Introduction and Cultural Framing

This paper describes the results of an exploratory qualitative study of the social meanings of stress and hair loss—or “hair fall,” as it is typically known in India—among a sample of 27 Kannada-speaking Hindu women in Mysuru, a city in the South Indian state of Karnataka. This research focus on hair fall arose spontaneously as part of a larger study of women’s distress, during which participants often spoke about hair fall as both a source and a symptom of affliction. The present analysis addresses how women describe and understand hair fall in relation to stress, and whether hair fall may serve as an idiom of distress in this particular context and population.

Idioms of distress are culturally specific ways of expressing distress that are recognized by others and produce a response from them (Nichter 1981, 2010). They vary across cultures and, importantly, are “linked metaphorically to key conflicts at the interpersonal and societal level and that are often based on local ideas about the functioning of the body and mind” (Hinton and Lewis-Fernández 2010:211). Identification and description of idioms of distress have been part of medical and psychological anthropology for decades, spurred partially by these subfields’ turn toward postcolonial subjectivity and frameworks that link the individual to the social (Good 2012; Robbins 2013). By treating non-biomedical expressions of suffering seriously, this approach resists biomedical taxonomies that reify distress as psychiatric disease (e.g., clinical depression). That de-centering is important clinically as well as philosophically because, as the field of Global Mental Health has demonstrated time and again, psychiatric interventions risk doing harm in places where psychiatry is not culturally relevant (e.g., Abramowitz 2010; Jayawickreme et al. 2012). In other settings, idioms of distress have been used in clinical applications, helping make mental health treatment more culturally acceptable and effective (Hinton and Lewis-Fernández 2010).Footnote 1

Research in a range of cultural contexts documents profound stigma, stress, and identity shifts related to hair loss, particularly in the psychology literature (Ghanizadeh and Ayoobzadehshirazi 2014; Hadshiew et al. 2004; Hansen 2007; Schielein et al. 2020; Russo et al. 2019). Some daily hair loss is a nearly universal experience: on average, people lose 100–150 hairs from their heads per day (Paus and Cotsarelis 1999). The biomedical literature links stress and hair loss above this baseline level through a variety of physiological mechanisms, including inflammation that can damage hair follicles or shorten their life cycles (Hadshiew et al. 2004). Cytokine upregulation has also been shown to play a role in slowing hair growth (Peters et al. 2017), altering hair follicle responses to stress hormones, and leading to potential spot baldness (Ito 2010). Research in medicine and psychology often acknowledges the psychosocial burden of hair loss as evidence of its prima facie importance, especially for women (e.g., Russo et al. 2019), but studies rarely address people’s lived experiences of this condition (Hadshiew et al. 2004).

Hair, Gender, and Culture in India

Hair holds deep religious, personal, ethnic, and gendered symbolism in South Asia (Hiltebeitel and Miller 1998), just as it does in other parts of the world (Sherrow 2006). Hair in India has a long history of academic analysis, particularly in the fields of symbolic and psychological anthropology (Berg 1951; Hershman 1974), and particularly in South India and even in Mysuru itself (Leach 1958; Iyer 1928, 1935). Gananath Obeyesekere’s (1981) classic monograph Medusa’s Hair is perhaps the best-known ethnography detailing how hair in South Asia—in this case, long, matted hair on the heads of ecstatic Buddhist-Hindu priestesses in Sri Lanka—serves overlapping personal and cultural symbolic functions. Although matted locks represent something significant to a broader public in which priestesses are embedded, they are also, according to Obeyesekere, “manipulatory, that is, used by individuals” (1981:36) to express closeness with the deity and reflect the processes of psychological travail that preceded their calling.

Those luminary scholars have cemented hair in South Asia as a focus of contemporary cultural studies, but there is also significant religious-textual context relevant to hair in India, especially in the Hindu canon. As far back as the (ca.) 2nd Century text the Laws of Manu, hair is described as a sign of fertility and therefore a key criterion on which to assess women’s suitability for marriage [e.g.: “A man should not marry a girl who is a redhead or has an extra limb or is sickly or has no body hair or too much body hair…” (Doniger and Smith 1991:74)]. During Hindu marriage ceremonies in many parts of India, including the study site, the bride’s hair is parted in a manner that is classically described as a field or furrow, and the groom (or, in some variants, another actor) fills the part with vermilion powder, its red color evoking fertility and sexuality (Hershman 1974; Thompson 1998). From that moment, a married Hindu woman will continue wearing vermillion in her hair until her death or widowhood.

