Medical Risks and Benefits of the Sweat Lodge

Introduction

O ne of the most universal spiritual and health practices among First Nations peoples in the Americas has been the sweat lodge. Sweat lodges are probably ancient and were certainly present when the first Europeans arrived, though by no means limited to the Americas: Herodotus, Homer, and the Prophet Muhammad described similar practices. ¹ Hippocrates himself asserted that fever and the conditions that produce fever are frequently curative, and the sweat lodge has always been considered beneficial to health by the cultures in which it is utilized (Russian bania, Turkish hamman, Jewish shvitz, and “sweat hut” of various African peoples are other examples). American Indians assert a variety of benefits from participation in sweat lodge ceremonies, encompassing and unifying the biological, psychologic, social, and spiritual realms. ² Indian people sometimes invite friends from outside their tribes to participate, and these ceremonies have grown in popularity and have been appropriated by those outside native culture, especially “new agers,” with mixed reactions from Indian Country. ^2,3

Accounts of at least four deaths associated with the sweat lodge, however, suggest that caution is needed. The deceased were all whites. An Iowa man died in 1998 in a makeshift sauna “patterned after” a sweat lodge. ³ No cause of death is given. An Australian man in 2004 died of dehydration and heat prostration, and in June 2002 a 34-year-old woman and 36-year-old man died in the United States in a “lodge” of airtight plastic. ⁴

The Finnish sauna appears to be roughly analogous physiologically, ^1,p.4 and there are several recorded sauna deaths, with contributing factors including heatstroke in an individual with Hashimoto thyroiditis, alcohol use, cocaine use, heart disease, and epilepsy. ⁵ Sauna bathing, however, is not usually supervised and is often undertaken alone. (Subjectively, the author has experienced both sauna and sweat lodge and finds both leave him physically feeling much the same as did high-school track practice.)

Having sounded the alarm about possible mortality, it must be emphasized that no Native American deaths are documented from the sweat lodge. This may be because it is typically done in a careful manner by highly experienced leaders who are familiar with the individuals and the process, and with participants who know their limits.

Joe Bruchac, author, ¹ elder, and sweat leader, takes most seriously the responsibility for sustaining the safety and health of those who participate in sweats he leads (personal communication, June 2009). “You just have to know who needs to have the heat or the time modified, or who needs to sit out a round. Talking to your people is the way to find out.” C., a sweat leader who prefers to remain unnamed, concurs. “I ask the people about their health. I learned what to ask from the elders that taught me. I have to be observant too. It's on me.” There is some variation in purpose and in detail of ritual among and within Indian nations, but the sweat ceremonies have evolved within communities in an adaptive fashion. The following describes a fairly typical lodge and ceremony. The structure consists of bent willow poles, a dozen or more, tied together to form a rough dome shape. Over these are placed skins or tarps (permeable but opaque) such that the interior can be made completely dark. An opening to the West or East faces the fire pit. An outside helper manages the fire and brings the hot rocks when asked by the leader just inside the door.

Participants file in clockwise and sit around a shallow pit, talking and joking until the leader calls for the first four rocks. These are placed in the pit, sage or cedar is put on one for fumes, then water is sprinkled upon the rocks for steam. The interior heats up. The initial rituals commence: spirit-calling songs and prayers. After a time the leader calls out something like “All my relations!” and the door flap is opened, cooling the inside a bit. Depending on the age, health, and experience of the participants, the leader may pass around water at various times. The leader will sometimes have prescribed what to do if someone is overcome by heat, or nearly so, especially if several “novices” are present.

Then more hot rocks are called for, the flap is closed again, water is poured on the heated rocks, and the interior becomes quite hot. Further praying and singing ensues. Individuals may be called on for their prayers and songs. Frequently the flap is opened a total of four times during a sweat. The intense darkness provides a feeling of being alone during quiet periods, but the overall experience is that of a shared spiritual activity and a sense of community, continuity with tradition, and profound physical and mental relaxation when the sweat is done. ⁶

When a sweat lodge is “grafted” upon a therapeutic or “new age” group, unless it is brought by an experienced leader and trained helper, there is reason for caution as to both risks and benefits. Nevertheless, we have recently seen increasingly frequent and often successful incorporation of the sweat lodge into treatment programs for substance abuse in Indian Country. ^7,8 Individuals most recently abstinent, especially those who may be in overt or subclinical withdrawal, are theoretically at risk for autonomic instability to such an extent that the heat of a sweat lodge could provoke seizures, transient dehydration, heat prostration, or dysrhythmias. Alcohol consumption is a risk factor, and covert consumption certainly may occur.

