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To understand the role of women in psychiatry, a context is necessary. This will be provided by tracing the history of women in medical roles.
1. The History Of Women In Health Care
Throughout history women have been healers and caretakers, playing multiple roles, as pharmacists, nurses, midwives, abortionists, counselors, physicians, and ‘wise women,’ as well as witches.
From 4000 BCE there were women who studied, taught, and practiced medicine, including Moses’ wife Zipporah. The ﬁrst known woman physician, Merit Ptah, practiced in 2500 BCE. The Chinese record, in 1000 BCE, women engaged in typical physician-like activities.
The Roman, Soranas, believed women were divinely appointed to care for women and children. His criteria for practitioners included literacy, anatomic understanding, a sense of patient responsibility, and ethical concerns, particularly regarding conﬁdentiality. However, Roman women physicians were rarely permitted to perform in the same capacities and positions as men.
Women founded and staffed early hospitals in 260–220 BCE; the deaconesses of the early Christian church developed the ﬁrst public health systems (Shryock 1959). Middle Eastern hospitals were founded in the sixth and seventh centuries CE. By the eighth century Arab medicine began to ﬂourish. Since Muslim men were forbidden from having contact with women who were not family members, women cared for women. In Islamic Spain, women received medical educations and were surgeons before the twelfth century.
European medical education formally began in Salerno, Italy, in the ninth century. By the tenth and eleventh centuries, women apparently studied there (Corner 1937). When medical degrees were ﬁrst awarded in 1180, they went only to men. Women received a special diploma until the ﬁfteenth century. A woman physician, Trotula, was an important eleventh century academic and teacher in Salerno. She wrote major texts on obstetrics and gynecology and headed a department of women’s diseases. Her contributions were signiﬁcant because, at that time, women provided all obstetrical care and many had no training. However, many of her accomplishments, and those of other women, were attributed to their husbands and sons.
An early twelfth century abbess, Hildegarde of Bingen, was a healer, philosopher, composer, and scientiﬁc scholar who provided scientiﬁc data on nervous system regulation and an understanding of normal and abnormal psychology.
Initially, women were ambivalently received when they expanded their traditional midwifery roles, and they were prevented from obtaining medical training. However, in England, the need for physicians during the Black Death of 1349 opened the way for women to study medicine.
In 1423 Constanza Calenda became the ﬁrst woman formally to obtain a medical degree. She lectured in medicine at the University of Naples. Although, in the fourteenth and ﬁfteenth centuries women practiced medicine in Italy, France, England, and Germany, their practice was usually limited to bleeding, administration of herbs and medicines, and reducing fractures, in addition to midwifery. In some parts of Europe, women also practiced as physicans, surgeons, orthopedists, and ophthalmologists. It was generally believed that women were better able to treat women’s diseases. Many served kings, royal families, and even the military.
Despite this success, by the end of the ﬁfteenth century the movement to exclude women from practicing gained momentum; they were speciﬁcally limited to functioning as midwives. This coincided with the misogyny of Johann Sprenger and Heinrich Kraemer, in the Malleus Maleﬁcarum of 1486, which laid out much of the philosophy of the inquisition. Witchhunting focused on the ‘spiritual and mental’ inferiority of women. Even when active witch-hunts subsided, their effects remained and women were eliminated from many medical roles.
In the seventeenth century, when examinations and licensing procedures were required for physicians, women were rarely allowed to sit for required examinations.
2. Women In Eighteenth And Nineteenth Century American And European Medicine
In colonial America, the healing role of women was critical to survival, since medical care of families was the responsibility of the women. There were no medical schools and relatively few trained physicians. Training was obtained by going abroad or apprenticing.
In 1765 Dr. John Morgan founded the ﬁrst ‘regular’ American medical school. By excluding women, it began a tradition of barring them from formal medical training in the USA. Still, many women set up ‘irregular’ practices without diplomas, having apprenticed in homeopathic or eclectic traditions. Toward the latter part of the nineteenth century, US women began to study in European medical schools.
