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"The Spirit Catches You and You Fall Down" 

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"The Spirit Catches You and You Fall Down" 

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As we are discussing Japanese and Chinese immigration, here is a true story from my hometown in Merced, CA about members of the Hmong community. As three-month-old Lia Lee Arrived at the county hospital emergency room in Merced, California, a chain of events were set in motion regarding her epilepsy. Lia’s doctors had trouble communicating with her Hmong parents because of a language barrier and a lack of translators. There was also a deep, cross-cultural misunderstandings between the Lee family and her American doctors.

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Winner of the National Book Critics Circle Award for Nonfiction

When three-month-old Lia Lee Arrived at the county hospital emergency room in Merced, California, a chain of events was set in motion from which neither she nor her parents nor her doctors would ever recover. Lia's parents, Foua and Nao Kao, were part of a large Hmong community in Merced, refugees from the CIA-run "Quiet War" in Laos. The Hmong, traditionally a close-knit and fiercely people, have been less amenable to assimilation than most immigrants, adhering steadfastly to the rituals and beliefs of their ancestors. Lia's pediatricians, Neil Ernst and his wife, Peggy Philip, cleaved just as strongly to another tradition: that of Western medicine. When Lia Lee Entered the American medical system, diagnosed as an epileptic, her story became a tragic case history of cultural miscommunication.

Parents and doctors both wanted the best for Lia, but their ideas about the causes of her illness and its treatment could hardly have been more different. The Hmong see illness aand healing as spiritual matters linked to virtually everything in the universe, while medical community marks a division between body and soul, and concerns itself almost exclusively with the former. Lia's doctors ascribed her seizures to the misfiring of her cerebral neurons; her parents called her illness, qaug dab peg--the spirit catches you and you fall down--and ascribed it to the wandering of her soul. The doctors prescribed anticonvulsants; her parents preferred animal sacrifices.

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The Spirit Catches You and You Fall Down

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Winner of the National Book Critics Circle Award for NonfictionWhen three-month-old Lia Lee Arrived at the county hospital emergency room in Merced, California, a chain of events was set in motion from which neither she nor her parents nor her doctors would ever recover.

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The Impact of Racism on the Sexual and Reproductive Health of African American Women

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The Impact of Racism on the Sexual and Reproductive Health of African American Women

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This article uses a socioecological model to describe racism and its impact on African American women's sexual and reproductive health. Although similar models have been used for specific infectious and chronic diseases, they have not described how the historical underpinnings of racism affect current sexual and reproductive health outcomes among African American women.

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Introduction

Although public health efforts have made considerable progress in promoting health equity in the United States, studies suggest that African American women are disproportionately affected by multiple sexual and reproductive health conditions compared with women of other races/ethnicities. HIV and pregnancy-related complications remain within the top 10 leading causes of death for African American women aged 20-54 and 15-34 years, respectively. African American women accounted for 60% of the estimated new HIV infections that occurred among all women in 2014 and are 2.8-3.7 times more likely to die from pregnancy-related complications compared with women of all other races/ethnicities.

To improve the sexual and reproductive health of African American women, several evidence-based prevention interventions have been developed and implemented. Although these interventions have been found to be efficacious in public health practice settings, research models are needed to address the underlying social determinants that directly and indirectly influence sexual and reproductive health disparities. We argue that racism, in both historical and contemporary contexts, is one condition that warrants more attention in models seeking to understand the sexual and reproductive health outcomes of African American women.

There is currently a dearth of research models that actually highlight the role of racism in sexual and reproductive health, with many studies focused on the reproductive ( i.e., perinatal) health of African American women. Thus, we offer a socioecological model to provide a contextual understanding of the role of racism on the sexual and reproductive health outcomes of African American women and provide public health considerations that promote health equity. Socioecological models allow a better understanding of how social determinants such as racism influence health at individual, interpersonal, community, and societal levels. This article considers the context of race-specific experiences of African American women. A thorough understanding of how racism has facilitated disparate sexual and reproductive health outcomes may provide a foundation to appropriately address sexual and reproductive health issues within this population.

Levels of Racism and African American Women's Sexual and Reproductive Health

Racism is an institutionalized system of oppression that designates value to persons based on race/ethnicity. Jones delineates three levels of racism that contribute to health disparities. Institutional racism is characterized by large organizations or governments that impose practices that negatively affect access to health services, resulting in differences in the quality of healthcare for racial/ethnic minority groups. Personally mediated racism occurs when healthcare providers' preconceived notions about racial groups result in the provision of substandard healthcare to racial/ethnic minorities. Last, internalized racism involves the embodiment and acceptance of stigmatizing messages from society by racially oppressed groups.

We suggest that the three levels of racism play a key role in the trajectory of sexual and reproductive health experiences and outcomes of African American women. Many studies suggest that African American women are more likely than white women to experience discrimination, receive sub-standard medical care, and undergo unnecessary surgeries such as hysterectomies. These inequities are independent of socioeconomic status and access to quality medical care. Furthermore, at equal levels of socioeconomic status, insurance coverage, and healthcare access, African Americans receive lower quality medical care than white Americans. This suggests that race-based mistreatment may underlie racial disparities in sexual and reproductive health. Therefore, to address the effects of racism on sexual and reproductive health outcomes, it is important to understand how racism influences other social determinants of health.

Applying the Socioecological Model to Understand the Influence of Racism on African American Women's Sexual and Reproductive Health

Socioecological models describe how individual, interpersonal, community, and societal factors shape population health. An underlying premise of this framework is that understanding these multiple levels of influence is necessary to avert health problems experienced by oppressed groups. We propose a multilevel model that describes the social determinants of health and important prevention opportunities (). Additionally, our model provides a framework to guide intervention planning, development, and implementation related to reducing risk factors and increasing protective factors related to sexual and reproductive health.

The five-level socioecological framework presented is adapted from Bronfenbrenner's ecological model for human development. The individual level, same as Bronfenbrenner's, represents characteristics of the individual, including knowledge, attitudes, behaviors, and history. The family/interpersonal support level, parallel to Bronfenbrenner's microsystem, describes familial and social networks of individuals, which may influence behavior and contribute to a range of experiences. Aligned with Bronfenbrenner's mesosystem, the neighborhood/community level accounts for the environments in which individuals live. Last, the societal level considers factors such as institutionalized racism. In slight contrast to Bronfenbrenner's macrosystem level (which describes the culture in which individuals live), and similar to the Alio et al. model devoted to infant mortality, the outer tier denotes the overall historical context of racism experienced by African American women, with the three levels of racism integrated across the model.

Individual level

African American women comprise the individual level of the proposed model. HIV and other sexually transmitted infections (STIs), pregnancy-related morbidity and mortality, stress, and internalized racism may be influenced by racism-related determinants ( e.g., unemployment) that potentially increase risk.

HIV/STIs

Limited education, unemployment, lack of quality care, distrust of physicians, and negative perceptions of the healthcare system serve as barriers to HIV/STI prevention, treatment, and care. In 2014, African American women had an HIV diagnosis rate that was 18 times greater than white women. Furthermore, in 2012, African American women were more likely than white women to be diagnosed with having primary or secondary syphilis, gonorrhea, or chlamydia (16.3, 13.8, and 6.2 times, respectively). They are also twice as likely to be diagnosed with bacterial vaginosis, a correlate of poor pregnancy outcomes ( e.g., low birth weight). For some African American women, racism continues to hinder optimal educational access, such that limited education is associated with poor HIV treatment adherence as well as unemployment, whereby some women may engage in sexual risk-taking behaviors to attain basic needs. Racism also affects women's interactions with healthcare providers. For example, African American women living with HIV have expressed mistrust toward healthcare professionals. This may stem from knowledge about both historical experiences of African Americans interfacing with the healthcare system and current discriminatory practices from providers. Importantly, increased HIV risk among African American women has also been associated with the historical and contemporary role of mass incarceration of African American men.

Pregnancy-related morbidity and mortality

Racism is a chronic stressor that not only contributes to HIV/STIs but can also directly affect the health of pregnant women and their children. African American women are also more likely than women of other races to experience pregnancy-related death. The black-white pregnancy-related mortality ratio ranged from 3.4 to 4 during 1998-2005. Additionally, infant mortality is more than twice as likely to occur among African Americans than whites. Racism-related factors associated with pregnancy-related mortality include economic vulnerability, stress, and experiences of discrimination.

Stress

The relationship between stress and health outcomes has been well documented. Because racism is a form of stress, it may contribute to adverse health outcomes. Stress is associated with HIV-related discrimination, negative birth outcomes, and depression among African American women. Racism also fosters poverty, unemployment, and other social factors that increase the likelihood of experiencing stress. Furthermore, chronic stressors such as discrimination and poverty that occur over time may worsen health disparities because they can be experienced across generations and negatively affect social relationships that are known to be health protective.

Internalized racism

Internalized racism can impact sexual and reproductive health by promoting psychological distress, substance use, and physical health conditions ( e.g., glucose intolerance) that contribute to pregnancy-related complications as well as negatively affect behavioral decisions that may contribute to HIV/STI risk. For African American women, internalized racism may manifest in low self-worth, low self-confidence, and depression. These experiences may, in turn, foster behaviors that compromise the health of African American women. In addition, negative societal stereotypes targeting African American women can unfavorably affect their sexual health. The relationship between self-esteem and engaging in risky sexual behaviors may be evident among some African American women who internalize negative stereotypes. For example, a recent study suggested that young African American women who perceive negative sexual stereotypes in the media are more likely than others to have multiple sex partners.

Family and interpersonal level

Family and interpersonal level factors associated with sexual and reproductive health outcomes include domestic and sexual violence, mass incarceration, and cultural mistrust. These factors may be influenced by historical racism and related experiences.

Domestic and sexual violence

Some researchers suggest that racism underlies much of the domestic violence that African American women experience because historically slavery promoted devaluation of African American women, strained African American male-female relationships, and provided little to no protection from sexual assault. More recently, it has been proposed that the intersection of domestic violence and HIV should be explored through the lens of historical racism due to a legacy of sexual stereotypes and negative images. When compared with white women, African American women have a significantly higher lifetime prevalence of rape, physical violence, and stalking by an intimate partner (34.6% among white women and 43.7% among African American women). These experiences have been associated with HIV acquisition among women and more frequent and more severe forms of domestic violence among women living with HIV. Additionally, domestic violence affects women's decision-making pertaining to sexual behavior and is associated with psychological trauma, which can increase the likelihood that women experience sexual health problems ( e.g., sexual dysfunction). These findings suggest that although domestic violence might be one determinant of HIV acquisition for African American women, it may be necessary to intervene from a sociocultural context that considers how historical factors related to domestic and sexual violence affect present-day sexual and reproductive health outcomes.

