Fig. 5.1
Gender analysis framework (Source: Liverpool School of Tropical Medicine, Gender and Health Group, University of Liverpool, Reproduced with permission)
Productive roles, i.e., paid work, or production of goods for subsistence or sale
Reproductive roles, i.e., domestic tasks including cooking, cleaning, caring for children and sick people
Community roles, i.e., participating in various tasks associated with managing community organizations, and operating and maintaining community services [45].
Different activities carry different mental and physical health risks. Gender norms, often implicit and unspoken, are the beliefs, prescriptions, and proscriptions for women and men’s capacities, characteristics, social behaviors, roles, and interests (Liverpool School of Tropical Medicine, undated). This framework incorporates the four core concepts of SBGA: sex, gender, diversity, and equity as outlined by Clow et al. [40]. Examining the intersection of other social hierarchies with gender is a necessary aspect of approaching gender as a multidimensional construct.
Marsh [45] has criticized the mental health services for ignoring the context of individual’s lives, in particular, women with severe mental illness who, like women in general, because of gender norms, are affected by the burden of caring for others, often prioritizing their needs above their own, placing more emphasis on their relational environment, which can both undermine health and act as a social buffer to stress [46]. Examining such differences in a life context has also been ignored in schizophrenia research. Using the above framework for SGBA in psychosis research has utility in exposing the possible impact of these variables on well-being by utilizing the various matrices, such as environment, gender norms, and activities, for example, with obvious implications for gender-responsive interventions.
5.2.2 The Constructs
5.2.2.1 Gender: A Multidimensional Construct
Recent conceptualizations of the feminine and masculine have moved beyond a simplistic understanding of global and opposing personality traits based on a unifactorial, bipolar model to a multidimensional and multifactorial construct [47, 48] operating “…on multiple levels including the subjective and intrapsychic, the interactional, the organizational and institutional and the cultural” [44] and encompassing the dimensions of gender-typed personality traits [49, 50], gender-related interests, global gender role behaviors [42], masculinity ideology [51], gender role conflict [52], gender role strain [53, 54], gender role stress [55], gender role conformity [56, 57], gender identity [48], and femininity ideology [42]. In order to represent the complexity of gender, research must, therefore, address gender as multivariable. Knaak [44] suggests delineating three overarching dimensions for the purposes of research: the subjective (e.g., man/woman/transgendered); the cultural (e.g., masculinities/femininities), and the institutional (e.g., social–structural). She argues that this multidimensional interpretation demands that “…gender cannot be adequately understood in isolation from other social hierarchies” (p. 306) and thus it is important to examine how the dimensions of class and race, for example, shape and interact with gender. Another obvious implication of the multiplicity of gender for research design is the need to utilize several measures, as any one gender measure may tap only a small portion of the gender construct [47].
While a robust body of literature examining gender exists in the fields of social psychology, developmental psychology, and women’s and men’s psychology, clinical psychology has paid scant attention to issues of gender [58]. Several constructs with corresponding measures generated from these fields are defined below. A lack of awareness of their existence may constitute another barrier to conducting SBGA in schizophrenia research.
Gender ideology is defined as: “…an individual’s internalization of cultural belief systems regarding gender roles” [42], operationally defined by gender role stereotypes [59]. It is distinct from the identity/trait approach where one is presumed to possess particular sex-based personality traits, in that the ideology approach views gender norms as being socially constructed. In this approach one can endorse the ideology that men and women should have these sex-specific characteristics without necessarily possessing them oneself. The process of internalization of cultural messages may often be barely noticed on a conscious level and taken for granted as a common place and natural aspect of daily life. The term ideology is used to convey “…the superordinate, organizing nature of these beliefs at both the individual level and the social-structural level,” thus constituting a belief system [54]. Masculinity ideology [51] refers to the internalization of cultural beliefs regarding masculinity specifically; similarly, femininity ideology refers to the internalization of cultural beliefs regarding feminine gender role norms [42, 60]. The Male Role Norms Inventory-Revised (MRNI-R) scale was developed to measure masculinity ideology, identifying seven factors: avoidance of femininity, negativity toward sexual minorities, self-reliance, aggression, dominance, non-relational attitudes toward sex, and restrictive emotionality. The following is a sample item: “A man should not react when other people cry.” Items are rated on a seven-point Likert-type scale ranging from 1 (strongly disagree) to 7 (strongly agree), with higher scores indicating higher levels of endorsement of traditional masculinity ideology. Levant et al. [42] also developed the Femininity Ideology Scale (FIS), which has five domains: stereotypical image and activities, dependence/deference, purity, care-taking, and emotionality. An example item is: “Women should dress conservatively so they do not appear loose,” rated for agreement on a five-point Likert-type scale.
