The impact of gender discrimination on a Woman's Mental Health.

The World Health Organization (WHO) recognizes that health outcomes are unequal for people, both across and within countries, with inequity especially disadvantaging women across their lifespan [1]. The overt social and economic inequalities more commonly experienced by women, such as lower rates of schooling and employment, less pay for similar jobs, under representation in leadership positions, and the higher level of psychosocial stressors and problems, from caregiving burden to intimate partner violence, all contribute to these disparities [2]. In recent years, these overt examples of gender inequality have rightly been the focus of many programs to improve health [3]. What has been less studied is the impact of a more pervasive - although often less overt and quantifable – form of gender discrimination. Evidence from research in the workplace demonstrates that day-to-day, more subtle words and actions can also negatively impact a woman's sense of well-being and success – in a way that is: (1) often unrecognized outside the experience of a women herself, and (2) commonly left to the woman to decide how and whether to address it [4] . Ruth Bader Ginsburg, the iconic United States supreme court justice who at times took on key cases to support equality for women and other groups who were at risk for experiencing discrimination, recognized this phenomenon in bringing her lived experience to her role as a judge: “All I can say is I am sensitive to discrimination on any basis, as I have experienced that upset”.

The study by Stepanikova et al. [5] published in this issue of EClinicalMedicine expands on previous research around gender inequality and health to investigate the impact of the broad construct of “perceived gender discrimination” in relation to a woman's mental health. Specifically, the authors sought to increase understanding of how this construct may contribute to the “Gender Gap” in the prevalence of common mental disorders such as depression, where affected women outnumber men by two to three-fold. Using the Czech sample of the large European Longitudinal Cohort Study of Pregnancy and Childhood (ELSPAC-CZ) initiated by the WHO to examine maternal and child health across several European countries, the investigators conducted a secondary analysis focused on a measure of gender discrimination that would include overt acts of gender discrimination, but also encompass the experience of a woman with respect to gender discrimination in her everyday life. Perceived gender discrimination was assessed by the following question: “Would you say that in the past 12 months, someone treated you unfairly because of your gender?”. Women were asked this question on three occasions, in mid-pregnancy, and 7 and 11 years after delivery. The Edinburgh Postnatal Depression Scale (EPDS), originally designed as a depression screening tool in pregnancy and the postpartum period that has also been validated for its use in women across the lifespan, measured depressive symptoms at each time-point. Linear mixed models were constructed to investigate the relation between the perceived gender discrimination and depression symptom scores.

The study findings were striking. More than 1 in 10 women - who were all pregnant or parenting young children at the time - responded yes to experiencing perceived gender discrimination. Woman who answered “yes” to the gender discrimination question had higher depression scores. This finding was robust to all adjustments for confounders that could otherwise increase risk for depression such as poverty, level of social support, and gender role inequality. This strongly suggests that perceived gender discrimination is an important factor in a woman's mental health. The biological research being conducted on the etiology of depression in women is of course important. Simultaneously, studies such as this one serve to remind and reinforce for us that the worldwide “Gender gap” in depression also has major sociocultural determinants. Work to address overt issues of gender discrimination that disproportionately affect women, from poverty to violence, must continue across the globe. At the same time, many of the inequities that contribute to a woman being treated unfairly based on her gender are things that happen every day, and occur in subtle ways that can also be highly problematic. Because these more subtle forms of perceived gender discrimination are so ingrained in our societal systems, reversing them will be hard, requiring international cooperation from health and social advocates, and from government and policy-makers of all genders. Evidence such as that provided by Stepanikova et al. further substantiates the need to advocate internationally for fair and equitable treatment across genders and other intersecting identities—we should not have to have experienced upset to be sensitive to, and correct, gender discrimination in our midst.

Declaration of Competing Interest

Dr. Vigod reports royalties from UpToDate Inc for authorship of materials related to depression and pregnancy, outside the submitted work.