This document summarizes research on gender differences in depression and the social construction of premenstrual syndrome (PMS), postnatal depression, and menopausal depression. It discusses how: 1) Epidemiological research finds that women experience depression at rates 2-4 times higher than men, especially during reproductive years. 2) Biological and hormonal theories have been proposed to explain this, but psychosocial risk factors like poverty, caring roles, abuse, and socialization also contribute significantly. 3) The construction of conditions like PMS, postnatal depression, and menopausal depression as medical disorders pathologizes normal experiences and subjects women through notions of monstrous femininity. 4) Cross

1. Research as aa bbaassiiss ooff iinnnnoovvaattiivvee pprraaccttiiccee
TThhee ccaassee ooff rreepprroodduuccttiivvee hheeaalltthh
Professor Jane M Ussher,
Centre for Health Research
University of Western Sydney

2. Gender Differences iinn DDeepprreessssiioonn
Epidemiological research –
 life time occurrence of depression in community
samples
 women outnumber men at a ratio of 2:1 - 4:1
 prevalence depression in previous 1-12 months
 women between 1.2 and 2.7 times more likely to have
experienced depression than men
Ussher (2011) Women’s Madness: Myth and experience, London, Routledge/New York

3. BBiioollooggyy ttoo BBllaammee::
RRaaggiinngg hhoorrmmoonneess aanndd rreepprroodduuccttiivvee
ddeebbiilliittaattiioonn
Pre-post adolescent gender difference:
“the female prevalence in depression is linked to women’s
reproductive years” (Cyranowski, Frank, Young, & Shear, 2000, p25)
“in later life (after age 55), the female excess of depressions
diminishes; mostly because of falling rates in women at a time
when their oestrogen levels are again low” (Angold et al 1999, p1044)

4. BBooddyy ttoo BBllaammee::
MMeennaarrcchhee,, PPMMSS,, PPNNDD,, MMeennooppaauussee
“The excess of depression in women compared with men
occurs at times of great hormonal fluctuations–at the
time of puberty, in the postnatal period, and
premenstrually–and it is worst in the few years before
menstrual cycles end (Studd, 1997, p.977).

5. EEvvaalluuaattiinngg rraaggiinngg hhoorrmmoonnee tthheeoorriieess
 Examination of adolescent onset: ‘turning on’ of the
endocrine system in girls pre to post-puberty
 But:
 only 4% of variance accounted for by oestrogen levels
 life events, and the interaction of oestrogen levels and life
events, 17% variance (Brooks-Gunn & Warren, 1989).
Ussher, JM. (2010) Are we medicalizing women’s misery? A critical review of women’s higher rates
of reported depression. Feminism and Psychology 20(1) 9-35

6. s Psycho-soocciiaall rriisskk ffaaccttoorrss ffoorr wwoommeenn’’ss
ddeepprreessssiioonn
Materiality
Physical and Social Environment
 poverty
 caring roles (inc. motherhood)
 employment status
 absence of social support
 social powerlessness and
discrimination
 current relationship context
 multiple role strain and conflict
 sexual violence or abuse, in
adulthood or childhood
Ussher (2011) Women’s Madness: Myth and experience,
London, Routledge/New York
Intrapsychic
Psychological factors
 female gender socialisation
 depressogenic attributional styles:
 Internal, global stable
 Rumination
 emphasis on affiliation = increased
vulnerability when relationships
under threat;
 Internalisation of devalued
traditional feminine roles;
 network events – events affecting
significant others

7. MMyytthh ooff PPrreemmeennssttrruuaall MMaaddnneessss
 Systematic review of the research literature on
menstrual cycle mood change (Romans et al 2012)
 14.9% found an association of negative mood and the
premenstrual phase
 38.3% found no association of mood with any MC
 Rates of severe premenstrual distress (PMDD)
 1.3% women – random community sample (Gehlert et al
2009)

8. PPoosstt--nnaattaall ddeepprreessssiioonn –– 1100--1155%%
wwoommeenn
Risk factors
 Younger age, partner violence, previous history of depression.
Preventative factors
 Realistic expectations of motherhood
 Rejection of Discourse of “perfect wife and mother”
 Support from partner and others
 Ability to communicate needs and concerns
 Ability to control some aspects of environment
 Physical rest and healthy diet

