Gender and Depression: How Structural Influences and Gender
Stereotypes Affect Depression Rates
by Cassidy Clark and Rachael Van Pelt
According to The Encyclopedia of Women in Today’s
World, women are twice as likely as men to experience depression sometime
in their lives, at a rate of one in four women (Bueskens 2011). The
reasons behind this significant disparity are debated: popular understandings
of depression in Western society blame hormones and genetics, a view
perpetuated by the medical community. However, feminists have challenged this
view, contending that there are other societal and structural factors that play
into the higher rates of depression in women. We argue that the particular pressure
that communities place on women to fill the stereotypical role of feminine,
‘good’ woman can lead to the observed higher rates. Other stereotypes about
women, especially how women deal with their emotions, what emotions are
acceptable for women to display, and historical understandings of
hysteria further tie women and mental illness together. Due to these
connections, we must critically examine the Diagnostic and Statistical Manual
of Mental Disorders (DSM)’s criteria for depression and ask if the symptoms
identified are truly gender neutral. Understanding the interplay between
stereotypes and mental illness leads us to question the objectivity of science:
due to the potential for individual scientists to incorporate their personal
gender biases into their work and the power that science has in defining
normality, we conclude that analyzing depression from a purely biological
perspective means missing other factors that can influence depression and rates
of depression diagnosis. In order to understand the influence of gender upon
depression, we must analyze how science, stereotypes and mental illness are
connected.
As an illness with ties to other disorders like anxiety
and Post-Traumatic Stress Disorder, growing rates of depression have worried
mental health professionals and have lead to inclusion of its symptoms in the
DSM (Bueskens 2011). Depressive episodes are characterized by: “a depressed
mood most of the day”; “diminished interest and pleasure in all our most
activities”; “feelings of worthlessness and excessive guilt”; “agitation or
psychomotor retardation”; and other symptoms relating to weight and sleep
pattern changes (“Managing Depressive Symptoms”). Although these symptoms are
not restricted to certain genders, the “experience” of depression may be
different: while women “report higher levels of anxiety, sleep troubles, and
physical problems”, men are more disposed to ‘ignoring depressive symptoms”,
through continual involvement in enjoyed activities or abuse of drugs and
alcohol (Bueskens 2011). The experience and prevalence of depression is also
altered by factors of race, age, and location. Although the average rate
is one in four women, rates vary widely between various groups and depend on
whether or not men are included: for example, three percent of the general
Japanese population feel depressed at some point in their life, compared to
about seventeen percent of Americans (Jacquot & Knack 2009).
Popular perceptions of the causes of depression center
mainly on genetic and biological factors. The National Institute of Mental
Health’s website about depression highlights these elements under the “Causes”
section of their webpage. The NIMH is a government organization that supports
research on and education about mental health issues and their website presents
itself as a resource for people who want to know more about various disorders.
Their page on depression includes the subtopics “What is Depression,” “Causes,”
“Signs and Symptoms,” “Who is at Risk?,” “Diagnosis,” “Treatments,” “Living With,”
and “Clinical Trials” (“Depression”). Under each heading, the organization
adopts an educational and medical stance on the topics. Under the “Causes”
section, the organization states that “depressive illnesses are disorders of
the brain” and goes on to discuss magnetic resonance imaging and genetics
research. It includes two brief sentences at the end of the section about how a
stressful “trigger” such as a traumatic life event may bring on an episode of
depression, though that there is not always a trigger. The main focus of the
NIMH in regards to depression is on how biological factors affect mental
health. They explicitly state that “longstanding
theories about depression suggest that important neurotransmitters—chemicals
that brain cells use to communicate—are out of balance in depression” and offer
that theory as an explanation to the public, along with the theory that women
might experience depression more often than men because of “the cyclical rise
and fall of estrogen and other hormones” (“Depression”).
