thesis on domestic violence in pakistan

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Intimate partner violence against women: a comprehensive depiction of Pakistani literature

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Tazeen Ali, 1 Rozina Karmaliani, 1 Rida Farhan, 2 Syeda Hussain 3 and Fatima Jawad 1

Background : Intimate partner violence against women is a significant problem in Pakistan associated with an alarming set of mental health issues.

Aims : To identify the prevalence of intimate partner violence in Pakistan and the causes, health effects and coping strategies used by women.

Methods : A comprehensive search based on the identified keywords was conducted using Google Scholar and PubMed. Relevant literature was also searched and included. Abstracts were then shortlisted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and 25 studies were selected. Quantitative studies on intimate partner violence were included in the review. The review comprises only reports published in English from 2008 to 2018.

Results : The review accounts for the overall prevalence of violence and its various subtypes against women in Pakistan: psychological 31.3–83.6%, physical 10.0–98.5%, sexual 2.5–77.0%, physical and sexual combined 1.0–68.0% and any other type 6.9–90.0%.

Conclusion : The evidence generated will help notify policy-makers and health officials about the determinants and effects of intimate partner violence, making it easier to address these issues and identify victims as early as possible. It also sheds light on the limitations of this study: tools used by the published studies not specifically designed for Pakistan and there is no standardized definition of violence against women. This calls for more studies to be conducted to help find a solution.

Keywords: intimate partner violence, women, spousal, domestic, Pakistan

Citation: Ali T; Karmaliani R; Farhan R; Hussain S; Jawad F. Intimate partner violence against women: a comprehensive depiction of Pakistani literature. East Mediterr Health J. 2021;27(2):183-194. https://doi.org/10.26719/emhj.20.107

Received: 02/09/19; accepted: 01/03/20

Copyright © World Health Organization (WHO) 2021. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

Introduction

Intimate partner violence (IPV) has been a topic of discussion since the 2000s and continues to be an issue that needs to be addressed. The World Health Organization (WHO) defines IPV as “any behaviour within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship”. A WHO study of 10 developing countries estimated lifetime prevalence of physical and/or sexual violence of up to 71% (1). Most often, violence is conducted by the husband but in-laws or close family members can also be common perpetrators (2).

While issues of IPV occur all over the world, the incidence may be more widespread in developing countries. One of the earliest studies reported the prevalence of overall domestic violence by husbands in 34.0–54.8% of married women (3). However, a large proportion of IPV cases are not documented as women are made to think that the forms of violence they face are acceptable due to cultural norms. According to a published study, “violence can increase a woman’s risk of a number of health problems, including chronic pain, physical disability, drug and alcohol abuse and depression” (4). This statement reflects accurately why this issue needs to be addressed and solved since it greatly decreases a woman’s quality of life. However, to formulate effective interventions, it is essential to understand the forces that encourage or lead to IPV. Research assessing IPV has found socioeconomic factors, low level of education and unemployment were found to be leading causes contributing to domestic violence (5,6).

Recently, data on violence against women has been collected through the population-based Pakistan Demographic and Health Survey (DHS) 2012–2013. A 2015 systematic review in Pakistan by Ali et al. included studies from 1985–2011 (7), however, to the best of our knowledge, no recent systematic analysis has been done on the available literature on domestic violence within the Pakistani context despite an increasingly alarming rate. Our literature review is an attempt to fill the gap and collate available data from multiple sources over the past several years to provide a comprehensive picture of different types of domestic violence in Pakistan so that effective interventions and measures can be taken based on the causes and trends and, thus, improve the quality of life of married women.

The aims of this review are to identify the range of prevalence of IPV and all forms of domestic violence (psychological, physical, sexual, and controlling) reported in published studies and reports from 2008 to 2018 and to identify the reported determinants, health effects, and coping strategies of women in Pakistan.

Methodology

Literature search strategy.

A literature search was performed using 2 databases: PubMed and Google Scholar. Three authors (TSA, RF, SNFH) independently performed an extensive literature search and shortlisted articles which were then cross-checked by 2 of the authors (RF, SNFH) and selected based on the eligibility criteria. The following keywords and phrases were used: IPV, domestic violence, violence against women, domestic abuse, spousal violence and Pakistan. Quantitative and Boolean operators were used to narrow down the search results. Moreover, all the available grey material and reports from organizations such as WHO and the Aurat Foundation were also reviewed and selected based on the inclusion criteria.

Since this is a review article, approval by the ethics committee was not required.

Eligibility criteria

Since the focus of the search was prevalence of IPV, all the related articles and reports were studied. Articles from 2008 to 2018 were assessed and those including: women undergoing any form of IPV (physical, psychological and sexual); a quantitative study design; English as the publication language; and where Pakistan was the study setting were selected. To control the quality of the chosen articles, only those which had provided a detailed methodology and clear results were included.

Articles were excluded if they were not conducted in Pakistan, or studied spousal violence against men or domestic violence involving in-laws or other family members.

Study selection

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart was used for study selection. We identified 9879 articles by database searching of MeSH words (Figure 1). After removing duplicates (n = 49) and checking relevance, 87 were shortlisted. The full text of the shortlisted articles was evaluated for the eligibility criteria and 25 were selected for the final analysis: 14 from PubMed, 10 from Google Scholar and 1 report from the grey literature. The quality of the selected studies was reviewed using a STROBE (Strengthening the Reporting of Observational studies in Epidemiology) checklist, which ensured that all articles were following a structured approach, including an introduction, methodology, results and a discussion section. It was also determined that all selected articles were published in peer-reviewed journals and had used nationally or internationally established tools to conduct their study. The selected studies were approved by one of the authors (TSA), who is an expert in the field of IPV. The one report selected was from Rutgers WPF, a reputable nongovernmental organization which has been working on women’s empowerment and domestic, sexual and gender-based violence since 1997 in over 18 countries.

Ethical considerations

Since domestic violence is a sensitive topic and can put the women interviewed at risk of danger if due safety and confidentiality are not taken into consideration, WHO has laid down recommendations for research on domestic violence against women (8). The selected studies were therefore reviewed to see if they had reinforced ethical considerations. Of the 25 articles, 18 had followed ethical guidelines, of which 11 had followed the WHO recommendations, while 7 had obtained approval from the ethical review committee of their respective institutions. Two articles had used secondary data for analysis, for which ethical approval was not required, while 5 articles did not mention any ethical considerations they might have taken in their research.

Data extraction

Data were extracted by 3 authors (TSA, RF, SNFH) by carefully studying the methodology and results of the selected articles. The methodology was entered into an extraction template which summarized the location, study design and sample size in the articles (Table 1). The results covered the title, authors, publication year and lifetime prevalence of IPV faced by women, which was further categorized into psychological/emotional violence, physical violence, sexual violence, both combined and violence of any other type (Table 2). The prevalence of each type of IPV was plotted against the publication year using Microsoft Excel and a trend line generated to better understand individual forms of IPV (Figure 2). The combined prevalence range of IPV from all the selected articles, causes and outcomes are described in the Results section. The IPV assessment tools used in the research are listed below.

Tools used by the selected studies to assess intimate partner violence

WHO Multi-Country Study on Women’s Health and Life Experiences: This tool has the ability to “estimate the prevalence of violence against women, with particular emphasis on physical, sexual, and emotional violence by male intimate partners”. It also assesses the extent to which IPV is associated with a range of health outcomes, identifies factors that may either protect women or put them at risk of partner violence, and documents and compares the strategies and services that women use to deal with violence by an intimate partner.

Aga Khan University Anxiety and Depression Scale: This is an Urdu language screening tool used for screening psychiatric morbidity (anxiety and depression) in Pakistan. This scale has 81% specificity and 74% sensitivity, 63% positive predictive value and 88% negative predictive value.

Conflict Tactics Scale (CTS): This measures family violence and IPV. The ability of the CTS to measure physical violence in the family (child and spouse abuse) makes it stand out. It assesses conflict-resolving tactics used by couples, reasoning, verbal aggression and physical violence. The reasoning subscale has a Cronbach’s alpha of 0.6 while the value for the other 2 subscales is 0.87.

Women’s Experience with Battering (WEB) Scale: This scale is a measure of a causal link between battering and health. It also evaluates the impact of interventions on battered women or violence prevalence. This tool conceptualizes violence based on severity, frequency and incidence of violent acts. It has a Cronbach’s alpha of 0.88.

Domestic Abuse Checklist (DAC): The DAC is a thorough evaluation of various types of violence inflicted on women by men. It uses international experience to make it functional for local use. It covers: violence, control, threats, severe violence and sexual abuse. This checklist can help health professionals identify victims early in cases with a family history (current or past) of domestic abuse and violence. The DAC Cronbach alpha is 0.89.

Prevalence of violence in published primary data level studies

These studies have shown the prevalence of violence to be 31.3–83.6% for psychological violence, 10.0–98.5% for physical, 2.5–77.0% for sexual, 1.0–68.0% for physical and sexual combined and 6.9–90.0% for any other type of violence, including verbal abuse, controlling behaviour or all types combined (Table 3). Figure 2 shows the trends seen in IPV over the years: psychological and physical violence have decreased, sexual violence and physical and sexual violence combined have increased, while other forms of violence have stayed constant.

The Pakistan Demographic and Health Survey 2012–13 report showed the highest physical violence in Khyber Pakhtunkhwa (57%), followed by Balochistan (43%), Punjab (29%) and Sindh (25%); 79% of the violence was perpetrated by the husband, followed by in-laws (20%). For IPV, it was reported that 52% of the women did not seek help or tell anyone (9).

The Demographic and Health Survey report comparing the attitudes of women and men towards spousal violence showed that generally women were more likely than men to justify at least one reason for violence (9): 34% of men agreed that they were justified in beating their wife, whereas 43% of women found the husband’s violence to be justified, showing that women blame themselves more than the men.

Reasons for violence

The reasons for violence most commonly identified in the selected articles included family problems (45%), household work (9%) and husbands’ negative behaviours (6%) (10). Low level of education also showed a significant association with domestic violence (5). Furthermore, low socioeconomic status, living in a joint family, household crowding, arranged marriage, conflicts between husband and wife, seasonally-based income, women’s low autonomy and younger age for first sexual intercourse were all identified as significant risk factors for IPV (11,12).

There is a considerable lack of mental health education in Pakistan and a high acceptance level for violence against women. Most women are involved in low-paid jobs, which provide them with economic support but cannot secure social and economic autonomy, resulting in performing dual duties both at the workplace and home (13). Owing to cultural attitudes, weak community sanctions against partner violence, and religio-political forces reinforcing patriarchy and gender domination (14), men feel justified in being violent when their needs are neglected. History of violence in the family or poverty during childhood and adolescence also foster insecure men who are unable to control their impulses (15).

