Goods on which one loses: Women and mental health in China

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Sot'. Sci. Med. Vol. 41, No. 8, pp. I159-1173, 1995 Copyright ~3 1995 Elsevier Science Ltd

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GOODS ON WHICH ONE LOSES: WOMEN AND MENTAL HEALTH IN CHINA

V E R O N I C A P E A R S O N

Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam Road, Hong Kong

Abstract--This article is broadly divided into three sections. The first part deals with the traditional aspects of gender discrimination in China. Before the Communist government came to power in 1949, discrimination against women was institutionalized within all the usual structures of society: family, the economy, education, culture and the political system. It was one of the major policy initiatives of the Communist government to do away with unequal treatment of women. However, it is very easy to demonstrate that significant discrimination against women still exists. The Chinese government argues that this is because of 'remnants of feudal thinking'. Although this may be partly true, there are aspects of current Chinese society that encourage the continuation of this cultural tradition.

The second part of the article examines what is known of the epidemiology of mental illness in China with particular reference to gender. As is the case in Western countries, depression and neurotic disorders are diagnosed more frequently in women than in men, although, overall, the prevalence rate is much lower than in Western countries. What is unusual is that schizophrenia, which is diagnosed at roughly equal rates for men and women in Western countries, is diagnosed more frequently in women in China. Despite this, women occupy fewer psychiatric hospital beds and generally receive fewer resources (e.g. health insurance) than men. Suicide rates are very much higher in China than, for instance, in America, and the suicide figures for young, rural women are particularly disturbing.

The third part of the article is based on three interviews with women in a psychiatric clinic in Hubei province. Through the information and life experience described by these women, it is shown how the matters discussed in the previous two sections have an impact on individual lives, and how illness is used as both a metaphor and a strategy.

Key words--women, mental health, China, suicide

It is only relatively recently tha t gender effects on menta l heal th s tatus have begun to at t ract at tent ion. Differences in menta l heal th between men and women may be seen as a reflection of their posit ion in the social world or as biologically determined or as an interact ion between the two. Whatever the causes the consequences are real and some of these consequences are very obviously man-made [1].

Discr iminat ion against women is a pervasive p h e n o m e n o n world wide. It is a fundamenta l tenet of the perspective put forward in this paper tha t the negative social s i tuat ion tha t women experience will need to be taken into account in any examinat ion of women ' s need for, and use of, menta l heal th services and the t rea tment they receive therein. As Paltiel

states:

. . . the mainstream literature pays little attention to the mental health effects of discrimination, not a discrete life event but a pervasive condition of women's lives in both developed and developing countries [2, p. 40].

Bernandez [3] suggests tha t there are four social factors affecting the menta l heal th of women. The first is the way in which they are socialized into their concept ion of normal female behaviour . Such behaviours may come to be regarded as na tura l when in fact they are not, and non-conformi ty interpreted as ' illness' or deviance. Second, if women as a cat-

egory are clearly defined as second class citizens and have a lower social status than men, this is likely to have a deleterious effect on the psyche of individual women. Thirdly, discr iminat ion in education, employment and other formal sectors may lead to bit terness and frustrat ion. Four th , the heal th professionals f rom whom they seek help may be as influenced by cultural stereotypes as laymen and consequent ly reinforce behaviours or set standards tha t are profoundly unhelpful for individual women.

This paper is a first a t tempt to consider some of these issues in the context of the People 's Republic of China. It is not an a t tempt to demonst ra te that biological differences between the sexes have no effect on mental health. Rather , it is an explorat ion of the social factors tha t bear on this subject. The topic is approached from bo th the macro and micro levels. The general posi t ion of women in Chinese society, past and present is outl ined because the context of menta l heal th issues, and the personal experience of psychological distress, are clearly of great importance. Then epidemiological da ta on the prevalence of menta l disorders is examined. Empirical material gathered by the au thor is presented, based on psychiatric hospital and ward surveys and three case studies of women from a series of 37 interviews under taken

1159

1160 Veronica Pearson

at a psychiatric out-patients' clinic. This material is then used to demonstrate how social and economic structures are reflected in the lives of women, their experience of psychological distress and the treatment offered them.

WOMEN 1N eRE-REVOLUTIONARY CHINA

Daughters were destined at birth to be married into another family, who would then benefit from their labour and reproductive capacities. They were, consequently, 'goods on which one loses'. Women belonged to, rather than in, their families. They could be legitimately sold, because of poverty, to pay off gambling debts, to become a wife or concubine, or into a brothel [4-6], or into a form of indentured labour when children, known as mui tsai [7]. This possibly transformed them into goods on which one gained, but they remained goods.

A missionary psychiatrist with experience of female patients in China who had been mui tsai in their youth commented:

She may, indeed, during her girlhood, pass several times into other hands until all family history is lost and, indeed, all personal history up to the time of being taken over by her owners. Herein lies a great difficulty in making a diagnosis; because in very many cases of women it is impossible to get any history whatever of early life and family. The women very often remember nothing of their parents, having been given away by them when little children [8, p. 413].

Traditionally, women were to obey their father when still single, their husbands when married and their sons when widowed. Wives could be divorced, amongst other things, for failing to bear sons, failing to obey and serve parents-in-law and being too garrulous [4]. Thus it has been widely acknowledged that, while life was hard for all ordinary people in traditional China, it was considerably more difficult for women of all classes for "throughout society, from the Imperial Court to the peasant household, men outranked women" [9, p. l].

One of the main platforms, at least in theory, of the Communist revolution was that women should be liberated from the weight of the 'four mountains': feudalism, capitalism, colonialism and male supremacy. Thus Mao Zedong coined the slogan "women hold up half the sky" to emphasize the revolution's commitment to ensuring them equal status. Maoist ideology had as a core component the necessity to transform the social relations of Chinese society, which meant radical changes in the status of women. The 1950 Marriage Law, passed one year after the Chinese Communist Party (CCP) gained power, embodied this commitment, giving among other things, the right to choose one's spouse freely and the right for women to seek divorce; which they did in droves. Nowadays, such optimism seems mis- placed.

THE CURRENT POSITION OF WOMEN IN CHINESE SOCIETY

What follows is not intended to be an exhaustive analysis of the present situation of women in China, but to give the reader a sense of the conditions in which they attempt to construct the narrative struc- ture of their lives. Rosen [10] argues that the current economic policies being pursued in China to establish a socialist market economy, which to an outsider look remarkably like capitalism, have disadvantaged women more severely than at any time since 1949. Women's liberation and economic development are seen to be in conflict, rather than the first preceding, or at least accompanying, the latter.

While the Chinese authorities acknowledge that discrimination exists, they tend to see it as 'remnants of feudalistic thought' rather than as a consequence of current social and economic policies. This tends to absolve them of the responsibility for taking effective action. Another reaction which denies the structural nature of women's disadvantaged status is to exhort women to improve their own position. Addressing the opening session of the Seventh National Congress of Chinese Women, a senior member of the Political Bureau of the Chinese Communist Party (a man) said:

Chinese women should fully understand their responsibilities and commitments in the country's opening and reform process... Chinese women should further emancipate their minds, break the bondage of traditional and outdated concepts and strive to play a greater role in China's economic and social life with better political understanding and professional skills (Beijing Review, 13-9-93, p. 7).

