Dehumanization is a psychological construct meaning denying a person’s humanity. The present study has investigated the process of dehumanization in female victims of intimate partner violence using the grounded theory approach.For this purpose, 130 women in Tehran were selected through the convenience sampling method, and after completion of the Revised Conflict Tactics Scales (CTS2), 60 female victims were identified. In-depth interviews started with these women, and the data reached theoretical saturation by interviewing ten victims.The data analysis shows the role of dehumanization in the experiences of female victims of intimate partner violence in the form of two models. The first model showed that from the victim’s perspective, dehumanization plays a crucial role in intimate partner violence. The second model showed that dehumanization was experienced by these women and is involved in developing strategies in their response to the violence. The combination of these two models showed that dehumanization and violence in the context of domestic violence have a reciprocal relationship, forming a cycle between cognitions, emotions, and negative behaviors between couples.Data analysis demonstrated that dehumanization might have a role in experiencing intimate partner violence and contribute to IPV recurrence. Over the past decade, most research in this field has emphasized intergroup violence .3 However, recent studies have shown that this phenomenon can be subtle and hidden in daily maltreatment.2Dehumanization is a psychological construct defined as denying an individual’s humanity.Violence against women and dehumanization4 IPV is one of the most common forms of domestic violence and refers to any intentional abuse perpetrated by an intimate partner5 and can be in the form of physical, sexual, and psychological violence or a combination of them.6 Like other forms of violence, dehumanization can be involved in IPV.7 For example, dehumanization may devalue women, which allows any control and physical harm as in physical violence, direct or implied contempt of women and justifying controlling them as a part of men’s property as in psychological violence, and also allows relegating women to a sexual object, lifeless and lacking in humanity, which justifies sexual violence.8 Rudman and Mescher9 also showed that sexual harassment of women and raping is more probable in men who implicitly dehumanize women. Most studies on violence against women have only focused on sexual violence. Furthermore, although some research has been carried out on university students, there is very little scientific understanding of the role of dehumanization in violence against women in a broader context.Domestic violence is a major public health issue, a violation of human rights, and a significant risk factor for developing mental and physical diseases.Experiencing dehumanization11 rather than the viewpoints of the dehumanized individuals. In recent years, there has been an increasing interest in dehumanized individuals’ perspectives. Bastian and Haslam12 showed that people might perceive themselves as less than human when exposed to negative behaviors. Moreover, Bastian and Haslam13 found that people dehumanize themselves when they experience social exclusion. Experiencing violence and abuse can change the view of the affected individual toward self, others, and the world.14 Particularly, if this violence, rape, or sexual harassment occurs in an intimate relationship, its physical and mental consequences would be far more.15 However, one question that needs to be asked is whether victims of intimate partner violence would experience self-dehumanization. Furthermore, far too little attention has been paid to the experience of being dehumanized by these women.Previous researchers have traditionally focused on the dehumanization of othersCurrent study16 little is known about experiencing dehumanization in victims of intimate partner violence. Apart from Bastain and Haslam, there is a general lack of research on the experience of being dehumanized by the victims. On the other hand, previous studies have investigated dehumanization in the context of sexual violence against women, but physical and psychological violence has been neglected so far. Furthermore, all the previously mentioned studies have serious limitations; for example, sexual violence has not been investigated among real victims in these studies.18 Thus, by employing a qualitative method, we attempt to illuminate the role of dehumanization and the experience of being dehumanized in psychological, physical, and sexual intimate partner violence.Although the experience of being dehumanized and dehumanizing the perpetrators can have devastating effects on the cognitions and emotions of the victims,ParticipantsSampling in this study is conducted in two phases. In the first phase, participants were recruited from different areas of Tehran, Iran, across places such as parks and mosques through a convenience sampling method. Eligible women, who matched the selection criteria of experiencing intimate partner violence, were identified by the Revised Conflict Tactics Scale (CTS2) results. This scale is used to screen and identify victims of intimate partner violence. The initial sample consisted of 130 women, 60 of them, whose score in each of the subscales of the CTS2 scale was above the 25th percentile and had a score higher than 15, were selected. In the second phase, we used theoretical sampling, in which we interviewed these women purposively until we reached theoretical saturation with 10 participants.Study Procedures19 grounded theory method. The analysis consists of three levels of coding: open coding, axial coding, and selective coding. Three researchers were in the analysis group, and the codes and their relationships were checked repeatedly within the group. Interviews continued until the theoretical saturation of data had been made when no new information or categories were revealed as more data were collected.The procedure consists of in-depth interviews with female intimate partner violence victims selected by the CTS2 questionnaire. The data was recorded on a digital audio recorder and transcribed. The first interview was analyzed using Strauss and Corbin’sThe Measuresrevised conflict tactics scale CTS2.The CTS220 is a 78-item self-report measure that assesses five tactics by which conflict can be resolved in a marital, cohabiting, or dating relationship. It includes perpetrator and victim subscales. Each consists of six items for negotiation, eight for psychological aggression, twelve for physical assault, seven for sexual coercion, and six for injury. Each item is rated on an 8-point scale. The reliability and validity of the scale were studied by the authors in 1996 and showed that all five subscales were consistent and related to the theory.21 was used. Panaghi et al. showed that the Persian form has appropriate validity and reliability for the Iranian sample and had acceptable convergent and divergent validity compared with its subscales. The subscales had good internal consistency (Cronbach’s a=.66 to .86). In this study, the Persian formIn-depth Interview. Different authors have measured dehumanization in a variety of ways. Each has its advantages and drawbacks. This study used in-depth semi-structured interviews to identify the role of dehumanization and the experience of being dehumanized in intimate partner violence. The participants were asked about their emotions, thoughts, and behaviors encountering intimate partner violence. There were two questions in which we directly asked the interviewees about dehumanization and self-dehumanization, and the other questions explored this phenomenon in a subtler form in their behaviors, their thoughts and emotions about self, their partners, and their perception about their partners’ behaviors, thoughts, and emotions about them. Each interview lasted between 30 to 60 minutes. Some of the interview questions are listed below:- What did you feel about yourself after experiencing intimate partner violence?- While your husband battered you, what did you think he thought of you?- What were your feelings about your husband after experiencing violence?- Did you ever perceive yourself or your husband as less than human? Could you explain your experience?- Do you ever think that your husband thinks you are less than human? Data analysis:19 method using three levels of coding: open coding, axial coding, and selective coding. In open coding, the researcher creates small units of meanings and labels them. The next level is axial coding which involves grouping and labeling units from the previous phase into broader categories and identifying their relationships. The final stage, selective coding, involves integrating categories and their connections to identify a core category that applies to all categories and integrating the information into an explanatory model using diagrams. In this study, data analysis was based on Strauss and Corbin’sValidity and Reliability:22 presented a method to assess the reliability and validity of qualitative research. According to this approach, Authenticity and Trustworthiness in qualitative research replaced reliability and validity in quantitative research, indicating how thorough the researchers have been in the research process.Lincoln and GubaThe authenticity of Research. A study has accuracy when it uses appropriate strategies to report the actual views of participants. In this study, we have tried to gather unbiased data from the interviews to indicate the participants’ real perspectives.Trustworthiness of research. To confirm the reliability of the research, the following should be evaluated: 1. Credibility, 2. Transferability, 3. Dependability, 4. Confirmability.Credibility. To enhance the credibility of the data, several triangulation methods