Self-silencing and women's health: A review

Family planning policy and gender in Nigeria: A thematic analysis of the government's health policy perspective

Family Planning (FP) lets people control the number and timing of child-births through using contraceptives and/or restoring fertility. Nigeria has several FP policies for managing its population, yet contraceptives usage remains suboptimal despite high FP awareness, suggesting that several factors might be inhibiting FP uptake. The literature spotlights gender as factoring into FP use due to Nigeria's patriarchal society, with men positioned as gatekeepers to women's sexual/reproductive health/expression. Therefore, we investigate if/how gender is considered in Nigeria's FP policies. We thematically analysed the 'National Reproductive Health Policy', 'National Family Planning Communication Plan' and 'Nigeria Family Planning Blueprint (Scale-Up Plan)', from a critical realist viewpoint. Our analysis generated an overarching theme-'A Gendered Human Right', with three further themes: Women's Right-Women's Issue', 'Adolescent Girls-not left out' and 'Men's Right as Supporters'. FP was portrayed as the right of women, adolescents (particularly girls ≥ 10 yrs) and men. It was highly feminised, with women, not men, majorly shouldering the FP responsibility and women's FP access was presented as hindered by men. Moreover, we advance recommendations for optimising Nigeria's policies to address gender imbalances hampering women's FP access and uphold the rights of all people, women/girls especially.

The pandemic within a pandemic: mental health and wellbeing of racially Minoritised women experiencing domestic abuse during the COVID-19 pandemic in the UK

BACKGROUND

The prevalence of domestic abuse is greater in times of humanitarian crisis, and the COVID-19 pandemic has been no different. Considerable evidence indicates that domestic abuse disproportionately impacts the mental health and wellbeing of racially Minoritised women. The present study aimed to explore racially Minoritised women's experiences of domestic abuse and mental health in the COVID-19 pandemic in the UK.

METHOD

An online cross-sectional survey was used with racially Minoritised women (n = 1202) in the UK during the third national lockdown.

RESULTS

Results demonstrate complex interplay of psychosocial factors, such as the roles of autonomy, resilience, self-silencing, family functioning, and social support as predictors of mental health and wellbeing during the 'shadow pandemic'.

CONCLUSION

Implications such as incorporating culturally competent mental health support, exploring the complex and multiple underpinnings of mental health in racially Minoritised victim-survivors of domestic abuse for future pandemic preparedness and support provision are discussed.

Using network analysis to elucidate the relationships among support systems, trauma and depressive symptoms, self-silencing, and risk of HIV viral non-suppression among black women living with HIV

Human immunodeficiency virus (HIV) remains a major public health issue in the United States (US) and Black women living with HIV (BWLWH) are disproportionately impacted among women. This study investigates the complexities in influences of family, friend, and special person support systems and their association with post-traumatic stress disorder symptoms (PTSD), depressive symptoms, gendered coping (self-silencing), and a composite HIV risk score related to risk of viral non-suppression through missed medical visits, low medication adherence, and high viral load. Cross-sectional data among BWLWH were analyzed using network analyses via RStudio. Data from 119 BWLWH was reduced to 104, because of missing data on indicators as well as pairwise deletion for the correlation function. Findings revealed variances based on the type of network. For composite risk scores, friend support source had a weak to moderate significant correlation, while symptoms of PTSD and depression only showed a weak positive correlation with the composite risk variable through self-silencing as a form of coping. The post-hoc analysis showed a strong correlation with care as self-sacrifice, based on the composite risk score. Based on the findings from this study, insight was given into symptoms for depression and PTSD, as well as self-silencing and viral non-suppression risk in relation to sources of support for BWLWH. Future interventions to improve the overall health of BWLWH may benefit from incorporating support from friends and lowering care as self-sacrifice.

