Attitudes of Palestinian Physicians Toward Wife Abuse

Sample

The study was conducted among a convenience sample of 396 Palestinian physicians from the West Bank and East Jerusalem, who work in four major hospitals in those areas. The mean age of the participants was 39.5 years (range 27-62, SD = 8.40); 73.6% of the participants were male; 19% were single, 78% were married, 1.5% were either divorced or separated, and 1.5% were widowed at the time the study was conducted. Nearly 93% of the participants were Muslim, and the remaining 7% were Christian; 59.6% were living in urban areas, 32.4% were living in rural areas, and the remaining 8% were living in refugee camps at the time of the study. Thus, the sample was heterogeneous with regard to the variables of age, gender, religious affiliation, and place of residence, even if it was a convenience sample.

Instrument

The instrument used in this study was a self-administered questionnaire in the Arabic language, which consisted of several sections, including qualitative open-ended questions and demographic questions. Because this article presents the results of a larger study about attitudes toward and perceptions of wife abuse, we will only describe the sections of the questionnaire that relate specifically to the results reported here.

Procedure

Due to the current tense political conditions in the Palestinian Authority, and due to the lack of an updated sampling framework, it was not possible to obtain a random sample of Palestinian physicians. Therefore, a convenience sample was derived, which comprised physicians employed at four Palestinian hospitals in East Jerusalem and in the West Bank (in the cities of Jenin, Nablus, and Ramallah). Physicians who were working at the emergency wards or in other wards at the hospitals on the day the questionnaire was distributed were approached by research assistants and asked to participate in a study on physicians’ attitudes toward and responses to wife abuse.

The physicians were instructed to fill out the questionnaire at their convenience, to place the completed forms in an envelope, and put the sealed envelope in a locked box in the emergency room at each participating hospital. The research assistants were instructed to collect the completed questionnaires at the end of each week, for 3 weeks after the questionnaires were distributed (i.e., the questionnaires were collected three times): 48% of the completed questionnaires were collected at the end of the 1st week, 23% were collected at the end of the 2nd week, and 12% were collected at the end of the 3rd week. Ultimately, 83% of the physicians who were approached to participate in the study actually completed the questionnaire. The study was conducted during the first 6 months of 2002.

Data Analysis

Data analysis was conducted following the approaches, phases, and techniques that are commonly used for analysis of qualitative results (Coleman & Unrau, 2005). In the first stage, I transcribed the responses to each one of the open-ended questions indicated earlier. In that way, a file of raw data was prepared for the next steps of data analysis. In the second stage, three graduate students in the field of public mental health were recruited and informed about the purpose of the study. All of them are well acquainted with the phases, tasks, and techniques of qualitative analysis. In the third stage, all four of us previewed the raw data. We identified meaning units, produced categories of responses for every open-ended question, assigned codes for the categories, and refined and reorganized the coding.

Comparisons among the author’s and the students’ four independent lists revealed high consistency and reliability among them for most categories. Afterwards, the four lists were reviewed by an expert in the field of domestic violence practice and research. There was a high level of correspondence between the expert, the author, and the graduate students with regard to their conceptualizations and categorizations. The final conceptualizations and categories were produced in relation to existing literature on the main dimensions of the study, that is, the definitions and causes of wife abuse, and possible interventions in cases of wife abuse, as will be shown in the following section. In the final stage, all five of us (myself, the three graduate students, and the expert) engaged in further discussions for the purpose of choosing the most appropriate and representative statements as illustrations of each category in the Results section. Moreover, we sought to identify the possible relevance of the sociocultural context of those conceptualizations, categories, and statements.

