Women mental health in India

“The reason firm, the temperate will,
Endurance, foresight, strength, and skill;
A perfect woman, nobly planned,
To warn, to comfort, and command.”

William Wordsworth.

Why talk of women mental health? This is the objection of many psychiatrists.

In the present scenario, when there are global concerns about gender equality and many international conventions have resolved against any form of discrimination against women, prioritizing women mental health does not seem to be justified. It has been argued that the specialty of obstetrics and gynecology, in medical science, exclusively caters to the specific health needs of women, but there is no such exclusive mental health discipline for men.[1]

The Constitution of India gave to women, the fundamental right to equality and the Right not to be discriminated against on grounds of religion, caste, and sex. To undo the injustice done to them, the Constitution included a special provision in article 15 (3), permitting the State to positively discriminate in favor of women by enacting laws/provisions so as to ameliorate their social, economic and political condition and to accord them parity.

Gender has been described as a critical determinant of mental health and mental illness.[2] The Indian culture is unique. Joint family system, patriarchy, marriage a must, especially women; marriage is a sacrosanct union, permanent union; subservient status of daughter-in-laws at home, preference for the male child, practice of dowry, lower educational status of women, strict code of conduct for females, and primary roles of women being childbearing and child rearing, and the “Indian Paradox” (the married woman with severe mental illness, subjected to domestic violence (DV) makes frantic efforts for restitution of conjugal rights rather than for separation or divorce), are all part of the Indian culture.[3,4] These factors significantly affect the occurrence, manifestations, treatment, and outcome of mental disorders in women of India. Thus women mental health can be conceptualized as having a wide range of related areas, including reproductive health, psychopharmacology, psychosocial determinants of mental health, and legal issues. However, traditionally, women mental health is conceived in terms of reproductive health, other areas have received little attention.

The Indian Psychiatric Society was formed in January 07, 1947. The first paper,[5] with a special focus on women's health, appeared in 1969 on the causal factors of puerperal psychosis. Women in the younger age group, coming from rural areas and from lower or lower middle-class income group, and usually in their first or second para were most prone to develop puerperal psychosis. A manual search of articles published in the Indian Journal of Psychiatry since its inception found 2 presidential addresses, the first on “Women and mental health”[6] and the other on “Marriage, mental health and Indian legislation;”[7] one editorial;[8] 9 original papers, 4 case reports, and one oration on “Interface between psychiatry and women's reproductive and sexual health,”[9] that have discussed exclusively women related issues.[1] From 2009 until date, there have been 16 publications on women mental health: 1 presidential address, 1 book review, 2 editorials, 2 letters to the editor, 4 research papers, and 6 review articles. Of these, 10 (62%) have focused on violence against women. These include the presidential address on “Violence against women: Where are the solutions?”[4] 2 guest editorials (“Sexual coercion: Time to rise to the challenge” and “Sexual abuse in women with special reference to children: Barriers, boundaries, and beyond”), 3 review articles and 2 research papers and 2 letters to the editor.

A review of the research on issues specific to women published mainly in the Indian Journal of Psychiatry reported that Indian Psychiatrists have worked in a wide range of areas, including psychological aspects of different reproductive phases: Pregnancy, puerperium, menopause, menstrual cycle, psychological consequences of contraception, infertility and surgical loss of uterus or breast; suicide, relationship between DV and mental health, suicidal behavior, and epidemiological trends.[1]

Gender differences have been reported mainly in the prevalence of common mental disorders, including depression, anxiety and somatoform disorders.[10,11] Depression is not only the most common women's mental health problem, but may be more persistent in women than men. Most important is the finding that the higher rates of depression, anxiety and somatic symptoms are related to a range of risk factors such as gender-based roles, stressors, negative life experiences and events.[1]

For common mental disorders, the gender-specific risk factors that disproportionately affect women included gender-based violence, socioeconomic disadvantage, low income and income inequality, low or subordinate social status and rank, and unremitting responsibility for the care of others.[10,12] Women are often exposed to sexual violence, which leads to high rates of posttraumatic stress disorder (PTSD). A better course and outcome of schizophrenia in women, compared to men has been reported.[13]

A few Indian studies have explored sexual dysfunction. One study reported on frigidity,[14] another study reported on marital and sexual dysfunctions (vaginismus, dyspareunia, and lack of sexual desire) in women attending a special clinic.[15] A postal survey of English-speaking women from a south Indian town found orgasmic difficulties in 28.6% females. More than 40% females reported to have never masturbated.[16] Avasthi et al.[17] reported difficulties in women during sexual activities in 17% women, which were not significant enough to demand thorough clinical assessment. Another cross-sectional study of sexual dysfunction in married women was carried out in a Tertiary Care Centre.[18] There is only one study on “Dhat syndrome” (a culture-bound syndrome), in women published in Indian Journal of Psychiatry.[19] This area remains largely unexplored.

The Presidents of the Indian Psychiatric Society, in the last 5 years played a pivotal role in furthering work on issues relating to women. Past President Dr. E. Mohan Das, was acutely aware that women mental health was an important and neglected area, so he created a “Task Force of Women Mental Health” in 2009. The task force was entrusted with the responsibility of: (1) bringing out an update on women mental health, with special reference to the Indian scenario, (2) to formulate guidelines for the pharmacological treatment of psychiatric disorders during pregnancy and puerperium, (3) and to carry out activities on different aspects of women's mental health. The book Women Mental Health 2009[20] was released by the President Dr. E. Mohan Das at the continuing medical education program on women mental health at Varanasi. The next President, Dr. Ajit Avasthi, gave a boost to the ongoing work by creating a “Committee on Women Mental Health.” The practice guidelines, “Treatment of psychiatric disorders in women during pregnancy and lactation: Recommendations for Psychiatrists in India”[21] were published.

