The studies selected were scrutinized to form a data extraction template with all the relevant data such as author, publication year, study title, purpose, setting, sample characteristics, design sampling, main results, perpetuating factors, and recommendations wererecorded in Table 1. Results of the articles were analyzed, and themes emerged which included (a) Status of Women in Society (b) Gender Inequality in Health (c) Gender Inequality in Education (d) Gender Inequality in Employment (e) Gender Biased Social Norms and Cultural Practices (f) Micro and Macro Level Recommendations. The keywords used were “gender discrimination” “Pakistan" "women" "men" "adolescent"
Literature Review findings:
Most of the 15 studies included in the review were conducted in Pakistan however the most frequent study design was cross-sectional (n = 7) followed by narrative research based on desk reviews (n=6), one was a case study, and another was cross-country comparison by using secondary data. Four studies were conducted in Province Punjab, two studies were conducted in KPK, and one in both KPK and Punjab. Only one study was conducted in Sindh province the remaining used whole Pakistan in desk review. The maximum sample size in a cross-sectional study was (n=506). Six major themes have emerged from the review which included (a) Status of Women in Society (b) Gender Inequality in Health (c) Gender Inequality in Education (d) Gender Inequality in Employment (e) Gender Biased Social Norms and Cultural Practices (f) Micro and Macro Level Recommendations.
a) Status of Women in Society
The position of women in Pakistani society, is complicated and faces multidimensional inequality. 13 Women are seen as a sexual object who does not have any power and say in any matter, however, the male is seen as a symbol of power who has all the guardianship of female. Due to male ownership and the patriarchal structure of the society women are submissive to men, treated as property, their rights are ignored and she denied her own identity. Out of 15, seven studies reported that a female can not take an independent decision, someone decides on her behalf mainly father before marriage then-husband and son. 1,2,3,4,7,9,13 Out of 15 studies, 3 reported that women are not allowed to participate in elections or have very limited participation in politics, she faces several inequalities in terms of freedom and access to health, education, and employment. 5 A study reported that Pakistani women are facing structural inequalities and discrimination that cultivate community structure and the gross power harm the women’s life massively. 1 Woman seen in the stereotyped role even on media whose only responsibility is home and family nothing else. 5 She has less access and control over financial and physical assets 13 and mostly in low economic families went through verbal abuse and physical violence. 7
b) Gender Inequality in Health
Gender disparity in health is obvious in Pakistan, a woman is suffering from the neglect of health and nutrition. The different axes of structural violence and social power relations are controlling the women’s health, they don’t have reproductive health rights, appropriate prenatal and postnatal care, and decision-making power for birth spacing and to avail health care as a result maternal mortality and morbidity is high in Pakistan. 13 Women can not a decision on her health and children’s health; she doesn’t have access to proper and timely health services and health education, consulting doctors seen as taboo. 13,15 Many papers reported son preference and they treat favorable in intrahousehold level, uneven distribution of household food leads to several deficiencies that compromised women health. 1,2 Socio-economic class and poverty emerged as another major barrier to women’s health, therefore, many cannot afford promising health care and others have less access and mobility issues. Gender-based violence is also very common in Pakistan that leads to harmful consequences on the health and wellbeing of women. 8
c) Gender Inequality in Education
Low investment in girls’ education was reported in almost all the papers that were under review, the major reason for the low investment is low returns from girls, as the boy perceived potential head of the house and a bread-winner-to-be. 9,10,11,12,13,15 A case study reports that people believe that Muslim women should be brought up in a way that they can fulfill the role of good daughter, good wife, and a good mother and school has a “bad influence” to develop these characteristics in women. 12 Girls become less obedient, become evil and don’t take interest in household chores that is the primary responsibility of her. 12 Mostly Maulvis who seems strong authority in rural areas misused Islamic teaching and educate parents that through education women become independent so she will not be a good mother, daughter, and wife so these distort the teaching of Islam mostly obstruct girl’s education. Other barriers that play important role in low girl education are related to access and women’s safety, five studies reported that most of the schools are far away, due to long distances and co-education system that perceived as un-Islamic, parents are reluctant to send their daughters for education and they feel unsafe and threatened. 1,4,12,13,15 Poverty is another root cause of gender disparity in education, as parents cannot afford the education of their children and when there is a choice, choice goes to boys due to their perceived productive role in the future, as a result, more dropouts and lower attainment of girls particularly who are residing in rural areas. 3,7,8,9,11,13
d) Gender Inequality in Employment