Definitions of Wife Abuse

Content analysis of the responses to the open-ended question on participants’ definitions of wife abuse revealed that most of the definitions referred to acts that are classified in the literature as verbal and emotional abuse (e.g., screaming, degrading, swearing, cursing, calling names, intimidating accusations; 99% of the responses), and physical violence (e.g., slapping, kicking, attacking with an object, pulling and pushing, shoving; 100% of the responses; see Haj-Yahia, 2000a, 2000b; Straus, Hamby, Boney-McCoy, & Sugarman, 1996). The participants also listed acts defined in the literature as economic abuse (e.g., preventing the wife from using the family’s money as she sees fit) and sexual abuse (e.g., having sex with the wife without her consent; see Haj-Yahia, 2000a, 2000b; Straus et al., 1996), although these acts were listed less frequently than acts of verbal, emotional, and physical abuse.

Three main trends in the physicians’ definitions are noteworthy. First, about 63% of the responses that included acts of physical violence, and about 29% of the responses that included acts of verbal and emotional abuse, referred mainly to acts of severe and persistent types of abuse, and less to acts defined in the literature as minor or moderate abuse and violence. Second, a substantial percentage of the physicians (about 47%) qualified their definitions in a way that might be taken as implicitly or explicitly blaming the woman for her husband’s violent behavior; for example, “hurting a woman when she didn’t do anything wrong,” or “hurting a woman without any justification and for no reason” (author’s emphasis). Third, there was a clear tendency among a substantial percentage of the physicians (about 42%) to provide definitions of wife abuse that are related to the sociocultural context of Palestinian society. This context has been reflected in the category of verbal and emotional abuse by including acts such as “insulting the wife in front of her children and/or in front of family members” (mainly in front of the husband’s mother and sisters), as well as “humiliating the wife and criticizing her in front of strangers.” It also included “harming the wife’s reputation or the reputation of her mother and sisters,” as well as “ridiculing or belittling the wife’s family of origin” (mainly her mother and sisters). Other acts of verbal and emotional abuse that have some relevance to the sociocultural context of Palestinian society included “excessive intervention by the husband in the way the wife brings up the children,” “forcing her to apologize to her mother-in-law,” “taking her jewelry away against her will” (an act that may also be viewed as economic abuse), and “preventing her from visiting her family of origin.” This context has been reflected in the category of verbal and emotional abuse by mentioning acts such as “marrying another woman or threatening to marry again,” “forcing the wife to engage in religiously unacceptable behavior” (e.g., to go out without covering her hair) or “socially unacceptable behavior” (e.g., to sever relations with her siblings), “abusing her family inheritance” (also considered economic abuse), and “supporting the husband’s own family rather than supporting and defending his wife after they have insulted her.”

Regarding physical violence, the physicians mentioned several acts that were found in the international literature, as well as other acts that were mainly relevant to the specific sociocultural contexts of Palestinian society and to other Arab societies in general. These contexts were reflected in several acts of physical violence mentioned by the physicians, such as “attacking the wife in front of the children and using hands or an object,” as well as “attacking the wife in front of the husband’s mother, sisters, mother-in-law, or sisters-in law,” and “having a tantrum or throwing things so that the neighbors can hear.” Other acts of physical violence that have some relevance to those contexts include “attacking the wife’s family of origin—especially her mother or sisters” and any “physical attack against the wife by a member of the husband’s family of origin,” as well as “violent behavior by the husband after he has been drinking alcohol or taking drugs which the neighbors may know about.”

As mentioned, fewer participants referred to acts that would be defined in the literature as sexual or economic abuse. The following are the main acts of sexual abuse that may be considered relevant to the sociocultural contexts of Palestinian society and Arab societies in general: “the husband is unfaithful to his wife,” “the husband forces his wife to engage in certain sexual acts that violate Islamic law” (e.g., anal or oral sexual intercourse), “the husband talks about his sexual relations with his wife in public,” “the husband ridicules or jokes about his sexual relations with his wife,” and “the husband forces his wife to watch pornographic films with him.”

Finally, the following are the main acts defined by the physicians as economic abuse, which may be considered relevant to the sociocultural contexts of Palestinian society in particular and Arab societies in general: “preventing the wife from continuing to study or work for a salary,” “if it was agreed upon prior to marriage that she would be allowed to do so,” and “misusing the wife’s inheritance or gifts that she received from her family of origin.”

