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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 2  |  Page : 108-113

Gender and mental health: Traversing treatise


Department of Social Work, University of Delhi, Delhi, India

Date of Submission09-Jun-2020
Date of Decision25-Jun-2020
Date of Acceptance30-Jun-2020
Date of Web Publication08-Oct-2021

Correspondence Address:
Dr. Meenu Anand
Department of Social Work, University of Delhi, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_158_20

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  Abstract 


World over, more women than men, suffer from common mental disorders that arise from social, psychological, and physiological differences on account of gender-based discrimination. Gender affects not only the rates of disorders, but also risk, timing of onset and course, diagnosis, treatment, and adjustment to mental disorder. The current paper contextualizes a feminist understanding to the role of gender in mental health. It discusses the role of sociocultural factors with respect to women and mental health leading to the violation of rights of women throughout their life cycle thereby impacting their sense of well-being and overall mental health. It also suggests few eclectic strategies to promote the well-being of women and prevention of mental disorder from a feminist lens.

Keywords: Feminist understanding, mental health, sex and gender, women


How to cite this article:
Anand M. Gender and mental health: Traversing treatise. Indian J Soc Psychiatry 2022;38:108-13

How to cite this URL:
Anand M. Gender and mental health: Traversing treatise. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Nov 26];38:108-13. Available from: https://www.indjsp.org/text.asp?2022/38/2/108/327745




  Introduction Top


Among the strongest and most consistent patterns of mental health problems are the differences between men and women. A feminist understanding to mental health highlights the sex and gender binaries in the context of mental health and reflects the interlinkages across gender and all forms of inequality including poverty, economic and educational disadvantage, disability, age, ethnicity, and sexual orientation. Gender is described as “the structure of social relations that centres on the reproductive arena, and the sets of practices (governed by this structure) that bring reproductive distinctions between bodies into social processes.”[1] Therefore, seen as an important determinant of health and disease, gender relations of power constitute the roots of gender inequality, determine whether a person's health needs are acknowledged, whether they have voice and agency over their lives and their health and whether they can realize their rights.[2]

As stated by Meekosha[3]

Gender is closely connected to sex, though there are different ideas about how. Sex is usually understood as relating to the biological and physiological body. Gender is often understood as the cultural interpretation of sexed bodies, embedded in the whole apparatus of a society's roles and norms. Thus, a sex/gender binary is set up parallel to that of nature/culture. Gender, as a relationship between sexes in societies, is usually seen as operating hierarchically-men being more powerful and dominant, while women are less powerful and weaker. These power relations produce stereotypes of masculinity and femininity-traits and behaviour that are expected of men and women. Role expectations of women as the nurturer, men as breadwinner and so on, define approved ways to perform gender[3] (pp. 2).

Gendering mental health

Keeping in mind, the structural hierarchies and their consequent impact on the psyche of men and women, the association between gender and mental health therefore has gained prominence not only in sociology but also in the fields of psychology, epidemiology, and public health.[4] There are diverse approaches to understand the causative factors associated with women and mental health.

Marmot[5] points out:

One approach to understanding mental illness in women is to examine biological causes, linked to endocrine control of the reproductive system, for example, or the activity of serotonin-specific neuronal systems. There are the obvious links between some mental illness and changes in reproductive function: the menstrual cycle, the postpartum period, and the peri-menopause. A quite different approach is to study the place of women in society and the role of social, economic, cultural and psychological causes of illness. These two approaches should not be in opposition. It is highly relevant and important to understand the biological processes that underpin mental illness. Equally, not to focus on the social determinants of illness that arise from the way society is organised or, regrettably, disorganised is to fail to understand the causes of mental illness in the fullest sense (pp xv-xvi).

