Women and mental health

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Some facts about women's mental health     

Introduction

Women and mental distress
Anxiety and depression 
Eating disorders
Self-harm 
Borderline personality disorder (BPD) 
Mental distress around pregnancy and childbirth 
Substance dependency 

The social context of women's mental distress     
Family life 
Social isolation 
Poverty
Childhood sexual abuse
Physical and sexual violence
Prison 
Physical problems around women's mental distress 
Hormonal and reproductive changes
Medication 
Chronic physical conditions      
Physical symptoms and mental distress     
Behaviours around common mental health problems   

Mental health of specific groups      
Young women 
Older women
Lesbian, bisexuals and transgender (LGBT) women 
Black and Minority Ethnic (BME) communities 

The way forward
Gender Equality Duty (GED)
Mainstreaming women's mental health

Useful resources 

Some facts about women's mental health

• Recorded rates of anxiety and depression are between one and half and two times higher in women than in men. [1]
• Rates of self-harm (including cutting, burning and overdose) are two to three times higher in women than in men. [2]
• At least one new mother in ten will experience postnatal depression. [3]
• Two thirds of women in prison have mental health problems and over half have been diagnosed with a personality disorder. [4]
• One in four women will experience domestic violence in their lifetime; this is cited as a cause of marital problems in one in five Relate counselling sessions. [5]
• Of the 1.15 million people in the UK who have an eating disorder, 90 per cent are female. [6]

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Introduction

This factsheet is aimed at students and professionals who work with women in mental distress. It may also be of interest to women who are in distress themselves, their friends, relatives and carers.

This factsheet examines the ways women experience mental distress and the social and physical contexts of their mental health problems. It also examines the mental distress of particular groups, including the young and the old, lesbians, bisexual women and transgender people, and Black and Minority Ethnic communities.

In recent years, more research from the Department of Health, mental health charities and other agencies has focused upon women's own experiences of mental distress. This research provides evidence of the treatment and care women need and deserve, and of the many ways women can be supported to meet their own mental health needs. Findings from this research base are cited throughout the factsheet.

The factsheet ends by describing how changes in social policy are impacting on women's mental health services and highlighting those service areas that need further improvement.

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Women and mental distress

Rates of mental distress do not vary significantly between men and women. However, there are clear variations in the rates of specific conditions. [7] The reasons for these differences cover a range of social, economic, physiological and emotional factors, which will be described in this factsheet. There is also evidence of gender differences in the ways that men and women express and experience mental ill health.

For more information on all the conditions described below, see Useful resources.

Anxiety and depression

Recorded rates of anxiety and depression are one and a half to two times higher in women than in men.

There is strong evidence to support the statement that rates of undiagnosed depression are likely to be equally high in men: men are less likely to talk about their problems or to consult a doctor about their mental health. 'Covert' or 'hidden' depression sometimes underlies problematic behaviours that are thought of as typically male, including substance abuse and violence. [8] By contrast, women are more likely to acknowledge their mental distress and to seek out appropriate help.

To date, 'appropriate help' has often proved elusive for women with anxiety or depression. Often, a diagnosis of anxiety or depression leads to medication as the first or only treatment option. [9] Women are therefore more likely than men to be prescribed antidepressants and tranquillisers (for anxiety or use as sleeping pills). As a consequence, women are more likely than men to be dependent on these types of medication.

Women living with anxiety and depression have repeatedly asked for better access to talking therapies and to opportunities for learning new skills and coping strategies. [10] These preferences are now reflected in national guidelines for the treatment of both anxiety and depression. These guidelines state that talking therapies are the most likely treatment to produce lasting benefits, especially when combined with other forms of social support and self-help. [11]

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Eating disorders

All eating disorders - anorexia nervosa, bulimia nervosa and binge eating disorder - affect many more females than males. Some researchers have suggested that eating disorders can be a means of coping psychologically with the lack of social, political and economic power that women experience in most societies. There is evidence that, in Western society, the high value placed upon thinness and the stigmatisation of obesity are factors in the development of many eating disorders. [12]

The distress of living with an eating disorder can be increased by the portrayal of eating disorders in the media, and by healthcare professionals. In the mass media, these conditions are often trivialised as 'slimmers' diseases', affecting vacuous, fashion-conscious women. [13] In medical settings, those with eating disorders have been given labels with sexist and belittling connotations, such as 'manipulative', 'spoilt' and 'attention-seeking.' [14] Until the end of the twentieth century, anorexia nervosa was usually treated through behaviour modification programmes that rewarded obedience with 'privileges.' Women have often experienced these programmes as oppressive, disempowering and humiliating. For the significant minority of women patients who have experienced physical or sexual abuse, these methods could lead to their reliving past traumas, a process known as 'retraumatisation'. Although it is now widely accepted that this type of behaviour modification rarely has therapeutic value, it is still applied in some hospital settings. [15] Being admitted to a hospital is now the last rather than first resort when treating even the most serious eating disorders. National guidelines now recommend that people with eating disorders should be treated as day or outpatients, and through talking treatments that have proved to be more effective than the earlier regimes. [16] However, a lack of specialist eating disorder services across large areas of England and Wales mean that local services often fall short of national standards.

Self-harm

Rates of repeated and long-term self-harm, which includes cutting, burning and overdose, are two to three times higher in women than in men. Many women who self-harm have experienced physical or sexual violence in childhood or in adult life. Self-harm can also be a response to pressures such as bullying, bereavement, relationship problems and work-related stress. Self-harm can be a symptom of borderline personality disorder, which is more commonly diagnosed in women than in men (see below). It can also exist alongside other conditions such as depression and eating disorders. Self-harm is particularly prevalent in prisons and secure mental health settings.

Research has shown that people who self-harm have often received inadequate treatment from Accident and Emergency services; examples of bad practice include the failure of staff to make referrals to mental health services and deliberate rough treatment of injuries as a 'disincentive' to future self-harm. Such rough treatment can cause retraumatisation in women who have experienced physical or sexual abuse. Like those with eating disorders and borderline behaviour disorder, women who self-harm have been labelled, 'manipulative' and 'attention seekers'. [17]

In response to these failures in treatment and care, national guidelines have been issued to frontline staff who come into contact with people who have self-harmed. [18]

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Borderline personality disorder (BPD)

The word 'personality' refers to the ongoing pattern of thoughts, feelings and behaviours that make up who we are. [19] Borderline personality disorder (BPD) is one of eight personality disorders that may be given as a psychiatric diagnosis.

Unlike other personality disorders, BPD is much more frequently diagnosed in women than in men. [20] More than half of women prisoners have been diagnosed with a personality disorder - most commonly BPD.