An Integrative Review of the Literature Examining Sexual Relationship Power, Depressive Symptoms, Silencing the Self, and HIV Vulnerability for Women in the United States

ABSTRACT

The purpose of our integrative review was to synthesize the literature examining relationships between depressive symptoms, silencing the self (STS), sexual relationship power (SRP), and HIV vulnerability among women in the United States. Literature searches were conducted through CINAHL, MEDLINE, PsycINFO, SCOPUS, Sociological Abstracts, and SocINDEX. Integrative review methodology of Whittemore and Knafl guided the review process, and 37 articles met inclusion criteria. The Theory of Gender and Power, modified by Wingood and DiClemente, was the guiding framework to organize and synthesize findings. Primary findings suggest that depressive symptoms, STS, and SRP in relationships may individually influence women's vulnerability for acquiring HIV, yet research lags behind. Evidence documenting relationships between these factors is insufficient to draw generalizable conclusions. Findings suggest that the current literature on this topic does not reflect those women most highly affected by HIV and those who identify as African American or Black in the Southeast region of the United States.

Young Women's Silencing-Type Behaviors in Heterosexual Relationships

Feminist researchers have demonstrated that engagement in silencing of the self (i.e., self-restrictive and sacrificial behaviors reflecting how women "should" be in relationships) remains a prevalent strategy for relationship maintenance. However, little is known about (young) women silencing themselves in relationships where abuse is present. Young women's experiences of silencing and other partner-focused behaviors (e.g., sexual compliance) within their relationships were thus explored. Young, partnered women (Mage = 21; N = 146) completed an online survey and open-ended questions about their current intimate relationships. Comparing between groups (abuse, n = 108; non-abuse, n = 38), the former scored higher on measures of total self-silencing, sexual compliance, and non-constructive communication and lower on measures of constructive communication (all p < .001). A mixed inductive and deductive content analysis found that while the importance of communicating with their partner was a preferred strategy for conflict management, multiple participants still emphasized self-suppression as an important part of their experience of relational conflict. Also, most participants indicated feeling as though they could be their authentic selves in their relationships, which suggests that their silencing may be situational and strategic in nature. These findings nuance previous understandings of self-silencing as inherently harmful and instead frame it as something sporadic and done strategically. They also bring forth questions about the extent to which young women's emphasis on communication and insistence that they can be authentic are a product of changing societal expectations of women in today's society compared to the 1980s/1990s when much of the foundational work on self-silencing was being done.

Bearing (Aguantando) With Intimate Partner Violence: A Grounded Theory Study of Self-Silencing Among Hispanic Women Who Experienced Intimate Partner Violence

Hispanic women who experience intimate partner violence (IPV) face unique disparities. They have poorer health outcomes and are less likely to seek help than their non-Hispanic counterparts. When women remain in relationships where IPV occurs and refuse to disclose or seek treatment, they may resort to self-silencing, which can also worsen health outcomes. The purpose of this study was to develop a theory that explains how self-silencing evolves among Hispanic women who experience IPV. Participants were recruited from two research studies focused on Hispanic women's health, and from snowball sampling, which involved referrals by previously registered participants. Data were collected via Zoom® and included individual interviews. A total of 25 women participated in this study. Analysis followed constructive grounded theory levels of analysis described by Charmaz and constant comparative methods described by Glaser and Strauss. A grounded theory entitled Bearing (Aguantando) With Intimate Partner Violence emerged from the data. The theory explains the main strategy Hispanic women use to deal with violence while remaining in a relationship where IPV occurs. The theory is constructed of four categories with subcategories. The results of this study provide an initial framework to understand the self-silencing process among Hispanic women who experience IPV. In addition, this study identifies different levels of interventions that can be useful for researchers and healthcare providers to promote Hispanic women's ability to become empowered, use their voices, and seek help.

Women and shame: narratives of recovery from alcohol dependence

OBJECTIVE

Existing literature indicates distinct pathways and the key role of shame and stigma into alcohol dependence (AD) and recovery for women. Internationally, there is a paucity of research exploring these factors from women's perspectives.

