Female Dhat Syndrome : A Condition Beyond Just Vaginal Discharge Deblina Roy Program Officer, Khamdih, Raipur, Chattisgarh, India

ABSTRACT ‘Dhat Syndrome’ is one of the most important and well known culture bound syndromes among men, but the same semen loss can be attributed to vaginal discharge among women. This problem mainly presents with the symptoms of excessive vaginal discharge (often colourless and mucoid) with the complaints of chronic fatigue and loss of will to do work affecting the person psychologicaly, economically , physically leading to increased unnecessary burden on the health related expenses. These symptoms often are misdiagnosed as Sexually Transmitted Disease or Reproductive Tract Infection and lead to inappropriate treatment by the provider. Thus the symptoms of vaginal discharge, chronic fatigue, loss of will to work and vague pain symptoms should be carefully evaluated clinically and psychologically for the appropriate diagnosis and treatment.

KEYWORDS: Dhat Syndrome , Vaginal discharge, Culture bound syndrome, Women, Anxiety INTRODUCTION ‘Dhat Syndrome’ essentially described as a culture bound syndrome, among males of adolescent to adulthood involving semen loss anxiety, but the entity however described in various case studies is quite common among females. In females it is associated with the personal perception of normal vaginal discharge perceived in an inappropriate manner. The features are commonly associated with complaints of weakness, loss of interest in daily household works, and associated anxiety. Dhat Syndrome in women is often called as Leukorrhoea. MAGNITUDE OF THE PROBLEM

Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care & Hospital,Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India Email: [email protected], Website: www.iisb.org 16 HISTORICAL ASPECTS women is consistent [6,7]. The Vedic concept regarding the various After the further purification of the ‘Veerya’ bodily systems describe that the essence of the essence of ‘Oja’ or radiance is created at the body is created by seven essential the eighth stage and the ninth one is the fluids; inner mind or ‘Mana'. These concepts lead The first among these is ‘Rasa’or (Chyle) the women feel responsible for the which is created from the food we eat . The thinking that vaginal discharge leads to a wastes after utilizing the food products loss of radiance of the face among the excreted as feaces . So according to people who suffer. Similar thought process Ayurveda ‘Rasa’ is the purified form of is also found among the men with 'night food. Then it is furtur utilized to make emission' (spermatorrhea) or those ‘Rakta’ i.e. blood, this blood is further indulging in excessive . The utilized to make the ‘Maans’ i.e. (flesh) the preservation of the semen is often a Flesh in more purified form makes the common point pressured in the Indian ‘Meda’ i.e. Fat. Bone (asthi) is a better settings and is also related to 'radiance of purified form of the ‘Meda’. Then the the face' which leads to the emphasis on the ‘Asthi’ i.e. bone further specializes into conservation of semen [4]. Marrow (majja) at the end the most purified The Traditional Birth Attendants in North and essential component at the seventh India often make diagnosis of vaginal stage turns into Semen i.e. (Veerya) which discharge just by looking at the lusterless is believed to be the most precious fluid of faces of the women, a study reported [8]. the body [4]. Singh AJ in their study found that majority This concept leads to the understanding of the respondents in their study told that that the Rasa or the food is the crudest and vaginal discharge led to pallor (pale faces). sperm or Veerya is the most purified form of They also reported that women remarked the rasa and made at the end. that deficiency of blood was involved in the The Scriptures have also said that 100 etiology of the vaginal discharge, since for Drops of blood is required to create a single the affected woman in the affected women, drop of semen, which needs sackful of a blood product got lost i.e. vaginal nutrients and food items. Which led to the secretions, which led to the discolored faces common belief that the loss of few drops of of such women and progressive weakness this vital fluid means loosing a lot of scarce [9]. and important energy of the body which in turn leads to weakness [5] . This in case of Gynaecologists have given many woman is depicted as vaginal discharge ; explanations regarding possible causes of vaginal discharge (DHAT) has also been the vaginal discharge among woman of said to be a major cause of weakness. Other south east Asia , namely , poor personal studies also found that this belief among the hygiene, lack of good nutrition, excess

Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care & Hospital,Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India Email: [email protected], Website: www.iisb.org 17 physical exhaustion and anxiety in sexual or antibiotics, and also activities [9]. Women who had less finding occasionally administered infusion of in the physical examination were treated intravenous glucose, as a treatment that has with Ayurvedic medicines , multivitamins, acquired powerful indigenous meanings as ferus sulfate, and were adviced to have a cooling [4,6]. nutritious diet, proper rest and maintain WHILE CARING FOR A FEMALE personal hygiene. The gynaecologists DHAT SYNDROME would often speak to the woman's mother- South East Asia where, religions like Islam in-law, and spouse to ensure that woman and Buddhism and are common , must be provided with a better nutrition and the cultures are dominated with sexual more rest. This validated the woman's morality. Just like in case of Orthodox distress and without a specifc biomedical Judaism, and other sects of Christianity, diagnosis the Ayurveda practitioners masturbation, abortion , homosexuality and called this phenomenon as ‘Dhat rog’, and premarital sexual relationship are would say that it is because of excess considered as unacceptable. These humoral heat in the body. religious beliefs are deep rooted in the The common treatment given by non culture which bring about the symptoms of psychiatric practitioners, was Ayurvedic guilt and anxiety in the sufferer regarding remedies (Femiplex and Lukol were two their sexual desires , being health commonly prescribed tablets) and dietary p r o f e s s i o n a l s , n u r s e s a n d t h e i r advice, advocating the avoidance of `heaty' i n t e r v e n t i o n s m u s t b e t a r g e t e d foods such as ghee, eggs or meat. Village appropriately keeping in mind their cultural traditional birth attendants (Dais) are also and religious beliefs. The interventions if frequently consulted by women suffering done otherwise will bring about issues in from ‘safed panni’. The village Dais stated trust and distress among the client. that, women are concerned about ‘safed Sensitivity, compassion and respect for panni’ because from 100 drops of blood beliefs and values of the client different only one drop of ‘safed panni’ is formed from own has to be kept in mind for the best [8]. It’s loss is seen as a loss of a vital bodily quality interventions otherwise the problem fluid which is essential to health. The dais might not be addressed at all. encouraged the families to have dietary Sexual Disorders and knowledge of Co- modification, and prepare herbal remedies morbidity.: there has been various studies for women suffering from this condition. to asses the sexual knowledge among the Village based healers who had shop-front patients with Sexual disorders and it has clinics and practice a mixture of been found in those studies that knowledge biomedical, Ayurvedic and folk treatments. regarding the disorder is not been adequate. They usually treat women who complain of A retrospective study by Grover et,al. found vaginal discharge with Ayurvedic poor knowledge regarding sexual matters

Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care & Hospital,Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India Email: [email protected], Website: www.iisb.org 18 among patients suffering from ‘Dhat of the cases it was not linked with the RTI. syndrome’ (low SKAQ-II scores) [9]. The study also found the complaints of generalized weakness and decreased ability CO-MORBIDITIES IN FEMALES to perform house hold works [10]. WITH DHAT SYNDROME D I F F I C U LT Y I N D I A G N O S I N G There have been various case reports from FEMALE DHAT SYNDROME which we get an idea reading the varied The presentation of the women in these nature of the symptoms of the syndrome cases is majorly attributed to the occurrence and the diagnosis also does not fit a of vaginal discharge and most common particular biomedical entity. Some associated complaints would be, researchers have emphasized that the generalized weakness (99%), 98% reported patients are from depressive spectrum of that back ache is associated with the disorders, some on the psychosomatic secretion of Dhat. Studies also found that disorders group. The description of the women perceive the sufferers of female condition has variation in each case [9,10]. Dhat syndrome having Lusterless faces as There has been a study in which Dhat their precious body fluids are lost [10]. The syndrome among females has been symptomatic presentation of the disease depicted as a disorder that is mainly under varies in various parts of India but loss of the depressive spectrum of disorders. In an TREATMENT APPROACH RCT done in Goa found that 14% of the surveyed women complained of vaginal The literature says that the non- discharge and attributed stress as the main pathological vaginal discharge if causal factor for it. High amount of considered as STI or RTI due to comorbid mental illness was found among unavailability of the screening tests and them and a high degree of somatoform their expensiveness will lead to resistance disorders were found [9]. They also found t o c o m m o n a n t i b i o t i c s a n d t h e that the distress was more in the poorly stigmatization of the women , leading to educated women and with increasing age further distress [17,18]. i.e. <40 years, the symptoms were less The traditional approach to the treatment perceived compared to the younger age in the Indian context is very varied group. A mixed method study (Qualitative [19,20]. The risk factors for the complaint and Quantitative ) reported that women of abnormal vaginal discharge may vary who had issues with their husbands in terms according to the cultural setting of the of domestic violence, substance abuse, study. In the South Asian setting, there is a coerced sexual activity and lack of control dearth of studies and researches are over the contraceptives had reported the needed to be carried out so that symptoms of vaginal discharge 5 times appropriate evidence based algorithms more than the woman who did not have can be prepared for women with these psychosocial issues, and in majority complaints that are non-infectious in

Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care & Hospital,Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India Email: [email protected], Website: www.iisb.org 19 etiology and they are offered psychosocial care and disability associated with the interventions appropriately. There is a symptom [19]. When diagnostic tests are need for alternative approaches for the unavailable, it is recommended that all management of common gynaecological women with the complaints of vaginal issues and RTIs among women. The care discharge should be screened for should include the following points p s y c h o s o c i a l i s s u e s a n d s o t h a t  Psychosocial interventions that personalized and appropriate care for such target factors such as beliefs about problems can be rendered along with the illness syndromic approach to the treatment of  D e p r e s s i o n a n d s o m a t i c RTIs. preoccupations  Accurate diagnostic tests for CONCLUSION identification and specific treatment India and south East Asia is culturally a of RTIs sexually conservative society, and This will lead to the achievement the twin predominantly a patriarchal constituency, goals of RTI control and symptom where it is unacceptable for women to a l l e v i a t i o n . T h e h i g h l y s p e c i fi c have sexual desires and express identification and treatment of RTIs will themselves sexually, which inturn leads to lead to the RTI control and reduction in a deviated expression of stress which is symptoms, along with effective targeting communicated as the vague symptoms of of psychosocial aetiologies may tiredness and vaginal discharge namely significantly alleviate the symptoms and ‘Dhat Syndrome in females’ [21,22].Lack further reduced economic burden on health of knowledge regarding the sexuality, the

Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care & Hospital,Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India Email: [email protected], Website: www.iisb.org 20 restrains in the expression of sexual desires 4. Kar S, Sarkar S. Dhat syndrome: and strong hold of the religion makes it E v o l u t i o n o f c o n c e p t , c u r r e n t difficult for the women to accept their own understanding, and need of an integrated desires. There is no suitable and acceptable approach. Journal of Human Reproductive way in the Indian culture for expression of Sciences. 2015;8(3):130. the sexual desires, which leads to the 5. Trollope-Kumar K. Cultural and chronic repression. Whereas vaginal biomedical meanings of the complaint of discharge can commonly be attributed leukorrhea in South Asian women. Tropical somatically and becomes a largely and International Health. acceptable version among the lay 2001;6(4):260-266. 6. Bang R and Bang AT.Women's communities making it socially and perception of white vaginal discharge- religiously acceptable showcase able ethnographic data from rural Maharashtra. symptom which explains the phenomenon In. Listening to women talk about their of the problem [23,24]. Last but not the Health – Issues and evidence from India. least Dhat Syndrome in females would J.Gittleson et al (Eds.). New Delhi. require a comprehensive approach bio- HarAnand Publications 1994 pp 79-94. medically as well as psychosocial and 7. Patel BC, Barg S, Kolhe R and educational interventions to correctly Sadhwani H. Listening to women talk address the whole syndrome. about their reproductive health problems in REFERENCES the urban slums and rural areas of Baroda. 1. Brabin L, Gogate A, Gogate S, et In. Listening to women talk about their al. Reproductive tract infections, health - Issues and evidence from India. J. gynaecological morbidity and HIV Gittlesohn et al (Eds). New Delhi, Har- seroprevalence among women in Mumbai, Anand Publications 1994, 131-144pp. 8. Kakar D.N. Dais- the traditional India. Bulletin of the World Health birth attendants in village India. Delhi: Organization. 1998;76(3):277-287. 2. Hawkes, Sarah Jane (1999) The New Asian Publishers, 1980. 9. Singh A. Vaginal discharge: Its prevalence of reproductive tract infections causes and associated symptoms as in rural Bangladesh. London School of perceived by rural north Indian women. Hygiene &.Available Indian Journal of Community Medicine. fromhttp://researchonline.lshtm.ac.uk/174 2007;32(1):22. 2273. 10. Rajkumar R, Bharadwaj B. Dhat 3. Chaturvedi, S, Chandra, Prabha S. syndrome: Evidence for a depressive & K. Issac, Mohan &Sudarshan, C.Y.. spectrum subtype. Asian Journal of (1993).Somatization misattributed to non- [Internet]. 2014 [cited 21 pathological vaginal discharge. Journal of November 2017];9:57-60. Available from: Psychosomatic Research.37. 575- http://www.asianjournalofpsychiatry.com/ 579.10.1016/0022-3999(93)90051-G.

