Sexual and reproductive health issues of women attending psychiatric clinic in India—A qualitative study

Abstract

BACKGROUND:

Women with mental illness (WMI) experience considerable disparities in sexual and reproductive health (SRH) when compared to the general population. Due to their restricted access to SRH services, they have unmet contraceptive needs, a greater prevalence of sexually transmitted infections (STIs), and sexual dysfunction. The study aimed to explore the SRH issues of WMI in a tertiary care psychiatric outpatient clinic in Bengaluru, India.

MATERIALS AND METHOD:

A qualitative hermeneutic phenomenological approach was used. A reproductive age group (18-49 years) WMI (n = 32) was selected by purposive sampling technique. The period of data collection was from January 2021 to September 2021. An in-depth face-to-face interview was conducted using a validated interview schedule. Hycner’s explicitation process was used to investigate the constituents of a phenomenon.

RESULT:

The codes revealed potential themes and subthemes. SRH issues faced by WMI were organized under three main themes, namely, (1) factors responsible for sexual dysfunction, (2) symptoms of STI and treatment adherence, and (3) use of contraception and its barrier.

CONCLUSIONS:

Sexual dysfunction among WMI is contributed by numerous factors. Women were exhibited limited knowledge of STI symptoms and treatment compliance. Such women experience issues with current method of contraception and are unaware of the alternatives. The findings of this study may be helpful for clinical nurses in drawing attention to and increasing knowledge of the reproductive health issues that women with psychiatric disorders face, taking the required precautions, and devising strategies for minimizing harm.

Introduction

Sexual and reproductive health (SRH) is a state of complete physical, mental, and social well-being in all aspects of the reproductive system.[1] SRH and mental health are linked and dependent on one another throughout life.[2] Women with mental illness (WMI) are vulnerable to reproductive health problems and adverse reproductive health outcomes in developing countries.[3] Sexual behavior was more negative in women with bipolar disorder. They were likely to have been forced by their partners to have sex resulting in a higher prevalence of sexually transmitted infections (STIs).[4] Studies highlight that WMI have problems in expressing their sexual needs, and often, they do not have the necessary assertiveness in negotiation about a safer sexual relationship, which could lead to their sexual exploitation.[2,5] Although the capacity of women to have a sexual activity or maintain former sexual life would be affected by their disease or medication side effects, their sexual needs appear to remain.[5,6] Furthermore, they had lack of access to sexual health information, violence and sexual abuse, unwanted pregnancy, shyness in expressing sexual desires, and limited knowledge of sexual behaviors.[7] Most women have attempted various forms of contraception but could not continue using them. They were not using safe contraception methods, which led to unmet needs and unintended pregnancies.[5] Women with schizophrenia and bipolar disorder stated that they had never discussed family planning methods with their psychiatrist.[6] Lack of sexual health education contributes to the increased prevalence of STIs and sexually offensive behavior among WMI.[7] The lack of access to SRH services experienced by WMI is increasingly documented. Barriers to access include a lack of routine inquiry, illness acuity, and feeling ashamed.[8] There is limited research from low- and middle-income countries that explores the SRH issues faced by WMI.[4,6,7] SRH is frequently overlooked by clinicians as they concentrate on treating people with psychiatric disorders.[9] It has been observed that women are reluctant to discuss their sexual needs because their focus will be on concerning psychological symptoms.[4] The researcher felt that qualitative research is an appropriate initial step to obtain more in-depth information about SRH experiences of WMI because of the complex nature of mental illness.[9] Hence, the current study attempts to explore the SRH issues of WMI.

