Special Articles A Psychiatric Residency Curriculum About Gender and Women's Issues Anna M. Spielvogel, M.D., Ph.D. Leah J. Dickstein, M.D. Gail Edick Robinson, M.D., F.R.C.P.C.

On behalf of the Committee on Women of the American Psychiatric Association Over the last 30 years, major advances have been made in our understanding of how biological factors and sociocultural influences contribute to gender differences, gender identity formation, and gendered role behavior. Sensitivity to the psychological effects of changing family structure and work force composition, the contribution of reproductive events, and the high rates of exposure to trauma in women is essential for optimal psychiatric assessment and treatment planning. This knowledge has not been systematically integrated into residency training. The authors present an outline for a curriculum in gender and women's issues, including educational objectives, learning experiences through which residents could meet these objectives, and recommended readings. The authors also discuss p0tential obstacles and suggest helpful strategies for implementing the proposed curriculum. (Academic Psychiatry 1995; 19:187-201)

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ender, along with age and ethnic background, has long been recognized as an important descriptor of patients. Understanding gender differences and the complex factors shaping women's and men's psychological development is helpful in formulating accurate psychiatric assessments and needs to be incorporated into the training of psychiatric residents. What is seen as normative or pathological in gendered role behavior in men and women necessarily will be influenced by the social and cultural context (1). The effects on physical and mental health brought on by profound changes in gender roles, such as an increase of women in the work force (2) and men's increased family participation, is being studied (3-8). ACt\DE:V1K' P5YCHI:\ my

New insight into the differences in psychological development for boys and girls (9,10) and increased awareness of gendered interactional patterns resulting from the power differential between women and men have called previous theories for development Dr. Spielvogel is associate clinical professor, Department of Psychiatry, University of California, San Francisco General Hospital, San Francisco, California; Dr. Dickstein is professor, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Kentucky; and Dr. Erlick Robinson is professor of psychiatry and obstetrics and gynecology, University of Toronto, Ontario, Canada. Address reprint requests to Dr. Spielvogel, Department of Psychiatry, University of California, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110. Copyright © 1995 Academic Psychiatry.

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and psychopathology into question (11-14). For instance, the description of masochism as a component of mature female development (15,16) has been challenged (17,18) and replaced by a more complex understanding of women and their tendencies to exhibit less aggression and accept more caregiving responsibilities than men (19). Women's growth through relationships and their increased ability for empathic connection is described as a strength (20,21) rather than a sign of immaturity or weakness. Women's roles have changed in many ways. More than 60% of women work outside the home, yet women continue to earn approximately 70% of the income earned by men with comparable skills (5). At the same time, men's traditional gender roles are shifting and require new definitions of masculinity and effectiveness (22,23). In classic psychoanalytic theory (24), masculinity is defined by activity, assertion, and independence. The resolution of the Oedipus complex through identification with the father and relinquishment of the boy's erotic attachment to his mother has been postulated to explain these male characteristics. Pleck (25) attributes masculine behavior to a submission to societal pressures, resulting in significant role strain for men. Women's increased participation in the work force, their assertiveness, and their expectation that men participate in family life cannot only cause confusion in men but also open avenues for increased emotional openness (3,26). In addition, the profound effects of culture, race, and socioeconomic status are increasingly acknowledged in descriptions of the psychological development of women and men (27,28).

Several excellent publications (29,30) examine which differences between men and women are biological in nature and which are learned adaptations to role expectations and repeated reinforcement of stereotyped gendered behavior. Many of these different role expectations are unconscious or denied and affect interactions of parents and teach-

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ers with children (13). These same unexamined gender role expectations in society often form the basis for research questions or theories, performance evaluations, or treatment decisions (31-35). Awareness of findings from such research is a prerequisite to evaluate the psychiatric literature objectively and to differentiate studies that have a gender bias from those that are free of gender bias (36). Several sex biases in research have been described (37). First, inadequate sample selection and generalization of findings may occur (e.g., although early clinical trials for most medication excluded women during their reproductive years and at other stages during the life cycle, the results were generalized to all women). Second, questionnaires and instruments often contain sex biases because sex-stereotyped language was used, the testing situation (e.g., high time pressure vs. low pressure situations), the type of tests, (e.g., multiple-choice vs. essay), or inadequate standardization of tests with representative samples. Third, observer bias may lead to negative ratings of performance, characteristics, or mental health of persons who do not conform to gender role expectations (32,33,38-40). Increased interest in correcting the neglect in teaching women's issues is emerging from organized medicine. For example, the Association of American Medical Colleges (41) recently released a publication on "Building a Stronger Women's Program," which describes how a number of medical schools have addressed women's health issues in their curricula. Recognizing that women usually see different physicians (e.g., internists, gynecologists, and psychiatrists) for their currently fragmented health careeven though interrelationships exist between hormonal changes, pregnancy, gender role strain, sequelae from violence, and psychiatric symptoms--a proposal was made to develop a new discipline, Women's Health (42). This proposed approach advocates training of practitioners handling a

