|Year : 2021 | Volume
| Issue : 2 | Page : 278-284
Female Dhat syndrome in primary care setting
Aseem Mehra1, Soundappan Kathirvel2, Shalini Gainder3, Ajit Avasthi1, Sandeep Grover1
1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Community Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||26-Apr-2020|
|Date of Acceptance||10-Jun-2021|
|Date of Web Publication||19-Aug-2021|
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The study aimed to evaluate the females presenting with the complaint of nonpathological vaginal discharge to a general gynecology outpatient service in a rural community clinic from the perspective of female Dhat syndrome. Methodology: Sixty-nine females considered to have nonpathological vaginal discharge after detailed gynecological evaluation, including required investigations, attending a rural community clinic were assessed for their belief about the vaginal discharge. The study subjects were also evaluated on the proposed criteria of female Dhat syndrome by using a semi-structured interview. Results: The mean age of onset of vaginal discharge was 36.1 (standard deviation - 8.5) years. Most of the females considered the loss of vaginal fluid as loss of a vital fluid from the body. Consumption of warm foods and drinks (75.8%) was the most common reason reported for vaginal discharge followed by eating unbalanced food/inappropriate food (73.5%). A majorty of the subjects considered vaginal discharge responsible for bodily weakness (87.0%), backache (71.0%) and stomache (66.7%). About two-third of the participants considered the taking energizing medications like vitamins/tonics/tablets and treatment from a gynecologist the treatment for vaginal discharge. Conclusions: Significant proportion of females with non-pathological vaginal discharge have a belief that they are losing a vital fluid of the body. The subject attributes their symptoms to factors such as consumption of warm foods and drinks, and eating unbalanced food/inappropriate food. Accordingly, assessment and management of women with Dhat syndrome require addressing these important issues.
Keywords: Female Dhat syndrome, nonpathological, vaginal discharge
|How to cite this article:|
Mehra A, Kathirvel S, Gainder S, Avasthi A, Grover S. Female Dhat syndrome in primary care setting. Ind Psychiatry J 2021;30:278-84
Dhat syndrome as a disorder is usually reported in males. However, there are few reports of a female equivalent of Dhat syndrome.,,,,,,,,,,, The passage of vaginal discharge in females was equated with discharge of semen for the first time in 1988. Chaturvedi described this entity as “psychasthenic syndrome associated with leucorrhea.” In a clinic-based study, the authors found that a more than half of the female patients (majority presented with somatic symptoms) and 13% of the healthy female had a belief that passing nonpathological whitish discharge per vagina is harmful to their health. In an ethnographic study from Uttaranchal, the authors evaluated females who presented with a concern of genital secretion and found an association of vague somatic symptoms such as burning head, dizziness, headache, backache, and progressive generalized weakness with genital secretions. The women labeled the genital secretion as “safedpaani,” “dhatu,” or “swedpradhar.” The women considered the “safedpaani” as the vital fluid of the body equivalent to Dhatu in males. On evaluation, these females usually did not have evidence of infection and in terms of quantity, the quantity of discharge was similar to normal physiological discharge. Few other ethnographic studies have also reported similar profile. [5,6] Other studies from different parts of the country have reported the association of leucorrhoea with somatic manifestations.,,,,,In some of these studies, patients attributed their symptom of vaginal discharge to stress and emotional factors, excess heat in the body, infection, consumption of hot and spicy foods, and effect of warm weather.,,,,,
In view of lack of specific criteria for female Dhat Syndrome, recently authors tried to propose the criteria for female Dhat syndrome. Till recently, although studies reported female equivalent of Dhat syndrome, no specific instrument was available to assess various dimensions of female Dhat Syndrome. Few years back, Dhat syndrome Questionnaire, developed for the assessment of Dhat syndrome in males was modified to assess the female equivalent of the disorder. This instrument was named as Scale for Assessment of Female Dhat syndrome (SAFeD). However, this study was conducted in a tertiary care hospital in the psychiatric outpatient setting.
