Psychological Experiences and Struggle for Social Acceptance and Justice Among Female Acid Attack Survivors in Pakistan

Acid violence is one of the most heinous types of violence against women in Pakistan . About 200 acid assaults occur in Pakistan annually (Batool et al., 2020).An epidemological investigation found that between 1994 and 2018, 9,340 women in Pakistan were the victims of acid assaults (Mujeeb et al., 2023).This study aimed to get a deep understanding of the psychological experiences and struggle for social acceptance and justice in female survivors of acid attacks in Pakistan. A qualitative research design was used to examine the experiences of acid survivors using a phenomenological approach. A semi-structured interview guide was used to interview twelve acid survivor females about their psychological experiences as well as their struggle for social acceptance and justice. The interviews were transcribed and analyzed using a five-step thematic analysis process. Seven major themes that emerged from the study were psychological distress, low self-esteem, social avoidance, social rejection, risk factor for under-reporting of cases and protective factors. The findings of the study revealed that acid attack is profoundly a traumatic experience that affects psychological well-being and create significant challenges in social integration and access to justice. This study provide unique insight into psychological findings and social struggles of acid attack survivors within cultural context of Pakistan. From a future perspective, the current research will aim to raise public awareness, enhance the profile of acid victims in scientific research, and help mental health professionals in deepening their understanding of acid attack survivors.

Acid violence is one of the most heinous types of violence against women in Pakistan. About 200 acid assaults occur in Pakistan annually (Batool et al., 2022). An epidemiological investigation found that between 1994 and 2018, 9,340 women in Pakistan were the victims of acid assaults (Mujeeb et al., 2023). Acid attacks, sometimes known as "intimate terrorism," include submerging the victim in sulfuric, nitric, or hydrochloric acid, causing them to suffer for the rest of their life (Mujeeb & Kamal, 2018). Acid attack violence is a crime that is on the rise in numerous areas of the world. Several developing countries, including Bangladesh, India, Nepal, and Pakistan, are on the verge of committing similar atrocities (Mondal & Rubel, 2013). Acid attack survivors receive no psychological evaluation and are treated unlawfully around the world; as a result, the situation for victims is deteriorating while perpetrators benefit from systematic shortcomings (Zalsman et al., 2016), judicial system flaws allow the perpetrator to escape accountability (Calcini, 2022). This study aims to investigate the psychological experiences of acid survivors, as well as their struggles with social acceptance and justice, to help raise awareness among the public and authorities, develop better mental health strategies, and improve the enforcement of laws.

Acid attack survivors suffer severe physical and psychological damage that can last a lifetime. Social reactions may be stigmatizing and marked by a fear of rejection, adding to the distress of the situation (Athar et al., 2020). Acid attack affects a victim's psychological, social, and financial well-being alongside its physical effects (Rahman et al., 2014). Anxiety, depression, social isolation, and social exclusion are common psychological problems among acid attack survivors (Zaman et al., 2023). Acid injuries can cause both temporary and permanent alterations, putting one's adaptive coping skills and ability to engage in optimal self-management to the test. Traumatic experiences, loss of performance, changes in one's mental picture of oneself and societal duties all strike at the core of one's existence. Along with physical health problems, such as pain and suffering, social challenges also play a role because acid victims are often treated differently than other members of society and receive negative social reactions from those around them (Ambereen & Yousaf, 2023).  Unfortunately, only physiological needs are met while treating individuals who have been injured by acid, ignoring psychosocial needs (Mamashli et al., 2019).

In 2011, the Pakistani criminal court system made acid attacks illegal, and the penalty for such an attack was placed at life imprisonment (Criminal Law Act, 2011). In the same effort to eliminate this form of violence, the selling of acid and other caustic substances was made illegal.  Although the Pakistani government has enacted these safeguards, they are not adequately enforced (Shaikh, 2020, October 7). Conviction rates for acid assaults, on the other hand, have decreased from 2016 to 2018, the most recent year for which Acid Survivors Foundation Pakistan has collected data (Baloch, 2020). This is discouraging since it implies that fewer people are convicted of a crime following a trial. 

