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Love and longing inside the bell jar
“I am a woman with normal needs even if I am abnormal in other
ways. My voices talk to me about sex and I feel tortured by them
because they tell me they will do bad things if I think about sex.
I do feel better when I have no voices and am on medication.
But once I am better, I feel the need to be loved and held, which is
not possible. I wonder then, which is a bigger torture – the voices
or not being ill?”
– Words from a 26 year old woman living with
schizophrenia.
There was a time when women with mental illness were
institutionalised and only a minority went on to have a
partner or get married. Advances in psychiatric treatment
have enabled women with mental illness to lead more
functional lives and fewer women are now in long term
institutionalisation. However, this has thrown open many
more challenges for women battling with mental illness
including that of handling their own sexuality. A study
done at Bangalore among 360 women being treated for
a psychiatric disorder revealed that nearly 77 % were
sexually active ever in their lifetime while 85 % were
sexually active within the last five years. This indicates
that even when fighting a serious mental disorder, women
continue to have a sexual life associated with its rewards
and problems.
This article will focus on some of the issues related to their
own sexuality that women with mental illness grapple
with, often without solutions or help. Mental illness for
the purpose of this paper is being
defined as schizophrenia or bipolar
illness (including cycles of both
mania and depression).
How does mental illness
influence the sexual
experience of women?
There are enough studies to indicate
that women with mental illness
have partners, get married, have
pregnancies and are sexually active
almost at the same rates as women
in the general population. However,
negotiating this path is often
tumultuous and difficult.
There are four important issues that
women with a mental illness face
in their sexual lives – problems in
acquiring and sustaining meaningful
relationships related to symptoms of
the mental illness; being vulnerable
to coercive sexual experiences
much more than other women; the
impact of psychotropic medications on sexual health, and
finally, the lack of specialised, reliable and safe spaces to
discuss sex.
Problems in acquiring and sustaining
meaningful relationships related to symptoms
of the mental illness.
There are two ways in which symptoms of mental illness
might interfere with a woman’s sexual life. The first is
related to poor judgment and social skill deficits resulting
in inadequate sexual negotiation.
The following scenario illustrates the point. M is a 29
year old woman with schizophrenia who wants to have a
boyfriend. She talks about wanting to be held, nurtured
and touched. M often fantasises of being pretty, smart and
having a boyfriend. However her parents do not want to
get her married and do not feel
that she needs a partner. M herself
is also unable to talk to boys in the
neighborhood or interact with males
at the rehabilitation centre. She
gets tongue tied, feels she cannot
understand social nuances and
becomes awkward. She feels helpless
and alone in her predicament.
What M is facing is called a social
skill deficit which is part of a
schizophrenic illness. Recent theories
of schizophrenia indicate that one of
the major dysfunctions that inhibit
persons with schizophrenia from
interacting normally with others is
deficits in social cognition.
Social cognition is an important
aspect of all social relationships;
particularly the art of getting to
know another person, communication
and negotiation. It is that part
of thinking which makes a person
sensitive to nuances, gestures and
subtle indications of acceptance and rejection. Women
(and men) with schizophrenia, depending on the nature
of the problem, may become either over-sensitive and
hence suspicious of any gesture or may not be able to pick
up subtle social cues, which are important aspects of any
relationship.
So while M would like to have partner, a romance, and
maybe even sex, her illness precludes her from approaching
potential partners or makes her over-sensitive to cues.
Poor judgment and loneliness
P is a 25 year old woman with bipolar disorder whose
family has abandoned her. Her illness is well controlled
with medication; however, P has had two abortions and has
had several tests for STDs and HIV. She has multiple sexual
partners and occasionally has sex for money.
P says –
“I don’t have anyone to call my own and no one cares for me.
At least for a physical relationship, men will agree to be part of
my life. I know it is momentary and brief, but for that moment, I
am the most important thing to this man. I can live with a chain
of such moments of people wanting me and me feeling that I
belong to somebody. I know that no one in their right senses will
have a long term relationship with a woman with mental illness.”
