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Forced Marriage and Health

Asma Ashraf*, RN, Dip Trop Nurs, MSc
Research Nurse, University College London, UK
Corresponding Author: Asma Ashraf, Research Nurse, University College London, Research Department of Infection and Population Health, Research Department of Infection and Population Health, Mortimer Market Centre, Off Capper Street London WC1E 6JB, email: [email protected]
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A forced marriage is a marriage into which either one or both spouses have been coerced without their consent. Coercion can include physical, psychological, financial, sexual and emotional pressure from relatives who regard a refusal to marry the person of their choice as a stain on the family’s honour (Meetoo and Mirza, 2007). Where an individual lacks the capacity to consent, coercion is not required for a marriage to be forced (Home Office and Foreign & Commonwealth Office, 2014a). Forced marriage should be distinguished from arranged marriage. An arranged marriage is a tradition where families take a leading role in bringing the two parties together and organising the ceremony; however the final decision rests with both spouses to be and they both must agree freely and without any pressure (Home Office and Foreign & Commonwealth Office, 2014a). This editorial concentrates on forced marriage but, as we shall see, it can sometimes be difficult to consider forced and arranged marriage separately.

What is forced marriage?

Forced marriage is a form of domestic violence. It is a way of controlling men and women. It discounts any right of choice for individual/individuals in choosing a partner and, in cases where the individual is below 18 years old, is a form of child abuse.
The practice of forced marriage takes place in many regions across the world: USA, Asia, Africa and European countries including the UK. The perpetrators are family members who often justify their actions on the basis that they are acting in their child’s best interests. Marriages are also believed to make family ties stronger. In a forced marriage arrangement, it is considered that the ‘honour’ of the family is protected and that, culturally and religiously, this is what needs to be done (Home Office and Foreign & Commonwealth Office, 2014a). Let us be clear now that no religion whether it is Buddhism, Christianity, Hinduism, Islam, Judaism or Sikhism advocates or supports the forcing of an individual into a marriage.
Perpetrators are misguided because they believe that they are helping the person that they are forcing into a marriage; they do not see that they are doing anything wrong. Young people are told from childhood that their parents/family will choose whom they will marry. Decisions relating to marriage may not even be communicated to the young person who may be unaware both of what is happening and that they can seek help and support. Even if they do know, it is very difficult for them to transcend the traditional framework, especially when parents/family members control their children from a young age in a covert manner by saying that they ‘know best’, ‘you cannot have a boyfriend or girlfriend because tradition forbids it’ and ‘that this is not what we do in our culture’. In some instances control may be overt. An individual maybe restricted from taking a job or their earnings taken from them, making them dependent on others. They may be isolated by being taken out of the country and left out of the UK for long periods, which further isolates them from help and support (Home Office and Foreign & Commonwealth Office, 2014a).
Leaving home is not an easy option for anyone but is much harder if individuals are from communities that do not consider this to be a normal part of growing up. Living alone with minimal means and support is very isolating and often results in the person returning back to the abusive situation. The person may not want to report the crime or leave their families because this would bring shame or ‘dishonour’ on their family. Among those who do leave there may also be a very real and valid fear that the individual will be found by their family (Home Office and Foreign & Commonwealth Office, 2014a).
Moreover, when the elders of the family circle send a message saying that they want the marriage of a person to take place, there is pressure placed on everyone involved to conform and ensure that the wedding goes ahead whether it was for the sake of so called ‘honour’, increasing/maintaining family wealth, or family commitments (Home Office and Foreign & Commonwealth Office, 2014a). What do you do, who do you turn to? The risk of a forced marriage in the name of so called ‘honour’ increases if there is a death in the family - if the father dies, if a female discloses any sexual abuse and if a person is known to be lesbian, gay, bisexual, or transgender. The belief is that the honour of the family will be saved and no one will ask questions if the marriage has taken place (Home Office and Foreign & Commonwealth Office, 2014a).
Honour itself is not a bad thing. In fact being honourable is a valued trait for many people; honour means having integrity and honesty; it can be about being kind, caring and sharing. The problem is when honour is misused, whether consciously or unconsciously, against people, to enforce submission through emotional and guilt-laden processes. This misuse of honour is not only prevalent in South Asian, Middle Eastern or Muslim communities, which is how the issue is often portrayed in the media, but is actually a much wider problem that occurs in African, Jewish and Eastern European communities (Meetoo and Mirza, 2007). In this context honour is used to assert power and control, mainly over women, but men as well. The purpose is to coerce individuals into submitting to pressures from their family and/or community. Such pressures are intense and failure to conform can escalate into what is now termed ‘honour’ based violence and even murder as in the cases of individuals such as Shafilea Ahmed (BBC News, 2012), Banaz Mahmod (BBC News, 2010) and Laura Wilson (Marsden, 2012). These three young women were unfairly and unjustly considered to bring shame on their family members who murdered them. The Iranian and Kurdish Women’s Rights Organisation (IKWRO, http://ikwro.org.uk/2015/07/research-reveals-violence/#more- 2539[PM1]) (2015), reports that, between 2010 to 2014, UK police recorded more than 11,000 cases of so called ‘honour’ based violence (IKWRO, 2015). According to Diana Nammi, the Executive Director of IKWRO (http://ikwro.org.uk/), this is nowhere near the real figure. Many of these crimes go unreported because the perpetrators are the victim’s family members and are heavily influenced by the belief that going to the police, health services or speaking to anyone about it is shameful (IKWRO, 2015).
An additional factor is the way in which an arranged marriage can sometimes be presented which may make it a form of forced marriage. This can happen when full consent free from coercion is not possible because it is imposed with great subtlety, to the extent that individuals may not realise what is happening (Anitha and Gill, 2009; Chantler, Gangoli, Hester et al., 2009). An issue that also is important when considering consent is that following the marriage, an individual may wish to withdraw consent. Women, however, are placed in a difficult position because they are often unable to leave the arranged marriage, which may have now become a forced marriage. Women and men are put into these positions because the social norms in some communities prevent them from seeking a divorce regardless of whether the marriage was arranged or forced (Samad and Eade, 2002).

