The difficulty of being an adolescent in a poor rural household
The difficulty of being an adolescent in a poor rural household
Vijay Gopichandran
This Sunday, I saw two young adolescents in my clinic. One was a 14-year-old girl and the other a 17-year-old boy. I realized how difficult it must be to be an adolescent in a typical poor rural setting in Tamil Nadu. They came to me for completely different reasons, but a lot was common between the two. I will describe the reason for which they came and present an analysis of some of the inferences I made for myself from seeing them.
The young girl, Lakshmi (name changed), was accompanied by her father. That itself was very strange. When a young girl is brought to the clinic, it is usually the mother who comes along. Lakshmi was a beautiful girl, with beautiful big eyes, with a sparkle shining in them. She also had a very pleasant smile on her face with a small hint of shyness spreading all over it when I greeted her "Good morning". Lakshmi shyly lifted her right hand to the side of her forehead and gave a salute indicating good morning. Her mouth was spelling out the words "Good Morning", but no sound was coming out. Lakshmi was a beautiful and shy little girl! I asked Lakshmi, "What brought you to the clinic? What is the problem?" Lakshmi did not answer. Her father answered instead. He said, "She is very short and is not growing well." His voice was filled with anxiety as he said these words. Something did not fit in well. Lakshmi did not seem too short. This judgment is not based on a measurement of the height, just a guess on general observation. I probed more, "And then what? What else is the problem?" To this, the father looked to the sides with the corner of his eyes to check out if anyone is watching and whispered, "She has not become a big girl yet." I understood he was referring to puberty. I understood now that the main problem for which they had come to the clinic was because Lakshmi had not attained puberty and had not started having her menstrual cycles. I understood that this condition required more private conversation and took father and daughter to a separate room nearby and asked the father, "But she is only 14 years old. Why this hurry?" The moment I asked this the father replied, "She is studying in 9th standard. All of her classmates have attained puberty already. So the school teacher told us that we have to check her and see why she has not attained puberty."
The normal age of menarche, the onset of menstrual bleeding in a young girl is anywhere from 10 years of 16 years. There is no need to perform tests or check-ups until 16 years of age. Only if the girl has not attained menarche by 16 years of age, we start doing tests and scans to identify whether there is a problem. If the girl has normal growth and secondary sexual characteristics such as the growth of hair in private parts, development of breasts, then we can wait till 16 years for menarche to start. However, it is only when growth is restricted and the development of secondary sexual characteristics are absent that we test and check up even at 13 years of age. Therefore, I started planning the physical examinations that I must perform to evaluate Lakshmi.
Even as I was preparing to perform a physical examination, Lakshmi started speaking shyly. She said, "Doctor, my father took me to a lady doctor last week. She did some tests and said that I have a problem. So she has asked me to take some injections for helping me have the periods." Lakshmi handed over the file that she was carrying in her hand. They had visited a gynecologist the previous week. The gynecologist had done an ultrasound scan of the pelvis. The scan had the remark "Small uterus and small ovaries visualized". Lakshmi's father asked me what was written in the scan. I said, "The scan shows that her uterus and ovaries are small" Lakshmi's father, in a very anxious tone said, "Yes, doctor. That is what that doctor also told. She said if we leave it like this, Lakshmi will never have periods. So she asked us to give injections to make her have periods. My wife and I are scared. Please help us and our daughter." Lakshmi was watching all this and she had tears in her eyes by now. She was crying and said, "Doctor, because of me, my parents are scared and afraid. Everyone is always talking about me and asking what is wrong with me. What should I do now?".
