Sexual Behaviors and Reproductive Health Outcomes: Title and subTitle BreakAssociations With Wife Abuse in India

Violence against women, including physical and sexual violence, is increasingly being recognized as an important global health problem. Although many women have suffered violence at the hands of strangers, more commonly the violence perpetrators are the women's intimate partners (husbands or boyfriends). Studies in developed and developing countries have found that numerous women have been victims of abusive behavior,¹ and that approximately 5% of the healthy years of life lost to women of reproductive age in developing countries is due to violence.²

Given that there has been some documentation of wife abuse in India,^{3 - 14} and that young women are at high risk for abuse, it is important to examine potential associations between abuse and reproductive health issues of women and their partners.^{15 - 17} Although traditional Indian value systems condemn sexual relationships outside marriage,^{18 - 20} there are suggestions that these norms are changing, resulting in increased premarital and extramarital sex.^{21 - 22} Cultural attitudes in India also embody the notion that wives should be respectful to their husbands and should try to obey their commands; however, the use of physical force by husbands as a means of controlling their wives is not as widely sanctioned in the culture. For example, findings from a recent large-scale survey of men in India found that the majority of men (about two thirds) felt that wives should follow the instructions of their husbands; however, only a minority of men (about one quarter) felt that physically beating one's wife was justified if she disobeyed her husband.²³ It is hypothesized here that men who engage in this less socially acceptable behavior of wife abuse may be more likely than nonabusive men also to violate traditional social norms by being sexually active with persons other than their wives. Furthermore, if abusive men are more likely to be sexually active with multiple partners, they also may be more likely to acquire sexually transmitted diseases (STDs). Although there have been suggestions that women in abusive relationships may be less likely than nonabused women to use contraception because they fear violent reactions from their husbands (he may feel that decreasing his wife's risk of pregnancy will increase her likelihood of having sex with other men),²⁴ 1 Indian study found a positive association between abuse and contraception.²⁵ Since the relationship between abuse and contraception has seldom been investigated and remains unclear, this study also examines associations between wife abuse and contraceptive use and unwanted pregnancy. Thus, this article extends past research concerning wife abuse in India by examining abuse related to several important domains of reproductive health, including men's experiences of sexual activity outside marriage, men's STD symptoms, the couple's use of contraception, and unplanned pregnancies.

This investigation is part of the male reproductive health supplement of the PERFORM System of Indicators Survey conducted during 1995-1996.²⁶ The study setting was the northern Indian state of Uttar Pradesh, one of the least developed Indian states,²⁷ although there is considerable variability in the sociodemographic characteristics of the people living in the state's 5 regions. The sampling frame for this systematic multistage survey (described in detail elsewhere)²⁸ consisted of married men, aged 15 through 65 years, from approximately 400 villages and towns in 5 districts in the 5 regions of Uttar Pradesh. A total of 8296 eligible men were enumerated in the household listing of the study districts implemented at the initiation of the PERFORM Survey. A total of 6902 of these men (83%) agreed to and completed the full male interview. Of the 6902 men interviewed, 6632 (96%) met the conditions of living with their wives and having complete information on all of the study variables reported here.

A structured face-to-face interview was administered to study participants by trained male interviewers from Uttar Pradesh. Care was taken to establish rapport with respondents prior to interview administration, and interviewers stressed that honest answers were needed to sensitive questions to gain insight into the health of the state's people. Participants were assured of the confidentiality of their responses. Interviews took place in a private area within the men's homes. If another person entered the interview area, interviewers either stopped the interview until the person left, moved to a private area and then continued, or left the residence and returned at another time when privacy was available.

The interview contained questions concerning health-related factors, including the men's physically and sexually abusive behaviors toward their wives. Wife abuse was assessed by asking men 1 question concerning physical abuse (specifically, "Have you ever hit, slapped, kicked, or otherwise physically hurt your wife?") and 2 questions concerning sexual abuse (specifically, "Have you ever had sex with your wife even if she was not willing?" and "Have you ever physically forced your wife to have sex?").

