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Influence of Marriage on Women’s Participation in Medicine: The Case of Doctor

Brides of Pakistan

Article  in  Sex Roles · March 2018

DOI: 10.1007/s11199-018-0909-5

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 Sex Roles
Influence of Marriage on Women's Participation in Medicine: The Case of Doctor
Brides of Pakistan
--Manuscript Draft--

Manuscript Number: SERS-D-17-00097R3

Full Title: Influence of Marriage on Women's Participation in Medicine: The Case of Doctor
Brides of Pakistan

Article Type: Original Research

Keywords: Women in Science, Technology, Engineering, and Mathematics; Marriage and Family
Measures; Muslim women; Gender Gap

Corresponding Author: Ayesha Masood

Lahore University of Management Sciences
Lahore, PAKISTAN

Corresponding Author Secondary

Information:

Corresponding Author's Institution: Lahore University of Management Sciences

Corresponding Author's Secondary

Institution:

First Author: Ayesha Masood

First Author Secondary Information:

Order of Authors: Ayesha Masood

Order of Authors Secondary Information:

Funding Information: Wenner-Gren Foundation Dr. Ayesha Masood

American Institute of Pakistan Studies Dr. Ayesha Masood
Arizona State University Dr. Ayesha Masood

Abstract: Despite the difficulties women in Pakistan face in their access to education, their
numbers have been increasing consistently in medical colleges. However, most of the
women medical graduates do not go on to practice medicine after graduation. One of
the reasons suggested by Pakistani media and society for this increase in the number
of women medical graduates is the desirability of women doctors in Pakistan's
marriage market. Based on an ethnographic study of Pakistani women doctors, I
examine why women doctors are considered desirable as spouses and how this
influences women's access to medical education. I found that women doctors are
valued as marital partners because of the status granted to them by their academic
credentials, chaste educational experience, and potential to contribute to family
income. Because of the value of medical education in marriage, parents are more
willing to invest in their daughters' education, facilitating women's access to medical
education. I also found that, as a way of bargaining with the patriarchy, women doctors
accept the social norms of arranged marriage because it allows them access to
professional education, economic opportunities, and a better bargaining position in the
marriage market. Overall, I found that, unless underlying patriarchal norms are
addressed, potentially empowering projects like women's education will be co-opted by
the existing structures of domination. I also discuss potential implications for changing
marriage patterns and increasing representation of women in Pakistan's medical
workforce.

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Email Addresses, Departments, Institutions, Schools and

Running head: DOCTOR BRIDES 1

Influence of Marriage on Women’s Participation in Medicine: The Case of Doctor Brides of

Pakistan

Ayesha Masood

Lahore University of Management Sciences

Author Note

Ayesha Masood, Suleman Dawood School of Business, Lahore University of

Management Sciences,

The research for the present paper was supported by grants from Wenner-Gren

Foundation, Arizona State University and American Institute of Pakistan Studies.

Correspondence concerning this manuscript should be addressed to Ayesha Masood,

Suleman Dawood School of Business, Lahore University of Management Sciences,

Opposite Sector U, DHA, Lahore, Pakistan. Email: ayesha.masood@lums.edu.pk

Manuscript (No Author Information; Includes any Tables and Click here to view linked References
Figures)

