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Sex-specific differences in various biological functions as well as in brain neuroanatomy and circuits may result in different prevalence, symptomatology, treatment responses, and outcomes in neuropsychiatric and many other disorders.

 In addition, men and women are not equally exposed to psychosocial stressors such as 

 How many sex/gender differences in health are due to biology or to the consequences of behavioral and sociological factors remains to be sorted out. This article will detail how women’s mental health is in need of improvement, and how the 

 has highlighted a number of preexisting difficulties.

Inspiring Collaboration in Cardiovascular Health

The recent mobilization of cardiologists is a perfect example of how we could advance women’s health, especially mental health. In women, 

 is the leading cause of death, causing 35% of all deaths worldwide. Yet it remains underdiagnosed and undertreated, and women remain underrepresented in clinical trials. Apart from common risk factors that are shared by males and females, sex-specific factors such as premature menopause, gestational diabetes, hypertension during 

, preterm delivery, polycystic ovary syndrome, systemic inflammatory and autoimmune disorders may play a 

. Other important and underrecognized risk factors (abuse and intimate partner violence, socioeconomic deprivation), most frequently observed in women, may also play an additional role.

Risk factors that were observed more traditionally in men have increased in women. For example, historically, women have used tobacco, alcohol, or illicit drugs less often than men, and they have consumed alcohol in lower amounts than men. However, over time, the gradual change in the societal role of women and the lessening of social taboos have led to a rise in both the frequency and level of 

alcohol, tobacco, and illicit drug consumption among women

Women usually start using psychoactive substances, including alcohol, as coping strategies to face depression, anxiety, and negative feelings, whereas men usually are more influenced by peers or sensation seeking. Consequently, the greater exposure of women to negative life events such as trauma and violence is a major contributing factor to the narrowing gap between rates of psychoactive drug use among men and women. Sex hormones and differences in pharmacokinetics and neurobiological circuits may also contribute to differences in susceptibility to dependence.

Moreover, men and women are differentially affected by triggers for relapse to drug taking. Potenza et al

 have studied neural correlates of cue-induced craving states in women and men addicted to cocaine and reported sex differences in cue-induced craving, with corticostriatal-limbic hyperactivity being linked to stress cues in women but to drug cues in men. In addition, women suffer more severe consequences of 

, tobacco, and drug use with lower doses than men; they also suffer from pregnancy complications (for review see Fonseca et al, 2021; Thibaut et al, 2019).

 Finally, women have a higher risk of relapse but achieve better results than men when they adhere to specialized treatment. Gender-oriented treatment is needed to take into account gender-related vulnerabilities.

In partnership with the Icahn School of Medicine at Mount Sinai, the journal 

 has convened a cardiovascular disease commission, including experts from 11 countries.

 The commission proposed 10 recommendations to reduce this global burden by 2030, including educating health care providers and patients on early detection; using heart health programs in highly populated and underdeveloped regions; and prioritizing sex-specific research in women on heart disease and intervention strategies.

 We should be inspired by this interesting collaboration in women’s health and create a similar list of recommendations, focusing on prevention, early detection, and treatment, to reduce the global burden of 

The COVID-19 pandemic highlighted the urgent need for sex-specific clinical and pharmacological studies. The fatality rate with COVID-19 and the severity of the disease were higher in men than in women; for every 10 females, there were 15 confirmed cases in males who have died and 18 male intensive care unit admissions.

 The higher death ratio reported in men may be partly explained by more preexisting cardiovascular or metabolic diseases, as well as higher risk-associated behaviors such as alcohol abuse, 

, and less compliance with sanitation measures.

 Hormonal (eg, estrogens) and genetic differences in the immune response may protect women against infectious diseases, but, at the same time, put them at higher risk of autoimmune disorders and inflammatory diseases.

 Yet the COVID-19 pandemic has affected women more than men, both as frontline workers and at home due to lockdown and quarantine measures.

Worldwide, 70% of the frontline health workforce (nurses, midwives, and community health workers) and facility service staff (cleaners, laundry, catering) is made up of women.

 As a consequence, women were more likely to be exposed to the virus.

