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TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE | DATE DUE DATE DUE “PR 213% Damrtaa 11m Was-p.14 fi'fi‘v “Avon” --' ' y' n... IO--.“ tun...» MEDICAL POWER RELATIONS AND ELECTIVE HYSTERECTOMY BY Jeanne M. Lorentzen A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Sociology 2000 .n" 'fi'n" fifiv glauw'i-I rvr.;:{ n’ . g-a QV\VN" “C a...) ”U“: ‘5 ‘ ‘ I‘vflcv""'~g 6.“ “only. “V“- d F. ‘ ~ { O A . ' L ”#1. EA' 'c‘ y- h‘. 5045 luguov O {'V‘b. . . q;~~ an AIR PA pa.- U'-~:¢\voo= yU ‘aa'el a l u ‘ :nhp :y‘! ”no. ‘ A“ Ewe...) Acu‘e $VI03 U {7‘ . ~ ..IOA . . .“. up: on ~Lfi~ a ‘ Voluu .0. ---»-A-va‘ tr). " bl.‘~.’c ""O ”54‘ ~ mm. “5 5“» nuyugva I Q ‘ F‘s ‘ - ‘ ‘ ‘Ar- . ‘ b - In ’1‘ n I“ . ' ‘ fi b-s~-‘-\.a‘ ‘V‘ d H. at a... '~ .“‘: stun... .--; uses «e. u: .V:nb.~. I ‘~.‘_. Q rev” "b 8:586? 9:52.“.9 Tn..." m. H V‘v‘ v . Avuayq I c in V' vbd ‘ x I VA. ‘~ Q -~. ~~Q . . .g. 3-5“ \n.q” V Q‘o‘-u HP ll‘ -. v " .-~ ’ QA.‘ ' .n.‘, Y“ a ’ 1 ABSTRACT MEDICAL POWER RELATIONS AND ELECTIVE HYSTERECTOMY BY Jeanne M. Lorentzen This study uses in-depth interviews with twenty women who’ve undergone elective hysterectomies in an investigation of the medical power relations involved in a woman’s decisions to have, and experience of hysterectomy. Feminist scholars have long been concerned with the power relations involved in medical care. However, few feminist analyses examine the medical power relations associated with particular medical diagnostics and treatment processes. This study uses the standpoint of women who’ve had hysterectomies as a means of generating a perspective driven methodology. Women’s perspectives on the hysterectomy process also influenced the questions asked and the method of inquiry. In addition, the women’s lived experiences of the hysterectomy process guided the analysis of the power relations associated with their experiences of that process. The women’s experiences of the hysterectomy process demonstrate that the associated medical power relations are processes of negotiation. The women seek medical care in order to alleviate health problems and to achieve socially determined appropriate gender norms in terms of bodily , I . . . .nybunor ban" ‘n m, 53...».b‘.-\~tl Add ... e a v Q - RAV‘IAVDIJ "if." a n} u:¢.ut.cu luydcbdo ., Av ) v r ' ' . 9 0’3" a ranvfi‘v“ v L.” .5 oytevuu‘.‘ nil: 'A‘ iat‘n nn-A 4 T‘ c‘ "N and \U' ousouynoyyu ~ \ p... ,. - . ‘3' ”yo: grahffiwskc d'v :wvvsyybbu.r-_~ ‘ \ I :::~~:~.~.J m... tn.» Jvuvu-‘».u ‘ ' 4 O I, .D: "Aw-c“ ‘VO v.45 “v” "~5- o states and reproductive functions. The women’s participation in medical power relations: (a) Exposes them to gendered medical ideology and stigmatized medical notions of female reproductive organs, (b) reinscribe gender norms, and (c) influences their experiences of, and decisions to have hysterectomies. The negotiated medical power relations associated with hysterectomy entail both costs and benefits for the women. DEDICATION I dedicate this work to Mildred M. Lorentzen, who never failed to express her belief that I was capable of accomplishing any goal which I set for myself. My gratitude for her loving support is immeasurable. iv V"w~¥;“""" ‘~v w-"V'C "' ‘~ u-v. . .»~.»~\—uw L . I . -~ ,. — ~Fn‘tt‘fi“:‘| hay-Ln- .un.‘¢u¢¢¢v . V‘s.‘ _ . . - . 3- 'RQFPBj u S >v‘; a... .uu.~~.\. ‘ e. a. _ - V - " Dccov -.-__‘» ~- ~ousu~u~V§ ya“-.. .— v . . q nun l-‘w-Ar‘nl‘ AvCL‘v 0U .. be .-..w \, v ‘ - . ~I‘a q A ‘ . .. .er "‘ M“ a -‘4 wa..~q J . _ ::CV‘ " F‘ “‘-~b-5 ~ §‘;~oa “h‘ ‘ bl 4‘ s . 'v.\~ .V \v-p‘ " VU -‘I 3.... b.» ~tz‘CVaao-A H v--~ ' ' ‘v ‘ . v- .2 w my 63“... ~ . Wzb A . h -V“ ‘*-.~ ““ g'fi‘ . .aj “aka a ‘s :1 «uq‘ . ~~uv -n ~~~ N ‘1 ~o._ ..;~'. > .‘u. . v ‘ ‘~.“-:‘ Nu...‘ ‘ “‘3 7‘ ~ l-‘i . u - W “‘s‘vz“ ‘ ‘»¢ 2.. u. ‘ c 5“ \ .~.‘§EV ‘ ‘_V n N ’ N.‘ "fi-A‘ - ‘ A "~=*s ‘ a § 1 I.“ .\‘ a, . ‘ ‘1 s VA V L.” ‘Q I ‘5 ~‘ \. . ‘ s v -n‘~ u N‘ “- v \‘ D k 5. A 4 x ACKNOWLEDGMENTS As is the case with all dissertations, this work represents far more than the efforts of a solitary individual. Foremost among the many individuals to whom I am indebted is the Chair of my dissertation committee, Professor Janet Bokemeier, whose wise council, generosity, and mentoring over the years helped me to complete my Ph.D. and grow in countless ways. I am grateful to my dissertation committee members, Professors Ann Millard, Steve Gold, and Chris Vanderpool, for their advice and support. I am also grateful to the women who shared their hysterectomy experiences with me, they made the task of gathering data a pleasurable undertaking. Although their numbers make it impossible to mention each individual by name, I am grateful to my friends and family for providing an abundance of care and support, especially my parents Albert and Mildred Lorentzen, my children Jennifer Martin and Scott Johnson, and my sisters and brothers. I am particularly thankful to my sister, Anita Lorentzen, for her encouragement and steadfast belief in my ability to achieve my goal. q... Ina-III Q t- , ' N “.‘u .uot ‘ .ov- Q-ADV n I It- yq I! .u- o o-vuuud- I , . Vp»ypq..av ~ An .Dobbvuuhu . u... ‘. H RR‘I- PIA“ ~~ " . Q Uni-vHHOVI-U - D a r' ~~v~~ ’\ nav- an Do‘oofififiy lo»\. .1 '-—;6 >;r~.rq —. hobhob ybynasg a. bbugoo-~¢\au-~ .- "‘-~QW' nu .ma." . . MIR-ohm " u I Von-..-:‘ 2 r'“'"‘" A" nu:— I. . . ~— 0~l.- v. ...~ V Q . "’rAnnno-. A“ 4A0.‘vu‘.‘_-v.. A n «:"ar _ ‘51.». . 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A\-' TABLE OF CONTENTS CHAPTER 1 THE PROBLEM Introduction . . . . . . . . . . . . . . . . . . . . l Assumptions Underlying the Study . . . . . . . . . . 21 Significance of the Study . . . . . . . . . . . . . 24 Limitations and Delimitations . . . . . . . . . . . 25 Definitions . . . . . . . . . . . . . . . . . . . . 26 Summary . . . . . . . . . . . . . . . . . . . . . . 28 CHAPTER 2 REVIEW OF THE LITERATURE Introduction . . . . . . . . . . . . . . . . . . . . 31 General Background Information . . . . . . . . . . . 31 Theory . . . . . . . . . . . . . . . . . . . . . . . 65 Summary . . . . . . . . . . . . . . . . . . . . . . 92 CHAPTER 3 METHODS . . . . . . . . . . . . . . . . . . . . . . 93 CHAPTER 4 EARLY EXPOSURE TO AND ACCEPTANCE OF MEDICAL AUTHORITY AND MANAGEMENT . . . . . . . . . . . . . 108 CHAPTER 5 WOMEN’S EXPOSURE TO AND ACCEPTANCE OF MEDICAL EXPERTISE, AUTHORITY AND MANAGEMENT . . . . . . . 143 CHAPTER 6 WOMEN’S PARTICIPATION IN MEDICAL POWER RELATIONS: THE PRODUCTION OF GENDERED BODIES . . . . . . . . . . 175 CHAPTER 7 BIOMEDICAL INFLUENCE ON WOMEN’S DECISIONS TO HAVE HYSTERECTOMIES . . . . . . . . . . . . . . 213 CHAPTER 8 SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . 262 ZXIWPENDIX A . . . . . . . . . . . . . . . . . . . . . . . 280 APPENDIXB.......................283 52131?ERENCES . . . . . . . . . . . . . . . . . . . . . . . 284 vi Introduction "Li: 8"“’:" I'- .ubu Bu“' “' o . _ \ ; antes-a: L‘vq>pv“ “’ en‘v‘u-o 5 ADJ-.bwgh-bu ‘ ' v vulgav r‘: f"““" r. so a». .o'vnea- in‘I b‘ng a ‘ ,. pfl‘ a A ..u bui- Insu$ ya- Dv- Ltd.“ ' sue «:3 L ”a?“ A ‘ V‘ -. Qua. \p . yr- .5. ' . . A," - Y'V‘ .s....u..s Erneg‘lgr‘na ' d :s-‘s w:~ " ‘ i" In ll ‘ ’1 . .¢dvd: Agent-l ,. 52".“ q ' ~.a..3. L- re a: ‘ “A v v2 *‘Af‘ l" o of ( (I) V ) I r ( ) m (I) 4 CHAPTER 1 THE PROBLEM Introduction This study investigates women’s experiences of elective? hysterectomy as they are influenced by medical power relations. Feminist scholars have long been concerned with the medical care women receive, and have problematized the health care directed at women (Fee, 1983) and the social relations emerging from women’s encounters with biomedicine. Davis (1988) identifies feminist critiques of women's medical care as including three primary concerns: (a) The medicalization of women’s bodies and reproductive functions, (b) lack of medical attention to women’s most common health problems, and (c) the social control function of medicine. These aspects of women's health care may influence women’s experiences of the hysterectomy process.2 Although over the past three decades there has been a reported, albeit nominal, decline3 in the numbers of women ‘ For the purposes of this study, the term “hysterectomy” refers to elective hysterectomy. izThe notion of hysterectomy as a process refers to the series of events or experiences and the associated social relations and encounters, and social, psychological, and éenncational responses involved when a woman has the medical .EDITCDCedure commonly referred to as hysterectomy. 3Such statistics are difficult to substantiate given the fféicrt that national health records for hysterectomy surgery 1 ‘ b Av- Loniflfl M'S’ereafiv. :I.u‘4 My 5 ‘ 5 u d ‘ -q:r\ V». 'Inirm‘ .. bu Adfibbi‘ . ~ ‘MvaO-r nvl‘m" A‘ -r .A'JL:.E\'\-\Iht! vs C. a T‘ . . ‘ A .26.. Pre‘.a.er.-e 3"; :yawv H‘;AF A“ Iona nsbl Aibfi'vac y... States ever ace 6; p.. to, c. l b :. tuna fivnagnh ‘qvv II» no» tum)...» L-- ' ’Y ‘ v-u. A \‘3‘ -, U~.~c3 U. h S ..d :9 V “L: A“: V' nun”, _ ‘ "5 sv H: u.--‘ ““FAK‘F~‘ . I‘va.y~: '9‘ Y‘ 1‘ T ‘n Vv u...“ -, "‘~A p . " b '5 “Nu. wave r . It“~ ‘ ' ‘ PA...- . L:.~::“'9I ; why.» C Ac‘ ‘- d K “‘be‘~ n“n c on.‘ AR“‘. . v. ‘ h- \‘V‘A Y.:“.-"‘ b-.. n .3: r~ n . u V.D. u or . y .1“ “A‘ ~ g - V“ mtj‘p“w ‘»d“"' a . x a... § ~. ‘ “ '-.:I: A ‘V y ”Vt... Yc‘,‘ a «; ~~ v...__- \ .F ’A a. ;I ‘r‘~~r‘:§nh o M.\..:Qs c \y A.. I \ U “a "n. ,“ '“MQ“““ c ‘v S A V- ‘ § _ ‘~:~"A ' t~. “v. ‘ V» . L \ having hysterectomies (Sandberg, Barnes, Weinstein & Braun, 1985), the United States still has the highest rates of hysterectomy of any nation in the developed world (Payer, 1996). Prevalence data from the Centers for Disease Control and Prevention (CDC) indicates 21.8% of women in the United States over age eighteen have had a hysterectomy at some time prior to, or during 1998 (CDC, 1999). This means that at the present time approximately one-fifth of women in the United States have had hysterectomies. Over 570,000 women have hysterectomies each year, making hysterectomy the most common nonobstetric operation performed in the United States (Kramer & Reiter, 1997). Such statistics underscore the necessity of determining and understanding the various factors contributing to the profusion of hysterectomies in the U.S. It has been argued that the majority of hysterectomies are not medically essential. Recent research in which hysterectomy recommendations were judged in terms of their appropriateness found that approximately three—quarters of recommendations for elective hysterectomies were illappropriate (Broder, Kanouse, Mittman & Bernstein, 2000). €i{?€3 a relatively recent phenomena, and there is some lllcelihood of reporting error. 2 k ,- art‘s-{rt test h*.'s.e. “0.... O "" ~~A R 9 r 44.: «Cr & Elbebl ‘R'AA; #- d {9“ Pk F t 3::vviaye .yu u“ ‘ 7“; r- o-ANVAF ‘- ':::: r“ S a o .Vnnko tau L... 93:;- ‘55“5.“ 3" al p ,- uoomo u‘votyb .x. fi I-Iys:ere~~~~ byw...’ a .. , , "Insaq lrn11u4 ”Av-b u.\.u 10v. Hue Us» A h. ‘9‘ I V’ ‘ '. l . 123.1; I ‘997, r ' I o. "Cfi h. o::,; ::“4F. V." r q ‘ w- :L.:E:_‘“H ‘p- _ v .~-o '“‘I i?:: g" D... «“13 de nanny,“ - ‘\'£"|"‘5 ‘~‘ ,- ..‘. ~ ‘ boon» a‘ evfi‘.‘ ” .a,‘ Pv.'n b. ‘4‘ - "'~‘\vu‘.: rh‘> Bud. rag. ¥~fi - ._. 1. , "i" F. "L ‘Q‘ G,‘ Q A ~“¥‘ ‘1“ A I "~.. . ”\- Most hysterectomies are defined as elective procedures4 (Kramer & Reiter, 1997), and the risks and consequences associated with this procedure are believed by some researchers and physicians to be frequently more harmful than beneficial to women (Hufnagal & Golant, 1989). Hysterectomy is major surgery entailing serious risks, which include mortality, significant surgical complications (Harris, 1997), short- and long-term morbidity (Carlson, 1997; Sandberg, et al., 1985), and social (Bernhard, 1992) and psychological consequences (Sloan, 1978; Lalinec—Michaud & Engelsmann, 1989). Given (a) the potential for such negative repercussions, (b) the often debatable costs and benefits of the surgery (Travis, 1985), as well as (c) the fact that alternative therapies exist for many health problems that result in hysterectomy (Pokras & Hufnagel, 1988; Fisher, 1988; Kramer & Reiter, 1997), what motivates so many U.S. women to undergo elective hysterectomies? Women’s decisions to undergo the experience of .hysterectomy must be placed within the social context in “daich they occur in order to understand why so many women ¥ 4The medical indicators for hysterectomy are diverse and Illinerous, and define, for physicians, whether the procedure i.£; regarded as elective or nonelective surgery. Elective hliesterectomy indicators are those conditions which are not <=§ a ‘:'v A A.“ . 9K u‘ieu av-U ‘ik‘ " . . . «Define Q. £3.48: [Eadbtvwou fin. . . . . . . 'Or-vm-‘Vh av ‘nflq‘vu « vu.§-AULA b fined. V Q ‘A a .» , . '9‘“’"“e av- fire Q oyucwcs- on yon \- n' - . . V " ' ‘Fh‘ \v 4‘ ‘“.S ‘5 CC“. I a, g . \ - vqhfirqnbnfiw terns ‘i soabvoaU~0V¢asl “on. H . ~§ 'C:"’f""> . an ~ . *‘vu‘vuit..b . ._ ‘ l V‘P‘ra . sturJ=:;A:II,e A‘s-‘1' b V -I b“4- — v -u . ”a " y; 3 “m vane." cf ~. ”Ln!“ E . .u.\,“ Voe c K .‘ I.“ _ q. ITV'A V “O‘ ..“"fl\.,“ u :n.‘ § .- o ‘D N g . §vi~ 8 NC "A V~ Li‘a— ‘ ‘OA‘ ‘ l 5. ‘fl. * ~~._‘:‘ ‘“ ‘ s»_‘.‘e fir“ (1.,M ~ 4 ..:.‘ \ “nthyed lived actualities of women who have experienced the medical power relations involved in the hysterectomy process. The medical construction of gender5 is accomplished through an individual’s encounters with professional medicine and the social relations engendered by biomedicine. This is achieved, in part, through doctor—patient interactions, which entail consultation, diagnosis and treatment. The medicalization and management of women's reproductive organs and their functions have resulted in a wide variety of medical treatments, such as hysterectomy, which have far reaching implications for women. The medical practices that are part of the hysterectomy process result from, and are implicated in the reproduction of dominant structural arrangements. Throughout history biomedicine and the lives and social status of women have been highly interconnected. Western biomedicine and its philosophy of health care has influenced, and continues to influence women’s health, well- .being and social status through discourse and practices “fluich frequently reflect and maintain structural inequality ‘SWest and Zimmerman (1991) define gender as “the activity C>f5 managing situated conduct in light of normative czcaruceptions of attitudes and activities appropriate for C311€3’s sex category” (p.14). The social construction of Sieerlder refers to “how gender is created through interaction EiIICi at the same time structures interaction” (p.18). 