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range of issues, including the physical and psychological aspects of women's reproductive life and the diagnosing and treating of complex posttraumatic stress disorders resulting from violence against women. Some fear that such an approach would further marginalize women's health care and its providers (43). Women's health needs can also be addressed by training psychiatrists to incorporate knowledge about women's reproductive life and specific health care issues into their clinical care and to collaborate in an informed manner with primary care providers. Such specialized training on women's issues is already being offered by some psychiatry programs. A preliminary survey of psychiatric residents from the University of California San Francisco (UCSF) indicated that most residents, particularly women, were interested in and would attend additional teaching about women's issues. At the American Association of Directors of Psychiatric Residency Training (AADPRT) Midwinter Meeting, San Diego, in 1993, the results of this survey were presented. The majority of the workshop participants agreed that the topics on women's issues needed to be added to current curricula. In designing a gender and women's curriculum, a number of issues must be considered. Should some courses and clinical experiences focus on women's issues only, or should gender issues always be taught by contrasting men's and women's experiences? Should certain clinical experiences be limited to women residents (e.g., leading groups on eating disorders or early sexual trauma)? Dickstein (44) and Fleming (45,46) describe seminars on women's issues first begun in the 1970s and then later modified to include "the new psychology of women and men" (30, p. 533). Other programs have continued to teach courses only on women's development and life cycle. UCSF offers clinical experiences for psychiatric residents focused on women patients. Residents at ACADEMIC rsYCHlA TRY

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UCSF can, for example, elect to serve as psychiatric consultants to the Women's Health Clinic or train with the inpatient women's issues consultation team. The Committee on Women of the American Psychiatric Association (APA), in consultation with a number of residency training directors, directors of women's mental health programs, residents, and fellows, has adopted this curriculum about gender and women's issues. The educational objectives of this curriculum were presented as part of a workshop at the AADPRT Midwinter Meeting, New Orleans, in 1994. Of the 26 participants, 80% rated the content and clinical applicability of the presentation as excellent. Preparing the curriculum on gender and women's issues, we have reviewed the curriculum on "Homosexuality and Gay Men and Lesbians" (47) and have followed its format. The curriculum is composed of rationale, learning objectives, suggested learning experiences, and a discussion of potential obstacles, as well as helpful strategies for implementing our proposal. The content of this curriculum builds on the work presented in the second conference on "Women's Studies in Psychiatric Education," presented by the Educational Development for Psychiatric Educators Project, January 27-28, 1983, in San Francisco, CA, and on recent reviews of gender and women's issues (28-30,48,49). RATIONALE This curriculum on gender and women's issues for psychiatric residents is based on the premise that accurate information about the development and full range of experiences of women and men should inform training and patient care. Because psychiatry is strongly influenced by sociocultural factors, psychiatric educators must incorporate historical, social, and cultural perspectives when teaching about the psychological development of women and men and the assessment of psychological health or psyIt;'l

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chopathology (1,3,5,29,30). Knowledge of potential gender biases in research (36,37,39) and clinical care (32,34,35,40) and knowledge of gender differences in psychopathology, prevalence (SO), course and treatment outcome (51-59) need to be incorporated into the mainstream of psychiatry. Women comprise the majority of psychiatric patients, and even though the number of publications (20,41,42,48,49) and national conferences on the psychological aspects of women's health care have increased over the last 10 years, many residency training programs still do not systematically incorporate issues specific to the treatment of women patients. Most women will try to become pregnant, yet psychological issues related to pregnancy, infertility, pregnancy loss, or the postpartum period (48) are rarely taught in psychiatric residency training programs. Particular groups of women, stigmatized and neglected for being mentally ill (60-62), substance abusers (63,64), homeless (65,66) or ethnic minorities (27,28) have only recently received attention. Fertility rates of chronically mentally ill women approach those of the general population (67). Specific skills regarding women and pregnancy should be incorporated into mainstream psychiatry and psychiatric residency training and include how to discuss family planning (68); how to evaluate and treat psychiatric symptoms during pregnancy (48, 69,70) and the postpartum (48,71); and how to assess the mothering abilities of psychiatrically impaired women (72). Description of the high prevalence and profound long-term consequences of multiple traumas in women psychiatric patients have only recently appeared in the psychiatric literature (55,56,73-79). The consequences of this body of research for assessment and treatment of women patients are being incorporated into practice standards and are essential in training and preparing residents for the future. While research theories and clinical work concerning gender differences have

not yet answered all the questions in this area and major debates continue, residents could be expected by the completion of their training to have gained knowledge about the latest findings, ideas, and skills regarding gender differences; to ask complex questions about gender effects; and to be aware of subtle gender biases.