Mass incarceration

Racism has contributed to the extensive history of mass incarceration of African Americans following slavery. This continuum of incarceration has affected the familial structure, including access to education, housing and employment, and ultimately disparate health outcomes. Fullilove highlights the relationship between incarceration of African Americans and disproportionate rates of HIV. Thus, policy changes that affect disparate sentencing laws, encourage successful reentry into society, and address social determinants are needed.

Cultural mistrust

Cultural mistrust refers to African Americans' tendencies to mistrust whites. Cultural mistrust has been associated with low self-esteem, dissatisfaction with healthcare, and delayed medical treatment. The legacy of medical mistreatment, scientific and medical experimentation, and sexualized violence against African American women likely continues to shape their mistrust of the medical profession. Indeed, one study found that cultural mistrust was linked to African American patients' lack of satisfaction with their providers, while another study found patient dissatisfaction as one predictor of low antiretroviral therapy adherence among persons living with HIV.

Neighborhood and community level

Neighborhood and community level factors influenced by racism affect the settings where African American women reside. Neighborhood characteristics ( i.e., concentrated unemployment), unequal healthcare access, and personally mediated racism affect the health of women and their communities.

Neighborhood characteristics

Neighborhood and community settings have historically been related to racism and potentially increase adverse health risks. These factors include, but are not limited to, concentrated unemployment, poverty, and under-resourced education. Throughout the past six decades, the unemployment rate for African Americans has remained approximately twice the rate experienced by whites. Health consequences associated with unemployment or insufficient income may include engaging in risky sexual behaviors in exchange for food or money for living expenses ( i.e., rent). These behaviors place many African American women at risk for HIV/STIs. Additionally, poor health outcomes have been attributed to living in impoverished communities that are residentially segregated by race. Overall, limited education is associated with poor HIV treatment adherence, preterm births and infant mortality, living in poverty, and violence.

Unequal healthcare access

Although healthcare segregation continued through the mid-1960s, the passage of the Civil Rights Act of 1964 was one attempt to grant African Americans with healthcare equal to that of whites. However, African Americans are more likely to be uninsured than whites and receive poorer quality medical care. Disparate access to and quality of care are underlying determinants of African American women's disproportionately high HIV/STI burdens and poor perinatal outcomes.

Personally mediated racism

Physicians' unconscious attitudes and stereotypes have been associated with disparities in treatment recommendations for African American patients. Personally mediated racism has been experienced by African American women in their interaction with providers who project stereotypes of sexual promiscuity toward them and provide inferior service. Although it may be unconscious, this type of discrimination is associated with delayed reproductive health screenings, such as HIV treatment adherence, Pap smears, and mammograms.

Societal level

Factors that facilitate racial and gender gaps at the societal level and impede healthy outcomes include cultural competence and institutional racism.

Cultural competence

Cultural competence encompasses behaviors, attitudes, and policies that allow medical establishments and providers to effectively serve clients of diverse racial/ethnic backgrounds. Patient-centered approaches that account for the process and delivery of healthcare are pertinent to culturally competent care and treatment. Medical providers' lack of cultural competence has the potential to negatively affect the sexual and reproductive health of African American women because it can result in stigmatizing patient-provider interactions. Stigmatizing experiences may result in African Americans not being willing to be tested for HIV or receive medical services to prevent HIV acquisition and transmission.

Institutional racism

Institutional racism reinforces personally mediated and internalized racism by promoting attitudes, practices, beliefs, and policies that give an advantage to whites and disadvantage to other racial groups. Although policies may be instrumental in creating societal change conducive to health equity, institutional racism is a root cause of racial disparities in health outcomes. Racially discriminatory policies affected healthcare access, treatment, and delivery of quality care, as well as housing, employment, and educational opportunities, and disparate sentencing laws toward African Americans. Historical and systemic healthcare barriers include accessibility and delivery of quality care by providers who are culturally and linguistically competent. Currently, the Affordable Care Act will allow individuals who were underinsured or uninsured to have access to quality care. While the long-term impact in healthcare settings is yet to be seen, early findings indicate the benefit of making health insurance available to many. Moreover, it has the potential to impact sexual and reproductive health outcomes by providing access to preventive care, including contraception, prenatal screenings, mammography, HIV/STI testing, and other sexual and reproductive health services. Additionally, policies that support equal access to quality education and employment will provide further opportunities to those who may not otherwise have access to adequate healthcare. Ultimately, structural changes that involve policy adjustments may ensure all members of society have opportunities that contribute to long-term health improvements.

Historical context

Understanding the historical underpinnings of racism's impact on the sexual and reproductive health of African American women provides context to current health outcomes. The historical and contemporary health and healthcare experiences of African American women provide a perspective that may be considered by healthcare providers and others who offer services and implement programs for African American women. Across the socioecological model, the historical context provides a framework to understand the relationship between health outcomes, social determinants, and experiences of racism within the lives of African American women. For example, at the societal level, experiences of sexual violence, including reproductive exploitation, medical experimentation, and policies targeting African American women, originated during slavery and were a form of institutional racism. Before the Civil Rights Act of 1964, legal segregation in healthcare as well as federally funded reproductive health procedures ( i.e., coerced sterilizations) were commonly practiced. At the neighborhood and community level, experiences of poverty, concentrated unemployment, and residential segregation, which also had roots in slavery, are exacerbated by contemporary institutional and personally mediated racism. Although stereotypes regarding African American women as sexually promiscuous began during slavery, some women have internalized these images. Thus, it is important to ensure that the historical context is taken into consideration, particularly since these historical experiences have been shaped by sexual violence, medical mistreatment, and social injustice. Although healthcare has greatly improved since this time, African American women still experience varying levels of racism and discrimination that ultimately impact their current health and well-being.

Conclusion

In this article, we offer a socioecological model that can be used to understand how racism underlies the social determinants of health and affects the sexual and reproductive health of African American women. In both historical and contemporary contexts, race-based mistreatment has been shown to place African American women at increased risk for HIV/STIs, pregnancy-related complications, and early mortality. Moreover, widespread health implications of racism are evident and exist at the individual, interpersonal, community, and societal levels. In this regard, African American women appear to be situated in contexts in which racism is rarely avoidable. A socioecological model that considers the historical influences of racism may improve understanding of the present-day sexual and reproductive health outcomes of African American women. In addition, such a model can strengthen reproductive justice efforts that acknowledge the historical context of sexual and reproductive mistreatment and promote social justice.

Although the purpose of our model was not focused on public health practice, per se, it does offer considerations that provide opportunities to promote health equity by reducing the effects of racism and improving African American women's sexual and reproductive health. Because racism is present at multiple levels within the social environment, strategies across the socioecological model are necessary to address its broad impact and may prove to be more efficient and effective. In this study, we propose examples of public health considerations to help improve the sexual and reproductive health outcomes of African American women. It should be noted that these considerations are not exhaustive, yet provide key strategies that could be implemented. For example, individual-level interventions that seek to decrease African American women's risk for HIV/STIs might also promote self-esteem in one-on-one or group-based interventions. This may work in conjunction with community-level interventions that provide quality educational and employment opportunities to inner-city residents. Economic incentives or microenterprise programs may also be viable options to increase employment opportunities for women. Coupling health interventions with employment programs not only addresses individual-level characteristics such as self-esteem and levels of stress exposure but may also address community outcomes. In addition, some African American women may need opportunities to increase their own understanding of the historical impact of racism and its links to contemporary health outcomes. This information might act as an impetus for further learning and support individual and community advocacy opportunities.

For the interpersonal level, interventions that involve family members can provide supportive opportunities to enhance the overall well-being of African American women. For example, interventions that involve partners of pregnant women might help reduce stress levels while also improving communication and coping skills. As mentioned above, there are numerous opportunities at the community level to improve health outcomes, specifically by developing partnerships that may facilitate structural changes. For example, rates of HIV are highest among African Americans and Hispanic/Latinos in communities where greater than 20% of persons lived below the poverty level and more than 8% did not have a high school diploma. Similar findings on socioeconomic correlates of HIV infection provide support for focusing interventions on social and structural determinants of health. These efforts not only help individuals but also address the social underpinnings of racism, which play a critical role in health outcomes and would likely be most effective in counteracting race-based mistreatment. In addition, efforts that acknowledge the role of mistrust of the healthcare system are better equipped to understand health-seeking behaviors and compliance matters.

As discussed by Frieden's health impact pyramid (), interventions that address societal-level factors have the greatest potential to achieve public health impact across disease outcomes and need governmental support to be effective. According to Frieden, although societal changes may be costly, the main obstacle to addressing these changes is a lack of political will. At a minimum, a systematic review of overarching health, economic, and education policies that may continue to disenfranchise African American women might be needed at this level. Since historically many policies were designed to further oppress and marginalize African American women, it is critical to examine how long-standing and even some contemporary statutes ( i.e., welfare system, access to quality healthcare) ultimately impact the health and well-being of marginalized populations, including African American women. Provider and staff education and training to improve cultural competence to heighten sensitivity to the needs of African American women and to better understand the cultural norms and behaviors is also needed. Moreover, research focused on African American women should prioritize the role of racism and health disparities to sufficiently address the root causes of inequity. Implementing culturally tailored interventions may improve African American women's health outcomes as well. Overall, strategies that support multisectorial partnerships at federal, state, and local levels may maximize the probability of implementing successful programs. Sexual and reproductive health equity, based on evaluation data of interventions and demonstration projects, can be achieved with a commitment to effectively address racism and other underlying social determinants that promote health disparities.

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The Impact of Racism on the Sexual and Reproductive Health of African American Women

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Although public health efforts have made considerable progress in promoting health equity in the United States, studies suggest that African American women are disproportionately affected by multiple sexual and reproductive health conditions compared with women of other races/ethnicities. HIV and pregnancy-related complications remain within the top 10 leading causes of death for African American women aged 20-54 and 15-34 years, respectively.

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Hysteria: A memoir of illness, strength and women's stories throughout history

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Hysteria: A memoir of illness, strength and women's stories throughout history

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The author blends memoir with literary and historical analysis to explore women’s medical treatment. Hysteria retells the stories of silenced women,  and by centering these stories of women who had no voice in their own diagnosis and treatment, Bryant finds her own voice: powerful, brave and resonant.

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Hysteria book. Read 6 reviews from the world's largest community for readers. When Katerina Bryant suddenly began experiencing chronic seizures, she was ...

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Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (512 pages, FREE audiobook or $7.40 paperback)

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Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (512 pages, FREE audiobook or $7.40 paperback)

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Published in 2007, Harriet A. Washington writes about the history of medical experimentation on African Americans. From the era of slavery to the present day, this book presents details of black Americans' abuse as unfortunate subjects of medical experimentation.

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GLMA: Health Professionals Advancing LGBTQ Equality

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GLMA: Health Professionals Advancing LGBTQ Equality

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Ensuring health equity for LGBTQ individuals and equality for LGBTQ healthcare professionals. This is an organization of healthcare professionals and students of all disciplines, including physicians, advanced practice nurses, physician assistants, nurses, behavioral health specialists, researchers, their supporters in the United States and internationally.

