Gender, mental health and violence. (Consequences of Gender Violence).

1. Introduction

Health, understood as psycho-social well-being, depends on a country's economic, political and social development, and on public health conditions (Ministerio de Salud, 1999, p. 19.). This concept of health as "well-being" implies not only the absence of illness, but also quality of life.

Chile's development model and the organization of our national economy in the context of an accelerated process of globalization have created conditions detrimental to the quality of life of most of the population. A number of factors generate conditions of chronic stress that affect all of society in some fashion: long and intense workdays; significant distances between the residence and the workplace; environmental contamination; crime associated with drug use and trafficking; competition; consumerism; loss of community spaces and a sense of identity: profound inequalities in access to services and opportunities for personal development; and discrimination based on class, gender, ethnicity and age.

Since 1997, mental health has been one of the 16 priorities of Chile's Ministry of Health. The government's Mental Health and Psychiatric Care Plan (1) for 2000-2005 focuses mental health services on the following problems and population groups:

* Care for children and adolescents with attention deficit disorder. Approximately 6% of all children five to seven years of age suffer from this disorder. ADD is more common among boys (Ministerio de Salud, op. cit., p.59). (2)

* Women and older persons who are victims of domestic violence. An estimated 33.6% of all women experience some degree of violence in the home, and 60 out of 1,000 women treated in the public primary health care services are victims of serious violence. According to projections of international studies, as many as 4% of the elderly are victims of abuse (ibid., p.76).

* People affected by political repression during the 1973-1990 dictatorship. Some 800,000 individuals are estimated to have been directly affected. Care is focused on families of the detained, disappeared and executed; people who were tortured, threatened, detained, forced into clandestinity, exiled (and later politically exonerated); and their immediate families (ibid., p.83).

* People suffering from depression. Approximately 7.5% of the general population suffer from depression, as well as nearly 30% of all those who seek care at the state-run primary health care facilities. In Chile, depression is responsible for more disability among women than any other mental health problem. Depression holds second place among the fifteen top causes of DALYs (Disability Adjusted Life Years) (ibid., p.88).

* Individuals with serious psychiatric disorders. Studies undertaken in Santiago estimate a 1.02% prevalence of schizophrenia among the general population (ibid., p.95).

* Alcohol and drug abuse and dependency Alcohol abuse affects 15% of the general population, and one-third show some level of alcohol dependency. In addition, 5% of the population admits to having used illegal drugs in the past year, and 1% show signs of drug dependency (ibid., p.106).

* The elderly affected by Alzheimer's and other forms of dementia. Estimates indicate that 5-10% of Chileans over age 65 suffer from these disorders (ibid., p.117).

In an effort to increase equity in health care, the Mental Health and Psychiatric Care Plan envisions a series of actions to be undertaken among population groups at higher risk for depression and with less access to treatment. Among these vulnerable groups are: women aged 20 to 45; women who suffer from chronic or recurrent illnesses; women during the post-partum period and menopause; those with several, closely-spaced children; women victims of domestic violence; women heads of household, and people in crisis situations, including adolescents and older persons (65 years of age or older) of both sexes.

According to data from 1989, hospital admissions due to mental illness accounted for only 2% of all admissions throughout the country. Of these, 44.8% were women. "Neurosis and personality disorder" were the primary cause of women's hospitalizations due to mental illness (32.7%). The primary cause of hospitalization due to mental illness among men was "alcohol-induced depression syndrome" (34.0%) (Flacso, 1991). Data from 1996 shows little variation in these tendencies: women accounted for 45% of the total hospital admissions related to mental health (SERNAM/INE, 2001, p.92).

A study on the use of benzodiazepine undertaken in Santiago in 1991 (Busto, et al., 1991) revealed that more women than men use this drug, with little variation according to socioeconomic level. More of the users of benzodiazepine lived with a partner, followed by widows and women separated from their husbands. (3) Benzodiazepine use was also more common among women (and men) above 40 years of age.

According to figures released in 2001 by the National Women's Service (SERNAM), women are more likely to use tranquilizers (16.9% of women as compared to 7.5% of men). Tranquilizer use is concentrated among adults 45- to 64-years old (19.6%) and declines proportionally with age. Among new users of tranquilizers (those who started taking these drugs in the past year), these tendencies are similar: 3.9% are men and 8.6% are women (SERNAM/INE, op. cit., p.95.).

