Why does gender matter in mental health law and services?

Gender EquityOversight
Written By Malachite Goudie-Groat

This summary comes from Parts 3 and 4 of our publication “Façade of Safety: Gender-based violence in BC’s involuntary mental health system”. We are grateful for the expertise and leadership shared with us to shape this work and encourage people to read the publication in full. If you are looking for more sources for what is mentioned in this summary beyond the source list at the bottom, you can check out Parts 3 and 4 of the publication or go to the Works Cited section in the publication.

Content note: This summary contains brief descriptions of ways that gender, sex, and sexuality was pathologized throughout history. Please see this page for resources.

Why gender matters in mental health law and services. Throughout history and continuing to now, gender has had an impact on how someone is treated within the mental health system, often in extremely harmful ways.

Binary ideas of gender, sex and sexuality have resulted in inequity for cis and trans women and girls; Two-Spirit, trans, and non-binary people; and other gender-diverse people. The health system, and mental health system in particular, has a long history of pathologizing people who do not conform to the current norms, social roles, and behaviours expected in relation to gender, or erasing and ignoring their health needs and concerns.

What we mean by gender

Navigating nuance in language

Language that tries to encompass complex and nuanced understandings of identity and self are fraught and imperfect. We also recognize that understandings of labels and language may differ across people, place, culture, and time but can also be experienced as either affirming or denying a person’s identity and dignity. This can be especially true in a time of increasing hate and discrimination based on gender, gender identity, gender expression, sex, and sexuality. In this summary post and the full publication, we have done our best to be thoughtful and intentional by using terms people have used to describe themselves as individuals and by using inclusive and up-to-date language to describe groups, but we recognize that no term(s) will reflect every person’s identity and understanding. If the terms or language used in this post or the publication do not match your own understandings or your identity, please know that it is not intentional and we are doing our best to keep learning.

Terminology

We’ve included brief terminology below but it is important to remember that gender identity, expression, sex, and sexuality can intersect in complex ways.

  •  A socially constructed understanding of a complex combination of norms, roles, behaviours, and expressions.

  • Our own internal sense of our gender.

  • How we express our gender outwardly.

  • Physical aspects of our bodies, such as our organs, chromosomes, and hormones make up biological sex. We often think of sex categories as limited to male, female, and intersex, although that fails to account for the complex interconnections of people who may have sex characteristics that fall outside what is considered “normal” as they access gender-affirming treatments like hormones or surgery.

  • Sexual orientation is a distinct concept that describes an enduring personal pattern of romantic attraction or sexual attraction (for example, gay, lesbian, bisexual, aromantic, asexual, pansexual, etc.)

Gender is a socially constructed understanding of a complex combination of norms, roles, behaviours, and expressions (click here for more information). For example, how we dress, how we speak, what role we play in our family, and how assertive we are can all be tied to socially enforced ideas of gender. Social construction of gender can change over time, from culture to culture, and from person to person. There is vast diversity in how society and an individual may understand their gender.

A wheel depicting many of the ways in which different aspects of identity can intersect to impact ideas of gender.

Because gender is socially constructed, it is also deeply influenced by intersecting aspects of a person’s identity. They can include:

  • gender identity and expression

  • sex

  • sexual orientation

  • family status

  • race

  • Indigeneity

  • disability

  • spirituality

  • place of origin

  • age

These aspects of a person’s identity may intersect with their gender and create specific ideas of what is considered “normal.” For example, gender norms for women often include being compliant and submissive. A Black woman expressing strong emotion may be perceived not only through those gendered expectations but also through the lens of racist stereotypes about “angry Black women.” So she may be more likely to be perceived as “angry” and therefore perceived as behaving outside what is considered “normal” or “appropriate.”

In addition, colonial conceptions of gender have typically reflected a binary understanding (boys and girls; men and women) that centre whiteness and narrow definitions of acceptable heterosexual masculinity. For example, women have been expected to be polite, caregiving, feminine, and submissive, while men have been expected to be assertive, strong, masculine, and dominant.

