The psychiatric patient is a rare figure among the case examples in any writing about biomedical ethics, feminist or not. Exciting and important advances made through an application of feminist approaches and theorizing to bioethics there have been aplenty, many of them in the pages of this journal. They have affected every aspect of how we construe ourselves, our health and ill health, our treatment, and our relationships with caregivers, as well as more fundamental conceptions, such as those of rights, fairness, self-identity, social power, and personal autonomy. Still, even though some early feminist work during the 1980s was about mental health, attempts to extend those advances to the mental patient, and to conceptions of mental disorder, have been scattered and incomplete, with three exceptions. Research has acknowledged the long Western history within which the feminine and female bodies have been associated with madness. Feminists have exposed and decried the gendering within psychiatric diagnostic categories, and have speculated as to why certain disorders are gender-linked. And the sexual exploitation of vulnerable female patients by male caregivers has been a source of outrage and concern. These explorations have provided essential groundwork for a feminist bioethics for psychiatry, undeniably. Yet—with some further, isolated exceptions—that has been about it.1
Feminist approaches to bioethics are not alone, of course, in failing to acknowledge cases from psychiatry. Within contemporary biomedical disciplines, [End Page 1] psychiatry is regularly depicted as differing from other subspecialties only in that it deals with the brain, and behavior, rather than other bodily systems. Isolated issues from the psychiatry setting, such as those about the validity of diagnostic categories, and about involuntary commitment and treatment, have been explored. But because of psychiatry's status as an undifferentiated subspecialty, it has often been presupposed that psychiatric ethics requires no particular attention. Even if defensible more generally, this is hardly a convincing justification for those bringing feminist theorizing to bear on biomedical ethics. A central focus of feminist bioethics has been health-care disparities affecting, and disadvantaging, vulnerable populations. And this is recognized to cut across all marginalized groups. Viewed from such a standpoint, psychiatry patients are in particular need of attention by feminists, for such patients represent one of the most marginalized groups in modern society. Their disorders often leave them with severe social dysfunction that limits them in a range of contexts and activities, added to which they remain subject to untold stigma and discrimination.
Beginning to make good this omission within feminist bioethics is the primary purpose of the present volume. The papers collected here cast a spotlight on the psychiatric patient, mental illness, and psychiatric care, distinguishing them from within the broader field of biomedicine. In so doing they also acknowledge some of the ethical issues that seem to be magnified when we turn to psychiatric practice. By more thoroughly extending feminist biomedical ethics to psychiatry and the category of mental illness, our hope is to stimulate greater recognition of a clinical setting in need of, and illuminated by, insights from feminist theory.
That theory is protean, granted, and not easily reduced to any particular ideas, approaches, or conceptions. (It is often said there are as many feminist theories as feminist theorists.) Nonetheless, feminist theory—or theories—contains some widely shared themes.
Consistent emphasis is placed on social power and power relationships, for instance, and the disparities in health care that result from imbalances among people and between groups. A focus on caring and care ethics is a recurrent theme, with its emphasis on the moral particularity that acknowledges contextual differences and is inimical to the principle-based approaches dominating much of traditional bioethics. Another theme is the gendered cultural norms that find their [End Page 2] way into medical diagnosis, research, treatment, and lore. Much attention is also paid to self-identity—a self usually depicted as embodied, and socially embedded, or relational. Several of these themes intersect with the pervasive one of personal autonomy. Rather than individual and isolated, the autonomous individual in most feminist analyses is socially situated, and understood in relational terms.
Each of the broad themes illustrated here—gendered cultural norms, the social imbalances wrought by imbalances of power, emphasis on caring and care ethics, re-conceptions of self identity, and revised conceptions of personal autonomy—as well as the interconnections among them—are exemplified and developed in these pages. They are applied to particular diagnoses, to clinical practices, treatment and care, to research categories, stigmatizing societal attitudes, and to the enhancement technologies that are the focus of the emerging field of neuroethics. (More detailed description of the essays comes at the end of this introduction.)
