I begin this trilogy with the somber opening statement: ‘Mental illness matters, conversations matter.’ And talking of conversations, the biggest taboo conversation is: ‘Complex calculus of mental illness, intimacy, sex, companionship, marriage and divorce.’
India has history of being close-lipped and cringe-faced about sex and mental health on an individual level. But talking about ‘mental illness’ and ‘intimacy and sex’ together is a ‘double-whammy’, deeply entrenched stigma.
Also, in India, companionship for sufferers of severe mental illnesses is proscribed by the society, while marriage is proscribed by the statute if one spouse has severe mental illness. Worse, if the sexual orientation of the mentally ill person is different from the dominant societal norms, despite recent salutary pronouncement by the Supreme Court, the deeply entrenched ‘Corrective/Conversion Therapy’ by psychiatric community still rules the roost. And finally, talking about the divorce and mental illness, if one spouse in the matrimony is mentally ill, Indian courts often grant divorce — ‘worst sufferers of this liberal divorce paradigm are mentally ill women.’
THE CURTAIN RAISER
If such is the existential situation, it is the time to first normalise the conversation about the subject and then forcefully change the narrative. To this extent, this trilogy is a curtain-raiser on this vitally important but most neglected subject.
It is time to start non-judgemental conversation to decode the complex calculus of mental illness, intimacy, sex, companionship and love, marriage, and divorce in India. In part one of the trilogy, I bring out of the closet the complex relationship between mental illness, intimacy, and sex.
The core purpose of this article is to create awareness of the unique challenges partners suffering from mental illnesses face and to arm them with resources and strategies that will help them grow and nurture such relationships.
THE CONTEXT FIRST
Let me set the context first. October has special significance for mental health. Every year it is globally observed as the World Mental Health Month with the aim to address mental health issues in an empathetic way. Also, contextually relevant is 10 October 2022, ‘The World Mental Health Day’, whose overarching theme this year is: ‘Making Mental Health and Well-Being for All a Global Priority’.
MENTAL ILLNESS SUBSUMES UMBRELLA NOSOLOGY
Like cancer, mental illness is an umbrella word that subsumes hundreds of mental disorders. About 145-page long, first edition of Diagnostic and Statistical Manual (DSM)-I of American Psychiatric Association (APA) published in 1952 included 106 mental disorders. In the latest DSM-5-TR (Text Revision), published in March 2022, the number of pages has ballooned to 1,120 with hundreds of diagnostic categories of mental disorder types and subtypes.
MENTAL ILLNESS, INTIMACY AND SEX
Mental disorders have profound impact on the intimacy, sex, and sexuality. Many impacts are owing to the mental health conditions themselves, but many more are heaped on sufferers by the train of treatment regime itself that is designed to ameliorate or cure mental illnesses.
It is impossible to cover such impact on all mental disorders in a capsule article. As such, I dwell upon the complex conundrums of prominent mental disorders and sex.
SUPPRESSION OF RIGHT TO INTIMACY, SEX AND PROCREATION OF MENTALLY ILL
I begin with how badly right of intimacy, sex, and procreation of mentally ill has been suppressed globally in the 20th century, with the running theme across nations and societies being: ‘Break their Lineage, Break their Roots, Break their Connections and Break their Origins’
Tyranny against mentally impaired is rooted in history and culture. In ancient Greece, which was made up of city states and relied on warriors to maintain power and empire, physical or mental impairment was considered unacceptable weakness. Disabled babies should be killed, as taught by Aristotle and Plato.
And thus, began Eugenics.
Societies across Americas, Europe, and Asia, have for centuries ruthlessly trampled upon the undeniable basic human right of intimacy, sex, and procreation of mentally ill, but this abominable practice reached crescendo in the 20th century powered by the powerful ‘Eugenic’ movement.
