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The Labor of Delivering Gender: A Case Study in Integrating Gender and Sexuality Studies into Medical Education at Stony Brook University

March 3, 2022April 9, 2022sbubrooklogueLeave a comment

by Sophia Garbarino, March 3, 2022

Abstract

This essay examines maternal healthcare practitioners’ perspectives about and experiences with incorporating sex- and gender-based medicine (SGBM) into healthcare training at Stony Brook University, a leading medical institute in the United States. SGBM refers to the style of clinical practice that accounts for the ways in which biological sex characteristics and social constructions of gender affect healthcare outcomes. This method is particularly critical for women’s and reproductive healthcare providers because they routinely treat patients that experience gender and its unique interactions with other sociocultural factors. Within the wide range of literature discussing the need to integrate an SGBM lens into medical education, only a handful of scholars have examined why it is so difficult to actually accomplish. Building on this emerging body of evaluation research, I conducted several oral interviews with faculty at the Stony Brook Schools of Medicine and Nursing, discussing how they have reacted to this relatively new but essential field of medicine from the early 1990’s to today. The university has recently claimed that its health institutions are progressive both politically and practically, but I argue that “progressive” is an exaggerated description. Based on the interviews, instructors continue to face institutional as well as logistical barriers to incorporating an intersectional gender lens into their didactic and practical curricula. Furthermore, this case study offers insight into how practitioners can improve the ways they currently teach gender in order to produce more equity-conscious and diversity-respecting maternal care providers.

Full Text

“Learning is not attained by chance, it must be sought for with ardor and diligence.”
– Abigail Adams (“Abigail Adams,” 2019).

Introduction

Medicine, particularly medical education, has historically ignored the humanities and social sciences, especially intersectional gender and sexuality studies. Maternal and reproductive health scholarship that actually includes women as its subjects and researchers did not emerge until the women’s health movement rooted itself in American academia just over two decades ago. However, the field’s first fifteen years or so focused on biology-based differences between men and women with minimal regard for any individuals identifying outside the cisgender, heterosexual norm. Gender and sexuality only entered the conversation in the last five years, and even now, intersectionality is barely acknowledged. Medicine continues to primarily use the additive model, which considers various forms of oppression (sexism, racism, ableism, etc.) separately rather than examining how they operate inseparably (Kang et al., 2017).

And yet, intersectionality is more important than ever before, especially in the United States. The number of Americans who identify as a person of color and/or LGBTQ* grows every day (Jones et al., 2021; Jones, 2021). Therefore, it is imperative that medical providers understand how to treat their patients with respect for diversity in all its forms. As with any sustainable change, the process of removing heteronormativity from medical practices must begin with medical training. In this essay, I aim to provide a snapshot of where American medical education stands on the inclusivity stage. I will accomplish this by examining maternal, reproductive, and family healthcare practitioners’ perspectives about and experiences with incorporating sex- and gender-based medicine (SGBM) into education at Stony Brook University, a leading medical institute in the United States. These perspectives reflect the larger institution’s state of inclusiveness and progressiveness.

For reference, SGBM refers to the style of clinical practice that accounts for the ways in which biological sex characteristics and social constructions of gender affect healthcare outcomes. This method is particularly critical for women’s and reproductive healthcare providers because they routinely treat patients that experience gender and its unique interactions with other sociocultural factors. Building on this emerging body of evaluation research, I conducted several oral interviews with faculty at the Stony Brook Schools of Medicine and Nursing, discussing how they have reacted to this relatively new but essential field of medicine from the early 1990’s to today.

Stony Brook University has recently emphasized its “progressive” approach to healthcare, especially regarding women’s and LGBTQ* populations. In response, I argue that while the Schools of Medicine and Nursing are certainly more aware of SGBM than they were two decades ago, the university still lacks clear intersectional gender- and sexuality-inclusive training and approaches the education they do have in a non-inclusive, binary way. In this essay, I will provide historical context for my analyses by briefly summarizing key events in the trajectories of feminism, the Women’s Health Movement, and sex- and gender-based medicine (SGBM) in the late twentieth century. I will then conduct an in-depth analysis of my case study research and its implications. Finally, I will conclude by proposing potential ways for practitioners to improve how they currently teach gender in order to produce more equity-conscious and diversity-respecting maternal care providers.

Background

How maternal and reproductive medicine evolved with American politics

When Betty Friedan’s groundbreaking book The Feminine Mystique was published in 1963, America began to realize that many of its women were dissatisfied with simply being housewives (Churchill, 2020). After World War II, women were not especially keen on relinquishing the professional and financial freedoms they had found in the factories while the men were fighting overseas. Simultaneously, the Stonewall Riots in 1969 marked the birth of what is now commonly referred to as the modern LGBTQ* rights movement (Duberman, 1993). In the following decades, both of these marginalized groups would find themselves at the center of the global political and health stages.

Policy and health were particularly inseparable during this era. The 1990s saw what is now known as Third Wave Feminism, placing women’s experience at the center of American politics and “integrat[ing] an ideology of equality and female empowerment into the very fiber of [American] life” (Walker 400, 1992).Women delayed marriage into their mid-twenties, felt sexually liberated, and entered male-dominated careers (Yarrow, 2018).Yet, the fight for equality raged on in the political and medical arenas, clashing in landmark health-related historical events such as the Anita Hill sexual harassment hearings (Gross, 2021), Planned Parenthood’s fight against conservatives over abortion rights (Prescott, 2019), and the Violence Against Women Act of 1994 (“History of VAWA”).

In the same decade, the Women’s Health Movement was progressing with full-force activism: reproductive endocrinologist Florence Haseltine co-founded the Society for Advancement of Women’s Health Research in 1989, which helped to pass the Women’s Health Equity Act one year later and created the Office of Research on Women’s Health at the National Institutes of Health. In 1993, following the groundbreaking discovery that the HIV virus can pass from pregnant parent to fetus, Congress required the inclusion of women in NIH-sponsored clinical research trials (Liu and Mager, 2016). Prior to this mandate, women of childbearing age were considered too high-risk to participate in clinical research due to the possibility of pregnancy, severely inhibiting knowledge production about sex and gender in healthcare (Participant 3, 2021). It was these socio-political and medical paradigm shifts within women’s health research that gave rise to what is now referred to as sex- and gender-based medicine (SGBM). Within the wide range of literature discussing the need to integrate an SGBM lens into medical education, only a handful of scholars have examined why it is so difficult to actually accomplish.

How sex- and gender-based medicine was born

In the midst of this emerging field of women’s health intervention evaluation, Lorena Alcalde-Rubio et al. reviews 22 articles that evaluate clinical interventions aimed at “reduc[ing] variability in healthcare,” five of which focus on sexual and reproductive health (Alcalde-Rubio, 2020). The majority of the 22 evaluations supported standardizing protocols as a feasible method of systemic change, which is consistent with the faculty’s opinions during my interviews. However, Alcalde-Rubio’s review does not specify what types of protocols should be standardized and importantly notes that 15 out of the 22 evaluations did not utilize gender perspectives adequately. Further, the review significantly reflects a larger fault in medical academia: researchers often focus too much on the purely clinical aspect of change. When it comes to destabilizing social constructions that are ingrained in us and impact every aspect of human life both inside and outside of medicine, education plays a, if not the most, critical role in producing systemic change. In other words, we cannot fix the problem without addressing its roots. As such, I will primarily address the education aspect that Alcalde-Rubio et al. does not.

A 2005 Dutch study (Verdonk et al.) attempts to explore the potential for long-term change in medical education. Researchers concluded that a lack of guidelines, political ideology conflicts, and the educators’ own levels of dedication contribute to the gap between what should be taught and what was actually being taught. Further, certain factors must be present to successfully incorporate gender into medical training, including faculties’ personal experiences and motivations, practical support, and “executable” proposals for adjustment. This suggests that the Western medical educators were generally aware of the need for gender education in the 1990s, the decade during which many of my interviewees were medically trained here at Stony Brook. However, Verdonk, like many others in the field, conceptualizes gender as binary and essentialist.¹ To make any meaningful progress, modern medical educators need to start deconstructing the gender binary and validating identities and sexualities beyond the cisgender, heteronormative ones.

