History of Women in Psychiatry
http://www.100md.com
《精神病学术期刊》
And we could go on for days talking about the contributions being made during this period by women and minority groups.
—Dave Barry
Feminism is the radical notion that women are people.
—Popular bumper sticker
There is very little information about American women who practiced psychiatry prior to the last few decades. One could argue that this was because, until recently, there were very few women in the field. While that is certainly true for women in leadership positions, there have been female psychiatrists since the middle of the 19th century and not just as isolated oddities. It is significant that women psychiatric patients have received abundant historical attention (1–4) while an otherwise excellent recent survey of the history of American psychiatrists makes no mention of women at all (5).
Historians who have approached women’s history have used two different methods to study women, particularly in fields traditionally dominated by a male perspective or male practitioners. One approach is to search for women who might have been overlooked by previous accounts, especially accounts that relied on leaders in the field (who have often been male). This method can be limited, however, because information about individual practitioners is not always available. In addition, a focus on the few women about whom there is information does not help explain women’s role in the profession as a whole (6). Another approach is to try to understand the relationship between power and organizational change over time (7, 8), as well as the ways that power is related to assumptions about gender (9, 10). This broader attention to power helps us look beyond numbers to understand the context in which women of the past and present entered and practiced in psychiatry.
This article provides a preliminary account of women in psychiatry in the United States using both of these methods. Existing historical work on women practitioners in medicine in general is reviewed, along with some evidence about women’s role in psychiatry. In addition, an analysis is provided of the relationship between the changing structures of academic medicine and psychiatry and women in and out of the profession. Both of these perspectives will be used to stimulate suggestions about how women can have a greater presence in academic psychiatry in the future.
19TH CENTURY
At the beginning of the 19th century in the United States, there was no single, powerful medical profession. Instead, the political and popular spirit of the age rebelled against monopolies. American medical schools in this time period were frequently for-profit institutions, owned by the professors who had private practices on the side. The medical course was brief and often consisted only of lectures without patient contact (11). A variety of practitioners competed for the scarce resources of patient pay, and a wide array of medicines were available to patients (12). Allopathic medicine, the precursor to what we know of as modern medicine, was only one of a number of competitors in this time period. Indeed, allopathic medicine, which often consisted of aggressive bloodletting and purging (13), frequently lost in competition with water cure, homeopathy, and other treatments that were considered to be more tolerable (14, 15).
In this context of a broad marketplace for remedies, women often acted as practitioners in a variety of healing venues (16). First, women frequently attended each other during childbirth, either as friends or as seasoned advisors (17). In addition, women’s organizations were interested in health issues and advocated domestic medical knowledge (18). Further, women participated in several healing movements, such as Christian Science (founded by Mary Baker Eddy) (19), the water cure movement (20), and homeopathy. Before allopathic medicine was formalized and regulated in the 20th century, women often participated in the informal medical marketplace, although they were not permitted to enter regular medical schools until mid-century.
In the second half of the 19th century, women began to enter allopathic medical schools. The first woman to graduate from an American medical school was Elizabeth Blackwell in 1847. In the several decades after Blackwell paved the way, women began to enter the medical profession in increasing numbers, some traveling to Europe for more experience or a broader education (21). A number of women flourished in the homeopathic medical schools that were successful in the late 19th century. One of the ways in which a substantial number of women entered medicine was through the creation of women’s medical schools during this time period. By the 1880s, there were over a dozen schools devoted to women’s medical education (22). As several historians have pointed out, separate institutions for women helped women not only gain access to training but also allowed them to benefit from contact with women’s networks. Women’s medical schools provided women role models in faculty and alumnae, connections to training opportunities beyond medical school, and possibilities for faculty positions (23, 24).
