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Chapter Five Gender and Mental Health

Introduction

'It will not be possible to address the needs of women and men equitably, appropriately and effectively if gender is not considered' ( DHa, 2003, p. 9)

Gender is 'fundamental to our sense of who we are, the roles we adopt, the way in which we experience and perceive others and in which they perceive us' (( DHa, 2003, p9). 'Gender' here refers to the socially, as opposed to biologically, determined characteristics of men and women. These characteristics have, historically, also been a fundamental source of inequality and discrimination.

But, while gender is a major determinant of inequality, differences based on, for example, wealth, ethnicity or sexual orientation will mean that there are also differences between men and among women.

To explore the ways in which gender is associated with mental health inequality the following sections draw on evidence illustrating the differences in the risks to mental health and well-being to which men and women are exposed, the resilience factors upon which they can draw, the patterns of mental health problems they experience and the ways in which services respond.

Unpacking the different influences and experiences will help in thinking about gender sensitive strategies for improving the mental health and well-being of men and of women, as well as for considering how services can be sensitive to gender, including different ways of experiencing recovery.

Gender and Mental Health: Some Indicators

Table 3.1 in Chapter 3 compares indicators of general and mental health for men and women in Scotland. Key mental health indicators of difference include:

• In Scotland, as in the rest of the UK (Palmer et al, 2003) mental health problems affect more women than men.
• The incidence and prevalence of depression and anxiety is higher among women than men ( ISD, http://www.isdscotland.org/isd); Melzer et al, 2001). This same pattern is consistent across ethnic groups (Nazroo, 1997; Melzer et al, 2001; Melzer et al, 2004).
• Anxiety - specifically fear of going out at night among aged over 60 is four times more prevalent among women than men; and 1.5 times more prevalent among women on low incomes as other women (Palmer et al, 2003).
• Based on community samples (Melzer et al, 2001) and hospital discharge figures ( ISD, http://www.isdscotland.org/isd) rates of schizophrenia and of alcohol and drug abuse are higher among men than women.
• In Scotland there are, however, rising levels of alcohol-related harm among women - especially among young women (Scottish Executive, 2003e).
• Suicide was the leading cause of death among Scots men aged 15-34 in 2000
  ( ISD, http://www.isdscotland.org/isd).
• Asian women aged between 15-35 years are two to three times more vulnerable to suicide and self-harm than their non-Asian counterparts (Soni-Raleigh, 1996, in Bhardwaj, 2001).

Mental Health Inequalities: Why does Gender Matter?

There are four main reasons why it is important to understand the impact of gender on mental health.

First, there are clear and consistent differences in the patterns of mental health problems experienced by men and women. For example:

• The age of onset of schizophrenia is earlier for men than for women. There are even debates around whether the forms of schizophrenia that occur in males and females are the same disorder (Piccinelli and Gomez Homen, 1997).
• Higher proportions of women experience depression and anxiety.
• Patterns of suicide and self-harm are different between men and women.
• Substance misuse is more prevalent among men.
• The prevalence of eating disorders such as anorexia nervosa is higher among women.
• The experience of perinatal mental health problems among women.

Secondly, there are differences in the distribution of the risk factors associated with mental health problems (Piccinelli and Gomez Homen, 1997). As discussed in Chapter 4 epidemiological studies have identified clear associations between socio-economic and environmental factors and mental health problems, whether as risk factors or as the social effects of experiencing a mental illness (for example, Melzer et al, 2004). What is important to understand is that these risk factors are not equally distributed between women and men. According to the Scottish Executive Strategic Group for Women: 'inequality between women and men is both a widespread and persistent feature of contemporary Scottish society' (Scottish Executive, 2003f). For example:

