Mind the (gender) gap…in Canada’s new mental health framework

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By Carolyn Shimmin

In January 2009 the Mental Health Commission of Canada (MHCC) released its first draft framework of a Canadian mental health strategy for public discussion. Entitled, Toward Recovery and Well-Being: A Framework for a Mental Health Strategy in Canada, the Commission held stakeholders’ conferences across the country as well as an electronic consultation on their website to get public feedback on the document. Divided into eight goals, the framework includes some good recommendations, such as a recovery-oriented mental health system in which people are able to make meaningful choices of services and supports (with a funding mechanism that allows individuals to make such choices). Though the framework appears to be a step in the right direction, one thing is glaringly apparent—as with all documents published by the Commission to date, it does not include a sex- and gender-based analysis.

Health research continues to document that sex and gender do matter—in research synthesis, policy and programs. In fact, research shows that a sex- and gender-based analysis leads to better science. Governments and research funding bodies have recognized this in their policies and practices. For example, in 2000, the federal government approved the Agenda for Gender Equality, an initiative which included new policies and programs and the accelerated implementation of commitments to include gender-based analysis. Health Canada’s commitment is expressed in the Women’s Health Strategy (1999) and Gender-Based Analysis Policy (2000). The Canadian Institutes of Health Research requires the application of a sex- and gender-based analysis on the basis that it is “good science,” ethical and essential to equity.

Most importantly, research shows that not paying attention to gender differences, or “gender neutrality,” leads to error, which in turn leads to missed opportunities, misuse of resources and poor outcomes. So why, in the creation of a national mental health strategy would the Mental Health Commission of Canada not use a sex- and gender-based analysis?

Despite the wealth of literature emphasizing the importance of examining mental health issues from a gender-based perspective, a GBA has not been reflected in recent reports on mental health in Canada. None of the large-scale Canadian reports such as the Romanow Commission’s Final Report on the Future of Health Care in Canada, 2002, the Standing Senate Committee on Social Affairs, Science and Technology’s Out of the Shadows at Last: Transforming Mental Health Mental Illness and Addiction Services in Canada, 2005, and the MHCC’s A Time for Action: Tackling Stigma and Discrimination, 2008, have involved a GBA of mental health in Canada.

Just as sex and gender matter in understanding health in general, they matter in understanding and seeking the best approaches to mental health and addiction. For example, there are sex- and gender-specific differences in the types and prevalence of certain mental health conditions. Postpartum depression is sex-specific and there is a higher prevalence of internalizing disorders such as major depression in women and externalizing disorders such as alcohol and drug addictions in men. There are also many mental health conditions which appear to be gender-neutral but are not. The onset of schizophrenia differs between men and women, with men typically developing schizophrenia much earlier than women. With the severity of schizophrenia being associated with age of illness onset, men often have more severe forms of the illness.

It has also been shown that women and men seek different types of care, with men overall less likely than women to seek help whether from professionals or from lay persons. There are also sex-specific differences in the metabolism and effects of psychotropic drugs. Research has shown that there are vital differences between males and females in the metabolism and effects of psychotropic drugs used to treat schizophrenia, depression and anxiety, which may affect clinical outcomes and costs. Research also indicates that women in North America are prescribed twice as many psychotropic (mood altering) drugs compared with men.

Gender roles in society can also have an enormous impact on mental health. The World Health Organization has found that men are far more likely than women to disclose problems with alcohol use to their health care providers. Women have more difficulty coming forward with alcohol and drug addictions because of women’s  perceived “place” in society as “people who bear and rear children” as well as the negative stereotype that women users are sexually promiscuous because of their drug use. This association is not seen in men. But men have more difficulty coming forward with a mental health problem as the characteristics of traditional masculinity including “don’t cry,” “be tough,” go it alone,” and “don’t show any emotion,” can cause men to perceive mental health problems as weakness and thus not seek out the necessary help (which explains the high rate of suicide in men and alcohol and drug addiction).

Yet, in the Commission’s 58-page framework for a national mental health strategy, gender is mentioned only once. When discussing the need for supports for family caregivers, it fails to mention that 80% of all caregivers in Canada are women, and that recent research has shown that men and women differ in both their caregiving experience (women giving more hours of unpaid care than men, traveling farther and more frequently to provide unpaid caregiving than men, performing more demanding forms of caregiving than men, and more often having responsibility for more than one care recipient than men) and their caregiving needs (research has shown that men are more likely than women to feel they have other options available to them when deciding to become a primary caregiver, and women are more likely to experience difficulties, both physical and psychological, as a result of providing care to someone diagnosed with a mental illness in particular).

When discussing stigma and discrimination against those living with mental illness the Commission’s framework does not mention that women and men both experience stigma differently and differ in their attitudes towards mental illness.

There also seems to be a misunderstanding of what gender means in the Commission’s framework—a lack of recognition that all people and populations are always gendered and that the contexts of men’s and women’s lives matter. Gender is presented as another “cultural difference” in the framework, comparing it to the difference between urban and rural settings, or different types of work. It is not acknowledged how sex and gender intersect through race, ethnicity, class, age, location, ability, sexual orientation, etc.

The effects of a lack of a sex- and gender-based analysis of poverty and homelessness can already be demonstrated in the MHCC’s homelessness project. In Winnipeg, one of the major cities participating in the project, those working and living in homeless shelters are well aware that there are more men on the streets because women are more likely to remain in violent relationships to have shelter for themselves and their children. Without a gender-based analysis, the project will never examine these different reasons why men and women are or are not on the streets.

Although the Commissioners mention that joint action must be taken to address the many social and economic factors that influence mental health and well-being, such as housing, income, education and employment, they state that they will not recommend or specify a guaranteed annual income for all Canadians, and will not make specific recommendations related to housing shortages in the general population.

The feminization of poverty will also not be examined nor issues of pay equity, all of which affect mental health. Since, on the average, women in Canada are poorer than men, the cost of mental health care services is of particular concern to women, especially for the types of services which women prefer, such as peer support groups. Although the framework recommends a recovery-oriented mental health system in which people are able to make meaningful choices amongst services and supports, and mentions a funding mechanism that allows individuals to make such choices, it does not specifically suggest that it be funded through Medicare. This raises the question: What sort of funding mechanism do they suggest?

The recent electronic consultation on the first draft of the Commission’s framework on a national mental health strategy has come to a close, and we at the CWHN hope that the Commissioners will listen to the voices calling for a sex- and gender-based analysis of mental health and addictions in Canada. If they don’t, we may end up with a system of mental health supports, services and interventions in Canada that only take into account half of the population—a system that will end up being costly not only in terms of public money, but also in terms of human lives.

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