Like Verdonk et al., Mary Rojek and Marjorie Jenkins (2016) examined medical schools, but this time in the United States. They surveyed faculty from medical schools that had already successfully integrated SGBM into their education. Their results suggested “it was important to involve all stakeholders… linking curricula to experiential learning and research. It was important to support faculty by providing them with educational resources” (Rojek and Jenkins, 2016). The majority of schools, though, are still behind in adding a sex- and gender-based lens to formal medical education. My research supports Rojek and Jenkins’ conclusions that formal institutional support is a crucial factor in determining integration success.

Also similar to Verdonk et al.’s case study, Hsing-Chen Yang examined the Eastern (Taiwanese) medical world’s perspectives about gender. Asian beliefs and social norms about gender are significantly different from Western ones, and even between individual Asian cultures themselves. Because Stony Brook’s Renaissance School of Medicine began accepting international applicants in 2014 (Medical School (MD) Applicant Profile, 2021), along with the majority of graduate students across the university identifying as people of color (Stony Brook University Fall Headcount, 2021), it is crucial to consider a diverse set of approaches to medical education. Because patient populations are now increasingly diverse—fueled by immigration and globalization—healthcare providers need to have a basic understanding of how gender functions in different cultures. Yang’s surveys found that healthcare professionals and teachers generally believe that sexism, gender awareness, gender equity, and patriarchy are among the most important to teach but this prioritization is not reflected in practice. However, the study omits two key factors: historical context and sociocultural context. Sexism, gender, and patriarchy have various meanings depending on the patient’s and the provider’s respective backgrounds. Therefore, Yang’s conclusions may be limited to predominantly Asian regions.

To see if Yang’s results holds true in Western medical culture, I came upon a 2010s-era study that revealed that American students also lack sex- and gender-based medical (SGBM) training, Majorie Jenkins et al. (2016) surveyed 1097 medical students across five major medical student organizations in order to examine institutional response to these findings. Jenkins’ survey suggests that while medical students are generally aware of SGBM’s existence, the majority do not receive adequate SGBM education at their respective medical schools. While it provides a solid look at what other American healthcare schools are doing about SGBM in relation to Stony Brook, Jenkins focuses solely on students’ perspectives rather than those of faculty, not accounting for logistical and institutional obstacles instructors face that students may not be aware of. I aim to fill this knowledge gap in this case study.

Methods

Stony Brook University

Stony Brook University (SBU) grew alongside the women’s movement. The university was founded in 1957 (“History and Mission”), and its Renaissance School of Medicine (RSOM) opened in 1971 (“History,” 2019). The RSOM currently houses 25 professional departments, including “Obstetrics and Gynecology,” which is an influential player in university progressive politics (“Departments,” 2019; Participant 5, 2021). One year after the RSOM admitted its first class, the SBU School of Nursing (SON) opened in 1972 (Strategic Plan 2016 to 2021, 2017). Graduate-level programs were gradually added in the following years, and the school’s first doctoral-level program, the Doctor of Nursing Practice (DNP) program, admitted its first cohort in 2007 (Participant 2, 2021). Now, Stony Brook’s Hospital is considered one of the best in the United States and boasts progressive and inclusive practices. This makes it an ideal institution to study the emerging field of sex- and gender-based medicine, especially considering its diverse student and faculty profile.

Sample

While gender undoubtedly affects all areas of health, obstetricians (OBs), gynecologists (GYNs), and nurses typically have the most direct patient contact with populations where gender is uniquely related to healthcare outcome (Participant 5, 2021). For example, maternal care and reproductive care specialists may see pregnant trans patients, same-sex couples with fertility concerns, and Black cisgender women, who have disproportionally higher rates of maternal mortality in the United States (“Working Together,” 2021). For this reason, I individually interviewed a total of six faculty at Stony Brook University, including three OB-GYNs from the Renaissance School of Medicine and three from the School of Nursing. Participants were recruited via email outreach based on whether they attended Stony Brook University for their undergraduate degree, graduate degree(s), residencies/fellowships, or any combination of those three. Each interview was approximately thirty minutes long and conducted over Zoom or phone call between the months of September 2021 and November 2021.

Table A. Participants’ Educational Backgrounds

Participant	Type of Clinician	Highest Degree Earned	Residency
1	Medical doctor	MD*	OB GYN*
2	Nurse practitioner and midwife	DNP*	N/A
3	Pediatric nurse practitioner	Ph.D.*	N/A
4	Family and acute care nurse practitioner	DNP*	N/A
5	Medical doctor	MD	OB GYN*
6	Medical doctor	MD*	OB GYN*

Key
DNP – Doctor of Nursing Practice
MD – Doctor of Medicine
PhD – Doctor of Philosophy
*Completed at Stony Brook University

Interview Questions

Educational Background

I asked the participants five main questions about various gender- and sexuality-related topics. The first question asked about the participants’ educational backgrounds, including where they earned their undergraduate degree(s), graduate degree(s), and where they completed their post-doctoral residency and fellowships if applicable.

Gender & sexuality education as a student

The second question asked about the participants’ experiences – or lack thereof – learning about gender as a student, including as a medical or nursing student and graduate-level nursing student or medical resident.

Current gender & sexuality education

The third question asked participants to compare their own student experiences to what current SBU students learn about gender. The fourth question asked about their experiences and opinions about teaching gender as a professor, including what challenges they may face and how they address them.

Institutional support

The fifth question asked participants if the university has offered and/or currently offers opportunities for faculty to further their own knowledge about gender and sexuality in healthcare, and if so, what types of opportunities and how helpful they were.

Results & Discussion

Participants’ own gender and sexuality training

None of the participants had any formal education about gender nor sexuality, with the exception of studying purely biological sex differences, when they were medical/nursing students. All participants received their first clinical degrees (BSN or MD) in the 1990s or early 2000s. At the time, SGBM was just beginning to grow as a legitimate field of medicine and was more commonly referred to as “gender-based biology” (Madsen et al., 2017).

For example, a few of the participants from both the RSOM and SON recalled learning about sex differences in symptom presentation and risk levels for certain conditions, such as the fact that men are more likely to have a heart attack while women typically show less obvious signs of a heart attack like pain similar to that of severe indigestion (Participant 3, 2021). Participant 2 recalled learning absolutely nothing about gender, especially its interactions with race and ethnicity. As a Black woman, she did not feel supported by the School of Nursing while earning her degree. Therefore, diversifying nursing education is particularly important to her, so a tremendous portion of the efforts to update the midwifery curriculum comes directly from her. This aligns with Verdonk’s 2005 findings, where a specific professor of Women’s, Gender and Sexuality Studies was an “important stimulus” and “trigger” person for SGBM integration. For Stony Brook’s midwifery program, Dr. Findeltar-Hines is the “trigger” person.

Another important consideration is that in the 1990’s, patients were often quite hesitant about revealing their gender identity and/or sexuality to practitioners (Participant 6, 2021). Furthermore, gender-affirming care standards, mostly relating to gender-affirming surgeries, did not exist until 1979 (Frey et al., 2017). The first major case study in hormonal puberty blockers, now a major treatment option for transgender, non-binary, and gender non-conforming pediatric patients, was not published until nearly twenty years later in 1998 (Cohen-Kettenis et al., 2011). Clinical progress took decades, and the curricula were trailing far behind as a result. This aligns with the Verdonk et al. case study of the Dutch medical center (2005), in which faculty’s personal experience and motivation was found to be a key factor in ensuring the success of gender education integration. Unlike the Dutch case study, though, Participant 2 acknowledges that gender exists on a spectrum and does not conceptualize it in mere binary terms, perhaps contributing to the Midwifery program’s progressive success in recent years. According to Participant 2, the program’s instructors have created a trans patient case study, use gender-neutral pronouns whenever possible, and are currently working on implementing gender/sexuality- and race-specific lectures.

This level of dedication to building gender-inclusive training is not consistent across the nursing and medical schools, however. While some participants recalled learning about “special populations” (Participant 4, 2021), which include trans and gay patients, it was from a very “cisgendered” perspective (Participant 1, 2021). This special population education was also added to the curriculum out of political pressure rather than student/faculty motivation. In the 1990s, HIV and AIDS awareness skyrocketed to the top of major health institutions’ priority list as the AIDS epidemic entered its “Middle Era” and gained international attention (Durvasula, 2018). This increased public health attention to women’s and reproductive health disparities, but commonly used terminology like the “4H Club [homosexuals, hemophilliacs, heroin users, and Haitians]” were homophobic and racist, essentially doing the opposite of increasing gender and sexuality awareness (Participant 3, 2021). In fact, prior to the AIDS epidemic, those who identified as female were prohibited from participating in medical research, so it’s not surprising that health practitioners and academics ignored gender education.

