Gender perspectives in world mental health policies
Mental health problems are increasingly taking tolls on people’s lives, with one out of every four individuals in America living with Serious Psychological Disorder(SPD) i.e. combination of feelings of sadness, worthlessness, and restlessness adversely impacting physical well-being. A study by the National Survey on Drug Use and Mental Health highlighted an increase of 18.1% for people living with some kind of mental illness.1From 2013-2017, there was an increase of 47% in depression diagnosis in America among 18-35 years old. Mental health problems are considered as one of the major driving factors for disability resulting over 40 million years of disability in 20-29 years old. Suicide is the most common cause of death among men aged 20-49 in England and Wales.2 Yet, there is still a long way to go in terms of mental illness being recognized and accepted as a significant health barrier in communities, national and global policy level.
Although WHO Mental Health Action Plan 2013‐2020 has targeted 80% of countries to have mandated mental health policy, only 68% till date have formulated it, with major gaps in implementation.This is however a praiseworthy development in itself. After the signing of Mental Health Declaration for Europe in Helsinki in 2005, many countries in Europe came forward with their own mental health policies and legislations. Post 2005, there were 38 out of 42 countries in European Union with their own mental health policy, with significant development in policy frameworks designs. Countries like Germany and Belgium have specific policies on Depression, Dementia, and Suicide Prevention respectively. Croatia and Romania have established national institutes for mental health; Germany designated a Federal Government Commissioner for Patients Affairs and Australia. Italy and Slovakia have revised advisory boards for mental health.3 Likewise among 52 Commonwealth associated countries, 11 of them did not have mental health policy in place, while 16 of them did not have an independent policy for mental health, but was linked to other policies. The rest of the 25 countries have the mental health policy whether in final or draft version.4 Studies have analyzed these policies from different lens: from human rights approach to allocation of funding and investment, and from having integrated suitable working environment for mental health providers to having matrix to measure health services qualities. One of the major component missing in every policy and their analysis, and which this article aims to highlight and advocate for, is having gender as a differential component and analytical lens.
Amidst these struggles for progressive policy development, the gender sensitivity and inclusivity in mental health policies is still an alienated concept. The WHO checklist for mental health policy, which until date serves, as the complying instrument for nation’s policies on mental health, has no reference to any gender based component. A study on Irish mental health policy and service provision done from a gendered perspective stated that although “Gender mainstreaming” is promoted by Irish government as a strategy to promote equal opportunities among men and women in its National Development Plan, the mental health policy does not explicitly mention gender or gender sensitivity, rather just promotes partnership and social inclusiveness in a gender-neutral way.5
Why is gender sensitivity and analysis fundamental to improvement of mental health policies? Arguments highlights that gender analysis helps in identification and treatments of health problems in underreported group, provides better understanding of epidemiology of health problems, improve the relevancy of public health services and increase public participation in health sector.6 In addition, there has been numbers of studies highlighting the difference in rates, causes of mental illness and services seeking behavior among men and women. Biological along with socio-cultural normative differences in terms of roles, expected attributes and power relations contribute to different nature of mental health problems and health service seeking behavior among women. Wide numbers of studies are available that highlights the high rate of depression, stress and eating disorders among adolescent girls and more suicidal attempts than boys. Whereas, there is high tendency of engagement in high risk behavior, drug uses and anger in boys along with more frequency of suicidal attempt than girls. Hormonal changes during menstruation cycle and pregnancy are also known to cause mood swings and antenatal/postnatal depression respectively among women and girls. Many psychosocial factors play role in elevating such cases like marital disharmony, work-life balance, inadequate social support and poor financial support. Also, women constitute around 70% of the world’s poor and earn significantly less than men when in paid work, which highlights the risk of health problems. A study from China suggests that the distress caused to women by factors such as arranged marriages, unwanted abortions, in-law problems and an enforced nurturing role precipitates psychological disorders.7
Sexual violence, to which over 35% of women worldwide suffer, 8 also counts as a significant causal factor for rising mental health issues. Adult women victims of childhood abuse or physical partner violence are 4 times in higher risk of depression. Studies show that nearly 1 in 3 rape survivors suffer from PTSD compared with 1 in 20 non-victims. A population-based study from Nicaragua has found that women who had experienced severe abuse during the last year were ten times more likely to experience emotional distress than women who had never experienced abuse. Studies have also shown impact of sexual abuse being more severe and complex among male survivors in the US and the Netherlands.
Gender based stereotypes and socialization process also play significant role in induction, diagnosis and treatment of mental health problems differently among men and women. Men and boys are in high-risk of distress and anger as they are not expected to be expressive of vulnerabilities. For which, men tend to use alcohol as remedy and considered using psychotropic drugs are sign of weakness. On the other hand, women are known to opt for psychotropic to handle emotional issues. The differences in treatment of such problems are also apparent with health service providers diagnosing depression more to women than men with the similar reports of problem.
Considering such wide range of evidences and studies on gender acquired risks and differences in mental health domain, it is astonishing that national policies don’t have gender as a differential lens. Studies and research have also significantly highlighted gender sensitive services but advocacy on a policy level is still a necessity. Also there remain significant gaps in research and studies of mental health status in developing countries as currently the literatures are dominated by developed countries statistics, whereas there is also significant gap on adequate research on male biology interlinking with psychological problems in comparison to female biology. Considering how mental health problems are epidemically spreading, it is recommendable for national and international authorities to design holistic and equitable policies, which can give way forward to gender sensitive mental health services.