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Ask the Mental Health Expert Archives 2001-2004

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DSM Gender Bias

Q. Do you think there is a gender bias in the DSM? Do you think gender bias exists in the diagnosis of mental illnesses in general? How would you suggest we deal with this?

A. I don't believe that DSM-IV diagnostic criteria were constructed on the basis of gender bias. However, the history of some psychiatric disorders has certainly been influenced by cultural and sex-based factors, including certain prejudices and preconceptions about women. The classic example is what used to be termed hysteria--a word that is derived from the ancient Greek notion that a "wandering of the womb" produced symptoms that we would now term somatoform in origin.

Indeed, our current categories of Somatoform Disorders include several disorders (e.g., Somatization Disorder, Conversion Disorder) that appear to be greatly over-represented in women. To some degree, this may reflect a preponderance of male clinicians labeling their female patients as hysterical--but the picture is not so simple.

For example, Hypochondriasis is one of the DSM-IV Somatoform Disorders that appears to be represented equally in men and women. If gender bias were at work in any systematic way, why would clinicians apply it to some Somatoform Disorders but not others? Similarly, while the rates of unipolar depression are twice as high in women as in men, this is not true in bipolar disorder. Again--if gender bias were operating in any systematic way, one would expect both disorders to reflect this. (Most likely, there are biological factors explaining the different unipolar vs. bipolar rates).

Where bias of a sort has existed, I believe it has been in the area of medication research. For too long, this has often excluded women. In part, this has been justified (rationalized?) on the basis of female endocrine factors that researchers did not want to deal with, or on the basis of risk to women who might possibly be pregnant or soon wish to be. But I don't think that's the whole story. I suspect there were some unconscious factors relating to stereotypes about women. In any case, I think it is clearly psychiatry's task to address the specific concerns of women, including those relating to both biological and sociocultural differences between men and women.

For example, premenopausal women have monthly alterations in sex hormones that may affect the metabolism of certain psychotropic medications. Women in the peri-menopause (5-6 years prior to menopause) face not only certain hormonal factors that may predispose them to depression, but a variety of familial and interpersonal stressors that men may not always face; e.g., changes in the mothering role as women move into menopause and children move out of the house. (Of course, many men also face similar issues). In short, while DSM-IV diagnoses may not be colored by gender bias, the mental health field as a whole has a long way to go before the needs of women (and men) are addressed adequately.

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