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| ARTICLE |
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| Year : 2018 | Volume
: 16
| Issue : 2 | Page : 140-146 |
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Highlighting the gender disparities in mental health among Syrian refugees in Jordan
Anita L Kisilu1, Lina Darras2
1 Arab Renaissance for Democracy and Development Legal Aid, Jordan
2 PhD, Psychosocial Support Unit Manager, Arab Renaissance for Democracy and Development Legal Aid, Amman, Jordan
| Date of Web Publication | 30-Jul-2018 |
Correspondence Address:
Anita L Kisilu
Arab Renaissance for Democracy and Development Legal Aid, Amman
Jordan
 Source of Support: None, Conflict of Interest: None  | 6 |
DOI: 10.4103/INTV.INTV_18_18
Jordan has been a host country to many refugees from neighbouring countries for many years and has recently become a place of refuge for thousands of Syrians. The Syrian crisis has resulted in millions of Syrians fleeing their homes, uncertain of When they will return. Most of those seeking refuge have witnessed and/or experienced traumatic events that have affected their mental well-being in addition to starting over as refugees. Despite the large number of non-profit organizations providing free mental health services to refugees, not everyone has equal access to these services. This report, based on a literature review and a focus group discussion, highlights the different gender dimensions of mental health among Syrian refugees in Jordan. These risk factors include access to and use of mental health services, manifestation of mental health and psychosocial problems, treatment by mental-health workers and the socio-economic outcomes of living with someone suffering from mental health.
Key implications for practice
- To highlight the gender disparities in mental health among Syrian refugees residing in Jordan
- To highlight the gender differences in mental health needs and services among Syrian refugees in Jordan
- To provide insight about the level of mental health services provided for Syrian refugees in Jordan.
Keywords: Gender, Jordan, mental health, refugees, Syria
How to cite this article:
Kisilu AL, Darras L. Highlighting the gender disparities in mental health among Syrian refugees in Jordan. Intervention 2018;16:140-6 |
Over the past several decades, Jordan has played host to thousands of refugees from neighbouring countries and around the world. Palestinians sought refuge in Jordan following the war in 1948, as did the Iraqis after the 2003 invasion of Iraq. The latest surge of refugees to Jordan comes from Syria in response to an internal conflict that has been protracted for nearly 7 years. Many believed that the war was only temporary and that they would return to their normal lives; however, this hope fades everyday with the reports of bombs tearing apart their homes, their schools and their families.
Owing to the trauma-inducing realities of conflict such as the loss of loved ones, coupled with the strenuous task of crossing national borders in search of safety, the stress endured by Syrian refugees can be debilitating. Still, even after reaching relative safety, refugees must then begin rebuilding What parts of their lives they still have intact so as to regain some sense of control and normalcy in their lives. It stands to reason then that those Who escape conflict are often left with feelings of distress, anxiety and helplessness, all of Which pose significant obstacles to resilience (Hassan, Ventevogel, Jefee-Bahloul, Barkil-Oteo, & Kirmayer, 2016). Therefore, it is imperative to provide mental health and psychosocial support (MHPSS) to Syrian refugees.
The World Health Organization (WHO, 2014) defines mental health as a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her or his community. Psychosocial support incorporates family and community in assessing people’s problems and needs based on the close relationship between the psychological (emotions and behaviours) and social (relationships and traditions) experiences that the individual goes through (EMPHNET, 2016).
This paper examines the gender differences regarding mental health as well as the gender differences in mental health seeking behaviour among Syrian refugees in Jordan based on a literature review of reports by non-profit organisations (NGOs) working with Syrian refugees in Jordan. The literature review is based on data gathered and published by various NGOs working in the region as they have more funding and better access to refugees both in camps and in urban areas combined with the practical expertise and knowledge in providing such services. An impromptu focus group discussion was also conducted with MHPSS professionals working with various NGOs in Jordan to gain a more personal professional perspective. The focus group discussion took place during a monthly meeting among MHPSS professionals from various NGOs working in with Syrian refugees in Jordan. These meetings are coordinated by the United Nations High Commissioner for Refugees (UNHCR) on a monthly basis and consist of professionals from different NGOs in Jordan working in MHPSS units coming together to discuss the issues they are facing or have faced and share the progress with each other. This was a perfect opportunity to gather first-hand information from professionals themselves. This paper highlights the different factors that may affect these differences such as biological factors, socio-cultural norms and the different ways psychosocial problems manifest from data gathered by different organizations working with Syrian refugees in Jordan since the crisis began. By highlighting these disparities, we hope to encourage mental health workers to identify and address the mental health needs of women, men, boys and girls as well as the potential barriers each face When seeking support.
