In the past women who were deemed to be ‘difficult’ were called ‘hysterical’ and their ‘odd’ behaviour even exhibited in lecture theatres, for entertainment, to doctors in training. But today, even after decades of feminism, are women still being dismissed as ‘out of our minds’ when we complain? The focus of the last two decades has been on men’s mental health because of their higher suicide rate. However, women are suffering significantly too in many ways and still disproportionately, losing out in mental health care. Gender plays a key role in how we experience our mental health but is paid insufficient attention. What has gone wrong for women and girls? Why are we still ‘out of our minds’ and what can we do about it?

When women complain about our lives are told we are ‘out of our minds’. That can mean three things. Written off as merely ‘crazy’ anyway and wasting others’ time. Simply driven to that point by the ways in which we are treated. Or our reaction on discovering that our mental health problems are apparently less important. We are NOT crazy when we need talk about the kinds of pain, suffering, abuse, violence and fear that women experience. Women continue to be oppressed in a multitude of different ways and this causes suffering. However, women also develop mental illnesses too and to deny that is to gaslight the women who are suffering. Women need expert help from professionals who also understand what oppression is and the trauma it causes. Our mental health problems are deemed less important by society so receive less investment. Feminism should not only be challenging the oppression of women but fighting for better treatment for mental illness which is real and not all caused by ‘trauma’. We need much better evidence about women’s mental health and illness, which has been chronically underfunded. We need to speak out about the need for more compassionate, women-centred care.

Families have the potential for causing harm and can play a part in the onset of mental health problems. Women’s behaviour is judged by a different set of standards to that of men. Parents still socialise girls differently from boys. The pressures of family life chip away at our confidence and self-esteem and powerfully influencing our ability to make successful adult relationships. Girls and women may be told that they are ‘hysterical’ or ‘out of their mind’ when their emotional response is quite justified by what is happening to them. However, life pressures can also trigger mental illness, and family stress such as living in poverty and with domestic violence can make this worse. Girls and young women experience much more sexual abuse during childhood than boys – the sheer extent of which was not acknowledged in the past. Improving material and psychological support to families is a mammoth task, but what is within our power, among our own friends, families and communities, is to do something when we suspect that young women are experiencing trauma and abuse – believing, helping and supporting them to find someone to share their stories with who is trustworthy and skilled.

Both research into mental illness and its care have largely been conceived of and designed by men. There is insufficient research into women’s experience of serious mental illnesses and training provided in how to help them. Some diagnoses have been only lately recognised in women; for example, autism and ADHD, which continue to be misdiagnosed. Services have striven to be ‘gender neutral,’ which in practice means primarily designed around men. Not only are women not treated with sufficient respect, dignity and compassion, but there is also evidence of widespread sexual assualt of women within mental health care and of frank abuse within services, with maltreatment associated with suicides of young women. Women are being re-traumatised. There is also insufficient recognition of the harms from and lack of adequate regulation of psychological therapy. Feminist psychiatrists are stuck between the two poles of mainstream feminism who see no role for psychiatry at all and defensive institutions. We need to ensure that women who are detained in hospital have advocacy and know their rights under the law, and build true collaboration across sectors to bring about change.

Anorexia has a higher mortality rate than any other mental illness and most deaths occur in women. The feminist view is that we are all at risk of developing eating disorders and that the battle for control over the young woman’s life between mother and daughter is key in how anorexia begins. However, current evidence suggests mothers have been unfairly blamed, and that genetic factors play a powerful part in our vulnerability to eating disorders, with genes interacting with environmental factors. Services and expertise to treat young people with eating disorders are lacking and talk of ‘terminal anorexia’ is abhorrent. The fact that these disorders affect more women than men has influenced the level of clinical and research funding that they get. Services must move away from their reliance on BMI to decide who gets care, and their practice of only accepting those who fit into rigid diagnostic boxes. We all must all challenge, as feminism urged us, our society’s obsession with body image. However, feminism also needs to embrace the science that explains how some women are much more vulnerable to developing eating disorder than others, and why biology also matters.