Ironically, even the neglect of the psychiatry patient within feminist bioethics may be accounted for by some of the shared presuppositions noted here. Feminist theorizing regularly emphasizes the embodied subject, whose "mental/psychological" and "physical" attributes are not usefully or perhaps even coherently separated. In replacing the binaries of Cartesianism with a more holistic subject, feminist theorizing can find no place for a disorder that is distinctively mental. Behavioral disorders, anorexia for example, neatly fit conceptions of embodied subjectivity. But the ontology of the embodied subject seems to risk occluding disorders that are more predominantly mental or psychological, such as the delusional thought processes associated with schizophrenia, and the aberrant feeling states of affective disorders. Healthy or unhealthy, markedly or solely mental processes are not a viable category when it comes to the embodied subject. And this perspective, so widely adopted or presupposed in feminist theorizing, resists and so has ignored fundamental categories, embedded in all psychology and medicine, by which psychiatric disorders are recognized and classified.
Many, even most, of the issues raised by feminists over biomedical practices and the bioethical theories that emerged over the last quarter of the twentieth century have been critical. They have addressed and rejected tenets of both traditional medical approaches, and traditional bioethical ones. We find exposés of the power differentials separating doctor and patient, for instance, and the rejection of the individualism implicit in traditional emphasis on patient autonomy, with its reliance on the informed consent that is the mainstay of both clinical treatment and medical research. [End Page 3]
Traditional conceptions of autonomy are particularly problematic in the context of psychiatric practice. Feminist critique asserts that individualistic conceptions of autonomy are inimical to the nature and experience of the actual patient throughout biomedical settings. They are applicable to neither men nor women, and implicate conceptions of self, action, and practice that disadvantage women in particular. The relationally embedded subject does not evaluate her best interests in isolation from those of others around her, for example, or from the power nexus in which she is located. But the psychiatric patient bears a more complex and problematic relation to these conceptions, and within mental health care these concerns take on an urgency found in few other medical settings. Her disorder often deprives the psychiatric patient of capabilities required to exercise full autonomy of any kind, at least for a time. (As a result, needless to say, her vulnerability is immeasurably increased.) Temporarily without the capabilities presupposed by the traditional, individualistic notion of autonomy rejected by feminist theorists (her sense of her own best interests, for example, required for her ability to provide informed consent), her identity must be understood differently if she is to be described in identity terms at all. Alternatives to the individualistic self-identity presupposed in traditional conceptions of autonomy are not merely desirable acknowledgments of the misapprehensions that are a legacy of our patriarchal past. Here, they are necessary revisions.
The cultural embeddedness of psychiatric practice is another feature with special implications for feminist analysis. All medical practice and all disease concepts, whether related to mental health care or not, are culturally embedded, and notions of bodily as well as mental or psychological function and dysfunction are pegged to local rather than universal or global norms. Psychiatry seems singular in this respect as well, however. Social and cultural norms are explicitly appealed to in determining when eccentricity (of action, belief, and belief formation) gives way to disorder; when affective states are pathological; how social dysfunction and therapeutic success and failure are defined, and so on. Moreover, in psychiatry these social norms are contested, often fiercely, rather than—as they are in most of the rest of medicine—widely accepted, stable, and agreed-upon.
The critique that psychiatry employs, exploits, and perpetuates these cultural values and expectations is well-known. It is associated with half a century of analysis that is broadly "anti-psychiatry." Within feminist critique, we encounter it in the identification of gendered norms within diagnostic categories, theory, and treatment practices. Psychiatry, it has been shown, mirrors the sexism and gender discrimination of its age. [End Page 4]
Where to go from this recognition represents one of the challenges for a feminist approach to psychiatric ethics. Those who have identified misogynistic cultural norms and values in diagnostic categories and treatment goals often issue a "buyer beware" message to the consumers of these services, advocating the use of less toxic alternative treatments (feminist therapy, for example). In addition, they call for a purging of these sexist elements from psychiatric classification, theorizing, and practice. Arguably, though, the ethical imperative for psychiatry does not stop there. The gender-sensitive clinician, who has expunged all sexist language and presuppositions from his or her practice, is also a member of influential social institutions (such as the American Psychiatric and Psychological Associations) that shape today's cultural norms as do few others. (The American Psychiatric Association's Diagnostic and Statistical Manuals, discussed below, represent one example of this influence.) How much institutionalized psychiatry has an obligation to explicitly acknowledge its past mistakes, omissions, and misapprehensions is itself an ethical question of pressing importance to which several answers are suggested in the essays that follow.