| Gender Dimensions of Mental Health Risk Factors and Vulnerability | |  |
Being vulnerable to something means that there is a greater chance of being affected by it. Biological vulnerability to mental illness means that something in an individual’s genetic make-up increases their susceptibility to mental illness. The male and female biology differs in several ways including certain mechanisms that make females more vulnerable to mental disorders such as depression. Females are twice more likely than men to suffer from depression, anxieties and somatoform disorders (Piccinelli & Wilkinson, 2000; WHO, 2017a). This can be attributed to the fluctuating hormone levels that women experience throughout their lives, such as during pregnancy and child birth and during menopause (Soares & Zitek, 2008).
Young girls are exposed to these vulnerabilities from a young age if they are married young. Child marriage existed in Syria before the crisis Where the legal age for girls to marry is 17 and in some cases even younger (Save the Children, 2014). However, rates have significantly increased among Syrian refugees as a result of the crisis. These early marriages result in early pregnancies Which can result in complications during pregnancy and birth, thus exposing girls to these vulnerabilities from a young age (Douki, Zineb, Nacef, & Halbreich, 2007). Girls under 18 years are more likely to experience severe complications during birth (Save the Children, 2014), because the body structure is not yet mature enough to deal with the physical stress of childbirth, thus increasing their chances of psychological trauma and post-natal depression. While the biological risk factors that make women more susceptible to mental health problems are well documented, more research is necessary regarding the biological risk factors that affect males.
Beyond biology, socio-cultural factors also impact mental well-being. Socio-cultural factors constitute the set of values, customs and traditions that distinguish a society or group. Some of these traditions impose additional pressures upon individuals, While deviation from them can lead to chastisement or alienation. These socio-cultural factors are not only a source of stress but also provide a sort of guideline of the accepted ways to release stress, determine the help system that individuals may use to deal with stress as well as accessibility to support systems to help with stress (UNHCR, 2015).
Stigma surrounding mental illness is widespread and common, because it is often greatly misunderstood (Ahmedani, 2011; Almoshmosh, 2015; Angermeyer & Dietricht, 2006). Stigma is one of the biggest issues individuals suffering from mental illness face in the Middle East and has been found to have a greater impact on mentally ill women, because they have less access to Care and suffer a worse social outcome (Douki et al., 2007). For example, some families would rather not disclose that one of the daughters in the family suffers from mental illness, because it might lower the marriage prospects for the other daughters. The other females in the family must then cope with the stress of potentially not having any suitors, compounded by pressure from both the family and the community to marry. Together, these stressors lower their self-esteem, making them feel as if they are not good enough for marriage, worsening their mental well-being.
Syrian women, especially those from the rural areas, are generally secluded in the home, because cultural norms restrict them from leaving the house as well as prohibit most forms of female employment (CARE, 2013b). According to Syrian refugees in Jordan, this is mostly due to the fact that females are more likely to be harassed by local men (CARE, 2013b; International Rescue Committee [IRC], 2013). This seclusion results in the women suffering from psychological problems such as depression from boredom or anxiety caused by harassment and the fear of being harassed on the street. The fear of facing harassment on the street may cause these women to lack incentive to leave the house in pursuit of mental healthcare. While harassment is reduced when women are accompanied by an older male relative, due to the crisis, adult males are absent from some families, because they have either remained in Syria to fight, passed away or travelled to look for better opportunities for their families. This makes life even more difficult for the widowed women or female-headed households, because it compels them to find a way to provide for themselves and their children.