• Across the UK, and in Scotland, women are more likely than men to be living in poverty (Bradshaw et al, 2003): those most at risk are female lone parents and retired women living alone.
• Across all professions in Scotland there are higher proportions of women in lower grades than in higher grades.
• Across Britain, on five out of seven indicators women experienced higher levels of social exclusion than men (Gordon et al, 2000, in Bradshaw et al, 2003).
• Some studies have suggested that women experience more life events and difficulties than men (Piccinelli and Gomez Homen, 1997; Astbury and Cabral, 2000; Belle and Doucet, 2003).
• Women are at much greater risk of experiencing domestic abuse than men: one Scottish study found that domestic violence against men comprised only 6-7%
  of the incidence of domestic violence (Gadd et al, 2002).
• Estimates suggest that 20-25% of women have experienced childhood sexual abuse, compared with 5-10% of men (Scottish Executive, 2004j).

Thirdly, how men and women experience and respond to these factors are not necessarily the same.

For example, while living on a low income for an extended period can cause stress and difficulty in personal and family relationships, one study found that women were more likely than men to feel isolated and depressed by their lack of money. Younger women in particular felt the effects of social isolation. In later life, however women tend to have better social relationships and to be less isolated than men (Yeandle et al, 2003).

Women may also be more prepared to acknowledge that they have difficulties, to express these difficulties in different ways, and to seek help more readily than men (Busfield, 1996; Rogers and Pilgrim, 2003).

Fourthly, how services respond, in terms of patterns of diagnosis, care and treatment pathways may also be different between men and women. Studies have shown how clinicians have different conceptions of female and male mental health (Busfield, 1996). Access to specific treatments such as psychotherapy or anti-depressants may also be different between men and women. Women and men may also respond differently to treatments and experience different outcomes (Piccinelli and Gomez-Homen, 1997).

Given the differences in patterns of mental health problems, the distribution of risk factors, the different ways in which men and women respond to these factors and to the experience of mental distress, the following two sections look separately at the experiences and outcomes for women and for men.

Women and Mental Health: Risk Factors

Ways for explaining the pattern of mental health problems among women have taken three directions:

• Analysis of the ways in which mental health and mental health problems are defined and diagnostic labels applied.
• The social and economic status of women.
• Women's experience of violence and abuse.

It is clear, however, that no single explanation can account for women's higher rates of mental health problems overall, or the different patterns of diagnosed mental disorder between men and women (Piccinelli and Wilkinson, 2000).

Conceptual analysis

Much of the social science literature has drawn attention to, and challenged, some of the assumptions relating to women's apparent 'vulnerability' to mental health problems. It has been argued, for example, that how mental disorder is understood, the diagnostic categories used and the way these labels are applied are 'gendered' (Busfield, 1996), that is they are based on assumptions about the social roles of men and women. In effect to be a woman (or a man) can be a risk factor in itself.

Socio-economic status

Social and economic factors have consistently been associated with what have been called 'the mental health consequences of women's everyday life' (Williams et al, 1993, in Barnes et al, 2002). As already described, statistically more women are in poverty than men. Linked with this is women's experience of:

• Low income in jobs over which they may have limited autonomy and control.
• Social exclusion and social isolation (Yeandle et al, 2003).
• Being responsible for managing limited household income and debt ( EOC, 2003), within a context in which household income may not be equally shared.
• Living in communities which are themselves characterised by impoverishment, potentially providing only negative support, or resulting in 'stress contagion' or contributing to social isolation (Belle and Doucet, 2003).
• Limited autonomy and decision-making autonomy over severe life events (Astbury and Cabral, 2000); powerlessness, for example in dealing with employers, landlords and government bureaucracies (Belle and Doucet, 2003).

As primary carers women's poverty can also impact on the mental health and well-being of children. The recent Social Exclusion report describes how low household income in childhood can create cycles of deprivation ( SEU, 2004).

Social and reproductive roles

Women's social roles, particularly as primary carer for children and/or other dependants impact in a number of ways:

• Economically restricting women's opportunities for well-paid full-time work (and with implications for future pension rights).
• Through 'role overload' (Piccinelli and Wilkinson, 2000) where women undertake both employment and household/childrearing responsibilities.
• Through social isolation.

