Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, 300-Prince Philip Drive, St. John's, A1B 3V6, Canada. )
Sujay Patel  ( Discipline of Psychiatry, Memorial University of Newfoundland, 300-Prince Philip Drive, St. John's, A1B 3V6, Canada. )

The menace of Karo-Kari has been a subject of wider debate by human rights activists in Pakistan, which has spread fast throughout the world. This is a homicide, which is mentioned under the caption of 'honour killing' and also described as 'transcultural homicide' because of its relation to specific cultures. Karo-Kari is a compound word, which means a 'black male' and 'black female', respectively. These are metaphoric terms for those who commit illicit pre-marital or extra-marital relations. A Karo-Kari act is initiated when a female is labeled as a Kari because of the perceived dishonour that she had brought to the family by being in illicit relationship with a man who is subsequently labeled as a 'Karo'. Once labeled as a Kari, male family members get the self-authorized justification to kill her and the co-accused Karo to restore family honour.1 This is especially true in the rural areas of the southern province of Sindh whereas, in other parts of the country, women are more likely to be accused of sexual improprieties and murdered in the name of honour killing. Official data shows that about 6000 were killed; most of these belonged to Punjab, followed by, Sindh, NWFP and Baluchistan. Of the 2774 murdered women, 1578 were killed in Punjab, 751 in Sindh, 260 in NWFP and 185 in Baluchistan. Of the 1327 murdered men, 675 were killed in Punjab, 348 in Sindh, 188 in NWFP and 116 in Baluchistan.2 In Sindh, it was noticed that literacy had a strange association with such killings, which is evidenced by the fact that nine such murders were committed in Karachi with literacy rate of 65.26%; the lowest literacy rate is in Tharparker (18.32%) where no such murder was committed.3 Women in rural areas are constantly suppressed and this reality is further augmented by low literacy level, male dominance and hidden agendas. Domestic violence and other sorts of atrocities are reported from time to time. It is not surprising that the prevalence of depression and other psychiatric ailment is much higher. The United Nations Charter4 has reaffirmed their faith in fundamental human rights, in the dignity and worth of the human person and in the equal rights of men and women and has determined to promote social progress and better standards of life in larger freedom. According to human rights article 3: "everyone has the right to life, liberty and security of person" and article 7 says "all are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination". Article 16 states "men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to find a family". The United Nations in its general assembly has passed a resolution about elimination of violence against women and in its article 4 has emphasized upon states to take active role in preventing violence against women in any form.5 Much has been discussed about this subject and the laws related to this, especially about the recently introduced bill for the protection of women. Questions arise as why the women are targets in one form or other, starting from the ancient Arab custom of burying the daughters alive, honour killings in different parts of the world, the ritual of "satti" and subjecting women to forced prostitution and bonded labour. It is important to look at this problem from a psychiatric angle. The theory of aggression against the own kind has something to say but by virtue of human nature and in many instances the still dominant "id" which is based on pleasure principle has lead to perpetration of crimes like "karo-kari". This can be further explained on the basis of low literacy, moral freedom and limited insight about ethical and religious values. A disturbed psychodynamics of perpetrators, which develop revenge and sadism and hence initiating violent crimes, is also a possible mechanism. A new study6 has found that there are biological brain differences among criminal psychopaths, compared with normal people, when they process facial emotion. The growing scientific and popular focus on genes has contributed to resurgence of behavioral genetic determinism. Personality traits have been found to be risk factors for engaging in criminal behaviour.7 The dopaminergic and adrenergic pathways are also known to be associated with impulsivity and hostility.8 Evans et al9 identified an association between the serotonin receptor 2C gene HTR2C and impulsivity in males. The theory of Xyy chromosome pattern has not gained much momentum but still holds place in the literature when it comes to explanation of violent behaviour.