The World Health Organization[6] recognizes that the social construction of gender identity and unbalanced power relations between women and men affect the health seeking behavior and health outcomes of women and men in different ways. Women's mental health cannot be understood in isolation from the social conditions of our lives. These conditions are characterized by social inequities (e.g., sexism, racism, ageism, heterosexism, and ableism) which influence the type of mental health problems women develop and impact on how those problems are understood and treated by health professionals and by society.[7]

Okasha and Chandra[8] argue:

In the context of today's fast changing world, viewing psychiatric illnesses needs a holistic worldview, a view that is de-centralised and which does not have a narrow perspective. The view is hence kaleidoscopic in that it is widened both physically and psychologically– where the disorder is viewed in a much larger context, and the multiple mirrors reflect images on each other. These images are those of the concepts of femininity and masculinity, of cultural and social realities, of violence and safety, of social networks and isolation and of motherhood and the nurturing roles of women. A kaleidoscopic view logically reflects the many multi-faceted identities, which women have today and which keep changing based on the interplay of lights and mirrors in the form of roles, relationships, the impact of biology and finally, the state of society (pp. 2).

Therefore, gender norms as well as the social reproduction of these norms in institutions and cultural practices are directly related to behavior that affects health, and the ensuing quality of life.[9] Norms around sexual relationships, fertility control, the use of physical violence, and alcohol and drug use, are strongly influenced by gender norms which determine how men interact with their partners, families, and children.[10] Moreover, for women to attain the optimum level of health over their lifetime, health systems need to plan for women's biological differences and gender roles. It is also the situation that women and men use health services differently, with their experience of health influenced by gender differences, from employment to caring responsibilities.[11]

Feminists also often opine that they have not been involved in the complex process of understanding and dealing with the issues around women's mental health.[12] How women's mental health issues have been a subject of neglect and indifference and low in the priority of policy and programs in many countries has been a subject that has been dwelled on by various feminists.[13] It has been pointed out that the inter sectoral relationships across women's oppression within mental health systems, as elsewhere, intersect with other marginalized positions of disadvantage, in particular those clustered around structures of racialization and class.[14]

Women's mental health through the feminine lens

World over, more women than men, suffer from common mental disorders that arise from social, psychological, and physiological differences on account of gender-based discrimination. Gender affects not only the rates of disorders, but also influence the risk factors, the timing their risk, timing of onset and course, diagnosis, treatment, and adjustment to the mental disorders. Gender and mental health therefore indeed have emerged as an important discourse in relation to sociocultural rubric of our society. As a critical determinant of mental health, gender has received significant attention with respect to promotion and protection of mental health and fosters resilience to stress and adversity.

Starting in early adolescence, women suffer more than men from internalizing disorders, which turn problematic feelings against the self in the form of depression and anxiety. This difference also implies that women endure attributions of self-blame and self-reproach more often than men. Women struggle with a greater sense of loss, hopelessness, and feelings of helplessness to improve their conditions. They also live with more fears in the forms of phobias, panic attacks, and free-floating anxiety states. Any prevailing discussion of mental health needs to include women's work in maintaining homes and communities which enables individuals and families to cope without service involvement. While much public rhetoric is devoted to celebrating communities and families, there is little policy and practical intervention to resource and sustain everyday well-being.[14]

Irrespective of culture, women fulfill the role of nurturers and providers of emotional support, and they have usually the main responsibility for care giving in the family. From a cultural perspective, certain aspects are of particular concern as they greatly interfere with the mental health of women. To link all these factors into a coherent theoretical model explaining the prevalence of psychological and psychiatric distress in women is a major challenge. Among such factors are poverty, migration, refugee status, violence, and consequences of globalization.