This focus on biological causes is also evident on the
NIMH page entitled “Women and Depression: Discovering Hope.” The organization
dedicates an entire webpage to depression in women, devoting a large portion of the page to the various causes of depression
they consider important specifically for women, which are “Genetics,”
“Chemicals and Hormones,” “Premenstrual Dysphoric Disorder,” “Postpartum
Depression,” “Menopause,” and “Stress.” Here again, the institute primarily
discusses biological and hormonal related explanations for depression, focusing
on the possibility that a family history of depression can increase risk for
development and the way that hormones change drastically around life events
exclusive to women, like menopause and pregnancy. These hormone changes may
affect the way that the brain works, which is another area of research (“Women
and…”). Even under the “Stress” heading, the website discloses that it is
unknown why traumatic events trigger depression in some women but not others.
Furthermore, this section mentions that “additional work and home
responsibilities” contribute to stress that women may feel, but fails to
connect these responsibilities to expectations for women: the idea that these
extra stresses and expectations are directly a result of being a woman, rather
than isolated instances, is where we begin our analysis. Overall, the page
focuses on biological factors specific to women that the NIMH claim to be the
most relevant causes of depression.
The focus on hormones and biology as primary sources for
depression is not constrained only to this government website: an analysis of a
popular advertisement for the antidepressant Cymbalta reveals the same sorts of
claims. In the television commercial a woman’s body is displayed on screen with
a glowing central nervous system while the narrator explains how the drug
“works on serotonin and norepinephrine,” two hormones connected with mood
(“Cymbalta…” 2011). Within the advertisement, no mention is given of other
causes or contributors to depression (unsurprising, given that the goal of
commercials is to sell their particular product). Given the authority of a
government organization and constant exposure to advertisements from
pharmaceutical companies, popular perceptions of depression in women are shaped
by the two sources discussed here:
 |
| (Figure 1: Cymbalta Ad) The visual of a body’s nervous system and brain being changed by these chemicals emphasizes the importance of hormones in causing depression. |
Instead of focusing on the biological basis for
depression, feminist scholars often concentrate on structural and societal
factors when exploring the possible reasons for the disparity between rates of
depression in men and women. Beyond factors like poverty and abuse that
disproportionately affect women and can contribute to rates of depression
(Bueskens 2011), a pervasive cause that affects all women is society’s
expectation of women to fill a stereotypical role. As doctors, researchers, and
the public increasingly choose to look at depression on a case-by-case basis
rather than as an overarching, society-plaguing problem with patterns, they
“individualize” depression (Clarke 2007, 366). As a result, Clarke states, the
biological understanding of depression advanced by medical profession overlooks
the power dynamics and gender roles that affect depression and cause women to
suffer from the illness at higher rates. Clarke observed a support group for
women with depression and came to the conclusion, after analyzing what the
women said and how the community atmosphere helped them, that while biological
factors can contribute to experiencing depression, there are many other factors
at play, which are succinctly summarized in the following figure.
 |
| (Figure 2: Clarke 370) |
While Clarke finds that “individual
factors,” including biological elements, play a role in depression, they are
just one part of the whole picture: the largest, unifying category that
connects all women is called “society” and contains the expectations of
femininity that lead to the many destructive stereotypes about women. Clearly,
according to Clarke, there are overarching, structural aspects of society that
cause women to be more likely to experience depression than men.
