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SUICIDAL IDEATION IN VICTIMS OF SEXUAL ABUSE IN KHYBER PAKHTUNKHWA, PAKISTAN

This study focuses on suicidal ideation in victims of sexual abuse. Drawing upon semi-structured interviews of thirty victims of sexual abuse in Khyber Pukhtunkhwah, Pakistan, this paper discusses the theme, i.e. domestic violence, including indiscriminate sexual abuse and the abhorring crime of incest, which remains hidden due to aggressively upheld patriarchal norms of women exploitation. The interviews conducted at six different locations, present women's narratives of their untold plight for the first time. The findings of this research show that among the respondents, only those women had strong suicidal ideations who were the victims of incest. Irritation, aggression and self-deprecating behaviour were strong symptoms of their suicidal temptations. Pain, physical and emotional, caused by overwhelming stress in the form of familial and social hatred, social disconnectedness, burdensomeness and the previous history of violence were the main factors that highly escalated their risk factor in committing suicide.


Introduction
Annually recorded deaths in the world caused by suicide are around one million (Bashir et al., 2014). These figures have increased due to the involvement of youth suffering from psychiatric disorders and other mental illnesses caused by traumatic incidents. On average, there is one death caused by suicide every 40 seconds and one suicidal attempt in every three seconds around the globe (WHO 2012; Radhakrishnan and Andrade 2012).These suicidal rates vary from country to country because of the differences in the determinants of suicidal behaviour. In most of the developed countries, suicidal behaviour, including ideation and attempts, is caused by psychiatric disorders; while in developing countries, issues in interpersonal relationships trigger this behaviour (Sualeha et al. 2018). Suicide is an act of self-annihilation, including all acts of poisoning and deliberate self-injury. The aim of such acts is not always to harm oneself but rather to take revenge or express huge distress, grief or rage. Revenge is usually taken by causing extreme distress or grief to others, and suicide is an act that causes such extreme distress to others, mostly close relatives or friends.
Road accidents are the first leading cause of death (WHO 2018), while suicide is the second leading cause of death worldwide among youth whose age ranges from 15 to 29 years (Christopher et al., 2017).Such acts of deliberate self-harm happen more among females than males. Females, belonging mostly to economically disadvantaged families and groups with less education, who experience physical and sexual violence, are comparatively more vulnerable to suicidal behaviour (Bashir et al. 2014). According to Aaron et al. (2004) in South India, the average rate of suicide for girls is 148 per 100,000 and for boys it is 58 per 100,000. This difference between boys' and girls' suicidal behaviour is attributed to several factors, particularly premarital sex and lifetime experience of sexual and physical abuse. Similarly, in Bangladesh, he rate of suicide among females is 50% higher than among males (Christopher et al. 2017). This difference is accountable -to females experiencing sexual and physical violence. In Brazil, experiencing sexual violence is one of the leading causes of suicidal behaviour among females (Antighini et al. 2001). In Ethiopia, 6% of females who attempted suicide were victims of sexual abuse (Mulugeta et al. 1998). Sexual victimization at an earlier age leads to suicidal behaviour in adolescence.
In the context of Pakistan, suicidal behaviour is still an under-researched and under-studied subject. Though suicidal behaviour is a deliberate public health problem in Pakistan, until the recent past, there were no official statistics available on suicide. In 2012, 13,377 suicides took place in the country, 7085 females and 6021 males (WHO 2017). According to WHO (2002), in Pakistan the estimated number of incidences of selfdestruction ranges from 13,000 to 27,000 annually. In 2009, 683 females reportedly Suicidal Ideation in Victims of Sexual Abuse 43 committed suicide in the country for reasons not known (Naveed et al. 2017).Although, contributing factors to suicidal behaviour among females are various, the most significant factors are the associated stigma and social ostracization of females victimized sexually (Murad et al. 2009;Naveed et al. 2017).

