Introduction: What’s in a Name? Why We Use “Women’s Reproductive Mental Health,” and Toward a Future of Different Names

When we first proposed this textbook to the American Psychiatric Association, we editors (all of whom call ourselves reproductive psychiatrists or perinatal psychiatrists) were adamant that the title be reflective of the subject—mental illness that arises at moments of female reproductive transitions. This is not the same as women’s mental health—women’s mental health is a broader definition that includes our subject, the intersection of mental illness with female reproductive cycles—but also includes other categories, such as female sex (e.g., brain sexual dimorphism, female-specific comorbidities, pharmacokinetic sex differences) and female gender (e.g., gender roles, gender-linked trauma). “Reproductive psychiatry” or “reproductive mental health” alone would not do because this book does not address mental illness related to reproduction in men. “Women’s reproductive mental health” seemed the most accurate term, but we are conscious of the fact that it may not long remain so. Definitions of “woman” are evolving rapidly in our society, and we recognize that many people assigned female sex at birth do not identify as women, that many people assigned male sex at birth DO identify as women, and that many people of both biological sexes identify as neither (Stroumsa and Wu 2018). The view that gender and sex can be categorized into two genetically fixed, nonoverlapping constructs has been swept away, and increasingly, our reliance on two culturally constructed categories is misleading and outdated (Hyde et al. 2019). As of the writing of this book, the data concerning mental illness at times of reproductive transition in people who are not cisgender women are extremely limited. We know little about either the biological or psychological effects on mental health of hormonal transitions for transgender men who choose to become pregnant, for example, or whether premenstrual mood symptoms present or are interpreted differently in nonbinary individuals than in cisgender women.

Although we are thus conscious that the resulting book is therefore focused primarily on the reproductive mental health of cisgender women, we are also confident that this will not always be the case. We hope and expect that subsequent editions will be able to incorporate more about people with gender-diverse identities and that one day there will be enough data for an additional book. Physicians have been writing about mental health associated with female reproductive transitions since the time of Hippocrates, and in the United States, it has been just over 20 years since the establishment of the first postdoctoral fellowship position in women’s mental health, yet this is the first comprehensive textbook on the subject. It may be another 20 years before enough data accumulate for a whole textbook on reproductive mental health in people with gender-diverse identities, but we do not think it will be another 2,500 years.

That said, we have tried whenever possible to incorporate available data in the appropriate chapters and to use inclusive language and case examples. In addition, we would like to outline here some special considerations for those living with gender-diverse identities and for sexual minorities who face challenges not shared by other groups, as well as some basic definitions that may not be familiar to all readers and may be useful in understanding the subsequent chapters.

Research indicates that LGBTQ+ individuals may experience increased barriers to health care, including discrimination, stigmatization, and lack of provider knowledge about the health care needs for this population (Baptiste-Roberts et al. 2017; Chapman et al. 2012; Institute of Medicine 2011). Psychiatry providers should be familiar with guidelines for the health care of LGBTQ+ patients, such as those published by the Gay and Lesbian Medical Association (2005), The Joint Commission (2014), and the American Academy of Child and Adolescent Psychiatry (Adelson and American Academy of Child and Adolescent Psychiatry Committee on Quality Issues 2012).

The term gender roles refers to society’s expectations regarding behaviors, traits, and attitudes according to one’s sex assigned at birth. A patient’s (or their partner’s) expectations and attitudes toward gender roles may affect their sexual functioning (e.g., traditional gender norms reflect expectations that women should be sexually subservient to men). Gender identity reflects how one identifies one’s own gender, such as male, female, transgender, or nonbinary. It is influenced by socially defined constructs, and it is increasingly apparent that there may be a heritable biological component as well (Polderman et al. 2018). Sexual orientation refers to one’s pattern of emotional and physical arousal and the gender(s) of persons to whom one is sexually or physically attracted. Sexual identity refers to individuals’ assessment of their own sexual orientation (e.g., lesbian, gay, bisexual, questioning or queer) (Levine and Committee on Adolescence 2013). Sexual orientation and sexual identity are unrelated to gender identity.

Providers working with transgender individuals should be familiar with the World Professional Association for Transgender Health (2012) standards of care. Transgender individuals seeking gender-affirming therapy (e.g., feminizing or masculinizing hormone therapy, surgery) require referrals from mental health providers, which is described further in the standards of care document. Psychotherapy is not an absolute requirement for hormone therapy and surgery, although it is highly recommended. Mental health professionals working with individuals seeking or undergoing gender-affirming therapy (e.g., hormone therapy, surgery) should be aware of the benefits and risks of these therapies on mental health and sexual function.

Part of the criteria for recommendation for gender-affirming therapy is persistent, well-documented gender dysphoria (World Professional Association for Transgender Health 2012). Gender dysphoria in adolescents and adults is typically defined as a distressing, marked incongruence or discrepancy between one’s gender identity and one’s sex assigned at birth and the gender role, primary sex characteristics, or secondary sex characteristics associated with that sex (American Psychiatric Association 2013; Knudson et al. 2010). DSM-5 (American Psychiatric Association 2013) includes specific criteria for the diagnosis of gender dysphoria. Despite some controversy regarding gender dysphoria as a diagnosis (e.g., potential stigmatizing or overpathologizing effect) (Davies and Davies 2020), the diagnostic label was changed from gender identity disorder to reduce the potential stigmatizing effect, and the diagnosis was retained in part to acknowledge the full impact of dysphoria and to increase access to gender-affirming services (e.g., billing requirements) (Byne et al. 2018).

Sexual identity can be fluid and dynamic across time (Diamond 2008). Thus, clinicians should be careful not to make assumptions about patients’ sexual behavior or about their family planning or reproductive health care needs based on their described gender or sexual identity. For example, many women who have sex with women also report having had sex with men (Diamond 2008). Discussion of issues such as contraception, risk for pregnancy and sexually transmitted infections, and accessing services for third-party involvement in reproduction (e.g., gestational carrier) or adoption is still relevant to women who have sex with women, as well as for trans men (who may continue to have vaginal intercourse with men) and for trans women, who have disproportionately high rates of HIV (Baral et al. 2013). Research regarding rates and phenomenology of sexual dysfunction among LGBTQ+ persons is scarce, although it remains important to assess sexual functioning in this population with consideration of the biopsychosocial model. Notably, LGBTQ+ individuals experience greater rates of victimization and mental health concerns (e.g., depression, anxiety) (Institute of Medicine 2011), which can negatively affect sexual function. Additional sexuality considerations across female reproductive milestones are outlined in the following discussion.