Ebook Clinical manual of cultural psychiatry (2/E): Part 2

7
Cultural Issues in Women’s
Mental Health
Lisa Andermann, M.Phil., M.D., FRCPC
Kenneth P. Fung, M.D., M.Sc., FRCPC

I

t is of key importance that a clinical manual of cultural psychiatry include
a chapter on women. As is emphasized throughout this volume with the
DSM-5 Outline for Cultural Formulation (OCF) format, one’s cultural identity focuses on not only ethnicity, race, and migration but also both biologically determined sex and culturally determined gender roles (American
Psychiatric Association 2013). Tseng (2003) writes that “even though the
Earth’s population is composed half of men and half of women, differences in
treatment between men and women have perhaps existed from the beginning
of the history of humankind” (p. 382). Of course, if women also belong to a
socially marginalized group, they may be subject to double discrimination.
Along with biological differences, experiences of unequal treatment, sociocultural discrimination, sexual harassment, and gender-based violence are all im287


288 Clinical Manual of Cultural Psychiatry, Second Edition

portant factors in the social determinants of women’s mental health
(Andermann 2006, 2010; Blehar 2006; Vigod and Stewart 2009; World
Health Organization 2000, 2009).
Women’s mental health has come into its own over the years as a subspecialty in psychiatry. In this chapter, we take a life cycle approach to explore
some of the cultural issues related to women’s mental health across the life
span: from birth through childhood and adolescence, adulthood and childrearing years, and aging. We trace some of the important historical developments in the women’s movement in North America and internationally and
how these have shaped the field of women’s mental health. Finally, we present
two cases, one with video vignettes using the OCF and information obtained
by use of the Cultural Formulation Interview (CFI), to illustrate how taking
women’s cultural identity and biology into account can shape assessment and

treatment recommendations. The use of a trauma-informed approach is also
an important component of this work.

Women’s Mental Health and the Women’s
Movement: A Brief History
From the earliest days of the history of medicine, Hippocrates’ theory of the
“wandering uterus” linked women’s sexuality to emotional instability because
the uterus was thought to be able to detach itself and wander around the body,
attaching itself to other organs such as the heart (causing chest pain) or the
stomach (causing gastrointestinal problems) and leading women to become
“hysterical” (Meyer 1997). The treatment was therefore to “anchor” the uterus
through pregnancy or through keeping the uterus moist via intercourse so that
it would remain in place. Many other explanations and cures can be found in
writings throughout the Mediterranean world over the following centuries
(Allison and Roberts 1994; Rodin 1992). Theories around women’s emotional
instability survived up to the late 1800s and have had a great influence over the
development of women’s reproductive rights. The term hysteria has almost
completely disappeared from the psychiatric literature, which has now evolved
to describe somatization and medically unexplained symptoms, and falls under the realm of psychosomatic medicine, at the borderland between medicine
and psychiatry. Histrionic personality disorder would be the equivalent description in DSM-IV-TR (American Psychiatric Association 2000) Axis II pa-


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289

thologies, with close links to the other Cluster B disorders, including
borderline personality disorder, and it is maintained in DSM-5, although
without the multiaxial system (American Psychiatric Association 2013). Interestingly, the term hysterical has remained in use as a colloquial, often pejorative, word used to describe a state of emotional excess and loss of control.
Whereas first-wave feminism of the late nineteenth and early twentieth

centuries in Europe and North America focused on women’s suffrage (the
right to vote), second-wave feminism of the 1960s and 1970s addressed a
broader range of issues, including legal and workplace inequalities, family
norms, sexual rights, and reproductive rights (Wood 2010). The development
of an oral contraceptive pill, as championed by Margaret Sanger, led women
to experience their sexuality without risk of becoming pregnant. In Boston,
Massachusetts, the Women’s Health Collective would go on to publish Our
Bodies, Ourselves, a groundbreaking manual of women’s health matters. The
book is now celebrating its forty-first anniversary, and it details how women
can take care of themselves and reduce the power differential in the physicianwoman relationship (Boston Women’s Health Book Collective 2011;
www.ourbodiesourselves.org).
In a chapter titled “Women’s Mental Health: From Hysteria to Human
Rights,” Astbury (2006) links the recognition of gender, women’s social position, and awareness of the effect of violence toward women arising from development of second-wave feminism as increasingly important determinants
of women’s mental health. She argues that in order to explain higher rates of
common mental disorders in women such as depression, anxiety, and posttraumatic stress disorder, “a model of women’s mental health is required that
moves beyond brain chemistry and biologic factors. At the very least, it is necessary to include events and experiences that themselves alter brain chemistry
and activate biologic stress mechanisms that, in turn, potentiate poor mental
health and damage self esteem” (p. 378). Research has shown that these childhood stressors, often related to psychological trauma and dysfunctional attachment relationships, may have lifelong effects not only on mental health
but also on physical health (Bremner et al. 2010; Bureau et al. 2010; Felitti et
al. 1998).
During the height of the women’s movement in the mid-1970s, Judith
Herman (1992) began her career in the study of psychological trauma, leading
to the groundbreaking book Trauma and Recovery. She writes:


