Why a gender lens on mental health is critical
This week the Royal Commission into Victoria’s Mental Health System held its first public hearings. The Royal Commission is an opportunity to consider the social and economic factors that contribute to poor mental health using a gender lens. With significant investment in men’s mental health in recent years, it is timely to switch focus and consider women’s experiences and how the mental health service system and other institutions are responding to their needs. Sarah Squire (@SquireSarah) and Susan Maury (@SusanMaury) of @GoodAdvocacy summarise some of the gender differences in prevalence, diagnosis and treatment in the first of a four part series. You can read the second in this series, on economic inequality and mental heath, here; the third, on financial hardship and mental health, here.; and the fourth, on the impacts of violence, sexualisation and gender stereotypes, here. The full submission can be found here.
Public perception may be that men experience worse mental health than women, but the evidence contradicts this belief. The Australia Bureau of Statistics informs us that women report higher rates of mental disorders in the past 12 months (22.3 per cent compared to 17.6 per cent for men) including anxiety (18 per cent, compared to 12 per cent men) and affective disorders including depression (7 per cent, compared to 5 per cent for men). Women have significantly higher lifetime rates of affective/depressive disorders, at 18 per cent (compared to 12 per cent for men) and much higher lifetime anxiety rates of 32 per cent (compared to 20 per cent for men).
In addition to higher rates of common mental health conditions such as anxiety and depression, women and girls are overrepresented among those with eating disorders; around 75 per cent of people experiencing anorexia nervosa or bulimia nervosa are female, with the peak period for onset being adolescence. In addition to genetic vulnerability and psychological traits, social-cultural factors including unrealistic ideals of beauty are a known risk factor for developing an eating disorder. The complexity of social networking, an increasingly visual tween culture and the early sexualisation of girls have also been identified as factors negatively affecting girls’ mental health.
Male suicidality is often presented as the key indicator of poorer mental health for men, and it is true that men are three times more likely than women to die by suicide. While this statistic is widely known, women’s greater suicidality is rarely reported. Known as the ‘gender paradox’, women have higher rates of suicidal behaviour than men, even though men are more likely to die by suicide.
Post-traumatic stress disorder
Another fact seldom reported is that women are twice as likely to experience post-traumatic stress disorder (PTSD) than men. PTSD is most often associated with men in military service; it is therefore important to point out that research indicates men and women in the military have similar levels of PTSD – women are not more disposed to experiencing it. Rather, it appears that women are exposed to more traumatic events than men, and family violence appears to be the primary driver of PTSD symptoms for women. A recent study of 150 pregnant rural and remote Indigenous women found that an astounding 40 per cent reported PTSD symptoms.
PTSD is by definition compromised mental health, but it also often co-resides with and exacerbates depression and anxiety in women, and can be a contributor to suicidality. Additionally, women whose PTSD is as a result of sexual assault have much more vivid recall of the traumatic experience than women who experience PTSD as a result of other types of traumatic experiences.
The hospitalisation rates for self-harm are alarmingly skewed towards girls and young women. Women are one and a half times more likely to be hospitalised for self-harm than men, with an alarming recent increase in self-harming behaviours amongst young women aged 15-24 years. Aboriginal and Torres Strait Islander women are almost twice as likely to be hospitalised for self-harm than other women.
Gender differences and gender bias in diagnosis and treatment
It is becoming widely accepted that medical research suffers from a dangerous, and at times fatal, bias towards males. Some well-known examples include divergent symptoms for heart attacks between men and women, resulting in a high rate of undiagnosed heart problems and death rate in women because male symptoms are the standard diagnostic tool.
An increase in the use of psychotropic medications has particular impacts for women. Women experience more severe side effects from psychotropic medication per dose of medication than men, including greater weight gain, cardiovascular and metabolic side effects, however clinicians are not always aware that these effects are gendered. There are also gender differences in brain structure and responses to stress.
In addition to biological differences, social differences can have a profound effect on mental health diagnosis and treatment. For example, research has found that women with severe mental illness are up to five times more likely to have experienced rape, attempted rape, or family violence. Despite this link, medical and mental health professionals often struggle to identify the signs of family violence or sexual assault.
Few professionals are aware that women experience PTSD at twice the rate of men. As a result, women’s PTSD is under-reported, under-diagnosed, and often left untreated.
Recently published Australian research indicates that telephone crisis-line workers consistently identified suicide potential for both males and females, but were less likely to provide appropriate intervention support to female callers. The social stigma commonly attached to suicide has a dual aspect for women because of the way it is gendered in attitudes and behaviours. For example, the stereotype of the ‘attention-seeking’ young female who is trying to manipulate those around her is a strong cultural narrative which has played out among professionals in health care settings.
Improving knowledge of women’s mental health – including understanding the social and economic determinants – and addressing systemic bias in the mental health system must be central to any reforms resulting from the Royal Commission.
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