The compounding effects of poverty and role expectations are highlighted in one study of women from black and ethnic minority communities. For the women interviewed: 'Pride in the home, as good home-makers is crucial to "who they are" as wives, mothers and daughters. Therefore living in cramped, unhygienic and unsuitable conditions over which they have no control means that an essential part of who they are as "women" is negated - this results in constant stress' (Mirza and Sheridan, 2003, p. 14).

It is perhaps not surprising that marriage has been found to be more beneficial to the psychological well-being of men, than for women (Piccinelli and Gomez Homen, 1997; Mcrae and Brody, 1989, in Williams, 2002).

In addition to social roles, reproductive roles are also implicated in women's mental health. According to data reproduced in the Scottish Intercollegiate Guidelines Network ( SIGN, 2003), for every 1,000 live births, 100-150 women will suffer a depressive illness and one or two women will develop a puerperal psychosis. Unpublished data for Scotland, indicates 186 women who gave birth in 1999 had an admission to a psychiatric hospital in Scotland in the following 12 months.

Discrimination

The experience of discrimination not only contributes to poverty and economic inequality but also puts at risk mental health and well-being. Women can experience the double or multiple jeopardy of economic and social discrimination based on gender and other personal characteristics with social significance. As Zappone argues, 'disrepecting individuals based on the basis of one or two more aspects of their identity creates substantial barriers for their health and well-being' (2003). For example:

• Studies of women from black and minority ethnic communities and asylum seekers have described the day to day experience of racial harassment (Wilson, 2001; Ferguson and Barclay, 2002; Essien, 2003; Mirza and Sheridan, 2003).
• The 'double oppression' experienced by women with disabilities, including in accessing health services is described by Breslin (2003).
• A review of the mental health risks faced by women in mid life argues that inequality can impact on mental health through inequitable access to resources known to affect mental health; discrimination, exploitation and oppression; and serious abuse of power including sexual and physical abuse (Milne and Williams, 2003).
• Young lesbian and bisexual women interviewed by Loudes (2003), described the prevalence of mental health problems among lesbians and the lack of support available. Those interviewed felt that mental health problems were linked to lack of acceptance, the pressures of having to hide one's sexual orientation and the pressures from being openly lesbian.

Women's experience of violence and abuse

According to one review 'Violence against women, whether by their intimate partners
or men not known to them, is probably the most prevalent … gender-based cause of depression in women' (Astbury and Cabral, 2000, p. 65).

In Scotland, in 2002, police returned details of 36,010 incidents of domestic abuse.
In 90% of cases where the information was recorded the victim was female and the perpetrator male (Scottish Executive, 2003h). Although not specific to women in low income families, one American study found that 83% of the low-income mothers in their study had been physically or sexually assaulted in their lifetimes (Bassuk, et al, 1998, in Belle and Doucet, 2003).

Figures cited earlier also suggest that where data are available girls are more vulnerable to childhood sexual abuse and that women who have been sexually abused as children represent a considerable proportion of those requiring acute psychiatric care and treatment (Nelson, 2001). However, this experience may go undetected by health services (Nelson, 2001; Scottish Executive, 2004).

Women who are refugees or asylum seekers may have been victims of torture (Wilson, 1993, in Wilson, 2001), including sexual assault and rape.

Women in secure settings

Although not a 'risk' factor per se women in secure settings, whether secure in-patient settings such as the State Hospital or prisons, have often experienced multiple disadvantages, including experience of sexual abuse and domestic violence. According to the most recent Inspection Report for HMP and YOI Cornton Vale, for example, 80% of prisoners within the prison have a history of mental illness; over 90% of admissions have addiction problems and over 60% have a history of being abused ( HMIP, 2004).

For the period 2002-2003, women comprised just over 4% of the average daily prisoner population in Scotland. Although HMP Cornton Vale provides for the largest number, four other prisons in Scotland also accommodate women prisoners.

Women also comprise only a small minority of the State Hospital population - only 6% of the total, but have different characteristics and needs to that of the male population (State Hospital, 2002).

