Physical and sexual violence and symptoms of gynaecological morbidity among married young women in India.

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Physical and sexual violence and symptoms of gynaecological morbidity among married young women in India a

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Shireen J. Jejeebhoy , K.G. Santhya & Rajib Acharya

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Population Council, New Delhi, India Published online: 03 Dec 2013.

To cite this article: Shireen J. Jejeebhoy, K.G. Santhya & Rajib Acharya (2013) Physical and sexual violence and symptoms of gynaecological morbidity among married young women in India, Global Public Health: An International Journal for Research, Policy and Practice, 8:10, 1151-1167, DOI: 10.1080/17441692.2013.860466 To link to this article: http://dx.doi.org/10.1080/17441692.2013.860466

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Global Public Health, 2013 Vol. 8, No. 10, 1151–1167, http://dx.doi.org/10.1080/17441692.2013.860466

Physical and sexual violence and symptoms of gynaecological morbidity among married young women in India Shireen J. Jejeebhoy*, K.G. Santhya and Rajib Acharya Population Council, New Delhi, India


(Received 11 February 2013; accepted 2 October 2013) Evidence from India about young women’s experience of physical and sexual violence within marriage and its sexual and reproductive health consequences is limited. Data, drawn from 12,220 married women ages 15–24 years old from six Indian states, were used to identify associations between the experience of violence and recent symptoms of gynaecological morbidity, using logistic regression analysis. Young women who had experienced physical, sexual, or both forms of violence in the 12 months preceding the interview were more likely than others to report symptoms of gynaecological morbidity (odds ratios, 1.8–2.1); associations were evident in all six states. However, associations were weak between those who had experienced violence earlier in marriage but not in the 12 months preceding the interview and those who had never experienced violence. Findings highlight the need for the health system to play a proactive role in recognising and responding to the needs of young women experiencing marital violence. Keywords: reproductive health; marital violence; India; gynaecological morbidity

Introduction Marital violence is widespread in India: a national survey shows that 35% of married women ages 15–49 years old have experienced physical violence and 10% have experienced sexual violence perpetrated by their current or former husband over the course of their married life (International Institute for Population Sciences [IIPS] & Macro International, 2007). There is growing recognition, moreover, of the implications of marital violence for the health and well-being of women and their children. In the reproductive health arena, marital violence has been associated with non-use of and an unmet need for contraception, as well as the occurrence of unintended pregnancy, induced abortion, symptoms of gynaecological morbidity, and even foetal and infant mortality (Garcia-Moreno, Jansen, Watts, Ellsberg, & Heise, 2005; Krug, Dalhberg, Mercy, Zwi, & Lozano, 2002). These adverse outcomes have also been observed among reproductiveaged married women in India. For example, studies have observed that reproductive-aged women who experienced marital violence were significantly more likely than those who did not to experience unwanted pregnancy, pregnancy loss, induced abortions, pregnancyrelated complications, and perinatal and infant mortality (Ackerson & Subramanian, 2009; Ahmed, Koenig, & Stephenson, 2006; Jejeebhoy, 1998; Johnson & Sengupta, 2008; Muthal-Rathore, Tripathi, & Arora, 2002; Singh, Mahapatra, & Dutta, 2008; *Corresponding author. Email: [email protected] © 2013 Taylor & Francis


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S.J. Jejeebhoy et al.

