Is There Such a Thing as a Normal Woman? Part 1: Sexism in Psychiatric Diagnosis
Paula Caplan, Ph.D.
Note: Part 1 is about sexism in psychiatric diagnosis. Part 2, to appear in the next issue of the Bulletin, is about sexism in relation to mother-blame and psychological/psychiatric theory and research, with suggested solutions for these realms. Portions of this article are based on the author’s September 28, 1999, keynote address of the same title to the Department of Health and Human Services-sponsored New England Conference on Women and Mental Health, Hartford, CT.
Even this far into the 21st century, if one examines psychiatric diagnoses, stereotypes and myths about and expectations of mothers, and classic theories of psychological development, it is hard to find any possibilities for women to be considered normal. Instead, they are usually considered pathological or otherwise deficient.
The ways that psychiatric diagnoses are conceived, constructed, and applied leave the field wide open for sexism and indeed for every conceivable form of bias. Mother-blame in clinical journals and mother-blame as hate speech result in the pathologizing of virtually anything that mothers might do. And classic theories of psychological development and designs of research questions and methodologies have often been profoundly sexist. None of this is surprising, since the vast majority of the world continues to be pervaded by sexism, so it naturally shapes virtually every realm.
Sexism Due to Lack of Science in Psychiatric Diagnoses
The Diagnostic and Statistical Manual of Mental Disorders, often called the therapist’s Bible, is widely used to pathologize all women (and many men). It is a product that is a multi-million-dollar business, because it has been translated into two dozen languages for global use, and it is marketed by its publisher, the American Psychiatric Association (APA), as a scientifically-based document. The APA’s profits come not only from publication of the manual itself but also from sales of a variety of related books and other products. I was a consultant to two committees that produced DSM-IV, but I resigned after learning of the profoundly unscientific way the manual was put together and the dishonesty of its head and many of its members about the lack of science and the harm it causes.1 What I saw as an insider was that, when junk science can be described in a way that supports the aims of the select few who make the final decisions, it is presented as good science, and when well-done research conflicts with their aims, they ignore, distort, or lie about it. I have said that that process should be called "Diagnosisgate" for these reasons.2 (See ISEPP's position on the DSM here).
To give just one rather representative illustration of how unscientific the manual is (for far more examples, see citation in Endnote1), let us consider how the DSM authors dealt with their idea of creating a category now called Premenstrual Dysphoric Disorder. That category, according to the DSM committee's own published information, would apply to at least a half-million North American women.3 The category first went into the DSM at a time when Robert Spitzer, then DSM head and one of the originators of this category, acknowledged in a press conference that psychiatrists had no cure to offer for this disorder beyond the nutritional, vitamin, and self-help suggestions published in the pages of women's magazines. However, he said that the category needed to go into the manual so that psychiatrists could find out how to help women who suffered from "it". The scientific basis (or its lack) was not really examined until seven years later, when the next edition of the DSM was being prepared. At that time, DSM-IV head Allen Frances had cannily appointed an all-woman committee to evaluate the research, and they were longtime experts on the subject, most or all of whom received money from Big Pharma. The PMDD committee wrote a report approximately 125 pages long and including a review of more than 400 research articles. It looked impressive.4 In their own summary, the committee said outright that almost none of the papers was relevant to the question of whether there is a premenstrual mental disorder. Many of the papers were instead related to such premenstrual physical experiences as bloating, breast tenderness, and food cravings -- or even to reports of increased irritability, for instance, but by no means to anything one might conceivably consider a "mental illness". The committee said that the few reports that were relevant were "preliminary" and had many methodological problems. On that basis, one might have expected the committee to tell Dr. Frances that there was no scientific justification for claiming there is a premenstrual mental illness. Instead, they reported that they could not reach a consensus.
Frances then announced that he had appointed two other people to decide the fate of this category, but he refused to name those people. I telephoned him, said the debate about this category had perhaps become unnecessarily adversarial, and suggested that we try together to focus on the welfare of the women who might be given this label, since both his group and opponents of the category were presumably most concerned about those women. I pointed out that I had given his PMDD committee documentation of the harm that had already been caused to women who had received this label. I said it would be reassuring if he could present some evidence at least that more women had been helped than harmed by this diagnosis. He responded, "Well, of course, there's no way of knowing that." But of course, there is a way of knowing that. That is what scientific research is for, and scientific research is supposed to be the basis for decisions about the DSM.5
Ultimately, under media pressure, Frances announced the names of the two persons who would decide the fate of the PMDD category. Psychiatrist Nancy Andreasen was a longtime advocate of the notion that all emotional problems are caused by brain disorders and had served on DSM committees with Spitzer, one of the category's inventors. Psychiatrist A. John Rush specialized in research about “depression” and had received Big Pharma funding for research about it. This pair recommended that the category be included in the DSM-IV and that it go not just in the appendix that was said to be for disorders requiring further study but also in the main text of the manual, which is supposedly reserved for well-supported categories. Further, they said it should be listed under Depressive Disorders -- even though, astonishingly, one did not have to be depressed to meet the PMDD criteria. (But remember, A. John Rush received Big Pharma funding to study “depression.”) This was particularly disturbing in view of the fact that it has been documented that women who report feeling upset premenstrually are significantly more likely than other women to be in abusive or other upsetting life situations. Therefore, diagnosing them as premenstrually mentally ill leads us in the wrong direction, away from focusing on the real sources of their problems.