Such exhortations might have been better directed at employers, husbands, government officials and the courts without whose active support women are unlikely to be able to free themselves from the dual domestic and work responsibilities that consume so much of their time and energy, or be able to gain redress for illegal discrimination.

Legal protections

Article 48 of the Chinese Constitution states:

Women in the People's Republic of China enjoy equal rights with men in all spheres of life, political, economic, cultural and social, including family life. The state protects the rights and interests of women, applies the principle of equal pay for equal work for men and women alike and trains and selects cadres from among women.

Like many things in the Chinese Constitution this is a statement of intent rather than a guarantee of rights. It does not take into account the profound conservatism of many of the male population who wield authority in the public and personal spheres of life. In an effort to ensure women their basic rights, the government passed the Law for the Protection of Women's Rights and Interests in 1992. It was accompanied by an intensive education campaign in both rural and urban areas to educate women about their fights. "To add to the strength of the drive,

Women and mental health in China 1161

judicial bodies held a series of public trials for violations and abuse of women's rights" (Beijing Review, 15-11-93, p. 18). The same article identifies the major problems as the kidnapping of women in rural areas, usually for sale as wives, and the forcing of women into prostitution. It also reports that nearly 90 per cent of rural wives suffer physical violence at the hands of their husbands. The president of the Women's Research Institute of the China Academy of Management Science has called for a law that specifically addresses the issue of wife abuse because current measures are so inadequate (South China Morning Post, 24-11-94). But as Rosen [10] points out, there are doubts about whether changes in enacted law influence changes in practice, or merely reflect changes in social and economic structures. Even those involved with drafting the Law for the Protection of Women's Rights and Interests criticize it for its lack of penalties and general imprecision (Beijing Review, 15-11-93).

Women's political involvement

In this and the following two sections, some comparative material concerning Hong Kong will be presented in order to put the situation in the People's Republic of China into some kind of context. Hong Kong, for comparative purposes, has the advantage of being a Chinese society yet with a significantly different political, economic and social system from that of the mainland. It is a partial democracy, an advanced, capitalist and industrial society and com- bines both Chinese and Western cultural influences.

Undoubtedly, women's participation in politics in China has increased enormously since 1949 but it is an area that continues to be dominated by men. Currently, 13.5% of the Eighth Chinese People's Political Consultative Conference are women as are 21% of the Eighth National People's Congress. Women account for 33% of cadres. In 1991, 6.5% of China's ministers and deputy ministers were women; 6.25% of the provincial governors and their deputies were women (Beijing Review, 8-11-93). Perhaps one of the more indicative figures is that women consti- tuted only 14% of the total membership of the CCP [10]. Bauer et al. [11] link women's lack of political power and influence to their continuing disadvantaged position.

In Hong Kong, 8.7% of government policy sec- retaries, and 8.5% of heads of government depart- ments, are women. Only 31.9% of government administrative officers, who might be considered to be an approximate equivalent of cadres, are female [12]. With regard to the holding of political offices, 11.5% of the Legislative Council (Hong Kong's equivalent of a parliament) are women. At the municipal level (Urban Council) 17.5% are women and at the district level, (District Boards) 9.7%. In 1991, of the candi- dates running for office, 11% of those for the Legisla- tive Council, 16% of those for the Urban Council and 10% of those for District Boards were female. In the

elections that took place in 1991 for the Legislative Council, 39.1% of all eligible women were registered to vote, in comparison with 39. i % of all eligible men. Of those who were registered, 51.3% of men and 46.6% of women actually voted. Hong Kong has four major political parties and female membership of them ranges from 6.5% to 18% [12]. Thus, despite variation in the political environments, the simi- larities in political representation and participation between China and Hong Kong seem to outweigh the differences.

Women and education

As Bonavia [13] says, education is ranked only slightly lower than rice in a scale of Chinese priori- t ies--but for sons not daughters. Although this position has changed substantially in the urban areas, it has been reinforced in the rural areas by the introduction of the contract responsibility system into agricul- ture over the last 15 years. This has permitted farmers a degree of choice in what they grow and allowed them to keep a substantial proportion of the profits that they make, a situation very different from the commune system, where everyone 'ate from one big pot'. It has also meant that children, as in the past, now have an economic value in production because there are many farm jobs of which they are capable. Under such circumstances girls tend to be kept at home to do agricultural work, while their brothers go to school. According to the One Per Cent Population Survey in 1987, 48% of males over 45 in the rural areas were illiterate. The corresponding figure for females was 88%. Among the age group 15-19, there was an illiteracy rate of 6% for males and 15% for females. In urban areas, of the older cohort 29% of the males and 67% of the females were illiterate, but only 2.3 of the younger men and 6% of the younger women [11]. In total, 70 % of people who are illiterate in China are women (Beijing Review, 15-11-93). There are many reports of discrimination at university entrance level, with fewer young women being allo- cated places and required to obtain higher marks in the entrance examination [10, 11, 14]. Where opportunities do exist for women, they frequently reinforce gender stereotypes [10].

In Hong Kong, six years of primary education was made free, universal and compulsory in 1971, and three years of secondary education followed in 1978. Thus among younger people in Hong Kong there is no noticeable level of illiteracy. However, there are marked differences between males and females in certain sections of the education system. For instance, although courses offered by the Vocational Training Council are open to both sexes, and attract many thousands of students, young men predominate by a wide margin of 2.5 : 1. The biggest difference lies in the part-time, day release technical courses where the ratio of men to women is 16.8:1. This suggests that employers are more willing to invest in the training of young men than young women, or that


young women are in more 'dead-end' jobs where training is not offered [15]. The difference between men and women in university enrolment is gradually diminishing, but at The University of Hong Kong in 1991 only 41% of undergraduates were female [16]. Perhaps more significantly, the pattern of enrolment is very different, with women congregating in the Arts faculty and men in medicine, engineering, architec- ture and so on. This clearly has an effect on career paths.

Women and work

Thirty eight percent of the labour force in China are women. Of these, 0.852% have earned 'senior professional titles' (Beijing Review, 13-9-93). As Rosen [10, p. 40] comments, the "general situation may be described as female soldiers under the com- mand of male generals". In almost any sort of work environment, women are less preferred workers because it is assumed that they will take maternity leave, will stay away from work when their child is sick and will be able to devote less energy to their labours because of their household responsibilities. Until the end of the 1970s none of these things mattered very much. Enterprises were not required to make a profit and bosses could afford to be more socially aware. Now that the emphasis has changed to economic development, managers find themselves in a very different position. An article in the Beijing Review puts it well:

. . . the transition period from a planned economy to a market economy will inevitably be hard on the Chinese people and Chinese women are paying the higher price. Mercantilism, the free flow of personnel and private enterprises, which were direct results of the market reforms have allowed people to have and compete for better opportunities. Given the fierce and fully free competition, women have appeared to be tess competitive and have been put in an unfavourable position (Beijing Review, 15-11-93, p. 19).