The first generations of women in medicine did not claim equality and equal opportunity with men. Instead, they relied on the assumption that women were particularly interested in domestic concerns to argue that women were uniquely qualified to improve women’s and children’s health (25). At a time when ideas about modesty prevented male practitioners from doing thorough examinations of women, women physicians argued successfully that women patients needed trained women professionals to preserve their modesty. While women physicians went into a variety of specialties, the argument that women provided something special to medicine was frequently used until beginning of the 20th century. This argument allowed for the training of many women in medicine, but it did not help them obtain postgraduate education or professional organization affiliation. These difficulties were significantly worse for black women (26).
As will be discussed shortly, psychiatry as a specialty was organized around mental institutions (asylums) in the 19th century. Although there is little information about individual practitioners, it appears that women physicians obtained positions in asylums because of concerns about preserving modesty in women patients. Women were appointed physicians in asylums in the second half of the 19th century, often with the explicit purpose of acting as women patients’ gynecologists. Some women were able to act as autonomous heads of the women’s department, but most often women in asylums had several layers of male supervision. About half of asylums at the beginning of the 20th century employed women physicians (27). Women were not permitted to become asylum superintendents and were not admitted as members into the professional organization until well into the 20th century (28, 29).
MID-19TH TO EARLY 20TH CENTURIES
As sociologist Andrew Abbott has demonstrated (30), the process of professionalization in medicine (and its specialties) is characterized by groups of practitioners making claims to ownership of abstract knowledge in a particular area. As Abbott has described, these claims to knowledge are often made to compete with other groups. Other scholars have pointed out that successful professions develop critical elements: a professional organization, a journal, and a set of licensing requirements (31, 32). Psychiatry has undergone several professional revisions over the last century and a half, and has employed the method described by Abbott at each occasion. Part of the claim to abstract knowledge involves a claim that other groups are not qualified to practice or need to be supervised. This exclusion of others’ authority is more typical of organizations dominated by men. Indeed, historians of the female-dominated fields of social work and nursing have pointed out that the process of professionalization worked significantly differently in these organizations (33, 34).
As was discussed above, women entered medicine at a time when allopathic physicians had to compete with everyone else in an open marketplace. There was no organized medical profession, and very few effective medical organizations. Although the American Medical Association was founded in 1847 with the goal of improving the education and quality of American physicians (35), it was relatively powerless until well into the 20th century (36). In the context of this relative lack of authority, in the second half of the 19th century a new specialty emerged within allopathic medicine. More than half a century before medical specialties were particularly well-accepted by the rest of the medical profession (37), the physicians who practiced in asylums (the 19th-century precursors to mental hospitals) created a specialty organization in 1844. The Association of Medical Superintendents of American Institutions for the Insane (which would eventually become the American Psychiatric Association) gave social, cultural, and professional authority to asylum physicians (psychiatrists) by creating an organization to help lobby for funds, create an aura of professional expertise, and aid in the development of the specialty (28). Women were specifically excluded from membership in the professional organization of this specialty until the 20th century.
In the late 19th and early 20th centuries, allopathic physicians in general began to consolidate their authority and worked to create a monopoly over medical practice. In the late 19th century, some American medical schools had begun to lengthen their course of study, introduce bedside teaching, and utilize scientific studies in educational programs (11). The well-known Flexner Report in 1910, produced by Abraham Flexner at the behest of the Carnegie Foundation (38), both qualified programs based on their educational quality and highlighted the importance of physicians trained in university medical schools. Although the Flexner Report helped to improve standards in medical education early in the century, it also set the standards that funding sources (such as the Rockefeller Foundation) used when deciding where to send money. Further, it helped concentrate professional power in the hands of a small group of medical elites (39). As a result of the report, a number of medical schools (including most of the separate schools for women and blacks [40]) closed in the early 20th century. By this time, many regular medical schools had become coeducational, but the opportunities for women physicians began to shrink in the early part of the century (22). The way that medicine was defined in the 20th century, as a vigorous scientific enterprise, was in sharp contrast to the nurturing arguments women used to enter medicine in the 19th century.