Perceived Causes of Wife Abuse

The results revealed that the Palestinian physicians mentioned about 40 causes that can be divided into five categories of perceived causes of wife abuse: (a) causes related to the wife; (b) causes related to the husband; (c) causes related to both partners; (d) causes related to the life conditions of the husband, the wife, or the family; and (e) causes related to the socioeconomic and political conditions in society at large.

The vast majority (76%) of the participants indicated causes related to the wife, besides presenting causes that are commonly indicated by practitioners from different societies and cultures. For the most part, the causes mentioned by the participants reflected their perceptions of the wife’s failure to live up to expectations. The participants’ responses included causes that could be attributed to “the wife’s disobedient behavior toward her husband” (e.g., “she is stubborn,” “she fails to fulfill her husband’s requests,” and “she behaves in a way that undermines her husband’s authority), and to “the wife’s failure to conform to moral codes of behavior for wives and mothers” (e.g., “she discloses family secrets in public,” “she is unfaithful to her husband,” and “she goes out of the house without her husband’s permission”). In addition, the participants’ mentioned causes such as “the wife fails to conform to religious norms of behavior for women as wives and as mothers” (e.g., “she does not dress according to religious codes,” “she does not pray,” and “she is not religiously observant”). Other responses reflected the participants’ perceptions of causes that could be attributed to “the wife’s unfeminine behavior, which can cause her husband to abuse her” (e.g., “she talks loudly,” “she laughs loudly at social gatherings”). Furthermore, the participants mentioned “the wife’s failure to conform to the role of housewife” (e.g., “she neglects her husband, her children, and her family responsibilities”) as well as “her failure to conform to expectations of her as a wife, mother, sister-in-law, and daughter-in-law” (e.g., “she doesn’t respect her husband, his mother, or his sisters and she doesn’t take care of them when they need her assistance”) as possible causes for abuse by the husband. Finally, the participants indicated that “when the wife is not considerate of her husband’s difficult situation he might find reason to abuse her” (e.g., “constantly nagging him to buy her things despite his difficulties”).

The second category of perceived causes of wife abuse, that is, causes related to the abusive husband, were mentioned by a substantial majority (58%) of the Palestinian physicians, and can be divided into three major subcategories. First, the participants indicated that “the husband’s failure to conform to expectations of men in traditional patriarchal societies” might be a serious cause for his abusive behavior (e.g., “because he has a weak personality and lacks self-confidence,” or “because he is unable to show his wife who makes decisions in the home”). Participants also indicated that “if the husband has not succeeded in showing his wife “who wears the pants,” he might feel compelled to use violence against her “in order to force her to respect and obey him.” Second, the participants mentioned numerous personal problems with the husband that might cause him to abuse his wife: for example, “he is addicted to drugs and/or alcohol,” “he is jealous, paranoid, and mentally ill,” “he has failed to fulfill himself,” “he is overly temperamental.” Third, the participants indicated that “when the husband has a macho personality and feels a need to domineer his wife he will tend to use violence against her” (e.g., “he has an intense need to be dominant,” “he has an overly authoritative personality,” or “he believes that women only understand force”).

The third category of perceived causes of wife abuse, that is, causes related to both partners, was indicated by the vast majority (82%) of the physicians, and can be divided into four possible causes. First, some participants indicated that “when each partner feels powerful, needs more power, and wants to dominate the other, the husband might use violence against his wife.” For example, “there are cases in which both partners believe that by dominating the other it is possible to have a satisfactory marriage,” or cases in which “each of the partners believes they are the highest authority on earth,” and for that reason “it is important to them to control the world, including their partner.” According to some Palestinian physicians, “this situation is unacceptable to some husbands”; hence, “it may cause them to use abusive behavior against their wives.” Second, some participants believed that “in cases where each partner has independent attitudes about various issues related to spousal relations and family life,” and “if they lack the skills to deal with their differences,” wife abuse can occur. For example, “when each partner still has the mentality of a completely independent and self-sufficient person, each partner wants to control the marital relationship and family life according to their desires,” and “when both partners are not aware that marriage and family life require compromise, cooperation, and mutual understanding.” According to this perception, “that kind of mentality can cause some husbands to abuse their wives.” Third, some participants mentioned that “when there is discord, disharmony, and lack of intimacy between partners” (e.g., “they are not compatible,” “they have major differences,” or “they don’t know how to love each other”), it is likely that wife abuse will occur. Finally, some participants indicated that “wife abuse can occur when neither partner is emotionally or intellectually mature” (e.g., “both of them married at a young age or never learned what marriage or family relations are,” “both of them are immature and quarrel about the slightest thing”).

