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Singapore Med J 2007; 48 (5) : 385
Review Article
ABSTRACT
Effective strategies for mental disorders
prevention and its risk factors’ reduction
cannot be gender neutral, while the risks
themselves are gender specifi c. This paper
aims to discuss why gender matters in mental
health, to explain the relationship of gender
and health-seeking behaviour as a powerful
determinant of gender differences, to
examine the gender differences in common
mental health disorders, namely, depressive
and anxiety disorders, eating disorders,
schizophrenia, and domestic violence, and
fi nally, to raise some recommendations
stemming from this review.
Keywords: gender differences, health-
seek ing behaviour, mental disorders, sex
Singapore Med J 2007; 48(5):385–391
INTRODUCTION
In 2002, World Health Organisation (WHO) passed its
fi rst Gender Policy, acknowledging the gender issue as
important on its own. At about the same time, WHO
began using the UN’s Millennium Development Goals
(MDGs), which go beyond the Health for All framework’s
focus on equity in general, specifying more particularly
that gender equality and the empowerment of women are
vital goals; MDG, Goal three.
(1)
Unfortunately, “gender”
is increasingly used inappropriately as a substitute for
“sex”, particularly in biomedical literature, a tendency
which has created confusion. Sex denotes biologically-
determined characteristics, while gender indicates
culturally- and socially-shaped variations between men
and women.
(2)
Gender is related to how we are perceived
and expected to think and act as women and men because
of the way society is organised, and not because of our
biological differences.
(3)
Absence of discrimination
on the basis of a person’s sex in opportunities, and the
allocation of resources or benefi ts, or access to services,
is gender equality. Therefore, gender equality refers to
the fairness and justice in the distribution of benefi ts and
responsibilities between women and men.
(4)
Gender-based differences may emanate from a
biomedical (genetic, hormonal, anatomical, physiological);
psychosocial (personality, coping, symptom reporting);
epidemiological (population-based risk factors); or even
a more global perspective. The latter analyses large-scale
cultural, social, economic, and political processes that
ultimately produce differential health risks for women
and men.
(5)
Rarely does biology act alone to determine
health inequities. Social determinants, including gender,
interact with each other and exacerbate biological
vulnerabilities. For example, women’s lower social
autonomy exacerbates their biological susceptibility
to the human immunodefi ciency virus (HIV).
(6)
Also, a
more than two-fold increase in risk has typically been
found for those in the lowest social class compared to the
highest, for psychological as well as physical morbidity.
(7)
Psychosocial risks accumulate during life and increase the
chances of poor mental health and premature death.
(8)
Mental health problems are among the most important
contributors to the global burden of disease and disability.
Mental and behavioural disorders are estimated to account
for 12% of disability-adjusted life-years lost globally and
31% of all years lived with disability at all ages and in
both sexes, according to year 2000 estimates. Yet, more
than 40% of countries have no mental health policy, over
90% have no mental health policy that include adolescents
and children, and over 30% have no mental health
programmes.
(9)
For a long time, general practitioners
have learnt from clinical experience that women receive
more services for mental disorder in primary care settings
than do men. On the other hand, psychiatrists and clinical
psychologists are aware that the difference is less marked
for specialist mental health services, and particularly
hospital-based services. Service utilisation data may have
important implications for health policy and services
organisation. However, they simply indicate the extent
of treatment, not the need for treatment. The clinician
should therefore go beyond their clinical practice and
acknowledge that they need help from epidemiologists
and from epidemiologically-based research to be able
to understand which sex, or which demographical group
within each sex, has the greater risk of experiencing
psychological distress and mental illness.
(10)
The aim of this work is to discuss why gender matters
in mental health, to explain the relationship of gender
and health-seeking behaviour as a powerful determinant
of gender differences, to examine the gender differences
in common mental health problems, and to raise some
recommendations stemming from this review to conclude
the paper.
A similar PubMed search strategy to a study previously
published by the author was followed to collect papers
reviewed in the current study.
