Impending Early Marriage Leading to Depression, Anxiety and Stress: Woes of Female Medical Students at Hyderabad

Background Pakistan, like the rest of south-east Asia, is plagued with old trends and traditions that target the fairer sex in particular. Marriage tops all charts in this regard and every parent in our increasingly misogynistic society wishes to marry off their daughter as soon as possible. Doctor brides however have always been seen positively. Parents wish to benefit from this factor and get their daughters married even before they graduate. Objective We hypothesize that the fear of an impending marriage leads to depression, anxiety and stress among female medical students. This study hopes to gauge the psychosocial and psychosomatic effects. Methodology This observational cross sectional psychosocial analysis was carried out on a total of 100 female medical students of Liaquat University of Medical & Health Sciences and ISRA University from March to June 2014. Informed consent was obtained and complete anonymity guaranteed. “Google docs” was used to collect data via online structured questionnaire forms. The data obtained was analyzed in SPSS. v. 16.0. Results 43 percent of the sample confessed that their families had, at least once, been approached for purpose of marriage. 16 percent admitted that they had themselves received marriage proposals. 88 percent of the sample held negative views regarding early marriage before graduation. Upon inquiry, 78 percent of those who had encountered prospects of marriage before graduation admitted to have felt depression, anxiety and stress along with mild psychosomatic symptoms. Conclusion Females constitute a significant majority of medical students in Pakistan and early marriage is known to adversely affect the prospects of a successful career. On the basis of our result, we conclude that even the fear of impending marriage is inducing depression, anxiety and stress among female students and can potentially harm their education and health.


Introduction
Pakistan, like the rest of south-east Asia, is plagued with age old trends and traditions that target the fairer sex in particular. Marriage tops all charts in this regard and every parent in our increasingly misogynistic society wishes to marry off their daughter as soon as possible. It used to be that she only needed to be fair, from a good family, charming, and pliable. Now it seems the perfect bride for the darling son of this or that familymust also be a doctor. Gone are the days when too much education was a boon on the backs of the bride-to-be, a consternation that suggested the chance for possible rebellion; the desire to overturn age old traditions. Today, the doctor bride signifies status, not simply the cache of brains in addition to beauty, but rather of the incredible largesse of having the option to work, to make lots of money, and then to forego it all in the path of devoted wifehood and motherhood. In this misogynistic equation a man who can boss a woman around is quite manly, but a man who bosses a doctor around is the manliest. (Rafia. Z, 2013 women. Of 28, 686 specialist physicians in the country, a paltry 7,524 are women. The percentage of female medical students may be high enough, but the bridal market places more urgent demands, promises more stability and social acceptance than the job market. (Rafia. Z, 2013) In a poor country, where healthcare is inaccessible to millions, female students, especially those that attend public universities take up already meager resources. When these girls do not practice they take away income generating opportunities from others who would utilise them. On another scale, the lost doctors represent an expenditure on healthcare that produces a net loss in that the benefits of the education are never dispersed into the general population. The problems are not Pakistan's alone. In post-apartheid South Africa, a country where Indian Muslims present a significant demographic, rumors have been circulating about the application of unofficial quotas that reject applications from female Indian Muslim students because too many of them fail to practice medicine after marriage and motherhood. While administrators of medical schools insist that they do not exist, the issue remains a contentious one even in that country. (Rafia. Z, 2013) The educational burden of medical school alone is stress worthy but when coupled with the fear that all their efforts and their hard earned degree shall go in vain and they will be wedded off at a tender age. We hypothesize that the fear of an impending marriage leads to depression, anxiety and stress among female medical students and this study hopes to gauge the psychosocial and psychosomatic effects.

Methodology
This observational cross sectional psychosocial analysis was carried out on a total of 100 female medical students of Liaquat University of Medical & Health Sciences and ISRA University from March to June 2014. Informed consent was obtained and complete anonymity guaranteed. "Google docs" was used to collect data via online structured questionnaire forms. The data obtained was analyzed in SPSS. v. 16.0. Information was also gathered from online reports and news periodicals.

