Mental Health of Women in Kerala: The need for a Gender Perspective

An attempt has been made in this paper to emphasise the need to explore “social” factors, reflected primarily in the iniquitous gender roles and authorities, structures that perpetuate women’s subordination, for understanding the growing mental distress among women in Kerala. Much has been written about the high status of women in Kerala and their central role, historically, in its development based on the remarkable achievements in the social sectors (Jeffrey 1992). This is reflected in the highest levels of literacy and health for Kerala women among the states of India. More recent work did highlight the state’s weaker position if health indicators like morbidity, in lieu of mortality, were considered (Hiraway and Mahadevia 1996). Besides, there is growing uneasiness in equating high status thus defined and empowerment (Eapen and Kodoth 2001). The emerging contradictions in social development, between the very high physical health indicators on the one hand and the alarming growth in female suicides, manifesting extreme mental distress on the other, lent some urgency to the study of women’s mental health problem in Kerala.

It is acknowledged that the so-called severe mental disorders such as schizophrenia show no significant gender difference. There is a greater prevalence of the more “common” type of disorders such as depression, phobias and anxiety among women compared to men across all socio-economic groups and diverse societies (Sonpar and Kapur 1999). Independent studies on mental depression across the world show that women are twice as likely as men to suffer from clinical depression (Davar 1998).

The Kerala Context

Our discussion on mental health of women in Kerala is severely constrained by the lack of proper surveys, epidemiological or community based, on prevalence of different types of mental illnesses, especially the common disorders. However, that mental distress, such as depression, stress and anxiety among women is growing in Kerala since the mid-seventies and more rapidly in the nineties is affirmed by professionals in the mental health field based on the growing numbers of women resorting to treatment privately or at Government mental health centres. It is also reported that numerous counselling centres have come up as a response to the need for individual or family counselling.

Details of the few studies available have been presented in the Chart. One study in a rural area of the state on the prevalence of priority psychiatric disorders found that with the exception of mental retardation (male 2.99 and female 2.68 per thousand), was more among females than males in convulsive disorders, schizophrenia, affective disorders and organic psychoses (Shaji et al 1995). Hence the widely accepted gendered character of mental illness did not seem to hold in this sample since women outnumbered men in severe and common categories. Another very large community based study, funded by the State Board of Medical Research focussing on one Primary Health Centre in each district and covering one lakh population (70,000 in rural and 30,000 in urban areas) is now almost complete. However, its focus is entirely on the prevalence of chronic schizophrenia. Some preliminary data available show no significant gender difference in prevalence of schizophrenia. This is in conformity with the generally acknowledged fact though it differs from the earlier study on rural Kerala. Also there is no rural-urban differential. About 0.2 percent of the population, females and males, in rural and urban areas is affected by this disorder. The prevalence rate is much higher for widowed (0.9 percent) and divorced (3.4 percent) population; gender differences are not available by marital status. Its onset among females is at a slightly higher age, (16-20 years) than males, (12-16 years) (Mani 2000).

We had collected hospital data for the period 1992-98 on number of outpatients, aged 15-49 years, for various types of mental illnesses at the General Hospital, Thiruvananthapuram. The limitations of such data are well known since hospital-seeking behaviour is different in the two sexes. However, it is interesting to find that the prevalence of depression and hysteria was consistently higher in women than in men. In the case of anxiety and phobia, the men outnumbered women (see Table 1).

Possible Explanations: Relevance of the Social Context

What explains the greater prevalence of common mental disorders among women? A number of studies have attempted to explain the greater proneness of women to depression in terms of hormonal changes during different stages of the reproductive cycle, particularly the pre-menstrual and menopausal syndromes. In Kerala too, some studies have attempted to relate mental distress with gynaecological problems; for instance pregnancy and maladjustment (Ammal 1980) and post-partum sterilisation with manifest anxiety (Ammal et al 1980). However, findings of many such studies are inconclusive in respect of causality. While there is no doubt that prevalence rates are differentially higher for females in the reproductive years, age related data show that morbidity rates in women fall off after the age of 40 years or so (Carstairs and Kapur 1976), thereby throwing serious doubt on the menopausal theory (Davar 2000).

