Running head: GENDER BIAS

Gender Bias in Classification of Mental Disorders Melissa Hisel Emporia State University LI 810 December 14, 2011 Professor Charles Seavey

GENDER BIAS

Gender Bias in Classification of Mental Disorders

Each standard and category valorizes some point of view and silences another This is not inherently a bad thingindeed it is inescapable. But it is an ethical choice, and as such it is dangerousnot bad, but dangerous. (Bowker & Starr, 1999)

Introduction The Diagnostic and Statistical Manual of Mental Disorders (DSM), which is currently undergoing its fifth revision, is a categorical classification system developed by the American Psychiatric Association to define and classify human behavior, so as to distinguish those behaviors that may be viewed as pathological or abnormal. Patients are evaluated within five multi-dimensional areas, or Axes of Disorder which are then grouped into classes. Each disorder is assigned a diagnostic code. A subject presenting with symptoms that are clinically significant, as indicated by impairment or distress, can be diagnosed as suffering from that disorder. (American Psychiatric Association, 2000) The current edition, DSM-IV, describes 374 disorders and encompasses the mental health disorders both of children and of adults; it lists any known causes, demographic statistics, the typical age of onset, and the research and treatment for each disorder. A person may be diagnosed with a clinical syndrome, a developmental or personality disorder, a combination of disorders, or a subtype assigned to conditions with greater symptomatic specificity. These conditions are categorized by degree of severity: mild, moderate, or severe. In recovery, patients may be diagnosed as in partial or full remission. Conditions are further categorized in light of the patients physical condition as it relates to mental health, stressors impacting mental health, and

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global functioning. (APA, 2000) It should be noted that the inclusion of physical maladies in the realm of mental disorder has been a cause for controversy, and questions as to whether psychiatry is overstepping the boundaries of traditional medicine have been raised. (Houts, 2000) Mental disorders are tangible and genuine, and a great many people suffer from their ill effects and benefit from their treatment. That said, diagnoses of mental disorders sometimes have an element of subjectivity, yet great power to influence peoples lives. These classifications are widely used beyond the arena of physicians and insurance companiesthey are also referenced in the judicial system, by social agencies, and by social policymakers. When used in the judicial system, DSM can affect the outcomes of cases related to child custody, criminal liability, fitness to stand trial, mental capacity, personal independence and other matters with significant implications. The results of an inappropriate diagnosis or flaws in the construction of the DSM can be personally disastrous for individuals and families. Being diagnosed with a mental disorder can have stigmatizing effects that have a vast detrimental impact upon a persons life: to be diagnosed with a mental disorder from the DSM is to be labeled by society as internally faulty or dysfunctional. (Kutchens & Kirk, 1997) Hospitals and physicians bill for treatments based on diagnostic codesinsurance companies will only reimburse for treatments associated with a coded diagnosis. With millions of dollars at stake for physicians and drug companies, the potential exists for the DSMs ethical waters to be a little muddy. The DSM is written by physicians who profit from the diagnosis of patients and whose research is funded in large part by pharmaceutical companies. (Tiefer, 2006) It is entirely obvious that, while unethical, manipulation of the classification system (whether by exaggeration of patient symptoms or by the invention of non-existent disorders) could financially

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benefit the doctors and the psycho-pharmaceutical companies who sponsor the production of the DSM and its research. The public expects the classification of mental disorders to be objective and genderneutral, but examination of certain disorders reveal what could be a bias toward generating disorders and medicalizing the normal behaviors of those who have less social power and who are intrinsically less likely to question authoritypeople who may have no idea how farreaching the impact of a diagnosis can be. For some time, there has been controversy surrounding the frequent adjustments made in the DSM, including the regular addition and removal of disorders. Some question the reliability of a classification system that undergoes such frequent revision: can it be trusted? The frequent changes seem to support the view that many diagnoses are social constructions without scientific evidence to support their inclusion in the classification. The most well-known instance of this was the decision to remove Sexual Orientation Disturbance, 302.0 (otherwise known as Homosexuality) from the classification in 1973, and later the utterly bewildering Ego-dystonic Homosexuality, 302 the condition of being homosexual and considering ones homosexuality a mental illness, which was eliminated in 1987. (Davis, 1997) This reflects not a change in scientific evidence, but a rather social/cultural bias against homosexuality, which had been less acceptable when earlier incarnations of the DSM were developed. The decision to remove the disorder was based not on evaluation of evidence but rather by a vote (5,584 favored removal and 3,819 opposed) of members during a meeting of the American Psychiatric Association. (Zur & Nordmarken, 2010) The eventual removal of the disorder roughly paralleled the growing sociocultural acceptance of variation in sexual orientation. This suggests the possibility of other social and cultural biases in the DSM and begs