9. MMyytthh ooff MMeennooppaauussaall DDeepprreessssiioonn
 Longitudinal study of 2,565 US women aged 45-55 – majority
who entered menopause did not become depressed;
 Women who did exhibit depression more likely to have
been depressed earlier in life (Avis, Brambilla, McKinlay,
& Vass, 1994)
 Study of 2000 Australian women aged 45-55:
“most of the time” felt clear-headed (72%), good natured
(71%), useful (68%), satisfied (61%), confident (58%), loving
(55%) and optimistic (51%) (Dennerstein, 1996).

10. SSoocciiaall ccoonnssttrruuccttiioonniisstt aannaallyyssiiss
 PMS, PND, Menopausal Syndrome as discursive
labels - pathologising deviations from idealised
femininity
 Gendered illness
 Continues the historical connection between the womb
and the brain: ‘wandering womb’
Ussher, JM (1989) The Psychology of the Female Body. London, Routledge.

11. Historical lleeggaaccyy ooff mmoonnssttrroouuss
ffeemmiinniinnee
MMeennssttrruuaall MMaaddnneessss
 Menstruation is 'the moral and physical barometer of
the female constitution' (Burrows, 1828, p.147)
 A cause of 'moral and physical derangement'
(Maudsley, 1873, p.88).

12. PPoosstt--nnaattaall mmaanniiaa
‘Every medical man has observed the extraordinary amount of
obscenity, in thought and language, which breaks forth from
the most modest and well-nurtured woman under the influence
of puerperal mania… Religious and moral principles alone
give strength to the female mind; and when these are
weakened or removed by disease, the subterranean fires
become active; and the crater gives forth smoke and flame’
1858, A Manual of Psychological Medicine
Dr. L.V. Marce: post-natal symptoms caused by unknown
‘connexions’ between the womb and the brain 1858

13. MMeennooppaauussaall DDiissttuurrbbaannccee
 menopause ‘universally admitted to be a critical and
dangerous time for (women)’ (Tilt, 1882, p15).
 During the change of life the nervous system is so
unhinged that the management of the mental and
moral fibres often taxes the ingenuity of the medical
confident…the disturbance can cause normally moral
women to act without principle…be untruthful…be
peevish…even have fits of temper…steal…leave
their families…brood in melancholy self absorption
(Tilt, 1882, p101)

14. 2200tthh CC. PPrreemmeennssttrruuaall cchhaannggee aass aa
PPssyycchhiiaattrriicc IIllllnneessss
 Premenstrual Tension (PMT): accumulations of ‘the female sex
hormone’, oestrogen (Frank, 1931),
 Premenstrual syndrome (PMS): (Greene and Dalton in 1953) –
40% women
 ‘Late Luteal phase Dysphoric disorder' (LLPDD) DSM-IIIR
(American psychiatric association, 1994),
 Premenstrual Dysphoric Disorder (PMDD): DSMIV (2000)
8-10% women

15. d Perinatal deepprreessssiioonn:: BBooddyy ttoo BBllaammee
It is very likely that the essential cause of post-natal
depression is the sudden decrease in hormones,
particularly oestradiol that occurs after delivery. In
this way it is similar to the depression of pre-menstrual
syndrome & the menopause which is also
related to decreases in ovarian hormones, particularly
oestrogen… (John Studd, 2004)

16. Menopausal AAttrroopphhyy && DDeepprreessssiioonn
Oestrogen deficiency is as much a disease as thyroid, pancreatic
or adrenal deficiency. No attempt will be made to detail all of
the unwholesome effects of this deficiency disease; a few will
suffice, e.g. thinning of bones, dowager’s hump, ugly body
contours, flaccidity of the breast, atrophy of the genitals.. &
depression
Feminine Forever, Robert Wilson, 1966
Low levels of hormones in your body will lead to mood
changes in about 50% of women, making you irritable,
depressed, weepy and nervous.
The Menopause Health Guide, 1995

22. IImmppaacctt oonn WWoommeenn:: SSuubbjjeeccttiiffiiccaattiioonn
RReeggiimmeess ooff TTrruutthh iinn SScciieennccee aanndd PPooppuullaarr CCuullttuurree::
Western women positioned, or take up subject position, of
monstrous feminine – mad, bad, and dangerous
Blaming the body for distress self-castigation
Construction of distress as an embodied pathology - ‘PMS’,
‘PND’, or Menopause medical and psychological
regulation
Ussher, J.M. (2003c). The role of premenstrual dysphoric disorder in the subjectification of women. Journal of
Medical Humanities, 24(1/ 2), 131-146.
Ussher, JM (2006) Managing the Monstrous Feminine: Regulating the Reproductive Body. London, Routledge.

