history of women in psychiatry

Academic Psychiatry, 28:4, Winter 2004 http://ap.psychiatryonline.org 337

History of Women in Psychiatry

Laura D. Hirshbein, M.D., Ph.D.

Dr. Hirshbein is with the University of Michigan Depart-ment of Psychiatry. Address correspondence to Dr. Hirshbein,University of Michigan Department of Psychiatry, 9C UH 9151,1500 E. Medical Center Dr., Ann Arbor, MI 48109; [email protected] (E-mail.)

Copyright � 2004 Academic Psychiatry.

And we could go on for days talking aboutthe contributions being made during this

period by women and minority groups.—Dave Barry

Feminism is the radical notion that women arepeople.

—Popular bumper sticker

There is very little information about Americanwomen who practiced psychiatry prior to the last

few decades. One could argue that this was because,until recently, there were very few women in the field.While that is certainly true for women in leadershippositions, there have been female psychiatrists sincethe middle of the 19th century and not just as isolatedoddities. It is significant that women psychiatric pa-tients have received abundant historical attention (1–4) while an otherwise excellent recent survey of thehistory of American psychiatrists makes no mentionof women at all (5).

Historians who have approached women’s his-tory have used two different methods to studywomen, particularly in fields traditionally domi-nated by a male perspective or male practitioners.One approach is to search for women who mighthave been overlooked by previous accounts, espe-cially accounts that relied on leaders in the field(who have often been male). This method can be lim-ited, however, because information about individualpractitioners is not always available. In addition, afocus on the few women about whom there is infor-mation does not help explain women’s role in theprofession as a whole (6). Another approach is to tryto understand the relationship between power andorganizational change over time (7, 8), as well as theways that power is related to assumptions aboutgender (9, 10). This broader attention to power helpsus look beyond numbers to understand the contextin which women of the past and present entered andpracticed in psychiatry.

This article provides a preliminary account ofwomen in psychiatry in the United States using bothof these methods. Existing historical work on womenpractitioners in medicine in general is reviewed,along with some evidence about women’s role in psy-chiatry. In addition, an analysis is provided of therelationship between the changing structures of aca-demic medicine and psychiatry and women in andout of the profession. Both of these perspectives willbe used to stimulate suggestions about how womencan have a greater presence in academic psychiatryin the future.

19TH CENTURY

At the beginning of the 19th century in the UnitedStates, there was no single, powerful medical profes-sion. Instead, the political and popular spirit of theage rebelled against monopolies. American medicalschools in this time period were frequently for-profitinstitutions, owned by the professors who had pri-vate practices on the side. The medical course wasbrief and often consisted only of lectures without pa-tient contact (11). A variety of practitioners competedfor the scarce resources of patient pay, and a widearray of medicines were available to patients (12).Allopathic medicine, the precursor to what we knowof as modern medicine, was only one of a numberof competitors in this time period. Indeed, allopathicmedicine, which often consisted of aggressivebloodletting and purging (13), frequently lost incompetition with water cure, homeopathy, and othertreatments that were considered to be more tolerable(14, 15).

WOMEN IN ACADEMIC PSYCHIATRY

338 http://ap.psychiatryonline.org Academic Psychiatry, 28:4, Winter 2004

TABLE 1. Numbers of New Certificates by the American Board of Psychiatry and Neurology

Year Men Women Total % Men % Women

1950 326 16 342 95% 5%1960 203 11 214 95% 5%1970 549 50 599 92% 8%1980 978 248 1226 80% 20%1990 618 348 966 64% 36%2000 636 461 1097 58% 42%

In this context of a broad marketplace for reme-dies, women often acted as practitioners in a varietyof healing venues (16). First, women frequently at-tended each other during childbirth, either as friendsor as seasoned advisors (17). In addition, women’sorganizations were interested in health issues and ad-vocated domestic medical knowledge (18). Further,women participated in several healing movements,such as Christian Science (founded by Mary BakerEddy) (19), the water cure movement (20), and ho-meopathy. Before allopathic medicine was formalizedand regulated in the 20th century, women often par-ticipated in the informal medical marketplace, al-though they were not permitted to enter regularmedical schools until mid-century.

