Domestic violence is highly prevalent in Pakistan. This paper proposes the strategies based on literature review, for the prevention and control of domestic violence. The reported causes for domestic violence against women include women's low educational levels, low empowerment, and least opportunities to indulge in political activities; wrong interpretations of religious, traditional and cultural norms in the society; poverty; dowry system; women's suppressed autonomy and males' addiction to alcohol. Through this article, we have attempted to highlight the need to recognize the domestic violence against women as an important issue and to enhance educational and health facilities for the prevention and control of violence with combined awareness programs including non governmental organizations through stake holders. Furthermore, comprehensive laws need to be developed and enforcement against dowry and alcohol abuse is required in low income countries like Pakistan.

Domestic violence against women in developing countries is budding as a serious concern for public health workers Women are subjected to various forms of violence especially in less developed societies. World Health Organization (WHO) defines domestic violence as "the range of sexually, psychologically and physically coercive acts used against young and adolescent women by current or former male intimate partners."1 There are many forms of domestic violence against women ranging from psychological abuse in the form of controlling behaviour, economic abuse or pressures and social isolation; physical in the form of torturing, beating or slapping, and sexual abuse in the form of forced sexual intercourse.1-3 According to one study conducted in Canada there are restrictions on activities of women from their partners, which could be the vulnerability towards domestic violence in the later stages.4 The traditional, behavioral and social norms that are often prevalent in an Islamic state as Pakistan, creates more difficulties for women. The prevailing systems of Purdah and Izzat are misused to push the social isolation of women and thus, women are more confined to their homes, they are not allowed to go out side, or even to seek any medical help or meet any relative.5 Even though they are aware about those restrictions, still they are unable to come forward to prevent themselves from domestic violence as either they are too young, weak, ill or they believe the hot-tempered behaviours of men as normal.6 Furthermore, in Pakistan majority of women consider the behaviours and actions of men in societies as inherited normal actions which really make them more vulnerable to any type of abuse in their home. Other prominent points for domestic violence in the Pakistani culture are societal pressures, imbalance of power between men and women which keeps women as followers of those rules and regulations of society and defiance to follow those rules leads to penalties like acid throwing, honour killings etc. In 2002 a research on domestic violence, showed that nonconsensual sex was reported by 98 (46.9%) of the women interviewed, in which only 43 (58.1%) reported only to their sister. After reporting, only 54.8% had a temporary decrease in the violent behaviour from their husbands.7 Furthermore, women always fear paybacks, have concerns about the future of their children, and even more they have lack of any other moral support like friends.7 In case a woman wants to approach any social support, she has to face rejection and non supportive response from her own community and parents. Women who reside in rural or tribal areas are subjected to higher murder rates.6

Domestic violence against women is prevalent not only in developing countries but, it also exists in developed societies. According to WHO 2002 report in 48 different countries, 10% to 69% of women were being physically hit by their intimate/partner at some point in their lives. Researches have showed that physically violated women report psychological and mental health abuse and one-third to over half of cases also reported sexual abuse.1 In Colombia, violence can take the form of marital rape, and is the leading cause of death and also contributes to 25% of the disease burden.8 In United Kingdom (UK), domestic violence is reported in every one out of four women.9 Further, an Indian research showed that women married to husbands who were more educated than them (7th class or even more), experienced significantly higher risks of coercive sexual intercourse. In case women show reluctance for forceful sexual activities, they are deprived of their basic needs such as clothes, proper food, and shelter. In order to fulfill their needs women have to be submissive for any sexual activity at any time.10 An Egyptian study showed a high prevalence rate of physical violence (34%) over women by their partners. About 47% of women were physically abused (beaten) in the last year. Furthermore, those who were physically abused, 47% of those women were not permitted to participate in recreational activities. Additionally, 16% of women were not allowed to go to the markets.11 According to a Canadian study, report of violent activity was limited to about 17% of the total 8771 numbers of participants in that study.4 Haitian women reported 16.4% of physical intimate partner's violence.12 Even in United States, one-fifth to one third of all the women (>12 million) are assaulted physically in their lifetime by either a current or former partner.13 Studies from India have shown meager dowry brought by the wife to be associated with considerably higher consequent risks for domestic violence.14