Materials and Methods

Study design and setting

A hermeneutical phenomenological approach was used. Women receiving treatment at a tertiary care psychiatric center in Bengaluru, South India, were invited to participate from January 2021 to September 2021. The inclusion criteria include WMI who were married and aged between 18 and 49 years, diagnosed, and registered as per the international classification of diseases (ICD-10)[10] and the duration of illness not less than one-year, Brief psychiatric rating scale (BPRS) score <18 (currently in remission) able to communicate in Kannada, English, or Tamil languages. WMI have the history of SRH issues such as sexual dysfunction, experiencing symptoms of STIs, and problems in using contraception for the past 1 year were invited to participate by purposive sampling technique. Female sexual function index, centers for disease control and prevention reproductive health assessment tool kit–STI, and family planning questionnaire were used to screen the SRH issues among WMI. Exclusion criteria include a clinical history of cognitive deficit, hearing, and speech disorder, and not willing to participate.

The interview schedule was developed based on a literature review and discussion with subject experts regarding sexual health experiences, sexual health issues, STIs, and the use of contraception. Some of the questions used for probing SRH issues were as follows: “What are your understanding of sexual health?” “What are the problems you are facing in your sexual life?” “Specify the reasons for the STI symptoms?” “How will you protect yourself from STI?” “What are the problems you are facing with the current use of contraception?”

Study procedure

The finalized interview schedule was piloted among nine WMI and found that it was feasible to adapt to Indian settings. Permission was obtained from the Institute authorities. In-depth, face-to-face interview was conducted in a private room in the follow-up outpatient department. The interviewer ensured that there was adequate confidentiality and respect for the WMI. The participants were explained about the voluntary nature of participation and the need for an audio recording of the interview. Each in-depth interview took 40–90 min to complete, and a time limit was not enforced. Probes were used for better clarification, and each participant was given enough time to express views. Flexibility was maintained during the interview. Data were collected until no new information could be elicited from WMI. A verbatim transcript was generated using audio recording.

Data analysis

Hycner’s (1999) explicitation process was used to investigate the constituents of a phenomenon and keep the context as a whole.[11] The steps of the explicitation process are briefly explained in Figure 1.

Figure 1.

Steps of data analysis carried out for the study (Hycner’s, 1999)

Rigor and trustworthiness of the data

The interviewer was an experienced and qualified person familiar with local languages, so the women felt comfortable in exploring the SRH issues. Face-to-face interview was conducted in a private room in the follow-up outpatient department and was completely non-judgmental. The interviewer ensured that there was adequate confidentiality and respect for the WMI. The researcher bracketed herself consciously to understand, in terms of the perspectives of the participants interviewed the phenomenon that she studied on the factors responsible for sexual dysfunction from an insider perspective, symptoms of STIs, and the barriers in using contraception. The audio recordings made of each interview and again bracketed herself during the transcription of the interview further contributed to the truth. Validity checks were done by returning to the participant to determine if the essence of the interview had been correctly captured. Member checks and audio recordings for the accuracy of the theme and sub-theme were done by the researcher (SV) and verified by the research guides (GR and SG). Peer debriefing was also performed by a qualified researcher who is not part of this research.

Ethical consideration

Ethical approval was obtained from the Institute Ethics Committee [----/24^th IEC/BY REVIEW (BEH.SC.DIV.)/2020-21 Dated 25/07/2020]. A written informed consent was obtained from the participants before the participation after a thorough explanation of the study and its procedure. The participants were also informed that their participation was voluntary and they could withdraw from the study at any time without any reason. Confidentiality and anonymity were maintained.

Results

A total of 32 participants were selected based on the inclusion criteria and involved in in-depth interviews. The demographic characteristics of the participants are shown in Table 1. All 32 audio recordings (WMI having sexual dysfunction (n = 15), symptoms of STIs (n = 11), and contraceptive issues (n = 6)) were transcribed into English text. Hermeneutical phenomenology relies on both interpretation and description of the lived-in experience. In this study, the researcher explored SRH issues of WMI and interpreted their responses using the themes and sub-themes to gain an understanding.[12] Initially, 42 codes were generated. and these codes were later finalized with three significant themes and 19 sub-themes. [Table 2]

Table 1.