 For example, in Italy and Spain, 66% and 72% of infected health workers were females, compared with only 34% and 28% of males, respectively (

 Moreover, the severity of COVID-19 was higher in pregnant women, with a higher risk of intensive care unit admission and 

potential risks for the fetus and/or the baby

In addition, psychological consequences of the COVID-19 pandemic were more often observed in women, both in the general population and in COVID-19 positive patients, compared with prepandemic data.

 The mean rate of depressive disorders for females is approximately twice that of males (1.63-3.89), and anxiety disorders are more common in women than in men, increasing two- to threefold in the occurrence of generalized anxiety disorder and personality disorders.

 These preexisting sex differences were even greater after the pandemic, as females were more affected by the pandemic than males for major depressive disorders (B=0.1 [0.1-0.2; 

<.001]) and for anxiety disorders (B=0.1 [0.1-0.2; 

<.001]), especially in the younger age group.

In the same way, in Japan, Tanaka and Okamoto

 reported that, following a decrease by 14% during the first 5 months of the pandemic (February to June 2020), 

 increased by 16% (between July and October 2020), with a larger increase among females and younger populations, compared to males and older populations.

 (PTSD) was reported in one-third of 381 patients who initially sought treatment at the emergency department in Rome (Italy) for severe SARS-CoV-2. Sex (being a female), delirium or agitation, and persistent medical symptoms were associated with PTSD.

Overall, women were more likely to be affected by the economic and social consequences of the COVID-19 pandemic.

 Additional household tasks, lower salaries, and less secure employments were more likely to occur in women compared to men. Riley et al26 have conducted a cross-sectional study in 2020 among 152 women experiencing homelessness and unstable housing in San Francisco. Half of these women experienced moderate-to-severe depressive and anxiety symptoms during the pandemic; these symptoms were associated with increased challenges accessing non–COVID-19 care and managing symptoms for chronic medical conditions.

Women were also at higher risk of domestic violence during the pandemic, with increases found internationally, which may, in turn, induce or aggravate psychiatric symptoms (

Finally, despite different pharmacokinetic and pharmacodynamic properties of many compounds according to sex, medications have been studied essentially in men, and the data obtained about the clinical efficacy and potential adverse effects have been extrapolated to women. In addition, 

 were often excluded from clinical trials. Furthermore, in several cases, adverse events of medications during pregnancy became apparent only after many reports of toxicity to the fetus and/or the newborn (eg, sodium valproate, lithium).

Yet despite known sex-specific differences, sex/gender effects remain largely under-studied in clinical and pharmaceutical trials. For example, 10 prescription drugs were withdrawn from the US market between 1997 and 2000. Eight of these 10 compounds showed higher health risks for women than for men. In 4 cases, they were prescribed more often to women, while the other 4 had more adverse events in women even though they were widely prescribed to both.

 Moreover, of the 350 cases of anaphylaxis after vaccination in adults, reported to the Vaccine Adverse Event Reporting System in the US between 1990 and 2016, 80% were observed in females, with influenza vaccines being most frequently reported.

In the United States, of the 300 new drug applications received by the FDA (1995-2000), only 163 included sex-based pharmacodynamic analysis, and 11 drugs showed a 40% or greater sex difference in pharmacokinetics. This information was listed on the drug label, yet no differences in dosing between males and females were recommended.

 The European Association of Science Editors reported that sex was not reported for 22% to 60% of animals used in biological and immunological preclinical studies. In a study based on 768 trials, 89% reported recruitment of males and females, but less than 1% reported that they analyzed gender effects.

. Among them, 16% stratified analyses by sex, but no studies reported a calculation powered for the analysis of its primary outcome by sex. In fact, a gender-sensitive perspective is urgently needed.

In 2016, the Cochrane Sex/Gender Methods Group published a paper entitled, “Why sex and gender matter in health research synthesis.”

 Clinical and pharmacological research reflects a mostly male perspective, assimilating women to men despite known biological and pharmacological differences. Participation of women of reproductive age in clinical trials is necessary, provided that there is adequate risk protection 

. In the near future, every pharmaceutical compound should clearly mention whether trials were conducted in women or not, and whether different adverse effects might be expected in women. For this purpose, the US National Institutes of Health, the Canadian Institutes of Health Research, and the European Commission have called for sex/gender analyses in all clinical trials. Heidari et al

 have published a procedure for reporting sex and gender information in study design, analysis, and interpretation of the data.