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On December 18, 2019, the US Fifth Circuit Court of Appeals upheld a lower court ruling invalidating the individual mandate in the Affordable Care Act but asked the lower court to reevaluate whether the other numerous provisions and nondiscrimination protections of the ACA can stand in absence of the individual mandate.

To read GLMA's statement on this decision, please click here.
Victory! Third Judge Strikes Down
Denial of Care Rule
On November 19, a third federal judge ruled that the Trump Administration's discriminatory denial of care rule is invalid. The rule would encourage healthcare providers to deny healthcare to individuals based on a religious or moral objection, endangering the health and well-being of LGBTQ people, women, people living with HIV and other marginalized communities. This lawsuit was brought by Lambda Legal, Americans United for the Separation of Church and State, the Center for Reproductive Rights, and the County of Santa Clara (CA) on behalf of several plaintiffs, including GLMA.

Thanks to the Affordable Care Act, the uninsured rate for low- and middle-income LGBTQ people has dropped by an overwhelming 35%. More LGBTQ people have health insurance than ever before - and that means access to healthcare we need, from life-saving HIV drugs to gender-affirming healthcare. Open enrollment for healthcare coverage runs from Nov 1 to Dec 15 - click here to learn more about ensuring we all #GetCovered.

Over 600 attendees join GLMA in New Orleans, LA for the 37th GLMA Annual Conference on LGBTQ Health. This year's conference theme, LGBTQ Health Across the Lifespan, highlights the importance of understanding the ever-changing healthcare needs of LGBTQ people throughout their lives, from birth to end-of-life care.

As you may know, HHS has a released new harmful proposed rule that would rollback Obama-era regulations about protections for LGBT patients in the Health Care Rights Law (Section 1557 of the Affordable Care Act). For guidelines on how to submit comments as a healthcare professional/healthcare provider in opposition to the proposed rule by the Aug. 13 deadline, click here.

On 5/24/19, the Department of Health and Human Services announced a regulatory proposal that would essentially eliminate gender identity and sex stereotyping from nondiscrimination regulations adopted under the ACA. This revision falsely suggests that healthcare providers and insurers may legally discriminate against transgender people, allowing them to deny transgender people medically necessary and life-saving care. GLMA and the American Psychiatric Association organized a letter of 31 health associations supporting nondiscrimination protections for transgender and LGB patients and GLMA President Gal Mayer, MD, MS, released a statement condemning the regulatory proposal. Click here to read the full statemnet.

On May 17, 2019, GLMA Executive Director issued a statement calling the historic passage of the Equality Act in the US House "a measure that can have lasting positive impact on the health and wellness of our communities." To see the full statement, click here.

On May 2, 2019, HHS released the final Denial of Care rule which encourages healthcare providers who object to healthcare services based on religious or moral grounds to discriminate against LGBTQ patients, people living with HIV, and women seeking reproductive healthcare services. GLMA President Gal Mayer called the rule "antithetical to the values we share as healthcare providers." Click here to read the full statement.

GLMA Disappointed with Affordable Care Act Ruling

On October 21, 2018, The New York Times published an article revealing that the Trump Administration is yet again targeting transgender individuals by taking steps to erase transgender individuals from federal definitions of sex or gender. According to a memo obtained by The New York Times, the Administration is seeking to narrowly define gender as "biological, immutable condition determined by genitalia at birth," essentially defining sex as unchangeably either male or female. GLMA President Gal Mayer, MD, MS and GLMA Executive Director Hector Vargas, JD, issued a statement in response. Click here to see the full statement.

On July 3, 2018, nine friend-of-the-court briefs were filed urging the US Court of Appeals for the Ninth Circuit to uphold the lower court ruling in Karnoski v. Trump that currently block's the administration's discriminatory ban on transgender military service. Dozens of retired military officers and national security officials joined state attorney generals, medical and health professional associations and civil rights organizations in filing these briefs with the court. GLMA was proud to join the brief of leading health professional associations. Click here to see the full brief.

GLMA submitted letters to the California Senate Committee on Health, California Senate Standing Committee on Judiciary, and all California State Senators in support of Senate Concurrent Resolution 110, a resolution calling for an end to nonconsensual, medically unnecessary surgeries on children born with differences in sex development (DSD). Click here to learn more about the letter, and what you can do to support SCR 110.

GLMA has become a champion of the All of Us Research Program, a new undertaking of the National Institutes of Health that seeks to speed up health research breakthroughs and advance precision medicine for Americans of all backgrounds. The goal of the program is to recruit over one million study partners who will share information about their health and lifestyle over time. GLMA stands with All of Us and will work with the program to ensure the LGBTQ community is well represented within the study. Click here to learn more.

GLMA Helps Submit Comments Opposing Discriminatory HHS Regulation!

On February 22, 2018, GLMA joined 70+ other health professional, public health, and research organizations, in a letter urging Congress to recognize gun violence as a significant threat to public health. The letter also calls for action to find "bipartisan solutions to reduce injuries and fatalities associated with firearms." Click here to read the full letter that was sent to both Senators and House Representatives.

On July 26, 2017, President Trump issued a tweet announcing his intent to reverse existing policy allowing transgender individuals to serve openly. GLMA condemns this change in policy, and strongly advises the administration to review the evidence thoroughly before taking further action on this discriminatory reversal in policy.

Read the full statement here.

GLMA is proud to announce the recipients for the 2017 GLMA LGBT Health Achievement Award, which honors exemplary individuals, organizations and publications for improving and advancing LGBT health and civil rights. For more information, and to see this year's honorees, click here.

For more information on how to register, please visit the

Due to increased interest following the release of the preliminary program for the Annual Conference, GLMA has extended lower-rate early bird registration to July 31st! conference website.

GLMA renews our commitment to remembering those who were lost in the Pulse shootings by joining other LGBT, Muslim, and Latinx organizations in a national effort to commemorate that day and in the #HonorThemWithAction campaign. Click here to read more.

GLMA joined 19 health professional associations in a friend-of-the-court brief to the US Supreme Court supporting the scientific consensus about the appropriate treatment for transgender people diagnosed with gender dysphoria and outlining the harms associated with denying a transgender person use of facilities, including restrooms, that correspond with the individual's gender identity. The case involves Gavin Grimm, a male high school student who is transgender, who was prohibited from using the boys' restroom at his school. To see a list of the organizations that joined the brief and access the brief itself, click here.

Call your Senator now! Confirmation hearings for Rep. Tom Price to serve as the next US Secretary for Health & Human Services are underway and GLMA members need to call Senators and tell them that Rep. Price should not be confirmed. Find out how you can take action here.

In what is believed to be a first for a US-based health professional association, GLMA recently revised its position statement on care for children with differences of sex development (DSD) to call for delay in any medically unnecessary surgical intervention until the patient can provide consent/assent to the treatment.

NIH Designates LGBT Community a Health Disparity Population

GLMA Stands with Orlando

GLMA's Statement on the Mass Shooting in Orlando

GLMA Leads Effort in the AMA to Pass Gun Violence Policy

LGBT Organizations Issue "A Call for Unity"

Support the Local Community through WeAreOrlando

GLMA Applauds Federal Action on LGBT Health

On May 13, 2016, the Department of Health and Human Services issued final regulations establishing that Section 1557 of the Affordable Care Act provides nondiscrimination protections in healthcare access and coverage for the entire LGBT community. GLMA President Jesse Joad, MD, MS, issued a statement. To read GLMA's response, click here.

Amicus Brief Filed Against Missouri Law Criminalizing HIV
DC Council Passes LGBT Cultural Competency Requirement
Final FDA Guidance on Blood Donation Falls Short

The FDA released final guidance establishing a one-year deferral period on blood donation for men who have sex with men (MSM), including gay and bisexual men. GLMA President Jesse Joad, MD, MS, and GLMA Executive Director Hector Vargas, JD, issued a statement. To read GLMA's response, click here .

Please GLMA applauded the Administration and the US Department of Health & Human Services for two game-changing policy initiatives calling for an end to conversion therapy for minors and requiring electronic health records systems to include sexual orientation and gender identity. Take Action Now to Support Nondiscrimination in Healthcare
ACT NOW to tell HHS you support efforts to establish clear and comprehensive regulations ensuring lesbian, gay, bisexual and transgender people do not face discrimination in accessing healthcare and coverage.

GLMA Applauds Game-Changing HHS Policy Initiatives
Learn more here.

The Department of Health and Human Services Office of Civil Rights issued a proposed regulation expanding on its position that discrimination based on gender identity is prohibited under the Affordable Care Act. "The nature of marriage is that, through its enduring bond, two persons together can find other freedoms, such as expression, intimacy, and spirituality. This is true for all persons, whatever their sexual orientation," wrote Justice Kennedy his majority opinion establishing the freedom to marry. Read GLMA's Statement The US Supreme Court issued a 6-3 decision in GLMA and the World Professional Association for Transgender Health submitted a friend-of-the-court brief to the Ninth Circuit US Court of Appeals in support of a transgender woman who was denied gender affirmation surgery while in the California State Prison system. The brief argues that, consistent with the WPATH Standards of Care, treatment for gender dysphoria, including gender-affirming surgery, is medically necessary care and that prisons must provide medically necessary care to transgender inmates. The American Medical Association's House of Delegates unanimously passed a GLMA-led resolution stating "there is no medically valid reason to exclude transgender individuals" from US military service. GLMA Applauds Proposed HHS Regulation on Transgender Discrimination
GLMA issued a statement applauding the move.

GLMA Statement Celebrating Supreme Court Decision on Marriage
here.

GLMA Statement on Supreme Court Decision Upholding the ACA
King v. Burwell upholding the Affordable Care Act. GLMA issued a statement applauding the decision, which reads, in part: "GLMA will continue its efforts working in coalition with other LGBT organizations and through a strong partnership with the US Department of Health & Human Services to ensure the ACA addresses the healthcare needs and concerns of LGBT people and those living with HIV..." Click here to learn more.

GLMA and WPATH Support Healthcare for Transgender Inmate Click here to learn more.

AMA Adopts GLMA-Led Policy on Transgender Military Service Click here to learn more.

GLMA and Other Associations Speak Out On Religious Freedom Laws
As the Governors of and legislators in Arkansas and Indiana work to address the concerns about how religious freedom legislation in their states impact discrimination against LGBT people, GLMA worked to organize health professional associations to join a letter sharing their perspectives as healthcare providers about the potential impact of these laws on care for LGBT patients and their families. We are extremely grateful for the response of our colleagues at sister organizations and the support they have shown to ensure these laws are not used to deny care to LGBT individuals and their families. Click here to read the letter.

