Two Gendering women’s minds: identity, confidence and mental wellbeing

In this chapter we explore the links between processes of gendering and mental wellbeing and discuss some of the impacts poorer mental wellbeing can have on women’s lives. Outlining some headline policy and statistical data pertaining to gender and mental health we provide a contextual map of some key issues within regional, national and global contexts. Focusing on feminist theories and debates that have emerged over the past four decades we explore the relationships between ill health, constructions of femininities and the socio-cultural conditions of women’s lives. While recognising that women are both more likely than men to self-identify as having mental wellbeing issues and be identified by health professionals as experiencing problems with their mental health, we argue that the cultural construction of the mental health sector as feminised should be resisted. The feminisation of mental health is problematic for woman as a whole, and also for men. As we discuss at the end of this chapter, the construction of mental health as a ‘woman’s problem’ creates a cultural barrier for men who would benefit from accessing support within the sector and perpetuates the myth of the physically and mentally ‘strong male’ which can be damaging for both men and women.

Our focus on the links between gender and mental wellbeing emerged from our research with women. While exploring women’s life histories and experiences, initially specifically in relation to educational and employment trajectories, it soon became clear that mental wellbeing was a recurrent issue for women from all backgrounds. Women’s self-confidence, self-esteem and mental wellbeing emerged as a significant theme in almost all of the qualitative interviews and focus group discussions. In addition to clinically significant experiences of depression, self-harming and other mental health issues, women repeatedly raised – both explicitly and implicitly – a range of broader wellbeing issues, such as low self-confidence and low self-esteem, as obstacles to their personal and professional development. The questionnaire survey data yielded on the whole more positive responses to questions of wellbeing than the more in-depth qualitative research, and 73 per cent of women agreed or strongly agreed that they were ‘usually a confident person’, although this was somewhat undermined by the simultaneous finding that 75 per cent of women agreed or strongly agreed that they ‘often underestimated their abilities’ in the same survey. Could both be the case? Perhaps so, after all, we are complex and contradictory beings. Moreover, surveys are notoriously limited tools, lacking the depth and nuance that the interviews in this study yielded. While not without complexity and contradiction, the qualitative voices of women were more consistent and unambiguous in their articulation of pernicious under-confidence.

What many participants seemed to be articulating was an inner voice that whispers in the ears of women of all ages, from all backgrounds and in all areas of life; the voice that tells them that they are ‘not really very good’, they ‘could do better’, that they ‘do not really deserve that job, that salary, that promotion’, that they are ‘inadequate mothers, poor wives or partners and failing daughters’. While many of the women we spoke with did feel confident and happy with whom they were, even in the most confident and successful life histories lack of esteem was raised in some way. Danielle, for example, talked about her professional insecurities, which she still feels despite her successful career in catering:

‘I still now have that little doubt even when I hire staff, which just sounds really silly but, “They’re going to take my job” …and I think “Why am I frightened of someone that’s been here a week?” But that’s a confidence thing.’

(Danielle, early 40s, manager, catering sector, North Yorkshire)

As is discussed in greater depth in later chapters, low confidence and undervaluing oneself can have tangible and long-term implications for a woman’s career. This can include women not permitting themselves to recognise and value their skills, which in turn can have an impact on their willingness to apply for promotion. As Alice said:

‘I think women aren’t necessarily encouraged to be proud of their achievements in quite the same way [as men]. Um, I know that personally for a very long time, I felt quite embarrassed telling people how well I’ve done [educationally and professionally].’

(Alice, late 30s, manager, education sector, volunteer, mother, West Yorkshire)

Underselling oneself can also have direct monetary impacts. May is a highly qualified professional, but felt undervalued when she discovered that she was being paid less than a male colleague. She explained that when she was appointed to a new post she was offered the lowest salary on that pay scale. A male colleague who was appointed to a similar post at the same time was also offered the lowest scale point but he queried this and his salary was increased. When asked if she felt that this was in some way a gendered issue she said:

‘I think that, in a way, it could be a gendered issue because it was just like, oh someone’s offered me a job so, you know, someone wants me and, yes, of course I’ll take the money. I was just kind of, you know, happy to be offered a job, really. I didn’t think about challenging the amount of money, really.’

(May, late 30s, part time, education sector, North Yorkshire).