Husband’s unemployment, lazy work attitude, drug addiction, increasing age (6), mistrust of the wife’s moral character, restriction on the wife stepping out of the home, womanizing or quarrelling with in-laws because of poor attention towards children (16) lead to battering and verbal or sexual violence. Unskilled husbands earning a low income resort to violence when their wives ask for money to fulfil their household chores (17). Research has established that the risk of depression, aggressiveness and violent behaviours is linked with unemployment, which can lead to an increased risk of physical, sexual and emotional abuse. Stressful life events, marital discord, financial difficulty, child marriage and misinterpretation of religion result in a high prevalence of anxiety, depression and common mental disorders in Pakistani women (18). Inability to make decisions and lack of mobility are common problems of women living in an extended family (14). There is also a lack of reproductive autonomy (19) as 14% of unwanted index pregnancies were reported (14).

Another major reason for the continued violence over the years is the woman’s adherence to patriarchal norms and having no say in the decision-making in domestic matters (20). A large number of women (35.8%) believe that hitting is valid if the wife argues with her husband and a further 22.4% reported their mothers also endured spousal violence, hence the huge acceptance for violence (21). Moreover, it was found that men felt threatened if their wives had any ownership of assets, and this resulted in an increase in controlling behaviours (22).

Outcome of intimate personal violence being reported in selected studies

The health outcomes are serious conditions such as injuries, forced abortions and chronic pain syndromes (2); mental health consequences such as stress disorder, sexual dysfunction, fear and anxiety (23); gynaecological disorders (24); chemical dependency, substance abuse and attempting suicide (25); psychiatric distress and feelings of anger in women (15); and difficulties in decision-making (10). Physical injuries (16.5%) reported over the last 12 months included: 13.9% associated with pain lasting for one day, 7.3% sprain/bruise/cut, 4.1% broken bone and 7.6% requiring medical attention (18).

It was also found that severely physically abused women had a greater likelihood of unplanned pregnancies, poor antenatal care, poor reproductive health and husband’s noncooperation in using contraceptives (24). These women were also more prone to experiencing complications during birth such as intrauterine fetal death, miscarriage, low birth weight, placental abruption and premature labour or birth (11). One study showed that 36% of the women felt they were compelled to indulge in sexual activity they deemed as humiliating while 19% yielded to their husband’s commands in fear of their reaction in case of refusal (14).

The occurrence of a great number of diverse mental health issues, including thoughts of suicide, illustrate the powerful links between mental health and exposure of women to IPV. There was an immense increase of depression and suicidal thoughts in women exposed to IPV (5,10,17,26,27). “Problems in performing usual activities”, “loss of interest in previously enjoyable things”, “feelings of worthlessness”, “memory and concentration problems” and “suicidal thoughts” were among the symptoms of depression, as shown in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (10,17). Furthermore, depression can also lead to a feelings of low self-esteem. Studies from Palestine, Ethiopia and Sweden showed that a low self-esteem was directly proportional to the length of the abusive relationship, this being known as the “normalization process”, where the woman blames herself and gradually comes to see her abuse as “normal” (28–30). In Pakistan, women are considered inferior to men and therefore, within marriage, violence against women is taken as a cultural norm, especially by elderly women and those who lack an adequate education, further increasing the likelihood of low self-esteem, resulting in psychiatric distress and consequently unhappy relationships (15).

Trends in violence

The published articles indicate a high magnitude of all forms of violence. A decreasing trend was seen for psychological and physical violence, mainly because, over the years, women have gained awareness regarding IPV and are not only empowered but are also demanding equal rights. However, since sexual violence still remains a taboo topic and marital rape is yet to be considered as violence, there is an increasing trend in sexual violence as well as physical and sexual violence combined. Other forms of violence, such as verbal abuse and controlling behaviours, remained constant throughout the period studied, indicating that not enough interventions have been undertaken thus far to reduce these forms of IPV. Moreover, considering the sensitive nature of the topic, there is always an iceberg phenomenon present while reporting cases, thus making it difficult to gauge the actual prevalence of violence.

Lack of context within the tool

With no indigenous tool for violence against women, all Pakistani studies have utilized tools developed elsewhere, which may account for differences in the magnitude and forms reported when compared with other cultures. The tools used in the published articles, which include WHO, WEB and the CTS, need to be standardized to measure the social and economic costs incurred due to violence against women.

Despite the help quantitative data offer to understanding the situation among women, they do not provide any information about how women experience and interpret violence in different public and private settings in Pakistan. Everyday violence, such as verbal abuse, humiliation, degradation, and threats of violence, is not adequately explored and is considered the norm in many households.

Most studies undertaken lack a theoretical foundation, with quantitative data focusing on a specific

region while indirect information forms the major part of the grey literature. All the empirical quantitative studies perform assessments on the nature, prevalence, severity, causes and impact of violence against women in Pakistan on a smaller scale, either in a single province or in urban or rural areas of another province. Reports, theses and review articles provide information at national level; however, their source is secondary data produced by police records, media reports, shelter homes, etc. It is known that secondary data might not produce evidence that can be generalized at population level.

It was also noted that different studies in Pakistan employed different sample sizes and study settings, making it difficult to arrive at a conclusive picture. Data available through empirical and grey sources can be thought of as depicting just the tip of the iceberg, projecting only the extreme cases. Numerous cases of abuse and violence go unrecorded because a great segment of the population firmly believes in privacy, making it a societal taboo to discuss or report personal family matters in public due to the notion that such matters are better resolved within the family.

It is a necessity for studies done on IPV to cast some light on the minds of the male perpetrator, especially concerning their views of gender roles. Efforts are needed to increase our understanding of masculinity and views on IPV and its connection to the masculine identity. Thus, it is essential to engage in a dialogue with men regarding data on gender-based violence, which could make an important contribution to studies on issues of violence against women. By emphasizing the role of gender stereotypes, it brings attention to the insecurities that often lie beneath the male identity, revealing areas for extended studies. Both men and women should be able to question their dreams alongside the realities that shape their psyches and force them to take on stereotypes to live a secure life, which ends up being rigid and uncompromising.

Urban areas verses rural areas studies

Women in rural areas file more IPV complaints than those in urban areas, even though rural areas are far less likely to have other violent crimes. Even if there are services for the victims of IPV in every district, rural women will find it difficult to ask for assistance as there is usually a stigma attached to those who complain about abuse. A “rural culture” usually means a close community, so people know what is happening in the lives of others. It is possible that the police, judiciary, social workers, health workers, religious representatives and other people know both the sufferer and the perpetrator.

The geography of the rural areas, as compared with the urban areas, is such that the residents face physical and social isolation, socioeconomic distress, population loss due to the outmigration of young people in the search of opportunities, and a lack of health care services. This is further combined with low education status and a more traditionalist, conservative view of women, leading to rigid political and social confines for women. Survivors of IPV may require legal aid for matters that result from domestic abuse such as protection orders, divorce and child custody proceedings. There can be more difficulties in obtaining an affordable attorney or legal help in contrast to urban areas. Law enforcement agencies as well as the courts in rural communities may not be acquainted with issues of IPV and the required solutions (31).

Small scale studies published in Pakistan lack analysis in identifying correlates and establishing causal linkages with factors that may increase women’s vulnerability to various form of violence. The existing body of literature is unable to identify causality with risk factors and outcome. Studies done to date only identify associations and then causality, establishing the dire need for longitudinal studies or interventional studies to test interventions for the prevention of violence.

Future implications

This study provides insight into the different types of IPV, causes, trends and effects, therefore allowing interventions to be carried out and each intervention to be tested for its effectiveness in different settings. Future systematic reviews can eliminate limitations by using a mixed methodology approach, reviewing articles from within and outside Pakistan and focusing on interventional study designs.

In conclusion, the prevalence of multiple forms of violence is quite high and is still on the rise, especially sexual violence and the combination of sexual and physical violence. The selected articles identified the common causes including family problems, unemployment, misunderstanding between couples, and violence being justified by men and accepted by women (normalization). The reported consequences result in psychological stress, physical injuries, gynaecological disorders, miscarriages and grave detrimental mental health leading to suicidal ideations.

Funding : None

Competing interests : None declared.

Violence exercée par un partenaire intime à l'encontre des femmes : une représentation exhaustive de la littérature pakistanaise

Contexte  : La violence exercée par un partenaire intime à l’encontre des femmes est un problème important au Pakistan, lié à un ensemble alarmant de problèmes de santé mentale.

Objectifs  : Identifier la prévalence de la violence exercée par un partenaire intime au Pakistan et ses causes, ses effets sur la santé et les stratégies d’adaptation utilisées par les femmes.

Méthodes  : Une recherche exhaustive basée sur les mots-clés identifiés a été menée à l'aide de Google Scholar et PubMed. La littérature pertinente a également été consultée et incluse. Les résumés ont ensuite été présélectionnés à l'aide des lignes directrices relatives aux éléments de rapport préférés pour les examens systématiques et les méta-analyses, et 25  études ont été sélectionnées. Des études quantitatives sur la violence exercée par un partenaire intime ont été incluses dans la revue. L’analyse comprend uniquement des rapports publiés en anglais de 2008 à 2018.

Résultats  : L’analyse prend en compte la prévalence globale de la violence contre les femmes au Pakistan et ses différents sous-types : psychologique 31,3-83,6 %, physique 10,0-98,5 %, sexuelle 2,5-77,0 %, physique et sexuelle combinés 1,0-68,0 % et tout autre type 6,9-90,0 %.

Conclusion  : Les données probantes produites aideront à informer les responsables de l’élaboration des politiques et de la santé sur les déterminants et les effets de la violence exercée par un partenaire intime, ce qui facilitera la résolution de ces problèmes et l’identification des victimes dès que possible. Elles mettent également en lumière les limites de cette étude : les outils utilisés par les études publiées ne sont pas spécifiquement conçus pour le Pakistan et il n'existe pas de définition standardisée de la violence à l’encontre des femmes. Il est donc nécessaire de mener de nouvelles études pour contribuer à trouver une solution.

عنف الشريك المُمارَس ضد المرأة - وصف شامل للأدب الباكستاني

تازين علي، روزينا كارمالياني، رضا فرحان، سيدة حسين، فاطمة جواد

الخلفية : يمثل عنف الشريك المُمارَس ضد النساء مشكلة كبرى في باكستان ترتبط بمجموعة مثيرة للقلق من مشكلات الصحة النفسية.

الأهداف : هدفت هذه الدراسة إلى تحديد معدل انتشار عنف الشريك في باكستان، وأسبابه، وآثاره الصحية، واستراتيجيات المواجهة التي تطبقها النساء.

طرق البحث : أُجري بحث شامل يستند إلى الكلمات الرئيسية المحددة باستخدام برنامجيْ Google Scholar وPubMed. كما بُحث في المؤلفات ذات الصلة وجرى إدراجها. ثم أُدرجت الخلاصات في قائمة مختصرة باستخدام بنود التبليغ المفضلة للاستعراضات المنهجية والمبادئ التوجيهية للتحليلات الوصفية، وبذلك اْختيرت 25 دراسة. وأُدرجت في الاستعراض دراسات كمية حول عنف الشريك. ويقتصر الاستعراض على التقارير المنشورة باللغة الإنجليزية في الفترة من 2008 إلى 2018.