Some individuals in alcohol treatment (and of course others) are taking antiepileptic medications such as divalproex, carbamazepine, phenobarbital, or topiramate. During even temporary dehydration, these may become overconcentrated and reach toxic blood levels. A similar warning applies to people taking lithium carbonate for bipolar mood disorder, or indeed potentially any medication principally metabolized by the kidneys. (The author has seen mild dehydration cause transient toxicity after vigorous exercise with both lithium and divalproex.) Especially with these individuals, dehydration must be prevented during participation in the sweat. Sports drinks and water beforehand and water during the ceremony, with education as to warning signs of dehydration and of drug toxicity, would all be advised as part of medical care for these participants. These problems should be readily preventable by ensuring adequate hydration; no data are available, but many individuals in Indian Country find the sweat invaluable as part of substance abuse treatment, and we suspect the benefits outweigh the risks for these people in general.

Other medications may increase risk for heat-related problems. Antipsychotic medicines are associated with a rare but serious febrile condition called neuroleptic malignant syndrome (NMS). It is not known whether heat exposure increases risk for NMS, but for safety should be assumed so to do. The condition has been reported more in older “first-generation” antipsychotics, possibly just because of more patient-years of exposure; newer antipsychotics cannot be assumed to be free from this risk.

Among specific known physiologic effects of the sauna (and by extension, the sweat lodge), a few seem particularly relevant. In cardiovascular terms, blood pressure is reduced 10%–20%, with a corresponding modest increase in heart rate. Myocardial perfusion is reduced a bit, to a degree that may become significant in a person with serious coronary artery disease. ⁹ Hence, individuals with unstable angina or a recent myocardial infarction should avoid the sweat lodge. Severe aortic stenosis is similarly a contraindication. On the other hand, repeated participation seems actually to improve cardiac function and reduce arrhythmias in people with heart failure. ¹⁰

The fluid and electrolyte balance effects are such that relative contraindications to the sweat include acute renal insufficiency, inadequately treated chronic renal failure, and poorly controlled diabetes mellitus (risking diabetic ketoacidosis). Trace elements including zinc, copper, iron, nickel, chromium, and molybdenum may have reduced levels following a sweat or sauna, and those who participate frequently or whose levels were already marginal may need replacement. This could be a risk factor for individuals with pre-existing absorption issues, such as those who have had a gastric bypass procedure.

People with rheumatic disease report improved joint mobility and reduced pain after participating. Skin effects are salutary in a nonspecific way except in people with dermatitis, who may experience increased itching. Since purine degradation may be increased, active or recent gout may be a relative contraindication. ¹¹ At least one person with sickle cell trait had severe rhabdomyolysis and acute renal failure after a single sauna visit. ¹²

Immunologically, increasing body heat in sauna increases expression of CD 11b (complement receptor) and CD 14 (endotoxin receptor) and downregulates CD 621, which attaches leukocytes to endothelium. Three (3) hours later, the endotoxin response persists. It is safe to assume that these occur during the sweat. Individuals with a high fever should avoid the sweat lodge, however.

Pregnancy is not an absolute contraindication, but caution and medical advice are essential.

Psychologically, those who consider the sweat lodge should understand that it is crowded, hot, and pitch-dark. On occasion people make unusual sounds when having spiritual experiences or when responding to one another. Anyone who is particularly fearful of those kinds of things should enter cautiously and with the leader's full awareness and a contingency plan, if at all. Also, participants are expected to follow protocols, and those who are unwilling or unable should not enter unless a sweat leader has made a particular exception. Sweat lodge participation can be helpful to some people who have attention deficit–hyperactivity disorder and related problems and who have enough self-control to get through the proceedings. ¹³

In sum, we know from historical, anthropological, and anecdotal evidence and experience and by extrapolating from sauna research that there are potential benefits from the sweat lodge, a time-honored and increasingly popular ceremony. Certain medical risks may exist, but awareness, education, management, and sensible ceremonial leadership serve to minimize their impact. Engaging in the sweat lodge alone, like being alone in sauna, appears significantly to increase medical risk, especially when alcohol has been consumed recently; ⁵ these two clear risk factors for lethality and the medical indications and contraindications listed above should be considered for safe practice.

As sweat ceremonies are used with increasing frequency as a culture-syntonic modality for indigenous youth, substance abusers, and others, ^{14 –16} this author recommends not only attention to medical risk factors but also preservation of the traditional approaches to training or creating leaders for these ceremonies. Narrative traditions show the benefits of the old ways, and the apparent sterling safety record of indigenous leadership is impressive. Therapists and other healers who aspire to lead sweat ceremonies should learn over time from experienced individuals of repute.

Furthermore, I recommend that anyone interested in participating in a sweat for the first time should seek a lodge with a leader of vast experience and superb reputation. If you have any significant illness, acute or chronic, it is wise to check with your physician first. ¹⁷ If the sweat leaders are not part of your own community, ask around. Experience and reputation should take precedence over ethnicity: “Sometimes there is criticism of the white people stealing Native American spirituality, (but) the truth is—no one can steal spirituality.” ¹⁷