Stephenson, Koenig, Acharya, & Roy, 2008). Associations with gynaecological morbidity and HIV infection have also been observed (Silverman, Decker, Saggurti, Balaiah, & Raj, 2008; Stephenson, Koenig, & Ahmed, 2006; Sudha, Morrison, & Zhu, 2007; Weiss et al., 2008). Several strands of evidence suggest the need to explore the extent to which associations observed among women in general also apply to married young women. For example, evidence (including that from India) suggests that young women and recently married women are at heightened risk for experiencing marital violence (Bates, Schuler, Islam, & Islam, 2004; Boyle, Georgiades, Cullen, & Racine, 2009; Dalal, Rahman, & Jansson, 2009; IIPS & Population Council, 2010; Santhya & Jejeebhoy, 2005). As many as 23% of all ever-married women, which translates into 62% of ever-married women who had ever experienced marital violence, had experienced such violence for the first time within 2 years of marriage (IIPS & Macro International, 2007). At the same time, recent evidence shows that married young women are about as likely to experience symptoms of gynaecological morbidity as older women are (11% each; IIPS & Macro International, 2007). Finally, there is conclusive evidence from India of the adverse reproductive health consequences of early marriage for young women (Santhya, 2011; Santhya et al., 2010). Despite the fact that marital violence is initiated at an early age, and despite the fact that reproductive health indicators are disturbingly adverse among young women, little is known about the implications of marital violence in regard to the experience of symptoms of gynaecological morbidity among young women in India. In this paper, we use data from a sub-national study of youth in India to examine the relationship between physical and sexual violence within marriage and young women’s experiences of symptoms of gynaecological morbidity. Findings are expected to inform the discussion on the inclusion of measures to prevent marital violence and/or provide early intervention for young women at risk for violence in programmes intended to improve the reproductive health situation of married young women. Setting The study was conducted using representative samples of youth drawn from both rural and urban areas of six states in India, namely Andhra Pradesh, Bihar, Jharkhand, Maharashtra, Rajasthan, and Tamil Nadu. Youth in these states together account for 39% of the total youth population in the country (Office of the Registrar General and Census Commissioner, 2006) and are similar to the youth population of the country as a whole in terms of age, level of literacy, religion, caste, and marital status. These states represent the different geographic and sociocultural regions within the country, and thus lie at the extremes of the socioeconomic and cultural spectrum of the country, reflecting, for the most part, the well-known regional diversity within the country in terms of social, economic, and demographic characteristics, as evident from Table 1. Andhra Pradesh, Maharashtra, and Tamil Nadu, from the southern and western regions of the country, are among the more economically progressive states in the country, accounting for 7% to 13% each of the national gross domestic product, while Bihar, Jharkhand, and Rajasthan, from the northern and eastern regions, are among the lesser-developed states, accounting for 2% to 4% each (Ministry of Statistics and Programme Implementation, 2008). Maharashtra and Tamil Nadu are among the most urbanised states, with over two-fifths of their populations living in urban areas. In contrast, Bihar, Jharkhand, and Rajasthan are characterised by large rural populations, with just one-tenth to one-quarter of their populations living in urban areas. Likewise,

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Table 1. Selected background characteristics of married young women ages 15–24 years old who had cohabited with their husband for at least 1 year.


Mean or percentage Sociodemographic factors Age (in years, mean) Age at marriage (or cohabitation, in years, if different) (mean)a Education: years of schooling completed (mean) Economic activity status: currently working (%) Residing in urban area (%) Household economic status (mean) Household composition Co-residence with husband: husband had been living away for 1 month or more Resides in nuclear family Gender role attitudes and son preference A woman need not obtain husband’s permission for most things Wanted more sons than daughters Agency Self-efficacy: can always confront a person who has done/said something wrong to her Household decision making: independently decides about spending money and buying clothes for herself Mobility: can go alone to friend’s or relative’s house or market inside the village/ neighbourhood Access to money: has an account in bank or post office Spousal relations Communication with husband: discussed with husband number of children to have Condom use Support networks Natal family support: visited natal home during first 6 months of marriage Participation in community-led activities Total (N)

21.1 16.6 4.7 43.3 22.1 15.1 9.7 35.0 28.2 23.6 30.9 67.7 69.7 9.7 86.7 4.7 89.8 7.9 12,220

Note: aNot included in the multivariate analysis.

while less than three-fifths of females aged 7 and older were literate in Bihar, Jharkhand, and Rajasthan, three-fifths to three-quarters were literate in Andhra Pradesh, Maharashtra, and Tamil Nadu (Office of the Registrar General and Census Commissioner, 2011). Indicators of health and experience of marital violence also vary. Child marriages are extremely common in Andhra Pradesh, Bihar, Jharkhand, and Rajasthan, with between half and two-thirds of young women ages 20–24 years old married before age 18; in comparison, child marriage was reported by 22% of young women in Tamil Nadu. Statewise differences in the reporting of marital violence among married women of all ages are also evident. Physical and sexual violence was reported, respectively, by 35% to 56% and 13% to 20% of women from the three northern and eastern states, compared to 31% to 42%, and 2% to 4%, correspondingly, in the southern and western states (IIPS & Macro International, 2007).