Two other feminist
scholars, Josephine Tan and Patricia M. Ulbrich explore this idea through two
specific feminine stereotypes. Tan looks specifically at the ideal of women
being non-confrontational and selfless and makes similar arguments to those of
Clarke in her article, “Self-Silencing, Anger, and Depressive Symptoms in
Women”. The central tenet of Tan’s argument is that the higher rates of
depression in women are “because of their greater tendency to self-silence in
intimate relationships in order to preserve harmony and the relationship and to
adhere to the traditional female role” (Tan 2008, 6). “Self-silencing” refers
to the idea that women tend to hide their true feelings from others, leading to
“feelings of anger and self-condemnation that can lead to heightened vulnerability
for depression in some women” (Tan 2008, 6). One stereotype of women is that
they not get upset or angry and “self-silencing” satisfies this societal
expectation, through women not expressing this anger. In the study she
conducted, Tan discovered that the women experiencing the most severe forms of
depression were most likely to report “greater anger expression, anger
suppression and self-silencing” (Tan 2008, 13), indicating that they were more
likely to have hidden their true feelings of anger from others until they
eventually had to express that anger. The study discusses how the women who
experienced more severe depression “ascribed more to the traditional female sex
role” (Tan 2008, 13) by attempting to be the ultimate, caring, selfless wife
and/or mother. These women were deeply affected by the expectations of society
(indicated by Clarke) that they be caring, non confrontational, and passive and
consequently, felt greater distress when they perceived themselves as failing
to fit their prescribed role. Tan stresses that more attention should be paid
to the structural factors that contribute to depression in women specifically
and investigates the influence of such factors on depression by working with
one particular female stereotype.
The stereotype that
Ulbrich addresses through her study differs from Tan’s: her examination of two
income marriages connects to the image of women as dependent on men.. In her
article “The Determinants of Depression in Two-Income Marriages”, Ulbrich
investigates how women (and men) in two-income marriages react to the ‘nontraditional’
family structure in which they participate. Although the general attitude of
society towards this issue at this time of this study (1988) was probably less
progressive than it is now, the idea that women’s work is less valuable is
still prevalent in current society and so Ulbrich’s work is still relevant. She
discusses the reality of how men often resent the fact that their wives work
and studied several particular factors in each observed marriage: “husband’s
attitude toward wife’s employment, husband’s perceived attitude, and wife’s
orientation to work” (Ulbrich 1988, 126). This study concluded that, for women
who had low earnings, their husbands tended to oppose their employment and they
also had higher instances of depression, which indicates that the value of
women leaving their traditional place at home is determined by their earnings
and that the husbands opinions on the wife’s employment affected the wife’s
mental health. The most important factor, however, that Ulbrich determined in
predicting depression in women was level of education, a factor closely
correlated with social status: it appears from her study that women of higher
social status had husbands who supported their employment. From this, we can
understand how the topic of depression in women is an intersectional issue and
how feminists choosing to look at it through various lens and taking into
account various social and power structures helps gain a better understanding
of how certain stereotypes are applied to certain women. Ulbrich’s work
illustrates how women are expected to be the passive subjects at the bottom of
the social hierarchy, something that not all women want to be. As seen in these
three studies, depression often stems from women conforming to expectations
unhappily. Society puts massive amounts of pressure on women to be “feminine”
which often means being a caretaker, being subservient to a man, and being able
to gracefully handle all responsibilities without making a fuss. This pressure
is so strong that even if a woman wants to deny these expectations, society has
ways to force them, by humiliation or rejection, to comply.
Stereotypes continue to be important factors not only in cases of
depression, but also within understandings of mental disorders: feminists have
analyzed the history of mental illnesses and the criteria used to evaluate
them, arguing that psychoanalysis has historically focused on women and that
symptoms associated with many disorders are connected with ideals and
stereotypes of femininity. As a result of this conceptualization of mental
disorders, women have been inclined to be diagnosed with such an illness at
much higher rates. In Hystories, Elaine Showalter traces the
history of ‘hysteria’, a term that “throughout most of its medical
history...has been associated with women” (Showalter 1997, 15). Although
the term hysteria would not be found in the DSM today, “many of its traditional
symptoms were reclassified as anxiety neuroses, obsessional disorders, manic
depression, or borderline personality disorders” (Showalter 1997, 17). As
scientists in the eighteenth to twentieth century attempted to discern the
causes of hysteria, these male professionals often blamed female reproductive
organs and identified symptoms of this illness as stereotypical qualities of females
(Showalter 1997, 15-17, 21, 33). For example, Charcot defined hysterics as
those who were “vain and preoccupied with their appearance, deceitful and
self-dramatizing”, all traits associated with women (Showalter 1997, 34). More concerning though are the political
dimensions of this connection of femininity and hysteria: Showalter states that
“doctors viewed hysterical women as closet feminists who had to be reprogrammed
into traditional roles, and politicians attacked feminists activists as closet
hysterics who needed treatment rather than rights” (Showalter 1997, 49). As
women continue to be diagnosed more often with mental illness, accusations of
madness will continue to threaten women’s claims and arguments. Although many
of the pioneers Showalter discusses have passed away and the medical profession
has moved on, their findings and prejudices continue to be powerful; Sigmund
Freud, possibly the most famous psychoanalyst in history, “relied on cultural
myths of masculine and feminine identity in shaping his interpretation of
hysteria” (Showalter 1997, 44). As long as the stereotypes associated with
gender continue to affect those in charge of shaping diagnostic criteria, the
association of women and madness will be perpetuated.