Thick, lustrous hair groomed in this way functions as an auspicious sign of fertility and virtuous Hindu wifehood, according to the literature (Miller 1998; Olivelle 1998; Thompson 1998). Unbound hair, by contrast, is described as being representative of ritual impurity, associated with women’s monthly periods, mourning, separation from one’s husband, spirit possession, and sexual availability (Hershman 1974; Hiltebeitel 1981). Hindu women in Mysuru typically wear their hair in a manner that conforms to these textual injunctions: parted in the middle and bound in a long braid or ponytail at the nape of the neck, often adorned with jasmine flowers and a swipe of red vermillion in the part. Dominant standards around hair and propriety extend even to non-Hindus and to women not personally invested in fertility, marriage, or “traditional” feminine representation. For instance, this norm is the unstated standard against which women who subvert mainstream feminine images by sporting short haircuts define themselves (Miller 1998; Thompson 1998), and there are many such women among Mysuru’s higher socioeconomic groups.

If Just as hair is a synecdoche of feminine virtue, lack of hair—especially unintentional hair loss—is associated with moral and spiritual precarity. As but one example, concern about women’s fallen hair appears in South Indian Hindu hagiography with the story of Āṇṭāḷ, a female saint in the Bhakti (devotion) literature. One version of the story describes how one of Āṇṭāḷ’s hairs gets stuck in a garland intended for the god Vishnu when she secretly tries it on, imagining herself his bride. When her father, a humble garland-maker, discovers the hair, he is horrified by this mark of impurity and produces a new garland to take its place. But Vishnu comes to him in a dream, requesting the garland with the hair because Āṇṭāḷ wore it with such strong devotion (Flueckiger 2015:81–82; Narayanan pers comm.; Venkatesan pers comm.). This hair in the garland is at once a source of ritual pollution and anxiety, and a marker of intimate connection with the divine. This example serves as the source of the present paper’s title because it clearly reflects both the anxieties and the polysemy that are part of women’s hair fall.

Aside from the ritual pollution of hair not attached to a head, intentional hair removal is also one of the markers of loss of femininity as fertility, particularly for upper-caste Hindu widows (Miller 1998). For these groups, ritual actions focus on the cooling of sexuality and gradual separation from the bonds of life through penitent action: wearing white in place of bright colors, eating non-spicy foods, removing all signs of being a wife, including the vermillion powder in the part, and even in some cases shaving one’s head (Miller 1998; Olivelle 1998). Relatively recent ethnographic work in Karnataka similarly reflects how the government-sanctioned cutting of the hair of Devadasis (female temple dancers, who may engage in ritual sex) is practically and symbolically central to attempts to surveil and control this “aberrant” population (Ramberg 2009).

While the foregoing discussion underscores how intimately hair, gender, sexuality, and social standing are entwined for Hindu women across the life course, we do not intend to imply that women consciously or directly draw on this embedded cultural meaning when they think about their own hair. In Mysuru, rumination about whether daily hair loss is normal or too much, and worse, the perception that hair loss might be increasing, is common and often openly discussed. Much like Obeyesekere’s (1981) research informants, however, women do not explicitly articulate associations between hair and sexuality, gender, or morality.

To that end, we conceptualize hair fall as an everyday phenomenon existing against a rich backdrop of cultural meaning that circulates in largely unstated realms. This paper works from the proposition that concern about hair fall is a salient aspect of distress in this context because of its apparent ability to both reflect and provoke distress, and because of its deep metaphorical connections to key aspects of gendered Hindu identity (Lewis-Fernández and Kirmayer 2019; Nichter 1981, 2010).

Methods

Research Setting and Partnership

The study took place in Mysuru, a city of about a million residents in the South Indian state of Karnataka. It was conducted in partnership with the Public Health Research Institute of India (PHRII), an NGO run by and for local women to deliver reproductive healthcare to marginalized groups in the Mysuru area. The state language of Karnataka is Kannada, but like most Indian cities, Mysuru is multilingual and religiously and ethnically diverse, with significant representation of Telugu, Urdu, Hindi, English, and Tamil-speaking groups, and Christian, Muslim, Hindu, and other religious groups.

Mysuru is a compelling site for studies of distress. There is more psychiatric care available in Karnataka than in many other parts of India because the National Institute of Mental Health and Neurosciences (NIMHANS) is headquartered in the nearby city of Bengaluru (Bangalore). NIMHANS provides gold-standard psychiatric training and residency for physicians and both inpatient and outpatient care. Yet, over the past decade of their work in their community, PHRII staff report that women virtually never avail themselves of those services, even when they are experiencing extreme distress, in large part because of the strong stigma associated with seeking mental healthcare in this cultural context (Koschorke et al. 2014; Raguram et al. 2004; Shidhaye and Kermode 2013). People also rarely use clinical terms to talk about distress colloquially, even though this is something that is emerging in other parts of India (Halliburton 2005; Weaver 2017).