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Methodology Study design The Youth in India survey focused on married and unmarried young women and unmarried young men ages 15–24 years old and because of the paucity of married young men of younger ages, married men ages 15–29 years. The survey treated rural and urban areas as independent sampling domains and a systematic, multistage stratified sampling design was adopted to draw sample areas independently for each of these two domains. In each state, fieldwork was conducted in a total of 300 primary sampling units (PSUs), that is, villages in rural areas and Census Enumeration Blocks in urban areas. In each PSU, households to be interviewed were selected by systematic sampling. Within each selected household, no more than one respondent was interviewed from one category, resulting in a maximum of two interviews (with one married and one unmarried respondent) from any household. In cases where more than one respondent from a single category was found in the household, one respondent was selected randomly, and no replacement of the respondent selected was allowed (for more details of the study design, see IIPS & Population Council, 2010). The development of the questionnaire was informed by other survey instruments and insights obtained in the pre-survey qualitative phase. The survey instrument was finalised after extensive pre-testing. The individual questionnaire included questions on background characteristics; parental interaction; gender role attitudes and self-efficacy; awareness of sexual and reproductive matters; connectedness and friendship; pre-marital sexual relationships; marriage process; married life, including physical and sexual violence; health and health-seeking; substance use; media exposure; and participation in youth programmes. Questions on violence were drawn largely from those used in the National Family Health Survey-3, the Demographic and Health Survey conducted in India in 2005–2006 among a total of 124,385 women ages 15–49 years old and 74,369 men ages 15–54 years old across the country, which intended to provide estimates of demographic, social, and health indicators (IIPS & Macro International, 2007). The survey was undertaken in a phased manner and took place in 2006 in Jharkhand, Maharashtra, and Tamil Nadu, and in 2007–2008 in Andhra Pradesh, Bihar, and Rajasthan. A total of 50,848 young people were interviewed in the survey, including 13,912 married young women. In each state, interviewers (graduates in science or social science streams) were extensively trained; training was conducted over a 3-week period by the principal investigators. Training included a strong emphasis on research ethics and safeguards to be undertaken while gathering data and included classroom sessions, role play, and field practice. Female and male interviewers were responsible, respectively, for interviewing female and male respondents. The response rate for interviews with married women was 85%. The main reason for non-response was that the respondent was not at home; the rate of refusal to participate was 1% or less. No replacement was permitted. Ethical guidelines were strictly followed (see IIPS & Population Council, 2010, for details). As mentioned earlier, only one married woman was interviewed from each selected household. Interviews with young women and young men were held in separate PSUs in order to ensure that responses from young women were not inadvertently shared with young men. Moreover, interviews were conducted in complete privacy. In case family members or others attempted to listen to the interview, the interviewer called on a co-interviewer designated for this purpose to hold parallel discussions with these individuals so as to permit privacy for the main interview, or the interview was postponed. In each state, the team prepared lists of available services where respondents


1155


in need of help or services could be referred, and the team referred and sometimes accompanied those in need or those who requested services to these facilities. Ethical approval for the study was obtained from the review committee of the International Institute for Population Sciences, Mumbai. Our analysis is based on data obtained from 12,220 married young women ages 15–24 years old; it excludes 1692 women who had cohabited for less than 1 year.

Variables Independent variable Each young woman was asked whether her husband had ever slapped her; twisted her arm/pulled her hair; pushed/shook/threw something at her; punched her with his fist or something else; kicked/dragged/beat her; tried to choke/burn her on purpose; or threatened or attacked her with a knife, gun, or any other weapon. Those who reported any of these forms of violence were asked whether the violence had taken place in the 12 months preceding the interview. Our measure of physical violence classifies women into three categories, irrespective of whether they had experienced sexual violence: never experienced physical violence; experienced physical violence anytime in married life but not in the 12 months preceding the interview; and experienced physical violence anytime in married life including in the 12 months preceding the interview. To assess sexual violence, young women were asked whether their husband had forced them to have sex when they did not want to, at any time during their married life and in the 12 months preceding the interview. As in the case of physical violence, we classified women into three categories, irrespective of whether they had experienced physical violence: never experienced sexual violence; experienced sexual violence anytime in married life but not in the 12 months preceding the interview; and experienced sexual violence anytime in married life including in the 12 months preceding the interview. Our third measure refers to any physical or sexual violence; this is a summary measure reflecting whether women had experienced either physical or sexual violence, or both forms of violence. Similar to the two variables above, our measure of any physical or sexual violence is categorised as follows: never experienced any physical or sexual violence; experienced physical or sexual violence anytime in married life but not in the 12 months preceding the interview; and experienced physical and/or sexual violence anytime in married life including in the 12 months preceding the interview.

Background characteristics Our analysis controlled for a number of background factors including age, years of schooling successfully completed, current work status (defined as having worked in the 12 months preceding the interview), place of residence (rural/urban), co-residence with the husband (i.e., whether the woman was living away from her husband for a period of 1 month or longer at the time of the interview), family type (nuclear or joint/extended), and household economic status. Household economic status was measured by a wealth index, composed of household asset data on ownership of selected durable goods, including means of transportation, as well as a number of amenities, including toilet facilities, drinking water, and cooking fuel. The wealth index was constructed by allocating appropriate scores ranging from 0 to 4 to a household’s reported assets or amenities and the value of the index ranged from 0 to 54 (IIPS & Population Council, 2010).


