Best of the Neuroethics Blog: A Feminist Neuroethics of Mental Health

Throughout the year, The Neuroethics Blog will be highlighting the most impactful, exciting, and popular posts from our nearly ten-year history.

Today's post is an update by Dr. Ann E. Fink on her piece entitled A Feminist Neuroethics of Mental Health, which was originally published on August 22, 2017 and is republished below.

Image courtesy of Ann Fink.
In the two years since The Neuroethics Blog published A Feminist Neuroethics of Mental Health, the place of gender and sexuality in public discourse and policy continues to evolve, along with the place of neurobiology in mental health knowledge. This update expands on prior definitions of gender/sex and sexuality, catches up with ongoing debates about the NIH's "Sex as a Biological Variable" (SABV) mandate, and reiterates the essay's urgent, real-life implications.

For brevity's sake, the original essay introduced sex/gender at an introductory level and drew on a health sciences literature almost exclusively relying on binary gender (men and women). While the essay highlighted the limitations of this binary, it is also important to note recent work that orients itself explicitly toward the health and well-being of trans and non-binary people (for example, see 1, 2). This prior discussion also did not fully address sexuality as the inextricably gender-entwined construct that it is (e.g. see van Anders' well-considered Sexual Configurations Theory3). These expanded and entangled views on sex/gender and sexuality become indispensable when considering the ethics4 of proposed interventions into identity, "love" and "lust.” 

Within the neuroscientific community, I have been gratified to see more nuanced conversations about gender/sex/sexuality, but much work remains to be done. The NIH's SABV mandate continues to be rightfully debated; biologists navigate between an untenable legacy of (presumably) "all-male" research subjects while skirting the edges of biological essentialism. Shansky5 delivers a thoughtful critique and notes an important problem: the spirit of SABV is too often interpreted as a mandated hypothesis of "sex" difference, grounded in implicit societal notions of a universal biology of sex, and of hormonal "female" difference from a male norm. Among the many problems with this type of implementation is the steady stream of spurious findings it will produce (5% according to current norms for hypothesis testing). Having witnessed this unsteady logic in the grant review process, I suspect that, unchallenged, it will continue to dampen the prospects of researchers who step outside of normative views of gender/sex/sexuality. This also points to a glaring gap in the landscape: the dearth of queer and other marginalized voices in positions of real influence regarding such policies.

Image courtesy of Pixabay.
Finally, the questions of social responsibility raised by the initial post have become even more pressing. Since the peak of the #MeToo movement, some high-profile sexual predators have faced sanction, but many questions remain regarding accountability for widespread sexual abuse and assault by wealthy, powerful people, sometimes at the highest levels of government. The last two years have also seen new legal assaults on trans rights and broader LGBTQ rights in the USA and elsewhere as gender/sex and sexuality, like race, continue to be used as divisive rhetorical tools in a vicious political climate. Recent verbal attacks against four accomplished young women of color in Congress find their roots in tired old stories of human biological categories that fuel tired old patterns of hate. Finally, the US, deplorably, openly, maintains concentration camps at its border, using dehumanizing rhetoric to jail masses of people including refugees seeking asylum from violence. The neuroethics literature has already described how such imprisonment and family separation are the most damaging experiences that young people, in particular, can endure6,7. Reports of sexual assault are common; the experience of trans people in these prisons is reported to be especially "horrific".

Rhetoric matters. Neuroscientists whose work touches on human identity and mental health must face the fact that their work and their words are charged with responsibility for this culture, this time. What does mental health mean to a person holding onto a job under the threat of sexual violence? What does mental health mean in a border prison? There may be good reasons for people in these situations to care about stress physiology and biological definitions of "sex", yet the dangers of reductionism weigh heavy. Scientific researchers, clinicians, human rights activists and gender scholars from the arts and humanities need to talk to each other. They need to be integrated with, and representative of, the population at large. They need to be able to think critically about research, and to place it within a framework of broader social responsibility. They need to think carefully about the deployment of power. Feminist neuroethics, the critical evaluation of identity and power in relation to neuroscience knowledge, is urgently needed in this moment.

