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Advancing the health of girls and women in bc

A Provincial Women's Health Strategy

Dr. Liz Whynot

Advancing the Health of Girls and Women in British Columbia, A Provincial Women’s Health Strategy (PWHS) is presented by the BC Women’s Hospital & Health Centre, an Agency of the Provincial Health Services Authority (PHSA), and the British Columbia Centre of Excellence for Women’s Health (BCCEWH). The Strategy was developed in consultation with many partners, including the Office of Healthy Children, Women and Seniors of the Ministry of Health Services, health authorities, and community representatives.

The aim of the Provincial Women’s Health Strategy is to improve the health of girls and women throughout BC. The Strategy describes an approach to understanding girls’ and women’s health and provides background information to promote the development of initiatives to integrate girls’ and women’s health into research, policy, and clinical care. To support the implementation of the Strategy, the PHSA, in partnership with the Ministry of Health Services, has established a Provincial Women’s Health Network to build on women’s health initiatives throughout the province.

The Strategy notes that, “overall, the health of girls and women in BC compares with the best in the world. However, while life expectancy among women has achieved an all-time high, there are nevertheless significant sources of disease and illness that continue to affect the quality of life of women and some groups of girls and women suffer from serious health problems. Researchers, policy makers and practitioners need to be strategic in addressing health conditions or diseases that are unique to, more prevalent among or more serious in women, or for which there are different risk factors or interventions for women and girls as compared to men and boys.” (PWHS, 2004:11)

The Strategy recommends that the initial priorities for action and research related to women’s health include:

• developing enhanced capacity for women’s health monitoring, surveillance, and reporting

• improving access to maternity care

• supporting women-centred approaches to mental health and addictions

These broad priority areas are intended to set the direction and focus for areas to improve women’s and girls’ health, and to recognize that many social determinants influence these priorities. Moreover, the Strategy reflects a set of values to guide its implementation: women are the centre; recognize diversity and promote equity.

This discussion will focus on the third priority area: supporting women-centred approaches to mental health and addiction. While the strategic priority focuses on mental health and addictions, the Strategy draws a clear connection between gender-based violence as a feature of women’s mental health and problematic substance use. “Mental health and addictions are often interrelated problems and both may be associated with a history of trauma and abuse for women.” (PWHS, 2004: 27)

WHAT WE KNOW: MENTAL HEALTH AND VIOLENCE AGAINST WOMEN

Research supports the strategic direction to link violence in the lives of girls and women with mental-health concerns. For example, significant rates of mental health problems are consistently found among abused women, and women who have endured violent relationships are four to five times more likely to require psychiatric treatment. (Stark, 1991) Mood (eg, depression, suicidality), anxiety (eg, post-traumatic stress disorder), and somatic disorders occur at high rates. (1999; Campbell, Sullivan, and Davidson, 1995; Cascardi, et al., 1995; Golding, 1999; Jones, et al., 2001; Stark and Flitcraft, 1995,1996; Tolman and Rosen, 2001) In some cases, the psychological impact of being abused can lead to the development of such significant mental-health problems that they may interfere with an abused woman’s abilities to make decisions and to protect herself. (Davies, et al., 1998)

Abuse can also have a signi.cant impact on the psychological resources of the woman; for example, she may experience a decreased sense of agency, loss of identity, and feelings of hopelessness, helplessness, guilt, and shame. (Aguilar and Nightingale, 1994; Fischer and Rose, 1995; Frisch and MacKenzie, 1991; Kirkwood, 1993; Nurius, et al., 1992; Walker, 1984) Psychological impact is not determined by the severity or frequency of physical assault (Heise, 1994; Johnson, 1996); rather, exposure to dominance is the strongest determinant of psychopathology, as well as threats of harm, sexual abuse, and emotional abuse. (Ratner, 1998)

Many of these mental-health problems post-date the battering. (Cascardi, et al, 1995; Stark and Flitcraft, 1996) Thus, some clinicians believe that mental-health problems should be treated as symptoms of abuse and not as mental disorders per se. (Gondolf, 1998; Stark and Flitcraft, 1995) However, pre-existing mentalhealth problems (including history of childhood abuse or sexual assault) may also be exacerbated by the abuse, often as a result of increased stress or prevention from obtaining treatment. (Jenkins and Davidson, 2001)

WHAT WE KNOW: SUBSTANCE USE AND VIOLENCE AGAINST WOMEN

Similarily, women in abusive relationships are at increased risk for use of substances, including illicit drugs, alcohol, tobacco, and prescription medications. (Golding, 1999; Hathaway, 2000; Ratner, 1998) Substance use may represent an abused woman’s strategy for coping with distress or it may re.ect pressure from the abuser to consume these substances with him. (Gondolf, 1998; Miller, et al, 1989)

I used the alcohol to medicate myself because I couldn’t deal with what he was doing to me. (Luisa)

He wouldn’t let me not drink, he would bring alcohol over, or you had to drink just to be near him. He would put a glass under my face, he knew I didn’t want to drink. He used that, too. “You’re a loser, look at you.” (Luisa)

According to Zubretsky, (2002) in many cases initial or escalated use of substances is coerced or manipulated by abusive partners, ranging from pressure that abusers place on women to use certain drugs to the experience of being tied down and forcibly injected with drugs. Efforts to stop using substances may precipitate the abusive partners’ use of increased violence. In addition to medicating the emotional and physical pain of trauma, a woman’s chemical use can aid her in reducing or eliminating feelings of fear.