النتائج : يفسر الاستعراض معدل الانتشار العام للعنف ضد النساء وأنماطه الفرعية المختلفة في باكستان، أي: العنف النفسي (83.6 - % 31.3)، والعنف البدني (98.5 - % 10.0 )، والعنف الجنسي (77 - % 2.5)، والعنف الجسدي والجنسي مجتمعيْن (68 - % 1.0)، وأي نوع آخر من أنواع العنف (90.0 - %6.9).

الاستنتاج : ستساعد الدلائل المتولدة في إخطار راسمي السياسات ومسؤولي الصحة بمحدِّدات عنف الشريك والآثار المترتبة عليه، مما يُسهِّل التصدي لتلك المشكلات وتحديد الضحايا في أقرب وقت ممكن. كما ستلقي الضوء على القيود المفروضة على تلك الدراسة، والمتمثلة في: عدم تصميم الأدوات المستخدمة في الدراسات المنشورة خصيصاً لباكستان، وعدم توافر تعريف موحد للعنف ضد المرأة. ويتطلب ذلك إجراء المزيد من الدراسات للمساعدة في إيجاد حل.

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Gender-Based Violence in Pakistan - a Critical Analysis

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Women’s Perceptions and Experiences of Domestic Violence: An Observational Study From Hyderabad, Pakistan

Farhana i. madhani.

1 Aga Khan University, Karachi, Pakistan

Rozina Karmaliani

Carla m. bann.

2 RTI International, Research Triangle Park, NC, USA

Elizabeth M. McClure

Omrana pasha, robert l. goldenberg.

3 Columbia University, New York, USA

This community-based observational study of 1,325 women seen for antenatal care examined how women in Pakistan define violence against women (VAW), with an emphasis on domestic violence, what an acceptable response to violence is, reasons for remaining silent, and whether participants are willing to disclose incidents of domestic violence to others. Nearly half of the study participants believed that physical violence was VAW. Verbal abuse, controlling behavior by the husband, conflict with in-laws, overburdening domestic work, and threatening to leave or remarry were also considered VAW. However, only five respondents (0.4%) considered sexual abuse to be VAW. Most women who screened positive for domestic violence responded by remaining silent or verbal fighting back. None sought professional help. Women who decided to remain silent feared that the abuse would escalate or that responding would not help them. Women cited social stigma and concerns about the impact of the violence on children as reasons for not disclosing violent incidents to others or seeking professional help. Women’s lack of autonomy further reduced their ability to take steps against violence. Although societal norms, particularly patriarchal beliefs and women’s subordination to men, likely explain women’s tolerance of abuse, their recognition of physical abuse as violence indicates that they do not necessarily believe it is always justified. Educational interventions to drive changes in the social norms around gender violence along with effective and enforceable legal measures are likely required to ensure women’s safety.

Introduction

Violence against women (VAW) is a global phenomenon that cuts across all cultures, religions, and socioeconomic groups and touches on fundamental issues of power, gender, and sexuality. The United Nations General Assembly ( UNGA; 1993 ) “Declaration on the Elimination of Violence Against Women” defines VAW as

any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. (p. 3)

Domestic VAW is a form of VAW that encompasses “physical, sexual and psychological violence occurring in the family, including battering, sexual abuse of female children in the household, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women” ( UNGA, 1993 , p. 3).

VAW, particularly intimate partner violence (IPV), is known to adversely affect victims’ physical and mental health and quality of life. The World Health Organization’s (WHO) Multi-Country Study on Women’s Health and Domestic Violence Against Women found that women who had experienced IPV in their lifetimes had poorer self-reported health, were more likely to recently have had pain and difficulty performing daily activities, and had greater emotional distress and suicidal thoughts than women who had not been abused ( Ellsberg, Jansen, Heise, Watts, Garcia-Moreno, & World Health Organization Multi-Country Study on Women’s Health and Domestic Violence Against Women Study Team, 2008 ). Women experiencing IPV during pregnancy are more likely to have postnatal depression ( Ludermir, Lewis, Valongueiro, de Araujo, & Araya, 2010 ) and are at greater risk for adverse pregnancy outcomes, including preterm birth and low birth weight ( Murphy, Schei, Myhr, & DuMont, 2001 ; Rodrigues, Rocha, & Barros, 2008 ) and infant and maternal mortality ( Chibber & Krishnan, 2011 ).

VAW is thought to occur at high rates worldwide and potentially modifiable cultural factors may play an important role in determining both actual rates of violence and attitudes toward its acceptability. In Western countries, domestic and marital VAW is addressed through governmental policies and frameworks. In many Islamic countries, however, several forms of domestic violence are typically not considered a major concern despite their frequency ( Douki, Nacef, Belhadj, Bouasker, & Ghachem, 2003 ). A number of studies have reported varying perceptions of domestic violence in different cultures. For instance, American Indian women defined physical abuse only as domestic violence, whereas European American women tended to include verbal and emotional acts along with physical abuse as domestic violence ( Tehee & Esqueda, 2008 ). Chinese adults defined domestic violence as physical or sexual acts of aggression between spouses as opposed to psychological aggression ( Yick & Siewert, 1997 ). Some studies have found that women have been socialized to believe that men are their guardians, and that men have the right to beat them if they behave unacceptably ( Jejeebhoy & Sathar, 2001 ; Schuler, Hashemi, Riley, & Akhter, 1996 ). In such contexts, social norms around gender have normalized VAW, particularly domestic violence, to the point where it is believed to be necessary, is construed as a sign of love or affection, and victims are blamed for violence that is perpetrated against them by their partners ( Amoakohene, 2004 ; Douki et al., 2003 ; Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005 ; Haj-Yahia, 2002 ; Kulwicki & Miller, 1999 ).

Very few women seek formal or legal help to escape violence, particularly domestic and IPV ( Chandra, Deepthivarma, Carey, Carey, & Shalinianant, 2003 ; Douki et al., 2003 ; Jejeebhoy & Bott, 2003 ; Panchanadeswaran & Koverola, 2005 ; Raj & Silverman, 2002 ; Shaikh, 2000 ). A report from the WHO found that 55% to 95% of women, when faced with violence, did not seek help from formal organizations or people in positions of authority ( Garcia-Moreno et al., 2005 ). A study of South Asian women living in Boston (USA) found that only 11.3% of the women experiencing violence perpetrated by their intimate partner reported receiving counseling, and only 6.9% visited a doctor for consequences of the abuse ( Raj & Silverman, 2002 ). In Bangladesh, 66% of women remained silent in response to physical abuse by their husband. The main reasons behind the silence were societal normalization of violence, stigma, and fear of greater harm ( Naved, Azim, Bhuiya, & Persson, 2006 ). In Asian cultures, patriarchal norms and the pressure to maintain harmony, peace, and family honor force women who are abused into staying silent because the prospect of facing violence is preferable to the social stigma and potential isolation associated with reporting abuse to authorities external to the family ( Panchanadeswaran & Koverola, 2005 ). Thus, VAW is widely overlooked and is deeply embedded in many cultures.

In Pakistan, where a strong patriarchal belief system dominates societal norms and behaviors, VAW is expected to be highly prevalent ( Fikree & Bhatti, 1999 ; Raj & Silverman, 2002 ; Shaikh, 2000 ). A recent systematic review found that the prevalence of physical IPV perpetrated by a husband against his wife ranges from 16% to 80%; psychological violence ranges from 48% to 84% ( P. A. Ali, Naylor, Croot, & O’Cathain, 2014 ). The prevalence of sexual violence against pregnant women ranged from 14% to 21% ( P. A. Ali, Naylor, et al., 2014 ). Moreover, patriarchal ideas contribute to women’s social, economic, and emotional dependence on their husbands. This may prevent women from leaving their abusive husbands. Furthermore, cultural practices and social norms may lead to the belief that VAW is acceptable and thus prevent women from disclosing their abuse experiences ( Andersson et al., 2010 ). Responses to victimization by women who are abused are influenced by their views of themselves, societal norms, and the attribution that they make for the causes of abuse.

The aim of this study was to explore how women in Pakistan generally define VAW and how they respond to violence when they face perpetration. The study also focused on women’s willingness to disclose incidents of violence to others as well as the reasons why they would not disclose VAW. Research on attitudes in Pakistan toward IPV in particular and VAW in general has yet to be conducted ( P. A. Ali, Naylor, et al., 2014 ). This article aims to explore these issues and add to the literature on cultural norms regarding gender and violence in Pakistan, providing context for service providers to implement appropriate interventions aimed at reducing the acceptability of VAW in this patriarchal society. Because of cultural norms and societal expectations of women, we hypothesized that Pakistani women do not define violence as it is defined by UNGA (1993) , which may contribute to greater acceptance of abusive behaviors. We also hypothesized that when faced with violence, most women would choose to remain silent because of cultural norms and the belief that no help could be sought.

We conducted a cross-sectional study with few open-ended questions of pregnant women in Hyderabad, an Urdu-speaking city in Pakistan of about 1 million inhabitants. This study was part of a larger study that examined a range of sociodemographic, psychosocial, nutritional, and clinical factors associated with infectious morbidity and pregnancy outcomes among mothers and infants. Details related to methodology and further results are described elsewhere ( Karmaliani et al., 2008 ). The study was approved by the Ethics Review Committee at the Aga Khan University and the Institutional Review Boards of the University of Alabama, Birmingham, and Research Triangle Institute International. The WHO ethical and safety guidelines for research in domestic violence were followed. Lady Health Workers (LHWs) were hired, trained, and certified to conduct interviews and to ensure that participants attended the study clinic for periodic clinical evaluations. LHWs in five selected units of the Hyderabad community screened 1,879 participants during their routine prenatal home visits. Of these participants, 1,774 (94%) gave verbal consent to attend the study to confirm eligibility. Based on a clinic visit, 1,376 of these women met the inclusion criteria, and 1,368 gave informed consent to participate in the parent study while at the clinic. Of these, 1,325 (96%) completed the domestic violence questionnaire.

Participants

Women in their 20th to 26th weeks of pregnancy (confirmed by ultrasound), who were permanent residents (i.e., intending to stay in Hyderabad for a minimum of 6 months) and able to give verbal and written consent, were included as study participants. Only one participant from each household was enrolled even when other women met study inclusion criteria. This minimized the risk of disclosure and harm to women’s safety because other family members would not know what was discussed with the participant ( WHO, 1999 ). Participants who did not meet the inclusion criteria had a clinical diagnosis of a life-threatening condition and/or planned to deliver outside of the project area were excluded from the study.

Study Procedures and Measures

Participants were interviewed in the research clinic without any family members present. Participants were screened for domestic violence and asked a series of open- and closed-ended questions about their experiences regarding domestic violence using a WHO screening instrument modified based on the Pakistani National Gender Indicators List for Violence Against Women . Qualitative questions regarding women’s perceptions of VAW and their experiences of remaining silent in response to violence are the primary focus of this article. The questions were primarily broad and open ended to ensure that women were free to express their views so that they were not influenced by prompts, and we could obtain an accurate representation of women’s beliefs about VAW. All women were asked what they believed encompassed VAW, although only women who indicated that they had experienced or were experiencing violence were asked about how they responded to the violence (closed ended) and why (open ended). A demographic questionnaire, which collected data about the participant’s age, employment status, and educational status, as well as the husband’s employment status, was also included in the study.