In 1847, Elizabeth Blackwell became the ﬁrst woman accepted to a ‘regular’ US medical school. When she received her MD from the Geneva Medical School, the New York State Medical Association censured the school. In 1850 Harriet K. Hunt, an ‘irregular’ practitioner in Boston, applied for admission to Harvard Medical School. She was admitted, but denied her seat when the all-male class threatened to leave if women were admitted. It was not until 1946 that Harvard Medical School ﬁnally admitted women.
By mid-nineteenth century, three all-female medical colleges were founded in the USA: the Women’s Medical College of Pennsylvania, one in Boston (now Boston University), and another in Cincinnati. Several US universities, including Syracuse, Michigan, Iowa, and California accepted women (Luchetti 1998).
During the Civil War, Dr. Mary Edwards Walker was awarded the Medal of Honor, the most prestigious military award, for her performance as a surgeon. She was, however, subjected to enormous criticism of her qualiﬁcations. The medal was rescinded in 1917 after a change in guidelines limited it to men in combat. It was reinstated in 1977 (Luchetti 1998).
In 1878 the National Eclectic Medical Association became the ﬁrst medical society in the USA to accept women for membership, but the American Medical Association (AMA) continued to be closed to women.
Negative attitudes about women physicians were supported by a ‘new science’ rationalizing the inferior status of women on biological grounds. An 1873 book stated, ‘higher education for women produces monstrous brains and puny bodies.’ It quoted an 1848 obstetrics textbook stating that women have ‘a head almost too small for the intellect but just big enough for love.’
The road continued to be difficult even for those women who managed to obtain training. Ann Preston, founder of the Women’s Medical College of Pennsylvania, described the entry of women onto the wards of the Pennsylvania Hospital, ‘We entered in a body, amidst jeerings, groaning, whistlings, and stamping of feet by the men students … On leaving the hospital, we were actually stoned by those so-called gentlemen’ (in Alsop 1950, pp. 354–5).
Denied hospital appointments, US women began to open their own hospitals and clinics. In 1857 Elizabeth Blackwell, her sister Emily, and Marie Zakrzewska established the New York Inﬁrmary for women and children. In 1862 Marie Zakrzewska founded a similar hospital in Boston. They also founded the Women’s Medical College of the New York Inﬁrmary in 1868. They believed that women received an inferior education and they sought to correct this problem by establishing rigorous entrance exams and longer clinical training than other medical schools.
There were many important successes for women at the end of the ninteenth century. Dr. Mary Putman became a member of the New York Academy of Medicine in 1880. In 1875 Emmeline Cleveland, Dean of the Pennsylvania Women’s Medical College, be-came the ﬁrst woman physician in the USA to perform major surgery.
The role of women in medicine, however, continued to be hotly debated. In 1881 Rachel Bodley, Dean of the Women’s Medical College of Pennsylvania, surveyed the 244 living women graduates of the school and found that, despite persistent belief that training for women was wasteful, the overwhelming majority were in active practice, and those who had married reported that their profession had no adverse effect on their marriages, nor had marriage interfered with their work. Many early women physicians were from medical families and they joined family members in practice. By 1876, 0.8 percent of US physicians were women. By 1890, 35 US medical schools admitted women, and in 1900 6 percent of physicians were women (Luchetti 1998).
During this period, women physicians graduated from some European universities in Italy, Switzerland, and the UK. There was a woman chair in obstetrics in Italy.
In 1866 Elizabeth Garrett-Anderson opened a dispensary for women and children in London during a cholera epidemic. People were grateful for medical attention, even from women. In 1874 Sophia JexBlake, Elizabeth Garrett-Anderson and others opened the London School of Medicine for Women. The medical hierarchy threatened to blackball any male who taught there, and no teaching hospital would allow women to practice. For several years women could not get the needed training for registration in medicine.