Some of the criteria for BPD include repeated self-harm or suicide attempts, self-destructive forms of behaviour, (such as binge eating, alcohol or drug abuse, dangerous driving or unprotected sex), intense and chaotic relationships, an unstable sense of self, feelings of emptiness and anger that feel inappropriate or difficult to control.

BPD frequently manifests itself in forms of distress or behavioural patterns that are the defining features of other mental health problems, such as depression, self-harm and eating disorders. Indeed, BPD is sometimes diagnosed after another diagnosis has been given but is later found to be inappropriate.

BPD has been linked to traumatic events in childhood such as physical and sexual abuse, neglect or abandonment; however, BPD is not usually diagnosed until adulthood, because the personality is seen as still developing until then. [21]

BPD, like other personality disorders, is a controversial diagnosis. It has sometimes been seen as a diagnosis for people who do not fit easily into any other category and are labelled 'difficult' or 'different'. [22]  Women diagnosed with BPD have sometimes found it to be a stigmatising label; like self-harm and eating disorders, it can be accompanied by accusations of 'attention-seeking' and 'manipulative' behaviour. [23]

Personality disorders have traditionally been seen as 'untreatable' but this perception is changing. Several types of talking treatment have proved helpful for people with BPD in managing their behaviour and improving their quality of life. [24]

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Mental distress around pregnancy and childbirth

Mental distress around pregnancy and childbirth (also known as perinatal illness) affects approximately one in six women. Distress can occur before, during or after pregnancy and can range from mild depression or anxiety to severe depression or, very rarely, psychosis. [25]

Any woman can experience distress around pregnancy and childbirth and it is often difficult to identity a single cause. Possible causes for postnatal depression include the major adjustments involved in becoming a mother, a lack of emotional and social support during or after pregnancy, trauma following a distressing labour and hormonal changes. [26]  Women with pre-existing mental health problems are at highest risk of becoming distressed at this time and, in particular, of developing the most serious perinatal conditions.

Mind's research has revealed inadequacies in provision nationally for women in distress around pregnancy and childbirth. Problems include the use of medication as the first choice of treatment, long waiting lists for other forms of treatment such as counselling and a lack of specialist perinatal psychiatric services. The majority of women Mind surveyed who had experienced perinatal illness said that they would have benefitted from more information on how to recognise symptoms, on common emotional changes and on how to access services. [27] 

Distress around pregnancy and childhood can be treated by various methods, including counselling, practical support and participation in support groups. National guidelines for the treatment of postnatal depression are expected in 2007.

Substance dependency

Substance (drug and alcohol) dependence is far more common in men than in women. [28]  However, the experience of substance dependence is often different for women. There has traditionally been a greater stigma attached to women who are dependent on drugs and alcohol, which can lead to women hiding their problems and choosing not to access health or social care services. Women who are lone parents are especially likely to hide their problems from fear that they may lose custody of their children. In these situations, substance dependency and co-existing mental health problems are likely to become more severe over time, with serious consequences for a woman's health and wellbeing.

Women are more likely than men to become dependent on prescription medication, including antidepressants and tranquillisers (for anxiety or for use as sleeping pills). This is in part because women are more frequently diagnosed with anxiety and depression and given medication to treat these conditions.

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The social context of women's mental distress

Social factors are integral to all personal experiences of mental distress. Whatever the underlying reasons for a mental health problem, the social context of a person's daily life may either support them in their difficulties or exacerbate the problem and stand in the way of recovery. For some people, a social factor, such as poverty or abuse, may be strongly implicated in their mental distress.

Some situations and experiences affect women more frequently than men, or affect women and men in different ways. Consequently, social factors help to explain many of the gender differences in mental health.

Family life

For some women, family life may contribute to mental distress. Many women have primary or sole care of children and women are more likely than men to have other caring responsibilities (for example, caring for older family members). Women are also more likely than men to do the majority of household tasks, even if they are in paid employment outside the home. The low social status traditionally given to the work that women do in the family can lower feelings of self-worth. This, combined with the stresses that come from conflicting roles and overwork, can have an adverse effect on women's mental health. [29]

Women who are mothers, or who want to have children, can experience particular barriers to their use of mental health services. They may avoid disclosing their problems for fear of losing custody of their children, leave hospital sooner than they otherwise would in order to look after children, or find themselves unable to use services because of child care commitments. [30] Women who are pregnant or planning to have children may also have concerns about taking psychiatric medication (see Medication).

Family life is often a major factor in other social contexts that can lead to mental distress.

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Social isolation

Isolation can cause mental distress and impede recovery from mental health problems. [31]

Anyone can become socially isolated, but the following experiences can put women at greater risk:

• being the sole or primary carer of young children
• having longer life expectancy than men, which means that in their later years women are at greater risk of living alone
• being less likely than men to be able to drive or to own a car. this can lead to dependence on public transport that is often inadequate, especially in rural areas
• fearing to go out alone at night, especially in cities. [32]

However, it is also important to remember that women are, in general, more likely than men to seek out supportive social contexts and to ask for help from others in addressing personal problems. The ability of many women to find social support in the face of difficult circumstances has been linked to better mental health in many areas, such as the lower suicide rate for women than for men. [33]

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Poverty

Poverty can be a major cause and effect of mental health problems. In addition to the stresses of living in financial hardship and poorer quality of life this can involve, mental ill health can make paid employment more difficult to find and sustain. The link between mental health and socio-economic status is particularly strong for women. [34]

Across all ages and cultures, women are more likely to be living in poverty than men, for reasons such as caring responsibilities and longer life expectancy. Women are also half as likely as men to be in paid employment and are disproportionately represented in low paid and insecure employment. [35]

For women in financial hardship or insecurity, interventions focused on accommodation and employment can be an important part of recovery from mental health problems. [36]

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Childhood sexual abuse

The prevalence of childhood sexual abuse is uncertain but studies suggest that is relatively common: 7 to 30 per cent of girls are estimated to be have been abused, which is three times higher than rates among boys. [37]

There are strong associations between childhood sexual abuse and mental health problems in adult life. Many of these are problems more commonly found among women, such as eating disorders and borderline personality disorder (BPD). [38]  Women who have been sexually abused in childhood are also at higher risk of physical or sexual abuse in adulthood, a process known as 'revictimisation'. [39]

It is now widely accepted that women with mental health problems who have been sexually abused in childhood have particular needs for care, treatment and support that must be addressed by mental health and other services. For more details, see the Department of Health guidance on this issue. [40]