In the second half of the 19th century, womenbegan to enter allopathic medical schools. The firstwoman to graduate from an American medicalschool was Elizabeth Blackwell in 1847. In the severaldecades after Blackwell paved the way, women beganto enter the medical profession in increasing num-bers, some traveling to Europe for more experienceor a broader education (21). A number of womenflourished in the homeopathic medical schools thatwere successful in the late 19th century. One of theways in which a substantial number of women en-tered medicine was through the creation of women’smedical schools during this time period. By the 1880s,there were over a dozen schools devoted to women’smedical education (22). As several historians havepointed out, separate institutions for women helpedwomen not only gain access to training but also al-lowed them to benefit from contact with women’snetworks. Women’s medical schools providedwomen role models in faculty and alumnae, connec-tions to training opportunities beyond medicalschool, and possibilities for faculty positions (23, 24).

The first generations of women in medicine didnot claim equality and equal opportunity with men.Instead, they relied on the assumption that women

were particularly interested in domestic concerns toargue that women were uniquely qualified to im-prove women’s and children’s health (25). At a timewhen ideas about modesty prevented male practi-tioners from doing thorough examinations of women,women physicians argued successfully that womenpatients needed trained women professionals to pre-serve their modesty. While women physicians wentinto a variety of specialties, the argument that womenprovided something special to medicine was fre-quently used until beginning of the 20th century. Thisargument allowed for the training of many womenin medicine, but it did not help them obtain post-graduate education or professional organization af-filiation. These difficulties were significantly worsefor black women (26).

As will be discussed shortly, psychiatry as a spe-cialty was organized around mental institutions (asy-lums) in the 19th century. Although there is little in-formation about individual practitioners, it appearsthat women physicians obtained positions in asylumsbecause of concerns about preserving modesty inwomen patients. Women were appointed physiciansin asylums in the second half of the 19th century, of-ten with the explicit purpose of acting as women pa-tients’ gynecologists. Some women were able to actas autonomous heads of the women’s department,but most often women in asylums had several layersof male supervision. About half of asylums at the be-ginning of the 20th century employed women phy-sicians (27). Women were not permitted to becomeasylum superintendents and were not admitted asmembers into the professional organization until wellinto the 20th century (28, 29).

MID-19TH TO EARLY 20TH CENTURIES

As sociologist Andrew Abbott has demonstrated (30),the process of professionalization in medicine (and itsspecialties) is characterized by groups of practitioners

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making claims to ownership of abstract knowledgein a particular area. As Abbott has described, theseclaims to knowledge are often made to compete withother groups. Other scholars have pointed out thatsuccessful professions develop critical elements: aprofessional organization, a journal, and a set of li-censing requirements (31, 32). Psychiatry has under-gone several professional revisions over the lastcentury and a half, and has employed the methoddescribed by Abbott at each occasion. Part of theclaim to abstract knowledge involves a claim thatother groups are not qualified to practice or need tobe supervised. This exclusion of others’ authority ismore typical of organizations dominated by men. In-deed, historians of the female-dominated fields ofsocial work and nursing have pointed out that theprocess of professionalization worked significantlydifferently in these organizations (33, 34).

As was discussed above, women entered medi-cine at a time when allopathic physicians had to com-pete with everyone else in an open marketplace.There was no organized medical profession, and veryfew effective medical organizations. Although theAmerican Medical Association was founded in 1847with the goal of improving the education and qualityof American physicians (35), it was relatively pow-erless until well into the 20th century (36). In the con-text of this relative lack of authority, in the secondhalf of the 19th century a new specialty emergedwithin allopathic medicine. More than half a centurybefore medical specialties were particularly well-ac-cepted by the rest of the medical profession (37), thephysicians who practiced in asylums (the 19th-cen-tury precursors to mental hospitals) created a spe-cialty organization in 1844. The Association of Medi-cal Superintendents of American Institutions for theInsane (which would eventually become the Ameri-can Psychiatric Association) gave social, cultural, andprofessional authority to asylum physicians (psychi-atrists) by creating an organization to help lobby forfunds, create an aura of professional expertise, andaid in the development of the specialty (28). Womenwere specifically excluded from membership in theprofessional organization of this specialty until the20th century.

In the late 19th and early 20th centuries, allo-pathic physicians in general began to consolidatetheir authority and worked to create a monopoly overmedical practice. In the late 19th century, some Amer-

ican medical schools had begun to lengthen theircourse of study, introduce bedside teaching, and uti-lize scientific studies in educational programs (11).The well-known Flexner Report in 1910, produced byAbraham Flexner at the behest of the Carnegie Foun-dation (38), both qualified programs based on theireducational quality and highlighted the importanceof physicians trained in university medical schools.Although the Flexner Report helped to improve stan-dards in medical education early in the century, it alsoset the standards that funding sources (such as theRockefeller Foundation) used when deciding whereto send money. Further, it helped concentrate profes-sional power in the hands of a small group of medicalelites (39). As a result of the report, a number of medi-cal schools (including most of the separate schools forwomen and blacks [40]) closed in the early 20th cen-tury. By this time, many regular medical schools hadbecome coeducational, but the opportunities forwomen physicians began to shrink in the early partof the century (22). The way that medicine was de-fined in the 20th century, as a vigorous scientific en-terprise, was in sharp contrast to the nurturing ar-guments women used to enter medicine in the 19thcentury.