Results
Majority of the sample validated the claims made by most reports and confessed to have received marriage proposals during their university life i.e. they were found marriage worthy by men even before they had graduated.
Figure 1: A significant proportion of female medical students reported to have received marriage proposals even before graduation. 43 percent of the sample confessed that their families had, at least once, been approached for purpose of marriage. 16 percent admitted that they had themselves received marriage proposals.  Depression is the mainstay of the symptoms while anxiety and stress too follow immediately.
The self-admitted psychosomatic symptoms that female medical students felt due to the impending feeling of marriage are described in the figure below. Fatigue, Back-ache and abdominal pain were the most prominent among the lot.

Discussion
Many women in the developing world are subject to marriage at an early age. Most such women have little choice in the age at which they marry, or whom they marry. Rebeca. J, 2013 in her article, examined patterns and trends of early marriage in the developing world. The incidence varies widely, from a high of 70 per cent in south Asia to a low of 30 per cent in South East Asia. Women who marry young tend to have less decision-making power in the household. They are also more likely to experience domestic violence. (Rebeca. J, 2013). Hence justifying the fear of early impending marriage.
The average age at marriage of women has been rising in most developing countries including south Asia. (Caldwell J.C, 1983). The rise in the age at marriage of women was explained by a marriage squeeze resulting from changes in the age structure of the population with mortality decline, an increasing concern of parents of daughters to secure sons-in-law with education and urban occupations, and a growing concept of child dependency. There was no evidence of the rise being a conscious effort to control family size. In the immediate future some women will probably remain unmarried, (Caldwell. J.C, 1983) and it is this fear that is driving the all parents of daughters to get them married early and it is the more likeable ones (i.e. doctors) that get married the earliest.
It is a general perception in Pakistan that uneducated people do not allow women to work and girls should be provided education to make them an effective part of society. But the fact highlighted by our study is that even the educated men and their families force their wives to stay home as housewives and abandon their medical practice and their duty towards humanity. Ikram. J, 2014, too validates our claims in his report that states that the elite class too preferred that female medical students should marry and serve their in-laws instead of doing their duty as a doctor. The problem thus lies at many levels (i.e. personal and societal) and the practice of young female medical students being approached and coerced for marriage is not only distressing for the primary victims (i.e. the female medical students) who suffer depression anxiety and stress but also the society at large who suffers from the dearth of doctors available to them. PMDC statistics that were quoted by the then president of PMDC state that "70 percent of the female students did not practice medicine after becoming doctor and completing their studies" (Faheem A, 2012). The discussion on the problems can continue forever and the evidence too is endless, suggesting that early marriage may lead to a myriad of issues including poverty (Otoo-Oyortey N, 2003), low quality of life (UNICEF, 2005) and poor reproductive health (Prakash R. et al, 2011) and increase in infant mortality rate (Finlay JE, 2011).
The solution too can be dual-pronged. We can educate parents to not marry off their daughters at an early age and thus easing the psychosomatic burden that the female medical students carry. In addition to that, the students can be made to sign bonds that make it mandatory for them to practice their profession for at least a certain amount of years. That would not only let the females retain a sense of their old self after their marriage and give them confidence, but also empower them to fight off the depression, anxiety and stress.
Another solution that has surfaced just recently is the innovative idea of allowing female doctors who have discontinued their medical practice due to marriage is to work from home by joining platforms such as "doctHERS" and others that use video consultation setup that facilitates doctor-patient interactions. (Ilyas F, 2016).

Conclusion
Females constitute a significant majority of medical students in Pakistan and early marriage is known to adversely affect the prospects of a successful career. On the basis of our result, we conclude that even the fear of impending marriage is inducing depression, anxiety and stress among female students and can potentially harm their education and health.

Conflict of interest
All the authors disclosed that there is no conflict of interest associated in the preparation of this article.