During the same year, there was a growing realization among psychiatric colleagues of the clinical, social and ethical dilemmas confronting clinicians while managing various issues relating to marriage in women with mental illness. Being a woman, having a severe mental illness and then getting married, constitutes a “triple tragedy.”[3] There was a felt need to develop guidelines relating to marriage for women with mental illness. The then President, Dr. M. Thirunavikarasu formed a core committee comprising 16 members, including two legal representatives (Principal Judge Family Court, Chennai, and additional district and sessions judge, Fast Track Court, Vizianagaram district), members of specialty sections of Forensic Psychiatry and Women Mental Health, and past President Dr. Siva Nambi to complete the task. However, as the topic involved many sensitive issues, there was no consensus. One objection was, “Why guidelines for only women, why not for men as well?” The other objection was to restrict to women with severe mental illness. Thus, during the tenure of the next President Dr. Roy A. Kallivayalil, the specialty sections on Forensic Psychiatry and Women Mental Health brought out the “Recommendations for psychiatrists for managing issues relating to marriage in patients with major mental disorders.[22] During the following year, the President Dr. Indira Sharma was instrumental in bringing out two position statements, “Marriage and law,”’ and “Violence against Women.” This supplement on “women mental health: Reflections from India,” is also a step in the same direction.

It is clear that in the recent past there has been a resurgence of interest in women mental health in the country. Research on violence against women has figured prominently in the recent past. Although some areas have been covered, many more deserve attention. For example multiple-perpetrator DV in married women with severe mental illness, cyber violence against women, stalking, marriage-related laws and mental illness, Indian legislation and gender specificity, female sexuality, surrogacy, psychosocial determinants of mental health in women, etc.

There have been a few stumbling blocks in the pathway to research on women mental health. There has been a tendency to consider women mental health as an exclusively women's domain because it is still largely perceived as reproductive health. Thus only female professionals are expected to work in this area, but many of them would be reluctant to do so unless they are backed up by their male professional colleagues as they would not like to be marginalized.

Many male professionals may avoid work in sensitive areas like psychiatric aspects of DV, dowry, rape, etc. The Dowry Prohibition Act, 1961, 498A IPC (of cruelty by husbands and relatives of husband) and the Protection of women from DV Act, 2005, were enacted to protect women from discrimination and violence at home. However, their abuse has been widely reported, especially when the wife has a severe mental illness. Women attempt to save their marriage, by implicating husbands and in-laws under these laws. It is stated that there have been many more deaths because of the abuse of these laws than the reported dowry deaths. Thus, these legislations have been viewed as “anti-men.” Dowry is often a nonissue as it was with mutual agreement. More work needs to done to study the social and legal issues of married women with severe mental illness.

Besides, there have been many more male psychiatrists in the country. Women psychiatrists constitute about 15% of the psychiatrists in India, of whom only 10% are at a senior level. The increasing number of women joining psychiatry is a relatively new phenomenon and similar to the trend in other countries.[23] Thus, there is a high probability that the research findings are likely to be skewed in favor of men.

The research on DV against women, has been largely “victim focused” (e.g., study of risk factors in women), rather than “perpetrator-focused,” even though intervention strategies are likely to more effective if they are “perpetrator-focused” because the perpetrator is the active participant in DV.

In research on women, there has been a tendency to explore and highlight the special stresses/weaknesses of women. The same exercise has not been done for men. For example, high degree of dependency of Indian husbands on their wives for food, home keeping and child rearing; because they are not apt in these activities, can be taken as a weakness, and a risk factor for perpetrating violence against wives. Going further it may be argued that making men proficient in domestic chores could significantly decrease the incidence of DV within households. This needs to be studied.

In the same line, it can be said that research findings on reproductive mental health are likely to have a male bias. A reproductive subtype of depression occurring during time periods associated with hormonal change (premenstrual, postpartum and perimenopause) has been described. Alternative explanations have not been sufficiently explored. Poverty and malnutrition may have a direct link in causing depression during pregnancy and the postpartum period, especially in a developing country like India.[24] Else, the diagnosis of depression itself should be debated as a normal reaction to physiological stress (pregnancy and postpartum), which may be particularly high in women with adverse life situations. Indian authors studying relationships between intimate partner violence (IPV) and depression and PTSD among pregnant women, observed a strong relationship between IPV, especially sexual violence, and psychiatric morbidity (depression, somatic and PTSD symptoms). It is noteworthy that the experience of IPV and its mental consequences are quite common in India. In this country, gender disparities are normative, and pregnancy is a particularly vulnerable period.[25] It follows that more work is needed on the nosological status of mental disorders (depression, anxiety disorders and somatoform disorders) during the physiological phases of a woman's life cycle.

In the ensuing years, with changing gender roles, technological advancements, affluence and globalization, there are likely to be many more challenges for both men and women. It must be understood that women's mental health and men's mental health are complimentary. A balanced approach is needed. Mental health professionals of both sexes should work to meet the challenge.