23. PPrreemmeennssttrruuaall EExxppeerriieenncceess RReesseeaarrcchh
70 women interviewed about subjective experience of PMS
(36 UK and 34 Australia).
 30% increase in symptoms premenstrually
 Intervention studies – mixed method, pre-intervention interviews:
 psychological therapy vs SSRI (Ussher, Hunter et al 2002)
 self-help PMS therapy (Ussher, Perz, Weisberg, 2006)
Qualitative analysis: Thematic decomposition: subject
positions taken up by women (as ‘PMS sufferer’).

24. PPrreemmeennssttrruuaall mmaaddnneessss
My reactions to certain situations would be extreme, with a lot
of anger, you know, total depression and just too extreme, like
a nut case.
I just completely lost the plot (sigh).
I’d need to completely isolate, because I didn’t think that
anyone else would understand or if they touched me I might
burst into tears and think I’m a complete loony.
Because you’re not sane. (laugh) You’re not really rational
(laugh).

25. MMeennssttrruuaall mmoonnsstteerr
Dr. Jekyll to Mr. Hyde. Horrible, bitchy, vicious, violent &
depressed.
I’m like something out of the exorcist – my head spins around!
I get cranky & nasty
we have sort of like a catchword in the house (devil mummy),
it's like 'you be careful because devil mummy isn't too far away
& just don't do anything or don't say anything’, I try to explain
it to them you know & say ' I'm really sorry, I'm not really in
control, I'm trying, but it's two people
Ussher, J.M. (2008). Managing the Monstrous Feminine: The Role of Premenstrual Syndrome in the Subjectification of Women.
In P. Moss and K. Teghtsoonian (Eds.), Contesting Illness: Authority, Bodies and Context (pp. 181-200). Toronto, Buffalo,
London: University of Toronto Press.

26. PPMMSS sseellff vvss.. NNoonn--PPMMSS sseellff -- SSpplliittttiinngg
 Mad – sane
 Bad – good
 Inertia – energy
 Introversion – sociability
 Out of control – control
 Irresponsible/ responsible
 Giving up – soldiering on
 Failing – coping
 Angry – calm
 Depressed – happy
 Irrational – rational
 Intolerant – tolerant
 Vulnerable – strong
 Passive – active
 Body – mind
 Irritable – even tempered
 Fat/ugly – OK
 Frustrated – not frustrated
Ussher, J.M. (2004). Premenstrual syndrome and self-policing:
Ruptures in self-silencing leading to increased
self-surveillance and blaming of the body. Social Theory
and Health, 2(3), 49-62.

27. Premenstrual cchhaannggee iinn nnoonn--
WWeesstteerrnn CCuullttuurreess
 Hong Kong, China, or India – menstruation
positioned as a natural event
 Women report premenstrual water retention, pain,
fatigue, and increased sensitivity to cold
 Rarely report negative premenstrual moods; don’t
position them as ‘PMS’.

28. Premenstrual cchhaannggee iinn nnoonn--
WWeesstteerrnn CCuullttuurreess
 In Australia, some women experience what they call pre-menstrual
syndrome or PMS, have you heard of this?
 I Never heard of that. [Laughs]
 What this is, some women say before their periods they feel, they feel
different in themselves in their moods, so they can feel tense or angry
or depressed//
 I Yeah, we experience this.
 I1 You have that?
 I2 Do, do you have a word or a way of describing that to other
people?
 [Interpreter and participants talking in first language – 6 secs]
 I So, yeah, no name for that. [Laughs]
Ussher, J.M., M. Rhyder-Obid, J. Perz, M. Rae, W.K.T. Wong, and P. Newman (2012). "Purity, Privacy and Procreation:
Constructions and Experiences of Sexual and Reproductive Health in Assyrian and Karen Women Living in Australia."
Sexuality and Culture 16 (4): 467-485.