(11)
In a PubMed search
Gender differences in mental health
Afi fi M
Ministry of Health
Headquarters,
Department of
Non-Communicable
Diseases,
PO Box 393,
Muscat 113,
Oman
Afi fi M, MBBCh,
MMed, DrPH
Specialist
Correspondence to:
Dr Mustafa Afi fi
Tel: (968) 9903 5672
Fax: (968) 2469 5480
Email: afi fi dr@
gmail.com
Singapore Med J 2007; 48 (5) : 386
within a single hour limit (on April 13, 2006), the Medical
Subject Heading (MeSH) database of the MEDLINE for
articles under the psychiatry and psychology category
(mental disorders, behaviour and behaviour mechanism,
psychological phenomena and process, and behavioural
disciplines and activities) was explored, limited to the last
15 years (from January 1991 to April 2006). The search
was then combined using the Boolean “AND” with the
key words “gender difference” OR “sex difference”. The
abstracts of psychiatry and mental health publications
with “gender difference” or “sex difference” in its title or
text over the last 15 years were then reviewed. From the
aforementioned rapid review, selected full papers were
downloaded or requested, and thoroughly reviewed and
comprised the current study references. Added to that,
WHO publications and online documents about gender
and health and/or gender and mental health were also
reviewed and added to the references list.
WHY DOES GENDER MATTER IN MENTAL
HEALTH?
A gender approach to health means to distinguish biological
and social factors while exploring their interactions, and
to be sensitive to how gender inequality affects health
outcomes. A gender approach to mental health provides
guidance to the identifi cation of appropriate responses
from the mental healthcare system, as well as from public
policy. Gender differences clearly exist, even where the
socioeconomic gradient may not be strong. Never married
and separated/divorced men have higher overall admission
rates to mental health facilities than women in the same
marital status categories. In contrast, married women have
higher admission rates than married men.
(12)
Gender, like
other stratifi ers, does not operate in isolation. It interacts in
an additive or multiplicative way with other social markers
like class and race.
Gender analysis improves understanding of the
epidemiology of mental health problems, decisions and
treatment of these problems in under-reported groups, and
also increases potential for greater public participation
in health.
(2)
Overlooking gender-based differences or
gender bias could have drastic consequences. Doctors
are more likely to diagnose depression in women
compared to men, even when they have similar scores
on standardised measures of depression or present with
identical symptoms. Gender stereotypes regarding
proneness to emotional problems in women and alcohol
problems in men, appear to reinforce social stigma and
constrain help-seeking along stereotypical lines. They
are a barrier to the accurate identifi cation and treatment
of psychological disorders.
(13)
Women’s mental health
affects others in society. Their increasing presence in the
workforce means that their mental health affects national
productivity. Their social role as caregivers means that
their mental health affects the mental health of their
children and elderly parents. Moreover, understanding
the needs of adolescent girls for services is important
for many mental disorders, especially those that affect
large numbers of young women, such as mood, anxiety
and eating disorders. Finally, all that would be translated
into better interventions and services for females and
their community.
(14)
GENDER AND HEALTH-SEEKING
BE HAVIOUR
To reduce gender disparities in health, the provision of
medical services alone is clearly inadequate.
(15)
Viewing
health through a gender lens necessitates steps to improve
women’s access, affordability and appropriateness to
the health services. Health services for women tend to
focus on their reproductive functions, neglecting the
needs of women outside the reproductive ages. A lack
of female medical personnel is sometimes a barrier for
women to utilise healthcare services.
(16)
Poor women fi nd
themselves without access to healthcare more often than
men from the same social group, even in rich countries
like the United States.
(17)
In many developing countries,
women complain about lack of privacy, confi dentiality
and information about options and services available.
(18)
Another barrier is that medical doctors either attribute
different meanings to identical symptoms for presenting
male and female patients,
(19)
or attribute women’s illnesses
to psychiatric disorders and prescribe inappropriate
medication.
(3)
Women’s higher mental and physical
morbidity have also been hypothesised as being caused
by their gender sensitivity to physical cues and to the
social acceptability of sick roles for women.
(20)
On the
other hand, emotional and cognitive capacities of women
themselves may limit their access to healthcare.
(21)
Amin and Bentley concluded that gender inequalities,
manifested through fertility, marriage, and work norms,
violence in marital relationships, and poor psychological
health, have resulted in rural Indian women accepting
high thresholds of suffering and not seeking treatment for
their symptoms.
(22)
GENDER DIFFERENCES IN MENTAL
HEALTH DIS ORDERS
Astbury found that gender differences in mental disorders
extend beyond differences in the rates of various disorders
or their differential time of onset or course and include
a number of factors that can affect risk or susceptibility,
diagnosis, treatment and adjustment to mental disorder.
(23)
Gender differences in prevalence of mental disorders vary
across age groups. Conduct disorder is the commonest
psychiatric disorder in childhood, with three times as
many boys as girls being affected.
