SRINAGAR, INDIAN-ADMINISTERED KASHMIR – Shock, sadness and silence engulfed Ishrat Hussain, 26, when she learned about her inability to conceive. She says she locked herself in a room in Srinagar, Kashmir’s summer capital, and trembled like a fish, wishing death upon herself.
“When I came to know about my inability, I was completely ripped off,” Hussain says, her voice choked with emotion.
A newly married woman, Hussain thought that she would soon become pregnant and enjoy motherhood. But when she was still unable to conceive two years after her marriage, she says she confided in her family and asked for their support.
She then visited a gynecologist, who diagnosed her with polycystic ovary syndrome, an endocrine disorder known to cause women to stop ovulating, gain unusual weight, develop irregular periods or skin problems like acne, and grow abnormal facial and body hair.
“I was shattered,” she says. “Life without children is nothing. It is a waste. I would never be able to know what it feels like to bear a child. I feel myself as a barren land.”
Hussain tries to muster the courage to put into words how people ridiculed her in her community in Kashmir, where infertility is taboo. Though she doesn’t feel comfortable talking openly about the pain of infertility, her loss is visible on her face. Whenever she does talk about her desire for motherhood, she dissolves into tears and becomes inconsolable.
“An infertile woman is generally viewed as incomplete with a notion of having a curse bestowed for some misdeed,” she says with tears filling her eyes.
She says that her community made her feel as if she were less of a woman because she couldn’t bear children – that it was her fault even.
“How can I live with this stigma throughout my life?” she asks. “I don’t know for what fault of mine God has punished me.”
But doctors in the region say that it’s not her fault at all, as Hussain is not the only woman in Kashmir suffering from polycystic ovary syndrome.
Doctors say that decades of conflict and political uncertainty in the Kashmir Valley have negatively affected the reproductive health of women with an epidemic of stress-related disorders. For women, doctors say that ongoing conflict means a perpetual cycle of post-traumatic stress disorder, hormone imbalances and the heavily stigmatized possibility of infertility. Psychologists and psychiatrists confirm the link between mental and emotional strain and physical consequences. Experts recommend counseling for conflict-related disorders and in vitro fertilization for women who can’t conceive.
Kashmir is a disputed territory between India and Pakistan. Many residents of Indian-administered Kashmir desire their independence from India, leading to conflict that has been ongoing for more than two decades.
About 15.7 percent of women in the valley of childbearing age will never have a child without clinical intervention, according to a study carried out in 2008 by the Department of Endocrinology at Sher-i-Kashmir Institute of Medical Sciences, the only tertiary care hospital in the valley.
Though no one cause can be pinpointed, Dr. Ashraf Ganaie of the Department of Endocrinology at Sher-i-Kashmir Institute of Medical Sciences identifies stress as one of the major reasons for the prevalence of polycystic ovary syndrome, estimating that 4 to 10 percent of women in Kashmir are currently suffering from this syndrome.
A 2006 study by Médecins Sans Frontières titled “Prevalence of PTSD in Conflict-hit Kashmir” attributed the high rate of miscarriages among women in Kashmir to post-traumatic stress disorder, an anxiety disorder caused by a traumatic or shocking event. The study also found that, out of 63,000 patients who visited the Government Psychiatric Diseases Hospital, Kashmir's lone mental health hospital, in 2006, 15 to 20 percent were suffering from the disorder. Of the 63,000 patients, 60 percent were women.
Doctors cite regional conflict as a major reason for the disorder.
According to Hussain’s medical reports, a traumatic incident during her childhood is still engraved in her mind. Her anxiety over conceiving a child likely increased these stress levels, which may have together triggered her polycystic ovary syndrome.
In 1992, several years after conflict broke out in Kashmir, Hussain was returning home around 1 a.m. with her father and uncle after attending a marriage ceremony in the valley’s Baramulla district, located approximately 60 kilometers from Srinagar. She says that a group of nongovernmental soldiers stopped their vehicle and ruthlessly beat her father and uncle.