290 Clinical Manual of Cultural Psychiatry, Second Edition

[C]linicians know the privileged moment of insight when repressed ideas,
feelings and memories surface into consciousness. These moments occur in
the history of societies as well as in the history of individuals. In the 1970s, the

speakouts of the women’s liberation movement brought to public awareness
the widespread crimes of violence towards women. Victims who had been silenced began to reveal their secrets….We began to receive letters from women
all over the country from women who never before told their stories. Through
them, we realized the power of speaking the unspeakable and witnessed firsthand the creative energy that is released when the barriers of repression and
denial are lifted. (p. 2)

Through her work, Herman compares and contrasts the experiences of
battered women, child abuse and incest survivors, war veterans, and prisoners
of war. In her approach to healing from the effect of trauma, she emphasizes
the importance of restoring connections between public and private worlds,
individuals and communities, and men and women.
We are currently in the midst of the third wave of feminism, which is more
diffuse than previous movements and inclusive of women of color from a diversity of backgrounds and ethnicities, including a global emphasis that includes the developing world; sexual orientation; abilities and disabilities; class
backgrounds; and appearance, including body types (Wood 2010). This is a
welcome development that allows for discussion of heterogeneity of culture
and identity differences between women of all backgrounds. Lu et al. (1995)
described this as “gender identity issues [interacting] synergistically with ethnic identity to shape one’s cultural identity” (p. 488), with resulting implications for assessment and treatment. Issues of sexual orientation (lesbian, gay,
and bisexual) also become important here but are more fully explored in
Chapter 8, “Sexual Orientation.”
Overall, the entire spectrum of the women’s movement is described as “a
collage of many movements that spans more than 170 years and include a
range of political and social ideologies” (Wood 2010, p. 94). Many countercurrents and backlash antifeminist responses are also made by women who
may prefer a return to hearth and home or another destiny of their own making. As with all other aspects of cultural identity, a woman’s position on these
issues cannot be presumed. In terms of clinical assessment, how a female patient identifies with the women’s movement shapes her cultural identity, ex-


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291

pectations, and life choices, and eliciting this knowledge can entail a complex
discussion that should be explored in treatment (see Table 7–1).
The concepts of gender, social position, and human rights, and how they
interrelate, are seen as an integral part of understanding the origins of, and
possible solutions for, inequalities in women’s health. Level of education, income, legal protections and freedoms, and social and professional opportunities are important measures of a woman’s rights in society. However, these can
be grossly affected when “gender based violence forces submission at an individual level, and, by engendering fear, defeat, humiliation and a sense of
blocked escape, or entrapment, it reinforces women’s inferior social ranking
and subordination in the wider society” (Astbury 2006, p. 385). In Gender
and Its Effects on Psychopathology, Frank (2000) writes:
Gender and gender role appear to be key determinants of the kind of psychosocial experiences we have, particularly the kind of experiences that many psychopathologists regard as related to psychiatric symptoms and syndromes.
Men are rarely raped. Except for a tiny fraction of cultures in the late 20th century, women have rarely been exposed to combat. (p. xv)