(24)
During adolescence,
girls have a higher prevalence of depression and eating
Singapore Med J 2007; 48 (5) : 387
disorders, and engage more in suicidal ideation and suicide
attempts than boys, who are more prone to engage in high
risk behaviours and commit suicide more frequently.
(25,26)
In adulthood, women had a higher prevalence of most
affective disorders and non-affective psychosis, and men
had higher rates of substance use disorders and antisocial
personality disorder.
(27)
Men may develop alternative disorders in response
to stress, such as antisocial behaviour and alcohol abuse.
They may be more likely to have been socialised to
express anger or other forms of acting out, whereas
women may be more likely to have been socialised to
express dysphoria in response to stress. In support of this,
studies have shown that expected gender differences in
depressive disorders were balanced out by higher male
rates of alcohol abuse and drug dependency.
(28)
DEPRESSIVE AND ANXIETY DISORDERS
Depression and anxiety are the most common comorbid
disorders, and a signifi cant gender difference exists in the
rate of comorbidity. Their diagnosis is often associated
with somatic complaints, and is known to affect around
one in fi ve people in the general community, and more than
two in fi ve primary care attenders in many countries.
(29)
Gender differences in rates or correlates of depression
exist but may differ for different countries. In Alexandria,
Egypt, the rate of having depressive symptoms in girls was
almost double that in boys. In Oman, however, there was
no signifi cant difference.
(30)
Moreover, age at fi rst onset
of depression and bipolar disorder is similar in males and
females.
(31)
Yet, adolescent girls have been found to be
signifi cantly more likely to experience low and moderate
levels of depression and anxiety than adolescent boys.
(32)
Among adults, women presented slightly more often with
milder types of depression than with severe depression
in outpatient settings. However, no gender difference
was found in the severity of depressive episodes among
hospitalised patients.
(33)
No gender difference was found
in the use of anti-depressive medication
(34)
nor in the
response to it.
(35)
Because gender interacts with other social
determinants, women’s strain due to stressful life
events is a consequence of their differential sensitivity
to events. It is a result of role differences, rather than
women experiencing more events. Women only have a
higher risk following crises involving children, housing
and reproduction, rather than those involving fi nances,
work and their marital relationship.
(36)
For physicians,
the postpartum period is often perceived as one that
requires little assistance other than the single visit
recommended at 4–6 weeks after delivery. Yet, fi ndings
from longitudinal studies suggest that recovery from
childbirth involves more than healing of reproductive
organs.
(37)
Some women face serious problems such
as depression.
(38,39)
The prevalence of major or minor
depression among pregnant women ranges from 7%
to 26%.
(40)
Depression during pregnancy is a strong
predictor of postpartum depression,
(41)
and is associated
with adverse foetal development; thus, the treatment of
antepartum depression is critical.
(42)
The prevalence of
postpartum depression ranges from 10% to 15% in the
fi rst year after childbirth, which may have deleterious
effects on the women’s relationships, her functional
status, and her ability to care for her infant.
(42,43)
Many
women with postpartum depression would not receive
mental health services because primary care providers
might be unable or unwilling to screen, treat, and/or refer
the women. Therefore, eliminating the barriers of mental
healthcare in the postpartum period and creating more
awareness among primary care providers about women’s
mental health in this period is crucial.
(43)
In general, women are not more vulnerable to
negative life events than men are. However, women with
no social support, who are exposed to life events, are
more vulnerable than men without support. Accordingly,
Dalgard et al concluded that the higher rate of depression
in women is not explained by gender differences in
negative life events, social support or vulnerability.
(44)
Chronic strain, low mastery, and rumination were each
more common in women than in men, and mediated the
gender difference in depressive symptoms. Rumination
amplifi ed the effects of mastery and, to some extent,
chronic strain on depressive symptoms. In addition,
chronic strain and rumination had reciprocal effects on
each other over time, and low mastery also contributed
to more rumination. Finally, depressive symptoms
contributed to more rumination and less mastery
over time.
(45)
The role of personality factors in gender
differences has been studied by Goodwin and Gotlib,
who found that the level of neuroticism, which was
signifi cantly higher among females, may moderate the
association between the female gender and increased risk
of depression among adults.
(46)
Women report more worry and more cognitive
variables associated with worry than men. Robichaud
et al found that women reported more worry than men
on two measures of the tendency to worry, as well as
more worries about lack of confi dence issues.
(47)
Women
also reported a more negative problem orientation and
engaging in more thought suppression, a type of cognitive
avoidance.