Additionally, the limited employment opportunities in Jordan pushes these women to find alternative ways to provide for themselves and their children, forcing some to sell the gold and jewellery they received When they got married (a traditional source of insurance) (CARE, 2013a), leading to increased feelings of loss. In extreme cases, the lack of employment or inability to provide for the family may result in a marriage of convenience or transactional sex, especially among uneducated women (CARE, 2013a, 2013b), leading to feelings of shame and increased psychological stress.
The sudden shift in gender roles Which has forced women to become the heads of the household has caused a significant amount of strain on Syrian women, because it has not been a slow, gradual societal shift, but a sudden one caused by loss and violence. Educated Syrian refugee women Who had stable sources of income prior to the conflict suffer great losses, because they must accept lower-wage jobs and adjust to their income being necessary for survival, as opposed to income complementary to their husbands’ as was the case in Syria. Moreover, their lack of documentation (Which they left behind or lost), the high unemployment rates for educated people in Jordan and the restrictions on work permits for Syrian refugees make finding employment almost impossible for some.
Younger girls have different socio-cultural stressors that contribute to poor mental health, one of them being early marriage. The rise in child marriages among the Syrian refugee community in Jordan has been attributed to the lack of economic and physical security as a result of the crisis with many seeing it as a way of protecting their daughters as well as reducing financial burden (Save the Children, 2014). Many younger women even reported accepting marriage proposals from unknown men to help reduce the economic strain on their parents as well as the stress caused by worrying about their safety (IRC, 2013). Moreover, marriage is generally regarded positively among young girls, because it is seen as honourable and is usually associated with a party and a beautiful White dress. However, the stress of raising and providing for a family, especially in the unstable financial conditions they are living in now as refugees makes this prospect more daunting. Furthermore, being taken out of school early to prepare for marriage but not receiving any proposals can lead to feelings of disappointment and low self-esteem, negatively impacting their mental well-being. Increasing pressure from family members can also add to the stress of not getting a marriage proposal, resulting in her feeling like a failure and causing her to attribute the lack of a proposal to her own insecurities. Additionally, stress from staying at home Where tensions are high While she would rather be in school may also have a negative impact on well-being (CARE, 2013a).
The socio-cultural factors that affect men’s mental well-being are different from those that affect women, given their culturally prescribed roles. For instance, men tend to identify the lack of employment and the related instability as major stressors, given that men are traditionally responsible for generating income (CARE, 2014) . The inability to fulfil this role generates feelings of hopelessness, uselessness and loss of identity, compounded by the stress of constantly worrying about their family’s safety (UNHCR, 2015). Feelings of shame and depression have also been reported by Syrian men in urban areas in Jordan because of being forced to work in low-paying jobs as well as being unable to continue their education (CARE, 2013a). The increasing occurrence of women becoming the sole breadwinners or having to work to contribute to the family’s income is also difficult for some Syrian men to accept, because it threatens their superiority and manhood (Douki et al., 2007).
For younger boys, a father’s lack of employment likely means that they will have to drop out of school owing to their family’s inability to afford it and that they may even be required to seek out work to help provide for their families (Khalil, Al Masri, & Fean, 2016). This leads to the increased rates of illiteracy and higher incidences of child labour Which can negatively impact psychological well-being (International Medical Corps [IMC] & United National International Children’s Emergency Fund [UNICEF], 2013). Death or absence of the father or main provider is another factor that compels young boys to grow up quickly and take up responsibilities they are not ready for, given that the eldest male in the family is expected to assume the role as the head of the family. This forces them to grow up quickly and thrusts the stresses of adult life upon them from an early age, causing them to skip stages in the developmental process. Although early marriage is not as common for young boys as it is for young girls, the boys Who are forced to marry early are faced with a similar set of challenges. Assuming the role as head of household or marrying and subsequently taking on the responsibility of providing for and raising a family and holding a comparably high social status prematurely thrust the stresses of adult life upon children.