Ethical Approval

All study procedures were pre-approved by the first author’s USA-based Institutional Review Board (# 04132019.025) and by PHRII’s India-based Ethical Review Board (# 2019-04-20-49). Participants provided oral-informed consent by phone prior to their participation, then again in person at the start of each focus group discussion. They were compensated for travel expenses to and from the PHRII office.

Field Methods: Sampling and Data Collection

The hair fall investigation was embedded in an ongoing study that explores how Kannada-speaking women in Mysuru express distress, how they perceive major causes and correlates of distress, and what pathways they might take for resolving that distress. It began in 2017. The data for this paper come from a series of 6 focus group discussions (FGDs) conducted in 2019 with a total of 33 PHRII service recipients (4–6 participants per group). Women were recruited for these FGDs by PHRII employees using snowball sampling, beginning with contacts in 17 socioeconomically distinct neighborhoods identified by PHRII staff through community relationships established over the past decade of research work. Eligibility criteria included being a woman between the ages of 18 and 65, speaking Kannada as their first language, self-identifying as Hindu, and being married or previously married. Women who did not meet these criteria, who declined to participate, or who could not participate due to impairment were excluded. These inclusion and exclusion criteria were designed to recruit a relatively ethnically and culturally homogeneous group from Mysuru’s diverse population. This homogeneity was important for the larger study’s aim of elucidating specific stress terms, which can differ significantly by subculture.

The FGDs followed a structured interview guide based on the authors’ prior exploratory interviews with women from the same population to develop a working understanding of Kannada stress terminology, concepts, causes, and themes (Weaver et al. 2021). The FGD interview guide prompted women to discuss the definition, recognition, causes, and treatments for 10 stress concepts that had emerged during prior interviews, including hair fall. We earmarked an additional 4 stress concepts that had potential theoretical or cultural importance (based on the researchers’ prior knowledge and results of previous interviews) for follow-up if people in the FGDs mentioned them without prompting (see Table 1, below, for a brief list of key terms and follow-up prompts used in the FGDs). This paper addresses only the data from conversations around hair fall.

Table 1 Key terms and probes used in FGD prompts
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Focus group discussions were conducted in Kannada at the PHRII office and led by a PHRII employee trained in cognitive interviewing, focus group facilitation, and epidemiological survey administration. All FGDs were voice recorded for later transcription and translation. After each FGD, researchers escorted participants individually to private areas to collect a series of demographic and personal data. We also used a Kannada version of the Patient Health Questionnaire-9 (PHQ-9) to measure each participant’s clinical depression symptomology to verify that the sample was not biased toward unusually high levels of depression symptoms. The Kannada PHQ-9 was translated, back-translated, and adapted for clinical use by local mental health professionals (Sasthri and Chandramouli unpublished). The PHQ-9 asks participants to rate their experience of 9 symptoms in the previous two weeks on a Likert-type scale: not at all, several days, more than half the days, or nearly every day, which are scored 0, 1, 2, and 3 and summed to create a summary score for each participant. Scores can, therefore, range from 0 to 27; clinical guidelines for the PHQ state that a score under 5 indicates no depression risk, 5–9 may indicate mild depression risk, 10–14 moderate depression risk, 15–19 moderately severe depression risk, and 20–27 severe depression risk (Kroenke et al. 2001).

Data Analysis

Translated and transcribed focus group discussions were analyzed by the first author using MaxQDA qualitative analysis software. We used a modified grounded theory approach with a combination of inductive and deductive codes not only to identify passages of text addressing hair fall, but also to allow space for new themes to emerge directly from the data (Bernard 2006; Corbin and Strauss 2007; Ryan and Bernard 2003). Some a priori codes such as “hair fall causes” were included. We developed additional codes as themes emerged across transcripts (e.g., “hair fall as sign of serious disease”). Finally, we ran a keyword-in-context search for “hair” across all transcripts to double check that we had not missed any relevant passages (Ryan and Bernard 2003). Throughout this process, we subjected the coded data to memoing and employed the constant comparative method to identify content trends (Glaser and Strauss 1967).