In 1877 the Royal Free Hospital in London allowed women access to its facilities. Dublin accepted women in the early 1880s and the Scottish schools followed in 1895. The Royal College ﬁnally opened its exams to women in 1910.
In Canada the situation was no different. Dr. James Barry (1797–1865), Inspector General of the British Army Medical Department and subsequently Inspector General of Hospitals for Canada, was discovered to be a woman after her death. She was the ﬁrst woman doctor to practice medicine in Canada.
3. Women In Twentieth Century Medicine
Despite many changes, negative attitudes about women in medicine persisted. In 1905, the President of the Oregon State Medical Society stated:
hard study killed sexual desire in women, took away their beauty, brought on hysteria, neuroasthenia, dyspepsia, astigmatism and dysmenorrhea … Educated women could not bear children with ease because study arrested the development of the pelvis at the same time it increased the size of the child’s brain and therefore its head. This causes extensive suffering in childbirth. (in Bullough and Voght 1973)
In 1900, women comprised 10 percent of the students at 18 medical schools, 50 percent at Boston University, and 40 percent at Tufts University. Johns Hopkins opened its medical school in 1893 with the ﬁnancial help of women, who exacted the condition that women be admitted on the same terms as men, based on qualiﬁcations. By 1917, Dr. Florence Sabin became the ﬁrst woman full professor at that institution (Luchetti 1998).
Abraham Flexner, in his Carnegie Commission Report on the status of US medical education (1910), stated: ‘Medical education is now, in the United States and Canada, open to women upon practically the same terms as men. If all institutions do not receive women, so many do, that no woman desiring an education in medicine is under any disability in ﬁnding a school to which she may gain admittance.’ Further, he stated, ‘Now that women are freely admitted to the medical profession, it is clear that they show a decreasing inclination to enter it.’
Flexner’s Report established medicine as an academic discipline in the USA, with high standards for training and practice. This resulted in the closing of many medical schools, often those that admitted women. Thus, the number of female physicians in the USA leveled off at between 4 and 7 percent until the 1970s, a lower percent than in the vast majority of other countries.
Other countries did not experience this abrupt drop and continued to report higher percentages of female physicians. In 1965, for example, 7 percent of US physicians were women, in the Soviet Union 65 percent, in Poland 30 percent, in the Philippines 25 percent, in the German Federal Republic 20 percent, in Italy 19 percent, in the UK and Denmark 16 percent, and Japan 9 percent (Lopate 1968).
Medicine has been viewed as a male profession in the USA more than in most other countries. Some hypothesize that this occurred because medicine has had higher prestige and income than many other professions. It is also likely that science requirements were not considered appropriate for US women who were thought to be suited to caretaking, but not instrumental activities. The practice of medicine represents a melding of roles, the caretaking functions of physicians ﬁt the ‘traditional’ views of women’s roles, but the technological and instrumental aspects do not. Although cultures conceptualize these issues differently, in Cuba where gender stereotypes are disparaged, traditional roles for women in health care persist and 30–40 percent of physicians are women, while virtually all nurses and midwives are women.
The choices of specialty has remained constant since women were admitted to medical schools in the USA. Women have characteristically entered pediatrics, internal medicine, psychiatry, family practice, and, more recently, obstetrics and gynecology, anesthesiology, dermatology, radiology, pathology, and many medical subspecialties. The surgical ﬁelds remain sparsely populated by women.
Regardless of the specialty, academic and administrative appointments as well as other decision-making positions are almost exclusively held by men; women tend to be involved in direct patient care (90 percent of female physicians in the USA). In the 1970s, the fact that women assumed this role was used as an argument for increasing their numbers in medical school. They could be counted on to meet the health care needs of the population.
In countries where women have made signiﬁcant progress in the health ﬁelds, changes have occurred most often in times of war, physician shortages, or major cultural reorganization. In Russia, midwives proved effective doctors in the Russo-Turkish War of 1870, thus beginning the inﬂux of women into medical schools. After the 1917 revolution, the prestige of medicine declined in Russia, and women were admitted to medical school in great numbers. By 1940 62 percent of Soviet physicians were women. As elsewhere, Russian women held a disproportionately small number of senior positions (Nadelson and Notman 1995).