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the question: which disorders in the current edition are real, and which are constructs reflecting not pathological abnormality in individuals but instead a societys unspoken beliefs about gender, sexuality, culture, and ethnicity? In the United States, the DSM is the authority on what is viewed as normal in human behavior, and it both represents the norms of society and profoundly influences them. There are multiple concerning areas of bias in the DSM. In this paper, I will focus on gender bias and the controversy surrounding the medicalization of womens bodies, as exemplified by the classification of symptoms related to the menstrual cycle and female sexuality as dysfunction: Premenstrual Dysphoric Disorder, the category Female Sexual Dysfunction, specifically reviewing Female Orgasmic Disorder. DSM: The Backstory The first classification system for mental illness used in the United States was published in 1918 by the American Medico-Psychological Association, entitled The Statistical Manual for the use of Institutions for the Insane. The origins of the present manifestation of the DSM stem from psychiatric taxonomies created by psychiatrists during and after World War IIfor the treatment of soldiers who were manifesting symptoms that did not align with the prevailing disorder construct that had been developed for use in state mental institutions. At that time, there were 3 distinct taxonomies for mental illness: the Standard Classified Nomenclature of Disease, the Armed Forces Nomenclature (otherwise known as Medical 203), and the Veterans Administration Nomenclature (a modified version of Medical 203). Additionally, there existed a general medical classification system: the International Statistical Classification, which was used for statistical reporting, and which contained its own categories of diagnoses not entirely compatible with any of the other taxonomies. (Houts , 2000)

GENDER BIAS In 1950, work began on the first edition of the DSM with the goal of creating a single

comprehensive classification system for mental disorders. It was created in a way similar to the current process used for revisionsby a committee of psychiatrists, the Committee on Nomenclature and Statistics, with input drawn from questionnaires sent to practitioners in the field. DSM-I was published in 1952. The revision initiated in 1965, was known as DSM-II, it was completed by a small committee, and reviewed by 120 psychiatrists. It was published in 1968. (Kutchins & Kirk, 1997) Outcry by activists who opposed the inclusion of homosexuality as a mental disorder in DSM-II, concerns about the quality of research connected to existing diagnoses and pressure from insurance companies that required more explicit diagnoses for payment of claims prompted the next revision, DSM-III. This revision reflected a more dramatic change in psychiatry and involved the addition of many more disorders as well as explicit lists of criteria required for making a diagnosis. No new studies into the reliability of these classifications were conducted, (Kutchins & Kirk, 1997) even though this new version included 30 new possible diagnostic categoriesof which three in particular appeared to reflect a male-dominant gender bias: Late Luteal Phase Dysphoric Disorder, Paraphilic Rapism and Masochistic Personality Disorder. Late Luteal Phase Dysphoric Disorder was defined as a disorder characterized by severe premenstrual symptoms. Paraphilic Rapism was defined as disorder characterized by mental abnormalities that predispose individuals to commit rape. Masochistic Personality Disorder was defined as a disorder characterized by someone who remains in relationships in which others exploit, abuse, or take

GENDER BIAS advantage of him or her, despite opportunities to alter the situation." (Herman, 1992)

The proposed inclusion of these disorders caused considerable uproar, as the implications reflect a male biasthe first being that at least once a month most or all women are mentally ill, the second being that violence against women is, at best, no fault of the man or, at worst, the fault of the woman who allows herself to be mistreated. It suggests that in psychology, our problems are typically biological rather than sociological. After public protest from feminists and review by APA committee members, only Paraphilic Rapism was incorporated into DSM-IV as a vetted disorder. The others remain in the publication, appended as diagnostic categories approved for further study. Critics assert that the underpinnings of these disorders reflect the leanings of the doctors behind the DSM. An overwhelmingly male professional body is the authority self-designated to make weighty decisions in the classification of female behavior and bodily functions. The profession of psychiatry is distinctly white (84%) and male (75%). According to the APAs women in psychiatry interest group webpage on historical demographic information, throughout the 60s and 70s, only about 12% of psychiatrists were women. By the 80s this number had only risen to about 19%. (www.psych.org) The revision of the manual began once again in 1988, although this time the revision was controversial with some practitioners, who were left wondering if enough knowledge had changed to warrant another review. The motivation for frequent revisions appeared suspect as the publication of each new edition (current copies retail for $115) and accompanying

