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During recent decades, women and girls of diverse ethnicities, social classes, sexual orientations, and life experiences have encountered dramatic and complex changes in education, health, work, reproductive and caregiving roles, and personal relationships. Although many of these changes have resulted in increased equality, opportunity, and quality of life, girls and women are also at risk for a variety of health concerns and life stresses National Healthcare Disparities Report, Stressors in the lives of women and girls include interpersonal victimization and violence, unrealistic media images of girls and women, discrimination and oppression, devaluation, limited economic resources, role overload, relationship disruptions, and work inequities.

Compared to men, women are two to three times more likely to experience many types of anxiety disorders U. The abuse and violence in our society e. In general, the physical and mental health concerns of women and girls are related to complex and diverse economic, biological, developmental, psychological, and sociocultural environments. Although many psychologists and members of the general public may believe that women's issues in psychology were dealt with and resolved in the s and s, the changing and increasingly complex life experiences of girls and women and the intersection of their gender roles with ethnicity, sexual orientation, ability, SES, etc.

Given that the majority of those seeking mental health services continue to be females e. The majority of those seeking treatment remains women and girls, and the demographics of the United States population are rapidly changing to increase more diversity in women and girls needing psychological services. Not only is potential harm reduced, but improved treatment will also likely benefit women and girls, particularly through greater awareness, education and prevention fostered by guidelines for psychological practice with girls and women.

These guidelines provide general recommendations for psychologists who seek to increase their awareness, knowledge, and skills in psychological practice with women and girls. The beneficiaries include all consumers of psychological practice, including clients, students, supervisees, research participants, consultees, and other health professionals.

Although the guidelines and supporting literature place substantial emphasis on psychotherapy practice, the general guidelines are applicable to psychological practice in its broadest sense. Rather than offering a comprehensive review of content relevant to all areas of practice, this document provides examples of empirical and conceptual literature that supports the need for practice guidelines. The "Criteria for Practice Guideline Development and Evaluation" APA, a defines the term "guidelines" as "statements that suggest or recommend specific professional behavior, endeavors, or conduct for psychologists.

Guidelines differ from standards in that standards are mandatory and may be accompanied by enforcement mechanism. Thus, guidelines are aspirational in intent. They are intended to facilitate the continued systematic development of the profession and to help assure a high level of professional practice by psychologists" p. Guidelines may be superseded by federal or state laws. The APA a also distinguishes between treatment and practice guidelines, noting that treatment guidelines "provide specific recommendations about clinical interventions" p.

In contrast, "practice guidelines consist of recommendations to professions concerning their conduct and the issues to be considered in particular areas of practice" p. These guidelines do not refer to practice with transgender individuals. As noted by APA a criteria, practice guidelines "may not be applicable to every professional and clinical situation" p. Consistent with APA criteria, these guidelines are not definitive and are deed to respect the decision-making judgment of individual professional psychologists.

In addition, these guidelines will need to be periodically reviewed and updated at least every ten years eight years is recommended beginning from the year of acceptance by the APA Council of Representatives to take into changes in practice, research and the effects of changing contemporary social forces and context. It should be noted that many of the guidelines and recommended practices addressed in this document apply to both genders with diverse social memberships.

Hence, the recommendation to integrate an understanding of gender role socialization into the practice of psychology should not be limited to working with girls and women. Although many of these guidelines are potentially applicable to both genders, this document focuses on the experiences of girls and women for two reasons. First, females in the United States, on average, have less economic, political, and social power than males and therefore have experiences that are more likely to contribute to issues of powerlessness.

The average pay gap between men and women has been persistent and ificant since statistics about gender and pay have been collected. The impact of such experiences upon the mental health and well-being girls and women needs to be considered as well as the manner in which such experiences affect psychological practice with diverse members of these populations and the obstacles and discrimination with which they may be faced.

Furthermore, compared to what is currently available about boys and men, a much more extensive scientific literature examines the gender role socialization and gendered experiences of girls and women in connection to issues of practice. As research proceeds on boys and men, however, future practice guidelines should expand the scope of our practice guidelines to encompass gender-sensitive concerns over the lifespan for both females and males across all identity . The project focusing on males began in the spring of , and that writing group has been invited to borrow freely from this document.

Beginning in the s and s, psychology as a discipline was widely criticized for its biases with regard to gender, race, ethnicity, class, and sexual orientation. A of classic studies and publications focused on these limitations. In recent times, gender bias has been observed to be more covert but still a detectable and powerful force in psychological practice.

Many symptoms associated with the aforementioned disorders have been conceptualized as exaggerations or stereotyping of traditional female gender roles and behaviors as defined by mainstream culture e. Misdiagnosis can also occur when a client's problem behaviors are inconsistent with societal expectations such as when an Asian woman, assumed by stereotype to be meek, reacts to discrimination with anger.