Who is at risk?

There is no typical victim of forced marriage. Whilst women are the main victims of this practice, it must also be remembered that men are affected and are victims too. Forced marriage occurs in both under and over 18 year olds, with or without a disability (Home Office and Foreign & Commonwealth Office, 2014b). In the UK, the Forced Marriage Unit (FMU https://www.gov.uk/forced-marriage), a government initiative set up to support victims of forced marriage, reported in 2014 that the highest numbers of callers to their helpline were of Pakistani ethnicity. Whilst it is important to note that Pakistanis are one of the largest migrant communities in the UK, the FMU also reported handling cases from many other ethnicities and revealed that forced marriage cases in the UK involved over 88 different countries (Home Office and Foreign & Commonwealth Office, 2014b).
According to the FMU, 79% of all cases of forced marriages reported to them during 2014 involved females; 21% of cases involved males. However it is believed that these figures are just the tip of the iceberg and many cases are going unreported (Home Office and Foreign & Commonwealth Office, 2014b). There are particular difficulties for males who are forced into marriage and not enough is known about these issues, thus the number of men affected may be much higher. However, there is a clear gender disparity in terms of reporting, which highlights that females are more likely to be victims. Females are more at risk because of patriarchal systems that promote violence against women globally (Carter, 2015).
Of the 1267 cases reported to the FMU in 2014 300 involved victims who were under the age of 18 (Home Office and Foreign & Commonwealth Office, 2014b). Although the UK has signed up to the United Nations Convention on the Rights of the Child (1989), the forced marriage of children is still possible because UK law allows young people aged 16-18 years to marry with parental consent. The link between child marriage and forced marriage is not easy to distinguish; survivors of child marriage are not able to identify themselves as being forced into a marriage or understand the moral and legal significance that they are children if aged between 16-18 years. In South Asia, there has been a general increase in the age of marriage mainly among urbanised and middle class populations. However, in parts of Bangladesh and India, marriages are still arranged and take place amongst very young children and in some cases between infants (Gangoli, McCarry and Razak, 2009). Child marriages do take place in other countries too. The consequences of child marriage and forced marriage in the younger age groups are often more serious for females who are more likely to experience other forms of domestic and sexual violence. Females can be victims at any age but younger girls are particularly vulnerable and are more likely to experience repeated rape, miscarriages, problems in childbirth, sexually transmitted infections, social issues such as poverty and loss of access to education to name a few (Chantler, 2012).