EARLY TO MID-20TH CENTURY

Although women had made significant inroads intomedicine in the 19th century, even to a limited extentin psychiatry, they were much less successful in the20th century. In the early 20th century, and even moremarkedly after the 1920 passage of the Women’s Suf-frage Amendment, the number of women physicianssignificantly declined. Some historians have attrib-uted this decrease to discrimination on the part ofregular medical schools. From the sharp decline inthe percentage of female medical students in theseyears (a decline from 25% in 1890 to 3.1% in 1910 atthe University of Michigan, for example), which wasnot entirely accounted for by a decline in women’sapplications, it is probable that some discriminationexisted (41). In the late 19th and early 20th centuries,there had been a shift away from arguments thatwomen could provide something special because oftheir sex. Instead, the general tendency of women inmedicine was to emphasize their abilities as doctorsfirst (25). While this shift made sense for the genera-tion of women that no longer had to break barriers



to gain admission to schools, it also left women vul-nerable to discrimination by placing them squarely incompetition with men. Further, this shift away fromwomen’s special contributions might have made thefield less interesting to women who did not want tocompete in a man’s world. In fact, the number ofwomen applying to medical school significantly de-creased. This decline follows the general trend ofwomen’s declining involvement in public professionsuntil after the women’s movement of the 1960s.

At the same time that the numbers of women inmedicine were decreasing in general, psychiatry as aspecialty was undergoing a significant shift. Whilepsychiatry in the United States had in general bene-fited from the consolidation of power of allopathicphysicians, psychiatry as a specialty came into a crisisin the early 20th century regarding its location ofpractice. Psychiatrists by the early 20th century wereless interested in the institutions that had definedtheir specialty, and some argued that institutions didnot help patients. In addition, asylum superinten-dents found that they were spending an inordinateamount of time on administration rather than patientcare (28). The combination of the decline of institu-tional psychiatry with the gradual rise of psycho-analysis changed the practice of psychiatry by themiddle of the century (42, 43). Psychiatrists shiftedtheir attention from severely mentally ill patients tothe ways in which everyday life was fraught withpsychiatric consequences. Psychiatrists in the early20th century were particularly interested in whatthey saw as the pathology of men and women vio-lating gender norms (44). Well-known figures such asKarl Menninger popularized the idea that psychia-trists’ expertise on mental health was critical to Amer-ican society (45).

By the end of World War II, psychiatrists enjoyedan unprecedented amount of public authority andapproval, due in part to their perceived success indefining and treating mental illness in soldiers (46).During World War II, psychiatrists began to be moreinfluential in shaping American ideas about mentalhealth and illness. William Menninger and his psy-chiatric colleagues, many of whom were trained asanalysts, were heavily involved in mental healthscreening of military draft recruits during the war.They were also involved in treating soldiers for neu-ropsychiatric casualties during the war. Psychiatristssuccessfully lobbied for the National Mental Health

Act of 1946, which provided for the foundation of theNational Institute of Mental Health (founded in 1949)(47).

MID-20TH CENTURY

By the middle of the 20th century, psychiatry was in-creasingly dominated by psychoanalysis. Some no-table women, such as Anna Freud and Melanie Klein,made significant contributions to psychoanalytic the-ory (48, 49). Still, psychoanalysis and its differentschools based much theory on narrow, and some-times conflicting, ideas about women’s nature, theirrole in their families, and their relationship to mentalillness (50). By mid-century, psychiatrists were argu-ing that bad mothering produced schizophrenia (anidea that was popularized as “Momism,” the termcoined to explain the hazard of overprotective moth-ers in the post-war era) (51). Psychiatrists of this timeperiod did not question the relationship betweenwomen’s social roles and their mental health.

As scholars and activists in the 1960s and 1970spointed out, one of the ways that psychiatry becamepopularized was by articulating a view of mentalhealth based on gender norms (52, 53). Indeed, thewomen’s movement in this time period identifiedpsychiatric and psychological views of women as asignificant method by which women’s roles had beenconstrained by American society (54). Betty Friedan’spath-breaking book, The Feminine Mystique (55), artic-ulated women’s protest toward psychiatrists for tell-ing them who they needed to be in relationship totheir husbands and their children.

1970S TO THE PRESENT

The second major wave of women entered medicinein the 1970s, and the numbers have been increasingever since. Interestingly enough, women in the 1970sand 1980s used some arguments to enter the field thatsounded very similar to those used in the 19th cen-tury. Observers of modern medicine in the 1960s and1970s began to comment that medicine was becomingtoo technical and that physicians were not sufficientlyattuned to the human element with their patients.Women who entered the profession during this timeperiod often argued, as observers did around them,that women had something to add to medicine byrecalling the human touch that had been lost with the

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increasing scientific and technical processes withinmedicine (22). Female psychiatrists began to pointout the pitfalls of men making assumptions aboutwomen’s lives in the context of psychiatric treatment(56, 57). In addition, women in psychiatric trainingbegan to articulate some of the conflicts and chal-lenges that faced women in medicine as well as theworkplace as a whole (58, 59).

By the late 1970s, new medications (60) and newdiagnostic categories (61) helped propel psychiatryinto a new biological age. Perhaps not coincidentally,women began to enter psychiatry in large numbersat that time. A review of the numbers of women whocompleted the psychiatry certification for the Amer-ican Board of Psychiatry and Neurology in the years1950, 1960, 1970, 1980, 1990, and 2000 reveals that themajor increases in women in the field have takenplace in the last quarter century (see Figure 1). Fur-ther, women entered the specialty at a time whenmany women patients specifically begun to requestwomen physicians. But although women have clearlybecome important to the profession, issues remain forwomen such as representation in places of authority(such as the American Psychiatric Association) andthe slow rate at which women are progressingthrough the ranks of academic medicine (62).

THOUGHTS FOR THE FUTURE

As a number of investigators have pointed out, theincrease in the number of women entering medicineor psychiatry has not led to as dramatic an increasein women in leadership positions as would be ex-pected given the numbers (63, 64). Women in aca-demic medicine have continued to experience diffi-culties making it up the rungs of the academic ladder(65), although there has been progress in the last de-cade (66). Adding numbers of women in and of itselfmight not have resulted in meaningful change, sug-gesting that climate (67) and preconceived notionsabout women (68) might be continuing to act as sub-tle or even overt obstacles to women’s progress.

So if the sheer numbers of women have nothelped achieve gender equity within the profession,we should reassess women’s roles within the profes-sion, particularly in the training of new generationsof psychiatrists. Although it is risky to contemplate areturn to arguments about women’s special contri-butions (69), women could provide a number of use-

ful perspectives to the profession as a whole. As anumber of scholars have pointed out, the influx ofwomen into the profession, along with feminist cri-tiques of traditional medicine, have generated newdiscussions on proper relationships between doctorsand patients (70). Does the presence of women makea difference in the traditional doctor-patient relation-ship? Could women’s perspectives help with theproblem of the gap between empathy and the DSMapproach toward mental illness (71)? How will gen-der affect working relationships between psychia-trists and other members of the health care team suchas nurses and social workers? And what impact willfemale psychiatrists in leadership positions have onissues relating to the diagnosis and treatment ofwomen patients?

Women in teaching roles in psychiatry can do agreat deal to break down gender barriers. Facultywomen can be role models and provide formal, andinformal (72), mentoring to women and male medicalstudents and residents. As some female psychiatristspointed out in the 1970s, early generations of femalepsychiatrists had to make their way through hereto-fore untraveled territory for women as they com-pleted training, often without any encounter with fac-ulty women (73). The current increasing presence ofwomen in psychiatry, particularly in teaching roles,can help all students and residents explore the wid-ening possibilities for women and men in psychiatry.

We need to understand the ways in which tra-ditional gender roles have affected men and womenin a variety of settings, from individual physician-patient relationships to the relationships between fac-ulty members and Chairs/administration to the rela-tionship between physicians and society. Are femalepsychiatrists less likely than men to seek leadershippositions in the profession, either by personal incli-nation, alternative priorities (such as families), or be-cause women tend to define themselves as powerless(74)? Are women not seeking advanced academic po-sitions because of a lack of women role models andmentors who show them that women can be success-ful in psychiatry? Based on existing historical workin psychiatry, it will not be enough to simply shiftlogistical details to have a meaningful increase inwomen in psychiatry (although some shifting clearlyneeds to occur for women and men to embark onchallenges such as research careers [75]). Women inteaching roles are an important resource to women in



training and the profession as a whole. As psychiatrycontinues to redefine itself in relation to society and

the rest of medicine, it would be a good time to assessthe role of gender in these professional transitions.

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