Book Review

Psychological Aspects of Women's Health Care: The Interface between Psychiatry and Obstetrics and Gynecology

N Engl J Med 1994; 330:514-515February 17, 1994

Article

Psychological Aspects of Women's Health Care: The Interface between Psychiatry and Obstetrics and Gynecology
Edited by Donna E. Stewart and Nada L. Stotland. 570 pp. Washington, D.C., American Psychiatric Press, 1993. $64.50. ISBN: 0-88048-421-7

Dr. Stewart is associate professor of psychiatry and obstetrics and gynecology and codirector of the Program in Women's Mental Health at the University of Toronto, and Dr. Stotland is associate professor of clinical psychiatry and obstetrics and gynecology at the University of Chicago. Thus, they have appropriate backgrounds for editing a book on the relation between psychiatric and reproductive health in terms of both training and clinical experience. It is unusual and appropriate that, of the 31 authors, at least 24 are women (the use of initials or unusual names prevents the sex of several authors from being obvious). All the authors have sound credentials for contributing to this highly readable and informative book. The information and research data are up to date.

The editors proposed to pull together, in one comprehensive volume, the most recent knowledge about mental health issues among women who are under obstetrical and gynecologic care. This book is intended particularly for consultation and liaison psychiatrists, but also for obstetricians, gynecologists, and other medical and mental health workers in women's health centers. The topics covered include both normal and problem pregnancies, postpartum disorders, the menstrual cycle, abortion, gynecologic disorders, sexual disorders, breast cancer, domestic violence and sexual abuse, issues in medical ethics, and issues in the medical care of members of minorities. The immense changes that have taken place during the past decade with regard to our understanding of issues of women's health and autonomy are well documented here. It is probably appropriate that the book was written primarily by women, because it provides relatively complete coverage of the patient's point of view that might otherwise have been muted. There is a chapter on the male perspective, appropriately written by a man.

The chapters are not even in length or in their coverage of research, yet all are well worth reading by their intended audiences. The currently salient topic of abortion is well covered by Stotland. This important chapter includes the strong statement of the American Psychiatric Association on abortion and points out that initial fears and assertions about the emotional repercussions of abortion (the hypothesized “abortion trauma syndrome”) have not been borne out. In fact, studies indicate that patients who are denied abortions that are requested on psychiatric or psychosocial grounds, as well as their children, have worse outcomes than control families. The author asserts that restrictive laws punish those already subject to poverty, abuse, and other unfortunate social forces.

A comprehensive chapter on breast disorders and breast cancer (by Andersen and Doyle-Mirzadeh) describes well the patient's distress at the time of diagnosis, the psychological sequelae of treatment, the emotional response to recurrence, and the salutary effects of support groups. They point out the emotional importance of the newer, relatively conservative treatment demanded by women's groups.

One of the longest and most complete chapters is Rose's on sexual assault, domestic violence, and incest. Sexual victimization is clearly linked to post-traumatic stress disorder and various other psychiatric disorders. However, it would be helpful for both liaison psychiatrists and obstetrician-gynecologists to know about the questionable status of the “repressed memory syndrome” and some instances of false reporting for secondary gain.

My only disappointment in the book (a minor one) was with the relatively frequent descriptions of psychoanalytic theory. The theories are quoted by a number of authors, even though they remain unproved, phallocentric, and so denigrating to women that they seem out of place in an up-to-date, scientific, feminist volume. Their inclusion could be compared to presenting, without critique, the Ptolemaic view of the universe in a physics books. For example, chapter 1 describes the pregnant women as increasingly “inward focused” and as exhibiting “heightened passivity” during gestation. One might question such a description after observing a pregnant lawyer in a court trial. Another example from chapter 12, on menopause, quotes Freudian theorists who state that “menopause is `symbolic castration' . . . 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.” However, the author of the chapter later points out that “the fact that this reproductive event is welcomed as a positive event by many women is frequently ignored.”

Many women might benefit from consulting this book for aid in making informed choices in conjunction with their physicians. For example, Sherwin makes a strong case for hormone replacement, based on the “incontrovertible evidence that [this therapy] can protect against degenerative diseases that seriously compromise the quality of life beyond the sixth decade.” She is convincing in her argument that the benefits outweigh the risks for many women.

Ruth G. Matarazzo, Ph.D.
Oregon Health Sciences University, Portland, OR 97201-3098