References
  1. Donald, C. A., et al. (2017). Queer Frontiers in Medicine: A Structural Competency Approach. Acad Med, 92(3), 345-350. doi:10.1097/acm.0000000000001533
  2. Budge, S. L., Chin, M. Y., & Minero, L. P. (2017). Trans individuals’ facilitative coping: An analysis of internal and external processes. Journal of Counseling Psychology, 64, 12. doi: 10.1037/cou0000178
  3. van Anders, S. M. (2015). Beyond Sexual Orientation: Integrating Gender/Sex and Diverse Sexualities via Sexual Configurations Theory. Arch Sex Behav, 44, 1177. https://doi.org/10.1007/s10508-015-0490-8
  4. Gupta, K. (2012). "Protecting Sexual Diversity: Rethinking the Use of Neurotechnological Interventions to Alter Sexuality." AJOB Neuroscience, 3(3), 24-28. doi:10.1080/21507740.2012.694391
  5. Shansky, R. M. (2019). Are hormones a "female problem" for animal research? Science, 364(6443), 825-826. doi:10.1126/science.aaw7570
  6. Boulware, J. N. (2018). Not Our Problem? The Neuroethical Implications of Youth Detainment. 2018 INS Essay Contest Winner. Retrieved from: http://www.dana.org/INS/essay-2018-scicomm/
  7. Teicher, M. H. (2018). Childhood trauma and the enduring consequences of forcibly separating children from parents at the United States border. BMC Medicine, 16(1), 146-148. doi:10.1186/s12916-018-1147-y                                                                      
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A Feminist Neuroethics of Mental Health

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. 

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Ann Fink, Ph.D., is a neuroscientist, educator and artist. She received her doctorate in Neuroscience from UCLA, and her publications on the neurobiological basis of memory, emotion and mental health  have appeared in the Journal of Neuroscience, Journal of Neurophysiology, PNAS, AJOB Neuroscience, and other journals. Ann’s interdisciplinary work addresses the ethics of neuroscience in relation to topics surrounding identity, mental health, and social justice. She was a prior Wittig Fellow in Feminist Biology at the University of Wisconsin-Madison and is currently a Professor of Practice in the Department of Biological Sciences at Lehigh University.

References
  1. Altemus, M., Sarvaiya, N., & Epperson, C. N. (2014). Sex differences in anxiety and depression: clinical perspectives. Frontiers in Neuroendocrinology 35(3), 320-330. 
  2. Steel, Z., Marnane, C., Iranpour, C., 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., Berglund, P., Demler, O., 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., Jordan-Young, R., Kaiser, A., & Fine, C. (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, N., & Whelan, J. (2008). Human natures: Psychological essentialism in thinking about differences between people. Social and Personality Psychology Compass 2, no. 3, 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 Collins, F. S. (2014). Policy: NIH to balance sex in cell and animal studies.  Nature 509 (7500), 282-3. 
  9. Richardson, S. S., Reiches, M., Shattuck-Heidorn, H., 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., Antle, D. M., Cote, J., 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., Todd, A. R., Bodenhausen, G. V., & Corrigan, P. W. (2010). Biogenetic models of psychopathology, implicit guilt, and mental illness stigma. Psychiatry Research 179(3), 328-332. 
  12. Koenig, A. M., and Eagly, A. H.. (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., Link, C. L., Lutfey, K. L., 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., Janicki-Deverts, D., & Miller, G. E. (2007). Psychological stress and disease. JAMA 298(14), 1685-7. 
  16. Felitti, V. J., Anda, R. F., Nordenberg, D., 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., & Sarnyai, Z. (2015). "More than skin deep": stress neurobiology and mental health consequences of racial discrimination.  Stress 18(1), 1-10.  
  18. Westfall, N. C., & Nemeroff, C. B. (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., Prins, S., Bates, L., & Keyes, K. (2016). Unequal depression for equal work? How the wage gap explains gendered disparities in mood disorders.  Soc Sci Med 149, 1-8. 
  20. Fine, C., & Fidler, F. (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., Murphy, E. R., & Karkazis, K. A. (2008). "Women's neuroethics? Why sex matters for neuroethics."  Am J Bioeth 8(1), 1-2. 
  22. Longino, H. E. (1990). Science as social knowledge : values and objectivity in scientific inquiry: Princeton, N.J. : Princeton University Press. 
  23. Smith, S. G., Chen, J., Basile, K. C., 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, J. T., et al. (2011). Social isolation. Annals of the New York Academy of Sciences, 1231, 17–22. 
  26. Hackman, D. A., et al. (2010). Socioeconomic Status and the brain: mechanistic insights from human and animal research. Nat Rev Neurosci 11(9), 651 – 659.

Want to cite this post?

Fink, E. A. (2019). Best of the Neuroethics Blog: A Feminist Neuroethics of Mental Health. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2019/08/best-of-neuroethics-blog-feminist.html

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