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friend-of-the-court brief to the US Supreme Court in the marriage equality cases they will hear oral arguments for on April 28th. The amicus brief highlights the scientific evidence that "sexual orientation is an innate human characteristic that deserves the full and equal protection of the law." The brief cites decades of studies establishing that genetic, hereditary, hormonal and biological influences are major factors in determining sexual orientation. Click here to read the press release.

GLMA Issues Statement on Change in FDA Blood Donation Policy Click here to read GLMA's statement.

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GLMA is a national organization committed to ensuring health equity for lesbian, gay, bisexual, transgender, queer (LGBTQ) and all sexual and gender minority (SGM) individuals, and equality for LGBTQ/SGM health professionals in their work and learning environments. To achieve this mission, GLMA utilizes the scientific expertise of its diverse multidisciplinary membership to inform and drive advocacy, education, and research.

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A woman in Immigration and Customs Enforcement (ICE) detention says her fallopian tube was removed without her consent

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A woman in Immigration and Customs Enforcement (ICE) detention says her fallopian tube was removed without her consent

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Medical staff in Georgia told 30-year-old Pauline that her irregular menstrual bleeding could be treated by a minor surgical procedure. A doctor would dilate her cervix and scrape off the lining of her uterus. Instead, the doctor informed her after the procedure that he had removed one of her fallopian tubes, and that she could expect difficulty conceiving.

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Pauline Binam, a 30-year-old former detainee at Irwin County Detention Center in Ocilla, Georgia, had been in custody for about two years when she started having irregular menstrual bleeding. She feared that confinement was taking its toll on her body.

Binam, who came to the US from Cameroon when she was 2 years old, was being held at the Immigration and Customs Enforcement (ICE) detention center while awaiting deportation.

According to her attorney, Van Huynh, she consulted with medical staff at the facility who told her that the condition could be treated by a minor surgical procedure in which a doctor dilates the cervix and scrapes off the lining of the uterus.

Instead, the doctor informed her that he had also removed one of her fallopian tubes and that she could expect to have difficulty conceiving if she wanted to have more children.

Binam is now at the center of a congressional inquiry into allegations of a pattern of nonconsensual gynecological procedures, including hysterectomies, performed on detainees at Irwin in recent years. ICE ordered her deported on Wednesday morning, but she narrowly avoided deportation only after two Congress members got involved in her case.

"I'm often not surprised by things in the world of immigration nowadays," Huynh said. "I was shocked and appalled, hearing Nurse [Dawn] Wooten confirming what Pauline had been telling me all through 2019."

Binam says she had invasive surgery with no opportunity to consent

Before her procedure in August 2019, Binam gave verbal consent, indicating that she understood the course of treatment. But she was not given the opportunity to consent to the much more invasive and life-altering surgery she received while under anesthesia. She later expressed to a psychiatrist that she was "bothered" that she had one of her fallopian tubes removed when she was expecting a different procedure, according to medical records from August 2019, which Huynh shared with Vox.

"She was adamant that she did not give consent for them to do anything to her fallopian tubes," Huynh said. "Had she been informed of what was being done with regard to her fallopian tubes, she would have been able to respond fairly to that."

To this day, Binam, who has a US-citizen daughter, doesn't know whether she'll be able to conceive again, or whether it was medically necessary that her fallopian tube be removed.

Wooten, a nurse at the facility, was the first to raise concerns about the hysterectomies, which were performed by a gynecologist described as "the uterus collector" in a whistleblower complaint filed Monday.

Multiple attorneys have since come forward alleging that their clients had been subjected to hysterectomies and other gynecological procedures. Rep. Pramila Jayapal, vice chair of the House immigration subcommittee, said that, based on conversations with three of those attorneys, it appears that at least 17 detainees had such procedures.

Mahendra Amin, a gynecologist associated with Coffee Regional Medical Center and Irwin County Hospital in Georgia, allegedly performed at least some of the gynecological procedures, including hysterectomies, that were described in the whistleblower complaint and by the detainees' attorneys. (His attorney has "vigorously" denied the allegations.)

It's not clear whether he alone performed the procedure on Binam or cooperated with other doctors, but he is listed as the "ordering" doctor on a pathology report relating to her surgery.

The House Committee on Homeland Security is investigating the allegations in the complaint, and more than 170 members of Congress have called for a separate investigation from the Homeland Security inspector general's office.

Testimony from Binam and other detainees at Irwin will likely be critical to those inquiries.

Binam was almost deported - just as she came forward with the allegations

Binam came to the US when she was 2 years old from Cameroon. She might have been eligible for the Deferred Action for Childhood Arrivals Program, which has allowed more than 700,000 unauthorized immigrants who came to the US as children to live and work in the country legally, if it weren't for a shoplifting conviction from when she was 17. She paid a resulting fine without understanding the consequences: She was essentially admitting guilt to the charges against her.

A couple of years later, she was charged with larceny in a separate case from the first shoplifting incident and was offered a plea deal. She took the deal, again admitting her guilt, which qualified as a second strike on her record. Immigration officials consequently launched deportation proceedings against her and detained her at Irwin starting in October 2017.

Though a mother of a US citizen who had lived in the US for decades would typically be able to apply for deportation relief, Binam's conviction and plea deal made her ineligible. In immigration court, she claimed that she feared returning to Cameroon, a place that she has never called home, and where there is ongoing conflict between the state and anglophone separatists. She was nevertheless ordered deported in an immigration court ruling that she is now appealing before the 11th Circuit.

Even though her appeal is still pending, ICE could have deported her at any moment. But it was only on Wednesday - in the wake of the whistleblower complaint's publication and after Huynh sought an emergency pause on her deportation, identifying her as a victim of a nonconsensual gynecological procedure - that ICE finally tried to put her on a 9:30 am deportation flight out of Chicago.

"We were just shocked to find out that - just as we were learning about all these things that were coming out from Nurse Wooten - they wanted to put her on a flight and try to deport her as soon as possible," Huynh said.

A petition that garnered more than 1,800 signatures overnight also sought to halt her deportation. But it wasn't until Jayapal and Rep. Sheila Jackson Lee (D-TX) intervened that she was finally pulled off the plane at the last moment and sent to another immigration detention center, the Montgomery Processing Center in Conroe, Texas.

"There's so much about immigration detention that takes away from a person's life," Huynh said. "It robbed her and her future because of what we're learning today."
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A woman in ICE detention says her fallopian tube was removed without her consent

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Pauline Binam, a 30-year-old former detainee at Irwin County Detention Center in Ocilla, Georgia, had been in custody for about two years when she started having irregular menstrual bleeding. She feared that confinement was taking its toll on her body.

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Margaret Sanger - Roe v. Wade, Planned Parenthood (~6 min)

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Margaret Sanger - Roe v. Wade, Planned Parenthood (~6 min)

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The History Of 100 Years Of Women's Health Care At Planned Parenthood

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The History Of 100 Years Of Women's Health Care At Planned Parenthood | NowThis

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Women And Hysteria In The History Of Mental Health - US National Library of Medicine, National Institutes of Health

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Women And Hysteria In The History Of Mental Health - US National Library of Medicine, National Institutes of Health

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Hysteria is was the first mental disorder attributable to women, Sigmund Freud considered it to be an exclusively female disease. There were two perspectives: scientific and demonological.

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Abstract

Hysteria is undoubtedly the first mental disorder attributable to women, accurately described in the second millennium BC, and until Freud considered an exclusively female disease. Over 4000 years of history, this disease was considered from two perspectives: scientific and demonological. It was cured with herbs, sex or sexual abstinence, punished and purified with fire for its association with sorcery and finally, clinically studied as a disease and treated with innovative therapies. However, even at the end of 19 th century, scientific innovation had still not reached some places, where the only known therapies were those proposed by Galen. During the 20 th century several studies postulated the decline of hysteria amongst occidental patients (both women and men) and the escalating of this disorder in non-Western countries. The concept of hysterical neurosis is deleted with the 1980 DSM-III. The evolution of these diseases seems to be a factor linked with social "westernization", and examining under what conditions the symptoms first became common in different societies became a priority for recent studies over risk factor.

Keywords: History, Hysteria, Mental Health, Psychiatry, West, Woman.

INTRODUCTION

We intend to historically identify the two dominant approaches towards mental disorders, the "magic-demonological" and "scientific" views in relation to women: not only is a woman vulnerable to mental disorders, she is weak and easily influenced (by the "supernatural" or by organic degeneration), and she is somehow "guilty" (of sinning or not procreating). Thus mental disorder, especially in women, so often misunderstood and misinterpreted, generates scientific and / or moral bias, defined as a pseudo-scientific prejudice [ 1].

19-20 th centuries' studies gradually demonstrate that hysteria is not an exclusively female disease allowing a stricter scientific view to finally prevail. 20 th century's studies have also drawn on the importance of transcultural psychiatry, in order to understand the role of environmental factors in the emotive evolution and behavioral phenomenology and in modifying the psychopathology, producing the hypotheses of a modification to hysteria from the increase of mood disorders.

1. Ancient Egypt

The first mental disorder attributable to women, and for which we find an accurate description since the second millennium BC, is undoubtedly hysteria.

The first description referring to the ancient Egyptians dates to 1900 BC ( Kahun Papyrus) and identifies the cause of hysterical disorders in spontaneous uterus movement within the female body [ 2, 3].

In the Eber Papyrus (1600 BC) the oldest medical document containing references to depressive syndromes, traditional symptoms of hysteria were described as tonic- clonic seizures and the sense of suffocation and imminent death (Freud's globus istericus). We also find indications of the therapeutic measures to be taken depending on the position of the uterus, which must be forced to return to its natural position. If the uterus had moved upwards, this could be done by placing malodorous and acrid substances near the woman's mouth and nostrils, while scented ones were placed near her vagina; on the contrary, if the uterus had lowered, the document recommends placing the acrid substances near her vagina and the perfumed ones near her mouth and nostrils [ 2, 3].

2. The Greek world

According to Greek mythology, the experience of hysteria was at the base of the birth of psychiatry.

The Argonaut Melampus, a physician, is considered its founder: he placated the revolt of Argo's virgins who refused to honor the phallus and fled to the mountains, their behavior being taken for madness. Melampus cured these women with hellebore and then urged them to join carnally with young and strong men. They were healed and recovered their wits. Melampus spoke of the women's madness as derived from their uterus being poisoned by venomous humors, due to a lack of orgasms and "uterine melancholy" [ 2- 4].

Thus arose the idea of a female madness related to the lack of a normal sexual life: Plato, in Timaeus, argues that the uterus is sad and unfortunate when it does not join with the male and does not give rise to a new birth, and Aristotle and Hippocrates were of the same opinion [ 2- 4].

The Euripidy's myth says that a collective way of curing (or, if we prefer, preventing) melancholy of the uterus is represented by the Dionysian experience of the Maenads, who reached catharsis through wine and orgies [ 5]. Women suffering from hysteria could be released from the anxiety that characterizes this condition by participating in the Maenad experience. Trance status guided and cured by the Satyr, the priest of Dionysus, contributed to solving the conflict related to sexuality, typical of hysteria disease [ 6].

