Women's mental health: triumphs and challenges. (The Malaise of Gender).

Mental health is the foundation of balanced development throughout life and plays an important part in inter-personal relationships. Mental health is key to an individual's successful social integration and full participation in the community and the workplace. Mental health is much more than the mere absence of mental illness; it is an indivisible part of an individual's health and well-being. It determines their ability to function efficiently, adapt to change, respond to crisis, establish satisfactory relationships with other members of the community and find meaning in their lives. (1)

Strengthening the ability to transform unjust and unequal situations based on gender discrimination and encouraging women's active participation in this change is the central focus of work in the field of women's mental health. One of the most significant challenges we face is the limited visibility of this issue on the public health agenda.

Recent statistics serve to underline the serious challenges to women and men's well-being in the current realities. The Disability-Adjusted Life Years (DALY) methodology has revealed that mental illnesses were responsible for 11.5% of global disability in 1998. In addition, half of the top ten causes of physical and mental disability are mental health concerns: depression, alcoholism, bi-polar disorder, schizophrenia and obsessive-compulsive disorders. (2)

Depression

Numerous clinical studies and community-based surveys have shown that depression is one of the most common public health problems. Some of this research has even suggested that rates of depression are similar to those of hypertension.

According to the experts, 17.1% to 21.3% of all women (and 12% of men) will suffer from serious depression at some time in their lives. In addition, women's first episode of depression is more likely to be of a more serious nature.

The many theories explaining women's greater risk for depression focus on two primary factors:

* Women are more likely to suffer serious depression when their reproductive roles force them to abandon or postpone their personal development; and

* Women are more vulnerable biologically due to critical moments in the life cycle associated with hormonal changes: adolescence, post-partum and menopause.

However, other studies have challenged the theories of women's greater vulnerability due to hormonal fluxes.

To broaden our perspective to other issues and to open the debate on the importance of different stages in women's life cycles, let us examine the following points:

1. Social pressures to adhere to a model of beauty tell adolescent women how they "should be" and have a strong influence on the identity of young womanhood and on adolescent girls' self-image. The mass media, fashion magazines and commercial advertisements reinforce these ideals of beauty, distorting the perception that young women have of their bodies as objects of desire and affecting their self-esteem. These unhealthy ideals and pressures are a fundamental factor in eating disorders.

2. Models of femininity associated with reproduction belittle the importance of sexuality-pleasure and place no value on women's relationship with their bodies. Fear, guilt and shame lead to depression. We must recognize these factors in the psycho-sexual development of adolescent women.

3. The mandates of maternity, the social representation of motherhood and women's insecurity about being good mothers, as well as the lack of social and family support networks, are at the root of postpartum depression 

4. The loss of the reproductive function around which many women have based their femininity, the burden of caring for elderly members of the family, unsatisfactory personal development, loneliness, an unsatisfactory marriage or sex life are some of the reasons that explain incidence of depression among women of middle age. Traditionally, estrogen deprivation and the end of ovulation have been used to explain depression among this age group.

However, all these hypotheses leave out one relentlessly ubiquitous phenomenon that silently leads to depression: violence.

Violence and Mental Health

Among groups of women in different stages of the life cycle, we witness various manifestations of violence. (3) The women share these experiences through different means--from theater productions to self-help groups--but the relationship of violence with women's mental health is always evident.

According to the DALY indicators, domestic violence accounts for nearly one year of life lost for every five healthy years of life among working women age 15 to 44. (4) Recent estimates also show that only 2% of all cases of sexual abuse of children within the family are reported, as are only 6% of those cases of sexual abuse by a non-family member and 5% to 8% of all incidents of sexual abuse in adulthood.

In Latin America, it is estimated that the cases of battering reported by adult women account for only 15-20% of all incidents of domestic violence. (5)

A study undertaken in Costa Rica from 1990 to 1998 revealed that each month an average of 2.8 women were killed by their husband, ex-husband, partner or boyfriend (CEFEMINA, 1998). (6) In Nicaragua, according to statistics from the Comisarias de la Mujer y la Ninez (Women and Children's Police Stations), in 1999 a total of 6,885 crimes against women and children were registered, an average 574 cases of violence each month. Of these crimes, 78% were cases of domestic violence and 28% were sex crimes. According to current official figures, every day 19 women are victims of violence, primarily at the hands of their partners. It is estimated that the under-registration of this statistic is more than 90%. (7)

In addition to the physical consequences of violence, other effects reveal themselves over time as psychological and emotional scars: depression, low self-esteem, feelings of uselessness and guilt, sexual dysfunction, and constant feelings of fear. All these complications symptomatic of battered women are evident in diminished intellectual performance and decreased productivity on the job, with the consequent impact on their earnings and economic situation. Above all, the psychological impact of gender-based violence is evident in women's inability to defend themselves and to report the abuse.

