Psychiatry and Women—Status: It’s Complicated

IWMPost Article

Throughout history, as in La Salpêtrière hospital in Paris or the theories of Sigmund Freud in Vienna, psychiatry has been often wielded as a tool to silence women who dared to challenge societal norms. The boom in reproductive psychiatry in the United States has started a revolution for tackling better the gender bias in the diagnosis and treatment of the mental health of women.

Upon arriving at the IWM on a Milena Jesenská Journalistic Fellowship, I was unexpectedly drawn into a serendipitous connection with the story of Milena. This brilliant mind of the Viennese intelligentsia of the beginning 20th century is mostly remembered for being the greatest love of Franz Kafka—having a brief liaison with one of the most famous male writers of your time certainly does not help to highlight your remarkable journalistic legacy. In 1917, aged 17, on the order of her father, Milena spent a few months confined within the walls of the Veleslavín insane asylum in Prague, following a vague diagnosis of “moral insanity.” Her perceived unconventional behavior, particularly her romantic involvement with a man that her father did not approve of, prompted her incarceration. Her poignant story is not unique. For a significant period, psychiatry was used to “treat” or to “cure” women who were a bit too free or too independent for their time.

Statistics continue to reveal an enduring stark disparity between genders when it comes to mental health experiences. Women are three times more likely than men to experience mental health issues. This state of affairs prompted the core of my research: Is mental disease a female specificity, or is society so ill-suited to the female gender that it pushes women automatically to the brink—and to the shrink?

I started my investigative journey on this thrilling topic in 2022 as a reporter investigating a high-profile criminal case in Germany: that of Christiane K., a 27-year-old woman who killed five of her six children in September 2020 between two COVID-19 lockdowns. Though she pleaded not guilty and was the victim of repeated sexual and domestic violence, she received a life sentence. What struck me about this case was not solely the criminal act itself, although few crimes are as taboo as infanticide by women. Rather, it was how it raised the societal perceptions of and judgments cast upon women, particularly mothers, who break down and through their violence—or desperation—challenge the whole myth of maternal perfection and the patriarchal underpinnings of society. How are women, especially mothers, evaluated and perceived? To what extent do gender biases pervade criminal justice systems? Moreover, how does psychiatry, particularly within judicial contexts, discredit or validate women’s behaviors? How can we ensure that forensic psychiatric assessments are accurate and devoid of gender discrimination?

As the result of a blend of chance and audacity, Christiane K.’s lawyer granted me unrestricted access to trial documents, witness testimonies, police reports, and psychiatric evaluations. Additionally, I met Christiane in prison several times, and we interacted regularly through talks and letters. While in Vienna, finishing the first version of a book that will soon be published in France and in Germany, I received around 60 letters written on school paper: the private journal of Christiane in jail—an incredible journey through her mind, memories, and traumatic psychiatric past. Above all, an incredible journey about what it means to be a mother, with all its ambivalences. 

As I later discovered through my research at the IWM, psychiatry assesses women through antiquated methodologies—employing tests, questionnaires, and evaluation frameworks developed in a political and social context where the role of women was clearly and narrowly defined: to be at home, with children, without the slightest financial autonomy or intellectual independence. Analogous to traditional medicine, the diagnosis of mental illnesses such as schizophrenia and autism is predicated on criteria largely centered on male experiences.

A telling experiment by psychiatrists Marti Loring and Brian Powell in the 1990s exemplifies this bias: they tasked 290 male and female psychiatrists with assessing two case studies of patient behavior, using standardized diagnostic criteria. When the patients were depicted as “male,” 56 percent received a diagnosis of schizophrenia, whereas 20 percent were when they were characterized as “female.” Another study revealed that clinicians in the United States equated “mentally healthy adult” behavior with “mentally healthy male” conduct. Consequently, women were often deemed less mentally healthy if they deviated from stereotypical “male” behavior. The syndrome of “hysteria” was expunged from the Diagnostic and Statistical Manual of Mental Disorders, often called the bible of psychiatry, only in 1980—a telling sign about the modernity of the discipline.

More recently, some data indicated a disproportionate use of chemical restraints on women in psychiatric facilities during the COVID-19 pandemic, particularly in the United Kingdom. An investigation by The Independent, based on National Health Service statistics collected from October 2020 to February 2021, revealed that 63 percent of thousands of forced chemical restraints administered monthly in psychiatric facilities were on women. Another inquiry in 2022 exposed a gender imbalance in electroconvulsive therapy (ECT) prescriptions in the United Kingdom, with women making up two-thirds of recipients. And this though research has shown women are also more likely to experience more frequent and severe side effects, including retrograde amnesia, which is attributed to the lack of dose adjustment per ECT session.

In a transatlantic echo to the Christiane K. story, the Lindsay Clancy case has sparked heated debates in the United States on maternal metal health. In January 2023, the 33-year-old nurse and mother from Massachusetts, described as wholly devoted to them, strangled her three children—aged five years, three years, and eight months—to death before attempting suicide. In her ongoing trial, she has pleaded not guilty to infanticide on the basis that her actions had been driven by severe postpartum depression exacerbated by inappropriate medication. Alleging premeditation, prosecutors have sought the maximum penalty: life imprisonment. Often socially romanticized, motherhood can precipitate depression, psychosis, and, tragically, infanticide. Postpartum depression affects about 20 percent of new mothers and yet the first efficient treatment was only authorized in 2023 in the United States. When mothers harm or kill their children, legal systems struggle to discern illness from intent. Suicide is the leading cause of death for young mothers within a year following childbirth. Mental health complications during pregnancy and after giving birth are prevalent but remains a glaring blind spot.

All of this shows why “reproductive psychiatry” is a crucial development, at least in the United States. Taught at universities, this new discipline boasts specialized physicians and dedicated units. It has started a revolution in the way psychiatry considers women, encompassing various conditions and experiences throughout the reproductive-health spectrum. From conception attempts to pregnancy, postpartum, and menopause, reproduction marks a significant milestone in many women’s lives, often precipitating mental health challenges from depression to mood disorders. While female mental health during menopause remains inadequately understood, reproductive psychiatry can provide vital support for menopausal patients grappling with mood disorders, cognitive changes, identity crises, sexual health concerns, and more. Following pregnancy and postpartum, perimenopause represents another critical juncture marked by heightened depression and anxiety, influenced by hormonal, immunological, and autoimmune factors. The boom in reproductive psychiatry, with its experts, new theories, tailored treatments, and clinics dedicated to women challenges the historical narrative of women’s insanity and could be the antidote to the longtime androcentric conception of what mental illness means. Stories such as those of Milena or Christiane K. should serve as a rallying cry to improve the understanding of the mechanisms of mental illness for more social justice and fair healthcare.

Prune Antoine is an independent reporter and novelist. She was a Milena Jesenská Fellow at the IWM in 2023.