The primary outcome of this study was to identify what broad categories of violence (e.g., psychological, economic, physical, sexual) were considered by participants to comprise VAW. This is reported as the proportion of women that believed a certain type of violence to comprise VAW. Another outcome was to identify what proportion of women took action when faced with violence. Among those who remained silent, we aimed to identify what the most common reasons for doing so were.

Participants were informed that they could withdraw from the study at any point, that they could choose not to answer any or all of the questions, that the interviewer would take notes, and that their responses would be kept confidential. Actions to prevent potential distress and referral for support through counseling were ensured.

Data Analysis

The qualitative responses were reviewed and common themes identified using content analysis (Krippendorf, 2012) to develop a coding framework. An iterative process was then used for coding responses based on this framework to ensure interrater reliability. First, one author (C.P.) coded the responses into categories based on the themes. The majority of responses were brief and unequivocally fell under one of the themes identified (e.g., “beating,” “yelling,” or “does not give me money for food”). A second author (R.K.) then reviewed the coding. Any discrepancies or uncertainties in coding were discussed among the two coders to reconcile differences and achieve consensus. Finally, to ensure study rigor, the primary author (F.I.M.) then reviewed the content analysis and recoded the qualitative responses; based on this review, in agreement with the other coders, minor revisions were made to the coding framework to improve clarity.

Responses to the question regarding what encompasses VAW were grouped into seven categories: (a) physical abuse, (b) verbal abuse, (c) sexual abuse, (d) controlling behaviors, (e) conflict with in-laws, (f) bad behavior, and (g) emotional abuse. The category “bad behavior” encompassed vague responses that were not probed further, and simply noted by the LHWs as “husband’s bad behavior” or simply “bad behavior.” It is presumed that the “bad behavior” referred to by participants would encompass behaviors or actions taken by an intimate partner, family member, or other person that would cause a woman (presumably the respondent) psychological or physical harm; however, without further probing, this cannot be confirmed. We included this category because the content analysis found a large proportion of respondents mentioned “bad behavior.”

A large number of participants choose to “stay quiet” in response to violence. Reasons for this were similarly grouped into 10 categories: (a) fear of escalating violence, (b) respect for elders/in-laws, (c) no one to confide in, (d) husband will leave/make her leave, (e) won’t make a difference/helplessness, (f) for the sake of children, (g) hope abuse will stop, (h) husband’s right, (i) self-respect, and (j) own fault. An additional “other” category highlighted responses that could not be categorized otherwise.

Frequencies were calculated for all the categories. In addition, chi-square tests and odds ratios (ORs) were computed to compare perceptions of and responses to VAW across demographic groups. Responses of open-ended questions were coded into categories using Microsoft Excel and were imported into SAS (v. 9.3) for quantitative analysis.

The demographic characteristics of the participants and their perceptions of domestic violence are shown in Table 1 . The average age of the participants was 27 years, and two thirds ( n = 886) had received some formal education. Seventy-eight percent ( n = 1,038) of the participants’ husbands had permanent employment, and on average, families owned about half of the five items included in the property index. Four percent ( n = 55) of the women reported that their husbands had other wives or sexual partners. Twenty-eight percent ( n = 375) of women were younger than 18 years old when they first had sexual intercourse, and 82% ( n = 1,087) had previous pregnancies. Six hundred eighty-one women (51%) reported experiencing some form of violence before and/or during pregnancy.

Sociodemographic Characteristics of Participants ( N = 1,325).

Note. Missing data by characteristic: employment ( n = 2), husband’s job ( n = 2), property index ( n = 4), ever pregnant ( n = 1), and wanted pregnancy ( n = 1).

The majority of the women interviewed referred to some sort of domestic violence as VAW ( Table 2 ), identifying different types of domestic violence as VAW. Forty-seven percent ( n = 616) of women stated that they thought physical abuse by a husband, including beating and burning, was VAW, whereas 8% ( n = 109) thought that verbal abuse, including being critical, using abusive language, teasing, taunting, and scolding, was VAW. Only five respondents (0.4%) mentioned sexual abuse as VAW. Controlling behaviors by the husband, such as not giving the wife money or food, preventing her from going out of the house to work or visit relatives, and overburdening her with domestic work, were considered VAW by 21% ( n = 279) of the women. About 22% ( n = 289) of women also explicitly stated that any kind of conflict with in-laws (physical, verbal, or emotional, but not sexual) was VAW. Emotional abuse by a husband or in-laws, comprising behaviors such as disrespecting women, not listening to her or giving her any importance, threatening to leave or remarry, and always being suspicious of her, were considered to be emotional abuse by 28% of respondents. In addition, a number of women stated that abuse stemming from the inability to have children would constitute VAW. Some women were not specific in their replies; 42% ( n = 557) described VAW as “bad behavior,” “domestic violence,” “fighting,” “quarreling,” “being aggressive,” or “having a bad attitude.” These responses usually referred to the husband’s actions and were grouped under one category: bad behavior/domestic violence.

Percentage of Women Indicating a Type of Abuse Is Violence Against Women, by Demographic Characteristics.

Note. These analyses include the 1,314 women who responded to the question about definition of violence against women.

DV = domestic violence.

Table 3 shows that the majority of women (55%, n = 360) reported verbally fighting back in response to verbal abuse, whereas 64% ( n = 417) remained silent. In response to physical abuse, 42% ( n = 68) of women verbally fought back, and 48% ( n = 78) remained silent. The majority (73%, n = 117) of women remained quiet in response to sexual abuse. Twenty-eight respondents (4%) returned to their parents’ home in response to verbal abuse, and 16 respondents (10%) returned after physical abuse. Very few respondents spoke with friends or family, and none consulted professional organizations or took legal action.

How Women Responded to Domestic Violence.

Women who indicated that they responded to abuse by remaining quiet were asked to describe their reasons for doing so ( Table 4 ). The women in this study cited a wide range of reasons for staying in violent relationships, the most common of which was fear that the violence would escalate with almost half (49.4%) of women stating this. Several also cited respect for their elders. Respondents cited a lack of hope that responding to violence would change their situation, stating, “there is no point in talking to him,” “there is no point talking about it every day as it will have no effect on his behavior,” “no use of asking for rights,” “no use in replying,” and “it makes no difference.” A few respondents (15%) indicated that they remained silent in response to verbal abuse out of respect for their elders and in-laws, stating: “I don’t want to be disrespectful towards my elders,” “I am weak and cannot do anything,” and “I am powerless.” Women also revealed that they had no one to confide in, especially those who remained quiet about physical and sexual abuse. A small percentage (12%, n = 39) of women who remained silent in response to all three types of abuse did so for the sake of the children and/or feared that their husbands would leave or make her leave. Self-blame was also evident, with 3 participants stating that the “abuse is due to our own fault.” Of the 73% of women who remained quiet in response to sexual abuse, 22% ( n = 16) stated that it was their husband’s rights to have sex with them. Fourteen respondents (19%) felt helpless when faced with sexual abuse, and a significant number of sexual abuse victims (40%, n = 29) feared that violence would escalate. Six women remained silent in response to the three different types of abuse to maintain self-respect. One woman stated that she chose to remain silent because “there is anger in silence.”

Reasons Why Women Stayed Quiet in Response to Domestic Violence.

An OR analysis revealed the characteristics of women who were more likely to respond to domestic abuse ( Table 5 ). Women older than 30 years of age (see Table 5 ) who had had a prior pregnancy (OR = 4.04, 95% confidence interval [CI] = [2.36, 6.90]) were more likely to fight back while women who wanted the pregnancy (OR = 0.65, 95% CI = [0.48, 0.89]) were less likely to fight back in response to verbal abuse. Women who had their first instance of sexual intercourse before the age of 18 (OR = 1.96, 95% CI = [1.00, 3.84]) and/or had a prior pregnancy (OR = 4.24, 95% CI = [1.18, 15.20]) were more likely to respond verbally or physically to sexual abuse. No other significant associations were found.

Percentages of Women Who Fought Back Verbally or Physically in Response to Abuse by Demographic Characteristics.

Note. Percentages are row percentages indicating the percentage of women in the subgroup who fought back verbally and/or physically (e.g., 54% of women aged 20 years or less fought back in response to verbal abuse).

OR = odds ratio; CI = confidence interval; REF = reference category.

An analysis of women who stayed quiet in response to abuse revealed similar results (not shown in table), with women aged 21 to 25 years (OR = 2.00, 95% CI = [1.26, 3.16], p < .01) and those aged 26 to 30 (OR = 1.67, 95% CI = [1.07, 2.63], p = .026) being more likely to remain silent in response to verbal abuse compared with women 30 years. Women with basic schooling of Grade 6 and more to be more likely to remain quiet in response to verbal abuse, although the association did not reach significance (OR = 1.43, 95% CI = [1.00, 2.04], p = .052). Women with a low family property index, a measure of socioeconomic status, were more likely to remain quiet in response to physical abuse compared with women with a high family property index (OR = 0.50, 95% CI = [0.25, 0.99]).

VAW is commonly perpetrated by a woman’s partner, often in her home, and is typically considered to be a private matter outside of the realm of public debate or exploration. Until recent decades, VAW remained largely hidden and undocumented ( WHO, 2000 ). In our study, most of the women (47%, n = 616) stated that physical abuse is VAW, but 109 (8%) considered verbal abuse to be violence, and only 5 (0.4%) women stated that they believed that sexual abuse is VAW. A likely explanation is that abuse, particularly sexual abuse, is widely accepted among women in South Asian societies, and so there is a high tolerance and acceptance of abuse as being part of life ( Chandra et al., 2003 ). Previous studies have demonstrated that societies dominated by patriarchal ideologies, such as those in Pakistan, are more likely to tolerate VAW, and thus make women more accepting of abuse ( Ahmad, Riaz, Barata, & Stewart, 2004 ; T. S. Ali, Krantz, & Mogren, 2012 ; Faramarzi, Esmailzadeh, & Mosavi, 2005 ; Haj-Yahia, 2002 ; Jewkes, 2002 ). In fact, it was perceived that men are required to use violence as a means to control their wives’ behavior, a measure that Pakistani women are conditioned to accept as normal ( T. S. Ali et al., 2012 ; Rabbani, Qureshi, & Rizvi, 2008 ; Zakar, Zakar, & Kraemer, 2011 , 2013 ). A study from Karachi found that two thirds of women interviewed believed a wife should always follow her husband’s instructions irrespective of her will, and 18.5% believed violence was justified if she did not follow her husband’s instructions ( P. A. Ali, Naylor, et al., 2014 ).