Defining suicidal behaviour
Suicide means a felonious and intentionally initiated act of self-annihilation (Stedman's Medical Dictionary 2006;Oxford Dictionary 2010). In legal studies, suicide is defined as a voluntary act of self-murder. Suicide is a multi-dimensional behaviour (Silverman et al. 2007a) that inculcates three different aspects of self-annihilation: the ideation, the attempt and death. Ideation, an invisible process that precedes attempt, is totally a mental construct, caused by different socioeconomic and socio-psychological factors. Ideation is further divided into two main categories: strong and moderate ideation (Klonsky and May 2015). Ideation is strong when the degree of confidence is higher and an individual is sure that death is better than life. Ideation is moderate when the degree of confidence in committing suicide is low and an individual is not sure whether death is better than life or not. In moderate ideation, the prevailing mental construct varies between pain and hopelessness (Silverman et al. 2007b). Pain is a state of anguish, disquietude and grief, while hopelessness is a state of despair and renunciation. When both pain and hopelessness are proportionate and overcome connectedness, an individual becomes sure that death is better than life. Connectedness, on the other hand, is attachment to or engagement with other individuals (Oxford Dictionary 2005). Broadly, connectedness is one's attachment to a role, interest, job or activities that keep an individual invested in living (Klonsky and May 2015). When an individual's social connectedness is overcome by pain and hopelessness, it provokes strong ideation while the opposite means passive ideation. Active and strong ideation for suicide means a low or zero degree of social connectedness and high degree of pain and hopelessness. On the other hand, passive or no ideation for suicide means a high degree of social connectedness and low or zero degree of pain and hopelessness. In active or strong ideation, an individual prefers death to life, while in moderate or passive ideation an individual is not sure of the preference.
The second category of suicidal behaviour is an actual attempt to commit suicide. Joiner (2005) argues that an attempt is an action of an individual to end his life. This attempt is determined by an individual's capability to put his ideation into action. However, an individual's capability is determined by many factors; genetic construction, such as pain sensitivity, exposure to fear and death and ease of access to lethal means play a significant role in suicide (Young et al. 2012). According to Joiner (2005), genetically loaded factors are called dispositional factors, while socially and environmentally constructed factors are called acquired and practical determinants. These factors are the key determinants of suicidal capability. Similarly, an attempt could be lethal or non-lethal (Klonsky and May 2015). A lethal attempt results in self-murder while in non-lethal attempts an individual fails to kill herself.

Defining sexual abuse
The term "sexual" means related to sex or of the sex (Oxford Dictionary 2010). The term "abuse" means ill use, maltreatment, cruelty and even violence or curse (Oxford Dictionary 2010). Hence, sexual abuse means unfair physical contact of two, or more than two, persons of the same or opposite sexes. Sexual abuse is maltreatment that involves physical contact of two or more persons of the same or opposite sex (Barth 2008). However, this term is not limited to physical contact; it also includes enticement, persuasion, employment, inducement and even all kinds of engagement in unfair treatment. Sexually explicit and implicit conduct are both included in this definition. Explicit conduct involves rape, molestation, prostitution and other forms of sexual exploitation; implicit conduct includes unfair treatment, particularly inducement, persuasion and seduction. In this study, sexual abuse refers to unwanted physical contact or sexual encounter. The term unwanted physical contact means only those incidents which involve intercourse with the opposite sex and without consent.
Since sexual abuse is an incident of overwhelming stress that results in the death of many innocent women in Khyber Pakhtunkhwa, this study was conducted to investigate the nature and extent of suicidal ideation in sexually abused women. The site of this study is the North-western province of Pakistan, Khyber Pakhtunkhwa, where sex and sexuality are considered obnoxious subjects to discuss publicly. This social abhorrence towards any references to sex and sexuality has resulted in silencing women victims of sexual exploitation and victimization. Hence, women victims prefer to die in silence before their sexual victimization becomes public. Indeed, this silence not only worsens the situation, but it also shields the perpetrators of this crime and provides them a safe haven. In the majority of such cases, the victims are neither accessed nor the incidents reported. This study investigates this plight and highlights reasons accountable for suicidal ideation in victims of sexual abuse in Khyber Pakhtunkhwa.