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19 Influence of Marriage on Women’s Participation in Medicine: The Case of Doctor Brides of
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Ayesha Masood
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26 Lahore University of Management Sciences
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38 Author Note
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Ayesha Masood, Suleman Dawood School of Business, Lahore University of
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43 Management Sciences,
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45 The research for the present paper was supported by grants from Wenner-Gren
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48 Foundation, Arizona State University and American Institute of Pakistan Studies.
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50 Correspondence concerning this manuscript should be addressed to Ayesha Masood,
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53 Suleman Dawood School of Business, Lahore University of Management Sciences,
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55 Opposite Sector U, DHA, Lahore, Pakistan. Email: Amasood2@asu.edu
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Abstract
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7 Despite the difficulties women in Pakistan face in their access to education, their numbers have
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9 been increasing consistently in medical colleges. However, most of the women medical
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12 graduates do not go on to practice medicine after graduation. One of the reasons suggested by
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14 Pakistani media and society for this increase in the number of women medical graduates is the
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17 desirability of women doctors in Pakistan’s marriage market. Based on an ethnographic study of
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19 Pakistani women doctors, I examine why women doctors are considered desirable as spouses and
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how this influences women’s access to medical education. I found that women doctors are
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24 valued as marital partners because of the status granted to them by their academic credentials,
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26 chaste educational experience, and potential to contribute to family income. Because of the value
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29 of medical education in marriage, parents are more willing to invest in their daughters’
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31 education, facilitating women’s access to medical education. I also found that, as a way of
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34 bargaining with the patriarchy, women doctors accept the social norms of arranged marriage
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36 because it allows them access to professional education, economic opportunities, and a better
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bargaining position in the marriage market. Overall, I found that, unless underlying patriarchal
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41 norms are addressed, potentially empowering projects like women’s education will be co-opted
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43 by the existing structures of domination. I also discuss potential implications for changing
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46 marriage patterns and increasing representation of women in Pakistan’s medical workforce.
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48 Keywords: Women in Science, Technology, Engineering, and Mathematics, Marriage
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51 and Family Measures, Muslim Women, Gender Gap
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Influence of Marriage on Women’s Participation in Medicine: The Case of Doctor Brides of
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7 Pakistan
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9 Despite the considerable socio-economic benefits associated with women’s education,
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12 women continue to lag behind men in educational attainment in many parts of the world. Perhaps
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14 the most enduring and challenging gender gap remains in STEMM (science, technology,
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17 engineering, mathematics and medicine) fields where, despite multiple policy interventions,
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19 women continue to remain underrepresented across all disciplines (Etzkowitz et al. 1992;
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Henwood 2010). However, a paradoxical trend is seen in the medical profession in Pakistan
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24 where the number of women students has been consistently increasing in the past decade so that
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26 in many medical institutions, women students now outnumber the men by 2:1 (Pakistan Medical
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29 & Dental Council [PM&DC] 2017). This trend is particularly striking because women in
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31 Pakistan face multiple challenges in their access to education, ranging from traditional gender
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34 roles and norms of gender seclusion and segregation to uneven distribution of educational
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36 resources in different areas (Smith et al. 2007). To make the matters more complex, a majority of
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these women graduates do not practice medicine after graduation, resulting in a predominantly
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41 masculine physician workforce and an acute shortage of physicians in Pakistan. One of the
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43 reasons suggested by Pakistani media and society is that this increase in the number of women
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46 medical graduates is because of the desirability of women doctors in Pakistan’s marriage market.
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48 The paradoxical representation of women doctors in Pakistan and its connection with the
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51 marriage market points to important gaps in our understanding of underrepresentation of women
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53 in STEMM. Researchers identify multiple factors that contribute to a gender gap in women’s
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56 representation in STEMM, including gender stereotypes, explicit and implicit biases against
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58 women, and the climate of academia and workplaces in STEMM (Blickenstaff 2005; Etzkowitz
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et al. 1992; Valian 2005; Xie & Shauman 2003). However, an important, yet relatively
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7 unexplored, dimension of this issue, particularly in developing countries, is the intersection of
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9 education with the marriage market. In most developing countries, where both career and marital
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12 decision-making has become increasingly individualized, career choice is based on individual
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14 preferences, economic opportunities, and gender role expectations.
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17 However, in many developing countries where arranged marriage is still a norm, neither
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19 career choice nor spouse selection is an individual’s decision. Parents and extended families
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often play a decisive role in marital decision-making as well as in career choices (Donner 2005;
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24 Drury 1993). In many of these societies, especially South Asia, daughters’marriage is considered
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26 an important responsibility for which parents begin to plan, often years in advance (Jafarey et al.
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29 2014). Research on women’s education further suggests that in societies where traditional gender
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31 roles prevail, women’s education is valued less in the marriage market, often making families
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34 reluctant to invest in the education of their daughters (Chiappori et al. 2006; Khan and Ali 2005;
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36 Memon 2007; Psacharopoulas, 1994). However, how the cultural norms of marriage influence
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parents’ decisions to invest in their daughters’ education remains relatively unexplored.
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41 Similarly, we know very little about how (and if) the value of women’s education in the marriage
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43 market influences women’s access and participation in STEMM careers. Therefore, it is
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46 important to understand how the practice and institution of marriage in patriarchal societies
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48 influence the career choices of women, as well as the implications of this intersection for
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51 representation of women in STEMM.
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53 To address this important theoretical gap, I specifically focus on the paradoxical
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56 representation of women in medical institution in Pakistan and its relationship to marriage
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58 norms. Based on an ethnographic study of women doctors in Pakistan, I explore the following
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research question: How do the marital norms and discourses in Pakistani society affect women’s
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7 participation in the medical profession? In doing so, I make the following contributions to
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9 research on the women in STEMM, specifically, and on women’s education more broadly. First,
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12 I contribute to the literature on women in STEMM by elucidating how, in the context of arranged
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14 marriages, future marriageability is an important mediator of women’s participation in STEMM.
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17 My findings suggest that an important reason for increasing numbers of women in medicine in
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19 Pakistan is the desirability of “doctor brides” in the marriage market. Women doctors are a
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highly sought-after commodity in the Pakistani marriage market because of the gendered
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24 construction of the medical profession. Women doctors, because of their medical education, are
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26 considered more likely to conform to prevalent gender norms as well as to be good wives and
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29 mothers while potentially contributing to family’s income. This makes women’s parents more
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31 likely to invest in their daughters’ education and specifically prefer the medical profession over
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34 other careers.
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36 Second, previous research suggests that educated women are less likely to enter arranged
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marriages and more likely to exercise their individual choice in marital matchmaking (Bhopal
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41 1999, 2000, 2011; Pande 2015). However, I found that instead of changing the dynamics of
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43 arranged marriages, women doctors engage in a strategic patriarchal bargain (Kandiyoti 1988)
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46 where they accept the norms of arranged marriages to gain access to education, career, and a
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48 better negotiating position in the mariage market. Overall, my findings caution against assuming
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51 a straightforward link between education and empowerment and suggest instead that, unless
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53 steps are taken to address the underlying values and norms in society, gender disparities in
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56 women’s participation in STEMM are likely to persist. Finally, previous research on educational
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58 decision-making and women’s representation in STEMM has primarily focused on western,
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developed countries. I extend this literature to Pakistan, a developing country with a Muslim
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7 majority, by highlighting how cultural context influences women’s representation in STEMM
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9 disciplines.
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12 Education, Marriage, and Empowerment
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14 Both sociological and economic theories of marriage emphasize the importance of
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17 education in the marriage market (Goldstein and Kenney 2001; Rose 2004; Sweeney 2002).
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19 Education, for example, is linked to spousal selection because educational attainment is
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considered a signifier of social capital and earning potential in a spouse (DiMaggio and Mohr
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24 1985; Furstenberg 2005). Educational systems mediate access to different social networks, not
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26 just those made directly in classrooms or educational institutions but also those that are made
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29 through friends, friends of friends, and acquaintances whom one meets, primarily because work
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31 and leisure activities are organized around the educational system. The education system thus
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34 acts as a filter allowing individuals to interact within certain circumscribed social circles; these
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36 interactions later potentially blossoming into marriages (Blossfeld 2009).
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These strong linkages between education and spousal selection have led some researchers
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41 to theorize educational systems as assortative marriage markets where couples are likely to be
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43 similar in traits like educational attainment, social status, race, and religion (Blossfeld and
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46 Trimm 2003; Mare 1991; Qian 1998). However, expansion of modern education in recent
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48 times—more so for women than men—has changed the dynamics of the marriage market. In
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51 dual-earner societies, for example, women’s education and labor force participation are
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53 becoming increasingly important (and desirable) in marriage (Blossfeld and Huinink, 1991).
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56 Conversely, in societies with traditional gender roles, increases in women’s educational
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58 attainment without accompanying changes in asymmetries of domestic labor have contributed to