Physical and sexual violence

Violence against women is very common: studies show that one in four women experiences domestic violence in her lifetime and that less than half of all incidents are reported to the police. [41] At least one in ten women have experience of sexual victimisation, including rape; a figure that is likely to be an underestimate due to low rates of reporting. Among women who have been raped or sexually assaulted, most are attacked by someone they know - almost half by their current partner. [42]

Physical and sexual violence has been strongly associated with a range of mental health problems among women, including depression, anxiety and post-traumatic stress disorder. [43]

Women who experience physical or sexual violence have particular needs for care, treatment and support that must be addressed by mental health and other services. For more details, see the Department of Health guidance on this issue. [44]

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Prison

The populations of women's prisons differ substantially from those of men's prisons. Women are far less likely to have committed violent offences and are more likely to state that financial hardship, particularly in relation to their children, contributed to their crime. Women make up only 5 per cent of all prisoners. However, the female prison population has increased dramatically in recent years and numbers continue to rise. [45]

Mental health problems and wider issues of social exclusion are a cause of concern across the prison population but are especially prevalent among women prisoners. As recent studies show:

• Two thirds of women prisoners have a mental health problem such as depression, anxiety or phobias
• More than half of women prisoners have been diagnosed with a personality disorder
• 30 per cent of women prisoners harm themselves (including cutting, burning and overdose) compared with 6 per cent of men prisoners
• Over a third of women prisoners have attempted suicide at some time in their lives
• Over half of women in prison have had experience of domestic violence, and one in three has experienced sexual abuse. [46]

The conditions of prison life often exacerbate pre-existing mental distress and can contribute to the development of new mental health problems. Failings that have been identified in prisons include overcrowding, inappropriate use of segregation units, and inadequacies in the care and treatment of prisoners with mental health and substance dependency problems. [47]

In addition, women's prisons are frequently located long distances away from inmates' homes (an average of 62 miles), which can make visiting difficult and increase feelings of social isolation. [48]

In prison, mothers' relationships with their children may be severely disrupted and anxieties over childcare issues are well-founded: Only 5 per cent of children remain in their own home after their mother has been sentenced and a third of women lose their homes and all their possessions while in prison. [49]

As a group, women in prison have greater need for mental health care and treatment than women in the general population, but have poorer access to mental health services. However, since April 2006, systems for delivering mental health services in prisons have changed substantially. Now responsibility for healthcare has been handed from prison authorities to local health bodies called primary care trusts (PCTs). PCTs already have responsibility for commissioning services for the general population. [50] It is hoped that this new re-organisation will improve healthcare standards in the prison population.

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Physical problems around women's mental distress

Physical ill health has been associated with mental health problems in both men and women. People with chronic physical illnesses are at greater risk of developing mental health problems, especially depression. People with mental health problems are also more likely to have physical illnesses such as heart and respiratory problems. [51] Mental ill health can also lead to forms of behaviour that put physical health at risk.

Studies on the relationship between physical and mental health show clear differences between men and women. These differences cover physiological factors, life experiences and the physical effects of particular mental health problems.

For more information on many the conditions described below, see Useful resources.

Hormonal and reproductive changes

Hormonal and reproductive changes can cause, or contribute to, some mental health problems. Hormone levels are known to influence mood and may, in part, explain the higher rates of depression in women. Hormonal changes have also been linked to pre-menstrual problems, which can range from milder feelings of depression or irritation to, very rarely, pre-menstrual dysphoric disorder, which involves marked changes in mood. [52]

Women are at higher risk of developing depression and other forms of mental distress in pregnancy and during the months after childbirth. Hormonal changes have been associated with all forms of mental distress around this time, including postnatal depression. [53]

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Medication

Evidence shows that medication is likely to be the first treatment option for people who are diagnosed with a mental health problem. As more women than men are diagnosed with the most common mental health problems, more women than men are taking psychiatric medication.

Medication can play an important part in enabling a person to recover from a mental health problem or to manage their condition effectively and improve their quality of life.

However, all psychiatric medication has the potential to produce side effects. Responses to psychiatric drugs are highly individual: a person taking medication may experience some side effects or none at all. If the person does experience side effects, these can vary in duration and severity. Some people decide that the benefits of their medication outweigh its side effects; others choose to stop taking their medication because the side effects are so distressing. Some side effects that women, in particular, can find distressing include weight gain, hair loss and interaction with the oral contraceptive pill. This is a broad subject and Mind publishes information booklets on all psychiatric drugs that are prescribed in the UK (see Useful resources).

One of the most damaging consequences of taking medication can be dependency on, or addiction to, the drug. Dependence on a drug, like side effects, is highly individual, the result of a combination of physical and psychological factors. Just as there are people who never experience side effects, there are people who never experience dependency. Not all psychiatric drugs are addictive or habit-forming and those that are should be prescribed within strict guidelines to minimise the chances of dependency occurring. Despite this, many women in the UK are dependent on psychiatric drugs, most commonly 'minor' tranquillisers such as benzodiazepines (prescribed for anxiety or used as sleeping pills).

Sometimes people are not aware of being dependent on a drug until they stop taking it, or attempt to do so. This can result in withdrawal or 'discontinuation' symptoms that can vary in duration and severity. In recent years, antidepressant drugs from the SSRI (Serotonin Selective Re-uptake Inhibitor) group have been linked to withdrawal problems. This has serious implications for women, who are more likely than men to be prescribed antidepressant medication.

Women who are pregnant face additional problems with psychiatric medication. Some drugs, such as SSRI antidepressants [54] and the mood stabiliser, lithium, have been linked to developmental problems in the womb. If a woman is pregnant, or planning to have children, she should be fully informed about the risks and benefits of the particular drug she is taking. She should be given practical advice and support from her doctor and others involved in her treatment and care. If appropriate, she should be supported by her doctor to come off the medication or to reduce her dose and seek alternative forms of treatment - which could involve alternative medication.

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Chronic physical conditions

Chronic physical conditions are been associated with higher levels of mental ill health. This is especially relevant to women, who, due to longer life expectancy, have higher rates of long-term physical illness and physical disability than men. Moreover, evidence suggests that depression in older people with chronic physical conditions is likely to be overlooked; doctors, and others, can see it as the 'natural' result of old age or infirmity. [55]

Physical symptoms and mental distress

'Somatisation' is the manifestation of mental health problems as physical symptoms. Studies show that somatic complaints are two to three times more likely in women than in men. Somatisation can lead to delay in the detection of mental health problems and unnecessary or inappropriate treatment of physical complaints.