Furthermore, feminists continue to critique the Diagnostic and
Statistical Manual for Mental Disorders, arguing that it both ignores external,
societal factors as the causes of illness and that a gender bias is evident in
the symptoms linked to many of the disorders. Feminists have realized
that as the DSM is revised, “the biomedical view has become more firmly
entrenched, reducing the stated influence of social and psychological theories
on the causes of mental illness” (Becker 2001, 336). This trend is problematic:
in the case of depression, we have already observed how an individual’s
experiences and the expectations placed upon them can affect their likelihood
of developing depression. Other mental illnesses have also been connected with
external events or influences that cannot be accounted for through a purely
biological perspective. An understanding of mental illness as purely
internal also risks “[denying] the very real social problems that women face” (Becker
2001, 336), a problem that is connected with the historical practice of
“[ridiculing] and [trivializing] women’s medical and political complaints”
(Showalter 1997, 8). Again, the political and social power of associating women
and mental illness is evident.
Through analyzing current critiques of diagnostic
criteria for several other disorders more commonly seen in women, we can work
to scrutinize the DSM guidelines for depression. As the DSM has been
revised and reshaped, continual appeals for certain disorders to be redefined
or to be taken out entirely have had varying levels of success. Premenstrual
dysphoric disorder (PMDD) is still included within the DSM, despite outcries
from feminist that “the institutionalization of a natural female bodily
function as a mental disorder” contributes to the idea of women as “mad”
(Becker 2001, 335). In other cases, like those of several personality
disorders, feminists push for diagnostic criteria to be changed due to the
gender bias incorporated into the terminology and symptoms used within the DSM.
Masochistic personality disorder (also known as self-defeating personality
disorder) has been a site of controversy, as feminists argue “against labeling
some women disordered when they display the same selfless, self-abnegating
behaviors widely encouraged in the socialization of girls” (Becker 2001, 335).
Women are expected to defer to others’ wishes, be kind and act courteous, while
men are not typically associated with these traits; consequently, women more
often have to suffer the stigmatization of being labeled with this mental
illness. Considering Dependent Personality Disorder (DPD), a similar issue
arises; feminists have observed that “the criteria of DPD exclude the kinds of
stereotyped expressions of male dependency that may be expressed in jealous,
controlling behavior”, and rely upon symptoms of dependency typical of women (Becker
2001, 339). Not only does this bias reflect dependency as “unhealthy” in women,
but the example of DPD also reinforces the consequences of ignoring external
influences and trivializing women’s complaints. Becker states that current
definitions of DPD encourage the idea that “when [dependency] is expressed in
an extreme form in women it primarily reflects dysfunction, as opposed to
reflecting the actual power differences between men and women that may
contribute to dependent behaviors in some women” (Becker 2001, 339). There are
real consequences to this gender bias: being diagnosed with a mental illness
(including ones like Borderline Personality Disorder, that are more often found
in women) can lead to being discredited in judicial settings, being stripped of
the ability to make decisions about your body, and being subject to the stigma
associated with disability (Becker 2001, 341). Gender bias and stereotypes
found in the DSM is connected to historical understandings of women as
‘hysterical’ and continues to shape political and social impressions of women.
