Mental Health in India’s Adolescent Girls

At ten years old, at the delicate intersection of childhood and adolescence, I lost my father.

The sudden, swift loss of a loved one left my family with a vacuum that felt insurmountable. Fear, inordinate sadness and hopelessness enveloped our home. Our South Asian family was heavily steeped in cultural norms. Showing one’s wounds to others was viewed negatively.

Crying was looked down upon, and seeking help would be an impermissible acknowledgement of weakness. Therapy was not a word in our vocabulary.

As I was expected to, I placed invisible bandages over my pain and suffering. I walked to school one week later with a forced smile pasted on my face. When asked how I was feeling, I quickly redirected the conversation, replying, “I’m okay.”

This external reticence surrounding my feelings and emotions continued throughout my adolescent years. While I experienced intermittent jolts of sadness and depression – likely as result of all that I had concealed and bottled up – I never once considered the option of therapy.

Now, as a pediatrician, I recognize the need to end the stigma and silence surrounding mental health in South Asian communities.

I have seen again and again the multi-generational consequences of mental illness, particularly depression. I co-founded Girls Health Champions, a non-profit training adolescents as peer-to-peer health educators, because I have seen firsthand that young people have significant unmet needs surrounding mental and physical health.

We know from both anecdotal and empirical evidence that adolescent depression and mental illnesses are on the rise, specifically for young women. Girls are over three times more likely than boys to experience depressive symptoms. The extent and complexity of mental illness among youth in India continues to be understudied, and the support for young people is stagnant.

Our suicide rate is a public health crisis – India accounts for 36.6% of suicides globally. Additionally, among Indian women and teenage girls aged 15–19, suicide has surpassed maternal mortality as the leading cause of death.

We have ample evidence to show that frank discussion and dialogue must start early and occur frequently. However, addressing the mental health of adolescent girls requires a thoughtful, multi-pronged strategy.

We must address cultural attitudes when approaching girls’ mental health education.

We know that South Asians, including young people, share a cultural resistance towards legitimizing mental health as a medical need. According to Dr. Nidhi Kosla, a mental health provider, South Asians “fail to report their [emotional] pain to avoiding burdening others or being seen as weak.” This might explain why many South Asians do not utilize resources such as therapy or psychiatric care, even if they are aware of them.

Additionally, in India, mental illnesses such as depression have often been equated with words such as “pagal”, or crazy. This language intensifies the shame and stigma young people experience. As a result, discussions of mental health must not only focus on awareness raising, but also on addressing and overcoming prevalent stigmas.

Mental health remains an underdeveloped and understaffed field in India’s medical practice. It is time to start building India’s mental health infrastructure.

Out of the 936,000 doctors in India, there are only roughly 4,500 psychiatrists to serve a population of 1.3 billion. In comparison, the USA, with a population a quarter the size of India’s, has 7,000 psychiatrists of Indian origin and 28,000 overall. 

India’s mental health infrastructure is also severely limited, with only 43 government mental health hospitals across all of India to provide services for the estimated 70 million people living with psychosocial disabilities.

In addition, most general practitioners and pediatricians are not adequately trained in identifying or managing mental health illnesses. These are often the people who serve as the first medical ‘touch points’ for young girls. Many providers may even hold negative attitudes towards mental health conditions themselves. Investment in training for frontline health workers is essential.

In both my experiences as a pediatrician and with Girls Health Champions, I have learned that a majority of young girls do not feel they can turn to their parents when it comes to discussing mental health-related issues. 

Parents play a critical role in providing a supportive climate around mental health.

We must educate them to have understanding, empathy, and awareness of mental health-related issues. Parents should develop the capacity to identify potential issues in their children and recognize when it would be appropriate to seek help.

I want our young people to know that it is okay to feel, to reach out for help, or even to say, “I am not okay”.

Day after day, I diagnose young girls with mental illnesses, including depression. During these visits, we often talk about the importance of removing the invisible bandages. We talk about the fact that ultimately, opening up is a sign of strength.

Raising the Girl Agenda in Myanmar

We are still coming off the buzz of a really energetic and earnest Girls’ National Conference in Myanmar. Bringing together adolescent girls from across 70 diverse communities, the conference supported girls to work together and articulate an agenda to submit to regional and national lawmakers.

This agenda will be in the form of a letter. It will describe the barriers faced by girls in communities across Myanmar and the ways that law-makers can help to knock down these barriers so that all girls can achieve their full potential.

Last year, we made a big deal of International Day of the Girl – dedicating almost an entire season to it! We created opportunities for girls from all of our project communities to contribute directly to the development of an agenda for national and regional change – an agenda that would support girls’ development, education, access to safe work, freedom of movement, expression and beyond.

