DRUG ADDICTION AND ALCOHOLISM AMONG SEXUALLY ABUSED WOMEN IN PAKISTAN

The study aims to identify factors which contribute to the prevalence of alcoholism and drug addiction among sexually abused women in an ultra-conservative society. A qualitative research design is used in conjunction with interviews from women and physicians, categories which included both psychiatrists and sexologists, across six districts of Khyber Pakhtunkhwa. The phenomena of drug addiction and alcoholism were more pronounced in victims working for the commercial sex sector. The findings suggest Post-Traumatic Stress Disorders (PTSD) as a driving factor of alcoholism and drug abuse, which in turn cascades into secondary and tertiary levels of trauma. Sexual victimization and re-victimization, familial rejection, stigmatisation and social degradation were contributing factors to relentless stress. Drugs in vogue among victims were Valium-two (Diazepam) and Lexotanil that contained Bromazepam. Hashish and alcohol were consumed sparingly by victims, while the use of cocaine 1 Sheraz Ali is the first author (sali@uswat.edu.pk) 2 Muhammad Tariq is the corresponding author (muhammadtariq@uswat.edu.pk) 88 Sheraz Ali & Muhammad Tariq and heroin was absent due to severe masculine perceptions and addiction. The study contributes to a better understanding of a socially-excluded, economically-disadvantaged and stigmatised group by taking a pro-feminist stance to advocate for the rights of victims.


Introduction
A startling report recently published by the World Economic Forum in regard to a Global Gender Gap for the year 2020 ranked Pakistan at 151 st among a total of 153 countries (WEF, 2020). The report goes on to show that Pakistan ranked 150 th in terms of education, 149 th in domains of health and 143 rd in regard to health of women. These appalling facts and figures show the state-of-affairs of an average women in Pakistan. However, statistics are just one side of the picture as there are many areas which have not been covered by reports, such as injustice and social acceptance among sexually exploited women who are prone to drug addiction and alcoholism. The phenomenon of drug addiction is common in patients suffering from Post-Traumatic Stress Disorder (PTSD), particularly sexually abused women. Victims of PTSD experience incessant traumatic stress which compels them to rely on drugs and other intoxicants to cope with extreme mental trauma. Likewise, sexual abuse of women itself falls within the realm of overwhelming stress, which pushes a whopping majority of victims into a state of post-traumatic disorder. The recovery from trauma varies from person to person with some making faster recoveries than others. However, the rehabilitation or recovery depends heavily on the intensity of trauma inflicted upon target women and their ability to cope, in regard to psychological development and maturity. Thus, it can be said that inability to cope with stress, due to the haplessness experienced by victims, triggers the use of drugs for mental relief (Iqbal et al., 2018).
People with perturbed emotional states are more vulnerable than others to addiction, which further aggravates their emotional feelings, behaviours and personality (Decci & Ryan, 2000). According to  addiction traps a patient in a quagmire of a relapsing nature whereby the victim is psychologically anchored to a disease. The use of drugs is seen as an escape route to secure temporary relief, which creeps into a variety of psychological and physical disorders with the passage of time. The word addiction refers to lack of or inability to control one's compulsive use of a substance and can be traced back to its origin in a Latin word, addicere, which denotes 'binding' . According to the Institute for Drug Abuse (2007), the compulsive and repetitive urge to delve into drugs is associated with chemical substances which hamper proper functioning of the brain. In general cases, neurotransmission processes in the human brain are interrupted, which adversely impacts communication systems within the brain, due to amplification in reception and transmission of signals. Causes of addiction are mainly attributed to over-stimulation of dopamine which controls emotional feelings of pleasure. Over-stimulation of the nervous system causes habitual consumption of drugs and compels the user to engage in repetitive yet unsocial endeavours. The enormous stress experienced by victims of sexual abuse, which manifests itself on a recurrent basis, makes such victims more vulnerable than others to addiction (Wood, 2000). As a consequence of securing immediate relief from trauma-related stress, the relapsing qualities of substance abuse and drugs create a double whammy for victims in the form of psychological and physical abnormalities . Furthermore, those researchers contend that dysphoria-affected people mostly consume drugs such as heroin, cocaine and alcohol. The victims of sexual abuse are more susceptible to dysphoria due to their inability to cope with enormous levels of post-traumatic stress. The preceding discussion denotes a high level of correlation between relapsing behaviours of drug abuse and post-trauma disorders which operate in a recursive or cyclical manner. This regressive behaviour on the part of addicted people impacts not only their physical and psychological states, but also the quality of their relationships. People generally distance themselves from those involved in immoral behaviour such as drug abuse and alcoholism, which in turn instils a feeling of social isolation and stigma for victims, leading to feeling of loneliness and selfdoubt.
