Have you ever had a day when so many coincidences happened that they seemed like something more? I had a day like that recently.
On the way to work one morning, I heard a story on NPR about reality television shows. The point was that interest in such shows is waning, except for an upcoming one called "When Women Rule the World."
That thought made me wonder whether women currently "rule" psychiatry in the United States. All of our present American Psychiatric Association officers are women, including the president-elect. The chair of the task force charged with revising our ethical principles also is a woman.
Does--or will--the gender of our leaders make any difference in psychiatry or in psychiatric ethics?
A Question of Compassion
At lunch later that day, I attended a lecture by Joan Cassell, Ph.D., a medical anthropologist who wrote "The Woman in the Surgeon's Body" (Cambridge: Harvard University Press, 1998). The title of the lecture was, "Are Women More Compassionate?"
The talk was fascinating, as was the makeup of the audience. There were about 50 women there and only 4 men. One of the men had to be there, another was the tech help, a third was a psychologist friend of mine who worked in community medicine. I later learned that he attended because in recent years all of the residents he taught have been women. As a result, he thought that his lectures--such as those on eating disorders--needed to be better tailored to address women's issues.
Dr. Cassell started the lecture by discussing her research on female surgeons. Her initial question was whether they are as "arrogant, daring, and warlike" as male surgeons. Her findings showed that sometimes they are and sometimes they're not, largely depending on whether they're relating to nurses, patients, or peers.
She also discussed the extent to which many gender characteristics are influenced by social forces and history. In response to a question from me, Dr. Cassell expressed uncertainty about whether biologic differences are a major factor, because those differences are so difficult to study.
As to the original question of whether women are more compassionate, Dr. Cassell answered, "I wish." She found very little evidence of more compassion among female surgeons, or among other female physicians, for that matter.
She went on to wonder whether the social forces of male power, the rise of evidence-based medicine, and increasing time constraints make the expression of compassion more difficult for all physicians.
What Impact Do Hormones Have?
Before I went on to my next clinic, I checked my files on female psychiatrists. I quickly saw that the number of women in psychiatry in the last 30 years has increased dramatically. However, according to a review article I pulled out called "History of Women in Psychiatry," no clear effect of women on psychiatry could be determined (Academic Psy. 2004;28:337-43).
Female psychiatrists, however, did feel the need for a support group. The Association of Women Psychiatrists is now celebrating its 25th anniversary.
At this point, I was off to see some women of a different sort. I have been the medical director for about 15 years of a clinic that specializes in the treatment of gender disorders, especially transsexualism.
It had always been striking to me, to the staff, and to most of the patients, that after some patients are placed on hormones of the opposite gender, some of their personality characteristics seem to change. At the clinic, staff often comment that patients who are making the transition to become men tend to become more aggressive, and those making the transition to become women generally are more concerned with social relationships.
Back home again, I spoke briefly by telephone with my 2 1/2-year-old granddaughter. As a grandparent of three young children, I am beginning to notice some gender differences I hadn't paid as much attention to as a parent. For quite some time, this particular grandchild has been very interested in princesses, apparently without any encouragement from her parents or other family members.
At first I was bemused with my granddaughter's princess preoccupation. After all, this gave me an opportunity to buy her princess clothes. Then, more recently, I read about how widespread this princess trend has become in the last several years among young girls. Some wonder whether this is a regressive development from the feminism of Gloria Steinem and the popularity of "Desperate Housewives." At least these modern princesses seem more independent and multicultural than those in classic tales.
Developing an Ethic of Care
After that conversation, I started to consider how this princess preoccupation affected the development of my granddaughter's values. I know the literature on moral development fairly well, having taught it to students over the years. I've also wondered how psychiatrists fare with their own moral development.
The major original research on this topic is by Lawrence Kohlberg, Ph.D. His research, most of which focused on boys, seemed to build on the gender development theories advanced by Jean Piaget, Ph.D. Those theories implied that women's moral development could get stunted because of their continued identification with and attachment to their mothers.
Along came Carol Gilligan, an assistant to Dr. Kohlberg, who challenged his conclusions with her book, "In a Different Voice: Psychological Theory and Women's Development" (Cambridge: Harvard University Press, 1982). She concluded that women's values might be different from--not better or worse than--men's, that women tend to value the connections of interpersonal relationships more, and that women therefore are more likely to develop an ethic of care over an ethic of justice.
