Phenomenology, disability and sexual functioning in female Dhat syndrome: a study of tertiary care gynaecology outpatients

Sample size calculation

Precision=5%.

Prevalence=28.99%.8

Population size=180.

CI=95% specified limits (23.85%–33.85%).

Estimated sample size (n)=115.

Based on the above calculation, an ideal sample size of 115 was determined, and an appropriate number of potential subjects were screened to meet this quota. The first two consecutive patients attending the obstetrics and gynaecology OPD from August 2019 to February 2020 were included.

Procedure

The first two consecutive patients who presented with complaints of vaginal discharge in the gynaecology OPD on the specified days were initially evaluated and clinically examined by a gynaecologist. This was purposefully done to minimise the selection biases. Relevant investigations were done to rule out any organic pathology. Patients without abnormal investigation reports and no other contributory medical causes were referred to the research investigator, who screened and evaluated them for FDS. The operational criteria we used for this diagnosis in our studies included: (1) presentation with non-pathological vaginal discharge, (2) reports of distress due to the passing of this vaginal discharge, and (3) attribution of other symptoms due to the loss of vaginal fluids. Other inclusion criteria were ages between 18 and 45 years and those giving valid informed consent. Exclusion criteria were less than 18 years of age, not meeting the operational criteria, failure to give consent, postmenopausal or menstrual irregularities. All patients with medical conditions that could confuse the diagnosis were also excluded.

A semistructured evaluation of the included patients’ sociodemographic and menstrual and sexual history details was carried out, and the DSM-5 was used to diagnose psychiatric illnesses. The subjects were assessed with the Scale for Assessment of Female Dhat Syndrome (SAFeD)6 to explore the phenomenology of vaginal discharge. The Hospital Anxiety and Depression Scale (HADS) was administered to rate anxiety and depression.9 The Perceived Stress Scale (PSS)10 was used to assess the stress perceived in the past month, and the World Health Organization Disability Assessment Scale 2.0 (WHO-DAS 2.0)11 was applied to determine disability. The DSM-5 Level 2-Somatic Symptom-Adult Patient (adapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15)12 was used to rate the severity of somatic symptoms. Sexual functioning was assessed with the Female Sexual Function Index (FSFI) for women who had had sexual intercourse in the past month.13 All scales were administered by a trained mental health professional. The relationship between the duration of vaginal discharge, the severity of perceived stress and somatic symptoms, and the disability summary scores were analysed using Spearman’s correlation.

Operational criteria for FDS

As mentioned above, our operational criteria for FDS are as follows:14 (1) presentation with non-pathological vaginal discharge, (2) reports of distress due to the passing of this vaginal discharge, and (3) attribution of other symptoms due to the loss of vaginal fluids. All of the above criteria must be met to establish a diagnosis of FDS. Clinicians must first determine the non-pathological nature of the vaginal discharge; thus, this is the first criterion of the operational definition. Though many women have vaginal discharge, most do not have associated somatic or psychological symptoms, so complaints of these symptoms are another essential component of the diagnosis. For example, Chaturvedi found that 17% of healthy women complained of vaginal excretions, but none were concerned about it.15 Another important distinction is that some women experiencing vaginal discharge may have somatic symptoms but do not attribute these symptoms to the secretions. Since the vaginal discharge does not distress these patients, they should not be diagnosed with FDS. Hence, to comprehensively assess and reliably diagnose FDS for our study, we used the above operational definition to include only patients who accurately represented the disorder. Using this formal system for assessment and diagnosis also suggests that the results are more likely to be replicable in subsequent studies.

Statistical analysis

Data were described in percentages and proportions using descriptive statistics. Additional correlational analysis using Spearman’s r correlation was done (as the data were non-parametric in distribution) to measure the association of clinical variables with the outcome variables.