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We recognise, in addition, that such factors as young women’s gender role attitudes and agency may well influence their negotiation skills with regard to condom use in marital relations; these factors, along with support networks – at community, natal family, and husband level – facilitate prompt care seeking in case of symptoms of gynaecological morbidity. Indicators reflecting each of these were also included as background variables. Gender role attitudes include attitudes about whether a woman must get her husband’s permission for most things, and son preference (i.e., a preference for more sons than daughters). Women’s agency was measured by their self-efficacy or ability to confront someone who has said or done something wrong to them, decision making on money matters, freedom to move around the village unescorted, and access to resources (i.e., ownership of a bank account). Also included were spousal communication (about the number of children to have) and condom use within marriage. Indicators assessing women’s support networks include whether they reported natal family contact in the first 6 months of marriage, and whether they participated in community-led activities. Finally, to account for interstate differences in socioeconomic and cultural factors, we included a variable (in the sixstate model) to reflect state.

Outcome variable All women were asked whether they had experienced three symptoms of gynaecological morbidity; questions included whether they had experienced problems in their private parts, including ulcers, itching, and swelling; burning sensation during urination; and vaginal discharge in the 3 months preceding the interview. Our outcome variable is thus the experience of one or more of these symptoms of gynaecological morbidity in the 3 months preceding the interview.

Analysis We recognise the need to minimise the limitations associated with cross-sectional survey data in establishing the temporal sequence of the experience of physical, sexual, or either form of violence in marriage and the experience of symptoms of gynaecological morbidity. To do so, we explored the prevalence of symptoms of gynaecological morbidity reported in the 3 months prior to the interview and compared experiences of young women who had never experienced physical or sexual violence with those of young women who had experienced either or both forms of such violence (including in the year preceding the interview), and those who had experienced such violence in the past but not in the year preceding the interview. Separate multivariate logistic regression analyses were conducted to assess the relationship between physical, sexual, and either form of (i.e., physical or sexual) violence and the experience of symptoms of gynaecological morbidity, after adjusting for other factors likely to influence the experience of symptoms of gynaecological morbidity. In view of the wide geographic heterogeneity of sociodemographic and cultural factors that characterise India, analysis is performed for the six states as a whole, as well as individually.



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Results Table 1 presents a profile of married young women ages 15–24 years old. Of note, young women were typically 21 years of age and were married or had begun cohabiting (if gauna, the northern Indian custom and ceremony that takes place some time after marriage and is associated with the bride’s move from her natal to her marital home, occurred later) early (16.6 years). They were, moreover, poorly educated (4.7 years of schooling) and from economically disadvantaged families (the mean score on the household economic status index was 15 of a maximum of 54). More than two-fifths were working (43%), one-third (35%) lived in nuclear households, and few were living away from their husband at the time of the interview (10%). Gender role attitudes remained traditional, with just 28% agreeing that a woman need not obtain her husband’s permission for most things, and one-quarter desiring more sons than daughters (24%). Young women’s agency was limited: 31% reported being able to confront a person who had said or done something wrong to her, 68% to 70% made decisions regarding spending money and buying clothes and had freedom of movement, and 10% had owned a bank account. Most young women reported communication with their husband (87%), but condom use was very limited (5%). Support networks were available to most, by way of natal family contact (90%), but very few participated in community activities (8%).

Physical and sexual violence Despite the fact that young women had been married, on average, less than 5 years, 27% of young women had experienced physical violence, one-third had experienced sexual violence, and almost half (47%) had experienced any (physical or sexual) violence perpetrated by their husband (see Table 2). We note, moreover, that a total of 12% of women reported the experience of both physical and sexual violence (not presented in table form). And many had experienced violence recently: 22% had experienced physical violence, 17% had experienced sexual violence, and 33% had experienced any (physical or sexual) violence in the 12 months preceding the interview. These findings suggest that large proportions of those who had ever experienced such violence had experienced it in the 12 months preceding the interview as well. State-wise differences in physical violence were moderate, with 20–32% of young women reporting the experience of physical violence at any time in married life, and 16–26% reporting such an experience in the 12 months preceding the interview. Statespecific differences in the experience of sexual violence were, in contrast, much wider: while 11% of young women in Andhra Pradesh reported ever experiencing sexual violence, more than half (54%) of those in Bihar so reported. Regional differences were wide: while 40–54% of women in the northern and eastern states had ever experienced sexual violence, 11–27% of those in the southern and western states had experienced such violence, and differences were also pronounced when sexual violence in the 12 months preceding the interview was considered (19–28% vs. 5–14%). In total, while 31– 44% of all young women in southern and western states had experienced any (physical or sexual) violence, considerably more (49–64%) of those in the northern and eastern states had such experiences. Patterns were largely similar in the case of any (physical or sexual) violence experienced in the 12 months preceding the interview (35–42% vs. 24–34%).