According to a recent statement from Phumzile Mlambo-Ngcuka, former executive director of United Nations (UN) Women, “This is a moment for governments to recognize both the enormity of the contribution women make and the precarity of so many.”

Women are currently facing a number of important issues: financial crisis is gradually developing in this post–COVID-19 period and, as a consequence, mental health issues are likely to grow exponentially. According to the UN, women aged 24 to 34 years are already 25% more likely than men to face extreme poverty.

 As such, the UN recommends allocating additional resources to protect women, putting women at the center of policy changes, and collecting more sex-disaggregated data to analyze the impact of pandemics on women.

 Moreover, the 17 Sustainable Development Goals proposed by the UN offer a unique opportunity to achieve gender equality before 2030,

 which is a key element in sustaining women’s health.

is professor of psychiatry at the University of Paris and University Hospital Cochin-Tarnier, and president of the International Association of Women's Mental Health.

Sex and racial differences in pharmacological response: where is the evidence? Pharmacogenetics, pharmacokinetics, and pharmacodynamics.

2. Howard LM, Ehrlich AM, Garnlen F, Oram S. 

Gender-neutral mental health research is sex and gender biased.

Sex differences in the developing brain as a source of inherent risk.

4. Vogel B, Acevedo M, Appelman Y, et al. 

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.

5. García-Moreno C, Riecher-Rössler A, eds. 

6. Thibaut F. Overview of women and addiction. In: Chandra PS, Herrman H, Fisher J, Riecher-Rössler A, eds. 

Mental Health and Illness Worldwide, Mental Health and Illness of Women

7. Potenza MN, Hong KI, Lacadie CM, et al. 

Neural correlates of stress-induced and cue-induced drug craving: influences of sex and cocaine dependence.

8. Fonseca F, Robles-Martínez M, Tirado-Muñoz J, et al.

 A gender perspective of addictive disorders. (Gender, F Thibaut and J Labad Arias, Section Editors).

9. Thibaut F, Chagraoui A, Buckley L, et al. 

WFSBP * and IAWMH ** Guidelines for the treatment of alcohol use disorders in pregnant women.

10. The Sex, Gender and COVID-19 Project. The COVID-19 sex-disaggragated data tracker. Updated October 27, 2021. Accessed November 3, 2021. 

https://globalhealth5050.org/the-sex-gender-and-covid-19-project/the-data-tracker/

11. Johnson HD, Sholcosky D, Gabello K, et al. 

Sex differences in public restroom handwashing behavior associated with visual behavior prompts.

Inborn errors of type I IFN immunity in patients with life-threatening COVID-19.

14. Bastard P, Rosen LB, Zhang Q, et al. 

Autoantibodies against type I IFNs in patients with life-threatening COVID-19. 

15. Tsiambas E, Chrysovergis A, Papanikolaou V, et al. 

Chromosome X riddle in SARS-CoV-2 (COVID-19) - related lung pathology.

16. United Nations. Policy brief: the impact of COVID-19 on women. April 9, 2020. Accessed November 3, 2021. 

https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2020/policy-brief-the-impact-of-covid-19-on-women-en.pdf?la=en&vs=1406

17. Boniol M, McIsaac M, Xu L, et al. Gender equity in the health workforce: analysis of 104 countries. World Health Organization. March 2019. Accessed November 3, 2021. 

https://apps.who.int/iris/bitstream/handle/10665/311314/WHO-HIS-HWF-Gender-WP1-2019.1-eng.pdf

18. Capobianco G, Saderi L, Aliberti S, et al. 

COVID-19 in pregnant women: a systematic review and meta-analysis. 

19. Della Gatta AN, Rizzo R, Pilu G, Simonazzi G. 

Coronavirus disease 2019 during pregnancy: a systematic review of reported cases.

20. Vivanti AJ, Vauloup-Fellous C, Prevot S, et al. 

Transplacental transmission of SARS-CoV-2 infection.

21. COVID-19 Mental Disorders Collaborators. 

Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic.

Uncovering the hidden impacts of inequality on mental health: a global study.