The impact of colonial conceptions of gender on First Nations, Métis, and Inuit people

For First Nations, Métis, and Inuit people, these colonial conceptions and categories were imposed via colonial tools like residential schools that taught and enforced binary conceptions of gender. The Indian Act created and compelled discriminatory patrilineal community membership that disenfranchised First Nations women from their communities. In the face of colonization, many First Nations, Métis, and Inuit people and communities continue to hold diverse and complex understandings of gender. Two-Spirit identities, for example, reflect a nuanced range of cultural, gender, sex, and sexual identity that vary by community. The enforcement of binary colonial approaches has undermined this complexity. Further, health research is often rooted in colonial conceptions of gender, which further erases Two-Spirit identities and experiences by omitting them from research.

For more information about the impact of colonial conceptions of gender on First Nations, Métis, and Inuit people, see the source list at the bottom of this post or the full list of sources in the publication.

Gender in mental health services in BC

In the face of extreme anti-trans hate in Canada and the growing political willingness to curtail gender-affirming rights through provincial legislation by populist governments, ensuring that all mental health services provide equitable and gender-affirming support is more important than ever.

Aspects of a person’s identity and life experiences can shape the way they experience involuntary treatment. Chronic oppression and discrimination related to an aspect of a person’s identity can create mental health inequities because of their negative impacts on wellbeing. For example, immense mental health inequities are experienced by transgender people in Canada because of their experiences with discrimination, transphobia, harassment, and dysphoria (caused by socialized norms to adhere to gender expectations). That oppression leads to higher risk of suicide, self-harm, and depression. It is also well established that gender-affirming relationships and health care positively impact the mental wellbeing of transgender people.

BC has seen massive growth in the use of detention and involuntary treatment under BC’s Mental Health Act in recent years

Between 2010/11 and 2020/21, involuntary admissions increased by approximately 83%. The fastest-growing group to experience detention and involuntary treatment is girls and young women. While accurate, reliable and recent data is hard to come by, it appears that:

  • Between 2008/09 and 2017/18 involuntary treatment of girls and young women between the ages of 10 and 19 increased by approximately 222%.

  • Boys and young men in the same age group experienced an increase of 58% over the same 10 year period.

  • Only 5 involuntary admissions of a person between the ages of 10 and 19 with a “gender other than male or female” were recognized in BC’s data over this 10 year period.

The above data is based on the BC Ministry of Health Integrated Analytics, Hospital Discharges with MH Diagnosis by Involuntary and Other, FOI Request HTH-2020-07130 (British Columbia: Ministry of Health, 2021) at page 7.

The disproportionate increase in the use of detention and involuntary treatment shows that the gender of children and youth is impacting their experiences with the Mental Health Act

Because this data appears to use binary sex categories but refers to “gender” in the data notes, it is unclear how the experiences of gender-diverse and intersex people are reflected. To the extent that they are reflected at all, it is also unclear if data reporting gender identity is based on a person’s own description of their gender (versus staff perceptions or assumptions). The very small number of patients reflected as having a “gender other than male or female” suggests gender-diverse identities are being largely erased in the data collection process. This is consistent with lived experience accounts in this project and others. For example, two trans youth interviewed by the Representative for Children and Youth recalled that when they were detained under the Mental Health Act, their care teams did not appropriately support their transition journeys.

Without a nuanced understanding of the history and context of gender in mental health treatment, it is easy to assume based on the data above that girls and young women simply have higher rates of individual mental health needs. This ignores the systemic forces that create gender-based risks for their mental wellness and for the use of detention and involuntary treatment. Locating vulnerability in girls and young women or viewing them as somehow inherently “at risk” erases how structural gender inequity creates risk and how individuals resist those impacts.

The history of pathologizing failure to comply with gender and sexual norms

Pathologize: To unfairly treat or view how someone behaves, or characteristics of them, as if it were a medical problem.