For May, the issue was not that her colleague was being paid more per se, although this in itself is poor employment practice, rather, the issue was that she had lacked the confidence to ask for a salary which she really did feel was more commensurate with the level of responsibility she was taking on. Fundamentally, May undervalued herself, she was simply grateful that she had been offered the job rather than recognising her worth and this came to be reflected in longer-term economic disadvantage, which over the years amounted to tens of thousands of pounds in differential earnings.

So prevalent were underlying feelings of inadequacy and lack of self-confidence throughout the interviews that it might even be seen as a common thread that tenuously connects women, a negative undercurrent of femininity that sits at the very core of women’s sense of self. Rita, for example, has ongoing health problems but she continues to work in a voluntary capacity. She feels, however, that the biggest barrier to progressing in her life is:

‘Self-confidence: I just wish somebody would just say “Rita, just do it, just do it!”…I just need a big push to do something…I wish I had the confidence to say “Right, I want to do this.”’

(Rita, early 40s, volunteer, Humberside)

Carla, who runs self-confidence courses for a group of women, recognises that the causes of low self-esteem among women, while diverse, are deeply embedded in gendered issues of power and women’s identity formation from an early age:

‘I’m working with, you know, some people who have issues with husbands and things like that, and boyfriends, like domestic abuse etc, so that knocks confidence anyway; so it could come from things like that, but it could be just the simple fact that they’ve got no self-esteem, it comes back from childhood and you know they’ve never been told that they’re good at anything, you know they even go to work but you’ve never been given any praise whatsoever.’

(Carla, mid-40s, manager, community sector, mother, North Yorkshire)

This is not to suggest that all women lack confidence and have low self-esteem. Nor are we suggesting that men do not experience low self-esteem and a lack of confidence at times in their lives. Both men and women are inevitably affected by the multifarious obstacles life throws in our paths, and we are particularly vulnerable to lack of confidence and mental wellbeing issues at higher stress points, such as losing or changing jobs, moving house, becoming a parent, experiencing relationship breakdown or suffering a death in the family. Throughout this book, however, we are focusing on the ways women in particular feel that lowered confidence and self-esteem have had an impact on their aspirations and achievements through their lifecourse.

The prevalence of mental health problems which people experience is not an issue confined to specific geographic contexts or particular human societies. Globally, mental health and wellbeing continue to pose major challenges for the public health agenda. It has been estimated that mental health disorders affect approximately 450 million people worldwide, accounting for over 12 per cent of the global burden of disease (World Bank, 2004; Diaz-Granados and Stewart, 2007) and in England alone the annual cost of mental health problems is estimated at over £100 billion (Centre for Mental Health, 2010).

While the terms ‘mental health’ or ‘mental wellbeing’ incorporate an enormous range of experiences, symptoms, illnesses and diseases, one of the most common manifestations of mental health problems is in the form of depression. The World Health Organisation (WHO) states that depression, predicted to be the second leading cause of global disability by 2020, is twice as common in women (WHO, 2012). Similarly, in the UK ‘mixed anxiety and depression’ is the most common mental health disorder ‘with almost 9 per cent of people meeting criteria for diagnosis’ (Mental Health Foundation, 2007, 9; see also ONS, 2010, 37). Nevertheless, for many years the impacts of chronic depression and mental health problems have been neither fully understood nor taken as seriously as they could be within health services both in the UK and globally.

In an attempt to address this issue, in 2007 the WHO conducted the largest worldwide study of the impacts of depression. They found that in comparison with other prevalent chronic diseases such as angina, arthritis and diabetes, depression impairs health ‘to a substantially greater degree’ (Moussavi et al, 2007, 861–2). Moreover, they found that women experienced higher levels of depression and subsequent health problems. Contributing factors to incidences of depression include: lower educational attainment and income levels; being unemployed; being separated, divorced or widowed.

