literature review of marital violence

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• v.29(2); 2022

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Women’s experiences of marital rape and sexual violence within marriage in India: evidence from service records

Padma-bhate deosthali.

a Senior Advisor, Centre for Enquiry Into Health and Allied Themes, Mumbai, India

Sangeeta Rege

b Coordinator, Centre for Enquiry Into Health and Allied Themes, Mumbai, India

Sanjida Arora

c Research Officer, Centre for Enquiry Into Health and Allied Themes, Mumbai, India. Correspondence : gro.tahec@adijnas

Sexual violence within marriage is common and manifests in various forms, including marital rape. It has serious physical and mental health consequences and is a violation of women’s sexual and reproductive health rights. Marital rape, reproductive coercion, inserting objects in the vagina or anus, and withholding sexual pleasure are forms of violence routinely experienced by women. Based on service records of survivors coming to public hospitals in an Indian city, this paper presents their pathways to disclosure and institutional responses such as hospitals and police. The findings highlight that a large proportion of survivors of domestic violence confide having experienced forced sexual intercourse by the husband while sharing their experience of physical, economic, and emotional violence with crisis intervention counsellors. However, a small number of women do report marital rape to formal systems like hospitals and police. These systems respond inadequately to women reporting marital rape, as the rape law exempts rape by husband. Sexual violence within marriage can have serious health consequences, and a sensitive healthcare provider can create an enabling environment for disclosing abuse and providing relevant care and support. The paper argues that a necessary precondition to enable women to access health care and justice is to nullify “Exception 2 to Section 375 of the Indian Penal Code” This exception exempts rape by the husband from the purview of the rape law.

Résumé

Les violences sexuelles dans le mariage sont communes et se manifestent sous différentes formes, notamment par le viol conjugal. Elles ont de graves conséquences sur la santé physique et mentale et constituent une violation du droit des femmes à la santé sexuelle et reproductive. Le viol conjugal, l’obligation de procréer, l’insertion d’objets dans les parties intimes et le refus du plaisir sexuel sont des formes de violences fréquemment subies par les femmes. Sur la base des dossiers des victimes s’étant rendues dans des hôpitaux publics d’une ville indienne, cet article présente leur cheminement vers la révélation et les réponses institutionnelles données par l’hôpital et la police. Les conclusions mettent en lumière le fait qu’une forte proportion des victimes de violences familiales confient qu’elles ont été obligées par leur mari de subir des rapports sexuels tout en ayant partagé leur expérience des violences physiques, économiques et psychologiques avec des conseillers spécialisés dans les interventions en situation de crise. Néanmoins, un petit nombre de femmes signalent le viol conjugal aux systèmes officiels comme les hôpitaux et la police. Ces systèmes répondent de manière inadéquate aux femmes qui font état d’un viol conjugal, puisque la loi sur le viol fait une exception pour le viol perpétré par le conjoint. Les conséquences des violences sexuelles pendant le mariage sont graves et un prestataire de santé sensible peut créer un environnement propice à la révélation de mauvais traitements et prodiguer un soutien et des soins pertinents. L’article avance qu’une condition préalable nécessaire pour permettre aux femmes d’avoir accès aux soins de santé et à la justice est d’annuler « l’exception 2 à la section 375 du Code pénal indien ». Cette exception concerne le viol par le mari qui est hors du champ d’application de la loi sur le viol.

La violencia sexual dentro del matrimonio es común y se manifiesta en diversas formas, entre ellas la violación marital. Tiene graves consecuencias para la salud física y mental, y es una violación de los derechos sexuales y reproductivos de las mujeres. La violación marital, coacción reproductiva, inserción de objetos en las partes privadas y la denegación de placer sexual son formas de violencia que sufren las mujeres de manera rutinaria. Basado en registros de servicios proporcionados a sobrevivientes que acuden a hospitales públicos en una ciudad de India, este artículo presenta las rutas de esas mujeres a la denuncia y las respuestas institucionales tales como las de hospitales y la policía. Los hallazgos destacan que un gran porcentaje de sobrevivientes de violencia doméstica confesaron haber sufrido coito sexual forzado por su esposo, cuando relataron su experiencia de violencia física, económica y emocional a consejeros de intervenciones en respuesta a crisis. Sin embargo, un pequeño porcentaje de mujeres denuncia la violación marital a sistemas formales, tales como hospitales y la policía. Estos sistemas responden inadecuadamente a las mujeres que denuncian la violación marital, dado que la ley sobre violación exime la violación perpetrada por el esposo. La violencia sexual dentro del matrimonio tiene graves consecuencias para la salud; un prestador de servicios de salud sensible puede crear un entorno propicio para denunciar maltrato y brindar atención y apoyo pertinentes. Este artículo argumenta que una precondición necesaria para ayudar a las mujeres a acceder a servicios de salud y justicia es anular la “Excepción 2 a la Sección 375 del Código Penal de India”. Esta excepción exime la violación por el esposo del alcance de la ley sobre violación.

The outrage after the rape and assault resulting in the murder of a health professional in December 2012 in India * led to several public demands for addressing the issue of violence against women and changes in the criminal justice system. One response by the Indian government was to introduce amendments to the criminal law of rape. Before these amendments, an act was considered rape only if there was an attempt at peno-vaginal penetration. The law did not include as rape other forms of sexual violence, such as inserting objects or any other body part into a woman's vagina, anus, mouth, or urethra. The Criminal Law Amendment Act, 2013 brought in critical changes providing a standardised framework on rape and sexual violence but, regrettably, the issue of sexual violence by the husband in a marital relationship (marital rape) is left out. These amendments thus failed to address the concern of sexual violence within marriage. The law retains the exemption from the offence of rape of forced sexual intercourse by a husband with his wife. This exemption is based on the notion that there is “implied and irrevocable consent to sexual intercourse by women” in marital relationships. 1 This impunity of marital rape ignores the relationship which has been established between sexual violence within marriage and health consequences for women.

Current evidence on sexual violence by an intimate partner

Violence against women (VAW) has been recognised as a public health issue and a violation of women's human rights. The 2030 Agenda for Sustainable Development Goals has emphasised the need to monitor VAW. Yet, there is limited high-quality, actionable data on the prevalence of VAW due to limited capacities to measure prevalence, lack of resources and the ethical and methodological challenges in researching VAW.