5 sje,g., see Bally. flange“? ‘ Cynuunnb a] f‘ I. '. 1391, I ". 6 "l '\ """. 33., 1:3.“ :1» bififial4;fl;“e's on; .uuivu¢b.na Ato‘ ‘ , " “.V‘VFVI qr — n. .t . H r3...»u-dsl “::~» kn ‘Fg Ah. ‘P‘ ‘ i ‘. U: teak VHAC 00‘s- ’17:!!cub“, ‘. .Utw bolué! erra‘e F- \ ‘24.“. c *‘ ' \sa‘ AN” ‘3‘ b ‘ a - “\A PLj~ :“~‘ S‘IL"° .‘ , “W‘s-b '2; fi ‘¥. H u U n; 'Iu‘ ‘§ 5‘“ Ch, ‘1’ Fl‘“ LV K "\ V. I “ ‘v {Du-L ~h“; 4:" ‘ 804;," CIA- ‘, V‘.\ . a . s. I s . LIA r.“\,,‘~“ ' “v C‘s“ VH '\ o “‘9 In rs ‘0 \4 I A, v \n' ‘V sg~ ~ .N.‘Q-..r snub. I“ ‘ s d ‘ ‘¢ \ u ‘3 :‘s‘ .. \s‘::“‘. ‘M ,N s “.‘h ' a— - “:~-. ;“ ‘ \s 't :u‘ . . k u“. ‘ \" u \ ~“E~ V . - C‘ '5- ‘ A ' v. k- ‘- “ Nz‘iv- § 'e‘ce; . S. i - r \ ‘ss «A ‘ H '5‘ v. v- (e.g., see Dally, 1991; Ehrenreich & English, 1981; Goudsmit, 1994; Kreiger & Fee, 1996; Lynaugh, 1990; Scully & Bart, 1981). However, whatever the extent and nature of biomedicine’s influence on society in general, or women in particular, Western medicine is a social institution shaped by the socio-historical context in which it developed and presently operates. Various belief systems (e.g., religious ideologies), cultural values, and structural influences (e.g., economic and gender systems) over the course of biomedicine’s emergence and development have impacted how medical professionals view disease/health, practice health care, and conceptualize humanity (Turner, 1987). Prior to the latter part of the nineteenth century the organization of Western health care encompassed a number of medical forms and systems with divergent health care philosophies (e.g., domestic care, osteopathy, homeopathy, midwifery, folk or native medicine, and faith healers) (Cockerham, 1995). Scientific advances, first in diagnostic tzechnologies (e.g., microscopic identification of disease cxrganisms) and later in medical therapies (e.g., vaccines, Eirltiseptics, anaesthetized surgeries, microscope, etc.) Eisstablished biomedicine’s scientific basis and efficacy, and fostered its dominance over competing medical systems (Vuori . - I 5 5h "5"“ "2° “- ...e .03.... hwuoo .. 1 .. care, as “3.1 an t .-_A'OA fl . 8"“ “c... “it“ but, Hg '4 . i I ‘ QY~n~u A"? ‘ '-' “.02..g U“. a. c, I . 1' . .“‘ ".Mfi”.cw-"‘ any-{3" u..u 5.».V _~...~..‘ ‘ . ‘5‘? ‘VR‘ - I ~'. F .::.E:>.- -, e a“ E . - s v.4- .' v.y“ : VA” c ‘. mneé“; C '- .~ *Vti L A... A ' ‘A . . ‘fiq; . .L"‘-: ‘7.” ~ A“ ‘ ‘ H shuk‘y“ .‘ ~ Q'R‘ . ‘ n. ”A Mo.‘ ~a ‘ ‘ ‘ . ntNo ‘5‘ ph ‘ 95‘ k --»- b A.’ hI cv- ‘ n 5. h“hp~. w & Rimpela, 1981). Expanding industrialization and urbanization, which created both the circumstances requiring non-domestic health care, as well as the disposable income to purchase such care (Lynaugh, 1990), also enabled biomedicine to advance in Western societies. As medical men professionalized and moved into new treatment areas, they required a clientele to purchase their services. This was accomplished, in part, by driving out alternative health care systems/forms (e g., midwifery) (Ehrenreich & English, 1978). Professionalization of biomedicine was a particularly aggressive and effective course of action. This intensive organization of physicians resulted in refinements and formalization in medical education, licensing requirements, and health policies authorizing a practical medical monopoly over health care (Cockerham, 1995). Biomedicine's contention of a scientific base was extremely important in its rise to dominance. Although the scientific revolution had successfully helped to undermine the traditional, Ipatriarchal order of feudalism, and, as such, was perceived liy'uany to be an emancipatory force, its masculinist view of 1111manity was only emphasized and promoted under developing czéxpitalism (Ehrenreich & English, 1978). In the 19”‘century, first wave feminists and female \ . ”I e T et. Av .. a“ a C fit. d ”a mm a r. I e ‘lo b“— an .2 m. . 2.. EZCES . 59; RAW 5V~¢ ”p gain» 9‘ -_- - V H - 5. - y -u A. - Q . S ‘«'85 yanh-v b- 95‘ A,- I \ ‘PF‘A ubb-vn Cf “A. UVo-u. » . A _‘V~ . ~~" t ‘ W. N‘ ' Q-Qusa‘ " ‘ I ... s elites placed their trust in a supposedly unbiased medical model, and attempted to utilize scientific medicine to gain greater autonomy, for example, by appealing for more reliable forms of birth control, and pain—free childbirth (Riessman, 1983). However, these appeals had unexpected consequences. Most consequential among the unanticipated results was increased medical control over women’s lives. Biomedicine’s gender bias is apparent in its construction of medical explanations and diseases, the methods it used to professionalize and sustain its legitimacy, and its efforts to promote the dominant structural arrangements which maintain women’s subordinate social status (Turner, 1987). Historical processes in which medical science created particular types of knowledge have influenced our understandings of ourselves and our world. Yet, biomedicine itself is influenced by its cultural milieu, thus, throughout history scientific medical understandings of male and female biology reflect and reinforce the simplified and standardized notions typical of Western gender ideology. A particularly salient example is the medical <2<>-optation of childbirth which resulted in greater health flaizards to mother and child due to more aggressive and risky medical interventions, and the fact that physicians were RAH ~23 (J U) yr U. h Ave. boo‘oe L'rblyg;'.3 cavnb .' A“ U ‘AV'CVQQ ‘5 A“ t ”la" .9.- “05¢yno I.y~_A 6' ~ ieb'» a H ‘~“ | ..v‘:n ‘ r ‘ f V uqt t. ‘ Zless qualified than the midwives they’d displaced (Ehrenreich & English, 1978). The current impact of :Ephysicians' co-optation of midwifery and the medicalization (csf childbirth is revealed in the medicalized birthing :Eprocess which is highly interventionist, expensive, and Jreliant upon technology, and which created an alienating IkDirthing experience for women (Riessman, 1983; Martin, 3.987). In addition, women’s loss of midwifery as a socially ssanctioned female occupation had socioeconomic implications ifor women's well-being, both at that time and later (Ehrenreich & English, 1978). Although more recently there ihas been growth in and professionalization of modern ‘midwifery (Rothman, 1987), this is likely a reflection of its concession to biomedicine’s authority. Although biomedicine’s focus on higher class women’s health occurred to some extent throughout the history of Western medicine's development, its occurrence in the late 19th and early 20th centuries escalated because these women were believed to suffer from a malaise of unknown origin. Ehrenreich & English (1978), write of this phenomenon describing physician treatment of this mysterious ailment as contributing to a “cult of invalidism” in which women of the middle- and upper-classes were encouraged to avoid all physical and intellectual activity. At this time women of 9 . as p “a mzdcie- a..3 « ‘ ‘ A“ fiL:y nhgvo 7a» Vin-t- vagou uQVQI , .. 1 5 .. V“ A. ngwlr‘a. "‘ F- . Us ulu‘-» . ‘dov \- Vi!r.laan Fag . r.‘$»“:‘ & “' l ‘ TL bu. ant-‘3‘: ‘ " fine ‘V-r-h» M- h 4‘ UV incun~ hw- ‘- ' ibrbsou§ng on Van: ‘ ng Q'JU‘QV' r v~00‘~- I ‘- ace, 32‘ .LiSldEI'Ed the “-., “F A ~-\.."' n.,‘ V“ 3‘3 e: C.“ \ ~ ~ h 9“ - N ‘.“‘:‘:fl~¥fi. " V .lee‘ ‘efi ‘VK. q k . . VI F‘ ~ ~1 A‘ ‘ ‘VJC‘A‘j “ C‘* v R ‘gE-3A _ .. ‘A ~‘ V‘s.‘l‘hr ‘ §y n gl t ,Q “ . “ a‘ » “.. R“ \‘h ~‘QL‘I§ v ~‘:o ‘ ‘L .~‘Q\,E .“ I \hy. C“ v a . ‘u ~v. . ‘ A ¥“V¥‘L‘p ‘~ ‘ F: L ‘ \a 8 ~‘ h.‘ .-‘.. ‘\\.QV : \.‘ '3. . ‘ “.‘lmq Q V. K. . ‘Ce- 5.. ‘ I ~Q a. o, ‘ \p “E ‘ ‘ N ‘ Cb the middle- and upper-classes were considered refined, physically and mentally vulnerable, needing the routine help of qualified physicians as they were prone to illness because of their delicate constitutions. This characterization of women was not extended to lower—class women, who were viewed as somewhat less human or deserving of medical intervention than women of higher social status (Krieger & Fee, 1994). The biomedical construction of womanhood as variable, depending on one’s social status, helped to reinforce both gender, race, and class ideology. Women were not only considered the “weaker” sex, but the primary association of full womanhood with only higher status white women (the cult of true womanhood) meant that lower—class women and women of color could never fully be women (Andersen, 1997). Krieger and Fee (1994) explain how the socially constructed categories of gender and race became transmogrified by medical science into fundamental biological categories. They contend that during the 19th century, the authority of medical science was employed to substantiate, through scientific research, the “natural” inferiority of blacks and women. This illustrates the manner in which scientific medicine helped to constitute women, as well as blacks (and by extension all races other 10 than win: ) as .. gender and ms: a - ”9 effort ‘8.» s b I! ~ v- fsfi V‘ v.8. ...e.e ADV». at- v o “5 ”CG" "5" Y‘ Uvb‘tbe‘s Wynne“ a 3f ExirlecessarV'v 9“ v- q. . “—hi' ’9 ‘TI‘HA. .‘ H.-- — ~:.‘SOA -’.Vr C»: T h. Q Ma fl' N -.. “ass :3; ‘ r“?‘ n ‘ .¢M:La.A:S of t;;‘ ‘. c.'¥-‘ Pfifl’\~ ‘ L~k~ d 3.; us 1 a . 9"" f‘; y- novc.‘ 5“” », 5‘v~.nbalb . :3 up ‘i val-Ema kyuk-Le d6”: <~~~A.. a: d n V ‘ ~V~ess ' .‘n. pv—na | Q en women’s health movement and feminist scholarship have resulted in numerous changes in organized medicine. These include a growing acceptance of modern midwifery, more women taking an active role in their own health care, the development of alternative health institutions and practices, and legislative, administrative and policy reform (Ruzek, 1980; Auerbach & Figert, 1995). Nevertheless, only those changes which do not threaten the enduring dominance of professional medicine are eventually accepted and are often co-opted by physicians to “relegitimate” their control and reduce demands for change (Ruzek, 1980;339). Riessman (1983) highlights women’s resistance by contending that medicalization is actually the outcome of a joint process involving both physicians and women. Although historically, middle and upper-class women did petition for medical intervention, not all women had the social status or power to provoke a medical response (Ehrenreich & English, 1978). In addition, Riessman’s contention that women sought medicine’s intervention to control their biology misses the point—-that women wanted the power to control their biological functions themselves, rather than physicians who co-opted this control. Biomedicine's understanding and reification of women’s Ibiology as something needing to be controlled was/is the 14 - .' WV. "‘ "' bike‘s Of 0‘: as... lfiflf) Jtvx ' Mk ‘ >4 7' Lue res K-‘~- , ' v «new. n91“ d” Lkowtg v‘»&VEo 3“.- .w; :..,;;..;,:...‘ . 14““ .5‘H-D$U~Aao e - n‘a;"\ An‘h ‘ . v H . :J.A..VSVH.A‘V, aaad P . D inwan ‘U-«V»¢o havl'e A.- C 1' 0&5 ..J . ‘. AP. V‘h . .1 ‘, Q «as: "‘ y..:l‘e..ue b‘v' .- a. ‘-~ . 9 I . piaztzcal doe; - -. u...-..a ~~w‘ ‘ . “3%..281 “61‘ r“ ‘V- scmi M \- “A ‘I yv. v. ‘” ‘- ‘6'; ‘E Q.‘.‘ ‘ . Y‘Qb. ‘t‘DL t ‘ Q s I '(\H ‘ «.3 G; ' vs ..I“ . ‘ V c..““ L y Y‘ ‘ 9. ' ‘-E.La ‘ ‘ J ‘3‘ \~ ~ ‘AV ~A h ‘ . le; medias u .. \"~A ti- . ~~~5~c- “"~\lr“ P. . " he‘d? A‘ ‘VH u an. ‘; u‘ y- \ ~E. l , ‘ t"c.~’ “\ y ‘s Q..‘~. ‘ A.‘Q ' \r- 1.3 F K. in .,3 O Q I L‘)‘. “s:\"“ . 4 . ~‘¢ fi‘ ‘ ‘3‘»; 5 f5 ‘\\QF\ \b \v‘ “a: 4 “‘ ‘ ‘..‘\s \‘hlfN‘ - i ‘ V. A c C x. basis of organized medicine’s oppression of women (Hubbard, 1990). The relationship between women and biomedicine is interactive. However limited the impact, women's organized and individual efforts have helped to shape the health care philosophy and practices of biomedicine. However, as yet, women have not organized to an extent which would seriously challenge biomedicine’s professional, cultural, social or political dominance. Despite recent structural changes, organized medicine has retained the social resources (e.g., social, economic and political power) necessary to withstand, or limit the impact of such challenges. Feminist frameworks contend that all social institutions are gendered and that the power relations within them construct gender (Abbott & Wallace, 1990). However, relatively few feminist analyses focus on the ways in which medical power relations construct gender through specific medical diagnostics or treatments. Those which do, differ in their theoretical assumptions and explanations of how gender is constructed through biomedical power relations (e.g., Martin, 1987; Queniart, 1992; Rapp, 1997). Although the social nature of specific medical practices and interventions may not be readily apparent, the construction of knowledge in medicine and the practices 15 v ‘ A.- » used on tact C- idiine 15 a so :M. RP“~QM! '1’. s . I buutcu‘uen.~ ‘ V . .‘ .1 “Fir-rs. '9’”sz (328:1- .. ‘ A. “‘K-‘OV ‘. ¥ t it! v5 AAA'V‘V‘ 5....5'.) “ V»\...,L ‘ 6 Hfgys‘ “A Kl". ‘ 0.“, fr: ..v, ‘4. C .VA‘ :1" arpfl’fim‘! H‘H U¥~.\—\Ifiv“A' V‘: Q . “. . ‘ ‘ ‘w- c 58 Vyv‘ue Ce: ‘;:“r‘ \ ‘ ‘7- A ...V rg‘me". “fl; ukv..‘.. ..L‘ a“ .a In; H gene rea~fih~ by“: A: 's ‘l'qh u:~gEY‘;-A*a ‘byhv. Q" N‘ ' ‘ :r‘ . hu‘lw‘ “f a» p a. L» “ “u ' A 5I‘V‘Vre I, ‘ I? c. we I fi .‘ l “WC-v. .‘~* \ao\ES .‘ ..L‘ ‘.‘ “a M...- Q. “ ‘ ~‘(Lvan ~~“‘e “fin-A F‘ L‘W- V ~. a b‘l- “1.:1‘ 6.. . ..“‘~ \ uy‘o“ A: ‘ .- \ I' a ‘ . “H 5‘ A; “V "e ‘ h \ “a“. \‘ ;. -.‘~c¥: ‘5‘ ‘\ «\‘9’NES Ac .y‘ K -. uA . .“ x,‘ . x “V ‘ \‘\e-\,_ 5' Av. \.. " V... . W ‘ I .,“ ‘8 \fi:’- -‘\ :‘ ‘~\a\-j ‘. ~ ‘ I C. . \.