EDUCATIONAL OBJECTIVES By the end of their residency training, all residents should have acquired the following knowledge, skills, and attitudes regarding gender and women's issues. Knowledge First, the resident should be able to demonstrate an understanding of the historical, socioeconomic, and developmental perspectives relevant to understanding the current roles of women and men, including biological and cultural aspects of existing gender differences in society (29,30); early gender role training and expectations provided to children by adult caregivers, teachers, and society (8,19,21,29); gender differences in psychological development throughout the life cycle that are affected by culture, ethnicity, and class (9,10,13,22,27-30); lesbian identity formation (80); the history of the recent women's and men's movements and their relevance to psychiatry (1); major shifts in gender role behavior and their effects on family structure, the work force, and mental health (3,5--8); the effects of gender role constraints, discrimination, and sexual harassment experienced by women (73,79); men's development and role strain (3,22-26); and the types of gender bias in researching and assessing characteristics of women and men psychiatric patients (32,36,37,39). Second, residents should develop an understanding of the gender differences in prevalence of psychopathology and clinical course, treatment, and outcome, including known etiological factors and major research

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in progress for defining and explaining these differences, as demonstrated by the increased prevalence of men among patients with substance abuse, antisocial personality disorder (32,50), and poor prognosis schizophrenia (51), and possible differences in etiology and treatment recommendations; the increased prevalence of women among patients with depression (49,52), some anxiety disorders (53), eating disorders (54), somatization disorders (55), and borderline personality disorders (56); differences in substance abuse patterns in men and women (57,63,64); emerging differences in medication responses between women and men, including evidence for lower neuroleptic doses required by women with schizophrenia (51,59); differences in the course of illnesses, such as better social adjustment and higher rates of significant relationships among women with schizophrenia (81); effect of the therapist's gender on treatment outcome (28,29,35,82); and differential adjustment of women and men to aging and loss (58). Third, residents need to develop an understanding of the psychological aspects of women's reproductive life and health care needs, including female sexuality and differential diagnosis of sexual disorders, such as dyspareunia, or hypo or hyperactive sexual drives (48); psychiatric disorders and the menstrual cycle (48,83); psychological factors influencing reproductive choices and their sequelae for mental health (29,48,84); pregnancy and postpartum-related psychiatric disorders (48,71), including occurrences of mood disorders, obsessive-compulsive disorders, panic disorders, and psychosis; the impact of pregnancy and the postpartum period on the course of major mental illness, the treatment of pregnant psychotic women and psychological, and legal implications of mothering or relinquishment for psychiatrically incapacitated women (48,69,70,72,85); psychological reaction to abortion, pregnancy loss or infertility, and effective treatment strategies (48); psychological and physical aspects of menopause (48); psychoACADEMIC PSYCHIATRY

logical sequelae of gynecological and breast surgeries (48,86); specific features of AIDS and HIV in women (87,88); issues for pregnant substance abusers (48,63,89); differences of life stressors and reproductive life in ethnic minority women (27,28,48); and use of women's groups for women with early sexual trauma, HIV infection, postpartum disorders, infertility, and menopause (48, 88,90). Fourth, residents should be aware of psychiatric signs, symptoms, and long-range effects of trauma experienced by women, the cumulative effects of repeated victimization and traumas, and treatment of the following types of abuse: incest and early sexual trauma (55,56,75,90), rape (74,76), battering (77), and physician-patient sexual misconduct (78). Skills The resident should demonstrate competence in 1) interviewing female and male patients with sensitivity to gender-specific communication styles, vulnerabilities, and strengths (91); 2) eliciting accurate and complete sexual and reproductive histories; 3) obtaining information about traumatic events common in women's lives, such as domestic violence, sexual abuse, sexual assault and harassment, with special sensitivity to cultural factors (55,73-76,79); 4) diagnosing and assessing male and female patients, with an understanding of gen~er differences informed by the patient's cultural background (21,28); 5) providing appropriate psychotherapeutic (20,28-30) and psychopharmacologic (59) interventions, with an understanding of gender differences and the impact of reproductive functioning on women (48,49,51,61,62,69,83,85); 6) recognizing gender-specific transference and countertransference reactions (82,91,92); 7) enhancing the self-esteem of women patients of all ethnic backgrounds (20,27,28, 82,91); and, finally, 8) critically reviewing the literature for gender bias (36,37). 1''1