The victims of sexual abuse are highly prone to embark on the use of drugs and alcohol as an escape mechanism for two main reasons. The foremost reason is to secure a false sense of relief from impending stress inflicted on victims through a variety of ways. Second, the victim in pursuit of happiness with passage of time becomes habitual to hedonic pursuits. Other than this, the inquisitive nature of humans minds also triggers addiction, which is most commonly attributed to normal people as against those who have fallen prey to sexual abuse. According to , in the beginning, the drug seems to be under control of individuals in terms of giving it up, but after prolonged usage, the situation goes beyond the voluntary control of users, causing complete dependency on drug and associated abnormalities. The addicted person is said to live in an abnormal state due to excessive dependency syndrome, which otherwise regulates the pleasures and pains when absent. It is pertinent to make a distinction between two terms: drug abuse, referring to initial stages of drug usage, and drug addiction, which denotes a state of psychological and physical anchoring on drugs to secure gratification and removal of discomfort (NIDA, 2007). In the same vein, Koob, (2004) proclaims the existence of two stages of addiction namely impulsive disorder and compulsive disorder. The former refers to psychological temptation by drugs in the spirit of movement, while the latter is obsession with recurrent use of a drug in a rather involuntary manner. The aforementioned two stages entail the transformation of pleasure-seeking drives into dependency-oriented syndromes, which result in anxiety and obsessive usage of drugs. Thus, the urge to secure temporary relief or pleasure becomes impending stress, due to the recursive nature of behaviours coupled with a feeling of regret (Koob, 2004;Koob & LeMoal, 2005a;Koob & LeMoal, 2005b).

Research Methodology
In this research study, we applied a qualitative research design for data collection due to the complex and multi-dimensional nature of issues under investigation, which presented a great challenge (Eisenhardt et al., 2016). The qualitative research method is comparatively very flexible and diverse, specifically when the problem under investigation is so complex and multidimensional (Mason, 2002). This approach is very different from the one prescribed in the dominant style of positivism-based research, which considers reality to be linear phenomena as demonstrated in equation below.
Qualitative research does not consider reality as a linear or static phenomenon, especially in situations where there are no a-priori theories present to be tested (Yousafzai, 2019). This method consists of approaches that are mainly interpretive in nature, but very productive, especially when enquiring about the lived experiences of participants in the social world. Qualitative research encompasses all forms of non-numeric social enquiries that focus on explaining human experiences of the social world and characteristics of social objects in textual form (Denzin & Lincoln, 2000). It is a systematic method of enquiring about human experiences and interpreting meaning grounded in them (Shank, 2002). Thus, we used a Qualitative research design which espoused constructivist epistemology and inductive methodology to secure rich accounts of lived experiences involving drug abuse and alcoholism among sexually abused women in Pakistan.