Material and method
The study, conducted in 2016, focused on sexually victimized women. The target area of this study was Khyber Pakhtunkhwa. 1 Khyber Pakhtunkhwa, as said before, is culturally very sensitive on issues of sex and sexuality. It was hard for us, as male researchers, to talk to victims of sexual abuse in parts of Khyber Pakhtunkhwa. However, being male feminists -advocates of feminism as a movement to end sexist oppression and inequality -we acted in the field with the will and commitment to contribute to feminism by identifying hidden factors contributing to suicidal behaviour in sexually victimized women. We did not hire any female enumerator for this study because we did not believe in the general perception that feminist research is a research by, for and about women (Gluck and Patai 1991 as cited by Gilbert 1994). Comparatively, female-to-male interaction is more effective in exchanging views than female-to-female interaction because in female-to-female interaction, jealousy and insult may be factors, while the same are lacking in female-to-male interaction (Goodwin 2002;Simmons 2002). In addition, women talk to men about their problems very confidently and in detail because they seek a solution to their problems (Eunson 2012). Similarly, ending sexism and sexual exploitation requires collective struggle by men and women alike. Hooks argues, "until men share equal responsibility for struggling to end sexism, feminist movement will reflect the very sexist contradictions we wish to eradicate" (1984,(80)(81).
Data for this pioneering study was collected at six different locations of Khyber Pakhtunkhwa, including district Swat, 2 Upper Dir, 3 Mardan, 4 Nowshera, 5 Peshawar 6 and Abbottabad. 7 It should be noted that these areas are the historic icons of Pakhtun culture. Thirty in-depth interviews were conducted with victims of sexual abuse and one focused group discussion was held. All these interviews were semi-structured and conducted face-toface. The respondents were identified through social networks. We identified the first victim of sexual abuse through social contact with a woman working in a nongovernmental organization in District Swat. Social contact is very effective with sensitive issues; it helps the researchers to identify respondents easily (Bryman 2008). This technique is helpful because there is direct facilitation,: researchers receive information from friends and organizations that provide clues and references to other respondents (Denscombe 2003).
Second, Khwendo Tolena 8 , a non-governmental organization providing legal aid to victims of sexual abuse and domestic violence was very helpful in arranging interviews for us with the victims to whom they provided legal aid. All the interviews with the respondents belonging to district Swat were held in the office of Khwendo Tolena, situated in district Swat. These victims did not feel any hesitation during their interviews because we paid Rs. 1000 to 2000 (US $10 to 20) to each victim. However, although such payments may be regarded as unethical, they served as an instrument to interact with the victims, and the benefit of this interaction was greater than the harm. Moreover, we wanted these victims to be supported in one way or another, and it was a good opportunity for us to help them. In addition, some measure of deception may be acceptable when the benefit of knowledge outweighs the harm (Honsby-Smith 1993). Victims of sexual abuse were also found in the local crisis centres of the provincial government's social welfare department; 46 Sheraz Ali & Johar Ali however, access to these victims was denied due to cultural sensitivity of the area where this study was conducted.
The majority of the victims were young, particularly those who were victims of incest. Among the victims, those who were engaged in commercial sex were comparatively older in age. The youngest age of the victims was 15 years and the maximum age was 40 years. None of the victims was educated and the majority were from rural parts of the province. The following figure (figure-1.1) shows details of the respondents interviewed in this study and the nature of abuse they experienced.