(47)
Anxiety disorders include panic disorder,
obsessive-compulsive disorder (OCD), post-traumatic
stress disorder (PTSD), social phobia, and generalised
anxiety disorder. Women outnumber men in each illness
category except for OCD, in which both sexes have an
equal likelihood of being affected. Not only are women
more likely to have panic with concurrent agoraphobia,
but they are more likely than men to suffer a recurrence of
Singapore Med J 2007; 48 (5) : 388
panic symptoms after remission of panic.
(48)
The gender
differences exist among patients with panic disorder in the
feared consequences of anxiety symptoms as well as in
the personality characteristics of extraversion.
(49)
Women
are 2–3 times more likely to develop PTSD after trauma
than males, and to have persistent symptoms.
(48)
Whether gender differences in depression could be
explained by gender differences in comorbid anxiety
is still controversial. Simonds and Whiffen found that
women are more likely than men to be diagnosed with
either disorder alone or comorbidity.
(50)
Furthermore, the
ratio of women to men who experience anxiety alone
or anxiety in combination with depression, tends to be
higher than the ratio of women to men who experience
depression alone. Therefore, they concluded that attempts
to explain the gender difference in rates of depression
would benefi t from the understanding that women are
more likely to experience anxiety.
(50)
Somatic depression
which is associated with high rates of anxiety disorders
is much higher among women than men.
(51)
Yet, Parker
and Hadzi-Pavlovic concluded that the female gender
remained a signifi cant predictor of depression after
accounting for the effects of prior anxiety.
(52)
EATING DISORDERS
The high variability of incidence found across very different
populations and climates suggests that sociocultural or
ecological factors play a substantial role in the aetiology of
eating disorders.
(53)
The vast majority of people with eating
disorders in the United States are adolescents and young
adult women. In addition to causing various physical health
problems, eating disorders are associated with illnesses
such as depression, substance abuse, anxiety, and especially
OCD. Eating disorders, including anorexia and bulimia,
are more common in women.
(54)
The available literature
indicates that anorexia nervosa is rare in the Arab culture.
(55)
Therefore, more than one study in the Arab world focused
solely on young females.
(56,57)
Yet, the prevalence of both
anorexia nervosa and bulimia was similar for both males
and females in an Omani study,
(58)
whereas the prevalence
of bulimia was higher among female adolescents in
comparison to their male counterparts in Morocco.
(59)
The
absence of gender differences in eating disorders in some
studies could be explained by the probable comorbidity of
anorexia or bulimia nervosa with obsessive-compulsive
neurosis in the study patients. OCD patients have a
substantial lifetime prevalence of anorexia and/or bulimia
nervosa. However, no signifi cant gender difference exists in
the lifetime prevalence of eating disorders among patients
with OCD.
(54)
SCHIZOPHRENIA
Schizophrenia is the most chronic and disabling of mental
disorders, with psychotic symptoms fi rst appearing
in the late teens or early twenties. Although men and
women alike are affected and the lifetime morbidity
risk is around 1% with little difference between them,
there are differences in the age of onset, pattern of
symptoms, brain structure impairment, response to
treatment and outcome.
(60)
Lifetime onset age differs
signifi cantly between men and women, where men get
ill with schizophrenia, on average, 4–6 years earlier
than women.
(61,62)
However, Lewine concluded that sex,
and not gender, was a signifi cant predictor of age at
fi rst hospitalisation, while the gender perspective may
best serve other aspects such as neuropsychological
functioning.
(63)
Conversely, Naqvi et al found that there
was no signifi cant gender difference in the age of onset
of the disorder.
(64)
The controversy could be explained
through the fi ndings of Salokangas et al.
(65)
They found
that women have a later onset of schizophrenia than men,
but only in its paranoid form.
(65)
Regardless of the later
onset, women experience more hallucinations or more
psychotic symptoms than men.
(66)
First admission to
psychiatric institutions occurs 3–6 years later in females
compared to males. No gender differences in number
of re-admissions or length of stay during follow-up
have been reported by most studies. In general, women
require lower doses of medication than men during both
acute and maintenance phases of the illness, at least
until menopause.
(28,66,67)
Electroconvulsive therapy is
signifi cantly more effective in female patients than male
patients suffering from schizophrenia.
(68)
DOMESTIC VIOLENCE AND PHYSICAL
ABUSE
Violence is a risk factor for injury and disability; mental
health disorders (mood, anxiety, PTSD, eating disorders,
sexual dysfunction, multiple personality disorder, OCD,
and suicide); chronic pain syndromes and somatic
complaints; and other negative health behaviours
(smoking, alcohol and drug abuse, physical inactivity,
overeating). Abused women are at increased risk for
emergency room visits and hospitalisations.