EARLY TO MID-20TH CENTURY
Although women had made significant inroads into medicine in the 19th century, even to a limited extent in psychiatry, they were much less successful in the 20th century. In the early 20th century, and even more markedly after the 1920 passage of the Women’s Suffrage Amendment, the number of women physicians significantly declined. Some historians have attributed this decrease to discrimination on the part of regular medical schools. From the sharp decline in the percentage of female medical students in these years (a decline from 25% in 1890 to 3.1% in 1910 at the University of Michigan, for example), which was not entirely accounted for by a decline in women’s applications, it is probable that some discrimination existed (41). In the late 19th and early 20th centuries, there had been a shift away from arguments that women could provide something special because of their sex. Instead, the general tendency of women in medicine was to emphasize their abilities as doctors first (25). While this shift made sense for the generation of women that no longer had to break barriers to gain admission to schools, it also left women vulnerable to discrimination by placing them squarely in competition with men. Further, this shift away from women’s special contributions might have made the field less interesting to women who did not want to compete in a man’s world. In fact, the number of women applying to medical school significantly decreased. This decline follows the general trend of women’s declining involvement in public professions until after the women’s movement of the 1960s.
At the same time that the numbers of women in medicine were decreasing in general, psychiatry as a specialty was undergoing a significant shift. While psychiatry in the United States had in general benefited from the consolidation of power of allopathic physicians, psychiatry as a specialty came into a crisis in the early 20th century regarding its location of practice. Psychiatrists by the early 20th century were less interested in the institutions that had defined their specialty, and some argued that institutions did not help patients. In addition, asylum superintendents found that they were spending an inordinate amount of time on administration rather than patient care (28). The combination of the decline of institutional psychiatry with the gradual rise of psychoanalysis changed the practice of psychiatry by the middle of the century (42, 43). Psychiatrists shifted their attention from severely mentally ill patients to the ways in which everyday life was fraught with psychiatric consequences. Psychiatrists in the early 20th century were particularly interested in what they saw as the pathology of men and women violating gender norms (44). Well-known figures such as Karl Menninger popularized the idea that psychiatrists’ expertise on mental health was critical to American society (45).
By the end of World War II, psychiatrists enjoyed an unprecedented amount of public authority and approval, due in part to their perceived success in defining and treating mental illness in soldiers (46). During World War II, psychiatrists began to be more influential in shaping American ideas about mental health and illness. William Menninger and his psychiatric colleagues, many of whom were trained as analysts, were heavily involved in mental health screening of military draft recruits during the war. They were also involved in treating soldiers for neuropsychiatric casualties during the war. Psychiatrists successfully lobbied for the National Mental Health Act of 1946, which provided for the foundation of the National Institute of Mental Health (founded in 1949) (47).
MID-20TH CENTURY
By the middle of the 20th century, psychiatry was increasingly dominated by psychoanalysis. Some notable women, such as Anna Freud and Melanie Klein, made significant contributions to psychoanalytic theory (48, 49). Still, psychoanalysis and its different schools based much theory on narrow, and sometimes conflicting, ideas about women’s nature, their role in their families, and their relationship to mental illness (50). By mid-century, psychiatrists were arguing that bad mothering produced schizophrenia (an idea that was popularized as "Momism," the term coined to explain the hazard of overprotective mothers in the post-war era) (51). Psychiatrists of this time period did not question the relationship between women’s social roles and their mental health.
As scholars and activists in the 1960s and 1970s pointed out, one of the ways that psychiatry became popularized was by articulating a view of mental health based on gender norms (52, 53). Indeed, the women’s movement in this time period identified psychiatric and psychological views of women as a significant method by which women’s roles had been constrained by American society (54). Betty Friedan’s path-breaking book, The Feminine Mystique (55), articulated women’s protest toward psychiatrists for telling them who they needed to be in relationship to their husbands and their children.