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Table 2. Percentage of married young women ages 15–24 years old who experienced physical and sexual violence, all states combined and by individual state.

Total (six states) Ever experienced Experienced but not in the 12 months preceding the interviewa Experienced in the 12 months preceding interviewb Total (N) Northern and eastern regions Bihar Ever experienced Experienced but not in the 12 months preceding the interviewa Experienced in the 12 months preceding interviewb Total (N) Jharkhand Ever experienced Experienced but not in the 12 months preceding the interviewa Experienced in the 12 months preceding interviewb Total (N) Rajasthan Ever experienced Experienced but not in the 12 months preceding the interviewa Experienced in the 12 months preceding interviewb Total (N) Southern and western regions Andhra Pradesh Ever experienced Experienced but not in the 12 months preceding the interviewa Experienced in the 12 months preceding interviewb Total (N) Maharashtra Ever experienced Experienced but not in the 12 months preceding the interviewa Experienced in the 12 months preceding interviewb Total (N)

the

the

the

the

the

the

Physical or sexual violence

Physical violence

Sexual violence

47.1 14.6

27.2 5.1

32.7 16.2

32.5

22.1

16.6

12,220

12,220

12,220

64.3 22.3

31.7 6.7

54.3 27.1

42.0

25.0

27.3

2017

2017

2017

53.4 18.4

28.8 6.6

40.2 20.9

35.0

22.2

19.3

2461

2461

2461

49.0 13.5

19.7 4.2

40.6 13.0

35.6

15.5

27.6

2181

2181

2181

30.9 7.3

24.7 4.7

10.6 5.2

23.6

20.0

5.4

2089

2089

2089

43.6 15.6

30.0 4.9

27.3 18.9

28.0

25.1

8.4

1714

1714

1714


1159

Table 2 (Continued)

Tamil Nadu Ever experienced Experienced but not in the 12 months preceding the interviewa Experienced in the 12 months preceding the interviewb Total (N)


Physical violence

Sexual violence

44.2 10.5

29.4 3.2

25.8 12.3

33.7

26.3

13.6

1758

1758

1758


a

Note: Experienced violence in married life but not in the 12 months preceding the interview. b Experienced violence in the last 12 months of married life; includes women who may have experienced violence earlier in married life.

Symptoms of gynaecological morbidity Overall, about one-fifth (21%) of married young women reported at least one symptom of gynaecological morbidity. Symptoms were more likely to be reported by young women in states in the northern and eastern region than those in the southern and western region, notably ranging from 12% in Andhra Pradesh to 28% in Bihar (data not shown in tabular form). Experience of physical and/or sexual violence and symptoms of gynaecological morbidity The experience of any (physical or sexual) violence was associated with increased reporting of symptoms of gynaecological morbidity in the 3 months preceding the interview (see Table 3). For example, 16% of young women who had never experienced violence reported symptoms of gynaecological morbidity, compared with 28% of those who had experienced such violence in the year preceding the interview and 21% of those who had experienced violence earlier but not in the year preceding the interview. Similar associations were observed when physical violence (18%, 30%, and 22%, respectively) and sexual violence (17%, 30%, and 25%, respectively) were considered separately. Notably, percentages of women who had experienced symptoms of gynaecological morbidity were consistently larger among those who had experienced violence in the year preceding the interview than those who had experienced violence earlier but not in the last year. A similar pattern is observed in every state. Associations were not consistently observed, in contrast, in regard to experiences of violence earlier in married life but not in the year preceding the interview; in many instances, women who had such experiences were as likely as those who had never experienced violence to report symptoms of gynaecological morbidity. Multivariate analyses Most of the associations between physical and sexual violence and the experience of symptoms of gynaecological morbidity discussed above remained significant after we controlled for the effects of a range of potentially confounding factors. As seen in Table 4, the odds that a married young woman aged 15–24 years had experienced symptoms of

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Table 3. Symptoms of gynaecological morbiditya (experienced in the 3 months preceding the interview) by young women’s experiences of physical and/or sexual violence in married life, women aged 15–24 years, all states combined and by state.