were used. Data triangulation in this study was done using different groups of victims of violence . Investigator triangulation was obtained in collaboration with researchers in the study. In this way, the data were periodically checked by the supervisors. Transferability. Connection with the scientific background of the study can be the basis for transferability. Furthermore, a detailed description of the procedure helps the transferability. In this study, we described the sampling and coding procedure in detail, and we described the scientific background of the study in the introduction and discussion sections.Dependability. One way to achieve dependability is an audit. To achieve the audit, all actions of researchers from the beginning to the completion of the analysis were recorded to validate the entire process. We recorded the interviews and checked all research procedures with one of the professors to avoid researcher bias.Confirmability. To show a study’s confirmability, it must demonstrate how the information is connected to its resources, and results and interpretations are directly extracted from the raw data. In this study, all the coding procedure from open coding, axial coding, and selective coding was provided in detail to the supervisors, and we used the audit to obtain confirmability.Demographic Characteristics of the Sample:The participants in this research were ten female victims of intimate partner violence. The demographic characteristics of the participants are demonstrated in Through open coding, 25 initial codes were identified; these codes were organized through open and axial coding into ten categories, some of which had sub-categories. These categories and their relations with each other are presented in great detail in Through selective coding, the relations between the codes were identified, and it was revealed that the role of dehumanization in intimate partner violence in their perspectives could be demonstrated in two models and a cycle. The first model shows dehumanization preceding the occurrence of intimate partner violence, and the second demonstrates dehumanization following its occurrence. Each of these models involves the central phenomenon, the causal conditions, the intervening conditions, the contextual conditions, the action and interaction strategies, and the consequences. These two models form a cycle of dehumanization and intimate partner violence.The First Model19 grounded theory diagram, which involves central phenomenon, causal conditions, intervening conditions, contextual conditions, action and interaction strategies, and consequences. Each of these factors is explained in detail in the following paragraphs.Central phenomenon. In the current model, the central phenomenon is the dehumanization of women. In this model, dehumanization can occur in animalistic and mechanistic forms. In this regard, one individual stated that” My husband sees me like an animal. I see him as an animal either. If he was a human, he could not do that to me, “and another commented, “My husband was a boxer, it was as if I was a boxing bag for him. He never considers me as a living thing”. One participant explained: “when we don’t fight, he says that a person only hits an animal, but when there is a fight, he hits me again,” one of the victims said, “He treated me like I am not a living thing,” similarly one participant asserted “That person looks at you like an object, like something worthless.”Causal conditions. From these women’s viewpoint, “women’s low cognitive ability” and “worthlessness of women” in their husband’s perspective are the causal conditions that lead to dehumanization. In this study, men’s thoughts about their wives had two sub-categories: Women’s low cognitive ability and Women’s worthlessness. Some quotes support the former sub-category; for example, one participant stated, “If he valued me and saw me as a human being, he would not have done this,” one woman said, “My role in this house was being a maid and a babysitter. No one values me here,” and another explained “My husband is very obsessive about his personal belongings, no one dares to touch them at all. I wish I was like his belongings and valued like his car or T.V.”Some other quotes supported the latter sub-category. In this regard, some participants talked about their conversations with their husbands; they heard things like: “You can not understand what I am saying,” “A two-year-old child is smarter than you. Your understanding is less than a child,” or “The wall understands me, but you don’t. If I had talked to a stone, It would understand me.” In response to the question:” What do you think your husband believes about you or other women?” a woman said: “He says to me, you are an idiot, you are not even a human, you are an animal, you cannot understand me.”Intervening conditions. In this model, the intervening conditions involve the strategies used by the victims of intimate partner violence in response to their husband’s violence. As the next model explains, women use passive and active strategies in response to their husbands’ violence. According to the common belief of these women, these strategies could lead to more dehumanizing beliefs in their husbands. These strategies are explained in detail in the next model.Contextual conditions. In this model, contextual conditions include certain attitudes of society towards women. According to the victims of intimate partner violence, society’s attitude of women’s inferiority might increase dehumanization of them. Some of these attitudes of inferiority are as follows: Women should not work, women should not be independent, women are intellectually weak, and women are worthless. In this regard, some victims said their husbands were affected by these societal attitudes and believed in them. For example, some of them asserted, “He believed that women should not be independent, and he didn’t let me have a job, and now most of my problems are due to this” another woman said, “In his opinion, women are stupid. For example, if a woman is in front of him while driving, he will insult her.” These perspectives, alongside other thoughts related to “low cognitive ability” and “worthlessness,” explained in the causal conditions section, can intensify women’s dehumanization in intimate contexts. Action and interaction strategies. According to the participants, dehumanization leads to all kinds of intimate partner violence. In the present research, IPV was observed in three forms: psychological, physical, and sexual. Some participants reported psychological violence and said: “I felt that I was being ignored,” or “Sometimes he doesn’t even answer my questions, he just nods his head,” or “If he wants to answer me, he will shout it. He doesn’t want to solve our problems like a logical person,” and “When he yells at me and insults me, I feel crushed.” Victims who reported physical violence mainly explain it like this: “He beats me terribly without thinking about the outcomes,” and “He beats me and doesn’t think what will happen next.” Some other participants reported sexual violence, examples of their description of their experiences were: “He wanted sex without caring about my desires,” and “When he sees that I don’t want to have sex with him, he should at least try a little... not doing what he wants, like animals that don’t have any foreplay. At least try to prepare me. He treated me like an animal.”Consequence. The consequences of violence in an intimate relationship could lead to self-dehumanization and the experience of being dehumanized. It also leads to the dehumanization of the husband as the perpetrator of the violence. In this regard, some victims of intimate partner violence, in response to the question about how they felt about their husbands and whether they see them as less than human, pointed out partner dehumanization and stated: “He doesn’t think at all about what he says, it is like that he says some recorded things like a robot,” or “If he were a human, he would understand what I am saying, but now he just repeats himself like a machine,” “He had no value for me at all. In my opinion he was not different from this table. I had no feelings for him,” and “In my opinion, in the relationship between a husband and a wife, feelings come first. You have a relationship with an animal if this feeling is ignored.”Some other answers of the victims about their feelings about themselves indicate self-dehumanization, for example: “It is as if I have no control over myself. I am a tool in his hands,” or “I felt that I had to obey him like an emotionless doll,” and “When he yells at me, I don’t move, I don’t react just like a statue.”The second model 19 grounded theory diagram, which involves central phenomenon, causal conditions, intervening conditions, contextual conditions, action and interaction strategies, and consequences. Dehumanization from women’s perspective after experiencing intimate partner violence is demonstrated in the second model see . This moThe central phenomenon. The central phenomenon in this model is dehumanization. Dehumanization here is seen as self-dehumanization, dehumanization of the husband, and the experience of being dehumanized. In this model, dehumanization can also occur in animalistic and mechanistic forms. Causal conditions. In this model, the main causal conditions or the conditions that lead to the occurrence of the central phenomenon include intimate partner violence. Intimate partner violence in this study includes psychological, physical, and sexual violence that leads to dehumanizing the husband, self, and experience of being dehumanized. The majority of those who responded to this item experienced this phenomenon as “rampage,” “profanity,” “fear,” and “prevention of independent activity.” Physical violence in these women was seen as being beaten by their intimate partners, and sexual