29.  How can we explain the emergence and course of
premenstrual distress?
 Can we reframe it without reinforcing the notion of the
reproductive body, and therefore the woman, as
monstrous ?

30. PPMMSS aass aa mmaatteerriiaall--ddiissccuurrssiivvee--
iinnttrraappssyycchhiicc eexxppeerriieennccee
 Materiality of premenstrual change – sensitivity, arousal,
mood; materiality of life stress/relational context
 Discursive construction of PMS, femininity
 Women’s intra-psychic negotiation and coping – within a
relational context
All 3 levels irrevocably interconnected

31. AA MMaatteerriiaall--DDiissccuurrssiivvee--IInnttrraappssyycchhiicc
aapppprrooaacchh ttoo PPMMSS

32. RReellaattiioonnaall CCoonntteexxtt ooff PPMMSS

33. PPMM RReeaaccttiivviittyy == lloossss ooff ccoonnttrrooll
AA rreellaattiioonnaall iissssuuee
Expression of emotion in relationships = PMS
But you haven't got any control over, you can't control
how you feel. Or sometimes if it's really bad I get
stroppy, you know? And it must be really (hurtful)
for my husband. I mean he's great, but that's not fair
on him. You can't go on like that forever
Ussher, J.M. (2003a). The ongoing silencing of women in families: an analysis and rethinking of premenstrual syndrome and
therapy. Journal of Family Therapy, 25, 387-404.

34. CCooppiinngg wwiitthh ‘‘PPMMSS’’ bbyy aavvooiiddiinngg rreellaattiioonnsshhiippss
 I: And then how did you feel when you stayed up there on your
own?
 J: Better. Because I just want to be on my own. I don't want
people around me. I don't want to have to talk to anybody. I
just want to be alone. Without any demands on me or anything.
…. so I can have some peace to make myself feel better. To
calm myself down.

35. RReesseeaarrcchh oonn RReellaattiioonnsshhiippss aanndd PPMMSS
FFuunnddiinngg:: AARRCC DDiissccoovveerryy 22000066--22000099
Examine construction and experience of PMS across
relationship type and context (Ussher, Perz)
Sample N = 327 Questionnaires
(N= 60 Interviews)
Age 18 – 48 years
Relationship status:
Currently partnered
63%
Not currently partnered
37%
Sexual orientation:
Heterosexual
Lesbian
63%
37%

36. SSeellff--SSiilleenncciinngg aanndd PPMMSS
Self-silencing: focus on others at the expense of the self,
accompanied by repression of one’s own needs and concerns,
(Jack 1991)
 Tied to idealised constructions of “perfect wife and mother”
 Linked to women’s depression (Jack 1991; 2007)
327 Australian women self-positioned as PMS sufferers:
 Significantly higher self-silencing than population norms (STSS)
Perz, J., & Ussher, J.M. (2006). Women’s experience of premenstrual syndrome: A case of silencing the self. Journal of
Reproductive and Infant Psychology, 24(4), 289-303.
Ussher, J.M. & Perz, J. (2010). Disruption of the Silenced-Self: The Case of Pre-Menstrual Syndrome. In D.C. Jack & A. Ali
(Eds.), The depression epidemic: International perspectives on women’s self-silencing and psychological distress. Oxford:
Oxford University Press (pp. 435-456)

37. SSeellff--SSiilleenncciinngg aanndd PPMMSS
 Higher Self-Silencing higher premenstrual distress
 But: self-silencing not significantly related to
depression – contrast previous research
 Why? Accounts of self-silencing being ruptured
premenstrually
Perz & Ussher, 2006; Ussher & Perz 2010

38. SShhoorrtt ffuussee mmeettaapphhoorr
 They were fighting over my son’s Bob the Builder
spoon and I just said ‘right’ and I snapped it in half
and said ‘no-one’s having it’ and that was it. I
regretted it later on, of course”.
 I have less patience with my husband & child & my
expectations of them increase (premenstrually).
Ussher & Perz 2010