All of the interviews were conducted face-to-face while ensuring privacy and confidentiality. None of the victims' name or picture was exposed or revealed to other sources. Neither their parents' name nor location was revealed. However, these interviews were tape-recorded; the data wer kept confidential and extra care was undertaken during these interviews, which were in turn manually coded and then transcribed. All of the interviews were held in private apartments where the respondents felt confident and secure and in locations to which the respondents had consented. These respondents were veiled in accordance with local norms, but during the discussion some of them preferred to uncover just their faces. Privacy and confidentiality are the two main elements which must be ensured before starting interviews on sensitive issues in sensitive areas (WHO 2004). Privacy and confidentiality are desirable for every respondent to be informed about (Borbasi et al. 2005). Breach of privacy and confidentiality may cause severe harm to both the respondent and the enquirer, particularly in the case of sensitive issues (Haverkamp 2005). Since Khyber Pakhtunkhwa is culturally more sensitive, especially in the issues related to women and sexuality (WHO 2004), extra care was required in interviewing sexually abused women.

Figure-1.1 Data collected in Khyber Pakhtunkhwa
Designed by the author.
In the above figure-1.1, the respondents are divided into four different categories, according to the nature of abuse as narrated by the victims during the interviews. These categories include incest, incestuous abuse, rape and commercial sex. This chart was developed after comprehensive observation and analysis of the data. In this figure, the respondents are prioritized according to the nature and severity of violence they experienced. In the first category, only those respondents are included who were victims of incest. In the second category, victims of incestuous abuse are included, and in the third and fourth categories, victims of rape and commercial sex are included. The category of incest was comparatively more severe than other categories because suicidal temptations were found only in victims of this category. For those victims, the degree of severity of violence was measured based on their responses. In this figure, incestuous abuse was put in the second category because this case was comparatively more severe than rape or commercial sex but less severe than incest. However, no suicidal ideation was found in victims of this category.
Incest is a type of abuse in which men in the family sexually victimize a woman without her consent (Lintel 2004;Nancy 1988Nancy , 1997Nancy and 1998. In incest, male members of the households, particularly her husband's brothers, father and even cousins, force a woman to engage in indiscriminate sex. This practice is also called sexual or criminal congress (Oxford Dictionary 2010). It may not be associated with polyandry because in polyandry, a woman has consent in sharing many men, but in the area where this study was conducted, a woman does not have consent in sharing more men; rather she is forced to this practice, incest, three types of victims were identified. Women who were bartered (wata sata), 9 sold (trafficked) and handed over in enmity (swara) 10 were victims of incest. The practice of handing over a woman in enmity to settle a dispute is known by different names. This practice is called vani in Punjab, swara in Khyber Pakhtunkhwa and dand in Sindh. This custom is practiced for the purpose of settling family dispute or due to enmity. Such a practice is illegal and liable for punishment because in such marriages, the consent of the woman is compromised, and it is usually underage girls who are subjected to it (SPARC 2015).
Trafficking of women is a criminal act because it is a type of human smuggling, liable for punishment. Wata satta is an act of exchanging women, and swara is handing over a woman to another group to settle family disputes. These acts are socially acceptable but simultaneously criminal and liable for punishment when lacking the consent of the woman or involving the exchange or marriage of child girls. Of the thirty victims of sexual abuse identified in this study, two were cases of watta satta and three were cases of swara. Of these five cases, none of the women happily entered into marital bonds; rather they were forced and their consent was compromised. Interestingly, despite huge and aggressive emphasis on religiosity, in these cases, no marital contract was signed. Of twelve cases of incest, seven women were sold. Among these twelve victims, four women were found with strong suicidal ideation. Among the rest of the victims, none revealed any suicidal ideation; therefore, we are not going in details concerning the victims of other categories because the target victims of this study were victims of the first category.

