[Assignment- First Two Year Batch-MEd. 2015-17
- Govt. College of Teacher Education, Thiruvananthapuram]
Mental Health, The
Gender Factor
Countless numbers of people worldwide suffer with some kind of
mental health problem; roughly one in four. However there is a notable but
hidden disparity between male and female sufferers.
A study (WHO, Gender Disparities In Mental Health) by the World
Health Organisation revealed that women are twice as likely as men to suffer
from anxiety and depression (however the study notes that women are also more
likely to be misdiagnosed with depression), while men are equally more likely
to suffer from substance addiction or antisocial personality disorder.
Gender disparities and mental health: The
Facts
Mental illness is associated with a significant burden of
morbidity and disability. Despite being common, mental illness is under- diagnosed by
doctors. Less than half of those who meet diagnostic criteria for psychological
disorders are identified by doctors. Patients, too, appear reluctant
to seek professional help. Only 2 in every 5 people experiencing a mood,
anxiety or substance use disorder seeking assistance in the year of the onset
of the disorder. Overall rates of psychiatric disorder are
almost identical for men and women but striking gender differences are found in
the patterns of mental illness.
Why gender?
Gender is a critical determinant of mental health and mental
illness. Gender determines the differential power and control men and women
have over the socioeconomic determinants of their mental health and lives,
their social position, status and treatment in society and their susceptibility
and exposure to specific mental health risks.
Gender differences occur particularly in the rates of common
mental disorders - depression, anxiety and somatic complaints. These disorders,
in which women predominate, affect approximately 1 in 3 people in the community
and constitute a serious public health problem.
Unipolar depression, predicted to be the second leading cause of
global disability burden by 2020, is twice as common in women. Depression is not only the most
common women's mental health problem but may be more persistent in women than
men.
The lifetime prevalence rate for alcohol dependence, another
common disorder, is more than twice as high in men than women. In developed
countries, approximately 1 in 5 men and 1 in 12 women develop alcohol
dependence during their lives.
Men are also more than three times more likely to be diagnosed
with antisocial personality disorder than women.
There are no marked gender differences in the rates of severe
mental disorders like schizophrenia and bipolar disorder that affect less than
2% of the population.
Gender differences have been reported in age of onset of symptoms,
frequency of psychotic symptoms, course of these disorders, social adjustment
and long term outcome.
The disability associated with mental illness falls most heavily
on those who experience three or more co- morbid disorders. Again, women
predominate.
Gender specific risk factors
Depression, anxiety, somatic symptoms and high rates of
co-morbidity are significantly related to interconnected and co-occurrent risk
factors such as gender based roles, stressors and negative life experiences and
events.
Gender specific risk factors for common mental disorders that
disproportionately affect women include gender based violence, socioeconomic
disadvantage, low income and income inequality, low or subordinate social
status and rank and unremitting responsibility for the care of others.
The high prevalence of sexual violence to which women are exposed
and the correspondingly high rate of Post Traumatic Stress Disorder (PTSD)
following such violence render women the largest single group of people
affected by this disorder.
Economic and social policies that cause sudden, disruptive and
severe changes to income, employment and social capital that cannot be
controlled or avoided, significantly increase gender inequality and the rate of
common mental disorders.
Gender bias
Gender bias occurs in the treatment of psychological disorders.
Doctors are more likely to diagnose depression in women compared with men, even
when they have similar scores on standardized measures of depression or present
with identical symptoms.
Gender stereotypes regarding proneness to emotional problems in
women and alcohol problems in men, appear to reinforce social stigma and
constrain help seeking along stereotypical lines. They are a barrier to the
accurate identification and treatment of psychological disorder.
Despite these differences, most women and men experiencing
emotional distress and /or psychological disorder are neither identified nor
treated by their doctor.
Violence related mental health problems are also poorly
identified. Women are reluctant to disclose a history of violent victimization
unless physicians ask about it directly.
The complexity of violence related health outcomes increases when
victimization is undetected and results in high and costly rates of utilization
of the health and mental health care system.
Women's mental health: The Facts
Depressive disorders account for close to 41.9% of the
disability from neuropsychiatric disorders among women compared to 29.3% among
men.
Leading mental health problems of the older adults are
depression, organic brain syndromes and dementias. A majority are women.
An estimated 80% of 50 million people affected by violent
conflicts, civil wars, disasters, and displacement are women and children.
Lifetime prevalence rate of violence against women ranges
from 16% to 50%.