Hippocrates (5th century BC) is the first to use the term hysteria. Indeed he also believes that the cause of this disease lies in the movement of the uterus ("hysteron") [ 2- 4].

The Greek physician provides a good description of hysteria, which is clearly distinguished from epilepsy. He emphasizes the difference between the compulsive movements of epilepsy, caused by a disorder of the brain, and those of hysteria due to the abnormal movements of the uterus in the body. Then, he resumes the idea of a restless and migratory uterus and identifies the cause of the indisposition as poisonous stagnant humors which, due to an inadequate sexual life, have never been expelled. He asserts that a woman's body is physiologically cold and wet and hence prone to putrefaction of the humors (as opposed to the dry and warm male body). For this reason, the uterus is prone to get sick, especially if it is deprived of the benefits arising from sex and procreation, which, widening a woman's canals, promote the cleansing of the body. And he goes further; especially in virgins, widows, single, or sterile women, this "bad" uterus - since it is not satisfied - not only produces toxic fumes but also takes to wandering around the body, causing various kinds of disorders such as anxiety, sense of suffocation, tremors, sometimes even convulsions and paralysis. For this reason, he suggests that even widows and unmarried women should get married and live a satisfactory sexual life within the bounds of marriage [ 2- 4].

However, when the disease is recognized, affected women are advised not only to partake in sexual activity, but also to cure themselves with acrid or fragrant fumigation of the face and genitals, to push the uterus back to its natural place inside the body [ 2- 4].

3. Rome

Aulus Cornelius Celsus (1 st century BC) gives a good and accurate clinical description of hysterical symptoms. In De re medica Celsus, he wrote "In females, a violent disease also arises in the womb; and, next to the stomach, this part is most sympathetically affected or most sympathetically affects the rest of the system [ 7]. Sometimes also, it so completely destroys the senses that on occasions the patient falls, as if in epilepsy. This case, however, differs in that the eyes are not turned, nor does froth issue forth, nor are there any convulsions: there is only a deep sleep".

Claudius Galen's theories on hysteria (2 nd century AD) are comparable to those of Hippocrates. Furthermore Galen says of hysteria " Passio hysterica unum nomen est, varia tamen et innumera accidentia sub se comprehendit" (hysterical passion is the name, but various and several are its symptoms), highlighting the variety of hysterical events [ 7]. In his work In Hippocratis librum de humoribus, Galen criticizes Hippocrates: "Ancient physicians and philosophers have called this disease hysteria from the name of the uterus, that organ given by nature to women so that they might conceive [ 7]. I have examined many hysterical women, some stuporous, others with anxiety attacks [...]: the disease manifests itself with different symptoms, but always refers to the uterus". Galen's treatments for hysteria consisted in purges, administrations of hellebore, mint, laudanum, belladonna extract, valerian and other herbs, and also getting married or repressing stimuli that could excite a young woman [ 2, 3, 7].

Hysterical cures are only revolutionized by Soranus (a Greek physician from the 1 st half of 2 nd century AD, practicing in Alexandria and Rome), who wrote a treatise on women's diseases and who is considered the founder of scientific gynecology and obstetrics : women' disorders arise from the toils of procreation, their recovery is encouraged by sexual abstinence and perpetual virginity is women' ideal condition. Fumigations, cataplasms and compressions are ineffectual, the hysterical body should be treated with care: hot baths, massages, exercise are the best prevention of such women' diseases [ 2, 3, 7].

4. Middle Ages

After the fall of the Roman Empire, Greek-Roman medical culture had its new epicenter in Byzantium, where physicians inherited Galen's science without making any significant innovations (the most famous was Paul of Aegina, 625-690 AD). Sometime before, Bishop Nestorius (381-451 approx.), who took refuge in the Middle East in an area between today's Iraq and Egypt, had brought with him his knowledge of classical science, contributing to the spread of Greek-Roman medicine in these areas.

The political events of the early Middle Ages caused a rupture between Christian Europe, with its auctoritas culture - in the hands of just a few scholars - and the Middle East of the Caliphs, where thanks to a climate of tolerance and cultural ferment, the texts of Hippocrates and Galen were translated and commented on in Arabic, becoming widespread and well-known [ 3].

In this context, two great scientists carry out their work : the Persian Avicenna (980-1037) [ 8, 9] and the Andalusian Jew Maimonides (1135-1204) [ 10]. Thanks to them, the legacy of Hippocrates and Galen is not only maintained, but spreads throughout Europe: the Reconquista of Spain (718-1492) and new contacts with the Near East bring important cultural exchanges, Avicenna's Canon of Medicine and Galen's Corpus are diffused along with the Latin translations ascribed to Gerard of Cremona (1114-1187), while Maimonides' texts are disseminated in the Jewish world, along with other basic medical texts, thanks to translations by the Ibn Tibbon family (13-14 th centuries). In particular, the medical schools of Salerno and Montpellier were vehiclesfor the dissemination of these works [ 11].

This was how Hippocratic concepts of melancholia and hysteria spread in late-medieval Europe, and in informed circles these diseases were treated according to what we shall call the "scientific" vision. In particular, this advocated the use of melissa as a natural remedy nerve comforter (melissa was considered excellent even in cases of insomnia, epilepsy, melancholy, fainting fits, etc.) [ 3, 12].

Besides the natural remedies, a sort of "psychotherapy" developed, practiced not only by Avicenna, but also for example by Arnaldus of Villa Nova (1240-1311). The latter, considered medieval Europe's greatest physician, will be counted along with Galen and Avicenna in the inventories of physicians' libraries throughout the Modern era [ 13].

It is also interesting to note that in the many treatises diffused at the time ( Constantine the African's Viaticum and Pantegni, but also the Canon of Avicenna and Arnaldus of Villa Nova's texts) women were often not described as "patients" to be cured but rather as the "cause " of a particular human disease, defined as amor heroycus or the madness of love, unfulfilled sexual desire [ 8].

But we cannot talk about women' health in the Middle Ages without citing Trotula de Ruggiero from Salerno (11 th century). While as a woman she could never become a magister, Trotula is considered the first female doctor in Christian Europe: she belonged to the ranks of famous women active in the Salerno School but discredited, among others, by Arnaldus of Villa Nova [ 14].

Called sanatrix Salernitana, Trotula was an expert in women' diseases and disorders. Recognizing women as being more vulnerable than men, she explained how the suffering related to gynecological diseases was "intimate": women often, out of shame, do not reveal their troubles to the doctor. Her best known work, De passionibus mulierum ante, in et post partum, deals female problems, including hysteria. Faithful to the teachings of Hippocrates, Trotula was devoted to the study of women' diseases, of which she tried to capture the secrets, without being influenced by the prejudices and morals of her time, also giving advice on how to placate sexual desire: in her work abstinence is seen as a cause of illness and she recommends sedative remedies like musk oil or mint [ 15].

Trotula works at a time when women are still considered inferior to men because of their physiological and anatomical differences. Hildegard of Bingen (1098-1179), German abbess and mystic, was another female doctor. Her work is very important for the attempt to reconciliate science with faith, that happens at the expense of science. Hildegard resumes the "humoral theory" of Hippocrates and attributes the origin of black bile to the original sin [ 16]. In her view, melancholy is a defect of the soul originated from Evil and the doctor must accept the incurability of this disease. Her descriptions are very interesting. Melancholic men are ugly and perverse, women slender and minute, unable to fix a thought, infertile because of a weak and fragile uterus [ 16]. In the ideology of Hildegard, Adam and Eve share responsibility with respect to original sin, and man and woman - sexually complementary - are equal in front of God and the cosmos [ 17].

The mainstream view of the time is one in which the woman is a physically and theologically inferior being, an idea that has its roots in the Aristotelian concept of male superiority: St. Thomas Aquinas' (1225-1274) Summa Theologica Aristotle's assertions that "the woman is a failed man" [ 18]. The inferiority of women is considered a consequence of sin, and the solutions offered by St. Thomas' reflection leave no doubt about what will overturn the relationship between women and Christianity: the concept of "defective creature" is just the beginning. In question 117, article 3, addressing the possibility that the human soul can change the substance, St. Thomas says that "some old women" are evil-minded; they gaze on children in a poisonous and evil way, and demons, with whom the witches enter into agreements, interacting through their eyes [ 18]. The idea of a woman-witch, which we shall call the "demonological vision", almost becomes insuperable: preachers disclose the Old Testament's condemnation of wizards and necromancers and the fear of witches spreads in the collective imagination of the European population. The ecclesiastical authorities try to impose celibacy and chastity on the clergy, and St. Thomas' theological descriptions regarding woman's inferiority are, perhaps, the start of a misogynistic crusade in the late Middle Ages.

From the thirteenth century onwards, the struggle with heresy assumes a political connotation: the Church aims tat unifying Europe under its banner, so breviaries become manuals of the Inquisition and many manifestations of mental illness are seen as obscene bonds between women and the Devil. "Hysterical" women are subjected to exorcism: the cause of their problem is found in a demonic presence. If in early Christianity, exorcism was considered a cure but not a punishment, in the late Middle Ages it becomes a punishment and hysteria is confused with sorcery [ 19, 20].

Political and religious status quo in Europe is threatened by the first humanist ideas and the Church responds by intensifying inquisitions: the apogee is reached in 1484 with the Summis desiderantes affectibus, Innocent VIII's Bull, which confirms the witch hunt and an obligation to "punish, imprison and correct" heretics [ 21, 22]. The German Dominicans Heinrich "Institor" Kramer and Jacob Sprenger are accredited with the publication of the famous Hammer of Witches, the Malleus Meleficarum (1486) [ 21, 22]. Although not an official Church manual, it takes on an official tone due to the inclusion of the papal Bull within the text. It is interesting to note that the title itself includes signs of misogyny: "Maleficarum" as witches, not "Maleficorum" as wizards... as if to say "evil is female/ evil origins from women"!

The devil is everywhere in these pages: he makes men sterile, kills children, causes famine and pestilence and all this with the help of witches. The compilers of the manual are familiar with the medicine of the age, and they investigate the relationship between sorcery and human temperaments: their descriptions rival those contained in the best psychopathology manuals [ 21, 22]. The text is divided into three parts and aims at proving the existence of demons and witches (warning the reader that anyone not convinced is also a victim of the Devil) explaining how to find and punish sorcery.

But what has this to do with women's health? It is quite simple: if a physician cannot identify the cause of a disease, it means that it is procured by the Devil. The inquisitor finds sin in mental illness because, he says, the devil is a great expert of human nature and may interfere more effectively with a person susceptible to melancholy or hysteria. Hysteria is considered a woman's disease, and who more than women are prone to melancholy? This disease is the basis of female delirium: the woman feels persecuted and the devil himself is the cause of this "mal de vivre", which deprives the women of confession and forgiveness, leading them to commit suicide.