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Attitudes Residents should demonstrate in their behavior and demeanor 1) sensitivity to existing stereotypes about men and women, including awareness of the influence of media images in shaping and perpetuating these stereotypes; 2) awareness of their own attitudes toward women and men of different ethnic backgrounds and the possible gender role biases that could influence their assessments and treatment decisions regarding their patients; 3) compassion and respect for women and men patients and empathy for their diverse life-style choices; and 4) commitment toward empowering women patients to trust and enact their own choices. LEARNING EXPERIENCES [ijdacticInstruction A separate course on gender differences and new perspectives on women's and men's development should be taught in the psychiatric residency. As well, topics on gender and women's and men's issues should be incorporated into the existing core curriculum. This approach would emphasize the importance of these issues while reinforcing the idea that this is not merely a subspeciality but a necessary component of adequate clinical care.

Course on Gender Issues. Gender issues can be introduced with a PGY-1 or PGY-2 seminar series. A review book such as Notman and Nadelson's Women and Men (29) or the section from the Review of Psychiatry, Vol. 10, "New Perspectives on Human Development" (30), would serve as a useful text. Topics presented in these seminars would include selections from items described in the educational objectives under the "knowledge" section, specifically the "historical, socioeconomic, and developmental perspectives" and "violence toward women." Residents should have access to the core readings

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suggested in the Appendix and review assigned articles or book chapters relevant to their case presentations. The suggested material could be presented in a series of five to seven seminars or could be taught as part of a seminar series on ethnic minority, gender, and gay and lesbian issues.

Core Curriculum. The remammg topics

cited under "knowledge, skills, and attitudes" should be incorporated into the core curriculum as follows: 1) Psychosocial aspects of women's reproductive life and health care needs could be covered during seminars on consultation psychiatry (48). Specific aspects such as depression around the menstrual period, postpartum, and menopause could also be covered during seminars on affective disorders (85); 2) Early female psychological development incorporating both classic and modem analytic theories can also be discussed in the seminars on child development (9,10,14,17,20,21); 3) The prevalence and etiology of gender differences in disorders (49-54), and courses of illness, as well as the implications for assessment and treatment in men and women should be discussed in seminars on psychopathology and substance abuse (57,63,64); 4) Techniques to elicit reproductive and sexual trauma history can be taught during an interviewing course or a psychotherapy seminar; 5) Psychotherapy seminars should also include such topics as gender role constraints in women and men in relation to ethnic backgrounds (1,3,8,25-30,32); genderspecific coping as it might relate to different symptoms in women and men (e.g., depression in women and antisocial behavior in men) (3,13,49,50); issues of self-esteem for women (18-20,28); psychological aspects of reproductive events on women's lives (48); and group therapy for victims of abuse, psychological responses to reproductive issues, and eating disorders (48,54,90); 6) Because of their high rates in psychiatric populations, the sequelae of early sexual trauma, violence

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toward women, and gender discrimination and sexual harassment should be covered in several different sections, including those on affective disorders, substance abuse, personality disorders, child psychiatry, and psychosomatic medicine (55,56,74-79); and 7} Gender differences in response to psychotropic medications should be discussed within a psychopharmacology course (59). A separate lecture should discuss the topic of psychiatric medication used for women during their childbearing years, pregnancy, and postpartum period (69-71).

Elective Courses. Interested, knowledgeable faculty may offer more intensive courses in the PGY-3 and PGY-4 years on such topics as feminist theory (14,17-21,28), psychosomatic and obstetrical and gynecological issues (48), and various types of violence toward women (55,56,73-78). Gender Awareness Experiential Training Similar to cultural awareness training described by Pinderhughes (93), facilitated groups are helpful for increasing gender awareness. During these groups, residents can explore their attitudes toward women and men and their own personal experiences with stereotypes. Group leaders may use a series of questions, such as "What would be your thoughts if your first child were a boy or girl?" and "What was your first memory of your parents teaching you how to be a girl or boy?" to stimulate discussion. Alternatively, residents could be given scripts to role-play situations depicting gender role stereotypes, followed by an exploration of their experience. A videotape of thoughtprovoking vignettes on women's issues (94) can also be used to stimulate discussion of residents' views about and personal encounter with gender bias. At a minimum, 1 hour at the beginning of residency training should be devoted to such a facilitated discussion. Optimally, a 3- to 4-hour workshop or a series of 3-4 group sessions should be offered. ACADEMIC PSYCHIArRY

