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Copyright World Psychiatric Association Women's mental health in Pakistan 1WPA Section on Women's Mental Health 2Psychiatric Clinic and Stress Research Center, Karachi, Pakistan 75500 Abstract In Pakistan, societal attitudes and norms, as well as cultural practices
(Karo Kari, exchange marriages, dowry, etc.), play a vital role in women's
mental health. The religious and ethnic conflicts, along with the dehumanizing
attitudes towards women, the extended family system, role of in-laws in daily
lives of women, represent major issues and stressors. Such practices in Pakistan
have created the extreme marginalisation of women in numerous spheres of life,
which has had an adverse psychological impact. Violence against women has become
one of the acceptable means whereby men exercise their culturally constructed
right to control women. Still, compared to other South Asian countries, Pakistani
women are relatively better off than their counterparts. Keywords: Pakistan, women's mental health, cultural practices, honor-killing, stove-burns, violence The women's movement in Pakistan in the last 50 years has been largely
class bound. Its front line marchers voiced their concerns about issues mainly
related to the urban-middle class woman. It is only in the last few years
that rural women's issues like 'Karo Kari' (honour killing)
and rape have been brought to light. Feudal/tribal laws of disinheritance,
forced marriages and violence against women (acid-throwing, stove-burning
homicide and nose-cutting) in the name of honour are being condemned by non-governmental
organizations and human rights activists in the cities. Still a vast majority
of the women in the rural areas and urban slums are unaware of the development
debates. The urban Pakistani women in many aspects are almost at par with the women
of developed countries. In the rural scenario, the picture is entirely different.
It is archaic, brutal and clearly oppressive. These trends often seep into
the urban lives of women through migratory movements of rural population,
which has yet to adjust to urban ways. At the societal level, restricted mobility for women affects their education
and work/job opportunities. This adds to the already fewer educational facilities
for women. Sexual harassment at home, at work and in the society has reached
its peak. Lack of awareness or denial of its existence adds to further confine
women to the sanctity of their homes. Violence against women further adds
to restriction of mobility and pursuance of education and job, thereby lowering
prospects of women's empowerment in society. At the family level, birth of a baby boy is rejoiced and celebrated, while
a baby girl is mourned and is a source of guilt and despair in many families.
Boys are given priority over girls for better food, care and education. Subservient
behaviour is promoted in females. Early marriage (child-brides), Watta
Satta (exchange marriages), dowry and Walwar (bride
price) are common. Divorcees and widows are isolated and considered 'bad omens',
being victims of both male and female rejection especially in villages. Marriage
quite often leads to wife-battering, conflict with spouse, conflict with in-laws,
dowry deaths, stove burns, suicide/homicide and acid burns to disfigure a
woman in revenge. VIOLENCE AGAINST WOMEN In Pakistan, there are cultural institutions, beliefs and practices that
undermine women's autonomy and contribute to gender-based violence. Marriage
practices can disadvantage women, especially when customs such as dowry and
bride's price, Watta Satta and marriage to the Quran (a custom
in Sindh where girls remain unmarried like nuns to retain family property
in the family) exist. In recent years dowry has become the expected part of
marriage. This increasing demand for dowry, both before and after marriage,
can escalate into harassment, physical violence and emotional abuse. In extreme
cases homicide or "stove-burns" and suicides can provide husbands an opportunity
to pursue another marriage and consequently more dowry. Women are confined to abusive relationships and lack the ability to escape
their captors due to social and cultural pressures. Parents do not encourage
their daughters to return home for fear of being stigmatized as a divorcee,
which tantamount to being a social pariah. Moreover, if a woman leaves her
husband, her parents have to repay him to compensate his loss. Cultural attitudes
towards female chastity and male honour serve to justify violence against
women. Violence against women is very common in Pakistan. The violation of women's
rights, the discrimination and injustice are obvious in many cases. A United
Nations research study (1) found that
50% of the women in Pakistan are physically battered and 90% are mentally
and verbally abused by their men. A study by Women's Division on "Battered
Housewives in Pakistan" (2) reveals
that domestic violence takes place in approximately 80% of the households.
More recently the Human Rights Commission report (3)
states that 400 cases of domestic violence are reported each year and half
of the victims die. In Balochistan and Sindh provinces, Karo Kari is practiced
openly. A woman suspected of immorality is declared a Kari while
the Karo is a man declared to be her lover. A woman suspected
of adultery or infidelity is liable to face the death penalty at the hands
of her husband or in-laws. Usually the killer goes scot-free as he is regarded
to have committed the crime in order to retrieve the lost family honour, which
a woman is expected to uphold at all costs. Watta Satta is also a tradition in many families in Punjab
and Sindh, whereby a girl is married off to her sister-in-law's brother. Such
an arrangement often leads to a complicated situation, since a woman ends
up becoming a mere object of revenge in the instance that her brother mistreats
or physically abuses his wife. Sadistic urges may be satisfied by a man by totally humiliating as well
as disfiguring his wife. Women who are victims of this particular form of
violence are usually young and attractive. Hundreds of women are disfigured or die of stove-burns every year. The
victims are usually young married women and the aggressors include husbands
and in-laws. The motive behind stove burning is to get rid of the woman and
remarry for more dowries or have an heir for the family. Battering or "domestic violence" or intimate partner abuse is generally
part of the patterns of abusive behaviour and control rather than an isolated
act of physical aggression. Partner abuse can take a variety of forms, including
physical violence, assault such as slaps, kicks, hits and beatings, psychological
abuse, constant belittling, intimidation, humiliation and coercive sex. It
frequently can include controlling behavior such as isolating women from family
and friends, monitoring her movements and restricting her access to resources. Physical
violence in intimate relationship is almost always accompanied by psychological
abuse and in one-third to one-half of cases by sexual abuse. A woman's response to abuse is often limited by the options available to
her. Women constantly cite reasons to remain in abusive relationship: fear
of retribution, lack of other means of economic support, concern for the children,
emotional dependence, lack of support from family and friends and the abiding
hope that the husband may change one day. In Pakistan divorce continues to
be a taboo and the fear of social stigma prevents women from reaching out
for help. About 70% of abused women have never told anyone about the abuse. The psychological consequences of abuse are more severe than its physical
effects. The experience of abuse erodes women's self-esteem and puts them
at a greater risk for a number of mental disorders like depression, post-traumatic
stress disorder, suicide, alcohol and drug abuse. Children who witness marital violence face increased risk for emotional
and behavioural problems, including anxiety, depression, poor school performance,
low self-esteem, nightmares and disobedience. Boys turn to drugs and girls
become severely depressed and sometimes totally refuse to get married. Children
under 12 years have learning, emotional and behavioural problems almost 6-7
times more compared to children of non-abusive parents. Health care providers can play a key role. They must recognize victims
of violence and help them by referring to legal aid, counsellors and non-governmental
organizations. They can prevent serious conditions and fatal repercussions.