Compared with 14 other cities around the world, Chile's capital of Santiago takes first place for prevalence of depression (29.5%) registered in primary health care facilities, the English city of Manchester is a distant second at 16.9%. Santiago also places second for prevalence of anxiety (18.7%) after Rio de Janeiro, where this mental health problem affects 22.6% of the population. In terms of alcohol dependence, Santiago holds sixth place at 2.5%. The greatest prevalence of alcohol dependency is in Mainz, Germany (7.2%) (Goldberg and Lecrubier, 1995, cited in The World Health Report 2001).

While official figures from the health sector indicate that 33.6% of all women experience some form of domestic violence--a recognized risk factor for depression--a recent study by SERNAM reports that 50.3% of all women living in the Metropolitan Region of Santiago have experienced some sort of violence in the home at some time in their lives (SERNAM, 2001). Another study carried out in 2000 in the low-income Santiago borough of San Ramon by the women's health NGO Educacion Popular en Salud (EPES, Popular Education for Health) revealed even higher rates of violence. In a survey of 358 women, 55.8% said they were currently enduring some form of physical, sexual, psychological or economic violence from their current partner. Of these women, 22.7% reported incidents of sexual violence (Calvin and Toro, 2001, p.37).

The San Ramon study reveals a serious deterioration in the health of women who experience sexual violence in their own homes, especially in terms of mental health: 58% suffer from anxiety, 56.8% depression, 53.1% sleep disorders and 50.6% stress. Over 30% of the women victims of sexual abuse by their partners reported suffering anxiety and depression for five or more years (Calvin and Toro, op. cit., pp.55-56).

Abused women, especially those who endure sexual violence, demonstrate a very wide range of mental health problems. The literature on this issue identifies the following among the mental health consequences of abuse: post-traumatic stress disorder; depression; anxiety; eating disorders; sleep disorders; split or multiple personality disorder; obsessive-compulsive disorder; and feelings of rage, humiliation and guilt. "Follow-up studies have shown that rape survivors have higher rates of persistent post-traumatic stress disorder than victims of other traumas" (Norris, 1992, cited in Heise, 1994). At the same time, "50 to 60 percent of victims experience severe sexual problems, including fear of sex, problems with arousal, and decreased sexual functioning" (Heise, 1994, p.20).

Because Chile has no nationwide system of recording consultations in health services related to domestic violence, there are no reliable statistics on the true magnitude of the damage that domestic violence causes to women's physical and mental health. The available data correspond only to extreme cases in which the victim sought care explicitly for serious injuries caused by domestic violence.

According to figures for 1999 from the Epidemiology Department of Chile's Ministry of Health, 3% of all public health consultations were women victims of domestic violence suffering post-traumatic stress syndrome (Ministerio de Salud, n.d., p.7.). Statistics from the National Forensics Service indicate that, of the 1,985 examinations related to sex crimes in 1998, 79.1% were performed on women; 25.5% for the crime of rape; 51.1% for sexual molestation, and 2.4% other sexual violence against women. Less than 21% of the examinations were performed on male victims (SERNAM/INE, op. cit., p.103).

According to National Forensics Service data from 1997, in 20.4% of incidents of sexual violence, the assailant was a stranger, four-fifths of all assailants were known to the victim previously. Of these known assailants, 35.5% were the father or another member of the family (ibid., p.103).

Because sexual abuse is often committed by someone the victim knows, usually a close relative, and because prosecution of these types of crime is so difficult, often the victim must maintain some sort of relationship with her/his abuser. This increases the likelihood that the sexual abuse will be repeated and the victim will suffer mental health consequences.

2. Gender and Mental Health

Mental health is clearly influenced by the social and cultural conditions of our societies. Indeed, five of the seven mental health priorities that Chilean health officials propose to address are problems with origins in the social and political realities of our country and cultural expectations linked to gender differences.

Our present society is characterized by significant changes in ideologies, models and life styles, as well as by contradictions in the roles assigned to women and men. Some therapists believe that the wide variety of symptoms and alterations in women's mental health, reflect "an unsatisfactory form of life, contradictory pressures and mandates, over-burdening, inhumane demands, a failure to appreciate women's true worth, lack of recognition of one's own needs, exhaustion, lack of personal space and self-denial" (Daskal, 1994, p.27).