Main findings

The mean age of our patients was 29.3 (7.5), similar to age group profiles reported in earlier studies.6 16 Approximately 68.6% of the patients were married housewives (table 1); this high rate may be due to sociocultural customs in India in which women marry early and assume the role of home maker.6 Other sociodemographics of the subjects were as follows: 88.6% were Hindus, reflective of the general population of the area in which the study was conducted (table 1); 67.1% were from a rural background; 64.3% had a family income of less than 20 000 rupees/month, indicating that the syndrome is more prevalent in the lower socioeconomic strata; and approximately 54.3% belonged to a nuclear family (table 1). A similar presentation is seen in patients with male Dhat syndrome.1 17 The possible reason for this may be that the research was conducted in a tertiary care centre that caters to the middle and lower socioeconomic classes and is reflective of the general population. Regarding education, 35.7% of the subjects were college/university graduates (15 years of education) (table 1). The illness belief persists, even among those patients with higher education. This finding suggests that education may not generally protect against culture-bound syndromes, particularly FDS. A similar result was reported earlier for Dhat syndrome in males.18 19 Noteworthy, the educational system in India currently does not expose students to detailed health-related information. Access to reproductive and sexual function information—and its variations—is significantly lacking.

In our study sample, the mean age of onset of vaginal discharge was 23.0 (6.6) years (table 2). The literature suggests that male Dhat syndrome and FDS are common in young adults and adolescents.20 Individuals within this age group tend to do more sexual exploration of their bodies and, due to inadequate knowledge, are more likely to interpret normal physiological changes as pathological, such as in male Dhat syndrome, where precum is often misinterpreted as semen.

The phenomenology of FDS

The mean duration of vaginal discharge was 6.25 (6.44) years. About 61.4% of the patients experienced vaginal discharge for less than 5 years (table 2). Similar findings are seen in male patients with Dhat syndrome, with a mean duration of symptoms of 4.26 years.20 Most female patients complained of passing vaginal discharge once or more daily and reported the discharge’s viscosity to be watery, wetting their undergarments due to the amount of fluid secreted.

Most patients had misconceptions about the causation of FDS and the production of vaginal secretions. About 21.4% of the patients believed dhat is vital for the body’s well-being, and 48.6% believed the secretion originates in the body’s bones. Thirty percent of the patients were unclear about the discharge components. These findings are consistent with the results of the other studies in which all patients believed dhat to be the body’s essential fluid.6 Studies also indicate similar beliefs exist in men, where patients with male Dhat syndrome perceived semen loss as harmful to health.21 In a study by Bhatia and Malik, the majority of male patients thought dhat was the same as semen.22

Most patients did not associate the flow of vaginal discharge with any specific condition, though 58.6% reported the discharge occurred just before and after menstruation (table 2). As discussed earlier, the amount of normal vaginal discharge varies during the menstrual and ovulatory cycles. This fluctuation of secretions was a common scenario reported in our study, indicating that women often worry about normal variations in vaginal discharge.

Patients reported biological factors as the most commonly perceived cause of vaginal discharge (table 2). Urinary tract infection (n=29, 41.4%) was deemed the leading cause as it is also the most common reason for pathological vaginal discharge. FDS, by definition, is non-infectious. However, the medical system does not generally acknowledge the possibility of FDS, and many gynaecologists remain uninformed about this anomaly. Therefore, despite contrary evidence, most medical clinicians continue to label it as an infection; unfortunately, the same belief persists among patients.

Some patients (n=15, 21.4%) could not give reasons for the passage of vaginal discharge (table 2). Still, among the study participants, consumption of warm drinks and food (n=24, 34.3%) was the second leading perceived cause of the vaginal discharge. In India, food intake and the heat retained by the body are given aetiological significance. The concept of hot-cold food is indigenous to the Indian subcontinent. Treatment is also directed in the form of heating and cooling therapies, and abstinence from specific food items is incorporated in prevention therapies.7 23 Similar beliefs are also found in patients with male Dhat syndrome, where diet is considered a significant reason for semen loss. Several studies have also reported these findings in the context of male Dhat syndrome.20 22 24 Similarly, females misattribute multiple factors for causing vaginal discharge. Therefore, identifying these false assumptions is essential to addressing dysfunctional beliefs for a better treatment outcome.20