Results

Participant Demographics

Of the 6 focus group discussions (FGDs), 5 addressed hair fall (one FGD was cut short). These results are, therefore, based on 5 FGDs, consisting of a total of 27 participants, rather than the full sample of 6 FGDs, consisting of 33 participants.

Although we recruited women who were Hindu and native-Kannada-speaking by design, the sample captured some diversity in caste background, education level, age, and income. Participants were all women and averaged 35 years old (range: 23–52). They had an average of 10 years of education (through the second year of high school, when students receive a degree in India’s “10 + 2 system”; the final two years result in an additional degree), ranging from 5 to 14 years. They represented an array of caste and ethnic communities, including the government-designated “scheduled tribes” (ST; indicating tribal groups), “scheduled castes” (SC; indicating low castes, many of which were at one point considered “untouchable”), “other backward castes” (OBC; indicating lower but not necessarily formerly “untouchable” castes), and “general” castes (primarily Gowda and Vokkaliga in this part of Karnataka). A combined 56 percent of the sample was from ST, SC, or OBC groups. Four women were formally employed, while the rest self-identified as “housewives.” All were married, one was separated, and one widowed. Their average estimated monthly household income was INR 17,259 (range: 5000–40,000, or roughly USD $66–533 at the time of writing), and they had an average of 1.6 children (range 1–4), and an average household size of 4.9 people (range 3–12). Their average score on the PHQ-9 was on the borderline between “no depressive symptoms” and “mild depressive symptoms” according to published cutoffs (Kroenke et al. 2001). This baseline measurement suggested that women in this study were not atypically distressed in biomedical terms. See Table 2, below, for a summary of these attributes.

Table 2 Demographic indicators and key outcome variables in the study sample (n = 27)
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Salience of Hair Fall

Across the FGDs, hair fall was a seemingly universal concern. Strikingly, every participant reported experiencing hair fall, and some even characterized it as a central concern for women like themselves (“It is the main problem for ladies nowadays,” said one). They also closely monitored their hair fall. “If we lose even one hair, we feel it!” exclaimed one participant. No participant characterized losing hair as a normal part of life, and most viewed any loss of hair as potentially problematic.

Causes of Hair Fall and Overlap with Other Idioms of Distress

Women associated hair fall with three main causes: 1) distress; 2) medical conditions; and 3) changes in one’s habits or life stage. They also talked about hair fall in relation to other idioms of distress that have been previously documented in this context. Below we address each of these themes.

In the first category, women regularly associated stress and hair fall. They often used the English word “tension,” an extremely common term used to discuss distress across South Asia (Weaver 2017). For instance, when asked about whether she had ever experienced hair fall, one woman said, “Five years ago, my husband had a problem. I was feeling sad at that time. Now those problems have gone, but that was a tension for me at that time. We didn’t get consultation from the doctors; I used to cry every day. As a result, I had hair fall.” Another agreed, “Too much hair fall happens if we take too much stress or tension.”

Others associated hair fall with stress but did not specifically use the term “tension.” The most common alternative term was “thinking too much” (tumbā yōcane), which 3 women used. One participant even cited a Kannada proverb about hair fall and rumination: “Old people say, ‘Oh ho, don’t think too much or your last three hairs will fall out!’ (Āyyō, tumbā yōcane māḍbēḍa irō 3 kūdalu udurutte).” Two women mentioned stress or pressure (ottaḍa), 1 talked about worries (cinte), and 2 used the technical term for depression (khinnate). As evidence of this association between stress and hair fall, 2 women gave the example of school-aged children, who, they claimed, lose more hair during stressful exam periods or because they read too much.

A second major category of hair fall causes was things that women referred to as “scientific” or “medical” causes. Many, but not all, of these centered around medical conditions involving hormonal change. One reported that she began having hair fall after her monthly periods got so heavy that she became severely anemic and had to get a blood transfusion. Two women mentioned that after birth, new mothers experience hair fall, particularly when their babies cry. Two others cited thyroid disorder as a cause, and one of those had experienced this herself. Two felt poor sleep increased hair fall, and 2 others mentioned cancer—either as a cause of hair loss, or in the context of chemotherapy-induced hair loss. One woman also mentioned jaundice and fever. Three women blamed diets lacking in sufficient vitamins or proteins, while 2 others specified that it was not the content, but the timing, of meals (“not eating on time”) that could induce hair fall.