In a review of literature on women and secure psychiatric services Lart et al (1999) describe the key characteristics of women in secure settings:

• They make up less than one-fifth of the population in secure settings in Britain, but comprise a heterogeneous group in terms of personal characteristics and forensic and psychiatric histories.
• They are less likely to have committed serious criminal offences than men, but more likely to have experienced previous psychiatric admission.
• They have a different pattern of diagnosis to men: women are more likely to be diagnosed as having a personality disorder, or borderline personality disorder, than men.

From the views of women in secure settings, interviewed as part of the process of developing a women's mental health strategy in England and Wales, the authors obtained the impression that 'secure settings are driven by an ethos of control and containment rather than rehabilitation, and that activities for women are patients are restricted because of the needs of the male majority' ( DH, 2002).

Women and Mental Health: Resilience Factors

The WHO identifies three main factors protective against development of mental health problems, especially depression, in women (Astbury and Cabral, 2000):

• Having sufficient autonomy to exercise control in response to severe events.
• Access to some material resources that allow the possibility of making choices in the face of severe events.
• Psychological support from family, friends or health providers is powerfully protective.

Other studies have described the personal and social strategies upon which women from black and minority communities draw (Wilson, 2001; Essien, 2003; Mirza and Sheridan, 2003).

Women and Mental Health: Preventing and Responding to Risk

Mental health improvement

Barnes et al (2002) found no research that addressed issues around mental health promotion or prevention that took a gender perspective.

Responding to mental health problems

A UK-based survey by Williams et al (2001, in Williams, 2002) concludes that mental health services:

• Do not meet women's mental health needs.
• Can replicate inequalities.
• Can be unsafe for women.
• Can be insensitive to the effects of gender and other social inequalities, such as race, class and age.

Other studies have highlighted the experiences of women using mental health services:

• In their literature review Barnes et al (2002) highlight the issues for women in in-patient care including considerations of safety and security, the availability of single sex wards, and women-centred approaches to therapy and treatment.
• A study of the mental health needs of asylum seekers in Glasgow (Ferguson and Barclay, 2002) although not a specifically gendered analysis includes the experiences of women. For example, some female respondents felt strongly that they were not able to discuss their health problems - particularly their mental health problems with a male doctor, as a result these problems were not addressed. The lack of interpreting services, or the provision of a male interpreter was also experienced as distressing, particular when issues of an intimate nature were involved.
• A study of black women in Bradford concludes that 'culturally aware services that are user friendly, and personal support, would go some way toward eradicating the fear and hopelessness they encounter when in contact with mental health services, and the stigma and shame they feel from their own communities and wider society' (Essian, 2003, p. 29).
• MIND research into the experiences of lesbian, gay and bisexual people, found that only eight out of 22 lesbians, and two out of eight bisexual women felt 'safe' disclosing their sexuality within any 'mainstream mental health service' (Golding, 1997).
• Two studies found that older women could experience 'double jeopardy' based on ageism and sexism. This double jeopardy can be influential on the risks of experiencing mental health problems, but also may result in inadequate or inappropriate treatment (Padgett, Burns and Grau 1998; Curtis, 1996, in Barnes et al, 2002).

There does not appear to have been any Scotland-wide research to indicate the experiences of women with mental health problems who use services. However, in England and Wales, women consulted as part of the process of developing a strategic approach to mental health care said they wanted were services that:

• Kept them safe.
• Promoted empowerment, choice and self-determination.
• Placed importance on the underlying causes and context of their distress in addition to their symptoms.
• Addressed important issues relating to their roles as mothers, the need for safe accommodation and access to education, training and work opportunities.
• Valued their strengths, abilities and potential for recovery.