Around that time, the DSM people began to claim – though evidence on this point was appallingly poor, and there was even evidence disproving it – that “antidepressant” drugs were the most important treatment for women given this label, and committee members accompanied Eli Lilly staff to a meeting where they persuaded the FDA to approve repackaging and renaming (in pink and purple) of Prozac to be called Sarafem and prescribed for women labeled with PMDD.6
When women tell me they feel badly premenstrually, I believe them. I know that hormonal changes can affect one's feelings. But so, for instance, can a sprained ankle, and sprained ankle is not included as a mental illness in the DSM, nor are the vast majority of other physical problems.
What Allen Frances and his colleagues did with the science related to "PMDD" is just one example of how fast and loose they played with the research, a pattern that leads to other problems. If one imagines the enterprise of psychiatric diagnosis as a sphere, consider that the DSM marketers claim it is filled with good science, but we know that is not true. If one removes from that sphere all of what is wrongly called good science, it leaves a vacuum. What goes into a void where there is no objectivity? Every conceivable form of subjectivity and bias. It is unsurprising, then, that sexism – as well as racism, classism, ageism, heterosexism and homophobia, and others – pervades the creation and application of psychiatric labels.7
Harm from Psychiatric Diagnoses
The DSM is probably the single most powerful source of support for the medical model of emotional anguish, with the strikingly similar psychiatric listings in the International Classification of Diseases adding still more force. It is deeply worrying that use of the medical model for emotional problems increases the likelihood of therapists unthinkingly prescribing psychotropic drugs (inappropriately, without obtaining fully-informed consent and/or without explaining to the person the full range of possibly helpful options), even electroshock, and ignoring the potentially negative consequences of applying a diagnostic label. The vast range of kinds of harm that begin with the labels includes the person's loss of custody of their children, loss of employment, loss of health insurance or skyrocketing of premiums on the grounds that the person has a pre-existing condition (the mental illness), and legal rights to make decisions about what happens to them, such as whether to have electroshock, take medication, and be physically confined, isolated, or restrained. Other adverse consequences of labeling include the dehumanizing of the labeled person and creation of a we/they world, in which therapists are more likely to feel superior to and qualitatively different from the people they are supposed to help. These are not inevitable consequences of labeling, but they are common ones.
Vast numbers of women (and men) who have real but undiagnosed physical health problems are inaccurately diagnosed as having mental disorders instead. Some physicians are quick to assume that any woman with complaints of any sort is hysterical, dependent, and attention-seeking and thus mentally ill. Other physicians' intentions may be more honorable, but when their training has not included the physical symptom picture presented by a given patient, they mistakenly conclude that nothing physical can be wrong and that therefore the problem can only be psychological. These phenomena account for many women being regarded as mentally disordered.
Many well-meaning therapists tell me that they believe they minimize risk from diagnosis by classifying all of their patients as having Adjustment Disorder, because it sounds so innocuous. However, a lawyer told me the following story about a client of his. The client, a woman who had recently moved to his state to begin a graduate program in psychotherapy, was told during the first week of classes by the program director that any student who had not been a therapy patient should seek some therapy sessions right away, just to see how it felt. The rationale was, "Soon you will be a therapist, so you need to have that experience of being a patient." The obedient student went promptly to a walk-in clinic at the local hospital and explained to the psychiatrist on duty why she was there. The psychiatrist agreed to see her for some sessions, during which they discussed anything that was bothering her, such as feeling lonely after having moved to a new place where she knew no one. Subsequently, the patient was in a vehicle accident and incurred physical injuries, for which she was treated at the same hospital. She was bewildered to receive a letter from her health insurance company, in which she was told they would not pay her medical bills from the accident because she had lied to them on her insurance application form. When she contacted them to protest that she had not lied, they replied that she had denied that she had a mental illness on the form when she applied to their company for insurance. "But I don't have a mental illness," she replied. The insurance company employee said that she clearly did have a mental illness, because her hospital chart showed that the psychiatrist had given her a DSM label. "But the psychiatrist knew I wasn't there because of a mental illness," she protested. That did not matter. The insurance company officials claimed that, simply by virtue of some therapist's having assigned her a DSM label (which the therapist likely did so that the insurance company would pay for the therapy), this woman was now irrevocably considered mentally ill. What power the DSM has! It is far too often erroneously assumed that anything in the DSM is true and that any therapist who uses a label from that manual is using it accurately.
