https://orcid.org/0000-0002-9786-9970
Figures
Abstract
This systematic review aims to describe the prevalence of marital rape in India, the analytic methods employed in its study, and its implications on mental health of victims. Online databases, PubMed, Embase, Web of Science and APA Psych, were systematically searched for articles published up until November 2020. Selected articles included those published from or studies conducted in India where the primary exposure was marital rape. The primary outcomes of interest are Post Traumatic Stress Disorder (PTSD) and Depression. Secondary outcomes related to PTSD and depression (e.g., suicidality) included in identified studies were also described. 11 studies were included after excluding studies based on our selection criteria: 9 quantitative studies and 2 qualitative studies. Sexual coercion by intimate partner was highly prevalent, ranging from 9%-80% and marital rape ranged from 2%-56%. Many of the studies reported statistically significant associations between marital rape and mental health outcomes, including clinical depression (7 of 8); PTSD (1 of 3). Quantitative studies were assessed for quality and risk of bias using the NIH Quality Assessment Scale and the modified Newcastle Ottawa Scale for cross-sectional and observational cohort studies, and most exhibited a low risk of bias. Qualitative studies identified a broad range of exposures and psychological sequlae of marital rape not captured by quantitative studies. Included publications exhibit a low to moderate association between marital rape and adverse mental health outcomes. Qualitative data also supplements these findings and provide relevant context. Further research on marital rape, its prevalence and consequences, is needed to advance policy, and health infrastructure on the subject.
Citation: Agarwal N, Abdalla SM, Cohen GH (2022) Marital rape and its impact on the mental health of women in India: A systematic review. PLOS Glob Public Health 2(6): e0000601. https://doi.org/10.1371/journal.pgph.0000601
Editor: Nafisa Halim, Boston University, UNITED STATES
Received: September 2, 2021; Accepted: May 16, 2022; Published: June 21, 2022
Copyright: © 2022 Agarwal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Yes - all data are fully available without restriction. All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Marital rape is defined as non-consensual sexual intercourse with one’s spouse [1]. Acts of forced sexual contact, including but not limited to vaginal penetration are considered marital rape in India, with the condition that the wife is younger than fifteen years of age [2]. Sexual violence in marital relationships is one of the most privatized and least addressed forms of violence [1]. In India, while rape outside of marriage is a crime, rape within marriage is not necessarily considered criminal and is socially tolerated, as outlined in Box 1 [3, 4]. Underreporting of sexual Intimate Partner Violence (IPV) masks the true burden of sexual domestic violence [5, 6]. Most sexual violence in India occurs within marriages but it is estimated that only about 10% of victims report spousal sexual abuse [7]. This suggests that the lack of accurate reporting on marital rape, has not only undermined an appreciation for the true burden of sexual assault in Indian society, but has also contributed to the paucity of research on the psychological impact of spousal sexual abuse. Further, women who are victims of spousal sexual abuse often suffer from other types of IPV as well; physical, emotional, and psychological, thus bearing a particularly potent burden of exposure and psychiatric risk.
Box [1]. Legal and Social Status of Marital rape in India
Legal and Social Status of Marital Rape in India
Sexual intercourse between a husband and his wife is not considered rape if she is over 15 years of age, per the second exemption in Section 375 of the Indian Penal Code. ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"https://devgan.in/ipc/section/375/","accessed":{"date-parts":[["2021","2","27"]]},"id":"ITEM-1","issued":{"date-parts":[["0"]]},"title":"IPC Section 375 - Rape |
Despite the evidence of adverse effects of marital rape on the mental and emotional health of victims, in India, rape in the context of marriage remains largely unaddressed in clinical practice, scientific research, and public health surveillance [8–10].
