The importance of gender in crisis care
The therapist assessing me for my seventh or eighth admission to a women’s crisis house says: “Have you ever been sexually, physically, or emotionally abused?”
She tells me they ask all the women who are admitted the same question so that everyone who has been abused knows it is safe to talk about it with them.
I tell her I’ve never been abused, not in the way she means anyway.
I know that this puts me in the minority. Estimates for the proportion of women with severe mental health problems who are survivors of domestic abuse are about 70 per cent*.
The therapist’s question makes me think about my experiences with men.
Some have been intrusive, intimidating, frightening incidents. Over the years, men have exposed themselves to me, followed me and sworn at me. All in public places, all in broad daylight. These experiences tell me that it’s not always safe to be a woman, even in places you’d expect your safety to be guaranteed.
What this means for my mental health is that when I am in a crisis, and I am anxious, I am more anxious around men I don’t know. It means I am frightened of being on a mixed ward where I can’t run away if a man decides to expose himself to me, or thinks it’s OK to tell me to “smile, darling”. I am frightened of being left in the custody of a male security guard while I am waiting to be assessed, of being on close one-to-one observation with a man who works on a ward. I am less likely to tell a male member of A&E staff that I am suicidal, or let him assess my injuries if I have self-harmed; when control of my body is all I have, it is harder to give up that control to a man. Even if he is a doctor. Even if he is trying to fix it.
This doesn’t mean I am never able to work with men or use mixed-gender services where they are longer term and community based, or where I have time to learn to trust the men involved or can walk out of the building if I need to. But imagine how much my fears would be magnified if I was a woman who had been coerced or beaten or otherwise abused by my partner, father, or son; if I was a refugee who left my home after being raped by a man in uniform; or if I was a trans woman, frequently subject to physical and psychological violence.
Mental health services should operate on the assumption that women who are frightened are more frightened of men. They will be right most of the time. Whereas if they assume this isn’t the case, things go wrong quite a lot of the time; gender-based needs are sometimes accommodated if you ask to see a woman or to be under a women’s service, or if somebody on the staff notices who you are frightened of and joins the dots. But how many people feel able to ask for it? It took me a year to realise I was allowed to, and sometimes asking to see a woman is treated as an insult to men working for services. We need to create an environment where these options are routinely offered upon assessment. Not every woman will be bothered either way. But some will be, and most of them would be too scared to ask of their own accord.
Some mental health trusts do fantastic work around this, but nobody is collecting the relevant data, so it is difficult to campaign for change at a broader level. Nobody is asking how many times a woman on a ward has been left on one-to-one observation overnight with a man (which could also read ‘how many times a frightened woman has been expected to go to bed while a male stranger watches her sleep’). Nobody is asking how often a man from the crisis team visits a woman alone in her home. Nobody is asking how many times a woman has asked to see a female member of staff. And as budgets get ever tighter, gender sensitivity is increasingly seen as an optional extra, particularly in crisis care. This is not OK.
The Care Quality Commission needs to start collecting data on these questions as a routine part of their inspections and they need to start holding services to account for how they respond to these needs. Maybe that way, we can begin to feel safe in our bodies when we are struggling – and this can be our starting point, as we move on from our crises, for learning to feel safe in our minds.
* This UCL study found that “69 per cent of women and 49 per cent of men with severe mental illness reported adulthood domestic violence.” Forty per cent reported being raped. Obviously there’s some overlap between those two groups, but that’s a lot of women, especially considering that the study looks at incidences in adulthood and so doesn’t include traumatic childhood abuse. Anecdotally, almost every woman I meet through mental health services has experienced some kind of abuse at some point in her life.