Weakness in the body, decreased stamina, a thin physique, irritability before and after menstruation, loss of facial and body beauty, mental illness, loss of sexual desire and impaired sexual performance were the commonly perceived consequences of vaginal discharge (table 2). Patients also reported various depressive, anxious and somatic complaints (table 2). Other researchers also found that patients complaining of vaginal discharge presented various physical and mental symptoms.6 8 25 26 Of note, the symptoms perceived by these women can be explained by Ayurvedic concepts. According to this ancient tradition of medical practice, vaginal fluids are believed to provide strength, power and sexual vigour; therefore, their loss drains a woman’s strength, leading to weakness. A belief deeply rooted in South Asian men is ‘40 drops of food are required to form one drop of blood, in turn, 40 drops of blood are needed to form 1 drop of flesh, and 40 drops of flesh are needed to form 1 drop of marrow, and finally, 40 drops of marrow are required to form one drop of semen’.1 According to the dietary theory of Ayurveda, semen is formed as the seventh stage product after a high degree of successive refinement/assimilation of food, passing through six stages: viz chyle, blood, flesh, fat, bone and marrow. Semen in Ayurvedic literature is equated to vaginal discharge. This gives rise to a belief system that vaginal discharge is formed from the dissolution of bones. Bone formation is a precursor to the production of vaginal fluids; thus, ‘melting’ bones lead to excessive discharge. For example, backache is believed to be caused by the melting of the backbone.23

According to this theory, an eighth stage end product is a substance called ‘radiance’. This conceptualisation could be why many women in India believe the loss of vaginal discharge leads to a loss of radiance. Since dhat is formed from blood, any loss of blood production could cause a pale facial discolouration.23 Some patients also described genital ulcers or itching as a consequence of vaginal discharge. The Ayurvedic system of medicine explains that excess body heat bursts out in the form of these ulcers.23 On the other hand, a normal physiological vaginal discharge, if it remains in contact with the skin, can result in itching and lesions around the genitalia.

The other common symptoms reported were loss of sexual desire and weakened sexual performance. Vaginal discharge is equated to semen; thus, the loss of vaginal discharge leads to a decrease in ‘female sperm’ and may contribute to infertility. Male patients with Dhat syndrome also tend to relate the loss of dhat with impaired sexual functioning. Medical quacks and traditional healers further strengthen the belief through advertisements of various products or treatments.24 27

Regarding the related clinical investigations, all the women reported that examining the blood and urine was essential (table 2). The consistent study results reflect that the desire for investigation persists despite earlier negative clinical reports. This drive to find a medical reason for the illness is related to patients’ perception that an infection could be the cause. It is similar to other psychiatric disorders, such as somatic symptom disorder and anxiety disorder, where patients persistently request repeated investigations despite negative findings and physician reassurance.2

The health-seeking behaviours of the patients were also assessed using the SAFeD Questionnaire.6 Our findings suggest that most patients had consulted different practitioners outside the allopathic system of medicine, perhaps due to the scarcity of qualified healthcare professionals in rural areas (table 2). Most of our study’s patients (72.9%) believed that the disease could be alleviated after treatment by a gynaecologist (table 2). Approximately only 22.9% of the patients considered that energising medication supplements, such as vitamins, tonics and injectables, were required to treat the symptoms (table 2). However, these findings are in contrast to the study by Grover et al,6 where the majority of females believed that energising medications could be beneficial in providing relief from the symptoms.6 The studies of male Dhat syndrome also reflect the role of multivitamins and tonics in improving the the disorder.20 22 This difference in the findings may be because Grover’s study was conducted in the psychiatry department. The majority of the women included in his study had either been referred from the gynaecology department or had already taken treatment from a gynaecologist with no proven benefit, whereas our study was conducted in a gynaecology OPD with patients still maintaining hope that gynaecological treatment might prove beneficial.

Dhat syndrome is commonly associated with comorbidities. However, very few studies have evaluated comorbidities in females presenting with non-pathological vaginal discharge.28 In our research, psychiatric comorbidity was found to be 38.6%. The most common psychiatric disorder diagnosed in our patients was major depressive disorder, followed by anxiety spectrum disorders. Comorbidities are also commonly associated with the male Dhat syndrome.1 22

The HADS9 was administered to all patients to assess depressive and anxiety symptoms. In our sample, 18.6% (n=13) had scored more than 11 on the depression scale of HADS, indicating a definitive case of depressive disorder, and seven patients (10%) had scored more than 11 on the anxiety scale of HADS, indicating a definitive case of anxiety disorder. This is understandable as the loss of vaginal discharge, like the loss of any precious or valued possession, can produce a state of clinical depression in vulnerable individuals.