violence was seen in forced sexual intercourse and unusual sexual relations.Intervening conditions. Intervening conditions in this model involve the emotions and cognitions of abused women. Intervening cognitions involve “being worthless in the viewpoint of the husband,” “having low cognitive ability in the viewpoint of the husband,” “being emotionally cold,” “being powerless,” “illogicality of husband,” “husband’s lack of understanding, “husband’s worthlessness” and “husband’s impulsivity.” The intervention emotions also include the feeling of “inferiority,” “hatred” and “anger.”Participants talked about these cognitions and emotions throughout the interview; some examples of them are reported here respectively: “In the beginning, I had a lot of feelings for him, or if we fought, I would be upset. But now I don’t have any feelings anymore. I see myself cold and mechanical,” “I felt that I had no control over myself. Because I didn’t want it, it was only because of his wish. If he said yes, I should have said yes. If he said no, I should have said no,” “My husband never had any logic, he just ranting and raving, his actions had no logic or reason,” “I feel that my husband does not understand me at all, he only speaks for himself, like a tape recorder” “He doesn’t matter to me anymore. A few days ago, when he told me about his accident, I said that it had nothing to do with me,” “I feel like my husband is treating me like an animal without thinking,” “I felt humiliated at that moment. When I compared myself with others, I felt inferior,” “After that, I hated him,” and “When my husband beats me, I feel angry.”A common view among interviewees was that the perception of being emotionally cold, powerlessness, and feeling inferior leads to self-dehumanization. Perceiving the husband as an illogical person, the low cognitive abilities of the husband, being worthless and impulsive, and feelings of anger and hatred are the intervening factors in dehumanizing the husband.Context conditions. Female victims of intimate partner violence believe that pregnancy and the presence of others at the time of violence are the major contexts in which dehumanization occurs. Some interviewees argued that the most compelling reason they experienced dehumanization was their pregnancy at the time of violence. Others stated that the presence of other people at the time of violence was the contextual reason for this experience.For example, in response to the question, “when were these feelings more than other times?” one interviewee said, “One time I remember well was when I was pregnant with my first child. I was only 19. He severely battered me to bleeding. I thought the baby would die,” and the other stated: “What made it stick in my mind is that I was pregnant at that time, my husband told me that I did that to kill the baby.” Another interviewee said: “I remember a time; he slapped me in front of my brother-in-law. It was hard for me to be beaten in front of him,” and another stated:” The time he beat me in front of the guests was the worst.”Action and interaction strategies. Female victims of violence use a variety of strategies in response to experiencing dehumanization. These strategies can be categorized into passive and active strategies. Active strategies include “abandoning home” and “retaliating against husband’s violence.” Passive strategies include “regret of marriage,” “cursing and wishing for husband’s death,” and “thoughts associated with death and suicide.”In this regard, an interviewee stated, “I felt that I was wrong; he was not the person I expected, and I have regretted all these years.” A participant said, “I asked God to do something so that he won’t return back, something happens to him, or he dies; I wanted to kill him. I was thinking of what to do to kill him.” Another participant argued, “I wish that he dies or I die,” another participant stated, “I decided to commit suicide several times, but I did not dare.” On the other hand, some participants expressed active strategies. One participant reported, “I decided to behave like him. If he insults me, I will do the same “. Another interviewee stated, “many times I decided to escape. Even once I gathered my things to go to Mashhad. I was going there to be a shrine server”. With a closer look at these strategies, it could be argued that they are hidden and indirect violence and, in some cases, open and direct aggressions.Consequences. The consequence of strategies used by female victims of violence exacerbates women’s dehumanization. In other words, when women use these strategies, the idea of their husbands that women cannot understand them is reinforced. There was a sense amongst interviewees that the husband’s feeling of not being understood by women, alongside other contextual conditions, could lead to intensified dehumanization of women and intimate partner violence.  For example, a violent husband would think that his ideas and thought cannot be understood by his wife when she retaliates against her husband or curses him. These ideas can lead the husband to dehumanize her more; therefore, more intimate partner violence would occur. When the woman experiences more violence, it will lead to more partner and self-dehumanization, and subsequently active and passive strategies again, forming a cycle between violence and dehumanization.The cycle of domestic violence and dehumanizationAccording to the models discussed, dehumanization and violence seem closely associated. Dehumanization of women, which is mainly affected by society’s attitudes toward women, leads to intimate partner violence, self-dehumanization, dehumanizing the husband, and the experience of being dehumanized. As mentioned in the two previous models, experiencing these three types of dehumanization by women leads to strategies that might intensify the women’s dehumanization by their husbands. Therefore, it could be concluded that integrating the abovementioned models can form a vicious cycle see .Together these results provide important insights into the role of dehumanization and the experience of being dehumanized in intimate partner violence and its consequences. What is interesting about this data is that dehumanization can be both a consequence of violence and a causal condition. Therefore, it can be concluded that the relationship between dehumanization and violence is bilateral rather than linear. Dehumanization in the context of intimate partner violence8 affirmed that dehumanization is associated with verbal violence, regarded as psychological violence. Moreover, several studies have recognized dehumanization in the context of sexual violence against women.24The current study showed that victims of intimate partner violence think they are dehumanized by their spouses, eventually leading to intimate partner violence. Many studies have demonstrated the relationship between psychological and physical violence and dehumanization. In this regard, Brennan 25 indicated that people with the least power in society dehumanize themselves and those responsible for their current situation. In our study, feeling powerless in women is consistent with these findings. Moller and Deci1 also affirmed that the feeling of being controlled by others leads to mechanistic self-dehumanization and dehumanization of the perpetrator.Data analysis revealed that dehumanization could also be a consequence of intimate partner violence. According to the victims of this study, women had experienced dehumanization by their husbands, dehumanize their husbands, and are vulnerable to self-dehumanization. There are several possible explanations for this result. It could be stated that the feeling of being powerless in these women is caused by being controlled by their spouses. Results from Yang and Jin26 “contempt toward self” in distressed couples among the Iranian population can be attributed to the autonomy of the individual in protecting himself/herself against the authoritarian power of his/her spouse. It can also be the condition where one of the couples wants to express his/her regret for being in this relationship. On the other hand, self-dehumanization could be regarded as “contempt toward self.” In a study by Sadeghi and Mazaheri,Intervening and contextual conditions of dehumanization in the context of intimate partner violence27 it was illustrated that pregnant women are more likely to be the target of offensive behaviors and animalistic dehumanization than non-pregnant women. Furthermore, it could be stated that with being a target of violence in front of other people, the feeling of inferiority intensifies in women. In this regard, it was demonstrated in studies by Haslam,2 Bastian and Haslam,12 and Esses, Veenvliet28 that the feeling of inferiority was highly correlated with dehumanization. Therefore, the possibility of dehumanization will be higher in such situations.It was demonstrated in this study that experiencing dehumanization could be intensified during pregnancies or in the existence of other people. These results are consistent with other studies and suggest that pregnant women are more likely to be the target of dehumanization or violence. In a study by Goldenberg and Goplen,30 Another possible explanation for this might be that, according to the ecological systems theory,31 structures, cultural systems, values, and attitudes affect a more comprehensive range of the lower levels at the ecosystem level. In this regard, Heise 32 marked that believing in the dominance of men over women, the relationship between masculinity and violence, strict gender roles, and interpersonal acceptance of violence could be associated with increased violence in lower levels or, in other words, the family level. On the other hand, the impacts of social and cultural viewpoints on dehumanization have been evaluated in several studies. In this regard, Harris and Fiske33 affirmed