The fourth category, that is, the perception that wife abuse is related to the life conditions of the husband, the wife, and the family, were indicated by the vast majority (about 87%) of the participants, and they can be divided into three major subcategories. In essence, the participants highlighted “harsh life conditions” (e.g., “the family’s difficult economic situation, poor living conditions, and unemployment”), as well as “family problems resulting from difficulty with one of the children” (e.g., “one of the children is ill,” “the children fail in school”) as major causes of wife abuse. In addition, they mentioned other life conditions that can be related to wife abuse, such as “discord and conflictual, unstable relations with both partners’ extended families or families of origin” (e.g., “the mother-in-law intervenes excessively in the couple’s life,” “the mother-in-law influences her son to beat his wife,” “the couple lives in the same house with the husband’s family of origin, which leads to unnecessary discord and tension”). In a similar vein, participants indicated that “the family’s experience with discord and conflicts with society can be related to wife abuse” (e.g., “conflict with neighbors can cause tension within the family,” “the couple’s extended family can be in conflict with another extended family, which causes tension among the entire family of the couple”). With regard to the fifth category, a substantial percentage (about 32%) of the participants indicated that “difficult political conditions can also be related to wife abuse.” For example, it was stated that “the Israeli occupation might cause the husband to project his anger and humiliation on his wife.” Moreover, they believed that “the occupation imposes stressful life conditions such as curfews, unemployment, restriction of movement, which upset the entire family, and as such can lead to wife abuse.”

Perceptions of Appropriate Interventions With Wife Abuse

Content analysis of the Palestinian physicians’ responses to the open-ended question about their perceptions of appropriate interventions and solutions for wife abuse can be divided into seven categories of suggested interventions and solutions: (a) direct intervention with abused wives, (b) direct intervention with abusive husbands, (c) intervention with both partners, (d) improving the family’s life conditions, (e) involvement of external parties, (f) legal interventions, and (g) divorce.

Summary and Interpretation of Results

The article presents comprehensive data from a study that dealt with Palestinian physicians’ definitions of wife abuse, their perceptions of the causes of wife abuse, and their perceptions of appropriate interventions with abused wives and abusive husbands.

Substantial percentages of the Palestinian physicians are aware of different types of wife abuse, and their definitions of acts of wife abuse are highly consistent with definitions presented in the professional literature (e.g., Haj-Yahia, 2000b, 2000c; Straus et al., 1996). At the same time, the findings revealed a relatively strong tendency to recognize severe and ongoing acts of violence as wife abuse, whereas they were less inclined to recognize episodic acts of mild or moderate violence as such.

The present study also revealed that the physicians’ tendency or lack of inclination to define a woman’s experience of abuse or violence as wife abuse is affected by the extent to which they blame the woman for the situation, which is strongly related to the traditional and patriarchal sociocultural context of Palestinian society in particular and of Arab societies in general. Numerous studies have shown that the disposition of physicians to be involved in assessment and identification of battered women is largely influenced by definitions of the problem (Flitcraft, 1995; Gerbert et al., 2002). This study did not examine how Palestinian physicians respond when they actually encounter a battered woman, when they themselves recognize and assess the woman’s experience as violent, or when she actually identifies herself as a battered woman. Based on the results of this study, it is likely that the physicians would respond by ignoring some experiences with abuse and violence or by remaining oblivious to them as long as the woman has not specifically identified herself as abused, or as long as they view the experience as a “mild” or “moderate” incident of episodic violence. Hence, physicians may fail to accurately assess the risk to the woman’s life. As indicated, Palestinian physicians introduced definitions of wife abuse that could be in accordance with or have relevance to the sociocultural contexts of the Palestinian society, and of Arab societies at large. Those contexts are typified or characterized by several values, besides other dimensions.