The double workday shouldered by many women leads to over-burdening and demands that are difficult to satisfy and eventually frustration and dissatisfaction with their own expectations and those of their families. Women's incorporation into the labor market and the changes that this has produced in the family structure are evident in the growing number of women heads of household. In 1970, 20.3% of all Chilean households were headed by a woman; by 1992, this figure had reached 25.3% (SERNAM/INE, op. cit., p.72). Nonetheless, because the family continues to be conceived as a nucleus composed of mother, father and children in which the role of the provider is primarily assigned to the man, women's current role in generating family income is not recognized.

In the current context, women must contend with fact that their work in the home is neither valued nor recognized and that they are not paid wages equal to men's. In Chile, women's average income is 68.2% of men's, a gap that does not diminish significantly even as women's educational levels increase: among university-educated professionals, women's average income is 53.4% that of men with the same level of education (ibid., pp.42-43).

All women and especially female heads of household are also discriminated against in their access to health care through the private insurance system (ISAPRE). Women pay more for equivalent services and face unfair restrictions and exclusions in these health care plans, especially for mental health care. These plans "are based on the implicit `maternity risk' in all women of reproductive age, even among women who cannot or do not wish to become pregnant" (Ramirez, n.d., p.2).

Discrimination based on sex increases the probability of mental health problems among women. The discriminatory situation itself places an additional burden on women--either through pressure to work longer hours and increase their income or through the stress they face in the work environment. In addition, women make greater demands upon themselves to show that "in spite of being women, they are worth something, they can, they know" (Daskal, op. cit., p.25).

In addition, violence is still socially accepted as a legitimate disciplinary measure within the family and as a way to resolve conflicts. This socially-accepted violence is a significant trigger of women's mental health problems. "Threats or fears of violence control women's minds as much as do acts of violence, making women their own jailers" (Bradley, 1990, cited in Heise, op. cit., p.25). Women's mental health suffers when they are forced to sacrifice part of their autonomy, renounce interpersonal relationships, or abandon personal projects due to physical, psychological or economic violence.

"Violence against women is an extremely complex phenomenon, deeply-rooted in gender-based power relations, sexuality, self-identity and social institutions" (Heise, op. cit., p.29). Gender relations perpetuated through socialization and economic inequalities play a central role in the reproduction of violence against women since these conditions place women in a subordinate position in our social hierarchical structure. In this way, "[a]cts of violence and society's tacit acceptation of them stand as constant reminders to women of their low worth" (ibid.). It is no coincidence that the risk groups for depression include women, adolescents and older persons, all of whom are relegated to subordinate positions within our societies. This status is shared with children, who are subjected to the socialization of gender roles that perpetuate the use of violence as a mechanism for resolving conflicts and exercising power.

A study on child abuse carried out by UNICEF and the University of Chile with a representative sample of eighth-grade students from a range of socio-economic levels and geographical regions throughout the country revealed that 63% of those interviewed stated they had suffered some form of physical violence from their father and/or mother, and 14.5% reported some form of psychological violence (UNICEF, 2000, pp.120-121).

In addition to the direct effects of violence on children's physical and mental health, studies have also found that "children who witness violence experience many of the same emotional and behavioral problems that abused children do, including depression, aggression, disobedience, nightmares, poor school performance and somatic health complaints" (Heise, op cit., p.28).

The deterioration of mental health that characterizes Chilean society--and which makes Santiago the city with the highest prevalence of mental health disorders registered in primary health care facilities--also has an impact on the quality of services provided. Not only are women most affected by mental health problems, they are also the majority of workers in community, social and personal services. (4) Women who care for needs and problems that involve a heavy emotional burden have specific occupational health needs which are overlooked by health policies and programs and often go untreated.

3. An Intersectoral Effort

Addressing mental health problems demands the concerted efforts of a variety of public and private actors to address the social, cultural, economic and political circumstances associated with the origin of these ills.

Promotion, prevention and treatment of women's mental health problems requires the incorporation of a gender perspective into the entire process of planning public policy so that each sector may operationalize internationally-accepted gender indicators, that express the government's commitment to eliminating the different forms of discrimination and violence against women.

The health, education, justice, labor and social security sectors, as well as community and police services, need thorough human resources training so their personnel question socialized gender roles and grow more sensitive to the social conditions that create and reproduce discrimination and violence against women. These public servants need to be trained to provide the users of their services with information and guidance regarding their rights.