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increased age at marriage, delayed or decreased fertility, and a declining marriage rate (Caldwell
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7 et al. 1983; Jeffery and Basu 1996; Samari 2017).
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9 Although there is ample evidence that education plays an important role in spousal
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12 selection and changing marriage patterns, there are important limitations in this line of inquiry:
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14 First, most research on marriage and education focuses on one side of the equation, namely, how
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17 women’s educational attainment implicitly or explicitly changes the demographics and economic
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19 feasibility of marriage (but see, Jafarey et al. 2014). On the other hand, the impact of marriage
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(and potential marriageability) on the women’s educational decision-making remains relatively
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24 unexplored. This is particularly important in the case of STEMM fields because differential
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26 gender role expectations and gender socialization—where women are expected to be more
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29 family-oriented—are important reasons why young women are less likely to participate in
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31 STEMM education (Eccles 1994; Eccles et al. 1990; Seymour 1999). We also know that women
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34 “opt out” of their careers to prioritize their roles as wives and mothers after marriage (Stone
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36 2007; Diekman et al. 2010). Expectations of marriage and domestic responsibilities also
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contribute to occupational segregation where women tend to remain concentrated in “women-
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41 friendly” professions (either by self-selection or increased attrition). In medicine, for example,
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43 women tend to choose subspecialties that have predictable work schedules to manage their
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46 conflicting domestic and work responsibilities (Allen 2005; Buddeberg-Fischer et al. 2006;
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48 Dorsey et al. 2005).
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51 Second, most research that links the marriage market with education is focused on
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53 societies where marital decision-making has become increasingly individualized. This is an
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56 important limitation because in many societies across the world arranged marriage is still the
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58 norm and the dynamics of spousal selection are likely to be different in these societies (Elias &
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Malik 2009; Sathar and Mason 1993;). To complicate matters further, in many of these societies
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7 (of which Pakistan is an example), parents and extended families exert considerable influence in
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9 educational decision-making as well (Rafiq et al. 2013). Some researchers suggest that in
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12 societies where women are expected to shoulder most household responsibilities, their education
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14 is valued less in the marriage market because educated women are considered less likely to
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17 conform to traditional gender role expectation. Parents in such societies are hence less likely to
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19 invest in their daughters’ education lest they become less eligible in marriage (Chiappori et al.
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2006; Khan and Ali 2005; Memon 2007; Psacharopoulas 1994).
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24 Moreover, patrilocality, a cultural norm in many societies like Pakistan, also deters
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26 parents from investing in their daughters’ education because their prospective earnings (if any)
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29 accrue only to their post-marital household (Jaffarey et al. 2014; Lahiri and Self 2007; DiPrete
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31 and Buchmann 2006). These distinct features of the Pakistani marriage market suggest that
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34 parents may be less likely to invest in their daughters’ education, potentially restricting women’s
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36 access to education. However, these cultural conditions do not seem consistent with the fact that
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the numbers of women in Pakistani medical colleges have been increasing steadily, in some
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41 cases, even surpassing the number of men. This paradoxical pattern points to an important
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43 limitation in our understanding of how education and the marriage market interact, especially in
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46 the case of arranged marriages.
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48 Finally, a thread that runs through research on education and arranged marriage is the
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51 issue of women’s empowerment and their agency. Education is often considered an agent of
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53 gender empowerment because it also allows women to have more say in their life decisions,
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56 including marital and spousal choice, by providing access to knowledge and economic
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58 opportunities, (Batliwala 1994; Jayaweera 1997; Grown et al. 2003). Indeed, researchers link
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increasing literacy to the change in marriage patterns from arranged marriages to where young
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7 people have much more say in the choice of their spouse (Ahearn 1994, 2001; Ghimire et al.
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9 2006). Educated women not only are less likely to have arranged marriages but, in some case,
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12 are also able to negotiate better matches for themselves (Bhopal 1999, 2000, 2011; Pande 2015).
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14 Thus, a potential consequence of growing numbers of highly educated professional women may
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17 be an increasing number of women who are less inclined to enter arranged marriages and more
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19 likely to take a more independent attitude toward their life, possibly fueling a social change in
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Pakistani society. However, we still have limited understanding of how (and if) increasing
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24 numbers of highly educated professional women have facilitated changes in the marriage market
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26 in Pakistan. The women doctors of Pakistan present an ideal case to explore these theoretical
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29 questions.
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31 Doctor Brides
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34 Although the female literacy rate in Pakistan remains low and women are consistently
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36 underrepresented across all STEMM fields in Pakistan (Pakistan Council of Research and
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Technology, 2013), the field of medical education is a conspicuous exception. The number of
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41 women in medicine has been rising consistently in past decades (PM&DC 2017), and in many
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43 medical institutions, more than 80% of students are now women. Unfortunately, the increase in
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46 number of women medical graduates has not translated into a concomitant increase in the
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48 number of working women doctors because many women who graduate do not go on to practice
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51 medicine (Arif 2011). Statistics from Pakistan Medical and Dental Council (PM&DC 2017), the
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53 registering authority for medical practitioners in Pakistan, provide some evidence of this marked
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56 disparity: Whereas women outnumber men in medical colleges, only 45% of registered medical
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58 practitioners and a mere 27% of medical specialists are women. The implications of this trend
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are grave: It has worsened the mismatch of physician supply and demand, resulting in an acute
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7 shortage of physicians. Moreover, because medical education in Pakistan is highly subsidized by
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9 the government, this leakage of women doctors from the workforce is a significant loss for an
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12 already resource-scarce health economy of Pakistan.
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14 To address the acute shortage of doctors in Pakistan, in an extremely controversial move,
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17 PM&DC instituted a gender-based quota on admission in September 2014 by limiting the
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19 number of women students to 50%. Although this quota was immediately challenged in the
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Lahore High Court and was subsequently declared as discriminatory by the Court (Lahore High
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24 Court Decision in Asma Javaid etc. vs. Government of Punjab etc. W. P.No.28142 of 2014), it
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26 generated considerable debate in Pakistan regarding women doctors’ career choices and their
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29 marriages. For example, Pakistani media portrayed the large number of non-practicing women
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31 doctors as evidence of the fact that medical education has become the latest status symbol for
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34 women in Pakistan, where they opt for the medical profession only to become more valuable in
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36 the marriage market (Abid 2014; Channel News Asia 2013; Humayun 2014; Junaidi, 2014;
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Wiquar 2014; Zakaria 2013). This issue of Pakistani women doctors, dubbed “the doctor bride
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41 phenomenon” (after an article published in Dawn, a Pakistani English newspaper) generated an
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43 intense discussion about whether a country like Pakistan with limited resources and in desperate
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46 need of health professionals should continue to invest in what was termed as a substitute for
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48 dowry (Abid 2014; Wiquar 2014). Overall, both the rising percentage of women medical
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51 students and their persistent underrepresentation in the medical profession raises important
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53 questions about the intersection of marital norms, career choices, and women’s agency.
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56 Marriage Market in Pakistan
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I propose that the intersection of medical education for women and marital norms in
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7 Pakistan can best be conceptualized through the metaphor of a market, where the currency is
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9 different, fungible forms of capital—social, cultural and economic, as proposed by Bourdieu
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12 (2011/1986). Instead of economic markets, where most decisions are taken by individuals,
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14 family is the primary unit of analysis in the marriage market. In South Asia generally, and
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17 Pakistan especially, status and prestige play an important role in the marriage market because
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19 people measure their standing in the community not only by their personal accomplishments but
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also through the cultural capital they have acquired through their social networks (Carter 1973;
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24 Mines 1988, 1994). Thus, as all families try to improve their social standing, every marriage
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26 transaction is a carefully orchestrated maneuver to maximize the accumulation of capital through
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29 new marital kinship connections (Dube 1997; Shah 2012; Shaw 2006; Shaw and Charsely 2006).
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31 Every possible effort is made to arrange marriages to families that belong to the upper
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34 socioeconomic class, have cultural markers of status (like fair coloring, fluency in English, and
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36 being well-educated), are of a suitable caste, have a good reputation, and have members in
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positions of power (Donnan 1985; Fischer 1991; Fricke et al. 1986;). The double meaning of
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41 risha, the Urdu word for marriage proposal, also signifies these underlying assumptions: It is
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43 also the most commonly used word for a familial connection (Shaw and Charsley 2006). In other
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46 words, a marriage proposal is literally an offer to connect two families, not just two individuals.
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48 A good rishta in Pakistan can thus provide families with an additional supply of economic and
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51 social capital. In this way, marriage becomes the easiest route for social mobility: Marrying a
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53 woman who has greater social, cultural, and economic capital raises the status of the groom and
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56 his family, and vice versa (Bloch et al. 2004).
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58 Method
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Field Site
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7 The data that I present in the present article is part of a larger study carried out to
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9 understand the social factors, organizational policies, and institutional practices that underlie the
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12 paradoxical representation of women doctors in medical education and their attrition from the
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14 workforce in Pakistan. Although gendered division of domestic labor, difficulties in balancing
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17 work and life, lack of social policies like childcare, and the climate of Pakistani medical
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19 workplaces play an important role is women doctors’ exit from the workforce, in the present
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paper, I primarily focus on the intersection of medical education and the marriage market of
