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Although women make up 52 percent of the U.S. population, their health care needs have traditionally taken a back seat to those of men. It has only been in the last decade, as women have started to fill positions as medical clinicians, researchers, educators, and administrators, that this neglect has begun to be remedied.
Donna E. Stewart, M.D., professor of psychiatry and chair of women's health at the Toronto Hospital and University of Toronto and a member of APA's Committee on Women, discussed what many would think to be a positive turn of events for women: the burgeoning of women's health centers. She pointed out, however, that many of these centers are basically marketing tools used by institutions and managed care organizations to attract women patients.
"A lot of people are jumping on this bandwagon," said Stewart, "but it may not ultimately help women."
Marketers realize that women form an important power base today, she said. Women make 70 percent of health care visits, fill 70 percent of prescriptions, purchase 70 percent of over-the-counter drugs, and arrange for their family's health care. Women live longer than men, and are thus in the health care system longer and have more chronic diseases, and many have independent earning power.
Stewart noted that she has been getting brochures from managed care organizations extolling women's health as a profitable area into which medical institutions should expand. The brochures note that women can be used as a way of extending services to men and children and thus enlarging market share.
Offering services to women is not in itself a bad idea, Stewart said. The problem is that many of these centers do not offer high-quality, comprehensive care or care that uses limited medical resources wisely. For example, she said, many centers offer bone densitometry, cardiac monitoring, mammography_high-cost services that the centers perform frequently on populations of women "who are probably at the very lowest risk for some of the conditions" these screenings cover. In contrast, "one hears little about low-cost screenings, such as Pap smears, breast self-examinations, and blood pressure monitoring," which are not nearly as lucrative but are more cost-effective in terms of resource usage.
"We need to speak out against false women's health initiatives to make sure women really do benefit from women's health centers," Stewart said to the psychiatrists in the audience.
She also told psychiatrists who may be involved in setting up or working in women's health centers to consider these questions: First, what is the purpose of the center? If the purpose of the center is unclear, examine the institution's goals. If the goals are too restricted or broad, what kind of strategic plan can be put in place to address that? What is the reporting relationship of the center to the parent institution? Is there any competition in the area, and if so, what services do competitors offer? Look to offer different needed services when possible. Does the center have institutional support in terms of adequate budget, staff, and material resources?
Carol Nadelson, M.D., editor in chief of the American Psychiatric Press Inc. and a clinical professor at Harvard Medical School, noted that in the past physicians_almost all men_were criticized for their authoritarian and paternalistic attitudes toward patients. As physicians began to change and consider patients a partner in the health care system, the revolution in health care economics came along. Now "the bureaucracies that pay the bill" have become the paternalistic and authoritarian figures, she said.
"This transformation is a red flag for women. It presents us with major concerns [about women's health care] not addressed in the inevitable inequity in the evolving health care systems. One issue we see prominently is that women have not been very involved in leadership roles in policymaking."
She cited Martha Minnow of Harvard Law School on the concept of dilemma of difference: Public policies that ignore differences between dominant and subordinate groups create a false neutrality that actually favors the dominant group, since its characteristics are taken as the norm. The norm in U.S. society is the male norm.
"So women's health may not be high on the agenda or may be seen from a male perspective," said Nadelson.
History has borne out this theory. Even today women are likely to have less access to health care resources than men, she said. Lower-paying jobs typically held by women do not carry health insurance as an employee benefit. If women are insured through a spouse's plan and the spouse loses his job, the women lose their coverage, too. Women are more likely to have transportation and child care problems that prevent them from going to a doctor. Medicare provides poorer coverage to women since it covers chronic illness, which affects women more often, to a lesser degree than acute illness, which affects more men. Women live longer and with more disability, thereby requiring more health care resources than men. Thus, policies that affect and limit the availability of health care will disproportionately affect more women than men, she said.
Nadelson said that more women are becoming involved in policymaking positions, but at an achingly slow pace. She anticipates that once women reach a critical mass in those positions, however, some health care systems may be thought about and designed differently from traditional systems. For example, research has shown that women physicians tend to spend more time with patients. Perhaps, then, people who are more likely to choose a woman physician may be those who want to talk to or spend more time with their doctor, said Nadelson. This may result in better overall care and treatment outcomes even though such care appears to be consuming more resources up front.
Margery Sved, M.D., an attending psychiatrist at Dorothea Dix Hospital in Raleigh, N.C., commented that women have been poorly served by medical research because it has often not included them in studies or, when women are included, they may be lumped together with men. Further, much of the research has not taken into account other aspects of diversity that may also have an important bearing on women's health.
Research populations, she noted, can be stratified in almost endless ways: Age, gender, race, ethnicity, sexual orientation, national origin, socioeconomic class, education, religion, occupation, income, immigration status, and so on.
"One or another of these areas may be more or less important in how others see us and we see ourselves," she said, "and each may have a biologic effect."
Research has shown that many of the health differences attributed to sex and race can be explained solely by sexism, racism, and class issues, Sved noted. For example, many differences attributed to race may actually be linked to the psychosocial effects of discrimination, lack of adequate access to health care, poverty, incarceration, and residential and occupational segregation.
Investigators are now becoming more sensitive to the value of stratification, Sved noted, which will improve the relevancy of study results.
Margaret F. Jensvold, M.D., chair of APA's Committee on the Abuse and Misuse of Psychiatry in the U.S., noted that women, as well as men, have long been the victims of psychiatry employed for the wrong motives and that some of the types of abuses are particularly relevant to women.
Psychiatrists, she said, must use their skills to benefit the patient; they have an obligation to be truthful, scientifically grounded, unbiased, and ethical. APA's position statement on this issue, approved in 1994, says that "abuse and misuse of psychiatry occur when psychiatric knowledge, assessments, or practice is used to further illegitimate organizational, social, or political goals."
The abuse or misuse may be perpetrated by the psychiatrist, a third party, or both.
Cases of abused or misused psychiatry fall into five major categories: workplace harassment; retaliation, in which "difficult" employees are disciplined by being forced to get a psychiatric evaluation; biased forensic evaluations, such as an evaluation whose goal is to undermine the victim in a sexual harassment case or a parent in a custody suit; forced fitness-for-duty examinations, in which an employer tries to force an employee out of a job by claiming the employee has a mental disability; and miscellaneous.
Sexual harassment cases can be a particularly brutal experience for victims, the vast majority of whom are women, said Jensvold. The defense attorneys typically attack the character and past sexual and psychiatric histories of the victim_which in essence revictimizes the woman, she observed. Moreover, the misuse of psychiatric information in these cases often leads to unjust outcomes.
APA's ethics principles cover most situations, but Jensvold noted there are two groups for which the principles need to be broadened: psychiatrists working in organized systems of care and forensic psychiatrists. She said that in May the Assembly approved, in principle, a draft of guidelines for psychiatrists working in organized settings, and APA and the American Academy of Psychiatry and the Law are now working together on APA's possible adoption of AAPL's ethics guidelines.
Discussant Herbert Pardes, M.D., commented that the richness of diversity in U.S. society is a "cause to be celebrated."
In listening to the panelists' comments, "I find most troubling the extent to which rigidity affects the whole range of issues." He called for psychiatry to work toward minimizing that "antagonistic rigidity, which has caused so much trouble in the world."--C.F.B.
(Psychiatric News, July 18, 1997)