Demographic characteristics of the women with mental illness (n=32)

Demographic Variables	n (%)
Age (Years)	36 (0)*
Years of education	9.78 (4.62)*
Income	6000 (0-20000)*
Occupation
Homemaker	15 (47)
Skilled worker	9 (28)
Agriculture	8 (25)
Religion
Hindu	28 (87.5)
Muslim	2 (6.25)
Christian	2 (6.25)
Types of family
Nuclear	24 (75)
Joint	8 (25)
Chronic medical illness
Yes	12 (37.5)
No	20 (62.5)
Mental illness (ICD-10 Diagnosis)
Psychotic disorder	9 (28)
BPAD	11 (34)
Depression	4 (13)
Anxiety spectrum disorder	7 (22)
OCD	1 (3)
Duration of illness	5 (1-19)*
Age at marriage	18.91 (4.69)*
History of childbirth
Yes	31 (97)
No	1 (3)
Number of children
None	1 (3)
One	2 (6.25)
Two	16 (50)
Three	10 (31.75)
More than three	3 (9)
Habits
Tobacco	5 (16)
None	27 (84)

Note. Data presented is the frequency with a percentage in parenthesis *Mean (SD) or Median (Q1-Q3)

Table 2.

Themes and sub themes of in-depth interview (n=32)

Theme	Sub themes
Factors responsible for sexual dysfunction (n=15)	Illness-related factors Lack of interest Pain during contact Side effects of the medicine Accepted sexual violence External variable Privacy Emotions during contact Extramarital relationship Responsibilities and other roles
Symptoms of STIs and treatment adherence (n=11)	Family issues for not giving attention to symptoms of STIs Misbelief Risk factor Poor knowledge of treatment options Treatment adherence to mental illness
Use of contraception and its barrier (n=6)	Refuse to use the method Poor knowledge of contraception Poor autonomy in fertility-related decision Problems with current use of contraception

Factors responsible for sexual dysfunction

Sexual dysfunction differed from each woman depending on the problem that they are facing. They experienced low desire, difficulties in arousal, lubrication, orgasm, dissatisfaction, and pain. Women claimed that a few reasons were to blame for their sexual dysfunction.

a. Illness-related factors

Participants believed that their loss of sexual desire was resulted from their mental illness and the medication they were receiving for it.

“As a patient taking medication, I have a responsibility to look after my health. Sexuality is not as vital as health. Even my partner will not express interest” (P. 25).

b. Lack of interest

Participants reported that the desire they have for sex is very low. They do not think about it and said that they never remember having so much sex interest.

“I do not feel like that because of my age and my children” (P. 31).

“Following touch, we both occasionally get itching, which is uncomfortable for both of us. So, after deciding that this was enough for us, we are now lying in a different room” (P. 27)

c. Pain during contact

Pain during and after having contact was another issue. One participant revealed that she feels discomfort anytime she is in touch with a partner.

“Every time we do, I feel pain, and my enjoyment instantly disappears. I have to stop enjoying it. This is one of the reasons why I am not interested” (P. 2).

d. Side effects of the medicine

Irrespective of the class, psychiatric medicine cause disturbances in the sexual life of the participants. It varies from sleepiness to a lack of sexual interest.

“I am taking a tablet, so I will go to bed early before my husband gets off work and arrives. I, therefore, do not have time to consider this matter” (P. 19).

e. Accepted sexual violence

Women must adjust with their intimate partner throughout their life to avoid problems in the family. They had sexual intercourse with their partner even though they did not want because they were afraid of what he might do. Relationships being affected in these ways led many to experience isolation and loneliness.

“My husband will not pay attention to me. I have sex with him even though I do not want to because I am worried about what he might do. Only 10 minutes left, so I will adjust with him and leave” (P. 29)

“My interest is the same as my husband’s. If he shows up, I cannot ignore him. I must accept that, or the family will have issues” (P. 12)

f. External variable

Participants identified a few external variables as potential contributors to their sexual dysfunction. At that time, it may impact a patient alone or a couple. It varies from individual to partner-related behavior.

