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Conflict induced stress is not only taking a toll on mental health in Kashmir but also causing reproductive problems and disorders in young men and women. Ibrahim Wani reports.

Almost every night Yasmeen sees a child running into her open arms in her dreams. Before she could embrace the child, some noise wakes her up. Tears fill Yasmeen’s eyes. In her five years of marriage she has not been able to conceive.

“Every day I have this feeling of emptiness,” she says.

This period has been a torture for her. Her behaviour has changed. She has become reactive to every argument. “I have become an object of extreme dislike for my in-laws, who never miss a chance to remind me what I don’t have (a child),” Yasmeen says.

Waking up in the middle of the night, tired and unable to go to sleep again, she struggles with a headache. She reaches out for the bottle of sleeping pills. Today will be just another day when she pops up a sleeping pill. However, her association with sleeping pills and anti-depressants has been long.

The first time she had a sleeping pill was ten years ago, after a bomb went off very close to her. Though she escaped unhurt, physically, the shock was too much for her. She had fallen unconscious.

“I would remain gloomy for days, and would get flashbacks of the scene. She was no longer able to concentrate on her studies, and would suffer from anxiety. I would faint whenever, I had the recollection of the scene of the blast,” she says.

When she finally took medical consultation, she was diagnosed with PTSD – Post Traumatic Stress Disorder. It was here that her tryst with anti-depressants started. She responded to the treatment well, and soon she was up and ‘normal’ again. But consequences remained.

Her menstrual cycle became irregular, and she started suffering from increased hair growth – medically referred to as Hirsutism. She had to go to the doctor again, who diagnosed her with PCOS-Polycystic ovarian syndrome.

PCOS is a major endocrine disorder in women of reproductive age. It is one of the leading causes of female infertility. Doctors identify stress as one of the main reasons of PCOS prevalence in Kashmir, with four to 10 per cent of all women suffering from it.

A study conducted at SKIMS among 112 young and adolescent female patients, found that 65-70 percent had psychiatric disorders, says Dr Ashraf, an Associate Professor of Endocrinology at SKIMS. Eight patients were found to be suffering from obsessive compulsive disorder (OCD), five had post traumatic stress order, and 27 had major depressive disorder.

PCOS is considered to be associated with a host of endocrine and metabolic disturbances such as hypertension, impaired glucose tolerance, type-2 diabetes mellitus, coronary artery disease and even breast cancer.

Serum insulin, insulin resistance and homocysteine levels are significantly higher in women suffering from the disorder.

One of the most glaring symptoms of the condition is hirsutism – or excessive hair growth and acne. This has lead many young girls towards skin treatment centres which have now come up in Kashmir. Rafia, 32, has already spent around 20,000 rupees for the treatment. “I felt as a social outcast with the excessive hair growth on my face. I had very low self esteem because of this problem. So I went for the laser treatment,” she says. Every now and then she has to follow the treatment with a laser, ‘touch up’. Even though the problem of excessive hair growth has been solved to some extent, but she has still has abnormally high levels of stress. “I get angry all the time, and have hardly any patience left,” she says.

Rafia too has been a victim to the conflict induced stress. “I cannot forget the day when some armed men barged into our house, and started looking for my brother,” she says. In the commotion shots had been fired, and one of the bullets had bruised her arm. This happened around 18 years ago, when she was just a 14-year-old, at the threshold of puberty.

Stress has an impact on the hormone levels. It disrupts the normal state,” says Dr Sadakat Rehman, Assistant Professor of Clinical Psychology at the Institute of Mental Health. “PTSD and depression are very common to Kashmir, particularly affecting women,” she says. These two disorders lead to fear psychosis, which leads to infertility through psychological as well as physiological factors.

The effect of the conflict induced stress is not related just to the increase in infertility. A study titled “Prevalence of PTSD in conflict-hit Kashmir”, in 2006 by Medicines Sans Frontiers (MSF) revealed high rate of abortions and miscarriages among women in Valley is due to the PTSD.

According to the study around 63,000 patients visited the hospital in 2006 of which 15 to 20 percent were suffering from PTSD. One of the observations is that 60 percent of the 63,000 cases were women that perhaps explain the high rate of abortions and miscarriages.

Rukaiya had three miscarriages. She developed PTSD when her brother died in crossfire between militants and security forces. The tragedy sent her into depression.

The MSF study also revealed that patients who witnessed killings, explosions and torture showed higher level symptoms like behavioural and emotional change, social avoidance, improper sleep, and reduced sexual desire. “Such patients will remain upset for longer times even if treated properly,” notes Dr Haque of Malaysia, one of the co-authors of the study.

“In many cases the depression becomes most manifest in the reduced sexual desire,” says Dr Sharik Masoodi, Additional Professor of Endocrinology at SKIMS Kashmir. Most of the women suffering from the mood disorder tend to have high levels of anxiety and sleep disturbance. This affects sexual performance as well as ovulation, he says.

But more importantly “In a society like Kashmir, it is very hard for people to come to terms with accepting that they have a mood disorder. So even though they are not able to bear children due to the mood disorder they seek medical attention instead of psychiatric help. Most of the tests reveal them to be normal but still they keep coming to the doctor for treatment,” says Dr Sharik. A situation ensues where a person is being treated for a problem he does not have, and the actual problem gets overlooked. “Thus the patient is being over treated for a problem he does not have, and under-treated for the real problem,” he adds. This creates more problems for the patient. Stress and infertility are cause as well as effect of each other, he further states. So this problem keeps on aggravating.