Subsequent to the lecture I read an article by a Dr. Sidney Bloch, an Australian psychiatrist, in which he described the new moral philosophy of care ethics (Psychiatric An. 2007;37:787-91). Better known in nursing, this philosophy uses a mother's feelings toward her child as a model to provide care to those feeling vulnerable.
This is not to say that Ms. Gilligan's ideas are now universally accepted. The entire topic might be more complex. Recent studies and books looking at possible brain differences in development between girls and boys run in the hundreds. Some suggest that girls might have a larger hippocampus, which would contribute to better multitasking memory. The brains of boys tend to have more areas devoted to spatial-graphic processing. Nevertheless, socialization and opportunity might prove to be bigger influences than physiology.
One can finish reading these studies feeling uncertain about where things stand. Men, women, and their brains are much more alike than they are different.
Generally, the studies do not try to attribute any influence to hetero- or homosexuality. Indeed, there are concerns about political correctness and stereotyping, which can elicit intense reactions toward anyone writing on the subject of innate differences between the sexes. Some people reacted vehemently against such theories advanced by Dr. Louann Brizendine in "The Female Brain" (New York: Bantam Press, 2007). When Dr. Brizendine, a neuropsychiatrist, was asked how she had endured the intense negative reactions, she answered: "Some days, I need ovaries of steel" (Yale Medicine 2008;42:41-2).
Power and Policy
I attended another lecture at the Medical College of Wisconsin right before I finished the article about Dr. Brizendine. This lecture, delivered by author Ellen Bravo, recounted some of the challenges faced by women as they pursue leadership positions. In her talk, called "Forget the Glass Ceiling: It's Time to Redesign the Building," Ms. Bravo pointed out that the United States is one of the few countries in the world with no paid family leave. The others are Liberia, Papua New Guinea, and Swaziland ("Paid Leave for Maternity Is the Norm, Except in ..." New York Times, Oct. 6, 2007). She also advocated for changes in the workplace for men and women that she hopes will benefit children.
In addition, Ms. Bravo recommended more male and female chief executive officer partnerships, akin to many parental partnerships. That reminded me that my coleadership with a woman at a community mental health center was the best leadership experience I think I ever had.
As I waited for sleep that night, I returned to my question from the beginning of the day. Do some of these differences in moral development or brain function influence women as leaders, or does socialization cause them to be like the men they succeed--especially if they need to adopt male values to rise to the top?
I had noticed that the July 2007 Reader's Digest did not have any female leaders among the four mentioned in the article, "World's Most Dangerous Leaders." Historically, though, when women have been in power, they often have been as ruthless and tough as men.
Perhaps it makes sense to look for answers in the animal kingdom. According to Dario Maestripieri, author of "Macachiavellian Intelligence: How Rhesus Macaques and Humans Have Conquered the World" (Chicago: University of Chicago Press, 2007), rhesus monkeys are a very successful primate species in terms of inhabiting more of the earth than other monkeys or apes. Bonobos are less successful in terms of numbers but form a congenial society led by females who use their sexuality to resolve social conflict.
Envisioning a More Ethical Way
So: Do women rule in psychiatry?
Rule is a strong word. After all, national leadership by women in our field is a recent development. The APA's officers are currently all women, but those positions have only 1-year terms, as it turns out. The APA's medical directorship, which happens to be held by a man, is a paid, ongoing position. In addition, the current board of directors happens to be split between the genders.
I do wonder what the current APA leadership would think of the princess phenomenon. I hope that my granddaughter, after reading or watching "The Wizard of Oz," identifies with some of the leadership qualities of Dorothy and her companions: a brain that wants to learn and use good judgment, a heart of compassion, the courage to acknowledge and address real dangers, and the will to foster those qualities in others.
The problems facing our beloved specialty remain numerous. Some seem to be getting worse, if not intractable. We continue to fight problems: with managed care, psychologists' quest for prescribing privileges, and the stigma against psychiatry; these struggles seem never ending. Perhaps leadership that places more emphasis on care and nurture of colleagues and patients would make a significant difference.
One certainly can dream that emerging female leadership will take a different and more effective ethical way.
DR. MOFFIC is a professor of psychiatry and behavioral medicine, as well as family and community medicine, at the Medical College of Wisconsin, Milwaukee. He can be reached at email@example.com.
BY H. STEVEN MOFFIC, M.D.