I’m pleased to have been invited to comment on this special issue of Academic Psychiatry on women in academic psychiatry. I found my appreciation of the articles enriched with reflection on overarching trends in the experiences of women in this country over the past several decades.
The historian Gary Wills captured the nature of the changing status of women with these words in the New York Review of Books:
There could not be a deeper transformation of all social arrangements. Change the status of women, alter the whole concept of womanhood, and the most intimate relationships are challenged, subverted, or reestablished at their inmost nexus—the relationships of wife to husband, husband to wife; of mother to children, of daughters to parents and siblings, of men to women employers or employees or professional colleagues (1).
Moreover, Mr. Wills marveled at the rapidity of the pace of change:
future Justice Ruth Bader Ginsberg was asked upon her graduation from Harvard Law School, by Dean Erwin Griswold to justify ‘taking the place of a man’ in the profession.  Fifteen years later, there were still only one hundred members in the National Association of Women Judges. Today there are 1,300. The presence of women has increased comparably in careers extending from professional and business, to sports, to the military and the religious ministry (1).
Mr. Wills points out that people today have understandable reason to react emotionally to a change "as deep and widespread as the women's movement." Fortunately or unfortunately, depending on one’s point of view, "for the first time in history, the equality of women with men was taken seriously in the second half of the twentieth century" (1).
Last month I took my daughter to Philadelphia to begin her freshman year at college. The parents and new students were addressed by President Amy Gutmann, the second woman president of the University of Pennsylvania. I later reflected that the current president and immediate past president of the American Psychiatric Association (APA) are distinguished female psychiatrists. In addition, women hold the positions of secretary and treasurer of the APA as well as the editorship of the American Journal of Psychiatry. Gary Wills is right, there has been profound change. Still, as the articles in this issue make clear, more needs to be done.
"The personal is political," was the mantra of 1970s feminism. Women proudly told their personal stories, deepening understanding of the politics of sexism and racism. Now, 30 years later, we can examine how far women have come, and what has become of "the personal is political." The articles in this issue address many facets of the experiences of women in medicine and psychiatry. From personal narratives, with their compelling stories and experiential lessons, to a history of women in medicine and psychiatry, to research on current conditions for women in psychiatry, articles in this issue of Academic Psychiatry illustrate the variety of methods that can effectively report on the status of women in our field. We need both the demographics and the stories. Evidence-based research, the mantra of modern medicine, will help transform psychiatry into a 21st century clinical science. Medicine has moved beyond the bloodletting and leeches that could not stand up to scientific scrutiny, and psychiatrists similarly must let go of approaches that do not stand on a firm empirical base. That said there are many healing truths that cannot be understood with a double-blind clinical trial. Expert clinicians in psychiatry have learned to make unconscious clinical assessments that become increasingly accurate with experience.
Freud said, "When you meet a human being, the first distinction you make is male or female,? and you are accustomed to making the distinction with unhesitating certainty" (6). Although gender identity has been deconstructed, analyzed, disordered, and sometimes bent in contemporary American culture, when a baby is born, we still want to know first whether it is a girl or boy. One could argue that in the United States today, race may be the first distinction made upon encountering another person, and indeed, minority and non-white women experience obstacles beyond gender bias. Janet Bickel describes the "intersection of gender and ethnicity" in her review of women in academic psychiatry. Bickel also notes that given the influx of women to the medical profession during the 1970s and 1980s, there are fewer women than expected in academic positions. Although according to the Association of American Medical Colleges (AAMC) data, psychiatry has one of the highest percentages of female tenured professors, these numbers are even less than predicted, given the numbers of women who have entered the profession.
In the future, will women academic psychiatrists populate the "clinical educator" tracks rather than the research tenure tracks? Will this lead to a "second class" of women academics, tacitly judged to be inferior? The Hirshbein (2), Bickel (3), and Bogan and Safer (4) articles in this issue confirm the AAMC data that women are not being promoted to higher ranks of academic medicine at the same rates as men. Surprisingly, Hirshbein, Fitzgerald, and Riba find that at the University of Michigan, tenured male faculty do the majority of core didactic teaching to medical students and residents, in spite of equal numbers of men and women in the clinical teaching track (5).