Only limited information is available for rural females, with respect to the nonpathological vaginal discharge. A study from north India, in a house to house survey reported vaginal discharge in 28.7% of females. Majority of these patients reported somatic symptoms and attributed the vaginal discharge to health, melting of bones, sexual promiscuity, poor hygiene, and diet. However, this information was collected using open-ended questions rather than using a structured instrument. Accordingly, there is a need to understand nonpathological vaginal discharge in females from rural background, from the perspective of female Dhat syndrome. Accordingly, this study aimed to evaluate the females presenting with the complaint of nonpathological vaginal discharge to a general gynecology outpatient service in a rural community clinic from the perspective of female Dhat syndrome.
| Methodology|| |
The study was approved by the Institute ethic committee.
The study was carried out at the Gynecology outpatient service in a rural community clinician a Sub-District Hospital, which falls in the catchment area of Community Clinic of Department of Community Medicine of Postgraduate Institute of Medical Education and Research, Chandigarh. The town has a total population of approximately 23,000, with male literacy of 79.6% and female literacy of 73.4%. For this study, all the females (aged ≥18 years), free from any diagnosed psychiatric illness, able to understand colloquial/Hindi or Punjabi language, and those who provided the written informed consent for the participation in the study were recruited. In addition, participants were required to have vaginal discharge, which could be attributed to any infective pathology. For this, all the patients presenting with vaginal discharge were initially evaluated by a gynecologist and underwent investigations to rule out common bacterial, parasitic or fungal infections. Those who were found to have nonpathological vaginal discharge were approached for further evaluation for their belief about the vaginal discharge. Those who provided the consent were assessed at the rural health clinic by the trained Gynecologists well versed with the local language, dialect, traditions, and customs. The study sample comprised 69 patients. Patients were also evaluated on the proposed criteria of female Dhat syndrome using a semi-structured interview.
These patients were evaluated on SAFED. SAFED assesses the various aspects of Dhat syndrome. The elements covered by the questionnaire include frequency, consistency, color, and quantity of discharge; situations in which patient has the discharge, patients beliefs about the composition of discharge, reasons for passage of discharge; consequences of excessive discharge; accompanying somatic, anxiety, and depressive symptoms; comorbid sexual dysfunction and beliefs about help-seeking and treatment.
Statistical analysis was done using the Statistical Package for Social Sciences, Sixteenth version (SPSS-16) (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). For categorical variables, the frequencies with percentages were calculated. For the continuous variables, the mean and standard deviation (SD) were calculated.
| Results|| |
The mean age of the study sample was 36.1 (SD - 8.5) years and the mean number of years of education was 8.6 (4.1). Majority of the participants hailed from extended/joint family (60.9%) and lower/middle socio-economic status (88.4%) and were Hindu (88.4%) by religion.
Participants started having the vaginal discharge at the mean age of 30.4 (SD −8.9) years, and the participants were symptomatic for a mean duration of 5.4 (SD - 4.5) years at the time of assessment.
The details of the passage of Dhat are shown in [Table 1], [Table 2], [Table 3].
|Table 2: Situations in which there is passage of Dhat and reason for passage of white discharge/Dhat|
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Associated psychological and somatic symptoms
The presence of vaginal discharge was associated with various psychological and somatic symptoms [Table 4].
|Table 4: Psychological symptoms accompanying white discharge/Dhat syndrome (present in last 2 weeks)|
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Help-seeking and treatment-related beliefs
Majority of the participants believed that there is a need for an investigation to understand the cause of vaginal discharge [Table 5].
| Discussion|| |
The current study aimed to evaluate symptoms and causation of passing nonpathological vaginal discharge among female patients to examine the existence of female Dhat syndrome. Nonpathological vaginal discharge has been referred to as a medium of communication about health issues, particularly sexuality, social distress or psychological problems.,, Hence, it can be considered that reporting of vaginal discharge in females may have deep cultural meaning.