Asking women about sexual violence by an intimate partner is challenging across cultures. Global estimates based on Demographic and Health Surveys (DHS) provide some insights into the prevalence of intimate partner violence. The latest available estimate on intimate partner violence from the World Health Organization (WHO) is that “globally about 1 in 3 (30%) of women worldwide have been subjected to either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime”. (WHO, 2021) Further, a multi-country study found that in 10 countries sexual VAW of age 15–49 years from an intimate partner varied from 6% to 59%. (WHO, 2005)

In India, the National Family Health Surveys (NFHS) † and National Crime Records Bureau (NCRB) ‡ are the only two sources which provide national-level data on VAW. The NCRB data include only those women and/or their families who have mustered up the courage to register a police complaint. Additionally, as the law does not recognise sexual violence by husbands, the reporting of marital rape is almost negligible. A working paper based on a comparison of NFHS and NCRB data indicated that less than 1% of cases of sexual violence by the husband are reported to the police. 2

The NFHS uses two categories to measure sexual violence: “use of physical force by the husband to have sexual intercourse even when the wife did not want to” and “forcing a woman to perform sexual acts she did not want to”. A study carried out in urban parts of Southern India reported on several forms of sexual violence by the husband. These included the use of physical force by the husband for engaging in “sexually degrading or humiliating acts, using weapons for forcing sex, forcing wife to engage in sex in absence of privacy, and criticising or humiliating wife for or during sex”. 3 The study did not include actions such as “preventing access to contraception and safe abortion” as forms of violence by the husband, but these have been now recognised as reproductive coercion, a form of domestic violence. A cross-sectional study in Gujarat and West Bengal also found underestimation by research studies of sexual violence in marital relationships. The study concluded that measuring sexual violence with questions focusing only on forced sex would lead to underestimation. Women were less likely to indicate sexual contact as coercive if physical violence was not involved. 4

The reported prevalence of sexual violence by intimate partners varies widely across studies in India. A survey carried out in 2010 reported that one in five men reported having ever forced their wives for sex. 5 In another study carried out in rural Karnataka, 36% of the women agreed to the statement that “a husband might force his wife to have sex even if she refuses”. 6 A mixed-method study in Chennai found that about 31% of women reported sexual violence by husbands. 7 A large-scale survey on married men in four districts of Uttar Pradesh found that about 32% of husbands in their lifetime had forced their wives to have sexual intercourse. 8 More recently, the National Family Health Survey (2019–2020) showed that 29% of ever-married women had experienced some form of physical or sexual violence from their husbands. 9

There is also substantial evidence on the occurrence of sexual violence by the husband during pregnancy. 10 A study conducted by Varma and colleagues 11 in an antenatal setting found that, in the previous 12 months, 14%, 9% and 15% of pregnant women faced physical, psychological, and sexual violence, respectively. A recent study found that 40% of women who reported domestic violence during pregnancy faced sexual violence from husbands. 12 More recently, the National Family Health Survey (2019–2020) showed that 29% of ever-married women had experienced some form of physical or sexual violence from husbands. 9

These estimates on the prevalence of marital rape should be interpreted carefully. In general, there is gross under-reporting of sexual violence in India due to stigma and barriers faced by survivors related to notions of shame and honour. 13

Health consequences of sexual violence in marriage

There is strong evidence in the literature to indicate that marital rape leads to severe physical, sexual, reproductive, and psychological health consequences. 14–16 As women are abused multiple times by a person they trusted, the consequences of marital rape on women's health are grave. 17 , 18

Health consequences include an increased risk of getting sexually transmitted or reproductive tract infections (STIs/RTIs) and HIV/AIDS due to forced sex and the wife’s inability to negotiate the use of condoms by her husband. 19–21 It is evident from the literature that men who inflict violence on their spouses are more likely to engage in sex outside marital relationships, have sexually transmitted infections, and thus pose an increased risk for their spouses through sexual coercion. 22–24 Further, sexual violence has also been found to be associated with stillbirths, pelvic inflammatory diseases (PIDs), poor access of women to prenatal care, and attempted suicides by women. 25

Women facing domestic violence were found to be 2.59 times more likely to experience perinatal and neonatal mortality in a study conducted in North India among 2199 pregnant women. 8 A study by Johri et al. recommended that reproductive health services must include screening for spousal violence as they found an association between miscarriage and violence faced by women from an intimate partner. 26

This paper attempts to describe the experiences of women facing sexual violence in marriage, how these women come in contact with the health system, and the response they receive from the health system and police. The findings raise important concerns regarding the inadequacy of redressal mechanisms and the limited roles played by the police and health system, influenced significantly by the impunity afforded to marital rape by the law. The paper highlights the pivotal role that a sensitive health system can play in identifying sexual violence by recognising the health consequences associated with it.

Methodology

The paper is based on service records of violence survivors. These service records include counselling records of a public hospital-based crisis intervention department and medico-legal forms of three public hospitals in Mumbai. The authors are part of a non-governmental organisation (NGO) working with public hospitals on strengthening their response to VAW. As part of monitoring the quality of services and adherence to standards of care, the authors are responsible for the review of service records, including medico-legal forms and counselling records, and building the skills of healthcare providers to provide a comprehensive response to women facing violence. A team of counsellors routinely reads the service records and monitors the documentation quality regularly.

For this paper, we have analysed the following records quantitatively and qualitatively:

These women did not come to the hospital with a complaint of marital rape. They sought services for domestic violence from the crisis intervention department at the hospital. We analysed the counselling records to understand the profile of survivors who disclosed sexual violence while seeking domestic violence services from the counsellor, their experiences of violence, consequences on health, and coping mechanisms. Counselling records are maintained by counsellors and include socio-demographic profile, history of violence, health consequences, support sought in the past, and intervention provided by the department.

• Medico-legal forms of all survivors who reported sexual violence from an intimate partner at all the three hospitals during a nine-year period (April 2008 to March 2017): We analysed these forms to present the profile of survivors, the types of sexual violence reported, the pathways through which these survivors reached the hospital, and their experience of seeking justice. Medico-legal forms include the basic profile of the survivor, the reported incident of sexual violence, time since the incident, details of physical examination, evidence collected, and medical opinion of the doctor.

The two data sources represent different pathways to disclosure, as shown in Table 1 .

Pathway to disclosure

The Anusandhan Trust’s Institutional Ethics committee approved the study to analyse these records (ATIEC06/2016, 15 October 2016). In the process of analysing the data, all ethical guidelines have been adhered to. The original service records were photocopied and the identifiers were removed from xerox copies with white ink. The data were entered into the Statistical Package for Social Sciences (SPSS) for Windows, Version 20.0. Armonk, NY by IBM Corp. The data were entered jointly by the data entry operator and counsellors to avoid abstraction of information. We gave a unique registration number to each case of domestic and sexual violence to maintain confidentiality. The unique registration numbers were used to maintain the Management Information System of these cases. This information system was accessible only to the team members who were involved in this project. The photocopied case records are also kept under lock and key.

Domestic violence survivors reporting sexual violence to counsellors: analysis of counselling records

Most often women first disclose physical, financial, and emotional violence to a counsellor. Once trust is established, women feel comfortable about sharing their experience of sexual violence with a counsellor.

Profile of women

At the hospital-based counselling centre, of a total of 1783 women registered during the period 2008–2017, 79.4% (1416) were currently married, 10.4% were separated/widowed or deserted, and 10.2% were never married. Of the currently married women (1416), 58.5% (828) women reported experiencing sexual violence from their husbands. The majority of women were young, with 8% being in the age group of 18–35 years.

Pathway to the crisis intervention department in public hospitals

Forty-one percent (339) of the women were referred to the crisis intervention department by the health system as they had come to the hospital for treatment of health complaints as a result of ongoing violence. The health complaints ranged from physical assault reported by 46%, attempted suicide by 28%, reproductive health complaints by 25% and attempted homicide by 1%.