Data presentation and analysis
The study shows that suicides are committed by women in the target area due to two main reasons; one is domestic violence and the other one is sexual abuse. There are also other reasons accounting for suicides in women, such as incidents of overwhelming stress, like the death of a life partner or son; however, the most common reasons are domestic violence and sexual abuse. The intimate partner usually carries out domestic violence, but sometimes other family members also take part in it, particularly the mother-in-law, sisterin-law and brother-in-law. Girls who are unmarried but subjected to domestic violence are those girls who live with their stepmothers or step-siblings. Methods used for suicides are hanging with the ceiling fan, jumping into a deep river, lying before a fast-moving train and taking pills or other poisonous materials, such as pesticides (Uzma et al. 2013;Hassan 2009). Most of the suicides committed by women in the target area were found in these forms.
Domestic violence, once started, continues for a longer time, covering years because the victim of domestic violence has no other option but to suffer in silence. Domestic violence covers a range of behaviour, including psychological and physical violence, such as intimidation, threats, use of abusive and vulgar language, physical punishment, excommunication, denial of health and education rights, denial of property rights and inheritance, denial of income earning opportunities and social participation (Khan 2000;Shaikh 2003;Women Aid 2009;Pillai 2001). Domestic life features strong privacy whereby arbitrary interference is totally forbidden because of prevailing social norms, which Durkheim calls normative pathology (Breault and Barkey 1982). Thus, the body of rules governing Pakhtun society contributes greatly to violence against women. Because domestic violence is not the focus of this study, we will not go into further details of domestic violence.
Sexual abuse is the second explanation for suicidal tendencies in women from the study area. A woman can suffer domestic violence and survive, but it becomes very hard for her to survive once she is sexually abused. Three main destinies are specified for sexually abused women in the study area: death, brothel and social excommunication. Victims of sexual abuse are targeted or re-victimized because of the assigned label of being deviant. This assigned label of sexual abuse is rendered as permission for re-victimization where men seek satisfaction of their lust in these victims. On the one hand, her family abandons the victim, while on the other hand men avenge her through sexual violence, psychological intimidation and disparagement that finally drive her to resign from life.
In the region where this study was conducted, people in certain situations are overwhelmingly disruptive in their behaviour, such as extreme sexual abuse/violence. This 50 Sheraz Ali & Johar Ali behaviour constantly threatens social and familial solidarity. The following table 1 shows suicidal ideation in victims of sexual abuse.  Table-1 shows suicidal ideation in women who experienced sexual abuse. In this study, 30 samples were collected, of which four victims had strong inclinations towards suicides. All these respondents were victims of incest, and all these victims were comparatively younger than other victims. The youngest age of these victims was 17 years and the maximum age was 20 years. The mean value of their age was 19, which means that the mean age of the victims with suicidal ideation was 19 years. In other research, the age for the highest suicidal tendencies was from 15 to 24 years (Strother 1986). Among the respondents with suicidal temptations, three out of four victims were trafficked while one victim was handed over in enmity. Three out of four victims were from district Swat while one victim was from Upper Dir.
All of these victims revealed suicidal ideation during their interviews because they, on approximation, uttered the word suicide two to three times. Their suicidal ideation was strong because all four respondents were sure that death is better than life. Their pain and hopelessness were stronger than their social connectedness. These victims were successful in escaping the places where they were trafficked. These victims, who had been subjected to huge sexual violence by relatives, particularly brother-in-law and father-in-law, preferred death to life and were clear in their claim. During the interviews, aggression and irritation in their behaviour was clearly evident, common symptoms of self-harming behaviour. These sentiments, although momentary, were supportive of self-annihilation -a matter of seconds. Continued irritation in behaviour gives birth to self-destructive sentiments. Such sentiments are strong in people who are still young and energetic but have less internal control.