As the above self-disclosure indicates, women with mental
illness grapple with immense loneliness and solitude. This
is imposed on them by society which often alienates them
and prevents them from joining the mainstream of social life
and networks. Abandoned (often even while living within
the family), women may get into relationships without
thinking of the consequences, just for a few moments of
connection with another person. This may result in trauma
through subsequent abandonment or consequences like
violence, STDs and HIV.
Illness exacerbations and sexuality
Women with bipolar illness will
often report feelings of excessive
sexual desire as part of their manic
illness and will identify it as being
responsible for indiscreet sexual
liaisons that might have negative
consequences.
The above three situations are
often not discussed or dealt with
by professionals and patients find
it difficult to bring it up- leading to
much of the trauma and angst that
women with mental illness face.
Medication and sexuality
Several of the second generation
of antipsychotic drugs and antidepressants
have an impact on sexual
functioning, particularly on sexual
desire and orgasms (causing anorgasmia). In addition, by
causing weight gain, they have a negative impact on self
image and on attractiveness further influencing a woman’s
sexuality. However, in most situations, an improvement
in overall functioning and decrease in symptoms actually
enhances one’s self esteem and persons with psychiatric
illness have mixed feelings about medication.
Sexual abuse and coercion
Several studies have shown that women with mental illness
are extremely vulnerable to sexual coercion. A study done
among female inpatients in Bangalore indicated that 30 %
of women psychiatric inpatients reported being sexually
coerced. The most commonly reported experience was
sexual intercourse involving threatened or actual physical
force and the most commonly identified perpetrator was
the woman’s husband or intimate partner or a person
in a position of authority in her
community. In contrast to the 30%
of women who reported sexual
coercion, only 3.5 % of the 146
records indicated that the coercion
had been discussed with the doctor
or mental health professional.
What was also disturbing was that
majority of the women reported
repeat victimisation. Western
studies have indicated that mentally
ill women who are most prone to
abuse are those who are homeless
and use substances. However, this
was not substantiated in our study,
where women were living with their
families and in their homes. Thirty
of the 50 coerced women (60%)
reported that they had not disclosed
their experience to anyone, and that
they had not sought help. Women
revealed a sense of helplessness,
fear, and secrecy related to their
experiences.
“Three years ago I was in my sister’s
house for a few days. My brother-in-law
is not all right. He is very crazy about
women. I think even my sister is aware
of this, but she keeps quiet. She has two
children and has to bring them up.
She does not work and that is why
I think she is scared. He had an eye on
me also. But I never realised. One day
I was alone at home. My brother-in-law
came. That day he got an opportunity.
He did not care, however much I
requested. He raped me.”
(22-year-old, psychosis not
otherwise specified)
“Another time, a few people took me to a school. They opened my
mouth and forcefully poured alcohol. Then they all raped me one
by one. In the morning I was lying there. No one has ever asked
me these questions earlier, so I have never told anyone. Now I feel
OK and don’t feel distressed about these experiences.”
(42-year-old, obsessive-compulsive disorder)
“This I have not told anyone until now. But today you are asking
me, that is why I told you. But I am not scared. Let anyone come
to know about it. I will only say it loudly.”
(23-year-old, bipolar disorder, mania with psychotic
symptoms)
“Our people are all like that. They get their children married
early. There will be many children. There are so many people
like me. But no one talks about such difficulties. They tolerate
all this with their mouths shut. If we tell anyone, we will be
losing our own respect. They would say, ‘Is she the only person
suffering like this?’ That is why I have not told this to anyone.”
(33-year-old, acute psychosis)
Reactions to coercive sex
Women reported a variety of reactions towards their sexual
experiences. One woman explained her sexual experience
this way:
“My mind is not all right for the past 3 years. My mother always
says that I roam around everywhere removing all my clothes.