23. Jalnapurkar I, Allen M, Pigott AT. Sex differences in anxiety disorders: a review. 

Increase in suicide following an initial decline during the COVID-19 pandemic in Japan.

25. Janiri D, Carfi A, Kotzalidis GD, et al. 

Posttraumatic stress disorder in patients after severe COVID-19 infection. 

26. Riley ED, Dilworth SE, Satre DD, et al. 

Factors associated with symptoms of depression and anxiety among women experiencing homelessness and unstable housing during the COVID-19 pandemic.

27. UN Women. COVID-19 and ending violence against women and girls. April 6, 2020. Accessed November 3, 2021. 

https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2020/issue-brief-covid-19-and-ending-violence-against-women-and-girls-en.pdf?la=en&vs=5006

28. United States Government Accountability Office. Drug safety: most drugs withdrawn in recent years had greater health risks for women. January 19, 2001. Accessed November 3, 2021. 

https://www.gao.gov/assets/gao-01-286r.pdf

Anaphylaxis after vaccination reported to the Vaccine Adverse Event Reporting System, 1990-2016.

30. Schiebinger L, Leopold SS, Miller VM. 

Editorial policies for sex and gender analysis.

31. Sex/Gender Methods Group. Why sex and gender matter in health research synthesis. Cochrane Methods Equity. 2016. Accessed November 3, 2021. 

https://methods.cochrane.org/equity/sex-and-gender-analysis

32. Heidari S, Babor TF, De Castro P, et al.

 Sex and gender equity in research: rationale for the SAGER guidelines and recommended use.

33. UN Women. Turning promises into action: gender equality in the 2030 Agenda for Sustainable Development. February 14, 2018. Accessed November 3, 2021. 

http://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2018/sdg-report-summary-gender-equality-in-the-2030-agenda-for-sustainable-development-2018-en.pdf?la=en&vs=949

Women are currently facing a number of important issues in mental health. How can clinicians improve this situation? 

Issues in Women’s Health: Global Lessons, Opportunities, and Challenges

. I am a man (he/him), so I have had to try to learn—both as a psychiatrist and as a man—what that might mean entail and, now, how to comment. After all, this is a psychiatry and society column, so how could it then ignore one of our major current societal issues that seems to have so many social psychiatric considerations?

My direct personal and professional involvement with abortion, limited as it is, goes back more than 50 years ago. While I was in medical school, my wife became pregnant, a pregnancy not planned. Abortion never entered my mind and was never brought up by my wife, nor anyone else. I then had the good fortune to be the primary caregiver of our darling daughter during the day of her first year of life while I was home doing my research project.

A couple of years later, I was in my second year of psychiatric residency training, which was a year before Roe v. Wade. I saw a number of women seeking an abortion, which could be obtained if it was psychiatrically risky to continue the pregnancy, or something like that, as I cannot recall the detailed criteria. With supervision, I approved them all, although I never knew the outcome of any of these decisions. I felt helpful and believed that this was the right decision all around, but with some guilt about the potential child.

I have tried to keep up with the recent media discussions about our abortion laws and the possibility of change in some states. However, by far the most informative and moving article that I read was by 

, “The Abortion I Didn’t Have”. In the article, Tierce discusses the reasons that she, 19 years old at the time, did not seek an abortion with her first unplanned child, as well as the ensuing repercussions for her life and that of her son. She then had a second child out of more overt choice, and then 2 abortions. Clearly, this was not a simple process for her, nor probably other women, based on her discussions of what she considered the complicated, ambivalent, and often contradictory benefits and drawbacks of her first decision.

That article led me to double-check what our professional American Psychiatric Association organizations have said about abortion. The last action that I found for the APA was in May 2018 and was titled a “

.” It clarified that careful research has indicated that having an abortion is generally not associated with any increase in psychiatric symptoms in the woman. However, that is a generality and there can be a range of abortion aftermath responses. The statement then goes on to its primary position that “abortion is a medical procedure, and a decision about an abortion should be between a woman and her physician.”

American Psychological Association commentary

 on “Abortion and Mental Health” was from around the same time, June of 2018. Theirs also reviews the science, including on the child’s future, and that “Unwanted pregnancy has been associated with deficits to the subsequent child’s cognitive, emotional and social processes.”

