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Review

Tazeen Ali,¹ Rozina Karmaliani,¹ Rida Farhan,² Syeda Hussain³ and Fatima Jawad¹

¹School of Nursing and Midwifery and Community Health Sciences, Aga Khan University, Karachi, Pakistan (Correspondence to: Tazeen Ali: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). 2Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan. 3Liaquat National Hospital and Medical College, Karachi, Pakistan.

Abstract

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)

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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.

Results

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).

Discussion

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.

Conclusion

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

Résumé

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

الخلاصة

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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