Considerable literature has appeared which argues that the gender differences in respect of common mental disorders is best explained by a psychosocial etiology in which the unequal social structures and practices emerge as major stressors. It is argued that the reproductive years are also dominated by the need to behave appropriately, preparing the woman for the role she is 2 expected to play in a “patrifocal” family structure:- self-effacing, obedient, chaste, home-loving and perceiving her own interest in terms of what is best for the family. Such socialisation can also result in a situation where women accept domestic violence as an undisputed aspect of marriage! The culturally prescribed codes of conduct which women have to follow are restrictive and discourage independence or pursuit of individual goals. Since this is part of the social ideology, it is very difficult for women to step outside it– all of which can cause them considerable mental distress.

It would therefore be more appropriate, as argued by Davar (1998) to address the problem as mental distress rather than illness in articulating an agenda for women’s mental health. Of particular importance to social etiology is the role of violence and culture specific behaviour which reflect the unequal relations of power between women and men. Even poverty affects women more than men due to their weaker fall-back position (very little control over resources) and also since they perceive themselves as primarily responsible for their children. Gender based violence is emerging as a grave risk to mental (and physical) health of women. Mental distress is greater in women following trauma or victimisation in the aftermath of violence, domestic violence or sexual abuse (Davar 1998).

Research into the causes of mental distress from a gender perspective is only just emerging in Kerala. Some of the studies do confirm the social origins of common mental distress in women, in particular due to domestic problems. For instance information compiled by a very recently set up Counselling Centre in Thiruvananthapuram, Thrani, shows that during the period from March to September 2000, telephone counselling was provided for 3413 callers, that is over 400 calls per month. However the gender break-up was not available. While an overwhelming number of calls were made around the time of publication of matriculation results, of the rest, a major reason was distress induced by marital and family problems. Women experienced growing mental distress due to their dual role, as home-makers and as workers outside the home; a feeling of being restricted in their mobility and the ignominy of suffering domestic violence, physical and verbal (Thrani 2000). Similarly another study attempting to capture the agony of women from broken marriages, finds that between 1995-98, the 3 number of petitions filed in the Family Court in Trichur increased by more than one and a half times, from 477 to 860. Of these almost two-thirds were filed by women primarily for divorce and maintenance, induced by protracted marital disharmony. On the basis of a few case studies, the author concludes that women appeared to suffer more from the stress and strain of discord between the spouses precipitated by alcoholism, beating and verbal abuse, interference of in-laws, desertion and suspicion (James 1999). Based on the experiences of a number of psychiatric patients in Trichur district, a doctor asserts that the most common cause of psychological suffering among women who have attained higher level of education is lack of employment opportunity and the roles they are expected to assume after marriage (cited in Halliburton 1998). Studies on the impact of Gulf migration bring out the psychological trauma faced by the “Gulf wives” who are on the average better educated than their husbands who emigrate for work. The common complaints observed were mild depression and psychosomatic disorders (Zachariah et al 2000).

The limited available evidence for Kerala is adequate to highlight the seriousness of the mental health problem. The prevalence of depression and The Need for a Gender Perspective other common mental disorders is more in women, resulting in many cases of suicide, to warrant social concern and effective intervention. The more detailed data base on suicides, which we analyse separately, further confirms the gendered nature of mental distress in which violence and intra-family relationships appear to be playing a major role. Increasing violence against women in Kerala and increasing mental distress do not seem to be unrelated.

Suicides
Kerala has one of the highest suicide rates in the country, 27 per lakh population which is three times the national average. It increased from around 15 per lakh population in the seventies. Within the state, Idukki, Trichur and Wynad have the highest rates of male and female suicides varying between 60- 65 per lakh male population and 20-35 per lakh female population. While the incidence of completed suicides is higher for men, studies also show that attempted suicides are higher for females (Vadakumcherry 1994; Jayasree 1997). This seems to be a universal phenomenon, as brought out by the World Health Assembly Report (1998); three times more women than men attempt suicide while three times more men succeed.

The data on suicides are compiled by the National Crime Records Bureau (NCRB) under Accidental Deaths and Suicides and it brings out some characteristics of the victims by gender. Most of the male victims were young and females were even younger. The rate peaks at the age group 15-29 for women, whereas it is at a higher age group for men, 30-44. There was no difference by sex in the older age group, 60 plus. While male student suicides constitute about 3 percent of total suicides, for female students it is nearer 6-7 percent. Suicide rates among the less educated and those educated upto matriculation were high, i.e. between 15-30 percent. But what is interesting is that the sex ratio (female to male) of suicides was higher for the illiterate women and those with only a primary level education, who can perhaps be described as the most vulnerable. Data for the three years 1995-97 show that while a higher proportion of men with higher education (graduation and above) commit suicide, there is a narrowing of the gender difference at this level.