Economic disparity due to gender inequality and lack of women’s participation is a burning issue in Pakistan. Women are almost 50% of the overall population, this huge number of populations is out of economic growth activities of the country. The low status of women in society, home care responsibilities, gender stereotyping, and social-cultural humiliated practices against women are the main hurdles in women’s growth and employment opportunities. Low education of females, restriction on mobility, lack of required skillsets, sex-segregated occupational choices are also big hurdles in the attainment of economic opportunities, the majority are out of employment however those who are in the economic stream are facing several challenges.3 Once the females are in the market they face discrimination in all layers of the economy, men have the hold on leadership positions, fewer females in decision making, low wages for females, fewer options to opt as professional workplace harassment, and unfavorable work environment that hinders to a long stay on the job. 1,3,7 Moreover, a study reported that in a patriarchal society the very limited number of females are in business and entrepreneurship the main hurdles are capital unavailability, lack of role models, gender discrimination in business, cultural and local customs, and lacking training and education. 7
e) Gender Biased Social Norms and Cultural Practices
The gender-discriminatory structure in Pakistani society has deeply rooted in social norms and cultural practices. Gender disparities occur at an intrahousehold level from the beginning of childhood in terms of food distribution, education, and health care rights and later during adolescence as early and forced marriages, denial of inheritance right, mobility restriction, abuse, and violence. 1,3,4,5,9,11 Birth of a boy child was celebrated, the girl seen as a burden, in a traditional stereotype gender role, household chores are a duty of female and that she cannot demand or expect any reward for it, on the other hand, male work has socio-economic value. 3,5,15 Likewise, the female has restricted power in decision making, as a cultural and social norm most of the decisions are done by male figures in a family or a leader of the tribe or community who is always a male, this patriarchal system is sustained and practiced under the name of Islamic teaching. 5,12,13 The prevalence of gender-based violence is also high, in the form of verbal abuse, physical abuse, sexual assault, rape, forced sex, etc., and consider a private matter which is not the concern of any court. 7 Another form of domestic violence is “honor killing” or the brutal murder of a female, Karo Kari,Siya Kari, Kala Kali, and Tora-Tora are different forms of honor killing all over Pakistan that is justified as killing in the name of honors or Ghairat. Similarly, women are seen as a commodity and faced other forms of gender-based violence that are bride price, Satta Satta, vani, marriage with Quran, swara, and kari that are prevailing in Pakistani culture. 1,4,8,14,15 Gender inequalities are also practiced by restricting women's political participation as a social norm. 13
f) Micro and Macro Level Recommendations
Positive change in gender disparity can only be achieved if women would have equal status and participation in all aspects of life that include, health, nutrition, education, employment, and politics. 1,3,4,8,11,15 It is crucial on a macro level as a society to eliminate discriminatory attitudes against women and pay attention to women empowerment at the policy level to legislation and then implementation to accountability. 1,3 For, this constitution of Pakistan should give equal rights to all citizens, and women should be educated about their rights. 1,4,5,9,13,14,15 To better the status of women the utmost intervention is an investment in girl education, until and unless women will not be educated, they cannot fight for their rights, gender parity only is achieved if educated women can participate in the decision making process of law and policymaking institutions that should be open, transparent, and accountable. 4,6,8,9,11,14Access to health care services is a woman’s right, proper education, nutrition, antenatal and post-natal care services, skilled birth attendants, and access and awareness about contraceptives to avoid early childbearing is important to improve the women’s health and to reduce maternal mortality.
Similarly, women should be given equal opportunities to take part in national development, and economic activities of the country to reduce poverty, this is possible through fair employment opportunities, support in women’s own business both financially and morally, equitable policies at the workplace, and uniform wages and salaries. Besides these female employees must be informed about their rights and privileges at the workplace and employment. 1,3,7,11 Policy actions should be taken to increase the level of women’s participation in economic growth and entrepreneurship opportunities, there should be active actions to identify the bottlenecks of gender parity and unlock the growth potential of social institutions. 6Another barrier for women empowerment is threatened and unsafe environment to thrive, there should be policies and legislation to protect women from harm, violence, and honor killing that ensure the health, safety, and wellbeing of her. 4,12
Education institutes and mass media are two powerful sources that can bring change in society. Govt must start a mass media awareness campaign on gender discrimination at home, education, and employment to break the discriminatory norms of patriarchal society and to reduce the monopoly of males in the marketplace. Parent’s education on gender-equitable practices is also important to bring the change at the microlevel, gender-equitable child-rearing practices at home including boys mentoring because they think discrimination against females is a very normal practice and part of a culture. 2
There is a scarcity of data on women’s participation and gender parity in health, education, and employment. There is a dire need to identify which type of institution has a greater effect on gender parity and type of intervention will be needed to reduce the gap and to see its link with growth analysis of the country. 6
Results of the Qualitative study design, primary data collection highlighted three major themes, as shown in Figure 2.