1970S TO THE PRESENT
The second major wave of women entered medicine in the 1970s, and the numbers have been increasing ever since. Interestingly enough, women in the 1970s and 1980s used some arguments to enter the field that sounded very similar to those used in the 19th century. Observers of modern medicine in the 1960s and 1970s began to comment that medicine was becoming too technical and that physicians were not sufficiently attuned to the human element with their patients. Women who entered the profession during this time period often argued, as observers did around them, that women had something to add to medicine by recalling the human touch that had been lost with the increasing scientific and technical processes within medicine (22). Female psychiatrists began to point out the pitfalls of men making assumptions about women’s lives in the context of psychiatric treatment (56, 57). In addition, women in psychiatric training began to articulate some of the conflicts and challenges that faced women in medicine as well as the workplace as a whole (58, 59).
By the late 1970s, new medications (60) and new diagnostic categories (61) helped propel psychiatry into a new biological age. Perhaps not coincidentally, women began to enter psychiatry in large numbers at that time. A review of the numbers of women who completed the psychiatry certification for the American Board of Psychiatry and Neurology in the years 1950, 1960, 1970, 1980, 1990, and 2000 reveals that the major increases in women in the field have taken place in the last quarter century (see Figure 1). Further, women entered the specialty at a time when many women patients specifically begun to request women physicians. But although women have clearly become important to the profession, issues remain for women such as representation in places of authority (such as the American Psychiatric Association) and the slow rate at which women are progressing through the ranks of academic medicine (62).
THOUGHTS FOR THE FUTURE
As a number of investigators have pointed out, the increase in the number of women entering medicine or psychiatry has not led to as dramatic an increase in women in leadership positions as would be expected given the numbers (63, 64). Women in academic medicine have continued to experience difficulties making it up the rungs of the academic ladder (65), although there has been progress in the last decade (66). Adding numbers of women in and of itself might not have resulted in meaningful change, suggesting that climate (67) and preconceived notions about women (68) might be continuing to act as subtle or even overt obstacles to women’s progress.
So if the sheer numbers of women have not helped achieve gender equity within the profession, we should reassess women’s roles within the profession, particularly in the training of new generations of psychiatrists. Although it is risky to contemplate a return to arguments about women’s special contributions (69), women could provide a number of useful perspectives to the profession as a whole. As a number of scholars have pointed out, the influx of women into the profession, along with feminist critiques of traditional medicine, have generated new discussions on proper relationships between doctors and patients (70). Does the presence of women make a difference in the traditional doctor-patient relationship? Could women’s perspectives help with the problem of the gap between empathy and the DSM approach toward mental illness (71)? How will gender affect working relationships between psychiatrists and other members of the health care team such as nurses and social workers? And what impact will female psychiatrists in leadership positions have on issues relating to the diagnosis and treatment of women patients?
Women in teaching roles in psychiatry can do a great deal to break down gender barriers. Faculty women can be role models and provide formal, and informal (72), mentoring to women and male medical students and residents. As some female psychiatrists pointed out in the 1970s, early generations of female psychiatrists had to make their way through heretofore untraveled territory for women as they completed training, often without any encounter with faculty women (73). The current increasing presence of women in psychiatry, particularly in teaching roles, can help all students and residents explore the widening possibilities for women and men in psychiatry.
We need to understand the ways in which traditional gender roles have affected men and women in a variety of settings, from individual physician-patient relationships to the relationships between faculty members and Chairs/administration to the relationship between physicians and society. Are female psychiatrists less likely than men to seek leadership positions in the profession, either by personal inclination, alternative priorities (such as families), or because women tend to define themselves as powerless (74)? Are women not seeking advanced academic positions because of a lack of women role models and mentors who show them that women can be successful in psychiatry? Based on existing historical work in psychiatry, it will not be enough to simply shift logistical details to have a meaningful increase in women in psychiatry (although some shifting clearly needs to occur for women and men to embark on challenges such as research careers [75]). Women in teaching roles are an important resource to women in training and the profession as a whole. As psychiatry continues to redefine itself in relation to society and the rest of medicine, it would be a good time to assess the role of gender in these professional transitions.