Questions of gender equality are even more daunting in the area of psychiatric research. In its report "Research Training in Psychiatry Residency," the Institute of Medicine notes, with some alarm, the shortage of clinical investigators and proposes changes in residency training program requirements to foster research careers. No easy solutions suggest themselves. At the APA Chief Residents’ Leadership Conference in October 2004, Donald Rosenstein, M.D., of the NIMH, asked the 160 plus residents, who were nearly evenly divided between men and women, how many had research experience? Almost every hand went up. Then he asked how many planned a research career, and only six people raised their hands. Six out of one hundred sixty! In the 2002-2003 academic year, only 19.7% of 5,581 general psychiatry residents were white men who graduated from U.S. medical schools. Over 30% of those residents were women—both majority and minority status—from U.S. medical schools, and approximately one-half of all residents were international medical graduates (IMGs). The obstacles that women, US minorities, and IMGS of both sexes face in academic careers must be addressed if we hope to have an adequate supply of clinical researchers in psychiatry. Research is the currency for advancement in the academic world, and women and underrepresented groups need to be involved for their own advancement as well as for scientific progress for the field.
At a time when many would agree with Wills’ statement that equality of women with men is being taken seriously, it seems relevant to revisit Freud; Freud, the author of theories of penis envy and female passivity who has been vilified as an oppressor of women. Although many psychiatric researchers have dismissed his theories as being irrelevant to modern psychiatry and lacking any form of an "evidence-base," women psychiatrists should now read Freud without defensiveness, and come to new conclusions, just as women in other academic disciplines are doing.
In his lecture, Femininity, delivered at Clark University in 1925, Freud reviewed his theories about the psychosexual development of women. Rereading that lecture in 2004 left me with mixed emotions. When Freud discusses the "fact" of female castration, I still get angry. I find his theory that passivity is the normal destiny of female sexual development distasteful. But much of what Freud says is remarkably forward thinking and even humble. "It is certainly incomplete and fragmentary and does not always sound friendly. But do not forget that I have only been describing women in so far as their nature is determined by their sexual function. It is true that that influence extends very far; but we do not overlook the fact that an individual woman is a human being in other respects as well. If you want to know more about femininity, enquire from your own experiences of life, or turn to the poets, or wait until science can give you deeper and more coherent information" (6).
Muriel Dimen’s essay, Strange Hearts: On the Paradoxical Liaison Between Psychoanalysis and Feminism, reviews Freud’s theories on women as feminism grew, from the first women analysts, Karen Horney, Melanie Klein and Freud’s daughter Anna, to postmodern feminist theorists. Although not concerned with clinical treatment, her description of the contradictions at the heart of feminism and psychoanalysis are reminders that psychiatry, too, can grow and strengthen from its contradictions. Dimen says, "the uncertainty at feminism’s heart is the tension between its two main goals, one ameliorative, the other revolutionary" (7). Later in the same paragraph she notes, "Like any progressive social movement, feminism tries to improve on what already exists while at the same time undermining the status quo. In so doing, it generates a tension, a paradox, between the desire and need to better women’s lives and the wish and necessity to redefine them" (7).
Women and their interests bring tension to psychiatry, and creative management of that tension will foster progress. Right now, the field is less divided in the face of change than it was a decade ago, but we still need a grand paradigm that accounts for both mental illness and human behavior. Progress will come from the resolutions of the conflicts and oppositions in psychiatry: women and men, science and stories, psychotherapy and neuroscience, metapsychology and medicine. In Critique of Pure Reason, (8) Kant said, "after they [the hypothetical opposing forces of dialectics] have rather exhausted than injured one another, they will perhaps themselves perceive the futility of their quarrel and part good friends" (8).
We should not let our conflicts injure the field, and by resolving them in a way that is not futile, we have the opportunity to foster progress. Women can help lead the way.