During the course of socialization, boys are trained to inculcate the acceptable male behaviors including competitiveness, independence, assertiveness, ambition, confidence, toughness, anger, and even violence (to varying degrees). They are expected to avoid characteristics associated with femininity as emotional expressiveness, vulnerability (weakness, helplessness, insecurity, and worry) and intimacy (especially showing affection to other males). Girls on the other hand, are socialized to develop traits like being nurturing, supportive and assigning high priority to their relationships. They are socialized and groomed to be emotionally expressive, dependent, passive, cooperative, warm, and accepting a subordinate status in marriage and employment. Competitiveness, assertiveness, anger, and violence are viewed as unfeminine and are not generally tolerated as acceptable female behavior. Gender socialization, therefore, has a direct impact on one's acquisition and development of self and understanding of social roles and responsibilities. This indeed affects the mental health of an individual.[15]

It is clear therefore that gender defines the range of behavior that is considered appropriate and permissible and generally the range is narrower for women than for males.[16] Thus, gender is not an attribute a person possesses but something a person acquires by “doing” through “routine, methodical and recurring accomplishment.”[17] It is related to how we are perceived and expected to think and act such as women and men because of the way society is organized and not because of our biological differences. Gender affects many aspects of life, including access to resources, inculcated methods of coping with stress, styles of interacting with others, self-evaluation, spirituality, and expectations of others. These also lead to violation of rights of women throughout their life cycle and impact their sense of well-being and overall mental health.

Violation of rights of women

Violence grounded on sex-based hierarchical order constitutes a breach of the fundamental rights to life, liberty, security, dignity, equality between women and men, non discrimination, and physical and mental integrity. It is often an integrated part of gender inequality and has a heavy impact on the mental health of the women involved as well as their surroundings.[17],[18] It is the most pervasive and insidious human rights abuse and is often espoused as a tool to socialize family members according to the prescribed norms of behavior within an overall perspective of male dominance and control. Violence takes place in its various forms within the family and its operational unit, the household, where oppression and deprivation of individual psyches and physical selves are a part of the structures of acquiescence; often enough, those being molded into an acceptance of submission and denial. Women, living in situations of power and control often experience domestic and/or sexual violence. The gender-based violence may include intimidation, threats, economic deprivation, sexual and psychological abuse apart from physical violence.[18]

Women experience the impact of gender-based socialization through the patriarchal structures in their day-to-day lives. Their subordination takes different forms - discrimination, disregard, insult, control, explanation, violence, oppression within the family, at work and in society at large. Throughout their life cycle, women face blatant discrimination in the form of sex related abortions, lack of opportunities for all round development, female infanticide, less education, discrimination in food intake, child prostitution, blamed for the sex of the child, dowry abuse, marital rape, torture, etc., They struggle to achieve equality and justice because of the widespread discrimination in diverse walks of life and violence of varied kinds that is perpetrated against them within and outside their households, right from their conception in the womb till their death.[17],[18] The manifestations of violence over the lifespan of a woman translate violence as the most obdurate, intractable behavioral gender difference having physical, psychological, and cognitive impacts.

Impact of violence on mental health of women

Violence has a profound effect on women. For every person who dies as a result of violence, many more are injured and suffer from a range of physical, sexual, reproductive, and mental health problems. Violence against women is not only a serious human rights violation but it is also associated with significant mental health problems, especially in low-income settings. It increases the risk of depression, anxiety, trauma symptoms, suicidal ideas, and substance abuse in women regardless of circumstances.[19] 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. The impact of gender-based violence on women ranges from immediate to long-term multiple physical, sexual, and mental consequences including death. It negatively affects women's general well-being and prevents them from fully participating in society. Violence in any form has a harmful impact on the growth and personality of the individual as a normal human being. All types of violence whether physical, psychological, emotional, financial, social, or intellectual have an impact on the dignity of the woman and deprive her of her own liberty and rights. Violence not only has negative consequences for women but also their families, the communities and the country at large.[18]

There is also a positive relationship between the frequency and severity of such social factors and the frequency and severity of mental health problems among women. Severe life events that cause a sense of loss, inferiority, humiliation, or entrapment can predict depression. Women are also more likely than men to suffer from comorbid mental disorders, i.e., the coexistence of more than one mental disorder. Comorbidity is associated with increased severity of mental illness and disability.[20] For example, women living in deprived socioeconomic circumstances are more likely to be exposed to intimate partner violence and to be living with men who have substance abuse problems. These multiple risk factors are, in turn, predictive of high rates of psychiatric comorbidity.[21]

It is clear from the above discussion that gender based differentials indeed affect the development of self, self-esteem and confidence of women and thereby impact their mental health. The violation of rights of women to utilize their full human potential during the life course negatively impacts mental health. Presented below are few strategies to enhance the mental health of girls and women from a rights based approach.

