Understanding stigma through a gender lens

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By Carolyn Shimmin

“I rarely disclose to people about my depression,” says a 30-year-old woman who wishes to remain anonymous. “I’m afraid I might be judged by others—employers, friends, partners, family. On top of having to deal with the depression, I feel like I have to deal with how others perceive me as well—it makes for a lot of work, and recovery doesn’t come easy.”

The stigma experienced by those living with mental illness and addictions in Canada has drawn more attention in recent years. A report published by the Canadian Medical Association in 2008 demonstrates the pervasiveness of such stigma—only half of Canadians would tell a friend that a family member has a mental illness, and 46% of Canadians think the term “mental illness” is used as an excuse for bad behaviour. 

One of the Mental Health Commission of Canada’s (MHCC) key initiatives is the implementation of a national anti-stigma campaign. The Commission suggests such a campaign will encourage individuals experiencing mental health difficulties to seek help, and will help eliminate stigma against them.

Although stigma is a familiar concept in the field of mental health, it is still rather complex and is often over-simplified. The term is used as a catch-all for an array of negative beliefs, attitudes and actions related to mental health. What is often left out of the discussion is that stigma exists within a social power structure that facilitates it. As Bruce Link and Jo Phelan write in Conceptualizing Stigma, stigmatization is contingent on “access to social, economic, and political power that allows…the full execution of disapproval, rejection, exclusion, and discrimination.” Researchers have found that, in addition to labelling and stereotyping, active discrimination and the misuse of power are the most damaging aspects of stigma. 

The key to an effective strategy against stigma must be an evidence-based understanding of its complexity, including recognition that women and men experience and apply stigma differently. A campaign or any anti-stigma programming that does not take gender into account risks failure, and may waste the often considerable resources invested. To date, the MHCC national anti-stigma campaign contains no sex- and gender-based analysis.

Women, men and stigma

Women living with mental health problems and/or addictions experience the associated stigma differently than men. The example of substance use or mental illness among pregnant women and mothers offers an illustration. Public discourses and policies surrounding pregnant women who use licit and illicit drugs are judgmental, blaming, and unsympathetic. Analysis done by the British Columbia Centre of Excellence for Women’s Health of media discourses and policy responses to these women revealed highly negative attitudes that reflect the perception that the women deliberately create their difficult predicaments. Little responsibility was assigned to the system. Yet, in the same study, researchers found that women with mental illness who were pregnant or mothering were portrayed as not responsible for their situation because their behaviour was regarded as out of their control, and the system was failing them.

These differences in assigning responsibility are linked to the nature of stigma attached to pregnant women’s behaviours. Though there has been some shift in Canadian public policy to embrace harm reduction approaches to substance use and addictions, the unique needs of pregnant women and mothers with addictions are frequently neglected. Similarly, public attitudes and child welfare policies may negatively affect women with mental illness who are pregnant or mothering (portraying these women as unstable mothers whose children should be taken away). These conditions may determine whether or not a woman will report substance use patterns or mental health issues during pregnancy and while mothering.

This sort of stigma is directly associated with gender roles. Researchers have argued that the stigma for women who use any licit or illicit drugs is more severe than for men because of women’s “place” in society, as those who bear and rear children and who are seen to uphold the moral and spiritual values of society. There is also the negative stereotype that women users are sexually promiscuous because of their drug or alcohol use. This association is not seen in men. The World Health Organization has found that men are far more likely than women to disclose problems with alcohol use to their health care provider.

To communicate effectively to and about women who experience substance use problems or mental illness, it is necessary to understand and reflect the social context in which such experiences emerge. It is also important to understand that stigma experienced by those living with addictions varies by gender and therefore, requires different approaches and treatment options.

A sex- and gender-based analysis also helps us understand the high rate of suicide among men. Growing up, boys encounter what William Pollack termed the “Boy Code”—a set of expectations about how boys and men should think, feel and act: “be tough,” “don’t cry,” “go it alone,” and “don’t show any emotion except for anger.” These characteristics of traditional masculinity and the stigma attached to any male who does not abide by these characteristics can cause men to perceive mental health problems as weakness and thus not seek the necessary help.

Overall, the World Health Organization has concluded that, “Gender stereotypes regarding proneness to emotional problems in women and alcohol problems in men, appear to reinforce social stigma and constrain help seeking along stereotypical lines. They are a barrier to the accurate identification and treatment of psychological disorder.”

Women’s and men’s attitudes

A 2007 study by Wang, Fick, Adair and Lai entitled Gender specific correlates of stigma toward depression in a Canadian general population sample, also found that factors associated with stigma appear to vary by gender, and therefore gender differences must be considered in initiatives aimed at reducing stigma.

Research examining Canadians’ attitudes towards depression, for example, found that men held more stigmatizing attitudes towards mental illness than women. Women working as health professionals, who had family or close friends living with depression, who believed taking medication may be the best help for depression, and who believed that traumatic events are a causal factor for depression, held fewer stigmatizing attitudes. These associations were not found in men; in fact, men who identified as health professionals, and who had family or close friends living with depression, strongly associated weakness of character as the causal factor for depression.