- Perception of women in society:
Perceptions expressed by the community were collected with regards to how women are perceived within society.
a) Woman as a sexual object:
Female participants highlighted that they were seen as “sexual objects” and “a means of physical attraction” which prevented them from comfortably leaving their homes, as family members also encouraged them not to do so. One female participant explained this further as, “we are asked to stay inside the house because men and boys would look at our body and may have bad intentions about us” (Adolescent girl, FGD in Astore). Male participants echoed this narrative as they agreed that women are judged by their physical appearance, such as the shape of their bodies. A male participant stated, “woman is a symbol of beauty and she's seen by the society as the symbol of sex for a man" (Male HCP, IDI in Gilgit).
b) Women as dependent beings:
One of the major study findings suggests the idea that women must be “helped” at all times, as they are naturally dependent upon other persons to protect them. One participant stated, “If a woman is alone, she is afraid of the man's actions” (adolescent girl, FGD in Lower Chitral). Some female participants, however, agreed with this statement to some extent because they felt that the male figure’s role is something women can utilize as a way to fit into society. Oftentimes, judgment may pass for women without an accompanying male. Participants put it as a wife not being able to survive without a husband and daughter not being able to survive without a father. One participant mentioned, “We are only allowed to go out when we have our father or brothers to accompany us” (Adolescent girl, FGD in Astore). `
Other participants agreed with the sentiment differently. Since it is implied that men become easily attracted to women, having a male figure with the woman will protect her from naturally prying eyes. However, if she cannot be accompanied by a male, she must protect herself by suppressing her natural state, a rather paradoxical situation. A male participant reported, “Women should cover themselves and stay inside the house” (married man, FGD in Nagar). One female participant verbalized, “We have breasts, and therefore, we are asked to dress properly". Another stated, “girls are supposed to dress properly and avoid eye contact with boys while walking on the road” (adolescent girls, FGD in Astore).
c) Women’s autonomy
Female participants, especially young adolescent girls, shared how restrictions governing their actions affected their livelihoods. Participants expressed how easy it is for males to gain permission and leave the house, while females often have a series of red tape in front of them. A young girl stated, “There are a lot of constraints when we see women in our culture. They must take care of everything at home, yet they must get everybody's permission to go five minutes away. Whereas a boy can go out of town and that too, without anyone’s permission. Looking at this, I wish I were a boy. I'd go wherever I want, and I could do whatever I want” (adolescent girl, FGD in Lower Chitral).
d) Males as an identity for females:
Women are often identified through a prominent male figure in their life and are not considered to have individual personalities and identities. A female participant mentioned that a “woman is someone having a low status in society. People know her through their husband or father name” (married women, FGD in Lower Chitral).
e) Child’s upbringing responsibility:
Culturally, it is expected of the female members in the family, often mothers, to rear children and take care of their upbringing. Male members, mainly fathers, are expected to provide financially and tend to the male children more than the female children. Female children are expected to learn from their mothers. These designations are deemed important because society would blame the designated parent for a child’s missteps, hence, tarnishing reputations. Yet, it seems like the mother takes a greater portion of the blame for male and female children, considering her role to raise the family within the household. A married woman explained that "If a girl does something, the mother is blamed for that. Even in our house, my mother-in-law talks to my mother if I argue or refuse for anything. This is the culture in my maiden home as well" (Married Woman, FGD in Nagar).
f) Unrecognized contribution of women:
Many female participants verbalized their concern for the disregard they receive from their families despite contributing significantly. Women who take on major roles in maintaining the household and family unit are not recognized for their efforts. By doing the cleaning, cooking, and other duties, they keep the family healthy and help keep costs low. One participant mentioned, “if women don’t clean the house, it is extremely dirty. If women do not rear children, no one else would do it. We do so much for the family” (married woman, FGD in Hunza).