When challenged, enterprise leaders who discriminate against women always give the same answer " . . . we cannot help it. We have to compete with rivals to survive the changing market and we are asked to make more profit. Making profit is now the highest priority" (Beijing Review, 15-11-93, p. 20). In the same article, a female official from the All China Federation of Trade Unions points out that in a survey of 1175 enterprises about 60% of workers expunged from the lists of formal and permanent employees since 1987 were women. She suspects those that have lost their jobs will find it hard to obtain new ones, or to start up their own business. As many welfare benefits, including health insurance, are ob- tained through employment this puts such women in a doubly disadvantaged position. They lose both their jobs and their welfare safety net simultaneously.

Employment in the rural areas is no better. Under the commune system everyone earned workpoints which were transformed into money according to the commune's income at the end of the year. Tradition-

ally, the jobs men performed earned more workpoints than those that women carried out although they earned them in their own right. However, Stacey [18] claims that more often than not, a woman's work points were paid to the male head of the family. As families reverted to working their own land, a woman's contribution once more was subsumed within the family so that she tended to have no income of her own. An article by Wang [19] describes the onerous lives of young peasant women in contrast to their brothers: 85% said that they were more or less content with their existence, while 15% were unhappy, some to the point of considering suicide.

There has been an increase in the labour force participation rate of women in Hong Kong from 36.8% in 1971 to 49.5% in 1991 [20]. The gap in earnings between men and women reduced by 10% between 1976 and 1986 but nonetheless in 1991 the overall earnings ratio was 0.75:1 (female to male). Within specific occupational groups wage differen- tials vary from 0.87 in the professional category to 0.64 in the plant operators and other manual jobs category. Of interest and concern is the fact that women with the same educational level as men do not enjoy the same career chances. For instance, in 1991 only 16% of women with a university education were classified as managerial and administrative, whereas 34% of men were so classified [16]. Although the numbers classified as professional are equal (50%), if nurses and teachers are taken out of the equation, women's position significantly deteriorates [16, 20]. In comparison with women in China, the work position of Hong Kong women is significantly better in a number of ways, although it must be born in mind that Hong Kong is a largely urban environment and consequently, unlike China, does not have to cope with the problems that rural populations present. At the same time, gender discrimination is still very marked in a number of respects. Overall it can be concluded that the position of women in Hong Kong is generally more favourable than that of women in China, even though the Hong Kong government has never made gender equality a platform in its policy agenda. Even so, there are marked areas of gender difference and discrimination. In comparison, despite official declarations, the Chinese government has enjoyed only limited success in providing 'a level playing field' for its female population.

The pressure to bear sons and female infanticide

The preference for male children is a fundamental aspect of Chinese society, supported by both pragma- tism and ideology. Elderly parents are supposed to be taken care of by their oldest son. In the eyes of many Chinese people, particularly those from the rural areas, no sons means a miserable and destitute old age, as there will be little or no welfare assistance from the state. Secondly, dying without a male heir was, according to Confucius, one of the three most unfilial acts. Carrying on the male line, continuing the


family name is still of paramount importance and only a son is able to do that.

Within this context, China's 'one-child' per family policy over the last 15 years has been bitterly resented and vigorously resisted, especially in the rural areas where more children make economic sense in farm- work and where ideas are more traditional. A small enquiry by Zhou [21] makes the issues abundantly clear. He studied 53 women in a rural area aged between 20-30, whose first born had been a girl. He found the following situation: 81% were unhappy to have given birth to a girl; all husbands were reported to be depressed about it and constantly complained; 60% acted in a cold and unfriendly way to their wives; 55% verbally abused their wives; 30% beat their wives; 28% of husbands wanted a divorce.

The mothers-in-law also participated: 80% treated their daughter-in-law coldly; 58% verbally abused their daughter-in-law and 9.4% beat them. Even the neighbours were unpleasant with 83% of the young mothers reporting that the neighbours said vicious and unpleasant things. The three most common causes given for this behaviour by the respondents were wanting the extra labour power (75%), fear of not carrying on the lineage (77%), and fear of having no one to provide for them in old age (87%). One of the worst and most common insults for these young women was to be called 'the devil who extinguished our family'. There is absolutely no doubt in any one's mind that the failure to bear a son is the fault of the mother, modern knowledge about genetics not with- standing. Not surprisingly, 85% of the women felt depressed, 67% reported that they suffered from neurasthenia and 81% of them had lost weight.

As well as leading to mistreatment, divorce and suicide of young mothers traditional attitudes com- bined with the one-child policy have resulted in a highly skewed birth rate. The normal sex ratio at birth is 100 girls to 105-106 boys. Throughout the 1960s and 1970s this was the case in China. The position changed after 1980. In 1981 it was 108.5, in 1986, it was 110.9 and 113.8 in 1989 [22]. This last figure is based on the ten per cent tabulations of the 1990 census. In demographic terms these figures are grossly skewed and most unlikely to be naturally occurring. In addition, national figures iron out local variations. Aird quotes sources for Anhui and Gansu of statistics from 1982 of county figures of 139 male births per 100 female births, commune figures of 175 male births per 100 female births and even some brigade figures of 800 male births per 100 female births [23]. These concerns are reflected in Chinese sources (Beijing Review, 15-11-93; People's Daily, 7-4-83).

So where have all the girls gone? The alternatives are: that they are not being registered and thus do not officially exist; that they are subject to sex selective abortion; that they are subject to female infanticide. All three explanations are likely to play a part. The Chinese government, naturally, denies that female

infanticide contributes significantly towards these figures [24]. It points out that the Marriage Law and Law for the Protection of Women's Rights and Interests stipulate that drowning babies is forbidden [24]. Authorities like Aird [23] and Banister [25] place more emphasis on infanticide, while others [22] claim a larger role for sex selective abortion. Over the last thirteen years, China has been both importing and manufacturing high quality, colour ultra-sound B machines capable of detecting a baby's sex. Accord- ing to the Ministry of Health [23] every county in China is now equipped with such machines. Govern- ment regulations ban their use for pre-natal sex identification, a position that has been reiterated and strengthened in the Law on Maternal and Infant Childcare, promulgated in October 1994. However, it is extremely easy to bribe or use 'back door' connec- tions in order to do this.

In addition, girl children may also be neglected. Ren [26] has shown that in Shaanxi, girl toddlers chances of surviving childhood are significantly less than boys. He attributes this to discrimination in the allocation of scarce survival resources and inferior health care. This is born out for the whole of China where the mortality rate for boys of five years and under is 6.37 in the cities and 6.88 at the county level. For girls it is 7.58 and 8.38 respectively (Beijing Review, 24-10-94). The longer this situation persists, the more obvious the consequences regarding the problem of finding a wife. Almost certainly, this is one of the reasons for the upsurge in the kidnapping and sale of young women that has been so prevalent since the mid-80s.