\:‘ A- ‘ fi‘: based on that construction (e.g., hysterectomy) reveal that medicine is a social undertaking which has social consequences for people's lives. From this perspective medical treatments are not unbiased responses to biological disease or injury. Therefore, elective hysterectomy is not simply an accomplishment of gynecologists who are responding to some physiological imperative by removing a problematic uterus and, frequently, other reproductive organs. Hysterectomy can be viewed as part of medical power relations, a social process in which women’s bodies and lives become defined as problematic, but medically manageable, and eventuating in encounters with physicians who recommend and perform hysterectomies. The reasons women choose hysterectomy and the meaning of hysterectomy for women, beyond its association with sterility and the end of natural motherhood, have not been explored (Klee, 1988). Therefore, understanding women's experiences with medical power relations that eventuate in the extreme procedure of hysterectomy requires an examination of these relations as they are experienced by women who've had elective hysterectomies. Examining women's experiences of medical treatment processes, like hysterectomy, is necessary in order to identify and understand medical power relations, and how they construct l6 e. and (:ch (I) :J (J. ((3 n , A“ 13313351 v'u . do Fe*"“‘ P“ regents to s' H 'r- e‘r: “ *' .mm-ha.1:n a '4 0‘ ngh‘ is also res“ VIE!“ a‘ V5 5‘ v n "- ‘ ‘ with medical power relations in some manner. More recent research suggests that patients have greater autonomy than had previously been assumed (Gabe & Calnan, 1989; Denny, 1995). Consequently, this study assumes that the participants in medical power relations are neither absolutely powerful (physicians) or powerless (patients). Although there may be great pressures for patients to submit their bodies and health states to medical examination and treatment, alternatives do exist. However, it is also recognized that attempts to exercise coercive power also exist. It is assumed that the series of events or experiences involved in the hysterectomy process may include but are not necessarily limited to 1) the experience of gynecologic/health problems, 2) the search for a means to address gynecologic/health problems, 3) medical encounters that may entail health care practitioner consultation, diagnosis procedures and recommendation for hysterectomy or alternative treatments, along with spoken and tacit messages concerning gender, 4) surgical removal of reproductive organs, 5) surgical recovery, and 6) any social interactions and/or psycho-social or emotional responses related to the hysterectomy process. It is also assumed that the very nature of medical 23 v. mt" . . .‘ . oD‘EC: a V 025, . . 5‘ any-t V5 5». Q .a. Afl~m~ ‘7‘ 'V,‘_.Lucé “V p. O ificance 0 Si ‘ ‘se 1 fi ‘ 7.9 Fm La.» nC' “‘at power relations, as well as professed scientific objectivity, obscures the actual workings of power relations, therefore, this study relies on the verbal communications of women who’ve experienced the hysterectomy process. Finally, it is assumed that the nature of the data (i.e., qualitative) is appropriate to theory advancement rather than making conclusions concerning the behavior and attitudes of the larger population of women who’ve experienced the hysterectomy process. Significance of the Study Investigations of the hidden power relations involved in specific medical treatments, such as hysterectomy, expose the normative but obscured processes through which medical social control and the construction of gender are attempted and/or achieved. Research of this nature problematizes the power relations associated with medical treatments and, by extension, the production and application of scientific medical knowledge. In so doing, such endeavors constitute an oppositional discourse which challenges the widely accepted “truths” advanced by biomedicine, and contributes to a reformulation of the ways in which particular medical treatments may be understood, accepted and applied. Consequently, the present analysis of the medical power relations associated with hysterectomy may contribute to an 24 a Q; itaerstana...g . '0 O censent to he. ..A... r n r.,: men s extent, s ":e to iv‘mw Ochv¢u fr tfi I V (D '1 (D () :c:;es, :ys:erectomes, {naus‘Aag " C‘ ”V ~‘ A The Present am zmpact of rt: 11} SA” “’ ‘ . .1, c: , a” “Vtuygb S M::; EI’nvé “NA ‘r»-. c."=s C t 9" RA‘. ‘ . quh- artist ‘ A", AL.“ () Ih 7‘ 44. g “" .. auu‘eec." t,’ ' - -.‘I . ..,: G‘R‘“ . sfisy‘eee’ t‘\‘ q ‘ ..‘V . — « 1:414- ‘ .‘s\‘ “a fi'. ‘ a: p0,,r It " u ‘C («A I Uk‘el“? ysl cent-v. .r“ y“~ r481- I‘e‘. . V“: Tire-Q, ‘~B~‘EC""M . i. ‘I R Y'.‘ ~ ~ - «sale,- ‘ C1; ~~. 1 “::e T; , U Q ati N‘ _ te.e PC“... \ 7‘, ‘E5~‘;_ Q ‘ \ P“ ‘ 'vqfiyh, ‘Hg‘.. iQ \ understanding of why women in the United States seek out or consent to hysterectomies. A greater understanding of women’s experiences of the hysterectomy process may also serve to inform physicians who recommend and perform hysterectomies, as well as women contemplating elective hysterectomies, and enable more knowledgeable decision- making for both groups. The present study will advance knowledge of the nature and impact of medical power relations as they are related to (1) women’s decisions to undergo hysterectomy, (2) women’s experiences of the hysterectomy process, and (3) the medical construction of gender through the process of hysterectomy. In addition, by examining obscured power relations in medicine, this study advances the present knowledge of medical power relations beyond the factors associated with gender, contributing to a greater understanding of the concept of power in general. The examination of the medical power relations associated with women's experiences of the hysterectomy process also enables a greater understanding of medical/scientific ideology which has filtered into the broader culture serving to reinforce medical authority. Limitations and Delimitetions The perspective and nature of this study is not conducive to formal hypotheses. The proposed research 25 ,e maZEW kHCWLQ g sub:€C:S ‘ has both H ue' ' ~ ‘7' A Le CLIES 4-‘v- b~.Avv O N‘ U ubuuV Q nauct e of r h . Q t ‘2 T «2 <1 design is intended to generate theory from the data in an inductive manner. Additionally, feminist epistemologies and qualitative methodology promote a view of reality that requires knowledge projects be grounded in the perspective of the subjects, and, therefore, eschew formal hypotheses (Smith, 1987). The qualitative research design of this study has both strengths and weaknesses. It’s primary limitation, which is true of all qualitative research endeavors, is that other interpretations of the findings are possible. Only women who’ve experienced elective hysterectomy are included in the sample for this study. The experiences of women who’ve had nonelective hysterectomies are not examined in this study because it is assumed that the primary influence in their decisions to have hysterectomies is the probability that death will ensue without the surgery. Definitions For the purposes of this study, elective hysterectomy is defined as the surgical removal of a woman’s uterus for reasons other than life threatening illness. In informal cmsnversations with women who’ve had hysterectomies, I’ve found that women tend to use the term “hysterectomy” as a lilanket designation for surgery which includes removal of tine uterus, but which also may have included other 26 . T t . 1 y .. l . g . ‘ Q .A H ‘I a‘ s -u Cg .fi . ”n... *5 “H“ C\ “u; Cy Nu“ AV .W‘ A m S J .m .1 ”1 £ Mo .ew. .l I 4.. “be. 4 r r S . d L e -1 . .m. - r _ H we r . ,.. d e .r O f ...a f e .zd h S .1 t O C O C . S u I E . S m.. .u wmu .1. >.» kc ‘5 r a» a: «v LL .1 . .fiu C r his ‘5‘ m» .r We ‘3 A c a c . I I v “An 0 r uh; .. C . x J. . e U .3 t e e b .l -. , .1 e t E i ,. .x ..0 X t t S x e e r r . . £ + . ..y. i . .3 .3 3 . .1 r .... NC ..A u mu 9» a: . M‘ A» ‘au «Q E 4‘ . s a: 4‘ LL .4 ‘ C r S e ..t p . .e ., e c . d ‘ . .A i 3 s: . d _ . .3 are n e. ...u we. «a .Qw ..1. m u. Kw ... t E M c 3 .. 1 .. c A c. i . . Mu“ 1hr“ (”a .c .34 LC. «,3 . 1 e 3 r 3.. .1. ...t C to 2 . .. procedures that remove ovaries, fallopian tubes and the cervix. Therefore, any surgery which included removal of the uterus is defined as a hysterectomy” for the purposes of this study. Additionally, since no medical records are examined to attempt to medically define the nature of women’s hysterectomy surgeries, the designation of elective hysterectomy will depend on the reasons for the surgery given by the women interviewed for this study. The term “hysterectomy” as used in this study, refers exclusively to elective hysterectomy. Two different concepts of power are explored in this study, therefore the explication of power as a social relationship is addressed at length in following sections. However, specific qualified uses of the term “power” are used throughout this text, the associated definitions have evolved from various influences, most notably Weber's (1994) classic writings on political power. Coercive power in this study refers to an individual's attempt to influence and/or (nontrol an individual's behavior, or to impact an iIndividual's body, life, and/or self, in opposition to an ixndividual’s expressed or indicated will (Wrong, 1979). "It.is recognized that medical terminology makes more 'prfnzise distinctions between surgeries which remove various reproductive organs other than the uterus. 27 . .d .1 31 power ,E’N -.' V a c power If threatened use he": 3 1:; 12:9 And A. h C‘— sly c 1b 4.. C RIK‘FS ‘ yV'.‘ O P u C0228 a .a-n at entials ~45; Y H‘Q‘E‘ q SI fey“. S' 5“ (7-59.. Smmury A V :rea‘EA ...Lcn‘f‘ S - C Legal power, as used in this study, refers to the use, or threatened use, of legal means to assert one’s preferences. Agenic power refers to an individual’s ability to consciously choose a course of action based upon multiple sources and types of information, including knowledge of competing interests, relative social resources, and power differentials and techniques (Flax, 1998). Summary Feminist perspectives are critical of women’s health care and the social relations engendered by medicine. Although medical power relations are considered to construct gender in a manner that maintains women’s subordinate status, few studies have examined how specific medical treatments construct gender. Therefore, this study problematizes the hysterectomy process and examines the medical power relations involved in this treatment process in order to gain a better understanding of the nature and impact of these relations on women's lives, and health and well-being. Chapter two reviews the relevant literature concerning (1) background information on hysterectomy, (2) feminist theoretical perspectives used in empirical analyses of umuiical power relations constructing gender through medical iruuerventions, (3) medicalization, (4) medical discourse on 28 '0 n u r fi‘Amv 5'.."‘.e-e.w . . I .4 we.” 7. IEJ.S»du-e t0 .rc-vides a 8‘41" ~ v A‘v'fl q 2.2a: prwlue ‘1 Ac. ‘ “I"‘"~ pvier re‘aV‘l Vol‘ \ ‘ ’ ‘ rm. A" ’V ‘7‘ 4.... e.:.o.v“v‘eu “‘ 5“ O . I o P 1g:~r1n‘~ n F‘ uyuyoAbu¢ no V- acr~yh‘ ‘ h ”A“ a. xiivtbc‘Lloe' suitoot \ E P o. ‘ ECt' “ere 85.; new: - \ .-...ore, c“ with A 1 a L‘eSCcr‘t V‘V‘ A :1‘\ ‘Vfiy h‘ H. . LFRV‘. ~o ‘.a~ ‘ ‘0 V (1% ' “HQ ahr‘QV“ n bygklb: ' ‘ “‘0. a». ‘ I ini~ 1 Ave . vu“_ Tk‘ . «+8 cnzr MK. . y. in“ 3‘ ‘\‘ ~ y“‘zc 9' V V‘Q' ‘yo'. R‘ l~ ‘ ‘7‘.- ..i g . *‘~r 81x 5 e: .2'» ‘34. Va‘ ‘:.at‘t\h~ *vdb by. E ~11 "'~ 'A _. ‘n‘~ u » Q“ . \«y..:es Cc A» § \4 w 7:" W, ‘1 t“: 5 A“). \y ' s ‘ u‘a C. ‘ . \ Vc‘ ‘ u ‘L' “:“fin‘s “’“3‘ Y‘A ‘ w -, e~wer s . tic-uh ‘ .‘ s. a) “& “A. L.- ‘A t VW’CV‘ - k hysterectomy, (5) medical images of women, and (6) women’s resistance to medical power relations. Chapter two also provides a summary of the two divergent notions of power that provide a conceptual foundation for investigations of power relations. Chapter three describes the methods employed in the present research and provides a summary description of the sample. Adolescent experiences, such as menarche, menstruation, initial gynecologic examinations, etc., were salient issues for the women in this study. Therefore, chapter four establishes the context for the women's later experiences of medical power relations associated with the hysterectomy process by examining adolescent exposure to and acceptance of biomedical ideology. Chapter five explores the women's adult exposure to and acceptance of biomedical ideology by examining their adult (pre-hysterectomy) experiences of gynecologic medical care. This chapter also examines the women's acceptance of medicalized views of women’s bodies and bodily functions. Chapter six examines the character of medical power relations by evaluating the degree to which the women’s enqperiences of gynecologic care and the hysterectomy process Inay be accurately typified in terms of traditional versus relational power. Chapter seven, examines the impact of nuaiical power relations on the women's decisions to have 29 issues address: .. . par?- r1 nut- 1 firs uv;.\—-$UUL&V¢¢ N 4' fl-na ‘. A c v-5»-bs-bn C4. t PF"?"\‘A‘(\~" In”- -v»..UCv-V3 , G‘.‘ 4 hysterectomies. Chapter eight provides a summary of the issues addressed in this study, and the major findings and contributions to the literature. It also includes a discussion of the findings’ relevance for theory, methodology and social implications, as well as suggestions for future research. 30 Introduction F t 1 m 9"! O *4 rJ ( ) {1; literature 8-”- , ‘ ~v~~ ‘” hv‘R.’ &.u (..er CV“:" H procedurES/121‘ ‘v‘fi 7“? a.- V bygkta‘I se~5-:: .6. w ‘- lt¢§v‘»kla»;CA Cr: ~‘A‘ - ‘mebes n ‘W‘ ‘ rr+lar‘ ‘ V. CH)- vc.g“ a“‘ ‘r ~ka868 C :c~‘: “¥‘~i 2" h Cal krO‘flfi‘Q M- :- a ‘s‘ 15% fi‘v“s "‘ ‘ GHQ "‘ \4 5a." 4)."... 7 ~“~a“z a d. ak‘fiv‘ k‘v‘. ' 7m“ itzlha} ; v ‘ ‘kl.a~‘:~ U~D ( CHAPTER 2 REVIEW OF THE LITERATURE Introduction The following is a review of relevant theoretical literature and empirical research on medical power relations and the construction of gender via medical procedures/interventions. The chapter is divided into two primary sections. The first section provides background information on hysterectomy and medical power relations, and reviews the empirical research which analyzes medical power relations and the construction of gender through specific medical interventions. The review of the empirical research focuses primarily on the theoretical perspectives used in their analyses of medical power relations. The second section provides the theoretical background of medical power relations and gender construttion, and addresses medicalization and medical discourse on hysterectomy, medical images of women, and women’s resistance to medical power relations. General Background Information Hysterectomy Although women submit their bodily states (in pursuit of preventative health care) and health problems to medical professionals for evaluation, physicians determine the 31 I ..