Dr Aniruddha and Dr Anjali Malpani, Mumbai based fertility experts who operate a website fertilty have studied the issue in detail. They state that in response to stress, the hypothalamus produces a hormone called corticotropin releasing factor (CRF) which activates the hypothalamic-pituitary-adrenal (HPA) system, causing it to release neurotransmitters (chemical messengers) called catecholamines, as well as cortisol, the primary stress hormone.

Biologically, since the hypothalamus regulates both stress responses as well as the sex hormones, it’s easy to see how stress could cause infertility in some women. Excessive stress may even lead to complete suppression of the menstrual cycle, and this is often seen in female marathon runners, who develop “runner’s amenorrhea”.

In less severe cases, it could cause anovulation or irregular menstrual cycles. When activated by stress, the pituitary gland also produces increased amounts of prolactin, and elevated levels of prolactin could cause irregular ovulation.

Since the female reproductive tract contains catecholamine receptors, catecholamines produced in response to stress may potentially affect fertility, for example, by interfering with the transport of gametes through the fallopian tube or by altering uterine blood flow. However, more complex mechanisms may be at play, and researchers still don’t completely understand how stress interacts with the reproductive system, they state.

But this problem is not confined to women only. According to a survey conducted in 2009 by the Kashmir chapter of Action Aid International, 29 per cent of the unemployed males in Kashmir smoke in order to relax themselves. Further a whopping 12 per cent, which includes women, take sleeping pills to overcome stress. Four percent of the respondents of the survey take drugs to reduce mental tension.

In males the primary effects of the stress manifest as erectile dysfunction, decreased libido, and decreased sperm count. “One third of the total infertility cases in Kashmir are due to male factor,” says Dr Shariq adding that among males the biggest problem is semen related. Dr Mirchandis on further state that one more indication of stress lowering sperm count in males is that testicular biopsies obtained from prisoners awaiting execution, who were obviously under extreme stress, revealed complete spermatogenetic arrest in all cases.

“Stress leads to an increase in the reactive oxygen species which then cause oxidate damage to sperm as well as Ova,” says a noted andrologist at SKIMS. The reactive oxygen species are free radicals, peroxidases etc which cause harm to cellular membranes. In this case the target is sperm membranes mostly. “The stress induced oxidative damage of the sperm membrane lowers sperm motility, and may even cause a damage of the paternal DNA,” adds the doctor.

What is most unfortunate in these cases is that assisted reproductive techniques (ARTs) do not work. “Even if the sperm is taken out of the testes in ART, it will still have the damage,” says the doctor.

One more relation of stress to infertility is through smoking and other anti-depressant drugs which are proven to be sperm damaging. “Smoking leads to low sperm motility as well as low sperm count,” says the doctor.

But more important is the stress induced erectile dysfunction and premature ejaculation, which is one of the primary causes of partner dissatisfaction.
The primary cause of stress in males in Kashmir is conflict related. A related factor is unemployment. A doctor who did not wish to be named said that a number of male patients in the young age group who have suffered some sort of trauma from one party or the other in the two-decade-long conflict complain of very low confidence and libido.

“They come to us just before marriage with the fear that they would not be able to consummate their marriages. In many cases marriages have been broken because of the same reason,” he says. The doctor further states that it is unfortunate that a study on low libido or low sexual esteem has not taken place in Kashmir. “The conditions here are such that such a study would be very difficult. But an indication to the enormity of this problem is the rush we see in places like Batamalo or Lal Chowk at shops operated by quacks who sell everything and anything as a sex tonic.”

The biggest reason for female infertility remains Premature Ovarian Failure (POF) also referred to as premature ovarian inception. A report carried by India Today states that medical experts are struck by the abnormally high rate of POF-20-50 per cent-among infertile Kashmiri women. According to the report a clinical screening of 2,000 women with infertility symptoms at the Rotunda-Hygiea IVF Clinic in Srinagar in the past three years puts the incidence of POF at 26 per cent. This is in stark variation with the nationwide POF rate of 1-5 per cent among infertile women below 40 years.

Dr Sharik is also of the opinion that ovarian failure is more common to Kashmir, but he adds that proper studies have not been conducted which will link it primarily to stress, though stress is a cause. Some genetic studies on the subject are planned.

In most cases of ovarian failure, childbirth is not possible even through artificial means. Ruksana, a government school teacher, is in early forties. She was divorced because of the problem four years ago.

She had tried every medical treatment available. “I went to Delhi for treatment but after spending lakhs of rupees nothing happened,” she says. Even though her husband was initially supportive, he later gave in to the pressure of his parents. “My husband was the lone son. My mother-in-law wanted a successor from him. When it became clear to her that I could not give her one she could not even stand my sight,” she says. Soon there was no option left. He divorced me. Today she lives with her brothers, but every day reminds her of  the vacuum. “My mother passed away a year after my divorce. My father had died much earlier.
Even though I live in the same house in which I was born, it gives me a feeling of being an outsider,” she says, “It belongs to my sisters-in-law who are also mothers.”

Ruksana is comparatively luckier. She has a job and is “not a burden on anyone”. Kulsoom who faced everyday ridicule in her husband’s place, came to visit her parents one day. A divorce paper reached her the next day. She has not signed it. It has been a year since then. Her husband has re-married.

(Some names have been changed)



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