Last week my friend Maria was finally given a diagnosis of autism at 28 years old. Maria has always been painfully aware that there was something different about her. She engaged with mental health services for many years but for a long time she received no diagnosis. She read different accounts of psychiatric disorders in the hope to better understand herself, but nothing seemed to fit. It wasn’t until she encountered a book on the experience of female autism that she had an ‘Aha!’ moment. The book identified unique traits that are more likely to be displayed by autistic females compared to autistic males. The first-person reports collated by the author reflected Maria’s own experiences- and everything clicked into place.
Although we lack consensus on the role of gender in psychopathology, there is no doubt that there are gender differences in the epidemiology of psychiatric disorders. Some disorders, such as autism and substance abuse, are more prevalent in men. Other disorders, such as anorexia and anxiety, are more commonly found in women. How can we account for gender differences in psychopathology? There are two main ways in which researchers have attempted to explain this. One is through ‘true difference’, whereby there are inherent gender differences that occur in psychiatric disorders. The other is gender bias. For instance, through ‘sampling bias’: a lack of inclusion of one gender in research studies results in a one-sided understanding of the given condition. A more prevalent form of gender bias is ‘data analytic bias’, where there is an equal sample of both men and women, yet the data is not analysed according to gender and thus fails to illuminate different gendered experiences. Alternatively, there may be a ‘referral bias’: one gender may be more likely to be referred for treatment.
Most mental health research largely ignores or minimises the role of gender differences.
Although there is growing research in the area, most mental health research largely ignores or minimises the role of gender differences. As such, we risk falling back on a gender-neutral account of psychiatric disorder, thus obstructing psychiatric knowledge and undermining the validity of the diagnostic criteria. Moreover, if we do not account for gender differences in psychopathology, certain people are likely to be misdiagnosed, diagnosed later in life or not diagnosed at all because their gender-specific symptoms are obscured from the interpretive framework. Beyond diagnostic issues, a gender-neutral account may lead to what Miranda Fricker calls hermeneutical injustice. Hermeneutical injustice occurs when a person cannot make sense of their experiences as their marginalised perspective is excluded from the interpretive framework. For example, until she found the book on female autism, Maria’s experience of autism was obscured by a male-coded understanding of her illness. As such, Maria lacked the hermeneutical resources required for her to make sense of her autism experience.
Identifying gender differences in psychiatry is essential for avoiding such hermeneutical injustice, developing accurate diagnostic criteria and for effective psychiatric assessment and treatment. Rather than pretending that gender differences do not exist or diminishing their role, phenomenological psychopathology should acknowledge how gender differences shape the illness experience. I argue that phenomenological psychopathology can offer important insight into the gender differences in psychopathology.
Rather than pretending that gender differences do not exist or diminishing their role, phenomenological psychopathology should acknowledge how gender differences shape the illness experience.
Phenomenological psychopathology has its roots in Karl Jasper’s seminal work General Psychopathology, where Jaspers marries psychiatry and phenomenology to form an approach to psychotherapy that puts the life-world of the psychiatric patient at the fore. Advocates of the phenomenological method recognise that it is impossible to conduct an isolated investigation on the ‘mind’ or ‘brain’ of a psychiatric patient because embodied subjectivity is irreducible to a mere mind. Rather, phenomenological psychopathology surpasses the limited scope of pre-structured interviews and diagnostic criteria by examining the patient's life-world. Phenomenological psychopathology aims to create an alternative language to that advanced by psychiatry; a language that originates from the patient’s experience of psychiatric illness.
The lifeworld of the patient is structured by gender, race, ethnicity, age, sexuality and other characteristics that give their psychiatric disorder a unique meaning. Therefore, we ought to consider how these structural factors intersect at a primordial level of the illness experience. By ignoring these aspects of the patient’s identity, we have only a partial view of the patient’s lifeworld. Phenomenological psychopathology in its current form is insufficiently sensitive to the intersectional character of lived experiences. Yet, by developing a phenomenological account of gender difference, we could go some way towards eliminating gender bias from the interpretive framework, and improve both our own and the patient’s understanding of the illness experience. Through an in-depth examination of the gendered interpersonal, intentional, temporal, spatial and affective structure of the patient’s life-world, plus their values and personal history, we can develop a gender-specific language that originates from the patient’s experience of psychiatric illness, meaningful first and foremost to the patient themselves.
Lucienne Spencer is a postdoctoral researcher for a Wellcome Trust funded project entitled ‘Renewing Phenomenological Psychopathology’ at the Institute of Mental Health, University of Birmingham.