“He used to say that because I am heavy and patient, I am not suitable for a sexual life” (P. 17).

“He occasionally drinks alcohol, and I do not like the scent that comes with it” (P. 8).

g. Privacy

Many couples have young or older children, and it was often believed that a couple should not engage in any form of physical intimacy while children are present.

“Although we occasionally engage in sex, my husband and I are interested in doing so. We do not have a separate bedroom because our home is so small” (P. 21).

“It is quite challenging for us because there are kids between us. Whatever we talk they will listen” (P. 28).

h. Emotions during contact

Women identified with sexual dysfunction can have a psychological, emotional, and physical effect on a survivor, which is not always easy to deal with it, so they are fearful of being victimized and inactive against the perpetrators.

“I am not getting feelings while having contact because he will force me to do” (P. 9).

“I will be more anxious, and numb during that time” (P. 16).

i. Extramarital relationship

External factors that affect the woman and the spouse also play a role in sexual issues.

“My partner is having a relationship with another woman, so he is not showing interest in me” (P. 14)

j. Responsibilities and other roles

Women played various other roles in the family, like mother, wife, sister, and so on. They often feel that fulfilling these roles is more important than sexual desire.

“Financially, I am the only person to support my family. I am so tired; I cannot tolerate it, and my health will spoil. Thinking all these I am not having sex” (P. 32)

“My brothers and children will be in my care. They are becoming older; therefore, I need to focus on their education and development rather than my sexual desires” (P. 30).

Symptoms of STIs and treatment adherence

Participants admitted to experiencing genital itching, atypical genital discharge, ulcers, or sores as STI symptoms. Each participant expressed how they developed the symptoms and the treatment adherence.

a. Family issues for not giving attention to symptoms of STIs

As a result of family issues, women are paying less attention and are not concerned about the symptoms of STIs.

“My vaginal discharge has lasted for three months. I am unable to focus on this issue because of other problems in my family (my son’s love marriage, my husband’s drinking and my in-laws’ health concerns)” (P. 1).

b. Misbelief

Participants believed that these symptoms were not actually because of any severe illness. It may be because of other associated problems, excessive heat, food allergy, and some belief in themself.

“I experience itching and irritation in my perineal area whenever I am in contact with my spouse. My husband smokes, thus I feel that the smoke combined with my blood cause this” (P. 13)

“Possible causes of this odd vaginal discharge are excessive heat in my body. I always do my agriculture work under the sun” (P. 3).

“I always get a white discharge after consuming any heat-producing meals, such as sweets, brinjal, or drumsticks” (P. 6).

c. Risk factor

Most of the women will get an infection from their partner, which they may not notice regularly.

“Every time we come into contact; I start to itch. But I was hesitant to inquire as to whether he was exhibiting the symptoms as well. Both the relationship and the symptoms worry me” (P. 5)

d. Poor knowledge of treatment options

Proper treatment for symptoms of STIs will prevent further damage and promote the reproductive health of WMI. Participants were not having adequate knowledge of the correct treatment options. They reported that

“I experience itching and white discharge in my perineum, but I have not sought therapy. I believed it to be typical for all women” (P. 4).

“My mother said that it is because the body produces too much heat” (P. 7).

“I do not want to go to a hospital for treatment because I feel embarrassed since it is a female problem” (P. 11).

“I used the ointment my nearby aunty provided me once. I stopped there and did not go on.

It will go off if I depart in this way” (P. 10).

e. Treatment adherence to mental illness

Women believed that the symptoms of STIs were caused by the medication they were taking for mental illness.

“I take regular psychiatric drugs. If I do not continue the treatment, I will start to have symptoms. I am not concerned because this white discharge can be related to the medication I am taking” (P. 15)

“I feel it is common for all the women who were on treatment for mental illness” (P. 26).

