Books & Electronic Media

Women's health: contemporary international perspectives

Edited by Jane Ussher. Published by the British Psychological Society, Leicester, England, 2001. ISBN 1 85433 308 9, price: £17.50.

This lively and engaging set of papers on women's health makes a unique contribution to the subject. From the health problems of girls to those of older women, including chapters on substance abuse, breast cancer, rape, HIV, harassment, domestic violence, premenstrual syndrome, pregnancy, abortion, mothering, menopause, hysterectomy, eating disorders and dementia, it offers an unusually wide range of perspectives from leading international researchers and scholars in the field. Women's voices from around the world explore these and other themes, highlighting the diversity of their experience. Much of the existing literature and research on women's health issues take `gender' rather than health itself as its central focus, and this collection provides a welcome alternative. In addition, health is situated in women's social, psychological and cultural contexts, and seen in the light of the different health issues that arise at the different stages in life.

Jane Ussher explores contemporary concerns about women's health and their historical background, providing the thematic outline of the book. This is supplemented by chapters on the methodologies that can be used in this field, and the part played by psychology in overall health. The bulk of the material that follows is related to aspects of sexuality and reproductive health. Of unusual interest in this context is the section focusing on issues of body image, bodily control and regulation, body manipulation and the gendered body. Women's desire to change their body shape is examined, together with its association with eating disorders in western societies. Mervat Nasser draws attention here to the parallels between eating disorders and other approaches to body image regulation, such as veiling in the Middle East. In this section too, Louise Newman focuses on transgender transformation, an extreme form of body manipulation, providing an overview of the issues involved and their implications for health. These include gender identity, development, and disorders in the context of current mental health services. A substantial section on mental health follows, which includes depression, stress, the effects of abortion, sexual abuse, and trends in psychotherapy. The book concludes with a section on the health of older women.

Women's health should appeal to a broad audience from academics and policy-makers to health practitioners. Specialists in areas such as anthropology, cultural studies, history, linguistics, medicine, nursing, philosophy, psychology, psychoanalysis and sociology will find plenty of useful material and fresh perspectives in it.

Kate Reed
School of Social Policy, Sociology and Social Research University of Kent Canterbury, CT2 7NZ, England

Cultural psychiatry: Euro-international perspectives

Edited by A. T. Yilmaz, M. G. Weiss & A. Riecher-Rössler Published by Karger, Basel, Switzerland, 2001. ISBN 3 8055 7048 1, price: Sw. fr. 89.

This volume is a product of a conference held in Basel, Switzerland, entitled "Transcultural psychiatry: challenges for diagnosis and treatment". It is divided into three parts. Part I considers interdisciplinary concepts informing cultural practice and research. A key paper here is by Mitchell Weiss, one of the editors of the book and a leading figure in the field of cultural psychiatry. He argues that general psychiatry and cultural psychiatry have developed along separate lines, but that there has been evidence of a mutual accommodation in recent years. Thus, there is an increasing recognition by clinicians of the need both for valid and reliable diagnostic assessments (using systems such as the Diagnostic and Statistical Manual (DSM)), and also of the need for cultural formulations (see below). Likewise, researchers are accepting that structured epidemiological instruments and ethnographic methods provide complementary sources of data, each of which informs and enriches the other.

This mutual accommodation is manifest in the second section of the book, which deals with migration, trauma and the context of migrant mental health problems. The focus is on Switzerland and other Western European countries, which are experiencing high levels of inward migration from Eastern Europe and formerly colonized countries.

A chapter on post-traumatic stress disorder (PTSD) and culture straddles general psychiatric and cultural psychiatric perspectives on this controversial issue. The author argues, for example, that efforts to understand traumatic reactions must consider three dimensions: personal uniqueness, universal responses to traumatic events, and the cultural and contextual aspects of responses to traumatic stress. The latter include aspects such as higher prevalence rates of somatization and dissociation among non-Western people with PTSD. Also, people from "traditional" cultures may perceive themselves to be more collectivist (in the sense of perceiving themselves as part of a whole) than others, which has implications for the expression and treatment of traumatic stress.

Another example of the mutual accommodation between general and cultural psychiatry is an illuminating clinical case study of a young Muslim Turk who immigrated to Switzerland. He presented with symptoms of depression and lower back pain. After providing a "classic" clinical history and diagnosis according to the DSM, the authors provide a cultural formulation along the lines proposed in the latest version of the DSM. This includes material on the cultural identity of the individual, cultural explanations of the individual's illness, cultural factors related to psychosocial environment and levels of functioning, cultural elements of the relationship between the clinician and patient, and an overall cultural assessment for diagnosis and care. This chapter will be of particular relevance to clinicians who wish to implement modern thinking about cultural psychiatry in their day-to-day clinical practice.

The final section of the book focuses on the application of principles derived from the field of cultural psychiatry to treatment. It is refreshing that several of the chapters in this section draw explicitly or implicitly on the assumption that traditional cultural values can serve as a resource that can provide sensible and productive directions in which psychotherapy can proceed, as opposed to stumbling blocks that demand circumvention.

The editors promise that the papers constitute "a sampling of the diverse activities, issues and orientations that constitute shared priorities for the field in Switzerland, Europe and beyond" (p 3). A broad geographical scope is reflected in the words "Euro-international perspectives" in the title of the book.

However, the "Euro" perspective is heavily weighted compared to the "international" perspective. The first author of 10 of the 14 chapters is based in Switzerland. Of the 21 chapter authors, 13 are based in Switzerland, 6 in the UK or USA and 2 in India. Thus large parts of the world are not represented in the list of authors. Also, many of the chapters are about issues arising from the psychiatric problems experienced by immigrants to Europe. While this is clearly an important topic for European mental heath practitioners, there are other issues that are equally crucial for their colleagues elsewhere.

Another bias is a focus on pathology and its risk factors. There are chapters dealing with neurasthenia and chronic fatigue syndrome; PTSD; low back pain and depression; and identity problems. We do not read much about successful coping strategies or protective factors. Many immigrants deal with their relocation in a positive and healthy manner. It is important to understand the factors that are associated with such positive outcomes. This understanding might inform interventions to promote resilience in immigrants and other populations.

Related to this is a focus on psychiatric problems with relatively high prevalence rates as opposed to those with low rates. In his chapter, Roland Littlewood points out that there has been a considerable amount of professional and lay attention on the increased rates of schizophrenia that have been observed in Caribbean immigrants to the UK. The findings from the few studies on non- psychotic illness indicate that, compared to white natives, that there are lower rates of suicide and parasuicide among women born in the West Indies, as well as lower rates of hospitalization for alcoholism, drug dependence, abnormal personality and neuroses. Likewise, the chapters in this book focus on disorders that have (or are presumed to have) higher rates among immigrants than the host population. Again, identification of cultural and other factors that promote resilience and thus reduce the probability of the development of psychopathology will prove useful in promotive, preventive and curative interventions.

These quibbles should not distract from the considerable strengths of this volume. It is accessible to a wide range of readers from diverse intellectual backgrounds. It succeeds in explaining the light that cultural psychiatry can shed on situations encountered by clinicians in their everyday work. It makes a valuable contribution to understanding the dilemmas of immigrant populations, thus reducing stereotypes and stigma. Finally, it brings together a wide range of contributions that treat interdisciplinary boundaries with the contempt they deserve.

Alan Flisher
Department of Psychiatry & Mental Health University of Cape Town Groote Schuur Hospital Observatory 7925, Republic of South Africa (email:

World Health Organization Genebra - Genebra - Switzerland