Physical or sexual violence Total (six states) Never experienced violence Experienced but not in the 12 months preceding the interviewb Experienced in the 12 months preceding interviewc Total (N) Northern and eastern regions Bihar Never experienced violence Experienced but not in the 12 months preceding the interviewb Experienced in the 12 months preceding interviewc Total (N) Jharkhand Never experienced violence Experienced but not in the 12 months preceding the interviewb Experienced in the 12 months preceding interviewc Total (N) Rajasthan Never experienced violence Experienced but not in the 12 months preceding the interviewb Experienced in the 12 months preceding interviewc Total (N) Southern and eastern regions Andhra Pradesh Never experienced violence Experienced but not in the 12 months preceding the interviewb Experienced in the 12 months preceding interviewc Total (N) Maharashtra Never experienced violence Experienced but not in the 12 months preceding the interviewb Experienced in the 12 months preceding interviewc Total (N)

the

the

the

the

Physical violence

Sexual violence

15.6 20.8***

17.7 22.1*

17.1 25.2***

28.4***

29.5***

29.8***

12,220

12,220

12,220

22.3 25.5

24.2 29.4

24.3 28.5

33.1***

36.2***

32.1*

2017

2017

15.8 19.9

17.9 25.4*

17.5 23.7*

28.5***

29.5***

28.7***

2461

2461

2461

19.9 19.0

20.6 24.1

21.4 18.4

28.3***

33.5***

27.8*

2181

2181

9.0 9.5* the

the

2017

2181

9.4 11.2

10.2 18.6*

19.6***

19.5***

26.5***

2089

2089

2089

13.6 18.7

15.1 14.3

15.3 26.0***

28.3***

28.7***

29.4***

1714

1714

1714


1161

Table 3 (Continued) Physical or sexual violence Tamil Nadu Never experienced violence Experienced but not in the 12 months preceding the interviewb Experienced in the 12 months preceding the interviewc Total (N)

Physical violence

Sexual violence

20.6 25.5

21.3 35.5*

22.0 26.3

28.4**

28.9**

30.8*

1758

1758

1758


a

Note: Includes all women who had cohabited for at least 12 months. b,c See Table 2 footnotes. Difference with ‘never experienced violence’ significant at *p ≤ 0.05 level; **p ≤ 0.01 level; and ***p ≤ 0.001 level.

gynaecological morbidity were greater among those reporting the experience of any form of violence in the year preceding the interview, as well as any physical violence or sexual violence considered individually, than among women who had never experienced such violence (odds ratios, 1.8–2.1). More moderate associations were also observed among women whose last episode of any (physical or sexual) violence or whose last episode of sexual violence had taken place over a year prior to the interview (odds ratios, 1.3–1.5). The consistency of this pattern in every single state was notable. In every state, the odds that a women had experienced symptoms of gynaecological morbidity were greater among women who had experienced any form of violence in the 12 months preceding the interview – physical (odds ratios, 1.3–2.3), sexual (odds ratios, 1.4–3.5), or either physical or sexual (odds ratios, 1.4–2.5) – than among those who had never experienced physical, sexual, or either of these forms of violence, respectively. In contrast, findings suggest that those who had experienced any violence in married life but not in the 12 months preceding the interview were, for the most part, no more likely to have experienced symptoms of gynaecological morbidity than were those who had never experienced violence in married life.

Discussion Findings confirm that physical violence and sexual violence are initiated early in marriage for significant proportions of young women in India. While evidence that is more recent than the 2006–2007 period, when our survey was conducted, is not available at national or sub-national levels, at least one small exploratory study conducted in the state of Bihar found that the experience of violence within marriage remained widespread, and that both women and men acknowledged that it was initiated early in marriage (Jejeebhoy, Santhya, & Sabarwal, 2013). This suggests that the more recent situation in terms of young women’s experiences of violence in marriage is unlikely to have changed. Moreover, our results corroborate findings from studies of adult women and highlight that even among young women, there is a strong association between experiencing violence and experiencing symptoms of gynaecological morbidity. Indeed, the association between violence experienced in the year prior to the interview and reported symptoms of gynaecological morbidity in the 3 months preceding the interview persisted even after we controlled for a number of demographic-, social-, economic-, and gender-related factors,

1162



Table 4. Odds ratios (and 95% confidence intervals) from logistic regression analysesa assessing the relationship between the experience of marital violence and symptoms of gynaecological morbidityb (experienced in the 3 months preceding the interview), young women ages 15–24 years old, all states, and by individual state.

Total (six states) Never experienced violence Experienced but not in the 12 months preceding the interview Experienced in the 12 months preceding the interview Total (N) Northern and eastern regions Bihar Never experienced violence Experienced but not in the 12 months preceding the interviewc Experienced in the 12 months preceding the interviewd Total (N) Jharkhand Never experienced violence Experienced but not in the 12 months preceding the interviewc Experienced in the 12 months preceding the interviewd Total (N) Rajasthan Never experienced violence Experienced but not in the 12 months preceding the interviewc Experienced in the 12 months preceding the interviewd Total (N) Southern and western regions Andhra Pradesh Never experienced violence Experienced but not in the 12 months preceding the interviewc Experienced in the 12 months preceding the interviewd Total (N)


Physical violence

Sexual violence

1.0 1.28 (1.07–1.54)**

1.0 1.27 (0.99–1.63)

