Khyber Medical University Journal (Dec 2023)
Psychological implications of early marriages: the unhealed wombs and shattered dreams
Abstract
Early marriages, defined as unions where one or both partners are under the age of 18, have long been the norm in Pakistan. Despite a legal minimum age of marriage set at 18 for males and 16 for females, this practice persists, often veiled under the guise of tradition, culture, and economic necessity. According to UNICEF, Pakistan ranks among the top countries with the highest rates of child marriages in the world, with approximately 21% of girls marrying before the age of 18. Various research reports have indicated that a significant proportion of young brides in Pakistan may exhibit symptoms of mental illnesses such as post-traumatic stress disorder, anxiety disorder, particularly depression and borderline personality disorder (BPD). There is a pressing need to raise awareness and educate society regarding the potential future risks of this polarizing situation. Additional research is imperative to highlight the urgency of this issue. In the heartland of South Asia, Pakistan, a persistent social phenomenon challenges the nation: early marriages. This deeply ingrained practice, despite a gradual decline in recent years, continues to be a contentious concern with wide-ranging implications. It is a recurring occurrence to encounter a juvenile female whose aspirations have been shelved. Occasionally, she bears physical evidence of recent motherhood, bearing witness to her early initiation into the realm of maternity. A diverse spectrum of cases is encountered with these underage females, ensnared by severe challenges imposed by deeply ingrained patriarchal beliefs within their familial contexts. These misguided ideologies coerce parents into sacrificing their daughters' happiness and well-being in conformity with societal expectations. In this article, we explore the multifaceted landscape of early marriages in Pakistan and the intricate nexus between early matrimony, postpartum depression, and their profound impact on the mental well-being of women. They typically contend with depressive symptoms, borderline personality disorder, and tendencies towards suicidal behavior. The consequences of these oppressive conditions have a profound impact on the lives of these young individuals, resulting in insidious episodes of depression and incapacitating panic attacks within Pakistan. Emphasizing the urgency of addressing this widespread concern is imperative, as it not only deprives these girls of their potential but also perpetuates a cycle of symptoms of borderline personality disorder such as fear of abandonment, dissociation, unstable and impulsive behavior, and self-harming behavior.1 Depression is a serious mental health condition characterized by persistent feelings of sadness, hopelessness, and anhedonia (a lack of interest or pleasure in most activities). It goes beyond the typical ups and downs that people experience in their daily lives.2 In Pakistan, mental disorders, including this particular one, carry a heavy stigma, contributing to the criticism and societal scrutiny faced by affected women.3 Amongst women, depression is characterized by a constellation of enduring symptoms, including chronic dysphoria, loss of interest or pleasure, changes in sleep patterns (insomnia or hypersomnia), changes in appetite or weight, fatigue, irritability, difficulty concentrating, feelings of worthlessness or guilt, suicidal thoughts, physical symptoms (aches and pains), social withdrawal, and, in some cases, changes in the menstrual cycle.4 The increased prevalence of depression among women in Pakistan can be attributed to a complex interplay of factors stemming from biological, psychosocial, and sociocultural sources. Key determinants include early marriages, exposure to trauma and abuse, and gender-based discrimination, among various contributing factors.5 It is crucial that society, acknowledging the undisclosed narratives and unexpressed challenges that linger within private confines, endeavors to deconstruct the intricate networks of longstanding traditions contributing to these distressing outcomes in Pakistan. Borderline personality disorder is a complex psychiatric condition characterized by a pervasive pattern of instability in interpersonal relationships, self-identity, and affective regulation. Key clinical features encompass tumultuous and unpredictable relationships typified by rapid oscillations between the idealization and devaluation of significant others. Patients often harbor an intense fear of abandonment, prompting desperate efforts to avert perceived rejection.6 An unstable self-concept characterizes these individuals, with fluid and inconsistent self-identities manifesting in different situations or social contexts. Impulsivity is a cardinal symptom leading to reckless behaviors such as substance abuse, self-harm, and risky sexual encounters, often employed as emotional coping mechanisms. Additionally, chronic feelings of emptiness, suicidal ideation, and self-harming behaviors further underscore the profound emotional turmoil experienced by affected individuals.7 Anger and aggression may surface, particularly in response to perceived criticism or abandonment. Paranoia and dissociation may occur during periods of acute distress. The condition involves considerable morbidity and requires specialized therapeutic interventions. These interventions include dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and, in certain instances, pharmacological approaches. These approaches aim to alleviate symptoms and improve overall functioning. Timely recognition and management are crucial in mitigating the impact of BPD on the lives of affected individuals.8 All member states of the European Union have established a minimum age for sexual consent. Most member states set this between 14 and 16 years. The lowest minimum age is 14 years, set in seven Member States: Austria, Bulgaria, Estonia, Germany, Hungary, Italy, and Portugal. The highest is set at 18 years – in Malta. The Marriage and Civil Partnership (minimum age) Act 2022 came into force in February 2023. This change in the law made it illegal for 16- and 17-year-olds to get married or become civil partners in England and Wales. The new legal age to marry is 18 in Europe – with the exception of Scotland, where the age of marriage is 16 years, which is also the age of majority.9 This divergent approach can set an undesirable precedent for global standards and potentially undermine efforts in developing nations, encouraging them to adopt practices that harm their future generations. The concern arises from the belief that individuals at the ages of 14 or 16 may not possess the necessary maturity to make informed decisions for themselves. This can potentially expose them to traumatic experiences and eventually serve as a catalyst for the onset of mental health issues. Deeply rooted cultural norms and traditions often prioritize early marriages as a means of preserving family honor, safeguarding girls from perceived threats, and being free from the responsibility of marrying their daughter off. In many cases, a father's consideration of his daughter's wishes is perceived as a dishonorable act, leading to arranged marriages with cousins to maintain family wealth within the clan.10 Moreover, poverty and limited economic opportunities force families to marry off their daughters early, viewing it as a way to reduce their financial burden. One of the prominent factors contributing to the persistence of early marriages is the substantial gender disparity in access to education. Girls who are denied access to education are more likely to be married off early, perpetuating the cycle of poverty and inequality.11 The absence of decision-making authority and the imposition of the family's wishes leave girls with no alternative but to contemplate ending their lives or enduring a lifetime of silent suffering, resigned to their predetermined destiny. Therefore, early marriages often lead to early pregnancies, posing severe health risks for young mothers such as postpartum depression. Maternal mortality rates are higher among adolescent mothers, and infants born to young mothers are more susceptible to health problems.12 Another pivotal consequence of early marriages is that they often subject young brides to physical and emotional abuse. They are at a higher risk of domestic violence with limited resources or support systems, which eventually leads to depression as well.13 While progress has been made in recent years, there is still much work to be done. When coupled with the risk of postpartum depression and BPD features, the psychological toll on young mothers, is significant. Collaboration between mental health professionals, advocates, and community leaders is essential to address these interconnected. Breaking free from this longstanding tradition requires collaborative efforts from individuals, communities, and policymakers. It is crucial to ensure that every child in Pakistan can grow up without the burden of early marriage and has the opportunity to pursue their dreams and aspirations. Only through collective action and a steadfast commitment to the empowerment of these young girls can we hope to break free from the shackles of tradition and usher in a brighter, more equitable future for all.
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