Epidemiology of forced marriage

It is difficult to obtain accurate information about the extent of forced marriage and data available are likely to grossly underestimate numbers. The Forced Marriage Unit, a joint initiative between the UK's Foreign and Commonwealth Office and Home Office, provides advice and practical support regarding forced marriages both in the UK and abroad. In 2010, the unit's expertise was sought on 1735 occasions (Reference SinghSingh 2011). Karma Nirvana (a specialist Black and minority ethnic non-governmental organisation) dealt with over 13 000 callers between April 2008 and the end of January 2011 (Reference SinghSingh 2011), and Reference Kazimirski, Keogh and KumariKazimirski et al (2009) estimated a national UK prevalence of 5000–8000 cases of actual or threatened forced marriage in 2008. A survey carried out by the charity Women's Aid (2008) in 2006–2007 found that 870 women in refuge accommodation (5% of the total) were fleeing forced marriages.

A study involving women with intellectual disability who were either married, pregnant or parents and living in the east London borough of Tower Hamlets found that all of the Bangladeshi women were married, compared with less than half of the others (Reference O'Hara and HemmieO'Hara 2003). Many of the women had questionable capacity to consent to marriage, implying that a number may have been within a forced marriage situation. Among the 1735 contacts with the Forced Marriage Unit in 2010 (Reference SinghSingh 2011), 70 cases involved people with disabilities (50 with intellectual disability, 17 with physical disability and 3 with both). No specific data were collected about the number of cases involving people with severe mental illness.

The majority of forced marriages reported in the UK involve South Asian families. However, there are instances involving East Asian, Middle Eastern, gypsy/traveller, European and African communities too (Reference Gangoli, Razak and McCarryGangoli 2006; Reference Hester, Chantler and GangoliHester 2007). Most victims who contacted the Forced Marriage Unit in 2010 were women (86%), but there should remain significant concern about male victims, as reported numbers have risen by 65% (from 134 victims to 220) between 2008 and 2009 (Reference SinghSingh 2011).

A study of 289 front-line practitioners from a range of agencies, including healthcare, police, Social Services and education (Reference Clawson and VallanceClawson 2010), found that:

1. • 71 cases of forced marriage were reported in people with intellectual disability, most being aged 18–25 years, with the youngest being 14;

2. • the proportion of males and females was more equal than in the general population (38% male, 45% female; 17% not reported) and most lived with their families, who were usually the instigators of marriage;

3. • 90% of the forced marriages were reported by a third party;

4. • almost 70% either lacked capacity or had capacity questioned with regard to consenting to marriage;

5. • most marriages (80%) took place outside the UK.

Children may be especially vulnerable to forced marriages, with a third of cases handled by the Forced Marriage Unit in 2010 related to people under the age of 18. Although child marriage is a worldwide phenomenon, it is most prevalent in African and South East Asian communities, so it may be more likely to affect these communities in the UK (Reference SinghSingh 2011). All psychiatric professionals, particularly those working in child and adolescent mental health services, should be especially aware of signs of forced marriage (see below) when seeing children within at-risk ethnic groups.

There are sporadic case reports in the psychiatric press regarding the marriage of vulnerable people with severe mental illness who lack capacity. Reference Peisah, Brodaty and BridgerPeisah et al (2008) presented two cases of older people with mental illness: an 87-year-old man who married a carer 50 years his junior while hypomanic; and an 82-year-old woman with moderate dementia who married her boarder, the marriage subsequently being found void by Australian courts. Reference Sillifant, O'Dwyer and MindhamSillifant et al (1995) questioned the legal issues involved in postponing, against her spouses wishes, the marriage of an incapacitous young woman who had psychotic depression and was an in-patient at the time of the planned wedding. Owing to the lack of capacity in each case, all of these situations could be considered as involving forced marriage, although the motives for each may have been different.

What are the motives behind forcing someone into marriage?

Reference Clawson and VallanceClawson (2010) points out that the motivations behind forced marriage vary and include what families would see as ‘positive’ reasons. Families of people with severe mental illness or intellectual disability may not see that the marriage they are organising is ‘forced’ because of cultural beliefs or lack of awareness of human rights in the UK. They may see themselves as protecting their children's future care or financial requirements, building stronger family ties, upholding long-standing commitments, or protecting or preserving perceived cultural/religious ideals and traditions (often misguided). Although it is important to understand a family's motives, these should never be accepted as justification for their actions. Every major faith has condemned the concept of forced marriage being justified on religious grounds, with freely given consent being a prerequisite of Christian, Jewish, Hindu, Muslim and Sikh marriages (Reference Gangoli, Razak and McCarryGangoli 2006; Reference RatnaikeRatnaike 2007).

