About Time We Stop Sweeping it Under the Carpet – The Effects of Psychological Abuse on Endocrine Conditions in Women in India

Women differ from men in many aspects of endocrinology including the physiology of hormones and incidence of endocrine disorders as well as their complications.[1,2] The non-biological and circumstantial factors influencing the development and management of endocrine disorders in women are less well studied. Intimate partner violence is one of the many environmental factors that significantly affect the risks, manifestations, severity and complications of health conditions in women. Estimates from the fourth National Family Health Survey (NFHS 4) revealed that nearly 30% of Indian women experience intimate partner violence in their lifetime.[3] Women are more likely to have suffered long durations of abuse before seeking help.[4] There is some evidence that women experience more frequent and severe intimate partner violence than men, although this may need further studies for substantiation.[5-7] Domestic violence or intimate partner violence includes physical, sexual, emotional, verbal and psychological abuse. Humiliation, control, isolation and neglect are forms of abuse that are less recognised because of normalisation of such behaviour in the patriarchal Indian society. The estimated lifetime prevalence of psychological abuse in Indian women is 22%.[8,9] A systematic review of studies on domestic violence in India concluded that there exists a gap in research on the effects of abuse on physical health.[9] One afternoon, I was called in to the medicine ward to see a woman who had recovered from adrenal crisis and severe hyperkalaemia. She had been diagnosed with primary adrenal insufficiency a few weeks earlier and had missed her steroid doses for 3 days. I began to speak with the woman about her symptoms and as her story unfolded, the husband cut her off bluntly, complaining to me about how much he had spent on skin products to get her to become her fairer-complexioned old self. He took on the victim’s role there, completely sidelining his wife’s suffering. I was shocked, but my disbelief quickly turned into disgust for the husband as I learnt from the lady that he was constantly humiliating her for turning dark complexioned and not ‘matching up’ to his looks anymore. He had stopped her from going to work saying that it was possibly one of the reasons for her condition. She was working as a salesperson in a cloth store and was in tears when she told me she missed her job so much as that was the only place where she felt respected. The obsession with fair skin is sadly not new to Indian culture.[10] A 28-year-old woman came to see me in the out-patient clinic recently. She was accompanied by her elderly parents. She had been applying topical creams containing steroids for generalised psoriasis for more than 2 years. She wanted me to examine her, but hung her head in shame as I did. To say it was a grotesque sight would be an understatement! Her skin was sagging with Cushingoid striae all over her chest, arms, abdomen and thighs. She then dressed herself and sank into the chair weeping bitterly. When I asked her gently about her agony, she said her husband had given her a ‘deadline’ of 1 year to transform herself into her previous self and turn into the beautiful wife she once was, else he would leave her! I learnt that her parents were not well to do and had married her off early. She was uneducated and unemployed. I felt numb and helpless at her desperation as she pleaded me to make her ‘beautiful’ again, lest her husband abandoned her. This ugly mentality of the husband got me wondering, ‘what do people think is real beauty?’ A 36-year-old woman visited me with her husband one day. When I asked her what was bothering her, her husband began to speak as she looked at him nervously. He began lamenting his childlessness ‘all because of his wife’ who was diagnosed with diabetes and infertility. The woman could not hold back her tears while I requested the man to leave the room so that I could have a few words with his wife in privacy. He left my consultation room in a huff, slamming the door after him. I was disturbed by his self-absorbed attitude and absolute lack of sensitivity towards his wife’s suffering. I remember bitterly a 26-year-old woman diagnosed with type 2 diabetes early in her pregnancy who came to my out-patient clinic with a hope of doing away with medication. She had been hiding her diagnosis from her husband and in-laws and would sneak into the bathroom to take her insulin shots. In a couple of weeks, she came to me in a state of panic. Upon calming her down and enquiring, she spilled the beans about her being disowned by her husband once he learnt she had diabetes. She had been living with her parents who were short of money to pay off her bills and were compelling her to go back. Similarly, women with type 1 diabetes have greater challenges since they are on insulin since diagnosis. They may conceal the diagnosis and take insulin in secrecy for fear of being rejected by members of their marital homes. Inability to administer insulin