that a group that is considered socially inferior is more prone to dehumanization. According to our findings, another main factor underlying experiencing dehumanization is gender stereotypes and viewing women as an inferior social group. This result may be explained based on the feminist perspective and patriarchal ideology.Consequences of dehumanization in the context of intimate partner violence2 According to this model, animalistic dehumanization is associated with a sense of inferiority. It seems possible that these results are due to the feeling of worthlessness caused by the dehumanization. According to the results of the present study, dehumanizing the husband is associated with feelings of hatred and anger, which has also been indicated in the studies by Haslam,2 Hodson and Costello,34 and Harris and Fiske.33 In this regard, Jack and Dawson 35 affirmed that animalistic dehumanization raises the victims’ adverse emotional reactions (such as hatred). The anger toward the dehumanizer was also observed in the studies by Haslam2 and Bastian and Haslam.12 In this regard, it was demonstrated in a study by Fischer and Roseman36 that reduced intimacy between the spouses and being controlled by the husbands caused a feeling of hatred in women. In the current research, being controlled by the husband, which is one of the factors of dehumanization, was regarded as one of the causes of hatred and anger in the dehumanized women.Dehumanization in victims of intimate partner violence could be associated with different emotions. It was stated earlier that dehumanization led to a sense of inferiority in women, which is in congruence with the dual model of Haslam.37 showed that passive violence is a strategy against people with higher social levels. In another study, greater use of direct violence was observed in men, whereas greater use of indirect violence was found in women.38The current research indicated that women used strategies against themselves or their spouses in response to their husbands’ dehumanization and self-dehumanization, divided into two active and passive categories. Active strategies included suicidal and self-destructive thoughts, violence toward the spouse, or leaving their homes. On the other hand, passive strategies include regretting their marriage, hatred, and wishing for the death of their husbands. A study by Buss39 In addition, suicide is known as a strategy to escape from painful self-consciousness in the theory of Baumeister.40 It could be stated that this self-consciousness is, in fact, self-dehumanization or the realization of being dehumanized by the spouse and feeling of inferiority. Furthermore, suicidal thoughts are regarded as self-violence based on the catharsis theory.A cycle of dehumanization and intimate partner violence13 it was noted that a cycle of dehumanization and violence could exist, but no specific studies have demonstrated this cycle and its factors.The most interesting finding of this study was that dehumanization and violence form a vicious cycle. Dehumanization of women has led to violence against them, which will be associated with the dehumanization of the spouse, self-dehumanization, and the experience of being dehumanized. Responding to such behaviors, women use active or passive-aggressive strategies, which lead to intensified dehumanization by their spouses. In a study by Bastian and Haslam, This study aimed to determine the role of dehumanization and the experience of being dehumanized in intimate partner violence. Although the current research is based on a small sample of participants, the findings confirm previous findings and contribute additional evidence that suggests dehumanization could occur in two forms, with three targets in families and intimate relationships, which leads to aggressive behavior.One of the more significant findings from this study is that dehumanization could invoke negative cognitions, emotions, and strategies. The second significant finding was that dehumanization involves a cycle of intimate partner violence. This study has gone some way toward enhancing our understanding of dehumanization in close relationships. More research on this topic needs to be undertaken before the association between dehumanization, and intimate partner violence is more clearly understood. Furthermore, the dehumanization of the perpetrator partner in victims of intimate partner violence should be explored in more detail in future studies to clarify its features and consequences, especially from the perpetrators’ perspective. AcknowledgmentsWe would like to express our appreciation to Professor Nick Haslam for his generous support.


However, the barriers associated with parents’ participation in PED-based cessation trials are unknown. The objective was to explore parents’ reasons for non-participation in a PED-based tobacco cessation trial. (2) Methods: We employed the framework method and conducted a qualitative data analysis of parental smokers who were eligible to participate in a PED-based tobacco cessation trial and did not choose to participate (n = 371). (3) Results: Two main themes emerged about reasons for non-participation: (a) Not interested in participating in a research study, and (b) concerns specific to the study. Parents had various reasons for not participating in the cessation trial including not being interested in quitting, parents’ health and well-being, parents’ beliefs about research, and time required for the study and follow-up visits. (4) Conclusion: General disinterest and specific study-related concerns were touted as reasons for non-participation in a PED-based tobacco cessation trial. Given the potential reductions in tobacco-related morbidity to both parents and children that tobacco control interventions can facilitate, future tobacco interventions should consider alterations in study design and recruitment strategies to encourage all eligible parental smokers to participate. Although there is no one best approach in which to conduct intervention research, traditional randomized controlled trials (RCTs) are considered the gold standard . This isDespite these factors, the pediatric ED (PED) and urgent care (UC) settings are regarded as potentially opportune venues in which to recruit parents into tobacco cessation interventions. This is because parents who receive government insurance, are socioeconomically disadvantaged, and are active tobacco users have high rates of utilization of emergency care settings for their children’s acute and non-acute healthcare needs ,12,13. Twww.clinicaltrials.gov NCT02531594 accessed on 20 May 2023)  is not an option for me, and I am not interested”. Another mother said, “I am not interested in any program to aid in smoking cessation because I am very stressed out right now; smoking helps, and I have no intention to quit smoking”. In addition, one mother pulled study staff aside and stated that she was not interested in participating as she was uncomfortable talking about smoking in front of her children.Some parents explained their disinterest in participating in a research study was due to their health and well-being. Ten parents reported “being overwhelmed” and one parent added, “I am overwhelmed and have not slept”. Four parents shared that they were “too tired to participate in a study”. One mother said, “There’s just a lot going on for me personally”. Two parents also reported having some personal health problems and therefore, they did not wish to participate in the study. For example, one mother said, “I’m dealing with some personal health problems”.Some participants reported not believing in research. Although the total number of participants (n = 3) not believing in research was small, the results indicated that their beliefs about research was rooted in their previous experiences of participating in a research study. For example, a mother stated that she had participated in research studies in the past and they were “more of a hassle than they are worth”. All three parents expressed that they did not want to “get in trouble” and they did not “believe in research”. One mother also said that she did not want her child “to be a guinea pig”.The results also indicated that 113 (30.5%) parents did not wish to participate due to the time that would have to be spent on the study due to recruitment as they were concerned that they would have a longer PED/UC visit or stay past the time when they were discharged. One family reported that they were “in the ED for two hours and ready to go home”. Some parents expressed that they were occupied with other things and would prefer being approached later. Some parents also expressed the timing of the study being “too much”.Most of the parents (76.9%) did not want to participate in the study because of the time requirements and commitment involved in follow-up visits. For example, a mother did not want to participate in the study as she did not wish to complete study procedures and added, “I would not have time to complete follow-ups”. Most expressed their concerns about the “study taking too much time” and “too many steps involved in the study procedures”. Some participants also expressed that they did not want to “obligate” themselves given their other responsibilities. For example, one mother said, “I am very busy right now and cannot commit to a long study”. Some participants further explained their reasons for not being interested in follow-up visits. One mother explained that she was “too busy” to do follow-ups because she worked at two jobs, and scheduling home visits and other components would not be easy for her. Another mother expressed that she did not “want to have to deal with scheduling the follow-up home visits”. Two fathers stated they “work[ed] so hard” and it would be too hard for them to complete the study procedures including the follow-up visits. Many parents did not want to