Gender schema refers to a cognitive structure in which information is processed according to sex-linked associations or sex–typing defined as: “The process by which a society thus transmutes male and female into masculine and feminine” [50]. Bem [61] argues that these schemata form in response to societal prescriptions, norms or standards constituting appropriate masculine and feminine behavior socialized through such forces as family, school, peers, and the media. These norms shape gender identity and can contribute to gender role strain [50, 62]. The Bem Sex Role Inventory was developed to measure sex-typed traits and gender identity. However, more recent research has criticized the scale with regard to its validity in terms of measuring self-perceived, gender-linked personality traits [59].
Gender roles “…are the behavioural norms applied to males and females in societies, which influence individuals’ everyday actions, expectations, and experiences. Gender roles are expressed and enacted in a range of ways, from how we dress or talk, to what we may aspire to do, to what we feel are valuable contributions to make as a woman or a man” (p. 5) [2]. The Gender Role Socialization Scale was developed to assess the degree of internalization of gender-role messages in women (e.g., “I feel embarrassed about my own sexual desires” rated for agreement on a seven-point Likert-type scale), and how these messages may affect health and well-being. The developers suggest that the scale “…can also be used to examine the relationship between internalized gender role messages and the various types of mental health concerns that women experience in order to facilitate the development of prevention and treatment protocols” (p. 190) [63].
Gender identity refers to how we see ourselves as female or male constructed in the context of strong societal messages and prescriptions for the acceptable gendered role for one’s presenting sex [2]. Gender identity influences our aspirations, social interactions, behaviors, characteristics, and body image [2, 64–66].
Institutionalized gender represents the unequal power distribution between the sexes in the political, educational, religious, media, medical, and social institutions in any society through different expectations and opportunities for women and men and girls and boys, such as social and family roles, job segregation, job limitations, dress codes, health practices, and differential access to resources such as money, food, or political power [2].
Gender role stress denotes the cognitive appraisal of specific situations as stressful when individuals judge themselves to be failing to live up to imperatives of traditional gender roles [67]. Corresponding scales have been developed for each sex: the Masculine Gender Role Stress Scale and the Gillepsie and Eisler FGRSS [67]. Each has five scales comprising particular situations that might cause stress owing to a feeling of not meeting feminine or masculine gender role norms. The following are examples of items on the MGRS: “Admitting that you are afraid of something”; “Staying home during the day with a sick child.” Sample items from the FGRS are as follows: “Having others believe you are emotionally cold”; “finding that you have gained 10 pounds.”
Gender role strain refers to the negative psychological consequences experienced by individuals when they try to live up to an idealized gender role schema [53]. Within this framework, gender role strain occurs partly because stereotyped gender role norms are often contradictory, unattainable, and inconsistent. This construct is embedded in the overarching theoretical framework of the gender role strain paradigm developed by Pleck [53]. This paradigm “emphasizes the centrality of gender ideology as a cultural script that organizes and informs everything from the socialization of small children to the emotions, cognition, and behaviour of adults” (p. 130) [42]. Conceptions of gender roles in the gender role strain paradigm depart from the older personality trait—orientations of gender role identity in that they are understood to be acquired via a “…variable process strongly influenced by prevailing gender ideologies, which themselves vary according to social location and cultural context” (p. 131) [42]. Pleck identified three subtypes of gender role strain: discrepancy strain, dysfunction strain, and trauma strain.
(1)
Discrepancy strain suggests that stereotypical gender role standards are exist and that individuals attempt to conform to them to varying degrees. Pleck hypothesized that “not conforming to these standards has negative consequences for self-esteem and other outcomes reflecting psychological well-being because of negative social feedback as well as internalized negative self-judgments” (p. 13) [54].