A person’s gender, gender identity, sex characteristics, and sexual orientation are not illnesses, they are fundamental parts of their identity. However, the health system, and specifically the mental health system, has a long history of pathologizing behaviour that does not conform to current social norms and expectations related to gender, sex, reproduction, and sexuality. It has (and continues to) frame non-compliance with accepted social norms as a health problem. Pathologization has typically occurred in two ways:

  1. Treating a person’s behaviours or identities that do not conform to socialized gender expectations as an individualized medical problem or biological flaw in need of treatment or eradication.

  2. Treating the distress a person experiences from the oppression because they do not conform to a narrow conception of gender as a medical problem or biological flaw in need of mental health treatment.

A few of the common examples of the ways the mental health system has (and continues to) pathologize aspects of gender, gender identity, and sexuality are through:

  • Hysteria is identified as one of the first mental illnesses associated with women. In the 19th century, the label was used for an almost limitless array of symptoms. A woman considered hysterical may be labelled by physicians as “difficult, narcissistic, impressionable, suggestible, egocentric and labile” and an “idle, self-indulgent and deceitful woman, ‘craving for sympathy’, who had an ‘unnatural’ desire for privacy and independence.” In the late 1800s in BC’s Provincial Hospital for the Insane, a diagnosis of hysteria was often treated with “a regime of ‘moral control’” that included monitoring food intake and elimination, as well as systems of reward and punishment that incorporated tools like restraints, solitary confinement, and loss of privileges. When shellshocked soldiers from World War I started experiencing similar symptoms, the diagnosis became more gender neutral. Over time, the use of hysteria as a diagnosis declined, and it was removed from the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) in 1980.

    Some have argued that the concept of hysteria has persisted through various iterations of the DSM to the gendered application of histrionic personality disorder, somatoform disorder, and dissociative identity disorder diagnoses today.

    “They just see you as a hysterical… a hysterical woman. A hysterical, crazy woman, and this person doesn’t need help. They’ve got a personality disorder. We don’t know what it is, so we’re just going to put this label on you and that’s it.” — Lived Experience Expert

    Lived Experience Experts reported experiences that suggest the gendered stereotypes at the heart of pathologizing “hysterical women” continue in BC’s involuntary treatment system.

    To reduce the amount of links in this accordion menu, please see the end of this post for source list for this section.

  • Since at least the 1900s, people with gender identities or sexual orientations that do not align with social expectations have been labelled as deviant, linked to violence, and seen as risky to the broader population. At the time, gender identity, gender expression, and sexual orientation were often conflated with “sexual deviance.” Canada surveilled, policed, and criminalized these identities as the focus of national security concerns. The mental health system was complicit in helping the RCMP develop psychological tests that attempted to “detect” people who did not conform to socialized norms. Through the late 1800s into the early 1900s, medical clinicians, often psychiatric professionals, began to frame gender identity as a biological flaw requiring treatment, instead of a moral failure. As Susan Stryker notes, this move was a “two-edge sword” because it opened the possibility of access to gender-affirming medical treatment but forced a core aspect of a person’s identity to be framed as an illness or biological flaw:

    Far too often, access to medical services for transgender people has depended on constructing transgender phenomena as a symptom of a mental illness or physical malady, partly because “sickness” is the condition that typically legitimizes medical intervention.

    Transness and gender-diverse identities have been and continue to be pathologized via the mental health system, although the form of pathologization has shifted over time. Before the DSM existed, the misalignment between a person’s gender identity and assigned gender was pathologized. Many clinicians considered this misalignment a delusion in need of treatment to eliminate.

    In 1980, this pathologization was formalized when diagnostic labels for transsexualism, gender identity disorder of childhood, and atypical gender identity disorder were added to the DSM. The diagnosis of gender identity disorder of childhood had differing diagnostic criteria for children assigned boys and those assigned girls at birth, with broader criteria that included a “preoccupation with female stereotypical activities” only for those with an assigned gender of boy. These differences continued until 2013 and are consistent with historical and ongoing concerns about effeminate boys as a threat to masculinity, the greater social acceptance (and therefore narrower pathologization) of behaviours that are associated with men and masculinity, and erasure or gatekeeping of transmasculine identities.