Previous studies have demonstrated associations between rape and several mental health outcomes, including depression, Post-Traumatic Stress Disorder (PTSD), and sleep disorders [11, 12]. Survivors of both physical and sexual IPV have recounted suffering from adverse mental health outcomes [13, 14]. Countries that criminalize marital rape, such as the United States also report marital rape victims suffering from adverse mental health outcomes such as PTSD and depression [15] with women raped by their spouses exhibiting even higher rates of anger, depression, and suicidal feelings as compared to those assaulted by strangers [10, 16]. Martial rape also impacts help-seeking behavior among survivors, which may vary across cultures. About 61% victims reported seeking help for sexual IPV in New Zealand, 40% in Tanzania and Jordan but only 24–26% in India; with only 2–4% seeking help from authorities in India [17]. This inability to talk about the abuse and seek help also negatively impacts women’s mental health, exacerbating the stress, anxiety and depressive symptoms experienced by victims [17]. This evidence from other countries suggests that the mental health burden from marital rape in India is potentially high. However, societal inattention to the issue, lack of infrastructure and procedure for screening, comorbid exposures and lack of help-seeking avenues, it has been challenging to estimate the consequences of marital rape within the Indian society.
This paper attempts to address this gap and map out the literature on the mental health consequences of marital rape and spousal sexual abuse within the Indian community. This systematic review will address the question; does marital rape result in adverse mental health outcomes such as depression, PTSD, anxiety disorders, and somatic symptoms?
Methodology
Search strategy
We conducted a systematic database search from January 1945 to November 2020, including compiling initial list of articles and then excluding non-relevant, duplicate, and ineligible papers. The search included 4 databases, namely PubMed, Embase, Web of Science and APA Psych Info in our search along with snowball selection from references of relevant articles. The key search terms were “marital rape”, “spousal violence”, “intimate partner violence”, “domestic violence”, “married women”, “India”, “Indian”, “Southeast Asia”, “depression”, “PTSD” and “mental health”. To keep the search broad, no filters were applied. No time or language restriction was applied to cover any and all literature published, including grey literature so that it would be included in the search. Articles published up until November 2020 were included. A process flow chart according to the PRISMA standard has been charted in Fig 1.
All articles were uploaded to Rayyan QCRI for review. All three authors had access to the Rayyan account. The initial round of review involved title and abstract selection was performed by NA. After exclusion of duplicates and a bulk of non-relevant articles, all three reviewers performed study selection based on a predetermined criterion using full text search for the remaining 104 studies. For the purpose of this systematic review no filters were applied pertaining to study design. Both qualitative and quantitative studies, along with reviews were included in our search to identify the depth and extent of research done regarding prevalence of marital rape experienced by Indian women and the effects on mental health.
Study selection criteria
We selected studies that included married Indian women who were exposed to spousal sexual abuse, and whose mental health outcomes were studied. No filters were applied in terms of summary measures used. We excluded studies that did not include spousal sexual abuse, only studied non-penetrative sexual abuse, or that focused on sexual abuse experienced by married Indian women that was not perpetuated by a spouse. Studies that included unmarried women were excluded.
If associations between marital rape and mental health outcomes was not explored, then those studies were excluded as well. Mental health outcomes included Major Depressive Disorder (MDD) and Post Traumatic Stress Disorder (PTSD). If studies measured one or both of these outcomes, they were included. Other adverse mental health outcomes (like suidcidal ideation and attempts) measured by these studies were reported as secondary outcomes.
The sample for potential studies should be of married, Indian women. Any other nationality, if exclusively mentioned would not be considered. Any study done with Indian women in any setting other than India will not be considered. Studies with the South Asian community in United States of America, Europe or any other setting were excluded.
Results
Eleven studies were included after excluding studies based on our selection criteria: nine quantitative studies and two qualitative studies. One study was excluded because of unavailability of full text, while another was excluded due to the inclusion of both married and unmarried women in the sample. One study was excluded because it did not assess presence of sexual violence at the start of the study period but only checked for its presence during follow-up, while two were excluded because the outcomes did not include either depression or PTSD. All studies included in this review are summarized in four tables. Tables 1 and 2 provide a short study description including the study objective, sampling strategy and size, recruitment strategy employed, a brief description of the study population and the study design.
Tables 3 and 4 provide a brief description of types of intimate partner violence experienced by participants, mental health outcomes studied, including the tools used to measure the prevalence of both exposure and outcome variables. The analytic methods employed and the results of each of these studies are also included in the following tables.