In the present study, about three-fourth reported the wetness in the vagina along with need to undergarments or change clothes. This finding is almost similar to the previous study conducted among the patient with psychiatric illness evaluated vaginal discharge. In terms of consistency, majority of the participants reported it to be like milky discharge, which is also reported in the earlier studies too.,,,, Majority of the patients in the present study reported that vaginal discharge is made up of vital fluid of the body. Existing studies have also reported similar findings. [12,15] Ayurvedic beliefs consider “Dhatu” as the most refined element of the body, which is considered to “tone” and “energize” the body. As per the anthropologist, Dhatu leaves the woman's body as a whitish, odourless discharge which is often associated with “heaty” symptoms such as burning hands and feet, dizziness, and joint pain. Findings of the present study are also in consonance with these beliefs.
In the present study, most of the participants reported vaginal discharge occurred irrespective of any specified situation. A significant proportion of patients also experienced vaginal discharge in other situations, too, such as, while passing urine, while feeling pressure or strain on the abdomen, during menstruation, just before and after menstruation, and at the experience of sex-related dreams. These findings are in similar lines, with the previous study based on the same instrument or those studies which have evaluated the concept by using different methods. [6,17] These findings suggest the existence of the concept across different treatment setting and hence, the nosological system should recognise the existence of the same. This can help in further research on the topic.
In terms of the reasons for passage of vaginal discharge, the participants reported the reasons such as consumption of warm foods and drinks, high energy food, eating unbalanced food/inappropriate food, urinary/vaginal infection or problems of the urinary tract. The previous studies which have evaluated the causes have also documented factors like consumption of food items which produce heat or which are warm, stress and emotional factors, excess heat in the body, infection, hot and spicy foods and hot weather, backache, the operation for family planning, having too many children, physical and sexual violence etc.,,Ayurvedic textbook reports that nonpathological discharge occurred because of excess humoral heat in the body and advocate the avoidance of “heaty” foods such as ghee, eggs, or meat. The cultural explanation for these symptoms might be the reason for these responses.
The most frequent consequences of passage of vaginal discharge are in similar lines with the existing literature,,,,and suggest that females who present with symptoms of weakness in the body, weakness in stamina, pain in genitals, and irritability before and after menstruation, menstrual disturbances, pain in genitals during sex, mental illness, weakness in sexual ability, loss of beauty of face and body and loss of sexual desire, should be evaluated for nonpathological causes and associated psychological and mental symptoms, which can have a bidirectional relationship with each other.,,,,
The associated psychological and somatic symptoms profile in the index study is almost similar as seen in the previous studies in females with vaginal discharge.,,,,, These findings suggest that unexplained gynecological symptoms may represent a somatic idiom of psychological distress.
Like the previous study, based on the same questionnaire, with regards to the treatment expectations, about two-third believed that symptoms of vaginal discharge could be relieved by taking energizing medications like vitamins/tonics/tablets. Other measures considered the beneficial effect of change in food, by taking energising injections, treatment from a gynaecologist, and consultation and discussion with a doctor. These explanations could be understood in a way that woman with vaginal discharge would be treated with multivitamins, iron, and advice on a nutritious diet, personal hygiene, and rest.
Limitation of the study
This was a cross-sectional study. The sample size although is larger than most of the earlier studies, which have evaluated the females with nonpathological vaginal discharge, the sample size can still be considered as small. The patients were not evaluated for comorbid psychiatric diagnosis. The confounding factors such as sexual violence, attitude, and knowledge toward the sex were not included.
| Conclusions|| |
The present study suggests that a significant proportion of females presenting with nonpathological vaginal discharge believe that they are losing a vital fluid of the body. These symptoms occur in the context of adverse psychosocial stressors and manifest with many somatic and psychological symptoms. These patients usually attribute their symptoms to cultural factors like consumption of warm foods and drinks, eating unbalanced food/inappropriate food, consumption of high energy foods, and urinary/vaginal infection or problems of urinary tract. The management requires addressing these issues. Accordingly, there is a need to develop intervention package or module to address females with nonpathological vaginal discharge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]