1.0 1.48 (1.24–1.77)***

2.05 (1.82–2.30)*** 2.03 (1.77–2.32)***

1.84 (1.58–2.14)***

12,220

12,220

12,220

1.0 1.20 (0.79–1.80)

1.0 1.32 (0.78–2.21)

1.0 1.23 (0.84–1.80)

1.91 (1.37–2.66)*** 1.99 (1.43–2.77)***

1.50 (1.11–2.02)**

2017

2017

2017

1.0 1.23 (0.89–1.71)

1.0 1.59 (1.04–2.43)*

1.0 1.34 (0.99–1.83)

1.99 (1.49–2.65)*** 1.84 (1.37–2.47)***

1.81(1.33–2.46)***

2461

2461

2461

1.0 0.96 (0.64–1.44)

1.0 1.21 (0.68–2.16)

1.0 0.82 (0.54–1.25)

1.63 (1.25–2.13)*** 2.00 (1.42–2.82)***

1.42 (1.05–1.93)*

2181

2181

2181

1.0 1.06 (0.54–2.07)

1.0 1.16 (0.50–2.63)

1.0 2.20 (1.17–4.15)*

2.39 (1.70–3.37)*** 2.21 (1.59–3.07)*** 2089

2089

3.54 (1.94–6.47)*** 2089


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Table 4 (Continued)

Maharashtra Never experienced violence Experienced but not in the 12 months preceding the interviewc Experienced in the 12 months preceding the interviewd Total (N) Tamil Nadu Never experienced violence Experienced but not in the 12 months preceding the interviewc Experienced in the 12 months preceding the interviewd Total (N)


Physical violence

Sexual violence

1.0 1.51 (1.08–2.11)*

1.0 1.02 (0.49–2.13)

1.0 1.92 (1.41–2.62)***

2.52 (1.86–3.42)*** 2.25 (1.70–2.98)***

2.21 (1.45–3.36)***

1714

1714

1714

1.0 1.36 (0.95–1.94)

1.0 1.83 (0.90–3.75)

1.0 1.27 (0.90–1.79)

1.40 (1.07–1.85)*

1.31 (1.00–1.72)*

1.58 (1.10–2.25)*

1758

1758

1758

a

Note: Odds ratios are obtained from individual multivariate logistic regression analyses. b After controlling for age, years of schooling completed, place of residence, current work status, standard of living, residence in nuclear family, communication with husband, natal family support, gender role attitudes, participation in community activities, self-efficacy, household decision making, mobility inside the village/ neighbourhood, having bank or post office account, current use of condoms, co-residence with husband, and region of residence. c,d See Table 2 footnotes. Difference with ‘never experienced violence’ significant at *p ≤ 0.05; **p ≤ 0.01; and ***p ≤ 0.001.

and this was consistently observed in each of the six states in which the study was conducted. The study highlights the importance of sexual and physical violence as likely risk factors of experiencing symptoms of gynaecological morbidity. Although our study was not designed to enable us to probe the mechanisms through which violence is associated with elevated risks for symptoms of gynaecological morbidity among married young women, insights may be drawn from available evidence from other studies. Both direct and indirect pathways are likely. Among direct and biological links, gynaecological morbidity may result from the trauma caused by physical and sexual violence; sexual violence may cause vaginal or urethral trauma through direct physical force and lack of lubrication that may exacerbate women’s risk for acquiring an infection (Stephenson et al., 2006). Among indirect links, women who suffer violence perpetrated by their husband may have husbands with other characteristics that place the women at risk for infection; evidence suggests that men who admitted perpetrating violence on their wife were also more likely than others to report multiple-partner sexual relations, non-use of condoms, and symptoms of infection thereby placing their wife at risk for acquiring infection (Verma & Collumbien, 2003). More indirectly, many have noted that the experience of physical and/or sexual violence limits abused women’s agency to adopt protective actions, seek appropriate care for themselves, or negotiate sex and condom use with their husband (Ahmed et al., 2006; Khan, Townsend, Sinha, & Lakhanpal, 1996), even if they suspect their husband of engaging in sex with multiple partners, as seen in a study that probed marital violence and the interrelation between gender norms, domestic violence, and women’s risk of HIV in the slums of Chennai (Go