Of the eleven studies, eight studies assessed the association between spousal violence (physical, sexual and psychological) and clinical depression [18, 20–23, 27–29], while two studied antenatal and postnatal depression as outcomes [23, 24]. Only four studies explored the association between spousal violence and Post Traumatic Stress Disorder (PTSD) [18, 25–27]. Two studies [18, 25] assessed for suicidality including ideation and attempts. Only one study [28] looked at Idioms of Distress as listed in the DSM-V criteria. See Fig 2 for outcome distribution in included studies.
Quality of studies
The included quantitative studies were assessed for quality and risk of bias using the NIH Quality Assessment Scale and the modified Newcastle Ottawa Scale for cross-sectional and observational cohort studies, respectively [30, 31].
Most studies exhibit low risk of bias in terms of comparability due to adjustment of appropriate confounders (Table 5). It is notable that the study conducted by Chowdhary et.al. (2008) scored high on the quality rating as well had low risk for bias.
Type of spousal violence
The forms of spousal violence that were studied included physical, sexual, verbal, psychological and emotional violence. Sexual violence was common to all the studies included (Fig 3). Some studies did not study sexual abuse as a separate exposure but combined all forms of violence into one variable, domestic violence [19, 26].
*Population-level studies representative of the diverse culture of India.
Some studies (n = 6) considered the combined effect of spousal violence on mental health outcomes [20–24, 32]. None of the studies exclusively examined the effects of sexual violence, including rape, coercion, forced prostitution, forced to watch, and enact pornographic material or other forms of non-penetrative sexual violence on depression. Only one study [18] assessed the causal relation between sexual coercion (including marital rape) and PTSD; while only one study [26] that enrolled pregnant women and aimed to determine if sexual coercion during pregnancy was related to development of adverse mental health outcomes.
Prevalence of spousal sexual violence and marital rape
Studies measured domestic violence including physical, sexual and psychological violence. Prevalence of current domestic violence reported by participants ranged from 13%-68% [17, 19, 22]. Studies also found that participants reported spousal abuse during pregnancy (12.3%) including emotional (11%), physical (10%) and sexual violence (1.8%) [21, 22, 33]. Sexual coercion by intimate partner was highly prevalent among women included in the studies, ranging from 9%-80% [18, 25, 26]. Despite sexual violence being the least reported out of all other types of spousal abuse, marital rape ranged from 2%-56% [18, 21, 23].
Mental health outcomes
Adverse mental health outcomes of marital rape were studied. Depression, including antenatal and postnatal depression, and Post Traumatic Stress Disorder (PTSD) were the primary study outcomes. We incidentally came upon some results on suicidality as they were measured as secondary outcomes in included studies. Depression was the most common outcome among the included studies (Table 6).
All the studies controlled for previous diagnosis of mental disorders and patients diagnosed with psychotic disorders but did not control for presence of abuse by anybody other than the spouse. One study also controlled for prevalence of substance abuse disorders among the women [24]. Three studies looked at the relationship between domestic violence perpetuated by the spouse during pregnancy with antepartum and postpartum depression being the outcome [21, 23, 24]. These studies did not control for pregnancy related anxiety or abuse by in-laws or a history of sexual abuse.
Depression.
Of the 8 studies that examined depression as an outcome 2 were rated ‘good’ on the NIH quality assessment tool while 4 were rated ‘poor’. One of the studies that was rated good, used population-based sampling, and controlled for a variety of confounders such as spousal substance abuse, marital discord, social and familial support, and a history of mental illness. Even after controlling for confounders the authors found a strong association between all types of spousal violence and Major Depressive Disorder (MDD) and suicidality [19]. Four studies, three rated poor and one rated fair on the NIH Quality Assessment Scale, found statistically significant correlations between depression and IPV [22–24, 26]. Spousal sexual abuse increased the likelihood of diagnosed depression symptoms (as per the ICD-10 classification) [22–24, 26]. Depression and spousal physical (r = 0.04) and non-physical abuse (r = 0.15), as well as sexual coercion (r = 0.06) was not significant [18].
PTSD.