Of course, this may be an overstatement because many men experience
sexual abuse, particularly in childhood. Focusing on ensuring human rights
for all, then addressing related issues such as demoralization, devaluation, and
loss of autonomy, is needed to rectify these social imbalances.
Even within the culture of medicine in which we practice, there is a very recent history and, some would argue, ongoing existence of a glass ceiling where
women are not given equal opportunities, mentorship, and promotion in academia and positions of authority. Although medical school classes are now
composed of equal and sometimes greater numbers of female students than
male students, these ratios are not observed at the faculty level. Numbers of
women in Canadian medical schools have risen from 14.3% in 1968/1969 to
57.7% today (Sheppard 2011). In the United States, the gender breakdown of
medical school applicants and enrollees is 53% male and 47% female, with an
increase noted among minority applicants (American Association of Medical
Colleges 2010). However, it was not until the 1980s that women rose to positions of leadership in mental health professional societies, with Dr. Judith Gold
becoming the first woman president of the Canadian Psychiatric Association in


Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history

Sample questions

Comments

Cultural formulation

Has your gender affected you in
any of these areas (education,
income, etc.)?
How do you balance your
professional identity with your
identity within the family/
relationship?
How is your role valued as a woman
in your 1) culture, 2) family of
origin, 3) current family? (Ask
during the social or
developmental history.)

These areas are highly influenced
by sociocultural factors.
Educating women is one of the
main strategies in poverty
reduction and improving family
health in developing countries.

Cultural Identity
Cultural Stressors/Supports

Identifying data

Level of education, income,
social opportunities,
professional opportunities

292 Clinical Manual of Cultural Psychiatry, Second Edition

Table 7–1.


Table 7–1.

Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)
Sample questions

Comments

Cultural formulation

Screen for premenstrual
dysphoric disorder.
Some cultures have prohibitions
against contact with menstrual
blood, believing it to be unclean
(e.g., Orthodox Jewish women
need to bathe in the mikvah
[ritual bath] every month after
menses to cleanse themselves).
Menopause can be interpreted
differently in various cultures,

with some critics asserting that
there is medicalization of this
phase of life in Western
medicine.
Postmenopausal women in some
cultures have traditionally
gained status as a matriarch
with influence (e.g., nai-nai in
Chinese, nonna in Italian, and
bubbe in Yiddish: terms for
grandmother).

Explanatory Model

History of present illness (where relevant)

Menstrual issues

Have you noticed your mood
being cyclically affected by
seasons, weather, or your
menstrual cycle?

Women’s Mental Health

293


Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)

Sample questions

Comments

Cultural formulation

Women’s fertility is highly
valued in many cultures, even
in many male-dominated
cultures.
Infertility can lead to great
distress and a sense of failure.
Even after children are born,
hysterectomy for medical
reasons may have
psychological repercussions
and may not be culturally
accepted.

Explanatory Model
Cultural Stressors/Supports

History of present illness (where relevant) (continued)

Fertility issues

Have you ever experienced any
fertility issues? What was the
effect on you and your family?
Have you had any obstetrical or

gynecological surgeries,
including female genital
mutilation? How do these affect
you?

294 Clinical Manual of Cultural Psychiatry, Second Edition

Table 7–1.


Table 7–1.

Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)

Body image concerns

Cultural formulation

Are you satisfied with your
appearance and weight?
Have you had any procedures that
altered your appearance?
Ask screening questions for eating
disorders.

Ideals of beauty and appearance
Explanatory Model
are culturally dependent, and
Cultural Stressors/Supports

physical appearance is often
linked to a woman’s self-esteem.
Globalization has led to a spread
of Western ideals about
appearance. This has been
linked to the rise of certain
types of eating disorders as well
as cosmetic medical procedures
such as breast augmentation
and Asian blepharoplasty
(“double eyelid surgery”).
Historically, foot binding, corsets,
neck rings, and other types of
disfiguring procedures have
been used to enhance physical
appearance in different
cultures.
Medically necessary procedures
such as mastectomy for breast
cancer also can have great
cultural and psychological
significance.

295

Comments

Women’s Mental Health

Sample questions

Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)
Sample questions

Comments

Cultural formulation

Expectations about household
routines are highly culturally
determined, yet the routines
often largely fall on women’s
shoulders. Depending on the
culture, this may also be
accompanied by a sense of
mastery and control over
household matters.
In many cultures, there may be
expectations that in-laws live in
the home to help out or be
cared for themselves.

Cultural Stressors/Supports

History of present illness (where relevant) (continued)
Household/child care issues

Who has the responsibility for

household chores and child care?
How are they shared?