    In 2013, the DSM shifted from pathologizing a person’s gender identity itself to pathologizing the suffering they experience because of their gender identity, moving to a diagnosis of “gender dysphoria,” which was thought to be less stigmatizing. This approach continues today and is the subject of significant critique because it frames the suffering caused by the social structures that lead to someone’s gender identity being marginalized as a mental health issue. It also forces gender-diverse people to create a medical record of their identity that can follow them through a health care system that is often unequipped to provide appropriate, non-discriminatory care. The current diagnoses in the DSM are also considered to be important to legitimizing the need for publicly funded gender-affirming health care in Canada, access to which is currently under attack in some provinces.

    Lived Experience Experts described how their gender identity is still pathologized in the current involuntary treatment system. For example, participants’ concerns about the impacts of mental health treatments on the appearance of their body in relation to their gender were dismissed as symptoms of their eating disorder:

    “There have been times that I have tried to engage with staff about my experiences of gender dysphoria—especially in relation to my eating disorder treatment experiences— that my fear of my body changing with renourishment are not just around, quote-unquote, “the fear of being fat,” rather the experience of dysphoria when I have more female characteristics appearing as well as a feeling of being “unsafe” in a more female-appearing body. In my experience, these conversations tend to be shut down and reduced to “just my eating disorder talking.” — Lived Experience Expert

    Another Expert spoke about how they were prohibited from their gender-affirming health care based on one clinician’s speculation that it was worsening their mental health symptoms when there was no evidence that was true. These experiences illustrate that when a person’s gender identity does not align with the social norms and expectations tied to their assigned gender, that misalignment is pathologized.

    Sexual orientation has also long been pathologized. As set out above, Canada has a long history of viewing anything other than heterosexuality to be deviant and a risk to both masculinity and people who were perceived as good, moral citizens (cis white heterosexuals complying with current gender norms). Canada has used state surveillance, policing, and purported “science” to try to locate and eradicate this risk, with the mental health system working alongside these efforts through troubling psychological testing and experimentation. When “homosexuality” was initially included in the DSM in 1952, it was under the heading of personality disorders. It was referenced in a list of “sexual deviation” behaviours that included “homosexuality, transvestism, pedophilia, fetishism, and sexual sadism including rape, sexual assault, mutilation,” sending a clear message about how the diagnosis was understood. While it was finally removed from the DSM in 1980, editions until 2013 continued including diagnoses based on distress connected to one’s sexual orientation, moving to pathologizing the stress and toll of being someone with a marginalized sexual orientation.

    To reduce the amount of links in this accordion menu, please see the end of this post for source list for this section.

  • Sexuality, and specifically behaviours or identities that do not follow social norms have long been pathologized by the mental health system. Deeply interconnected and sometimes totally linked to understandings of gender, what is considered “normal” sexuality and sexual activity also varies across time and cultures. Social norms and expectations in these areas have often been based on binary ideas of gender where men and women exist in opposition to each other, with women’s sexuality defined as subordinate and in service of men’s sexuality and masculinity. The accepted purposes of sexual activity were limited to reproduction or the sexual satisfaction of men.

    In various versions of the DSM from 1952 to 2013 there are many ways in which sexuality has gone through shifting diagnostic labels including:

    • ranges of sexual desire that are considered above “normal”

    • ranges of sexual activity that are considered below “normal”

    • pain issues

    • arousal issues

    For example, when frigidity was a diagnostic label, it was commonly attributed to women who did not reach orgasm. However, at that time, “marriage manuals indicated that sex ought to result in simultaneous orgasms as the climax of intercourse.” Similar trends can be seen with diagnoses related to gender identity that was considered abnormal.

