And Thinking About The Sexes….

A woman on our board has made us rise above the fray.

Struggle of The Sexes

“Chodorow sees gender differences as compromise formations of the Oedipal complex. She begins with Freud’s assertion that the individual is born bisexual and that the child’s mother is its first sexual object. Chodorow, drawing on the work of Karen Horney and Melanie Klein, notes that the child forms its ego in reaction to the dominating figure of the mother. The male child forms this sense of independent agency easily, identifying with the agency and freedom of the father and emulating his possessive interest in the mother/wife. This task is not as simple for the female child. The mother identifies with her more strongly, and the daughter attempts to make the father her new love object, but is stymied in her ego formation by the intense bond with the mother. Where male children typically experience love as a dyadic relationship, daughters are caught in a libidinal triangle where the ego is pulled between love for the father, the love of the mother, and concern and worry over the relationship of the father to the mother. For Chodorow, the contrast between the dyadic and triadic first love experiences explains the social construction of gender roles, the universal degradation of women in culture, cross-cultural patterns in male behavior, and marital strain in the West after Second Wave feminism. In marriage, the woman takes less of an interest in sex and more in the children. Her ambivalence towards sex eventually drives the male away. She devotes her energies to the children once she does reach sexual maturity.”http://en.wikipedia.org/wiki/Nancy_Chodorow

This will be our discussion in class  on Friday. Do women have harder lives? According to Dr. Chodorow, yes, indeed, beginning with the Oedipal challenge of falling in love with her father, still intensely in love with her mother, and feeling perpetually torn, leading to the future torn feeling between her husband and her own children. The girl, unlike the boy, can never experience the bliss of a dyadic relationship, as it is challenged by a third-party. The boy, by contrast, can love his mother, admire his father, find a wife, and seamlessly go from one dyadic relationship to another. This Oedipal challenge leaves a girl to experience intense guilt for having a firmer alliance in one direction and not another. So many marriages teeter with the challenge of raising children because the husband, often gets demoted. Second marriages are often about husbands yearning and seeking for the time in his first marriage where he felt like he really mattered, instead of feeling like he was a wallet. How does a woman, expend energy on raising children, while still ensuring that her husband is narcissistically gratified. One could say that husbands should not need this narcissistic gratification from his wife and that he should embrace his new role as a father, but if the dynamics of a marriage are such that the wife makes her husband feel that he is the center of her universe, it would be quite ambitious to think that the husband can gently leave that perch?

Clarene, twenty-seven, is quite tight with her mother, loves her father, and lives with her boyfriend, Stan, much to the dismay of her father, but not her mother. Clarene’s mom likes Stan because he is caring and kind to Clarene. By contrast, Clarene’s dad feels that Stan is not “good enough” but then again, when pressed, Clarene says no one would be “good enough.” “He does not want me to separate from him,” Clarene says, wanting me to know that Clarene’s point of view is that she is “daddy’s little girl” and Stan interferes with that dynamic. Knowing this, however, Clarene is still torn between pleasing Stan and pleasing her father, in a way that might remind her of her childhood when she could not please both parents at the same time. When she did well in school, her mother was proud, but her father said she could do better. Clarene painfully recalls the multitude of times when she wanted to make her dad happy, but she never felt she did. Clarene’s brother, Eliot, never seemed to care if he made his dad happy. Eliot only cared what his mother thought of him, and yet he admired his dad a great deal, according to Clarene. This difference between Clarene needing to please all, whereas Eliot was more narrow in his “love-objects” gives Clarene, and hence all women, in general, according to Dr. Chodorow, the burden of needing consensus among her loved ones. Dr. Chodorow would say that as long as women take care of their children, girls’ lives will always be more complicated by this ever-pressing guilt involved in pleasing one, but not the other. This explains how girls, from a young age, form groups, where the dynamics are critical, whereas boys, focus on activities where slights tend to be less felt or noticed. This long history of emotional complexity may explain why girls migrate towards helping professions, understanding the push and pull of relationships.