g) Restriction for self-expression:
Both men and women struggle with self-expression as certain expectations for both genders hold people back from expressing their true selves. Men, for example, as indicated by participants, are expected to remain firm in challenging situations and not show emotion. Even in hobbies, participants shared that, parks and recreational activities are geared towards young boys and men, while girls and women are given more quiet and indoor activities. A female participant verbalized that, “boys have a separate area where they play cricket and football daily but for girls like us, only indoor activities are arranged” (adolescent girl, FGD in Gilgit). In places where males and females freely mix or live closely in one area, people also often find themselves taking extra precautions in their actions, as to not be seen as disgraceful by the community. One female participant reported, “two communities are residing in our area. Events for females, such as sports day, are very rarely arranged. Even then we cannot fully enjoy because if we'll shout to cheer up other players, we would be scolded as our community is very cautious for portraying a soft image of females of our community” (adolescent girl, FGD in Gilgit). Another participant stated that, “after prayers, we cannot spend time with friends as people would point that girl and say that she always stays late after prayers to gossip when she is supposed to go home” (adolescent girl, FGD in Gilgit).
h) Deprivation of women’s rights
A woman's liberty has always struggled to be accepted as power struggles within communities often favor males, thus, women are given lower status. Participants highlighted that, in general, men are seen as superior to women. One participant stated, “men are the masters of women…” (FGD married women Gilgit). On the other side of the coin, even though men suppress female liberty, women often do not know what their rights would be, leaving them vulnerable to deprivation. A female participant explained that “women do not dominate society that's why people take away their rights from them" (married woman, FGD in Lower Chitral). Female participants also shared that they see men as having stronger and more dominant personalities, making them better suited to decide on the provision of rights, medical care, making an income, gaining life opportunities, and reproduction. One female participant verbalized, "If there's one egg on the table and two children to be fed, it is considered that males should get it as it is believed that males need more nutrition than us" (HCP, IDI in Upper Chitral). Another reported that “There is a lack of equal accessibility of health care facilities and lack of employment equality for women” (HCP, IDI in Upper Chitral).
Figure2: In here
Theme 2: Perception of men in society:
a) Male Dominance:
Inferiority and superiority and common concepts are seen in Pakistan's largely patriarchal society. This allows men to be seen as the dominant decision-maker in the family and as the sole breadwinner. Women, however, are caught in a culture of subordination to men with little power over family and individual affairs. A female participant said, “if we look at our society, men are dominant. They can do anything while a woman cannot, as she is afraid of the man's reactions [gussa] and aggression” (adolescent girl, FGD Lower Chitral). While another reported, "In our society, husband makes his wife feel his superiority over her and would make her realize that it is him, who has all the authority and power” (married woman, FGD at Lower Chitral).
b) Inclination towards the male child:
There is often an extreme desire for the birth of sons over daughters, which adds to the culture of gender discrimination in Pakistan. Male children are important to the family as they often serve their parents financially, when they are able, even once they are married and up until the parents reach old age. This is one of the main reasons that parents are more inclined towards the birth of a male child rather than a female child. Hence, why education is also more prioritized for male children. For women, female participants expressed that their desire for a male child is to appease the husband’s family and reduce the pressure on her to fit in. According to a female participant, “when my son was born, I was satisfied as now nobody would pressurize me. I noticed a huge difference in the behavior of my in-laws after I gave birth to my son. I felt I have an existence in their family” (married woman, FGD in Astore). Participants highlighted, that, women who have brothers are often more protected as brothers create a sense of intimidation, a considerable benefit for women. According to a young participant, "brothers give us the confidence to move within the society because people think before saying anything about us" (adolescent girl, FGD in Astore).
c) Lack of communication of husband with wife:
Married couples often lack communication skills as they rarely discuss important matters with each other. Men often choose not to share issues with their wives as they believe that they are not rational enough to understand the situation. A male participant stated, “Women are so sensitive to share anything. They can only reproduce and cook food inside the home” (married man, FGD in Skardu).
d) Men are protectors
Many female participants verbalized their consideration of men as protection, as they take on the heavier burdens of finances and public security. They feel confident in a man’s ability to contribute to their livelihoods in those ways. One participant mentioned, “We go out when we have our father or brothers to accompany us” (Adolescent girl, FGD in Astore). Another highlighted, “men are our protectors. We can only survive in the society because of them” (Married woman, FGD in Astore).