Both of these research findings regarding the woman and the child helped assuage my earlier residency guilt. The American Psychological Association policy comes out similar to that of psychiatry, and includes their subsequent and ongoing advocacy and legal action on abortion.

Out of many controversial Supreme Court decisions over the past 50 years, this one seems distinct in its viability. Why might that be? It is literally a life and death issue. However, any changes in Roe v. Wade can be a precedent to reconsider other decisions.

For some, this abortion decision is simply a yes or no. However, for me as a psychiatrist and as a man, it is not. All of these experiences and considerations leaves me with 8 tentative—indeed very tentative—conclusions as to what I currently think may be the major mental health implications for mother and child:

Do what is practically and psychological possible to not develop an unwanted pregnancy.

There are invariably complex psychological reasons to have or not have an abortion, and at times of unresolved ambivalence, therapeutic discussion may be indicated.

It is virtually impossible to compare the outcome of the abortion choice with the path not taken, so it is important to try to come to peace with the final personal decision.

Having inadequate and difficult-to-access abortion services seems to be a sign of misogyny, and poor women will be the most affected.

If our abortion laws are changed, they should be done very gradually and in a manner that allows some comparison with outcomes related to the prior law.

As the Preamble and Section 7 of The Principles of Medical Ethics states about our responsibility to society, abortion is an ethical matter for us.

Given the cracks occurring in Roe v. Wade, it seems that our professional societies’ views on abortion need updating.

Our professional societies and ourselves need to educate the public about the mental health implications of abortion, especially in regards to children of unwanted pregnancies.

On Friday, the Supreme Court is supposed to meet to hold a preliminary vote on their decision. What will they—and we—say?

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

Share your thoughts, comments, and feedback with PTEditor@mmhgroup.com.

What do we know about the psychiatric implications of having an abortion and not having access to such services? And what are the medical ethics involved?

Psychiatric and Personal Reflections on Abortion

More good news regarding treatment choices in major depressive disorder (MDD) and postpartum depression (PPD), as the 2 companies working on zuranolone announced that they will submit a New Drug Application (NDA) to the US Food and Drug Administration (FDA).

Following discussions with the FDA, including a pre-NDA meeting this fall, Biogen Inc. and Sage Therapeutics Inc. decided to initially seek FDA approval of zuranolone in the treatment of MDD in late 2022, with plans to file for PPD in the first half of 2023. The initial submission package for MDD will include data from ongoing pharmacology and clinical studies, plus data from the LANDSCAPE and NEST clinical trial program studies, both of which include several studies examining the effectiveness of zuranolone in several thousand patients in various dosing, treatment paradigms, and clinical endpoints. Data from PPD 301-SKYLARK, a NEST program ongoing placebo-controlled study of zuranolone in patients with PPD, will be added to the separate filing for PPD. 

“We are pleased to share what we believe is an efficient filing pathway for zuranolone, with the goal of bringing a new treatment option to the millions of people who suffer from depression worldwide,” said Alfred Sandrock Jr, MD, PhD, Head of Research and Development at Biogen, in a press release.

Zuranolone is a once-daily, 2-week, investigational oral neuroactive steroid (NAS) GABA-A receptor positive allosteric modulator (PAM) in development for the treatment of MDD and PPD that is designed to potentially serve as a rapid-acting sustainable treatment option. The drug received the Breakthrough Therapy Designation from the FDA in February 2018.

Recently, Sage shared results from their SHORELINE study, which found the agent to be safe and effective in the sample of patients with MDD.

 In that trial, investigators found that almost half of all participants who positively responded to the initial 14-day course of zuranolone 30 mg did not require additional treatment to maintain wellness through a year of follow-up.

“In the clinical development programs, zuranolone has shown remarkably consistent, rapid, and sustained reductions in depressive symptoms, including anxiety and sleep loss, in addition to a well-tolerated safety profile,” said Barry Greene, Chief Executive Officer at Sage Therapeutics, in a press release. “We believe we have a solid filing package with four adequate and well controlled trials now in hand and, if approved, zuranolone will fill a real unmet need and be welcomed by people living with depression.” 