Judith Butler, in her work, “Performative Acts and Gender
Constitution,” introduces the idea that gender is constructed through the
repetition of certain acts. She asserts that “gender identity is a performative
accomplishment compelled by social sanction and taboo” (Butler 520). Feminists
believe that the different genders are not automatically present at birth, but
that society imposes them upon us and punishes us through a variety of means if
we do not comply. There are two points relating to Butler’s work that we would
like to make in our discussion of the higher rate of depression in women than
in men. The first comes in when analyzing the feminist scholars’ arguments
about how societal pressures lead women to become depressed. We believe what
they mean is that they have been sanctioned, as Butler would describe it, and
feel that they cannot act the way they would like. Due to the necessity of
complying with certain gender norms, women feel the need to perform in a
certain way and, in turn, suppress their true desires. This suppression caused
by societal pressures is, the scholars say, a factor in causing depression in
women. Both in simply observing the world around us and in looking at Clarke,
Tan, and Ulbrich’s research, it is not difficult to see the various ways that
women have to perform their gender in certain ways and possibly forego some
desires or behaviors that diverge from the standard. In the case of causing
depression, many women experiencing the illness attribute it to having to live
up to expectations. We think that one woman in Clarke’s study put it best:
‘Part of being depressed
is obviously how you feel about yourself but that also comes from society . . .
me thinking I have to be thin, I have to have a boyfriend, I have to have a
family. Part of me feeling happy is me realising that I don’t have to do any of
that ... I’m ok as who I am ... having clarity about what makes me happy . . .
skills to be comfortable in my own skin.’ (Clarke 2007, 376)
The woman who made this
comment is really talking about how society expects her to perform her gender
in a certain way, i.e. by “[having] a boyfriend” or “[having] a family,” which
are considered socially acceptable ways to express femininity.
The second point we would like to highlight pertains to the gender
bias in the DSM criteria for diagnosing depression. If men and women are
socialized to perform their genders in certain and divergent ways, as Butler argues
that they do, then why would their expressions of depression be the same? It
makes sense that men often will not fit into the diagnostic criteria because
they, in most cases, would have been punished for revealing the emotions
necessary for a diagnosis (while women are often socialized to display more
emotionality and, thus, would fit the criteria when facing depression). In
western society, men are expected to be brave and strong and unwavering, not
emotional. The DSM requires certain factors to exist for a diagnosis of
depression, and it might simply not be recognized in men if they do not
outwardly express these factors. However, the reason for the phenomenon of men
not expressing these factors might not be that they are not experiencing
depression, but that their expression of it is different from how it is
outlined in the DSM because they have been socialized not to act certain ways.
It is not that men never feel “worthless” or “guilty,” (“Managing Depressive
Symptoms”) diagnostic criteria set forth by the DSM, but that they might not
express these feelings in the same way as women and thus might not be diagnosed
with depression.