Between 2014 and 2016, there was a 52 percent decrease in the number of acid assaults, leading many to feel that Pakistan was making progress in the expansion of rights of acid survivors. However, this decline might be explained by the under-reporting of cases of acid attacks (Abbas, 2018). Yet, the reason for the under-reporting of cases is rarely investigated; this study may attempt to address this gap by providing crucial data regarding factors that contribute to unreported cases. `
The goal of this study is to explore the psychological experiences of acid survivors and their fight for justice and societal acceptance. This study is aimed at addressing these elements to provide new perspectives to the literature and information that can be used to formulate strategies for more effective assistance of survivors.

Research Questions
 

• What are the psychological experiences that acid attack survivors experience?
• What challenges are faced by acid attack survivors in seeking social acceptance?
• What are the challenges acid victims face while seeking justice?

Method

Research Design

The current study used a qualitative research design with a phenomenological approach to investigate the lived experiences of acid attacks, how this traumatic event affected psychological well-being of acid survivors, and what factors contributed to their struggle for social acceptance and justice. Purposive sampling was employed to choose participants, helped the researcher locate participants based on predetermined sample inclusion criteria to collect richer data from participants with characteristics pertinent to the study. It was done with the help of the renowned NGO ASF.  

Sample

The study included 12 female acid survivors who met the eligibility criteria. Participants were between 25-40 years of age. The time since acid attack was ranged from 5-10 years. All women had burns on face, arms and chest. The sample reflect diversity in marital status, including married, unmarried and divorced/separated women which allowed for range of psychosocial perspective. Women who were less than 18 years old, those who had been in the incident less than three years prior or had burns that did not cover the upper body surface were excluded from the study.

Semi-Structured Interview Guide

Psychological experiences, challenges for social acceptance, and justice among female acid survivors were assessed using an interview guide that includes open-ended, close-ended and probing questions. The researcher created the interview guide following a thorough review of the literature and in-depth discussion with the experts, including a supervisor and a clinical psychologist who assisted the participants. There were four different types of questions in the interview guide. In the first category, initial information about the incident was asked, which helped the researcher in determining the primary cause of the incident. In the second category, questions about psychological experiences were asked, which provided information about acid survivors' initial psychological experiences and current mental state. The third category of questions focused on social acceptance and provides information about survivors' struggles with stigmatization, social acceptance, and other people's behavior. Questions about their struggle to get justice fall into the fourth category, which elicited information about whether they reported the incident to the law enforcing authority and what factors contributed to their decision.

Procedure

 The study began with the approval from the Head of Department of Clinical Psychology at Shifa Tameer-e-Millat University, followed by agreement of the Acid Survivor Foundation, from which participants were selected. The study was conducted in accordance with the Foundation's standards, which included a strict policy on survivor confidentiality, including firm protection of names and data collected by acid survivors. Following a thorough review of the literature, a semi-structured interview guide was developed with four categories: incident details, psychological experience, social difficulties, and struggle for justice.

Permission was obtained from the participants through an informed consent form. Participants were made aware of the ethical issues and given assurances regarding the confidentiality and security of their personal data. With their consent, the interviews were recorded over a video call. A minimum of 40 minutes and a maximum of 90 minutes were allotted for each interview. The interviews were concluded upon reaching the saturation point, based on discussions with supervisor and the qualitative research expert after which narratives were transcribed for effective evaluation.

The study was carried out in compliance with the American Psychological Association's (APA) ethical criteria. The researcher took permission from concerned authorities for data collection and ensured the confidentiality of the participants. Pre-interview briefing was provided to participants about the goal of the study, a brief background of the research, an estimated time, and the confidentiality of their responses. Prior to the interview, each participant gave their informed consent. Researchers read the script aloud to the individuals to obtain their full agreement. Participants were assured that the information shared would be used for research purposes only. Interviews were recorded. They were given right to withdraw from the study without any penalty. The researcher ensured that in the case of traumatic triggers, given the sensitive nature of the study, a psychologist must be available with the participant.

