IJE Advance Access originally published online on June 17, 2005
International Journal of Epidemiology 2005 34(4):862-863; doi:10.1093/ije/dyi128
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Commentary |
Commentary: Vaginal discharge and stress: a commentary on directions of influence
Population Council, Indian Habitat Centre, Lodi Road, New Delhi 110003, India
E-mail: shireen{at}pcindia.org
Patel et al.'s findings1 add to a small but growing body of evidence linking reproductive tract and psychological symptoms among women.2–5 The study, situated in Goa, India, goes beyond other studies in at least two significant ways. First, unlike earlier studies, it is based on a large sample of women drawn from a community rather than facility-based setting and hence reports on a more representative sample of the population. Second, the study incorporated an innovative and culturally sensitive set of questions that relate to psychosocial exposure as well as socio-demographic characteristics and reproductive tract infections/sexually transmitted infections (RTI/STI) symptoms. Patel et al., concluding that there is a powerful link between mental health risk factors and reported experience of vaginal discharge, question the rationale for syndromic management of vaginal discharge reports among women in India and argue for a more comprehensive syndromic management algorithm that takes psychosocial factors into account.
The direction of causality is difficult to attribute in cross-sectional studies linking reproductive tract disorders and psychological symptoms. Patel et al. argue that vaginal discharge may be a consequence of mental health risk factors and indeed some one-third of women in the study who had experienced discharge attributed it to stress and anxiety. However, authors remain somewhat vague in speculating on the pathways of influence in this relationship—why would stress and anxiety, for example, lead to the experience of vaginal discharge? And if the link cannot be decomposed, is there a possibility of other causal pathways, e.g. that psychological factors are a consequence of and not only a risk factor for vaginal discharge reports or that both discharge and stress and anxiety are co-determined by a third factor, e.g. marital discord and non-marital sexual partnerships of husbands? Inferences may be drawn from the literature that supports both these hypothesized relationships.
The case for reproductive tract infection as a determinant of psychological stress may be inferred from a number of studies describing women's roles in patriarchal settings characterized by hierarchical gender relationships and huge double standards relating to sexual behaviour. In these settings, women tend to be reluctant to even acknowledge or communicate the occurrence of vaginal discharge, let alone seek treatment, preferring the route of ‘silent endurance’6 to any revelation that may raise questions about sexual fidelity or ability to bear children. For example, in a study in Tamil Nadu, India, women report apprehension about even expressing the condition. For example, ‘How will I tell anyone about it (white discharge): they will think that I have done something wrong’.7 As a result, many women who experience vaginal discharge do not in fact seek care. Even in Patel et al.'s study, in a relatively well-developed state of India, no more than half of those who experienced vaginal discharge had sought medical treatment, and in other studies, percentages were even lower (Giza, Egypt;8 rural Maharashtra, India.9 In these circumstances, any symptom suggestive of STIs, including vaginal discharge, has been observed to provoke such consequences as fear and anxiety, stigma, shame, and embarrassment among women, as well as verbal and physical abuse, fear of childlessness, abandonment and the threat of or actual divorce, or disruption of marital relationships.10–12 This body of evidence would suggest, therefore, the possibility that it is the experience of vaginal discharge that may compromise psychological and emotional well being.
Conversely, the argument that both discharge and stress and anxiety are co-determined by a third factor, e.g. marital discord and the experience of non-marital sexual partners among husbands can be made on the basis of considerable evidence of the limited sexual negotiation power of married women. In many settings, women have limited decision-making authority on matters concerning their own lives and health. In those settings, it is unlikely that they can insist on condom use, refuse sex or make decisions on abandoning a threatened marriage, even when they are aware of the protective influence of condoms and the risks associated with multiple partners (Zimbabwe;12,13 Mexico;11 India7). Concerns about infidelity and breach of trust experienced by women who experience RTI symptoms have also been reported.12,14 These kinds of findings lend support to the hypothesis that both discharge and stress and anxiety are co-determined by non-marital sexual partnerships of husbands.
Clearly more research is needed for exploring this relationship with a prospective design or even a cross-sectional design that probes the circumstances and possible onset of symptoms of discharge or anxiety in an attempt to temporally order the two experiences. Equally, research is required for decomposing the pathways of influence between vaginal discharge and psychological distress. A better understanding of directions and pathways of influence is required to incorporate the modification of syndromic management logarithms so that women with complaints that are non-infectious in aetiology are offered psychosocial interventions.
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