All the studies examining the association between marital rape and PTSD were rated poor according to the NIH Quality Assessment Scale. Among these 3 studies, 2 studies found that sexual coercion and abuse were not statistically significantly associated with PTSD symptoms [25, 26]. However, one of them did observe a significant association between all identification of spousal abuse as a societal problem and help seeking to be significantly associated with chronic PTSD [25]. The third study found a positive, significant correlation between sexual coercion and PTSD severity (r = 0.39) [18]. The association between PTSD and depression symptoms was also significant (r = 0.50) [18]. It was seen that although only 14% of the participants were diagnosed with PTSD, a greater number were exhibiting symptoms which might indicate that subthreshold PTSD is more common [18].
Secondary outcomes.
Only 1 study of the 2 that that assessed suicidality as one of the outcomes rated as good quality as per the NIH Quality Assessment Scale. Of these studies, one of them observed a significant association between sexual violence by spouse and suicidal behavior after adjusting for confounders but only in the cross-sectional study [19]. This association was not significant in the longitudinal analysis [19]. Suicidal behavior (ideation and attempts) was prevalent among women who reported spousal sexual abuse, where one study estimated a significant, moderate association between suicidality and domestic violence [25].
The qualitative studies included in this review studied the prevalence of different types of domestic violence among the participants and the association between domestic abuse and poor mental health outcomes [27, 28]. One study assessed the prevalence of depression, PTSD, and suicidality [27]. It reported that most women suffered severe sexual abuse which was perpetuated by their spouse and exhibited symptoms of depression, PTSD and suicidal ideation [27]. The other study assessed “Idioms of Distress” (IOD) listed in the DSM-V criteria as the outcome of interest. 6 survivors of domestic sexual abuse were included in the study and all of them displayed symptoms of severe mental distress, anxiety, suicidal thoughts, distrust of people, sleeping and concentration problems, low self-esteem, changed goals and aspirations and feelings of sadness [28]. Participants reported that such feelings and loss of interest in any chores or daily tasks prompted further violence [28]. However, the authors did not study the association of different forms of domestic abuse and the observed IODs [28].
Discussion
Review findings
This systematic review identified a limited body of research looking at the mental health implications of spousal sexual abuse, and several gaps in this literature. Although most of the studies did not exclusively look at marital rape and its impact on the victims, they demonstrated associations between spousal violence, and depression and PTSD. This review sheds light on possible adverse mental health outcomes, with depression being the most studied one. Even though several studies combined types of spousal violence into one variable or did not define sexual abuse comprehensively, there is evidence to suggest that spousal sexual abuse is detrimental to the mental health or married women. Almost all the studies that presented depression as an outcome, found it to be significantly associated with spousal IPV [19, 22–24, 26] PTSD was less commonly studied, followed by suicidality and psychiatric distress. One study in this review looked at the association between help-seeking and PTSD, and reported that women who recognized domestic abuse as a common malady and sought help tended to suffer from chronic PTSD and severe symptomology [25]. Other included studies found the expression of PTSD symptoms among women who were victims of spousal sexual abuse, including sexual assault during pregnancy and reported varied outcomes regarding the association [18, 26]. This could be due to the lack of standardization and differences in sampling; for example one recruited women visiting antenatal clinics while another recruited participants by means of newspaper advertisements [18, 26]. The majority of included studies did not observe a statistically significant association between marital rape and suicidality or psychiatric distress, but there could be several reasons for that such as underreporting of symptoms, clinical diagnosis not available (subthreshold), single variable for spousal sexual abuse among others [24, 25, 32].
Qualitative research sheds light on sexual abuse among married couples that was not completely captured by quantitative studies. Majority of the participants suffered from depressive and PTSD symptoms, poor quality of life, loss of interest and will to perform daily activities and even suicidal ideation [27, 28]. The studies also shed light on the lack of awareness about sexual abuse and the normalization of domestic violence. The structured interviews conducted as a part of two of the included studies showed that women were forced to perform sexual acts such as watching and enacting pornography, touching or exposing genitals, forced anal and oral sex, and even solicitation by spouse [27, 28]. Incest also emerged as an issue but was hardly reported [27]. Thus, in-depth qualitative research can uncover sexual abuse that is not covered by questionnaires and even acts that the victims themselves fail to classify as spousal sexual abuse. Most validated and widely used tools to assess domestic violence only ask about forced penetration or sexual coercion, while leaving out acts such as anal and oral sex, forced masturbation of self or the perpetuator, genital mutation and many others that would also qualify as sexual abuse [27]. This allows for gaps in determination of the extent of sexual violence prevalent among participants.