One main reason accounting for suicidal ideation in these respondents was their young blood. Second, the type of violence they suffered was torturous and painful, both physically and psychologically. Third, they were quite secluded in their lives. Fourth, they Suicidal Ideation in Victims of Sexual Abuse 51 were totally disconnected from society. The victim who was handed over in enmity experienced huge physical violence, coupled with indiscriminate sexual encounters for more than a year. Others suffered from physical violence in the form of domestic burden, along with indiscriminate sexual encounters. In this study, it was found that usually a woman is subjected to huge violence when she is handed over in enmity or sold for money or other property. When a woman is handed over in enmity, she is subjected to indiscriminate sex, as well as domestic violence, because of the degree of hate and enmity involved. Second, when a woman is sold for money or other property, she is also subjected to indiscriminate sex and domestic violence because her right to resist is confiscated with the payment made for her. Physical and sexual violence is common in both cases. In this study, victims with strong suicidal ideation had a previous history of violence. Strong suicidal ideation was found only in these two types of victims. They all experienced quite harsh and indiscriminate sexual encounters along with domestic violence. In addition, other people knew of their victimization which resulted in huge social hatred. The victims were totally disconnected from society and discriminated against. Although they had left the houses where they were trafficked, they preferred death to return, and the degree of confidence in their preference was very high.
It was found that in the target area, trafficking and handing over of women in enmity result in huge violence. A woman handed over in enmity is sexually tortured and exploited by family members to satisfy their desire for revenge. On the other hand, a woman priced and sold is sexually exploited due to two main reasons: one is collective payment by the collateral relatives and the other is sexual frustration. Her right to protest or resist is also confiscated when she is sold. In such circumstances, a woman's destiny is pre-ordained by her owners whereby only two options are left for her: one is obedience while suffering in silence and the other is death. When a woman becomes exhausted by violence, she finally resorts to suicide. That is how preferences vary with the time and severity of violence.
This study also shows that many victims of sexual abuse breathe their last when encountering social hatred. Social and familial hatred and rejection cause overwhelming stress in victims. Because sexual abuse is considered as a taboo and results in huge social and familial hatred, suicidal ideation increases in women who are sexually victimized and re-victimized. Such suicidal ideation breeds in victims due to the associated stress of a social curse. One of the incest victims who was nineteen years old, explained: People have come to know about my status in the family. I am treated less than an animal. My husband and his brother's illicit deeds are known to people in the neighbourhood. I am no more stranger to them. Everyone looks at me with his thirsty eyes. Everyone's relationship with me is now sex-centred. They do not 52 Sheraz Ali & Johar Ali demand anything except an encounter. Nobody forgives me when finding an opportunity. I want an escape from this world. I will commit suicide but never go back from where I fled.
Victimization and re-victimization finally bring exhaustion where by the victim will not suffer further encounters of violence. However, committing of suicide is very difficult. Since the victim seeks redemption from violence, suicide seems the easiest and shortest way to get rid of it. The victim is not only subjected to violence but also to social disdain and abhorrence. People's avenging attitudes centre upon the victim. It was found that many victims commit suicide in silence without reporting the violence they suffer from. Some victims do not have the ability to face social curses and familial dishonour and so commit suicides. They are people whose internal bodily control and order are disrupted by overwhelming stress in the form of social and familial disconnectedness and hatred.
In a human body, the peripheral nervous system has a component, called the autonomic nervous system that functions automatically. This autonomic nervous system is regulated by the endocrine glands, part of the limbic system that is called the emotional brain. The emotional brain is the primary part of the brain that deals with stress. The autonomic nervous system is divided into sympathetic and para-sympathetic nervous systems (Kalat, 2010). These two systems work in opposition to each other. When stress occurs, the system becomes activated and the sympathetic nervous system triggers, while the parasympathetic system tries to calm down the situation to normal. When the sympathetic nervous system becomes acute and stronger in reaction than the counter parasympathetic system, disorder in homeostasis occurs. Homeostasis is an internal mechanism that works via the autonomic nervous system to counterbalance disrupting change (Kalat 2010;Myers 2009;Plotnik 2010). In people who commit suicide, the sympathetic nervous system overcomes the parasympathetic nervous system, resulting in huge disorder of the homeostasis and failure to control themselves. This uncontrollable state brings an internal upheaval in the body, which impels victims to commit suicide.