The jurisdiction of this study was Khyber Pakhtunkhwa and the target population was victims of sexual abuse and physicians, which included both sexologists and psychiatrists. A total of 50 interviews were conducted and 04 focused group discussions were held. The interviews were semi-structured in nature, comprising various types of questions such as mini-tour and grand-tour questions, as well as probing techniques such as the use of vignettes to elicit rich information (Merton et al. 1990). We chose a semi-structured protocol for interviews because it gives greater leeway to informants and researchers to express themselves the way they experience the social world (Kothari 2016). In addition to this, the matter at hand is taboo in this conservative culture; hence semi-structured interviews were very effective as against a positivist approach of administering questionnaires (Mason 1996;Creswell & Creswell, 2018). An interview guide for semi-structured interviews provides greater opportunity to determine the sequence of questions that give shape to discussion in an uninterrupted manner. Moreover, the interviews were conducted in the mother tongue of participants to allow for the collection of rich empirical data (Bryman, 2016;Gilbert 2008); these were transcribed verbatim within 24 hours with the help of memos and a diary for reflexivity.
We carried out all interviews face-to-face despite the cultural barrier of purdah (veil) and male-to-female interactions. The concept of male-feminists, i.e. persons who argue in favour of a feminist movement to remove sexual oppression and inequalities was not familiar to the respondents. However, we acted with determination despite occasional hiccups. Moreover, no female interviewees were hired so as to cast aside the misperception of feminist research being conducted by women, for women and about women (Gluck & Patai, 1991;Gilbert, 1994). Many commentators have conducted studies on emancipation of women from sexual exploitation. Hooks (1984) asserts that calling an end to sexual abuse of economically marginalised, culturally disadvantaged and naturally vulnerable women through collective endeavours, should include equal representation for both men and women. In the work mentioned, Hooks proclaims that unless men get involved in the empowerment of women to safeguard women from sexual abuse, it would otherwise be a paradoxical contradiction and a stigma on the face of our modern societies. Likewise, Hopkins (1998) asserts that the central theme in feminism should be characterised by adherence to basic ideals and concerned political stances as against only women's stance on the issue (Heath, 1987). Instead of labelling it as a women-oriented movement, the idea of male advocates of feminism is both feasible and appropriate at this juncture of history (Lemons, 1997). Feminism is a movement to end sexism and sexist exploitation, not to provoke anti-male sentiments; hence, it is for everybody if understood in its true letter and spirit (Hooks, 2000). Therefore, we participated in this research study as male feminists with a commitment to contribute and collaborate. We spoke to women as feminists, not on behalf of or for them. Every man can speak with women as a feminist but should do so with collaborative and participatory voice and action (Stanovsky, 1997;Galam, 2008;Breeze, 2007). In this study, the data was divided into two categories. One category consists of physicians, including sexologists and psychiatrists, and the other category consists of sexually abused women. Table-1 shows details of the respondents of the physicians' category (See Table 1).
All these participants were randomly selected from 06 districts of Khyber Pakhtunkhwa (KP). Of these participants, ten experts interviewed were psychiatrists and sexologists respectively. These two categories of participants were selected for this study with the aim of identifying the hidden factors of sexual victimisation that affect women's physical and mental health. Psychiatrists and sexologists were key informants on the mental and physical health of sexually abused victims in the territorial jurisdiction of this study. Table-2 shows details of the respondents in the second category, which included sexually victimised women selected from 06 locations of Khyber Pakhtunkhwa (See Table-2).
All participants were contacted through use of personal social capital and referrals based on extended social networks. In addition, we received help and facilitation in data collection from KS Global Research and Women's Huddle (Khwendo Tolena). The former is an international consultancy firm working for the welfare of women, while the latter is a not-for-profit organisation that provides legal assistance to victims of sexual exploitation, abuse and domestic violence in Swat district. Our being native Pashto speakers and residents of the area where this study was conducted helped in a variety of ways. For instance, knowledge of local languages, cultural sensitivity, adaptability to social norms and values all contributed to overcoming challenges in the collection of rich data for a culturally sensitive topic.

