Tuesday, August 22, 2017

A Feminist Neuroethics of Mental Health

By Ann E. Fink

Ann Fink is currently the Wittig Fellow in Feminist Biology at the University of Wisconsin–Madison, with an appointment in Gender and Women’s Studies and concurrent affiliations with Psychology and the Center for Healthy Minds. Her research in cellular and behavioral neuroscience has appeared in the Journal of Neuroscience, Journal of Neurophysiology, PNAS and other journals. Ann’s interdisciplinary work addresses the ethics of neuroscience in relation to gender, mental health and social justice. 

Emotionality and gender are tied together in the popular imagination in ways that permeate mental health research. At first glance, gender, emotion, and mental health seem like a simple equation: when populations are divided in two, women show roughly double the incidence of depression, anxiety, and stress-related disorders1-3. Innate biological explanations are easy to produce in the form of genes or hormones. It could be tempting to conclude that being born with XX chromosomes is simply the first step into a life of troubled mood. Yet, buried in the most simplistic formulations of mental illness as chemical imbalance or mis-wiring is the knowledge that human well-being is a shifting, psychosocial phenomenon. Learning and memory research offers a treasure trove of knowledge about how the physical and social environment changes the brain. Feminist scholarship adds to this understanding through critical inquiry into gender as a mode of interaction with the world. This essay explores how a feminist neuroethics framework enriches biological research into mental health. 

Problems with “Biology-from-birth” stories 
What if understanding gender and health isn’t a tale of two gonads (or genitalia, or chromosomes)? The primary theoretical problem with applying binary biology to health is essentialism4,5, an oversimplified view of gender as comprising two distinct groups of people separated by innate and static biological traits. Feminist neurobiology counters this view with the observation that gender, a complex biopsychosocial phenomenon, cannot be reduced to dimorphism. This is illustrated by work from neuroimager Daphna Joel indicating that brains (unlike most genitalia) live happily in the land of intersex. Joel proposes a “brain mosaic”: human brains are a hodgepodge of statistically “male”-biased, “female”-biased, and neutral characteristics, rather than reflecting two categories6. Similarly, psychologist Janet Hyde demonstrates that genders are more alike than different in most cognitive and behavioral characteristics7.

The different components of biological sex.
Image courtesy of Wikimedia Commons.
What about those characteristics that differ by crude biological measures of sex? To ignore binary health disparities could be irresponsible. This reasoning precipitated the 2015 NIH mandate to study “sex as a biological variable”8, a corrective for the exclusion of “female” tissues and organisms from prior biomedical research. This move has in turn raised questions about what it means to properly study sex, and what, if anything, such research has to do with gender9,10. The problem: sex and gender represent complex, interacting outcomes of social and biological forces. The first danger of essentialism is, therefore, to scientific knowledge in its own right. Other potential forms of harm then emerge from this oversimplification.

One danger of “biology-from-birth” stories is the possibility of iatrogenic (arising from medical care) disparities in health arising from inappropriate treatment differentials. As an example9,10 the hypnotic drug zolpidem is cleared more slowly, on average, from women’s bodies compared to men’s, leading to concerns about inappropriate dosing. This gender difference, however, is mediated by weight, which correlates with gender. Potential harm and benefit emerge from this example. Dosing by gender risks overdosing men who weigh less than average, and ineffectively dosing women who weigh more than average. To base decisions on gender, rather than directly predictive indicators, in such cases might constitute negligence. This concern is amplified for people who do not fit neatly into binary categories of sex/gender.

Mental illness labels raise unique questions about autonomy and psychological competence. Furthermore, the definition of psychological disorders is particularly entangled with gender roles. Innate biological explanations risk activating stigma11 by framing mental illness as static and disqualifying, and equating susceptibility with inferiority. The interactions of gendered stigma and mental health stigma can also deliver a double-hit of marginalization12. The medico-social risks of stigma and assessments of incompetence include undermined consent, patient autonomy, and bodily integrity, as seen, for instance, in the dismal and ongoing justification of coerced sterilizations (tellingly, first labeled “asexualization”13). In a more subtle example, one suspected reason for women’s disproportionate cardiovascular mortality is their more frequent referral to psychiatrists than cardiologists (e.g. [14]).

Image courtesy of Wikimedia Commons.
If essentialist categories of identity and mental illness pose a threat to the health and autonomy of pathologized groups, a related risk is the justification of ongoing inequities and violence in larger social structures. Early-life maltreatment and lifelong adversity are major additive risk factors for poor psychological and physical health15,16; these vary by gender and other aspects of social identity17,18. Economic instability follows suit: a 2016 study links the gender wage gap to mood disorders19. To willfully ignore gendered, racialized or otherwise targeted harm in assessing health risk is to tacitly condone such harm. A feminist neuroethics recognizes the need to address social causes of biological susceptibility. 

The future of gender, neurobiology and mental health 
Feminist neurobiology avoids the pitfalls of simple, untenable “biology-from-birth” explanations. Rippon et al.’s guidelines for sex/gender research in neuroimaging4 are broadly applicable: their framework takes into account gender similarities (“overlap”) and brain mosaicism, recognizing brains as the ever-changing material substrates for equally dynamic mental states and social interactions (“entanglement”). They also call for improved experimental design, analysis20, and interpretation. Feminist neuroethics respects historicity in science, acknowledging prior harm and proposing restorative and protective measures21. Feminist ethics can also protect against other forms of biological essentialism, including deterministic concepts of mental capacity. In agreement with philosopher Helen Longino’s formulation of science as a social endeavor requiring participation by a representative community22, feminist analyses acknowledge that mental health represents a continually debated set of norms.