Results

Five step Thematic analysis (Braun & Clarke, 2006) was used to evaluate discourses in five steps: Familiarize with data, generate initial codes, search for themes, review themes, and define themes.

Table 1: Psychological Experiences and Struggle of Social Acceptance and Justice (N = 12)

Psychological Distress

This theme highlights the prevalence of psychological distress that acid survivors experience daily. The psychological consequences can be both poignant and distressing. It has a significant influence on the victim. This study revealed several factors that contributed to their psychological distress, including suicidal ideation that appeared similar at the time of the incident and several years later. One participant reported, “When I was in the hospital, I wanted to be injected with poison since there was no point in living, and I still want to swallow acid and die.”

Learned helplessness was another factor contributing to psychological distress. They possess tendency to remain silent and do nothing because of their incapacity in the face of enmity from survivors’ families. One of the participants states, “My husband and mother-in-law spit on me, beat me, and insults me, but I cannot leave them; where would I go if I do?”

Another factor contributed to the psychological distress of acid survivors was the fear of being re-victimized. The recurrence of a traumatic incident is referred to as re-victimization (Mittal et al., 2021). The results showed that most women feared that the attacker would attack them or their kids again, particularly if they lived in the same neighborhood as before the attack. They were preoccupied with closing the doors and windows. This anxiety persists even after several years of attacks. One participant said, “I am terrified that He will attack me again; I have daughters, and I always lock the windows and doors, but I still feel terrified.”

Finally, acid survivors frequently experience a sense of hopelessness in life, thinking that the incident has left them permanently scarred and that nothing will ever change for the better, and that they will be tormented in the same way indefinitely.
A 40-year-old participant who divorced her husband through ASF said, “my life is ruined; there is nothing that could be done now, and even if I get treatment, the ugliness will stay.”

Low Self-Esteem

The prevalence of low self-esteem among acid survivors was the second theme that emerged. It depicts how facial disfigurement, and a perceived loss of identity can lead to low self-esteem, that can lead to self-hatred, self-doubt, a sense of worthlessness, and helplessness among acid survivors.

Self-hatred is portrayed by acid survivors as believing that they will never be "good enough”. One participant mentioned, “whenever I see myself in a mirror, I feel that I am ugly, I hate myself.” Another participant stated, “my eyes are completely ruined whenever, I try touching the surface, my finger goes inside the eye socket i am terrified and disgusted by myself.”

Participants demonstrate self-doubt or low confidence in their ability to complete tasks. Individuals tend to feel out of control because they are unable to change their circumstances or move away from them (Grupe & Nitschke, 2013). One participant mentioned, “I don't feel like I can do any of my daily tasks; and I think the situation will remain the same; I do not believe I can change it.”

Participants with low self-esteem also felt worthless, because they believed they were insignificant. Due to loss of identity, as one participant put it, “I have already lost my body, my face, my identity, and now I am nothing but a living corpse”

Social Avoidance

For many acid attack survivors, isolation and social exclusion from society are unavoidable consequences of living with disfigurement. As a result, many survivors are restricted to their houses, spending years or perhaps their whole lives hidden from public view. One of the participants stated,“I just want to stay at home till I die.” “I've shut myself up at home; I no longer meet people, I can be part of neither celebration nor hardships,”said another participant.

Most of the participants mentioned that they are housebound mainly due to social stigmatization and low self-esteem. As one participant mentioned, “People treat me as if I am untouchable, they don’t even see me, and if they see me, they see me with disgust and hatred, that’s why I don’t want to go outside.”

Social Rejection

 Social rejection is the fourth theme that involves victims’ blaming, character blaming, and social criticism. According to this research, acid survivors suffered in various ways in their struggle to social acceptance. People tend to reject them based on their facial disfigurement.

Victim blaming is a demeaning act in which the victim(s) of a crime or an accident are held liable as a whole or in part for the crimes perpetrated against them (Andrews et al., 2003). The most important issue that contributes to the obstacle to social acceptance of acid survivors is victim blaming. People frequently rationalize or attribute the occurrence to the victim. People say she must have done something to provoke her husband to throw acid; no one can take such a step out of nowhere, one participant explained.
Character blaming is the second most common challenge that participants face in their struggle for social approval. Participants stated that their neighbors and in-laws disparage their character to shift blame away from them. One participant narrated, “My mother-in-law splashed acid on me and then they defamed me by stating I was having an affair with some unknown males.”