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24 Pakistan. I conducted ethnographic fieldwork for this study in Lahore, Pakistan from September
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26 2015 to March 2017. Lahore is the second most populous city in Pakistan and a major hub of
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29 medical education and training in the country (with 19 public and private medical colleges and
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31 universities and more than 100 public and private hospitals). Because I had studied as a medical
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34 student and later worked as a woman doctor in the same city, I had numerous contacts at local
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36 medical institutions which made it easier to gain access.
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39 Participant Observation
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41 I carried out participant observation at various medical institutions (two public teaching
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43 hospitals, two private hospitals, and one public specialty hospital). I also visited doctors in their
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46 homes, and I participated in their formal and informal gatherings like get-togethers, parties,
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48 academic lectures, and conferences during my fieldwork. During participant observation, I
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51 followed doctors in their daily routines, observed their work and their interactions with their
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53 colleagues and patients, and participated in their informal conversations and day-to-day work
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56 routines. At each site, I introduced myself to everyone present and described the purpose of my
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58 study as clearly as possible. Because the issue of women doctors was a topic of intense debate at
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that time, it usually led to passionate discussions because many doctors were eager to share their
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7 opinions and their experiences. This informal socialization was an extremely rich source of data.
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9 I jotted down initial observations in the form of scratch notes at the site and then expanded on
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12 these notes by writing detailed observational and analytic field notes later in the day (following
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14 the method described by Bernard 2006, pp. 387-413).
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17 Participants
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19 Although I interacted with numerous doctors, their family members, and members of
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Pakistani society during field work, I selected three group of participants for detailed interviews.
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24 The first group consisted of 60 women doctors in various stages of their career (group 1). Their
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26 demographic details are given in Table 1. I selected these participants using non-probabilistic,
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29 purposive sampling to maximize exposure to theoretically salient social categories (like different
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31 medical specialties, occupational experiences, and family living arrangements), as recommended
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34 by Patton (1990). Although nonprobability sampling does not allow for formal generalizations, it
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36 is an appropriate approach for in-depth ethnographic studies like the present one (Bernard 2006).
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To understand the familial context, I had initially intended to interview the family
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41 members of each participant (group 2). However, this proved difficult because many participants
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43 were not comfortable (despite assurances of confidentiality) in disclosing to their families that
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46 they had participated in a research study about their familial dynamics. However, I was able to
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48 conduct in-depth, semi-structured interviews with the parents, parents-in-law, and husbands of
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51 six women doctors (30 individuals in total, 18 men and 12 women). These interviews were 30–
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53 40 minutes long and covered topics related to women’s educational and workplace experiences.
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56 To understand the occupational context, I also conducted in-depth, semi-structured
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58 interviews with policymakers and health administrators in medical institutions (group 3). This
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group included three officials from the Specialized Healthcare and Medical Education
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7 Department, two from PM&DC, four medical superintendents, three professors, two associate
8
9 professors, two assistant professors, and one senior registrar (17 participants, all of whom were
10
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12 men). Because there were several assistant, associate, and full professors in group 1, I also
13
14 covered the management aspect of their job in their respective interviews. I must note that the
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17 participants I mention here are those with whom I conducted detailed, formal interviews. As part
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19 of the ethnographic study, I had the opportunity to talk to additional people about various aspects
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of their medical education and career (for example, I talked to matchmakers to understand the
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24 role of medical education in the marriage market). Some of these conversations were brief,
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26 others were long and detailed, and I used my field notes to capture details in these conversations.
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29 Interviews
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31 For the present study, I used a specific method of interviewing called person-centered
32
33
34 interviews (Levy and Hollan 2015, p. 313). It is based on the idea that the social world is
35
36 intersubjective and a person’s intentions and motivations can be understood only within the
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social, material and symbolic context in which they are embedded. Furthermore, unlike a
40
41 traditional ethnographic interview, which is based on group-level information, a person-centered
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43 interview explores how individuals experience the reality of their world to understand, from an
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46 individual’s point of view, what it is like to live in that area. The interviewee acts as an informant
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48 (about the cultural and social beliefs in a particular cultural locale) as well as a respondent (about
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51 what she thinks/feels about these beliefs) (Levy and Hollan 2015). This dual mode of
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53 questioning allowed me to explore how people understood their social context and cultural
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56 norms and how they responded to them in their day-to-day lives.
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At the beginning of each interview, I asked participants if I could record their interviews
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7 and audio-recorded them whenever consent for recording was granted (and took detailed notes if
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9 not). I started the interview with an open-ended question, such as “Let’s start with your
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12 childhood and schooling.” I let participants direct the narrative, occasionally probing further or
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14 asking follow-up questions. I also used questions like “What do you think about….” and “What
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17 do people say about…” to gather information about perceived social norms and individuals’
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19 responses to them. The interviews lasted an average of 45 minutes, with the longest being 2
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hours. I conducted the interviews in Urdu, which is the national language of Pakistan, with a
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24 smattering of English and Punjabi. Becuase I am fluent in all three languages, no translator was
25
26 needed. I coded the field notes gathered during participant observation, interview notes, and
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29 audio recordings using MAXQDA. I did coding and data analysis iteratively: After initial
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31 analysis, I conducted one or two follow-up interviews with selected participants to further
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34 elucidate salient research themes, as needed.
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36 Finally, it was easier for me to access women doctors and to fall in the rhythm of their
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workplaces because of my previous experience as a medical doctor. However, it also means that
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41 I had to be self-reflexive throughout the research about my own biases. For that I maintained a
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43 reflexive journal throughout my fieldwork. Moreover, I maintained long-term contact with
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46 participants beyond the interviews to capture any significant subsequent developments in their
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48 lives. I shared the results from my study with my participants individually and in groups for
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50
51 respondent validation, and I incorporated their suggestions in subsequent writing.
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53 Results
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56 The narratives of participants reveal multiple dimensions of desirability of women in the
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58 marriage market of Pakistan. Using an inductive approach (Bernard and Ryan 2010), I identified
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five main themes pertaining to the value of medical education in the marriage market. Medical
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7 education is considered desirable because it is considered a mark of status (“status”); it produces
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9 a certain kind of modern, class-based morality in women deemed respectable by society
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12 (“looking like a doctor”); the structure of medical education and career conforms to gender
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14 norms in Pakistani society (“honorable profession”); it allows women to contribute to family’s
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17 income (“economic advantage”); and finally, women doctors are considered good mothers
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19 (“good mothers”). Details of coding are given in Table 2. In the following, using the framework
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of social, cultural, and economic capital, I explore these themes in detail. All quotes, unless
23
24 noted otherwise, are from interviews and research notes.
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26 Status
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29 When I asked my participants how medical education figured in the marriage market, the
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31 most frequent answer that I received was that “it is a mark of status.” Medicine as a profession
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33
34 has always enjoyed a high degree of prestige across the world (Hodge et al. 1964; Shortell 1974),
35
36 and Pakistan is no different in this regard. Doctors are well paid and highly respected
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39
professionals. A doctor in Pakistan is commonly referred to as a maseeha (literally, a Christ-like
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41 miracle worker), capturing the prestige doctors enjoy in society. Being educated, women doctors
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43 are considered part of the educational elite of Pakistan, an upwardly-mobile, upper middle class
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46 that is well-educated and connected. Many participants felt that adding a doctor daughter-in-law
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48 to the family enhanced the prestige and status of the whole family. Hira, a mother of two doctors,
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51 remarked:
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53 I think now people are more educated now and they think it will be a show of
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56 class that the bride is a doctor. Even though education has been modernized now,
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there are other fields, but people still think that a doctor is a doctor and it’s the
5
6
7 best.
8
9 Farah, a doctor herself and mother to a medical student, further explained the importance
10
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12 of status and respect given to doctor in marriage: “It is all because of status. So that a mother-in-
13
14 law can proudly proclaim in social gatherings that my daughter-in-law is a doctor. This
15
16
17 immediately tells people that this is a good, respectable family.” Selma, mother-in-law to a
18
19 doctor, similarly remarked: “If the girl is doctor, it means she came from a good family. That her
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21
22
parents paid attention to how they brought up their children and educated them.” The
23
24 significance of social stature of the future bride and, more importantly, how much she could add
25
26 to family’s status also highlights the market-like nature of the Pakistani marriage system.
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29 Looking Like a Doctor
30
31 My participants further pointed out that women doctors are considered valuable in
32
33
34 marriage because their educational credential imply that women doctors have a certain
35
36 subjectivity, acculturation, and mode of being, or as one participant put it, “doctors look
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39
respectable.” In Pakistan, being an educated woman signifies having an embodied class-based
40
41 morality in which women are expected to cultivate middle class values of hospitality, politeness,
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43 domesticity, and refinement (Khurshid 2012). Educated women are also expected to have the
44
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46 self-discipline to know how their actions could harm them and their families (Khurshid 2015).
47
48 Fareeha, a mother-in-law to a woman doctor, explained:
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50
51 A doctor is refined and well groomed. You will not see her raising her voice, or
52
53 be rude, or use bad words in her language that other so-called educated girls do.
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56 You can tell apart a doctor just by the way she talks.
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Mona, a mother-in-law who has chosen a doctor as a daughter-in-law, further emphasized
5
6
7 this point: “Doctors don’t have their head in the clouds. They are practical. They don’t pester
8
9 their husbands for jewelry or extra money, or go on fighting with their in-laws like the other BA
