The Diagnostic Statistical Manual (DSM) is the mental health “encyclopaedia” that clinicians consult when diagnosing patients. The fifth version will be released in May 2013, after over 10 years of preparation. Previous iterations of the DSM have been criticized for not being sensitive enough to gender differences, despite findings that show that mental illness is often expressed differently in men and women.
This “gender blindness” is one of the factors responsible for misdiagnoses, ultimately causing a misalignment between treatment needed and treatment received. Hopes are that that the DSM-5 will address some of the alleged gender bias in the previous version. Nevertheless, mental health professionals are divided as to whether the proposed changes will be enough to eradicate the bias we have been observing in the mental health field.
Dr. Joy Johnson, scientific director at the Institute of Gender and Health and professor of nursing at the University of British Columbia, explains that some disorders have been profiled as primarily male- or female-related. “Anorexia nervosa is one,” she says. “Men also experience it and are being inappropriately treated because programs are not being set up to the same extent [as they are for women].”
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Johnson also cites depression as a key example of gender bias in the diagnosis of psychological disorders. She explains that the current profile for depression is based on a female model. “We know that a lot of our measures and criteria are not sensitive enough to the way that men experience depression.” This could be responsible for the higher rates of depression diagnosed among females. In other words, our very definition of depression — the symptoms that clinicians look for to give a diagnosis — may be set up such that women are more likely to display its symptoms .
Not all mental health professionals agree that gender bias exists within the definitions of mental illnesses. “They’ve actually done a very good job at this point to ensure that gender bias does not occur,” says Dr. Valerie Taylor in reference to the community involved with revising the DSM. Taylor is the psychiatrist-in-chief at Women’s College Hospital, and a professor of psychiatry at the University of Toronto.
Taylor’s concern, rather, lies in how clinicians’ interpretation of the DSM and their decisions regarding treatment may be unintentionally biased by stereotypes. She explains that women are more likely to be prescribed antidepressant medication than men, which, she says, speaks to clinicians’ bias and not necessarily bias found in the DSM. Taylor suggests that women may sometimes be seen as more fragile, with worse coping skills than men, and thus more in need of psychiatric medication. She proposes that this issue could best be resolved by better education for clinicians in how to properly apply the DSM.
Johnson agrees that the solution to bias on the part of clinicians is to raise awareness. “When you get up to the Empire State building, two inches away, you can’t see it,” she says. “Gender is like that. You have to step back and see how it is shaping the way all of us interact and understand our social world.”
So what changes are on the table for the next version of the DSM? One proposed change is the reorganization of personality disorders, including the removal of “histrionic personality disorder,” which is supposedly primarily geared towards women.
Taylor explains that some personality disorders are biased towards a certain group and incorporate traits that are not necessarily dysfunctional. “You don’t want to pathologize that behaviour,” she explains. Taylor emphasizes that the ultimate crux of the DSM is that for something to be considered a disorder, it has to be causing problems for someone. “You can be as unique as you want to be. It is fine if there is no distress.”
It is unclear whether additional changes to the DSM will have an impact on gender bias or whether advancements regarding this issue will be restricted to personality disorders. But those responsible for the new edition of the manual have access to a fresh summary of gender and cross-cultural issues associated with various mental disorders.
A special study group convened early in the revision process of the DSM-5 wrote a book that identifies differences in symptoms, symptom severity, and course of illness across gender and ethnicity. “That was a very nice first step,” says Dr. Donna Stewart, chair of Women’s Health at University Health Network and University of Toronto. “It remains to be seen how much of the DSM-5 will reflect that.”
Stewart’s greatest concern with the current draft of the DSM-5 is the proposed inclusion of a new disorder called “Premenstrual Dysphoric Disorder” (PMDD). PMDD refers to psychiatric symptoms that consistently occur around the period of the menstrual cycle. The concern is that PMDD may not be a unique disorder so much as a form of depression that worsens around the time of menstruation. Stewart fears that the inclusion of this disorder has the potential to stigmatize women. “If you say that a percentage of women are incapacitated every month, it logically adds to the stigma of women occupying certain positions.”
Stewart’s approach to PMDD is a controversial one. Taylor cites PMDD as an example of a disorder that is not gender-biased but could easily be misconstrued as such; it must be well explained so that it is not confused with normal symptoms of Premenstrual Syndrome, or “PMS.”
Similarly, Johnson explains that because of their physiological makeup, there might be certain types of diagnoses that only apply to men or women, and that PMDD may be an example of this. She stresses that these differences are not what we are referring to when we speak of gender bias, and likens them to those we observe with other medical illnesses, such as prostate cancer. But she cautions against the medicalization of women’s menstrual cycle and PMS. “When are there true differences and when are those differences being socially constructed?” she asks. “Those are hard differences to tease apart.”
Some questions remain unanswered. Is the difference in prevalence of certain disorders between men and women real or an artefact? Where there is bias, is its source our definition of a disorder, or the clinicians’ interpretation? To untangle this daunting complexity, gender bias demands the attention of researchers. Fortunately, an increasing number of studies on mental illness are being broken down by sex, and these studies are coming to the attention of clinicians through conferences, workshops, and study groups like the one assembled for the creation of the DSM-5.
The goal is unanimous: mental health professionals should be equipped to properly identify the presence of mental illness and recommend the appropriate treatment. A lot has been accomplished since the days when female hysteria was a common diagnosis, but it may be too optimistic to suggest that the end of gender bias in medicine will come in May 2013 with the publication of the DSM-5.
