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Discuss cultural and gender variation in prevalence of disorders

Prevalence is a statistical concept in medicine (or psychiatry). It refers to the percentage of individuals within a population who are affected by a specific disorder at a given time. Two disorders (major depression and bulimia nervosa) will be addressed in this section.

Cultural variation in prevalence of depression

Weisman et al. (1996) found cross-cultural variation in data from 10 countries. The study found that the lifetime prevalence of depression ranged from 19.0 % (Beirut in Lebanon) to 1.5 % (Taiwan). Korea had rates of depression twice as high as those in Taiwan (2.9%) although they are both Asian countries. Paris had a rate (16.4%) close to that of Beirut although Beirut had experienced war for 15 years. Women had a higher rate than men in all countries. The researchers argue that different risk factors, social stigma, cultural reluctance to endorse mental symptoms as well as methodological limitations of the study may account for some of the differences.

Marsella et al. (2002) argue that depression has long been a major topic of concern in Western medical history but it seems that depression is now becoming the world’s foremost psychiatric problem because of global challenges such as war, natural disasters, racism, poverty, cultural collapse, ageing populations, urbanizations, and rapid social and technological changes. There is growing evidence that rates of depression are increasing, particularly in individuals born after the Second World War.

Possible explanations of cultural variation in the prevalence of depression

Differences in social and cultural background

Dutton (2009) finds that cultural variation in prevalence of major depression could be due to cultural differences in stress, standards of living, and reporting bias. People in some countries have much harder lives. They may be exposed to war, civil war, rapid political and economic changes, crime, and discrimination. Unemployment and standards of living also differ across cultural groups.

Sartorius et al. (1983) found that there are substantial cultural differences in the stigma associated with mental health problems. It could be that individuals in cultures where psychological disorders are associated with stigma (e.g. the Middle East or China) are more likely to report physical pain instead of psychological problems. Variation in symptoms could indicate that symptoms of depression can be culturally influenced. See Kleinman (1982) on neurasthenia as an alternative diagnosis for depression which could explain a cultural variation in the prevalence of depression


Marsella (1995) proposed that urban settings are associated with increased stress due to problems of housing, work, marriage, child rearing, security, and other urban difficulties. Urban crowding, poor working conditions or underemployment, chronic hunger, gender discrimination, limited education and human rights violations are all thought to weaken both individuals and the social support that could serve as buffers against mental health problems.

Gender variation in prevalence of depression


According to Nolen-Hoeksema (2001) women are about twice as likely as men to develop depression. She argues that in spite of three decades of research on gender difference in depression, it has not been possible to find a variable that single-handedly can account for the gender difference in depression.

Women’s lifetime prevalence for major depressive disorder in the USA was found to be 21.3% compared to 12.7% for men (Kessler et al. 1993). Females are more likely to report physical and psychological symptom and to seek medical help.

According to Piccinelli and Wilkinson (2000) the gender differences in depression are genuine and not just a result of differences in diagnostic procedures.

Possible explanations for gender variation in prevalence of depression

Biological factors: hormones

Biological explanations for women’s higher vulnerability to depression have focused on the effect of sex hormones (estrogen and progesterone) on mood. According to Nolen-Hoeksema (2001) there is little scientific support to the theory that women are more depressed than men only because of differences in sex hormones.

Adverse experiences in childhood (e.g. childhood sexual abuse) have been linked to increased risk of developing depression partly because of long-term deregulation of the stress response system (HPA axis). Weiss et al. (1999) suggested that women are more likely than men to have a deregulated response to stress because they are more likely to have been exposed to regular episodes of traumas early in life.

Nolen-Hoeksema (2001) suggests that women and men experience the same stressors but women seem to be more vulnerable to develop depression because of gender differences in biological responses to stressors, self-concepts or coping styles. Experiences of continuous stress could increase physiological and psychological reactivity to stress and lead to hyperactitviy of the stress system. This could increase vulnerability to depression (diathesis-stress model).

Sociocultural factors

Women’s low power and status: Nolen-Hoeksema (2001) Women have less power and status than men in most societies. They are more likely to experience sexual abuse, constrained choices, poverty, and lack of respect. These factors can contribute directly to depression because they make women feel that they are not in control of their lives. Women’s social roles carry a number of chronic strains, which could contribute directly or indirectly to depression. Higher rates of depression in women could be due to the fact that women face a number of chronic burdens in everyday life as a result of their social status and roles.