Obviously, the women most affected are elderly and single, in most cases they have already been in mourning or victims of violence. Sorcery becomes the scapegoat for every calamity and etymological explanations are also provided: for Sprenger and Krämer, the Latin word foemina is formed from fe and minus, that is "who has less faith". This text is the worst condemnation of depressive illness and women to be found throughout the course of Western history: until the eighteenth century, thousands of innocent women were put to death on the basis of "evidence" or "confessions" obtained through torture [ 21, 22].

5. Renaissance

At the end of the Middleage, journeys along the coasts of the Mediterrinean sea contributed to a quick diffusion of Greek Classics, preserved and disseminated by the Arabians.

The humanistic movement (born with Dante, Boccaccio and Petrarch) emphasized a respect for the writings of the Antiquity. During these centuries, a new realistic approach to man as a person was born, which opposed the scholastics and introduced a fresh point of view about nature and man [ 19].

Italian philosopher Giovanni Pico della Mirandola (1463-1494) espoused the principle that each man is free to determinate his own fate, a concept that perhaps more than any other has influenced the developments of the last three centuries: only man is capable of realizing his ideal and this condition can, however, be achieved only through education [ 23]. Pico's thesis was implemented by the Spanish educator Juan Luis Vives (1492-1540). His pragmatic orientation produced occasional flashes of insight; for instance, he thought that emotional experience rather than abstract reason detained the primary role in a man's mental processes: in order to educate a person it is necessary to understand the complex functioning of his mind [ 19].

Up to this time the medical vision of hysteria, inherited from the Hippocratic-Galenic tradition, continues to dominate [ 24]. At the end of the 16th century, in European countries affected by the Counter-Reformation, the theological vision tends to overwhelm the medical community. During this period the most intense activity of the Roman Inquisition, in which magic has replaced the fight against heresy, is recorded. Thus in these states, a new generation of physicians emerges, which is destined to be subordinated to inquisitors [ 24]. It is precisely the physician and theologian Giovan Battista Codronchi (1547-1628) who, by criticizing the medical therapy of the time aimed at treating hysteria, give us a detailed description of them.

Codronchi said that midwives, recalling Galenus' and Avicenna's theachings, took care of the hysterical women introducing the fingers in their genital organs in order to stimulate orgasm and semen production [ 24]. The physician prohibited this treatment at all, an attitude due to the concern typical of that historical phase related to sex and sexual repression. The treatment for him must be practices by the spiritual guides [ 24]. And if Codronchi is also a proud supporter of the existence of demons, in favour of which he argued by referring to biblical and philosophical sources, the Italian Renaissance had already tried to condemn witch hunts and to give a "scientific" explanation of mental illness: among others, Girolamo Cardano (1501-1576) and Giovanni Battista Della Porta (1535-1615) were interested in sorcery and marginality, but did not see a demonic cause in them. They identified the origin of certain behaviors in fumes, in polluted water and in the suggestion (for Cardano) or in the acquisition of certain substances that induce "visions" and "pictures" (according to Della Porta) but both base most of their considerations on physiognomy [ 25]. Another important physician, the Dutch Johann Weyer (1515- 1588) intended to prove that witches were mentally ill and had to be treated by physicians rather than interrogated by ecclesiastics [ 19]. In 1550 he became the private physician of the Duke William of Cleves, who was a chronic depressive. The Duke observed that witches manifesedt many of the same symptoms as his relatives became insane. So, he sympathizes with Weyer's theory that these women are really suffering from mental illness, but he cannot keep the witch hunter under control because of his transient psychotic episodes cause by an apopletic stroke [ 19]. In 1563, Weyer publishes De prestigiis Daemonum, which is a step-by-step rebuttal of the Malleus Maleficarum. He's been called by his contemporaries "hereticus" or "insanus", but his pages reveal that he's not rebellious but that he's a religious man [ 19].

However, for the doctors of that time, the uterus is still the organ that allows to explain vulnerable physiology and psychology of women: the concept of inferiority towards men is still not outdated.

Hysteria still remains the "symbol" of femininity [ 26].

6. Modern Age

The 16 th century is a period of important medical developments, as proved by the writings of Andreas Vesalius ( De humani corporis fabrica, 1543) and French surgeon Ambroise Paré (1510-1590).

These authors' findings are the basis of the birth of modern medical science [ 24], combined with the "philosophical revolution", in which René Descartes (1596-1650) explains how the actions attributed to the soul are actually linked with the organs of the body, and also combined with the studies on the anatomy of the brain by physician Thomas Willis (1621-1675). Willis introduces a new etiology of hysteria, no longer attached to the central role of the uterus but rather related to the brain and to the nervous system [ 24]. In 1680, another English physician, Thomas Sydenham (1624-1689), published a treatise on hysteria ( Epistolary Dissertation on the Hysterical Affections) which refers back to natural history through describing an enormous range of manifestations and recognizing for the first time the fact that hysterical symptoms may simulate almost all forms of organic diseases [ 19]. However, the author fluctuates between a somatic and a psychological explanation [ 27]. Sydenham demonstrates that the uterus is not the primary cause of the disease, which he compares to hypochondria: his work is revolutionary as it opposes the prejudices, but it will take several decades for the theory of "uterine fury" to be dismissed [ 26].

The scientific development does not mark a dramatic shift from a demonological vision of medicine, but progresses hand in hand with evolution of theories on exorcism. The written records tell us of several outbreaks of hysteria, the most famous of which is undoubtedly the one occurred in the village of Salem (Massachusetts) in 1692. The texts recall an episode in which a slave originally from Barbados talks about the prediction of fate and some girls creat a circle of initiation. This latter was formed by women yunger then twenty years of age and unmarried.The action of creating a circle of initiation was in itself an open violation of the precepts of the Puritans.

There is no record of the first stages of the disease: the girls result "possessed" since February 1692. The symptoms described were staring and barred eyes, raucous noises and muffled, uncontrolled jumps, sudden movements etc. The local doctor, William Griggs, referred the problem to the priest. The slave and two other women were summoned, and the former admitted witchcraft and pacts with the devil. Gradually they began to accuse each other. Eventually, 19 were hanged as "witches", and over 100 were kept in detention. Only when the girls accused the wife of the Colonial Governor of being part of this circle herself, the latter forbade further arrests and trials for witchcraft [ 27]. Marion Starkey, at the end of World War II, reports the case comparing it with more contemporary events [ 27]. Her explanation of classical hysteria is that the illness manifested itself in young women repressed by Puritanism, and was aggravated by the intervention of Puritan pastors, this leading to dramatic consequences. The incident proves thus that hysteria could be seen as a consequence of social conflicts [ 27].

Social conflicts do not occur exclusively in closed societies, such as small communities such as puritanical circles, but they also occur in more open and dynamic societies asbig cities. In 1748 Joseph Raulin published a work in which he defines hysteria as an affection vaporeuse and describes it as a disease caused by foul air of big cities and unruly social life. In theory, the disorder can affect both sexes, but women are more at risk for their being lazy and irritable [ 26].

Between the 17th and 18th centuries a trend of thought that delegated to the woman a social mission started developing. If from a moral point of view she finds redemption in maternal sacrifice that redeems the soul but it does not rehabilitate the body, from the social point of view, the woman takes a specific role. In 1775 the physician-philosopher Pierre Roussel published the treatise "Systeme physique et moral de la femme" greatly influenced by the ideas of Jean-Jacques Rousseau. Femininity is for both authors an essential nature, with defined functions, and the disease is explained by the non-fulfillment of natural desire. The excesses of civilization causes disruption in the woman as well as moral and physiological imbalance, the identified by doctors in hysteria [ 26]. The afflictions, diseases and depravity of women result from the breaking away from the normal natural functions. Following natural determinism, doctors confine the woman within the boundaries of a specific role: she is a mother and guardian of virtue [ 26]. In this context, the woman-witch appears more and more an artifice to secure the social order of ancien régime.

The Enlightenment is a time of growing rebellion against misogyny and sorcery becomes a matter for psychiatrists: in the Encyclopédie we read that sorcery is a ridiculous activity, stupidly attributed to the invocation of demons. And further: mental illness starts to to be framed within the "scientific view" and hysteria is indeed described in the Encyclopédie as one of the most complicated diseases, originally identified by ancient scientists as a problem related to the uterus. Even more interesting is the fact that the causes and symptoms of hysteria and melancholy are linked to the humor theory. Fortunately, the "demonological vision" of women's mental illness did not prevent previous medical theories from being maintained [ 28].

The last "witch" was sentenced to death in Switzerland in 1782, 10 years after the publication of the latest volumes of the Encyclopédie. Her name was Anna Göldi, and her memory was rehabilitated only in 2008 [ 29].

In the 18th century, hysteria starts being gradually associated with the brain rather than the uterus, a trend which opens the way to neurological etiology: if it is connected to the brain, then perhaps hysteria is not a female disease and can affect both sexes. But this is not such a simple shift as it may seem.

The German physician Franz Anton Mesmer (1734-1815) found in suggestion a method of treatment for his patients suffering from hysteria, practicing both group and individual treatments. He identified in the body a fluid called "animal magnetism" and his method soon became famous as "mesmerism". Indeed, it was thought that the magnetic action of the hands on diseased parts of the body could treat the patient, interacting with the fluid within the body. Only later we realized that this was a mere suggestion. Mesmerism had subsequent developments in the study of hypnosis [ 30].

The French physician Philippe Pinel (1745-1826) assuming that kindness and sensitivity towards the patient are essential for good care, frees the patients detained in Paris' Salpêtrière sanatorium from their chains. Pinel's theory derives from ideas linked to the French Revolution: "mad" is not substantially different from "healthy", the balance is broken by the illness and treatment must retrieve this balance. Nonethelsess, Pinel too considered hysteria a female disorder [ 19, 31]. Jean Martin Charcot (1825-1893) the French father of neurology, pushed for a systematic study of mental illnesses. In particular, he studied the effectiveness of hypnosis in hysteria, which, from 1870 onwards, is distinguished from other diseases of the spirit. Charcot argues that hysteria derives from a hereditary degeneration of the nervous system, namely a neurological disorder .By drawing graphs of the paroxysm, he eventually shows that this disease is in fact more common amongst men than women [ 32- 36].

During the Victorian Age (1837-1901) most women carried a bottle of smelling salts in their handbag: they were inclined to swoon when their emotions were aroused, and it was believed, that, as postulated by Hipocrates, the wandering womb disliked the pungent odor and would return to its place, allowing the woman to recover her consciousness [ 34]. This is a very important point, as it shows how Hippocrates' theories remained a point of reference for centuries.