Victims of sexual abuse suffer from chronic stress, which is usually caused by external affairs, specifically by disruption in familial and social relationships or damage to self-respect and honour. Chronic stress is common among people with suicidal tendencies or feelings. It is a state of mental disorder caused by many factors, including those that are genetically transferred and environmentally influenced. One respondent with suicidal ideation replied to a question: what would you do, if you were not given justice and forced to go back from where you escaped? I would definitely commit suicide because committing suicide is better than suffering from the unending violence, killing me every day and every night. It is better to die in silence rather to be killed in violence.
Such sentiments arise in people who have a previous history of violence, anti-social activities or unusual behaviour due to familial disruption. A previous history of alcoholism and drug addiction, or even symptoms of depression, all indicate vulnerability of the individual and account for the higher risk factor involved in committing suicide. In this study, victims with suicidal ideation had previous histories of violence and suffering due to familial and social disentitlement. This previous history of violence and familial disruption significantly increased their risk factors in committing suicide. Irritation, aggression and self-deprecating behaviour were strong symptoms of their suicidal temptation.
However, lethality in such behaviour is comparatively low, but such symptoms increase the vulnerability of indulgence in depression, drug addiction and alcoholism. When such behaviour is coupled with alcoholism or drug addiction, the risk factor greatly elevates. In this study, since the respondents with suicidal ideation were victims of incest and none was addicted to drugs or alcohol, their previous history of violence was very strong. Socio-psychological factors in these cases were very forceful in the form of social curse, as well as familial and other relational disrespect and degradation. Seclusion, neglect in relationship, fear, an inferiority complex and self-rejection, with a high degree of hopelessness, were common socio-psychological characteristics, dominant in respondents with suicidal ideation. Alcoholism or drug addiction in these respondents was lacking due to inaccessibility to these drugs; the women mostly spent their time in joint families where they were subjected to indiscriminate sexual encounters and their freedom was totally confiscated. They were not allowed to carry out social relationships with other people in their neighbourhoods or surroundings but were confined to the four walls of their houses. In such situations, they did not have access to drugs or alcohol. Psychiatric disorder in these respondents was due to huge stress caused by previous suffering because there is a strong link between suicidal ideation and stress or depression (Pfeffer 1986). Our respondents, as given in table-1.2, indicated through their behaviour and utterances that suicide is a possibility. Their self-deprecating behaviour and strong aggression were warnings for suicide. They were all sure that death is better than the lives they were leading.
Suicidal ideation radiates from emotional evaluation of an incidence through which an individual has passed (Agnew 2001). This emotional evaluation of the incidence causes strain, which is of two types, one objective other subjective. Objective strain occurs when experiencing the incidence is disliked by the social world. In subjective strain, an individual herself dislikes the incident she experiences. According to Agnew (2001), strain increases the possibility of negative emotions. These negative emotions drive an individual to corrective actions. Corrective actions are determined by the degree of strain and the emotional response to it. Comparatively, women experience more strain than men do, and they are high in subjective strain (Agnew 2001;Broidy 2001). Men are likely to adopt deviant behaviour such as violent crimes when experiencing strain (Merton 1938;Jang and Agnew 2015;Heydari et al. 2013), while women are likely to adopt self-destructive behaviour in response to strain (Agnew 2001;Broidy 2001).
One main reason for women to adopt self-destructive behaviour is the social stigma attached to sexual abuse. Stigma is an attribute that reduces a person from a normal human to a discounted one (Goffman 1963). This attribute conveys an identity that is more devalued and disdaining in a particular social context (Crocker et al. 1998). In the Pakhtun social setup, different attributes are assigned to victims of sexual abuse that finally drive them to resignation from life. These attributes do not mean that they were deviant in their behaviour; rather they were labelled as deviant. Deviant behaviour stems from various social problems. However, labelling someone as deviant gives birth to new problems that arise from the reaction of self and others (Lemert 1967). Lemert (1967) further argues that deviance is used either as a "mean of defence, attack or adaptation" to the problems caused by labelling. Labelling someone as deviant increases the likelihood of deviant and criminal behaviour (Becker 1963).