Finally, a feminist neuroethics incorporates social causality and responsibility into biobehavioral health. Its guiding principle is a sustained attention to the problems of power, violence, and inequality that are so readily buried in reductionist research models. This view adds to mental health research by asking: 1) what interventions curb the staggeringly gendered experience of sexual and intimate partner violence23 or the exposure to stress and deprivation that contribute to both social stratification and mental illness?, and 2) what are the neurobiological effects of, and remedies for, marginalization and interpersonal violence? (for starters, see: 24-26). A feminist neuroethics invokes biology as an enquiry into a dynamic world, embraces ambiguity, and promises a more nuanced and valuable knowledge of human health. 

References

1. Altemus, M., N. Sarvaiya, and C.N. Epperson. 2014. Sex differences in anxiety and depression: clinical perspectives. Frontiers in Neuroendocrinology 35(3): 320-330. 

2. Steel, Z., C. Marnane, C. Iranpour, et al. 2014. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. International Journal of Epidemiology 43(2): 476-93. 

3. Kessler, R. C., P. Berglund, O. Demler, et al. 2005. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):593–602. 

4. Rippon, G., R. Jordan-Young, A. Kaiser, and C. Fine. 2014. Recommendations for sex/gender neuroimaging research: key principles and implications for research design, analysis, and interpretation. Frontiers in Human Neuroscience 8: 650. 

5. Haslam, Nick, and Jennifer Whelan. 2008. Human natures: Psychological essentialism in thinking about differences between people. Social and Personality Psychology Compass 2, no. 3 (2008): 1297-312. 

6. Joel D, Berman Z, Tavor I, et al. (2015) Sex beyond the genitalia: The human brain mosaic. PNAS 112(50): 15468-15473. 

7. Hyde, J.S. 2005. The gender similarities hypothesis. American Psychologist 60: 581-592. 

8. Clayton, J. A., and F. S. Collins. 2014. Policy: NIH to balance sex in cell and animal studies.  Nature 509 (7500):282-3. 

9. Richardson, S. S., M. Reiches, H. Shattuck-Heidorn, et al. 2015. Opinion: Focus on preclinical sex differences will not address women's and men's health disparities.  Proc Natl Acad Sci USA 112 (44):13419-20. 

10. Ritz, S.A., D.M. Antle, J. Cote, et al. 2014. First steps for integrating sex and gender considerations into basic experimental biomedical research. The FASEB Journal 28: 4-13. 

11. Rusch, N., A. R. Todd, G. V. Bodenhausen, and P. W. Corrigan. 2010. Biogenetic models of psychopathology, implicit guilt, and mental illness stigma. Psychiatry Research 179(3): 328 – 332. 

12. Koenig, Anne M., and Alice H. Eagly. 2014. Extending Role Congruity Theory of Prejudice to Men and Women With Sex-Typed Mental Illnesses. Basic & Applied Social Psychology 36 (1):70-82. 

13. Stern, A. M. 2005. Sterilized in the name of public health: race, immigration, and reproductive control in modern California.  Am J Public Health 95 (7):1128-38. 

14. Maserejian, N. N., C. L. Link, K. L. Lutfey, et al. 2009. Disparities in physicians' interpretations of heart disease symptoms by patient gender: results of a video vignette factorial experiment.  J Womens Health (Larchmt) 18 (10):1661-7. 

15. Cohen, S., D. Janicki-Deverts, and G. E. Miller. 2007. Psychological stress and disease.  JAMA 298 (14):1685-7. 

16. Felitti, V. J., R. F. Anda, D. Nordenberg, D. F., et al. 1998. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.  Am J Prev Med 14 (4):245-58. 

17. Berger, M., and Z. Sarnyai. 2015. "More than skin deep": stress neurobiology and mental health consequences of racial discrimination.  Stress 18 (1):1-10.  

18. Westfall, N. C., and C. B. Nemeroff. 2015. The Preeminence of Early Life Trauma as a Risk Factor for Worsened Long-Term Health Outcomes in Women.  Curr Psychiatry Rep 17 (11):90. 

19. Platt, J., S. Prins, L. Bates, and K. Keyes. 2016. Unequal depression for equal work? How the wage gap explains gendered disparities in mood disorders.  Soc Sci Med 149:1-8. 

20. Fine, Cordelia, and Fiona Fidler. 2015. Sex and Power: Why Sex/Gender Neuroscience Should Motivate Statistical Reform. In Handbook of Neuroethics, ed. Jens Clausen and Neil Levy, 1447-1462. 

21. Chalfin, M. C., E. R. Murphy, and K. A. Karkazis. 2008. "Women's neuroethics? Why sex matters for neuroethics."  Am J Bioeth 8 (1):1-2. 

22. Longino, Helen E. 1990. Science as social knowledge : values and objectivity in scientific inquiry: Princeton, N.J. : Princeton University Press. 

23. Smith, S.G., J. Chen, K.C. Basile, L.K., et al. (2017). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Downloaded on 8/4/2017 from https://www.cdc.gov/violenceprevention/nisvs/summaryreports.html 

24. Sapolsky, R.M. (2005) The Influence of Social Hierarchy on Primate Health. Science 308 (5722):648-52.  

25. Cacioppo, JT et al. (2011) Social isolation. Annals of the New York Academy of Sciences, 1231: 17–22. 

26. Hackman, DA et al. (2010) Socioeconomic Status and the brain: mechanistic insights from human and animal research. Nat Rev Neurosci 11(9): 651 – 659.


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Fink, A. (2017). A Feminist Neuroethics of Mental Health. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/08/a-feminist-neuroethics-of-mental-health.html

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