Beyond frank stress and medical or nutritional concerns, women volunteered several additional causes of hair fall related to change (e.g., in seasons, life stage, hair products). One talked about how after she got a bobbed haircut, her hair never grew back as long as it had been before. She attributed this to hair fall—that is, the hairs were falling out before they had a chance to grow long. One observed that she experienced more hair fall at the onset of winter. Two women reported that bathing in water heated electrically or through solar power caused them to have hair fall. Several reported that changing the brand of one’s shampoo or hair oil would trigger hair fall. One felt that certain types of hair oil would promote hair fall, even while others asserted that oiling the hair and massaging the head would prevent it. Finally, 1 woman attributed hair fall to age. “Even if we don’t think too much, there will be hair fall for women after 30–35 years of age. Actually, even before 30; 18-year-old girls will also have this problem. Even I am facing it now. This is the reason for my tension.”

In addition to these proximate causes leading directly to hair fall, women talked about broader factors in their lives that created stressful conditions that could precipitate hair fall. These stresses were social in origin, typically relating to husbands or parents-in-law (sometimes both), neighbors’ gossip, or the heavy burdens of domestic management. One woman explained that she became most stressed when her husband “shouts at me, listening only to my mother-in-law and just scolding my kids. I get tense that he will not listen to me.” Intra-household discord resulting from sons’ split allegiance between their mothers and their wives was common; women also complained of their mothers-in-law’s split allegiance between their daughters-in-law and their own daughters.

Beyond family, women worried a lot about neighborhood gossip; several talked about how they hated to hear their neighbors gossiping about others, or how they themselves had been double-crossed by people they had treated as confidants. “…People will speak nicely with us, but when we are not there they speak nonsense about us. It hurts us a lot; we feel bad about that. We think they will be speaking well in front of us, but then they will back-bite us. We can’t understand why. We will even get confused: with whom we should talk, or if it’s better if we don’t talk to anyone at all. I will just stay alone at my home without talking to anyone else.” Another said, similarly, “If I share things with neighbors, I feel they might tease or criticize me later. We can’t share our tensions with everyone.”

Finally, domestic burdens were an extremely common source of stress for women. “I feel that I cook for the whole week, and so I want a break on Sundays. I ask my husband to take us to hotel [restaurant] on Sundays, but he doesn’t. I feel sad at that time. I feel that all I do in life is cook and feed others and eat.” Others talked about the stresses of the daily household routine: getting children and husbands fed and out the door each morning, while simultaneously solving their problems and making sure household finances are distributed properly.

Consequences of Hair Fall

While the FGD prompts did not specifically ask women to discuss the consequences of hair fall, it arose spontaneously during discussion. We already described how women perceived that stress led to increased hair fall; but, importantly, they also felt the opposite: that hair fall created stress. Two women talked about how their hair fall caused them to worry that perhaps they had a serious undiagnosed illness, yet they felt too scared to go to the doctor and find out. “We feel scared,” explained one participant, “about why there is so much hair fall. Is there a problem with us?” A second participant echoed her, “Even for me, there is so much hair fall.” And then a third chimed in: “That has become a major issue. Hair fall itself is a tension now!”

Given the close association between femininity, propriety, and hair in this cultural context, it stands to reason that women might fear hair fall in part because of the social consequences of being perceived as less feminine or of not fulfilling particular gendered roles. This theme did, in fact, emerge in the FGDs. One woman reported that her husband “scolded” her unfairly when a hair fell in the food she had cooked for him—a moment remarkably reminiscent of Āṇṭāḷ’s hair falling in the Bhakti hagiography we described in the introduction. Her husband chided her, she complained, even though she knew it was her daughter’s hair that had fallen in the food and told him so. Another woman said that if she had a short haircut, her family would not take her to functions (weddings or other social events), so she felt compelled to cope with treatments such as oiling, rather than simply getting her troublesome hair cut. And a third woman critically observed that college girls rarely wear their hair long these days, speculating that this was because their studies disturb their mental state and make it impossible for their hair to grow long. “Just see the college girls, earlier they used to have long braids, but now girls take even small things seriously and get tension. They get tensed even to read. Some of them have no time limit for reading. I haven’t seen girls with longer hair now.” The implication here is that as girls increasingly venture outside domestic roles into public spaces and higher education, their hair can no longer grow long because of the physical and mental stress induced by activities like too much reading.

Hair Fall Treatments and Care Seeking

Almost everyone reported actively engaging in treatments to minimize hair fall; only 2 reported that they did nothing to treat it. “I have not done or used anything. I have just left it, thinking if it wants to then let it grow, otherwise no,” said one, who had given up after treatments failed to slow her hair fall. In general, discussion about these treatments was lively; women became visibly animated as they shared tips and strategies among themselves.