Mental illnesses are also known to be associated with criminal behaviour as a study10 reveals that among homicide offenders 20% had psychotic illness and 54% had personality disorder as principal or secondary diagnosis. Psychopathy has been discussed widely in the context of criminality especially in terms of its characteristic callous and unemotional personality profile. According to Kiehl11, organic findings on fMRI of criminal psychopaths indicated their failure to show the appropriate neural differentiation between abstract and concrete stimuli in the right anterior temporal gyrus and surrounding cortex. There is a support for the theory that psychopaths are associated with right hemisphere abnormalities for processing conceptually abstract material. There are many possible explanations in terms of mental mechanisms for those who resort to crimes like 'Karo-Kari', however, there are few questions that may arise: are the perpetrators real psychopaths which by definition has a salient feature of 'lack of remorse or guilt', are they insane? If yes, then, how are they left loose in community, are they mentally ill? If yes, then, why have they not come across the mental health services? It is quite understandable in the given cultural context where mental illness is still a stigma and most of the people will not give due importance to psychiatric disorder. Is it easy to rule out the possibility of 'mass psyche' disturbance? Can it be a social norm? The answer to this cannot be in affirmation as Karo-kari is only endemic in Pakistan and in different forms at a global level. It will not be surprising if one day it would emerge as one of the new culture-bound syndrome, this time specific to Pakistan by the name of "Karo Kari Syndrome" which may be explained in clinical terms as "sudden feeling of loosing honour, feeling as if the powers are gone, extreme anger, irritability and wild impulse of killing the identified targets" the features somewhat similar to 'Latah' which is a recognized culture-bound syndrome. It may also reflect the pleasure principle of 'Id' which has remained immature and has not attained full evolution and transformation. This problem is being perceived wrongly by the global observers and portrayed as if this menace is a part of national psyche which meets the hidden approval. The human right activists have raised their voice in the media against it but it would also be appropriate if the mental health professionals provide their input into this issue. It is also surprising that the United Nations and W.H.O. who advocate for the mothers and make policies to save the women from dying because of health related issues are so helpless in saving the women who are killed under the 'honour killing' pretexts.

1. Gadit AM, Patel S. Karo-Kari: Women need further protection. Comment. The Lancet, 2006, 368: 1938.

2. www.asianews.it/view.php "Muslim leaders give thumbs up to law protecting women" by Qaiser Felix - date accessed: 24th December, 2006.

3. www.sindhedu.gov.pk/Links/karokari%20new.htm "Nexus of illiteracy and honour killing" Sindh Education department- date accessed: 24th December, 2006.

4. www.un.org/Overview/rights.html "Fiftieth anniversary of the Universal Declaration of Human Rights: 1948-1998" United Nations- date accessed: 22/12/2006.

5. www.ohchr.org/english/law/eliminationlaw.htm "Mission Statement" United Nations High Commission for Human Rights-date accessed: 22/12/2006.

6. www.rcpsych.ac.uk/pressparliament/pressreleases2006/pr857.aspx "Biological brain differences found in criminal psychopaths when processing Facial Emotions" The Royal College of Psychiatrists, London- date accessed: 21/12/2006.

7. Carson RA, Rothstein MA. The clash of culture and biology. Behavioral Genetics 1999, 44: 224-32.

8. Reif A, Lesch KP. Toward a molecular architecture of personality. Behavioral Brain Research 2003; 139: 1-20.

9. Evans J, Reeves B, Platt H, Leibenow A, Goldman D, Jefferson K. Impulsiveness, serotonin genes and repetition of deliberate self-harm(DSH). Psychol Med 2000; 30: 1327-34.

10. Fazel S, Grann M. Psychiatric morbidity among homicide offenders: a Swedish population study. Am J Psychiatry 2004; 11: 2129-31.

11. Kiehl KA, Smith AM, Mendrek A, Forster BB, Hare DD, Liddle, PF. Temporal lobe abnormalities in semantic processing by criminal psychopaths as revealed by functional magnetic resonance imaging. Psych Res 2004; 3: 297-312.