    When the misogyny embedded in these gender and sexuality norms of the dominant white western culture intersects with anti-Indigenous racism, the potential for harm increases. The In Plain Sight report on Indigenous-specific discrimination in BC’s health care system highlighted several ways that Indigenous women face “virulent misogynistic stereotypes” from health care providers. For example, younger Indigenous women were “characterized as sexually promiscuous.” This led to girls being falsely assumed to be sexually active, to mistaken diagnoses of sexually transmitted diseases and to patients being treated in ways that left them feeling dirty and ashamed.

    Lived Experience Experts in this project highlighted the ways involuntary treatment can allow for invasive and voyeuristic questioning about the details of their sexuality and who they have sex with—aspects of their life that had no bearing on their mental health needs at the time. For example, a doctor asked one Expert, who was receiving treatment for an eating disorder, whether she was a virgin, which she found irrelevant and inappropriate. Another Expert, who is trans, fielded probing questions from their care team about their and their partner’s genitals, which had no relation to the reasons for their hospitalization.

    To reduce the amount of links in this accordion menu, please see the end of this post for source list for this section.

Eugenics, white supremacy, and the mental health system

In the late 1800s and into the early 1900s, a growing eugenics movement emerged in Canada. It focused on evolutionary “improvement” in the human population through controlled reproduction. This eugenics movement was deeply rooted in discriminatory beliefs that resulted in the desire to maintain a strong, white, middle-class population free from disabilities and other perceived “defects.” Immigration increased to support the expansion of settler resource extraction, economic development, and to support World War I. As immigration increased, fear rooted in white supremacy, racism, and ableism grew so eugenic policies were developed to reduce the rate of reproduction of people who were deemed undesirable.

The eugenics movement in Canada is deeply connected to today’s mental health system. For example, people with mental health disabilities, labels, or diagnoses were considered biologically flawed, based on a strong belief that mental health needs were contagious or hereditary. At the same time, provincial mental institutions in BC were dealing with ongoing issues of overcrowding, growing numbers of people detained in them, and a growing cost for their operations. Through a lens of eugenics, this combination created a desire to reduce the growth (reproduction) of people with mental health needs. Sexual sterilization became a mental health “treatment” during this period.

  • 1918: The “mental hygiene” movement in Canada was formalized through the National Committee on Mental Hygiene (which became the Canadian Mental Health Association) and was framed as focusing on preventing mental illness in the face of increasing demand on mental hospitals. However, these prevention priorities reflected understandings rooted in eugenics, including preventing the hereditary spread of mental disease and implementing stricter immigration requirements to weed out unwanted newcomers.

  • 1925: BC’s provincial government struck a Royal Commission on Mental Hygiene to study the reasons for:

    • the increase in people detained in provincial mental hospitals

    • causes and prevention of “lunacy”

    • the ways “insane, mentally deficient and subnormal” people were entering BC

    • the treatment of “subnormal” children

    One of the primary recommendations made by the Commission was to sterilize people detained in mental institutions so that they could be released into the community without any risk of reproduction. In practice, it appears that sterilizations were not always tied to discharge from a facility as these objectives would suggest. Instead, sexual sterilizations were also performed on people who were never institutionalized, suggesting the intent to sterilize all people considered to be “defective.”

  • 1933 - 1972: BC implemented the report’s recommendation by enacting the Sexual Sterilization Act. It authorized the non-consensual sexual sterilization of people. Requests had to be approved by a Board of Eugenics.

The gendered use of invasive psychiatric “treatments”

Many of the most invasive mental health treatments throughout history, some of which we find abhorrent today, have had different impacts based on gender. Women have been subject to these procedures in grossly disproportionate rates compared with men. Most of the data presented below with respect to these practices is limited to a binary understanding of gender that conflates sex and gender, either due to the time period or a lack of adequate data collection in the mental health system. This limitation erases any impacts related to gender identity and expression in many of the examples and we have tried to apply best practices in transparency and not replicate the conflation, confusion, or erasure. Given the clear pathologization of gender in the examples below, gender-diverse people would likely have been impacted by many of these assessments based on what was considered “normal” or “abnormal” based on social expectations of gender at the time. Much of the official recordkeeping is also silent on race and Indigeneity, erasing any ability to understand the intersectional impacts of these procedures. However, where data is not available, there is no doubt that racialized and Indigenous people were likely to have been subject to the procedures at disproportionate rates due to racism and colonial bias.