However, an equally serious problem for women in mental distress is the lack of recognition that may be given to their physical illnesses. This is because their symptoms may be seen as 'imagined' or psychosomatic. Research suggests that women with mental health problems are more likely than other groups to have their physical complaints disregarded and their requests for services denied. Studies have found that women with mental health problems have significantly more undetected medical problems than men and that women with bipolar affective disorder (manic depression) are three times as likely as men to have undiagnosed medical problems. [56]

Until recently, the long-term physical impact of childhood abuse was a neglected area of research. However, evidence now suggests that the chronic physical pain experienced by many survivors of childhood abuse may be linked to physical rather than psychological causes. Physical symptoms identified among women survivors of childhood sexual abuse include pelvic pain, gynaecological problems, irritable bowel syndrome, back pain and muscular tension in the jaw, neck and shoulders. Many women survivors have experienced the additional distress of having these problems regarded by doctors as psychosomatic. Some women have found themselves stigmatised as 'attention-seeking' or 'time-wasting' when presenting with these symptoms. [57]

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Behaviours around common mental health problems

Many mental health problems have indirect effects on physical health. Both anxiety and depression can result in headaches, weight loss or gain, muscular tension and lethargy.

In addition, many of the mental health problems that are more commonly diagnosed in women take the form of behaviours that can have devastating physical consequences:

• The physical effects of eating disorders include loss of bone mass, tooth decay, intestinal pains and heart problems. Anorexia nervosa has the highest mortality rate of any mental health problem
• Self-harm takes the form of cutting, scratching, hitting, burning or poisoning (including overdose). In addition to the physical pain of the injuries themselves, self-harm can have long-term effects - from scarring to the damage of internal organs. A recent study shows that more than 5 per cent of people who have been seen in hospital after self-harm will commit suicide within 9 years [58]
• Borderline personality disorder often includes self-harm and is accompanied by at least two other forms of self-destructive behaviour, such as binge eating, alcohol or drug abuse, dangerous driving or unprotected sex. All of these behaviours adversely affect physical health and lower the mortality rate of women in this group.

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Mental health of specific groups

Women in some social groups are more vulnerable than others to experiencing mental distress. While not all women in these groups will be affected, issues around age, ethnicity and sexuality can contribute to mental ill health.

However, membership of specific social groups can also provide access to information, social contact and a range of community-based services. The cultural contexts of many social groups can help women to gain valuable insights into their individual lives. Membership of a specific social group can therefore be important to many women in maintaining their mental health and wellbeing.

Young women

Evidence has shown a sharp decline in the mental health of young people over the past 25 years. This trend affects both young men and young women and covers the full range of mental health problems. [59]

In general, young women are more prone than young men to mental health problems such as depression, self-harm and eating disorders, which are often the outcome of 'internalising' negative emotions. Through internalisation, young women may hide or suppress negative emotions, or express emotional pain by harming their own bodies. Young men are more likely to externalise their distress in the form of conduct or anti-social behavioural problems. [60]

Internalised mental distress is difficult to detect, which may in part explain the higher rates of diagnosed mental health problems in young men than young women. However, a recent survey revealed significant levels of mental distress among young women, most of who had never been in contact with mental health services. The Teen Emotional Health Survey (2005) showed high levels of depression, self-doubt and poor self-image. The most frequently cited psychological burden was the pressure to look physically attractive, which was mentioned by 94 per cent of respondents. Other problems included bullying (mentioned by 60 per cent of respondents), the volume of school and college work, the pressure to succeed academically and family relationships. The survey confirmed evidence of high and increasing levels of drug and alcohol use among young women: a third of fourteen year olds admitted to drinking at least once a week, mostly in order to 'feel happy.' [61]

There is a strong correlation between child and adolescent mental health difficulties and mental health problems in adulthood. [62] Problems that are more likely to be diagnosed in women than in men, such as eating disorders, borderline personality disorder and self-harm, often have their onset in teenage years or in early adulthood.

Teenage girls and young women are a high risk group for traumatic experiences such as sexual abuse, rape and domestic violence. [63] As discussed above, girls who experience sexual or physical abuse are more likely to develop mental health problems in later life.

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Older women

Many people have direct experience of mental distress in later life: In its 2005 study, Mind found that 40 per cent of GP attendees, 50 per cent of general hospital patients and 60 per cent of care home residents are older people with mental health problems. After the age of 65, one in six people develop clinical depression and one in twenty people develop dementia. [64]

Mind also found that older people had experienced discrimination in their use of mental health services. In most local health authorities, older people are not eligible for adult mental health services after age 65; instead they are transferred to older people's or geriatric services, which generally leads to a reduction in the range and level of treatment options available. [65]

Issues around old age are especially relevant to women's mental health: due to higher life expectancy, women make up the larger part of this demographic group and, among all older people, women are more likely than men to be diagnosed with a mental health problem. [66] Higher rates of mental ill health have been associated with the greater social and personal pressures that women often face in later life: isolation and poverty are more common in older women than in older men. Older women are less likely to have a company or personal pension and more likely to be reliant on state pensions. Older women are less likely to be drivers or to have access to a car. Bereavement, chronic physical illness and institutional care are also more likely to impact upon older women's mental health. [67] However, the higher rates of diagnosed mental health problems in older women may in part reflect the fact that women are, in general, more likely than men to acknowledge their own distress and seek out appropriate help. Mental ill health is not an inevitable consequence of old age. There are many ways that older people can look after their health and find the support they may need for independent living. For more details about this, see the Mind factsheet, Older people and mental health.

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Lesbians, bisexuals and transgender (LGBT) women

Statistics consistently show higher levels of mental health service use, and higher levels of self-reported mental distress, among lesbians and bisexual women than among heterosexual women. Problems cited include higher rates of suicide, self-harm, anxiety and depression. [68] Higher rates of alcohol and drug use have also been identified. [69]

Lesbians and bisexual women may experience mental distress for reasons unconnected with sexuality, and establishing causes is always difficult. However, many studies have shown associations between negative attitudes towards homosexuality (including acts of discrimination) and mental ill health among gay, lesbian and bisexual people. In particular the experience of homophobic bullying (from verbal taunts to physical attacks) has been linked to mental distress. [70] The more subtle forms of discrimination that gay people face in their daily lives, such as a lack of gay-friendly social spaces or difficulties in accessing sexual health services, can also adversely affect mental health. Most forms of such discrimination are based on 'heterosexism,' which is the assumption, by individuals, social groups and institutions, that heterosexuality is the normal, superior or the only orientation. [71] Bisexual women can also experience the dual impact of exclusion from LGB services that are primarily geared towards lesbians, in addition to heterosexist discrimination.