What current SBU students learn

Current SBU students learn more than participants’ did but the integration of gender and sexuality into the curriculum is slow. Challenges include time constraints (Participant 1, 2021), disparities in instructors’ own knowledge about the topics (Participant 1, 2021), and resistance from more traditional faculty (Participant 2, 2021). Ultimately, it is up to individual faculty to decide how much they want to adjust their curricula to include diversity education.

The Renaissance School of Medicine did not start internally pushing for inclusive education until two to three years ago (Participant 1, 2021; Participant 6, 2021), and since then, progress has been very slow. The majority of interviewees recognized the need for specialized gay and trans* education, but that was about the extent of their reported knowledge. Only one or two faculty mentioned non-binary and gender-nonconforming patients (Lian, 2021; Participant 3, 2021), and one mentioned the relationship between race, socioeconomic/citizenship status, and healthcare outcomes (Participant 6, 2021). None offered evidence of education that focuses on the vast variety of other gender and sexuality spectrums, including sexualities that are not strictly straight/gay/bisexual. Only one doctor mentioned how clinical placement affected patient populations. For example, attending physicians working at a Flushing, NY clinic might see more Asian patients while someone working in a “resident clinic” would typically see patients in less privileged socioeconomic groups. The resident clinics have more Hispanic and non-English speaking patients “by default” (Participant 6, 2021).

It is also worth noting that while a few participants mentioned race, gender, sexuality, socioeconomic status, and ability status separately, it was evident that all of them viewed gender and sexuality using an additive lens. The additive model considers systems of oppression to be individual entities rather than structures that cannot operate without one another. Intersectionality was undoubtedly an unfamiliar term, so interviewees were largely unable to answer questions about the intersections of identity factors like gender and sexuality. A potential cause of this issue is the lack of precise terminology in the broader field itself (Madsen, 2017).

The School of Nursing, however, began adding diversity and inclusion to its branding in 2017, which, coincidentally, is the same year the Midwifery Program appointed the first woman of color as its Director. In its academic success goals, the Strategic Plan 2016 to 2021 (2017) specifically lists “recruit diverse nursing faculty” and “expose [nursing students] to global health and healthcare disparities.” Since then, the midwifery program has been adapting lectures to use more inclusive terminology, such as saying “patient” instead of “woman” and “parent” instead of “mother.” Additionally, the program was the first in the SON to add a transgender-specific case study to the curriculum. As the program director noted in her interview, “Education is always evolving… We [educators] have to stay creative and innovative in order to get the basic education things that we want learned [by the students]” (Participant 2, 2021). This is both in agreement and in direct contrast with Yang’s Taiwanese survey of healthcare professionals and teachers regarding gender education expectations. Yang claimed that workplace sexism is a primary cause of the disparity between what instructors believe should be taught and what is actually taught about gender. She also argued that this same sexism prevents educators from viewing gender as a human issue rather than a “woman issue” (Yang, 2020). Participant 2 suggests that all educators must address gender education, including the traditionalists, and simultaneously expresses that workplace discrimination is not an excuse for lack of progress.

All faculty are required to retain clinical practice while teaching, and all participants hold additional leadership positions within their respective schools (Participant 4, 2021). Combined with minimal access to formal training, some traditionalists would say that faculty simply don’t have the time to educate themselves about gender so it is much harder for them to teach it (Participant 1, 2021). However, integration does not necessarily need to involve revamping the entire curriculum (Participant 3, 2021). Faculty could also incorporate gender diversity education into existing training, such as making a simulated patient a woman of color or a child with two mothers. Additionally, instructors could use case studies to emphasize a wide variety of lessons, such as Participant 2’s pediatric case study with a transgender (assigned female at birth) patient named “Timmy” (2021). This case study provides opportunities to practice using proper gender pronouns, learn about hormonal gender affirming treatments, and how to interact with parents of gender-diverse children. Across all interviews, participants said that they would like to improve the time dedicated to gender and sexuality education, so the motivation is there. These sentiments align with those of the students that Jenkins et al. surveyed in 2005, meaning formal course offerings have not improved much since then.

According to the participants, the students are the main driving force behind integrating gender and sexuality training into their healthcare studies. This result was also expected based on the Jenkins et al. survey (2005). On top of being very receptive and eager to learn about diversity, they even provide feedback asking to learn more (Participant 2, 2021; Participant 1, 2021; Participant 4, 2021). Depending on clinical placements, students also have the opportunity to interact with diverse patient populations (Participant 4, 2021), and at Stony Brook Hospital, residents consistently see high levels of diversity (Participant 5, 2021; Participant 1, 2021). While not all healthcare practitioners will work directly with gender-diverse patients, it is still extremely important for all medical providers to understand and be able to apply gender-inclusive theories. According to a recent 2021 Gallup poll, 5.6% of American adults, and one in six adults in Generation Z alone, identify as LGBT (Jones, 2021). Furthermore, the U.S. Census estimated that in 2019, over 36% of women were women of color, and this proportion is projected to grow to over 55% by 2060 (“Women of Color in the United States,” 2021). These statistics are particularly relevant to maternal and reproductive healthcare; therefore, it is critical that these healthcare providers are trained, at least on a basic level, in gender and sexuality studies (Participant 5, 2021).

Institutional support

Based on Verdonk’s 2005 study of a Dutch medical center, institutional support must be present in order to successfully incorporate sex- and gender-based education into healthcare curricula. This may be in the form of financial resources, guest lecture support, accessible educational resources, and visual/presentation support (Verdonk, 2005). With this in mind, I asked participants about how Stony Brook University supports its healthcare faculty in diversifying the curricula, if at all.

Using a binary gender lens

SBU as an institution provides some structured learning opportunities for faculty specifically about using an intersectional gender lens when practicing healthcare, but students and faculty want more. In terms of gender education, because the topic is so relevant to daily patient care for OB GYNs, a few formal lectures have been offered, and OB GYN residents discuss gender- and sexuality- related cases during grand rounds (Participant 5, 2021). For medical students, as of 2020, all SBU medical and dental students are required to take a “Transition to Medical and Dental School” course that talks about gender and diversity issues (Participant 1, 2021)

Using a heteronormative **LGBTQ* lens**

In terms of LGBTQ* inclusivity, two of SBU’s major medical institutions, Stony Brook Medical Center and Stony Brook Southampton Hospital, scored a 100/100 on the Human Rights Campaign (HRC) Foundation’s 2020 Healthcare Equity Index [HEI] and were named LGBTQ Healthcare Equality Leaders (Healthcare Inequality Index 2020).² According to Stony Brook, “[t]he HRC is the largest national lesbian, gay, bisexual, transgender and queer civil rights organization” (“Health Equality Leader,” 2021). However, the HRC has received a substantial amount of criticism for, despite its claims, failing to represent and advocate for LGBTQ* folks of color. Much of this controversy surrounded the Don’t Ask, Don’t Tell Repeal Act of 2010 (“H.R.2965,” 2010). In the months leading up to its official passing, the HRC used a disabled, gay veteran of color to promote fake inclusivity while it simultaneously “profited from the practice of diversity management” (Montegary, 2015). Further, the HRC has been called “cisgenderist” and white supremacist for several years (Johnson, 2011; Rosen, 2021). As such, their HEI rating may not have as much practical weight as Stony Brook claims.

Stony Brook University released an LGBTQ+ Health Needs survey in early summer 2021 and received over 1,218 responses from Long Island, NY residents as of September 30th, 2021. Its purpose is to “provide information critically needed by healthcare providers, social service providers, government officials and public health staff to expand service offerings and serve as effective advocates for LGBTQ+ people” (“LGBTQ+ Health Needs Survey”). Moreover, the survey was made available in both English and Spanish, increasing access to non-English speakers. Suffolk County alone is 20% Hispanic/Latinx, according to the U.S. Census Bureau estimates (“Quick Facts”).