I was moved by the plight of this beautiful girl and her parents. The society, especially rural societies, where the walls between homes are very porous and everyone pokes their nose into everyone else's business, if a girl takes a little longer time to attain menarche, she is labeled as "abnormal". The society, in all its well-meaning concern, had taken it upon themselves to label Lakshmi as abnormal and advice her parents to take her to the hospital for treatment. Poor Lakshmi and her parents had landed right into the fire, from the frying pan. The gynecologist who has seen her had broken protocol and performed unnecessary scans and tests on a young girl who still had 2 more years by when she could normally attain puberty. The unnecessary scan had been misinterpreted by the gynecologist as abnormal. The uterus and ovaries of a young pre-pubertal child will obviously be small. That cannot be interpreted as abnormal. Either out of ignorance or out of profit-making intention, the gynecologist has adviced costly injections, probably Gonadotropin-Releasing Hormone injections (a type of hormone injection that would kick start the puberty cycle). It took me a full 30 minutes to undo all the psychological damage done by society and subsequently by the gynecologist. I reassured Lakshmi and her father, gave Lakshmi nutritional supplements, advised her to eat well, play well and forget about menarche. I gave her a reasonable time till the end of 10th standard when she would just finish 15 years of age, after which we can see if we need to intervene. Lakshmi and her father left the clinic with a very small but significant smile on their face. It is very difficult to be an adolescent girl in a poor household in rural Tamil Nadu.
About an hour after I sent Lakshmi and her father home, another young boy walked into the clinic. He was about 17 years of age. Abdul (name changed) had dropped out of school and was working in a provision store in the nearby town. I first saw him about a month ago. He had come with complaints of dizziness and extreme fatigue. He and his mother were the main breadwinners of the family of 6 consisting of the mother, a grandmother, Abdul, two younger sisters, and a younger brother. His father had died when he was very young. Abdul had dropped out of school when he finished 10th standard and had started working in the provision store packing provisions and delivering them to houses. Abdul told me all this when I had interacted with him the previous visit. He also said, his weakness and tiredness is because he is unable to eat regularly and has a poor appetite. He also had a burning sensation in the stomach which prevented him from eating well. On further discussion, Abdul opened up and said that he was in love with a childhood sweetheart, who was just 16 years old, but her parents had started looking for prospective grooms for her to marry. The pressure of earning a livelihood to support his family, carrying the burden of educating and getting his younger siblings married, working odd hours with irregular food, and convincing his lady love's parents to wait for him and give their daughter to him in marriage, were all weighing down on Abdul heavily. These were unimaginable burdens to bear on the skinny shoulders of the adolescent boy. When I saw him this Sunday he looked bright and cheerful. I smiled at him and asked him, "How are you, Abdul? How is your love story?" Abdul smiled broadly and said, "Her parents have agreed to wait for 2 more years. I will save some more money to build my own home in the village and in the next 2 years I will marry Fameedha" Abdul would just be 19 years old then and Fameedha would be 18. Two adolescents would marry and start an adult life as a couple. I was remembering my own life when I was 17. I was in school, studying twelfth standard. All that I knew were school, studies, friends, tuitions, coaching classes. My entire life when I was 16 and 17, was occupied by planning and preparation for a future career. I did not worry about money, livelihood, food, siblings to support, or a serious marital relationship. And here is Abdul, a robust, young boy, who had completely bypassed the adolescent life and skyrocketed his way right into a burdened adulthood at 17 years. I felt sorry for Abdul, it is indeed very difficult to be an adolescent boy in a poor rural household.
When they teach us adolescence as part of pediatrics, psychiatry or community medicine, in medical school, they talk to us about the physical changes of puberty. They also teach us that adolescence is a tumultuous period of search for identity and establishing a sense of self. They teach adolescent life skills. We read about adolescent-friendly clinical services which must address the needs of adolescents in a friendly, non-judgmental and accommodating manner. But little do we realize that in the real world, adolescents of today go through pressures far beyond peer pressure. They go through societal pressures, bear the burden of societal expectations, and sometimes lose their entire adolescence in the bargain. Lakshmi and Abdul taught me that I must be highly sensitive when I handle adolescent patients. They are going through a lot - physically, mentally and socially. The least I can do is offer them a safe space to talk, discuss, ask questions, learn and teach me how to help them.