 

See also…http://www.latimes.com/nation/nationnow/la-na-nn-pew-moms-exhausted-dads-20131007,0,2841039.story

Dorothy Holmes PhD

 

 

 

http://newcenterforpsychoanalysis.org/edu-event.asp?id=339&month=9&year=2013&the_type=Course

 

Dorothy Holmes PhD is an African American, female, senior psychoanalyst from Bluffton, South Carolina who speaks with the openness and honesty of her unique demographic, in a world, when she trained, was dominated by Caucasian men. She asked her analyst how he could possibly understand what a black woman goes through, and by her report, he responded that he was not going to interfere with her feelings of being alone in the world. This, she tells the audience, is what kept her going. She had a space to express how she perceived that her life must be hard to understand, based on her gender and her race, but predictably, she came to see that there is a sense of common humanity if people extend their imaginations into the other’s subjectivity. I asked her about racial relations in the South, and she kindly told me that I was projecting. “Projecting what?” I asked, worried that I had stepped over a racial line. She did not quite answer my question, but I assumed she meant that hatred is everywhere and that I wanted to believe that somehow, Los Angeles, was more tolerant than Bluffton. In fact, I do want to believe that, but it also may be true, and I was wondering about her experience as a Black woman in the South. At the same time, I recognize that my curiosity about racial relations and its geographic differences, is not necessarily something she wants to speak about. She then goes on to talk about how her patients assume she grew up poor, when in fact, she did not. Her relaxed nature in talking about this discrepancy was refreshing. How people came to assume her economic background could be prejudice, ignorance, and/or their own need to see her as a rags to riches story. I felt like she was an immigrant to our Westside culture. She could speak our psychoanalytic language, while at the same time, she could speak to issues of race and gender, which we, who live, in what feels like a more tolerant place, do not understand. The conclusion was the old saw. Deep listening transcends race, gender and economic situations.

Thinking About Feminism

I started medical school in 1986, a year in which there was a quota for women. The class had to be 33% female. Now, medical schools are 50%, without a quota. How did this change take place, in, what feels to me, to be such a short period of time? The answer is the second wave of the women’s movement, http://en.wikipedia.org/wiki/Feminist_movement,

“Amongst the most significant legal victories of the movement after the formation of NOW were a 1967 Executive Order extending full Affirmative Action rights to women, a 1968 EEOC decision ruling illegal sex-segregated help want ads, Title IX and the Women’s Educational Equity Act (1972 and 1974, respectively, educational equality), Title X (1970, health and family planning), the Equal Credit Opportunity Act (1974), the Pregnancy Discrimination Act of 1978, the illegalization of marital rape(although not illegalized in all states until 1993 ^[26]), the legalization of no-fault divorce. A 1975 law requiring the U.S. Military Academies to admit women, and many Supreme Court cases, perhaps most notably Reed v. Reed of 1971 and Roe v. Wade of 1973. However, the changing of social attitudes towards women is usually considered the greatest success of the women’s movement.”http://en.wikipedia.org/wiki/Second-wave_feminism,

These politics allowed me to have my profession, and yet, although I was aware there was a quota, and that made me joke with many of my female classmates that we should get shirts which said  “we would have gotten in, if we were men,” I still did not have the perspective that I was benefiting from my foremothers. In fact, I had issues with the women’s movement. I felt that the demands on women were too great. It was not possible to work one hundred hours per week and have a family. I mean it was physically possible, but emotionally quite taxing. There was a never-ending feeling of not doing enough. The blending of work and domestic life was challenging, and although there was a generation of women before me who served as examples, the medical training system, at the time,  was male dominated and so role models were hard to find. Although working with people, for so many  hours, can create deep friendships, I envied the women at home who could have tea with their neighbors, and spend hours getting to know each other. It seemed that the women’s movement forgot about the value of female friendships, which served to create a network of closeness and warmth which is tremendously valuable to women, to society, and to families.  On the other hand, I cannot imagine women not having the opportunity to go to professional schools, so I owe my foremothers a debt of gratitude. Having said all that, I resonate with Debora Spar, http://www.glamour.com/inspired/2013/08/why-women-cant-have-it-all-according-to-barnard-college-president-debora-l-spar, who says that women cannot have it all. Each choice involves a loss of other possibilities, as every maturing adult realizes, who has to choose a path in life. The women’s movement felt to me to be misleading, but perhaps it represented an idealization, which, inevitably, as time goes by, becomes more like everything else in life-a step forward, but still a compromise.