More negative motivating factors include controlling unwanted behaviour and sexuality (e.g. perceived promiscuity, being gay/lesbian), protecting ‘family honour’, ensuring that property and wealth remain within a family, preventing ‘unsuitable’ relationships (e.g. outside of ethnic, cultural, religious or class groups), assisting residence and citizenship claims, or by-passing certain immigration and asylum rules (Reference Hester, Chantler and GangoliHester 2007).

For people with intellectual disability, other motivating factors may be involved (Reference SamuelSamuel 2008; Reference Clawson and VallanceClawson 2010):

1. • the family may be looking to obtain a long-term care option or financial security for their child

2. • they may see marriage as a ‘rite of passage’ that should be available for all

3. • they may worry that younger children will be seen as undesirable if an older sibling with an intellectual disability is not already married

4. • the marriage may be seen as the only or right option, or both

5. • obtaining physical assistance for ageing parents

6. • believing that the marriage will somehow ‘cure’ disability.

Some families mistrust social care and healthcare systems, preferring to look after intellectually disabled relatives themselves. There is some evidence that women with intellectual disability are forced to marry ‘disgraced’ men who are regarded as ‘unsuitable’ partners for others. This highlights the low worth placed on many women who have an intellectual disability.

Many of these issues may be equally applicable to people with severe mental illness who lack capacity. Conversely, in some situations families might seek a label of mental illness to explain a person's refusal to consent to a proposed (possibly forced) marriage, but to date little has been written about this group.

Capacity and consent

It is important to remember that, according to the Mental Capacity Act 2005 for England and Wales, the court and/or any individual (including a parent) cannot in any circumstances give consent to marriage on behalf of an adult who lacks the capacity to give his/her own consent. Consequently, any marriage ceremony that involves an incapacitous person must be viewed as forced, regardless of why it took place.

The Mental Capacity Act 2005 offers a useful framework around which to assess decision-specific capacity at a given time. However, assessing capacity to consent to marriage is complex, involving a number of separate capacity assessments in different areas. Box 1 highlights some areas needing further exploration. These assessments are not a comprehensive list and may need to involve a number of professionals.

Where there are communication problems it might be helpful to use pictures and easy-to-read literature or to enlist the help of a speech and language therapist. Clinicians should be aware of possible acquiescence shown by people with intellectual disability when answering questions; likewise, care should be taken to avoid relatives answering questions on a person's behalf, or acting as a potentially biased translator. Reference MurphyMurphy (2003) found that sex education made a significant difference to the knowledge and understanding of sexual relationships and capacity to consent. Various resources are available to help such assessments (e.g. Health Scotland 2008; Reference KellyKelly 2009).

Legal aspects of forced marriage

On 10 October 2011, UK Prime Minister David Cameron included issues of forced marriage in his speech on immigration and deemed it ‘little more than slavery’ and ‘completely wrong’ (Number 10 2009). The Home Secretary, Theresa May, announced on 12 December 2011 that the public would be consulted on making ‘forcing someone to marry’ a criminal offence (Home Office 2011). Following the consultation, the government announced on 8 June 2012 its intention to introduce new legislation making forcing someone to marry a criminal offence punishable by a prison sentence. The timetable for creating the new legislation is not yet clear. The question of whether or not making ‘forcing someone to marry’ a criminal offence will help victims is one that is much debated (Reference GillGill 2011). There are a number of arguments for and against (Box 2).

At the time of writing, ‘forcing someone to marry’ is not in itself a criminal offence in the UK; however, within a forced marriage, various offences may be committed. Examples given in the Sexual Offences Act 2003 include inciting or facilitating a person without capacity to engage in sexual activity, and the spouse may not appreciate that they are committing an offence in this situation. Women may be subject to repeated rape, often until they become pregnant. It should also be pointed out that young people under the age of 16 cannot legally consent to a sexual relationship.