Mind's 2003 study found that the attitudes of mental health professionals often reflected the heterosexist culture. Nearly half of lesbians and more than half of bisexual women had experienced negative or mixed reactions from mental health professionals when disclosing their sexuality. Although overt forms of discrimination were rare, the study found that assumptions of heterosexuality and a lack of empathy around lesbian and bisexual issues were widespread. [72]

Older service users may have encountered more extreme negative attitudes to their sexuality in the past, including the perception of their sexuality as a symptom of mental illness. Such attitudes are now very rare but can still occur, particularly among mental health professionals whose theoretical approaches are heterosexist. Freud, for example, described lesbians as immature women at a lower point in development, and believed homosexual women rejected femininity and wanted to be masculine. [73]
 
Over recent years, various social factors have given lesbians and bisexual women a stronger position in UK society, such as the introduction of Civil Partnerships (giving the same legal recognition to same sex partners as to opposite sex partners) and improved visibility in the mass media. These developments are likely to have positive effects on mental health.

As well as better recognition in the mainstream, lesbians and bisexual women have access to a range of organisations, operating local and national levels, which focus specifically on their needs. Most of these organisations are run by lesbian, gay or bisexual people and can be useful for the social opportunities they may provide or for specific services such as information, advice or counselling. It is also possible to find counsellors or therapists who identify as lesbian or bisexual, or who work for organisations that are positive about LGB issues. For more details of these services, see Useful resources.

'Transgender' is a broad term covering people who temporarily change their gender and appearance, those who do not believe in rigid or prescribed gender roles and people with gender dysphoria. Gender dysphoria is an overwhelming desire to live as a member of the opposite sex. People with gender dysphoria may become transsexual; that is, they may seek medical treatment to align their body with their sense of gender identity.

In comparison with lesbian, gay and bisexual issues, transgender mental health issues are relatively under-researched. However, it is believed that the experience of gender dysphoria, together with the stigma and discrimination transgender people may face, can have a major impact on mental ill health. [74] For details of organisations that serve transgender people, see the Mind booklet Understanding gender dysphoria. [75]

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Black and Minority Ethnic (BME) communities [76]

Mental health services, and concepts of mental ill health, reflect the cultures in which they originate and develop over time. Consequently, in the UK, mental health issues reflect the culture of the majority ethnic group, White British, and more widely, the European and American influences on medicine and psychology over the past two hundred years. The most powerful influences in Western medicine and psychology have historically been male; White British men occupy most of the senior positions in UK health services today. [77]

This context may cause women from Black and Minority Ethnic groups to feel culturally alienated from mental health services and from concepts used by mental health professionals to describe and address their distress. The nature and degree of cultural alienation will depend on many factors, from issues of language, religion and other cultural practices to familiarity with the majority culture. A crucial factor is always the efforts that organisations make to provide culturally sensitive services. The need for cultural sensitivity in women's mental health services has received sustained attention nationally in recent years and examples of good practice have been shared. [78] As a group, women have less social, political and economic power across all cultures. [79] Consequently, women from BME groups in the UK may experience the dual impact of powerlessness within their family or community setting and alienation from mental health services. The high levels of suicide and self-harm among young south Asian women have been cited to illustrate this point. [80]

Specific groups of BME women are heavily represented in rates of psychiatric diagnoses and service use: Pakistani and Bangladeshi women have higher rates of depression than their male counterparts and than White British women; higher rates of psychosis (including bipolar disorder and schizophrenia) are diagnosed among Black Caribbean women than among women from other groups. It is believed that these findings are partly explained by racial stereotyping within mental health services that reflects racism in the wider society. Many mental health service users from BME groups are also living in poverty, which is an important social factor in mental distress. [81]

The differences between the diverse ethnic groups that live in the UK today are such that generalisations are problematic. If you wish to know more about the mental health issues facing any specific BME group, it is likely that Mind publishes a factsheet on these issues - see 'Diversity' under the 'Information' section of Mind's website. In addition, there are groups and organisations, operating at local and national levels across the UK, that focus on the needs of women from particular BME groups. Many of these organisations are staffed by women who share the culture of their service users. Such groups can be useful for the social opportunities they may provide or for specific services such as information, advice or counselling.

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The way forward

Gender Equality Duty (GED)

The Gender Equality Duty (2007) is a piece of national government legislation that is in force from April 2007. The GED requires all public authorities to promote gender equality and eliminate sex discrimination. It applies to all public sector services, including health and social care, and to all charities and voluntary agencies that provide a service to the public. [82]

The GED is different from earlier legislation because it does not rely solely on individual complaints about sex discrimination. Instead, it places responsibility on service providers to demonstrate that they give men and women equal treatment. Service providers must design their services to meet the different needs of men and women on the basis of high quality evidence. The findings from consultations with service users and employees should make up an important part of this evidence. Service providers must address current inequalities in service provision and consider how gender differences may make a service more or less accessible.

This legislation will have a major impact on mental health services and on other public services that are implicated in health and wellbeing, such as housing, transport, education and employment.

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Mainstreaming women's mental health

The demands of the Gender Equality Duty (see above) reflect the aims first set out in 2002 on 'mainstreaming' women's mental health. Mainstreaming means integrating women's specific needs into all aspects of mental health care and treatment. Women service users have consistently cited a number of gender specific issues that need to be addressed by mental health services:

• Safety. This means protection from any form of harassment or abuse, whether physical, sexual or psychological. This is a fundamental human right and is essential to the wellbeing of women in their use of any mental health service. It is the highest priority of women who are inpatients on mental health hospital wards. [83]
• Access to female staff. Women have said that it is important to them to choose the gender of their key worker (doctor or therapist). [84]
• Acknowledgement of the social causes of mental distress. Women have reported an over-emphasis on biological causes of their mental distress to the neglect of social and personal factors such as poverty, social exclusion and experiences of physical and sexual abuse. [85]
• Family friendly services. Women want mental health services to support them in their role as mothers, recognise their fear of losing custody of their children due to mental distress, and recognise their potential desire to have children if they are not already mothers. Childcare facilities in all settings and family friendly visiting areas in residential settings would help women to maintain relationships with their children. [86]
• Housing and employment options. Women want access to safe accommodation and services that would support them to start, retain or return to meaningful employment. [87]

Some progress has been made since on these issues. In particular, the issue of inpatient safety has been the subject of government legislation, [88] as well as local and national campaigns. [89]  Although not all women inpatients have access to the safe, secure, single-sex wards that are their legal entitlement, improvements have been made in this area. Furthermore, awareness of the need for single sex provision, and of wider safety concerns, has been raised both within mental health services and among the general public. [90]

The Department of Health has produced implementation guidance to assist service providers in meeting the needs of women service users. [91] More detailed guidance has focused on the provision of women-only day services in the community. Such services usually adopt a 'holistic' approach to health and wellbeing, including physical, social and emotional issues. They may or may not be affiliated with mental health services. The implementation guidance stresses the effectiveness of non-medical interventions, such as befriending, information and advice, social activities and complementary therapies. It describes the importance of services that are designed and run by women who share the knowledge, culture and experiences of their users. [92]

Although it is likely to take time before all the intended improvements have been made, women service users now have a supportive policy context and evidence gathered from user-focused studies and successful campaigns. The resources below should be useful in helping women and those with an interest in women's mental health to explore these issues in more detail and access the services available.