- \- 82 ..u 7 ‘ m1. 9. L— Qprla 7V." ff‘ .sterecto q" a '1 0 i on a It . ‘ ”\V‘ ‘Krco .n-° ' l¢ovvrient ‘ Avr- » V“. I" ‘ CEIEC "A v: C h . 0“ no; 1 care C ..a~‘ ‘ - ~ds5. Y F A. - § . ‘v- s ‘9- V“! . ( I idencej ‘sfi. ‘45.. an " 4.6"? f“ -~»al a .l «J a: Q. 5Q‘*EA§ ‘1‘“ 4 ‘?v V V“ appropriateness of particular medical interventions, such as hysterectomy, based on a biologically deterministic, gender- biased and reductionist medical model (Vuori & Rimpela, 1981; Baer, 1989; Kreiger & Fee, 1996). Under such a model, the surgical removal of even a “normal” uterus, which is frequently the case in elective hysterectomy (Hufnagel & Golant, 1989) and/or related organs, constitutes medical intervention which is deemed appropriate. In light of the high rates of hysterectomy performed in the United States, hysterectomy has apparently become part of the normative health care that biomedicine provides for and promotes to women. The power relations of biomedicine have greatly influenced women’s lives, but women are not passive victims of medical authority. Women, to some extent, have participated in the medicalization of their bodies and lives (Riessman, 1983; Oinas, 1998), but they have also made collective and individual efforts to resist medicine’s social control (Ruzek, 1978, 1980). Despite the fact that women’s attempts to resist medical control have frequently resulted in organized medicine's increasing its efforts to control women’s lives (Ruzek, 1980; Tiefer, 1994), women continue to appeal to medicine to address their health and social problems. 32 Women wit a variety of p receiving a pl". fer .ysterectc-t seek medical h iezemines t}: e v-.. ._ 4': , 5?. L --..Eless . CEIEI‘R‘.‘ “a 3.3.9. scay ‘\~.. ”‘ .. ! ..azy hemen pref lte t} »S Cf .. “Q “A, ‘ . _ .-taerate dc. \ :"‘v-" ‘~“l:t‘ C -:~. ‘ “HOS-1" h "“ tare (‘ \F V; “‘iirVeTQh‘ ( .y4‘gb p . \e ““itial‘: Women who have hysterectomies seek out medical help for a variety of problems, and only undergo surgery after receiving a physician’s medical diagnosis and recommendation for hysterectomy. No matter what problem motivates women to seek medical help, it is the physician as gatekeeper who determines the appropriate treatment. Women may be required to sign “informed consent” documents prior to surgery, but the degree to which women have been fully informed about the risks and consequences of hysterectomy is unknown. Nevertheless, in the end, it is women who ultimately determine whether or not they’ll undergo hysterectomy, and many women presently choose to have hysterectomies in the absence of malignant gynecologic disease (elective hysterectomy) (Travis, 1985; Bernstein, et al., 1992). Despite the biological or biomedical reasons or rationales for women undergoing hysterectomies, the empirical evidence suggests that the majority of determinants of hysterectomy are highly social in nature. The moderate decline in hysterectomy rates have been attributed to changes in women’s status and the growth of managed care (Steege, 1997), technological and medical advancements (Reiter & Gambone, 1991), and a trend towards initially utilizing alternative treatments by more recently trained gynecologists (Bickell, Earp, Garrett & Evans, 33 .n and atic P» ‘3 EL. 3:... ‘n- ras & Ht § it. «v n. P; fihd 1994). Conversely, the factors associated with an increased likelihood of undergoing hysterectomy include lower socioeconomic status (primarily measured in terms of education and occupation) (Kjerulff,Langenberg & Guzinski, 1993; Marks & Shinberg, 1997; Meilahn, et al., 1989), parity (Vessey, et al., 1992), and residing in the Southern region of the United States (Graves, 1992). Although women of all ages have hysterectomies, nearly three-quarters of women having hysterectomies are between 30 to 54 years of age (Wilcox, et al., 1994), with the highest rates occurring for women between the ages of 40 and 44 (Pokras & Hufnagel, 1988). The influence of race on hysterectomy rates is unclear. Although some research suggests that Black women have slightly higher rates of hysterectomy than white women (Meilahn, Matthews, Egeland & Kelsey, 1989; Wilcox, et al., 1994), most research on hysterectomy neglect race. The primary medical indicators for hysterectomy have been found to differ by race. The presence of fibroids is the main indicator for Black women, who are less likely than white women to undergo hysterectomy for endometriosis, genital prolapse or gynecologic cancer (Wilcox, et al., 1994). This suggests that Black women may be somewhat more likely to experience elective hysterectomies. Actual risk 34 8 * grkgsterec- r'kfiH' .QV " semen I C. x t. E . 4" “M s . . C i Vr A .& ‘ ..I4 ‘H\ ”I“ n g o . S .1 C S C c. c... . . l 1. No. .4. no C .. . a f T. . . -. 2.. C S S r E I .3 a C S l E : e e S Y E in. E . l :1 P. r r n) C p t r I .2 a S O C e S F. a e O a l .C Q. T a C .. l C. e t E k u t C C .u C 1 . e t S T. ..u r. T a c. . . ”w. m1». T. C C :1 e Ti 9 C 2 S 4. T. .. E -. . d n . 5 C. .. . l e e 3 o. W. t l n. .. . 2,. S n... H“ 5 ,5; a. it. mt. O .5... mt. nw J. «at. m .r. m. M... .b. k -. .. . . c. 1 for hysterectomy is not determinable because the annual surgical rates do not take into account the proportion of women who’ve already had hysterectomy and are therefore no longer at risk (Vessey, et al., 1992). There are a wide variety of non-malignant medical indicators for hysterectomy. They include dysmenorrhea (painful menstruation), endometriosis (endometrial tissue in sites other than the endometrial cavity), recurrent uterine bleeding (differentiated from normal menstruation), leiomyoma8 (fibroids), chronic pelvic pain, endometrial hyperplasia (endometrial abnormalities, possible precursors to gynecological carcinomas), pelvic inflammatory disease (infections in the uterus, ovaries, fallopian tubes or pelvic peritoneum), pelvic relaxation (uterine or vaginal prolapse resulting from relaxation of supporting muscles and ligaments), and sterilization (Bernstein, et al., 1992). Cbnsequences of Hysterectomy The health consequences of hysterectomy include surgical complications and mortality, and short- and long- term morbidity. The operative mortality rate for elective hysterectomy (for non-malignant conditions) is approximately 8The presence of fibroids is the most common indication for hysterectomy and account for over a quarter of all hysterectomies, even though there is no approved medical therapy to treat fibroids and the majority of women with fibroids remain asymptomatic (Bernstein, et al., 1992). 35 4 per A l. e most fI’Ej‘ OtO t A ted wit Cia A v a: =~ 2a fitQ v“ on F: .¢I ¢e:¥“l Y ..1‘ t v a period of re 20 to 24 per 10,000, with the risk increasing with age and the most frequently occurring short—term complications (occurring within 3 weeks of surgery) are bleeding from operative injuries and reoperation, both of which result from surgeon error (Bernstein, et al., 1992). Most women who have a hysterectomy experience one or more complications associated with the surgery, and must endure an extended period of recuperation (Korte, 1994). Other short—term complications include blood clots (up to 40% of deaths after gynecologic surgery are due to pulmonary embolisms) (Colditz, et al., 1987), and infections (Bernstein, et al., 1992). Long-term risks associated with hysterectomy include vaginal cancer (Bell, Sevin, Averette & Nadji, 1984; Wharton, Fletcher, & Delcols, 1981; Stuart, Allen & Anderson, 1981), and coronary disease9 (Colditz, 1987; Rosenberg, et al., 1981). Bachman (1990), in a review of studies examining the impact of hysterectomy on women’s lives, concludes that studies prior to the 1980s indicated that post-hysterectomy women were likely to be depressed and have low self—esteem, while more recent research (e.g., Rhodes, Kjerulff, 9Coronary disease is associated primarily with bilateral oophorectomies (removal of both ovaries) and hysterectomies which include bilateral oophorectomies (Bernstein, et al., 1992). 36 “a QC Nu ~x 5 .3 f ... E .berg & :er '“ture of the “L cc-ncludes t1". T nfi .25;- l . ; Q .4 «O f wl a e l ‘1 .1 E C \ : I C Q r 5 S r I :l. U. C .l n Fm“ f r E E C C. l .d d a l r .1 . f E V. T .w .l .l a t r. ..y. .1 S .2 MC S O . C r O r .r. .1 a m... b C .. a a e .S. .l C P .l S t r .4 .1 . C C C S .1 l c.. C. r... P. e S d S i . E Du Q h. l W C e t e n: S :1 E. .2 a .SL «a F: .1 Y‘ ‘1‘ \J Y; “H ‘3‘ Cs ¥\ H U. at» b» e 1|; WI Q» “Md Q5 Q» L» .I e ..l a 5. C4 .. :4 l 3. ..e ..1. a a. s e : -. . . .w ..-u q . p . . . 5L nw "7.. we. 41“ LL (m .hl» ...HC . .. 4 R N: at Langenberg & Guzinski, 1999) presents a more positive picture of the post-hysterectomy experience. Bachman (1990) concludes that the literature suggests that hysterectomy, post-surgery, is not associated with psychological problems, but, rather, that the additional removal of ovaries may cause depression. In general, the state of the research on the quality of life after hysterectomy is insufficient to make informed generalizations (Kinnick & Leners, 1995). Medical Power Relations Empirical evidence identifies the physician-patient relationship as a social domain characterized by power differentials and efforts at social control. In a review of the literature focusing on medical social control, Lorber (1997) summarizes how social control by physicians may be fostered by (1) the power differentials between the parties, (2) physician assumptions and behaviors based on stereotypes, (3) physician neglect to consider the influence of social context on patients' health problems, and (4) the application of stigmatized diagnoses and treatment by physicians.10 Therefore, research which endeavors to '°As yet, the evidence is mixed as to whether the gender of the physician has an impact on the manner in which health care is carried out, or whether it has anything to do with the efficacy of health care (Olesen, 1997). Although some differences have been found in the styles of interaction and attitudes of female and male health care practitioners (e.g., Fisher, 1994), there is little indication that female 37 i- m \— r‘~' HD“ 5 ticn n \r I tera ah“ c:~e‘ § . .n crienta. erstand ”8‘ st part, . v"! D . Q“ ‘6‘ I; we 34“.! .U earth ab a: 3... ‘ v». Q. fs~ M action 0 aticns ( A ...-:r .' . j‘ ‘ ”-5 ”h. understand medical power relations requires that the above aspects be examined. Medical sociologists have taken great interest in the interaction between patients and physicians, but, for the most part, this literature fails to problematize the asymmetrical nature of the patient-physician relationship or interaction (Davis, 1988). Research which does address power relations in medical encounters is primarily feminist in orientation (e.g., Fisher, 1994; Davis, 1988; Fisher 1986; Fisher & Todd, 1983, 1986; Fisher & Groce, 1985; West 1984). Research addressing medical power relations and the construction of gender most frequently focuses on direct interaction occurring within the confines of the examination room. Acknowledging that this approach has specific limitations (which are discussed below) does not diminish the important contribution these studies have made to understanding medical power relations. Davis (1988) observes, Clearly, these studies are a step forward...in terms of the way medical interaction is being investigated. Not only are issues like institutional authority and gender inequality re- instated as part and parcel of most medical physicians are any less inclined than male physicians to use their authority to exert social control (Auerbach & Figert, 1995) . 38 v s a C1. . . C. eh he a: S e . . C. l C C . . .C C. .a g ‘ .w.‘ «a ”u by bk» VF“ Hm Vs F.» vi n Y... C AC 5 p.» Y. nu «d e A . u . e S C AV e O .1 S .1 C . . e t e .l e . i C. r .l 3. S .C . 3. e C t .3 E C . .. . . , t .. .. a r. r. L F. a. .l 3. C a n P; Ac. In; A» r. u .5. n rL 3:. .1; My 5..» .‘u n #L .l .l r“ t 5 pl .8 e a a S l D. r S e l A: a n-» 5 he 8 a» nu MC ”A ... e d .l C. S l S C e .3 S . . 9.. r1. ... s . T. E yr. 5 S E a C L .. w i. A c m. a v. no. a. 1 mi .. at interaction, but valuable insights are provided into some of the difficulties faced by women in medical encounters. More important, however, these studies mark a pioneer endeavor to connect socially structured relations of power between practitioners and patients to medical talk as an interactional accomplishment (p.54). Although research efforts focusing on verbal exchanges between patient and practitioner are helpful in elucidating the nature of power relations within direct, face—to—face medical interactions, they may be less effective in assessing the broader or extended impact of medical power relations. A great deal of literature11 demonstrates that patient behavior frequently differs when patients are no longer interacting directly with medical practitioners. This suggests that the extent and nature of physician influence over patients, previous and subsequent to consultation and treatment, cannot be determined from research solely focusing on medical interactions during consultations. For example, both Fisher (1986) and Davis (1988) use observation techniques to examine the nature of ;power relations within patient-practitioner consultations. 'Their findings differ somewhat in terms of the form of power relations occurring between practitioner and patient, but Ixoth are limited to understanding the manner in which "For example, there’s an extensive literature, empirical arui otherwise, on patient compliance. For examples, see Shorter (1991) , Svarstad, (1986) , and Thompson, (1984) . 39 . . 0 ~ a». e a. .u u a O C C .2 .l n 5.. r» o ‘1. .l C \H t C e a n. r a r. ;i VVA 1 . BIICW ?