For example, in KC & NNC v City of Westminster v IC [2008], a young man with autism, severe intellectual disability and who lacked capacity was married over the telephone to a woman living in Bangladesh who had no intellectual disability. The Court of Appeal ruled that this marriage, although recognised in Bangladesh and in Sharia law, was not entitled to recognition under UK law. The Court ruled further that consummating the marriage would be tantamount to rape or indecent assault.

The Forced Marriage (Civil Protection) Act 2007 enables courts in England, Wales and Northern Ireland to issue protection orders with a range of conditions, the breaching of which can result in prosecution and a custodial sentence for those responsible. In Scotland, the Forced Marriage etc. (Protection and Jurisdiction) (Scotland) Act 2011 offers similar protection from forced marriage.

Where there are concerns, local authorities can apply to the Court of Protection for declarations and orders to protect vulnerable individuals. The Court can operate alongside both the Forced Marriage (Civil Protection) Act 2007 and Mental Capacity Act 2005. The latter gives the Court decision-making powers over property, affairs, healthcare and personal welfare for adults who lack capacity. Under the former, the Court can act to restrain family members from arranging a marriage or to prevent a person being taken overseas for the purpose of marriage. It may also assist attempts to repatriate those taken out of the country and forced into marriage.

It is important that all clinicians working in the field of mental health and intellectual disability are aware of these legal aspects of forced marriage so they can better support service users and offer appropriate information and assessments to courts, should they be required to submit reports or act as an expert witness. Guidance on legal aspects of forced marriage has been published by the Ministry of Justice (www.justice.gov.uk/protectingthe-vulnerable/forced-marriage). Key legislation is summarised in Box 3.

Consequences of forced marriage

For many victims, isolation and the feeling that there is no one to trust or speak to about their situation can be one of the biggest problems. This may be even more likely in people with severe mental illness and those with intellectual disability, who may be more dependent on family members to meet their care needs. Cognitive and communication difficulties, sensory impairment, thought disorder and other psychopathology may reduce the likelihood of victims disclosing the fear or existence of a forced marriage.

Both male and female victims may be subject to repeated sexual assault (including rape), domestic violence from their partner or extended family, or enforced domestic family service. Women may be disproportionately affected by sexual assaults. Additional consequences for people with intellectual disability and their spouses are shown in Box 4.

The physical and emotional stresses within a sexual relationship, let alone any abuse, can have major consequences on mental health, giving rise to new illness or exacerbating an existing problem.

Rates of mental illness, including self-harm, suicide and eating disorders, have been found to be elevated in South East Asian communities within the UK, particularly in adolescent girls, and domestic abuse and marital relationships may be factors (Reference Husain, Waheed and HusainHusain 2006). Between 2001 and 2009, the Southall Black Sisters (SBS) project supported or advised 3380 women who were seeking to escape domestic violence. Of these, 409 (12%) were identified as having clear mental health problems and most (307) were of South Asian backgrounds. Of the 409 women with mental health problems, 299 were subject to domestic violence, 21 had been forced to marry, 13 had a diagnosed mental illness, 252 had contemplated suicide or self-harm and 73 had attempted it. These women were most likely to be aged 16–25 years. Over the years SBS has dealt with 18 suicides, and during the study period there were 8 deaths. Hanging and jumping were the most common methods (Reference Siddiqui and PatelSiddiqui 2010). These findings highlight the potential impact of domestic abuse, including forced marriage, on mental health, although further research is required. Siddiqui & Patel's report contains a number of recommendations on services, therapeutic support, government policy and legal issues, as well as research.

There is little research evidence on the extent of mental health problems in the population of people forced into marriage; however, one might expect depression, anxiety-related states (including adjustment disorder) and features of post-traumatic stress disorder to be more prevalent. People with more severe intellectual disabilities may have the same mental health problems but display ‘behaviourally equivalent’ symptoms such as irritability instead of sadness in depression (Reference Marston, Perry and RoyMarston 1997). They might also exhibit specific disabilityrelated disorders as defined in the Royal College of Psychiatrists' (2001) diagnostic criteria for people with an intellectual disability. Comorbid pervasive developmental disorders such a childhood autism, Asperger syndrome or high-functioning autism could further increase vulnerability.