participate in the study due to their busy work schedule or because they were not comfortable with home visits. Although clinical research coordinators offered a neutral follow-up location such as the hospital, these parents still declined to participate in the study. Some parents also reported that having limited transportation to follow-up at a “neutral” site as the reason for their decline. For example, one mother said, “I do not have a car or easy transportation to come to the hospital for the follow-ups”.This second overall theme focuses on parents who were concerned about specific HF RCT participation. This theme consisted of three sub-themes: (a) concerns about HF RCT study procedures; (b) concerns about child health and well-being; and (c) concerns about other parent consenting. Each of these sub-themes is further described below.In total, 117 (31.5%) parents shared that they had concerns about the study which could have included concerns about study procedures  and therefore, were not interested in participating. Specifically, some parents expressed their concerns about the follow-up requirements and sample collection at baseline, 6-weeks, and 6-months. Four mothers declined participation in the study due to specific concerns about sample collection. For example, one mother said, “My child does not like to be touched. Sample collection would make her upset”. Another mother also did not want samples taken from the child.All children had a potential TSE-related chief complaint  when their parents were approached about potential participation in the HF RCT during the PED/UC visit. In total, 29 (7.8%) parents expressed their concerns about their child’s health and well-being at the time of recruitment. Many parents said that they wanted to “focus on the child’s care”. For example, one mother said, “I just want to focus on [the child] getting better”.Five parents declined participation in the study due to not having the child’s other parent available at the time of the visit. For example, a mother was interested in participating in the study but said, “I need to talk with my husband, and he is not here with us. I am happy to be approached again in the future”. Similarly, two mothers wanted the child’s father to read over the consent document before agreeing to participate in the study. They expressed their concern about samples and were worried the other parent might not agree with their decision.The purpose of this study was to explore parents’ reasons for not participating in a tobacco cessation RCT in the PED/UC setting. The results showed that of the 1012 potential parental smokers who brought their child to the PED/UC and were eligible to participate in a free tobacco cessation and child TSE reduction trial, 37% declined to participate and were included in this study’s qualitative analysis. This percentage of non-participation in the HF RCT is concerning because the pediatric healthcare setting is an important locus of tobacco control that if used effectively and routinely, could result in reductions in tobacco-related morbidity to both parents and children ,28,29. AOur qualitative analysis indicated that parents who did not participate in this free HF RCT had a lack of interest in the study, concerns about specific study components, and concerns about follow-up requirements. Most prior research that has examined reasons for non-participation in the healthcare setting have focused on reasons why parents do not consent to their child’s participation in a pediatric clinical trial versus their own consent to participate ,20,21. NThe present study required parents to be active participants in the RCT. In order to assess parent tobacco outcomes, parents had to agree to follow-up visits at 6-weeks and 6-months after the initial PED/UC visit. Parents were asked whether they would allow their child to have biological samples collected so that child TSE outcomes could be assessed. These procedures are similar to other parental cessation trials which involved the assessment of the effects of the intervention on both the parent’s tobacco outcomes and child’s TSE outcomes ,31,32. FThe strengths of this study include the large sample size and the examination of reported reasons for non-study participation in a large RCT in a PED/UC. However, limitations need to be acknowledged, which includes the lack of generalizability since this study was conducted at a single children’s hospital. While we were able to examine open texts of parents who declined participation, focused interviews of parents who declined would have provided more informative data on reasons for non-participation. We did not collect reasons for participation among parents who participated in the RCT, which comparing reasons for non-participation versus participation among parents is suggested in further research to inform future recruitment efforts. Additionally, we did not have access to parents’ demographic characteristics, or their tobacco use patterns or motivation to quit, as these and other factors such as preferred incentive amounts, type of follow-up methods, and preferred intervention and study components may have been associated with study participation. Thus, future work should consider using mixed methods research  on these factors in parents who decline to participate to better understand factors influencing sample and selection bias in ED settings and/or in studies requiring parental consent and child assent.In conclusion, this study indicates that general disinterest and specific study-related concerns were touted as reasons for non-participation in this tobacco cessation intervention. Future studies should consider study design and recruitment strategies that are recommended to improve recruitment and enrollment rates such as simple explanations about the purpose and benefits of research study by medical staff; assurance that the study procedures are non-invasive and will not affect clinical care; and the inclusion of preferred incentives, brief time requirements, short follow-up windows, and liberal opportunities for follow-up methods that include flexible, participant-preferred modalities  and locations  ,17,21.


In the US, stimulant use is associated with a 3–6 times greater rate of HIV seroconversion in sexual minority men (SMM) than in those who do not use stimulants. Annually, 1 in 3 SMM who HIV seroconvert will be persistent methamphetamine (meth) users. The primary objective of this qualitative study was to explore experiences of stimulant use in SMM living in South Florida, a high priority region for the Ending the HIV Epidemic initiative.The sample included 25 SMM who use stimulants, recruited via targeted ads on social networking apps. Participants completed one-on-one semi-structured qualitative interviews, conducted from July 2019 through February 2020. A general inductive approach was used to identify themes relating to experiences, motivations, and overall relationship with stimulant use.Mean age of participants was 38.8, ranging from 20 to 61 years old. Participants were 44% White, 36% Latino, 16% Black and 4% Asian. Most participants were born in the US, self-identified as gay, and preferred meth as their stimulant of choice. Themes included: (1) stimulants as cognitive enhancements for focus or task completion, including transitioning to meth after first using prescription psychostimulants; (2) unique South Florida environment where participants could be open regarding their sexual minority status while also being influential on their stimulant use; (3) stimulant use as both stigmatizing and a coping mechanism for stigma. Participants anticipated stigma by family and potential sexual partners due to their stimulant use. They also reported using stimulants to cope with feelings of stigma due to their minoritized identities.This study is among the first to characterize motivations for stimulant use in SMM living in South Florida. Results highlight both the risk and protective factors of the South Florida environment, psychostimulant misuse as a risk for meth initiation, and the role of anticipated stigma on stimulant use in SMM. Understanding stimulant use motivations can help to shape intervention development. This includes developing interventions that address individual, interpersonal, and cultural factors that drive stimulant use and increase risk of HIV acquisition.Trial registration NCT04205487. Stimulant use  among sexual minority men who have sex with men (SMM) is up to 20 times more prevalent than in the general population . StimulaPrevious findings have highlighted the role of stimulants in sexualized drug use for SMM, such as “party and play (PnP)” or “parTy” in North America , 7, 8. CProminent theories such as the Cognitive Escape Model propose that SMM may be psychologically motivated to escape or avoid chronic stressors such as HIV and minority stressors with substance use , 15. SMMAdditionally, we suggest that affiliation with gay culture may have important risk and protective implications for stimulant use in SMM. Previous studies have examined the perceptions and motivations surrounding stimulant use in SMM. In 2005, Kurtz found that meth use in SMM living in Miami was associated with the desires to decrease loneliness and feel more physically attractive in the face of aging and illness . ParsonsWith the persistence of stimulant use among SMM , 24, 25 This study took place within the broader context of the formative phases of a randomized control trial of PrEP Readiness Interventions for Supporting Motivation (PRISM), an intervention to increase PrEP uptake and decrease stimulant use among SMM in South Florida The goal of this formative work was to assess the acceptability and feasibility of a motivational interviewing and contingency management intervention components of the intervention, including questions regarding PrEP use and perceptions, substance