At least one in five women suffer rape or attempted rape
in their lifetime.
Depression, anxiety, psychological distress, sexual violence,
domestic violence and escalating rates of substance use affect women to a
greater extent than men across different countries and different settings.
Pressures created by their multiple roles, gender discrimination and associated
factors of poverty, hunger, malnutrition, overwork, domestic violence and
sexual abuse; combine to account for women's poor mental health. There is a
positive relationship between the frequency and severity of such social factors
and the frequency and severity of mental health problems in women. Severe life
events that cause a sense of loss, inferiority, humiliation or entrapment can
predict depression.
Up to 20% of those attending primary health care in developing
countries suffer from anxiety and/or depressive disorders. In most centres,
these patients are not recognized and therefore not treated. Communication
between health workers and women patients is extremely authoritarian in many
countries, making a woman's disclosure of psychological and emotional distress
difficult, and often stigmatized. When women dare to disclose their problems,
many health workers tend to have gender biases which lead them to either
over-treat or under-treat women.
Research shows that there are 3 main factors which are highly
protective against the development of mental problems especially depression.
These are:
*having sufficient autonomy to exercise some control in
response to severe events.
*access to some material resources that allow the possibility
of making choices in the face of severe events.
*psychological support from family, friends, or health
providers is powerfully protective.
WHO's Focus in Women's Mental Health
*Build evidence on the prevalence and causes of mental
health problems in women as well as on the mediating and protective factors.
*Promote the formulation and implementation of health
policies that address women's needs and concerns from childhood to old age.
*Enhance the competence of primary health care providers
to recognize and treat mental health consequences of domestic violence, sexual
abuse, and acute and chronic stress in women.
Women's
issues
*Typical stressors
Women
are often expected to occupy a number of roles at the same time: wife, mother,
homemaker, employee, or caregiver to an elderly parent. Meeting the demands of
so many roles simultaneously leads to stressful situations in which choices
must be prioritized. Women are often forced to choose whether to pursue or
further a career versus whether to devote more time to home and family.
Many
women prefer to work outside the home because it gives them a greater sense of
life satisfaction. For other women, such as those who run single-parent
households, employment is not an option—it is a necessity. Compared with men,
women are frequently given jobs with less autonomy or creativity, which
decreases their level of job satisfaction. Women may also have more difficultly
being accepted in the workplace because of hierarchical structures preferring
men. Documentation repeatedly shows that women's salaries are lower than those
of men in comparable positions; women tend to be paid less even when performing
the same job as a man.
When
women do choose or are required to work outside the home, they continue to
perform the bulk of household duties as well. Sarah Rosenfield reported that
compared to men, women perform 66% more of the domestic work, sleep one-half
hour less per night, and perform an extra month of work each year. Needless to
say, increased workloads and decreased attention to rest and relaxation are
stressful and pose obstacles to women's mental health.
Divorce
results in more severe consequences for women who choose or are able to stay
home in deference to child-rearing. Such women depend on marriage for financial
security. Such domestic skills as childcare and housecleaning are not highly
valued by society, and thus are poorly compensated in terms of money. Women who
have never been employed and then experience divorce often have few options for
securing adequate income.
Although
women's ability to form meaningful relationships is a buffer against stress, it
can also be a source of stress. Caring about another person can be stressful
when that person is not doing well physically or emotionally. Many families
take for granted that the female members will care for elderly parents who are
no longer self-sufficient. As a result, many women in their forties or fifties
are caught between the needs of their college-age offspring and the needs of
dependent parents or parents-in-law. Interpersonal conflicts resulting from
these heavy burdens may cause stress or lower self-esteem. Women may also view
unsuccessful relationships as representing failure on their part to fulfill
traditional feminine qualities such as nurturance, warmth, and empathy.
Additional
sources of stress common to women include victimization, assertiveness, and physical
unattractiveness. Victimization is a constant concern due to the power
differential between men and women. Assertiveness may be stressful for women
who have had little experience in competitive situations. Physical
unattractiveness may cause some women who adhere to unrealistic standards of
feminine beauty to experience shame, or place them at risk for developing
eating disorders. Women considered unattractive may also suffer discrimination
in the workplace or in admission to higher education. In addition, the double
standard of aging in contemporary society means that all women will eventually
have to cope with the stigma of
unattractiveness simply through growing older.