Skipping steps in the developmental process can have adverse effects on mental well-being and stability, especially if the individual is forced into a life full of adult responsibilities, because they do not yet have the capacity to deal with such complex problems (WHO, 2017b). Furthermore, these young boys are left in limbo between childhood and adulthood which is noticeable in their behaviour. Dr. Lina Darras, a psychologist working with Arab Renaissance for Democracy and Development, observed this confused behaviour among some of the male teens in her sessions (Darras, psychosocial support unit manager, 18 January 2017). She indicated that when talking about some of the issues regarding gender-based violence (GBV), the boys joked and behaved in a manner characteristic of adolescent males. Their demeanour changed, however, when the subject discussion shifted to responsibility, seeing as they were the ones responsible for their households. Further adding to their confusion is the way they might be treated in the household, workplace or schools. Because they are not yet adults and do not immediately command the same respect an adult male automatically receives, the attitudes they may encounter from others can cause frustration as they have been placed in a position of power but are not treated accordingly. Additionally, illiteracy due to dropping out of school further exacerbates these boys’ frustrations as they try to keep up with the fast-developing world.
| Gender Dimensions of Access and Use of Mental Health Services | | |
Many NGOs in Jordan provide free psychosocial support to Syrian refugees both in camps and urban areas. Nevertheless, although these services are available to all, not everyone actively seeks these services. Previous research demonstrates gender differences in help-seeking behaviour in that that men have lower help-seeking patterns compared to women, especially When it comes to mental health problems such as depression and other emotional disorders (Moller-Leimkuhler, 2002; WHO, 2002). Moreover, stigma surrounding mental illness in the Arab and Syrian culture may affect mental health seeking behaviour (Al Hadid, 2016). Suicide (or attempts at it), for example, is highly stigmatized in Arab cultures and practitioners in some countries in the region are required by law to report suicide attempts to the authorities (UNHCR, 2015). Consequently, the fear of being persecuted may restrict or even prevent individuals suffering from mental distress from seeking help or disclosing their thoughts to mental health practitioners (UNHCR, 2015). Other barriers to the use of these services include socio-cultural factors, fear of negative perceptions and limited accessibility.
As previously discussed, cultural norms sometimes prevent or limit some from accessing mental health services. The cultural restrictions on women to stay in the home, in conjunction with the harassment they may face When they do leave the house, discourages them from going to seek mental health and information services (CARE, 2013a; IRC, 2013). When the women do leave the house, they are expected to be accompanied by a male member of the family Which is problematic if the man is the source of her distress. Moreover, a male chaperone might not always be available or convinced that she needs mental health assistance. When it comes to trauma from GBV or domestic violence caused by a husband, gender cultural norms can prevent women from reporting abuse, because it is considered a family matter that should not be made public (IRC, 2013). Thus, women may feel that reporting the trauma caused by such an event is without avail and that healthcare officials would turn them away or even take advantage of their vulnerability.
Additionally, the lack of or few numbers of female physicians, especially regarding reproductive health (CARE, 2013a) may prevent some women from using mental health services, because some women are not permitted by their husbands or families to see male physicians and some may not be comfortable receiving treatment from a male physician. However, UNHCR (2015) reported that women are more likely than men to seek psychosocial services, especially if they offered a safe space for them and their children. Girls face the same restrictions women do and increased safety concerns mean that many girls stay at home instead of going to school Which in turn restricts their access to services provided in schools (UN WOMEN, 2013).
Conversely, men have more access to services because they are not bound by the same cultural restrictions. However, some may have difficulty accessing some of these services on account of the long distances to service locations and the high costs associated with travelling to obtain treatment. In Jordan, for instance, basic services including mental health are more accessible in camps than in urban areas due to the close proximity for those living in camps. On the other hand, IMC (2016) demonstrated that compared to camps (26%), services benefitting Syrian refugees were higher in urban areas (76%), Which could be due to the fact that more services are offered by various NGOs in urban areas. Regarding men’s use of mental health services, the perception that men should not cry or be afraid as both are signs of weakness (UNHCR, 2015) may prevent them from seeking the required mental health services and prevent them from healthily exploring, understanding and dealing with their emotions, causing them to lose touch with their feelings. However, psychologists working with Syrian refugees in engaging men and boys in issues regarding GBV noted that this perception was less in older men Who were telling the younger men that it was okay to cry and be vulnerable.
| Gender Differences in the Manifestation of Mental Health and Psychosocial Problems | | |
Subtle differences exist in the manifestation of mental health and psychosocial problems between men and women, and boys and girls Which can be attributed to socio-cultural factors. A common manifestation of stress in men, for example, is violence Which is justified or explained away as being because of anger or stress (IRC, 2014). In regard to women, however, social convention dictates that they should be reserved, so it is frowned upon for women to be loud or violent especially in public. However, While women cannot raise their hands to their husbands, they do tend to take out their anger on their children. In fact, adolescents reported that the recent crisis and its stresses have led to the increased incidences of domestic violence in the home (IMC & UNICEF, 2013). Other MHPSS concerns reported among Syrian adult refugees were anxiety, psychosis, acute stress and mood disorders (IMC & UNICEF, 2013).
