© Springer International Publishing Switzerland 2015
Margarita Sáenz-Herrero (ed.)Psychopathology in Women10.1007/978-3-319-05870-2_11. Women’s Mental Health Around the World: Education, Poverty, Discrimination and Violence, and Political Aspects
(1)
Department of Psychiatry, Alava University Hospital, Vitoria-Gasteiz, Spain
(2)
Roberto Clemente Center, New York, NY, USA
Abstract
In this chapter, we will discuss the specific challenges that women face in the healthcare system, including the lack of access that much of the world’s female population suffers. We will defend a change of approach to women’s health issues whenever they need to use the health system.
To this end, we will describe some of the gender inequalities that arise from family microsystems as well as from the social and political macrostructures of power and world organization that are some of the causes of female pathological conditions. We refer here to some that particularly affect women: gender violence, poverty, migration, human trafficking, and violence used against women during armed conflicts. To conclude, we talk about lack of justice.
After analyzing these aspects, we suggest some recommendations for mental health professionals with regard to possible lines of work in the healthcare system, with the objective of making a change possible, a change based on the empowerment of women, considering health professionals as active agents and enablers of that empowerment.
1.1 Introduction
“All symptom is, in essence, a precipitate of meanings related to different dimensions of human life: childhood history, psychic suffering, intersubjective conflicts (couple or family), social failure, situations of helplessness, conceptual breaks with reality, and are presented as manifestations of a malaise that cannot be reduced to an absolute determinism, whether biological, psychic or cultural. Epidemiological studies reveal a female, general and mental, excess morbidity in adulthood, which highlights the need to reflect on this situation” [1].
There is no society or community in the world where women are treated as equals to men, with inevitable consequences for their health. Thus, “women’s mental health can only be understood if their life’s context is taken into consideration; biological, sociocultural and the person” [2].
The World Federation of Mental Health announced in 1996 that often psychological stress in women has social origins; discrimination against women in employment, education, food distribution, health access, and the resources for economic development render them vulnerable to physical and sexual violence, psychiatric disorders, and psychological stress.
According to the 2009 World Health Organization (WHO) report “Women and Health,” women and men face many similar health problems; nevertheless, the differences are so great that women’s health requires special attention. Taking into account the same report it is fair to say that some disorders affect men and women to the same extent, but only women face more difficulties obtaining the healthcare assistance that they need. Gender inequalities in education, freedom, or income, for example, limit girls and women when it comes to protecting their own health.
Health problems faced by women share common features worldwide, but many great differences are also observed, determined by various living conditions. Girls and women’s health is influenced by social and economic factors, such as access to education, family health, and place of residency. These differences are established not only in developing countries, but also in developed ones.
The differential prevalence of psychological disorders has led to the investigation of more accurate differential diagnoses that take into consideration the importance of culture in the construction of subjectivity. Defending the need to work with a differential diagnosis does not imply establishing differences and defending unequal illnesses, but presupposes taking into consideration living conditions and different risk factors affecting men and women. We need to develop approaches that consider a range of discriminations suffered by women, and these approaches must include the effect of poverty, lack of cultural resources, violence, and social devaluation [3].
To achieve this approach work is needed to shed the gender bias underlying theoretical models and healthcare practice. The gender bias, as pointed out by Carmen Valls-Llobet [4]:
Extrapolates to the general population (meaning women) research results obtained from the male population. Assuming that risk factors and health protection are the same for everyone leads us to suppressing the gender differential morbidity and mortality.
The belief that men and women get ill in different ways. The weight of this belief is so great that many “women’s problems” are sent from primary care or women’s health centers, limiting women’s health to reproductive health. Other symptoms are usually ignored, and after repeated demands for medical attention, analgesics or anxiolytics are prescribed; as a result, the demand is psychologized and medicalized.
The clinical approach, especially biomedical and pharmacological, is derived from framing the claim as pathology.
In this context, “the increased use of psychotropic drugs for women can be a source of self-regulation of the exogenous elements in order to reduce discomfort” [5].
It is true that during the last few decades the health sciences have evolved, allowing some of the problems of women to be visualized, but much work remains. To contribute to breaking down gender bias, Professor Valls-Llobet [4] puts forward five proposals.
1.
Democratization of knowledge production. Health research should consider experimental subjects in both men and women.
2.
Research designs, in addition to the biological differences between sexes, must also consider gender, and the positions and social roles that each plays.
3.
To achieve a better diagnosis, family life and work conditions should be taken into consideration.
4.
Sex is a demographic control variable and gender should be considered a relational analytical variable.
5.
Innovative designs should be implemented to detect the attitudes of health workers during their clinical practice in order to detect any inequalities.
With the conviction of the universal right of all people to a public healthcare system that ensures their welfare, this system should work within all scopes incorporating the gender perspective transversely. This involves two main axes of action:
Enhances the participation and role of women as active agents in the protection of her own health.
The incorporation of interdisciplinary teams (physicians, psychologists, social workers, social educators) trained in addressing health issues from the perspective of gender. It would have to boost the collective empowerment of healthcare system workers, with the objective of introducing the gender perspective into their daily practice, training them and stripping them of the aforementioned gender bias.