EPIDEMIOLOGICAL DATA ON MENTAL HEALTH

The most comprehensive study of psychiatric disorder in China is known as the Twelve Centres Epidemiological Survey, and was carried out with the advice and assistance of the World Health Organiz- ation [27, 28]. A review (in English) of all the surveys in this area carried out in China is contained in Cheung [29] but it ignores gender differences.

Women and schizophrenia

The Twelve Centres Epidemiological Survey found that the point prevalence rate for schizophrenia was 6.00/1000 in the urban areas and 3.42/1000 in the rural areas [30]. Left[31] gives prevalence figures from a variety of countries, ranging from 0.9-8.0/1000, suggesting that the Chinese figures are within an expected range. There was a marked gender difference in the Chinese sample. The lifetime prevalence rate for women was 7.07/1000 and for men, 4.33/1000. This difference held good in both urban and rural areas and was significant at the < 0.01 level [32]. Thus the rate for women was almost double that for men. Chen [32] attributes these differences to the higher psychological and social burdens that women have to bear.


To the Western eye, one of the most remarkable aspects of the results from the Twelve Centre Epi- demiological Survey is that apparently significantly more women than men suffer from schizophrenia. Phillips and Pearson [33] have expressed some reser- vations about case finding in the Twelve Centres Epidemiological Survey in relation to the large urban/rural difference in the occurrence of schizophrenia. The gender differences may also be an artefact of case finding methods. If they reflect a true difference, this would be a most unusual circum- stance.

No national statistics are kept of the distribution of psychiatric beds by gender. Even the officially reported numbers of hospital beds are likely to be unreliable [34]. Thus any suggestions must be tenta- tive. However, I have visited at least 15 psychiatric hospitals in China and in all those where the pro- vision of beds was a response to the demand from the community, male beds outnumbered female beds by at least 6:4 and sometimes more. This was also found in a study of three psychiatric hospitals in China [35]. Thus we have a situation where according to the most scientifically conducted epidemiological study so far there is a significant excess of female patients suffering from schizophrenia, but an equally significant preponderance of beds for males. Between 75-80% of psychiatric hospital beds in China are occupied by people diagnosed as suffering from schizophrenia (both men and women), so these figures are not a reflection of admissions for different illnesses between sexes.

How may this be explained? It is well known that there are certain differences between men and women in the way that they are affected by schizophrenia. Schizophrenia tends to develop up to six years earlier in men than in women and more women than men suffer their first onset after the age of 40 [36, 37]. Several studies have reported a worse prognosis, at least where hospital discharge rates are concerned, in men than in women [38]. Women have fewer relapses and are less likely to develop a chronic course [39, 40]. The International Pilot Study [41] found female sex to be the best predictor of a remittent (versus chronic), course of illness and one of the five best predictors with respect to the percentage of follow-up time which the patients spent in a psychotic state. Overall, men do not respond as well to psychotropic medication, requiring higher doses of medication, which they do not tolerate as well as women; their long term adjustment as measured by such indices as social life, marriage, work record, and general level of function- ing is not as good as that of women [42].

To explain these differences, it has been suggested that estrogen may provide protection through a mechanism not yet understood, or that there may be two different kinds of illness involved, one of which tends to start later and have a more benign course and is prevalent in women; the other to predominate in men, with earlier onset and more damaging long

term effects [39, 42]. As yet the work remains to be done in China that would permit us to know whether the position is the same there in these respects.

One of the likely explanations to account for the excess of men in psychiatric hospital is the difference in social expectations. The role behaviour associated with being a housewife and mother is possibly easier to maintain in the private domain of the family than that associated with being a breadwinner, a success in the marketplace. Women's domestic survival skills outside the hospital are likely to be higher than those of men. In research I carried out in a hospital for long-term psychiatric patients in southern China 40.8% of women were 'ever-married' but only 10.2% of men (significant at the <0.0001 level). In a hospital for acutely ill psychiatric patients in Beijing, in a comparison of an admission ward for men and another for women, I found that 48% of the men were 'never-married' but only 27% of the women (significant at the < 0.05 level). Part of this difference may be explained by the fact that schizophrenia develops later in women and they marry earlier than men. Thus their symptoms may not become apparent until after they are married. Under these circumstances, once parents die men may have no effective family with whom they can live and lack the necessary skills to care for themselves.

Another effect that gender role expectation can have on bed occupation patterns was suggested by several Chinese psychiatrists, who thought that women feel a greater sense of responsibility towards parents, husbands, and children and are consequently more reluctant to be admitted and tend to stay for shorter periods of time (at least in the acute sector). The obverse of this is that families cannot function very efficiently without the mother/wife in the house, so that pressure is put on women to return home as quickly as possible. Men on the other hand, particularly those working in enterprises and covered by health insurance, are pleased to be relieved of work and tend to prolong their stays.

In both hospital studies, it became apparent that there were significant differences regarding the pay- ment status of men and women. In the long-term hospital 19.4% of all the men were supported by health insurance provided by their employer. This was true of only 10% of all the women. Thus proportionately more women were 'charity' cases, or having to be supported by their families.

Evidence from the acute hospital fleshes out this picture. At this hospital many treatments were offered in addition to the basic 'bed, board and medication' arrangement, and were charged for separately. These treatments included laser therapy, music therapy, acupuncture, psychotherapy, occupational therapy, behaviour therapy and ECT. Only in the last two was there no significant difference between men and women, suggesting that they were being given on the basis of need rather than ability to pay. The overall difference in the cost of treatment


between men and women was significant at the <0.0000 level. This suggests that men had more health insurance and/or that families were more willing to pay inflated costs for men than for women. Interestingly, in the long term hospital where the monthly costs were all inclusive, very little difference was detected between the treatment offered to men and women. Phillips [35] found that length of stay was most significantly related to whether hospital costs were being met by the family or by health insurance. Neither diagnosis nor severity of the condition were as important. In a situation where women are: less often covered by health insurance, given less priority in access to family finances, needed for the smooth running of the household, and are thought to be more easily contained when they are in an excit- able or aggressive state, it is not surprising to find that there are fewer psychiatric hospital beds for women in comparison with men.

Women and depression

The lifetime prevalence rate of schizophrenia is seven times higher than that for affective disorder (including bi-polar disorder) in China. The point prevalence rate is 13 times higher. Only 29 cases of affective disorder (female and male) were found in the overall sample of 38,136 in the Twelve Centres Epi- demiological Survey. By Western standards this was astonishingly low. However, there were marked gender differences. The point prevalence male/female ratio was 1:1.35 for affective psychosis. The male/female ratio for reactive psychosis was 1 : 3.4 [28]. Figures given in Chen, et al. [43] allow us to make comparisons with a Chinese population in Hong Kong. Using DSM3, the authors also found that major depressive disorder and dysthymic disorder were female dominated at the < 0.05 level of significance. However, they found no gender differences in the categories of schizophrenia and bi-polar disorder.

It could be argued that the greater prevalence of depression in women in both Western countries [44~,6] and Chinese societies is an indication that the tendency to develop depression is biologically based An equally plausible hypothesis is that women, sharing a disadvantaged status, have more to be depressed about. In support of this view McGuffin and Katz [47] were unequivocal in stating that the findings from their study led them to the conclusion that most of the gender differences between the sexes regarding the prevalence of depression are due to environmental factors.