(2)
Dysfunction strain applies to the negative consequences of those who do conform to normative gender roles such as aggression and emotional constriction as prescriptions for masculinity, which are psychologically harmful, promote unhealthy behavior, and as such cause psychological strain. Similarly, the very same qualities that characterize depression and low social rank such as passivity, submission, perceptions of self as inferior or in an unwanted subordinate position, and low self-confidence [68], for example, have been regarded as normal and desirable qualities of femininity. These gender role norms are encouraged through socialization, tradition, and discrimination [69–72].
(3)
Trauma strain refers to the traumatic experience of certain groups of men whose gender role strain has been particularly severe such as war veterans, survivors of child abuse, and marginalized groups such as men of color and gay and bisexual men.
When Pleck developed the gender role strain paradigm, it was within the context of a critical examination of masculinity ideologies. Since then it has been widely used as a framework for understanding and researching gender, primarily in the field of men’s psychology [59, 73]. However theoretically, the gender role strain paradigm is also relevant for women, as has been demonstrated by other researchers [53, 54, 74, 75, 154]. Some researchers have suggested that men experience more social pressure to adhere to gender roles than women [59, 76]. In fact, Levant has described the need to transform traditional notions of masculine ideology, which he has termed “a new psychology of men,” as “overdue and urgently needed” (p. 259), pointing to the disproportionate representation of men experiencing public and social health problems resulting from the male role socialization process, such as substance abuse, homelessness, perpetration of family and interpersonal violence, estrangement or detached fathering, sex offenses, fatal automobile accidents, and lifestyle and stress-related fatal illnesses [73].
Gender role conflict (GRC) is defined as “a psychological state in which socialized gender roles have negative consequences for the person or others [that] occurs when rigid, sexist, or restrictive gender roles result in personal restrictions, devaluation, or violation of others or self” (p. 130) [77]. In other words, GRC refers to the interpersonal and intrapersonal conflict that arises from the rigid enactment of traditional gender roles, from the violation of gender roles, or from gender role devaluations (e.g., men who freely express emotions may be devalued by others because emotionality is associated with femininity). An example where both inter- and intrapersonal conflict could potentially occur is when men “…internalize masculine gender role ideals that encourage for example, aggressiveness, overemphasis on achievement, and relational emotional disconnection” (p. 334) [61]. Gender role conflict is related to the concepts of gender role strain and gender ideology. Patterns of gender role conflict have been hypothesized as observable negative outcomes of gender role strain [78]. O’Neil and colleagues [52] developed the Gender Role Conflict Scale-I (GRSC-I), an empirically derived measure of male gender role conflict or gender role strain, that has been described as “…readily complementing masculinity ideology measures” (p. 151) [78]. The scale assesses men’s gender role attitudes, behaviors and conflicts in four domains: restrictive emotionality, success/power/competition, restrictive affectionate behavior between men, and conflict between work and family relations. The GRSC-II was developed to measure men’s degree of comfort or conflict in specific gender role conflict situations.
5.2.3 Methodological Issues: Barriers to SGBA in Psychosis Research
5.2.3.1 Underrepresentation of Women in Research Studies
A significant limitation with schizophrenia research inhibiting a sex- and gender-based analysis is the underrepresentation of women in research studies [79–81]. In fact, Longenecker and colleagues [79], in their analysis of epidemiological incidence and non-epidemiological study participation, found “…a widespread mismatch between the incidence of schizophrenia in females and their participation in research” (p. 242). They cite the incidence rate of 1.4 male schizophrenia patients to every female patient, or 58 % men, taken from a recent meta-analysis by McGrath and colleagues in 2008. Their analysis reveals that this imbalance is exaggerated in non-epidemiological studies, where 66 % of research participants are men. They report that this overrepresentation of males in the literature has been consistent over the last two decades. Focusing on the incidence of first-episode psychosis, Iacono and Beiser [82, 83] describe an excess of men in most studies and report that in many instances the male to female ratio among study participants exceeds 3 to 1, which they attribute to a higher incidence of schizophrenia in men than in women.
5.2.3.2 Aggregated Data/Controlling for Sex
A further factor in schizophrenia research inhibiting an SGBA is that most studies do not provide information on sex or gender separately or where they do in some of the few studies where large numbers of women have been recruited, researchers have “controlled for sex” rather than treating women and gender as important areas to explore [81, 84, 85].