METHODS AND MEASURES

Taking a critical realist epistemological position, unstructured life story interviews were analysed via narrative analysis to explore how seven women from the UK, storied shame in their recovery from AD.

RESULTS

Shame followed a common trajectory across participants' stories, appearing as a reoccurring factor throughout AD and recovery. Participants narrated shame as gendered, contributing to a loss of personal control in defining a valued personal identity. Drinking began as a shame-management strategy but evolved into a source of shame, compounded by fears of being labelled an 'alcoholic woman'. Recovery involved reclaiming the self through de-shaming a shame-based identity and developing a positive, non-drinking identity. By evaluating 'shaming' recovery frameworks, sharing stories and reconstructing their own, participants were able to work through shame, resist pathologising identity labels and internalise esteemed 'sober' identities.

CONCLUSION

This research provides important insights into the intersection between shame, identity, gender and culture in women's recovery from AD. Implications for clinical practice, future research and policy are considered.

A qualitative investigation into the role of illness perceptions in endometriosis-related quality of life

Endometriosis is related to adverse quality of life (QoL) and wellbeing outcomes. The way in which endometriosis is perceived by individuals experiencing the condition has not been directly considered, yet illness perceptions (IPs) are predictors of QoL in several chronic conditions. This research aims to gain an understanding of the IPs held by individuals experiencing endometriosis and their impact on QoL. Semi-structured, one-to-one interviews with 30 UK-based participants sought to gain an understanding of participant experiences and perceptions linked to endometriosis. Three themes were constructed through reflexive thematic analysis: a life disrupted; lost sense of self; and complex emotional responses. Largely negative IPs were held by individuals experiencing endometriosis which, along with endometriosis-specific symptoms, fuelled fears for the future and reduced QoL. IP-based interventions may support the QoL of those experiencing endometriosis whilst effective treatment is sought.

Parents' experiences of life after medicalised conception: a thematic meta-synthesis of the qualitative literature

BACKGROUND

Medicalised Conception (MAC) assists many couples to achieve pregnancy worldwide. As the impact of MAC has been linked to increased pregnancy-specific anxiety and parenting difficulties, this review aimed to explore parental experiences of pregnancy and early parenting following MAC, identifying parents' psychological, social and health needs.

METHOD

Five databases were searched systematically from inception to March 2023. Identified articles were screened for eligibility against the inclusion criteria and the results were analysed using thematic synthesis. The Critical Appraisal Skills checklist was employed to appraise methodological quality.

RESULTS

Twenty qualitative studies, drawing on a total of 19 participant samples, were included in this review, most with samples with history of subfertility. The findings were synthesised into three main themes (consisting of seven subthemes): 1) The vulnerable parent: fear, doubt, uncertainty, 2) the stark realisation of the parental dream, 3) psychosocial needs and support. Parents lacked a sense of safety during pregnancy and reported acting protectively both antenatally and postnatally. Furthermore, their identity transition was complex and non-linear, influenced by sociocultural context.

CONCLUSIONS

Considerable unmet psychosocial needs were identified including the potential for anxiety in pregnancy, the possibility of feeling excluded and marginalised, and a reluctance to share distress and experiences with healthcare professionals. These findings suggest a need for consistent, holistic care, integrating psychological services.

The association between adverse childhood experiences, self-silencing behaviours and symptoms in women with fibromyalgia

Poor adult health has consistently been associated with Adverse Childhood Experiences (ACEs). The process is not fully understood but is likely to involve a complex interaction of biological and psychosocial factors. Early life stress can affect the developing brain resulting in long-term hyper-responses to stress and raised inflammatory biomarkers. Women with fibromyalgia syndrome (FMS) frequently report ACEs and also self-sacrificial behaviours whereby they repress their own needs and emotions to preserve personal relationships. This behavioural profile (termed self-silencing) may develop following ACEs but has not previously been considered in the context of FMS. This study examined whether self-silencing mediates the link between ACEs and FMS symptoms. Women with (N = 539) and without (N = 184) an FMS diagnosis completed measures of Silencing-the-Self, health symptoms and ACEs. Number of ACEs and symptom levels were significantly associated in both groups. One aspect of self-silencing, care and self-sacrifice (putting others needs before your own) mediated the association between ACEs and symptoms in the FMS group only. Externalised self-perception (judging oneself according to perceived external standards) was negatively associated with symptoms but presented no mediating effects. Results present preliminary new information to explain the association between ACEs and FMS. Recognition of the factors which underlie symptomology is important in understanding the condition and supporting patients.

