Sex and Gender Issues
Although schizophrenia occurs equally in men and women, there are important sex and gender differences in the way the disorder is experienced. Research has shown significant differences in the pre-morbid competence of men and women and in the presentation of the illness, including differences in age of onset, age of initial hospitalisation and response to medications (Nasser, Walders & Jenkins, 2002). The way men and women are socialised to deal with adversity and illness may also influence how each sex experiences schizophrenia. Recognising these differences is important as they have implications for prevention, treatment, and promotion of recovery.
Evidence for sex differences in schizophrenia
Most research has found the average age at onset of schizophrenia is lower in men than in women, with women developing schizophrenia an average of five to ten years later. The peak age of onset for men is in their early to mid twenties, while for women it is in the late twenties to early thirties (Kulkarni 1996; Angermeyer et al. 1990; Seeman 1986).
Course and outcomes
Several studies have reported that women have a less severe course of schizophrenia than men do. Overall, women have fewer hospitalisations and inpatient stays, fewer negative symptoms, good social adaptation and a better response to lower doses of antipsychotic medication. However, women who do not make a good recovery often have worse outcomes than men do in the same situation (Kulkarni 1996; Angermeyer et al. 1990).
Women have a greater affective component in their clinical presentation, while men experience more negative symptoms (Kulkarni 1996 ; Angermeyer et al. 1990; Seeman 1986).
Attention also needs to be paid to the impact of social factors and how these influence each gender's experience of schizophrenia. Women, for example, are disproportionately the targets of domestic violence (Cox 1994), while men are more likely to experience homelessness.
Possible explanations for the observed gender differences in schizophrenia
A broad range of biopsychosocial reasons have been suggested to explain the differences between men and women's course and outcome of schizophrenia.
- There may be two distinct types of schizophrenia: an early onset, more severe type that mainly affects men, and a later-onset, less severe type most likely to affect women.
- There may be some non-specific stress impinging on men which selectively causes the condition to occur earlier.
- Women may have some biological protection which prevents schizophrenia from occurring earlier and, once developed, promotes a more favourable course. In line with this theory, the role of oestrogen in women is being investigated.
Issues affected by sex and gender
Women differ from men in their response to antipsychotic medications yet the standard dosages that are advocated for treatment of psychosis are usually based on the responses of men (Kulkarni 1996). Research suggests that, both with respect to acute response and to maintenance, women with schizophrenia under 40 require lower antipsychotic doses than men. With increased age this female advantage may disappear (Seeman 1986). The prescription of antipsychotic medication should be tailored to account for these gender differences. Additionally, as women generally experience more affective symptoms than men do, different medication (possibly with an increased use of mood stabilisers) may be warranted for women (Kulkarni 1996).
Research has indicated that women, especially postmenopausal women, are more vulnerable than men to tardive dyskinesia (a medication side effect). The side effects of some medications used in the treatment of schizophrenia can also cause sexual dysfunctions (Seeman 1986). These problems can become a disincentive for men and women to continue taking medication.
Age of onset
Men are more likely to develop schizophrenia in their late adolescence or early twenties, which represents a very formative time in terms of developing identity, relationships and careers. Thus men who develop schizophrenia at this age could find their maturation is delayed by the illness. Rehabilitation for men needs to reflect a 'learning to build' process whereby social and vocational skills are taught (Kulkarni 1996).
The later onset of schizophrenia in women means that they are more likely to have established relationships, careers and families. Thus, psychosocial therapies, which deal with losses sustained at a later age, may be important for women. The recovery therapies for women involve a 'rebuilding' rather than a 'learning to build' as may be the case for men (Kulkarni 1996).
Suicide is a major public health problem for Australia and most of those who die in this manner are men (Jorm 1996). People with schizophrenia have a higher risk of suicide compared to the general population and the risk for men with schizophrenia is greater still (Seeman 1986; Caldwell & Gottsman 1990).
Help seeking and support
Men and women differ in support they seek and receive: men and women differ in their use of mental health services, with women being far more likely to seek help for minor mental health problems. The gender differences are less pronounced when considering access to hospital treatment. This indicates many men do not receive or access services until they are experiencing severe mental health problems (Jorm 1996).
These differences in service utilisation could reflect the stigma attached to men who need help. There is social pressure for men to be 'strong' and independent, thus it may be harder for a man to admit he is not coping and consequently seek help.
Women in general are more successful at establishing close friendships, which provide them with an important means of support. Many men do not have the ability to foster intimate friendships and thus lack this source of support.
Drug and alcohol misuse is more prevalent among men, indicating this may be used as a means of coping (albeit dysfunctional).
Safety and homelessness
It is indisputable that a safe environment is conducive to the promotion of recovery and the prevention of relapse in people with schizophrenia. Yet many women and men with a mental illness do not have this basic need met.
Women with a mental illness have a greater risk of their safety being violated simply because of women's situation in society generally. Women are still overwhelmingly the primary recipients of domestic violence and sexual abuse in Australia, with the home being where most violent acts are perpetrated (Cox 1994).