Social criticism is the most important component in acid survivors' struggle for social acceptance. Because of their lasting scarring and disfigurement, survivors are subjected to ridicule and stigmatization. A participant reported, “people look at me with hatred in their eyes, they make fun of me and gossip about me, they tell them I've turned into a witch, and that they're terrified of me.”

Risk Factor for Under-Reporting of Cases

The foremost common reason for underreporting the case is to protect their family honor. Participants revealed that their family pressurize them to do so because the police involvement would bring shame to the family. “My family had been defamed by neighbors, and people were gossiping about my family, so my parents forced me to withdraw my case”, one participant affirmed.

Bribery is another frequent factor contributing to the underreporting of acid survivors' cases. Acid violence offenders are rarely detained or punished, and survivors have claimed that police officers released the offenders in return for bribes. “My husband spent a month in jail but got out after bribing the cops; the cops have not caught him since then and forced me to withdraw my case,”said one participant.

Another common reason for not reporting the case was fear of retaliation; participants stated that they wanted to report the crime to authorities but were afraid that the offenders would harm them in retaliation. “I'm afraid my spouse would attack me if I filed a complaint against him,” one of the participants said.

Protecting Factors

Children have been discovered to be the most important factor in inspiring survivors and deterring them from completing suicide. Participants expressed suicidal thoughts but stated that their children were their primary reason for living. A participant in her 30s with two children stated, “my children are the only value I have left in this life; if I didn't have children, I would be dead by now.”

According to this study, non-governmental organizations (NGOs) such as the ASF of Pakistan play an important role in protecting acid survivors. They not only offer counseling but also help them report crime and regain custody of their children, which is a common problem among acid survivors. "ASF used to send a madam to talk to me about my mental condition, which made me feel good for a while," one participant recalled. ASF helps me financially and with child custody," another participant said. "When I filed the case, the police did not take it seriously," said another participant, "so ASF assisted me in filing the case.

Discussion

This study aimed to explore the psychological experiences and struggle for social acceptance and justice among female acid survivors. The findings suggest that family disputes, rejection of proposals, and neighborhood disputes are the leading causes of acid attacks. Psychological distress (suicidal ideation, in-law violence, fear of revictimization and hopelessness), low self-esteem (self-hatred, self-doubt, and sense of worthlessness), social avoidance, and social rejection (victim blaming, character blaming, social criticism) were reported among the participants. The study also addressed a gap in the literature on acid survivors' struggle for justice by examining the risk factors of underreporting the cases and protecting factors for survivors.

The first theme suggests that acid survivors experience psychological distress characterized by suicidal ideation, learned helplessness, fear of re-victimization, and Hopelessness. According to the findings of a study on acid attacks and their clinical and psychological implications, acid survivors experience psychological distress, which can lead to suicide ideation (Zalmai & Amiri, 2021). According to cognitive-behavioral models of suicide, people's reactions to stressful life events and unpleasant emotions, such as ruminating on negative memories or feelings of thwarted belongingness, can increase their risk of suicidal crises (Williams et al., 2011). Rumination, avoidance, and learned helplessness have all been connected to increased levels of distress (Karekla & Panayiotou, 2011). According to a study, the South Asian community's patriarchal structure is one of the most important factors in predicting the likelihood of domestic violence within the family, which causes psychological distress for survivors of acid attacks (Chokshi et al., 2010). The dread of re-victimization is another element that may be contributing to psychological suffering among acid survivors.  Victimization hurts the victims, even if it just happens once. Nonetheless, a lot of participants voiced concerns about experiencing the traumatic experience again or becoming a victim again (Mittal et al., 2021). Reliving trauma is a persistent source of terror for acid survivors (Singh et al., 2018). Finally, hopelessness also contributed to psychological distress of the acid attack survivor. People have a natural urge to control their perspectives of themselves and the world, which helps people maintain a sense of safety and relationships with others (Grawe, 2017). Acid survivors who lose control over their experiences feel a great deal of hopelessness because of the discrepancy between their desires and reality (Powers, 2005). This mismatch may cause psychological distress (Azam, 2014), which is in line with the study's findings. These results are aligned with trauma research, which have shown that traumatic experiences might exacerbate depressive symptoms like hopelessness, suicidal thoughts, and victimization (Wang et al., 2023).