( DH, 2002a)

Men and Mental Health: Introduction

There has not been such an extensive social science or policy literature in relation to men's mental health as found in relation to women. However, as the information presented above and in Chapter 3 suggests, the mental and physical health profiles of men are distinct from those of women. Men, for example:

• Tend to experience an earlier onset of schizophrenia with poorer clinical outcomes (Piccinelli and Gomez Homen, 1997).
• Have higher levels of suicide than women, at all ages, but with particularly high rates among younger and older men ( DH, 2001; WHO, 2003; Samaritans, 2003).
• Have lower levels of diagnosed depression (Piccinelli and Gomez Homen, 1997; Singleton et al, 2001). It has, however, been suggested that men may suffer from depression just as often as women, but that it goes unrecognised and/or men are more reluctant to seek help (Real, 1997; Royal College of Psychiatrists, 1998; Rogers and Pilgrim, 2003; Miller, 2004).
• Have higher levels of substance misuse (Singleton et al, 2001; Scottish Executive, 2003). Figures for Scotland suggest that 33% of adult males, compared with 15% of adult females exceed the recommended weekly alcohol consumption (Scottish Executive, 2003e). Men also comprised 66% of new patients/clients recorded on the Scottish Drug Misuse Database in the financial year to March 2004 ( www.drugmisuse.isdscotland.org accessed 29 September 2004).
• May be over-represented in groups at risk of post-traumatic stress disorder ( www.mind.org.uk/Information/Factsheets/Men accessed 27 September 2004).

Men and Mental Health: Risk Factors

Socio-economic disadvantage

As the figures in Chapter 3 indicate, socio-economic risk factors impact differently on men and women, and also on different groups of men. For example, although proportionately more women than men are in poverty ( EOC, 2003), more men than women are unemployed (Scottish Executive, 2002c). Rates of unemployment are particularly high among men aged under 25 years, compared with young women. Homelessness and rooflessness are also higher among men than women (Scottish Executive, 2004l; Scottish Executive, 2002c).

Further, how men experience or respond to poverty or unemployment, may be different from the response of women in similar economic circumstances (Yeandle et al, 2003). Fathers and older men on low incomes, for example, may have less daily contact with friends or family than women (Gordon et al, 2000, in EOC, 2003). Unemployment in particular has been implicated as a risk factor for men. Research cited by the Royal College of Psychiatrists (1998) suggests that up to one in seven men who become unemployed will develop a depressive illness in the following six months. Reflecting this, a preliminary analysis of the characteristics of men who used the Camelon Well Man clinic in Falkirk over a sixteen-month period found that those who were unemployed were less likely to describe themselves as content, and more likely to feel anxious/stressed or depressed than men who were employed or retired (Camelon Well Man Clinics, unpub paper).

Physical health

As the figures in Chapter 3 indicate, men have a shorter life expectancy, and fewer years of healthy life expectancy than women. Men, for example, have higher mortality rates in relation to cancer, heart disease and stroke (Scottish Executive, 2002c). Prevalence rates for heart disease are higher for men than for women, at all ages ( ISD, http://www.isdscotland.org/isd). Men may also be more susceptible to some infectious diseases such as tuberculosis (Wizemann and Pardue, 2001 in Doyal et al, 2003). Men's poorer physical health takes on particularly salience, given the relationship between poor physical and mental health described in Chapter 4.

Crime and violence: men as victims; men as perpetrators

Men are more likely to commit criminal offences, and to engage in violent behaviour. Men are also the victims of abuse and violence, frequently (though not exclusively) perpetrated by other men (Scottish Executive, 2002c; Gadd et al, 2002; Miller, 2004; Scottish Executive, 2004j). For Miller (2004) this means that accounts of men's mental health, and service responses, have to acknowledge men who may be damaged by the experience of sexual abuse and violence and those with the 'capacity to harm'.

Social roles

Issues of gender roles/masculinities may also be implicated as a risk factor. On the one hand, notions of masculinity and of appropriate male behaviour may act as a barrier to men feeling able to express their feelings, or to admit to experiencing emotional/ psychological difficulties (Men's Health Forum, 2004; Miller, 2004). It has been suggested, for example, that the higher rates of suicide in young men may in part be due to their reluctance to express distress (Rogers and Pilgrim, 2003). On the other hand, it has been suggested that the perceived breakdown in traditional gender roles has left men uncertain of what is expected of them in terms of significant relationships ( www.mind.org.uk/Information/Factsheets/Men accessed 27 September 2004).