39. PPrreessssuurree ccooookkeerr mmeettaapphhoorr
There's a few days of the month where I feel I'm not
myself, or there's you know, anger or tension that
builds up and then I release it at that point. And
others around me suffer the consequences!
The issues that I suppress during my ‘normal’ time
come up when premenstrual. I get angry that I am the
only one who cares about the housework. I get angry
on behalf of all women everywhere who have to pick
up after everyone else.
Ussher & Perz 2010

40. PPoossiittiioonniinngg ooff eemmoottiioonnss
 Anger, irritability, depression positioned as PMS
 Negates issues which may precipitate emotion
 Women experience guilt and self-blame
 Exonerates partner from responsibility

41. IInntteerr--ssuubbjjeeccttiivvee ccoonntteexxtt ooff PPMMSS
 Response of partner impacts on women’s construction
and experience of premenstrual distress
 Supportive partners: recognition, understanding, support, share
responsibility, facilitate self-care
 Unsupportive: disbelieving, rejecting, argumentative, no support,
no sharing responsibilities
Ussher, J.M., Perz, J., & Mooney-Somers, J. (2007). The experience and positioning of affect in the context
of intersubjectivity: The case of premenstrual syndrome. International Journal of Critical Psychology, 21,
145-165.
Ussher, J.M. & Perz, J. (2013) PMS as a Gendered Illness Linked to the Construction and Relational
Experience of Hetero-Femininity. Sex Roles 68, 1-2, 132-150

42. PPaatthhoollooggiizziinngg vvss uunnddeerrssttaannddiinngg
 You know, on the one day,
probably 3 months ago or so
and he came in and said
‘who am I talking today?’ is
it schizo Elaine, nice Elaine,
sexy Elaine or cranky
Elaine’? And I just, and I
was really pre-menstrual
and I thought ‘that’s just so
unnecessary. I’m not that
bad’.
 he's very understanding he
never used to be but he is
now he sort of he knows to
leave me alone or he knows
when to come up and give
me a cuddle

43. OOvveerr--rreessppoonnssiibbiilliittyy vvss ssuuppppoorrtt
 On a Sunday night if I’ve got the
ironing to do and I’m cooking
dinner and I’ve got to make the
lunches for the kids tomorrow and
they’re in the bath and he’s out in
the garden, just that week of the
month I can’t cope with doing all
that at once. I shouldn’t have to
tell him that the kids need a bath,
or they need to be read to. I get
really frustrated that I have to ask.
It’s about… someone just…
recognising that you’re actually
feeling really out of sorts and
taking some of the responsibility
off you to actually manage it:
“Well, now you’re feeling crap.
And I know there’s nothing that
much that can fix that, and you
don’t have to worry about, where
the food’s coming from”, or, I
mightn’t even think about a bath,
and then she’ll say, “How about
you go and have a bath? And I’ll
run it for you,” and I’ll be like,
“Oh, that would be really nice!”
It’s about just being able to just
be.

44. LLeessbbiiaann--HHeetteerroosseexxuuaall ddiiffffeerreenncceess
No differences in accounts of premenstrual change:
 intolerance, irritation, emotional sensitivity, negativity towards
others, overwhelmed in the face of life’s demands.
But, women in lesbian relationships report significantly:
 Higher levels of premenstrual coping
 Lower levels of self-silencing
 Lower relationship tension
 More supportive partners
Ussher & Perz, 2008; Perz & Ussher 2009

45. AAccccoouunnttiinngg ffoorr lleessbbiiaann eexxppeerriieenncceess ooff PPMMSS
 Gender role:
 Mutuality, reciprocity, egalitarianism
 Higher level of expressiveness
 Empathy  understanding and confidence in conflict
resolution
 Presence of Children
 Fewer lesbian couples had children
Perz & Ussher, 2009

