(The characters sketched in this piece are composites of several individuals I’ve  encountered in my training and my life.  They contain elements of real patients and acquaintances but do not represent strictly true accounts of specific people.)

The couple who walked into my office for a consultation the other week seemed, at first, similar to many of the South Asian immigrants I've met.  He, confidently dressed in Western clothing, entered and spoke first.  She, slim and even-featured in a brightly colored sari, had a diffident smile and walked a step or two behind her husband.  

They'd come, he (and she) said, because she was depressed.  She seemed sad, a bit withdrawn, wasn't sleeping well.  Could I help?

The husband graciously offered to leave the room so I could talk privately with the patient.  She remained vague about her concerns.  She reiterated that she felt a bit down, but then said that really she was feeling all right.  She admitted to waking frequently at night but then said really she felt well rested enough.  She agreed she'd lost some weight, but then volunteered that she'd been about this weight before the birth of her first child so that seemed all right to her.  And her marriage?  Well, yes, perhaps there were some problems in her marriage.  What problems?  Oh, nothing.  Well, maybe something.  Maybe nothing important.  

I probed gently, cautiously.  The marriage was an arranged one.  I nodded, unsurprised.  At twenty years of age, this woman had married a man she'd known only a couple of weeks and then followed him to the farthest corner on the globe from her family and his.  Since then they'd had two children together, and made a place and a life for themselves in a local community of similar immigrants.  On the surface, things were fine.

And beneath that?  Well, perhaps their sex life wasn't... what she would wish.  She was resolutely vague on this matter, absolutely unwilling to offer up any detail or clarification.

We made no headway until the patient's husband returned and revealed the room's elephant: He was gay.  He had had several homosexual encounters with men over the course of the marriage.  He understood this was contributing to his wife's pain.  He wondered whether I would be willing to help her out.  With an antidepressant.

In truth, I was stunned.  Evidently the man did not see his homosexuality as any significant barrier to maintaining his marriage.  I glanced at the woman.  She had turned her face entirely away from both of us and was staring resolutely at the door.  Every tendon in her taut pose said I want out of here.  
 
Open homosexuality in India is, frequently, tantamount to social suicide.  The term 'gay' is used as an insult, indicating unmanliness or cowardice.  Avowed homosexuals are often treated as outcasts from mainstream society.  Nonetheless, since the decriminalization there of homosexual intercourse in 2009, gay social scenes have blossomed cautiously in the larger cities.  Yet in a nation in which three-quarters of the population lives in rural areas, this is still a drop in the bucket.  Indian society is structured around the extended family unit.  A single person past the age of marriage generally loses social status and suffers gossip and stigma.  Marry one must then, and present one's parents with healthy and studious heirs.  

Any wonder, then, that many of India's gay population simply bow to the cultural expectation of marriage?  No need to suffer the singles scene; marriage to someone suitable can be arranged swiftly enough to avoid tripping the gaydar of the lucky bride (or groom).  If s(he) has any.  One can easily be married in India far younger than the age when many gay Westerners discover their own true sexual orientations.

And then what?  

Escape to the West offers some slippage of the knot.  Far from the watchful eyes of family and neighbors, hairline cracks in the marriage eggshell are not so visible.  If one spends a lot of time with male friends, if one's wife seems saddened and distracted, who is to notice really?  And if one can grit one's teeth and think of England enough times to produce a male heir, then none will be the wiser.

But with freedom comes peril.  Divorce is not so taboo here.  In India, a divorcee can expect social opprobrium and little chance of remarriage.  The cost associated with leaving an unsuitable husband may thus be far greater than the benefit.  (Divorced men have more hope of a second chance.)  But in the West, that calculus can be reversed.  

What to do with the couple before me?  An antidepressant seemed unlikely to improve the situation.  The wife had no past history of any mood disorder, and antidepressants don't fix trying life circumstances.  Counseling seemed in order, but I wasn't culturally equipped to provide it.  What would be the goal?  To maintain the marriage?  To dissolve it?  The husband's wishes seemed clear but I wasn't sure the wife would ever say enough to me for us figure out what it was she wanted.

Ultimately I told them I'd ask my colleagues to see if I could find them a referral to a South Asian psychiatrist who, I felt, might have a better chance of helping them.  Neither of them seemed particularly happy with that - after all, there is also a stigma against mental illness among Indians that presents a strong barrier to either consulting a psychiatrist or becoming one.  It had probably taken a good deal of courage and need for them to come to me in the first place, and here I was passing the buck to somebody else.  I felt sorry for these two people, yoked sadly in an arrangement that fulfilled neither.  But the pills and workbooks in my arsenal were not designed for such a situation.  What they seemed to need, I thought, was the answer to Reinhold Niebuhr's Serenity Prayer: serenity to accept the things one cannot change, courage to change the things one can, and the wisdom always to know the difference.