of her illness before her marriage. They even accused her of theft. Two months passed, and she was racked with despair, unable even to get permission to visit her family. She convinced herself that she should get used to the quarrels with her hus band and his family . After a while her husband became addicted to drugs and everything got worse, especially when he didnt have access to drugs. One day when her husbands family were quarreling with her she suddenly found herself in flames. After smothering the fire, they sent her to the hospital. Now she is hospitalized with burns over 32% of her body.

Questions for students 1. 2. 3. 4. 5. 6. 7. 8. What are the problems faced by Mrs F? What are some probable factors that may trigger violence against women like her? What are the most important factors that may have made her vulnerable to suicide? What are the roles of cultural, social, economic and religious factors in the occurrence of violence against women? What are the facilities or organizations that might have helped the victim in this case, if she had sought help beca use of domestic violence or suicidal thoughts? What are some interventions that communities can take to prevent domestic violence? How can health and mental health care systems play a role in decreasing violence against women? What are the roles and responsibilities of health care providers?

Women and Health Learning Package: Internalization of Domestic Violence www .the-networktufh. org

Case Study: Mrs F