The manifestations of psychological trauma commonly seen in children according to mental health professionals were epilepsy, mood disorders, fear reactions especially to loud noises and planes, aggression and insomnia (IMC & UNICEF, 2013; IRC, 2013; UN WOMEN, 2013). When compared to boys, however, girls demonstrated more pro-social behaviour but also had more emotional overall difficulties (IMC & UNICEF, 2013). In regard to coping with stress, individual differences among adolescents were noted in that some turned to religion, others preferred listening to music or reminiscing over the good times they had in Syria. However, the most common coping mechanisms were talking with parents and/or friends and withdrawal (IMC & UNICEF, 2013). Moreover, whereas girls were reported to have higher incidences of self-harm such as refusing to eat and cutting themselves as coping mechanisms, boys tended to turn to smoking, violence and stealing (IMC & UNICEF, 2013; UNHCR, 2015).
| Gender Disparities in the Treatment of Syrian Refugees in Mental Healthcare Settings | | |
As a rule, humanitarian assistance is directed at populations believed to be the most vulnerable and, as is often the case, women and children are over Whelmingly regarded as more vulnerable than men despite the challenges that men endure. Accordingly, humanitarian assistance is directed more towards women than it is towards men (Turner, 2016). However, this results in men feeling left out due to the high number of services targeting women and children and the limited number of services targeting them. Moreover, since men are perceived as a threat or the main cause of distress, health workers might treat them differently by being harsher or less sympathetic towards them compared to women and children (Turner, 2016).
The lack of sufficient psychological support for mental health staff and volunteers (IMC, 2016) is another factor that may affect treatment. It was reported that only 35% of the organizations in Jordan provide psychosocial support for staff and volunteers (IMC, 2016). A classic example of Where bias due to the lack of psychological support of mental healthcare workers is in the cases of sexual gender-based violence (SGBV), especially if the mental health staff have been working with female victims of SGBV for a While and are then faced with a male client. Their bias may affect the sympathy they feel and show towards the male client. This is worsened by the lack of training for trainers as well as no action from community workers to identify and refer people with mental disorders to specialists or to follow up on them to ensure that they adhere to prescribed treatment (IMC, 2015).
| Gender Dimensions of Mental Health and Socioeconomic Outcomes of Living with an Individual Suffering from Mental Illness | | |
Although every individual in a household is impacted by living with an individual with mental health challenges, women are arguably impacted the most, because they are largely responsible for the physical care of those individuals (Douki et al., 2007). Girls in general are expected to help their mothers in the home with household duties, looking after the other family members and those that may need help in the home. Furthermore, as previously mentioned, girls tend to suffer a worse social outcome, especially regarding marriage prospects. Men on the other hand tend to be affected more economically being the breadwinners.
While women are responsible for the physical care of individuals with mental health challenges, men are generally responsible for supporting them financially. The pressure on them is further increased for those − particularly refugees − who have limited access to income generating opportunities. This would in turn affect the boys who are old enough to work as they would be forced to leave school and look for work to help cover any additional costs associated with living with an individual affected by mental health problems. Stress on a family might be greater if the mentally ill individual is female, not only because of the increased stigma they face, but also because they are more vulnerable.
| Conclusion | | |
Conflict environments and their devastating realities can present significant threats to an individual’s mental health (Hassan et al., 2016). These threats are only intensified When one must flee conflict and seek refuge in unfamiliar environments. It is understandable then that refugees experience feelings of anxiety, fear, hopelessness and even psychological trauma. Accordingly, the provision of mental and psychological support services must be regarded as critical to refugees’ resilience. It is important to recognize, however, that notable gender differences exist regarding mental health and mental health support services, particularly: vulnerability to and manifestation of mental health challenges; access to and quality of mental health support as well as how one is affected by living with an individual suffering from mental health challenges. Understanding these differences as well as the daily stressors refugees face is critical to providing the high-quality mental health support that refugees need and deserve. Furthermore, given that more than half of the refugees are children (UNHCR, 2015), it is imperative that they receive the appropriate services and treatment with the expectation that it will safeguard their future and give them hope for a better and brighter one.