Promoting mental health among women

The strategies to mental health promotion and prevention include socially integrated and clinically guided approaches for early interventions and treatment of mental illness. A comprehensive cross-sectoral approach is indeed crucial. Addressing social determinants of mental health through the realization of the human rights of women and girls to education, nutrition, health care, equal social and economic participation, safety, and individual autonomy and freedom from discrimination are essential underpinnings of a response in any country or community. Promoting mental health among women and girls needs partnerships with health and non-health sectors and initiatives across multifarious sectors to support the rights and reduce exposure to adversity including violence, discrimination, and poor access to education and income generating work.[19] Some of the strategies to promote the mental health and well-being of girls and women are as follows:

Promotion of well-being

The promotion of mental health for girls and women, the prevention of these disorders and the secondary and tertiary prevention services should be a priority in the health agenda of all countries. Health promotion interventions target the determinants of health and well-being rather than illness and can take place at an individual, community, or structural levels. These aim to improve individual well-being, enable healthier and more sustainable communities, facilitate environments which support improved health and achieve structural changes in policy and law which benefit health and reduce health inequalities. There is some overlap with interventions to treat disorders since the treatment of disease also addresses a major determinant of poor well-being in its own right. A range of effective interventions exist to promote mental well-being. As for prevention of mental disorder, mental well-being promotion can occur at three levels as follows:[22]

  1. Primary promotion involves interventions which promote protective factors for mental well-being
  2. Secondary promotion involves early intervention to promote the mental well-being of people who have recently experienced reduced well-being
  3. Tertiary promotion involves interventions to promote the mental well-being of people with long-standing poor well-being.


Life course approach

Taking a life-course perspective implies the recognition that mental health at each stage of life is influenced by both unique and common factors at different stages of life and recognizes that mental health accumulates throughout life. Thus, appropriate preventive interventions and strategies must be appropriate to different stages of life.[23] Effective prevention has to take account of people as unique individuals who have different needs at various stages of life and be able to take advantage of different settings or structures that play influential roles during critical stages in life. Gender-specific concerns across the lifespan may enable a better understanding of the specific sociocultural issues and concerns pertaining to both sexes.[14]

Gender norms

Changes in gender-related social norms, values, and practices can ultimately transform the way society values girls, and improve women's status. Over time, these changes should result in improved health and increased well-being for men and women.[24]

Role of educational institutions

Schools and colleges/universities can play a major role in using classrooms as forums to sensitize both boys as well as girls on gender. Awareness generation in schools on mental health, sensitization on issues such as female feticide, domestic violence, dowry, rape can go a long way in inculcating values based on equality of opportunities to both sexes, human rights, and social justice. Furthermore, capacity building and sensitization of teachers, school authorities as well as parents is necessary to make the school environment more inclusive, gender friendly and flexible in nature. Linkages of the schools with various communities or specialist organizations may also be developed for ongoing training programs and referral services.

Community level interventions

Using a multi-pronged approach to take up gender issues within the sociocultural context, that is, a holistic concept of health at the community level may facilitate in creating a gender friendly environment. Central to a number of community-based approaches is the realization that changes within a community can be best achieved through engaging people of the community. This change can be brought about by efforts to improve key determinants of mental health, including attempting to build a socially inclusive community, freedom from discrimination and gender based violence and access to economic resources.[23] Thus, preventive and promotive level programs related to mental health as a positive concept, eliciting male participation, early identification of mental disorders, reducing stigma, and discrimination can be effectively taken up at the community level in an effective manner for a wider reach. The thrust on de-institutionalization and rehabilitation of those suffering from mental disorders, especially women and children may be taken up at the mass level through creative and innovative strategies.