Vijay Gopichandran
This Sunday, I saw two young adolescents in my clinic. One was a 14-year-old girl and the other a 17-year-old boy. I realized how difficult it must be to be an adolescent in a typical poor rural setting in Tamil Nadu. They came to me for completely different reasons, but a lot was common between the two. I will describe the reason for which they came and present an analysis of some of the inferences I made for myself from seeing them.
The young girl, Lakshmi (name changed), was accompanied by her father. That itself was very strange. When a young girl is brought to the clinic, it is usually the mother who comes along. Lakshmi was a beautiful girl, with beautiful big eyes, with a sparkle shining in them. She also had a very pleasant smile on her face with a small hint of shyness spreading all over it when I greeted her "Good morning". Lakshmi shyly lifted her right hand to the side of her forehead and gave a salute indicating good morning. Her mouth was spelling out the words "Good Morning", but no sound was coming out. Lakshmi was a beautiful and shy little girl! I asked Lakshmi, "What brought you to the clinic? What is the problem?" Lakshmi did not answer. Her father answered instead. He said, "She is very short and is not growing well." His voice was filled with anxiety as he said these words. Something did not fit in well. Lakshmi did not seem too short. This judgment is not based on a measurement of the height, just a guess on general observation. I probed more, "And then what? What else is the problem?" To this, the father looked to the sides with the corner of his eyes to check out if anyone is watching and whispered, "She has not become a big girl yet." I understood he was referring to puberty. I understood now that the main problem for which they had come to the clinic was because Lakshmi had not attained puberty and had not started having her menstrual cycles. I understood that this condition required more private conversation and took father and daughter to a separate room nearby and asked the father, "But she is only 14 years old. Why this hurry?" The moment I asked this the father replied, "She is studying in 9th standard. All of her classmates have attained puberty already. So the school teacher told us that we have to check her and see why she has not attained puberty."
The normal age of menarche, the onset of menstrual bleeding in a young girl is anywhere from 10 years of 16 years. There is no need to perform tests or check-ups until 16 years of age. Only if the girl has not attained menarche by 16 years of age, we start doing tests and scans to identify whether there is a problem. If the girl has normal growth and secondary sexual characteristics such as the growth of hair in private parts, development of breasts, then we can wait till 16 years for menarche to start. However, it is only when growth is restricted and the development of secondary sexual characteristics are absent that we test and check up even at 13 years of age. Therefore, I started planning the physical examinations that I must perform to evaluate Lakshmi.
Even as I was preparing to perform a physical examination, Lakshmi started speaking shyly. She said, "Doctor, my father took me to a lady doctor last week. She did some tests and said that I have a problem. So she has asked me to take some injections for helping me have the periods." Lakshmi handed over the file that she was carrying in her hand. They had visited a gynecologist the previous week. The gynecologist had done an ultrasound scan of the pelvis. The scan had the remark "Small uterus and small ovaries visualized". Lakshmi's father asked me what was written in the scan. I said, "The scan shows that her uterus and ovaries are small" Lakshmi's father, in a very anxious tone said, "Yes, doctor. That is what that doctor also told. She said if we leave it like this, Lakshmi will never have periods. So she asked us to give injections to make her have periods. My wife and I are scared. Please help us and our daughter." Lakshmi was watching all this and she had tears in her eyes by now. She was crying and said, "Doctor, because of me, my parents are scared and afraid. Everyone is always talking about me and asking what is wrong with me. What should I do now?".
