Kestrel Unit, Forensic Services, Morisset Hospital, PO Box 833, Newcastle, NSW 2300, Australia
I read Sumathipala et als (2004) review on dhat syndrome with interest. The authors contention is that dhat syndrome is not culture-bound. My argument is although dhat is globally prevalent, the specificity of the culture (Ayurvedic concept) and certain psychosocial features being pathogenic in the development of dhat syndrome in the south Asian context cannot be ignored and the essence of the cultural perspective of semen loss anxiety in different geographical areas has been misunderstood.
According to the traditional Indian Ayurvedic system of medicine, genital secretions are considered a highly purified form of dhatu, or bodily substance, and loss of this precious substance is thought to result in progressive weakness or even death. In south Asia, the complaint of loss of genital secretions is regarded with concern by both men and women. The cultural and biomedical meanings of the complaint of leucorrhoea in south Asian women (Karen, 2001) demonstrate that the complaint of vaginal discharge accompanied by a host of somatic symptoms could not fit a particular biomedical diagnostic category, and is understood within the ethno-medical context of Ayurveda.
As noted by Malhotra & Wig (1975), Asian culture condemns all types of orgasm because they involve semen loss and are therefore dangerous. In contrast, the Judaeo-Christian cultures of the 18th and 19th centuries in Europe considered most types of sexual activities outside marriage to be sinful.
The so-called culture-bound syndromes have been the focus of the debate between adherents of biopsychological universalism (universal human psychopathology) and adherents of an ethnological cultural relativism (typical aspects of a particular culture). Culture-bound syndrome is not always bound (Westermeyer & Janca, 1997) but heavily related to certain cultural traits or cultural factors that can be found in different geographical areas, or across ethnicity or cultural units or systems, which share the common cultural view, attitude or elements attributed to the formation of the specific syndromes. Based on this new understanding, the term should be changed to culture-related specific syndrome to reflect its nature accurately (Tseng & McDermott, 1981).
REFERENCES
Karen, T.-K. (2001) Cultural and biomedical meanings of the complaint of leukorrhea in South Asian women. Tropical Medicine and International Health, 6, 260-266.[CrossRef][Medline]
Malhotra, H. K. & Wig, N. N. (1975) Dhat syndrome: a culture-bound sex neurosis of the orient. Archives of Sexual Behavior, 4, 519 -528.[Medline]
Sumathipala, A., Siribaddana, S. H. & Bhugra, D.
(2004) Culture-bound syndromes: the story of dhat
syndrome. British Journal of Psychiatry,
184, 200
-209.
Tseng, W. S. & McDermott, J. F., Jr (1981) Culture, Mind and Therapy: An Introduction to Cultural Psychiatry. New York: Brunner/Mazel.
Westermeyer, J. & Janca, A. (1997) Language, culture and psychopathology: conceptual and methodological issues. Transcultural Psychiatry, 34, 291 -311.
Section of Epidemiology, Institute of Psychiatry, London
Sri Jayawardenpura General Hospital, Nugegoda, Sri Lanka
Section of Cultural Psychiatry, PO 25, Institute of Psychiatry, London SE5 8AF, UK
We are delighted to note the varying and huge response to our paper (Sumathipala et al, 2004). It is interesting to note that most of the comments are from the Indian subcontinent where the dhat syndrome is prevalent.
Drs Kuruppuarachchi & Wijeratne point out that semen loss anxiety is a form of communicating distress. We agree, but our conjecture is that male preoccupation with semen loss has been universal and we need to place the related depression and anxiety in the specific context. Our contention with which Kuruppuarachchi and Wijeratne agree is that ICD10 and DSMIVTR are culturally influenced classificatory systems. Wigs (1994) suggestion that culture-bound syndromes should be integrated into existing rubrics of psychiatric classification is an appropriate one. Most of the correspondents feel that culture-bound syndromes should be separate, which is an assertion we disagree with.
Drs Painuly & Chakrabartis suggestion that there are cases of pure dhat also reflects the possibility that there are cases of pure depression. To argue that treatments should reflect the diagnosis is putting the horse before the cart. It is not true to say that neurasthenia does not exist any more. Neurasthenia as a diagnosis exists not only in China but also in France, once again emphasising that idioms of distress do cross cultural boundaries.
Dr Gonjanur misses the point we were making. The semen loss anxiety which led to Kellogg and Graham marketing corn flakes and Graham crackers, respectively, as treatment (for semen loss) has disappeared from the West because of changes in the social, political and economic climate. Why have the symptoms that were widely prevalent and described in the UK, USA and Australia in the 19th century disappeared over time? Dr Shankar seems to argue that Ayurveda is a culture; it is a system of medicine developed at a specific time. It should be left to historians to discern whether Ayurveda reflects the culture or the culture is influenced by Ayurvedic concepts in exactly the same way as Western medical systems reflect or influence Western cultures. We believe that culture-bound syndrome as a nosological category is a colonial invention and deserves to be dumped in the bin of history. We agree that culture plays a key role in how symptoms are allowed and encouraged to be developed and expressed by individuals. However, the role of culture is essential for all our patients and not a few selected ones. Everyone has culture.
One of the key factors that the correspondents have chosen not to discuss is the distinction between disease and illness. Dhat as a symptom and syndrome reflects illness in the broadest term. The clinicians are trying to place this in a disease category, thereby paying lip service to cultural influences only in the pathological diagnostic sense, not in a broader idiom of distress. Although some acknowledgement is made to the heterogeneity of the syndrome, we believe that cultures themselves are markedly heterogeneous and the clinicians must address not only the cultural values and identity of individuals but also those of the cultural groups to which the individual belongs, and place the expression of distress in its historical and social context. It would appear that our correspondents are arguing for exemption for a geographical syndrome. It is indeed a pity that Westermeyer & Jancas (1997) argument is not universally accepted in the classificatory and nosological systems as it deserves to be the exact point we have striven to put across. Culture-bound syndromes have fascinated anthropologists and psychiatrists alike as accounts of strange syndromes, myths and symbols. We urge clinicians to place these symptoms in the context of cultural values and not simply medicalise and pathologise distress that can be dealt with using other models. Another question that deserves to be raised and answered is why amok in Malaysia is seen as a culture-bound syndrome but similar behaviour of random shootings and running amok is not seen in this way in the USA? It is time that we gave up the ghost of colonialism and looked at culture-bound syndromes with a new eye. We acknowledge that culture is an important pathogenic and pathoplastic influence but our belief is that culture-bound syndromes are a historical anomaly. Dhat as symptom is important but the classification of dhat syndrome is problematic.
REFERENCES
Sumathipala, A., Siribaddana, S. & Bhugra, D.
(2004) Culture bound syndromes: the story of dhat
syndrome. British Journal of Psychiatry,
184, 200
-209.
Westermeyer, J. & Janca, A. (1997) Language, culture and psychopathology: conceptual and methodological issues. Transcultural Psychiatry, 34, 291 -311.
Wig, N. N. (1994) An overview of cross-cultural and national issues in psychiatric classification. In Psychiatric Diagnosis (eds J. Mezzich, Y. Honda & M. Kastrup), pp. 3 -10. New York: Springer.
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