There were two key steps to making this work. Firstly, we held Regional Forums in 15 geographic hubs. Then, based on the outcomes from those events, we built the content and activities needed to make the National Conference both productive and deeply connected to the views and attitudes of adolescent girls.

In the lead up to those Regional Forums, our staff moved around the country with a mission to ensure every girl currently enrolled in our weekly leadership circles — over 3,000 girls — could attend a forum in her region. This would mean every girl could meet with others from nearby areas to discuss the specific, and sometimes invisible, barriers they share which can diminish self-perception and limit  choice.

Girls’ Regional Forums

The forums were focused on consensus-building activities. The day’s discussions were based on what we already knew about the situations of girls in different areas and the concerns girls have expressed to us in the past. In small groups, girls worked through various possible barriers to identify which applied most directly to their lives. They also discussed specific examples of times when, as a girl, they have encountered a barrier, been discriminated against, or felt unheard.

Girls’ National Conference

Immediately following the regional forums, we held our inaugural Girls’ National Conference in the City Hall of the ancient capital of Mandalay. The theme was “Girls, do you know you can fly?”  Attending the conference were 140 adolescent girls – peer-selected delegates representing nearly all of Girl Determined’s project communities.  Each spokesgirl shared on behalf of girls in her unique community, speaking out in a broader discussion with other girls facing sometimes similar and sometimes different issues.

Over two full days, the conference brought girls’ voices and experiences to the fore, while encouraging girls to act as change-makers in their communities and consider a different future for girls and women. Girls heard from one another and were introduced to basic concepts of civic action. Through consensus-building activities, they drafted a joint-letter expressing the concise needs of adolescent girls nation-wide.

Four main issues came out as the most detrimental to girls’ success in Myanmar:

    • inadequate or limited access to education
    • inadequate or limited access to health, nutrition, and sanitation needs
    • feeling unsafe and not knowing how to respond in dangerous situations
    • feeling unable to make decisions and express opinions about their own lives

We expect to see more girls taking issues into their own hands by expressing their needs in a structured way and demanding accountability by those in positions to make decisions.

Building On The Outcomes

Now that the conference has ended, two tasks remain.

Firstly, we will refine and revise the letter before the girls present it to members of parliament. A delegation of six girls from the conference will present the letter and express their concerns and hopes directly to parliamentarians.

Secondly, we will report back to ALL the girls who contributed their experience and insight on what their inputs have gone towards – both at the National Conference and during the direct appeal to lawmakers.

We will report back to all these girls through an article in our Wut Hmon magazine, and through a summary video of the National Conference.  This way, girls who weren’t at the national level gathering can see how their concerns were carried forth by their peers, and can experience the full process from regional forums to visits with parliaments.

We are excited to see how this plays out in the coming months, as girls’ voices resonate through Myanmar to create awareness of the hardships girls face, and of how they can rise up together.

My Menstruation is not a Sin!

Throughout the world, menstruation shares a common universal feature; women have historically been shamed because of it.

Although female sexual and reproductive health has started to become more important as a topic of study and discussion in the last few decades, many women to this day experience an overwhelming level of stigma around menstruation.

In many low-middle income countries, access to sanitary products such as pads and tampons is extremely restricted, forcing young girls and women to use inappropriate products, such as a piece of old cloth or banana leaves. A dire consequence of using unsanitary products is the development of genital and urinary tract infections that can, if unimpeded, cause severe complications.

While this is a truly worrying situation, it is not highlighted enough as a public health issue – primarily due to the stigma and shame surrounding menstruation.

The lack of proper sanitary products and/or facilities often forces girls and young women to miss school. This in turn affects women’s long-term economic development. This is not only seen in low-middle income countries; in the UK for example, girls and women often cannot afford the sanitary products they need – a problem known as ‘period poverty’.

In many countries across the globe, menstruation is considered dirty and repulsive. In some cultures, it’s even seen as a sign of ‘loss of virginity’ – insinuating moral and ethical depravity. In many countries, women and girls are ordered to leave their homes for the duration of their menses to prevent ‘desecration’ of their homes. In all these scenarios, girls and women find themselves ostracized, humiliated and expected to accept this without question or debate.

Even in parts of the world where the situation may not be so extreme, some degree of stigma remains around menstruation – large enough to prevent girls and women from seeking medical care because they feel too ’embarrassed’. Within the bounds of such societies, menstruators may not seek medical help and may not be able to recognize important health-related problems should they arise.

In the UK, almost 80% of adolescent girls have experienced a distressing symptom relating to their menstrual cycle but have not approached a medical professional for advice.