Biology and socio-cultural factors have important implications to an individual’s mental health. Pregnancy is a common trigger for problems such as depression, especially if there are complications during birth Which is highly likely for early pregnancies (Save the Children, 2014). Accordingly, campaigns to raise awareness on the complications associated with early pregnancies and their impact on mental well-being should be conducted in the hope of reducing the incidences of early marriages and pregnancies. While the impact of biology on women’s mental health is well known, more research is needed to determine the impact biology has on men’s mental health. Indeed, While biology is a determinant of one’s susceptibility to mental health challenges, society and culture impact the extent and magnitude of those challenges.
Society and culture and the prescribed gender roles can sometimes trigger mental health challenges. This impacts men and boys differently than it impacts women and girls. Generally, socio-cultural norms in Arab and Syrian societies are stricter on females than they are on males. These additional burdens and reduced freedoms have the potential to deteriorate women and girls’ mental health. When mental health challenges develop, women are at a dual disadvantage, because socio-cultural norms prevent them from displaying signs of suffering, while also limiting their ability to seek treatment. Moreover, the fact that mental health challenges are highly stigmatized in the Arab and Syrian society results in both males and females being discouraged from seeking treatment due to fear of alienation. Men in particular may have concerns of being regarded as weak while women may be more concerned about their ability to marry. Launching more mental health awareness campaigns can help to reduce the stigma surrounding mental illness in these communities and encourage support for those seeking treatment. Additionally, providing home visits for those who are restricted to the home or have privacy concerns will increase the number of people receiving the services they need in the comfort of their own home.
A shift in gender roles, Which has led to some women having to work to sustain the family, also presents a new challenge for both men and women. Women Who were accustomed to being taken care of financially by their husbands are now the sole breadwinners of their families While the men face the shame of being unemployed and unable to provide for their families. This lack of employment has had a negative impact on all family members; men have lost their role as provider, women have gained a new role as provider on top of their role as carer, boys are forced to drop out of school and look for employment and girls are more likely to be subjected to early marriages. In regard to treatment and quality of care, men are at a unique disadvantage because of the general regard that men are less vulnerable than women and children. Men have fewer programs dedicated to their resilience, While aid workers have been found to be biased towards women and children, viewing men as the source of strife, rather than vulnerable and in need of treatment.
Given the various stressors men face from their lack of employment, the changing gender roles, the fact that their vulnerabilities are generally overlooked by mental health workers as well as the limited services targeting men, more services should be created for men. These services should specifically target men and their vulnerabilities and include social zones and psychosocial support (PSS) centres Where men can gather and meet other men in their communities. These services can also provide sessions on stress management, relaxation techniques and lessons on alternative ways to deal with stress. Additionally, psychological support should be offered to all mental health workers not only to ensure that all beneficiaries receive quality services, but also to reduce the bias towards male refugees.
Mental health challenges not only impact the individuals suffering from them, but other members of their household. Males and females are affected differently When it comes to the socio-economic outcomes of living with an individual suffering from mental illness. Women are generally the first and last resort When it comes to looking after a family member with disabilities (Douki et al., 2007). Conversely, males are expected to provide financial support in particular. If the individual suffering from mental illness is female, other female family members may have their marriage prospects diminished. Because of the differing gender roles and the differing challenges faced by both genders, it is imperative that mental health workers and volunteers are given the appropriate gender sensitive training to ensure quality services.
This literature review provides a practical guideline for mental health workers working with Syrian refugees in Jordan. By highlighting these gender differences and offering some recommendations on how to tackle these differences, we hope that mental health workers will take the necessary steps to address them to ensure quality service and access for all.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.[28]
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