5.2.3.3 Sex Bias in Diagnosis/Sampling Bias
Both sex bias in diagnosis and sampling bias confound the actual rates of incidence and prevalence. For example, women in older age groups are at a higher risk of developing psychosis than men; thus, male–female incidence ratio studies should ideally include participants of all ages [86]. Studies that are limited to inpatients may also promote sampling bias owing to the overrepresentation of men, which Aleman et al. [86] suggest is because of a less favorable course of the disorder for the male sex citing the example of violence and aggression being more common in men. Psychosocial aspects of gender role norms may be partly related to this overrepresentation. For example, Walker and Lewine point out that male patients are more likely than female patients to display antisocial behavior and have police contact and criminal records, leading to the perception by treatment providers and families that men are more aggressive and threatening. Conversely, female patients are viewed as more helpless, withdrawn and depressed. They suggest that these perceptions, in addition to self-perceptions of men and women (women are more likely to view themselves as ill, as needing treatment and to seek and comply with treatment), partially influence whether a person is in treatment, particularly in an inpatient setting. Seeman [87] and Falkenburg and Tracy [88], in their reviews of sex differences, have also pointed to higher expectations of families for sons with regard to education and achievement than daughters, resulting in higher expressed emotion (EE) in families toward sons and perceptions of greater need for treatment for sons.
In addition, some authors have also suggested that because there are more women experiencing co-morbid affective symptomatology, women are predominantly diagnosed with schizoaffective disorder and it may be more difficult to assign categorical diagnoses to women than to men [89, 90].
Epidemiological research adopting SBGA in schizophrenia is an important factor in the reduction of methodological artifacts.
5.2.3.4 Gender in Context
Another major methodological challenge in conducting SGBA involves how to incorporate the multiple social categories and determinants, such as ethnicity, social class, sexual identity, age, and culture, that intersect with gender, and that have an impact on the distribution of health and illness within and across populations [64, 65]. Researchers advocating an SGBA highlight the need to include social and biological determinants, which overlap and work together to produce health, but at the same time acknowledge both the conceptual and analytical challenges this creates. Researchers are increasingly improving ways of doing this. Johnson et al. describe some promising models that facilitate the investigation of both biological and multiple social influences in a single study [64, 65]. For example, they recommend employing intersectional analyses, which acknowledge a person’s multiple social identities, and multilevel and systems modeling, as they can simultaneously analyze both individual-level and group-level factors that have an impact on health and disease. An in-depth discussion of these approaches is beyond the scope of this chapter; suffice it to say, awareness of the available analytical models to address some of these challenges is a helpful first step in promoting an SBGA in schizophrenia research.
5.3 Gender: A Critical Determinant of Mental Health
5.3.1 Institutionalized Gender: Social–Structural Level Oppression
Emerging evidence indicates that the impact of gender in mental health is compounded by its interrelationships with other social, structural determinants of mental health status, including education, income and employment as well as social roles and rank. There are strong, albeit varying, links between gender inequality, human poverty and socioeconomic differentials in all countries [3].
Referring back to the definition in the first section of this paper, we saw that institutionalized gender refers to the distribution of power between the sexes at the system level within political, educational, religious, media, medical, and social institutions in any society. These institutions shape the social norms that delineate different expectations and opportunities for women and men, such as social and family roles and practices, job limitations, for example, and differential access to resources such as money, food, or political power. Such differential opportunities and access may lead to differences in health risks, health services use, health system interaction, and health outcomes for men and women [2, 3, 40].
We have known for quite some time that subordinate group status affects mental health [3]. In the American Journal of Psychiatry 30 years ago, Carmen et al. [91] pointed out that the:
…link between women’s disadvantaged status and their mental health creates an obligation for mental health professionals to understand how the social context contributes to the origin and persistence of the problems of their patients (p. 1319).
With increasing evidence of this link, particularly research emphasizing the role of trauma, social inequality, and migrant status in psychosis, a lack of gender-based analysis is conspicuous. This section underlines the relevance of conducting both micro- and macro-levels of analysis through SGBA in psychosis research.