The combination or comorbidity of depression and other chronic diseases was found to be an especially lethal cocktail, and in recognition of this, the WHO report concluded by urging primary care providers ‘not to ignore the presence of depression when patients present with a chronic physical condition, in view of the marked effect that it has on an individual’s health’ (Moussavi et al, 2007, 861). In addition to academic research, in recent years there has been a more general growing global recognition of the significance, prevalence and, often, gendered nature of mental health problems. Global institutions such as the WHO and the United Nations as well as national governments are increasingly acknowledging – at least at the level of policy rhetoric – the links between mental health problems on the one hand and gendered sociocultural and environmental factors such as alienation, powerlessness, poverty and discrimination on the other (Joseph, 2001, 370). In more extreme cases, we can understand that being criminalised can undoubtedly have negative impacts on mental ill health, but one could argue that mental ill health may contribute to criminalisation. It seems too much of a coincidence that ‘three-quarters of the female prison population in Britain suffer from mental health problems’ (Appignanesi, 2008, 3). While it is beyond the scope of this volume to fully engage with this debate here, it poses a key question for analysis elsewhere: did they all become mentally unwell after being incarcerated or was their poor mental health a contributing factor in their criminalisation?

Mental health disorders, treatment and outcomes are gendered issues with evidence of significant differences in levels of diagnosis, patterns and symptoms (Busfield, 1996). Indeed, as Ussher states, ‘[f]or centuries women have occupied a unique place in the annals of insanity. Women outnumber men in diagnoses of madness, from the ‘hysteria’ of the eighteenth and nineteenth centuries, to ‘neurotic’ and mood disorders of the twentieth and twenty-first’ (Ussher, 2011, 1). Throughout the world women are, for example, more likely than men to experience depression, anxiety, seasonal affective disorders, eating disorders, panic disorders, have a higher incidence of attempted suicide and are more likely than men to suffer from more than one mental illness or disability (Appignanesi, 2008). Women are also more likely to be subject to psychiatric treatment and the range of ‘therapies’ experienced within this realm such as electro-convulsive therapy (ECT) (Ussher, 2011, 1).

Men, as a group, on the other hand, experience more overt problems with anger, engage in high risk behaviours, have higher rates of completed suicide and higher prevalence of alcohol and substance misuse (WHO, 2002; Diaz-Granados and Stewart, 2007, 197; Mental Health Foundation, 2007, 27). Gender differences in patterns of mental health service access are also evident with women making greater use of services, receiving more medication and having higher rates of hospitalisation than men. As Malatesta (2007, 1) points out, however, it is ‘ironic’ that despite women being the primary consumers of mental health services, ‘research addressing their unique needs lags behind that of men’s issues’.

Recognising the need for a greater global focus on, and strategies towards, tackling the gendered impacts of mental health disorders, in 2007 the World Health Assembly (WHA) issued a resolution urging member states (the UK included) to mainstream a gender analysis across all levels of policy formulation, planning, delivery and training throughout the health sector. Similarly, for Diaz-Granados and Stewart, a gender analysis of health provision at national and regional levels is essential in order to tackle gender disparities in mental wellbeing. Specifically:

a gender-sensitive national mental health surveillance program that includes health system indicators as well as community indicators would not only ensure that appropriate care reaches those at higher risk (ie refugees, immigrants, single-parent mothers, women who experience intimate partner violence), but it would also promote the use and planning of community programs aimed at increasing mental well-being.

(2007, 198)

Gendered experiences of mental health and wellbeing both in the UK as a whole and within the Yorkshire and Humber region itself tend to reflect global trends identified above. It is recognised, for example, that in Yorkshire and Humber, as across the UK more generally, mental health problems affect more women than men (Palmer et al, 2003; Mental Health Foundation, 2007). Similarly, risks of developing mental health problems can be exacerbated by the material conditions of people’s lives including socio-economic class and income levels, the kinds of employment people are engaged in, periods of unemployment, and the social contexts of one’s cultural or ethnic background. Adults in the poorest fifth of the population, for example, are twice as likely to develop mental illness as those on average incomes and people from manual backgrounds are at higher risk than those from non-manual backgrounds (Mental Health Foundation, 2007).

Mental health problems can in turn have a disproportionate impact on an individual’s socio-economic context, leading to a vicious circle of significant social isolation. People with mental health problems are, for example, more likely to live alone, have little contact with their families, have fewer friends, be divorced or separated and are more than twice as likely to be lone parents than those without a mental health problem – a situation that again affects more women than men (Mental Health Foundation, 2007).