46. IImmpplliiccaattiioonnss ffoorr IInnnnoovvaattiivvee
PPrraaccttiiccee

47. Women Centred PPssyycchhoollooggiiccaall TThheerraappyy ffoorr PPMMSS
DDrraawwiinngg oonn nnaarrrraattiivvee aanndd ccooggnniittiivvee bbeehhaavviioouurraall tthheerraappyy ssttrraatteeggiieess
 8 weekly sessions (Ussher, Hunter & Cariss, 2002)
 Self-help package (Ussher & Perz, 2006)
 Reformulate ‘PMS’ in context of woman’s life:
 Re-author premenstrual change – not pathology
 Self-care:
• doing things you enjoy; diet and exercise; time out
 Positive thinking (CBT)
 Anger management; assertiveness
 Relationships and PMS
Ussher, J.M., Hunter, M., & Cariss, M (2002). A women centred cognitive behavioural treatment
package for premenstrual symptoms. Clinical Psychology and Psychotherapy, 9, 3319-3331.

48. EEvvaalluuaattiioonn ooff iinntteerrvveennttiioonnss
 RCT: Comparison of
psychological vs medical (SSRI)
intervention vs combination
 All interventions significantly
reduce symptoms over 6 month
period
 Psychological intervention more
effective at follow-up plus
improved self-efficacy/coping
Hunter, M., Ussher J.M., Browne, S., Cariss, M., Jelly, R.,
& Katz, M. (2002). Journal of Psychosomatic Obstetrics
and Gynaecology, 23, 193-199.
 RCT: Comparison of self-help
pack and pack plus minimal
intervention
 PM ‘symptoms’ still present
 Both resulted in reduction of
distress, improvement in coping
 Pack plus minimal intervention
more effective
Ussher, J.M., & Perz, J. (2006). Evaluating the relative
efficacy of a self-help and minimal psycho-educational
intervention for moderate premenstrual distress
conducted from a critical realist standpoint. Journal of
Reproductive and Infant Psychology, 24(4) 347-362.

49. PPMMSS CCoouuppllee IInntteerrvveennttiioonnss
 Comparison of individual and couple intervention for
moderate-severe premenstrual distress – with wait list
control
 Randomised controlled trial; mixed methods
 90 women and their male partners; 30 couples each
condition
ARC Discovery Grant, Ussher & Perz, 2008-2012

52. PPrreemmeennssttrruuaall eemmoottiioonnss aass
uunnddeerrssttaannddaabbllee
Oh! It… it’s a weight off my mind. ’Cause at first I
used to think I was just, you know, going a little crazy,
and I was so angry, and, um... and it’s kind of helped
with my emotions, helped me deal with, “those are
PMS feelings.” (Olivia)
I know now, you’re not actually the wicked witch
(Danni)
It does allow me to not blame myself so much (Nicki)

53. RReessiissttiinngg ccrriittiiccaall sseellff--ssuurrvveeiillllaannccee
I just don’t care. Don’t cook dinner and things like that
(Jackie)
a little easier on myself…being a little kinder (Olivia) ,
cutting myself a little bit of slack (Merrin),
being gentler on myself (Celia),
a little bit nicer to myself (Danni),
self indulgent and precious (Nancy)
Ussher, J.M. (2008). Challenging the Positioning of Premenstrual Change as PMS: The Impact of a psychological intervention on
women’s self-policing. Qualitative Research in Psychology, 5(1), 33-44.

54. AAvvooiiddaannccee ooff ccoonnfflliicctt
To protect others:
 It was in the kitchen and… I can remember just getting
so cranky I just went in and sat down in um our formal
lounge room just to stay away from everyone because
I was just so angry (Katie)
To protect the self:
 I just wanted to really minimise anything that would
impact on me ’cause I knew I was really sensitive”
(Kathryn)

55. CCaarree ooff tthhee sseellff
Solitude is wonderful, being by yourself, doing your
own thing (Jill)
I just need half an hour in front of the TV and not to talk
too much (Melanie)
I don’t really want to go out. I’d rather curl up with a
book and have a quiet time (Marylin)
I need flannelette sheets (laugh). You know, just that
comfort. Comfort and, um, you know, comfort food and
comfort environment and a bath (Tracy)

56. CCoonncclluussiioonn
 Women’s distress needs to be taken seriously - as a
social construction and lived experience
 Can’t be seen as biological, psychological or
discursive:
a material-discursive-intrapsychic phenomenon
 Supportive interventions and health education needs
to take all three levels on board