Half of all mental health problems start by the age of 15 and the teenage and young adult years are particularly difficult for girls with high and increasing rates of anxiety, depression and self-harm. Many different factors contribute, including social media, peer pressures, focus on appearance, friends, relationships, schoolwork and, as Everyone’s Invited has recently highlighted, personal safety. There is tremendous pressure to conform with the expectations of others. Attitudes to women and girls seem to have gone into reverse during the author’s lifetime. It is too simplistic to view the problems of young women as a simply a ‘lack of self-esteem’. The difficulties they face in society are consistently underestimated and not taken seriously. Fast access to therapy is crucial. Bullying must be addressed effectively. Sexist and mysogynistic attitudes in school must be challenged and, given the easy access now to pornography, the issues of consent should addressed head on by both parents and schools. Using the example of Everyone’s Invited, women and girls need to reach out and support each other. The personal is still political.

A diagnosis of borderline personality disorder (BPD) has become a way of excluding women from mental health care or detaining them for long periods in hospital. Three times as many women as men are given this diagnosis, and it pathologises the way that women behave in extremis when they are powerless and tramatised. Some undoubtedly have symptoms of chronic PTSD resulting from trauma, but crucially bipolar disorder, autism and PMDD are missed, and the mental health system traumatises further. Supported by many, both patients and professionals, a BPD diagnosis it is even more vehemently rejected by others, because of the associated stigma. Self-harm is a way that we try to cope with extreme emotions and is commonly used to (too) quickly make a diagnosis of BPD or EUPD. ‘Attempted suicide’ has not been an offence since 1961 but the police have become more involved in prosecution through ill-judged and unevidenced interventions such as Serenity Integrated Monitoring (SIM). Unpicking exactly how women reach this point, finding better and more compassionate ways of understanding and helping them with their lives including effective psychological therapy, is essential.

Around 30% of women worldwide have been subjected to either physical or sexual intimate partner violence (IPV) in their lifetimes. In Europe, one in 20 women over the age of 15 has been raped. Meanwhile gross misogyny and sexual violence against women is becoming more normalised in society. When women have been victims of physical, sexual violence, emotional abuse or coercive control the impact on their mental health can be severe.The sense of shame can be overwhelming. Mental health problems are not an inevitable consequence of IPV but anxiety, depression, post-traumatic stress disorder, psychosis, self-harm, substance misuse and getting a diagnosis of borderline personality disorder (BPD) are all more common. Domestic violence can also result in suicide and is linked to murder-suicide and ‘honour’ killing. However, women who have killed abusive men have been repeatedly denied justice. Mental health services need training about IPV and sexual violence and to make strong links with organisations in the community. Each of us needs to ensure that we would know what we would do to help a friend, family member or colleague who is experiencing domestic violence or sexual assault.

Women from Black, South Asian and other ethnic minority groups experience gendered racism. Gender and race intersect in such a way that Black and ethnic minoritised women are not only sometimes afraid of seeking help from mental care, but also are invisible to services and their needs are ignored. There has been a significant tension in feminism between respecting culture and faith and attention to women’s human rights (cultural relativism). However, when women feel entrapped within their families and culture and are subject to forced marriage, domestic violence or FGM, resulting in major mental health problems and suicide, we cannot condone abuse and violence. Black women’s mental health and wellbeing is an important focus for Black feminism, which was largely excluded from second-wave feminism. Concepts of ‘mental illness’ do not always fit easily with personal healing that focuses on emotional and spiritual growth and overcoming oppression. Cultural humility is essential and its crucial for services to collaborate with NGOs that are trusted by the women in communities and run by them. As women we must call out discrimination and racism and challenge it.