10
11
12 pass girls do.” When I asked Raheela, a doctor herself and mother of a woman medical student
13
14 who was recently engaged to be married, about the desirability of a doctor daughter-in-law, she
15
16
17 took a more literal approach:
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19 I think educated people, doctors are much more refined. We [pointing to include
20
21
22
herself and me] don’t exceed our limits. We don’t wear strange dresses. I have
23
24 met my daughter’s class, half of it wears a headscarf, but if you see girls in other
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26 private universities, you would be surprised to see the kind of dresses they are
27
28
29 wearing now. So, this profession polishes you, the way you dress, talk and
30
31 behave.
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33
34 This kind of comportment, termed as “demure modern: (Lukose 2009, p. 77-80; also,
35
36 Marrow 2013), is a careful balance struck between more western style and traditional norms of
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38
39
dressing. Doctors during their education and subsequent training develop a sense of dressing
40
41 according to this cultural ideal. Fouzia, a medical resident, explained:
42
43 When my clinical rotations started, our professor told us that everyone should be
44
45
46 smartly dressed, no jeans or casual dresses for boys, ironed shalwar qameez
47
48 [traditional loose shirt and trousers] or dress trousers were a requirement. Girls
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51 should wear simple full sleeved shalwar qameez, no flashy ornate jewelry, and no
52
53 western dresses. He said, “A doctor should look like a doctor. Your patients won’t
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55
56 listen to you if you look like a young, careless or an unparh [uneducated] person.”
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Romana, another doctor, noted that “students in my class were often reprimanded for
5
6
7 wearing jeans or western dresses.” Hooria, a women doctor, concurred: “We were told to speak
8
9 in English, in classes and in hospital. Our teachers told us to speak confidently, authoritatively,
10
11
12 and in a refined manner, so we are recognized as doctors.” This enforcement of sartorial norms
13
14 and code of conduct serves a dual purpose. Looking like a doctor serves as a visible marker of
15
16
17 identity, which creates a hierarchy in the doctor-patient relationship, producing an aura of
18
19 authority, respect and class around the figure of doctor. More importantly, it also serves to
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21
22
inculcate women with certain kinds of dispositions and modes of being (modern dressing, polite,
23
24 fluent in English, and authoritative bearing in the case of women doctors) which are considered
25
26 desirable, prestigious, and authoritative. Thus, being a doctor is not just a set of educational
27
28
29 credentials and skills, it also includes performance of a certain recognizable and desirable class-
30
31 based embodied subjectivity and disposition.
32
33
34 Honorable Profession
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36 Another consistent theme explaining why women doctors were considered desirable for
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38
39
marriage was the cultural construction of medicine as a respectable and honorable profession for
40
41 women. Especially interesting is the cultural connection between medical education and chastity.
42
43 A doctor is desirable because the difficult and time-consuming medical education ensures that
44
45
46 she has had little time to socialize with the other gender, and thus she conforms to norms of
47
48 modesty and purdah expected by women in Pakistan. Kokab, a doctor herself and mother of two
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50
51 daughters who were in medical colleges, explained:
52
53 I think people prefer doctor women as a spouse because medicine is respectable.
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55
56 Because most of the doctors are bakirdar [chaste, literally someone with
57
58 character]. They are so tied up in studies they don’t have time to look around and
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be interested in boys. In comparison, there are girls in my family studying other
5
6
7 things, and they have these late-night study sessions with boys, so I think
8
9 medicine is much more respectable in comparison.
10
11
12 This connection is not superfluous. Many medical institutions themselves make sure that
13
14 their students have minimal interaction with students of the other gender. Rehana, mother-in-law
15
16
17 of a woman doctor, explained:
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19 Medical Colleges have a better environment [acha mahool] than other educational
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21
22
institutions. Women medical students just keep their head down, keep to
23
24 themselves and focus on studies. But in private universities, you see boys and
25
26 girls sitting together, going on dates. That’s also why parents like to send their
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28
29 daughters to medical colleges.
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31 To unpack this theme, it is important to first understand the structure of medical
32
33
34 education and the profession in Pakistan, a legacy of its colonial past. First medical colleges for
35
36 women were established in South Asia by British colonials to cater to the needs of women who
37
38
39
practiced purdah [a local practice of gender seclusion and segregation] (Arnold, 2000, p. 90). It
40
41 was assumed that secluded women preferred to be seen by women doctors and hence the need to
42
43 provide women doctors (Nair 1990). To accommodate these patients, women-only hospitals
44
45
46 were also established where only women doctors and staff practiced (Forbes 1996). The first
47
48 medical college established when Pakistan became an independent state was a women-only
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50
51 medical college (Fatima Jinnah Medical College) to ensure a supply of women doctors for
52
53 women patients and make it socially acceptable for women to access medical education (but no
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55
56 women-only engineering or law colleges were similarly created). However, due to the increasing
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58 demand of women doctors, all men-only medical colleges were opened for women as well (for a
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more detailed discussion of gendered transformation of the medical profession in Pakistan and
5
6
7 South Asia, see Arnold 2000; Forbes 1994, 1996, 2005). However, even in co-educational
8
9 medical colleges, gender boundaries between men and women students remained very much
10
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12 intact. The following excerpt from my field notes is an example:
13
14 In all the lecture theaters that I visited in Afridi and Lincoln medical colleges,
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16
17 men and women students were seated on opposite sides, with a respectable
18
19 distance between them. Asked a women student about the reason. She said: “It is
20
21
22
a tradition, It has always been like this. And it would be weird sitting in mixed
23
24 gathering.” A teacher also commented: “It allows students to focus on study and
25
26 prevents any mischief.”
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29 This arrangement ensured that students were segregated by gender even when they are in
30
31 same class room or lecture theater. Saleha, a 34-year-old women doctor, told me that on her first
32
33
34 day of medical college her professor specifically forbade the men and women students from
35
36 talking to each other. Farzana, another young post-graduate trainee, mentioned that her medical
37
38
39
college is “especially conservative. If someone saw a girl and a boy talking to each other, it is an
40
41 immediate scandal.” Other participants cited policing of gender norms by asking women students
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43 to cover their heads (that is, wear a headscarf), or issuing vague threats of giving bad grades
44
45
46 should a boy and girl student be seen together.
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48 Through these spoken and unspoken policies, medical institutions rigidly conform to the
49
50
51 norms of gender relations in Pakistani society. This indicates that medicine is considered
52
53 honorable primarily because its educational climate conforms to the gender norms of Pakistani
54
55
56 society. Through the control on women doctors’ interaction with men, their dress, and their
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conduct, medical colleges produce a certain kind of sexed, gendered, and classed subjects, the
5
6
7 coveted “doctor brides.”
8
9 Economic Advantage
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12 Interestingly, these norms of modesty and chastity that make women desirable as
13
14 potential brides also makes medicine an acceptable profession for women, providing them with
15
16
17 potential economic opportunities. Because women patients in Pakistan prefer to see women
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19 doctors especially for gynecological/obstetrical issues, doctors who are practicing in these
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22
specialties (literally doing women’s work) are quite successful. This potential of economic gain
23
24 also makes them (and especially gynecologists) attractive matches. Samina, a doctor, pointed to
25
26 the importance of a possible increase in income as a factor in the desirability of women doctors
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29 as daughters-in-law:
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31 It is because husbands think that it will be another earning hand. If he is a doctor,
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33
34 he thinks that I will open a clinic and she will work there, and earn some money.
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36 If he is not, he can always rely on extra income brought in by his wife.
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39
The cultural acceptability of medicine as a profession for women was also emphasized by
40
41 participants because for many women it is possible to practice medicine in a way that conforms
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43 to norms of modesty (Grünenfelder 2013). Many participants pointed out that women doctors
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46 could open a clinic in their home (a common practice in Pakistan), thus eliminating the need to
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48 go to offices where they have to interact with men. They also mentioned that women doctors
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51 could choose to see only women patients “and help their own kind, while honoring their
52
53 families.” These strategies of creating an almost separate sphere of work for women in medicine
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55
56 are so successful that, in an informal conversation, Javed, a professional matchmaker, suggested
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58 that “people do not just ask for a doctor bride’s match; they want specifically those women
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doctors who have specialized in gynecology. Because they are money-making machines [due to
5
6
7 their successful practices].”
8
9 Moreover, although in Pakistan’s society men are generally expected to be breadwinners,
10
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12 given the state of the economy, it is becoming increasingly difficult to manage a household with
13
14 one spouse’s wage. Thus, economic considerations are becoming increasingly important for
15
16
17 prospective marriage matches to such an extent that sometimes people seek a doctor bride
18
19 because she can generate income. Amjad (a doctor who is married to a doctor) specifically asked
20
21
22
his mother to find a doctor wife, as he explained:
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24 I am the eldest son. I have to care for my parents, marry off my sisters.
25
26 Somewhere down the line, I have to educate my own kids, build a house, buy a
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28
29 car. I am a doctor but there is no way I can carry out all these responsibilities on
30
31 my own salary. Having a doctor as wife, who can at least help me with these
32
33
34 things, is a big plus.
35
36 Interestingly, this is one theme where attitudes between different groups of participants
37
38
39
varied. Although a majority of the women doctors and their parents all noted the importance of
40
41 economic security and the potential to generate income as reasons why doctors are considered
42
43 desirable in marriages, their husbands and parents-in-law were more ambivalent. All husbands
44
45
46 except one (quoted previously) were skeptical of the idea that their wives should work after
47
48 marriage. The response of Munir, whose doctor wife was employed, is perhaps the best example
49
50
51 of this position. He said: “I know my wife is earning a lot, but that is not why I married her. As a
52
53 man, it is my responsibility to provide for her and our children. I don’t spend her money. It’s
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56 unbecoming of a man.” Husbands’ primary interest is not in the medical career of their wife, or
57
58 her education. Rather it is that their wife keeps her end of bargain in the division of labor to
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which they are accustomed. Indeed, women doctors’ career and paid work, however valued, is
5
6
7 always considered less important than and secondary to their domestic work. There was a
8
9 general agreement among the men doctors that I met that a wife should not be too attached to her
10
11
12 career. “I don’t care if she works or not. That is entirely her own choice. But I want my wife to
13
14 take care of the home,” was the consensus. These attitudes were reflected in the narratives of
15
16
17 parents-in-law as well. Fazeela, a mother-in-law who was clearly unhappy at her working doctor
18
19 daughter-in-law, noted:
20
21
22
We did not bring her in our family for money. We thought an educated woman
23
24 will be a better, wiser and less quarrelsome daughter-in-law. But she started
25
26 working. We did not ask her. We don’t get any benefit out of it. It is all for her
27
28
29 own happiness.
30
31 These attitudes also provide a clue to the paradoxical representation of women doctors in
32
33
34 the workforce. Although doctors are desired in marriage, this desirability is primarily because of
35
36 their cultural capital: status, prestige, and an investment in the socialization of the future
37
38
39
generations. Their professional work holds less importance for their husbands and their in-laws,
40
41 which significantly reduces the support women get in their career after they are married (and
42
43 dependent on their husbands and families-by-marriage).
44
45
46 Good Mothers
47
48 Finally, women doctors’ desirability in marriage was also because they were considered
49
50
51 good mothers. In the Pakistani marriage market, even the skills and techniques that women
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53 doctors acquired as part of their professional training serve to reassert their place as a subject of
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55
56 marriage discourses. Their profession is seen as an extension of their caring and nurturing roles
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which makes them more capable wives and mothers. Naseem, whose two sons are married to
5
6
7 women doctors, explained her choice of daughters-in-law in precisely these terms:
8
9 Educated women take better care of their children. A doctor mother can benefit
10
11
12 her children so much, not just by taking care of their health, but also by
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14 transferring their knowledge to their kids. No school or academy can teach like a
15
16
17 mother.
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19 This was the theme that was most frequently mentioned in husbands’ and parents-in-
20
21
22
law’s narratives of their own decision-making regarding the choice of a daughter-in-law. Faseeh,
23
24 husband of a woman doctor, remarked:
25
26 I think the most important think my wife brings to the table is her education and
27
28
29 her skills as a doctor. Even when she is not working, she is caring for our
30
31 children. We never had to take them to a doctor, she takes care of their illnesses at
32
33