A study of depressed and suicidal young men draws attention to the ways in which different risk factors may interact: reactions to worry or upset, and the experience of violence or bullying could result in the men smashing something up, or picking fights. The depressed and suicidal groups in the study were also more likely to have been in trouble with the police than those who were not depressed. At the same time the suicidal group were significantly more likely to keep concerns to themselves - particularly where fathers were believed to want the men 'to fight their own battles' (Buchanan and McCoy, 1999).

Multiple identities; multiple disadvantage

Just as women are not a homogeneous group, so among men there are different 'masculinities' that is, differences between men based on, for example, class, age, disability, ethnicity and sexual orientation. These are also potential sources of multiple disadvantage and discrimination for some groups such as men from black and minority ethnic communities (see Chapter 6) and gay, bisexual and transgender men (see Chapter 7).

Men and Mental Health: Preventing and Responding to Risk

To begin to raise the profile of men's health, Men's Health Forum for England and Wales has published its policy programme for men's health. This argues that national and local policies and services need to recognise and address men's health issues, defined as ones arising from 'physiological, psychological, social, cultural or environmental factors that have a specific impact on boys or men and/or where particular interventions are required for boys or men in order to achieve improvements in health and well-being at either individual or the population level' (Men's Health Forum, 2004). This is clearly intended to encompass mental health and well-being.

In Scotland the Scottish Executive is funding men's health pilot projects - 'Well Man Clinics' - across Scotland. Over two years £4m will be distributed with the aim of encouraging men to take a greater interest in their health and well-being.

The National Programme for Mental Health and Well Being is funding a telephone advice line - Breathing Space - targeted at (but not exclusively for) young men suffering from low mood and depression.

Implicit in the Men's Health Forum proposals, and the men's health pilots is the need to consider the way services, including mental health services are delivered to reach and be accessible to men. Miller (2004), for example suggests that since men have a poor record as users of psychological therapy, it is important to consider creative ways of facilitating access. The Equal Minds conference workshop looking specifically at men and mental health identified five service design features for enhancing the accessibility of initiatives targeted at men's mental health and well-being:

• Accessibility and flexibility of services in terms of time, location and ethos. For example, in places with which men were familiar, providing 'Men Only' sessions with male staff, linking in with other activities, such as physical activity programmes.
• Holistic in approach, focusing not just on 'mental health', but on the whole person.
• Early intervention to engage men as anxieties and concerns build up, including the availability of, for example, stress and anger management at an earlier stage.
• Avoiding stereotyping men as unresponsive and lacking in emotional intelligence and supporting men to express their feelings and aspirations.
• Building up trust and confidence to be able to work on issues of identity and role that can underlay men's anxieties and self-perceptions or lack of self-esteem.

Gender and Mental Health Implications

Implications for policy

A number of current policy strands provide the basis upon which to further develop gender-sensitive approaches to mental health and well-being.

• Although not specifically referring to gender, Improving Health in Scotland - the Challenge, the most recent Scottish Executive health improvement strategy (Scottish Executive, 2003a) aims both to improve health for all and reduce health inequalities. The strategy focuses on four priority areas, each of which have different implications for women and for men: early years, teenage transition, the workplace and communities.
• The Framework for Mental Health (Scottish Office, 1997), which has provided the basis for service design in Scotland, includes under service principles and values reference to 'addressing the special needs of women' as one of a number of means for promoting individual self-determination. Although the gendered implications are not followed through into the service elements, policies or guidance have been developed subsequently which are either solely aimed at women's needs, for example, guidance on perinatal mental illness/postnatal ( SIGN, 2002; Scottish Executive, 2004m), or where the impact will be felt to a larger extent on women, such as guidelines on eating disorders, or the Doing Well by People with Depression initiative. Proposals have also been put forward for developing forensic psychiatry services for women ( FMHSMCN, 2004).
• The principles of non-discrimination, equality and respect for diversity, enshrined in the Mental Health (Care and Treatment) (Scotland) Act 2003, clearly have implications for acknowledging specific experiences and needs relating to gender as well as other dimensions of people's social identities. Within the Act one gender specific requirement is for Health Boards to provide, under certain defined circumstances for any woman who is the mother, or adoptive mother of a child under one year, who has been admitted to hospital for treatment for post-natal depression.