‘ to Hfi \ri— a ‘s asce Plus b‘AA \ firediate re ."\ H .- ‘v “fi‘ n ..u-._ 1 JETStd '0' like 7‘” . efixamlned .. ..... .c ....n. IJII illl.|. e L» .ll FL« t M” E . I e S X. .i i t V! e .1 VJ .1 d E £1“ 1 .l t. r C t , LC E .itL 1“; 8 ii .1 an Au Au at w i at .du no mt Q.» n O ..u Y 3 CL 5 .l UP LL 8 As any S T; r 1; Ci at .3 .\ ‘5‘ .. \ A.» .a a» A: 2» AV fiLs 5.34 .C ~s~ practitioner power impacts women patients during face-to- face contact. Although the strength of this method is that it narrowly circumscribes the arena to direct interactions, this aspect may also be considered a weakness. This method limits an investigator’s ability to determine if patients’ immediate reactions to practitioner power are germane to women’s everyday lives. The extent to which women actually accept, internalize, or act upon physician messages and/or understandings as valid and as applicable to their lives and health, and their understandings of gender are left unexamined. Additionally, this type of research is does not examine social linkages aligned with medical power relations which reinforce medical constructions of gender. Although medical treatments appear to be unbiased responses, by highly trained and objective experts, to health problems presented by autonomously situated patients, Medicine is not an objective science in the sense that it exists outside, or above, culture and society. On the contrary, medicine is a part of culture, a social institution that is both formed by society and an active agent forming that society (Oinas, 1998;54). If it is plausible to assume that all institutions are gendered and scientific processes are formed and biased by social context, then it also reasonable to assume that specific medical treatments can result from the gendered 4O tatlcu' 1i CfiSU p \— p‘ *1 a any it 1 -sa cate \‘ rid. “gt u A g m rner, 19 . fl‘w ‘ 'A'hq.‘ ‘ v‘ " VL-finuu‘ awn/5", {HE-«.- R 1“ R L A". . .- q \[. Ac power relations between patients and physicians. The consultation/diagnostic experience is but one interaction among many in the course of medical treatments in which women may encounter messages about their health, bodies and gender. All such encounters are likely to impart various types of messages, not just about gender, but about how particular treatments are considered and defined in relation to socially acceptable notions of gender. Additionally, historically situated medical discourse circumscribes how individuals are able to experience, understand, and communicate about our selves, bodies, and bodily states (Turner, 1984). Markens (1996) contends that; Physiological experiences are products of social context-diet, environment, the organization of paid and unpaid labor, and the like-and are interpreted, understood, and recognized by the medical (i.e., social) classifications with which we label them (p. 44). The influence of biomedicine is extensive throughout society (Lorber, 1997) and, according to Foucault (1967, 1977, 1979), constrains how the subject may be essentially constituted. Observation techniques for gathering data on medical power relations, as they are associated with particular medical interventions, are insufficient because the arena of medical influence extends beyond the patient— practitioner interaction found in the consultation. To capture the more complex and interconnected nature of 41 jadical power to gain 50:: .fl ‘ ‘r‘eract;3.. bk 0: beyond ...e ‘w ‘;7.—. C'CECEXCu --.J: . «at H U“, .eriences of There is ‘ I ‘l I:«. .5. 1 . I‘Ca‘ ln»er‘," i— ., «. twat tbs}; a “v1 ' I '\ y‘slqrni‘ “Y in t. mgr“ ‘.\a“~ ' :5. ‘4‘ “IA h . ‘ c. ‘ V»E$.¥es ‘ u‘: \. 35“; | \‘Q A z ‘ Q‘. Hg‘ medical power relations with other social forces/agents, and to gain some understanding of the degree to which women are influenced by medical power relations beyond the direct interactions with medical professionals, it is necessary to go beyond the examination room. Formulating a more contextualized understanding of women's experiences of medical power relations requires data generation methods which provide more in-depth and complex information. Consequently, this study uses in-depth interviews which asks the research participants questions which relate to specific interactions with physicians, but also questions women in terms of broader perceptions of medical care and physician attitudes, as well as other social influences on their experiences of hysterectomy. There is little literature addressing medical power relations and the construction of gender through specific medical interventions. Those efforts that do so are similar in that they are feminist in orientation, but differ primarily in terms of how power is conceptualized. .Médical Power Relations as Negotiation Rayna Rapp (1997) analyzes the social impact and cultural meaning of amniocentesis. She describes amniocentesis as a medical technology which produces information defining a fetus in terms of its normalcy that 42 requires we: inten’ie'ding examines the E) V {J m H :r O o D. m tnat the tied: into the hrs a 4. M,‘ ~L ‘5‘1 ‘ are \ . :Qm‘ requires women to make a decision about abortion. Through interviewing pregnant patients and genetic counselors, Rapp examines the discourse over the contested meanings of motherhood and pregnancy which arise in women’s experience of amniocentesis. Rapp contends that although the language of biomedicine is powerful in defining the body and its experiences, and that the medical discourse on amniocentesis has filtered into the broader culture, the messages medicine conveys to women actually become transformed through women's participation in medical power relations. Although women may be highly influenced by the practices and imparted meanings of medical science, Rapp asserts that women’s understanding of these meanings suggests that the meanings are not wholly defined by biomedicine. Women in their cultural and social diversity negotiate the meanings of pregnancy and motherhood through their interaction with biomedicine. Women enter into medical interactions with preconceived notions of gender, pregnancy and motherhood which are influenced through women's numerous and diverse social experiences and cultural milieu. From this perspective, meanings are not static but are constantly in process, ever-changing through negotiation which includes rmiltiple communicants. From this perspective power is part 43 .4: every 533 6- .4 vaav \ Rapp F‘C'WEI rela: ; o: ‘1 O n " N - Situ ated 33.63:, ' | ir+evahtn ..- .. . x. lcn *1 ‘ y: s; ’ Q‘.§ath:: -. w is 1 N \“ b“ ‘ GS “gr-e15: :_ . ’N‘!‘ ‘ “-1- y‘yy N TC“ ‘ V\‘ W I touer ls ~S:~.; ‘ U , . ‘ fi‘at‘r‘, ‘V. 'fl.‘ ._ ‘L ;-~‘ V‘u : .tr. A ‘1‘ “‘e C:- —’_‘A \1 ~ ‘ t“.‘ ‘t‘. 5‘ A“ I \VA‘el-S ~ of every social interaction, and gender is understood to be constructed routinely in virtually all social interactions. West and Zimmerman (1991) contend that gender is a, ...routine, methodical, and recurring accomplishment....the “doing” of gender is undertaken by women and men whose competence as members of society is hostage to its production. Doing gender involves a complex of socially guided perceptual, interactional, and micropolitical activities that cast particular pursuits as expressions of masculine and feminine “natures" (p. 14). Rapp’s approach is compelling in its definition of the power relations in biomedicine as a process of negotiation. Both “power” and “gender” are viewed as reflexive processes, that is, as constructed through interaction while also structuring interaction. Women are conceived as active but situated agents who help to shape gender through their interaction with the institution of medicine. Medical power relations are comprised of both physicians and patients (as well as numerous other actors) and while health care providers may constrain and help to shape gender norms or ideals, they do not determine how gender is ultimately constructed. Gender is constructed through women's interaction and negotiation with scientific medicine's interpretation of gender. Although the authoritative expertise of health care practitioners may be highly influential, women are not blank 44 slates ".I.b T fi... A 5'. "°"”eo‘ bV‘o» \— . trelfi‘p‘ p “cyst 91 Gnnu‘y q Viva- ‘ 9 T‘NG“ LV."'V\J :ns..“ :““‘n "v“ a I {II (I) slates awaiting medical transformation. Their interaction with medicine does not wholly determine their experience or conceptions of gender. In medical interactions women bring with them their knowledge of medical science (however accurate), and a previously constituted sense of gender formed over their lifetimes (Rapp, 1997), as well as a socially situated self. Women’s previous understandings of gender and medicine are part of women's medical interactions and these, along with the meanings imparted by medicine’s actual practice, may be modified through negotiation. From such a perspective power is understood to be transactional, rather than an entity which may be possessed by some, but not all individuals. Utilizing this conceptualization of power, the experience of hysterectomy may be understood as part of a process in which gender is constructed through a contextualized negotiation between women and medical professionals and practices. Employing a relational or transactional notion of power, the medical construction of gender through treatment processes may be viewed as proceeding partly through biomedically reductionist terms/practices, but women would be considered as participants in constructing gender, as well as in constructing medical power relations. Health care practitioners, influenced by a dominant medical 45 fl/‘V‘ V‘ C.- voeu up u .i x . .c I . i .3 5 ~ . E .3 n? an ‘1. r. .t .d v. v a at ...u at a. N: 3 NH. 6 4 u e Q» ~5 1 a u... A .t r. E . t T. e .. .t .. c; 5. v. 4. a. .2 ... r. a. r T. w... E r. ... C . . nu. ._ . C . .1 ad. .6 .. . A: Q» ‘ 4 L e C x ‘1‘ ideology, are mutual, albeit authoritative participants in medical power relations defined as a process of negotiation. This treatment of medical power relations is highly influenced by Foucault’s writings on power and by post- structuralist feminist theory, in which individuals are constituted through knowledge/power projects (e.g., medicine, law, and religion). The weaknesses of this perspective are evidenced by Rapp’s use in her analysis. The women in Rapp’s study are assumed to have relatively firmly constituted notions of gender prior to their interactions with medical professionals. If power and gender are negotiated within medical interactions, then they are also negotiated in other pre- and non-medical interactions, and this contradicts the notion that the women enter into medical power relations with firmly constituted senses of self and gender. That Rapp does not recognize the pervasive societal influence of medicine is also problematic. The authority of biomedical ideology extends to the various social forces/agents that influence women's understandings of self and.gender. Societal members are exposed to the scientific Ibiomedical paradigm and authority throughout their lives, and.the possibility that this influences notions of gender, cmxtside of direct interaction with medical agents, is not 46 M v‘ A, Q R" ”ca-ud nvc‘w“‘ r.»~4.. CO] y. “L. uflu «\u .u o N“ ‘Voq ?‘ ‘*V ‘ . Va‘ a“. \-u't my L Lr A5“ ‘5}. considered by Rapp. Medical Power Relations as Determined by Patriarchy Utilizing in-depth interviews of primiparous12 women and systematic observation of women attending prenatal classes, Anne Queniart (1992) analyzes women's experience of pregnancy as it is influenced by medical ideology. She describes a process whereby women’s experience of pregnancy and childbirth is mediated through medical ideology which locates risk factors solely within women’s biology and their individual health behaviors (e.g., smoking). This ideology is depicted as establishing the belief that women, through rational behavior, are solely responsible for pregnancy outcomes and as discounting the influence of social and environmental risks which are outside an individual's control. According to Queniart, women's exposure to medical ideology often occurs through its dissemination in popular medical literature. Women compare their pregnancies to the medical ideal, as interpreted by this body of literature, and act in response to their estimation of how closely they approximate it. Women’s concern for their fetus, especially since they are singularly responsible for its normalcy l2The term “primiparous” refers to individuals who have born one child, or the first child of several. 47 ’qnnAy ‘Gyvvt fan?!“ .Avvv 'nov‘v‘ uv. una "*vvg‘ b‘vo;\.& (according to medically legitimized and determined risk factors), results in a medically mediated quest for a “normal" pregnancy. Under this medical ideology, constructions of normal pregnancies are defined narrowly through “statistical correlations between heterogeneous elements" (p.164), rather than through consideration/acceptance of widely different pregnancy states which may vary, yet still constitute normalcy. As such, the possibility of experiencing a medically defined normal pregnancy is highly constrained. Biomedicine constructs pregnancy by defining normalcy and by essentializing its role in producing normal pregnancies, women are constructed as responsible for, but not capable of managing their own biological functions. In order for women to experience “normal” pregnancies they must submit their experience of pregnancy to medical management. Queniart contends that medical ideology, through its cultural and social universality and its power to define what constitutes normalcy, enables biomedicine to indirectly exert virtually total social control over women and their reproduction. From this perspective, the gender relations in ibionedicine are conceptualized as operating through a ;patriarchal ideology which is imposed upon women without 48 W A‘“ Mae: ‘4 “A x."- W .‘~~S._,.:- \. ‘ F‘. ‘_ . “a V‘\ ‘ L , 5‘.:~ A‘ V C FA ‘1 L“! _\‘ “‘- ‘VCI y“ \‘C‘V‘A ‘ 3‘1‘1". .“ ‘ “A ~ Nx‘fi‘ ._ y. F. i ~“ ““ A‘ ‘ \¥~ “ :n‘y- ~iv~h .‘. h‘ A ”u .