However, many doctors/nurses do not ask women about the experience with violence
and are not prepared to respond to the needs of the victims. A variety of norms and beliefs are particularly powerful perpetrators of
violence against women. These include the notions that men are inherently
superior to women, that it is appropriate for men to discipline women, and
that women's sexual behaviour is linked to male honour. Nobody is expected
to intervene on behalf of the victim as such issues are considered private
matters to be resolved by the immediate parties themselves. Programs designed to change these beliefs must encourage people to discuss
rather than antagonize or alienate them by appearing to 'demonize' men. A
good tool is to encourage people to develop new norms by using techniques
such as plays on TV and theatre. PSYCHIATRIC ILLNESS IN PAKISTANI WOMEN A large study at Jinnah Post Graduate Medical Center, Karachi back in early
1990s (4) showed that twice as many
women as men sought psychiatric care and that most of these women were between
20s and mid 40s. Another 5-year survey (1992-1996) at the University Psychiatry Department
in Karachi (Agha Khan University/Hospital) (5)
showed that out of 212 patients receiving psychotherapy, 65% were women, 72%
being married. The consultation stimuli were conflict with spouse and in-laws.
Interestingly, 50% of these women had no psychiatric diagnosis and were labeled
as 'distressed women'. 28% of women suffered from depression or anxiety, 5-7%
had personality or adjustment disorders and 17% had other disorders. The 'distressed women' were aged between 20 to 45. Most of them had a bachelor's
degree and had arranged marriage relationships for 4-25 years with 2-3 kids,
and the majority worked outside home (running small business, teaching or
unpaid charitable community work or involved in voluntary work). Their symptoms
were palpitations, headaches, choking feelings, sinking heart, hearing weakness
and numb feet. A study on stress and psychological disorders in Hindukush mountains of
North West Frontier Province of Pakistan (6)
showed a prevalence of depression and anxiety of 46% in women compared to
15% in men. A study on suicidal patients (7)
showed that the majority of the patients were married women. The major source
of suffer was conflict with husband (80%) and conflict with in-laws (43%). A study of parasuicide in Pakistan (8)
shows that most of the subjects were young adults (mean age 27-29 years).
The sample showed predominance of females (185) compared to males (129), and
the proportion of married women (33%) was higher than males (18%). Housewives
(55%) and students (32%) represented the two largest groups among females.
Most female subjects (80%) admitted problems with spouse. A four-year survey of psychiatric outpatients at a private clinic in Karachi
(9) found that two thirds of the patients
were females and 60% of these females had a mood disorder. 70% of them were
victims of violence (domestic violence, assault, sexual harassment and rape)
and 80% had marital or family conflicts. CONCLUSIONS Pakistani women are relatively better off than their counterparts in other
developing countries of South Asia. However, fundamental changes are required
to improve their quality of life. It is imperative that constructive steps
be taken to implement women friendly laws and opportunity be provided for
cross-cultural learning. Strategies should be devised to enhance the status
of women as useful members of the society. This should go a long way to improving
the lives and mental health of these, hitherto "children of a lesser God". References 1. Tinker GA. Improving women's health in Pakistan. Karachi: World Bank; 1999. 2. National Commission on the Status of Women. Report of the status on women in Pakistan. Islamabad: 1997. 3. Rehman IA. The legal rights of women in Pakistan: theory and practice. Karachi: Human Rights Commission of Pakistan; 1998. 4. Naem S. Psychological risk factors for depression in Pakistani women. College of Physicians and Surgeons; 1990. 5. Zaman R. Karachi: University Psychiatry Department; Five-year survey (1992-1996). Unpublished manuscript. 6. Mumford D, Nazir M, Jilani FM. Stress and psychiatric disorders in Hindu Kush: a community
survey of mountains villages in Chitral, Pakistan. Br J Psychiatry. 1996;170:473–477. 7. Niaz U. Human rights abuse in family. Journal of Pakistan Association of Women's Studies. 1994;3:33–41. 8. Khan MM, Islam S, Kundi AK. Parasuicide in Pakistan: an experience at University Hospital. Acta Psychiatr Scand. 1996;93:264–267. [PubMed] 9. Niaz U. Contemporary issues of Pakistani women: a psychosocial perspective. Journal of Pakistan Association Women's Studies. 1997;6:29–50. |
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Acta Psychiatr Scand. 1996 Apr; 93(4):264-7.
[Acta Psychiatr Scand. 1996]