My medical education, more than 40 years ago, was centred around the male body as the normative human being.
As the American feminist and legal activist Catherine Mackinnon wrote only a few years later in Difference and Dominance: on sex discrimination: ‘A male body is the human body; all those extra things women have are studied in ob/gyn’. That was at a time when there was no imperative even to include women in randomised controlled trials of treatment, and they were excluded for many more years because the impact of their pesky hormonal fluctuations got in the way of standardising groups and making comparison between subjects.
My psychiatry education was similarly centred around the normative male patient, even though so many of the patients I cared for were female. I learned nothing of the impact of hormones and the different effects of psychotropics on the male and female bodies. The psychiatric equivalent of ‘ob/gyn’ became perinatal psychiatry.
Mackinnon wrote:
…’man has become the measure of all things. Under the sameness standard, women are measured according to our correspondence with man, our equality judged by our proximity to his measure. Under the difference standard, we are measured according to our lack of correspondence with him, our womanhood judged by our distance from his measure. Gender neutrality is thus simply the male standard, and the special protection rule is the female standard, but do not be deceived: masculinity is the referent for both.’
This came to mind last week, when I was speaking to an audience in Manchester, discussing the difference between suicide rates in men and women, and hearing how being a woman is almost viewed as ‘protective’ in comparison to being a man, because men, who take their lives at three times the rate of women, are the reference point. Then again, this week, when reading Emma Pryce Jone’s fantastic piece for World Suicide Prevention day in Australia last month about how all the suffering of those who are ‘othered’ is somehow disregarded in public education around suicide:
…‘the phrase’ don’t suffer in silence’ is central to messaging around men’s suicide, but for many women that is precisely what defines womanhood: suffering in silence.’
When researching and writing Out of Her Mind the gender neutrality of not only mental health research but also care provision itself, and the reporting of mental health issues in most of the media, soon became apparent. It was sometimes very difficult to get sex/gender breakdowns from government documents of even simple things like who was on a waiting list for psychological therapies. Reports in the press and on TV of suicides and abusive care in mental health units and the extent of sexual assault taking place in our hospitals usually feature photographs or film of young women (for example the Panorama programme about the unit in Manchester, or the young people’s unit in Glasgow) yet whether, or how much, this might be a gendered issue is not discussed. Agenda Alliance’s research with young women, Pushed Out Left Out their final Girls Speak demonstrated in 2022:
…when statutory services, and some non-specialist youth services, assume so called “gender-neutral” or “gender-blind” approaches, this leads to the specific and gendered needs of young women being overlooked and underestimated. Ultimately, there is nothing neutral about “gender-neutral” policy that fails to consider the distinct needs of girls and young women.’
This is true of so much of mental health care from the lack of attention until recently of the failure to provide adequate period products in wards to the disregard of the sexual health needs of women with severe mental illness.
Gender neutrality is a concept that attempts to remove the notion of being male or female from a person or entity. It also encourages people, regardless of their sexual orientation or identity to feel accepted, hence the adoption of gender-neutral language in recent years. But it is problematic when applied across the board to something like the provision of mental health care. Care must be informed by knowledge and understanding of gender differences and how they relate to childhood and adult life experiences, social, cultural and realities of family life, the experience and course of illness and treatment needs and responses. Some places have already begun to consider this – for example the Republic of Ireland. In contrast, women were barely mentioned in the last mental health strategy where I live in Scotland.
We need not only gender sensitive research, with sex/gender disaggregation of data, but gender sensitive mental health care and we need it now.
It’s long overdue.
Out of Her Mind: How we are failing women’s mental health and what must change is on sale now.
Patching the Soul 