Forms of violence

The history of violence revealed that 91% of women had been experiencing violence since marriage. One in four women (25.6%) who were married for less than a year were pregnant when they reached the crisis intervention department. They reported that they were not using any form of contraception due to the sexual control exerted by their partners.

Table 2 shows different forms of sexual violence reported by women. Sixty-eight per cent of the women reported “forced sex,” referring to forced penile penetration and 8% of women reported that they had experienced “forced anal or oral penetration”. These forced sexual acts would be recognised as “rape” under Section 375 only if exception 2 to the law were not to exclude marital rape.

Forms of sexual violence disclosed to a counsellor

The analysis of case records also revealed several forms of sexual violence experienced by women in addition to forced sexual intercourse ( Table 2 ). Twenty-four per cent of women reported reproductive coercion as the husband refused to use any contraceptive and also prohibited her use. Four percent of women reported facing sexual violence from the husband’s relatives.

As seen here, sexual violence within marriage takes various forms that go beyond “forced sexual intercourse”/marital rape. The partner's refusal to use contraception or allow the woman to use any form of contraceptive, and forcing the woman to have children, are recognised as reproductive coercion and a form of sexual violence. Women also complained of being forced into oral and anal sex against their wishes and having sexual acts forced on them against their will, as well as acts that they found repulsive. Twenty-nine per cent of women reported husbands’ withholding of sexual pleasure. Their husbands either had other partners or were going to sex workers, and the women shared that lack of sexual relations was painful for them and was difficult to talk about to anyone.

About 92% of women informed about experiencing physical and financial violence concurrently with ongoing sexual violence. Table 3 presents other forms of violence reported by women.

Forms of violence reported by those experiencing sexual violence

Health consequences

The impact of ongoing abuse on the physical and mental health of survivors was assessed by counsellors. Physical health consequences such as injuries were reported by 82% of women while reproductive health problems like abortion, miscarriage, RTIs, and prolapse of the uterus were reported by 22% of women. Mental health consequences were reported by 98% of women, among whom 26% had attempted to end their life while 29.4% reported thoughts of ending life (suicidal ideation). Other mental health consequences experienced by survivors included nervousness and tension (72%) and feeling afraid all the time (36%). Forty-eight percent of the women sought help from police by filing a domestic violence complaint but in all these cases the police had registered a non-cognisable offence, i.e. an entry in a police diary that does not warrant any investigation. At present, there is no option for such women to file a criminal complaint due to “exception 2 in Section 375 of the Indian Penal Code”.

Women reporting marital rape to the hospitals: analysis of medico-legal forms of survivors of rape

Based on the data from three public hospitals in Mumbai, from 2008 to 2017, of 1664 rape survivors, at least 18 women reported marital rape and sought medico-legal support.

Women reporting marital rape were mostly young. Thirteen were in their 20s, and five were in their 30s. Of the 18 women, 8 were residing with their husbands and 10 were separated from their husbands due to severe violence. Those currently living with their husbands were married for a year or two.

Pathway to hospital

Ten women reported directly to the hospital, and police brought in eight. The women who reported to the hospital directly had been raped in the previous one to five days. These women suffered injuries and came to the hospital for treatment. One of these women was pregnant when she had been raped. Of those brought by police, the incident occurred two to three days back in one case, and two to six months ago in the remainder. As there were ongoing threats of rape or physical assault or attempts at rape by the husband, the women wanted to file a case of rape.

Forms of sexual violence and health consequences

The forms of marital rape included forced peno-vaginal and anal intercourse, inserting materials like rods, bottles, chilli powder in the vagina, forced oral sex, and forcing women to watch pornographic material. Women reported experiencing physical assault along with sexual violence. Thus, women came to the hospital to get treatment for vaginal/anal injuries, bruises, and bite marks on the body.

All the women reported experiencing domestic violence including forced sexual intercourse. Only women separated from their partners had registered domestic violence cases against their partners that included physical, emotional, and economic abuse. The women who were separated from their partners said that the husbands had either come to meet them at their residence on the pretext of asking for forgiveness or meeting the children. They had then raped them, or assaulted the women on the roads and dragged them home before raping them.

“In one such case, a woman (22-year-old) has been living separately from her husband due to sexual abuse, physical violence and demands for money. When she was going back home from the office, her husband caught her and asked for money, had sex with her forcefully and put kerosene on her. She suffered burns and reached the hospital for treatment.” (From service record of a 22-year-old survivor)

“A survivor who had divorced her husband because of domestic violence said that he came to her house, asked for forgiveness, and had forced sex with her.” (From service record of 32-year-old survivor)

It was not the first time the partner had raped them after separation. But the continued threats and fear prompted them to seek help. These threats also included threats to rape a child or relative. Two women had been raped by their husbands several times, but they reported the recent incident as the husband threatened to rape their child or relative.

Women currently married and living with their partners had been experiencing domestic violence for one or two years. The incident reported by them was not the first incident they had experienced, but the consequences of such repeated acts pushed them to seek support. They told the doctor about the violent sex that their partners forced on them. In one case, a 20-year woman married for six months came to the hospital after sustaining several injuries. She disclosed to the doctor that her husband would have sex violently with her.

“A 21-year-old survivor married for a year said that her husband injected a syringe of blood in her back when she was pregnant, which she suspects to be HIV-positive blood. She came to the hospital for a medical check-up and abortion. She disclosed that her husband had been inserting pens and bottles in her vagina, throwing chili powder, and forcing her to watch pornographic material on the mobile.” (From service record of a 21- year- old survivor)

Response of police to marital rape

All 18 women contacted the police either directly or after the medico-legal examination at the hospital. Women reported that they had been kept waiting for a long time at the police station as the police did not know what to do in cases where women reported rape by their husbands. For those who had reached the police first, such delay caused loss of medical evidence and delay in accessing medical care, causing further agony to the survivor.

For 2 of the 10 separated or divorced women, the police had registered domestic violence cases under the Indian Penal Code (IPC) 498A and/or IPC 377, but none had filed a rape case. § The police were not aware of the amendments to rape law that recognised sexual violence by the husband who was separated or divorced as rape. ** Of the eight women who were currently living with their husbands, the police noted the complaint and brought three women to the hospital but did not register a First Information Report (FIR) †† as the perpetrator of rape was the husband. The police told four women that they could not do anything in cases of rape by the husband, as marital rape was not a crime. In the case of the 21-year-old woman who reported that her husband had injected HIV-positive blood, a social worker accompanied the woman to the police and the police filed a case under Section 498A. ‡‡ The inadequate police response is of concern as all the women had suffered severe violence. The least that the police should have done was record a cognisable offence or FIR and ensure immediate medical care and examination of the survivors.

Response of health workers to marital rape

Women narrated their experience of violence to the examining doctor. Whether they came directly to the hospital or were brought by police, the hospital had followed the protocol mandated by the MoHFW for examination, treatment, and evidence collection of victims/survivors of sexual violence. The health workers had registered a medico-legal case documenting the history as told by the survivor. They had also carried out a medico-legal examination and provided treatment without speculation over whether or not this was a case of “rape” as per the law. They noted the current and past incidents of violence, conducted a medical examination, collected evidence where necessary, and provided the woman with treatment and counselling. They followed due procedure without any debate around whether a “rape pro forma” should be filled or not. It is important to note that such a response is not routine but an exception in Indian public hospital settings. The study hospitals have been following a Standard Operating Procedure since 2008 and receive technical support, such as training, supervision, and monitoring of the quality of response to survivors of rape from the NGO to which the authors belong.