Domestic violence is now more of an emerging topic for researchers as it widely prevails in Pakistan, not only in rural areas but also in more developed cities like Karachi. A study in Karachi showed that 34% of the interviewed women when asked about domestic violence reported physical abuse.15 Another study in Pakistan estimated that 99% of housewives and 77% of working women are beaten by their husbands.7 Other than physical abuse, another study showed that all of the male participants in the interviewed sessions admitted shouting or yelling at their wives, including while they were pregnant.16 Moreover, another study conducted in Karachi, Pakistan in 1999 reported that about thirty four percent women were being physically abused by their husbands; among them 50% were abused in pregnancy too. This abuse was higher when women were anxious /depressed and wanted to report or seek any kind of help.15 One study conducted in Pakistan concluded that 32.8% respondents admitted to ever having slapped their wives and 77.1% admitted to ever engaging in a non-consensual sex with their wives.17 It has been reported in previous researches on domestic violence from the perspective of men, with a sample size of seventy, in which all respondents admitted to ever verbally abusing their wives and more than a third admitted to ever engaging in non-consensual sex with their wives.18 Another study coded the percentage of domestic violence in Pakistan as 65% (physical violence), and almost one third (30.4%) of those reported sexual violence both often leading to serious injuries, which required emergency medical attention.19 A comparative study over physical abuse of women in Pakistan concluded that 22% of women in Karachi said they were slapped and 11 percent of them mentioned forced sexual intercourse in which only 10% of women reported to seek medical help.20 According to Human Rights commission of Pakistan (HRCP), the finding of one study conducted in Pakistan shows that marital rape or nonconsensual sex was reported by 46.9% of the women interviewed out of seventy seven. Another study they reported, conducted on seventy Pakistani men, in which 77.1% of men engaged in the non-consensual sex with their wives.21

Domestic violence against women is found in many forms of physical abuse in Pakistan. This includes burning women using kerosene oil or petrol and acid throwing which is prevalent in urban as well as rural areas.21 Moreover, not only intimate partners are involved in acid throwing or burning but, in-laws are also found to be involved in this act in Pakistan. According to Human Rights' Commission of Pakistan (HRCP) report, a study conducted by a private organization reported over 15 acid attack cases in Bahawalpur from January till June 2004, of which two victims died while others suffered acute injuries, including permanent loss of vision. Around 400 women fall victim to acid burns each year, often inflicted by their husbands or in laws. And in the last 10 years, 15,000 cases had been reported throughout the country.21 Domestic violence is at an alarming stage when the data and survey reports are analyzed and many women in Pakistan are facing all forms of abuse; physical, psychological and sexual in both rural and urban areas.

Violence experience might cause serious conditions such as injuries, fractures, wounds, skeletal deformations, gastro-intestinal problems, abdominal injuries, vaginal lacerations, forced abortions and chronic pain syndromes, sleeping disorders, sexual dysfunction, genital infections, HIV-infection, post traumatic stress disorders (PTSD), generalized anxiety disorders and serious depressive conditions and also suicidal thoughts.22,23

There are many common precipitating factors which are responsible for domestic violence in Pakistan. Some example are: domestic violence against women due to daily conflicts, family related problems, disagreements between women and men on any decision, choice preferences, conflicts of the two genders, etc. All of those factors are quite broadly discussed in majority of studies as they are globally applicable to any social make up. In Pakistan, there are some distinguished factors which make women prone to domestic violence like women's low educational levels, least participations in political activities due to low empowerment, existing misconception about Islamic thoughts and traditional norms, misuse of women in the name of honor justifying honor killing, low socioeconomic levels and poverty, existence of unjust traditional dowry system in the society, the common beliefs in the inherent superiority of males ignoring the women's autonomy, and even the alcoholic addiction of men which is not even allowed in Islam.