Thus, to provide a few illustrative examples, the incidence and prevalence of depression and anxiety is higher among women than men and the same gendered pattern is consistent across ethnic groups (Melzer et al, 2001, cited in Myers et al, 2005). Rates of suicide, schizophrenia and of alcohol and drug use are higher for men but there are rising levels of alcohol-related harm among women, especially among younger women (Myers et al, 2005). Interestingly, Soni-Raleigh reported in 1996 that Asian women aged between 15–35 years are two to three times more likely to be vulnerable to suicide and self-harm than their non-Asian counterparts (Soni-Raleigh, 1996). These rates have continued and a report published 15 years later by the Southall Black Sisters (2011) states that British Asian women continue to commit suicide at a rate that is twice the national average, being three times more likely to kill themselves than other ethnic groups.

In the UK, the highest rates of mental illness are found in the North East, affecting approximately 18 per cent of the population. The Yorkshire and Humber region itself is in line with national averages with approximately 12 per cent of the adult population deemed at high risk of mental illness (ONS, 2011d). As outlined in Box 1.1, however, indices of social deprivation and health problems tend to be relatively high in many areas of the Yorkshire and Humber region which has an impact on and is in turn affected by ill health and poorer mental wellbeing.

In summary, despite being so prevalent and having such serious socio-economic impacts, and despite the chronic effects poor mental health has on both the individual and society as a whole, there continues to be a global lack of attention to provision of mental health services. This is a problem which is similarly reflected in both regional and national UK contexts with mental health and wellbeing continuing to be perceived as the ‘Cinderella’ of the health service. In recent years, however, successive governments have made some encouraging policy statements and developed some positive initiatives. In the mid-2000s, pre-empting the World Health Assembly’s 2007 resolution mentioned earlier, the former Labour government recognised the need to mainstream gender into mental health in local planning and social care services and called for a ‘cultural change’ within mental health services in order to understand the needs of women and develop more gender-aware training and provision. Within this, one of the policy initiatives highlighted in the women’s mental health strategy is the need for women-only community day services and support in every health authority. As the Department of Health (DH) stated:

The needs of women are central to the government’s programme of reform and investment in public services and to our commitment to addressing discrimination and inequality. Modernising mental health services is one of our core national priorities [There is also a recognition that] understanding the needs of women – both as service users and in the workforce – requires cultural change.

(DH, 2004, np)

That the government made a public commitment to gender mainstreaming in mental health sectors was a welcome advance. Nevertheless there is a long way to go in order to achieve the ‘cultural change’ required across health services and greater resources need to be allocated to more targeted and gender-aware service provision and training. In the climate of recession following the 2009 global banking crisis and financial mismanagement, and the subsequent service cuts witnessed across the UK and internationally, the resourcing and modernising of the mental health sector has not, however, been a political priority.

That so many women experience problems with their mental wellbeing, ranging from a lack of confidence in their abilities or low self-esteem to serious mental health issues such as chronic depression, could lead one to believe that there is something about the formation of women’s gendered identity, their sense of self, that is seriously flawed. Recognition of the ‘problem’ of gender identity formation can, however, lead to quite different responses and perceived solutions. As Prior (1999) explains, and as will be explored in more detail below, some of these reasons include ‘arguments about the intolerable constraints involved in traditional female roles, the acceptability of illness as a mode of protest and attention-seeking for women, and the inability of a male-dominated society to accept creative but different female behaviour’ (Prior, 1999, 78). Prior, however, warns against making overly simplistic connections between gender and mental health, emphasising that to gain a better understanding of ‘the relations between gender and psychiatric disorder requires a very careful unravelling of the complex character of psychiatric ideas and practice as well as of gender relations’ (Prior, 2002, 160).

While the feminisation of mental health has tended to characterise the contemporary health arena over the course of the twentieth and twenty-first centuries, it is interesting to note that until the late nineteenth century, men were more likely than women to be labelled and committed to asylums as ‘mad’. The feminisation of mental health gathered pace rapidly during the late Victorian period, however, so that ‘by the 1890s the predominance of women had spread to include all classes of patients in all kinds of institutions except for asylums for the criminally insane, a dominance that has continued ever since’ (Holmshaw and Hillier, 2000, 41). There are several reasons suggested for this gender shift, linked, for example, to gender differences in poverty, power and a popular view held among the (male) psychiatric and medical profession that ‘women were more vulnerable to insanity than men because the instability of their reproductive systems interfered with their sexual, emotional and rational control’ (Holmshaw and Hillier, 2000, 41; see also Bernheimer and Kahane, 1985; Levine-Clark, 2004).