Conclusions
Strong suicidal ideation was found in this study among those sexually abused women who were comparatively young and were the victims of incest abuse. They were subjected to indiscriminate sexual encounters by their co-inhabitants, including husband's brothers and cousins. Their ideation to commit suicide was strong and active because in their responses they clearly revealed that death is better than life. All four victims were sure that committing suicide is the only way to redemption. They had completely lost their hope and were self-rejecting in their interpretation. Social and familial disconnectedness and hatred had escalated their emotional and physical pain. Pain is the pre-condition for suicidal ideation or attempt, which all four victims experienced because of incidents of overwhelming stress. They were sold/handed over in enmity and subjected to indiscriminate sex and domestic violence, which in turn greatly contributed to their emotional disorder. The violence carried out against them was in the private sphere, where interference was impossible; therefore they were completely helpless. Their pain and hopelessness resulted in huge stress. Irritation and aggressive behaviour, as well as frustration and hopelessness, were the common symptoms of their probable indulgence in self-annihilation attempts. In the area where this study was conducted, sexual abuse has been a very chronic and acute problem, and a majority of the victims of sexual abuse are killed to restore family honour. Victims are rejected by their families and society. Therefore, social and familial hatred and disconnectedness precede other rules of behaviour so that primarily the relational health of the victim is negatively affected. In this study, all the victims were socially excluded and men's relationship with them was totally sex-centred. Such oppressive and discriminatory behaviour of the social world resulted in chronic stress and gave birth to suicidal ideation.
In this study, we have identified social evils that exist in society in order to create public awareness and draw the state's attention toward intervention by implementing effective remedial policies. Trafficking of women is a strong contributing factor to incest that ultimately leads to suicidal behaviour. This obnoxious practice prevails in the Pakhtun society in an invisible form. Incest is difficult to be identify unless reported by the victim; therefore, direct intervention in this matter is no less than impossible. However, through education and information, victims' protection/welfare programmes and justice can be achieved. Since, male immorality/criminality is a strong contributing factor for female sexual victimization, therefore, education of men would be very effective.

1
The North-western province of Pakistan, sharing its border with Afghanistan in the West. Nowshera is a big city situated in the northwest of Pakistan. It is a junction connected with the rest of the cities in Khyber Pakhtunkhwa. A majority of the people in this area are Pakhtuns. 6 Peshawar is the capital city of Khyber Pakhtunkhwa. It is the largest city, situated in the northwest of Pakistan. 7 Abbottabad is a large city situated in the northwest of Pakistan and shares its border with Punjab province. Pashto and Hindko speakers share this area. 8 Khwendo Tolena is a non-governmental organization situated in district Swat that provides legal protection to victims of domestic and sexual violence. 9 Watta satta is a traditional practice of exchanging women. Usually, a brother-sister pair is chosen from each family, but sometimes pairs from cousins and close relatives are made. A male from one family marries with a female from the other family and vice versa. A contract is signed and the wedding is celebrated when the female happily marries or gives consent. But when the consent of the female is absent, in such situation marriage is decided secretly and the couple is forced to marry. This kind of exchange is illegal because it lacks the consent of the female. Section 310-A of the PPC mentions that any act compelling or enforcing a woman to enter into a marital bond is prohibited, and the accused will be imprisoned for seven years and liable for Rs. 500,000 fine. This act covers all those marital bonds where the consent of the woman is compromised or she is forced to sign this contract. 10 Swara is a practice of handing over a woman to another family in enmity. This practice is totally illegal because here the woman is forced and her consent for marriage is neglected. This practice has been one of the main reasons of sexual and domestic violence. Women handed over in enmity are treated like slaves and subjected to exploitation. They are considered as daughters or relatives of the enemy. Section 310-A and 498-B of PPC deal with such cases.