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—Dave Barry
Feminism is the radical notion that women are people.
—Popular bumper sticker
There is very little information about American women who practiced psychiatry prior to the last few decades. One could argue that this was because, until recently, there were very few women in the field. While that is certainly true for women in leadership positions, there have been female psychiatrists since the middle of the 19th century and not just as isolated oddities. It is significant that women psychiatric patients have received abundant historical attention (1–4) while an otherwise excellent recent survey of the history of American psychiatrists makes no mention of women at all (5).
Historians who have approached women’s history have used two different methods to study women, particularly in fields traditionally dominated by a male perspective or male practitioners. One approach is to search for women who might have been overlooked by previous accounts, especially accounts that relied on leaders in the field (who have often been male). This method can be limited, however, because information about individual practitioners is not always available. In addition, a focus on the few women about whom there is information does not help explain women’s role in the profession as a whole (6). Another approach is to try to understand the relationship between power and organizational change over time (7, 8), as well as the ways that power is related to assumptions about gender (9, 10). This broader attention to power helps us look beyond numbers to understand the context in which women of the past and present entered and practiced in psychiatry.
This article provides a preliminary account of women in psychiatry in the United States using both of these methods. Existing historical work on women practitioners in medicine in general is reviewed, along with some evidence about women’s role in psychiatry. In addition, an analysis is provided of the relationship between the changing structures of academic medicine and psychiatry and women in and out of the profession. Both of these perspectives will be used to stimulate suggestions about how women can have a greater presence in academic psychiatry in the future.
19TH CENTURY
At the beginning of the 19th century in the United States, there was no single, powerful medical profession. Instead, the political and popular spirit of the age rebelled against monopolies. American medical schools in this time period were frequently for-profit institutions, owned by the professors who had private practices on the side. The medical course was brief and often consisted only of lectures without patient contact (11). A variety of practitioners competed for the scarce resources of patient pay, and a wide array of medicines were available to patients (12). Allopathic medicine, the precursor to what we know of as modern medicine, was only one of a number of competitors in this time period. Indeed, allopathic medicine, which often consisted of aggressive bloodletting and purging (13), frequently lost in competition with water cure, homeopathy, and other treatments that were considered to be more tolerable (14, 15).
In this context of a broad marketplace for remedies, women often acted as practitioners in a variety of healing venues (16). First, women frequently attended each other during childbirth, either as friends or as seasoned advisors (17). In addition, women’s organizations were interested in health issues and advocated domestic medical knowledge (18). Further, women participated in several healing movements, such as Christian Science (founded by Mary Baker Eddy) (19), the water cure movement (20), and homeopathy. Before allopathic medicine was formalized and regulated in the 20th century, women often participated in the informal medical marketplace, although they were not permitted to enter regular medical schools until mid-century.
In the second half of the 19th century, women began to enter allopathic medical schools. The first woman to graduate from an American medical school was Elizabeth Blackwell in 1847. In the several decades after Blackwell paved the way, women began to enter the medical profession in increasing numbers, some traveling to Europe for more experience or a broader education (21). A number of women flourished in the homeopathic medical schools that were successful in the late 19th century. One of the ways in which a substantial number of women entered medicine was through the creation of women’s medical schools during this time period. By the 1880s, there were over a dozen schools devoted to women’s medical education (22). As several historians have pointed out, separate institutions for women helped women not only gain access to training but also allowed them to benefit from contact with women’s networks. Women’s medical schools provided women role models in faculty and alumnae, connections to training opportunities beyond medical school, and possibilities for faculty positions (23, 24).
