Celebrating Women in Psychiatry

The history of psychiatry is replete with examples of poor outcomes for women in need, often women who sought medical help. Lobotomies are an extreme but illustrative example, as most lobotomized patients were women, although most institutionalized patients at the time were men.

In 1937, Freeman and surgeon James Watts published on the surgery’s benefits, based on a case study of six patients with psychiatric symptoms. They credited the surgery for alleviating patients’ symptoms: “insomnia, nervous tension, apprehension and anxiety.” They identified drawbacks, too. Patients were “more comfortable,” but markedly more docile.

“Every patient loses something by this operation,” they conceded. “Some spontaneity, some sparkle.”

All the same, scientific acceptance of lobotomies grew.

In the 1940s, when psychiatric asylums were understaffed, underfunded and overcrowded, neuropsychiatrist Dr. Walter Freeman popularized psychosurgery to “liberate” patients from the hopelessness of therapeutic nihilism and the probability of lifelong custodial care. The most frequently performed lobotomy was the transorbital. A physician guided a long cannula (Freeman first used an ice pick) through the patient’s eye socket and into the brain and then moved it left to right — a motion some have compared with that of a windshield wiper — to sever the patient’s lower frontal lobes. In 1949, its putative founder was awarded a Nobel Prize.

By 1952, an estimated 50 000 patients in the United States and Canada had been lobotomized.

A comprehensive survey of US psychiatric facilities between 1949 and 1951 found that most patients lobotomized by doctors were women.4 At a time when women were expected to be calm, cooperative and attentive to domestic affairs, definitions of mental illness were as culturally bound as their treatments.

A surgery that rendered female patients docile and compliant, but well enough to return to and care for their homes, had many proponents before the drug chlorpromazine, the first “major” tranquilizer, became available in 1954.

Chlorpromazine’s success launched our modern psychopharmcologic era, anointing drugs as the treatment of choice in asylum and outpatient psychiatry. Tellingly, prescribing patterns reinforced earlier tropes.

By 1968, the “minor” tranquilizer Valium (diazepam), marketed as an antidote for socially dysfunctional women — the excessively ambitious, the visually unkempt, the unmarried and the menopausal misfits — was the best-selling drug in the world as well as one prescribed overwhelmingly to women.

The disproportionate use of lobotomies and tranquilizers by doctors as therapies for female patients exemplify how gender bias has shaped twentieth-century medicine, but is there evidence that bias influences physician decision-making today? Unfortunately, yes.

Recent studies of “implicit bias,” loosely defined as a preference an individual has but doesn’t consciously recognize, show that medical practitioners are as susceptible to the same biases as their non-physician peers. Although this finding is not surprising — humans cannot opt out of their culture to be objective — it is problematic in medicine for several reasons.

One reason is the capacity to harm. Practitioners treat patients who vary by age, weight, sex, ethnicity, blood pressure and other variables. They know a patient is never simply one of these categories. But when a physician reduces the multifaceted patient to a prejudicial category, and acts on implicit bias, the patient’s well-being may suffer.

Treatment for Women Had to Change

Although this unfiltered view of medicine’s past may be unsettling, it also provides us with possibilities for change. The past needn’t be prologue. If modern medicine is, to some extent, of our own making, then it is also within our power to remake it.

Biological Issues

Maureen Sayres Van Niel, M.D. stated: “Research shows there are significant biological differences between males and females with regard to anatomy, physiology, and metabolism.

Women’s brains are different from men’s with regards to size of brain structures and in global and regional gray matter percentages. For example, MRI studies in humans have found that the hippocampus is larger in women than men when compared to the total volume of the brain.

The implications of these brain differences in relationship to behavior are an intriguing topic of current research. In addition, female hormones such as estradiol and progesterone interact with various neurotransmitters in the brain, including dopamine and serotonin in ways that are not yet fully understood.

Research is ongoing to determine how these biological differences may have behavioral, cognitive and clinical implications or affect treatment outcomes in women.

Women also have different pharmacokinetics from men, affecting the absorption, distribution, bioavailability, and metabolism of medications. This leads to differences in the way women metabolize psychotropic drugs in the liver and may increase the circulating levels and duration of action of medications, such as zolpidem, as recently cited by the Food and Drug Administration (FDA).

Best Practice Highlights for Working with Women Patients from American Psychiatric Association on Vimeo.

Medications such as carbamezine, oxcarbazepine, phenytoin, and topiramate increase the rate of breakdown of oral contraceptives in the liver, making the birth control pills less effective in preventing pregnancy in women taking these medications. The use of medications in the peripartum period also presents unique challenges to be considered for the mother and the baby. Finally, females have been found to experience more pain relief effects from opioid painkillers, which is hypothesized to result from the effects of estrogen.

In 2013 the US Food and Drug Administration announced the first gender-specific guidelines for the use of certain medications. The study of these gender-based reactions to psychotropic medications is in its inchoate stages and is expected to grow over the next decade.”

Empathy and understanding in women for women makes the need for more female psychiatrists urgent.

Gender Bias

Gender is correlated with the prevalence of certain mental disorders, including depression, anxiety and somatic complaints. For example, women are more likely to be diagnosed with major depression, while men are more likely to be diagnosed with substance abuse and antisocial personality disorder.

The issue of gender bias with regard to Diagnostic and Statistical Manual of Mental Disorders (DSM) personality disorder criteria has been controversial and widely debated. The current DSM (4th ed., text revision; DSM–IV–TR; American Psychiatric Association, 2000) makes no explicit statement regarding gender bias among the personality disorders (PDs), but it does suggest that six disorders (antisocial, narcissistic, obsessive-compulsive, paranoid, schizotypal, schizoid) are more frequently found in men.

Three others (borderline, histrionic, dependent) are presumably more frequent in women. There are many ways to interpret differential prevalence rates as a function of gender (Corbitt & Widiger, 1995). Some critics have argued that they are an artifact of gender bias (Caplan, 1995; Kaplan, 1983; Walker, 1994).

In other words, the PD criteria assume unfairly that stereotypical female characteristics are pathological.

The Women and Mental Health Special Interest Group at The Royal College of Psychiatrists marked their 25th anniversary in 2021 by highlighting the stories of 25 amazing women psychiatrists.

They asked for nominations of people who may be seen as unsung heroes and may not have received recognition or awards, yet are still doing an amazing job.

The 25 women psychiatrists were selected from a range of specialty, grades and geographical locations to showcase their variety and depth of achievements.

This film, directed by Inshra Russell, hears from the 25 women about their work, their lives, and the wider role of women in psychiatry.

You can find out more about the project and read detailed narratives from each of the 25 women here.

BECOME a Psychiatrist