There is this famous case of the US Supreme Court — ‘Buck v. Bell’. The story is, in 1927, Carrie Buck, a poor white woman, was the first person to be sterilised in Virginia under a new law. Carrie’s mother had been involuntarily institutionalised for being “feebleminded” (severely mentally ill) and “promiscuous”. Carrie was assumed to have inherited these traits and was sterilised after giving birth. Justice Oliver Wendell Holmes wrote in the judgement with reference to Carrie: “Three generations of imbeciles are enough.”
The US Supreme Court judgement turned precursor to sterilisation of 65,000 Americans with mental illness or developmental disabilities between the 1920s and the 1970s, with more than 20,000 in California itself.
Europe including Scandinavian nations and China had their own horror stories.
AKTION T4: THE FINAL SOLUTION
Unsurprisingly, Nazi genocide of psychiatric patients is the greatest criminal act in the psychiatric history with no parallel in the world.
On 14 July 1933, the Nazi government instituted “Law for the Prevention of Progeny with Hereditary Diseases”, which with the avowed goal of creating an Aryan “master race,” called for sterilisation of all persons who suffered from hereditary diseases such as ‘mental illness, learning disabilities, physical deformity, epilepsy, severe alcoholism, etc’. These people were dubbed as “life unworthy of life” and “useless eaters”.
Thence began the Nazi Germany Pogrom Code named AKTION T4, to systematically exterminate patients with ‘severe psychiatric, neurological, or physical disabilities’.
To give one example, estimated 220,000 to 300,000 Schizophrenia patients were killed under the pogrom. This represents between 73 percent and 100 percent of individuals with Schizophrenia living in Germany between 1939 and 1945.
Worse was the fate of children with early signs of mental and physical disability. On 18 August 1939, the Reich Interior Ministry issued a decree requiring all physicians, nurses, and midwives to report new-born infants and children under 3 years who showed signs of mental or physical disability. And beginning October 1939, public health authorities began encouraging parents to admit such children to specially designated paediatric clinics: ‘These, clinics were children’s killing wards where specially recruited medical staff murdered their children by lethal overdoses of medication or by starvation.’
SOMETHING LIKE WAR
What about India?
Independent India has its own dark history of state-sponsored population control, often with eugenic aims, ‘particularly targeting poor, underprivileged, mentally, and physically impaired’. According to the United Nations, India alone was responsible for 37 percent of the world’s female sterilisation in 2011. Also, India carried out 4 million sterilisations during 2013-2014 on mostly women (with less than 100,000 surgeries on men).
Forced sterilisation of mentally ill and disabled women and girls has been the rule rather than the exception in the country including in mental asylums and prisons.
Worst happened during 1975 Emergency as part of Sanjay Gandhi’s “gruesome campaign” to sterilise poor men including a large number of physically and mentally impaired. An astonishing 6.2 million Indian men were sterilised in just a year, which was “15 times the number of people sterilised by the Nazis”, according to science journalist Mara Hvistendahl.
Post Emergency was the turn of forced sterilization of women including women and girls with physical and mental disabilities. These coercive sterilisations embodied gendered violence of the worst order, and time and again we hear of women dying of forced sterilisation.
Documentary ‘Something Like a War’ (1991), by Deepa Dhanraj, examines India’s blotched forced criminal sterilisation from the point of view of women themselves. In 1994, reports of hysterectomies of women and girls with disabilities (physical and mental) raised a storm in the country including a report by the India Today.
Narratives in above paragraphs depict how the inalienable basic human rights of intimacy, sex and of procreation and even of the very life of the mentally ill have been butchered globally, including in India. It is time to bring the whole subject matter in the open with the bold pronouncement: “Mentally ill have as much need and basic human right of ‘intimacy and sex’ including of the procreation as the normative population despite the litany of woes brought in the train of their mental health conditions as well as the very psychotropic medicines they are administered to cure or manage mental illness.”
This subject turns critically important in light of the World Health Organization’s ‘World Mental Health Report (2022), as per which one billion people worldwide suffer from some form of mental disorder. How can one deny the right of ‘intimacy, sex and procreation’ to this biggest minority population of the world?