In Showalter’s (1987) classic work The Female Malady, she explores the image of the feminine as synonymous with ‘madness’, arguing that this link goes beyond women’s statistical overrepresentations in mental health circles. She highlights the ways in which representations of the ‘mad’ as feminine, and vice versa, leach into cultural representations such as in art and literature and are underpinned by the gendered dualisms famously outlined by Ortner (1974) of female/male-nature/culture–irrational/rational: ‘While the name of the symbolic female disorder may change from one historical period to the next, the gender asymmetry of the representational tradition remains constant. Thus madness, even when experienced by men, is metaphorically and symbolically represented as feminine: a female malady’ (Showalter, 1987, 4, cited in Prior, 1999, 79).

Philip Martin also alludes to classic feminist analysis of the masculine ‘One’ and the feminine ‘Other’ when he argues that, ‘[w]oman and madness share the same territory…they may be said to enter a concentric relationship around a central point occupied by fundamental male normality’ (Martin, 1987, 42, cited in Ussher, 2011, 1). Considering the framework of the triad of violence played out along a long continuum we set out in Chapter One, we can see how both Showalter (1987) and Martin (1987) are talking here about forms of symbolic violence (Bourdieu, 2001) being done unto women’s gendered identities.

Historically, however, and particularly outside of the realms of feminist understandings, the lack of self-confidence many women feel has often tended to be individualised – seen as the woman’s personal problem – rather than understood as resulting from structural and ideological factors, integral to the social construction of women’s gendered identities in society. From this perspective, then, the woman herself is the root cause of her illness. Unfortunately, this process of individuation is all too apparent to this day within key social institutions such as the medical profession, the media and within the family.

We accept that there are aspects of self-esteem and mental wellbeing that can be especially gendered experiences for women qua women. In line with several other feminist analyses, however, the required ‘cultural change’ referred to by the Department of Health (DH, 2004) involves a reconfiguration of the individuation of these issues and a recognition of the fundamental implication of socio-cultural structures in the creation of mental illness as a ‘woman’s problem’. We suggest that a focus on women’s wellbeing requires an examination of what it is about women’s lives that makes them vulnerable to illness. We need to examine the ways in which ‘[i]ncreased responsibilities place tremendous physical and psychological demands on women, putting them at risk of developing an array of mental health problems’ (Antai-Otong, 1997, 330). We also need to understand the ways in which in both local and global contexts women’s lives are so often characterised by a range of complex conditions including hard labour, genderbased discrimination, poorer nutrition, exposure to violence and that all these ‘difficult circumstances faced by many women negatively affect their health and well-being and produce some common needs’ (Stein, 1997, 1–2). What is important, however, is that there is a need to critically explore ‘how social institutions, such as medicine, frame women’s experience of health and illness and help to maintain their social subordination’ (Hockey, 1993, 250).

A similar point is made by Goudsmit (1994), although her analysis forms a useful and significant counterpoint to the problem of individuation of poor wellbeing, that of the ‘psychologisation’ of women’s illness (Goudsmit, 1994, 7). As Goudsmit (1994) illustrates, gender stereotyping by (often male) medical professionals can lead to the diagnosis of women presenting with physical symptoms as mentally or psychologically unwell. Goudsmit cites several illuminating examples dating from the late 1980s and early 1990s, including that of a woman who presented to her doctor with fatigue and abdominal pains and was given a diagnosis of irritable bowel syndrome brought on by the stress of recently starting a new job. After returning to her GP on several occasions as her symptoms worsened, but not receiving further treatment or diagnosis, she eventually went to a hospital casualty department where a (female) doctor conducted a physical examination which revealed a tumour that turned out to be cancer of the colon. In another example, Goudsmit cites the cases of three women who were all diagnosed with ‘hysterical hyperventilation’ which turned out, only after requiring hospitalisation, to be diabetes.

