Tuesday, October 20, 2009

Women's mental health in Pakistan


ABSTRACT

In Pakistan, societal attitudes and norms, as well as cultural practices (Karo Kari, exchange marriages, dowry, etc.), play a vital role in women's mental health. The religious and ethnic conflicts, along with the dehumanizing attitudes towards women, the extended family system, role of in-laws in daily lives of women, represent major issues and stressors. Such practices in Pakistan have created the extreme marginalisation of women in numerous spheres of life, which has had an adverse psychological impact. Violence against women has become one of the acceptable means whereby men exercise their culturally constructed right to control women. Still, compared to other South Asian countries, Pakistani women are relatively better off than their counterparts.
Keywords: Pakistan, women's mental health, cultural practices, honor-killing, stove-burns, violence
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The women's movement in Pakistan in the last 50 years has been largely class bound. Its front line marchers voiced their concerns about issues mainly related to the urban-middle class woman. It is only in the last few years that rural women's issues like 'Karo Kari' (honour killing) and rape have been brought to light. Feudal/tribal laws of disinheritance, forced marriages and violence against women (acid-throwing, stove-burning homicide and nose-cutting) in the name of honour are being condemned by non-governmental organizations and human rights activists in the cities. Still a vast majority of the women in the rural areas and urban slums are unaware of the development debates.
The urban Pakistani women in many aspects are almost at par with the women of developed countries. In the rural scenario, the picture is entirely different. It is archaic, brutal and clearly oppressive. These trends often seep into the urban lives of women through migratory movements of rural population, which has yet to adjust to urban ways.
At the societal level, restricted mobility for women affects their education and work/job opportunities. This adds to the already fewer educational facilities for women. Sexual harassment at home, at work and in the society has reached its peak. Lack of awareness or denial of its existence adds to further confine women to the sanctity of their homes. Violence against women further adds to restriction of mobility and pursuance of education and job, thereby lowering prospects of women's empowerment in society.
At the family level, birth of a baby boy is rejoiced and celebrated, while a baby girl is mourned and is a source of guilt and despair in many families. Boys are given priority over girls for better food, care and education. Subservient behaviour is promoted in females. Early marriage (child-brides), Watta Satta (exchange marriages), dowry and Walwar (bride price) are common. Divorcees and widows are isolated and considered 'bad omens', being victims of both male and female rejection especially in villages. Marriage quite often leads to wife-battering, conflict with spouse, conflict with in-laws, dowry deaths, stove burns, suicide/homicide and acid burns to disfigure a woman in revenge.
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VIOLENCE AGAINST WOMEN
In Pakistan, there are cultural institutions, beliefs and practices that undermine women's autonomy and contribute to gender-based violence. Marriage practices can disadvantage women, especially when customs such as dowry and bride's price, Watta Satta and marriage to the Quran (a custom in Sindh where girls remain unmarried like nuns to retain family property in the family) exist. In recent years dowry has become the expected part of marriage. This increasing demand for dowry, both before and after marriage, can escalate into harassment, physical violence and emotional abuse. In extreme cases homicide or "stove-burns" and suicides can provide husbands an opportunity to pursue another marriage and consequently more dowry.
Women are confined to abusive relationships and lack the ability to escape their captors due to social and cultural pressures. Parents do not encourage their daughters to return home for fear of being stigmatized as a divorcee, which tantamount to being a social pariah. Moreover, if a woman leaves her husband, her parents have to repay him to compensate his loss. Cultural attitudes towards female chastity and male honour serve to justify violence against women.
Violence against women is very common in Pakistan. The violation of women's rights, the discrimination and injustice are obvious in many cases. A United Nations research study (1) found that 50% of the women in Pakistan are physically battered and 90% are mentally and verbally abused by their men. A study by Women's Division on "Battered Housewives in Pakistan" (2) reveals that domestic violence takes place in approximately 80% of the households. More recently the Human Rights Commission report (3) states that 400 cases of domestic violence are reported each year and half of the victims die.
In Balochistan and Sindh provinces, Karo Kari is practiced openly. A woman suspected of immorality is declared a Kari while the Karo is a man declared to be her lover. A woman suspected of adultery or infidelity is liable to face the death penalty at the hands of her husband or in-laws. Usually the killer goes scot-free as he is regarded to have committed the crime in order to retrieve the lost family honour, which a woman is expected to uphold at all costs.
Watta Satta is also a tradition in many families in Punjab and Sindh, whereby a girl is married off to her sister-in-law's brother. Such an arrangement often leads to a complicated situation, since a woman ends up becoming a mere object of revenge in the instance that her brother mistreats or physically abuses his wife.
Sadistic urges may be satisfied by a man by totally humiliating as well as disfiguring his wife. Women who are victims of this particular form of violence are usually young and attractive.
Hundreds of women are disfigured or die of stove-burns every year. The victims are usually young married women and the aggressors include husbands and in-laws. The motive behind stove burning is to get rid of the woman and remarry for more dowries or have an heir for the family.
Battering or "domestic violence" or intimate partner abuse is generally part of the patterns of abusive behaviour and control rather than an isolated act of physical aggression. Partner abuse can take a variety of forms, including physical violence, assault such as slaps, kicks, hits and beatings, psychological abuse, constant belittling, intimidation, humiliation and coercive sex. It frequently can include controlling behavior such as isolating women from family and friends, monitoring her movements and restricting her access to resources. Physical violence in intimate relationship is almost always accompanied by psychological abuse and in one-third to one-half of cases by sexual abuse.
A woman's response to abuse is often limited by the options available to her. Women constantly cite reasons to remain in abusive relationship: fear of retribution, lack of other means of economic support, concern for the children, emotional dependence, lack of support from family and friends and the abiding hope that the husband may change one day. In Pakistan divorce continues to be a taboo and the fear of social stigma prevents women from reaching out for help. About 70% of abused women have never told anyone about the abuse.
The psychological consequences of abuse are more severe than its physical effects. The experience of abuse erodes women's self-esteem and puts them at a greater risk for a number of mental disorders like depression, post-traumatic stress disorder, suicide, alcohol and drug abuse.
Children who witness marital violence face increased risk for emotional and behavioural problems, including anxiety, depression, poor school performance, low self-esteem, nightmares and disobedience. Boys turn to drugs and girls become severely depressed and sometimes totally refuse to get married. Children under 12 years have learning, emotional and behavioural problems almost 6-7 times more compared to children of non-abusive parents.
Health care providers can play a key role. They must recognize victims of violence and help them by referring to legal aid, counsellors and non-governmental organizations. They can prevent serious conditions and fatal repercussions. However, many doctors/nurses do not ask women about the experience with violence and are not prepared to respond to the needs of the victims.
A variety of norms and beliefs are particularly powerful perpetrators of violence against women. These include the notions that men are inherently superior to women, that it is appropriate for men to discipline women, and that women's sexual behaviour is linked to male honour. Nobody is expected to intervene on behalf of the victim as such issues are considered private matters to be resolved by the immediate parties themselves.
Programs designed to change these beliefs must encourage people to discuss rather than antagonize or alienate them by appearing to 'demonize' men. A good tool is to encourage people to develop new norms by using techniques such as plays on TV and theatre.