Sexual sterilization

From 1933 to 1973, the Sexual Sterilization Act was in force in BC. There is limited detail available in terms of when and how the Act was used, but what is available illustrates it was very clearly gendered. In 1945, the Essondale Report was completed which reviewed the use of sexual sterilizations authorized under the Act at the Essondale Provincial Mental Hospital (later renamed Riverview) between 1935 and 1943. The Report found:

The Essondale Report also assessed whether the sterilizations achieved their intended impacts and, therefore, whether the Sexual Sterilization Act was “successful.” In concluding the Act was a success, the Report relied on several gendered and patriarchal understandings of gender and sexuality, including gendered social expectations. For example, one measure of success was whether or not a woman had gotten married and her sexual activity stayed within her marriage. Another measure of a successful case involved a woman who was subject to sterilization and was then reported to be a good housekeeper.

Although data on race and Indigeneity were not reported at the time, control and coercion related to reproductive health and health more generally have been a historic and ongoing colonial tool. We know that sterilization of Indigenous women and girls did take place at Essondale as well as in Indian hospitals, which were part of racist segregation of the health system. While the data erases the colonial impacts in BC, Indigenous women and girls were disproportionately affected by coercive sterilization in Alberta, which had similar legislation. We also know that coercive sterilization practices of Indigenous women and girls have continued with recent reports of it occurring beyond the Sexual Sterilization Act’s repeal.

Lobotomies

Lobotomies: The intentional disconnection of the prefrontal cortex from the rest of the brain in order to change unwanted or undesirable behaviour.

Lobotomies are another example of a highly invasive procedure that was carried out disproportionately on women. Benefits were thought to include a reduction in “insomnia, nervous tension, apprehension, and anxiety.” Risks included patients becoming markedly more docile and losing “some spontaneity, some sparkle.” The practice occurred in BC at Essondale/Riverview.

It is widely accepted that lobotomies were carried out on women far more frequently than men. Although Canadian data is not available, it likely followed trends of the United States, where up to 75% of people subject to lobotomies were women. This has been attributed to expectations of women and their role in society and the family where they were “expected to be calm, cooperative, and attentive to domestic affairs.” A procedure that would make women “docile and compliant” and where they could still carry out their expected duties at home had many supporters before chlorpromazine (a drug with sedating effects) became available in 1954.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT): A psychiatric procedure that involves passing electricity through a person’s head to cause a convulsion or grand mal seizure.

While there is debate, many classify ECT as a procedure that intentionally structural and functional changes in the brain, typically resulting in “signs of confusion, generalized cognitive impairment, loss of judgment, and emotional instability.” Research has shown that modern ECT can be effective, but can also cause lasting effects include persistent and significant negative impacts on mental function, including memory and attention. In Canada and the US, “approximately 70 percent of shock survivors” are women, which shows they are the subjects of most ECT treatments. This aligns with the best data we have access to on the use of ECT during involuntary treatment in BC, which appears to be based on biological sex and can be seen in the graph below.

Graph depicting the rates of ECT use in BC based on biological sex. Source of data: British Columbia Ministry of Health, “Electroconvulsive Therapy among Mental Health Involuntary Hospitalizations in BC”

Academic analysis attributes this gendered trend to the pathologizing of women’s distress solely through symptoms, instead of trying to understand the underlying causes, which may be related to gendered norms and expectations themselves, experiences of gender-based violence, or oppression. When treatments do not resolve these symptoms, because the structural or contextual causes have not been addressed, women are labelled as treatment resistant, and extreme procedures like ECT are pursued. While erased in the data, if gendered norms impact the rates of ECT, gender-diverse people whose identities do not conform to the socialized definition of normal sex and gender are also likely to be disproportionately impacted.

