Women and Psychiatry Research Paper

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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