This finding is particularly relevant to the Mental Health Commission of Canada’s plan to target health care providers in its anti-stigma campaign. It tells us that, to be effective, messaging targeted to health professionals needs to take into consideration these demonstrated gender differences in attitudes.

Youth is another priority group identified in the Commission’s anti-stigma plan. Research has shown that gender differences in negative mental health attitudes and willingness to use mental health services are already present early in adolescence. In a study examining the willingness of teens to use mental health services it was found that more girls than boys turned to a friend for help for an emotional concern, whereas more boys than girls turned to a family member first. So, here again, messaging to youth must take into account that girls’ and boys’ attitudes about mental health are different in important ways.

Stigma does not take place in a vacuum. A 2003 study by Corrigan, Thompson, Lambert, Sangster, Noel and Campbell entitled Perceptions of discrimination among persons with serious mental illness, found that more than half of the study group (949 participants out of 1,824), which involved people with serious mental illness, reported some experience with discrimination. The most common targets of this discrimination were mental disability, race, sexual orientation, and physical disability. Discrimination frequently occurred in employment, housing, and interactions with law enforcement. The study concluded that anti-stigma programs need to target not only discrimination related to mental illness but also that associated with other group characteristics such as race, gender, sexual orientation, and physical disability.

Combating stigma

“There are four approaches used to combat stigma against those living with mental illness,” says Janet Currie, a health researcher who has done extensive research on anti-stigma campaigns. “The first is protest, where mental health consumers watch media, etc., identifying stigmatizing words, phrases and attitudes and bringing this to the attention of the public. The second is to organize contact with people living with mental health problems. The third is anti-stigma campaigns, which receive the most money. The fourth approach is a human rights-based method that looks at landlords, employers, prisons, etc. and is court-based—outlawing such discrimination.”

Currie says that large sums of money are put into anti-stigma campaigns which, though facilitated by government, are largely funded by pharmaceutical companies. “The underlying message is don’t be afraid to report your mental illness. This, in turn, leads to an increase in labelling which potentially can cause an increase in stigma, as stigma is contingent on labelling.” But, Currie says, the ads do not talk about the punishment that goes along with being labelled—that once a diagnosis is put in your medical record it can affect your health insurance premiums and can be used in court cases, especially separation and custody cases. “It’s a hidden discrimination. And diagnosis of anxiety and depression are quite common with women,” she says.

In Michael Smith’s book Stigma, he writes that anti-stigma campaigns tend to use three different approaches: normalization, media and social attitudes, and rights-based protest. The MHCC anti-stigma campaign to date resembles the normalization approach, which seems to be the most frequently used, with examples in England (“Beyond Blue”), Australia (“Changing Minds”) and New Zealand (“Like Minds, Like Mine”). This approach emphasizes how common mental health problems are, and asserts that people living with mental illness are “just like us,” except that they have a genetic or medical difference. This approach is based on achieving acceptance rather than equality, and it has been argued that even people who may not be “just like us,” who may, for instance, have cognitive impairment as a result of schizophrenia, deserve to be included like everyone else. 

If mental health organizations and anti-stigma campaigns were to look at the experiences of those living with severe chronic mental illnesses, such as schizophrenia, says Currie, that there would be a call for healthy and safe public housing. Instead, the call is for large sums of money to be invested in advertisements “telling people to be kinder to those living with mental health problems,” but not actually creating social and economic change for those living with the illness.

One significant finding about normalization approaches is that there is a gender difference in the effectiveness of anti-stigma campaigns.  Research has shown that women with family members or friends with depression had lower stigma scores than women who did not, but this was not observed in men.  In fact, the research shows statistical correlations in men between the belief that weakness of character is a causal factor for depression and having family and close friends with depression.  Therefore, personal contact with individuals with depression is shown to have a positive effect on stigma in women, but to have no effect in men. This is relevant to the MHCC’s anti-stigma campaign, which is repeated and direct peer-based contact with people who have experienced mental illness in the hopes of reducing negative stereotypes. If, as research suggests, this approach will only work with women, it provides a clear example of how initiatives to reduce stigma that ignore gender differences risk failing at least half of this population.

Smith writes that a rights-based approach is based on the idea that those stigmatized because of mental illness represent a group of people who are wrongfully shamed, humiliated and marginalized. We see this type of stigma applied to other minorities as well. The rights-based approach seeks to counter discrimination by monitoring and enforcing equal access to health care, housing, employment and justice. This in turn leads to practical improvements for those living with mental illness not only in daily life, but also in self-confidence and social inclusion. While this approach requires major social and economic changes, and is thus the most challenging, it ultimately leads to deeper and more permanent change. 

Clearly, to create real change and to effectively reduce stigma for those living with mental health illnesses, it is imperative to acknowledge the gender differences in the way stigma is experienced and applied. The only approach so far that seems to acknowledge this is a human rights-based approach. If gender is not addressed, an anti-stigma campaign could very well have the reverse effect—doing more harm than good for those living with mental illness.

Carolyn Shimmin is the Information Centre Coordinator at the Canadian Women’s Health Network.