Embodied distress in reproductive psychiatry

Howard et al's paper1 highlights the complex interplay between social, cultural, physiological and hormonal factors that influence women's mental health in the context of reproductive psychiatry. Reproductive conditions are not just bodily states. For most women, they are deeply connected with their perception of self, and strongly interlinked with social and cultural expectations of womanhood, roles and identity. The term “embodiment” refers to the daily experience of both having and being a body2. Several gynecological conditions may lead to embodied distress, disrupting intimate interpersonal relationships, motherhood and social life, and contributing to poor quality of life. Up to a third of women presenting to gynecological services have pelvic pain3. Vulvodynia, dysmenorrhea and endometriosis are the commonest conditions involved. Most women, however, do not report gynecological pain, especially dysmenorrhea, as they believe (often due to social conditioning) that pain is part and parcel of being a woman and having menstrual periods. This often leads to delay in diagnosis. The average delay between the start of symptoms and the diagnosis of endometriosis is 7.5 years, while other chronic inflammatory diseases such as rheumatoid arthritis are diagnosed much sooner, even though they have similar economic and societal costs. In 2018, “What is endometriosis?” was the third most trending health-related question on Google. However, it is common for women living with this condition to experience dismissal associated with gendered medical discrimination around chronic pain, especially that linked to menstruation. Qualitative research among women with endometriosis often captures the nature of the embodied distress4. These women talk about not feeling like themselves, experiencing reactions from the medical and social environment which prompt feelings that they are “going mad”, and perceiving that they are a burden to their loved ones, which often results in self-silencing. The most common words and themes which appear when endometriosis is described in health care contexts refer to symptoms (fatigue, pain, cramps, heavy bleeding); temporality (time, years, always); actors (doctors, medical systems); challenges (struggle, trying, work); and body (organs). As health professionals, if we are to fully understand the experience of this and other chronic painful gynecological conditions, we have to pay attention to their individual, structural and systemic aspects. We often talk about diagnostic overshadowing, which occurs when health care professionals misattribute a person's physical symptoms to his/her existing mental illness. This misattribution increases the likelihood of delays in treatment, potentially giving rise to complications that further negatively influence health outcomes. In conditions such as dysmenorrhoea and endometriosis, the opposite kind of diagnostic overshadowing often takes place. Women's psychological and social distress related to these conditions is seldom recognized or addressed, being overshadowed by the physical distress. Vulvodynia and painful sex (dyspareunia) are two conditions even more shrouded in silence, as women often feel ashamed to discuss them, viewing them as personal failure5. Many professionals again do not seem to recognize the severity of the problem or its impact on self-worth, self-image and relationships. The term “epistemological purgatory” has been used6, referring to a liminal space where women are caught regarding their own lived experience and embodied knowledge about these painful conditions as opposed to expert knowledge. Howard et al discuss the toll that infertility takes on women's mental health. In conditions such as vulvodynia or endometriosis, which may also lead to infertility, the pressure actually seems to often be on conception rather than on symptom control. Any pain in the pelvic region is often normalized7. For many years, conditions such as vulvodynia were considered to be of psychological origin. Even now, it is not unusual for women with vulvodynia or dyspareunia to be told that their pain is just of a psychological nature, thus preventing any investigation or recognition of the symptom. This is a paradox, because on the one hand vulvodynia and dysmenorrhoea may be mistakenly attributed to psychological reasons, and on the other the psychological consequences of these conditions may not be recognized. Both these approaches in the health care system may increase the embodied distress faced by women. This is also reflected in the constant back and forth on how these disorders are placed in our classificatory systems. Until recently, sexual pain disorders were considered as female sexual dysfunctions. Following much advocacy by patient groups and professional societies, the ICD-11 has now classified them under genitourinary pain disorders. Appropriate treatment, attitudes of health professionals and research funding are often determined by where conditions are located in classificatory systems. How this change in the ICD-11 will influence a better understanding of these disorders remains to be seen. Another major issue that is rarely addressed in reproductive health is the impact of stigma and taboos related to menstruation on women's mental health. While studies on premenstrual dysphoria are many, the social and cultural aspects of menstruation have been largely neglected. Howard et al refer to the concept of “period poverty”, defined as poor access to sanitary products during menstruation, which is known to impact women's mental health even in countries such as the US. In low- and middle-income countries, in addition to period poverty, there is often also water and sanitation insecurity. Research from the WASH (water, sanitation and hygiene) sector has emphasized that limited sanitation and lack of water during menstruation have a negative impact on women's mental health8. In many societies, there is still taboo, shame and embarrassment associated with women being impure and polluting the environment during their periods. Studies from several parts of the world have found that women often report humiliation, shame and worry, as well as a perceived loss of dignity, related to water and sanitation insecurity during periods. These concerns are also commonly expressed by women who are homeless and those in disaster and conflict situations. Socially acceptable norms around dignified behavior, purity and cleanliness during menstruation may in the above situations clash with availability of resources. Period and sanitation poverty may well be a gendered risk factor for poor mental health in many communities. It is, therefore, important to move away from a purely biomedical model of premenstrual and menstrual distress to one that also addresses cultural, socioeconomic and environmental conditions. Finally, one cannot ignore the role of culture and bodily idioms of distress related to reproductive mental health9. For instance, women in South Asian cultures often use vaginal discharge as an idiom of expressing psychological distress, including depression. Studies have also found an association between partner violence and report of gynecological symptoms in these cultures. As psychiatrists, we must be alert to such bodily expressions of emotional distress, and educate primary care health providers to the adequate recognition of common mental disorders in women even though they might report mainly reproductive symptoms. In conclusion, reproductive psychiatry involves a careful understanding of the meaning of pain, bodily distress and the impact of various gynecological conditions on a woman's identity and interpersonal relationships. These vary across cultures and have different expressions and relevance at different stages of a woman's reproductive life.