Fertility brings an increased risk of receiving a mental health diagnosis, from pre-menstrual dysphoric disorder (PMDD) to depression following miscarriage, post-natal psychosis and ante- and post-natal depression. Suicide is a leading cause of death in new mothers. Across the world, women’s reproductive systems remain a political battleground and subject to external controls from access to contraception and abortion in the USA to getting better mental health care for perinatal mental illness. Women can feel disempowered and unheard by the professions as recent maternity scandals in the UK have revealed. There is also pressure for women to have ‘natural’ births without intervention. What part do misogyny, patriarchal attitudes and aspects of feminism itself play here? We can all advocate and support fellow women who are struggling with any of the complications of fertility and not getting the care they need. There are ‘red flags’ we can all remember for getting mental health care involved in the perinatal period: Providing pregnant women with the information to make truly informed decisions about their health care is crucial. Perinatal mental illness is real and can kill.

Why is it so difficult for older women in our society to feel that they are seen and heard? What matters in our society is not the quality of a woman’s mind, but her appearance of aging. Yet older women are still trying to find meaning in life, despite the impact on their mental and physical health of the menopause, children leaving home, retirement from work, problems in relationships, caring for others and coping with chronic ill health. Women carry a heavy burden of intergenerational caring – for partners, parents, children and grandchildren. As they age, women experience sequential losses in life, of roles that have been important to us. Suicide rates are rising in older women for reasons unknown, and depression can be more severe. Electroconvulsive therapy (ECT) can be life-saving. Alzheimer’s disease is twice as common in women, but we do not know why. Given the massive impact of dementia on women, research is still inadequately funded. Together with younger women we must consider what a feminist old age might look like and, as we age, work at staying engaged with the world. There are things older women can both share with, and learn from, younger women.

A disproportionate number of women in prison have mental health problems and they are nine times more likely to die from suicide than women in the general population. They have insufficient access to help both inside where the focus has largely been on men, and outside where they often lack suitable help and support on release. For many women, improsionment is a tragedy that damages them, their families and the next generation, some of whom are born in prison, where giving birth can be particularly traumatic and potentially lethal. And men cannot be forgotten by women who are in prison, because many of them are in prison because of the actions of a man. However, it is crucial not to assume that ‘trauma’ explains all of their problems, particularly some kinds of violent behaviour. We need to keep many more women out of prison and try to help women much earlier along their life paths, long before they go to prison. Mental health care provides too little, too late. We must challenge our own stigmatising attitudes towards women in prison, support those NGOs who work tirelessly with women in the criminal justice system and advocate much more powerfully for women in prison.

Those identifying as LGBTQ+ experience an excess of mental health problems and suicide in our society, and their mental health needs are poorly catered for. In the recent past, aversion therapy was given to lesbian and transwomen and conversion therapy remains legal. The ‘gender wars’ have also opened up spaces within society and feminism that can be difficult to negotiate. For transwomen, timely access to adequate care remains a major problem causing considerable emotional distress while public anti-trans sentiment has increased. Repeated denial of the lived experience of trans people is causing psychological harm. The rise in gender dysphoria in assigned female at birth (AFAB; or natal female) girls and their treatment has caused major controvery. We must to acknowledge both the distress of trans people, who feel frustrated and angry at having to jump through the hoops of psychiatric assessment and being blamed for male violence from which they are also at risk, and the distress and fear of women who have been conditioned lifelong to fear, and/or have experienced violence, at losing their safe spaces. Seeking ways to ensure that everyone feels welcomed not only in services but also in society.

Women ‘hold the world together’ through their emotional labour in relationships and families, unpaid housework, mothering and caring work regardless of their jobs outside the home too. They have borne the heaviest burden of the Covid−19 epidemic on society worldwide. Yet the emotional and physical impact of their work remains undervalued. They still experience sexism in the workplace, and the intersectional factors of race, class and deprivation magnify their suffering. Feminism identified the ‘problem with no name’ which became a diagnosis of anxiety then depression and women are twice likely as men to be diagnosed with these common mental health problems, anxiety and depression, and this excess of depression is real, it is not simply unhappiness, but is neverthlesless related to particular stresses of the lives we lead. Historically, we were precribed benzodiazepines and now antidepressants, which do help many. However, health care systems largely ignore the massive part that gender plays in why more women than men get depressed. There is inadequate access for many women to the kind of therapy and support they need. Women need to come together to create these therapeutic spaces.