The impact of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) can hardly be exaggerated, and with the advent of a revised edition expected in 2013, focus has rightly been on the implications for feminism and feminist bioethics of revisions to particular diagnostic categories either already present, soon to be revised, or proposed as additions to the classification. Two of these have received particular attention in the essays that follow: Lisa Cosgrove discusses the category known as Hypoactive Sexual Desire Disorder, and that of Premenstrual Dysphoric Disorder. And the proposal to add Binge Eating Disorder to DSM-V introduces obvious concerns in light of the analysis Kate Morgan provides here of the medicalization and surgical treatment of obesity.
In addition to these particular changes, a number of others with relevance to feminist concerns are worth noting. Proposed revisions and their rationale (found at www.dsm5.org) include changes to sexually dimorphic conditions; disorders previously shown to be gender linked; disorders whose gender link might be suspected if not established; and finally, conditions so freighted with social and political implications and presuppositions for women and feminist perspectives that any alteration must be subject to close scrutiny. [End Page 5]
Examples from this first category include the Premenstrual Dysphoric Disorder (PMDD), discussed by Cosgrove, and Genito-Pelvic Pain Penetration Disorder. Proposed revision to PMDD moves it from the appendix to the main text (the rationale for this move remains undisclosed, as of September 30, 2010). Feminists have long insisted that male norms frame disorder categories, and have cited this condition as an obvious example. Changes are also proposed to states of pain and distress due to sexual intercourse in what is now to be called Genito-Pelvic Pain Penetration Disorder, a condition marked by anxiety, fear over, or inability to have vaginal intercourse, or marked vulvo-vaginal or pelvic pain—"symptoms" all notably and troublingly embedded in social norms and expectations. A last example: it is proposed that Sexual Interest/Arousal Disorder in Women will include previous diagnoses of Hypoactive Sexual Desire Disorder and Female Sexual Arousal Disorder. Involving responses to and attitudes toward norms of sexual conduct and sexuality, these last conditions introduce a whole range of concerns emphasized in forty years of intense feminist analysis and critique. These include consternation that women's sexuality has been the subject of intense and unwelcome medicalization, and skepticism over the sources from which these accounts of normal female experience and sexuality have been derived.
Proposed changes to disorders with established gender links include those under "Somatoform Disorders," with a reclassification of Body Dysmorphic Disorder (to be grouped with Anxiety and Obsessive-Compulsive Spectrum Disorders). Because Somatization Disorder, Hypochondriasis, Undifferentiated Somatoform Disorder, and Pain Disorder share somatic symptoms and cognitive distortions, the proposal is to group these under a category entitled Complex Somatic Symptom Disorder. A legacy of identifying the bodily with the feminine, and cultural attitudes toward the female body more generally, including its objectification—to name a few of the feminist issues here—suggest that any changes in this category cry out for examination through a feminist lens.
The diagnosis of Generalized Anxiety Disorder represents an example of a disorder whose symptoms—here worrying—are associated with women, even if no gender link has been established. Thus, altering Generalized Anxiety Disorder to Generalized Anxiety and Worry Disorder (GAWD) may be seen as pathologizing what are normal consequences of gendered socialization and social role differentiation. Moreover, disregarded in the definition of GAWD ("excessive anxiety and worry [apprehensive expectation] about two [or more] domains of activities or events [for example, domains such as family, health, [End Page 6] finances, and school/work difficulties]") are the gender expectations and roles that will influence who worries, and about what.
Several other disorders to which changes are proposed challenge the political and ethical tenets found in feminist theory and analysis, and many more have implications for women, even when they are not disorders of women themselves. The inclusion of "fetal alcohol syndrome," with its implied attitude of blame toward mothers, reminds us of the politics of blame and stigma associated with such categories as schizophrenogenic mothers, and the category of Munchausen by Proxy disorder (Factitious Disorder by Proxy, in DSM-IV-R). And because of the support it has received from fathers' groups, and the fraught politics around custodial arrangements after divorce, attention must be paid to the proposed inclusion of Parental Alienation Disorder, diagnosed in the child turned against a separated parent. The proposed addition of male-linked Paraphylic Coercive Disorder also deserves recognition here. Involving distressing fantasies that are based on sexual coercion (and serving to create a new category for rapists who are not sadists), this disorder engages with issues about violence against women, misogyny, and the power analyses of the sexual domination of women by men, and raises again the question of whether medicalizing such conditions presupposes entrenched gender bias.
