Psychiatry and Sexism: Gender Bias in BPD Diagnosis?

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The subject matter of singer/songwriter Aimee Mann’s new album “Queens of the Summer Hotel” conveys the plight of women suffering from disaffection due to the sexism of the male-dominated psychiatric profession in the 1960s. The song “Give Me Fifteen” epitomizes the prevailing medical culture — a brash male doctor boasting of his ability to diagnose women in just 15 minutes.

How does he do it? Mostly by not really trying to understand women, because they “are so simple after all.” The bouncy tune and rhythm of this song contrasts with its bleak subject matter: the frequently harsh medication and electroconvulsive therapy that psychiatric patients (particularly women) endured in the 1960s and 1970s.

Mann told the Los Angeles Times that “Give Me Fifteen” mirrors the real world in which women’s health concerns are dismissed or misunderstood by the medical establishment. “It’s enraging, and every woman has absolutely experienced it — not being taken seriously,” Mann said.

This is not her first foray into the world of mental illness. Her previous album, aptly titled “Mental Illness,” won a Grammy award in 2018.

“Queens of the Summer Hotel” was conceived for a stage-musical adaptation of Susanna Kaysen’s 1993 memoir Girl, Interrupted — and James Mangold’s 1999 film by the same name — detailing Kaysen’s real-life teenage experiences at McLean Hospital in Massachusetts in 1967. The title takes inspiration from a poem by Anne Sexton, who, like Kaysen, was also treated at the famous psychiatric hospital, along with Sylvia Plath and Robert Lowell, who figure into a song on the album. “I had this idea of calling a mental institution a summer hotel because that just has a lot of weight to it,” Mann explained to SPIN.

Certainly, 18-year-old Kaysen must have felt anything except on holiday when she was admitted to McLean. She was sent there following a suicide attempt and a cursory psychiatric evaluation invoking a diagnosis of borderline personality disorder (BPD), a stigmatizing disorder notoriously overdiagnosed in women. Although she was told she had to stay for only a few weeks, Kaysen was a patient for nearly 2 years. Her account questions whether a prolonged hospitalization was medically necessary or was instead a result of an oppressive male-dominated medical establishment.

I admit, I was part of that establishment. I could have been that brash psychiatrist. I diagnosed many more women with BPD than I did men, whom I usually diagnosed with antisocial personality disorder. I asked my supervisor how to treat women with BPD and he smugly replied, “Art, you refer them” — tongue-in-cheek, but nevertheless proud of his sexist remark.

A feminist perspective of BPD theorizes that women with extreme emotional instability — considered the hallmark of BPD — are labeled as such in response to gendered power relations rather than a pathology that is endogenous to women. The feminist framework links diagnostic inequities to a broader political and medical context — the fact that men significantly outnumbered women in the medical profession for many decades.

Now, with women comprising the majority of first-year medical students, psychiatric narratives that have been imposed upon women can be changed, and the ways in which power and oppression have shaped their views of themselves can be resculpted. Furthermore, new storylines can be created (and put to music) that are meaningful for female patients, regardless of labels, diagnostic categories, or the presumed power and expertise of the physician.

As I have written elsewhere, we all have biases and blind spots. Unfortunately, gender myths are ingrained as biases that negatively impact the care, treatment, and diagnosis of women and ethnic minorities. According to the book Unwell Women: Misdiagnosis and Myth in a Man-Made World by feminist theorist Elinor Cleghorn, PhD, “[t]he discrimination women encounter as medical patients is magnified when they are Black, Asian, Indigenous, Latinx, or ethnically diverse; when their access to health services is restricted; and when they don’t identify with the gender norms medicine ascribes to biological womanhood.”

Yet, the question of why women, rather than men, are more frequently diagnosed with BPD remains largely unanswered despite current evidence for the origin of personality disorders in genetics and neurobiology, and despite suggestions that biased sampling is the most likely explanation for gender bias in the diagnosis of BPD. However, the essential issue is whether the larger prevalence in women is due to a biased sample or a biased diagnosis.

The bulk of the evidence suggests the latter. In fact, medical myths about gender roles have existed for centuries, with its foundation cemented in ancient Greece — and women are still victims of gender and diagnostic bias today. Bias in medical knowledge, research, and practice has resulted in inadequate treatment of women’s pain and a host of other conditions including heart disease, bleeding, and autoimmune disorders — and especially mental health disorders. Physicians must make a concerted effort to be aware of their biases and rectify them in order to best serve their patients.

Although the medical profession is working to revamp its practices and eliminate explicit forms of discrimination and more subtler microaggressions — indirect expressions of prejudice that contribute to the maintenance of existing power structures — there is a long legacy to quash when it comes to women’s bodies and minds.

Women like Kaysen in search of an honest and accurate diagnosis continue to struggle against thinly disguised misogyny in medical orthodoxy.

Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board, a 2021-2022 Doximity Luminary Fellow, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.

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