To the Editor: We applaud the call by Sally L. Satel (1), in her editorial in the May 1998 issue, to move women's mental health into the mainstream of psychiatric research. We agree that "both women and men deserve the best psychiatry can offer." We too would be dismayed if we felt medical research that directly addresses women would marginalize women's medical needs. However, we feel that direct attention to gender is necessary for quality clinical care in psychiatry.
Since 1993, medical schools have been required to include women's health in their curricula, and more attention should be directed to women's issues as a result. In psychiatric research in particular, specific attention to gender is imperative to counteract the systematic exclusion of women. For example, women in childbearing years have been routinely excluded from psychopharmacological clinical trials based on the assumption that informed consent did not adequately protect them. Thus standard dosages of psychotropic drugs are rarely adjusted for women's height and weight as compared with males, and side effects are understudied in women.
The discrepancy between rates of diagnosed disorders among women in the general population and those who participate in research is another example of the exclusion of women from research. While 30 percent of individuals with alcohol use disorders are women, they constitute only 8 percent of the participants in alcohol studies (2). Legislation passed in 1991 requiring women to be included in research funded by the National Institutes of Health should help remedy this lack of knowledge regarding women's mental health needs.
Empirical evidence is available to answer many of the important questions posed by Dr. Satel. She suggests that "inherent distortions" exist in women's reports of traumatic experiences and that such reports are sometimes motivated by secondary gain. However, research indicates that childhood sexual abuse is more likely to be forgotten than exaggerated (3), and that women's reports of combat stress are as consistent as the measurement error inherent in psychometric assessment (4).
As for women's perpetration of domestic violence, data show that women often act aggressively against their male partners in self-defense but commit less severe violence and endure far more physical and psychological injury than their partners (5). Dr. Satel suggests that there are disadvantages to single-sex inpatient units; however, improved outcomes have been noted for several disorders, including substance abuse, treated on such units (6).
How can psychiatry make women's mental health mainstream rather than special? Key areas of research and education include the need to focus on conditions unique to women, such as psychological aspects of breast cancer; diagnoses prevalent in women, such as depression; stressors that affect women differently than men, such as violence; and genetic factors, treatment approaches, and barriers to gaining access to care that differ by gender. When these issues become routine components of psychiatric research and services, women's health will not require specialty status.
While Dr. Satel states that the unique needs of women are limited to obstetrics and gynecology, our research agenda asserts that gender differences extend beyond the reproductive function. We argue that the needs of women are marginalized when they are ignored. Differences between men and women do not necessarily make women "special" unless research derived from studies of males is assumed to be the gold standard.
Dr. Kimerling is an adjunct assistant professor in the department of psychiatry at the University of California, San Francisco, School of Medicine and San Francisco General Hospital. Dr. Ouimette is a senior research associate in the department of psychiatry and behavioral sciences at Stanford University School of Medicine in Stanford, California. Dr. Cronkite is a senior research associate in the department of sociology at Stanford. All three are associated with the Center for Health Care Evaluation at the Palo Alto (Calif.) Veterans Affairs Health Care System.