Inpatient settings are not necessarily safe places for women particularly where men outnumber women (Kulkarni 1996). Threats to women's safety in inpatient settings may range from rape or sexual harassment by other patients or staff, to being subjected to a lack of privacy in the bedroom and bathroom areas (Cox 1994). Men may also feel threats to their safety and privacy in inpatient settings.
Most homeless people in Australia are men (Jorm 1996) and nearly a quarter of these men have schizophrenia (Hodder et al. 1998). Over 90% of homeless men reported experiencing a major trauma. The stress and trauma associated with being homeless has extremely detrimental effects on the mental health of these men.
A gross disproportion of homeless women have schizophrenia compared to the general community (46% as opposed to 1%) and these women are at enormous risk of being the recipients of violence (Hodder et al. 1998). The latter research found every homeless women had been subjected to some form of major trauma such as rape or physical assault.
The provision of vocational rehabilitation and vocational programs are important for the promotion of recovery and prevention of relapse in people with schizophrenia (Lehman 1995). Being unable to work because of mental illness or being unable to find work is particularly difficult for men because their identity has traditionally been closely tied to work (Jorm 1996). However, this is not only an issue for men and the problems of being unable to find work needs to be addressed for any person with schizophrenia.
Men represent 95% of the people in Australian gaols and although the exact figures are not known, the proportion of these men with mental illness is significantly higher than in the general population (Jorm 1996).
Gay and lesbian people with schizophrenia
There is virtually no research available that investigates the needs of gay men and lesbians who have schizophrenia. Much of the literature which deals with gay and lesbian people focuses on other mental health problems, especially those related to depression and substance abuse. No research inquiring specifically into outcomes for gay and lesbian individuals who have schizophrenia could be uncovered by an extensive search of a number of databases of psychiatric, medical or sociological literature, legislative acts or in text books relating to homosexuality and mental health.
While there are many studies of homosexual activity among inpatient, outpatient and the homeless people with a mental illness (Gottesman & Groome 1997), many of whom also had schizophrenia, it is interesting to note that in a number of these studies, most of those individuals did not identify themselves as homosexual, as they had also been actively heterosexual.
Specific social identity developed around a sense of being gay or lesbian is separate and distinct from the performance of same-sex sexual acts. Cass (1996) explains how this is predominantly a Western cultural phenomenon, and this should be taken into account when working with people who may participate in same-sex sexual acts, but may not identify with being gay or lesbian.
Sexual behaviour is often discussed in psychiatric literature. It has been acknowledged that individuals with schizophrenia tend to retain their sexual drive, and their heterosexual or homosexual orientation (Jacobs & Bobek 1991). However, it is the consequences of this behaviour, especially in relation to the transmission of the HIV virus and other sexually transmitted diseases, that are the issue for most authors rather than issues related to gay or lesbian identity (e.g. Goisman et al. 1991; Rector & Seeman 1992). The effectiveness of education to reduce the likelihood of contracting sexually transmitted diseases, including HIV has been studied and reported, but again, with little reference to social identity based on sexual orientation (Gottesman & Groome 1997).
The fact that individuals who have a gay or lesbian social identity make up a percentage of the general population in so-called Western countries such as Australia implies that such individuals will also be diagnosed with schizophrenia at the same rate as the general population.
Issues for homosexual people with schizophrenia
Consolidation of identity is one of the major difficulties experienced by individuals with schizophrenia in relation to their illness. CASs (1996) describes the process of identity formation (based on sexual orientation) in Western societies for gays and lesbians, and suggests that there are at least six stages through which this identity formation passes to achieve identity synthesis as a gay or lesbian person. Consequently, mental health care service providers need to be mindful not only that such identity issues may exist, but that their approach to that person needs to be on an individual basis, dependent on which stage the person has reached in identity formation.
Homosexual people experience discrimination in a wide range of life areas including: accommodation, employment, access to health and other services and spousal and partner rights (in financial and property settlements, superannuation and access during hospitalisations) (HREOC 1997).
The amount of legislative protection available to individuals who experience discrimination on the basis of their sexual orientation varies significantly between each State and Territory. Where legislation exists, it is complaints driven, in that it requires that the individual who is discriminated against to have the personal, financial and emotional resources to pursue satisfaction under the law against those who discriminate against him or her.
Mental health services should be delivered in a non-discriminatory environment which recognises and respects the right of the individual with schizophrenia to equal access to mental health care and services, irrespective of sexual preference. This right should be afforded to all people with schizophrenia, irrespective of the existence of anti-discrimination legislation such as the NSW Anti Discrimination Act and interpretations of the Human Rights and Equal Opportunity Commission Act 1986.
For a list of references for this quality of life section on Sex and Gender Issues, click here.
For more information on gay and lesbian issues, visit the Sydney PRIDE Centre's website who run an associated support group with the Schizophrenia Fellowship of NSW.
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