*Typical coping strategies
Studies
suggest that women typically react to stress by seeking social support,
expressing feelings, or using distraction. These strategies might include
praying, worrying, venting, getting advice, or engaging in behaviors that are
not related to the problem at all (including such antisocial behaviors as drinking alcohol).
Seeking social support and distraction are considered avoidant coping
strategies because they do not focus on solving or overcoming a problem, only
on alleviating the stress associated with the problem. Research is inconclusive
regarding whether men or women are more likely to use problem-solving, which is
considered an active coping strategy.
*Typical patterns of psychopathology
Women
are more likely than men to experience internalizing disorders. Primary
symptoms of internalizing disorders involve negative inner emotions as opposed
to outward negative behavior. Depression (both mild and severe) and anxiety
(generalized or "free-floating" anxiety, phobias, and panic attacks)
are internalizing disorders common to women. Symptoms include sadness; a sense
of loss, helplessness, or hopelessness; doubt about one's ability to handle
problems; high levels of worry or nervousness; poor self-esteem; guilt,
self-reproach, and self-blame; decreased energy, motivation, interest in life,
or concentration; and problems with sleep or appetite.
Men's
issues
*Typical stressors
Situations
that typically produce stress for men are those which challenge their self-identity
and cause them to feel inadequate. If their identity closely matches a
traditional male role, they will experience stress in situations requiring
subordination to women or emotional expressiveness. They will also experience
stress if they feel they are not meeting expectations for superior physical
strength, intellect, or sexual performance. Research indicates that men who
strictly adhere to extreme gender roles are at higher risk for mental
disorders.
Certain
cultures are thought to adhere more strictly to traditional male gender roles.
In a study by Jose Abreu and colleagues, Latino men were identified as adopting
the most exaggerated form of masculinity, followed by European Americans, and
then African Americans. The Latino image of masculinity is often referred to asmachismo and includes such qualities as
concern for personal honor, virility, physical strength, heavy drinking,
toughness, aggression, risk-taking, authoritarianism, and self-centeredness.
African American males are also thought to have a unique image of masculinity;
however, Abreu's study showed that African Americans are more egalitarian in
terms of gender roles than European Americans.
*Typical coping strategies
Men
typically respond to stress by putting on a tough image, keeping their feelings
inside, releasing stress through such activities as sports, actively attempting
to solve the problem, denying the problem, abusing drugs or alcohol, or
otherwise attempting to control the problem. As stated previously, research is
inconclusive regarding whether males or females use problem-solving strategies
more often. This type of coping strategy, however, has more frequently been
attributed to males. Problem-solving is seen as an active coping strategy,
which is more effective than such avoidant strategies as denial,
abuse of drugs or alcohol, or refusing to talk about problems.
*Typical patterns of psychopathology
Men
are more likely than women to experience externalizing disorders. Externalizing
disorders are characterized by symptoms involving negative outward behavior as
opposed to internal negative emotions. Such externalizing disorders as
substance abuse (both drugs and alcohol) and antisocial behavior (such as
anger, hostility, aggression, violence, stealing, etc.) are common to men.
Substance abuse results in such negative physical and social consequences as hallucinations,
blackouts, physical dependency, job loss, divorce, arrests, organ and brain damage, and
financial debt. Antisocial behavior impairs interpersonal relationships and can
also result in negative consequences in other areas of life, such as run-ins
with the criminal justice system.
Men
are not exempt from such internalizing disorders as anxiety and depression. In
fact, one study found that high levels of masculinity appear to be related to
depression in males. Some researchers feel that men's abuse of substances could
be considered the male version of depression. Because male gender roles
discourage admitting vulnerability, men may resort to substance abuse as a way
of covering their feelings.
Men
who adhere to rigid gender roles are also at a disadvantage in interpersonal
relationships, especially intimate relationships. They may avoid emotional
expressiveness, or may behave in domineering and hostile ways. These behaviors
increase their risk of social isolation, disconnection from nurturance,
and participation in unhealthy relationships.
Suggestions
Implications for Policies and Programmes
Implications for Policies and Programmes
*Governments need to
monitor the mental health effects of their economic reforms and take urgent
action to bring about a more gender equitable distribution of the benefits of
globalization. Active measures need to be taken to protect social capital, as
this too, is powerfully related to how people rate their health.
*Currently, the rates of
detection, treatment and appropriate referral of psychological disorders in
primary health care settings are unacceptably low. The high rates of depression
in women and alcohol dependence in men strongly indicate a large unmet need for
improved access, at a community level, to low or preferably no cost gender
sensitive counselling services. Psychologists and social workers working in
community based health services that are responsive to the psychosocial issues
of those they serve, are well placed to provide cost effective mental health
services.