In each of these cases, the assumption that the problem was psychological led to a failure to conduct a physical examination which put their lives at risk. Goudmsit also conducted an analysis of medical texts and found that women were ‘often portrayed as weak, suggestible, emotionally unbalanced, irrational, manipulative and unable to cope with even relatively minor stress’ (1994, 8). As she goes on to point out, in the literature she examined, there was no recognition that chronic physical symptoms can in turn ‘undermine a woman’s self-confidence and self-esteem and that this could also account for the raised scores in psychometric tests [conducted on women]. The literature simply didn’t, and still doesn’t, acknowledge the fact that emotional problems may often be the result, rather than the cause of certain [physical] conditions’ (Goudsmit, 1994, 8).

It can, then, clearly be harmful, indeed life-threatening, to assume that women’s health problems are mentally rather than physically based. It is equally problematic to assume that mental wellbeing problems which women may experience are the result of her individual personality traits – perhaps because she is a ‘weak’ woman (Goudsmit, 1994, 8), rather than resulting from her socio-economically and culturally located gendered positionality, or indeed resulting from the effects of a physical illness. In all of these possible scenarios, the underlying problem lies with particular perceptions of and constructions of women as gendered beings within wider gender regimes.

The perspective that constructions of women’s gendered identities and the circumstances of women’s lives can lead to mental ill health and that, moreover, psychiatric responses to such disorders can serve to reinforce and reproduce women’s subordination finds support from a range of theorists (see, for example, Busfield, 1989; 1996; 2002; Women in Mind, 1986; Ehrenreich and English, 1979; Doyal and Elston, 1986). More recently, and possibly most notable within this field, is the work of Jane Ussher (see for example Ussher, 1991; 1997; 1999; 2000a; 2000b; 2000c; 2011). Ussher articulates, synthesises and extends the body of feminist work that has explored and critiqued the links between gender and mental health over the past few decades. As she states, while we must not ‘deny the reality of women’s experience of prolonged misery or distress, which undoubtedly exists…if we examine the roots of this distress in the context of women’s lives, it can be conceptualised as a reasonable response not a reflection of pathology within’ (Ussher, 2011, 1–2, emphasis added). Along similar lines, American psychologist Paula Caplan asks, ‘[do] we live in such a crazy-making, sick, impersonal society that it does serious psychological damage to half of us?… Should we be calling [women] the mentally ill…or society’s wounded?’ (Caplan, 1995, 6).

Much contemporary academic work in this field began to emerge in the early 1970s, an emergence that can be directly linked to the impacts of second wave feminism (Busfield, 1996, 1). Gove and Tudor (1973), for example, explored the relationship between women’s mental health and marital status in the United States and found that married women experienced more mental health problems than their male counterparts. Along similar lines to Ann Oakley’s arguments in her now famous mid-1970s ‘Housework’ research in the UK context, they argued that these problems were ‘grounded in the lack of alternative gratification available to housewives; the low status of housework; the unstructured and invisible nature of housework; the poor conditions experienced by women in paid employment; and the conflicting role expectations faced by women’ (Gove and Tudor, 1973, cited in Hockey, 1993, 251).

Over the past four decades a significant body of work has developed exploring the relationships between ill health, constructions of femininity and the socio-economic and cultural conditions of women’s lives.¹Close An obvious but important point to emerge from many of these writings and debates is that distinctions between illness, and behaviours associated with illness, are difficult to disentangle, but frequently gendered. Are new mothers, for example, who are diagnosed as suffering from post-natal depression, depressed because they are clinically ill or because they have undergone a major physical, emotional and social upheaval, feel overwhelmed, under-supported, and feel social and familial pressure to be the ‘perfect mother’? As Hockey states, ‘[v]isiting the doctors may not necessarily reflect disease but rather the medicalisation of stresses women experience as a result of [social, cultural or material conditions]’ (1993, 252). Conversely, as Goudsmit (1994) warns, it is equally problematic to assume that a woman visiting her GP with feelings of sadness, low self-esteem, fatigue and so on, are not physically ill, and to fail to consider that the physical illness and the bodily ill-health she is experiencing could have led to poorer mental wellbeing as a secondary illness.

