Women and children being left behind in Australia's mental health priorities
There are high levels of awareness in Australia concerning the importance of men’s mental health. However, in today’s post Sarah Squire, recently appointed as the head of the Women’s Research, Advocacy and Policy (WRAP) Centre at Good Shepherd Australia New Zealand, argues that this is coming at the expense of awareness and investment in women’s mental health. There are specific gendered differences when it comes to addressing mental health needs, and the absence of women and girls within national mental health policy is deeply concerning.
Australian mental health policy – women and children last?
With no policy on women’s mental health, and with only a general women’s health policy languishing on a shelf in Canberra since 2010, it appears that the Federal Government has adopted a reverse Birkenhead Drill position.
In contrast, public attention and both government and philanthropic investment in men’s mental health has increased markedly over the last decade. For example, over the last three years the Movember Foundation has spent over $4.4 million of its global fundraising revenue on services and programs to address poor mental health and suicide among Australian men. The government’s 2011 Taking Action to Tackle Suicide package provided $23.2 million over four years for support services and campaigns to address male suicide in recognition of ‘the social determinants that increase the risk of suicidality for men’. Apart from perinatal mental health, there has been no corresponding recognition of – or investment in – women as a specific group.
Of course men and boys’ mental health is important. But why has there has not been a corresponding investment in the mental health of women and girls? This is despite similar lifetime prevalence of mental health conditions for men and women (48 and 43 per cent respectively) and a higher prevalence of anxiety and post-traumatic stress disorder (PTSD) among women, according to the most recent ABS data. Additionally, data trends indicate an alarming increase in self-harm and suicide attempts among girls and young women.
Suicide and the gender paradox
Women have higher rates of suicidal behaviour than men, even though men are more likely to die by suicide. This ‘gender paradox’ is reflected in the oft-cited ‘Eight suicides per day… six of them men’ statistic which has become almost obligatory in any public discussion of suicide, in discussions of the so-called ‘crisis among men and boys’, and in rebuttals to women’s demands for equality.
This repetition functions to hide the alarming increase in suicidal ideation among women in recent years, particularly young women and young Aboriginal and Torres Strait Islander women. Measured by hospital admission, the intentional self-harm rate for women (which encompasses suicide attempts and non-suicidal self-injury) is now 40 per cent higher than men’s, with a large increase in the adolescent years. The number of women who have injured themselves so severely that they require hospital treatment has increased by 50 per cent since the year 2000.
These patterns are emerging at young ages, and appear to be worsening. According to the second Australian Child and Adolescent Survey of Mental Health and Wellbeing, there is an increasing prevalence of depression among children aged 4-17, and very high levels of suicidal behaviour. Adolescent girls in particular are faring poorly, with suicidal behaviours more common over all age groups and most common among 16 – 17-year-olds, with one in seven having seriously considered attempting suicide. Girls are twice as likely to self-harm as boys, with one in ten girls aged 12-15 years harming themselves in the previous 12 months.
The focus on male suicide also functions to render women’s non-fatal suicidal behaviour as less important, as if women’s suffering is less serious than men’s suffering. The usual social stigma 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, according to Suicide Prevention Australia.
Further, the mantra of the male suicide rate overshadows the experiences of particular groups who are at much greater risk of experiencing psychological distress and suicidality, such as members of LGBTI communities and Aboriginal and Torres Strait Islander communities.
What’s behind women’s poor mental health?
There are many genetic, individual, familial and environmental factors at play in determining whether someone develops a mental health condition. These include a strong relationship between low socioeconomic status and poor mental health, which the World Health Organisation notes can be observed in children as young as three. But for women as a group there is one overarching social determinant of poor mental health where the evidence is startling – gender inequality.
Inequality in the workplace, including direct and indirect sex discrimination, the omnipresent gender pay gap, women’s concentration in low paid industries and occupations, and precarious working conditions including poor quality part time work, all negatively impact on women’s capacity to earn a decent income while simultaneously eroding physical and mental health.
Analyses of household data show that women continue to bear the overwhelming responsibility for child rearing and other unpaid work in the household, with total paid and unpaid work hours skyrocketing when women become mothers (while fathers’ total work hours remain largely unchanged). Time spent out of the employment market while caring for children results in a ‘child penalty’ that casts a long shadow of women’s working lives.