*All health care providers
need to be better trained so that they are able to recognize and treat not just
single disorders such as depression and alcohol dependence, but also their co
occurrence. Clinicians need to be equipped to assess and respond to gender
specific, structurally determined risk factors and to become proficient in
providing much needed advocacy for their patients with other sectors of the
health and social welfare system. Without these skills, rates of comorbidity
among patients will compound. Skill in trauma focussed counselling is a
priority for clinicians in all health sectors who encounter women.
*The concept of 'meaningful
assistance' in mental health care needs to be promoted. Meaningful assistance
implies a patient centred approach. Gender disparities in mental health will
not be reduced until women's own mental health concerns and life priorities are
taken into account in programme design and implementation.
*Gender based barriers to
mental health care, especially cost and access, bias and discrimination must be
removed. Intersectoral collaboration across government departments and gender
sensitive policy making in education, housing, transport and employment are
required to ensure that the multiple structural determinants of mental health
are facilitated to work in positive synergy, maintain social capital and support
social networks.
*Social safety nets and
income security are especially important for women and their mental health. A
public health approach necessarily broadens the notion of effective treatment.
The most obvious way of reducing violence related mental health problems is to
reduce women's exposure to violence. Women who have been but are no longer
being battered show significant reductions in their level of depressive
symptoms, while those who continue to experience violence do not. Providing
access to refuges and alternative forms of safe housing is thus a powerful
mental health ‘treatment.’
*Childhood sexual abuse, in
particular, is predictive of multiple negative health outcomes including high
rates of psychiatric morbidity as well as homelessness, prostitution, substance
use disorders and suicidality. The earliest possible identification and
protection of those exposed to adverse childhood events, and ideally the
elimination of these events, is necessary to prevent re-victimization and
arrest the progression and compounding of poor mental, physical, sexual and
social health outcomes. Consequently, the goal of preventing childhood neglect
and exposure to all forms of trauma and adversity must inform the design and
implementation of maternal and child health, family violence services and
social welfare and social security services.
*'Zero tolerance' health
education and promotion campaigns to reduce violence against women and children
need to be designed using culturally appropriate formats in order to counter
traditional beliefs and attitudes that condone and perpetuate violence.
*National mental health
policies must be developed that are based on an explicit analysis of gender
disparities in risk and outcome.
Conclusion and Recommendations
Effective strategies for risk factors’ reduction in
relation to mental health cannot be gender-neutral, while the risks themselves
are gender-specific, and women’s status and life opportunities remain low
worldwide. Low status is a potent mental health risk. For too many women,
experiences of self worth, competence, autonomy, adequate income and a sense of
physical, sexual and psychological safety and security, so essential to good
mental health, are systematically denied. The pervasive violation of women’s
rights, including their reproductive rights, contributes directly to the
growing burden of disability caused by poor mental health. Therefore, an
inter-disciplinary action to set policies which protect and promote women’s
autonomy and women mental health is crucial. Ministries of health should take
steps to develop and integrate gender-relevant indicators in the existing
national health information systems, and to find mechanisms to monitor gender
sensitivity in the health system. It should be a standard practice to
disaggregate all epidemiological data by sex and age for all diseases and
health conditions, allowing gender analysis of data and monitoring the
sex-specific burden of disease over the lifetime. Besides documenting
differences in prevalence rates of mental disorders and other diseases, it is
crucial to examine how women’s and men’s differences – such as their roles and
responsibilities, their knowledge base, their position in society, their access
and use of health resources – influence the vulnerability to mental disorders.
There is also a need to strengthen women’s access to and control over resources
that promote and protect health through addressing gender-based barriers to
utilize services. We should not forget the importance to integrate a gender
approach to health in training primary care providers to identify and to treat
mental illness. Linking gender sensitivity to training as well as performance
appraisals assures that the issue is taken seriously and translated into
practice. More attention should be given to identify factors that would
facilitate coping with stress or distress and to design intervention programmes
on the communal as well as the primary care level. In addition, it is important
to review, evaluate and strengthen community services and the role of
non-governmental organizations to protect and promote women’s autonomy and
mental health. We should not overlook the importance of strengthening the role
of media and education and training of media personnel to increase community
awareness of women mental health, reducing the stigma of mental problems and
promoting women’s mental health.
Submitted by Ms.Arantxa KG.
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