The tendency of Chinese doctors to over-diagnose schizophrenia and under diagnose depression and bi- polar disorder is well documented [28,29,48-51]. This is also my impression based on reading hundreds of case files, and interviewing with Chinese psychiatrists. It has been suggested that someone who is quietly depressed, withdrawn and uncommunicative, is relatively acceptable in a Chinese society that values self-contained and decorous behaviour [52, 53]. Those

that come to the notice of doctors are those whose behaviour brings them to public attention.

Suicide

This argument is certainly plausible but does not mean that depression is rare, only that it goes unde- tected. Evidence to support this view comes from an examination of suicide statistics, a subject on which the Chinese authorities are notably silent. Infor- mation comes largely from two sources, a World Bank report [54] and a study by Li and Baker [55] (see Table 1). The top three causes of injury death in China are suicide (33%), motor vehicle crashes (16%) and drowning (14%). In America, death by suicide accounts for 20% of all injury deaths. As Table 1 shows, the suicide profile in China differs from that in the West in that there are more completed suicides amongst women than men.

There is also a sharp difference between the urban and rural suicide rates; 10.00 vs 27.7/100,000. There is a marked peak of female suicides in the age bracket 20-24 and among this cohort the suicide rate among women is five times greater in the rural areas than in the urban areas (78.3 vs 15.9/100,000) The same pattern is seen among Chinese males in the same age bracket. The rural suicide rate is four times that of the urban areas, 40.7 vs 9.9/100,000. Furthermore, Li and Baker [55] point out that the rural population were under-represented in the sample (43%). The 1990 census classified 73.77% of the population as rural (Beijing Review, 17-6-91, p. 30). This means that the suicide rate is probably higher than these figures suggest.

Such high levels of suicide must reflect the social, cultural and economic changes that Chinese society is facing. Such issues seem to bite hardest in the rural areas generally, but affect young women most seriously, among whom suicide seems to be a silent epidemic. Li and Baker [55] speculate that marriage problems and poverty may be the major causes of suicide for this group of women.

Wolf [17] points out that suicide had long been an escape for women of all classes when their situation became unbearable. She discusses statistics kept by the Japanese colonial administrators in Taiwan between 1905 and 1940 which clearly demonstrate that young women in their early twenties were at greatest risk of suicide. Croll [4] reports similar findings for the mainland. Both writers interpret this as a reflection of the difficulties that awaited young women on marriage and before bearing a son. One of the reasons why the present Chinese government has remained so quiet about the suicide figures is that the social circumstances associated with suicide were

Table 1. Age adjusted suicide rates among males and females in China and America

Males Females China 17.7 24.3 America 20.6 5.4


supposed to be eliminated under socialism, or at least alleviated. These current figures suggest that this is not the case and that such behaviour is not a 'feudal remnant' but is clearly attributable to present conditions. Examples can easily be found in our earlier discussion of the 'one-child' policy, the preference for sons, female infanticide and ill treatment at the hands of husband and mother-in-law.

An article carried in the China Women's Daily (Reuter's report, South China Morning Post, 15-10- 88) gives a greater depth of understanding. Fifty one young women, most of them teenagers, died in 15 separate group suicides in villages in Jiangxi province. Many of the victims dressed in their best clothes before throwing themselves into lakes together, in the belief that they would come back to a better life. Many had despaired of their poverty and lack of education and resented their parents for forbidding them to go to high school or leave their village. One of the girls was reported as saying, before her death: "We have nothing good to eat, wear or do. At home we are controlled by our parents and when we marry by our husbands. City girls wear fine clothes and go to cinemas . . . it is the life of an angel". The newspaper said many of the parents of the suicide victims had disowned the dead girls because of local superstitions. One group of six young women was buried on wasteland in the belief that they would become ghosts (and therefore should be kept well away from habitation) and the families of another four nailed their corpses to their coffins to prevent them from escaping.

To a Western eye, at least, the discrepancy between the high rates of suicide and the low rates of depression presents something of a puzzle. Attempts at a solution can only be speculative and are likely to require a combination of factors. As has already been mentioned, withdrawn behaviour, particularly in a woman, may be positively valued as a sign of recti- tude and modesty. Individuals in China are not encouraged to express their feelings, nor are they socialized to believe that catharsis is good for the soul. Thus, even intense misery may go unspoken and unrecognized. There is also a cultural expectation that individuals will accommodate themselves to circumstances, rather than expecting their environment (and those in it) to change to suit the individual. This further encourages the person to direct the distress inward.

However, this is only part of the story. As will become apparent from the case studies presented later in the article, it is perfectly possible for women to identify and communicate the sources of their unhappiness. But if they are ready to do that, who will be willing to hear them? On one level, there is the obvious problem, particularly in rural areas, of the lack of doctors able to recognize anything other than the most flamboyant of symptoms. Even well trained doctors are schooled in the medical model, with almost no social science perspective to temper their

biological inclinations [49, 50]. It must be remem- bered that psychology and sociology were quickly banned after the Communist Party came to power in 1949. This not only affected medical training but also ensured that there were no other professionals (like social workers or psychologists) who could provide a different perspective.

It is a common wisdom that Chinese people 'som- atize' their problems; that is, distress is expressed either using the body as a metaphor or is genuinely experienced as a physical symptom. Comparisons are frequently made with Westerners who are thought to 'psychologize'. My personal experience in interviewing in psychiatric contexts, does not wholly support this view of the way Chinese people express distress. I have found that gentle, non-threatening questions, and a search for meaning rather than symptoms, often elicits psychological rather than physical material. If a Chinese patient says to me that she has a 'pain in her heart', a frequent occurrence in a psychiatric clinic, I know from experience that it is often a way of expressing sadness and distress, and can then probe for her understanding of what is causing it. Or I can choose not to hear, and avoid the messy and frustrating business of feelings. But my approach is based on the belief that psychological pain and distress are relevant to my role as a counsellor. This is not a frame of reference that Chinese doctors usually share.

To assume that the high rate of suicide reflects an equally high rate of depression may not be entirely correct. Suicide is, of course, not only a gesture of despair but may also be one of anger and revenge. This is particularly likely among a group who in other ways have so little control over their own lives, and little means of redress against the injustices they suffer. Many people still believe that the unquiet spirit of a suicide will return to haunt the household and wreak its revenge, thus gaining power in the spiritual world that was not possible in the temporal one.

In destroying themselves, they also inflict damage on their persecutors. Wolf [17] points out that in Western societies, when a person commits suicide friends and family tend to ask 'why'? In China they ask 'who'? It is assumed that the individual has been driven to take this extreme action by the persecution of others; usually, in the case of a young woman, her husband and his family. A suicide reflects very badly on the family and involves officials in an investigation, thus exposing family troubles to common scrutiny. In the routine life of a village, even with the advent of television, gossip about one's neighbours is a major form of entertainment and a suicide is guaranteed to get the village talking--a sweet revenge in such a 'face' conscious society.