What is clear is that the extent to which individual incidences of ill health are more or less physiologically or socially constructed is complex and this debate, to some extent, can serve to obscure the fundamental issues at play. The fact that women are more likely to experience poorer mental wellbeing than their male counterparts is not a random phenomenon or a coincidental correlation. Women’s wellbeing is inextricably interrelated to the ways in which they experience their lives as gendered beings within specifically spatially and temporally located structural, symbolic and cultural frameworks – frameworks which, we suggest, can themselves be considered to be, at least to some extent, forms of violence (Bourdieu, 2001; Farmer, 2004). Thus, there is something fundamentally flawed about the ways in which women’s gendered identity is constructed that means that they are more prone to mental illness, but that flaw lies not within women themselves but in the normative patriarchal constructions of their gendered beings: of femininity, women’s roles, divisions of labour and their relative status in society.

Our research supports the conclusions of other authors, such as those cited above, that women’s gendered roles and socio-cultural constructions of femininity can have a particularly negative impact on their mental wellbeing at points in their lives. This in turn is in line with the evidence that indicates that mental health issues appear to affect more women than men throughout the world. Nevertheless, an important factor to consider is that the differences in the extent of men’s and women’s mental health experiences may not be as marked as they at first appear. Statistics that tell us that women experience greater levels of mental health issues are largely based on the numbers of people reporting problems with mental wellbeing (which can be quantified), not the actual incidence of such issues (which cannot). In other words, those who do not report mental health issues or access formal sources of support or medical treatment are thus largely rendered statistically invisible. One could critique the nature of statistics themselves in that rather than providing ‘objective’ numerical data as many may surmise, statistics are socially constructed in as much as we often find what we set out to seek. The data we end up with depends on how that data has been collected and on the questions that were asked. As Reinharz explains:

[d]espite the power and ubiquity of surveys and other forms of statistical research, feminists have also been critical of their use. One root of this criticism is hostility to statistics that are seen as part of patriarchal culture’s monolithic definition of ‘hard facts’…many factors, including gender, affect the respondents’ answers [and] results of a survey hinge on the exact form a question takes.

(Reinharz, 1992, 86–7)

Notwithstanding the need for a critical eye to be cast over statistical ‘facts’, we would concur that women tend to feel more able to access support and seek treatment than their male counterparts. This tendency is underpinned by socio-cultural factors fundamentally connected to constructions of our gendered identities. On the one hand, there continues to exist an underlying cultural belief that women should be both mentally and physically weaker than men, while on the other, women tend to be encouraged to form stronger social networks, and to talk more openly about their feelings. This can mean that women are better able to provide support networks to others, as described by Paula, whose friends and colleagues working in the voluntary and community sector recognised her symptoms of depression and assisted her in seeking help:

‘Erm, but I think for…because…well, certainly in the women’s services it’s the case that people talk about things all the time, therefore there’s always someone who’s experienced it who can say to you, “Sounds to me like you’re depressed” and understand and be sympathetic.’

(Paula, early 50s, financial/community sector, Humberside)

The reasons men do not report or seek help for mental health issues to the same extent as women are also related to socio-cultural constructions of their gendered identities, and more specifically to cultural constructions of hegemonic masculinity.²Close Men are less likely to feel able to be open about their mental health problems – admitting to physiological problems may be difficult enough, unless they were incurred in an acceptably masculine arena such as in the workplace or on the sports field, but admitting to poor mental wellbeing might be perceived by some as demonstrating a level of weakness that no ‘real man’ would experience. This in turn perpetuates the feminisation of mental illness, both statistically and perceptually: it becomes a woman’s problem, another illustration of why women are ‘the weaker sex’. It also has a negative impact on men themselves, perpetuating the myth of the hegemonic male to which all men should aspire. It creates a cultural barrier for men who would benefit from social, emotional and medical support at times when they are experiencing poor mental wellbeing.

In sum, it is crucial to recognise that mental health issues have an impact on both women and men, but that women are more likely than men to seek support and medical treatment, and, significantly, are more likely to be offered medical treatment and to be labelled as having mental health problems. While calling for greater support and resources for women and men with mental wellbeing issues, the cultural construction of mental health as a feminised arena per se should be resisted. Rather, there is a need to have a wider understanding and acknowledgement, beyond the mental health profession, of the ways in which mental ill health is a condition of human society which is in turn fundamentally conditioned by the constructions of both men’s and women’s gendered identities into falsely immutable categories.