(69)
In domestic
violence, women are usually the victims of the attack
and the perpetrator may well be motivated directly by
the desire to demonstrate his own masculinity to enforce
his male power and to control the women. This has led
many experts to adopt the term, gender-based violence, to
describe domestic violence.
(3)
A review of evidence from
40 well-designed population-based studies suggested that
between 25% and 50% of women around the world report
being victims of physical abuse by men at some point
in their lives.
(70)
However, reliable data on the extent of
domestic violence are sparse, particularly in developing
and Arab countries. An explanation could be that women
are often extremely reluctant to report attacks for fear
of not being believed or being re-victimised. Moreover,
Singapore Med J 2007; 48 (5) : 389
information is often not recorded in a systemic or
sympathetic way. In Arab countries, domestic violence is
not yet considered a major concern, despite its increasing
frequency and serious consequences. Surveys in Egypt,
Palestine, and Tunisia show that at least one out of three
women is beaten by her husband. The indifference to
this type of violence stems from the Arab’s attitudes that
domestic violence is a private matter. There is usually
a justifi able response to misbehaviour on the part of
the wife.
(71)
The prevalence of self-reported violence
among pregnant women is also common, being 21% in a
relatively-recent study.
(72)
CONCLUSION AND RECOMMENDATIONS
Effective strategies for risk factors’ reduction in relation
to mental health cannot be gender-neutral, while the
risks themselves are gender-specifi c, and women’s status
and life opportunities remain low worldwide. Low status
is a potent mental health risk. For too many women,
experiences of self worth, competence, autonomy, adequate
income and a sense of physical, sexual and psychological
safety and security, so essential to good mental health, are
systematically denied. The pervasive violation of women’s
rights, including their reproductive rights, contributes
directly to the growing burden of disability caused by poor
mental health.
(73)
Therefore, an inter-disciplinary action to
set policies which protect and promote women’s autonomy
and women mental health is crucial. Ministries of health
should take steps to develop and integrate gender-relevant
indicators in the existing national health information
systems, and to fi nd mechanisms to monitor gender
sensitivity in the health system.
It should be a standard practice to disaggregate all
epidemiological data by sex and age for all diseases and
health conditions, allowing gender analysis of data and
monitoring the sex-specifi c burden of disease over the
lifetime. Besides documenting differences in prevalence
rates of mental disorders and other diseases, it is crucial
to examine how women’s and men’s differences – such as
their roles and responsibilities, their knowledge base, their
position in society, their access and use of health resources
– infl uence the vulnerability to mental disorders. There is
also a need to strengthen women’s access to and control
over resources that promote and protect health through
addressing gender-based barriers to utilise services. We
should not forget the importance to integrate a gender
approach to health in training primary care providers
to identify and to treat mental illness. Linking gender
sensitivity to training as well as performance appraisals
assures that the issue is taken seriously and translated into
practice. More attention should be given to identify factors
that would facilitate coping with stress or distress and to
design intervention programmes on the communal as well
as the primary care level. In addition, it is important to
review, evaluate and strengthen community services and
the role of non-governmental organisations to protect and
promote women’s autonomy and mental health. We should
not overlook the importance of strengthening the role of
media and education and training of media personnel to
increase community awareness of women mental health,
reducing the stigma of mental problems and promoting
women’s mental health.
The author wishes to acknowledge two limitations
in his review. The fi rst is that the current review is a
traditional or non-systematic narrative review which was
based on a selective approach of literature. The author
selected papers that seemed to him to be appropriate
to the review paper. Conversely, in meta-analysis, the
selection is comprehensive and replicable, where studies
are collected, coded, interpreted using statistical software.
Hence, results in meta-analysis are more objective
and exact than in the traditional review. However, in
meta-analysis, one should focus on certain aims, which
the author fi nds infeasible to implement in the current
study. Actually, the current study has answered, posed,
and pointed diversifi ed issues, and the limitation of the
paper length constituted a constraint for the author. Yet,
in a future study, the author intends to use meta-analysis
to investigate the controversy in gender differences in
eating disorders. The second limitation is the dearth of
mental health research in the Arab world.
(11)
That actually
constituted another constraint for the author to elaborate
more on the subject in the context of the local settings of
Oman and the Arab world.
ACKNOWLEDGEMENTS
The author wishes to thank the reviewers for their
valuable comments, without which the paper would never
be in its present shape.
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