Depression, either as a single depressive episode or as a recurrent depressive disorder, is a common mood disorder which is characterised by low mood, resulting in loss of interest and enjoyment, reduced energy and diminished activity. With increasing severity other symptoms such as reduced concentration, attention, self esteem and self confidence manifest, and physical symptoms may protrude, such as disturbed sleep and diminished appetite. These may accumulate in ideas or acts of self harm and suicide. The gender difference in depressive illness, is one of the strongest patterns seen in psychiatric epidemiology [2,3,4,5]. Similar, albeit less strong gender differences can be seen through a variety of mental health disorders, typically with internalising disorders (of mood and anxiety) which are more common in women, and externalising disorders such as schizophrenia and substance abuse which are more common in men.. Such a strong pattern, seen in many cultures around the world can help in the comprehension of depression, an illness that still evades human understanding .
The aim of this essay will be to help identify some key aspects of the social causes of depression and how they relate to gender roles within society. This will ascertain their importance in mechanisms that drive someone into depressive illness – the ‘gender role hypothesis’ of depression . However the point of this essay is not to systematically review the scientific literature and identify the cause, but rather to explore the concept of how much gender roles in society contribute to this pattern. In the conclusion, it will allow us to see how changing gender roles, such as feminism, in modernising societies such as the UK, will impact on women’s health. The essay will explore risk factors which relate to gender role where they have evidence to cause depression. Such factors are emotional attention, interpersonal relationships, personality, stress response, the impact of co-morbid anxiety and what are termed artefact hypotheses, such as gender biased diagnostic techniques.
Sex and gender are terms that have become divorced since Dr Robert Stoller’s observations of gender being a social construct and sex being biologically determined. It isn’t necessary for someone of a certain sex to inherit the same gender and same gender role  – although in western society it is the norm. While this essay will look at the epidemiological pattern of depression through a social lens, it should be kept in mind that there will be a biological background that cannot be excluded. It can be argued, such as by John Nicholson, that the gender role itself has its development in biology or socio-biology, or gender role as developed by evolution of human behaviour (as proposed by E.O Wilson and David Barash). However, these ideas are not as widely accepted as the theories for socially determined gender roles as put forward by Stoller and Ann Oakley. For the purpose of this essay, gender roles are a set of behaviours socially expected of someone conforming to a particular gender.
A key feature of the female gender role is emotional behaviour, with women being caring and compassionate, and men being dominating and aggressive . This is of course an excessive generalization, but a recognised pattern, most likely influenced by sex of the person. However, it is important to note that there is a large overlap in emotional behaviour between the genders  but more specific to gender are those behaviours used to cope with life events. More emotionally sensitive women may present to doctors sooner, although this has been disproved at least once . This is an artefact argument I shall come to later. Emotionally sensitive persons, who tend to display more depressive symptoms, may have impaired anti-rumination strategies . Rumination is a method of coping whereby the person focuses on the depressive symptoms and the triggering event, rather than trying to distract themselves, for example with thoughts of good things to come.
Research has found that rumination by more emotionally sensitive persons leads to a negative emotion ‘spiral’. Focusing on the negative thoughts and emotions leads to further negative thoughts and emotions. , By controlling for emotional attention in their study results, there was a non-statistically significant difference for gender and symptoms of depression . This is further backed up by evidence that rumination exacerbates and prolongs depression and that women tend to ruminate more when sad or depressed, a trend seen from prepubertal childhood . Another personality trait, such as neuroticism, has also been associated with depression. Controlling for it has been suggested to eliminate the statistical significance of gender and depression , and although there is suggestive evidence against this idea , it should not be dismissed entirely until more research is done.