The first generations of women in medicine did not claim equality and equal opportunity with men. Instead, they relied on the assumption that women were particularly interested in domestic concerns to argue that women were uniquely qualified to improve women’s and children’s health (25). At a time when ideas about modesty prevented male practitioners from doing thorough examinations of women, women physicians argued successfully that women patients needed trained women professionals to preserve their modesty. While women physicians went into a variety of specialties, the argument that women provided something special to medicine was frequently used until beginning of the 20th century. This argument allowed for the training of many women in medicine, but it did not help them obtain postgraduate education or professional organization affiliation. These difficulties were significantly worse for black women (26).
As will be discussed shortly, psychiatry as a specialty was organized around mental institutions (asylums) in the 19th century. Although there is little information about individual practitioners, it appears that women physicians obtained positions in asylums because of concerns about preserving modesty in women patients. Women were appointed physicians in asylums in the second half of the 19th century, often with the explicit purpose of acting as women patients’ gynecologists. Some women were able to act as autonomous heads of the women’s department, but most often women in asylums had several layers of male supervision. About half of asylums at the beginning of the 20th century employed women physicians (27). Women were not permitted to become asylum superintendents and were not admitted as members into the professional organization until well into the 20th century (28, 29).
MID-19TH TO EARLY 20TH CENTURIES
As sociologist Andrew Abbott has demonstrated (30), the process of professionalization in medicine (and its specialties) is characterized by groups of practitioners making claims to ownership of abstract knowledge in a particular area. As Abbott has described, these claims to knowledge are often made to compete with other groups. Other scholars have pointed out that successful professions develop critical elements: a professional organization, a journal, and a set of licensing requirements (31, 32). Psychiatry has undergone several professional revisions over the last century and a half, and has employed the method described by Abbott at each occasion. Part of the claim to abstract knowledge involves a claim that other groups are not qualified to practice or need to be supervised. This exclusion of others’ authority is more typical of organizations dominated by men. Indeed, historians of the female-dominated fields of social work and nursing have pointed out that the process of professionalization worked significantly differently in these organizations (33, 34).
As was discussed above, women entered medicine at a time when allopathic physicians had to compete with everyone else in an open marketplace. There was no organized medical profession, and very few effective medical organizations. Although the American Medical Association was founded in 1847 with the goal of improving the education and quality of American physicians (35), it was relatively powerless until well into the 20th century (36). In the context of this relative lack of authority, in the second half of the 19th century a new specialty emerged within allopathic medicine. More than half a century before medical specialties were particularly well-accepted by the rest of the medical profession (37), the physicians who practiced in asylums (the 19th-century precursors to mental hospitals) created a specialty organization in 1844. The Association of Medical Superintendents of American Institutions for the Insane (which would eventually become the American Psychiatric Association) gave social, cultural, and professional authority to asylum physicians (psychiatrists) by creating an organization to help lobby for funds, create an aura of professional expertise, and aid in the development of the specialty (28). Women were specifically excluded from membership in the professional organization of this specialty until the 20th century.
In the late 19th and early 20th centuries, allopathic physicians in general began to consolidate their authority and worked to create a monopoly over medical practice. In the late 19th century, some American medical schools had begun to lengthen their course of study, introduce bedside teaching, and utilize scientific studies in educational programs (11). The well-known Flexner Report in 1910, produced by Abraham Flexner at the behest of the Carnegie Foundation (38), both qualified programs based on their educational quality and highlighted the importance of physicians trained in university medical schools. Although the Flexner Report helped to improve standards in medical education early in the century, it also set the standards that funding sources (such as the Rockefeller Foundation) used when deciding where to send money. Further, it helped concentrate professional power in the hands of a small group of medical elites (39). As a result of the report, a number of medical schools (including most of the separate schools for women and blacks [40]) closed in the early 20th century. By this time, many regular medical schools had become coeducational, but the opportunities for women physicians began to shrink in the early part of the century (22). The way that medicine was defined in the 20th century, as a vigorous scientific enterprise, was in sharp contrast to the nurturing arguments women used to enter medicine in the 19th century.