Both the Stony Brook Medicine [SBM] and the School of Nursing [SON] have recently created committees to educate practitioners and spread awareness about gender-informed care. The SBM LGBTQ* advisor committee meets monthly and aims to establish a set of priorities for LGBTQ* patient care, as well as create a more welcoming environment for patients, practitioners, and staff (“Two Stony Brook Hospitals;” Participant 1, 2021). Additionally, the SON’s brand new IDEA committee [Inclusion, Diversity, Equity, and Access] aims to use student feedback to build a more inclusive learning environment (Participant 4, 2021; Participant 3, 2021). Faculty veterans accustomed to traditional academic politics may argue that committees are a poor use of resources, especially in higher education; however, as university administration researcher David Farris writes in “Not Another Committee” (2017), with regular communication, perceived equality among members, and actively focused leaders, committees can actually be quite effective. Nonetheless, it is still important to note that the learning opportunities produced by these committees, particularly at Stony Brook, are created for clinician audiences and are less advertised to didactic instructors (Participant 1, 2021).

Hiding behind generalized health inequity

Pre-COVID, nursing faculty went on a few retreats that focused on diversity inclusiveness, but it was addressed in a very general manner (Participant 4, 2021). Recently, Stony Brook Medicine ran a two-day conference entitled “The Long March to Equity,” which covered general healthcare disparities and their historical trajectories into modern day medicine (Participant 3, 2021). This was the only example mentioned by multiple participants, and I was unable to find any other examples.

One OB-GYN did mention Women’s Health Day, an annual conference at the Renaissance School of Medicine that focuses on various health issues (cardiovascular, eyesight, muscle, breast cancer, etc.) and is exclusively targeted at an all-female audience (Participant 6, 2021; “Women’s Health Day,” 2019). This participant noted that the OB-GYN department also hosts a women’s health clinic on the same day at which anyone can get a routine check-up for free. The department has also started a bi-weekly clinic that provides discounted services for uninsured patients (Participant 6, 2021). However, she also explained that basic needs such as transportation already inhibit many of their regular patients from accessing necessary healthcare appointments. While treating women for free or at lower rates is somewhat helpful, it does not address the issue of inequitable access in an intersectional way; essentially, these clinics are just a Band-Aid solution to a deeper, more complex problem.

Distinct differences between medical and nursing education

The next result I will discuss was unexpected but certainly worth noting. I found clear differences between the perspectives/openness of the medical doctors and nurses. While the medical and nursing models have been known to be incredibly separate for decades (Reed and Watson, 1994), I was surprised by how much the models impacted the providers’ perspectives on sex- and gender-based medicine. For reference, the medical model focuses on “diagnosis, treatment, and cure” and has been widely criticized for its “narrow and unsatisfactory view (Reed and Watson, 1994). On the other hand, the nursing model “offers a more humanistic approach to patient care” (Reed and Watson, 1994).

The Medical Model’s Shortcoming

During the interviews, OB-GYNs consistently steered their responses towards healthcare outcomes, while I found the important connection between education and patient experience to be missing. For example, medical doctor participants mentioned “sobering” maternal mortality statistics, grand rounds³ (Participant 5, 2021), and student feedback being important (Participant 1, 2021), but only one explicitly said they prioritized making patients “feel more comfortable… and heard” (Participant 5, 2021). Yet, is the entire reason for improving medical education to benefit the patients?

Additionally, all three of the OB-GYNs discussed referrals⁴ as a way to support gender- and sexuality-based diversity. While having and being knowledgeable about sufficient resources is absolutely necessary, it does not address the alarming fact that many maternal and reproductive care providers are entirely unfamiliar with the concepts of intersectionality and non-binary gender and sexuality spectrums. Patients should not need to see another doctor in order to be treated with bare-minimal respect and dignity.

The Nursing Model’s Humility

On the contrary, nursing faculty were much more open to discussing how their personal experiences and medical training affects the quality of care they deliver. For example, Participant 3 took a few gender studies courses during her undergraduate career at Stony Brook, which exposed her to “thinking about other cultures, other health belief systems that wasn’t just coming out of a textbook” (2021). This, she said, impacted both the way she teaches and the way she cares for her queer⁵ patients, particularly helping her grasp new concepts like non-binary genders and different cultural understandings of disability. Here, the connection between the importance of inclusive education and patient experience is clear. Further, Participant 4 explained how crucial it is for students to work with diverse patient populations during school so that when they enter the workforce as licensed providers, they will already have achieved at least a basic level of intercultural competence.

Faculty diversity

One final point I must discuss is that all six participants identified as women, and four identified as women of color (see Table A on page 9). This sample is not representative of the Renaissance School of Medicine’s and School of Nursing’s faculty at all. The School of Medicine’s Obstetrics and Gynecology department has 42 physician faculty, of which only 13 (about 30%) are women of color. Furthermore, not a single woman is a full professor (with tenure). The department Director and Chair, the two highest leadership positions in the department, are also both white men (“Our Providers,” 2021). Within the School of Nursing, there are 32 faculty, of which 27 (about 84%) are white women and 4 (12.5%) are women of color. There is only one woman of color who holds a director-level position (“Faculty & Staff Directory,” 2021). It seems, then, that the School of Nursing has not yet met its goal to “Recruit diverse nursing faculty” (Strategic Plan 2016 to 2021, 2017).

With these numbers in mind, it is not surprising that Stony Brook University is lagging behind when it comes to incorporating SGBM into healthcare training. The key “trigger person” suggested by Verdonk’s 2005 study is hardly present, which may be why the Midwifery Program is the most progressive program within the School of Nursing (Participant 2, 2021). Verdonk also notes that personal experiences are significant contributors to SGBM’s successful incorporation into medical education (2005). Therefore, because the School of Medicine’s OB-GYN department has two white men occupying its highest leadership positions, and because the School of Nursing only has one woman of color in a leadership position, gender-inclusive training may be extremely difficult to accomplish with the existing faculty structure.

Conclusion

In summary, when the participants, the majority of whom were initially medically trained in the late 1990s to early 2000s, were students, they did not receive any education about SGBM with the exception of purely medicalized topics. Today, Stony Brook medical and nursing students are taught more gender-inclusive curricula but not as much as faculty nor students would like. Participants expressed facing challenges such as finding time to create new content, lacking personal knowledge and familiarity with SGBM, and lack of institutional support in the form of formal, specific training opportunities. Overall, Stony Brook’s “progressive” practices and curricula continue to use a heteronormative lens and show no intentions of trying to dismantle it.

This case study provides a snapshot of the American medical system, which currently faces discrimination and disparities on both clinical and educational fronts. With more Americans openly identifying as LGBTQ* than ever (Jones, 2021), and with populations of color continuing to grow (Jones et al., 2021), addressing gender- and sexuality-based healthcare disparities is an essential piece to improving the health of the nation. If the COVID-19 pandemic has shown us anything, it’s that we are in a deep crisis, and we have been for decades, leaving marginalized groups with inexcusably inequitable care. One of the most effective ways to produce long-term, sustainable change is by educating future generations of providers. This is why it is so important to ensure our healthcare students are receiving, at bare minimum, adequate training on these topics.

Potential ways to improve SGBM education and ensure competency is 1) provide formal, structured training for educators; 2) incorporate SGBM into the didactic and clinical curricula using updated lectures, new case studies, more diverse patient populations, and inclusive simulations; 3) appoint more (qualified) individuals from marginalized groups to leadership positions; 4) allot more funding to gender- and sexuality-inclusive educational initiatives; and 5) continuously assess, collect feedback, and adjust accordingly.

To form a more robust understanding of the medical educators’ attitudes towards SGBM education, future research could involve more individual case studies of academic medical institutions and/or comparing multiple universities. Faculty and student demographics differ between schools and geographic regions, which may affect attitudes as well as financial and socio-political ability to incorporate SGBM into formal medical education.

Footnotes

¹ Essentialists believe that certain groups (categorized by race and sex especially) have traits and behaviors that are determined by biological factors. Gender essentialism inherently supports gender inequality by viewing gender as a binary concept, i.e. man versus woman (Hepburn).

² HEI LGBTQ scores were calculated based on four major criteria: 1) quality LGBTQ patient-centered care, 2) “Patient Services and Support,” 3) “Employee Benefits and Policies” including “transgender inclusive healthcare benefits,” and 4) Patient and Community Engagement” (Healthcare Inequality Index 2020 14).

³ “A grand round is a formal meeting at which physicians discuss the clinical case of one or more patients. Grand rounds originated as part of residency training wherein new information was taught and clinical reasoning skills were enhanced. Grand rounds today are an integral component of medical education” (Stöppler, 2021).