34 home. She checks my mother’s blood sugar level and my father’s blood pressure
35
36 daily.
37
38
39
Raheem, husband of another woman doctor similarly stressed the values her wife brought to
40
41 marriage as an educated person:
42
43 A person’s experience with schooling and their success changes their values in
44
45
46 life. They pick better schools for their children, coach them at home. Doctors, you
47
48 know, are the best of the best. Nobody can teach children better than a doctor
49
50
51 mother.
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53 Other participants mentioned the importance of “an educated mother ensuring her
54
55
56 children’s success in school,” “providing a good environment in home,” and “coaching her kids
57
58 so that they are proficient in English and can succeed in school.” To understand this point, it
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important to understand that in Pakistan’s educated middle class, education is considered a
5
6
7 primary strategy for family’s social mobility (Drury 1993). Parents expect their children to
8
9 succeed in education to increase the family’s social capital (by securing good jobs, arranging
10
11
12 good matches, and cultivating a persona of authority) (Donner 2005). An educated mother is thus
13
14 seen as a mobilization strategy because she can modernize the domestic sphere and provide
15
16
17 proper socialization for children at home. Families thus take care to select educated mothers who
18
19 can provide good education at home, that is, as a strategy of investing in the next generation’s
20
21
22
social capital.
23
24 Influence on Career Choice
25
26 To understand how the value of a medical education affects educational decision-making
27
28
29 in Pakistani society, I focused specifically on the narratives of the parents of the women doctors.
30
31 All the parents whom I interviewed mentioned that the prospect of a good rishta [marriage
32
33
34 proposal], facilitated by medical education, played a role in their decision to invest in their
35
36 daughter’s medical education. The specific “sweet spot” of a socially acceptable education with
37
38
39
the potential of gains in cultural, social, and economic capital that makes women doctors
40
41 desirable as a prospective spouse also explains why so many families choose medicine as an
42
43 education and career pathway for their daughters. In Pakistani society, timely marriage of
44
45
46 daughters is one of the primary responsibilities of a parent, and an unmarried daughter is
47
48 considered a great dishonor for the family. The demand and value of doctor brides in the
49
50
51 marriage market thus creates a feedback cycle that explains (in part) the surge of women in
52
53 medical colleges. Naima, a woman doctor whose daughter is also a medical graduate, explained:
54
55
56 I think marriage definitely has a role. Every parent wants their daughter to be
57
58 married in time, to have a good husband. And doctors do find good rishta [match]
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easily, so parent guide their daughters to this profession. They are thinking about
5
6
7 their future.
8
9 Hanif, all three of whose daughters are doctor, was more direct in his response: “I have
10
11
12 three daughters that I have to marry. People give huge dowries, cars, houses, money in the bank.
13
14 I could not afford that. So, I made my daughters doctors so they can marry into good families.”
15
16
17 Some indirect evidence of the length parents are willing to go to ensure that their daughters get
18
19 into medical colleges comes from the interviews of teachers of medical colleges who are directly
20
21
22
involved in the admission process. The principal of a private medical college, explained:
23
24 Fees in private medical colleges can range from eighty to more than a hundred
25
26 thousand rupees. Not a lot of people can afford it. But fathers sell their properties,
27
28
29 mothers sell their jewelry just to pay the fees, so their daughters can be a doctor
30
31 and get a good match.
32
33
34 An associate professor who teaches in a medical college explained further:
35
36 It goes both ways I think. Every year parents come to us, to get their daughters in
37
38
39
medical colleges, they are willing to pay extra fees, pay for hostels and
40
41 everything. I ask them why are they spending so much and they say that they want
42
43 their daughters to get good matches. But then people also come to me and say we
44
45
46 have a son, recommend us a good doctor as a match.
47
48 Parents of women doctors—who play a significant role in the choice of their daughters’
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51 education and careers—are not just responding to the demand of doctor brides, they are also
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53 trying to ensure that their daughters achieve a good life, which for a woman in Pakistan always
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56 includes a husband and children. By educating their daughters in what society deems desirable,
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58 they are merely trying to safeguard their daughters’ future happiness. This is further evidenced
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by the fact that, in various themes of desirability of medical education in marriage, economic
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7 advantage was most salient for parents. Noreen, mother of a woman doctor, explained:
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9 Becoming a doctor gets a good match, but that is not the only thing. An arranged
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12 marriage is a shot in dark [tukka]. Nobody can predict how the husband or in-laws
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14 will treat you. If something happens, at least your degree is there. You can work,
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17 take care of your kids.
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19 Jameel, father of a doctor, similarly explained his decision to educate his two daughters in
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medicine:
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24 One of my distant relatives died young with three kids. His wife was educated, a
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26 graduate I think, but who employs a graduate these days? Even men cannot get a
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29 job. Their family was ruined. I did not want that to happen to my children. Now
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31 as doctors, even if they do not get a job, they can practice in their homes, support
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34 their families if something happens.
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36 In Pakistan, patrilocality and husband’s absolute control on the right to dissolve the
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marriage without any liability (financial or otherwise) puts women in an extremely precarious
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41 bargaining position after marriage (Kandiyoti 1988). This is further exacerbated by the social
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43 stigma attached with divorce and the impossibility of a woman living alone without the
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46 protection of a man (Khan and Reza 1998). Education, especially professional education like
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48 medicine, gives women a little better footing. If they decide to leave a marriage, at least they do
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51 not have to rely on the financial help of their fathers and brothers to provide for them and their
52
53 children (assistance that is not always granted). Thus, parents of women doctors, by educating
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56 their daughters as doctors, are also provisioning for a better negotiating position after marriage.
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58 Women Doctors’ Response
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To understand how women doctors respond to the cultural discourses regarding their
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7 marriage and education, I focus on the narratives of women doctors. Although all women doctors
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9 that I interviewed acknowledged that their education made them valuable in marriage market,
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12 they were much more ambivalent about the role potential marriageability played in their
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14 educational decision-making. Some of them completely disagreed that they chose medicine
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17 because of marriage. Zunaira, a 27-year-old woman doctor, spoke passionately about this idea:
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19 I think that is true that people want to have a doctor daughter-in-law, but that is
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not why I chose medicine. It may have been in some corner of my parents’ mind,
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24 but I chose medicine because I loved the profession. I wanted to help people.
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26 Zubia, a 30-year-old post graduate trainee, similarly explained:
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29 Nobody can get in a medical college just because they want to get married.
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31 Women get in medical colleges because they make the merit, they study hard,
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34 don’t waste their time and get good grades. They don’t invest five years of their
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36 life in studies just so some mother-in-law can parade them as a trophy.
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On the other hand, some women doctors were more accepting of the position their
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41 education gave them in the marriage market. Javaria, a 34-year-old doctor, explained:
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43 I did not study medicine because of marriage. At that time, I do not think any
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45
46 student is thinking that far ahead. But I received very good marriage proposals.
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48 Now if I honestly think about it, given my family’s social status and their
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51 financial conditions I would have never gotten married in such a good family if I
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53 was not a doctor. So medical education did play a role in my marriage.
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For these women, medical education often became a buy-in the marriage market by
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7 improving their position. Sadaf, a 29-year-old woman doctor, who stated that her medical
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9 education played a crucial role in her marriage, went on to assert:
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12 Yes, medicine was important in my marriage. My husband wanted a doctor as a
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14 wife. I don’t know why people are creating such a fuss about it, though. Girls go
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17 on these horrible diets to make them size zero, wear make-up, dress up just so
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19 they can get good matches, but all that is okay. How is becoming a doctor for a
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21
22
good match any different?
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24 More importantly, regardless of their attitude toward being a desired doctor bride, all of
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26 the women doctors were extremely vocal and critical of government policies that used this
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29 narrative to restrict their access to medical education. Some of them even suggested that “such
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31 narratives [of doctor bahu] were created to exclude women from professional education.” Zoha,
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34 a first-year medical resident, remarked:
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36 I think people are just wary of women being educated and becoming independent.
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39
The media only talks about the this (the desirability of women doctors in
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41 marriage) because it suits their purpose. So that they can justify that quota. They
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43 never mention problems women face at work, or lack of infrastructure for women.
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46 Or that these in-laws don’t let these doctor bahus [daughters-in-law] work after
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48 marriage.
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51 Sara, another woman doctor, even suggested that marriage plays a role in all educational
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53 decisions, not just those of women. She said: “Even men think of choosing a good career, so they
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56 can provide for their families, how is it any different from what women doctors do? Why is there
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58 no quota on men in engineering then?” Women doctors thus not only challenged the perceptions
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that devalued their motivations, but also linked it to the patriarchal attitudes of the society.
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7 Indeed, it was women students who eventually petitioned against the quota and who were
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9 instrumental in securing full access to medical education.
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12 However, more interesting in this regard is the silence of women doctors on the issue of
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14 arranged marriages. Whereas all of them spoke against the policy of imposing a quota, none of
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17 them questioned the system of arranged marriages that creates the condition for women to
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19 become a medium of exchange in this market. Indeed, all married women doctors whom I
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interviewed had some form of arranged marriage. When I probed further on this issue, it became
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24 apparent that women doctors did not take the given of arranged marriage as an unquestioned
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26 ideal. Take the example of Shaheena, a 34-year-old women doctor, who is the first woman in her
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29 family to have an education past high school. She was preparing for her final examination in
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31 medicine when her parents informed her that they have arranged her marriage and she is having
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34 her nikkah [a ceremony to sign the marriage contract] in two days. She had never even seen her
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36 husband-to-be, let alone talked to him. Her only response to her parents was: “You could have
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told me after the examination. Now I will not be able to concentrate on my studies.” When I
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41 asked Shaheena, being an educated woman, if she ever thought about marrying in a different
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43 way, she said:
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46 When I joined a co-educational medical college, people in my family came and
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48 warned my father not to send his daughter to study with men. She will besmirch
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51 your name, they said. But he said, “I trust my daughter and I trust my upbringing
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53 [tarbeat].” When my father trusted me and gave me a good education how could I
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56 think of betraying my father’s trust?