It could be argued however, that the coping style may be different due to the type of stress observed by the individual. A more significant life event may be harder to distract oneself from, and so easier to ruminate. A woman’s role may determine her to be exposed to more significant stressors, for example through her role as the homemaker. There may be problems affecting children, housing, fertility, versus issues which will affect men more (for example, through their role as the breadwinner) but occur less often – unemployment and finance problems. Although evidence suggests that while men and women are exposed to different stressors, it is insufficient by itself to explain the gender difference [11,12]. Therefore, I feel that the evidence shows that rumination is an important risk factor for depression, and women ruminate more than men, due to their socialisation making them more emotionally sensitive. It should be noted that males and females may receive different stressors for depression outside of their gender role. For example, sexual and physical abuse, as an adult or as a child, may play a role in explaining the gender difference. If women are more likely to be abused as adults or as children, (this might become a risk factor towards depression later on), then this might help explain some of the pattern seen. Evidence for this suggests it might play as much as 35%  of the gender difference in adult depression.
Another way gender role and stress may interplay is through interpersonal relationships. The traditional female gender role will imply that a woman will put in more effort to attaining more friends. Therefore the loss of interpersonal relationships will have more of an impact on the female than it would on the male. Evidence shows that it is the lack of relationship, rather than the support the relationship provides , is the more significant stressor, and so further proves the point.
This is of particular importance when looking at adolescent mental health, a key time when the gender difference in depression is first seen . It could be argued that the starting of the gender difference is due to a restriction of the adolescent female into her expected role. This only adds to, rather than offers an alternative view point, that if the adolescent female loses some of her important relationships, she might feel more like she has lost an important part of her identity. There is evidence that loss of interpersonal relationships is a significant stressor in adolescent females, because they have invested more emotion and are more likely to blame themselves .
This can also help explain the link between Body Mass Index and mood disorders, where high BMI affects women more, possibly putting them at a social disadvantage . However, it is hard to identify whether social disadvantage has encouraged the depression and hence higher BMI, or higher BMI has caused social disadvantage and so depression. I feel that it is probably the latter, as evidence on coping strategies provides little evidence that eating is a common coping strategy in depression . However the two studies examined different populations, American and Japanese, which casts doubt on their results
Another study looked at sleep disturbance rather than depression. It suggested that adolescent girls, being more sensitive to familial disruption and increased domestic and grooming expectations, had increased sleep disturbance . This is similar to an argument that I studied earlier – increased expectation of fitting into the role of the female gender will increase sleep disturbance. This positively correlates with depression as either a cause or a symptom of sleep disturbance .
Looking at other co-morbid conditions of depression may help to illuminate the role of gender difference in depression. Anxiety is frequently seen co-morbid with depression, especially in primary care, such that it has its own classification in the ICD-10. It is therefore logical to think that any gender difference in anxiety (which can be seen) could be linked with the gender difference in depression. Similar risk factors already discussed, ruminative behaviours and social network crises, predispose women to anxiety more than men. I think this adds to the evidence of suggesting a common aetiology between depression and anxiety. Using gender roles, anxiety does not fit into the male gender role of being confident and aggressive, and hence goes some way to explain the gender difference in anxiety, rather than in depression.
It would seem that mothers discuss different coping strategies with their children; for boys a more problem solving approach and for girls more emotional coping strategies to help deal with distress . These coping strategies and depression in women, comply with my previous ideas and also help to explain the gender difference in depression. While evidence may suggest that anxiety and depression share a common aetiology, evidence also suggests that anxiety states are not part of the aetiology of depression [18,19] and so the gender difference in anxiety is just a reflection, rather than a cause of the gender difference in depression.
Evidence suggests that in depression and its risk factors, that anxiety during adolescence, due to a difficult transition from the child to the adult, may make the woman more sensitive to depression after a triggering event. A model suggested by Cyranowski et al, combining female gender socialization and the hormone oxytocin which intensify the need for interpersonal relationships, coupled with anxiety, might cause sensitivity to depressive events. There is a good fit of the evidence , bringing biological as well as psychological and sociological theories together. However, more recent evidence has shown that men and women are equally sensitive to triggering events[11,12]. A better idea is that anxiety and depression share a common aetiology. On the road to depression and anxiety, a fork in the road is approached, where the type of trigger or another risk factor not discussed, decides whether the person becomes depressed or anxious.