Data Display/Presentation and Analysis
For this study, various victims were identified and contacted especially those sexually abused women who had become addicted to drugs and alcoholism. The data collected indicates that almost all of the victims interviewed who were rendering services of commercial sex had reached the higher end of addiction, i.e. compulsive disorder which, if left unattended for a prolonged period of time, would wreak havoc with their physical and psychological wellbeing. A total of 13 women from the sex trade were interviewed where nine confessed to drug addiction, while the remaining 04 women were alcoholic owing to their habitual drinking patterns. The preceding statistics unveil the fact that a startling 30.7 percent of women related to the prostitution profession were alcoholic. On the other hand, five women used hashish for mental comfort on a routine basis; it is rather a mild drug as compared to alcohol and does not trigger extreme addiction. Based on the empirical evidence collected, it appears that a whopping 38.4 percent of prostitutes were regular users of hashish. Moreover, such women were also reported to use pills in addition to, or in lieu of, the consumption of hashish or as a proxy of hashish when it was unavailable. One of the victims consumed relaxing pills in tandem with alcohol consumption daily, but there were two others who used pills in tandem with alcohol sparingly. The empirical data collected suggests that almost 55 percent of women in the sample consumed drugs side by side with hashish and alcohol. A chronic victim, in terms of alcohol and pills usage, reported that usually she consumes Valium-2 tablets or Relaxin in tandem. The same respondent, whose name is concealed through use of a pseudonym, Ms. Zee, explained her consumption patterns: I consume drinks every night and sometimes I take a pack or two even during the day time. In the absence of alcohol, I might not be able to survive as I get much needed relief from alcohol and take up drugs to lower my stress levels when they are high. I am living a stressful life as I am well aware that my good days will only last during the time I am young. Once I become grey haired, my demand in this business will decline.
Alcoholism and drug addiction go hand in hand when considered as results of sexual abuse because of the fact that such incidents trigger overwhelming stress beyond the victims' control. It can be said that consumption patterns and the temptation to use drugs are proportional to the intensity of trauma inflicted upon such persons. The temptation is, of course, internal drive triggered by external events such as social isolation, stigma and emotions of fear. In the beginning, the relief also provides a temporary sense of false pleasure which tends to disappear as the person becomes habitual, due to a higher threshold for consumption on a regular basis. The victim at this stage is oblivious of long-term ramifications and tends to pay a deaf ear to calls of conscience, but down the line feelings of guilt seem to resurface again and again. The hangover period pushes the victim to a zone of depression where discontinuation of drugs triggers psychological and physical disorders, which in turn inwardly affect social relationships with significant others and societal stakeholders.

) Details of victim's tendencies in alcohol and drug consumption
In the sample, no respondent reported the use of heroin or cocaine as these drugs are generally used by men, due to higher effects of intoxication as well as issues pertaining to availability. The empirical evidence suggests that most of the common drugs used by female respondents included nicotine, hashish, alcohol, Valium -2 and Lexotanil. Pills are easily available over the counter in local pharmacies in district Swat and other areas of Pakistan. The aforesaid pills contain Brimazepam, which is useful for treatment of insomnia and anxiety. These drugs are prescription-based, but due to lack of law enforcement apparatus and an effective mechanism of checks and balances, their usage is in vogue as per the norms of the area, despite laws contrary to this consumption pattern: the drug act of Pakistan. In addition to pharmaceuticalmanufactured pills, hakeems (physicians practicing unani [Greek] system of medicine) also serve as a source of an unregulated supply of drugs, such as Tinol pills. Tinol drugs are mainly associated with men and are actually made from an amalgamation of various drugs. None of the respondents reported the use of Tinol as hashish is widely used and available in good supply in the area. Moreover, discontinuation of hashish consumption does not trigger obvious disturbances as the user still enjoys control of bodily functions despite a rise in heart beat and tremors as withdrawal symptoms. Some of the drugs such as hashish tend to lower blood pressure which gives a false sense of relief. When the patient avoids hashish use, the blood pressure rises back to normal causing anxiety among patients, which results in secondary and tertiary levels of trauma psychologically. Despite evidence to the contrary, a majority of the drug users interviewed were physically weak, in particular those in their thirties. As all the respondents who confessed to drugs were involved in prostitution, the effects of drugs on their health was more pronounced due to the fact that excessive sexual activity, in tandem with drug usage, had taken a big toll on their health and psychological wellbeing.
