Mental disorders and gender
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Gender is correlated with the prevalence of certain mental disorders, including depression, anxiety and somatic complaints. Major depression is twice as common in women. The lifetime prevalence rate of alcohol dependence is more than twice as high in men, and men are more than three times as likely to be diagnosed with antisocial personality disorder. There are no marked gender differences in the diagnosis rates of serious psychological disorders like schizophrenia and bipolar disorder.
Sigmund Freud postulated that women were more prone to neurosis because they experienced aggression towards the self, which stemmed from developmental issues. Freud's postulation is countered by the idea that societal factors, such as gender roles, may play a major role in the development of mental illness. When considering gender and mental illness, one must look to both biology and social/cultural factors to explain areas in which men and women develop different mental illnesses. Societal patriarchy and gender roles have adverse effects on the psychological perceptions of both men and women. These gender roles may include the pressure on men not to show their emotions and the fact that women, on average, have lower self-esteem and sense of control than men. When certain factors, such as work outside the domestic sphere, are controlled, women and men tend to experience a full range of mental illnesses at approximately equal rates. In some cases when such factors were controlled, women showed lower rates of mental illness on the whole.
The object relations theory postulates that because women are mostly responsible for parenting, mothers emphasize the importance of relationships to their daughters while pushing their sons into independence. Sarah Rosenfield uses this theory to argue that males and females develop different types of symptoms when they are mentally ill. Men tend to display externalized symptoms, expressing problematic emotions in outward behavior. Women tend to develop internalized symptoms, where problematic feelings are directed towards the self. In accordance with the internalized-externalized dichotomy, women are more commonly diagnosed with mental illnesses such as anxiety, depression, and phobias. Once thought to be more common in women, borderline personality disorder has been found to be equally prevalent among both men and women. Men more commonly experience substance abuse, antisocial disorders, and violence. Both men and women are more likely to be institutionalized if their diagnosis is not typical of their gender (Martha Lang, 2006).
Violence against women and connections to mental health
Intimate partner violence and domestic violence
Intimate partner violence (IPV) is a particularly gendered issue. Data collected from the National Violence Against Women Survey (NVAWS) of women and men aged 18-65 found that women were significantly more likely than men to experience physical and sexual IPV.
There have been numerous studies conducted linking the experience of being a survivor of domestic violence to a number of mental health issues, including post-traumatic stress disorder, anxiety, depression, substance dependence, and suicidal attempts. Humphreys and Thiara (2003) assert that the body of existing research evidence shows a direct link between the experience of IPV and higher rates of self-harm, depression, and trauma symptoms. The NVAWS survey found that physical IPV was associated with an increased risk of depressive symptoms, substance dependence problems, and chronic mental illness.
A study conducted in 1995 of 171 women reporting a history of domestic violence and 175 reporting no history of domestic violence confirmed these hypotheses. The study found that the women with a history of domestic violence were 11.4 times more likely to suffer dissociation, 4.7 times more likely to suffer anxiety, 3 times as likely to suffer from depression, and 2.3 times more likely to have a substance abuse problem.
The same study noted that several of the women interviewed stated that they only began having mental health issues when they began to experience violence in their intimate relationships. A case study of one woman, who had seven children and had left an abusive marriage after being stalked by her husband, found that her chronic depression began at the age of 25, when she was married. She quotes that “I only got sick when I got married.”
In a similar study, 191 women who reported at least one event of IPV in their lifetime were tested for PTSD. 33% of the women tested positively were lifetime PTSD, and 11.4% tested positive for current PTSD.
Another study found that in a group of women in a psychiatric inpatient hospital ward, women who were survivors of domestic violence were twice as likely to suffer depression as those were not. All twenty of the women interviewed fit into a pattern of symptoms associated with trauma-based mental health disorders. Six of the women had attempted suicide. Moreover, the women spoke openly of a direct connection between the IPV they suffered and their resulting mental disorders.
The direct psychological effects of IPV may contribute directly to the development of these disorders. In Humphreys’ and Thiara’s study, 60% of the women interviewed feared for their life, 69% feared for their emotional wellbeing, and 60% feared for their mental health. Some of the women discussed an undermining of their self-esteem, as well as an “overwhelming fear and erosion of their sense of safety.” Johnson and Ferraro (2000) refer to this overwhelming fear as “intimate terrorism,” decimating a women’s sense of security and contributing to a worsening psychological state.
Humphreys and Thiara (2003) refer to these consequential mental disorders as “symptoms of abuse.” That sentiment is echoed by some survivors who don’t feel comfortable identifying with loaded diagnoses such as depression or PTSD.
Medical screening for domestic violence
Scholars studying the effects of IPV on mental health note the necessity of screening for domestic violence in primary care patients. Roberts, Williams, Lawrence and Raphael (2008) conclude from their study that women who presented to doctors with somatic symptoms including abdominal pain and headaches are often subjected to a variety of investigative tests, without domestic violence ever being raised as a potential cause.
McLeer, Anwar, Herman and Maquiling (1989) find from their research that when protocol for detection of IPV was introduced, the rate of identification of battered women increased from 5.6% to 30% in one year. When followed up eight years later, only 7.7% were identified.
Ramsay, Richardson, Carter, Davidson and Feder (2002) found in a systematic review that about half to three-quarters of women in primary care responding to surveys believe that routine screening for domestic violence is acceptable, and a higher proportion is shown among women with a history of having been abused. In contrast, only a minority of nurses and doctors favored screening, shown in the results of two surveys.
Introduction of discussion of domestic violence into standard primary care may have revealing effects in itself. In one case, a domestic violence victim states that “the introduction of the words ‘domestic violence’ to me, as hard as they were to swallow, were like a fresh light on my situation because it made me think differently about things.”
Thiara and Turner (2000) find other obstacles to treatment of IPV survivors include physicians’ belief that the abuser requires treatment rather than survivor, a sense of feeling unqualified to treat IPV survivors with the appropriate sensitivity and effectiveness (and therefore sidestepping questions that could lead to IPV disclosure), and overt victim-blaming.
Survivors themselves note the need for “immediate and flexible services” including 24/7 hotlines, as well as non-judgmental and victim-trusting approaches from physicians.
Another barrier to seeking treatment is that a threat often used against women IPV victims is that they are “crazy,” and seeking treatment may seem to a survivor like a confirmation of this sentiment.
Even when women have sought treatment, there are still problematic elements to existing treatment services. In mixed-sex hospitals, there have been worrying reports that suggest a lack of safety for women survivors.
It is crucial to adopt an intersectional approach when considering how to treat survivors. In Humphreys’ and Thiara’s study, they found that “black and minority ethnic women were significantly more likely than white women to suffer substantial problems both emotionally and materially." This intersectional approach can include a push for more female doctors, as well as people of color in the medical profession.
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