Women and neurosis

The Twelve Centre Epidemiological Survey found very low rates of neurotic disorder, defined to include hysteria, hypertension, anxiety, phobic conditions


and depression [56]. Out of a total sample of 6952 people interviewed only 16 cases of neuroses in men and 134 in women were found. Xiang [56] explains this by saying that Chinese doctors are diagnosing neurasthenia when faced with symptoms which West- ern doctors would identify as neurotic [57, 58]. The overall female rate is 39.93/1000 (urban 37.21/1000; rural 42.69/1000). The overall male rate is 4.71/1000 (urban 4.22/1000; rural 5.18/1000). If one accepts the level of neurotic disorder as a measure of distress, then women would appear to be more affected than men. However, a confounding factor is neurasthenia which is treated as a physiologically based disorder in China. We do not know whether doctors tend to diagnose neurasthenia more often in men (a physical disorder) and neurosis more frequently in women (a psychological disorder). If one looked at the com- bined figures for both these disorders a more equal pattern might emerge. In the current state of our knowledge, it is not possible to know.

THE EXPERIENCE OF DISTRESS

There are routinized forms of suffering and oppression that are either shared aspects of human conditions ... experiences of deprivation and of degradation and oppression that certain categories of individuals.., are specially exposed to and others relatively protected from [59, p. 280].

Although they had China in mind when they wrote this, Kleinman and Kleinman did not include the condition of womanhood. Yet their approach certainly subsumes the female condition in China. They go on to argue that "to interpret such problems solely as illness is to medicalize (and thereby trivialize and distort) their significance" [59, p. 290]. Others have argued that insufficient weight is given to the extent that women's identity and sense of self derive from the social context in which women are defined as a devalued group [60]. It is important that the statistics cited earlier regarding the greater number of women diagnosed as suffering from depression or neurosis should be "fleshed out" by the "flow of lived experience" [59, p. 292]. It is more appropriate to describe those experiences as distress rather than illness because it is a relatively neutral word that will then allow an examination of the various interpretations that are placed on the same behaviour by the actor (the patient) and the audience (the family, neighbours and medical professionals). It is not intended that it should imply any level of severity of adversity.

The aim in this section is to portray distress as experienced by three women who visited the out- patients' department of a psychiatric hospital in Hubei province and the doctor who treated them. They were all interviewed by myself (with the aid of an interpreter) and by a middle-aged, female psychiatrist of many years experience, who was vice-direc- tor of the hospital. The interviews described here are part of a series of 37. Each interview took approxi- mately one hour, in comparison with the usual

practice in the clinic of 10 minute interviews. The material is presented to give a coherent picture but it should be born in mind that this masks the gradual revelation of the more sensitive, disturbing and em- barrassing information.

Mrs Ning--the woman who rides the bus

Mrs Ning is a small, gentle, quiet woman of 49 who has spent her entire life looking after others. She has been married for thirty years to a man who is a long-distance bus driver. They have four children, the oldest of whom is 25 and married, and the youngest of whom is 15. When she was still a child, her parents (who had many children) gave her to a childless couple, although still maintaining contact with her. Her husband came to live with her and her adopted parents on marriage. Such uxorilocal marriages are not highly valued, are generally considered demean- ing for the husband and thought to be against the natural order of things. Not having a son, Mrs Ning's adoptive parents felt they needed a son-in-law to secure their old age. Mr Ning found this arrangement acceptable because he was not made to take his wife's name. In fact, because of his job (which is well paid), he rarely stayed with his wife through most of their married life. Mrs Ning has always lived in the same village, looking after her adoptive parents and working on their farm. Mrs Ning only had three years of primary education and is functionally illiterate.

When I asked the couple what was the problem that had decided them to come to the clinic (the standard opening question in this series of interviews) Mr Ning answered. He told us that he first decided his wife was psychiatrically ill fourteen years ago when she quarrelled violently with her adoptive mother. At that time, his wife had insomnia, suicidal ideas and thought that dead relatives were coming to get her. She asked her husband to take offerings of food to their graves to placate their spirits. He was reluctant to do this, seeing it as pandering to his wife's superstitious, illiterate, rural behaviour but did so in order to keep her quiet. Eventually she got better without being admitted to hospital.

Mr Ning recounted the events on this current occasion. His wife was reluctant to return to her home in the village, wishing to ride on her husband's bus every day. She has been acting this way for three weeks. When he insists that she leaves and goes home she loses her temper and smashes things, cries and says that she wants to kill herself and asks him to save her. Mr Ning makes a good living and his wife wants to know where all the money goes, because she sees very little of it. He says it is hard to account for but that most of it goes on their two children who are at college. He is paying their fees and daily expenses. Before the patient became ill, she accepted this, but since becoming ill she has also become very suspicious. Another thing she is suspicious about is her husband knowing many passengers. (The implication is female passengers in particular.) Sometimes, he


says, when he finishes work, he is so tired he has no sexual desire so they have not had sexual relations for some months. He usually stays in the city and will see his wife once a month when he takes some days off. At those times, she will usually come and stay with him although he occasionally goes back to the village. Before the patient became ill, she was satisfied with this arrangement but since her illness she does not find it acceptable and has been living with him all the time. Because he does not want his children to be illiterate like his wife, they have always lived with him so that they could go to school in town. This is also why he is willing to spend so much money on sending the two older children to college, where he hopes the 15 year old will also go. When I asked him why he thought his wife had a psychiatric illness his answer was fast and plain; because she no longer obeys him. Prior to the last three weeks she had "obeyed him well". Her usual character was to be gentle but this had now changed.

At this point we took the rather unusual step of asking the husband to wait outside while we talked to Mrs Ning by herself. (Usually, interviews in Chinese psychiatric settings are conducted with family mem- bers present.) The first thing she told us was that she was not ill. She was unhappy about her family life and felt that her adopted mother's character was bad. Certainly she was much happier when she lived away from her adoptive parents. Some of the other vil- lagers have bullied her because she cannot read or write. She is happiest when she lives with her husband. Although he treated her very well, she has recently become very unsure about his fidelity. This started when he stopped making love to her on their infrequent meetings. She shyly admitted that her husband was "able to please her" when they had sexual relations. She knows that he is very tired after work but it seems to her that his job has not changed, so there is no reason why he should be more tired now than before. Thus she remained uncon- vinced that this was the real reason and suspected that he had a girlfriend. In addition, his inability to account for where all his money goes confirmed her feelings that he is spending it on a girlfriend. While she was prepared to tolerate much, this drove her too far. Her solution was to ride on the bus, where she is sure that he makes his contacts, so that she can supervise his behaviour and discourage potential (or actual) girlfriends.

When Mr Ning came back into the consulting room, Dr Tao told them that Mrs Ning's depression and anxiety were due to the menopause. She told Mr Ning that it was more serious than he thought and that he must treat his wife well and look after her. Mr Ning responded, as a demonstration of his caring, that he had already bought his wife some vitamins. Dr Tao prescribed imipramine. After they left, Dr Tao told me that her diagnosis was involutional depression, commenting that it was the Chinese cus-

tom that women have to tolerate their husband's behaviour without complaint or comment.