In terms of occupational categories, suicide rate was overwhelmingly high for housewives. This is the finding of many studies within and outside India which relate mental distress with marital status. An unavoidable inference would be that marriage is stressful for women (Davar 1998). For men the rates were high among the unemployed followed by the category of self-employed.

According to the NCRB statistics, almost one fifth of suicides for males and females is on account of dreadful disease/prolonged illness of which less than one tenth is due to insanity. Another 40 percent of suicides in the case of males is due to “causes not known”; for women it is slightly lower. Hence a large proportion of the cases are out of the purview of analysis. Of the remaining, the most significant motivation for women (accounting for almost a quarter of the suicides) is on account of family / marriage related problems (Table 2). While for men too, this is a major reason, economic factors like bankruptcy and unemployment are a close second.

It has been argued that this pattern of motivation is not very different from the all-India picture, which raises the question why women and men in Kerala are killing themselves three times as often as other Indians for the same reasons (Halliburton 1998). A closer examination of the evidence on suicides by occupation and level of education of the victims brings out some possible region specific differences not captured by the causes. For instance, the proportion of unemployed women and men who committed suicide in Kerala was more than double than that of all India. Similarly, while almost a quarter of the female victims were matriculates the proportion was much lower for India.

We now examine a micro-level study on survivors of attempted suicides which yields more detailed information on the causes of inter-personal problems within families, and has a gender focus (Jayasree 1997). It covered 133 cases during 1994-95, more than half of which were women. We do not find dreadful disease as a major cause for attempting suicide. The findings confirm the dominance of marital disharmony, in terms of inter-personal problems with spouse, as the major factor associated with suicidal attempts among females (36 of the 75 women). This was followed by problems with other family members and failure in examination. For men, the cause was economic crisis followed by family related problems. Probing the question of marital disharmony further, it was found that one third of the women were suffering from domestic violence while almost a similar number were harassed by the in-laws and alcoholic husbands. In the case of a small proportion, the husband’s suspicious or jealous nature was the cause. The fact that for men the major reasons for attempting suicide are unemployment or financial problems also suggests the perceived gender division of labour in society. Men are supposed to be the bread winners in the family, failing which they develop depression. Harassment by the in-laws was not linked directly to the dowry problem in this sample; however, an autopsy study conducted in a district in Kerala revealed that more than one third of the women who had died had a dowry problem. It appears that suicidal intent and lethality among women having a dowry problem is high. The Need for a Gender Perspective

We have attempted to emphasise, given the data base/studies available, the social etiology of mental distress among women in Kerala and the need for more community based surveys to assess its prevalence. Halliburton (1998) has argued as some others have done too, that the high rate of suicide in Kerala can be explained in terms of its unique achievement in literacy. In particular the high proportion of matriculates has raised career expectations of the educated work-seekers and created a mismatch between levels of education and the types of jobs available. In the case of women the persistence of traditional social norms and practices including the gender division of labour inhibits female enterprise despite the modernising influence of education. Education, even higher education in Kerala, does not appear to have motivated many women to challenge the societal gender roles and demeaning social practices such as dowry. While to a large extent their own perceived interest response indicates an internalisation of their subordination, there is no doubt that this results in extreme distress and frustration ending in suicides. However, the question still remains why the suicide rates of the less educated in Kerala society, especially women are high. The latter can perhaps be explained only in terms of growing violence of the men at home exacerbating the problems of daily living.

Appendix
Before we conclude, a note on the phenomenon of family suicide. Though not new, it has caught considerable attention due to the sudden spurt in recent times. There were 381 family suicides in 1996 and reports are that individual suicides have to some extent declined (Indian Express 11.6.99). Journalistic reports suggest that a major cause of family suicides is financial bankruptcy, mostly debt-induced, compelled by the growing consumerist culture in the state. Another reason is the “Othello” or suspicious husband syndrome who kills his wife and then kills himself. Criminologists have questioned whether these are in fact family suicides; they are more likely homicide followed by suicide (Vadackumchery 2000). The importance of gender is brought out clearly in this issue too. Most of these suicides appear to have been decided by the dominant personality, that is, the husband and imposed on the rest of the family members. The question is why does the wife agree? And the answer to that lies in her perceived interest, determined by the societal gender roles; she has no identity without her husband. The minor children may have no say but older children can and do protest. This was seen in a recent case of family suicide in Cochin; one of the three daughters spewed out the poisoned milk and survived. In some cases the woman takes the decision and kills herself and the children.