However, this is not the case in most other health facilities in the city or other parts of India, where providers are not trained to respond sensitively to cases of sexual violence. The difficult experience of one of the survivors is evidence of this. The woman was denied medico-legal examination by two public hospitals in the city and spoke about how she was kept waiting at the hospital. The doctor discussed her case with senior colleagues and told the survivor that rape by her husband was not “rape” and that the hospital could not carry out a medico-legal examination. When she insisted, they asked her to register a police complaint and come back with the police. Finally, she was referred to the hospital where a crisis intervention department is located and her complaint was recorded but by then she had lost two days. This narrative depicts the routine response of most hospitals, where there is a failure to recognise marital rape as “rape” that requires medico-legal care, and underscores the need to have clear protocols and training of healthcare providers to adhere to them.

The findings from service records of survivors suggest that marital rape and other forms of sexual violence within marriage are common. Sexual violence within marriage is not limited to rape/forced sexual intercourse but also includes reproductive coercion, which causes health consequences that bring survivors in contact with a health provider. Large numbers of survivors of marital sexual violence seek health care from hospitals and counselling services from the crisis intervention department. However, very few survivors reach the hospital to report marital rape for medico-legal purposes.

Fifty-eight per cent of domestic violence survivors reported facing sexual violence from their husbands. Despite this high proportion, it is likely that many women may not have disclosed marital rape to the counsellor due to shame and the perception of sexual violence as being part and parcel of intimate relationships. It is recognised that patriarchy allows men to exert sexual and reproductive control over women. 27 It is, therefore, quite likely that the proportion of women experiencing marital rape is much higher.

Marital rape may be under-reported for many reasons other than stigma around reporting intimate experiences. These include the absence of a physical injury, normalisation of husbands forcing sex on their wives, perceptions about the difference in sexual desire of men and women, or of non-consensual sex being inevitable in marriage, 28 and the socio-cultural norms and legal statutes that condone such violence. 29

It should be noted that, rather than existing in isolation, sexual violence in marriage coexisted with physical, emotional, and economic violence. The survivors who sought services for domestic violence from the crisis intervention department spoke about marital rape and other forms of violence only as part of history-taking by the counsellors when they were encouraged to describe their experiences in detail. Findings highlight the significant impact of marital sexual violence on the physical and psychological health of women.

The findings of this study support the evidence in the literature that married women commonly experience forced sex. 30 , 31 Marital rape appears to be a daily phenomenon in the lives of a large number of women, and yet only a few women sought any formal support for marital sexual violence.

The paper presents the case of 18 women who reported marital rape and wanted their complaints to be recorded and their husbands arrested. They did not remain silent because of shame but reported it to the police and the health system. However, the response of the police was found to be very problematic in these cases. As per the amended law, in the cases of women who were separated from their husbands, the police should have promptly registered an offence of rape (against the husband) but no such case was registered, perhaps because of the police's attitude and the lack of standard protocols. The perception about marital rape amongst the police is that it is “part and parcel” of marriage. They are also influenced by societal norms that justify all forms of domestic violence, including forced sexual intercourse by the husband. Such perceptions prevent them from recognising that even within a marital relationship the consent of women is essential for sexual relationships. There are media reports that the common response of the police towards women reporting marital rape included “go back home and adjust” and “this is an internal matter”. 32 , 33

The findings from 18 cases make a strong case for marital rape to be recognised as an offence and not to be condoned just because an intimate partner perpetrates it. Not recognising marital rape is unconstitutional and violates a woman's fundamental right to healthy life and dignity. The fact that these 18 women reported marital rape indicated that they had enough of it and wanted justice.

Contrary to the response of the police, the trained health workers in the hospitals from which medico-legal forms are analysed did not compromise on their therapeutic duty. They responded by documenting the women’s history and conducting relevant medico-legal examinations and evidence collection. They ensured survivors’ access to care and provided an empathetic environment for them to seek redressal. A supportive response by healthcare providers was made possible through ongoing sensitisation and training, implementing Standard Operating Protocols (SoPs), monitoring, and supervision. Given the high occurrence and serious impact of marital rape on women's health, and the lack of legal recourse, the role of health systems is critical in the provision of supportive care and documentation. Women may not seek any legal or police support but do access treatment for the health consequences of violence. The health consequences of sexual violence must be recognised so that they can be identified and appropriate support provided to women. Several research studies have recommended that social workers, counsellors, doctors, and nurses routinely assess for sexual violence. 34–36 A longitudinal study that included clinical examination of women recommended that healthcare providers ask women with a complaint of STIs about partner sexual violence. 24

The experience of the public hospital-based crisis intervention department in this study demonstrates that hospitals geared to respond to VAW could identify abuse based on symptoms, such as vaginal infections, repeated abortions, reluctance to use contraception, multiple pregnancies, boils/swelling on genitals, amongst others. The SoP ensured a sensitive response to women reporting marital rape without speculation over whether it is criminalised or not. In contrast, a study in Bangalore had reported that healthcare providers recognise their critical role in responding to marital sexual violence in India, but their response was constrained due to barriers such as the absence of hospital protocols requiring them to assess signs and symptoms associated with VAW, and high caseload. 37 The health system can be made more responsive, as evidenced by the crisis intervention department, by allocating resources for training and sensitisation and implementing rights-based SoPs. Such an approach has been found useful and replicated in other settings. 38 The ongoing work on strengthening health systems’ response to violence survivors has significant learnings for building an effective and sensitive response of police towards survivors of marital sexual violence.

The findings of this paper highlight that Exception 2 to Section 375 of the IPC, 1860, that “sexual intercourse or sexual acts by a man with his wife, the wife not being under eighteen years of age is not rape”, is problematic. The exception contradicts the Constitution of India and various international covenants and the Protection of Women from Domestic Violence Act (PWDVA) 2005 39 itself. Section 3(a) of the PWDVA defines sexual abuse as “any conduct of sexual nature that abuses, humiliates, degrades or otherwise violates the dignity of a woman”, and squarely places spousal sexual violence as a type of domestic violence. Despite the clear legal recognition of sexual violence within marriage by PWDVA, the exception to Section 375 condones rape within marriage. But the PWDVA is civil law. The civil remedy available in such cases is a Protection Order to stop violence and offer compensation and other reliefs to the aggrieved wife. The only criminal law that a woman can use is Section 498A IPC which recognises cruelty within marriage. Cruelty is defined as any conduct that may cause serious injury or harm or drive a woman to commit suicide as a consequence of ongoing abuse. Such a definition raises the bar of evidence very high as women often have no evidence of acts of violence perpetrated against them. 40 The Supreme Court has rejected cases of marital rape where women reported sexual violence by the husband that included insertion of torches into the vagina, leading to hospitalisation following severe haemorrhage. 41

One of the recommendations of the Justice Verma Committee that was set up after the Nirbhaya case described above was that marital rape be penalised. (Verma Committee Report, 2013). In 2014, the Special Rapporteur on Violence Against Women also recommended “the amendment of Criminal Law (Amendment), Act 2013 [to] include a definition of marital rape as a criminal offence”. 42 In 2015, the Pam Rajput Committee appointed by the Government of India to study the status of women in India strongly recommended that marital rape be criminalised and argued that marriage does not presume consent. 43

International criminal law has a broad definition of rape that includes various invasive acts perpetrated by and against people of any sex or gender. It also recognises rape within marriage as a crime. In the last decade or so, several countries have amended national laws to align with these human rights standards. Such amendments are critical in ensuring access to health care and other services for redressal. There are still 36 countries in the world that do not criminalise marital rape, of which India is one.