EARLY TO MID-20TH CENTURY
Although women had made significant inroads into medicine in the 19th century, even to a limited extent in psychiatry, they were much less successful in the 20th century. In the early 20th century, and even more markedly after the 1920 passage of the Women’s Suffrage Amendment, the number of women physicians significantly declined. Some historians have attributed this decrease to discrimination on the part of regular medical schools. From the sharp decline in the percentage of female medical students in these years (a decline from 25% in 1890 to 3.1% in 1910 at the University of Michigan, for example), which was not entirely accounted for by a decline in women’s applications, it is probable that some discrimination existed (41). In the late 19th and early 20th centuries, there had been a shift away from arguments that women could provide something special because of their sex. Instead, the general tendency of women in medicine was to emphasize their abilities as doctors first (25). While this shift made sense for the generation of women that no longer had to break barriers to gain admission to schools, it also left women vulnerable to discrimination by placing them squarely in competition with men. Further, this shift away from women’s special contributions might have made the field less interesting to women who did not want to compete in a man’s world. In fact, the number of women applying to medical school significantly decreased. This decline follows the general trend of women’s declining involvement in public professions until after the women’s movement of the 1960s.
At the same time that the numbers of women in medicine were decreasing in general, psychiatry as a specialty was undergoing a significant shift. While psychiatry in the United States had in general benefited from the consolidation of power of allopathic physicians, psychiatry as a specialty came into a crisis in the early 20th century regarding its location of practice. Psychiatrists by the early 20th century were less interested in the institutions that had defined their specialty, and some argued that institutions did not help patients. In addition, asylum superintendents found that they were spending an inordinate amount of time on administration rather than patient care (28). The combination of the decline of institutional psychiatry with the gradual rise of psychoanalysis changed the practice of psychiatry by the middle of the century (42, 43). Psychiatrists shifted their attention from severely mentally ill patients to the ways in which everyday life was fraught with psychiatric consequences. Psychiatrists in the early 20th century were particularly interested in what they saw as the pathology of men and women violating gender norms (44). Well-known figures such as Karl Menninger popularized the idea that psychiatrists’ expertise on mental health was critical to American society (45).
By the end of World War II, psychiatrists enjoyed an unprecedented amount of public authority and approval, due in part to their perceived success in defining and treating mental illness in soldiers (46). During World War II, psychiatrists began to be more influential in shaping American ideas about mental health and illness. William Menninger and his psychiatric colleagues, many of whom were trained as analysts, were heavily involved in mental health screening of military draft recruits during the war. They were also involved in treating soldiers for neuropsychiatric casualties during the war. Psychiatrists successfully lobbied for the National Mental Health Act of 1946, which provided for the foundation of the National Institute of Mental Health (founded in 1949) (47).
MID-20TH CENTURY
By the middle of the 20th century, psychiatry was increasingly dominated by psychoanalysis. Some notable women, such as Anna Freud and Melanie Klein, made significant contributions to psychoanalytic theory (48, 49). Still, psychoanalysis and its different schools based much theory on narrow, and sometimes conflicting, ideas about women’s nature, their role in their families, and their relationship to mental illness (50). By mid-century, psychiatrists were arguing that bad mothering produced schizophrenia (an idea that was popularized as "Momism," the term coined to explain the hazard of overprotective mothers in the post-war era) (51). Psychiatrists of this time period did not question the relationship between women’s social roles and their mental health.
As scholars and activists in the 1960s and 1970s pointed out, one of the ways that psychiatry became popularized was by articulating a view of mental health based on gender norms (52, 53). Indeed, the women’s movement in this time period identified psychiatric and psychological views of women as a significant method by which women’s roles had been constrained by American society (54). Betty Friedan’s path-breaking book, The Feminine Mystique (55), articulated women’s protest toward psychiatrists for telling them who they needed to be in relationship to their husbands and their children.