Theme 3: Factors reinforcing gender discrimination.
a) Influence of generation gap:
With a tight-knit family situation and collective mindset that Pakistanis value, differences of opinion exist within family systems, and between different generations, which can affect how one views gender. Participants highlighted the role of the older paternal matriarch who often favors their sons and male family members. Daughter in-laws, as expressed by married women, often struggle to find their voice in this situation. One participant mentioned, “we don’t take decisions on when to have the child or what method needs to be used for family planning. Our mothers-in-law decide and we have to obey” (married woman, FGD in Astore). The family system that often includes three generations living closely, allows traditional norms to carry forward, as opposed to a typical nuclear family that may fizzle out these ideas. This includes considering attire, conduct, and relationships. One participant mentioned, “I live with my mother-in-law. I have to cover my head whenever I had to leave the house. My sister-in-law lives separately with her husband, and she does not have to follow these rules” (married woman, FGD in Nagar).
b) Media influence on gender discrimination:
Characteristics perpetuated through media also play a vital role in the association of stereotypes to males and females. Advertisements, for example, pictorials represent young girls and boys. However, advertisements for activities such as washing powders show young boys playing happily. But advertisements for cooking oils and spices usually show young girls helping their mothers in the kitchen, with men often enjoying something else or are nowhere to be seen. These 15 seconds are impactful in perpetuating gender conduct solely for societal acceptance. One participant verbalized, “every household has a radio, on which different advertisements are going on. People get messages through media” (married man, FGD in Sindh).
c) Gender Discrimination in Healthcare:
Results showed the need for increased attention towards SRH issues, especially for males. Participants felt disregarded in terms of their health because they did not have services catered to them. Oftentimes, only female HCPs are present in facilities and many male participants felt discomfort while sharing SRH related concerns with them. One participant stated, “Males usually do not visit the clinics as they feel uncomfortable sharing their SRH concerns with LHVs. Therefore, they send their wives and we counsel them” (HCP, IDI in Gilgit). Hence, any SRH information given to males is often second hand where they may not get all the information they need. Since they are getting some information, they do not feel the need to go in person which can cause treatment delays if they have a concerning SRH issue. Another female participant reported, "Males don't visit our clinics because they feel shy in discussing SRH issues with females due to cultural concerns. Sometimes, when their wives tell us about those issues, we realize that the case has worsened and ask them to visit the hospital in the main city" (HCP, IDI in Gilgit).
d) Gender Discrimination in Schools:
Adolescent boys shared their concerns about schools not meeting their needs in terms of sharing information on SRH. They explained that girls often attend SRH sessions on sexuality, breast cancer, and menstruation, where boys do not have the same access to SRH awareness sessions. A young boy stated, "We also go through changes during puberty, but no one teaches us about it at school" (Adolescent boy, FGD in Ghizer). Therefore, they look to outside sources such as friends and the internet to answer their questions, which can often result in misinformation. One participant mentioned, “I only discuss issues related to SRH with my friends. But I mostly search on the internet” (Adolescent boy, FGD in Lower Chitral). The authenticity of each source can be questioned, thus, indicating the need for adolescent safe spaces for both adolescent boys and girls to speak about their SRH questions and concerns. Another participant explained, “separate spaces are suitable for both girls and boys because both can freely express themselves” (Adolescent boy, FGD in Ghizer).
Theme 4: Gaps & recommendations from the eye of participants/community/society:
Several challenges pertain to the issues outlined in this study of gender discrimination. A lack of female autonomy and empowerment were recognized as critical reasons for the disregard of women in society and discrimination against them. They do not have the means to participate in society, nor are they allowed to speak against traditions. Therefore, attention must be centralized around these concepts to increase female autonomy and decision-making roles, while allowing them to negotiate their capacity in a role with other people. One of the major contributors to this is male dominance, which must be brought down to build up women. The male role is often overbearing, yet they remain absent from their women’s life. Women life is on their female relatives, further exacerbating the effects of opposing social roles held by men and women. To reduce this, communication is key between spouses and family, and community members surrounding issues that impact the communal livelihood.
Gender discrimination affects both the micro and macro levels of Pakistani society, kept in tow by established institutions. Therefore, public systems such as media outlets, healthcare practices, and schooling systems, must exhibit a change in the way they conduct affairs. Thus, they must include gender equity and equality that eliminates gender discrimination. Perpetuating stereotypes, such as allowing boys to be active outdoors and forcing girls indoors on television advertisements and in schools, only feed a culture of gender discrimination. Depicting these narratives makes it harder for individuals to change their situations and change the perspectives of society. In terms of SRH, HCPs play an important role in acquiring knowledge and training to best treat male and female patients. Both males and females become neglected in different SRH areas about a lack of resources, staff, and attention. Schools and communities also play an important role in sharing SRH knowledge with young people. Once they are knowledgeable, you educate generations to come and generations before that may be unaware of the challenges that individuals face such as puberty, pregnancy, and motherhood. Thus, authentic information sharing can be taught through certified curriculums in schools, furthering the education of communities and using knowledge acquisition to close the gap between male and female educational levels.