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First-year psychiatric residents would also benefit from a session on sexual harassment and sex discrimination in the workplace. The Equal Employment Opportunity Commission trainers at respective institutions can be engaged to co-facilitate such a residents' group with a faculty member. This session can be conducted experientially by asking residents to respond, in writing, to a series of scenarios that describe potential cases of sexual harassment and sex discrimination, and then their responses could be discussed. This forum allows for a useful discussion of male-female differences in what defines a work environment free of harassment (79). Women residents and faculty can be given the opportunity to meet to discuss their own experiences with gender role strain, how to cope effectively in an academic setting, and how to be most helpful to women patients with work-related stress. These groups can both help female professionals with their own concerns about gender-rela ted issues and increase their awareness of issues experienced by their female patients. Depending on interest, these groups can meet only once a year or, when requested by residents, as frequently as monthly. Clinical Experiences At a minimum, each resident should I} do several supervised complete assessments of reproductive and trauma histories in female patients; 2} treat one woman during her pregnancy in both inpatient and outpatient settings; 3) treat one woman experiencing infertility, pregnancy loss, or a postpartum disorder; 4} treat one woman who presents with the sequelae of incest; 5} treat one woman who is the victim of domestic violence; and 6} work with one person with a serious eating disorder. In addition, each resident should provide consultation to at least three obstetric and gynecological patients. Residents could keep a log of what I(n

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kinds of patients and issues they encountered, and their teaching faculty could monitor residents' experiences so that key areas are covered. Among the residencies with specific women's programs that might provide elective training opportunities for interested residents are the Women's Issues Consultation Team at UCSF, the Program in Women's Mental Health at the University of Toronto, Canada, and the Women's Life Cycle Clinic at the University of California at Los Angeles. Faculty Supervision Ideally, all faculty would address gender when demonstrating or observing interviews, assessments, diagnosis, and treatment planning. Knowledge and interest among the teaching faculty could be enhanced by distributing a description of a core curriculum on women and gender issues, along with core references listed in the Appendix. In addition, each resident should have supervision by at least one faculty member who is interested in, knowledgeable about, and skilled in dealing with gender and women's issues. These faculty members do not have to be women. In programs where there are no faculty members interested in this area, efforts should be made to recruit clinical volunteer faculty or to gain access to other qualified psychiatrists who can supervise residents. Supervisors could review the residents' caseloads, assess their knowledge of gender and women's issues, and help focus educational experiences to fulfill the training objectives. The supervisor should ensure that residents treat at least the minimum number of patients whose cases involve gender role strain or women's issues. The supervisor may also recommend supplementary educational experiences, such as conferences, seminars, and workshops. In addition, each resident should have women and men supervisors during her/his training 144

to have the opportunity for relationships with supervisors of the same and the opposite sex as the resident. (1,92,95). Departmental Lectures Grand rounds, journal clubs, and visiting lectures by national and local experts should include topics on new advances in gender and women's issues to promote interest in these areas. Residents' and Program Evaluation Each residency program should establish written educational objectives related to gender and women's issues in psychiatric training. Residents' knowledge should be examined in content examinations; clinical supervisors should monitor residents' exposure to required clinical experiences and assess their skills and attitudes in working with patients through direct observation and "indepth" discussion of gender and women's issues. Residents should judge whether the educational objectives have been met and should comment on the effectiveness of teaching methods. DISCUSSION Implementation of the proposed curriculum requires addressing several obstacles and ways to overcome them. The first obstacle derives from the assumption that faculty and graduating residents are already sensitive to and expert in gender and women's issues; therefore, it is unnecessary to allocate time for specific teaching in this area. This argument can be countered in several ways: 1) Presenting topics on gender and women's issues in grand rounds and seminars will emphasize the lack of teaching about these issues in the current curriculum; 2) Encouraging residents to express their desire to learn about gender and women's issues. In many settings, elective seminars on women issues are very well at\'t )U;f\.H: 14. NL'I'v1BER ,*. WINl ER 1995