The role strain hypothesis suggests that social roles and cultural influences contribute to the higher ratio of female depression. In many cultures married women have no paid employment and they have to rely on the role of housewife for identity and self-esteem. This may be rather frustrating at times and it is not highly valued in modern society. Bebbington (1998) found that marriage could have negative effects on women. The researcher speculated that many women have limited choices after marriage. Staying at home and looking after small children is generally associated with higher levels of depression.

Cultural variation in prevalence of bulimia

Cultural beliefs and attitudes have been identified as factors leading to the development of eating disorders (etiology). Prevalence of eating disorders varies among different ethnic and cultural groups and across time within such groups. Bulimia nervosa was first identified and classified as a specific disorder in 1979.

Makino et al. (2004) compared prevalence of eating disorders in Western and non-Western countries based on a review of published medical articles. They found that prevalence rates in Western countries for bulimia nervosa ranged from 0.3% to 7.3% in females and from 0% to 2.1% in males. Prevalence rates for bulimia in non-Western countries ranged from 0.46% to 3.2% in females. The study concluded that prevalence of eating disorders appears to be increasing in non-Western countries but it is still lower than in Western countries.

Explanations of cultural variation in prevalence of bulimia

The Westernization hypothesis

According to Rubinstein and Caballero (2000) eating disorders seem to have become more common among younger females after the Second World War, where female beauty ideals have gradually become thinner. This is reflected in the increase of articles on dieting in women’s magazines in the same period as well as in thinner icons of female beauty (e.g. Miss America).

One explanation for the development of eating disorders such as bulimia in non-Western countries is a perceived social pressure to conform to the standards of female beauty imposed by modern industrial society or Western culture.

Becker et al. (2002) Impact of introduction of Western television on disordered eating patterns among Fijian adolescent girls

The field study investigated changes in eating patterns in 1995 after television had been introduced to a remote province in Fiji, and again in 1998 when television had been available for three years). The traditional Fiji body ideal at the time was robust and the pressure to be thin found in many Western countries was absent.

The study used quantitative (survey) and qualitative methods (semi-structured interviews) on issues such as television viewing, dieting, body satisfaction, and purging. Adolescent girls from two secondary schools participated.

The results showed an increase in dieting and self-induced vomiting to control weight from 0% in 1995 to 11.3% in 1998.

The researchers suggested that increasing globalization and exposure to Western media could explain the increase in symptoms related to eating disorders in non-Western countries. The specific combination of binge eating and purging to control weight, which is the core symptom of bulimia nervosa, only appeared after introduction of television. This could support that bulimia is a culture bound syndrome.

The study did not use clinical diagnoses, which is a limitation. There may be a tendency to report symptoms (e.g. purging) in anonymous self-reports but a clear diagnosis cannot be made. The questionnaires revealed clinical signs (vomiting and body dissatisfaction) associated with eating disorders and in particular bulimia. The study only included girls so nothing can be concluded on changes in eating behavior among males (sample bias).

An argument against….

Nasser (1994) used questionnaires to investigate eating attitudes in a sample of 351 girls in secondary school in Egypt. He found that 1.2% of the girls fulfilled the criteria for a diagnosis of bulimia nervosa and 3.4% qualified for a partial diagnosis. The results indicate that eating disorders are emerging in cultures that did not know such disorders in the past where a round female body was still considered attractive and desirable, and was associated with prosperity, fertility, success, and economic security. The researcher concluded that no society is truly immune to the development of eating disorders because of the globalization of culture through the media.

Gender variation in prevalence of bulimia

Makino et al. (2004) reviewed studies on eating disorders in 11 Western countries. They found that more female participants suffered from eating disorders and had abnormal eating attitudes than male participants.


Men are generally less likely to develop eating disorders, perhaps due to less pressure on men to conform to an ideal body weight or shape (Rolss et al. 1991). Men who develop eating disorders tend to resemble females in terms of dissatisfaction with their body (Olivardia et al. 1995).

Certain sub-populations of men with jobs that require weight restrictions (e.g. wrestlers and jockeys) seem to be at increased risk of developing eating disorders. There may be a possible link between male homosexuality and eating disorders because of a higher emphasis on attractiveness and slimness in gay subcultures (Silberstein et al. 1989).


There has been a steady increase in diagnosis of bulimia nervosa in the UK from 1988 to 2000 (Currin et al. 2005) but since 1996 there has been a decline. This meta-analysis used data from general practitioners (GPs) in the UK. The study found that incidence of bulimia nervosa per 100 was 94 cases for females and five cases for males. Overall females are more likely to be diagnosed with bulimia than males.

Currin et al. (2005) found that the highest risk for bulimia nervosa is in young women between 10 and 19. Certain sub-populations such as ballerinas and models have been associated with increased risk for developing eating disorders because of high pressure to be thin.