⁴ A referral is when a healthcare provider does not have sufficient expertise in a particular field and suggests that the patient see a more knowledgeable specialist in that field (“Referral,” 2021).

⁵ Here, I use the term “queer” to mean “not aligning with the norm” rather than the more conventional “non-heterosexual” meaning.

Acknowledgements & Disclosures

Thank you to Liz Montegary for providing guidance for my research process, and thank you to all faculty who interviewed with me. This research was not funded in any way by any institution and was a fully independent project.

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Music Therapy: The Art of Psychological Treatment

December 20, 2021April 9, 2022sbubrooklogueLeave a comment

by Sanjana Sankaran, December 20, 2021

Nearly 800,000 people die from suicide every year (Suicide Data). Approximately seventy percent of the American youth that struggle with depression requires treatment (The State). People with depression have a daily battle with themselves to prevent those feelings of despair and loneliness from taking over. Those living with mental health disorders may develop effective coping mechanisms to deal with their issues. Music therapy, a method of therapy and a de-stress technique for which the positive effects are not yet highly known, involves “the professional use of music and its elements as an intervention in medical, educational, and everyday environments with individuals” (Wang and Agius 595). Music therapy not only involves listening to music but also consists of thinking, analyzing, and playing it. Many people view music as a means of amusement and frivolity for those involved. Both mental health issues and the fine arts are often stigmatized in our society. In regards to mental health, several people feel the need to downplay their problems since many illnesses do not manifest with obvious physical symptoms. Hence, society issues out old cliches, suggesting that people need to learn how to ‘deal with their problems.’ In actuality, mental health can affect not only one’s mind but also one’s body and, if left untreated, can severely affect one’s quality of life. Over recent years, many have come to view the fine arts as an impractical endeavor since several jobs in this field may not lead to a stable job or income. Historically, humans have always turned to the arts to express their feelings, through music, visual arts, or the written word. Music can have a profound effect on the biochemical as well as the physiological aspects of the brain. More and more researchers today find that psychotherapeutic drugs are not as effective in treating mental health patients as they used to be, partly due to drug tolerance. As a society, we must alter our mindset away from treating psychological problems exclusively through psychotherapy and drugs and must instead leverage the nontraditional method of music therapy for those who experience daily stressors and mental health disorders.

The standard practices of mental health treatment today involve two significant methods – psychotherapeutic drugs and psychotherapy – both of which, given the statistics of how the rate of mental health diagnosis is accelerating, are not enough. People with mental health disorders nowadays have a lot more options as to how to treat themselves: psychotherapy, medication, case management, hospitalization, therapy groups, alternative medicine, electroconvulsive therapy, and peer support (Mental Health Treatments). In the early- to mid-1900s, methods of curing mental health ailments involved lobotomies and shock therapy. Even with all of the progress made today, a recent study shows that approximately 10 million adults in America have suicidal thoughts, have not been able to seek treatment or have experienced both. In the past six years alone, the population of youth (ages 12-17) with depression has gone up by 4.35%, and two million kids now have major depressive episodes and need to seek treatment (The State). A team of neuroscientists from Naples, Italy found that antidepressant drug treatments are mostly ineffective for major depressive disorders. (Fornaro e. al. 494). Inefficacy can be attributed to tolerance, an anomaly that occurs when depressive symptoms reappear after previous treatment with antidepressants” with the return of depressive symptoms of MDD occurring in 9–33% of patients across published trials” (Fornaro et al. 494). Drug tolerance can build over time as the body requires higher doses of the drug in order to have the same effect as the initial dose once did, ultimately resulting in other biological side effects. Many antidepressant drug trials tend to last shorter than 52 weeks, contributing to the lack of understanding as to how effective these drugs will be long-term. The National Institute of Mental Health stated that 25% of 103 patients had depressive episodes. Further these patients were found to have 43 out of 171 following depressive episodes and experienced drug tolerance after a 20 year follow up (Fornaro et al. 496).

In the book, Music Therapy in Mental Health for Illness Management and Recovery, written by Michael J. Silverman, the director of the music therapy program at the University of Minnesota, he states that “ even when medications are effective in alleviating the symptoms of mental illness, they do not necessarily facilitate psychiatric recovery as pharmacological treatments do not contribute to the development of knowledge and skills necessary for a successful transition back to the community” (Silverman 55). The state of mental health is worsening – therapies previously used for decades are now proving to be not enough in curbing the rampant increase in prevalence of depression and other mental health disorders. Psychiatric treatment needs to implement a new type of therapy, like music therapy, that includes psychological interventions to analyze how people’s behavioral and thought processes have improved over time. By seeking new methods of treatments, specifically music therapy, society will move closer towards respecting rather than ostracizing mental health patients.

Music therapy was developed post World War I and II as a way to ease the minds of many soldiers with PTSD (Craig). Since then, this field has led to a wide range of studies, all seeking to answer the questions of how music therapy works and its purpose. If we have many different types of psychotherapy, why are neuroscientists and psychologists seeking more holistic treatments for their patients that are not guaranteed to work? Let us start with what precisely music therapy is and the basis behind it. Music therapy includes two main facets: psychoacoustics and the appreciation and hearing of music. Psychoacoustics refers to how someone perceives and comprehends music. In contrast, the brain’s mechanisms of appreciation and hearing of music is something that is developed across an entire lifespan and is influenced by many environmental factors (Craig, para. 19-20).

There are two main methods of music therapy: listening and active playing. When listening to music, therapists will put on music for the patient, recommended by medical experts who know about the patient’s specific case (Craig, para. 41-42). Some therapists will go down the more analytical route of listening to music. Therapists may ask questions that evoke personal thought analysis and insight. Some may also follow the Bonny method of guided imagery and music. Bonny methods consist of a patient listening to a song and seeing an image. This leads to the therapist asking specific guided questions that lead to the patient talking about their thoughts and emotions (Craig, para. 43-44). Music therapy can change a person’s attention, emotion, memory processing, behavior, and communication. A combination of all of these changes can result in changes in neural processing that can effectively change the biochemical state of depressed minds and improve their lives

Many studies prove that music therapy has been effective in treating people with mental disorders. In a study done by Sergio Castillo-Pérez MD and his team, he states that “depression remains a major health problem and, despite using pharmaceutical agents, patients continue to report high levels of unrelieved depression” (Castillo-Perez et al. 390). This group of researchers decided to study a group of low to medium depressed people receiving psychotherapy treatment compared to music therapy. A group of 79 patients between the ages of 25 to 60 years old were split into the two groups of therapy. The subjects chosen have never taken any psychotherapeutic drugs or have any other neurophysiological problems. All subjects were asked to self-report their level of depression with a well-known survey known as the Zung depression scale (Castillo-Perez et al. 387). The subjects self-reported how they were feeling age week for eight weeks. The music therapy itself involved a 50-minute self-administered music session, and once a week the participants would have a group session with doctors and other patients to provide a comfortable environment. The study controlled for stressful environmental variables that may occur such as sudden noises, changes in temperature, any environmental change or trigger (Castillo-Perez et al. 389).

The psychotherapy administered in this study was standard conductive-behavioral therapy (CBT). At the end of the tests, the researchers quantitatively analyzed the patients’ progress with the Hamilton scale (another type of depression scale) based on their behaviors and their self-reported scores of the Zung scale. The people with significant improvement meant they had to have a Hamilton scale of 0 to 7. The Hamilton scale was used after the 3rd, 5th, 7th, and 8th weeks. After only three weeks, within the music therapy group, one person improved; however, none improved within the psychotherapy group.. By the end of the study, 29 subjects improved with music therapy, and only four did not. For psychotherapy, only 12 subjects improved with 16 people showing little to no improvement. These data from the Zung and Hamilton tests were also cross-referenced with the Friedman test, and showed to be statistically significant with a p-value as little as 0.0356 (Castillo-Perez et al. 389).