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Useful resources

The list below is not exhaustive and covers only national-level resources. To find out what is available in your local area, check your phone book, contact your Primary Care Trust (in England) or Local Health Board (in Wales) or contact MindinfoLine for details.

Mind booklets
Available from Mind publications on 0844 448 4448 or the bookshop 

Mind 2006, Making sense of antidepressants
Mind 2004, Making sense of antipsychotics
Mind 2003, Making sense of minor tranquillisers
Mind 2005, Understanding anxiety
Mind 2005, Understanding addiction and dependency
Mind 2004, Understanding borderline personality disorder
Mind 2006, Understanding depression
Mind 2004, Understanding eating distress
Mind 2004, Understanding gender dysphoria
Mind 2006, Understanding postnatal depression
Mind 2004, Understanding premenstrual syndrome
Mind 2005, Understanding self-harm

Mind factsheets

Mind 2005, Children and young people and mental health
Mind 2002, Lesbians, gay men, bisexuals and mental health
Mind 2005, Older people and mental health
Mind 2006, Sexual abuse
Mind 2002, Statistics 3: Race, culture and mental health

Other Mind publications
Mind week report 2004, Not alone? Isolation and mental distress
Mind week report 2006, Out of the blue? Motherhood and depression
Mind 2005, Access all ages
Mind report 2004, Ward Watch: Mind's campaign to improve hospital conditions for mental health patients

For more Mind publications, see the bookshop

Other publications

Department of Health 2003, Mainstreaming gender and women's mental health: Implementation guidance

Department of Health 2006, Supporting Women Into The Mainstream: Commissioning women-only day services

Department of Health 2002, Women's Mental Health: Into the mainstream

Social Perspectives Network 2005, Women and Mental Health: Turning rhetoric into reality - sharing practice perspectives and strategies for action on women's mental health.

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National organisations

Age Concern England
Tel: 020 8765 7200 (general enquiries)
Helpline: 0800 009966
Web: www.ageconcern.org.uk

Age Concern Cymru
Tel: 029 2043 1555
Web: www.accymru.org.uk
Provides information and advice on issues around old age, including finance, health, the law and leisure activities. Delivers services through local centres across England and Wales and campaigns on issues that affect the lives of older people.

Association for postnatal illness (APNI)
Tel: 020 7386 0868
Web: www.apni.org
Provides a telephone helpline, information leaflets for those affected by postnatal illness and for healthcare professionals. Coordinates a network of volunteers, (telephone and postal), who have themselves experienced postnatal illness.

Battle Against Tranquillisers (BAT)
PO Box 658
Bristol BS99 1XP
Tel: (0117) 966 3629 or (0117) 965 3463
Web: www.bataid.org
Helps those who are addicted to tranquillisers through information and practical support, including a helpline and support groups.

British Association for Counselling and Psychotherapy (BACP)
Tel: 0870 443 5161
Web: www.bacp.co.uk
The leading professional organisation for counsellors and psychotherapists and reference point for anyone seeking a counsellor or therapist in the UK. Provides information about individual practitioners including, gender, areas of special interest, theoretical approach and languages spoken.

Borderline UK
Web: www.borderlineuk.co.uk
Mental health service user-led resource offering information and support on all aspects of borderline personality disorder.

Bristol Crisis Service for Women
PO Box 654
Bristol BS99 1XH
Tel: 0117 927 9600 (general enquiries)
Helpline: 0117 925 1119
Email: bcsw@btconnect.com
Web: www.users.zetnet.co.uk/BCSW/
Support women in emotional distress, with in particular those who self-harm, through a national helpline, publications, support groups and training for professionals.

Depression Alliance
Tel: 0845 123 23 20
Web: www.depressionalliance.org
Works to relieve and prevent depression by providing information, training and services such as support groups and a penfriend schemes.

Eating Disorders Association (EDA)
Tel: 0870 770 3256
Helpline: 0845 634 1414
Help email service: helpmail@edauk.com
Web: www.edauk.com
Provide information, advice and support to anyone affected by eating disorders. Services include publications, helplines, email and text support and self-help groups.

Equal Opportunities Commission (England)
Tel: 020 7222 1110 (general enquiries)
Helpline: 0845 601 5901
Web: www.eoc.org.uk
Works to eliminate sex discrimination and inequality related to gender issues through campaigns, information and assisting organisations to put legislation into practice.

Equal Opportunities Commission (Wales)
Helpline: 0845 601 5901
Web: www.eoc.org.uk
Works to eliminate sex discrimination and inequality related to gender issues through campaigns, information and assisting organisations to put legislation into practice.

First Steps to Freedom
Tel: 0845 120 2916 (information and helpline)
Web: www.first-steps.org
Gives practical support to those trying to recovery from obsessions, compulsions and phobias, including anxiety, eating disorders, tranquilliser withdrawal. Services include publications, online information, a helpline, telephone self-help groups and telephone counselling.

The Gender Trust
PO Box 3192
Birmingham BN1 3WR
Tel: 01273 234 024
Web: www.gendertrust.org.uk
Provides information and support services for all people with experience of transgender or transsexual issues or gender dysphoria.

National Black and Minority Ethnic Mental Health Network
Tel: 020 7582 0812
Web: www.bmementalhealth.org.uk
Network of mental health service users, carers and others concerned with the inequalities BME groups face in mental health. Campaigns to influence government policy through consulting its membership.

National Friend
Tel: 0121 684 1261
Web: www.friend.dircon.co.uk
Gives information on local LGB helplines across the UK.

National Institute for Clinical Excellence (NICE)
Tel: 020 7067 5800
Web: www.nice.org.uk
Independent organisation responsible for providing national guidelines for the treatment of illnesses and chronic health conditions. NICE guidelines are available for depression, anxiety, eating disorders and self-harm. All guidelines can be read online free of charge.

National Self-Harm Network
PO Box 7264
Nottingham NG1 6WJ
Web: www.nshn.co.uk
Provides online information and support for people who self-harm and is run by people with personal experience of self-harm.