(This paper forms part of a larger study in collaboration with PraveenaKodoth. See Eapen and Kodoth 2001. I would like to acknowledge Meera N’s help in the research assistance given)

Notes

1. This was asserted by Dr.ElizabethVadakekara, who heads a recently set up Counselling Centre, “Thrani” which does round the clock counselling. The growth in the number of counselling centres (we could not obtain any statistics on them) is itself a reflection of the growing demand for such a facility primarily to relieve depression, anxiety and related mental disorders.

2. This is a term used by Mukhopadhyay and Seymour (1994) to describe a family structure that gives precedence to men over women. They distinguish it from ‘patriarchy’ which tends to imply a monolithic system in which males always predominate in all settings and socio-economic contexts and all stages of the family life-cycle. The ‘patrifocal’ concept is more flexible being more adaptable to change and assuming various forms in different parts of the country.

3. There are five Family Courts in Kerala located at Thiruvananthapuram, Kollam, Kottayam, Thrissur and Kozhikode.

REFERENCES
Ammal, R. S. “Relationship of Gynecological Problems to Neuroticism”, Psychological Studies, 25.1. 1980: 26-30.

Carstairs, G. M. and Kapur, R. L. Great Universe of Kota: Stress and Change and Mental Disorder in an Indian Village, London: The Hogarth Press, 1976.

Davar, Bhargavi V. Mental Health of Women: A Feminist Agenda, New Delhi: Sage Publications, 1998.

Davar, Bhargavi V. “Mental Illness among Indian Women”, Anubhav, 4.3.2000. Eapen, M. and Kodoth, P. Demystifying the High Status of Women in Kerala:An Attempt to Understand Contradictions in Social Development, Report submitted to Institute of Social Studies Trust, New Delhi. 2001:

The Need for a Gender Perspective Halliburton, Murphy. “Suicide: A Paradox of Development in Kerala”, Economic and Political Weekly, 33.36&37.1998: 2341-2345.

James, Lizzy. “Family Counselling in Family Court: An Analysis of PsychoSocial Dynamics of Families of Litigants” (Thrissur Family Court) Discussion Paper No.13, Thiruvananthapuram: Kerala Research Project for Local Level Development, 1999.

Jayasree, A.K. “Gender Issues in Suicides: A Study among Suicide Attempters in Kerala State” 1997.

Jejeebhoy, Shireen J. “Wife-Beating in Rural India: A Husband’s Right?” Evidence from Survey Data, Economic and Political Weekly, 33.15.1998: 855-862.

Jeffrey, Robin. Politics, Women and Well being: How Kerala became a ‘Model’, London: Macmillan, 1992.

Mani, Suraraj. Report of the “Need Assessment of Severe Mental Morbidity of Kerala State, Thiruvananthapuram: Kerala State Mental Health Authority 2000.

Mukherjee, Chandan et al. “Crime Against Women: A Preliminary Statistical and Spatial Analysis of National Crime Records Bureau Data”, Presented at the Centre for Development Studies, Thiruvananthapuram 1999.

Mukhopadhyay, Carol Chapnick and Susan Seymour. ed., Women, Education and Family Structure in India, Boulder: Westview Press 1994.

National Crime Records Bureau Accidental Deaths and Suicides in India (1995- 97)

Shaji, S. et al., “Prevalence of Priority Psychiatric Disorders in a Rural Area in Kerala”, Indian Journal of Psychiatry, 37.2. 1995: 91-96.

Sonpar and Kapur. “Non-Conventional Indicators of Gender Disparities Under Structural Reforms”, Paper Presented at the Workshop on Gender Discrimination Under Structural Reform, New Delhi: Institute for Social Studies Trust, 1999.

THRANI Personal Communication 2000. Vadackumchery, James. “Suicides: A Study about the Victims of Unsuccessful Attempts in Kerala State” 1994.

Zachariah, K.C. et al., Dynamics of Migration in Kerala: Dimension, Differentials and Consequences, Thiruvananthapuram: Centre for Development Studies 2000.

Contributor
MRIDUL EAPEN. Is Associate Fellow at the Centre for Development Studies, Trivandrum. Her current areas of interest are Employment, Rural Transformation, Gender. Her major recent publications include, “Rural Industrialisation in Kerala: Its Dynamics and Local Linkages”, Manohar Publishers, New Delhi and (jointly) “Family Structures, Women’s Education and Work: Re-examining the High Status of Women in Kerala”, forthcoming in an edited Volume, published by Kali for Women, New Delhi.