An important finding in our study was that only five women (0.4%) stated that they believed that sexual abuse is VAW, and the majority (60%) of those who experienced sexual abuse remained silent. Societal norms dictate that a man controls a woman’s sexuality, and that a married woman is required to be sexually available to her husband at all times ( Abraham, 1999 ). Married adolescents perceive that acquiescing to forced sex by husbands is part of their marital duty and is a show of commitment ( Jejeebhoy & Bott, 2003 ; M. E. Khan, Townsend, Sinha, & Lakhanpal, 1997 ). In this context, the use of force when a request for intercourse is met with refusal is considered normative behavior ( Population Council, 2004 ). A study in India confirmed the acceptance of sexual abuse as part of marital life; neither men nor women perceived this kind of violence to be wrong ( Martin, Tsui, Maitra, & Marinshaw, 1999 ). Sexual violence has been shown to have an adverse impact on women’s mental and physical health independent of their experience of other forms of violence ( Dutton et al., 2006 ). A study in Pakistan found that almost 76% of women who experienced sexual violence had suicidal thoughts ( T. S. Ali, Mogren, & Krantz, 2013 ). Thus, societal norms that keep sexual violence hidden are likely to contribute to the burden of disease attributable to injuries, sexually communicable diseases, and mental health.

Studies have shown that many women find nonphysical violence to be more devastating than physical abuse ( Panchanadeswaran & Koverola, 2005 ; WHO, 2005 ). Several studies have documented the detrimental effects of psychological violence, both in Pakistan and globally, due to the internalization of feelings of self-doubt and fear ( P. A. Ali, Naylor, et al., 2014 ; T. S. Ali et al., 2013 ; Dutton et al., 2006 ; Lagdon, Armour, & Stringer, 2014 ; Zakar, Zakar, Mikolajczyk, & Kramer, 2012 ). Women who experience controlling behaviors are also more likely to experience higher levels of violence ( Johnson, 1996 ). Economic violence (i.e., limiting control over and access to resources) in particular is known to worsen social inequalities and lead to physical and sexual violence ( Fawole, 2008 ). In our study, a significant percentage of women (49%) considered controlling behavior, usually by the husband, to be VAW. Commonly mentioned forms of controlling behavior, such as denial of food and money to pay for household expenses, or the husband threatening to leave them or throw them out of the house, reflect the helplessness of the women and their dependence on their husbands. Male-dominated hierarchies influence the decision-making power in all domestic spheres: economic, social, and sexual. Women are often viewed as a burden to the household, and are not granted the same rights and opportunities as men, particularly regarding access to economic resources ( Go et al., 2003 ; Niaz, 2003 ; Schuler et al., 1996 ). Our study found that physically abused women who remain silent in response to the violence are more likely to be of a lower socioeconomic status, highlighting their dependence on their husbands for financial resources.

A sizable proportion of respondents (22%) stated that some kind of conflict with in-laws (whether verbal or physical) was VAW, indicating the role that in-laws play in provoking and perpetrating VAW. In Pakistani society, a woman typically moves into her in-laws’ house to reside with her husband’s family, where women must respect both her husband and her in-laws ( Kapadia, Saleem, & Karim, 2009 ). The movement into the husband’s family increases the chances of conflict with her in-laws over domestic matters, such as performing household tasks, a finding confirmed in a Pakistani study ( A. Khan & Hussain, 2008 ). In fact, women often perceive the presence of inlaws in the household as a contributing factor to the incidence of domestic violence ( Fikree & Bhatti, 1999 ). Two women from our study stated that they believed “teasing from in-laws because of dowry” was abuse, indicating the presence of conflict due to dowry-related matters. In South India, a study found that violence is less likely when women bring bigger dowries at the time of marriage ( Srinivasan & Bedi, 2007 ). A Pakistani study also linked conflict with in-laws to greater risk of experiencing sexual violence, likely because of a lack of social support ( Kapadia et al., 2009 ).

The ways women responded to domestic violence provide further insight into women’s perceptions of violence. Consistent with other studies, most women remained silent ( Andersson et al., 2010 ; Rabbani et al., 2008 ). Domestic abuse, particularly sexual abuse, is typically considered normal and, therefore, must be received silently ( Rabbani et al., 2008 ; Zakar et al., 2013 ). The majority of women who remained quiet in response to violence did so because they feared that the violence would escalate. Many appeared to feel helpless, stating that responding actively to violence would not help their situation but rather would put them at risk of enduring greater violence. These responses do not imply that women believe that violence is necessarily justified, but that women are expected to tolerate the violence. This is an interesting and important finding, as it suggests that women accept violence perpetrated against them due to societal expectations of women rather than a belief that VAW is justified. Several studies have noted that even in Pakistan, women who report experiencing any kind of IPV (psychological, physical, and/or sexual) demonstrate higher rates of adverse health outcomes. They are found to have higher rates of poor mental health outcomes such as depression, anxiety, and suicidal ideation, as well as injuries and poor reproductive outcomes such as unplanned pregnancies, poor prenatal care, and pain in the abdomen and/or vagina ( N. S. Ali, Ali, Khuwaja, & Nanji, 2014 ; P. A. Ali, Naylor, et al., 2014 ; Zakar et al., 2012 ). This is comparable with the adverse health outcomes experienced by women in other parts of the world, including Western countries ( Bonomi, Anderson, Rivara, & Thompson, 2007 ; Chibber & Krishnan, 2011 ; Lagdon et al., 2014 ). This could indicate that even though women may tolerate IPV and VAW is more generally acceptable in Pakistan, the physical and mental health effects among women who experience perpe- tration particularly by a spouse are as detrimental as when they are experienced by women in a less patriarchal culture.

Even though VAW is widely accepted, several women in our study revealed that they responded to abuse verbally or physically. Older women were more likely to respond this way. Of particular note, multigravida women had 4 times the odds of responding to verbal abuse compared with primigravida women, although this may be an indication of the younger age of primigravida women. Older women may feel more established in the household and may feel they are able to assert some authority. Younger women, however, may have lived in their husband’s household for a shorter time and so feel less confident in responding to violence. Interestingly, the association between age and responding to violence verbally or physically did not hold for physically or sexually abused women, which may be the due to the greater severity of violence and greater fear of escalation. Previous studies have documented that IPV experience increases the risk of unwanted pregnancy ( Chibber & Krishnan, 2011 ; Zakar et al., 2012 ); however, to our knowledge, ours is the first to document an association between responding to unwanted pregnancy and responding to violence in this context.

None of the women from our study consulted with professional organizations or took legal action for any of the abuse, which is similar to findings in other studies ( Andersson et al., 2010 ; A. Khan & Hussain, 2008 ). Social stigma and minimal social support leave few choices for victims of violence and being separated from their partners would likely bring shame and dishonor to the families ( P. A. Ali, Naylor, et al., 2014 ; Andersson et al., 2010 ; A. Khan & Hussain, 2008 ). The literature cites the many reasons why victims of abuse do not disclose abuse to their health care professionals; most commonly reported reasons are fears of retaliation by their partner, shame, humiliation, denial about the seriousness of the abuse, and concern about confidentiality ( Gerbert, Caspers, Bronstone, Moe, & Abercrombie, 1999 ). Formal institutions also tend to be perceived as ineffective in assisting women facing violence ( P. A. Ali, Naylor, et al., 2014 ).

In our study, very few participants talked to family and friends in response to verbal and physical abuse. One respondent stated that she did “not want to let neighbors and others know that there is domestic violence because of my social status.” The literature, however, highlights that irrespective of who perpetrates the violence, women are more likely to speak to their friends, neighbors, or immediate family members than anyone else ( Andersson et al., 2010 ; Goodkind, Gillum, Bybee, & Sullivan, 2003 ). The lack of consultation with family or friends among our respondents is possibly because women who consult with friends or family were often advised to return home to the abuser and to sort out the matter within the household, or to simply accept the violence passively ( Douki et al., 2003 ; Haj-Yahia, 2002 ; Jejeebhoy & Bott, 2003 ; Panchanadeswaran & Koverola, 2005 ). This lack of social support explains why many women felt that they had no one to confide in about their experiences.

Limitations

Although the open-ended nature of the question allowed for a variety of answers and a way for the study participants to freely respond, many responses were vague (i.e., the category “bad behavior/domestic violence”). Unfortunately, the LHWs were not trained to prompt the participants to clarify women’s views and some data were lost. Even some of the more specific answers (e.g., “beating”) are very broad in meaning. For instance, “beating” could refer to a milder form of physical abuse, such as slapping, or a more severe form, such as kicking. Some women may have perceived certain types of violence to be VAW but may not have mentioned them because of social norms that dictate that they must remain silent about these issues. For example, sexual issues are considered to be very personal and are not to be discussed outside the home. Explicitly asking about specific types of violence may have prompted women to state that they considered it to be violence. Similarly, in terms of responses to violence, there could be a possibility of recall biases. Because pregnancy is supposed to be a joyous period for women, women’s feelings and actual responses may have been replaced with “keeping silent.” Furthermore, pregnant women may even be more fearful about potential consequences of disclosing acts of violence, so accurate responses may not have been obtained.

In-depth qualitative research about the perceptions and responses to violence among pregnant and nonpregnant Pakistani women is necessary to determine what and how women view domestic violence and whether pregnancy influences their perceptions of and responses to violence. Furthermore, participants should be recruited from urban as well as rural areas of Pakistan and among people from different socioeconomic backgrounds, as results may vary greatly between these groups of people. A comprehensive understanding of women’s perceptions and responses to violence and whether the acceptance of violence is linked to sociodemographic factors such as age, income, education level, employment status, number of pregnancies and living children, and childhood experience of abuse will contribute to developing future interventions. Furthermore, the term husbands’ rights could have been explored more in terms of understanding how women in Pakistan define the term. Due to the nature of the parent study, follow-up on the consequences of women’s participation in the study and the effectiveness of referral could not be achieved. Future research should also consider examining the effectiveness of measuring how abused women cope with VAW because this could lead to identifying ways to improve the mental health of these women.

Conclusions and Recommendations

Understanding women’s perceptions of VAW and their responses to being silent will assist in developing interventions to change traditional ideas that make violence acceptable and to assist women in recognizing abusive behaviors and seeking help. Staying silent in response to violence may cause women psychological harm, leading to depression, anxiety, fear, guilt, shame, or self-harm tactics. Tolerance of abuse can result in greater risk of injury and psychological disturbance, as greater acceptance of violence is linked with greater incidence of violence.

Our data suggest that women appear to identify several forms of abuse correctly but appear to tolerate it rather than take action against it due to societal norms. To break the cycle of violence, a change in attitudes and perceptions is needed. Behavioral interventions to change societal norms and create opportunities to decrease women’s economic dependence on men are key. Education can play a central role in shifting the power dynamic between men and women because it provides girls with the skills and ability to earn a livelihood, raising their self-esteem so that they respond to violence with greater confidence. Girls who remain in school longer are less likely to be the victim of abuse ( Karmaliani et al., 2008 ). Creating opportunities for girls to access basic schooling and ensuring gender-equitable access to primary level education at a minimum could empower future generations of women. According to the World Economic Forum (2013) , Pakistan, at 135th place among all countries, is one of the worst performing countries in the world in terms of gender inequality. Therefore, knowledge about gender equity, women’s rights, family violence, and positive coping strategies should be incorporated in the basic education at primary and secondary school curricula for both girls and boys.

