Gender competence and mental health promotion

Cultural competence is a familiar construct. It encompasses individual attitudes and behaviors, as well as organizational policies related to consideration of culture in practices and services. It reflects values about diversity and rights to equitable access to care, and the skills to enable people, agencies and systems to work effectively in culturally pluralist situations.

Gender competence is less familiar. It comprises the capacity to recognize gender-based discriminatory attitudes and behaviors; knowledge about gender-based policies and initiatives to improve equality of opportunities and outcomes; and actions to counter gender-based stereotypes in research, learning environments and clinical practice. Gender competence in health care promotes equity in health outcomes.

Stereotypes are qualities assigned to groups of people based on gender, ethnicity, nationality, sexual orientation or other traits. Gender-based stereotypes are fixed beliefs and attributions about characteristics, capabilities and behaviors based on a person's sex. They are always limiting, including of rights and entitlements. They reinforce disparities in privileges and power in private and public spheres of life, and influence day-to-day exchanges in relationships. They are automatic and can be embedded in a single word or descriptive phrase, and are harmful when used to predict, judge or understand human behavior1.

Worldwide, women carry higher burdens of unpaid work and caregiving, and have disproportionate experiences of childhood maltreatment, and violence perpetrated by an intimate partner. They have less access to the protections of education, income-generating work and financial decision-making. These carry risks for their mental health across the life course2.

Gender-based stereotypes are revealed in attitudes and beliefs about women's roles and responsibilities, including work, caregiving and income generation; and violent transgressions of their human rights, in clinical practice, research and public health initiatives.

There are principles about the management and prevention of occupational fatigue in workplaces in which there are long and irregular hours, including shift work. These prescribe maximum safe working hours, required nights of consecutive rest to recover from nightshifts, and intervals for sleep between shifts. However, because of gender stereotypes, there are no workplace safety requirements about occupational fatigue when the home is the workplace, and the work is caring for an infant.

Smith and Ellwood3 assessed time spent on caregiving and available for sleep among mothers of three-month-old infants, using an electronic recording device. On average, there were 49 feeds, each lasting about 75 min, and 70 other occasions of carrying/holding/soothing the infant, for about 18 min each time, a total of more than 82 hours caregiving work per week. Mothers’ sleep was in 18 different episodes, each lasting about 3 hours. The experiences are worse if the baby cries inconsolably and wakes frequently. Among women admitted consecutively to a residential early parenting centre for assistance with their unsettled babies, 80% had on average less than 6/24 hours sleep in the prior week, and 91% met criteria for clinically significant fatigue4.

The usual ways in which clinicians enquire about these experiences include: Are you working?; When are you giving up work?; When are you going back to work?; Does he help you? Researchers classify women as not working or as working outside the home5. This reveals stereotypes that the endeavour of caring for an infant is not work, is not socially valued and is a female obligation with which men help. Women incorporate these pervasive stereotypes, reflected in the common responses that “I don't work” or “I am only a mother” .

Prevalence varies among countries, but violence against women and girls is a universal phenomenon. Violent transgressions of the human rights of females begin prior to birth and occur across the life course in domestic, institutional and community settings. They encompass, but are not limited to, female feticide, sexual abuse of girls, female genital mutilation, dowry-related violence, sexual harassment and intimidation at work, trafficking, and violence perpetrated by an intimate partner. Women who are Indigenous or members of ethnic or religious minority groups, occupying low socio-economic positions, or refugees or asylum-seekers, are especially vulnerable6. Experiencing or witnessing interpersonal violence, especially when it occurs within households, is always harmful to mental health. The World Health Organization considers violence to be the principal gender-related cause of mental health problems among women7.

For most of the 20th century, violence against women received scant research attention or recognition by clinicians and policy-makers. The first epidemiological surveys of perinatal mental health problems among women were published in the 1960s. Difficulties in the relationship with an intimate partner were more prevalent among the group with than without mental health problems, but this was conceptualized as women being depressed, having difficulties in their biological role and regarding their husbands as unhelpful and unsympathetic8.

The first systematic review of the evidence about the relationship between intimate partner violence and perinatal mental health problems was published in 2013. Violence experienced during pregnancy was associated with a near five-fold increase in antenatal (odds ratio, OR=5, 95% CI: 4.04-6.17) and postnatal (OR=4.36, 95% CI: 2.93-6.48) depression9. Most countries, including well-resourced high-income nations, were unable to contribute data to this review because none were available.

Despite this evidence, the predominant theme in the contemporary literature is that women's mental health problems are biologically caused and have adverse effects on their partners, children and families. The alternative interpretation that their mental health problems might be a consequence of their environmental exposures remains rare5.

Gender-informed approaches to mental health promotion require specific acknowledgement of gender-based risks. These are underpinned by frank recognition of gender stereotypes and how these influence the ways in which research is conceptualized and designed, and data are collected and interpreted, as well as the language that is used in clinical encounters and recommendations in health promotion initiatives.

Gender competence requires explicit and intentional consideration of past experiences and current predicaments within their social and cultural contexts. Gender competence therefore seeks to comprehend and address experiences of discrimination, interpersonal violence and being devalued, and to counter internalized beliefs about roles, rights and responsibilities. Researchers, clinicians and public health professionals who advocate for these strategies and implement these approaches can be powerful agents of social change.