Treatments could be store-bought or homemade, and most women said they used homemade treatments as a matter of practicality, affordability, and effectiveness. Women made treatments at home by infusing coconut or castor oil with herbs, or making a paste to apply to the hair. Four women said they had used YouTube to find recipes for anti-hair-fall treatments. Homemade treatments included ingredients such as onion juice (mentioned by 5 women), curry leaves (5), fenugreek paste (4), aloe vera (3 women), henna (2), betel leaf (2), coriander (2), hibiscus (1), and beet juice (1)—components of Ayurvedic medicine valued for their cooling, shine-producing, dandruff-treating, hair retaining, and moisturizing properties.

A few women mentioned using commercial treatments to address hair fall. In Mysuru (and across India), there are large markets for shampoos, conditioners, oils, serums, and other products that claim they mitigate or prevent hair fall. Like the home preparations, these commercial treatments aim to directly counteract heat in the scalp using cooling Ayurvedic herbs, such as henna leaf (Lawsonia inermis), neem leaf (Azadirachta indica), amalaki fruit (Emblika officinalis), and bhringraj leaf (Eclipta alba). The two treatments women mentioned by name in this study were Ashirvad (“Blessing”) herbal hair oil, produced by a Bangalore-based company with “Adivasi [tribal] Ayurvedic herbs…collected from deep forests,” according to their website (https://ashirvadherbalhairoil.in/), and Indulekha Bringa oil, produced by a national distributor. At the time of this writing, these treatments cost between 27 and 36 Indian rupees per mL (or 0.36–0.48 US dollars), and typically were sold in bottles of 50–250 mL, making them expensive by local standards.

Of those who had used these commercial treatments, no one reported that they had yielded particularly good results; one even found them so harsh that they caused her intolerable headaches and she had to stop using them. Women generally reported much better results with the home treatments they produced themselves; only 2 said that home treatments did not help.

In addition to these treatments applied directly to the hair, women talked about making lifestyle changes to address hair fall. Three mentioned paying attention to diet—particularly eating leafy greens and pulses. “Rather than spending money on other things [treatments], we should consume it—then our health will be good and our hair will grow,” explained one participant who had tried the expensive store-bought treatments with no results. Another two women said simply, “I have to reduce getting tensed” to address their hair fall problems.

Finally, 3 women consulted biomedical physicians for their hair fall. One of the doctors told the participant that she was experiencing hair fall because of “hormonal and menstrual problems,” while another doctor attributed hair fall to improper sleep. Neither doctor had provided any treatment, but a third woman said she had gone to her doctor and taken an (unspecified) medicine to treat it. One additional woman, when asked about what she could do to manage hair fall, said she had wanted to go to “the [outpatient] hospital” for it, though she had not done so.

Discussion

This qualitative study explored how one group of Hindu, Kannada-speaking women in South India understand, describe, and manage hair fall. Hair fall in this cultural context refers to all kinds of hair loss, ranging from regular hair shedding during bathing or brushing to more severe loss that might lead to thinning or patchiness. The introduction outlined the cultural importance of hair for women in this context by describing how classical Hindu texts and rituals describe long, thick hair as a symbol of femininity, fertility, and appropriate womanhood. Against that background, this study theorized hair fall as a potential idiom of distress and used focus group discussions to explore causes, consequences, and treatments for hair fall. The results suggest that hair fall possesses attributes of an idiom of distress and also intersects with known idioms of distress in this part of India.

In a basic sense, hair fall proved useful for stimulating group discussion about stress. The discussion not only elucidated hair fall’s relationship to stress but also generated new insights for us, as researchers, about the kinds of stresses that most impacted women across their lives beyond hair fall. In what follows, we briefly summarize key themes emerging from the results and situate them in the broader literature and study aims.

Across the focus group discussions (FGDs), hair fall was a topic of lively discussion and clear concern. This was reflected in the fact that every participant reported hair fall, and they closely monitored their daily hair loss. All but 2 reported that at the time of the study that they were actively engaged in treatments to mitigate or prevent hair fall. Whether homemade or purchased, these treatments incorporated Ayurvedic herbs known to have cooling and conditioning properties. This approach to treatment aligns with ethnophysiologies of emotion and heat in this context, where women talk about distress causing tale bisi (“hot head”) (Nichter 1979; Weaver et al. 2021). In this model, the heat of intense emotions such as anger or distress can accumulate in the head, causing scalp temperature to rise and the hair to loosen and fall out. Conversely, keeping a “cool mind,” or being someone who is not easily perturbed, is considered a valuable personal attribute in many parts of India (Ecks 2014), and arose in spontaneous discussion in the study site as well.