296 Clinical Manual of Cultural Psychiatry, Second Edition

Table 7–1.


Table 7–1.

Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)

Relationship issues

Comments

Cultural formulation

Are you in an intimate
relationship?

In many cultures and religions,
dating before marriage may not
be acceptable. However, in
Western and other cultures, it is
expected, and lack of dating
experience may be negatively
perceived (see case of Ms.
Diamond).

Cultural Stressors/Supports

How is your relationship with your
partner?

In Western culture, there may be Cultural Stressors/ Supports
greater emphasis on the nuclear
family than on extended family.
Inequality between partners in
the home may be a source of
tension, especially if there are
cultural differences or issues
arising from acculturation.

Women’s Mental Health

Sample questions

297


Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)
Sample questions

Comments

Cultural formulation

How is your relationship with your
family? With your in-laws?

In many cultures, there may be
tension between women and
their in-laws, especially
mothers-in-law, which may be
related to power struggles and a
wish to have the husband’s/son’s
support and attention.

Cultural Stressors/Supports

How is your relationship with your
children? Are they living with
you?

There can be intergenerational
conflict due to differences in
acculturation.
Relationships can change as
children become young adults;
this can affect the marital
relationship as children leave
home, especially if the woman’s
identity is substantially linked
to being a mother (empty nest
syndrome).

Cultural Stressors/ Supports

History of present illness (where relevant) (continued)
Relationship issues
(continued)

298 Clinical Manual of Cultural Psychiatry, Second Edition

Table 7–1.


Table 7–1.

Intimacy issues

Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)
Cultural formulation

Would you describe any problems
with your sex life?

In some cultures, you may not be
able to ask the question directly,
especially when you first get to
know your patient; indirect
questions about aspects of
marital life may be more
acceptable.
Screen for DSM-5 sexual
dysfunctions (e.g., female

sexual interest/arousal disorder,
female orgasmic disorder) and
other disorders (dyspareunia,
vaginismus).
History of trauma may have an
effect (see below).
Many other factors, including
demands of modern life such as
sleep deprivation and home and
work responsibilities, medical
conditions, and personal
choice, may also affect sexual
interest and functioning and
should be considered to avoid
overdiagnosis.

Explanatory Model

299

Comments

Women’s Mental Health

Sample questions


Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)
Sample questions

Comments

Cultural formulation

History of present illness (where relevant) (continued)
Separation/Divorce

Have you gone through separation
or divorce before?

Traditional cultural values about Cultural Stressors/Supports
marriage and nonacceptance of
divorce may make it difficult to
leave nonworking relationships,
even abusive ones.
Some separated or divorced
families may still live together
for practical or cultural reasons.

Recent history of trauma

Is there any form of abuse or
violence in your current or recent
relationships? Or any genderbased violence in any other
situation?

Ensure that the woman is safe in
her home. If not, work to
understand the situation from a

cultural perspective and
collaborate on creating an
acceptable safety plan.
Become familiar with community
resources, such as women’s
shelters, hotlines, and legal
advice. Supportive therapy is
extremely important in these
situations.

Cultural Stressors/Supports
Relationship With Clinician

300 Clinical Manual of Cultural Psychiatry, Second Edition

Table 7–1.


Table 7–1.

Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)
Sample questions

Legal protections and
freedoms

Comments

Cultural Stressors/Supports

Women’s Mental Health

Have you experienced any gender- It can be important to educate
based discrimination?
newcomers and immigrant
Have you experienced a “glass
women about their legal rights
ceiling” at your work?
in North America to help them
empower themselves.
Continuing to work against
gender-based discrimination
around the world through
advocacy is needed (e.g.,
women not being able to drive
in certain countries; Saudi
Arabian women were granted
voting rights only in 2011;
harsh punishments, even death
penalty, for adultery).

Cultural formulation

301


Practical guide to culturally competent assessment on gender issues: identifying data/history
of present illness and psychiatric history (continued)
Sample questions

Comments

Cultural formulation

Have you ever experienced baby
blues/depression/mood changes
shortly after giving birth?
Did you perform any cultural
postpartum rituals? Did you
experience any stress or benefits
related to this?
Do you feel you have adequate
social support in your
postpartum period?