One value is that women must be respected by their offspring, and that their status as mothers should be strengthened. Another value is that the wife’s honor must be maintained in relations with her husband’s relatives, and that her status in the extended family should be enhanced (Al-Khayyat, 1990; Haj-Yahia, 2000b). Hence, unsurprisingly, physicians’ definitions of wife abuse included acts of abuse in front of her children and in front of relatives, as well as acts that are considered damaging and that undermine her status in the extended families of both partners. Another value is that family privacy must be preserved, and outsiders should be prevented from intervening in family affairs. The reputation of the wife and her family should also be maintained, and they should not be insulted in public (Haj-Yahia & Sadan, 2008). Accordingly, it was found that the physicians’ definitions of wife abuse included acts that are considered damaging to her motherthood role as well as her responisibility to maintain the reputation and honor of her family. Finally, the issue of marital sex is considered highly personal and must remain confidential at all costs, and sexual fulfillment and pleasure in marriage must derive from direct sexual relations between partners and not from “instrumental” relations, such as pornographic films (Al-Khayyat, 1990; Haj-Yahia, 2000b, 2000c, 2002). Consequently, it was found that physicians’ definitions of wife abuse were a reflection of these values, where they included acts that are related to the nature of undesirable sexual relations as well as to the approach of the husband toward such relations. It should also be mentioned that many of the behavior codes in Palestinian society, like most other Arab societies, are influenced by religious values and beliefs. It is not surprising, then, that many of the participants believed that forcing women to engage in behavior that is against religious law, or husband’s behavior such as drinking alcohol or gambling, is considered abusive.

The perceived causes of wife abuse revealed in this study, which are attributed to the wife herself, largely reflect the physicians’ patriarchal perspectives as well as their traditional expectations of women. These causes are consistent with the perspectives and expectations that a woman should be obedient and submissive, and that she should make concessions to her husband, children, and family (Haj-Yahia, 2000c, 2002). In addition, these perceived causes are consistent with the perspective that the wife is largely to blame for violence against her and she bears responsibility for such violence.

The Palestinian physicians’ perceptions of the causes of wife abuse, as related to the husband, point to several trends. One trend reflects the tendency to blame the husband for not being masculine enough. Another trend highlights medical problems and psychopathology as causes of violence, which absolve the husband of responsibility for his violent behavior. A third trend, which contradicts the first two, places full responsibility on the violent husband and attributes the problem to his traditional and patriarchal orientation toward women (contrary to the prevailing expectation in Palestinian society; Haj-Yahia, 2010). However, it should be emphasized that the third trend was noted less frequently than the first two in the participants’ answers. It is very likely that this trend reflects changes that are taking place in Palestinian society, such as the growth of the women’s movement and increasing awareness of the problem of violence.

Furthermore, the Palestinian physicians’ tendency to attribute the causes of wife abuse to both partners implies that both of them are perceived as responsible for violence. This trend is consistent with the tendency to blame the wife for violence against her, in addition to being consistent with the tendency to blame the violent husband in certain cases—although there is also a certain tendency to understand the husband and even to absolve him of responsibility for his violent behavior (Btoush & Haj-Yahia, 2008; Haj-Yahia, 2003). In addition, the tendency to attribute the causes of wife abuse to both partners is consistent with the prevailing view in traditional Arab societies that spousal conflict is undesirable and can be prevented, and that in order to attain peace and harmony in the family and between spouses, agreement and congruency must prevail between the two partners (Haj-Yahia, 2000b, 2000c, 2002).