One analysis of gender and health argues that although sex and gender both impact
on health and health care, most NHS modernisation policies (as they apply to England and Wales) have been gender blind - to the detriment of both women and men (Doyal et al, 2003).

In England and Wales the response, in relation to mental health, has been to take a gendered, but women focused, approach. The strategy 'Into the Mainstream' ( DH, 2002) and implementation guide ( DH, 2003a) aim to help those 'planning and delivering services to understand better what is meant by being sensitive to the needs of women and ensure that women feel better served by the mental health care system in terms of their individual experience' (Department of Health press release, 23 September 2003). The principles on which the strategy is based are:

• Mainstreaming gender and the specific needs of women.
• Involving women.
• Taking a whole systems approach.
• Partnership and multi-agency working.
• Endorsing the role of the voluntary sector.

These principles are felt to be relevant to all age groups and to men as well as women.

Any approach taken in Scotland to further ensure gender sensitive mental health promotion and improvement and mental health service delivery might want to consider the two dimensions set out in Chapter 1 above:

• How to embed mental health within broader social policies aimed at redressing the social and economic inequalities differentially experienced by women and men.
• How to embed gender sensitivity into mental health services and programmes.

Embedding consideration of the differential mental health impacts on women and on men into other policy domains

Given the social and economic inequalities experienced by women global policies including those relating to low pay, benefits, childcare, access to employment, and community regeneration will differentially impact on women, and those social and economic factors which put at risk women's mental health and well-being ( SEU, 2004; Scottish Executive, 2003f).

In addition are those social policies which largely, if not exclusively address aspects of women's or men's experience, which may impact on their mental health and well-being for example, domestic abuse initiatives (Scottish Executive, 2000b; Scottish Executive 2003g; Scottish Executive, 2004n); initiatives for women offenders (Scottish Executive, 2002d) or young male offenders; or prostitution and trafficking (for example, the expert group on prostitution in Scotland, established in 2003).

Embedding considerations of gender within the mental health service system

This has two further elements:

i. Ensuring that programmes and initiatives for improving mental health and well-being are gender sensitive.

Issues to consider might be:

• What does mental health/illness mean for women and for men? What is well-being?
• Given the different employment patterns of men and women, what are the implications for mental health at work?
• To what extent are initiatives for tackling suicide and self harm gender sensitive?
• What does building community capacity mean for men and women?
• How can initiatives improve the mental health of younger men and women, and older men and women?
• How gender sensitive are mental health improvement programmes for children and young people?
• How do measures for improving infant mental health impact on mothers or on fathers?
• How is stigma and discrimination experienced by men and by women with mental health problems?
• What does recovery mean for women and for men with mental health problems?

ii. Ensuring mental health services are gender sensitive

This may include consideration of:

• The need for women-only or men-only services.
• Workforce development to ensure gender sensitivity.
• Issues of equality of access to responsive gender sensitive services including in terms of the times as which clinics are held, availability of child care or care for dependants, enabling people, as far as practicable/appropriate to have a clinician or carer of the same gender.
• The needs of specific groups of men and women with mental health problems such as:

Women from different black and minority ethnic communities

Men from different black and minority ethnic communities

Women with children or other caring responsibilities

Women who have experienced violence or sexual abuse

Men who have experienced violence or sexual abuse

Gay, bisexual and transgender men

Lesbian, bisexual and transgender women

Older men

Older women

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