In addition, addressing the wide range of mental health problems demands increased collaboration from the media and a greater effort on the part of the health sector to increase the coverage of its programs. Public discussion is needed to reduce the stigmatization of those who suffer mental health problems and to educate the general public about the symptoms of mental illnesses and the conditions that favor recovery.

Domestic violence must also be addressed as a public health concern. The creation of an information system is fundamental, along with the development of norms and guidelines that facilitate the detection of violence in all health care programs to include the registration of all detected cases, rather than just those that are reported as crimes at the moment of treatment. This would facilitate case follow-up, more accurate statistics on violence-related morbidity and further research in this area, thus improving both the ability to intervene and to optimize resources earmarked for treatment.

At the same time, the creation of teams specialized in the treatment of women and families affected by violence is urgently needed. These teams should be capable of monitoring cases and coordinating resources from different sectors to provide comprehensive care to the victims. Safe houses for women and children in situations of violence that threaten their physical integrity and even their very lives are also essential.

The prevention of domestic violence requires careful coordination among the health and education sector programs, in order to: promote children's and women's rights; strengthen the effective introduction of these issues into school curricula; and design programs that target students and the population at the local level. Educational programs that facilitate the incorporation and development of social skills--such as the ability to handle and resolve conflicts within the family and the community--are also needed to complement aspects of programs aimed at strengthening women's rights.

At the community level, the participation and organization of women around their own needs must be strengthened, incorporating a gender perspective in specific training activities, as well as in initiatives and actions aimed at promoting organizational support.

4. Some Proposals for Reform

* Improve women's legal status, removing all legal norms and guidelines that limit women's free exercise of their rights or hinder women's equal opportunities in access to services or employment.

* Introduce changes in the Domestic Violence Law to punish abuse as a crime, which would allow effective precautionary measures and eliminate forced mediation in the face of physical violence, threats of and/or use of weapons, and sexual violence.

* Promote the approval of the Sexual and Reproductive Rights Law, which guarantees protection for women's physical and mental integrity.

* Change the Budget Law to allow resources to be designated for services that treat problems of mental health and domestic violence, in accordance with the guidelines proposed in the Mental Health and Psychiatric Care Plan; facilitate the effective implementation of the laws on domestic violence and sex crimes.

* Improve access to mental health services in the ISAPRE system, eliminating existing restrictions, and incorporating comprehensive care programs for these problems, in accordance with the guidelines of the Mental Health and Psychiatric Care Plan.

* Recognize the economic value of domestic work and improve the social status of women who do not work outside the home through social security for housewives.

Bibliography

Busto, M. A. et al. 1991, Descripcion del patron de uso de benzodiazepinas en la provincia de Santiago. Prevalencia de uso, abuso y dependencia. Santiago, Chile: CORSAPS.

Calvin, M. E. and M. S. Toro. 2001. Violencia sexual conyugal y oferta publica de servicios para su atencion. Primer informe de investigacion. Santiago de Chile: EPES, May, Year 3, No. 2.

Daskal, A. M. 1994. "Algunas reflexiones acerca de la Salud Mental de las Mujeres." Paper presented at the Primer Congreso Nacional Mujer y Salud Mental, June 11-13, 1992, SERNAM.

FLACSO, 1991. Mujeres Latino-americanas en cifras. Santiago, Chile: FLACSO.

Heise, L. 1994. Violence Against Women: The Hidden Health Burden. World Bank Discussion Papers 255, Washington D.C.: PAHO.

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Notes

(1.) According to the priorities identified by the Mental Health and Psychiatric Care Plan, the financing of this plan requires a budget increase from 1.2% to 5% of the total budget for health.

(2.) No specific actions are proposed for adolescents who present this problem. Whether or not associated with emotional or behavioral disorders, hyperactivity or attention deficit disorder (ADD) is the mental health problem most common among school-age children and adolescents. Studies show that this disorder has a biological origin and is genetically determined, with behavioral manifestations strongly influenced by environmental factors.

(3.) Ed. note: As of December 2001, there is still no divorce law in Chile.

(4.) In 2000, 46.1% of all salaried women are employed in community, social and personal services, accounting for 55% of all workers in this sector (SERNAM/INE, op. cit., p.41).

M. Eugenia Calvin Perez

The author is a social worker in charge of planning for the Chilean NGO, Educacion Popular en Salud (EPES, Popular Education for Health). This article was prepared for a recent workshop on equity, gender and health sector reform organized by the Pan American Health Organization. We thank PAHO for their gracious permission to translate and publish this article.