Use of contraception and its barrier

WMI are disadvantaged groups and experience serious reproductive health problems including improper and low rates of contraception. Women who are married and living with their partner must use any one method. Participants conveyed some reasons for using and not using the method to delay or avoid getting pregnant.

a. Refuse to use the method

Women expressed that there is a refusal to use the method by themselves and by their partners.

“I am having one child, so I believe my family is complete. I am avoiding contact and refraining from employing methods out of concern for my health. My partner also dislikes me using any method” (P. 18).

b. Poor knowledge of contraception

Participants were not aware of the temporary and permanent methods of contraception. This may be related to the fact that they knew no method.

“I lack education. I, therefore, lack any approach. I have no one to lead me” (P. 20).

“My husband does not approve of whatever approach I use. As the days passed, I believed my pregnancy would come to an end” (P. 24)

c. Poor autonomy in fertility-related decision

Health professionals and family members promoted sterilization, indicating that it is the most appropriate method for WMI which may undermine a woman’s autonomy related to fertility-related decisions.

“After the birth of my second child, I underwent a tubectomy. My family decided without consulting me. They have agreed not to have children in the future because I take medication, which will have an impact on my health” (P. 22)

d. Problems with the current use of contraception

WMI is using any one method of contraception. Due to various reasons, they were unable to continue using, resulting in unwanted pregnancy and poor health.

“I was using Copper-T when I got fat, and my abdomen grew, making it seem odd. I also started experiencing joint pain, so I am now taking medication. I wanted to eliminate this method because I am unhappy with it” (P. 23).

Discussion

The study aimed to explore the lived-in experiences of SRH issues such as sexual dysfunction, symptoms of STI, and use of contraception among women attending psychiatric clinics in India. Women expressed that they were on regular psychiatry medications, irrespective of the class, which caused disturbances in their sexual life varying from sleepiness to lack of sexual interest. These findings were like the study that explored the biopsychosocial risk factors, including antipsychotic medications and antidepressants, cause a lack of sexual desire and subjective arousal.[13] The duration of antipsychotic exposure increases prolactin blood levels and is inevitably linked to anovulation resulting in impaired sexual functioning. Married women had a higher rate of sexual dysfunction, which supports the findings of our study that all the women in this study are married.[14] It might also be due to the social and cultural influences in India.

Participants expressed that their normal sexual function is affected by various factors such as loss of sexual feelings, low desire, and pain during contact. A similar study shows a higher prevalence in the elements of sexual functioning lubrication (100%), orgasm (100%), and satisfaction (100%). Compared to other domains, dysfunction is less commonly reported, including desire (97.9%), arousal (97.6%), and pain (96.8%), perhaps due to low expectation in a culture where women do not experience high levels of sexual satisfaction.[15] However, highly divergent data on sexual function demand further study to establish a particular conclusion among WMI.[16] Participants living in small families do not have privacy for their physical intimacy. Due to their poor socio-economic status, they live in a small house with no separate bedroom for everybody. Similar study findings supported that the social determinants of health, including poverty and housing instability, cause sexual dysfunction.[15] Participants reported that their sexual health is being affected by their responsibilities as a wife, a mother, or a sister. Compared to the various roles of a woman in a family, sexual health is least preferred. Furthermore, it has been reported in previous research that sexual dysfunction was significantly associated with age. Age-related changes like hormonal and physiological changes, and various sociodemographic factors can affect sexual functioning in women.[17]