In Pakistan, due to lack of education and less awareness, the basic right of autonomy of women is being suppressed not only by their partners but also by the society. Many studies have been conducted on social status of women in Pakistan, which shows that there are limited opportunities in educational fields as well as employment and the traditional norms have restricted their mobility and basic right of autonomy of women in Pakistan.24 It is documented in the constitution of Pakistan that, "All human beings are born free and equal in dignity and rights. All citizens are equal before law and are entitled to equal protection of law. There shall be no discrimination on the basis of sex alone; Steps shall be taken to ensure full participation of women in all spheres of national life". Articles 1, 2, 7, 16, 21(2), 25(2) and Articles 25, 27, 35, 37.21 Due to in adequate administrative measurements, majority of women are not allowed to get educated, have other outdoor activities or work for any volunteer welfare organization. That adds to one of the factors for domestic violence, as women are not only unaware of their basic rights and roles as defined by the constitution of Pakistan but, they have also limited access even to report any type of abuse against themselves. Based on the raised concerns by Non governmental organizations about female education, Government of Pakistan has established some schools and other learning centers for women within the community but, due to social restrictions women are not able to utilize these amenities like health, education or any other recreational activities. The reported literacy rate of Pakistan in 1997-98 was estimated at 40 % in which 51% is for males and 28 % for females; 60% in urban areas and 30 % in rural areas.21,24 Women with a good education are more likely than uneducated women to be exposed to mass media, to have broader social and cultural networks, and to have equal as well as more communicative relationships with their husbands.24 Over all education enables women to be confident in reporting, struggling for their rights and be aware of their surroundings

Almost all of Pakistani social make ups are male dominant and that is the main factor for unequal power distribution of two genders. As it is a male dominant society, men carry out any type of violence against women as a means of suppressing them and giving women lower ranks in society. Due to their low empowerment status in the society, they have a lack of control over possessions or they have no participation in group-based savings and credit programs which is another factor associated with domestic violence. At times social support from organizations are present in some social systems but due to activity limitations of women, out side movements and contacts with others leads them to be more in isolation in their societies.7 Though due to government efforts, women got opportunities to participate in local body elections. In the past year however, due to some religious groups' announcements, tribal and Jirgas' (group of leaders) decisions, they were not allowed to be a part of local government. This was a golden opportunity for women to take part in policy and reform making and to raise the issue of domestic violence not only at local level but also globally. Jirgas at various union councils had declared earlier that women would not be allowed to caste a single vote and as result more than 50 percent women's reserved seats on local government councils in the NWFP also remained vacant. The Aurat (women) Foundation warned that women, especially in the rural areas of Punjab and NWFP were facing resistance in contesting for by-elections. No official action was however taken to ensure women would be able to exercise their right to vote. Even though 22% of seats in the lower house of parliament and 18% of seats in the upper house are held by women, this number is not sufficient for them to make any reforms or have some support by amending any part of the constitution. However, tribal leaders, Jirgas, cultural and societal runners almost comprises completely of men, and they have made their decisions on their own regarding the rights of women which have already caused suffering for women not only in terms of domestic violence but, also in terms of social neglect.21 Furthermore, women who are struggling for empowerment are not only restricted by their partners but, also by their parents and still in case if a woman gets success she faces tough circumstances from family and society.7

In Pakistan, though some cultures and social systems consider women as their sign of honour and respect at the same time they restrict women from any type of external activities. Purdah system (veil for women) and Izzat (protection of honor) of women by their partners, parents, brothers and in-laws implies more restrictions for the females. The rationale behind is to provide security to the women, which has been advised by Islam. However, Islam never restricted women's education or empowerment or their freedom.16,21 Thus so called behavioural norms that are seen living in a fully independent Islamic state like Pakistan, creates more difficulties for women. For instance the prevailing system encourages the isolation of women and thus, women are more confined to their homes and they are not allowed to go out side, meet any relatives, or even seek any medical help. Likewise, it is reported in a study that reproductive health problems like family planning issues, having concerns for avoiding pregnancies and risk of transmissions of sexually transmitted diseases also put women at risk for domestic violence.16 This leads to women's role as a subordinate to men and their role is confined only to the household chores and child care. In the Holy Quran Allah says, "Men are the protectors and maintainers of women, because Allah has given the one more (strength) than the other, and because they support them from their means" (4:34) and in another place Allah ordered, "And live with them with kindness and equity"(4:19). Prophet Mohammad (PBUH), had also reminded Muslims in a Hadith that, "The best among you is one who is best towards his wife".18 The Islamic laws and teachings related to the rights and status of women are not interpreted accurately by different social and community settings whereby, it is not understood by any one which law is applicable where. Men often confuse social and cultural norms with Islamic perspectives and mix up all the religious teachings with their own innate actions, which make Islamic laws and teachings unclear or almost absorbed. In the end it is the woman who has to face the consequences of all those norms and man made laws of which domestic violence is most prominent. Furthermore, the governments have not yet made any country wide committee to decide consensually about certain practices which are mixed up throughout the country with cultural norms. Due to this the whole country is running through blind perceptions of traditional and cultural norms which they perceive as an Islamic way of living.21