The second theme suggests that acid survivors have low self-esteem, characterized by self-hatred, self-doubt, and feelings of worthlessness. The inability to fit in with a group can lead to low self-esteem (Whalley & Kaur, 2020). Acid survivors may experience low self-esteem because of their alienation and isolation from society, as well as society's judgment of them as unusual and out of the norm (Gulrez, 2016). Self-hatred among acid survivors is also backed by a study that revealed that acid survivors usually have feelings of self-hatred, self-guilt, worthlessness, and low self-esteem because of hurtful comments and humiliation from close family members (Patel, 2014). Self-doubt in acid survivors is supported by a study titled "Acid burns attacks: looking beneath the surface," which claims that the impact of acid attacks causes victims to have self-doubt (Cleary et al., 2018). Sense of worthlessness among acid survivors was also prevalent among acid survivor in the current study, this finding is corroborated by another study, which describes that acid victims experience psychological trauma in many ways including feelings of worthlessness and shattered self-confidence (Goswami & Handa, 2020).

The third theme was social avoidance, which indicated that acid survivors prefer to stay at home due to their facial deformities, misery, and social rejection. This is backed by research titled "A Phenomenological Analysis of Coping Strategies among Acid Survivors," which claims that acid survivors use an avoidance strategy, which involves restricted social interaction, to avoid encountering people due to their disfigurement and social stigmatization (Batool et al., 2022). Social isolation has been a prevalent affliction among acid survivors that refers to the victims' emotions of loneliness, sadness, low self-worth, humiliation, and other mental health difficulties. According to a study, people who experience traumatic events may develop an avoidance coping style as a protective measure to lessen their exposure to trigger environments (Korem et al., 2023).

The fourth theme indicated that survivors experienced social rejection, including victim blaming, character blaming, and social criticism. Victim-blaming, which is the practice of holding victims partially accountable for their misfortune, was experienced by acid survivors in the current study. This is consistent with another study that reports that survivors of acid violence received blame from society instead of empathy (Deb & Chaudhary, 2015). Another study highlighted that social stigma surrounding acid attack often aggravate victim blaming (Sharma et al., 2022).  Findings also depict character blaming of the survivors which they encounter because of the acid attack. An article written on gender-based violence reveals that in gender-based violence women are subjected to character assassination which is done to protect the culprit (Irfan, 2021, January 20). Additionally, the current study shows that social rejection in the form of social criticism is experienced by acid survivors. These results are in line with previous empirical research, such as a study that examined the interpersonal relationships of female victims of acid burns and discovered that the victims' psychosocial well-being was negatively impacted by harsh public remarks (Mujeeb & Kamal, 2018).

The results of this study also identified the risk factors for underreporting of cases, including family pressure, family honor, bribery, and fear of retaliation as some of the reasons why survivors opted to disregard or not report the case to legal authorities. The first factor was to protect “family honor”, which is consistent with another study that found that since most offenders are related to their victims, families frequently persuade the victim to drop the case or not to pursue it to protect the offender and label it a "family problem" (Zaman, 2014). The current study's findings are corroborated by another study that discovered rural women who experience domestic abuse believe that reporting the abuse to the police might disgrace the family (Shah, 2019, September 22).
The use of bribery, identified as the second significant factor in the current research, sheds light on its profound impact on justice delivery. Bribery often results in offenders being released from prison before completing their sentences, undermining accountability. A 2016 article titled “This Crooked System: Police Abuse and Reform in Pakistan” further illustrates the systemic challenges faced by those without political or financial clout when attempting to file a First Information Report (FIR), particularly against influential individuals. A senior police officer described the FIR as an "instrument of tyranny" frequently exploited by the ruling class to oppress the vulnerable. Moreover, economically disadvantaged groups have expressed concerns about withdrawing a filed FIR due to the "money cost of doing business with the police," highlighting the entrenched role of bribery in obstructing equitable access to justice (Ataullah, 2016).