Interdisciplinary work is not only essential in the field of health, but also the answer to many of the problems that arise in the field of women’s health. Women’s health should be addressed from the social health domain where different institutions (health, justice, social services, education, employment, etc.) are involved.
1.1.1 The Social Health Approach
The traditional structure of health and social services is not well suited to the mixed nature of women’s needs. Between the scopes of the health and social services, zones of confluence are particularly confusing and present coordination difficulties because they are dependent on various government agencies. These difficulties may have a negative impact on people’s quality of life.
There are elements that are considered fundamental and defining in terms of the social health approach:
It is a response to complex needs that require mixed interventions, social and health, simultaneously or sequentially, but always complementary.
It is has the objective of guaranteeing the continuity of care, avoiding mismatches, gaps or waiting times between the different services.
It is ruled by the interdisciplinary principle.
It is based on an integral interventional approach focusing on the person and oriented toward guaranteeing the maximum level of quality of life and autonomy.
The principal objective of the social health approach is a response to complex needs. There are certain populations for whom, because of their nature and their healthcare and social characteristics, maximal coordination between the two fields is required. Among these population groups are the elderly dependent and people with chronic disease (major disabilities, mental disorders, etc.). To these groups we can add those whose diagnoses are conditioned to their gender role, highlighting the urgent need for coordination regarding gender violence.
There are many advantages of the social health approach; we emphasize the main ones below:
It introduces greater facilities in the articulation of services of different kinds in the context of community action, therefore responding better to new social demands.
Favors permanence in the community, articulating the means of preventing hospitalization or long-term residencies.
Offers greater possibilities of developing an interdisciplinary approach that enriches professional practice.
Facilitates access to the most vulnerable population groups that otherwise present significant barriers in access to care owing to social isolation.
Favors a more rational use of resources and higher levels of efficiency and effectiveness.
Promotes continuity of care.
Favors reduction of dysfunction at different levels and in different fields of care.
If we consider that women’s health is conditioned from childhood by the gender roles imposed, the treatment approach must come from within the scope of social health and with incorporation of several disciplines into the two work teams of primary and specialized care.
1.2 Gender Violence
1.2.1 Violence Against Women as a Public Health Problem
The declaration of violence against women as a social problem has been accompanied by the recognition by the health sector of violence against women as a public health problem.
In 1996, the World Health Organization (WHO) declared gender-based violence an international priority for health services, owing to its grave consequences on health, its magnitude, and the significant economic impact involved. That same year, the WHO carried out several actions that paved the way for the recognition of this problem, among them resolution WHA 49.2513 of the 49th World Health Assembly.
The WHO’s commitment to addressing the problem of violence against women was reinforced in 1998 with the declaration of this matter as a public health priority through the publication of the document “Violence against women. A priority health issue” [6], and with the development of the “World Report about Violence and Health” [7].
In addition, the WHO urged its Member States to assess the problem and take measures to prevent and solve it.
1.2.2 Classification of Gender-Based Violence
In most of the literature on the subject, there is agreement that violence against women takes three main forms: physical, psychological, and sexual violence [8].
However, and although this is the most common differentiation, based on the proposal of the “Expert Report on Combatting Violence Against Women” of the Council of Europe (1997) [9], there are frequently other forms of violence, giving rise to description of the following types:
Physical violence: all action carried out voluntarily that causes or may cause damage and personal injury to women. It includes the use of physical force or objects to threaten their physical integrity.
Sexual violence: any threat to the sexual freedom of women in which they are obliged to bear or carry out acts of a sexual nature. It includes any act or sexual expression carried out against their will that violates their physical or emotional integrity, such as jokes, rude expressions, unpleasant comments, obscene phone calls, undesirable sexual proposals, forcing them to watch pornography, any non-consensual act or sexual intercourse (harassment, rape, incest), any relationship or sexual act deemed by women to be humiliating or painful, or the obligation to prostitute themselves.
Psychological violence: any action, generally of a verbal or financial nature, that causes or may cause psychological damage in women. It includes the use of mechanisms of control and communication that threaten women’s psychological integrity, well-being, self-esteem or consideration, in both public and private, in front of other people, such as: to denigrate them; to despise what they do; to make them feel guilty; to treat them as if they were slaves; to make unpleasant comments about their physique; to humiliate them in public or in private; to give them a bad reputation, to force them to be accountable for their relationships and contact with other people; to force them to break off with friends; to prohibit them from talking to people of the opposite sex; to show jealousy of friendships; to limit them in their living space or show it disrespect; to make jokes: sexist jokes of denigrating nature, to undervalue their contributions or action; insults made in public or in private; threats and intimidation; emotional blackmail; threats of suicide if the couple expressed their desire to separate, etc.
Economic violence: inequality of access to common resources. It includes denying or controlling women’s access to shared sources of money, generating economic dependency, impeding their access to employment, education or health, denying their rights of property, etc.
Structural violence: intangible and invisible barriers that impede women’s access to basic rights. It includes the denial of information on their fundamental rights, the relationships of power in school or at work, or discriminatory legislation in all social spheres.