Women conceived of hair fall as a site of action—that is, as a thing that should and could be changed, possibly even eliminated with proper treatment. They also conceived of hair fall as something that could spiral out of control if not kept in check through regular washing, oiling, and treating of the scalp. At no point did any participant state that some hair fall is normal; they seemed to perceive even baseline daily hair loss as problematic. Marketing around commercial products for hair fall treatment also acknowledges no baseline threshold of normal daily hair loss but rather advertises an implicit or explicit ability to completely stop it. This stands in contrast to the biomedical model of hair loss, which reports that some daily hair loss is part of the regular cycle of growth and replacement (Paus and Cotsarelis 1999).

In terms of the causes of hair fall, women articulated a clear connection between hair fall and stress of all kinds, both episodic and chronic in nature. Episodic stressors included things like school exams, studying too hard, illnesses, or social conflicts, while chronic stressors were invariably social concerns having to do with family conflict, neighbor, or peer criticism, and the general stresses of managing busy households. This echoes findings from other studies of stress among women in India, including the first author’s prior work in North India, which demonstrate that social concerns such as children’s academic success or ensuring that they maintain good relationships with neighbors and family are often at the forefronts of their minds (Snell-Rood 2015; Weaver 2017, 2019).

When describing the relationship between hair fall and stress, women employed idioms of distress that have been identified in the prior literature. They most frequently used the terms “tension” (in English) or the Kannada phrase “thinking too much” (tumbā yōcane) to talk about distress that can lead to hair fall. (Said one woman, “We will keep on thinking and worrying; we will be depressed. So I have got hair fall. Even I think, ‘Oh I had long hair, but now I have lost so much due to hair fall!’”). Prior research on “tension” in India (Atal and Foster 2021; Weaver 2017) and “thinking too much” across cultures (Hinton et al. 2016; Kaiser et al. 2015) documents that these two idioms are used to express a broad range of distress experiences, from quotidian annoyances to debilitating pathological afflictions. These expressions, the authors point out, provide culturally acceptable ways of airing grievances, expressing distress, and soliciting support without reverting to the often highly stigmatizing or culturally unfamiliar framework of biomedical psychiatry. The connections women made between hair fall and “tension” and “thinking too much” suggest linkages between hair fall and broader categories of distress in this context. That finding is important to the topic at hand because it implies that hair fall does serve idiomatic functions—perhaps best reflected in the proverb one respondent offered: “Oh ho, don’t think too much or your last three hairs will fall out!” It also appears to function as a symptom of these other idioms of distress. A recent study among Cambodian refugees similarly documents hair loss as a symptom of culturally significant idioms of distress for this population (Hinton et al. 2018).

Although women certainly agreed that hair fall and stress were related, they described it as a potentially cyclical rather than a unidirectional relationship. Stress caused hair fall, as we already discussed, but the reverse was also true: hair fall caused stress. Women expressed a sense of inevitability around hair fall: once it began, it could be slowed or minimized but never entirely eliminated. For some, hair fall was stressful because it caused social strain, as in the case of the woman who said her family would refuse to take her to social functions if her hair was too short. This stress was also aesthetic; women found thick, long hair beautiful, and hair fall jeopardized that esthetic goal. “My hair was very thick before,” bemoaned one participant. “People would say it was like a bunch of grapes (drākṣiya gon̄calu), but now I’ve lost all that good hair.”

Beyond these social and aesthetic concerns (which were certainly salient), women also found hair fall stressful because they feared it could indicate a more serious underlying health problem. Many women described links between hair fall and physiological illness, pointing to an underlying biomedical conception of hair fall. Women frequently talked about hormonal conditions that cause hair changes, such as childbirth, thyroid disorder, or menstrual irregularities. Women also stated that hair fall could be caused by poor diets lacking “vitamins” or “protein,” and endorsed healthy diets consisting of legumes and leafy greens as a way to treat or prevent hair fall. One woman even stated that it was the improper timing of meals that would lead to hair fall, reflecting the intricate rules around preparation, serving, and timing of meals that is patterned in many parts of India by religion, caste, season, and life stage (cf. Khare 2004). This finding speaks to the polysemy of hair as a potential signal of overall physical health status in this cultural context, not just an indicator (or responsive factor) of stress on metaphorical levels.