In another example, Crosby and Sprock found that when clinicians rated a case of a woman with antisocial symptoms, they were more likely to exhibit biases that were consistent with relying on prototypes i. African-American women are more likely to be diagnosed with schizophrenia than White women Marecek, Issues of gender identity have been viewed as pathology rather than an alternate form of gender and sexual expression American Psychiatric Association, For example, girls with attention deficit disorders exhibit fewer disruptive behavior problems than boys but have been found to suffer more severe cognitive disabilities Biederman et al.

Problems that coexist with ADHD may also differ for girls and boys and across SES and ethnic groups, further complicating the diagnostic process. Underidentification of attention problems in girls appears related to fewer teacher referrals, yet attention problems are associated with lower self-esteem and more frequent peer rejection for girls than for boys Biederman et al. Inaccurate conceptualization of diagnoses can also be influenced by sampling biases. These biases can occur when diagnostic criteria or prevalence rates are based primarily on symptoms studied only in clinical contexts or are based on empirical studies of a disorder that include the biased representation of males or females, single sex participants, or one ethnic group.

Hartung and Widiger identified potential gender sampling biases associated with diagnostic such as histrionic personality disorder, conduct disorder, somatization disorder, gender identity disorder, and dependent personality disorder. Problems in diagnosis and treatment may occur when the literature on a particular problem is based primarily on a sample of only men and boys, women and girls, or predominantly one ethnic group, and then generalized to all clients. Addiction and alcohol dependence research has often been based on male samples and generalized to all clients Greenfield, However, women and girls metabolize alcohol differently, experience impairment or intoxication after fewer drinks, are at greater risk of dying from alcohol-related incidents, experience more rapid negative consequences of alcohol abuse, and are less likely than men to seek assistance from addiction-specific treatment settings.

Empirical findings have shown gender differences in rates of diagnosis, differential responses to treatment, and differing barriers to treatment for women versus men. There are also gender differences in treatment outcomes and predictors for methamphetamine, cocaine, opiates, and tobacco dependence. Research on criminal behavior has overly focused on African American men as subjects. Many assessment instruments have been critiqued for bias that pathologizes people of color, female trauma survivors, individuals with disabilities, persons with strong religious convictions, sexual minorities, older adults, and those from lower socioeconomic classes and other countries Brown, The unique biological, social, and psychological realities of persons with diverse social identities point to the value of considering how gender and other social identities may affect the expression of a disorder.

Further, women and girls may be misdiagnosed with more stigmatizing and chronic disorders e. Women of color may experience additional trauma from multiple experiences with discrimination and oppression that lead to further misdiagnosis that does not take into context. In addition, men and women may experience trauma differently and may respond more effectively to different treatment approaches due to the type of traumas they are likely to encounter; potential differences in neurobiological stress pathways; and cultural and gender socialization experiences that influence self-concept, expectations, and meaning systems and whether the stressor is chronic or a single event stressor APA, ; Cloitre et al.

Trauma is an important area to consider in more detail because a high proportion of girls and women of all ethnic, SES, sexual orientation, and ability status are exposed to traumatic stressors and their mental health may be severely affected. Girls are also raped. Such abuse not only in immediate psychological symptoms e.

Although sexual assault traumas are experienced by women of diverse social identities across the lifespan, the specific issues and challenges of girls and women vary. They stated:. Psychologists who do not have the requisite training potentially endanger their clients, and likely commit an ethical violation.

Those who are teaching psychologists-to-be but who do not teach them about partner violence are abrogating their responsibility and risk perpetuating the conditions which foster this problem p. They may have even lower expectations of outcomes for women of color, lesbians, and women with disabilities. They also may use interventions that do not consider the client's cultural background or ability level APA, ; Brown et al. Inattention to contextual factors also contribute to lack of recognition of the physical and mental health consequences of battering and other forms of violence. An example is the lack of recognition of traumatic brain injury despite knowledge of the high proportion of injuries to the face, head, and neck during battering.

It may also contribute to the underdiagnosis of or double standards about problems such as alcohol abuse Collins, ; Greenfield, , and the effects of discrimination on stress and performance. For instance, research has found that high school girls expect more educational and career barriers than high school boys, and perceived barriers e.

Psychologists may also lack awareness regarding the particular strengths and resources of women and girls that help them deal with stressful issues. For example, many women and girls of color in the United States live in extended families that create larger communities that provide additional support for their growth and development Reid, Another area of gender bias in psychological practice concerns inattention to the ways in which culture and ethnicity influence problems such as depression and schizophrenia in women and girls Brown et al. Research has demonstrated that therapist insensitivity to racial stereotypes, the interaction of race and gender, cultural values and mores, and social and economic conditions have an impact on women and girls who live in poverty and women and girls of color Adams, ; APA, b; Brown et al.