As we can see, psychologists and neuroscientists today are doing more and more research regarding music therapy. Castillo-Perez’s study is just one of many examples in which music therapy has proven to improve the quality of life for people with depression more than psychotherapy. The three main methods of treatment for depression today are psychotherapy, antidepressants, and electroconvulsive therapy for severe cases. However, Perez and the rest of his team say, “Pharmaceutical treatments […] make no difference in the odds ratio of suicide attempts” (Castillo-Perez et al. 387). That is what needs to fundamentally change in how we treat and understand therapy for depressed patients. Pharmaceutical drugs will not influence the likelihood of someone committing suicide because there can be many sudden environmental circumstances and triggers. Musical therapy, on the other hand, aims to help depressed patients by trying to invoke the mesolimbic system, which correlates to positive and rewarding thoughts. As people living in the 21st century, we can understand that there is something special about listening to new music by our favorite artists, or dancing and singing to a high energy song that can affect our minds positively. Songs can reflect how we feel and can heighten our current emotions, and this is something that medicine and therapy at a certain point cannot do as effectively as initially administered.

As with many people who learn music from an early age, I found that playing a music instrument helped me relax and de-stress, especially after a long day of school and tests. After my piano lessons on Sundays and six-hour days at high school, I would hop on that leather bench and play Emile Pandolfi and feel my heartbeat slow down and my cheek muscles tense from all the grinning. Playing the theme from Harry Potter on the piano was my mode of artistic expression and relaxation. It is easily accessible, then, to imagine how music can help those who have severe emotional or mental disorders. To the parents of kids with mental health disorders, understand that music can be an outlet for kids to release their emotions and can have a tremendous effect on their functioning and behavior; to the kids who never seemed interested in playing music, that is okay. Part of music therapy merely involves passively listening to music in a relaxing setting. Society needs to alter its perspective on music from being misconstrued as a way of wasting time to a way of elevating one’s moods and taking a mental break.

To truly get an insight on a student’s perspective of music and its effects on mental health, I interviewed a bandmate of mine from high school who has been playing trumpet since the fifth grade. Her lifelong appreciation of music started when she began taking piano lessons in the second grade. She then began taking trumpet lessons and joined the band in the 5th grade and has continued primarily with trumpet since then. When I asked her about her mental health, she said, “As someone who has depression and anxiety, a part of me is always anxious, and the daily fight is not letting it become a 100% of me, and using coping mechanisms to get out of it.” She had to move 350 miles for college and said that it was a difficult transition due to the workload and having to meet new people, making it difficult to find time to relax. Being a part of the wind ensemble at her college allowed her to ease into the transition of a college student. When asked how music has helped her with her mental state and journey, she stated, “playing music was definitely a double-edged sword. Although I had stress and anxiety from the responsibilities that came with being on the band e-board, the intrinsic joy I got from getting together with people I cared about and playing amazing music was amazing” (Anonymous). She found that listening to music gave her a sense of solace and tranquility. It allowed her mind to focus on just the music, and in the process, she forgot all of her anxieties and elevated her mood. The lyrics, instrumentation, and many other aspects of music therapy can reflect the emotions we feel and can elevate how we feel. Music can alter the state of chemical neurotransmitters in our minds and change our emotions – this is something drugs and psychotherapy cannot do as effectively.

Due to social media today, music has become much more prevalent in students’ lives and has influenced the way college students handle stressful situations.A significant reason explaining music therapy’s lack of usage is because there are many misconceptions about the way music therapy works. Music therapy Director of University Minnesota Dr. Silverman, discusses the ill-conceived notions of music therapy, stating that “a common misperception of music therapy is that it is used exclusively to treat musicians” ( 55). Silverman emphasizes that music therapy was always used to help treat people with a broad range of neurological and psychological issues among a variety of adults, children, and seniors. Another common misconception is that music therapy is not as effective because it is merely the act of passive listening to pre-recorded music. However, music therapy is not just listening to music. Director Silverman says that in a study done comparing two groups of depressed patients who underwent passive music therapy and active music therapy, the active music therapy patients stayed throughout the sessions. Active music therapy involved lyric analysis, recreation music playing, and percussional music therapy (Silverman 55). All of this active participation served as psychological interventions that helped alter the person’s mood, behavior, and mindset.

In a survey I administered to fellow Stony Brook Students and my fellow high school alumni who have taken part in music since a young age, I discovered their opinions on the use of music in a therapeutic way. Of the 57 people who responded, 79% played an instrument, 22% of people said they listen to jazz or a variety of orchestral or classical music while studying, 80% of people listen to music when stressed out, and 73% of people found music to be therapeutic overall (“Music As Therapy”). 28% percent of the people I surveyed have mental health disorders such as anxiety, depression, and eating disorders. Even though the majority of people surveyed did not have disorders, 80% of the people who deal with everyday environmental stressors choose to listen to music to cope. When asked on a scale of one to five (five being complete improvement in mood and one being mood unchanged), 31 people said they felt better after listening to music when they felt anxious, sad, depressed, or other negative emotions. 12 people say their mood completely changed for the better (“Music As Therapy”). Although these results are biased because many of these people have played an instrument, they show that a majority of students understand that music has therapeutic qualities and utilize it as a coping mechanism or a tool when experiencing stress, anxiety, or depressive thoughts. Music is a type of escapism that allows people to avoid focusing on their current troubles and gives them the ability to focus all of their energy on one thing only – music.

Having said all of the above, why do people still believe that conventional treatment methods are effective and do not want to change? Discussions of new treatment methods lack because people only know what is largely acknowledged in society. Mental health was and still is stigmatized because it affects one’s mind and does not often manifest with physical symptoms like cancer. Only in the past few years has the topic of mental health been brought to the forefront. If many Americans do not wish to discuss their mental health problems, then how can new and more productive methods of treatment be used? Therein lies the existing problem that needs to change. Currently, in the time of self-quarantine, anxiety can run high even with people who have not been diagnosed with a mental health disorder because we live in a time of uncertainty. In a time when the fear of virus spread is high and ‘stay at home’ orders are strict, quarantine serves as an obstacle for people who need weekly in-person therapy sessions. People need to utilize resources at home that are easily accessible to cope with their anxiety, like music resources. If people are privileged enough to have access to the internet, there are a plethora of resources that can be used for music therapy, such as YouTube, Spotify, or an instrument if one has it.

Society needs to acknowledge that music therapy is a method that has proven to be successful amongst a wide range of people with varying disorders and varying levels of depression. Well known music therapist Dr. Dany Bouchard eloquently describes how to handle anxiety during the time of COVID: “Music has a connection with memory, brings us emotions, all kinds of stuff. It is how you use it now in order to make it a music prescription” (Rowat, para. 15). Music can help with COVID-related anxiety by serving as a focusing tool that allows our mind to target what is going on now rather than worrying about an uncertain future (Rowat, para. 18). Being open to trying new modes of therapy can be much more effective for anyone. As time goes on, some people with mental health disorders may have to increase their drug dosage due to drug tolerance that inevitably develops. At times, people who go to therapy may feel that it is not working, and can revert to unhealthy habits and coping mechanisms. Mental health overall is something that affects people every day through their actions and their emotions. Treatment of mental health disorders is an important aspect of healthcare that needs to be improved; it is a series of actions and behaviors one takes in order to see an actual result. Music can alter the state of someone’s mood and change someone’s behavior after prolonged daily music sessions. Additionally, the collaborative nature of music therapy allows people with mental disorders to have a massive support system on their path to recovery. Music therapy moves away from the idea persisting in mental health recovery that it is up to the person to improve themselves, and it is a solitary journey. Take 10 or maybe even 20 minutes per day to actively take part in something that involves music, whether it’s through such as playing, writing, singing, or listening. People with mental health problems are in a daily battle with their minds to prevent feelings of depression and anxiety from overcoming their thoughts. While psychotherapeutic drugs and therapy are helpful to an extent, music therapy can provide long term positive effects.

Works Cited

Anonymous. Personal interview. 15 April, 2020.

Castillo-Perez, Sergio, et al. “Effects of Music Therapy on Depression Compared with Psychotherapy.” The Arts in Psychotherapy, vol. 37, no. 5, Nov. 2010, pp. 387-90. ScienceDirect, doi:10.1016/j.aip.2010.07.001. Accessed 15 Apr. 2020.

Craig, Heather. “What Is Music Therapy and How Does It Work?” Positive Psychology, 18 Mar. 2020: par 1-101, positivepsychology.com/music-therapy/. Accessed 15 Apr. 2020.

Fornaro, Michele, et al. “The Emergence of Loss of Efficacy during Antidepressant Drug Treatment for Major Depressive Disorder: An Integrative Review of Evidence, Mechanisms, and Clinical Implications.” Pharmacological Research, vol. 139, Jan. 2019, pp. 494-502. ScienceDirect, doi:10.1016/j.phrs.2018.10.025. Accessed 15 Apr. 2020.