5.3.1.1 Gender-Specific Determinants
The Gender in Mental Health Research Report [3] outlines several gender-specific determinants of mental health, such as gender-based violence (physical, sexual, psychological), gender-based income disparity, unpaid labor, and lower social rank. In their review of sex differences in schizophrenia, Falkenburg and Tracy [88] cite studies that demonstrate the differential gender-exposure and risk patterns that disproportionately affect men and women with psychosis. For women these include sexual abuse, socioeconomic disadvantage, and duty to assume responsibility for the care of others [3]. Other researchers have also reported that women with serious mental illness are also at a greater risk for revictimization and for post-traumatic stress disorder [92]. Falkenburg and Tracy point out that despite lower fertility rates than community samples, over 50 % of individuals with a schizophrenia diagnosis become parents with the male partners often absent and approximately one-third losing custody of their children [88]. Single parenting has been identified by the World Health Organization [3] as a risk factor for living in poverty, and an especially high risk for poor physical and mental health.
Gender-specific risk factors for men with psychosis include different responses from relatives [37] where differential gender role expectations lead to, for example, more consistent and severe criticism from relatives (or high EE), increasing relapse and having a negative impact on illness course [87, 88]. Several studies examining high EE report differential responses and attitudes of relatives toward men and women with psychosis [30]. For example, in their review, Falkenburg and Tracy identified lower parental tolerance of symptomatic behavior and sense of responsibility for caring for men, higher levels of fear and conflict owing to higher rates of aggression in men, increased guilt and self-blame and lower attendance at therapy in families of men [88]. Even when controlling for symptomatology, gender role expectations of parents influenced the hospital outcomes of their sons or daughters [93].
Al-Issa cites studies where differential gender role expectations for men and women and the lower social status ascribed to women have an impact on access to treatment [94]. For instance, he outlines studies of French–Canadian villages, where communities were helpful to their young men who were suffering from delusions but not their young women, and families were willing to pay for a son’s treatment but not for a daughter or wife [95].
In an original 26-year period cohort study in Sweden, Månsdotter et al. [96], grounding their research in gender relational theory, examined the effects of gendered life in childhood and adulthood on mental health, focusing on the spheres of mother’s paid/unpaid work, childcare practice, gendered partnership, and gender ideology. The investigators based their research on the well-accepted theory that the improved gender equality of Nordic countries has had an impact on the health patterns of men and women. Women (n = 421) and men (n = 526) were followed and surveyed at five different time-points, from age 16 to age 42, with a comprehensive questionnaire developed by the investigators. Gendered ideology was measured using a scale indicating support for societal gender equality ranging from 1 (fully supporting a gender-equal society) to 10 (fully rejecting a gender-equal society), and categorized into traditional: “ranking 4–10,” and non-traditional “ranking 1–3.” Similarly, gendered partnership and gendered childcare also used a five-point Likert-type scale, each asking a question about the perceived overall equality in one’s relationship with a partner and division of childcare responsibility, categorized into traditional and non-traditional. The main findings were that for women, reduced anxiety was associated with a more gender-equal ideology at age 30, while for men, reduced depressive symptoms were associated with more gender-equal childcare division at age 42. Månsdotter and colleagues speculate that the reduced depressive symptomatology for men may be related to the health-promoting effects of expanding social roles and childcare per se for mental health and specifically the positive influence of increased intimacy. One of the study limitations identified by the authors includes a lack of statistical power when categorizing individuals into traditional or nontraditional, and when stratifying the analyses by gender. Nevertheless, this type of research demonstrates the utility of employing an SBGA for incorporating both micro- and macro-levels of analysis, as was done here through examining gender relations, institutionalized gender, and gender ideology.
5.3.2 Gender Role Socialization and Mental Health: Internalized Oppression
In addition to the deleterious effects on the mental health of women due to gender inequality, men too suffer adverse effects from limiting gender role norms. A large body of literature spanning decades emphasizes the effects of gender on mental health, with empirical investigations demonstrating harmful psychological impacts (depression, low self-esteem, and substance abuse, for example) of internalized gender role expectations on both men and women [54, 61, 67, 70, 72, 97–101, 154]. More recent research demonstrates an association between higher masculinity ideology and increased PTSD symptomatology in male veterans [102].
5.3.2.1 Gender Role Socialization, Stress, and Coping
Gender role expectations have been shown to correlate closely with differential mental health problems according to sex [67]. For example, rates of depression, agoraphobia, eating disorders, anxiety disorders, and PTSD are much higher for women than for men. Conversely, rates of substance abuse and antisocial behavior are higher for men [3].