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supplementary guidebooks provide a good source of revenue for the APA. The rapid advance in the speed of scientific progress in the DSM was called into question. The challenge posed by the rapid expansion of mental disorders observed over the past half century has been that such a rapid expansion of a domain of science was inconsistent with most other fields that relied on classifications and nomenclatures as part of their science. (Houts, 2000) More disturbing is the suggestion that the addition of disorders provided novel opportunities for the pharmaceutical industry, with which many members of the DSM review committees have been associated. (Kutchens & Kirk, 1997) In 1994, DSM-IV was published with a few hundred changes. Today, DSM-V is in the works with an anticipated publication date sometime in 2013. The Medicalization of Womens Bodies The theory of medicalization is a contention that some normal human behavior and experiences are increasingly classified by the medical profession as medical problems that require treatment from professionals. The medicalization of womens bodies is the view that some normal behavior and functions of womens bodies are viewed as medical problems by a male-dominated medical establishment that reflects the sexism of a patriarchal society that seeks to equate the feminine with illness. As Maya Lavie-Ajayi (2005) puts it, this overweening medicalization of womens sexuality serves rather to reinforce their subjugation by the medical hegemony and their exploitation by the pharmaceutical industry. What follows is an overview of three of the disorders that have been accused of reflecting the greatest gender bias against women: the aforementioned Late Luteal Phase Dysphoric Disorder (now renamed Premenstrual

GENDER BIAS Dysphoric Disorder), as well as the category of disorders relating to female sexual function, Female Sexual Dysfunction and Female Orgasmic Disorder.

Premenstrual Dysphoric Disorder 311 It is medically established that from menarche until menopause, females experience hormonal fluctuations throughout all phases of the monthly menstrual cycle that cause mental and physical changes in women. (Offman, 2004) Whether these changes are normal physiological functions of the female reproductive system or indications of a mental defect is the question. In DSM-III, Late Luteal Phase Dysphoric Disorder (LLPDD) was categorized as an Unspecified Mental Disorder. According to the DSM, symptoms of the disorder are: Depressed mood or dysphoria Anxiety or tension Unstable, rapidly changing emotions Irritability Decreased interest in usual activities Concentration difficulties Marked lack of energy Marked change in appetite, overeating or food cravings Hyper insomnia or insomnia Feeling overwhelmed Other physical symptoms, i.e. breast tenderness, bloating

Consider these symptoms manifesting in a man: would eating too much, or acting irritably or angrily, elicit the diagnosis of a mental disorder? It seems unlikely. The APAs subcommittee charged with re-evaluating the disorder concluded that very little research supported the existence of a premenstrual illnessand the most relevant research was

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preliminary and methodologically flawed. Consequently in DSM-IV, the disorder was renamed Premenstrual Dysphoric Disorder and was moved to the appendix as a depressive disorder not otherwise specified, grouped with other disorders in need of further study. (Offman 20) And yet PMDD was still assigned a diagnostic code and is referenced in the manuals main text. There is nothing preventing psychiatrists from diagnosing a patient with PMDD, except for the threat of non-payment by an insurance provider. (Christler & Caplan, 2002) How could a theoretical dysfunction that could not be empirically founded make its way into the definitive classification scheme of mental illness? One reason may have been the possibility that PMDD is an entirely socially constructed disorder that has become so entrenched in popular culture that few would doubt its existence. Because natural functions of the female body may be inconvenient to men, they have sought to medicalize it and find a way to chemically alter it into a more pleasant condition. The pharmaceutical industry has little reason to object: with a potential market of nearly all the American women between the ages of twelve and fifty-five, the pharmaceutical treatment of premenstrual symptoms could be hugely lucrative. An example of this is the direct marketing and renaming of Prozac as Sarafem for use under a new DSM diagnosis of Premenstrual Dysphoric Disorder. (Zur & Nordmarken, 2010) Eli Lilly, the manufacturer of Prozac, wrapped the drug in pink and purple packaging and renamed it Sarafem, intended to sound similar to seraphim, which is a type of angelsuggesting perhaps that Prozac could make these crazy women angels? (Chrisler & Caplan, 2002) It is crucial to reinforce that changes do occur in womens moods and behavior as related to hormonal changesbut hormonal change is not the only reason a woman may experience the symptoms of PMDD. Other factors affect the emotions of women of childbearing age. Perhaps

GENDER BIAS because women are socialized to be caretakers, they may experience more stress than men or perhaps they cope with stress differently. The experience of stress should not equal mental illness. Christler and Caplan (2002) suggest that PMDD may also serve as a scapegoat for women who behave in ways that are considered socially unbecoming of a lady. Rather than admitting to anger, frustration, or exhaustion, some women may blame the fact that they are premenstrual. Rather than admitting to depression, they embrace Premenstrual Dysphoric