See also…https://shirahvollmermd.wordpress.com/2010/01/23/the-pathology-is-political/

Reposting: In Honor of Margaret Thatcher’s Passing: “The Iron Lady”- Feminism and Love-Together At Last

‘Iron Lady’ is a remarkable film, layered with so much of life’s challenges and disappointments. Meryl Streep did an Oscar worthy performance as a remarkable female leader in a man’s world, supported by the love affair with her husband, with the background music from ‘The King and I’. What is remarkable about this film is that a life unfolds in a messy way. There is the young Margaret Thatcher. There is the powerful and confident Margaret Thatcher. There is the smitten Margaret Thatcher. And sadly, there is the elderly, deteriorating Margaret Thatcher. The richness of seeing these various stages of life makes this a movie that I imagine only appeals to a more mature audience in that one has to appreciate what it is like to look back on so many chapters of one’s life, with both clarity and haze. There is also the wonderful thread of a woman succeeding in a man’s world, with conviction and confidence which seems almost magically based. It is not clear from the film how she was able to be so tenacious. What I loved most about the film was watching a woman trailblaze British government, while at the same time maintaining a deeply meaningful relationship with her husband. So often, movies depict lives in which one chooses one or the other: ambition or love. The title “The Iron Lady” does not speak to a woman capable of caring for another, but that is the delight of the movie-indeed the delight in life. The idea that Margaret Thatcher hit that delicate balance between work and home, gave me great admiration for her. The movie also depicts her sunset years, which are both terrifying and rich with memories. Those scenes are hard to take, yet they give us perspective on the arc of life. Ms. Thatcher, ‘The Iron Lady,’ has had quite the arc.  The music from “The King and I” pointed to the great irony, that she was the “King” and yet, she loved the dance. “The Admirable Lady” might be a better name for this movie.

Mad Men

“Mad Men,” the title of a hit television series plays on words “ad men” which is the center of the story, set in the 1960s, where smoking, drinking and womanizing are part of the everyday workings of an advertising agency. I am intrigued by their choice of the word “mad” in the title, as the association with mental illness catches my ear. In the last episode of this season (no spoiler, I promise), a woman is placed in a mental hospital in order to “control” her mind, according to one of the partners, Pete Campbell. His rage about this action gives heart to his otherwise heartless and sad character. It is fascinating also that the title is “Mad Men” as opposed to women, implying that only the men are relevant to this story. The women are mere accessories. Yet, the women, including the Sally, the daughter of Don Draper, the main character, give spice to the drama of men running an advertising agency with ruthlessness and charm. The women add a sense of a previously persecuted gender which is now on the verge of developing self-assertion and personal power. The men are “mad”, but the women are moving towards more sanity, thereby making the men less “mad”, or so I hope the future seasons demonstrate.

Gender Gap

Psychiatry, particularly child psychiatry, is a female-dominated profession. Although I don’t have statistics handy, over the last twenty years, more than 50% of the trainees have been women. In this year’s fellowship program at UCLA there are six women and one man. In the incoming class at UCLA the gender distribution is the same. Yet, when I go to administrative meetings of the voluntary clinical faculty, I am the only female in the room, besides the administrative assistant. “The women have kids,” the chair of the committee says glibly, as if that explains why the women do not attend. I have a different take. Men feel more of a fellowship at these leadership meetings, whereas women might feel them to be cold and empty, especially when compared to chatting with a girlfriend, or hanging out with a dear family member. It seems to me that as men and women have different brains, they have different signals of pleasure. Going up a professional ladder might be more inherently rewarding for most men, but not for most women. Of course, there are outliers, but I am speaking about the folks under the large part of the bell curve. Regardless, I am lonely at these meetings because I feel like an outlier. Any time one’s brain does not match one’s peers, isolation ensues. The gender gap is yet one more example of the importance of neurobiology. That is what makes sense to me.

Re-Posting Since I Did A Repeat Performance: Teaching about Anorexia Nervosa

        “The young woman is looking for some sort of control over her life,” I say to fourth-year medical students, as a way to help explain the self-destructive behavior that might underlie Anorexia Nervosa. “What does she say when you ask her about how it feels to have control over her life by not eating,” an eager, soon to be primary care physician asks me. “Well, she would deny the experience. She would say that she does not have a problem; that her parents are overly concerned and they always have been. Her denial of her problem, stimulates a question about what is going on, on a deeper level of her brain. This leaves us, the clinician, to speculate that it is possible that on an unconscious level, there is a positive affirmation in her starvation, in her ability to control her bodily urges.” I say, wondering if these future physicians are looking at me glassy-eyed because they are tired or because I am not explaining the unconscious very well, or both. “So, what is a primary care physician supposed to do?” Another eager and enthusiastic fourth-year medical student, interested in Internal Medicine, asks me. “Well, as with so many complicated diseases, the primary care physician, needs to shepherd the patient through the health care system. The patient will need monitoring of her electrolytes, her weight, her blood pressure. She will also need to see a nutritionist, along with, a mental health provider. The primary care doctor needs to coördinate care; provide the patient with a “medical home,” the new buzz phrase. The student looks at me with recognition, maybe a little embarrassment that the answer was obvious, and yet because we are dealing with mental health issues, the clarity of the situation gets blurred.