No Panic
Tel: 01952 590 005
Helpline: 0808 808 0545
Web: www.nopanic.org.uk
Aims to give relief and rehabilitation to people who have anxiety disorders, including those experiencing tranquilliser withdrawal. Services include a helpline, information materials, telephone self-help groups and supported recovery programmes.

Pink Therapy
Tel: 020 7291 4480
web: www.pinktherapy.co.uk
London network of therapists who are positive about working with sexual minority people; many therapists identify as gay, lesbian, bisexual or transgender. Services include an online directory of therapists working across the UK who are positive about people from sexual minority groups.

Prison Reform Trust
tel: 020 7251 5070
web: www.prisonreformtrust.org.uk
Campaigns for change in policy and practice and provides information on issues such as conditions in prisons, alternatives to custodial sentences, support to prisoners and their families and the needs of different groups in the prison population.

Refuge
Tel: 020 7395 7700
helpline: 0808 2000 247 (24-hour, run by Refuge and Women's Aid)
email: info@refuge.org.uk
web: www.refuge.org.uk
Gives support and practical help to women who experience domestic violence, including a helpline, outreach services and a network of refuges across the UK. Runs specialist refuges for African, African Caribbean and South Asian women.

Safra
P.O. Box 45079
London N4 3YD
Web: www.safraproject.org
Organisation for lesbian, bisexual or transsexual women who are identify as Muslim religiously or culturally. Aims to empower women in these groups, raise awareness of their needs and eliminate the interrelated discrimination Muslim LGBT women may face.

Social Perspectives Network (SPN)
Tel: 020 7089 6864 or 020 7089 6840
Web: www.spn.org.uk
Coalition of mental health service users, carers, policy makers, health professionals and others who aim to influence mental health policy from a social perspective. Priorities include 'Women, Children and Families', 'BME and Culture' and 'LGBT Issues.'

Stonewall Cymru
Tel: 029 2023 7744
Web: www.stonewall.org.uk
Campaigning and lobbying organisation aimed at achieving equality for lesbians, gay men and bisexuals. Provides information on equalities and other LGB issues and works with other organisations to address the needs of LGB people in society.

Stonewall (England)
Tel: 020 7593 1850
Web: www.stonewall.org.uk
Campaigning and lobbying organisation aimed at achieving equality for lesbians, gay men and bisexuals. Provides information on equalities and other LGB issues and works with other organisations to address the needs of LGB people in society.

Threshold
Tel: 0808 808 6000 (freephone)
Email: info@thresholdwomen.org.uk
Web: www.thresholdwomen.org.uk
Women's organisation whose services include a national helpline giving information and emotional support on mental health issues.

Welsh Women's Aid
Tel: 02920 39 08 74
Helpline: 0808 80 10 800 (Wales Domestic Abuse Confidential Helpline_
email: angharadjones@welshwomensaid.org.uk
web: www.welshwomensaid.org
Works to end domestic violence against women and children through campaigning, telephone and email helplines and a network of refuges across Wales.

Women's Aid (England)
PO Box 391
Bristol BS99 7WS
Tel: 0117 944 4411 (general enquiries)
Helpline: 0808 2000 247 (24-hour, run by Refuge and Women's Aid)
Helpline email: helpline@womensaid.org.uk
Web: www.womensaid.org.uk
Works to end domestic violence against women and children through campaigning, telephone and email helplines and a network of refuges across England.

Young Minds
Tel: 020 7336 8445
Web: www.youngminds.org.uk
Campaigns to improve the quality of children's mental health and provides information on mental health issues for children and young people, parents and carers.

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This factsheet was written by Rachael Twomey, November 2006.