PSYCHIATRIC ILLNESS IN PAKISTANI WOMEN
A large study at Jinnah Post Graduate Medical Center, Karachi back in early 1990s (4) showed that twice as many women as men sought psychiatric care and that most of these women were between 20s and mid 40s.
Another 5-year survey (1992-1996) at the University Psychiatry Department in Karachi (Agha Khan University/Hospital) (5) showed that out of 212 patients receiving psychotherapy, 65% were women, 72% being married. The consultation stimuli were conflict with spouse and in-laws. Interestingly, 50% of these women had no psychiatric diagnosis and were labeled as 'distressed women'. 28% of women suffered from depression or anxiety, 5-7% had personality or adjustment disorders and 17% had other disorders.
The 'distressed women' were aged between 20 to 45. Most of them had a bachelor's degree and had arranged marriage relationships for 4-25 years with 2-3 kids, and the majority worked outside home (running small business, teaching or unpaid charitable community work or involved in voluntary work). Their symptoms were palpitations, headaches, choking feelings, sinking heart, hearing weakness and numb feet.
A study on stress and psychological disorders in Hindukush mountains of North West Frontier Province of Pakistan (6) showed a prevalence of depression and anxiety of 46% in women compared to 15% in men.
A study on suicidal patients (7) showed that the majority of the patients were married women. The major source of suffer was conflict with husband (80%) and conflict with in-laws (43%).
A study of parasuicide in Pakistan (8) shows that most of the subjects were young adults (mean age 27-29 years). The sample showed predominance of females (185) compared to males (129), and the proportion of married women (33%) was higher than males (18%). Housewives (55%) and students (32%) represented the two largest groups among females. Most female subjects (80%) admitted problems with spouse.
A four-year survey of psychiatric outpatients at a private clinic in Karachi (9) found that two thirds of the patients were females and 60% of these females had a mood disorder. 70% of them were victims of violence (domestic violence, assault, sexual harassment and rape) and 80% had marital or family conflicts.
CONCLUSIONS
Pakistani women are relatively better off than their counterparts in other developing countries of South Asia. However, fundamental changes are required to improve their quality of life. It is imperative that constructive steps be taken to implement women friendly laws and opportunity be provided for cross-cultural learning. Strategies should be devised to enhance the status of women as useful members of the society. This should go a long way to improving the lives and mental health of these, hitherto "children of a lesser God".

source:www.ncbi.nlm.nih.gov

1 comment:

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