Potential pitfalls for professionals

Practitioners dealing with suspected or actual cases of forced marriage may be faced with a number of dilemmas. First, they may not feel confident in recognising the signs of people at risk of forced marriage. Practitioners may feel that they do not have a good understanding of the potential victim's culture or they may not question their understanding of forced marriage and be more accepting of what they are told is an ‘arranged marriage’. They may fear being perceived as, at best, ‘culturally insensitive’ or at worst, racist. Practitioners may not have a clear understanding of their roles and responsibilities regarding safeguarding or question whether forced marriage is indeed a safeguarding issue. They may be ignorant of how best to reduce the risks to their patients, or worry about damaging relationships with local communities. What is clear, however, is that ‘there is nothing honourable about abuse in the name of honour, and forced marriage demands protection not political correctness’ (M. Sanghera, personal communication, 2011); it is still an abuse of human rights. Practitioners need to have a clear understanding of the differences between religious or cultural practice and see forced marriage as a form of abuse. Forced marriage then needs to be dealt with as abuse through the appropriate agencies. The following sections hope to address these issues, giving fictitious case scenarios and practical advice.

Warning signs of forced marriage

Impending or ongoing forced marriage may have an impact in a variety of areas, including health, engagement with services and police involvement. Likewise, identifying factors within the family history, such as siblings being forced to marry, may alert professionals to potential risk. Box 5 summarises general ‘symptoms’ or warning signs of a forced marriage.

In addition to these general warning signs, some potential indicators are more common for children or people with intellectual disability. They may talk about marriage, jewellery or wedding clothes. Wider family members may actively raise concerns about an impending marriage or a parent may approach professionals to sign a passport application or immigration forms. Children and young people may be taken out of their school or day centre placement without explanation and then taken out of the country. Changes in emotional state or displays of ‘challenging behaviour’ might also be present (Reference Clawson and VallanceClawson 2010).

It is important to recognise that a professional whose suspicions are raised may have only one chance to prevent a forced marriage and its consequences. This ‘one chance rule’ forms the basis of statutory guidelines (Forced Marriage Unit 2010) on the processes that should be incorporated in the safeguarding systems of all regions following the Forced Marriage (Civil Protection) Act. Advice on how professionals can implement these processes is summarised in multi-agency guidelines (Foreign and Commonwealth Office 2009; Reference Clawson and VallanceClawson 2010).

What actions should be taken by front-line professionals?

If in a consultation a front-line professional suspects a forced marriage has taken place or is about to take place, they should not pursue family involvement (counselling, mediation, arbitration, etc.). They should, as soon as possible, discuss the situation with their local trust and Social Services safeguarding teams, who should have a specialist in forced marriage with appropriate links to police and the Forced Marriage Unit (Fig. 1). Family liaison must only be pursued if agencies can be sure it will not place the individual at further risk and should only be used with great caution.

FIG 1 Decision tree for professionals suspecting forced marriage (Foreign and Commonwealth Office 2007: p. 27. Reproduced by kind permission of the Forced Marriage Unit).

If there is concern that a person is imminently going overseas, the police and Social Services should be informed immediately, as there may be limited time to develop an adequate safety plan or seek protection (Foreign and Commonwealth Office 2009). In all cases it is important to gather as much information as might be relevant in supporting the person. Ideally, this should be done by trained specialists, but there may be occasions where the front-line professional will need to assist by creating opportunity and time for this to happen, for example insisting on seeing the person privately, staying with the person until advice and support is available, inviting them back to clinic for review if more time is required and it is safe to do so.

Where possible, information should include:

1. • a photocopy of their passport, details of the wider family and places they might stay overseas;

2. • information that only person would be aware of (if identification needs to be verified overseas), details of travel plans, names and addresses of close relatives remaining in the UK, a safe method of contact (e.g. secret mobile telephone, trusted friend);

3. • estimated return date and a written statement by the person explaining that they want the police, Social Services or third parties to act on their behalf should they not return by that date.

If an interpreter is needed, beware of using family members and be cautious of using local interpreting services in small, close-knit communities where inadvertent disclosures could happen. Consider using out-of-area interpreting services or in-house trust staff, ensuring they are aware of the risks and the need for absolute confidentiality. Even within the team information should be shared only on a need-to-know basis.

In some circumstances it would be justified, with the individual's consent, to admit them to hospital to provide immediate protection. Likewise, if someone at high risk were in a psychiatric hospital and about to be removed by relatives, professionals could seek to deny leave, initiating safeguarding procedures, while pursuing options either under the Mental Health Act or Deprivation of Liberty Safeguards (in England and Wales) and involving the Forced Marriage Unit and the trust's legal services. This would allow time for a more thorough assessment.