Though every mental illness has its own complex relationship with ‘intimacy and sex,’ I deal here with the more important ones. And I begin with the good news that despite challenges brought in by mental illnesses, it is possible to be in a healthy, loving, and long-term partnership with someone who has a mental illness.
Rather it is what must be the paradigm.
I posit humbly: ‘Despite suffering from mental Illness, the conjugal life can still be fulfilling.’
CONNECTION BETWEEN DEPRESSION, INTIMACY AND SEX
Major depressive disorder (MDD) brings plethora of sexual challenges, including erectile dysfunction and impotence in men and sexual pain and severe loss of sexual desire in women.
Plainly speaking, MDD is serious dampener to libido and desire to have sex whether one is in a relationship or not. People with depression often recoil in their cocoon, shunning connections and deny them opportunities of intimacy and sex and that in itself perpetuates depression.
As women are more likely suffer from depression than men, it often leads to them feeling insecure about their bodies, feeling less desirable, often doubtful about their sexual confidence and severely insecure about participation in sexual activities.
Women in the throes of depression often experience low libido and low arousal, while men suffer from erectile dysfunctioning and in rare cases even impotency.
Unfortunately, Selective Serotonin Reuptake Inhibitors (SSRIs), antidepressants prescribed to ameliorate depression, often worsen sexual dysfunction both in men and women because SSRI depressants increase serotonin in the brain, which tempers depression and anxiety but often also have severe negative impact on sex drive or inhibit the ability to feel sexual pleasure.
But there are ways to cope up.
As a starter, depression, however severe, in most cases is not a permanent condition. It is awful while it is there but, depression finally goes away, and the sex drive returns to normalcy. This makes the role of understanding and considerate partner critically important.
Also, not all medications are severe inhibitors to the sex drive. Being open to the doctor and shifting to a medication regime that has fewer sexual side-effects is a potent nostrum. Also, exercise, even leisurely morning walks often lessens depression.
And if the sexual dysfunction persists, one should not shy away from meeting a therapist to eradicate the traumatic experience, let go of the psychological barriers and shame.
Also, there is a saying when it comes to ability or inability to enjoy sexual pleasures no one knows one’s body more than the person himself/herself. It is here that when one is low, often taking to solo sexual gratification activities, like masturbation, to discover oneself holds key so that one can discuss with the partner and practice what touch one likes. Also, a series of mindful exercises help in letting go of the trauma and promote body awareness and acceptance of the existential issues related to intimacy and sex.
ANXIETY DISORDER AND SEXUAL ISSUES
Anxiety disorders are double whammy. On one hand like depression, anxiety disorders lead to decreased sexual desire and appetite. Anxiety distracts sufferer from sexual stimuli, turning detrimental to sexual desire and arousal. Contrarily, there are cases where anxiety disorder sufferers experience heightened sexual desire and appetite for sex, which in more severe cases, leads to compulsive sexual behaviours about which I will talk a bit later.
Anxiety symptoms like excessive worries, obsessive thoughts, panic, and fear of falling short of partners’ expectations are linked to premature ejaculation in men and intense pain during sexual arousal and difficulty reaching orgasm in women.
Also, in cases laden with anxiety, prior unsatisfactory experiences with sex, often leads to vicious cycle of the anxiety and sexual dysfunction in both women and men.
The coping strategies discussed in the case of depression also have salutary effect on banishing the negative sexual side-effects of anxiety disorder. Also, the role of the partner is again critical because anxiety like depression is not permanent and in most cases anxiety disorder has a shorter timespan than Major Depressive Disorder (MDD) and is more easily treatable.