For analysis purposes, each male participant was classified into 1 of 4 groups on the basis of the men's responses to the 3 abuse questions: (1) the no abuse group, defined as men who did not report perpetration of physical abuse, nonconsensual sex, or physically forced sex; (2) the physical abuse only group, defined as men who reported perpetrating physical abuse, but who did not report perpetration of nonconsensual sex or physically forced sex; (3) the sexual abuse without physical force group, defined as men who reported having nonconsensual sex with their wives, but who reported that they did not physically force their wives to have sex (note that men in this group also may or may not have reported physical abuse); and (4) the sexual abuse with physical force group, defined as men who reported physically forcing their wives to have nonconsensual sex (note that all of this group reported having nonconsensual sex and they may or may not have also reported physical abuse).

The interview also included questions concerning 3 groups of variables regarding the men's reproductive health and behavior. The first of these variable groups focused on the men's sexual behavior outside marriage, specifically, whether the men had engaged in premarital sex (intercourse before marriage) and whether the men had engaged in extramarital sex (intercourse with someone other than their wife after marriage).

The second group of reproductive health variables concerned the men's STD symptom status and were adapted from the Philippines Safe Motherhood survey and others.²⁹ Men were asked about having each of 7 STD indicators during 3 points in their lives (before marriage, any time after marriage, and at the time of the interview). These indicators were based on clinically derived recommendations for syndromic diagnosis and treatment of STDs from UNAIDS and the World Health Organization³⁰ and included having any of the following: a discharge from the penis, genital or anal sores, difficulty urinating, painful urination, frequent urination, swelling in the testes or groin area, and a positive syphilis test. The sensitivity and specificity of this approach will vary depending on the type of STD and whether the STD is currently symptomatic; however, studies conducted in developing countries suggest that this syndromatic approach may be superior to reliance on clinical diagnosis alone.³¹ For analysis purposes, men who reported that they had 1 or more of these indicators were classified as being symptomatic for an STD.

The third group of reproductive health variables concerned the couple's contraceptive behaviors and associated outcomes. Specifically, men were asked whether the couple used contraception during the time of the study and whether the couple ever had an unplanned pregnancy.

The survey also gathered sociodemographic information, including the men's geographic district of residence, rural/urban status, age (classified as "younger" if the men were <31 years and "older" if they were ≥31 years), level of education (classified as "lower" if the men had <6 years and "higher" if they had ≥6 years of schooling), household size (classified as "smaller" if the men lived in a household of <8 persons and "larger" if they lived in a household with ≥8 persons), and number of children (classified as "fewer" if the men had <4 and "greater" if they had ≥4 children). In addition, information was collected concerning the men's "caste," a complex social class system that helps to define a person's place in society in terms of rank, wealth, privilege, and occupation. Following a well-founded practice in demographic research in developing countries,^{32 - 33} the families' socioeconomic status was assessed by asking respondents whether their households included any of the following possessions: a clock, fan, radio, television, bike, and a motorbike or car. For analysis purposes, families were classified as being of "lower" socioeconomic status if they owned none or 1 of these possessions and of "higher" socioeconomic status if they owned 2 or more of these possessions.

Descriptive statistics and bivariate analyses, weighted to take the sampling procedures into account, were used to examine sociodemographic and reproductive health variables by the 4 abuse groups. Logistic regression analysis³⁴ was used to model each reproductive health variable as a function of abuse and the potentially confounding sociodemographic variables (district of residence, rural/urban status, caste, socioeconomic status, education level, age, household size, and number of children). Adjusted odds ratios and 95% confidence intervals from the logistic regression models were used to assess the associations between each reproductive health variable and abuse while controlling for sociodemographic factors. All calculations were performed using the SUDAAN software package³⁵ to take the sampling methods into account.

The main PERFORM Survey evaluation protocol was reviewed and approved by a group of medical/clinical experts in India, the executive director and staff of the State Innovations in Family Planning Services Project Agency (a parastatal agency of the Uttar Pradesh state government), staff of the US Agency for International Development, and the Committee on Human Subjects Institutional Review Board of the School of Public Health at the University of North Carolina at Chapel Hill.