Implications for health professionals

Unfortunately, in western countries, forced marriage has been regarded as a cultural practice in which outsiders should not interfere. Viewing forced marriage through a cultural lens can be very problematic because health professionals and non-professionals alike may be reluctant to speak up and discuss the matter because they fear being accused of cultural insensitivity, of causing offence or even worse, to be perceived as racist (Gill and Anitha, 2011). Conversely, though, not addressing the issue with someone who is at risk or not talking about it openly encourages and condones the practice (Gill and Anitha, 2011). However, there is growing awareness and understanding of the problem as a human rights abuse (Home Office and Foreign & Commonwealth Office, 2014a). Since the late 1990s, the UK government has recognised this as a problem and has introduced various measures to protect victims of forced marriage (Thiara and Gill, 2010). More recently, in June 2014, forcing someone to marry against their will became an illegal act which carries a prison sentence (Home Office and Foreign & Commonwealth Office, 2014a).
In terms of health care, the response has been slow but changes in UK law mean that ignoring or avoiding the issue of forced marriage is no longer an option. Jasvinder Sanghera a survivor of forced marriage and Karma Nirvana’s (http://www.karmanirvana.org.uk/) founder, a charity supporting people facing forced marriage, has stated, ?cultural acceptance does not mean accepting the unacceptable’ and acknowledges that often there remains a lack of professional confidence. Many victims facing forced marriage feel that health care practitioners are unable to help them but this should not be the case at all. Doctors and nurses as examples of healthcare workers have a duty to safeguard and protect anyone who is in a vulnerable position and a duty of care to all (The Code for Nurses and Midwives, 2015 and Good Medical Practice, 2013). Healthcare practitioners should also be aware of working jointly in a multi-agency capacity with the police, schools and social services.
Healthcare practitioners are in a good place to identify those facing forced marriage and so called ‘honour’ based violence but need to learn more about the issue. The National Institute for Clinical Excellence (NICE) Domestic Violence Guidelines (NICE, 2014) highlight that health care workers need to learn more about forced marriage to be able to address training needs; research is needed in this area to gain a better insight and to support victims. For example, little is known about the long term psychological effects in terms of mental health (Meetoo and Mirza, 2007). There is some research to suggest that forced marriage and other types of violence against women may be linked to depression, self-harm and suicide in South Asian women who have faced forced marriage and so called ‘honour’ based violence however this is not clear cut (Gangoli, McCarry and Razak, 2009; Wilson, 2006). Chantler (2012) in her review of the literature on forced marriage identified a real gap in evidence to prove the health consequences of forced marriage, which, if known, would enable appropriate interventions to be developed. What is clear is that forced marriages can have serious effects on people.
Individuals who are being forced or who have been forced into marriage and/or been the victims of so called ‘honour’ based violence could present in any area of the National Health Service (NHS).
Potential warning signs may include:
• An individual accompanied to health centre, clinic or hospital
• Self-harm/attempted suicide
• Eating disorders
• Depression/Isolation
• Substance Misuse
• Unwanted pregnancy
• Female Genital Mutilation
(Home Office and Foreign & Commonwealth Office, 2014a)
These signs are not unique to forced marriage or so called ‘honour’ based violence but a wider problem relating to other forms of domestic violence and the control, mainly, of women.
Healthcare practitioners should be aware that, as with all forms of domestic violence, which they must routinely ask about, forced marriage and so called ‘honour’ based violence should be accounted for when asking routine questions about a patients background and home life (Home Office and Foreign & Commonwealth Office, 2014a). In encounters with patients there may only be one opportunity to find out if an individual needs help (Bewley and Welch 2014). It is important to speak to the person of concern on their own, and not in front of family members or any other accompanying adults; this means that they should not be used as interpreters. Examples of appropriate questions include ‘how are things at home?’ and ‘are you worried about anything or anyone?’ Ensure that all information including injuries or treatment is fully documented. If you are worried that someone is at risk of being or has been forced into marriage, talk to them about your concerns, and make it clear that, unless there is a safety or child protection issue or action is necessary to prevent a crime, nothing the individual says will be disclosed to anyone else or to any outside agency. It is not appropriate to dismiss any need for immediate protection or to sidestep responsibilities for action. It is also important to avoid approaching family or community members without the victim’s consent or to get drawn into any attempt at mediation with family members as this may also endanger the victim (Home Office and Foreign & Commonwealth Office, 2014a).
The priority is to do what the person you are supporting wants, as long as they are not deemed as a vulnerable person. All cases should be discussed with a senior member of the medical team and safeguarding leads. The person may not want to have to prosecute their family or relatives but victims of forced marriage do need to understand that what is happening to them is not right—morally or legally— and that they can be helped. Forced marriage is a crime and should not be tolerated; the person in front of you could be at risk of serious injury and harm.
Further information and guidance about dealing with forced marriage is available through The Multi-agency practice guidelines: Handling cases of Forced Marriage (Home Office and Foreign & Commonwealth Office, 2014a) and should be read by all professionals including healthcare practitioners. These facilitate insight into how victims may present and how they could be supported (Home Office and Foreign & Commonwealth Office, 2014a). Further advice is available from the Forced Marriage Unit (https://www.gov.uk/forcedmarriage). Make sure the person you are supporting is fully aware of the plan.

Conclusion

The issue of forced marriage is complex and entwined with an inappropriate ‘honour’ system, which violates basic human rights on choice and freedom to consent. Both men and women can be victims; young people, especially females, are particularly vulnerable (Home Office and Foreign and Commonwealth Office (2014b). There is increasing recognition of forced marriage as harmful; it needs to be understood that globally there is an issue of violence mainly against women and girls but also men too. Let’s be clear that there is a gender disparity in terms of who suffers most violence (Temmerman, 2015). It is not helpful to label forced marriage as a cultural practice because this may exacerbate the problem giving people an excuse to carry on abusing people. There are clearly inequalities of gender, race, poverty and access to education for those that suffer from forced marriage and honour based violence. However there is no ‘typical’ victim and the person in front of a healthcare professional could be anyone.
More research is needed on forced marriage and honour based violence for healthcare professionals to intervene appropriately (Temmerman, 2015). However to begin with safeguarding training for healthcare professionals needs to include forced marriage and ‘honour’ based violence.

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