Sex therapists recommend a specialised technique to help sufferers get the problem out of their head and reconnect with their sensual and sexual feelings. One is “non-demand touching,” i.e., touching (and being touched) without particular outcome or expectation in mind — with a partner or solo, for however long one wants. It is not about foreplay or arousal, simply touching and being touched (from head to toe) with a sense of curiosity to get reacquainted with respective bodies helps without bothering what is happening but rather experiencing what is happening Also, talking to the partner openly often helps one pass through the phase of anxiety. It is tricky but immensely helpful
BIPOLAR DISORDER, SEX AND SEXUAL INDISCRETION
Unlike Major Depressive Disorder (MDD) and anxiety disorders, relationship between intimacy, sex, sexuality, and sexual indiscretion in bipolar disorder is extremely complex.
In Bipolar Disorder, sufferers alternate between the abyss of depression and the flame out of mania with the period of depression lasting much longer than that of the mania. In between is the remission period of varied duration. During remission, a bipolar patient has rather normal life of intimacy and sex.
However, in Bipolar Depression the depletion of sexual energy and desire, experience of low libido and the loss of interest in all activities related to intimacy and sex, is the mirror image of that in Major Depressive Disorder (MDD) with similar coping strategies as in MDD.
But there is one significant difference.
Antidepressants that often succeed in ameliorating MDD conditions, work differently in Bipolar Depression and instead. Instead of improving Depression and its intimacy and sex related side-effects, anti-depressants often transport Bipolar patients from depression to the other pole mania, a period of extremely heightened sexual energy, high libido, heightened sexual activities and sexual indiscretions often with dangerous consequences.
As per diagnostic criteria of bipolar disorder a key predictor of mania often in heightened sex related goal directed activity with high potential of painful consequences.
In the paras below I remove the veil of secrecy this hidden taboo subject of mania talking about which is banned at home, about which patients are seldom warned by practising psychiatrists and sufferers themselves dare not talk about it either privately or publicly due to extremely high stigma surrounding it: ‘total lack of sexual inhibitions and rampant sexual indiscretion in manic state.’
Is it not discussed either privately or publicly because we as a society fear knowing the naked truth. So, I begin with the damning revelation: “There is causal connection between mania and heightened hyper-sexuality, promiscuity, and sexual indiscretion. Sexual-exhibitionism and promiscuity are often key predictor of bipolar mania.”
A conservative Indian mind will be shocked to know, that sexual derangement are norms in bipolar manic attack and not exception. DSM versions III to latest DSM 5-TR all acknowledge goal directed increased sexual appetite and sexual indiscretion as key determinant of mania. With mania comes bundled plentiful of “sexual preoccupation, high hyper-sexuality, uninhibited sexual provocation, lewdness, shamelessness, nudity, exhibitionism, unpredictable promiscuity, multiple extramarital affairs.”
I know my dare devil hypothesis may be questioned by both the psychiatric community and bipolar patients and their parents as well as laymen. But not telling the truth the way I understand today after decade and half research on the subject, shall be like keeping an unholy mum.
In search of the truth, I reached Wisdom, Madness and Folly (1952) by John Custance, the first authentic memoir of a manic depressive that I could lay my hands on. The book gives an extraordinary insight into a bipolar mind. And what I found in writings of Custance will be shocking to conservative Indian mind.
Custance wrote about his sexual dalliance during manic high: “Religious feelings and emotions combined with sexual impulses caused me to give away three hundred pounds, (which I could ill afford) to ladies of easy virtues… First time I was accosted somewhere in Bond Street…it was a call. Someone wanted me and I could not refuse… I had found a mission. I could and must serve these women… I gave money away till my bank warned me about overdraft, but I was convinced God would give me money to carry on.” (Wisdom, Madness, and Folly; Page 48)
Custance wrote further: “Judging from my own experience, sexual symptoms of manic state seem to be most powerful and important… normal inhibitions disappear. Release of the sexual tension seems to me to be the primary and governing factor of all the ecstasies and many other experiences of manic state” (Wisdom Madness and Folly; Page 44)
But this is the experience of one individual. That too immoral westerner. Why should we virtuous Indians care? Also, one single case of such an example in a manic episode cannot be the norm. And definitely not applicable in the case of Indian Bipolar rooted in Indian culture with strong value systems.
