Sara L. Kornfield

Satisfaction with pregnancy loss aftercare: are women getting what they want?

While there is increasing recognition that early miscarriage represents a significant loss experience that often provokes depression and anxiety, women’s dissatisfaction with some aspects of care received from healthcare professionals following a pregnancy loss and the potentially negative consequences of this are often less recognized. This review examines available literature to identify what comprises “treatment as usual,” how satisfied women are with the typical services they receive from healthcare personnel, and whether these services are consistent with women’s self-identified needs. Results are reviewed according to four major themes—patient satisfaction with: attitudes of healthcare providers, provision of information, interventions provided, and follow-up care. In general, women and families who have experienced a miscarriage report low levels of satisfaction in the presence of perceived negative attitudes from healthcare providers, insufficient provision of information, and inadequate follow-up care that did not focus on emotional well-being. Higher levels of satisfaction are reported among women whose providers were emotionally attuned to the magnitude of the loss, provided information, and involved women in treatment decisions when possible. Limitations of current research are reviewed and directions for future research, training, and practice are briefly discussed.

Mental health outcomes of abortion and its alternatives: implications for future policy.

Since abortion’s legalization in 1973, there have been vocal movements by conservative political and right wing religious groups to ban the procedure. Prolife or ‘‘anti-choice’’ activists specify that abortion is harmful for many reasons, including that it can cause detrimental effects to the mental and emotional health of the pregnant woman, resulting in a ‘‘post-abortion syndrome.’’ Critics became so vocal that during the Reagan administration, Surgeon General C. Everett Koop was asked to prepare a report about the negative mental health sequelae of abortion for the women who undergo them. Koop’s report found no evidence to support the assertion that women suffer from poor mental health outcomes after having an elective abortion (Koop, 1989). Despite this and other more recent scientific evidence citing similar findings, the U.S. Supreme Court referenced maternal mental health in its decision to uphold a ban on late-term abortions (Gonzales v. Carhart). Specifically, the Supreme Court stated that women may experience ‘‘regret, . . . severe depression and loss of esteem’’ while simultaneously acknowledging that ‘‘we find no reliable data to measure the phenomenon’’ (Carhart, 2006). Similarly, legislators in South Dakota used this same rationale in developing a new law that compels physicians to inform women seeking abortions that they will be putting themselves at risk for emotional distress and suicide (Simon, 2008). The existing empirical evidence, presented below, has not been accepted by opponents of elective abortions in the United States; many still believe that abortion can be harmful to women’s mental health

Exploring the need for interventions to manage weight and stress during interconception

Interventions to manage weight and stress during the interconception period (i.e., time immediately following childbirth to subsequent pregnancy) are needed to promote optimal maternal and infant health outcomes. To address this gap, we summarize the current state of knowledge, critically evaluate the research focused on weight and stress management during the interconception period, and provide future recommendations for research in this area. Evidence supports the importance of weight and stress management during the reproductive years and the impact of weight on maternal and child health outcomes. However, evidence-based treatment models that address postpartum weight loss and manage maternal stress during the interconception period are lacking. This problem is further compounded by inconsistent definitions and measurements of stress. Recommendations for future research include interventions that address weight and stress tailored for women in the interconception period, interventions that address healthcare providers’ understanding of the significance of weight and stress management during interconception, and long-term follow-up studies that focus on the public health implications of weight and stress management during interconception. Addressing obesity and stress during the interconception period via a reproductive lens will be a starting point for women and their families to live long and healthy lives.

What has sex got to do with it? the role of hormones in the transgender brain

Sex differences and hormonal effects in presumed cisgender individuals have been well-studied and support the concept of a mosaic of both male and female “characteristics” in any given brain. Gonadal steroid increases and fluctuations during peri-puberty and across the reproductive lifespan influence the brain structure and function programmed by testosterone and estradiol exposures in utero. While it is becoming increasingly common for transgender and gender non-binary individuals to block their transition to puberty and/or use gender-affirming hormone therapy (GAHT) to obtain their desired gender phenotype, little is known about the impact of these manipulations on brain structure and function. Using sex differences and the effects of reproductive hormones in cisgender individuals as the backdrop, we summarize here the existing nascent neuroimaging and behavioral literature focusing on potential brain and cognitive differences in transgender individuals at baseline and after GAHT. Research in this area has the potential to inform our understanding of the developmental origins of gender identity and sex difference in response to gonadal steroid manipulations, but care is needed in our research questions and methods to not further stigmatize sex and gender minorities.

What Does Sex Have to Do with It? The Role of Sex as a Biological Variable in the Development of Posttraumatic Stress Disorder

Purpose of ReviewThis review highlights the neurobiological aspects of sex differences in posttraumatic stress disorder (PTSD), specifically focusing on the physiological responses to trauma and presents evidence supporting hormone and neurosteroid/peptide differences from both preclinical and clinical research.Recent FindingsWhile others have suggested that trauma type or acute emotional reaction are responsible for women’s disproportionate risk to PTSD, neither of these explanations fully accounts for the sex differences in PTSD. Sex differences in brain neurocircuitry, anatomy, and neurobiological processes, such as those involved in learning and memory, are discussed as they have been implicated in risk and resilience for the development of PTSD. Gonadal and stress hormones have been found to modulate sex differences in the neurocircuitry and neurochemistry underlying fear learning and extinction.SummaryPreclinical research has not consistently controlled for hormonal and reproductive status of rodents nor have clinical studies consistently examined these factors as potential moderators of risk for PTSD. Sex as a biological variable (SABV) should be considered, in addition to the endocrine and reproductive status of participants, in all stress physiology and PTSD research.