Conversion therapies

Conversion therapy: Pseudoscientific treatments that attempt to suppress a person’s gender identity and/or sexual orientation in order to make them adhere to cisgender and heterosexual norms.

Canada’s mental health system also has a long history with conversation therapy. These practices increased in the 1970s after the removal of homosexuality as a DSM diagnosis. Conversion therapy practices primarily stem from beliefs that diverse sexual orientations and gender identities can and should be “fixed.” There is wide consensus among medical experts that conversion therapy practices are ineffective and associated with poor health outcomes, notably including suicide ideation and attempts. Conversion therapy is also more likely to be experienced by members of 2SLGBTQ+ communities who are also racialized, Indigenous, or economically insecure.

While many people think of conversation therapy in a faith-based context or other situations outside of formal health services, these approaches have historically been and continue to be present in regulated health care settings. Importantly, the denial of gender-affirming health care can be considered under the umbrella of conversation therapy, and Lived Experience Experts in this project reported widespread occurrence of that denial during detention and involuntary treatment. Conversion therapy in a regulated health care setting also includes treatments like the prescription of psychotropic medications or other treatments to suppress sexual urges or preferences. In 2021, Canada amended the Criminal Code to criminalize conversion therapy practices. It is clear from these examples of extreme procedures that the mental health system has a history of both pathologizing and disproportionately using invasive or harmful treatments on people whose identities do not align with existing gender norms and expectations, as well as those who experience suffering due to that misalignment.

Despite the importance of gender, BC does not monitor gendered impacts

Given the long history of the mental health system pathologizing aspects of a person’s identity, including labelling their gender identity, gender expression, or sexuality to be mental health or biological problems, it is important that today’s mental health system take steps to ensure that this trend does not continue.

Gender has been identified as a key influence on involuntary patients’ experiences in existing research. Yet, we are not aware of any high-quality data collection, monitoring, or evaluation of how BC’s detention and involuntary treatment system impacts people based on their gender. Data that we have received through Freedom of Information (FOI) requests seems to either rely on biological sex or conflate biological sex and gender. For example, one FOI request we received used the data heading of “Gender,” but the data is divided by “M” and “F,” presumably referring to male and female. In the most recent year covered by the FOI-HLTH-2020-07130 response we received (2017/18), not one single patient was reported as having “gender other than male or female,” indicating that likely both intersex people and gender-diverse people have their identities erased through this process.

This raises several questions:

  • How does this data treat gender and sex, including all of the nuance and complexities that exist in different individual, cultural, or community understandings of these categories?

  • In data collection, who defines a patient’s gender and/or sex? Are patients asked their gender and/or sex, or do health care staff assume it? Is this data collected in an affirming way, or does it risk misgendering or de-gendering patients?

  • How can the health system collect data in an affirming and transparent way that ensures a person’s experiences of involuntary treatment related to gender and/or sex are not erased from existing data?

  • How can BC create mental health law and data collection approaches that support accountability and evaluation, to ensure that all people receive mental health services that respect their gender and/or sex?

Throughout history and continuing to now, gender has had an impact on how someone is treated within the mental health system, often in extremely harmful ways. Improving data collection is an important part of oversight and accountability for a better mental health system. BC must improve its data collection on gender in order to monitor, evaluate, and implement changes to eliminate harmful gender-based impacts.

This summary from Parts 3 and 4 of our publication was strongly shaped by many sources, some of which have been listed in order of appearance below:

Gender identity and expression:

The impact of colonial conceptions of gender on First Nations, Métis, and Inuit people:

Increasing anti-trans hate in Canada:

History of pathologization:

For an in-depth list of sources that shaped this work please see the Works Cited section of Façade of Safety: Gender-based violence in BC’s involuntary mental health system.

Malachite Goudie-Groat
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