Or is it really so? What is the real truth of Bipolar Mania? Whether hyper-sexuality and sexual indiscretion integral to it or just an incidental exception?
With these questions in mind, I dared to look at the scientific literature on the matter. And what I learn has humbled and shocked me: “What I have found is that there is abundance of plentiful scientific literature linking mania with inappropriate sexual behaviour.
Let me dwell upon just a few of them: Arteaeus of Cappadocia, as early as 150 AD, talked of definitive lewdness and shamelessness as predictors of mania. But Arteaeous was a man of another era, science has got much more advanced today. What is the recent literature?
I found it sobering to find that Arteaeus’ findings are corroborated by Tuke in the 19th century and by the father of modern psychiatry, Kraepelin, in the early 20th century. Also, Bluer, contemporary of Kraepelin, found the same inter-linkages between mania and hypersexuality.
The intersection of mania and sexual indiscretion is further validated by Campell and Mayer Gross towards the mid-20th century and by Spalt and Jamison towards end of the 20th century.
The list keeps growing.
Goodwin and Kay Redfield Jamison, based on meta-study of seven studies, reported in 2007 that 57 percent of bipolar patients experienced heightened sexual energy, lack of inhibition and indiscretion during mania. This is hell of a number to be ignored
All researchers concur: “Sexual indiscretion is a key predictor of mania.”
Consequences of sexual Indiscretion in mania are many: They ruin relationships, destroy familial fabric, bring unwanted diseases, and leave behind a truck load of destructive debris. Most often because it is pleasurable in nature, impulsive, reckless sexual behaviours and significantly increased sex drive are not even considered as a problem.
Admitted an increased interest in sexuality on its own during a manic phase should not be a big problem so long as it finds the safe outlet but that is hardly the case because in bipolar mania often hyper-sexuality and sexual indiscretion get turbocharged with other dangerous symptoms of bipolar mania — impulsivity, risk-taking, behaviour and poor judgement, all these combined have lethal impact, and destroy the sanity of the person and send him reeling under irresponsible behaviour with huge collateral damage.
In the last two decades I have come across a sample of at least hundred Indian men and women, boys, and girls, inexperienced and mature, who have landed in trouble because of this taboo consequence of mania. A few lost their relationship, yet in a few other cases there was a painful collapse of marriage. In couple of cases I also personally know of completed suicide on this count.
In a country this big, anecdotal sample of one hundred is minuscule and unreliable. But make no mistake. When manic fever finally subsides and sufferers return to the depressive pit, manic phase sexual indiscretion comes to haunt them and often in life, he or she dies every day, but biggest sufferers are partners and family.
Should we continue with the unholy silence? Should we merely dub it a Western phenomenon? Or, should we do a sincere soul searching? Is it not time for at least the psychiatric community to guide Bipolar patients that there can be such a situation and if such a situation presents itself, one must immediately ask for help.
In past two decades I have been treated by six psychiatrists and one therapist for my bipolar disorder — only one of them had the courage to tell me that extremely high libido and sexual indiscretion can be a painful problem arising out of manic crescendo and with devastating consequences.
This is why I decided to lift the veil and break out from the deadening Indian silence prevailing in Indian society whose collateral damage is humungous to bipolar patients, their partners, and families.
CONNECTION BETWEEN PTSD AND SEX
Let me inject a personal note.
As I have written time and again and talked on TV shows and mental health conferences, I was brutally, serially and sexually assaulted in childhood which had deleterious impact on my adulthood sexual life. My pain lessened only after I decided to break open about my sordid past in my The Economic Times opinion piece (Rising Urban and Professional Suicides, The Economic Times, 21 January 2010) and simultaneously in the TV show ‘Zindagi Live’ telecast multiple times in 2010 on Hindi channel (IBN) — sister concern of the News18 network.