1. Sage Therapeutics and Biogen announce plans to submit a New Drug Application (NDA) for zuranolone to the U.S. Food and Drug Administration in the second half of 2022 with rolling submission expected to start in early 2022. News Release. Sage Therapeutics. October 19, 2021. Accessed October 19, 2021. 

https://investor.sagerx.com/news-releases/news-release-details/sage-therapeutics-and-biogen-announce-plans-submit-new-drug 

2. Sage Therapeutics receives FDA Breakthrough Therapy Designation for SAGE-217 for the treatment of major depressive disorder. News Release. Sage Therapeutics. February 7, 2018. Accessed October 19, 2021. 

https://investor.sagerx.com/news-releases/news-release-details/sage-therapeutics-receives-fda-breakthrough-therapy-designation

3. Kuntz L. Anticipated phase 3 interim results for Sage’s depression treatment, zuranolone. Psychiatric Times. October 14, 2021. Accessed October 19, 2021. 

https://www.psychiatrictimes.com/view/anticipated-phase-3-interim-results-for-sage-s-depression-treatment-zuranalone

New Drug Application to be submitted for MDD in late 2022, with separate filing for PPD planned for early 2023. 

New Agent for MDD, PPD Takes a Step Closer to Approval 

The first days of September seemed to be “flooded” with societal news with psychiatric implications. For instance, there was the unprecedented and unanticipated flash flooding in New York, New Jersey, and connected areas as Hurricane Ida made its destructive way from Louisiana out to sea again. On the other end of the country, the wildfire approaching Lake Tahoe is still not under enough control.

Then, of course, the startling news that the Supreme Court will not engage or comment on the new ban on abortions in Texas. (As strangely connected as it may seem, the Women’s Mental Health Conference scheduled for Dubai from February 6-9, 2022, was just cancelled because of the COVID-19 pandemic uncertainties.) As far as I know, there are no mental health exceptions to these new abortion restrictions. At least these were available during my residency training in the fall of 1972 when I screened pregnant women—and I approved all requests for such exceptions for abortion due to mental health risk.

 have been trying to keep up with such news with our once-a-week brief Psychiatry & Society videos that are released each Wednesday, as well as other periodic postings, including the poems of 

. With all that is going on, however, it seems like that is not enough. Thus, we will be trying out an additional series, brief written pieces on society and psychiatry on Mondays, Tuesdays, Thursdays, and Fridays. Such is the unique blessing of psychiatry that we can apply our knowledge to so many events in life.

Look for these columns to begin next week, following the unusual confluence of Labor Day in the United States and the first night of Rosh Hashanah. Interestingly, although Rosh Hashanah is the Jewish New Year and the beginning of our High Holy Days, it is also thought to be the celebration of the beginning of the world. In other words, it is really a global ecological anniversary. What this confluence may be telling us is that we have our work cut out for us to make the world a better place. Meeting some of the goals of Rosh Hashanah—forgiveness, social justice, and turning to our best selves—can provide hope that we can ultimately succeed in this challenge.

Comments and suggestions on this and future columns are welcomed and will be shared with Dr Moffic. Please email us at PTEditor@mmhgroup.com.

In this new series, you will find reflections on psychiatry and society as seen in—and inspired by—current events. 

When We’re Flooded With News

The enactment of Texas law SB8 can have deleterious impact to the health of women seeking care. Furthermore, this law, in my opinion, has the potential to fracture the physician-patient relationship. Women have, and should have, the right to be educated about their medical options in order to make an informed decision regarding their health.

I hope that we consider the mental health implications—increased anxiety, poor self-esteem, and depression—for women who are denied access to abortion, irrespective of the different perspectives on this controversial topic.

Hopefully this poem provides some food for thought.

is associate professor at the University of South Carolina School of Medicine - Greenville and medical director and division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health - Upstate. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

The newest law in Texas dictating women's health brings with it many issues for consideration. 

Reflections on Women’s Health 

The 9 months of pregnancy evoke a multitude of emotions for the mother carrying the "angelic parasite". Expectant mothers are mindful that morning sickness is quite common, but it does not deter them from keeping their eye on the prize. However, intractable vomiting during pregnancy, also known as 

(HG) is a condition that can have deleterious psychological and physiological effects in the form of depression, anxiety, significant weight loss (>5% of original body weight), and dehydration.