‘ k" . ‘y 4 ‘ 1‘ ‘~ ‘BF‘ ‘ their conscious recognition of the social relations it produces. Power is understood as strictly hierarchical and repressive. Medical power relations constrain women’s ability to recognize the ideology's subordinating influence over their lives and also enables patriarchal medicine to regulate social relations with almost complete impunity. The purpose of this ideology is the control of women’s reproduction. This occurs through a process that defines all fetuses as being at risk from women’s pathological biology, and constructs women as incapable of managing their own biological functions. This ideology both devises the problem and legitimates medical management of women's reproduction. This approach is similar to the radical feminist perspective in that it views medical science as a patriarchal institution which generates social relations that oppress women. It is also radical in its depiction of medical ideology as directed at controlling women’s reproduction and as the primary source of women’s oppression (Abbott & Wallace, 1990). Queniart’s framework differs from radical feminism in that women are not seen as resisting, or even capable of resisting, patriarchal social control. According to Queniart's analysis women are politically incapacitated and have little control over their experiences 49 15 51 g . HAWV 7‘ UV-J-AU . . flq-v- ‘ ya. JV ...‘.‘l a"ava » I v ‘Av-O-Y. ‘L..\,. C ‘~. n-C:QL ' v ‘ P v! '- ....,61 c w‘\ A - Lu r 1 I D (Y because they are not aware of the social relations created by the power of medicine’s patriarchal ideology. This view is similar to Jaggar (1983;371) who contends, “women’s male- dominated perceptions of reality are distorted by male- dominant ideology and by the male-dominated structure of everyday life.” Yet, Queniart’s own recognition of the social relations produced through medical ideology contradicts her assertion of total medical control. Although her efforts highlight the ideological component inherent in biomedical power relations, her formulation of power relations and gender construction within medicine is static and cannot account for the changes that have occurred in biomedicine which were influenced by women’s individual and organized activities (e.g., Ruzek, 1978). Medical power relations conceptualized in this manner are based on an essentialist understanding of the subject, and, therefore, can only presume women to be non-agenic. An examination of the extent to which women patients participate in maintaining medical ideology can't be seriously considered under the assumptions inherent in an essentialist conceptualization of power. The part women themselves may play in accepting and promoting an oppressive idecdogy, to whatever extent, cannot be directly considered within the confines of such a framework. 50 .A_A,- ¢ ‘yvoo I ..y-" ‘ «F'Cw ‘»-\_“ I 1|; ‘- V Using this framework, hysterectomy may be viewed as the result of biomedically reductionist and masculinist constructions of what constitutes normal female reproductive organs. Since women cannot judge the normalcy of their own reproductive organs, except through physical symptoms which are legitimated through medical diagnosis, as mediated by medical ideology, they must rely on a physician's medical determination of normalcy. The risk factors (e.g., for cancer) for women who retain their reproductive organs are determined medically by statistical measures which narrowly define what conditions constitute normal reproductive organs. Therefore, medical ideology produces a greater likelihood of women's reproductive organs being defined as abnormal. In utilizing Queniart’s approach, hysterectomy would be viewed as a product of women's subordinate status and biomedicine’s patriarchal power to construct gender in a manner that maintains the status quo. Hysterectomy from this radical feminist perspective becomes just another form of male violence through which patriarchy is reinscribed. In this framework women's biology, because it differs from men’s, is ideologically devalued and, therefore, promotes and justifies women’s subordination and patriarchal medical management of their reproduction. 51 .. e t Tm «a Pu C. q a «1 ¢ 0 t l . q p.-vu D “.Y A. IE ' . w- ‘5- 21?. a- 5 u Hoe“ est:- 1" L. s.‘QV\.z “t. Although this approach provides insights which help to explain how patriarchy may be perpetuated, it fails to illuminate why control of women’s reproduction is necessary to patriarchy. It can't explain why control of women’s reproduction is advantageous to patriarchy. This approach does not account for the fact that some women do question medical knowledge and practices. According to the assumptions of this perspective, the purpose of hysterectomy within medical power relations can only be understood in terms of its control of female reproduction, which it does by physically ending the possibility of reproduction. Under this framework, the purpose of hysterectomy is simply to subjugate women. Even when medical management does not result in hysterectomy, women are maintained as subordinate and dependent through their acceptance of the patriarchal medically mediated fact that their reproductive organs require medical management if they are to avoid risks to their health and status. .Medical Power Relations as Determined by Patriarchal capitalism Emily Martin (1987) utilizing data collected from groups of women who volunteered to participate in in-depth interviewing, analyzes how women's experiences and understandings of menstruation, birth and menopause are influenced by medical knowledge. According to Martin, 52 E o-‘n Lu H J l Lu n .. M. u" ”.14 .2. . ml. h v "I"; A .‘~'~‘»h 1 VA ...1 6.4:". ' l. medical metaphors of menstruation, birth and menopause arose in the course of Western medicine’s development and are infused with cultural assumptions concerning the nature and purpose of women's reproductive organs and functions. According to Martin, medical discourse promotes metaphors of women's bodies as being, a hierarchical, bureaucratically organized system under control of the cerebral cortex and a manufacturing plant designed for production of babies (p.173). Martin describes medical metaphors as impacting not only women’s experiences but as influencing they ways in which they perceive their own bodies. Martin asserts that women's understandings of their own experiences of childbirth, menstruation and menopause demonstrate feelings of fragmentation and objectification. Women feel detached from their bodies and bodily processes over which they've had difficulty retaining control. Martin documents how medically controlled birth operates under the medical metaphor of birth as production. She states, “medically, birth is seen as the control of laborers (women) and their machines (their uterus) by managers (doctors), often using other machines to help" (p.146). According to the production metaphor, this system (a woman's body) is attended to by medicine when it 53 ‘ 1 Luvuh‘ BYR- 1 “VI experiences a breakdown. But Martin found that women resist and attempt to retain control over their bodies during the birthing process in numerous subtle ways. Examples of resistance given by Martin include women in labor who take long walks in the hospital to avoid being strapped to a fetal monitor (p.142), and women who choose to birth at home (p.143). Martin contends that under the influence of the medical model (which is informed by metaphors of production) the organization of women's medically managed experiences of birth are reinforced by the same metaphors. Therefore, she suggests that if birth is viewed as production in society, it will constrain women’s perceptions of available birthing alternatives (p.158—159). Physicians as managers determine time frames (e.g., due dates), and the normal course of pregnancy (e.g., progress measured in terms of trimesters and appropriate fetal size), and women have come to accept and expect these restrictions placed on their pregnancy experiences. Martin asserts that dominant medical metaphors of women's bodies also include notions of menopause as failed production. She states, menopause is seen in terms of this model as a case of the breakdown of authority: ovaries fail to respond, and the consequence is decline, regression, and decay (p.173). 54 exper: Y \. '5‘ 4‘ Q \. q F?" n V :E.‘ ”flat :1...“ “VI-AAA n NEIE I ~- VA. But many menopausal women, according to Martin, do not subscribe to this medical view of their menopause experience, and many menopausal women she interviewed perceived it as a positive experience. In her study, Martin found the discourse of some women was passive while others were more active. This suggests that there's a qualitative difference in women's experience of gender oppression, just as there is difference in the possibilities of women resisting and manner in which they resist. Martin provides a socialist feminist analysis of women's reproductive experiences as mediated by medical metaphors. Medical metaphors of reproduction as production are described as emanating from a patriarchal ruling-class of medical professionals within a particular cultural context. She describes the historical development of medicine as constructing economic-based metaphors of women’s biological functions. The socialist feminist perspective explains women's subordinate social status as generated by the nature of social institutions (Abbott & Wallace, 1990) and focuses on the intersection of class and gender as interdependent systems of oppression which determine men's and women’s status in society (Andersen, 1997). Therefore, the socialist feminist framework explains power relations in 55 ' «a .4 bluffs WW” 8 .Mb 0"» "Iv ‘ A”. ‘VHH biomedicine as a product of patriarchal capitalism. The structure of organized medicine reflects and supports patriarchal capitalism, resulting in l) a hierarchy in which financial and political power accrue to those at the highest level (who are predominantly male), 2) a division of both labor and specialization which are stratified by gender, race and class, and 3) definitions of health and illness (Fee, 1983;30) derived from a patriarchal capitalist ideology. Martin's utilization of this framework, in which women’s subordination within biomedicine results from both economic and patriarchal exploitation, extends its explanatory power through her specification of cultural influences. The concept of ideology is particularly important in socialist feminism’s explanation of biomedical construction of gender. Martin’s approach explains the ideological process by which medical meaning is constructed, and the content of medical metaphors as they originated in ideology typical of the dominant group of individuals, i.e., middle- and upper-class medical professionals. Medical power relations are understood to be part of pat:riarchal capitalism, with its ideology promoting biCLlogical differences between males and females as constituting basic and consequential differences requiring a 56 division of labor based on sex. Because women’s capabilities are defined strictly in terms of their biological capacity to bear children they are relegated to the domestic sphere, and men's biology is conceived as predisposing them to power and the public realm (Eisenstein, 1979a & 1979b). Therefore, biomedicine constructs gender through medical treatment modalities which reinforce women's subordinate status by defining women and their biology as deficient and needing medical management. Fee (1983) states, the medical system often acts as an “extended patriarchy” that reinforces patterns of male domination. If we examine the medical system itself, we find the power relations of the traditional family writ large in the health care hierarchy (pp.9-10). Therefore, according to the socialist feminist framework, gender and class ideologies determine power relations in biomedicine. It influences the character of the physician-patient relationship, medical definitions of health and illness, and promotes medical neglect of the social influences on health (Fee, 1983), presumably because acknowledgment of the system's negative influences on health and well-being challenge the system itself. Medical diagnoses and their associated treatments can then be viewed as imbued with ideological assumptions, and as supporting women's social reproductive labor. From a socialist feminist perspective power relations in 57 row/v hov .V. *5” . {Aau “‘Ay' , Uy‘he. . '5‘.» “, L‘~u~ fill (.r“ I“ w ’ 1 rl’ biomedicine result in the medical management of women’s reproductive organs so that women's social reproductive labor may continue to be exploited. The emphasis in this perspective is on social reproductive labor which women perform primarily in the domestic realm, and which is assumed to primarily benefit men. This perspective, like Queniart’s, employs a more traditional, essentialist understanding of power. Medical power is viewed as hierarchical, and women are understood as being relatively powerless, as “carried along by forces beyond their control” (p. 194). Despite this characterization, Martin asserts that women resist medical ideology and that the very fact of having a female body with particular reproductive functions and capacities is an act of resistance. This is problematic since knowledge of one's oppression does not constitute resistance in and of itself, especially if that knowledge has no external impact on the social forces which create that oppression. Additionally, assertions regarding natural, or embodied resistance are based on biological essentialism. In Martin's analysis, medical power and ideology is viewed as being so powerful that women’s efforts to resist it can only be understood to be ineffective (and women powerless) because women patients are viewed as having little impact on medical ideology 58 ~ 1 unra fif '- \ O‘VV‘U . ' 'L A" h. *1.J.‘u ‘ v n ' £77153 5 Av- pa : O».c ' v A6 ‘"a V. 5;.» I." n s.