Almost half of the 6632 men (46%) reported perpetrating some type of wife abuse (answered "yes" to at least 1 of the 3 abuse questions). Specifically, 3608 men (54%) comprised the no abuse group (all men in this group answered "no" to all 3 abuse questions); 1112 men (17%) comprised the physical abuse only group (all men in this group answered "yes" to the physical abuse question and "no" to both sexual abuse questions); 1476 men (22%) comprised the sexual abuse without physical force group (all men in this group answered "yes" to the question concerning having sex with their wife when she was unwilling and "no" to question concerning physically forcing their wives to have sex, with about 40% of this group [n = 628] also answering "yes" to the physical abuse question); and 436 men (7%) comprised the sexual abuse with physical force group (all men in this group answered "yes" to both sexual abuse questions, with about half of the group [n = 245] also answering "yes" to the physical abuse question).

Bivariate analyses found that each of the sociodemographic characteristics of the men, including their district of residence, varied significantly by wife abuse (Table 1). Greater proportions of rural men, men of lower castes, and men of lower socioeconomic status were in each of the 3 abusive groups. Men with lower education levels were more likely in both the physical abuse only group and the sexual abuse with physical force group. Compared with older men, a somewhat smaller proportion of younger men were in the physical abuse only group; however, somewhat larger proportions of the younger men were in the sexual abuse without physical force group and the sexual abuse with physical force group.

Bivariate examination of other sociodemographic characteristics using analysis of variance found that the mean household size did not differ significantly by abuse group (F_3,6628 = 1.08, P = .36; for no abuse, mean [SD] = 7.9 [0.1]; for physical abuse only, mean [SD] = 7.6 [0.1]; for sexual abuse without physical force, mean [SD] = 7.9 [0.1]; and for sexual abuse with physical force, mean [SD] = 7.9 [0.2]). However, the mean number of children did differ significantly by abuse group (F_3,6628 = 10.03, P<.01), with the no abuse group having a mean (SD) of 3.2 (0.10) children, the physical abuse only group having a mean (SD) of 3.5 (0.1) children, the sexual abuse without physical force group having a mean (SD) of 3.0 (0.1) children, and the sexual abuse with physical force group having a mean (SD) of 2.9 (0.1) children.

Significant bivariate associations were found between each of the reproductive health variables and abuse. Table 2 shows that greater proportions of men fell within each of the 3 abusive groups if they reported having premarital sex, extramarital sex, STD symptoms at any of the 3 times assessed, or their wives having an unplanned pregnancy. Although a significant bivariate association also was found between abuse and contraception use, the association is somewhat weaker and the pattern is less consistent (the same proportion of men in both the contraception use and nonuse groups reported sexual abuse without physical force).

Table 3 shows that the logistic regression analyses, which controlled for all of the sociodemographic factors, found strong and statistically significant relationships between men's sexual behaviors outside marriage and wife abuse, with the strength of these associations being strongest for sexual abuse with physical force, followed by sexual abuse without physical force, and then physical abuse alone. Furthermore, the relationships between abusive behaviors and sex outside marriage were more pronounced when extramarital sex was examined compared with premarital sex.

When logistic regression analyses were used to model the men's STD symptom status as a function of the men's abuse group and sociodemographic factors, statistically significant positive relationships were found between abuse and men's STD symptoms, with these associations usually being strongest for sexual abuse with physical force, followed by sexual abuse without physical force, and then physical abuse alone. These findings held regardless of the timing of the STD (before marriage, after marriage, or at the time of the interview).

Logistic regression modeling of contraception use in relationship to abuse status while controlling for sociodemographic factors found a relatively small but statistically significant positive association between contraception use and sexual abuse without physical force. Modeling of the unplanned pregnancy variable using logistic regression found that, after controlling for sociodemographic factors, unplanned pregnancies were significantly more common among each of the 3 abusive groups compared with the no abuse group, with the magnitude of the association being strongest the for sexual abuse with physical force group, followed by the sexual abuse without physical force group, and finally the physical abuse alone group.