Treatment of illnesses

The treatment of women's mental health problems must start from theoretical or practical approaches grounded in women's own experiences. Clinical care must provide an environment of security and protection in which their empowerment is encouraged and the real causes of their illnesses are tackled, such as the physical, psychological, and social factors that condition their lives. Simultaneously, women must demand and explore newer models of mental health, where women can express their “female” malaise.[25]

Role of non governmental organizations

Non-governmental organizations along with key stakeholders from the state and the private sector can play an important role in organizing promotive and preventive level programs at the micro as well as macro levels on mental health. They can play a major role in providing holistic activities including treatment, rehabilitation, community care, research, training, and capacity building, awareness and lobbying for mental health as a positive concept. Along with community-based groups, associations and networks of persons who have successfully handled mental illness, they can make significant and vigorous efforts necessary for mobilizing various political, cultural, administrative, and community resources.[26]

Replacing psychiatric institutions with community care

Large institutions, which are so often associated with human rights violations, can be replaced by community mental health-care services, backed by psychiatric beds in a general hospital and home care support. Mental health services need to be linked to services and supports in the community, enabling people with mental health conditions to enjoy educational, employment, social service, and housing opportunities on an equal basis with others.

Increasing investment in mental health

Governments need to dedicate more of their health budget to mental health. In addition, the mental health workforce at each level of the health-care system needs to be developed and trained to ensure that all people have access to good quality mental health services that promote recovery and respect for human rights.

Policy level interventions

The efforts to recognize and uphold a human right to health must incorporate strategies to protect, respect, and fulfill mental health as well as physical health. Establishing and upholding affirmative mental health rights can fundamentally advance the dignity and welfare of persons with mental disabilities, and simultaneously, advance the recognition and development of the right to health generally.[27] Policy level interventions in the form of formulation of laws (e.g., The Mental Healthcare Act, 2017) can lead to enactment of necessary laws followed by its strict implementation.

Need for a global thrust

To realize mental health on the ground, especially in developing countries, awareness raising and advocacy, pointing out high prevalence and burden of mental health problems and the development of quality mental health policies are critical. In order to address women's mental health in the context of the global priorities of the development and political community, it is necessary to understand and strategically utilize various legal and political instruments such as conventions, and other internationally agreed consensuses to justify and mobilize commitment from stakeholders and secure funding.[28]


  Conclusion Top


It is apparent that mental health matters in women's lives with respect to how culture and biology, mind, and body are interlinked in bringing about mental health. The Women, Gender and Equity Knowledge Network of the CSDH has recommended that, in order to diminish the negative impact of gender, there is a need to “transform the gendered politics of health systems by improving their awareness and handling of women's problems, as both producers and consumers of health care, improving women's access to health care, and making health systems more accountable to women.”[29]

Comprehensive gender-sensitive mental health care requires the planning, delivery, monitoring and quality improvement initiatives of mental health care to be informed by a knowledge and understanding of gender differences in women and men and their inter-relationship with respect to childhood and adult life experiences (e.g. violence and abuse); day-to-day social, cultural, and family realities; expression and experience of mental ill health and treatment needs and responses. The persistent violations of human rights that continue to affect persons with mental disabilities will only be reduced through diligent efforts to recognize and remedy these violations at all levels.[27] The feminist lens provides a useful prism to consider a raft of biological and social risk factors, not from the vantage point of consolidating notions of women's inferiority but to see men and women as “equal but different” and address what factors are shared and what are the unique contributions to the biological, psychosocial, and cognitive impacts of men and women.[30] There is a need to focus on developing health systems that strengthen as well as pay attention to the multifaceted developmental issues such as gender and power relationships, access to economic resources and human rights.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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