‘ itself. Using a socialist feminist framework, the medical ideological basis of hysterectomy would determine how and on whom hysterectomy is employed in efforts to medically manage women’s reproductive organs. If the female body is medically understood (in terms of a production metaphor) as a hierarchy that is bureaucratically organized under control of the brain and a manufacturing plant for the production of babies, where does hysterectomy fit in this metaphor? If the reproductive organs are analogous to a manufacturing plant, what ideological purpose is served by removing the source of production? This can only make sense if it is understood, in light of the socialist feminist perspective, that women's value under patriarchal capitalism is not solely based on their ability to physically reproduce. The importance of women's social reproduction under patriarchal capitalism makes the removal of women’s reproductive organs beneficial in instances where they may be perceived as interfering with social reproduction. Under patriarchal capitalism, according to the feminist socialist perspective, social reproduction includes domestic household responsibilities, as well as assuring the future availability of a labor force through childbearing and socialization functions. 59 m2: ] a pat: the me lfic‘1. Q“ «“2“ ¥ C? W e 'C. . U»C" u ~‘ n e“ s . ;F~" "H‘A\‘ "vx ‘L ‘I \ ‘\ [‘fi‘ ~r . Hysterectomy, from this perspective, may be viewed as a medical effort to enable women with reproductive health problems to perform social reproduction. Those health problems determined by medical experts to most likely impede women's daily social responsibilities and tasks, would be more likely to result in hysterectomy. The requirements of a patriarchal capitalist system would be seen as influencing the medical determination of which health problems are defined as sufficient reasons for removing a woman’s reproductive organs. This, in addition to the ideological component which influences and specifies how women can view hysterectomy would be based on medical production metaphors. The purpose of medical management, according to socialist feminism is to reinscribe the social relations which benefit men, as well as capitalism. Therefore, medical power relations socially construct gender and influence medical definitions and meanings of biological organs which results in particular treatments that, in turn, influence women's images of themselves and their experience of gender oppression. There is a scarcity of empirical research analyzing medical power relations and the construction of gender through specific medical treatment processes. This area of research has been largely overlooked, most likely because of 60 AIA'. bv-A «b «a p. ‘Y‘s ‘Qn‘ n\~ .‘ ~ L.» n", I V4 p\.\ the fact that medical treatments are widely accepted as being scientifically (objectively) devised and implemented, as being beyond social influence. There is little recognition that power relations include the treatment domain. Medical treatments are viewed simply as applications and interpretations of medical knowledge. If, as Foucault advanced, knowledge and power are immutably connected (McNay, 1992), then medical treatment processes, as applications of knowledge, are also applications of power. Investigations of medical power relations are influenced by how power is conceptualized. Power considered to be strictly hierarchical and as a possession of the subject limits how participants in power relations may be defined. For example, representatives of professional medicine can only be understood as dominant, and women patients as passive victims. Alternatively, power conceptualized as relational defines power as a process which is interactive and contingent on the participation of both more and less powerful social actors, as constructing social individuals in a manner which presents an opportunity for agenic change. Yet, power viewed as relational necessitates a strictly local, micro focus that cannot account for or facilitate the empowerment of subjected 61 ”A” “V.“ CE: .9AMD“ flows... "n , . v' \ué h v. AA."V‘" yyd. [K crpr; H "b r: . 1.. w 5.. All» +L A o ab H.|u ~\~ Ad 2‘ a9:~ “'\4§A. .- §u fin ‘Q‘e é U «AV. 1' groups. The.Medical Discourse” on Hysterectomy The medical discourse surrounding hysterectomy involves a dominant biomedical discourse and a number of sub-or counter-discourses which include the popular media, the women's health movement and physicians who contest the dominant medical discourse. The dominant medical discourse on hysterectomy is primarily advanced by gynecologists, who comprise a surgical medical specialty (Ross, 1996). Obstetricians/gynecologists have historically focused on the diverse benefits of hysterectomy rather than on the associated risks and complications or the health benefits of retaining the uterus (Hufnagel & Golant, 1989). Prior to the Zou‘century, hysterectomy was advanced as a cure for a multitude of problems, including lustfulness, overeating and insanity (Sefcovic, 1996;370). In the early part of the 20th century, as hysterectomy became safer to perform and its popularity grew, physicians advanced views of women’s biology and health which increased the rates at which hysterectomies were being performed. These views promoted the insignificance of the uterus to women’s health and its l3The notion of discourse here is understood as medical smaientific and/or specialist language, and the associated ideas and social outcomes through which the medical estarflishment (a) exercises power and (b) describes the *medicel phenomenon and the world (Jary & Jary 1991;124). 62 T“~’ . thus 4 Fr '- (D A‘ La“ ( . 9-.“ “Nit: .“h y . S V removal as a general prophylactic. Physicians asserted that the only function of the uterus was reproduction, otherwise it was by nature potentially pathological (Dally, 1991). In the dominant discourse of the time, the mere presence of a uterus in a woman was the rational for removing it. Physicians claimed that it was a surgeon’s duty, for the sake of women’s health, to remove the uterus before it actually became diseased (as ultimately, it was assumed it would). In the latter part of the 20th century, obstetricians and gynecologists advanced hysterectomy as a sterilization procedure, and justified these operations as having been done as per patient demand (Dally, 1991). The rates of hysterectomy in the U.S. remain high, and the dominant medical discourse has not greatly shifted from its advancement of hysterectomy as a method by which women can dispense with the nuisance of their biological functions. Conditions and diseases affecting the uterus which have alternative treatments continue to be treated with hysterectomy by many obstetricians/ gynecologists (Hufnagel & Golant, 1989). Additionally, the current hysterectomy discourse advances the surgery as a way for women to improve their quality of life (Carlson, Miller & Fowler Jr., 1994). 63 L ..n h' u.¢\, Av- ‘ CV..S- t V €1.26; 1 s "Fa“.‘o VVogg“, Vn it. > be. .V C A: the A sub-discourse on hysterectomy, emanating from within the medical profession itself, represented in the work of Hufnagel & Golant (1989) and others, questions the prevailing medical disregard for the health and social functions of the uterus. This discourse advances constructions of the uterus as being beneficial and a critical factor in women’s health, which cannot be reproduced through hormone replacement therapy. The women’s health movement is informed by the work of such medical experts who challenge the dominant discourse. Challenges to hysterectomy in the early 1970s, from feminists and the women's health movement (Sefcovic, 1996), centered on the high rates of hysterectomy being performed in the U.S. (Ross, 1996). This sub-discourse questioned the health benefits of hysterectomy and gained media attention. At present this discourse is chiefly silent on the subject of hysterectomy. Despite the fact that hysterectomy is one of the most performed surgeries in the U.S., very few articles or books focusing exclusively on the subject have ever been published (Sefcovic, 1996). In the latter part of the'19th century, the American press addressed hysterectomy from the standpoint of medical practitioners who viewed hysterectomy as a “cure all” for women/s problems (Roy, 1990;188). As in the past, the 64 E .A" A V..\, C x ‘Q ..ie‘:‘\ =n h‘h u‘u»..‘ nnrh‘ rv- K. a Theo: '5‘ ~er6 tC r yd-h 4 '5. ‘« Qv . x v” H hm ..a. current discourse of daily newspapers does not normally challenge the dominant discourse on hysterectomy. It tends to report information on hysterectomy as given by the medical establishment, but focuses primarily on the possible sexual and emotional consequences (Sefcovic, 1996). As such, it bolsters the dominant medical discourse. Books and magazines articles addressing hysterectomy tend not to portray women as victims of their biology, and, therefore, present an alternative discourse challenging the dominant discourse. (Sefcovic, 1996). Theory Power is an “essentially contested” (Lukes, 1974) term. Conceptualizations of power within the social sciences depend on theoretical and disciplinary perspectives, which begin with assumptions constraining the ways in which power may be understood. According to Radtke and Stam (1994) traditional views tend to conceive of power in essentialist or economic terms.14 Derived from individualistic and voluntarisitc assumptions, power is viewed as an entity which may be possessed, transferred or acquired, and autonomous individuals, utilizing personal resources, are ‘viewed as interacting consciously to attain goals. Radtke .and.Stam contend that a somewhat less individualistic l“This critique originated with Michel Foucault, (1980). 65 rt fin 1’ VB ‘9- ‘Vt‘; FA E «.3 «Q a: conceptualization of power includes the notion of process. That is, power may be possessed by individuals, but it is also a process resulting from social interaction.15 With the advent of third-wave feminism and post- structuralism more radical conceptualizations of power came to the forefront. Radtke and Stam (1994) remark on the influence Foucault has had on these more recent views of power in the social sciences, such that, the exercise of...power requires no external surveillance or coercion; rather, because the individual is constituted through power, the exercise of power can occur through a process of self—discipline or self—regulation. Moreover, the exercise of power is implicated in the mechanisms and procedures for producing knowledge, and hence, in knowledge itself. Consequently, all social practices are shaped by power, including...the reproduction of traditional gender arrangements (p.4). Feminists employing a more traditional notion of power contend that women's health care experiences have largely been determined by the patriarchal authority and gender-bias of scientific medicine (Krieger & Fee, 1994), in which physicians, through their scientific medical authority, act as gatekeepers and promoters of medical services and treatments (Lorber, 1997; Foster, 1995), and research ‘5Hartsock’s (1985) critique of this view of power is that it is relatively individualistic in its assumption that conflicting interests are the motivating factor behind the exercise of power. 66 1“ ....£ {flux ”LY'C bea9h . n ._.I \L) (1) a .n 5...... UV~un ‘ ‘RAV- -‘v‘. 5- . ih.‘ a “vg‘l (Auerbach & Figert, 1995). The authority and power of physicians enables them to do ideological work (Waitzkin, 1983), to act as agents of social control who reinforce dominant structural arrangements that maintain women's subordinate social status (Fisher, 1994). From this perspective the possibility for change in women’s social locations is limited because of the hegemonic nature of power. Social change primarily depends on mass efforts to identify, resist and modify medical power. Feminists influenced by Foucault employ a more relational or transactional notion of power. Foucault’s conceptualization of power stems from his rejection of Marxian and psychoanalytic notions of power as being incomplete due to their focus on power as a form of repression (McHoul & Grace, 1993). For Foucault, power is more commonly a constructive force, creating knowledges, methods and techniques, such as surveillance and normalizing tactics, commonly employed by disciplinary regimes to produce docile bodies that are self-regulated (Foucault, 1979). Grosz (1990) explains Foucault’s position on power, To pose power in terms of the state and its repressive and ideological functions, or in terms of the Oedipus complex and the Symbolic Father’s prohibitive power over the son is to pose power in terms of sovereignty or law. It is to understand power juridically, in forms that are both anachronistic and reductionist. Power is not so much a law that says no, as a proliferative, 67 i Q 812:1 I CHIC; pcwe: seis \v u‘ b .0 IE" .‘ld AD AP. ‘1‘ . #- .eg: Rs v17. v. C» 6+}. v.31 :‘A- ' "v.“er productive series of forces that creates new objects, properties, subjectivities, and knowledges. For Foucault, forms of knowledge, such as medicine, law and religion, are disciplinary/power regimes that motivate self-regulation (in terms of behavior, beliefs and values) through expert knowledge constructed as “truth.” Repressive power is unnecessary since expert knowledge both produces desire for a particular existence, and “truths” which assure the validity of that desire as well as its attainment. In this way subjects are viewed as being socially constructed through participation in such discourses which overtly aim to reveal “truth,” but aspire to authority and power. Power lies in the act of creating a subjective reality, through categorization and divisionary practices, and influencing others to self-regulate in terms of specific knowledges. Power is not an entity, quality, or thing, nor can it be possessed, given, seized or exchanged. Grosz (1990) states, For Foucault...power is not possessed, given, seized, captured, relinquished, or exchanged. Rather, it is exercised. It exists only in actions. It is a complex set of ever-changing relations of force - a moveable substratum upon which the economy, mode of production, modes of governing and decision-making, forms of knowledge, etc., are conditioned (p. 87). Foucauldian power is found in every type and level of human action. Therefore, power is local, specific, and unstable, rather than centralized, global or uniform. Power 68 S .P" . 