7. Contemporary Age

French neuropsychiatrist Pierre Janet (1859-1947), with the sponsorship of J. M. Charcot, opened a laboratory in Paris' Salpêtrière. He convinced doctors that hypnosis - based on suggestion and dissociation - was a very powerful model for investigation and therapy. He wrote that hysteria is "the result of the very idea the patient has of his accident": the patient's own idea of pathology is translated into a physical disability [ 35]. Hysteria is a pathology in which dissociation appears autonomously for neurotic reasons, and in such a way as to adversely disturb the individual's everyday life. Janet studied five hysteria's symptoms: anaesthesia, amnesia, abulia, motor control diseases and modification of character. The reason of hysteria is in the idée fixe, that is the subconscient or subconscious. For what concerns eroticism, Janet noted that "the hysterical are, in general, not any more erotic than normal person". Janet's studies are very important for the early theories of Freud, Breuer and Carl Jung (1875-1961) [ 35, 36].

The father of psychoanalysis Sigmund Freud (1865-1939) provides a contribution that leads to the psychological theory of hysteria and the assertion of a "male hysteria". Freud himself wrote in 1897: "After a period of good humor, I now have a crisis of unhappiness. The chief patient I am worried about today is myself. My little hysteria, which was much enhanced by work, took a step forward" [ 37]. In 1889 he published his Studies on Hysteria with Joseph Breuer (1842-1925). The key-concepts of his psychoanalytical theory (the influence of childhood sexual fantasies and the different ways of thinking of the unconscious mind) have not yet been formulated, but they are already implicit in this text. Among the cases presented, we find the hysteria of the young Katherina, who suffers from globus hystericus. The text does not refer to the famous Oedipus complex, which emerges through the study of male hysteria, developed after this treatise [ 36- 38].

We now reach a crucial point: until Freud it was believed that hysteria was the consequence of the lack of conception and motherhood. Freud reverses the paradigm: hysteria is a disorder caused by a lack of libidinal evolution (setting the stage of the Oedipal conflict) and the failure of conception is the result not the cause of the deasease [ 36- 38]. This means that a hysterical person is unable to live a mature relationship. Furthermore, another important point under a historical point of view is that Freud emphasizes the concept of "secondary advantage". According to psychoanalysis the hysterical symptom is the expression of the impossibility of the fulfillment of the sexual drive because of reminiscence of the Oedipal conflict [ 36- 38]. The symptom is thus a "primary benefit" and allows the "discharge" of the urge - libidinal energy linked to sexual desire. It also has the "side benefit" of allowing the patient to manipulate the environment to serve his/her needs. However, it is a disease of women: it is a vision of illness linked to the mode (historically determined) to conceive the role of women. The woman has no power but "handling", trying to use the other in subtle ways to achieve hidden objectives. It is still an evolution of the concept of "possessed" woman [ 37, 38].

During 19 th Century, description of hysteria as a variety of bodily symptoms experiencedby a single patient is labeled Briquet's syndrome. In 20th Century several studies are based on a particular presentation of hysteria's symptoms: a loss or disturbance of function which does not conform to what is known about the anatomy and physiology of the body, as loss of speech but not of singing. Psychiatrists note that any function of the body can be affected by hysteria [ 34].

An analysis of the framing of these diagnoses in British medical discourse c. 1910-1914 demonstrates that hysteria and neurasthenia, although undergoing redefinition in these years, were closely connected through the designation of both as hereditary functional diseases. Before the war these diagnoses were perceived as indicators of national decline. Continuity, as well as change, is evident in medical responses to shell-shock [ 38].

The identification of hysterical fit, according to Pierre Janet's theories, was for a long time considered impossible: an example of this diagnostic dilemma is provided by the Royal Free Disease, an epidemic of neurological, psychiatric and other miscellaneous symptoms which swept through the staff of the Royal Free Hospital in London between July and November 1955 and which affected a total of 292 members of staff. In the Medical Staff Report it was concluded that an infective agent was responsible [ 34]. In 1970 McEvedy and Beard put forward an alternative suggestion that Royal Free Disease was an epidemic of hysteria (for example the sensory loss affected a whole limb or part of a limb but the pattern rarely followed the distribution of nerves to the skin) and also pointed out that the spread of the symptoms, predominantly affecting young female resident staff, is characteristic of epidemics of hysteria, which usually occur in populations of segregated females such as girl schools, convents and factories. They wrote also that hysteria had a pejorative meaning in their society, but that should not prevent doctors from weighing the evidence dispassionately [ 34].

Besides defining the nature of hysteria, 20 th Century psychiatrists also considered its history and geography. During World Wars hysteria attracted the attention of military doctors, and several authors have recorded their impressions on the frequency of hysteria in this period. Under battle conditions, the way in which hysterical symptoms provide a solution for emotional conflicts is particularly clear. A soldier torn between fear of facing death and shame at being thought a coward may develop a hysterical paralysis of his arm, sickness being a legitimate way out of the conflict [ 34]. For instance, in 1919 Hurst wrote that "many cases of gross hysterical symptoms occurred in soldiers who had no family or personal history of neuroses, and who were perfectly fit". In particular, in 1942 Hadfield commented that the most striking change in war neurosis from World War I to World War II was "the far greater proportion of anxiety states in this war, as against conversion hysteria in the last war" [ 34]. But World War II not only allowed for a comparison with World War I in terms of patterns of neurotic symptoms, but also become a opportunity for cross-cultural comparisons between troops from widely differing cultural backgrounds [ 34].

Abse's studies (1950) on hysteria in India during World War II demonstrate that, 57% of the 644 patients admitted to the Indian Military Hospital in Delhi during the year 1944, were diagnosed as suffering from hysteria and 12% were diagnosed as suffering from anxiety states. Abse also collected data from a British Military Hospital in Chester (June to October 1943) and he demonstrated the existence of a majority of anxiety states (50%) than hysteria cases (24%) [ 34].

Others studies confirm these data. In particular, in 1950 Williams demonstrated that Indian hysterics were often of high morale and were of all grades of intelligence, whereas among the British, gross hysterical reactions were the breakdowns of men with low stability and morale and usually of low intelligence [ 34]. Moreover, these studies demonstrate that from World War I to World War II there was a small relative decline of hysteria among British soldiers which was paralleled by a relative rise in anxiety states and by contrast, hysteria was still the most common form of neurosis among Indian soldiers in World War II. The contrasting patterns shown by soldiers suggest that hysteria and anxiety neurosis bear a reciprocal relationship, so that the decline of the former is compensated for by a rise in the latter [ 34].

But this also seems to demonstrate a different progress of hysterical disease in Western and non-Western societies. In the second half of the 20 th century, we witness a "decrease" of hysteria (as response to stress, which represents the patient concept's of bodily dysfunction) in western societies. Data of annual admissions for hysteria to psychiatric hospitals in England and Wales from 1949 to 1978 show that they are diminished by nearly two-thirds, with a marked decline in the proportion from 1971 onwards, and a similar decrease is recorded in a study conducted in Athens as well [ 34]. Hysteria was in fact a major form of neurotic illness in Western societies during the 19 th Century and remained so up to World War II. Since then there appears to have been a rapid decline in its frequency and it has been replaced by the now common conditions of depressive and anxiety neuroses.

But the studies focused on Indian patients as well as on others non-Western countries as Sudan, Egypt and Lebanon [ 34] demonstrate that during the second half of 20 th Century hysteria, as one of the somatic ways of expressing emotional distress, remained a prominent condition among psychiatric patients, although anxiety and depressive neuroses may have gained a little ground. Hence, psychiatrists supposed that it was an unstable transitional phase and predicted the disappearance of hysteria by the end of 20 th Century [ 34].

There seems to be an inverse relationship between decreasing of hysteria and increasing of depression in Western society. The idea that depression was more likely to manifest itself in those born after the Second World War has been suggested in 1989 by Klerman [ 39]. More recently it has been documented by studies repeated over time in America and Australia, although there are exceptions in specific areas in relation to specific socio-environmental conditions and migration [ 40- 44].

A systematic review of misdiagnosis of conversion symptoms and hysteria, based on studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease, demonstrate that a high rate of misdiagnosis of conversion symptoms was reported in early studies but this rate has been only 4% on average in studies of this diagnosis since 1970 [ 45]. This decline is probably due to improvements in study quality rather than improved diagnostic accuracy arising from the introduction of computed tomography of the brain [ 40].

We know that the concept of hysterical neurosis is deleted with the 1980 DSM-III: hysterical symptoms are in fact now considered as manifestation of dissociative disorders.

The evolution of this disease seems to be a factor of the social "westernization". Several studies on mental diseases seem to validate this hypothesis. In 1978 Henry B. Murphy (1915-1987) [ 46] individuated the main causes of melancholy in social change and consequent socio-economic changes. A picture characterized by self-blame feelings, low self-esteem and helplessness. These features were described as being due to a rapid social change in two different social theatres: in those areas of England interested in turning the feudal economy into an industrial7at the centre of one at the end of the 17 th century, and more recently in some areas of Africa affected by rapid economic development. In both cases the onset of psychopathological symptoms has been related to two main factors: on the one hand, the disruption of an enlarged family and the loss of a close emotional support for the individual, and on the other hand by a marked striving towards economic individualism. In this new psychological and external contest destiny and future will no longer be determined by fate, but menbuildtheir own destiny, an unknown and hard responsibility towards life [ 47]. In 1978 Murphy wrote that in Asia and in Africa these symptoms are rare, except among the Westernized persons, and that it could be useful to examine under what conditions these symptoms first became common in different societies [ 46].

From the expression of discomfort "hysteria" to the expression of discomfort "melancholy" the different conception of the self isessential. The world of hysterical manifestation is a world of "dissociation": something dark (trauma, external influences) affects a symptom not directly interpretable. From here the development in the West of hypnotic therapies (up by Mesmer to Freud and Janet) [ 36] and, in the West more than in non-Westernized world, it is the implementation of exorcism and purificatory rituals that mark the meeting with the groups: Tarantism and Argia in South Italy [ 47], Narval-Wotal practices of West African immigrants [ 48- 52]. A world linked to a vision of women as a means unaware of evil forces, "out of control" from reasonableness or (in European Positivism) be an "immature" with manipulative behavior that seeks to achieve an improper position of power. Also the world of Melancholy is female, predominantly female since women suffer from depression at a ratio of 2.5 to 1 compared to men [ 48, 43]. But it is a reality in which, indeed, the patient (and therefore the patient woman) is aware of the conviction-conquest of being the master of its own destiny (and therefore to blame for their failures). We can see this passage in 1980s Africa.