1970S TO THE PRESENT
The second major wave of women entered medicine in the 1970s, and the numbers have been increasing ever since. Interestingly enough, women in the 1970s and 1980s used some arguments to enter the field that sounded very similar to those used in the 19th century. Observers of modern medicine in the 1960s and 1970s began to comment that medicine was becoming too technical and that physicians were not sufficiently attuned to the human element with their patients. Women who entered the profession during this time period often argued, as observers did around them, that women had something to add to medicine by recalling the human touch that had been lost with the increasing scientific and technical processes within medicine (22). Female psychiatrists began to point out the pitfalls of men making assumptions about women’s lives in the context of psychiatric treatment (56, 57). In addition, women in psychiatric training began to articulate some of the conflicts and challenges that faced women in medicine as well as the workplace as a whole (58, 59).
By the late 1970s, new medications (60) and new diagnostic categories (61) helped propel psychiatry into a new biological age. Perhaps not coincidentally, women began to enter psychiatry in large numbers at that time. A review of the numbers of women who completed the psychiatry certification for the American Board of Psychiatry and Neurology in the years 1950, 1960, 1970, 1980, 1990, and 2000 reveals that the major increases in women in the field have taken place in the last quarter century (see Figure 1). Further, women entered the specialty at a time when many women patients specifically begun to request women physicians. But although women have clearly become important to the profession, issues remain for women such as representation in places of authority (such as the American Psychiatric Association) and the slow rate at which women are progressing through the ranks of academic medicine (62).
THOUGHTS FOR THE FUTURE
As a number of investigators have pointed out, the increase in the number of women entering medicine or psychiatry has not led to as dramatic an increase in women in leadership positions as would be expected given the numbers (63, 64). Women in academic medicine have continued to experience difficulties making it up the rungs of the academic ladder (65), although there has been progress in the last decade (66). Adding numbers of women in and of itself might not have resulted in meaningful change, suggesting that climate (67) and preconceived notions about women (68) might be continuing to act as subtle or even overt obstacles to women’s progress.
So if the sheer numbers of women have not helped achieve gender equity within the profession, we should reassess women’s roles within the profession, particularly in the training of new generations of psychiatrists. Although it is risky to contemplate a return to arguments about women’s special contributions (69), women could provide a number of useful perspectives to the profession as a whole. As a number of scholars have pointed out, the influx of women into the profession, along with feminist critiques of traditional medicine, have generated new discussions on proper relationships between doctors and patients (70). Does the presence of women make a difference in the traditional doctor-patient relationship? Could women’s perspectives help with the problem of the gap between empathy and the DSM approach toward mental illness (71)? How will gender affect working relationships between psychiatrists and other members of the health care team such as nurses and social workers? And what impact will female psychiatrists in leadership positions have on issues relating to the diagnosis and treatment of women patients?
Women in teaching roles in psychiatry can do a great deal to break down gender barriers. Faculty women can be role models and provide formal, and informal (72), mentoring to women and male medical students and residents. As some female psychiatrists pointed out in the 1970s, early generations of female psychiatrists had to make their way through heretofore untraveled territory for women as they completed training, often without any encounter with faculty women (73). The current increasing presence of women in psychiatry, particularly in teaching roles, can help all students and residents explore the widening possibilities for women and men in psychiatry.
We need to understand the ways in which traditional gender roles have affected men and women in a variety of settings, from individual physician-patient relationships to the relationships between faculty members and Chairs/administration to the relationship between physicians and society. Are female psychiatrists less likely than men to seek leadership positions in the profession, either by personal inclination, alternative priorities (such as families), or because women tend to define themselves as powerless (74)? Are women not seeking advanced academic positions because of a lack of women role models and mentors who show them that women can be successful in psychiatry? Based on existing historical work in psychiatry, it will not be enough to simply shift logistical details to have a meaningful increase in women in psychiatry (although some shifting clearly needs to occur for women and men to embark on challenges such as research careers [75]). Women in teaching roles are an important resource to women in training and the profession as a whole. As psychiatry continues to redefine itself in relation to society and the rest of medicine, it would be a good time to assess the role of gender in these professional transitions.
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