Postpartum rituals may include
dietary and activity
proscriptions and restrictions
and organized support.
Postpartum rituals can also
include different ways of
dealing with the placenta,
decisions about baby care such
as breast-feeding. and
circumcision for male babies.
Certain rituals may especially
cause problems when they
cannot be performed in North
America, either because of

logistics (e.g., burying a
placenta in an apartment) or
because of legal restrictions
(e.g., female circumcision).
Rituals can be a source of support
or stress.
Unwanted social support (e.g.,
from a mother-in-law) has been
linked to worsening of
postpartum depression.

Explanatory Model
Cultural Stressors/Supports

Psychiatric history
Postpartum depression

302 Clinical Manual of Cultural Psychiatry, Second Edition

Table 7–1.


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303

1981 and Dr. Carol Nadelson becoming the first woman president of the
American Psychiatric Association in 1985 (Canadian Psychiatric Association
2006; National Library of Medicine 2011). The glass ceiling continues to be
an issue in faculty development and promotions.

Greater awareness of our own history with regard to gender inequities,
professional identity, and the existence of power differentials within the culture of psychiatry is needed. Globalization of the Western biomedical model
may have exported some of these hierarchical constructs to low-income countries as an unintended consequence. Of course, different family structures
and social and cultural values are implicated as well. In situations where medical resources are lacking, explicitly highlighting the importance of women’s
mental health in manuals for developing countries such as Where There Is No
Psychiatrist (Patel 2003) sends an important message to all health care workers, with statements such as “the promotion of gender equality, by empowering women to make decisions that influence their lives and educating men
about the need for equal rights, is the most important way of promoting
women’s mental health” (p. 229). Useful suggestions about how to inquire
about domestic stress, obtain collateral history from husbands and relatives,
ensure follow-up for women, and start support groups and advocacy initiatives are also included. Patel (2003) writes that as a health service provider
“you must be constantly aware of the powerful role played by gender inequality in the health of women. There are many ways in which you can help reduce the impact of this inequality on women’s mental health” (p. 229) and
offers the following clinical examples:
• If a woman presents repeatedly for minor health problems, take time to ask
about her domestic situation and other stresses and how these may be affecting her physical and mental health.
• With the woman’s permission, speak to her husband and family members,
explain the difficulties the woman is facing, and educate them about how
this situation may be affecting her health.
Treating health complaints in men and women with equal concern is important because it is well known that in many places,


304 Clinical Manual of Cultural Psychiatry, Second Edition

[W]omen with any health problem are less likely to receive the same quality of
health care as men. Women’s complaints are taken less seriously by relatives
and health workers. Women who are depressed often do not get the right
treatment for their problems; instead they are prescribed sleeping pills and vitamins. Mentally handicapped girls are less likely to be sent to special schools.
Whereas a mentally ill man may get married, mentally ill women are often left
alone. Mentally ill women may be severely condemned for any behavior that
could be perceived as a violation of feminine nature, such as lack of attention
towards the preparation of food or neglect of children. Mental illness in

women may be seen as a disgrace to the family. Many mentally ill women receive little social support. Married mentally ill women are more likely to be
sent back to their parental home, deserted or divorced. (Patel 2003, p. 228)

Allowing women time to speak about their problems and concerns and
providing psychoeducation about symptoms and mental health conditions
for the woman and her family, counseling, and suggestions on improving relationships are all mentioned in Patel’s (2003) manual as means of promoting
mental health for women.
On a social level, bringing a discussion of women’s mental health issues to
local women’s groups and forming self-help or support groups for women
with mental health conditions if none exist are also community-building recommendations in the manual.
It is also important to mention that if language differences are present,
working with professional interpreters rather than asking husbands or family
members to translate is vital so that women’s voices can be heard directly. Cultural consultants, also known as cultural brokers, with “insider knowledge” or
specific cultural knowledge can also provide useful context and collateral information for assessments (Andermann 2010).
In research settings, women and ethnocultural minorities now need to be
included in study populations in order for those studies to provide valid and
generalizable results. The National Institutes of Health (2001) has mandated
that any funded research must be able to capture information about both sexes
and diverse racial and ethnic groups, as well as show whether an intervention affects these groups differentially. The era of the “70-kg man” is now in the past.