Substance use has many implications for women’s safety. When intoxicated, a woman may not be able to make decisions that might protect her from the abuser. Or she may be reluctant to leave an abusive relationship because of her dependence on the abuser for access to drugs. (Hart and Stuehling, 1992)

MAKING THE CONNECTION: VIOLENCE, MENTAL HEALTH, AND SUBSTANCE USE

The Provincial Women’s Health Strategy recognizes that “trauma, violence and socioeconomic status similarly affect psychoactive substance use among girls and women, affecting both initiation of substance use and changing or overcoming problematic patterns of use.” (Currie 2001; National Center on Addiction and Substance Abuse 2003, in PWHS, 2004: 12) “Mental disorders and substance use problems are serious among girls and women in British Columbia. Indeed, research has shown that mental health problems and problematic substance use in women are often interconnected and that these problems in turn are exacerbated by women’s experiences of violence and trauma.” (eg, Harris 1998; Anderson and Chiocchio 1997 in PWHS, 2004: 37) Women’s poverty and experiences of violence are also inextricably linked to their mental health and in.uence their recovery. (Harris 1997, 1998; Sarceno and Barbui, 1997, in PWHS, 2004: 12)

A large proportion of women with substance-use problems are victims of domestic violence, incest, rape, sexual assault, and child physical abuse. (Ouimette, et al, 2000) Mental-health problems are also associated with, and exacerbated by, some types of psychoactive substance use; research has shown that as many as two-thirds of women with substance-use disorders may have a concurrent mental-health problem, such as depression, posttraumatic stress disorder, panic disorder and/or an eating disorder. (Zilberman, et al, 2003)

Women in abusive relationships are more likely to be inappropriately prescribed medication than women not experiencing abuse. (Loring, 1992) Many prescriptions are related to diagnoses of mental illness, rather than recognizing women’s conditions as the impact of violence and trauma. In addition, women express fears of addiction to prescription medication or a loss of alertness, which could increase their risk for more abuse. (McCauley, 1998; Zubretsky, 2002)

WHAT WE NEED: SERVICE GAPS

According to Zubretsky, abused women find themselves in the ultimate catch-22: substance use may begin or escalate as a response to the trauma of victimization, and efforts to stop using substances may precipitate abusive partners’ use of increased violence. One battered woman’s words about her own recovery capture the essence of the dilemma. She said, “As an alcoholic, AA and treatment saved my life; as a battered woman, it nearly killed me.” (Zubretsky, 2002: 1)

Despite significant correlations between trauma and abuse, mental health, substance misuse and addiction, and physical health for women and girls, health services, community services, and treatment programs are frequently ill-prepared to provide the range and depth of services needed for chemically involved or mentally ill abused women. For example, women experiencing abuse are disproportionately represented in chemical-dependency treatment populations, and transition houses often have sobriety as a condition for gaining access to safe housing.

Women with mental-health diagnoses also may be denied access to transition houses, although this trend is changing. Women may be prescribed medications to address mental-health issues, which can be addictive; both the mental-health diagnosis and the addiction might prevent them from having access to a transition house. Health services may focus on the addiction or mental-health issues for women and girls rather than making the connection to current or previous gender-based trauma and abuse, thus potentially re-traumatizing women. These examples all highlight the need for women-centred care, which provides a framework for health care that acknowledges the interconnectedness of social and health issues.

The Provincial Women’s Health Strategy highlights the connection between violence against girls and women, mental health, physical health, and substance use and has established a provincial priority to address this complex health issue for women. While there is still much work to be done to achieve a truly integrated, women-centred approach, the Strategy provides the foundation for working in partnership within the health system and across systems to address women’s health, safety, and sobriety.

Dr Liz Whynot is President of BC Women’s Hospital and Health Centre, the lead agency within the Provincial Health Services Authority (PHSA) with the mandate to address a range of health issues for women in BC. As the only facility in BC devoted primarily to the health of women of all ages and backgrounds, BC Women’s provides a broad range of specialized health services and is the largest single provider of maternity services in Canada. It coordinates and evaluates specialized health services, disease prevention, and health-promotion activities, and works with the other health authorities in BC to support equitable and cost-effective health care for girls and women.

Since 1996, BC Women’s has hosted the British Columbia Centre of Excellence for Women’s Health, one of four Centres of Excellence for Women’s Health in a national program funded by Health Canada through its Women’s Health Strategy. The BCCEWH conducts or facilitates research on a variety of women’s health issues in collaboration with providers, policy makers, and women in BC and across Canada. Its mandate is to develop new knowledge to provide policyrelevant evidence for improving women’s health, especially women on the margins of society.

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