Recognising marital rape as an offence and criminalising it will ensure that the police and other law enforcement agencies are mandated to respond to marital rape and not to trivialise it. As women have inevitable contact with the health system, doctors, nurses, and hospital-based crisis centres can play a critical role in supporting women. 44 Thus, the penalisation of marital rape and sensitisation of the health system and police can help build a sensitive response of police towards survivors of sexual violence.

The resistance to including marital rape as an offence in the existing definition of rape is rooted in patriarchal values and gender norms that define the “duties” of a wife. The marital exemption to rape is based on implied consent. The data presented here make a strong case for recognising marital rape as a crime. Removing marital exemption to rape requires policy and institutional support and allocation of resources for necessary infrastructure, human resources, and staff capacity building. The health system can play a critical role in documenting the present and past incidents of sexual violence and can help the survivor access care and justice. Whether or not the law recognises an incident of violence as an offence, the role of health professionals is to provide treatment and refer the survivor to support services. The police also must follow due process, listen to what the woman says, record her complaint and help her seek supportive services.

Limitations of the study

The primary limitation to generalising the findings of this study is that the analysis is based on service records of women who could reach the public hospital, not on population data. Moreover, since the data is based on self-reporting by women, rape and sexual violence within marriage may be more common than reported in this study.

Acknowledgements

We would like to extend our sincere gratitude to members of CEHAT’s Programme Development Committee and Anusandhan Trust Institutional Ethics Committee for reviewing the project at different stages. We would like to thank Chitra Joshi, Mrudula Sawant, Sujata Ayarkar, Aarthi Chandrasekhar and Rajeeta Chavan for providing counselling services to the survivors of violence.

Funding Statement

This project was funded through the American Jewish World Service (AJWS)

* There has been widespread national and international condemnation of the assault and gang rape of a 23-year-old health professional in Delhi in 2012, which led to her death. This case is also widely known as the Nirbhaya case.

† NFHS is the only national-level source of data on the prevalence of intimate partner violence along with related indicators

‡ The National Crime Records Bureau (NCRB), under the Ministry of Home Affairs, Government of India, collects and analyses all data on crime as defined by the IPC.

§ These are sections under criminal law.

** The current law criminalises any form of sexual intercourse by the husband upon his wife during a period of separation, as provided under section 376B of the Indian Penal Code, 1860.

†† First Information Report (FIR) is a “written document prepared by the police when they receive information about the commission of a cognisable offence” (Indian Law Watch).

‡‡ Section 498A makes it criminal for a husband and his relatives to subject a married woman to cruelty. The law has defined 'cruelty' “to include inflicting physical or mental harm to the body or health of the woman and indulging in acts of harassment to coerce her or her relatives to meet any unlawful demand for any property or valuable security” (India Code: Digital Repository of all Central and State Acts).

Disclosure statement

No potential conflict of interest was reported by the author(s).

A Social Learning Theory Model of Marital Violence

• Published: March 1997
• Volume 12 , pages 21–47, ( 1997 )

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• Sharon Wofford Mihalic 1 &
• Delbert Elliott 1  

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A social learning theory model of minor and severe marital violence offending and victimization among males and females was tested. Results support social learning as an important perspective in marital violence. However, males and females are impacted differently by their experiences with violence in childhood and adolescence. Prior experiences with violence have a more dramatic impact in the lives of females than males, both during adolescence and adulthood.

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Mihalic, S.W., Elliott, D. A Social Learning Theory Model of Marital Violence. Journal of Family Violence 12 , 21–47 (1997). https://doi.org/10.1023/A:1021941816102

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REVIEW ARTICLE

Intimate partner violence: a literature review, article information.

Identifiers and Pagination:

Article history:, article metrics, crossref citations:, total statistics:, unique statistics:.

Background:

Intimate Partner Violence (IPV) is a complex issue that appears to be more prevalent in developing nations. Many factors contribute to this problem.

This article aimed to review and synthesize available knowledge on the subject of Intimate Partner Violence. It provides specific information that fills the knowledge gap noted in more global reports by the World Health Organization.

A literature search was conducted in English and Spanish in EBSCO and Scopus and included the keywords “Intimate, Partner, Violence, IPV.” The articles included in this review cover the results of empirical studies published from 2004 to 2020.

The results show that IPV is associated with cultural, socioeconomic, and educational influences. Childhood experiences also appear to contribute to the development of this problem.

Conclusion:

Only a few studies are focusing on empirically validated interventions to solve IPV. Well-implemented cultural change strategies appear to be a solution to the problem of IPV. Future research should focus on examining the results of strategies or interventions aimed to solve the problem of IPV.

1. INTRODUCTION

Intimate Partner Violence (IPV) is the most prevalent type of violence against women worldwide. It is defined as a “behavior by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse, and controlling behaviors” [ 1 ]. The United Nations has defined violence against women as “any act of gender-based violence that results in or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life” [ 2 ].

The percentage of women experiencing violence in various parts of the world has been recorded. Different factors appear to influence the incidence of this worldwide problem. However, there are no single studies that summarize findings on the subject. The aim of this article was to review available knowledge regarding Intimate Partner Violence. There is a need to understand this problem so that viable solutions and or preventive measures could be implemented.

2. METHODOLOGY

2.1. searching strategy.

The literature search was conducted in English and Spanish using EBSCO (Psychology and Behavioral Sciences Collection, Academic Search Premier, and Fuente Academica Premiere) and Scopus. It included the keywords “Intimate, Partner, Violence, IPV” and thematic issues on the subject, such as “depression, anxiety, body, ache.” Only the findings of empirical studies were considered. The articles ranged from 2004 to 2020. The analysis of full texts of articles was carried out several times and data were extracted according to the aim of this study.

3.1. Percentage of Women Experiencing Violence

Data presented by Women UN (2019) indicates that approximately 35 percent of women worldwide have experienced some form of violence in their lifetime [ 3 ]. One-third of women worldwide who have ever been involved in a relationship have experienced physical or sexual violence inflicted by an intimate partner [ 4 ].