One of the psychiatrists from the group of practitioners explained that: At the beginning, the use of alcohol or drugs helps in giving temporary relief from pain caused by stress, but at the later stage addiction starts and the use of drugs or alcohol becomes compulsive due to frequency of use. Continuous use of drugs affects the psychological and physiological reactions of the body, which give birth to new symptoms such as irritation, restlessness, disorientation etc.
Drug addiction is associated with many behavioural problems such as the inability to cope with routine social order. Addiction itself is a physiological problem where a person becomes dependent on drugs or the use of drugs becomes compulsive. This state of physiological dependence is called compulsive disorder (O'Brien et al., 2006). The major symptoms of physiological dependence are diagnosed with the development of a tolerance/withdrawal syndrome (Kranzler et al., 2006). Tolerance syndrome is a state of physiological dependence on drugs caused by frequent use with increased quantity to maintain the effect. Withdrawal syndrome is a cluster of symptoms that develop when the person stops the use of drugs after prolonged use. Irritation in behaviour, aggression, disorientation and mood swings are some of the behavioural problems caused by excessive use of drugs or alcohol. The consequences of such behavioural problems are seen in the form of selfannihilation or self-harm, chronic stress, depression and seclusion.
According to Shah (2017), reportedly around 50 million people suffer from mental illness and disorder in Pakistan with only 400 qualified psychiatrists available in a country which spends a dismal 0.4 percent of its health budget on mental health. In domains of contemporary literature in psychology, the term stress has been defined in a number of ways by leading scholars. According to Thor and Cannon (2010), stress refers to a psychological state of anxiety due to an enormous burden of responsibilities and mental hiccups which go beyond what the individual can cope with. In domains of philosophy, stress refers to absence of peace of mind and control (Lovallo, 1997). However, not all stress is negative, as some forms of stress such as eustress are positive, while other forms indicate distress. as is evident from their nomenclatures of distress: hypo-and hyper-stress (Aschbacher & Mason, 2020). Among the previous categories, the distress type is further sub-divided into acute, episodic acute and chronic stress, indicating the nature and of and associated intensities. The more obvious causes of chronic stress are familial and relational stress and strained experiences or episodes. Hyper-stress is triggered when more of the person is demanded than what his or her mental faculties can cope with (Lovallo, 1997;Goldstein, 1995;a& Glaser et al. 1992).
Another psychiatrist from the group of practitioners explained that, Women who are sexually victimized are very stressed because of the labels associated with sexual abuse. In such situations, the use of drugs or alcohol is very common because chronic stress is associated with restlessness and restlessness causes huge pain. Therefore, drugs, whatever available, are taken to get relief which becomes an addiction in the latter stages.
It goes without saying in domains of psychology that victims of sexual abuse are prone to suffer from chronic stress owing to loss of social continuity, familial relationships and tarnishing of self-image and honour. Despite being victims, such women are mostly neglected in familial interactions, especially where gender segregation is higher. In the jurisdiction of the study's target area, sexually exploited women are labelled as vulgar. Such a label reduces their dignity and respect across family and society in broader terms, which in turn also impacts their relational health. The pressures of being seen with contempt, isolation and dishonour, triggers an acute sense of stress, which goes beyond the women's capacity to cope both psychologically and physically. In the wake of such adverse circumstances, women either take the route of suicide or resort to drug addiction. The human brain is a strong social organ which feels both pleasure and pain in a process of regulating and coping with external demands. In so doing, the human brain transmits neurons courtesy of chemicals called neurotransmitters (NIDA, 2007). As a consequence of drug abuse, this system of the brain is interrupted due to activation of neurons and their associated chemical structures, resulting in abnormalities of the nervous system. However, to a greater extent, it depends on the nature of the drug being used and the associated damaged it can cause in such a scenario.