Understanding the potential for bias within DSM criteria for
depression leads us to a better appreciation for the influence of the medical
community and biological sciences upon our daily lives, but also brings up the
uncomfortable reality of the amount of authority society gives them. Despite
the power given to science, it does not objectively capture the whole picture of
how our bodies and minds work: the ‘truths’ of science are affected by
scientist’s individual biases and opinions and shape what is considered normal
within society. The medical community has perpetuated traditional gender roles
and behaviors, not only in the arena of mental disorders, but also in
narratives describing the reproductive process. In “The Egg and the Sperm”,
Emily Martin chronicles the continual association of a female’s egg with
passivity and the male’s sperm with aggression despite new evidence that the
egg plays an active role in reproduction; although research has indicated that
previous understandings of reproduction were flawed, “researchers who made
[this] discovery continued to write papers and abstracts as if the sperm were
the active party who attacks, binds, penetrates, and enters the egg” (Martin
1991, 493). Instead of science operating in an objective space, “the picture of
egg and sperm drawn in popular as well as scientific accounts of reproductive
biology relies on stereotypes central to our cultural definitions of male and
female” (Martin 1991, 485). How the egg and sperm function reflects back upon
female and males’ own gender performitivity: the stereotypes associated with
gender are transferred to the act of conception and the language describing it
changes as a result. Similarly, in the case of the DSM, the language describing
symptoms of depression (especially the focus emotions and moods) reflects the
influence of gender roles upon science and emphasizes that the biases of the
people who write the books and manuals affects everyone’s understanding: as
women are expected to perform their gender by being emotional and if these symptoms
are the only ones listed, depression and other mental illnesses will only be
identified in women. Future research is also affected as standard manuals like
the DSM “[set] out a template for new knowledge that shapes which scientific
questions will be asked and which will be overlooked” (Becker 2001, 336).
Recognizing and working to end acceptance of gender stereotypes within the
scientific community will have an effect on future scientific investigations,
which is vital if we hope to end the association of women and mental disorders.
Furthermore, the ability of science to rewrite normality
and acceptable behavior has consequences for all. By defining increasing
numbers of behaviors as indicators of a mental illness, we risk viewing
“problems of living and the distress associated with them...as diseases rather
than as behavior that is transactional or socially deviant” (Becker 2001, 334).
Showalter also asks “Can we redefine hysteria in a way that allows more space
for the mysteries of human emotions?” (Showalter 1997, 11). Science is
another part of our culture which assists in characterizing normality which in
turn influences stereotypes. In “The Sex/Gender Perplex”, Anne Fausto-Sterling
provides a history of the classification and understanding of intersex
individuals to argue that both sex and gender are constructed. Since such
individuals display internal and external signs characteristic of both males
and females, doctors did and continue to “base their assessment of sexual
identity on the overall shape of the body and the inclination of the patient” (Fausto-Sterling
200, 640) and if the patient’s body falls outside what is considered normal,
surgery ensues. The decision of assigning a male or female sex is not purely
based upon scientific understandings: when identifying a child as female,
“despite published medical information showing a range of clitoral size at
birth, doctors may use only their personal impressions to decide that a baby’s
clitoris is ‘too big’ to belong to a girl and must be downsized” (Fausto-Sterling
200, 644). Thus, normality for a certain gender can be shaped by individual
doctors with their own biases; this conclusion can be extended to our
understanding of mental disorders as well. Mental illness is a way of marking
behaviors or thoughts as ‘wrong’ and through constituting incorrect behaviors
(or gender performances) as symptoms of a disorder, the medical profession
marks certain behaviors as right. This, in turn, shapes our societal
understanding of stereotypes for each gender and discredits those who fall
outside the ‘right’ parameters. As we investigate mental disorders, we must be
cognizant of the impact of defining these illnesses on everyday conceptions of
normality and the effects on individuals who do not fit into those
representations.
In order to gain a more comprehensive understanding of
depression and its higher prevalence among women, feminists must continue to
investigate and popularize the other societal and structural factors that
contribute to its development and bring to light the severe consequences of
enforcing strict gender stereotypes. Interested individuals must be wary of how
gender stereotypes affect the diagnostic criteria used to evaluate patients and
must consider this bias within their research. By connecting gender stereotypes
to women’s depression experiences, historical and current definitions of mental
illness, and science’s ability to constitute normality, we can begin to
understand the complex ways that gender interacts with society and stereotypes.
Becker states: “When human problems are viewed as illnesses, the values,
beliefs, and politics that influence clinicians when they make diagnoses are
concealed behind the mask of a purportedly neutral and objective science” (Becker
2001, 335). In order to determine some sort of truth about what depression is,
and if it truly affects women at higher rates due to biology, gender
stereotypes, or for structural reasons, we must uncover this mask and
critically analyze the institutions and professions that define it.
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