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Shaheena’s response should not be read as one of helpless surrender in front of
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7 insurmountable odds, rather it is one of tacit acceptance. She accepts the eventuality of an
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9 arranged marriage (and trusts her parents that they would choose someone appropriate), but at
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12 the same time, this acceptance (and her parents’ trust in her obedience) opened the doors of
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14 higher education for her. Faiza, a 36-year-old woman surgeon, also had an arranged marriage but
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17 because of her education, she was able to negotiate a match where she could continue her work:
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19 My parents started receiving proposals for me as soon as I went to medical
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college. They had told me beforehand that I will only ever get married according
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24 to their choice. I told them that I am fine with this, I wasn’t going to destroy their
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26 izzat [honor]. I only asked them that they should tell the prospective groom and
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29 his family that I will not stop practicing, and they will not try to stop me.
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31 More importantly, even when their families had a strong tradition of arranged marriages,
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34 some women doctors contested it by attempting to arrange their own marriages. Saba, an
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36 anesthetist, and her class fellow fell in love with each other during their education. They decided
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to let their parents, who approved of their match, know and sent a formal marriage proposal for
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41 Saba (an arrangement sometimes referred to as an arranged-love marriage). Sameen, another
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43 woman doctor, was not so lucky. She fell in love with someone during her education and her
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46 family did not approve. She ended the relationship even though the man and his family offered to
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48 arrange a wedding without her family’s approval. She told me:
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51 The boy I loved, persuaded his family to ask my parents for my hand in marriage.
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53 My parents simply refused because the boy was of a different caste, and because
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56 he and I were of almost the same age. My parents told me that I should have
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58 known that our family does not marry outside the caste, and I was stupid to get
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involved with an outsider boy. I always knew that he and I could never marry. My
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7 parents would not accept him and I would never go against their wishes and marry
8
9 on my own. I could not dishonor them in front of everyone after how much they
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12 had done for me.
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14 These examples demonstrate two important (and seemingly contradictory) points. On one
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17 hand, women doctors know of the possibility of alternatives based on their own individual
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19 choices. But on the other hand, despite knowing the possibilities of individual choice, and having
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22
the means to do so (as their love affairs indicate), none of them directly challenges the discourses
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24 of matchmaking and arranged marriage. Even those like Faiza, who negotiated for more
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26 favorable matches, or like Sameen or Saba, who tried (successfully or unsuccessfully) to marry
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29 based on their own choices, ultimately decided to submit to the approval of their families and an
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31 arranged marriage. Indeed, their negotiation for a better match, or a spouse of their choice, was
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34 made possible only because their subjective position as respectable, educated women made any
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36 choice other than normative, acceptable arranged marriage almost impossible.
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Sameen explained it further: “I have three younger sisters, all of them studying. One
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41 misstep of mine would cost them their education. If I run away and marry against my family’s
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43 wishes or get divorced, my family will be dishonored. My sisters will get pulled out of school
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46 and they will not get good matches.” Naheed, another women doctor, whose parents similarly
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48 refused to allow her to marry according to her choice explained her decision to go along with the
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51 arranged marriage:
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53 I cannot say that I was not hurt. But at the end of the day your choices have
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56 consequences for you and your family. If I had insisted on marrying against my
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58 parents’ wishes, I could never ask for their help with any problem in my marital
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life. Because my parents told me that they would marry me where I wished, but
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7 then I would be dead to them. They said, do not show us your face after
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9 dishonoring us. How could I insist on my choice after that? I loved my parents
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12 more than anyone else.
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14 Memoona, a woman doctor who had an arranged marriage similarly explained why she thinks
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17 arranged marriages are better than the ones based on your own choice:
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19 I think arranged marriage is better, at least in our society. In Pakistan, it is not two
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22
individuals marrying each other. It is two families joining each other. If someone
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24 marries on their own choice, they lose their family’s support and love.
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26 These responses highlight the complex nature of how women respond to different
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29 discourses regarding their marriage and education. Although they do not question the marriage
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31 system in Pakistan, it should also be remembered that they do strongly assert their right to
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33
34 medicine quite vociferously, even to the point of challenging it in court. So why do women
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36 accept the eventuality of arranged marriage? I propose that this tacit acceptance of women
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39
constitutes a form of negative agency where they refuse to be circumscribed and defined by the
40
41 society (Wardlow 2006). Instead of directly opposing the patriarchal structures, women’s uneasy
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43 acceptance of certain discourses is a way of bargaining with patriarchy (Kandiyoti 1988).
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46 Women doctors know that as educated women they can potentially go against the wishes of their
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48 families to assert their own choice in marriage. But they also realize that, given the patriarchal
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50
51 order with which they have to contend, insisting on their own choice in marriage can have
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53 multiple potential consequences: they can lose familial support after marriage, dishonor their
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56 families, and lose their status as respected doctors and daughters. So instead, they focus on the
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58 socially acceptable avenue (medical education) which gives them access to professional
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education, status, and respect in the society; (some) negotiating power in matchmaking; and a
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7 chance to be economically independent working in a “honorable” profession.
8
9 Discussion
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12 In the preceding discussion, I have deliberately yet cautiously used the metaphor of the
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14 market as an organizational principle: cautiously, because this metaphor reduces women doctors
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16
17 to commodities and objects of exchange, and deliberately, because I want to highlight the
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19 gendered dynamics of relations of domination that are prevalent in the marriage system of
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22
Pakistan. The results I reported indicate that within the Pakistani system of arranged marriages—
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24 where marriage is seen as a transaction to maximize the social capital of a family—women
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26 doctors become desired brides because of their cache of social, cultural, and economic capital.
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28
29 Bourdieu (2011/1986, p. 82) in his discussion of capital classifies it into three types:
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31 …economic capital, which is immediately and directly convertible into money
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33
34 and may be institutionalized in the forms of property rights; as cultural capital,
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36 which is convertible, on certain conditions, into economic capital and may be
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39
institutionalized in the forms of educational qualifications; and as social capital,
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41 made up of social obligations (“connections”), which is convertible, in certain
42
43 conditions, into economic capital and may be institutionalized in the forms of a
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45
46 title of nobility.
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48 Education (or more accurately, evidence of education in the form of certain institutionally
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50
51 recognized credentials) counts toward these forms of capital. Women doctors are coveted as
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53 prospective daughters-in-law in Pakistan because their educational credentials mark them as
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56 respectable, prestigious women. Their education acculturates them in a specific class-based
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58 subjectivity: they are chaste, yet domesticated; they are modern—proficient in English, confident
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in their demeanor, comfortable in public—but not modern enough to forgo their family and
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7 domestic duties for their career (cultural capital). Women doctors also acquire the social status of
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9 a maseeha [a miracle worker] and develop professional connections during their medical
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12 education that can later be leveraged for the social and medical well-being of their families
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14 (social capital). Even though they are generally expected to be devoted housekeepers, if needed,
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17 they can also provide financial support for their families (economic capital). Finally, as mothers,
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19 they serve to provide the right kind of atmosphere for the education of the children at home, and
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22
their education becomes an investment in the capital of future generations.
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24 The experiences of Pakistani women doctors reveal how ostensibly empowering projects
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26 of education and work can be appropriated by the already existing patriarchal order. Their
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29 multilayered and varied responses to the prevalent norms and discourses related to career
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31 selection and marriage illustrate that resistance can be complex and tangential instead of being
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33
34 obvious and confrontational. Given patriarchal dominance across all social institutions, women
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36 can only access certain avenues of self-expression and power (education and career, for example)
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38
39
only if they reinforce (willingly or unwillingly) other sites of their oppression and domination
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41 (such as in marriages). For example, in a strategic patriarchal bargain (Kandiyoti 1988),
42
43 Pakistani women doctors forgo their individual choice and accept (albeit tacitly) the norm of
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45
46 arranged marriages to access better educational and economic opportunities. Although this
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48 bargain allows them to improve their social standing in the local marriage market, it reinforces
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50
51 the norms of parental authority and familial control of women’s sexuality.
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53 Similarly, women doctors also reassert the gendered and classed hierarchies that exist
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56 between them and other women by accepting the norms of arranged marriage and using their
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58 position of desired “doctor bride” to negotiate for better matches. Thus, they simultaneously
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devalue less educated women, who are not doctors, by asserting their social position as bearers
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6
7 of a certain class and subjectivity and legitimize a system of marriage where women can be
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9 ranked and traded between families based on their perceived social value. The manifold
10
11
12 implications of women doctors’ responses echo Abu-Lughod’s (1990, p. 53) astute observation,
13
14 “if systems of power are multiple, then resisting on one level may catch people up at other
15
16
17 levels.”
18
19 These linkages of professional education and marital discourses in Pakistan further
20
21
22
highlight the need to understand empowerment in situ and as a dialogical process, where the
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24 empowering (or otherwise) value of education needs to be understood from the perspective of
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26 not only women themselves, but also the social networks within which they are embedded.
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28
29 Although professional education does provide women doctors with a degree of economic
30