Make no mistake, sufferers of childhood sexual assault develop multiple mental illnesses, including PTSD, and have troubled and painful adult sexual life. In most cases it is the victim thing but in odd cases they also face hypersexuality, or out-of-control sexual behaviour and worst they turn sexual predators in revenge act.
Scientific studies reveal that people with traumatic childhood experience have less satisfying adulthood sex lives, including long-lasting psychological consequences. These are often associated with ‘post-sex blues’ or ‘postcoital dysphoria (PCD)’.
One may find it strange but in sufferers of PTSD and PCD, even amazing, enjoyable sex with a loving partner can be triggering experience owing to past traumas. Studies corroborate experiencing orgasms can feel awful psychologically in such cases because of sexual abused in childhood. Extreme PTSD cases can also result in some people to have ‘low-to-no sexual desire at all, both in men and women.’
But all is not lost. There is a ray of hope.
Therapy is a potent solution in such cases. But travesty is beyond metropolises, India has few good therapists or clinical psychologists. The majority of them suffer in silence due to extreme stigma and lack of psychiatric facilities.
Fortunately, at least in the case of caring partners, something else also works: Let me call it ‘Aftercare’
Aftercare helps couples avoid negative psychological effects of their sexual encounter, it staves off post-sex blues, and helps relieve underlying sexual shame. In Aftercare, caring and understanding couples devote to cuddling, talking, and caring for each other after sex, ensuring both partners feel at ease — especially after an intense consensual sexual experience. This solution has been seen to be often effective for those suffering from PCD or PTSD.
But sadly, in a country in which talking about sex itself is a taboo, Aftercare is more of a fiction, though it is a potent solution.
SCHIZOPHRENIA, INTIMACY AND SEX
I know many in India and outside, both men and women, leading relatively normal (though subnormal) professional, familial and sex life despite suffering from Schizophrenia. But in more severe cases lack of sexual life rather sexual dysfunction is the bitter truth.
Psychiatric symptoms, institutionalisation, and psychotropic medication contribute to frequent impairments in sexual functioning in Schizophrenic patients. Studies though reveal, women suffering from schizophrenia have relatively better social outcome and longer lasting (sexual) relationships, and more offspring than men with schizophrenia.
Nonetheless, in general, sex and schizophrenia in have troubled cohabitation in both males and females. Both social and interpersonal impairments limit development of stable sexual relationships.
Patients of Schizophrenia often consider their sexual problems to be highly relevant, but rarely there is conversation on this among patients, clinicians, and caregivers, leading to an underestimated unmet sexual need of such patients.
Additional problem is encountered in severe forms of Schizophrenia where international studies using structured interviews or questionnaires indicate sexual dysfunctioning in relatively large numbers. Although sexual functioning can be impaired due to varied reasons, the intensive use of antipsychotic medication (more particularly risperidone and classical antipsychotics) and more frequent crippling institutionalisation are dominant spoilers.
Though severe form of Schizophrenia and sex have complex antagonistic relationship, all is not lost. Psychosocial strategies to treat antipsychotic-induced sexual dysfunction comprise psychoeducation and relationship counselling. Studies also suggest pharmacological strategies including but not limited to lowering doses or switching to a prolactin sparing antipsychotics have some promising result, but we are way off finding solutions to the complex difficulties associated with Sex and Schizophrenia.
POSTSCRIPT
Indubitably, relationship between severe mental illness, intimacy and sex is complex but I dare say: Mentally ill? So what? Life can still have rainbow colours. In Part 2 of the trilogy, I cover the more difficult arena of mental illness, love, companionship, and the institution of marriage
This is Part 1 of the three-part series on mental health.
Akhileshwar Sahay is a multidisciplinary thought leader with Action Bias and Impact Consultant. He suffers from Incurable Bipolar Disorder and is an avid researcher in the arena of mental illness and mental wellness. He was a member of GoI’s Mental Health Policy Group and is a past member of GoI’s Central Mental Health Authority (CMHA). Views expressed are personal.
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