use motivations and initiation experiences. As such, the researchers conducted semi-structured interviews to learn about participants’ lived experiences with stimulant use, for those who both do and do not use PrEP. During enrollment, and before randomization into the trial, participants completed a one-on-one, in-person semi-structured qualitative interview about 60 min in length, conducted from July 2019 through February 2020.Participants were identified via an adapted, targeted sampling strategy , where tParticipants were given a supplementary quantitative survey to derive additional information, including demographics, Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores , and theThe research team of six was diverse with respect to race/ethnicity, sexual orientation, training levels and discipline. Team members held sexual, gender and racial/ethnic minority affirming views. The senior authors provided ongoing training in qualitative methods, study objectives and SMM health disparities. Interviewers were trained in qualitative methods and supervised by the study’s senior authors.The general inductive approach was used to identify themes relating stimulant use and drug initiation experiences . Codes wParticipants included 25 SMM who use stimulants. The average age of participants was 38.8 and ranged from 20 to 61 years old. A little more than half of participants were persons of color (Latino (36%), Black (16%) and Asian (4%)) and 44% were White. Most participants were currently using a daily, oral PrEP (64%), while 24% had never used PrEP and 12% had discontinued their PrEP regimen. Based on the ASSIST, 44% of participants scored a moderate risk severity for meth use, 24% scored moderate risk severity for cocaine/crack-cocaine, and 44% scored moderate risk severity for inhalants. Most participants were born in the US, described themselves as gay, were uninsured and were employed full-time .Alternatively, some participants discussed starting to use stimulants as cognitive enhancements for focus or task completion Table . For exaI'm already like familiar with Adderall, from when I was growing, taking it like when as a teenager. So, um, mostly it's like if I need to get something done or like, um, if I need to like paint all night or clean, .... back in 2009 or 2010, but, like, I had an Adderall prescription then, so I just did it [meth] once in a while, and... that was it, but then, last spring, the doctor that was prescribing me 120 milligrams of Adderall a day retired (laughs) and nobody else was prescribing it, and I came down here, and slept, like, the first week I was here and still wasn't waking up, and then someone I met on [a social networking app] had it [meth] with him. I woke up, and I was like, ‘Hey, this might be not a bad way [to make up for the Adderall], so- .I was still being prescribed Adderall, so I didn’t feel the need to even want to try it [meth] again…Then when they did take me off of the Adderall, I went back [to using meth]—those 9 months, I was like, ‘God, there’s got to be something else I can do in the meantime.” And then I remembered my friend. I was like, ‘Hey, you think you can like [connect me with some meth]?’ And then that’s when I went and tried it again—this time smoking it—and it was a lot less of a shock to the system. .Most participants who reported using stimulants for cognitive enhancement indicated that they transitioned to meth after first using prescription stimulant medications commonly prescribed for attention deficit hyperactivity disorder (ADHD) . For example:Participants commented on how living in South Florida allowed them both to be more open about their sexual minority status compared to their home countries or other states, while also being influential on their stimulant use. For SMM who immigrated or migrated to Miami from less open or affirming countries or states, participants described South as a place where sexual minorities can live in peace. “[I came here] to be able to be myself. To be able to be gay in peace… There's a little bit of danger for people being gay in Brazil. You know, other people won't like it, and then they will do crimes against you, or hurt you, or anything like that. Here it's more safe and open. I never felt any prejudice [here]” . Another participant said, “I am French. I moved here Miami almost four years ago… Um, I basically started my gay life here in Miami. Not that much in France. And then I discovered my gay life here in Miami. Um, and so far, I'm super happy here,” .Everybody's on something and they have their [drug of] choice. So it's either you're doing GHB while you're having sex and doing Tina, and hanging out with the muscle boys of South Beach, or you're doing cocaine, or you're, you know, drinking at the same time. But you're on something and you're part of the crowd and it's up to you how far you want to take it. Then you have the South Beach queens and in Fort Lauderdale, Wilton Manors is full of Tina. It's the bears, the muscle queens, and they see it as part of a sex drug. So. to them, crystal meth or Tina or whatever they want to call it, either they slam [inject] it, they smoke it, they put it up their ass [‘booty bump’], they do whatever .It's everywhere [in South Florida]. Every gay house, every gay community. Gay roommates living together, they all, they all have PrEP. And they- they do [meth] for having sex and all that, .However, participants also connected stimulant use to perceived social acceptance and perceived prevalence specifically within the South Florida gay community. Participants described stimulant use as a regular part of the night life and social life for SMM in South Florida.The guys I end up fucking would usually have it [meth]. So, I'd say, "What’s up? Can I hit that?" And they'd say, "Sure, whatever." I mean, is it—I think using meth just pertains to, like, the sexual activities, sexual activities in general here in South Florida. I feel like everyone that's gay and—I mean, everyone that's gay in South Florida is on [social networking app] and they all do meth .Another participant expressed how meth use was common during sexual encounters and hard to turn down when frequently presented:Some guys I'll talk to and the first thing they ask is ‘Do you party?’ I'm pretty open about whether I want to party so I'll either say yes or no… But if they use the capital T and write ‘parTy,’ then you know that they're using meth. But if they don't, then you don't know if they're using coke or if they aren't using anything… So when they use [the capital T in party] I automatically know that it's meth. When they don't, that's when I'm a little more guarded about whether I am going to tell them [that I party]—especially if they don't use it [meth] and I still want to have sex with them .[There is the] stigma of it, or judgment of people, every time that you think about bringing it up, you don't know if that's gonna be something that, like, hangs up, or blocks you, or whatever, so- I think I kind of consciously and subconsciously screen who I meet based on [whether] I think that they do [meth] or not… because I'll probably want to do it at some point while I'm with them, so… even if they aren't... it's probably better [to know now] if they aren't just gonna get up and walk out, (laughs) .Participants reported that their stimulant use could be thought of as both stigmatizing and as a coping mechanism for stigma. First, participants discussed their fear of family finding out about their stimulant use. For instance, one participant reported, “It's really bad. If my parents, if they know this, they will kill me, like… So when you think about the moral thing, you know, your family and everything, I think it's really bad,” . Others described anticipating stigma or rejection from potential partners regarding stimulant use during sexual situations. Multiple participants noted that as they talked to potential partners online, they were careful about how they responded to questions about “partying,” due to concerns that people would screen them out based on their answers to questions.But in the gay community, I feel like [there is a lot of stigma]. Most of the people that I see around, it's [meth] very much related to depression and being lonely. And being sad for not being able to have a family, or thinking about it. Or being, like, judged by society and other people, or maybe their family members, or their friends… But I see lots of people are very depressed, and that's why they do so much drugs, .It eases my depression. You know, to me, it makes me feel like I'm a better person .Others described substance use as a coping mechanism for experiences of stigma related to their sexual identity or minority stress:Familiar taste of poison. Exactly what it would be like. It's, you want to do it, like you have to do it, like you see you love it, but at the same time, for as much as you love it and you dance with it, it kills you. Like you know slowly but surely like it's, it's killing you- .