A Concept Analysis of Self-Silencing

Self-silencing describes the phenomenon of "loss of voice." A clear and comprehensive definition of self-silencing is relevant for nursing research and practice to promote a better understanding of detrimental health outcomes that may result from self-silencing. This concept analysis used a modified version of Walker & Avant's method to identify attributes, antecedents, and consequences of self-silencing. Self-silencing has psychological and sociocultural dimensions that may result in negative health consequences. Directions for research, practice, and policy are included.

Understanding the Impact of Intimate Partner Violence Type and Timing on Pre-exposure Prophylaxis Knowledge, Acceptability, Sexual Behavior, and Gender Roles Among Women of Color

Knowledge and acceptability are key factors for pre-exposure prophylaxis (PrEP) use among women with a history of intimate partner violence (IPV) and research suggests that different types of IPV affect PrEP uptake differently. Few studies have examined whether the type (i.e., physical, sexual, and psychological) and timing (i.e., lifetime, past year) of IPV experiences are related to PrEP knowledge and acceptability, or whether gender roles and sexual risk behaviors affect PrEP use. We aimed to examine the associations between lifetime and past-year physical, sexual, and psychological IPV experiences on PrEP-related outcomes (i.e., knowledge, acceptability, sexual behavior if on PrEP) and the association between gender roles and PrEP-related outcomes. A total of 186 women of color at risk for HIV participated in this study, of whom 54% had ever experienced partner violence. Results showed that lifetime psychological (OR 3.0, 95% CI 1.1-9.4) and lifetime physical IPV (OR 5.5, 95% CI 1.2-18.9) were significantly associated with increased PrEP knowledge. lifetime psychological (OR 6.3, 95% CI 1.0-13.6) and lifetime physical IPV (OR 4.3, 95% CI 4.3-11.5) were significantly associated with increased sexual behavior if on PrEP. Past year physical IPV was significantly associated with interest in using PrEP (OR 1.9, 95% CI 1.7-4.3) and with sexual behavior if on PrEP (OR 4.0, 95% CI 1.1-13.1). Being subordinate to others was also significantly associated with interest in using PrEP (OR 1.5, 95% CI 1.2-2.4) Self-silencing was significantly associated with increased sexual behavior if on PrEP (OR 1.2, 95% CI 1.0-1.5). Gender norms and IPV type and timing can influence whether a person is interested in PrEP use. Both lifetime and past-year IPV experiences need to be examined in the context of gender norms when prescribing PrEP to encourage uptake and continuation among vulnerable women at risk for HIV.

Nurse’s competences in promoting women’s health in light of the Galway Consensus

ABSTRACT Objectives: to identify nurses’ competences in promoting women’s health. Methods: descriptive study with a qualitative approach that adopted the Galway Consensus as a theoretical-methodological framework. Data collection was performed through semi-structured interviews. Results: most of the Galway Consensus’ competence domains were present in the nurses’ interventions related to health promotion in women’s care. “Assessment of needs” and “Implementation” were the most highlighted domains, followed by “Leadership” and “Impact assessment”. The domain “Defending/Advocating Rights” was not identified. Final Considerations: within the nurses’ work with women, some of the Galway Consensus domains of competencies for health promotion were present. However, there is a need, in the context of continuous health education, to expand strategies and enhance the development and application of these health promotion competences.