The large numbers of women in medicine in the former USSR, in low prestige positions, reduced the differentiation between doctors and paramedical workers. The feldscher (semiprofessional health worker or physician’s assistant) was a female role, and apparently remains so in Russia and the other former Soviet republics.
The rise of female health professionals in China occurred along with the reorganization of the medical care system and the society. About half of Chinese physicians are women. In 1950, 50,000 midwives were reeducated as local health workers or ‘barefoot doctors’ (usually women peasants who receive basic medical training and provide medical care to meet the needs of fellow workers).
The increase in numbers of women physicians in the early 1970s in the USA coincided with the civil rights and women’s movements. At the beginning of the twenty-ﬁrst century almost 50 percent of graduating medical students and over 20 percent of all physicians are women. There continue, however, to be disparities in the leadership roles of women in medicine. A 2000 report (Nonnemaker 2000) indicated that although women graduating from medical schools were more likely to enter academic careers, their numbers at higher academic levels were signiﬁcantly lower than expected and their rates of advancement were slower than men’s.
4. Women In Psychiatry
There are historical references to the care of the mentally ill from early classical times. Mental illness was generally framed in terms of religion and there were sanctuaries performing religious rites to treat people. As pagan faiths lost favor, there was a deterioration in the quality of treatment afforded the mentally ill, because mental illness was increasingly seen as caused by supernatural powers, evil spirits, or demons (Zilboorg 1941). It took many centuries before there was institutional care comparable to ancient times (Zilboorg 1941).
The ﬁrst ‘morotrophium’ or house for ‘lunatics’ is recorded in the Byzantine world in the fourth century CE. These institutions began to spread to other areas of the world, generally privately funded. Pilgrimages were made to shrines believed to eject evil spirits. One of the early morotrophiums (house for lunatics) was St. Dymphna, a home for mental healing run by women in 1200 CE.
Over the next several centuries asylums were established in many parts of Europe and the Middle East, often with the support of women. In the sixteenth century, the Sisters of Charity took in the mentally ill when hospitals refused to admit them (Tomes 1994). By the seventeenth century some French institutions began to train nurses to care for these patients. In general, however, care was punitive and often inhumane.
A seventeenth-century Swiss woman physician, Barabara von Roll pioneered in the treatment of mental illness and opened the ﬁeld of ‘psychosomatic medicine’ by documenting the connection between physical and mental health. (Brooke 1997).
By the eighteenth century mental illness received greater attention in Europe and the USA. Although the focus was primarily on nosology and categorization, some therapeutic approaches included bloodletting, purgatives, dousing in ice water, and placement of the patient in a spinning chair until the patient lost consciousness. Benjamin Rush, the founder of US psychiatry, was an advocate of the latter method since he believed that congested blood in the brain caused mental illness, and the movement would relieve it (Alexander and Selesnick 1966).
During the nineteenth century, wives of US physicians entertained asylum patients in their homes, to ‘calm a fevered mind’ (Tomes 1994). They were often responsible for the ‘moral’ atmosphere of the institutions and advocated respect and attention to promote recovery. Dorothea Dix pioneered efforts to care for the mentally ill and reform inhumane practices.
In the late nineteenth century, about 200 women physicians staffed US asylums (Lunbeck 1994). In 1880, Alice Bennett became the ﬁrst woman chief of a women’s division, Norristown State Hospital. Bennett’s unpopular and outspoken opposition to mechanical restraint and neglect of the chronically insane eventually caused her to lose her position.
By the twentieth century increasing numbers of women worked with the mentally ill. The development of psychoanalysis in Europe attracted many women who were important in the development of the ﬁeld. In 1923, the American Psychoanalytic Association admitted two women, Lucille Dooley and Marion Kenworthy. Karen Horney challenged psychoanalytic theory, and a school of psychoanalysis evolved around her work.