Clearly, the Palestinian physicians’ attribution of wife abuse to the life conditions of the husband, the wife, and the family indicate a prevalent traditional tendency to absolve the husband of responsibility for wife abuse, on one hand, and to attribute the problem of wife abuse to “external forces” that control the life of people (i.e., lack of external locus of control), on the other (Haj-Yahia, 2000b, 2000c; Sharabi, 1999).

In addition, the Palestinian physicians’ suggestions for intervention with abused wives and abusive husbands reflect a strong tendency to medicalize and pathologize the problem of wife abuse, as well as a tendency to absolve the husband of direct responsibility for violence against his wife. These suggestions also reflect a certain tendency to view wife abuse as a problem caused by problems or difficulties in spousal relations (e.g., lack of intimacy and harmony, lack of mutual respect, and failure to adjust to each other). Thus, the blame for violence was placed both implicitly and explicitly on both partners. Clearly, the Palestinian physicians also failed to acknowledge the legitimacy of spousal conflicts and tended to view such conflicts as harmful and unhealthy. These suggestions are also consistent with the prevailing approach in traditional societies (Bennett & Manderson, 2003; Haj-Yahia, 2011), such as Palestinian and Arab societies, which consider wife abuse as an issue that primarily concerns the family and the couple (Btoush & Haj-Yahia, 2008; Haj-Yahia, 2000b). This approach does not attribute the problem as much to the abusive husband, and it is even less inclined to consider the wife’s need for protection and support as a victim. This tendency is consistent with the traditional perspective, which emphasizes the importance of preserving and maintaining the marriage and the family at all costs, even if the battered wife continues to suffer and even if her safety is threatened (Astbury, 2003; Haj-Yahia, 2000b).

The physicians’ suggestions for improving the family’s life conditions as a way for treating wife abuse may also reflect a minimal level of willingness to acknowledge the problem of violence as a sociolegal one, a low tendency to recognize the woman’s physical and emotional insecurity, and the physicians’ unwillingness to recognize wife abuse as a problem deriving from the behavior of the husband.

As indicated, the physicians gave first preference to intervention by extended family members before involving any of the other parties mentioned above—if anyone outside of the nuclear family is involved in any case. This tendency reflects the traditional and collectivist orientation of Arab societies, where the problem of wife abuse is kept within the family and priority is given to maintaining the marriage and the family (Btoush & Haj-Yahia, 2008; Haj-Yahia, 2011; Haj-Yahia & Sadan, 2008). In these contexts, the woman is usually implicitly or explicitly blamed for violence against her. In addition, such societies are less inclined to view wife abuse as a social problem that calls for treatment of the violent husband (except in cases where there is no choice but to acknowledge that the husband has a problem that causes violent behavior, such as drug or alcohol addiction or mental illness; Haj-Yahia, 2000b, 2000c, 2011). In those responses, the physicians’ expectations of community figures, traditional mediators, clergy, and political figures were also similar to their expectations of relatives. Even when the participants suggested involving social services, their expectations of those services were highly similar to their expectations of the other external parties, that is, community members and family.