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et al., 2003). Moreover, abused women have been found to tolerate the violence in silence and may be less likely than others to have access to support networks that may help them in obtaining services to address their sexual and reproductive health needs (Chan, Brownridge, Tiwari, Fong, & Leung, 2008; Jewkes, Levin, & Penn-Kekana, 2002). Finally, perceived gynaecological symptoms have been associated with depression and mental distress, conditions that abused women may be more likely to experience than those who do not experience marital violence (Patel et al., 2006). We note that our study made efforts to control some of the indirect pathways noted above, namely, women’s agency and gender role attitudes, and women’s support networks. However, associations remained significant in every single state even after such controls were applied. These findings lead us to suggest that such pathways as the direct biological route and the husband’s extramarital relations may have played a stronger role in explaining the link between violence perpetrated by the husband and symptoms of gynaecological morbidity than women’s agency or support networks did. At the same time, we hypothesise that violence in marital relations may be so shrouded in shame, self-blame, and a culture of silence that even women who have agency in other aspects of their life and who have access to wide social networks may not be in a position to exercise their agency or draw on their social networks to avoid the deleterious consequences of violence perpetrated by their husband. We acknowledge several limitations in our analysis. First, although we made efforts to ensure that our violence indicator would, in all likelihood, precede our outcome variables, given the cross-sectional nature of our data, it is possible that we were not always successful in doing so (e.g., in cases in which both the first experience of violence and the symptom of gynaecological morbidity were experienced in the 3 months prior to the interview). Second, we note that symptoms of gynaecological morbidity were selfreported, and previous studies have highlighted that women’s own reports do not always correspond with clinically or lab-detected morbidity, and may therefore have resulted in different associations than if clinically or lab-detected morbidity had been available (Jejeebhoy, Koenig, & Elias, 2003). Third, we acknowledge that the symptoms of gynaecological morbidity covered in the survey were not comprehensive, and such symptoms as pelvic pain, menstrual abnormalities, or difficulties in conceiving, for example, were not assessed; this omission may have resulted in underestimating the prevalence of symptoms of gynaecological morbidity. Finally, we note that our data did not permit us to control for supply side factors influencing health outcomes, such as access to and quality of services to treat symptoms of gynaecological morbidity. Notwithstanding these limitations, our findings confirm a strong association between violence experienced in marriage and the experience of symptoms of gynaecological morbidity even among young women. Findings suggest several priority programmatic areas for action as well as issues requiring research attention. The most obvious recommendation is to strengthen efforts to prevent the incidence of violence among married youth, through education, counselling, programmatic opportunities to change deeply entrenched inegalitarian gender norms, and, at the same time, raising awareness and enforcement of laws protecting women from domestic violence. There is also a need, particularly given the consistent associations between violence and symptoms of morbidity observed, and given that young women who experience violence in marriage are unlikely to disclose such violence or its gynaecological morbidity outcomes (IIPS & Macro International 2007), for programmes to play a proactive role in recognising and



1165

responding sensitively to the needs of young women experiencing such violence. Healthcare providers must be trained to recognise and offer sensitive screening of young women during routine history-taking in a wide range of services, and providers must incorporate support services – counselling, treatment, referral, and emotional support – into existing health services for women experiencing violence in marriage. Screening must become part of routine services, and health-care providers must, in particular, recognise the likelihood of experiences of violence among women presenting with gynaecological symptoms even if not corroborated by laboratory findings. Moreover, given that many abused young women may not approach a health-care provider or follow up on referrals recommended by a provider (Jejeebhoy, Santhya, & Acharya, 2010), sensitive outreach activities must be included that reach young women in home settings in confidential and non-judgemental ways, and that support them in accessing appropriate services. Findings also suggest the need for further research. While our analysis has tried to ensure, as far as possible in a cross-sectional study, appropriate temporal ordering, we acknowledge its limitations in asserting causality. There is a need for more longitudinal studies, or at least cross-sectional studies that are better equipped to provide histories of both violence as well as reproductive health outcomes, such as symptoms of gynaecological morbidity. At the same time, the pathways through which violence results in adverse reproductive health outcomes among married young women are not well documented. There is a need for research, both quantitative and qualitative, communityand facility-based, that traces these links and probes likely intervening pathways. A better understanding of the extent to which pathways are biological, indirect, or both has important implications for the thrust of health-programme strategies. Strong evidence of biological pathways calls for investments in physical examinations, and testing for and treating infection, while strong evidence of indirect pathways would call for a focus on community-based support and on changing traditional gender role attitudes. Likewise, longitudinal studies that explore the links between exposure to violence in marriage and other reproductive health problems, such as, for example, infertility, miscarriage, neonatal and infant mortality, and an unmet need for contraception are needed. Acknowledgements This paper was presented at the seminar entitled Violence in Adolescence and Youth in Developing Countries organised by the International Union for the Scientific Study of Population, and held in New Delhi, 2012. We gratefully acknowledge the comments made by reviewers and participants at this seminar. M. A. Jose and Komal Saxena provided huge research support. Support from the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, the Richard and Flora Hewlett Foundation, and the UK Government Department for International Development to the Population Council is gratefully acknowledged.

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