Spiritual violence: the destruction of women’s cultural or religious beliefs through punishment, ridicule, or the imposition of a system of beliefs that is alien to their own. It includes the submission and invisibility of women’s cultural or religious beliefs or analyzing them from an ethnocentric perspective.
1.2.3 International Recommendations for the Prevention of Gender-Based Violence
“Violence against women is perhaps the most shameful human rights violation. It knows no geographical or cultural limits, or economic position. As long as it continues, we cannot say that we have actually made progress towards equality, development and peace.” Kofi Annan, Secretary-General of the United Nations
The Declaration on the Elimination of Violence Against Women, adopted by the General Assembly of the United Nations in 1993, shows international understanding and recognition that violence against women is a violation of human rights and a form of discrimination against women.
The human rights norms that emerge from the Convention on the Elimination of all Forms of Discrimination against Women, subsequently ratified by the World Conference on Human Rights of the United Nations (UN) of 1993 and other international instruments, not only extend the validity of areas that were previously not considered the subjects of rights, but also establish differences between formal equality and substantive equality. It is recognized as well that so-called universal human rights—even though they guarantee in formal terms the legal equality of men and women—were defined according to the lives and experiences of men and do not take into account the needs and everyday existence of women.
Therefore, the following are recommended:
Expanding democracy based on the effective participation of citizens and the full observance of human rights.
Developing a National Plan with the State guarantees compliance with the principle of gender equity.
Creating government initiatives to improve the social status of women.
Promoting the production of up-to-date statistical information permitting visualization of the gaps and iniquities of gender at all levels.
To penalize the media and professionals involved in cases that through promotional campaigns use women as objects or marginalize women’s social, intellectual, racial or economic status.
The Platform for Action document adopted at the Fourth World Conference on women, held in Beijing in 1995, defines violence against women as one of the 12 critical areas of concern that should be given particular emphasis by Governments, the international community, and civil society.
At its 42nd session, in 1998, the Commission on the Social and Legal Status of Women of the United Nations proposed new measures and initiatives that should be applied by the Member States and by the international community in order to put an end to violence against women, including the incorporation of a gender perspective in all policies and relevant programs. Among the conclusions agreed upon during the session, there are measures to provide support to the work of nongovernmental organizations: to combat all forms of trafficking in women and girls, to promote and protect the rights of migrant workers, in particular women and children, and girls, and promoting the coordinated activities of research on violence against women.
In relation to violence against women in the domestic sphere, the WHO multi-country study results on the health of women and domestic violence against women underscore the need to take urgent measures on a wide variety of instances, ranging from local health authorities and community leaders to national governments and international agencies [10].
As the study graphically shows, violence against women is a widespread and deeply rooted practice that has serious consequences for the health and well-being of women. Its persistence is morally unacceptable; the costs are immeasurable for individuals, for healthcare systems, and for society in general. However, until relatively recently, no other relevant public health problem had been so widely neglected and misunderstood.
The wide differences in the prevalence and patterns of violence found between one country and another, and mostly between one context and another within the various countries examined, suggest that there is nothing “natural” or inevitable about this problem. Attitudes can and must change, the conditions of women can and must be improved, and men and women can and must convince themselves that violence cannot be accepted in human relationships.
The following recommendations have been extracted, primarily from the conclusions of the study, although they are also based on studies and lessons learned from experiences in numerous countries. Specifically, the recommendations corroborate the conclusions and recommendations presented in the WHO’s World Report on Violence and Health [11]. Recommendations are grouped into the following categories:
Strengthening the commitment and actions at the national level.
Promoting primary prevention responses.
Involving the education sector.
Strengthening the health sector response.
Supporting women living with violence.
Sensitizing those who are part of the criminal justice systems.
Supporting research and collaboration.
In order to address and prevent violence against women, it is necessary for many sectors (educative, legal, health, economic, etc.) to take action in many areas. However, it is important that the State takes the final responsibility for the security and well being of its citizens. In this sense, the national governments, in collaboration with nongovernmental organizations and international organizations, must give priority to this issue.
Following international recommendations, State is called upon to implement prevention programs of gender-based violence, to investigate such acts, and prosecute and punish perpetrators, as well as to ensure the female victim’s rights to care and assistance.
Various strategies and different models of legislation have been established in different countries; some include educational measures and preventive actions, while others establish specific courts or police offices for the matter. In the best cases, prevention, education, and integrated services for victims (from health to legal assistance in the same agency) conform to a comprehensive approach to the elimination of gender-based violence. Thus, not all approaches define violence against women in the same way, nor do they act against all of its manifestations.
1.2.4 Prevention and Response
Further assessment is required to determine the effectiveness of violence prevention measures [12]. Some of the interventions with more promising results are the promotion of education and work opportunities for women and girls, the improvement of their self-esteem and their negotiating skills, and the reduction of the inequalities of gender in communities.
Other efforts that proved to be effective are: intervening with adolescents to reduce violence in their relationships; supporting programs for children who have witnessed acts of violence between partners; massive public education campaigns; and adopting measures of collaboration with men and boys to challenge attitudes to gender inequities and the acceptability of violence.
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