      I am back to wondering my age-old question. Do medical students, our future physicians, need to understand human behavior? If so, what is the best way to teach them? If not, should their psychiatry curriculum be limited to psychopharmacology? My answer is clear. A major challenge in being a physician is to help people, help themselves. Understanding how patients get in their own way is critical to helping all patients stay on a good path. This seems both obvious and neglected.

45 Year Old Female, Single, Never Married: Is Something Wrong?

       Marjorie, forty-five, pretty, financially successful, smart, from a stable family, never married, often encounters “you are so lovely, why are you not married?” Together, we dissect this comment as both an insult and a compliment.  “Why do I have to be married?” Marjorie wonders aloud. “Why does that prove to people that I am normal?” Again, Marjorie ponders the assumptions that her friends and family make when they offer up their thoughts about her life. “Is marriage somehow the crown jewel?” She asks. I began to think about gender, knowing that many people in Marjorie’s world would probably say the same thing to a man, so this issue of marriage as the stamp of “normal” does not seem to be gender specific. At the same time, a single woman experiences a certain prejudice; a feeling that she is defective because she does not have a husband. Marjorie explains to me that if a woman is married, friends and family do not need to “worry”. The quality of the marriage seems to be less important  then the fact of the marriage. Similarly, a single woman might have a great support system, but this issue does not fall in the radar of being “OK”. I tend to think that Marjorie’s well meaning friends and family want her to be happy; in their worlds,  happiness comes with a family. A family begins with a marriage. I can see that, but I can also see that there are other ways to find happiness in the world. Marjorie is not so sure.

Women, Moods and Their ObGYNs

     Heidi, twenty-nine, suffered painful feelings of guilt and inadequacy after the birth of her first child. Eventually, she felt more confident, but then after the birth of her second child, she had a recurrent postpartum depression. On a routine postpartum visit to Dr. Little,  her obstetrician, she explains her mental difficulties of handling her two children. By Heidi’s report, Dr. Little hands her a prescription for Zoloft 50 mg, a one-month supply with three refills. “Time to blog” I immediately think to myself. “Should I call Dr. Little?” I wonder. “What would I say?” I could try to get more history on Heidi. Maybe I should educate her about prescribing psychotropic medications and the importance of good follow-up. Perhaps I should say that medication, especially in the post-partum period needs to be given along with psychotherapy. Then, I think, maybe I could give a Grand Rounds presentation to the OBGYN departments at local hospitals, entitled “Medicines for the Female Mind.”

     As I learn more about Heidi’s history, I continue to wonder about Dr. Little. How did she learn how to prescribe SSRIs? Was she trained by a psychiatrist? How does she think they help her patients? Why would she give Heidi so many refills? Why would she, (again, according to Heidi) not refer her for psychotherapy? Did she get any training on the importance of the mother-child relationship? Does she appreciate the value of a good attachment in terms of primary prevention of mental health issues in the child? Is she open to learning more about maternal bonding?

    I wondered what Heidi thought about receiving a mood altering medication from her obstetrician. “She is a great doctor” Heidi tells me. Heidi appreciates that she can receive Zoloft from Dr. Little since she does not have to have the “shame” of seeing a psychiatrist. “If it were up to me I would not take any medication,” she tells me. “Who is it up to?” I ask. “Well, that is not what I meant. I meant that I wish I did not have these problems.” “I can understand that” I reply.

    I wondered if Dr. Little colluded with Heidi’s wish to minimize her psychological pain by “medicalizing” her suffering such that, as with hypertension,  the doctor prescribes a medication, gives multiple refills, and then briefly checks on the condition many months out.   Mental suffering is hard to contend with, both by the sufferer and the observer. Women who struggle after they give birth are doubly stigmatized. Society looks at all women as if they are made to have babies, and hence a newborn should make the mother happier than she has ever been. When a mom feels depressed after giving birth, the shame of depression is compounded by the shame of not enjoying her child. The depth of this shame, layered over the depth of despair, layered over multiple hormonal changes, layered over changes to the family structure, can be profound. Psychotherapy, along with medications, are the mainstay of treatment for these complex feeling states. Dr. Little, I hope you are reading this.