Mrs Wang--the straw that broke the camel's back

Mrs Wang was barely able to participate in the interview at all. She was extremely agitated, crying and wailing. All she would say was that "there are so many doctors but they can't make me better" and that she wanted to go home. She was accompanied by her husband, who told us that she had become ill for the first time at 7 p.m. the previous evening. When we asked him to explain what happened, Mr Wang said that last night he had complained about his wife coming home late from the fields; that his attitude towards her had been 'bad'. He had acted coldly and left the house almost immediately. His wife followed him and it was at that point he had realized that she was acting strangely, wailing and crying. He called on the assistance of the patients' parents and sisters who came to the conclusion that Mrs Wang had been possessed by spirits. Mr Wang did not accept this explanation and took her to the local hospital where she was given a heavy sedative. She calmed down under its influence but once it had worn off, she had become disturbed again. So he decided to bring her to the psychiatric hospital.

On further questioning the background to the story emerged. Mr and Mrs Wang have been married for seven years. There had been problems with both sets of parents from the beginning and the patient has been feeling uncomfortable about these family difficulties for some time. Mr Wang's father did not accept the marriage. At first we were told that he had said that the family was not economically secure enough to 'receive' a daughter-in-law. Eventually Mr Wang said that his father in fact threatened to hang himself at the gate of Mrs Wang's parents' house if his son tried to bring her into his home. Thus they had to go and live with Mrs Wang's parents, who were not very happy with the arrangement because of the negative connotations of uxorilocal residence. After three years, Mr Wang went to live in town, having inherited his father's job as a purchasing agent (a common practice in China). He also said that he wished to be a good son and look after his father in his old age. But his wife's parents felt strongly that this was not his responsibility as his father had refused to give the married couple a home, while they had. In their eyes, his duty was to look after them in their old age as he had joined their family on marriage. Thus Mr and Mrs Wang had been living apart for some time, with Mr Wang paying an occasional visit to his wife who remained with her parents. Last night he had made one such visit unannounced. He was angry when his wife was not there to receive him and no food had been prepared. Thus, when she returned from her labours in the fields he had berated her and then left. He said that he now realized that his behaviour had been unrea- sonable. Mrs Wang was admitted with a diagnosis of


hysteria. Dr Tao said that she thought Mrs Wang would recover well within the week.

Mrs L u - - t h e dissatisfied daughter-in-law

Mrs Lu has been married for four years and has one daughter. A son died three hours after birth and she was persuaded to have two other pregnancies aborted. This is the third time her family have brought her to the clinic. From her perspective she has not felt well since she married. She said that she had had a headache for two years, suffered from insomnia, had no strength, vomited on waking every day and her hands and feet felt very hot. She told us that she kept many of her feelings inside but then ended up losing her temper. Her husband said that at first he thought his wife just had a mild problem in her thinking but that he changed his mind after she had a serious quarrel with his brother's wife over money and property.

Mrs Lu reported that she had first had 'nervous problems' four days after her marriage, which had been arranged by their parents. The couple only met once before they were married. She freely described her sense of being dissatisfied with her new family, who were poorer than her own. She did not like her husband's physical appearance or the way he spoke and felt dissatisfied when she compared her own situation with others. This was particularly so when she went back to visit her own family. When with them, she is able to work quite hard, even doing heavy field labour. But in her husband's family her poor health only permits light duties. Mrs Lu said that she had strong self-esteem and does not like being forced to get along with people whom she had not chosen. The quarrel over property and money arose when her parents-in-law divided the family property between their sons. Mrs Lu thought that she and her husband had been treated unfairly in the division and this led to a huge row with the sister-in-law she felt had received favourable treatment.

In the last 18 months, Mrs Lu's feelings towards her husband had changed, becoming more positive. She said that now she loves him very much but that he had taken a job as a building labourer in town and only came home for two weeks in every three months. The family were very much in need of the money but she missed him and was afraid that he would find a girlfriend. Indeed, at various times she has accused him of infidelity which he strenuously denied (as he did to us).

Both Mr and Mrs Lu believed in spirits and ghosts, and at least partly, attributed her problems to spirit possession. They have consulted a shaman ten times. The shamans' interventions had provided some tem- porary relief but no permanent solution. They did not feel that this conflicted with seeking medical help, considering it proper to seek assistance of any kind that might be of benefit. Dr Tao's diagnosis was mild depression and she prescribed traditional Chinese

herbs to help Mrs Lu sleep and to improve her appetite.

Discussion

A number of pieces of research have found that depression is related to the control that a woman feels she has over her life [45, 60]. The age and sex hierarchy that typifies Chinese society frequently means that there is little autonomy for women. This is apparent in the three cases presented. Decisions about marriage, residence, and childbirth and abortion were all potentially out of the control of the individuals concerned. As all of them were based in rural areas, they also had little choice about jobs, although that would be a common experience for men and women. Mrs Ning and Mrs Wang seemed willing to accept their lot in life until a particular event pushed them beyond what they were willing to take. Mrs Lu's life seemed more of a constant struggle against her fate since the time of her marriage.

All of these women came to the attention of the medical services when their private distress took a more public form: Mrs Lu's bursts of temper, Mrs Ning's temper and decision to ride the bus and Mrs Wang's ceaseless wailing and crying in public. Barnes and Maple [61] ask why women tend to experience depression and 'nerves' rather than anger and revolt. But in the ways that were available to them, all these women were rebelling and it was their refusal to suffer quietly that brought them to the attention of the psychiatrist, a point that Brown et al. [62] also make.

It is not the patient's opinion about what is wrong that is significant. Rather, it is the family's. It is their initial 'diagnosis' of the problem that will decide what source of help, if any, should be sought. Once the patient has been defined by the family as being psychiatrically ill, the patient is assumed not to be capable of expressing a reliable opinion on the subject.

At least to a Western observer, illness in this context is being used as a metaphor by the partici- pants in the interaction. Mrs Ning does not believe that she is ill but says she is angry and upset. Both her husband and the psychiatrist prefer to understand her behaviour within the context of illness. It is her husband's means to understand the domestic rebel- lion that has disturbed his peace and inconvenienced him, although he thinks that it is 'only light'. Dr Tao tries to use her medical authority to convince him that his wife's case is 'a little serious' in order to persuade him to show more concern and consider- ation for her. Illness will explain Mrs Ning's behaviour and should give her access to solicitude, but at a price; giving up the legitimacy of her anger.

The metaphor in the cases of Mrs Wang and Mrs Lu is somewhat different. The sick role in Chinese society is, on the whole, one that is honourable and respected. Miles [44] in her study of women with neurotic disorder pointed out that many of the


husbands were unwilling to concede that their wives were ill. This was not the case with our three examples. Being ill brought clear benefits in the exemption from normal role duties (Mrs Lu not performing heavy field work for her husband's family, Mrs Wang exempted from her duties in their entirety) and exemption from blame for their condition. Blame is then imputed to the other social actors involved (Mrs Wang's husband and both sets of parents) or to some entity that has caused the illness (the Lu's belief in spirits). Illness brings them benefits in attention that otherwise seem significantly lacking in their lives. In Mrs Wang's case, it provided a respite from a situation that had clearly become intolerable.