I am aware that some people feel that receiving a label, or receiving a label and then psychotropic medication, has been extremely helpful to them, and I do not question that. But in general, psychiatric labeling tends to narrow our vision of the causes of women's and men's pain and anguish and of the ways we might help.
Sexism and Specific Diagnoses
The DSM is the most influential basis for how we as a society decide who is normal, but the very foundation of the book is nebulous. "Mental illness" is a construct, and even the DSM authors acknowledge the impossibility of creating a good definition of it. When that overarching construct is ill-defined, how can each of the hundreds of categories and subcategories of alleged mental illness have any validity? Here follow just a few examples of labels that were constructed and/or are applied in sexist ways – Post-traumatic Stress Disorder, Borderline Personality Disorder, Self-defeating Personality Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, and Premenstrual Dysphoric Disorder.
Post-traumatic Stress Disorder used to be the "normal reaction" in the DSM, because it was described as likely to develop in anyone who had experienced major trauma. However, Dr. Allen Frances in DSM-IV removed the statement that the criteria are normal reactions to an abnormal situation, and the statement was not restored in DSM-5. This is devastating for battered, raped, or severely emotionally and verbally abused women as well as for others, such as people who have been traumatized by war, because it means that deeply human reactions to trauma are classified as mental illness at the drop of a hat.8 This is not only inaccurate but also severely damaging, because in addition to struggling with the effects of trauma, the labeled person now has to grapple with feeling something is wrong with them for not being “over it” yet.9
Borderline Personality Disorder is a label often given to victims of battering, abuse, and severe harassment -- most often women -- making it another classification that conveys the messages that “You should get over it” and “You are seriously defective, probably with a chemical imbalance in your brain.”10 From my own experiences listening to many traditional therapists, I have observed that it is a label they often give to patients they dislike.
Self-defeating Personality Disorder appeared in the appendix for categories requiring further study in DSM-III-R but not in subsequent editions. It was a slightly masked title for what was originally called “Masochistic Personality Disorder” and was to be applied to people who, for instance, put others’ needs ahead of their own and settled for less when they could have more. The danger of this category was especially great for women, who are traditionally socialized to fit these patterns, and even more for victims of wife battering, rape, and child sexual abuse, who are more likely to be women.11 The absence of the term from the current manual by no means prevents practitioners from using this label – or even if not using the label itself, interpreting women’s suffering as caused by a sick enjoyment of the abuse, failure, deprivation, or other harm they suffer. In addition, the use in the current manual of terms like “unspecified” or “other” disorders in practice allows the professional to call anything at all a mental disorder.
The sexism in the DSM is illustrated by the fact that there is no male equivalent in the DSM of either Premenstrual Dysphoric Disorder (for instance, no Testosterone-Based Aggressive Disorder) or Self-defeating Personality Disorder (since Self-defeating Personality Disorder is in many ways a somewhat exaggerated form of traditional female socialization, a male equivalent might be called John Wayne Syndrome or Macho Personality Disorder). Sociologist Margrit Eichler and I decided, for educational and consciousness-raising purposes, to design an alleged mental disorder we called Delusional Dominating Personality Disorder (DDPD), the consequences of a somewhat exaggerated form of traditional male socialization.12 We designed DDPD using the DSM format and submitted it to the DSM committee for inclusion in DSM-IV. We pointed out that not all men suffer from DDPD and that some women do. We also noted that DDPD is frequently seen in major military and political leaders and the heads of large corporations. For brevity’s sake, I shall only list here the first four of the 14 proposed criteria for DDPD. They are:
1. Inability to establish and maintain meaningful interpersonal relationships.
2.Inability to identify and express a range of feelngs in oneself (typically accompanied by an inability to identify accurately the feelings of other people).
3. Inability to respond appropriately and empathically to the feelings and needs of close associates and intimates (often leading to the misinterpretation of signals from others).
4. Tendency to use power, silence, withdrawal, and/or avoidance rather than negotiation in the face of interpersonal conflict or difficulty
(The full list of criteria is included in Caplan, 1995, cited in endnotes.)