Almost half of the men in this study reported abusing their wives, suggesting that wife abuse is a common problem in India as it is in many other countries. For example, research in Canada, Chile, Colombia, Ecuador, Guatemala, Japan, Korea, the Netherlands, New Zealand, Norway, Tanzania, Uganda, the United States, and Zambia reports that from 17% to 60% of the women studied have been abused by their partners¹ (note that some of the differences seen in these prevalence estimates are probably due to the various methods used to assess abuse).

In this study, strong significant relationships were found between abuse and men's premarital and extramarital sex, STD symptoms, and unplanned pregnancies. Furthermore, these associations often demonstrated a gradient of strength, being strongest among men who sexually abused their wives using physical force, followed by men who sexually abused their wives without using physical force, and then men who physically abused without sexually abusing their wives. Links between abuse and men's sexual activities outside marriage, and those between abuse and men's STD symptoms, suggest that the more abusive men may have tended to be sexually active with multiple partners, and that these extramarital sexual activities may have resulted in STD infection of the men. Since STD-infected persons are at elevated risk of human immunodeficiency virus (HIV) infection,^{36 - 37} findings from this study may help explain the increase in HIV found among monogamous married women in India³⁸ ; it may be that many wives who are abused by their nonmonogamous husbands are also at increased risk of STD/HIV infection from these men.

These findings must be viewed in light of the methodological constraints of the investigation, the first being that the reproductive health and abuse data were from interviews with the men in the study. Although this study used only the men's reports to assess contraception use, information from a previous survey of the wives in these same households allowed comparison of husbands' and wives' reports concerning contraception, finding somewhat similar rates.²³ Unfortunately, the earlier women's survey did not include questions concerning abuse, so we could not compare the men's reports of abuse documented here with their wives' perceptions concerning abuse. However, other research that has compared abuse reports of male and female members of couples has found fair statistical agreement³⁹ on a physical violence question similar to the one used in this research (kicked, bit, or hit), but lesser agreement on a question concerning physically forced sex (perpetrators were less likely than victims to report this behavior).^{40 - 41} These findings from previous investigations imply that our study may have underestimated the true extent of sexual abuse; however, we cannot be positive whether the men in our study tended to underreport, or even overreport, the various types of abuse assessed. Since the classification of men's STD status relied on the men's reports of STD symptoms (due to the prohibitive cost of implementing STD laboratory tests in this setting), at least some of the men were probably misclassified in this domain. A second study limitation is that only men who were living with their wives were included in the sample. Even though divorce and separation are extremely rare in India,⁴² if the most severely abused wives left their husbands, then the abuse prevalence estimates reported here might slightly underestimate the true extent of the problem. Third, the approach used here to classify men into "abuse groups" is only one of several that may have been used; using another classification scheme may have yielded somewhat different findings. Finally, this study focuses on a limited number of reproductive health and confounding variables. Future research is encouraged to examine potential links between abuse and additional reproductive health variables while taking into account an even wider range of potentially confounding factors.

Despite the methodological constraints of the study, these findings may be useful to health care professionals and policymakers. Given the high prevalence of wife abuse and the ties between abuse and reproductive health behaviors or outcomes, all health care professionals (including those who treat STDs) should ensure that patients are routinely screened for violence in their lives, and that identified patients are provided with the needed treatment and/or interventions. Toward this end, health care professionals should strengthen their working relationships with those who serve violence victims (domestic violence programs, battered women's shelters, and the like). Furthermore, clinicians should be aware of the potentially dangerous implications posed to women in abusive relationships by standard STD prevention measures (eg, abused women's attempts to negotiate condom use with their partners may exacerbate abuse). In addition, clinicians are encouraged to discuss with their patients how various family planning options will affect numerous domains of their health and well-being, including the possible abusive behavior of husbands. Health care professionals, researchers, legal professionals, and others concerned with health issues are encouraged to work together to prevent wife abuse and to offer therapeutic health, social, and legal services to violence victims.