A number of factors that contribute to under-reporting and the perpetuation of violence against women:

* Gender socialization which sets men above women;

* The low classification of women's positions and roles;

* The slow or limited incorporation of gender in agendas, policies, strategies, service planning, projects and research;

* The scarcity of public policies that take gender into consideration;

* The perpetration of "secondary violence"--blaming women victims for the abuse, which makes them vulnerable to other forms of violence;

* The lack of training among those who should identify, diagnose and propose solutions for situations of violence. One significant opportunity is found in the health sector and especially in primary health care;

* Public health curricula fails to address the issue of violence or provide methodological tools for treatment. Very few countries have successfully incorporated human resources training in domestic violence in university curricula;

* Those indicators that measure the relationship between gender violence and mental health are insufficient;

* Domestic violence continues to be represented as a private issue.

Triumphs and Challenges

Over the past ten years, considerable attention has been focused on women's health concerns, especially in the area of sexual and reproductive health. The women's movements--both in the area of health as well as human rights--and other organizations of civil society have collaborated to monitor the governments' fulfillment of the Cairo and Beijing agreements, recognizing women's participation in society and understanding health as a human right of all women.

Based on these commitments, the countries began to open dialogue on issues of gender, violence and sexual and reproductive health. Nonetheless, the field of mental health has remained hidden. Clearly, mental health is a requirement sine qua non for personal development, economic progress, national development and, above all, human development. As a human right of all women, mental health must be incorporated as a visible part of the public health agenda. Those of us who are committed to this task face the following challenges:

1. To work for the inclusion and transversalization of gender in public policies, in health policies and especially in policies related to mental health, with an emphasis on women;

2. To provide information and assistance assuring that the curricula of human resources training in health and mental health include the issues of gender and violence;

3. To develop indicators of gender in mental health. The information systems diagnosing mental health statistics have focused on gathering information on suicide and self-inflicted injuries and the prevalence of some psychiatric disorders and on showing health care coverage in terms of numbers of persons treated, number of hospital beds, turnover of these beds and rates of hospitalization;

We must have information that allows us to identify the practical and strategic needs of the users of these services. This information must not only be desegregated by sex, but also we must develop gender indicators that allow us to evaluate the state of mental health, indicators that measure the use of time, domestic roles, public roles, participation in decision-making, use of financial resources, care for the family health, abuse of toxic substances, etc.;

4. To encourage more horizontal practices in mental health so that women and men may work together to help social actors and health care professionals understand the realities of their mental health and daily life. Such actions have a long history in the treatment of mental health problems but very limited experience in terms of promoting mental health and preventing mental illness. This effort requires practices that are linked to contextual realities: the people from the community must participate in the management of self-care and mental health;

5. To train primary health care and mental health care professionals to provide care that meets the practical and gender-specific needs of the communities that they serve;

6. To involve the different social and institutional actors in educational initiatives to overcome gender inequities. The socialization of gender based on stereotypes foments inequitable and unjust gender relations. Overcoming this reality demands interventions in the health sector and within the family and the community, such as the campaigns designed by the educational sector that draw attention to gender inequity and power relations that put women at disadvantage;

7. To discredit the myths that revictimize women and that serve to hide violence against women. We must draw attention to gender violence as a social problem, a public health concern and an issue of women's human rights;

8. To de-medicalize daily life and provide women and men with the tools that will facilitate community empowerment and women's autonomy and participation in decision-making;

9. To include initiatives of non-violence, solidarity and conflict negotiation at the community level. In this effort, self-help groups are effective mechanisms for transformation and mental health.

Notes

(1.) PAHO, "La Salud mental en las Americas: Nuevos retos al comienzo del milenio" (Washington, DC: PAHO) March 2001.

(2.) Ibid.

(3.) These women's groups were part of the project "Mujer y Vida cotidiana" (Women and Daily Life) which promotes mental health care and prevention in the municipality of Marianao in Cuba.

(4.) PAHO, "La ruta critica de las mujeres afectadas por violencia intrafamiliar en America Latina. Estudios de caso en diez paises" (Washington, DC: PAHO) 2000.

(5.) Ibid.

(6.) PAHO, Hacia un Modelo para la Atencion Integral de la Violencia Intrafamiliar: Ampliacion y Consolidacion de las Intervenciones Coordinadas por el Estado y la Sociedad Civil. (Washington, DC: PAHO) 2000 p.27.

(7.) Ibid., p.62.

The author is a Cuban physician, specializing in psychiatry, and human sexuality. She has been assistant coordinator of the Cuban branch of the Red de Genero y Salud Colectiva (Gender and Collective Health Network) of the Asociacion Latinoamericana de Medicina Social (ALAMES, Latin American Association of Social Medicine).