For people with intellectual disability or severe mental illness whose capacity and communication are affected, additional considerations will need to be made. It may be beneficial to involve a communications specialist and independent advocate (equivalent to the appropriate adult) in interviews. Capacity and consent issues may need to be more formally addressed.

Sometimes, families organising a marriage for a child or relative with intellectual disability do not think that they are doing wrong or do not understand that absence of capacity to consent would render it a forced marriage. Such situations can be complex and discussion with family members requires careful consideration to avoid putting the potential victim at increased risk of harm (Reference StobartStobart 2009). In all cases, involve a child or adult protection specialist with expertise in forced marriage, and contact the police if the person is at risk of harm. Establish whether the person has capacity to consent to marriage, wants to be married and is of a legal age to marry. If not, explain to the family why the marriage should not happen, if this does not increase risk. Discussion might include legal implications and safeguarding concerns. If necessary, child or adult safeguarding procedures should be implemented. Professionals should never: ignore the matter; assume that the family will stop organising a marriage because of discussions with them; fail to obtain the victim's views; or lose contact with the family or victim (Reference Clawson and VallanceClawson 2010).

When a person discloses that they have been or are about to be forced to marry, they may have limited options to avoid the situation. For example, should they remain within the family and to try to resolve the situation, or succumb to the family's wishes, or flee the family and seek legal protection? Each of these choices has its own risks and consequences, but if there is concern about potential violence in the home, the first two are most risky. Box 6 highlights important things to do if a person discloses concerns about forced marriage.

What if the person is already married?

Sometimes cases of forced marriage only come to light after the event and when children have been born. These situations can be extremely complex to manage and safeguarding processes and child protection procedures may need to be started in close liaison with the Forced Marriage Unit. If offences are suspected, police involvement within these processes will be required. It is vital to assess each case individually and to make sure the needs of all parties, including spouse and children, are listened to and the risks assessed. The quality of the relationship as well as capacity and consent issues will be central to decisionmaking. Assumptions should never be made about the risks or otherwise of a situation, even if couples have been married for a long time.

MCQs

Select the single best option for each question stem

1. 1 Forced marriage:

   1. a occurs when one or both spouses do not or, through lack of capacity, cannot consent to the marriage

   2. b is the same as an arranged marriage

   3. c in the UK is most commonly seen in the African community

   4. d is classified as an abuse only when it affects people with an intellectual disability or severe mental illness

   5. e is supported by most major religious faiths.

2. 2 As regards the forced marriage of people with an intellectual disability in the UK:

   1. a the vast majority of victims are women

   2. b victims frequently express dissatisfaction with the marriage

   3. c few cases are reported by a third party

   4. d up to 80% of marriages occur in the UK

   5. e at face value, motives behind the marriage may seem a positive attempt to protect the person.

3. 3 As regards legislation on forced marriage:

   1. a others can give consent to marriage on behalf of an adult who lacks capacity to consent

   2. b ‘forcing someone to marry’ is a criminal offence in England, Wales, Northern Ireland and Scotland

   3. c the Mental Capacity Act 2005 provides a useful framework for assessing capacity

   4. d only the individual under threat of a forced marriage can apply for a court protection order to prevent this happening

   5. e offences under the Sexual Offences Act 2003 are unlikely to be committed.

4. 4 The following is not a potential warning sign of forced marriage:

   1. a failure to return from visits to country of origin

   2. b decline in engagement and behaviour

   3. c not allowed to attend extracurricular activities

   4. d excellent exam results

   5. e sibling surveillance.

5. 5 A young woman with known schizophrenia is assessed in the emergency department following a panic attack and faint. While alone with a liaison psychiatric nurse she discloses her fear that her parents have arranged a forced marriage, to take place during a family holiday to Pakistan in 2 days' time. The nurse should:

   1. a support her to discuss this fear in the company of her parents

   2. b reassure her that these fears are more likely be linked to her mental illness and consider reviewing her medication

   3. c discharge her with the intent of writing a referral to the local mental health team for routine follow-up

   4. d call her older brother to clarify these concerns

   5. e seek urgent advice and help from the Forced Marriage Unit and start to form a protection plan.

MCQ answers