Somatic symptom disorder, as per the DSM-5, was diagnosed in 7.1% of the subjects. The Somatic Symptom Scale was used to rate the severity of somatic symptoms, and results showed a majority of the women had experienced somatic symptoms in the past week. In our sample, perceived stress in the past month was rated with the PSS10; findings indicated the majority (n=48, 68.6%) had perceived a moderate amount of stress. Stress and mental tension have been reported as both causative factors and consequences of vaginal discharge in many studies.16 20 29 30 The concept of stress in causing vaginal discharge is also evident. Women often report an increase in the amount and frequency of vaginal discharge during stressful situations.16 In some other studies, mental tension was attributed as a cause of abnormal vaginal discharge.16 25

Disability in the patients was evaluated using the WHO-DAS 2.0.11 The total disability summary score was in the lower range, suggesting that FDS causes less disability (table 3). The disability score, measured by the WHO-DAS 2.0, was more than 25% in the domain of ‘participation in society’. The distress caused by vaginal discharge may limit the females’ mobility during festive and other religious activities and leave them feeling uncomfortable about participating in these events. Attempting to rid themselves of their illnesses, distressed patients may visit various healthcare professionals, incurring a significant loss of time and money. No prior study has evaluated disability in patients with FDS, so a comparison with other findings is not possible.

Measured by the FSFI13 scale, sexual functioning was assessed in women who had had sexual intercourse in the past month; results found that 48.3% could be diagnosed with a sexual dysfunction disorder. The most commonly affected domains were desire and arousal. Sexual complaints like premature ejaculation, erectile dysfunction and decreased libido are also seen in patients with male Dhat syndrome. A possible explanation is that non-pathological vaginal discharge causes physical discomfort to the women, and therefore, women may not feel comfortable participating in sexual activities. Moreover, depression and anxiety symptoms are commonly associated with the syndrome. For example, anxiety symptoms are associated with reduced attention span and concentration with decreased attention to sexual stimuli; impaired cognitive processing of sexual stimuli can then lead to decreased arousal.31

A moderate positive correlation was found between the duration of discharge, perceived stress, severity of somatic symptoms and total disability. A moderate positive correlation was also found between perceived stress, somatic symptoms and disability caused by the illness. We found a moderate negative correlation between the depressive symptoms score (r=−0.469, p=0.011) and a weak negative correlation between the anxiety symptoms score (r=−0.387, p=0.042)and the total sexual functioning score (tables 5 and 6).

Limitations of the study

The study was based in a tertiary care centre hospital which may limit the generalisability of the findings for females with this disorder within the community. It was a time-bound study, and due to the COVID-19 pandemic, the estimated sample size could not be attained. The small sample size further limits the generalisability of the findings to the community patients. Because the recruitment was conducted in a busy obstetrics and gynaecology OPD, the data for all patients presenting with vaginal discharge could not be collected. Furthermore, the data were not normally distributed across most variables due to the selection of which non-parametric or distribution-free statistics were computed. Some researchers consider non-parametric statistics as having lower power compared with parametric statistics. Finally, we did not have a control group. Therefore, interpretations of our findings are limited by the lack of comparison with the general population.

Implications

The current study illustrated that the clinical presentation of women with non-pathological vaginal discharge is similar to that of male Dhat syndrome. Pervasive misconception and misinformation give rise to numerous physical and psychological symptoms associated with Dhat syndrome. The most common psychiatric comorbidities linked with FDS are major depressive disorder followed by anxiety disorder. Patients with vaginal discharge complaints require clinical assessment of biological, social, psychological and cultural factors. The management plan for these patients should include treatment of physical and social causes and the correction of cultural misbeliefs associated with vaginal discharge. Finally, women with non-pathological vaginal discharge seeking consultation in gynaecology OPDs should also be evaluated for possible psychological issues.