These therefore, as Keller (2001) observes, create some significantly interesting anomalies when correlated with feminist studies of admission rates of women in England during the era, whereby according to Kromm (1994: 507), it denoted ‘a clear shift in the understanding of madness as a gendered disorder’. She goes on to argue that theatrical and pictorial representations increasingly depicted woman as the embodiment of madness in various postures of melancholia as opposed to mania (Kromm, 1994). Furthermore, Showalter (1985) argues that the over-representation of madness amongst women was far from being merely a nineteenth-century and twentieth-century phenomenon, but existed from the seventeenth century onwards.
To rehearse the analysis of these feminist studies of the feminisation of madness Denise Russell (1995: 18), in support of Kromm’s assertion that there existed a preponderance of women in British public mental hospitals in the nineteenth century, considers the late eighteenth-century interest in ‘specifically female problems’ as an origin of perceiving insanity as a gendered condition. It is argued that these forms of feminine pathology were dominated by the medical preoccupation with female sexuality and moral purity. In turn, this continues as a dominant discourse in relation to the labelling of women as suffering from mental illness (Barnes and Bowl, 2001; Ussher, 1991).
Joan Busfield (1994), however, contests the assertion of overwhelming numbers of nineteenth-century women in asylum care, and instead asserts that at least in relation to that century the empirical evidence pointing to proportional differences between male and female admission data is quite small. Statistical evidence notwithstanding, diagnosed insanity and high admission rates in the asylum system related to gender depended heavily on the institutionalised perception of woman as essentially associated with the likelihood of insanity.
Yet the Victorian era marked an important change in the discursive regimes that confined and controlled women, because it was in this period that the close association between femininity and pathology became firmly established with the scientific, literary and popular discourse: madness became synonymous with womanhood (Ussher, 1991: 64).
While the debate concerning the precise numbers of women in asylum care in previous centuries will no doubt continue, there has been little dissent concerning the claim that there has been a universal predominance of women diagnosed with mental illness in the twentieth century (Miles, 1988; Ramon, 1996; Ussher, 1991). Phyllis Chesler (1996: 46) baldly states that more women are being hospitalised with a diagnosis of mental illness than ‘at any other time in history’. These diagnoses are, she argues, predominantly affective depressive disorders in keeping with women’s subdued and passive presence in society, a topic also explored by Redfield Jamison (1996) in her personal account of bipolar depression. Chesler goes on to allude to the continuing dichotomised perceptions that have persisted, lying between the socially accepted, rewarded but inadequate role of the passive, melancholic female and her antithesis: that of the deplored voluble, ‘aggressive’, masculinised female counterpart.
When female depression swells to clinical proportions, it unfortunately doesn’t function as a role-release or respite. For example … ‘depressed’ women are even less verbally ‘hostile’ and ‘aggressive’ than non-depressed women; their ‘depression’ may serve as a way of keeping a deadly faith with their ‘feminine’ role (Chesler, 1996: 51).
Wetzel (2000) stands in agreement with Jennie Williams (1999) in arguing that in both the developed and developing world, conditions of oppression affect women living in patriarchal societies, such as Malaysia. These forms of oppression towards women include low status, poverty and exploitation, sexual violence and other acts of human rights violation (Barnes and Bowl, 2001; Wetzel, 2000). Other critiques have noted the relationship between mental distress and the oppression that marriage may impose on women, together with the escalated risk factor connected with the role of motherhood (Ramon, 1996; Ussher, 1991). This has accordingly resulted in a global bias towards a high risk of diagnosis of mental illness for women and their subsequent admission to institutional care.
Long term psychiatric intervention (based upon psychosexual theories) has been inappropriately applied to women throughout the world, when their real problems were poverty, violence and economics (Wetzel, 2000: 209).
Apart from the issue of gender bias, a further issue of interest for this study lies in the ethnic breakdown of admission rates during this period and subsequent decades. For example, in 1900 the Singapore asylums largely held Chinese and Indian migrants who formed the vast majority of inmates (Teoh, 1971). It is claimed that this situation continued over the next century and was comparable with other asylums in Malaya, such as in Penang (Tan and Wagner, 1971). The implications of continuing bias in this regard is considered in this study, in reference to patient admission at Hospital Tranquillity.
In relation to the issue of ethnic preponderance in contemporary psychiatric care in the West, a relatively small but important body of critique considers the issue of mental illness and the impact of migration and that of cultural dislocation, together with the effects of consequential separation of individuals from their supportive networks. Such analyses focus on the significance of ethnic bias of psychiatry in Britain where British-born men from African-Caribbean background have been predominancely diagnosed with schizophrenia (Nazroo, 1997; Rack, 1982). Furthermore, an interesting aspect of the escalated ethnic presence in psychiatric services noted in Britain, and which appears to hold significant import for modern Malaysia, is that subsequent generations are also at greater risk of diagnosis and hospitalisation, despite a level of familiarisation and acculturation in the adopted alien culture (Barnes and Bowl, 2001). This said, Ramon (1996) highlights the issue of class as being a further factor to consider along with ethnicity and migration. She argues that elements such as education and, presumably, upward social mobility can act as protective factors countering the effects of migration and cultural dislocation (Ramon, 1996). Suman Fernando (1995, 1999), however, draws a general conclusion of institutionalised racism encountering cultural difference; while others have considered the phenomenon in terms of actual illness and social stressors. In this vein Ajita Chakraborty (1991: 1208) condemns the ‘value-based and often racist undercurrents in psychiatry’ and goes on to note the fundamental tolerance of mental illness amongst families in India, with the inference that stigma is a persistent effect of Western colonial values. This in turn tends to corroborate the psychiatric assumption that most South-Asian psychiatric patients in Britain have a supportive family network and enjoy what Nazroo describes as a ‘protective culture’, having fewer mental-health needs than other immigrants (Nazroo, 1997: 7). Thus resonating with Teoh’s assumption that separation from ‘stable and emotional family support’ represented a significant risk factor for Indian male migrants in colonial Malaya (Teoh, 1971: 28).
Finally, in contemporary Britain Chinese psychiatric service users have equally been subject to stereotyping, in terms of the assumption that they enjoy a supportive and insular family network, leading to the relative abandonment of carers by the support services (Yee and Shun Au, 1997). In view of the Chinese diaspora and the issue of Chinese asylum admissions in colonial Malaya and Borneo, these latter-day assumptions may contain useful references in understanding the position of Chinese patients in the modern Malaysian psychiatric institution, as represented by Hospital Tranquillity (Kleinman, 1988b).
Back in nineteenth-century Singapore, Gilmore Ellis brought with him contemporary notions of therapeutic care that involved rehabilitative exercises, such as occupational labour; in keeping with British values of the day. These in all likelihood were gender normative activities, and for women revolved around the skills of the good housewife, and which are enacted on hospital wards to this day, as will