I was moved by the plight of this beautiful girl and her parents. The society, especially rural societies, where the walls between homes are very porous and everyone pokes their nose into everyone else's business, if a girl takes a little longer time to attain menarche, she is labeled as "abnormal". The society, in all its well-meaning concern, had taken it upon themselves to label Lakshmi as abnormal and advice her parents to take her to the hospital for treatment. Poor Lakshmi and her parents had landed right into the fire, from the frying pan. The gynecologist who has seen her had broken protocol and performed unnecessary scans and tests on a young girl who still had 2 more years by when she could normally attain puberty. The unnecessary scan had been misinterpreted by the gynecologist as abnormal. The uterus and ovaries of a young pre-pubertal child will obviously be small. That cannot be interpreted as abnormal. Either out of ignorance or out of profit-making intention, the gynecologist has adviced costly injections, probably Gonadotropin-Releasing Hormone injections (a type of hormone injection that would kick start the puberty cycle). It took me a full 30 minutes to undo all the psychological damage done by society and subsequently by the gynecologist. I reassured Lakshmi and her father, gave Lakshmi nutritional supplements, advised her to eat well, play well and forget about menarche. I gave her a reasonable time till the end of 10th standard when she would just finish 15 years of age, after which we can see if we need to intervene. Lakshmi and her father left the clinic with a very small but significant smile on their face. It is very difficult to be an adolescent girl in a poor household in rural Tamil Nadu.
About an hour after I sent Lakshmi and her father home, another young boy walked into the clinic. He was about 17 years of age. Abdul (name changed) had dropped out of school and was working in a provision store in the nearby town. I first saw him about a month ago. He had come with complaints of dizziness and extreme fatigue. He and his mother were the main breadwinners of the family of 6 consisting of the mother, a grandmother, Abdul, two younger sisters, and a younger brother. His father had died when he was very young. Abdul had dropped out of school when he finished 10th standard and had started working in the provision store packing provisions and delivering them to houses. Abdul told me all this when I had interacted with him the previous visit. He also said, his weakness and tiredness is because he is unable to eat regularly and has a poor appetite. He also had a burning sensation in the stomach which prevented him from eating well. On further discussion, Abdul opened up and said that he was in love with a childhood sweetheart, who was just 16 years old, but her parents had started looking for prospective grooms for her to marry. The pressure of earning a livelihood to support his family, carrying the burden of educating and getting his younger siblings married, working odd hours with irregular food, and convincing his lady love's parents to wait for him and give their daughter to him in marriage, were all weighing down on Abdul heavily. These were unimaginable burdens to bear on the skinny shoulders of the adolescent boy. When I saw him this Sunday he looked bright and cheerful. I smiled at him and asked him, "How are you, Abdul? How is your love story?" Abdul smiled broadly and said, "Her parents have agreed to wait for 2 more years. I will save some more money to build my own home in the village and in the next 2 years I will marry Fameedha" Abdul would just be 19 years old then and Fameedha would be 18. Two adolescents would marry and start an adult life as a couple. I was remembering my own life when I was 17. I was in school, studying twelfth standard. All that I knew were school, studies, friends, tuitions, coaching classes. My entire life when I was 16 and 17, was occupied by planning and preparation for a future career. I did not worry about money, livelihood, food, siblings to support, or a serious marital relationship. And here is Abdul, a robust, young boy, who had completely bypassed the adolescent life and skyrocketed his way right into a burdened adulthood at 17 years. I felt sorry for Abdul, it is indeed very difficult to be an adolescent boy in a poor rural household.
When they teach us adolescence as part of pediatrics, psychiatry or community medicine, in medical school, they talk to us about the physical changes of puberty. They also teach us that adolescence is a tumultuous period of search for identity and establishing a sense of self. They teach adolescent life skills. We read about adolescent-friendly clinical services which must address the needs of adolescents in a friendly, non-judgmental and accommodating manner. But little do we realize that in the real world, adolescents of today go through pressures far beyond peer pressure. They go through societal pressures, bear the burden of societal expectations, and sometimes lose their entire adolescence in the bargain. Lakshmi and Abdul taught me that I must be highly sensitive when I handle adolescent patients. They are going through a lot - physically, mentally and socially. The least I can do is offer them a safe space to talk, discuss, ask questions, learn and teach me how to help them.
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