More broadly, programs that educate women and men about violence should be implemented in an effort to change cultural norms around VAW. These programs should aim to increase awareness about the types of violence, particularly in a domestic context, and the risk they may involve, such as psychological and physical injuries. Sexual violence should be a major component of these programs, as it appears to be the most widely accepted form of abuse. The media can play an important role in educating masses about women’s rights. Enrolling religious leaders to play a role positively in preaching to the people about Islamic values and women’s rights that strongly condemn VAW could be an effective manner of bringing about behavior change.

Women should also be encouraged to seek help. Disclosing information about abuse experiences empowers women to take action against abuse as it ends the silence ( McFarlane, 2007 ). For this to be possible, the establishment of both formal and informal support systems is necessary. International health organizations recommend that health care practitioners follow a protocol to identify and manage victims of abuse ( Gazmararian, Peterson, Spitz, Saltzman, & Marks, 2000 ). Primary health care practitioners in Pakistan rarely have resources to support victims of domestic violence, screening tools to detect victimization, or knowledge of referral services for victims ( Zakar et al., 2011 ). It is therefore important to include violence specific knowledge and skills in the health care practitioners’ curricula. Setting up support groups of local women as a resource for abused women to seek help and advice has also been suggested ( Andersson et al., 2010 ).

Recently, the Parliament of Pakistan has passed a number of laws to enhance women’s rights. However, the extent of their enforcement is limited, and it is believed that the legislation has had little effect on preventing VAW ( Gill & Stewart, 2011 ; Immigration and Refugee Board of Canada, 2013 ). There is a need for correct understanding and implementation of these laws among communities and law enforcement agencies. Authorities, especially the police, should be trained to help women, as studies have shown that women who sought help from police were more likely to receive necessary health care, and were less likely to be repeatedly assaulted ( McFarlane et al., 2005 ). Unless resources and mechanisms are put in place to enforce the law by protecting victims and taking appropriate punitive action against perpetrators, widespread change in how victims respond to violence is unlikely to occur.

Acknowledgments

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded through grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Bill and Melinda Gates Foundation (5 U01 HD40636 and 5 U01 HD40607).

Biographies

Farhana I. Madhani is currently a PhD student at McMaster University School of Nursing, Canada. She is an assistant professor at the Aga Khan University, School of Nursing and Midwifery (AKU SONAM), Karachi, Pakistan. She graduated with master’s in science from University of Wisconsin–Madison and baccalaureate from AKU SONAM. She is interested in women’s mental health, gender-based violence, methodological issues in conducting violence against women studies, poverty and mental health, and nursing education specific to clinical teaching. Her PhD thesis focuses on women’s mental health in the context of microfinance.

Rozina Karmaliani is a professor at AKU SONAM, and in the Community Health Sciences (CHS) Department of Medical College at AKU. She began her career as a community health nurse and preceptor in the CHS department at AKU in 1988. She then went on to complete her MPH in public health administration in 1994, her MScN in public health nursing administration in 1997, and her PhD in nursing in 2000, all from the University of Minnesota. Her areas of research interests include women and children’s health, mental health, women and violence, gender and equity, child abuse and neglect, community health, program evaluation, health systems, nursing education, nursing management, and bioethics.

Cyra Patel (MSPH, MBA) completed her BA in community health at Brown University (2008) and her MSPH in international health at the Johns Hopkins Bloomberg School of Public Health (2012). She has worked in a variety of settings on projects aiming to improve women’s health, from domestic violence to reproductive health. During her time at Brown University, she completed her honors thesis on perceptions of intimate partner violence among South Asian women in Rhode Island and victim service needs. She currently works in the Implementation Research Group at the Sax Institute in Sydney, Australia, where she is working on projects that aim to provide evidence-based health care.

Carla M. Bann completed her PhD in quantitative psychology at the University of North Carolina at Chapel Hill in 1999. She is a fellow of statistics and psychometrics at RTI International and prior to her fellow appointment served as senior director of Program Evaluation and Outcome Measurement at RTI. She has served as the statistician on numerous projects focused on improving maternal and child outcomes.

Elizabeth M. McClure completed her PhD in epidemiology with a focus on perinatal at the University of North Carolina at Chapel Hill (2013). She began her career at the Eunice Kennedy Shriver National Institute of Child Health and Human Development, coordinating a multisite research network to improve neonatal outcomes. Since 2001, she has been at RTI International, conducting research to improve maternal and perinatal outcomes and leading the data coordinating center of a multicountry research network.

Omrana Pasha is an internist and an epidemiologist with more than 18 years of experience working on issues of women’s and children’s health. She completed medical college at the AKU in Pakistan, postgraduate training in internal medicine at Beth Israel Medical Center in New York City, and a MSPH from the University of Alabama at Birmingham. She worked at Save the Children Federation, Inc., in Westport, Connecticut, and the Rollins School of Public Health at Emory University in Atlanta, Georgia, before joining AKU in Karachi, Pakistan, as a member of the faculty in 2004. She currently serves as an associate professor in the Departments of Community Health Sciences and Family Medicine at AKU.

Robert L. Goldenberg completed his medical degree at Duke University (1968) and obstetrics residency at Yale University (1974). He has conducted research on preterm birth and stillbirth, with emphasis on improving outcomes in low-resource settings, resulting in more than 500 peer-reviewed publications. He is currently a research professor at Columbia University (New York, NY) in obstetrics and gynecology.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Pakhtun Men's Perceptions of the Conditions Promoting Domestic Violence in their Culture

--> Saeed, Muhammad (2012) Pakhtun Men's Perceptions of the Conditions Promoting Domestic Violence in their Culture. PhD thesis, University of York.

This thesis reflects on Pakhtun men�s perceptions of the conditions promoting domestic violence against women in their culture. The existing literature on domestic violence in Pakistan, the primary focus of which is the women victims of such violence, shows some staggering and skewed statistics, owing to the deeply embedded patriarchal social structure, gender-prejudiced attitudes prevailing at every level of society as well as poverty, illiteracy, a strict pattern of gender- specific roles and spaces, socio-economic dependence of women on men supported by religion. However, men�s views on this issue have rarely been addressed in Pakistan in general and Pakhtun society in particular. I examine how the social and cultural environment of Pakhtun society influences the construction of (violent) masculinity and gender-power relations. These create the potential for violence, specifically domestic violence against women. The research was carried out in four different locations of the Khyber-Pakhtunkhwa province of Pakistan. Data was generated through semi-structured and in-depth interviews of 32 male respondents, eight in each of the selected areas, on the basis of three categories, i.e. ethnicity, age, and educational status of the respondents. Drawing upon my respondents� views I show that Pakhtunwali, the core of the Pakhtun social structure, is a key contributing factor offering potential for the construction of violent Pakhtun masculinity particularly through the notions of badal (revenge), gherat (self-honour or Pakhtun honour), and nang (Pakhtun pride). It also encourages a strict pattern of gender hierarchies and spatialization, which leaves women marginalized at all levels. Thus in Pakhtun society one learns to be aggressive in order to dominate and control, and one way this aggression is expressed is through violence against women. I argue that the joint family structure, the general perception of women�s issues including domestic violence as a highly personal and private matter, the absence of an effective and competent criminal justice system, and lack of domestic violence laws provide the perpetrators with considerable impunity.

--> Pakhtun_Men’s_Perceptions_of_the_Conditions_Promoting_Domestic_Violence_in_their_Culture --> -->

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Prevalence of domestic violence against women in pakistan: policy analysis.

Violence perpetuates in many forms around the world, but domestic violence is increasing at alarming rates, especially in Pakistan. The apprehension of domestic violence is only possible if one explores the underlying causes of such a complex process. The causal framework of this process is a condensation of cultural, social, economic, and political aspects. Most prominently, gender rules and cultural norms guide one’s actions since an individual’s behavior is based on his/her interaction with other humans and the social organization. Therefore, the present policy brief aims to review major causes and consequences responsible for the prevalence of domestic violence against women in Pakistan while considering all five levels of social organization including individual, microsystem, mesosystem, exosystem and macrosystem, in order to build up the urgency and present the importance of this issue. To serve this purpose, data was collected through interviews and survey questionnaires. Subsequently, various policy alternatives were proposed and evaluated using Policy Delphi rankings and certain assessment criteria such as importance, desirability, feasibility, efficiency, equity, and security that could be effective to exterminate the prevailing domestic violence against women in the country.

Key findings

The findings of multilevel analysis illustrated that at the individual level, childhood abuse, watching marital abuse and substance abuse serve as significant factors conducive to abuse conduction by the victim; at the microsystem and mesosystem level, male control of wealth and decision making lead to conflicts; at the exosystem and macrosystem levels, exclusion of women from decision-making forced them to bear physical or verbal abuse since they were dependent economically and socially on men because of the patriarchal structure of Pakistan’s society. Similarly, gender associations and role expectations were found playing a huge role in instigating a misogynistic rhetoric. In Pakistan, girls were found to be perceived as social, economic, and religious liabilities on their families. Moreover, certain social issues, including tribal/caste system in Pakistan, experiencing domestic violence as a child, patriarchal society where men tend to dominate all walks of life, misinterpretation of religion by many scholars and people, lack of education for women, gender norms and associated roles, family structures, and poor policy and implementation structure were found to be the root causes and determinants of all other factors that contribute to the prevalence of  domestic violence against women in Pakistan. Further analysis identified certain negative consequences of domestic abuse including domestic violence’s continuation through generations, physical deformities such as acid burns or even death in some cases, mental trauma and depression, social unrest and disorganization, disintegration of a harmonious family life, and shifts in personality traits and marginalization of a community. In addition to that, certain policy actors were also highlighted that could influence the policy process as being directly or indirectly involved with the cases of domestic violence in Pakistan including government, perpetrators, victims and their children, respective families, social community, NGOs and the United Nations. Moreover, it was found that if no action would be taken in a country where literacy rates are low and general understanding of consent is missing, the situation would only worsen. However, only government policies and the use of law could prevent this nuisance. Therefore, the study proposed significant policy alternatives in order to control the prevalence of domestic abuse in Pakistan including implementation of laws against domestic violence, bringing reform through awareness alone, state should define elementary rights of women as per religion, criminalization of all forms of domestic violence by the state and no action policy. Practically, the alternative of designing curriculums whereby sex education would be provided through which children could be informed about the concept of domestic violence was found the most efficient, yet it might be unfeasible in different settings because the religious sections and some parents might contest this option. Although, the alternative to equalize inheritance laws for men and women and to provide equal ownership of assets was also found to be highly effective, but only with proper implementation and accountability of the legal procedures. Since this policy option could help women in acquiring an equal economic standing to their male counterparts, they could speak against violence without fearing divorce and economic burdens. Similarly, spreading awareness through NGOs and social media was found to be a valuable policy alternative since it was efficient and both the state and civil society could work cohesively to bring reform through this mode. This alternative was also found to be politically feasible. However, the analysis conferred that the decision regarding policy alternatives should be based on a mix of legality and security of an individual. Therefore, the criminalization of domestic violence by the government and the creation of such laws was found to be the most desirable and feasible policy alternative in the current context. Furthermore, the policy alternative to spread awareness through the help of NGOs and the media could be the second valuable option since it also scored well on the criteria of feasibility and liberty. Ideologically, it could serve as a perfect alternative considering its effectiveness. Moreover, the education of women was found vital for transformation and to help them recognize and exercise their rights. This policy could act as a cornerstone for change and/or as a savior for the women already abused, and for women in general. However, the alternative of no action was found to be inefficient and inequitable as women would continue to be marginalized in that case. Therefore, it was proposed that state should have the responsibility to protect the rights of a socially, politically, and economically repressed section of the community.