[1] Department of Health, 2002, Women's Mental Health: Into the Mainstream, London: DH; Mind, 2005, Statistics: How common is mental distress? London: Mind Publications.
[2] Department of Health, 2002, Women's Mental Health: Into the Mainstream, London: DH.
[3] Mind, 2006, Understanding postnatal depression, London: Mind Publications.
[4] Prison Reform Trust, 2006, Prison Factfile: Women, London: Prison Reform Trust.
[5] Women's Aid, 2006, How common is domestic violence? www.womensaid.org.uk
[6] Eating Disorders Association, 2004, Some statistics, at www.edauk.com/NewsEventsPressMedia/PressMediaInformation/Somestatistics.
[7] Department of Heath, 2002, Women's Mental Health: Into the Mainstream, London, DH.
[8] Mind, 2005, Men's mental health, Mind Publications.
[9] Department of Health, 2002, Women's Mental Health: Into the mainstream, London, DH.
[10] Department of Health, 2002, Women's Mental Health: Into the mainstream, London, DH.
[11] National Institute for Clinical Excellence, 2004, Anxiety: Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care, London, NICE; National Institute for Clinical Excellence, 2004, Depression: management of depression in primary and secondary care, London, NICE.
[12] Schmidt, U. 'Eating disorders' in Kohen, D. (ed). 2000, Women and Mental Health, London: Routledge
[13] Schmidt, U. 'Eating disorders' in Kohen, D. (ed). 2000, Women and Mental Health, London, Routledge.
[14] Rowbotham, S. 2006, 'Feed the need: increasing service users' involvement in the field of eating disorders', Mind Annual Conference, 15 March, Harrogate.
[15] Rowbotham, S. 2006, 'Feed the need: increasing service users' involvement in the field of eating disorders', Mind Annual Conference, 15 March, Harrogate.
[16] National Institute for Clinical Excellence, 2004, Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders, London: NICE.
[17] Batty, D. 2004, 'Self-harm patients "deserve dignity"', The Guardian, 28 July 2004,
[18] National Institute for Clinical Excellence, 2004, Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, London: NICE.
[19] Mind, 2004, Understanding personality disorder, London: Mind Publications.
[20] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[21] Mind, 2004, Understanding borderline personality disorder, London: Mind Publications.
[22] Bexson, T. 2004, 'Learning to feel', Mental Health Today, November 2004.
[23] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[24] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH; National Institute for Mental Health in England, 2004, Personality disorder: No longer a diagnosis of exclusion, London: NIMHE.
[25] Mind week report, May 2006, Out of the blue? Motherhood and depression, London: Mind.
[26] Mind, 2006, Understanding postnatal depression, London: Mind Publications.
[27] Mind week report, May 2006, Out of the blue? Motherhood and depression, Mind: London.
[28] Mind, 2005, Men's mental health, London: Mind Publications.
[29] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[30] Cobb, A. 2002, Mind's response to 'Women's Mental Health: Into the mainstream', London: Mind.
[31] Mind week report, 2004, Not alone? Isolation and mental distress, London: Mind.
[32] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: Mind.
[33] Mind factsheet, 2005, Men's mental health, London; Mind.
[34] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[35] Department of Health 2002, Women's Mental Health: Into the mainstream, London: DH.
[36] Cobb, A. 2002, Mind's response to 'Women's Mental Health: Into the mainstream', London: Mind.
[37] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[38] Spataro, J. et al. 2004, 'Impact of child sexual abuse on mental health', British Journal of Psychiatry, vol.184, 416-421; Senior, R. et al. 2005, 'Early experiences and their relationship to maternal eating disorder symptoms, both lifetime and during pregnancy', British Journal of Psychiatry, vol.187, pp.268-273.
[39] Coid, J. et al. 2001, 'Relation between childhood sexual and physical abuse and risk of revictimisation in women: a cross-sectional survey', The Lancet, vol.358, pp.450-454.
[40] Department of Health, 2003, Mainstreaming Women's Mental Health: Implementation guidance, London: DH.
[41] Women's Aid, 2006, How common is domestic violence? Bristol: Woman's Aid.
[42] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[43] Coid, J. 2003, 'Abusive experiences and psychiatric morbidity in women primary care attenders', British Journal of Psychiatry, vol.183, pp.332-229.
[44] Department of Health, 2003, Mainstreaming Women's Mental Health: Implementation guidance, London: DH.
[45] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[46] Prison Reform Trust, 2005, Prison Factfile: Women, London: Prison Reform Trust.
[47] Prison Reform Trust, 2005, Prison Factfile: Overcrowding, London: Prison Reform Trust; Prison Reform Trust, 2005, Prison Factfile: Mental Health, London: Prison Reform Trust.
[48] Prison Reform Trust, 2005, Prison Factfile: Women, London: Prison Reform Trust.
[49] Prison Reform Trust 2005, Prison Factfile: Women, London: Prison Reform Trust.
[50] Anon, 2006, 'The challenge of providing NHS care in prison', BBC News online, 9 April.
[51] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[52] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[53] Mind, 2006, Understanding postnatal depression, London: Mind Publications.
[54] 'SSRIs' stands for 'selective serotonin reuptake inhibitors.' This group of antidepressants was first marketed in the UK in 1989. It includes the drugs Prozac and Seroxat that have received high profile media coverage. For more information, see Mind's booklet Making sense of antidepressants.
[55] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[56] Franciosi, L. 2005, 'Women's mental health and wellbeing: a global perspective', Community Practitioner, vol.78, no.11, pp.387-388.
[57] Nelson, S. 2003, 'Your body tells the truth', Mental Health Today, June, pp.20-23.
[58] Skegg, K. 2005, 'Self-harm', The Lancet, vol.366, October, pp.1471-1483.
[59] Ward, L. 2005, 'Doubt and depression burden teenage girls', The Guardian, 24 February.
[60] Young Minds, www.youngminds.org.uk/gender (accessed on 29 November 2006).
[61] Ward, L. 2005, 'Doubt and depression burden teenage girls', The Guardian, 24 February.
[62] Mind Health Foundation, 2004, Lifetime Impacts: Childhood and adolescent mental health , understanding lifetime impacts, London: Mind Health Foundation.
[63] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[64] Mind, 2005, Access all ages, London: Mind.
[65] Mind, 2005, Access all ages, London: Mind.
[66] Office of National Statistics, 2003, Mental health of older people, London: The Stationery Office.
[67] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[68] Hughes C. and Evans, A. 2006, 'Health needs of women who have sex with women', British Medical Journal, 25 October.
[69] Warner, J. et al. 2004, 'Rate and predictors of mental illness in gay men, lesbians and bisexual men and women', British Journal of Psychiatry, vol.185.
[70] Moore, P. 2004, 'Homophobia and gay health', Rainbow Network News, http://www.rainbownetwork.com/News/default.asp?iChannel=2&nChannel=News
[71] Mind, 2004, Lesbians, gay men and bisexuals' mental health, Mind: Publications.
[72] Mind, 2003, Mental health and social wellbeing of gay men, lesbians and bisexuals in England and Wales, London: Mind.
[73] Mind, 2004, Lesbians, gay men and bisexuals' mental health, London: Mind.
[74] The Gender Trust 2006, How does a transsexual person adjust socially?, at www.gendertrust.org.uk/htm/index1.htm under 'FAQs'.
[75] Mind, 2004, Understanding gender dysphoria, London: Mind.
[76] Mind, 2002, Statistics 3: Race, culture and mental health, London: Mind Publications. "Mind uses the term 'Black' for people of African, African Caribbean and Asian origin who face particular pressures as 'visible' minorities in a racist society. 'Minority ethnic people' refers to people who may or may not be visibly part of a minority: for instance Irish people. We acknowledge that no terminology is acceptable to all and that self-definition should be encouraged and respected."
[77] NHS Information Centre, 2006, www.ic.nhs.uk/pubs/nhsstaff
[78] Social Perspectives Network, 2005, Women and Mental Health: Turning rhetoric into reality - sharing practice perspectives and strategies for action on women's mental health (PDF file)
[79] Franciosi, L. 2005, 'Women's mental health and wellbeing: a global perspective', Community Practitioner, vol.78, no.11.
[80] Gill, A. 2004, 'A lethal code of honour', Community Care, 28 October.
[81] Mind, 2002, Statistics 3: Race, culture and mental health, London: Mind Publications.
[82] Equal Opportunities Commission, 2006, Gender Equality Duty
[83] Cobb, A. 2002, Mind's response to 'Women's Mental Health: Into the Mainstream', London: Mind.
[84] Department of Health, 2002, Women's Mental health: Into the mainstream, London: DH.
[85] Department of Health, 2002, Women's Mental Health: Into the mainstream, London: DH.
[86] Department of Health, 2002, Women's Mental health: Into the mainstream, London: DH.
[87] Department of Health, 2002, Women's Mental health: Into the mainstream, London: DH.
[88] Department of Health, 2002, Mental Health Policy Implementation Guide: Adult Acute Inpatient Care Provision, London: DH.
[89] One good example of a local campaign is Southwark Mind's Campaign for Women Only Psychiatric Ward (CWOPW), which started in 1998 and led to the establishment of single-sex wards in Southwark in 2004.
[90] Mind, 2006, www.mind.org.uk/News+policy+and+campaigns/Campaigns/Ward+Watch
[91] Department of Health, 2003, Mainstreaming Gender and Women's Mental Health: Implementation Guidance, London: DH.
[92] Department of Health, 2006, Supporting Women into the Mainstream: Commissioning women-only community day services, London: DH.