However, some of the so termed ‘artifact hypotheses’ may suggest that all the above research and studies are not finding any physical or real link between depression and gender, but rather that is a fault in the techniques in the data collection. Some suggestions that fit this hypothesis are that women are more likely to seek treatment for any illness, more likely to discuss a potentially stigmatising condition such as a mental health disorder or are able to recall symptoms better, and so doctors are more able to make a diagnosis. Alternatively, women are being overdiagnosed or men being underdiagnosed, as either the fault of the doctor or biased diagnosis techniques. It is also argued that substance abuse masks depression and anxiety in men .
Some quite surprising research suggests that there is no gender difference in the symptoms a male or female may present to indicate depression, and that men and women show no preference in stating that they feel emotionally down . I have little confidence with this unique result, as the accepted idea and other evidence suggests otherwise .. Evidence suggests that substance and alcohol abuse are not the male equivalent to anxiety. Therefore, controlling for alcohol and substance use still leaves a significant gender difference. However, in depression, it has been suggested as a coping strategy, and so it is not unconceivable to think that alcohol abuse, assumed to be an externalizing disorder, is in fact a coping mechanism for depression in men. If diagnosed as alcohol abuse rather than depression, this could make up some of the gender difference.
However, what is more interesting, is the suggestion that diagnostic techniques are gender biased, especially Beck’s Depression Index. Two studies reached the same conclusion that items in the Beck’s Depression Index related to crying and loss of interest in sex gave an over-diagnosis and underestimation of recovery in women [21,24]. Crying is considered more congruent with the female gender role, and loss of interest in sex can occur outside of depression, especially in women, again fitting their gender role . Therefore, to ensure correct diagnosis, the researchers suggest the use of the Goldberg Depression Scale rather than Beck’s Depression Index. This is troubling, as many of the research already referenced used either interviews by trained lay people or the Beck’s Depression Index, which casts doubt on the accuracy of the conclusions reached thus far.
So to conclude, I have explored some of the risk factors for depression and their aspect as gender roles to help explain the gender difference in depression. There is some doubt cast upon this research and any other research done into the epidemiology of depression because of doubts over the Beck Depression Index bias. I still feel the evidence is strong enough to hold some meaning. On the other hand, differing gender roles is not a sole explanation. The example of child abuse is one of many outside the gender role hypothesis. There is plenty of room for other social, psychological and biological causes of depression and its epidemiological patterns not explored in this essay.
A simple and brief conclusion would be to say that gender role is a part of a large mechanism of a multi-factorial illness. More research is required to ascertain the full answer to the question proposed by the title. Ideal research would be to re-analyse the epidemiological patterns in 10, maybe 20 years time. Then it could be assumed that gender roles would continue in their path to become more equal. Less of a difference between the genders and rates of depression and anxiety might be expected. There may also be less of a difference between genders and other mental health disorders.
However, additional preliminary evidence can already help draw some ideas. Studying couples with a shared life event for example, women have been shown to be at a greater risk of depression if there was a traditional division of roles in the family. One of the findings of the WHO mental health surveys  is that younger people have less distinct gender difference for major depressive disorder than older people. A correlation was found between less traditional gender roles and decreased rates of depression with increased rates of substance abuse. This suggests changing, modernising gender roles are resulting in decreased rates of depression among women.
However, the increase in substance abuse is a cause for concern. The trend is towards equal gender roles, with the female gender role becoming more masculine, so bringing new health concerns. While fair gender roles within society as a whole, such as employment, may have a beneficial effect in protecting against depression , there is still an imbalance of roles within the home. This is reflected in how children are brought up and how they develop their coping strategies for stress.
Therefore, gender roles have a large role to play in epidemiological patterns of depression, and in the aetiology of depression itself. As gender roles become more equal, it will result in better health for women in society, and while not the focus of the essay, it can be safely assumed a similar pattern can occur for men as well. Equality it seems can go a long way in reducing risk to disease.
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