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Disorder, which for some may sound less embarrassing. The willingness of women to diagnose themselves with PMDD rather than address underlying causes of those symptoms can surely do more harm than good, and can only serve to legitimize the notion that women act erratically at least part of the time (researchers have variously indicated the length of PMDD symptoms as lasting from 5 days to 3 weeks out of every month). (Chrisler & Caplan, 2002). Female Sexual Dysfunction 625.8 Female Orgasmic Disorder 302.73 The area of female sexual dysfunction has drawn similar controversy for reflecting not an actual biological disorder but rather socially constructed views about how women ought to behave. A 1999 study reported in the Journal of the American Medical Association claimed 43% of women between the ages of 18 and 59 experience some form of sexual dysfunction. (Lauman, Paik, & Rosen) Can it be that nearly half of all women are sexually dysfunctional? The implication of dysfunction is that there exists a counterbalancing normhowever, DSM provides no medical definition of normal sexual function for women. Leonore Tiefer (2006), associate clinical professor of psychiatry at both the New York University School of Medicine and Albert Einstein College of Medicine, has criticized these disorders of female sexuality as designed to

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make the social and political factors that affect womens sexual lives invisible by placing the burden of normality on women themselves. After eliminating the possibility of physiological problems creating symptoms, a psychiatrist might apply the category of Female Sexual Dysfunction to any woman whose sexual experience encompasses any of the following: an inability to perform or reach an orgasm, painful sexual intercourse, a strong repulsion of sexual activity, or an exaggerated sexual response cycle or sexual interest (APA, 2000) The disorders of female sexual dysfunction described in DSM seem to position the female sexual experience as identical both physically and emotionally to those experiences of men, and any deviation from the male norm represents a female deficiency or illness. DSM also fails to take into account the effect of relationship issues in the female sexual experiencefor women, sex does not occur in a vacuum removed from emotion. Female sexual function can be affected by relational difficulties. Female Orgasmic Disorder is a mental disorder characterized by the absence of orgasm with sexual intercourse. Feminist scholar Annie Potts (2002) coined the phrase orgasmic imperative, or the notion that Western society views orgasm as an essential element of the female sexual experience. However, data shows something entirely different: that many women do not relate orgasm with sexual satisfaction.(Lavie-Ajayi, 2005). Potts suggests that orgasm is not the ultimate goal of sex for all women at all times. The importance placed on female orgasm is an example of male norms being imposed upon the female experience. Classifying the absence of male sexual norms in females as a mental illness seems a type of insanity itself. Instructing woman that they should experience sex in a way very similar to their male counterpart can leave women with confusing expectations and unnecessary frustration ultimately leaving them feeling personally inadequate.

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Like many other disorders in DSM, the category of female sexual dysfunction provides ample opportunities for pharmaceutical profiteering. Documentary filmmaker Liz Caneer, maker of Orgasm, Inc., a documentary film on female sexual dysfunction, suggests that the potential for profit was the inspiration behind the creation of the category: Pfizer and a number of other drug companies sponsored the first meetings on FSD. In the end, 18 of the 19 authors of the definition of the disease had ties to 22 drug companies. This definition was extremely broad: Almost any sexual complaint you have, whatever causes it, will fall into this disease category. (Kelly, 2011)

Reflections of the DSM in Popular Culture

Question: Why is it called PMS? Answer: Because mad cow disease was already taken. Genuine mental illness is a serious matter, and yet in popular culture it is often the subject of jokes or referenced flippantly. A person may be colloquially labeled crazy, nuts, or off their rocker, but there is serious stigma that accompanies being diagnosed with a mental disorder, and it is veiled only thinly by jokes and other cultural reference to madness. When it comes to PMS and PMDD, the popular media present PMS as a medical label explaining almost any fluctuating disturbance of a womens well-being in the reproductive years. This labeling is influenced by cultural assumptions about the role and behavior of women. (Blake, 1995) The effects of this categorization of behavior as a disorder can be observed in our humor, our music, movies, magazines and on television. For example, season 3, episode 8 of the television sitcom Roseanne (1990) is entitled PMS, I love you. The episode chronicles a 24-hour period in which main character Roseanne,