Somewhat unexpectedly, since many women said hair fall could be related to a medical condition, they rarely reported seeking any form of medical treatment for it. Only 3 out of the 27 women said they had ever been to a medical doctor for hair fall, and only one had actually received a medication for it. Instead, women relied almost exclusively on homemade treatments. These generally consisted of herb-infused oils or pastes that women would make from ground-up or boiled herbs prescribed in Ayurvedic medicine to cool the head and promote healthy hair and scalp. A few mentioned brand-name products they had purchased from markets to treat hair fall, but they were generally unsatisfied with the results. They reported much more satisfaction with homemade treatments, which were inexpensive and therefore relatively more accessible. Notably, no women referred to these treatments as “Ayurvedic,” even though they listed Ayurvedic ingredients as the key active factors in their formulations. This finding reflects the long tradition of medical syncretism in India, where people freely draw on Ayurveda, Unani, homeopathy, herbalism, bonesetting, faith healing, and biomedicine in parallel and often do not label practices as deriving from one tradition or the other (Ecks 2014; Flueckiger 2006). It also reflects a trend the first author found in prior research, where women often found homemade and herbal treatments preferable to biomedical ones because of concerns about medications’ side effects (Weaver 2019).

Limitations

This study was exploratory and, therefore, should not be treated as generalizable. While we attempted to recruit a sample that would capture diversity in caste, socioeconomic status, and age, the sample was limited to Hindu women who speak Kannada as their native language. Moreover, because of participant confidentiality concerns and the way the focus group discussions (FGDs) were recorded and transcribed, we were unable to preserve direct links between participant identifiers, demographic indicators, and individuals’ specific statements during FGDs. This foreclosed insights about how personal characteristics shaped women’s responses. We also did not collect in-depth individual narratives about hair fall experiences; the data were limited to comments that women were willing to express in a group setting. Although the FGD facilitator ensured confidentiality, women likely avoided sharing the most difficult personal experiences, which might have shed light on the broader ethnographic circumstances in which hair fall exists. Ethnographic work addressing women’s personal experiences with stress and hair fall over time would be a useful next step in this research.

Conclusions and Future Directions

Across India, hair has strong gendered, moral, and life-stage connotations for women. Unsurprisingly, then, women routinely express anxiety over hair loss—or “hair fall,” as it is known in this context. This study theorized hair fall as a potential idiom of distress among Kannada-speaking Hindu women in Karnataka. It explored how women conceive of the links between distress and hair fall, and considered whether hair fall might provide a non-stigmatizing alternative for discussing stress without reverting to biomedical psychiatric terminology, which can be highly stigmatizing in this cultural context (Shidhaye and Kermode 2013; Raguram et al. 2004; Weiss et al. 2001).

Our results point to hair fall as a salient as an idiom of distress for Kannada-speaking Hindu women in Mysuru. Women described hair fall as both a product and a cause of stress, and they often used other idioms of distress identified in the literature to discuss it (Hinton et al. 2016; Kaiser et al. 2015; Nichter 1979; Weaver 2017). Women viewed hair fall as a problem to be addressed through proper actions. They generally agreed that hair fall could be slowed or even stopped with appropriate treatment, which they pursued enthusiastically. They related hair fall to circumstances that extended well beyond the proximate concern of hair loss, describing it as a condition that both arises from, and contributes to, stress—particularly locally salient forms of distress such as “tension” and “thinking too much,” and particularly socially generated forms of stress such as family strife. As a physical symptom that appeared to index far more than physical pathology (though women did in some cases associate hair fall with disease), hair fall was connected to gendered questions of social belonging, propriety, and beauty.

This research draws attention to the cultural significance of hair fall and its apparent idiomatic function in this specific cultural context, but questions remain. Outside a focus group or interview setting, does hair fall serve as a communicative device about more than just hair fall itself? That is, during un-staged conversations, do women use hair fall as a way of talking about larger life stresses, as they did in this research? How does hair fall function in relation to other idioms of distress, such as the associations with “thinking too much” and “tension” that arose in the present study? Would it be useful to ask women about hair fall in clinical or future research settings to screen for potentially pathological distress? Do men also experience and express hair fall idiomatically? Does hair fall function in the same way in other parts of India, or in other nations? The preliminary results of this study suggest that each of these would be valuable future directions for research.

Given the value of idioms of distress for clinical applications, especially in contexts where biomedical psychiatry is either not widespread or is stigmatized (Hinton and Lewis-Fernández 2010), hair fall could be a promising direction for scholars and practitioners interested in using non-medicalized terms in this part of South India and possibly more widely in India.

Although this study was limited to relatively superficial focus group discussions, the results demonstrate that hair fall is a socially acceptable way of approaching rich conversation about categories, causes, and consequences of distress in women’s lives.