Social stressors and discrimination from membership in marginalized groups can lead to a variety of internal and external problems. Perhaps the most blatant example of gender bias and abuse in psychological practice occurs when a clinician violates ethical standards in sexual relationships with clients. This problem has not only the potential to interfere with treatment efficacy, it also renders women and girls more vulnerable to stress and traumatization.

Women with disabilities span across every ethnicity, gender, sexual orientation, SES, and age ever known. One of every five Americans has a disability U. Census Bureau, It is evident by this statistic that persons with disabilities, particularly women of color with disabilities, have less access to and availability of mental health services Surgeon General, Beyond increase risk for abuse and neglect, persons with disabilities traditionally have experienced systematic institutional victimization from all aspects of society including, but not limited to, the medical profession, the educational system, and the workforce.

This victimization of women with disabilities, particularly women of color with disabilities, is especially prevalent. Women of color with disabilities experience simultaneous oppression within society by belonging to three or more marginalized groups e. Moreover, these individuals are faced with having to choose which marginalized identity is most salient in what time frame, which can, in itself, lead to internal conflicts.

In addition, an individual can be an oppressor, a member of an oppressed group, or simultaneously an oppressor and oppressed, adding to their psychological stress. As the layers begin to mount e. The need is overwhelming and only likely to grow. Section 2. Gender related and multicultural issues relevant to practice will change as the broader sociocultural context changes. Good practice requires that psychologists remain abreast of new developments in contemporary social forces and their interaction with gender and other social identities. There are many contemporary issues that could be cited here, however, four particularly salient and recent examples include the increasing prevalence of global terrorism, violence, and war in which women are particularly victimized by vulnerability to rape, assault and poverty; the effects of the media in popular culture that portrays an image of woman as thin, white, sexualized, and victimized; biopsychosocial realities and changes relevant to women's reproductive experiences; and the phenomenon of increasing lifespan with an aging population that consists mostly of women.

Women and girls suffer the consequences of violence in war through rape, abuse, torture, and the loss of economic security. Violence against women continues as the threat of terrorism and war across the world does not abate.

Literature that addresses psychological responses to the effects of terrorism and other traumatic incidents suggests that individuals, both adults and children, who directly experience traumatic incidents that involve perceived threat or actual experience of harm to physical integrity often report symptoms of either acute stress disorder or post-traumatic stress disorder PTSD which may be exacerbated if they have suffered earlier trauma in the form of ongoing oppression or discrimination based upon their ethnicity, SES, sexual orientation, ability, etc.

Mood disorders, adjustment disorders, phobias and other conditions may also be psychological sequelae for parents and children Koplewicz et al. In discussing the influence of contemporary forces, mention must be made of the increasingly powerful presence of the media in modern life. Media coverage of the terrorist attacks generally emphasized men as victims and experts, rendering women and girls nearly invisible and relegating them to stereotypical support and victim roles. There was brief mention made of the sense of some African-Americans that the terrorist attacks were isolated incidents, differing ificantly from ongoing community violence and localized terrorism experienced by African Americans in many urban settings Jenkins, Media coverage of school shootings has often neglected to emphasize or mention that the perpetrators of the broadcast violence are usually men and boys, with some evidence that misogyny may be one causative factor.

The websites of the APA and the National Association of School Psychologists NASP , among others, provided abundant materials for psychologists and the public to deal with the traumatization of children that might result from watching the repeated news broadcasts related to the planes hitting the World Trade Center buildings. In general, the media has become an enormously powerful influence regarding access to information; exposure to violence; and conveyor of cultural stereotypes regarding gender, race, ethnicity, and sexual orientation. The media plays a major role in shaping contemporary values and attitudes.

Media images of poor women represent another area of research of importance for practitioners. Women and their children are the largest group of poor individuals in this country, and gender and ethnic stereotypes about poor women can influence both the clinician and the client. Bullock, Wyche, and Williams found that while print media is sympathetic to poor women, the structural causes of poverty are not discussed. Hence, women, and particularly women of color, may be blamed for their poverty status. The limitations of the media coverage of poor women as well as a wide variety of constantly changing sociocultural context factors and their interaction with gender have the potential to affect practice.

Although reproduction has always been relevant to the lives of girls and women, recent social developments have contributed to ificant changes in the complexity and biopsychosocial meanings of reproduction. As the social roles and pressures experienced by girls and women have expanded, the timing of events related to menarche and childbearing have changed.

Reproductive technologies and reproductive medical interventions have become more available and sophisticated, and attitudes toward reproductive choice have also changed. The diverse social identities of girls are also related to perceptions of menarche. As girls mature and gain more body fat at puberty, girls' bodies are less likely to conform to an increasingly thin cultural body ideal.

Similarly, issues associated with reproduction and childbirth can evoke a range of feelings from joy to fear in women and girls. There is also increasing societal concern for the effects of postpartum depression after several high profile cases of women suffering from postpartum depression killing their children. Feminists have strongly critiqued a medical care system that does not provide appropriate care and protection for such mothers.

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