Clearly, physicians’ perceptions of legal interventions for treating cases of wife abuse reflect the values and norms of Palestinian society and other Arab societies (Btoush & Haj-Yahia, 2008) as well as most other traditional and collectivist societies in the world (Astbury, 2003; Bennett & Manderson, 2003). These values emphasize and reflect the inferior and submissive status of women on one hand, and the superior and dominant status of men on the other. They also reflect and emphasize central values such as family honor and the family’s reputation in the community, family unity and continuity, family cohesion, self-sacrifice for the family network and collective, mutual support among all family members, and respect for members of the extended family and community leaders (Astbury, 2003; Haj-Yahia, 2011; Haj-Yahia & Sadan, 2008). Furthermore, they are indicative of the lenient approach toward wife abuse as well as the view of the problem as a personal issue that concerns the family, and not as a public, social, or legal issue (Btoush & Haj-Yahia, 2008). The minimal percentage of Palestinian physicians who support legal interventions with cases of wife abuse is consistent with the familial and social values of Palestinian society described earlier, and with the prevailing attitudes toward wife abuse in Palestinian society. In Palestinian society—as in many other traditional and collectivist societies—battered women who call the police may be considered rebellious and may be accused of overstepping family boundaries that all family members (including the wife) are expected to maintain (Astbury, 2003; Haj-Yahia, 2002, 2003, 2011). Therefore, the strong tendency of the Palestinian physicians to oppose legal intervention in cases of wife abuse may reflect their view that battered women should obey their husbands on one hand, and consistent with the traditional view of the family institution on the other. Concomitantly, this tendency may result from the doctors’ fear of being accused by society in general, and by the wife’s relatives in particular, of provoking her and encouraging her to rebel against her husband, her family, and prevailing social values. Therefore, the doctors may be afraid that by making such accusations they will be ostracized by society and risk conflict with the wife’s family. Moreover, the Palestinian Authority, like most Arab countries, has not enacted a law for the prevention of wife abuse. Consequently, many Palestinian physicians, like the other members of their society, may believe that wife abuse is not a legal, public issue, but rather a personal and familial issue, and as such it should be kept within the boundaries of the family. Palestinian physicians may not report cases of wife abuse to law enforcement agencies because there are no appropriate legal and professional provisions for intervention with battered women in the Palestinian criminal justice system and their patients may be harmed by the legal system’s response.

Besides the relevance of these values and norms, the Palestinian physicians’ reluctance to advocate divorce as a way of treating and preventing wife abuse can also be attributed to the economic situation in the Palestinian Authority and to the lack of an institutional social security system that provides support to battered women. This situation often makes battered women dependent on financial assistance from their family of origin. Notably, the strong social and familial control over battered women in Arab societies is not only a source of severe emotional stress for the woman, but also constrains her and prevents her from working and supporting herself and her children independently (Cohen & Savaya, 1997; Haj-Yahia, 2000c, 2002). It is not surprising, then, that not only were most of the Palestinian physicians who participated in the study hesitant to support divorce as a deterrent to wife abuse, but other studies have shown that women themselves are hesitant to support that solution and view it as a last resort (Haj-Yahia, 2000b, 2002).

Limitations of the Study

Notwithstanding the comprehensive data obtained in this study, several limitations need to be addressed. One possible limitation is the use of a self-administered questionnaire for data collection. Although the self-administered questionnaire can ensure anonymity and confidentiality, it is subject to response biases and social desirability effects. As indicated, the participants in this study responded to the questionnaire independently in order to ensure anonymity and confidentiality. However, due to the sensitivity of the topic, it is possible, for example, that the physicians showed some tendency either to refrain from expressing their attitudes (as indicated earlier, not all of the physicians responded to all open-ended questions). It is also possible that they responded in a manner that would be perceived as socially acceptable, either by the researcher or by their colleagues and the society at large. There is a need for further efforts to minimize the self-report bias. For example, reports by battered women who were treated by the physicians participating in the study could provide an opportunity for cross validation of responses. Specifically, the reliability and validity of the results would be strengthened if the battered women were to indicate how they perceive the physicians in terms of the three dimensions that were examined in this study.

Another limitation of this study is that it lacked direct questions about actual clinical encounters of physicians with abused and battered women. Accordingly, it is highly recommended that future studies among physicians include questions about this dimension (i.e., their clinical encounter with cases of domestic violence). In addition, it would be worthwhile to conduct studies in which abused and battered women are asked about their own experience with physicians. It should also be noted that the physicians were not asked about their perceptions of the possible effects of violence against women. Undoubtedly, the physicians’ perceptions and awareness of the different types of effects of women’s experiences with violence against them can influence their attitudes toward intervention. Hence, it would be worthwhile for future studies to examine this dimension in general, as well as its relevance to physicians’ actual interventions and their attitudes toward intervention with battered women.