According to gender role stereotypes, women are “expected” to be submissive, dependent, and anxious about appearance, whereas men are “expected” to be indulgent, aggressive, and demonstrate sexual prowess [67].
Empirical investigations provide evidence that cognitive appraisal and coping is influenced by gender role socialization resulting in gender differences in vulnerability to certain stressors [67, 155]. Gillespie and Eisler [156], in 1992, developed models of gender role stress, drawing explicitly on the cognitive stress model [103], in which stress occurs owing to the cognitive appraisal that one has violated gender role imperatives. These models have been tested using the masculine and feminine gender role stress scales described earlier. With the development of these scales, empirical studies have shown an inverse relationship between gender role stress and measures of physical and psychological well-being for both women and men [55].
A review of stress research of the past few decades by Dedovic et al. [104] highlights some recent results from endocrinological, developmental, and neuroimaging studies that suggest that gender socialization might play an important role in the metabolic effects of stress. Dedovic et al. also suggest that as some differences between men and women in hypothalamic–pituitary–adrenal (HPA) axis responses to psychosocial stressors cannot be explained by biological variables alone, gender is likely to be a critical factor, and propose a model that integrates these specific findings, highlighting gender socialization and stress responsivity [104]. The authors point to research that manipulates the psychosocial stressor context or uses stressors emphasizing achievement versus social integration, which provide strong support for the role of gender in explaining male–female variations in stress responses.
Surprisingly, the impact of gender role socialization on cognitive appraisal and coping with regard to psychosocial stressors has not been explored in individuals experiencing psychotic phenomena, obviously an important area for inquiry considering the role of stressful life events as precipitants for psychotic experiences, in shaping the content of hallucinated voices and delusions [105], and in men’s and women’s responses to these phenomena. However, Myin-Germeys et al. [106], in a very interesting study examined sex differences in stress reactivity utilizing experience method sampling. They report that the women in their sample of 42 participants meeting the criteria for psychotic disorder (22 men; 20 women) were more likely to display elevated stress reactivity or emotional reactivity (reflected in both an increase in negative effect and a decrease in positive effect) to daily stress than men. The authors suggest that emotional reactivity to daily stress may be an underlying etiological mechanism for psychosis and constitutes part of the liability to psychosis. The authors speculate that as the small stressors and disturbances in daily life are equally distributed among men and women, it may be the case that women develop higher levels of stress sensitivity through a history of increased exposure to life events and possibly also higher levels of exposure to trauma. However, they did not investigate cognitive appraisals regarding why participants found a particular event stressful, which would have extended findings further with regard to possible underlying cognitive mechanisms and gender differences in terms of what constitutes stress for men and women, thus enabling an SGBA. Research employing an SGBA could be useful for examining HPA axis responses in relation to psychotic experiences and other life stressors, for example.
5.3.2.2 Gender and Self-Esteem
Because sex and gender distinctions are central, important, and pervasive in Western culture, it can be argued that gender is the earliest, most central, and most active organizing component of one’s self-concept [47].
According to a cognitive psychological framework, individuals learn shoulds and musts from important persons in their lives and observe how others act and interact and the societal messages conveyed about those people. Mahalik [61] outlines how masculine/feminine gender role socialization contributes to self-schemata or gender role schemata influencing self-esteem. He discusses how gender role socialization contributes to gender-related cognitive distortions for men and women who are experiencing gender role conflict and underlines the implications for cognitive behavioral interventions. Empirical investigations have demonstrated associations between gender role conflict and depression as well as decreased self-esteem in men [100]. The underlying theoretical framework for this work is the gender role strain paradigm. Similarly, a large body of research based on objectification theory [107–109] has examined the impact of gender role socialization, and in particular, its deleterious impact of on female body image and self-esteem.
Mahalingam and Jackson [99] point to ethnographic research that indicates that idealized cultural gender roles shaped by patriarchy, such as chastity and masculinity, play a critical role in controlling women’s and men’s behavior through cultural gender imperatives, ultimately influencing self-worth. In their research with son preference societies they suggest that such societies resulting in an excessive male population lead to hypermasculine and hyperfeminine ideals, increasing patriarchal power structures, with detrimental impacts on mental health. This research underlines the importance of incorporating the multiple social categories and social determinants, such as ethnicity, social class, and culture, that intersect with gender to have an impact on mental health in research designs.
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