Many researches have found that poverty is a contributing factor for domestic violence against women particularly in Pakistan, where men are primary bread earners. As it is expected from men to be more economically productive and they have to give economic support to their homes, in case of failure to accomplish that goals they get frustrated and as a result women have to face the abuse. Several studies have shown that demographic factors such as age, number of living male children, and extended family residence are associated with risk of domestic violence because the larger family leads to more expectations from men.11 Conflicts occur if house hold expenses, children education, other expenses are not being paid by the partners. This also results in violence (both verbal and physical) against women.

Dowry is an amount of cash or in the form of other materials like jewelry, household items and equipments etc, made to the groom's family to marry away a daughter and it takes different forms in different cultures through out the world including Pakistan. Additionally, the size and amounts of the dowry is found the most common reason for disputes, with the groom's family demanding more than the bride's family can offer, resulting in persecution of brides which leads to all types of domestic violence.25 The dowry related issues irking domestic violence against women is not only present in rural and tribal areas of Pakistan but, also in many urban families of cities like Karachi.

In The Holy Quran it is ordered to all Muslims: "And give women (on marriage) their dower (Mahr) as a free gift; but if they, of their own good pleasure, remit any part of it to you, take it and enjoy it with right good cheer." (An-Nisa':4).26 This mean that Mahr or dowry is not so much strictly ordered and it is not obligatory to pay money or any thing to women moreover, in Islam dowry is referred to as a gift. In Pakistan, many cultures consisting of the system to demand dowry from the bride's family are actually in contrast to the Islamic belief. The bride is forced to pay a negotiated amount to the groom unless the man chooses not to take it, and dowry is purely a cultural norm set by the people, not by the religion.

Prophet Mohammad (PBUH) said, "The best of the marriages is one which is least burdensome in the financial sense to the families of the bride and the groom".26 Though dowry has been never suggested by Islam, it is present and women are suffering as a cause from domestic violence.

Low empowerment and women's reduced autonomy is a contributing factor for domestic violence in Pakistan and studies show that lower socioeconomic status, females' low education levels and lack of opportunities are core factors for low empowerment.14 Due to low education, women in Pakistan are not considered to be competent enough to participate in decision making thus, decisions are taken by the male members in the woman's life about issues even pertaining to her own life such as, about females work, marriages, major purchases, number of children, and even the decisions regarding female's education.24 In Pakistan, the number of women in decision making posts is thus; lower than in any other country in the subcontinent.24 Even if a woman wants to seek any medical help in order to avoid pregnancy due to her illness, the decision is only taken by men and if she insists she is subjected to physical abuse. Additionally, men also display and abuse the high rank and power given to them by society as a head of the family.16 Going through the studies of different cultures in Pakistan, women are not considered for equal opportunities in making any decision not even at the time of their marriages or any other decision related to them.

Though Pakistan is an Islamic country, a vast majority of men are addicted to alcohol or other substance abuse and addicted intimate partners are mostly seen as perpetrators for domestic violence against women. Alcohol utilization is another triggering factor for the violence, as it inhibits judgmental capabilities, decreases the abilities to understand social norms and roles. Excessive alcohol and other drugs' consumption have also been noted as a factor in provoking aggressive and violent male behaviour towards women and children. Even when the wife points out the hazards of alcohol to her partner, it often results in violence. The main implication made by males justifying their violent behavior towards their women is that the religion gives them such a liberty, which is a totally falsified belief as quoted by Qura'an. In fact, their behaviour regardless of which gender they belong to is unjustified in terms of true Islamic teachings. Again apart from the fact that alcohol is prohibited in Islam because of the untoward effects that it causes, it has been found as an abuse, especially against women in their home.