Drugs such as heroin and cocaine cause damage to the brain more quickly than others and engulf the communication system of brain. Due to the fact that brain processes are amplified through use of drugs, the feeling of relief is temporary. Drugs target the human brain through activation of dopamine levels, which gives greater feelings of pleasure in times of stimulation, given its addictive nature. Thus, through a recursive or cyclical process the victim gets gradually trapped in vicious cycle of addiction, passing through two stages of drug abuse and addiction respectively. The addiction stage triggers psychological and mental disturbances if the drug in question is not discontinued. According to the Institute of Drug Addiction (2007), some of the drugs can stimulate the brain with higher quantities of dopamine as against natural processes of sex and food intake. The brain's excessive intake of dopamine compels victims to remember events through actions which cause repetitive consumption of such drugs.

Conclusion
In the ultra-conservative societal system of KP province, the study reveals the prevalence of Post-traumatic stress disorder (PTSD) and its associated ripple effects in the form of primary, secondary and tertiary levels of trauma among victims. In this study, it was found that victims of sexual abuse are rejected in their family relationships upon disclosure of abuse history. In the culture where the study was conducted, generally women who were abused are never considered for long-term relationships due to the "adulteress" label. Here the long-term relationship refers to marriage, i.e., tying the knot of marriage. No person is this society is willing to marry such a victim of sexual abuse due to lack of societal tolerance and stigma associated with such women. Such a societal view of victims of sexual abuse adds to the mental agony inflicted upon them in the research jurisdiction. In the light of empirical evidence collected from various categories of respondents (physicians), it has been found that an overwhelming majority of victims were experiencing symptoms of chronic stress, indulgence in irritating behaviours, neuroticism and traumatic stress disorder. These symptoms serve as a breeding ground and stepping stones for suicidal tendencies, drug addiction and alcoholism. As established earlier, sexual abuse results in overwhelming stress. Hence, sexually abused victims who suffer with such symptoms experience lack of social adjustment in society. Moreover, for some peculiar reason, women with such symptoms are labelled as insane and neglected by male counterparts for long-term relationship purposes.
The study, based on analysis of empirical data collected, entails that sexual abuse victims who later engaged in prostitution were regular users of drug and alcohol in addition to using pills. These give immediate gratification upon intake but not without long term ramifications such as women being given labels of vulgarity and social unacceptability. Moreover, none of the victims of sexual abuse reported the use of cocaine or heroin, which are mostly considered severe masculine drugs due to their high level of intensity and after-effects. The women rendering services in the commercial sex market enjoyed a higher level of liberty as they could travel from one place to another, in contrast to those confined to four walls. Finally, despite all the drawbacks and post-trauma effects, these women were more confident than average women in their interaction with people. The study unveils the fact that victims of sexual abuse were disowned by their families without any due inheritance of property, which added to their social vulnerability and in turn contributed to the perpetual nature of their stress and tendencies to use drugs and addiction for instant relief.

Future research
The current study espoused a qualitative approach to explore the factors contributing to prevalence of drug addiction and alcoholism among sexually exploited women across 06 ultra-conservative districts of Khyber Pakhtunkhwa (KP) Pakistan. The research serves as a stepping-stone for conduct of mixed methods and quantitative approaches to be conducted by future researchers to further validate findings. Moreover, longitudinal studies are needed to confirm the findings of the current study through a prolonged observation of various patterns with a greater sample size and research budget. The authors also suggest Government support as the issue under study is considered a taboo and sensitive, especially in the context of the purdah barrier. Government backing in conduct of future studies will solve some of the limitations confronted by future researchers.