31 independence, society tends to view their education in the context of accepted feminine roles,
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33
34 that is, education acculturates women to become better daughters, wives, and mothers. Unless
35
36 these underlying conceptions about women’s role in society and their participation in
37
38
39
professional careers are properly understood and addressed, even the seemingly empowering
40
41 projects of professional education will continue to reinforce the patriarchal structures of
42
43 domination in which women are embedded. Grounding concepts like empowerment in the
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45
46 heterogeneity of lived experiences of women hence problematizes the straightforward
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48 relationship assumed among development, education, and empowerment.
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50
51 Practice Implications
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53 My study has important practical implications. First, I have shown that without changing
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55
56 the patriarchal social structure, merely creating a critical mass of educated women is less likely
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58 to drive social change. For example, in Pakistan, unless women challenge the marriage system
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that continues to treat them as a medium of exchange rather than as individuals with unique
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6
7 desires and aspirations, their education will remain an alternative form of dowry rather than an
8
9 avenue of empowerment. However, this is not something that can be resolved through policy
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11
12 interventions. It can only happen by young men and women contesting these cultural norms and
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14 bringing about incremental changes. However, progress on this issue has been slow. This is
15
16
17 because the system of arranged marriages forms the very basis of Pakistan’s patrilocal, extended
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19 family system. By choosing marriage partners and by subsequent deliberate weakening of the
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21
22
conjugal bond, paternal families ensure that their sons remain bound in filial obligations and the
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24 labor of their daughters-in-law remains available for the extended family (Kandiyoti 1988). More
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26 importantly, speaking out against such norms is often considered a sign of westernization and a
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28
29 rebellion against Pakistan’s cultural and religious heritage. Indeed, researchers working on
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31 women rights in Pakistan face severe resistance by being labelled as “feminists” and “liberals”
32
33
34 who are working on a foreign agenda against Pakistan (Charania 2014). Threat of such sanctions
35
36 makes it difficult to start a meaningful conversation about arranged marriages in Pakistan.
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38
39
Second, I recommend proper implementation of family-friendly policies to ensure that
40
41 women doctors persist in the workforce. My study indicates that women’s work outside their
42
43 homes is considered less valuable than their domestic labor. As a result, working physicians
44
45
46 often do not receive the requisite support from their families. Acknowledging the value of
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48 women’s work by providing them with resources (like generous maternity leave, childcare, and
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50
51 flexible work hours) at the workplace can go a long way to ensure a supply of physicians for
52
53 Pakistan’s healthcare system.
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55
56 Finally, most, if not all, Pakistani schools and medical institutions lack career guidance
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58 and counselling facilities. As a result, students continue to rely on their families and peers for
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advice in educational decision-making, allowing the gendered construction of professions to
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6
7 perpetuate. Providing students (especially young girls) with guidance facilities in schools can
8
9 help them choose and aspire to a diverse range of professions. Similarly, career counselling for
10
11
12 women medical students during and after graduation can help women physicians manage their
13
14 careers, balance their jobs with their domestic responsibilities, and improve their retention and
15
16
17 progress in medical careers.
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19 Limitations and Future Research Directions
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21
22
Although my research improves our understanding of the intersections between career
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24 decision-making and marital choice, it has some limitations. First, I specifically focused on
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26 medical education because medicine is the only STEMM discipline in Pakistan where women
27
28
29 outnumber men in educational institutions, which makes it the ideal case to investigate the
30
31 intersection of career choice, marital decision-making, and women’s agency. As I discussed, the
32
33
34 medical profession is considered suitable for women and desirable in marriage because of its
35
36 specific gendered construction: medicine fulfills the cultural criteria of an honorable profession.
37
38
39
Although my findings cannot be extrapolated to other STEMM disciplines, it is likely that other
40
41 professional and STEMM fields in Pakistan have similar gendered connotations. However,
42
43 because I was primarily interested in the experiences of women doctors, I did not examine the
44
45
46 relationship of marriage and other professional and STEMM fields, and this remains an
47
48 important limitation of my study. Future research should focus on the cultural value of other
49
50
51 STEMM fields and also compare how these evaluations underlie the differential patterns of
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53 gender representation in various professions.
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55
56 Second, another important limitation of my study is the particular context of Pakistan.
57
58 The overlap of the marriage market and the gendered construction of medical profession in
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Pakistan results in the peculiar trend of increasing women in medical education and their
5
6
7 subsequent attrition from profession. Although my research points to the importance of
8
9 accounting for cultural context in research on women in STEMM, the present findings cannot be
10
11
12 generalized to other social contexts. Future research can investigate how the relationship
13
14 between the marriage market and the representation of women in various STEMM professions
15
16
17 plays out in different cultural contexts.
18
19 Conclusion
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21
22
Underrepresentation of women in STEMM disciplines remains a persistent global
23
24 challenge despite multiple policy interventions (Etzkowitz et al. 1992). Medical training
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26 institutions of Pakistan, where women outnumber men, are an interesting counter example to this
27
28
29 pattern, and inquiry in this paradoxical pattern highlights how professional education is valued
30
31 differently by women doctors, their families, and society. In the present article, I investigated the
32
33
34 various social dynamics and discourses that contribute to the increasing participation of young
35
36 women in medical education. My findings suggest that this trend is primarily driven by
37
38
39
construction of the medical education as being gender-appropriate for young women which, in
40
41 turn, makes them desirable commodities in the local marriage market. Parents, the primary
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43 decision-making authority in educational and marital choices, therefore consider medicine to be
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45
46 the best investment toward their daughters’ future. Realizing the imperfect choices given to
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48 them, young women often strike a patriarchal bargain where they choose to conform to their
49
50
51 parents’ decisions in return for access to better education and socio-economic opportunities. At
52
53 the macro-level, however, this decision-making pattern continues to reinforce patriarchal
54
55
56 authority and its associated customs. My research thus highlights the complex relationship
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58 among education, cultural norms, and personal empowerment that needs to be investigated in
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other professional and cultural contexts. Unless these underlying conceptions about women’s
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6
7 role in society and their participation in professional careers are addressed, even the seemingly
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9 empowering projects of professional education will continue to reinforce the patriarchal
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12 structures of domination in which women are embedded.
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References
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7 Abid, A. M. (2014, October 22). Female doctors becoming ‘trophy’ wives: Is quota the right
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9 move? Dawn. Retrieved from http://www.dawn.com/news/1139639
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12 Abu‐Lughod, L. (1990). The romance of resistance: Tracing transformations of power through
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14 Bedouin women. American Ethnologist 17(1), 41-55.
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17 Ahearn, L. M. (1994). Consent and coercion: Changing marriage practices among Magars in
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19 Nepal (Unpublished doctoral dissertation). Ann Arbor, MI: University of Michigan.
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Ahearn, L. M. (2001). Invitations to love: Literacy, love letters, and social change in Nepal. Ann
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24 Arbor, MI: University of Michigan Press.
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26 Allen, I. (2005). Women doctors and their careers: What now? British Medical Journal,
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Table 1
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6
Demographic Characteristics of the Participating Women Doctors
7
8
9
Demographics n (%) or M(SD)
10 Age < 25 4 (6%)
11 25–35 27 (45%)
12 35–45 15 (25%)
13
> 45 10 (16%)
14
15 Education Gender segregated schooling only 35 (58%)
16 Mixed (some schooling in girls-only schools and rest in 15 (25%)
17 co-educational)
18 Co-educational schooling only 10 (17%)
19
20
Medical Education Medical graduation only 22 (37%)
21 Post-graduate Trainee 11 (18%)
22 Specialist 27 (45%)
23 Marital Status Married 49 (82%)
24 Never Married 9 (15%)
25
26 Married, Divorced 2 (3%)
27 Employment Unemployed as doctors 15 (25%)
28 Status
29 Self-employed 4 (7%)
30
31
Formally employed 34 (57%)
32 Formally employed and private practice 3 (5%)
33 Organizational House Officers 3 (5%)
34 Status of those Medical Officer 24 (40%)
35 Employed (n = 41) Assistant Professor 7 (12%)
36
37 Associate Professor 5 (8%)
38 Professor 2 (3%)
39 Family Mean Age (father; range = 84–55) 68.92 (7.68)
40 Characteristics Mean Age (mother; range = 80–49) 64.16 (7.49)
41
Means years of schooling (father; range = 22–10) 17.55 (2.60)
42
43 Mean years of schooling (mother; range = 22–0) 14.28 (5.01)
44 Mean years of schooling (husband; range = 22–17) 17.60 (2.05)
45 Employment Status of mother (unemployed) 49 (82%)
46 Employment status of husband (unemployed) 0 (0%)
47
48
49
50
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17 DOCTOR BRIDES 54
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19
20 Table 2
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22
23 Definitions, Examples, and Frequencies of Themes Across All 107 Participants
24
25 Theme Definition Exemplars Frequency of Theme: n (%)
26 Status When someone “People want doctors as daughter-in-law only Women Fathers-
27
describes medical because of status, so they can brag among their Doctors Fathers Mothers in-law
28
29 education/degree as relatives that we have brought a doctor in the 60(100%) 5 (83%) 6 (100%) 4 (67%)
30 part of status, prestige, family.” (as informant)
31 respect, honor etc. “My mother-in-law chose me because someone in Mothers- Policy-
32 specifically in context her family had married to a doctor. So, she wanted to in law Husbands makers All
33 of marriage be equal, to say my daughter-in-law is also a doctor.” 6 (100%) 3 (50%) 15 (88%) 84 (79%)
34 (as participant)
35 Looking When the specific “Doctors are wiser, you know. Other girls create Women Fathers-
36 like a aspects of women problems with mother-in-law, use bad language. A Doctors Fathers Mothers in-law
37
doctor doctors’ code of doctor is sober, she will never do such things.” (as 32(53%) 3 (50%) 6 (100%) 3 (50%)
38
39 conduct are mentioned informant)
40 in relation to marriage. “My daughter is a doctor. Her cousins spend all day Mothers- Policy-
41 These include their talking about TV, clothes. She was only busy with in law Husbands makers All
42 dress, language, her books. When the time came, it was she who got 3 (50%) 2 (33%) 10 (59%) 57 (53%)
43 bearing, proficiency in good proposals, educated boys like her.” (as
44 English, and their participant)
45 management skills
46 Honorable Narratives that speak “Our society thinks doctors are more honorable. Women Fathers-
47
48
profession of medicine as They are not like other girls who have affairs.” (as Doctors Fathers Mothers in-law
49 honorable for women informant) 48(80%) 6 (100%) 6 (100%) 3 (50%)
50 in the context of “I chose medicine for my daughter because it had a
51 marriage; mention of women’s only college. It is a respectable way for a Mothers- Policy-
52 chastity woman to study.” (as participant) in law Husbands makers All
53 2 (33%) 3 (50%) 8 (47%) 78 (73%)
54
55 Economic Mention of “Doctors can earn. It was not an issue before. People Women Fathers-
56
Advantage contribution to did not want their wives to earn. Now living Doctors Fathers Mothers in-law
57
58 family’s income or standards are so high. Husbands 46(77%) 6 (100%) 6 (100%) 1 (17%)
59 economic security in think why should education go to waste. They marry
60 context of marriage, a doctor as a helping hand.” (as informant) Mothers- Policy-
61 whether actually “I lived wage-to-wage all my life. I did not want that in law Husbands makers All
62 working or not life for my daughter. Now as a doctor she can earn 0 1 (17%) 6 (35%) 65 (61%)
63 for herself.” (as participant)
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13
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17 DOCTOR BRIDES 55
18
19
20 Good Mention of parenting “Women doctors are really good mothers, that’s why Women Fathers-
21 Mothers skills of women people like them. They are all position holders, high Doctors Fathers Mothers in-law
22
doctors in context of achieving in the school. They can teach their kids 10(17%) 2 (33%) 3 (50%) 6 (100%)
23
24 marriage themselves. No need to pay for expensive tuitions.”
25 (as informant) Mothers- Policy-
26 “We selected a doctor as daughter-in-law because in law Husbands makers All
27 they can care for their families and kids. My 6 (100%) 6 (100%) 5 (29%) 38 (36%)
28 daughter-in-law teaches her kids herself. They
29 always get an A.” (as participant)
30
Note. Text was coded as informant when participants were providing the group level information, and as respondent when they were
31
32 speaking about their own perceptions (based on Levy and Hollan 2015).
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Compliance with Ethical Standards

Running Head: Medical Pedagogy and Marriage in Pakistan 1

Statement of Ethical Standards

The research for this paper involves human subjects. It complies with the ethical
standards of research and was approved by Institutional review board at Arizona State University
(ID: STUDY00003018). All participants were informed of potential risks involved with
participating in the study and informed consent was obtained. The author has no conflict of
interest to declare.

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