The third factor was identified as fear of retaliation, particularly when spouses or in-laws were perpetrators. This factor contributes to the underreporting of acid attack cases because survivors frequently fear that if they report the incident to the police, the perpetrator may come for revenge. This is consistent with research on interpersonal victimization that demonstrates that victims frequently exhibit fear when disclosing information to safety services, and this fear acts as a significant barrier to receiving assistance or documenting the incident to authorities (Heron & Eisma, 2021).

Furthermore, some protective factors for acid survivors were also revealed through this study including children and formal support. Participants claimed that their suicide impulses were restrained by their concern for children.  This is consistent with another study that emphasizes the resiliency and development of female survivors of domestic violence, stressing that children frequently act as strong motivators for psychological rehabilitation of mothers (Young, 2007).

The findings of this study show that formal support, such as the involvement of a non-governmental organization (NGO), acts as a protective factor for participants. This is consistent with earlier studies that indicate. Such support provided by NGOs, in our case ASF, aids in both mental and physical well-being (Athar et al., 2020). Formal support such as skilled education, awareness, and psychological counseling can improve the psychological health of people who have experienced trauma. Such support has been linked to a decrease in traumatic symptoms (Schexnaildre, 2011).

Limitations

Although this research makes a substantial contribution to the field, the limitations should be considered. The first limitation is that only one organization was used to select participants for this study and there may be differences in opinions among acid survivors associated with various NGOs based on the psychological treatment and rehabilitation services they provide. Another limitation is that all study participants were uneducated and from rural areas. There is a possibility that educated urban women have a different perspective on life.

Future Recommendation

The current study significantly enhance the understanding of the psychological impact of acid violence on female acid attack survivors and their ongoing struggles for social acceptance, underscoring the critical need for tailored psycho-social interventions to address the unique challenges they face. Future research should prioritize urban women and other organizations working with survivors to gain deeper insights into the broader social and psychological dimensions of acid violence. Policymakers should enact stringent laws to prevent re-victimization by ensuring that perpetrators are either imprisoned for life or prohibited from residing in the same neighborhood as their victims. Barriers to justice, such as survivors withdrawing cases or not reporting incidents, must be addressed through comprehensive policy reform and public awareness initiatives to empower survivors to seek justice and hold perpetrators accountable. For survivors unable to leave their homes, home-based skills development programs should be established to promote financial independence and self-sufficiency. Corrective surgeries, essential for survivors’ physical and emotional recovery, should be prioritized and potentially funded through offender restitution. Dedicated support centers should be created to provide safe spaces for survivors to share their experiences, access emotional support, and build resilience. Public campaigns can play a vital role in raising awareness about the long-term consequences of acid violence, reducing stigma, and fostering societal support for survivors. Healthcare institutions, particularly surgical centers, should adopt a compassionate, trauma-informed approach to treatment, with medical professionals avoiding language or behaviors that could contribute to body dysmorphic disorder (Uludag, 2022). By addressing these recommendations, society can better support survivors, reduce stigma, and promote justice, offering them the means to rebuild their lives with dignity and hope.

Conclusion

The purpose of this study was to examine the psychological experiences of acid survivors and their struggle for social acceptance and justice. Twelve acid survivors were interviewed, and the data was analyzed by thematic analysis. Psychological distress, low self-esteem, social avoidance, social rejection; Reasons for withdrawing the police report and not making the police report were all identified as key issues. These results suggest that there is a need for mental health interventions for acid survivors to make life easier for survivors, as well as setting up initiatives to address the variables that contribute to reluctance to report the case or retract a police report. Attempts to change policy and ensure safety must continue until the safety of women seeking freedom in public is no longer in question.

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Received 12 July 2023
Revision received 15 January 2025