Finally, any change to the description of Gender Identity Disorder, with its already widely criticized and suspect sexist and hetero-normative presuppositions, must be of intense interest to feminist ethics. Revisions here provide an increase in (ostensible) precision seemingly likely to increase the incidence of diagnosis, when there is "marked incongruence between one's experienced/expressed gender and assigned gender of at least 6 months duration." The effect of social values and socialization on such attitudes notwithstanding, DSM-V will in addition retain reliance on earlier language of "persistent discomfort with sex, or sense of inappropriateness in the gender role of that sex." Since both criteria have been criticized for separating attitudes like these from the broader context within which they may be adaptive and even reasonable responses, this, too, must remain of concern to feminists.
Each of the broad themes from feminist bioethics sketched earlier is exemplified and developed in the essays that follow, as well as the interconnections among them—emphasis on the social imbalances wrought by imbalances of [End Page 7] social power; on gendered cultural norms; on caring and the care ethics that challenge forms of principle-based ethics; reconceptions of self-identity and revised notions of autonomy, and methodology that is particularist and respectful of social and cultural context, distrustful of essentialism, and alert to the intersections of gender with race and class.
Across all medical practices, patient autonomy is centrally identified with the practice of acquiring the patient's informed consent to treatment. Yet, as Lisa Cosgrove illustrates, financial conflict of interest is rampant throughout this field, linking clinicians to Big Pharma in ways insufficiently addressed through recent policies requiring transparency. Such conflict of interest leads to imbalanced and inaccurate information about mental-health treatment options for women, Cosgrove points out, resulting in consent that is less than fully informed. Called for here, she illustrates, is a more robust, Foucauldian account of informed consent.
The notorious categories of medical psychiatry enshrined in the DSMs and ICDs have been subject to unrelenting critique both by feminists and by the anti- and post-psychiatry movements of the last half-century, as was noted earlier. In her exploration of the gendered norms that arise in psychiatric nosology, Carol Gould focuses her attention on one disorder, Histrionic Personality, and her critique is no less radical than that of the gay activists whose protests resulted in the removal of homosexuality from DSM-IV (1980). Drawing attention to the way Histrionic Personality Disorder pathologizes feminine roles and styles, and directing us to the Aristotelian notion of character, Gould questions its status as a personality disorder of any kind. She proposes instead that this condition be seen as a "cultural disorder," resulting from attitudes toward traditionally feminine styles of interaction.
Gender presuppositions are embedded not only within diagnostic categories, but also within every aspect of psychiatric lore, theorizing, research, and practice, and they have been the subject of feminist inquiry and critique so extensive that one might have supposed the topic exhausted. In her original and unexpected analysis, Gwen Adshead disabuses us of this presumption, however. Analyzing women who commit violent crimes, she illustrates the gendering that colors research on, but also treatment of, women who are violent.
As a widespread and apparently gender-linked disorder, depression has long been of particular interests to feminist theorists. Robyn Bluhm rehearses the history of attempts to explain the gender link, often cast in an oversimplified equation involving women as oppressed victims of a patriarchal system, depressed because they are powerless. It may not be so simple, however. By revising [End Page 8] the notion of autonomy to conform to feminist relational theories of identity and agency, Bluhm shows that we may recognize the effect of social positioning on women without casting them as helpless, hapless victims.
Conceptions (and illusions) of autonomy surface throughout Ginger Hoffman and Jennifer Hansen's assessment of the claim that the mood enhancer Prozac may be a feminist drug. Allowing women to escape oppression and feel empowered to achieve other goals, these authors admit, recognizably enhances their autonomy as it is understood in much feminist analysis. So it does in allowing women who are depressed to escape their debilitating moods. Yet on a closer examination, the feminist stance must prefer approaches that fix, rather than merely numb, they point out; mood enhancement for a more competitive and assertive personality may be inimical to feminist values; and from a feminist perspective, there may be preferred approaches to severe depression, such as cognitive behavioral therapy.