I don’t remember now. But I like new
clothes and jewelry. I like to dress up
well. Once I was in the house alone in
the night. Maybe I had not closed the
door properly. Some 3 to 4 people just
barged in removed my clothes, played
with my body and ‘did it’ one after
the other. One fellow pressed my breast
hard, biting it and my face. But I don’t
know who they are because it was very
dark. I think they do not belong to our
town. They are some rogues. After that,
my stomach has become somewhat big.
I feel I have become pregnant.”
“If I tell anyone, they will scold me only. As it is, they always
scold me and call me ‘mad.’ Everyone looks down upon poor
people like us. Also, if I tell anyone, they will not believe me.
What is the use of telling anyone now? Is it not wrong whatever
men do? They only blame us. My husband has left me. From here
I have to go to my mother’s house. He will not let me stay with
him. But I want to go there and live. But everyone thinks I am
mad. So will he allow me? If I stay alone also it is a problem.
When a woman lives alone, men try to take advantage. (With)
a woman like me, it is very easy for them. I am very scared.”
(25-years-old, bipolar disorder, mania with psychotic
symptoms).
The stories above which have been extracted from an
earlier article by the author indicate the poignancy and
dilemmas facing women with a mental illness. Being `mad’
they feel makes them a victim, makes them helpless and
also leaves them with a sense that people will not believe
their experiences because they come out of `madness’.
Under these circumstances, possibly the only space they
have available is with a mental health professional. However
there is often a lack of discussion on sexuality with mental
health professionals even in the framework of recovery.
Positive stories.
A study exploring sexual lives of people with schizophrenia
using a grounded theory approach, found that sexuality was
more meaningful when it was not
limited to only its physical aspect.
Such factors as the presence of
intimacy, less confusion about sexual
orientation, previous positive sexual
experiences and relationships,
the quality of current intimate
relationships, and opportunities for
sexual expression were identified as
important contributors to satisfying
sexual lives. Men and women living
with a mental illness reported
that dealing with their sexual lives
made them feel more complete as
a person and that discussing and
resolving their sexual concerns was
an important part of reintegration
into society.
Reclaiming sexual lives in one’s journey through
mental illness
We all need to understand that like everyone else, women
with mental illness too need to experience sexual wellbeing.
This might not necessarily be only through a sexual
relationship but through acknowledging and validating
the woman’s sexuality and discussing her concerns related
to it. It is also important that families, friends and most
importantly mental health professionals realise this in
their attempts at helping a mentally ill woman reintegrate
into society. Providing a safe place where a woman with
mental illness does not feel vulnerable and can express
herself freely without having to worry about exploitation
is probably the foremost need of today in India.
“There is something demoralizing about watching two people get
more and more crazy about each other, especially when you are
the extra person in the room.”
Sylvia Plath, The Bell Jar, Chapter 2, pg. 14
Key References
Chandra PS, Deepthivarma S, Carey
MP, Carey KB, Shalinianant MP. A
cry from the darkness: women with
severe mental illness in India reveal
their experiences with sexual coercion.
Psychiatry. 2003 Winter;66(4):323-34.
Chandra PS, Carey MP, Carey KB,
Shalinianant A, Thomas T. Sexual
coercion and abuse among women
with a severe mental illness in
India: an exploratory investigation.
Comprehensive Psychiatry. 2003 May-
Jun;44(3):205-12.
Volman L, Landeen J. Uncovering the
sexual self in people with schizophrenia. Journal of Psychiatric
and Mental Health Nursing. 2007 Jun;14(4):41-17.
Dr. Prabha S. Chandra, MD, MRCPsych, is a medical
graduate from the Lady Hardinge Medical College, New Delhi
and a postgraduate in psychiatry from the National Institute
of Mental Health and Neurosciences (NIMHANS), Bangalore,
India. She is currently a professor of psychiatry at NIMHANS.
Her research focuses on women with mental illness,
especially where it interfaces with sexuality, reproduction,
motherhood, violence, and life cycle issues..
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