and skipping doses in such patients may prove disastrous and fatal due to complications such as diabetic ketoacidosis. A 23-year-old unmarried woman with type 1 diabetes did not want her diagnosis on record because she feared she would not be accepted as a suitable bride due to her disease. I recall a few years ago, a healthy woman with an uneventful pregnancy who developed Graves’ disease 9 months postpartum. Although it seemed like an expected risk period for the disease, a deeper look into the history revealed severe psychological distress due to long-standing abuse faced by the woman, which reached a crescendo post-delivery. She was left to care for the baby all by herself during day and was humiliated by the husband every evening when he returned. He would criticise her ways of childcare, body shame her and mock her ignorance about certain matters. She was gradually isolated from her family and friends and prevented from returning to work. She lost significant weight and developed florid features of hyperthyroidism. She begged him repeatedly for a visit to the doctor, which he would disregard, until one day when she ventured out with her baby to seek help on her own. Many a time in the patriarchal Indian society, a husband who genuinely wants to help the wife may restrain himself due to fear of being labelled by his family members as taking sides or leaning towards his spouse. In addition, it must be noted that spouse abuse itself is not restricted to one gender. A number of men are victims of psychological abuse at the hands of their wives, and prevalence seems to be rising.[11] This may not come to light due to social reasons or lack of reporting.[12] Transgenders are not exempt from violence either. Well, this is not an exhaustive list of all the women I have come across, who have suffered emotional abuse and lack of support from their spouse for managing their endocrine condition. It is obvious that the emotional turmoil can have a definitive negative effect on the disease as well as its treatment. Many endocrine conditions carry with them their psychological and emotional effects on the person, in addition to the physical symptoms. These may include anxiety, social stigma of the diagnosis and depression. Such symptoms may be magnified by lack of support and abuse by the spouse. In a survey among women with polycystic ovarian syndrome in India and the UK and the effects of the condition on emotional and psychological well-being, women born in India were found to have higher rates of anxiety and depression compared to those born in the UK.[13] Intimate partner violence may further affect the emotional well-being of these women. Women who are exposed to violence are at higher risk for developing metabolic syndrome and cardiovascular disease as a consequence of the proinflammatory state triggered by sleep disturbance, hostility and depression.[14] It is well known that Graves’ disease may be precipitated by emotional stress.[15] Recently, there has been an emphasis on the psychological well-being of patients with diabetes as it may affect achievement of optimal glycaemic control.[16-18] However, healthcare professionals are not routinely taught how to approach the psychological aspects affecting the management of endocrine conditions. In a study on physicians’ opinions about abuse victims, at least one-third of them held victim-blaming attitudes and more than two thirds felt they lacked resources to assist these patients.[19] Physicians’ response to the psychological aspects of patient care may be limited by time, lack of knowledge, fearing ‘opening of a pandora’s box’ with initiation of such a discussion as well as cultural barriers.[20] However, many times, the healthcare professional may be the only support system for patients, and recognising as well as validating the victim’s experience and attempting to find practical solutions may go a long way in ensuring better management of the patient’s health condition. Guiding a victim and referring her to a mental health specialist would help her manage her situation better. Some physicians may make genuine attempts at catering to the psychological needs of the patient, although they are usually not trained in these aspects. Too often than not, it is assumed that the psychological domain of disease is completely the responsibility of the mental health professional and little care is taken to look into any such factors affecting the course of the disease or its management. It is important to acknowledge the importance of this role of healthcare professionals in the holistic management of patients. Basic training in management of the psychological and emotional aspects affecting the manifestations of endocrine diseases as well as the treatment of these patients would improve compliance, follow-up, prognosis and results of therapy. Inclusion of this domain of treatment of endocrine conditions in guidelines and policies would make holistic management achievable. Author contributions SB is responsible for conceptualisation, preparation of manuscript and reviewing. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence AI not used.