Another limitation of the study relates to the sample and the sampling method. In light of the existing political conditions in the region, it was difficult to obtain a comprehensive sampling frame that included physicians from all areas of the Palestinian Authority. As a result, it was not possible to select a random sample of Palestinian physicians. Even if it had been possible to select a random sample, it would not have been feasible to reach the selected participants owing to the closure of the Gaza Strip and restrictions on travel in the West Bank. Nonetheless, a convenience sample was obtained, which was heterogeneous in terms of age, gender, religion, area of residence (the West Bank and East Jerusalem), type of locality of residence (rural and urban areas as well as refugee camps), and years of work experience. However, it is still difficult to guarantee the generalizability of the findings to all Palestinian physicians. Future studies of Palestinian physicians should attempt to recruit a large random sample, which includes specialists in various fields from all areas of the Palestinian Authority (e.g., family practitioners, physicians in different hospital wards, emergency room and trauma physicians, physicians in private and outpatient clinics, gynecologists, and dentists).

It also should be noted that the responses of male and female physicians were not analyzed separately, nor were comparisons made by gender. Because the responses of the participants were not transcribed by gender, there was no possibility of conducting separate analyses or comparisons. Future research should devote particular attention to this issue, that is, the relevance of physicians’ gender to their attitudes toward wife abuse. Similarly, future research should examine the relevance of physicians’ age and marital status to these attitudes.

Implications for Future Research and Theory Development

The results of this study have been interpreted and contextualized, with heavy reference to the collectivist, traditional, and patriarchal nature of Palestinian society and Arab societies at large. Nevertheless, in light of the qualitative nature of the results, independent variables that could reflect these characteristics of Arab societies were not empirically examined in this study. As such, the empirical relevance of these contexts to the physicians’ attitudes toward wife abuse was not addressed. It would be worthwhile to empirically examine the extent to which the physicians’ attitudes toward issues relating to domestic violence can be attributed to and explained by their patriarchal ideology as well as by their traditional and collectivist orientations. For example, studies could examine physicians’ perceptions of masculinity and sex role stereotypes, attitudes toward women, marital role expectations, attitudes toward family honor, attitudes toward women’s rights in the public and private spheres, and attitudes toward women’s status and roles in the public and private spheres, as well as many other variables that derive from patriarchal ideology. Specifically, future studies could focus on examining how those perceptions and attitudes explain the physicians’ attitudes toward wife abuse as well as their actual responses to battered women under their care. In addition, future studies can examine the extent to which those perceptions and attitudes explain Palestinian physicians’ perspectives on other issues related to domestic violence, such as justifying wife abuse, blaming abused women for violence against them, and attitudes toward different types of intervention with abusive husbands. It is highly recommended that future studies examine the extent to which Palestinian physicians’ actual involvement or lack of involvement in detecting and helping battered women is explained by their patriarchal ideology and traditional orientations as well as by variables that characterize the collectivist nature of Arab societies.

Implications for Professional Training

The results of this study highlight the need to debunk the tendency of some Palestinian physicians to attribute wife abuse to the behavior or misbehavior of the wife as partner, mother, daughter- and sister-in-law and to other factors that have not received empirical support in the international literature. It is also important to enhance the physicians’ knowledge about risk factors and causes of wife abuse that have been emphasized in recent decades in the empirical literature but were not highlighted in their responses (e.g., men’s patriarchal ideology, and learning and intergenerational transmission of violence). It is important as well to enhance the physicians’ awareness of the potential harm that can be caused by keeping cases of wife abuse within the family rather than involving health and mental health practitioners and the criminal justice system in combating the problem of violence against women. There is also a need to educate Palestinian physicians about the short-term and long-term health and mental health consequences of violence against women. Finally, it is important to educate Palestinian physicians about advocacy efforts made by professional societies of physicians throughout the world to prevent violence against women. It is assumed that such awareness will help mobilize Palestinian physicians in efforts to prevent and combat violence against women.