Predictors of Posttraumatic Stress Symptoms and Association with Fear of Falling After Hip Fracture

To determine whether fall‐related hip fracture, alone or in the presence of Fear of Falling, is likely to induce PTSD in an elderly population.

Gender-Affirming Hormone Use in Transgender Individuals: Impact on Behavioral Health and Cognition

Purpose of ReviewWith increasing numbers of transgender and gender non-binary individuals presenting for care, knowing how to elucidate the mental health and cognitive outcomes of gender-affirming hormone therapy (GAHT) is necessary. This article reviews the present literature covering GAHT effects on mood, behavioral health, and cognition in these individuals and offers research priorities to address knowledge gaps.Recent FindingsAlthough there are some conflicting data, GAHT overwhelmingly seems to have positive psychological effects in both adolescents and adults. Research tends to support that GAHT reduces symptoms of anxiety and depression, lowers perceived and social distress, and improves quality of life and self-esteem in both male-to-female and female-to-male transgender individuals.SummaryClinically, prescribing GAHT can help with gender dysphoria-related mental distress. Thus, timely hormonal intervention represents a crucial tool for improving behavioral wellness in transgender individuals, though effects on cognitive processes fundamental for daily living are unknown. Future research should prioritize better understanding of how GAHT may affect executive functioning.

Startling Differences: Using the Acoustic Startle Response to Study Sex Differences and Neurosteroids in Affective Disorders

Purpose of ReviewNeuroactive steroid hormones, such as estradiol and progesterone, likely play a role in the pathophysiology of female-specific psychiatric disorders such as premenstrual dysphoric disorder (PMDD) and postpartum depression and may contribute to the marked sex differences observed in the incidence and presentation of affective disorders. However, few tools are available to study the precise contributions of these neuroactive steroids (NSs). In this review, we propose that the acoustic startle response (ASR), an objective measure of an organism’s response to an emotional context or stressor, is sensitive to NSs. As such, the ASR represents a unique translational tool that may help to elucidate the contribution of NSs to sex differences in psychiatric disorders.Recent FindingsFindings suggest that anxiety-potentiated startle (APS) and prepulse inhibition of startle (PPI) are the most robust ASR paradigms for assessing contribution of NSs to affective disorders, while affective startle response modulation (ASRM) appears less diagnostic of sex or menstrual cycle (MC) effects. However, few studies have appropriately used ASR to test a priori hypotheses about sex or MC differences.SummaryWe recommend that ASR studies account for sex as a biological variable (SABV) and hormonal status to further knowledge of NS contribution to affective disorders.

Relationship Between Pregnancy Complications and Psychiatric Disorders: A Population-Based Study With a Matched Control Group

OBJECTIVES This study sought to identify whether pregnancy complications differ between women with and without a psychiatric disorder diagnosis prior to pregnancy. METHODS Women who gave birth between 2007 and 2009 in Pennsylvania and were enrolled in Medicaid from one year prior to their pregnancy until their delivery were included (N=9,930); those with psychiatric disorders were compared with a matched control group (N=4,965 for each). Logistic regression analysis estimated the odds of having a pregnancy complication among those with a psychiatric diagnosis prior to pregnancy, adjusting for demographic characteristics and chronic general medical conditions. RESULTS Compared with the control group, women with a psychiatric disorder prior to pregnancy had greater odds of having at least one pregnancy complication (odds ratio=1.48, 95% confidence interval=1.37-1.61). Compared with the control group, their odds of antepartum hemorrhage were 1.50 times higher, their odds of preterm labor were 1.45 times higher, and their odds of preterm birth were 1.61 times higher. CONCLUSIONS Women with psychiatric disorders prior to pregnancy were more likely to experience pregnancy complications, including pregnancy hemorrhage, preterm labor, and preterm birth, after the analysis controlled for age, race-ethnicity, and chronic illness status before and during pregnancy. The finding of an association between psychiatric disorders and a higher complication risk suggests the importance of population-based preconception interventions for women with psychiatric disorders and prenatal monitoring to reduce the risk of pregnancy complications in this group.

Women’s Health: Obstetrics and Gynecology

Recent shifts towards the integration of mental health care in primary care settings have made clinical psychologists practicing in women’s health care settings an indispensable asset to both patients and medical providers. Women of all ages have higher rates of primary and specialty care visits than men, and many women of reproductive age receive primary and preventive health care within obstetrics and gynecology (ob/gyn) settings where medical providers are often the first professionals to triage and address complex mental health problems. Women face unique psychosocial and mental health challenges, including stress from multiple roles and caregiving responsibilities, relational context, and possible exposure to violence. In addition to discussion of these contextual factors, this chapter will examine current research regarding those conditions more commonly seen and treated by clinical psychologists in ob/gyn settings, including mental health issues surrounding pregnancy and childbirth, sexual health and functioning, pelvic pain, urinary incontinence, perimenopause and menopause, and infertility. For each area, when evidencein the research literature exists for the benefit of psychological intervention, this information also will be presented.