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played by comedian Roseanne Barr, terrorizes her family and friends because of her monstrous premenstrual symptoms. Roseannes television husband, Dan, characterizes Roseannes PMS as being like a rollercoaster ride with Sybil at the switch. (Sybil was notorious case of a woman diagnosed by her psychiatrist as having 13 different personalities created by her terrible childhood, a.k.a. Disassociative Identity Disorder, 300.14) The female character Crystal attempts to explain her own premenstrual symptoms to Roseannes sister Jackie: Crystal: Just before my time of the month, when my hormones start acting up, I'm good for one solid day of pure mean. Jackie: You? Crystal: Oh, yeah. One time I went around and busted a streetlight for every man who ever broke my heart. Dan: I remember, the great blackout of '84 R&B singer Mary J. Blige has a song entitled PMS with the lyric: And I don't need you to remind me See cause PMS Is talkin no all right now if you understand, understand where I'm comin from Sing along, PMS This is the worst part of everything The worst part of being a woman is PMS Premenstrual disorders have captured the public imagination and have become part of the hilarious notion that women are hysterical nags who are, clearly, nuts. Popular media also echo the clichs about sexuality and gender that the DSM has made official. In 2001 sisters Laura and Jennifer Berman (a urologist and sex therapist, respectively) appeared on the Oprah Winfrey talk show to discuss the 1999 study on female sexual dysfunction, presenting as fact, the contested

GENDER BIAS statistic that 43% of women are sexually dysfunctional and proclaiming something ought to be

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done about it. Jennifer Berman recently published a self-help book in the same vein, entitled, It's not him, it's you: How to take charge of your life and create the love and intimacy you deserve. Dr. Berman also hosts a reality television program where she provides intensive sex therapy on camera. The Oprah.com website currently features articles on female sexual dysfunction, indicating that some experts believe female orgasmic disorder is the hardest disorder to treat. (Ricciotti, 2003) The wide dissemination of information about these conditions and their appearance in popular culture can lead women to self-diagnosis and acceptance of these disorders as absolute fact.

Conclusion Much of that which is published in the DSM becomes almost immediately part of American culture or, as Antoni Gramsci would have put it, spontaneous consent. Alia Offman and Peggy Kleinplatz (2004) described the way the DSM melds with culture as scientific facts are created in a social context and become embedded in popular beliefs.(Offman 22) The members of the American Psychiatric Association who are responsible for creating, assigning, and treating the diagnosis of mental illness could certainly be viewed as some of societys official intellectual elite, with a median income of $175,000, (www.medscape.com), getting to define who is well and who is brokenand in so doing, fuel the capitalist machine with profits born of the invention of endless diagnoses and endless treatments and cures. There is an axiom attributed to the sociologist William Isaac Thomas known as the Thomas Theorem, which says if people define things as real, then they are real in their consequences. This may well be true in the many cases in the Diagnostic and Statistical Manual

GENDER BIAS of Mental Disorderswhere the tendency is to place all pathology within the individual and

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disregard the possible impacts of political and societal factors contributing to human behaviors. The possibility that the bias that underlies some of the disorders included in the DSM will seep into everyones lives, and the possibility that our prejudices will wind up on the pages of the DSM, are real. These notions that women are crazy at least part of the time and that a womans sexual drive and preferences should be the same as a man will have long-lasting effects that may never be fully understood.

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APPENDIX A
Axis I:

Clinical Syndromes Disorders are grouped into one of 16 classes: Disorders usually first diagnosed in infancy, childhood, or adolescence Delerium, dementia, and amnestic and other cognitive disorders Mental disorders due to a general medical condition Substance-related disorders Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Somatoform disorders Factitious disorders Dissociative disorders Sexual and gender identity disorders Eating disorders Sleep disorders Impulsecontrol disorders Adjustment disorders Personality disorders

The Diagnosis Examples of Disorders: Depression Anxiety Female Sexual Dysfunction 311 300 302.73

Axis II: Developmental Disorders Developmental disorders are those presenting early in life like mental retardation, autism spectrum disorders, etc. Personality disorders are persistent syndromes affect the patients interactions with the world.

Personality Disorders

Axis III Physical Conditions Axis IV Psycho-social /Environmental Stress

Physical illnesses, injuries or other disabilities which affect a persons mental state

These are Life events that can impact the disorders of the first two axes and are rated by severity.

Axis V Global Functioning

A system of rating how well a person functions overall in their life.

GENDER BIAS References

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Tiefer L (2006) Female Sexual Dysfunction: A Case Study of Disease Mongering and Activist Resistance. PLoS Med 3(4): e178. doi:10.1371/journal.pmed.0030178 Zur, O. and Nordmarken, N. (2010). DSM: Diagnosing for Money and Power" Summary of the Critique of the DSM. Retrieved 12/4/11 from http://www.zurinstitute.com/DSMcritique.html.