The Relationship Between Self-Silencing and Depression: A Meta-Analysis

Introduction: Over time, several studies have provided knowledge about the relationship between self-silencing and depression. However, even if there is a tendency to obtain positive correlations, results ranging from null to large effects are rather variable, and until now no meta-analysis exists of these results, to our knowledge. Under these circumstances, the purpose of the present study is to quantitatively integrate existing results refecting the relationship between self-silencing and depression and to explore potential moderators of this relationship, in regards to conceptual aspects and characteristics of the samples. Methods: Our meta-analysis incorporates 31 published and 11 unpublished studies (with a total of 10,108 participants and 131 effect sizes), written in English, which statistically quantify the link between self-silencing and depression. For the analysis of the overall effect, specific meta-analytical procedures were used for heterogeneity, publication bias, and potential moderators. Results: There is an overall significant positive and medium correlation between self-silencing and depression (r = 0.391, p < 0.001). The heterogeneity of the results is partially explained by components of self-silencing, measured in each study and certain features of the samples such as age, sexual orientation, and level of education. Discussion: For researchers on this topic, our results offer a more precise input for computing sample sizes and also generate expectations of results as a function of specific methodological features. For practitioners, our results suggest the importance of approaching components of self-silence in counseling and therapy (with increased attention towards the externalized self-perception and the divided self) as mechanisms in depression (especially for younger and highly educated clients, and for non-heterosexuals).

The Cardiovascular Cost of Silence: Relationships Between Self-silencing and Carotid Atherosclerosis in Midlife Women

BACKGROUND

Individuals engage in a range of behaviors to maintain close relationships. One behavior is self-silencing or inhibiting self-expression to avoid relationship conflict or loss. Self-silencing is related to poor mental health and self-reported physical health in women but has not been examined in relation to cardiovascular health, particularly using direct measures of the vasculature.

PURPOSE

To test associations between self-silencing and carotid atherosclerosis in midlife women; secondary analyses examined moderation by race/ethnicity.

METHODS

Women (N = 290, ages 40-60) reported on self-silencing in intimate relationships and underwent physical measurements, blood draw, and ultrasound assessment of carotid intima-media thickness (IMT) and plaque. Associations between self-silencing and mean IMT and plaque index (0, 1, ≥2) were tested in linear regression and multinomial logistic regression models, respectively, followed by interaction terms between self-silencing and race, adjusted for demographic factors, CVD risk factors, partner status, depression, physical activity, and diet.

RESULTS

Forty-seven percent of women demonstrated carotid plaque. Greater self-silencing was related to increased odds of plaque index ≥2 (e.g., for each additional point, odds ratio [95% confidence interval] = 1.16 [1.03-1.31], p = .012), relative to no plaque). Moderation analyses indicated that self-silencing was related to odds of plaque index ≥2 in non-white women (1.15 [1.05-1.26], p = .004), but there was no significant relationship in white women (1.01 [0.97-1.06], p = .550). No associations emerged for IMT.

CONCLUSIONS

Among midlife women, self-silencing was associated with carotid plaque, independent of CVD risk factors, depression, and health behaviors. Emotional expression in relationships may be important for women's cardiovascular health.

'Silencing the self' and women's mental health problems: A narrative review

In the context of women's mental health several propositions have been made to account for their increased susceptibility to certain psychiatric illnesses. However, given the topic's multifacetedness, no single explanation is found sufficient in itself. 'Silencing the Self' theory sheds new light on this issue because it acknowledges the importance of social and cultural processes. Besides with its relational perspective, it centers on the primacy of core relationships and its influence on a woman's mental health. Even though, since its inception three decades ago, the theory has been studied in relation to various psychological and physical disorders; it has hitherto received inadequate attention by scholars. Nonetheless, it has the potential to inform our understanding when formulating women's mental health issues. The aim of this review is to provide a comprehensive narrative account of the extant work on 'silencing the self' in relation to psychiatric illnesses like depression, eating disorder and premenstrual dysphoric disorder. It attempts to synthesize the work done till date, as a starting point for further investigation of unexamined areas.