[It’s a] Participants were asked to describe their overall relationship with their stimulant of choice, considering the likes and dislikes discussed in the interview. Most participants labeled their relationship with stimulants as “love-hate.” They discussed their overarching knowledge that stimulant use was bad for their health in the long run, but their current desire for the pleasure associated with stimulant use counterbalanced the negative impact. As one participant stated, his relationship with meth was:Oh, she's [meth] a pretty one… But you have to watch your back. .Another participant described his relationship with meth as follows:This qualitative study examined the complex cultural, interpersonal and individual level determinants of stimulant use among SMM living in South Florida. Although sexual enhancement remained a primary motivation for stimulant use –35, the Use of meth for ADHD self-medication was a new and important finding from our results. Participants framed their meth use as a form of self-medication, either as an amphetamine/dextroamphetamine substitute or use for focus and energy. Meth can be used to self-treat ADHD symptoms , as presOur results also highlight the role of South Florida as a potential risk environment for stimulant use among SMM. As Miami is an EHE priority jurisdiction, there is a renewed need for multi-level interventions targeting risk contexts in South Florida such as social norms surrounding stimulant use, use in social spaces and pressure on social networking applications where exposure risk is high for stimulant use. Finally, addressing stigma as a motivation and consequence of stimulant use is crucial. Although SMM feel they can be open about their sexual minority status in Miami, they still have residual feelings of stigmatization from their family and former communities that can lead to stimulant use as a coping mechanism. They also face rejection from their peers and potential sexual partners because of said usage, thereby posing a double bind. Previous research has also linked intersectional stigma regarding stimulant use, perceived judgement, and social structural barriers as negatively impacting both PrEP uptake, adherence and persistence , 41, 42.Participants in this study often described the role of living and participating in the South Florida gay community as facilitators to their stimulant use. Given Miami’s designation as a EHE priority region, understanding the impact of South Florida as an environmental risk factor for substance use and HIV is important. South Florida is a tri-county area composing on Miami-Dade, Palm Beach and Broward Counties. This sprawling urban area offers availability to South Beach in Miami and Wilton Manors in Broward, both established resort communities with a large population of sexual minorities, high prevalence of substance use, and high HIV incidence –45. PrevParticipants also acknowledged stimulant use as both a cause and effect of stigma. Participants used stimulants as a coping mechanism for internalized, anticipated and enacted experiences of stigma due to their minority status. This finding supports the research surrounding substance use as function of self-medication for minority stressors or as a form of cognitive escape , 15, 17.Understanding SMM’s motivations for stimulant use is important for developing interventions to address stimulant motivations that may increase sexual risk taking, decrease PrEP uptake, adherence and persistence, and make SMM more likely to acquire HIV. Future initiatives should focus on addressing the individual, interpersonal and cultural norms in South Florida that can facilitate stimulant use, thus intervening on the negative effects of stimulants on HIV-related outcomes such as PrEP uptake and adherence. First, as younger, especially racial/ethnic minority, SMM experience high rates of HIV diagnoses combined with lower PrEP uptake and persistence –56, the Our findings should be understood in light of their limitations. First, although the study is focused on stimulant use overall, many of participants primarily used meth. Crack and cocaine may have different short-term and long-term effects when compared to meth, and people who use crack or cocaine may not have the same motivations for use or lived experiences as those who use meth. Next, we enrolled participants who self-reported their HIV status. Verification with an HIV test would have improved validity but was out of the scope of this formative portion of the research study. Additionally, we excluded participants who reported only having sex with one main partner. We recognize that HIV transmission within main partnerships is also possible. Furthermore, while we have a diverse group of men in both age and race/ethnicity, our findings from men living in South Florida may not be generalizable to other areas that are more rural, less diverse or more affluent. Generalizability is generally not a goal of qualitative research . FinallyOverall, our results help elucidate motivations for, and experiences with stimulant use among a population of SMM living in South Florida, a US HIV epicenter. First, our results help move the literature beyond the dominant narrative of sexualized drug use as the only driver of meth and other stimulant use. Second, it highlights the risk and protective factors associated with the gay community. Third, we have a novel focus on stigma as a chronic stressor that men experience related to their stimulant use as well as something they are motivated to escape via stimulant use. Understanding stimulant use motivations can help to shape intervention development, and in particular, developing interventions that address individual , interpersonal , and cultural  factors that drive stimulant use. To our knowledge, this study is the first to examine stimulant use among SMM as an outcome of stigma, cognitive enhancements and as an interaction within the context of urban South Florida.


An iterative data analysis was performed. Results were reported under the following themes: accepting illness through coping strategies provided by Muslim religious beliefs and practices, experiencing problems with the expression of needs and feelings within the couple, experiencing closeness within the family, and experiencing illness in the hospital setting as Muslims. Our results show that Islamic beliefs can facilitate acceptance of a cancer diagnosis. It is also noted that religion seems to unite spouses in supporting each other and maintaining hope in a difficult context. Communication issues may persist between a couple due to stressors related to cancer. The results of this study could raise awareness about the importance of exploring religious and spiritual beliefs when supporting couples affected by cancer.Although survival rates for patients with cancer have increased, this disease continues to affect couples significantly. Religion and culture seem to be part of the therapeutic process for people with cancer. Despite the abundance of the Arab Muslim community in Western countries, there is a lack of documented data on Arab Muslim couples experiencing cancer. A simple exploratory qualitative study was conducted through semi-structured interviews on six married couples ( Although survival rates for patients with cancer have increased according to improved curative therapies, the impact of this disease on families persists ,2,3. SpoFor some populations, such as Arab Muslims, families’ and couples’ experiences with cancer are different due to cultural and religious beliefs . The lacIn Canada, the city of Montreal contains the largest Arab Muslim population in the country . In the This study aims to investigate the impact of religious beliefs, particularly Islamic beliefs, on the process of accepting a cancer diagnosis among couples.A definition and a model were used to explore this study’s phenomenon. First, Purnell’s definition was selected to narrow the meaning of culture. According to Purnell, culture is a set of values, customs, lifestyles, beliefs, and thoughts that shape people’s decisions and worldviews . In addiAn exploratory qualitative design was employed . This tyThe sampling methods used for recruiting participants were accidental sampling ,47 and sData were collected using a socio-demographic questionnaire and dyadic semi-structured interviews.Participants completed a socio-demographic questionnaire before the semi-structured interviews began. The questionnaire items provided information on age, level of education, type of employment, marital status, number of children, year of arrival in the province of Quebec (Canada), ethnic origin, branch of Islam of practice, immigration status, and their level of religiosity. Although the classification of religiosity level remains important in the health sciences, it can be nebulous and imprecise . The levThe interviews were conducted from June to October 2021 entirely via videoconference due to COVID-19 pandemic health measures. The mean length was 52 min. The structure of the guide was inspired by the Calgary Family Assessment Model . This moTM  Qadr is a notion. For us, it is not to consider an evil, whereas it is a blessing. We don’t know! We must believe in God’s destiny [and accept it]. Whether it is good or bad, according on our perception of good and bad. But the divine perception always has a reason.Brahim (couple 5), who qualifies himself as “Highly Religious”, specified that he would have been satisfied with the fate that God has destined for him, and would be satisfied with this, whether there was a cure or not. In this sense, this participant reported:We must accept God’s fate, so we decided to follow the doctor’s treatment. If there is healing, it is good. If there is no healing, that’s good too. That’s God’s destiny. That’s what we told ourselves.Cancer was also reported by several participants as a positive event that strengthened their piety. In this context, Sarah (couple 1) said:The fact that I accepted the illness and said to myself: it is God, who gave it to me. Yes, I know that it is serious, that it is aggressive, that it can recur. But by doing what is necessary with Him, He is merciful! Today, I am still alive, four years later. I can only thank Him, and thanking Him is not just by saying “Thank you, God”, but by doing things. He told us himself, it’s being in the whole hierarchy of practice.Most participants reported performing prayer in order to make requests or thank God. Prayer was reported by Hussain (couple 3), who described himself as “Spiritually Awake”, as the only way to hope and to support his sick wife: “[…] Sometimes you reach a point, like, you can’t do anything else, just pray, just ask God”. Khaoula (couple 4), who qualified herself as “Fairly Religious”, reported