Over the next few decades, many notable women psychoanalysts emigrated from Europe to the USA. Prior to World War II, 30 percent of European and 20 percent of US psychoanalysts were women (Chodorow 1986). They contributed substantially to the growth and inﬂuence of psychoanalysis in the USA. Among the early women leaders were Clara Thompson, Hilda Bruch, Helene Deutsch, Phyllis Greenacre, Judith Kestenberg, Marianne Kris, Margaret Mahler, Edith Jacobson, Stella Chess, Frieda Fromm-Reichmann, and many others who pioneered as researchers and clinicians.
Grete Bibring became the ﬁrst woman to head a department of psychiatry and become a full professor at Harvard Medical School. She was at Beth Israel Hospital in Boston. Viola Bernard was the ﬁrst woman APA vice-president; she also led other psychiatric organizations and made pioneering contributions to social psychiatry.
Psychosomatics evolved in the 1930s with the signiﬁcant contributions of women, such as Therese Benedek and Helen Flanders Dunbar. Marion Kenworthy was notable in exerting an inﬂuence on the military, successfully facilitating an increase in the number of mental health units on army bases (Deutsch 1959). In addition, she was a founding member and president of the Group for the Advancement of Psychiatry and became the ﬁrst woman president of the American Psychoanalytic Association in 1958.
After World War II, women leaders emerged in organizations and academia, including Evelyn Ivey, Eveoleen Rexford, Helen Beiser, Jeanne Spurlock, Mildred Mitchell-Bateman, and June Jackson-Christmas. It is notable that the latter three were African-American.
Much of the leadership in the development of child psychiatry came from women, including those mentioned above. Melanie Klein developed internationally accepted theory concerning early life psychodynamic processes. Anna Freud contributed signiﬁcantly to the understanding of ego development.
The 1970s marked another increase in numbers of women in psychiatry, coinciding with the women’s movement in the USA. Still, women had few leadership roles although 20 percent of psychiatrists were women. In the 1980s and 1990s, women’s leadership increased. Carol Nadelson was elected the ﬁrst woman APA president in 1985, followed by Elissa Benedek and Mary Jane England. Carolyn Robinowitz became senior American Psychiatric Association Deputy Medical Director, and the ﬁrst woman psychiatrist medical school dean. The APA has had several women officers, including its ﬁrst women assembly speaker, Donna Norris. Other psychiatric organizations have had a few women leaders but have not developed female leadership in proportion to the increasing numbers of trained women psychiatrists.
Neuroscientist Nancy Andreasen was the ﬁrst woman editor of the American Journal of Psychiatry. Judith Rappaport became the head of child psychiatry at the National Institutes of Mental Health. In Canada, Judith Gold was the ﬁrst women president of the Canadian Psychiatric Association. In Australia, Beverly Raphael, the ﬁrst woman psychiatry chair, became the ﬁrst woman president of the Royal Australia New Zealand College of Psychiatry. Sarah Romans became the ﬁrst woman psychiatry chair in New Zealand. Felice Lieh Mak, chair of psychiatry in Hong Kong, was the ﬁrst woman elected president of the World Psychiatric Association, and Astrid Heiberg became the ﬁrst woman professor of psychiatry in Norway. Women psychiatrists continue to expand their leadership roles in many countries of the world, and to become signiﬁcant researchers in evolving areas of psychiatry. However, women’s roles in organizational and academic leadership continue to be small.
5. Female Leadership In Medicine And Psychiatry: The Twenty-ﬁrst Century
Although the number of women trainees in psychiatry in the USA approaches 50 percent, and there are substantial numbers of women in junior faculty positions in psychiatry, as in all areas of medicine, there are many fewer women at senior ranks than would be projected by the size of entering cohorts.