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305

Epidemiology and Psychopathology
Some well-known gender differences in psychopathology have been consistently observed in several epidemiological studies. Women tend to have a
higher prevalence of mood and anxiety disorders, except for bipolar disorder,
whereas men have higher prevalence of externalizing disorders such as substance use disorder. Recent research, such as the World Health Organization’s
World Mental Health Surveys, found this pattern to be consistent across 15 developed and developing countries (Seedat et al. 2009). By examining traditional gender role variations across age cohorts and countries, the study found

that these patterns remained largely stable for most mental disorders examined.
There were, however, a few notable exceptions, such as major depressive disorder and substance dependence. This finding, consistent with some of the previous studies on depression, suggests that increased gender equity may
potentially lead to decreased depression among women, likely through decreased stress and increased opportunities and resources. It is noteworthy to
mention one striking example in which culture and social context affect the
difference in the usual pattern of suicides in the West, which typically shows
higher rates of attempts in women and higher rates of completion in men, who
use more lethal means. In parts of rural China, the reverse is true, likely because
of psychosocial and cultural factors, including availability of lethal pesticides
(Law and Liu 2008). Of additional concern, the suicide rate in China is described as two to three times the global average, with low rates of depression
and mental disorders found, giving financial or relationship stressors more
prominence in the etiology of suicide.
Many factors interact to modify the prevalence rates of mental disorders
among women. For example, a multisite community-based U.S. study with
more than 3,000 women oversampled for minority women found that depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale (CES-D) significantly differed by race and ethnicity (Bromberger et
al. 2004). In this study, 27.4% of African American and 43.0% of Hispanic
American women had CES-D scores greater than 16, versus 22.3% of white
American women; Chinese and Japanese American women had lower prevalence rates of 14.3% and 14.1%, respectively. The racial/ethnic differences
were no longer significant when socioeconomic factors were accounted for.
The study findings also suggested that the effect of socioeconomic factors


306 Clinical Manual of Cultural Psychiatry, Second Edition

might be partly mediated by differences in physical health and psychosocial
stressors among the groups.
Postpartum depression (PPD), often defined as depression occurring
within the first year after childbirth, may affect as many as 7.1% of women in
the first 12 weeks and up to 19.2% if minor depression is included (Gavin et
al. 2005). In a review of PPD among immigrants (Fung and Dennis 2010),
several Canadian studies suggested elevated prevalence of PPD among immigrant or refugee populations. However, some of the studies comparing U.S.born with foreign-born mothers suggested either no difference or a lower rate

in the latter. Foreign-born mothers may have certain culturally protective factors. Another complicating factor in interpreting these findings is that of ethnicity because black and Hispanic mothers were found to have higher levels of
depressive symptoms than white mothers in several U.S. studies. Similarly,
postpartum immigrant women from minority groups had higher rates of depressive symptoms than did either Canadian-born mothers or immigrant
mothers from majority groups in a Canadian study. In all cases, a thorough
safety assessment is required, which includes both suicidal and homicidal ideation, particularly asking about whether the patient has thoughts of harming
the infant or infanticide (Table 7–2).
For schizophrenia, no sex difference is observed in most studies of prevalence rates, but the incidence rate estimates have been consistently higher in
women than in men (Abel et al. 2010). Compared with men, women have a
broader distribution in the age at onset of schizophrenia and a more prominent second peak around middle age. Women tend to have more affective
symptoms, whereas men may have more negative symptoms. A later age at onset, more affective symptoms, and fewer negative symptoms all have been associated with a better prognosis and are associated with being female in most
studies. Biological studies showing hormonal interactions, particularly the
protective effects of estrogen, can explain some of these differences between
men and women (Blehar 2006; Seeman 2006; Vigod and Stewart 2009).

Clinical Assessment
At the level of clinical assessment, Table 7–1 shows how the clinician can integrate gender-specific questions into a standard interview. Topics such as


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307

body image (weight), menstruation, surgeries, and history of PPD can be discussed during the history of the present illness and medical and psychiatric
history. Important topics to cover during the developmental and social histories include gender roles, level of functioning, relationships, children, trauma,
sexual history, and occupation (Table 7–3).
With regard to the mental status examination, some particular cultural areas of inquiry can inform the diagnostic assessment of psychopathology. This
ensures that culture and gender issues are taken into account and avoids assumptions or mislabeling that can occur if a cultural lens is not used appropriately.