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tended, and residents repeatedly request additional training in women's and gender issues; 3) Lobbying the Residency Review Committee for psychiatry in the United States and the Royal College of Physicians and Surgeons in Canada to include the teaching of women's issues among the special requirements for accreditation of psychiatric residencies is needed; 4) Incorporating questions about women's and gender issues into the yearly evaluations of residents is necessary. Should such testing provide evidence about an existing lack of knowledge or skills in this area, it would support the need for additional teaching; and 5) Incorporating, with the help of experts in gender and women's issues, relevant questions on gender and women's issues into certification examinations, such as the National Boards of Medical Examiners and the American Board of Psychiatry and Neurology Specialty Boards, is desirable. The second anticipated objection, resulting from the fear that a focus specifically on gender and women's issues will lead to undesirable subspecialization and fragmentation of services and training, may be answered with the following arguments: 1) Integration of teaching of these issues as much as possible into current core curricula emphasizes this knowledge is requisite for basic good clinical care, rather than part of nonessential subspeciality teaching; and 2) Establishment of a specialty clinic or inpatient treatment team to focus on women's issues not only provides excellent training opportunities for residents, but also answers a strong demand on the part of patients for such services. The third obstacle may be the perception that such training is discriminatory to men, because some feminists or female patients believe that only female residents should specialize in women's health issues. There may be concerns that men cannot sensitively treat women who, for example, have been victims of sexual abuse (90) or are experiencing infertility or pregnancy loss. This obstaACADEMIC I'5YCI f1A I RY

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cle can be responded to in the following manner: 1) While women patients undergoing certain kinds of emotional distress may feel more comfortable choosing a female therapist, all residents should have the knowledge and experience to treat women's mental health concerns. Therefore, all training experiences relevant to gender and women should be open to both male and female residents, except when patients' strong preference for a women therapist precludes assignment of a male resident; and 2) Teaching about gender and women's issues focuses on understanding differences, not on discussing which gender is superior or inferior or suggesting that all men are insensitive and abusive. The fourth obstacle to implementing this curriculum might be a lack of faculty experts in gender and women's issues. Interest and expertise in gender and women's issues is more frequently found among female faculty. However, because there is a dearth of women in senior academic or administrative positions (96), residency programs might not be able to rely on faculty in high enough positions to influence the curriculum. Leadership in implementing teaching in women's and gender issues can be provided by national psychiatric groups: 1) The APA, the AADPRT, and other groups can facilitate information exchange, networking, and mentoring of interested faculties and can support the development of curricula about gender and women; and 2) The APA and its affiliates can sponsor workshops, lectures, and symposia; develop and distribute educational material to stimulate interest; and promote teaching and research in gender and women's issues. CONCLUSION We have outlined a curriculum for teaching psychiatric residents about gender and women's issues. Residents exposed to this curriculum could be expected, by the end of their training, to know about the latest ideas, 1'1:;

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findings, and controversies regarding gender differences; to ask complex questions about gender effects; and to be aware of subtle gender biases. The challenges are many in developing and implementing a gender-sensitive curriculum; however, such a curriculum is essential if psychiatry is to

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provide effective and appropriate care for both women and men.

This paper was presented in part at the American Association of Directors of Psychiatric Residency Training Midwinter Meeting, New Orleans, Louisiana, January 13-16, 1994.

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6. McBride AB: Mental health effects of women's multiple roles. Am Psychol199O; 45:381-384 7. Scarr S, Phillips F, McCartney K: Working mothers and their families. Am Psycholl989; 44:1402-1409 8. Symonds A: The dynamics of depression in functioning women-sexism in the family. J Am Acad Psychoanall986; 14:395-406 9. Tyson P, Tyson R: The Psychoanalytic Theory of Development: An Integration. New Haven, CT, Yale University Press, 1990 10. Stem D: The Interpersonal World of the Infant. New York, Basic Books, 1987 11. Silverman D: What little girls are made of? Psychoanalytic Psychology 1987; 4:315-334 12. Stoller R: Primary femininity. J Am Psychoanal Assoc 1976; 24:59-78 13. Seiden AM: Psychological issues affecting women throughout the life cycle. Psychiatr Clin North Am 1989; 12:1-24 14. Miller JB: Toward a New Psychology of Women, 2nd Edition. Boston, MA, Beacon Press, 1986 15. Deutsch H: The significance of masochism in the mentallife of women.lntJ PsychoanaI1930; 11:48--60 16. Blum HP: Masochism, the ego ideal and the psychology of women, in Female Psychology: Contemporary Psychoanalytic Views. New York, International

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