Indian Institute of Sexology Bhubaneswar Sanjita Maternity Care & Hospital,Plot No-1, Ekamra Marg, Unit-6, Bhubaneswar-751001, Odisha, India Email: [email protected], Website: www.iisb.org 21 article/S1876-2018(14)00035-5/fulltext. Psychosocial Distress Among Women in 11. Grover, S., Avasthi, A., Gupta, S., Urban Mumbai. Culture, Medicine, and Dan, A., Neogi, R., Behere, P., Lakdawala, Psychiatry. 2010;34(3):529-547. B., Tripathi, A., Chakraborty, K., Sinha, V., 17. Kar S, Singh A. Where lies the fault Bhatia, M., Patjoshi, A., Rao, T. and in diagnosing dhat syndrome among Rozatkar, A. (2015). Phenomenology and females? Understanding through a case beliefs of patients with Dhat syndrome: A study. Indian Journal of Psychological n a t i o n w i d e m u l t i c e n t r i c s t u d y. Medicine. 2017;39(4):506 International Journal of Social Psychiatry, 18. Grover, S., Avasthi, A., Gupta, S., 62(1), pp.57-66. Hazari, N. and Malhotra, N. (2016). Do 12. Grover, S., Gupta, S., Mehra, A. female patients with nonpathological and Avasthi, A. (2015). Comorbidity, vaginal discharge need the same evaluation knowledge and attitude towards sex among as for Dhat syndrome in males?. Indian patients with Dhat syndrome: A Journal of Psychiatry, 58(1), p.61 retrospective study. Asian Journal of 19. Singh A J. Vaginal discharge: Its Psychiatry, 17, pp.50-55. causes and associated symptoms as 13. Patel V, Pednekar S, Weiss H, perceived by rural north Indian women. Rodrigues M, Barros P, Nayak B et al. Why Indian J Community Med [serial online] do women complain of vaginal discharge? 2007 [cited 2018 Feb 6 ];32:22-26 A population survey of infectious and Available from: http://www.ijcm.org.in psychosocialrisk factors in a South Asian /text.asp?2007/32/1/22/53388 20. Trollope-Kumar K. Symptoms of community. International Journal of reproductive-tract infection—not all that Epidemiology. 2005;34(4):853-862. 14. Kristin K, Schensul L, Stephen, t h e y s e e m t o b e . L a n c e t Jadhav K, Singh R, Bavadekar A, Saggurti 1999;354:1745–46. 21. Srivastava D. Dhat Syndrome: An N. (2010)Treatment Seeking, Vaginal Overview. Global Journal For Research Discharge and Psychosocial Distress Analysis. 2012;3(7):235-236. Among Women in Urban Mumbai. 22. Grover S, Gupta S, Mehra A, Culture, medicine and psychiatry. 34. 529- Avasthi A. Comorbidity, knowledge and 47. 10.1007/s11013-010-9185-8. attitude towards sex among patients with 15. Rajkumar R, Bharadwaj B. Dhat Dhat syndrome: A retrospective study. syndrome: Evidence for a depressive Asian Journal of Psychiatry. 2015;17:50- spectrum subtype. Asian Journal of 55. Psychiatry [Internet]. 2014 [cited 21 23. Patel V, Oomman NM. Mental November 2017];9:57-60. Available from: health matters too: gynaecological http://www.asianjournalofpsychiatry.com/ morbidity and depression in South Asia. article/S1876-2018(14)00035-5/fulltext. Reprod Health Matters 1999;7:30–38. 16. Kostick K, Schensul S, Jadhav K, 24. Palai P., Singh AJ and Pillai V. Singh R, Bavadekar A, Saggurti N. Treating Vaginal Discharge in Slum Treatment Seeking, Vaginal Discharge and Women. Bull PGI, 1994; 28:107-1101.

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