With a focus on the Americas, the percentage of women who have experienced physical or sexual IPV in the past 12 months progressively increases as one examines data from North, Central and South America (1.1% in Canada, 6.6% in the United States, 7.8% in Costa Rica, and 27.1% in Bolivia) [ 5 ]. Compared to countries in Central and South America, Bolivia reports the highest percentage (52.3%) of women ever experiencing physical violence by an intimate partner. However, the percentage of women reporting ever experiencing sexual violence by an intimate partner was similar across nations ( i.e. , Bolivia 15.2%, Nicaragua 13.1%, Guatemala 12.3%, Colombia 11.8%, Ecuador 11.5%, El Salvador 11.5%, Haiti 10.8%, and Peru 9.4%). Moreover, the percentage of women who reported ever experiencing IPV in the form of emotional abuse (insults, humiliation, intimidation, and threats of harm) also occurred relatively equally across nations ( e.g. , Nicaragua 47.8%, El Salvador 44.2%, Guatemala 42.2%, Colombia, 41.5%, Ecuador 40.7%), with a few exceptions (Haiti 17.0%, Dominican Republic 26.1%) [ 6 ].

Data from Colombia indicates that 31.1% of women in that country reported experiencing economic or patrimonial violence from an intimate partner, 7.6% experienced IPV in the form of sexual violence, and 64% experienced psychological violence from a partner [ 7 ]. Similar numbers have been recorded in Ecuador. The National Institute of Statistics and Censuses (INEC 2019) notes that 43 out of 100 women in the country have experienced some form of IPV. Of this group, 40.8% of women reported experiencing psychological violence ( e.g. , humiliation, insults, being threatened with a weapon), 25% said they were victims of physical violence and 8.3% were victims of sexual violence [ 8 ].

3.2. Social Norms and Sociodemographic Factors

Women must contend with societal norms related to domestic violence. For example, in some countries, male dominance or patriarchal systems in which the wife is considered a possession or property of the husband are considered the societal norm. Some studies have shown that social attitudes justifying and or accepting IPV in some developing nations or specific localities increase the incidence of this problem in those areas. Women in these places are likely more tolerant of this problem if it were to happen to them and are less likely to leave a violent relationship [ 9 - 12 ]. Likewise, exposure to violence perpetrated by political groups ( e.g. , police, armed forces) also seems to increase the prevalence of IPV in nations [ 13 - 15 ].

Sociodemographic factors also appear to affect the prevalence of IPV. Studies around the globe indicate that a low level of education in women may put them at a higher risk for IPV [ 16 - 19 ]. This low level of educational attainment could be related to existent socioeconomic disadvantages, a culturally upheld belief that women do not need education because their assigned role is to stay at home and take care of household duties, including the raising of children, and a lack of a network of support that could potentially encourage their educational advancement. For example, a recent study suggested that Latinas who experience IPV “tend to be younger, have more socioeconomic disadvantage, and are fearful of seeking help from authorities” [ 20 ].

The marital status of female victims of IPV has been extensively studied, with common findings of IPV appearing to happen less often to married women in comparison to divorced or separated women in most countries [ 21 , 22 ]. However, the findings must be considered within cultural contexts. As previously stated, in some countries, married women are viewed as property of the husband, and physical aggression or violence towards the wife is tolerated or accepted within the culture. In general, cohabitating couples worldwide report higher rates of IPV. The higher rates could be related to socioeconomic status or to the perception that the relationship is less permanent. More studies need to address the contributing factors as to why cohabitating women tend to have a higher rate of IPV compared to married women, as well as examine the norms by varying cultures and their effect on IPV. Single women typically report less rates of IPV in comparison to married, divorced or separated women. However, this trend appears to vary by country. Single women in Canada and Australia, for example, report higher rates of IPV in comparison to married women in these two nations [ 22 ]. Possible contributing factors for the increase in IPV among single women in Canada and Australia could be related to age or to lifestyle choices. Riskier lifestyles could potentially expose younger women to a greater chance of experiencing intimate partner violence. Latin American and Caribbean nations, data indicate that IPV typically occurs more often among urban women in comparison to rural women [ 23 ]. Nonetheless, some studies in the United States suggest that IPV typically occurs more often in rural settings and small towns [ 24 , 25 ]. Further studies are needed to address the underlying causes of the link between sociodemographic factors and IPV.

3.3. Childhood Victimization

In addition to possible social factors influencing the rates of IPV, women impacted by childhood victimization can experience long term negative effects, and data suggest that “childhood victimization and domestic violence are highly correlated” [ 26 ]. For example, women who witnessed IPV during their childhood are more prone to experiencing IPV as adults [ 27 - 30 ]. Similarly, studies suggest that women who have been physically abused [ 31 - 34 ] or sexually abused [ 35 - 38 ] in childhood also are more likely to experience IPV in adulthood.

3.4. Mental Health

Research has shown that women who experienced IPV report increased levels of mental health symptomatology. For example, women who were abused by an intimate partner reported increased symptoms of depression, anxiety [ 39 , 40 ], and obsessive-compulsive characteristics [ 40 ]. Similarly, women exposed to IPV and who present depressive symptoms exhibit significant weight gain [ 41 ]. Low-income post-partum women in Brazil who experienced IPV are at a greater risk of presenting suicidal ideation [ 42 ], and women living in poverty in Nicaragua who were victims of IPV and perceived they did not receive social support from their families were more likely to indicate they had attempted suicide at some point in their lives [ 43 ]. There appears to be a bidirectional relationship between IPV and mental health problems. More specifically, at least one study has shown that women who experienced child abuse and subsequently developed mental health illnesses ( i.e. , Post Traumatic Stress Disorder, symptoms of depression, binge drinking) were more likely to experience IPV during adulthood [ 44 ].

3.5. Health Complains and Illnesses

In addition to mental health ailments, women victims of intimate partner violence (IPV), in its many forms, have self-reported having frequent health complaints and illnesses. Because of the complexity of physical ailments and symptoms, research studies are limited in addressing the specific correlations of physical health and IVP [ 45 ]. For example, Onur et al. (2020) wrote that women diagnosed with Fibromyalgia Syndrome (characterized by chronic musculoskeletal pain) also reported being victims of partner violence (physical, social, economic, and emotional) [ 46 ]. Raya et al. (2004) observed that Andalusian women victims of IPV perpetration were more likely to suffer from hypertension and asthma [ 47 ]. More recently, Soleimania et al. (2017) observed that Iranian women who had experienced IPV in the form of psychological abuse had a greater incidence of somatic symptoms than women who had not experienced any form of abuse [ 48 ]. There appears to be an additive effect on the body when it comes to experiencing abuse. Women who have experienced various forms of abuse in their life ( e.g. , child abuse, past IPV, present IPV, and financial problems) have reported higher levels of somatic complaints in comparison to women who had only experienced IPV [ 49 ]. At least one study noticed that there was a greater incidence of type 2 diabetes in women who reported experiencing physical intimate partner violence [ 50 ].

3.6. Utilization of Health Care Providers

Aside from the various somatic complaints that are being described by women who have experienced IVP, Lo Fo Wong, et al. (2007), observed that women who had been physically and psychologically abused by their partners used healthcare providers more often and were also prescribed pain medication more frequently [ 51 ]. Also, Comeau, et al. (2012) noticed that women who had been abused by their intimate partners used antidepressants to deal with symptoms of depression [ 52 ]. Lastly, higher use of anxiolytics and antidepressants also has been observed in women who had suffered intimate partner violence [ 53 ].