Implications

Domestic violence is a pertinent issue that requires immediate action. Affirmatively, it is a structural issue in Pakistan and needs to be viewed holistically in order to alleviate it from the society. Firstly, the state should set goals in order to cater to this issue and these goals should comprise of what the state wants to do, what it should prevent and what should be the bottom line for developing policies. Thenceforth, all school curriculums should include basic knowledge of domestic violence, “good touch” and “bad touch”, sexual consent and should urge upon children to inform their teachers, parents or siblings about any misbehavior with them. Women should be provided equal educational opportunities. The government could pass laws regarding the necessary enrollment of all genders in schools and provide quality education to all children. This will have a ripple effect. Both girls and boys will be illuminated with the negative effects of domestic violence, the number of children being educated will increase and in the long run, domestic violence may be curbed. Although these actions can be taken in the short-run, but their effects might be evident over some period. Moreover, recreation centers and mental and medical health centers should include formally trained personnel who could cater to women who are abused. Similarly, proper counselling and immediate medication can prevent huge losses. Furthermore, the state should develop a helpline primarily for women who feel threatened or are going through domestic violence. This will reduce inefficiency by immediate reporting of such cases. However, in the long term, the state should focus on making laws regarding the criminalization and the penalties of domestic violence. Subsequently, there should be effective campaigns on media through informational advertisements, radio programs and newspapers regarding the existence and implementation of these laws. The media should present cases of domestic violence so it forms an example for the rest of the abusers while depicting the consequences of such actions. To serve this purpose, it is eminent for the state to build capacities within different institutions. For example, the police departments should be strengthened enough that they can take immediate actions in case any incident is reported. More women should be employed within the police department so other women feel safe and comfortable to report their cases. Furthermore, the judiciary should be strengthened so that legal proceedings can be smooth and easy. Since legal procedures are tedious in Pakistan, many people refrain from getting involved in them because of the process and impartiality, therefore, if all these actions are taken efficiently, women may speak against their abusers and justice might prevail. The success of this initiative will be seen in the long-term, yet it can be measured through the number of cases reported or observed annually. Moreover, the government can assign individuals to monitor the progress of policy implementation and cater to the loopholes. Similarly, a cohesive strategy is required if mass awareness is a goal. The state alone will be unable to solve the issue. Hence, non-governmental organizations such as Aurat Foundation and Kashf Foundation should work collectively and with the government to conduct awareness campaigns from door-to-door and from the urban centers to the rural areas. Here again, the state can help these NGOs by initiating public-service messages across the media regarding the advancement of NGOs for this cause and to promote the reporting of any such incidents if one experiences themselves or witnesses an incident in their surroundings. In addition to that, the state can help set up committees in different rural and urban centers that comprise of one government personnel, an NGO member, and 2 to 3 members of that area. These members would include two females and one male member so that they can act as mediators between the NGOs and the ordinary people. In case women do not feel comfortable talking to people from the NGOs, they could report to these members. However, the success of this policy initiative is dependent on information transparency as all reported cases should be uploaded on an online forum, keeping the victim’s name anonymous and this information should be accessible even by ordinary citizens. One way to measure the success of these policies is to conduct direct feedback from the masses. This could be through door-to-door campaigns or necessary fulfillment of surveys before people log-in to their social media accounts. Feedback from the committee members is another way to see if these policies have led to an increase in the number of reported cases. If so, it would imply that women are now comfortable sharing their cases at least.

Intimate partner violence against women in Pakistan: a review of qualitative research

Affiliations.

• 1 Department of Community Health Sciences, Aga Khan University, Karachi.
• 2 Student 3rd Year, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
• PMID: 32400749
• DOI: 10.5455/JPMA.20759

Objective: To consolidate research data and provide an insight into areas that need further research regarding intimate partner violence.

Methods: The review targeted qualitative research-based studies done in the English language and conducted in Pakistan from 2008 to 2018 regarding intimate partner violence against women. A thorough search of Google Scholar and PubMed databases was done. Data from each selected article was extracted using a data-extraction template.

Results: Of the 2,479 results, 21(0.8%) articles were selected along with 4(0.16%) texts from grey literature. An in-depth analysis led to six broad categories: experiences/perspectives of married women facing intimate partner violence; perspectives of married men towards intimate partner violence; perspectives of religious leaders who support the idea of men controlling their wives; societal norms, such as dowry, patriarchy and daughters being considered a burden; impact on women and family as damage to the women's physical and mental health affects not only her but also the society as a whole; and coping strategies used by most women.

Conclusions: The review helps in understanding the common trends and situation of Pakistani women who are exposed to violence, the common limitations faced by researches, and areas which require further research to prevent intimate partner violence.

Keywords: Intimate partner violence, Qualitative, Review, Spousal violence, Domestic violence, Pakistan.

Publication types

• Family Health
• Intimate Partner Violence* / prevention & control
• Intimate Partner Violence* / psychology
• Intimate Partner Violence* / trends
• Qualitative Research
• Social Norms*
• Women's Health / standards*
• Women's Rights / trends*

• UN Women HQ
• Asia and the Pacific
• Protection against harmful practices

Ending violence against women

Multiple forms of violence against women (VAW) are prevalent in Pakistan in both private and public sphere. Consequences of violence against them are seen in their limited participation in public life, constrained mobility, low self-esteem and physical harm, and very smaller share in leadership roles. The normative gaps in legislation on early marriage and domestic violence in various parts of the country and implementation of federal anti-rape law need immediate attention of relevant authorities. Domestic violence remains a private affair and seldom discussed or reported, especially in rural poor households. Data gap remains a barrier to identify and curb cases of VAW. Despite efforts of government authorities, including gender crime cell of national police Bureau and commission on the status of women, the accuracy and availability of data exists as a key challenge and needs to be addressed on urgent basis. Along with that, the patriarchal norms remain unquestioned and are deeply engrossed in society.

UN Women, along with the relevant government institutions is working towards transforming social norms and institutional mechanisms to address the issues of violence against women. The interventions in this regard include capacity building on pro-women laws and existing services for GBV survivors, behaviour change communication campaigning and awareness raising among communities.

Access to justice

Pakistan has passed a series of progressive laws in the last two decades that protect women against harmful practices and promote their active role in the public sphere. However, women’s quest for justice – especially the survivors of gender-based violence – remains a woeful journey full of agony and uncertainty. The conviction rate in such cases stands at only 1-2.5% in Pakistan, which calls for urgent action. The barriers to women’s access to justice include procedural hurdles, deeply entrenched patriarchal norms, lack of gender-responsive infrastructure, and inadequate conceptual understanding and technical capacity to deal with gender-related crimes and survivors of violence.

UN Women in Pakistan, works with justice sector institutions to sensitize on issues related to VAW and gender crimes to improve enforcement and case management. UN Women also works to improve the overall medico-legal service and forensic capacity of relevant institutions for effective prosecution and timely conviction.

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Home > ISEM > Dissertations and Theses > 2

Dissertations and Theses

Domestic violence in pakistan from 1990 – 2020: a mixed method approach.

Hamida Khatri , Harrisburg University of Science and Technology Follow

Completion Date

Fall 8-10-2020

Document Type

Degree name.

Master of Science (MS)

Program or Discipline Name

Information Systems Engineering and Management

First Advisor

Dr. Stanley C. Nwoji

This study assessed domestic violence from the perspective of the victims who experienced trauma due to sexual, emotional, and psychological abuse in Pakistan.

Creative Commons License

Recommended Citation

Khatri, H. (2020). Domestic Violence in Pakistan from 1990 – 2020: A Mixed Method Approach . Retrieved from https://digitalcommons.harrisburgu.edu/isem_dandt/2

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Dreaming of escape: The Pakistani women fleeing domestic violence

Pakistani women who fled abusive relationships share the dreams that inspired them to leave.

When my mother was two years old, she was given as a “gift-child” to a wealthy widowed aunt who did not have any children of her own. Three years later, her birth mother, who was just 26 at the time, died of leukaemia.

My mother rarely saw her siblings or father, who eventually remarried, and – looking back now at my own upbringing in Odense, Denmark, I can trace the trauma I absorbed from my mother back to her own childhood.

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But, as a child, I did not know why my mother was so cold and strict; why she never showed me any love or warmth. I did not know about her childhood or the feelings of loss and rejection she carried with her and passed on to me. I did not know any of this because feelings were not something we shared or discussed in my family. In fact, the only emotions my mother seemed capable of expressing were anger and sadness.

As a teenager, I rebelled against this, as I rebelled against so many of my family’s plans and expectations – the Quran lessons, the restrictions on my freedom, but none more so than my father’s plan to move us all to Pakistan, the country both he and my mother were from.

He had built a large house there that he intended for us all to live in with his ailing mother. Instead, aged 15, I ran away. At first, I stayed with a friend, before making my way to Copenhagen.

After a few weeks in the capital, I moved into Freetown Christiania, a commune that was established by squatters on the site of a former military barracks in 1971. The year I spent there in 1991, changed my life forever.

I met artists and activists, people who looked out for me and helped me whenever I needed it, and a photographer who introduced me to what would become my profession.

During this time, I also began to look back on my childhood and understand that it had been shaped not only by the anger and guilt I had been raised with but by the ways in which I had used dreams as a means of escape from it.

My dreams, which often involved me flying through the sky like a bird, seeing places that felt safe and meeting people who seemed loving and kind, had helped me to stay afloat and given me hope. They had become my safe place.

I remembered how my mother and her friends had often interpreted their own dreams, believing they had seen in them visions and predictions for their futures.

In Islam, there is a practice called “Istikhara”, in which someone will say a particular prayer before sleeping when they have an important decision to make. They consider their dreams to be a form of guidance from God, helping them to make the right decision.

As I learned photography and spent countless hours in a darkroom, seeing the images I had captured being revealed on paper, it felt like watching dreams come to life.

I was drawn to taking photographs of the people I called the “unseen” – those overlooked and living on the fringes of society. I photographed homeless children and transgender people in Argentina, Indigenous people in Bolivia and Columbia, residents of the favelas in Brazil. The most important thing for me was always to see and capture people as they are – so that their inner personality shines through their photographs.