WMI experienced symptoms of STI like unusual genital discharge, genital itching, genital ulcer, or sore, but they were not aware of taking treatment. The findings were similar to the study conducted and explore that the association between bipolar disorder and the subsequent development of STIs shows that the female gender is a risk factor for the acquisition of STIs.[18] Impaired autonomy, greater impulsivity, and higher susceptibility to coercive sex are all factors that promote STI vulnerability in psychiatric patients. Furthermore, a higher incidence of poverty, placement in risky environments, overall poor health, and reduced access to medical care also contribute to the high prevalence of STIs and their complications in this population.[19] Women were feeling embarrassed to express the symptoms and taking treatment from physicians. Similar study findings reported that STIs may be asymptomatic; some patients with STIs may not have sought medical treatment and thus were not diagnosed.[20] WMI should be assumed to be sexually active, even if they do not voluntarily disclose their sexual behavior to professionals. Encourage them to use safer sex practices including condom use.[21] Previous literature has highlighted the fact that there is a need for implementing sexually transmitted disease prevention programs in psychiatric settings, including screening, referral for treatment, and behavioral modification interventions.[18,19]

WMI expressed that there is a refusal to use and inadequate knowledge about any one method of contraception. These findings like a recent Indian study on contraceptive practice among women with schizophrenia found that the commonly cited reasons for not using contraception where lack of awareness was 35.5%, not receiving any information at 32.3%, fear of side effects at 25.8%, and social reasons/opposition from the family 9.6%.[21] Unplanned pregnancy is one of the effects of unmet contraceptive needs, resulting in medical termination of pregnancy. Our qualitative research revealed that women underwent sterilization as a contraceptive method and the family members largely took the decision. However, few studies in India suggest that WMI were not allowed to decide on sterilization. This finding is by the qualitative study of six sterilized women with severe mental illness (15% of the sample) provided narratives of physicians, parents, or partners making the sterilization decision.[22] Furthermore, some health professionals encouraged female sterilization, which is one of the most significant methods for WMI, which may weaken a woman’s autonomy connected to fertility-related decisions. The finding differs from the review conducted on copper-T for WMI: they developed side effects like obesity and joint pain. The review has shown that long-acting reversible contraceptives are associated with low failure rates, favorable safety profiles, few contraindications, cost-effectiveness, and rapid return to fertility after removal, chosen by only 14% of women.[23] Usually, copper-T will not cause any side effects. Common myths and lack of education about copper-T were the reasons for not adhering to this method.

Strengths and limitations

To the best of our knowledge, this was the first qualitative study to explore the lived-in experiences of SRH issues among WMI in a mental health care setting. The present study was qualitative, involving a group of women of reproductive age (15-49 years) having SRH problems for the past year who volunteered to participate. The study was limited to women who are having sexual dysfunction, experiencing symptoms of STIs, and issues in using contraception from a single setting. Women with contraception were only six interviews; this is relatively small; however, saturation was achieved as there was no new information emerging from the later interview. The findings should therefore be interpreted with caution as they might not represent the experience of the wide population of WMI.

Conclusions

The study results indicate that WMI in the reproductive age group is experiencing SRH problems. It is important to address and discuss sexual health risk behaviors to overcome the issues and lead a healthy sexual life. The utilization of SRH care is associated with improved mental health, and clinical benefits such as prevention of sexual dysfunction, adequate information on sexual health, reduced rates of STIs, and proper use of contraception. Therefore, SRH and mental health care service professionals need to work together to provide effective integrated health care. Sexual health interventions are designed to help WMI achieve pleasurable and safe sexual experiences free of coercion and discrimination. These women are to be provided with school-based sexuality education tailored to their level of understanding to attain the requisite knowledge and practice safe sex. Families and healthcare systems should provide opportunities for WMI to talk about their sexual needs and make their own choices. Therefore, in mental health care settings, women will be encouraged to use appropriate methods of contraception to prevent the transmission of STIs and to improve their sexual health.

Disclaimer

This paper is part of the researcher’s PhD study, and the contents can be allowed to be mentioned in the thesis.

Ethics approval Ref No

NIMH/24^th IEC/BY REVIEW (BEH.SC.DIV.)/2020-21 Dated 25/07/2020

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.