When she tried to stop them, the army also attacked her until she lost consciousness, resulting in multiple injuries – including emotional ones that continue to affect her today. The soldiers took her father and uncle, and she never saw them again.
“I still remember vividly that incident, which still continues to haunt me and give me sleepless nights,” she says. “Those scars are still fresh in my mind. On that night, I was lying unconscious on the road [un]til morning. Some villagers came to my rescue and dropped me at my home.”
Hussain says that for many years after the incident, she and her family searched every police station and approached many police officers to hunt for her father and uncle, but to no avail. Doctors later diagnosed her with major depressive disorder due to the incident and prescribed her medication for several years, which she took until she got married.
The news of her infertility sucked her back into her earlier depression, Hussain says. She again started to develop feelings of guilt and unworthiness. After undergoing a variety of futile fertility treatments both inside and outside the valley, she also had to face strong resentment from her in-laws, who blamed her for not being able to conceive.
“My husband was a lone son among four sisters,” she says. “Everyone in his family was demanding his second marriage without divorcing me. I was silent and said nothing because I was held responsible for no fault of mine. My in-laws made me so ashamed that I felt like killing myself.”
She says her family always supported her, as did her husband initially.
“Initially, my husband supported me,” she says. “But then due to the stigma of infertility, he slowly withdrew his support.”
She suggested in vitro fertilization or adoption, but she says he rejected both ideas.
“He was adamant to have a natural baby,” she says.
Hussain says she became so stressed about her in-laws’ demands for a second wife that she divorced her husband and returned to her parents’ home. She is currently on medication to regulate her mental health as she struggles to cope with her inability to conceive and also grieves for her past losses.
Clinical psychologist Iram Nazir says that women in general are sensitive to stress, and any stressful experience can negatively affect their hormonal levels.
“Due to the decreased insulin sensitivity after any bad experience,” she says, “there is a rise in the glucose level in the body, which in turn stimulates increased insulin production and raises noradrenaline levels, a stress-related chemical released during emotional upsets.”
Nazir links these rises with polycystic ovary syndrome. She says that the syndrome is a major precursor of infertility in which ovaries develop multiple small cysts and fail to produce hormones that regulate the menstrual cycle.
“The women suffering with this disorder don’t have regular periods due to the elevated insulin levels that stimulate excess androgen production by the ovaries, and thus they may be unable to ovulate and become pregnant,” Nazir says. “The androgens can cause premature follicular wastin, which can result [either in] inconsistent or absent ovulation and lead to infertility.”
Ganaie, the endocrinologist, says that there has been an unprecedented increase in the number of polycystic ovary disorder patients visiting the hospital in recent years.He cites a variety of factors responsible for the spike, including a rising trend of late marriage during the past two decades.
“The trend of late marriages has emerged as a major challenge for people due to the last two decades of violence," he says, "and is affecting both bachelors as well as married women as her childbearing capacity reduces with age primarily due to hormonal change and other stress levels.”
He says stress is a powerful trigger.
“It is considered to be the mother of all the lifestyle diseases,” he says.
Ganaie says that an unpublished study that he supervised attributed 90 percent of infertility cases in the valley to polycystic ovary syndrome and related diseases, 5 percent to premature ovarian failure and another 5 percent to other stressors in life.
“In the last few years, we have received more than 150 women who suffer from premature ovarian failure,” he says.
He contributes the rise in stress levels to the ongoing conflict here.
“There has been an increase in stress levels to live in a conflict zone, which has led to high prominence of infertility among women,” he says.
Dr. Arshid Hussain, a psychiatrist at the Government Psychiatric Diseases Hospital, carried out a joint research project with Ganaie on the prevalence of psychiatric disorders and stress in patients with polycystic ovary syndrome in 2011 with a specific focus on infertility in women.
“Stress can badly impact the reproductive well-being of women,” says Hussain, who is not related to Ishrat Hussain. “We find high mood disorders having significant association with life stresses and high prevalence of stress among the patients with PCOS.”