There can be several reasons for the low levels of reported sexual violence: underreporting due to stigma, lack of awareness of what qualifies as spousal sexual abuses, and rejection of such complaints by society [25, 27]. Indian society provides limited autonomy to women, treating them as property of their spouses [34, 35], a structural relation widely used to justify spousal sexual abuse. Lack of appropriate legal measures that may offer protection to victims of spousal sexual abuse, and secondary victimization by medical personnel act as a major deterrents to reporting [36–38]. Severe sexual abuse negatively impacts help-seeking behaviour, as one of several key factors that limit help seeking, including education status, age, decision-making capacity, source of livelihood and support of family and peers [39].
International and national relevance
Beyond these findings from India, there is evidence from other LMICs that shows that an association between IPV and adverse mental health outcomes exists. The WorldSafe study that was conducted in four countries (Chile, India, Philippines, and Egypt) found that suicidality and depression are highly common among victims of spousal abuse [19, 40]. After analysis of national level data from the National Health and Family Survey (NFHS), studies revealed that women who report experiencing spousal sexual abuse were more likely to report mental health symptoms rather than a condition itself [33]. This shows the existing stigma around mental health in the Indian society, and rejection of the idea of mental wellbeing being equally important as physical health. Symptoms of depression are often misclassified by survivors as “tension” which can be another factor that deters them from seeking medical help [22, 27]. Domestic abuse was found to be associated with subthreshold and clinically diagnosable depression among married and even pregnant women, indicating the need for screening for violence victimization at hospitals and antenatal clinics [19, 21–23, 26].
Limitations
This review has some limitations. First, we only searched three databases for articles that fit this criterion. Studies that were not conducted in India were excluded, which could have resulted in missing the abuse within the Indian community living in other countries. However, this does not significantly impact the results of this review as the aim was to explore the lack of research on marital rape in India and address the stigma surrounding this issue. Second, differences in use of standardized tools in both measuring spousal abuse and mental health outcomes can produce differences in observed results. Some studies use nationally collected survey data while others use much smaller single clinic samples. Nonetheless, these different settings give us a strong foundation to build further research on. Sexual abuse within marriage is a very stigmatized subject and research in this field is limited. Considering that both sexual violence and mental health are very sensitive and difficult topics, along with being culturally rejected makes it harder to study the relation between them. But this limitation also reinforces the need for further study in the relation between marital rape and mental wellbeing.
Strengths and future research
Notwithstanding these limitations, this review demonstrates the importance of elevating martial rape in India as a critical public health concern. The low number of cases reported, and lack of dialogue around marital rape helps explain why most affected women do not seek help for mental disorders. Almost all reviewed studies showed an association between marital rape and adverse mental health outcomes, despite likely widespread underestimation of marital sexual abuse prevalence. The qualitative studies provided relevant context regarding the lack of recognition of actions that may be considered abuse and mental health symptoms. Thus, further research in the association between marital sexual abuse and poor health outcomes, especially mental health is needed. Culturally relevant and validated scales to measure marital rape, awareness about body autonomy and marital rights, comprehensive protocols in healthcare institutions to measure sexual IPV and a more robust legal infrastructure are just some ways to help capture more accurate estimates of the prevalence of marital rape in India. This issue warrants greater attention from researchers as well, and the resulting scholarship can lead the conversation of how marital rape is a pressing public health problem. This can drive action at societal, institutional, and interpersonal levels, and help bring this issue to the forefront, encouraging more people to seek help.
Recommendations
Marital rape violates fundamental human rights and is linked to adverse psychological consequences. Lawmakers should be made aware of these highly adverse effects, as it may motivate criminalization of marital rape in India. Marital rape and its effects on health and wellbeing warrants greater scholarly focus and nuanced, sensitive research to drive informed and evidence-based decision making.
Supporting information
S1 Checklist. PRISMA 2020 checklist for conducting a systematic review.
https://doi.org/10.1371/journal.pgph.0000601.s001
(DOCX)
S1 File. Search strategy for PubMed (includes all search terms).
https://doi.org/10.1371/journal.pgph.0000601.s002
(DOCX)
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