Gender, mental health, and intersectionality

Last month a pilot project was launched to add mental health nurses to police call-outs in five parts of the UK. This came as figures revealed the number of mental health patients being detained in police cells due to lack of beds, or being sent to private hospitals.

There's a long literature on oppression, discrimination, and mental health. Yet not much on intersectionality, the study of multiple and linked oppressions/discrimination, and mental health. Intersectionality is a concept from feminist theory which looks at the intersections between groups of oppressed peoples. Each person has multiple identities, shaped by history and social relations. Different combinations of these identities produce their own oppressions. Whilst originating in feminist theory, intersectionality has travelled to provide analysis to a wide range of social and political issues.

You may be surprised to learn that in the UK the leading cause of death of men under 35 isn't drugs, alcohol, or violence. It is suicide. Men are three times more likely to kill themselves than women. Globally, depression is predicted to be the second leading disease burden by 2020. Looking at the issue of mental health using intersectionality can provide important insights into how to tackle this issue.

Gender

Gendered identities shape our health vulnerabilities and our behaviour to ill-health. It is important to note here the well documented issue of men who, in general, do not seek out medical advice and other forms of support to the same extent as women. The reasons for this often include an exploration of 'hegemonic masculinity', the notion of men as strong, resilient, and invulnerable. The argument is that showing physical or emotional weakness runs counter to the prevailing idea of what being a man is.

However, there is still wide variation in constructions of masculinities. A significant LSE study argued that hegemonic masculinity by itself do not determine behaviours, it is about a complex interplay of influences including religion and culture. In the study, seeking health services and help enabled the men in the study to fulfil more hegemonic roles such as providers and being strong. Similarly, there was a strong emphasis on seeking help from others, which derived from cultural values of interdependence.

Aside from shaping health-seeking behaviour, gendered identities shape the response from health service. According to the Mental Health Foundation's Fundamental Facts, and based on research by the World Health Organisation, doctors are more likely to treat depression in women than in men, even when they present with identical symptoms. The perceptions of gender (and other identities) are significant contributing factors.

This is not to say that men are more affected by mental illness than women, just that they are differentially affected. According to the same study, depression is more common amongst women, as is anxiety. Men are more likely to have a substance misuse problem, or a personality disorder, and men make 53% of calls to the Samaritans.

The World Health Organisation's research on Gender Disparities in Mental Healthexplores some of the gendered reasons behind differences in mental health. In particular it cites 'low rank' and consequent vulnerability to social and economic shocks as a major factor in depression among women, “Women's subordinate social status is reinforced in the workplace as they are more likely to occupy insecure, low status jobs with no decision making authority.” It also notes how globalisation had widened gender inequality, with countries undergoing restructuring seeing significant increases in depression and anxiety; and an increase in issues such as trafficking. Gender-based violence is also a factor, with women experiencing abuse far more likely to develop mental health problems.

Sexuality and gender identity

Mental illness is particularly high in the LGBT community. In particular, transgendered people have one of the highest rate of depression, self-harm, and suicide.

In a 2012 Scottish study, 55% of transgendered persons had been diagnosed (past or present) with depression, and a further 33% believed themselves to have depression but had not been diagnosed. Over half (53%) had self harmed (overwhelmingly before transitioning). Worryingly, a third (35%) had avoided seeking crisis support for their mental health because of their trans identity, and 20% said their experience of the health service had led them to self-harm. Half (52%) had experienced discrimination at work, up to 65% in a healthcare setting, and 19% had been homeless at some point.

As the NHS site succinctly says,

“Trans people often feel isolated, and find it difficult to talk to others about how they feel. Trans people can face discrimination and harassment. This can affect their personal relationships, their ability to obtain housing and healthcare, their employment opportunities and their safety.”

Elsewhere in the LGBT community, gay men have a suicide rate double the UK average. In 2010 the magazine Attitude launched its 'Issues issue' tackling the taboo of mental health head on. Its editor at the time, Matthew Todd, said:

"There is this cliché that we are all having a great time partying, but actually we know, and the research is now showing, there are a hell of a lot of unhappy gay people; far higher rates of depression, anxiety and suicide than among straight men; far higher rates of self-destructive behaviour; substance abuse and sex addiction; and high levels of issues around intimacy and forming relationships."

Stonewall's Mental Health Factsheet states 22% of Gay and bisexual men are experiencing moderate to severe depression. The same document goes on to say:

“In the last year, 79 per cent lesbian and bisexual women say they have had a spell of sadness, felt miserable or felt depressed. This increases to 84 per cent of bisexual women and 86 per cent of black and minority ethnic women.”

This shows, in stark numbers, how these identities interact in the context of mental health.

BME

Amongst ethnic minorities the picture is more varied. In terms of sheer numbers, between 1995-2001 6% of people who took their own lives in England and Wales were from an ethnic minority group. In Scotland this was 2% and in Northern  Ireland 1%. Ethnic minorities made up around 9% of the population in 2001. 

However, there is much variation within statistics. The diagnosis of schizophrenia among Afro-Carribbean communities is around eight times higher than average. Anxiety rates amongst Indian women are also higher than average, and Pakistani women had a higher rate of mixed anxiety depressive disorder. White British communities have higher rates of self-harm compared to BME communities.

There are also debates about how racism comes into play. One report argued that, when presented with the same symptoms by white patients and black patients, doctors will disproportionately diagnose black and Caribbean patients with schizophrenia, and white patients with bipolar disorder. Black male patients are perceived by medical professionals as being more aggressive, whereas the evidence is completely contrary to this. Earlier this year, the charity Mind produced a report into the continued barriers to crisis care for BME patients. In particularly, they found Indian, Bangladeshi and Chinese people had consistently low referral rates.  Another explanation is that persistent and ingrained day to day racism itself is to blame. Studies in the UK and US have found that BME people in areas with greater ethnic diversity are up to half as likely to develop psychosis compared to people in areas with poorer diversity.

Mental health will likely be one of the major health issues of this century. Although it has not been possible to cover, here, the myriad permutations of identity, the message from the analysis is clear. A self-aware approach to intersectionality allows us to make visible the layers of identity, discriminations, and power structures that interact with mental health.  By looking at the way these identities, oppressions, and power structures simultaneously come together, we can tackle the root causes.