“Mental Health Treatments.” Mental Health America National, Mental Health America: par 1-10, http://www.mhanational.org/mental-health-treatments. Accessed 15 Apr. 2020.

Rowat, Robert. “We Asked a Music Therapist How to Relieve Anxiety Caused by Social Distancing.” CBC Music, 20 Mar. 2020, p. 1. CBC: par 1-23, http://www.cbc.ca/music/we-asked-a-music-therapist-how-to-relieve-anxiety-caused-by-social-distancing-1.5504973. Accessed 15 Apr. 2020.

Sankaran, Sanjana. “Music As Therapy.” Survey. 15 April. 2020.

Silverman, Michael J. “An Overview of Music Therapy as a Psychosocial Intervention for Psychiatric Consumers.” Music Therapy in Mental Health for Illness Management and Recovery, Oxford UP, 2015, pp. 60-67. doi:10.1093/acprof:oso/9780198735366.001.0001.

“The State of Mental Health in America.” Mental Health America National, Mental Health America, 2017, http://www.mhanational.org/issues/state-mental-health-america. Accessed 15 Apr. 2020.

“Suicide Data.” World Health Organization, 27 Sept. 2019, http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/. Accessed 15 Apr. 2020.

Wang, Shentong, and Mark Agius. “The Use of Music Therapy in the Treatment of Mental Illness and the Enhancement of Societal Wellbeing.” Psychiatria Danubina, vol. 30, 30 Nov. 2018, pp. 595-600, http://www.psychiatria-danubina.com/UserDocsImages/pdf/dnb_vol30_noSuppl%207/dnb_vol30_noSuppl%207_595.pdf. Accessed 15 Apr. 2020.

Adolescent Peer Relationships and Mental Health during the COVID-19 Pandemic

May 25, 2021April 9, 2022sbubrooklogueLeave a comment

by Sophia Garbarino, Clare Beatty & Brady Nelson, May 25, 2021

See Sophia’s poster for the URECA 2021 Symposium here.

Abstract

In adolescence, females are more likely than males to experience an episode of depression (Hyde et al., 2008). Having a strong social network has been shown to protect against the development of depression and anxiety symptoms (Santini et al., 2015). In the U.S., adolescent social circles were largely disrupted during the initial phases of the COVID-19 pandemic. Although it has been suggested that higher perceived social support protects against poorer mental health (Magson et al., 2021), few studies have examined the potential association between relationship quality and mental health during the COVID-19 pandemic. In a sample of 104 12 to 18 year-old girls, the present study examined peer relationship quality prior to the COVID-19 pandemic and changes in depression and anxiety symptoms during March to April 2020. Relationship quality was measured with the self-report Network of Relationships Inventory – Relationship Qualities Version (NRI-RQV). Depression was measured with the Child’s Depression Inventory (CDI), and anxiety was measured with the Screener for Child Anxiety Related Disorders (SCARED). Across the entire sample, there was an increase in both depression (t = -4.88, p < 0.001) and anxiety (t = -3.07, p = 0.003) symptoms during the COVID-19 pandemic. In addition, pre-COVID-19 perceived closeness of friendships predicted changes in depression and anxiety symptoms during the COVID-19 pandemic. Specifically, greater same-sex (r = -0.29, p = 0.003) and opposite-sex (r = -0.21, p = 0.04) friendship closeness were inversely correlated with generalized anxiety symptoms. Opposite-sex friendship closeness was inversely correlated with depression symptoms (r = -0.26, p = 0.008). Parent-child relationships were also examined but were not associated with changes in mental health. Findings suggest that healthier peer friendships may serve as protective factors against depression and anxiety in adolescents. As vaccine distribution increases and social distancing policies become more relaxed, adolescents may be able to strengthen relationships that were impacted by the COVID-19 pandemic, contributing to improved mental health.

Keywords: COVID-19, adolescents, relationships, friendships, depression, anxiety

Introduction

Background

Adolescence is a critical developmental period for the emergence of sex differences in depression. By ages 13 to 15 girls are approximately twice as likely as boys to experience an episode of depression (Hyde et al., 2008). Prior research has taken a particular interest in the psychological mechanisms responsible for this shift, focusing specifically on girls.

For both sexes, strong social support networks have been shown to protect against the development of depressive and anxiety symptoms (Santini et al., 2015). In early 2020, when the initial phases of the COVID-19 pandemic began, these social networks were largely disrupted, especially for children and teenagers. The daily routine of interacting with classmates and peers at school was abruptly interrupted due to the shift to remote learning. During this time, research suggests that females in particular experienced a notable increase in depressive and anxiety symptoms (Hawes et al., 2021).

While some studies suggest that higher perceived social support protects against poorer mental health (Magson et al., 2021), few studies have examined the potential association between relationship quality and mental health during COVID-19. The present study examined pre-pandemic peer relationship quality and its potential for predicting depressive and anxiety symptoms during the early COVID-19 pandemic.

Hypotheses

The present study tested two hypotheses: 1) Individuals would display an increase in depressive and anxiety symptoms during the initial stages of the COVID-19 pandemic as compared to pre-pandemic symptoms, and 2) Both parent and peer relationships would inversely correlate with depressive and anxiety symptoms during the COVID-19 pandemic. In other words, healthier and closer relationships would be associated with fewer depressive and anxiety symptoms during COVID-19.

Methods

Participants

The sample consisted of 104 girls from an ongoing longitudinal study at Stony Brook University, the Impact of Puberty on Affect and Neural Development across Adolescence (iPANDA) project. This project is currently investigating the relationship between neural reward sensitivity and the development of depression. Eligibility included being assigned female at birth, aged 8 to 14, being literate in English, having no known medical or developmental disabilities, and living within 30 miles of Stony Brook University in Long Island, NY. One of the child’s biological parents also had to be willing to participate. The baseline sample consisted of 317 girls along with one of their biological parents. Baseline data collection was followed by two additional waves, each spaced approximately two years apart. The third wave was still in progress when the COVID-19 pandemic began in late March 2020, therefore not all of the participants had completed the data collection.

Measures

The iPANDA participants (N = 104) were included in the present study if they completed the included measures within the appropriate timeframes. One measure was completed prior to the pandemic (before March 18, 2020), and two measures were completed before and during (March 18, 2020 and after) the pandemic. The average time between the pre-COVID and during-COVID assessments was 55 weeks.

Network of Relationships Inventory – Relationship Quality Version (NRI-RQV)

The NRI-RQV questionnaire is a self-report measure that assesses participants’ relationships with their 1) mother or mother figure, 2) father or father figure, 3) boyfriend or girlfriend, 4) sibling, 5) best same-sex friend, and 6) best opposite-sex friend. The questions had Likert-style responses (1 to 6: 1 = low occurrence, 5 = high occurrence, 6 = not applicable) and were presented in matrix format with each relationship type. Questions were classified into one of ten scales; the five positive scales measured companionship, intimate disclosure, emotional support, approval, and satisfaction, while the five negative scales measured conflict, criticism, pressure, dominance, and exclusion. Each scale contained three items and was scored by averaging the item responses (Furman & Buhrmester, 2010). The present study focused on the Closeness score, which is the mean of the five positive scale scores, for the mother, father, best same-sex friend, and best opposite-sex friend relationships. Participants completed the NRI-RQV assessment pre-COVID.

Children’s Depression Inventory (CDI)

The CDI questionnaire is a self-report measure that assesses participants’ depressive symptoms (Kovacs, 1992). Scores were calculated by summing the item responses, which were Likert style (not often/doesn’t apply to me, sometimes/somewhat applies to me, very often/strongly applies to me). Participants completed the CDI assessment pre-COVID and during COVID.

Screen for Child Related Anxiety Disorders (SCARED)

The SCARED questionnaire is a self-report measure that assesses participants’ anxiety symptoms. Each item had Likert-style responses (0 to 2: 0 = not true, 2 = very true) and was categorized into one of five subscales: panic disorder or significant somatic symptoms, generalized anxiety disorder (GAD), separation anxiety disorder, social anxiety disorder, and significant school avoidance. A total sum score of 25 or above (out of 82) indicated the possible presence of an anxiety disorder (Birmaher et al., 1997). The present study focused only on the GAD subscale, where a sum score over 9 indicated the possible presence of GAD. Participants completed the SCARED assessment pre-COVID and during COVID.