As I travelled the world doing this, visiting places I had seen in my childhood dreams, I realised that my dreams had become my reality. It renewed my interest in dreams and the subconscious and I decided to train as a psychotherapist, specialising in dream interpretation.

Just as I wanted my photographs to capture the truth of who someone was, I wanted to establish a similar understanding of those I worked with as a psychotherapist. I found it fascinating to learn how a person’s trauma and dreams intersect and how, if treated right, dreams can help someone heal.

It reminded me of a documentary I had watched about Pakistani women who had endured domestic violence and sought refuge in a shelter.

The shelter called Dastak was located in a quiet neighbourhood of Lahore and had been started by AGHS Legal Aid Cell in 1990, a legal aid organisation co-founded by sisters Hina Jilani and the late Asma Jahangir, both renowned human rights activists and lawyers.

It provides free temporary accommodation for women and their children, as well as legal, financial and psychological support.

I was curious to know more about these women. So, in 2004, I travelled to Lahore for three weeks to photograph some of the women at Dastak, for a project with Amnesty International.

It was my first visit to Pakistan since I was five years old, and I was surprised at how easily I could immerse myself in the culture and relate to the women at Dastak.

For years I had distanced myself from my Pakistani roots, but when I had my own children, it suddenly became important for me to understand my culture and where I came from.

More importantly, I was keen to explore what I had been carrying inside of me. As a psychotherapist and a young mother, I wanted to make sure to not pass on any of my trauma to my children.

The photographs that I took of the Pakistani women during that visit were displayed in an exhibition in cities across Denmark, highlighting the abuse they had suffered.

From the moment I first met the women at Dastak, I had felt an instant connection with them.

As the years passed, and I gained more experience as a psychotherapist, I often thought of returning. But this time, I wanted to explore the lives of the women from a different angle – that of the dreams they had had before leaving their abusive marriages.

Eventually, on March 11, 2020 – the same day the Danish prime minister held a news conference asking all Danes to return home as soon as possible because of the COVID-19 pandemic – I made it back to Pakistan.

I stayed for as long as I could, having long and intense conversations with the women at the shelter about the dreams they had had after performing Istikhara, before leaving on the very last plane out of Pakistan on March 18.

The stories they shared with me touched me deeply. Here are some of them.

‘I dreamt of a safe place with kind people’

Mariam* has an effortless elegance as she moves around her room on the first floor of the shelter. She invites me to sit on the bed beside her and smiles when she hears me speak Urdu. She had been expecting a foreigner, not someone who would speak her language, albeit with a bit of an accent.

She seems relieved and is curious about my family background. Telling her about my life in Denmark helps break the ice, and I feel an instant connection with her.

As she begins to share her own story, her voice is calm and her gaze strong. She left her abusive husband with her four young children in the summer of 2019, she explains. She had endured years of beatings and being burnt with cigarette butts. Some nights her husband would tie her to an electric heater and electrocute her, she says. Sometimes he would beat the children, Mariam adds, her voice cracking as she starts to sob.

We take a break from the interview to talk about other things. I am conscious that my questions could retraumatise her.

When we continue, she tells me: “My husband would drink a lot. I was earning money working in a sewing factory. He would take all my salary and sometimes my children and I didn’t have food for many days.

“It was an arranged marriage. I was in love with another man, but my family didn’t approve of him.”

One day her husband beat her up so badly that she could barely walk. She managed to make it to a rickshaw and returned to her family home. There, she told her brothers that she wanted a divorce.

“My brothers wanted to go to my house and beat up my husband. I told them not to. It would just cause more violence and bloodshed,” she recalls.

“Then my brothers said I could stay with them and keep working in the factory but I must leave my children with my husband. I couldn’t do that.

“A cousin had told me about Dastak so I came here to seek advice.”

A few days later, she returned to the house she had shared with her husband to take her children. When she arrived, her husband and brother-in-law attacked her. But she was determined not to leave without her children.

She told them that if they did not stop beating her, she would report them to the police. They finally relented and let her leave with the children.

“I never learned to read or write. All I want for my children is that they get to study and make something of their lives,” she says, explaining that that is why she has sent her seven-year-old daughter to a boarding school run by Dastak.

“I know she gets a good education and I get to see her every week,” she says, adding: “My husband didn’t allow my children to go to school.”

While we are talking, her youngest daughter, who is just four, comes into the room and hugs her mother.

“She never lets me out of her sight. Witnessing the violence has affected her a lot,” says Mariam.

Mariam also has two sons, aged eight and nine. They are still affected by the violence they witnessed, but they are attending an informal school at the shelter and are doing better, she says.

“My eldest son has frequent nightmares that his father has come to kill his mother. And he is afraid of what will happen to him, who will take care of him?” she explains.

As for the dream Mariam had after doing Istakhara and before leaving her marriage, she says: “Before I even heard about Dastak, I dreamt of a safe place with kind people. I saw this house. The dream came true [and] I felt as if God had given me [the] strength to escape and find this place.”

She still has recurrent nightmares in which her husband comes to kill her, but she says: “I feel strong, and I want to take care of my children. I feel safe here and I am not afraid of him any more.”

‘I’m running, escaping’

Laila* is 23 but seems much younger. She rubs her hands together nervously as we talk.

Her family forced her into marriage a year earlier, she explains.

“I didn’t want to marry this man, but my mother and brothers arranged it. I told them many times, ‘I don’t want to get married’ but they had made their decision,” she says

“When I got married and moved into my husband’s family house, my in-laws blamed me for not bringing enough dowry. I told them I didn’t want to get married to their son in the first place and I didn’t want to stay with them.”

When I ask Laila what life was like with her husband and his family, she looks down at her hands. I notice she is holding a small needle that she keeps pricking herself with.

She seems reluctant to share the details but eventually tells me that she fled their house after just eight days. Her aunt, who used to live at Dastak, had told her she could find refuge there.

After leaving her husband, she started praying a lot and doing Istikhara.

“I dreamt that my sister brought me to a burial yard and put me on a chair on an unknown grave. She watched me from a distance and then laughed and laughed at me,” she says of the dream she had soon after leaving her marriage. “My sister and I are not talking to each other in this dream. I ask myself in the dream, ‘This is strange, why am I here, what is it?’ I felt really scared after this dream.”

Laila says she is not very close to her sister but that she misses her mother and brother. “They have refused to talk to me since I decided to get a divorce,” she explains.

Laila has had another dream since moving into the shelter. “I’m running into the forest, and I hide under the huge trees,” she says. “It’s as if I am running, escaping.”

Her body language changes as she remembers it. She looks up and smiles, hopeful.

‘I can’t stop looking at the water, it’s so beautiful’

Yasmeen* insists we eat breakfast before we begin. She smiles and laughs a lot, particularly when discussing her daughters.

She is only 25 but her face strikes me as that of someone older.

When she was 13 years old, her father arranged her marriage to a much older man.

“The first year of our marriage went ok,” she says. “Then he started to yell at me and would become very angry.

“When our eldest son was born, and then the other children came, I thought it would get better with time, so I put up with it for many years but it didn’t get better. It got much worse. He would often be physically abusive and threaten to kill me. I felt that one day he would actually kill me. It was as if my mere existence triggered his anger and violence.”

When they married, Yasmeen’s husband worked as a rickshaw driver but would give all the money he earned to his parents.

“He’d come home with all kinds of excuses to me like, ‘My rickshaw broke down’, leaving me with no money to buy food for the children. So, I decided to find work. I started cooking for a family, but my husband would take all of my salary,” Yasmeen explains.

The woman she worked for suggested she leave him and take her children to a shelter. When Yasmeen finally felt ready, her employer drove her and her daughters to Dastak. But she had to leave her two sons, aged 10 and 2, behind with their father.

She explains why: “I know they will get a good education. When they get older, they will come back to me. I wanted to make sure that all my children including the girls get a good education, not like me.”

Some women leave their sons behind because they feel their husbands and in-laws will take better care of boys than they would of girls, who are often treated as a burden.

Yasmeen’s eight-year-old daughter wants to become a doctor while the seven-year-old would like to join the army.

“My daughters stayed with me here for two months. Now they have moved to a boarding school, where they have much better school facilities. They like it at their new school and have already made new friends,” she says.

Yasmeen, who gets to visit them once a week, says it is important to her that her daughters remain safe and get educated. Still, she has found it difficult to be without them. Her family, she adds, has not supported her decision to leave her husband.

“They even came here to Dastak to take me back to him. ‘He won’t beat you again’, they said. I know for a fact, that I can’t go back. He would kill me,” she says.

Since she came to the shelter she has had the same nightmare twice. “I dream that my father is coming to get me,” she says. “We fight and eventually he beats me up and cuts me into small pieces.

“That dream scares me a lot. After a nightmare like that, I pray a lot and it gives me comfort. I ask to see some sign that I have made the right decision,” Yasmeen adds.

The nightmare prompted her to do Istikhara, in the hope that she would receive a sign that she had made the right decision.

“Recently, I began dreaming of water. I’m sitting at the sea, just sitting there and thinking ‘this is immense’. I can’t stop looking at the turquoise blue water, because it’s so beautiful and it makes me happy,” she says. “I’m filling my bottle with the water several times – and I keep drinking the water.”

She has felt at peace, she says, since having this dream and feels it has given her the strength to hope for a positive outcome.

‘I’m dying here, please let me out!’

Assia* is 18 years old and her hands are decorated with intricate henna patterns.

When I ask her questions, she answers promptly and precisely.

“Our families arranged a marriage between me and my first cousin,” she says. “Soon after the wedding, I found out that he was in a relationship with a woman who lived next door.

“I confronted him and asked him to stop. He got angry and started beating me up. He said that he would keep us both. For six months I stayed and watched him seeing the other woman. The beatings continued.”

She told her family about the affair and the abuse, and that she wanted a divorce.

“They didn’t believe me. He is my uncle’s son, he is family. So, a divorce was not an option,” she tells me.

Her family convinced her to return to her husband. When she did, he beat her up again. She endured a further two months of abuse before she left for Dastak, where her cousin had stayed a few years earlier.

“My family still tells me to go back to my husband,” says Assia.

When she was still with her husband, she did Istikhara. Her body stiffens as she remembers the dream she had. “I dreamt that my parents locked me up in a closet in their house. I screamed, ‘No, I can’t live in a closet, I’m dying here, please let me out!’ I faint because I can’t breathe, and then I wake up.”

Assia tells me that she prays a lot and it gives her comfort. Back when her family were arranging her marriage, she says she had dreams about witches.

More recently, she has had a dream that gives her hope for the future.

“I dream I’m running, and the witches are coming for me. I’m scared and I’m screaming. I see a tent and I go inside. There is someone good there. I hug him as I cry. He asks me, ‘What is wrong my child? Don’t worry, nothing bad will happen to you’.”

“It is like evil has been left behind and something good will come my way. Now I understand this dream. My family is behind me. I’m not going back again, I am looking at the future now,” she says, adding that she recently received her final divorce papers and is excited about being able to make her own decisions and live her life on her own terms.

*Names have been changed to protect the individuals’ identities.