Issues surrounding family involvement in treatment are laid out in the essay by Elleke Landeweer, Tineke Abma, Linda Dauwerse, and Guy Widdershoven, and provide examples of several related themes from feminist bioethics. Focusing on the particularity of caring relationships (and its implicit rejection of principle-based approaches), this discussion demonstrates the patient's ties to a complex relational network that includes family members as well as caregivers. With its association of enmeshment and entrapment, family embeddedness has been approached cautiously by feminist theorists, as these authors recognize. Yet their case analysis demonstrates the way a relational perspective that includes family members in decisions over treatment and care can reduce reliance on forced seclusion and coercive treatment.
Like women and the feminine, madness has long been subject to discriminatory social attitudes, and indeed those attitudes have been fostered and fed by misogyny and the alignment of madness with women. Stigma then, is a feminist issue of particular and long-lasting import. Angela Thachuk's analysis of contemporary stigma adds to this observation: she finds the persistence of such stigma in the familiar and powerful conceptual models that liken mental to physical illnesses. Employing several tenets at the heart of feminist method, such as emphasis on the social, political, and cultural context within which marginalization and deprivation of epistemic authority affect those with psychiatric disorder, Thachuk illustrates that with their conception of mental illnesses as afflictions of a morally neutral body, such models actually serve to perpetuate the very social attitudes they purport to banish. [End Page 9]
Norah Martin's concerns lie with the suicide help lines and crisis responders routinely violating the confidentiality, informed consent, and trust of callers when active intervention (using police powers) is employed to save lives. Unraveling the elements of this situation from a feminist bioethical perspective sensitive to issues of power and oppression, Martin demonstrates a tension between saving lives while respecting persons, and a commitment to caring in the face of undeniable suffering while maintaining trust. Feminist theorizing about trust by Annette Baier and Nancy Potter form a starting point here as Martin explores active intervention from a feminist ethical perspective, and completes her analysis with policy proposals for the help lines that would be compatible with a feminist bioethics.
Not only its relation to social power understood in Foucauldian terms, but also the nature of autonomy itself are explored by Kate Morgan in her analysis of the illusions of choice and control entertained by the hypothetical "Josephine" as she employs technology to remake her body. Gastric bypass surgery and other "aesthetic" interventions, Morgan argues, while they promise liberation from insidious cultural attitudes of fat hatred, must be recognized as examples of Foucault's Apparatus—not liberation, empowerment, and healthy personal fulfillment, but cultural and biomedical surveillance.
The intersection between race, class, and gender is the focus of Sara Bergstresser's "obituary" for Esmin Green, who died in 2008 on the floor of the Kings County Psychiatric Hospital (Brooklyn, New York) waiting for medical attention. The case is a powerful example of institutional/structural violence against the marginalized, carried out by what purport to be caring institutions, and a reminder of what feminists have long recognized: that the intersection of marginalized categories is a place of particular vulnerability, where some of the most wrenchingly unjust disparities of social power are to be found.
Jennifer L. Hansen received her Ph.D. in philosophy from Stony Brook University. She has taught at Gettysburg College and currently teaches at St. Lawrence University. Her areas of research include philosophy of psychiatry, continental feminist philosophy, and William James. She has published several anthologies on continental feminist thought with Ann Cahill and articles dealing with gender anddepression, moral and political dilemmas involved with psychopharmacologicalenhancement, and conceptual issues in psychiatry.
Jennifer Radden received her graduate training at Oxford University and has taught for many years at the University of Massachusetts Boston, as professor of philosophy since 1997. She is also consultant in medical ethics at McLean Hospital in Belmont, Massachusetts, and has published extensively on mental health concepts, the history of medicine, and ethical and policy aspects of psychiatric theory and practice.
Nancy Nyquist Potter is professor of philosophy at the University of Louisville, where she teaches ethical theory, Aristotle, and other foundational courses as well as philosophy and mental illness, and race, gender, and mental illness. Her most recent book is on Borderline Personality Disorder (Oxford University Press 2009) and she is now publishing work on defiance and conduct disorder. She is part of the health care team in Emergency Psychiatric Services and is president of the Association for the Advancement of Philosophy and Psychiatry.
The editors would like to thank Ginger Hoffman for help with this review of the proposed DSM-V changes.
1. Early work included that by Phyllis Chesler, Kate Millett, and Elaine Showalter. [End Page 10]