Dr. Mushtaq Kirmani, a psychologist who practices in Baramulla, says that mental health in the valley remains precarious because of violence and the alarming increase in stress levels. As a result, women are facing various health issues, such as menstrual irregularities, sleep problems and hair loss. The most at-risk for these issues are those who have suffered more than one highly stressful event in their lives.
Kirmani adds that women tend to react differently to stress than men and are affected by depression twice as much as men.
“The psychological trauma due to turmoil has induced the increase in stress levels in the valley, resulting in many abnormalities,” Kirmani says. “And the most common nowadays is problems to conceive normally.”
One 25-year-old woman suffers from post-traumatic stress disorder. Her parents asked to withhold her name to protect her mental health.
For this woman, that event was the Shopian double rape and murder, which took place in Kashmir’s Shopian district in 2009. Two young women were brutally raped and murdered, their bodies later found in a stream near their home. The 25-year-old lived in the same area and knew the victims.
After the incident, the woman’s behavior changed, says her parents, who also declined to be named to protect their daughter’s mental health. Her daughter stopped taking meals and told her parents that she no longer wanted to go to school because she had to cross a bridge like the one involved in the Shopian incident in order to reach school.
Her fear of the same incident happening to her also caused her to develop sleep problems and reproductive issues, such as irregular periods and excess white discharge, her parents say. When their daughter did not venture out of her house for several days, they took her to seek treatment.
The medical reports suggested that she was suffering nightmares and flashbacks of the traumatic event that shocked the valley. Doctors said that her post-traumatic stress disorder might negatively affect her fertility if she decided to try to conceive.
“The Shopian incident was a trigger to the painful memories for the victims who have directly or indirectly suffered and a shock for the new ones,” says Nahida Geelani, a psychiatrist who works in a private practice here. “After the incident, some of the girl patients were so scared that they used to carry poison pills, knives and pesticides along with them to defend themselves. The fear of the incident was so powerful that some patients and parents even sought suggestions from us like how to defend themselves if they get caught in a Shopian-like situation.”
Many girls seek help to address their psychological problems. Still, many cases go unreported, Geelani says, as women shy away from reporting their grievances because of the stigma attached.
But Hussain the psychiatrist says that prompt care is crucial.
“If someone feels any change in their normal functioning, she should get herself checked clinically without any delay,” he says.
Asiya Nayeem, a senior counselor with Kashmir LifeLine, a mental health helpline in Kashmir, says counseling and medication can be necessary.
“Proper medication as well as psychotherapeutic counseling is a must for the women suffering from various stressful conditions,” she says. “This can improve their coping ability with their stressors, which can enhance their adaptation with social, occupational and emotional functioning.”
Nayeem says that as remedial measures, helpline workers encourage the stressed women who call to maintain hope and to incorporate the main pillars of health into their lives:
“Good nutrition, sound sleep, relaxation, exercise and proper hydration and positive outlook for life,” she lists.
An increasing number of women who are infertile are turning to in vitro fertilization.
“Women who cannot conceive due to any reason suffer from various mental ailments,” says Iram Rizvi, a clinical psychologist who works as a consultant for several organizations in Kashmir. “They have to face the pressure from their in-laws as well as from the society in such a situation. The new technologies like IVF have provided these hopeless women with an alternative to get their dreams realized.”
Rotunda Hygeia is Kashmir’s first and only infertility treatment center. It has orchestrated more than 1,500 successful pregnancies since its establishment in 2003, says Dr. Ruheel Nisa, the center’s lab director.
She says that the center’s overall success rate is about 40 percent, varying by age group. It is the highest among patients ages 25 to 30, but it can be less than 20 percent for patients younger than 21 or older than 40.
Nisa adds that some people in the mostly Muslim region believe that in vitro fertilization is un-Islamic. But she assures them that the clinic’s practices respect Islam.
“I want to make sure all that this technology is not un-Islamic,” she says. “We go for same-partner IVFs, so we completely do it under religious limits.”
Nisa attributes infertility in the valley to various causes, including stress, polycystic ovary syndrome, tubal blocks and hormonal disorders.