Data Analysis

Using IBM®️ SPSS®️ Statistics (v.27) software, we conducted two paired samples t-tests to examine whether depressive and anxiety symptoms increased during the pandemic as compared to pre-pandemic. Further, we conducted follow-up partial correlations (controlling for pre-pandemic symptoms) to investigate the relationship between relationship quality and depressive/anxiety symptoms during the pandemic.

Results & Discussion

Figure 1. Pre-COVID-19 vs. COVID-19 SCARED GAD Subscale t-test

Figure 2. Pre-COVID-19 vs. COVID-19 CDI Total t-test

Table 1. Correlations between SCARED GAD (COVID-19), CDI (COVID-19), and peer relationships

	COVID-19 SCARED GAD Subscale	COVID-19 CDI Total
NRI-RQV Best Same-Sex Friend Closeness (pre-COVID)	-0.287**	-0.080
NRI-RQV Best Opposite-Sex Friend Closeness (pre-COVID)	-0.205*	-0.259**

Controls: pre-COVID SCARED or pre-COVID CDI
p < .05* p < .01** p < .001***

Table 2. Friendship closeness vs. COVID-19 symptoms regressions

	COVID-19 SCARED GAD Subscale (β)	COVID-19 CDI Total (β)
NRI-RQV Best Same-Sex Friend Closeness (pre-COVID)	-.168**	.074
NRI-RQV Best Opposite-Sex Friend Closeness (pre-COVID)	-.018	-.124****

Controls: pre-COVID-19 SCARED and CDI; COVID-19 SCARED or CDI
p < .05* p < .01** p < .001*** trending****

Results indicated support for the first hypothesis. Across the sample, participants had greater depressive (t = -4.88, p <.001) and anxiety (t = -3.07, p < .01)symptoms during the COVID-19 pandemic, as compared to pre-pandemic. However, results indicated only partial support for the second hypothesis. Pre-pandemic friendship closeness was associated with changes in anxiety and depressive symptoms; specifically, stronger pre-COVID same-sex friendship closeness uniquely correlated with smaller increases in anxiety symptoms during COVID (r = -.29, p < .01), while stronger pre-COVID opposite-sex friendship closeness uniquely correlated with smaller increases in depressive symptoms during COVID (r = -.26, p < .01). When controlling for pre-pandemic symptoms, pre-COVID same-sex friendship closeness still predicted changes in COVID anxiety symptoms (r = -.17, p < .01). Mother and father relationships were not found to be significantly predictive of changes in mental health during COVID.

Conclusion

Interpretations

It is possible that participants were more comfortable expressing worry to same-sex friends (girls), buffering against increased anxiety symptoms. Perhaps they shared feelings about missing friends or romantic interests at school. Findings also suggest that opposite-sex friends (boys) may have helped improve participants’ moods, buffering against increased depressive symptoms. The girls may have had a crush or two and were happier interacting with them, even if only virtually, while following stay-at-home orders.

Limitations

The sample was predominantly Caucasian and middle class, and from the Long Island, New York area. As such, the sample is certainly not representative of the entire United States, as the U.S. is much more racially and socioeconomically diverse. It is unclear whether or not these results would be similar for individuals of different backgrounds, since a variety of factors, including race, ethnicity, sex, and economic class, impact the degree to which people have been affected, either positively or negatively, by the pandemic (Center for Disease Control and Prevention). For example, Black and Indigenous Americans had the highest COVID-related death rates, while Asians and Whites had much lower rates (APM Research Lab Staff). According to the Pew Research Center, lower-income individuals were also more likely to report lost income and jobs due to the pandemic (Parker et al., 2020). As such, the present study’s sample may not have been affected by COVID-19 as much as other groups.

Further, all measures were self-reported, so participants may have been reluctant to share the full extent of their relationships and COVID-19 experiences. Another important consideration is that there was over a year, on average, between the pre-COVID and during-COVID assessments, meaning we could not account for potential significant life changes, such the death of a parent, losing touch with a friend, moving to a new place, and changes in relationship nature itself. Therefore, the present study’s results regarding pre-pandemic relationship quality may not be fully applicable to pandemic-era relationship health.

Future Directions

Overall, the results were largely what we hypothesized. Increased anxiety and depressive symptoms during the COVID-19 pandemic were evident across the sample and peer relationships predicted changes in mental health. Future studies should investigate these findings further and consider potential gender, race, and socioeconomic class differences that were not found in the present sample. Social factors like gender norms, double sex standards, race/ethnicity, and wealth may further influence the nature of adolescents’ social support networks and how they experienced the COVID-19 pandemic.

References

APM Research Lab Staff. (2021, March 5). The color of coronavirus: COVID-19 deaths by race and ethnicity in the U.S. APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race

Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., & Kaufman, J. (1997, April). The screen for child anxiety related emotional disorders (SCARED): Scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry 36: 545–553. https://doi.org/10.1097/00004583-199704000-00018

Center for Disease Control and Prevention. (2021, April 19). Health equity considerations and racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html

Furman, W., & Buhrmester, D. (2010). Network of relationships questionnaire manual. Unpublished manuscript, University of Denver, Denver, CO, and the University of Texas at Dallas.

Hawes, M.T., Szenczy, A.K., Klein, D.N., Hajcak, G., & Nelson, B.D. (2021, January 13). Increases in depression and anxiety symptoms in adolescents and young adults during the COVID-19 pandemic. Psychological Medicine, 1–9. https://doi.org/10.1017/s0033291720005358

Hyde, J.H., Mezuklis, A.H., & Abramson, L.Y. (2008). The ABCs of depression: Integrating affective, biological and cognitive models to explain the emergence of the gender difference in depression. Psychological Review, 115, 291-313. https://doi.org/10.1037/0033-295x.115.2.291

Magson, N.R., Freeman, J.Y., Rapee, R.M, Richardson, C.E., Oar, E.L., & Fardouly, J. (2021). Risk and protective factors for prospective changes in adolescent mental health during the COVID-19 pandemic. Journal of Youth and Adolescence, 50, 44-57. https://doi.org/10.1007/s10964-020-01332-9

Kovacs, M. (1992). Children’s depression inventory. Multi-Health Systems, Inc.

Parker, K., Horowitz, J.M., & Brown, A. (2020, April 21). About half of lower-income Americans report household job or wage loss due to COVID-19. Pew Research Center. https://www.pewresearch.org/social-trends/2020/04/21/about-half-of-lower-income-americans-report-household-job-or-wage-loss-due-to-covid-19/

Santini, Z.I., Koyanagi, A., Tyrovolas, S., Mason, C., & Haro, J.M. (2015, April 1). The association between social relationships and depression: A systematic review. Journal of Affective Disorders, 175, 53–65. https://doi.org/10.1016/j.jad.2014.12.049

Abstract

Full Text

Introduction

Background

How maternal and reproductive medicine evolved with American politics

How sex- and gender-based medicine was born

Methods

Stony Brook University

Sample

Interview Questions

Educational Background

Gender & sexuality education as a student

Current gender & sexuality education

Institutional support

Results & Discussion

Participants’ own gender and sexuality training

What current SBU students learn

Institutional support

Using a binary gender lens

Using a heteronormative LGBTQ* lens

Hiding behind generalized health inequity

Distinct differences between medical and nursing education

The Medical Model’s Shortcoming

The Nursing Model’s Humility

Faculty diversity

Conclusion

Footnotes

Acknowledgements & Disclosures

Works Cited

Works Cited

Abstract

Introduction

Background

Hypotheses

Methods

Participants

Measures

Network of Relationships Inventory – Relationship Quality Version (NRI-RQV)

Children’s Depression Inventory (CDI)

Screen for Child Related Anxiety Disorders (SCARED)

Data Analysis

Results & Discussion

Figure 1. Pre-COVID-19 vs. COVID-19 SCARED GAD Subscale t-test

Figure 2. Pre-COVID-19 vs. COVID-19 CDI Total t-test

Table 1. Correlations between SCARED GAD (COVID-19), CDI (COVID-19), and peer relationships

Table 2. Friendship closeness vs. COVID-19 symptoms regressions

Conclusion

Interpretations

Limitations

Future Directions

References

Using a heteronormative **LGBTQ* lens**