The issue of whether the patients and families see the behaviour as primarily psychological or physical is a contentious one given the debate on the soma- topsyehic orientation of the Chinese and the current debate on neurasthenia in Chinese populations [57, 58]. Pearson [63], based on an analysis of the complete series of interviews (three of which are discussed in the present article) demonstrates that most of the families when asked to give an explanation for the cause of the psychiatric illness, give social reasons, although the initial symptomatology described often includes physical phenomena insomnia, poor appetite, dizziness and headache for instance. Gentle questioning very quickly elicits a whole gamut of emotional and social difficulties, which patients and families, but not necessarily the doctors, link directly to the illness. Perhaps, as Klein- man and Kleinman write, "the causal line from the environment to person is held to be mediated by the body" [60, p. 287].

Although counselling services have gained ground in China in recent years [64], they are still quite rare and only to be found in large cities. Thus, the choices available to troubled people are very limited. Doctors of Western or Chinese traditional medicine are generally available and in rural areas, more traditional healers, like shamans, may also be consulted [63, 65]. Seeing a doctor almost inevitably puts the behaviour into a medical framework. Both the doctor, and the patient and their family feel more comfortable with a diagnosis [44]. The patient wants the security of knowing what is wrong and that it is treatable. The doctor has to demonstrate competence by diagnosing and prescribing. Naming the disorder is the first step for both sides in making it manageable. It helps also to legitimize it as a 'proper' illness and lend credence to the sick role.

Inevitably, this medical process has little to say about gender issues in society that contribute towards the experience of psychological distress. The doctor's job is generally agreed to be to return the patient to their pre-illness condition; they do not see it as their function to consider whether that condition brought about the illness in the first place [44]. Naturally, Dr Tao and I discussed our impressions from the joint

interviews and discovered that they were very different. It would be wrong to give the impression that Dr Tao was mechanical or unfeeling in her approach to patients. She was gentle, patient and often sensitive. But as far as she was concerned, their social circumstances might be interesting and regrettable, but they were not germane to the issue of illness. I, on the other hand, thought they were essential to the understanding of the patients' illness behaviour.

It was a fundamental difference we never resolved. Her training had not included any social science or non-medical therapeutic techniques. She was motiv- ated to help, but the choices available to her were limited by her definition of her professional role and the paucity of therapeutic and community resources. Even the option of asking the patient and relatives to come back and see her was not available, although some made that request. The hospital authorities (of which she was one) claimed that it was too 'compli- cated' to arrange a rota in advance, so returning patients almost always saw a different doctor. From the point of view of the hospital, this was unimpor- tant as they were treating illnesses which responded to medication and it really made no difference who wrote out the prescription.

Social support has long been known to have a buffering effect between deleterious social circumstances and developing depression or neurotic disorders [44~6]. In Miles study [44], one of the factors involved with a negative outcome was lack of social contact. Only in the very rarest of circumstances would this be the experience of a psychiatric patient in China, of whom over 95 per cent live with their families [66], and who generally live in more tightly knit communities. Belle [45], however, differentiates between social support and social involvement, finding that while the former was associated with good mental health the latter was not. Social ties may actually create more burdens than they lift. Indeed, the disappointment when those expected to provide support, most notably husbands and mothers, do not, is acute [44]. Such factors can be seen to be at work in our case studies. All of them were socially involved and certainly not isolated, but none of them were receiving social support. Rather, those whom they thought should be emotionally available to them were not (all husbands were absent from home), and those with whom they lived (parents or in-laws) were part of the problem. On the whole, friends do not perform the role of confidante among older people in China, particularly in intimate matters, as it is not usual to discuss such things outside the family.

CONCLUSIONS

In the introduction Bernandez' four social criteria affecting women's mental health were outlined [3]. These were socialization into rigid gender roles, having a lower social status than men, discrimination in employment and other formal sectors, and health


professionals who share the same cultural stereotypes about women's proper behaviour as laymen, We have seen that all of them pertain to the position of women in China.

Official policy in China strongly condemns discrimination against women. Equality between the sexes is clearly specified in the Constitution and a new law has been passed to protect women's rights and interests. However, policy in this area suffers difficulties common to policy formulation in the People's Republic generally; namely that the central authorities do not have the necessary power or control over resources to make the provinces implement centrally devised strategies. The government claims that current discrimination against women is the result of remnants of feudalistic thinking and to a limited extent that may be true, for instance in the preference for sons to continue the family name. But it is also the case that current government policies have contributed to continued discrimination. Examples are the 'one-child' policy and the pursuit of a 'socialist market economy', where profit outweighs all other considerations and employ- ing women is considered to be less profitable. Thus it is possible to demonstrate that, despite government policies to the contrary, there continues to be significant discrimination against women in China, particularly in rural areas.

On a macro level, clear gender differences are seen in the suicide rates, which are much higher for women than for men, particularly amongst young women in rural areas. These women are most vulnerable, not only because of the paucity of life chances and choices available in rural areas (true for both sexes) but because it is the age at which they are most likely to marry, and begin to suffer at the hands of husband and mother-in-law, especially if they bear a daughter. In truth, the suicide statistics in China indicate that life is hard for both men and women.

Women are diagnosed with depression and neurosis significantly more often than men (as they are in Western countries), although depression, in comparison with Western norms, is diagnosed comparatively infrequently. The epidemiological data for schizophrenia are unusual, indicating that significantly more women than men suffer from this illness, whereas the International Pilot S tudy suggests that schizophrenia occurs equally in men and women [41]. However, although no national figures are available, what is known suggests that there are fewer psychiatric hospital beds occupied by women. Evidence is also produced that suggests that the amount spent on treatment for women may be significantly less than that on men. This is certainly a product of women having less health insurance. Thus they are more reliant on family resources to pay for their hospital treatment. Families may be financially unable to do this, or unwilling to commit so many resources to the treatment of a female member. Either way, women miss out. As Skultans says in relation to her research on psychiatric practices in Kathmandu, "women are

simply getting less of whatever is considered to be the preferred mode of t reatment" [67, p. 975].

The three case studies are obviously not a definitive statement of how social expectations affect women's experience of distress but they do highlight how such matters influence individual lives. Arranged marriages, abortions, in-law problems, an enforced nur- turing role all take their toll. On the whole, these women did not expect and did not ask, for very much. But two at least were pushed beyond the bounds of what they could tolerate and found in illness an effective way to make demands and seek redress. For the third, her attempts to 'rebel' and assert control over her life were negated by being defined by others as illness.

Are women victims of historical, social, economic and political forces at large in Chinese society? This is, of course, only one perspective. There are many women, especially in the urban areas, who have achieved high levels of education and employment and manage to juggle both career and domestic responsibilities. But the figures demonstrate that for others, the odds are too great.

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Goods on which one loses: Women and mental health in China