praying to thank God for good news, despite her husband’s metastatic cancer:So that’s why when I get home, well, I do my prayer. I say to myself: well, I thank God… Nacer had his treatment or his exams, or we had good news from the doctor, for example, after a meeting, so, I do my prayer.Zoulikha (couple 5), who revealed that she is “Highly Religious”, explained that she found refuge during prayer moments and allowed herself to become emotional and vulnerable, as well as asking God to heal her husband Brahim:During those difficult times, do you know what I used to do? At the time of Dhor (daily prayer marking the start of the afternoon.) or El- Asr (daily prayer marking the end of the afternoon.), I would call upon God in my prayers… All that I had in my heart, I emptied in my prayer… I was praying and crying… I had a feeling that God would not abandon me… I was saying: “Oh God, it is you who created my husband, and it is you who will heal him”. About this, God said: “Ask me, and I will exalt”.Several participants mentioned that the illness had revived their religious faith, and a few had seen their religious practices change throughout this experience. Mohamed (couple 1) reported that from his own perspective, his wife’s faith evolved because of her weakening health. At the same time, Sarah—his wife—said that she became more religious because of the perspective on her life this experience brought her:The illness redefines your perspective […] of your own life… let’s say you can die tomorrow. Because when you are healthy, you don’t have the same perspective, you know? Our horizon is not drawn in the same way and we don’t see things in time in the same way. […] It accelerated my way of research and development [religious] that I began slowly.Some participants stated that their religious practices have become more important in their lives since the cancer. Leila (couple 2) confided, speaking of her husband: “[…] It has increased a lot, let’s say. He has always been a believer, but he wasn’t practicing a lot. So yes, he started to practice religion a lot more since my diagnosis”. Moreover, Khaoula (couple 4) mentioned being more assiduous in her religious practices since Nacer’s illness:Since Nacer’s illness, and with all the uncertainty it has brought, I have become more religious. […] Before, I used to do it, to stop it, to do it, to stop it [praying]. But now, it has become like a ritual. I now do my prayer every day, you know. So, yes, the illness has increased my faith a little.For Julie (couple 6), who is a convert to Islam and who considers herself “Fairly Religious”, reading and listening to Quranic verses have also been part of her strategies to cope with the disease: “[…] Even though I don’t speak the language and I have difficulty reading Arabic, I have tried to read the Qur’an…to listen to the reading of the first verse, but it’s not easy to understand it…”.Most participants reported experiencing problems with the expression of their needs and their feelings during their disease or that of their spouse. In this sense, some participants testified that they did not feel sufficiently considered by their spouses throughout their cancer. Sarah (couple 1) reported feeling that her husband did not show enough interest in her health condition:He never asked me “What are you taking for treatment? Why are you taking this treatment? What does this treatment do?”. He never came up with those questions. So that was a little bit difficult for me because it hurts when I’m at my lowest. I would have liked him to show more interest in my situation.Leila (couple 2) also reported being affected by what she interpreted as a lack of interest from Hussain:He didn’t show his feelings. I thought it was a little bit weird. At one point, it was like, “Okay, he doesn’t care. He doesn’t care!” It’s funny to say, but he never cried. He didn’t really have any reaction. When I announced it [the diagnosis], like, my dad cried, my sisters cried, my brother also. Everyone got emotional. Then, he [my husband] was normal. It was like, “It’ll pass. It’s okay”. Then it had kind of made me angry, like!Half of the spouses interviewed reported hiding their emotions to “protect” or not worry their ill partner. At the same time, these participants also reported a need to share their distress with their spouses. On this point, Hussain stated in response to his wife Leila’s statement:I was smiling in front of her and trying to be strong, I supported her and I never talked about how I felt because I didn’t want to worry her. We had to focus on her health, that was the most important thing.  closed the curtains every time, without me asking for it. Even though there was often no man, they still took the time [to do it]. I really appreciated it, because I realized later that when they put it [the port-a-cath needle] on other people, they didn’t close them [the curtains].Five participants described adjusting their religious practices in hospital settings. This adjustment was reported by participants identifying with various degrees of religiosity. Brahim (couple 5), who identified himself as “Highly Religious”, indicated that he adapted his prayer to the hospital context by shortening his ablutions :I always kept my timouma  nearby, so I could pray directly on my [hospital] bed… I didn’t pray in the hallway or anything, so it didn’t attract people’s attention. I wasn’t praying out loud  […] Anyway, I don’t even think people were noticing that I was praying.Sarah (couple 1) testified removing her hijab and wearing a short-sleeved jacket . The “modesty zone” includes the entire body apart from the face, hands, and feet) during hospitalizations: “I don’t wear my hijab when I am hospitalized, and I also agree to wear a jacket”. Khaoula (couple 4), who described herself as “Fairly Religious”, mentioned that she did not pay particular attention to religion during her husband’s hospitalizations, and preferred to carry out her religious practices privately, at home: “I adapt. I adapt myself. So, when I go home, I perform my prayers”.This study reveals coping strategies provided by Muslim religious beliefs, the effects of cancer on family and couple dynamics, and the experience of hospitalization. To our knowledge, no study had yet explored this phenomenon. In this sense, several interesting findings emerged from the analysis of our results. Our study results propose that religious faith evolves over the course of the couple’s experience. Participants explained that the illness made them aware of the importance of religious practices in their personal lives. Moreover, religion seems to have united the partners during this ordeal, through the mutual hope that was fostered during the illness in addition to the prayers invoking healing. Up to date, no study has clearly described that cancer might lead Muslims to practice their religion more thoroughly. However, findings from a descriptive correlational study conducted in Spain suggest that cancer contributes to the consolidation of beliefs as well as spiritual and religious practices of patients with cancer . This stOur findings also described the dyadic experience of Arab Muslim couples with cancer. Our participants first had trouble expressing their needs within the couple since finding out they had cancer. In this sense, some participants had more difficulty communicating their apprehensions and feelings about their spouse’s illness, leading to a feeling of lack of compassion and support toward the ill spouse. This finding has similarities with the experience of couples outside North America. A Chinese study that explored the experience of couples with colorectal cancer in China and a Norwegian study presenting the experience of couples facing cervical cancer demonstrate similar results ,67. In tParticipants in our study reported feeling respect towards their religious practices from healthcare professionals. This finding is in contradiction with the conclusions of consulted studies in which Muslim patients share discriminatory experiences as well as a lack of consideration given to their religious beliefs in hospital settings ,71. NeveFinally, our study results highlight the need for future educational activities or support groups for the minority groups of patients with cancer and their spouses, as well as a continuous education series for multidisciplinary teams of healthcare providers. For instance, creating clear and concise patient booklets/brochures, which will provide culturally appropriate information, could increase the patient’s adherence to medical care, improve response/resilience to stress, and augment the quality of life during each stage of the “cancer journey” for the afflicted patients and their close relatives.One of the strengths of this study is the simultaneous participation of both spouses during the interviews. Consequently, the statements brought by the spouses were directly confirmed or refuted. In this sense, the dyadic interview questions encourage freedom during the discussions within couples in addition to encouraging the sharing of truthful and sincere information between them . This stThis study informs that couples can be challenged by a cancer diagnosis. Furthermore, the participants’ narratives confirm that religious beliefs positively influence hardship in the context of life-threatening illnesses. Healthcare professionals can learn to adapt and understand the influence of religious beliefs, practices, and customs during various life transitions, such as birth, illness, suffering, and death. In addition, religious beliefs appear to be a common thread that spouses use to support each other and maintain hope in a difficult context. In sum, the results of this study can inform about the importance of providing culturally appropriate care to families and couples affected by cancer in order to improve their care experience.