The penalty attached to the physical and emotional ‘labour of love’ is broader than caring for young children. For many women – especially those in mid-life – care is a lifelong responsibility involving care for teenagers and emerging adults, ageing parents and/or partners. This time of life coincides with financial pressures to remain in the workforce to increase superannuation balances, which for women are often depleted through many years spent in low paid work or out of the workforce. Many older women find themselves without an adequate income when they retire, particularly those who do not own their own home and find themselves at the mercy of the private rental market. It is perhaps not surprising that depression is a significant issue for many women in mid-life with the peri-menopausal period bringing with it a 16 fold increase in diagnoses of depression.
Gender inequality affects girls from a very young age, beginning with stereotypes and reinforced through practices such as giving girls less pocket money than boys despite their greater share of household chores, as detailed in Growing Up Unequal. A staggering 98 per cent of 10-17 year old girls surveyed by Plan International Australia last year said they did not receive equal treatment to boys. 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 in the hidden middle years.
Of particular importance is the impact of family and sexual violence, itself a manifestation of gender inequality, which has a severe and long lasting effects on women’s mental health. A recent systematic review and meta-analysis has shown a three times increase in the likelihood of depressive disorders, a four times increase in the likelihood of anxiety disorders, and a seven times increase in the likelihood of PTSD among women who have experienced family violence. An Australian study indicates that 89 per cent of women exposed to three or four types of gender-based violence experienced a mental disorder. Women who have experienced violence also report higher rates of suicide attempts, with 35 per cent of women exposed to gender-based violence reporting suicide attempts.
So although it has been obscured in the policy landscape and the public imagination, the evidence supporting a greater investment in women’s mental health is incontrovertible. What has been lacking is a policy response, either as a dedicated set of measures, or through the mainstreaming of issues for women and girls as part of national policy instruments such as the Fifth National Mental Health and Suicide Prevention Plan and the regular reporting of national and state mental health commissions.
Policy mechanisms to support women and girls’ mental health
Closing the knowledge gap is the clearest starting point when formulating a policy response. This includes improving gender analysis of mental health trends and developing specific promotion, prevention, intervention and postvention measures for women within existing mental health and suicide prevention frameworks; this needs to be undergirded with adequate funding to mental health organisations. Suicide Prevention Australia has documented a wide range of gender gaps and made detailed recommendations across data collection, policy, the service system, workforce development and community awareness and education.
For adolescent girls and young women, the exponential increase in suicidal behaviour makes understanding their particular experiences of psychological distress and suicidality a research imperative. This investigation needs to include the relationship between the social and economic determinants that have emerged in recent years, including the impact of mobile technologies and an increasingly visual culture that makes girls in their middle years feel like their primary value lies in their appearance rather than their intellect, skills or character.
But there are many other steps that can be taken to improve the mental health of women within policy settings outside of the mental health system. Employment policies that support women’s participation in paid work, for example, will increase income as well as support the sense of purpose and social connectedness that comes with having a job – all of these factors support good mental health, or what has been termed a ‘contributing life’.
Given the link between poverty and poor mental health, social security and tax and transfer policies should enable women to have an adequate income as this will improve their mental health, as well as improve their capacity to raise mentally healthy children. For mothers on low incomes, particularly single mothers, an adequate standard of living is the critical foundation for a contributing life. Welfare policies should therefore adopt an empowerment approach and provide a level of income support for single mothers that is above the poverty line, as opposed to penalising and vilifying them.
Continued investment in the prevention of violence against women and children (such as through Our Watch) and various prevention and intervention measures (such as those outlined in the National Plan to Prevent Violence Against Women and their Children and the Victorian Government’s comprehensive response to the Royal Commission into Family Violence) are critical given their impact on women and children, who are impacted in their own right.
New investment is also required to promote gender equality across all areas of public and private life. It has been 28 years since the Australian Government ratified the International Labour Organization Convention 156 on workers with family responsibilities and ran a campaign to encourage men and women to ‘share the load’ (p120). We are well overdue for another social marketing campaign in this space, with the popularity of a recent Indian advertising campaign demonstrating the appetite for this content. Such a campaign could effectively engage men in progressing gender equality by using the idea of co-parenting as a foundational concept. And who knows, perhaps we could improve men’s mental health at the same time by dismantling rigid conceptions of masculinity, which have been shown to be strong contributing factors in male suicide rates.
A redistribution of mental health funding in favour of women could be used to fund national, state and local campaign activity that encompasses the full spectrum of social and economic determinants of women’s mental health. This campaign could go some way to improving deeply held attitudes and behaviours that continue to curtail the lives of women and girls in the public, private and virtual domains.
In the meantime, there is much that a broad range of civil society organisations, social commentators, media outlets and individuals can do to change the narrative about women and girls by intervening in public conversations about gender and mental health. Such interventions can in turn shape new cultural norms that privilege the experiences of those most in need of a voice.
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