Perception of Menstrual Normality and Abnormality in Spanish Female Nursing Students

Menstrual problems are usually taboo; and often, some, such as dysmenorrhea, are presumed normal. This study seeks to compare the menstrual characteristics and symptoms of female university students reporting self-perceived normality concerning their cycles and menstruation with those who perceive their menstruation as being abnormal. A cross-sectional descriptive study was conducted among 270 nursing students using a self-report questionnaire that included sociodemographic and gynecological issues, together with Visual Analog Scale, the Andersch and Milsom Scale, and the Spanish version of the EuroQol-5 Dimension (EuroQol-5D) to measure self-perceived health status. A bivariate analysis was performed using the chi-square test, linear trend chi-square, and Student's t-test, and a multivariate analysis of stepwise binary logistic regression was performed to predict the perception of cycle abnormality. In total, 77.4% of participants displayed normality; however, in self-reporting of menstrual characteristics, 67.4% identified alterations. Young women suffering from menstrual dizziness were 1.997 (CI95% = 1.010-3.950; p = 0.047) more likely to manifest abnormal menstruation, 4.518 (CI95% = 1.239-16.477; p = 0.022) more likely if they suffered from Grade 3 menstrual pain, and 2.851 (CI95% = 1.399-5.809; p = 0.004) more likely if they perceived that menstruation interfered with their daily lives. Many menstrual changes and symptoms are still considered normal, making it difficult to identify and address these issues. Therefore, it is necessary to develop health policies and strategies to improve menstrual health literacy for increased knowledge and earlier diagnosis.

A reformulated contextual model of psychotherapy for treating anxiety and depression

This paper describes a reformulated contextual model that uses cognitive theory (dual process theory), motivation theory (personality) and behavioral adaptation (self-correcting control systems) to show how anxiety and depression are caused, treated and prevented by an interaction between people and contexts. Depression and anxiety are the result of implicit beliefs (not cognitions) that all experience is unrewarding and threatening, these being components of the implicit belief that life is bad. Implicit beliefs are formed automatically from contextual cues and in healthy individuals are consistent with rational appraisal. They become more negative than reality through a process of adaptation when behaviors, directed by rational thinking, repeatedly create cues that signify lack of reward or threat. Such behaviors occur when social or other obligations lead people to choose behaviors that fail to satisfy their own unique goals in life and approach threatening situations, contrary to their automatic reactions. Therapeutic interventions and lifestyle change reverse these adaptive processes by positive experiences that create positive implicit beliefs, a change effected in different ways by contextual and specific mechanisms both of which correct the same fault of negative implicit beliefs. Effective therapeutic relationships and interventions are achieved by detecting and responding to a patient's unique needs and goals and their associated implicit beliefs. Mental health requires not only that people experience life as good as defined by their own goals and beliefs but also the avoidance of contexts where social and other pressures induce people to behave in ways inconsistent with their automatically generated feelings.

Depression and Gender Roles among Hispanic Immigrant Women: Examining Associations of Gender Egalitarianism, Marianismo, and Self-Silencing

Background

Efforts in the prevention and treatment of depression among Hispanic immigrant women require studies to identify modifiable factors of depression. Some factors that may merit investigation are gender roles such as egalitarian gender attitudes, marianismo, and self-silencing.

Methods

This cross-sectional study included 231 Hispanic immigrant women living in Miami-Dade County, Florida. Logistic regression was used to examine associations of covariates, egalitarian gender attitudes, marianismo, and self-silencing in relation to depression.

Results

Egalitarian gender attitudes were not associated with depression. For marianismo domains, higher scores on the spiritual pillar scale were associated with lower odds of depression. With regard to self-silencing, higher scores on externalizing self-perception and divided self were associated with higher odds of depression.

Conclusions

Findings add to the limited literature on depression among Hispanic immigrants and provides some insight on sociocultural factors that may be considered in depression interventions for Hispanic immigrant women.