Women continue to make slower progress in academic psychiatry as in the rest of academic medicine. They often lack research training and rarely have the mentorship that will enable them to advance their careers. They are, less often than their male colleagues, offered research opportunities during training or at entry level academic positions, and they tend to be assigned clinical, teaching, and administrative tasks that are time-consuming and do not allow them to develop the necessary skills to enable them to progress academically. The pressures are greater for women interested in academic careers since they are in their peak childbearing years when they must also commit themselves to their career development.
Women in academic psychiatry, as in other ﬁelds of medicine, are less likely to have peer-reviewed grants or publications than men. Senior women in psychiatry in the USA are relatively productive in terms of research and publications, but they constitute only 5 percent of professors and 2 percent of department chairs in psychiatry. Controlling for relevant variables, women psychiatrists also earn less than men (Leibenluft 1999). This is not substantially different in other countries and in other medical ﬁelds.
It is interesting to note that the citation rate for women’s articles has been reported to be higher than it is for men (Sonnert and Holton 1996). One report also found that both men and women full-time faculty were equally career motivated and that marital and family status were not correlated with publication numbers. Being a parent, however, caused greater problems in academic productivity for women than for men (Carr et al. 1998). Women also had less institutional support. Compared to men with children, women with children had fewer publications. Lack of on-site and backup childcare, and other family leave policies presented signiﬁcant problems for women faculty with children. Women with children had greater dependent responsibilities but similar professional time allocated responsibilities. There were no signiﬁcant differences between the sexes for faculty without children (Carr et al. 1998).
Women experience a longer time to promotion than men. The difference in research productivity and publications, however, does not account for the large gender difference in promotion to senior ranks (Tesch et al. 1995, Tesch and Nattinger 1997).
Although childbearing and rearing remain key reasons for womens slower progress in their careers, there are other obstacles. Women’s commitment, qualiﬁcations, and capabilities are questioned and doubted more than men’s. Discrimination and the subtle harassment and demeaning of women continues to exist. Women are often related to in transferential roles. They are perceived and treated by many men as mothers, daughters, sisters, etc., making it difficult to also be a colleague and peer (Moss-Kanter 1977, Milwid 1982). This is also observed in group situations where women’s opinions have been observed to spark negative and resistant responses, and their credibility in positions of leadership is often questioned (Nadelson 1987, Reich 1989).
A 1965 report in the Harvard Business Review suggested that these views are deeply entrenched. They reported that half of the men surveyed were not comfortable working for a woman; one ﬁfth felt that women were temperamentally unﬁt to be leaders, and half of both men and women did not feel that women could succeed. Twenty years later the majority of men no longer felt that women were temperamentally unﬁt for management but the women continued to feel pessimistic about acceptance in the corporate world (Bowman et al. 1965, Sutton and Moore 1985).
Interestingly, an AAMC report (Bentsen 1998) stated that medical school deans, when questioned about the qualities necessary for their success, weighed interpersonal skills higher than any others, including academic and clinical experience, in their list of important qualities necessary for medical school leadership. They also highly ranked personality traits, managerial experience and taking pride in the accomplishments of others. Many of these traits are those characteristically attributed to women.
Men and women also have different perceptions of the need for female leadership. A survey at a medical school searching for a dean revealed that 99.9 percent of the women students and faculty and only 50 percent of the men thought that more women leaders were needed in medicine (Scadron et al. 1982). More current data on women in medical leadership implies that this attitude has not substantially changed. The usual reasons given for the lack of female leadership are that the numbers of women available are not sufficient, and/or that they are not motivated because of family responsibilities. The evidence suggests, however, that men and women in similar cohorts have different career trajectories, and that women are not promoted at the same rate as men, despite comparable qualiﬁcations (Tesch et al. 1995).
Clinical psychiatry has a rich history of female contributions and leadership. If the ﬁeld is to continue to evolve and expand its knowledge base, women must play a vital role in research. That 50 percent of US trainees are women suggests that the talents and potential contributions of this substantial group will be lost if only 50 percent, rather than all of them, are seen as potential future researchers.
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