Developmental Issues in the Woman’s Life Cycle
Childhood

When working with women (and men), taking a life cycle approach is important because an awareness of different developmental trajectories is an essential feature of understanding male and female patients (Andermann 2006).
We provide a few examples to highlight each of these stages in different cultural settings. Seeman (2006) writes that “regardless of specific diagnosis, females almost always express psychological distress somewhat differently than
males. Age is a key factor between the two” (p. 3). She goes on to describe the
preponderance of boys identified in child mental health services, with higher
rates of hyperactivity syndromes, autism, learning disabilities, conduct disorders, anxiety, and depression. These problems are overtaken at the time of puberty, when rates of psychiatric illness suddenly change. In adolescence and
beyond, most disorders, with the exception of substance abuse, schizophrenia,
and impulse-control disorders, are found in girls and women.
Childhood is a time of exponential growth and learning in the physical,
psychological, and cognitive spheres, including mastery of language and social
interactions with the intimate family and the wider world. Culture is absorbed
into the consciousness of the child during all aspects of family life, including
daily routines; playtime; meals; social occasions; religions and festivals; and
contact with siblings, parents and grandparents, extended family, teachers,
neighbors, and communities (Andermann 2006). There are many theories of
child development in the literature, but less is known about how culture affects


Practical guide to culturally competent assessment on gender issues: mental status
examination
Sample questions

Comments

Cultural formulation

Mental status
Appearance

Inquire about the meaning of the
Explore cultural or religious

patient’s clothing, fashion
meaning (e.g., a tattoo may be
choices, piercings, or tattoos.
used to ward off evil spirits;
I notice that you are wearing a
hijab [headscarf ] worn by
headscarf. Can you share with me
Muslim women). This may also
what that means to you?
include subcultures that certain
I notice that you have a tattoo.
youths identify with and may be
What does that mean to you?
of developmental significance.
How many tattoos do you have? The meaning of provocative dress
When did you get them and why?
may need to be explored gently
rather than jumping to
conclusions.

Cultural Identity

308 Clinical Manual of Cultural Psychiatry, Second Edition

Table 7–2.


Table 7–2.

Mood/Affect

Practical guide to culturally competent assessment on gender issues: mental status
examination (continued)
Comments

Cultural formulation

You seem embarrassed about
crying; do you have certain
concerns about crying here?
You don’t seem angry even though
you just described a very difficult
situation you experienced; how
do you express your anger?

Emotional expression and display Explanatory Model
(e.g., crying) are highly
Relationship With Clinician
culturally influenced.
Although there may be stereotypes
that women cry more easily than
men, in a clinical setting,
women may often apologize for
crying or feel that it is
inappropriate.
Women who have experienced
trauma or abuse may harbor a
lot of anger, and this may be
directed at themselves (e.g., selfharm in severe cases) or others.

Women’s Mental Health

Sample questions

309


Practical guide to culturally competent assessment on gender issues: mental status
examination (continued)
Sample questions

Comments

Cultural formulation

Do you sometimes feel that life is
meaningless and hopeless?
What are your reasons for living?
How does your faith or culture view
self-harm or suicide?

Screen for suicidal risk using
Explanatory Model
standard practice, keeping in
mind that in some cultures it
may be taboo to talk about death
or suicide; begin with indirect
questions such as about hopeless
and passive suicidal thoughts.
Women from most cultures

attempt suicide more than men
but have a lower completion rate
because of the tendency to use
less lethal means; there may be
cultural exceptions, such as
women from parts of rural
China; we do not know how this
may affect immigrant women
from these areas.
Because divorce and leaving a marriage may not be culturally acceptable, some women may feel
especially trapped and hopeless,
leading to suicidal thoughts.

Mental status (continued)
Suicidal ideation

310 Clinical Manual of Cultural Psychiatry, Second Edition

Table 7–2.


Table 7–2.

Practical guide to culturally competent assessment on gender issues: mental status
examination (continued)

Homicidal ideation

Sample questions

Comments

Cultural formulation

Do you ever feel so hopeless that
you want to end it all for you
and your children?

It is important to screen for
infanticidal ideation in cases of
suspected postpartum
depression.

Explanatory Model

Women’s Mental Health 311