3.7. Use of Cigarettes

Aside from using various types of medications, Sullivan et al. (2015) noticed that women who had been victims of IPV tend to smoke greater quantities of cigarettes in comparison to women who have not experienced violence [ 54 ]. Furthermore, it has also been observed that women who experienced perinatal IPV were twice as likely to smoke cigarettes in comparison to women without a history of IPV [ 55 ]. It is worth noting that smoking during pregnancy is a strong predictor of low birth weight [ 55 - 57 ] and preterm birth [ 58 ]. Children born under these circumstances are more prone to being described as having more social problems, attention problems, as well as anxiety and depression by age 7 [ 59 ] and low birth weight adolescents show increased levels of mental health problems (emotional symptoms, social problems, and attention deficit) [ 60 ].

3.8. Current Scenario

Many contributing factors impact women suffering from intimate partner violence. These influences could be cultural, socioeconomic, political, and educational, to name a few. Major findings support the notion that women, who are less educated, socioeconomically disadvantaged, reside in patriarchal societies, or cohabitate are at greater risk of IPV. Another contributing factor is mental health symptomology. Further analysis is needed to better understand the correlation between mental health issues and IPV. Is poor mental health a precursor to IPV, or is IPV a potential cause for poor mental health? Various cultures have differing views pertaining to the topic of mental health and address this problem differently. Without proper treatment and proper advocacy for mental health, some women may feel caught in a cycle of hopelessness, stay in abusive relationships, and contribute to the social perception that IPV is an acceptable way of life.

With the current global crisis of COVID-19 and governments issuing stay-at-home orders, psychologists predict an increase in intimate partner violence. The Secretary-General of the United Nations stated the orders have led to a “horrifying global surge” in IPV [ 61 ]. Because of the difficulty to flee from the abusers, women may be at an even higher risk of “IPV-related health issues” [ 61 ]. The global pandemic is a major contributing factor to job loss, economic stress, and evictions. Economic crisis can potentially negatively impact relationships, regardless of marital status. With the looming effects of the pandemic, the World Health Organization will need to consider the level of depression, anxiety, stress, marital status, and socioeconomic status in women across varying cultures, and how the pandemic may have contributed to an increase in IPV.

3.9. Interventions

Empirically validated interventions aimed to address IPV are scarce. One study observed positive results through the implementation of a culturally relevant program with immigrants of Mexican origin. Specifically, the study observed that Latino men benefited from attending group sessions aimed to address, among others, their histories of childhood maltreatment, their challenges encountering different gender roles as they moved to the United States, their sense of control over their wives, and the development of “unequal but non-abusive relationships”. The program included teaching men non-aggressive strategies and problem-solving skills through role-plays. Through these interventions, men became more understanding of their wives’ experiences, as they transition to the United States, learned the impact of their aggressive behavior, and also learned to cooperate more within the home [ 62 ]. In addition to this report, another study focused on the empowerment of Latino women through the Moms’ Empowerment Program. This intervention included providing advocacy services and social support to women. It targeted women’s self-blame for experiencing IPV and helped women set forth goals to promote change in their lives while focusing on preserving their children’s safety. Overall, the program appeared to be successful in helping reduce women’s exposure to mild violence and physical assaults [ 63 ]. Another recent study carried out in Brazil observed positive results with the implementation of cognitive-behavioral interventions in women victims of IPV. Thirteen sessions with a weekly frequency, which included, among others, psychoeducation, problem-solving, and cognitive restructuring, showed effectiveness in reducing women's anxiety and depression and increasing their life satisfaction [ 64 ]. Aside from individual or group interventions, one study carried in Ghana examined the utilization of community-based structures ( i.e. , police, health and welfare organizations, and religious leaders) to raise awareness to the problem of violence against women, to guide talks about gender equality, challenge social norms that endorse violence, provide counseling services to couples experiencing IPV, and create referral structures to help victims.. The prevalence of IPV in the communities that received these types of interventions was lower than that of those areas that did not receive these services [ 65 ].

IVP is a complex issue that needs continued research and attention to provide better interventions. Global findings indicate that certain cultural groups are more tolerant of this problem and that they may tend to normalize it and/or accept it. Overall, IPV is more widespread in developing nations, especially those experiencing political-related-violence. Considering these findings, World Health Organization surveys and future studies should consider assessing the incidence of IPV among immigrants to the United States with histories of having experienced political violence. A study in 2008 showed that eleven percent of immigrant Latinos to the United States had experienced political violence in their countries of origin. Latino women who had lived this type of violence also reported experiences of feeling discriminated [ 66 ]. Future studies should focus their attention on clarifying these findings and their possible relationship with IPV, so that prompt interventions with immigrant populations could be developed.

A recent study shows that Hispanics and Blacks in the United States constantly worry about possibly experiencing violence perpetrated by police, a form of political violence. Hispanics worry about police violence four times more than Whites and Blacks worry about this type of violence five times more than Whites [ 67 ]. Considering these results, the WHO should also explore if reports of police brutality in black or immigrant communities in the United States correlate to rates of IPV in these communities.

Although there is ample information about the various factors associated with IPV, only a few studies have focused on examining empirically validated interventions to address it. Without this knowledge, it would be impossible to truly know if available interventions work or not. Research findings suggest that women, and in particular women from marginalized groups, should receive assistance and guidance to gain access to higher education institutions. Their educational attainment likely will become a protective factor in their life that could prevent them from ever experiencing IPV. Parity in access to higher-paying jobs likely could help reduce the prevalence of IPV. Well-implemented cultural change strategies also appear to be a solution to the problem of IPV. Societal structures ( e.g. , law, religion) and organizations ( e.g. , welfare) seem to be key participants in the development of respectful and nonviolent relationships between men and women that likely could prevent IPV from ever taking place. Early detection of violence within the home and follow-up interventions could prevent children from normalizing such behavior. Health care system screenings could detect early signs and symptomatology of IPV. These screenings could potentially ensure that multisystem interventions be implemented to disrupt the development of IPV and provide survivors with needed support. Lastly, research suggests that governments and their officials should refrain from endorsing politically violent acts. Governmental acts of violence likely could endorse or ignite the problem of IPV in nations.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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Published contents, about the editor, journal metrics, readership statistics:, total views/downloads: 2,837,622, unique views/downloads: 615,936, about the journal, table of contents.

• INTRODUCTION
• Searching Strategy
• Percentage of Women Experiencing Violence
• Social Norms and Sociodemographic Factors
• Childhood Victimization
• Mental Health
• Health Complains and Illnesses
• Utilization of Health Care Providers
• Use of Cigarettes
• Current Scenario
• Interventions

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Open Access

Peer-reviewed

Research Article

Marital rape and its impact on the mental health of women in India: A systematic review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Boston University School of Public Health, Boston, Massachusetts, United States of America

Roles Supervision, Writing – review & editing

Affiliation Epidemiology Department, Boston University School of Public Health, Boston, Massachusetts, United States of America

• Nandini Agarwal, 
• Salma M. Abdalla, 
• Gregory H. Cohen

• Published: June 21, 2022
• https://doi.org/10.1371/journal.pgph.0000601
• Peer Review
• Reader Comments

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 .

