Sociocultural context and intersectionality are vital to women's reproductive mental health.

Sociocultural context and intersectionality are vital to women's reproductive mental health Howard et al1 have synthesized, with expertise and sensitivity, the substantial evidence about the links between some reproductive events in women's lives and mental health problems. There is detailed consideration of the role of sexual biology, in particular hormonal factors. Sociocultural context is acknowledged as relevant, but might be considered further in the research agenda that is called for and the proposed health worker training. Gender refers to socially constructed characteristics – behaviors, roles, opportunities and expectations associated with being a woman (or a man) – and is influenced by culture and context. The term is sometimes used interchangeably, and inaccurately, with sex. Gender interacts with sociocultural norms, ethnicity, socioeconomic position, age, place, and access to resources, in what is termed intersectionality. The social determinants of mental health problems and the provision of comprehensive health care can only be fully understood and addressed through a gender-informed intersectional lens. As a prominent example, knowledge, facilities and a safe environment are needed to manage menstruation hygienically and with dignity. Disposable sanitary products are not accessible to most women and girls in resource-constrained countries, especially the poorest. They must use cloths to absorb menstrual blood, and require access to water and privacy to wash and dry them for re-use. Cloths are often difficult to secure and so risk of blood stains on clothing or seats is high. Girls are much less likely to go to school when menstruating, because they lack access to essential requirements for safe and dignified management of menstrual blood. Some cultures have traditional beliefs and practices related to menstruation being polluting. Women and girls who are menstruating may have to avoid men and boys, be precluded from religious functions and prohibited from food preparation. They might not be permitted to use the household toilet while menstruating, because the blood is thought to be contaminating. Where there is no household water supply and open spaces are used, girls are subject to violence and intimidation while toileting, including managing menstruation. These experiences are persistent sources of anxiety, shame, social avoidance, and hypervigilance. Women who have migrated from low- to high-income countries view menopause as a normal life stage, and do not see a need to seek menopause-specific health care. Instead, they use self-care strategies and traditional remedies, often from their country of origin, and seek health information from family and friends. They rarely initiate conversations about menopausal health with health workers, because this is considered an intimate topic and is not openly spoken about4. Their preference is for clinicians to raise the topic with them, but primary care practitioners report that they do not feel culturally competent to do this, and generally avoid the topic unless a woman raises it5. Clinicians’ gender stereotypes about what is normal and what is pathological influence their recognition and validation of symptoms and their recommendations6. Women with endometriosis have been found to have waited an average of 7.5 years between seeking help for pain and having their condition investigated and treated. Doctors believed that women had endometriosis only when lesions were found on diagnostic investigations, but had not believed much earlier accounts of pain and symptom-related disability. Heavy menstrual bleeding, another serious problem for some young women, is often normalized, leading to delays in investigation and treatment. Being disbelieved while experiencing pain or excessive bleeding is strongly associated with elevated symptoms of depression, anxiety and social withdrawal7. In high-income countries, menopause has become stereotyped as a hormone deficiency disease and a problematic life stage in which mental and physical health deteriorate. It is notable that none of the population-based surveys assess the menopause-related benefits for quality of life. None ask about improvements in well-being from cessation of regular bleeding and the expenses of sanitary products, reduced anaemia, and being able to wear light-colored clothing and exercise without constraints. A recent review8 of prospective cohort studies on mental health problems over the menopause transition found no compelling evidence for a universally increased risk of depressive symptoms or major depressive disorder. Women with a history of depression are indeed at increased risk of recurrence, and risk can be enhanced by experiencing coincidental adverse life events. No compelling evidence was found that the risk of anxiety, bipolar disorder or psychosis is increased. The authors noted that the stereotyped association of menopause with poor mental health can lead to negative expectations as women approach the menopausal transition. One could also argue that these gendered stereotypes have the further potential social harm of leading employers to view women in mid-life as risky prospects or as unable to be appointed to senior roles. In the light of all this, the assessment of and response to mental health problems associated with reproductive events require broad considerations. It should not be assumed by clinicians or in health promotion strategies that psychological symptoms, including during the menopause transition, are just attributable to biological changes9. It has historically been conveyed to women as “the weaker sex” that biology is destiny, that their intrinsic sex-specific vulnerabilities render them less able to learn, to participate in the non-domestic sphere, to be given public appointments and to lead. These powerful social stereotypes still prevail. Although more women in high-income countries participate in the economy and politics than in the past, equity is rarely achieved, including in remuneration. Women continue to carry a disproportionate load of unpaid household labour, and are far more likely than men to experience violent victimization. The situation is much worse for women of color, who continue to encounter racism as well as sexual discrimination throughout the life course. In countries in which gender inequality is entrenched and roles are severely restricted, biological vulnerability is often used as a justification. Women's mental health benefits from equality of opportunities, including for post-secondary education, income-generating work, and promotion commensurate with capability. These are enabled by access to reproductive choice, shared household work, and personal safety. If mental health problems are experienced, rights-based approaches in which women are encouraged to participate socially and economically and are given skills to counter discrimination need to be implemented. An empowerment model of health care has been proposed9 in which women's sociocultural experiences and circumstances are assessed explicitly, and potentially modifiable risks are addressed, and in which women's expertise is built through health education and agency fostered, so that they become knowledgeable partners in their care. Health care workers can promote optimal reproductive mental health by recognizing intersectionality and their gender-based stereotypes, and how these influence what is asked about and how they respond. Whether or not pharmaceutical treatments, including hormone therapies, are offered, it is essential to also provide evidence-based psychological treatments, counter catastrophizing, and promote a solution-focused and optimistic approach to reproductive events.