A large contributor to these misbeliefs is the lack of education and awareness on menstruation. This leads to an inundation of false conceptions and misrepresentations. Due to the restrictive social norms in many parts of the world, it is a topic rarely discussed within the family structure.

Not only does this mean an uneducated society when it comes to female sexual and reproductive health, but it also means that many young girls have no or very limited knowledge on what to expect and how to react when their menses start. Instead, they become more confused, isolated and unable to manage their menstruation in a safe, clean and dignified manner.

Many countries have addressed several of these demanding issues. In Kenya for example, free sanitary products are available and in neighbouring Ethiopia, menstrual hygiene clubs have been established in many schools.

How we are trying to help

The Swedish Organization for Global Health (SOGH) – in association with Uganda Development and Health Associates (UDHA) – has launched a project titled Ekibadha: Our Periods Matter, in recognition of this extremely important matter.

The UDHA Dignity Project

The project aims to understand and highlight the difficulties women and girls in rural Uganda are facing regarding their cycles. The project is in its first stages, but our goal is to develop a community-based initiative that involves the entire community which will be sustainable – economically and environmentally.

“Men should be more involved” said one of the women we interviewed last summer in one of the rural villages in Muyage District. We agree! Men need to be part of the conversation, this is not just a ‘women’s issue’.

To learn more about the project, please visit www.sogh.se/ekibadha-our-periods-matter/

How you can help

You can help us take this project forward. We are currently raising funds to support preliminary data collection, which is fundamental to shaping and guiding the project. Data will also give us the basics to apply for institutional funds. Click here and help us out, every penny is worth it! https://www.gofundme.com/MHproject-Uganda

Interview with a woman in Muyage District about menstrual health by SOGH and UDHA.

For any further information or to get personally involved please email us at MHproject@sogh.se. You can also help by spreading the word, sharing this article on social media.

#OurPeriodsMatter #BloodyIssues

The Impact of HIV on Adolescent Girls & Young Women

World AIDS Day celebrates its 30th anniversary this year with the theme of ‘Know Your Status’.

Great progress has been made since the first World AIDS Day in 1988 – 3 in 4 people living with HIV today know their status.

However, the work is not yet done – especially for women. Women account for more than half of the people living with HIV worldwide. In particular, adolescent girls (10-19 years) and young women (15-24 years) are significantly affected by HIV and have high prevalence rates.

In Eastern and Southern Africa, women make up 26% of new HIV infections despite making up only 10% of the population. Statistically, young women will acquire HIV five to seven years earlier than their male counterparts.

Why are women and girls at high risk of infection?

HIV disproportionately affects young women and girls because of their unequal social, cultural and economic status in society. These challenges include gender based violence, laws and policies that undermine women, and harmful cultural and traditional practices that reinforce stigma and the dynamic of male dominance.

Here some other reasons why gender inequality leaves women vulnerable to HIV:

  1. Lack of access to healthcare services – women encounter barriers to health services on individual, interpersonal, community and societal levels.
  2. Lack of access to education – studies show that educated girls and women are more likely to make safer decisions regarding sexual and reproductive health and have lower risk of partner violence.
  3. Poverty – an existing and overarching factor that increases the impact of HIV.
  4. Gender-based violence & intimate partner violence – these types of violence prevent young women from protecting themselves from HIV.
  5. ‘Blesser/Sugar Daddy’ culture and transactional sex – sex with older men for monetary or material benefits, exposes young women and girls to low condom use, unsafe sexual practices and increased rates of STIs.
  6. Child marriage – girls who marry as children are likely to be abused by their husbands and forced into sexual practices.
  7. Biological factors – adolescent girls are susceptible to higher rates of genital inflammation, which may increase the risk of HIV infection through vaginal intercourse.

Importance of HIV testing

HIV testing in young women and girls is essential. Many receive access to treatment and care services after testing. Some important determinants of testing are:

  • Going through antenatal care
  • Being married
  • Having primary and secondary education

We need to aim for more young women and girls to being tested so that they know their status, and can access adequate care and treatment services. HIV testing is necessary for expanding on treatment and ensuring that people with HIV have healthy, productive lives.

Addressing the Impact

To address the impact of HIV on young women and girls we need to have approaches and interventions that incorporate the diverse perspectives of women and girls. This is needed on all platforms from campaigning and policy-making to program design. As the World Health Organization recommends, a woman-centred approach that includes women as participants is required, so that our needs, rights and preferences are considered.

Better strategies are needed across all health system to improve accessibility, acceptability, affordability, uptake, equitable coverage, quality, effectiveness and efficiency of services, particularly for adolescent girls worldwide.