Modern Africa is characterized by a variety of different economic and social situations which are not easy to compare, but in which urbanization and the progressive loss of tribal links is a common trend. In recent years several research projects concerning the transformation of psychopathology, based on African populations and African Immigrants in Sardinia, Italy, confirmed Murphy's hypotheses on the role of social change and its socio-economic consequences in the genesis of a depressive symptomatology [ 48]. Studies involved populations in which traditional social structure still survives and which have just marginally been affected by social changes; populations undergoing a rapid change towards economic individualism, although these have now become a rarity in modern-day Africa; populations whose traditional social structures and underlying human relationships have been able to compromise and face the processes of partial change by actively adapting to the new realities [ 48]. is the starting point is the distinction between the character of African psychopathology, the prevalent form of which is characterized by ideas of reference, persecutory delusions and psychosomatic symptoms, and the "western" depression, which involves self-guilt, unworthiness and suicidal conduct. The "Westernization" of the pathology is expressed through the changing of symptoms, from African to West models. A detailed analysis of the African community surveys revealed in the Bantu area the existence of populations characterized by a psychopathological risk similar to the one highlighted in westernized settings such as among the women in Harare who presented a yearly prevalence rate for anxiety and depressive disorders. A psychosocial key - confirmed by several studies - may suggest that maintaining close links with the group of origin can play a protective role against mood-related disorders [ 48].

Several studies identify the existence of two counter-posed means of expressing depression which are most likely "culturally determinated" from a "different level of westernization" [ 42]. Researchers in transcultural psychiatry suggest that social factors may influence the modification of the melancholical phenomenology and modulate the risk of depression [ 53- 55].

A survey on the Dagon Plateau conducted amongst farmers and nomadic Fulani herdsmen in Mali, reveals a very low frequency of depression and depressive cadres that are exclusively linked to secondary reactions of serious somatic disease in illiterate individuals [ 50]. In addition, the psychopathology over the Plateau is manifested with two opposing syndromic lines, first the constellation of symptoms of persecution, psychosomatic and psichastenia, loss of interest in things, syndrome guilt, sadness, suicidal ideas. This is typical of educated individuals [ 51].

A study carried out in the Namwera area in Malawi on the Mozambique border, during a deep micro and macro-social transformation which led to the establishment of a multiparty form of democracy following popular referendum, demonstrates that an emotional earthquake was caused by the conflict in having to choose between innovation and tradition. This situation in fact flew into a full-blown epidemic of hysteria among young women [ 48]. In the above context, in 1988, a dress factory, financed through an Italian co-operation, had been established in a village populated by the Yao and Chicewa groups, characterized by an agricultural economy. The project was articulated in order to allow women to redeem the equipment following a training period and set up independent activity [ 48].

In view of the particular condition of women in these cultures, this sudden passage from a traditional female role to a more independent activity seemed to be particularly suited for a study of the relationship between personal transformation and psychopathological changes. The study was carried out using three samples of age-matched women: dressmakers, farmers/housewives (traditional role), and a group of nurses and obstetricians [ 48]. The history of their development, including the presence of stressful events and other risk factors, together with the degree of satisfaction with their jobs and married life and other socio-anagraphic variables, was investigated by means of a specifically validated interview [ 51].

The choice of an innovative occupation (dressmaker/nurse) could be read as an adaptive answer in order to survive. Innovative occupations were source of satisfaction as job in itself, but they were causes of serous interpersonal and couple conflicts, linked to the new woman role and job. Housewives and dressmakers were more dissatisfied with their situation than nurses and they presented an increased number of psychopathological symptoms and the number of depressed subjects diagnosed according to DSM-IIIR was higher [ 48, 51].

Housewives also experienced an increased frequency of psychosomatic symptoms, such as headache, excessive fatigue, feelings of worthlessness, and often reported suffering from the conviction that people did not recognize the importance of their role, and that someone could affect their health which is interpretable as an external localization of the source of their distress, in according to the character of African psychopathology. [ 48, 51] On the other hand, dressmakers showed a high frequency of depressive symptoms, problems about self-esteem, belief of social uselessness and suicidal thoughts [ 48, 51].

In a characteristic manner the suffering women also differed in the attribution of the causes of their discomfort. The "entrepreneurs" believed that the cause of their suffering had to be sought in their mistakes, the traditional women attributed to "evil spell" their ailments [ 51].

Among the three groups, nurses showed the highest frequency of psychological well-being and emotional stability. This should be interpreted as the result of good integration into a new identity due to a job related to a women's traditional role and to satisfaction about financial stability. Without drastically breaking with tradition, according to several psychosocial lines, a cultural institution such as an innovative job is perceived by both society and the individual as being an integral part of the evolving self, and it creates conditions for cultural transmission to go on. This interpretation explains why nurses did not suffer from conflicts between tradition and innovation, while dressmakers, whose new individualistic role broke with women's traditional one, did not feel accepted by their group and were consequently more vulnerable to mood disorders and particularly to depression, a "western" depression [ 48].

Instead, in populations which were far removed from the processes of westernization depressive disorders were relatively rare and nearly always secondary to severe somatic disorders, while they manifested themselves as primary disorders only in better educated subjects [ 48]. Several studies demonstrated that the threshold of onset of depression is situated on a higher level compared to western cultures and tend to support the hypothesis of a means of expression characterized by syndromic aggregations halfway between "western" style or "guilty" and "traditional" or "dislocation from the group". Environmental factors seem to affect the the evolution of depressive symptoms and risk of depression, through modifications in the social organization thatelicit an attitude of "compulsive self-responsabilization" which would otherwise have been destined for extinction [ 48].

8. Focus on Sardinian Modern Cases

We should like to conclude by discussing some Sardinian cases which seem to contradict what has been said above: in modern times, they apparently document the continued use of Hippocrates' and Galen's ancient medical theories in relation to hysteria.

THE MANAGU HOSPITAL IN SIDDI, SARDINIA, ITALY

This small rural hospital, which was open from 1860 to 1890 in the small village of Siddi (in the heart of the Marmilla area, Sardinia) admitted 463 patients, the subject of our recent research. 122 were women (mainly peasants, maids and housewives), and of these, 10 were suffering from hysteria (sometimes the diagnosis was simple hysteria, on other occasions they were suffering from convulsions, constipation, intermittent fever...) [ 56]. In analyzing the simplest cases, where the hysteria was not combined with other diseases, we found the constant use of antispasmodics, sedatives and refreshing concoctions in the form of decoctions, infusions, creams, ointments and poultices. First of all, a decoction of tamarind and barley, extract of belladonna, valerian and liquid laudanum. Following this, infusions of fennel, mint and orange flowers, chamomile flowers and lime, cassia pulp and elder-tree ointment [ 57]. Only in one case (1868) was additional treatment prescribed in the form of polenta poultices, sulphates of potassium iodide, leeches, rubbery emulsions with iron carbonate and gentian extracts, and in another (1871) morphine acetate, infusions of senna leaves, citric acid and ammonium acetate ethers [ 57].

Treatment varied when the hysteria was associated with other symptoms such as, for example, epileptic convulsions: in the first phase the patient was administered zinc oxide, valerian extract, enemas with an emulsion of asafoetida and an egg yolk (to be repeated every 4 days) and then baking soda, water, fennel, turpentine and rosewater for rubs. Finally electuaries and polenta poultices [ 57].

The case of a young female patient at Managu is similar to the previous ones. Hospitalized for less than 54 days, the young woman was subjected to treatment based on emulsions of chloral hydrate, Burgundy pitch plasters, lemonade, water mint and lemon balm [ 57].

VILLA CLARA, CAGLIARI'S PSYCHIATRIC HOSPITAL, SARDINIA, ITALY

We are at the beginning of the twentieth century: the psychiatric hospital Villa Clara in Cagliari is an institution which ensures the implementation of the most advanced "psychiatric therapy". In actual fact, this advanced therapy consisted in the "application of leeches, drastic purges, cold baths and in procuring groups of blisters, usually on the neck" [ 58]. Villa Clara's story is contained in 16,000 archival files, still being sorted, but if there were any need of corroboration, its history is screamed out in the words of Giovanna M., Villa Clara's Register 1. Giovanna M. was admitted to Genoa hospital when she was 10 years old, diagnosed with madness: she had a terrible headache, but preferred to say she had a "cranky head" and three years later in 1836, she was moved to the basement of Cagliari's Sant'Antonio Hospital [ 58]. She describes this "as dark as a tomb, the only place on the island where the mad... or the insane... or the maniacs... or the idiots - as we were called- were locked up. We were 50 people in chains, in the smell of our own excrement, with rats gnawing at our ulcers..." [ 58]

In the early years of the new century, after a long break at Cagliari's new San Giovanni di Dio Hospital, Giovanna M., now old and blind, was transferred to the Villa Clara psychiatric hospital, where Professor Sanna Salaris formulated a diagnosis of "consecutive dementia" and hysteria. But despite being constantly subjected to careful clinical observation, she was only treated here with "tonics ... two eggs and milk ... balneotherapy, rhubarb tinctures, potassium iodide, lemonade and laudanum, insulin and laxatives, a lot of purgatives: always, for everything". Giovanna M. died in the mental hospital in 1913 due to "ageing of organs" and "senile marasmus", as confirmed in the necrological report. Anna Castellino and Paola Loi know all there is to know about Giovanna M. and end their work Oltre il cancello with Giovanna's words: "And you'd better believe it: I was 90 years old. Fate, which takes away healthy, free, young people, never pardoned me once. It has let me live all this time, quite lucid, but closed up in here ... since I was ten years old .... eighty years in psychiatric hospital for a headache" [ 58].

CONCLUSIONS

Lengthy the history, social changes seem to offer a fertile substrate for the evolution of complex innovative systems of interpreting reality, of attributing the causes and controlling events, of living emotions. A critical study of the historical development and the interpretations of mental diseases may contribute to providing an explanation for the means of psychopathological expression. Moreover, it may provoke a re-discussion of the threshold and vulnerability concept in cases where it could be hypothesized that the new cognitive systems, although adaptive to new social requirements, might represent a factor of vulnerability ("culturally specific") to specific mental disorders.

We have seen that both the symptomatic expression of women' malaise and the culturally specific interpretation of the same malaise witness the changing role of women. From incomprehensible Being (and therefore mean of the Evil) to frail creatures that try, however, to manipulate the environment to their own ends (in Freud's view) to creature arbiter of his fate (in the modern transformation from hysteria to melancholia), where the woman seems to have traded power with the loneliness and guilt.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflicts of interest.

REFERENCES

8. Vanzan A. Malinconia e Islam. POL.it [revista en la Internet]. Julio de 2007. Disponible en: http://www.pol-it.org/ital/islam.htm. POL.it [revista en la Internet]. Julio de 2007. Disponible en: http://www.pol-it.org/ital/islam.htm.

15. Trotula de Ruggiero. On women's health. Palermo: La Luna wise. 1994.

42. Carta MG, Mura G, Lecca ME, et al. Decreases in depression over 20 years in a mining area of Sardinia: Due o selective migration? J Affect Disord 2012. 2012. [Epub ahead of print] [ PubMed]

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Women, Power, and Reproductive Healthcare Brochure

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While female physicians have been far from center stage in the past, some of medicine's biggest history-makers were women.