I have witnessed firsthand the impact HG can have on a mother’s well-being. My wife, Jennifer, experienced this condition all throughout her pregnancy. As a spouse, I attempted to comfort her as best I could but, at times, felt helpless. During the pregnancy she lost more than 30 pounds, and she required several hospitalizations. It was difficult, at moments, to find any silver linings that would help alleviate fears we had about her quality of life and the angelic parasite in her womb. Thankfully, with the help of a multidisciplinary medical team and a support system consisting of family and friends, my wife’s health improved. The ability to take a shower, brush her teeth, and enjoy a sip of water was rejuvenating.

Our daughter, Claire, now 2.5 years old, was born without any complications. She is the blessing that keeps on giving. It is important to remember that not everyone has a happy ending in the case of HG. This population is often stigmatized due to practitioner bias and skepticism regarding severity of symptoms. I encourage the medical community to realize the gravity of this condition, which is associated with increase rates of termination of pregnancy and suicidal ideation.

I have written a poem dedicated to my wife and all the women who have experienced hyperemesis gravidarum. I hope and pray that it fosters reflection.

White porcelain welcomes two feeble disturbed patellae into their familiar position.

Exhausted cranium searches her way toward the bowl that yeans for a day without chartreuse liquid.

Listless larynx sighs to the angelic parasite: 3 months

White porcelain welcomes mammoth tears that plead for comic relief while in the wilderness.

Calloused stained appendages engulf a seat pleading for casual gluteal conversation.

Delirious heart sighs to the angelic parasite: 6 months

White porcelain welcomes famished countenance that no longer sees its reflection.

Nauseated hair follicles produce repugnance that penetrates the deflated soul.

Malnourished colors skeletons sighs to the angelic parasite: 9 months.

A personal reflection on the psychological impact of hyperemesis gravidarum. 

Hyperemesis Gravidarum: Ode to Its Psychological Impact 

SPECIAL REPORT: SEXUAL AND GENDER MINORITIES PART 2

Fertility considerations in the context of gender-affirming medical care for transgender and nonbinary (TNB) youth have garnered increasing attention in recent years, given the potential for treatments affecting fertility and the expanding availability of fertility preservation 

 The World Professional Association for Transgender Health and the Endocrine Society recommend fertility counseling, including discussions about fertility preservation, as part of the informed consent process for treatment with pubertal suppression and 

 Despite these recommendations, there is little direct guidance about fertility counseling for clinicians. Reported rates of fertility preservation among TNB youth in the United States remains low, ranging from 2.7% to 4.7%, in contrast to relatively higher rates of TNB youth reporting the desire to have genetically related children (

There is no consensus among TNB youth and their families regarding who is best positioned to provide fertility counseling in the context of initiating gender-affirming medical 

 In one study, many families identified the physician prescribing hormones as potentially the most knowledgeable about the effects of puberty suppression and GAH on fertility, but mental health clinicians were also highlighted as key individuals who can help TNB youth explore their attitudes and values related to fertility and family planning and support youth and their families in treatment decision-making.

Given that interdisciplinary care, including mental health clinicians, is recommended for TNB minors seeking gender-affirming medical interventions, psychiatrists and other mental health clinicians are uniquely positioned to participate in the fertility counseling process. Yet, many mental health clinicians report they lack an understanding of the fertility implications of gender-affirming hormonal care, which interferes with their ability to effectively counsel their 

Pubertal Suppression and Gender-Affirming Hormones

Psychiatrists should discuss fertility with TNB youth during medical and mental health visits—early and often.

Gender Issues

Issues in Women’s Health: Global Lessons, Opportunities, and Challenges

Psychiatric and Personal Reflections on Abortion

New Agent for MDD, PPD Takes a Step Closer to Approval

When We’re Flooded With News

Reflections on Women’s Health

Hyperemesis Gravidarum: Ode to Its Psychological Impact

Fertility Considerations for Transgender and Nonbinary Youth: Opportunities for Psychiatrists

What Can Be Done About Anxious and Violent Men?

What Makes Men’s Depression Different?

Is it Time to Leave the Doctor’s Office?