Public health interventions for domestic violence can be given through three traditionally characterized levels of prevention. Primary prevention in which certain steps are taken to prevent violence before it occurs. This may include awareness programs both for women and other people to prevent domestic violence. Secondary prevention which is focused more on instantaneous response to violence, which also includes care before accessing to hospitals and emergency room care depending on the type of violence. Nurses particularly can play the best role in the initial assessment, and providing psychological support to patients to prevent them from psychiatric disorders such as depression. The third type is Tertiary prevention which is focused on long-term care of the victims, such as rehabilitation and reintegration, and measures to decrease the chances of reoccurrence of any type of further abuse on women.1 Over all, there are three types of preventive measures related to help victims in their serious situation when they are subjected to domestic violence. Further more, interventions should be designed to work with women - who are usually the best judges of their situation - and to respect their decisions.

1. There is a need of recognition at the national level of the issue. Though government of Pakistan has considered this issue but, consistent follow-up is mandatory.

2. There should be enough educational programs in all societies and cultures, both for women and men at the same levels.

3. There should be enough opportunities of employments and participation in political parties along with security and safety for women and the seat allocation for recruitments of both genders should be considered on equality grounds. More funds should be allocated to women's development in the country.

4. Government should make it compulsory to incorporate the programme in all health care facilities of Pakistan for proper screening of all types of domestic violence and abuse. Adequate emergency treatments with rehabilitative measures should be provided. All health professionals should be made aware of domestic violence, its factors, possible treatment and moreover the preventive measures. Along with medical facility, government also can have crisis centers for violated women in the main health care centers like Rural Health Centers (RHC), Basic Health Unites (BHU) and tertiary hospitals throughout the country. Furthermore, specialized health care professionals should be introduced in the crisis centers who could easily handle any case. All of the facilities should be easily accessible to all women in any setting through out the country.

5. Awareness programmes should be conducted for both women and men. It should be done by using the resources like nurses, doctors and psychologists, working under governmental and non-governmental organizations (NGOs). This could easily be done either by direct or indirect teaching. The direct methods would include one to one teaching, counseling, or group based teaching. Indirect methods would involve the use of media, pamphlets, role plays, drama and talk shows.

6. There should be religious definitions of the basic rights of women like autonomy and freedom in Pakistan on federal levels and the government needs to evaluate all of the basic rights of women. For this a central committee can be made which should include religious leaders, Ulema, and scholars who can consensually define the rights of women in the lights of Islamic teaching and literature. But, for this the other ethnic and minority religious groups should be considered when finalizing any package for basic rights of women. Government should also ensure that every citizen of the country is following the main themes defined by the religious committee.

7. Government should to make sure that women have enough access to reach any political opportunity and there should be a training programme available for their capacity building on politics.

8. There is also a need of reforms in the police departments and judicial processes which place constraints on women from accessing justice. Women police should be trained to deal with women facing domestic violence so that women could feel safe and protected. Indeed the presence of a nurse or doctor in the police department team would facilitate a pleasant environment for the sufferers.

9. Alcohol production, transport and drinking should be banned as Pakistan is an Islamic country and in Islam alcohol is strictly prohibited. Government can take help from social groups, religious leaders and even they can strengthen their law and order situation to decrease alcohol and other addictive material usage in the country.

10. Exclusive celebrations of marriages were banned in the country some years ago and that worked very effectively through the country. Similarly government can also ban weighty dowry systems in different cultures, and fix certain amount in the lights of Islamic religious teachings which should be followed in any culture and in any region of the country.

11. Government should develop recreational programs like family parks, and other entertaining places where women along with their family can enjoy and relax.

Domestic violence is prevalent in Pakistan at an alarming rate. Women are the sufferers and are subjected to physical, psychological and sexual abuse in their home by partners, in-laws and in some circumstances by their brothers and parents. The factors associated with domestic violence in Pakistan are low-economical status of women, lack of awareness about women rights, lack of education, falsified beliefs, imbalanced empowerment issues between males and females, male dominant social structure and lack of support from the government. Integrated supportive services, legal intervention and redress should be made available in situations of domestic violence. Support and help for women to rebuild and recover their lives after violence, should be a part of the intervention strategy, including counseling, relocation, credit support and employment. In order to prevent women from domestic violence and provide them medical as well as judicial and legal support, new plans and interventional maps should be made in the societies in collaboration with health team members, religious and societal leaders, NGOs, police department and people from other similar groups. This strategy implementation should be enforced.

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