Misogyny in psychiatry

"Tone A, Koziol M. 

(F)ailing women in psychiatry: lessons from a painful past

CMAJ. 2018 May 22;190(20):E624-E625. doi: 10.1503/cmaj.171277.

...The history of psychiatry is replete with examples of poor outcomes for women in need, often women who sought medical help. Lobotomies are an extreme but illustrative example. Ask medical students about the lobotomy’s history and you will probably hear a narrative similar to that of the US Public Broadcasting Service’s (PBS) acclaimed 2008 documentary, The Lobotomist. In the 1940s, when psychiatric asylums were understaffed, underfunded and overcrowded, neuropsychiatrist Dr. Walter Freeman popularized psychosurgery to “liberate” patients from the hopelessness of therapeutic nihilism and the probability of lifelong custodial care. The most frequently performed lobotomy was the transorbital. A physician guided a long cannula (Freeman first used an ice pick) through the patient’s eye socket and into the brain and then moved it left to right — a motion some have compared with that of a windshield wiper — to sever the patient’s lower frontal lobes. In 1937, Freeman and surgeon James Watts published on the surgery’s benefits, based on a case study of six patients with psychiatric symptoms. They credited the surgery for alleviating patients’ symptoms: “insomnia, nervous tension, apprehension and anxiety.”² They identified drawbacks, too. Patients were “more comfortable,” but markedly more docile. “Every patient loses something by this operation,” they conceded. “Some spontaneity, some sparkle.”² All the same, scientific acceptance of lobotomies grew. In 1949, its putative founder was awarded a Nobel Prize. By 1952, an estimated 50 000 patients in the United States and Canada had been lobotomized.

What the documentary omits is that most lobotomized patients were women, although most institutionalized patients at the time were men. This gaping disparity, noted by scholars, is made more troubling by the general silence surrounding it today.³ Yet the disparity has been in plain view from the start. Five of the six patients in the case study by Freeman and Watts were women whose symptoms — apprehension, insomnia — seem incommensurate with their treatment, but whose status as women sanctioned it. A patient previously fearful of aging could now “grow old gracefully” and care for her home. She complained of a lack of spontaneity, but her husband praised the changes her surgery had wrought, declaring her “more normal than she had ever been,” possibly the least credible measure of therapeutic success in the annals of history.² By 1942, 75% of the lobotomies Freeman and Watts had performed were on women.

It wasn’t just Freeman and Watts. A comprehensive survey of US psychiatric facilities between 1949 and 1951 found that most patients lobotomized by doctors were women.⁴ At a time when women were expected to be calm, cooperative and attentive to domestic affairs, definitions of mental illness were as culturally bound as their treatments. A surgery that rendered female patients docile and compliant, but well enough to return to and care for their homes, had many proponents before the drug chlorpromazine, the first “major” tranquilizer, became available in 1954.

Chlorpromazine’s success launched our modern psychopharmcologic era, anointing drugs as the treatment of choice in asylum and outpatient psychiatry. Tellingly, prescribing patterns reinforced earlier tropes. By 1968, the “minor” tranquilizer Valium (diazepam), marketed as an antidote for socially dysfunctional women — the excessively ambitious, the visually unkempt, the unmarried and the menopausal misfits — was the best-selling drug in the world as well as one prescribed overwhelmingly to women.⁵ ..."

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I admit that, while I admired Ken Kesey's One Flew Over the Cuckoo's Nest in my youth, today I see its blatant misogyny and rape apology.