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pgph.0000601.g001

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.

Ethics statement

This study did not involve human participants or animal subjects.

Patient involvement

No patients were involved nor was any patient input included at any stage in this paper.

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.

https://doi.org/10.1371/journal.pgph.0000601.t001

https://doi.org/10.1371/journal.pgph.0000601.t002

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.

https://doi.org/10.1371/journal.pgph.0000601.t003

https://doi.org/10.1371/journal.pgph.0000601.t004

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.

https://doi.org/10.1371/journal.pgph.0000601.g002

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.

https://doi.org/10.1371/journal.pgph.0000601.t005

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.

https://doi.org/10.1371/journal.pgph.0000601.g003

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 ).

https://doi.org/10.1371/journal.pgph.0000601.t006

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 ].

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 ].

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

S1 File. Search strategy for PubMed (includes all search terms).

https://doi.org/10.1371/journal.pgph.0000601.s002

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Results are from logistic regression models controlling for age, Hispanic or Latina/x ethnicity, marital status, parity, tobacco use, prenatal visit utilization, stillbirth, and placental abruption. Other race includes Alaska Native, American Indian, Chinese, Filipino, Guam/Chamorro Hawaiian, Indian, Japanese, Korean, Other Asian/Pacific Islander, Samoan, and Vietnamese. In the sample, 4100 patients had a history of substance use, and 33 760 had no history of substance use; 4636 had a urine toxicology test, and 2199 had any positive test result at labor and delivery. Error bars indicate 95% CIs.

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Jarlenski M , Shroff J , Terplan M , Roberts SCM , Brown-Podgorski B , Krans EE. Association of Race With Urine Toxicology Testing Among Pregnant Patients During Labor and Delivery. JAMA Health Forum. 2023;4(4):e230441. doi:10.1001/jamahealthforum.2023.0441

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Association of Race With Urine Toxicology Testing Among Pregnant Patients During Labor and Delivery

• 1 Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
• 2 Friends Research Institute, Baltimore, Maryland
• 3 Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
• 4 Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 5 Magee-Womens Research Institute, Pittsburgh, Pennsylvania

An estimated 16% of pregnant persons in the US use alcohol (10%) or an illicit substance (6%, including cannabis). 1 Urine toxicology testing (UTT) is often performed at the time of labor and delivery for pregnant patients to evaluate substance use. 2 , 3 We sought to elucidate associations between race and receipt of UTT and a positive test result among pregnant patients admitted to the hospital for delivery.

This cohort study followed the STROBE reporting guideline. Data were extracted from electronic medical records (EMRs) of patients with a live or stillbirth delivery between March 2018 and June 2021 in a large health care system in Pennsylvania. The study was approved by the University of Pittsburgh institutional review board. Informed consent was waived because the research constituted minimal risk. All patients presenting for delivery were verbally screened for substance use using questions adapted from the National Institute on Drug Abuse Quick Screen. 4 Policy specified UTT would be performed for those with a positive screen result, history of substance use in the year prior to delivery, few prenatal visits, or abruption or stillbirth without a clear medical explanation.

We studied 2 binary outcomes: the receipt of UTT (point of care presumptive testing) and a positive test result at delivery. The primary variable of interest, patient race, was conceptualized as a social construct that could manifest in biased or discriminatory delivery of health care. Self-reported race was categorized as Black, White, and other (Alaska Native, American Indian, Chinese, Filipino, Guam/Chamorro Hawaiian, Indian, Japanese, Korean, Other Asian/Pacific Islander, Samoan, and Vietnamese). Substance use history was defined as having a diagnosis of an alcohol, cannabis, opioid, or stimulant use or disorder during pregnancy in the EMR within 1 year prior through delivery. A positive UTT result was defined as at least 1 positive result of a test component, including amphetamines, barbiturates, benzodiazepines, buprenorphine, cocaine, cannabis, methadone, opiates, or phencyclidine. We used multivariable logistic regression models including race and substance use history, adjusting for age, Hispanic or Latina/x ethnicity, marital status, parity, tobacco use, prenatal visit utilization, stillbirth, and placental abruption. We derived mean predicted probabilities of outcomes by race and substance use history. 5 Analyses were conducted using Stata, version 17.

Among 37 860 patients (100% female; mean [SD] age, 29.8 [5.5] years), 16% Black, 76% were White, and 8% were other race ( Table ). Overall, 11% had a history of substance use; opioid use was more common among White patients (40% of all substance use), whereas cannabis use was most common among Black patients (86% of all substance use). The mean predicted probability of having a UTT at delivery was highest among Black patients compared with White patients and other racial groups regardless of history of substance use ( Figure ). For Black patients without a history of substance use, the mean predicted probability of receiving a UTT at delivery was 6.9% (95% CI, 6.4%-7.4%) vs 4.7% (95% CI, 4.4%-4.9%) among White patients. Among Black patients with a history of substance use, the mean predicted probability of receiving a UTT at delivery was 76.4% (95% CI, 74.8%-78.0%) vs 68.7% (95% CI, 67.3%-70.1%) among White patients. In contrast, among those with a history of substance use, the mean predicted probability of having a positive test result was 66.7% (95% CI, 64.8%-68.7%) among White patients and 58.3% (95% CI, 55.5%-61.1%) among Black patients.

In this cohort study, Black patients, regardless of history of substance use, had a greater probability of receiving a UTT at delivery compared with White patients and other racial groups. However, Black patients did not have a higher probability of a positive test result than other racial groups. Limitations of the study include a lack of a sufficient sample size to investigate other racial and ethnic minoritized groups, such as Alaska Native and American Indian patients, and that data were from a single geographical area and may not generalize nationally. To address racial biases, health care systems should examine drug testing practices and adhere to evidence-based practices.

Accepted for Publication: February 4, 2023.

Published: April 14, 2023. doi:10.1001/jamahealthforum.2023.0441

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Jarlenski M et al. JAMA Health Forum .

Corresponding Author: Marian Jarlenski, PhD, MPH, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, Pittsburgh, PA 15261 ( [email protected] ).

Author Contributions: Dr Jarlenski and Mr Shroff had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jarlenski, Terplan, Krans.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Jarlenski, Krans.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Shroff, Terplan, Brown-Podgorski, Krans.

Obtained funding: Jarlenski, Krans.

Administrative, technical, or material support: Krans.

Supervision: Jarlenski, Krans.

Conflict of Interest Disclosures: Dr Roberts reported receiving grants from the Foundation for Opioid Response Efforts and the University of California, San Francisco CSF Bixby Center for Global Reproductive Health and National Center of Excellence in Women's Health outside the submitted work. Dr Krans reported receiving grants from the National Institutes of Health, Merck, and Gilead outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grant R01DA049759 from the National Institute on Drug Abuse (Dr Jarlenski and Krans).

Role of the Funder/Sponsor: The National Institute on Drug Abuse had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement .