Psychological Aspects Womens Health PDF

Psychological Aspects of
Womens Health Care

The Interface Between
Psychiatry and
Obstetrics and Gynecology
Second Edition
This page intentionally left blank
Womens Health Care
The Interface Between Psychiatry
and Obstetrics and Gynecology
Second Edition
Edited by
NADA L. STOTLAND, M.D., M.P.H.
DONNA E. STEWART, M.D., D.PSYCH., F.R.C.P.C.
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book
concerning drug dosages, schedules, and routes of administration is accurate
as of the time of publication and consistent with standards set by the U.S.
Food and Drug Administration and the general medical community. As
medical research and practice advance, however, therapeutic standards may
change. For this reason and because human and mechanical errors sometimes
occur, we recommend that readers follow the advice of a physician who is
directly involved in their care or the care of a member of their family.
Books published by the American Psychiatric Press, Inc., represent the views
and opinions of the individual authors and do not necessarily represent the
policies and opinions of the Press or the American Psychiatric Association.
Copyright 2001 American Psychiatric Press, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
04 03 02 01 4 3 2 1
Second Edition
American Psychiatric Press, Inc.
1400 K Street, N.W.
Washington, DC 20005
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Library of Congress Cataloging-in-Publication Data
Psychological aspects of womens health care : the interface between psychiatry
and obstetrics and gynecology / edited by Nada L. Stotland, Donna E. Stewart.
2nd ed.
p. cm.
Includes bibliographical references and index.
ISBN 0-88048-831-X (acid-free paper)
1. GynecologyPsychosomatic aspects. 2. ObstetricsPsychosomatic
aspects. I. Stotland, Nada Logan. II. Stewart, Donna E., 1943-
RG103.5 .P7725 2000
618.019dc21
00-033141
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Cover image: Digital Imagery copyright 2000 PhotoDisc, Inc.
This book is dedicated to Harold, Lea, Naomi, Eve, and
Hanna Stotland and to
Eileen Stewart, Andrew Malleson, M.D., and Michael Malleson.
The editors wish to thank Janet Dalzell, Jennifer Wood, and the staff at
the University Health Network Womens Health Program,
who made this book possible.
Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
ROBERT O. PASNAU, M.D.
1 The Interface Between Psychiatry and Obstetrics and

Gynecology: An Introduction . . . . . . . . . . . . . . . . . . . . 1
I
Pregnancy
2 Normal and Medically Complicated Pregnancies . . . . . . 13

DIANE A. PHILIPP, M.D., F.R.C.P.C.
MELANIE L. CARR, M.D., F.R.C.P.C.
3 Fetal Anomaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
GAIL ERLICK ROBINSON, M.D., D.PSYCH., F.R.C.P.C.
KATHERINE L. WISNER, M.D., M.S.
4 Psychiatric Disorders During Pregnancy . . . . . . . . . . . 51

LAURA J. MILLER, M.D.
5 Psychotropic Drugs and Electroconvulsive Therapy

During Pregnancy and Lactation . . . . . . . . . . . . . . . . . 67
DONNA E. STEWART, M.D., D. PSYCH., F.R.C.P.C.
6 Adolescent Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 95
DIANA L. DELL, M.D., F.A.C.O.G.
7 Postpartum Disorders . . . . . . . . . . . . . . . . . . . . . . . . 117
8 Perinatal Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

IRVING G. LEON, PH.D.
II
Gynecology
9 Psychological Aspects of the Menstrual Cycle . . . . . . . 177

MARGARET F. JENSVOLD, M.D.
CORINNA E. DAN, R.N., B.S.N.
10 Infertility and the New Reproductive Technologies . . . 205

JENNIFER I. DOWNEY, M.D.
11 Induced Abortion in the United States . . . . . . . . . . . 219

NADA L. STOTLAND, M.D., M.P.H
12 Menopause: Myths and Realities . . . . . . . . . . . . . . . . 241

BARBARA B. SHERWIN, PH.D.
13 Chronic Gynecologic Pain. . . . . . . . . . . . . . . . . . . . . 261

JOHN F. STEEGE, M.D.
ANNA L. STOUT, PH.D.
14 Gynecologic Disorders and Surgery . . . . . . . . . . . . . . 277

PAULA J. ADAMS HILLARD, M.D.
15 Gynecologic Oncology . . . . . . . . . . . . . . . . . . . . . . . 307

LINDA HAMMER BURNS, PH.D.
16 Women and HIV Infection . . . . . . . . . . . . . . . . . . . . 331

JAN MOORE, PH.D.
DAWN K. SMITH, M.D., M.S., M.P.H.
III
General Issues
17 Reproductive Choices and Development:

Psychodynamic and Psychoanalytic Perspective . . . . . 365
MALKAH TOLPIN NOTMAN, M.D.
CAROL C. NADELSON, M.D.
18 Female Sexual Disorders. . . . . . . . . . . . . . . . . . . . . . 379

ROBERT TAYLOR SEGRAVES, M.D., PH.D.
KATHLEEN BLINDT SEGRAVES, PH.D.
19 Psychopharmacology in Women . . . . . . . . . . . . . . . . 401

OLGA BRAWMAN-MINTZER, M.D.
KIMBERLY A. YONKERS, M.D.
20 Alcohol and Substance Abuse in Obstetrics and

Gynecology Practice . . . . . . . . . . . . . . . . . . . . . . . . . 421
SHEILA B. BLUME, M.D., C.A.C.
MARCIA RUSSELL, PH.D.
21 Eating Disorders and Reproduction . . . . . . . . . . . . . . 441

22 Breast Disorders and Breast Cancer . . . . . . . . . . . . . . 457

BARBARA L. ANDERSEN, PH.D.
WILLIAM B. FARRAR, M.D.
23 Women and Violence . . . . . . . . . . . . . . . . . . . . . . . . 477

CAROLE WARSHAW, M.D.
24 Psychological Aspects of Lesbian Health Care . . . . . . 549

MARGERY S. SVED, M.D.
25 Ethics and Womens Health . . . . . . . . . . . . . . . . . . . 571
26 The Male Perspective . . . . . . . . . . . . . . . . . . . . . . . . 585

MICHAEL F. MYERS, M.D., F.R.C.P.C.
27 Collaborations Between Psychiatry and

Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . 597
28 What Is a Minority? Issues in Setting and Dialogue . . 611

MINDY THOMPSON FULLILOVE, M.D.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
Contributors
Barbara L. Andersen, Ph.D.

Departments of Psychology and Obstetrics and Gynecology, Ohio State
University, Columbus, Ohio
Sheila B. Blume, M.D., C.A.C.

Former Medical Director, Alcoholism, Chemical Dependency and
Compulsive Gambling Programs, South Oaks Hospital, Amityville, New
York; Clinical Professor of Psychiatry, State University of New York at
Stony Brook, Stony Brook, New York
Olga Brawman-Mintzer, M.D.

Associate Professor of Psychiatry, Mood and Anxiety Program, Department
of Psychiatry, Medical University of South Carolina, Charleston, South
Carolina
Linda Hammer Burns, Ph.D.

Licensed Psychologist; Assistant Professor, Department of Obstetrics and
Gynecology, University of Minnesota Medical School, Minneapolis,
Minnesota
Melanie L. Carr, M.D., F.R.C.P.C.

Department of Psychiatry, University Health Network, Toronto, Ontario,
Canada
xi
xii Psychological Aspects of Womens Health Care, Second Edition
Corinna E. Dan, R.N., B.S.N.

Community Health Nurse and Program Coordinator, Department of
Adolescent Health/Health Education and Outreach, Erie Family Health
Center, Chicago, Illinois
Diana L. Dell, M.D., F.A.C.O.G.

Assistant Professor, Departments of Obstetrics and Gynecology and
Psychiatry, Duke University Medical Center, Durham, North Carolina
Jennifer I. Downey, M.D.

Associate Clinical Professor of Psychiatry, Columbia University College of
Physicians and Surgeons, New York, New York
William B. Farrar, M.D.

Department of Surgery, Ohio State University, Columbus, Ohio
Mindy Thompson Fullilove, M.D.

Associate Professor of Clinical Psychiatry and Public Health, Columbia
University; Research Psychiatrist, HIV Center for Clinical and Behavioral
Studies, New York State Psychiatric Institute, New York, New York
Paula J. Adams Hillard, M.D.

Professor, Department of Pediatrics, Childrens Hospital Medical Center;
Professor, Department Obstetrics and Gynecology, and Director of
Womens Health, University of Cincinnati College of Medicine, Cincinnati,
Ohio
Margaret F. Jensvold, M.D.

Senior Scientist, Institute for Research on Womens Health, Washington, DC;
Center for Life Strategies, Bethesda, Maryland
Irving G. Leon, Ph.D.

Lecturer, Department of Psychology, University of Michigan, Ann Arbor,
Michigan
Contributors xiii
Laura J. Miller, M.D.

Associate Professor and Chief, Womans Services Division, Department of
Psychiatry, University of Illinois at Chicago, Chicago, Illinois
Jan Moore, Ph.D.

Division of HIV/AIDSEpidemiology Branch, Centers for Disease Control
and Prevention, Atlanta, Georgia
Michael F. Myers, M.D., F.R.C.P.C.

Director, Marital Therapy Clinic, Department of Psychiatry, St. Pauls
Hospital; and Clinical Professor, Department of Psychiatry, University of
British Columbia, Vancouver, British Columbia, Canada
Carol C. Nadelson, M.D.

Clinical Professor, Department of Psychiatry, Harvard Medical School;
Director, Office for Womens Careers, Brigham and Womens Hospital,
Boston, Massachusetts; and President, CEO, and Editor-in-Chief,
American Psychiatric Press, Washington, DC
Malkah Tolpin Notman, M.D.

Clinical Professor of Psychiatry, Cambridge Hospital, Harvard Medical
School; and Training and Supervising Psychoanalyst, Boston
Psychoanalytic Institute, Boston, Massachusetts
Robert O. Pasnau, M.D.

Professor Emeritus, Department of Psychiatry, University of CaliforniaLos
Angeles School of Medicine, Los Angeles, California
Diane A. Philipp, M.D., F.R.C.P.C.

Staff Child Psychiatrist, Hincks and Dellcrest Treatment Centre, University
of Toronto, Toronto, Ontario, Canada
Gail Erlick Robinson, M.D., D.Psych., F.R.C.P.C.

Professor in Psychiatry and Obstetrics/Gynecology, University of Toronto;
Director, Programme in Womens Mental Health, Department of
Psychiatry, University Health Network, Toronto, Ontario, Canada
xiv Psychological Aspects of Womens Health Care, Second Edition
Marcia Russell, Ph.D.

Senior Research Scientist, Prevention Research Center, Berkeley, California
Kathleen Blindt Segraves, Ph.D.

Associate Professor, Department of Psychiatry, Case Western Reserve
University; and Director, Behavioral Medicine Service, Department of
Psychiatry, Metrohealth Medical Center, Cleveland, Ohio
Robert Taylor Segraves, M.D., Ph.D.

Professor, Department of Psychiatry, Case Western Reserve University; and
Chairperson, Department of Psychiatry, Metrohealth Medical Center,
Cleveland, Ohio
Barbara B. Sherwin, Ph.D.

Professor, Departments of Psychology and Obstetrics and Gynecology, McGill
University; and Co-Director, Menopause Clinic, McGill University Health
Center, Montreal, Quebec, Canada
Dawn K. Smith, M.D., M.S., M.P.H.

Medical Epidemiologist, Division of HIV/AIDS PreventionSurveillance and
Epidemiology, Centers for Disease Control and Prevention, Atlanta,
Georgia
John F. Steege, M.D.

Professor, Department of Obstetrics and Gynecology, University of North
Carolina, Chapel Hill, North Carolina
Donna E. Stewart, M.D., D.Psych., F.R.C.P.C.

Professor, Departments of Psychiatry, Obstetrics and Gynecology, Anesthesia,
Surgery, Medicine, and Family and Community Medicine, University of
Toronto; and Lillian Love Chair in Womens Health, University Health
Network, Toronto, Ontario, Canada
Contributors xv
Nada L. Stotland, M.D., M.P.H.

Professor, Departments of Psychiatry and Obstetrics and Gynecology, Rush
Medical College; and Chair, Department of Psychiatry, Illinois Masonic
Medical Center, Chicago, Illinois
Anna L. Stout, Ph.D.

Associate Professor, Departments of Psychiatry and Behavioral Sciences and
Obstetrics and Gynecology, Duke University Medical Center, Durham,
North Carolina
Margery S. Sved, M.D.

Chief, Adult Psychiatry Service, Dorothea Dix Hospital, Raleigh, North
Carolina; Adjunct Associate Professor, Department of Psychiatry,
University of North Carolina School of Medicine, Chapel Hill, North
Carolina; and past president, Association of Gay and Lesbian Psychiatrists,
Philadelphia, Pennsylvania
Carole Warshaw, M.D.

General Internal Medicine and Primary Care, Cook County Hospital; and
Clinical Associate Professor, Department of Psychiatry, University of
Illinois, Chicago, Illinois
Katherine L. Wisner, M.D., M.S.

Assistant Professor of Child Psychiatry, University of Pittsburgh; and Medical
Director, Pregnancy and Infant/Parent Center, Pittsburgh, Pennsylvania
Kimberly A. Yonkers, M.D.

Associate Professor, Department of Psychiatry, University of Texas
Southwestern Medical Center, Dallas, Texas
Foreword
ROBERT O. PASNAU, M.D.
This book is the long-anticipated sequel to the first edition of Psychological As-
pects of Womens Health Care written almost a decade ago. In this edition, the au-
thors continue the tradition of writing and speaking plainly about the
fascinating, and at times baffling, relationships between women patients and
their obstetrician and gynecologist physicians. As the authors note, the field
has changed dramatically since the first volume was published. The major
forces leading to these transformations have been the significant medical and
surgical advances in clinical practice and the prevailing attitudes toward
health care influenced by managed care. These transformations also reflect
the growing awareness that the interface between psychiatry and obstetrics/
gynecology is more than the old psychosomatic study of disease and symp-
toms. It now encompasses the behaviors and attitudes surrounding reproduc-
tion, human sexuality, and abuse.
The present book follows closely the outline of the first edition. Drs. Stot-
land and Stewart have solicited chapters from major leaders in the specialties
of psychiatry and obstetrics/gynecology covering every major area of contem-
porary concern, and they set a very high standard indeed. The first section is
devoted to pregnancy. As the authors explain, over the past 10 years scientists
have developed methods of genetic testing for preimplantation embryos and
for gene mutations responsible for some ovarian and breast cancers. Sextu-
plets have survived to full gestation. Research on the use of psychotropic
medications during pregnancy has also been more fully developed and stan-
dardized. The second section covers gynecology. Again, the progress in the
past decade in the management of HIV/AIDS and pelvic pain and in the psy-
xvii
xviii Psychological Aspects of Womens Health Care, Second Edition
chiatric aspects of the menopause are extensively reviewed. In the final sec-
tion, General Issues, the editors have been particularly effective in
providing widely ranging but fair reviews of subjects that include eating dis-
orders, sexual dysfunction, and violence against women, to mention only a
few. Of significant value is Dr. Stotlands chapter on the provision of consul-
tation-liaison services to obstetrics/gynecology services. This chapter, as is
true for all those preceding it, is well written and referenced and the style is
free and readable. The approach continues to be eclectic in the style of con-
temporary clinical psychiatry. The editors and the contributors have done
their parts in producing a useful, valuable, and scholarly book.
I recommend this volume for medical and nursing students, residents in
obstetrics/gynecology and psychiatry, and for all practicing clinicians work-
ing in the area of womens health.
1
The Interface Between Psychiatry
An Introduction
Since the first edition of this book was published, scientists have devised
techniques for genetic testing of preimplantation embryos and for the gene
mutations responsible for some familial breast and ovarian cancers. Sextuplets
have been brought to term. Knowledge of lesbian health and health care has
grown. HIV/AIDS has continued to spread disproportionately fast among
women, especially African-American women. The provision of health care
and the relationships between patients and health care professionals have been
drastically altered by managed care entities. Increased and better screening
has minimally decreased breast cancer deaths. Fewer women have access to
abortion services. We thank the chapter authors for bringing the results of
several years of new findings to this compendium of issues at the interface of
psychiatry and obstetrics and gynecology.
This interface may be conceptualized narrowly, as a subspecialty of the
psychiatric study of somatic symptoms and diseases (Alexander 1950). From
another perspective, however, psychosomatic obstetrics and gynecology in-
cludes a realm both broad and deep that begins with mens and womens feel-
ings and behaviors related to female reproductive physiology (Benedek and
Rubenstein 1942). It ranges from the events surrounding conceptionor its
1
2 Psychological Aspects of Womens Health Care, Second Edition
frustrationto reactions to terminal gynecologic malignancies. It encompass-

es the joyous embodiment of romantic love and the enactment of the most
brutal victimization. Although only a small percentage of psychiatric and oth-
er mental health professionals explicitly devote their clinical or academic
practices to this area, virtually all encounter these issues in their work with
patients and their families, with medical students, and with residents.
Although many organ systems and their pathologies are associated with
psychologic meanings, dynamics, conflicts, and symptoms, the relationship
between psychiatry and the reproductive system is especially rich. Hysteria
originally designated a psychiatric illness caused by the wanderings of the
uterus from its proper site in the pelvis. The term was coined over 2,000 years
ago and was still in use in the late twentieth century (Pomeroy 1975). Long
after dissection had demonstrated the realities of the anatomy of uterine con-
nections, Sigmund Freud linked hysteria to forbidden sexual wishes and sex-
ual frustration (Freud 1931/1961).
In 1891, JAMA published an article titled Can the Gynecologist Aid the
Alienist in Institutions for the Insane? (1891/1991). Portions of this article
were reprinted for historical purposes in 1991. The author or editor, who is
unnamed, cites the work as alleging a link between the functions, dysfunc-
tions, and removal of the ovaries and uterus and psychiatric illness and treat-
ment. A quote from the article asserted that oophorectomy may be relied
upon generally to cure insanity limited to the menstrual period(p. 3230); this
statement presaged attempts a century later to treat premenstrual symptoms.
Other recent controversies are also foreshadowed. Bemoaning the indisposi-
tion of alienists to accord the gynecologist a place in cooperation with them
the article explains,
there was said to have been too keen a desire to try oophorectomy as a pan-
acea for all kinds of insanity in women. There was also an effort made to
introduce female physicians upon this tide of so-called necessity, and thus
were blended disadvantageously questions of public policy, or expediency,
with what should have been scientific inquiry. (Can the Gynecologist Aid
the Alienist in Institutions for the Insane? 1891/1991, p. 3230)
Clinical work and experimental studies performed in the years after

Freuds major contributions have disproved some of his assumptions about
female psychosexual development, sexuality, and psychopathology. At the
same time, new facets of patients sexual histories prove to be as important in
the etiology of psychiatric illness as those asserted in the past, albeit in a dif-
ferent way. Many patients with personality disorders, posttraumatic stress
disorders, and other diagnoses have histories of sexual and physical abuse.
The Interface Between Psychiatry and Obstetrics and Gynecology 3
Sexually transmitted diseases and new reproductive technologies challenge

the psychologic coping mechanisms of patients and the skills of their psychi-
atrists today.
AIDS has introduced the possibility of a serious illness or a lingering
death into many sexual encounters (and into gynecologic care). The discrep-
ancy between knowing the methods by which disease transmission can be re-
duced and implementing those methods in interpersonal behavior remains
unresolved. Women and children are the fastest-growing populations infected
with the virus. In order to design and implement strategies to reduce the
transmission of HIV, public health workers must be informed of the psychol-
ogy, sociology, and anthropology of female reproductive behavior (see Chap-
ter 16). Breast and pelvic malignancies raise other psychosocial issues. The
exchange of knowledge between psychiatrists and obstetrician/gynecologists
(OB/GYNs) may improve the diagnosis and effective treatment of breast and
gynecologic malignancies by identifying the factors that deter women from
self-examination and regular medical screening. An awareness of these fac-
tors will help the psychiatrist enhance patient compliance by helping patients
understand and cope with their fear of pelvic examinations, and it will help
gynecologists adapt examination techniques to minimize emotional distress.
In other areas, improvements in outcomes and discoveries at the cutting
edge of theory and practice may have paradoxical effects. Among the middle
and upper classes, maternal and perinatal mortality rates have decreased and
anesthetic techniques have improved. Parents-to-be are informed of and par-
ticipants in obstetric decisions. Thus every couple demands to have a perfect
childbirth and a perfect child, and failure to meet those demands has, at least
in part, contributed to 80% of obstetricians in the United States having been
sued at least once for malpractice (Charles and Kennedy 1985).
These demands for perfection often begin not only before birth but also
before conception. Astounding, previously unimaginable developments in re-
productive technology seem to offer the possibility of biologic parenthood to
every infertile woman or couple (Christie and Pawson 1987). Yet these devel-
opments pose a host of problems, the resolution of which will require knowl-
edge of biology, psychology, sociology, anthropology, ethics, and law, but the
clinical dilemmas face psychiatrists in the field right now (Dickstein 1990). At
what point in the diagnostic and treatment process for infertility do continued
expense, life disruption, and bodily intrusion constitute an obsession? How
can the psychiatrist help the patient and the treatment team make prospective
policy and ongoing decisions? What ethical and psychiatric issues are raised
by the voluntary and paid donations of gametes, embryos, and gestational
services of one woman to another (Lantos 1990)? What roles, if any, should
psychiatrists play in screening, support, and treatment? Unprecedented fam-
ily constellations could offer us the opportunity to discern how family dy-
namics and psychologic development are shaped by genetics and by the
environment.
The dialogue between obstetrics and gynecology and psychiatry, and
among OB/GYNs, patients, and psychiatrists, is interwoven with social
change (Stotland 1988). Tensions are reflected in language: doctor and patient,
with their rich mutual obligations founded in age-old relationships, become
provider and consumer. Primum non nocere (First, do no harm) becomes caveat
emptor (Let the buyer beware). OB/GYNs are often womens primary care
physicians and the experts on their most intimate bodily parts. As such, they
become the object of the strong negative and positive attitudes of their pa-
tients; they are transferentially endowed by their patients with magical tech-
nical and emotional powers. In turn, most obstetricians offices are bedecked
with photographs of infants they have delivered, testimony to a mutual emo-
tional investment in their patients that goes beyond the skills of the ac-
coucheur.
Women have also reacted with vituperation to the actual and perceived
arrogance, insensitivity, psychologic ignorance, and authoritarianism of OB/
GYNs. Laypersons and medical gadflies have published books with titles
such as Male Practice: How Doctors Manipulate Women (Mendelson 1982), Seizing
Our Bodies: The Politics of Womens Health (Dreifus 1978), and Immaculate Deception:
A New Look at Women and Childbirth in America (Arms 1975) alleging and some-
times documenting negative physical and emotional effects of gynecologic in-
terventions, some of which are unsupported by scientific evidence. The book
Our Bodies, Ourselves (Boston Womens Health Collective 1984) conveys the
message that the self-esteem and physical health of women can be improved
by knowledge about their own anatomy, physiology, pathology, and treat-
mentthat this knowledge need not remain the arcane preserve of physicians.
Social scientists and other professionals have documented physicians de-
meaning attitudes toward women patients in articles such as A Funny Thing
Happened on the Way to the Orifice: Women in Gynecology Textbooks
(Scully and Bart 1973) and The Training of a Gynecologist: How the Old
Boys Talk About Womens Bodies(Hellerstein 1984). In some womens
consciousness-raising groups, women examined their own and each others
bodies in a more prosaic and immediate attempt to demystify, inform, and ac-
cept themselves. Self-help groups teaching and performing menstrual extrac-
tion and suction abortions as well as routine examinations moved into the
previous professional preserve. Other self-help or consumer groups continue

to focus on providing information, support, and preparation for reproductive
experiences such as infertility, pregnancy, childbirth, and breastfeeding (Bing
1973; La Leche League International 1987; Seiden 1978). Todays alterna-
tive approaches include baby massage and prenatal yoga.
In this environment, OB/GYNs practicing in good faith have been hard
put to fathom the skepticism, rage, and litigiousness of their patients. Few, if
any, specialties require such mastery of a combination of ever-increasing sci-
entific knowledge and technical skills in addition to long hours, legal liability,
and exposure to clinical situations of overwhelming emotional intensity
(Friedman 1986). Training programs in obstetrics and gynecology include lit-
tle instruction in psychodynamics, psychopathology, and interpersonal skills
either in formal didactics or by example. Often, the patient population in
teaching hospitals consists of disadvantaged women whose social circum-
stances distance them from the upper-middle-class doctors-in-training, pre-
vent them from seeking timely care, disincline them to complain about their
care, and interfere with the pleasures of a successful outcome (as when a res-
ident delivers a baby to an overwhelmed young teenager who will take it
home to a dangerous housing project). Trainees are brought face to face with
the medical outcomes of social problems, such as domestic violence, rape, in-
cest, and sexual abuse, that they do not have the time, knowledge, support,
or resources to address (Adler 1972). These factors conspire to increase their
focus on the cognitive knowledge and technical agility that their mentors
reward.
The changing circumstances of medical practice further erode opportu-
nities for doctors and patients to get to know and trust one another. Managed
care, with choices of plan made at the employer rather than consumer level,
inhibits or obliterates patients choices of physicians. Patients make frequent
geographic moves. Doctors have little motivation to understand their own re-
sponses to patients and medical situations, to examine patients responses to
them, or to develop skills that put patients at ease. Physicians practice in
groups and subspecialties, both of which decrease continuity of care. In fact,
it might be said that the sicker and/or more distressed a woman is, the less
likely it is that she will obtain care from a physician who is familiar with her
personality; defenses; usual responses to illness; family, religious, and social
supports; and other coping mechanisms. The psychiatrists role in providing
this sort of information and enhancing these skills is ever more important un-
der these circumstances (Dunbar 1954; Karasu et al. 1979; Lipowski 1986;
Stotland and Garrick 1990).
Contraception and induced abortion are areas in which personal feelings

about sexuality, reproduction, and gender roles as well as religious and cul-
tural rules and values color and politicize medical practice. Contrary to pop-
ular belief, abortion has been practiced throughout recorded history and was
permitted until a few centuries ago by the Roman Catholic Church (Newman
1991). New physicians, sworn by the Hippocratic and other oaths to protect
life, are arrayed opposite each other as they define life and the priorities of
one form of life over another. Legalization and the improvement of medical
techniques have reduced the gynecologic complications of induced abortion
to a small fraction of those of childbirth. The same is true for major psychi-
atric sequelae. The decision to terminate a pregnancy is a weighty one, how-
ever, necessarily made under the pressure of time and best made with support
and without coercion in either direction. Governmental restrictions on abor-
tion limit the options for poor and psychiatrically ill patients and the profes-
sional autonomy of psychiatrists and gynecologists to discuss those options
with their patients (Webster v. Reproductive Health Services 1989).
This volume is a clinical and theoretic sourcebook for the practitioner
facing the many universal and specific issues of obstetrics and gynecology
that arise in psychiatric practice. These issues may include presenting symp-
toms, as when a patient is referred for care after suffering a rape or being di-
agnosed with infertility or malignancy. In other cases, the role of the obstetric/
gynecologic event or condition in the psychiatric illness is not volunteered or
even recognized. Sexual abuse, a frequent feature in the history of patients
with several major psychiatric disorders, may require particularly informed
and expert diagnostic skills or several years of building trust in a psychother-
apeutic relationship to reveal itself. The fact that a psychotic, manic, or de-
pressed inpatient is postpartum may be apparent only when one learns her
childrens ages from the family or reproductive history. Feelings about a hys-
terectomy or the loss or termination of a pregnancy may play a role in the
dynamics of a current conflict. Women also have questions and concerns
about the psychiatric aspects of menstruation and menopause. We hope that
this work will remind readers of the many rich connections between psychi-
atry and obstetrics and gynecology and will inform their research, teaching,
and clinical work.
The choice of topics to be addressed in this book was determined by
three guiding principles: 1) What issues specific to women are encountered
by psychiatrists and other mental health workers? 2) What psychologic issues
should be considered in providing womens health care? 3) What are the spe-
cial problems seen in a consultation or liaison service to an obstetric/gyneco-
logic program? Notman and Nadelsons (1978) pioneering work in the area
of womens health is an excellent starting point, but the past two decades have
seen rapid technologic and theoretic developments. Thus, a fresh look at
some of the old issues and an attempt to explore some of the new dilemmas
are required. Nowhere is this more apparent than in the rapidly developing
field of new reproductive technologies. We have tried to emphasize those top-
ics in which new developments have occurred. We have been guided in our
choice of subjects by our clinical work, in which we daily see women referred
by physicians for problems specific to their gender. Our research in psycho-
somatic obstetrics and gynecology and our teaching of medical students and
residents has helped to focus our attention on those issues that are most com-
mon and problematic.
This book is divided into three sections: Pregnancy, Gynecology,
and General Issues. The Pregnancy section consists of seven chapters
covering topics ranging from the psychology of normal gestation to physical
and psychiatric complications during and following pregnancy. Robinson
and Wisners chapter on fetal anomalies (Chapter 3) addresses the new pre-
natal diagnostic techniques as well as the management of dynamic issues that
emerge when abnormalities are detected. In Chapter 5, Stewart and Robin-
son discuss the use of psychotropic drugs and electroconvulsive therapy in
the pregnant and lactating patient. Dells chapter on adolescent pregnancy
(Chapter 6) explores the etiologic factors and treatment strategies for this
population. Leons chapter on perinatal loss (Chapter 8) describes the emo-
tional reactions of parents bereaved by miscarriage, stillbirth, or neonatal
death and suggests approaches for treating clinicians.
The Gynecology section consists of eight chapters dealing with both
common gynecologic problems and some of the more controversial issues
such as induced abortion and the new reproductive technologies. In Chapter
9, Jensvold and Dan explicate the role of the menstrual cycle in exacerbating
as well as precipitating psychologic symptoms in biologic and social contexts.
Sherwin gives a comprehensive account of the psychiatric aspects of meno-
pause in Chapter 12 and reviews the sometimes confusing literature on exog-
enous hormone administration. In Chapter 13, Steege and Stout discuss the
assessment of chronic pelvic pain and its management by the gynecologist
and/or mental health professional. In Chapter 15, Burns presents a thought-
ful overview of the psychosocial concomitants of gynecologic malignancies as
well as the emotional demands on the oncology team itself. Finally, in Chap-
ter 16, Moore and Smith consider the special meanings and implications of
HIV/AIDS for women.
The General Issues section addresses several timely topics. We have

tried to present a broad and balanced picture. A psychodynamic perspective
on reproductive choices and development is offered by Notman and Nadel-
son in Chapter 17. Segraves and Segraves, in Chapter 18, offer the latest wis-
dom on sexuality, sexual dysfunction, and sex therapy. Substance abuse
(Chapter 20) and eating disorders (Chapter 21) are other issues too frequent-
ly overlooked in obstetrics and gynecology practice and are discussed here by
Blume and Russell and by Stewart and Robinson, respectively. Andersen and
Farrars chapter on breast disorders and breast cancer (Chapter 22) is espe-
cially important in this era when uninformed fears of breast cancer influence
womens compliance with medical recommendations and considerable con-
troversy about diagnosis and treatment persists. Violence against women, in
the form of spousal abuse, rape, and incest, has a major impact on their phys-
ical and emotional health. Recent findings have altered both diagnostic and
treatment approaches, as discussed by Warshaw in Chapter 23. Sved, in a
chapter new to this edition (Chapter 24), discusses the special and insuffi-
ciently acknowledged health care issues for lesbian patients. The rapidly
changing health care scene adds new ethical and legal issues, discussed by
Nadelson in Chapter 25, to the already complex world of womens health. In
Chapter 26, Myers addresses a topic often missing in works of this kind: the
reactions of men to womens reproductive events. In Chapter 27, Stotland ad-
dresses the provision of psychiatric consultation and liaison to obstetric and
gynecologic services. Finally, Fullilove addresses the meaning of minority sta-
tus in Chapter 28.
This book can be used for teaching medical and other health care stu-
dents, as a reference for residents in psychiatry and obstetrics/gynecology,
and to inform the clinician who is working to improve the care provided to
women patients.
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I
Pregnancy
2
Normal and Medically
Complicated Pregnancies
DIANE A. PHILIPP, M.D., F.R.C.P.C.
MELANIE L. CARR, M.D., F.R.C.P.C.
The miracle of pregnancy and the transformation of women into mothers

has fascinated people from antiquity to the present. However, it is only during
the past century that mental health professionals have begun to contribute to
our understanding of the psychologic aspects of pregnancy and the psycho-
social phases that women pass through on their journey into motherhood.
Although this century has seen tremendous strides in the field of obstetrics,
including the management of formerly nonviable high-risk pregnancies, there
is a lag in our understanding of womens psychologic adaptations to medically
complicated pregnancies. In this chapter, we begin by exploring the psycho-
logic aspects of normal pregnancies, particularly in first-time mothers. Next,
by providing a brief overview of medically complicated pregnancies, we create
a framework for examining current understanding of the psychologic adap-
tation of pregnant women to their high-risk status. Finally, we consider the
role of the psychiatrist consultant to obstetrics and gynecology.
The Psychoanalytic View
The psychoanalytic movement was among the first to consider the psycho-
logic meaning of pregnancy to young girls and women. Although Freuds
theory regarding pregnancy is now viewed as antiquated, it bears brief men-
13
tioning because it was the dominant view for much of the twentieth century.
Freud understood the female wish for pregnancy by adapting his notion of
the Oedipal conflict to girls. He believed that young girls, in coming to terms
with the absence of a penis, initially blamed their mothers for their castrat-
ed bodies and turned to their fathers to replace the lost penis. Freud
viewed the final resolution of this phase as a replacement of the wish for a
penis by the wish for a baby (Freud 1933/1964).
As more women began to offer their perspective in the psychoanalytic
arena, the emphasis began to shift away from this notably phallocentric ex-
planation. Influential in finally breaking with the older view, Benedek (1970)
saw pregnancy as a basic biologic drive in women, not merely a substitutive
function:
Thus motherhood is not secondary, not a substitute for the missing penis,
nor is it forced by men upon women in the service of the species, but the
manifestation of the all-pervading instinct for survival in the child that is the
primary organizer of the womans sexual drive, and by this also her person-
ality. (p. 139)
These ideas have been developed in more recent reports by authors who
have seen the wish for motherhood as based not only on biologic drive but
also on an identification with what is essentially female. Several therapists
have noted a richness in themes of identification with the womans own
mother (Kestenberg 1977; Lester and Notman 1986; Pines 1972, 1982). Over
the course of the past century a shift has occurred in the psychodynamic con-
ceptualization from viewing pregnancy as a wish for a penis like the father
toward an acceptance of the importance of an identification with the mother.
Psychologic Stages of Normal Pregnancy
In the late 1950s, Greta Bibring set out to do a longitudinal study of normal
pregnant women using a multidisciplinary team of mental health and health
care professionals (Bibring 1959; Bibring et al. 1961). As a result of her ob-
servations, Bibring postulated that pregnancy, like puberty or menopause,
is a period of crisis involving profound psychologic as well as somatic chang-
es (Bibring 1959, p. 116). Further elaborating on the analogy to puberty and
menopause, she noted that these are all biologically mediated transitions
from which there is no return. Once one becomes a mother there is no return-
ing to the previous childless stage (Bibring 1959). We would add that the ad-
Normal and Medically Complicated Pregnancies 15
vent of effective contraception and the legalization of abortion have placed

pregnancy in a unique position; it is the only developmental stage that may
or may not be embarked upon depending on a womans choice and her cul-
tural milieu. Bibring was perhaps the first to describe normal stages of psy-
chologic development in pregnancy (Bibring et al. 1961). Numerous other
investigators have provided greater detail about the phases of pregnancy; we
attempt to synthesize the various perspectives in this chapter.
Although most authors view the psychologic stages of pregnancy as be-
ginning with conception, we find it more useful to use a broader context and
consider the development of mothers as beginning in childhood and continu-
ing well into the postpartum. Girls can be observed preparing for mother-
hood by trying on the role in play. As Morris (1997) pointed out, a familiar
scene is that of young girls fighting over who will play the mother in a simple
game of house. Stern (1995), writing from the perspective of an infant psy-
chiatrist, suggested that long before conception occurs, the young girl or
woman imagines herself as a mother as well as imagining her infant and child.
When the woman finds a partner, these representations and schemas, as
Stern calls them, undergo further elaboration because she now has new infor-
mation about the childs future father. Once pregnant and into the postpar-
tum, the woman is faced with increasing information about the fetus, herself,
and her husband, and so the internal representations of these individuals
evolve (Stern 1995).
Once conception has occurred, there are three distinct psychologic phas-
es that most women pass through during their pregnancies. These stages
roughly correspond to the three trimesters of pregnancy and appear to be
triggered by various psychologic, biologic, and cultural influences. The first
stage of pregnancy is usually thought to begin when the woman realizes she
is pregnant and to last until she experiences quickening (fetal movements), at
approximately 4 1 2 months. During this stage, as new and often uncomfort-
able physical symptoms develop in the expectant mother, ambivalence about
the pregnancy is common. Ultimately, in a wanted pregnancy, the fundamen-
tal task of this first stage is the acceptance of the pregnancy (Sandelowski and
Black 1994). Women struggling with this task may show behavioral signs,
such as denial of the pregnancy or unusual reactions to bodily changes (Co-
hen 1979).
Several other psychologic changes begin at this time. In the clinical liter-
ature, psychologic slippage or forgetfulness has been described (Raphael-
Leff 1991). Only recently has this notion been examined empirically, in a
cross-sectional study of memory in pregnancy (Sharp et al. 1993). This study
confirms womens subjective experiencesover 80% of the pregnant women

studied perceived their memory as impaired compared with only 16% of non-
pregnant control subjects. On objective measures of memory, the pregnant
subjects were significantly impaired in comparison with control subjects in
their recall of lists of words. Because no differences were found in the perfor-
mances of women among the three trimesters, the authors concluded that no
single hormone could be singled out as causative. Certainly one might have
expected that the rising levels of estrogen in pregnancy would, in fact, be pro-
tective because estrogen has been found to heighten verbal memory in wom-
en (B. B. Sherwin 1998). Nevertheless, beginning in the first trimester and
continuing into the early postpartum period, a womans memory may be
somewhat compromised. This change can become clinically significant in sit-
uations in which patients are given large amounts of information to retain.
The predominant fear expressed by women in the first trimester of a
wanted pregnancy is a fear of miscarriage (Leifer 1977). Other themes of this
stage include increased emotionality, preoccupation with bodily needs (par-
ticularly food), and an obsession with her secret (Raphael-Leff 1991).
Many women continue to keep the pregnancy secret until they have passed
into the second trimester. As the viability of the pregnancy seems more en-
sured, the mother embarks on the telling process. She typically progresses
in a hierarchic order from those closest to her outward (Raphael-Leff 1991;
Rubin 1970).
The second psychologic phase of pregnancy was historically thought to
be initiated by quickening and the undeniable realization that life exists with-
in. With the advent of fetal ultrasound, the progression into this next phase
of development may be accelerated for some women (Raphael-Leff 1991).
Regardless, with the reduction or disappearance of many unpleasant physical
symptoms, the second trimester of a womans pregnancy is a time of relative
peace and fulfillment. The most important tasks for a woman in this stage are
initiating an emotional affiliation with, or attachment to, the fetus and recog-
nizing the fetus as a separate individual contained within her (Bibring et al.
1961; Cohen 1979; Leifer 1977; Lester and Notman 1986; Pines 1982;
Raphael-Leff 1991).
In his work, Stern (1995) pointed out that from about the fourth to the
seventh month there is rapid growth in the richness, quantity, and specificity
of the networks of schemas about the baby-to-be (p. 23). This is apparently
heralded by either quickening or by fetal ultrasound. Also at this time, signs
of motherliness or a wish to nurture the infant become apparent (Lester
and Notman 1986). Leifer (1977) identified several behaviors indicative of at-
tachment such as talking to the fetus, calling the fetus by a pet name, and ma-
neuvering the fetus so that the partner may observe movement.
Hormonal correlates of maternal attachment were examined in a large,
multicenter study of pregnancy. Fleming and colleagues (1997) used both
cross-sectional and longitudinal data and found that attachment to the fetus
significantly increased between the first and second trimesters. However, no
correlation was found between the hormonal changes of pregnancy and the
measures of maternal attachment assessed during pregnancy. Interestingly, an
increase in the estradiol to progesterone ratio (E/P) through the course of
pregnancy was consistently related to stronger feelings of attachment in the
postpartum. Therefore, hormonal factors may contribute to attachment, par-
ticularly in the early postpartum.
With the sensation of fetal movements, the mother begins to recognize
the fetus as a separate entity. Issues of separation and individuation from her
own mother may be triggered by this process. In addition, it is during this
phase that the woman may have anxieties about identifying with, or becom-
ing like, her own mother (Morris 1997). The typical resolution of this period
is a reworking of previous attitudes that helped the young woman separate
from her mother in earlier developmental phases. Ideally, the pregnant wom-
an develops a new-found appreciation for her mother and the mothering role
in general (Bibring et al. 1961; Cohen 1979; Morris 1997; Pines 1972, 1982).
According to Cohen (1979), unresolved conflict with ones own mother is
more stressful than marital conflict and is a predictor of maladaptation to
pregnancy. However, in the study by Fleming et al. (1997) no change was
found in mothers relations with their own mothers, although it is unclear
how this relationship was measured and if questions of separation and iden-
tification were examined.
As expectant mothers come to accept their fetuses as separate from them-
selves, they may also develop new feelings of ambivalence toward the preg-
nancy. For many women, the stage after quickening brings relief that there is
indeed life within as well as a sense of fulfillment (Leifer 1977; Rubin 1970).
However, it is not uncommon for women to harbor feelings of resentment to-
ward the fetus (Benedek 1970; Pines 1972; Trad 1991). Around this time, a
woman begins to show and thus loses control over who knows of the preg-
nancy (Rubin 1970). The mother may feel treated as a pregnancy and not
as a person. Consequently, she may have an increasing sense of aloneness,
which may be exacerbated if she has predominantly childless, nonpregnant
friends (Raphael-Leff 1991) or if she continues to feel ambivalent or negative
about the pregnancy.
The third and final psychologic stage of pregnancy begins when physical
discomforts again predominate and the mother has a sense of her infant as
viable (Lester and Notman 1986; Raphael-Leff 1991). During this stage
maternalfetal attachment is expected to be at its highest, and nesting behav-
ior is occurringthat is, preparations for the babys arrival, such as purchas-
ing furniture or selecting a name (Leifer 1977). The absence of this nesting
behavior at this stage may indicate a maladaptation to pregnancy (Cohen
1979; Leifer 1977). Thus the predominant themes during this time center on
preparation for the babys arrival, somatic concerns, and worries about the
delivery.
According to Stern (1995), the elaboration of schemas about the expect-
ed baby declines beginning around the seventh month. The image apparently
becomes less clear than previously. Fleming and colleagues (1997) described
a similar phenomenon and reported a slight decline in positive feelings about
the fetus in the weeks immediately preceding the birth. These may be protec-
tive functions on the part of the mother, to ward off any potential feelings of
disappointment should the real baby differ significantly from the fantasized
one (Stern 1995).
During this final stage, expectant mothers again focus on bodily sensa-
tions, and appearance may become an increasing concern. In a survey of ob-
stetric patients at 36 weeks gestation, Hofmeyr et al. (1990) found that
although 20% of the patients reported feeling more attractive, more than 50%
felt less attractive and 60% had a decreased interest in sexual relations with
their partners. This sense of being unattractive appears to increase through-
out the course of pregnancy but actually peaks in the postpartum (Berk 1993;
Leifer 1977).
At this time in the pregnancy, anxiety about the delivery increases (Leifer
1977). Fears tend to group around several themes. Worry about the health of
the baby often ranks highest (Kestenberg 1977; Neuhaus et al. 1994). Pain
and loss of control during delivery are other major concerns (Mackey 1995).
Antenatal classes have attempted to address some of these fears. Unfortunate-
ly, to date only a limited amount of research is available regarding the efficacy
of prenatal classes in improving psychologic outcomes for women, and the re-
sults of this research are conflicting (Nichols 1995; Zwelling 1996).
With each developmental milestone of the fetus, the sense of the unre-
lenting push toward separation is reinforced (Trad 1991). At no point is this
more true than with delivery of the infant. Delivery is a profound culmination
of much of the physical and psychologic preparation of the mother and her
partner. In one brief moment, two become three, and the course of their lives
is set on a new, unalterable path. Postpartum issues are discussed elsewhere

in this volume (Chapter 7), but it is important to reiterate that development
of the mother continues after the birth as an interactive process between the
woman and her baby (Bibring et al. 1961; Stern 1995).
Medical Complications of Pregnancy
The notion of high risk can be broken down into both medical and psycho-
social categories (L. N. Sherwin and Mele 1986). In this discussion we prima-
rily consider the former; the latter is covered elsewhere in this text. The
designation of high risk is given to approximately 30% of pregnancies in the
United States, and these pregnancies account for 50% of perinatal mortality.
Complications may develop at any stage of pregnancy as a result of preexist-
ing or emergent maternal disorders, obstetric difficulties, or fetal compro-
mise. A cursory overview of these medical complications follows, to set the
stage for discussion of the psychologic aspects of high-risk pregnancy. A more
detailed description is beyond the scope of this chapter, but appropriate ref-
erences are included. It behooves the psychiatrist working at the interface of
psychiatry and obstetrics to have a working knowledge of the medical com-
plications that can develop in pregnancy in order to have a full appreciation
of the patients course and to provide an effective liaison service.
Maternal factors associated with increased risk during pregnancy include
hypertension, diabetes, cardiovascular disease, renal disease, malignancies,
and HIV. Some of these present for the first time, or only, during pregnancy.
For example, hypertension is a complicating factor in approximately 5%10%
of all pregnancies (Sibai 1992). Preeclampsia, a disorder specific to pregnancy,
is characterized by hypertension, edema, and proteinuria. It accounts for the
majority of hypertensive gravidas and develops with increasing frequency af-
ter the twentieth week of gestation. Eclampsia is preeclampsia with convul-
sions. The only specific treatment is delivery, but temporization with bed rest,
medications, and careful monitoring may be justified if the patient is remote
from term (Mabie and Sibai 1994). The remaining minority of cases involve
chronic hypertension. Management of this latter group is controversial; many
experts now recommend not treating mild elevations in blood pressure. The
benefits of treating severe hypertension in pregnancy appear to outweigh the
risks of the medications used, however, because maternal and fetal morbidity
and mortality are significantly reduced with treatment (Sibai 1992).
Since the introduction of insulin, fetal and neonatal mortality in pregnan-
cies complicated by diabetes has reduced from approximately 65% to 2%5%

(Landon and Gabbe 1992). Strict glucose control, both preconception and
prenatally, appears to further reduce the risk of congenital malformations in
the fetuses of diabetic women (Palmer 1994). As with hypertension, the vast
majority of cases of diabetes (90%) develop during pregnancy as gestational
diabetes (Landon and Gabbe 1992). For some of these women, however, that
diagnosis intrapartum may foreshadow a diagnosis of noninsulin dependent
diabetes later in life (Palmer 1994).
Cardiovascular disease complicates 0.4%4% of pregnancies and is the
most frequent nonobstetric cause of maternal mortality (Biswas and Perloff
1994). The effect of cardiac disease on the pregnancy differs depending on
the severity of the underlying disorder. With close monitoring and manage-
ment, women with other medical illnesses such as mild to moderate renal dis-
ease, blood disorders, seizure disorders, multiple sclerosis, and even certain
cancers in remission are increasingly able to have a successful pregnancy out-
come. It is only when these disorders are severe that the prognosis for mother
and fetus may be compromised.
In the past two decades, HIV has increasingly complicated the pregnan-
cies of young women. In an extensive review, Fowler et al. (1997) reported
that of the estimated 30 million individuals infected with HIV worldwide, 11
million are women and 3 million are children (90% of whom were infected
perinatally). It is notable that in women of childbearing age, risk factors that
prompt HIV testing are frequently underrecognized by clinicians (Schoen-
baum and Webber 1993).
Pregnancy does not appear to affect the progression of HIV (Hoyt 1997).
However, treatment for HIV-related conditions may be delayed because of
risk to the fetus (De Ferrari et al. 1993a, 1993b). In terms of HIVs impact on
the pregnancy, North American studies comparing HIV-infected women
with healthy control subjects have demonstrated no significant differences in
obstetric complications or birth outcomes (Minkoff et al. 1990; Selwyn et al.
1989). Many factors are believed to increase the risk of transmission of HIV
from mother to fetus; however, new retroviral treatments administered dur-
ing pregnancy and later to the neonate can reduce the risk of perinatal trans-
mission from 25% to 8% (Centers for Disease Control and Prevention 1996).
Knowledge about risk reduction in HIV-infected pregnancies has given new
hope to HIV-infected women considering their reproductive options.
Obstetric factors that increase risk in pregnancy include habitual abor-
tion, multiple gestation, placenta praevia, and abruptio placentae. Miscar-
riage is a common problem in pregnancy, but most women will go on to
deliver a healthy baby in a subsequent pregnancy. A small subset of women,

however, will repeatedly lose their pregnancies, a condition known as habitual
abortion. Possible contributing factors include chromosomal abnormalities,
dysfunction of the maternal endocrine system, infection, structural anomalies
of the reproductive tract (e.g., cervical incompetence), and underlying mater-
nal disease (Pernoll and Garmel 1994). Treatment of habitual abortion, there-
fore, is aimed at the underlying cause.
With the increasing numbers of women delaying childbearing and the
new reproductive technologies, the number of multiple-gestation pregnancies
has increased substantially in the past two decades (Bowers 1998). It is well
known that the presence of additional fetuses increases the risk of complica-
tions for the mother and the fetuses. Ideally, early diagnosis with ultrasound
allows for increased surveillance and improved outcomes. Unfortunately, not
all cases are diagnosed antepartum (Palmer 1994).
Of all pregnancies, 2%3% are complicated by serious hemorrhage, often
in the third trimester (Pernoll 1994a, 1994b). Placenta praevia, which occurs
in 1 of every 200 pregnancies, is a major cause of such bleeds. Placenta prae-
via is the implantation of the placenta in the lower segment of the uterus so
that the placenta extends to the margin of the internal os of the cervix, par-
tially or completely obstructing it. It presents as painless vaginal bleeding,
and diagnosis is established by ultrasound. Management depends on the
amount of bleeding, gestational age, fetal well-being, and presentation.
The other major cause of third-trimester bleeding is abruptio placentae,
in which the placenta begins to separate from the interior uterine wall too ear-
ly in gestation. In 20% of cases this bleeding is contained within the uterus,
behind the fetus, resulting in a concealed abruption. Close monitoring of
both mother and fetus is essential if abruption is suspected, because both are
at serious risk of significant morbidity and death.
Fetal complications that cause a pregnancy to be designated as high-risk
include intrauterine growth retardation (IUGR) and intrapartum fetal dis-
tress. IUGR complicates 3%7% of all pregnancies. Many factors are associ-
ated with IUGR, including infection, multiple gestation, poor nutrition,
eating disorders, chromosomal abnormalities, congenital malformation, ma-
ternal hypertension, maternal smoking, and drug and alcohol abuse. Once
IUGR is diagnosed, serial determinations of growth are undertaken, and
treatment is aimed at contributing factors. After the age of viability, delivery
is considered if fetal compromise is evident (Gabbe 1986).
In some cases, complications develop during the intrapartum period in a
pregnancy that had progressed smoothly until term. Significant steps have
been made in identifying fetal compromise during labor. Lower morbidity

and mortality rates have resulted, primarily through the determination of fe-
tal risk for hypoxia. The benefit of intrapartum surveillance is that it allows
for confirmation of fetal well-being and may prevent unnecessary obstetric
intervention. Unfortunately, false-positive results still occur, and operative
deliveries are sometimes undertaken unnecessarily. The advantages of in-
creased technology must be weighed against the disadvantages, including the
psychologic aspects of having a monitored labor.
Psychologic Aspects of High-Risk Pregnancies
Although a vast body of literature exists on the medical aspects of high-risk

pregnancies, there is only a small body of knowledge about resulting psycho-
logic reactions. In this section we attempt to explore the meaning of this diag-
nosis to expectant mothers, the ways in which it may affect the developmental
milestones outlined, and some specific issues pertaining to these patients.
In general, it appears that once women are diagnosed with high-risk preg-
nancies, they struggle with each psychologic stage of pregnancy. The normal
ambivalence of early pregnancy may be protracted and therefore may delay
acceptance of the pregnancy. After quickening, these women may have great-
er difficulties attaching to their fetuses. Furthermore, in the final stage of preg-
nancy, nesting behaviors may be delayed or even absent and dependency
may be heightened. Some of these difficulties may persist into the post-
partum.
In considering the psychologic adaptation to high-risk pregnancy, it is im-
portant to recognize that even women with normal pregnancies may perceive
themselves to be at risk. Marteau et al. (1991) found that a pregnant wom-
ans perceived risk of having a baby with an abnormality did not correlate
with her actual risk. In a recent study, Searle (1996) noted that although wom-
en tend to underestimate the actual risk of an abnormal outcome, placing it
at around 1/1000, most of these women were anxious that their own pregnan-
cy was at risk. Anxiety about the well-being of the fetus ranked highest
among their concerns. By far the most important anxiety reducer (for 90.5%)
was the availability of routine antenatal screening tests, which provided these
women with the reassurance that all was well (Searle 1996). One must won-
der, however, what role the routine availability of these tests plays in creating
a sense of risk and abnormality in the first place.
The high-risk group itself is not homogeneous, and thus it is difficult to
draw conclusions about all women with high-risk pregnancies. For example,
the patients reaction to the diagnosis is affected by the stage at which the
pregnancy is identified as high risk, the etiology of the risk, the nature of the
treatment, and the personality structure and defenses of the pregnant woman
(Kemp and Page 1987; Wolreich 1986).
In exploring the meaning, to women, of a medically complicated preg-
nancy, it is important to recognize that much of the self-esteem of women who
choose motherhood may become entrenched in the successful completion of
this task. The knowledge of carrying an imperfect pregnancy may affect a
womans self-esteem detrimentally and leave her with feelings of inadequacy
and failure (Jones 1986; Raphael-Leff 1991). Indeed, Kemp and Page (1987)
found that women carrying high-risk pregnancies scored lower than women
with normal pregnancies on measures of self-esteem. More recently, Kemp
and Hatmaker (1992) found that women with high-risk pregnancies also
scored lower on a measure of self-actualization. If we subscribe to the view of
pregnancy as an identification with the mother and the feminine ideal, then
this low self-esteem and low self-actualization may even affect a womans
sense of herself as a woman.
Psychologic Stages in High-Risk Pregnancy
Any event perceived as threatening by the mother may compromise her abil-
ity to master the various stages of pregnancy (Cohen 1979). In examining the
impact of a designation of high risk on psychologic development in pregnan-
cy, we have focused on the responses of the mother. The reactions of the part-
ner and older children are also significant, however, and although beyond the
scope of this chapter, must be considered in the care of the high-risk mother.
When the label of high risk is given, either before conception or very
early on, the first psychologic task in pregnancy is more complex and at times
paradoxical. These women must accept the pregnancy but concomitantly are
faced with the threat to the survival of that pregnancy (Penticuff 1982). The
normal ambivalence of early pregnancy may be prolonged and may persist
for the duration of the pregnancy or until the perceived threat has subsided
or resolved (Penticuff 1982).
In the next psychologic phase of pregnancy, one fundamental task is at-
tachment to the fetus. Research examining this question in high-risk pregnan-
cies is limited, and although earlier findings suggested that these mothers
were no different from normal control subjects, clinical observation and more
recent investigation suggest that the label of high risk may interfere with at-
tachment. In two earlier studies, Kemp and Page (1986a, 1987) used fetal at-
tachment measures to compare women carrying low- and high-risk
pregnancies during their third trimester. They found no significant differenc-
es in degree of maternal attachment to the fetus. The authors speculated that
a certain degree of denial regarding the severity, or even the presence, of the
high risk designation may allow for attachment to proceed relatively normal-
ly. However, they also noted that the subjects were all beyond 28 weeks ges-
tation and may have become more optimistic because of the long duration of
the pregnancy (Kemp and Page 1986a). Furthermore, because quickening
usually occurs around 20 weeks gestation, many may have actually begun
the task of attachment to the fetus prior to receiving the diagnosis of high risk.
Therapists working with expectant parents with high-risk pregnancies
have noted that this population holds off on developing feelings of attach-
ment to the fetus for fear of disappointment (Moore 1983; Penticuff 1982).
More recently, Kemp and Hatmaker (1992) looked at health-promoting and
health-protective behaviors in pregnant women from a homogenous socio-
economic background. They found that women with high-risk pregnancies
were less likely to engage in health-protective and health-promoting behav-
iors than were those with low-risk pregnancies. Although these findings run
counter to what one might hope for in high-risk pregnancies, one can specu-
late that the absence of these behaviors may reflect an absent or diminished
attachment to the fetus. In other words, attachment is negatively affected by
the diagnosis of high risk; therefore, these women are less likely to demon-
strate protective and nurturant behaviors toward their fetuses. Notably, un-
like the earlier study on attachment, these women were polled between 20
and 41 weeks gestation and thus some may have received their diagnoses be-
fore quickening, when attachment seems to begin. Although it seems likely
that maternal attachment to the fetus is altered or delayed in high-risk preg-
nancies, more research is needed in this area to clarify how and when this
occurs.
Separation issues, which also come to the fore once fetal movements are
perceived, may also be affected by a high-risk pregnancy. Not only is the
woman aware of fetal movements, but some of the interventions that she
must undergo, either for her own health or for that of the fetus, help to un-
derscore both their separateness as well as their merged status. The mother
is acutely aware that medications she must take for her own health may pose
risks to the developing fetus (Raphael-Leff 1991). Similarly, she may receive
certain medications (for example, corticosteroids to mature fetal lungs) that
are aimed at helping her fetus but may result in side effects for her. In the case
of preexisting medical conditions, the pregnancy may jeopardize the mothers
health or there may be a risk of passing on a genetic or infectious disorder to
the infant. Finally, with the intrusion of medical intervention, the usual sense
of being treated as a pregnancy may be exaggerated. The mother may feel
overlookeda vessel for the fetus toward whom all attention is being paid.
Normal resentment toward the fetus at this time may be compounded and
confused by feelings of guilt and responsibility.
The final weeks of pregnancy are notable for nesting behaviors as well
as for a deepening dependency on social supports. With regard to nesting ac-
tivity, Penticuff (1982) has suggested that preparatory behaviors are dimin-
ished or absent in high-risk pregnancies. For example, the couple may
postpone preparing the nursery or selecting a name for the baby.
As described previously, dependency tends to increase throughout preg-
nancy and is greatest in the third trimester. The label of high risk has been
thought to increase the normal dependency of pregnancy (Wolreich 1986).
However, some controversy exists as to whether this increase is adaptive.
Wolreich (1986) hypothesized that heightened dependency and the assump-
tion of the sick role may make the frequency of visits and intensive testing
more tolerable. In addition, the regression and passivity of pregnancy may al-
low for increased compliance with parental figures such as medical personnel.
On the other hand, this increased dependency and tolerance of the sick role
may mean that the mother anticipates a more negative outcome (Kemp and
Page 1987). Such a belief may lead to a sense of learned helplessness, depres-
sion, and decreased compliance. In contrast, being treated as sick may be
very difficult for some because these women often do not feel ill (Gupton
et al. 1997; Gyves 1985). In such situations one might expect a more resistant
or independent stance, which also results in decreased compliance with med-
ical regimens.
In women who are hospitalized or are prescribed bed rest, regression and
dependency may be further intensified by the enforced abandonment of usu-
al activities, including work, and the provision of most aspects of daily care
by others (Rogers 1989). Studies in recent years have looked at the effect of
antepartum bed rest or hospitalization on psychologic functioning (Gupton
et al. 1997; White and Ritchie 1984). Several issues have been found to create
stress and anxiety in these women, such as concern about ones own health
and that of the fetus, uncertainty and lack of control, feeling like a prisoner,
feeling that one is missing out, concern about other children in the family, role
reversals with the partner, and in the case of hospitalized patients, the separa-
tion from the usual supports of spouse and family (Gupton et al. 1997; White
and Ritchie 1984). There is also financial stress if the expectant mother stops
working or requires costly procedures, treatments, or services.
For many women with medically complicated pregnancies, the birth of a
healthy baby signifies a resolution of the uncertainties experienced during
pregnancy. Nevertheless, difficulties from earlier developmental periods may
spill over into this next stage, leading to problems in the early motherinfant
dyad and perhaps beyond (Bibring 1959; Penticuff 1982). In fact, Priel and
Kantor (1988) found that women who had carried high-risk pregnancies not
only perceived their newborn infants as more difficult than the average
baby but also expected the average baby to be much easier than did
mothers who had experienced normal pregnancies. Burger and colleagues
(1993) found that at 48 years postpartum, mothers who had had complicat-
ed pregnancies viewed their children as vulnerable to illness almost twice as
frequently as did women without pregnancy complications. This significant
difference remained even when those infants who were in fact ill in the post-
partum were removed from the analyses and only mothers with healthy new-
borns were included. Mothers with severe prenatal complications were also
significantly more likely to report having had a postpartum depression. View-
ing a child as more difficult or more vulnerable, as well as having postpartum
depression, has serious implications for parentchild interactions. It would
seem, then, that the psychologic difficulties that women with high-risk preg-
nancies may experience can have consequences that reach well into the post-
natal period.
It should also be noted, however, that several studies examining pregnant
women diagnosed as high risk have found that they manage fairly well. In a
study examining the psychologic impact of the diagnosis of gestational diabe-
tes, Spirito et al. (1989) found that most women coped well with this unantic-
ipated development. Subjects were interviewed several weeks after the
diagnosis was established, which may have allowed for a period of adjust-
ment. Kemp and Page (1987) also found no significant difference in the anx-
iety levels of women carrying high-risk pregnancies and those carrying low-
risk pregnancies. Again, this study looked at women in their third trimester
who may also have had time to adjust and were therefore no longer anxious.
As described previously, this study found no differences on measures of at-
tachment; however, the authors did not look at the major tasks of this phase
that is, nesting behaviors and coping with increasing dependency needs.
Thus, on certain measures of general adjustment, it is possible that for some
women the diagnosis of high risk does not have a deleterious effect. However,
when the specific psychologic tasks are examined at the appropriate develop-
mental phase, a number of these women may be found to be struggling.
Clearly, there is a paucity of well-designed studies examining these questions,
and definitive conclusions are difficult to make at this time.
Women infected with HIV warrant special consideration. Some of their
issues highlight difficulties pertinent to all medically ill women embarking on
a pregnancy. Other issues differ distinctly. Sowell and Misener (1997) used
focus groups to examine the reproductive choices of HIV-infected women.
Participants who wanted children, once aware of their HIV status, saw child-
bearing as an opportunity to leave something behind when they were gone
an opportunity to feel complete. In a study of women having children after
breast cancer, Dow (1994) also found women to report feeling complete as
a rationale. Furthermore, for many breast cancer survivors, having children
also meant getting well again, although they worried that they might not sur-
vive to see their children grow up. Regardless of whether this belief turned
out to be accurate in the long run, getting well again has at least been a pos-
sibility for these women. For those infected with HIV, however, one of the
struggles is knowing that they will probably succumb to their illness and leave
their children behind. For some of the women in Sowell and Meisners (1997)
study, this knowledge influenced them to not have a baby.
Unique to HIV is the meaning of the disease in our culture and the stig-
matization and shame that come with the diagnosis. De Ferrari et al. (1993a,
1993b) commented on some of the specific problems associated with HIV in-
fection, such as discrimination, social isolation, poverty, grief, and in the case
of pregnant women, guilt over potentially infecting an unborn child. Because
a large proportion of HIV-infected pregnant women are substance abusers,
their ongoing drug dependence makes them less able to be compliant with
health care, thus compounding their sense of culpability and shame.
Psychiatric Intervention
Working at the interface of psychiatry and obstetrics and gynecology can be

both challenging and rewarding. Psychiatric involvement can be beneficial at
every step of the process, from preconception through to the postpartum pe-
riod. As noted by Bibring (1959), relatively simple interventions can result in
significant change for the mother. Furthermore, the psychiatrist can play a
role in helping others in the womans immediate environment.
For some women the role of the psychiatrist may begin even before con-
ception. In women with chronic diseases, prepregnancy counseling in con-

junction with the obstetric team can be very helpful. Couples may need to feel
that they have permission to not have a child or to explore options like surro-
gate pregnancy or adoption. Once the patient becomes pregnant, certain ele-
ments in her history may signal perinatal psychiatric difficulties, such as
previous obstetric mishap, infertility, familial or congenital diseases, conflicts
about separation from parents, and poor relationships with physicians (Co-
hen 1979; Nadelson 1978). Stewart and Lippert (1988) reviewed reasons for
psychiatric referral during pregnancy and childbirth. They cited extreme am-
bivalence toward pregnancy, marital conflict related to the pregnancy, psy-
chosocial problems, unstable environment, and prenatal anxiety as common
reasons for referral. Another frequent referral question is to review the risk/
benefit ratio of continuing psychotropic medications for a preexisting psychi-
atric disease during pregnancy or whether to initiate medications during the
course of a pregnancy (see Chapter 5). Finally, psychiatric consultation is
sometimes sought because of noncompliance with prenatal care. This typical-
ly occurs in pregnancies already considered high risk for medical or social
reasons or because of substance abuse (Stewart and Lippert 1988). Once a
patient is referred, the time-limited nature of pregnancy can be especially suit-
ed to short-term psychotherapeutic intervention aimed at improving adjust-
ment and resolving conflicting feelings about the fetus (Bibring 1959; St-
Andre 1993; Wolreich 1986).
Working with obstetric personnel can be challenging for the consulta-
tion-liaison psychiatrist. The medical team may have their own reactions to a
jeopardized pregnancy that can interfere with providing optimal medical care
and emotional support to the pregnant woman. Diplomatically helping the
staff understand their responses can assist in modifying unhelpful, over-
involved, or even hostile behavior. Gyves (1985) noted stresses particular to
the team working with high-risk pregnancies. First is the uncertainty of
whether to label something as a problem and whether to inform the patient
of it. Second, certain disorders have controversial treatments and dissent may
exist within the team as to which direction to take. A further stress for the
clinician can occur if the family chooses a course of action that differs from
what is recommended. Finally, families often have very high expectations of
the team, leaving little room for error in situations in which the outcomes can
be devastating (Gyves 1985).
To be most effective, the psychiatrist working in this multifaceted area
must have an understanding of the psychology of normal pregnancy, a famil-
iarity with the medical and obstetric complications and management of high-
risk pregnancy, and an appreciation of the psychologic reactions associated

with high-risk status for the pregnant woman and her family. The impact of
interventions at this time can be far-reaching, both for the new mother and
for her baby.
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3
Fetal Anomaly
KATHERINE L. WISNER, M.D., M.S.
Fetal anomalies may be genetically programmed at conception by the trans-

mission of defective genes or chromosomes or they may arise during preg-
nancy as a result of maternal illness or exposure to harmful substances. Prenatal
genetic counseling and diagnostic techniques have made possible the in utero
detection of a large number of these fetal defects. These technologic advances
also bring psychologic stresses in the form of decisions about whether to have
testing, anxieties related to the tests and the wait for results, and the possibility
of having to choose whether to terminate a pregnancy.
This chapter discusses these reactions as well as the emotional conse-
quences and management of elective genetic terminations or of giving birth
to a child with a defect. The psychiatrist may have a role in direct counseling
of patients who are adjusting to the emotional trauma of losing a wanted preg-
nancy or who are adapting to having a child with abnormalities. The psychi-
atrist may also be involved in supervising or assisting other members of the
treatment team.
Prepregnancy
Risk of Hereditary Disorders
Geneticists and genetic counselors advise patients who are at risk for a hered-
itary disorder about the consequences of the disorder, the probability of de-
33
veloping the disease or transmitting the gene, and the ways in which this
transmission may be prevented. Ideally, this information is given before preg-
nancy so the couple can make informed decisions about childbearing.
Counselors also provide general information on the risk of chromosome
abnormalities for women of late maternal age. The risk of chromosomal ab-
normalities being detected at 16 weeks gestation in a woman who is 35 years
old is 1/250 for Down syndrome and 1/130 for all chromosome abnormali-
ties. These risks increase until, in a woman who is 46 years of age, they are
1/15 and 1/10, respectively (Hook 1983). If a woman has previously given
birth to an abnormal child, the geneticist uses clinical assessment of the affect-
ed infant, confirmation from medical records, and construction of a family ge-
netic tree to make an accurate diagnosis and estimate the risk for future
pregnancies.
Single gene or mendelian disorders have three inheritance patterns:
autosomal dominant, autosomal recessive, and X-linked recessive or domi-
nant genes. When one parent has an autosomal dominant disorder (such as
tuberous sclerosis or Huntingtons disease), there is a 50% probability that
the offspring will be affected. Autosomal recessive disorders include the he-
moglobinopathies and several progressive metabolic disorders such as Tay-
Sachs disease. When both parents are carriers of an autosomal recessive con-
dition the risk of transmission to children is 25%, and each child has a 50%
risk of being a carrier. When the mother carries an X-linked recessive disor-
der (such as hemophilia or Duchenne dystrophy), there is a 50% risk that
each son will be affected as well as a 50% probability that each daughter will
be a carrier.
Most common birth defects, such as cleft lip, cleft palate, and neural tube
defects, involve multifactorial inheritance. The recurrence risk of these dis-
orders is rarely over 5% when only one parent is affected (Harper 1983).
Chromosome disorders may involve numerical abnormalities caused by non-
disjunction (e.g., Down syndrome due to trisomy 21) or structural abnormal-
ities such as chromosome translocations (e.g., Down syndrome due to a
translocation between chromosomes 14 and 21). The risk of nondisjunction
after one occurrence is approximately 1%. With translocations, chromosomal
material may be neither lost nor gained but merely out of place; in these
cases, the translocation is said to be balanced and the individual will be a
carrier (i.e., not symptomatic). Asymptomatic carriers of balanced transloca-
tions, however, have a 5%20% risk of transmitting the unbalanced chromo-
some complement (i.e., too little or too much genetic material) to the child,
who will, therefore, exhibit symptoms (Jackson 1980).
Fetal Anomaly 35
Psychologic Reactions to Discovery of Risk Factors
The parents perceived risk for any genetic disorder differs from the statistical
risk (Swerts 1987). Five major factors influence perceived risk: 1) the potential
degree of harm or lethality, 2) the degree to which the risk can be controlled
through safety or rescue measures, 3) the number of people affected, 4) the
degree of familiarity with the consequences and effects of the disorder, and 5)
the degree to which the parents exposure to the risk is voluntary.
Couples who have an increased risk for giving birth to a child with a ge-
netic disorder are faced with the complications of a natural biologic process
that is usually taken for granted. They may have a strong feeling of being de-
fective. This presents a narcissistic threat to their self-esteem, to the extent
that self-esteem is based on the expectation of creating a normal healthy child
(Blumberg et al. 1975). A sense of guilt associated with being a carrier of a
genetic disease may also be present. It is common for these couples to feel an-
ger toward women who are enjoying normal pregnancies and to feel guilt be-
cause of difficulties with reproduction (G. E. Robinson and Stewart 1989).
They may undergo a grieving process for the loss of their idealized family.
Their sexual enjoyment may be affected by both their distress and by the re-
alization that the procreative act can result in tragedy. Marital distress caused
by this crisis complicates decisions about future pregnancies.
Genetic counseling and the possibility of detecting fetal defects prenatally
play an important role in making decisions about further pregnancies (Boue
et al. 1991). Over half of counseled families who have infants with Down syn-
drome and up to 80% of those who have a child with neural tube defects re-
ported that they were positively influenced in their decision to have more
children by the information received during counseling sessions. Preconcep-
tion counseling may reduce the couples guilt, their sense of defectiveness,
and their grief.
Pregnancy
Indications for Prenatal Genetic Testing
The goals of prenatal diagnosis are detection of fetal genetic disorders, im-
provement of outcome, provision of information to prepare parents, and iden-
tification of severely affected pregnancies that parents can elect to terminate.
Indications for prenatal testing include advanced maternal age (women over
35 years of age), a known balanced translocation in one of the parents, a pre-

vious child with a chromosome disorder or neural tube defect, a mother who
is a carrier for an X-linked disease (to determine fetal gender and to provide
molecular diagnosis, where applicable), and parents who are both carriers of
recessively inherited metabolic disorders (Golbus et al. 1974). Some examples
of the types of disorders that are common indications for prenatal diagnostic
testing are shown in Table 31. This list is not exhaustive, as hundreds of con-
ditions can now be diagnosed through prenatal testing.
The type of prenatal diagnostic test, the timing of testing, and the approx-
imate waiting time for results are depicted in Table 32. Couples may not be
willing to undergo prenatal diagnostic testing because of lack of information
about the test, a perception of being at low risk for a fetal abnormality, con-
cern about fetal injury or loss following the test, religious beliefs, or an un-
willingness to consider elective termination as an option (Davies and Doran
1982; Dixson et al. 1981).
Prenatal Diagnostic Tests
Serum Screening
Alpha-fetoprotein (AFP) is a normal human fetal protein that is found in high
concentrations in the fetal serum throughout gestation. Rising levels of AFP
can be detected in the sera of pregnant women as early as 7 weeks gestation,
and levels increase steadily until at least 30 weeks gestation (Burton 1988).
Elevated levels of maternal serum AFP (MSAFP) can be used to detect 80%
85% of open neural tube defects and other malformations, including ompha-
locele or gastroschisis, intestinal atresias, congenital nephrosis, and Turners
syndrome. MSAFP levels are approximately 25% lower when the fetus has
Down syndrome (Knight et al. 1988). The use of multiple markers (MSAFP,
human gonadotropin, and unconjugated estriol) can detect 60%85% of
anomalies (Wenstrom et al. 1995).
MSAFP screening can be done with reasonable reliability between 15
and 21 weeks gestation. About 4% of women will have an elevated MSAFP
level on initial testing, and 30% of these women will have a normal result
on repeat testing. For multiple marker screening, 8% of women will have a
positive result on the initial test, but only 1%2% of those will have an abnor-
mal fetus (Carroll 1994). Patients who have abnormalities in the serum
screening and are found through ultrasound and examination to have a single
viable fetus at the anticipated gestational age may be advised to undergo
amniocentesis.
TABLE 31. Indications for prenatal diagnostic testing
CVS/Amniocentesis
Diagnostic Chromosome Enzyme
Type of disorder Example ultrasound MSAFP DNA analysis analysis analysis
Single-gene disorders, known Cystic fibrosis X
or suspected
Multifactorial disorders, known Neural tube disorders X X
or suspected
Chromosomal disorders in Fragile X syndrome X X
the consultand or a family
member
Abnormal trait or carrier state Tay-Sachs disease X X
Prenatal diagnosis for late Down syndrome X X X
maternal age or other causes
Teratogen exposure Fetal alcohol syndrome X
CVS = chorionic villus sampling; MSAFP = maternal serum alpha-fetoprotein.
Fetal Anomaly
Note.
37
TABLE 32. Prenatal diagnostic testing
Waiting time
Time of testing for results
Type of test (weeks of gestation) (weeks)
Early amniocentesis 1014 23
Chorionic villus sampling 912 12
Diagnostic ultrasound (routine screening) 1819 Immediate
Midtrimester amniocentesis 1618 24
Maternal serum screening 1521 1
Serum testing may create unnecessary maternal anxiety because some

women will be falsely identified as having high-risk pregnancies (Evans et al.
1988). Patients undergoing genetic testing because of elevated MSAFP levels
have been found to have a higher state of anxiety than those undergoing test-
ing because of advanced maternal age. This anxiety only returns to normal
levels after assurance of a definitively negative amniocentesis result (J. Rob-
inson et al. 1984). Women who undergo serum screening have significantly
lower anxiety levels in the third trimester of pregnancy than do women who
have not been screened (Marteau et al. 1988).
Ultrasound
Two main types of ultrasound are in common use: continuous ultrasound is used
to detect moving structures such as the fetal heart, whereas pulse ultrasound is
used to outline structures within the uterus. In obstetrics, ultrasound is used
for the screening and diagnosis of fetal age, multiple pregnancy, intrauterine
growth retardation, and fetal malformations including craniospinal defects
such as anencephaly, cardiac defects, and musculoskeletal, gastrointestinal,
and renal abnormalities. Diagnostic ultrasound has no known risks to the fe-
tus or mother and produces little anxiety in low-risk women (Campbell et al.
1982). Women tend to view scans as benign procedures allowing them to con-
firm the baby is healthy (J. Green and Stratham 1996). Scans may promote
maternalfetal bonding (Campbell et al. 1982) and may lead to a decrease in
behaviors such as smoking and drinking (Reading et al. 1982), especially in
women who receive a high level of feedback during the ultrasound examina-
tion (Reading et al. 1988).
Midtrimester Genetic Amniocentesis

Midtrimester genetic amniocentesis is carried out at approximately 16 weeks
gestation. After the exact positions of the placenta, fetus, and umbilical cord
Fetal Anomaly 39
are determined by ultrasound, a needle is inserted through the abdomen into

the amniotic sac. Amniotic fluid is withdrawn for AFP and karyotype testing.
In several studies, the rates of total fetal loss in the group receiving mid-
trimester amniocentesis (3.5%) and in nonrandomized control subjects (3.2%)
were not significantly different. It is estimated that the risk of fetal loss be-
cause of midtrimester amniocentesis does not exceed 0.5% in experienced
hands (Lowe et al. 1978). Serious fetal injury and bacterial infection within
the uterus are extremely infrequent. The results are usually available 24
weeks later at approximately 20 weeks gestation.
Early Genetic Amniocentesis
Early genetic amniocentesis can be performed between 10 and 14 weeks ges-

tation, although accuracy is greater at 1214 weeks gestation (Rooney et al.
1989). Preliminary reports suggested that early genetic amniocentesis was saf-
er than chorionic villus sampling (CVS) (Godmilow et al. 1988) and as safe
and accurate as midtrimester genetic amniocentesis (J. M. Johnson et al.
1996). Rates of procedure-related fetal loss have been reported to range be-
tween 3.3% and 6.6% (Hackett et al. 1991; Hanson et al. 1987), with an av-
erage loss of 2.7%. A recent multicenter study found that women who have
early genetic amniocentesis have an increased risk of having children born
with Talipes equinovarus (Canadian Early and Mid-trimester Amniocentesis
Trial Group 1998).
Chorionic Villus Sampling
Chorionic villus sampling is another method of obtaining fetal cells for genet-
ic analysis. Using ultrasound guidance, a catheter is inserted through the cer-
vix or a needle is passed through the abdominal wall to aspirate chorionic
tissue from the developing placenta. The material obtained is then sent for
karyotype determination and other studies as indicated. In a multicenter, ran-
domized clinical trial of CVS and midtrimester genetic amniocentesis, the dif-
ference between the rates of pregnancy loss with the two procedures was
determined to be no greater than 2.8% for women 35 years of age and older
(Canadian Collaborative CVS-Amniocentesis Clinical Trial Group 1989).
The most likely risk is probably 1%1.5%. Early reports about a possible as-
sociation with fetal limb defects when CVS is performed at less than 10
weeks gestation (Firth et al. 1991) have not been validated (Kuliev et al.
1996).
Psychologic Consequences of Chorionic Villus Sampling,

Midtrimester Genetic Amniocentesis, and
Early Genetic Amniocentesis
Couples who undergo prenatal diagnostic testing may experience significant
psychologic stress. Prior to testing, women worry the procedure will be pain-
ful, cause injury to the fetus, or result in miscarriage (J. Green and Stratham
1996; Marteau and Slack 1992). They may also be concerned about the re-
sults of the test (Evers-Kiebooms et al. 1988; Finley et al. 1977). Women with
decreased social support have increased anxiety (J. Robinson et al. 1975). Bea-
son and Golbus (1979) found increased anxiety in women who already had
children with chromosomal disorders, but other investigators have not
(Evers-Kiebooms et al. 1988; Tabor and Jonsson 1987). Women having the
tests as a result of positive screening tests are particularly anxious (J. Green
and Stratham 1996). No increase in anxiety has been found in women who
have been adequately counseled, although counseling done immediately pri-
or to the test was not found to be beneficial (Nielson 1981). Anxiety levels
are also elevated in women prior to undergoing CVS (G. E. Robinson et al.
1988; Spencer and Cox 1987). A drop in anxiety immediately after testing
has been noted for patients who underwent midtrimester genetic amniocen-
tesis (Tabor and Jonsson 1987), early genetic amniocentesis (G. E. Robinson
et al. 1998), or CVS (G. E. Robinson et al. 1988). Tabor and Jonsson (1987)
found this to be especially true for younger women and women who perceive
themselves to be at low risk for an abnormality. Older women remained anx-
ious until the results were obtained. Beason and Golbus (1979) found an im-
mediate drop in anxiety with a subsequent rise during the wait for a possible
miscarriage and test results. Women receiving results earlier in the pregnancy
experienced anxiety reduction much earlier than did the group receiving re-
sults after 1718 weeks (G. E. Robinson et al. 1988, 1998). Even after obtain-
ing the results, about 25% of women receiving midtrimester amniocentesis
remained concerned about the outcome of the pregnancy (Dixson et al.
1981). McCormack et al. (1990) found that most patients had a better expe-
rience with CVS than with previous midtrimester genetic amniocentesis.
Women who undergo CVS develop an increase in maternalfetal bonding
earlier than do those having midtrimester amniocentesis (Caccia et al. 1991).
Pregnancy Loss After Testing

Women who have a miscarriage after a genetic procedure experience grief,
guilt, and anger. Women who have CVS may perceive the procedure to be
Fetal Anomaly 41
more risky and may feel additional guilt over having chosen it (G. E. Robin-
son et al. 1991). Also, because of the early timing of CVS, a miscarriage that
would have spontaneously occurred may be falsely attributed to the proce-
dure and create needless guilt. Even after genetic terminations or miscarriag-
es, women tend to prefer earlier procedures (G. E. Robinson et al. 1988,
1998).
Reactions to Detection of Fetal Anomaly
Detection of a fetal anomaly is always a disturbing event (J. Green and

Stratham 1996). A pregnancy that has been desired and perhaps long sought
may suddenly lose its value. The first reaction is one of shock and denial, ei-
ther expressed openly or masked by an apparent calm acceptance of the di-
agnosis (Jackson 1980). It is often difficult for couples to absorb information
during this period of shock. The second stage is characterized by anxiety as
they try to come to terms with future plans and alternatives for care. Many
individuals have problems grasping the meaning of probability figures and
using them for decision-making (dYdewalle and Evers-Kiebooms 1987). Ei-
ther parent may exhibit hostile and angry behavior directed at the partner,
the physician, or the counselor. The parents may then enter a phase of de-
pression as they deal with this difficult problem. These stages vary in length
and severity and may fluctuate before the parents reach the stage of accep-
tance and equilibrium.
Reactions to Genetic Termination
Reproductive loss for any reason is always distressing. In an elective termina-

tion because of genetic disorders (i.e., genetic termination), the couple must
face not only the loss of a wanted pregnancy but the fact of making a con-
scious decision to end it (Leon 1995). Ideally, discussion about the actions to
be taken if an abnormal result is discovered occurs during pretest counseling
(Marteau 1995). If the disorder is incompatible with life, the decision may be
reasonably straightforward. For many others, a clear identification of a prob-
lem with known consequences, such as Down syndrome, will allow them to
make the choice despite ambivalence and pain. Problems in decision making
increase with the identification of mosaicism or sex chromosomal disorders
in which the outcome is not clearly a severe abnormality (Drugan et al. 1990).
Acute grief reactions are experienced by 77%92% of women and 82% of
men following a genetic termination (Blumberg et al. 1975; Lloyd and
Lawrence 1985). This distress may last for many years after termination
(White-van Mourik et al. 1992).
Couples often feel guilty about their decision to terminate a pregnancy.
Couples who are at risk of having a child with an X-linked disorder and who
terminate a pregnancy based only on knowledge of male gender must deal
with the added guilt of knowing there is a 50% probability that the fetus
would not have had the disorder (Blumberg et al. 1975). Couples may expe-
rience marital problems caused by projection of their anger onto each other
or by isolation due to depression. The woman may have stronger feelings
about the loss or may be more open about expressing her feelings. In an at-
tempt to handle his own sadness as well as deal with his partners grief, the
man may suppress his own feelings.
The woman who has an induced abortion following genetic amniocente-
sis has probably experienced fetal movement, has usually been visibly preg-
nant, and has had to undergo delivery in order to terminate the pregnancy.
It has been hypothesized that elective terminations following CVS may be
less traumatic, but G. E. Robinson et al. (1991) found that women who had
an elective termination following either method had equally elevated levels of
depression.
Couples who terminate a pregnancy for genetic reasons experience a
grief reaction and mourn for their unborn child (Magyari et al. 1987). Proto-
cols for the management of neonatal death have been proposed (Langer and
Ringler 1989; Magyari et al. 1987; Phipps 1981). In the protocol of Magyari
et al. (1987), the finding of an abnormality is discussed immediately with the
parents in the context of a nondirective planning meeting. The couple is given
a factual description of the termination procedure. Mothers who choose ter-
mination are admitted to a private room on a nonmaternity ward where the
spouses can remain together during the procedure. The psychologic manage-
ment of pregnancy loss is discussed in more detail in Chapter 8.
Selective Termination
Selective termination may be considered in multiple gestations in which one
or more fetuses are severely abnormal or when continuation of the multiple
pregnancy presents a risk to the mother or the pregnancy (Zaner et al. 1990).
This problem is more common in infertile patients who achieve pregnancy
after ovulation induction. Zaner et al. (1990) have argued that restricting se-
lective termination to pregnancies of three or more fetuses provides the great-
est chance of causing the least harm. They also advise early counseling for
couples involved in ovulation induction to prepare them for the possibility
Fetal Anomaly 43
of selective termination. McKinney et al. (1996) found that women who un-
derwent selective reduction experienced guilt, ambivalence, and bereave-
ment, but most felt they had made the right decision for themselves and their
families.
Fetal Gender Determination

Fetal gender determination can be done by ultrasound or chromosomal ex-
amination. In cases of X-linked recessive disorders, if the fetus is male and
molecular analysis cannot detect whether it is affected, the couple may elect
to terminate the pregnancy knowing that there is only a 50% chance it would
be affected. Termination of fetuses of a particular gender merely for sociocul-
tural reasons presents an ethical problem. Some physicians suggest that the
gender of the fetus should be kept from the parents unless it is related to a
genetic disorder. Others believe that caregivers do not have the right to with-
hold this information. Termination for the purpose of gender selection rarely
occurs after midtrimester amniocentesis (S. R. Johnson and Elkins 1988).
Psychologic Reactions to Perinatal Death

Stillbirth or neonatal death caused by genetic abnormalities elicits not only
grief reactions but guilty feelings on the part of the parents for having pro-
duced a defective child. Waiting for the autopsy results to confirm or allay
their fears of having passed on a chromosomal defect to their baby is painful.
Carrying a chromosomal defect that may harm future children is emotionally
distressing.
Children also react to the death of a sibling. The parents can assist by
providing accurate information about the death, explaining that it was not the
surviving childs fault, including the child in mourning ceremonies, and shar-
ing parental grief (Leon 1990). Childrens repetition of questions parallels the
same phenomenon seen in parents questioning of doctors. For a sibling who
is free of a genetic illness, assurances that the fatality is not contagious and
cannot happen to him or her can be helpful.
Postpartum
Psychologic Reactions to the Malformed Baby
The birth of a malformed baby constitutes an intense narcissistic injury for
parents. Already coping with the psychophysiologic depletion that follows la-
bor and delivery, these couples must also grieve the loss of the expected in-
fant and accept the malformed child (Solnit and Stark 1961). They must
attempt self-regulation in the face of chronic depression and rage when con-
fronted with the disappointment inherent in producing a damaged child (Fa-
jardo 1987). Couples may feel unable to accept the child because the
narcissistic injury is intolerable, or alternatively, they may experience severe
guilt leading to overinvolved parental dedication (Solnit and Stark 1961). Par-
ents of children with problems such as congenital heart disease may have
more problems accepting the childs condition because outwardly the child
appears completely normal (Emery 1989). This stress intensifies any preex-
isting relationship difficulties. Men and women may handle the stress differ-
ently: women may be more preoccupied with hands-on care, whereas men
may focus on trying to emotionally support the wife (Svavarsdottir and Mc-
Cubbin 1996).
Mourning a malformed infant does not take place in the usual manner
because the continuation of the childs life and the increased demands for
physical care preoccupy most parents. Drotar et al. (1975) found that, despite
reassurances, concern that the baby will die interferes with attachment to the
child. Premature mourning for a child who subsequently recovers requires
the parent to reverse psychologic energy and reintegrate the child into the
family. Difficulty accomplishing this task can result in disturbed parentchild
relationships and behavioral dysfunction in children (M. Green and Solnit
1964; Naylor 1982). The continuation of mourning into a persistent, de-
pressed, self-reproachful state is more likely if the mothers mourning reaction
is not understood and if the care and planning for the child are carried out
without her active participation.
Parents of a malformed infant experience guilt and shame and frequently
seek causal connections between the defect and prior thoughts, fantasies,
wishes, or actions (Kessler et al. 1984). This guilt may or may not be realistic.
Defenses against guilt include repression (behaviors such as substance abuse),
intellectualization and rationalization, and isolation of affect. A common way
for couples to handle the guilt is to decide against further reproduction.
Shame is frequently associated with responses to the anticipated or actual
disapproval of others. Common defenses against shame include denial, reac-
tion formation, compensation, or displacement, such as focusing on the defi-
ciencies of the medical caregivers.
The parents must begin a lifelong reconciliation to the ongoing disap-
pointments and special care required by the limitations of a child with a ge-
netic defect. The child may be at risk of abuse, particularly if either parent
Fetal Anomaly 45
has a history of child abuse, or of extreme social isolation from family and
friends (Fost 1981).
Parents of children born with malformations may not remember the
rational content of the first conversation with their doctor (Solnit and Stark
1961). They need repeated contact with their physician to accomplish the
task of mourning. Parents also need assistance with decision structuring as
they take responsibility for evaluative judgments and accept/reject decisions
(Vlek 1987).
Psychotherapy
In the initial stages of work with families in which a child is malformed, Solnit
and Stark (1961) recommended support and clarification of the reality of the
childs condition as the parents are able to discuss their questions and fears.
Avoiding the interpretation of unconscious conflicts during mourning was
recommended. Group support for parents of children with fatal genetic ill-
nesses can decrease parental isolation, allow discussion of the parents need
for both closeness and distance from the infant, and calm their fears about
events immediately preceding their childs death (Mack and Berman 1988).
In such a group, the parents may be able to admire the lovable qualities about
each others children and share in each others grief when the children die.
Zuskar (1987) advocated a short-term family crisis intervention model
for managing the psychologic reactions to a baby born with genetic defects.
This model includes multiple short meetings, initial work with the couple
alone followed by placement into couples groups, an empathic and accepting
therapeutic style to facilitate adaptation, provision of a supportive environ-
ment for emotional work, direct confrontation of beliefs about the fetuss im-
pairment as causality, and attention to the marital relationship. Attention to
biologic information and reproductive technology, the parents psychologic
capacities to receive information and use coping skills, and the parents social
milieu will allow the therapeutic team to develop a comprehensive treatment
plan and achieve the most successful outcome.
Acknowledgment
The authors wish to acknowledge the valuable assistance of Dr. Elaine Hut-
ton in reviewing the information on genetics.
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4
Psychiatric Disorders
During Pregnancy
LAURA J. MILLER, M.D.
Introduction
Pregnancy is a time of profound biologic, psychologic, and interpersonal

change in the lives of many women. Although transient reactions of anxiety
and sadness are common, most women navigate this transition without major
psychopathology. However, for women who experience an episode of mental
illness while pregnant, the effects on them, their offspring, and their families
can be devastating. This chapter aims to summarize research and clinical
findings that shed light on the interaction between pregnancy and psychiatric
disorders and to suggest interventions that stem from these findings.
Psychiatric Disorders Temporally Related

to Pregnancy
Schizophrenia and Related Psychotic Disorders
Changes brought about by deinstitutionalization and sociocultural factors

have resulted in increased rates of pregnancy among women with schizophre-
nia (Miller 1997). Compared with demographically similar nonmentally ill
women, women with schizophrenia have significantly fewer planned preg-
51
nancies and more unwanted pregnancies (McNeil et al. 1983; Miller and
Finnerty 1996). Pregnancy among women with schizophrenia is often accom-
panied by risk factors such as substance abuse, poverty, homelessness, insuf-
ficient prenatal care, poor nutrition, poor social support, and being a victim
of violence (McNeil et al. 1983; Miller and Finnerty 1996; Rudolph et al.
1990; Sacker et al. 1996; Stewart 1984). Risks are further increased by the
direct effects of psychotic symptoms on behavior. For example, women with
delusions about their pregnancies are significantly less likely to recognize la-
bor than are mentally ill women without such delusions (Spielvogel and Wile
1992). Delusions related to pregnancy may also result in attempts at prema-
ture self-delivery, sometimes by self-injurious methods (Yoldas et al. 1996).
These risk factors result in increased morbidity for both pregnant wom-
en and their offspring. Most women with schizophrenia report a worsening
of their mental status during pregnancy (McNeil et al. 1984). Many women
lose assisted housing arrangements because they are pregnant (Bachrach
1988) and have difficulty finding facilities equipped to deliver needed mental
health and prenatal care (Dolinar 1993). Offspring, in addition to inheriting
a vulnerability to schizophrenia, suffer the consequences of increased obstet-
ric complications (Sacker et al. 1996).
A central problem for many pregnant women with schizophrenia is the
fear of losing custody of their babies. Anticipated custody loss may trigger ex-
acerbations of psychosis and other grief-related reactions (Apfel and Handel
1993). Fear of custody loss often deters women from seeking intervention
(Stewart 1984). Although symptoms of schizophrenia may affect parenting
capabilityfor example, because of hallucinations and delusions about chil-
dren, reduced ability to read and respond to nonverbal cues, interpersonal re-
moteness, and unpredictable behaviormany women with schizophrenia are
capable of safe parenting. A comprehensive parenting assessment can serve
as a basis for rational decisions about parenting capability. Such assessments
use standardized tools to evaluate parenting behavior, motherchild attach-
ment patterns, understanding of child development, and internal representa-
tions of the child (Jacobsen et al. 1997). The pattern and content of specific
symptoms, insight into illness, acceptance of and response to treatment, co-
morbid risks, and social support are also assessed. Parenting rehabilitation
strategies including parenting coaching, therapeutic nurseries, parenting sup-
port groups, and parenting classes can target specific parenting problems. Un-
fortunately, many mental health facilities are ill equipped to assess parenting
capability and prepare women for custody determinations (Nicholson et al.
1993; Rudolph et al. 1990).
Psychiatric Disorders During Pregnancy 53
Mood Disorders
Major Depression
Mild to moderate symptoms of depression are relatively common during
pregnancy, although episodes of major depression seem no more likely to oc-
cur during pregnancy than at other times in a womans life (Affonso et al.
1991; Coble et al. 1994a; Kitamura et al. 1994; Kumar and Robson 1984;
OHara 1986). Antenatal depressive symptoms are especially prevalent
among adolescents, inner-city women, and women with past histories of ma-
jor depression (Barnet et al. 1996; Coble et al. 1994a; Hobfoll et al. 1995).
Psychosocial risk factors for depression during pregnancy include less social
and spousal support, more previous children, early parental bereavement,
and termination of a prior pregnancy (Affonso et al. 1991; Barnet et al. 1996;
Demyttenaere et al. 1995; Hobfoll et al. 1995; Kitamura et al. 1994; Kumar
and Robson 1984; OHara 1986).
Antenatal depression is significant not only because of its prevalence but
also because of its consequences. Depression can impair the mothers nutri-
tional intake and prenatal care, increase her likelihood of using potentially
harmful addictive substances, and lead to suicide attempts (Coverdale et al.
1997; Pajer 1995). Untreated antenatal depression significantly increases the
likelihood of postpartum depression (Barnet et al. 1996; Hobfoll et al. 1995),
which in turn may affect the womans long-term prognosis (Parry 1999) and
parenting capability (Jacobsen 1999). A depressive outlook may also color
womens decisions about pregnancy outcome and obstetric interventions
(Coverdale et al. 1997). For example, some depressed women feel so inade-
quate that they cannot imagine raising a child and ask to terminate a preg-
nancy they might otherwise want to continue. Others may decline treatment
for pregnancy complications because they believe a negative outcome is in-
evitable.
Diagnosing depression can be more difficult during pregnancy because
insomnia, decreased energy, decreased concentration, and appetite changes
are common to both pregnancy and depression. Screening instruments such
as the Beck Depression Inventory may overdiagnose depression because of
these overlapping somatic effects (Salamero et al. 1994), but these can be
modified for use during pregnancy (OHara et al. 1984). More problematic,
however, is underdiagnosis of depression during pregnancy. In clinics without
screening measures, significant depression is often missed despite high levels
of contact with health care professionals during pregnancy (Kumar and Rob-
son 1984; Powers et al. 1993).
Bipolar Mood Disorder

Because of the potential risks of prescribing mood-stabilizing medication dur-
ing pregnancy (see Chapter 5), it is particularly important to understand the
potential risks of untreated bipolar mood disorder during pregnancy. Al-
though some women with bipolar disorder improve during pregnancy, sus-
taining euthymic baseline states without medication (Sharma and Persad
1995), others develop acute manic episodes if unmedicated. Untreated mania
can decrease compliance with prenatal care, increase addictive drug use, in-
crease high-risk sexual behavior that exposes both mother and fetus to sexu-
ally transmitted diseases including HIV infection, and increase the likelihood
of the woman being a perpetrator or a victim of violence (Finnerty et al.
1996). When pregnancy complications develop, mania may interfere with ob-
stetric treatment (e.g., making it impossible for a woman to maintain bed rest
[Dickson et al. 1992] or comply with a diet for gestational diabetes mellitus
[Finnerty et al. 1996]).
Anxiety Disorders
Panic Disorder
A subset of women experience a decrease in the frequency and severity of
panic attacks during pregnancy (Villeponteaux et al. 1992), whereas other
women experience new onset of panic disorder (Cowley and Roy-Byrne
1989) or worsening panic during pregnancy (Griez et al. 1995). Panic attacks
occurring during pregnancy may be confused with preeclampsia (Benjamin
and Benjamin 1993) or may contribute to complications like placental abrup-
tion, presumably by producing sympathetic nervous system arousal and tran-
sient hypertension (Cohen et al. 1989). Agoraphobia associated with panic
disorder can compromise womens ability to visit a prenatal clinic (Olsen et
al. 1992).
Obsessive-Compulsive Disorder
Pregnancy is one of the most common triggers for the onset or exacerbation
of obsessive-compulsive disorder (Neziroglu et al. 1992). When severe, com-
pulsions may directly affect obstetric risk factors, such as when nutritious
foods are avoided because of contamination fears or when time-consuming
rituals preclude prenatal clinic visits. Obsessions sometimes include ego-
dystonic thoughts of harming the fetus that women may be afraid to mention
to others (Iancu et al. 1995). Occasionally, symptoms remit at the time of

birth (Iancu et al. 1995), but this is not the norm.
Posttraumatic Stress Disorder

Symptoms of posttraumatic stress disorder arising during pregnancy may be
related to one of the following situations: 1) women with histories of sexual
abuse whose traumatic memories are reactivated by the experience of preg-
nancy and childbirth; 2)women who develop posttraumatic stress disorder as
a result of traumatic childbirth experiences; 3) women who develop both
posttraumatic stress disorder and pregnancy because of a rape.
The experiences of pregnancy, childbirth, and obstetric interventions can
reactivate memories of sexual abuse. Some women experience flashbacks
and/or sensations analogous to forced intercourse and/or overwhelming feel-
ings that their bodies are out of control, that they must depend on others in
a way that frightens them (Rhodes and Hutchinson 1994). These feelings can
result in difficulty collaborating with labor, so that there is a failure to
progress. For example, a woman might tense her thigh and vaginal muscles
rather than relax them to push, or might direct all of her pushing efforts into
her arms, as if to brake the process of delivery. Other manifestations in-
clude dissociation during labor and regressive behavior, such as assuming a
childlike voice, hiding under the covers, and assuming a fetal position
(Rhodes and Hutchinson 1994). As a coping strategy, some women may at-
tempt to control every aspect of delivery to the point at which they are seen
as overcontrolling by obstetric staff. If the reasons for the behavior are not un-
derstood, obstetric personnel may come to regard the mother as an adversary
who must be overcome in order to provide care to the baby (Josephs 1996).
These patterns are especially common in pregnant adolescents because many
pregnant teenagers have been sexually abused (Boyer and Fine 1992).
Even with no preexisting trauma history, childbirth itself is a sufficiently
traumatic experience for some women that it produces symptoms of posttrau-
matic stress disorder (Ralph and Alexander 1994). Childbirth is sometimes
inadvertently rendered more traumatic by prenatal classes that convey the
impression that women who use analgesia during labor are failures (Stewart
1985). Although this feeling, in itself, is unlikely to cause posttraumatic stress
disorder, it can be a contributory factor. Another vulnerable group is that of
women who became pregnant as a result of rape. Many are unaware of the
pregnancy for the first few months. Postrape counseling may help women rec-
ognize the possibility of pregnancy earlier as well as decrease the psychiatric
sequelae.
Sleep Disorders
It is normal for sleep patterns to be altered during pregnancy. The most com-
mon pattern consists of longer sleep and more naps in the first trimester, nor-
mal sleep in the second trimester, and numerous nighttime awakenings in the
third trimester (Brunner et al. 1994; Coble et al. 1994b; Suzuki et al. 1993).
Frequent awakenings toward the end of pregnancy are partly caused by in-
creased urinary frequency, pain, fetal movements, and difficulty finding a
comfortable position (Brunner et al. 1994; Suzuki et al. 1993). They may also
be caused by qualitative changes in sleep architecture, perhaps hormonally in-
duced (Brunner et al. 1994).
In some women, pregnancy is associated with new onset or recurrence
of sleep disorders, including sleepwalking (Berlin 1988), night terrors (Snyder
1986), restless legs syndrome (OKeeffe 1996), and obstructive sleep apnea
(Littner and Brock 1996). Of these, the most common is restless legs syn-
drome, an unpleasant sensation in the legs that is relieved by movement and
causes sleep disturbance because it usually occurs at night (OKeeffe 1996).
It occurs in up to 27% of pregnant women, especially in the second half of
pregnancy. This disorder is associated with depression and is exacerbated by
deficiencies of folate, vitamin B12, and/or iron. The symptoms are also inten-
sified by the use of caffeine, cigarette smoking, or alcohol, although the rea-
sons for this are unknown. Treatment includes eliminating caffeine and
alcohol ingestion; stopping smoking; supplementing with folate, B12, and/or
iron as indicated; and taking hot baths before bedtime. Severe cases can
respond to psychopharmacology with L-dopa, bromocriptine, clonazepam,
carbamazepine, clonidine, or oxycodone, but the risks of prescribing these
agents during pregnancy must be taken into account (see Chapter 5).
Obstructive sleep apnea is rare during pregnancy but is important to de-
tect because severe cases result in sufficient maternal hypoxemia to cause fetal
intrauterine growth retardation. Noninvasive tests of fetal well-being, such as
nonstress tests, serial ultrasound examinations, kick counts, and umbilical
Doppler flow studies, can help determine whether the fetus is being affected
by maternal sleep apnea (Littner and Brock 1996). In some cases, apnea is a
result of sleeping in the supine position and can be remedied by instructing
the woman to sleep on her side (Loube et al. 1996). In other cases, treatment
measures such as continuous positive airway pressure, dental prostheses, tra-
cheostomy, or overnight supplemental oxygen are necessary (Littner and
Brock 1996).
Factitious Disorders
In the context of pregnancy, factitious disorder is the feigning or intentional

production of signs and symptoms of pregnancy complications. These can in-
clude vaginal bleeding, premature labor, premature rupture of membranes,
vomiting, reduction in fetal movements, pyrexia, and seizures (Goodlin 1985;
Jureidini 1993). Failure to detect the factitious nature of symptoms can result
in misdiagnoses such as placenta previa, placental abruption, and fetal dis-
tress and can lead to premature delivery by cesarean section. Factitious disor-
der during pregnancy poses a risk for the later development of factitious
disorder by proxy, which is the feigning or production by the mother of symp-
toms or illness in her child (Jureidini 1993), and of other forms of child abuse
(Goodlin 1985).
Recognizing the factitious nature of symptoms is challenging but can be
facilitated by 1) including factitious disorder in the differential diagnosis of
pregnancy complications, 2) communicating with other health care providers
for patients who seek care from multiple sites, and 3) eliciting a history of pri-
or child custody loss. Management is usually best conducted by obstetricians
in consultation with psychiatrists. Although patients rarely improve from di-
rect interpretation of their behavior, an understanding of their motivations
may be obtained through collateral historians and may guide intervention.
Collaboration with child welfare agencies may offer protection for offspring
as well as help motivate women to consider psychiatric intervention and
parenting rehabilitation.
Disorders Specific to Pregnancy
Hyperemesis Gravidarum
Hyperemesis gravidarum is a condition of intractable vomiting during preg-

nancy that is of sufficient severity to result in electrolyte imbalance, weight
loss, ketosis, acetonuria, and/or organ damage and is without a known organ-
ic cause other than pregnancy. Although mild nausea and vomiting are expe-
rienced in most normal pregnancies, hyperemesis gravidarum is relatively
rare and occurs in approximately 0.510/1,000 pregnancies (Hod et al. 1994).
Endocrinologic explanations for the etiology of hyperemesis gravidarum
have been postulated, although none have been clearly proven. The etiologic
role of psychogenic factors has been controversial. Belief in such factors arose
because vomiting ceased in some cases with placebo treatments, hospital ad-
mission alone, or psychosocial interventions. Psychodynamic explanations
initially centered on vomiting as an unconscious attempt to get rid of the fetus
(OBrien and Newton 1991).
Empirical studies have suffered from methodologic difficulties, including
a lack of adequate control subjects and a failure to differentiate the psycho-
logic causes of hyperemesis from its effects. One well-controlled follow-up
study found no evidence of significant differences in long-term psychopathol-
ogy between women with hyperemesis and control subjects, although acute
psychiatric disturbance could not be excluded (Majerus et al. 1960). Other
studies have found hyperemesis to be associated with factors such as hyster-
ical personality, below-average intelligence, poor motherdaughter relation-
ships, unplanned and/or undesired pregnancies, susceptibility to hypnosis,
and eating disorders (Apfel et al. 1986; Fairweather 1968; Fitzgerald 1984).
Hyperemesis has also been conceptualized as a learned behavior in response
to psychosocial triggers that vary from woman to woman. In some cases, it
is postulated that the trigger is an extreme anxiety response to normal
nausea and vomiting of pregnancy, which in turn worsens the nausea and
vomiting, creating a vicious circle (Deuchar 1995).
Overall, available data suggest a spectrum of psychophysiologic causa-
tion, with some cases heavily influenced by psychopathology, others appar-
ently unrelated to psychologic disturbance, and some having both emotional
and somatic determinants. A logical clinical approach begins with screening
for the presence of a personality disorder, current interpersonal conflict, eat-
ing disorder, ambivalence about the pregnancy, extreme anxiety, and/or spe-
cific psychosocial triggers of vomiting. Noting apparent connections
between the factors and the symptoms can guide effective treatment.
Denial of Pregnancy
Difficulties with recognizing and accepting pregnancy fall on a continuum

from disavowal of the emotional reality of pregnancy through suppression of
awareness of pregnancy to psychotic denial of pregnancy. Emotional denial
occurs in women who acknowledge that they are pregnant yet do little or
nothing to alter their lives accordingly. For example, they do not change diet,
wardrobe, exercise regimen, or future plans. They do not fantasize about the
baby, think of names for the baby, or prepare a nursery. This type of denial
is often seen in women who have lost a prior baby, such as through stillbirth.
In these cases, working through unresolved grief may help mothers bond
with their new babies and allow those babies to have identities separate from
those of their lost siblings. This pattern is also seen in many women who use
addictive drugs and feel guilty about potential consequences (Spielvogel and
Hohener 1995).
More extreme denial may be seen in women who suppress awareness of
pregnancy through all or most of gestation. Typically, such women gain little
or no weight; those who do gain weight attribute it simply to getting fat.
Many have episodes of bleeding throughout the pregnancy; those who do not
may attribute amenorrhea to menopause or to irregular periods. Few experi-
ence typical pregnancy-related symptoms such as nausea; those who do ex-
perience such symptoms attribute them to other causes. Symptoms and signs
of labor are misinterpreted; for example, contractions may be experienced as
the urge to defecate and ruptured membranes as urination. During labor and
delivery, these women often show signs of dissociation. In most cases, signif-
icant others do not know that the women are pregnant. In part, this is because
the women conceal signs of pregnancy, but in many cases it seems to reflect
a profound interpersonal isolation and lack of intimacy with significant oth-
ers. Pregnancy is usually discovered during labor or after the birth of the
baby but is occasionally discovered earlier by accidentfor example, by view-
ing fetal bones on X-rays that the mother receives for unrelated complaints (
Brezinka et al. 1994; Brozovsky and Falit 1971; Finnegan et al. 1982).
Women who deny pregnancy in this way are a heterogeneous group.
Risk factors for this form of denial include 1) young age (most reported cases
are in adolescents); 2) passivity (e.g., women who do not refuse unwanted sex
and/or do not insist on contraception, then become pregnant and do not seek
abortions even if they want them); 3) family and/or cultural taboos (e.g., fam-
ilies or subcultures in which it is unthinkable to become pregnant while un-
married or families in which a woman believes dire consequences will result
from pregnancyIf you ever got pregnant, your father would have a heart
attack!); 4) history of sexual abuse, leading women to deny pregnancy in or-
der to stave off traumatic memories; 5) limited intelligence or paucity of
knowledge about reproductive anatomy and physiology; 6) relevant life stres-
sors, such as separation from the father of the child; and 7) social isolation
(Brezinka et al. 1994; Finnegan et al. 1982; Resnick 1970; Saunders 1989;
Spielvogel and Hohener 1995).
Certain obstetric and gynecologic conditions also enhance the likelihood
of pregnancy denial. These include breech presentation, which causes body
habitus to be less recognizable as pregnant, and irregular menses, which make
pregnancy-related amenorrhea less noticeable (Brezinka et al. 1994).
The consequences of extreme pregnancy denial can include failure to re-

ceive prenatal care; inadequate nutrition during pregnancy; failure to avoid
pregnancy-related risks such as radiologic procedures or teratogenic drugs;
failure to notice warning signs of premature labor, premature rupture of
membranes, or other pregnancy complications; unassisted delivery, some-
times accompanied by complications such as excessive bleeding or infection;
neonaticide, occurring either actively (e.g., the mother is overwhelmed by
fear and rage after the sudden breakdown of defensive denial and kills the ba-
by) or passively (e.g., the baby drowns in the toilet because of being mistaken
for a bowel movement); and loss of custody of the child (Brezinka et al. 1994;
Resnick 1970; Saunders 1989; Spielvogel and Hohener 1995).
Psychotic denial of pregnancy usually occurs in women with preexisting
psychotic disorders, most commonly schizophrenia. It consists of maintaining
the belief that one is not pregnant despite experiencing the physical changes
of pregnancy and experiencing positive pregnancy tests, ultrasound examina-
tions, fetal heart tones, and even the baby after birth. In many cases, the de-
nial comes and goes and is intensified by stress. Psychotic denial is more
common in women who have lost custody of a baby and/or anticipate losing
custody, suggesting that it is a defense against overwhelming feelings of loss
(Miller 1990).
Denial and its resultant risks can be minimized by screening for pregnan-
cy in high-risk populations (e.g., adolescents and women with schizophrenia
or drug addiction), discussing sexuality and reproduction in a nonjudgmental
manner, and screening for past sexual abuse and past fetal/neonatal loss.
Emotional denial often responds to brief, focused psychotherapy. Extreme,
nonpsychotic denial usually collapses in the face of external validation of
pregnancy, but supportive psychotherapeutic and family interventions may
be necessary depending on the sources of denial and the consequences of ac-
knowledging the pregnancy. Psychotic denial may respond to pharmaco-
therapy and supportive psychotherapy; if persistent, however, hospitalization
may be required in order to to avoid precipitous, unassisted delivery and/or
harm to the fetus or neonate (Miller 1990; Spielvogel and Hohener 1995).
General Principles of Intervention During Pregnancy
The increased contact with health care professionals afforded by prenatal care
allows for early detection of psychiatric disorders during pregnancy. Early de-
tection, in turn, allows prompt intervention and prevention of exacerbations
later in pregnancy or postpartum. This may decrease the need for medication
during pregnancy, decrease obstetric complications, and promote optimal
parenting.
Early detection can be promoted by the use of screening tools designed
for this purpose (Powers et al. 1993). Mental health screening questions can
be incorporated into general prenatal intake histories in the form of self-
administered questionnaires (on paper or computer) or as semistructured
interviews. In addition to instruments that screen for general psychiatric
symptoms, instruments are available that have been developed specifically
for use with pregnant women in prenatal care settings. These include the Ma-
ternal Attitudes to Pregnancy Instrument (MAPI; Blau et al. 1964), the Life
Events Scale for Obstetric Groups (Barnett et al. 1983), the Maternal Adjust-
ment and Maternal Attitudes scale (MAMA; Kumar et al. 1984), and the
Pregnancy Psychologic Attitudes Test (PPAT; Mamelle et al. 1989).
When psychiatric symptoms are present, a comprehensive psychiatric
evaluation can assist in making a diagnosis and guiding interventions. For
certain symptoms, specific forms of psychotherapy may be particularly effec-
tive: for example, cognitive-behavioral therapy for depression, obsessive-
compulsive disorder, and panic disorder; relaxation techniques and hypnosis
for hyperemesis gravidarum; or interpersonal psychotherapy for depression.
In cases of severe psychiatric disorders, the risks of active symptoms may out-
weigh potential risks of pharmacotherapy or electroconvulsive therapy dur-
ing pregnancy (see Chapter 5). Decisions about somatic treatment during
pregnancy must take into account not only the risks of treatment and of un-
treated symptoms but also the patients insight into her illness, her ability to
recognize early symptoms, her social supports, and her therapeutic alliance.
Involving the family members and self-help support networks of pregnant
women may be helpful, given the high levels of psychosocial stress associated
with many antenatal psychiatric conditions.
When presenting mentally ill pregnant women with decisions about ob-
stetric interventions, it is important to evaluate whether and how psychiatric
symptoms are affecting the decision-making process. For women with prior
histories of psychiatric disorder who become pregnant, health care directives
stating treatment preferences can be written in anticipation of possible relapse
(Coverdale et al. 1997). For women with extreme anxiety about obstetric in-
terventions (e.g., in cases of posttraumatic stress disorder), helping them gain
and maintain a sense of control is helpful. This can be facilitated, for example,
by avoiding unnecessary vaginal examinations, preparing them emotionally
for necessary examinations, getting explicit permission to touch them before
doing so, and maintaining their active involvement in decision making

throughout the pregnancy (Rhodes and Hutchinson 1994). After difficult la-
bors, postnatal debriefing either individually or in a group may prevent the
later development of anxiety symptoms (Ralph and Alexander 1994).
For patients who require psychiatric hospitalization during pregnancy,
setting up collaborative links between mental health, obstetric, and pediatric
staff can facilitate optimal care (Miller 1992; Muqtadir et al. 1986). In some
cases, hospitalization can be avoided with prenatal home visits by case man-
agers and nurse midwives, such as for women with agoraphobia.
Major mental illness during pregnancy raises questions about a womans
ability to care for her baby after birth. Assessment of parenting capability (Ja-
cobsen et al. 1997), followed by provision of extra social support and parent-
ing rehabilitation when needed, may decrease the possibility of custody loss
and may improve the future course of the lives of the mother, the baby, and
the rest of the family.
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5
Psychotropic Drugs and
Electroconvulsive Therapy During
Pregnancy and Lactation
Any discussion on the effects of psychotropic drugs in pregnancy and lacta-

tion must start by stating the limits to our knowledge. Many studies have
failed to consider confounding variables such as diagnosis; maternal age; use
of alcohol, tobacco, or street drugs; gravidity; socioeconomic status; previous
pregnancy loss; genetic history; use of multiple drugs; timing of drug exposure;
and dosage. Few prospective controlled studies of the treatment of psychiatric
disorders in pregnant women are available (Altshuler et al. 1996). Moreover,
drugs that consistently produce defects in other animals may not have similar
effects in humans (Elia et al. 1987). It is wise to remember that the U.S. Food
and Drug Administration (1979) has not approved any psychotropic drugs for
administration during pregnancy and urges caution in their use. A multidis-
ciplinary task force is developing new guideline documents (Center for Drug
Evaluation and Research 1997). During the 1990s, patterns of psychotropic
drug exposure in pregnancy changed. Selective serotonin reuptake inhibitors
are now the most commonly prescribed antidepressant drugs, and a host of
new antianxiety and psychotropic drugs have been approved for clinical use.
67
Effects of Pregnancy on
Drug Metabolism, Action, and Side Effects
Pregnant women may receive psychotropic drugs for several reasons. Some
may be undergoing treatment with antidepressants, antipsychotics, mood sta-
bilizers, or minor tranquilizers, either for an acute psychiatric illness or for
maintenance therapy, when they become pregnant. Other women may devel-
op a psychiatric illness that requires treatment during pregnancy or lactation
(Robinson et al. 1986).
The potential benefits of pharmacotherapy in the pregnant or lactating
woman must be carefully weighed against the possible risks to the woman
and her developing fetus or infant. The risk side of the risk/benefit equation
includes the risks of maternal and newborn toxicity, side effects and with-
drawal, and fetal physical or behavioral teratogenicity (Cohen et al. 1989).
Although the benefits of psychotropic drugs for the severely psychotic, de-
pressed, or suicidal pregnant woman may outweigh the risks to the infant, a
careful appraisal of current knowledge in this area is essential before a ratio-
nal clinical decision can be reached (Robinson et al. 1986). This chapter con-
tains current information on the use of antipsychotics, antidepressants, mood
stabilizers, and anxiolytics during pregnancy and lactation. Use of electrocon-
vulsive therapy (ECT) in pregnancy is also discussed.
Despite public education, drug use in pregnancy is still commonplace.
Because more than 50% of pregnancies are unplanned, many drug exposures
will occur before the pregnancy is even diagnosed. Rayburn et al. (1982)
showed that 90% or more of all pregnant women take one or more drugs in
addition to dietary supplements during pregnancy. In a North American
study, Heinonen et al. (1977) reported that 36% of pregnant women took
sedatives, tranquilizers, or antidepressants at some time during their preg-
nancies.
Several physiologic changes in pregnancy alter the effects of drugs. Data
on drug metabolism rates, dosages, and side effects in nonpregnant women
may not apply to pregnant women. The significant increases in total body wa-
ter content that occur during pregnancy may result in lower drug serum con-
centrations than are found in nonpregnant women. Total protein is also
reduced in pregnancy, thereby altering drug binding. A physiologic drop in
blood pressure in the second trimester of pregnancy may result in orthostatic
hypotension, causing significant problems in pregnant women treated with
some antipsychotic and tricyclic antidepressant drugs. The emptying rate of
Psychotropic Drugs and ECT During Pregnancy and Lactation 69
the gastrointestinal tract is decreased by 30%50%, and gastric acid is de-

creased, thus altering drug absorption. Constipation, a common condition in
pregnancy, may be worsened by medications with anticholinergic side effects.
Glomerular filtration rates are increased in pregnancy, causing some drugs
such as lithium to be excreted more quickly and thereby requiring higher dos-
es to achieve therapeutic serum levels. Hepatic hydroxylases involved in drug
metabolism may be inhibited during pregnancy (Mortola 1989; Wisner and
Perel 1988).
The physiologic changes of pregnancy necessitate careful monitoring of
a womens drug response, side effects, and toxicity throughout the pregnancy
and early postpartum period (Wisner and Perel 1988). Higher doses are
sometimes required in pregnancy to achieve therapeutic serum levels. After
delivery, the doses may need to be decreased to prevent maternal toxicity
(Koplan 1983; Stewart 1988).
All psychotropic drugs cross the placenta and enter the fetal circulation
to some degree. The penetration to the fetal compartment is influenced by the
characteristics of the drug, the dosage, and the stage of pregnancy (Mirkin
1976). When repeated doses of a psychotropic drug are administered to sus-
tain plasma concentrations, the drug is usually distributed equally to mother
and fetus (G.H. Levy 1981). Both the placenta and the fetus have enzyme sys-
tems involved in drug metabolism, but many details are as yet incompletely
understood (Chao and Juchau 1983). It is also known that some enzyme sys-
tems are not mature at birth, impairing the ability of the newborns liver to
conjugate the metabolites of common drugs such as diazepam (Kanto 1982).
Thus, fetal physiology must also be considered in prescribing psychotropic
drugs in pregnancy.
General Effects on the Fetus and Neonate
Morphologic Teratogenicity
During the first several cell divisions, the developing embryo is thought to be
protected against the effects of drugs administered to the mother because the
placenta has not yet formed. This period of protection is between conception
(approximately day 14) and the first missed period (approximately day 28 of
a 28-day cycle). After the first missed period, however, the placenta is suffi-
ciently developed to transfer drugs in the maternal circulation to the develop-
ing fetus (Cohen 1989).
It is impossible to guarantee that any psychotropic drug is not teratogenic

and able to cause fetal deformity because the baseline rate of birth defects in
the Western World is approximately 3%, and the cause of most birth defects
remains unknown (Beeley 1986). Although the incidence of birth defects
caused by drugs is probably low, low levels of teratogenicity caused by drugs
are extremely difficult to distinguish from the spontaneous occurrence of
anomalies and require large exposure samples (American Medical Associa-
tion 1983).
Several factors, however, are known to increase the teratogenic risks of a
drug: 1) exposure to the drug during organogenesis (central nervous system,
gestational days 1025; limb development, days 2426; cardiovascular sys-
tem development, days 2040); 2) dosage and regularity of use (lack of ma-
ternal toxicity does not indicate lack of fetal toxicity); 3) interaction with
other environmental factors, such as other drugs, alcohol, tobacco, and other
toxins; and 4) the genetic constitution of the mother and fetus. It is hypothe-
sized that the continuum of abnormal development ranges from fetal death
(resulting in miscarriage or stillbirth) to physical malformation, growth retar-
dation, or functional deficits (behavioral teratogenicity) (J. G. Wilson 1977).
Behavioral Teratogenicity
The rapidly developing field of behavioral teratogenicity includes functional

deficits such as delayed behavioral maturation, abnormal activity, and im-
paired problem solving and learning, all of which may develop following fetal
exposure to teratogens (Vorhees and Butcher 1982). Research in animals has
shown that most drugs that act on the central nervous system have a low po-
tential for physical teratogenicity but a higher potential as behavioral terato-
gens, which probably arises from less-severe damage (Vorhees and Butcher
1982). Many behavioral teratogenic agents may not yet have been identified
in humans because they are unaccompanied by physical malformation. Few
studies on the long-term follow-up of children exposed to psychotropic drugs
in utero are available. (See specific information on major tranquilizers, anti-
depressants, and lithium in the section on Known Effects of Specific Psycho-
tropic Drug Groups in this chapter.) Other investigators have criticized the
available studies for their small sample sizes, lack of data on dosage and tim-
ing, circumscribed inquiry, lack of standardized psychometric instruments,
and inadequate follow-up period (Edlund and Craig 1984). It is therefore un-
wise to assume that any psychotropic agent is safe in pregnancy (Wisner
and Perel 1988), although the use may be appropriate in many clinical situa-
tions. Use of psychotropic drugs during pregnancy and lactation should in-
clude thoughtful weighing of risks of prenatal exposure versus risks of
maternal mental illness or relapse following drug discontinuation (Altshuler
et al. 1996).
Effects of Psychotropic Drugs During

Second and Third Trimester and Labor
Psychotropic drugs appear to be safer during the second and third trimester
of pregnancy. Major malformations are not produced during the second and
third trimesters, but drugs can affect the growth and functional development
of the fetus. In particular, the central nervous system continues to develop
throughout pregnancy and the neonatal period, and damage after the first tri-
mester can produce microcephaly, mental retardation (Beeley 1986), and be-
havioral teratogenicity. Some clinicians recommend that the drug doses be
lowered or discontinued approximately 2 weeks prior to the expected date of
delivery to reduce the possibility of side effects, toxicity, and withdrawal in
the newborn (Kerns 1986; Robinson et al. 1986; Wisner and Perel 1988),
whereas other experts do not discontinue psychotropic drugs before labor in
order to reduce the risk of in vitro fetal withdrawal or maternal relapse of psy-
chiatric illness (Altshuler et al. 1996).
Both the major and the minor tranquilizers have been used by obstetri-
cians during labor to reduce anxiety, increase relaxation, or decrease nausea.
Long-acting benzodiazepines, however, should be avoided in the third trimes-
ter because they adversely affect the neonate (Mandrelli et al. 1975). If ben-
zodiazepines are required they should be used in the lowest effective dose for
the shortest period of time necessary to minimize fetal exposure (Altshuler et
al. 1996).
Effects on the Neonate
Antipsychotics, tricyclic antidepressants, and benzodiazepines are lipid solu-

ble and largely protein bound and are slowly eliminated from the newborn.
The neonate may be more susceptible to these drugs because liver enzymes
are not fully developed; plasma protein concentrates are lower, leading to in-
creased free drug available to act on the brain; the blood-brain barrier is in-
complete; and the immature central nervous system may be more sensitive to
these drugs (Altshuler et al. 1996; Nahas and Goujard 1978).
Effects During Lactation
Psychotropic drugs, like most medications, are excreted to some degree in

breast milk. The concentration of the drug in breast milk depends on its sol-
ubility, protein binding, and drug pH compared with plasma (Robinson et al.
1986). There are wide variations among drugs, and concentrations may vary
in breast milk samples taken at different times of the day.
The American Academy of Pediatrics Committee on Drugs (1994) has
classified major and minor tranquilizers and antidepressants under the cate-
gory of drugs whose effects on nursing infants is unknown but may be of
concern. Various case reports of toxic effects, drowsiness, impaired temper-
ature regulation, and no ill effects have been described in breastfed infants of
mothers receiving psychotropic or mood-stabilizing drugs (Gelenberg 1987).
The effects of these drugs on the immature neurotransmitter system are un-
known (Mortola 1989; Robinson et al. 1986).
Wisner et al. (1996) reviewed the use of antidepressants during lactation,
and although they found limited findings to be reassuring, they recommend-
ed an expanded database of motherbaby serum levels, behavioral assess-
ments of babies during nursing and longitudinal development, and
evaluation of nurslings.
Known Effects of
Specific Psychotropic Drug Groups
Antipsychotic Agents
Teratogenicity
Numerous reports in the literature describe individual or short series of cases
in which the use of neuroleptics in the first trimester has coincided with the
occurrence of congenital anomalies (Table 51). Results of larger studies are
conflicting.
The French National Institute of Health and Medical Research conduct-
ed a retrospective study involving 12,764 births (Rumeau-Rouquette et al.
1977). Infants in the control group demonstrated congenital malformation
not considered to be related to chromosomal abnormalities in 1.6% of cases.
Of the 315 women who received phenothiazines during the first trimester,
3.5% gave birth to malformed infants. This was considered a statistically sig-
TABLE 51. Psychotropic drugs in pregnancy and lactation
Psychotropic Drugs and ECT During Pregnancy and Lactation

Drugs Teratogenicity Effects on the neonate Lactation
Antipsychotics
Phenothiazines Congenital anomalies increased if used Third trimester use of neuroleptics may Excreted in breast milk. No seri-
(especially aliphatics) weeks 610. Cardiovascular anoma- cause extrapyramidal symptoms in in- ous side effects reported as yet;
lies increased. Use with caution in fant: excessive crying, motion, hyper- increased drowsiness. Use with
first trimester. Appears to be fairly tonia, hyperreflexia, respiratory caution.
safe. distress, vasomotor instability, and
slow early learning tasks. Jaundice pos-
sible, especially in prematures.
Butyrophenones No evidence at present for teratogenic- Haloperidol toxic in animal stud-
ity. ies. Use with caution.
Clozapine, olanzapine, Unknown. Effects unknown. Effects unknown.
respiradone, quetiapine
Antidepressants
Tricyclics and No link with fetal deformity or limb Withdrawal symptoms in infant may Excreted in breast milk. No ef-
heterocyclics dysgenesis. Use with caution in first include heart failure, tachycardia, fects shown for amitriptyline,
trimester. Appears to be fairly safe. myoclonus, seizures, respiratory dis- nortriptyline, desipramine, clo-
tress, urinary retention, cyanosis, mipramine, or dothiapin.
irritability, feeding difficulty.
Serotonin reuptake Caution in first trimester. Data on Fluoxetine-exposed infants show no Small amounts in breast milk.
inhibitors fluoxetine, paroxetine, sertraline, difference up to school age compared Early data show no serious ef-
and fluvoxamine show no evidence with control subjects. Other drugs fects for sertraline, fluoxetine,
of malformation. Appear fairly safe. unknown. or paroxetine.
Monoamine oxidase Phenelzine teratogenic in animals. Effects unknown. Effects unknown.
inhibitors Avoid in first trimester.
73
74
TABLE 51. Psychotropic drugs in pregnancy and lactation (continued)

Mood stabilizers
Psychological Aspects of Womens Health Care, Second Edition

Lithium carbonate Increased cardiovascular anomalies. Third trimester use may cause hypo- Excreted in breast milk. Severe
Use with caution in first trimester. tonia, lethargy, cyanosis, poor sucking, toxic reactions. Contraindicat-
Give in small divided doses if shallow respiration, low Apgar score, ed while breastfeeding.
necessary. Refer for fetal ultra- arrhythmias, hypotension.
sonography.
Valproic acid Spina bifida reported (1%5%). Effects unknown. Limited data compatible with
breastfeeding. (American
Academy of Pediatrics)
Carbamazepine Craniofacial defects and spina bifida re- Effects unknown. Limited data compatible with
ported. breast feeding (American Acad-
emy of Pediatrics)
Anxiolytics
Benzodiazepines Safety in first trimester not established. With chronic use in pregnancy, with- Excreted in breast milk. Lethar-
Incidence of cleft lip/palate may be in- drawal symptoms include tremor, gy, jaundice, poor temperature
creased. hypertonia, and hyperreflexia. High regulation possible. Long half
doses prior to delivery result in low life drugs contraindicated while
Apgar scores, hypothermia, and neu- breastfeeding.
rologic depression. Floppy infant
syndrome, decreased sucking rate, and
jaundice possible.
Meprobamates Cleft lip/palate, and other severe con-
genital anomalies possible. Do not
use.
TABLE 51. Psychotropic drugs in pregnancy and lactation (continued)
Psychotropic Drugs and ECT During Pregnancy and Lactation

Barbiturates Associated with dose-related growth Chronic use in pregnancy associated Long-term effects unknown.
retardation, facial dysmorphism, oral with withdrawal in infant 1014 days
clefts, and skeletal anomalies when after birth; increased tone, tremor,
used in first trimester. and irritability.
Hydroxyzine Teratogenic in animals. Jitteriness, myoclonic jerks, and hypo-
tonia possible after large doses prior
to delivery.
Antiparkinsonian agents No studies. Usually given with Effects unknown. Effects unknown.
neuroleptic. Amantadine teratogenic
in animals. Cardiovascular malfor-
mation?
75
nificant increase in malformations (especially following the use of aliphatic

phenothiazines), but it is not clear whether confounding variables such
as dosage, concurrent drugs, and maternal health and age were taken into
account.
Slone et al. (1977) reported the results of the Collaborative Perinatal
Project of 5,282 gravidas and their children, including 1,309 cases of prenatal
exposure to phenothiazines. The authors found no significant increase in the
incidence of congenital malformations related to exposure in the first trimes-
ter except for a questionable association with cardiovascular malformations.
Perinatal mortality rate, birth weight, and IQ at age 4 were all found to be
normal in this group.
The California Child Health and Development Project, which studied
over 19,000 births, originally showed no increase in congenital anomalies fol-
lowing phenothiazine use in pregnancy (Milkovich and van den Berg 1976).
On reanalyzing the data, Edlund and Craig (1984) demonstrated a trend to-
ward increased congenital anomalies when the drugs were given after 4
weeks, the most critical period being from 610 weeks gestation. The ex-
posed samples yielded an incidence of congenital anomalies of 5.4% versus
3.2% in the control subjects.
Studies to date have not revealed a significant increase in fetal abnormal-
ities for pregnant women receiving thioridazine, perphenazine, trifluopera-
zine, fluphenazine, or haloperidol (Ananth 1975; Goldberg and DiMascio
1978). No evidence has been found of teratogenicity for the dibenzox-
azepines, thioxanthenes, or diphenylbutylpiperidines; their safety in pregnan-
cy, however, has not been established.
Caution must be exercised in drawing conclusions from these studies.
Edlund and Craig (1984) and others have pointed out numerous confound-
ing methodologic errors. Many studies may have minimized potential effects
by looking at nonpsychotic populations using small amounts of drugs as
antiemetics or anxiolytics rather than the dosages typically used to treat psy-
choses. There is also some evidence that children of psychotic women have
a higher risk of fetal damage independent of drug exposure (Stewart 1984;
Wrede et al. 1980). On the basis of available data it appears that psychotic
illness per se may confer the greatest increase in risk of poor fetal outcome.
Perinatal exposure to low-potency phenothiazines may confer an additional
risk of poor outcome in 4/1,000 patients (0.4%) (Altshuler et al. 1996). In
general, the higher-potency drugs such as haloperidol appear to be safer;
however, little data are yet available on clozapine, olanzapine, respiradone, or
quetiapine.

The use of neuroleptics in the last trimester has been reported to cause ex-
trapyramidal symptoms in the neonate, sometimes lasting up to 6 months (W.
Levy and Wisniewski 1974). Infants regularly exposed to neuroleptics in the
third trimester may be especially difficult to care for because they may suffer
from excessive motion, crying and sucking, hypertonicity, hyperreflexia, and
vasomotor instability. Brazelton (1970) found effects on neonatal weight, re-
sponse to nursing, and early learning tasks, but these seemed to occur only
in the immediate postnatal period.
Effects on Breastfeeding Infants

The quantity of major tranquilizers excreted in breast milk is usually less than
30% of the maternal plasma concentration (Ananth 1978). An exception may
be haloperidol excretion, which was reported in one case study to be approx-
imately 60% (Whalley et al. 1981). Aside from some drowsiness with chlor-
promazine and some galactorrhea with chlorpromazine and thioridazine, no
significant human neonatal side effects have been reported despite several
large studies (Ananth 1978). Some studies in animals, however, have shown
behavioral abnormalities in offspring following administration of haloperidol
during lactation (Ananth 1978). Infants who are breastfed while their mothers
are receiving major tranquilizers should be carefully clinically monitored. Se-
rum levels in the infant may be helpful in assessing risk and drowsiness.
Long-Term Effects on Children Exposed in Utero

Slone et al. (1977) studied 4-year-old children whose mothers had received
phenothiazines during pregnancy and found their IQ scores to be the same
as those of a control population. Kris (1965) followed-up a small sample of
children who had been exposed to 50150 mg chlorpromazine in utero and
found the children to be healthy with normal behavior. The flaws of
these studies are described in the Behavioral Teratogenicity section earlier
in this chapter.
Antidepressants
Teratogenicity
Crombie et al. (1975) reviewed 10,000 pregnancies in England and Wales,
and Kuenssberg and Knox (1972) reviewed another 15,000 pregnancies in
Scotland. The Finnish Register of Congenital Malformations for 19641972

was used by Idanpaan-Heikkila and Saxen (1973) to analyze 2,784 cases of
birth defects and an equal number of matched control births. No link was
found between fetal deformities, including limb dysgenesis, and the use of tri-
cyclic antidepressants in pregnancy in these studies. The Collaborative Peri-
natal Project (Heinonen et al. 1977) prospectively examined the relationship
of tricyclic antidepressants to pregnancy outcome but the numbers were too
small to justify generalizations. The European Network of the Teratology In-
formation Services has prospectively collected and evaluated data on 689
pregnancies exposed to tricyclic and nontricyclic antidepressants. The inci-
dence of spontaneous abortion and late fetal/neonatal deaths was within nor-
mal limits. Two-thirds of mothers were receiving multiple drugs and 95%
were exposed in the first trimester. Of infants without malformations, 31 had
neonatal problems associated with chronic multidrug use, especially near
term. Evaluated after the first few weeks of postnatal life, 97% of live-born ba-
bies were morphologically normal and there was no increase in particular
malformations or patterns of defects (McElhatton et al. 1996).
A prospective study from a drug exposure in pregnancy registry was un-
able to demonstrate any teratogenicity following first-trimester exposure to
fluoxetine (Pastuszak et al. 1993). A study of infants exposed to fluoxetine in
utero showed no increased rate of major birth defects but found higher rates
of minor abnormalities, preterm births, low birth weights, and admissions to
special nurseries (Chambers et al. 1996). However, this study did not control
for depression effects, was randomized, and the women receiving fluoxetine
were older than control mothers. A well-designed study of infants exposed to
tricyclic drugs or fluoxetine in utero was unable to demonstrate any teratoge-
nic, birth weight, Apgar score, language development, IQ, or social develop-
ment changes in exposed infants followed-up to school entry compared with
unexposed control infants (Nulman et al. 1997). A recent meta-analysis of ep-
idemiologic studies showed no association between first-trimester fluoxetine
use and human teratogenic effects (Addis and Koren 2000). In another study,
no congenital anomalies were found in 63 infants exposed to paroxetine in
the first trimester (Inman et al. 1993). A recent study of exposure to sertraline
(147 women), paroxetine (97 women), and fluvoxamine (26 women) showed
no increase of infant teratogenicity at birth (Kulin et al. 1998).
Inadequate data are available to evaluate new antidepressants such as bu-
propion, trazodone, buspirone, nefazadone, mirtazapine, or venlafaxine.
Monoamine oxidase inhibitors have been shown to have teratogenic proper-
ties (Heinonen et al. 1977; Poulson and Robson 1964). Although the num-
bers in these studies are small, it is probably wise to use other antidepressants
in pregnancy.
Stimulants such as methylphenidate or amphetamines are also used to
treat depression. Unfortunately, most case reports of their use in pregnancy
are from women who abused these drugs. In large doses these drugs are as-
sociated with fetal growth retardation, premature delivery, irritability, jerki-
ness, shrill cries, lassitude, and apnea (Briggs et al. 1994; Oro and Dixon
1987). One study found medical use of amphetamines to be associated with
fetal oral clefs (Milkovich and van den Berg 1977).

Withdrawal symptoms, irritability, and convulsions in the neonate have been
reported following the use of desipramine, imipramine, and nortriptyline dur-
ing pregnancy (Shearer et al. 1972; Webster 1973). There have been case re-
ports of infants born with heart failure, tachycardia, bowel obstruction,
respiratory distress, and urinary retention. Signs of toxicity in the infants of
mothers taking large amounts of these medications just before delivery may
include breathlessness, cyanosis, tachypnea, irritability, seizures, and feeding
difficulties (Ananth 1976; Eggermont et al. 1972). More admissions to special
care nurseries were reported in infants exposed to fluoxetine in utero (Cham-
bers et al. 1996).

Controversy exists concerning the effects of antidepressants on breastfeeding
infants. Sovner and Orsulak (1979) suggested that amounts of imipramine
and desipramine in breast milk samples are similar to those found in plasma
and recommended that women not breastfeed while receiving antidepres-
sants because of concern about subtle effects on the neurologic or behavioral
maturation of the infant.
Wisner et al. (1996, 1999) critically reviewed the literature on antidepres-
sants during lactation and reported that amitriptyline, nortriptyline, de-
sipramine, clomipramine, dothiapin, and sertraline were not found in
quantifiable amounts in nurslings and no adverse effects were reported. The
authors felt these were the drugs of choice for breastfeeding women. Adverse
effects were reported in some young infants whose mothers has been treated
with doxepin or fluoxetine during breastfeeding; however, they found that in-
fants older than 10 weeks showed no accumulation of drugs and were at low
risk for adverse effects. Moreover, Chambers et al. (1999) found lower weight
gain in 26 breastfed infants whose mothers were receiving fluoxetine. How-

ever, Stowe et al. (2000) found only low concentrations of paroxetine in in-
fants serum and a lack of any observable adverse effects after maternal use
while breastfeeding.
Current information, therefore, does not warrant an absolute recommen-
dation on the use of antidepressant drugs in women who are breastfeeding,
because the risk/benefit ratio must be assessed on an individual basis. Infants
who are breastfed while their mothers are receiving antidepressants should
be carefully clinically monitored, and infant serum levels of antidepressants
should be measured in cases of extended drug exposure (Birnbaum et al.
1999). The American Academy of Pediatrics (1994) does not believe that ma-
ternal antidepressant use precludes breastfeeding, but it classifies antidepres-
sants as drugs whose effects on nursing infants are unknown but may be of
concern.
Lithium, Carbamazepine, and Valproic Acid

Teratogenicity
Weinstein (1980) reviewed the records of The International Register of Lith-
ium Babies and found an 11% rate of malformation in 225 exposed infants.
Of these malformations, 8% were Ebsteins anomaly or other major cardio-
vascular malformations. Ebsteins anomaly is a rare condition that occurs in
1 infant per 20,000 live births. Subsequent investigators (Kallen and Tand-
berg 1983) also reported that exposure to lithium is linked to cardiovascular
anomalies, resulting in a contraindication for lithium in the first trimester.
Two more-recent studies (Jacobson et al. 1992; Zalzstein et al. 1990), howev-
er, suggested that the link to Ebsteins anomaly is much weaker than previ-
ously reported.
A pooled overview of studies suggests the risk of Ebsteins anomaly fol-
lowing first trimester lithium exposure is 1020 times as common as in the
general population (0.1%) (Altshuler et al. 1996). Therefore, in women with
unstable bipolar disorder or a recent severe affective illness, it may be reason-
able to continue lithium and screen for cardiovascular effects with a targeted
ultrasound at week 18 of gestation. The use of lithium in the second and third
trimesters may infrequently cause a large fetal goiter that may necessitate a
cesarean section (Nars and Girard 1977) or may cause cardiac arrhythmias
(Llewellyn et al. 1998).
Carbamazepine, previously considered safe in pregnancy, has now been
associated with fetal craniofacial defects, developmental delay, nail hypopla-
sia (Jones et al. 1989), and spina bifida (Rosa 1991). Caution should be exer-
cised until further data are available.
Valproic acid, another mood stabilizer used in bipolar affective disorder,
has been associated with spina bifida in 1%5% of the offspring of mothers
treated during the first trimester. The risks of valproic acid are even greater
than those of lithium for teratogenic potential, and its use is probably con-
traindicated in pregnancy.
Several other malformations, including ear rotation, short nose, de-
pressed nasal bridge, elongated upper lip, and fingernail hypoplasia, have
been described in infants with in utero exposure to anticonvulsants (Gaily
and Granstrom 1992; Scolnik et al. 1994).

Life-threatening toxicity from lithium has been noted in some newborns of
mothers receiving lithium in the third trimester, particularly when maternal
lithium levels exceed therapeutic levels (Morrell et al. 1983). Affected babies
may show hypotonia, lethargy, cyanosis, depressed Apgar scores, hypoten-
sion, cardiac arrythmias, poor sucking reflex, and shallow respiration
(Ananth 1976; Llewellyn et al. 1998; N. Wilson et al. 1983). Lithium levels
may remain high for more than a week; the serum half-life in infants has been
estimated at 96 hours (MacKay et al. 1976).

Levels of lithium in breast milk average 40%50% of those in maternal se-
rum, and levels in infant serum are approximately equal to those in breast
milk (Schou and Amdisen 1973). Lithium in breast milk has been associated
with cyanotic episodes, lethargy, hypothermia, and hypotonia in the neonate
(Tunnessen and Hertz 1972). Because the long-term effects of lithium on ne-
onates are unknown, mothers receiving lithium are advised not to breastfeed
(Ananth 1978; Robinson et al. 1986; Wisner and Perel 1988). Use of lithium
during lactation is considered contraindicated by the American Academy of
Pediatrics (1994). Valproic acid and carbamazepine are considered compati-
ble with breastfeeding by the American Academy of Pediatricians (1994), but
the available data are very limited.
Long-Term Effects on Children Exposed in Utero

Schou (1976) discovered no significant differences in physical or mental
anomalies at age 5 between children exposed to lithium in utero and their un-
exposed siblings. This study was too poorly designed, however, to draw de-
finitive conclusions.
Anxiolytics
Teratogenicity
Several studies have yielded conflicting evidence about the relationship be-
tween the use of benzodiazepines during pregnancy and the occurrence of fe-
tal malformations, especially cleft lip with or without cleft palate. In a pooled
overview of studies (Aarskog 1975; Laegreid et al. 1990; Rosenberg et al.
1983; Safra and Oakley 1975; Saxen and Saxen 1975; St. Clair and Schirmer
1992), use of benzodiazepines in first trimester increased the odds of having
oral clefts. Because the subjects were heterogeneous, several benzodiazepines
were studied, and the anomalies were reported in different drugs, the final an-
swer to the oral cleft question remains uncertain and caution should be exer-
cised. The literature on in utero benzodiazepine exposure and behavioral
teratogenicity in humans is limited, but some studies suggest that benzodiaz-
epine exposure may cause developmental delays (Viggedal et al. 1993).

Benzodiazepines that are lipid soluble and have a low molecular weight can
easily cross the placenta, especially late in pregnancy (Kanto 1982). The long
half-lives of these drugs may result in marked accumulation in the mother
and the fetus when regularly administered (Mirkin 1976). Chronic use of di-
azepam throughout pregnancy has been reported to lead to withdrawal
symptoms including tremor, hypertonia, and hypereflexia lasting up to 8
weeks in the neonate (Volpe 1981). These irritable infants are difficult to care
for. Mandrelli et al. (1975) reported hypotonia, low Apgar scores, hypother-
mia, impaired response to cold, and neurologic depression in infants whose
mothers had received high doses of diazepam prior to delivery. The muscular
hypotonia sometimes found in these infants has been labeled floppy infant syn-
drome (Gillberg 1977). Use of injectable diazepam at delivery has been linked
to kernicterus because of competition between bilirubin and the preservative
sodium benzoate (Schiff et al. 1971). Long-acting benzodiazepines should be
avoided in the third trimester because they may inhibit newborn respiration
and diminish responsiveness immediately after birth. Moreover, the imma-
ture liver has difficulty metabolizing these drugs (Kanto 1982). Larger doses
of diazepam may result in low Apgar scores at birth, apneic spells, hypotonia,
and poor sucking (Cree et al. 1973). All sedative drugs have been associated
with decreased newborn sucking rates (Kanto 1982).
Chronic use of barbiturates prior to delivery can lead to withdrawal
symptoms in the newborn that may not occur until 1014 days after birth.
Symptoms may include tremulousness, crying, irritability, hyperphagia, and
increased tone (Hill and Stern 1979).

Benzodiazepines constitute a risk to nursing newborns because they produce
lethargy and impaired temperature regulation. They are not metabolized in
the fetal liver or gut, and from days 14 the infant is unable to conjugate them
with glucuronic acid, which may result in newborn jaundice (Kanto 1982). If
a mother needs benzodiazepines on a prolonged basis, breastfeeding is con-
traindicated because of the possibility of accumulation and lack of data on the
effects of long-term exposure through breast milk (Mortola 1989; Robinson
et al. 1986). When given to the nursing mother in therapeutic doses, phe-
nobarbital appears to have little or no demonstrable effect on the infant, but
long-term effects are unknown (Ananth 1978).
Agents Used to Treat the

Extrapyramidal Side Effects of Neuroleptics
Few studies are available on the specific teratogenicity of agents used to treat
the extrapyramidal side effects of neuroleptics in the first trimester because
these agents are coadministered with neuroleptics. Some reports link diphen-
hydramine to congenital anomalies (Heinonen et al. 1977), and cardiovascu-
lar malformation has been reported in an infant exposed to amantadine
during the first trimester (Nora et al. 1975).
Guidelines for the

Clinical Use of Psychotropic Drugs
The goals for treating psychiatric disorders in pregnancy may be altered to

achieve control of symptoms rather than complete remission. Nonpharmaco-
logic strategies, such as cognitive-behavioral therapy, interpersonal therapy,
dynamic psychotherapy, family therapy, marital therapy, light therapy, ECT,
environmental support, and sometimes hospitalization, may be preferable to
the use of drugs in first trimester (Mortola 1989; Nurnberg and Prudic 1984;
Wisner et al. 1999). Despite these strategies, psychotropic drugs are some-
times required, particularly if the woman is so severely depressed or psychot-
ic that her well-being or that of her fetus is in jeopardy (Altshuler et al. 1996).
A severely ill woman may fail to eat properly, may not attend appointments
for prenatal care, and may respond to command hallucinations to harm her-
self or her fetus. The American Medical Association (1983) recommends the
following guidelines for physicians when prescribing drugs to women of
childbearing age or those who are already pregnant: 1) avoid unnecessary ex-
posure to drugs and select those drugs with the most favorable risk/benefit
ratios; 2) inform patients of the implications of drug exposures in pregnancy;
3) when drugs are necessary, advise patients of the need for contraceptive
measures when indicated; and 4) identify and report any birth defects.
In general, psychotropic drugs should be used in pregnancy only when
they are clearly indicated for the prophylaxis or treatment of psychiatric ill-
ness and then only in the lowest effective doses for the shortest period of time
necessary. An individual risk/benefit appraisal is required. Because of altered
pharmacokinetics and metabolism during pregnancy, higher doses may be re-
quired than are used in nonpregnant women. It is generally believed that di-
vided maternal doses have less effect on the fetus than once-daily dosing
schedules. New drugs should be avoided until safety and side effects have
been well established through use in nonpregnant women (Wisner and Perel
1988).
Antipsychotics
Few data support the choice of one antipsychotic over another during preg-
nancy. Halogenated phenothiazines, however, appear to slightly increase ter-
atogenicity (Rumeau-Rouquette et al. 1977). We favor high-potency agents
because they usually cause fewer autonomic, anticholinergic, hypotensive,
sedative, and cardiovascular side effects. We currently prescribe haloperidol
during pregnancy and lactation in the lowest effective divided dose and try
to avoid its use in the first trimester when possible.
Antidepressants
Because the doseresponse curves and therapeutic efficacy of any antidepres-

sant have not yet been established in pregnancy, the choice of which of these
drugs to use is primarily based on side effects and safety. We tend to favor
nortriptyline, desipramine, or fluoxetine during pregnancy and lactation be-

cause of their reduced side effects (including hypotension), better published
evidence for safety, and the correlation between serum levels and therapeutic
effect. Tricyclic antidepressants and fluoxetine have the most robust pub-
lished, long-term, neurobehavioral data on exposed infants (Nulman et al.
1997). We administer the lowest effective dose and try to avoid first-trimester
exposure when possible. We avoid maprotilene because maternal seizures
have been reported (Edwards 1979) and monoamine oxidase inhibitors be-
cause they may be teratogenic (Heinonen et al. 1977). Data evaluating some
of the newer serotonin reuptake inhibitors or reversible monoamine oxidase
inhibitors in pregnancy are still insufficient.
Lithium and Carbamazepine
General recommendations for use of lithium in women of childbearing age

include the following: 1) the drug should be given for unequivocal indica-
tions; 2) patients should be warned of the possible teratogenic and toxic ef-
fects on the fetus; 3) effective contraception should be encouraged; 4) the
drug should be gradually withdrawn in first trimester in cases of unexpected
pregnancy (except in severe or unstable bipolar illness); and 5) referral for a
targeted ultrasound examination to detect fetal cardiovascular malformations
should be considered (Gelenberg 1983; Llewellyn et al. 1998; Weinstein
1980).
A recent study showed that recurrence risks for bipolar disorder rose
sharply in the postpartum period when lithium was discontinued during
pregnancy (Viguera et al. 2000). Recurrence risk was greater after rapid dis-
continuation than after gradual discontinuation. We reserve lithium in preg-
nancy and lactation for patients with unstable or severe bipolar disorder and
usually taper the dose by 30% the week before the expected due date to re-
duce the risk of toxicity. Recent studies suggest that lithium may be less ter-
atogenic than previously thought (see earlier discussion). Patients maintained
on lithium should be closely monitored and targeted ultrasound should be
performed at gestational week 18 to examine for cardiovascular malforma-
tion. Weinstein (1980) has suggested that when lithium is used in pregnancy,
sodium-depleting diuretics and low-salt diets should be avoided, serum lithi-
um levels should be closely monitored (at least once per month in early preg-
nancy and weekly toward the end), care should be taken to distinguish the
nausea and vomiting of pregnancy from those associated with lithium toxic-
ity, serum levels should be kept at the lowest effective level, and lithium
should be given in three to five equal doses not exceeding 300 mg/dose. Lith-
ium levels should be carefully monitored after delivery to avoid toxicity be-
cause physiologic fluid shifts occur.
We reserve carbamazepine and valproate for women who have lithium-
resistant unstable bipolar disorder. We augment with folate, 4 mg/day in the
hope that this may reduce the risk of neural tube defect. An ultrasound is per-
formed at gestational weeks 1019 to rule out neural tube defect and other
congenital anomalies.
Anxiolytics
Nonpharmacologic interventions should be the main strategy for the man-

agement of most anxiety or insomnia during pregnancy and lactation. These
interventions include relaxation, cognitive-behavioral therapy, psychothera-
py, and environmental change and support. No anxiolytic can be regarded as
completely safe in pregnancy or lactation, but if circumstances dictate (such
as in panic disorder), lorazepam may be a reasonable choice because of its
lack of active metabolites and its glucuronide metabolism, high potency, and
good absorption (Wisner and Perel 1988). The drug should be given at the
lowest effective dosage for the briefest possible time and avoided, if possible,
in the first trimester and near term. It is prudent to bear in mind that sleep
disturbance and anxiety are common in late pregnancy and that risk/benefit
considerations seldom warrant hypnotics or anxiolytics at this time except for
the treatment of severe anxiety and panic disorder. Use of antidepressants to
control panic disorder should also be considered.
Electroconvulsive Therapy in Pregnancy

Indications
Electroconvulsive therapy is generally regarded as a safe and effective treat-

ment for specific psychiatric diagnoses in pregnancy and the puerperium (Na-
tional Institute of Health Consensus Conference 1985) and is underused in
treating pregnant women with psychiatric illnesses. It is primarily useful for
severe depression, psychosis with affective features, and catatonia. ECT may
be prescribed in the following situations: 1) on an emergency basis when the
psychiatric status of the mother presents a hazard to herself or the fetus, 2) as
a back-up for failure of other treatments in severe psychiatric conditions, and
3) to avoid the risk of exposure to potential teratogens in first trimester (Fink
1981). It may also be used in pregnant patients who have a history of success-
ful ECT treatment. ECT is an effective treatment for postpartum psychosis
that allows continuation of breastfeeding if desired.
Clinical Considerations
Remick and Maurice (1978) and Wise et al. (1984) have commented on the
lack of conclusive data on ECT in pregnancy and have suggested the follow-
ing guidelines:
1. Thorough physical examination

2. Involvement of an obstetrician
3. Consideration of high-risk pregnancy as a relative contraindication
4. External fetal monitoring for several hours before and after ECT
5. Endotracheal intubation
6. Low-voltage, nondominant ECT with electroencephalographic moni-
toring
7. Electrocardiographic monitoring of the mother
8. Oxygen pretreatment and assisted ventilation until the return of sponta-
neous respiration in the mother
9. Evaluation of maternal arterial blood gases during or after ECT
10. Doppler ultrasonography of fetal heart rate
11. Tacodynamometer recording of uterine tone
12. Glycopyrrolate as anticholinergic of choice
13. Screening for pseudocholinesterase deficiency if using succinylcholine
14. Weekly non-stress tests of fetal well-being
15. Careful monitoring and control of maternal blood pressure
The patient should be placed in the left lateral position with a wedge under
the right hip to ensure that the gravid uterus does not obstruct blood flow
through the inferior vena cava. These very cautious considerations are for
general information only, and the advice of an obstetrician and anesthesiolo-
gist should be obtained for the individual patient.
Conclusions
The clinician presented with a psychiatrically ill pregnant or lactating patient

must make important clinical decisions about psychotropic drugs and ECT
in the face of considerable uncertainty (Kuller et al. 1996). Careful attention

to the most recent and reliable information available and consideration of the
unique features of each patients circumstances will assist in weighing the risk/
benefit ratio and determining the best clinical strategy. Written documenta-
tion of the factors considered, the patients informed consent, and careful, on-
going monitoring are vital in the optimal management of this difficult clinical
dilemma.
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6
Adolescent Pregnancy
DIANA L. DELL, M.D., F.A.C.O.G.
Scope of the Issue
Each year in the United States about 10% of all adolescent women between
the ages of 15 and 19 become pregnant. Of these, only about 13% consciously
planned their pregnancies; approximately 33% will abort their pregnancies;
14% will miscarry; and 52% will bear children. Of the 500,000 adolescent
women who give birth each year, more than 175,000 are 17 years of age or
younger. Of these 500,000 births, only 75% are first births and 72% are out
of wedlock (Maynard 1997).
The United States has far higher rates of pregnancy, childbirth, and abor-
tion among adolescents than other Western industrialized nations (e.g., Can-
ada, England, Wales, France, Sweden, and the Netherlands). The adolescent
abortion rate in the United States is often higher than the entire pregnancy
rate (abortion plus childbearing) seen in the other nations even though access
to abortion services is much easier in other countries. Rates of unintended or
mistimed pregnancy do not appear to be a function of higher rates of sexual
activity among teenagers in the United States, because rates of sexual activity
are about the same in all of the nations compared. The bottom line is that
American teens do not practice contraception as often or as effectively as
teens in other nations (Zabin and Hayward 1993).
Unfortunately, the largest differences in birth rates are usually seen at the
youngest ages: for example, the birth rate for 14-year-old women in the Unit-
ed States is 5/1,000, which is four times higher than that of second-ranking
Canada. Among American women aged 18 years or younger, there are fewer
births in affluent areas and much higher rates for birth and abortion concen-
95
trated in the most economically deprived areas. These economically deprived

areas are the same areas that have the highest rates for infant mortality, vio-
lent deaths among youths, violent crime, illicit drug use, and homicide (Zabin
and Hayward 1993)
The question of why adolescents do not use contraception more effec-
tively has been the object of intensive research. In a recent survey of 200
consecutively enrolled patients aged 1318 years in an adolescent-oriented
maternity program, more than 40% of the respondents had positive attitudes
toward childbearing. Interviewed during the third trimester, 20% of respon-
dents said that they did not mind getting pregnant, 17.5% said I wanted to
get pregnant, and 5% said that their boyfriend wanted them to get pregnant.
Only 12% of participants attributed their pregnancies to contraceptive failure.
Even smaller percentages cited a fear or dislike of contraceptive side effects
(5%) or a fear of parental discovery and/or disapproval (5%) as the reason for
not using contraception. The authors concluded that a positive attitude to-
ward pregnancy rather than a negative attitude toward contraceptive technol-
ogies was most likely to predict whether adolescents used contraception
(Stevens-Simon et al. 1996b).
Normal Adolescent Development
Attempting to understand the phenomenon of adolescent pregnancy and to

provide adequate care for pregnant adolescents requires an understanding of
the cognitive and psychosocial development of adolescents. Although age
ranges are often assigned to the developmental tasks for early, middle, and
late adolescence, the chronologic age does not always correspond to the level
of maturity. Additionally, an individual adolescent may be functioning at one
level cognitively and at another level psychosocially (Drake 1996).
In the terms used by Piaget (see Singer and Revenson 1978), cognitive
development moves from the concrete operations of children to the formal
operations that begin in adolescence. During the stage of concrete operations,
children can manipulate concrete objects but can function only in the present,
with no capacity to conceptualize the future. With the emergence of formal
operations at about 11 years of age, adolescents learn to evaluate the environ-
ment in less concrete ways. They develop increasing capacities to think logi-
cally, work with abstract ideas, predict consequences of behavior, and
speculate about future events (Drake 1996). Normal psychosocial develop-
ment is often divided into three stages, each of which spans about 3 years.
Adolescent Pregnancy 97
Some authors have further defined stages of psychosexual development that

roughly correspond to the same chronologic time spans.
Early adolescence is characterized by turmoil stemming from the physi-
cal changes of puberty, loss of body control, and an intense preoccupation
with physical appearance (Drake 1996). Adjusting to their new body image
makes early adolescents self-conscious and raises their concerns about being
normal and appearing acceptable. Psychosexual development may corre-
spond with undifferentiated exploratory sexual behavior with members of
the same or opposite sex (Stevens-Simon and Reichert 1994). Very early ad-
olescents seldom seek sexual activity but may be an especially vulnerable
group for sexual advances from others (Drake 1996).
Middle adolescence focuses on self-identification and self-realization.
Girls show more interest in developing intense, loving relationships with
boys. Boys are more interested in the pleasure of sexual activity than in the
maintenance of loving relationships (Drake 1996). Both genders exhibit be-
havior that is more defiant, narcissistic, and self-reliant. With narcissism
comes a sense of personal omnipotence and what Elkind describes as per-
sonal fables, which are stories about ones own uniqueness and invulnera-
bility. For boys, this may be a sense of immortality that fosters risk-taking
behavior; for girls, it may be a belief that she cannot become pregnant so she
does not need to use contraception (Lewis and Volkmar 1990, p. 218). Mid-
dle adolescents often loosen their emotional ties to the family of origin and
begin to engage in a series of experimental, monogamous, heterosexual rela-
tionships (Stevens-Simon and Reichert 1994).
In late adolescence, there is a progression away from the narcissistic sense
of personal omnipotence toward a more integrated, solid sense of oneself and
how that self copes with and integrates into the adult world. Psychosexually,
the move is toward developing stable, mutually intimate relationships (Drake
1996; Stevens-Simon and Reichert 1994).
The developmental stage at which an adolescent woman becomes sexu-
ally active is extremely critical. Her level of cognitive and psychosocial devel-
opment will predict not only how well she protects herself from pregnancy
but how she responds to the event of pregnancy if she fails to adequately prac-
tice contraception.
Because early adolescents are still very present oriented, self-centered,
and less capable of abstract thinking, they have difficulty accepting the reality
of a pregnancy. They often deny that they are pregnant, even in the presence
of an enlarging abdomen or positive pregnancy test. They are secretive and
when possible will often conceal pregnancy until an advanced stage of gesta-
tion. They seldom have more than a casual relationship with the father of the
fetus. They anticipate and often receive very negative reactions when family
members become aware of the pregnancy. Unless directed by parents or oth-
er adults, they tend to seek prenatal care late or not at all. Once enrolled in
prenatal care, they have difficulty focusing on threats to their own health or
the health of the fetus. They are not emotionally ready to assume a parenting
role and require adult guidance and assistance with the responsibility for in-
fant care (Drake 1996).
Middle adolescent women often have begun some form of sexual exper-
imentation. They move from a stage of exploratory behavior toward a stage
of developing intense, loving relationships. If pregnancy occurs at this stage,
the woman often has a deeper emotional attachment to the father of the fetus.
She may have consciously or unconsciously chosen to become pregnant as a
means of confirming her feminine identity, as a means of securing a closer re-
lationship with the father of the fetus, or as a means of gaining adult status.
Some adolescent women, especially those who are doing poorly in school or
do not have opportunities for advanced education and career training, will
choose pregnancy during this time as a career choice of motherhood over
education/employment (Drake 1996).
Depending on the circumstances surrounding the decision to seek preg-
nancy or the more ambivalent posture of just not using contraception, middle
adolescents still tend to seek prenatal care later in pregnancy than do more
mature groups. However, middle adolescents are more capable than early ad-
olescents of making the needs of the fetus a priority and of assuming respon-
sibility for parenting, although assistance with child care is needed to allow
completion of educational goals (Drake 1996).
Late adolescents have a much stronger sense of themselves and a stron-
ger relationship with the father of the fetus. They are more like adult women
in most categories: they seek prenatal care earlier, are motivated to do what
is best for a healthy pregnancy, and can usually assume the task of parenting
on their own (Drake 1996).
Abnormal Adolescent Development
Sexual victimization in childhood can adversely affect normal adolescent psy-

chosexual development in addition to being independently associated with a
broad spectrum of physical, emotional, and behavioral problems. The asso-
ciation between prior sexual abuse and adolescent pregnancy is very strong.
Numerous studies have demonstrated that former victims of sexual abuse are
overrepresented in adolescent prenatal programs, with some groups ap-
pearing more at risk than others (Stevens-Simon and Reichert 1994). In one
sample of 535 pregnant adolescents, 66.2% had some history of sexual vic-
timization; Of these, 70% of the white adolescents had been abused prior to
conception compared with 42% of black adolescents and 37% of Hispanic ad-
olescents (Boyer and Fine 1992).
Rainey et al. (1995) prospectively queried 202 consecutive nonpregnant,
sexually active, nulliparous adolescent women aged 1319 who sought rou-
tine medical care at two teen centers. In this group, 20% reported prior sexual
abuse. Sexually abused and nonabused girls reported similar ages at me-
narche; similar rates of miscarriages, abortions, and sexually transmitted dis-
ease; similar ages for initiation of consensual sexual intercourse; similar
frequencies of intercourse; and similar rates of contraceptive use. Sexually
abused adolescents were three times more likely than their nonabused peers
to state that they were seeking pregnancy (34.2% vs. 11.3%, P < 0.001).
Abused patients expressed more concerns about their ability to conceive,
were more likely to report previous pregnancy testing, were twice as likely to
report feeling that something was wrong with them and that they could not
conceive, and were more likely to have older boyfriends who encouraged
them to get pregnant. The authors postulated that infertility concerns could
be another expression of the low self-esteem commonly seen in adolescents
with prior sexual abuse (Rainey et al. 1995).
In the same study it was noted that sexually abused girls were more likely
to report socially deviant behaviors: smoking cigarettes, frequent alcohol use,
other illicit drug use, and involvement with the police or juvenile court system
within the preceding 6 months. The authors speculated that adolescent preg-
nancy may be another manifestation of self-destructive and socially deviant
behavior attributable to prior sexual victimization (Rainey et al. 1995).
Ongoing violent behavior and sexual victimization are also related to ad-
olescent pregnancy. Current estimates suggest that up to 30% of college-age
women have had at least one violent incident in a dating relationship. In one
large urban sampling, 32% of pregnant adolescents reported having been
physically or sexually abused during the prior year and 22% were being
abused during the current pregnancy. Abused women tended to enter prena-
tal care later: 24% of the abused adolescents in this sample entered prenatal
care during the third trimester compared with 9% of those who were not
abused (Parker 1993).
In abusive relationships, both male and female partners tended to ex-
press more negative feelings toward the pregnancy: 51% of abused women
reported negative feelings about the pregnancy compared with 31% of non-
abused women, and 29% of the abusing partners reported negative feelings
about the pregnancy compared with 13% of the nonabusing partners (Parker
1993).
Process of Pregnancy Resolution

Late Diagnosis
For reasons that are not always clear, adolescent women often prolong the in-
terval between suspecting and confirming that they are pregnant. This delay
accounts for complications associated with late entry into prenatal care and
higher rates of elective second trimester abortion. Bluestein and Rutledge
(1992) reviewed the literature that has been generated to explain this delay
and found that this phenomenon was not adequately explained by socio-
demographic attributes (including age, race, education, or ability to pay for
pregnancy testing) or by clinical attributes (including parity, contraceptive
practices, menstrual regularity, and presence of pregnancy symptoms). They
surveyed 123 pregnant adolescents aged 1419 years, 54% of whom carried
their pregnancies and 46% of whom aborted their pregnancies. The mean du-
ration of delay in seeking a pregnancy test was 4.35 weeks. In this sample,
only difficulty in acknowledging the pregnancy exerted a significant net effect
on delayed testing (P < 0.05). Interestingly, difficulty acknowledging the preg-
nancy was also associated with depressive symptoms (P < 0.01), problems
talking with partners (P < 0.05), and an initial negative reaction to the preg-
nancy (P < 0.01) (Bluestein and Rutledge 1992).
Difficulty acknowledging a pregnancy may be a manifestation of denial
that reflects cognitive immaturity. For other adolescents it may represent psy-
chosocial immaturity, with ambivalence or feelings of guilt about sexual ac-
tivity. Whatever the reasons, during this period of delay pregnant adolescents
may be alone as they face difficult decisions concerning their pregnancy
(Bluestein and Rutledge 1992).
Counseling
Although unwanted or mistimed pregnancy can create a crisis in the life of a

woman at any age, adolescent women are at special risk because of their own
developmental issues. Early and middle adolescents, for example, have not
completed individuation and are ill-equipped for making autonomous deci-

sions; older adolescents may have more decision-making ability but are unac-
customed to making decisions of this magnitude. Counseling for pregnancy
resolution must explore all available options: abortion, adoption, and keeping
the baby. It should include the family whenever possible, must be free of
counselor bias, and must be provided in very practical terms that will facili-
tate appropriate decision making (J. H. Gold 1991).
Keeping the Pregnancy

Farber (1991) conducted in-depth interviews with 28 unmarried adolescent
mothers from six subgroups, identified as black and white teens from middle-
class, working-class, and lower-class families. In her sample, the process of
recognizing the pregnancy took many forms, ranging from immediate ac-
knowledgment to a long period of denial. Fears about the anticipated re-
sponse of the parents was a consistent finding, both before and especially
after confirmation of the pregnancy. Nonetheless, the young women, with
only one exception, looked immediately to their families for direction and
generally were advised to keep the child. Only one subject even referred to
the father of the fetus in the decision-making process (Farber 1991).
All adolescent women in this study bore their pregnancy and kept their
child. This decision was seldom based simply on the desire to be a mother.
The pregnant adolescent was not acting as an isolated individual able to cal-
culate the best outcome for her own self-interest and proceed toward a deci-
sion consistent with her level of self-esteem, career aspirations, or cultural
load. Parents and extended family members often exerted direct influence on
the parenting decision, and the final choice of pregnancy resolution included
concerns about obedience to parents and grandparents, a belief in the sanctity
of life, acceptance of the consequences of their actions, and the perceived best
interests of the child (Farber 1991).
One case illustrates how final resolution can be a complex and difficult
process that ultimately may be based on identifying the least harmful alterna-
tive. One black middle-class teen who had planned to go to medical school
did not acknowledge her pregnancy until her preferred choice of safe abor-
tion was no longer an option. She had to choose among hurting her beloved
grandmother who opposed adoption, maintaining the support of her mother
who favored adoption, and guarding against endangering her career aspira-
tions through early motherhood. She ultimately kept her child, to be raised
with assistance from her mother (Farber 1991).
Although the sample size of Farbers study was small, some trends were
evident. One consistent pattern was the overwhelmingly negative reaction of

the families of black middle-class teenagers, with reactions ranging from dis-
appointed shock to fury. Black middle-class and working-class families ex-
pressed marked disappointment about their daughters futures. Among white
middle-class and working-class families, the first expression of concern was
about potential complications of being pregnant at such a young age. The
families of black lower-class teens were also hurt, disappointed, and angry,
but the black lower-class teens themselves expressed either positive or neutral
feelings about the pregnancy, and with one exception did not report fearing
the parents reaction. Lower-class teens and their parents, especially the moth-
ers, quickly accepted as inevitable that the young woman would keep and
raise her child (Farber 1991).
Abortion
Although abortion has been legal in the United States since 1973, the avail-
ability and accessibility of abortion services to adolescent women has been
changing dramatically over the past few years. Decreased public funding, de-
creased provider availability, and parental consent laws have had a dispropor-
tionate effect on adolescent and economically deprived women.
For the adolescent woman to make decisions about her pregnancy, she
needs information about what specific alternatives are available to her, includ-
ing the abortion options specific to her stage of gestation as well as commu-
nity resources that are available for either abortion or prenatal care. If she
chooses abortion, she has a much greater need than does an older woman for
intensive education about female physiology and specific characteristics of
the abortion procedure that will be used. Accurate information about the sen-
sations she will experience can markedly diminish immediate and longer-
term negative responses (Zakus and Wilday 1987).
Despite politically motivated reports to the contrary, abortion is followed
by relatively few psychologic sequelae. Most women experience some antici-
patory grieving during the decision-making process; after the abortion proce-
dure, the resolution of that grief response is relatively rapid, with most
women reporting a sense of relief and a rapid return to their previous level of
functioning (J. H. Gold 1991; Zakus and Wilday 1987).
Several categories of women have been identified who may be at special
risk for emotional difficulties in the months or years after an abortion:
Women who feel they are not free to make their own choice about termi-
nating a pregnancy. Adolescents are particularly vulnerable to feeling that
parents or partners coerced them into having an abortion (Zakus and

Wilday 1987). Unfortunately, the same may also be true for an adolescent
woman who carries a pregnancy to term against her wishes; she will expe-
rience the same regret, guilt, and anger as the woman coerced into having
an abortion (J. H. Gold 1991).
Women with a history of sexual abuse. Not only are previously abused ad-
olescent women at greater risk for pregnancy, they appear at greater risk
for experiencing gynecologic examinations and the abortion procedure it-
self as an additional trauma (Zakus and Wilday 1987).
Women with other unresolved grief reactions. For adolescents, it is very
common for the crisis of pregnancy to result in dissolution of the relation-
ship with the father of the fetus. Grieving the loss of that relationship may
compound the transient abortion-related grief reaction (Zakus and Wilday
1987).
Women with preexisting psychiatric disorders (Zakus and Wilday 1987).
Adolescent women who appear at special risk for emotional difficulties in the
wake of pregnancy resolution decisions should be identified in the initial
counselingwhether they decide to carry or abort their pregnancies. These
women often benefit from crisis intervention strategies that address the cur-
rent life situation and the patients own coping skills (Zakus and Wilday
1987).
Adoption
A generation ago, adoption was the most popular option for out-of-wedlock
pregnancy, especially among white adolescents and families. Currently, less
than 5% of adolescents who give birth choose adoption as the preferred res-
olution of their pregnancy. In an effort to understand this dramatic shift,
Custer (1993) conducted in-depth interviews of 21 unmarried white adoles-
cents carrying an unplanned pregnancy. The subjects, their significant others,
and people they identified as being influential in helping to make decisions
about the future were interviewed during the last trimester of pregnancy and
again at 68 weeks postpartum. The most important phenomenon noted was
the absence of societal sanctions against adolescent parenthood, concurrent
with reciprocal sanctions against relinquishing a child for adoption. The cul-
ture was now saying that it is acceptable to be a single adolescent mother but
definitely not acceptable to give away a baby (Custer 1993).
Societal sanction appeared to be primarily centered on the idea of adop-
tion not being good for the child. Numerous subjects voiced concern that the
child would suffer, that it would not be loved and would therefore hate the
birth mother. There was also an element of societal disapproval related to the
perception that adolescents should assume responsibility for their actions:
Its your responsibility to take care of the situations you get yourself into. If
you dont want the kid, why were you messing around? (Custer 1993).
The apparent lack of accurate knowledge among adolescents about
adoption was startling. Only limited information was provided to the patients
by the health care professionals who provided prenatal care. Only three of the
subjects had any degree of accurate knowledge about adoption, only eight re-
called being asked if they were considering adoption, and only two remem-
bered actually receiving any adoption information or counseling at any time
during the pregnancy (Custer 1993). Custer concluded that anticipation of
psychologic distress is the most powerful immediate barrier to adolescents
giving up their infants for adoption. The combination of general societal
sanctions, low levels of knowledge, and absence of professional intervention
served to confirm the adolescents beliefs that severe, intolerable, and ongo-
ing psychologic distress would accompany giving up an infant for adoption
(Custer 1993). This conclusion gains additional strength when considered in
the context of psychosocial developmentmiddle adolescents conform to so-
cietal standards to avoid censure by authority figures, whereas late adoles-
cents conform to maintain the respect of impartial observers and avoid self-
condemnation (Drake 1996).
General Health Care for Adolescent Women

Confidentiality is a major issue in dealing with adolescent patients. Adoles-
cents are more likely to give an accurate history if assured that whatever in-
formation they provide is not shared with others unless safety is an issue, as
in suspected abuse/neglect or suicidal ideation. Conveying this information
to both patients and parents at the initial visit is helpful (Brown-Jones and Orr
1993). Even with this assurance, adolescents may have difficulty communi-
cating information about sexuality to adults who resemble parental authority
figures.
Sexual Activity
Physical maturation profoundly influences the onset of sexual activity and
the subsequent risk for adolescent pregnancy. Hormone production in girls
usually begins between 7 and 9 years of age, with rapid escalation from age
9 until the onset of menstruation. The age of menarche in girls from Western
industrialized nations has been steadily declining for the past 100 years, with
the average age now cited as 12.6 years. Earlier physical maturation means
that the variance between physical maturation and psychosocial maturation
is probably greater than that found in previous generations. This disparity
may place peripubertal girls at greater risk for pregnancy and the acquisition
of sexually transmitted diseases before they have the cognitive and psychoso-
cial skills to manage a sexual life (Zabin and Hayward 1993).
Menarche can be considered a marker for the initiation of sexual behav-
ior, with age of first intercourse for girls usually occurring within 23 years
after menarche. The impact is most evident at the youngest ages; by age 13,
almost 40% of those girls whose menarche occurred at 11 years or younger
are sexually active; 20% of girls with menarche at age 1314 are sexually ac-
tive at or before menarche; and only 10% of those with menarche after age
14 are sexually active at or before menarche (Brown-Jones and Orr 1993;
Zabin and Hayward 1993).
Half of all first pregnancies in adolescents occur within the first 6 months
of sexual activity, with about 20% occurring in the first month. Early adoles-
cents are less likely than older adolescents to use contraception or to use it
effectively; they also have longer delays between initiation of sexual activity
and seeking contraceptive services: 23.5 months for women age 15 or young-
er versus 10.6 months for women ages 1619. Because this activity is occur-
ring in a phase in which the adolescent is relating increasingly to peers and
less to parents, the presence of a sexually active and/or noncontracepting peer
group may have a much greater impact on younger adolescents than it would
have at a later age (Zabin and Hayward 1993).
Sexually Transmissible Disease
Three million adolescents acquire a sexually transmissible disease every year.

They are at greater risk than adults for several reasons: they are more likely
to have multiple sex partners, more likely to have high-risk partners, and less
likely to use barrier protection for intercourse. For adolescent women there is
the additional issue of having an immature cervix, which does not provide the
same barrier to infection that a more mature cervix provides and is more like-
ly to be injured by sexually transmissible organisms. In fact, many of the se-
rious health consequences of sexually transmissible diseases that appear in
adults, such as cancer and infertility, are the result of infections acquired dur-
ing adolescence (Donovan 1997).
All adolescent women should be encouraged to use both a reliable meth-

od of female birth control and condoms. This process is facilitated both by
empowering young women to take charge of their bodies and by demonstrat-
ing the correct use of condoms on a mannequin in the office setting. Many
adolescent women have never seen or touched a condom and the office dem-
onstration dramatically reduces anxiety, which may facilitate increased use
(Brown-Jones and Orr 1993).
Unfortunately, evidence indicates that physicians do not always provide
adequate information or screening services for sexually transmitted disease.
Mahler (1997) screened 1,217 California physicians who were board certified
in either family medicine, internal medicine, obstetrics and gynecology, or pe-
diatrics regarding the routine services they provided to adolescents. Only
47% said that they asked all patients aged 1518 whether they were sexually
active and 3% said that they never asked; only 31% furnished all teenaged
patients with information about sexually transmitted disease, including HIV.
Once an adolescent has demonstrated sexual activity by presenting for
pregnancy testing, it is important to do immediate screening for sexually
transmitted disease. Matson et al. (1993) followed-up 168 pregnant adoles-
cents from low socioeconomic backgrounds from their original pregnancy di-
agnosis to their first prenatal visit. Of those patients who had screening pelvic
examinations at the time of pregnancy testing, 29% were positive for gonor-
rhea, chlamydia, or both. This study design would not detect syphilis, HIV,
or other blood-borne infections. The average delay from pregnancy diagnosis
to first prenatal visit (at which routine evaluations for sexually transmitted
diseases are normally done) was 35.7 days, with 40% of patients seen more
than a month after pregnancy diagnosis and an additional 25% seen more
than 46 days later.
The implications generated by these data are important for both the
mother and the fetus. Adolescents are an increasing percentage of the HIV-
positive population, with theoretic concerns that their future risk is enormous
(DAngelo et al. 1994). Because recent data show a marked decrease in trans-
placental transmission of the virus when HIV pregnant women are treated
with antiviral agents during pregnancy, finding ways to ensure early screen-
ing and treatment of all HIV-positive women is a public health imperative.
Emergency Contraception
Emergency contraception is used after unprotected intercourse to prevent

pregnancy, but is used so infrequently that it has been called the best-kept
contraceptive secret in America (M. A. Gold et al. 1997). The most common
method used is the Yuzpe method: two oral contraceptive pills, each con-
taining 50 g of ethinyl estradiol, are taken within 72 hours of unprotected
intercourse, followed by two additional 50-g pills 12 hours later. Some wom-
en experience nausea from this estrogen dose, so an antiemetic may be help-
ful; if vomiting occurs, the dose should be repeated.
In Great Britain, where all contraceptive pills can be purchased over the
counter, a pill that is packaged and marketed specifically for postcoital use is
also available (M. A. Gold et al. 1997). In the United States, the Food and
Drug Administration has approved the use of oral contraceptives in this man-
ner, but information about the method has been slow to disseminate.
Emergency contraception may be especially suited for use in the adoles-
cent population, in which first intercourse is usually unplanned and unpro-
tected. The Yuzpe method reduces the risk of pregnancy after unprotected
intercourse by 75% and could decrease the abortion rate by 50%. Nonethe-
less, when college students were screened in one womens health clinic, 85%
of students who had previously had an abortion did not know anything
about emergency contraception (M. A. Gold et al. 1997).
Other agents, including mefipristone or antiprogesterone preparations,
may also be suited for postcoital use. Further research about long-term effects
of postcoital contraception and increased education about this method for
primary care physicians who treat adolescents are sorely needed.
Prenatal Care for Adolescent Women
Adolescents appear to have increased risks for certain potentially serious con-
ditions during pregnancy, including pregnancy-induced hypertension, ane-
mia, preterm labor, preterm delivery, and having low-birth-weight infants.
Whether these increased risks are primarily a function of age or secondary to
other variables (Scholl et al. 1994) is an ongoing research issue. The real chal-
lenge is to find ways that help pregnant adolescents achieve the best possible
outcomes for themselves and their infants.
When an adolescent woman becomes pregnant, her level of cognitive de-
velopment and her level of psychosocial development will predict how she
behaves with regard to herself and her pregnancy. Not only does she face the
usual developmental tasks for her stage of adolescence, but she now has the
added developmental tasks superimposed by the pregnancy (Drake 1996).
The field of maternalchild nursing has had a longstanding appreciation for
these principles and has contributed much of the information in this impor-
tant area.
A recent publication by Drake (1996) provided an especially useful sum-
mation of these principles. Table 61 outlines the developmental tasks of ad-
olescence as they are experienced by pregnant adolescent in the early, middle,
and late stages of cognitive and psychosocial development. Table 62 outlines
the developmental tasks of pregnancy as they are experienced by early, mid-
dle, and late adolescents.
Special Populations of Pregnant Adolescents
Substance Abuse
Use of psychoactive substances during pregnancy has become an area of

growing concern over the past two decades. This concern is fueled by statis-
tics showing that new drug use occurs among women at a rate twice that
among men. In one study from Maryland, baseline statistics showed that 16%
of all newborns in 1986 were designated as high risk based on maternal drug
use. Four years later, the number had increased almost threefold, to 46%. Al-
though it was unclear whether the apparent increase in drug-exposed infants
was secondary to increased surveillance or higher rates of drug use, the au-
thors felt certain that no reduction had occurred in the proportion of women
using drugs during pregnancy (Marques and McKnight 1991).
A prominent finding in the Maryland study was that white pregnant
teens were much more likely to fall into the two highest-risk groups for drug
abuse compared with only 12% of black pregnant teens. The authors con-
trasted their findings with another public health population in Florida in
which black adolescents were 10 times more likely to be tested and thus ap-
peared to have higher rates of substance abuse (Marques and McKnight
1991).
Similar findings were noted in another study that examined prenatal al-
cohol use in adolescents. Significantly more white adolescents were among
the moderate/heavy drinkers than black adolescents. Drinking is common
during adolescence and adolescents have different patterns of drinking than
adults. One national survey reported that more than 27% of female high
school seniors reported at least one occasion in the 2 weeks prior to question-
ing when they had consumed five or more drinks. When compared with a
cohort of pregnant adults, pregnant adolescents of both races had higher rates
TABLE 61. Achievement of developmental tasks of adolescence by the pregnant adolescent
Developmental tasks of
adolescence* Early pregnant adolescents Middle pregnant adolescents Late pregnant adolescents
Achievement of a stable Weakly developed sense of self. A developing sense of self. May still A strong sense of self. Have devel-
identity Much difficulty in adapting to the be developing ideas of what they oped feminine identities and are able
demands of pregnancy. Too much want to do, how they want to behave. to adapt to pregnant and parenting
turmoil and confusion for identity Pregnancy may have been desired to roles like adult mothers.
formation. Responsibilities of par- confirm feminine identity.
enthood may be thrust on them.
Body image Body in stage of rapid growth. Body reaching maturity. Usually Comfortable with mature body and
Awkward and self-conscious react negatively to body image maternal appearance.
about being different. May conceal changes imposed by pregnancy.
the pregnancy.
Sexuality Prefer same-gender peers. Usually May have entered relationship with Able to form close relationships with
have only casual relationship with father of the fetus but relationship both genders. Have a stable relation-
the father of the fetus. lacks depth and closeness. May ship with the father of the fetus.
have desired the pregnancy to
strengthen the relationship with the
father.
Personal value system Premoral or preconventional Role conformity or conventional Self-accepted moral principles (Kohl-
(Kohlberg 1964). Obey to avoid (Kohlberg 1964). Maintain good berg 1964). Conform to maintain re-
punishment. Conform to obtain relationships for others approval. spect of impartial observer and to
rewards, have favors returned Conform to avoid censure by avoid self-condemnation (Mercer
(Mercer 1990). Need concrete authorities and resultant guilt 1990). Self-motivated to do what is
incentives to comply with recom- (Mercer 1990). Do what is suggested best for a healthy pregnancy.
mendations for healthy prenatal for prenatal care to avoid reproach by
behaviors. parents or health care providers.
109
110
TABLE 61. Achievement of developmental tasks of adolescence by the pregnant adolescent (continued)
adolescence* Early pregnant adolescents Middle pregnant adolescents Late pregnant adolescents
Psychological Aspects of Womens Health Care, Second Edition

Vocation/career In the sixth to ninth grade. Not In the tenth to twelfth grade. If doing May have completed high school.
able to be future oriented or con- poorly in school and not encouraged Are able to define career choices and
cerned about career choices. Also to have educational and employment goals. May combine choices and
are not able to have motherhood goals, motherhood may be primary goals. May combine employment or
as a role without support. role. education with motherhood.
Independence from Dependent on parents or other Usually still dependent on parents May be independent if gainful em-
parents adults. Need much assistance or another adult. Share parenting ployment is available for them or
with parenting resposibilities. responsibility with adult family their partners. Can take primary re-
members. sponsibility for parenting with the fa-
ther of the fetus.
* As identified by Mercer (1990).

Source. Drake P: Addressing Developmental Needs of Pregnant Adolescents. J Obstet Gynecol Neonatal Nurs 25:518524, 1996. Reprinted with permission
of Association of Womens Health, Obstetric, and Neonatal Nurses (AWHONN).
TABLE 62. Achievement of developmental tasks of pregnancy by adolescents
pregnancy* Early adolescents Middle adolescents Late adolescents
Seeking safe passage Hampered by denial of pregnancy. May not be assertive in Actively seek information about
Not able to clearly state questions expressing concerns. Late pregnancy, birth, and infants.
and concerns. Seek prenatal care prenatal care is common. Usually start prenatal care in the
late or not at all. middle trimester.
Acceptance of the pregnancy High levels of secrecy and denial May have chosen the mothering Mixed reaction of adolescents,
by self and others of pregnancy may occur. Usually role to gain mature status. partners, and families. More ac-
strong negative reaction by Families reaction usually ceptance if adolescents are finan-
families. negative: shock, anger, guilt, cially independent.
and sadness (Johnson 1995).
Acceptance of the reality of Have difficulty focusing on the May be willing to make the needs Able to focus on the fetus. Can un-
the unborn child fetus because they are present- of the fetus first priority. derstand the consequences of be-
oriented, self-centered, and Influenced by developing feminine havior on fetal growth and
concrete thinkers. identities and the significance of development.
the mothering role.
Acceptance of the reality of Not emotionally ready to assume May be able to take on some Can get prepared and assume the
parenthood a parenting role. Require adult responsibility for parenting. To tasks of parenting competently.
guidance and assistance to share continue own education, assistance
responsibility for infant care. with child care from adults is neces-
sary.
* As identified by Rubin (1984).

Source. Drake P: Addressing Developmental Needs of Pregnant Adolescents. J Obstet Gynecol Neonatal Nurs 25:518524, 1996. Reprinted with permission of
Association of Womens Health, Obstetric, and Neonatal Nurses (AWHONN).
111
of binge drinking during the first trimester, and adolescent binge drinking did
not decrease until after the first trimester. Heavy drinking was a risk factor
for later recognition of pregnancy in both adult and adolescent cohorts,
which has important implications for prevention of fetal alcohol syndrome
(Cornelius et al. 1994).
In the same study, the use of marijuana and crack/cocaine decreased dur-
ing pregnancy for both adolescents and adults. Tobacco use, on the other
hand, decreased in the adult cohort but actually increased in the adolescent
cohort. The proportion of tobacco smokers in the adolescent sample in-
creased from 52% to 64% during pregnancy; black adolescent women were
less likely to use tobacco than white adolescent women; and by the third tri-
mester, 92% of the white adolescents were smoking (Cornelius et al. 1994).
Berenson et al. (1992) surveyed 342 pregnant adolescents from diverse
ethnic origins to explore the relationship between violence and substance
abuse. They reported that adolescent women with a history of combined
physical and sexual assault were seven times more likely to use psychoactive
substances than were adolescents without a history of assault. Substance
abuse was five times more likely for those who had been sexually victimized
and three times more likely for those who had been physically assaulted.
Drug use was most strongly associated with assault by a mate, whereas alco-
hol and tobacco were more commonly associated with assault by a member
of the victims family of origin.
Scafidi et al. (1997) evaluated psychosocial stress in 104 adolescent moth-
ers between the ages of 13 and 21 years. Drug-abusing adolescent mothers
experienced more psychosocial stressors than did adolescent mothers who
were not substance abusers. Drug-abusing adolescent mothers also reported
poorer physical health, poorer mental health, lower vocational and education-
al status, more family and peer relations problems, less constructive use of lei-
sure time, and poorer social skills than the comparable group. Overall, poor
mental health was the most significant factor associated with drug abuse in
this cohort of adolescent mothers.
Mental Illness
Kovacs et al. (1994) noted that the investigations prospectively examining

mental illness in children as a predictor of adolescent pregnancy were limited.
The authors used existing longitudinal data from a psychiatric clinic sample
of 83 girls who were aged 813 years at study entry. They followed-up with
the girls over time and identified 25 girls who had had their first pregnancies
at age 18 or younger. The authors had postulated that girls with depressive
disorders should be at greater risk for adolescent pregnancy, but the data did
not support this theory. In the final multivariant analysis, only conduct dis-
orders appeared to have a major role. Among girls with conduct disorders,
54.8% had teen pregnancies versus 12% of girls with other diagnoses.
In a subsequent study by Zoccolillo et al. (1997), the role for conduct dis-
order as a predictor of greater risk for adolescent pregnancy was also ac-
knowledged; 9 of 25 pregnant adolescent women studied had that diagnosis.
In addition, conduct disorder was also a major risk factor for polysubstance
use, with 67% of the subjects in this study also meeting diagnostic criterion
for substance abuse or dependence. The authors suggested that screening for
conduct disorder may be an efficient way to identify girls at especially high
risk for early pregnancy; screening is relatively easy, most adolescents will not
meet the criterion, and intensive pregnancy prevention efforts could be direct-
ed toward those who do.
A common explanation for poor contraception and unwanted pregnancy
in past years has been an assumption that these behaviors were a reflection
of poor self-esteem. Matsuhashi and Felice (1991) found just the opposite in
the first reported study assessing body perceptions in pregnant adolescents.
They assessed 43 primiparous pregnant adolescents, aged 1418 years, dur-
ing the third trimester of pregnancy. In comparison with a never-pregnant
control group matched for age, race, Tanner stage of pubertal development,
and socioeconomic status, the pregnant girls reported higher overall self-es-
teem, a more positive body image, a surer self-identity, and feelings of being
more productive as family members. The authors suggested that some ado-
lescent girls may actually be developing their own sexual identity through a
pregnancy.
That principle may apply to repeat pregnancy rates as well. Stevens-
Simon et al. (1996a) assessed attitudes toward childbearing in a racially di-
verse group of 200 consecutively enrolled, poor, pregnant adolescents aged
1318 years in an adolescent-oriented maternity program. During the first
postpartum year, the repeat pregnancy rate was 11.5%. Those adolescents
who became pregnant again were more likely to have expressed positive atti-
tudes toward childbearing during the index pregnancy (60.9% vs. 39.6%; P =
0.05). Interestingly, they were also more likely to have reported a miscarriage
prior to the index pregnancy (30% vs. 9%; P = 0.04), and those with miscar-
riage prior to the index pregnancy conceived more quickly after the index
pregnancy. Those who conceived again within 1 year were more likely to
have dropped out of school before high school graduation (P = 0.004), more
often admitted to the use of illicit drugs (P = 0.05), had more frequently
moved away from their parental home (P = 0.006), and were more likely to
have rated their families as unsupportive during the index pregnancy (P =
0.009). They were not significantly different with regard to age, race, Medic-
aid use, or depression scores, but they were less likely to have planned post-
partum levonorgestrel (Norplant) use during the index pregnancy (22% vs.
49%; P = 0.02).
Planning for the Future
As we look for conclusions about the complex issue of adolescent pregnancy,

the only thing that is perfectly clear is that it is multifactorial and does not
have any simple or easy solutions. It is imperative that we begin finding solu-
tions, because our population is in a phase that will produce an accelerated
number of middle and late adolescents during this decade. McElroy and
Moore (1997) estimated that between the years 1990 and 2000, the number
of women ages 1519 would increase by 1 million. Unless significant reduc-
tions are achieved in the adolescent birth rate, we can anticipate a substantial
increase in the number of births in this group.
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7
Postpartum Disorders
Mental disturbance following childbirth was first mentioned by Hippo-

crates, but the first good clinical description of postpartum psychosis was
written by a French psychiatrist, Louis Marc, in 1858. There was little interest
in this disorder until Paffenberger (1961) showed that admission to mental
hospitals was enormously increased during the first month postpartum and
Hamilton (1962) argued that puerperal psychosis was a distinct disorder.
Psychologic disturbances can occur in the postpartum period in the form of
maternity (baby) blues, postnatal depression, or psychosis. Although any
psychiatric disorder may present or recur in the postpartum period, it is clear
that affective disorders are most common. Not uncommonly seen after
delivery, however, are adjustment, attachment, obsessive-compulsive, and
anxiety disorders as well as schizophrenia.
Postpartum Adaptation
The postpartum period involves numerous physiologic, psychologic, and so-

ciocultural changes. All of the following have been investigated as possible eti-
ologic factors in postpartum disorders.
Biologic Factors
Dramatic changes in hormone and electrolyte balance and fluid volume level
occur during labor and the postpartum period. After birth, progesterone and
117
estriol rapidly fall, returning to prepregnancy levels by 3 days after delivery.

When estrogen falls after birth, prolactin, which has risen during pregnancy,
is no longer blocked and lactation is initiated. Suckling by the infant stimu-
lates the secretion of oxytoxin. The usual cyclic variation of androgens is ab-
sent during both pregnancy and lactation. Plasma corticosteroids reach a
peak during labor and decrease significantly within 4 hours postpartum. Thy-
roid function returns to prepregnancy levels approximately 4 weeks after de-
livery. Beta-endorphins rise during labor, reach a peak immediately before
delivery, and decline after parturition. Plasma renin falls after childbirth. So-
dium excretion rises and calcium excretion falls. Several days after birth, a
rapid weight loss occurs. Testosterone is associated with greater reported
mood disturbances after delivery (Buckwalter et al. 1999).
Several methodologic problems have hampered studies on the biologic
basis of postpartum disorders. Early researchers could not accurately assay
hormones, particularly free, unbound plasma concentrations. Psychologic
rating scales used in various studies differed; some, confounded by the nor-
mal physical symptoms of the puerperium, were obviously inappropriate
measures of maternal mental states. Blood sampling often took place at inap-
propriate times, ignoring activities such as breastfeeding that can alter hor-
mone levels. Seasonal variations in hormones and circadian rhythmicity were
often overlooked. Studies that examined one hormone in isolation were inad-
equate because of complex endocrine interrelationships.
Psychosocial Factors
Transition to parenthood has a significant impact on both men and women,

their relationship as a couple, and their work and social activities. New con-
flicts may arise and old ones resurface. Problems in the relationship between
the woman and her own mother may increase her difficulties in the develop-
ment of her new maternal identity. She must also come to terms with her own
femininity.
A womans postpartum adaptation is intimately linked to the quality of
the relationship with her partner (Zelkowitz and Milet 1996). A supportive
relationship with the childs father can help mitigate the stresses of being a
new mother. In many cases, the family system must be reorganized, and
many couples adopt more traditional roles. Couples with reasonably egalitar-
ian relationships often have more difficulty adjusting to new parenthood be-
cause, regardless of previous philosophies, it is usually the mother who
accepts the major share of parenting tasks. The parents must decide how their
Postpartum Disorders 119
new roles will affect their previous work patterns and implement the neces-
sary changes. With the added burden of child care, the relationship between
the partners often suffers, and there is less time for socializing. Groups of oth-
er new parents can be very supportive in helping the couple work through
these normal adjustments. Age, parity, culture, expectations, financial prob-
lems, and housing difficulties may all affect normal postpartum reactions and
the developing relationship between the mother and her new baby.
Infant Feeding
It is generally agreed that breastfeeding is best for young infants, for both nu-
tritional and other health reasons. It may also facilitate motherchild bond-
ing. Although 65% of North American mothers begin breastfeeding, only
25% continue for 4 months. Although they are aware of the benefits of breast-
feeding, many mothers prefer bottle feeding for various reasons (Wollett
1987), including modesty, discomfort, an unsupportive environment, difficul-
ties in breastfeeding, a wish to share feeding responsibilities with others, or
uncertainty about the amount of breast milk provided. The fathers attitude
toward breastfeeding often plays a vital role. Either partners beliefs about the
effect of breastfeeding on contraception or breast size and shape can also in-
fluence its acceptance. In addition, women who are returning to the work-
place shortly after the birth may find it impossible to continue breastfeeding,
whereas women on a demand schedule may feel overburdened by the respon-
sibility of being available every few hours. Some women think their husbands
will become more involved if they choose bottle-feeding. A womans attitude
toward breastfeeding is greatly improved with support from her physician,
hospital staff, and other health care providers. Information and support about
breastfeeding is valuable in helping women weather the difficult first few
weeks after birth. It is vital, however, that the woman not be made to feel
guilty, whatever her informed choice.
Maternity Blues
Maternity blues is a common, benign, transitory condition occurring in the

first 10 days postpartum. Its incidence ranges from 28%80% (Harris 1980;
Lanczick et al. 1992).
Clinical Presentation
Maternity blues typically begin 34 days after delivery (Stein 1982) and peak
on days 45. The most frequently reported symptom is weeping. In the first
few hours after delivery, crying may be accompanied by happy feelings. Han-
dley et al. (1980) felt that depressed mood is characteristic of maternity blues,
whereas Kennerley and Gath (1986) found that although women described
themselves as low spirited they did not consider themselves to be de-
pressed. Emotional lability seems to be a characteristic feature. Elation (post-
partum pinks) may also occur and may be mild or predict more serious
mood disturbance.
Researchers have also described irritability, lack of affection for the baby,
hostility toward the husband, sleep disturbance, headaches, feelings of unre-
ality, depersonalization, exhaustion, and restlessness in women suffering
from maternity blues. Although many mothers describe themselves as being
absentminded, distracted, and lacking in concentration, psychologic tests
have produced no evidence that cognitive impairments are common (Kenner-
ley and Gath 1986).
Etiology
No clear correlations have been established between maternity blues and var-
ious psychosocial factors. Maternity blues have been reported in all social
classes (Ballinger et al. 1979; Stein 1980) and in many different cultures
(Davidson 1972; Harris 1980). The condition is unrelated to marital status
(Davidson 1972), although associations have been reported with poor marital
relationships (Ballinger et al. 1979; Cutrona 1984). No positive association
has been reported between the blues and other external stressors (Paykel et
al. 1980; Pitt 1973). Hospital delivery does not appear to be a causal factor,
because there is an equal incidence in home deliveries (Yalom et al. 1968).
Contradictory findings have been reported for the association of mater-
nity blues with personality factors (Nott et al. 1976; Pitt 1973), the primipa-
rous state (Ballinger et al. 1979; Nott et al. 1976; Stein 1980), ambivalent
attitudes toward pregnancy (Nilsson and Almgren 1970), fear of labor (Ball-
inger et al. 1979; Kennerley and Gath 1986), and anxiety and depression dur-
ing pregnancy (Davidson 1972; Handley et al. 1980). OHara et al. (1991)
reported a history of personal and family depression, more problems with so-
cial adjustment, and stressful life events in women who get postnatal blues
compared with women who do not.
Biologic Factors
The high incidence, typical onset at 3 days postpartum, fluctuating course,
and lack of clear psychosocial causation of maternity blues have led many re-
searchers to suspect a biologic cause. However, no consistent correlations
have been found between maternity blues and prolactin, cortisol, thyroid hor-
mones, beta-endorphins, norepinephrine, 5-hydroxytryptamine, cyclic ade-
nosine monophosphate, electrolytes, or pyridoxine (George and Sandler
1988). OHara et al. (1991) reported higher levels of free and total estriol be-
fore and after delivery in women who develop blues compared with those
who do not. Harris et al. (1994) found a relationship between severity of the
blues and the high levels and steep rate of rise of progesterone antenatally as
well as a steep drop postnatally.
Obstetric and Gynecologic Factors

Yalom et al. (1968) noted a higher incidence of obstetric anomalies or subjec-
tive discomfort during pregnancy in women with maternity blues, whereas
Pitt (1973) and Ballinger et al. (1979) did not. No link was found among ma-
ternity blues and physiologic monitoring during pregnancy (Blumberg 1980),
cesarean section (Kendell et al. 1981), or breastfeeding compared with bottle-
feeding (Ballinger et al. 1979; Cox et al. 1982). Researchers have reported
that women who experience maternity blues were of a younger age at me-
narche (Yalom et al. 1968), have a shorter menstrual flow (Yalom et al. 1968),
experience more menstrual irregularities (Handley et al. 1980), and have a
history of premenstrual tension (Ballinger et al. 1979) compared with those
who do not experience this condition. Davidson and Robertson (1985), how-
ever, failed to find any association with previous menstrual difficulties.
Treatment
Women with maternity blues benefit from reassurance that the symptoms are
common and will disappear quickly. Emotional support and instruction on
newborn care may also be helpful. Women should be advised to seek help if
symptoms are severe or persist for more than 2 weeks.
Prognosis
Most women completely recover from maternity blues in a few days to 2

weeks. In a small number, however, the symptoms escalate into more serious
psychiatric conditions. Many women experience maternity blues after each

pregnancy.
Disorders of the MotherInfant Relationship
Disorders of the motherinfant relationship range from delayed attachment

to infanticide. Studies of these disorders are limited by problems in method-
ology, including the difficulty of measuring maternalinfant attachment.
Incidence
Delayed attachment is reported in approximately 10% of mothers. Absolute

rejection of the infant and obsessive, hostile thoughts about the baby are seen
in 1% of mothers. Estimates of child abuse vary greatly and depend on the
criteria used and cultural norms. Infanticide occurs in 1/50,000 births in the
United Kingdom (Brockington and Cox-Roper 1988).
Clinical Presentations
Approximately 40% of primiparous women experience mild detachment or

negative feelings toward their infants in the immediate postnatal period, with
a gradual increase in the strength of maternal feelings over the ensuing few
weeks (Robson and Powell 1982). In more severe, persistent disorders of at-
tachment, the mother expresses disinterest, neglect, and failure to protect,
nurture, or interact with the infant. Delayed attachment can be primary or
can occur secondary to another psychiatric disorder, such as an adjustment
disorder, depression, mania, psychosis, anxiety, obsessive-compulsive disor-
der, or personality disorders. Margison (1982) has described infant rejection
in which the mother shows persistent hostility, often wishes the child had nev-
er been born, and is determined to avoid the maternal role. Other women
may feel normally loving toward their infants but may be afraid of contact be-
cause of obsessional, intrusive, and distressing thoughts about their babies,
including impulses to harm them (Brockington and Cox-Roper 1988).
Etiology
Cultural factors and social class influence the way a woman first relates to her
child (Robson and Powell 1982). The role of maternal personality factors in
facilitating or interfering with attachment is still being studied. Women who

have had disrupted or inadequate mothering themselves (Frommer and
OShea 1973) and single teenage mothers without social supports should be
considered at special risk for attachment disorder. Painful and difficult child-
birth experiences have also been linked to early maternal detachment (Rob-
son and Kumar 1980). Congenital defects or prematurity in the infant may
result in a lack of attachment or rejection because of fear of subsequent loss.
Problems with obsessional hostile feelings toward the newborn may be a
manifestation of obsessive-compulsive illness or depression (Beck 1995). So-
cioeconomic or environmental stresses tend to exacerbate difficulties in at-
tachment. Persistent rejection of the newborn is found most frequently in
unwanted pregnancies (Resnick 1970).
Management
Most delays in attachment resolve spontaneously within the first few days or
weeks postpartum. Education about delayed attachment may alleviate the
mothers guilt. Although it has not been clearly established that brief separa-
tion leads to attachment disorders, it is important to maintain close contact if
either the mother or the baby requires hospitalization. Mothers who suffer
from continued bonding problems may benefit from practical advice and sup-
port concerning infant care, psychotherapy to explore the determinants of the
problem, behavioral approaches designed to decrease anxiety when coping
with the baby, and occasionally joint admission to a motherinfant unit. Se-
vere disturbances of attachment, in which the infant is at serious risk of abuse
or neglect, may require protective custody, joint treatment, or enforced super-
vision where available. Obsessional thoughts of hostility toward the baby
may respond to psychotherapy, often combined with pharmacotherapy with
an antidepressant such as clomipramine or a selective serotonin reuptake in-
hibitor. Women with attachment difficulties secondary to other psychiatric
disorders should be reassessed after the primary disorder has been treated.
Delayed attachment or early temporary separation from the mother has not
been proven to have significant long-term effects on the baby (Robson and
Powell 1982). Children who suffer from ongoing lack of bonding, however,
may show failure to thrive, stunted emotional and cognitive development,
and difficulty in developing peer relationships. These infants are also at more
risk of being abused and rejected. A comprehensive review of infanticide

(Resnick 1970) found that the victims of neonaticide (murder of the newborn
within 24 hours of its birth) were most commonly unwanted babies of moth-
ers who were young, unmarried, and without evidence of psychosis or de-
pression. Many of the women were denied or failed to seek an abortion for
an unwanted pregnancy they were afraid to reveal to their families.
Postnatal Depression
Postnatal depression is an affective disorder lasting more than 2 weeks, the

severity of which meets criteria for DSM-IV affective disorder (American
Psychiatric Association 1994). Carefully designed research has cast doubt on
the existence of postnatal depression as a distinct entity (OHara and Zekoski
1988). In a group of pregnant women and matched, nonpregnant control
women, rates of depression were 10.6% for postpartum women during the
first 9 weeks after delivery and 10.0% for control subjects. OHara and Zeko-
ski (1988) concluded that there was no evidence that postpartum subjects
were at greater risk for depression than control subjects. However, hospital-
ization rates to psychiatric hospitals are higher in the 30 days after delivery
than at any other time in a womans life (Paffenberger 1961). Regardless of
whether postpartum depression is a distinct illness, the subsequent negative
consequences to the mother, her marital relationship, and her child make
postnatal depression an important condition to diagnose and treat.
Prevalence and Epidemiology
A meta-analysis of numerous studies found the average prevalence rate of

postnatal depression to be 13% (OHara and Swain 1996). Lower occupation-
al status of the mother and lower family income were found to be small but
significant predictors of depression, whereas maternal age, marital status, ed-
ucation, parity, and length of relationship with partner all failed to signifi-
cantly predict postnatal depression (OHara and Swain 1996; OHara and
Zekoski 1988).
Postnatal depression usually begins within 16 months after delivery. In

some women, maternity blues simply continue and become more severe. In
others, a period of well-being is followed by gradual onset of depression, char-

acterized by tearfulness, despondency, emotional lability, guilty feelings, an-
orexia, and sleep disturbances as well as feelings of being inadequate to cope
with the infant, poor concentration and memory, fatigue, and irritability
(Robinson and Stewart 1986). Some women may worry excessively about
the babys health or feeding habits and see themselves as bad, inadequate,
or unloving mothers.
Etiology
Studies of postnatal depression have been handicapped by methodologic er-
rors and the inability to identify it as a distinct disorder. A relationship has
been reported, however, between measurable anxiety during pregnancy and
the level of postpartum depressive symptoms (Hayworth et al. 1980; Watson
et al. 1984). Kumar and Robson (1984) found no increase in previous psychi-
atric diagnoses in women with postpartum depression, in contrast with the
findings of OHara (1986) and OHara et al. (1983). OHara (1986) also
found that a higher percentage of depressed subjects (66.7%) had a family his-
tory of depression than did nondepressed women (20.7%).
Several well-designed studies (Braverman and Roux 1978; Kumar and
Robson 1984) have reported an increased risk of postpartum depression in
women who experience marital problems during pregnancy. Hopkins et al.
(1986), however, failed to confirm this finding. Women with postnatal depres-
sion perceived their husbands to be less supportive than did women who
were not depressed, but these differences were apparent only postpartum, not
during pregnancy (OHara 1986; OHara et al. 1983). Cutrona (1984) found
that the availability of companionship and a feeling of belonging to a group
were more important predictors of good adjustment than was intimacy with
the husband. Only a few studies (Hopkins et al. 1986) found no association
between measures of social support and the occurrence of postnatal depres-
sion. No relationship has been demonstrated between various obstetric vari-
ables and postnatal depression.
Contradictory findings have been reported concerning the contribution
of a poor relationship between the woman and her mother to postnatal de-
pression (Kumar and Robson 1984; Nilsson and Almgren 1970; Paykel et al.
1980; Watson et al. 1984). Although OHara et al. (1984) and Cutrona
(1984) found a relationship between external stressors and higher levels of
postpartum depressive symptoms, Hopkins et al. (1986) found a relationship
only with having a baby who is difficult to care for or a baby with neonatal
complications. Similarly, Kumar and Robson (1984) found no association be-
tween stressful life events and postnatal depression.
Biologic Factors
Although it has been suggested that postnatal depression is caused by low lev-
els of progesterone or estrogen or high levels of prolactin, no significant rela-
tionships have been found (Harris 1994; Hendrick et al. 1998). Some women
may be especially vulnerable to normal hormonal changes that may trigger
depression (Hendrick et al. 1998; Stewart and Boydell 1993). Alder and Cox
(1983) found that women who were breastfeeding their infants and taking
oral contraceptives postpartum had a higher risk of depression at 35 months
postnatally than did women who were breastfeeding exclusively but not tak-
ing oral contraceptives. No conclusive evidence relating the various neu-
rotransmitter systems, free or total tryptophan levels, or cortisol levels and
postnatal depressive symptoms has been demonstrated (Llewellyn et al.
1997). However, Harris (1996) showed a minor association of postnatal de-
pression and thyroid dysfunction in thyroid antibodypositive women.
Summary of Etiologic Factors

The most relevant etiologic factors for postnatal depression are those found
in association with depression in general: personal or family psychiatric his-
tory of depression; lack of support, especially from the spouse; and occur-
rence of a number of negative life events around the time of delivery (OHara
and Swain 1996; Stowe and Nemeroff 1995).
Treatment
Postnatal depression is treated on both a psychosocial and a biologic basis.

Identification and acknowledgment of the depression itself may be a helpful
feature, dispelling the womans fears of physical disease and personal inade-
quacy. Individual or group psychotherapy may help the woman resolve con-
flicts about mothering or her new role. Joint counseling is indicated if there
are conflicts with or a lack of support from her partner. Information about
newborn care, social assistance, and practical supports such as homemaking
may also be beneficial. Medication, such as nortriptyline, 75100 mg/day; de-
sipramine, 150300 mg/day; fluoxetine, 2060 mg/day; paroxetine, 2060
mg/day; or sertraline, 50150 mg/day, is helpful for many depression and
anxiety disorders. The use of minor tranquilizers to reduce anxiety should be

limited to brief or adjunctive therapy to reduce the risk of dependency. Estra-
diol has been reported as a useful treatment in two small studies and requires
further investigation (Ahokas et al. 2000; Gregoire et al. 1996). Chapter 5 dis-
cusses the use of drugs in the breastfeeding mother.
Prevention
Discussion of postpartum mood disorders during prenatal classes is likely to

improve early detection and presentation for treatment. Gordon and Gordon
(1960) found that patients with a postnatal depression who received active so-
cial intervention as well as dynamic psychotherapy required shorter treat-
ment and were less likely to require hospitalization. The women attending
these groups, especially those accompanied by their husbands, experienced
fewer emotional problems than did those in the control group. Halonen and
Passman (1985), Shereshefsky and Lockman (1973), and Broussard (1976)
found that either prenatal counseling or relaxation training could decrease
the level of the womans distress and improve the marital relationship post-
partum. In a study of 15 women, Wisner and Wheeler (1994) found that
starting antidepressants within the first 24 hours after birth in women with a
history of postnatal depression decreased the expected recurrence rate. Oral
estrogen has been proposed as prophylaxis for women with histories of affec-
tive disorders occurring only in the puerperium, but studies remain limited
(Sichel et al. 1995).
Prognosis
Postnatal depression usually lasts several months if not treated (Kumar and
Robson 1984; Watson et al. 1984). Women may have difficulties in bonding
with their infants and may express feelings of rejection, dislike, or indifference
(Margison 1982; Teti et al. 1995). Women with postnatal depression are also
more likely to experience future episodes of depression (Caplan et al. 1989).
Although the occurrence of a postnatal depression does not guarantee be-
havioral, cognitive, or social problems in the toddler or young child, exposure
to maternal depression in the early postpartum months may have an endur-
ing influence on the childs psychological adjustment (Murray et al. 1999).
Subsequent depression in these women has been associated with poor adjust-
ment of the child at 4 years of age (Caplan et al. 1989; Phillips and OHara
1991).
Puerperal Psychoses
Puerperal psychoses are psychotic disorders arising after childbirth. Contro-

versy exists over the specificity and timing of these disorders because early
research suffered from confounding variables such as differences in case def-
initions and the time period allowed for the occurrence of such disorders
(Brockington et al. 1982). Consequently, some authors consider these disor-
ders to be distinct entities with specific etiologies, clinical presentations, and
prognoses (Brockington et al. 1982; Hamilton 1962), whereas most believe
that they are simply episodes of psychotic illness triggered by the stresses of
pregnancy and delivery (Kendell et al. 1987). Although women with schizo-
phrenia frequently suffer from psychotic relapses within weeks after delivery,
most authorities now agree that most postpartum psychoses are affective dis-
orders (Kendell et al. 1987).
Brockington et al. (1982) found that early postpartum psychosis could be
blindly differentiated from nonpuerperal psychosis. McNeil (1986) found
that manic postpartum disturbances were characterized by more confusion
and disorganized speech than were nonpuerperal episodes, and postpartum
psychoses were generally characterized by more disorganized behavior. Oth-
er distinctive characteristics included a symptom-free phase between delivery
and onset of psychosis, marked confusion, changeability, unpredictability in
clinical features, and distinguishing psychologic characteristics related to con-
cerns about motherhood (Hamilton 1982). Clouding of consciousness (Pro-
theroe 1969) and an excess of Schneiderian symptoms (Kadrmas et al. 1979)
are also characteristic features.
Incidence and Prevalence

The incidence of psychiatric admission for postpartum psychosis is 12 per
1,000 postpartum women. The relative risk of admission for psychosis within
the first 30 days following childbirth is 21.7, decreasing to 12.7 in the first 90
days. Despite this decrease over time, the relative risk remains elevated for 2
years following delivery. Women with a history of bipolar affective disorder
appear to be particularly vulnerable (Kendell et al. 1987).
Epidemiology
Primiparous women appear to have a higher risk for postpartum psychosis;
in Edinburgh, 62% of cases occurred in primiparous women versus 47% in
the general population (Kendall et al. 1981). No significant relationship to

maternal age (Kendell et al. 1987), class, or culture has been found. Although
Kendell et al. (1987) found an increased number of admissions in single wom-
en, this finding may be related to a lack of spousal support (Paffenberger
1964).
Early Versus Late Onset
McNeil (1986, 1987, 1988a, 1988b) found a number of significant differences

between women who had early onset (within 3 weeks of delivery) and those
with late onset postpartum illness. Women with early onset psychoses tended
to have affective illnesses, to be primiparous, younger, and to have suffered
emotional disturbance during pregnancy. Women with late onset illnesses
tended to have schizophreniform illnesses; were older, of lower socioeconom-
ic class, and single; and had suffered premorbid mental problems and more
emotional disturbances before pregnancy but fewer during pregnancy.
Most postpartum psychoses begin within the first 3 weeks after delivery.
There is nearly always an asymptomatic period of 23 days after delivery.
Prodromal symptoms include sleep disturbances, fatigue, depression, irrita-
bility, and emotional lability. The mother often has difficulty caring for her
infant. Characteristically, she feels confused, perplexed, bewildered, and
dreamy and may complain of poor memory, although performance on formal
mental tests is often normal (Brockington et al. 1982). Clinical presentation
may be an atypical or brief reactive psychosis, major affective disorder,
schizophreniform disorder, or an organic brain syndrome.
The most common presentation of puerperal psychosis is an affective dis-
order. In psychotic depression, the woman is tearful; has psychomotor retar-
dation, sleep, and appetite disturbances; and is preoccupied with feelings of
guilt and worthlessness. She may have delusions about the infants being
dead or defective. She may deny having given birth or have hallucinations
commanding her to harm the baby. These typical depressive features are of-
ten accompanied by a sense of confusion.
In postpartum mania, the woman is excited, euphoric, grandiose, irrita-
ble, and hyperactive. She requires little sleep, and her appetite may be mark-
edly reduced or exaggerated. She may have grandiose delusions about her
baby. Insight is usually lacking.
In a schizophreniform presentation, the woman demonstrates thought

disorder, delusions, inappropriate affect, hallucinations, agitation, motor re-
tardation, bizarre delusional ideas about herself or her child, and lack of in-
sight.
Women who present with an organic brain syndrome have prominent
symptoms of confusion, bewilderment, and memory loss. This syndrome
may be caused by medical conditions such as encephalitis, autoimmune dis-
orders, endocrine disturbance, electrolyte imbalance, or sepsis but can occur
in the absence of any recognizable medical disorder (Robinson and Stewart
1986; Welner 1982) and may be an atypical presentation of bipolar affective
disorder.
Etiology
Researchers have been unable to confirm a link between puerperal psychosis

and levels of prolactin, thyroxine, estrogen, progesterone, adrenocortcoids,
follicle stimulating hormone, or beta-endorphins (Brockington et al. 1982;
Steiner 1979; Stewart et al. 1988). A 2.5-fold increased incidence of puerperal
psychosis is seen after cesarean compared with vaginal delivery (Kendell et
al. 1981). Other obstetric variables have not been found to increase risk.
Studies by Protheroe (1969) and Winokur et al. (1978) suggested that al-
though an inherited predisposition to psychotic illness exists, a specific inher-
ited predisposition to puerperal illness does not. However, a strong link has
been found between bipolar disorder and puerperal psychosis with affective
symptoms: women with a history of bipolar affective disorder have a 50%
chance of developing postpartum psychosis (McNeil 1987). Women with a
history of manic episodes are especially at risk for developing postpartum
psychosis (Brockington et al. 1982). Moreover, the severity of past psychiatric
illness appears to be significantly related to the occurrence of postpartum psy-
chosis (McNeil 1987). First-degree relatives of women with bipolar disorders
also have an increased incidence (20%) of postpartum psychosis (Uddenberg
and Englesson 1978). Women with a history of schizophrenia have a 24%
chance of developing postpartum psychosis (McNeil 1986).
Treatment
Treatment of puerperal psychosis usually requires admission to a hospital,

particularly if the mother is at risk of harming herself or her child through
neglect, abuse, or acting on delusions or hallucinations. Mothers may be ad-
mitted independently or (preferably) together with their infants, if feasible.

The womans partner should be involved in the treatment from the begin-
ning. Puerperal psychosis requires both pharmacologic and psychosocial
therapy.
Specific drug treatments vary with the presentation. For depressive psy-
chosis, an antidepressant such as nortriptyline, desipramine, or a serotonin
reuptake inhibitor combined with a major tranquilizer such as haloperidol, 1
10 mg/day, or olanzapine, 515 mg/day, usually controls the psychotic symp-
toms as well as the depression. If the patient does not respond to these med-
ications, electroconvulsive therapy is often effective, usually providing
complete remission after six to eight treatments.
Hypomanic or manic presentations are treated with lithium carbonate in
daily doses of 6001,200 mg until a therapeutic serum level of 0.81.2 mg/L
is reached. Patients who are unresponsive to lithium carbonate may be treat-
ed with other mood stabilizers such as carbamazepine or valproic acid. A
major tranquilizer may be necessary to control acute symptoms until an ade-
quate serum level of lithium or another mood stabilizer is obtained.
Women who present with a schizophreniform disorder should be treated
with a major tranquilizer such as haloperidol, 410 mg/day or olanzapine, 5
15 mg/day. Those who do not respond adequately sometimes benefit from a
trial of electroconvulsive therapy, particularly if affective or catatonic symp-
toms are present.
Conflicts about mothering, career, marital problems, issues relating to
the womans own mother, and concerns about femininity may require atten-
tion after the psychotic symptoms remit. Idealistic expectations of parent-
hood often need to be explored. The woman requires both practical and
emotional support from her spouse, family, and friends, sometimes including
education about child care. Individual or marital therapy may be indicated.
Community social services may be extremely helpful for the mother and in-
fant after discharge.
Prognosis
Prior to the development of psychotropic drugs, untreated puerperal psycho-

sis required an average of 58 months of hospitalization, with many women
continuing to have symptoms for many years (Brockington et al. 1982). Cur-
rent treatments have substantially shortened the psychotic episodes: 95% of
adequately treated women improve within 23 months.
Reviewing the results of several studies, Brockington et al. (1982) found
that 31% of women suffered a further puerperal episode and that psychosis
complicated 21% of future pregnancies. They estimated the risk for each suc-
ceeding pregnancy to be 20% and postulated that the risk was higher in wom-
en with more severe psychosis and multiple risk factors. Prophylactic lithium
given immediately after delivery to women with a history of postpartum af-
fective psychosis appears to reduce the recurrence risk to 10% (Stewart et al.
1991). Careful follow-up is indicated after subsequent deliveries, both for
support and early case identification and treatment.
Schopf et al. (1984) found that 65% of women studied had at least one
nonpuerperal relapse and only 25% remained free of later psychopathology.
Of those who had nonpuerperal relapses, 43% had been diagnosed as suffer-
ing from affective psychosis, 38% from schizoaffective psychosis, and only
19% from schizophrenia. They found that nonpuerperal relapses were strong-
ly related to a family history of psychosis and the occurrence of a psychotic
episode before the index episode. Davidson and Robertson (1985) looked
specifically at women in whom the puerperal illness was the first onset of ill-
ness. Overall, 56% had at least one recurrent illness during follow-up. Of
those women diagnosed as having unipolar depression, 40% had a nonpuer-
peral illness, whereas 30% had another puerperal disorder. Those diagnosed
as having bipolar affective disorders had a 66% recurrence of nonpuerperal
disorders and a 50% occurrence of subsequent puerperal psychosis. All of the
women who had schizophrenia developed a chronic illness with frequent ex-
acerbations.
Effect on the MotherChild Relationship
Evidence on the long-term effects on children of mothers with puerperal psy-

chosis is conflicting. The psychiatric history, premorbid personality, nature
and timing of the puerperal psychosis, current marital and environmental cir-
cumstances, degree of life stress, access to support, and health and tempera-
ment of the baby may all play a role. In the United Kingdom, many women
are admitted to hospitals with their babies, either to a specialized mother
infant unit or to a general psychiatric ward. Although it is difficult to do ran-
domized, controlled studies of the effectiveness of motherinfant admissions,
a beneficial effect on the parentchild relationship and on parenting compe-
tence is apparent when measured 2 years later (Stewart 1989).
It is difficult to predict which infants may be at risk of harm from their
mothers. Most women who commit neonaticide are not psychotic at the time
(Resnick 1970). Filicide (the murder of a child by its parent more than 24
hours after birth), however, is most often associated with mental illness as
part of a suicide attempt, as a response to hallucinations or delusions, as a de-
lusional attempt to prevent the child from suffering, or as an accidental result
of a violent outburst. Women with manic, depressed, or schizophrenic illness-
es may also place their children at risk through neglect and lack of judgment,
and careful supervision is required while the mother is ill and recovering.
Postpartum Anxiety Disorders
Anxiety disorder with or without panic attacks may develop de novo in the
postpartum period (Metz et al. 1988) or a previous anxiety disorder may be
exacerbated at this time (Cowley and Roy-Byrne 1989). Panic attacks are typ-
ical in nature and respond to the usual pharmacologic treatments. The extent
to which pregravid anxiety disorder predicts the occurrence of postpartum
anxiety is unknown (Cohen et al. 1994). Postpartum worsening of panic at-
tacks is hypothesized to be caused by the rapidly changing concentrations of
reproductive hormones on monoaminergic binding sites (Charney et al.
1990) or to the relationship between falling progesterone levels during the
postpartum period and resulting rises in blood PCO2 (Villeponteaux et al.
1992). The presence of even mild symptoms of panic disorder during preg-
nancy may indicate the possibility of a postpartum anxiety disorder and the
need for treatment with antidepressant medication, such as imipramine 150
300 mg/day, fluoxetine 1040 mg/day, or sertraline 25100 mg/day, with or
without cognitive behavior therapy (Cohen et al. 1994).
Postpartum Obsessive-Compulsive Disorders
Development of obsessive-compulsive disorders and obsessive-compulsive

symptoms is not uncommon in the early postpartum period. Women with
these disorders usually experience unwanted intrusive thoughts about harm-
ing their babies and may avoid situations in which they feel they are at risk
of acting on their thoughts (e.g., bathing or sleeping with the infants, prepar-
ing food with sharp knives). Not infrequently, women with postpartum de-
pression may also develop obsessive-compulsive symptoms. These women
usually recover promptly when treated with serotonin reuptake inhibitor an-
tidepressants or clomipramine combined with supportive psychotherapy.
However, some postpartum women appear to have a pure obsessive-compul-
sive disorder without affective changes (Williams and Koran 1997). These
women are often more treatment resistant, although success has been experi-
enced using higher doses of serotonin reuptake inhibitor antidepressants
(e.g., fluoxetine 80 mg/day) with cognitive-behavioral therapy over a period
of several months.
Conclusions
Postpartum psychiatric disorders have a major impact on women, their chil-

dren, and their families. It is important for physicians to be aware of the pos-
sibility that a woman will develop an emotional disorder in the postpartum.
Frequently, women are discharged home within 24 hours of birth, isolated,
and do not see a health care provider again until their 6-week postpartum
follow-up visit, when it may be discovered that they have been ill for many
weeks. Women may hesitate to admit feeling depressed or unattached to the
baby. Health care providers may dismiss their signs and symptoms as normal
reactions to new motherhood. Women who may be particularly vulnerable
to developing a postpartum disorder include those who have a history of psy-
chiatric disorders, especially a bipolar affective disorder; are anxious or de-
pressed during pregnancy; are younger mothers; lack a support network;
have had difficult deliveries; or are under other current stresses. All women,
however, should be considered to be at increased risk and a strong case can
be made for screening for psychosocial risk factors during prenatal and post-
partum care (Evins et al. 2000; Reid et al. 1998). There is a great need for
physicians and community-based groups to provide information, support,
and reassurance to new mothers and to participate in detecting and treating
postpartum illness at an early stage.
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8
Perinatal Loss
IRVING G. LEON, PH.D.
G rief following perinatal loss has been discovered relatively recently by the
medical profession. Thirty years ago perinatal death was considered a
nonevent by medical caregivers (Bourne 1968)perhaps a disappointment,
but certainly not a significant loss. Medical practice, accordingly, was oriented
toward suppressing emotional reactions to the loss: parental contact with the
dead baby was virtually unthinkable. Tranquilizers were dispensed to dull
parental, especially maternal, distress. Parents were advised to forget what
had happened and women were advised to try to become pregnant again as
soon as they physically recovered. Today, the standard of care by medical
caregivers is exactly the opposite: parents are now encouraged to see, touch,
hold, name, and bury their stillborn or dead infant to make that childs life
and death more real. Tranquilizers are avoided; instead, parents are encour-
aged to grieve together. They are usually urged to wait until this loss has been
sufficiently grieved before embarking on another pregnancy.
Recent longitudinal, prospective studies indicate that at 6 months after
pregnancy loss, women report significantly greater distressanxiety, physical
complaints, and especially depressionthan do their counterparts delivering
healthy babies; these differences tend to wane by 1 year (Beutel et al. 1995;
Janssen et al. 1996; Neugebauer et al. 1997; Vance et al. 1995). This finding
confirms the consensus held by most researchers and clinicians that over the
course of the year following perinatal loss most women are able to resume
preloss functioning, accompanied by a lingering, transient shadow grief
(Peppers and Knapp 1980) often triggered by important anniversaries and re-
minders of the loss. However, about 25% of women experiencing pregnancy
loss may be expected to have more serious and often enduring psychiatric dif-
ficulties following this loss (Zeanah 1989). This chapter explores why preg-
141
nancy and newborn demise is such a difficult loss to endure, identifies the
many ways this loss affects family members, and suggests medical and psy-
chiatric approaches that may deter the development of psychiatric difficulty
and effectively address those problems when they arise.
Epidemiology and Etiology
Perinatal loss is typically defined as fetal demise beyond 20 weeks gestation

through infant death 1 month postpartum and occurs in approximately 1.2%
of all pregnancies in the United States (Cunningham et al. 1997). Although
this rate is less than half the perinatal mortality rate in the United States in
1950, it is still significantly higher than other industrialized countries with
wide differences among different groups in our country. There are half as
many perinatal deaths in Japan than in the United States and the perinatal
mortality rate for blacks in America is almost twice that of whites (Herz
1993). In short, we can do better.
About 15%25% of all recognized pregnancies result in miscarriage. The
actual rate of spontaneous abortions may be twice as high, because a subclin-
ical early pregnancy loss is more likely to be viewed as a late period than a
miscarriage (DeLuca and Leslie 1996). Ectopic pregnancies, increasing more
than threefold between 1970 and 1986, now occur in almost 2% of all preg-
nancies (Stone 1995).
It is beyond the scope of this chapter to review medical aspects of preg-
nancy loss, but a few basic points are worth noting. Although most miscar-
riages are caused by major genetic abnormalities in the embryo or fetus that
are not likely to recur, perinatal loss is usually the result of maternal factors
leading to preterm delivery of a nonviable fetus. Many maternal factors, such
as cervical incompetence, hypertension, and diabetes, are now successfully
treated. The increasing incidence of ectopic pregnancies is due to the higher
incidence of pelvic inflammatory disease and complications resulting from
the use of intrauterine devices and from surgeries leading to tubal damage
(Stone 1995).
Most of the psychologic investigation and the resulting changes in med-
ical practice have focused on the relatively infrequent late-term perinatal loss,
especially stillbirth. Furthermore, although with wider application of existing
medical technology it is possible to reduce the rate of perinatal loss even fur-
ther, the greater frequency of pregnancy among older women will increase
their rate of miscarriages. Although there was a greater appreciation (and
Perinatal Loss 143
study) of the impact of miscarriages through the 1990s, there continues to be

virtually no investigation of the specific psychologic repercussions of ectopic
pregnancy losses.
This chapter more broadly considers miscarriages and ectopic pregnan-
cies as well as perinatal death, noting the relevant differences among these
losses. Related losses such as infertility (see Chapter 10) and pregnancy ter-
mination for fetal anomaly (See Chapter 3) will not be discussed in detail, al-
though both are usually profound losses that complicate and magnify
subsequent pregnancy losses. Because sudden infant death syndrome (SIDS)
or crib death does not entail the unique aspects of a loss around pregnancy
and also involves the death of an older infant, its repercussions are usually
different and are not discussed here. Finally, elective abortion, when chosen
without pressure from others during an unwanted pregnancy, usually does
not result in the extended grief reaction of other pregnancy losses (Blumen-
thal 1991; Dagg 1991) and therefore is not discussed.
Historical and Cross-Cultural Considerations
Historical Review
Before the 1970s, the lack of awareness among medical and psychologic care-
givers that perinatal loss generally evokes intense grief mirrored societys
minimization or ignorance of this loss. As a logical outgrowth of their pio-
neering work on the development of parental attachment to the newborn,
consolidated in bonding, Kennell et al. (1970) were among the first to rec-
ognize the pattern of grieving following the death of a baby. Mounting appre-
ciation during the 1970s of the usually profound grief following perinatal loss
culminated in the first major study of this death by Peppers and Knapp in
1980 (Motherhood and Mourning: Perinatal Death) followed by more than a dozen
handbooks over the next 15 years directed toward bereaved parents. In seek-
ing to describe the normative pattern of grieving perinatal loss, clinical inves-
tigators during the 1970s demonstrated, ironically, how individualized the
reactions to this loss were, thus providing richly textured and highly personal
accounts (Grubb 1976; E. Lewis 1976).
Throughout the 1980s, quantitative investigations reported that perina-
tal loss in the Western industrialized world was a major loss of a family mem-
ber (see reviews by Leon [1990, 1992b] and Zeanah [1989] for more detail).
However, methodologic flaws such as failing to develop measures specific to
perinatal loss or to track the course of this grief made it difficult to appreciate
what is unique about this death at the inception of life as well as to identify
early risk factors leading to later psychologic difficulties.
Hospital practice, however, dramatically improved during the 1980s.
This decade marked the increasingly routine use of protocols embedded in
perinatal bereavement programs helping parents to grieve. Kellner et al.
(1981) pioneered perhaps the earliest multidisciplinary, hospital-based peri-
natal mortality counseling program, integrating effective delivery of services
with data collection for research. RTS Bereavement Services (formerly Re-
solve Through Sharing) offered specialized training to hundreds of hospitals
(especially obstetric nurses confronting perinatal losses in their patients)
throughout the country (Limbo and Wheeler 1986). Finally, pastoral and lay
caregiversmany of whom were dismayed by their own perinatal losses being
ignored by medical professionalsplayed a crucial role in developing self-help
groups and materials emphasizing the vital importance of social support and
increasing recognition of this previously overlooked loss. Under the leader-
ship of Sister Jane Marie (Lamb 1986) for over a decade, SHARE (founded
in 1977) provided a model for over 400 community-based self-help groups
oriented to pregnancy loss throughout the world. Ilses (1990) work, Empty
Arms, is perhaps the brochure most frequently distributed to parents following
a perinatal loss to help them normalize powerful reactions and encourage
them to construct memories to facilitate grieving.
During the late 1980s and early 1990s, more sophisticated self-report
measures of perinatal loss were developed and increasingly used, thus helping
to track longitudinally the course of perinatal bereavement as well as to un-
derstand better the different dimensions of this loss. Using their Perinatal Be-
reavement Scale, Theut et al. (1989, 1990) reported that recovery from
pregnancy loss was often facilitated by a successful subsequent pregnancy.
Using the Perinatal Grief Scale, a 33-item questionnaire increasingly becom-
ing the standard in the field, Toedter et al. (1988) distinguished three distinct
factors (i.e., active grieving, difficulty coping, and despair) that make up peri-
natal loss. They reported that it was not the intensity of initial grief but rather
prepregnancy mental health that appeared to have the greatest impact on dif-
ficulties in coping and depression for couples 2 years postloss (Lasker and
Toedter 1991). These important studies challenged some of the prevailing
clinical wisdom and results of earlier, poorer research. For example, it had
been believed (and recommended) that the bereaved couple should complete
grieving before beginning the next pregnancy and that a more intense, early
grief reaction predicted prolonged difficulties.
Perinatal Loss 145
Cross-Cultural Reactions to Pregnancy Loss
Because societal beliefs in part structure the boundaries of life and death in
which perinatal loss is experienced, cultural attribution is a crucial ingredient
in understanding the impact of pregnancy losses. Aside from a few general
(Lawson 1990; Layne 1990) and anecdotal (T. H. Lewis 1975; Mammen
1995) accounts, culture has been largely ignored. Although quantitative stud-
ies have usually found sociodemographic variables to be poor predictors of
psychologic and behavioral responses to perinatal loss (Kellner et al. 1984;
Lasker and Toedter 1991; Nicol et al. 1986), qualitative examination of how
different subgroups within our culture respond to perinatal loss continues to
be lacking.
A recent volume edited by Cecil (1996a), The Anthropology of Pregnancy
Loss, begins to correct the omission of cross-cultural investigation by provid-
ing ethnographic descriptions of pregnancy loss in rural India, Jamaica, New
Guinea, Tanzania, and Cameroon as well as historical accounts of pregnancy
loss in eighteenth-century England and early-twentieth-century Ireland.
The experience of pregnancy and its demise becomes part of the very
fabric of a cultures beliefs and identity. In particular, pregnancy loss is com-
monly attributed to the woman being estranged from her spiritual and social
world. Whether viewed as a target of evil spirits in India (Jeffery and Jeffery
1996) and Cameroon (Savage 1996) or as a victim of sorcery in Jamaica (So-
bo 1996) and New Guinea (Winkvist 1996), the woman is still commonly
viewed as ultimately responsible for reproductive outcome. In many of these
cultures, pregnancy loss is considered a punishment for actual misdeeds
(Wembah-Rashid 1996), for negative emotions such as anger, envy, or jealou-
sy (Savage 1996), or for breaking societal taboos (Winkvist 1996). Physical
explanations coexist with social/spiritual perspectives, allowing for the possi-
bility of less condemning and more sympathetic responses (Chalmers 1996;
Wembah-Rashid 1996; Winkvist 1996). Notably absent in virtually all of
these cultural accounts is the grief reaction now almost ubiquitously reported
in Western studies. Because many of these unborn children were regarded as
not fully human (Savage 1996; Wembah-Rashid 1996; Winkvist 1996) or as
the product of some transgression, mourning was often actively discouraged.
Pregnancy loss simply did not signify the death of a valued, potential member
of society. Importantly, many of these cultures believe pregnancy begins dur-
ing the second trimester, often at quickening (Jeffery and Jeffery 1996; Sobo
1996; Wembah-Rashid 1996), thereby making the most common pregnancy
loss, early miscarriage, a true nonevent.
Depending on the societal definition of pregnancy and the causal expla-

nations for these losses, grieving is not an inevitable or even appropriate re-
sponse for all or most members of a community. We also need to respect the
nonmedical, seemingly irrational ideas of many women who experience these
losses. Many Western women describe feelings of being punished for mis-
deeds (What did I do to deserve this?) or attribution of pseudomedical ex-
planations (e.g., eating certain foods, having intercourse during pregnancy,
exercising), suggesting that we in the West share a need with non-Western cul-
tures to create more social, personal, and spiritual understandings of these
losses beyond what science can tell us. Indeed, not only medically sound ex-
planations (Dunn et al. 1991) but even inaccurate, self-blaming beliefs may
provide some reason for these losses, some sense of control and efficacy
against their recurrence (Affleck et al. 1985; Tennen et al. 1986).
Although data are limited, it may be surmised that grief reactions to preg-
nancy loss were significantly less intense and common in the early twentieth
century in the West. Several investigators have suggested that the more com-
mon occurrence of perinatal and infant loss in undeveloped countries today
(Scheper-Hughes 1991) and in the West many years ago (Cecil 1996c) may
have led to the view that such a loss was just one of those things (Cecil
1996c, p. 190), an almost expected disappointment but not a tragedy. Again,
when infant mortality was high, babies were often not recognized as fully hu-
man and not worthy of much grief; the development of maternal attachment
during pregnancy may have only gradually become a cultural norm, consol-
idating as the odds for survival increased (Cecil 1996b; Scheper-Hughes
1991). Today, a woman who becomes pregnant again after a perinatal loss
may take a task-oriented, unenthusiastic approach to the pregnancy, thus
avoiding the usual attachment to the unborn child until a healthy baby is
born (Phipps 1985). Finally, historical accounts indicate that not much more
than a century ago in the United States, children were still viewed as econom-
ic assets rather than as solely objects of love and caregiving (Mason 1994; Zel-
izer 1985). The medical discovery of perinatal grief in the past quarter-
century perhaps naturally followed how increasingly normative that grief be-
came in the preceding 50 years.
Impact of Perinatal Loss on the Mother
There are many aspects to the psychologic repercussions of pregnancy loss.

The unique nature of this loss is critically important and often missed by stud-
ies that compare or evaluate this loss with other family losses (such as death
Perinatal Loss 147
of a spouse or older child). The following areas can be used as a clinical guide
for assessing maternal responses and risk factors. This discussion includes
clinical issues faced by mental health workers, whether as part of a multidis-
ciplinary team in the hospital at the time of loss (Kellner et al. 1981) or as a
therapist working with the client sometime after the loss.
Mourning the Death of a Baby
By the last trimester of pregnancy, both of the expectant parents, but especial-
ly the mother, develop an intense attachment to their unborn child as a
unique, separate person (Condon 1985; Lumley 1982; Stainton 1990). Pa-
rental images of the unborn child are so powerfully consolidated by this time
that a statistically significant degree of continuity exists in parental perception
of the babys temperament (e.g., activity, rhythmicity, adaptability, mood) in
utero and postpartum (Zeanah et al. 1985).
Based on this attachment, parents grieve the death of their unborn child,
already a beloved family member before birth. The usual pattern of grieving
has been recognized for over 50 years (Lindemann 1944). After the initial
shock and numbness on learning of the death (especially if it was unexpect-
ed), a period of intense confusion usually follows, with lapses in memory,
anxiety, restlessness, irritability, and somatic distress. As the reality of the
death gradually sinks in, the bereaved parents yearn for the return of the
deceased. Inconsolable sadness, preoccupation with memories of the de-
ceased, and intensely painful periods of loneliness, guilt, anger, and hopeless-
ness wash over the bereaved. Over the next year, the parents gradually
become reconciled to this permanent loss; everyday activities are resumed,
vigor in other relationships and the world in general is renewed, and capacity
to feel pleasure is restored.
It usually takes more work to make perinatal loss feel real. Because so
much of the image of the unborn child is imbued with fantasies during preg-
nancy (Deutsch 1945; Pines 1972), it comes as no surprise that couples after
perinatal loss often struggle with whether a pregnancy actually occurred
(Helmrath and Steinitz 1978; Lovell 1983). The raw material of memories fu-
eling the grieving process is scarce or absent following perinatal loss. For this
reason, virtually all researchers and clinicians working in this area recom-
mend giving parents as many opportunities as possible to get to know their
babyseeing and holding their child and going home with mementoes and
pictures testifying to their babys existence. Much of perinatal loss involves
grieving the loss of the futurerelinquishing the wishes, hopes, and fantasies
about one who could have been. It may be accurate to say that most grieving
involves retrospective mourning (i.e., detaching oneself from the relationship
that once was), whereas perinatal loss demands prospective mourning (i.e.,
detaching oneself from the relationship that was to be) (Leon 1990). Recent
studies of bereavement in general (Klass et al. 1996) and of the death of a
child (Knapp 1986; Rubin 1985) or that of a childs parent (Altschul 1988;
Harris 1995) in particular suggest that it is normal for an intermittent, usually
attenuated, grief to recur throughout ones life following major losses. This
may occur after perinatal loss when the lost child-to-be would have reached
the age at which cherished wishes for him or her would have occurred.
A critical determinant of the magnitude and quality of grief following
perinatal loss is how much and in what way the child was wanted and loved.
The common research finding of more profound grief following a later-term
pregnancy loss (Cuisinier et al. 1993; Goldbach et al. 1991; Janssen et al.
1997; Kirkley-Best and Kellner 1982; Theut et al. 1989; Toedter et al. 1988)
is logical based on the deepening attachment usually formed toward the
child-to-be as the pregnancy progresses. Similarly, the generally muted, limit-
ed, or even absent grief following uncoerced decisions to surrender unwanted
pregnancies or childrensuch as by elective abortion (Blumenthal 1991;
Dagg 1991), relinquishing a child for adoption (Cushman et al. 1993;
McLaughlin et al. 1988), or surrogacy (Fischer and Gillman 1991; Hanafin
1987; Schmulker and Aigen 1989)provides powerful testimony that the
womans attachment to her baby is a variable, psychologic process rather
than a biological, instinctive inevitability. These same losses usually provoke
much more intense grief when the babies are in fact wantedsuch as when
the pregnancy is terminated because of fetal anomaly (Leon 1995; Zeanah et
al. 1993) or when the loss is an essentially involuntary decision (e.g., studies
of extended birthmother grief when adoption was only feasible choice avail-
able, prior to the legal availability of abortions or societal acceptability of un-
married parenthood [Deykin et al. 1984; Rynearson 1982].
To understand grief following pregnancy loss, clinicians should remem-
ber that along with the commonly felt loss of a very real baby may be the just
as powerful evocation of a prior loss. Images of the child-to-be are a conglom-
eration of current and earlier object ties (Bibring 1959), a kind of projective
screen of salient relationships among which incompletely mourned people
may figure quite prominently. Not infrequently, an intractable, more chronic
grief following perinatal loss may involve the unconscious resurfacing of an
earlier loss, especially the death of a parent while the woman was still in child-
hood (Leon 1987, 1990).
Perinatal Loss 149
Clinicians must recognize that grieving is a highly individual and vari-

able process (Parkes 1985; Zizook and DeVaul 1985), not one that can be
readily put on a schedule or compartmentalized into stages. Studies of grief
in general (Wortman and Silver 1989) and perinatal loss in particular (Lin
and Lasker 1996) indicate that most people do not, in fact, follow the step-
wise pattern and diminuition of grief so frequently assumed.
Repairing Narcissistic Losses
Reproduction fulfills many cherished wishes and ambitions that have little to
do with parenting a child and everything to do with enhancing self-esteem.
Pregnancy promotes self-worth and enriches feminine identity by fostering a
sense of omnipotence, both in the act of creation and in becoming a parent
(who is imbued with so much power in the mind of the young child); affirm-
ing gender identity through reproduction; and defusing death anxiety by en-
suring a biologic continuity in projecting oneself into the next generation
(Leon 1990, 1992b).
Pregnancy loss, therefore, causes multiple blows to self-worth and self-
image. The growing intimation of omnipotence is shattered by this loss. The
woman is unable to experience even the usual sense of control over her body.
She faces the harsh finality of death when she least expects it, in the very act
of creating life. Her own mortality is awakened, as she sometimes fears she
will die as well. Pride in her femininity is transformed into shame and humil-
iation. Ultimately, she feels she has failed. Many of the usual reactions to
pregnancy losspersisting worthlessness, intense guilt, rage at the unfairness
of it all, feelings of emptiness and fragmentation, and psychosomatic symp-
toms (Furman 1978; Kohut 1971; Lasker and Toedter 1991; Peppers and
Knapp 1980)may be better understood as resulting from the profound dep-
rivation of normal narcissistic motives of pregnancy rather than the usual pat-
tern of grieving the death of ones baby (i.e., object loss) (Leon 1990, 1992b).
Such profound narcissistic damage helps explain why many women ex-
perience a significant improvement in well-being when they are able to
achieve a successful pregnancy following pregnancy loss (Hunfeld et al. 1997;
Murray and Callan 1988; Theut et al. 1990). This enables them not only to
parent but to repair a damaged self.
Narcissistic rage directed at medical caregivers may originate in the in-
tense disappointment and hurt of the loss but is invariably compounded
when caregivers are unable to appreciate the magnitude of this loss. Empathic
communication that enables the woman to feel understood is vital in reducing
narcissistic damage and healing self-esteem (Leon 1990). Quantitative studies

indicate that after pregnancy loss, parents expressed significantly higher self-
esteem when they were satisfied with the support they received from hospital
caregivers (Murray and Callan 1988); the degree of parent satisfaction with
care was directly related to the attentiveness and sensitivity of health care pro-
fessionals rather than the total number of interventions they received (Lasker
and Toedter 1994; Radestad et al. 1996b). In the words of Furman (1978),
For the professional person to tell the parents just to bear it is not enough;
to be with them and to extend oneself in bearing it can do much more (p.
216).
Women who suffer miscarriage or ectopic pregnancy may experience ad-
ditional narcissistic damage because of its occurrence in the early part of preg-
nancy when there is usually much less separation between fetus and self and
also because of the bodily damage to the fallopian tubes often accompanying
ectopics. Furthermore, because most psychologic interventions are designed
to grieve the loss of a baby, these early losses are often minimized, neglected,
or ignored, resulting in patients reporting greater dissatisfaction in their care
than those suffering later perinatal losses (Cuisinier et al. 1993; Lasker and
Toedter 1994; Radestad et al. 1996a).
Surmounting Developmental Interference
Pregnancy ushers in a new stage of developmentparenthood (Leifer 1977;

Shectman 1980)that profoundly changes self-perception, perception of the
meaning and purpose of life, and the value of family and relationships. As
with any other developmental advance, turmoil in ones inner world is
heightened, often leading to confusion, anxiety, and insecurity. This process
of inner disorganization facilitates reintegration and further development of
the personality, optimally increasing adaptation (Benedek 1959; Bibring
1959).
Pregnancy loss is a crisis within a crisis. Instead of progression to the next
developmental stage, developmental interference occurs. Studies demon-
strate that having had children previously reduces the depressive consequenc-
es of pregnancy loss (Graham et al. 1987; Janssen et al. 1997; Neugebauer et
al. 1992b, 1997; Toedter et al. 1988). Women who have lost a pregnancy of-
ten talk of not getting on with their life goals, plans, and dreams. They feel
stuck, off track, as if running in place.
Interpersonal isolation compounds the sense of internal stagnation. The
woman may feel profoundly estranged and lonely, cut off from family and
Perinatal Loss 151
friends who are moving on with their lives and having families of their own.
Soon after a pregnancy loss, it is often too painful to go to places frequented
by young families. Many of the usual responses to perinatal loss, such as vi-
sualizing or hearing a baby, wishing to have another baby as soon as possible,
and feeling intense pain and envy when exposed to other babies, may come
from the frustration of not being able to parent.
Pregnancy losses near the beginning and end of a womans reproductive
life may also complicate developmental issues. For the teenager, pregnancy
may be less a wish to parent than to feel like an adult or, regressively, seek to
feel loved by (i.e., be taken care of by) a baby (Mishne 1986; Rosenthal 1993).
When such a pregnancy is lost, the young woman must contend with the
thwarted needs both to grow up and to satisfy early childhood longings, often
quickly prompting another pregnancy. For women who have delayed parent-
hood into their 30s or later, the perceived danger of never becoming a biolog-
ic parent looms over this loss.
Reviving Psychologic Conflicts
In their extensive review of the perinatal loss literature, Bourne and Lewis
(1992) note a relative absence of psychoanalytic work in the area of revived
psychologic conflicts. This absence may be the result of an unspoken alle-
giance to some traditional but now outdated psychoanalytic belief that un-
conscious psychologic conflicts cause perinatal loss (Leon 1996b).
Earlier conflicts and relationship paradigms may be activated by and in-
terwoven with a perinatal loss. Clinical accounts (Condon 1986; Leon 1987,
1990, 1996a) and quantitative studies (Hunfeld et al. 1997; Lasker and
Toedter 1991; Toedter et al. 1988) indicate that earlier psychologic problems,
especially prior depression (Beutel et al. 1995; Janssen et al. 1997; Neugebau-
er et al. 1997), can interfere with the successful resolution of perinatal loss.
Although complicated grief following perinatal loss can often be treated with
short-term psychotherapy (Leon 1987, 1990, 1996a), serious, ongoing char-
acter problems may require more extended therapy to prevent further regres-
sion and to address aspects of grief (especially rage and guilt) intensified by
the personality disorder.
Mastering Exacerbating Circumstances of the Loss
The circumstances and causes of a loss typically are crucial factors influenc-
ing the course and outcome of bereavement (Bowlby 1980; Raphael 1983).
Clinical (Parkes 1980; Volkan 1970) and quantitative (Lundin 1984; Priger-
son et al. 1997) studies indicate that a sudden, unexpected losstrauma com-
plicating griefsignificantly interferes with adaptive resolution of grief, often
resulting in higher psychiatric and physical morbidity. The ability to gradu-
ally digest and process a major loss before the actual deathanticipatory
mourningusually facilitates grief resolution, clearly documented in the sig-
nificantly greater likelihood of parents to adaptively mourn the loss of an old-
er child from a terminal illness as opposed to a sudden death (Knapp 1986;
Leon 1990; Rando 1983).
Pregnancy loss is typically an unexpected death, often resulting in some
traumatic aftermath. Flashbacks of the hospital experience, intense anxiety
on returning to the hospital, and initial numbness soon after the loss are all
tell-tale signs that the trauma needs to be processed before and while the
death is grieved.
Other circumstances complicating the loss also need to be considered.
Loss of a baby who survived some time after birth, thus leading to increased
maternal attachment, often results in more extended grief. Medical threats to
the mothers life concurrent with pregnancy loss (such as ectopic pregnancy
and preeclampsia/eclampsia) may provoke an additional degree of trauma.
When mothers engage in behavior contributing to fetal death (e.g., substance
abuse) or demonstrably substandard medical care is provided, the intensity
of guilt or rage may complicate coping with the loss. Skillful clinical acumen
and tact will be necessary to determine and communicate how much the un-
derstandable preoccupation with this aspect of the loss is an adaptive cathar-
sis of trauma or a barrier to dealing with other critical issues (e.g., grieving
the babys death). Only by encouraging a detailed telling of the story will it
be possible to assess the degree of trauma as well as to begin to resolve that
trauma.
Other Important Factors

Infertility Compounding Perinatal Loss
Clinical experience (Leon 1990, 1996a) indicates that infertility profoundly
complicates pregnancy loss. Infertility usually heightens the developmental
interference with realizing parenthood. The grief over a pregnancy loss fol-
lowing infertility may be exacerbated by how precious and long overdue this
pregnancy has beena psychic gestation measured often in years rather than
months. Infertility may interfere with grief resolution by denying the oppor-
tunity for closure and reparation during the subsequent pregnancy and birth
Perinatal Loss 153
of a healthy child (Kirkley-Best and Kellner 1982; Peppers and Knapp 1980;
Theut et al. 1989). The stigma associated with infertility (Griel 1991; Men-
ning 1988) and the ensuing feelings of shame, failure, and worthlessness cre-
ate additional obstacles to obtaining psychologic help (Leon 1990, 1996a),
thus demanding clinical sensitivity in normalizing the psychologic repercus-
sions. That some members of the psychiatric, especially psychoanalytic, com-
munity continue to believe that unconscious conflicts cause perinatal loss
(e.g., Pines 1990) and infertility (e.g., Bydlowski and Dayan-Lintzer 1988)
provides a haunting reminder of how much women, in one way or another,
are held responsible for reproductive outcome in our culture (and many oth-
ers) and how much psychiatric thinking has served that social ideology.
Social Support Mediating Aftermath

Perhaps more than any other single variable, the availability or absence of so-
cial support may influence both the process and outcome of pregnancy loss.
When couples are able to mutually understand and support each other (For-
rest et al. 1982; Janssen et al. 1997; LaRoche et al. 1984; Nicol et al. 1986;
Toedter et al. 1988; Tudehope et al. 1986) and medical caregivers are felt to
be sensitively responsive to the loss (Harmon et al. 1984; Murray and Callan
1988; Smith and Borgers 1988), grief is reportedly more tolerable and the
outcome more benign. Social support essentially means providing empathy,
engendering a feeling of being understood, appreciated, and respected. Ones
pain is taken seriously and compassionately. It is defined less by what is said
and how many things are done than by how these things are said and done
(Furman 1978; Leon 1992a; Swanson-Kauffman 1986).
Job Stress or Relief

Often-overlooked factors influencing the aftermath of pregnancy loss are the
demands and satisfactions of work. Most women will still be grieving on re-
turning to work. A fulfilling job can be extremely therapeutic in reducing nar-
cissistic injury by promoting a feeling of competence again and by offering a
welcome distraction from the continuous pain of grief. Other aspects of the
work environment may make grieving more difficult or even intolerable. To-
tal indifference by coworkers may be especially disorienting and painful.
Some corporate or professional work climates may not tolerate even a muted
grief. For health care workers, a macho medical ethos may permit compas-
sion for ones patients while expecting immediate recovery for oneself. Med-
ical, especially obstetric, caregivers need to be reminded that returning to a
job so closely related to their loss may require that reentry be gradual and that
their anxiety, sadness, and numbing while on the job is valid and normal.
Putting Religious Faith to the Test

Almost universally, the meanings and causality of pregnancy loss are sought
beyond the answers of science. Not how, but why did this happen to me? Re-
ligious beliefs may ease or intensify distress. Believing in the childs continued
existence in heaven and an eventual reunion there following ones own death
may be comforting and may relieve some of the pain of separation. Even if
one does not claim to know Gods purpose, believing that a God or gods ex-
ists (in whatever form ones religion describes) and that such a death is not
without meaning can be reassuring. For others, religious beliefs become a
source of increased guilt, a feeling of being punished. For those whose belief
in God is based on a sense of fairness and justice, this loss may severely chal-
lenge their faith, leading to a bitter or cynical retreat from God or an eventual
modification and reaffirmation of that faith. Clerical counselors may be most
prepared to discuss religious matters, but all clinicians should inquire about
and be ready to address these concerns. One need not (maybe cannot) have
the answers in order to be enormously helpful by facilitating the processes of
searching, questioning, challenging, abandoning, changing, and finding reli-
gious faith.
Family Reactions
Mothers and Fathers: Grieving Apart and Together
Although fathers clearly grieve for their unborn, stillborn, and newborn chil-
dren who die, their grief tends to be significantly less intense and shorter than
that of their mates (Benfield et al. 1978; Helmrath and Steinitz 1978; Smith
and Borgers 1988; Theut et al. 1989; Vance et al. 1991, 1995; Zeanah et al.
1995). Peppers and Knapp (1980) attributed this pattern of incongruent
grieving to the significantly earlier and more intense attachment by the ex-
pectant mother to the unborn child within her body compared with that of
the prospective father. Although attempting to be supportive, husbands often
betray impatience and irritation over their wives seemingly endless grieving.
Husbands fear their wives will never get over it, and often want to get
back to normal before their wives are ready.
Perinatal Loss 155
The texture of grief often differs between mothers and fathers. Because
the child-to-be is more a part of the womans physical and psychologic self
and felt to be more under her control, maternal guilt and diminished self-
esteem tend to be more important ingredients of grief among women than
among men (Leon 1990). For a man, relief over his wifes physical recovery
may also eclipse grief over what has been lost.
Cultural gender roles that discourage masculine expression of intense
feelings in general and of sadness in particular often magnify the different ex-
pressions of perinatal loss by fathers and mothers (Gilbert and Smart 1992).
Men believe that they should be strong. Social norms reinforce these role
expectationshusbands are often asked how their wives are doing, with little
concern about how they themselves are faring. They may feel ashamed and
fear losing control of their intense emotions. They may grieve alone, crying
in the car on the way to work, or their frustration and disappointment may
be channeled into a more acceptably masculine emotionanger.
Men are often assigned and assume the responsibility of taking care of
their wives and managing concrete tasks, such as funeral arrangements, thus
reinforcing the masculine preference to act rather than to feel. The sense of
helplessness may propel them to work overtime to combat depressed feelings,
to avoid being with a depressed wife, and to find some sense of accomplish-
ment on the job. They may seek out distractions in sports or, more problem-
atically, retreat into substance abuse. A husband may feel it is his duty to
cheer his wife up rather than share his grief with her, increasing his wifes iso-
lation and estrangement from him. Although his wife may crave physical af-
fection and cuddling in order to feel loved, he is more likely to press for
sexual intercourse as a way of feeling close to her, leading each to feel disap-
pointed by the other.
These are general patterns. Some men experience a deeper loss of their
child than do their wives following pregnancy loss. Notwithstanding these
normative differences, most couples successfully weather the storm, eventu-
ally reporting increased closeness and a stronger marital bond (Gilbert and
Smart 1992; Harmon et al. 1984; Helmrath and Steinitz 1978; Peppers and
Knapp 1980). No evidence of increased incidence of divorce following peri-
natal loss has been found.
Couples work can be an especially timely and appropriate intervention
after pregnancy loss. It may provide a bridge to appreciate and empathize
with the partners experiencemodeled by the clinician when appropriate
that is enriched by exploration of salient individual issues.
Effects on Siblings: The Invisible Loss
Perinatal sibling loss has been called the invisible loss because the dead
baby usually is not seen, little is heard about the loss, and often the siblings
many questions, confusions, and feelings go unacknowledged (Leon 1986b).
This has significantly improved over the past 15 years. Siblings are increas-
ingly allowed or encouraged to see the baby as they participate in opportuni-
ties for the whole family to grieve. However, the professional blindspot in this
area continues, with virtually no quantitative research on the impact of peri-
natal loss on siblings and the most effective ways of helping them cope with
this loss.
As early as age 2 or 3 years, a child can begin to grasp the essential con-
cept of death as the permanent cessation of all functioning (Bowlby 1980;
Furman 1974). Preschoolers, however, dramatically distort causality. Magi-
cal thinking and egocentrism dominate their interpretation of events. Thus,
a childs jealousy toward the new baby during pregnancy may, after perinatal
loss, become a conviction that he or she caused the death. At the same time,
sibling rivalry should not be the only lens through which perinatal sibling loss
is viewed. If permitted, young children (especially beyond toddlerhood) often
powerfully and poignantly grieve their siblings death. Ultimately, the childs
developmental level, individual dynamics (including reactions to this preg-
nancy), and family style of grieving will decisively influence the childs reac-
tions to this loss.
Clinicians can play a valuable role in helping parents understand and
cope with their childrens reactions to perinatal loss. The range of normal re-
actions should be reviewed with parents. Anxiety is common (Will someone
else die too?). Depressed feelings may be based on many factors, including
guilt (Was I to blame?), lowered self-worth due to neglect (Nobody pays
attention to me anymore), and grief over the loss. These feelings may take
the form of tired, bored, or angry behavior or of somatic complaints. It is nor-
mal for children to become preoccupied with death for a while, staging mock
funerals or asking many questions about what happens to the body. A childs
reluctance to show any interest may be based on the familys overt or unspo-
ken rules about avoiding that topic. Children may also respond nurturantly
toward their parents grief (What can I do to make the pain go away, Mom-
my?). Perinatal sibling loss may foster a childs empathy.
Attending the funeral usually helps even young children by making the
death concrete and providing social support. The child needs to be prepared
for what he will see and hear and have a trusted adult nearby to answer any
Perinatal Loss 157
questions that arise. It is crucial that parents explain what happened and how the baby
died in clear, simple, concrete terms using words the child can understand. This should
be done when pregnancy loss occurs early (e.g., miscarriage or ectopic) as
well as late; parents often deny a childs knowledge about the pregnancy or
believe such a discussion creates an unnecessary burden, overlooking how
the sometimes devastating impact of miscarriage (Beutel et al. 1995; Herz
1984; Neugebauer et al. 1992a, 1997) will be more confusing and troubling
to children if not put into some understandable context. Drawing pictures can
be a useful aid. Having the child repeat the explanation in his or her own
words may tell the parent what has been understood or confused. It may be
necessary to clarify for a younger child that the death was not caused by any-
thing he or she felt or did but rather by a baby disease that cannot happen to
anyone older in the family. Children may also need to hear that the parents
sadness over the death of the baby does not mean that they love their living
children any less, although it may be hard for them to be as attentive when
they are so sad. It helps parents to talk about the death, sad as they may be,
and helps them feel better about themselves as parents when they are able to
help their children cope with the loss and answer any questions.
A mental health consultation with a clinician familiar with childhood
grief may be warranted when sibling distress becomes chronic. As with adult
responses, unresolved perinatal sibling loss is often associated with earlier
problems predating the loss. Clinical studies (Leon 1986a, 1986b, 1990)
strongly suggest that childrens disturbed reactions to perinatal sibling loss
were strongly linked to a failure by parents to provide accurate and clear in-
formation about the loss and to support their childs feelings; to parental un-
resolved grief usually leading to an extended disruption in parenting; or to
parents engaging the child in destructive patterns of family interaction, in-
cluding scapegoating, extreme overprotectiveness, or using a subsequent
child as a replacement for the dead baby.
Caregiver and Community Responses
How Caregivers Respond
Early work exploring the reactions of caregivers to perinatal loss focused on

their tendency to resort to psychologic defenses to protect themselves against
the intense feelings aroused by these losses (Bourne 1968; Klaus and Jnell
1982; Peppers and Knapp 1980; Stack 1982). This temporary relief of their
own distress was bought, however, at the high price of failing to engage with
their bereaved patients as well as blocking more effective coping. Among ob-
stetricians, widespread knowledge of parental grief following perinatal loss
(Kirkley-Best et al. 1985) has enabled them to be more helpful to their pa-
tients.
Medical training that dictates that it is unprofessional to have strong feel-
ings because of the danger of becoming emotionally involved with ones
patients must be challenged. Such thinking is bad for patients and caregivers.
It is natural for medical caregivers who have participated in a pregnancy to
feel loss, sometimes profound, at its demise. It is just as natural for caregivers
to feel sad when they are with people who are grieving, helping them feel they
are not alone and that their pain is shared by others. Bereaved parents need
to see that their caregivers care.
Medical caregivers frequently feel guilty, inadequate, and helpless after a
pregnancy loss, even when they know they did nothing wrong. They may fail
to recognize the enormous importance of their emotional response to their
vulnerable patients. What medical caregivers say and do at the critical time
of this loss is not forgotten. Heartfelt, comforting words or touches can be-
come lifelong sustaining memories that promote healing, just as seeming in-
difference can leave painful scars, irreparably damaging the patientdoctor
relationship.
Overwhelming helplessness in the wake of pregnancy loss may cause
trauma among medical caregivers: unforgettable memories returning as flash-
backs or dissociative detachment masking as indifference. The cumulative
strains on caregivers who regularly deal with these losses can be debilitating.
Measures for resolving the occupational grief and trauma that affect medical
caregivers need to be devised at individual, group, and institutional levels
(Gilliland and James 1993).
How Friends and Extended Family React
Until recently, there was little communal recognition of and compassion for
perinatal loss. Talk about the baby was often replaced with a deafening si-
lence that seemed to say, contrary to parents grief, that nothing had hap-
pened and no one had died (Helmrath and Steinitz 1978; Peppers and Knapp
1980). Well-meaning advice intended to comfort and distract the bereaved
was more likely to impede grieving by encouraging suppression (Just try not
to think about it and youll feel better), reinforcing maternal guilt (It was
meant to be), and denying the loss (You can always have another child).
Perinatal Loss 159
Many people still recoil from the tragedy of pregnancy loss. Fearing they will
say the wrong thing, they will often say nothing. It is also common to expect
bereaved parents to return to normal and become their old selves within
weeks or a few months at most.
It may be especially difficult for grandparents to tolerate their childrens
grieving. Grandparents often avoid talking about the baby for fear they will
upset their children, which in turn leads bereaved parents to feel more iso-
lated and misunderstood. Although adult siblings can be an important source
of support, if siblings are pregnant or have young children, envy felt by the
bereaved parents may be intolerable, increasing estrangement from extended
family.
The most beneficial source of community support and understanding for
perinatal loss has been self-help groups in which bereaved parents reaffirm
for one another the normalcy of grieving by providing a place where those
feelings may be freely expressed (Klauss and Jnell 1982; Peppers and Knapp
1980; Wilson and Soule 1981). For those whose grief has abated, these
groups may provide a valuable channel for supporting others, transforming
self-preoccupation into altruism (Videka-Sherman 1982). However, only a
small percentage of the bereaved ever attend a self-help group; this resource
is rarely used by minorities or the most socially isolated. Recommending a
support group should never substitute for a caregivers listening and respond-
ing to perinatal grief.
Psychologic Management of Pregnancy Loss
Hospital Practice
Klaus and Jnell (1982) provided the basic model of preventive intervention
following perinatal loss. Doctors empathically but honestly keep parents fully
informed of the babys condition when problems emerge. Immediately after
the death, the doctor meets with parents to give the tragic news, offer comfort
and support, and answer any medical questions they may have. Parents are
encouraged to validate their loss by having contact with their baby as well as
taking home pictures and mementoes of the baby (e.g., footprints, baby brace-
let, receiving blanket, and lock of hair). Dulling grief with sedation is avoided.
Instead, the normalcy of the intense grief that can be anticipated (including
rage, irrational guilt, and somatic symptoms) is explained. Because the par-
ents are often in a state of shock at the time of death, a second meeting is
scheduled for a few days later to discuss many of the same concerns, continu-
ing to provide support and empathy for their feelings. The importance of
sharing their grief is emphasized, as is the fact that no one is to blame. Parents
are usually encouraged not to attempt another pregnancy until they have
grieved this loss (at least 6 months). At 3 to 6 months after the loss, a third
meeting is scheduled to review the autopsy findings, address any new issues,
and determine whether additional follow-up meetings or mental health refer-
ral is needed.
With minor variations this basic approach has become the standard of
care for all pregnancy losses, including outpatient obstetric practice (Leppert
and Pahlka 1984). Many hospitals have created their own multidisciplinary
grief support teams (Brown 1992; Kellner et al. 1981; Lake et al. 1983). An
alternative approach is training all obstetric caregiversoften with the aid of
protocolsin the hospital management of perinatal loss (Carr and Knupp
1985; Hutti 1988). A danger exists that sole reliance on grief specialists (let
them do it) will devalue the importance of all medical caregivers developing
skills in responding to these losses.
However caregiving is delivered, it needs to be individualized (Leon
1992a). Too great a reliance on specific instructions will deplete the genuine
interaction with bereaved parents that is the essence of good care. As impor-
tant as contact with the dead baby is for most parents in order to make the
loss real and to help them grieve their loss, such contact is not equivalent to
mourning. Quantitative studies have not yet conclusively demonstrated that
such contact facilitates grieving or is indispensable. Caregivers need to guard
against exercising undue pressure on parents to view their baby. Caregivers
will never go wrong when they allow themselves to empathize with their pa-
tients. By listening carefully, caregivers may be able to sense to what extent
the loss is experienced as the death of a child, a profound blow to self-worth,
the revival of an earlier loss or trauma, and/or an obstacle to becoming a par-
ent. Finally, because these losses so often leave parents traumatized in the
wake of feeling profoundly helpless, empowering them by offering options
rather than dictating care is usually therapeutic. For example, instructing par-
ents to wait at least 6 months before attempting another pregnancy is less ef-
fective than discussing the pros and cons about timing future pregnancies,
allowing the parents to decide what is best for them (Davis et al. 1989).
Although models of follow-up care are available (Ewton 1993; Ilse and
Furrh 1988; Maguire and Skoolicas 1988), insufficient follow-up after the
family leaves the hospital is a serious deficiency in the management of preg-
nancy loss. In addition to facilitating continued grieving, follow-up care may
Perinatal Loss 161
provide the needed support for the next emotionally difficult pregnancy,
fraught with anniversary revivals of anxiety and grief (Bourne and Lewis
1984; Phipps 1985). Research has repeatedly emphasized both the value of
follow-up contact and how often it is overlooked. A single 15- to 40-minute
phone call within 10 days of a neonatal death significantly reduced loneliness,
depression, and guilt 26 months postloss (Schreiner et al. 1979). Even re-
search interviews at 6 weeks and 6 months after a miscarriage appeared to
have unintended therapeutic effects (Neugebauer et al. 1992b). Other inves-
tigations (Clyman et al. 1979; Helstrom and Victor 1987; Kellner et al. 1984)
have indicated that up to 75% of parents who experienced a pregnancy loss
wanted to discuss the details of the death or come in for a follow-up appoint-
ment 24 months after the loss. A recent national maternal health survey re-
ported that over 50% of the sample experiencing perinatal loss wanted more
information (Covington and Theut 1993).
Mental Health Considerations
Mental health professionals play a crucial role in the continuum of caregiving

for pregnancy loss. They can make diagnostic differentiations, such as distin-
guishing intense, immediate grief reactions from frankly psychotic episodes
or appreciating the impact of earlier characterologic disturbance, such as bor-
derline personality. They may serve valuable educational and supervisory
roles. Accustomed to equating care with overt procedures, medical caregivers
often need to learn that empathic listening and responding to a parents in-
tense grief is not doing nothing, but is in fact beneficial. Outside the hospi-
tal as therapists, mental health professionals may mitigate the potentially
destructive and chronic consequences of unresolved grief.
Thanatologists typically distinguish more-or-less normal grief from the
range of pathologic or complicated grief reactions, including chronic, de-
layed, inhibited, or distorted mourning (Bowlby 1980; Horowitz et al. 1997;
Jacobs 1993; Worden 1982). Treatment recommendations are similarly divid-
ed between supportive counseling oriented toward facilitating resolution of
normal grief and interpretive psychotherapy directed toward defusing patho-
logic reactions (Worden 1982).
Although distinguishing self-remitting grief reactions from disturbed re-
sponses requiring psychologic intervention certainly has both heuristic and
practical value, my clinical experience suggests these distinctions are best
viewed as two poles on a continuum. That is, many if not most bereavements
possess aspects of normal and disturbed grief; treatments, similarly, blend as-
pects of counseling and psychotherapy. Many responses viewed as symptom-

atic of distorted grief (e.g., furious hostility, depersonalization, loss of patterns
of social interaction, and agitated depression) (Lindemann 1944) are not un-
usual reactions in the months following perinatal loss. It has been notoriously
difficult to predict accurately the individuals at risk for later psychologic prob-
lems (Kellner et al. 1984; LaRoche et al. 1984; Leon 1990; Zeanah 1989).
Too many quantitative studies continue to view marked distress and depres-
sive symptoms in the weeks and first months following pregnancy loss as psy-
chiatric disturbance (e.g., Friedman and Gath 1989; Neugebauer et al. 1997)
rather than intense grief. Patterns of grieving in general (Klass et al. 1996;
Wortman and Silver 1989) and perinatal loss in particular (Brown 1993; Lin
and Lasker 1996) do not fit the dichotomy of normal versus pathologic griev-
ing. Those labeled as having uncomplicated grief may be discouraged from
seeking the help they could use, whereas those burdened with the idea of be-
ing sick may be too frightened to obtain the help they need. Many women
who seek psychotherapy after perinatal loss describe significant unresolved
childhood loss, disappointment, or emotional deprivation, especially with
their own mothers, that has indirectly been awakened by this loss (Leon
1990).
During the year following pregnancy loss, psychologic help may prevent
the development of further disturbance by facilitating grief and addressing
maladaptive reactions based on prior emotional difficulties and/or inadequate
social supportespecially between the partnerstwo of the factors most con-
vincingly associated with later emotional problems in quantitative studies
(Lasker and Toedter 1991; Zeanah 1989). Substance abuse, the development
of severe psychosomatic problems, suicidal behavior, or serious intent (not
solely the thoughts or wishes of dying that are common) require immediate
attention. When grief, depression, impaired job performance and interper-
sonal functioning, or any other emotional or behavioral difficulties do not be-
gin to subside over the second half of the first year, treatment may be
indicated. In subsequent years, psychotherapy may effectively address emo-
tional difficulties based on earlier unresolved pregnancy loss that have be-
come entwined with a prior unresolved loss or other latent conflicts and/or
deficits (Condon 1986; Leon 1987, 1990; Turco 1981).
If the bereaved parent is able to form an effective therapeutic alliance, an-
tidepressants usually are not necessary, because considerable symptomatic re-
lief is generally achieved with short-term psychotherapy. In the presence of
immobilizing depression or suicidal risk, antidepressants may be needed.
With the increased use of selective serotonin reuptake inhibitors (e.g., fluox-
Perinatal Loss 163
etine, sertraline, and paroxetine) causing fewer side effects, antidepressants

are increasingly being prescribed for depressive reactions associated with be-
reavement. Antidepressants without regular psychotherapy are not the appro-
priate treatment for maladaptive grief reactions.
Treating Pregnancy Loss
Whatever the setting, a consultation sets the stage for treating pregnancy loss.
Flexibility is crucial both in the number of sessions needed (usually three to
six) and whether the partner is included, which is initially based on a clients
wish. Consultation balances the tasks of crisis intervention, counseling, and
assessment. The first session usually involves the patient telling the story of
what happened (not, I would emphasize, a psychiatric interview with history-
taking designed to obtain a DSM diagnosis). This approach fosters the ther-
apeutic alliance, facilitates grieving and processing trauma by making the
events real for the client and clinician, and highlights what is unique about
this loss. The therapist counsels by providing direction as needed (e.g., the
importance of sharing feelings with ones partner and explaining the appro-
priate details to ones children) and almost always by offering reassurance
about the normalcy of intense grief (i.e., youre not going crazy). Psycho-
logical evaluation clarifies the multiple factors that make this loss so difficult,
provides a history, and develops a diagnosis as the consultation progresses.
Flexibly structured short-term psychotherapy is usually the optimal inter-
vention for recent perinatal loss (Leon 1987, 1990, 1996a). Even if long-term
intensive psychotherapy appears warranted based on significant prior distur-
bance, clients rarely are prepared to accept that recommendation: they are
not seeking characterologic change at this time, are inclined to experience
such a recommendation as another narcissistic blow, and need the prospect
of short-term relief. Clients are empowered by deciding when they are ready
to stop rather than having to submit, helplessly, to a prescribed number of
sessions, whether by theoretical design (Mann 1973) or according to the limits
of managed care. Usually, one can be optimistic about significant improve-
ment within 34 months following the consultation. By the end of the consul-
tation, it can be valuable to distinguishto the degree they can be heardthe
longer-term issues that will not be the focus of these sessions, thereby setting
realistic expectations for the treatment.
A cardinal principle in treating pregnancy loss is flexibility. All modalities
should be considered and a multimodal approach used when appropriate. Al-
though individual work may focus on complicated intrapsychic dynamics,
marital work may be crucial in clarifying the different responses to this loss,
and family work may promote a safe family atmosphere to grieve. Therapists
need to be careful not to usurp the parental role in addressing this loss with
children. Having a preferred orientation does not prevent using other ap-
proaches when warranted. Cognitive-behavioral techniques may be quite ef-
fective with specific symptoms (e.g., encouraging systematic desensitization
with phobic reactions related to avoiding grief-evoking stimuli). A flexible ap-
proach to the frequency of meetings is also helpful. Weekly meetings are the
norm, although more frequent sessions on short notice during more emotion-
ally intense times (e.g., anniversaries) are effective, as are less-frequent meet-
ings, especially in tracking the extended stresses of infertility treatments or a
future pregnancy.
The positive therapeutic relationship is not the means but the essence of
this work. If a solid alliance cannot be established, the prospects for effective
short-term therapy are poor. Grieving is understood not solely as an intrapsy-
chic process but also as an interpersonal transaction. In a sense this is an
adaptive form of projective identification (Hinshelwood 1991) in which the
bereaved, overwhelmed by the sadness of her loss, is assisted in expressing
and getting through the pain of her grief by its being shared and felt by an-
other. This process demands stable object relatedness in the bereaved (i.e.,
having basic trust in others) and a willingness by the therapist to participate
in a subdued fashion in the grieving. Maintaining an empathic connection is
more important than getting it right (i.e., interpretation of unconscious con-
flicts). Past dynamics are explored only as they influence current loss issues.
Transference expression is not encouraged and interpreted only when neces-
sary (i.e., when threatening the alliance).
Taking account of subcultural attitudes and religious beliefs, not as ste-
reotypes but as normative contexts from which individual differences
emerge, is another important facet of what the loss means to the parent. Chal-
lenging the stigmatization associated with some of these losses (e.g., infertility,
pregnancy termination for fetal anomaly, adoption counseling) promotes a
recognition of the social forces that help shape their impact.
Depending on the situation and timing, the therapist may gently encour-
age or advise against certain actions (e.g., it usually does couples no good to
exacerbate intense grief by attending baby showers before they are ready or
by celebrating major holidays when they feel they have nothing to celebrate).
This is not telling them what to do but rather giving them permission to do
what they already know is right for them.
Terminations vary. Even when the help has been deeply appreciated,
Perinatal Loss 165
endings tend to be more brief and less intense in this work than in more tra-
ditional therapies. The therapist will usually have an intuitive sense of a pre-
mature, unexpected, avoidant bolting as opposed to a readiness to end
soon because the work is drawing to a close. Ironically, although the essence
of this work is grieving multiple losses, the loss of the therapist is usually not
grieved by the patient but is instead relinquished without much fanfare, as a
transitional object loses its significance for the young childonce indispens-
able to her sense of security and well-being, but now expendable (Winnicott
1953).
Conclusions
Although major advances have been made in the understanding and manage-
ment of pregnancy loss, more work is needed, especially in appreciating the
individual experience of this loss. More case clinical studies are needed to de-
sign interventionsstudies that involve families, fathers, and children as well
as mothers. Quantitative measures assessing the multiple dimensions of this
loss (such as the Perinatal Grief Scale [Toedter et al. 1988]) are vital in track-
ing the course and outcome of reactions beyond a uniform model of grieving
(Lin and Lasker 1996). Nonclinical studies must go into greater depth than
the self-reports found in anecdotal handbooks. All of these approaches broad-
en our understanding of normal and maladaptive reactions to pregnancy loss,
enabling a more individualized approach in hospital and psychologic practice
than currently exists. Finally, integrating the impact of subcultural, ethnic,
and religious influences on the individual phenomenology of these losses will
provide a much needed anchor in the social realm.
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II
Gynecology
9
Psychological Aspects of the
Menstrual Cycle
MARGARET F. JENSVOLD, M.D.
CORINNA E. DAN, R.N., B.S.N.
Biomedical researchers have commonly viewed the menstrual cycle as a

confounding factor in research rather than as a legitimate subject of scientific
study. This view has contributed to the exclusion of women of reproductive
age from much health research (Kinney et al. 1981). At the same time a plethora
of media articles have conveyed primarily negative images of the menstrual
cycle and of premenstrual syndrome, along with conflicting diagnostic and
treatment information and jokes (Chrisler and Levy 1990). If women and
their health care providers are confused about the menstrual cycle, there is
good reason.
Nevertheless, we do have some knowledge. Research during the past
couple of decades has helped clarify what the questions are and has pointed
to directions for future research. This chapter is intended not to be entirely
comprehensive, citing all research findings, but rather to present current re-
search findings and illustrative points to provide a framework for clinicians,
researchers, and health care consumers for conceptualizing the role of the
menstrual cycle in psychiatry.
Many, if not most, physiologic parameters vary in a circadian manner
(e.g., body temperature, cortisol level, thyrotropin-releasing hormone level,
sleep-wake), usually without causing symptoms and often with the person
not even aware that the changes are occurring. Likewise, many physiologic
parameters vary over the course of the normal menstrual cycle, not causing
symptoms and often with the woman being unaware of the change. Cultural
factors are well documented to have a significant influence on expectations
177
and perceptions related to the menstrual cycle. With both physiologic and
cultural factors contributing to changes over the menstrual cycle, how is one
to make sense of pathology related to this cycle? This chapter addresses the
physiology, cultural considerations, and diagnosis and treatment related to
the menstrual cycle with attention to methodologic and political concerns.
Physiology
Normal Menstrual Cycle
The core events of the normal menstrual cycle are an integrally interconnect-
ed neuroendocrine feedback loop: the hypothalamicpituitaryovarian axis.1
Readers are referred elsewhere for detailed accounts of the endocrine events
of the normal menstrual cycle (Severino and Moline 1989; Speroff et al.
1982). The menstrual cycle can be thought of as consisting of two phases, the
follicular phase and the luteal phase, with cyclicity occurring in a number of
organs and tissues (Figures 91 and 92). What is happening suprahypotha-
lamically over the course of the menstrual cycle is less known to us, but ani-
mal research shows that neurotransmitters cycle catamenially2 in various
parts of the brain (McEwen 1988). The uterus is not a core player in the nor-
mal menstrual cycle, but rather is a target organ for hormonal action. Its reg-
ular, recurrent menstrual flow is an external indicator to the woman that yet
another menstrual cycle has been completed and that a new one is beginning.
What constitutes the endogenous time clock of the menstrual cycle is rel-
atively unknown at present. The suprachiasmatic nucleus and associated
structures are suspected (Kawakami et al. 1980). Circadian cycling is thought
to be driven by the suprachiasmatic nucleus, with light input through the
retinohypothalamic tract serving as a zeitgeber, or entraining factor, that af-
fects the cycle length but not the presence or absence of the circadian cycle
altogether. In the absence of lightdark cues the circadian time clock freeruns,
still cycling in a regular circadian manner but with a slightly longer cycle
length on average (27 hours free running compared with 24 hours daynight
entrained). Whether ovarian input to the brain serves as a zeitgebersimply
entraining the timing of a catamenial cycle that would freerun without ovari-
1
A hypothalamicpituitarygonadal axis exists in men as well, of course: the hypothal-
amuspituitarytesticular axis. That it has no external indicator of its timing does not
in itself mean that it does not have an endogenous timing mechanism.
2
Catamenial means of or related to menses or the menstrual cycle.
Psychological Aspects of the Menstrual Cycle 179
FIGURE 91. The normal menstrual cycle. Hormonal, ovarian, endometrial, and bas-
al body temperature changes and their relationships throughout the normal menstrual
cycle are shown. E2 = estradiol; FSH = follicle stimulating hormone; LH = luteinizing
hormone; P = progesterone.
Source. Reprinted from Carr BR, Wilson JD: Disorders of the Ovary and Female Re-
productive Tract, in Harrisons Principles of Internal Medicine, 11th Edition. Edited by
Braunwald E, Isselbacher KJ, Petersdorf RG, et al. New York, McGraw-Hill, 1987, p.
1823. Copyright 1987, The McGraw-Hill Companies. Used with permission.
an inputor whether ovarian input is integral to the continued catamenial

cycling of the brain is not entirely known. There is some evidence in each di-
rection. Gonadotropin-releasing hormone (GnRH) agonist treatment evi-
FIGURE 92. Hypothalamicpituitaryovarian axis. The pathways of endogenous and

exogenous hormones are shown. FSH = follicle-stimulating hormone; GnRH = gona-
dotropin-releasing hormone; LH = luteinizing hormone.
dence indicates that when ovarian input is removed, catamenial cycling of

central nervous system symptoms stops (Hammarback and Backstrom
1988). On the other hand, a study of patients with premenstrual syndrome
using a progesterone antagonist, RU-486, showed that when the normal hor-
monal milieu of the latter quarter of the menstrual cycle is removed, thus dis-
placing the timing of menstrual flow, menstrually related mood symptoms
still occur at the usual time in some patients (Schmidt et al. 1991). This indi-
cates either that endocrine events earlier in the cycle ordain the timing of the
cyclic mood symptoms or that central nervous system cycling continues in-
dependently of the peripheral hormonal milieu, at least for a time.
An exogenous factor affecting the menstrual cycle that has been studied
is the presence of other cycling females. The tendency toward synchrony of
cycles among females who spend an extended time together is mediated by
pheromones produced by the women themselves that expedite or delay the
onset of the ovarian cycle (McClintock 1984).
Variability in the Normal Menstrual Cycle
An occasional anovulatory cycle or shortened luteal phase is not uncommon.

However, certain groups are more prone to menstrual irregularities, including
heavy exercisers, anorexics, and women taking neuroleptic medications (Sul-
livan and Lukoff 1990) or abusing substances. At least for heavy exercisers,
anovulatory cycles appear to be associated with increased bone loss.
Cultural Aspects
Evidence for a strong cultural influence on our view of the menstrual cycle
comes from several fronts. Menstrual taboos have existed across cultures and
across time, including today. Deutsch (1944) discussed the psychologic mean-
ing of menstruation, pointing out the reasons why women deny and hide it
and also pointing out the tendency to prefer to view the menstrual cycle as a
biologic function rather than as having great psychologic significance for
the woman. The words we use to describe the menstrual cycle convey our
tendency to view it negatively, rather than positively (Martin 1987). Premen-
strual syndrome seems to be to the twentieth century what neurasthenia was
to the nineteenth centurya nebulous disorder primarily of women that in-
volves the menstrual cycle, has numerous symptoms, etiologies, and treat-
ments proposed, and conveys a negative view of women (King 1989).
Premenstrual syndrome meets the criteria for a culture-bound syn-

drome. It constitutes a negotiated realitythat is, its reality is that negoti-
ated between those who treat it and those who suffer it (Morokoff 1991).
Premenstrual syndrome is unique in the extent to which the societal nego-
tiation process has been overt and publicwith research, debates, protests,
letters back and forth, and papers supporting various points of view. The ten-
tative compromise solution placed late luteal phase dysphoric disorder (LLP-
DD) in the appendix to DSM-III-R (American Psychiatric Association 1987),
highlighting its negotiated and controversial status. In DSM-IV (American
Psychiatric Association 1994), premenstrual dysphoric disorder (PMDD) is
listed as an affective disorder, with recognition of this entry as a criteria set
and axes provided for further study. This latest placement is being debated
by researchers and clinicians who are concerned about categorizing this co-
hort of women as depressed (Severino 1996). In general, the inclusion of
PMDD in the main body of DSM-IV is seen as a step forward in improving
the diagnosis and treatment of this disorder (Steiner 1997).
Symbolic analysis of culture-bound syndromes provides an understand-
ing not afforded by the biomedical approach alone (Morokoff 1991; Severino
1996). Johnson (1987) argued that premenstrual syndrome addresses the tra-
ditional concepts of women and work, reinforcing the cultural double-bind of
the imperative for women to be both productive and reproductive. Although
women with premenstrual syndrome may be unable to work for a limited pe-
riod of time, they must still relate to others in a manner that is pleasing (as is
culturally mandated) most of the time. Formal evaluations of cognitive func-
tioning in women with premenstrual syndrome indicate no reduction in cog-
nitive performance even though the women reported increased feelings of
inadequacy (Morgan et al. 1996). What is new is not the negative view of
women as being weak, emotional, and unable to work, which in premenstrual
syndrome is captured in the premenstrual phase, but rather the positive view
of women as strong, powerful, and capable, which is captured in the nonpre-
menstrual phases of the menstrual cycle.
Interpreted literally, premenstrual syndrome allows women access to
power most of the time, while invalidating them and their experience part of
the time. However, a regularly disabled woman is not seen as a capable wom-
an, and the woman with premenstrual syndrome may be angry or assertive
premenstrually and submissive the rest of the time, whether or not appropri-
ate to the circumstances (including oppression). Morokoff (1991) argued that
premenstrual syndrome captures our cultural ambiguity regarding women
and conception, with symptoms occurring at the time of greatest ambiguity
about whether the woman has conceived and, more important, whether the
woman should conceive. Premenstrual syndrome appears to constitute a tran-
sitional compromise for a culture in which womens roles have changed and
mens roles have not.
Studies show that women report more negative symptoms when they be-
lieve they are premenstrual than when they are led to believe that they are
not premenstrual. A study analyzing womens perception of perimenstrual
impairment found that with positive reframing of changes that occur peri-
menstrually, impairment decreased (Morse 1997). Studies also indicate that
women report more premenstrual symptoms when they are aware of the fo-
cus of the study than when they are not (Hamilton et al. 1989). These find-
ings substantiate an expectancy component to symptom reporting. This
psychosomatic aspect of symptom occurrence may complicate research find-
ings (Mortola 1998).
Pathology and the Menstrual Cycle
Does a unique disorder of primarily psychologic symptoms occurring only

premenstrually exist? If so, what is the relationship of it to other psychiatric
and medical disorders? Do other psychiatric and medical disorders them-
selves vary with the menstrual cycle?
A brief history of the term premenstrual syndrome is necessary to put into
context our modern conceptualization of these questions. When Frank
coined the term premenstrual tension in 1931, he distinguished between what he
considered to be three different groups of women. The first group had mild
symptoms premenstrually, such as fatigue, that he considered to be normal.
The second group included women with systemic illnesses that varied with
the menstrual cycle; he cited two examples, a patient with catamenial asthma
and one with catamenial epilepsy. The third group was a small minority of
women who experienced what he called premenstrual tension, a disorder
of severe emotional symptoms occurring premenstrually, including suicidali-
ty, a personality change, and/or reckless behavior for which they later had
remorse. Relief of these symptoms occurred with onset of menses. Subse-
quent writers from the 1930s to the 1950s added progressively more and
more symptoms to the list of possible premenstrual tension symptoms, such
that by the 1950s it was recommended that any and all symptoms that vary
with the menstrual cycle be considered as falling under the rubric of premen-
strual tension, including asthma attacks and seizures. Dalton first used premen-
strual syndrome in medical literature in 1953, a change that emphasized the

wide variety of possible symptoms, both physical and psychologic. As all
symptoms related to the menstrual cycle became lumped together, a great
deal of confusion followed and it became necessary to ask certain questions:
Is there really a single premenstrual syndrome, or many? Is progesterone the
drug of choice for all cases of premenstrual syndrome, as claimed by Dalton
(1964)? Franks (1931) original delineation of a severe syndrome with prima-
rily psychologic symptoms, distinct from either systemic illnesses varying
with the menstrual cycle or normal, mild symptoms, was lost in the confu-
sion. In recent years research has started bring us out of the confusion, and,
in the process, has pointed us back toward Franks forward-looking original
impressions.
Disorders Varying with the Menstrual Cycle
Dysmenorrhea
Dysmenorrhea is defined as recurrent, catamenial pelvic pain. Primary dysmenor-
rhea occurs in the absence of discrete pathophysiology and secondary dysmenor-
rhea occurs in the presence of discrete pathophysiology, including uterine
fibromyomas and endometriosis. Now that primary dysmenorrhea is known
to be caused by an excess of prostaglandins in the endometrial tissue and is
treatable with prostaglandin synthetase inhibitors, it should no longer be con-
sidered a manifestation of neurosis or dismissed as just part of being a wom-
an or just a symptom of premenstrual syndrome.
Medical Disorders
The frequency or intensity of symptoms of a number of medical disorders
vary by menstrual cycle phase, including lupus erythematosus, acute inter-
mittent porphyria, herpes genitalis, pneumothorax, and others (M. Jensvold
and G. V. Foster, unpublished manuscript, 1984). Among women with mi-
graines, 10%70% have migraines occurring regularly during or just before
menses (Digre and Damasio 1987; Lokken et al. 1997). In a study of asthma,
35% of reproductive-age women with asthma reported that their asthma
symptoms worsened just before or at the time of menses. Daily spirometry
only confirmed significant deterioration in airway resistance at the time of
menses in the group who reported an association of symptoms to the men-
strual cycle (Hanley 1981).
Psychiatric Disorders
What evidence indicates that psychiatric disorders vary with the menstrual
cycle? A few studies have begun to address this question.
Bulimia. In two prospective studies of bingeing behavior in bulimic wom-

en, one study found a modest but statistically significant premenstrual exac-
erbation of binge eating, without an increase in depression (Gladis and Walsh
1987). One prospective study found a significantly increased frequency of
binge episodes in the luteal phase (Price et al. 1987). A third study analyzing
the clinical similarities of PMDD and bulimia found a comorbidity of 16.6%
for PMDD and bulimia and only a 2.3% comorbidity for women not affected
by PMDD. The researchers also found a common personality dimension,
harm avoidance, to be more frequent in women with PMDD and bulimia
suggesting that similarities exist between the two disorders (Verri et al. 1997).
A report of two patients contrasted one whose bulimic bingeing increased reg-
ularly premenstrually and one whose bulimic bingeing showed no association
to the menstrual cycle (McDaniel 1989).
Panic disorder. In three studies of panic disorder, 40%90% of the wom-

en studied retrospectively reported worsening of panic or anxiety premen-
strually. Using prospective ratings, two of the studies found no evidence of
menstrual cyclerelated changes in panic (Cook et al. 1990; Stein et al. 1989),
but the third found significant worsening in intensity of full situation panic
attacks, with other parameters not showing significant variation. The authors
concluded that actual fluctuations in anxiety symptoms across the menstrual
cycle were rather small (Cameron et al. 1988). Yonkerss (1997a) analysis of
PMDD and panic concluded that women with premenstrual syndrome expe-
rienced increased occurrence of panic attacks and that biological mecha-
nisms or vulnerabilities are shared in women with panic and women with
PMDD (p. 62)
Affective disorders. A great deal of evidence links affective symptoms

and the menstrual cycle. Overlap exists among symptoms reported by wom-
en with PMDD and those reported by women with other affective disorders
(Yonkers 1997b). Prevalence rates for premenstrual depression were found to
be 65% by several groups examining prevalence in patients with current or
lifetime diagnoses of affective disorder. In patients complaining of premen-
strual depression, 39% exhibited depression through daily ratings and 36%
showed intermittent depression throughout the cycle (McMillan and Pihl
1987). Patients who pursued treatment for premenstrual depression were

found to be at high risk for suicide attempts because of the increased severity
and intensity of symptoms (Stout et al. 1986). Additionally, one recent study
of 113 women found a correlation between premenstrual suicide attempts
and a history of previous psychiatric illness (Baca et al. 1998). Lifetime diag-
noses of major depressive disorder were found to have prevalence rates of
57%100% among women in five different samples who suffered from pre-
menstrual depression. Complaints of premenstrual depression have been
found to have predictive value in terms of future depression (Graze et al.
1990). Halbreich (1997) has suggested that premenstrual syndrome symp-
toms constitute an expression of vulnerability traits (p. 20) that may also
indicate traits for depression or anxiety.
Data suggest a susceptibility to psychopathologic cycling among women.
Most people with rapid cycling bipolar disorder are women (Wehr et al.
1988). The same is true of those with seasonal affective disorder. However,
the mood disorders of only a few of these women cycle in relation to the men-
strual cycle (Conrad and Hamilton 1986; Kukopulos et al. 1985; Wehr et al.
1988). The reasons for womens increased susceptibility to cyclic disorders
are not known, and the mechanisms of the interrelationships between mood
and cycling are not well understood.
Posttraumatic stress disorder and dissociative disorders. S o m e e v i -

dence exists of a menstrual cyclerelated pattern in posttraumatic symptoms
and dissociative disorders in some women who present complaining of pre-
menstrual syndrome (Jensvold et al. 1989).
Premenstrual Syndrome and

Premenstrual Dysphoric Disorder
Two definitions of premenstrual syndrome are currently in use in the re-
search and clinical literature, a common definition and PMDD. A third def-
inition, LLPDD, was briefly in use while the disorder was listed in the
appendix to DSM-III-R. For the purposes of this chapter, we will indicate the
name used in the cited report with an understanding that LLPDD and
PMDD are very similarthe definition of PMDD includes one more symp-
tom than that of LLPDD, a subjective sense of being overwhelmed or out of
control (Severino 1996). The common definition mentioned above requires
a combination of common psychologic and physical symptoms that occur
premenstrually and are absent during the follicular phase. Commonly cited
psychologic symptoms include sadness, irritability, and tension or anxiety,
and commonly cited physical symptoms include bloating and breast tender-
ness. PMDD, in contrast, has been used to date only in some of the most re-
cent mental health literature, as would be expected, because it is a recently
available diagnosis. It emphasizes psychologic symptoms (physical symptoms
are optional), includes a severity criterion, and requires confirmation on daily
prospective ratings (see Figure 93).
FIGURE 93. Meeting diagnostic criteria by self-report and daily ratings.
Is there a unique disorder, PMDD, that can be distinguished from other

disorders? Women can be identified who report severe symptoms, including
occupational or social impairment, that occur only premenstrually; who are
confirmed to fulfill PMDD criteria on prospective ratings; and who do not
seem to have another current psychiatric illness (Steiner 1997). Recent place-
ment of PMDD in the main body of DSM-IV indicates its reliability and va-
lidity as a diagnostic category. Based on phenomenology and course, studies
support classification as a depressive mood disorder. Whether PMDD, as

conceptualized, is the optimal taxonomy continues to be explored (Halbreich
et al. 1983; Hamilton and Gallant 1990; Spitzer et al. 1989). Certainly, rigor
is needed in our categorizations so that research and treatment may be most
appropriately directed.
What is the relationship of PMDD to other psychiatric disorders? One
of the diagnostic criteria for PMDD is that the symptoms are not attributable
to another psychiatric disorder. However, in the presence of another psychi-
atric disorder, it is hard to know whether the premenstrual symptoms are at-
tributable to that psychiatric disorder. Categorization of PMDD as a mood
disorder in DSM-IV is supported by study findings of low serotonin and
melatonin metabolism as well as numerous studies reporting symptom im-
provement with selective serotonin reuptake inhibitors (Parry 1997). In one
comparison of PMDD and depression, PMDD is suggested to be an expres-
sion of traits indicating vulnerability to depression (Halbreich 1997), whereas
another study suggests that biologic cognitive studies and treatment response
factors help to differentiate PMDD from other mood disorders (Yonkers
1997B). The true nature of the relationship between concurrent PMDD and
other psychiatric disorders remains to be elucidated.
Findings in Premenstrual Syndrome Research
Prevalence of symptoms. Several studies have shown at least 75% of

women reporting at least one symptom occurring premenstrually. However,
the number of women who report that symptoms are severe or bothersome
enough to warrant treatment is much lower. Psychologic symptoms are often
reported to be the most distressing. Positive changes also occur premenstru-
ally (Stewart 1989) but are often overlooked. Two studies have examined the
prevalence of women who fulfill diagnostic criteria for LLPDD. One study,
a community-based survey with prospective ratings, found that 3.4% of
reproductive-age women reported severe symptoms (R. F. Haskett, unpub-
lished data, May 1987). In the other study, 4.6% of college-age women report-
ed severe symptoms (Rivera-Tovar and Frank 1990), suggesting that 3%5%
of women of reproductive age may meet criteria for LLPDD. A more recent
study of women with PMDD also endorsed the 3%5% figure (Gehlert and
Hartlage 1997).
Prevalence of Axis I and Axis II disorders. Only one study has ex-
amined lifetime prevalence of both Axis I and Axis II disorders in women
meeting criteria for LLPDD. Depression was found to be more prevalent in
women with LLPDD in this study than in those in the community-based Ep-
idemiologic Catchment Area study, although the prevalence of other psychi-
atric disorders was similar in both studies. Of women meeting LLPDD
criteria, 78% had a lifetime history of Axis I disorder, with prior depression
being most prevalent; 10% met criteria for Axis II disorders, with avoidant
personality being most prevalent; and 20% had current psychiatric disorders
despite attempts to exclude women with current psychiatric disorders (Pearl-
stein et al. 1990). In a study in which data were pooled from five institutions
(Hurt et al. 1992), 670 women who sought treatment for premenstrual syn-
drome were examined, of whom 39% were found to have only past psychiat-
ric disorders, 27% had a current psychiatric disorder, and 33% had no
psychiatric history. The authors concluded that LLPDD was not synony-
mous with another psychiatric disorder and that past psychiatric history in-
creased the risk of LLPDD. Present psychiatric disorder was not shown to
increase the risk of LLPDD over that observed in women with no psychiatric
history. The prevalence of LLPDD varied substantially as a function of the
four methods of analyzing daily ratings data (Hurt et al. 1992).
Hormone studies. Numerous studies have been conducted but have

shown no consistent abnormalities in peripheral hormone levels in women
with premenstrual syndrome (Rubinow et al. 1988). Some evidence exists of
a hormone axis instability (Roy-Byrne et al. 1987), and several studies have
now shown abnormalities in serotonin metabolism (Ashby et al. 1990),
whereas others have linked fluctuating serotonin-receptor concentrations
with changes in estrogen and progesterone levels (Biegon et al. 1980). Circa-
dian phase shifts may be implicated in some patients (Parry and Wehr 1987;
Parry et al. 1997). The concept of multiple cyclic change . . . occurring as a
diversified, dynamic, time-related process (Halbreich et al. 1988, p.183) is
probably more accurate than any hypothesis of unitary abnormalities in ac-
counting for the diversity of symptoms reported with premenstrual syn-
drome. One recent study found hypothalamic and pituitary hormone
differences between women with premenstrual syndrome and control sub-
jects that suggested neurobiologic vulnerability in women who experience
premenstrual syndrome symptoms (Rosenstein et al. 1996). A second study
found a decrease in premenstrual syndrome symptoms with ovarian suppres-
sion, indicating that women with premenstrual syndrome may be experienc-
ing atypical sensitivity to normal hormonal changes (Schmidt et al. 1998). In
a recent analysis of existing hormonal studies and treatment modalities, Mor-
tola (1998) suggested that premenstrual syndrome is the result of a complex
interaction between ovarian steroids and neurotransmitters (p. 256).
Methodologic and Political Issues in

Premenstrual Syndrome Research
Prospective ratings. The method used to analyze daily ratings greatly

affects the percentage of women meeting the diagnostic criteria. Currently,
daily ratings are seen as the standard for diagnosis, with negative prospective
ratings automatically taking precedence over the womans positive self-
report. Cases with discordant retrospective self-report and prospective ratings
should be examined more closely for the presence of any of a number of fac-
tors contributing to the discordance. Reasons to trust prospective ratings over
self-report are the evidence of misattributions and negative expectancies.
However, several reasons exist for not assuming that prospective ratings are
necessarily the ultimate conveyor of truth, including the possibility of inad-
vertently creating false-positives or false-negatives by setting cutoffs too low
or too high; intercycle variability; and evidence that as many men as women
fulfill diagnostic criteria for premenstrual syndrome on the basis of prospec-
tive ratings (Gallant 1991). Approaches to discordant cases should be individ-
ualized; for example, if a psychiatric disorder is present in the follicular phase,
treatment of that disorder is indicated.
Some evidence indicates that more severe cases show greater concor-
dance in self-report and daily ratings and less severe cases show greater dis-
cordance. In one well-designed study, retrospective reports of premenstrual
syndrome were predictive of future major depression even in women without
a past history of depression and without a family history of depression. Ret-
rospective reports were a better predictor in this study than daily ratings
(Graze et al. 1990).
Diagnostic options. Official psychiatric diagnostic nomenclature has

denoted a unique disorder of primarily psychologic symptoms premenstrual-
ly: PMDD. Alternatives to the current denotation are still being debated
among clinicians and practitioners. These include a psychiatric disorder with
a menstrually related or catamenial pattern (similar to the seasonal pattern
denotation in DSM-IV) or a category of hormone-related disorders in which
male disorders related to hormones could also be denoted.
Chasm between research and practice. Current research practices

automatically exclude from most premenstrual syndrome research women
whose self-report and daily ratings are discordant and women who choose
not to comply with 2 months of daily ratings. The diagnosis of PMDD, as
currently specified, diagnoses moderate caseswomen who have impairment
premenstrually but who can tolerate and are willing to complete 2 months of
ratings prior to treatment. However, clinicians are presented with cases that
run the full spectrum of severity. Thus a chasm exists between research
(which needs rigorously defined homogeneous patient populations) and clin-
ical needs (with the mandate to help all women who present for help).
Political issues. Stotland (unpublished paper, 1991) has pointed out two
main categories of risks to women from an LLPDD/PMDD diagnosis. The
first of these is the risk to all women if common, menstrually related experi-
ences are pathologized. The second risk is that of the impact of a narrowly
defined LLPDD on the majority of women who now present for treatment
of PMS who would be excluded. To say either that all women who have
menstrual cycles have a disorder or that no women who have menstrual cy-
cles have a menstrually related disorder is to minimize the subject and to fail
to listen to womens experience.
Symptoms are not synonymous with syndromes and must be distin-
guished. The media often portray as mild or moderate premenstrual syn-
drome what researchers would call normal (Chrisler and Levy 1990).
Concern that women with normal menstrual cycles and minimal or no symp-
toms will be declared to have disorders is not lessened by the fact that some
symptom rating scales still used in the field classify all women as having vary-
ing severities of premenstrual syndrome and provide no way of classifying a
woman as not having premenstrual syndrome.
No other diagnosis requires prospective ratings to confirm the patients
self-report. Mandatory compliance with daily ratings of patients with other
disorders has not been studied (Stotland 1991). The assumptions that pro-
spective ratings are always correct and that discordance between prospective
ratings and the womans retrospective self-report automatically invalidates
that self-report may be discriminatory. Hormones contribute to disorders or
symptoms in men, such as aggressivity, but do not receive attention as such.
Law. Use of premenstrual syndrome as a legal defense has succeeded in

Canada and England, but this defense has been controversial and generally
unsuccessful in the United States and barriers to its successful use seem to be
formidable (Severino and Moline 1989). Concern has been expressed that,
with its use, all women will be on trial. Numerous questions remain about the
implications if premenstrual syndrome is successfully used as a defense. For
example, what should be done with the premenstrual syndrome offender
who fails or refuses to obtain court-ordered treatment? Is there clear evidence
treatment will succeed in light of the enigmatic pathophysiology?
Treatment and the Menstrual Cycle
Chronotherapy
Chronobiology has been described as
the broad spectrum of interacting and interdigitating rhythms that all togeth-
er comprise the time structure of a living organism . . . [By learning the patterns
of] biological variations we can compare, correlate, and finally predict their
course. This development makes it necessary and possible for physicians to
concentrate more closely on the individual needs of their patients through
patient-monitoring and time-specified medications. (Haen 1988, p. 7)
Studies of the timing of melatonin release in women with PMDD have re-
vealed that nocturnal melatonin concentrations are lower in women with
PMDD compared with those in control subjects (Parry 1997). Parry (1997)
suggests that changing sleep cycles and using light therapy can alter melato-
nin circadian rhythms, thus effecting mood changes.
The issue of chronotherapy, or timing therapy, has received much less
attention in psychiatry than it deserves. The question arises that if symptoms
occur during certain menstrual cycle phases for a particular woman, when
should treatment be administered? Should it be administered constantly
(throughout the menstrual cycle), periodically (recurrently, e.g., premenstru-
ally only), or at varying times (e.g., with increased dosages premenstrually)?
The question also arises whether fluctuations in symptoms are caused by
physiologic variables (which would occur in any woman with a normal men-
strual cycle), pathologic variables (which would occur only in persons with
the disorder), or as an interactive process between the two. If the latter, what
is the nature of this interaction?
Lithium treatment illustrates these concepts well. Individual cases docu-
ment that for some women with bipolar illness, mood symptoms and lithium
levels vary according to menstrual cycle phase. One womans bipolar illness
was in good control when she was receiving a constant dose of lithium except
for a premenstrual recurrence of symptoms, at which time her serum lithium
levels dropped premenstrually. When her lithium dosage was increased pre-
menstrually, her serum levels remained constant with good control of symp-
toms (Conrad and Hamilton 1986). In another case, a woman with bipolar
illness had regular recurrence of hypomania earlier in the cycle, depression
later in the cycle, and symptomatic relief with onset of menses. Her lithium
levels were lowest when she was hypomanic, highest when she was de-
pressed, and intermediate with euthymic mood (Kukopulos et al. 1985).

Do physiologic factors account for these changes in lithium levels? A
study of lithium levels in regularly menstruating women found that serum
lithium levels following administration of a single dose of lithium were iden-
tical regardless of the phase of the menstrual cycle and regardless of whether
the women were receiving oral contraceptive medication (Chamberlain et al.
1990). This finding indicates that physiologic factors in the normal menstrual
cycle do not account for menstrual cyclerelated changes in lithium levels and
that these changes are probably more related to changes in pathology (i.e.,
manic or depressive, rather than luteal or follicular). In a study of 54 persons
with rapid cycling bipolar illness, 92% were women, but none was found to
switch moods in relation to the menstrual cycle, highlighting the fact that not
all women with bipolar illness cycle in relation to the menstrual cycle (Wehr
et al. 1988). Also, Hatotani et al. (1983) found an association between mood
and the menstrual cycle in bipolar patients but found that mood was some-
times slightly out of synchronization with the menstrual cycle. This raises the
question of how mood and the menstrual cycle are really associated. Why
does bipolar illness entrain to the menstrual cycle in some regularly menstru-
ating women but not all? What accounts for cycling that moves in and out of
synchronization with the menstrual cycle? What is the role of oral contracep-
tive medication in entraining pathology to the menstrual cycle or in freeing it
from entrainment? The data raise as many questions as they answer.
Interaction Between Endogenous Hormones and

Psychotropic Medications
Women take more medications, including more psychotropic medications,

than do men, but even when corrected for the number of medications taken,
women have more adverse effects to medications than do men. Almost cer-
tainly one of the contributing factors to this is a lack of attention to the men-
strual cycle. By not taking the menstrual cycle into account, the clinician risks
either overtreating or undertreating the patient. If the phase of the menstrual
cycle is not considered, cycle-dependent symptoms may be misinterpreted as
side effects or ineffectiveness of the medication.
Clinically significant side effects in relation to gender or hormone levels
are known for mood stabilizers (lithium), antidopaminergic and antipsychotic
drugs, anticonvulsants (e.g., phenytoin), some benzodiazepines (e.g., diaz-
epam), propranolol, and alcohol (Hamilton 1991). One patients premenstru-
al depression was documented to require a varying dose of antidepressant
medication throughout the cycle. She tolerated a constant low dose of tricy-
clic antidepressant well but this dose was only partially effective. A constant
higher dose was effective for premenstrual symptoms, but was not tolerated
in the follicular phase. Finally, a varying dosage of tricyclic antidepressant,
with higher dosage premenstrually, was both effective and well tolerated
(Jensvold et al. 1992). One study of the effects of benzodiazepines over the
menstrual cycle in women with premenstrual syndrome found a decreased
sensitivity at the -aminobutyric acid/benzodiazepine-receptor complex, indi-
cating a decreased treatment effectiveness that was especially marked during
the third week of the menstrual cycle (Sundstrom et al. 1997). Women with
catamenial epilepsy had a marked decrease in phenytoin during menses com-
pared with control subjects and with women with noncatamenial epilepsy.
Recurrent premenstrual failure of migraine prophylaxis was associated with
lower steady-state serum levels of propranolol during menses. Some drugs do
not show clearly significant menstrual cycle effects, including salicylates, ami-
nopyrine, nitrazepam, and paracetamol. Without systematic monitoring of
drughormone interactions, the drug differences that have come to our atten-
tion can be considered to be the tip of the iceberg. Future studies will find
that some drugs do not show any substantial menstrual cyclerelated effects,
but we do not yet know which drugs those are.
When menstrual cyclerelated effects have been found, they often occur
in subgroups of women (e.g., those receiving lithium or phenytoin), with re-
ported effects generally tending toward increased clearance premenstrually
(Hamilton 1991). Sex steroid hormones can have differential effects on partial
pathways for various metabolites. Competition between drugs and hormones
for the same metabolic sites may account for some of the differences in met-
abolic rates (Hamilton 1991) in women as compared with men or over time.
Interindividual differences in the use of alternative metabolic pathways or in
the levels of or sensitivity to endogenous sex steroid hormones may explain
why only some women experience menstrual cyclerelated effects (Hamilton
1991).
Interaction Between Exogenous Hormones and

Psychotropic Medications
Oral Contraceptives
In a review of interactions between oral contraceptives and other medica-
tions, Teichmann (1990) concluded that medications showing clinically sig-
nificant interactions included antidepressant medications, antihypertensives,

insulin, synthetic glucocorticoids, theophylline, and caffeine. The Medical
Drug Reference (Ellsworth et al. 1997) lists clinically significant interactions be-
tween oral contraceptives or estrogens and 16 medication classifications. Oral
contraceptives tend to increase clearance of drugs metabolized by glucu-
ronidation (e.g., some benzodiazepines) and decrease clearance of drugs me-
tabolized by oxidative pathways, including the P450 cytochrome oxidase
system (e.g., imipramine, diazepam, caffeine, and chlordiazepoxide).
Of women of reproductive age in the United States, 27% receive oral con-
traceptive medication, which means that a number of women presenting to
psychiatrists are using or will use chemical contraceptive agents (Hatcher et
al. 1994). Psychiatric side effects of oral contraceptives were more frequent in
older, higher-dosage preparations, but mood effects have been observed in
the lower-dose preparations and we have observed these low-dose oral con-
traceptive mood effects to be responsive to antidepressant medication. Oral
contraceptives may entrain psychopathology to the menstrual cycle in some
cases or free symptoms from entrainment to the menstrual cycle in others. In
one large study, 276 oral contraceptive users were compared with 276 non-
users. Research indicated that oral contraceptive users experienced longer
patterns of perimenstrual negative mood than did nonusers (Bancroft and
Rennie 1993). In some cases, a woman may need to stop hormonal therapy
in order to know what role the oral contraceptive is playing in her symptoms,
whether exacerbating them, ameliorating them, or having no effect at all.
Contraceptive medications now available to women in the United States
include combination medication (estrogen and progestogen for 21 days fol-
lowed by a hormone-free week, the most commonly used preparations); se-
quential medication, including triphasic pills (varying dosages of hormone
sequentially, also commonly used); mini-dose progesterone (daily oral mi-
cronized progesterone, which has fewer side effects but is less commonly used
because of its slightly decreased effectiveness as a contraceptive agent); long-
acting subcutaneous progesterone injection (DepoProvera); and long-acting
subcutaneous progesterone implant (Norplant). Other long-acting progester-
one derivatives and chemical contraceptive agents are being tested and used
in Europe, Scandinavia, and elsewhere (Hatcher et al. 1994).
Postmenopausal Hormone Replacement Therapy

In a survey study, 32% of postmenopausal women were found to use hor-
mone replacement therapy (HRT) (Harris et al. 1990). HRT differs from oral
contraceptives in that it uses natural conjugated estrogens that do not affect
the cytochrome P450 oxidase system, whereas oral contraceptives use syn-
thetic estrogens (e.g., ethinyl estradiol) that do affect that system. Also, the
dosages of hormones are about 1.12.5 times higher in oral contraceptives
than in HRT.
Hormone replacement therapy can cause mood effects, with progester-
one thought to be responsible for recurrent dysphoric moods associated with
HRT (Magos et al. 1986); however, estrogen has been shown to trigger rapid
mood cycling in vulnerable women (Oppenheim 1984). Consequently, wom-
en with histories of affective disorders should be monitored closely for mood
effects when HRT is started.
Postmenopausal hormone therapy is known to cause symptoms similar
to those of premenstrual syndrome in some women (Magos et al. 1986), in
effect, an iatrogenic premenstrual syndrome. This leads some women to
present to psychiatrists for treatment of new-onset or recurrent premenstrual-
like symptoms or mood symptoms. We have found that symptoms can be
minimized by decreasing the hormone dose or changing the timing, for ex-
ample, changing the 10-day interval of progestogen from once monthly to
once every 3 months. If these interventions do not provide sufficient relief,
then stopping HRT or adding a psychotropic agent should be considered.
Gonadotropin-Releasing Hormone Agonists

Potent agonists bind powerfully to GnRH receptors at the level of the pitu-
itary, thus blocking the pulsatile action of GnRH. After transiently increasing
release of luteinizing hormone and follicle-stimulating hormone from the pi-
tuitary, GnRH agonists then paradoxically block the pituitarys normal re-
sponse to GnRH, thus effecting a chemical oophorectomy. This therapy
must be used with extreme caution. Use of GnRH for endometriosis and oth-
er conditions is growing. Three forms of GnRH agonists are now available:
intramuscular, intranasal, and depot GnRH. The forms vary with respect to
ease of administration and in how much control one has over the adminis-
tered dose. Estrogen deficiencyrelated symptoms, including hot flashes and
osteoporosis, are considerations.
GnRH agonists have been reported to help severe premenstrual symp-
toms, although some women experience transient worsening during the first
month of treatment. One womans first hypomanic episode was precipitated
by GnRH; some womens mood disorders, previously linked to the menstru-
al cycle, have become unlinked from cycle on GnRH. A recent study at the
National Institute of Mental Health concluded that GnRH administration
successfully improved the symptoms of premenstrual syndrome. Symptoms
recurred with administration of estradiol and progesterone, indicating that

the interruption of the bodys natural hormonal changes can improve pre-
menstrual syndrome symptoms (Schmidt et al. 1998).
Gynecologic versus Psychotropic Medications

for the Treatment of Premenstrual Symptoms
Because the hypothalamicpituitaryovarian axis is an interconnected feed-

back loop, interventions at different levels of the feedback loop may, at least
theoretically, affect a particular targeted menstrually related symptom.
Gynecologic Treatments
Several methods that prevent ovulation have been tried for the relief of pre-
menstrual syndrome. Surgical ovariectomy (Casson et al. 1990) and chemical
ovariectomy using GnRH (Hammarback and Backstrom 1988; Schmidt et al.
1998) appear to provide lasting relief of severe premenstrual psychologic and
physical symptoms, although their use is inappropriate for most patients with
premenstrual syndrome and requires psychiatric screening and long-term
follow-up studies. Hysterectomy without ovariectomy provides more variable
results, as would be expected, because it removes mensesthe external time
cuebut the hormonal cycle remains intact. Danazol, an androgenic agent, in-
hibits ovulation and provides relief for some premenstrual symptoms, par-
ticularly mastalgia, but appears to cause or exacerbate depression and
irritability in some patients. Oral contraceptives appear to worsen premen-
strual syndrome in some women, have no effect on others, and perhaps ame-
liorate symptoms in others.
Progesterone as a treatment for premenstrual syndrome is now essential-
ly disproven; numerous double-blind, controlled studies have failed to show
its superiority over placebo (Hurt et al. 1992) and a progesterone antagonist
study disproved the hypothesis that luteal-phase progesterone plays a role in
causing catamenial mood symptoms (Schmidt et al. 1991).
Psychotropic Agents
A study of fluoxetine treatment for LLPDD found that premenstrual physical
symptoms as well as psychologic symptoms were helped by fluoxetine (Stone
et al. 1991). Further studies of serotonin reuptake inhibitors such as fluoxet-
ine and sertraline have indicated that both symptomatic and functional im-
pairment decrease with treatment (Yonkers et al. 1997). Other studies have
shown efficacy of both alprazolam and desipramine treatment over placebo

for LLPDD/PMDD.
Nonbiologic Treatments of Menstrually Related Symptoms
Dynamic issues regarding the menstrual cycle and what it means to the indi-
vidual woman are important in some cases. Menstrual cyclicity can have an
indirect impact on psychotherapy as well, with some psychotherapeutic work
being more possible, more necessary, or more or less effective during certain
phases. One example is the woman with state-dependent, recurrent premen-
strual flashbacks of earlier trauma (Jensvold et al. 1989). If expectancies or
misattributions are thought to play a significant role with a particular patient,
then cognitive therapy techniques, interpersonal therapy, or feminist therapy,
which examines the woman in her environmental context (including societal
influences) rather than narrowly focusing on intrapsychic factors, may be
helpful. Support groups may also play a useful role in treatment because
group members recognize dysfunctional behavioral or emotional patterns or
expectancies and develop increased insight and confidence and improved
coping.
Conclusion
It seems now that Frank was forward looking in 1931 in distinguishing

among women with a unique psychologic disorder occurring premenstrually,
women with mild symptoms, and women whose systemic illnesses varied
with the menstrual cycle. Excessive lumping together of disorders over sub-
sequent decades has caused confusion among researchers, clinicians, patients,
and the public. State-of-the-art research is now sorting out various threads
and addressing questions implied by Franks clinical observation: Is there va-
lidity to a single diagnostic category describing psychologic symptoms occur-
ring only premenstrually? Do other psychiatric disorders vary with the
menstrual cycle? How can one address real problems without stigmatizing
women and without playing into the already excessively negative views of the
menstrual cycle and of women? What are the roles of gynecologic agents and
of psychotropic agents in treating psychiatric disorders related to the men-
strual cycle? Psychiatric symptoms and the menstrual cycle represent a con-
fluence in which mindbody issues can be addressed in interesting and
important ways, with the potential for much to be learned about chronobiol-
ogy, brainendocrine interactions, and cultural overlay as well as the promise

of improving the health of women patients.
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10
Infertility and the New
Reproductive Technologies
JENNIFER I. DOWNEY, M.D.
I nfertility, defined as 1 year or more of unprotected coitus without pregnancy,

is a common health problem. Medical authorities such as Speroff et al. (1994)
estimated that 10%15% of couples in the reproductive age group are affected
by infertility. The only population-based survey of infertility in women, the
National Survey of Family Growth, found in 1988 that the proportion of those
who were infertile was 18% among childless couples in which the wife was
1544 years of age (Mosher and Pratt 1990). The demand for infertility treat-
ment is growing because of postponed childbearing, increases in the proportion
of infertile couples seeking care, the shrinking supply of adoptable infants,
new techniques for treating infertile couples, and heightened public awareness
of these treatments. In the past, most infertility problems were attributed to
women; in reality, 40%50% of cases are wholly or in part due to a male factor
(Jaffe and Jewelewicz 1991).
Psychologic Effects of and Adjustment to Infertility
Menning (1980) proposed that infertility investigation and treatment bring

on a life crisis because infertility poses a threat that is not solvable in the im-
mediate future and that may tax the couples existing problem-solving re-
sources, threaten their achievement of important life goals, and awaken
unresolved key difficulties from the past. She has described a series of feelings
experienced by many couples, from surprise to denial, anger, isolation, guilt,
205
and grief, followed by resolution if the feelings are worked through and over-
come. Some couples may fail to resolve the problem and continue to seek new
treatments, even after every potentially beneficial method has been tried.
This model of infertility as a life crisis for many couples is helpful because it
enables the clinician to think about the problem without pathologizing it and
to organize data by phase in the process of resolving the problem.
The impact of infertility on marriage appears to vary greatly. It is un-
known at present which couples are at risk for marital difficulties when facing
involuntary childlessness. Cook et al. (1989) found that 71% of women par-
ticipants reported that infertility had affected their marriage, but among those
affected, the proportion of women who felt this impact to be positive was sim-
ilar to the proportion who felt it it be negative. In some cases, the shared stress
of infertility may strengthen a couples bond. Medical diagnosis and phase of
treatment may also affect the likelihood of harmful marital effects. For exam-
ple, Connolly et al. (1987) found that marital difficulties were more likely if
the cause of infertility was a male factor and that longer duration of treatment
was associated with decreased emotional well-being of the couple.
When infertility affects a marriage, a key area that often deteriorates is
sexual functioning and enjoyment. Negative effects on the sex life of couples
have been widely reported, including impotence, anorgasmia, and lessened
sexual desire (Berger 1980; Keye 1984; Lalos et al. 1985). Up to 10% of cases
of infertility may be partially or completely explained by sexual dysfunctions
of the man, such as premature ejaculation and impotence (Seibel and Taymor
1982). Among both women and men, planned intercourse for medical tests,
such as the postcoital examination of cervical mucus, has been found to have
an adverse impact on sexual functioning (DeVries et al. 1984; Drake and
Grunert 1979).
Most investigators have found that women tend to be more distressed by
infertility than are their male partners. Keye et al. (1981) reported that 57%
of women but only 12% of men thought that infertility was the worst thing
they had ever had to face in life. McEwan et al. (1987) found that 40% of
women but only 13% of men evinced psychologic symptoms of clinical sever-
ity and that the women who were most disturbed were younger patients with-
out a clear diagnosis of the infertility problem.
This difference in the level of reported distress between men and women
is found throughout the phases of infertility evaluation and treatment. Wright
et al. (1991) found that at the time of a couples visit to an infertility clinic,
women had significantly more overall psychiatric symptoms, depression,
anxiety, and hostility and reported more stress and less self-esteem than did
Infertility and the New Reproductive Technologies 207
men. Assessing men and women after the failure of a first episode of in vitro
fertilization (IVF) treatmentthe other end of the spectrum usually reached
after years of unsuccessful treatmentNewton et al. (1990) reported that 25%
of women experienced mild or more serious depressions, as defined by scores
on the Beck Depression Inventory (Beck 1978) of 1018 for mild depression
and scores of greater than 18 for serious depression. Only 10% of male par-
ticipants were depressed, and most of these were only mildly so.
Effects on the infertile couples family and social relationships can be pro-
found. The couples parents are often eager for grandchildren and apply spo-
ken or unspoken pressure on their grown offspring to reproduce. Cultural
and religious affiliations that place a high value on bearing children may in-
crease the infertile couples sense of failure and public embarrassment. Sib-
lings and friends who have already conceived and borne children may be
avoided because exposure to them exacerbates the infertile couples sadness
or because they are objects of envy. Because fertility is inevitably linked to
sexual function, affected couples may feel embarrassed to reveal their prob-
lem or to have others allude to it. A frequent result is social isolation as the
couple begins to avoid family gatherings at which their childless state may be
mentioned and other social events at which pregnant women and small chil-
dren may be present.
The financial burden of infertility can be considerable. Because of the
ambiguous status of infertility as a medical problem, government-sponsored
medical insurance programs such as Medicaid usually do not cover infertility
treatment. Private insurance may reimburse only part of it; for example, treat-
ments with IVFwhich currently cost between $8,000 and $12,000 per cycle
in the United Statesare usually not covered. Adoption is also expensive: le-
gal and other fees often average above $20,000 and may be considerably
more if the adoption is privately arranged. As a result, infertility treatment is
usually available only to couples of at least middle-class financial status, and
couples undergoing treatment may make significant financial sacrifices such
as foregoing vacations and using the money they had saved for a down pay-
ment on a house.
Months and sometimes years of infertility treatments affect patients
views of reality in sometimes subtle ways. Commonly, couples may become
so focused on pregnancy as the concrete solution to their dilemma that they
develop the attitude that all their life problems will be resolved if pregnancy
occurs. Such patients can be particularly resistant to psychiatric interventions
when needed because they believe that pregnancy is the only treatment nec-
essary for whatever is bothering them.
Studies on the psychologic sequelae of successful fertility treatment are

limited, but clearly the consequences can be deleterious. Pregnancy may be
unexpectedly uncomfortable and fraught with excessive anxiety (Shapiro
1986). Parenthood may not have been anticipated in a realistic way. Use of
the new reproductive technologies is associated with an increased incidence
of multiple births, which carry their own risks of physical and psychologic
morbidity (Attia and Downey 1992). These pregnancies are often complicat-
ed, with treatment requiring months of bed rest. Once the babies are born,
the parents find that having more than one infant to care for can be physical-
ly, emotionally, and financially overwhelming. Garel et al. (1997), in a follow-
up study of mothers with triplets, found that at 4 years after delivery all of
the mothers were distressed and fatigued and that a significant minority re-
gretted having triplets, were depressed, and were taking antidepressants.
Furthermore, it is unclear whether offspring conceived via infertility
treatment grow up unharmed. The secrecy surrounding techniques such as
artificial insemination by donor and the uncertainty about parentage that af-
fects all involved parties when gametes are anonymously donated constitute
risks to a happy childhood and family life (Sokoloff 1987). A small Australian
study (Kovacs et al. 1993) of children aged 68 years who were conceived by
donor insemination showed no abnormal findings on the Child Behavior
Checklist (Achenbach 1978; Achenbach and Edelbrock 1983), but little other
research has been done. More detailed and extensive studies on the psycho-
logic well-being of children conceived using the new reproductive technolo-
gies are desperately needed.
Specific Infertility Interventions and

Their Psychologic Effects
Infertility evaluation usually begins with a history taken from the couple, a
physical examination of the female partner, and a few basic studies. These in-
clude a basal body temperature chart kept by the woman for 12 months: the
temperature is taken each morning before the woman rises and is charted on
a graph; days on which intercourse occurs are also noted. The rationale for
this study is that a rise in temperature signals the time of the surge of lutein-
izing hormone and ovulation, thus indicating the beginning of the womans
fertile period. Other early studies almost invariably include a postcoital ex-
amination or a sperm count. For the postcoital examination, a sample of cer-
vical mucus, usually collected within 8 hours of the last intercourse, is
assessed for its receptivity and for the number of sperm per high-power field
that are present and moving. Semen specimens may also be examined to as-
sess the number of motile sperm and the percentage of those sperm that has
normal morphology.
These early studies may be repeated numerous times in the course of in-
fertility evaluation and treatment, and although simple both in concept and
execution, they are associated with psychologic morbidity. The need to take
and chart ones temperature daily is a constantly repeated reminder of the
couples failure to conceive and leads in many cases to a loss of spontaneity
and enjoyment in sexual intercourse, the timing of which is determined by
fertile days on the chart. The postcoital examination also requires sched-
uled sexual activity and has the additional drawback of symbolically inviting
a third person (the physician and/or laboratory technician) as an observer to
the sexual act. Under these conditions, the incidence of both female anorgas-
mia and male impotence increases. Semen specimens usually must be studied
within hours after collection, and production of semen by masturbation in a
bathroom at the medical facility near the laboratory is often suggested. Under
these conditions of intense performance anxiety, a significant number of men
have difficulty obtaining the specimen, and the infertility evaluation becomes
acutely embarrassing.
The female partners failure to ovulate regularly is a relatively common
cause of infertility, occurring in 40% of the cases in which the infertility is
attributable to the woman. Treatment consists of one of several hormonal reg-
imens. If the woman does not have ovarian failure (i.e., if she has not already
undergone menopause, in which case no hormonal therapy will work), clomi-
phene, a nonsteroidal drug that blocks estrogen receptors, is usually the first
drug used. The psychiatric side effects of this drug include nervousness, in-
somnia, and depression. Human menopausal gonadotropin preparations by
daily injection are often used if clomiphene is ineffective. This treatment is ex-
pensive, however, costing several thousand dollars per cycle for the drug
alone, and is associated with multiple ovulation: 30% or more of pregnancies
achieved with the drug are multiple, and three or more fetuses are present in
5% of these cases. Ovarian hyperstimulation syndrome is a potentially life-
threatening complication of treatment with human menopausal gonadotro-
pins, and close monitoring by a knowledgeable physician is essential. As with
clomiphene, ovulation and conception may not occur during the first cycle, in
which case repeated cycles become necessary. In some cases, bromocriptine or
gonadotropin-releasing hormone administered intravenously with a pump
may be used to induce ovulation. (See the latest edition of Speroff et al.s [1994]
Clinical Gynecologic Endocrinology and Infertility for additional information.)

To date, virtually no published reports exist that describe the psychiatric
side effects of ovulation-inducing agents. The astute clinician will recognize,
however, that hormonal treatments affecting the pituitary axis have the po-
tential for effects on mood and thinking. Furthermore, the associated stresses
are significant; these regimens of medication must be taken month after
month despite multiple physical side effects, require close medical monitor-
ing, are very expensive, require scheduled intercourse, have health risks, and
may produce a multiple pregnancy if conception occurs. Thus, in the usual
clinical situation, the couple will show signs of psychiatric distress, but the po-
tential contributing factors to blame will not be immediately evident.
If the female partner has normal cervical mucus and appears to ovulate,
and the male partner has normal sperm count and morphology, a hysterosal-
pingogram (radiographic examination of the female reproductive tract using
radiopaque dye) and/or laparoscopy (direct visualization of the female repro-
ductive organs performed under anesthesia during which a laparoscope is in-
serted through a small incision) may be performed to establish whether any
anatomic abnormalities exist that might hinder the successful movement of
an ovum through the fallopian tubes to the uterus. Such abnormalities in-
clude adhesions from previous pelvic surgery or infections, endometriosis
from implants of the uterine lining that have seeded elsewhere in the repro-
ductive tract, and congenital anomalies such as a bicornuate uterus. Obstruc-
tion of the fallopian tubes is a common factor in female infertility (30%50%
of cases). Thin adhesions and implants from endometriosis may be removed
using the laparoscope. In other cases, hormonal therapy to shrink endometri-
al implants or surgery to restore the patency of the tubes (tuboplasty) may be
attempted. Hormones used to suppress endometriosis include estrogen-
progestin combinations (birth control pills) given continuously, medroxy-
progesterone acetate, and danazol, an androgenic compound derived from
the steroid 17 ethinyltestosterone. All of these compounds may cause
symptoms of depression or emotional lability. The success of tuboplasty,
which may require microsurgical techniques, is variable depending largely on
the preoperative condition of the tubes, and it cannot be relied on to produce
a successful pregnancy.
About 5% of cases of infertility are attributed to cervical factors after a
series of poor postcoital tests. This type of infertility is sometimes caused by
excessively thick cervical mucus, which can be modified by treatment with
low-dose estrogen or circumvented by the intrauterine insemination of sperm.
In other cases, sperm allergy, on the part of either the male or the female
partner, may be suspected. Interventions have included corticosteroid thera-

py, use of condoms for periods of time to reduce exposure to semen, and in-
trauterine inseminations of washed sperm. All have been of equivocal benefit
so far. A major contributing factor when postcoital tests are poor is often poor
coital technique. A careful sexual history may reveal an impotence problem
and that vaginal intercourse may not occur or that the couple is using vaginal
lubricants, which may have a spermicidal effect.
Among the assisted reproductive technologies (ART) are IVF and ga-
mete intrafallopian transfer (GIFT), interventions that are generally used af-
ter years of unsuccessful infertility treatment. With IVF, the woman is usually
treated with ovulation-enhancing drugs and undergoes laparoscopy for the
retrieval of eggs. The retrieved eggs are cultured, fertilized in vitro with the
mans sperm, and implanted in the uterus. GIFT is a similar technique, ex-
cept that fertilization takes place in the fallopian tube, into which follicles and
sperm have been placed. In zygote intrafallopian transfer (ZIFT) the fertilized
egg is returned to the tube. Such treatment is intense and expensive and suc-
cess is uncertain. For years, pregnancy rates from a single cycle of IVF have
hovered around 15%; a single cycle of GIFT yielded a viable pregnancy
about 25% of the time (Society for Assisted Reproductive Technology and the
American Fertility Society 1991). Technical advances are beginning to im-
prove these odds, however.
Couples who conceive are at high risk of having a multifetal gestation,
with its attendant increases in medical risks, rate of pregnancy loss, expense,
and difficulties of simultaneously raising more than one child. Couples who
fail to conceive after spending years and large amounts of money in a go-for-
broke situation are at risk for significant psychologic sequelae. For instance,
Newton et al. (1990) reported that both men and women experienced in-
creased depressive and anxiety symptoms and depressive disorders after un-
successful IVF treatment and that childless women were at particular risk.
The new reproductive technologies acquire an increased degree of psy-
chologic risk when the gametes (sperm or eggs) are donated or a surrogate is
involved to carry the pregnancy. Donor insemination (called artificial insem-
ination by donor) is actually not new and is medically very simple to perform.
It is also highly successful in producing pregnancy when the female partners
fertility is intact but the male partner has a low sperm count (oligospermia)
or no viable sperm (azoospermia). Egg donation is a much newer and more
elaborate procedure and involves locating an anonymous donor or a cooper-
ative friend or relative. The donor and the infertile woman are then treated
with medications to synchronize their cycles. At the appropriate time, the
eggs are removed from the donor using a laparascope, and an IVF or GIFT
procedure is used to fertilize the egg with the male partners sperm. The in-
fertile woman then carries the pregnancy. In cases where the infertile woman
has sufficient eggs but for some reason cannot carry a pregnancy, a reverse of
this procedure may be employed and a gestational surrogate may be found to
lend her uterus for the duration of the pregnancy. In another variation, do-
nor insemination is used to impregnate the surrogate, who then both contrib-
utes the egg and carries the pregnancy to delivery.
Oocyte donation was originally used in women of childbearing age who
had experienced premature ovarian failure. More recently, it has been em-
ployed to impregnate women over 50 years of age who are postmenopausal
(Sauer et al. 1995). This is an example of how infertility technology may out-
strip an understanding of its consequences. We know that pregnancy for
women past menopause has more physical hazards such as hypertension and
gestational diabetes (Flamigni and Borini 1995), but the psychologic and so-
cial risks to the offspring conceived and to the couple (especially if both mem-
bers are old) are not well understood (Ethics Committee of the American
Society for Reproductive Medicine 1997).
After many years, during which treatments for male infertility remained
scant, a new technique has recently become available. This procedure, intra-
cytoplasmic sperm injection (ICSI), employs an IVF procedure in which eggs
removed from the female partner under laparascopic visualization are inject-
ed with carefully selected sperm. The sperm is delivered inside the cell mem-
brane, thus enhancing chances of successful fertilization. An early report
comparing couples who chose ICSI with those who chose donor insemina-
tion showed that couples employing ICSI did so because the technique al-
lowed them to conceive a child who is biologically theirs, whereas couples
choosing donor insemination did so because they could not afford IVF (Scho-
ver et al. 1996). This is another example of how economic factors play a ma-
jor role in determining what kind of infertility treatment couples receive.
Berger (1980) has reported on the severe stress couples experience when
the male partner is diagnosed as azoospermic or severely oligospermic. Of the
men studied, 60% developed transient impotence, and their wives reported a
high frequency of rageful dreams and fantasies of leaving the infertile partner.
Donor insemination is so medically simple to perform that couples may pro-
ceed with it before fully exploring their feelings about incorporating a (usual-
ly) unknown mans genetic heritage into their relationship. In addition to the
couples shame at their deficiency, legal and religious ambiguity about the sta-
tus of the procedure may induce the couple to try to keep it secret. Total se-
crecy is a burden to maintain, however, and in the heat of some family crisis,
the fact of the insemination is likely to be blurted out in a harmful way
(Sokoloff 1987), especially when couples who plan to keep donor insemina-
tion secret from the offspring confide in family and friends, as a significant
percentage do. For instance, Amuzu et al. (1990) reported that 50% of couples
conceiving through donor insemination had told at least one person in their
social circle. Knowledge of ones genetic parentage is increasingly being seen
in the United States as the birthright of every adult individual, a situation that
complicates the task of maintaining secrecy.
On the other hand, when the donor of the gametes is known (which is
much more likely if the donor is female), other complicating factors arise: the
infertile couples ongoing relationship with the donor, the donors feeling of
emotional proprietorship, and the possibility that the offspring may have
multiple parents to deal with. Additionally, when the woman who carries
the pregnancy will not keep the baby, she may encounter unforeseen difficul-
ties in relinquishing it to the parents. This is understandable, because women
who volunteer to be surrogates are often motivated not only by financial
need, the desire to be pregnant, and the wish to give a baby to an infertile cou-
ple but also by the desire to master unresolved feelings about a previous preg-
nancy loss (Parker 1983; Schover et al. 1991).
Psychologic Treatment Issues for Infertility Patients
Numerous studies have suggested that one response to infertility treatment,

especially if unsuccessful, is depressive symptoms. An episode of depression
by DSM-IV criteria (American Psychiatric Association 1994) must of course
be distinguished from feelings of distress and discouragement that commonly
occur and do not constitute an episode of depressive disorder (Downey et al.
1989). Mood swings may occur (with or without the presence of exogenous
hormones and with or without a history of premenstrual mood symptoms)
over the course of the month as women grow hopeful or anxious during the
days before and after ovulation only to become frustrated and disappointed
with the onset of menstruation. Women may appear to have moderately se-
vere agitated depressions around the time of menses but become asymptom-
atic 2 weeks later and repeat this cycle every month.
Any complaint of depression needs careful evaluation, especially with re-
gard to severity, because in a small number of infertility patients (both male
and female) psychiatric illness may develop or be exacerbated by the stress of
the infertility workup. Some episodes will be manageable with the physicians
support and variations in the pace of infertility treatment. Others will require
psychotherapy and, in a few, the addition of psychotropic medications. At this
point, great tact on the part of the mental health practitioner is necessary (as
well as the support of the gynecologist or urologist), because infertility treat-
ment is often deferred when patients are receiving other medications and pa-
tients bent on achieving fertility may refuse any medication that would delay
their efforts to conceive.
Although few women or men undergoing infertility treatment will devel-
op a psychiatric disorder, many are so focused on achieving their goal of preg-
nancy that they will lose the ability to keep the problem in perspective with
the rest of their lives. An infertile couple may feel that time is so pressing that
even a respite of a few weeks during which they do not pursue treatment is
unacceptable. The psychiatrist may be able to help such exhausted or symp-
tomatic couples take a holiday from treatment. This is often the first interven-
tion when distress seems to be building toward dysfunction, and in some
cases it may be the only intervention needed.
It is important that the treating clinician not have preconceptions about
how the infertility problem will affect the couples relationship. Some women
are more anxious about being childless than are their partners and feel isolat-
ed as a result. Other women find that facing this life crisis with their partners
has strengthened their relationship. The emotional benefits of approaching
infertility as a shared problem suggest that when one member of an infertile
couple seeks psychologic help it is valuable for the clinician to see both part-
ners, at least as part of the initial assessment, so that the less-symptomatic
partner can be brought into the treatment as needed.
Couples undergoing infertility treatment may be under such pressure to
perform sexually in order to comply with the many requirements of the eval-
uation and treatment that they begin to develop sexual dysfunctions such as
impotence, anorgasmia, or lack of sexual desire. Frequently, the sexual symp-
toms will lessen with relatively simple interventions, such as limiting the tak-
ing of basal body temperature or taking 12 months break from treatment.
Persistent, severe sexual dysfunction needs more extensive exploration.
One of the most common problems infertility patients face has to do with
the relaxed attitude often advised by their friends and family as an aid to
enhancing fertility. It is innately stressful and not at all relaxing to be strug-
gling to reach a difficult goal such as conception. Although it may be benefi-
cial to learn relaxation techniques to enhance coping strategies, no good
evidence has yet shown that relaxation enhances fertility. Adoption, although
it may relieve the pressure to conceive, has also not been shown to enhance
fertility beyond allowing additional time during which unprotected inter-
course may lead to conception (Collins et al. 1983; Lamb and Leurgans
1979).
Couples seeking conception are prone to accept responsibility for the in-
fertility problem when it does not have to do with their behavior, for instance,
by assuming that conflicts about pregnancy may be causing their infertility.
Clinicians can be most beneficial to such patients by clarifying that stress and
conflicts do not ordinarily affect fertility, and that difficulties conceiving are
not the patients fault.
A perceived loss of control is perhaps the most common stress of infertil-
ity. For women accustomed to planning their careers and other aspects of
their lives, infertility may be experienced as their first major disappointment
and as an unjust shock. Envy of friends and family members who conceive
easily is common: Why them and not us? couples ask. Anger toward the
treating physician is also common, and one of the tasks of the mental health
professional is helping the infertility patient determine when his or her expec-
tations of the physician are unrealistic.
A central task in the clinical management of infertility patients is helping
them to achieve a sense of mastery in managing their treatment. As more and
more new reproductive technologies become available, it becomes increasing-
ly difficult for patients to decide when enough is enough (Taylor 1990).
The internal pressure to persist, no matter what the emotional and financial
cost, is intense. As Becker and Nachtigall (1994) point out, it is common in
our society for individuals to take risks by engaging in medical treatment to
avoid regret.
As they seek a clear statement from the physician on the chances of
achieving pregnancy, couples may need help from a mental health profession-
al so that they can make an informed decision. Once they have this informa-
tion, couples may need assistance in weighing the benefits and costs for
themselves in relation to the other alternatives open to them, such as adop-
tion or living without children.
The appropriate mode of psychiatric treatment, if indicated, will depend
on the couples or patients presenting symptoms, their psychiatric history,
and their characterologic strengths and deficits. Conjoint marital or sexual
therapy may be indicated, as may individual psychotherapy or briefer periods
of counseling. Support grouporiented therapies available in an infertility
clinic setting (Stewart et al. 1992) or given under the aegis of RESOLVE (the
national self-help organization for infertile couples) are appropriate when
couples are willing to seek help in a group setting and are not too anxious and
suggestible.
Speroff et al. (1994) have stated the goals of infertility treatment in their
text for gynecologists: to seek out and correct the causes of infertility, to pro-
vide accurate information, to give emotional support for the couple, and to
counsel them about the proper time to discontinue investigation and treat-
ment.
Inherent in this advice is the idea that for all of us who treat patients with
infertility problems, the goal is not to achieve pregnancy at any cost but rather
to assist couples in resolving their infertility crisis and becoming able to move
on in life. This may mean having a birth child, adopting or fostering a child
or children, or living child-free in a manner in which their creativity and urge
to contribute to the benefit of the next generation can find expression.
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11
Induced Abortion in the
United States
Introduction and Definitions
The termination of a pregnancy is a powerful act, with significant psychologic

meanings and implications arising from personal psychodynamics and expe-
rience, religion, interpersonal relationships, and biology. Induced abortion is
an act enmeshed in its social surroundings in every respect: etiology, perfor-
mance, and sequelae. Although, as elaborated in this chapter, pregnancies
have been terminated at every time in history and on every continent of the
world, the psychologic aspects of abortion are so closely culture bound that
it is not possible either to discuss it generically or to do justice to more than
one culture and its legal system. Therefore, this chapter focuses on induced
abortion in the United States, which in itself contains a wide range of atti-
tudes and practices.
Abortion is a medical intervention that evokes a great amount of feeling
in the United States. Elections for public office are won and lost on the basis
of candidates positions toward abortion funding, access, availability, accept-
able grounds, and the right of potentially concerned parties other than the
pregnant woman herself to be informed of or to consent to the procedure
(Tribe 1990). Both the intensity of feeling about abortion and the avoidance
of the subject are reflected in confusing terminology. The term abortion is used
by gynecologists to describe both induced abortion and spontaneous abor-
tion, or miscarriage. Induced is a more accurate descriptor than elective; abor-
tion is also induced in cases of fetal defects incompatible with life and of
219
medical complications threatening the life of the mother. The term abortion as
used in this chapter refers to induced abortion.
Role of Psychiatry
The psychologic causes and experience of abortion are parallel to those of the
other reproductive events discussed in this book, but with more publicity,
passion, and misperception. Psychiatrists have been involved in access to the
procedure, and organized psychiatry, as represented by the American Psychi-
atric Association (APA), has taken an official position on induced abortion.
This position, adopted in 1978 and reconfirmed in 1992 and 1995, is as fol-
lows:
The emotional consequences of unwanted pregnancy on parents and their

offspring may lead to long-standing life distress and disability, and the chil-
dren of unwanted pregnancies are at high risk for abuse, neglect, mental ill-
ness, and deprivation of the quality of life. Pregnancy that results from
undue coercion, rape, or incest creates even greater potential distress or dis-
ability in the child and the parents. The adolescent most vulnerable to early
pregnancy is the product of adverse sociocultural conditions involving pov-
erty, discrimination, and family disorganization, and statistics indicate that
the resulting pregnancy is laden with medical complications which threaten
the well-being of mother and fetus. The delivery that ensues from teenage
pregnancy is prone to prematurity and major threats to the health of mother
and child, and the resulting newborns have a higher percentage of birth de-
fects, developmental difficulties, and a poorer life and health expectancy
than the average for our society. Such children are often not released for
adoption and thus get caught in the web of foster care and welfare systems,
possibly entering lifetimes of dependency and costly social interventions.
The tendency of this pattern to pass from generation to generation is very
marked and thus serves to perpetuate a cycle of social and educational fail-
ure, mental and physical illness, and serious delinquency.
Because of these considerations, and in the interest of public welfare,
the American Psychiatric Association 1) opposes all constitutional amend-
ments, legislation, and regulations curtailing family planning and abortion
services to any segment of the population; 2) reaffirms its position that abor-
tion is a medical procedure in which physicians should respect the patients
right to freedom of choicepsychiatrists may be called on as consultants to
the patient or physician in those cases in which the patient or physician re-
quests such consultation to expand mutual appreciation of motivation and
consequences; and 3) affirms that the freedom to act to interrupt pregnancy
must be considered a mental health imperative with major social and mental
health implications. (American Psychiatric Association 1978)
Induced Abortion in the United States 221
Several other medical specialty and practice organizations, including the

American College of Obstetricians and Gynecologists, have taken a similar
stance. The American Medical Association, after considerable debate, decid-
ed to leave attitudes about induced abortion to the individual physician. Al-
though the official APA position probably represents the stance of a sizable
majority of psychiatrists, there are those whose cherished values and beliefs
are violated by it. They question the appropriateness of such a stance within
a profession dedicated to the preservation of life, the relevance of abortion
policy to psychiatry in particular, and the effectiveness of access to abortion
in eliminating or reducing the problems to which the APAs statement ad-
dresses itself: child abuse, neglect, and deprivation. On the other hand, some
psychiatrists regard abortion as such a fundamental human right that they
threatened to boycott a psychiatric convention scheduled in a state in which
the legislature had passed statutes limiting abortion access. Of particular im-
portance to the practice of psychiatry are the psychosocial factors in un-
planned pregnancies, the decision-making process, the effect of pregnancy
and abortion on womens mental well-being, physicianpatient confidentiali-
ty, the right and obligation of physicians to see that patients have access to
and knowledge about all therapeutic options without barriers, and the auton-
omy of the pregnant woman, regardless of her age, to make decisions about
her care in consultation with the health professionals who provide that care.
Conceptual and Methodologic Issues
The issue of abortion is so contentious that fundamental realities are often

overlooked. Consideration of these realities is essential not only for policy-
making but also for clinical practice and scientific study. First of all, abortion
is performed only on women who are pregnant. If an abortion is not per-
formed (and barring complications such as spontaneous abortion), these
women will go on to deliver. Study of the outcome of abortion without com-
parison with the sequelae of labor, delivery, and motherhood has very limited
scientific validity and practical utility. The only truly appropriate control
group for such studies is women who found their pregnancies similarly prob-
lematic, who sought abortion, and who were unable to obtain it. Findings
from the few such studies that have been performed are summarized here.
Women considering abortion are not only pregnant, but pregnant under cir-
cumstances they experience as untenable. The circumstances also make a
substantive contribution to outcome; the abortion procedure does not have
an impact in isolation. Last, the effects of social and medical context on the
experience and outcome of abortion are often overlooked. These consider-
ations are discussed further in the section on psychiatric issues.
Gynecologic and Public Health Issues
Data in this section are taken from Public Health Policy Implications of Abortion
(American College of Obstetricians and Gynecologists 1990), a handbook for
health professionals that was developed collaboratively by a group of medical
organizations, including the American College of Obstetricians and Gynecol-
ogists, the American Medical Association, and the APA, and published in Jan-
uary 1990. It can be obtained through those organizations. Statistics were
derived from the Centers for Disease Control and Prevention (Koonin et al.
1998) and the National Center for Health Statistics.
Procedures to terminate a pregnancy vary somewhat by trimester. Until
recently, second-trimester abortions were generally induced by the intrauter-
ine instillation of chemical agents, such as urea or saline, that precipitated the
onset of uterine contractions and the expulsion of the fetus. Currently,
second-trimester pregnancies are also terminated by methods similar to those
used in the first trimester: cervical dilation and uterine evacuation. Since
1981, 90% of all abortions have been performed using suction curettage. Un-
der local anesthesia, the cervix is dilated and the uterine contents removed by
suction. The procedure takes 1012 minutes. This procedure cannot be per-
formed late in pregnancy.
At least half of all induced abortions in the United States are performed
within the first 8 weeks, and 90% within the first trimester, of pregnancy. Dur-
ing this time, the risk of medical complications is less than 0.5%. Abortions
performed after 20 weeks of gestation constitute fewer than 1% of all such
procedures; most of these occur at 2123 weeks. Most abortions are per-
formed in freestanding (nonhospital) clinics, where the cost is about one-third
(average, $213) of that in a hospital, the safety is equivalent (for early and un-
complicated abortions), and the access and psychologic experience easier (un-
less complicated by the presence of protesters). Maternal mortality from
abortion performed under safe conditions is 0.5 per 100,000 procedures; the
rate from childbirth is 25 times greater. During the 1960s, before abortion
was legalized in the United States, illegal abortion led to approximately 20%
of pregnancy-related admissions to hospitals in major population centers and
20% of all deaths from pregnancy and childbirth. These kinds of statistics are
still obtained in areas of the world where safe abortions are not available.
Access to abortion is geographically uneven; the vast majority of abor-
tion providers are in urban areas. Of all counties in the United States, 82%
lack a facility performing abortions; the 30% of women who live in a county
without a provider obtain, on average, substantially fewer abortions than
women in areas with a provider. Most general hospitals perform no abortions
at all, and those that do perform very few. Other barriers to service include
the federal ruling that Medicaid funds cannot be used for abortion services
except to save the mothers life and requirements for notification or consent
of the patients parents. As growing numbers of women enter military ser-
vice, the prohibition on abortion services at military hospitals, even when pri-
vately financed, affects greater numbers of women. Evidence indicates that
such barriers deter timely and safe care and lead to adverse public health con-
sequences (Berger 1978).
The antiprogestin mifepristone (RU 486) is 95% effective in inducing
abortion when taken orally and followed by a dose of prostaglandin. It is as-
sociated with minimal side effects and with no known complications or long-
term health implications. It is available and in use in China and in France;
clinical trials are under way in other countries all over the world. The U.S.
Food and Drug Administration has approved the use of mifepristone (Rosen-
blatt et al. 1995) and a private, nonprofit consortium has been founded to un-
dertake the research and distribution of RU 486 within the United States.
Antiabortion groups have reportedly threatened to initiate major actions, in-
cluding boycotts, against any pharmaceutical company that seeks to market
the drug in this country. Some women prefer surgical procedures because
they are definitive and immediate, but most prefer medical abortion because
it feels more private and less intrusive. There is a federal ban on the study of
other abortifacients.
Epidemiology
The World Health Organization estimates that as many as 53 million induced

abortions are performed globally every year (World Health Organization
1997). Rates of induced abortion in the United States have been compiled ac-
cording to race, age, and marital and reproductive status. The figures quoted
here were published by the American College of Obstetricians and Gynecol-
ogists in 1990 and updated with the latest available figures from the Centers
for Disease Control and Prevention (Koonin et al. 1998). Of women who un-
dergo abortions, approximately 58% are white; 45% are nulliparous; 89%
have two or fewer children; and 54% have not undergone an induced abor-
tion previously. Seventy-nine percent of all women and 96% of teenage wom-
en obtaining abortions are unmarried. Marriage precipitated by pregnancy
places teenagers at higher risk for abuse, school failure, and dependence on
public support than their unmarried agemates (Zuravin 1991). Over 60% of
women undergoing abortion are younger than 25 years; 42% of pregnancies
in teenagers are terminated by induced abortion. Although women over 40
become pregnant more rarely and account for relatively few induced abor-
tions, 51% of their pregnancies are terminated by induced abortion. The
numbers and rates of induced abortion remained fairly constant throughout
the 1980s and approximate those before abortion was legalized. In 1986, ap-
proximately 33 million legal and 27 million illegal abortions were performed
throughout the world (Tietze and Henshaw 1986).
History and Anthropology
Induced abortions have been performed throughout recorded history in ev-

ery part of the world and in virtually every sort of culture. An exhaustive
cross-cultural study performed by Devereux (1976) revealed a wide range of
methods by which pregnancy termination is attempted or achieved and an
equally wide range of social regulations, from those that proscribed abortion
to those that mandated it under certain circumstances. Discussion of abortion
practices and beliefs in selected cultures serves to put the practice into some
perspective (Newman 1991). Induced abortion is mentionedand pro-
scribedin the Hippocratic oath. Therefore, it must have been practiced and
discussed in ancient Greece (Edelstein 1989). Moving to the twentieth centu-
ry, in the former Soviet Union, an officially atheist state that sought to in-
crease its population, abortions were provided by the state health system
(although supplementary, sub rosa fees were required for anesthesia), and
women underwent an average of nine abortions each (Page 1989). In China,
it is reported that the number of induced abortions is at least equal to the
number of live births. Population control is a national priority in China, and
considerable pressure may be exerted on women or couples when conception
has occurred without prior approval by their respective work group (Engel-
hardt 1989). Abortions are also widely performed in Roman Catholic coun-
tries, where they are illegal, only illicitly available, and lead to thousands of
maternal deaths (Bromham and Oloto 1997).
In contrast, induced abortions are legal, common, safe, and accepted in

Japan. This accepting social context is not associated with a lack of feeling
and meaning, however (Klass and Heath 1997). Japanese religious and cul-
tural beliefs hold that the soul of the embryo may cause health and other
problems for the mother if not laid to rest in a religious observance. There is
a goddess who takes a special interest in embryos and young children, and
shrines dedicated to her are hung with offerings of baby toys and bibs (Ohnu-
ki-Tierney 1984).
In the United States, abortion was first the province of the lay midwife
who was responsible for most of womens reproductive health care. Around
the middle of the nineteenth century, as medicine was increasingly profes-
sionalized and organized, obstetrics and gynecology became recognized as a
medical specialty and physicians moved to establish hegemony over womens
reproductive functions. Textbooks described menstruation and childbirth as
debilitating events that made women vulnerable to medical disorders and un-
suited to stresses such as those associated with higher education, lest their
reproductive functions be impaired. Women of the lower classes, who per-
formed heavy labor inside and outside the home even when pregnant and
postpartum, were thought to have more primitive physiologies. With a focus
on the middle and upper classes and the assumptions that childbearing within
marriage was womens God-given duty and that conception outside marriage
was sinful, abortion began to be decried by organized medicine. Eventually,
it was outlawed.
Nevertheless, the practice of abortion continued. Womens magazines of
the nineteenth and early twentieth centuries regularly carried thinly disguised
advertisements for purported abortifacients. Abortion went underground,
sometimes performed secretly by licensed physicians and more often by shad-
owy practitioners to whom women were referred by their physicians, friends,
and relatives. In areas where legal scrutiny was tight, elaborate arrangements
were made that involved meetings in out-of-the-way locations, blindfolded
transport to unknown locations, and exchanges of cash. Anesthesia was rare-
ly used because it lengthened the time for the clandestine procedure and
made it difficult for the woman to flee in the case of a police raid. Serious com-
plications and deaths were common; until the early 1970s most large hospi-
tals had entire wards full of patients being treated for septic abortions. Care
was complicated by the fact that the women were both unwilling and unable
to give accurate histories when they presented hemorrhaging and/or infected
for emergency care to often judgmental hospital staff. In cities such as Chica-
go, elaborate networks served to direct and bring women to quality physi-
cians who would risk losing their medical licenses by performing abortions to
prevent these dire complications.
Because many of the state laws prohibiting abortion allowed for excep-
tions when continued pregnancy was thought to threaten the life or, less com-
monly, the health of the woman, psychiatrists played a significant role in
providing more affluent and/or sophisticated women access to medically safe
abortion. As medical knowledge improved, medical illnesses once incompat-
ible with successful pregnancy outcomes, such as diabetes, became manage-
able in the context of pregnancy. It was difficult to establish medical grounds
for termination without blatant falsification of laboratory results and other
verifiable findings. Psychiatric conditions, on the other hand, were not so ver-
ifiable. The earliest versions of DSM had just appeared, with highly subjec-
tive criteria for various diagnoses. If a psychiatrist asserted that a woman
would commit suicide or suffer other psychiatric sequelae if her pregnancy
were not terminated, there was little way to prove otherwise.
In many hospitals, committees were formed for the sole purpose of mak-
ing decisions in these cases. Nearly always, a pregnant woman had to make
her case to a panel of male physicians. Some of these women have written poi-
gnantly about the humiliation of presenting their painful stories to the gate-
keepers who controlled access to the procedure they so desperately wanted.
One of these women had three preschool children when she became pregnant
for the fourth time. Her husband, who was the sole support of the young fam-
ily, insisted that he would abandon the family if another child was born. This
woman, Kate Michelman, went on to head the National Abortion and Repro-
ductive Rights Action League.
Legal Issues
Up to 1.5 million induced abortions are performed in the United States each
year; this number was estimated to be much the same before the Roe v. Wade
decision by the Supreme Court legalized abortion in 1973. The absolute num-
bers have fallen 15% since 1990, and the percentage of pregnancies terminat-
ed by induced abortion has continued to decline since 1987 (Koonin et al.
1998). The Roe v. Wade decision declared a right to privacy between a woman
and her physician concerning the decision of whether to have an abortion
and an unencumbered right to abortion during the first 12 weeks of pregnan-
cy. During the second trimester, the state was permitted to regulate abortion
only to protect maternal well-being.
The passage of Roe v. Wade has had some paradoxical consequences over
the years. The collective memory of the consequences of outlawing abortion
faded. People who favor rights to abortion became complacent. People who
opposed abortion mobilized and made abortion an acknowledged and unac-
knowledged symbol of other social agendas. In response, the United States
Congress has enacted legislation enjoining the use of federal funds to support
abortion services. The Supreme Court, as its composition changes, has up-
held various state laws limiting access to abortion. Laws requiring that the
husband or father of the fetus be informed or give consent have been over-
turned. Other laws requiring that the parents of a pregnant girl under the age
of majority be informed and/or give consent have been upheldwith the
provision, called a judicial bypass, that the young woman can gain access to
abortion by presenting herself to a judge with evidence that she is mature
enough to make the decision and is independent of or abused or neglected by
her parents.
Laws that require waiting periods between the time that abortion is
sought and the time that it is performed are allowed, as are those requiring
that government-generated statements be provided about the stages of gesta-
tion and the availability of support for mothers and children in the state. Un-
der the guise of public health statistic-keeping, some states record the names
of physicians who perform and patients who undergo abortions, data that is
not kept for other procedures and that can be, and is, used to harass the phy-
sicians and patients and their families. The latest attempt to curtail access is
the debate over late-term abortion (Epner et al. 1998). The successes of the
antiabortion movement in obtaining restrictions on abortion have led some
women to feel that the Roe v. Wade decision is more a facade than a guarantee
of access; an impression that is to some degree accurate. However, the activ-
ities of antiabortion groups at womens clinics have also been constrained by
legislation, generally precipitated by violence at those clinics, thus mitigating
somewhat the additional stress imposed by clinic harassment.
Ethical Perspectives
As mentioned, access to abortion services has become the subject of heated

controversy. Irreconcilable factions argue that abortion is murder or that legal
access is an imperative not only for justice for women but also for their very
survival. Induced abortion has come to signify major social concerns and
fears: the continuity of the nuclear family structure and traditional gender
roles, the erosion of sexual morality, the liberation of women from oppression
and abuse, and the opportunity for children to enter the world as wanted
members of loving families with the resources to provide for them.
Cultural icons have crystallized around these positions: the fetus for
groups self-identified as pro-life, the bloody coat hanger of the back-alley
abortionist for those who are pro-choice. These symbols are also reflections
of levels of discourse about the ethics of induced abortion. Because the op-
posing points are irreconcilable, no attempt to reconcile them is made here. It
is important, however, that the issues be delineated. The levels of discourse
reflect the medical, psychologic, and social complexities of the procedure (B.
Brody 1982; Warren 1982). At the most basic level are the biologic, medical,
and legal realities. Abortion is the termination of a pregnancy. Society has an
interest in the successful propagation of the species; a particular pregnancy
may advance or deter that goal. Pregnancy almost always occurs as the result
of sexual intercourse between a man and a woman. This intercourse may be
more or less consensual or coercive, and the sexual partners may have con-
gruent, divergent, or contradictory investments in procreation and intentions
with regard to the parenting of a potential child.
Fertilization may also take place deliberately, without intercourse, by re-
course to more (in vitro fertilization) or less (artificial insemination by turkey
baster) sophisticated technologic means. It always involves the genetic mate-
rial of a male and a female human individual, although the genetic, gestation-
al, and social parents may all be different persons. Because procreative
maturity precedes legal maturity (the age of majority), pregnancy can and
does occur in minor women whose capacity to weigh alternatives and whose
moral rights to make decisions about their own care and futures is another
ethical and legal question.
Another level of discourse concerns the ethical responsibilities of the
medical profession. Induced abortion may be performed by a lay attendant,
attempted by the pregnant woman herself, or carried out by a physician or
other medically trained and licensed professional health care provider. This
array of possibilities raises analogous ethical problems for the gynecologist
and psychiatrist alike. Abortion may be viewed as a service that doctors are
obligated to provide on request, a procedure for which physicians are the ap-
propriate gatekeepers (many court decisions and official organization posi-
tions stipulate that the decision is to be made by a woman and her doctor),
or a prima facie violation of medical ethics. The substantial dangers of abor-
tion performed outside the medical system, an eventuality that seems un-
avoidable given the available anthropologic and demographic evidence, are
sometimes weighed in ethical decisions as well (Jacobson 1988).

Another question concerns the womans responsibility for conception
and the embryo thus engendered. A more or less explicit image persists of the
sexually wanton female who seeks to rid herself of the predictable outcome
of her lifestyle at the expense of her childs life. In point of fact, however,
many realities constrain womens control over sexual activity and contracep-
tion. These include not only rape and incest but also lack of access to infor-
mation about reproduction and contraception, lack of access to contraceptive
devices and medical services, and sexual activity in which financial, social,
and psychologic coercion falls short of narrowly defined sexual assault (Da-
Vanzo et al. 1991). Contraceptives also fail.
An alternative image exists, that of the virtuous woman who accepts re-
sponsibility, maintains the pregnancy once conceived, and makes the person-
al sacrifice involved in the experience of pregnancy, labor, delivery, and either
child care or child relinquishment to adoption in the interest of her child
(Vaux 1989). This stance imbues the woman in the earliest stages of pregnan-
cy with the role and moral obligations of the parent of a child already born.
It also raises the issue that pregnancy, delivery, parenthood, and the potential
child become the instruments by which the woman is punished for sexual
intercourse; the argument that most sentimentalizes attachment to the poten-
tial child sometimes conceptualizes that child as a retribution rather than a
blessing.
The question of when human life begins overlaps with the question of
the definition of human life. A fertilized ovum is living matter with the ge-
netic composition of a human being and the potential to develop into a hu-
man being. To date, however, that development can happen only within a
womans body. Embryologic research indicates that the differentiation of cells
resulting in the formation of a normal organism can occur only in a given se-
quence and in the matrix and structure of embryonic development as a
whole. The cells that are to differentiate into, for example, liver cells can do
so only if the rest of development is proceeding normally around them at
each of the requisite stages. Put another wayone relevant to the ethics of
abortionthe cells and tissues of the preembryo and embryo are not inevita-
bly destined to become a human being.
Even given the circumstances of normal development, no clear or con-
sensual definition of human life exists. It may be defined by genetic composi-
tion, human form, the appearance of brain waves, the ability to experience
sensation, or the awareness of the self and other people as human. What dis-
tinguishes human life from other forms of life, and what privileges, if any,
does our humanity confer on us? Both humans and animals experience plea-
sure and pain, and both exert strenuous effort to stay alive. Although cells bi-
opsied from human tissue are alive, capable of reproduction, and endowed
with a full complement of human chromosomes, it would be difficult to argue
that such a collection of cells constitutes human life or a human being. The
assertion that any particular stage of human development constitutes the be-
ginning of human life is fraught with problematic implications.
Fetal viability has been raised as an issue both by ethicists and lawmak-
ers. Publicity about the survival of some infants born extremely prematurely
has led the public to believe that the medical community is steadily moving
back the point in pregnancy at which the fetus can live outside the mother.
Scientific evidence does not support this belief, however, and some perinatol-
ogists think it likely that we have already approached the limits of our abilities
to support extrauterine life in prematurely born infants.
All of these problems complicate attempts to apply the usual standards
of beneficence, autonomy, and justice to the consideration of the ethics of
abortion. The APAs position statement seems to imply that not allowing a po-
tential child to come into being can be beneficent for that child. Abortion
ends a potential or an actual life as well as the hopes and interests of those
who wanted to see it realized, although it may further the good both of the
woman whose pregnancy and potential motherhood are experienced as intol-
erable and of others for whom she is responsible or to whose lives she can
make a contribution. The availability of abortion may hurt society because
it undermines respect for potential life and for support during pregnancy and
childrearing. It may benefit society because it diminishes the social burden of
unwanted and poorly cared for children and the loss or injury of women who
resort to unsafe attempts to terminate their pregnancies.
Psychiatric Sequelae
Psychiatrists help patients make decisions about problem pregnancies and

deal with their short- and long-term reactions to induced abortion. In 1988
C. Everett Koop, Surgeon General of the United States, was charged by Pres-
ident Bush to determine the medical and psychologic effects of abortion on
American women and to publish a review of the findings. Dr. Koop, who was
personally opposed to abortion, solicited opinions and scientific information
from a wide variety of medical and interest groups, including the APA, and
concluded that there was insufficient information to assert that abortion had
negative sequelae (Koop 1991).
The public is nevertheless very concerned about the psychiatric sequelae

of abortion. The popular press and antiabortion groups have published alle-
gations that abortion causes serious, disabling, permanent psychologic dam-
age: an abortion trauma syndrome (DeVeber et al. 1991). This term, which
is absent from the peer-reviewed literature, seems to have been coined to re-
semble posttraumatic stress disorder. Allegations that the medical community
is deliberately withholding or overlooking data supporting this position have
also been made (Pro-Life Action Ministries, undated). Patients and the gen-
eral public may turn to psychiatrists for accurate scientific findings concern-
ing the psychologic sequelae of induced abortion (Stotland 1996).
Confusion often arises because of the failure to differentiate between
passing negative feelings and psychiatric syndromes and because of the mis-
attribution of the distress some women feel about an abortion. The first prob-
lem is compounded by semantic ambiguity; in the English language, depression
is used both as a description of a mood and as a technical term to denote the
diagnosis of a major psychiatric illness. With regard to the second problem,
abortion is performed only on women who are pregnantand pregnant in
problematic circumstances. Womens reactions to induced abortion arise not
only, and perhaps not mainly, from the procedure itself but also from psycho-
logic, social (Major et al. 1997), and political circumstances and the commu-
nicated attitudes and behaviors of the personnel who perform the procedure.
The psychosocial impact of finding oneself to have conceived an unan-
ticipated and undesired pregnancy is considerable. The process of arriving at
the conclusion that the pregnancy cannot or should not be maintained is an
additional stress, often involving confrontation with realities such as poverty;
the implications of interrupting ones work or education; the end or threat-
ened end of the relationship with ones partner, who may be the father of
ones other children; genetic defects; or overwhelming burdens of caring for
other young children. A womans religion or significant others may disap-
prove of abortion, even to the point of excluding a woman who has under-
gone an abortion from membership in the religious community or from the
protection and regard of the family. Abortion may be accessible only illicitly
or only through a complex process such as obtaining parental approval, judi-
cial bypass, or medical justification. Of particular importance for psychiatric
study is the fact that women may choose abortions because they have psychi-
atric illnesses that make pregnancy and motherhood problematic. Given
these realities, it is difficult or even impossible to assess the impact of the abor-
tion in isolation.
Published studies of psychologic reactions to induced abortion have to
some degree paralleled prevailing social attitudes and expectations. For exam-
ple, a large (479 women) Swedish study revealed that 75% of the subjects had
experienced no regrets or self-reproach and all of the 1% with psychiatric
problems had had prior psychiatric illness (Ekblad 1955). Despite such find-
ings, authors tended to assume negative effects until the early 1960s. Since
that time, a succession of studies have been published, and methodology has
been consistently improved. All studies agree that negative emotional effects
are nearly always transient (Butler 1996), that most women who choose abor-
tion tend to feel increasingly relieved and comfortable with their decisions,
and that in many cases their overall life satisfaction and success are improved
(Addelson 1973; H. Brody et al. 1971; Ford et al. 1971; Lask 1975; Marder
1970; Niswander and Patterson 1967; Osofsky and Osofsky 1972; Peck and
Marcus 1966; Schusterman 1976; Simon et al. 1967; Whitmore 1995). Wom-
en who were denied abortion tended to have poorer outcomes, especially if
the burdens of motherhood were compounded by great multiparity or lack
of social support (Pare and Raven 1970).
The incidence of major psychiatric illness following induced abortion
has been studied and compared with the occurrence of major psychiatric ill-
ness after delivery and in patients denied abortion. A large study in Great
Britain reported that the incidence of psychosis was 0.3/1,000 after abortion
and 1.7/1,000 postpartum (Brewer 1977). All other such studies report similar
findings. A 1989 study performed by a researcher at Johns Hopkins Univer-
sity followed-up adolescents who presented to a school health clinic seeking
pregnancy tests (Zabin et al. 1989). Some were not pregnant; of those who
were, some chose to abort and some to carry to term. Those who terminated
their pregnancies experienced the most favorable outcomes in terms of psy-
chologic adjustment and completion of educationbetter outcomes than
women who had not even been pregnant. The authors, surprised by this find-
ing, theorized that vulnerability to unfounded fears of pregnancy might be
correlated with other psychologic vulnerabilities.
No specific illness or pattern of pathologic response to induced abortion
has been described, other than anecdotally, in the scientific literature. Risk
factors for psychiatric illness following induced abortion include prior psychi-
atric illness, pressure or coercion to undergo the abortion, marked ambiva-
lence about the decision, and a lack of social supports (Blumenthal 1991;
Major et al. 1997). Negative attitudes of those who provide care during and
after the procedure also increase patients risk of psychiatric sequelae. Psychi-
atrists treating patients who are considering abortion can best help them by
providing information and collaborating with them and with significant oth-
ers of their choosing to arrive at autonomous but socially supported decisions

that reflect their own circumstances, religious beliefs, and values.
The reactions of men to their partners induced abortions have not been
well studied. Male partners are often overlooked and their psychologic needs
not attended to. In one study of men accompanying women to an urban hos-
pital abortion service, the men reported that the circumstances surrounding
the abortion had constituted a developmental challenge. Some men retreated
to dependence on their parents, leaving their wives or girlfriends to obtain the
necessary information and make the decision largely without their support.
Most mastered the challenge, however, and emerged from the experience
with an enhanced feeling of fatherliness and responsibility (Rothstein 1991).
Like women who undergo abortion, they had decided that parenthood
should be the result of a considered decision that one could provide for a
child and should not be undertaken by chance.
Psychiatric Implications of Legal Constraints
Restrictions on abortion services threaten all women with unintended moth-

erhood or illegal abortion, outcomes likely to be psychologically stressful. Be-
cause restrictions limit access for some women but not others, they raise
ethical and public health questions for all physicians. For example, the so-
called Hyde Amendment passed by the United States Congress proscribes
the use of federal funds for abortion services. Therefore, Medicaid funds oth-
er obstetric and gynecologic services but not abortion. Because few medical
facilities operate without federal funds, this legislation affects a large propor-
tion of the population, relegating them to second-class medical care. Women
with social support, means, and sophistication have always been able to ob-
tain safe abortions.
Why is abortion a psychiatric issue? There are several reasons. The pro-
cedure is medical, and psychiatrists are physicians. In times and places where
abortion services are not freely available to women, abortion may be allowed
only when deemed medically necessary in the interest of a womans health.
Where abortion is permitted only to save the mothers life, suicidal patients
may qualify. Before abortion was generally legalized, sophisticated patients
sometimes used psychiatrists to gain the consent of hospital review boards.
As a result, psychiatric grounds were perceived by some authorities to be un-
derjustified and overused, and some states and the military specifically disal-
lowed psychiatric grounds for abortion. Other laws have been more liberal,
allowing psychiatric factors to be considered on a par with other medical fac-

tors that have a significant likelihood of impairing the mothers health if the
pregnancy continues (Shepler 1991).
Each of these circumstances is problematic for psychiatry. Excluding sui-
cide or mental health indications isolates psychiatric illness from the rest of
medicine and reinforces both the misconception that mental illnesses are not
real and the stigma surrounding psychiatric patients and practitioners. Allow-
ing psychiatric indications for abortions places psychiatrists in an untenable
position. Suicidality and other adverse psychiatric outcomes, like all medical
outcomes, are not entirely predictable, especially when the patient who is pro-
viding the data for the decision is in the midst of a crisis and has a vested in-
terest in obtaining a particular procedure. Several decades ago it was possible
for a psychiatrist to write a letter indicating that a patient was suicidal without
entering this information in her permanent medical record. Today, a psychi-
atrists observation that a patient is mentally ill and/or suicidal will follow her
through life and may threaten her career opportunities and her ability to ob-
tain life and health insurance. Given the current scrutiny of psychiatric care
and the widespread role of religious groups opposed to abortion in support-
ing medical services, the psychiatrist who declares a pregnant patient suicidal
may be constrained to hospitalize her for a time or even until she delivers.
The psychiatrist may be in a bind because the clinical evidence in a case may
not warrant the conclusion that the patient is suicidal although the patient or
the psychiatrist (or both) may feel strongly that an abortion would be in the
patients best interest. The psychiatrist must then either lie about the findings
or see the patient denied abortion. Studies indicate that patients who are de-
nied abortions requested on psychiatric or psychosocial grounds, as well as
their children, suffer adverse outcomes as compared with control families but
that these patients seldom complete the act of suicide during the pregnancy
(Dagg 1991).
Psychiatrists have a particular interest and expertise in the circumstances
associated with the unplanned pregnancies. These circumstances range from
ignorance, poverty, and lack of contraceptives to abuse, immaturity and im-
pulsivity, various degrees of interference with reality testing, and more indi-
vidual and interpersonal psychodynamics. Psychiatrists treat patients with
histories of severe psychiatric complications of pregnancy and delivery. We
treat patients who appear or have been shown to be unable to master the re-
sponsibilities of motherhood, including patients who have suffered terrible
emotional pain and exacerbations of psychiatric illness after losing custody of
children in the past. We treat patients for whom we have prescribed psycho-
tropic medications in the early days and weeks before pregnancy could be
diagnosed, with unknown effects on the embryo and fetus (see Chapter 5),
and patients who require psychotropic drugs to forestall repeated decompen-
sations.
Limitations on access to abortion may put the psychiatrist in another sort
of legal bind as well. The 1989 United States Supreme Court decision affirm-
ing the Missouri law in the case of Webster v. Reproductive Health Services let
stand language stating that public funds may not be used to advise or counsel
a woman to have an abortion. This language, which has been repeated in the
laws of other states, could be interpreted to mean that a psychiatrist caring
for a woman with a history of severe postpartum psychiatric illness, loss
of custody, severe psychiatric vulnerability, or treatment with psychotropic
drugs in early pregnancy may not inform the patient of the full range of ther-
apeutic options. When a patients care is publicly funded, or takes place in a
publicly funded facility (few medical facilities, including private offices, have
no public funding), such a law may proscribe the discussion of abortion. An-
tiabortion activists have threatened to visit doctors offices with simulated
psychiatric histories in order to expose physicians who violate the law.
As noted earlier, U. S. Supreme Court decisions since Roe v. Wade in 1973
have precipitated the passage of state laws restricting abortion access. Some
legislative and judicial restrictions on abortion are couched in terms of notifi-
cation and consent of third parties. The Pennsylvania legislature passed a bill
requiring the signature of a womans husband that was vetoed by the gover-
nor. Several states have enacted laws requiring the notification and/or consent
of the parents of a minor woman seeking abortion that have been found to
be constitutional so long as they include a provision for judicial bypass (Shep-
ler 1991). These laws have a clear emotional appeal to the publics sentiments
about parental protection of minor children and the sanctity of the family.
However, they ignore realities about adolescent development, troubled fami-
lies, and the judicial process. All of the major medical organizations endorse
the physicians role in advising and helping pregnant young women to inform
and enlist the support of their families when that is in their best interest. Most
young women do so. Unfortunately, adolescents from abusive and neglectful
families are at increased risk of unintended pregnancy; forcing them to tell
their parents further exposes them to the risk of abuse, expulsion from the
home, and self-destructive behavior, including suicide. Mandating parental
involvement is also a contratherapeutic intrusion in the physicianpatient re-
lationship, whether the physician in question is an obstetrician, pediatrician,
family practitioner, or psychiatrist.
Judicial bypass requires than an adolescent without adequate family sup-

port, and in the middle of the crisis precipitated by an unwanted pregnancy,
be aware of the judicial bypass procedure. She must locate the court, make
excuses for her absence from home and/or school, and present herself at the
court. In rural areas, she may have to travel a considerable distance. Once at
the court, she must make her intentions known to staff so that she can be di-
rected to the appropriate room. The law requires that this process be confi-
dential, but in rural areas both the courts staff and the judge may well know
her and her family personally. In Minnesota, such a law was found to pro-
duce no positive outcome. Judges who heard these cases almost invariably al-
lowed the abortion to take place. In other states, judges have granted virtually
no requests for abortion. For these reasons, major medical societies, including
the American Academy of Pediatrics, have taken official positions against pa-
rental notification laws.
Although it recognizes the deeply felt religious and moral aversions of
some psychiatrists to induced abortion and the profound decision most feel
abortion to be, the APA, in concert with other medical and public interest or-
ganizations, has taken a strong stance opposing legislation that places danger-
ous and inequitable restrictions on womens access to safe abortion services
as well as limitations on all physicians ability to discuss, recommend, and
provide services for their patients. It is truly tragic that psychosocial igno-
rance and inadequacies lead to so many problem pregnancies in a world that
has the scientific knowledge to prevent them.
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12
Menopause
Myths and Realities

BARBARA B. SHERWIN, PH.D.
Menopause is both a natural and a universal event in the human female

life cycle. A set of defining characteristics for this biologic event was formulated
at the first International Congress on Menopause (Utian and Serr 1976).
According to this formulation, the climacteric marks the transition from the
reproductive to the nonreproductive stage of life in women that spans several
years. Menopause occurs during the climacteric, at a mean age of 51 years,
and is defined by the last menstrual period. In addition, decreased ovarian
activity and sociocultural and psychologic factors could act individually or in
concert to produce climacteric symptoms.
Because menopause is a universal phenomenon, it is curious that it was
not until 1976 that an international definition of this event was first formulat-
ed and published. One explanation may be related to changes in statistics re-
garding female life expectancy. In 1900 the average life span of a woman
living in the United States was approximately 50 years; in 1995, 40% of white
American women reached 85 years of age. It is projected that this percentage
will continue to rise with time (U.S. Bureau of the Census 1990). Therefore,
many women now live one-third of their lives beyond cessation of their re-
productive capacity, and the quality of life during the latter one-third of the
life span has, understandably, become a major issue of concern to both health
professionals and women themselves.
Surgical menopause occurs when both ovaries are removed before natu-
ral menopause has occurred. Before the 1970s, bilateral oophorectomy was
241
performed fairly commonly in association with hysterectomy undertaken for

benign gynecologic conditions. The rationale underlying this was the preven-
tion of ovarian cancer and the belief that ovarian function was expendable if
pregnancy was no longer possible. Epidemiologic evidence suggesting that,
in the absence of a family history, women have a low risk of ovarian cancer
served to curtail this practice of indiscriminately removing normal-appearing
ovaries. An even more compelling reason for retaining the ovaries in pre-
menopausal women emerged when it became clear that acceleration of car-
diovascular disease (Parrish et al. 1967) and osteoporosis (Lindsay et al.
1980) were associated with early oophorectomy. For these reasons, conserva-
tion of normal ovaries at hysterectomy has become the more common prac-
tice in North America.
Consistent with the 1976 definition of the climacteric syndrome (Utian
and Serr 1976), the etiology and frequency of symptoms that may occur at this
time are discussed in this chapter from neurohormonal, sociocultural, and psy-
chologic perspectives and an attempt is made to synthesize this material.
Neurohormonal Processes
Change in Sex Hormone Secretion in Menopausal Women
In premenopausal women, the ovary secretes 95% of the estradiol that enters
the circulation (Lipsett 1986). After menopause, the ovary virtually stops pro-
ducing estradiol. Estrone, a much weaker estrogen, becomes the predomi-
nant estrogen arising from peripheral conversion of androstenedione
(Longcope 1981). Although it was once thought that the drastic decrease in
ovarian estradiol secretion at menopause was due solely to follicle depletion
and ovarian senescence, it is now clear that age-related alterations in hypotha-
lamic function also occur (Wise et al. 1989). Thus, the transition to meno-
pause is a multifactorial process involving both neural and ovarian factors.
In women, both the adrenal glands and the ovaries contain the biosyn-
thetic pathways necessary for androgen synthesis and secretion. The ovary
produces approximately 25% of plasma testosterone, 60% of androstenedi-
one, and 20% of dehydroepiandrosterone (DHEA), whereas the adrenal pro-
duces 25% of circulating testosterone, 40% of androstenedione, 50% of
DHEA, and 90% of DHEA sulfate. The remainder of circulating androgens
in the female are thought to arise through peripheral conversion, which prob-
ably accounts for the production rate of 50% of testosterone and 25% of
DHEA (Longcope 1986). Although ovarian production of estrogens decreas-
Menopause: Myths and Realities 243
es drastically, about 50% of women produce even greater amounts of andro-

gens after menopause because of ovarian stromal hyperphasia that occurs
under the influence of high levels of luteinizing hormone (Judd et al. 1974).
When it occurs, however, this increase in ovarian testosterone production is
time limited, so that eventually testosterone levels decrease in all women.
Neurobiologic Effects of Estrogen and Androgen
Estrogen has both inductive and direct effects on neurons. It induces RNA
and protein synthesis through genomic mechanisms that, in turn, cause
changes in levels of specific gene products, such as neurotransmitter synthe-
sizing enzymes (Luine et al. 1975). Other prolonged neuronal regulatory ef-
fects include the expression of gonadal hormone receptors in specific brain
areas. The direct effects of estrogen on the brain appear to take place more
rapidly. For example, estrogens can alter the electrical activity of neurons in
the hypothalamus (Kelly et al. 1977).
Autoradiographic studies have demonstrated that neurons containing
specific cytosolic receptors for estrogen are found in specific areas of the
brain, predominantly in the pituitary, hypothalamus, limbic forebrain (in-
cluding the amygdala and lateral septum), and the cerebral cortex (McEwen
1980). Estrogen has widespread effects throughout the brain, including the
brainstem and midbrain catecholaminergic neurons, midbrain serotonergic
pathways, and the basal forebrain cholinergic system (McEwen 1999).
Autoradiographic studies have also demonstrated that specific cytosolic
receptors for testosterone predominantly are found in the preoptic area of the
hypothalamus, with smaller concentrations in the limbic system (amygdala
and hippocampus) and cerebral cortex (Chamness et al. 1979). Moreover, the
brain contains aromatizing enzymes necessary to convert androgens to estro-
gens. The anterior hypothalamus is the most active aromatizing central tis-
sue, although limbic system structures also convert androgens to estrogens
(Naftolin and Ryan 1975). It is important to note that the limbic system, es-
pecially the amygdala, plays a critical role in emotion; the fact that sex steroid
receptors are found in these brain structures supports the idea that these hor-
mones may influence emotion and affect.
Peripheral Effects of Estrogen
Because the tissue integrity of the female reproductive tract is dependent on

estrogen, degenerative changes in these structures ensue when levels of estro-
gen decrease after menopause. The vaginal mucosa of postmenopausal wom-

en who do not receive estrogen therapy becomes attenuated and pale because
of decreased vascularity. Marked atrophic changes may result in atrophic
vaginitis, in which the vaginal epithelium is very thin and may become in-
flamed or even ulcerated (Bergman and Brenner 1987). These changes, in
turn, may lead to a severe diminution in vaginal lubrication and/or dyspare-
unia. The urethral epithelium is also estrogen dependent (Ostergard 1980),
and urge incontinence is a frequent complaint in untreated postmenopausal
women (Brenner 1988).
Consequences of Hormonal Changes at Menopause
Physical Symptoms
Because estrogen affects a multitude of organ systems, the drastic changes in
the hormonal milieu that occur around the time of menopause may have con-
sequences for both physical and psychologic functions. Hot flushes, the car-
dinal menopausal symptom, occur in 60%90% of menopausal women,
albeit with a high degree of variability in their frequency and intensity. For
65% of postmenopausal women, the vasomotor phenomena of hot flashes
and cold sweats persist for at least 1 year, and for 20% these symptoms con-
tinue for more than 5 years (Brenner 1988). Because hot flashes occur more
frequently at night, sleep is often disrupted. Hot flashes are reliably relieved
by estrogen replacement therapy (Coope et al. 1975), and although some re-
searchers have noted a simultaneous beneficial effect of exogenous estrogen
on hot flashes and sleep quality (Schiff et al. 1980), others have found these
two things to be dissociable (Sherwin and Gelfand 1984). If sleep disturbance
is associated with frequent awakenings during the night because of hot flash-
es, it seems clear that estrogen administration will probably eliminate both
symptoms. The efficacy of exogenous estrogen is less well established, how-
ever, for sleep disturbance not associated with nocturnal flushes.
Psychologic Symptoms
Historically, myriad psychologic symptoms have been associated with meno-
pause, the most prominent of which are depression, irritability, and mood la-
bility. It is now thought that affective disorders occurring during menopause
do not constitute a distinct subtype of depression. Winokur (1973) found that
women were not at greater risk for a first episode of depression at menopause
than they were other times during the life span. In that study, however, more
stringent severity criteria for the diagnosis of depression during menopause

were used because of the high frequency of depression and nervousness
symptoms that occurred in this sample of menopausal patients. The circular-
ity of this reasoning makes the results difficult to interpret. In a sample of fe-
male outpatient admissions diagnosed with major nonbipolar depression, it
was concluded that there was insufficient evidence to consider onset of de-
pression at menopause as a distinct entity (Weissman 1979), despite the fact
that 47% of the depressed menopausal women and 65% of the depressed
postmenopausal women had no history of depression.
Although some epidemiologic studies have failed to find an increased in-
cidence of depression and minor psychologic symptoms in peri- and post-
menopausal women (Kaufert and Syrotuik 1981; Ballinger 1990; Thompson
et al. 1973), others have documented an increase in the prevalence of depres-
sive symptoms at this time (Bungay et al. 1980; Greene and Cooke 1980;
Hunter and Whitehead 1989). Increases in the prevalence of depression are
more pronounced in the perimenopausal compared with menopausal years
(Charney and Stewart 1997). Of women who seek medical consultation for
menopausal symptoms, 79% have physical symptoms and 65% have varying
degrees of depression (Anderson et al. 1987). In surveys of general popula-
tions, the occurrence of a depressive episode was positively associated with a
surgical but not with a natural menopause (McKinlay et al. 1987). Moreover,
a history of depressive episodes prior to menopause was a strong predictor of
an episode at menopause (Avis et al. 1994).
Measuring changes in mood in premenopausal women before and after
a trial of hormone replacement therapy (HRT) is the experimental technique
most commonly used to investigate the effects of sex steroids on affect. Many
earlier studies were uncontrolled with respect to blindness (George et al.
1973), the presence of malignant disease (Chakravarti et al. 1977), and con-
current psychiatric illness (Dennerstein et al. 1979), thus rendering their find-
ings difficult to interpret. In more-controlled studies, reported discrepancies
may be related to both the psychiatric status of the populations investigated
and the doses of estrogen administered.
Several studies of nonpsychiatric populations of postmenopausal women
have reported changes in affect to be a function of circulating levels of sex
hormones. In two prospective studies of women who had undergone oopho-
rectomy, depression scores covaried inversely with circulating levels of both
estradiol and testosterone (Sherwin 1988; Sherwin and Gelfand 1985). More-
over, depression scores increased when a placebo was substituted for estrogen
in these surgically menopausal women. These results therefore confirmed the
positive association between mood and plasma sex hormone levels in healthy
nondepressed women. It is important to note that, in both studies, women
never became clinically depressed, and the doses of hormones administered
induced circulating levels that were within the physiologic range for women
of reproductive age.
In another study, affective responses to exogenous estrogen were investi-
gated in postmenopausal women who differed at pretreatment with regard to
the intensity of their depression (Schneider et al. 1977). Of 10 women whose
pretreatment depression scores were in the mildly, or subclinically, depressed
range, nine improved after treatment with 1.25 mg of conjugated equine es-
trogen daily, whereas 6 of the 10 women who were more severely, or clinical-
ly, depressed before treatment actually became more depressed with the same
dose of exogenous estrogen. When women with severe, refractory depression
were given very large pharmacologic doses of conjugated equine estrogen
(1525 mg/day), depression scores decreased in most of the women after 3
months (Klaiber et al. 1979). On the basis of these findings and those of our
own studies of nondepressed women (Sherwin 1988; Sherwin and Gelfand
1985), it now seems reasonable to suggest that the administration of estrogen
in doses conventionally used to treat menopausal symptoms enhances mood
in nondepressed women but is therapeutically ineffective with respect to
mood disturbances of a clinical magnitude. Recent work suggests that treat-
ment-resistant depression during menopause may be alleviated in some wom-
en by antidepressant augmentation with physiologic doses of estradiol (Stahl
1998).
Several mechanisms of estrogenic action on indolamine metabolism
could account for its mood-enhancing effect. First, it has been demonstrated
that exogenous estrogen decreases monoamine oxidase activity in the
amygdala and hypothalamus of rats (Luine et al. 1975). Because monoamine
oxidase is the enzyme that catabolizes serotonin, the net effect of estrogen ad-
ministration would be to maintain higher serotonin levels in the brain. In-
deed, it has been found that regularly cycling depressed women have higher
levels of plasma monoamine oxidase activity than do nondepressed women
(Klaiber et al. 1972).
A second mechanism of action is related to estrogens impact on tryp-
tophan in plasma. Tryptophan, the precursor of serotonin, is displaced from
its binding sites to plasma albumin by estrogens both in vitro and in vivo (Ay-
lward 1973), thereby allowing more free tryptophan to be available to the
brain, where it is metabolized to serotonin. A significant negative correlation
between depression scores and free plasma tryptophan was reported in wom-
en who had undergone oophorectomy and whose mood and free tryptophan
levels were enhanced after treatment with exogenous estrogen (Aylward
1976). The results of this clinical study provide some, albeit indirect, support
for an estrogenic effect on neurotransmitter concentrations.
Finally, a prospective study of surgically menopausal women found an
increase in the density of tritiated imipramine binding sites on platelets coin-
cident with higher estradiol levels and lower depression scores (Sherwin and
Suranyi-Cadotte 1990). To the extent that estrogen increases serotonin con-
centrations or the amount of time this neurotransmitter remains in the syn-
apse, it will, in accordance with the biogenic amine hypothesis of depression
(Schildkraut 1965), enhance mood.
Gynecologic Aspects
Gynecologic Assessment
The premenopausal period is characterized by changes in the regularity of the

menstrual cycle and in the duration and volume of menstrual bleeding.
Menopause is said to have occurred when 12 successive menstrual cycles
have been missed. Gonadotropin levels increase because of the lack of posi-
tive feedback resulting from the vastly diminished ovarian production of es-
tradiol. Follicle-stimulating hormone levels of greater than 50 IU/mL and
luteinizing hormone levels of greater than 35 IU/mL are considered, in the
absence of organic disease, to be diagnostic of menopause (Jaffe 1989). The
vaginal epithelium becomes atrophic, and decreased lubrication may be ap-
parent. When the endometrium is biopsied with a curette after menopause,
atrophy of this tissue in noted (Benirschke 1986). In time, a decrease in the
size of the uterus and breasts occurs. Hair on the upper lip and the chin may
increase in some women, probably because of testosterone production by the
postmenopausal ovary that is unopposed by the premenopausal levels of es-
trogen (Jaffe 1989). Because menopausal women are in a high-risk age group
for breast cancer, most gynecologists recommend breast self-examination and
yearly mammography for menopausal and postmenopausal women.
Hormone Replacement Therapy
The ideologic dispute as to whether menopause is a normal reproductive

event, an endocrine deficiency disease, or an endocrinopathy requiring med-
ical intervention continues to rage. Does menopause need to be managed,

or is it a reproductive event, like menarche, to be simply experienced? In-
deed, it is unlikely that this disupte will ever be resolved, because it is a con-
ceptual and not an empirical issue. The differing conceptualizations of
menopause have a major impact on whether medical intervention ought to
play a role. Perhaps a more dispassionate and more useful approach is one
that weighs the short- and long-term consequences of estrogen depletion for
each individual woman.
The variability among women with respect to the intensity and frequen-
cy of the early symptoms of hot flashes and cold sweats means that some are
greatly disturbed by these vasomotor phenomena, whereas others experience
them so mildly that they do not have any negative influence on daily func-
tioning. Highly symptomatic women may be treated with HRT for a limited
period until its gradual withdrawal does not provoke a resurgence of vasomo-
tor disturbances. Another consideration is that, regardless of the severity of
these vasomotor symptoms, all untreated women will in time develop atro-
phy of the estrogen-dependent urogenital tissues, which may give rise to
symptoms such as atrophic vaginitis and urge incontinence. Whether a wom-
an wishes to begin HRT to effectively alleviate these symptoms usually de-
pends on her own assessment of the degree of discomfort she is experiencing.
On the other hand, evidence now indicates that HRT can protect against de-
generative diseases that seriously compromise the quality of life beyond the
sixth decade. The two most compelling reasons for using long-term HRT are
1) that estrogen helps to maintain bone density, thereby protecting against os-
teoporosis (Lindsay et al. 1980) and 2) that estrogen administration reduces
mortality from cardiovascular disease by two-thirds (Bush et al. 1987) and ul-
timately reduces mortality from all causes by 10%60% (Henderson et al.
1991). Evidence from epidemiologic studies suggests (but does not prove)
that HRT may also reduce the risk of Alzheimers disease in women by 30%
50% (Paganini-Hill and Henderson 1996). The accumulated research find-
ings therefore strongly suggest that postmenopausal women who receive
HRT experience both increased longevity and an enhanced quality of life
during the latter decades of their life span.
Risks of Hormone Replacement Therapy
It became clear in 1975 that the use of unopposed estrogen was associated
with a marked increase in the incidence of endometrial cancer (Weiss et al.
1976). Adding a progestin to the therapy for 1012 days each month effective-
ly protects the endometrium from the stimulatory effects of estrogen (Gelfand

and Ferenczy 1989), and estrogen-progestin regimens given either continu-
ously or in cyclic sequence are now recommended as HRT for women with
an intact uterus.
Orally administered estrogen induces changes in hepatic metabolism
that could have adverse influences. Among these potential changes are in-
creased production of renin substrate and decreased production of antithrom-
bin III (DeLignieres et al. 1986). No increased incidence of hypertension or
thrombosis has been noted, however, in postmenopausal women receiving
oral estrogen replacement (Ettinger 1988).
Considerable controversy has existed regarding the association between
HRT and the incidence of breast cancer in postmenopausal women. A qual-
itative review of studies on estrogen and breast cancer published between
1970 and 1995 concluded that short-term use of estrogen (5 years or less)
does not increase breast cancer risk, whereas longer durations of use may be
associated with a small but significant increase in risk (Ewertz 1996).
Despite the knowledge gained during the past 10 years with respect to
the beneficial effects of HRT for postmenopausal women, its use is not man-
dated for all such women. For example, not every women is at risk for the
development of osteoporosis. Indeed, it has been established that tall, slim,
small-boned Caucasian women who smoke are at greatest risk. The decision
as to whether an individual woman is a suitable candidate for HRT should,
therefore, be predicated on assessing her risks and providing her with infor-
mation so that she can be a full partner in the decision-making process.
Psychosocial Issues for Women in Midlife
Psychologic Theories
Historically, psychologic theorizing with respect to the etiology of menopaus-

al symptoms first occurred within the psychoanalytic framework. The psy-
chologic loss theory of menopause is based on the contention that the ability
to bear children is central to the meaning of a womans life. Logically, then,
to lose this ability is to lose lifes meaning (Deutsch 1945). Other Freudians
have expressed the view that menopause is symbolic castration (Benedek
1950) and deprives the woman of any means of compensating for the anger,
hopelessness, and frustration she has always felt at not being born a male
(Prados 1967). With regard to treatment of symptoms that arise at this time,
psychoanalytic theory is geared toward helping women accept the mortifica-

tion of menopause (Deutsch 1944).
Sociocultural Theories
The sociocultural model posits that the major determinants of psychologic

disturbance at the time of menopause are role changes and cultural attitudes
toward aging. The culture of a given society may be regarded as that which
attributes meaning to reality and thereby transforms a natural or biologic
event into a cultural event. It follows that the psychologic impact of meno-
pause will be strongly influenced by the importance a particular culture at-
taches to procreation, fertility, aging, and female roles (van Keep and Prill
1975). Cross-cultural studies have shown that menopause is indeed experi-
enced differently in different cultures. In cultures in which women receive
rights at menopause that were denied them during their fertile period (e.g.,
some castes in India), menopausal symptoms are minimal (Flint 1975; Maoz
et al. 1977). Because North American society is youth oriented and stereo-
types of aging women are largely negative, our culture does not provide a
supportive environment for menopausal women.
Level of education and socioeconomic factors also seem to influence the
experience of menopause. Several authors from different countries have re-
ported that menopausal women with less education and from lower socioeco-
nomic classes have a higher degree of symptoms at menopause than do more
advantaged women (Jaszmann et al. 1969; Maoz et al. 1977; van Keep and
Kellerhals 1974).
Postparental Phase and Other Transitional Phenomena
Menopause, of course, occurs during midlife, a time that is commonly regard-

ed as a period of psychosocial transition and readjustment. Women who here-
tofore had heavily invested their emotion and energy in childbearing are
forced to redefine their role at menopause because the children are growing
up and leaving the home and reproductive capacity ceases. From the perspec-
tive of role theory, it would be important at this time to develop new, alternate
roles in order to maintain self-esteem when old roles lose importance (Havi-
ghurst 1966). The departure of grown children from the parental home,
which tends to occur coincident with menopause, has come to be known as
the postparental stage of life. Some authors hold that this change inevitably
constitutes a psychologic loss because the mother loses one of her major roles
and thus the rewards that accompanied it (Blood and Wolfe 1960). This for-
mulation, therefore, points to the conclusion that depression occurring during
menopause may be caused by empty-nest syndrome.
In fact, a careful reading of the literature suggests that this conclusion is
a function of the population studied. For example, menopausal women who
are hospitalized with a major depressive disorder after their last child has left
home have been characterized as having had overprotective or overinvolved
relationships with their offspring (Bart 1971; Bart and Grossman 1978). Re-
sults of general population surveys tell another story. In nonclinical popula-
tions, middle-aged women whose children had left home reported somewhat
greater happiness, enjoyment of life in general, and greater marital harmony
than did women of similar age with at least one child still living at home
(Glenn 1975). The findings of this cross-sectional study are consistent with
those of retrospective (Deutscher 1964) and longitudinal (Clausen 1972) in-
vestigations of the postparental stage in nonclinical populations. This evi-
dence indicates that, for previously well-functioning middle-aged women, the
so-called crisis of the empty nest is mythical.
Certain life stresses may be temporally linked with menopause. Some of
the negative events that may occur in a womans life at this time include onset
of a major illness or disability in her spouse, death of her spouse, employment
uncertainty for either partner, the need to care for ones own elderly par-
ent(s), and loss of support from important friends or family through illness,
death, or geographic relocation. It is clear that stressful life events, particular-
ly losses or bereavements, may lead to somatic or psychologic symptoms for
women during the climacteric (Greene and Cook 1980) just as they do during
other life phases.
Studies of the impact of marital status on the experience of menopause
are equivocal, probably because it is the quality and not the fact of the rela-
tionship that determines whether it serves as a buffer against other life stress-
es (Gove et al. 1983). Studies in the United States (McKinlay et al. 1987) and
England (Hunter 1990) have found that single women were least likely to be
depressed, followed by married women and those who were widowed, di-
vorced, or separated. Moreover, less well-educated women who were wid-
owed, divorced, or separated were the most likely to be depressed (Hunter
1990).
Sexuality
Survey data generally show a considerable incidence of problems in various
aspects of sexual functioning in postmenopausal women. Various studies
have reported a 10%85% decrease in sexual interest (Cutler et al. 1987; Mc-
Coy and Davidson 1985) and a 16%47% decrease in the frequency of or-
gasm (Hallstrm 1977; Kinsey et al. 1953) in menopausal women. Although
numerous studies have found that exogenous estrogen alleviates atrophic
vaginitis and associated dyspareunia and increases vaginal lubrication
(Morrell et al. 1984; Myers and Morokoff 1986), exogenous estrogen failed
to increase sexual desire or libido. Several prospective studies of surgically
menopausal women, however, have demonstrated that the addition of test-
osterone, which is normally produced by the ovaries, to an estrogen replace-
ment regimen increased sexual desire, sexual arousal, and the frequency of
sexual fantasies compared with women treated with estrogen alone (Sherwin
et al. 1985; Sherwin and Gelfand 1987). The consistency between these find-
ings and those of investigators in England (Cardozo et al. 1984) and Australia
(Burger et al. 1984) who used subcutaneously implanted pellets containing
both estradiol and testosterone strongly suggests that in women, as in men,
testosterone is the sex steroid that is critical for the maintenance of sexual
desire.
Numerous nonhormonal factors may also influence sexual functioning
in postmenopausal women. Clearly, one such factor is the desire and capacity
of the partner for sexual activity (Davidson et al. 1983). A positive relation-
ship also exists between previous sexual interest or importance of sex and the
frequency of sexual activity in later middle life (Pfeiffer and Davis 1972). Fi-
nally, cultural and societal notions of sexual attractiveness and attitudes con-
cerning the expression of sexuality beyond the reproductive years also have
a significant influence on the maintenance of sexual activity in middle-age
and elderly women.
Life Begins at Fifty
With so much emphasis on the negative impact of the changing hormonal mi-
lieu and the losses and life stresses that often occur coincident with meno-
pause, the fact that this reproductive event is welcomed as a positive event by
many women is frequently ignored. For example, the departure of children
from the home also means that women are able to redirect their time and en-
ergy to tasks and activities that bring other important sources of gratification.
Reentering the work force or devoting more time to an already established
career, travel, and other leisure activities are all potential benefits of the post-
parental years. Solid marital relationships may become closer and more inti-
mate at a time when a couple has more opportunity to spend time alone
together. Moreover, the absence of menstrual cycles and the accompanying

freedom from the need to be concerned about birth control methods may
serve to enhance the sexual relationship. Although the climacteric can be
characterized as potentially offering the opportunity for freedom to explore
new roles, it should be noted that this freedom presumes both the time and
the personal and economic resources for such explorations, which a middle-
class bias often ignores.
Menopause and the Mental Health Professional
The most common reason for referring a menopausal woman to a mental

health professional is for the diagnosis and treatment of a depressive disorder
associated with the endocrine changes occurring during this reproductive
event. Recent studies have failed to confirm the existence of involutional mel-
ancholia as a distinct subtype of depressive illness, leading to its removal from
current psychiatric nomenclature. A great deal of evidence has shown, how-
ever, that depressive symptomsif not a distinctive syndromeare experi-
enced by many women at the time of menopause. Clinical observations
suggest that women who experienced premenstrual syndrome during their
reproductive years and those with a history of depressive illness may be at a
greater risk for the development of a depressive episode at the time of meno-
pause than are women without such a history.
The initial approach to the management of mood and behavioral infor-
mation on disturbances in menopausal women requires information on the
womans symptoms and the hormonal context in which they occur, a person-
al history of depression, a family history of affective disorder, feelings about
aging and mortality, and concurrent life stresses. If a woman is experiencing
distressing signs of estrogen deficiency, such as hot flashes and vaginal dry-
ness, has no contraindications to HRT (such as a history of breast cancer),
and does not fulfill diagnostic criteria for a major depressive disorder, then a
trial of HRT may be indicated as a first approach. Women who have under-
gone surgical menopause usually experience more severe symptoms of estro-
gen deficiency, owing to the abruptness of the change in their hormonal
milieu. In the absence of contraindications, HRT would be particularly im-
portant for these women. In these cases, it is also critical to explore the psy-
chologic impact of the hysterectomy and bilateral oophorectomy and the
reasons that necessitated the surgery.
Because of the demonstrated ability of estrogen to alter the concentra-
tions or availability of neurotransmitters in the synapse, it is possible that

menopausal women with affective symptoms in the presence of mild or min-
imal hypoestrogenic somatic symptoms may also respond to a trial of HRT.
It is important to note, however, that presently no evidence suggests that a
major depressive illness will be significantly alleviated by the doses of estro-
gen conventionally used to treat postmenopausal women. The decision to in-
stitute adjunctive psychopharmacotherapy will depend on the severity and
duration of the depressive symptoms and on the premorbid and family histo-
ry of affective illness.
Acknowledgment
The preparation of this manuscript was supported by a grant from The Med-
ical Research Council of Canada (No. MA-11623) awarded to B.B. Sherwin.
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13
Chronic Gynecologic Pain
JOHN F. STEEGE, M.D.
ANNA L. STOUT, PH.D.
This chapter reviews vulvovaginitis and chronic pelvic pain, two of the most
vexing problems in clinical gynecology. Both problems are marked by their
often chronic and intractable natures as well as by the frequent contribution
of psychologic factors to their severity. They represent opportunities for effec-
tive collaboration between the gynecologic and mental health specialties.
Types of Chronic Gynecologic Pain
Vulvovaginitis
Vaginal yeast infections, trichomoniasis, and the mixed infection of bacterial

vaginosis are extremely common. Monilial (yeast) vaginitis typically is
marked by a white, cheesy discharge; trichomoniasis (Trichomonas vaginalis in-
fection) by a frothy, mildly malodorous discharge; and bacterial vaginosis by
a chronic, intermittent, irritating, and malodorous discharge. Women with
such clearly identifiable acute symptoms and signs will seldom require mental
health consultation. Many women with these disorders, however, may later
develop chronic continuing vaginal and vulvar symptoms, even though the
bacteriologic precipitants may have been brought under control. The possible
role of psychologic factors in perpetuating symptoms may lead to referral for
psychologic evaluation.
More troubling than these entities is the patient who undergoes careful,
frequent examinations with no pathogenic organisms visualized. Gynecolo-
gists often recognize that such individuals may be unduly focused on any per-
261
ceived irregularities of vaginal sensation or secretion. Intense symptoms of

vaginal discomfort may be a calling card or presenting symptom for affec-
tive disorders, anxiety disorders, marital discord, somatization tendencies, or
sexual dysfunction. For example, continued dyspareunia may be caused by
vaginismus triggered by repeated uncomfortable vaginal events associated
with vaginitis. When pain persists, the patient may return to her physician,
claiming that her vaginitis is back, assuming that any pain in this area must
be caused by recurrent infection. This situation may benefit from collabora-
tion between the gynecologist and the mental health clinician.
In the postmenopausal patient, specific vaginal infections are far less
common, except for atrophic vaginitis in women who are not receiving estro-
gen replacement therapy. Postmenopausal women, however, are prone to the
development of vulvar dystrophies, which can present with intense vulvar
burning and itching in the absence of any significant vaginal infection. These
distressing symptoms can become such an impediment to normal functioning
that they may precipitate depressive episodes. Conversely, vulvar symptoms
may represent a depressive equivalent.
Chronic Pelvic Pain
Pelvic pain is usually defined as chronic when it has lasted for 6 months or
more on a continuous or a cyclic basis. It may be useful to distinguish be-
tween patients who have pain that is chronic and those who have a true
chronic pain syndrome. In chronic pain syndrome, the pain is accompanied
by impaired function in recreational activities and household responsibilities,
possible vegetative signs of depression (especially sleep disturbance), and sig-
nificant alterations in the patients roles within her family (Steege et al. 1991).
Psychologic evaluation and treatment are often helpful in such patients.
Dyspareunia
Dyspareunia, or painful intercourse, is usually described as being either in-

troital (in the area around the opening of the vagina) or deep (Steege 1984).
Patients often describe introital dyspareunia as pain at the opening or as
trouble getting in during intercourse. The pain is usually continuous but
can be exacerbated perimenstrually in the presence of contributing factors,
such as recurrent nonilial vaginitis or inflammation of the vestibule. Deeper
pelvic pain is often described as pain inside or by noting that the partners
penis feels as though it hits something. Traditionally, deep dyspareunia has
Chronic Gynecologic Pain 263
been felt by gynecologists to be more likely causd by organic factors, whereas

introital dyspareunia is more often psychologically based. Although these
generalizations are still partly valid, enough exceptions occur to impel careful
inquiry into all aspects of the problem. A careful history should delineate the
location of the pain, the relationship of the pain to the sexual response cycle,
and any alterations of the sexual response cycle. Tactful inquiry should be
made regarding any variation of symptoms with different sexual partners.
General Pelvic Pain
Pain that is present over the entire lower pelvic area, sometimes greater in
intensity on one side than on the other, may occur on either a cyclic or a
continuous basis. Cyclic discomforts are more typically associated with en-
dometriosis, although pain associated with pelvic adhesive disease can also be
somewhat cyclic, being worse before and during menstruation. Similarly,
pain that is possibly attributable to pelvic congestion (overdistention of the
pelvic venous system) will often be worse premenstrually (Beard et al. 1989).
Worsening endometriosis often starts out as cyclic dysmenorrhea, with the
pain gradually subsuming more and more of the menstrual month as time
goes on. Continuous pain is more often caused by adhesive disease that is ei-
ther postinfectious or postsurgical in nature. Dyspareunia may be present,
along with chronic daily pain. It is more common when the pelvic pathology
is central in location rather than in the adnexal areas.
The role of organic pathology in the pathophysiology of chronic pelvic
pain is poorly understood despite research efforts (Steege et al. 1991). Most
series in the literature report that no abnormal laparoscopic findings are
present in approximately 10%60% of women undergoing this procedure for
evaluation of chronic pelvic pain. These numbers, however, may be an over-
estimation of the percentage of negative pelvic findings, because most of the
studies were published before it was recognized that endometriosis can
present in atypical or unpigmented forms. A woman with negative findings
on laparoscopy may nevertheless have some physical contributions to her
pain, such as trigonitis, urethritis, functional pelvic musculoskeletal problems,
postural changes, or irritable bowel syndrome. Some of the studies describing
psychologic profiles in women with negative laparoscopies fail to describe
evaluations for such problems.
Sizable fractions of women with organic pathology also demonstrate sub-
stantial psychologic changes on psychometric testing and clinical or struc-
tured interview (Castelnuovo-Tedesco and Krout 1970). This confusing
picture makes it clinically difficult to decide in an individual case whether the

primary difficulty is physiologic or psychologic. For example, several studies
document that women with organic pathology, most often endometriosis or
adhesions, will more often have pelvic pain than those without any organic
pathology. Although the location of the pain often correlates with the location
of the pathology, the intensity of the pain demonstrates no quantitative rela-
tionship to the amount of tissue change present (Fedele et al. 1990; Stout et
al. 1991). It therefore remains a matter of difficult clinical judgment to decide
on the appropriate medical or surgical treatments of the organic pathology.
Diagnosis and Treatment
Vulvovaginal Symptoms
Vulvovaginitis
A complete evaluation of vulvovaginitis includes a careful history of sexually
transmitted diseases, use of intrauterine devices, the medical risk factors de-
scribed previously in this chapter, and a sexual history. Physical examination
should include a complete routine pelvic examination as well as a microscopic
examination of the vaginal secretions for the detection of Trichomonas, a search
for the clue cells indicative of bacterial vaginosis, and a rough quantitation of
yeast forms. Specific cultures for yeast are seldom of benefit, because they are
often positive in asymptomatic women and do not provide a quantitative
measure. T. vaginalis cultures may be useful in the rare instance when symp-
toms appear to be typical of that disease, but the microscopic test is not diag-
nostic. Cultures for bacterial vaginosis are useful only on a research basis.
In the postmenopausal woman with intense vulvar symptoms, careful vi-
sual inspection of the vulva is essential. A biopsy should be performed to
evaluate any suspected abnormalities. Vulvar carcinoma is notoriously diffi-
cult to recognize visually, and the vulvar dystrophies are so varied in appear-
ance that biopsy is often necessary for proper diagnosis.
In many situations these diagnostic tests are indeterminate, yet the symp-
toms persist. Often, the gynecologist in this situation may prescribe topical
steroids and other vaginal medications as therapeutic trials. When the mental
health professional sees such a patient, it is often useful to initiate a candid
dialogue with the gynecologist to better understand the degree to which bac-
teriologic or fungal diagnoses are truly well established.
Vulvodynia
Vulvar pain without any evidence of visual or intraepithelial change is a per-
plexing problem for both the gynecologist and the mental health professional.
Investigation by routine histologic and culture techniques is often unreveal-
ing. Present studies are focused on the potential role of human papillomavirus
in this disorder, but results are far from conclusive. Although allowing the
possibility of as-yet undiscovered organic etiologies, health professionals
must be prepared to deal with the often simultaneous problems of significant
depression and despair for such patients in the face of continuing symptoms.
These symptoms may also be somatic symptoms of a primary psychiatric
condition.
Chronic Pelvic Pain
Adequate assessment of chronic pelvic pain includes a careful chronologic

history of pain development as it affects the womans daily life. Disability of-
ten develops gradually, and particular inflection points in the curve of disabil-
ity may be punctuated by external life events or events within the family. A
careful history should also include the chronology of the development of any
particular sexual dysfunctions. Although such dysfunctions may be initially
triggered by organic events, they may become chronic. Sexual dysfunctions
may be more apt to occur in women with previous difficulties in sexual ad-
justment.
In a careful physical examination for chronic pelvic pain, the examiner
should systematically look for vulvar epithelial changes and sensitivity, vagi-
nal introital muscle tone and control, levator plate tension, cervical motion
tenderness, and general pelvic tenderness during the bimanual and rectovag-
inal examinations. The two conditions most often associated with chronic
pelvic painendometriosis and adhesionsare often difficult to detect by
physical examination and imaging techniques. Laparoscopy should be freely
used for diagnosis and probably for treatment of these conditions. In one en-
couraging report of laparoscopic adhesiolysis, long-term relief was noted in
75% of women without a chronic pain syndrome as defined previously in this
chapter and in 40% of those with chronic pain syndrome (Steege and Stout
1991). Other reports have noted improvement rates of 50%85% following
such procedures (Daniell 1989; Sutton and MacDonald 1990), depending to
some extent on the degree of adhesive disease treated.
Psychologic Aspects of Chronic Gynecologic Pain
Early reports in the medical literature implied that women who reported
chronic pelvic pain had a high degree of feminine identity problems arising
from conflicts regarding adult sexuality (Gidro-Frank et al. 1960), psychiatric
disturbance characterized by mixed character disorders with predominant
schizoid features (Castelnuovo-Tedesco and Krout 1970), and high neuroti-
cism and unsatisfactory relationships (Beard et al. 1977). Studies by Duncan
and Taylor (1952) and Benson et al. (1959) reported an association between
the onset of symptoms of pelvic pain and emotional stress.
Although these initial studies identified the importance of psychologic
factors in patients with chronic pelvic pain, some of their generalizations
about psychopathology have been questioned from several perspectives. Be-
cause some physical abnormalities that cannot be identified on pelvic exami-
nation can often be observed on laparoscopic surgery, women who were
considered to have normal pelvic examinations in early studies may be diag-
nosed with some type of organic pathology if evaluated by currently accepted
diagnostic procedures. In a study of 1,200 women undergoing diagnostic lap-
aroscopy for pelvic pain, Cunanan et al. (1983) found that 63% of the women
with normal pelvic examinations before diagnostic laparoscopy had abnor-
mal findings on diagnostic laparoscopy. On the other hand, questions have
been raised about the assumption of a cause-and-effect relationship between
physical findings and pain symptoms. Kresch et al. (1984) identified some
possible pathologic conditions in 29% of asymptomatic women who under-
went laparoscopic surgery for tubal ligation. Recent work with diagnostic lap-
aroscopy under conscious sedation technique, with the purpose of mapping
the association of pain with pelvic organs and their pathology, may provide
clinically useful information about both the patients general level of visceral
and somatic sensitivity and the role of pelvic pathology in causing pain (Palter
et al. 1996; Steege 1997).
Conclusions of previous studies suggesting the high prevalence of psy-
chopathology are called into question by other methodologic issues, includ-
ing 1) a selection bias in the sample of patients studied psychologically,
because of the high refusal rates for psychologic assessment reported in some
studies, 2) a potential bias of psychologic evaluators not blinded to the pres-
ence or absence of organic disease, and 3) a lack of appropriate control
groups to establish population base rate data for psychosocial factors, such
as marital and sexual adjustment difficulties. In all of the studies of which
we are aware, limited information is available on the psychologic status of
pelvic pain samples before onset of pain.

Some of the confusion about the relative contribution of psychologic fac-
tors in chronic gynecologic conditions has probably arisen because of the
varying definitions of chronic pelvic pain and other gynecologic conditions.
At least three different operational definitions of chronic pelvic pain appear
in the literature with some frequency. These definitions focus on different as-
pects of the chronic condition: 1) duration (chronic pelvic or gynecologic pain
that has lasted 6 months or longer, a time marker used in other chronic pain
conditions); 2) anatomic-chronic (pelvic or gynecologic pain lacking an ap-
parent physical cause sufficient to explain it); and 3) affective-behavioral (pain
accompanied by significant disturbance of mood and altered physical activi-
ties such as work, recreational, or sexual activity).
Studies in which psychologic inquiry has focused on patients for whom
no apparent physical findings can be identified may reflect more psychologic
contributions to the pain. Obviously, chronic pelvic pain samples selected on
the basis of accompanying affective disturbance may be expected to reflect a
strong association with depressive symptoms. Other studies that have select-
ed patients with chronic pelvic pain on the basis of pain duration may include
women with documented organic pathology, most commonly endometriosis
and pelvic adhesive disease; however, these women may report varying levels
of pain severity and impairment. Stout et al. (1991) reported that the extent
of physical disease evaluated by diagnostic laparoscopy did not correlate sig-
nificantly with ratings of pain levels or several other indices of impairment.
These findings confirmed the need for exploration of other factors such as
psychologic variables, which have been shown to account for a significant
portion of individual differences in functional impairment in other pain
conditions.
In the literature on chronic pain, investigators have examined several
personality variables, including anxiety, depression, and certain patterns on
personality inventories that have been described as neurotic, particularly
those characterized by hypochondriasis and somatization tendencies (Stern-
bach 1974). In several studies (Chaturvedi 1988; Papciak et al. 1987; Postone
1986), alexithymia (lack of words for feelings) has been investigated as a
personality characteristic that may promote and maintain pain symptoms.
Bradley et al. (1981) pointed out that an important shortcoming of many per-
sonality studies is that most such studies of patients with chronic pain present
composite responses, therefore fostering an inaccurate picture of homogene-
ity in these patients. Keefe et al. (1986) found that depression was a significant
predictor of pain behavior in patients with low-back pain independent of
demographic or medical status variables. However, psychologic variables

(depression, anxiety, helplessness) were not found to be independent predic-
tors of pain behaviors in patients with rheumatoid arthritis (Anderson et al.
1988), pointing out the danger of generalizing from one chronic population
to another.
In reviewing studies of chronic pelvic pain (specifically focusing on those
in which diagnostic laparoscopy was used to investigate the organic compo-
nent) and other chronic gynecologic conditions, an association has been noted
between these conditions and certain psychologic variables. Rosenthal et al.
(1984) administered the Minnesota Multiphasic Personality Inventory (MM-
PI) (Hathaway and McKinley 1970) to 163 consecutive patients referred for
chronic pelvic pain, 60 of whom underwent diagnostic laparoscopy. The most
frequent finding was a somatizing pattern (elevations on scales 1 and 3). Ab-
normal physical findings were present in 75% of the women who underwent
diagnostic laparoscopy; however, 75% of those patients thought to have an or-
ganic cause for their pain also had evidence of psychopathology on the MM-
PI. The MMPI was therefore a poor predictor of organic pathology.
Magni et al. (1986) examined the psychologic characteristics of 30 wom-
en who underwent diagnostic laparoscopies for chronic pelvic pain and 30
matched controls using the Middlesex Hospital Questionnaire (Crown and
Crisp 1966) and the Zung Self-Rating Depression Scale (Zung 1965). No dif-
ferences in somatization scores were observed in patients with chronic pelvic
pain with or without organic pathology, although both groups had higher
scores than did control subjects. Patients with pelvic pain and without ob-
served physical pathology were, however, more depressed than were patients
with organic pelvic pain and controls.
Harrop-Griffiths et al. (1988) used a structured psychiatric interview (the
National Institute of Mental Health Diagnostic Interview Schedule; Robbins
et al. 1981) in a study of 25 women with chronic pelvic pain and 30 women
with other gynecologic concerns. They found that patients with chronic pel-
vic pain had a significantly higher prevalence of lifetime major depression,
current major depression, lifetime substance abuse, adult sexual dysfunction,
and somatization. Stout and Steege (1991) found that 50% of 294 women
seeking evaluation at a pelvic pain clinic scored in the depressed range (< 16)
on the Center for Epidemiologic Studies Depression Scale (Radloff 1977) at
the time of their initial visit. Slocumb et al. (1989) found that patients with
abdominal pelvic pain syndrome scored higher as a group on the Hopkins
Symptom Checklist (Derogatis et al. 1974) scales of anxiety, depression,
anger-hostility, and somatization; they also pointed out, however, that 56% of
the patients with pain rated themselves within the normal range on all scales.
Stewart et al. (1990) found that women with clinically unconfirmed vul-
vovaginitis were significantly more emotionally distressed than were the
women with confirmed vulvovaginitis and healthy control subjects.
Sexual history has been explored in several inquiries, indicating that
women seeking treatment have a high incidence of sexual trauma, including
molestation, incest, and rape (Beard et al. 1977; Duncan and Taylor 1952;
Gross et al. 1980; Haber and Roos 1985; Raskin 1984; Reiter and Gambone
1990; Schei 1991; Walker et al. 1988). In the study by Harrop-Griffiths et al.
(1988), the two groups undergoing diagnostic laparoscopies were also admin-
istered a structured interview on sexual abuse. Patients with chronic pelvic
pain with or without positive laparoscopy findings were more likely than con-
trol subjects to have experienced childhood and adult sexual abuse. In the
study by Reiter and Gambone (1990), 48% of 106 women with chronic pelvic
pain had a history of major psychosexual trauma (molestation, incest, and
rape), as compared with 6.5% in a control group of 92 pain-free control sub-
jects presenting for annual routine gynecologic examinations (P < 0.001).
Rapkin et al. (1990) did not find a higher prevalence of childhood or adult
sexual abuse in a group of women with chronic pelvic pain than in women
with chronic pain in other locations or in control subjects, although women
with chronic pelvic pain reported a higher prevalence of childhood physical
abuse. The authors concluded that their findings did not support the hypoth-
esis that pelvic pain is specifically and psychodynamically related to sexual
abuse and suggested that abusive experiences, whether physical or sexual,
may promote the chronicity of many different painful conditions.
As might be expected, many of these same studies also report a high in-
cidence of marital distress. Stout and Steege (1991) found that 56% of 220
married women presenting for evaluation of chronic pelvic pain scored in the
maritally distressed range (< 100) on the Locke-Wallace Marital Adjustment
Scale (Locke and Wallace 1959).
Women presenting with chronic gynecologic conditions often present
with concomitant sexual dysfunction, particularly dyspareunia. Although es-
tablishing accurate baseline functioning is difficult, some women report satis-
factory sexual functioning before the onset of pain symptoms, whereas others
appear to have long-standing sexual difficulties. In any case, sexual dysfunc-
tion is likely associated with chronic gynecologic pain, either as an antecedent
or as a consequence. Decreased sexual desire and conditioned vaginismus are
correlates of this problem that often need specific intervention in addition to
any indicated medical treatment.
Because studies to date have been cross-sectional in design, it is not pos-

sible to determine whether the negative psychologic states reported are a pre-
disposing factor or a reaction to the pain condition. It is important to note that
no significant differences in personality or psychosocial variables have been
found in most studies of women with chronic pelvic pain with or without
identified organic pathology, perhaps suggesting that chronic pelvic pain in
some women may be more closely associated with psychosocial factors than
with organic factors. In reviewing the literature regarding the relationship be-
tween chronic pain and depression, Romano and Turner (1985) concluded
that at least two distinct groups of chronic pain patients may exist: one sub-
group in which pain and depression are a final common presentation reached
by a number of pathways and a second group in which depression develops
in reaction to pain, as occurs in some other acute and chronic medical diseas-
es. Patients with chronic gynecologic conditions also appear to be a heteroge-
neous group; however, the high prevalence of sexual trauma, marital and
sexual dysfunction, and emotional distress in previously studied samples of
these patients warrants specific attention to these areas in any clinical evalua-
tion. Further research is needed to explore whether these psychosocial factors
have a specific relationship to the development and persistence of chronic gy-
necologic conditions.
Management of Chronic Gynecologic Pain
In current gynecologic practice, the woman usually referred for psychiatric

care has had negative laparoscopy resultsthat is, the referring physician be-
lieves that gynecologic causes have been ruled out. Unfortunately, it is far
more common for the patient to have some organic pathology and to have
been repeatedly subjected to medical and surgical measures in pursuit of pain
relief. Many of these women have developed a chronic pain condition, char-
acterized by significant changes in mood and activities, that needs behavioral
and psychologic approaches as well as psychopharmacologic treatment in
some cases. This group of patients with chronic pain presents an opportunity
for fruitful collaboration between the gynecologic and mental health special-
ties. In most of these cases it is clinically difficult to diagnose any particular
underlying psychopathology as the precise cause for the pain. More often,
clinical judgment will determine that attention to both physical and psycho-
logic factors may be important, that both should proceed simultaneously, and
that the hope of assigning a particular degree of responsibility to either ele-
ment must be surrendered. In some cases, the treatment of intrapelvic pathol-

ogy by laparoscopic approaches, such as lysis of adhesions or vaporization of
endometriosis, may be useful. When the parameters of chronic pain syn-
drome described here are also present, however, behavioral and psychologic
assistance is also required.
Reports of controlled trials of psychologic interventions specifically for
chronic pelvic pain are very limited; however, increasing evidence substanti-
ates the belief that combined medical and psychologic approaches are likely
to result in greater improvement than are gynecologic treatments alone in
many women with chronic pelvic pain. Pearce et al. (1987) reported the re-
sults of a prospective, randomized, controlled trial of two different psycholog-
ic interventions in the treatment of chronic pelvic pain. Seventy-eight women
with chronic pelvic pain of at least 6 months duration and with no obvious
pathology observed on laparoscopy were allocated to a pain analysis, a stress
analysis, or a minimal-intervention control group. All groups received an ex-
planation of the pain as being caused by abnormalities in pelvic blood flow.
In addition, the stress analysis group received training in identifying and im-
plementing alternative cognitive and behavioral responses to concerns other
than pain and in applying Jacobsonian relaxation strategies in stressful situa-
tions. The pain analysis group focused on monitoring and modifying events
antecedent and consequent to pain, graded exercise, and reinforcement of
well behaviors. Both the stress analysis and the pain analysis group report-
ed significantly lower pain intensity ratings at 6-month follow-up visits than
did the control group.
In studies by Kames et al. (1990) and Peters et al. (1991), significant im-
provement in pain ratings and functioning was reported after multidisci-
plinary pain management approaches. Peters et al. (1991) randomly assigned
106 patients with chronic pelvic pain to either a standard-approach group or
an integrated-approach group. The standard approach consisted of excluding
organic pathology by diagnostic laparoscopy and then referring the patient
for psychologic treatment if no somatic cause was found. The integrated ap-
proach included attention to somatic, psychologic, dietary, environmental,
and physiotherapeutic factors from the beginning of the evaluation. After a
1-year interval, women in the integrated-approach group showed significant-
ly greater improvement in their general pain experience, in the disturbance of
their daily activities, and in the associated pain symptoms. Because the par-
ticular types of treatments applied to any individual patient were not stan-
dardized in either of these studies, it is unfortunately not possible to identify
the effective therapeutic components in these combined approaches.
In general, the psychologic treatment component of chronic gynecologic

conditions appears to be most effective when psychosocial factors are evalu-
ated simultaneously with organic factors. Although patients with chronic pel-
vic pain are often unwilling to view their pain symptoms as other than
organically based, many individuals are aware of some factors that worsen
their pain, such as worry, muscle tension, or depression. A crucial aspect of
successful psychotherapeutic intervention is making a connection with the pa-
tient at her own level of conceptualization of the pain problem.
Therapeutic interventions for the patient with chronic pelvic pain usually
focus initially on exploring behavioral and cognitive patterns that exacerbate
the pain symptoms and developing coping strategies to interrupt these pat-
terns. New information is often obtained by having the patient record pain
ratings across the day. Depending on the relative influence of particular fac-
tors on pain ratings, psychologic treatment interventions have often included
relaxation training directed at reducing muscle tension components, stress
analysis to identify difficult life areas, assertiveness training to teach skills for
dealing more directly with people or circumstances that may be controlled or
avoided by the patients complaints of pain, and cognitive interventions di-
rected at specific emotional responses to pain that may feed back to increase
anxiety, depression, and perceived pain.
Psychologic approaches may also involve spouses or families to assist in
defining a valued role in the family despite some possible limitations in pre-
vious activities. Changes in sexual activity often accompany pelvic pain, and
specific education and counseling may be required to allow the patient to re-
turn to a level of comfort. Sexual counseling suggestions often include infor-
mation about adequate physiologic arousal, changes in sexual positions, and
instruction in vaginal relaxation exercises to treat a conditioned vaginismus
response. As a trusting therapeutic relationship is established and coping
skills are developed, some women may be receptive to pursuing psychother-
apeutic approaches that are inclusive of broader issues related to unresolved
emotional issues from past experiences.
Medical management of chronic pelvic pain may include the use of anti-
depressants, although therapeutic trials of these agents in treating this condi-
tion are lacking. Tricyclic antidepressants and the newer serotonergic agents
are used by many clinics providing care for patients with chronic pelvic pain.
Although analgesic prescriptions should be limited to nonnarcotic agents,
chronic pain is better treated by the continuous use of such medications,
thereby eliminating the tendency for medication to act as a reinforcer of pain
behaviors or complaints. Other medications aimed at the symptomatic relief
of bladder and bowel dysfunction are often additive. We have found that it is
often better to treat various contributing factors simultaneously. When nar-
cotics are found to be necessary, it is useful to prescribe them on a contract
basisthat is, from one physician, one pharmacy, and at a strictly prescribed
rate with no early refills.
Nonpharmacologic methods are also useful in selected individuals. Alter-
ations of gait or stance that might be traced to a musculoskeletal problem can
be best evaluated by a physical therapist. Chronic spasm of the levator, psoas,
and piriformis muscles can frequently contribute to chronic pelvic pain. Ap-
propriate muscle strengthening, stretching, and relaxation exercises can also
help. Transcutaneous nerve stimulators have been used sparingly in patients
with pelvic pain but are sometimes useful.
When pain and related disabilities are severe, many clinicians feel that in-
tensive inpatient treatment is warranted (Fogel and Stoudemire 1986; Maruta
et al. 1989; Stoudemire and Fogel 1986). In such a case, a multispecialty team,
particularly on a combined medical-psychiatric unit, is the most productive
approach because it may best maintain a balanced approach to the often com-
plicated and integrated psychologic and physical components to chronic pel-
vic pain.
Conclusions
Chronic pelvic pain is a common complaint. Although a minority of women

will present with this problem in the absence of any organic pathology, chron-
ic pain in most women will have developed in the presence of disease process-
es, such as adhesions and endometriosis. It is often clinically impossible to
assign specific degrees of responsibility to physical and psychologic contribu-
tions to pain. Clinical care is therefore facilitated when needs in both areas
are addressed as clinically appropriate and efforts to assign degrees of respon-
sibility are suspended. This approach requires close collaboration between
the gynecologist and the mental health professional.
The patient experiencing chronic pain in the total absence of organic pa-
thology presents a more difficult problem and often represents more long-
standing and complicated psychopathologic processes. Again, collaborative
management will be useful to evaluate and minimize unnecessary treatment
while continuing to offer psychologic assistance aimed at helping the patient
and her family cope with her difficulties.
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14
Gynecologic Disorders and Surgery
PAULA J. ADAMS HILLARD, M.D.
Gynecologic disorders and gynecologic surgery have the potential to evoke

significant emotional responses. A sexually transmitted disease (STD)
contracted from a partner with whom a woman had been intimate suggests
betrayal and violation of trust and self. That some STDs are incurable and
have the potential for carcinogenesis or death as a consequence is understand-
ably terrifying. From the time of menarche, women learn to identify monthly
cycles and rhythms of menstrual function, and disturbances of normal func-
tioning may be distressing. Surgeries on the genital organs threaten child-
bearing potential, sense of feminine identity, and sexual functioning. This
chapter provides background information on several of these common gyne-
cologic concerns and a discussion of the impact that they may have. Although
the potential for adverse psychologic consequences for the individual is signif-
icant and the number of individuals with these common gynecologic problems
is large and increasing, little attention has been directed toward the psychologic
consequences of many of these problems.
Sexually Transmitted Diseases
The current complement of STDs is an alphabet soup of acronyms, including

infections caused by the following organisms: Neisseria gonorrhea (GC for
gonococcus), herpes simplex virus (HSV), human papillomavirus (HPV),
HIV, Chlamydia trachomatis (as yet without a common acronym), and Treponema
pallidum. An increasing number of individuals have experienced disease relat-
ed to one of these organisms, with some types of infections reaching epidemic
proportions, primarily among young adults and adolescents. Although some
277
bacterial infections are easily treated and cured with antibiotics, viral infec-
tions are usually incurable and may have potential sequelae for future health
and fertility, as with chlamydia-associated pelvic inflammatory disease. The
potential for HPV-associated cervical, vulvar, and vaginal intraepithelial neo-
plasia may be significant, and the potential lethality of HIV infection is well
known. Individuals who initiate sexual activity at an early age and those who
have had multiple sexual partners are at greater risk for contracting an STD.
Sexually active adolescents and young adults are a particularly high-risk
group (Bell and Hein 1984; Institute of Medicine 1997).
Public health reporting of STDs is required in all states for N. gonorrhea,
syphilis, and AIDS (not HIV seropositivity). The incidences of HSV, HPV,
and chlamydia are estimates only, although an increasing number of states
are mandating report of these infections (Webster et al. 1993). Nationally, the
rates for gonorrhea and primary and secondary syphilis have declined since
1990, reaching low points in 1993 that were below or approaching year-2000
objectives (225 cases or fewer of gonorrhea and 10 cases or fewer of primary
and secondary syphilis per 100,000 persons). However, rates for both diseas-
es remained higher than the year-2000 objectives for certain population sub-
groups: adolescents and young adults, minorities (especially blacks), and
persons living in the southern United States (Centers for Disease Control and
Prevention 1994b). The greatest number of cases of gonorrhea occurred in
the ages 2024 group (Centers for Disease Control and Prevention 1996b).
Chlamydia trachomatis causes an estimated 35 million infections annually in the
United States (Centers for Disease Control and Prevention 1994a; Judson
1985). Sexually active adolescents and young adults are at particular risk for
chlamydia infections (Bell 1990). From 1986 to 1990, an epidemic of syphilis
occurred in the United States, primarily among drug users who traded drugs
for sex (Webster and Rolfs 1993), and a concomitant increase occurred in the
incidence of congenital syphilis (Dunn et al. 1993). Subsequently, rates of
syphilis have declined (Centers for Disease Control and Prevention 1994b).
Herpes Simplex Virus

It has been estimated that more than 2 million cases of genital herpes occur
annually in the United States (Droegemueller et al. 1987). From 1988 to
1994, the seroprevalence of genital herpes (herpes simplex virus type II, or
HSV-II) in the United States was 22%, corresponding to 45 million infected
people. The seroprevalence was higher among women (25.6%) than among
men (17.8%) and higher among blacks (45.9%) than among whites (17.6%).
Less than 10% of those who were seropositive reported a history of genital
Gynecologic Disorders and Surgery 279
herpes infection (Fleming et al. 1997), which means that many individuals
have been infected with the virus and are potentially infectious to sexual part-
ners but have no history of a typical lesion.
Human Papillomavirus
The rate of consultations with private physicians for HSV and for genital
warts (HPV infections) has increased markedly (Becker et al. 1987); nearly
1.2 million office visits for genital warts were reported in 1988. Cervical HPV
infection is associated with cervical dysplasia and abnormal Pap smears, the
reported rates of which appear to be increasing, especially among adolescents
(P. J. Hillard et al. 1989b), and the degree of abnormality reported on the Pap
smear may range from mild squamous atypia to frankly invasive carcinoma.
This spectrum of abnormalities is often not appreciated by the lay public, who
may view the Pap (or cancer) smear as having only one of two possible re-
sultsnormal or indicative of cancer. Thus the potential exists for the gener-
ation of significant anxiety. Providing patients with accurate information
about this spectrum of abnormalities, the procedures necessary to evaluate
abnormal results (colposcopy and biopsy), and any planned treatment and
expected outcome can help to alleviate this concern (P. J. Hillard et al. 1989a).
In selected patients with mild cervical abnormalities on biopsy results,
observation without specific therapy may be recommended because sponta-
neous regression may occur in up to 60%80% of patients (American College
of Obstetricians and Gynecologists 1994). Compliance with recommenda-
tions for subsequent Pap smears is essential, because progression may also oc-
cur. Fear about possible progression may sometimes paradoxically result in
failure to keep subsequent appointments or in other maladaptive behaviors
(Biro et al. 1991). It has been argued that because mild cervical dysplasia can
be effectively eradicated with a single treatment in a high percentage of pa-
tients, this treatment should be considered for all such patients to spare them
the psychologic and emotional trauma of repeated abnormal cervical cytolo-
gy on follow-up (Tay and Yong 1995). Most clinicians feel that the potential
for morbidity from treatment modalities outweighs any psychologic risk for
most women; however, treatments should be individualized.
Higher-grade abnormalities (cervical intraepithelial neoplasia [CIN] 2,
moderate dysplasia and CIN 3, severe dysplasia, or carcinoma in situ) gener-
ally require ablative therapy, which may range from office laser vaporization
to cervical cryotherapy, hysterectomy, or excision using an electrical current.
Cervical cryotherapy and laser vaporization have been shown to have essen-
tially similar rates of lesion cure or eradication (in the range of 85%90%)
(Townsend and Richart 1983), and thus have largely replaced hysterectomy
as therapy for cervical dysplasia (in the absence of other gynecologic prob-
lems that would warrant a hysterectomy). Reassurances of this fact should be
given at the onset of a diagnostic work-up because the patients fear of hys-
terectomy, with its real and perceived losses, may be an unstated concern.
Loop electrical excision is a newer technique; its efficacy appears to be com-
parable with that of cryotherapy or laser vaporization (T. C. Wright et al.
1992). The type of treatment recommended depends primarily on the prefer-
ences of the treating physician and the modalities available.
In patients who do not fulfill the criteria for outpatient ablative therapy,
cervical conization is necessary. This procedure preserves childbearing poten-
tial with little or no detrimental effect on future fertility or childbearing. Cri-
teria for conization include inability to visualize the lesion completely with
disease of the endocervical canal or significant discrepancy between Pap
smear and biopsy results. Cervical conization involves the removal of a cone-
shaped biopsy specimen using a laser or conventional scalpel. This procedure
is usually performed in an operating room with the patient under general or
regional anesthetic. In the absence of complications, the patient can be admit-
ted and discharged on the same day. The potential for resolution of cervical
dysplasia is good with therapy, but follow-up is critical because recurrences
are possible.
As with other STDs, it is important for women to be aware that their risk
of HPV acquisition is determined not only by their own sexual history and
number of partners but also by those of their partners. Evidence suggesting
that HPV-associated genital lesions are not eradicated by treatment is psycho-
logically distressing for the patient, and the prospect of an incurable disease
is often associated with anxiety. How HPV-related disease is transmitted,
how infectious it is, and the degree of risk of progressive disease remain in
great part unknown (although generally considered to be sexually transmis-
sible, the possibility of nonsexual transmission has been raised). It is distress-
ing that these questions, with very practical implications, remain unanswered
by scientific evidence, and medical professionals who acknowledge the uncer-
tainties related to HPV are sometimes viewed as incompetent or insensitive
to the patients concerns.
HIV Infection
HIV infection is a major cause of morbidity and mortality among women

and children in the United States. In 1995, women accounted for 19% of the
reported cases of AIDS. HIV infection is the third leading cause of death
among all women aged 2544 years in the United States and the leading
cause of death among black women in this age group. An estimated 7,000 in-
fants are born to HIV-infected women in the United States each year; without
treatment, approximately 15%30% of these infants would be infected (Cen-
ters for Disease Control and Prevention 1996a). HIV counseling and testing
services are important for women to reduce their risk of infection or, if al-
ready infected, to initiate early treatment and prevent HIV transmission to
others, including their infants. Attention has been given to the psychologic
factors motivating STD risk reduction and HIV prevention (Darrow 1997;
Gillespie 1997). In addition, the body of literature focusing on the risks of
HIV infection among the seriously and chronically mentally ill is increasing
because the risks of HIV and other STDs are higher in this population
(Carey et al. 1997; Weinhardt et al. 1997). As HIV infection becomes a
chronic disease, the psychosocial factors related to coping behaviors become
important to understand (Nannis et al. 1997). A complete discussion of the
psychiatric conditions associated with HIV infection and AIDS is beyond the
scope of this chapter, but mood disorders, substance use, and organic mental
disorders are common (Judd et al. 1997).
Psychologic Effects
The psychologic effects of STDs have been systematically addressed in only

a limited manner. STDs have been characterized as among the most stigma-
tizing diseases that most Americans . . . acquire (Darrow and Pauli 1984).
The effects have been most extensively studied for genital herpes infections,
but to some extent, psychologic reactions described with herpes may also oc-
cur with any of the other STDs. Psychologic distress related to herpes was
first characterized in a report of herpes self-help groups (Luby and Gillespie
1981).
With herpes, as with other serious disease, the initial diagnosis of the in-
fection may be shocking for the patient; the impact of an STD diagnosis may
be differentiated from that of other infectious diseases by the stigma associat-
ed with STDs in general (Darrow and Pauli 1984). Once the diagnosis is
made, the patient often searches for a cure; he or she subsequently may be
overcome with a sense of isolation and loneliness when, as with HSV or
HPV, the incurable nature of the disease is realized (Luby and Gillespie
1981). A diagnosis of a curable STD, such as gonorrhea or chlamydia, may
not result in such feelings, but HIV infection, with its ultimately fatal out-
come, has great potential for psychologic distress. As concerns increase, an-
ger becomes important. Initially, the patients anger is directed toward the
infecting partner, but it may also be directed toward the physician who is un-
able to cure the viral disease. Anxiety and fears about the infectious nature of
the disease, its impact on future childbearing and fertility, and the potential
risks of cancer may generalize to other areas of the individuals life. Fears
about the impact of the disease on sexual activity, sexuality, and sexual per-
formance begin to surface. Some individuals go on to feel that they are con-
tagious or dangerousa leper effect. Patients may become self-involved,
decide to become celibate, or engage in anti-sexual or moralistic behavior.
Depression, feelings of helplessness, or guilt may increase over time in some
patients and they may ask why me? (Luby and Gillespie 1981), a reaction
similar to that of patients diagnosed with life-threatening illnesses, such as
cancer.
One study (Orr et al. 1989) has reported an association between STDs
and low self-esteem among adolescents, although it is not clear whether prob-
lems with self-esteem are a cause or effect of STD acquisition. Elevated levels
of psychologic disturbance among patients in STD clinics have been noted
(Ikkos et al. 1987), and in some individuals the sequelae of an STD such as
herpes may include a reactivation of underlying psychopathology. The extent
to which these reactions occur and their severity and duration vary among
individuals; however, an awareness of possible psychologic reactions will aid
the physician in helping patients develop the skills to cope with their disease.
Several studies of herpes have reported elevated levels of psychologic dis-
tress with adverse effects on sexuality, self-image, and love relationships last-
ing many months after the diagnosis or initial episode of the disease (J. R.
Hillard et al. 1989). Concern that herpes affects young people at a critical
phase of psychosocial development as they are attempting to develop lasting
attachments has been expressed (Luby and Klinge 1985, p. 494). Attempts
to define individuals or populations at greater risk of significant and long-
lasting psychiatric distress have not been particularly successful, and thus all
individuals who contract herpes (and by extension, other STDs) should be
considered to be at risk for persistent psychologic symptoms (J. R. Hillard et
al. 1989).
Effects of Diethylstilbestrol
The association between in utero exposure to diethylstilbestrol (DES), a syn-

thetic estrogen, and vaginal clear cell adenocarcinoma was first described in
1971, and it has not generally been prescribed during pregnancy since that
date. Thought to decrease the risk of pregnancy loss and miscarriage, DES
was ultimately shown to be ineffective for this indication. Many thousands of
women were exposed to DES before birth, but vaginal adenocarcinoma for-
tunately remains rare, with an estimated risk in exposed women of 1/1,000
or less (Berek and Hacker 1989). Vaginal, uterine, and cervical structural ab-
normalities have also been associated with DES, and infertility and pregnan-
cy loss, including preterm delivery, have been correlated with DES exposure
(Herbst et al. 1981). The prognosis for a good pregnancy outcome in women
exposed to DES is generally good, with reports suggesting that about 80%
will have a live-born child (Herbst and Holt 1990).
Mothers who received DES during pregnancy must deal with feelings of
anxiety, guilt, and anger, particularly if their daughters also have reproductive
problems. Their daughters may themselves be anxious about their own fu-
ture fertility and may feel anger toward their mothers and toward the medical
profession that prescribed the treatment. In one study, however, 80% of DES-
exposed daughters felt trust and alliance with their mothers and doctors and
only a minority reacted with hostility or fear, a finding that ran contrary to
the investigators expectations (Burke et al. 1980). An appropriate physician
patient relationship may be particularly important in minimizing the adverse
emotional sequelae for mothers and daughters exposed to DES.
Psychologic Preparation for

Gynecologic Procedures
Preoperative Preparation for Gynecologic Surgery
Psychologic preparation is an important part of preoperative preparation for

any type of surgery, but particularly so for gynecologic procedures (Youngs
and Wise 1980). A womans first reaction to gynecologic problems depends
on the severity of the diagnosis, its potential or imagined sequelae (life or fer-
tility threatening), the extent of the required treatment (office biopsy, ambu-
latory surgery, major surgery), and the womans own psychologic make-up
and reactions to stress in general. The practicing psychiatrist or other mental
health professional can address gynecologic concerns most effectively if he
or she has a basic understanding of the most frequently encountered gyneco-
logic problems, their management, and the potential issues that commonly
surface.
In any situation involving gynecologic pathology and the recommenda-

tion for operative intervention, informed consent and medical decision mak-
ing are critical (American College of Obstetricians and Gynecologists 1993;
Rockwell and Peitone-Rockwell 1979). The term informed refusal has been pro-
posed as another dimension of this concept (American College of Obstetri-
cians and Gynecologists Committee on Professional Liability 1996). The
acronym BRAIDED has been proposed as a mnemonic for remembering the
basic components of informed consent (Hatcher et al. 1990). Patients should
have a clear understanding of expected Benefits, potential Risks, and Alter-
natives (both medical and surgical); of their right and responsibility to make
Inquiries about the physicians recommendations; and of their right to make
the Decision to withdraw from procedure, to have an Explanation of the type
of surgery planned and its indications, and to have Documentation of all
informed-consent components. Although some physicians consider the in-
formed consent process to be a mere formality, it is essential to patient under-
standing and acceptance of surgery and minimizes the potential for
subsequent misunderstanding or, even worse, a lawsuit. Although this med-
icolegal aspect of informed consent may be foremost in consideration, the
benefits to subsequent physicianpatient communication, understanding,
and trust should not be underestimated. Computer-aided CD-ROM pro-
grams are now available that provide preoperative patient educational mate-
rial, print responses to questions about the surgical procedure, and serve as
an informed consent document (American College of Obstetricians and Gy-
necologists 1995); however, these programs do not replace face-to-face
physicianpatient discussions about the potential risks and benefits of the
surgery.
Psychologic preparation prior to surgery has been addressed relative to
cognitive coping techniques (Ridgeway and Mathews 1982). The logistics of
surgeryhow long hospitalization is expected to last and the average period
of recovery or time off from workare important to convey to every patient.
Specifics about pre- and postoperative procedures may be helpful for some
patients (Johnson et al. 1985; Ridgeway and Mathews 1982). The ability to
predict which women benefit most from which type of preoperative prepara-
tion would be useful, but most of the studies that address coping styles have
been unable to identify predictive factors.
Involving the family or partner in discussions of surgery may be helpful
if the woman chooses to do so. The patients resources and previous coping
skills should be assessed. It should be emphasized that surgery is stressful for
the patient and will require the mobilization of personal resources, including
family and friends (Youngs and Wise 1980). Following a surgical procedure,
psychologic characteristics and coping styles may affect the perception of
pain, the use of pain medication, and other characteristics of postoperative re-
covery (Ridgeway and Mathews 1982; Thomas et al. 1995; Wilson 1981).
The gynecologist may recognize women at higher risk for adverse psycholog-
ic sequelae and refer them for evaluation, counseling, or therapy prior to sur-
gery (Stellman 1990). If the patients degree of anxiety is judged by the
gynecologist to exceed that usually noted, surgery should be deferred (if pos-
sible) pending a referral for psychiatric evaluation (Schwab 1971).
Preoperative preparation includes a discussion of the specific pathology
and indications for the surgery. The type of surgery to be performed should
be described in terms that are understandable but not condescending. For
procedures such as oophorectomy, this discussion should include the expect-
ed benefits, risks, and alternatives as well as the effect on physiology in terms
of the production of ovarian steroid hormones. The need for hormone re-
placement therapy should be addressed. With a hysterectomy, it is important
that the woman understand the basicsthat she will no longer experience
menses and will not be able to have children.
Dilation and Curettage
Disturbances in menstrual regularity, sometimes accompanied by excessively

heavy flow, are common at the extremes of reproductive life, particularly in
the perimenopausal years prior to the cessation of menses. Because the risks
of uterine fibroids and endometrial pathology (including hyperplasia, polyps,
and malignancy) increase with age, histologic sampling of the endometrium
is warranted for abnormal bleeding in women who are over age 40 or who
have other risk factors such as obesity, chronic anovulation, or polycystic ova-
rian disease.
In the past, endometrial sampling typically required a dilation and curet-
tage (D&C), an outpatient procedure typically performed in an operating
room setting under general anesthesia. However, new endometrial sampling
techniques have allowed endometrial biopsies to be performed in the physi-
cians office, and thus fewer patients require a D&C (Grimes 1982); women
also tend to cope better with the less-invasive endometrial biopsy than with a
D&C. Hysteroscopy, in which the endometrial cavity is visualized directly us-
ing fiber optics, is an additional diagnostic tool that may be performed in lieu
of or in addition to a D&C. Evidence for the efficacy of D&C as a therapeutic
technique is not well established despite its widespread use (Grimes 1982).
Sterilization
Female sterilization is now the most frequently chosen contraceptive option

among married and formerly married women (Abma et al. 1997; Mosher and
Pratt 1990). Female sterilization may be performed in the immediate postpar-
tum period or as an interval outpatient procedure. Techniques of tubal occlu-
sion include use of suture, cautery, plastic rings, or clips. Women considering
sterilization should be counseled about alternative methods of contraception,
including male sterilization, which has a significantly lower risk of morbidity
and mortality. Women often feel that because they have assumed the health
risks and discomforts of pregnancy and childbirth, their partner should as-
sume his share of responsibility by obtaining a vasectomy. However, some
women remain protective of the concerns their partners express regarding a
vasectomy as a threat to his potency, virility, and manhood. Some women are
pragmatic in their desire to end childbearing and assume the responsibility
for permanent sterilization just as they have for reversible methods of contra-
ception. A woman in a physically abusive relationship with an obsessively
jealous and controlling man may experience an increase in abuse when mak-
ing a decision for sterilization if the abusive partner attempts to preserve his
control over her by forbidding such a procedure.
Sterilization should be considered to be permanent, although recent stud-
ies have suggested that the procedures risk of failure is higher than previous-
ly recognized (Peterson et al. 1996). Less permanent but still long-lasting
methods of contraception such as an implantable subdermal device (Nor-
plant) or an intrauterine device may be appropriate alternatives for women
who are not ready for sterilization. Regret after sterilization procedures is in-
frequent, ranging from less than 1% to 3% (Huggins and Sondheimer 1984),
but certain groups appear to be at higher risk for subsequent regret. Women
who are younger at the time of the procedure and who later changed part-
ners, those who made the decision for socioeconomic reasons, and those who
had the procedure at the time of an abortion or immediately postpartum may
be somewhat more likely to regret sterilization (Huggins and Sondheimer
1984). Some childless women express a strong desire for sterilization and
should not arbitrarily be denied the procedure. The womans motivation and
expectations regarding sterilization should be explored to ascertain that the
decision is not based on misinformation (e.g., the idea that the tubes will
come untied after a period of time), unrealistic expectations of benefits (e.g.,
the expectation that a faltering marriage will be saved), or a hastily made
decision.
Laparoscopy
Laparoscopy is a surgical procedure usually performed on an outpatient ba-

sis. It involves the use of fiber optics to visualize the pelvic and abdominal
organs in order to explore possible causes of pelvic pain, such as adhesions
or endometriosis, or for other surgical indications. Laparoscopy may also be
considered to be therapeutic when techniques such as laser ablation of en-
dometriosis or lysis of adhesions are performed under laparascopic visualiza-
tion. Laparoscopy, or pelviscopic surgery, is increasingly replacing traditional
open laparotomy procedures, which has resulted in decreased hospital stays,
decreased pain, and possibly decreased costs for the patient. In addition, the
psychologic sequelae of these less-extensive surgeries may be reduced, al-
though this issue has not been addressed systematically. Laparoscopy is now
frequently used to diagnose and remove ectopic pregnancies, and other pel-
viscopic techniques such as ovarian cystectomies, oophorectomies, or myo-
mectomies are being performed laparoscopically by a growing number of
gynecologists. Laparoscopically assisted vaginal hysterectomy is a newer
technique that may be used to avoid an abdominal hysterectomy.
Surgical Procedures to Correct Anatomic Stress Urinary

Incontinence or Pelvic and Vaginal Relaxation
In many women, damage to uterine and vaginal supporting structures during

childbirth and changes related to aging often result in some degree of pelvic
and vaginal relaxation, including cystocele, urethrocele, rectocele, enterocele,
or uterine prolapse. Cystocele refers to the loss of bladder support; urethrocele in-
volves loss of urethral support; rectocele includes weakening of the supporting
fascia in the rectovaginal septum; enterocele is a herniation of the pouch of
Douglas cul de sac into the rectovaginal septum; and uterine prolapse is a weak-
ening of uterine support and uterine descent into the vagina to the vaginal
introitus or beyond. A significant degree of pelvic and vaginal relaxation is
not typically seen in nulliparous women. These conditions may be asymp-
tomatic or may have symptoms, such as stress urinary incontinence, that are
extremely limiting and distressing. Surgery to correct symptomatic pelvic re-
laxation is almost always a purely elective procedure; that is, the decision for
surgery should be dictated by the woman herself, based on the degree to
which her activities are disrupted by her symptoms or the extent of her social
disability as a result of urinary incontinence. Women should be made aware
that incontinence is not an inevitable consequence of aging, and that an eval-
uation of the specific cause frequently leads to therapies, including surgery,

that are helpful or curative.
The types of surgery used for vaginal/pelvic relaxation vary depending
on the anatomic alterations involved. An anterior and posterior colporrhaphy
are frequently performed to correct a cystocele and rectocele, respectively,
and are usually performed in conjunction with a vaginal hysterectomy to cor-
rect the accompanying uterine prolapse. The diagnosis of anatomic stress in-
continence is confirmed by cystometric and dynamic testing, which is used to
rule out other possible causes such as neurologic problems or hyperactive
bladder contractions. If anatomic stress urinary incontinence is a factor, a ret-
ropubic bladder neck suspension may be performed. Sexual dysfunction may
occur after vaginal vault procedures because of vaginal shortening or alter-
ation of the vaginal axis (Amias 1975; Bachmann 1990b; Masters and
Johnson 1966; Sloan 1978).
Expectations for the results of surgery should be discussed prior to the
procedure, because no surgery for stress urinary incontinence is 100% suc-
cessful. In addition, it is important for the woman to understand that al-
though unlikely, it is possible that her voiding problems will be worse after
surgery or that the problem will recur, making it necessary that a second sur-
gical procedure be performed.
Nonsurgical therapies for pelvic relaxation include the use of pessaries,
which provide mechanical support for the pelvic organs. Nonsurgical thera-
pies for stress urinary incontinence include electrical stimulation, urethral
plugs, or vaginal weights and exercises to strengthen the muscles of the pelvic
floor (Newman and Burns 1997; Rackley and Appell 1997). Other behavioral
methods including timed voiding and fluid restriction are frequently helpful
for mild stress urinary incontinence. Most major cities have centers at which
specialists address incontinence problems with sensitivity and expertise.
Hysterectomy
Hysterectomy is the one surgical procedure that has most defined the field of
gynecologic surgery. Hysterectomy rates have declined since 1970 (Easterday
et al. 1983), although a number of factors including physician gender, train-
ing, acceptance of alternatives to hysterectomy, and community practice pat-
terns effect marked variations in the rate (Bachmann 1990a).
Hysterectomy involves the removal of the uterus, including the uterine
cervix, and may be performed transvaginally or transabdominally. Vaginal
hysterectomy is generally accompanied by less postoperative pain and a more
rapid return to normal function. Factors that influence the route of surgical
approach include anatomy, specific pathologic conditions, previous surgery,
physician skill and experience, and the need for associated procedures (such
as a retropubic bladder suspension).
Before the risks of cervical malignancy and premalignancy were recog-
nized, supracervical or subtotal hysterectomy with removal of the uterine cor-
pus, leaving the cervix in situ, was much more commonly performed. In
recent years, supracervical hysterectomy has been performed solely in situa-
tions of excessive hemorrhage or severe pelvic pathology in which further at-
tempts to remove the cervix have been judged to involve life-threatening risk.
However, some resurgence of interest in the supracervical procedure has oc-
curred; proponents argue that retaining the cervix offers fewer adverse effects
on sexual function and less potential for subsequent pelvic relaxation (Cutler
1988; Kilkku et al. 1983; Munro 1997; Scott et al. 1997). Opponents argue
that these potential benefits have not been proven and that leaving the cervix
in situ entails the risk of subsequent cervical intraepithelial neoplasia or inva-
sive cancer.
Women may be confused about which type of hysterectomy their gyne-
cologist has proposed. This confusion arises because the medical term total
hysterectomy, meaning removal of the uterus and the cervix, is often interpreted
by women to mean removal of the uterus and ovaries, the medical term for
which is total hysterectomy with bilateral salpingo-oophorectomy. The literature on ad-
verse reactions to hysterectomy is obfuscated by reports that do not take this
distinction into account. In a premenopausal woman, removing the ovaries
results in a surgical menopause that is usually rapid in onset and has severe
symptoms.
Gynecologists are divided as to the benefits versus the risks of ovary re-
moval at hysterectomy (Garcia and Cutler 1984). Proponents of ovarian con-
servation argue that many normal ovaries would need to be removed to
significantly reduce the death rate from ovarian cancer and that normal ova-
ries continue to produce valuable hormones prior to or even beyond meno-
pause (Underwood 1976). Ovarian steroid hormones significantly impact
many body functions, influence the health of the female genital organs (i.e.,
the vagina and urethra), play a critical role in the preservation of bony mass
and the prevention of osteoporosis, and reduce the risks of cardiovascular dis-
ease (Barrett-Connor and Bush 1991). Thus, the removal of these hormones
without adequate replacement has important adverse health consequences.
Meijer and van Lindert (1992) provided a quantitative model for assessing
risks and benefits of prophylactic oophorectomy, taking into account the risks
of various types of ovarian and breast malignancy, osteoporosis, and cardio-

vascular disease as well as the risks of noncompliance with hormone therapy.
Hormone replacement therapy can often be accomplished with oral or
parenteral (transdermal patch) estrogen and progestin. However, such treat-
ment does have potential side effects in addition to its problems of ongoing
compliance and cost (Speroff et al. 1991).
It has been assumed that the postmenopausal ovary is not hormonally
active. However, data have shown continued secretion of ovarian androgens
that may support the well-being and general health (including libido) of post-
menopausal women (Garcia and Cutler 1984). Studies have suggested that
oophorectomy (with or without hormone replacement therapy) is associated
with adverse effects on libido, vaginal lubrication, and pleasure with coitus,
although one study found no correlation between psychosexual variables and
biochemical androgen markers (Nathorst-Boos and von Schoultz 1992). It
has been suggested that androgen replacement as well as estrogen replace-
ment after hysterectomy and oophorectomy may result in fewer physical and
psychologic symptoms, although this issue remains controversial (Sherwin
and Gelfand 1985).
The argument favoring an oophorectomy is that ovarian conservation
entails the risk of subsequent ovarian cancer (Travis 1985). Of all gynecologic
cancers, ovarian cancer is the most insidious in onset and frequently eludes
detection in its early stages; 60%75% of ovarian cancers present in advanced
stages (Knapp and Berkowitz 1986). It is frequently argued that the 2%5%
risk of developing ovarian cancer or requiring a second surgery for residual
ovarian disease warrants an oophorectomy at the time of hysterectomy, par-
ticularly if the woman is approaching menopause (Terz et al. 1967). The av-
erage age of menopause is 51a fact that is relatively unknown among the lay
public, who frequently assume menopause arrives in the mid-40s. Age 45 or
even 40 is commonly cited as the age beyond which many physicians would
recommend a prophylactic oophorectomy.
Alternatives to Hysterectomy
In most developed countries increased skepticism has arisen about not only
the necessity for oophorectomy but also that for hysterectomy itself. Nonsur-
gical hormonal therapy should be considered as the initial treatment for
many gynecologic conditions, including abnormal bleeding or menorrhagia
(Chuong and Brenner 1996). Alternatives to hysterectomy, such as myomec-
tomy or endometrial ablation by laser, electrical means, or thermal energy,
have been proposed and are gaining acceptance in the medical community.
Women are becoming aware that alternatives to hysterectomy exist and are
asking their clinicians about these options. Although some of these proce-
dures may ultimately prove to be appropriate surgical management, the final
word based on definitive, long-term follow-up studies is not yet in.
Myomectomy, or removal of uterine leiomyomata, is gaining in popular-
ity as an alternative to hysterectomy for women with uterine fibroids, even
among women who have completed childbearing and who would not have
traditionally been considered for such a procedure. Some women note that
the sensation of uterine contractions accompanying orgasm is pleasurable,
and for these women, myomectomy may be appropriate. Other women feel
that the monthly reassurances of menses are important to them. Myomecto-
my can be accompanied by risks similar to those of hysterectomy, including
the potential for excessive blood loss; it is incorrect for women to believe that
this is a minor surgical procedure. In addition, studies suggest that about
one-third of women who have a myomectomy have recurrent fibroids and
that the need for a hysterectomy subsequent to myomectomy is 20%25%
(Te Linde 1977).
Endometrial ablation, as an alternative to hysterectomy, involves the
destruction of the endometrium through the cervix using an electric current,
a laser, or a balloon that transmits heat to the endometrium. The main indi-
cation for endometrial ablation is heavy menstrual blood loss in the absence
of organic disease (Garry 1995). Most of these techniques have involved
preoperative hormonal treatment to thin the endometrium, use of a general
anesthetic, hysteroscopically directed laser, or electrical removal or destruc-
tion of the endometrium followed by a short postoperative hospital stay. The
advantages of these procedures include a significant reduction in hospital stay
and a potential to minimize the morbidity associated with hysterectomy
(Bachmann 1990a; Easterday et al. 1983). The goal of endometrial ablation
is to completely destroy the endometrium, thus eliminating or significantly
decreasing menses. Currently, endometrial ablation is performed much less
frequently than hysterectomy. Future studies will document the actual mag-
nitude of risks and complications associated with the procedure, and it may
prove to be a useful technique (American College of Obstetricians and Gyne-
cologists Committee on Quality Assessment 1996). In December 1997, the
U.S. Food and Drug Administration granted pre-market approval for the use
of a uterine balloon therapy system for endometrial ablation. This and similar
devices offer the potential for a simple office procedure as an alternative to
hysterectomy. Long-term studies are lacking, and caution is indicated prior to
widespread adoption of this technique.
Patients who request alternative surgical procedures deserve accurate in-

formation about hysterectomy as well as the alternative procedures (Bach-
mann 1990a) because their reasons for avoiding a hysterectomy may be
based on misconceptions about the procedure. Although it has been suggest-
ed that alternative procedures are less likely to have psychologic consequenc-
es than hysterectomy, this assertion has not been studied carefully (Goldfarb
1990; J. B. Wright et al. 1996). One prospective, randomized, controlled trial
found that hysteroscopic surgery and hysterectomy had a similar effect on
psychiatric and psychosocial outcomes and found no evidence that hysterec-
tomy led to postoperative psychiatric illness (Alexander et al. 1996). Other
studies have reported greater satisfaction among women who had a hysterec-
tomy than among those those who had endometrial ablation (Crosignani et
al. 1997; OConnor et al. 1997).
However, hysterectomy remains an important alternative when conser-
vative treatment fails (Carlson et al. 1994b). Quality of life measures suggest
that women having a hysterectomy for leiomyomas, abnormal bleeding, and
chronic pelvic pain report improvement over time when compared with those
who receive nonsurgical management (Carlson et al. 1994a, 1994b). Other
studies attempting to assess the consequences of hysterectomy in womens
lives have found reports of improvement in general and sexual outcomes in
the short term (3 months postoperatively), but less positive reports in the
longer term (2 years) (Bernhard 1992). Quality of life and overall satisfaction
are difficult to measure; one study with 210 year follow-up found generally
high levels of self-reported satisfaction after the procedure (Schofield et al.
1991).
Psychologic Reactions to Hysterectomy

For many women, removal of the uterus has unique medical, emotional, and
sexual significance and meaning (Bachmann 1990b; Polivy 1978). Its relation-
ship to childbearing or childbearing potential is a factor for many women as
is its association with femininity and completeness (Polivy 1974). Loss of
menses may be perceived as a specific benefit of the surgery, particularly if
the indications include abnormal or excessive bleeding or pain (Schofield et
al. 1991); however, some women feel that menses represent a familiar and
comforting rhythm or monthly cycle or that menstruation cleanses the body
(Bachmann 1990a). Misconceptions about anatomy and sexual functioning
are common, with women expressing the concern that a hysterectomy actu-
ally involves removal of the vagina, rendering sexual activity impossible post-
operatively. Concerns about a decrease in sexual attractiveness as a woman
or to ones partner may be culturally related (Bachmann 1990b).

Sexual responsiveness after hysterectomy has been addressed in several
studies (Dennerstein et al. 1977; Zussman et al. 1981). The physical effects of
hormone deficiency from oophorectomy contribute to symptoms of vaginal
dryness, dyspareunia, or decreased genital sensation. However, in the ab-
sence of oophorectomy or estrogen deficiency, several studies have suggested
no adverse effect of hysterectomy on sexual function (Bachmann 1990b; Hel-
strom et al. 1993). One study found that the presence of preoperative psychi-
atric problems had little influence on postoperative sexuality (Helstrom et al.
1994).
The psychologic, social, and sexual consequences of hysterectomy on
womens partners has been largely ignored. One recent study showed a pos-
itive effect not only on the sexual life but also on the overall quality of life of
most men (Lalos and Lalos 1996).
There is a current move championing supracervical or subtotal hysterec-
tomy, with the view that the cervix itself triggers orgasm or affects the capac-
ity to experience orgasm (Cutler 1988), although relatively little data exist
(Kilkku et al. 1983; Munro 1997; Scott et al. 1997). It is also argued that re-
taining the cervix reduces the likelihood of painful coitus (Sloan 1978). These
arguments are not well accepted among those gynecologists who believe care-
ful surgical attention to minimizing loss of vaginal length will prevent subse-
quent dyspareunia.
Despite the suggestion that hysterectomy adversely effects sexual func-
tioning, several studies have shown either no change or a beneficial effect
(Clarke et al. 1995; Dennerstein et al. 1977; King et al. 1993; Lalinec-
Michaud and Engelsmann 1985, 1989). Historically, the belief that removing
the uterus could precipitate mental illness has been advanced; in 1890, Kraft-
Ebing described his observation that psychoses were more frequently caused
by hysterectomy than by any other type of surgery. Although posthysterecto-
my depression is widely believed to occur (Ananth 1978), several review ar-
ticles have questioned the frequency of its occurrence (Bachmann 1990a;
Cohen et al. 1989; Newton and Baron 1976; Patterson 1963; Polivy 1974).
Psychologic distress has recently been reported to be less frequent after hys-
terectomy, with decreased symptoms (Ryan et al. 1989). Several recent stud-
ies have found no evidence that hysterectomy leads to postoperative
psychiatric illness (Alexander et al. 1996). It is likely that recent changes in
gynecologic practice resulting in more stringent indications for hysterectomy
as well as the move toward recognizing, acknowledging, and respecting the
patient as a partner in decision making, have contributed to a lower frequency
of adverse sequelae than had been reported previously (Gath et al. 1995).
Some studies have compared the risk of postoperative psychiatric depres-
sion or referral for psychiatric services and hospitalization after hysterectomy
with the risks after other surgical procedures such as cholecystectomy or car-
diac surgery (Ananth 1978; Bachmann 1990a; Gould and Wilson-Barnett
1985; Polivy 1974; Roos 1984). Some of the older studies suffer from signif-
icant flaws, including studying small samples, containing little statistical data,
or being based on anecdotal information. Other studies are retrospective,
with problems of recall and bias. Many were published in the 1960s, when
the indications and frequency of the procedure were different. Some studies
have varying and often short (as little as 6 weeks) follow-up periods, whereas
others have long (35 years) follow-up periods but have problems with con-
clusions of causality. Many studies lack control groups for age, parity, or
menopausal status; the meaning of a hysterectomy for a 20-year-old nulli-
gravid woman is likely to be different than it is for a 60-year-old woman. Ed-
ucation and social class may also affect a womans reactions to any type of
surgery. Many studies have failed to control for whether the hysterectomy
procedure included an oophorectomy. In addition, some studies do not sepa-
rate subjects by the indications for hysterectomy; a hysterectomy for malig-
nant disease evokes more anxiety and legitimate concerns of mortality than
does a hysterectomy for benign indications (Drellich 1956; Walton 1979). Ad-
junctive therapies for malignancy, such as chemotherapy or radiotherapy,
may have an impact on the risk of sexual dysfunction (Corney et al. 1993;
Flay and Matthews 1995; Schover et al. 1989).
Studies may not control for the route of the procedure (e.g., vaginal ver-
sus abdominal); surgical morbidity varies by the type and route of the proce-
dure (Easterday et al. 1983). Psychiatric morbidity may also vary. The
definition of adverse psychologic sequelae is frequently not clear; some stud-
ies use vague terms such as emotional problems, and depression is a term used
loosely in some studies. Other problems include cultural and social assump-
tions about womens primary role and the functions of childbearing.
From the literature, it appears that some women may be at high risk for
adverse psychologic reactions or psychiatric sequelae from hysterectomy
(Ananth 1978); this most notably and consistently includes women who have
had previous psychiatric problems or psychiatric care (Iles and Gath 1989;
Martin et al. 1980; Moore and Tolley 1976; Polivy 1974; Salter 1985). This
group appears to have a several-fold increased risk over women without such
a history. An association between abnormal menses and anxiety or depres-
sion has also been reported, which may be important in predicting a reaction
to hysterectomy (Salter 1985; Thornton et al. 1997). A history of sexual

abuse may also be predictive of an adverse reaction (Wukasch 1996).
An optimal level of preoperative anxiety may also occur (Drellich 1956);
an attitude of casual unconcern may suggest a significant level of denial that
will ultimately result in symptoms (Ridgeway and Mathews 1982).
Women who have a hysterectomy at a young age are at an increased risk
for adverse reactions (Kaltreider et al. 1979). In psychologic terms, it has been
stated that this may be caused by a disruption of sexual/gender self-concepts
that were not yet well established. An associated risk factor is that of an emer-
gency procedure, as there may be little time to psychologically prepare for the
hysterectomy (Tang 1985).
Poor social support may also be a predictor of adverse psychologic se-
quelae (Webb and Wilson-Barnett 1983a, 1983b; Wolf 1970). It appears that
hysterectomy functions as does any stress, with a need for support from fam-
ily, friends, and partner (Kraaimaat and Veeninga 1984). Preoperative marital
problems may be a predictor of postoperative problems (Polivy 1974). Low
socioeconomic status and less-well-educated women also seem to have higher
risks of adverse reactions, perhaps related to misconceptions and fears (Wolf
1970).
Women with a history of multiple surgeries or chronic pelvic pain con-
stitute another high-risk group (Bachmann 1990a). It has been said that
Some women have psychic conflicts sailing under a gynecologic flag (Rog-
ers 1950) and some suggest that if no pathologic diagnosis is found from the
surgical specimen, the risk of adverse psychologic sequelae is higher (Barker
1968). It has also been said, however, that women are not as concerned
about unnecessary hysterectomies as defined by others as they are about un-
wanted hysterectomies as defined by themselves (Burchell 1977).
Preoperative preparation for hysterectomy, with a focus on the groups of
women at higher risk, may prove helpful in minimizing the likelihood of ad-
verse psychologic reactions (Coppen et al. 1981; Stellman 1990). The pa-
tients own anticipation of the effects of surgery should be explored; negative
expectations about hysterectomy in particular have been correlated with de-
terioration in sexual functioning (Dennerstein et al. 1977). Many women
want and appreciate a preoperative discussion of the potential effects of hys-
terectomy on sexual function (Krueger et al. 1979).
Hysterectomies have been categorized as being emergent, mandatory, ur-
gent, advisable, or elective (Easterday et al. 1983). Particularly for advisable
surgery, which constitutes the majority of hysterectomies, patient participa-
tion in the decision-making process will facilitate an appropriate or adaptive
response to the surgery. Hysterectomies performed to prevent problems or

for premalignant disease should be clearly indicated. With a hysterectomy,
women must take into account several quality-of-life considerations (Easter-
day et al. 1983; Roeske 1979) that are influenced by her own psychologic and
emotional health and by her own past experiences. She is often in the best
position to consider these factors, but she may need guidance from her gyne-
cologist or a therapist.
It is important to state the risks versus the benefits of the procedure. Pre-
operative preparation for surgery, with education and counseling by both gy-
necologists and other clinicians, is particularly important for hysterectomy
(Williamson 1992). The most effective manner in which to accomplish this
preparationwhether in written form, verbally, or using new computer tech-
nologyis not yet well established (American College of Obstetricians and
Gynecologists 1995; Young and Humphrey 1985).
It is also important to state very clearly which symptoms will be alleviat-
ed by the surgery and to foster realistic expectations (Williamson 1992). Pre-
menopausal women in whom a hysterectomy without oophorectomy is
planned should be advised to expect some persistence of cyclic symptoms
(e.g., premenstrual syndrome or premenstrual dysphoric disorder) related to
ovarian hormone production if these symptoms were present prior to hyster-
ectomy. However, several studies report amelioration of symptoms after hys-
terectomy (with ovarian conservation) in women with premenstrual tension,
implicating psychologic factors associated with the menstrual cycle in the eti-
ology of symptoms (Metcalf et al. 1992; Osborn and Gath 1990; Silber et al.
1989). Hysterectomy with oophorectomy and subsequent hormone replace-
ment therapy has been suggested in rare situations for the relief of severe pre-
menstrual symptoms (Casper and Hearn 1990).
Liaison Between Psychiatrist and

Obstetrician/Gynecologist
Direct communication between the therapist and the obstetrician/gynecolo-

gist is important; miscommunications sometimes arise if the physicians rely
solely on the patient for information about the gynecologic diagnosis or rec-
ommendations for treatment. When hospitalization is planned, psychiatric
follow-up during the inpatient stay may be appropriate or indicated. Psychi-
atric care may be even more critical than gynecologic care in the weeks to
months after surgery. Gynecologists may feel that their care has been com-
pleted by the time of the standard 46 week postoperative office visit. How-
ever, this may not be sufficient follow-up for individuals at risk for depression
or other severe psychiatric sequelae.
A psychiatrist or psychologist who has an ongoing relationship with a pa-
tient may need to ensure that preoperative preparation for any planned gyne-
cologic procedure is adequate. The therapist will want first to understand the
patients understanding and expectations and then to explore the underlying
meaning to the individual woman. The patient may have misconceptions
about the procedure. Ideally, the gynecologist will have given the patient ac-
curate information about the nature of the diagnosis and the recommended
treatment; the psychiatrist may, however, need to address basic issues of anat-
omy, physiology, pathology, and therapy or to speak with the gynecologist if
it appears that the patient has significant misunderstandings. Although as-
sumptions about the patients underlying concerns may prove to be false,
common concerns such as those related to loss of sexual function, reproduc-
tive capability, or femininity may be suggested and explored as an initial ef-
fort to understand the issues for the individual.
A planned surgery may sometimes prompt the gynecologist to refer a pa-
tient for preoperative preparation, although it may be more common for the
psychiatrist to be consulted when problems arise postoperatively. Prevention
and attempts to alleviate psychiatric risks are always preferable to consulta-
tion after a problem becomes severe (Schwab 1971).
Psychiatric problems after a hysterectomy or other gynecologic proce-
dure should be evaluated in the same way as problems presenting after other
life events (Dennerstein and van Hall 1986). Depression should be evaluated,
and treatment should be initiated with antidepressants or other appropriate
medications (including hormone replacement therapy) if indicated. Suicide
potential should be assessed. Psychotherapy is often most useful in conjunc-
tion with the use of antidepressants. The issue of hysterectomy or other sur-
gery as a precipitating factor for psychiatric symptoms and the significance
that the patient ascribes to her uterus can be explored during the course of
therapy (Dennerstein and van Hall 1986).
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15
Gynecologic Oncology
LINDA HAMMER BURNS, PH.D.
Sweet weight,
in celebration of the woman I am
and of the soul of the woman I am
and of the central creature and its delight
I sing for you.
Anne Sexton, In Celebration of My Uterus
Each year in the United States, 81,000 women are newly diagnosed and
approximately 26,500 die from gynecologic cancer, and 180,200 women are
newly diagnosed and 43,900 die from breast cancer (Parker et al. 1997). In
short, although many more women contract breast cancer, proportionately,
more women die of gynecologic cancer. Gynecologic cancer is defined as carci-
noma of the female reproductive organs (e.g., uterine, ovarian, cervical,
vaginal, vulvar) and is usually treated by a specialist in gynecologic oncology.
Increasingly, screening of healthy, asymptomatic women for some gyne-
cologic cancers through Papanicolaou (Pap) smears (and increasingly sonog-
raphy) is becoming fundamental to the routine care of women. Within the
array of gynecologic cancers exists variation in diagnosis, treatment, and op-
tions. For example, more than two-thirds of cervical cancers in the United
States are detected in situ, largely as a result of the Pap smear, and are highly
curable. By contrast, ovarian cancer is the most deadly gynecologic cancer,
and yet no effective screening method exists. Ovarian cancer typically affects
older women who present with vague symptoms in advanced stages of the
disease, when it is most difficult to treat. Cervical cancer is now largely con-
307
sidered a sexually transmittable disease, with sexual history and socioeco-

nomic status as major factors in its development, whereas ovarian cancer is
more likely to be related to genetic factors, reproductive history, obesity, and
age. Treatment of gynecologic cancers may include surgery, radiation thera-
py, and/or chemotherapy; for example, early cervical cancers may involve a
single minor surgery (colposcopy) using laser or cryotherapy with little long-
term impact on functioning or well-being, whereas some more-advanced can-
cers involve total pelvic exenteration that dramatically affects the womans
long-term health, psychologic adjustment, sexuality, and reproductive life.
Psychosocial Aspects of Gynecologic Cancer
Throughout history, the uterus has had special meaning to women and men.
The importance of the uterus as a psychosexual organ varies from woman to
woman, culture to culture, and encompasses a broad range of meanings: a
childbearing organ, an excretory organ, a regulator and controller of body
processes, a sexual organ, a source of female competency, a reservoir of
strength and vitality, and maintainer of youth and attractiveness (Bachman
1990). Even for women who have children, premature loss of childbearing
ability may create worries about accelerated aging, inadequacy, incomplete-
ness, altered sexual experiences, and loss of femininity (Bachman 1990).
Despite ambivalent feelings about the discomfort or inconvenience of men-
struation, many women value it as a means of setting the rhythm of life, as
an important cleansing process, and/or as a reassurance of health and well-
being. As such, it is understandable how the loss of these organs can have
complex and significant meanings for women that affect not only their re-
sponse but also their psychologic adjustment to the disease.
It is not uncommon for a woman to feel that gynecologic cancer is pun-
ishment for past sexual misdeeds (e.g., promiscuity, contraction of a sexu-
ally transmitted disease) or reproductive failures (e.g., elective abortion,
miscarriage, or infertility). These issues become particularly complex if a
womans gynecologic cancer is related to her sexual behavior or that of her
partner (e.g., cervical). It is noteworthy that the womans sexual experiences
are the only sexual risk factor often considered, even though she assumes the
risk of her partner and his previous/current sexual partners. A monogamous
woman who develops cervical cancer is often assumed to have been promis-
cuous while her partners sexual risk behavior is disregarded! When issues of
infidelity do arise, the result can be relationship and psychologic distress, so-
Gynecologic Oncology 309
cial stigma, or misconceptions that the cancer was self-inflicted or preventable

and as such does not warrant support. Feelings of guilt and self-recrimination
may follow the diagnosis, although these feelings may not be openly shared.
Equally difficult is the cancer diagnosis that may have a genetic etiology (e.g.,
ovarian), prompting family discussion and/or risk identification of first-
degree relatives. As with many genetic conditions, women often feel guilty
and responsible for passing on bad genes and putting their loved ones in
jeopardy. In addition, many women still fear that cancer is contagious or an
automatic death sentence and, as a result, fear telling family and friends be-
cause they are afraid of rejection, abandonment, or reproach. Finally, some
women, especially those who have lived healthy, low-risk lifestyles, simply
cannot believe the cancer diagnosis and respond with denial, avoidance, or
minimization, which may affect compliance and other health behaviors.
Newsom et al. (1996) found that cancer patients who believe that they
could have prevented their illness may be at greater risk for depression. In a
study of 120 adults with recurrent cancer, five domains of control were iden-
tified: 1) self-blame, 2) control over cancer onset, 3) control over symptoms,
4) control over the course of the illness, and 5) overall control over life events.
Although self-blame was not found to be related to symptoms of depression,
perceived control over cancer onset predicted subsequent depression. The au-
thors concluded that helping cancer patients resolve feelings of regret and re-
morse is an important intervention.
Today, a diagnosis of cancer is less likely to mean a precipitously short-
ened life and is more likely to mean a chronic illness. Because many patients
are cured by initial therapy, psychologic response is less likely to involve prep-
aration for death and dying and more likely to entail adjustment to what may
be extensive, invasive, and prolonged medical treatment. The losses of gyne-
cologic cancer are, therefore, more likely to be loss of health, lifestyle, repro-
ductive ability, or sexual satisfaction.
Cross-Cultural Issues
Cross-cultural issues have increasingly gained attention in the care of cancer

patients as an important aspect of medical and psychosocial care, because cul-
tural beliefs and values necessarily influence the patients reaction to illness,
treatment choices, illness behavior, and psychologic response. In a review of
the major cultural considerations in the optimal care of patients with chronic
medical illness, Trill and Holland (1993) found the following factors to be in-
fluential in health-related behaviors: family function, gender roles, language,

disclosure of disease-related information, pain, attitudes toward illness and
health practices, immigration, religion, autonomy versus dependency, and
death and bereavement. Finally, many patients straddle two cultures and it is
often difficult to assess which cultural practices and beliefs they (or their fam-
ily members) have retained from their original culture and which they have
adopted from the new culture.
Culturally defined gender roles may affect a womans coping mecha-
nisms, the response of others, and the caregivers response. Gender role ex-
pectations can be highly significant for women with gynecologic cancer in a
culture that highly values women for their reproductive ability. A (or the) ma-
jor loss for many young women with cancer is the loss of reproductive ability.
Although alternative forms of childbearing or family building may be consid-
ered, the loss remains significant for most womenalthough it is not often ad-
dressed in the early stages of cancer treatment. In some cultures, women are
expected to suffer silently and stoically (e.g., Scandinavian, American Indi-
an), whereas in other cultures women are expected to relinquish their auton-
omy and become completely dependent on male family members and
caregivers (e.g., some Hispanic cultures). Family beliefs about illness, includ-
ing family involvement in patient care and acceptable levels of patient depen-
dence on family members, are also influenced by cultural values and are
important factors in treatment planning and implementation.
The need for autonomy or dependency appears to be strongly influ-
enced by cultural values, with significant implications for caregivers and med-
ical decision making. Religion is another area that can determine patient
acceptance of illness, the suffering it entails, and acceptable behaviors regard-
ing death and dying. Finally, acceptable practices regarding dying and be-
reavement vary significantly across cultures, with behaviors and customs
often having significantly different meanings.
Developmental Life Stages
Although women of all ages may have some feelings about the loss of repro-
ductive organs, the stage of a womans life may influence the degree of her
feelings. Typically, an older woman who has completed her childbearing will
respond differently to the loss of her reproductive organs than will a younger,
childless woman. Eriksons (1963) developmental life stage model outlines
normal developmental milestones and describes how failure to achieve devel-
opmental stage goals threatens a womens normal and healthy maturation.

Psychologic issues of cancer across the developmental lifespan involve altered
relationships, dependence versus independence, achievement disruptions, in-
tegrity of body image, and existential issues (Rowland 1989).
Young Adulthood (Age 1930)
According to Erikson (1963), the developmental tasks of young adulthood

are separation and individuation and intimacy versus isolation; during this period, the
young person establishes an autonomous and stable sense of self. Cancer in-
terrupts these tasksat a time when a young woman should have increased
autonomy and independence, she must rely instead on her parents for phys-
ical as well as psychologic care. Life goals must be readjusted or redirected,
limitations integrated, and relationships realigned, all within the context of
complex medical treatment and side effects (e.g., alopecia, nausea, vomiting,
surgical scars, weight loss/gain, fatigue, ostomies, vaginal stenosis, fistulas,
anxiety, or depression).
Sexual Functioning
Gynecologic cancer interrupts a young womans establishment of healthy, in-
timate, and romantic relationships by challenging the integrity of her body
image (e.g., impaired feelings about oneself as a sexual person, dampening of
sexual feelings) and by altering established relationships (e.g., unsteady ro-
mances unable to weather the demands of cancer). Cancer may strike before
the young woman has become sexually active, established a stable sexual
identity, explored romantic relationships, or explored reproductive goals.
Postoperative psychosexual problems in women who have had a hysterecto-
my appear to be more prevalent in women with the following profiles: 1) pre-
operative history of depression, sexual dysfunction, or other psychologic
disturbances; 2) age less than 3540 years; 3) limited education; 4) conflict
about future childbearing; 5) poor understanding of the surgery and its con-
sequences; 6) belief that the uterus has unique psychologic and sexual impor-
tance; and 7) absence of pelvic pathology (Bachman 1990). In evaluating
sexual problems in the young woman, it is important to determine her sense
of her sexual self; her previous sexual functioning; the extent of her physical
impairment because of the disease; the etiology of the sexual problem; and
the status of her romantic relationship(s).
Family Relationships and Reproduction

Although young women with gynecologic cancer have more reproductive
choices than ever before, the issue of reproductive loss remains primary and
fundamental. Today, assisted reproductive technologies offer many women
(depending on the type of cancer) the opportunity to extend or preserve their
reproductive ability. Patients increasingly expect caregivers to protect their re-
productive options and/or consider their reproductive futures as part of treat-
ment. Gynecologic cancer can be less traumatizing when caregivers offer
information on family-building alternatives such as in vitro fertilization, do-
nor oocytes, surrogacy, and/or gestational carrier.
Work
Achievement disruptions during this era typically involve postponement or
relinquishment of education or career goals and redefinition of life plans and
long-held hopes and dreams. The completion of education and/or the estab-
lishment of a career are important tasks of this stage; failure to proceed on
course puts many young women out of synch with their peers, thus increas-
ing social and economic pressure and precipitating reassessment of original
goals and life plans.
Existential Issues
Existential issues focus on the question how and why me?; on feelings
about death or dying; and on incorporation of the illness and its consequenc-
es into ones sense of self. The specter of potential death does not fit into
young peoples schema of life and/or that of their peers. Combined with the
typical self-absorption and egocentricity of this stage, it is understandable that
many young women feel isolated and detached, even from caring friends and
family. Issues of survivorship may enhance feelings of inability to relate to
peers or difficult romantic attachments. Having lost important friendships
and relationships, these women may gain an altered perspective, a new inter-
nal schema and inner strength, and a better sense of their internal resources,
all of which affect their relationships with others as well as with themselves.
Mature Adulthood (Ages 3145)
Often considered the most stable era of life, mature adulthood is character-
ized by personal maturity, consolidation of career, and development of stable
relationships, including nurturance of the younger generation through either

parenthood or mentorship. Erikson (1963) defined this stage as generativity
versus stagnation, contending that failure to achieve a productive and creative
sense of self leads to personal impoverishment, pseudointimacy, excessive de-
pendence, or premature disengagement from society. Emphasis on generativ-
ity during this era highlights the childbearing losses of women who had
postponed childbearing or had experienced infertility or childbearing losses
(e.g., miscarriage). Although unusual, gynecologic cancer during pregnancy
is considered a reproductive crisis, especially if the pregnancy lost is the wom-
ans only or final pregnancy.
Sexual Functioning
The impact of cancer on sexuality is largely determined by the type of cancer
and its treatment, (e.g., cervical dysplasia treated by cone biopsy versus inva-
sive vulvar cancer requiring total exenteration). Both estrogen and/or test-
osterone deficiency caused by absent ovarian function due to surgical or
radiation-induced menopause (resulting in vaginal shrinking and reduced lu-
brication) may contribute to sexual problems and feelings of being old be-
fore my time. Side effects of cancer treatment such as scarring, depression
and anxiety, hot flashes, ostomies, or the use of vaginal dilators are often in-
terpreted as insults to ones sense of self and body integrity. The most com-
mon sexual problems encountered by women with gynecologic cancer are
painful intercourse, lack of arousal, less satisfaction with sex, and less enjoy-
ment of intercourse (Anderson and deProsse 1989a, 1989b; Krumm and
Lamberti 1993). Women who do not follow advice regarding the use of vag-
inal dilators and/or do not resume their preillness level of sexual functioning
are more likely to develop physical and sexual changes that ultimately affect
sexual satisfaction. Interestingly, most women believe that cancer could be
transmitted through sexual intercoursea factor often overlooked in caregiv-
er discussions of sexual functioning with women and their partners (Krumm
and Lamberti 1993). Suggestions for enhancing sexual functioning include
arousal-enhancing rather than anxiety-reducing techniques; lubricants (e.g.,
Astroglide); variation of sexual positions; controlled depth of penetration to
manage pain; and the use of vaginal dilators (Schover 1997).

For women who are mothers, their role as mother is often significantly affect-
ed by cancer. Women are typically distressed and anxious about their inabil-
ity to care for their children, find trustworthy caregivers, and deal with their
childrens response to their illness as well as the possibility that they may not
live to raise their children. Many women feel guilty for being irritable with
normal childish behaviors (e.g., bickering, pushing limits) or disappointed by
their childrens inability to provide them with comfort and support. In a study
of childrens responses to their mothers cancer (Hilton and Elfert 1996), the
developmental level of the child was the definitive factor. With preschoolers,
the dependency needs of the child made childcare a primary concern, where-
as with teenagers, increased home and caregiving demands interrupted the
adolescents moves toward independence, creating role confusion and in-
creasing family tension. Furthermore, parents were unaware of increased dis-
tress or psychologic symptoms in their children.
Work
For many women, diminished productivity at work represents myriad losses:
personal fulfillment, financial remuneration, a social sphere, personal direc-
tion, and life structure, meaning, or purpose. Anderson and deProsse (1989b)
found that although women with cancer were not able to work as many hours
as their healthy counterparts, their career paths remained intact. Neverthe-
less, cancer treatment often results in missed raises or promotions, lost oppor-
tunities to change positions, pressure to make up for time away, and fatigue
that prevents work performance at previous standards (Petzel et al. [in press]).
Furthermore, both illness-related job disruptions and the high cost of medical
care may threaten long-term personal and familial financial commitments
(e.g., childrens educations, mortgages) (Rowland 1989).
Existential Issues
Cancer is a traumatic event in which many women experience a shattering
of assumptions about themselves and the world in which they live: 1) the
world is benevolent; 2) the world is meaningful; and 3) the self is worthy
(Janoff-Bulman 1992). The existential struggle involves giving meaning to the
cancer experience and regaining a belief in a predictable and benevolent
world.
Midlife or Older Adulthood (Age 4665)

According to Erikson (1963), the developmental task of midlife is integrity ver-
sus despair, characterized by achieving a balance between the triumph of ones
accomplishments and the despair of ones failures. Inadequate resolution dur-
ing this era results in despair about ones achievements and disappointments.
Although midlife is often a stage of reflection and self-examination during
which individuals redirect energies and replot life goals, cancer can trigger
identity crises and distress in women who fear aging or for whom woman-
hood and/or feminine identity is linked to reproductive ability, sexual organs,
and/or sexuality. Cancer treatments may accelerate aging at a time when
many women are already adjusting to typical midlife changes such as in-
creased weight, diminished skin elasticity, or musculoskeletal problems. In
fact, some women simply cannot tolerate the physical limitations or alter-
ations in appearance imposed by cancer and/or aging, thus precipitating seri-
ous psychologic distress.
Sexual Functioning
Anderson and deProsse (1989a), in a longitudinal study, found that although
sexual functioning was significantly disrupted for women with gynecologic
cancer, their marital and other social relationships remained satisfactory. In a
study of cancer patients spouses (Sabo et al. 1986), men assumed the sup-
portive role preferred by their wives, but the women interpreted this role re-
versal as rejecting and insensitive, thus leading to relationship distress.
However, in a study of experiences of the male partners of women with gy-
necologic cancer, Lalos et al. (1995) found that both partners experienced
sexual intercourse as much more negative after treatment had been complet-
ed, and most men reported impaired sexual desire. Men found it difficult to
know how to behave and communicate with their wives, with most reporting
that they had nobody to whom they could speak openly about their wifes
cancer. Furthermore, most men had not obtained basic information about
their partners disease, leading many researchers to conclude that increased
involvement of spouses in cancer treatment and decision making leads to bet-
ter adjustment in both the patient and the spouse (Anderson and deProsse
1989a; Schover 1997).

It is not uncommon for women to operate as the emotional kingpin in fam-
ilies, providing emotional connection, stability, and direction in the family
system. Not surprisingly, when these women are unable to perform their var-
ious roles as mother, daughter, sister, and/or wife, they experience discomfort
and the family system is destabilized, often with distressing results. Cancer
has the potential for affecting a womans unfinished business with family
members or triggering the reemergence of old issues or conflicts. Relation-

ship distress may affect multiple relationships or be confined to a single rela-
tionship (e.g., marriage, parent/child) and may include recognition of a
chronically unhappy marriage (spouses who are unavailable, unreliable, or
uninterested as the demands of cancer treatment and emotional dependence
intensify). Cancer often precipitates long-postponed personal reflection or re-
lationship examination that results in the realignment of personal priorities,
revamping of relationships, or resetting of personal goals in an attempt to
make ones remaining years as meaningful, productive, and pleasant as pos-
sible.
Women in this stage are typically less involved in beginning parenthood
and more likely to be launching children. However, whether their children
are very young, adolescents, or independent adults, womens roles as moth-
ers and caretakers often remain significant and they may grieve the loss of
these roles. Alternatively, during this era many women have responsibility for
the care of parents or older family members. Within this context, cancer may
trigger family adjustments such as the placing of older family members in res-
idential care, which often triggers feelings of guilt, regret, or worry. Relin-
quishing these important nurturing roles can be very difficult for many
women, especially if it also means relinquishing their own independence and
autonomy (e.g., having to live with their own children).
Work
Anger, frustration, and disappointment may arise when cancer requires cur-
tailment of career goals, precipitates early retirement, or creates financial in-
security. Women may feel frustrated by their inability to pursue career goals
or enjoy a pleasant and worry-free retirement. Feelings of discouragement
and depression are understandable when women must spend their golden
years being ill and watching their hard-earned retirement savings go to med-
ical bills. Some patients choose less-expensive medical treatments or even
contemplate suicide as a means of protecting their spouse and family from fi-
nancial ruin (Rowland 1989).
Existential Issues
Characteristic of the midlife era is heightened introspection and reflection,
which may lead to potential despair about failures, unattained goals, or the
meaning of ones life (Rowland 1989). Depression may be associated with
less denial and greater recognition of death as a possible outcome of the dis-
ease. Overemphasis on death, despair about ones lack of accomplishments,

or introspection may put a woman at risk of self-imposed isolation or of pre-
mature surrender to the illness (Rowland 1989). Struggles with existential is-
sues often involve such questions as is this what I lived and worked for?;
why me?; and what now?
Aging Adulthood (Age 66 and older)
Late adult transition involves reworking the past, finding a balance between
social and self-involvement, making peace with inner and external enemies,
and coping with death (Levinson 1986). It also involves adapting to changes
associated with normal aging, such as physical and mental deterioration or
limitations imposed by other health problems.
Family Relationships
Aging and illness often involve relinquishing status and authority within the
family and within society. For many women, cancer precipitates the abdica-
tion of leadership roles: they are no longer the primary family caretakers, but
rather the responsibility of the younger generation. Issues of autonomy and
independence often surface as women grapple with feelings of being a bur-
den to spouses, children, or grandchildren. An important task is finding new
purposes in life and adapting to losses of health, work, friends, and family,
which for many women involves creating a legacy for their families or getting
their affairs in order.
Sexual Functioning
Thranov and Klee (1994) investigated the extent of sexual problems and the
prevalence of sexual activity in women aged 5263 with gynecologic cancer.
Little or no desire for sexual relations was the most common sexual problem
found (74% of women and 42% of their partners), although 54% of the wom-
en were sexually active. Only 22% of the women with a partner expressed
dissatisfaction with their sexual life or lack thereof. Sexual activities were not
related to diagnosis or stage of disease. Despite decreased sexual desire and
dyspareunia, a large percentage of women continued to be sexually active,
leading the study authors to conclude that patients and their partners should
be given information on sexual changes caused by their disease, reassured
about regaining sexual capacity, and informed about the feasibility of sexual
satisfaction.
Work
Retirement, a normal transition at this stage, typically involves yielding of au-
thority and status and the review of ones life successes and failures. These
normal transitions can be complicated by abrupt changes or interruption of
an enjoyable retirement by illness, medical treatment, or adapting to physical
disabilities, decreased income, or limited mobility.
Existential Issues
In one recent study (Cicirelli 1997) of 388 adults over age 60, most expressed
a wish to continue living if they faced a terminal illness or nonterminal illness
that resulted in sustained lower quality of life (immobility, extreme dependen-
cy, pain, or loss of mental faculties). A minority (10%) favored ending their
life under such circumstances; these adults tended to be of higher socioeco-
nomic status, less religious, more lonely, placed a higher value on the quality
of life, and expressed greater fear of the dying process. Brown et al. (1994)
asked women with gynecologic cancer about their reactions to a poor prog-
nosis and their preferences for withdrawing or withholding life-sustaining
technologies. Only 5% anticipated giving up, whereas 78% expressed resolve
to continue the fight against their disease. Most preferred receiving in-home
care and would refuse artificial life-sustaining measures such as ventilator
support (90%), surgery for another life-threatening condition (34%), artificial
nutrition (37%), and antibiotics (22%). These women anticipated managing
their disease with a fighting spirit; although many would reject life-sustaining
measures, far fewer would take active measures to shorten their lives.
Disturbed Psychologic Response
Although several studies suggest that the initial, short-term response to cancer
may include psychologic distress and impaired social functioning, most can-
cer patients adjust successfully and, over time, do not differ on most psycho-
logic outcome measures from individuals with benign disease. The vast
majority of psychologic problems in women with cancer involve the efforts
of psychologically stable individuals to adjust to cancer and its treatment.
Women at risk for disturbed response are more likely to have a history of
maladaptive coping strategies, previous severe psychiatric disorder, low levels
of social support, and/or a history of previous suicide attempts. The most
common types of psychologic disturbances in cancer patients are depression
and anxiety. Most cancer patients experience heightened anxiety and depres-
sion at diagnosis and at crisis points in the disease or treatment. However, up
to 50% of women develop a psychiatric disorder, most of which are adjust-
ment disorders and mood problems (Derogatis et al. 1983) that can result in
poor reporting of medical symptoms, poor adherence or refusal of treatment,
deterioration of relationships, and delayed return to preillness functioning be-
cause of loss of motivation and pessimistic outlook. Preexisting psychiatric
problems can worsen during treatment-complicating care (e.g., patients with
a history of chemical dependency or abuse requiring special attention). Psy-
chologic symptoms in cancer patients also warrant a search for organic caus-
es (see Table 151). Social problems in families relating to alcoholism,
criminal activity, cultural pressures, poverty, physical or sexual abuse, and
other forms of maltreatment should be consideredespecially in elderly or
vulnerable patients.
Depression
When sadness becomes depression, women must not only manage the bur-
den of cancer but the consequences of depression, which often increase the
level of disability, decrease compliance, increase suicidality, and lead to poor-
er outcome (Roth and Holland 1994). Major depression occurs in approxi-
mately 25% of cancer patients, with the highest prevalence in those with the
greatest disability and most distressing symptoms (McCoy 1996; Valente et
al. 1994). Women at increased risk of depression have a history of affective
disorder or alcoholism, poorly controlled pain, concurrent illness, advanced
illness, poor prognosis, and severely disfiguring treatments and are being
treated with medications that produce depressive symptoms (Bukberg et al.
1984; Massie 1989b; Massie and Holland 1989).
Psychiatric consultation should be considered when depressive symp-
toms last longer than 2 weeks, worsen rather than improve, or interfere with
the patients ability to function or cooperate with treatment (see Tables 152
and 153). Prolonged and severe depressive symptoms usually require com-
bined psychotherapy and somatic treatment. Typically, the decision to pre-
scribe a psychotropic medication depends on the level of distress and how
significantly the patients symptoms impair her daily functioning. It should
be remembered that inadequate attention and detection are the biggest barri-
ers to effective treatment.
The most commonly used antidepressants for cancer patients in the past
were the tricyclic antidepressants (e.g., amitriptyline, nortriptyline, imip-
TABLE 151. Medications that may induce depression
Analgesics/anti- Griseofulvin Miscellaneous

inflammatory Isoniazid Amphetamine withdrawal*
Ibuprofen Metronidazole Caffeine
Indomethacin* Nalidixic acid Cimetidine
Baclofen Nitrofurantoin Digitalis
Cocaine Procaine penicillin Disulfuram
Opiates* (morphine, Streptomycin Halothane
codeine) Sulfonamide Inderal*
Pentazocine Tetracycline Metoclopramide (where?)
Penacetin Methysergide
Phenylbutazone Antineoplastics Methrizamide
Arathioprine Phenylephrine
Anticonvulsants 6-Azouridine
Carbamazepine L-Asparaginase Neuroleptics
Ethosuximide Bleomycin Fluphenazine*
Phenobarbital* Cisplatin Haloperidol
Phenytoin* Cyclophosphamide Prochlorperazine
Primidone* Doxorubicin
Mithramycin Sedatives/tranquilizers
Antihistamines Vinblastine Barbiturates*
Vincristine Chloral hydrate
Antihypertensive Diazepam*
agents* Antiparkinsonian Ethanol
Clonidine agents Flurazepam*
Guanethidine Amantidine Major tranquilizers
Hydralazine Bromocriptine Minor tranquilizers*
Hydrochlorothiazide Levodopa* Triazolam*
Methyldopa* Alprazolam
Propranolol Hormones
Reserpine* ACTH* Stimulants
Spironolactone Corticosteroids* Amphetamine* (abuse)
Estrogens/oral contracep- Diethylproprion
Antimicrobials tives Fenfluramine (abuse)
Ampicillin Methylphenidate
Cycloserine Immunosuppressive
Dyapsone agents
*Drugs that have a high incidence of depressive side effects.

Source. Valente SM, Saunders JM, Cohen MZ: Evaluating depression among patients with
cancers. Cancer Practice 2:6571, 1994. Reprinted with permission.
ramine) (Massie 1989b) (see Table 154), which were started in low doses
(2550 mg) given at bedtime and increased slowly over days to weeks until
symptoms improved (usually the peak dose is lower than that tolerated by
physically healthy patients). Heterocyclic antidepressants, including the
second-generation antidepressants (e.g., trazadone), have been found useful
as sedating medications in agitated patients and those with insomnia. The
TABLE 152. Discriminators of depression from medical illness
Guilt and self-reproach

Psychomotor retardation
Recurrent suicidal thoughts
Difficulty concentrating, confusion, forgetfulness
Social withdrawal, isolation
Increased irritability, problematic anger
Increased relationship disruption, disturbances
Anhedonia
Preoccupation with (or obsessive) negative thoughts
Anxiety, panic attacks, newly emergent phobias
TABLE 153. Assessment guide for major depression in cancer patients
Risk factors Precipitants Symptoms

History (past/present) Stress from
Affective disorder Meaning of cancer Sad facial expression/mood
Chemical dependency Unmet needs Decreased interest in self
Physical abuse/self-injury Pain/symptom distress Anhedonia
Poor control of pain/ Anxiety/fears Social withdrawal
symptoms
Advanced stages of cancer Financial concerns Somatic symptoms: anor-
exia, insomnia, fatigue
Medications with Automatic negative
depressive side effects thinking
Inadequate social supports Drugs causing Slow thought, concentra-
depression tion
Impaired body image Thoughts of suicide
Changed work/family roles
Source. Valente SM, Saunders JM, Cohen MZ: Evaluating depression among patients with
cancers. Cancer Practice 2:6571, 1994. Reprinted with permission.
most commonly used antidepressants for cancer patients at present are selec-
tive serotonin reuptake inhibitors (e.g., fluoxetine, sertraline, paroxetine, flu-
voxamine), which have fewer side effects (lower cardiac risks, hypertension,
and anticholinergic effects) than do the tricyclic antidepressants. Newer anti-
TABLE 154. Medications commonly used to treat depression
Dosages
start dose/ Primary side effects and
Medications daily dose, mg comments
Tricyclic antidepressants
(TCAs)
All TCAs may cause cardiac
arrhythmias; blood levels are
available for all but doxepin.
Get baseline EKG.
Amitriptyline (Elavil) 1025/50100 Sedation; anticholinergic; ortho-
stasis
Imipramine (Tofranil) 1025/50150 Intermediate sedation; anticholin-
ergic; orthostasis
Desipramine (Norpramin) 25/75150 Little sedation or orthostasis; mod-
erate anticholinergic
Nortriptyline (Pamelor) 1025/75150 Little anticholinergic or orthostasis
intermediate sedation; therapeu-
tic window
Doxepin (Sinequan) 25/75150 Very sedating; orthostatic; inter-
mediate anticholinergic; potent
antihistamine
Heterocyclics
Amoxapine (Asendin) 25/100150 Sedation; risk of tardive dyskine-
sia; extrapyramidal side effects
Maprotiline (Ludiomil) 25/5075 Moderate sedation; risk of seizures
Second-generation
antidepressants
Buproprion (Wellbutrin) 15/200450 May cause seizures in those with
low threshold; initially activating
Trazodone (Desyrel) 50/150200 Sedating; not anticholinergic
Selective serotonin reuptake
inhibitors
Serotonin reuptake inhibitors
have no anticholinergic or
cardiovascular side effects
Fluoxetine (Prozac) 20/2060 Headache, nausea, anxiety, insom-
nia, very long half-life, may be
even longer in debilitated patients
Sertraline (Zoloft) 50/50150 Nausea, insomnia, diarrhea
Paroxetine (Paxil) 20/2060 Nausea, somnolence, asthenia,
muscle spasm
TABLE 154. Medications commonly used to treat depression (continued)
Dosages
start dose/ Primary side effects and
Medications daily dose, mg comments
Psychostimulants May cause nightmares, insomnia,
Should be given in two divided psychosis, anorexia, agitation,
doses at 8 AM and noon; can be restlessness
used as antidepressant,
analgesic adjuvant, and to
counter sedation of opiates
d-Amphetamine (Dexedrin) 2.5/530
Methylphenidate (Ritalin) 2.5/530
Pemoline (Cylert) 18.75/37.5150 Follow liver tests
Monoamine oxidase
inhibitors (MAOIs)
MAOIs are orthostatic; risk of
hypertensive crisis; strict dietary
and medication restrictions;
should never be used with
meperidine
Isocarboxazid (Marplan) 10/2040 Hypertensive/hypotensive
Phenelzine (Nardil) 15/3060 Drug/diet interactions
Tranycypromine (Parnate) 10/2040
Source. Roth AJ, Holland JC: Treatment of depression in cancer patients. Primary Care and Cancer
14:2329, 1994. Reprinted with permission of Primary Care and Cancer, Melville, NY.
depressants such as nefazodone (Sersone) and bupropion (Wellbutrin) prom-

ise relief for depression without sexual side effects. Psychostimulants (e.g.,
methylphenidate) are being used increasingly to treat depression in cancer pa-
tients, especially those suffering from depressed mood, apathy, low energy,
poor concentration, and weakness. In small doses they are helpful in counter-
ing the effects of morphine, and response is more rapid than that for tricyclic
antidepressants. Finally, psychopharmacology with cancer patients requires
alertness for interaction with other medications, chemotherapy, and medical
conditions (see Table 154).
Anxiety and Panic Disorders

Anxiety is ubiquitous in cancer patients, typically occurring at turning points
of illness such as diagnosis, recurrence, treatment failure, and even at termi-
nation of successful curative treatment when patients fear the loss of close
monitoring or the supportive relationships of medical staff. Anxiety can also
be situational secondary to pain, underlying medical conditions, hormone-
secreting tumors, medications, treatment (e.g., hospitalization, needles), or as
a side effect of medications (Massie 1989a). The most common preexisting
chronic anxieties (predating cancer diagnosis) are phobias (e.g., claustropho-
bia) and panic disorders, although anxiety disorders such as generalized anx-
iety disorder and posttraumatic stress disorder are often activated by cancer
or its treatment.
Anxiety is often complicated by pain, nausea, and depression. Evaluation
of the cause of anxiety may lead to immediate control of symptoms, with the
long-term outcome dependent on etiology. Psychotherapy, medication, and
behavioral interventions are usually effective in the short term, but are least
effective in the management of long-standing anxiety disorders. Anxiolytic or
antidepressant medications are often effective. Self-regulatory therapies (e.g.,
hypnosis, meditation, biofeedback, progressive relaxation, guided imagery,
and cognitive behavioral techniques) have also been effective with anxiety
disorders.
Nausea, Vomiting, and Pain
Symptoms such as nausea, vomiting, and anticipatory nausea may develop

either before or during chemotherapy. Patients differ in how prone they are
to nausea and vomiting depending on their neurologic makeup and their anx-
iety level. Some chemotherapeutic medications are more likely to cause nau-
sea than others. Approximately 45% of cancer patients experience nausea,
vomiting, or both within the 24 hours before chemotherapy. These symp-
toms appear to be caused by the interplay of associative learning and the
stress associated with chemotherapy.
Cancer pain regrettably continues to be undertreated, and severe pain is
experienced in 60%90% of patients with advanced cancer. Poorly controlled
pain results in heightened levels of anxiety and depression. Despite patient
beliefs or myths, cancer patients rarely abuse pain medications or become ad-
dicted to them. Psychologic techniques such as hypnosis, relaxation training,
biofeedback, distraction, guided imagery, acupuncture, acupressure, massage
therapy, biofeedback, and sensation redefinition may assist in pain control.
Antidepressant medications are often used successfully as an additional pain
management technique (Mastrovito 1989).
Psychologic Treatment
The first psychiatric group in the United States devoted to the study of the
psychosocial consequences of cancer and surgical treatment was established
by Sutherland in 1950 (Holland 1989). The emerging field of psychooncolo-
gy has two dimensions: 1) the impact of cancer on the psychologic function
of the patient, the patients family, and staff; and 2) the role that psychologic
and behavioral variables may have in cancer risk and survival (Holland
1989). Care of cancer patients increasingly involves a team of professionals
specializing in oncology, including psychooncologistspsychiatrists, psychol-
ogists, social workers, and psychiatric nurses with special interest and/or
training in the psychologic aspects of cancer and its treatment. Psychooncol-
ogists are familiar with cancer diagnosis, prognosis, and treatment; the psy-
chosocial issues of cancer for the patient and her family; and their own
personal responses to patients who have a life-threatening illness.
Consultation-liaison psychiatry developed in the early 1970s when psy-
chiatrists, acting as hospital consultants for inpatients, expanded their respon-
sibilities to include a liaison role. They conducted multidisciplinary teaching
rounds and groups that focused on psychologic and behavioral problems,
ethical dilemmas, and conflicts between patients and staff and among staff
members (Artiss and Levine 1973). Psychiatrists, as psychooncologists, pro-
vide consultation-liaison services as well as outpatient psychopharmacologic
care and psychotherapy. Multidisciplinary teams including social workers,
psychologists, specially trained nurses, and clergy may offer support groups
for patients and their families as well as individual patient care.
Components of effective interventions include an emotionally support-
ive context in which to address fears about the disease, information about the
disease and its treatment, behavioral and cognitive coping strategies, relax-
ation training to lower arousal and enhance sense of control, focused inter-
ventions for disease-specific problems, and social support (Anderson 1997).
Five patterns of coping with cancer were identified by Dunkel-Schetter et al.
(1992): 1) seeking or using social support, 2) focusing on the positive, 3) dis-
tancing, 4) cognitive escape-avoidance, and 5) behavioral escape-avoidance.
They found that women with cancer use a large repertoire of behaviors to
cope flexibly rather than rigidly adhering to a particular coping style, with
distancing being the most commonly used pattern.
The goals of psychotherapy are to help the patient regain a sense of self-
worth, to correct misconceptions, to integrate the present illness into a con-
tinuum of life experiences, and to provide practical help in managing treat-
ment side effects (Roth and Holland 1994). Psychotherapy emphasizes past
strengths, supports previously successful ways of coping, and mobilizes inner
resources. The length of therapy must be tailored to the patient to reduce
symptoms to a tolerable level. In addition, family members may be helpful as
part of the therapy, or group attendance may be beneficial. Adjuvant psycho-
logic therapy emphasizes fostering a positive attitude, helping the patient ad-
here and cope with treatment, and reducing emotional distress (Moorey and
Greer 1989). It is a cognitive-behavioral therapy based on the cognitive mod-
el of adjustment to cancer in which appraisals, interpretations, and evalua-
tions that the individual makes about cancer determine her behavioral
reactions. Therapy involves mobilizing coping behaviors (fighting spirit, de-
nial, fatalism, helplessness/hopelessness, anxious preoccupation) and finding
problem-oriented solutions; the problems encountered may be emotional
(e.g., depression), interpersonal (e.g., problems communicating with spouse),
or related to the cancer type (e.g., body image problems of vulvar cancer
patients).
Self-help and mutual support programs date from the 1940s, when the
American Cancer Society began its volunteer visitor programs offering prac-
tical help for patients at home (Mastrovito et al. 1989). These patientvisitor
programs offer a dimension of help beyond the scope of professional practi-
tioners. Support volunteers (e.g., Gildas Club) typically have personal expe-
rience with cancer, good communication skills, emotional stability, the ability
to model good coping skills, sensitivity, empathy, and good listening skills.
Alternative or complementary cancer therapies are increasingly being
used, although safety and efficacy standards have not been developed in
these products or approaches. Cassileth et al. (1984) reported the six most
widely used alternative therapies today to be metabolic therapy, diet treat-
ments, megavitamins, mental imagery approaches, spiritual or faith healing,
and immunotherapy. Patients also report the use of homeopathic therapies,
massage, tai chi, acupuncture, acupressure, nutrition, and herbal therapies.
These treatments may have direct effects, placebo effects, side effects, and/or
potential drug interactions. When taking a patients history and developing a
treatment plan, it is important to consider any alternative treatments the pa-
tient may be using (e.g., St. Johns wort).
Conclusion
For women of all ages, gynecologic cancers are responsible for a significant
amount of mortality and morbidity, including physical suffering and psycho-
social distress. Adding to the distress for women are the high degree of uncer-
tainty of the illness, its prognosis, and its treatment as well as the lack of social
awareness or community support. Breast cancer often steals the limelight of
womens cancer; gynecologic cancers often linger in the shadows, receiving
much less attention, funding, support, or consumer education. Yet the toll of
gynecologic cancers on the reproductive, sexual, and psychologic lives of
women (both young and old) is profound. Therefore, it is important that
caregivers be cognizant of the complex lives women live, the unique and pow-
erful meanings of their reproductive organs, the potentially devastating im-
pact of gynecologic cancer and its treatment on their physical and
psychologic health and well-being, and the social costs in their lives. The grief
expressed by women with gynecologic cancer is not simply for the loss of
good health, it is also for the loss of the parts of themselves that some feel
make them uniquely women.
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16
Women and HIV Infection
JAN MOORE, PH.D.
DAWN K. SMITH, M.D., M.S., M.P.H.
Epidemiology of HIV/AIDS in Women
Global HIV/AIDS Epidemiology
The World Health Organization (1998) estimated that of the 5.2 million
adults (age > 15 years) infected with HIV in 1998 worldwide, 40% were
women. Of the 32.2 million adults living with HIV/AIDS, 43% were women.
Women as a proportion of new HIV infections in 1998 ranged from 5% in
Australia and New Zealand to 50% in sub-Saharan Africa, with other regions
in the 15%35% range.
More than 95% of HIV-infected people live in the developing world.
Sub-Saharan Africa, which contains only 10% of the worlds population, was
home to 70% of those infected in 1998 and the site of 80% of HIV/AIDS
deaths that year. In 1998, AIDS was responsible for an estimated 2 million
deaths5,500 funerals a day. An estimated 1/7 HIV infections in sub-Saharan
Africa and 1/10 infections worldwide occurred in 1998 alone. Half of these
African infections occurred in women. In India, HIV infection rates among
antenatal women are greater than 1% in urban areas of at least five states and
13.6% among women in Pune with sexually transmitted diseases (STDs) who
reported that their only risk factor was sex with their husbands.
In most regions of the world, it is estimated that more than 90% of HIV
infections among women are acquired heterosexually, often from husbands
331
or regular sex partners. An additional contributor in some regions (e.g., Afri-

ca, Asia) is unsafe blood transfusion, which is of particular concern for wom-
en in association with pregnancy and childbirth. In North America and
Europe, intravenous drug use contributes significantly to the HIV epidemic
in women.
Although less than 1% of new infections globally in 1998 occurred in
the United States, most of our data about disease trends, manifestions, and
progression in women come from the United States and, to a lesser extent,
Europe.
AIDS Case Surveillance in the United States
Reported AIDS cases are the most commonly used measure of the HIV/
AIDS epidemic in the United States. Through December 1997, 98,468 cases
of AIDS in women had been reported to the Centers for Disease Control and
Prevention15% of all persons ever reported with AIDS in the United States
(Centers for Disease Control and Prevention 1997b). In 1997 alone, 13,105
cases of AIDS in women were reported, accounting for 22% of the AIDS cas-
es reported that year.
In 1997, most of the women reported to have AIDS were black (60%) or
Hispanic (20%) (Centers for Disease Control and Prevention 1997b). Com-
pared with the 1997 AIDS incidence rate per 100,000 population for white
women, the rate for black women was nearly 13 times higher and that for
Hispanic women was 7 times higher (Table 161A).
HIV Case Surveillance in the United States
Three factors have led to a decreased ability to rely on reported AIDS cases
as a primary indicator of the size and trends in the epidemic of HIV infection.
First, the time from HIV infection to the development of AIDS can extend
for 10 years or longer, so that even accurate AIDS surveillance does not give
a timely indication of trends in HIV infection. Second, because of the recent
availability and increasing use of highly active antiretroviral therapy and pro-
phylaxis for opportunistic infections, which delay the onset of AIDS in many
HIV-infected people, reported AIDS cases are now declining while the num-
bers of HIV-infected people living without having developed AIDS are in-
creasing (Centers for Disease Control and Prevention 1997d). Last, these
same medical therapies are reducing mortality among people with AIDS,
thus increasing the number of people living with AIDS. The combination of
TABLE 161A. Female adult/adolescent AIDS cases reported in the United States in 1997a
Asian/Pacific American Indian/

Black, n (%) Hispanic, n (%) White, n (%) Islander, n (%) Alaska Native, n (%)
Intravenous drug use 2,511 (32) 750 (29) 907 (36) 11 (17) 14 (39)
Heterosexual 2,790 (35) 1,174 (46) 991 (40) 30 (47) 13 (36)
Blood product 122 (2) 31 (1) 41 (2) 5 (8) 2 (6)
b
No identified risk reported 2,457 (31) 623 (24) 546 (22) 18 (28) 7 (19)
Total number 7,880 2,578 2,485 64 36
Rate/100,000 38.8 21.3 3.0 1.5 4.7
a
Table excludes 133 women with unknown race/ethnicity.
b
At time of AIDS case report.

333
these factors means that reported AIDS cases no longer provide a represen-
tative picture of the HIV epidemic. For these reasons, the Centers for Disease
Control and Prevention has recommended that all states develop routine,
confidential HIV surveillance systems to more accurately measure the epi-
demic. Annual data for 1997 were reported for the 27 states that have surveil-
lance for HIV among adults (Table 161B), but the reporting states do not
include several states with high rates of infection among women (e.g, New
York), so the data are not yet nationally representative.
In the 27 states that had integrated HIV and AIDS surveillance from Jan-
uary 1994 through June 1997, the number of people reported with HIV in-
fection (not AIDS) was compared with the number first reported after they
had already developed AIDS. Of people in whom HIV infection was the ini-
tial diagnosis, 28% were women (compared with 17% of AIDS diagnoses),
57% were black (compared with 45% of AIDS diagnoses), and 32% were
aged 1329 (compared with 14% of AIDS diagnoses). Of HIV diagnoses
among people aged 1324 years, 44% were women and 63% were black.
These data strongly suggest that young women, especially black women, are
continuing to be infected with HIV at high rates (Centers for Disease Control
and Prevention 1998b).
Modes of Exposure to HIV for

Women in the United States
In 1997, 32% of women reported with AIDS had a history of intravenous

drug use and were assumed to have become infected with HIV through this
route (see Table 161A) (Centers for Disease Control and Prevention 1997b).
Heterosexual contact accounted for 38% of AIDS cases in women, this pro-
portion having steadily increased from approximately 15% in 1983. The
number of women infected with HIV through heterosexual contact may be
underestimated. Women who inject drugs frequently have male sex partners
who also inject drugs or have other risk factors; therefore, these women may
have become infected with HIV through sexual contact. Additionally, ap-
proximately 28% of women who have AIDS report that they have none of
the established risk factors. At least a portion of these cases includes women
who were heterosexually infected by partners whose HIV status or risk his-
tory was unknown to the woman, including sexual contact with a bisexual
male.
Women who have multiple sex partners are at increased risk for HIV be-
cause their chance of encountering an HIV-infected partner is greater than
TABLE 161B. Female adult/adolescent HIV (not AIDS) cases reported in the United States in 1997a
Asian/Pacific American Indian/

Black, n (%) Hispanic, n (%) White, n (%) Islander, n (%) Alaskan Native, n (%)
Intravenous drug use 386 (13) 57 (19) 204 (21) 1 (7) 9 (43)
Heterosexual 992 (33) 112 (37) 375 (39) 4 (29) 5 (24)
Blood product 23 (1) 2 (1) 13 (1) 0 (0) 0 (0)
b
No identified risk reported 1,615 (54) 134 (44) 362 (38) 9 (64) 7 (33)
Total number 3,016 305 954 14 21
a
From 27 states that reported HIV cases among adults in 1997. Table excludes 269 women with unknown race/ethnicity.
b
At time of AIDS case report.

335
that for women with fewer partners. These women are also at increased risk
for acquiring other STDs that may facilitate HIV transmission, thus contrib-
uting to a higher incidence of HIV infection (Holmberg et al. 1989; Royce et
al. 1997). Finally, although recent data suggest some leveling, the National
Survey of Family Growth has shown that first sexual experiences are occur-
ring at younger ages (Centers for Disease Control 1991). The literature sug-
gests that women who begin sexual intercourse at a young age are more likely
to have multiple partners and thus to be at greater risk for HIV infection than
are women who delay intercourse (Greenberg et al. 1992). These factors may
contribute to a significant increase in the still small number of AIDS cases
among adolescent and young adult women, the latter of whom may presum-
ably have been infected as adolescents.
Transfusion recipients and recipients of other blood products now ac-
count for a small and declining percent of women with AIDS (4%). Virtually
all new cases of transfusion-related AIDS are associated with the receipt of
blood before 1985 (i.e., before HIV antibody screening of blood donations
was implemented) (Ward et al. 1988).
Female-to-female sexual transmission of HIV has been of interest and
concern to health care providers and HIV-infected women. Three cases of
female-to-female transmission have been reported in the medical literature
(Marmor et al. 1986; Monzon and Capellan 1987; Perry et al. 1989). How-
ever, a review of AIDS cases in 164 women who reported having sex only
with other women revealed that in all cases another risk factor was present:
93% of the women had a history of intravenous drug use and 7% had a his-
tory of blood transfusion before March 1985 (Chu et al. 1992). None of these
cases was attributable to female-to-female sexual transmission.
HIV/AIDS Mortality in the

United States
Mortality rates clearly demonstrate the severe impact of AIDS on women,

particularly black women. As early as 1990, AIDS and HIV-related diseases
were the sixth leading cause of death among women aged 2544 years in the
United States (Centers for Disease Control and Prevention 1993b) and the
leading cause of death among black women of this age group. In 1996, HIV/
AIDS was the fourth leading cause of death among all women aged 1544
and continued to be the leading cause of death among black women (Figure
161).
FIGURE 161. A, Death rates among all women ages 2544 years (19821996). B, Death rates among African-American women ages 2544
years (19821996).
337
Manifestations of HIV Infection in Women
The first case of AIDS in a woman in the United States was reported in Au-
gust 1981 (Centers for Disease Control 1981), and the first description of the
clinical and epidemiologic characteristics of women with AIDS appeared in
May 1982 (Masur et al. 1982). However, because of the early severe impact
of the epidemic on homosexual/bisexual male communities, almost all early
studies of the natural history of HIV infection were conducted in cohorts of
white homosexual men living in AIDS epidemic centers such as New York
and San Francisco. Studies of blood transfusion recipients and intravenous
drug users have included women but not in sufficient numbers to definitively
examine gender differences in HIV disease progression.
In recent years, several studies have followed-up with groups of women
over varied periods of time and have attempted to describe aspects of the
course and clinical manifestations of HIV infection in women, including two
large prospective cohort studies of women with HIV infection and behavior-
ally matched, uninfected women (Barkan et al. 1998; Smith et al. 1997). Ex-
cept for gynecologic findings and mental health, these studies have shown
few gender-based differences in HIV disease manifestations and disease pro-
gression. Recent findings suggest that the clinical implications of viral load
may differ by gender (Farzadegan et al. 1998; Sterling et al. 1998), but con-
firmatory studies are not yet completed.
Non-AIDS-Defining Conditions
Following the occurrence of acute antiretroviral illness in some patients at the

time of HIV infection (Flanigan et al. 1992; Kinloch-de Los et al. 1993;
Schacker et al. 1998; Tindall and Cooper 1991), a long period of asymptom-
atic HIV infection occurs during which HIV establishes a chronic infection,
primarily involving lymph nodes. Over several years, untreated HIV infec-
tion leads to the gradual impairment of the immune system by several mech-
anisms, eventually leaving the infected person susceptible to the many
opportunistic infections and malignancies that define AIDS.
The hallmark of HIV disease progression, a decline over time in CD4+ T
lymphocytes, has been prospectively studied in a few cohorts of women and
heterosexual men; these studies have suggested no substantial difference be-
tween HIV-infected men and women in immunologic decline (Chaisson et al.
1992; Selwyn et al. 1992). Because women experience a mild form of immu-
nosuppression during pregnancy, including a decline in CD4+ T lymphocytes
Women and HIV Infection 339
(Biggar et al. 1989), the effect of pregnancy on disease progression in women

was a matter of concern at first. However, larger prospective controlled stud-
ies have shown no increase in disease progression associated with pregnancy,
suggesting that pregnancy has little or no independent effect on the progres-
sion of HIV disease (Brettle and Leen 1991; Deschamps et al. 1993).
Several studies report that the prevalence and persistence of human pap-
illomavirus infection are higher in HIV-infected women than in uninfected
women and are strongly associated with the development of cervical dyspla-
sia, the precursor to invasive cervical cancer (Feingold et al. 1990; Wright and
Sun 1996). Other studies of HIV-infected women have shown an association
between immunosuppression and severe grades of dysplasia on Pap smear or
cervical biopsy results (Maiman et al. 1991; Schafer et al. 1991). In addition,
studies of treated cervical dysplasia suggest that HIV-infected immunosup-
pressed women have high rates of recurrence or persistence of dysplasia after
receiving standard therapies (Fruchter et al. 1996; Maiman et al. 1990).
AIDS-Defining Conditions
The occurrence of AIDS-defining conditions differs somewhat for men and
women, but the available data suggest more similarities than differences. A
recent analysis of gender differences among AIDS cases diagnosed from 1988
through mid-1991 indicated similar prevalence for most, but not all, AIDS-
defining conditions when differences in race/ethnicity and the mode of trans-
mission were controlled. In a comparison of 7,183 female and 21,776 male
intravenous drug users, only esophageal candidiasis, herpes simplex virus
(HSV), and cytomegalovirus were significantly more frequent among women
than among men, whereas toxoplasmosis, cryptococcosis, histoplasmosis,
Kaposis sarcoma, and lymphomas were significantly less common in women
(Fleming et al. 1993).
Few studies have been published about the causes of death among HIV-
infected women, either alone or in comparison with those of HIV-infected
men. Among women in the United States aged 1544 years who died in 1987
and whose death certificates mention HIV/AIDS, the leading causes of death
were drug abuse (26.5%), followed by Pneumocystis carinii pneumonia (19.7%),
other pneumonia (14.1%), and septicemia (9.8%) (Chu et al. 1990).
HIV/AIDS Manifestations in Developing Countries

Few studies have examined the manifestations and progression of HIV dis-
ease in representative cohorts of women in developing countries. The limited
data available suggest no significant differences in survival rates of women

compared with men (Morgan et al. 1997a) but suggest survival rates for
adults of both genders may be half that of adults in developed countries
(Mocroft et al. 1996; Todd et al. 1997). Similarly, time to AIDS appears short-
er in developing countries (Anzala et al. 1995; Morgan et al. 1997b). Studies
have not rigorously examined potential gender differences in the manifesta-
tions of HIV disease in these populations, but all gender-specific conditions
described in North American and European women (e.g., HPV infection/cer-
vical dysplasia, vaginal candidiasis, pelvic inflammatory disease) have also
been found in women in developing countries.
Health Care Issues for Women with HIV Infection
Critical to optimal medical, psychologic, and social service care for women
are 1) the early diagnosis of HIV infection; 2) the provision of education both
about HIV disease and the importance of early care; and 3) access to and ad-
herence support for the use of highly active antiretroviral therapy and pro-
phylaxis for opportunistic infections.
Accumulating evidence indicates that many opportunities for identifying
women with HIV infection are missed (Boekeloo et al. 1993; Schoenbaum
and Webber 1993). Standard recommendations for HIV testing rely largely
on the patients history of behaviors associated with a risk of HIV infection.
However, standard risk history questions failed to identify most asymptom-
atic HIV-infected women in studies in which results from blinded testing are
available. Providers are often reluctant to ask sensitive questions about sexual
and drug use behaviors and women are frequently unwilling to disclose such
behaviors to providers whom they do not know or trust (Boekeloo et al.
1993; Centers for Disease Control and Prevention 1994; Schoenbaum and
Webber 1993). In addition, women may be unaware of behaviors of their sex-
ual partners that place them at risk of heterosexual transmission (Doll et al.
1991).
HIV Infections in Pregnancy
Recent medical advances in the ability to reduce HIV transmission from

mother to infant have increased the emphasis on routine HIV counseling and
testing of pregnant women. The Public Health Service issued recommenda-
tions in 1995 that all pregnant women be counseled and offered voluntary
HIV testing in prenatal settings (Centers for Disease Control and Prevention
1995). Early data suggest that most women in prenatal care in the United
States are being offered HIV testing (Royce et al. 1998) and that approximate-
ly 80% accept (Fernandez et al. 1998; Royce et al. 1998). Surveillance data on
HIV-infected pregnant women indicate that about 80% know their HIV sta-
tus by the time of delivery (Wortley et al. 1998). Interventions to overcome
barriers to prenatal HIV testing (e.g., lack of prenatal care, misperceptions of
no risk for HIV by women and their health care providers, and logistical
problems related to getting a test) are being planned and are expected to result
in even higher rates of testing. Widespread HIV testing of pregnant women
is hoped to not only decrease rates of perinatal transmission but also to en-
sure that HIV in women is diagnosed and treated earlier in the course of the
disease.
Treatment of HIV Infection in Women
After HIV infection is diagnosed, several conditions must exist for women to
receive appropriate treatment for the infection and its related conditions: 1)
providers of high-quality health care services must be available; 2) women
must have financial access to these services; and 3) these women must use ac-
cessible services and adhere to recommended follow-up and therapy.
Health care professionals experienced both in womens health care and
HIV-related treatment are not easily found. For example, providers may be
very knowledgeable about the treatment of HIV, but because of their inexpe-
rience with socioeconomically disadvantaged women, they alter treatment
decisions based on expectations derived from the sociodemographic rather
than the clinical characteristics of their patients (Centers for Disease Control
and Prevention 1994; Stein et al. 1991). Providers experienced in womens
health care frequently are not familiar with HIV-related treatment issues and
so may not prescribe the most effective antiretroviral or prophylaxis therapies
(Boekeloo et al. 1993); this situation is especially worrisome because mortal-
ity rates of patients with AIDS appear to be related to the level of experience
of medical personnel in the treatment of AIDS (Stone et al. 1992).
Treatment of HIV infection in women is not gender specific, and pub-
lished guidelines for the content and periodicity of physical and laboratory
examinations, vaccinations, and the selection of appropriate drug therapies
should be followed (Centers for Disease Control and Prevention 1997a,
1997e, 1998e, 1998f). Recommendations for screening and treatment of gy-
necologic and obstetric conditions in HIV-infected women are also available
(Centers for Disease Control and Prevention 1997a, 1998c, 1998f).

Recent advances in the use of potent antiretroviral combination therapies
have provided unprecedented delays in the progression of HIV disease (Col-
lier et al. 1996; Deeks et al. 1997; Palella et al. 1998). To achieve this benefit,
however, patients must adhere to complex drug regimens. Nonadherence to
antiretroviral therapy may result not only in treatment ineffectiveness but also
in the development of drug-resistant HIV strains. Particular concern has
been raised about nonadherence by HIV-infected persons living in disadvan-
taged situations. Data collected on poor, inner-city, HIV-infected women in-
dicate that they are less likely to be taking antiretroviral medication than are
infected men (Solomon et al. 1998). It is unclear, however, how much of this
gender difference can be attributed to the unwillingness of health providers
to prescribe state-of-the-art drugs to disadvantaged persons, some of whom
use illicit drugs, and how much can be attributed to womens failure to fill pre-
scriptions and adhere to prescribed treatments.
All patients, regardless of gender, race/ethnicity, or income have reported
difficulty in following the current recommended regimens for HIV treatment
(Cramer and Mattson 1991; Epstein and Cluss 1982; Glasgow 1991). HIV-
infected women who have many competing life stresses are likely to have
great difficulty maintaining drug regimens. They may need assistance in
working out a realistic schedule for taking medications and in developing sup-
port networks to assist them in maintaining highly complex treatment regi-
mens. Without these supportive services women may be unable to fully
benefit from available medical advances in treatment.
Principles of Care in Developing Countries
Widespread availability of affordable HIV testing is not found in most devel-

oping countries; thus, identifying HIV infection in women prior to serious ill-
ness is uncommon. With increasing availability of inexpensive rapid testing
technologies and the dissemination of HIV test counseling protocols appro-
priate to these settings, it is anticipated that greater numbers of women (and
their male partners) will learn their HIV status in a timely fashion. Because
long-term use of antiretroviral medications is not logistically or financially
feasible in most developing countries, treatment issues are focused on preven-
tion, early identification, and treatment of opportunistic or comorbid infec-
tions, especially tuberculosis, bacteremia, and diarrheal disease (DeCock et
al. 1993; Grant et al. 1997; Lucas et al. 1993). In addition, recent documen-
tation of the effectiveness of short, relatively inexpensive courses of antiretro-
viral treatment in late pregnancy for reducing perinatal transmission (Centers

for Disease Control and Prevention 1998a) is anticipated to increase access to
HIV testing for women and thus their use of the prevention and treatment
therapies available to them.
Psychosocial Issues and HIV Infection

Among Women in the United States
Although all serious, debilitating illnesses have been shown to affect psycho-
logic and social functioning (Anderson et al. 1989; Manne and Zautra 1990;
Revenson and Felton 1989), HIV infection may have a greater impact than
most medical conditions. The stigma associated with the disease and the ac-
tivities related to its acquisition (e.g., illicit drug use, sexual behavior), the po-
tential for discrimination against oneself and ones family, and the greater
likelihood that members of ones family or social circle are also infected pre-
sent unique psychologic and social challenges for HIV-infected people. Most
research on the psychosocial effects of HIV has been conducted with gay
men, the population initially most affected by the AIDS epidemic. Gay men
affected by HIV in the early phase of the epidemic, however, tended to be
white, well-educated, and to have substantial financial and social resources.
Because the epidemic has moved to intravenous drug users and women, the
socioeconomic face of the epidemic has changed dramatically (Centers for
Disease Control and Prevention 1993a, 1995); those most affected by the sec-
ond wave of the epidemic have been poor and from racial/ethnic minority
groups. Poor, urban, minority women (a group already experiencing myriad
stressful life events, elevated psychologic distress, and few social and econom-
ic resources) have been hit particularly hard by HIV and AIDS. Because of
the vulnerability of this group, particular concerns have been raised about
many womens ability to cope with the added stress of living with HIV infec-
tion or the prospect of becoming infected.
In this section of the chapter, we review the limited literature available on
the psychologic and social issues for women related to getting an HIV test,
receiving test results, adjusting to a positive diagnosis, and living with HIV
infection. Issues that present particular challenges to HIV-infected women
compared with infected men are addressed, including 1) confronting ones
risk for HIV; 2) disclosing HIV status to sex partners, other adults, and chil-
dren; 3) changing sexual behavior; 4) making reproductive decisions; and
5) making plans for the future.
HIV Antibody Testing
Nonpregnant women typically are not offered HIV testing unless they pre-
sent to the medical system with HIV-related symptoms. Studies have shown
that approximately one-half of HIV-infected women are not diagnosed until
they enter the health care system with HIV-related symptoms or an AIDS-
defining illness (Beevor and Catalan 1993). Women, nonwhites, and people
at heterosexual risk are likely to be detected later in their course of disease
than are men, whites, drug users, and gay men (Sorvillo et al. 1998). A pri-
mary reason women are not tested earlier is that their risk for HIV is fre-
quently overlooked or not assessed by health care providers (Schoenbaum
and Webber 1993). Additionally, women may overlook or misperceive their
own risk for HIV and thus fail to seek testing. Recent studies have shown that
failure to acknowledge risk for HIV is the primary reason that people, includ-
ing women, delay or do not obtain HIV testing (Lehman et al. 1998).
Confronting HIV risk may be particularly difficult for women. Not only
must they assess their own behavioral risk but they must also examine the
potential risk behaviors of male partners (i.e., intravenous drug use or sex
with other partners). Although some women are unaware of the risk behav-
iors of their sex partners (Doll et al. 1991), others deny or overlook evidence
of their partners HIV risk. In a study including high-risk, uninfected women,
approximately 63% reported inconsistent condom use in the 6 months prior
to the study (Moore et al. 1998b). When asked the reasons for nonuse of con-
doms at last incident of unprotected intercourse, approximately 85% said that
their partner was not at risk, although only a small proportion actually knew
the HIV status of their partner and many had earlier acknowledged their
partners involvement in risk behaviors.
Confronting partners with their risk behavior can cause considerable tur-
moil in a relationship. Anticipation that the relationship will be disrupted or
the partner will be made upset may prevent women from initiating any dis-
cussion with their partner about HIV (Harrison et al. 1995). In a study of
women who knew or suspected that their partner had other sex partners, the
most frequently reported reasons for not broaching the issues of partners risk
behavior or of his getting an HIV test were concerns that the partner would
feel accused of infidelity or of having a disease and that he would be dis-
pleased with the woman for bringing up the subject (Moore et al. 1995).
Many health care professionals and researchers have written about womens
fear of violence from their partner as a primary obstacle to initiating discus-
sions about HIV. Data available on the subject suggest that although fear of
abuse may be the reason for lack of confrontation for some women, many
more women do not bring up issues related to HIV for fear of displeasing or
upsetting the partner (Harrison et al. 1995; Moore et al. 1998b). Additionally,
recent data suggest that only a small proportion of women decline HIV test-
ing for fear of abusive repercussions from male partners (Maher et al. 1998).
The threat of violence, however, is a real concern for at least a portion of
women at risk for HIV (Gielen et al. 1997; Moore et al. 1995), and health
care professionals must be mindful of this possibility as they help women face
their own and their partners HIV risk.
Women may need support not only in deciding to obtain an HIV test but
also in taking the steps to get the test. They may have informational needs
such as where to go for a test, what to expect from the testing situation, and
the implications of different test results. Once women have been tested and
are waiting for test results, support needs are likely to be even greater. Re-
search suggests that waiting for HIV test results is highly stressful for both
men and women, particularly for persons perceiving themselves to be at high
risk for HIV (Ickovics et al. 1994; Jacobsen et al. 1990). People with few so-
cial supports and a history of prior psychiatric difficulties are typically more
distressed during this time (Kelly et al. 1993; Perry et al. 1990b). Women
without sufficient internal or external resources to deal with the waiting peri-
od are likely to need help generating internal coping strategies and external
sources of social support to get through this time. Pretest counseling often in-
cludes helping women identify persons to whom they can disclose that they
are awaiting HIV test results and who could offer support during the waiting
period. They also may need help anticipating and planning how they would
cope with a positive test result.
Receiving HIV Test Results
Negative Results
Depression, anxiety, and suicidal thoughts tend to decrease in most people af-
ter notification of negative results; emotional stabilization is a well-established
positive outcome of learning ones status (Ostrow et al. 1989; Perry et al.
1990a, 1990c). Reduced depression and anxiety, however, are sometimes ac-
companied by a return to old patterns of risk behavior. Research has shown
that both men and women reduce high-risk sexual activity after testing and
while awaiting results, but gradually resume risk behaviors after receiving a
negative diagnosis (Ickovics et al. 1994; G. Marks, Length of Time Since
Testing HIV Seropositive and Prevalence of Sexual Activity, unpublished
data, 1993). Ickovics et al. (1994) interviewed women about sexual risk be-
havior prior to HIV testing, when they returned for results 2 weeks later, and
again 3 months after receiving negative results. The authors found that sex-
ual risk-taking decreased during the waiting period but returned to pretest
rates at the 3-month assessment. In some cases, receiving a negative test result
may actually confer a feeling of invulnerability or immunity, resulting in an
increase in risk behaviors above those seen prior to testing.
Women receiving negative test results need support in maintaining the
reductions in risk behavior they achieved while waiting for test results. They
may need reminders that a negative test result does not mean they cannot nor
will not become infected with HIV in the future, nor does it mean that their
sex partner is uninfected. Women who receive negative HIV test results
should encourage sex partners to be tested. Until the partner receives a neg-
ative test result and the couple decides to practice monogamy, protection
should be used during each sexual episode.
Positive Results
Womens advocates, health care providers, and public health professionals
have been concerned that a positive HIV diagnosis may cause severe psycho-
logic reactions (i.e., anxiety, depression, suicide) and social ramifications (i.e.,
loss of partners, children, friends, family, job, and health care benefits) for
women who have relatively few internal and external resources to help them
cope (Chung and Magraw 1992; Ickovics and Rodin 1992). Particular con-
cerns have been raised about the consequences of a positive HIV diagnosis
for pregnant women, a group already vulnerable to adverse psychologic and
social events (Lester et al. 1995).
Only limited data have been published on the psychologic consequences
of an HIV diagnosis for women. Studies from mixed gender samples and oth-
er populations (e.g., gay men, intravenous drug users) have shown that many
people experience depressive symptoms and anxiety when they learn of their
HIV infection (Cleary et al. 1993; Jacobsen et al. 1990; Ostrow et al. 1989);
however, most persons do not experience severe psychiatric disorders such as
clinical depression or suicidal thoughts and attempts. When these disorders
do occur, they do so more often in people with a prior history of psychiatric
disorder (Perry et al. 1993). Additionally, after a period of adaptation to the
diagnosis, most newly diagnosed people return to levels of depressive symp-
toms and anxiety typical of similar uninfected populations (Dew et al. 1990;
Perry et al. 1990a). For example, Perry et al. (1990) found that 2 months after
HIV testing, people diagnosed with HIV did not differ on suicidal thoughts,
wishes, and intent from those receiving a negative diagnosis. For both HIV-
infected and uninfected people, lower scores on psychopathology ratings
were found at the 10-week follow-up compared with scores prior to learning
their serostatus. Studies comparing men and women are rare, but the avail-
able data suggest that women experience more distress and depression after
diagnosis than do infected men (Cleary et al. 1993; Fleishman and Fogel
1994; Perry et al. 1993), although gender differences tend to be less striking
when socioeconomic status and drug use are similar between the two groups.
Brown and Rundell (1993) reported few occurrences of depression, suicidal
ideation, or other psychiatric disorders among a group of HIV-infected wom-
en in the military; 41% of these women qualified as having a psychiatric di-
agnosis, but hyposexuality or sexual dysfunction constituted the majority of
these cases.
Few studies have reported on the adverse social events and losses expe-
rienced by women after receiving a positive HIV diagnosis. Early studies of
gay men reported some loss of health care benefits, confidentiality, economic
resources (i.e., housing, income, and insurance), and social support and rela-
tionships (Bayer et al. 1986; Lo et al. 1989). Advocates and public health
practitioners have been particularly concerned about the social and economic
repercussions of HIV testing of pregnant women, a group already at social
and economic risk. Lester et al. (1995) followed-up 22 HIV-infected pregnant
women and a comparison group of 20 uninfected pregnant women. They
found no evidence of increased economic loss among infected women and
greater satisfaction with social supports among infected than among uninfect-
ed women. HIV-infected women, however, reported higher levels of health
care discrimination, personal isolation, and anxiety than did uninfected wom-
en. Additional data on this issue among pregnant and nonpregnant women
are sorely needed to assess potential negative, unintended consequences of
HIV testing and to ensure that newly diagnosed HIV-infected women receive
the social support services they need.
Disclosure of test results is of primary concern to newly diagnosed men
and women (Hays et al. 1993; Marks et al. 1991; Semple et al. 1993). In a
study of the psychobiologic stressors of HIV-infected women, Semple et al.
(1993) reported that most women viewed disclosure as one of their most
pressing concerns following HIV diagnosis. Data indicate that most HIV-
infected women disclose their status to at least one person (Gielen et al. 1997;
Lester et al. 1995; Simoni et al. 1995). Generally, disclosure is made most fre-
quently to partners/spouses/lovers, with rates reported between 85% and
100% in various studies (Gielen et al. 1997; Lester et al. 1995; Simoni et al.
1995); disclosure is then made to close friends and immediate family mem-
bers, followed by extended family, coworkers, and acquaintances.
Most women cite fear of abandonment or rejection as their primary rea-
son for failing to disclose HIV status to other adults (Gielen et al. 1997; Si-
moni et al. 1995). Available data suggest, however, that women frequently
receive supportive reactions from others when they disclose (Simoni et al.
1995), and in one study, HIV-infected women reported more satisfaction
with social support from friends and family than did uninfected women (Lest-
er et al. 1995). Several studies have reported disrupted relationships, prima-
rily with sex partners, following womens disclosure of HIV results. Simoni
et al. (1995) found that 6 of 30 male partners reacted to the womans disclo-
sure of her serostatus by leaving the relationship. Gielen et al. (1997) reported
that 8% of newly diagnosed women anticipated violent reactions from their
partner on disclosure of their HIV infection. Of those expecting violence, 4%
actually experienced some violent reaction when the partner was told and an-
other 4% who had not anticipated such a reaction reported violence at follow-
up. Violent reactions from partners were not direct physical attacks to the
woman but instead involved activities such as throwing objects against the
wall or kicking the television.
Women frequently need assistance in deciding when and how to tell sex
partners about their HIV status and in anticipating partner reactions. In some
states, infected persons must tell their sex partners of their serostatus or au-
thorities will locate partners and inform them of their exposure to HIV.
Womens advocates have suggested that partner notification laws may place
women at risk for violence from male sex partners who learn of their expo-
sure to HIV (North and Rothenberg 1993). Although data suggest that part-
ner violence is not a frequent reaction to disclosure (Gielen et al. 1997),
women should be assisted in anticipating partner response and in planning
when, where, and how to tell partners, particularly those with a history of do-
mestic violence. Additionally, women may need information about where to
go for help if their partner becomes violent.
Women also must decide if and when to talk to their children about their
HIV infection. Few data are available on the extent to which infected women
disclose their HIV status to their children, but much has been written about
mothers concerns with regard to informing children (Armistead and Fore-
hand 1995; Semple et al. 1993). Armistead and Forehand (1995) interviewed
HIV-infected women about decisions and challenges they faced, and found
that women perceived disclosure to children as the most emotionally difficult
issue they faced. The authors discussed several reasons mothers may choose
not to disclose their HIV status to their children, including 1) desire to protect
children; 2) fear that children will feel stigmatized by their illness; 3) concern
about childrens feelings toward them and the way they contracted HIV; and
4) concern about childrens ability to keep a secret and not tell others about
their disease. Women must take into account several factors when making the
decision to disclose to a child, including the childs age, coping ability, the sta-
tus of mothers illness and functioning, and the likelihood that the child will
hear about the mothers illness from others. Women are likely to need assis-
tance in thinking through repercussions to children and in deciding what the
child should be told. Few data are available to guide women in their decisions.
Draimen (1993), writing about the professionals role in helping mothers de-
cide about disclosure to children, states that Although professionals can help
the parent explore the consequences related to disclosure and nondisclosure,
whether or not to disclose is a highly personal and demanding choice about
which the parent is the best judge (p. 21).
Living with HIV

Coping and Adjustment
Few data have been reported on adjustment and coping by women living with
HIV infection. Available data suggest that asymptomatic HIV-infected wom-
en and uninfected women from similar socioeconomic backgrounds differ lit-
tle in their social and psychologic functioning (Lipsitz et al. 1994; Moore et
al. 1999; Pergami et al. 1993). For example, Moore et al. (1999), in a study
that included HIV-infected and uninfected women, reported high levels of de-
pressive symptoms and adverse social events in both groups, with no differ-
ence in the number of depressive symptoms between the groups and more
adverse social events in the uninfected group (e.g., insufficient money for ne-
cessities, physical assaults, and removal of children from the home). Intrave-
nous drug and crack use were more important predictors of psychosocial
dysfunction than was HIV status; however, the women in this study were at
a relatively early stage of infection. Studies of men have shown that distress
increases with the onset of HIV-related symptoms or with a diagnosis of
AIDS (Belkin et al. 1992; Rabkin et al. 1991). Most studies of HIV infection
in women have not followed participants to the later stages of disease and the
development of AIDS. HIV-infected women are likely to show higher levels
of psychosocial dysfunction as they become more sick, and differences be-
tween infected and uninfected women may become more striking.
Considerable attention has been given by AIDS researchers to the effects
of psychosocial stress on HIV disease progression. Psychologic stressors have
been shown to affect the onset of illness by negatively impacting the immune
system (Herbert and Cohen 1993; Persky et al. 1987), and thus researchers
have speculated about the possible effect of stress on people with HIV in-
fection (Glaser and Kiecolt-Glaser 1987). Data collected from mens cohort
studies throughout the United States present an inconsistent picture of the im-
portance of social and psychologic factors on rates of immunologic decline
(Burack et al. 1993; Lyketsos et al. 1993), although it appears that if an effect
exists, it is likely to be small (Perry and Fishman 1993). This topic has been
of great interest to researchers and clinicians of HIV-infected women because
of the high levels of psychosocial stress found in this population. Data ad-
dressing this issue in women have not been published, although they should
soon become available from the ongoing longitudinal studies of HIV-infected
women.
Sexual Behavior
Many HIV-infected women modify their sexual behavior after learning their
diagnosis (Hankins et al. 1998; Moore et al. 1998c). Although most remain
sexually active (i.e., approximately 70% in the early stages of disease), more
HIV-infected women than uninfected women (matched on sociodemograph-
ics and risk behaviors) report being abstinent (Hankins et al. 1997; Zierler et
al. 1999). Additionally, more infected (54%) than uninfected women (26%) re-
port always using condoms with male partners (Moore et al. 1998a). Among
infected women not consistently using condoms, Moore et al. (1998b) found
that approximately one-half reported having an HIV-infected partner. Of
those women with an uninfected partner, approximately half used condoms
for all episodes of vaginal sex. Among the inconsistent users or nonusers of
condoms, approximately 60% indicated that their uninfected partner knew of
the womans HIV status but elected not to use condoms. Currently, the only
methods of HIV protection known to be effective are abstinence and use of
the male condom. Because men wear condoms, they can elect not to use them
and thus not to protect themselves. These data point to the importance of in-
volving uninfected partners of HIV-infected women in safe-sex counseling to
ensure that they understand the risks they are taking and work to change un-
safe sexual behaviors. Without the male partners cooperation, HIV-infected
women will be unable to ensure that their sex partners are protected.
Reproductive Decision Making

HIV-infected women are faced with difficult decisions about continuing a
current pregnancy or becoming pregnant in the future. In the early phase of
the HIV epidemic, the possibility of transmission from mother to child was
expected to greatly change the childbearing plans of infected women and re-
sult in pregancy termination among those already pregnant. Early studies,
however, reported that HIV serostatus was not associated with pregnancy
termination (Johnstone et al. 1990; Selwyn et al. 1989) nor with becoming
pregnant in the future (Barbacci et al. 1989; Sunderland et al. 1992). More
recent studies suggest that HIV-infected women have less desire and inten-
tion to become pregnant than do matched, uninfected women (Lester et al.
1995) and that infected women may change childbearing plans after learning
their serostatus (Hankins et al. 1998). It is unclear how these desires and in-
tentions affect contraceptive behavior and pregnancy rates.
With the publication of the AIDS Clinical Trials Group 076 (1998) re-
sults, which showed a two-thirds reduced risk of perinatal HIV transmission
with a zidovudine regimen, more infected women may see pregnancy as a re-
alistic option. Data collected after the publication of 076 results are not yet
available on womens decisions to terminate pregnancy or avoid future preg-
nancies. The decision to bear a child is likely to be difficult for HIV-infected
women despite medical advancements that have greatly reduced chances of
having an infected child (Centers for Disease Control and Prevention 1997c).
Women still must deal with issues related to their own mortality and the effect
that this disease will have on the childs quality of life. With the advent of new
medications to improve length and quality of life of infected persons, women
may feel they have a better chance of raising their children, and thus more
infected women may decide to reproduce.
Planning for the Future

Despite promising new therapies, many HIV-infected women will face declin-
ing health and the prospect of early death. The needs of people preparing for
disability or death have been written about extensively (Kastenbaum and
Aisenberg 1972; Kbler-Ross 1969, 1975). Because HIV-infected women are
relatively young compared with many other women with declining health,
they have the additional need to plan for the future of dependent children. In
many families with children, the HIV-infected mother has been the only par-
ent providing care (Schable et al. 1995), and so an alternative placement must
be sought for children when the mother becomes debilitated.
Contemplating the alternative care of ones children can be an over-
whelming task for mothers. Armistead and Forehand (1995) discuss reasons
HIV-infected women may delay or avoid planning for the future of their chil-
dren, including 1) having to face their own impending death; 2) a lack of al-
ternative caregivers whom the mother trusts to raise her children; 3) negative
experiences with welfare agencies; and 4) lack of access to legal services nec-
essary for making formal custody arrangements. In some large metropolitan
areas, agencies have been organized for the specific purpose of helping wom-
en make decisions about the future of their children and ensuring that these
plans are legally documented and carried out when the woman can no longer
care for her children. New York Citys Early Permanency Planning Program,
for example, assists HIV-infected mothers in planning for future placement
of children and assists children in making the transition to the new family (Le-
vine 1995). These programs are relatively new, concentrated in only a few
metropolitan areas, and may reach relatively few HIV-infected women. One
study has shown that most HIV-infected women with children are unaware
of or have not contacted available child care agencies (Schable et al. 1995).
Other studies report that most infected women do not make formal plans for
transferring guardianship of children, and thus the fate of children is left pri-
marily to surviving relatives (Lester et al. 1995; Levine 1995). HIV-infected
women repeatedly indicate that the well-being of their children is their most
pressing concern (Armistead and Forehand 1995; Semple et al. 1993). Legal,
social service, and psychologic assistance are needed to help them confront,
plan for, and transition their children into acceptable alternative placements.
Summary
As the number of HIV-infected women in need of health care services swells

in the coming years, these biomedical and psychosocial issues will become in-
creasingly salient to medical providers caring for womens health. It is imper-
ative that care providers, administrators, funders, and advocates build the
expertise and services necessary to improve HIV counseling and testing ser-
vices for women, the risk-reduction interventions to lower the rates of new
infections, and the medical, psychologic, and social service care for women
who are already infected.
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II I
General Issues
17
Reproductive Choices and
Development
Psychodynamic and
Psychoanalytic Perspective
MALKAH TOLPIN NOTMAN, M.D.
Reproductive choices profoundly affect an individuals life. Some are made

almost automatically in the course of the life cycle, whereas others are made
inadvertently, influenced by social expectations, life experiences, and uncon-
scious factors. Even if choices are conscious and deliberate, however, they
express deep-seated attitudes, beliefs, and expectations about oneself, ones
gender role, and ones relationship to society.
In the past several decades social changes have influenced the size of fam-
ilies and the timing of pregnancies. Increased career opportunities and the rise
in the number of women working outside the home have affected reproduc-
tive decisions. The desire to have children is very powerful for both men and
women; however, women have traditionally defined themselves and been de-
fined more by their family roles than by their work. Women also experience
a pregnancy more intimately and their wishes for children have more closely
expressed the primary fulfillment of female gender role and aspirations. A re-
cent study (Ravin et al. 1997) reported that when asked to choose between a
gestational or genetic tie with a child, women more often chose the gestational
tie, whereas men chose the genetic tie. This supports the longstanding view
365
that the experience of pregnancy has greater significance for women, and that
men and women have different reproductive perspectives.
For a woman, a pregnancy also has a developmental significance. It
evokes her identification with and relationship with her mother. The woman
with a troubled or ambivalent relationship with her mother can experience a
pregnancy, particularly a first pregnancy, as distressing. It marks her transi-
tion from a daughter to a mother, and she may feel anxious that she will re-
peat her mothers problematic mothering. It also may cause angry feelings
toward her mother to surface (Bibring et al. 1961).
If a womans relationship with her mother is positive, pregnancy pro-
vides a less conflicted shift between daughterhood and motherhood and is
also a step toward a concept of adulthood. Intrapsychially, the baby repre-
sents a separate individual and calls for the development of care and respon-
sibility for another person apart from oneself. This process is intensified once
the baby is born and taking care of it is less automatic than during the preg-
nancy. In her identification with the baby, the mother can feel gratified in her
new role as caretaker. The baby also represents its father as well as others in
the family; if the mother is angry or ambivalent toward the father, this can be
expressed as anger or ambivalence toward the baby. These feelings are some-
times expressed during pregnancy and delivery.
Wishes to conceive and carry a pregnancy and to deliver a baby, howev-
er, do not necessarily reflect a grasp of the real tasks of parenting, with its ac-
companying demands, responsibilities, and personal life changes. Instead,
they can represent a fantasy of the fulfillment of an identity as a man or a
woman or other fantasies such as passing on ones genes and in some way
achieving immortality. Even for those who choose not to have children,
knowing that one has the capacity to do so is an important part of the adult
gender identity.
The societal importance of producing children varies to some extent with
differing economic conditions and values. In all cultures, however, womens
roles as mothers and nurturers of young children remain central, although
there is an enormous range in the other roles and activities that each culture
assigns to men and women (LeVine 1991). In most cultures, women are the
primary caretakers of infants and children whether they stay at home or work
in the fields, factories, or offices. This role is an extension of pregnancy and
nursing. Pregnancy, childbirth, and nursing establish a bond between infant
and mother that is not available in the same way to the father; they are unique
experiences for women who will always be known as the childs mother even
if the father is not known.
Reproductive Choices and Development 367
The reproductive clock and the knowledge that fertility is time limited
also form a background context for many womens choices in a way that has
no equivalent for men. Women are aware of their capacity to have babies
from early childhood, and they also learn during the course of their develop-
ment that they have a biologic clock, although they may not think conscious-
ly of it until well into adulthood. A womans sexual behavior is always
affected by the possibility of pregnancy, whether she is consciously thinking
about it or not. This possibility creates both a promise and vulnerability.
Cessation of fertility at menopause also has a different impact on women
in different cultures and in different life circumstances, but it is universal in
marking an end to childbearing possibilities. Recent technology has extended
the time frame for pregnancy beyond normal menopause through the use of
egg donation and hormone treatment, but it is unlikely that geriatric-age
childbearing will become widespread. Many women actually end their child-
bearing well before menopause occurs. Knowing that fertility is time limited,
however, affects many decisions before the menopause. A feeling of loss dom-
inates the menopausal years despite the fact that for many women cessation
of childbearing comes with relief and the positive impetus for a new period
of life and psychologic development.
The reality that reproductive capacity is finite also influences other life
choices. Most women maintain an awareness of their biologic clock as it af-
fects their career and marital choices and their wishes to experiment with
work and lifestyles. Often this awareness is not conscious until it becomes a
pressing issue, usually when a woman reaches her 30s (Nadelson 1989; Not-
man 1973, 1979).
As career opportunities for women have expanded, health status has im-
proved, and technology has advanced, first pregnancies at a later age have be-
come more common. Infertility, however, has also become more common
and is a psychologically stressful experience for most couples. Women feel
particularly vulnerable. It is not unusual to feel deeply responsible for infer-
tility, and many women blame themselves consciously or unconsciously for
delaying attempts at pregnancy, for past sexual behaviors, or even for fanta-
sies and feelings that they feel guilty for having. Many women also have neg-
ative feelings toward their bodies that can come into play if they discover they
are infertile. This can be true even if the man bears the responsibility for the
infertility.
Development of new reproductive technologies has had complex effects,
but these technologies are often sought, and most women have been grateful
to be offered new possibilities when fertility seemed foreclosed. The most dif-
ficult aspects have been the cycles of hope and intense disappointment that
many women experience. Despite the many possible causes of fertility prob-
lems, women have traditionally been seen as responsible and they have felt
burdened and guilty for failing to conceive. This has begun to change in the
face of newer data that indicate a high prevalence of male factors responsible
for infertility (Rosenthal and Goldfarb 1997).
Decisions About Marriage
Despite enormous social change over the past three decades, marriage is still
perceived by many women as their central adult role. Women can be inde-
pendent but have psychologic needs for intimacy and connection that are met
in marriage and childbearing. Other activities, especially work, continue to
be regarded by women as temporary or subordinate to family functions and
identifications. This expectation has not been the same for men. Neverthe-
less, more than 50% of mothers of young children are working, and women
are earning a substantial proportion of family income.
In the 1970s, Bernard (1991) and others (Gove and Tudor 1973) docu-
mented that marriage improves mental health and satisfaction for men but
not for women. Data indicated that more married than unmarried women
were depressed, whereas more unmarried than married men were depressed.
This probably reflected the social constraints of marriage in the 1950s and
1960s, when women were dependent on men for financial support, had few
activities outside the home, and were expected to put their husbands wishes
first. Opportunities for self-realization, independence, and development out-
side the family were limited.
Women have always experienced considerable social pressure to marry.
In the past, their social and economic status depended on the status of the
men who were responsible for themthat is, their fathers and husbands. The
decision for a woman was usually not whether to marry, but whom and when
to marry. Loss of self-esteem and damage to her pride and her familys repu-
tation when a woman remained unmarried led to the familiar desperation of
women who became old maids. This was not so for an unmarried man,
whose status as bachelor had a more positive ring and was seen as involving
choice and self-determination. The expectation was that a man could choose
to marryand a woman was chosen (Bernard 1991; Nadelson and Notman
1981).
When Kuhn, in 1955, studied a group of men and women who had not
married, their reasons for doing so were often expressed negativelyhostility

toward marriage or toward members of the opposite sex; dependency on par-
ents; poor health; feelings of physical unattractiveness; unwillingness or in-
ability to assume responsibility; social inadequacy; perception of marriage as
a threat to career goals; economic problems; and geographic, educational, or
occupational isolation that limited the chances of meeting an eligible mate
(Nadelson and Notman 1981). Two decades later, a shift was noted: being
single was more often stated as a positive choice. Both men and women spoke
of increased freedom and enjoyment of life, opportunities to meet people, eco-
nomic independence, and a chance for personal development (Stein 1976). In
addition, people more openly stated their wishes about not wanting children,
about their homosexuality, and about their negative family experiences.
Unconscious and conflictual issues such as strong dependency needs, dif-
ficulty forming a stable and secure identity alone, or an intolerable fear of iso-
lation or loneliness also influence the motivation to marry. The desire for
children is a strong motivator for marriage, and many conscious and uncon-
scious factors influence the decision to have or not have children. Some peo-
ple have little interest in actually being with children or in parental roles.
Others believe that they cannot be good parents. Some explicitly prefer the
freedom of childlessness or want to invest their energy in careers, although
this may also be a way of covering deeper anxieties about parenting. Some-
times women fear pregnancy despite a strong wish for children. Others strug-
gle with their unresolved, difficult, and/or ambivalent relationships with their
mothers, which affects their confidence in becoming mothers themselves
(Nadelson and Notman 1981; Veevers 1979). They may fear that becoming
a mother would draw them back to a regressive or devalued position, or they
may identify with the negative aspects of their mothers experience. In this
era of recombined families, many couples exist in which one partner has had
children in a previous marriage and does not want more, leaving the other
partner without children of his or her own. Sometimes the decision not to
have children is not explicitly stated. Some couples postpone the decision un-
til a future time that never arrives. Sometimes personal circumstances such as
careers in dance, athletics, or other demanding professions communicate an
ideology that negates childbearing or makes it difficult. Homosexuality had
been a determinant of childlessness in the past, but recently the number of
lesbian women becoming pregnant has increased. Veevers (1979) noted that
with the exception of race, childlessness tends to be influenced by the major
socioeconomic determinants known to influence fertility in general: educa-
tion, urbanity, socioeconomic status, religious beliefs (p. 208). However, this
does not address the psychologic determinants. Social changes have made
childlessness more acceptable.
Women who remain childless may feel bereft and need to mourn what
parenthood meant to them. Sometimes these feelings do not emerge until lat-
er, and the process of working through them involves a shift in orientation
and a search for other experiences to fulfill needs. Infertile women also face
the narcissistic injury that usually accompanies that realization, which can
threaten their sense of femininity and even their perception of fully being an
adult because adulthood is so often closely associated with parenthood (Ma-
zor 1978).
Gender Identity and Development
It is useful at this point to review ideas about gender development and its re-
lationship to reproduction. Gender identity, or the awareness of ones gender,
was thought at one time to be established when a young child becomes aware
of his/her genitals and of the differences between males and females. In
Freuds (1905/1961) early formulations, this process took place later in child-
hood than current data suggest (Tyson and Tyson 1990). The influences that
shape gender identity begin before birth with the parents expectations and
beliefs about gender, particularly when the prenatal determination of the gen-
der of the baby is made.
Classic Freudian theory held that girls had long-standing penis envy, and
that this was an organizing and driving force in female development. From
this perspective, girls think of their mothersand of all womenas being de-
fective because they lack a penis (Freud 1905/1961). Contemporary psycho-
analytic thinking, informed by developmental observations and research,
recognizes that although penis envy exists in some women, it is not the central
organizer of development and that the greater power and value that society
gives to men plays the major role in some womens sense of self.
Furthermore, according to early psychoanalytic theory, girls blamed
their mothers for the missing penis and subsequently turned to their fathers
as love objects. This was the initiation of the female Oedipus complex. Other
factors also drew girls to their fathers, such as their expanded interests in the
world and their desire for their fathers approval and affection. Fathers were
more active and more related to the world outside the family than were moth-
ers. Girls were thought to develop erotic feelings toward and to fantasize
about having a baby by their fathers, which led them to both identify and
compete with their mothers (expressed in the wish to marry daddy when I
grow up). These feelings placed girls at risk of alienating their mothers.
Forming their own identities and negotiating these competitive and aggres-
sive feelings while at the same time remaining close to their mothers, whom
they need and identify with, was a developmental challenge for girls.
Contemporary theory about development suggests that a complex pro-
cess occurs during the first years of life. Children begin developing their gen-
der identity from birth, influenced by the external environment as well as by
genetics and prenatal hormones. Both boys and girls early development oc-
curs within the context of a close relationship with their mothers, who are
usually their primary caretakers. For girls, the relationship with the parent of
the same gender facilitates a different kind of mutual identification than for
boys. A mother identifies with her daughter and sees herself in the girl baby,
and a girl gradually identifies with the mother. This identification remains a
powerful force throughout life, although it is not without conflict. Thus, a
girls gender identity develops from identification with her mother and also
with her mothers feminine roles and activities in whatever way the particular
culture presents these (and with many individual variations). Turning toward
her father is also supported by her identification with her mother, who, after
all, preceded her in this (Clower 1976; Freud 1933/1964; Notman et al. 1991;
Person 1980).
Boys also have close relationships with their mothers, but because moth-
ers are different from them, boys need a male identification figure. To develop
a sense of masculinity, boys distance themselves from early attachments to
and identification with their mothers and, to some extent, from their child-
hood activities; they relinquish and build emotional barriers to these early at-
tachments, including what are perceived to be feminine ways (Chodorow
1978). At the same time, envy of the capacity to have babies is found in little
boys, and in their development toward a masculine identity they must aban-
don this possibility (Fast 1984; McDougall 1989). Both mothers and fathers
behave differently toward their female and male children from earliest infan-
cy (Block 1976; Moss 1967). These behaviors transmit cultural patterns that
promote and consolidate gender differences. Personality differences between
men and women are also shaped by these processes as well as by biologic
factors.
Although the development of gender identity continues throughout
childhood and is consolidated in a more permanent way in adolescence, it
does not depend primarily on the awareness of genital differences. Ones
body image does play an important role in ones sense of self; it incorporates
the multiple identifications and learning that take place from early life, includ-
ing the powerful effects of socialization. Yet gender identity also includes the
cognitive awareness of the behavior and attitudes that go with being female
or male and the way these roles are shaped in a given culture (Silverman
1981; Stoller 1976). Some cultures have preadolescent and adolescent rituals
to mark the transition into the more adult roles. For boys, these can involve
abrupt separation from their mothers and other women and initiation into the
company and behaviors of men.
Gender identity development also includes ideas about reproductive ca-
pacity, which are more elaborated for girls. Girls thoughts about their ability
to have children are both concrete and the subject of fantasies. Their repro-
ductive capacities are thought of as being fulfilled in the future, when they
reach sexual maturity. Their breasts are not apparent until puberty. Boys
have a somewhat different experience than girls in that although their genitals
change in size and shape, their external genitalia are outwardly visible and
present at birth. Many women have negative feelings toward their bodies.
This has been studied in relation to feelings of defectiveness about not being
male, to social pressures toward thinness and bodily perfection, to the deval-
uation of women, and to identification with a depressed mother.
Pregnancy and parenthood are sources of emotional maturation for both
parents (Anthony and Benedek 1970; Cath et al. 1989). In parenthood, iden-
tification with parents is revived for both men and women. Although the fa-
ther of the child does not participate as intimately in pregnancy, having a
child is an important confirmation of potency and masculinity (Benedek
1979; Bibring et al. 1961; Notman and Lester 1988). For women who do not
become pregnant or mothers, other pathways exist for reworking their iden-
tification with their mothers and consolidating their female gender identity.
Some adopt children, others work with children, and still others identify with
other aspects of maternal roles.
Sexuality
Ideas that women were sexually unresponsive and that sexual passivity was
normal and desirable for women have been replaced with a better under-
standing of sexual functioning. Contraception has also made it possible to
separate sexuality from reproduction to some extent in most western cultures.
Resistance to contraception can be based on religious prohibitions or cul-
tural values that promote a concept of masculinity dependent on producing
children. Although seeking sexual gratification has become more acceptable
for women, some differences appear to exist in mens and womens attitudes
and experiences of sexuality. For women, sexual functioning is more often

linked to intimacy in a relationship than to pure genital gratification (Person
1980). For men, sexual performance consolidates gender identity. It is not
clear how much the physiologic differences in male and female sexual re-
sponse cycles affect psychologic experiences.
Homosexuality
Just as patterns of heterosexual behavior vary, so do patterns of homosexual

behavior. A wide range of personalities and characteristics of relationships ex-
ists among homosexuals just as among heterosexuals. Psychoanalytic under-
standing of homosexuality has changed considerably, and the idea that
homosexuality is inevitably pathologic has generally given way to an appre-
ciation of the complexity of homosexual choices and styles and an awareness
that this is a variation of orientation.
It is likely that most people have some potential to respond erotically un-
der certain circumstances to individuals of the same gender. A spectrum of
homosexuality to heterosexuality appears to exist: for some individuals only
a homosexual or heterosexual orientation seems possible, whereas others ap-
pear to be bisexual. Individuals with homosexual orientations sometimes
marry and have children and later act on these homosexual feelings and
come out, often breaking up their marriages. Some have ongoing homosex-
ual relationships during a marriage but remain married and even continue to
be heterosexually active. Sometimes the feelings of emotional and sexual at-
traction to individuals of the same gender are unconscious until some expe-
rience of life circumstance mobilizes them. Sometimes they are conscious but
not acted on.
The issue of having children is complex for many homosexuals. Some
lesbians choose to have children by adoption or donor insemination. Some
have arranged for known donors, whereas others have chosen anonymous
donors. Gay men may seek out a partner in order to have a child or may
adopt. Different kinds of relationships have been emerging as these families
develop.
Contraception
The effectiveness of contraception depends on both the effectiveness of the

individual method of contraception and how well the method fits the lifestyle
and preferences of the person using it. Many effective contraceptive methods
conflict with individual preferences and may not be used as intended; thus,
they may not be as effective in practice as a less foolproof method to which
there is less resistance. For example, a woman who hesitates to touch or ex-
plore her genitals may be inhibited in using a diaphragm. For a contraceptive
decision to be made, it is important to take these factors into account as well
as the nature of the sexual relationship between the two people.
The only available reliably reversible method of contraception for men
is the condom, which has the additional benefit of protection from sexually
transmitted diseases, including AIDS. Because it must be used during and in-
terrupts each act of sexual intercourse, however, some couples find it awk-
ward to use. It is perceived to interfere with spontaneity, romance, and
sensation. For a man who has anxieties about sexual performance, these
problems can forestall condom use.
Vasectomy has been used by some men worldwide. It is sometimes, but
not reliably, reversible with microsurgical techniques. The decision for steril-
ization is often made because the couples and/or individuals feel that they
have the number of children they want. They may later regret their decision
when a subsequent marriage or the death of a child evokes new desires for
parenthood. Women sometimes also choose more permanent methods, such
as tubal ligation or even hysterectomy; a hysterectomy marginally indicated
for medical reasons is sometimes welcomed by a woman who has religious
prohibitions against contraceptives. Reasons for choosing sterilization can
range from failure with other methods to feeling overwhelmed by one or
more childbirths and wanting to avoid more pregnancies. For some people
it is a politically correct choice for the man to have the contraceptive pro-
cedure.
Other important considerations in assessing which contraceptives to use
are the individuals capacity for planning or impulsiveness, the actual avail-
ability of various methods, and unconscious resistances that may be present.
A persons life circumstances can also contribute to the appropriateness of a
particular method. For example, a young girl living with parents who do not
know and would not approve of her sexual activity is likely to have trouble
with a diaphragm because she must obtain a medical prescription and must
keep it hidden, which may be difficult and make its use less reliable. A con-
dom is much more readily available.
Oral contraceptives, although generally safe and effective, are often less
acceptable to women who are not in stable relationships, who are sporadically
sexually active, who have concerns about long-term effects or side effects, or
who have other medical contraindications. Instances have also been reported
in which instructions have been given to take the pill regularly, but women
use it episodically or only with a sexual encounter. Barrier methods such as
the diaphragm and spermicidal creams or jellies require planning as well as a
willingness to interrupt sexual activity, which can be particularly difficult for
adolescents. The expectation of intercourse implied by the use of these meth-
ods can be difficult for some women to acknowledge.
Some men may consciously state that they want to use contraceptives but
have an unconscious resistance related to the link between masculinity, po-
tency, and their ability to impregnate a woman. Interference with pregnancy
may thus be experienced as a threat to masculinity. Some men also resent
having to pay attention to contraception because he sees it as a womans job
and the resulting pregnancy as her concern. For women, unconscious wishes
for pregnancy may interfere with contraceptive use; becoming pregnant may
be an unconscious way of reacting to a loss or a disappointment (Notman and
Lester 1988). Women who experience conflicts about a career choice may be-
come pregnant in an unconscious attempt to avoid the conflict.
Consultative Interaction
New data about contraception, pregnancy, induced abortion, sterilization,

rape, menopause, and sexual functioning have challenged widely held myths
and provided new insights and information that are often not well known to
patients or those providing primary care (Nadelson et al. 1985). Formal con-
sultation in these areas is not often sought because these problems are not
usually defined as psychiatric or may involve the relationship between a phy-
sician and patient (e.g., because of noncompliance with medication or a regi-
men or because of differences between the priorities and wishes of patient
and physician).
Reproduction and sexuality are emotionally charged subjects. Physicians
providing obstetric or gynecologic care are vulnerable to their own emotional
responses and may avoid investigating these concerns with patients. Emotion-
ally related problems may be avoided by physicians and referred to others
with less experience or knowledge in the specifics of these health care issues.
Obstetrician/gynecologists function as primary care physicians for many
women during their reproductive years; thus, attention to sexuality and the
emotional aspects of gynecologic problems is especially important. Yet gyne-
cologists are often not prepared for a sensitive discussion of sexual problems;
information about sex and reproduction is often not integrated into the edu-
cation of health providers in a way that specifically addresses the kinds of
problems faced by physicians in practice.
Gynecologists must also become accustomed to new realities, such as the
possibility of sexually transmitted diseases in a wide cross-section of patients,
requests for contraceptive services, infertility treatment and sexual counseling
for unmarried couples, and gynecologic care of patients who are bisexual or
lesbian. New reproductive technologies have raised clinical as well as ethical
issues for which the gynecologist and psychiatrist may be unprepared. Physi-
cians have neither the data nor the ethical position to be gatekeepers to ser-
vices, but prejudices can nevertheless intrude. Infertile couples may request
fertility techniques although they seem unsuitable to the gynecologist be-
cause of socioeconomic or psychiatric factors. Fertility procedures can be
very stressful and hospital and clinic personnel may not always be responsive
to the patients sensitivities. The intense cycles of hope and disappointment
that such procedures inspire can cause patients to make emotional and/or gy-
necological demand that gynecologists are not prepared to meet. Physicians
may also have personal beliefs about the appropriateness of pregnancy for
some individuals (e.g., lesbians) that affect the way they provide services.
Today, challenges are being made to the provision of thoughtful and ad-
equate care. Constraints imposed by managed care and other medical care
systems may make obtaining consultations or performing some procedures
difficult and may limit the time a physician has to spend with a patient. Phy-
sicians may often be asked to perform a permanent procedure, such as steril-
ization, in which he/she acts merely as a technician. Thus, as the role and
responsibility of the physician, patient, institutions, and society are ques-
tioned from ethical, political, medical, psychologic, and economic perspec-
tives, being informed about the issues involved in reproduction becomes even
more important.
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18
Female Sexual Disorders
ROBERT TAYLOR SEGRAVES, M.D., PH.D.
KATHLEEN BLINDT SEGRAVES, PH.D.
Sexual function is influenced by complicated and interactive biologic and

psychologic factors. Thus, the diagnosis of sexual dysfunction is complicated
because of the numerous diverse etiologies that must be considered. The differ-
ential diagnosis of sexual disorders is not widely understood by physicians.
Because of the interaction between biologic and psychologic factors, evaluation
of many disorders of female sexual function by necessity involves close collab-
oration between practitioners in obstetrics and gynecology and those in psychi-
atry. The psychiatric clinician will focus on a careful sexual and psychiatric
history, attempting to ascertain the specific nature of the psychologic problem
(e.g., affective disorder, marital discord, or transient stress) and whether it
appears to be secondary to other psychiatric disease. Evaluation by the gyne-
cologist will be equally meticulous and will attempt to rule out diverse physical
etiologies, including vulvovaginitis, normal hormonal changes associated
with menopause or perimenopause, endometriosis, and other pathologic
conditions.
The field of gynecology has shown an increasing awareness of the need
to assess sexual function, and most gynecologists recognize the need to col-
laborate with psychiatrists in this assessment. It is indeed the rare psychiatrist
or gynecologist who is capable of independent assessment and treatment of
the full spectrum of female sexual disorders. The requisite knowledge base
crosses subspecialty boundaries and is still evolving. This chapter examines
various topics at the interface of psychiatry and gynecology concerning fe-
male sexual response.
379
Nomenclature
Sexual dysfunction due to a general medical condition and substance-induced sexual dys-
function were added to the conditions defined in DSM-IV (American Psychi-
atric Association 1994). Other changes in DSM-IV included small changes in
diagnostic criteria and in terminology. For example, inhibited female orgasm was
changed to female orgasm disorder and inhibited male orgasm was changed to male
orgasm disorder.
Reviewing the historical development of the nomenclature used to de-
scribe female sexual disorders will be helpful in highlighting the rapidly
changing terminology in this area of psychiatry. Some consensus regarding
terminology resulted from Masters and Johnsons (1966) description of four
stages of sexual response (excitement, plateau, orgasm, and resolution) and
definitions of three separate female psychosexual disorders: dyspareunia,
vaginismus, and orgasmic dysfunction (primary and secondary). For approx-
imately 10 years, the diagnostic system introduced by Masters and Johnson
was used by most clinicians and clinical investigators. A major change in di-
agnostic nomenclature resulted from the work of two sex therapists: Lief
(1977), who identified the phenomenon of low sexual desire, and Kaplan
(1977), who introduced a three-stage model of sexual responsedesire, excite-
ment, and orgasmand clearly influenced DSM-III (American Psychiatric
Association 1980). In the revised manual, DSM-III-R (American Psychiatric
Association 1987), a sexual aversion disorder was included; what previously
had been diagnosed as frigidity or general sexual unresponsiveness might
now be diagnosed as hypoactive sexual desire disorder. These rapid changes
in terminology make it extremely difficult to combine findings from literature
only 1015 years old with findings of contemporary investigations.
Many investigators stress the importance of accurately diagnosing the
impaired phase of the sexual response cycle. Kaplan (1983a) postulated that
the earlier the impairment in the sexual response cycle occurred, the worse
the psychopathology and prognosis. This hypothesis, however, has not been
subjected to empirical investigation. Other investigators (K. B. Segraves and
Segraves 1991a, 1991b; R. T. Segraves and Segraves 1991) have noted the
large overlap between disorders of the various phases of the sexual response
cycle. Because of the frequent overlap between organic and psychologic fac-
tors in sexual disorders, an international consensus conference recently pro-
posed that the female sexual dysfunction nosology be modified to include
both organic and psychologic factors in the same system (Basson et al.
2000b).
Female Sexual Disorders 381
Prevalence
It is difficult to obtain true estimates of the incidence and prevalence of female

sexual disorders in the general population, because few studies have em-
ployed random sampling of the population, standardized sexual interviews,
or operational definitions of syndromes (Nathan 1986). The changing noso-
logy mentioned earlier also contributes to the difficulty in combining the
available data base.
Several studies have indicated that female sexual disorders are quite com-
mon in general medical and gynecologic clinics (Burnap and Golden 1967;
Catalan et al. 1981; Ende et al. 1984; Levine and Yost 1976). For example,
Ende et al. (1984) reported that 27% of women attending a general medical
practice reported lack of sexual desire, and 25% reported lack of orgasm. In
a study of sexual problems in a gynecologic clinic, Levine and Yost (1976)
found that 17% of the women reported difficulty achieving orgasm in partner-
related activity.
Studies reporting the frequency with which different syndromes appear
in treatment settings have reported high frequencies of orgasm disorders
(Bancroft and Coles 1976; Renshaw 1988) and desire disorders (Hawton et
al. 1986; Lief 1985; LoPiccollo 1980; Schover and LoPiccollo 1982). Most in-
vestigators have reported female arousal disorder to be somewhat rarely en-
countered in clinical practice (Nathan 1986). Vaginismus and dyspareunia
each appear to have a prevalence rate close to 5% (Renshaw 1988).
The largest clinical study of the relative prevalence of female sexual dis-
orders was of women seeking treatment as part of a large multisite pharma-
ceutical study (K. B. Segraves and Segraves 1991a, 1991b; R. T. Segraves and
Segraves 1991). Of 532 women seeking treatment for sexual problems, 475
(89%) had a primary diagnosis of hypoactive sexual desire disorder; 40 had
a primary diagnosis of female arousal disorder; and only 17 had orgasm dis-
orders as a primary diagnosis. One of the most remarkable findings of this
study was the frequency with which patients had multiple diagnoses. Of the
women with a primary diagnosis of hypoactive sexual desire disorder, 41%
had either an arousal or orgasm disorder as well, and 18% had disorders of
all three phases of the sexual response cycle.
In a recent representative sample of adults in the United States who com-
pleted a sexual questionnaire (Laumann et al. 1994), women reported the fol-
lowing difficulties in the preceding 12 months: 1) inability to reach orgasm,
24%; 2) lack of interest in sex, 33%; and 3) trouble with lubrication, 18%. An-
other recent study involved a random selection of Icelanders between the
ages of 55 and 57. This study found that 16% of women had inhibited sexual
desire, 6% had inhibited sexual excitement, 3.5% had inhibited orgasm, and
3% had dyspareunia (Lindal and Stefansson 1993)
Differential Diagnosis
It is important to emphasize that both biologic and psychologic factors may

coexist in sexual disorders. Thus, rather than attempt to diagnose whether
the problem is organic or psychogenic in etiology, the clinician should focus
on which factor is the major contributor to the problems and which factor is
correctable. In general, problems that are situational or partner-specific will
be predominantly psychogenic in etiology (Moore 1989). Similarly, lifelong
problems often have a large psychogenic component (Kaplan 1983b). In clin-
ical practice, the presumption of a predominantly psychogenic etiology for a
sexual problem is often made when a biologic etiology has been excluded in
gynecologic examination. This is not an optimal strategy, however, because
most sexual problems have a mixed organic/psychogenic etiology.
Dyspareunia
Dyspareunia is a common complaint in gynecologic practice and often has a

primary organic etiology. Various physical factors may cause dyspareunia
(Kaufman 1983a; Moore 1989). Common organic causes are vaginitis, pelvic
infections, vulvar vestibulitis, and senile vaginitis. The most common psy-
chologic cause of dyspareunia is lack of sexual arousal (Rosen and Leiblum
1995), which may have numerous etiologies. The clinician must establish
whether the dyspareunia is secondary to lack of lubrication. If the patient is
postmenopausal, the possible diagnosis of atrophic vaginitis should be con-
sidered.
Vaginismus
Vaginismus is caused by involuntary contractions of the perivaginal muscle.

These involuntary contractions may result from any cause of pelvic pain,
such as endometriosis or pelvic inflammatory disease, or from a psychologic
fear of penetration (Kaplan 1983b). Some of these patients may have a history
of sexual trauma or abuse (Becker et al. 1986; Kinzel et al. 1997). Although
many forms of vaginismus occur with any attempt at vaginal penetration
(e.g., coitus, pelvic examination, tampons), some cases may occur only with
coitus and not during a pelvic examination. Thus, the absence of vaginal con-
tractions during a pelvic examination does not rule out this diagnosis.
Hypoactive Sexual Desire Disorder
Concern regarding disorders of sexual desire have assumed a position of in-

creased importance in the field of sex therapy and are some of the most per-
plexing and prevalent of the sexual disorders (Rosen and Leiblum 1989;
Spector and Carey 1990). One of the first steps in differential diagnosis is to
determine whether the problem is primary or appears secondary to another
disorder. For example, decreased sexual desire may be a response to other
sexual dysfunction (Levine 1989), chronic illness (Schover and Jensen 1988),
depressive illness (Levine 1989), or may be a side effect of medication (R. T.
Segraves and Segraves 1993), fatigue, and external stressors. A second step
in differential diagnosis is to determine whether the problem is global or sit-
uational. If a patient reports decreased sexual desire in her relationship but
normal sexual fantasies and frequent masturbation, the clinician would sus-
pect relationship deterioration as a probable etiology. Lifelong patterns of low
sexual desire are generally assumed to be psychogenic, although it is quite
possible that some patients have lifelong patterns of low sexual desire second-
ary to constitutional factors.
The role of hormonal influences in the genesis of hypoactive sexual de-
sire disorders is unclear. Although some investigators have reported benefi-
cial effects from androgen therapy in patients who have undergone surgical
menopause (i.e., oophorectomy) (Alexander and Sherwin 1993), findings are
inconsistent across studies (Andersen 1995; Beck 1995). Some clinicians use
exogenous androgens in premenopausal women with hypoactive sexual de-
sire disorder (Koehler 1998). Oral contraceptives frequently elevate serum
hormone binding globulin, decreasing the amount of free testosterone and
perhaps causing decreasing libido (Koehler 1998). A recent single-blind study
suggested that bupropion may be effective in a subgroup of nondepressed
women with hypoactive sexual desire disorder (Segraves et al. 2000).
Female Sexual Arousal Disorder
Information concerning female arousal disorder is limited (Moore 1989;

Nathan 1986; R. T. Segraves 1996), and this diagnosis is infrequently made
in psychiatric practice. In one multisite study of 532 female patients with sex-
ual disorder, only 8% had this diagnosis, and most also had problems with
desire and/or orgasm; less than 2% had female sexual arousal disorder as a
solitary diagnosis. However, this problem is found more commonly in gyne-
cologic clinics (Rosen et al. 1993).
According to DSM-IV, the diagnosis of female arousal disorder can be
made if vaginal lubrication fails. It is not uncommon for a discrepancy to exist
between subjective and objective measures of sexual arousal and for some
women to experience vaginal lubrication without conscious awareness of sub-
jective sexual arousal (Hoon and Hoon 1978; Palace and Gorzalka 1992). In
clinical practice, psychogenic arousal disorders usually present as a failure of
subjective sexual arousal. A complaint of lubrication failure in the presence of
increased subjective arousal is most often caused by estrogen deficiency (Ban-
croft 1983). Diabetes mellitus may also be associated with a decreased lubri-
cation response to sexual stimulation (Kaufman 1983b). It is of note that a
recent study did not find sildenafil to be effective in the treatment of idiopath-
ic female arousal disorder (Basson et al. 2000a).
Female Orgasmic Disorder
A careful sexual history is paramount in the differential diagnosis of inhibited

female orgasm. First, it is necessary to establish whether the disorder is life-
long or acquired. Acquired inhibited female orgasm may be caused by vari-
ous psychologic and biologic factors. If the problem is situational (e.g.,
anorgasmic with husband but easily orgasmic with masturbation or an alter-
native partner), the clinician should immediately suspect relationship deteri-
oration. Global acquired inhibited female orgasm may be caused by affective
disorder, anxiety disorder, or overwhelming transient stress (Kaplan 1992).
In most cases, sexual desire and arousal will also be affected. If the pa-
tient reports a decreased capacity to become orgasmic despite normal libido
and normal sexual arousal, one should consider the possibility of organic eti-
ologies. Various physical causes for anorgasmia exist (R.T. Segraves and Se-
graves 1993); correctable causes such as pharmacologic side effects should be
ruled out first (R. T. Segraves 1995). Neurologic conditions such as spinal
cord lesions (Berard 1989), multiple sclerosis (Lilius et al. 1976; Lundberg
1978), cancer, chemotherapy, and surgery injuring the neurologic innervation
of the genitals (Poad and Arnold 1994) may result in the inability to reach or-
gasm. Current evidence suggests that anorgasmia may be a complication of
diabetes mellitus in women (Kolodny 1971; Schreiner-Engel et al. 1987). Al-
though it has been proposed that weak pubococcygeal muscles may decrease
sexual responsivity (Kegel 1956), little evidence supports this contention

(Chambless et al. 1984).
Psychotherapeutic Treatment
Treatment for sexual complaints continues to evolve, ranging from a strict

psychoanalytic intrapsychic approach, to a basic behavioral approach involv-
ing prescribing a set of homework exercises (regardless of the complaint),
to the present approach, which relies on an individualized multiple perspec-
tive. Sexual functioning depends on multiple factors such as culture, values,
beliefs, assumptions, and expectations as well as environmental factors. The
biologic components (chronic health conditions, hormones, medication) and
developmental events (menstruation, pregnancy, childbirth, and aging), al-
though poorly understood in women, point to the complexity of sexual func-
tioning. Today, therapists draw from multiple theoretic orientations when
designing treatment approaches. Patients present with what appear to be
more complicated complaints. One explanation for this is the way in which
we now define sexual complaints. Another possible explanation is that most
women now seeking treatment have tried various techniques suggested in
self-help books and recommended by the popular press. Gone are the days
when a woman would present with the problem of anorgasmia for which
masturbation training would quickly reverse the problem.
A woman today may present with hypoactive sexual desire. When the
therapist explores the problem, this woman reports no problem with arousal
or orgasm. The interview reveals no medications or medical conditions that
might help to explain the problem. The woman reports she is in a good and
stable relationship and cannot identify any external stressors that might relate
to her complaint. Another example is a woman with the complaint of second-
ary anorgasmia. The womans history reveals that she was molested by an
uncle when she was 10 years old. The woman is a computer analyst, has been
married for the past 12 years, and has a 9-year-old daughter. She describes
her marriage as stable and her husband as loving and nonabusive. Still anoth-
er example is of a woman presenting with an unconsummated, 12-year, sta-
ble and caring relationship. Simply prescribing sensate focus exercises to
these women would be a disservice. Indiscriminately assigning set exercises
may exacerbate some sexual problems by emphasizing the negative associa-
tions to the behavior or may increase anxiety because of the performance
component of the exercise. Such a treatment approach may diminish self-
esteem or exacerbate partner conflict.
Therapists who treat the sexual complaints of women are made painfully
aware of the paucity of available research concerning the sexual functioning
of women. Womens sexual concerns necessitate both creative thinking and
tenacity on the part of the therapist. A careful and comprehensive biopsycho-
social assessment can aid in preparing effective treatment approaches. Identi-
fying the predominant sexual phase involved in the complaint and the
associated phases that may be secondarily affected is important in designing
effective treatment plans. For example, a woman may report that she is un-
able to reach orgasm during extensive and what she determines to be ade-
quate stimulation. Given the number of effective treatment approaches for
anorgasmia, the therapist might be tempted to begin treatment. Further ques-
tioning, however, might reveal that this patient engages in sexual behavior
when she experiences no sexual desire or drive. She reports the need to use
artificial lubricant, as she reports being dry during foreplay. The woman
denies having any pain during intercourse. When questioned, she reports
that she is never conscious of wanting to engage in sexual activity of any
kind. She is willing and compliant participant in sexual activity initiated by
her partner because, by her report, she cares very much for her husband and
for their relationship. Here, the presumptive diagnosis is anorgasmia second-
ary to hypoactive desire disorder. This condition is generally more difficult
to reverse completely. Treatment would be tailored to the presumed contrib-
uting factors, with the realization that not much is known about the possible
biologic contributing factors.
The therapist may want to interview the couple to determine how each
perceives and explains the problem. The woman might be asked to become
more aware of her sexual thoughts and level of sexual desire independent of
her partner. Therapy might first focus on helping the woman to identify her
internal dialogue, noting what is sexually enhancing and what is a sexual
turnoff. Attempting to build on any desire-enhancing thoughts and behav-
iors may provide a starting point from which an attempt can be made to in-
crease the womans sexual awareness. She might benefit from fantasy
training exercises or increased exploratory exposure to romantic or erotic
material (novels that are erotic and not necessarily explicit). These activities
would be mutually arrived at (between therapist and patient) and carried out
(without expectation of increased drive) so that the woman can just experi-
ence the activity. Thus, this is done more as awareness training rather than
as the creation of a performance ideal. These activities might be followed by
exploration of her internal dialogue during sexual activity or during exposure
to sexual material and identification of her attitudes or feelings regarding her
internal dialogue. The goal would be to make the woman more aware of her
own drive, her sexual thoughts or fantasies, and her own comfort level for a
range of sexual activities.
In time, the woman and her partner may benefit from sensate-focus ex-
ercises (pleasuring experiences) to help them learn what enhances or detracts
from sexual arousal. During this treatment, the partner would benefit from
knowing the treatment plan and being included in the process; the partners
cooperation and sensitivity would be important to the successful treatment of
this problem. He/she might be asked to put his/her needs on hold temporarily
in an effort to promote the womans explorations into her sexuality.
Treatment approaches must be individualized to the patient/couple. Al-
though sensate-focus exercises have a place in the treatment of certain sexual
complaints, they are presented as a part of a more comprehensive approach
to the womans presenting problem. Treatment of sexual complaints might
necessitate drawing from cumulative theories and techniques (e.g., psychody-
namic, systems theory, cognitive-behavioral, marital, family, stress manage-
ment, communication skills training, social skills training). It is hoped that
identifying biologic determinants of female sexual functioning will help in the
design of more effective and efficient treatment approaches to female sexual
complaints.
Effect of Pregnancy on Sexual Behavior
With a few exceptions (Masters and Johnson 1966), most investigators have
reported a gradual decline in sexual interest as pregnancy progresses (Reamy
et al. 1982) that is more pronounced in the third trimester and is accompanied
by a decline in coital frequency and noncoital sexual activity (Cohen 1985;
Perkins 1982). This decline in sexual activity is more marked in nulliparous
than in multiparous women and is more marked in women who demonstrat-
ed minimal sexual interest prior to pregnancy (Cohen 1985). It should be not-
ed that the decline in sexual activity during pregnancy has been found in
multiple countries (Cohen 1985).
Various explanations have been advanced for this decline in sexual activ-
ity. Massive changes in hormone levels occur during pregnancy and the post-
partum period; however, no evidence links these endocrine changes to
changes in sexual activity. Cultural and psychologic factors are more likely to
account for the change (Bancroft 1983). Religious and cultural taboos against
sex during pregnancy are common (Bancroft 1983), and fears that sexual ac-
tivity will cause miscarriage or complications of pregnancy, although unprov-
en, are ingrained in many societies (Cohen 1985). Feelings of ambivalence

and increased emotional lability are also common during pregnancy. In addi-
tion to affecting a womans sense of body image, the somatic changes during
pregnancy often require modification of sexual technique. Although sexual
changes during pregnancy are common, psychiatric consultants are being
used in rare cases.
Effects of Gynecologic Conditions and

Procedures on Sexual Behavior
Involuntary Infertility
Diagnosis of infertility can result in a narcissistic crisis in one or both part-

ners, depending on the level of personal investment in having a child. Given
all of the factors involved in the discovery, evaluation, treatment, and after-
math of infertility, profound relationship changes, including changes in sexu-
al function, should be expected.
Infertility may cause a series of emotions to surface within the couple.
One or both partners may begin to feel alone, empty, anxious, depressed, ug-
ly, sexually inadequate, unproductive, barren, and responsible for a break in
the continuity of the family (Salzer 1986). Daily reminders of ones infertility,
such as commercials and movies with cherub-like children cooing in their par-
ents faces, demonstrating the perfect family; announcements of the arrival
or expectation of a baby among family and friends; and holidays that empha-
size the family (Mothers Day and Fathers Day often hit closest to the source
of the pain) only enhance these emotions.
Sexual dysfunction may be the cause or the result of a couple experienc-
ing infertility. A thorough psychosexual history is needed to determine
whether the infertility is caused by a sexual problem, such as premature ejac-
ulation, vaginismus, impotence, and retrograde ejaculation, that may rarely
contribute to infertility.
When the male partner cannot penetrate the womans vagina because of
vaginismus, the couple may benefit from sex therapy. The woman is taught
to begin to insert the smallest in a set of vaginal dilators. Once she is able to
do this comfortably, her partner is instructed, under her guidance, to begin
by inserting first one finger, then two, until the woman is mentally and phys-
ically ready to accommodate his penis. This process often requires a great
deal of time and patience on the part of both couple and therapist. Treatment
of infertility by artificial insemination with the mans sperm is an option dur-

ing this process.
Although sexual dysfunction can be the cause of infertility, it is more of-
ten the result of both the evaluation and the ongoing treatment of infertility.
Usually, it is the woman who seeks treatment first. In many cases, she is seen
several times before her partner becomes involved. She may undergo physi-
cally invasive and painful diagnostic tests, and both partners may experience
the evaluation and treatment of infertility as a major invasion of privacy.
When the man is not involved in the work-up, his physicianpatient relation-
ship is limited, which may lead him to feel like an outsider or just a producer
of sperm. Involving both partners early in their fertility work-up can mini-
mize some of these problems.
Vaginismus or erectile failure might occur only during the ovulatory pe-
riod of the cycle (Leiblum 1993) or prior to specific tests. Stress imposed by
the demand to engage in a completed intravaginal intromission can result in
lack of lubrication or vaginismus in the woman and erectile failure in the
man. The man may become impotent prior to certain tests (semen analysis,
postcoital test, sperm penetration assay) for which he is asked to produce an
erection and to ejaculate at a certain time of a specified day because he is
aware that his sperm will be observed and graded within a couple of hours
by a member of the treatment team.
During the process of trying to conceive, there may come a time when
infertility becomes the final diagnosis. Even with all of the new techniques
and advancements, treatment of infertility does not always lead to successful
pregnancy and childbirth. A responsible treatment team should address this
issue both among themselves and with the couple. Current practice often re-
inforces the couples denial, delaying the reparative work needed to go be-
yond the infertility. Accepting the diagnosis of infertility may result in intense
mourning, which may negatively impact whatever sexual functioning is left
in the relationship. Sexual apathy may be predominant, along with sexual
avoidance. During the struggle to conceive, sex becomes associated with re-
production. Accepting infertililty often results in the couple not wanting to en-
gage in intercourse because it reminds them of what can never bewhy
bother? Others may become promiscuous or want to engage in sex more fre-
quently as a means of bolstering their sense of self-esteem or desirability.
Trying to recapture the active, spontaneous, mutually enjoyable sex life
the couple experienced prior to the diagnosis of infertility is a difficult and
sometimes impossible task. Some couples are never able to resume earlier
pleasures. Infertility and its treatment may end in broken relationships. Other
couples struggle to find new and different ways to be intimate and to engage
in sexual relations that do not resonate with the times and positions that be-
came routine during their attempts to conceive. Some couples need time to
become intimate again before they can resume intercourse. The therapist
must be sensitive to the wide variations in responses and the time needed to
rebuild.
Menopause
With menopause, a marked drop in estrogen production occurs that is often
accompanied by vasomotor instability (hot flashes) and vaginal atrophy
(Coop 1996). Some women report a decline in sexual activity associated with
menopause (Pearce et al. 1995). Many factors may account for this decrease,
including concomitant aging and decreased sexual ability in the partner
(Coop 1984) as well as sociocultural expectations, psychologic distress asso-
ciated with the symbolic meaning of menopause (Rinehart and Schiff 1985),
and discomfort with menopausal symptoms (Bachmann et al. 1985). Estro-
gen replacement therapy may help alleviate the physical symptoms of meno-
pause and thus contribute to an increase in coital frequency, although it is
doubtful that estrogen has a direct effect on libido (Pearce et al. 1995).
Recent evidence suggests that androgens decline gradually with age and
that the symptoms of androgen deficiency may develop insidiously. One of
the major features of androgen deficiency is hypothesized to be loss of libido
(Davis 1998; Kaplan 1977). Circulating testosterone levels in premenopausal
women are approximately half that of women in their 20s. Most of the pub-
lished evidence about the beneficial effects of androgen replacement have
involved women who received this therapy after hysterectomy and/or
oophorectomy (Young 1993). Davis (1998), however, has reported success us-
ing androgen replacement therapy in premenopausal women with androgen
deficiency syndrome.
Two studies suggest that the reaction to erotic stimuli may undergo only
minor changes with menopause. Morrell et al. (1984) found that postmeno-
pausal women had decreased vaginal responses to erotic stimuli compared
with premenopausal women. Differences in subjective arousal were also
found. Myers and Morokoff (1985) did not find a difference in vaginal re-
sponse to erotic stimuli (measured by photo plethysmography) between pre-
and postmenopausal women. In view of the multiple influences on sexuality
in the menopausal female, evaluation of a complaint of decreased sexual re-
sponsivity should involve close collaboration between the psychiatrist and
the gynecologist.
Hysterectomy
Evidence concerning the sexual consequences of hysterectomy combined

with oophorectomy is unclear. Some investigators have found no evidence of
harmful effects on sexual function (Coopen et al. 1981), whereas others have
reported decreased libido after this procedure (Munday and Cox 1967).
Clearly, research in this area is complicated by numerous factors, including
the psychologic meaning to the patient, the partners reaction, the degree of
discomfort preceding the procedure, the presence or absence of postoperative
complications, and whether the procedure includes bilateral oophorectomy
(Farrell and Kieser 2000; R. T. Segraves and Segraves 1993). A recently pub-
lished 2-year prospective study found that sexual functioning improved after
hysterectomy (Rhodes et al. 1999).
Evidence indicates that estrogen-androgen preparations may be especial-
ly effective in restoring libido in women who have undergone surgical meno-
pause. The first double-blind study was reported by Greenblatt et al. (1950).
Postmenopausal women were randomly allocated to one of four groups tak-
ing diethylstilbestrol, methyltestosterone, a combination of both of these
drugs, or placebo. The estrogen preparation relieved hot flashes, and the an-
drogen preparation increased libido. Most women preferred the combination
therapy. Similar findings have been reported by others.
Surgery for Malignancy
In recent years, interest has focused on sexual functioning after treatment of

gynecologic cancer (Andersen 1995, 1996; Schover et al. 1987). Research has
documented considerable psychologic distress accompanied by sexual disin-
terest after disfiguring surgical procedures (Andersen 1996).
Pelvic exenteration involves surgical removal of the uterus, fallopian
tubes, ovaries, urinary bladder, rectum, and vagina. Surgical reconstruction
of a neovagina is often performed; however, many patients report a total ces-
sation of sexual activity after this surgery (Andersen and Hacher 1983;
Broun et al. 1972; Demsey et al. 1975).
Radical vulvectomy is often followed by loss of orgasmic capacity and
blunting of genital sensation (Andersen and Hacher 1983; Andersen et al.
1988; DiSala et al. 1979). Schover and von Eschenbach (1985) reported that
most women are able to resume normal sexual activity after radical cystec-
tomy.
Other Surgical Procedures

Certain surgical procedures such as sympathectomy, abdominoperitoneal re-
section, retroperitoneal lymphadenectomy, and aortoiliac surgery interrupt
the sympathetic innervation of the genital organs and cause male sexual prob-
lems. It may be suspected that these procedures would also interfere with fe-
male sexual responsivity; however, minimal evidence exists concerning the
sexual effects of these procedures in women (Schover and Jensen 1988).
There have been reports that many women remain orgasmic after colectomy-
proctomucusectomy and total misorectal excision (Havenga et al. 1996;
Sjogren and Poppen 1995).
Induced Abortion
An immediate negative response to therapeutic abortion is not uncommon
(Friedman 1974); however, few women experience serious psychiatric com-
plications or long-term adverse effects on sexual behavior (Gebhard et al.
1958).
Oral Contraceptives and Sexual Behavior
Evidence of a relationship between oral contraceptive use and altered sexual

behavior is inconclusive (R. T. Segraves and Segraves 1993). Although sev-
eral investigators have reported an association between oral contraceptives
and diminished libido (Leeton et al. 1978), available evidence does not sug-
gest that oral contraceptive use has a direct effect on sexual desire (Bancroft
1983; Bardwick 1973; Cullberg 1972). Some women may experience dimin-
ished libido secondary to mild dysphoria or nausea during the first several
months of oral contraceptive use. If a patient presents with a solitary com-
plaint of diminished libido after beginning oral contraceptives and this does
not appear to be related to the psychologic meaning of using birth control, a
reasonable approach would be to confer with the gynecologist concerning
whether a trial of a different agent is warranted.
Psychiatric Drugs and Sexual Function
A fairly extensive body of literature documents the association of sexual dys-

function with the use of psychiatric drugs, especially antidepressants that in-
hibit serotonin reuptake) (Crenshaw and Goldberg 1996; Musher 1990;

Rosen et al. 1999; R. T. Segraves 1995). All of the selective serotonin re-
uptake inhibitors (SSRIs) on the market in the United States, including flu-
oxetine, fluvoxamine, sertraline, and paroxetine, have been reported to cause
anorgasmia (Ashton et al. 1997; Montejo et al. 1997) although fluvoxamine
may have a lower incidence of drug-induced anorgasmia than the other SS-
RIs (Nemeroff et al. 1995; Waldinger 1998). Approximately 30%50% of pa-
tients experience sexual difficulties while receiving SSRIs (R. T. Segraves
1996).
Cyclic antidepressants, such as imipramine, amitriptyline, desipramine,
and nortriptyline, also appear to have a high incidence of drug-induced sex-
ual dysfunction (Balon et al. 1993). Clomipramine, a tricyclic antidepressant
in the world market but approved for the treatment of obsessive-compulsive
disorder in the United States, probably has the highest incidence of drug-
induced anorgasmia. One placebo-controlled, double-blind study of the effi-
cacy of clomipramine for the treatment of obsessive-compulsive disorder
found that more than 90% of patients experienced ejaculatory or orgasmic
delay while receiving this drug (Monteiro et al. 1987). Sexual problems oc-
curred in both men and women. Venlafaxine has multiple actions, including
inhibition of sexual dysfunction similar to that of the SSRIs (Ashton et al.
1997).
The monoamine oxidase inhibitors are also associated with anorgasmia.
A double-blind, placebo-controlled study by Harrison et al. (1986) found that
both phenelzine and imipramine interfered with ejaculatory and orgasmic
function.
Of the newer antidepressants, nefazodone (Feiger et al. 1996) and
sustained-release bupropion (Hughes et al. 1996) have been shown to have
minimal sexual side effects and a much lower incidence of such side effects
than sertraline. The results of a questionnaire study by Modell et al. (1997)
suggested that bupropion may augment sexual function beyond baseline,
whereas the SSRIs depress sexual function. Mirtazapine may also have a very
low incidence of sexual dysfunction.
Antidepressant-induced anorgasmia can be treated with drug substitu-
tion, lowering of dose, drug holidays, and the use of antidotes such as yohim-
bine or buspirone. We routinely combine SSRIs with bupropion to offset
orgasmic delay induced by the SSRIs. Also, bupropion can be used on an as-
needed basis (100 mg bupropion 12 hours prior to coitus). One recent con-
trolled study found that high doses of buspirone were effective in reversing
SSRI-induced sexual dysfunction, whereas another study found contradicto-
ry results (Landen et al. 1999; Michelson et al. 2000). Case reports suggest
that sildenafil may reverse female anorgasmia induced by SSRIs (Fava et al.
1998; Schaller and Behar 1999).
A double-blind study by Riley and Riley (1986) demonstrated that diaz-
epam delays orgasm attainment. Case reports suggest that alprazolam may
have a similar effect (Sangal 1985). Anorgasmia has not been reported with
buspirone. If a minor tranquilizer is required, buspirone would be the pre-
ferred choice.
There is minimal evidence concerning whether mood stabilizers affect
sexual function in women. Carbamazepine could decrease libido because it
causes an elevation of serum hormone binding globulin, thus decreasing the
amount of free testosterone available (Isojarvi et al. 1995).
Orgasmic dysfunction has been reported with most of the antipsychotic
drugs including thioridazine (Kotin et al. 1976), trifluoperazine (Degen 1982),
and fluphenazine (Ghadirian et al. 1982). The new atypical antipsychotics
may be associated with less sexual dysfunction than traditional antipsychot-
ics, although futher research is necessary to establish this.
Conclusions
This overview of sexual disorders at the boundary between obstetrics and gy-
necology and psychiatry is a reminder of how little definitive information is
available and of the frequent need for a collaborative team approach to diag-
nosis and treatment planning. The field of human sexuality is an excellent op-
portunity for the psychiatrist, as a physician with training in both physical
and psychologic medicine, to make a significant contribution to patient care.
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19
Psychopharmacology in Women
OLGA BRAWMAN-MINTZER, M.D.
KIMBERLY A. YONKERS, M.D.
Introduction
For many years, pharmacologic treatment for women was based on the as-
sumption that women and men metabolize and respond to drugs in a similar
manner. This assumption was reinforced by a lack of research data due to the
exclusion of women from the pharmacologic clinical treatment trials that de-
termined therapeutic doses of drugs. Recently, however, the U.S. Food and
Drug Administration revised the guidelines that excluded women of child-
bearing potential from clinical trials, and the National Institutes of Health in-
troduced similar changes for government-sponsored studies (U.S. Food and
Drug Administration 1993).
Despite these limitations, data from available studies suggest that consid-
erable gender differences may exist in the pharmacokinetics (i.e., absorption,
distribution, biotransformation, and elimination) and the pharmacodynamics
(i.e., biochemical and physiologic effects) of many pharmacologic agents. It
has also become clear that certain gender-specific events such as menstrua-
tion, oral contraceptive (OC) use, and pregnancy can affect drug metabolism
and even end-organ receptor sensitivity.
As with other pharmacologic agents, the pharmacokinetics and pharma-
codynamics of many psychotropic agents may be affected by these factors.
Unfortunately, although women are prescribed psychotropic agents more fre-
quently than are men, available data on gender-related variation in the effects
of these agents are limited. This chapter highlights recent data on gender dif-
401
ferences in the pharmacokinetics and pharmacodynamics of drugs and the ef-

fects of menstruation and OC use on the administration of psychotropic
agents. It should be noted that issues such as use of psychotropic agents dur-
ing pregnancy and breastfeeding are important topics as well, but are beyond
the scope of this chapter.
Gender Differences in Pharmacokinetics
Absorption and Bioavailability
The amount of drug absorbed by the gastrointestinal tract depends on the

acid base and lipophilic properties of the medication as well as the physiology
of the gastrointestinal tract. The degree to which a drug is ionized affects its
solubility. It has been suggested that women may secrete less gastric acid than
do men, leading to potential gender differences in absorption (Grossman et
al. 1963). This decrease in gastric acid secretion may decrease both enzymatic
action and the absorption of weak acids but may increase absorption of weak
bases.
Several studies suggest gender differences in gastric emptying and gas-
trointestinal transit time. For example, Wald et al. (1981) reported that gas-
trointestinal transit time was significantly prolonged in women during the
luteal phase of the menstrual cycle. Other researchers (Datz et al. 1987) dem-
onstrated similar results (i.e., that women empty solids from their stomachs
more slowly than do men). The mechanism for these differences is unknown,
but researchers hypothesize that it may be due to the effects of progesterone
and estradiol on the gastrointestinal tract. However, some studies have failed
to demonstrate significant effects of menstrual hormones on gastrointestinal
transit time (Degen and Phillips 1996).
Gender differences in the activity of various gastrointestinal enzymes
may also affect drug metabolism. For example, the gut contains large levels
of cytochrome P450 (CYP450) 3A4 isoenzyme (Kolars et al. 1991; Strobel et
al. 1991), an important liver enzyme that appears to be more active in women
than in men. It is unknown, however, whether increased activity of CYP450
3A4 in the liver also affects the gastrointestinal enzyme analogue.
It should be noted that, despite potential differences in gastric acid secre-
tion, gastrointestinal transit time, and enzyme activity, no consistent differ-
ences in the absorption and the bioavailability of specific agents have been
observed. Only a few cases of gender differences in the absorption of some
Psychopharmacology in Women 403
drugs have been documented. For example, Aarons et al. (1989) observed
that, after oral administration, aspirin was absorbed more rapidly in women
than in men, and other researchers have found higher bioavailability of aspi-
rin in women then men, indicating potential clinically relevant gender differ-
ences in the gastrointestinal tract (Ho et al. 1985).
Distribution
Several factors may affect the distribution of a drug in the body, including
acid base, water and lipid solubility, and the affinity of the drug for binding
proteins (Riester et al. 1980) as well as differences in blood volume, cardiac
output, and organ size (Gilman et al. 1990). The ratio of lean body mass to
adipose tissue mass may also affect distribution. In general, women have a
lower ratio of lean body mass to adipose tissue (Seeman 1989). Thus, drugs
with high affinity for adipose tissue, such as diazepam, would be expected to
demonstrate a greater volume of distribution in women.
Specifically, the half-life for these drugs may become prolonged and
serum levels may be greater in patients with less lean body mass. This infor-
mation may be critical to understanding patients responses to treatment.
Women patients with a higher percentage of fat at any given body weight
may also require higher initial dose, but maintenance of the same dose over
time will cause drug accumulation leading to potentially toxic effects. How-
ever, the effects of gender in relationship to specific drugs have not been spe-
cifically studied.
Metabolism
Metabolic processes in the liver are divided into two types of reactions.
Phase I reactions, including oxidation, hydroxylation, N-demethylation, re-
duction, and hydrolysis, are mediated through CYP450. Phase II reactions
consist of glucoronidation, sulfation, methylation, and acetylation of parent
molecules and phase I reaction products. Data have indicated that significant
gender-related differences in hepatic enzyme activity may exist.
Cytochrome P450
In 1971, OMalley et al. reported that the metabolism of phenazone (antipy-
rine) is influenced by gender. At that time, antipyrine metabolism was
thought to reflect total CYP450 activity. However, in recent years many
isoenzymes of CYP450 have been identified, and data on potential gender
differences in the activity of these various isoenzymes is increasing. Because

most antidepressants and antipsychotic drugs are either metabolized byor
inhibit to varying degreesone or more CYP450 isoenzymes, the potential
gender differences in the activity of these isoenzymes may be of particular rel-
evance to the clinician.
Cytochrome P3A4. Cytochrome P3A4 (CYP3A4) is considered clini-

cally the most important CYP450 enzyme, constituting as much as 60% of
the total P450 content of in vitro liver specimens (Guengerich 1990).
CYP3A4 metabolizes a broad range of compounds, including alprazolam, mi-
dazolam, diazepam, terfenadine, astemizole, carbamazepine, sertraline, tricy-
clic antidepressants (TCAs), calcium channel blockers, erythromycin,
steroids, quinidine, lidocaine, and others (Kerr et al. 1994; Murray 1992; Pol-
lock 1994; D. A. Smith and Jones 1992).
In vitro evidence for varied inhibition of CYP3A3/4 by frequently pre-
scribed antidepressants, such as the selective serotonin reuptake inhibitors
(SSRIs) fluvoxamine, fluoxetine, and sertraline, is important (von Moltke et
al. 1995). Plasma concentrations of some drugs metabolized by this isoen-
zyme have been observed to increase during concomitant therapy with flu-
voxamine, nefazodone, fluoxetine, and sertraline but not with paroxetine
(Andersen et al. 1991). Thus, potential gender differences in the activity of
CYP3A4 may be of considerable clinical importance. Indeed, substantial data
indicate that young women may have approximately 1.4 times the CYP3A4
activity of men. For example, erythromycin is metabolized 25% more rapidly
by microsomes made from the human female liver than by microsomes made
from the male liver (Hunt et al. 1992).
Other drugs showing similar gender differences in clearance include di-
azepam (Greenblatt et al. 1980a; Hulst et al. 1994), verapamil (Schwartz et al.
1994), and midazolam (Gilmore et al. 1992; Rugstad et al. 1986). It is possible
that progesterone, which has been shown to activate CYP3A4 in vitro (Ker-
lan et al. 1992; Kerr et al. 1994), may be responsible for the observed gender
differences in enzyme activity in vivo. However, it should be noted that other
researchers have found no evidence for gender-related differences in
CYP3A4-mediated drug metabolism, although these discrepancies may be
caused by interindividual variations in CYP3A4 activity (Lobo et al. 1986;
May et al. 1994; Schmucker et al. 1990; Shimada et al. 1994; Sitar et al. 1989;
Yee et al. 1986).
Cytochrome P2D6. Cytochrome P2D6 (CYP2D6) is the most exten-

sively studied of the CYP450 isoenzymes (Brosen 1990). Approximately 5%
10% of Caucasians lack this isoenzyme as a result of an autosomal recessively

transmitted defect in gene expression. Such poor metabolizers may exhibit
greater bioavailability, higher plasma concentrations, prolonged elimination
half-lives, and (possibly) exaggerated pharmacologic response from standard
doses of drugs metabolized by CYP2D6. When drugs that inhibit CYP2D6
are administered with drugs metabolized by this enzyme, individuals who are
extensive metabolizers will, in effect, be converted to poor metabolizers.
CYP2D6 metabolizes many different classes of drugs, including anti-
depressants, antipsychotics, -adrenergic blockers, type 1C antiarrhythmics,
dextromethorphan, and some chemotherapeutic agents. Codeine and ven-
lafaxine are both O-demethylated by this enzyme (Brosen and Gram 1989;
Otton et al. 1994). Nortriptyline, desipramine, and imipramine are hydroxy-
lated by CYP2D6. Several different drugs potentially inhibit the CYP2D6
enzyme, including quinidine, fluphenazine, haloperidol, thioridazine, ami-
triptyline, desipramine, and clomipramine. All SSRIs except fluvoxamine are
potent inhibitors of CYP2D6 in vitro (Brosen 1990; Crewe et al. 1992; Otton
et al. 1993; Pollock 1994).
Few studies to date have examined the influence of gender on CYP2D6-
mediated metabolism. Gex-Fabry et al. (1990) have shown that the hydroxy-
lation of clomipramine is higher in men than in women. Similarly, Abernethy
et al. (1985) found that oral clearance of desipramine is greater in men than
in women. However, the authors of these two studies did not account for dif-
ferences in body weight. Similar results were also shown for propranolol
(Gilmore et al. 1992; Walle et al. 1985, 1989, 1994) and ondansetron (Prit-
chard et al. 1992); however, some data indicate that these two drugs may not
be metabolized predominantly by the CYP2D6 system (Ashford et al. 1994;
Walle et al. 1989).
Cytochrome P2C. Cytochrome P2C (CYP2C) is a subfamily of en-

zymes that includes 2C9, 2C10, 2C19, and others. Diazepam, clomipramine,
amitriptyline, and imipramine are demethylated by CYP2C enzymes. In ad-
dition, warfarin (Rettie et al. 1992), phenytoin (D. A. Smith and Jones 1992),
tolbutamide (Knodell et al. 1987), and certain nonsteroidal anti-inflammatory
agents (Newlands et al. 1992) are also believed to be metabolized by CYP2C
enzymes. Based on observed increases in plasma concentrations of concomi-
tantly administered drugs metabolized by this family of enzymes, it is be-
lieved that the SSRIs fluvoxamine, fluoxetine, and sertraline may inhibit
CYP2C isoenzymes (Jalil 1992; Skjelbo and Brosen 1992).
Research has shown that the activity of CYP2C19 may be higher in men
than in women. Hooper and Qing (1990) have demonstrated that men clear
methyl phenobarbital, a compound metabolized by CYP2C19, approximate-

ly 1.3 times faster than in women. The metabolism of piroxicam exhibited a
similar gender effect (Rugstad et al. 1986). However, these differences were
not seen by others when adjustments were made for weight (Richardson et
al. 1985).
Cytochrome P1A2. Cytochrome P1A2 (CYP1A2) isoenzyme is in-

volved in the metabolism of theophylline, caffeine (Wrighton and Stevens
1992), TCAs (Brosen et al. 1993; Pollock 1994), clozapine (Jerling et al.
1994), and possibly thiothixene (Ereshefsky et al. 1991). CYP1A2 is induced
by cigarette smoke, charcoal-broiled foods, and cabbage (Brosen et al. 1993;
Guengerich 1992; Pollock 1994). Furthermore, CYP1A2 shows potent inhi-
bition by fluvoxamine in vitro (Brosen et al. 1993). However, other SSRIs do
not appear to inhibit this isoenzyme.
Data regarding gender-related differences in the activity of CYP1A2 are
scarce and conflicting. Using data from studies of caffeine and thiothixene
metabolism, it appears that CYP1A2 activity may be higher in men than in
women (Ereshefsky et al. 1991; Relling et al. 1992). In contrast, Nafziger and
Bertino (1989) reported that theophylline is cleared significantly faster in
young women than in men. Interestingly, gender differences in theophylline
metabolism do not appear to be present in elderly patients, suggesting that
this difference could be hormone dependent rather than caused by genetic
differences (Cuzzolin et al. 1990). Furthermore, clomipramine demethyla-
tion, which may be performed by CYP1A2, is not influenced by gender (Gex-
Fabry et al. 1990). Thus, given the available data, no definite conclusions on
the effects of gender on CYP1A2 activity can be drawn at this point.
Conjugation
Many drugs are excreted by the kidneys after conjugation with sulfate or glu-
curonic acid. Frequently, conjugation reactions are the second metabolic step
after the drug has been metabolized, involving relatively slower cytochrome-
mediated hydroxylation. Because cytochrome-mediated metabolism is often
the rate-limiting step, it may not be possible to detect any gender-related dif-
ferences in conjugation reactions for these drugs. However, several drugs are
metabolized solely by conjugation and appear to display gender-related dif-
ferences in their elimination. For example, the benzodiazepines temazepam
and oxazepam, which are eliminated by conjugation, are cleared faster by
men than by women (Divoll et al. 1981; Greenblatt et al. 1980b). Faster elim-
ination in men was also observed for the clearance of digoxin (Yukawa et al.
1992), although the observed differences may be related to differences in re-

nal function. Clearance of paracetamol was also greater (22%) in young men
compared with young women (Miners et al. 1983). However, other com-
pounds that are cleared by glucoronidation, such as ibuprofen, are not influ-
enced by gender (Greenblatt et al. 1984).
Effects of the Menstrual Cycle
As mentioned earlier, several possible menstrual-phasespecific changes may

have considerable impact on the metabolism of drugs in women. For exam-
ple, gastrointestinal transit time varies during the menstrual cycle (McBurney
1991; Sweeting 1992). Subsequently, absorption in the small intestine may be
increased during the luteal phase when the gastrointestinal transit time is pro-
longed. Other potential menstrual-phaserelated changes that may affect
drug metabolism include increases and decreases in the volume of distribu-
tion. Although empirical data are lacking, it can be hypothesized that increas-
es in fluid retention that are related to the menstrual phase may dilute the
concentration of medications, thus resulting in lower plasma levels and vice
versa. One study also found evidence of menstrual-phase changes in trans-
capillary fluid dynamics that resulted in fluid shifts between intravascular and
extravascular spaces (Pollan and Oian 1986).
A small number of reports have demonstrated a menstrual-phase influ-
ence on drug pharmacokinetics. Lew et al. (1993) found that the elimination
of methylprednisolone is more variable in premenopausal women than in
postmenopausal women or in men, suggesting a menstrual cycle effect. These
authors could not, however, correlate the magnitude of drug elimination to
the phase of the menstrual cycle. Furthermore, Lane et al. (1992) found that
caffeine clearance is slower in the luteal than in the follicular phase of the
menstrual cycle. In contrast, phenytoin elimination appears to be highest at
the end of the menstrual cycle (Shavit et al. 1984). The menstrual cycle does
not, however, appear to affect the metabolism of other compounds studied,
such as alprazolam (Kirkwood et al. 1991), nitrazepam (Jochemsen et al.
1982), and phenobarbital (Backstrom and Jorpes 1979).
Finally, data indicate that monoamine oxidase activity may be decreased
by estrogens and increased by progesterone, suggesting menstrual variations
in a critical metabolic pathway for most psychotropic drugs (Banwick 1976;
Klaiber et al. 1979). The clinical significance of these changes is unknown.
These data highlight the importance of establishing menstrual cycle
phase when investigating pharmacodynamic as well as pharmacokinetic

properties of psychotropic medications in women. Furthermore, it may be
clinically relevant to explore the potential effects of menstrual cycle phase
when adverse effects of medications occur or when there are fluctuations in
drug efficacy.
Oral Contraception
Oral contraceptives are among the most widely used drugs in the world. OCs
influence the pharmacokinetics and pharmacodynamics of other compounds.
For example, estrogen exerts a stimulatory effect on protein synthesis, which
in turn may affect protein-binding of various drugs. OCs may also interfere
with the elimination of other drugs through inhibition of various cytochrome
P450 isoenzymes (phase I reactions), which leads to increased pharmacologic
activity of drugs metabolized by the appropriate isoenzymes. Clearance of the
benzodiazepines triazolam, alprazolam (Stoehr et al. 1984), and nitrazepam
(Jochemsen et al. 1982), compounds that are metabolized by CYP450 isoen-
zymes, was reduced when OCs were taken concomitantly. The TCA imi-
pramine is also affected by OCs. For example, Abernethy et al. (1984) found
that OCs inhibited the metabolism of intravenous imipramine. When imi-
pramine was given orally, this effect was counterbalanced by the change in
oral availability and decreased apparent oral clearance. In contrast, clomi-
pramine is not influenced by OCs, although its metabolic rate is enhanced by
estrogens and inhibited by progesterone in animal models (Fletcher et al.
1965). OCs may also affect phase II reactions, such as conjugation with glu-
coronic and sulfuric acid, through enzyme induction. Thus, benzodiazepines
that undergo conjugation, such as temazepam, show higher clearance in the
presence of OCs (Stoehr et al. 1984).
The clinical significance of the effects of concomitant OC use in patients
receiving psychotropic medications was demonstrated by Ellinwood et al.
(1984). They found impairment in cognitive and psychomotor tasks in wom-
en taking diazepam and OCs during the week that the subjects did not take
hormones, because benzodiazepine levels peaked more quickly. They postu-
lated that OCs decrease the rate of absorption of diazepam, and during the
week off of hormones the plasma levels quickly rose to intoxicating levels.
Contrasting findings were reported by Kroboth et al. (1985) for other benzo-
diazepines such as alprazolam, triazolam, and lorazepam. In this study,
psychomotor changes were most marked in women who received OCs.
However, in both cases plasma levels did not correlate with the observed clin-
ical effect. Finally, although no data are available, changes in protein synthesis
can affect end-organ response to drugs at the cellular level.
In summary, it appears that, given the potential interaction between ex-
ogenous hormones and various psychotropic medications, it may be impor-
tant to assess OC use prior to any psychopharmacologic intervention.
Gender Differences in Psychotropic Agents
Antipsychotic Agents
The literature analyzing pharmacokinetics, pharmacodynamics, and side ef-

fects of psychotropic agents by gender is the most substantial for antipsychot-
ic drugs. Most studies have found that women treated with antipsychotic
medications experienced greater improvement than did men. For example,
Chouinard and Annable (1982) found that women had greater improvement
than did men after treatment with pimozide and chlorpromazine. Similarly,
Szymanski et al. (1995) reported that female schizophrenic patients had a bet-
ter treatment response to antipsychotics than did men, whereas plasma drug
levels did not differ significantly between men and women. However, some
reports have indicated a lack of gender differences in neuroleptic treatment
response in men and women when subjects were matched for clinical, treat-
ment, and demographic characteristics (Pinals et al. 1996).
Researchers have hypothesized that the generally greater efficacy of neu-
roleptics in young women may be caused by the presumed antidopaminergic
effects of estrogen (Fields and Gordon 1982; Villeneuve et al. 1978). Estrogen
has been thought to play a protective (i.e., neuroleptic-like) role in the disease
protection process of schizophrenia, leading to the delay of illness develop-
ment (Seeman 1996; Seeman and Lang 1990) and a better response to neu-
roleptics. Interestingly, Kulkarni et al. (1996) found that schizophrenic
women who received estradiol in addition to neuroleptic treatment improved
more rapidly compared with the group that received neuroleptics only. How-
ever, this difference was not sustained for the entire duration of the trial.
Clinicians have also noted that women may require lower doses of neu-
roleptics than men despite similarities in weight and age. It appears that wom-
en may achieve higher plasma levels of antipsychotics than men (Chouinard
et al. 1986; Simpson et al. 1990). Simpson et al. (1990) found higher fluphen-
azine levels in women despite comparable dosing and similar age and weight
characteristics. Chouinard et al. (1986) investigated fluspirilene, a long-acting
injectable neuroleptic, and found that women required roughly half the dos-
age required by men despite similar weight and age characteristics. In this tri-
al, the prescribed doses were titrated to therapeutic efficacy, but serum levels
were not available. Another study found that men had significantly higher
oral clearance of thiothixene than did women and that clearance did not nec-
essarily correlate with body weight (Ereshefsky et al. 1991). The authors also
found a reduction in clearance for subjects over the age of 50. Centorrino et
al. (1994) reported that, despite a 60% lower milligram per kilogram dose in
women, the levels of clozapine were 40% higher in nonsmoking women than
men and did not vary by diagnosis or age in the study sample.
Gender-related differences were also observed in the expression of anti-
psychotic-induced side effects. For example, the incidence of tardive dyskine-
sia (TD) has been reported as greater in women than in men in several
studies (Chouinard et al. 1979; J. M. Smith and Dunn 1979). Women have
also been reported to suffer more severe TD symptoms. J. M. Smith and
Dunn (1979) reported that the severity of TD increased significantly in wom-
en older than 67 years. Yassar and Jeste (1992) combined data from indepen-
dent studies on prevalence, age, and gender differences in TD and found that
TD is more prevalent in older women. Chouinard et al. (1980) noted that
young men reported a higher prevalence of severe dyskinesias than did wom-
en; they explained this discrepancy by suggesting that postmenopausal status
and loss of estrogen-induced supersensitivity may favor the development of
TD in postmenopausal women.
Data on the impact of gender on the development of Parkinsonism are
limited. Jeste (1995) reported that women who take lower doses of neurolep-
tic medications have similar or lower risks of Parkinsonism compared with
men.
In summary, the available literature indicates that several clinically signif-
icant gender-related differences in the effects of neuroleptic medications may
exist. However, further well-controlled research is clearly indicated.
Benzodiazepines
In contrast to the research on antipsychotic agents, relatively few studies have
evaluated the therapeutic effects and side effects of benzodiazepines in wom-
en. Available studies focus primarily on potential gender-related differences
in the pharmacokinetics of benzodiazepines. For example, Greenblatt et al.
(1980a) found that diazepam, which is oxidatively metabolized, has a higher
clearance in younger women than in men. This difference disappeared in
women 6284 years of age. MacLeod et al. (1979) found that women metab-
olized diazepam more slowly than did men, regardless of age. Nitrazepam, a
benzodiazepine metabolized by reduction, was not found to have gender-

related differences in clearance (Jochemsen et al. 1982). Metabolism of alpra-
zolam, a benzodiazepine that undergoes oxidation, was not influenced signif-
icantly by gender or menstrual cycle phase (Greenblatt and Wright 1993).
However, temazepam and oxazepam, benzodiazepines that undergo conjuga-
tion, had slower clearance rates among women patients compared with men
in several studies (Divoll et al. 1981; Greenblatt et al. 1980b; R. B. Smith et
al. 1983). This difference was present regardless of age (R. B. Smith et al.
1983).
As mentioned, data regarding gender differences in the effects as well as
the side effects of benzodiazepines are limited. Ellinwood et al. (1984) found
that cognitive and psychomotor tasks performed by women taking diazepam
and OCs were more impaired during the week off hormones because benzo-
diazepine levels peaked more quickly. Interestingly, van Haaren et al. (1997)
observed that high doses of chlordiazepoxide increased response efficiency in
male rats, but decreased response efficiency in female rats in animal models.
Finally, Pesce et al. (1994) found that the incidence of benzodiazepine with-
drawal seizures produced by the administration of flumazenil was significant-
ly lower in male than in female diazepam-treated mice.
In summary, it appears that despite varied methodology in the available
studies, current data suggest gender-related differences in the metabolism and
potentially in the effects and side effects of the various benzodiazepines.
Antidepressant Agents
Although mood disorders are more prevalent in women than in men (Kessler
et al. 1996), little attention has been devoted to the research of antidepressant
effects in women. This is not surprising in light of the exclusion of women
from many pharmacologic trials, a policy that, as mentioned earlier, has only
recently been revised.
Several gender-related differences in the pharmacokinetics of antidepres-
sants have been reported, however. For example, higher plasma levels of cer-
tain TCAs were observed in women compared with those observed in men.
Moody et al. (1967) found that women had higher plasma levels of imi-
pramine than did men. Similarly, Preskorn and Mac (1985) reported that
women and older subjects had higher plasma levels of amitriptyline than did
young men. Gex-Fabry et al. (1990) found that the hydroxylation clearance
of clomipramine is lower in women than in men, whereas Abernethy et al.
(1985) reported greater oral clearance of desipramine in men than in women.
However, neither the Abernethy nor the Gex-Fabry studies normalized for
body weight. In contrast, Ziegler and Biggs (1977) found no significant gen-
der differences in plasma levels of amitriptyline and nortriptyline. Finally,
Greenblatt et al. (1987) found that the volume of distribution of trazodone
was greater in women and the elderly, but clearance was significantly reduced
only in older men.
In recent years data have also emerged on potential gender differences in
the pharmacokinetics of SSRIs and other new antidepressants. In fact, several
researchers have observed that plasma concentrations of sertraline were ap-
proximately 35%40% lower in young men than in women and elderly men
(Ronfeld et al. 1997; Warrington 1991). Similarly, plasma concentrations of
fluvoxamine have been shown to be 40%50% lower in men than in women,
with the magnitude of effect possibly greater at lower medication doses (Hart-
ter et al. 1993). Of the other antidepressants, the levels of nefazodone were
found to be higher in elderly women compared with younger subjects and
elderly men (Barbhaiya et al. 1996). In contrast, Klamerus et al. (1996) re-
ported that gender did not substantially alter the disposition or the tolerance
of venlafaxine.
As mentioned, data regarding gender-related differences in treatment re-
sponse to antidepressants are scarce. Several available studies indicate that
women may respond less to TCAs than do men, but may respond better to
SSRIs and monoamine oxidase inhibitors (MAOIs). A study by Davidson
and Pelton (1986) evaluated the efficacy of TCAs and MAOIs by gender in
three types of atypical depression. They found that depressed women who
also had panic attacks had a more favorable response to MAOIs than to
TCAs, whereas men who were depressed and had panic attacks responded
more favorably to TCAs. Similarly, Raskin (1974) found that young women
(younger than 40 years) responded less well to imipramine than did older
women and men. Finally, Steiner et al. (1993) compared the effects of parox-
etine, imipramine, and placebo in outpatients with major depression and
found that women responded better to paroxetine than to imipramine.
Thus, it appears that some clinically meaningful gender-specific dif-
ferences may exist in the efficacy and tolerability of the antidepressant
medications.
Conclusions
This chapter reviews the available literature on the potential gender-related

differences in the pharmacokinetics and pharmacodynamics of psychotropic
medications. The surprising outcome of this review is that significant gaps ex-
ist in the experimental data addressing these issues. Nevertheless, available
evidence suggests certain potentially meaningful gender-related variations in
the pharmacokinetics of various compounds. Furthermore, the menstrual cy-
cle phase and the use of OCs may also affect the metabolism, distribution,
and clearance of certain drugs. Examination of specific psychotropic agents
indicates that 1) the effects of benzodiazepines are influenced by gender, men-
strual cycle phase and concurrent use of OCs; 2) antipsychotic agents may be
more effective in women, although women are more likely to experience ad-
verse drug reactions; and 3) women may respond better to different classes
of antidepressant agents than men, specifically the SSRIs and the MAOIs.
These data also indicate the need for further well-controlled research in this
field.
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20
Alcohol and Substance Abuse in
Obstetrics and
Gynecology Practice
SHEILA B. BLUME, M.D., C.A.C.
MARCIA RUSSELL, PH.D.
Women, Alcohol, and Drugs
Historical and Social Factors
Abuse of alcohol and other psychoactive drugs predates recorded history. Al-
though the types of drugs used and abused in different cultures have varied
over time, nearly all societies that have permitted substance use have had
separate rules for each gender. These rules have been based on deeply in-
grained cultural stereotypes of the differential effects of these drugs on men
and women.
Western thought, dating back as far as the ancient Romans and Israelites
(Gomberg 1986; McKinlay 1959), has held that alcohol is a sexual stimulant
that makes women promiscuous. Although careful studies of women in the
United States have not substantiated this idea (Klassen and Wilsnack 1986),
the stereotype is widely accepted and has led to a destructive stigma applied
to all chemically dependent women. This stigma characterizes them as both
generally and sexually immoral (i.e., fallen women), and in turn simulta-
neously enhances denial and leads to underrecognition of chemical depen-
dence in middle-class and professional women (Moore et al. 1989). It further
421
results in the social acceptance of physical and sexual victimization of chem-

ically dependent women (Blume 1991). Rapists are considered less responsi-
ble for their acts if intoxicated at the time of the rape, whereas victims are held
more to blame if intoxicated (D. Richardson and Campbell 1982). It is hardly
surprising, therefore, that women suffering from addictive diseases are often
the victims of violence, both at home and in society (B.A. Miller et al. 1989;
Testa and Parks 1996).
Social customs related to the use and abuse of substances affect women
in various ways. Drinking norms that dictate lower levels of intake by women
protect them from developing alcoholism (Klee and Ames 1987; Kubicka et
al. 1995). The evolution of social custom has produced a convergence of use
patterns for some drugs among male and female teenagers; more girls are
now initiating smoking than are boys (Center on Addiction and Substance
Abuse 1996). The tendency of physicians to prescribe more psychoactive
drugs for women than for men (Cooperstock 1978) puts women at a higher
risk for becoming dependent on prescription drugs and puts alcoholic women
at increased risk for mixed addictions. Wives, daughters, and mothers of al-
coholics or addicts often assume the social role of caretaker. In their efforts to
cope with familial dysfunction, they may display maladaptive behavior char-
acterized as codependency (Cermak 1986). Depression, somatic complaints, eat-
ing disorders and alcohol or drug abuse are often seen in this group.
Epidemiology
Womens alcohol use has increased over the past half-century. Although no
dramatic overall changes have occurred in the past few years, heavy drinking
has continued to rise among younger cohorts. For the year 1992, Grant et al.
(1994) found that 4.5 million American women suffered from alcohol abuse
or dependence. A general population study of Americans aged 1554 years
yielded the following lifetime prevalence rates for women: any substance
abuse or dependence 17.9% (versus 35.4% for men); alcohol abuse or depen-
dence 14.6% (versus 32.6% for men); and other drug abuse/dependence, ex-
cluding nicotine, 9.4% (versus 14.6% for men). Among women, 12-month
rates of abuse or dependence were any substance 6.6% (versus 16.1% for
men); alcohol 5.3% (versus 14.1% for men); and other drugs 2.2% (versus
5.1% for men) (Warner et al. 1995). In evaluating epidemiologic surveys, the
possible influence of social stigma on the accuracy of reporting by women
should be considered. It is not known if women underestimate their sub-
stance use more than men.
Alcohol and Substance Abuse 423
In 1993 approximately 4.1% of women in the United States (4.4 million)

admitted to some illicit drug use (including nonmedical use of prescription
drugs) during the month prior to a household survey (Substance Abuse and
Mental Health Services Administration 1994). Women of childbearing age re-
ported a higher prevalence of 8.1% (1.2 million) for ages 1825 and 5.9% (1.1
million) for ages 2634.
High-risk groups for alcohol and drug problems among women include
inner-city and criminal justice populations, women in the military, and lesbi-
an women (Wilsnack 1984). A family history of alcoholism increases the risk
of alcohol abuse or dependence in women (Russell et al. 1990).
Studies of gynecologic populations reveal higher prevalence rates than
are found in the general public. For example, of 147 women visiting two pri-
vate gynecologic practices for routine care, 12% met criteria for alcohol abuse
or dependence. Of 95 women treated in the same locations for premenstrual
syndrome, 21% were also alcoholic (Halliday et al. 1986). In a similar study
of 1,967 gynecologic patients, 17% were heavy drinkers and 14% regularly
used psychoactive drugs with the potential for nonmedical use (Russell and
Coviello 1988). Data from 21 states participating from 1985 to 1988 in the
Behavioral Risk Factor Surveillance System indicated that alcohol use by
pregnant women declined from 32% to 20% over this period; binge drinking
was reported by 2.8% (Serdula et al. 1991). No declines in alcohol use were
observed among pregnant women who were less educated or under age 25
years, and rates of use were highest among smokers and unmarried women.
Positive urine toxicology screening tests have been reported in 13.1% of
335 women in private and 16.3% of 380 women in public obstetric care
(Chasnoff 1990) and in 29.5% of 200 women admitted in active labor to an
inner-city hospital (Parente et al. 1990).
Psychologic Aspects
Longitudinal studies of girls who later developed drinking problems have re-
vealed feelings of low self-esteem and impaired ability to cope (Jones 1971)
and drinking to relieve shyness, get along better on dates, and get high (Fill-
more et al. 1979). Additional risk factors have been identified in retrospective
studies. In a large general-population sample of adult women, a history of
sexual assault increased the risk for a lifetime diagnosis of alcohol abuse or
dependence (3.5 times more likely) and drug abuse or dependence (four
times more likely) (Winfield et al. 1990). In addition, women who develop
chemical dependency are more likely than men to satisfy diagnostic criteria
for an additional psychiatric diagnosis, especially major depression (Helzer

and Pryzbeck 1988; Hesselbrock et al. 1985). Alcoholic women are also at
risk for suicide (Gomberg 1986). When alcoholism and major depression oc-
cur in the same woman, the depression predates the onset of alcoholism two-
thirds of the time. Such dual-diagnosis patients have a favorable prognosis
if they receive adequate treatment for both disorders (Rounsaville et al.
1987), whereas efforts to relieve chemical dependence by treating underly-
ing disorders alone have usually been unsuccessful.
Physiologic Factors
Women have been found to be more sensitive to alcohol than are men. When
given equal doses of alcohol per pound of body weight under standard con-
ditions, women attain higher blood alcohol levels than do men. This is partly
due to the lower average water content in the bodies of women, because al-
cohol is distributed in total body water. It may also be a result of more com-
plete absorption of alcohol in women, which results from lower levels of the
metabolic enzyme of alcohol, alcohol dehydrogenase, in gastric tissue (Frezza
et al. 1990). Women also show more variable peak blood alcohol levels,
which some, but not other, investigators have found to correlate with the
menstrual cycle. Although little evidence exists that patterns of drug use vary
with the menstrual cycle in normal women, those who suffer from premen-
strual dysphoria tend to increase the use of alcohol and marijuana during the
premenstruum (Mello 1986).
Gender differences in relative body water and fat content also lead to
longer half-lives for lipid-soluble psychoactive drugs, such as diazepam and
oxazepam, in women (Barry 1986). Aging further exaggerates this trend.
Effects on Sexuality and Reproduction
In examining the effects of psychoactive substance use on womens sexuality,

the strong influence of socially conditioned expectation must be considered
(Wilsnack 1984). Because alcohol is thought to be sexually stimulating, wom-
en report more subjective sexual arousal when they have consumed alcohol,
even when physiologic measurements show otherwise. In physiologic exper-
iments, alcohol has been shown objectively to have a dose-related depressant
effect on sexual arousal (Wilson and Lawson 1976) and orgasm (Malatesta et
al. 1982) in women. Alcoholic women report a wide variety of sexual dys-
functions, including premenstrual dysphoria, lack of sexual interest, anorgas-
mia, vaginismus, and dyspareunia. At the same time, these women believe
that alcohol arouses them and fear they will not enjoy sex if they are sober.
Physicians can help these women by explaining alcohols depressant effects
and reassuring them that abstinence from alcohol and other drugs is likely to
improve their sexual functioning in the long run (Gavaler et al. 1993).
Another commonly held expectation is that cocaine and amphetamines
function as enhancers of sexual functioning. In fact, chronic use of either drug
can cause impotence and ejaculatory failure in men, inhibition of orgasm in
women, and loss of sexual desire in both sexes (Washton 1989).
Heroin dependence has been reported to depress sexual desire and sup-
press ovulation (Gaulden et al. 1964). Menstrual periods often return to nor-
mal within a few months after the institution of methadone maintenance
treatment (Wallach et al. 1969). Methadone itself, however, depresses sexual
activity in a dose-related fashion (Crowley and Simpson 1978). Abuse of sed-
ative drugs and minor tranquilizers such as diazepam may also depress both
sexual desire and orgasm in women.
Alcoholic women commonly experience amenorrhea, anovulatory cy-
cles, luteal phase dysfunction, and early menopause (Mello et al. 1989). They
may therefore seek help for infertility, unaware that their alcohol or sedative
intake might play an etiologic role. In addition, even at levels of social drink-
ing, alcohol has also been shown to increase the risk of spontaneous abortion,
especially in the midtrimester (Mello et al. 1989).
Adverse effects of alcohol and drug abuse on pregnancy and the devel-
oping fetus are produced by a complex interaction of pharmacologic, lifestyle,
and nutritional factors, including absent or insufficient prenatal care. Al-
though some women use only one drug, multiple drug use, including heavy
smoking, is common (Mello et al. 1989). Premature labor, abruptio placentae,
stillbirth, and a wide variety of other obstetric complications have been re-
ported to be associated with maternal abuse of alcohol and other chemicals
(Levy and Koren 1990). Alcohol is also known to suppress uterine contrac-
tions and in the past was employed in the treatment of threatened preterm la-
bor (Fadel and Hadi 1982).
Cocaine, because of its acute stimulant, vasoconstrictive, and cardiac
arrythmiaproducing properties, has been linked to sudden death in the preg-
nant woman (Burkett et al. 1990) as well as to premature rupture of the mem-
branes, preterm labor, and fetal distress (Mastrogiannis et al. 1990).
Unfortunately, the association between acute ingestion of cocaine and prema-
ture labor has led to a mistaken belief among young women that cocaine can
shorten their labor while making it less painful (Skolnick 1990). This miscon-
ception may actually lead to an increase in the use of cocaine in late pregnan-
cy. Investigations of additional specific adverse effects resulting from prenatal
cocaine exposure, including structural birth defects, growth and developmen-
tal retardation, childhood behavior problems, and an increased incidence of
sudden infant death syndrome, have produced contradictory and equivocal
results (Center on Addiction and Substance Abuse 1996; G. A. Richardson
and Day 1994). A full understanding of the long-term results of cocaine use
in pregnancy awaits further research.
Cigarette smoking has been associated with an increased risk of sponta-
neous abortion, placenta previa, and abruptio placentae (Levy and Koren
1990). Studies of the influence of marijuana use on the course of pregnancy
have been equivocal; some studies suggest an increased incidence of protract-
ed labor and precipitate labor (Levy and Koren 1990).
Adverse effects of drugs of abuse on the fetus include both general and
substance-specific influences. Table 201 summarizes these effects. In addi-
tion to those listed, an increased incidence of sudden infant death syndrome
or neonatal apnea has been correlated with prenatal exposure to both cocaine
and nicotine. Heroin dependence has been linked to a range of obstetric com-
plications. On the other hand, women who are maintained on stable doses of
methadone and are provided with adequate prenatal care and nutrition have
an improved course of pregnancy and may produce offspring of normal size
and weight (Blinick et al. 1973). Postnatal abstinence syndrome is common in
such infants but can be managed (Hoegerman et al. 1990).
Evidence for long-term neurobehavioral abnormalities caused by metha-
done exposure is equivocal (Rosen and Johnson 1985). Fetal alcohol syn-
drome (FAS), first described and named in 1973, consists of the following
signs and symptoms (Institute of Medicine 1996): 1) prenatal and postnatal
growth retardation; 2) central nervous system dysfunction (including any
combination of reduced head circumference, mental retardation, hyperactiv-
ity, and disordered learning, coordination, or balance); 3) a characteristic fa-
cial dysmorphism, with shortened palpebral fissures, epicanthic folds, and a
shortened, depressed nose bridge, elongated, flattened upper lip, and dis-
placed, deformed ears; and 4) additional birth defects ranging from mild
(birthmarks, single palmar crease) to severe (cardiac, joint, eye, and ear ab-
normalities).
The term alcohol-related birth defects (ARBD) refers to abnormalities that
are presumed or suspected to be related to maternal drinking during pregnan-
cy and that do not meet the criteria for FAS. Although it has been established
through both human and animal studies that heavy drinking throughout
TABLE 201. Commonly reported teratogenic effects of abused drugs
Other Other
Specific fetal effects Opiates Alcohol sedative Cocaine stimulant Hallucinogens Marijuana Nicotine
Structural nonspecific X X X X X
growth retardation
Specific dysmorphic X X
effects
Behavioral X X X X X X X X
Neurobiochemical X X X
(abstinence syndrome)
Increased fetal and X X X X
perinatal mortality
Alcohol and Substance Abuse

Women reporting use 5 >50 <5 <20 <5 <5 534 >50
in pregnancy*, %
*(varies with population)

Source. This table was first published in the Western Journal of Medicine (G. Hoegermann, C. A. Wilson, E. Thurmond, et al. Drug-exposed neonates. West J
Med 1990; 152:559564) and is reproduced by permission of wjm western journal of medicine.
427
most of pregnancy produces both FAS and ARBD, the relative risks of vari-
ous amounts and patterns of drinking are still in question. Experiments in an-
imals indicate that alcohol consumed in a binge pattern may produce more
severe damage than an equal quantity consumed over a longer period.
Although no absolutely safe level of alcohol intake during pregnancy has
been established, negative effects of light, moderate, or social drinking have
been subtle and more difficult to document than the effects of heavier drink-
ing (Institute of Medicine 1996; Russell 1991). Nevertheless, most authorities
recommend abstinence, following the advice of the U.S. Surgeon General,
who issued the following statement in 1981: The Surgeon General advises
women who are pregnant (or considering pregnancy) not drink alcoholic bev-
erages and to be aware of the alcoholic content of foods and drugs (p. 1).
Most drugs of abuse pass freely into breast milk and can cause harm to
the nursing infant. Even small quantities of alcohol consumed during lacta-
tion may cause measurable differences in motor development (Little et al.
1989). Several available references address the treatment of the chemically de-
pendent pregnant woman (Center for Substance Abuse Treatment 1993; L. J.
Miller 1994; Mitchell 1994). Alcohol use may also be associated with an in-
creased risk of breast cancer in women in a doseresponse relationship (Long-
necker et al. 1988).
Other Physical Complications of Alcohol and Drug Use
Alcoholism has been found to progress more rapidly in women than in men.
This is also true for the physical complications of alcoholism, including fatty
liver, hypertension, obesity, anemia, malnutrition, peptic ulcer, cirrhosis of
the liver (Ashley et al. 1977; Gavaler 1982), and both peripheral myopathy
and cardiomyopathy (Urbano-Marquez et al. 1995). These conditions may in
turn cause further obstetric and gynecologic morbidity (Blume 1986).
Another important set of complications of alcohol and drug dependence
are sexually transmitted diseases. The proportion of women among all newly
reported cases of AIDS has grown steadily over the past decade. Of AIDS
cases in women, 79% are related to the use of drugs. Of these women, 50%
have been users of intravenous drugs and 25% have been nonusing sexual
partners of male intravenous drug users (Center on Addiction and Substance
Abuse 1996). Studies of HIV-positive women participating in a methadone
maintenance program showed no differences in fertility when compared with
HIV-negative control subjects, and very few differences in the course of preg-
nancy were found between the two groups (Selwyn et al. 1989). About one-
third of infants born to HIV-positive women will be HIV positive themselves

at 18 months of age (Blanche et al. 1989).
A sharp rise in the incidence of both primary and secondary syphilis was
reported during the 1980s, especially among women (Rolfs and Nakashima
1990). Seropositivity for syphilis in American women has been linked to drug
use, including cocaine (Minkoff et al. 1990). However, analysis of a large,
general-population sample showed problem drinking to be a predictor of sex-
ually transmitted diseases in both genders, and a greater risk factor than ille-
gal drug use (Ericksen and Trocki 1994).
Identification and Treatment of Psychoactive Substance

Abuse in Obstetric/Gynecologic Practice
Screening
As discussed, the prevalence of heavy drinking and drug use is elevated in

gynecologic patients, and maternal substance use increases pregnancy risk.
Therefore, screening for substance use in obstetric and gynecologic settings
is an important aspect of care. Currently, brief questionnaires are the most
cost-effective and sensitive method of identifying risk drinking and risk for
substance abuse. The TWEAK (Russell 1994) and TACE (Sokol et al. 1989)
were developed in obstetric and gynecologic patients to detect risk drinking
in pregnancy, and they also detect alcohol problems. A self-administered
questionnaire that includes questions on smoking, alcohol, and other drug
use and on risk factors for substance abuse (Figure 201) can be conveniently
administered in the patient waiting room and then reviewed by the clinician
with the patient. Elevated levels of mean corpuscular volume and/or -
glutamyltransferase observed in routine blood tests, although less sensitive
than questionnaires, may be helpful in detecting heavy alcohol use that is pre-
dictive of ARBD in obstetric patients (Ylikorkala et al. 1987). Laboratory
tests for drugs in maternal and newborn blood or urine are used to screen for
substance use in some perinatal clinics, but this remains controversial because
of the potential for false-positive results, problems of confidentiality, and the
threat of legal sanctions that can complicate the delivery of prenatal care
(Birchfield et al. 1995; Blume 1997).
Positive screening results should be followed in all cases by a careful di-
agnosis in which accepted criteria are used; a positive laboratory test should
not be used as a substitute for a clinical assessment. Criteria for diagnoses of
FIGURE 201. Health Questionnaire

FIGURE 201. Health Questionnaire (continued)
alcohol and drug abuse or dependence have been published by the American
Psychiatric Association (1994). In addition, women may drink excessively or
use drugs without meeting criteria for a diagnosis of alcohol or drug abuse or
dependence. However, they should be counseled about the potential risks to
their health, especially as it relates to their reproductive health, and those who
are unable or unwilling to moderate their substance use should be encour-
aged to use reliable methods of contraception if they are at risk of becoming
pregnant. Heavy drinkers or drug users planning to become pregnant should

be advised to attain abstinence before conceiving to avoid damage to the fetus
early during gestation.
Treatment Considerations
The most important factors in approaching the chemically dependent woman

identified in obstetric/gynecologic practice are a nonjudgmental, helping atti-
tude; a thorough knowledge of available specialist practitioners and treatment
resources in the community; and the involvement of family members or sig-
nificant others in carrying out the referral to treatment for chemical depen-
dency. Education or warnings about the need for abstinence are not sufficient
for alcohol- or drug-dependent pregnant women. Although some are able to
abstain during pregnancy without treatment, most relapse after delivery, to
the detriment of their health, family life, and future pregnancies. These wom-
en need rehabilitative treatment, sometimes preceded by detoxification, to re-
cover. Sample protocols are available to assist in detoxification of the pregnant
woman who is dependent on alcohol or sedatives. Opiate-dependent preg-
nant women may be either detoxified or shifted to a methadone maintenance
regimen (Center for Substance Abuse Treatment 1993). Self-help fellowships
such as Alcoholics Anonymous, Narcotics Anonymous, and Women for So-
briety are widely available and play an essential role in long-term recovery.
Both self-help (e.g., Al-Anon Family Groups, Naranon, Adult Children
of Alcoholics groups) and professional services are indicated for those obstet-
ric/gynecologic patients whose lives have been adversely affected by the
chemical dependence of a family member. At times a structured intervention
can be arranged in which family and friends confront the alcohol- or drug-
dependent person with the assistance of a trained professional (Johnson Insti-
tute 1983). Structured intervention should be considered as an approach if
the chemically dependent obstetric/gynecologic patient is initially unwilling
to accept the need for alcohol or drug treatment concomitant with her
obstetric/gynecologic care.
Barriers to Treatment
Women are seriously underrepresented in alcoholism treatment in the United

States. Although they constitute approximately one-third of alcoholics, only
one-fourth to one-fifth of patients in treatment are female. Likewise, there is
a serious shortage of treatment for other drug dependence, especially for the
pregnant patient. A study by the U.S. General Accounting Office (1990)

found that approximately 280,000 pregnant women needed drug abuse treat-
ment in 1989, but less than 11% of this number received it.
Many women who are in need of care are single parents and unemployed
or underemployed, which makes them less likely to have adequate insurance
coverage. Furthermore, the lack of available child care often prevents them
from entering inpatient or residential programs. Although a few programs ad-
mit both mothers and children, such facilities are rare.
An additional barrier to treatment is the fear of losing child custody.
Women who must rely on a public agency for child care in order to enter
treatment are often reluctant to do so because of the risk of being found guilty
of neglect (Blume 1997). Pregnant patients also fear criminal prosecution for
prenatal child abuse or for the delivery of controlled substances to a minor
(via the umbilical cord). Publicized cases of prosecution and incarceration of
pregnant or newly delivered women have further eroded the fragile trust of
chemically dependent women in the health care system and will lead to more
births to mothers lacking prenatal care. In some jurisdictions, the removal of
newborn infants from their mothers solely on the basis of a positive drug test,
without any effort at assessment, diagnosis, intervention, or treatment, has
created a reluctance among both professionals and patients to make use of
this important diagnostic tool. The ensuing policy debate has led to proposed
legislation in several states to protect the rights of women and encourage
chemical dependency treatment rather than prosecution (Blume 1997).
Educating Obstetrician/Gynecologists About

Psychoactive Substance Abuse
Programs aimed at the prevention of chemical dependency in women and

chemical-related birth defects in children have taken two related approaches:
public and professional education. Both aim at acquainting young people and
adults with the teratogenicity of alcohol and other drugs and with the concept
of chemical dependencies as treatable diseases. Both also depend on enhanc-
ing the health care professionals recognition of these diseases in women and
successful referral of these patients to treatment.
The evaluations of efforts at professional education have shown that
obstetrician/gynecologists will read and respond to a state-sponsored FAS in-
formation packet (Russell et al. 1983) or a community education program
(Little et al. 1983). To sustain appropriate screening and referral patterns in
obstetric practice, however, ongoing educational efforts are necessary (Wein-
er et al. 1983). Primary care workers and health educators must also be in-
volved, especially in high-risk populations such as Native Americans and
Alaska Natives, but preliminary evidence indicates that such prevention pro-
grams can be effective (May and Hymbaugh 1989).
Psychiatrists have an important role in these prevention activities. The
training of all obstetrician/gynecologists should include methods of identify-
ing, motivating, and referring women who have chemical dependencies. This
training can be provided by psychiatrists who have skills and experience in
this area. Other opportunities arise in consultation and continuing-education
programs for physicians and other health professionals. Psychiatrists can also
help improve the procedures for screening and intervention in obstetric/
gynecologic practice.
The goals of prevention through social change include education to re-
move the inaccurate social stigma attached to chemically dependent women.
At the same time, they stress the promotion of supportive networks that pre-
serve womens social protections from the expectation that they drink or take
drugs like men. Finally, they provide psychosocial support for women un-
dergoing stressful transitions, such as separation, divorce, and bereavement,
to help them cope with these changes without developing dependence on
chemicals of abuse. Psychiatrists can participate by helping to organize such
support systems and by acting as consultants to community-based prevention
programs. Finally, all concerned citizens can advocate enlightened public pol-
icies that offer appropriate and accessible help to women in need rather than
punitive and stigmatizing measures.
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21
Eating Disorders and Reproduction
The social and medical construction of the term eating disorders is in itself a
paradox. Although obesity affects approximately 30% of North American
adult women, resulting in greatly increased morbidity, mortality, health care
costs, and social stigma (Carek et al. 1997; Rosenbaum et al. 1997), eating
disorders has usually been restricted to anorexia nervosa, bulimia nervosa, and
variants of these disorders, which affect about 5% of young North American
women. In addition, the epidemic of malnutrition prevalent throughout the
world, including among poor North American families, has been largely
ignored by eating disorder interest groups other than as a point of reference
for the effects of starvation. One might well wonder how this construction of
eating disorders has evolved.
The study of eating disorders, involving (as it usually does) relatively at-
tractive middle-class teenagers and young women, appears to be of much
greater interest to the (largely male) experts than the study of predominantly
older, relatively less attractive, lower social class, high-risk obese and over-
weight middle-aged and older women. The problems of malnutrition receive
less attention in the developed world, probably because they are seen to have
socioeconomic causes and solutions and are thought to be geographically re-
mote. In fact, caloric restriction, overconsumption, and under supply are all
critically important issues in womens physical, psychologic, and sociocultur-
al health. This chapter narrowly focuses on the topics traditionally included
in eating disorders (caloric restriction) as they affect one specific aspect of
womens livesreproduction.
Social pressures for thinness in women escalated greatly during the twen-
441
tieth century as a result of remarkable shifts in attitudes concerning womens

attractiveness. After centuries of admiration for curvaceous women, thinness
became idealized. One paradoxic aspect of this quest for thinness is that, as
nutrition has improved, the average weight of women in industrialized soci-
eties has increased by five pounds (Polivy et al. 1986). These factors have led
to a greatly increased pressure to diet.
Various theories have been proposed to explain this emphasis on thin-
ness. One factor may be the tendency of modern society to idealize youthful-
ness (Shainess 1979). Prepubescent girls acting as fashion models promote the
belief that the ideal shape is that of a child. Excessive thinness eliminates the
curves suggestive of adulthood. Moreover, throughout history, upper-class
women have served as role models for fashion. In contradistinction to the
past, being overweight no longer denotes wealth. Rather, in todays industri-
alized society, it is lower-class women with inadequate diets and insufficient
exercise who are the most likely to be overweight (Polivy et al. 1986).
The devotion to thinness that began in the upper classes has now spread
throughout society. Preoccupation with weight may also reflect the new pres-
sures on women to compete with men; eliminating the feminine figure may
be an attempt to reinforce the move away from traditional female stereotypes
(Orbach 1978). Because dieting may be regarded as a sign of internal control,
slim women may be viewed as more disciplined and in control.
Pressures for thinness have resulted in a general increase in body con-
sciousness that is much more marked for women than for men. Surveys of
high school students indicate that girls usually want to weigh less than their
current weight (Jakobovits et al. 1977), whereas most boys want to gain
weight. National surveys of adults conclude that a womans self-esteem often
relates to her feeling pretty and slim (Berscheid et al. 1973). Surveys of
college-age women have found dieting and disordered eating to be wide-
spread (Herman and Polivy 1980).
One way that young women may control body weight is through exces-
sive exercising. The athletic triad of amenorrhea, osteopenia, and eating dis-
orders has received increasing attention in the past decade. Adolescents may
seek care for amenorrhea or other menstrual problems without disclosing an
eating disorder. Rome et al. (1996) found 18.9% of adolescents attending a
reproductive endocrinology clinic to have elevated Eating Attitudes Test
(EAT)-26 scores suggestive of an eating disorder.
Many women with eating disorders are secretive about them, and prob-
lems in diagnosis are compounded by the fact that some women with eating
disorders appear to be of normal weight by actuarial or population mean
Eating Disorders and Reproduction 443
standards. Careful examination of their longitudinal weight histories, howev-

er, may reveal premorbid obesity that led to highly restrictive dieting coupled
with bulimic behaviors. Relative starvation and nutritional chaos may thus
be obscured. Eating disorders result in a mortality rate of approximately 5%
and lead to significant morbidity secondary to weight loss, vomiting, electro-
lyte disturbances, gastrointestinal problems, osteoporosis, psychiatric se-
quelae, and reproductive complications (Garfinkel 1982). Although the
medical effects have been described for many years, the reproductive aspects
of eating disorders have been inadequately studied (Stewart and Robinson
1989).
It is known that many patients with eating disorders develop amenor-
rhea, and over the past decade more attention has been paid to infertility in
these women (Abraham et al. 1990; Allison et al. 1988; Stewart et al. 1990).
As more effective treatment of eating disorders and infertility evolves, more
women with eating disorders eventually become pregnant. Little is known
about the course of their pregnancies or the health of their infants. Many psy-
chologic conflicts that are common in patients with eating disorders, such as
body image, autonomy, sexuality, dependency, and relationships to parents,
are highlighted during normal pregnancy. It is therefore likely that pregnancy
is an especially stressful time for women with eating disorders (Jenkin and
Tiggemann 1997; Stewart et al. 1987). This chapter examines what is current-
ly known about the effects of eating disorders on menstruation, sexuality and
fertility, pregnancy, the fetus and newborn, and infant feeding. Several studies
have shown that the postpartum period and breastfeeding are also important
risk periods for eating disorders (Foster et al. 1996; Jenkin and Tiggemann
1997; Stein and Fairburn 1996).
Definition of Eating Disorders
Anorexia Nervosa
Anorexia nervosa is a psychiatric disorder characterized by refusal to maintain

body weight at or above a minimally normal weight for age and height (e.g.,
weight loss leading to maintenance of a body weight less than 85% of that ex-
pected or failure to achieve expected weight gain during a period of growth,
leading to body weight less than 85% of that expected); intense fear of gaining
weight or of becoming fat even though underweight; disturbance in the way
in which ones body weight or shape is experienced, undue influence of body
weight or shape on self-evaluation, or denial of the seriousness of the current

low body weight; and, in postmenarcheal females, amenorrhea (i.e., the ab-
sence of at least three consecutive menstrual cyclesa woman is considered
to have amenorrhea if her periods occur only following hormone administra-
tion) (American Psychiatric Association 1994). This self-imposed starvation
triggered by the relentless pursuit of thinness and fear of fatness occurs in se-
rious form in about 1% of adolescent and young adult women (Garfinkel and
Garner 1982).
Bulimia Nervosa
A related disorder, bulimia nervosa, has several key characteristics: 1) Recur-

rent episodes of binge eating occurthat is, eating, in a discrete period of time
(e.g., within any 2-hour period), an amount of food that is definitely larger
than most people would eat during a similar period of time and under similar
circumstances. These binges are usually accompanied by a sense of lack of
control over eating during the episode (e.g., a feeling that one cannot stop eat-
ing or control what or how much one is eating). 2) To prevent weight gain
from binge eating, recurrent inappropriate compensatory behaviors are em-
ployed, such as self-induced vomiting; misuse of laxatives, diuretics, enemas,
or other medications; fasting; or excessive exercise. 3) This binge/purge cycle
occurs, on average, at least twice a week for 3 months. 4) Self-evaluation is
unduly influenced by body shape and weight. 5) The disturbance does not
occur exclusively during episodes of anorexia nervosa (American Psychiatric
Association 1994). Bulimia nervosa may occur within the context of anorexia
nervosa or as a separate syndrome with little weight loss. Its prevalence in se-
rious form is 1.7% among adolescent and young women (Ben-Tovim 1988).
Eating Disorder Not Otherwise Specified
The eating disorder not otherwise specified (EDNOS) category is for disor-
ders of eating that do not meet criteria for a specific eating disorder: 1) For
females, all of the criteria for anorexia nervosa are met except that the indi-
vidual has regular menses. 2) All of the criteria for anorexia nervosa are met
except that, despite significant weight loss, the individuals current weight is
in the normal range. 3) All of the criteria for bulimia nervosa are met except
that the binge eating and inappropriate compensatory mechanisms occur at
a frequency of less than twice a week or for a duration of less than 3 months.
4) Inappropriate compensatory behaviors are used by an individual of nor-
mal body weight after eating small amounts of food (e.g., self-induced vom-
iting after the consumption of two cookies). 5) Large amounts of food are
repeatedly chewed and spit out but not swallowed. 6) Recurrent episodes of
binge eating occur without regular use of inappropriate compensatory behav-
iors (binge eating disorder) (American Psychiatric Association 1994). ED-
NOS occurs in an additional 5% of the female population (Button and
Whitehouse 1981; King 1986).
Effects on Menstruation
It has long been known that women with anorexia nervosa may suffer from
primary or secondary amenorrhea (Gull 1974). Indeed, one of the criteria for
the diagnosis of anorexia nervosa includes absence of periods for three cycles.
Pirke et al. (1985) have shown that 50% of patients with bulimia nervosa also
suffer from amenorrhea. It is therefore prudent for clinicians to inquire about
eating and dieting behaviors in women who report absent or irregular men-
strual cycles.
Starkey and Lee (1969) observed the menstruation cycles of 58 patients
with a previous diagnosis of anorexia nervosa and found that all patients had
established menstrual patterns prior to the onset of the disorder, but most be-
came amenorrheic concurrent with the onset of the eating disorder. Most re-
ported improved weight gain with treatment but, in the group who did not
gain weight, none experienced the return of menses. Nillius (1978) reported
that 34% of 287 amenorrheic women had amenorrhea caused by self-induced
weight loss. Fries (1974) found a high proportion of women with eating dis-
orders among 30 Scandinavian women with secondary amenorrhea caused
by self-induced weight loss.
Copeland and Herzog (1987) and Devlin et al. (1989) described endo-
crine findings associated with menstrual cycle abnormalities in women with
anorexia nervosa and bulimia nervosa. In general, these women tended to
have fewer secretory spikes of luteinizing hormone (LH) and a trend toward
lower mean 24-hour LH levels than did control subjects. Stimulation with go-
nadotropin-releasing hormone produced elevated LH responses in women
with bulimia nervosa and blunted LH responses in those with anorexia. Es-
tradiol levels were uniformly lower in women with anorexia nervosa, and
stimulation with estradiol revealed diminished LH augmentative responses
and a trend toward diminished follicle-stimulating hormone (FSH) aug-
mentative responses in patients with anorexia nervosa and bulimia nervosa
compared with control subjects. Pirke et al. (1985, 1988) have shown that ap-
proximately 50% of normal-weight women who have bulimia nervosa have
menstrual abnormalities with impaired follicle maturation caused by im-
paired gonadotropin secretion. These authors have also shown that in normal
young women of normal body weight who diet for 6 weeks (8001,000 kcal/
day), various changes in endocrine function develop and, in about 20% of
these women, menstrual cycle disruption occurs for 36 months after dieting.
Kreipe et al. (1989) have shown that women with EDNOS also frequent-
ly have menstrual dysfunction. Because this disorder occurs more frequently
than criteria-confirmed anorexia or bulimia nervosa, the full extent of the
contribution of eating disorders to the clinical symptom of disordered men-
struation is still unknown. However, it is likely to be substantial in developed
countries (see also Rome et al. 1996).
Effects on Sexuality and Fertility
Psychologic theory has postulated that eating disorders may be a defense

against sexuality in young women. Eating disorder patients show delays in
several aspects of psychosexual development including age at first kiss, mas-
turbation, genital fondling, and first intercourse (Schmidt et al. 1995). Mor-
gan et al. (1999) reported that unplanned pregnancies were the norm in
women with bulimia nervosa, especially resulting from mistaken beliefs
about fertility.
Of all couples having regular, unprotected intercourse in the childbearing
years, 15%18% are unable to conceive within 1 year (Menning 1980). It has
been assumed that among women with eating disorders, only those with an-
orexia nervosa accompanied by amenorrhea contributed to the overall rates
of infertility. Recent studies, however, have shown that unexplained infertility
may sometimes be due to an undisclosed eating disorder or severe weight
control. At the other end of the spectrum, obesity may also interfere with sex-
uality and fertility (Clark et al. 1998; Galletly et al. 1996).
Bates et al. (1982) found that 47 women with unexplained infertility or
menstrual dysfunction who were referred to a reproductive endocrinology
clinic had practiced weight control by caloric restriction to maintain a fashion-
able body habitus. When 36 of the women followed a dietary regimen de-
signed to increase their weight to predicted ideal body weight, 73% conceived
spontaneously and 90% with secondary amenorrhea resumed menstruation.
It is of interest that 97% of these infertile women and their husbands had
been previously evaluated for infertility with various diagnostic gynecologic
studies without any cause being discovered.

In infertility patients with amenorrhea, Nillius (1978) found that a num-
ber of costly and complicated gynecologic and endocrinologic investigations,
and sometimes hormonal induction of ovulation, were carried out without
the patients inadequate dietary intake ever coming to light. Allison et al.
(1988) found an increased prevalence of abnormal eating attitudes in a small
sample of infertility clinic patients. Stewart et al. (1990) reported a 17% prev-
alence of eating disorders in 66 consecutive patients attending a reproductive
biology unit for infertility investigations. The patients were prospectively
screened with the EAT-26 item (Garner et al. 1982), and women with positive
screening tests then underwent a standardized interview to confirm or refute
the diagnosis of an eating disorder. Of these women, 7.6% had anorexia ner-
vosa or bulimia nervosa and 9.1% had EDNOS. Among infertile women
with amenorrhea or oligomenorrhea, 58% had eating disorders. It is of inter-
est that none of these patients had previously disclosed her eating disorder to
the infertility specialist. The similarity of this finding to that of Rome et al.
(1996), who found a prevalence of 18.9% of elevated EAT-26 scores in ado-
lescents attending a reproductive endocrine clinic, is striking.
Abraham et al. (1990) raised the question of whether ovulation should
be induced in women suffering or recovering from an eating disorder in view
of their poorer prognosis in pregnancy. They found that 13 of 14 consecutive
women in whom ovulation had been induced met the criteria for an eating
disorder at some time in the past, with five women currently fulfilling these
criteria.
Several investigators have recommended that infertility specialists rou-
tinely ask questions about a womens eating and dieting behavior, history of
eating disorders, exercising habits, and past and present body weight before
proceeding with infertility investigations (Abraham et al. 1990; Stewart and
MacDonald 1987; Stewart et al. 1990). Patients usually fail to volunteer in-
formation about eating disorders to their gynecologists and may appear to be
of normal weight. An awareness of the frequency of eating disorders in infer-
tility patients, however, followed by careful clinical inquiry, should correctly
identify most cases. It has become more common for infertility clinics to pro-
vide psychologic support services for couples who are distressed by the diag-
nosis, investigation, and management of infertility problems (Stewart et al.
1992). Psychiatrists working with infertility patients can provide useful re-
sources in the early identification and treatment of concurrent eating disor-
ders or disordered eating that fails to meet full eating-disorder diagnostic
criteria.
Prevalence of Eating Disorders in Pregnancy

The best data on the prevalence of eating disorders in pregnancy derives
from a study of 530 pregnant women screened with the Eating Attitudes Test.
Test results indicated that 4.9% of the women scored above the recommended
threshold (Turton et al. 1999). Eating disorder symptomatology was associ-
ated with younger age, previous symptomatology, lower education, poorer
housing, lack of employment, and previous miscarriage.
Effects on Pregnancy
Hyperemesis Gravidarum
Hyperemesis gravidarum is intractable vomiting during pregnancy that requires
hospitalization and is accompanied by dehydration, electrolyte imbalance, ke-
tonuria, and weight loss. In a study of patients with hyperemesis gravidarum
who were referred for psychiatric consultation (Stewart and MacDonald
1987), it was found that several had had an eating disorder before conception
but had not revealed this initially. A comparison with women who had hype-
remesis gravidarum without a history of eating disorders found that those
with eating disorders responded less favorably to treatment and spent twice
as many days in the hospital during pregnancy. Approximately half of the hy-
peremesis patients with eating disorders had presented to an infertility clinic
for induction of ovulation. Lingam and McCluskey (1996) also draw atten-
tion to this issue. Although hyperemesis gravidarum may be caused by vari-
ous psychologic, social, physical, and physiologic problems, it is wise for
obstetricians and consulting psychiatrists to remember that an eating disorder
may also play an important role in some women. Further studies are required
to investigate the true prevalence of eating disorders in women with hypere-
mesis gravidarum.
Food aversions, cravings, and pica are common occurrences in pregnan-
cy. Their association, if any, to eating disorders is unknown. These phenom-
ena may accompany hyperemesis gravidarum but often present in the
absence of vomiting. Most food aversions and cravings are considered nor-
mal in pregnancy.
Low Maternal Weight Gain

Low maternal weight before pregnancy and poor weight gain during preg-
nancy correlate significantly with an increase in intrauterine growth retarda-
tion, low birth weight, congenital anomalies, and perinatal mortality (Abrams
and Laros 1986). Although many of the data were collected during famines
or in concentration camps, eating disorders are also a cause of low prepreg-
nancy weight and failure to gain weight in pregnancy because of inadequate
nutrition. Stewart et al. (1987) described 15 women who had previously suf-
fered from anorexia nervosa or bulimia nervosa and who later conceived a
total of 23 pregnancies. Compared with women whose eating disorders were
in remission, women who had an active eating disorder throughout pregnan-
cy gained less weight and had more pregnancy complications. Lacey and
Smith (1987) examined the impact of pregnancy in a report on eating behav-
ior in 20 patients who had untreated bulimia nervosa and who were of nor-
mal weight. They found that although the frequency of bulimic behavior
generally diminished as pregnancy advanced, symptoms tended to return in
the puerperium. In nearly half of the study sample, eating patterns were more
disturbed after delivery than before conception.
Careful nutritional, weight, and psychosocial histories should be ob-
tained in women who fail to gain weight adequately in pregnancy. Early psy-
chiatric referral is indicated in women with psychiatric diagnoses or eating
disorders.
Effects on the Fetus and Newborn
Several investigators (Brinch et al. 1988; Lacey and Smith 1987; Stewart et
al. 1987; Strimling 1984; Treasure and Russell 1988) have described fetal
problems associated with a maternal eating disorder. More recently, Blais et
al. (2000) reported elevated therapeutic abortion rates in women with eating
disorders. These difficulties may include intrauterine growth retardation, pre-
maturity, low birth weight, low Apgar scores, increased risk of congenital
anomalies, and higher perinatal mortality. Intrauterine growth retardation
from any cause may have considerable consequences including fetal antenatal
or intrapartum asphyxia, which may lead to fetal death or an increase in fetal
distress and damage (Van der Spuy 1985). Once delivered, these small infants
are at increased risk for hypothermia, hypoglycemia, and infection and have
increased perinatal mortality (Van der Spuy 1985). Stewart et al. (1987)
found that babies born to women with active eating disorders during their
pregnancies were smaller and had lower 5-minute Apgar scores than did ba-
bies of mothers whose eating disorders were in remission. Lacey and Smith
(1987) described higher incidences of fetal abnormalities, including cleft lip
and palate; multiple gestation; obstetric complications, including breech pre-

sentation; and surgical intervention in 20 untreated bulimic women of nor-
mal weight. Brinch et al. (1988) followed-up with 50 women with histories of
eating disorders and found double the rate of premature births in their off-
spring and six times the expected rate of perinatal mortality. Treasure and
Russell (1988) described the outcome of seven pregnancies in women with
anorexia nervosa who conceived despite low weight. The abdominal circum-
ference of all seven babies was well below the third percentile at birth. Conti
et al. (1998) found that women with disordered eating were at greater risk of
delivering a small-for-gestational-age term infant. Bulik et al. (1999) found
that women with anorexia nervosa had more miscarriages and cesarean sec-
tions, premature births, and low birth weight infants. These studies all suffer
from small sample sizes, and further work is required to replicate their find-
ings and assess effective interventions in large, controlled studies.
Effects in the Postpartum Period
Investigators have described a postpartum exacerbation of clinical eating dis-

orders (Lacey and Smith 1987; Stewart et al. 1987). Eating disorder symp-
toms may also increase markedly in the 3 months postpartum and then
plateau over the next 6 months. Weight concerns and concern about residual
weight after the birth of the child were found by Stein and Fairburn (1996) to
be particularly distressing to many women and served to precipitate a clinical
eating disorder in a few cases. Moreover, women with eating disorders have
been shown to be at risk of depression and anxiety in the postpartum period
(Stewart et al. 1987). Morgan et al. (1999) reported postnatal depression in
one-third of women with bulimia nervosa. They also found that although bu-
limic symptoms improved during pregnancy, 57% of women had worse
symptoms after delivery but 34% were no longer bulimic. Blais et al. (2000)
found that women with bulimia nervosa showed a decrease in eating disorder
severity during pregnancy and postpartum, whereas women with anorexia
nervosa returned to prepregnancy levels by 6 months postpartum.
Effects on the Infant and Feeding
In general, low birth weight infants who survive the early weeks of life are at
risk for long-term developmental consequences with continued delays in
physical and neurologic development and impaired intellectual ability, partic-

ularly when associated with low intrauterine growth before 26 weeks of ges-
tation (Van der Spuy 1985). No work has yet been reported on the long-term
follow-up of low birth weight infants born to mothers with eating disorders.
It is hoped that, in view of the prevalence of eating disorders in young wom-
en, this work will soon be undertaken.
An additional problem in some mothers with eating disorders results
from the worry that their infants will become obese, a concern that leads to
early nutritional deprivation or caloric restriction. Lacey and Smith (1987)
found that 15% of bulimic mothers reported restricting calories in their child
before 1 year of age. Stewart et al. (1987) found a decreased rate of breast-
feeding in women with active eating disorders and more difficulties with post-
partum adjustment. Brinch et al. (1988) reported a 17% rate of failure to
thrive in the first year of life in the infants of mothers with eating disorders.
Stein et al. (1996) found that although the infants were smaller (length and
weight for age), little evidence showed that these mothers preferred smaller
children, were dissatisfied with their childs shape, or misperceived the childs
size. They concluded that the growth disturbance did not appear to be a di-
rect extension of the maternal psychopathology to the infant. Treasure and
Russell (1988) reported that the children of four patients attending their eat-
ing disorders clinic had been investigated for poor growth attributed to inad-
equate feeding. They also reported that five of six mothers with anorexia
nervosa had difficulty in breastfeeding and introduced bottle-feeds in the first
few months of life. Foster et al. (1996) reported that body shape dissatisfac-
tion and low maternal fetal attachment may account for why some women
chose to bottle feed. Stein and Fairburn (1989), Fahy and Treasure (1989),
and Van Wezel-Meijler and Wit (1989) also found poor nutrition, concerns
about the motherchild relationship, and developmental concerns while as-
sessing the infants of eating disordered women. McCann et al. (1994) found
the eating habits and attitudes toward body shape and weight in 26 mothers
of children with nonorganic failure to thrive had higher levels of dieting re-
straint than in 26 matched mothers of normal weight infants. Despite their
childrens low weight, 50% of index mothers restricted sweet foods and
30% restricted fattening or unhealthy foods. Stein et al. (1995) also found
abnormal eating habits and attitudes in mothers of children with feeding dis-
orders, and Waugh and Bulik (1999) found that mothers with eating disorder
had more difficulty with breastfeeding and made fewer positive comments
about food and eating than did other mothers of toddlers.
Pediatricians (Pugliese et al. 1987) have also reported failure to thrive in
infants whose parents had been restricting calories in their children because
of fears that they might become overweight, although it is not clear that these
parents actually had eating disorders themselves (as opposed to overconcern
about obesity). Further investigations are required to establish the role of ma-
ternal eating disorders in nutritionally deprived children in wealthy devel-
oped countries.
Conclusions
Currently available information suggests that a history of eating disorders or

weight-reducing behavior should be part of the routine assessment of patients
with amenorrhea, oligomenorrhea, and infertility as well as in prenatal pa-
tients with hyperemesis gravidarum, those who fail to gain weight adequately
in pregnancy, and those who have babies who are small for gestational date.
Women in whom eating disorders are discovered before conception should
be counseled to delay pregnancy until the eating disorder is adequately treat-
ed and truly in remission. If the woman has already conceived, the earliest
possible diagnosis of an eating disorder should be made so that proper psy-
chiatric treatment, dietary advice, and weight monitoring can be implement-
ed to reduce the risk of maternal and fetal complications. Follow-up after
delivery should be vigilant for postpartum exacerbations of eating disorders
and depression. Infants of mothers with eating disorders should also be care-
fully observed for failure to thrive so that early corrective measures can be
implemented. Similarly, the parents of infants who fail to thrive should be as-
sessed for eating disorders, overconcern about obesity, or abnormal eating
behaviors. Franko and Spurrell (2000) recommended a team approach that
emphasizes communication and clear goal setting for pregnant women with
eating disorder. Study of the reproductive effects of eating disorders offers
many rich opportunities for psychiatrists to collaborate with obstetricians and
gynecologists, nutritionists, nurses, and perinatologists in primary and sec-
ondary prevention programs directed toward mother and infant.
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22
Breast Disorders and Breast Cancer
BARBARA L. ANDERSEN, PH.D.
WILLIAM B. FARRAR, M.D.
Introduction
Although the diagnosis of cancer is a devastating experience, most women

cope successfully. In fact, many report renewed vigor in their approach to life,
stronger interpersonal relationships, and a survivor adaptation. These out-
comes do not, however, describe the process of adjustment, which may in-
clude feelings of an emotional crisis at diagnosis, fears of cancer treatment
and changes it may bring, and a dread of life changes or adjustments. For de-
cades the understanding of the psychologic processes and outcomes was
largely clinical, consisting of detailed case studies of patients and clinical de-
scriptions of difficult treatment experiences (e.g., Sutherland et al. 1952). The
message from these reports was that the psychologic trajectory for women
treated for breast cancer was guarded at best.
More recently, controlled research on the behavioral and psychologic as-
pects of cancer has described the specific difficulties that cancer patients may
face, the proposed etiologic mechanisms for these processes, and the tested
psychologic interventions to enhance coping (see Andersen 1992 for a re-
view). In much of this research women with breast cancer have been the
study participants, although those with disease at other sites have received
study as well (e.g., Fawzy et al. 1990).
This chapter provides a scholarly overview of the psychologic processes
This research was supported by grant No. DAMD17-96-1-6294 from the United States
Army Medical Research and Development Command and grant No. 1 RO1 MH51487
from the National Institute of Mental Health (NIMH).
457
of adjustment to breast cancer from symptom appearance to cure or death.

We also include discussion of the biobehavioral factors that may influence the
course of the disease and brief discussions of intervention strategies for the
consulting psychiatrist. In preface we briefly review benign breast disorders
because many produce symptoms or signs closely resembling those of breast
cancer.
Benign Breast Disorders
Benign breast disorders are common. Fibrocystic disease, the most frequent
condition, is clinically apparent in about 50% of women. This disease is char-
acterized by hyperplastic changes that may involve any or all of the breast tis-
sues. Changes may be hormonally mediated and caused by a relative or
absolute decline in progesterone or, by contrast, an increase in estrogen.
When hyperplastic changes are also accompanied by cellular atypia, the risk
for malignancy is increased. The clinical picture is usually one of multiple bi-
lateral lesions that may become painful and/or tender, particularly premen-
strually. The disease is often diagnosed and problematic during the young
adult years, with the end of symptoms after menopause (unless, of course, ex-
ogenous estrogens are taken). Treatment decisions are moderated by the age
of the woman, symptom severity, and the relative risk for breast malignancy.
Particularly troublesome cysts are aspirated to relieve pain (and to determine
the absence of malignancy), but in severe circumstances subcutaneous mas-
tectomies may be considered.
Several other types of benign breast growths may be found. Fibroade-
noma is the most common benign tumor. Clinically, these neoplasms are cir-
cumscribed, solitary, and freely movable; they are found most commonly in
women younger than 30 years. These tumors require pathologic evaluation
for definitive diagnosis. Other benign growths include intraductal papilloma,
mammary duct ectasia, and galactocele. In diagnosing these conditions,
mammography or cytologic examination of the fluids is required.
Breast Cancer
Epidemiology, Clinical Features, and Disease Description
Breast cancer accounts for 30% of all cancers and 17% of all cancer deaths in
women (Parker et al. 1997). Incidence rates are lower for black and Asian fe-
Breast Disorders and Breast Cancer 459
males than for white, Hispanic, and Native American females. Relative sur-
vival rates have fluctuated over the years but have remained basically
unchanged. Despite the lower incidence of disease, survival rates have re-
mained consistently lower for black women. Similarly, fewer black women
are initially diagnosed with localized disease (48%) than are white women
(60%) (Parker et al. 1997).
Several variables have been identified as correlates (risk factors) of breast
cancer. The demographic factors of age (age increases risk), race (as discussed
above), ethnicity (Jewish women, particularly Askenazi Jews, have higher
rates than non-Jewish women), and socioeconomic status (women in the
highest group have a risk almost twice as great as those in the lowest group)
have been noted. Reproductive variables are important; nulligravida women
and women who have their first child after the age of 30 have almost a three-
fold increase in risk compared with those giving birth the first time at age 20
or younger. Much of the above findings of increased risk among women with
nulliparity, late first birth, and other factors, such those associated with late
menopause, have led to varying hormonal hypotheses. Finally, the role of diet
in breast cancer is controversial, although it has led to recommendations such
as reducing fat intake.
One important factor for breast cancer may be familial or genetic risk.
Women who have had a mother or sister diagnosed with breast cancer are at
almost three times the risk. Not all women with such profiles, however, actu-
ally have either of the BRCA1 or BRCA2 gene mutations that have been
identified for breast cancer. In fact, the latter mutations account for no more
than 5%10% of all breast cancers in the United States. Since the identifi-
cation of the genes, researchers have struggled to catch up with the many
psychologic issues that surround the choice to pursue genetic testing and sub-
sequent cancer-prevention follow-up measures that a woman may elect (e.g.,
watchful waiting, prophylactic mastectomy). Early psychosocial research sug-
gests that women who are eligible for but decline genetic testing may be those
who are, indeed, experiencing the greatest psychologic distress surrounding
these issues. Perhaps even more importantly, even those women tested and
found to be carriers of the gene mutations show low rates of mammogram
adherenceonly 24% of carriers versus 21% of testing decliners report having
followed through with a mammogram at regularly scheduled 6-month inter-
vals (Nelson 1998). Thus, although women who receive adequate genetic
counseling and testing may not experience the negative emotional sequelae
feared, this information may not lead to reductions in cancer morbidity and
mortality.
Despite the emphasis on mammography as a screening device, carcino-

ma of the breast is usually first discovered as a lump (usually in the upper out-
er quadrant) by the woman or her physician. Usually, it is painless and freely
mobile, but with progressive growth the tumor may become fixed to the chest
wall. A less common sign is a serous or bloody nipple discharge. Extension
to the skin may cause retraction and dimpling, whereas ductal involvement
may cause nipple retraction. Blockage of skin lymphatics may cause lymphe-
dema and thickening of the skin, a change referred to as peu dorange. Inflam-
matory signs may also appear, such as warmth and redness of the overlying
skin and swelling of the surrounding breast tissues.
Definitive diagnosis requires either tissue cytology (open breast biopsy)
or a fluid biopsy (fine needle aspiration). Malignant tumor types vary greatly.
Approximately 90% of cases arise in the ducts, and the remainder originate
in the lobules. About 70% of all breast cancers are infiltrating duct carcino-
mas. Less common types include medullary, invasive lobular, mucinous, tu-
bular, and papillary; in many tumors, several patterns exist.
Breast cancer spreads by local infiltration, moving directly into the sur-
rounding breast tissue and eventually involving the overlying skin or the un-
derlying muscle. When it occurs, lymphatic spread is mainly to the axillary
nodes, with 40%50% of patients having progressed to nodal involvement at
diagnosis. Nodal status (both axillary and internal mammary) and tumor size
are among the most important prognostic factors (Donegan 1997). In the Na-
tional Surgical Adjuvant Breast Project studies (a federally funded cancer clin-
ical trial cooperative group), women with negative lymph nodes had an
actuarial 5-year survival rate of 83% compared with 73% for patients with
one to three positive nodes, 45% for those with four or more positive nodes,
and 28% for those with more than 13 positive nodes (Fisher et al. 1983).
In 1894 radical mastectomy was described by Halsted and Meyer. This
procedure consisted of an en bloc dissection of the entire breast, the pectoralis
major and minor muscles, and the axilla. By 1970, however, controversy sur-
rounding surgical management was apparent and a prospective randomized
clinical trial was begun by the National Surgical Adjuvant Breast Project.
More than 1,700 women with clinically negative axillary nodes were enrolled
and received radical mastectomy, total (simple) mastectomy followed by
local-regional radiation, or total mastectomy alone. Results indicated that in
node-negative as well as surgically determined node-positive women, no dif-
ferences occurred between groups in survival times, indicating that the less
radical surgery could provide superior functional and cosmetic results with-
out compromising mortality. Also, breast reconstruction performed at mas-
tectomy or later was possible. Most women treated with lumpectomy are
those with small primary tumors (less than 2 cm in diameter); whether such
women then go on to receive adjuvant radiation therapy is usually deter-
mined by the presence, if any, of nodal disease. Radiation therapy for women
with positive axillary nodes significantly reduces local-regional relapse (e.g.,
surgical site, chest wall), but its effect on survival remains controversial.
Because breast cancer is often a systemic disease, adjuvant chemotherapy
or hormonal therapy is standard. In fact, data now suggest that chemotherapy
will benefit nearly all early stage breast cancer patients (McNeil 1997), includ-
ing the previously untreated node-negative and/or postmenopausal estrogen
receptorpositive women who received tomoxifan alone. The four most com-
monly used chemotherapy agents are cyclophosphamide, methotrexate, 5-
fluorouracil, and adriamycin; newer studies also include paclitaxel (Taxol).
Used alone, each of these agents can induce responses in 25%45% of pa-
tients; when combined (typically as either cyclophosphamidemethotrexate
5-fluorouracil or as cyclophosphamideadriamycin5-fluorouracil), they are
even more effective. Hormonal therapy with tomoxifen is often given for up-
wards of 5 years after diagnosis. Response is correlated with the incidence of
estrogen and progesterone receptors. For example, the response rate to
progesterone treatment in estrogen receptorpositive tumors is 50%60%,
whereas it is less than 10% in estrogen receptornegative tumors.
For women with metastatic disease, symptoms may be palliated with
combination chemotherapy. Partial responses are obtained in 50%75% of
patients, but complete clinical responses are seen infrequently (5%10%),
with the mean survival time following recurrence diagnosis being 18 months.
Because of these discouraging data and the similarly difficult prognosis for
those initially diagnosed with multiple positive nodes (e.g., more than 8),
bone marrow transplant with autologous stem cell rescue is being considered
as an option. However, the differential effectiveness of this procedure is as yet
unknown (Zujewski et al. 1998).
Detection
Development of malignancy and appearance of symptoms can be protracted.
The psychologic and behavioral aspects of illness representation (Leventhal
et al. 1980) and symptom interpretation (Andersen et al. 1995) have been of-
fered as theoretic frameworks for understanding illness interpretations and
patient delay. Studies indicate that the lions share of cancer delay (i.e., from
symptom/sign awareness to seeking a physician consultation) is accounted for
by the time necessary for the patient to decide the symptoms indicate illness
rather than a normal and/or nonserious health condition (e.g., a breast lump
is thought to be a cyst or fibrocystic disease rather than a cancerous lump)
(Andersen et al. 1995). This delay in accepting symptoms as serious also oc-
curs among physicians who postpone cancer-diagnostic testing (e.g., Howson
1950; Mommsen et al. 1983).
Diagnosis
Diagnosis of cancer, whether initial or recurrence, is the period of greatest
acute stress for the patient. This crisis is defined by sadness (depression), fear
(anxiety), confusion, and occasionally anger (Andersen et al. 1989b). The
cognitive coping responses prompted by diagnosis include positive/confront-
ing strategies, fatalistic responses, hopelessness/helplessness, and denial/
avoidance (Burgess et al. 1988).
To examine the emotional responses at diagnosis, we assessed the moods
of 65 women with cancer (clinical stage I or II gynecologic cancer) within 5
10 days of learning their diagnosis and prior to treatment (Andersen et al.
1989b). Their responses on a self-report mood questionnaire (Profile of
Mood States [POMS]; McNair et al. 1971) were compared with those of
women from two age-matched comparison groups, a group of women with
recently diagnosed benign gynecologic disease and gynecologically healthy
women receiving routine examinations. The cancer patients were followed-
up for approximately 4 years. During that time a subset of the women experi-
enced cancer recurrence, and moods were reassessed at this second diagnosis.
Depression was significantly elevated for the cancer patients only at the
time of the initial diagnosis; a further, significant increment in distress oc-
curred at cancer recurrence. Anxiety was a common affective experience for
women who were anticipating medical treatment, whether for benign or ma-
lignant disease, but no further elevations were found at recurrence. This pat-
tern suggests that the anxiety may be prompted, in part, by treatment-related
fears. Anger was present to a significant degree for the cancer patients only
at the time of recurrence, but levels at the initial diagnosis were not elevated.
These data indicate that initial diagnosis is characterized by significant de-
pressed affect, whereas recurrence may be characterized by anger and more
significant depressed affect. Anxiety is also present during both diagnostic
periods.
Depression
Depression is the most prevalent affective problem for cancer patients (Dero-
gatis et al. 1983; Lansky et al. 1985). When major depression and adjustment
disorder with depressed mood are considered, prevalence rates are on the or-
der of 15% (Derogatis et al. 1983). In general, higher rates of depression are
found for patients in active treatment than for those who are in follow-up,
who are receiving palliative rather than curative treatment, who have pain or
other disturbing symptoms, and who have a history of affective disorder.
Among individuals who do not have these characteristics, the base rate of ma-
jor depression is likely to be on the order of 6%, comparable with that of the
general population.
It can be difficult to make a diagnosis of depression in cancer patients, as
it is for patients with other serious illnesses, although we note some salient
considerations. Vegetative symptomsthat is, poor appetite or actual weight
loss, sleep disturbance (e.g., insomnia, hypersomnia), loss of energy or fa-
tigue, and loss of sexual desire or interestmust be determined to be represen-
tative of depression, disease-related events, or some combination of factors.
Depression for most cancer patients is reactiveit occurs soon after the
diagnosis, and the content of the depressive ruminations reflect the diagnostic
event (Noyes and Kathol 1986). When depressive symptoms are present at
the time of diagnosis, they tend to be intermittent and rarely persist once
treatment has begun or is concluded. Emotional rebound following treat-
ment appears to occur, particularly for anxiety-related symptoms (vant Spijk-
er et al. 1997). Finally, because cancer is a realistic health stressor, patients and
physicians alike regard a depressive reaction to the diagnosis as normal. As
such, patients may not feel comfortable (or able) to complain about their feel-
ings, even when the feelings are extreme. Similarly, physicians or nurses may
not recognize severe depressive reactions because of their infrequent occur-
rence and because of the normality of less severe reactions. These circum-
stances lead to the underrecognition and undertreatment of major depression
among cancer patients (Derogatis et al. 1979). However, the effect of depres-
sive symptoms and medical conditions on adjustment and well-being is addi-
tive; individuals experiencing depression in the context of cancer report twice
the reduction in social functioning than would, for example, be associated
with either condition alone (Wells et al. 1989).
When depression does occur, some symptoms are more or less charac-
teristic for the patient. In addition to dysphoric mood, other common symp-
toms may include loss of interest or pleasure, loss of energy or fatigue, and
difficulty thinking or concentrating (e.g., feeling confused or bewildered).
Other common feelings include intermittent anxiety, helplessness, and con-
cern about the future (Lansky et al. 1985). Endicott (1984) suggested other
possible but less common reactions, including fearful or depressed appear-
ance, social withdrawal or decreased talkativeness, brooding or pessimism,

and mood that is not reactive (i.e., the patient cannot be cheered up, does not
smile, and/or does not react to good news). Reactions such as these can be
considered as symptoms or signs of major depression in medical patients. In
contrast, psychologic characteristics of depressed psychiatric patients that are
uncommon for cancer patients include feelings of low self-esteem and guilt; it
is also rare for cancer patients to be melancholic, psychotic, or suicidal (Buk-
berg et al. 1984; Saunders and Valente 1988).
Anxiety Disorders
Anxiety disorder is the psychiatric problem second in frequency among can-
cer patients. Derogatis et al. (1979) estimated the prevalence to be 7% among
cancer outpatients undergoing treatment. In a study of 44 breast cancer pa-
tients interviewed at diagnosis, Hughes (1981) estimated that 25% had severe
anxiety reactions. Anxiety-related problems are typically manifest by symp-
toms of generalized anxiety: the classic fear, worry, and rumination. Other
symptoms include motor tension (e.g., shaky feeling, muscle tension, restless,
and easy fatigability), autonomic hyperactivity (e.g., abdominal distress, fre-
quent urination), and/or indications of vigilance and scanning (e.g., difficulty
concentrating, trouble falling or staying asleep, feeling on edge). Much of the
anxiety-provoking thought content is focused on medical examinations and
cancer treatments (e.g., fear of pain or disfigurement) and the short- and long-
term disruption they may produce. Other targets include the life disruption
and change that may occur because of the cancer; the most common spheres
of worry include family, money, work, and illness (e.g., who will care for the
children when I am in the hospital? What if our insurance does not cover the
bills? Will I be able to go back to work? Will my life ever be the same?).
The suggestion that responses to life-threatening diseases such as cancer
could meet the criteria for posttraumatic stress disorder (PTSD) is an inter-
esting development in the study of the anxiety-related problems of cancer pa-
tients (American Psychiatric Association 1994). Early studies have suggested
that although anxiety responses of this magnitude may indeed occur, they are
not prevalent. Alter et al. (1996) assessed 27 women at least 3 years after their
cancer diagnosis and reported that 4% of the women had current PTSD
symptoms whereas 22% met criteria for lifetime cancer-related PTSD. Cor-
dova et al. (1995) assessed 55 women and reported a 5%10% rate of symp-
toms. Current data suggest that the incidence of these responses may be
directly related to the rigor of cancer therapy and/or the occurrence of signif-
icant morbidities.
Anger
Anger has occupied a special role in theorizing. It has been hypothesized that
anger is relevant to the etiology and/or progression of cancer (e.g., Morris et
al. 1981), but empirical evidence is weak. As discussed previously, we have
not found any evidence of elevated anger at initial diagnosis; however, higher
levels may be reported at cancer recurrence. The foci for the anger at recur-
rence include frustration with the failure of presumably curative treatments.
Biobehavioral Responses
Various data indicate that adults undergoing chronic stressors experience
high rates of adjustment difficulties and important biologic effects, including
effects on the immune system. For individuals with cancerparticularly wom-
en with breast cancerthe immune system may be relevant to host resistance
against progression and metastatic spread. Andersen et al. (1998) examined
the relationship between stress and several aspects of the cellular immune re-
sponse in the context breast cancer diagnosis and the postsurgery period.
Women (n = 116) newly diagnosed and surgically treated for stage II (70%)
or III (30%) invasive breast cancer participated in the study. Before beginning
adjuvant therapy, all patients completed a validated questionnaire assessing
stress about the cancer experience and provided a blood sample for a panel
of natural killer cell and T-cell assays. The researchers hypothesized a nega-
tive relationship between stress and immunity. All data analyses controlled
for variables that might also be expected to exert short- or long-term effects
on these responses, such as age, stage of disease, and length of time of surgical
recovery, and ruled out other potentially confounding variables (e.g., nutri-
tional status). Significant effects were found and replicated between and with-
in assays, including the finding that stress significantly (P < 0.05) predicted
natural killer cell lysis, a measure of the capacity of the womens immune
systems to find and kill target (cancer) cells. Data showed that the physiologic
effects of stress inhibited a panel of cellular immune responses, including
cancer-relevant natural killer cell cytotoxicity and T-cell responses. Further
studies will need to determine whether health consequences emerge for indi-
viduals who report high levels of stress with the diagnosis and surgical treat-
ment of their tumors and will also need to clarify the biobehavioral
mechanisms proposed for such adverse effects (Andersen et al. 1994).
Treatment
Anticipation of difficult treatment is a component of the emotional distress oc-
curring at diagnosis. Current therapies include surgery, radiotherapy, chemo-
therapy, hormonal therapy, and, for some, bone marrow transplant. These
treatments are significant stressors, and supporting data consistently portray
more distress (particularly fear and anxiety), slower rates of emotional recov-
ery, and perhaps additional behavioral difficulties (e.g., conditioned anxiety
reactions) among patients receiving these therapies compared with reactions
in relatively healthy women undergoing medical treatment for benign con-
ditions.
Few investigations of the psychologic reactions to cancer surgery have
been performed. For breast cancer patients, part of the fear surrounding sur-
gery is responding to the loss of all or part of the breast. In addition, women
are fearful of surgery in general. Studies indicate that postoperative anxiety
is predictive of recoverypatients with lower levels of postoperative anxiety
recover more quickly (e.g., get out of bed, complain less) than do those with
higher levels of anxiety. What may distinguish cancer surgery patients,
however, are higher overall levels of distress and slower emotional rebound.
Gottesman and Lewis (1982), for example, found greater and more lasting
feelings of crisis and helplessness among cancer patients in comparison with
benign surgery patients for as long as 2 months following discharge.
Considering the latter data, findings on the interaction patterns of physi-
cians and cancer patients on morning surgical rounds is disturbing. Blan-
chard et al. (1987) found attending physicians on a cancer unit to be less likely
to engage in supportive behaviors and to address patients needs than were
physicians treating general medical patients. The heavier volume and more
seriously ill patients common to cancer units may account for this unfortu-
nate finding. Oncology nurses may find their job significantly more stressful
than other assignments (e.g., cardiac, intensive care, or operating room nurs-
ing) (Stewart et al. 1982). Taken together, these data suggest that the interac-
tions between oncologists, oncology nurses, and cancer inpatients may
influence adjustment more than is commonly acknowledged.
For empirical understanding of radiation fears, the surgical anxiety stud-
ies described above have been used as a paradigm. Here, again, high levels of
anticipatory anxiety are found, and if interventions to reduce distress are not
conducted (Rainey 1985), heightened posttreatment anxiety is also found
(Andersen and Tewfik 1985; Andersen et al. 1984) and may be maintained
for as long as 3 months after therapy (King et al. 1985). However, when acute
treatment side effects (e.g., fatigue, skin reactions) resolve, no higher inci-
dence of emotional difficulties is found for radiotherapy patients than for sur-
gery patients (Hughson et al. 1987).
Of all cancer treatments, the behavioral and psychologic aspects are best
understood for chemotherapy, particularly its side effects of nausea and vom-
iting. A classical conditioning conceptualization has been offered to explain
anticipatory nausea and vomitingthat is, following at least one cycle of che-
motherapy, patients may report nausea and/or vomiting prior to chemother-
apy administration (usually on the first day) of the second or subsequent
cycles. Treatments such as the use of hypnosis, progressive muscle relaxation
with guided imagery, systematic desensitization, attentional diversion or redi-
rection, and biofeedback can be helpful to patients (see Carey and Burish
1987 for a review). Research has also targeted individual differences among
patients (e.g., high pretreatment anxiety or general distress, severity of post-
treatment vomiting in the early cycles, age) and situational issues (e.g., more
emetogenic regimens, higher dosages or greater amounts of chemotherapy)
that increase risk of anticipatory reactions.
Immediate Posttreatment Recovery
Despite the difficulties of cancer treatment, the crisis levels of emotional dis-
tress that occur at diagnosis lessen during treatment initiation, continuance,
and early recovery (i.e., 212 months posttreatment) (Andersen et al. 1989b;
Bloom 1987; Devlen et al. 1987). Bloom (1987) reported on the controlled
prospective longitudinal study of women with stage I or II breast cancer treat-
ed with modified radical mastectomy. Comparisons were made with women
receiving biopsy for benign disease, women receiving cholecystectomy for
gall bladder disease, and healthy women. All women were seen within 3
months of surgery and again at 6, 9, and 12 months after treatment. Women
with breast cancer showed greater psychologic distress related to social and
interpersonal relationships. In addition, more distress was seen in women
with stage II disease; these women also had more negative attitudes toward
self and the future, more concern with physical symptoms, more anxiety,
more strain, and more interpersonal difficulties. They did not, however, show
any greater evidence of psychopathology warranting psychiatric intervention
during the first posttreatment year.
Similar patterns of positive long-term adjustment have been found in oth-
er longitudinal studies of cancer patients (Andersen et al. 1989b; Devlen et
al. 1987). Investigators have pursued these findings by testing mediators for
adjustment and individual differences that might be related to outcomes. For
example, women who approach the breast cancer experience with optimism
rather than pessimism tend to fare better, coping with the experience with ac-
ceptance rather than denial or surrender (Carver et al. 1993).
Several investigations have been made into the psychologic counseling

provided to breast cancer patients during the early recovery months. Inter-
ventions are typically provided as either individual or group therapy. Studies
have varied in their methodologic sophistication; however, they have gener-
ally demonstrated more positive outcomes for women receiving intervention
when compared with women not receiving intervention. For example,
P. Maguire et al. (1983) provided individual counseling by a nurse specialist
to women immediately following mastectomy. The 152 women who partici-
pated were assigned to either intervention or control conditions and followed-
up for 1218 months. Women receiving the intervention reported greater so-
cial recovery, were more likely to return to work, and had better adaptation
to breast loss and use of a prothesis than did women in the comparison group.
The beneficial effects of another multimodal intervention were reported
by Gordon et al. (1980). Three intervention components were included: ed-
ucation (providing information about cancer, its treatment, and its emotional
effects); counseling (to provide support and clarification of feelings); and en-
vironmental efforts (e.g., advocacy for patients in the health care system).
Outcome assessment continued for 6 months after treatment. Intervention
patients reported a more rapid diminution of negative affect, such as anxiety
and depression, a greater likelihood of returning to their previous vocation,
and a more active resumption of activities.
Social support and participation in support groups are components of an-
other intervention format. Social support may consist of emotional concern,
physical aid, or information provision and may commonly be provided by
friends and family. Various data indicate that social support can reduce psy-
chologic distress and perhaps improve health outcomes. Perhaps the most
well-known peer social support intervention is the American Cancer Societys
Reach to Recovery patient visitation program for women with breast cancer.
The effects of such a visitation program in the Netherlands was reported by
van den Borne et al. (1987). In their study, regular contact between patients
appeared to decrease negative affect and feelings of uncertainty and to in-
crease self-esteem.
Telch and Telch (1986) compared supportive group therapy with a cop-
ing skills intervention offered to male and female cancer patients. Participants
were randomly assigned to either of the interventions or a no-treatment con-
trol group. Analyses revealed a consistent superiority to the coping interven-
tion, which provided relaxation and stress management; communication,
assertion, and problem-solving skills; emotional management; and activity
planning. Final assessment at 6 weeks after treatment indicated that patients
receiving the coping intervention reported improvement across all outcome

variables, including mood, self-efficacy, the number of problems experienced,
and activity management.
Long-Term Recovery and Survival
The long-term picture for those treated for breast cancer is clouded by the un-
predictable course of this disease; even those with years of asymptomatic dis-
ease can recur with distant metastases and rapidly decline. Thus for the
cured cancer patient (i.e., typically referring to individuals surviving at least
5 years), two broad classes of stressors have been suggested (Cella and Tross
1986). The first includes residual sequelae, including lingering emotional dis-
tress from the cancer experience and life threat. This might be manifest when
patients dread follow-up physical examinations or ruminate about disease re-
currence. The second class of stressors includes continuing sequelae, such as
coping with the changes to ones premorbid life and making adjustments that
require new behaviors or emotions.
The earliest writings (from the 1950s to the 1980s) suggested that the
psychologic trajectory of cancer patients was troubled with somatic problems,
psychologic distress (Bard and Sutherland 1952; G. P. Maguire et al. 1978),
impaired relationships (Dyk and Sutherland 1956; Wortman and Dunkel-
Schetter 1979), preoccupation with death (Gullo et al. 1974), and/or general
life disruption such as reduced employment or career opportunities (Schon-
field 1972). Many of these pioneering reports (of primarily breast cancer pa-
tients) were clinical in focus and generally uncontrolled on disease variables
now recognized as moderators of adjustment. By the end of this same period,
cancer had become more public, more survivable, and clinical trials were able
to examine treatment toxicity following the establishment of effectiveness. Al-
though little change has occurred in the age-adjusted death rate for breast can-
cer since the 1950s (American Cancer Society 1997), significant changes have
been made in the standard therapy (as discussed above).
Data on the interpersonal relationships of cancer patients suggest that, in
general, satisfaction predominates. Study of women treated for breast cancer
indicates that most relationships remain intact, satisfactory, and on occasion
become stronger (Lichtman and Taylor 1986; Tempelaar et al. 1989). The
most important relationships are those within the family, and thus studies
have focused on them. When problems do occur, they include the estrange-
ment and distress originally hypothesized for most patients (Wortman and
Dunkel-Schetter 1979). In one common scenario, the woman may be inclined
to discuss her feelings and experiences in an attempt to cope with or under-

stand the cancer stressor, but her partner may be more inclined to advise her
to put the experience behind you and may not want to listen (Lichtman and
Taylor 1986). It is clear that the level of distress in kin may approach that of
the patient (B. R. Cassileth et al. 1985). Another common stressor for women
with breast cancer is the subsequent risk of disease for their female children.
For many breast cancer patients, the one life area that is at some risk is
sexual functioning, although the incidence of sexual problems has declined
with the lesser surgeries. Lumpectomy patients report less alteration in body
image, greater comfort with nudity and discussing sexuality with ones part-
ner, no or few changes in intercourse frequency, and a lower incidence of
sexual dysfunction than do patients receiving more extensive surgeries. Ad-
ditionally, important individual differences in the extent of sexual morbidity
may exist, such as how a woman views herself as a sexual person (Andersen
et al. 1997). Even if sexual disruption occurs, however, it need not portend
disturbance of other life areas, such as marital adjustment, as indicated in
studies comparing breast cancer patients with healthy women (Andersen and
Jochimsen 1985).
Recurrence
Cancer recurrence is devastating. As noted earlier, the magnitude of distress

is even greater than that found with the initial diagnosis. Studies in which can-
cer patients with no evidence of disease are contrasted with those receiving
palliative treatment (e.g., B. R. Cassileth et al. 1985) report the greatest dis-
tress for those with disseminated disease. Difficult decisions (e.g., beginning
a regimen that offers little chance for cure and has side effects versus no treat-
ment) are made in a context of extreme emotional distress and physical debil-
itation (P. A. Cassileth and Cassileth 1983).
We previously reviewed the psychologic interventions to assist coping
with difficult treatments or the recovery process. Data also indicate that im-
portant gains can be achieved during terminal stages (e.g., Linn et al. 1982).
Group support interventions have been important because they can serve
various purposes not offered by individual therapy (Taylor et al. 1986).
Group members can serve as role models for each other in their coping ef-
forts and in confronting the possibility of decline and death, and they can also
provide altruistic support to one another. Spiegel et al. (1981) have provided
two important reports on the emotional and survival benefits of such an in-
tervention. Using a randomized, prospective design, women with metastatic
breast cancer were assigned to group therapy or no-treatment conditions. The

study assessments occurred at the beginning and at 4, 8, and 12 months later,
although the groups continued to meet for 2 years. Women participating in
the support groups reported less emotional distress and fewer maladaptive
coping responses, such as overeating, smoking, or drinking. A later report
provided data on 10-year survival differences between the groups (Spiegel et
al. 1989). At that time, only three of the 86 patients were alive and death
records were obtained on all other participants. Survival from time of ran-
domization and onset of intervention was a mean of 36.6 months in the inter-
vention group compared with 18.9 months in the control group, a significant
difference. Survival plots indicated that divergence in survival began at 20
months after entry, or 8 months after the formal intervention study ended.
Hypotheses for this important effect include the additional provision of social
support from the therapy sessions or enhanced self-care (e.g., better treatment
compliance, improved diet, hypnosis for pain control, more exercise), among
others. Future studies will examine the reliability and the mechanisms for
these remarkable findings.
Reducing Psychologic Distress Throughout the

Cancer Experience: Roles for the Psychiatrist
Suggestions have been made regarding the management of emotional distress

in the cancer patient (Massie and Holland 1990). An often overlooked strat-
egy is the continuing emotional support of the patient by the oncologist. Psy-
chiatrists are in a unique position to assist their physician colleagues with such
supportive efforts. Supplementary psychiatric consultation may be consid-
ered when severe affective symptoms last more than 2 weeks, when they
worsen, or when they interfere with the patients ability to function or coop-
erate with treatment. Brief crisis-oriented therapy may be particularly useful
at time of diagnosis (initial or recurrent), and may help the woman regain a
sense of self in this difficult circumstance, correct misconceptions regarding
diagnosis or treatment, and integrate the illness experience into prior life ex-
periences. Other therapeutic efforts may be to include family members in the
intervention sessions or to suggest participation in patient support groups.
When medication is considered, surveys of current psychotropic medi-
cations indicate that hypnotics (43% of all prescriptions), antipsychotics
(28%), anxiolytics (27%), and antidepressants (3%) are typically chosen for
psychologic and physical symptom management (e.g., hypnotics and antipsy-
chotics are often prescribed for nausea and vomiting rather than for affective
distress) (Stiefel et al. 1990). For depression and anxiety, the tricyclic or selec-
tive serotonin reuptake inhibitor antidepressants can be safely and effectively
prescribed and should be used (Massie and Holland 1990). Severe depression
in advanced disease can be effectively treated with psychostimulants, such as
methylphenidate, to improve mood and energy levels.
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23
Women and Violence
CAROLE WARSHAW, M.D.
Violence against women constitutes a major social and public health

problemone that affects women of all ages, cultural backgrounds, and socio-
economic levels (American Medical Association 1992; Crowell and Burgess
1996; Koss et al. 1994). Abuse and violence are common, often chronic social
experiences rather than unusual events that occur among a small percentage
of women. The greatest risk of sexual and physical violation will come from
someone a woman knows and trustsa parent, a caretaker, a person she is
dating, or an intimate partner.
Over the past several decades, an overarching framework for under-
standing the impact of trauma on the human psyche has emerged through
work with survivors of both civilian and combat trauma (Bloom 1997; Her-
man 1992b; Horowitz 1974, 1986; van der Kolk 1987). Information about
specific forms of violence against women, such as childhood sexual abuse,
sexual assault, and domestic violence, however, is often found in separate lit-
eratures, and knowledge about the cumulative effects of violence across the
lifespan and experiences of women from diverse communities is still limited.
Despite these limitations, research documenting the effects of violence against
women and girls demonstrates that abuse, violence, and discrimination play
a significant role in many of the mental health problems experienced by wom-
en in this country and throughout the world (Crowell and Burgess 1996; Fe-
litti et al. 1998; Fischbach and Herbert 1997; Golding 1999; Heise et al. 1994;
Koss et al. 1994; Marella et al. 1996).
While Veterans Administration (VA) hospitals were focusing almost ex-
clusively on the combat-related trauma symptoms experienced by male Viet-
nam veterans, rape crisis workers and therapists were hearing about similar
477
traumatic responses from women who were talking about sexual assault ex-
periences for the first time. Recognition that many of these women were be-
ing raped by husbands or partners led to a burgeoning awareness of the
pervasiveness of ongoing violence in womens lives and to the birth of the do-
mestic violence advocacy movement. At the same time, large numbers of
women were also being seen within the mental health system for symptoms
associated with childhood sexual abuse that were not initially recognized as
such. Initial pathologizing or victim-blaming responses on the part of mental
health providers led to tensions between womens advocates and clinicians.
Conscious of the need to create a public awareness that would hold abusers
accountable for their violence, not victims, advocates have been reluctant to
frame womens responses to abuse in purely psychologic terms. These ap-
proaches have been instrumental in reconfiguring clinical paradigms and un-
derscoring the importance of framing victimization as a societal problem
rather than as an attribute of the victim. As Brown (1995) has pointed out,
we do not look for characteristics of other crime victims to understand why
they have been victimized. Misdiagnosis and retraumatization within the
mental health system itself have not been uncommon experiences for abuse
survivors (Ray and Rappaport 1995). Over the past 10 years, many of these
practices have been changed (Carmen and Rieker 1998). In areas such as do-
mestic violence, however, collaborative models integrating both treatment
and advocacy approaches have been slower in developing.
This chapter summarizes what the past two decades of research and clin-
ical work have taught us about the prevalence, impact, and treatment of dif-
ferent forms of violence against women. Although many similarities exist in
the ways women experience abuse and violence and in the treatment of
violence-related mental health issues, important differences can also be
found. Some of these differences relate to issues surrounding the particular
types of violence a woman has experienced; others involve factors unique to
a womans development, social context, and life experiences. Thus, the rec-
ommendations that follow must be tailored to the individual woman with
whom one is working.
Definitions
Rape
Rape is commonly defined as a sexual act involving oral, anal, or vaginal pen-
etration by a penis, other body parts, or objects accompanied by the use of
Women and Violence 479
threat, duress, physical force, intimidation, deception, or lack of ability to

consent. Like other forms of violence, sexual assault may be experienced at
any point during the lifespan. Sexual assault or coercion by a stranger, marital
partner, acquaintance, or date are all considered to be rape. Women and girls
are most likely to be raped by someone they know.
Childhood Sexual Abuse
Childhood sexual abuse involves sexual contact and/or other sexual behaviors
(e.g., genital exposure, involvement in pornography) by an adult or adults or,
in some definitions, by a person or persons at least 5 years older than the vic-
tim (Wyatt and Peters 1986). Such abuse may be incestuous or not. Sexually
abusive behaviors range from single perpetrator exhibitionism, fondling, or
intercourse to child pornography and systematic assault by multiple perpetra-
tors. Abuse may be accompanied by loving or seductive behaviors or may
be brutal and sadistic. Although isolated abusive events do occur, sexual
abuse is often chronic, with an average duration of 4 years (Courtois 1988).
In addition, sexually abused children often face many other adversities in the
course of their development that contribute to later difficulties (e.g., emotion-
al abuse and neglect; parental substance abuse; and punitive, blaming, or dis-
missive responses if they reveal the abuse) (Goodwin 1996).
Domestic Violence
Domestic violence is an ongoing pattern of domination and control perpetrated

against a current or former intimate partner sustained by a combination of
actual or threatened physical violence, sexual assault, and psychologic abuse.
This occurs in adult and adolescent dating, in married or separating relation-
ships, and among both homosexual and heterosexual couples. Physical vio-
lence is only one of many tactics batterers use to harm their victims,
undermine their autonomy and sense of self, and keep them isolated and en-
trapped (American Medical Association 1992; Ganley 1995; Renzetti 1992).
Whenever physical or sexual abuse occurs, psychologic abuse is invari-
ably present and may be quite severe. This often takes the form of verbal in-
timidation and threats, ridicule and humiliation, destruction of property,
threats to significant others, stalking and monitoring a victims activities, and
controlling access to money, personal items, and contact with friends, family,
and children (Browne 1987; Carmen 1995; Follingstad et al. 1990; L. E.
Walker 1984, 1994). Accusations about sexual infidelity can be particularly
humiliating. Emotional withdrawal, threats of abandonment, and threats to

harm or take away children are also used as tactics of control.
Psychologic abuse is not only a significant component of domestic vio-
lence but is also more pervasive and often more damaging than physical
abuse. Recent studies indicate that psychologic abuse is more predictive of
low self-esteem, depression, and posttraumatic stress disorder (PTSD) than is
physical abuse and in some couples predicts future physical and/or sexual vi-
olence (Arias and Pape 1999; Murphy and Cascardi 1993; OLeary 1999).
Women who are being abused describe the psychologic abuse as the worst
aspect of their experiences. The combination of the abusers use of these tac-
tics and social conditions that limit options for freedom and safety is what
keeps women trapped in abusive relationships (Warshaw 1996a).
Prevalence of Gender-Based Violence

in the United States
Overall Rates
It has been well documented that women bear a disproportionate share of in-
timate violence in our society. Across studies, acute risk appears to be the
highest for young women, particularly those between the ages of 12 and 18
years (Bachman and Saltzman 1995). Estimates of the lifetime prevalence of
sexual assault among women averages between 13% and 25% (Brickman and
Briere 1984; Crowell and Burgess 1996; Essock-Vitale and McGuire 1985;
Kilpatrick et al. 1987, 1992; Koss and Oros 1982; Koss et al. 1987; Tjaden
and Thoennes 1998; Wyatt 1992). Earlier retrospective studies of childhood
sexual abuse suggested that between 8% and 62% of women have been sex-
ually abused as children (Felitti 1998; Finkelhor et al. 1990; Russell 1982,
1984; Tjaden and Thoennes 1998; Wyatt 1985). Most current estimates fall
in the 27%28% range, but these may be low (Wyatt 1992). Longitudinal
follow-up studies of adults with documented histories of childhood abuse in-
dicate that respondents are likely to underestimate the occurrence of such
events (Felitti et al. 1998; Femina et al. 1990; Williams 1995). Researchers
conducting general population studies estimate the 1-year incidence of part-
ner abuse among heterosexual women to be from 1.2% to 12% (Schulman
1979; Straus and Gelles 1990; Straus et al. 1980; Tjaden and Thoennes
1998). Lifetime prevalence ranges from 21% to 34% (Frieze et al. 1980; Rus-
sell 1982; Tjaden and Thoennes 1998).
Cultural Differences
Data on violence against women across cultures are mixed. Studies that con-
trolled for socioeconomic status have found similar rates of domestic violence
and childhood sexual abuse among black, Hispanic, and Caucasian women
(Centerwell 1984; Stark 1993; Torres 1991; Wyatt 1994). Rates of partner
abuse also appear to be comparable between lesbian and heterosexual cou-
ples (Lie and Gentlewarrier 1991; Lie et al. 1991; Lockhart et al. 1994; Schilit
et al. 1990; Waterman et al. 1989). In some studies, reports of sexual assault
and partner abuse are lower among Latina women (Sorenson 1996) and
Asian-American women, whereas Native American women report higher
rates of domestic violence (Tjaden and Thoennes 1998). How women experi-
ence abuse may be influenced to some extent by race and ethnicity (Plichta
1995; Wyatt 1992, 1994).
Revictimization
Up to 50%65% of adult rape victims report histories of childhood sexual
abuse (Russell 1982; Wyatt et al. 1992). Women who were sexually abused
as children were often physically abused as well (Cloitre et al. 1997) and are
at increased risk for later sexual (Fromuth 1986; Gidycz et al. 1993; Koss and
Dinero 1989; Urquiza and Goodlin 1994; Wyatt and Riederle 1994; Wyatt
et al. 1992) and physical assault (McCauley et al. 1997; Messman and Long
1996; Sappington et al. 1997; Schaaf and McCanne 1998). Recent epidemi-
ologic data indicate, for example, that 18% of women who reported being
raped before the age of 18 also report being raped as adultstwice the rate of
women who have not been raped as children or adolescents (Tjaden and
Thoennes 1998). Some authors have attributed this phenomenon to dissocia-
tive states associated with severe trauma that may impair a womans ability
to attend to danger signals (Cloitre et al. 1997), whereas others have attribut-
ed it to women not learning that they have a right to protect themselves from
harm.
Low-income women appear to be at even greater risk for revictimization.
In one study, the lifetime prevalence of severe physical or sexual assault
among very-low-income women was found to be 84%; 63% of those studied
had been physically assaulted as children, 40% had been sexually assaulted
as children, and 60% had been physically assaulted by an intimate partner
(Bassuk et al. 1998). Women living in extreme poverty face multiple sources
of stress in addition to violence, including ongoing discrimination, lack of so-
cial and material necessities, and lack of access to resourcesconditions that
can adversely affect trauma recovery.
Medical Consequences of Abuse
In recent years, attention to the impact of abuse and violence on womens

health has grown. Prevalence studies indicate that 5%27% of women seen in
a range of clinical settings are currently being abused by their partners (Ab-
bott et al. 1995; Dearwater et al. 1998; Gin et al. 1991; McCauley et al.
1995). Between 36.9% and 54.2% of women seen in emergency departments
have reported physical or emotional abuse by a partner at some time in their
lives, and in one study, 14.4% said they had experienced physical or sexual
abuse during the past year (Dearwater et al. 1998).
Numerous studies have described the high prevalence of abuse histories
among women seeking care for medical problems other than physical injuries
(Koss 1993; Stark et al. 1979). Presentations associated with abuse include
chronic pain (e.g., persistent headaches, chest pain, back pain, and pelvic
pain) (Domino and Haber 1987; Karol et al. 1992; Rapkin et al. 1990; E. A.
Walker et al. 1988) and complications of head and neck injuries such as sei-
zures (Bowman 1993; Loewenstein 1991; Ross 1989) or difficulties with con-
centration, impulse control, and performance (L. S. Brown 1989). Positive
correlations have also been found between a lifetime history of abuse and gas-
trointestinal illnesses (e.g., irritable bowel syndrome) (Drossman 1994;
Drossman et al. 1995; Leserman and Drossman 1995; E. A. Walker et al.
1993, 1995) and autoimmune disorders (van der Kolk 1997). There appears
to be a strong doseresponse relationship between the degree of exposure to
adverse childhood experiences (childhood abuse and household dysfunc-
tion), health risk factors (smoking, drug and alcohol abuse, obesity), and se-
rious adult illnesses (ischemic heart disease, cancer, chronic lung disease, and
liver disease) (Felitti et al. 1998). Complications of pregnancy, prolonged la-
bor, preterm deliveries, low birth weight, and postpartum difficulties are also
found at higher rates among women with histories of physical and sexual
abuse (Boyer 1995; Jacobs 1992; McFarlane et al. 1992). Additionally, sexual
abuse and assault increase womens risk for exposure to the complications of
unprotected sex, such as HIV/AIDS, other sexually transmitted diseases, and
unplanned pregnancies (Boyer 1995; Cohen et al. 2000; Zierler et al. 1995).
Women who have been abused frequently present with exacerbations or
poor control of chronic medical conditions, such as diabetes, hypertension,
asthma, or angina (Courtois 1988; Warshaw and Ganley 1995), or develop
sleep and appetite disturbances, fatigue, dizziness, weight change, and other
physical symptoms associated with depression, anxiety, or posttraumatic
stress. Often the abusers prevent their partners from receiving medical care
or restrict their access to sleep, exercise, proper diet, and medication. Addi-
tionally, avoidant posttraumatic stress responses associated with a history of
sexual abuse or assault may interfere with taking medication, having regular
Pap smears or mammograms, or agreeing to invasive medical procedures
that may retrigger the experience of physical violation and loss of control
(Courtois 1993; Goldman et al. 1995).
For some women, abuse increases during pregnancy, whereas for others
pregnancy may be a protected time. Rates of intimate partner abuse during
pregnancy range from 0.9% to 20% depending on when and how women are
asked (Gazmararian et al. 1996; Parker et al. 1993). Pregnant adolescents ap-
pear to experience intimate partner abuse at higher rates than adults (Parker
et al. 1993). Poverty also increases womens risk for abuse during pregnancy.
One study of low-income women found that 65% of women experienced ei-
ther verbal or physical abuse during pregnancy and 20% experienced either
moderate or severe violence (OCampo et al. 1994). Violence also appears to
predict substance abuse during pregnancy (Amaro et al. 1990; J. Campbell
and Kubb 1996; Bennett 1995; Martin et al. 1996).
Disabled women may be at even greater risk for physical and sexual vi-
olation (Gil et al. 1994). Although partner abuse among women with disabil-
ities has not been systematically assessed, one case comparison study found
the prevalence of partner abuse to be equal among women with and without
physical disabilities. However, disabled women were more likely to be abused
by attendants or health care providers and to be abused for a longer duration
(Young et al. 1997). Women with physical disabilities or other chronic health
conditions are also more likely to be sexually abused as children and sexually
assaulted as adults (Golding 1994; Sobsey et al. 1995). In one small study,
over 70% of disabled women had experienced violent sexual encounters at
some time in their lives (Stimpson and Best 1991). Women who are hearing
impaired (Melling 1984) or developmentally disabled (Doucette 1986; Hard
1986; Mansell et al. 1998; Sobsey and Varnhagen 1991) are particularly vul-
nerable to abuse.
Mental Health Consequences of Abuse and Violence
In mental health settings the prevalence of abuse appears to be even higher.

For example, individual studies have found that 81% of women psychiatric
inpatients (Jacobson and Richardson 1987) and 68% of women outpatients
(Jacobson 1989) had histories of abuse either as adults or children. In another
study, 72% of women psychiatric inpatients reported childhood sexual or

physical abuse or both (Bryer et al. 1987). Histories of childhood sexual
abuse are reported by 30%75% of the women who are seen in inpatient and
outpatient psychiatric settings (Briere and Runtz 1988; Bryer et al. 1987; Chu
and Dill 1990; Courtois 1993; Craine et al. 1988; Elvik et al. 1990; Goodwin
1989; Lombardo and Pohl 1997). In addition, approximately 50%65% of
the women who use public mental health services have been found to be sur-
vivors of childhood abuse (Carmen et al. 1984; Craine et al. 1988; Jacobson
and Herald 1990; Muenzenmaier et al. 1993; Rose et al. 1991).
Specific psychiatric disorders associated with interpersonal violence in-
clude acute stress and posttraumatic stress disorders, other anxiety disorders
such as panic and obsessive-compulsive disorders, somatization and eating
disorders, major depression and dysthymia, dissociative disorders, and Axis
II diagnoses such as borderline personality disorder as well as sexual dys-
function, self-mutilation, and substance abuse (Alpert et al. 1995; Astin et al.
1995; Briere and Runtz 1988; Burnam et al. 1988; J. C. Campbell and Alford
1989; Carnes 1991; Commonwealth Fund and Commission on Womens
Health 1995; Craine et al. 1988; Crowell and Burgess 1996; Den Herder and
Redner 1991; Gelles and Straus 1988; Golding et al. 1988; Hotaling and Sug-
arman 1986; Houskamp and Foy 1991; Kluft 1990; Maltz 1991; Resick 1987;
Russo and Green 1993; Westerlund 1992; Winfield et al. 1990). Between
68% and 86% of hospitalized patients diagnosed with borderline personality
disorder have been found to have histories of childhood physical and/or sex-
ual abuse or to have witnessed severe violence (Bryer et al. 1987; Herman et
al. 1986; Westen et al. 1990); similar findings have been reported for outpa-
tients diagnosed with this disorder (Herman et al. 1989; Wagner et al. 1989).
Survivors of more severe, long-standing childhood abuse are two to five times
as likely to develop a psychiatric disorder (Briere and Elliott 1994) and may
present with as many as six or seven discrete diagnoses as part of a more com-
plex posttraumatic response (Turkus 1995).
Posttraumatic Stress Disorder
Several authors have suggested that PTSD may be the most appropriate di-
agnosis for women suffering from the range of psychologic sequelae that fol-
low sexual assault, battering, and childhood sexual abuse (Chalk and King
1998; Koss et al. 1994). Women who have been assaulted develop responses
similar to those of victims of other types of trauma: shock, confusion, horror,
and helplessness as well as dissociation, nightmares, flashbacks, numbing,
avoidance, and hypervigilance (Crowell and Burgess 1996; Herman 1992b).

Flashbacks can be visual, auditory, olfactory, tactile, or somatic and may be
triggered by a range of stimuli: subsequent abuse, hearing about someone
else being assaulted, media portrayals of violence, sensory stimuli associated
with the original traumatic experience(s), invasive medical procedures, or an-
niversaries of the trauma. Flashbacks can also can also be cognitive (paranoid
or suicidal thoughts), affective (feeling terrified or enraged), behavioral
(cringing or fleeing), or interactional (Elliott and Briere 1995; Pearlman and
Saakvitne 1995; Turkus 1995; van der Kolk et al. 1996).
The PTSD framework makes sense of the fluctuations that trauma sur-
vivors experience between being flooded and needing to dampen those feel-
ings while remaining vigilant to potential new dangers. PTSD may present as
an extension of acute stress disorder or may develop after a period of dor-
mancy (delayed PTSD). It may resolve on its own or with treatment or may
take on a chronic form. The relative intensity of PTSD symptoms may vary
over time. Although flashbacks are more prominent initially, avoidant symp-
toms may predominate later in the course. This symptom progression may
make trauma-engendered fears less accessible to change and thus painfully
constrict womens lives, particularly in the areas of intimacy, sexuality, and
the ability to move freely in the world (Blank 1993). The hypervigilance
associated with PTSD can also constrain a womans sense of freedom and
safety. It is these adaptations that appear to have the most profound and po-
tentially damaging effects (Carmen and Rieker 1998).
Neurobiology of Trauma
The recent flood of research on the neurobiology of trauma has led to greater
understanding of the links between biology, behavior, and psychologic dis-
tress. As van der Kolk (1997) has described, people with PTSD develop sig-
nificant alterations in physiologic reactivity and stress hormone secretion,
making it difficult to properly evaluate sensory stimuli and respond with ap-
propriate levels of physiologic and neurohormonal arousal. Several psycho-
physiologic models have been posited to explain PTSD (Davidson and van
der Kolk 1996). These include noradrenergic dysregulation (increased sensi-
tivity of the sympathetic nervous system under stress) (Southwick et al.
1999), disturbances of serotonergic activity (stress resilience, sleep regulation,
impulse control, conditioned avoidance, and aggression), and kindling (low-
ering of the excitability threshold after repeated electrical stimulation). After
traumatic exposure, limbic nuclei become sensitized, leading to excessive
responsivity and increased startle and arousal responsescores feature of

PTSD that often persist after other symptoms resolve. Activation of the
amygdala is postulated to mediate the autonomic stimulation resulting from
exposure to trauma, thus transforming sensory input into physiologic signals
that, in turn, produce and modulate emotional responses (van der Kolk
1997).
In addition, people with PTSD may exhibit enhanced reactivity and neg-
ative feedback inhibition of the hypothalamicpituitaryadrenal (HPA) axis,
a pattern that appears to be distinct from that found in depression and from
acute and chronic stress among individuals who have not developed PTSD
(Yehuda et al. 1991). Adaptations to chronic stress result in reduced resting
glucocorticoid levels, decreased secretion in response to subsequent stress,
and increased concentration of glucocorticoid receptors in the hippocampus
(Resnick et al. 1995; Yehuda et al. 1993, 1995). This reduced cortisol re-
sponse following assault has been associated with an increased likelihood of
developing PTSD, leading to the hypothesis that elevated cortisol is impor-
tant to the integration of traumatic experiences (van der Kolk 1997). Other
studies have indicated that HPA axis hyperreactivity among women exposed
to early childhood abuse causes increased adrenocorticotropic hormone and
cortisol responses to lab-induced stress. These changes in corticotropin releas-
ing factor activity may predispose women to the development of subsequent
mood and anxiety disorders (Heim et al. 2000).
Recent data also indicate several neurologic differences among adults
who were abused as children that affect the development of the limbic system
and cerebral cortex, particularly the left hemisphere (Cicchetti and Carlson
1989) and the connecting structures used to process and interpret sensory
data (van der Kolk 1997). Hippocampal volume, for example, may be re-
duced in women who have experienced severe childhood sexual abuse (Stein
et al. 1997). These findings are similar to those of combat veterans with
PTSD and may either represent a consequence of trauma exposure or a risk
factor for the development of psychiatric complications following exposure.
Stein et al. (1997) suggested that mesial temporal lobe dysfunction may di-
rectly mediate certain aspects of PTSD and dissociative disorder symptoms.
Interestingly, they found no differences in memory testing between abused
and nonabused groups. They speculate that these data may be better concep-
tualized as a dysfunction within the systems that monitor and regulate access
to memory in emotionally charged contexts (Stein et al. 1997), potentially in-
terfering with the processing of new stimuli (van der Kolk 1997). In addition,
subjects with PTSD exposed to scripts of their traumatic experiences show
decreased activity in the speech areas of the left hemisphere (Brocas area)
necessary for the cognitive labeling and sequencing of experience, making it
more difficult for trauma survivors to process the initial trauma and subse-
quent triggering events and to describe their experiences in a coherent narra-
tive form (Marmar et al. 1994; Shalev et al. 1996; van der Kolk 1997).
Trauma and Memory
Recent concerns about the possibility of therapists implanting false memories

of childhood abuse have created considerable controversy within the mental
health field (Hyman and Pentland 1996; Hyman et al. 1995). Research exam-
ining the nature of traumatic memory and recognition of the ubiquity of dis-
sociation under conditions of extreme duress have expanded current
understanding of these phenomena. Although much is still unknown (e.g.,
the mechanisms for forgetting and recovering memory for traumatic events),
clear evidence has shown that childhood memories can be both forgotten and
later recalled (see International Society of Trauma Stress Studies 1998 for crit-
ical review of these issues). Retrospective studies indicate that between 20%
and 59% of those in treatment for childhood sexual abuse report prior mem-
ory deficits or total lack of recall for the abuse (Briere and Conte 1993; Elliott
1997; Herman and Schatzow 1987; Loftus et al. 1994). More compelling are
the handful of prospective follow-up studies of young adults with document-
ed childhood sexual abuse, which demonstrated that 32%60% of female re-
spondents did not recall the abuse on reinterview (Widom and Morris 1997;
Williams 1995; Williams and Banyard 1997) and that previously forgotten
memories of abuse can be recovered with reasonable accuracy (Scheflin and
Brown 1996; Williams and Banyard 1997), although methodologic concerns
have been raised about some of this research (Pope and Hudson 1995).
Considerable laboratory evidence also suggests that patients can, in fact,
be induced to remember events inaccurately and to believe that they experi-
enced events that they did not. Again, critiques of these studies focus on the
artificial nature of the experiments, small sample sizes, and the fact that most
subjects resist implantation. However, some individuals do appear to be more
vulnerable to this type of manipulation (Schooler et al. 1997). Finally, some
disagreement remains as to whether traumatic memories are qualitatively dif-
ferent than other memories. Several authors have posited that traumatic
memories, although similar in many ways, are more accurate and less likely
to deteriorate. Encoding may be enhanced by the increased levels of stress
hormones and neuromodulators present during intense emotional arousal,
and memories may be stored in sensory rather than narrative form (Shobe
and Kihlstrom 1997; van der Kolk et al. 1996; Yehuda and McFarlane 1997).
When trauma occurs during childhood, before the development of complex
language capacities, memories may be even more fragmented and resurface
as sounds (abusers voice, family enjoying Thanksgiving dinner in the next
room), bodily sensations (nausea, gagging, or pain), smells (alcohol, semen,
or abusers cologne), childhood affect states (feeling icky), or images (a win-
dow or door that was stared at, a large hovering belly). Positron emission to-
mography scans of PTSD patients have shown heightened brain activity in
the parts of the limbic system connected with amygdala, which suggests that
traumatized people experience emotions as physical states rather than ver-
bally encoded experiences (van der Kolk et al. 1996, p. 233).
Sexual Assault and Posttraumatic Stress Disorder

Adult victims of sexual assault (particularly of completed rape) represent the
largest single group of trauma victims affected by PTSD (Foa et al. 1991;
Kessler et al. 1995). Immediately following sexual assault, up to 95% of wom-
en develop symptoms of acute PTSD. Distress seems to reach its peak at 3
weeks after the assault for victims of single-episode sexual assault in adult-
hood and continue at this level for the next month (Crowell and Burgess
1996; Davidson and Foa 1991; Rothbaum et al. 1992). Although many symp-
toms may resolve after 3 months, residual fear, sexual difficulties, and prob-
lems with self-esteem can persist for 18 months or longer (Resick 1987), and
nearly 25% of victims continue to be affected for several years (Hanson
1990). Other studies indicate that after 3 months, approximately one-half of
adult sexual assault survivors will still meet criteria for PTSD; many will
meet these criteria for a year or more (Foa et al. 1995; Resnick et al. 1993;
Rothbaum and Foa 1993; Rothbaum et al. 1992). Postrape recovery appears
to be more difficult when assault occurs an earlier age and when women ex-
perience greater fear of being injured or killed (Hanson 1990; Kilpatrick et
al. 1987; Resick 1987). Sexual assault by a known assailant is at least as dev-
astating as stranger rape (Katz 1991; Koss et al. 1987), but women are less
likely to seek help or file police reports under those conditions (Golding et al.
1989).
Domestic Violence and Posttraumatic Stress Disorder

Rates of PTSD among battered women are estimated to be between 33% and
58% (Astin et al. 1993, 1995; Dutton 1992; Houskamp and Foy 1991; Kemp
et al. 1991; Kubany 1996). PTSD in victims of partner abuse has been corre-
lated with the severity of the abuse, a history of repeated (Norris and Kani-
asty 1994) and/or childhood victimization (Astin et al. 1995; OKeefe 1998),
the presence of sexual assault (Browne 1993a, 1993b; J. C. Campbell and Al-
ford 1989; Shields and Hanneke 1988), and the degree of psychologic abuse
(Arias and Pape 1999). Serious mental illness and disorders related to severe
childhood abuse (e.g., dissociative identity disorder, disorders of extreme
stress not otherwise specified [DESNOS], borderline personality disorder)
not only leave women more vulnerable to adult victimization but also to
symptoms that are exacerbated by the abuse.
For women who are still in danger, even if they have left the situation the
stress is not postthe trauma is ongoing and symptoms may be an adaptive
response to danger. Development of PTSD, however, can make it more diffi-
cult to mobilize resources, putting women at even greater risk for being iso-
lated and controlled by an abuser. Although it appears that many battered
women do well without mental health intervention because their symptoms
decrease or disappear once they are relatively safe, others need assistance in
reducing their distress before they can mobilize the resources necessary to
change their lives. For some women, the long-term posttraumatic sequelae of
abuse do not appear until much later. In addition, many women continue to
be traumatized even after they have left an abusive partnerthrough stalking,
prolonged divorce or custody hearings, visitation, and revictimization by the
legal system.
Comorbidity and Posttraumatic Stress Disorder

Increased rates of psychiatric and medical comorbidity, service use, function-
al impairment, and cost are also associated with PTSD (Solomon and David-
son 1997). The prevalence of bulimia nervosa, particularly purging behavior,
appears to be significantly higher among women with histories of sexual vic-
timization and PTSD (Dansky et al. 1997; Kilpatrick 1997; Waller 1991).
PTSD also influences the risk for first-onset major depression and alcohol de-
pendence (Breslau et al. 1991, 1997).
Depression
Depression is common among women who have been sexually (as well as
physically) assaulted in childhood and/or adulthood. Several factors seem to
increase a womans risk for depression, including perpetrator behavior and a
history of multiple sexual victimizations (Kilpatrick et al. 1987; Sorenson and

Golding 1990). Women with histories of childhood sexual abuse and adult
sexual assault show significantly higher rates of depression than do women
in control groups (Bagle and Ramsey 1986; Brown and Root 1990; Ellis et
al. 1982; Gidycz and Koss 1989; Jehu 1988). In fact, the lifetime prevalence
of major depressive disorder among victims of sexual assault is more than
twice that of nonassaulted women (Burnam et al. 1988; Sorenson and Gold-
ing 1990). This is particularly true for the women at greatest risk for re-
victimizationhomeless women diagnosed with serious mental illness. The
chronic and intense exposure to violence that such women face has been
found to contribute to the severity of their psychiatric symptoms (Goodman
et al. 1997). Depression associated with PTSD may be a distinct phenome-
non. The numbing and feelings of deadness associated with PTSD are
among the most difficult symptoms to eradicate, even when intrusion and hy-
perarousal have improved (van der Kolk et al. 1994).
Although symptoms of anxiety predominate immediately after sexual as-
sault, early signs of depression can be seen within a few hours. Women report
sadness, apathy, and suicidal thoughts (Ruch et al. 1991). Within a few
weeks, moderate to severe depression may develop (43%56%) (Frank et al.
1979) and last up to 3 months according to some studies (Ellis et al. 1982; Foa
et al. 1989; Resick 1987). Other retrospective studies have found that pos-
trape depression may persist for many years (Ellis et al. 1982; Resick 1987;
Resick and Schnicke 1992).
Domestic violence also increases womens risk for depression. Preva-
lence rates for depression among women abused by an intimate partner range
from 37% to 63% (J. Campbell and Kubb 1996; Gelles and Straus 1988; Glea-
son 1993; Hilberman 1980; Hilberman and Munson 1978; McGrath et al.
1990). Frequency and severity of violence (R. Campbell et al. 1995; Cascardi
et al. 1999; Gelles and Straus 1988), psychologic abuse (Follingstad et al.
1990; OLeary 1999) and lack of social support (R. Campbell et al. 1995) ap-
pear to be stronger predictors of depression than are cultural and demograph-
ic factors or prior history of mental illness (J. Campbell and Kubb 1996). In
several studies, significant reductions in depression occurred among women
who were able to end the violence (R. Campbell et al. 1995; Follingstad et al.
1991). Finally, the prevalence of suicidal ideation and suicide attempts are sig-
nificantly higher among victims of sexual assault (Ellis et al 1982; Frank et al.
1979; Kilpatrick et al. 1985; Stepakoff 1998), women battered by their part-
ners (Stark et al. 1979), and women who were sexually abused as children
(Briere and Runtz 1986).
Substance Abuse
Follette et al. (1996) reported that approximately one-third of previously

abused women had lifetime alcohol problems compared with approximately
20% of women in the general population. Other studies confirm the relation-
ship between childhood sexual abuse and subsequent alcohol and drug abuse
by women (Briere and Runtz 1988; Bryer et al. 1987; Epstein et al. 1997;
Langeland and Harters 1998; Najavits et al. 1997; Wilsnack et al. 1997). In
one study, the risk of alcohol abuse was nine times greater among women
who had been sexually abused as children (Briere and Runtz 1988).
Strong correlations have also been found between battering and sub-
stance abuse among both victims and perpetrators. This relationship is a
complex one. Alcohol consumption may contribute to violent behavior in al-
ready abusive men, but there is no evidence that substance abuse actually
causes violence against women and children (Bennett 1995; Bennett et al.
1994; Substance Abuse and Mental Health Services Administration 1998).
Research also suggests that alcohol and drug use among abuse survivors is
more likely to result from current or past victimization (e.g., self-medication
or coercion into consuming alcohol and other drugs) (Collins et al. 1997),
with the use of alcohol and drugs by battered women increasing dramatically
after physical abuse begins (Hotaling and Sugarman 1986; Stark and Flitcraft
1988). A woman may be punished by an abusive partner for refusing to drink
with him or for entering substance abuse treatment.
Alcohol consumption has also been cited as a risk factor for sexual as-
sault among adolescent and college-age women. Again, this relationship is not
straightforward. Alcohol may impair a womans judgment about the safety of
her situation. Drinking may also place women in environments in which they
are more likely to encounter offenders, or it may be misperceived by men as
a sign of sexual availability. It is important to remember that although high
levels of drug or alcohol consumption may put a woman at risk, they do not
cause the violence (Crowe and George 1989; Crowell and Burgess 1996; Fill-
more 1985; W. H. George et al. 1992, 1995; Lasley 1989; Winfield et al.
1990).
Dissociation
For those who experience the most extreme forms of childhood abuse (e.g.,
sadistic; systematic; multiple perpetrators; greater duration, intensity, fre-
quency, and threats; infliction of injury and humiliation; forced witnessing or
participation in abuse of others), dissociation is a common response (Chu et

al. 1990). The degree of dissociation appears to vary with the severity of the
abuse (Goodwin 1996; Putnam 1985). This may manifest as a component of
DESNOS or in any of the dissociative spectrum disorders or states. In one
study of individuals diagnosed with multiple personality disorder (now called
dissociative identity disorder), 97% had experienced serious trauma in child-
hood and 68% of those had been sexually abused (Putnam et al. 1986). Nu-
merous reports have been made of women initially misdiagnosed with
schizophrenia who were later found to have trauma-related dissociative dis-
orders, all of which can manifest with transient psychotic states (Gabbard
1992; Goodwin 1996; Jennings 1994a).
Complex Posttraumatic Stress Disorder or

Disorders of Extreme Stress Not Otherwise Specified
Although the PTSD diagnosis adequately captures the psychophysiologic re-

sponse to adult single-event sexual assault, important dimensions of the im-
pact of ongoing abuse and violence are not addressed by this diagnostic
construct. The frequency of comorbidity associated with PTSD, in fact, has
led to the notion that comorbidity is a misnomer masking a more complex form
of PTSD that develops in people who have been abused over long periods of
timeone that includes both Axis I and Axis II sequelae of chronic abuse
(Brady 1997; S. Roth et al. 1997; Zlotnick et al. 1996). Childhood sexual
abuse and entrapment in an abusive partner relationship are qualitatively dif-
ferent from many other types of trauma; according to several studies, they are
premeditated, ongoing, and most often perpetrated by someone to whom the
victim is attached and on whom she depends (Courtois 1995, 1997; Dutton
1992; Goodwin 1996; Herman 1992b; Hilberman and Munson 1978; Rieker
and Carmen 1986; Stark et al. 1979). The abuser often denies and distorts
the abuse, and the victim is coerced or threatened to maintain secrecy (Rieker
and Carmen 1986). When abuse occurs during childhood, it has the potential
to derail personal and social development (Putnam and Trickett 1993).
Complex posttraumatic stress disorder (Herman 1992a, 1992b), or disorders of
extreme stress not otherwise specified, is not officially listed as a diagnosis in DSM-
IV (American Psychiatric Association 1994), although it is contained in the
International Classifications of Disease (ICD)-9. The symptoms that make
up DESNOS are listed as associated features of PTSD. DSM-IV field trials
indicate that this construct is internally consistent and reliable (Peclovitz et al.
1997) and distinguishes early from late onset trauma (van der Kolk et al.
1996). Women who are severely abused by a partner may also experience
more complex posttraumatic responses, particularly if they were abused in
childhood as well.
Diagnostic criteria for DESNOS are consistent with developmental
models (S. Roth et al. 1997) and involve alterations in the following domains:
affect and impulse modulation (suicide attempts, high-risk behavior and self-
mutilation) (Boudewyn and Liem 1995); states of consciousness (dissocia-
tion) (Waldinger et al. 1994); self-perception (self-loathing and shame); per-
ceptions of the perpetrator (idealization); relations with others (e.g., traumatic
reenactments, intense rage) (Kendall-Tackett et al. 1993); and systems of
meanings (no one can be trusted) (Angel and Gronfein 1988; Johnson et al.
1997; Kleinman 1977; Pepitone and Triandis 1988; S. Roth et al. 1997). In
addition, womens sexuality is often affected, manifesting as compulsive sex-
ual behavior, dissociation during sex, or sexual avoidance (Turkus 1995).
These responses reflect some of the complex ways women attempt to regain
a sense of control over feelings of violation and betrayal. Symptoms may also
develop in response to triggering life events (a womans daughter reaching
the same age she was when she was abused) or therapy-related events (real
or perceived abandonment by therapist) (Harvey and Harney 1995; Turkus
1995).
Developing a More Complex Trauma Framework
The developmental impact of prolonged exposure to abuse by a caretaker or

of sexual assault on a womans sense of herself goes far beyond what is de-
scribed by current psychiatric nosology, even by diagnoses that specifically
address traumatic events. For example, although a PTSD diagnosis may ex-
plain the terrifying flashbacks many women have when they attempt to re-
sume sexual activity after an assault and sexual dysfunction may describe their
symptoms, neither diagnosis captures the complex ways in which women re-
configure their experience of themselves as sexual beings following rape. The
effects of abuse in childhood and/or adulthood affect womens experiences of
themselves and others throughout their lives (Browne 1993a; Campbell and
Kubb 1996; Carmen et al. 1984; Den Herder and Redner 1991; Herman
1992b). Many women who have been victimized do not develop psychiatric
disorders, but few are unaffected by those experiences (Courtois 1997).
Over time, the experiences of trauma survivors and the mental health
professionals working with them have challenged traditional symptom-
driven models of behavior that pathologize victims but fail to examine the cir-
cumstances that have caused symptoms to emerge. Trauma theory provides
a framework for understanding symptoms as psychophysiologic survival
strategies used to adapt to potentially life-shattering situations. It also allows
for a more balanced approach to treatmentone that focuses on resilience and
strength as well as on psychologic harm (Briere 1997; Dutton 1992, 1996;
Gondolf and Browne 1998; Herman 1992b; McCann and Pearlman 1990).
For example, trauma theory has reframed borderline symptoms as both
reenactments of abusive or neglectful interactions with caretakers and as ef-
forts to protect the self and others from potentially annihilating psychic as-
saults (Goodwin 1996). Without a trauma framework, it is difficult to make
therapeutic sense of the feelings and behaviors (e.g., rageful feelings and self-
destructive behaviors) that can make life so stormy for survivors of severe
abuse.
Work with battered women has led to similar perspectives. Many women
initially attempt to remedy their situations themselves by talking, seeking
help, fighting back, or trying to change the conditions that they either per-
ceive or are told caused the abuse. When those attempts fail, they may retreat
into a mode that appears more passive and compliant but may actually reflect
how they have learned to reduce their immediate danger. When those tactics
no longer work, they may learn to dissociate from feelings that have become
unbearable, perceiving that if they cannot change what is happening outside
of themor if they face near-certain death if they try to leavethey can at least
try to change their own responses and leave the situation emotionally. For
some women, substance abuse becomes another way of either coping with or
leaving the situation. For those who become increasingly isolated from out-
side resources, suicide or homicide may seem like the only way to end the
abuse (Dutton 1992; Warshaw 1996a).
Nor do women experience these events in isolation. A body of clinical
literature describes the retraumatizing effects of more subtle forms of social
and cultural victimization (e.g., microtraumatization due to gender, race, eth-
nicity, sexual orientation, disability, and/or socioeconomic status or what
Root [1996] describes as insidious trauma) and the ramifications of living
in societies that tolerate the pervasive disregard of the human rights of wom-
en and children (L. Brown 1995; Hamilton 1989; Kanuha 1994; Root 1996).
Other authors stress the importance of understanding how gender discrimi-
nation and other forms of oppression affect womens experience of violence
(G. R. Brown and Anderson 1991; Espin and Gawalek 1992; Greene 1994;
Joseph and Lewis 1981). Greene (1994), for example, noted that internalized
racism and discrimination based on ones race, ethnicity, gender, or sexual

orientation create a range of overlapping psychological realities that may
facilitate, challenge, or undermine optimal development (p. 344) as well as
recovery from trauma. It is not just the experience of discrimination or vic-
timization that influences womens psychologic development; it is also their
complex responses to those experiences and the social contexts in which they
occur. As Weskott (1986) describes, female development is a process in which
devaluation is both internalized and struggled against (p. 4). These strug-
gles are clearly compounded by abuse. It is those very strategies of resistance,
however, that subsequently become both growth-limiting adaptations and im-
portant sources of strength (Krieger 1996; Root 1996; Weskott 1986).
Limitations of Mental Health Models
Even a trauma framework defines an overwhelming response to minor stim-

uli as being part of a disorder. Viewing this heightened sensitivity as patho-
logic rather than as a reflection of acute social awareness is risky because it
discounts the experience that allows women to recognize potentially danger-
ous behaviors and attitudes before they reach more serious levels (Warshaw
1992). It defines the problem as being in the woman and she, rather than a
society that tolerates this type of abuse, becomes the focus of intervention
(Warshaw 1992).
Clinicians who work within a purely biologic or disorder-specific frame-
work run risks similar to those of their medical and surgical colleagues of fail-
ing to recognize and respond to the continuing violence in a patients life.
They may see abuse as being caused by a particular womans vulnerability
or as only a secondary problema social stressor affecting the course of her
primary biologic or developmental disorder.
Traditional psychoanalytic theory presents a different set of limitations.
The context of ongoing violence and danger that creates and perpetuates a
womans symptoms may not be addressed or may be regarded as symptom-
atic rather than etiologic. In addition, a clinician bound by the constraints of
remaining true to the neutrality of a psychodynamic framework may find it
difficult to play a more active role in advocating for safety and in helping
women gain access to community resources. There are, of course, more re-
cent models that recognize the importance of social and relational contexts
(Atwood and Stolorow 1984; L. S. Brown and Root 1990; Dutton 1992;
Kleinman 1977; Koss and Harvey 1991; Triandis 1972).
When domestic violence is framed solely under the rubric of family vi-
olence, it obscures the gendered aspects of this problem and is more likely
to be seen in terms of dysfunctional couple or family dynamics. In doing so,
clinicians can lose sight of the larger social dynamics that shape gendered be-
haviors in families and are thus less able to help women to gain perspective
or mobilize necessary resources. Family systems approaches can, in fact,
present even greater dangers to battered women. Assuming equal power
within and responsibility for relationship dynamics, it inadvertently holds a
battered woman responsible for her partners criminal behavior and keeps
her engaged in the countertherapeutic task of trying to change herself in or-
der to change him. In addition, couples sessions often precipitate further
threats or violence. The dynamics of battering have been described as a form
of domestic terrorism, more akin to hostage situations than to dysfunctional
couples (Andersen et al. 1991; L. E. Walker 1988). In that kind of setting, par-
ticularly when her partner continues to engage in violent, controlling behav-
ior or threats, it is not safe for a woman to be honest or to assert herself. Nor
is she likely to be free to make her own choices (Gondolf and Fisher 1988;
Krueger 1988). Again, newer models of family and couples therapy are being
developed that specifically address domestic violence (Goldner 1999; Hansen
1993). However, little data exist on the effectiveness or safety of these treat-
ment modalities, and they have been studied in couples in which the level of
violence is low (OLeary 1999).
Clinical Interventions:
Assessment, Treatment, and Collaboration
Over the past 25 years, principles and practices for working with survivors
of abuse and violence have evolved to form current standards of care. These
apply to all types of gender-based trauma and can be easily integrated into
clinical practice.
Recognizing Safety as a Priority
For all victims of abuse and violence, the issue of safety is paramount. The
traditional focus of mental health interventions has been on safety from self-
harm. However, ongoing danger from a current or former perpetrator and
prevention of victimization by others are also critical safety issues.
Attending to Issues of Respect and Collaboration
The experience of being treated with respect, feeling free to make ones own
choices, and participating in straightforward, caring, give-and-take relation-
ships can be therapeutic in itself and provides an opportunity to counter in-
ternalized abuse-related dynamics. Because victims of abuse are often more
vulnerable to reinjury and exquisitely attuned to relationship dynamics, the
power imbalances inherent to clinical interactions must be consciously at-
tended to. This is of particular concern when using more directive treatment
modalities.
Actively communicating that the perpetrator alone is responsible for his
(or her) abusive behavior and that he (or she) is the one responsible for stop-
ping it counters the abusers power to convince the victim that the abuse is or
was her fault. Therapies that focus on helping women understand why they
unconsciously chose an abusive partner or seduced a caretaker or that labels
them as codependent or enabling are not only ineffective but harmful as well
(Koss et al. 1994). Addressing the influence of earlier abusive relationships on
womens ability to find safe, mutually honoring relationships as adults can be
taken up in the later phases of treatment, when they are no longer being bul-
lied by a partner, being revictimized by the courts, or blaming themselves for
experiences that were beyond their control. Although experiencing or wit-
nessing abuse in childhood appears to increase a womans risk of being
abused as an adult, the major risk factor for partner abuse is being a woman
in a society that tolerates domestic violence. Using a trauma framework to
address coping strategies such as substance abuse, self-cutting, or seeming
passivity in the face of ongoing threats not only provides perspective for
women on behaviors they may experience as shameful but also reduces the
likelihood that clinicians will respond in ways that are inadvertently judgmen-
tal or pathologizing (Dutton 1992).
Advocating for Women and for System Change
Advocacy on the victims behalf adds another dimension to traditional clini-

cal interactions. It facilitates rather than directs change by actively helping
women become aware of their options, gain access to community resources,
make their own choices about how best to end ongoing violence, and mitigate
the impact of the abuse on their lives. It is important for clinicians to acknowl-
edge the barriers women face in ending and recovering from abuse and to ad-
vocate for change in those systems using the vehicles available to them. This
could involve advocating with insurance companies to reimburse an individ-

ual patient for long-term trauma therapy, working through professional orga-
nizations to influence reimbursement policies on a larger scale, incorporating
issues of abuse and violence into clinical training curricula, or working with
other systems to increase their understanding of the psychologic effects of
trauma.
Assessing for Trauma
Anyone seen in a clinical setting should be asked specifically about past and
current abuse. It is important to let women know that
Abuse experiences are common.

You are willing to listen.
You believe her and are concerned.
The abuse is not her fault and no one deserves to be treated that way.
Resources are available to help her if she is currently in danger.
She will not be judged or stigmatized as a result of what she has said to
you.
All information will be kept confidential within the confines of subpoenas
and mandatory reporting laws (inform women about the limitations of
confidentiality in your state; this information can usually be obtained
through state professional organizations).
Routine inquiry is essential to avoid misdiagnosis and misinterpretation

of symptoms and to provide appropriate intervention (Dutton 1996). It helps
reduce the isolation that abusers use to establish control over their victims.
Although assessment is often the initial phase of treatment, it is also an ongo-
ing process. Many survivors have concrete reasons for not initially disclosing
abuse. A woman could lose custody of her children if she is given a psychiat-
ric diagnosis or if it is discovered that she lives in a violent household. Her
partner may have told her that he will kill her or her children if she reports
the abuse or tries to leave. Survivors may also experience intense guilt and
shame, particularly about sexual assault and abuse; this can make it difficult
for them to raise or discuss these issues until they feel safe in the therapeutic
relationship or more secure in their own lives (Harvey and Harney 1995). For
women who have been sexually abused as children, memories may be absent
or incomplete at the time they enter treatment (Briere 1992a).
Inquiries about abuse should not be made in the presence of a possible

perpetrator or another person whom the woman has not privately identified
as someone she can trust with that information. Such questions should not be
asked during a couples therapy session, through an untrained translator,
with a personal assistant or guardian in the room, or in the presence of a per-
son providing additional information, even if a woman is acutely psychotic
or unable to provide it herself. These questions should not be asked on ques-
tionnaires sent to the womans home. Patients should be told that the infor-
mation they give is confidential and, within the confines of the law, will not
be revealed to the batterer or anyone else without their permission. For those
clinicians who practice in states with mandatory reporting laws, it is essential
to inform the patient of this requirement at the beginning of the evaluation,
preferably before he or she has discussed the abuse. It is also important to dis-
cuss reporting obligations before inquiring about child abuse. In addition,
strategies should be developed for safely separating patients from abusers
should that become necessary. If there appears to be an immediate threat
from the abuser, the clinician should be prepared to notify the police or secu-
rity and to outline any potential risk (e.g., abuser is in the waiting room in-
timidating staff). Once initial safety is established, however, a patients wish
to have another person present should be respected.
It sometimes feels awkward to suddenly introduce the subject of abuse,
particularly if there are no obvious indications that the woman has been vic-
timized. Abuse-related questions can be framed in many ways that let women
know their experiences are common and that you are comfortable with and
interested in knowing (e.g., I dont know if this has happened to you, but
because so many women experience abuse and violence in their lives, its
something I always ask about or Tell me about your relationship). It is,
however, important to ask explicit questions about specific abusive experienc-
es. Simply asking a woman Have you ever been abused? places her in the
doubly difficult position of having to evaluate her assailants behavior as well
as report it (Table 231).
Several trauma screening tools are available, such as the Trauma Symp-
toms Inventory (Briere 1995; Briere et al. 1995), the Clinician Administered
PTSD Scale (CAPS) (Blake et al. 1995), the Structured Interview for Disor-
ders of Extreme Stress (SIDES) (Peclovitz et al. 1997), and the Dissociative
Experiences Scale (DES) (Bernstein and Putnam 1986), to name a few. These
can usually be obtained by contacting the authors (Briere 1997; E. B. Carlson
1997; Tolman 1988, 1999; J. P. Wilson and Keane 1997). Questions can eas-
ily be adapted from instruments such as these and integrated into standard
TABLE 231. Asking about abuse
Partner abuse
Has your partner ever physically hurt you? Has he (or she) ever threatened to hurt
you or someone you care about? (Give examples of specific acts)
Do you feel safe in your current relationship? Are you ever afraid of your partner?
What kinds of things does he or she do that make you afraid?
Has your partner ever humiliated you, controlled you, or tried to keep you from
doing things you want to do? When you are with your partner, do you feel like
you are walking on eggshells?
Has your partner ever forced or pressured you into engaging in sexual activities that
made you uncomfortable or into having sex when you didnt want to?
Do you feel you can say no if you don't want to have sex?
Childhood sexual abuse and sexual assault
Were you ever told by an adult to keep a secret and threatened if you did not?
Were you ever touched in a way you didn't like?
How old were you when you first had sex (including anal, vaginal, and oral pene-
tration)?
How old was the person you had sex with?
Were you ever forced or pressured into engaging in sexual activity when you were
a child? At any other time in your life?
Did you tell anyone about what happened to you?
How did they respond? What happened as a result of your telling?
assessments (see Norris and Riad 1997).

If a woman discloses a history of current or past victimization, a more in-
depth assessment of her situation is required. More information is needed
about the nature of her traumatic experiences and the scope of their impact
on her life; her current safety status; how the abuse has affected her and her
children and how she protects them and herself; the presence of medical ill-
nesses and psychiatric symptoms (disorders known to be related to trauma,
including suicidality, self-cutting, and high-risk sexual behavior, as well as co-
existing health, mental health, or substance abuse problems); the coping strat-
egies she uses and how they affect her daily life (currently and at the time of
trauma); her developmental context (e.g., family dynamics, quality of other
relationships, events surrounding childhood abuse, response of others, feel-
ings at the time and currently, self-organization); her degree of isolation ver-
sus support; what she has tried in the past and how that did or did not work
for her; and her own assessment of the situationwhat she would like to see
happen and what issues she faces in achieving those goals.
Specific Assessment Issues
Women seeking help for a recent sexual assault or rape-related PTSD may
have already been asked to provide detailed accounts of their experience to
emergency room personnel and to the police. It is important to assess the na-
ture of the trauma that precipitated treatment. Acquisition of more detailed
information should be paced to the patients needs.
For women currently being abused by an intimate partner, the same ca-
veats apply. Asking about the details of the abuse (e.g., pattern of abuse, tac-
tics of control and intimidation, level of fear and entrapment, sexual coercion
or assault, and the abuses impact on the woman and her children) can serve
several important functions. It allows providers to document critical informa-
tion for women seeking legal protection, redress, or custody and provides a
safe opportunity to examine the ongoing nature of the abuse and its impact.
In addition, asking a woman what she has done to try to remedy her situation
and how her efforts have been received creates a chance to explore new op-
tions and to acknowledge the resourcefulness she has exhibited in coping
with her situation.
It is important to remember that although the symptoms or issues that
emerge during an assessment may seem to point to a history of trauma, the
woman before you may not see it that way. Although some women may seek
treatment for symptoms or issues explicitly related to a particular traumatic
experience, not everyone will link their current distress to such events. Many
will not recall earlier traumas until later in the course of therapy. Therefore,
it is incumbent on therapists to keep an open mind about the potential pres-
ence of trauma in a womans history, to attend to abuse-related information
as it arises, and to validate those perceptions without digging for memories
or assuming that because a woman has a particular constellation of symptoms
she has been sexually abused as a child. It is also important to document
womens descriptions of abusive experiences in their own words, particularly
when there is the potential for legal action. Guidelines have been developed
by several responsible professional organizations to help clinicians negotiate
this complex terrain (American Psychiatric Association [1993], American
Psychological Association, International Society for Traumatic Stress Studies,
American Medical Association [see Goldman et al. 1995]).
Race, Ethnicity, Culture, and Religion

Women of color may be reluctant to discuss abuse if they perceive this as be-
traying their community or likely to invoke discriminatory criminal justice ac-
tions toward the perpetrator. Cultural or religious constraints may make it

difficult for a woman to discuss the abuse with someone outside her commu-
nity. Alternatively, women may be afraid to discuss these issues with someone
from the same cultural background. Issues of privacy, shame, safety, and con-
fidentiality all affect a womans decision to reveal that she is being abused.
Mental health treatment may be stigmatized, making it more difficult for
women to seek help for trauma-related symptoms. Women may face social
isolation and ostracism if they attempt to leave an abusive spouse, making it
harder for them to consider this as a possibility. The idea of breaking mar-
riage vows may create serious spiritual conflicts for some women as well.
Immigrant women also face obstacles to treatment. Those who are un-
documented may find it even more difficult to reveal a history of partner
abuse, in part because they are afraid of bringing attention to their situation,
and in part because batterers threaten to have them deported if they tell and
to leave them without resources or support. Some batterers control their
wives by deliberately failing to file their petitions for permanent residency.
State domestic violence coalitions are usually aware of services that specifical-
ly address these issues
Lesbian Women
Discussing partner abuse may also be difficult for women in lesbian relation-
ships who have experienced homophobic responses outside the gay and les-
bian community and denial about domestic violence within. It may be more
difficult for lesbians to find confidential sources of help, particularly when
their abusive partner is involved in organizations that provide services to bat-
tered women. Not uncommonly, a lesbian batterer will attempt to control her
partner by threatening to out her if she reveals the abuse or tries to leave
(homophobic control; Hard 1986) or by defining the womans efforts to de-
fend herself as mutual combat, undermining her efforts to get help (Hard
1986; Renzetti 1992; West 1998). Internalized responses to homophobia and
violence in a womans family of origin may contribute both to perpetration
and to an increased vulnerability to victimization once it occurs. Although
there are couples in which the abuse or violence is mutual or in which one
partner initiates and the other fights back, for many women the pattern of one
partner systematically controlling the other is no different from that in abu-
sive heterosexual relationships (Marrujo and Kreger 1996). It is important to
ask for explicit examples of what actually happens in the relationship when
these questions arise. Abusers typically use tactics of denial and distortion
and do not take responsibility for their behaviors. Any therapist working with
lesbian couples must interview each partner separately to ask about abuse.
Therapists should also be aware that lesbian survivors of childhood sex-
ual abuse may have some unique concerns about the therapeutic relationship.
They may be grappling, for example, with their sense of safety as a lesbian
within the therapy. This may manifest as a need to know about a therapists
view of lesbianism or familiarity and comfort in working with lesbians. A cli-
ents sense of safety may be undermined by a therapists refusal to disclose
his or her own views and experiences; by a therapists interpretation of lesbi-
anism as a response to the incest; or by a therapists inability to identify the
homophobia faced by the client as a potential cause of trauma-related disor-
ders (T. Pintzuk, personal communication, 1998).
Women with Disabilities or Other Mental Health Problems

Women already diagnosed with mental health or substance abuse problems
contend with an additional set of concerns. They may fear not being taken
seriously because of previous experiences with helping professionals or be-
cause abusers have convinced them this is so. These issues may affect a wom-
ans ability to process information and sort out options and may limit her
access to shelter. In addition, women with serious physical disabilities or med-
ical problems, some of which have been caused by the abuse, may find it even
more difficult to leave a partner or family member on whom she depends for
access to services and basic care.
Disabled women are even more likely to feel trapped in abusive relation-
ships, particularly when jobs and transportation are limited or when their
only alternative is to live in an institution or return to an abusive family (Asch
and Fine 1992). Personal assistants may also turn out to be abusers, further
decreasing womens options for living independently. In addition, women
with disabilities are often perceived as asexual and de-gendered, reducing the
likelihood that partner abuse will be recognized. These relationshipsharder
wonmay also be harder to give up (Gil et al. 1994). Therapists can learn
more about the specific needs of women with nonpsychiatric disabilities and
find ways to make their own practice settings more accessible by contacting a
disability rights advocacy group such as the Disabled Womens Network
(DAWN) in Canada or the Health Resource Center for Women with Disabil-
ities in Chicago.
Treatment and Intervention
Overview
Recognition of the impact of abuse and violence against women has led to the
emergence of a number of treatment approaches. Although few have been
tested empirically, there is growing consensus about the types of interven-
tions that are most helpful to survivors of abuse. Published studies have fo-
cused on interventions following single-event sexual assaults. These have
shown considerable success in preventing or reducing the severity of PTSD
and, to some extent, depression and anxiety. Focal short-term psychodynam-
ic therapies have also demonstrated some efficacy in treating PTSD (Marmar
1991). There is less research on which treatment modalities will be most help-
ful for individual women (Chalk and King 1998; Crowell and Burgess 1996).
Few outcome studies have been completed that assess treatment for women
sexually abused as children or women abused by intimate partners. Most re-
ports are descriptive, feature nonstandardized approaches to care, or demon-
strate relatively modest positive results (Barnett et al. 1997). The dearth of
studies in this area is not surprising given that treatment for the chronic ef-
fects of abuse is often multimodal and long-term.
As clinicians come to recognize the distinct developmental affects of
chronic abuse, more complex treatment models have begun to evolve. These
approaches combine trauma theory with developmental psychodynamic per-
spectives (self-psychology and object relations) and a feminist-based emphasis
on empowerment and social context. They often involve nontraditional,
body-centered therapies as well. Feminist theory explicitly addresses the role
of power dynamics both within a womans life and within therapeutic en-
counters. Advocacy models attend to the social reality of ongoing danger and
entrapment and the impact of social institutions and communities on a wom-
ans ability to change her life. These flexible client-responsive treatment ap-
proaches are more difficult to study than short-term protocol-driven models
but nonetheless reflect current expert opinion in this area.
There are also several promising studies of group treatment modalities
(Courtois 1988; Lubin and Johnson 1997; Talbot et al. 1998; Winick et al.
1992; Zlotnick et al. 1997) and interventions designed specifically for manag-
ing the symptoms and self-harming behavior of women diagnosed with bor-
derline personality disorder, a high percentage of whom have experienced
abuse in childhood (Linehan 1993; Simpson et al. 1998). Many of those tech-
niques have been adapted into more complex treatment programs designed
specifically for women with severe trauma histories and DESNOS (e.g.,
Bloom 1997; Courtois 1997) or SMI (Harris 1998). More recently, eye move-
ment desensitization and reprocessing has been shown to be effective as an
adjunctive tool for treating PTSD (Shapiro 1995).
Although many techniques are available for treating PTSD, dissociative
identity disorder, and DESNOS, they generally are geared toward addressing
specific sets of symptoms. Healing from the interpersonal and developmental
effects of abuse and violence requires the safety, consistency, caring, and re-
spect of an ongoing therapeutic relationship. Although some women respond
to short-term interventions, others may need many years to recover from the
traumatic effects of longstanding abuse. Often, therapists are trained to value
specific intervention techniques or particular theoretic orientations, which
may lead them to dismiss other forms of treatment that might be helpful. Al-
though the issues unique to sexual assault, sexual abuse, and domestic vio-
lence are described in separate sections, many of these also overlap. Trauma
must be addressed within the context of who a woman is and where she is in
her life and must acknowledge her particular strengths, vulnerabilities, resil-
ience, defenses, and support.
The following section describes a phase model for treatment that reflects
the growing consensus among clinicians and researchers working with survi-
vors of sexual abuse and other forms of chronic severe trauma (Courtois
1997; Harvey and Harney 1995; Herman 1992b). The emphasis is on estab-
lishing stability and safety and on building a therapeutic relationship (early
phase) before proceeding to the trauma-focused work (middle phase) that can
be painful and disruptive to both the therapist and the client. The final phase
involves the integration of memories, development of new capacities, recon-
nection to others, and rebuilding of ones life (Dutton 1992). This process is
not linear, of course, but rather provides a framework for conceptualizing and
conducting this often challenging work.
Building Collaborative Alliances:

The Centrality of the ClientTherapist
Relationship in the Early Phase of Treatment
For many women, recovering from the sequelae of abuse is an ongoing strug-
gle fraught with relationship difficulties and symptoms that fluctuate over
time. In some situations, a woman and her therapist may be able to navigate
through these difficulties without additional intervention. In other circum-
stances, debilitating symptoms, work instability, ongoing danger, coexisting
substance abuse or eating disorders, and other harmful behaviors often re-
quire a wider range of interventions than can be addressed by an individual
therapist alone.
For someone who has experienced severe, chronic abuse, particularly as
a child, the work involved in building therapeutic alliances cannot be overes-
timated. As Elliott and Briere (1995) noted, therapy is a powerful re-stimu-
lator of abuse-era related feelings, perceptions, and experiences. It can take
years to create an environment in which a woman can reframe her relation-
ship to the traumatic events she has endured and reconstruct her beliefs about
how relationships can function in the absence of coercion and violence. This
outcome is possible only if the relationship between client and therapist is col-
laborative (Briere 1996; Courtois 1997; Dutton 1992; Herman 1992b;
Schechter 1996; Warshaw 1996b). Providing information about trauma and
other related issues is strongly encouraged, and treatment plans should be
jointly conceived, evaluated, and redesigned on a regular basis.
Challenges of Collaboration:
Transference, Countertransference, and Ethics
The process of constructing a collaborative relationship poses challenges to
both client and therapist. Survivors of abuse may, for example, express
thoughts or feelings or engage in behaviors that represent conscious or disso-
ciated reenactments of or strategies to protect themselves from traumatic in-
terpersonal experiences. Therapists unaware of transference dynamics may
respond in complementary ways (e.g., react angrily to being accused of acting
like a perpetrator) instead of realizing that a component of the clinical inter-
action or a concurrent life event is reminiscent of a past negative event or re-
lationship (Rieker and Carmen 1986). On the other hand, abuse may be
occurring in the present and such reactions must not be attributed to earlier
experiences or transference when that is not the case.
The therapist is vulnerable to reactions such as distancing from clients
and avoiding issues that seem overwhelming. Listening to women talk about
their experiences of abuse can evoke a range of painful responses that can be
traumatizing in themselves. This phenomenon of secondary or vicarious
traumatization has been increasingly recognized within the trauma field (Dut-
ton 1992; Elliott and Briere 1995; Pearlman and Saakvitne 1995). In addi-
tion, many therapists have experienced some form of gender-based trauma
themselves and are at risk for having their own feelings triggered when work-
ing with other survivors.
It is important for therapists to discuss the parameters of treatment with
clients so they will know what they can and cannot expect from a therapeutic
relationship and to create the opportunity for clients to discuss their own con-
cerns. It is easy to perceive clients as too needy or demanding when they
exceed the capacity of the therapist or of an ethical treatment to meet needs
that should have been met at an earlier time. It is important to protect both
the client and the therapist from unrealistic expectations and disappointments
that can re-create dynamics of earlier abusive interactions. There will be dis-
appointments or times when a client may feel rejected, abandoned, or not
seen; agreeing on parameters at the outset helps create a safe and mutually
respectful atmosphere in which to explore these issues when they arise.
Overinvolvement on the part of the therapist, whether it be exploitive
(meeting ones own needs at the expense of the patient) or well intentioned
but nave (overidentifying with the client or wanting to cure her through
unlimited caring and availability) is problematic. Women who have been sex-
ually abused in the past are more likely to be subjected to boundary viola-
tions by mental health providers (Gabbard 1994; Gartrell et al. 1986). Any
form of exploitation, including sexual involvement, is clearly unacceptable
and if therapists become aware of those dynamics, immediate consultation
should be sought. Therapists who extend themselves beyond their capacities
may find themselves becoming depleted and unable to respond appropriately
and protecting themselves in ways that ultimately abandon the patient. This
type of overinvolvement can curtail a clients autonomy, disrupt her ability to
experience rage (including rage at the therapist), and interfere with opportu-
nities to grieve irreparable lossescrucial issues for many survivors. Fears of
being overwhelmed by a patients demands, fears for the patients safety, con-
cerns about liability, or fears of invoking the boundary police may also
cause therapists to become overly rigid and to distance themselves from pa-
tients. These behaviors, although protective of the therapist, are in fact dimin-
ishing and disrespectful to patients, who in turn may experience them as
punitive, rejecting, and abandoning.
With patients for whom abuse has severely disrupted their capacity to
trust, relate to others, and protect themselves; who may be more volatile and
who have not internalized mechanisms for managing intolerable feelings; and
who engage others in roller coasterlike attempts to manage themselves, it is
important to understand not only the context of these behaviors but our own
responses as well. This is notoriously difficult when patients are chronically
suicidal and the therapist feels responsible for their survival. Without ade-
quate support, therapists may distance themselves from their patients, hospi-
talize them either too soon or too late, become punitive, or make themselves
continuously available in ways that disrupt their own lives.

On the other hand, providing genuine care, respect, and kindness; going
out of ones way during crises (e.g., scheduling additional contact, visiting a
client in the hospital, mutually determining the best way to handle emergen-
cies); or facilitating access to necessary resources should not be cause for con-
cern. A fine line exists between continual and consistent availability; it is the
therapists consistency that helps clients create the internal sense of security
necessary to weather emotional storms. Therapists cannot undo what was
done in the past nor should they attempt to protect patients from their own
knowledge, feelings, and experiences. Outside perspective, support, and con-
sultation are vital for therapists doing this type of work to reduce their own
isolation, depletion, and traumatization.
These dynamics are not limited to one-on-one clinical interactions. Sur-
vivors of abuse can experience retraumatization as a result of interactions
with the health and mental health systems as well. The distortion of meaning
and denial of experience that are used as tactics of psychologic control in abu-
sive relationships can be inadvertently repeated in clinical/medical encounters
if clinicians are unable to recognize and validate the traumatic contexts in
which a persons symptoms are developed and maintained.
Co-Creating Safety and Stability

While the therapeutic relationship is being built, the therapist works with the
client to ensure her safety, manage stress, and perform daily tasks. Helping a
client stabilize her life may include working with her to initiate or maintain a
regular day and evening schedule, engage in some form of exercise, receive
medical care, learn and practice grounding and self-soothing techniques, and
create or strengthen a support network that values and nurtures her in this
process. In addition to these activities, the therapist and client can work to-
gether to discover what kinds of events or interactions trigger dissociation
and flashbacks so that the client can begin restructuring her responses to
these triggers and thus reduce their negative impact on her life. This process
of restructuring can be aided by various relaxation and other de-escalation
techniques. Medication may also be helpful, provided that the woman is ed-
ucated about it and that the medication does not interfere with her ability to
protect herself (Bloom 1997; Courtois 1997; Turkus 1995). Benzodiazepine
use, for example, can compromise a womans ability to protect herself or to
leave an abusive relationship. For women with symptoms that may necessi-
tate hospitalization, reviewing preferred de-escalation strategies (e.g., finding
alternatives to or more tolerable forms of restraint and seclusion) before or at
admission can reduce the risk of retraumatization and can enhance a wom-
ans sense of choice and empowerment. Several individual states and institu-
tions have begun to modify their seclusion and restraint policies accordingly
and model policies are available (Carmen and Rieker 1998; Jennings 1994b).
Special Considerations When Abuse is Ongoing:

Domestic ViolenceSpecific Issues
Many abused women are still in danger at the time they seek help and are at
greater risk when they try to leave or seek outside help to end the violence.
Inquire about perpetrator risk factors such as suicide attempts; depression;
past violence; violence toward others; types of substance abuse; threats of fur-
ther violence, suicide, or homicide; escalation of threats or actual violence;
availability of weapons; obsession with or access to his/her partner or signs
of stalking; abuse during pregnancy; or violent sexual assault. Exposure to
other dangerous environments should also be assessed. After reviewing all of
these risk factors, a woman should be asked to consider whether she thinks
she is in danger of being seriously injured or killed. If she says yes, this should
be taken very seriously. If she says no but the clinician still has concerns
about her safety, these should be discussed frankly and efforts should be
made to help her think through her options. If she is at risk and is planning
to leave the relationship, the clinician should advise her to seriously consider
leaving without informing her partner and should assist her in finding a safe
place to go.
Women currently in danger should be encouraged to develop safety and
escape plans if they are staying with an abusive partner or the abuser has ac-
cess to them and to explore their options if leaving. It is helpful for women to
rehearse their plans so they will be in place when needed. Women can do a
number of things in addition to calling the police or a crisis line or getting a
protective order from the courts. They can review previous episodes for in-
formation that identifies predictable patterns and locations that may be dan-
gerous; think about how to anticipate and reduce danger if possible; make
provisions for children (rehearse escape strategies, places to stay, numbers to
call, how to make credit card calls); locate (in advance) a safe place to go in
an emergency; make provisions for leaving quickly; and have necessary items
and papers packed, accessible, and if at all possible hidden from the abuser.
Police can escort a woman back to her home if she needs to gather belong-
ings, but if an abuser suspects his/her partner is leaving he/she may destroy
valuable items and papers. A woman can also develop and rehearse an escape
plan and develop a plan for getting help when she cannot escape (e.g., signal
to neighbors, teach the children to dial 911)
Clinical Issues
Women trapped in abusive relationships may be immobilized by depression,
panic attacks, or severe stress responses such as brief reactive psychoses,
acute stress disorder, or PTSD. In such situations, treatment is clearly war-
ranted to enhance a womans capacity to function and make choices that will
ultimately lead her to safety. However, reframing these disorders as under-
standable responses to terror and entrapment will lead to intervention strate-
gies that both provide perspective to the woman and focus on the dangers she
is facing.
Battering appears to be a risk factor for suicide attempts (Stark and Flit-
craft 1995). Some women do not feel they have any other options for ending
the abuse and the pain they are experiencing. They may have made multiple
unsuccessful attempts to protect themselves, stop the abuse, or leave. For oth-
er women, the risk of suicide may increase after they have left the relation-
ship, before they have had a chance to recover their sense of self-worth and
their ability to function on their own. Whether the separation is by choice or
because the batterer has left them for another woman, the experience of aban-
donment and loss may become too painful to tolerate (Dutton 1992).
Homicidal ideation also warrants emergency psychiatric evaluation. In
most cases, women who kill their partners have been severely abused for long
periods of time and see no other way out. They believe they need to kill to
prevent the murder or serious injury of themselves or their children. Experi-
enced clinicians have found it very rare for battered women to premeditate
the murder of an abusive partner. Rather, they develop self-defense strategies
(e.g., carrying a weapon) that have potentially lethal outcomes both for the
victim and her partner. Assessing a womans level of danger and discussing
the risk of lethality, the likelihood of incarceration, and the range of other al-
ternatives can help diffuse the immediate danger. Discussing the possibility of
measures such as being transported to out-of-state shelters, relocation, wit-
ness protection plans, and hospitalization provides the victim with alterna-
tives to homicide when her own danger is high (Dutton 1992). The therapist
should try to assess if such circumstances reflect her current situation by ask-
ing her to describe how she perceives her options for safety; if homicide is a
possible scenario, she should be asked directly whether she has plans to kill
or harm her partner and, if so, whether she has a weapon or plan for carrying
out that action. If she has a plan, duty-to-warn considerations come into play.
If a clinician is aware of a patients intent to harm a third party, such as the

patients spouse or partner, the practitioner may have a legal duty to breach
the patients confidentiality and warn the third party of the impending dan-
ger. The Tarasoff (1976) decision enjoins clinicians to take reasonable steps to
protect a third party from harm. This may include hospitalization or shelter-
ing of a victim who sees homicide as the only way to be safe.
Confidentiality and Documentation Issues
Any information that becomes available to the batterer can increase a wom-
ans danger and can be used to control her or used against her in court with
regard to custody issues. It is important to be sensitive to nuances of docu-
mentation. Any symptoms that result from or are aggravated by abuse should
be documented, and the potential for the symptoms to subside once the vic-
tim is safe should be discussed. Diagnoses and medications should be used
with caution (consider using acute stress disorder or adjustment disorder not otherwise
specified rather than PTSD if a woman is still being abused). Discussion should
be framed around the relationship of symptoms to the abuse; the womans
strengths, coping strategies, ability to care for her children, and efforts made
to protect them should be described. For therapists involved in custody eval-
uations, it is important to recognize the appropriateness of a womans anger
toward the abuser and her reluctance to expose her children to a violent, abu-
sive parent. Women are often penalized in these situations for being the less
cooperative parent. Therapists must take care not to be fooled by the seeming
health of an abuser whose partner may look more symptomatic (Koss et al.
1994). Abusers frequently use custody battles and visitation as ways to con-
trol a partner who is attempting to leave.
Providing Information About Domestic Violence
Many battered women are either numb or in a state of terror and confusion
at the time they seek help and have not had room to do more than survive.
Providing information about the dynamics of abuse; typical battering tactics;
common sequelae; the pattern of abuse and the likelihood that it will contin-
ue; the impact of abuse on children; risks, danger, and safety planning; and
available options and resources is also a powerful intervention tool. It helps
decrease isolation and shame, helps women gain perspective, aids in decreas-
ing psychologic entrapment, and offers a sense of hope and connection.
Abusers control and intimidate their partners to make themselves feel
powerful. The typical controlling behaviors used by perpetrators should be

described. It is important to convey the message that despite a partners
promises, most violence continues and escalates over time and has serious
medical, psychologic, and social consequences; even if the violence is infre-
quent, it still has a powerful effect. A single violent incident paired with
threats, intimidation, and psychologic abuse will continue to undermine a
womans freedom and self-confidence, thus increasing the feelings of fear, iso-
lation, and entrapment that will keep her at risk for future assault.
If a woman is seeking help for her abusive partner, discuss what is known
about perpetrators, about the limits of treatment programs, the possibility of
his continued controlling behavior even if he stops his violence, and his need
for long-term commitment to counseling and change. The importance of a
genuine commitment to change cannot be overestimated. When a womans
abusive partner is in counseling, she may stay with him longer in the hope
that he will stop the abuse. Many batterers enter counseling solely to keep
their partners from leaving. It may be necessary to revisit these issues during
the course of therapy to ensure her safety.
Recent outcomes research indicates that cognitive-behavioral, gender-
based intervention programs for batterers can be effective in reducing assault
recurrences, particularly for men who complete the programs (Gondolf
1997). Men who were court-ordered into treatment programs were more like-
ly to complete them. Within the 15-month follow-up period of this study
(Gondolf 1997), only one-third of the men were still physically violent toward
their partners. Counter to the initial hypotheses, batterer personality profile
did not predict outcome. Being intoxicated during the follow-up period in-
creased the likelihood of recidivism (Gondolf and Browne 1998). Treatments
for batterers that do not directly address their abusive behavior are ineffective
and may actually increase the violence (Substance Abuse and Mental Health
Services Administration 1998).
Because of the ongoing dangers battered women face, it is important to
be aware of interventions that can potentially increase their risk of harm, such
as confronting the batterer with the intention of getting him to change. In
some cases, violence may escalate during treatment; therefore, programs for
batterers without supports for battered women should not begin until women
have access to adequate shelter and advocacy. In addition, many agencies of-
fer anger control groups that fail to confront the underlying issues of power
and control. A batterer may then feel entitled to lose control and reprimand
or punish his partner. Anger management alone is a potentially ill-fated inter-
vention unless it also challenges the batterers need to control his partner and
his right to use violence against her (Schechter 1987). According to the Sub-
stance Abuse and Mental Health Services Administration (1998),
Batterers treatment can be effective if programs place a premium on survi-

vor safety (even though the batterer is the client), insist that batterers take
personal responsibility for their behavior, mandate no-violence contracts,
impart emotional regulation techniques, follow up on treatment completers
and dropouts, and evaluate program outcomes regularly. (p. 54)
Referral to couples counseling in situations of ongoing violence, threats,

or intimidation is another potentially harmful intervention. Schechter (1987)
and Dutton (1992) outlined clear parameters for addressing the issue of cou-
ples therapy in the context of domestic violence. Some women may request a
referral for couples therapy because they feel this is the only way to get help
for their partner. However, couples counseling is indicated only when vio-
lence and coercive tactics have ceased for longer than the longest period for
which the abuse stopped in the past, after the batterer has successfully com-
pleted a treatment program, and when both parties request this form of treat-
ment. The abuser must take exclusive responsibility for his or her assaults
and acknowledge that family reunification is not the goal of treatment. Work-
ing to rebuild the relationship and repair the damage will only be helpful if
that dynamic has truly changed (Dutton 1992; Schechter 1987). Stopping the
abusers violence and controlling behavior should not be the focus of couples
therapy. If a woman does pursue couples therapy, however, these behaviors
do need to be addressed.
Court mediation is also not an appropriate intervention in cases of do-
mestic violence. It assumes the presence of two equal parties who can negoti-
ate in good faith and solve problems together. Abusers, however, manipulate,
intimidate, and bully their partners and cannot negotiate responsibly. Be-
cause of this, battered women should be encouraged to seek legal assistance
before discussing divorce, child custody, visitation, and other issues with their
partners (Schechter 1987).
Many batterers check the odometers on their partners cars and go
through their partners purses, briefcases, pockets, and drawers. Insurance in-
formation sent to the home may also put her in danger. The therapist and the
victim should discuss what written material will be safe for her to take home
and whether precautions should be taken to avoid written information about
the abuse on materials he may see. She may need to write important phone
numbers on scraps of paper or memorize them, or she may be able to leave
the information at work or with a friend.
Providing Access to Community Resources:

Role of Domestic Violence Advocacy Programs
Domestic violence advocacy programs and shelters provide various services
for battered women and their children as well as public education and train-
ing for service providers. They are the major source of support for many
women. Others may feel most safe when connected to a mental health pro-
vider (with advocacy playing an important but adjunctive role) or in peer sup-
port groups. Most battered women do not stay in shelters, either because of
insufficient resources or because they have other options, but they do use a
wide range of services available through domestic violence programs. Clini-
cians should find out about the nearest domestic violence programs in their
communities. Typical services include a 24-hour hotline and crisis interven-
tion counseling; assistance in evaluating options, resources, safety planning,
and referrals; information about legal remedies and legal and court advocacy
(such as assistance with protective orders); emergency shelter, hotel vouchers,
or safe homes; counseling, support groups, and referrals for therapy; immi-
grant rights information; advocacy with child protective services; literacy
programs, job training, and transitional housing; and appropriate referrals for
perpetrators/abusers. It is important to note that some of these services may
not be available in the victims community.
Rape-Specific Treatment
Sexual assault hotlines and advocacy groups provide a framework for ad-
dressing womens needs in the immediate aftermath of an assault. They ad-
dress issues of safety and stabilization, assist women in negotiating the
medical and legal systems, help women deal with other peoples reactions to
the assault, inform women about the range of posttraumatic responses they
might experience, and provide a supportive place for women to process their
experiences.
Outcomes-based research on sexual assault has focused primarily on cri-
sis intervention of a different sortthe reduction and/or prevention of PTSD
symptoms. These interventions have used treatment modalities that are ame-
nable to this type of empirical research, such as limited numbers of sessions,
cognitive or behavioral techniques, and protocol- rather than client-centered
approaches to session content and pace. Although it is not possible to gener-
alize about the efficacy of these approaches for women who experience more
chronic forms of trauma, several recent studies have demonstrated promising
results for victims of violence in general.
Sexual assault, even as a single event, must be responded to in context,

addressing feelings of shame, guilt, responsibility, anger, and despair as well
as posttraumatic fears that may arise. The time in a womans life (e.g., first
sexual experience), the circumstances surrounding the assault, and her rela-
tionship to the perpetrator affect her experience and must be attended to in
therapy, regardless of techniques used to address symptoms.
Techniques
Stress inoculation training was adapted by Kilpatrick et al. (1982) and Veronen
and Kilpatrick (1983) from learning theory concepts (Meichenbaum 1974) to
treat the fear and anxiety experienced by rape victims. Over the course of
treatment, participants identify cues that trigger fear, develop coping skills
through the use of deep breathing, thought stopping, and role playing, and
apply these techniques when engaging in feared behaviors (Kilpatrick et al.
1982; Resick et al. 1988; Resnick and Newton 1992).
Cognitive processing therapy provides victims with exposure to traumatic
memories and trains them to challenge maladaptive cognitions (i.e., meanings
and lessons one has taken from the traumatic experience) that cause unnec-
essary pain and constrict womens lives. Participants are encouraged to write
about the traumatic event and are taught how to reconfigure their thinking
about the trauma in ways that modify its impact on daily functioning. This
technique has been effective in reducing PTSD and depression (Resick and
Schnicke 1992). In comparison with control subjects, patients receiving this
intervention had a significantly greater reduction in symptoms 3 months after
the training.
Two other studies examined the effectiveness of these treatments for rape
victims suffering from PTSD immediately after an assault. Foa et al. (1991)
compared the effectiveness of stress inoculation training with the use of pro-
longed exposure techniques (i.e., repetitive descriptions of the rape and its af-
termath within a highly structured, intensive treatment program), and
supportive counseling. They found that all three led to posttreatment im-
provement; stress inoculation training was most effective in reducing fear,
anxiety, and depression, but exposure was most effective for reducing PTSD
at 3 months. Any contact with a therapist was found to reduce many forms
of rape-induced distress (Koss et al. 1994), but active treatment seems to be
necessary to reduce PTSD.
Although exposure therapy appears to be highly successful for selected
individuals, negative effects have also been reported. These treatment modal-
ities appear to be more appropriate for women who do not have dissociative
symptoms, who are not primarily depressed, and who are physically safe
(Ehlers et al. 1998; Pitman et al. 1991). In one study, participants exhibited a
poorer response if they felt defeated during a traumatic experience, alienated
following the event, and had developed a sense that their lives would never
be the same. Because this pattern of responses is common for trauma survi-
vors, further investigation is necessary to determine which women would and
would not benefit from these techniques. For survivors of chronic childhood
abuse who have not yet developed the internal capacity to modulate affect
and arousal, symptoms may be exacerbated by exposure.
Many clinicians see group interventions as the modality of choice for sur-
vivors of rape. Groups uniquely undermine rape-induced isolation, validate
feelings, confirm experiences, counteract self-blame, and empower survivors
by offering them an opportunity to work through issues in a nonhierarchical
setting (Koss and Harvey 1991).
Women who have been raped may seek treatment for other reasons and
only later in therapy address issues specifically related to the assault. For ex-
ample, a woman may have accommodated her posttraumatic sexual avoid-
ance, which may emerge later as a concern in a new relationship, or a woman
may have previous assault experiences triggered by current life events (ha-
rassment at work) that make those experiences more available for working
through. In addition, a woman may be raped during the course of therapy,
raising issues for the noncognitive-behavioral therapist about how best to
prevent chronic PTSD. Developing relationships with local sexual assault
programs and clinicians who are skilled in some of the above techniques can
provide useful adjuncts to ongoing treatment (Foa 1997; Foa and Rothbaum
1998).
Working Through the Trauma:

Acknowledgment, Grieving, Acceptance,
and Integration in the Middle Phase of Treatment
Additional work involving the traumatic material that exacerbates symptoms

generally begins once safety and a collaborative therapeutic relationship have
been established, but this is not always the case. The therapeutic process is
generally more fluid than linear, flowing back and forth between phases as
the circumstances of the clients life change. In any case, if involuntary intru-
sions continue to interfere with a clients functioning, controlled and predict-
able exposure to traumatic material can help her to further integrate this
material and contain its impact.
The goal of the middle phase of treatment is to gradually help a woman

reexperience the trauma in a safe and tolerable way that allows her to ac-
knowledge and come to terms with what has happened in her life. For a sur-
vivor of childhood sexual abuse, this might involve helping her slowly
reconstruct her story and struggle with the doubts she may entertain about
abusive incidents and her role in them. Helping women reduce their sense of
shame, addressing the anger and rage that may or may not be directed toward
the abuser, and processing the grief or noncompensable losses (Dutton
[1992]) that one could not previously afford to feel are also important tasks
during this time.
For women recovering from the traumatic effects of an abusive partner
relationship, freedom from violence is an ongoing goal. Taking cues from
each woman about her sense of pacing and timing is crucial. Sometimes wom-
en may be overzealous about discovering what happened and may become
traumatized if therapists do not provide perspective to these patients on the
importance of pacing their uncovering and taking care of themselves in the
process.
A range of techniques may be used to assist the patient in this process,
including writing, drawing, music, movement, body work, and other expres-
sive therapies. As with rape survivors, groups can help to reduce isolation,
expand support networks, and destigmatize events experienced as shameful.
Time-limited groups have also been useful, allowing women to tell their sto-
ries in a safe and structured way in the presence of others who have had sim-
ilar experiences and to address issues of grief and mourning. Many survivors
find 12-step and other peer support groups helpful as well, depending on the
needs of the woman and the style of the group.
Another modality that appears to be helpful is eye movement desensiti-
zation and reprocessing therapy (Shapiro 1989, 1995; Vaughan et al. 1994; S.
A. Wilson et al. 1995, 1997), which involves the deconditioning of anxiety
through reactivation and reexposure to traumatic memories and the transfor-
mation of pervasive abuse-related beliefs about ones self and ones world
into more adaptive cognitions (van der Kolk et al. 1996). In this treatment,
exposure is under the control of the patient, which often engenders an in-
creased sense of mastery in the face of the traumatic experience. Some studies
have suggested unusually rapid therapeutic responses using three to four ses-
sions of therapy to treat isolated trauma. Although the body of research sup-
porting the efficacy of this modality is growing (Boudewyns and Hyer 1996;
J. Carlson et al. 1998; Marcus et al. 1997; Rothbaum 1997; Scheck et al.
1998), some reports have questioned these findings, citing studies that sug-
gest that the eye movements do not contribute to the therapeutic effects (Lohr
et al. 1995, 1998). The technique should be used after initial stabilization, and
at present is perhaps best considered a trauma-focused modality to be used
in the context of comprehensive treatment by practitioners well versed in
trauma-focused therapy.
Cultivating Self and Relational Development,

Reconnecting, and Rebuilding:
Late Phase of Treatment
The client and therapist face additional challenges in the late stage of treat-
ment, including restructuring the relationships that need to change to reflect
the womans growing sense of empowerment and mourning the loss of rela-
tionships that cannot survive this transition. Other issues that may not have
received priority at stages in which crisis was more common can now be more
easily addressed, including concerns about sexuality, nonlife-threatening
eating disorders, and addictions that have not responded to earlier interven-
tions. Additional work on boundary and other interpersonal communication
issues at home and in the workplace may also be done during this time. Even-
tually the process of terminating therapy will emerge as an appropriate next
step. This is significant and restorative work. It provides an opportunity for
the client and therapist to jointly explore and work through the feelings of
abandonment, grief, and fear that are nothing new to individuals whose most
significant relationships have been characterized by betrayal and violence
(Briere 1992a; Courtois 1997; Dutton 1992; Herman 1992b; Harvey and
Harney 1995).
Spiritual needs may also emerge during this phase if not earlier. Women
may find themselves reclaiming a spiritual dimension that was lost in the face
of the abuse. For many women, reconnecting to a former religious practice or
discovering new forms of spirituality can reflect an opening to life beyond the
abuse and may provide connections to others who have been on similar heal-
ing journeys. Spiritual endeavors/work/practices can also provide a frame-
work for women to make sense of their experiences and to recognize the
strength and wisdom they have gained during this difficult process. The tran-
sition from experiencing life as a continuous state of seige to creating a com-
munity and reclaiming ones capacity for compassion and generosity can be
important aspects of healing. Some women may emerge from this process
with deep commitments to help others who have had similar experiences or
to change conditions that perpetuate violence and abuse.
Medication
Although there is currently no psychopharmacology of abuse, treatment rec-

ommendations are based on a limited number of randomized clinical trials
for PTSD treatment conducted with combat veterans and assault survivors
and a small but growing number of open drug trials for civilian PTSD. De-
spite the dearth of controlled-trial research, clinicians have been able to draw
on treatment literature for associated disorders (depression, anxiety, panic,
and borderline personality disorder) and the ongoing treatment experience of
PTSD/trauma centers. Existing studies have not examined response differ-
ences for victims of single versus multiple traumas or acute versus chronic
PTSD, nor have they examined gender differences in treatment response.
Medication should be used in the context of ongoing trauma therapy and
offered in ways that enhance a womans sense of control over her life. This
can be done by discussing options and encouraging choices. Women should
be encouraged to discuss the pros, cons, and possible impact of taking medi-
cation, and clinicians should make efforts to ensure that women will not be
defined by or controlled by their use of it. By taking psychotropic medication
within the context of an abusive relationship, the victim can provide ammu-
nition for the abuser, who might use this information to reinforce the idea that
she (the victim) is the one with problems, not him. For example, an abuser
may use a prescription for psychotropic medication as evidence that his/her
partner is crazy and/or incapable of caring for their children. Discussing
these issues directly can help a woman counter those perceptions and reduce
an abusive partners ability to define her reality.
Medications can, however, be a valuable part of treatment for PTSD and
can be used to achieve the following goals (Davidson 1997): reduction of core
PTSD symptoms of intrusiveness, avoidance, psychic numbing and hyper-
arousal; reduction of associated disability and vulnerability to stress; treat-
ment of comorbid symptoms (e.g., depression, anxiety, panic); reduction of
psychotic and dissociative symptoms; and improved impulse control and re-
duction of self-destructive behavior.
Options for treatment include antidepressants, anxiolytics, anticonvul-
sants, opioid antagonists, and mood stabilizers. Data emerging from double-
blind, placebo-controlled clinical trials support the use of antidepressants,
particularly selective serotonin reuptake inhibitors (SSRIs) and tricyclic anti-
depressants for treatment of PTSD. In some studies (Dow and Kline 1997)
both tricylics and SSRIs were found to be useful in patients with depression
plus PTSD, but those agents predominantly affecting serotonin reuptake
were associated with better outcomes than were those affecting norepineph-
rine reuptake. The magnitude and type of trauma may also influence an in-
dividuals response (Davidson 1997). Although heightened anxiety is
characteristic of PTSD, benzodiazepines have not proved useful in controlled
trials and may be associated with rebound anxiety when discontinued. Small
open studies of anticonvulsants have demonstrated moderate to good im-
provement of PTSD.
Monoamine Oxidase Inhibitors
Results of studies using irreversible monoamine oxidase inhibitors (MAOIs)

have been mixed. In general, MAOIs have led to improvement in intrusive
symptoms and insomnia but not in avoidance and numbing, hyperarousal,
depression, or panic (Southwick et al. 1994). Side effects (e.g., sexual dysfunc-
tion, dizziness, sleep disruption, weight gain) and dietary restrictions tend to
limit use of these drugs. Reversible MAOIs do show some promise for broad-
er reduction of PTSD symptoms. Moclobemide significantly reduced both
intrusive and avoidant symptoms in one open trial and may prove useful once
it is available in the United States.
Tricyclic Antidepressants
Imipramine (Frank et al. 1988) and amitryptiline (Davidson et al. 1990) also
reduce symptoms of PTSD, depression, and anxiety as compared with place-
bo. They appear to be more effective for intrusive symptoms and less effec-
tive in reducing numbing and avoidance (Layton and Dager 1998). In
addition, they appear to be more effective in patients with less severe symp-
toms, more stability, and fewer panic attacks. As Layton and Dager (1998)
have pointed out, dosages used in these studies were high and caused intol-
erable side effects for many patients. Desipramine, however, did not demon-
strate significant effectiveness. SSRIs appear to be more effective and have a
more tolerable side effect profile. Tricyclic antidepressants have been tested
mainly in veterans with severe and chronic PTSD, whereas SSRIs have been
tested on civilians as well.
Selective Serotonin Reuptake Inhibitors
The SSRIs have been effective in reducing PTSD symptoms in open trials
(Layton and Dager 1998). In the only double-blinded, placebo-controlled
study (van der Kolk et al. 1994), fluoxetine provided significant reduction in
overall PTSD symptoms (all three clusters), particularly numbing and arous-
al. Interestingly, these findings are more robust in civilian trauma than in
combat trauma. Sertaline, paroxetine, and fluvoxamine also have shown effi-
cacy in open trials. In one small (n = 5) open 12-week clinical trial, Rothbaum
et al. (1992) found that sertraline significantly reduced PTSD among women
who had been raped. A more recent randomized controlled trial confirmed
these results (Brady et al. 2000).
Treatment of depression does not necessarily reduce psychic numbing,
which appears to be a distinct phenomenon. SSRIs, unlike other drugs that
have been studied for PTSD, seem to address both (Friedman 1997; van der
Kolk et al. 1994). They may provide additional efficacy for reducing alcohol
consumption (Brady et al. 1994) and a range of possible serotonergically me-
diated symptoms associated with PTSD such as rage, impulsivity, suicidal in-
tent, depression, panic, and obsessional thinking (Friedman 1997).
Trazodone and Nefazodone
In another open trial, nefazodone (a 5-HT2 antagonist with SSRI properties)

showed promise in reducing all three symptom clusters among civilians with
chronic PTSD who completed the trial (Davidson et al. 1998). The dropout
rate in this study, however, was greater than 50%. Trazodone has also shown
some efficacy in reducing combat PTSD symptoms, particularly reexperienc-
ing and arousal (open trial) (Davis et al. 2000). Trazodone is frequently used
to treat the sleep disturbance associated with PTSD and with some of the SS-
RIs.
Buspirone and Cyproheptadine
Buspirone, a nonsedating anxiolytic that acts as 5-HT1A partial agonist, has

been reported to reduce anxiety, depression, insomnia, and flashbacks.
Cyproheptadine, a 5-HT antagonist, appears to reduce nightmares in some
patients with PTSD.
Anticonvulsants
Anticonvulsants have also been shown to have some beneficial effects in peo-
ple with chronic PTSD (Lipper et al. 1986; Wolf et al. 1988). In open trials
valproic acid (Fesler 1991) and carbemazepine were found to reduce reexpe-
riencing and arousal, and valproate reduced avoidance, numbing, and arous-
al. Carbemazepine may also be useful in reducing some of the self-injurious
behaviors associated with borderline personality disorder or DESNOS (Lay-
ton and Dager 1998). Gabapentin, a newer anticonvulsant, has shown prom-
ise for treating PTSD with dissociation.
-Adrenergic Blockers
High-dose -blockers were found to be effective in two open studies for re-
ducing explosiveness, nightmares, intrusive recollections, sleep disturbance,
hyperalertness, and startle responses among veterans of the Vietnam War
(Kolb et al. 1984). They also improved self-esteem and psychosocial function-
ing. In another study, -blockers produced some improvement in hypervigi-
lance and hyperarousal among abused children (Famularo et al. 1988). They
were not successful in one open trial with Cambodian refugees (Friedman
1997).
2 Agonists
2 Agonists reduce 2-adrenergic receptor activity in the locus caeruleus, thus

decreasing adrenergic tone. There have been positive findings at 0.20.4 mg/
day in Vietnam War veterans, including reductions in self-mutilation, intru-
sive symptoms, insomnia, startle responses, and angry outbursts as well as
improvement in mood and concentration (Kolb et al. 1984; van der Kolk
1987). For some, clonidine appears to lose efficacy over time.
Benzodiazepines
Recommendations for the use of benzodiazepines to treat acute and chronic

PTSD remain unclear and studies have yielded mixed results. Benzodi-
azepines appear to reduce anxiety, arousal, irritability, and insomnia in people
with PTSD and in a small number of those with dissociative identity dis-
order. They have not been found to be effective for intrusive symptoms or
for avoidance and numbing. Davidson et al. (1997) have posited that a reduc-
tion in startle response and hyperarousal during the acute phase may prevent
the development of chronic PTSD and may thus make these agents useful in
conjunction with other medications, such as antidepressants or anticonvul-
sants (Friedman 1997). Several authors, however, have voiced concerns about
the potential exacerbation of hyperarousal symptoms on withdrawal, par-
ticularly from shorter-acting agents such as alprazolam, and about the risks
associated with concomitant substance abuse. Recently, observations with
temazepam have been promising. Clonazepam and buspirone have also dem-
onstrated some efficacy in reducing PTSD symptoms (Ryan et al. 1992; Sha-
lev et al. 1993).
Narcotic Antagonists
Use of narcotic antagonists, studied because they should theoretically reduce

endogenous opioid-induced numbing, has met with mixed results, showing
improvement in some studies and worsening in others. One open-label trial
found naltrexone to be useful in reducing self-injurious behavior among a
small sample (n = 7) of women, presumably by blocking postcutting opioid
elevations (A. S. Roth et al. 1996).
Antipsychotics
Few studies are available on the use of antipsychotics for PTSD, dissociative
identity disorder, or DESNOS. They have not proven to be useful in those
contexts and are currently only recommended for treatment of concomitant
psychotic symptoms or disorders. Dissociative symptoms can sometimes be
relieved with low doses of antipsychotic agents (Saporta and Case 1991). The
auditory hallucinations, thought withdrawal, and delusions of passive influ-
ence sometimes seen in people with dissociative identity disorder (Kluft
1985), however, do not appear to respond to these medications (Loewenstein
et al. 1988; Putnam 1989).
In summary, SSRIs are the most effective medications for PTSD after as-
sault or abuse and, among civilian trauma survivors, appear to have the few-
est side effects. If symptoms only partially resolve after a few weeks, clinicians
should consider using a second drug such as an anticonvulsant or -blocker.
Associated insomnia can be treated with low-dose trazodone at bedtime, and
acute or persistent agitation can be treated with clonidine or small regular
doses of a benzodiazepine such as clonazepam. Mood stabilizers can also be
useful in treating agitation. For acute trauma, reduction of autonomic arousal
with a benzodiazepine or clonidine might theoretically prevent the develop-
ment of chronic PTSD.
Addressing Systemic Barriers to Care
Clinicians face several structural barriers that may interfere with their ability
to respond to women who have been abused. For example, increasing time
constraints and capitation agreements that restrict referral for social and psy-
chologic services make it harder for clinicians to integrate routine inquiry
about abuse. Policies that can potentially place women in jeopardy if they do
receive services, such as mandatory reporting and discriminatory insurance
practices, have made some clinicians and patients reluctant to discuss these
issues. Mental health reimbursement policies that make diagnosis a prerequi-
site for treatment place women with a history of past or current abuse in the
position of having to choose between receiving mental health services and
risking having these diagnoses used against them by the abuser or child pro-
tective services to obtain custody of their children.
Micromanagement strategies, used by insurance companies to reduce
unnecessary mental health care use, can be disruptive and traumatic in
themselves. They create an environment in which short-term medication
management or potentially retraumatizing directive treatments focused on
symptom reduction rather than healing have become the standard of care. In
many settings, the consistency and safety required for long-term trauma re-
covery are no longer reimbursable.
It is unfortunate that just when an expanding body of research is clearly
delineating the impact of trauma on the human psyche and the need for more
intensive treatment for many survivors (Smith et al. 1995; Straus et al. 1996),
market forces are decreasing the likelihood that these kinds of services will be
available. This becomes increasingly true as managed care further erodes the
possibility of choosing ones provider and type of treatment, removing even
the consumer-based economic power from individuals seeking care. For low-
income women whose only access to services has been through the public
mental health system, this lack of choice has been the norm (Carmen 1995).
Thus, clinicians are often in the predicament of responding to new prac-
tice expectations without necessarily having the skills, supports, or resources
to do so and are faced with policies that place their own economic and pro-
fessional needs in conflict with the needs of their patients. Although these de-
velopments can certainly increase provider frustration, they are also leading
to new partnerships between the mental health, legal, and advocacy commu-
nities to generate awareness and to prevent these types of systemic revictim-
ization (Warshaw 1997).
In addition to the larger systemic issues, mental health providers may
also be isolated in their practice settings and lack the necessary supports to
sustain this important and challenging work. Cultivating sources of personal
renewal and professional support (e.g., consultation, peer supervision, indi-
vidual therapy, diversification, social action) can be invaluable to therapists in
both creating balance in their own lives and sustaining the empathic presence
so necessary to this work.
It can be useful to find other clinicians who do trauma-related therapy
and to develop referral networks and participate in cross-consultations with
those providers. Some domestic violence programs have identified mental
health providers who are experienced in working with battered women and/
or addressing the overlap between mental health, legal, and safety issues.
State sexual assault coalitions can also provide those resources. In addition,
there are networks of therapists who specialize in working with trauma sur-
vivors and who may conduct peer consultation groups or know of trauma-
related list servers. State or national domestic violence and sexual assault
coalitions or professional organizations, such as the International Society of
Traumatic Stress Studies, American Psychiatric Association, American Psy-
chological Association, or the National Association of Social Workers, may
provide additional resources. In addition, each state has a federally funded
protection and advocacy office and a state-sponsored office of consumer af-
fairs that may know of peer support resources for clients receiving publicly
funded mental health services. Some of these services are available through
not-forprofit organizations under contract to provide services for state-system
clients.
Conclusion
Working collaboratively with other systems to create the kind of society that
will stop violence against women and prevent its traumatic sequelae is also
important. Mental health providers have a significant role to play in voicing
concerns about the impact of abuse and violence on the lives of the women
they work with clinically and in not allowing those concerns to be dwarfed
by the current emphasis on neuroscience and limited mental health reim-
bursement policies. Working with women who have survived unthinkable
trauma teaches us about the complexity and unpredictability of human life;
of the intersections among individual biology, human development, social
and cultural contexts, and larger societal norms; and of the importance of car-
ing, respectful human interactions. When we do not address the denial of in-
tolerable feelings at a personal level we are in danger of re-creating them not

only in individual relationships but also on a social and political level as well,
and when we do not acknowledge the impact of social forms of abuse of pow-
er, they are often internalized and reproduced through individual interac-
tions. Mental health providers can play a critical role in preventing violence
against women in addition to treating its consequences by beginning to ad-
dress the social as well as psychologic conditions that create and support this
kind of violence in our society.
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24
Lesbian Health Care
MARGERY S. SVED, M.D.
A study of excellent care for women that is mindful of the complex interface
between medical and psychologic issues must examine this interface as it relates
to all women. The needs and issues of both majority and minority women
should be included. This text seeks to ameliorate the troubled relationship
between women and the providers of their obstetric and gynecologic care. In
their introduction, Drs. Stewart and Stotland discuss the difficult relationship
that has arisen between women and their physicians. This relationship, often
fraught with adversarial undertones, leaves some women preferring to not
seek health care services. Training programs are cited as deficient in attention
to the development of interpersonal skills, the understanding of psychody-
namics, and other psychologic aspects of health care. The way medical care
is currently administeredcomplicated by the access issues of the managed
care environmentstands as an impediment to the evolution of a healthy
doctorpatient relationship.
Into this relationship (or lack thereof) comes the lesbian patient. The
same barriers to good care that have complicated the relationship between all
physicians and women are evident in the relationship between a lesbian pa-
tient and a physician. Other complex barriers are also frequently in place.
This chapter defines the barriers to care that exist for lesbian women and sug-
gests ways to remove those barriers. It attempts to address the question of
which medical and psychologic issues must be considered when providing
primary or obstetric/gynecologic care to lesbian women. The ultimate goal of
this book is the development of professionals who are knowledgable not only
about female sexual organs but also about female sexual feelings and behav-
549
iors; who are dedicated to understanding not only the familiar majority but
also the often-invisible minorities; and who are invested not only in the deliv-
ery of mechanical medical services, but also in the delivery of sensitive and
humane medical care.
Definitions
In the context of health care, lesbians have been an invisible minority (Rob-
ertson 1992). Although somewhere between 2% and 10% of North American
women are lesbian, they have been a marginalized and ignored element of the
population (Michaels 1996). Hepburn and Gutierrez (1988) surveyed hetero-
sexuals and found that only 25% reported knowing an individual who is ho-
mosexual. In an earlier study, Johnson et al. (1981) found that of 110
gynecologists surveyed, 50% were sure that they had never treated a lesbian
patient.
A lesbian is a woman whose sexual and affectional orientation is directed
toward other women. An individuals behavior may range from celibate to
exclusively homosexual, bisexual, or situationally heterosexual. Any number
of factors can influence or direct an individuals behavior. These include eco-
nomic status, cultural milieu, genetics, sexual desire, family pressures, person-
al awareness, and various internally and externally generated factors. Not all
women who partner with women consider themselves to be lesbians; similar-
ly, not all women who partner with men consider themselves to be heterosex-
uals. Labeling or defining oneself as lesbian, bisexual, or heterosexual is a
highly individualized phenomenon. Such self-definition may change over
time. A practitioner should be interested in both an individuals self-generat-
ed label and in her history of behavior.
Lesbians are as diverse a group as the population at large, including in-
dividuals from all geographic, economic, racial, religious, ethnic, age, and oc-
cupational groups. The spectrum includes women who may be actively
involved in gay and lesbian politics and/or culture, women who may be clos-
eted and isolated from the supports and resources available within the lesbi-
an community, and women who view their sexual orientation as only a minor
part of their personal identity.
Lesbian sexual behavior has the same potential diversity as all human
behavior. Lesbian sexual activity includes a full range of human sexual ex-
pression, including (but not limited to) kissing, breast stimulation, fantasy,
masturbation, digital or manual penetration of the vagina, penetration of the
anus, and use of sex toys including vibrators. Types of contact may include
Psychological Aspects of Lesbian Health Care 551
genital/genital, oral/genital, and oral/anal. Some women may be celibate, ei-

ther by choice or circumstance. Other women may have male sexual part-
ners, again by choice or by circumstance. Some women may engage in
sadomasochistic activity and some women may be professional sex workers
with male and/or female clients.
Barriers to Health Care for Lesbians
Many women find themselves forced to hide their relationships with other
women from their employers, medical providers, family of origin, or religious
community for fear of being ostracized or rejected because of their sexual ori-
entation. A medical provider dedicated to providing good quality medical
care must be attuned to these kinds of fears and work to create an environ-
ment of trust and confidentiality in which patients can freely discuss all of the
issues that affect their health and well-being. Several researchers have pub-
lished work suggesting that lesbian women are likely to avoid seeking both
routine health care and care for medical problems (Banks and Gartrell 1996;
Bradford and Ryan 1988; Deevey 1990; Hume 1983; Stevens and Hall 1988;
Trippet and Bain 1992; J. C. White and Dull 1997; Zeidenstein 1990).
Chafetz et al. (1974), Saunders et al. (1988), and J. C. White and Dull (1997)
wrote that lesbian women were often more inclined to seek advice and help
for medical issues from their circle of friends or nonallopathic practitioners
than from medical physicians. Several factors have been identified as barriers
to health care for lesbians. These include previous negative experiences with
health care providers; previous negative experiences with legal, social, or oth-
er services; incorrect assumptions on the part of both lesbian women and
medical practitioners regarding the need for routine health screening for les-
bian women; the decreased likelihood among many lesbian women that con-
traceptive issues or perinatal care will serve as an entree into medical care;
financial constraints, made worse because lesbian partners are rarely eligible
for insurance coverage on their partners policy; and aspects of some lesbian
communities that may encourage self-care or nonallopathic health care
(Rankow 1995c).
A great deal of research has revealed institutionalized heterosexism with-
in the medical establishment. Numerous researchers (Chaimowitz 1991;
Douglas et al. 1985; Garfinkle and Morin 1978; Mathews et al. 1986; Randall
1989; Townsend 1997; Wallick 1997; T. A. White 1979) have documented
aspects of this negative attitude toward homosexuals by health care providers
including nurses, psychologists, medical students, and physicians. Some of
these researchers revealed that significant percentages of health care workers

have an aversion to homosexual clients, considering them repulsive, immor-
al, and generally less healthy than heterosexual clients. A survey of gay and
lesbian physicians documented that 67% of respondents knew of gay, lesbian,
or bisexual individuals who received substandard care because of their sexual
orientation (Shatz and OHanlan 1994). Neither medical school curricula nor
residency training programs have been found to adequately deal with issues
of homosexuality. Of 86 medical school curricula studied by Wallick et al. in
1992, the mean class time devoted to teaching about homosexuality (out of a
total of 4 years of study) was 3 hours, 26 minutes. However, exposure to a
curriculum focused on cultural competency and homosexuality may help im-
prove attitudes (Muller and White 1997; Olsen and Mann 1997; Rankow
1997b; Townsend and Wallick 1996).
When a lesbian woman does seek medical care, the same factors outlined
above may affect her ability to reveal her sexual orientation to her health care
provider (Johnson and Guenter 1987). As a result of the well-documented
homophobia among both the general population and among health care pro-
viders, lesbians are often understandably hesitant to reveal their sexual orien-
tation. Fear of rough treatment during physical examination, fear of hostility,
fear of inadequate or denied medical care, and fear that a breach of confiden-
tiality may jeopardize her employment, her home, her standing in the com-
munity at large, her family relationships, or the legal custody of her children
may all affect a womans likelihood to seek medical care or to disclose her sex-
ual orientation. In fact, the fears associated with involvement in the tradition-
al medical community often greatly outweigh the fears associated with
potential illness, even though delays in screening and treatment have the po-
tential to increase both morbidity and mortality. Furthermore, Stevens and
Hall (1988) listed these possible problems when the patient feels unable to
disclose that she is lesbian: 1) invisibility within the health care system; 2)
the assumption by practitioners that all patients are heterosexual; 3) missed
opportunities for health education and irrelevant health education; 4) offen-
sive and often heterosexist lines of questioning and comments; and 5) faulty
diagnosis and treatment.
Decreasing Barriers to Care for Lesbian Women
Barriers will truly be lowered only when society at large ceases to discrimi-
nate on the basis of gender or sexual orientation. Medical training will then
be more likely to include information on the needs of lesbian clients, which

will help practitioners foster a supportive practice environment for all pa-
tients. In the meantime, however, a health care provider can attempt to create
a practice open to anyone regardless of sexual orientation, beginning with
members of the phone staff (e.g., receptionists, nurses) who are usually the
patients first contact with a medical practice and continuing with modifica-
tion of the various intake forms a patient fills out and of the attitudes ex-
pressed both overtly and covertly by all staff members with whom a patient
comes into contact (e.g., nurses, physician extenders, laboratory technicians,
and physicians).
One of the most important factors in the care of lesbians and all women
involves avoiding language that implies assumptions. Female patients should
not be assumed to be Mrs. Smith, and when asking about health insurance,
questions such as is the policy under your husbands name? should be
avoided. It also should not be assumed that the woman needs to use or is us-
ing contraception. When the initial interactions of a relationship include such
assumptions, the patient may feel that the questioner has a bias in favor of
patients who fit an assumed profile. Assertively correcting the questioner
(Call me Ms. Smith; No, Im not married; No, I dont need any birth
control) can feel extremely risky.
An individual patients sexual orientation should not be assumed based
on appearance, marital status, or whether an individual has ever been preg-
nant. Furthermore, an individual who states that she is lesbian should not be
assumed to have no sexual contact with men. Abandoning assumptions
means asking very basic, nonjudgmental, open-ended questions, such as Are
you involved in a significant relationship?; Tell me about your living situa-
tion. Who shares the household with you?; Tell me about the people who
are important to you. Where do you get the most support?; Are your rela-
tionships satisfying or are there any concerns youd like to discuss?; Are
you sexually active? With men, with women, or with both?; Do you have
any need to discuss birth control?; How are you dealing with issues of saf-
er sex?; Are there any other questions or concerns that you would like to
discuss? (Rankow 1995c).
It can be very helpful to preface intimate questions with an explanation
about their importance in the individuals health care and with reassurances
(when they can be made honestly) of confidentiality: People are at risk for
different diseases and need different tests depending on what activities theyre
engaging in now and in the past. I will need to ask you some personal ques-
tions that I ask all of my patients about sexual activity to help give you the
best possible care. Everything you tell me will be kept confidential. This can
then be followed by more detailed questions regarding the age at onset of sex-
ual activity, number and genders of past and present partners, specific behav-
iors engaged in, and knowledge of and compliance with guidelines for risk
reduction.
As with all patients, an individuals support system should be explored.
When appropriate, and when desired by the patient, this support system
should be included in the patients health care. Research has shown (contrary
to some popular myths) that many lesbians enjoy consistent support from
strong partner relationships and friends (Bradford and Ryan 1988). It is im-
portant for practitioners to be aware that lesbian women often turn to friends
as their primary source of support, unlike heterosexuals, who consider both
family members and friends as equally supportive (Kurdek and Schmitt
1987).
Health care providers can follow these very concrete suggestions to con-
vey to patients that they are in a safe environment in which they can relax
and trust their practitioner (Rankow 1995c, 1997c; J. C. White 1995):
Include a patients partner or friend if desired by the patient

Discuss issues of confidentiality, including how disclosed information will
be treated in the written medical record
Display magazines, brochures, and images that reflect the full diversity of
the patient population, including lesbian women
Post a nondiscrimination policy in the office waiting room: We do not dis-
criminate on the basis of race, national origin, gender, language, income, age, education,
sexual orientation, or disability.
Use inclusive language for all health education materials and for patient
history and intake forms
Health Concerns of Lesbian Women
The health concerns of lesbians have only recently begun to be studied in any
systematic way. Previously, research funding had not been awarded to study
whether lesbian women had any specific, unique health care issues (Stevens
1992). The earliest studies were performed with sample sizes so small and
narrow that the relevance of the results was unknown. Most of the early work
involved surveys of self-identified lesbians and primarily sampled those who
were young, white, middle class, and well educated. Many opportunities for
data collection and research were missed. For example, the Centers for Dis-
ease Control recorded little data early in the HIV epidemic about the sexual
orientation or activity of women diagnosed with AIDS. This supported the
belief that lesbians were at low risk for HIV/AIDS because a woman who re-
ported any heterosexual behavior after 1978 was grouped with heterosexual
women (Peterson et al. 1992). In addition, many possible sources of data were
neglected, because researchers often did not ask questions that allowed strat-
ification of results by sexual orientation or behavior.
Clearly, better research with larger numbers and more diversity among
respondents is necessary to better define the health care needs of lesbian
women (Hollibaugh et al. 1993; Rankow 1998; Solarz 1999; J. C. White
1998). Results from newer research are starting to be published, including
how to perform research that includes lesbians (Bradford et al. 1997; Herek
et al. 1991), and several large multicenter prospective studies include infor-
mation that will allow stratification by sexual orientation (e.g., Womens
Health Initiative, Harvard Nurses Study). Health practitioners will need to
follow the relevant literature for results of new research regarding lesbian
health.
Breast Cancer
No research findings comparing the risk of breast cancer in lesbian women

with that in heterosexual women are available, although some are under way
(S. A. Roberts et al. 1998). Some studies have suggested that risk factors for
breast cancer such as nulliparity, childbearing after age 30, never having
breastfed, and increased alcohol consumption exist more frequently in lesbi-
an women (Biddle 1993; Bradford and Ryan 1988; Bradford et al. 1994; By-
bee 1991; Johnson et al. 1987b; McKirnan and Peterson 1989; Rankow
1995a, 1995b; Rankow and Tessaro 1998a; W. F. Skinner 1994). Some re-
searchers have also noted that lesbians appear to receive fewer mammograms
and clinical breast examinations and are less likely to perform regular breast
self-examinations in keeping with recommended standards of care (Biddle
1993; Bradford and Ryan 1988; Bybee 1991; Haynes 1992; Johnson et al.
1987a; OHanlan 1993; Rankow and Tessaro 1998b). There are also con-
cerns that lesbian women who are estranged from their families because of
their disclosure of their sexual orientation may not have access to family med-
ical records, including history of breast cancer (Rankow 1995c). Current re-
search may help clarify risk factors. Lesbians should follow guidelines for all
women, including regular self breast examinations, yearly breast examina-

tions by a health care provider, and mammogram schedules based on age and
known risk factors.
Sexually Transmitted Diseases
Early research showed that sexually transmitted diseases did not occur fre-
quently in lesbian women (Robertson and Schachter 1981), and many clini-
cians believed that sexually transmitted diseases appeared in lesbians only if
they had been sexually active with men. Several researchers (Johnson et al.
1981; Robertson and Schachter 1981) noted that rates of infection with sex-
ually transmitted diseases such as gonorrhea, syphilis, genital herpes, and
chlamydia are very low among lesbians who are sexually active exclusively
with other women. J. C. White and Levinson (1993) found the rate of trans-
mission of human papillomavirus (HPV) between women to be quite low, al-
though HPV is transmissible from one female partner to another. However,
clinical experience suggests that a number of infectious agents can be passed
between female sexual partners, including Candida, Gardnerella vaginalis, Tri-
chomonas, Chlamydia, and hepatitis A. Newer research is starting to show that
genital HPV infection and squamous intraepithelial lesions are not uncom-
mon among women who have sexual intercourse with women and do occur
in those who have never been sexually active with men (Carroll et al. 1997;
Marrazzo et al. 1998; OHanlan and Crum 1996).
The limited research on infectious disease transmission between women
greatly hampers clinicians ability to define cost-effective guidelines for treat-
ment of female partners of women with various gynecologic infections and
for prevention of sexually transmitted diseases in lesbians. The following rec-
ommendations are based on current knowledge and experience (Rankow
1995c, 1997a; J. C. White 1997):
Routine screening for sexually transmitted diseases in the absence of signs

or symptoms is probably not cost effective in women who are exclusively
sexually active with other women.
When a woman has a recurrent infection, or certainly if her partner is
symptomatic, the partner should be examined and cultured as well. Recur-
rent or resistant vaginal infections may indicate the presence of HIV.
Lesbians need Pap smears and pelvic exams; how frequently they need
them depends on their individual history of sexual behavior, previous sex-
ually transmitted diseases, and number of partners and should follow cur-
rent guidelines for all women (Marrazzo et al. 1998).
Because some lesbians may have regular or occasional sex with men, all
routine standards of care for both prevention and treatment of infection
should apply. Adolescents may be at particular risk of engaging in unpro-
tected activity with both male and female partners.
To know what anatomic areas require culturing (vagina, throat, anus), the
practitioner must have knowledge of what sexual activities have been prac-
ticed. Assumptions should not be made.
Anticipatory guidance about safer sex can serve as a less threatening in-
troduction to sensitive topics. Providers should be knowledgeable about
the full range of human sexual behavior and be comfortable discussing
this in language appropriate for the patient.
Most HIV-positive lesbians are reported to have acquired the infection

through intravenous drug use or unprotected heterosexual activity (often
with gay or bisexual men or intravenous drug users). Bevier et al. (1995) re-
ported that women who report both drug use and sexual activity with other
women were likely to engage in multiple high-risk behaviors, including un-
protected vaginal or anal intercourse with bisexual or drug-using male part-
ners, sex for money or drugs, sex while high, and sharing of injection
materials. Intravenous drugusing women who reported having intercourse
with women were significantly more likely to test positive for HIV than drug-
using women who reported having intercourse with men only. Because this
is counter to the widespread assumption that lesbians are at low risk for HIV
disease, it is especially important to explore the full range of risk behaviors
with women who have sex with women.
Only a few incidents of woman-to-woman HIV transmission have been
reported in the literature (Chu et al. 1990; Greenhouse 1987; Marmor et al.
1986; Monzon and Capellan 1987; Perry et al. 1989; Rich et al. 1993; Saba-
tini et al. 1984). However, grassroots lesbian AIDS projects are documenting
growing numbers of HIV-positive women whose only apparent risk factor is
unprotected sexual activity with an HIV-positive female partner. Because it is
known that HIV and other sexually transmitted diseases are transmissible
through exchange of body fluids such as cervical or vaginal secretions and
menstrual blood, it is imperative that practitioners provide all of their patients
with up-to-date guidelines for safer sex (Rankow 1995c): 1) Direct genital-to-
genital stimulation between women may allow mucosal exposure to blood,
sexual fluids, or genital lesions and may therefore be an unsafe practice. 2)
Sexual partners should use latex barriers, male or female condoms, or house-
hold plastic wrap to protect against oral contact with vaginal fluids, menstrual
blood, blood resulting from traumatic penetration, fecal-borne pathogens,
HPV, herpes virus lesions, and breast milk. Although intact skin is usually
thought to be adequate protection, latex gloves or finger cots may be worn if
one partner has cuts on the fingers or hands. 3) Only water-based lubricants
should be used with latex or plastic wrap because oil-based products (includ-
ing food products that contain oils) may degrade the integrity of the barrier.
4) Ideally, sex toys should not be shared. Alternatively, such objects should
be well cleaned and/or covered with a fresh condom between partners or pri-
or to moving from rectum to vagina. 5) Lesbian women engaging in sexual
activity with men should follow standard guidelines for safer sex, including
the use of condoms and spermicide for each encounter.
It is essential that public health education messages reflect the reality that
lesbian and bisexual women do contract HIV/AIDS and other sexually trans-
mitted diseases. Clinicians need to be aware that the current information in
medical literature regarding lesbians may be neither complete nor accurate.
Prevention efforts must be comprehensive and should include harm reduc-
tion information for female-to-female transmission, heterosexual activity, and
drug-related risks.
Gynecologic Care and Screening
Several researchers have studied the issue of lesbian women and Pap smears
(Biddle 1993; Buenting 1992; Bybee 1991; Johnson et al. 1981; Kunkel and
Skokan 1998; Marrazzo et al. 1998; Rankow and Tessaro 1998a; Robertson
and Schachter 1981). It appears that lesbians are less likely to get pelvic ex-
aminations and Pap smears and more likely to wait longer than the recom-
mended interval between such exams. Furthermore, some practitioners have
erroneously informed patients that they do not need Pap smears in the mis-
taken belief that lesbian women do not get cervical cancer (Ferris et al. 1996).
The risk factors for cervical dysplasia and cancer in lesbian women are
the same as in heterosexual women, including sexually transmitted disease in-
fection at an early age, multiple sexual partners, smoking, diethylstilbestrol
exposure, and exposure to HPV, HIV, or herpes simplex virus. It is impor-
tant that a practitioner ascertain an individual patients history to determine
an appropriate schedule for pelvic examination and Pap smears. Practitioners
should make sure that patients have an accurate understanding of their own
risk status, as well as knowledge about the importance and recommended fre-
quency of screening.
Although no full-scale research has been performed on the incidence of

gynecologic cancers in lesbian women, it is known that various factors, such
as nulliparity and nonuse of oral contraceptives, may increase a womans risk
of endometrial and ovarian cancer. This increases the importance of regular
pelvic examinations for these women. Furthermore, women who do not see
a practitioner regularly for such screening may also miss the opportunity to
receive other important preventive care, including blood pressure checks,
cholesterol screening, examination of stool for occult blood, and health edu-
cation.
Reproductive Issues
Among the assumptions that a practitioner must work to avoid is the belief
that a lesbian woman does not have or is not planning to have children
(Patterson 1992). In fact, many lesbians parent children from previous hetero-
sexual relationships and many are creating families with children through
adoption, fostering, or conception via donor insemination or heterosexual in-
tercourse. It is vital that practitioners advise women who intend to use insem-
ination that privately obtained semen (as opposed to semen obtained through
a licensed sperm bank) may put them at risk of contracting HIV. Licensed
sperm banks carefully screen their donor sperm, and fresh sperm donated by
a friend or acquaintance will not have been screened and could therefore
transmit HIV or other organisms. There is, however, little likelihood of HIV
infection if the sperm donor test results are negative for HIV, he abstains
from all sexual activity with any possibility of H IV transmission for 6
months, and he is then retested and results are again negative.
To provide optimal prenatal care, a practitioner must continue to provide
an open, safe environment in which a patient can freely express her needs.
Asking a patient about whom she might like to include in prenatal visits or at
the birth (as opposed to asking whether the father will be present) helps con-
vey to the woman that she is in a supportive environment. Asking whether
the woman will be a single parent or will be coparenting allows the patient to
communicate her familys structure honestly and comfortably. Information
about parenting issues, support, and other resources is often available to
women from their health care providers. Therefore, it is helpful to know
whether a patient has any children or is involved in any parenting relation-
ships.
Although all patients should be encouraged to file a durable power of
attorney to designate individuals who have emergency decision-making pow-

ers, this process is particularly important for women involved in same-sex re-
lationships. These relationships often do not have the legal protections or
rights assumed by a heterosexual spouse. Complications and emotional dev-
astation can occur when partners are denied access, information, or involve-
ment in the care of a loved one. Similarly, legal documents should be drawn
up and available to health care providers to allow a nonbiologic parent to
have medical authority over her children.
Mental Health Issues
In any health care practice providing primary or gynecologic care, various

psychosocial and mental health issues may need to be addressed. Compared
with physical health issues, the literature available about mental health and
lesbians is extensive. A recently published book, Textbook of Homosexuality and
Mental Health (Cabaj and Stein 1996), summarizes current knowledge. Little
research is available, however, about the prevalence and incidence of major
mental illnesses in lesbians, although no mental illnesses are known to occur
more often in lesbians than in other women (Rothblum 1994b). In most con-
texts, the psychosocial issues that lesbian women bring up with their health
care providers are similar to those of heterosexual women and cover the spec-
trum of depression, anxiety, problems with families (children, parents, part-
ners), work-related problems, substance abuse, loneliness, losses, past or
present physical or sexual abuse, and other traumatic events and include sig-
nificant mental illnesses that should be referred for psychiatric evaluation or
treatment (Rothblum 1990, 1994a; Trippett 1994).
Bradford et al. (1994) summarized the mental health information ob-
tained from the National Lesbian Health Care Survey. They reported that
rates of depression and suicide attempts in the lesbian women in their sample
were similar to rates in heterosexual women. However, more lesbians had
participated in counseling at some time during their life than had heterosex-
uals. Rates of physical abuse, sexual abuse, and incest were high but not sig-
nificantly different than similar reports for all women. This survey also
suggested that substance abuse might be more frequent and eating disorders
less frequent in lesbians. Earlier research, which primarily used samples of
lesbians found in bar settings, did show that lesbians had significantly higher
rates of alcohol abuse, often three times more than heterosexual women
(Cabaj 1996; Diamond and Wilsnack 1978; Hall 1993; Lewis et al. 1982).
Newer research, with better sampling, identification, and methods, showed

no significant difference in current drinking when comparing lesbian and het-
erosexual women. However, more lesbians reported past problematic drink-
ing and participation in 12-step recovery programs (Hughes and Wilsnack
1997; Hughes et al. 1997).
Some unique stressors exist for lesbian women. Issues such as social iso-
lation, homophobia, discrimination, fear of hate crimes, coming out, and
the experience of being different are complex and potentially alienating.
Bradford and Ryan (1988) outlined some of the social abuses suffered by les-
bians, which included verbal and physical attacks and lost employment.
Members of most minority groups learn about coping with discrimination
and difference from their families of origin, who usually share the minority
status (DeMonteflores 1986). The effects of discrimination and difference are
increasingly complicated for those who are members of more than one mi-
nority.
Disruption of relationships with the family of origin may also occur with
disclosure of ones sexual orientation or because of fears of the response to
disclosure. Rejection by family, friends, religious community, coworkers, or
fellow students can be devastating. Lesbians in many states may be denied or
lose housing, custody of children, employment, health care, or legal represen-
tation solely on the basis of sexual orientation. Such constant blows and
threats from all corners of an individuals personal and professional life can
result in chronic fear, depression, and damaged self-esteem. Some women re-
spond by internalizing this hatred and directing it against themselves. Abuse
of cigarettes, food, alcohol, and other drugs may occur in the face of these
types of stress. Furthermore, other sequelae of continual stress may include
physical symptoms such as gastric complaints, headaches, or pain syn-
dromes.
Some lesbian women attempt to avoid these stresses by withholding in-
formation about their sexual orientation from family, friends, and coworkers.
The individual begins living a kind of double life, in which she presents her-
self publicly as heterosexual while secretly considering herself (or living) as a
lesbian. J. Smith (1988) has suggested that the energy invested in such a dou-
ble life and the experience of living with the constant threat of exposure could
take an emotional toll that results in an increased chance for dysthymia and
depression.
Practitioners may be presented with various issues related to trauma, es-
pecially if nonjudgmental, routine questions are included to elicit current and
past traumatic events. Acknowledging the trauma and providing support may
be all that is necessary, although providing referral to resources or treatment

options experienced with lesbians may be helpful. For instance, lesbian wom-
en share with heterosexual women a similar likelihood (about 38%) of being
survivors of childhood sexual abuse (Klinger and Stein 1996). Those provid-
ing gynecologic health care to survivors of childhood sexual abuse need to be
particularly sensitive to these patients emotional issues (Rankow et al. 1998).
Although identification, symptoms, complications, and treatment are similar
to those of heterosexual women, knowledge of lesbian-only resources where
available is often helpful.
As in any relationship, lesbian relationships may be complicated by do-
mestic violence. However, community resources available to heterosexual
women with abusive partners, such as shelters and the legal system, may be
homophobic and may deny that lesbian battering exists. As with heterosexual
women, discussion of the abuse, strategies for safety, and referral to appropri-
ate resources may be necessary steps in helping the victim (Klinger and Stein
1996; Renzetti 1989).
Any of the life events that may need to be explored with some patients
may have different ramifications for lesbians. Loss of a partner (through ei-
ther death or separation) may be a uniquely difficult trauma for lesbians be-
cause the normal social supports available for heterosexual couples are
absent. Some lesbians choose to acknowledge the permanence of their rela-
tionships with marriage or other commitment ceremonies, whether or not
these are supported by their families or faith communities. Finding a faith
community accepting of homosexuality is not always easy. Lesbians may
have nowhere to find support for issues related to their children and school.
Health care practitioners should have an awareness of local, regional, and
national resources that may provide needed information, support, and ex-
perience.
Some researchers have expressed particular concern about the effect of
psychosocial stresses on lesbian women at the extremes of the age spectrum.
Teenage womenwhether lesbian or unsure of their sexual orientationand
older women may have special concerns. Specific issues may depend on the
individuals age, age when she acknowledged her homosexuality, and her so-
cial, cultural, and political milieus.
Because adolescence is an intense period during which an individuals
identity is explored and begins to gel, lesbian youths have a potentially diffi-
cult path. The adolescent tasks of defining self, individuating from family, de-
veloping social skills, and finding ones place within society are more complex
for lesbians, who must struggle with issues of adolescence without the benefit
of supportive societal institutions, role models, and the rituals of passage and
celebration available to their heterosexual peers (Kreiss and Patterson 1997).
Some studies have found that gay and lesbian youths are at significant risk
for suicidality (Moscicki et al. 1995; Proctor and Groze 1994). Gibson (1989)
suggested that this risk represents three times the risk for heterosexuals. Ho-
mosexual adolescents are also at greater risk for homelessness and its atten-
dant risks of exposure to violence, rape, drug and alcohol use, and sexually
transmitted diseases, including HIV/AIDS.
Health care practitioners can alleviate some of the stresses on lesbian
teens by providing an environment in which they can expect nonjudgmental
care. Inclusive and comprehensive information on risk-reduction guidelines
should be offered to all young patients. It is important to allow for the possi-
bility of the full spectrum of behavior, to avoid judgments or assumptions
about sexual identity, and to assure confidentiality. Practitioners should be
well aware of the painful pressures affecting lesbian adolescents, including so-
cial isolation, rejection by family and/or peers, and resulting depression and
self-hatred (Kourany 1987).
Older lesbian women may also have an increased risk of social isolation.
Coming out may have been essentially impossible within their lifetimes,
and the result may be intense alienation. Some authors have written about the
triple challenge faced by older lesbian women who must struggle against age-
ism, sexism, and homophobia (Gentry 1992). For women who were unable
to disclose themselves as lesbians when they were young, these burdens can
become particularly heavy. Some researchers have suggested that older lesbi-
an women are less likely to be involved in the greater lesbian community
(Bradford and Ryan 1988). Practitioners should be alert and sensitive to the
structure of an individuals support system. The practice environment should
be supportive of disclosures that an individual may choose to make but pa-
tients should not feel pressured to disclose.
Summary
Health care practitioners need to be sensitive to the possibility that any of the
issues discussed here may affect their lesbian patients. However, it is equally
important that practitioners realize the limitations of current research in this
field. No assumptions can be made based solely on a patients sexual orien-
tation. Thorough, methodic, nonjudgmental history-taking is the only way to
explore these kinds of issues with each patient individually. In the future,
carefully designed epidemiologic studies will provide better information so

that practitioners have better resources to guide their care of lesbian patients.
Good health care for lesbian women strongly resembles good health care
for any group: a nonjudgmental atmosphere that allows the patient to guide
personal disclosures, is respectful of the amazing variety of human behavior
and experience, is free of all assumptions, is mindful of the importance of lan-
guage in defining the dynamics of a relationship, and pays careful attention
to the needs of the specific individual being served. Antilesbian biases
throughout society in general and the medical profession in particular point
to the importance of very consciously working to create an atmosphere of se-
curity and respect that will allow the health care needs of nonheterosexual
women to be defined and addressed.
Furthermore, epidemiologic studies will help define whether lesbian
women have a greater incidence of particular medical problems. Such studies
are also needed to help practitioners draw up reasonable guidelines for pro-
tecting their patients from exposure to infectious diseases, treating patients
who have acquired such diseases, and preventing the spread of infection to
partners. Concerns regarding substance use and depression need to be ex-
plored, with studies designed to adequately represent the truly diverse lesbian
population. Furthermore, many of the issues that are important in both ob-
stetrics/gynecology and psychiatry involve family and couple dynamics and
require an understanding of an individual patients personal psychologic mi-
lieu and social supports.
Good (1976) wrote of the importance of gynecologists understanding a
patients sexual and psychosexual orientation in order to provide sound ho-
listic care. He commented that the specialty of obstetrics and gynecology
treats conditions and deals with anatomy that is always subject to intense
emotional and psychosocial implications. Lesbian women face a complex
overlay of issues because of their sexual orientation. Excellent health care for
lesbian women takes these issues, and their potential effect on the patients
life, into account.
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25
Ethics and Womens Health
D espite their basis in rationality, ethical principles are influenced by personal

values and beliefs and by societal context. In medicine, as new technologies
have emerged and health care delivery systems have changed, beliefs about
the responsibilities, obligations, and relationships between health care
providers and patients have been challenged, and some have changed
(Nadelson 1996).
The increasing complexity and cost of technology, coupled with limited
resources to provide care, create new ethical dilemmas related to the need to
make decisions based on competing priorities, often without established
guidelines about processes or guiding principles. Values and ethical systems
also vary widely among cultures and individuals and often conflict.
As health care delivery systems evolve, decisions about medical care are
increasingly being made by those whose training and ethical frameworks are
not in health care but in business and economics. Thus, their perspective and
priorities may differ from those with medical training who traditionally were
responsible for these decisions. For example, the chief executive officers
(CEOs) of profit-making managed care organizations do not expect to deliver
care in the same way as if they were running nonprofit organizations. They
must be focused on the interests of their investors. Their primary concern is
not the public good, although they may provide public benefit. They might
decide whether or not to include a specific procedure as a benefit of a partic-
ular health plan based more on economic factors than on clinical indications.
Likewise, in the interest of efficiency and better information transfer, they
might decide to institute computerized medical records and require disclosure
of patient diagnostic and treatment information, thus making confidential pa-
571
tient information more accessible to a range of people, many of whom have

no involvement in patient care. Although patients may consent to this release
of information, they do so under duress, because they fear losing health care
coverage if they do not. The concept of informed consent is altered by this
practice; it is not truly informed consent if the patient has no alternative. Phy-
sicians may also favor having data more available to them, not being cogni-
zant of implications for patients in terms of their privacy concerns or their
risk of losing future insurability if certain information is not treated confiden-
tially.
These issues have ethical implications for all involved in health care de-
livery. This chapter describes general principles of medical ethics and focuses
on those that have special consequence for womens health.
Changing Codes of Medical Ethics
Codes of medical ethics have existed since ancient times and have varied with
culture and era. Currently, as guiding principles, most Western countries em-
phasize the autonomy or self-determination of patients, a concept of benefi-
cence that implies doing good rather than merely doing no harm, a concept
of justice related to access to resources, and the physicians primary responsi-
bility to his/her individual patient (Nadelson 1991).
Different priorities are placed on these principles in different countries
and systems of care. Thus, patient autonomy might be considered less im-
portant than equitable access to resources, and limiting the availability of a
particular procedure or medication may be a policy based on socioeconomic,
age, or prognostic factors. Patient autonomy might also be considered less
important than family interests (so that another person, such as a spouse or
parent, might be required to consent to a procedure), or than government in-
terests (so that the government might make a specific treatment or procedure
unavailable, such as contraception or abortion, contrary to the desire of the
woman involved). Paternalism is the intentional limitation of the autonomy
of one person by another, where the person who limits autonomy justifies the
action exclusively by the goal of helping the person whose autonomy is lim-
ited. Paternalism seizes decision-making authority by preventing persons
from making or implementing their own decisions (Beauchamp 1995, pp.
19141915). Thus, paternalism is a fundamental concern in medical ethics;
whether and when it can be morally justified has been the subject of much
debate.
Ethics and Womens Health 573
In the United States, the locus of paternalism in health care has shifted
with changes in delivery systems. Many of the manifestations of paternalism
observed in physicians in the past are less evident in the practices of individ-
ual physicians today and more apparent in health care systems themselves.
These systems, like all bureaucracies, are even less likely to be empathic with
the needs or autonomy of individuals than many physicians were in the past
or to take account of differences between patients (Nadelson 1994), and they
are more likely to consider societal interests as primary in order to predict and
control costs and health outcomes.
Debates about confidentiality and informed consent often involve pater-
nalism and autonomy, as the earlier example of the company CEO making a
decision to abrogate patient confidentiality illustrates. These issues have been
most striking in debates about whether managed care organizations and the
physicians they employ must inform patients of all appropriate treatments for
their medical conditions and, in addition, notify them of the limits imposed
by their particular health care contract.
Decisions about the availability of a particular type of care are often dealt
with paternalistically, although ostensibly the patient may seem to have some
choice. The patient may be asked to pay a high copayment for certain proce-
dures, or care may be denied based on gatekeeping policies, the nature of
which are often not disclosed to the patient or physician. For example, al-
though psychiatric care may be covered with specific guidelines regarding
number of visits allowed or the payment per visit, indirect limits can be im-
posed by limiting approved providers, not providing options for patients to
receive partial benefits if they wish to seek care outside of their particular
health care plan, not allotting all visits written into the plan by setting up ex-
clusionary criteria for each visit, or by limiting approved services, such as psy-
chotherapy, to a certain number of visits. These decisions are often made by
gatekeepers who may have no mental health background, have not seen the
patient, and who are following a rigid protocol that determines the number
of visits allocated to a particular symptom or diagnosis.
Pellegrino and Thomasma (1988) have indicated that the conflicting eth-
ical principles in contemporary health care are based on business, contractu-
al, preventive, covenantal, and beneficence models. From the business
perspective, they suggest that medicine has come to be seen as a commodity
and that the ethical obligation of doctor to patient has become that of busi-
nessman to consumer. The contractual model is an extension of the business
model whereby a contract formalizes the relationship, which could protect the
patient from excessive physician paternalism or economic self-interest, but
could also limit the commitment and responsibility inherent in the physician
patient relationship. The preventive or public health model obligates the
health care provider to protect many healths and does not place as high a
priority on the individual doctorpatient relationship. Current health care de-
livery systems involving managed care organizations, including health main-
tenance organizations, use various combinations of these models and focus
less on individual patients and more on the groups of patients or lives they
cover.
A somewhat different perspective is the covenantal model, which is
grounded in the trust and obligation between the physician and the patient.
In reemphasizing the importance of the principle of beneficence inherent in
this model, Pellegrino and Thomasma (1988) have suggested that the physi-
cian and patient are joined because of the patients needs and that both part-
ners recognize the patients dependence on the physician and the physicians
responsibility for making good and moral judgments on the patients behalf.
This model acknowledges that the patient who is ill may not be capable of
totally free and informed consent or autonomy by virtue of anxiety, fear, or
lack of knowledge, and he/she expects that the physician will act beneficently.
The nature of the covenantal relationship and the principle of benefi-
cence call into question the ethics of many current medical practices, includ-
ing the role of physician as a gatekeeper or guardian of societys resources in
the rationing of health care (Nadelson 1986; Pellegrino and Thomasma
1988). Serious ethical questions arise if the physician cannot be trusted to act
in his/her patients best interests. If the physician becomes a double or triple
agent, acting for a managed care organization, the government, an insurance
company, an employer, and presumably for the patient as well, the convanen-
tal relationship is compromised.
Physicians in todays society find it increasingly difficult to differentiate
their roles and responsibilities as agents of their patients from their roles as
agents of those with interests beyond those of the individual. Conflict be-
tween these roles is particularly evident in laws requiring that confidentiality
be breached, such as by reporting child abuse, threats of harm to another in-
dividual, or certain illnesses, such as sexually transmitted diseases. Protecting
the confidentiality of physicianpatient relationships runs counter to societal
concern about the public good in these situations, and confidentiality may not
be upheld as an overriding ethical principle in courts of law (Freudenheim
1991). The earlier illustration regarding the confidentiality of medical records
is another example of a breach of confidentiality not necessarily based on the
wishes or concerns of the individual patient.
Compromising confidentiality has many potential repercussions, includ-

ing the possibility that patients will no longer trust their physicians with cer-
tain types of information or seek appropriate or necessary care. Requirements
for reporting HIV-positive individuals for the purpose of tracing contacts and
advising them about risks or for reporting patients who have made threats of
violence or committed child abuse or other crimes of violence are of particu-
lar concern to patients. Use of genetic testing raises additional concerns about
confidentiality because of the potential that this information might be used to
exclude people from health insurance or employment or for other discrimi-
natory practices.
Another aspect of the conflicting roles of physicians that has important
ethical considerations is the pressure to make decisions based on nonclinical
indications. For example, for economic reasons such as increasing reimburse-
ment or decreasing cost, a physician may be pressured to recommend one
treatment rather than another, to use an alternative medication instead of one
that he or she might ordinarily prescribe, or to discharge a patient from the
hospital when, in his or her clinical judgment, these are not the best decisions
for the patient. Although physicians are held accountable for their medical de-
cisions and can technically override the decisions of health care organizations
and insurance companies, the decision of whether to pay for a treatment ef-
fectively precludes certain types of care for many patients. Insurance and
managed care companies have argued that they are not practicing medicine
and are justified in making decisions about reimbursement, an opinion that
is increasingly not shared by the courts and legislatures.
Physicians may also be asked to take responsibility for treatments they
have not personally recommended or administered because other personnel,
who may not be legally qualified, have been the direct caretaker of the pa-
tient. This request places the physician in an ethical (and legal) dilemma and
potentially harms the patient, often without his or her knowledge or consent
(Nadelson 1986).
Ethical Issues: Women Patients
In the United States, many of the practices described above affect women
more than men because women are more often poor, uninsured or underin-
sured, and have had more limited access to comprehensive health insurance
(Institute of Medicine 1991). In addition, many insurers do not cover gender-
specific preventive care, such as mammograms or Pap smears, and may not
pay for specific medications such as hormone therapy or certain antidepres-

sants. Failure to reimburse for medications more adversely affects women
because they are prescribed more medications, including psychotropic medi-
cations, than are men (National Institutes of Health 1992; Taggart et al.
1993).
Women are also higher users of health care services generally, are more
likely to use home health care because they have more chronic illness, more
often live alone (especially as they age), and pay more out-of-pocket than do
men because their coverage is less adequate (Commonwealth Fund 1997).
Higher copayments or other restrictions on access to care are likely to further
increase costs and limit services available to women.
Policies related to reproduction, including availability of sterilization or
abortion, and allocation of resources for new reproductive technologies clear-
ly affect women more than men and decisions about them are often paternal-
istic. For example, the decision in the United States to prohibit development
or use of RU 486, an abortifacient with other possible medical uses, was
based on the values and beliefs of those with decision-making authority, not
those of the women who would be most affected. Other examples include de-
cisions about insurance coverage for infertility treatments, funding birth con-
trol or abortion services, and banning the use of fetal tissue for research, the
latter of which occurred because it was felt that more women would seek
abortions if they felt there was a justification for it or that good use could
be made of the products of conception (Hilts 1991).
The special characteristics of womens reproductive roles lead to specific
ethical considerations. Because decisions about childbearing, contraception,
abortion, sterilization, and surgery involving reproductive organs have pro-
found social consequences, the autonomy of a woman in deciding these ques-
tions is often challenged. In many cultures, woman have not been in a
position to achieve their own goals if those goals are distinct from those of
their family and society. Decisions about medical care or surgical procedures
that have an impact on sexuality and childbearing are often made by others
and reflect the personal, cultural, or religious values of the physician, family,
or society (Nadelson 1994). For example, whether sterilization or abortion is
funded can determine whether a woman can make that choice. In these cases,
assumptions are made and actions are taken that compromise a womans au-
tonomy. As Nelson (1992) stated,
Social response to womens reproductive abilities typically has made their

bodies part of the public domain in a way that mens are not . . . And as
wombs have become increasingly public spaces medically, they have also be-
come increasingly public politically; womens choices, not only about how
they manage their pregnancies, but also about how they will manage their
work, their leisure, their use of both legal and illegal drugs, and their sexu-
ality, are further subject to societys scrutiny and to the laws constraints.
(p. 13)
One of the more troubling contemporary ethical dilemmas concerns the

purposes and uses of prenatal testing. When used to diagnose fetal disorders,
prenatal testing may lead to a decision to have an abortion, which may be
counter to public policy. Even those who support the right to choose abor-
tion, however, may be uncomfortable about the potential use of abortion for
social reasons including family finances, unmarried status, or even gender se-
lection. From an ethical perspective any restriction can be said to limit a wom-
ans autonomy and place the interests of the mother in opposition to those of
the fetus, but the limits of fetal, maternal, and paternal rights have not been
clearly defined.
Because prenatal testing can reveal the gender of a fetus, abortion could
occur because that gender is undesired. In addition to the ethical problem this
raises, other potential consequences exist. In families and cultures in which
male children are more valued than female children, major changes in popu-
lation demographics could occur and have been reported. The argument has
also been made that once these new technologies are available, control of
their use is not possible. Thus, unethical or coercive practices could result, in-
cluding forced abortion and even infanticide. Debate about a particular abor-
tion procedure, called partial birth abortion in the popular press and federal and
state legislatures, has raised concerns about legislating medical procedures,
the ethics of overriding the clinical judgment of a physician in determining
medical indications, and the autonomy of both physician and patient in mak-
ing medical decisions.
Extensive use of reproductive technologies, including requests from eld-
erly, unmarried, and homosexual people, also raises ethical dilemmas. Pater-
nalism is evident in biases about what constitutes legitimate families and
who should be accorded use of new technologies. Gender bias about moth-
erhood for elderly women is clearly demonstrated by the lack of similar con-
cern about the high numbers of elderly men becoming fathers (Angell 1997).
New technologies, Brody (1988) notes, raise the specter of reproduction to-
tally controlled by females . . . Patriarchal dominance and male lineage are
suddenly at risk. Affiliative rights and knowledge of parenthood, particularly
of fatherhood as an aspect of identity, become unsure. Even the social mother
can no longer state with certainty that this is her biological offspring (p. 203).
These techniques and their use raise questions about the role of biologic
versus social parents, the rights of children born from these procedures, and
the nature of informed consent by all parties. A woman donating ova or mak-
ing a surrogate contract, for example, may have been coerced, especially if fi-
nancial recompense is part of the decision. She may not able to make an
informed decision because she cannot predict her feelings after gestation. The
advent of surrogacy has also brought into focus questions about whether
women can be used as incubators and whether fetuses have become com-
modities, raising the specter of forced pregnancy presented by Margaret At-
wood in her novel The Handmaids Tale. Certainly, contractual surrogacy and
ovum donation place pressure on poor women to rent their bodies or parts
of their bodies.
Mental health professionals are often called on with the expectation that
they can predict outcomes and psychologic risks despite the absence of data
on psychologic impact. Not only is information lacking on how men and
women involved in these technologies will fare, but no data are available on
the outcome for children born into these families. In addition, no guidelines
or criteria for selection of surrogate mothers and families have been formed,
although there has been a great deal of polarized debate.
Additional ethical questions involving the rights and status of children
born through these new techniques remain unsettled. The right to know
ones genetic, family, and medical background has been controversial in cases
of adoption; it is also controversial in cases of surrogacy or other types of re-
productive technologies. A potential conflict exists between the privacy inter-
ests of the parents and the right of the child to know. In many instances
records are altered or simply not kept.
Use of embryo freezing with potential for later use raises additional eth-
ical dilemmas and legal problems when couples divorce, die, or seek to ter-
minate the life of the embryo. A new kind of paternalism also arises when
procedures and technologies are reserved for specific types of individuals or
situations (e.g., only where there is an organic impediment to conception, or
when the women requesting the techonology are married heterosexuals or
within certain age boundaries) (Van Hall 1988). These decisions are often
made by practitioners, with their own biases and expectations, rather than as
a result of an informed and deliberative decision-making process.
Substance abuse during pregnancy is another subject of ethical and legal
controversy. Historically, the fetus was more often viewed as a potential
threat to the mothers life and health because pregnancy and childbirth result-
ed in substantial morbidity and mortality rates. In recent years, as the physi-
cal dangers have decreased, mothers have come to be seen as potential threats
to their offspring. Thus, pregnant alcohol- and drug-addicted women have
been subjected to legal action and even prison sentences. This pits the auton-
omy of the mother against the interests of the fetus. In addition, it changes
the nature of the obstetricianpatient relationship, because the obstetrician is
treating both the mother and the fetus as the patient rather than just the
mother. As in the case of abortion, the fetus is accorded the same rights and
personhood as the mother despite the total physiologic dependency of the fe-
tus on the mother. Ethicists have long debated when and whether the person-
hood of the fetus can be differentiated from that of the mother (Blank 1986;
Bowes and Selgestad 1981; Cole 1990; Harrison 1990; Johnsen 1987; Lenow
1983; McNulty 19871988; Murray 1987; Nadelson 1994; Rhoden 1987).
Another controversy involving pregnant women relates to consent for in
utero treatment of their fetuses and whether failure to consent constitutes fe-
tal abuse. Here, a distinction between moral and legal responsibilities of the
mother has been made. It has generally been held that a pregnant woman
cannot be coerced into accepting a treatment to benefit her fetus. The physi-
cians ethical duty according to the American Medical Association Board of
Trustees (1990) is to be noncoercive and accept the informed decision of the
patient.
The emergence of AIDS in all segments of our society has also raised
ethical considerations regarding HIV testing, the right to privacy, and the
protection of others. This has increasingly emerged as an issue for women be-
cause the AIDS rate in young women is rapidly rising, often related to coer-
cive sexual practices, and women have not benefited from some of the
successful new treatments (Benderly 1997).
PhysicianPatient Sexual Interaction
Concern is increasing about sexual interaction between physicians and other

health care providers and their patients. Although the incidence of these sex-
ual contacts is difficult to accurately document, reports suggest that it is a sig-
nificant problem (American Medical Assocation 1990). In the past, sexual
activity with patients was defended by some physicians as not necessarily
harmful and possibly therapeutic, but the profession has judged it to be cate-
gorically exploitative and unethical, compromising the ability of the physician
to be objective and to give necessary care. Studies have also determined that
it is damaging to patients and may have acute as well as long-term conse-
quences. In addition to the shame, guilt, and mistrust patients experience,

they have been reported to suffer from posttraumatic stress disorder, anxiety
and depressive disorders, sexual symptoms, sleep disorders, and substance
abuse. Reports have also been made of increased suicide risk and psychiatric
hospitalization (American Medical Association 1990; American Psychiatric
Association 1989; Bouhoutsos et al. 1983; Burgess 1981; Feldman-Summers
and Jones 1984; Gabbard 1989; Herman et al. 1987; Kluft 1989; Pope and
Bouhoutsos 1986; Simon 1991).
Several reasons exist for the decision to consider doctorpatient sexual
intercourse to be unethical. First, it breaches the fundamental trust of this fi-
duciary relationship. Second, it casts doubt on the physicians capacity for ob-
jective professional judgment. Third, it must take account of the patients
psychologic involvement with the physician inherent in the clinical situation.
Patients rapidly develop feelings toward their doctors, called transference,
which involves the displacement of feelings derived from past relationships
onto the current doctorpatient relationship. The doctor can thus be viewed
as an all-knowing parent, and a great deal of power is turned over to the doc-
tor by the patient (Gabbard and Nadelson 1995).
Although some believe that a relationship might not be unethical in cer-
tain circumstances, for example, when the clinical encounter is brief such as
occurs in an emergency room, or when the care provided does not involve an
intense interpersonal relationship, as occurs when a patient receives anesthe-
sia. However, there is reason to be cautious even in these circumstances. The
patient may overidealize the physician as a savior and succumb to a seduc-
tion. Likewise, questions have been raised about when a patient ceases to be
a patient and how long can one assume that the transference would be oper-
ative. No clear guidelines exist, and certainly questions about paternalism can
be raised by the restrictiveness of many current ethical and legal standards
and procedures.
Efforts to enforce ethical guidelines forbidding sexual activity between
doctor and patient have been hampered by concerns about confidentiality
and public exposure that have made it difficult for patients to register formal
complaints (Marmor 1976). Substantial progress, however, has been made in
the past decade. Civil actions have been brought in the courts, and several
states have adopted criminal, civil, and licensing regulations that specifically
proscribe sexual contact with patients on the part of psychotherapists, physi-
cians, other health care providers as well as others in positions of authority
such as teachers and employers (Jorgenson et al. 1991). Between 5% and 10%
of psychiatrists and psychologists have reported sexual contact with patients
(Gartrell et al. 1989). Some data available on sexual interaction between pa-
tients and nonpsychiatric physicians suggest that the figures are comparable
in the United States and other countries. For psychiatrists in the United
States, it has been estimated that about 88% of reported incidents of sexual
misconduct involve male psychiatrists and female patients; 7.6% involve male
psychiatrists and male patients; and 3.5% involve female psychiatrists and fe-
male patients (Gartrell et al. 1989; Simon 1989). In a series of over 2,000 cas-
es of therapistpatient sex, Schoener et al. (1989) noted that approximately
20% of cases involved a same-sex dyad, and 20% of the therapists were fe-
male.
Conclusion
This chapter considers the basic principles of medical ethics and briefly
touches on some contemporary and emerging ethical issues, including those
that especially affect women. For the physician, the complex dynamics of the
relationship with the patient demand continual vigilance in order to maintain
clarity about his or her role as the patients advocate as opposed to the agent
of society and about the special nature of the boundary of professional and
personal relationships. For society, the changing role of women and the emer-
gence of new technologies, especially those involving reproduction, have
raised questions with profound ethical implications. It is also clear that cultur-
ally determined ethical values often clash. At this time, medical decision mak-
ing and the processes for resolving some of the dilemmas discussed here are
inconsistent. It will likely take some time to resolve these ethical issues.
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26
The Male Perspective
MICHAEL F. MYERS, M.D., F.R.C.P.C.
S canning the table of contents of this book on the health care of women,
one sees that the substance of every chapter in each of the three sections affects
(and is affected by) menmen as husbands or boyfriends, men as other family
members (e.g., fathers, brothers, sons), men as friends, and men as clinicians
to women. Furthermore, the notion of men in relation to women (Bergman
and Surrey 1992) forms a critical element in understanding many of the
illnesses and problems described here: the presenting symptoms, the etiology
of the symptoms, how openly and comfortably the woman communicates her
distress, how significant men in her life react or do not react, the ways in which
male and female physicians interview, diagnose, and treat women patients,
and what is taught and granted ascendancy in our medical schools and training
settings. Our time-honored biopsychosocial model of assessing and treating
patients demands an in-depth appreciation of the role of gender in the exem-
plary care of women.
It is impossible to do an exhaustive analysis of the male perspective in all
of the areas covered by this text. I have selected only certain clinical situations
in the hope that many of my observations and those of others extend further.
My data are the stories of men and women patients seen over my 25 years
of psychiatric practice as both an individual therapist and marital therapist;
my professional liaison with colleagues in obstetrics and gynecology who re-
fer patients (individuals and couples) to our marital therapy teaching clinic;
my clinical research on the male patient; my insights from a course on gender
issues taught to residents in psychiatry; and, where applicable, my review of
published literature on men in relation to the health care of women.
585
Men and Pregnancy
Most men feel a tremendous surge of satisfaction, happiness, and validation

of their masculinity on learning that their wife or partner is pregnant. These
emotions are quickly confounded by others, however, if the pregnancy is un-
wanted, unplanned, or threatening to health or relationship equilibrium. Di-
amond (1986) described other needs and conflicts that are triggered for men
by pregnancy: envy toward the prospective mother; concerns of responsibil-
ity, adulthood, and aging; competition and a need for connection with ones
own father; wishes to revitalize the relationship with ones parents; jealousy
toward the developing fetus, who is the object of his partners rapt attention;
and unresolved conflicts in the couples marriage or partnership. Because
men cannot become physiologically pregnant, many express their needs cre-
atively (e.g., building a nursery, saving money for the new addition, writing
a childrens book, constructing a playground) (Diamond 1992).
Ross (1982) has called the father the forgotten parent in psychoanalytic
literature. He observed 65 boys between the ages of 3.5 and 10 years and not-
ed various intense wishes among them both to have and to care for babies
(Ross 1983). He felt that the paternal identity of an adult man does not just
exist in a vacuum but begins much earlier in life and is merely activated or
crystallized by the birth and presence of his children. Caths (1986) emphasis
on the dynamic interplay between the man and woman and how they view
each other as prospective and actual parents of their children is significant. He
calls this the alliance of couplehoodthat is, the positive and negative contribu-
tions to family mutuality that begin long before conception. How the couple
nurtures each other ensures the nurturance of their offspring. Greenberg and
Morris (1974) have used the term engrossment to describe the excitement, joy,
and fascination that fathers manifest with their newborn infants.
As clinicians, we are likely to witness and be asked to assist with the more
unfortunate male concomitants of pregnancymen who are completely
against the pregnancy and who demand termination; men who become vio-
lent during their partners pregnancy (Gazmararian et al. 1996); men who
withdraw from their partners both emotionally and sexually; men who over-
work and neglect their partners; men who act out sexually with other women
(and sometimes other men), including beginning an affair; men who drink to
excess and/or abuse other drugs; men who become anxious (May 1994) or
clinically depressed; and men who threaten abandonment or who actually do
leave the relationship. Many of these situations present as emergencies and
The Male Perspective 587
require urgent medical and psychiatric attention to protect the health and
well-being of the pregnant woman and her relationship.
Men and the Postpartum Period
Feelings of exclusion, diminishment, and alienation are not uncommon in

new fathers. Some men have a delayed reaction to the babys birth. They be-
have as if no change has occurred in their lives and make little or no effort to
assist with the baby. They may also resent giving up their freedom or inde-
pendence to share the workload at home. Some men feel inept at or anxious
about child care and may feel threatened by the competence and facility with
which their wives adapt to motherhood and may feel belittled when their
wives try to teach them basic skills of bathing and feeding their new daughter
or son (and these feelings may be warded off by defensiveness, rigidity, and
offense). Some men regress into childlike behavior, demanding attention
from their busy, tired, and often beleaguered wives, whereas other men may
feel guilty about their competitive, jealous, and resentful feelings toward their
new baby. Classically, men do not talk about these emotions until (or if) they
are blurted out during a fight or when the man is disinhibited by alcohol.
Marital problems are not uncommon in couples during the postpartum
period. Anticipating and accepting the realities and responsibilities of parent-
hood are much easier for couples who are older, reasonably mature as indi-
viduals, and who are informed and prepared. However, many couples have
an unplanned pregnancy, are very young, and have not had much time to get
to know each other. Hence, their ability to communicate, to trust and count
on the other, and to feel and expect commitment to the family are tenuous.
Miscommunication and misunderstandings abound and soon both partners
feel disillusioned, resentful, and unhappy.
Navigating their way through the stormy passages of new parenthood
can be tough when people cannot really talk well with each other. Both part-
ners are coming to terms with giving up much of the freedom and self-interest
that they enjoyed before the baby was born. They are both adapting to the
new roles of mother and father (Marks and Lovestone 1995). Lovemaking
must be scheduled around the babys sleepwake cycle and not uncommonly
the fatigue that new mothers feel eclipses their libido. Few husbands truly un-
derstand this; they may develop angry, hurt, rejected, and confused feelings.
Furthermore, their concerns about birth control may not be in harmony, and
one partner or the other may be terrified of another pregnancy so early, es-
pecially when postpartum psychiatric disorders have occurred (Peindl et al.

1995).
The most common marital symptoms are poor communication (both
quantitative and qualitative); frequent arguments and fights, perhaps with
physical violence; lack of sexual desire in one or both; overwork in the man
with corresponding loneliness, resentment, and increased exhaustion in his
partner; financial worries; misuse of alcohol or other drugs; and an undiag-
nosed psychiatric illness in one or both of them (Areias et al. 1996; Merchant
et al. 1995). Dual-career and two-paycheck couples may have the additional
problem of never seeing each other except when they are exhausted, especial-
ly if they work opposing shifts to ensure that one of them is always the care-
giver. These couples may feel tremendous friction because of gender-role
rigidity and ambiguity; their stated goal may be to share domestic and child-
care responsibilities equally, but each may end up feeling overburdened or
shortchanged. In traditional marriages, exhaustion is equally as common in
both partners.
Men and Infertility
How do men react to and cope with infertility (Meyers et al. 1995a)? Mourn-
ing of ones anticipated or assumed ability to have a child always accompa-
nies the threat or the reality of infertility (Myers 1990). All stages of
bereavement are common (e.g., denial, shock, anger, bargaining, depression,
and acceptance), and because men tend to be less openly expressive than
women, their distress may not be evident. They may also be suppressing feel-
ings to remain supportive and strong for their wives, although this stance
can backfire when or if the mans wife misinterprets his controlled manner as
disinterest or coldness. Speaking privately with each partner often clarifies
that the man does indeed have many feelings about their difficulty conceiving
a child.
Mourning may be accentuated if the man learns that the infertility re-
sides within him. Shooting blanks, the common colloquial expression for
azoospermia, covers up the underlying pain and assault to gender identity
(ones inner sense of masculinity and maleness). Clinically, these men may
manifest their distress by withdrawing from their wives (both emotionally
and sexually), brooding, overworking, preoccupying themselves with sports,
becoming irritable, drinking, or acting out sexually with other partners.
Their need for privacy may be heightened and their wives may feel that they
are not free to talk about their infertility problem with trusted friends and
family members. Marital strain is not uncommon (Meyers et al. 1995b).

Men may also find that the diagnostic procedures and investigations that
they must undergo are stressful. I have never felt so naked in my life were
the words of one man as he described his experience of being asked so many
questions about his medical history and sexual life, of undergoing an exten-
sive physical and genital examination, of submitting to laboratory tests, and
of providing a specimen for semen analysis. Attempting pregnancy by sched-
uling intercourse at the time of ovulation each month can become difficult af-
ter some time, no matter how much couples try to relax, be versatile, or use
humor. Many husbands begin to feel the pressure of intercourse on demand;
they feel objectified or that they are machines that deposit sperm on schedule
once a month. Engaging in sex becomes a chore or work and is no longer
erotically pleasurable.
How do men react to the new reproductive technologies? Few gender-
specific data are available (Edelmann et al. 1994; Laffont and Edelmann
1994), but it would seem that the more information that both partners have
the better. This includes lectures, reading material, consultations with various
specialists, and a sense of freedom and opportunity to ask questions. Hus-
bands must be encouraged to ask questions about costs, invasive procedures,
success rates, timelines, time involvement, medical and psychologic compli-
cations, and any possible religious or moral conflicts that they may have
about the technology. Relinquishing control and trusting physicians and their
procedures may be challenging for some men living with an infertility prob-
lem, possibly in opposition to their wives who do not share their reservations.
Men and Abortion
Although men do not actually experience termination of a pregnancy, they

certainly have a host of feelings about abortion. I restrict my discussion here
to clinical situations in which men are faced with an unwanted pregnancy in
a loved one (as opposed to male beliefs, feelings, polemics, and political views
on abortion). Although the decision to end a pregnancy is ultimately the
womans, many couples agonize over coming to that point and rarely is the
man completely neutral about the decision. A continuum of male ideology
seems to exist, ranging from absolute conviction that the pregnancy must be
terminated to absolute horror or revulsion at the mention of therapeutic abor-
tion.
What are some of the attitudinal determinants in men regarding abor-
tion? Some young men, much like their female counterparts, are very clear
that they are not psychologically ready to become fathers (e.g., they are ado-
lescents, students, unemployed, undergoing psychiatric or substance depen-
dence treatment, not ready for a committed relationship). Some men are clear
that they cannot afford a child or another child. They have the maturity to
recognize the economic responsibility of being a father and take the matter
seriously rather than renounce this onto their partner or the state. Some hap-
pily married men who have had a family and who are just beginning to feel
freed up (or who have long-range plans for more protected time with their
wives) will fight hard against an unwanted pregnancy. Their wives, however,
may privately want another child or may at least be open to becoming preg-
nant. Because their marriage is strong and they can afford another child,
these women may be aghast at and threatened by how vehemently opposed
their husbands are toward continuing with the pregnancy. Some men are con-
scious of negative or ambivalent feelings about their relationship or marriage
before learning of the pregnancy and thus have no desire for fatherhood
when considering separation or marital therapy.
A range of psychologic determinants may be operative in men who want
their partners pregnancy to continue. Some men have religious or spiritual
prohibitions against abortion that influence their wishes and beliefs about
their partners pregnancy. This includes men without current religious affili-
ation but whose rearing included religious observance. They may experience
a resurgence of strong antiabortion feelings when faced with an unwanted
pregnancy. Some may have had one or more previous partners become preg-
nant and have therapeutic abortions; they have reflected on these experiences
and do not believe that they can support another termination. For some men,
impregnating a woman is narcissistically driven; becoming a father regulates
their gender identities as men. Such men will resist their partners wish to end
the pregnancy by abortion. When their partners have shaky self-worth, asser-
tiveness, and autonomy, men who are controlling will ensure against a thera-
peutic abortion by cajoling, coercion, threats of abandonment, sexual acting
out with others, and abuse (physical, verbal, sexual, emotional).
Mens Reactions to Breast Cancer
Women who are diagnosed with and treated for breast cancer are far from
monolithic and so are their partners or husbands. What is known, however,
is that these men do have a reaction when their loved one is faced with cancer.
One study of women and their partners over a 1-year period following sur-
gery showed improvement in negative emotions, psychologic distress, psy-

chologic well-being, and performance of vocational, domestic, and social
roles for both partners (Hoskins 1995). Studies indicate that younger women
experience more emotional distress than do older women, although the in-
verse relationship between age and emotional distress is not consistent across
all studies (Northouse 1994). Younger husbands reported more problems car-
rying out domestic roles and a greater number of life stresses than did older
husbands. Even when women with breast cancer have good helping relation-
ships with others, research findings suggest that the partner plays a huge role
in their adaptation, particularly when communication is characterized by
high empathy and low withdrawal (Pistrang and Barker 1995). Studies of
women with recurrent breast cancer show that partners have a mutual influ-
ence on one another (Northouse et al. 1995a), that one or both members of
more than 50% of the couples scored outside the normative range on either
depressed mood or marital adjustment (Lewis and Deal 1995), and that wom-
en reported more emotional distress than did their husbands (although each
had a similar number of psychosocial role problems) (Northouse et al.
1995b).
It is well known that women with breast cancer worry about their part-
ners reaction to their physical appearance; however, this focus on cosmetics
is not always an issue for women alone. It is not unsual to learn of men who
cannot look at the scarred or missing breast or who no longer feel sexual with
their wives. At least one study has shown significant emotional distress and
depression in husbands 4 months after their wives surgery (Omne-Ponten et
al. 1993). There was little scored difference between men whose wives had
had mastectomies and men whose wives had had breast-conserving surgery.
What may be more important in how a man copes with breast cancer in his
partner are other variables, such as his personal health status; his subjective
sense of happiness with and commitment to the marriage prior to the diagno-
sis; his coping resources, including a capacity for living with threat, uncertain-
ty, and loss; his psychologic maturity; the nature and number of his
supportive relationships outside the marriage; his occupational and/or finan-
cial security; his preexisting healthy relationship with children; and his reli-
gious and/or spiritual leanings.
Men and Menopause
Menopause is one of the critical stages in the individual life cycle (Erikson
1963). Life cycle stages in both men and women correspond closely to critical
stages in marriage. Although the actual prevalence of marital dysharmony

during menopause is not known, we do know that a peak in divorce occurs
after 2025 years of marriage (Cherlin 1981). Clinically, many men and
women seek marital therapy at this stage of life and marriage, and many un-
happily married women and men leave their marriages.
Menopause is characterized by normal unrest and struggle, a transitional
stage that is common in most marriages. Furthermore, menopause corre-
sponds with middle adulthood, including a restabilizing and reordering of
ones priorities. The marital task is to resolve conflicts and to strengthen the
marriage for the long haul. Despite enormous conflict and tremendous un-
happiness in couples coming for marital assistance at this time of life, what is
not always understood is the tenacity of marital bonding in the face of adver-
sity, the commitment to the marriage covenant (for better and for worse),
and the toughness and resilience of people who have been together for a long
time.
Husbands and wives may differ in their rates and directions of emotional
growth at menopause. Problems with loss of youthfulness may arise that con-
tribute to feelings of depression, extramarital affairs, or both in either partner.
In enduring marriages, intimacy may be threatened by the aging process and
by boredom despite stability and security. Children leaving the family home
may increase or decrease intimacy; the empty nest syndromethat is, dissat-
isfaction and unhappiness when children leave the homeis not universal
(Bernard 1982) and is identified in both men (Scher 1992) and women.
Menopause is a time of new beginnings when women, who have put many
of their personal needs and wishes on hold for their husbands and children,
are now free to pursue their own goals. This may include leaving a loveless,
empty, or grim marriage.
What about male menopause? This term has become a pejorative de-
scriptor applied to men in their middle years who suddenly do something out
of character or indicative of a problem with aging. Examples might include
training for triathlons; becoming a vegetarian; visiting an ashram; getting a
hair transplant; having a facelift; buying a jazzy sports car; or taking up with
a much younger woman. Sometimes menopause in a woman is juxtaposed
with a midlife crisis in her husband, a combination that can threaten marital
equilibrium. We live in a youth-oriented society, and many men in their mid-
dle years are attracted to younger women and not to their female contempo-
raries (Myers 1989). We are products of the culture in which we live, a culture
of menopausal myths and myths that erode womens self-esteem (Notman et
al. 1991).
When Male Physicians Treat Female Patients
Gender is merely one of the many variables (age, socioeconomic level, race,
ethnicity, sexual orientation, marital status, language, and so forth) that con-
tribute to the unique and dynamic interplay when male physicians treat fe-
male patients. I only wish to emphasize some basic facts that form the
bedrock of all male physicianfemale patient encounters and inform diagno-
sis and treatment. Left unrecognized, these factors can lead to omission, error,
biologic reductionism, scientific inaccuracies in research, and treatment non-
compliance.
It must first be acknowledged that gender discordance exists within the
physicianpatient relationship. Male physicians must accept that because
they are men they will be viewed differently than if they were women. Being
viewed differently is value neutral; it should not be misconstrued as being
viewed more positively or negatively. The transference feelings that the wom-
an patient brings to the professional relationship will be centered in her early
and current relationships with men and women, her previous experience with
male and female physicians (especially ones who work in obstetrics and gy-
necology or other branches of medicine related to womens illnesses), her ide-
ology about male and female gender roles, including men and women in the
professions, and her personal and family history (mother absence, father ab-
sence, sexual abuse or assault, males or females as role models, and so forth).
These factors may contribute to the various transferences (e.g., dependent,
mistrustful and guarded, hostile, regressive, erotic) that can occur when wom-
en are treated by men.
Second, male physicians must respect the concept of countertransference
when they treat women patients. In other words, they must be open to iden-
tifying and reflecting on their feelings, attitudes, beliefs, and values toward
women in general and their women patients in particular. This requires a
nondefensive and sometimes emotionally laden (anxiety, guilt, shame, anger,
hurt) inner appraisal of personal and family-of-origin issues, especially ones
lifetime relationships with females. If physicians are under strain at home
(e.g., living with marital conflict, separation, isolation, or depression), they
must be encouraged to seek help. They must also be open to new concepts
and gender-specific research that exposes outdated scientific inaccuracies,
flawed experimental design and methodology, and sexism in academia and
medical centers. Physicians must be able to embrace the evolving directives
concerned with gender-neutral language in our work with patients and col-
leagues as being respectful and professional. They should also keep abreast
of new developments in sexual harassment policies in the workplace and the

ethical guidelines issued by licensing bodies and medical institutions to re-
spect and preserve the boundaries of the doctorpatient relationship.
Third, many male physicians are interested in and could learn from for-
malized teaching about the myriad transference and countertransference is-
sues when men treat women. These are elementary and central features of
the physicianpatient relationship, and yet they are not well taught in medical
school or residency programs. Teaching methods include didactic lectures, as-
signed readings, seminars, videotapes, and role-playing exercises of common
clinical situations. When possible, this teaching is best done by other physi-
cians, both men and women, who practice the same branch of medicine as
the trainees (importing nurses, psychologists, or psychiatrists to teach obstet-
rics and gynecology residents about transference and countertransference is-
sues may fail). The best teachers in each discipline are male clinicians who
are everyday role models and whose treatment of women patients and col-
leagueship with women health professionals are exemplary.
Conclusion
Men are significant characters in the lives of all women and key players in the
psychologic aspects of womens health care. In this chapter, I have selected
only a small number of obstetric, gynecologic, and other disorders to exam-
ine how men influence and are influenced by women. I hope that some of
these observations are generalizable to other clinical situations and, further-
more, that physicians who treat women extend their reach to the men who
are so important in their patients lives.
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27
Collaborations Between Psychiatry
This book addresses the psychiatric issues related to obstetrics and gyne-
cology and the womens reproductive health issues relevant to psychiatry.
This chapter is about process. Given the many clinical, educational, and
research areas in which psychiatry and obstetrics/gynecology have important
collaborative contributions to make, how does the collaboration take place?
Sites range from the laboratory bench and classroom to the delivery room
and the halls of government. Methods include written materials, formal
lectures, conjoint or consultative work in the office or at bedside, joint commit-
tees, and the formation of multispecialty organizations that develop programs,
activities, and publications of mutual interest. Although I am most familiar
with activities and circumstances in the United States, this chapter attempts
to acknowledge, at least, the differences among countries with respect to service
organization.
History
Reproductive organs, functions, and events have always aroused scientific cu-
riosity and evoked powerful affects. The history of psychosomatic medicine
and consultation psychiatry arose in large part at the intersection of psychia-
try and obstetrics/gynecology. The ancient Greek word hysteria denoted a dis-
ease in which otherwise unexplainable physical symptoms were thought to
597
be caused by the wanderings of an unmoored uterus (hyster-) from its normal

position in the pelvis to the body sites manifesting the symptoms (Pomeroy
1975). Freud (1931/1961) conceptualized development in terms of psychosex-
ual stages and considered the formation of a successful heterosexual relation-
ship, including procreation, to be the sine qua non of normal maturity. Freud
also understood many psychologic symptoms as the disguised expression of
unfulfilled, repressed sexual desires.
One of the landmark psychosomatic collaborations of the twentieth cen-
tury was that of Benedek, a psychiatrist and psychoanalyst, and Rubinstein,
a gynecologist. They studied women during the course of psychoanalysis
undertaken for reasons unrelated to the object of their research. The patients
kept track of their menstrual periods, the gynecologist monitored urinary
levels of the then newly discovered female hormones, and the psychoanalyst
recorded evidence of the patients moods and thought content in their dreams
and associations (Benedek and Rubinstein 1942). These collaborators con-
cluded that hormonal changes characteristic of the ovulatory phase were as-
sociated with affects and thoughts of nurturance and interest in sexual
intercourse. It seemed to them that cyclic changes of this kind would enhance
the likelihood of conception and therefore the preservation of the species.
During the 1940s and 1950s, psychoanalysis was a (or the) dominant
force in American psychiatry. The power of psychodynamics to explain hu-
man feelings and behaviors was impressive, and attempts were made to use
it in arenas ranging from international relations to preschool education. Be-
cause many or most psychoanalysts were also physicians, considerable inter-
est arose in applying psychoanalytic knowledge and technique to medical
diagnosis and treatment and thereby also in enhancing the integration of psy-
chiatry into the rest of medicine. Such an integration was otherwise some-
what threatened by psychoanalysts distance from and even rejection of the
traditional authoritarian approaches of clinical medicine (Alexander 1950;
Dunbar 1954). Psychoanalytic technique was used in the study of patients
with various medical illnesses (Alexander 1950; Dunbar 1954). Authors de-
scribed constellations of personality traits and unconscious conflicts that
characterized sufferers from several major diseases. Physical symptoms were
conceptualized in terms of neurotic compromisefor example, the asthmatic
patients wheezing was a cry for the mother; the hypertensive patients car-
diovascular changes resulted from repressed rage; infertility was the result of
an unconscious terror of motherhood. Therapeutic interventions based on
these etiologic formulations were reported to have positive effects. In some
major medical centers, psychiatrists and psychoanalysts were assigned to
Collaborations Between Psychiatry and Obstetrics and Gynecology 599
some or all medical units to work with medical colleagues and patients on a
regular basis.
Over the years, for various reasons, these arrangements eroded. Im-
provements in research methodology called previous conclusions into ques-
tion. Many of the patients studied had already suffered from their diseases for
many years. There was no way to know whether the psychodynamics re-
vealed in their diagnostic interviews were the cause or the result of their years
of pain and disability. Suppressed feelings of neediness and anger were to be
expected under the circumstances. Imputed causal connections between per-
sonality types and medical disorders did not hold up to scientific scrutiny.
Researchers discovered genetic, infectious, and other etiologic factors for
hitherto mysterious signs and symptoms. For example, the ability to examine
the fallopian tubes through laparoscopy and microscopy sometimes revealed
evidence of surgically repairable tubal damage that had resulted from prior
pelvic infections. These discoveries led some clinicians to conclude that psy-
chodynamic explanations for infertility, for example, were a wastebasket,
an etiologic last resort, for conditions not yet conquered by real science and
that these explanations stigmatized already suffering patients as being some-
how responsible for their own conditions.
Other factors that played roles in the decline of psychiatric and psycho-
dynamic involvement in medical care included funding, personnel, the devel-
opment of other mental health disciplines, and the burgeoning of biologic
approaches to psychiatry (Fenton and Guggenheim 1981). Some of these ap-
proaches, such as the dexamethasone suppression test, were expected to sup-
plant the need for the understanding of childhood experience and current
conflicts. Increasingly effective psychoactive medications were developed and
quickly adopted into the armamentarium of nonpsychiatric physicians, in-
cluding obstetrician/gynecologists (OB/GYNs).
At the same time, evidence of synergistic relationships between biologic
and psychosocial factors in the genesis and phenomenology of illness contin-
ued to appear. We now know, again, that mind and body are inextricably in-
terrelated, but in ways more numerous and complex than earlier supposed
(Sharpe et al. 1996). Life events can precipitate mood and neurohumoral
changes that affect immune responses. Eating disorders and reproductive
dysfunctions are related. Psychosocial factors exist in infertility; some infertile
couples are not having sexual intercourse or are using a schedule or technique
that precludes conception for reasons of ignorance or inhibition. Situations
like these continue to baffle clinicians and patients and lead to needless med-
ical interventions and expenditures (Christie 1997). The consulting psychia-
trist can help by encouraging the infertility team to incorporate a few simple
screening questions into the initial diagnostic process (Christie and Pawson
1987).
Consultation-liaison psychiatry reinforces and uses the medical identity
of psychiatry (Lipowski 1986). Several organizations and publications are de-
voted to psychosomatic and consultation-liaison issues. Subspecialty groups
address issues related to specific medical conditions: oncology, nephrology,
AIDS, and obstetrics/gynecology. The latter is discussed below. However,
few if any medical care institutions support the assignment of a psychiatrist
to each clinical specialty service. Most of the clinical problems discussed in
this book are handled by general psychiatrists or psychiatrists in another sub-
specialty (child and adolescent, forensic, geriatric) or in general consultation-
liaison psychiatry rather than by psychiatrists who spend much or all of their
time working with OB/GYNs. This chapter provides an overview of issues
and activities for the psychiatrist working with obstetrics and gynecology.
Clinical and Cultural Substrate of

Obstetric/Gynecologic Practice
Psychiatric consultation to another medical specialty is facilitated by familiar-

ity with the content and style of that specialtys practice (Stotland and Garrick
1990). Although OB/GYNs share many issues with all other physicians, they
also face some challenges unique to their specialty. Most of the subspecialties,
as well as the general practice, of obstetrics and gynecology attract practition-
ers who enjoy active intervention and expect their interventions to result in
relatively prompt and positive clinical outcomes. This stance serves them well
for much of their clinical work but leads to frustration in many of the situa-
tions in which psychiatric consultation is sought: failure of the patient to com-
ply with medical recommendations, behavior that is actively self-destructive
and/or threatens the well-being of the fetus or newborn, grief responses to
procreative losses, physical complaints without diagnosable physical founda-
tion, and intense transference reactions to the gynecologist (Stotland 1988).
In 4 years of training, residents in obstetrics and gynecology must master
a huge and explosively growing body of medical information as well as an
array of techniques, including ultrasonography, amniocentesis, chorionic vil-
lus sampling, normal and complicated childbirth, and several kinds of mac-
roscopic and microscopic surgery. Some of these techniques, such as induced
abortion and the use of reproductive technologies, are highly contentious.
This field of study overlaps significantly not only with general surgery and
oncology but also with pediatrics, urology, and infectious disease. The desig-
nation of obstetrics and gynecology as a primary care specialty has protected
the field from some of the more draconian cuts in educational funding, but
has also added a whole new burden to training and practice: mastery of the
whole body of general office practice.
This load of clinical and academic work involves the care of patients
whose problems and treatments carry a tremendous emotional valence. Ob-
stetrics and gynecology involves not only routine pelvic examinations and
normal deliveries, which are in themselves emotionally demanding on patient
and staff, but also the care of patients who have been raped; who have given
birth to extremely small and/or damaged infants; who seek to terminate preg-
nancies at various stages; whose pregnancies are highly desired but threat-
ened by medical or psychiatric illness; who have sexually transmitted diseases
that threaten their fertility, health, or survival; who have malignancies; and
who have difficulties with their sexual and/or reproductive functions. Little
or no time is available for OB/GYNs, especially residents, to talk to these pa-
tients at length; to learn about the emotional dimensions of these clinical
problems; to acquire skills for diagnosing, referring, and treating the psychi-
atric complications of these conditions; or to acknowledge and accept the pro-
found feelings that these conditions engender in the treating physician (Adler
1972).
In addition to the clinical, technical, and emotional complications, many
of the most vexing ethical conflicts in clinical medicine are faced by the OB/
GYN (Strong et al. 1997): Should a pregnant woman be forced to undergo an
obstetric intervention in the interest of her fetus or be punished if her behav-
ior results in fetal damage? Which patients, if any, should be admitted to ar-
tificial insemination, in vitro fertilization, or surrogate mother programs
(Lantos 1990)? Are physicians obligated to provide induced abortions, and
at what stages of gestation and under what circumstances? What constitutes
informed consent for sterilization? Legal and social standards vary widely
from culture to culture.
Not uncommonly, OB/GYNs must repair medical damage caused by be-
havior that they find personally repugnant (e.g., cocaine abuse during preg-
nancy) or that they must provide services of which they do not fully approve
(e.g., contraceptives for early adolescents). When these ethical and emotional
demands are placed on a sleep-deprived resident who is struggling to develop
technical skills and who chose this specialty in the hope of facilitating expedi-
tious and happy outcomes, the result may be avoidance, depression, and rage.
These emotions are often reflected in requests for psychiatric consultation

and in the functioning of the health care team requesting them (Karasu et al.
1977).
Recent changes in the social context of medical practice in the United
States have had a particularly problematic impact on OB/GYNs. The prolif-
eration of malpractice litigation has hit obstetricians especially hard. In the
state of Illinois, for example, nearly 100% of obstetricians will be sued by pa-
tients at some point duirng their careers. Charles and Kennedy (1985) have
documented the interruption of practice, avoidance by colleagues, loss of self-
esteem, changes in practice patterns, and suspicion of future patients caused
by malpractice suits even for the majority of doctors who will be found inno-
cent of the charges brought against them. Physicians feel constrained to per-
form diagnostic and therapeutic interventions on preventive legal, rather than
medical, grounds. This tends to warp cognition as well as emotion.
Obstetrics is also legally perilous because any allegedly damaged infant
and its family make a wrenching spectacle in the courtroom, because the life-
long care of such an infant is so costly, and because the statute of limitations
on bringing a lawsuit does not apply until the infant has reached the age of
majority and has had the opportunity to realize the nature and cause of his
or her disability. Advances in reproductive technology and obstetric tech-
nique constitute a two-edged sword (Hummel and Kettel 1997; Mahowald et
al. 1996): the public expects the medical profession to be able to solve any
problem and to produce a perfect outcome in every case, whereas the very
patients who are at higher risk because of delayed childbearing are those who
are most likely to seek legal recourse for any frustration. These problems are
of less concern in countries other than the United States, where the prolifer-
ation of lawsuits of every type is a significant social challenge.
Consumer criticism of medicine has also been highly focused on obstet-
rics and gynecology. Finding physicians wanting in knowledge and attitude,
a group of mothers in the Chicago area founded the La Leche League to pro-
mote breastfeeding (La Leche League International 1987). Chapters were
founded in countries all over the world, and the demographics of infant feed-
ing changed; the proportion of mothers breastfeeding on leaving the hospital
rose from a small minority to a significant majority. Unfortunately, manufac-
turers of infant formula were doing extensive marketing in countries where
breastfeeding was the normal mode of infant feeding at the same time. For-
mula feeding was associated with sophistication, but many families lacked the
resources to sterilize the bottles and refrigerate the formula. Many infants
died as a result.
At about the same time, physical therapists, nurses, and nonmedical per-
sons began to teach prepared childbirth classes that educated expectant par-
ents about the anatomy and physiology of pregnancy, labor, delivery, and the
postpartum period (Bing 1973). These classes also, however, brought women
and their significant others together to question and defy traditional medical
authority (Chalmers and McIntyre 1994). They encouraged patients to be-
lieve that they could and should comprehend medical questions and make in-
formed choices about their own care and substitute relaxation and distraction
techniques, over which they had control, for dependence on analgesics and
anesthetics administered by professionals that could lead to iatrogenic com-
plications. They also encouraged the participation of significant others in the
experience of labor and delivery, diminishing to a significant degree the cen-
tral emotional role of the physician (Seiden 1978). Organizations and articles
in the popular press questioned routine repeat cesarean delivery and the in-
dications for the enormous number of hysterectomies performed in the Unit-
ed States as compared with other affluent countries. Books like Our Bodies,
Ourselves, which was written by a womens collective, explained issues that
had been the exclusive domain of OB/GYNs (Boston Womens Health Col-
lective 1984).
All of these developments, such as the increase in sensational malpractice
litigation, aroused or gave voice to suspicion and hostility between patients
and doctors (Arms 1975), at least in the United States. OB/GYNs found it
ironic that, despite the enormous efforts they expended acquiring and apply-
ing knowledge and skills in the interest of womens health, they should be
viewed in the press and the consulting room as purveyors of needless and of-
ten damaging interventions and as dismissive of women and their autonomy
over their reproductive organs and functions (Leppert et al. 1996). There
was, however, significant clinical and documentary foundation for womens
complaints (Friedman 1986; Hellerstein 1984; Scully and Bart 1973). No em-
pirical foundation existed for many obstetric and gynecologic practices, such
as episiotomy, prohibitions against intercourse for 6 weeks after childbirth, or
the removal of healthy ovaries along with diseased uteri. Textbooks some-
times implied, or even stated, that women who were in menopause or preg-
nant were emotionally and cognitively incapacitated and that their physicians
would have to guide them paternalistically through this reproductive stage.
With a few exceptions, the people complaining about OB/GYN care
were female, and the people complained about were male. Since the first edi-
tion of this book was prepared, a revolution has occurred in the gender com-
position of North American obstetrics and gynecology training programs.
Some residency classes are entirely female and male applicants feel they have
to justify their interest in the field. Yet the academic and organizational lead-
ership of the specialty is still largely male; the second woman president in the
history of the American College of Obstetricians and Gynecologists complet-
ed her term in 1998. It is not clear whether changes in gender composition at
the entry level have had a significant impact on attitudes and practices, at least
to date. The ethos of the field is passed along and strongly colors not only
clinical practice but also the personal experiences of newer practitioners. If a
trainee is never exposed to patients who labor and deliver happily and suc-
cessfully without medical intervention, he or she is likely to demand maxi-
mum intervention for his or her own deliveries. Another factor driving styles
of practice is managed care, diminishing hospital stays, length of outpatient
visits, and continuity of care. The American College of Obstetricians and Gy-
necologists has convinced the United States Congress to mandate that wom-
en have access to OB/GYNs as primary care providers rather than requiring
specialty referral. In many other countries, access to specialty care is still at
the discretion of a family practitioner.
Consultation-Liaison Mechanisms
The realities of practice and developments in knowledge and technique in ob-

stetrics and gynecology can be assimilated by the liaison psychiatrist by at-
tending grand rounds and other conferences in the obstetrics and gynecology
department. The psychiatrist can also use the occasion of the conference to
meet members of the department and to make comments on psychiatric as-
pects of the cases and issues discussed. Curbside consultations can be
sought and referrals made for formal inpatient and outpatient consultations.
Attendance at obstetrics and gynecology meetings is tangible evidence of in-
terest, involvement, availability, and credibility.
The psychiatrist may also elect to participate in inpatient-care rounds reg-
ularly or to be present at or available to one or more outpatient clinics (Nick-
els and McIntyre 1996). On rounds or in a clinic, the psychiatrist can get an
excellent sense of the ethos of the service and the personalities and level of
psychologic sophistication of the students, residents, and attending staff as
well as the typical psychosocial and psychiatric problems of the patients. The
psychiatrists participation underscores the integration of psychiatric with
medical concerns and offers the opportunity for helpful comments and inter-
ventions without the necessity for formal psychiatric consultation. The psy-
chiatrist can help members of the service learn to recognize early signs of
psychiatric disorders before they develop into difficult management problems
or emergencies as well as to decide when and how to call for formal consul-
tation. Psychiatrists occasionally amaze obstetrics and gynecology staff by
using interviewing skills to obtain information crucial to diagnosis and treat-
ment (the patient is upset because her husband is not the biologic father of
the child she is about to deliver; the patient with prepartum bleeding is non-
compliant with the order for bed rest because she has had attention deficit/
hyperactivity disorder since childhood, not because she is bad or stupid; the
patient doesnt follow medical recommendations because she is deaf and can-
not hear them; the patient will not give consent for surgery because a relative
died during an operation).
Services in most academic and large community hospitals include family
planning, sometimes with separate sections for adolescents, normal and high-
risk prenatal care, infertility diagnosis and treatment, general gynecologic
care, urogynecology, gynecologic cancer diagnosis and treatment, and servic-
es in other subspecialty areas. In a busy department, there will be far too
many services and clinics for even the most energetic and dedicated psychia-
trist. Interested residents, fellows, and even medical students taking senior
electives in consultation psychiatry can add to the psychiatric presence, get
valuable experience, and develop subspecialty practice and research interests.
This sort of program requires an investment of time by faculty or senior con-
sultants that is approximately equivalent to the time that would be required
for the direct provision of services. In addition, the liaison is disrupted by the
inevitable rotation and graduation of trainees unless permanent staff main-
tain a clinical presence.
Formal teaching is an important component of the substance and tech-
nique of liaison work. While busy OB/GYNs seldom seek classroom hours,
the staff members in charge of resident conferences and grand rounds are al-
most always eager to fill time slots, and now that obstetrics and gynecology
is a primary care specialty, training programs are under pressure to include
psychosocial issues in the curriculum. The audience, although wary of unre-
alistic demands on physicians time and psychologic sophistication, is gener-
ally interested in scientifically stimulating and clinically useful information
about common psychiatric problems such as anxiety and affective disorders.
It is best to come prepared both with new findings about neurotransmitters,
imaging, or psychopharmacology and with specific and easily implemented
suggestions for screening, diagnosis, referral, and treatment. Nonpsychiatric
physicians are often uncertain about how to distinguish among the various
categories of mental health professionals and when to refer to each, so it is

worthwhile to detail the different trainings and practices of counselors, social
workers, psychologists, and psychiatrists.
It is not enough to recommend that screening for major psychiatric ill-
ness be a part of obstetric and gynecologic care. Obstetricians appreciate, and
are more likely to use, a short list of questions to add to their admission his-
tory (Have you ever been referred or referred yourself to see a psychiatrist,
psychologist, or social worker?; Have you ever been admitted to a hospital
for psychiatric treatment?). Other suggestions include the wording of ques-
tions about sexual practices (What is the nature of your sexual practices in
the past and at this point in time? rather than Are you gay?) and exposure
to sexually transmitted diseases; criteria for prescription of antidepressants
and referral for psychiatric care; assessment for organic brain syndromes;
and assessment of competence to consent for surgery, care for oneself, and
care for an infant. Brief standardized and validated assessment instruments
that can be completed by the nurse or the patient in the waiting room are in-
creasingly popular; the psychiatrist should bring copies and information
about how to obtain them; screening questionnaires are available for depres-
sion, domestic violence, and alcohol abuse. Simple charts of antidepressant
names, dosages, and side effects are useful. Many OB/GYNs are also inter-
ested in the psychologic aspects of issues in their areas of expertise: induced
and spontaneous abortion; pregnancy, labor, and delivery; new reproductive
technologies; and malignancies and in how to approach and support patients
facing these events.
Interdisciplinary Organizations and Activities
Issues in psychosomatic obstetrics and gynecology are discussed in many fo-

rums today. Symposia can be found on the programs of any major psychiatry
or obstetrics and gynecology meeting; the keynote address at the 1998 An-
nual Clinical Meeting of the American College of Obstetricians and Gynecol-
ogists was on depression. National and international organizations devoted
entirely to the field include the International Society for Psychosomatic Ob-
stetrics and Gynecology, which publishes the Journal of Psychosomatic Obstetrics
and Gynaecology and has member societies in many countries, including North
America (the North American Society for Psychosocial Obstetrics and Gyne-
cology). The North American Society holds yearly meetings in early spring;
the International Society holds meetings approximately every 3 years.
Groups devoted to specific topics such as postpartum psychiatric illness (the

Marc Society) and menopause (the North American Menopause Society)
can also be found. Participation in these organizations acquaints members
with the range of work being done and the people who are doing it. Member-
ship consists of professionals in both mental health and obstetrics and is in-
terdisciplinary, including physicians, psychologists, nurses, social workers,
and midwives. Similar organizations exist in Europe, Asia, South America,
and Australia/New Zealand.
The American College of Obstetricians and Gynecologists has founded
the Jacobs Institute for Womens Health, which offers periodic symposia on
policy and practical issues related to womens health and publishes the quar-
terly journal Womens Health Issues. Members of many professional and con-
sumer groups have also come together to address the policy and legislative
implications of several interdisciplinary issues that are discussed in the next
section. For example, the American Medical Association, the American Psy-
chiatric Association, and the American College of Obstetricians and Gynecol-
ogists were among the participants in an amicus curiae brief in the Webster v.
Reproductive Health Services abortion law case decided by the Supreme Court in
1989 (Webster v. Reproductive Health Services 1989).
Issues for the Future
At the interface of psychiatry and obstetrics and gynecology lie a number of

emerging and emergent social, policy, and ethical as well as medical prob-
lems. These include the impact of the abuse of alcohol and crack cocaine on
the fetus, with its attendant issues of maternal versus fetal rights, autonomy,
punishment, and care; the unknown and sometimes notoriously problematic
implications of surrogate motherhood and embryo freezing and transfer; the
legislative and judicial restrictions on induced abortion, as mentioned previ-
ously; AIDS as a heterosexually and prenatally transmitted disease; and
many others.
Interdisciplinary research in some of these areas has been significantly di-
minished by governmental restrictions on funding and even on the nature of
the research performed. For example, very little research has been done on
contraception for the past 10 or more years despite the continued high inci-
dence of unintended pregnancy. Too little work has been published about in-
duced abortion despite allegations and misinformation about its psychosocial
concomitants. Research involving fetal tissue has been banned in the United
States, Canada, the United Kingdom, and parts of Europe.

At the level of clinical practice, funding is again a major issue, at least in
the United States. No longer do hospital and academic departments have the
luxury of hiring psychiatric liaison-consultants to teach and spend time in
clinical service areas. Patients health insurance policies often severely limit
their access to psychiatric services. Mental health care is increasingly carved
out for management by companies that limit the choice and availability of
services. Carveouts may mean that the insurance that funds a patients obstet-
ric and gynecologic care in a given facility requires that her psychiatric care
be provided in another facility. These constraints are, fortunately, not charac-
teristic of many other countries.
Similarly, both faculty and trainees in United States medical schools are
under increasing constraints to generate clinical income to pay their salaries
and support the teaching enterprise, often while trying to fulfill a mission to
care for the medically indigent and uninsured. Some subspecialty care, such
as infertility diagnosis and treatment, is lucrative. Once a good liaison rela-
tionship has been formed, the psychiatrist may be able to convince the infer-
tility, oncology, or other service that psychiatric screening and support are
important for clinical care and that they can be built into funding for the pro-
grams, or that patients and their insurance companies can be expected to pay
for them (Frankel and Hall 1996). Governmental and private funding for re-
search at the interface of psychiatry and obstetrics/gynecology is available in
adolescent sexual behavior, psychosocial factors in cancer prognosis, treat-
ment of premenstrual dysphorias, and well-being at and after menopause.
The National Institutes of Health, National Institute of Mental Health, and
the Public Health Service have offices dedicated to womens health. Informa-
tion about research opportunities is available from them.
Psychiatric consultation to obstetrics and gynecology is rich in breadth
and depth. The consulting psychiatrist can participate in scientific develop-
ments at the cutting edge of human genetics and reproduction, in human
events from the conception to the end of life, and in the most tragic and
wrenching to the most heroic and joyous experiences. An awareness of the
social context and the clinical realities facing the OB/GYN will help the con-
sultant develop a consultative style and content that the consultee will appre-
ciate and use in the interests of patients. Participation in interdisciplinary
organizations and activities offers the interested psychiatrist the opportunity
to meet and work with colleagues in other fields, to advance knowledge and
care, and to act in concert in the public arena.
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Webster v Reproductive Health Services, 109 S.Ct. 3040 (1989)
28
What Is a Minority?
Issues in Setting and Dialogue

MINDY THOMPSON FULLILOVE, M.D.
In the complex social organization of the human, the dominance of the so-
cietal factors becomes most patent. The physiological processes of fertiliza-
tion and incubation, although the same in all societies, take place in social
settings that vary historically, leading to damage, death, or survival of the
foetus. In any one period of history, the supportive or destructive conditions
in which fertilization and incubation take place vary with the class or social
group to which the adults belong. Nurturance is accomplished by widely di-
versified procedures, depending on the society and the group within the so-
ciety to which the child and parents belong. It is no longer easy to generalize about
the three processes as they occur in a particular species. The physiology of reproduc-
tion in people is comparable in all settings. Different societal settings in-
crease or decrease the probability of the survival of the offspring, as well as
behavioral patterns involved in reproduction. It is possible that with the in-
creased mastery by humans over environmental factors by means of im-
proved technology, the very physiology of the processes of fertilization,
incubation and nurturance may change.
Ethel Tobach, American Museum of Natural History, 1971
Preparation of this chapter was supported in part by a fellowship from the Open Society
Institute.
611
Reprinted from Tobach E: Some Evolutionary Aspects of Human Gender.

American Journal of Orthopsychiatry 41:710-715, 1971. Copyright 1971 by the
American Journal of Orthopsychiatry. Used with permission.
What is a Minority?
What is a minority? This chapter suggests that the label minority is an arbi-
trary political construction that has life meaning because it indicates the eco-
nomic, social, and cultural opportunities available to individuals. Specifically,
the political construction of majorities and minorities is reflected in the con-
struction of social spaces that vary in the nature and quantity of resources
they possess. The social construction of habitat by human groups in conflict
with each other creates the conditions within which girls mature into wom-
anhood, have babies, and raise children. Tobach, in the analysis quoted
above, reminds us that the physiology of reproduction is the same in all set-
tings, but as the settings vary, so too will the health and welfare of mother and
infant be altered (Tobach 1971). This chapter considers the problem of mi-
nority status as a major factor shaping the patterns of health and disease
among women in the United States.
In a country obsessed with race, it is typically assumed that we know
what we mean when we say minorityis it not a synonym for the minority
racial and ethnic groups? Furthermore, because those groups are stigmatized
and subject to discrimination, minority carries the connotation despised
by the majority.
Because minority signals that we are talking about racial groups, it is
helpful to examine the concept of race. Racial classification is a pseudoscien-
tific system based on the premise that human beings can be visually sorted
into groups. In practice, these groups are assigned relative biologic superior-
ity or inferiority that in turn is incorporated into a social system giving polit-
ical and social supremacyas well as better health outcomesto the allegedly
superior group (Cooper and David 1986).
The racial system of classification is so fundamental to our thinking in
the United States that we often forget to examine and challenge its flawed as-
sumptions. In reality, racial classification is a crude system that lumps dispar-
ate peoples with different language, culture, and history into a small number
of groups (see Table 281). It does not match well with the identities that peo-
ple ascribe to themselves. What, for example, would be the identity of a wom-
an flute player with one Vietnamese and one Senegalese parent, born
Catholic, but currently a practicing Buddhist, who lives in Oakland, Califor-
What Is a Minority? Issues in Setting and Dialogue 613
nia with her husband and sees her girlfriend on alternate Fridays? In the spirit
of the Bay Area, such a woman might well inform you that she is a Sagittari-
an, a vegan, and was Marie Antoinette in a past life just to complicate matters.
TABLE 281. We are not one people
It is difficult to speak of sexuality issues among Latinos in the United States

as if they were just one homogeneous group of individuals. The U.S. Lati-
no populationestimated to be more than 20 million peopleincludes indi-
viduals who speak many different languages and come from different
regions, races, classes, and cultures of the Americas.
Ernesto de la Vega (1990)
The number and sheer depth of stereotypes about Indians create stress and
anxiety for many Native Americans. At the root of such stereotypes is the
mistaken view that we are one people. Like Europeans, Native Americans
are not one people, although our experiences with the outside world have
helped to create a pan-Indian identity. Ones tribe (nation)Choctaw, Peo-
ria, Tlingit, Malecite, Arikara, Okanagan, Snohomish, Caddois where
ones primary ethnic identity lies. Each tribe has developed its own lan-
guage, customs, and beliefs; each has had a different history; and each has
exercised its own strategy for dealing with the relentless invasion of new
peoples and with the catastrophic changes that have taken place in their tra-
ditional lifestyles.
Ronald M. Rowell (1990)
One must be sensitive to the lumping of Asians and Pacific Islanders to-
gether as one homogenous group. In addressing the health care/AIDS in-
formation and education needs of Asians and Pacific Islanders in the
United States, it is necessary to recognize the cultural diversity of this pop-
ulation. There are at least 43 different Asian and Pacific Islander groups,
from more than 40 countries and territories, who speak more than 100 dif-
ferent languages and dialects (some unwritten). Each group has a distinct
culture and heritage.
Deborah A. Lee and Kevin Fong (1990)
People with black skin share a common motherland in Africa but, as a re-
sult of the diaspora, have lived on many continents and under many gov-
ernments. Haiti, the West Indies, the United States, as well as all the
countries of Africa, have been home to black people. Emerging from each
homeland are people with cultures, beliefs and history that are as different
as they are alike.
Robert Fullilove,
American Public Health Association Annual Convention,
October, 1990, New York, NY
Let us consider, as well, the concept of minority. By definition, a minority

is the numerically smaller of two groups. In the United States, groups are
formed along many lines of demarcation: race, sexual orientation, religion,
ethnicity, country of origin, social class, and many others. The small groups
homosexuals as compared with heterosexuals, Catholics as compared with
Protestants, independently wealthy as compared with working peopleare
called minority. Of course, a persons affiliation may include many groups. A
single individual might belong to the majority racial group but a minority re-
ligious group, as did President John F. Kennedy, who had to overcome prej-
udice against Catholics in his bid to become president.
Minorities might be considered weak and helpless, but minority groups
have learned how to get and keep power; in South Africa under the apartheid
system it was possible for a very small white minority to control the wealth
and power of a massive country. Minorities might be considered inferior and
despicable, but that is not inherently so; in the United States, a shrinking per-
centage of the population controls an expanding proportion of the countrys
wealth. The small size of the power elite is taken as proof of its special status.
The members of the Fortune 500 are not a minority, therefore: they are the
elect.
Because minority signifies a relational category, minority status may dis-
appear when the referent is changed. In the Central Harlem neighborhood of
New York, 86% of the residents are African American. When whites are out-
numbered by people of coloran event demographers say will happen in the
twenty-first centurythey will be considered a minority.
In the analysis of health problems, race and minority are treated not as
flawed and fluid concepts but as rigid and meaningful representations of re-
ality. The assumption that we can measure race permits us to compile moun-
tains of data specifying disease by racial and ethnic categories. That such
analyses regularly inform us that minorities have more health problems than
the majority confirms its meaning as an important variable. The thinking is
that because we find racial differences, race is important and we must contin-
ue to measure race.
Several recent studies have helped to challenge this circular reasoning.
Greenberg and Schneider (1994) answered the issue directly in an article ti-
tled Violence in American Cities: Young Black Males is the Answer, but
What was the Question? This tongue-in-cheek title is meant to draw the
readers attention to the analysis that points to violence as a problem of young
black men. The authors cited a number of articles drawing this association
and noted:
Black male homicide is an extremely serious problem. But near singular

concern, or giving the appearance of singular concern, with solving the cri-
sis of urban violence by focusing on assaultive violence by young black
males begs the question of what are the roots of urban violence. Focusing
on any one population, no matter how serious its problem, leads critics, such
as psychiatrist Peter Breggin, to charge that a narrow age/race/sex focus
leads to asking narrow questions, such as genetic causes of violence. It leads
away from asking broad questions, such as if other populations, old and
young, whites and Hispanics, and females living in environments similar to
young black males might also be highly susceptible to violence. (pp. 179
180)
To address these larger issues, Greenberg and Schneider focused on the

process of marginalization that has altered the landscape in many American
cities. They noted that pariah land uses were increasingly concentrated in cer-
tain inner-city areas of New Jersey. They called these pariah land uses
TOADS, standing for Temporarily Obsolete Abandoned Derelict Sites, and
LULUS, standing for Locally Unwanted Land Uses. They proposed a mar-
ginalization hypothesis, that is, that marginalization of people and land use
exacerbates violence.
In examining three marginalized New Jersey cities, Newark, Camden,
and Trenton, as compared with the rest of the state, they found strong sup-
port for their hypothesis. Of particular importance is the finding that margin-
alization affects all the populations living in the distressed areas. The reality
of Camden, Newark, and Trenton is that young white males have virtually
the same probability of manifesting a violent cause of death as young black
males (Greenberg and Schneider 1994, p. 185). The authors concluded that
Violence flourishes in unstable personal, neighborhood, and regional envi-
ronments . . . . If we want to try to explain high rates of urban violence, we
must stop equating violence with homicide, and we must focus on the macro,
neighborhood, and personal environments of all the people that reside in
these marginal places (p. 185).
The influence of location is demonstrated in two important studies from
the cardiovascular literature. In the first of these, Fang and colleagues (1996)
examined the death rates from cardiovascular disease of blacks and whites
living in the city of New York but born in various parts of the country. Inter-
estingly enough, death rates vary for each group, and the patterns differ for
different forms of heart disease. Death rates from coronary heart disease for
blacks born in the Northeast were similar to those for whites born in that ar-
ea. Blacks born in the South had a rate of death from coronary heart disease
that was 30% higher than that of Northeastern-born blacks. A third group of
blacks, born in the Caribbean, demonstrated significantly lower death rates

from coronary heart disease than those born in the Northeast. The authors
concluded, If the favorable survival patterns of Caribbean migrants were
conferred on other blacks, the current interracial pattern would be reversed,
and mortality from cardiovascular disease among blacks would be well below
that among whites (p. 1551).
In the second study, Geronimus et al. (1996) studied excess mortality
among blacks and whites in the United States. The team studied mortality
among blacks in selected areas of New York city, Detroit, Los Angeles, and
Alabama (in one area of persistent poverty and one higher-income area each)
and among whites in areas of New York city, metropolitan Detroit, Kentucky,
and Alabama (in one area of persistent poverty and one higher-income area
each). Sixteen areas were studied in all. Obviously, if race were the overriding
factor determining health outcomes, then blacks would have had higher mor-
tality than whites in all areas, with little difference across sites. The actual
findings presented a more complicated picture. The authors summarized by
saying,
Our findings are generally consistent with the association between race and
excess mortality in the United States that is often reported. However, the
poverty rate and the location of a groups (urban and northern vs. rural and
southern) are also important. White residents of Detroit fared as poorly as
residents of some black areas that we studied. One black comparison group
(that in Queens-Bronx) had a mortality rate only slightly higher than the na-
tional average for whites. (p. 1555)
These studies present a clear pattern in which location and resources

shape health outcomes. Three issues need to be examined at this point. First,
it is important to understand that groups, and the individuals in groups, are
related to each other. The relational processes are quite specific to historical
and geographic factors. Second, the construction of particular ecosystems is
the culmination of the great forces of time and place. Understanding features
of ecosystems can give us important insights into the health process in a given
area. Third, the health process in a given area is integrated into the individu-
als lifestory in characteristic ways. Based on an understanding of relational
process, ecosystem, and lifestory, it is possible for the care provider to under-
stand and assist in resolving health problems of women from minority
groups.
The Relational Process
Waves of migrants have come to or been dragged to the United States over
the past four centuries. Some of the incoming groups have been welcomed
into the workforce and into the power structure. Others have struggled for
the very survival of their group. The stakes have been high: control over the
wealth and bounty offered by a huge, well-endowed continent. Among the
weapons of the battle have been those ismssuch as racism and religious
intolerancethat allowed people to deny the humanity of their competitors.
In 1903, W. E. B. Du Bois, the foremost black historian and commentator,
said, The problem of the color line is the problem of the 20th centurythe
relation of the darker to the lighter men in Asia and Africa, in America, and
the islands of the sea (Du Bois 1967, p. 23). Almost 100 years later, despite
battles for equality that have attracted international concern and attention, we
still live in a world in which race, ethnicity, religion, and gender determine
ones chance to live a healthy and productive life. In fact, the barriers of stig-
ma create an ecology for minority people that is distinctly different from that
of majority people.
When the barriers of culture intersect with the barriers of oppressionand
even of genocidewe face additional barriers of anger, fear, dissembling, and
contempt. The characteristics of the intersection of culture with oppression are
shaped by the history of the meeting. The story of Japanese people in the Unit-
ed States includes their internment in concentration camps in World War II,
when Americans did not trust the loyalty of Japanese to their new country.
Chinese men came to America to work on the railroads and were forbidden
to bring their wives. The old single men remain part of the story of Chinatown
in San Francisco and elsewhere. The almost complete annihilation of Native
Americans by war and disease beginning immediately on contact with white
civilization ranks with the Holocaust as a horrific story of genocide.
Within most groups, women have relatively less power than men. How-
ever, the status of women differs from group to group. In the 1990s, the as-
cension to power of the Taliban in Afghanistan threatened the very survival
of women, arousing international concern for their safety. This is in marked
contrast to accomplishments of women in the United States, where they have
gained a large measure of social and political freedom and decreased the dif-
ferentials in economic opportunity. The meeting of groups is often an oppor-
tunity for women to rethink culturally defined status and roles in a creative
and unceasing process of balancing attachment to ethnic traditions with the
pursuit of womens liberation.
Thus, intergroup relations provide an opportunity for women to ques-

tion received tradition about their social status. One of the most remarkable
struggles to have come out of this intergroup contact is the struggle against
female circumcision, which is practiced in many countries in Africa. This
ancient ritual is a rite of passage for girls on the threshold of womanhood.
Because it is thought to ensure a womans purity, it increases a womans mar-
riageability in many cultures. However, the practice is a dangerous one that
can have serious, even life-threatening consequences for women. The strug-
gle against female circumcision is spurred by contact between African women
and women from other countries. Increasing recognition of the health cost of
the ritual is empowering women to call for the banning of the custom. Yet be-
cause it challenges traditions that are centuries old and are endorsed by the
patriarchal societies in which they are practiced, the struggle to eliminate fe-
male circumcision is likely to be bitter and protracted.
Women who immigrate from one country to another are also exposed to
differing traditions of womens status. Women immigrating to the United
States largely find themselves given more opportunity than they experienced
at home. This is both exciting and stressful. One implication of the new free-
dom is that women can step into American-style gender roles. This Ameri-
canization of women is often deeply disturbing for their husbands and can
lead to tension, strife, and in some cases violence. It also poses challenges for
women, who are often given opportunity on the one hand but deprived of
traditional sources of support on the other. This new balancing act has impor-
tant implications for childbearing and childrearing as well as for womens
health overall.
Ecologic Settings
In this section, I describe three ecologic settings. These brief accounts are not
meant to provide an exhaustive description of the settings in which minority
people live and work. Rather, they are meant to enable the reader to compare
and contrast the life of people living in each of these settings and the health
care problems that occur there.
Inner-City Disintegration and the Growth of the Underclass
The growth of the underclass has been described as a form of American

Apartheid (Massey 1990), created by an interaction between rising rates of
poverty and high levels of residential segregation. Where these social forces
have intersectedfor example, among blacks and Puerto Ricans in large ur-
ban areas of the Northeast and Midwestthey have acted to create an urban
underclass that is persistently poor, spatially isolated, and disproportionately
minority. Furthermore, the structures and social networks that enabled the
poor to survive poverty have been weakened, if not decimated, by the same
forces that have created the underclass itself.
As Sampson (1990), Wallace (1990), and others have pointed out, the
growth of the underclass is not simply a result of economic decline but rather
economic collapse in conjunction with the collapse of other complex social
policies on housing, fire protection service, and transportation networks.
Sampson cites as an example the decision in Chicago to concentrate poor
blacks in massive federal housing projects. He notes,
with the concentration of poor blacks in housing projects, social transfor-

mation of the ghetto became profound . . . . Undeniably, family disruption in
the black community is concentrated in public housing. In 1980, of the 17,178
families with children living in Chicago public housing projects, only 11%
were married couple families. Teen-age pregnancy and out-of-wedlock births
are similarly high. (p. 529)
Whereas Sampsons work focused on the association between housing

policies and crime rates, D. Wallace and Wallace (1990) provided similar
analysis on the association between housing policies and health. Characteris-
tic of the areas housing the urban underclass is a process of contagious hous-
ing destruction, in which a significant proportion of the residential housing
is destroyed through neglect, abandonment, and inadequate municipal servic-
es. The Taylor Homes in Chicago or the Latrobe Homes in New Orleans
have a snaggle-toothed appearance characteristic of this contagious process.
In the South Bronx, contagious housing destruction was responsible for mas-
sive displacement of the poor. According to the authors,
People had to move in such large numbers in so short a time that local com-
munities were destroyed and local essential services imbalanced with respect
to utilization . . . . These changes have two meanings: the breaking up of
communities by forced migration and the crowding of the poor into the re-
maining housing . . . The old social networks which had coped with the ef-
fects of poverty and overcrowding had been destroyed in the migrations.
Churches, social clubs, and political organizations died. The effects of over-
crowding and increased poverty from rising rents had (and have) few miti-
gating influences. (p. 268)
In sum, the structure of families, of social networks, and of neighborhoods

that is, all aspects of the social networks of the poorhave been undermined.
A great deal of scholarship from many disciplines makes it clear that so-
cial networks are important for the maintenance of health. The social net-
works of the poor have several specific functions that ensure survival. First,
the network acts as a resource bank, in which members share whatever
they have. These banks are critically important because they provide a mech-
anism to tide you over in times of scarcity. Second, the network collectively
acts to raise the children. Parents are thus freed to solve the economic prob-
lems of the family without having to worry about inadequate supervision for
the young ones. Third, the network acts to provide reality testing counter-
balancing the stress, trauma, and negative messages that the poor receive. So-
cial reality testing mitigates the potential narcissistic wound of a racist attack
by reframing it. For example, black people will commonly say to each other,
White people will be white people, which acts to discount a racist act or
message. In the aftermath of urban desertificaton, what is left of the social and
cultural capital that had ensured survival for area residents?
An important paper by Kelly (1994) examined these issues in the life of
a young woman living in the declining West Baltimore community. As de-
scribed by Kelly, Arson and abandonment are frequent, as evidenced by the
abundance of charred and boarded-up buildings which often become safe
houses for drug dealers . . . Business opportunities are puny, with the excep-
tion of as myriad of grocery stores and liquor shops inherited by Korean im-
migrants from an earlier cohort of Jewish entrepreneurs (p. 91). Kelly was
drawn to the area because of the high rates of adolescent pregnancy. Contact
over several years with Towanda Forrest, who gave birth to her first child at
age 14, provided Kelly with insights into the process of early pregnancy in a
distressed setting.
Kelly linked the impoverishment of the setting with Towandas choice to
have a child. Although Towanda was aware of the value of education in an
abstract fashion, she herself was unable to read above the second grade level.
The education available to her in overcrowded, underfunded ghetto
schools offered little hope for decent employment. Furthermore, she did not
know people with good education or good jobs, adding to her suspicion that
such options were beyond her reach. Yet within a context that set such serious
limitations on life choices, childbearing was viewed as important and life af-
firming. Viewed from within the context of her life setting, Towandas choice
to have a childKelly even called it her triumphis quite rational.
Kelly made the point that policymakers outside of the inner city view ear-
ly childbearing with suspicion and contempt. She challenged such an

assessment as inadequately informed from the emic,that is, the insider
perspective. Health care providers are just as likely as others from the outside
to argue for behaviors that are unrealistic given the context. Campaigns for
condom use and delay of pregnancy and to just say no to drugs have all
fallen short of their goals, in large measure because the implementation of
such preventive actions is not consonant with external constraints on behav-
ior. In the impoverished setting of urban desertification, the pursuit of better
health depends on contextual interventions that rebuild the housing and eco-
nomic infrastructure of the area.
Health Care at the Mexican-American Border
Warner (1991), a researcher at the Lyndon B. Johnson School of Public Af-

fairs at the University of Texas in Austin, described the United States
Mexico border as transborder metropolitan areas that have grown from
sparsely populated deserts into a region with 10 million inhabitants. The
transborder cities include Tucson, Arizona, and Nogales, Mexico, with a pop-
ulation of 1 million; San Diego, California, and Tijuana, Mexico, with a cur-
rent population of 3.5 million; Rio Grande Valley and El Paso, Texas, and
Juarez, Mexico, with a population over 1 million; and Laredo, Texas, and
Nuevo Laredo, Mexico, with 400,000 people. The region has a unique char-
acter because of its increasing interdependence: many of the regions prob-
lems cannot be solved by local municipalities without assistance from both
federal governments or binational cooperation.
The disparities between the United States and Mexico create conditions
that have an enormous impact on the area. Of the many Mexicans who cross
the border to find work in the United States, most are poor, and many are
illegal entrants. The receiving communities are taxed to supply health care,
especially because few provisions have been made for funding the health
needs of illegal immigrants. As noted earlier, many Mexican-American moth-
ers deliver their babies out of the hospital. Warner (1991) points out the seri-
ous consequences of the major gaps that exist in the services available to the
poor: In 1980, of the births occurring in Texas border counties, 6,215 of the
28,645 births to persons giving a Texas residence were out of the hospital,
while 2,550 of the 4,216 listing a Mexico residence were out of the hospital
(p. 245).
Communicable diseases, including sexually transmitted diseases (STDs),
are a significant threat to the health of the population in the border area.
STDs have long been a problem because of the cross-border use of red light
districts and the increased difficulty of contact tracing. Of 1,502 cases of
AIDS reported in Mexico through mid-1988, roughly 20% were thought to
come from the six Mexican border states.
Finally, the border communities show all of the problems attendant to
rapid growth, uncontrolled development of industry, poverty, and instability.
At the most extreme, the border residents live in colonias, or unincorporated
settlements on both sides of the border. As Warner noted, These communi-
ties often lack septic tanks, sewers, or running water, and outdoor privies
commonly abut water wells, making most of the water unfit for consump-
tion (p. 242).
Caribbean Immigrants in the New South
DeSantis, a researcher at the University of Miami, has written extensively on

the problems of women arriving from Cuba and from Haiti in 1980 (DeSantis
1989). She points out that
The mass arrival in 1980 of 125,000 Cubans during the Mariel Sealift or
Freedom Flotilla and the 36,000 Haitians who entered during the same
year overwhelmed the health care, social, political, and economic systems of
Southeast Florida. Community agencies were already straining to meet the
needs of other low-income groups in the area. The influx of Cuban Mari-
elitos and Haitian Boat People caused health care professionals to be-
come increasingly frustrated by the sheer numbers requiring curative and
preventive health care. The frustration also resulted from lack of knowledge
about the new immigrants who differed from previous groups of Cubans
and Haitians in their health care orientations, educational backgrounds, so-
cioeconomic status, and social support systems. (p. 70)
These two groups entered the United States at the same time but differed
on almost every other measure of education and economic prospects. Cuban
refugees comprised several subgroups, including families, gay men, and peo-
ple with criminal histories or mental illness. Although poorer than earlier ref-
ugees from that country, all came from a society with universal literacy and
an aggressive health care system based on Western biomedical medicine. The
Cubans had received appropriate preventive health careincluding vaccina-
tionswhile in Cuba, and had learned to value a system of health care similar
to that in the United States. Finally, Cuban refugees for the most part felt se-
cure that they would be able to stay in the United States.
DeSantis (1989) observed that the Cuban immigrant parents shared
decision making and tended to bring the extended family into decisions
about the childs health care. She hypothesized that efforts of the Cuban gov-
ernment toward sexual equality in the domestic realm had led to this male
female sharing of household functions. Cuban mothers felt empowered to act
on their childrens behalf. If a child became ill, the mothers said, Its the par-
ents fault. They did not love him enough (p. 80).
The Haitian boat people, by contrast, came from one of the poorest
countries in the world. They were often illiterate, rural people, with a long
tradition of folk medicine and little access to Western biomedical care. The
Haitians as a group had a less secure status in the United States and feared
they might be deported back to Haiti where they faced death, torture, or oth-
er kinds of abuse. This group, although willing to use the American health
care system, did not share the philosophy of the system. Haitian mothers, his-
torically responsible for child care in Haiti, continued to carry alone most of
the responsibility in this domain. Few older women were available to assist
these women in carrying out their responsibilities. In contrast with their Cu-
ban counterparts, DeSantis found that Haitian women felt relatively power-
less to affect their childs health. Although they did not believe illness was
preventable, once signs and symptoms were present, they quickly sought
treatment for the child.
Lifestory
Ecologic settings are locations within which the lifestory unfurls. Well-being
and mental health are dependent on the presence or absence of a health-
promoting environment as well as the individuals ability to extract goods
from that environment. Stories of womens experiences provide insight into
these processes. McDowells (1996) beautiful memoir of growing up in Besse-
mer, Alabama, Leaving Pipe Shop: Memories of Kin, is occasioned by the need to
understand the possible contribution of asbestos to her fathers untimely
death. As she examines her family story, she realizes that many of her rela-
tives died at early ages. In a sense, she lived through, on a personal basis, the
excess mortality from heart disease that Fang et al. (1996) studied in a more
theoretical manner. These early deaths meant that she was orphaned before
she had entered graduate school. By her mid-40s, only one of the relatives
from her parents generation was still surviving. It is worth considering the
relationship between the early orphaning in this story and the early parenting
in the story of Towanda Forrest mentioned earlier.
In both cases, the warp of family life is shaped by the trials and tribula-
tions of everyday life in a poor, segregated industrial community. In is per-
haps the key word to understanding McDowells story. The problems of
racism are, in many ways, external to Pipe Shop. McDowell does not open
her memoir by talking about race. Rather, she starts with a line that is all-too
familiar to many adult children: You got to come home (p. 17). Although
offered at the outset as a simple intergenerational interaction between aunt
and niece, this family summons leads her to a deeper understanding of the
context of her home community. For example, the problem of asbestos hov-
ers in the background of the storydid her father die of asbestos poisoning?
It is only when she has broadened her view of Pipe Shop past the interior
world of childhood that she can begin to appreciate the problems faced by
black industrial workers in the deep South.
The sense of in is profoundly present in the chapter Restriction and Rec-
lamation: Lesbian Bars and Beaches of the 1950s by Joan Nestle (1996), in
the book Queers in Space: Communities, Public Spaces, Sites of Resistance. Nestles
struggle, however, is profoundly different from McDowells. As a lesbian try-
ing to find spaces in New York city within which to be a lesbian, Nestle is con-
stantly reminded of the outside forces arrayed in opposition. She writes,
Silenced and policed, we congregated in allotted spaces. Borders were

marked and real: vice laws, police, and organized crime representatives con-
trolled our movements into and out of our countries. But what could not
be controlled was what forced the creation of these spaces in the first place
our need to confront a personal destiny, to see our reflections in each others
faces and to break societal ostracism with our bodies. What could not be
controlled was our desire. (p. 61)
Nestles narrative illuminates the search to create safe space that occu-
pied gay men and lesbian women at that time. This search evolved from fur-
tive meetings in hidden places to open displays of gay and lesbian political
activity, such as the gay pride marches that have become a regular occurrence
in many cities. Despite the new openness, the policing of gay/lesbian life con-
tinues in modern times and influences many social interactions, not least of
which is the search for health. Cochran and Mays (1988) have pointed out
that many lesbian women are afraid to reveal their sexual orientation to their
physicians, indicating that the doctors office is not yet a part of the gay-
positive space Nestle and others have sought to master.
Lifestories are quite particular and belie the generalizations that words
like minority and race seek to imply. Understanding the health of the individual
is absolutely dependent on a willingness to understand the individuals
unique path through life regardless of how that path differs from ones own.
The minority woman, in her capacity for procreative and recreative sexuality,
does not differ from her majority counterpart, but because she lives under
more adverse conditions, her ability to realize her wishes and dreams is more
limited. Given her risk for ill health, the chances are great that she will have
contact with the health care system. At that moment, when the health care
provider and the patient meet, the provider faces the challenge of establishing
a dialogue that can assist in the diagnosis and treatment of illness. This dia-
logue is at the heart of health care. Through that communication must come
accurate information about the patients symptoms, behaviors, and attempts
at self-care. Eventually, it must enable the provider to convince the patient to
follow a prescription for care. Finally, the dialogue is most truly a healing in-
teraction if both provider and patient have felt affirmed and respected.
As we speak across differences, we face barriers created by the differences
in values and traditions. Hussain (1990) described an encounter at the Af-
ghan Mission Hospital with a young man who appeared to be dying. A mem-
ber of the Puthan tribe from the mountainous area of Pakistan, the dying man
feared the taint to his honor that a death away from home would bring. His
family decided to take him home, a decision adamantly opposed by Hussain,
who thought hospital-based care was the patients only hope. Despite the doc-
tors grim prognosis, the man survived and returned to bring a gift to the doc-
tora second gift, in fact, the first being the lesson in respecting others
values.
Implications for Practice
Writers speaking on minority issues emphasize, almost without cessation, the

variation that characterizes minority populations and that must be the first as-
sumption one makes in addressing another human being. The task, given the
diversity of human cultures and human experiences, is not to assume that any
survey of minority cultures can prepare the practitioner for the task of
cross-cultural communication. Rather than approach the situation with as-
sumptions about behavior or attitudes, the practitioner must have a strategy
for data collection.
First, the practitioner must be aware that 1) the patient has cultural ex-
pectations about roles and greetings and 2) the patient from a stigmatized mi-
nority group will be sensitive to signs of disrespect. Because we cannot know
the assumptions of all the cultures with which we will interact, it is useful to
behave toward the patient as one would behave toward an honored member
of ones own culture. It will never hurt the practitioners image for the trans-
lator to clarify an act by saying, That is how they show great respect in their
culture. By contrast, it will be particularly injurious to the developing rela-
tionship for patients to discover they have been slighted or treated discourte-
ously. Dr. Muriel Pettione, a senior attending physician at Harlem Hospital
Center, a major hospital serving the black community in New York City, of-
ten points out how offensive it is for young residents to show signs of disre-
spect, such as calling an older woman patient by her first name. Indeed, that
kind of impropriety will destroy trust and injure communication.
Second, practitioners, who perforce must act without a manual of cul-
tures, should use the services of key informants, as anthropologists call
those members of the community who help them to understand culture. So-
cial workers, nurses, typists, taxi driversin fact, anyone with a command of
the two culturescan help the practitioner to understand the words and ac-
tions of the patient. With the help of the guide, the practitioner can assemble
a working understanding of the life-setting of the patient. Is the patient well-
to-do or poor? Educated? Fluent in many languages and cultures? Living in
adequate housing and in a safe neighborhood? Involved in stable social and
sexual relationships? Because such questions are a routine part of the biomed-
ical examination taught to health care practitioners, it is not important to elab-
orate in more detail on what to ask. Rather, it is important to underscore that
such questions provide information and prevent unwarrantedand perhaps
stigmatizingassumptions.
Finally, practitioners must be aware that they act in the context of cultur-
al conflict. We have not, in the United States, succeeded in being a melting
pot. Rather, some people have been incorporated into the dominant culture,
whereas others have been blocked out. Therefore, individuals from different
cultures do not necessarily meet as equals. The health care provider must
take the responsibility for establishing a dialogue of equality. When that oc-
curs, the providerpatient relationship will have a capacity for respect, for un-
derstanding, and for healing.
It is, in any event, rare that we have empathy for each other. Purdy, a pa-
thologist in California, described living through a serious earthquake (Purdy
1990); just before the earthquake he had struggled to diagnose a specimen
that eventually was identified as metastatic ovarian cancer. After the earth-
quake, he found (unusual for him) that he wanted to meet the patient. For
Purdy, the earthquake, which had shaken his belief in the world as secure,
allowed him to empathize with the young woman with terminal cancer. He
wrote,
Like all of us, [Sarah] had plans for the summer, for next year, for many
years to come. Now she would have to plan for something else. She remind-
ed me of the child I saw during the earthquake, screaming at God to ease
up on it. A couple of nurses hugged him and tried to console him, but he
was too shaken for human comfort, too aware that no human was mightier
than what had just shaken the earth. He was alone in his fear, as I was, as
Sarah is, each of us complacent about the security of our routine lives, tak-
ing everythingour health, our safety on terra firmafor granted, never
knowing when the earth might all of a sudden shake the life from us or when
the faults beneath our own surface may begin a unique, solitary, and fright-
ening slippage. (p. 2883)
It seems that these transcendent human experiences have a unique im-

portance, because they allow us to see across all the barriers of difference and
to understand the samenesses in human existence. As health care providers,
we will encounter many of these powerful human events. With attention and
concern, we can make many effective and emphatic encounters.
Conclusion
What is a minority? This chapter has sought to suggest that minority takes on
meaning for health practitioners because it implies powerlessness. A corollary
of powerlessness is the relegation to less desirable habitat. A corollary of poor
habitat is poor health.
Perhaps the fundamental implication of this analysis is that those con-
cerned with the health of minority women have two obligations. The first is
obvious: to deliver decent care in a respectful manner. The second obligation
is less often recognized and is rarely part of the curriculum in health profes-
sions schools: to challenge the distribution of resources that makes for bad
habitat. This implies challenging the right of powerful groups to an unequal
share of the worlds goods. It also implies challengingwithin all groupsthe
oppression of women and the limitations on their freedom.
On another level, close inspection of the concept of minority teaches us
that we are each a member of the minority of one and the majority of human-
kind. It is this deeper reality of humanness and individuality that should
guide practitioners as they help women stay healthy.
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Index
Page numbers printed in boldface type refer to tables or figures.
A abnormal adolescent development

and, 98100
Abortion counseling and, 100104
habitual, 21 abortion and, 102103
induced (elective). See Induced adoption and, 103104
abortion keeping pregnancy and, 101102
male perspective on, 589590 emergency contraception to prevent,
Abruptio placentae, 21 106107
Absorption of drugs, gender differences future planning for, 114
in, 402403 late diagnosis of, 100
Acquired immunodeficiency syndrome. mental illness during, 112114
See HIV/AIDS normal adolescent development and,
Adaptation, during postpartum period, 9698
117119 perinatal loss and, 151
biologic factors affecting, 117118 prenatal care for, 107108,
infant feeding and, 119 109111
psychosocial factors affecting, repeat, rate of, 113114
118119 scope of issue, 9596
Adhesions, pelvic pain and, 264 sexual abuse associated with, 98100
Adolescent(s) substance abuse during, 108, 112
developmental tasks of, 109111 termination of, legal constraints on,
health care for, 104107 227, 235236
emergency contraception and, Adoption, adolescent pregnancy and,
106107 counseling and, 103104
sexual activity and, 104105 -Adrenergic blockers, for
sexually transmitted diseases and, posttraumatic stress disorder, 522
105106 Adriamycin, for breast cancer, 461
lesbian, 562563 Advocacy, for victims of violence,
Adolescent pregnancy, 95114 497498, 514
629
Affective disorders, menstrual cycle and, Amniocentesis, 37

185186 early, 39
Africa, AIDS/HIV in, 331 psychologic consequences of, 40
Aging adulthood. See also Older women genetic termination following, 42
gynecologic cancer in, 317318 midtrimester, 3839
existential issues and, 318 psychologic consequences of, 40
family relationships and, 317 time issues with, 38
sexual functioning and, 317 Amoxapine (Asendin), for depression
work and, 318 associated with gynecologic cancer,
2 Agonists, for posttraumatic stress 322
disorder, 522 Amphetamine(s), sexuality and, 425
AIDS. See HIV/AIDS d-Amphetamine (Dexedrine), for
Alcohol-related birth defects (ARBD), depression associated with
426, 428 gynecologic cancer, 323
Alcohol use/abuse. See also Substance Androgens
abuse deficiency of, 390
epidemiology of, 422, 423 neurobiologic effects of, 243
physiologic factors and, 424 secretion after menopause, 242243
during pregnancy, in adolescents, secretion following hysterectomy,
108, 112 290
psychologic aspects of, 423424 Androstenedione, secretion after
sexuality and reproduction and, menopause, 242
424425, 426, 427, 428 Anger
Alliance of couplehood, 586 about fetal anomalies, 41
Alpha-fetoprotein (AFP), maternal breast cancer diagnosis and, 465
prenatal screening for, 36, 37, 38 Anorexia nervosa, 443444. See also
time issues with, 38 Eating disorder(s)
Alpha-2 agonists, for posttraumatic Anticipatory nausea, gynecologic cancer
stress disorder, 522 and, 324
Alprazolam, gender differences in, Anticonvulsants. See also specific drugs
411 for posttraumatic stress disorder,
Alternative cancer therapies, 326 521522
Ambivalence, maternal, toward Antidepressants. See also specific drugs
pregnancy, 17 gender differences in, 411412
Amenorrhea, eating disorders and, 443, heterocyclic
445447 for depression associated with
American College of Obstetricians and gynecologic cancer, 320,
Gynecologists, 606, 607 322
American Medical Association, 607 during pregnancy, 73
American Psychiatric Association for postpartum anxiety, 133
(APA), 607 during pregnancy, guidelines for
position on induced abortion, clinical use of, 8485
220 second-generation, for depression
Amitriptyline (Elavil) associated with gynecologic
for depression associated with cancer, 322
gynecologic cancer, 322 sexual behavior and, 393394
gender differences in, 411, 412 tricyclic. See Tricyclic antidepressants
Index 631
Antiparkinsonian agents, during B

pregnancy, 75, 83
Antipsychotic agents. See also specific Bacterial vaginosis, 261
drugs Barbiturates, during pregnancy, 75
gender differences in, 409410 Battered women. See Violence against
for posttraumatic stress disorder, women
523 Benzodiazepines
during pregnancy, guidelines for gender differences in, 410411
clinical use of, 84 for posttraumatic stress disorder,
sexual behavior and, 394 522523
side effects of, gender differences in, during pregnancy, 74, 8283
410 Beta-adrenergic blockers, for
teratogenicity of, 72, 73, 76 posttraumatic stress disorder, 522
Antiretroviral combination therapy, for Biobehavioral responses, breast cancer
HIV/AIDS, 342 diagnosis and, 465
Anxiety Biologic clock, 367
about delivery, 18 Biologic factors. See also specific factors
about fetal anomalies, 41 maternity blues and, 121
in pregnancy, following fertility postnatal depression and, 126
treatment, 208 postpartum adaptation and, 117118
Anxiety disorders Biologic framework, for violence against
breast cancer diagnosis and, 464 women, 495
gynecologic cancer and, 323324 Bipolar mood disorder, in pregnancy, 54
postpartum, 133134 Blood transfusions, HIV transmission
in pregnancy, 5455 via, 336
Anxiolytics. See also specific drugs and drug BRAIDED acronym, 284
types Breast(s)
during pregnancy, 7475, 8283 benign disorders of, 457, 458
guidelines for clinical use of, reconstruction of, 460461
86 Breast cancer, 457471
Appearance, during pregnancy, alcohol use and, 428
concern with, 18 clinical features of, 460
Assisted reproductive technologies detection of, 461462
(ART), 208213, 211213, diagnosis of, 462465
367368 anger and, 465
anxiety during pregnancy following anxiety disorders and, 464
use of, 208 biobehavioral responses to, 465
ethical issues related to, 577578 depression and, 462464
male reactions to, 589 epidemiology of, 458459
multifetal gestations with, 211 hormone replacement therapy and,
normality of offspring and, 208 249
for postmenopausal women, 212, immediate posttreatment recovery
577 in, 467469
Attachment. See Maternal attachment; among lesbian women, 555556
Maternal-infant relationship long-term recovery and survival in,
Autosomal recessive disorders, 34 469470
Azoospermia, 212 male perspective on, 590591
Breast cancer (continued) sexual

pregnancy following, 27 definition of, 479
psychiatrists role in reducing history of, in women abused as
psychologic distress and, adults, 481
471472 Childbirth, posttraumatic stress
recurrence of, 470471 disorder due to, 55
treatment of, 460461, 465467 Childbirth classes, 603
Breastfeeding. See also Lactation Childlessness, 370
decision making about, 119 Children
Bromocriptine, for infertility, 209 fear of loss of custody of, in
Bulimia nervosa, 444. See also Eating schizophrenic pregnant women,
disorder(s) 52
menstrual cycle and, 185 long-term effects of maternal drug
Bupropion (Wellbutrin) therapy on, 77, 8182
for depression associated with as motivator for marriage, 369
gynecologic cancer, 322 planning for, after being diagnosed
sexual behavior and, 393 with HIV infection, 351352
Buspirone, for posttraumatic stress social importance of producing,
disorder, 520 366
Butyrophenones, during pregnancy, 73 China, induced abortion in, 224
Chinese Americans, 617
C Chlordiazepoxide, gender differences
in, 411
Cancer. See Breast cancer; Gynecologic Chlorpromazine, gender differences in,
cancer 409
Carbamazepine, during pregnancy, 74, Chorionic villus sampling (CVS), 37,
8081 39
Cardiovascular disease, in pregnancy, genetic termination following, 42
20 psychologic consequences of, 40
Caregivers, perinatal loss and, 157158 time issues with, 38
Caribbean immigrants, 622623 Chromosome abnormalities, 34
CD4+ T lymphocytes, decline in, in Chromosome analysis, prenatal, 37
HIV infection, 338339 Chromosome translocations, 34
Cervical cancer, 307308 Chronotherapy, menstrual cycle and,
among lesbian women, 558 192193
Cervical conization, for human Cigarette smoking, teratogenicity of,
papillomavirus infection, 280 426, 427
Cervical dysplasia Cleft lip/palate, anxiolytics and, 82
in HIV infection, 339 Client-therapist relationship, for treating
among lesbian women, 558 victims of violence, 505509
Cervical factors, infertility due to, Clinician Administered PTSD Scale
210 (CAPS), 499
Chemotherapy, for breast cancer, 461 Clomiphene, for infertility, 209
psychologic reactions to, 467 Clomipramine
Child abuse gender differences in, 411
of malformed children, 4445 sexual behavior and, 393
neurologic consequences of, 486 Clozapine, during pregnancy, 73
Index 633
Cocaine resistance to, 372373

sexuality and reproduction and, sterilization for. See Sterilization
425426 Counseling
teratogenicity of, 426, 427 for adolescent pregnancy, 100104
use during pregnancy, in adolescents, abortion and, 102103
112 adoption and, 103104
Cognitive processing therapy, 515 keeping pregnancy and, 101102
Cold sweats, menopause and, 244 for breast cancer patients, 468
Collaboration, violence against women genetic, 35
and, 497 prepregnancy, with chronic diseases,
Collaborative alliances, for treating 28
victims of violence, 505509 Countertransference, 506, 593
Comorbidity, posttraumatic stress Covenantal model, of health care, 574
disorder and, 489 Crack use, during pregnancy, in
Complementary cancer therapies, 326 adolescents, 112
Condoms, 374 Crisis intervention, for parents of
Conduct disorders, adolescent malformed babies, 45
pregnancy related to, 113 Cryotherapy, cervical, for human
Confidentiality papillomavirus infection, 279280
about lesbian womens issues, Culture. See also Minorities
553554 assessment for trauma and, 501502
breaches of, 574575 gynecologic cancer and, 309310
paternalism and, 573 menstrual cycle and, 181183
violence against women and, 511 perinatal loss and, 154
Conjugation, gender differences in reactions to pregnancy loss and,
metabolism of drugs and, 406407 145146
Consent, informed, 284 violence against women and, 481,
paternalism and, 573 494495
Consultation-liaison psychiatry, 325, Custody loss, fear of, in schizophrenic
597608 pregnant women, 52
clinical and cultural substrate of Cyclophosphamide, for breast cancer,
obstetric/gynecologic practice 461
and, 600604 Cyproheptadine, for posttraumatic
consultation-liaison mechanisms for, stress disorder, 520
604606 Cystocele, 287, 288
future issues for, 607608 Cytochrome P450 (CYP450), gender
with high-risk pregnancies, 28 differences in metabolism of drugs
historical background of, 597600 and, 403406
interdisciplinary organizations and
activities and, 606607 D
Contraception, 373375. See also Oral
contraceptives (OCs) Death. See Mortality; Perinatal loss
adolescent use of, 96 Dehydroepiandrosterone (DHEA),
encouragement of, 106 secretion after menopause, 242
emergency, for adolescents, Dehydroepiandrosterone (DHEA)
106107 sulfate, secretion after menopause,
long-lasting methods of, 286 242
Delivery, 1819 Diabetes, in pregnancy, 1920, 26

anxiety about, 18 Diazepam
Denial gender differences in, 410, 411
of fetal anomalies, 41 orgasmic delay caused by, 394
of pregnancy, 5860 sexuality and, 425
Dependency, in high-risk pregnancies, Diethylstilbestrol (DES), in utero
2526 exposure to, 282283
Depression Dilation and curettage (D&C), 285
about fetal anomalies, 41 Disabilities, violence against women
breast cancer diagnosis and, with, 483, 503
462464 Disorders of extreme stress not
gynecologic cancer and, 319321, otherwise specified (DESNOS),
321323, 323 violence against women and,
infertility and, treatment of, 213214 492493
major Disorder-specific frameworks, for
in cancer patients, assessment violence against women, 495
guide for, 321 Dissociation, violence against women
in pregnancy, 53 and, 491492
screening instruments for, 53 Dissociative Experiences Scale (DES),
medical illness versus, 321 499
at menopause, 244247 Distribution of drugs, gender
postpartum, 131 differences in, 403
during postpartum period. See DNA analysis, prenatal, 37
Postpartum period, depression Documentation, violence against
during women and, 511
premenstrual, 185186 Domestic violence. See also Violence
psychotic, postpartum, 129 against women
violence against women and, definition of, 479480
489490 posttraumatic stress disorder and,
Desipramine (Norpramin) 488489
for depression associated with Donor insemination, 212213
gynecologic cancer, 322 Down syndrome, 34
gender differences in, 411412 Doxepin (Sinequan), for depression
for postnatal depression, 126 associated with gynecologic cancer,
Detachment, maternal, 122 322
Developing countries Drug abuse. See Substance abuse
epidemiology of HIV/AIDS in, Drug therapy, 401413. See also specific
331332 drugs and drug types
HIV/AIDS manifestations in, for breast cancer patients, 471472
339340 for chronic gynecologic pain, 272
principles of care for HIV/AIDS in, drugs inducing depression and, 320
342343 endogenous hormones and,
Developmental interference, by menstrual cycle and, 193194
perinatal loss, 150151 exogenous hormones and, menstrual
Developmental tasks cycle and, 194197
of adolescence, 109111 gender differences in pharmaco-
of young adulthood, 311 kinetics and, 402407
Index 635
absorption and bioavailability menstruation and, 443, 445446

and, 402403 in pregnancy
distribution and, 403 effects on infants and feeding,
metabolism and, 403407 450452
gender differences in psychotropic fetal and neonatal effects of,
agents and, 409412 449450
antidepressant agents, 411412 maternal effects of, 448449
antipsychotic agents, 409410 postpartum, 450
benzodiazepines, 410411 prevalence of, 448
menstrual cycle effects on, 407408 sexuality and fertility and, 446447
oral contraception and, 408409 Eating disorder not otherwise specified
for postnatal depression, 126127 (EDNOS), 444445
during pregnancy, 6786 Ebsteins anomaly, prenatal lithium
antidepressants in, 73, 7780, exposure and, 80
8485 Eclampsia, 19
antiparkinsonian agents in, 83 Ectopic pregnancy, 142
antipsychotic agents in, 7277, 84 Egg donation, 211212
anxiolytics in, 7475, 8283, 85 Elective abortion. See Induced abortion
behavioral teratogenicity due to, Electroconvulsive therapy (ECT),
7071 during pregnancy, 8687
guidelines for, 8386 clinical considerations with, 87
long-term effects on children, 77, indications for, 8687
8182 Embryo freezing, ethical issues related
mood stabilizers in, 74, 8082 to, 578
morphologic teratogenicity due Employment
to, 6970, 72, 7375, 76, gynecologic cancer and
7779, 8081, 82 during aging adulthood, 318
neonatal effects of, 71, 7375, 77, during mature adulthood, 314
79, 81, 8283 during midlife and older
physiologic changes affecting, adulthood, 316
6869 during young adulthood, 312
during second and third perinatal loss and, 153154
trimesters and labor, 71 Endometrial ablation, 291
for puerperal psychoses, 131 Endometrial cancer, hormone
sexual behavior and, 392394 replacement therapy and, 248249
for victims of violence, 519523 Endometriosis
Dysmenorrhea, 184 adhesions and implants from,
Dyspareunia, 269 infertility due to, 210
chronic, 262263 pain in, 263, 264
differential diagnosis of, 382 Enterocele, 287
menopausal, 244 Enzyme analysis, prenatal, 37
Estradiol, secretion after menopause,
E 242
Estrogen
Eating disorder(s), 441452 affective effects of, 246247
definition of, 443445 antidopaminergic effects of, neuro-
menstrual cycle and, 185 leptic effectiveness and, 409
Estrogen (continued) during young adulthood, 312

hepatic metabolism and, 249 infertility and, 207
neurobiologic effects of, 243 of lesbian women, 561
peripheral effects of, 243244 Family violence, violence against
Estrone, secretion after menopause, 242 women and, 495496
Ethics, 571581 Fathers, perinatal loss and, 154155
changing codes of, 572575 Fear
of collaborative alliances, 506508 of custody loss, in schizophrenic
of induced abortion, 227230 pregnant women, 52
issues affecting women and, 575579 of miscarriage, 16
in obstetrics and gynecology, of violence from partner, due to
601602 discussion of AIDS, 344345
physician-patient sexual interaction Fertility. See Infertility
and, 579581 Fetal anomalies, 3345
Ethnicity. See also Minorities elective abortion for
assessment for trauma and, 501502 reactions to, 4142
Existential issues, gynecologic cancer selective, 4243
and genetic testing for
during aging adulthood, 318 indications for, 3536, 37, 38
during mature adulthood, 314 pregnancy loss after, 4041
during midlife and older adulthood, psychologic consequences of, 40
316317 tests used for, 36, 3839
during young adulthood, 312 malformed babies and
Exposure therapy, 515516 psychologic reactions to, 4345
Extended family, perinatal loss and, psychotherapy and, 45
158159 perinatal death due to, psychologic
Eye movement desensitization, for reactions to, 43
victims of violence, 517518 reactions to detection of, 41
risk factors for, psychologic reactions
F to discovery of, 35
risk of, 3334
Factitious disorders, in pregnancy, 57 Fetal complications, 2122
Failure to thrive, maternal eating Fetal distress, intrapartum, 2122
disorders and, 450452 Fetal treatment, ethical issues related to,
Fallopian tubes, obstruction of, 579
infertility due to, 210 Fetus. See also Pregnancy
Family, extended, perinatal loss and, gender determination in, 43, 577
158159 maternal drug therapy and, 69
Family crisis intervention, for parents of viability of, induced abortion and,
malformed babies, 45 230
Family relationships Fibroadenomas, of breast, 458
gynecologic cancer and Fibrocystic disease, of breast, 458
during aging adulthood, 317 Filicide, puerperal psychosis and,
during mature adulthood, 132133
313314 Financial burden, of infertility, 207
during midlife and older Floppy infant syndrome, 82
adulthood, 315316 Flumazenil, gender differences in, 411
Index 637
5-Fluorouracil, for breast cancer, 461 tests used for, 36, 3839
Fluoxetine (Prozac) Genital herpes, 278279
for depression associated with Gestational diabetes, psychologic
gynecologic cancer, 322 adjustment to, 26
for postnatal depression, 126 Gestational surrogates, 212
for postpartum anxiety, 133 Gonadotropin(s), secretion after
Fluphenazine menopause, 242243, 247
gender differences in, 409 Gonadotropin-releasing hormone
sexual behavior and, 394 (GnRH)
Fluspirilene, gender differences in, agonists of, 196197
409410 for infertility, 209
Fluvoxamine Grandparents, perinatal loss and, 159
gender differences in, 412 Greece, ancient, induced abortion in,
Follicle-stimulating hormone (FSH), Grief
eating disorders and, 445446 following genetic pregnancy
Food aversions and cravings, in termination, 4142, 42
pregnancy, 448 following perinatal loss, 141,
Friends, perinatal loss and, 158159 147149, 161163
Funding, for consultation-liaison Group therapy, for victims of violence,
psychiatry, 608 504505, 516, 517
Guilt
G about genetic testing causing
pregnancy loss, 41
Galactocele, 458 about malformed baby, 44
Gamete intrafallopian transfer (GIFT), following genetic pregnancy
211 termination, 42
Gender determination, of fetus, 43, 577 Gynecologic cancer, 307327
Gender differences in aging adulthood, 317318
in distress related to infertility, existential issues and, 318
206207 family relationships and, 317
in pharmacokinetics, 402407 sexual functioning and, 317
absorption and bioavailability work and, 318
and, 402403 cervical, 307308
distribution and, 403 among lesbian women, 558
metabolism and, 403407 cross-cultural issues with, 309310
in psychotropic agents, 409412 definition of, 307
antidepressant agents, 411412 disturbed psychologic response to,
antipsychotic agents, 409410 318324, 320
benzodiazepines, 410411 anxiety and panic disorders as,
Gender identity, 370372 323324
Gender roles, perinatal loss and, 154 depression as, 319321, 321323,
Genetic counseling, 35 323
Genetics, gynecologic cancer and, 309 nausea, vomiting, and pain as,
Genetic testing, prenatal 324
ethical issues related to, 577 psychologic treatment for,
indications for, 3536, 37, 38 325326
Gynecologic cancer (continued) Gynecologic surgery, 283296

endometrial, hormone replacement to correct anatomic stress urinary
therapy and, 248249 incontinence or pelvic and
among lesbian women, 558, 559 vaginal relaxation, 287288
in mature adulthood, 312314 dilation and curettage, 285
existential issues and, 314 hysterectomy. See Hysterectomy
family relationships and laparoscopic, 287
reproduction and, 313314 preoperative preparation for,
sexual functioning and, 313 283285
work and, 314 sexual behavior and, 391
in midlife and older adulthood, sterilization, 286
314317 Gynecologists. See Obstetrician/
existential issues and, 316317 gynecologists
family relationships and
reproduction and, 315316 H
sexual functioning and, 315
work and, 316 Habitual abortion, 21
ovarian, 307, 308 Hallucinogens, teratogenicity of, 427
oophorectomy to prevent, 290 Haloperidol, for puerperal psychoses,
pain with, 324 131
psychosocial aspects of, 308309 Health care. See also specific conditions
surgery for, sexual behavior and, adolescent, 104107
391 emergency contraception and,
vulvar, pain and, 264 106107
in young adulthood, 311312 sexual activity and, 104105
existential issues and, 312 sexually transmitted diseases and,
family relationships and 105106
reproduction and, 312 covenantal model of, 574
sexual functioning and, 311 ecologic settings and, 615616,
work and, 312 618623
Gynecologic care, for lesbian women, Caribbean immigrants in South
558559 and, 622623
Gynecologic factors, maternity blues inner-city disintegration and
and, 121 growth of underclass and,
Gynecologic interventions, negative 618621
physical and emotional effects of, 4 lifestories and, 623625
Gynecologic pain, chronic, 261273 Mexican-American border as,
dyspareunia and, 262263 621622
management of, 270273 for lesbian women
pelvic, 262, 263264 barriers to, 551554
diagnosis and treatment of, 265 gynecologic, 558559
psychologic aspects of, 266270 health care provider attitudes
in vulvodynia, diagnosis and and, 551552
treatment of, 265 paternalism in, 573574
in vulvovaginitis, 261262 for women with HIV/AIDS,
diagnosis and treatment of, 340343
264 in pregnancy, 340341
Index 639
principles of care in developing in pregnancy, 20, 27

countries and, 342343 psychosocial issues among women in
treatment of HIV infection and, United States and, 343352
341342 HIV antibody testing and,
Hemorrhage, in pregnancy, 21 344345
Hereditary disorders. See Fetal living with HIV and, 349352
anomalies receiving HIV test results and,
Heroin, sexuality and, 425 345349
Herpes simplex virus (HSV) infections, substance abuse and, 428429
genital, 278279 HIV testing
Heterocyclic antidepressants disclosing results from, 348349
for depression associated with ethical issues related to, 579
gynecologic cancer, 320, 322 psychosocial issues related to,
during pregnancy, 73 344345
High-risk pregnancies, 1922 receiving results from, 345348
fetal complications and, 2122 Homicidal ideation, among battered
maternal factors associated with, women, 510511
1920 Homosexuality, 373. See also Lesbian
obstetric factors associated with, women
2021 Hormonal therapy, for breast cancer,
psychologic aspects of, 2223 461
psychologic stages in, 2327 Hormone(s). See also specific hormones
HIV/AIDS, 3, 280281, 331352 endogenous, psychotropic
epidemiology of, 331336 medications and, 193194
case surveillance in United States exogenous, psychotropic
and, 332, 333, 334, 335 medications and, 194197
global, 331332 postnatal depression and, 126
modes of exposure for women in postpartum adaptation and, 117118
United States and, 334, 336 Hormone replacement therapy (HRT),
female-to-female transmission of, 195196, 247249
336, 557558 affective symptoms of menopause
health care issues for women with, and, 253254
340343 for menopausal symptoms, 244
in pregnancy, 340341 risks of, 248249
principles of care in developing Hospitalization, psychiatric, during
countries and, 342343 pregnancy, 62
treatment of HIV infection and, Hot flashes, 244
341342 Human immunodeficiency virus. See
among lesbian women, 557558, 559 HIV/AIDS
manifestations in women, 338340 Human life, definition of beginning of,
AIDS-defining conditions and, 229230
339 Human menopausal gonadotropin, for
in developing countries, 339340 infertility, 209
non-AIDS-defining conditions Human papillomavirus (HPV), 265,
and, 338339 279280
mortality in United States due to, in HIV infection, 339
336, 337 among lesbian women, 556
Hydroxyzine, during pregnancy, 75 India, AIDS/HIV in, 331

Hyperemesis gravidarum, 5758 Individuation, during pregnancy, 17
eating disorders and, 448 Indolamine metabolism, estrogens
Hypertension, pregnancy and, 19 impact on, 246
Hypoactive sexual desire disorder, Induced abortion, 6, 219236
differential diagnosis of, 383 for adolescent pregnancy
Hypomania, postpartum, 131 counseling and, 102103
Hypothalamic-pituitary-adrenal (HPA) emotional difficulties following,
axis, posttraumatic stress disorder 102103
and, 486 American Psychiatric Association
Hypothalamic-pituitary-ovarian axis, position on, 220
180 barriers to, 223
Hysterectomy, 288296 psychiatric implications of,
adverse reactions following, factors 233236
associated with, 295 conceptual and methodological
alternatives to, 290292 issues in, 221222
categorization of, 295296 definition of, 219
expectations for results of, 296 epidemiology of, 223224
hormone replacement therapy ethical perspectives on, 227230
following, 290 fetal gender and, 43, 577
oophorectomy with, risks versus for genetic disorders, 4142
benefits of, 289290 gynecologic and public health issues
preoperative preparation for, 295 in, 222223
psychologic reactions to, 292296 history and anthropology of,
risks versus benefits of, 296 224226
sexual behavior and, 391 legal constraints on, psychiatric
supracervical (subtotal), 293 implications of, 233236
total, 289 legal issues affecting, 226227
with bilateral salpingo- psychiatric sequelae of, 230233
oophorectomy, 289 psychiatrys role in, 220221
vaginal, laparoscopic, 287 selective, in multiple gestations,
Hysteria, 597598 4243
definition of, 2 sexual behavior and, 392
Hysterosalpingography, 210 Infant(s). See also Neonates
Hysteroscopy, 285 feeding of. See also Breastfeeding;
Lactation
I maternal eating disorders and,
450452
Imipramine (Tofranil) maternal relationship with. See
for depression associated with Maternal-infant relationship
gynecologic cancer, 322 Infanticide, 122
gender differences in, 411, 412 Infertility, 205216, 367
for postpartum anxiety, 133 compounding perinatal loss,
Immigration, 617618 eating disorders and, 443, 446447
Immune system, breast cancer and, 465 ethics of treatment for, 3
Implantable subdermal devices, 286 interventions for, 208213
Index 641
male, treatment for, 212 Journal of Psychosomatic Obstetrics and

male perspective on, 588589 Gynecology, 606
psychologic effects of and adjustment Judicial bypass, 236
to, 205208 for induced abortion, 227
psychologic treatment issues with,
213216 L
sexual behavior and, 388390
treatment for. See Assisted Lactation. See also Breastfeeding
reproductive technologies alcohol use during, 428
(ART) drug therapy during, 72, 7375, 77,
Infidelity, gynecologic cancer and, 7980, 81, 83
308309 Laparoscopy, 287
Information, about domestic violence, in infertility, 210
providing to victims, 511513 Laser vaporization, for human
Informed consent, 284 papillomavirus infection, 279280
paternalism and, 573 Legal issues, in induced abortion,
Informed refusal, 284 226227
Inner city disintegration, 618621 Leiomyomata, surgical removal of, 291
Interdisciplinary research, 607 Lesbian women, 549564
International Society for Psychosomatic assessment for trauma, 502503
Obstetrics and Gynecology, 606 avoiding assumptions about, 553
Interpersonal relationships barriers to health care for, 551554
with family members. See Family decreasing, 552554
relationships breast cancer in, 555556
following breast cancer treatment, definition of, 550551
469470 gynecologic care and screening of,
maternal-infant. See Maternal-infant 558559
relationship health care provider attitudes
Intracytoplasmic sperm injection (ICSI), toward, 551552
212 health concerns of, 554555
Intrauterine devices, 286 HIV transmission between, 336,
Intrauterine growth restriction (IUGR), 557558
21 mental health issues of, 560563
In vitro fertilization (IVF), 211 pregnancy among, 369
Isocarboxazid (Marplan), for depression reproductive issues of, 559560
associated with gynecologic cancer, sexually transmitted diseases in,
323 556558
Isolation, interpersonal, perinatal loss Liaison-consultation psychiatry. See
and, 150151 Consultation-liaison psychiatry
Life, definition of beginning of, 229230
J Life Events Scale for Obstetric Groups,
61
Jacobs Institute for Womens Health, Lithium
607 menstrual cycle and, 192193
Japan, induced abortion in, 225 during pregnancy, 80, 8182
Japanese Americans, 617 guidelines for clinical use of,
8586
Lithium carbonate Marital problems

during pregnancy, 74 chronic gynecologic pain and, 269
for puerperal psychoses, 131 following genetic pregnancy
Litigation, malpractice, against termination, 42
obstetrician/gynecologists, 602 infertility and, 206
LLPDD. See Premenstrual syndrome postnatal depression and, 125
Loop electrical excision, for human during postpartum period,
papillomavirus infection, 280 587588
Lumpectomy, 461 Marital status, menopause and, 251
Luteinizing hormone (LH) Marriage, decisions about, 368370
eating disorders and, 445 Mastectomy
following menopause, 247 psychologic reactions to, 466
radical, 460
M total (simple), 460
Maternal Adjustment and Maternal
Major depression Attitudes scale (MAMA), 61
in cancer patients, assessment guide Maternal attachment
for, 321 delayed, 122
in pregnancy, 53 in high-risk pregnancies, 2324
screening instruments for, 53 hormonal correlates of, 17
Male infertility, treatment for, 212 during third psychologic stage of
Male perspective, 585594 pregnancy, 18
on abortion, 589590 Maternal Attitudes to Pregnancy
on breast cancer, 590591 Instrument (MAPI), 61
on infertility, 588589 Maternal-infant relationship
of male physicians treating female following high-risk pregnancies, 26
patients, 593594 postpartum disorders of, 122124
on menopause, 591592 clinical presentation of, 122
on perinatal loss, 154155 etiology of, 122123
on postpartum period, 587588 incidence of, 122
on pregnancy, 586587 management of, 123
Malformed babies, psychologic neonatal effects of, 123124
reactions to, 4345 Maternal serum AFP (MSAFP)
psychiatric treatment for, 45 prenatal screening for, 36, 37, 38
Malpractice litigation, against time issues with, 38
obstetrician/gynecologists, 602 Maternity blues, 119122
Mammary duct ectasia, 458 clinical presentation of, 120
Mania, postpartum, 129, 131 etiology of, 120121
Maprotiline (Ludiomil), for depression prognosis of, 121122
associated with gynecologic cancer, Mature adulthood. See also Older
322 women
Marc Society, 607 gynecologic cancer in, 312314
Marginalization, 615 existential issues and, 314
Marijuana family relationships and
teratogenicity of, 427 reproduction and, 313314
use during pregnancy, in adolescents, sexual functioning and, 313
112 work and, 314
Index 643
Medical illness, depression versus, normal

321 physiology of, 178179, 179, 180,
Melatonin, premenstrual syndrome 181
and, 192 variability in, 181
Memory phases of, 178, 179
in pregnancy, 1516 physiology of, 178181
trauma and, 487489 treatment and, 192198
Menarche, age of, 105 chronotherapy and, 192193
Mendelian disorders, 34 gynecologic versus psychotropic
Menopause, 241254 medications for
gynecologic assessment and, 247 premenstrual syndrome and,
hormonal changes at 197198
consequences of, 244247 interaction between endogenous
neurobiologic effects of estrogen hormones and psychotropic
and androgen and, 243 medication, 193194
peripheral effects of estrogen and, interaction between exogenous
243244 hormones and psychotropic
sex hormone secretion following medication, 194197
menopause and, 242243 nonbiologic, 198
hormone replacement therapy Meprobamate, during pregnancy, 74
following. See Hormone Metabolism of drugs, gender differences
replacement therapy (HRT) in, 402, 403407
male, 592 conjugation and, 406407
male perspective on, 591592 cytochrome P450 and, 403406
meaning of, 367 Metastatic breast cancer, treatment of,
mental health referrals and, 461
253254 Methadone, during pregnancy, 426
positive aspects of, 252253 Methotrexate, for breast cancer, 461
psychologic theories of, 249250 Methylphenidate (Ritalin), for
sexual behavior and, 390 depression associated with
sexuality following, 251252 gynecologic cancer, 323
sociocultural theories of, 250 Mexican immigrants, health care of,
surgical, 241242 621622
transitional phenomena related to, Midlife, gynecologic cancer in,
250251 314317
Menstrual cycle, 177199. See also existential issues and, 316317
Menopause family relationships and
cultural aspects of, 181183 reproduction and, 315316
disorders of sexual functioning and, 315
amenorrhea, 443 work and, 316
dysmenorrhea, 184 Minorities, 611627
medical, 184 assessment for trauma, 501502
premenstrual syndrome. See definition of, 612616, 613
Premenstrual syndrome ecologic settings of, 618623
psychiatric, 185186 Caribbean immigrants in South
drug therapy and, 407408 and, 622623
eating disorders and, 443, 445447 health impact of, 615616
Minorities (continued) Narcotic antagonists, for posttraumatic

ecologic settings of (continued) stress disorder, 523
inner-city disintegration and Nausea
growth of underclass and, anticipatory, gynecologic cancer and,
618621 324
lifestories and, 623625 gynecologic cancer and, 324
Mexican-American border as, Nefazodone
621622 gender differences in, 412
marginalization of, 615 for posttraumatic stress disorder, 520
practice implications of, 625627 sexual behavior and, 393
relational process and, 617618 Neonates
Mirtazapine, sexual behavior and, 393 breastfeeding of. See Breastfeeding;
Miscarriage. See Perinatal loss Lactation
Monoamine oxidase inhibitors death of. See Perinatal loss
(MAOIs) malformed, psychologic reactions to,
for depression associated with 4345
gynecologic cancer, 323 psychiatric treatment for, 45
for posttraumatic stress disorder, maternal drug therapy and, 71,
520 7375, 77, 79, 81, 8283
during pregnancy, 73 maternal rejection of, 122
sexual behavior and, 393 maternal relationship with. See
Mood stabilizers. See also specific drugs Maternal attachment; Maternal-
during pregnancy, 74, 8082 infant relationship
sexual behavior and, 394 Neonaticide, puerperal psychosis and,
Mortality. See also Perinatal loss 132
due to HIV/AIDS, in United States, Nesting behavior
336, 337 in high-risk pregnancies, 25
maternal during third psychologic stage of
from childbirth, 222 pregnancy, 18
from induced abortion, 222 Neuroleptics. See Antipsychotic agents;
Mourning. See also Grief specific drugs
male, for infertility, 588 Newborns. See Neonates
for malformed baby, 44, 45 Nicotine
Multifactorial inheritance, 34 teratogenicity of, 426, 427
Multiple births, 208 use during pregnancy, 426
Multiple-gestation pregnancies Night terrors, in pregnancy, 55
complications of, 21 Nitrazepam, gender differences in,
selective termination in, 4243 410411
Myomectomy, 291 Nondisjunction disorders, 34
North American Menopause Society,
N 607
North American Society for
Narcissistic injury Psychosocial Obstetrics and
infertility and, 388 Gynecology, 606
malformed babies and, 4344 Nortriptyline
repairing following perinatal loss, gender differences in, 412
149150 for postnatal depression, 126
Index 645
O as treatment for psychiatric

disorders, 2
Obsessive-compulsive disorder Opiates, teratogenicity of, 426, 427
postpartum, 133134 Oral clefts, anxiolytics and, 82
in pregnancy, 5455 Oral contraceptives (OCs), 194195,
Obstetric factors, maternity blues and, 374375
121 for adolescents, 107
Obstetrician/gynecologists drug therapy and, 408409
consumer criticism of, 602, 603 sexual behavior and, 392
educating about substance abuse, Organic brain syndrome, postpartum,
433434 130
gender of, 603604 Orgasmic disorder
liaisons with psychiatrists, 296297 differential diagnosis of, 384385
malpractice litigation against, 602 drug-induced, 393394
reproductive choices and, 375376 Ovarian cancer, 307, 308
Obstetrics and gynecology (OB/GYN) oophorectomy to prevent, 290
collaboration between psychiatry Ovulation
and. See Consultation-liaison agents to stimulate, 209210
psychiatry eating disorders and, 447
interface between psychiatry and, Oxazepam, gender differences in, 411
18
Obstructive sleep apnea, in pregnancy, 55 P
Oedipus complex, 370
Olanzapine Paclitaxel (Taxol), for breast cancer,
during pregnancy, 73 461
for puerperal psychoses, 131 Pain
Older adulthood, gynecologic cancer in, gynecologic. See Gynecologic pain,
314317 chronic
existential issues and, 316317 with gynecologic cancer, 324
family relationships and gynecologic cancer and, 324
reproduction and, 315316 Panic disorders
sexual functioning and, 315 gynecologic cancer and, 323324
work and, 316 menstrual cycle and, 185
Older women in pregnancy, 54
assisted reproduction technology use Papanicolaou (Pap) smears, 307
for, 212 for lesbian women, 558
assisted reproductive technology use Papillomas, intraductal, of breast, 458
for, 577 Parenthood, emotional maturation and,
gynecologic cancer in. See 370
Gynecologic cancer Parenting capability assessment of, 62
lesbian, 563 Parkinsonism, gender differences in,
pregnancy in, perinatal loss and, 151 410
Oligospermia, 212 Paroxetine (Paxil)
Oocyte donation, 212 for depression associated with
Oophorectomy gynecologic cancer, 322
with hysterectomy, benefits versus gender differences in, 412
risks of, 289290 for postnatal depression, 126
Partner abuse, among lesbian women, mental health considerations and,

502503, 562 161163
Paternalism, in health care, 573574 Peu dorange, 460
Pelvic exenteration, sexual behavior Pharmacokinetics, gender differences in,
and, 391 402407
Pelvic pain, chronic, 262, 263264 absorption and bioavailability and,
diagnosis and treatment of, 265 402403
Pelvic relaxation, surgical, 288 distribution and, 403
Pelviscopic surgery, 287 metabolism and, 403407
Pemoline (Cylert), for depression Phenelzine (Nardil)
associated with gynecologic cancer, for depression associated with
323 gynecologic cancer, 323
Penis envy, 370 sexual behavior and, 393
Perinatal loss, 141165 Phenothiazines, during pregnancy, 73
caregiver responses to, 157158 Physical abuse. See Violence against
cross-cultural reactions to, 145146 women
due to genetic abnormalities, Physicians. See also Obstetrician/
psychological reactions to, 43 gynecologists; Psychiatrists
epidemiology and etiology of, conflicting roles of, 574575
142143 male, treating female patients,
family reactions to, 154157 593594
siblings and, 156157 sexual interaction with patients,
spouses and, 154155 579581
fear of, 16 Pica, in pregnancy, 448
friends and extended familys Pimozide, gender differences in, 409
reactions to, 158159 Placenta, drug crossing of, 69. See also
after genetic testing, 4041 Teratogenicity
historical background of, 143144 Placenta previa, 21
impact on mother, 146154 Postmenopausal women. See Aging
employment and, 153154 adulthood; Menopause; Older
infertility compounding loss and, women
152153 Postpartum period, 117134
mastering exacerbating adaptation during, 117119
circumstances of loss and, biologic factors affecting,
151153 117118
mourning and, 147149 infant feeding and, 119
religious faith and, 154 psychosocial factors affecting,
repairing narcissistic losses and, 118119
149150 anxiety disorders during, 133134
reviving psychologic conflicts depression during, 124127
and, 151 clinical presentation of, 124125
social support and, 153 etiology of, 125126
surmounting developmental prevalence and epidemiology of,
interference and, 150151 124
psychologic management of, prevention of, 127
159165 prognosis of, 127
hospital practice for, 159161 treatment of, 126127
Index 647
disorders of mother-infant denial of, 5860

relationship during, 122124 drug metabolism, action, and side
clinical presentation of, 122 effects during, 6869
etiology of, 122123 drug therapy during. See Drug
incidence of, 122 therapy, during pregnancy
management of, 123 eating disorders in, 448452
neonatal effects of, 123124 effects on infants and feeding,
eating disorders during, 450 450452
male perspective on, 587588 fetal and neonatal effects of,
maternity blues during, 119122 449450
clinical presentation of, 120 maternal effects of, 448449
etiology of, 120121 postpartum exacerbation of, 450
prognosis of, 121122 prevalence of, 448
puerperal psychoses during, ectopic, 142
128133 emotional maturation and, 370
clinical presentation of, 129130 fetal anomalies and. See Fetal
early versus late onset of, 129 anomalies
effect on mother-child high-risk, 1922
relationship, 132133 fetal complications and, 2122
epidemiology of, 128129 maternal factors associated with,
etiology of, 130 1920
incidence and prevalence of, 128 obstetric factors associated with,
prognosis of, 131132 2021
treatment of, 130131 psychologic aspects of, 2223
Posttraumatic stress disorder (PTSD) psychologic stages in, 2327
breast cancer diagnosis and, 464 HIV infection in, 340341
complex, violence against women among lesbian women, 369
and, 492493 loss of. See Abortion; Perinatal loss
drug therapy for, 519523 male perspective on, 586587
menstrual cycle and, 186 maternal ambivalence toward, 17
neurobiology of trauma and, medical complications of, 1922
485487 memory in, 1516
in pregnancy, 55 physiologic changes in, drug effects
violence against women and, and, 6869
484485 physiologic stages of, 1419
comorbidity and, 489 in postmenopausal women, 212
domestic, 488489 prevention of. See Contraception;
sexual, 488 Oral contraceptives (OCs)
Preeclampsia, 19 psychiatric disorders during, 5162
Pregnancy, 1329 anxiety disorders, 5455
abuse during, 483 factitious, 57
during adolescence. See Adolescent mood disorders, 5354
pregnancy psychotic, 5152
assisted reproduction technologies sleep disorders, 56
and. See Assisted reproductive specific to pregnancy, 5760
technologies (ART) psychiatric intervention in, 2729,
concern with appearance during, 18 6062
Pregnancy (continued) role in reducing psychologic distress

psychoanalytic view of, 1314 due to breast cancer, 471472
sexual behavior and, 387388 Psychiatry
substance abuse during, 425426, collaboration between obstetrics and
427, 428 gynecology and. See
ethical issues related to, 578579 Consultation-liaison psychiatry
Pregnancy Psychologic Attitudes Test interface between obstetrics and
(PPAT), 61 gynecology and, 18
Premenstrual dysphoric disorder role in educating obstetrician/
(PMDD). See Premenstrual gynecologists about substance
syndrome abuse, 434
Premenstrual syndrome Psychoanalytic theory, violence against
culture and, 182183 women and, 495
diagnostic criteria for, 187, 187 Psychological/psychiatric interventions.
historical background of, 183184 See also specific interventions
as legal defense, 191 for chronic gynecologic pain,
research on 271272
hormone studies, 189 following perinatal loss, 163165
methodologic issues in, 190191 for gynecologic cancer, 325326
political issues affecting, 191 hospitalization as, during pregnancy,
prevalence Axis I and Axis II 62
disorders and, 188189 oophorectomy as, 2
prevalence of symptoms and, for parents of malformed babies, 45
188189 in pregnancy, 2729, 6062
Prenatal care, for adolescent women, Psychologic conflicts, perinatal loss and,
107108, 109111 151
Prenatal testing. See also specific tests Psychologic factors
ethical issues related to, 577 chronic gynecologic pain and,
indications for, 3536, 37, 38 266270
tests used for, 36, 3839 lesbian women and, 560563
Prepared childbirth classes, 603 with sexually transmitted diseases,
Prepregnancy counseling, with chronic 281282
diseases, 28 Psychologic loss theory of menopause,
Preventive intervention, for perinatal 249250
loss, 159161 Psychologic responses
Psychiatric disorders. See also specific to abuse, 484. See also Violence
disorders against women, mental health
adolescent pregnancy related to, consequences of
112114 to breast cancer diagnosis,
following induced abortion, 230233 462465
violence against women with, 503 anger and, 465
Psychiatrists anxiety disorders and, 464
client-therapist relationship and, for biobehavioral responses to, 465
treating victims of violence, depression and, 462464
505509 following breast cancer treatment,
liaisons with obstetricians and 467470
gynecologists, 296297 to gynecologic cancer, 318324, 320
Index 649
anxiety and panic disorders as, Rape. See also Violence against women
323324 definition of, 478479
depression as, 319321, 321323, posttraumatic stress disorder and,
323 488
nausea, vomiting, and pain as, treatment for, 514515
324 Rectocele, 287, 288
psychologic treatment for, Refusal, informed, 284
325326 Rejection, of infant, 122
to hysterectomy, 292296 Religion
to positive results of HIV antibody assessment for trauma and, 502
testing, 346349 faith and perinatal loss and, 154
Psychooncology, 325 Reprocessing therapy, for victims of
Psychoses. See Postpartum period, violence, 517518
puerperal psychoses during; specific Reproductive choices, 365376
psychoses after being diagnosed with HIV
Psychosocial factors infection, 350351
gynecologic cancer and, 308309 biologic clock and, 367
HIV infection among women in consultative interaction and, 375376
United States and, 343352 contraception and. See Contraception
maternity blues and, 120 decisions about marriage and,
in postnatal depression, 125126 368370
postpartum adaptation and, 118119 gender identity and development
Psychostimulants. See also specific drugs and, 370372
for depression associated with homosexuality and, 373
gynecologic cancer, 323 lesbian womens issues concerning,
teratogenicity of, 426, 427 559560
Psychotherapy reproductive technologies and. See
in gynecologic cancer, goals of, Assisted reproductive
325326 technologies (ART)
for menstrually related symptoms, sexuality and, 372373
198 Reproductive clock, 367
for parents of malformed babies, 45 Reproductive functioning
for sexual disorders, 385387 alcohol and, 426, 428
short-term, following perinatal loss, gynecologic cancer and
163165 during mature adulthood,
313314
Q during midlife and older
adulthood, 315316
Quetiapine, during pregnancy, 73 during young adulthood, 312
Reproductive technologies. See Assisted
R reproductive technologies (ART)
Research
Race. See also Minorities interdisciplinary, 607
assessment for trauma and, 501502 on premenstrual syndrome
Radiation therapy, for breast cancer, hormone studies, 189
460, 461 methodologic issues in, 190191
psychologic reactions to, 466 political issues affecting, 191
Research (continued) during pregnancy, 73

on premenstrual syndrome (continued) sexual behavior and, 393
prevalence Axis I and Axis II Self-esteem, low, adolescent pregnancy
disorders and, 188189 related to, 113
prevalence of symptoms and, Self-help groups, 45
188189 for gynecologic cancer, 326
Respect, violence against women and, perinatal loss and, 159
497 for substance abuse, 432
Respiradone, during pregnancy, 73 for victims of violence, 517
Restless legs syndrome, in pregnancy, Sensate-focus exercises, for sexual
55 disorders, 387
Roe v. Wade decision, 226227 Separation, during pregnancy, 17,
Role changes, menopause and, 250 1819
RU-486, 181, 223 in high-risk pregnancies, 2425
Sertraline (Zoloft)
S for depression associated with
gynecologic cancer, 322
Safety, of victims of violence, 508 gender differences in, 412
with ongoing violence, 509516 for postnatal depression, 126
Schizophrenia for postpartum anxiety, 133
during pregnancy, 5152 Serum screening, prenatal, 36, 38
pregnancy in, denial of, 60 Sex hormones. See also specific hormones
Schizophreniform disorders, secretion after menopause, 242243,
postpartum, 130, 131 247
Screening Sexual abuse. See also Violence against
gynecologic, of lesbian women, women
558559 adolescent pregnancy associated
for major depression, 53 with, 98100
for maternal serum AFP, 36, 37, 38 childhood
for psychiatric disorders during definition of, 479
pregnancy, 61 history of, in women abused as
for substance abuse, 429, 430431, adults, 481
431432 chronic gynecologic pain and,
for trauma, 499500 269
Second-generation antidepressants, for posttraumatic stress disorder and,
depression associated with 488
gynecologic cancer, 322 treatment for, 514515
Sedatives Sexual arousal disorder, differential
sexuality and, 425 diagnosis of, 383384
teratogenicity of, 426, 427 Sexual behavior
Selective serotonin reuptake inhibitors among adolescent women, health
(SSRIs). See also specific drugs care and, 104105
for chronic gynecologic pain, 272 after being diagnosed with HIV
for depression associated with infection, 350
gynecologic cancer, 321, 322 first activity and, adolescent
for posttraumatic stress disorder, development and, 9798
520, 523 of lesbian women, 550551
Index 651
Sexual desire Siblings, perinatal loss and, 43, 156157

decline in Singe gene disorders, 34
differential diagnosis of, 383 Sleep disturbances
during pregnancy, 387 menopause and, 244
menopause and, 390 in pregnancy, 55
Sexual disorders, 379394 Sleepwalking, in pregnancy, 55
chronic gynecologic pain and, 269 Smoking, teratogenicity of, 426, 427
differential diagnosis of, 382385 Social relationships, infertility and, 207
hysterectomy and, 391 Social status of women, 617618
induced abortion and, 392 Social support
infertility and, 388390 for breast cancer patients, 468
treatment of, 214 following perinatal loss, 153
menopause and, 390 Social victimization, violence against
nomenclature for, 380 women and, 494495
oral contraceptives and, 392 Sociocultural model of menopause, 250
in pregnancy, 387388 Soviet Union, induced abortion in, 224
prevalence of, 381382 Sperm allergy, infertility due to,
psychiatric drugs and, 392394 210211
psychotherapeutic treatment of, Spiritual needs, of victims of violence,
385387 518
surgery and, 391392 Spontaneous abortion, rate of, 142
Sexual functioning Spouses. See also Marital problems
alcohol and, 424425 perinatal loss and, 154155
eating disorders and, 446447 Sterilization
following breast cancer treatment, female, 286
470 male, 374
following hysterectomy, 293294 Stillbirth. See Perinatal loss
gynecologic cancer and Stress. See also Posttraumatic stress
during aging adulthood, 317 disorder (PTSD)
during mature adulthood, 313 HIV disease progression and,
during midlife and older 349350
adulthood, 315 lesbian women and, 561
during young adulthood, 311 menopause and, 251
infertility and, 206 Stress inoculation training, 515
menopause and, 251252 Stress urinary incontinence, surgical
Sexually transmitted diseases (STDs), correction of, 287288
277282. See also specific diseases Structured Interview for Disorders of
in adolescents, health care and, Extreme Stress (SIDES), 499
105106 Substance abuse, 421434
incidence of, 278 educating obstetrician/gynecologists
among lesbian women, 556558 about, 433434
psychologic effects of, 281282 epidemiology of, 422423
substance abuse and, 428429 historical and social factors in,
Shame, about malformed baby, 44 421422
Shock, about fetal anomalies, 41 physical complications of,
Short-term psychotherapy, following 428429
perinatal loss, 163165 physiologic factors in, 424
Substance abuse (continued) morphologic, due to drug therapy,

during pregnancy 6970, 72, 7375, 76, 7779,
in adolescents, 108, 112 8081, 82
ethical issues related to, 578579 substance abuse and, 426, 427, 428
prevention of, 434 Terminology, interface between
psychologic aspects of, 423424 obstetrics and gynecology and
screening for, 429, 430431, psychiatry and, 4
431432 Testosterone, secretion after
sexuality and reproductive effects of, menopause, 242
424426, 427, 428 Therapeutic relationship, for short-term
treatment of, 432433 psychotherapy following perinatal
barriers to, 432433 loss, 164
violence against women and, 112, Thioridazine, sexual behavior and, 394
491 Thiothixene, gender differences in, 410
Suction curettage, for induced abortion, Time-limited groups, for victims of
222 violence, 517
Suicide risk, among battered women, Tobacco use, teratogenicity of, 426,
510 427
Support groups Transference, 506
for breast cancer patients, 468469, Transfusions, HIV transmission via,
470471 336
for parents of malformed babies, 45 Transitions, menopause and, 250251
Support programs, for gynecologic Tranylcypromine (Parnate), for
cancer, 326 depression associated with
Support systems, of lesbian women, 554 gynecologic cancer, 323
Surgery Trauma. See also Child abuse;
for breast cancer, 460 Posttraumatic stress disorder
psychologic reactions to, 466 (PTSD); Violence; Violence
gynecologic. See Gynecologic against women
surgery; Hysterectomy assessing for, 498503, 500
sexual behavior and, 391392 disabilities and mental health
Surgical menopause, 241242 problems and, 503
Surrogates, gestational, 212 in lesbian women, 502503
race, ethnicity, culture, and
T religion and, 501502
screening tools for, 499500
Taliban, 617 Trauma Symptoms Inventory, 499
Talipes equinovarus, with Trazodone (Desyrel)
amniocentesis, 39 for depression associated with
Tardive dyskinesia (TD), gender gynecologic cancer, 322
differences in, 410 gender differences in, 412
Teen pregnancy. See Adolescent for posttraumatic stress disorder,
pregnancy 520
Temazepam, gender differences in, 411 Trichomoniasis, 261, 264
Teratogenicity Tricyclic antidepressants. See also specific
behavioral, due to drug therapy, drugs
7071 for chronic gynecologic pain, 272
Index 653
for depression associated with Vaginitis

gynecologic cancer, 319320, atrophic, 244
322 monilial, 261
gender differences in, 411412 Vaginosis, bacterial, 261
for posttraumatic stress disorder, 520 Valproic acid, during pregnancy, 74, 81
during pregnancy, 73 Vasectomy, 374
sexual behavior and, 393 Venlafaxine
Trifluoperazine, sexual behavior and, gender differences in, 412
394 sexual behavior and, 393
Tryptophan, estrogens impact on, Violence. See also Trauma
246247 due to discussion of AIDS with
Tubal occlusion, 286 partner, fear of, 344345
Tuboplasty, for infertility, 210 against neonates, puerperal
psychosis and, 132133
U Violence against women, 477526
advocacy for women and system
Ultrasound change and, 497498
continuous, 38 assessing for trauma and, 498503,
prenatal, 37, 38 500
time issues with, 38 in lesbian women, 502503
pulse, 38 race, ethnicity, culture, and
Underclass, growth of, 618621 religion and, 501502
United States in women with disabilities or
AIDS case surveillance in, 332, 333 other mental health
HIV/AIDS mortality due to, 336, problems, 503
337 definitions of, 478480
HIV case surveillance in, 332, 334, in lesbian relationships, 562
335 medical consequences of, 482483
induced abortion in, 225226 mental health consequences of,
modes of womens exposure to HIV 483493
in, 334, 336 depression as, 489490
psychosocial issues and HIV dissociation as, 491492
infection among women in, memory and, 487489
343352 neurobiology of trauma and,
Urethrocele, 287 485487
Urinary incontinence, stress, surgical posttraumatic stress disorder as,
correction of, 287288 484485, 488489,
Uterine prolapse, 287 492493
Uterus, meaning of, 308 substance abuse as, 491
ongoing, 509516
V access to community resources
and, 514
Vaginal mucosa, estrogen effects on, 244 clinical issues with, 510511
Vaginal vault procedures, 288 confidentiality and
Vaginismus documentation and, 511
differential diagnosis of, 382383 provision of information and,
sex therapy for, 388389 511513
Violence against women (continued) Vulvovaginitis, chronic gynecologic

prevalence of, 480481 pain in, 261262
cultural differences in, 481 diagnosis and treatment of, 264
overall rates and, 480
revictimization and, 481 W
recognizing safety as priority and,
496 Webster v. Reproductive Health Services, 607
respect and collaboration issues and, Weight gain, in pregnancy, low, eating
497 disorders and, 448449
substance abuse and, 112, 491 Womens Health Issues, 607
trauma framework for, 493496 Work, gynecologic cancer and
limitations of mental health during aging adulthood, 318
models and, 495496 during mature adulthood, 314
treatment and intervention for, during midlife and older adulthood,
504518 316
collaborative alliances for, during young adulthood, 312
505509
late phase of, 518 X
medications in, 519523
with ongoing abuse, 509516 X-linked recessive disorders, 34
potentially harmful, 512513
for rape, 514515 Y
systemic barriers to, 524525
techniques for, 515516 Young adulthood, gynecologic cancer
working through trauma and, in, 311312
516518 existential issues and, 312
Vomiting family relationships and
gynecologic cancer and, 324 reproduction and, 312
in hyperemesis gravidarum, sexual functioning and, 311
5758 work and, 312
Vulvar carcinoma, pain and, 264 Yuzpe method, 107
Vulvectomy, radical, sexual behavior
and, 391 Z
Vulvodynia, chronic gynecologic pain
in, diagnosis and treatment of, Zygote intrafallopian transfer (ZIFT),
265 211

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Psychological Aspects of

Womens Health Care

1 The Interface Between Psychiatry and Obstetrics and

2 Normal and Medically Complicated Pregnancies . . . . . . 13

4 Psychiatric Disorders During Pregnancy . . . . . . . . . . . 51

5 Psychotropic Drugs and Electroconvulsive Therapy

8 Perinatal Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

9 Psychological Aspects of the Menstrual Cycle . . . . . . . 177

10 Infertility and the New Reproductive Technologies . . . 205

11 Induced Abortion in the United States . . . . . . . . . . . 219

12 Menopause: Myths and Realities . . . . . . . . . . . . . . . . 241

13 Chronic Gynecologic Pain. . . . . . . . . . . . . . . . . . . . . 261

14 Gynecologic Disorders and Surgery . . . . . . . . . . . . . . 277

15 Gynecologic Oncology . . . . . . . . . . . . . . . . . . . . . . . 307

16 Women and HIV Infection . . . . . . . . . . . . . . . . . . . . 331

17 Reproductive Choices and Development:

18 Female Sexual Disorders. . . . . . . . . . . . . . . . . . . . . . 379

19 Psychopharmacology in Women . . . . . . . . . . . . . . . . 401

20 Alcohol and Substance Abuse in Obstetrics and

21 Eating Disorders and Reproduction . . . . . . . . . . . . . . 441

22 Breast Disorders and Breast Cancer . . . . . . . . . . . . . . 457

23 Women and Violence . . . . . . . . . . . . . . . . . . . . . . . . 477

24 Psychological Aspects of Lesbian Health Care . . . . . . 549

26 The Male Perspective . . . . . . . . . . . . . . . . . . . . . . . . 585

27 Collaborations Between Psychiatry and

28 What Is a Minority? Issues in Setting and Dialogue . . 611

Barbara L. Andersen, Ph.D.

Sheila B. Blume, M.D., C.A.C.

Olga Brawman-Mintzer, M.D.

Linda Hammer Burns, Ph.D.

Melanie L. Carr, M.D., F.R.C.P.C.

Corinna E. Dan, R.N., B.S.N.

Diana L. Dell, M.D., F.A.C.O.G.

Jennifer I. Downey, M.D.

William B. Farrar, M.D.

Mindy Thompson Fullilove, M.D.

Paula J. Adams Hillard, M.D.

Margaret F. Jensvold, M.D.

Irving G. Leon, Ph.D.

Laura J. Miller, M.D.

Jan Moore, Ph.D.

Michael F. Myers, M.D., F.R.C.P.C.

Carol C. Nadelson, M.D.

Malkah Tolpin Notman, M.D.

Robert O. Pasnau, M.D.

Diane A. Philipp, M.D., F.R.C.P.C.

Gail Erlick Robinson, M.D., D.Psych., F.R.C.P.C.

Marcia Russell, Ph.D.

Kathleen Blindt Segraves, Ph.D.

Robert Taylor Segraves, M.D., Ph.D.

Barbara B. Sherwin, Ph.D.

Dawn K. Smith, M.D., M.S., M.P.H.

John F. Steege, M.D.

Donna E. Stewart, M.D., D.Psych., F.R.C.P.C.

Nada L. Stotland, M.D., M.P.H.