We created the category more than two decades ago, and I began to speak about it in lectures. Every time I read the full list of criteria to any group of any kind, as I read the first few, people would laugh. As I read the next few, they would fall silent and appear to be listening carefully. By the time I would get to the last ones, they were shouting out things like, "I KNOW people like this! Why aren't they considered a problem?!" Needless to say, the DSM committee gave no sign that they even considered it for inclusion in the manual. Although virtually everything that women may do can qualify for "mental disorder" according to the DSM, traditionally-socialized masculine behavior that often causes pain, physical harm, and even physical illness in people who meet DDPD criteria and to the people with whom they live and work is far less often considered pathological by those who create the official diagnostic categories. That is why people laughed when they heard the first criteria of DDPD: They were surprised that anyone might suggest calling hurtful or inhumane "masculine" behavior a mental disorder. It is encouraging that in recent years, there has been increasing recognition of the harm caused by what has come to be called toxic masculinity, though it is important to recognize that this is a widespread social problem and should not be called a mental illness, lest the methods for reducing such social problems be overlooked rather than implemented.
Major Depressive Disorder (MDD) is a category leading to dangers for girls and women, because in a sexist society such as ours, there are a great many causes for grief, sadness, a sense of helplessness or hopelessness, feelings of worthlessness, irritability, difficulties with sleeping or eating, and other emotions, beliefs, and problems listed under this category in the DSM. Since having such feelings after bereavement or other major loss are deeply human ones and should not be called signs of mental illness, it is important to mention a particular part of MDD’s descriptions in the current and previous editions of the DSM. There has been a justified outcry that in DSM-5, it is said that MDD should not be diagnosed if the person has been bereaved less than two weeks. It is both absurd and dangerous to consider these kinds of feelings pathological as soon as the first two weeks after the loss are over. But what should also be known is that in DSM-IV, Allen Frances’s edition specified that MDD could be diagnosed in a bereaved person as long as the person had any of the following: “marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.” Since these are very common characteristics of bereavement, the DSM-IV allowed for application of the MDD label to a person on the first day of their loss, making it in that way even worse than DSM-5.14 This matters, because in all of the justified outcry about the two-week limit in DSM-5, it is crucial not to render invisible the suffering of all of the bereaved people who were hurtfully diagnosed with MDD based on DSM-IV.
Generalized Anxiety Disorder is similar to Major Depressive Disorder, given that what is called “anxiety” is usually fear, and in a sexist and violent society, there are myriad reasons for girls and women to be afraid.
Premenstrual Dysphoric Disorder’s unscientific nature, described earlier, is not the only problem with the category. Because its name confines its application exclusively to women, who have menstrual periods through many decades of their lives, it has opened the floodgates for the pathologizing of nearly everything about women. Most women have had the experience of their legitimate feelings and concerns being dismissed on the grounds that they must be premenstrual. And as the medical community has joined with Big Pharma, both “peri-menopause” (the time recently delineated for purposes of pathologizing as when hormones start to change when women move toward cessation of menstruation) and menopause itself (the cessation of menses) have been treated as causes of “mental illness,” and there is a long tradition of demeaning and pathologizing older and old women based on the notion that without the hormonal levels typical of women who are still menstruating, they are unfeminine, unwomanly, “dried up,” somehow less than human. I am not being entirely flippant when I suggest that it’s only a matter of time until the APA creates a category of psychiatric disorder for girls from birth till their first menstrual period and attributing it to the fact that their hormone levels differ from those of menstruating women.
In summary with regard to psychiatric labeling, once you add to all who have been or could be diagnosed with the labels discussed above, plus all the women who could qualify for any of the other hundreds of mental disorders listed in the DSM, is there any chance we could find a normal woman?
As if the ways described here of pathologizing women were not enough, myths and stereotypes about mothers and sexism in psychological theories and research add much to that pathologizing, and some of these will be addressed in Part 2 of this two-part essay, which will appear in the Bulletin’s next issue.
1Caplan, Paula J. (1995). They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal. DaCapo/Perseus Books.
7Caplan, Paula J., & Cosgrove, L., Eds.sp (2004). Bias in psychiatric diagnosis. Rowman and Littlefield.
8Ibid. and Caplan, Paula J. (2005). The myth of women’s masochism. iUniverse.
9See Caplan, 1995, and Caplan, Paula J. (2016). When Johnny and Jane come marching home: How all of us can help veterans. Open Road.
10Becker, Dana, & Lamb, Sharon. (1994). Sex bias in the diagnosis of Borderline Personality Disorder and Posttraumatic Stress Disorder. Professional Psychology: Research and Practice 25, 55-61. Becker, Dana. (1997). Through the looking glass: Women and Borderline Personality Disorder. Westview.
13Hickey, Philip. (2017). Elimination of the bereavement exclusion: History and implications. Madinamerica.com, October 5. https://www.madinamerica.com/2017/10/elimination-of-the-bereavement-exclusion-history-and-implications/