1.. . arab- -..D-‘ ; Q . “N. .- ‘oou; ‘ In is not viewed as a component of social structure, institutions or institutional practices, Rather, power is both (a) historical systems aligned across structures, institutions, rituals, practices, and individual lives, bringing them together in some contexts, and dividing them in others - a ‘substratum' of force relations; and (b) the particular use of the products of these alignments (e.g., knowledges, practices) to interrogate, regulate, supervise, observe, train, harness, and confine the behaviors and subjectivities of individuals and groups (Grosz, 1990;88). Power is a system of relationships of power among individuals who are somewhat free to act and resist (Deveaux, 1994). Medical power relations are formed through women’s varied types of participation in biomedical discourse, What the discourse does, whom it acts upon, how it is distributed, and the forms of resistance it meets...are all open to transformation (McHoul & Grace, 1993;46). Since individuals are active participants in medical power relations, power may be negotiated in a multitude of diverse ways because power relations are ever dynamic, change is a given, although the direction of change is indeterminate. Individuals and medical professionals create power relations through local negotiation. Deveaux's (1994) critique of Foucauldian feminist analyses of power relations focuses on two aspects of 69 FHA-“way- Uv V- C n P“ ~15" “V .08 ‘ ‘A . “A... Hi pen 2. .7. C “u‘ ~.$ .s .\ Lu . t :a ct . . .— u t: u b. Foucault’s thesis which are inconsistent with feminist goals, ...the tendency of a Foucauldian conceptualization of the subject to erase women’s specific experiences with power; and the inability of the agonistic model of power to account for, much less articulate, processes of empowerment (p. 224). Although traditional and relational formulations of power have strengths which may be beneficially employed in analyses of medical power relations, their weaknesses create problems in terms of the possibilities for social change. Both formulations constrain the possibilities of resistance to power relations, albeit in very different ways. Deveaux (1994) offers a possible solution. She contends that power relations can best be understood by placing the subject’s interpretation and mediation of her experiences at the center of our inquiries into the how and why of power. Such an analysis might ask: what do relationships of power feel like from the inside, where are the possibilities for resistance, and what personal and collective processes will take us there. (pp. 243-244). The Historical Context of Medical Power The ideological underpinnings of medical power relations originate in the socio-historical development of scientific knowledge which resulted in a gender-biased medical model and the dominance of biomedicine (Rosser, 1994). The medical model is a set of practices and a philosophy of health care which is the dominant belief 7O system of Western medical professionals. It largely determines how medical professionals view disease, how they pursue the practice of health care, and how they conceptualize humanity. The medical model includes three primary assumptions which influenced the historical development of biomedicine; 1) man's right of sovereignty over nature, 2) a mechanistic view of human bodies, and 3) the cause of disease as external to the body (Vuori & Rimpela, 1981). As it developed over time and became more specified, the medical model defined 1) disease as an abnormal bodily state (i.e., functioning differently from normal biological standards established through scientific techniques) having an explicit cause which can be scientifically discovered in the human body (which is the same regardless of social influences), and 2) medicine, its practices and philosophy of health care, as a neutral science (Mishler, 1981). Nevertheless, “...medicine is a part of culture, a social institution that is both formed by society and an active agent forming that society” (Oinas, 1999;54). The ideology reflected in the medical model, and the practices of modern medicine (e.g., knowledge production, treatment, etc.) are profoundly biased by the social context (patriarchal gender relations) in which it developed and now 71 operates (Mishler, 1981). At the same time, the “conceptual practices of power” (Smith, 1990) of medicine that stem from the medical model conceal its bias. Feminists contend that the “neutral” biological standard at the base of the medical model is actually male (Lorber, 1997) and, therefore, that women's biology is defined by science as deviant (Hubbard, 1990), defective, disease-prone, and in need of medical management (Ehrenreich & English, 1978; Martin, 1987). The medical model asserts man’s right to manipulate nature. The notion of a gendered subject is associated with an historical period when women were primarily associated with nature and considered less than fully human (Rosaldo, 1974). The implications of the gendered subject within the medical model is not only that women, due to their close association with nature, do not have the equivalent right as men to dominate nature (even their own female nature), but that medical professionals have a sovereign right to control nature (including women),16 and benefit from this franchise (Haraway, 1978; Harding, 1986; Merchant, 1979; Fee, 1981, 1982; Keller, 1985). The medical model's assumptions of the '°It may also be argued that the medical model promotes the right of physicians to benefit from the sovereign right to control nature. For example, the historical process of biomedicine’s professionalization and dominance occurred, in part, through the expropriation of women’s traditional healing functions and through the medicalization of women's reproductive functions. 72 'f'C.’ uu’» v. n\~ Cu 4 Q “L. ya“? relationships between man and his world, biology and social status, and science and disease reflect the implicit hierarchy of power relations, in which women are defined as less than fully human and, therefore, appropriately controlled by medicine.17 Biomedicine’s gender bias is apparent in its construction of medical explanations and diseases, the methods it used to professionalize and those it uses to sustain its legitimacy, and its efforts to promote the dominant structural arrangements which maintain women's subordinate social status. Historical processes, in which medical science created particular types of knowledge which continue to inform contemporary medical conceptions and practices, have influenced our understandings of ourselves and our world. Yet, biomedicine itself is influenced by its cultural milieu, thus, throughout history scientific medical understandings of male and female biology reflect and reinforce the simplified, standardized and dichotomized notions of Western gender ideology. As biomedicine developed it incorporated science and its method into medical knowledge and practice. Its legitimacy rested on its claim to scientific expertise and l7Race, class and age have also been implicitly a part of this biomedical hierarchy of humanity. 73 *H (L) (1‘ u ‘1 r- J: 'v 1,. § m value neutrality (Ehrenreich & English, 1978). This representation of biomedicine helped to create the image (if not the reality) that biomedicine was highly effective and, therefore, beneficial to humankind because it actually cured disease (Illich, 1976). As the medical profession (i.e., physicians) developed in the United States, its professed impartiality appeared to assure its relatively effective services were available to all, regardless of individual or group social status (Ehrenreich & English, 1978; Hubbard, 1990). The development of the scientific understanding of biological sex differences and the resulting construction of women's biology as deviant and pathological were used to justify women's exclusion from particular social roles (e.g., as students in higher education) and the primacy of their inclusion in other roles (i.e., motherhood and roles relating to motherhood). Another result of the scientific construction of female biology was medicine's focus on women’s reproductive health and neglect of their non- reproductive health (Davis, 1988), which in turn resulted in the exclusion of women from much of medical research and the lack of funding for women’s health concerns (Auerbach & Figert, 1995). Hubbard (1990) states, When they studied women’s biology and noted quite accurately that there are ways in which it differs 74 from their own, they interpreted these differences as reasons to disqualify women on scientific grounds from participating in their world (p.40).18 Consequently, scientific medicine’s masculinist construction of women’s biology and the rational for women’s presumably considerable medical needs may be understood as a product of the socio-historical and economic context in which it developed (Martin, 1987). Women’s biology was constructed by medical science as a rationalization of women’s subordination and this served (and continues to benefit) men’s interests. From this perspective biomedical discourse may be viewed as participating in the construction of gender through knowledge claims and medical practice. Medical discourse, in effect, not only rationalizes women’s subordination but provides a paradigm of womanhood that is non-agenic and inherently disordered. Through such power relations19 biomedicine maintains and reconstitutes its dominant status. l“These are the “conceptual practices of power” to which that Smith (1990) refers. '9Medical power relations are multifaceted, extending beyond gender issues. For example, challenges directed at medical authority and practice are confronted and addressed through various medical efforts, but most significant, in terms of social power, are those activities undertaken by the American Medical Association, presently one of the most powerful professional organizations in the United States. 75 and 9 J 1'". A A i ,- , ”my ‘v‘- \ HM . ..a Pb Uw . «Q .lx ‘ :c."‘ ”,1 .1 C._ ' ~~..‘.' . "'M. ,. 7‘ 'y" ‘N. Martin (1987) contends women’s association with nature and man’s with culture was a consequence of the gendered division of labor. This resulted in women being viewed as less than fully human since men’s place in the public sphere was thought to require higher level functions. In other words, women’s association with nature required their dependency on men. Male dominance was conceived as necessary to women's well-being, and justified as natural. Nineteenth century medical metaphors of women’s reproductive systems focused on notions of hierarchy and authority, and centered entirely on potential for production (Martin, 1987). Menstruation, as failed production, and menopause, as declining potential production, became medically defined as pathological. Those organs and bodily functions of women having no analogue in men were denigrated. The consequences of medical language and imagery concerning reproduction include the use of particular medical interventions (e.g., hysterectomy), a particular, often negative, conception by women of their own bodies, as well as women’s insights into the medical view of female bodies (Martin, 1987;14). Historically medicine has explained the etiology of Imanstrual and menopausal symptoms as originating in women’s 'PSychopathology (Stanton & Danoff-Burg, 1995). Negative and 76 \ (3 l T') 'nn V -3- Lu. 1 Huu «cu. I ‘RA‘Y- VVA‘ u) U) .'~, N3. .‘Q‘ (‘1’ (7) (n 'Y (I) I inaccurate scientific images of women based on gender stereotypes are present in medical textbooks (Scully & Bart, 1981) and have contributed to a psychologization of women’s illnesses, in which the cause of symptoms is assumed to be psychological rather than some external pathogen. This can have, and has had, negative consequences for women’s health, especially when it results in misdiagnoses of serious illnesses (Goudsmit, 1994). Cultural stereotypes influence the medical construction of women's biology, health, and humanity. These in turn influence diagnoses and the types of medical treatment deemed appropriate for women. The consequences of these images for women may be manifold, but as yet, they have been left largely unexamined. Professional medicine is part of the ruling apparatus, or the relations of ruling, that organize, guide and regulate contemporary society (Smith, 1987). Medical knowledge, like all knowledge,20 is “determinately situated” (Harding, 1997;384), which means that medical knowledge is shaped by the standpoint of its makers. Standpoint refers to a “common location within hierarchical power relations...[which] creates groups” (Collins, 1997; 376). The standpoint of gynecologists is situated in the relations 2°Harding (1997) states, “all knowledge claims are dEterminately situated” (p. 384). 77 of ruling, and this location informs the manner in which gynecology views women and their reproductive organs, and is part of the process leading to hysterectomy. Medicine’s claim to objectivity is part of “the conceptual practices of power" (Smith, 1990) that obscure the actual hierarchical ordering of social relations. These conceptual practices “construct institutions that make seem natural and normal those relations of domination, exploitation, and oppression” (Harding, 1997;385). Therefore, the conceptual practices of medicine that create knowledge may make the practice of removing a woman’s reproductive organs appear natural and normal. Women who have elective hysterectomies may believe that the knowledge base of gynecology is scientific and, therefore, neutral. Such women may be more inclined to readily accept their physician's diagnosis and recommendation for hysterectomy. Women who question the basis of medical expertise may be more inclined to seek alternative therapies prior to deciding to have a hysterectomy, and the manner in which they experience and decide to have a hysterectomy may be influenced by their attitude towards medical authority. Hysterectomy may be viewed by many women as a “normal" Event, partly because so many women have had hysterectomies, 78 oil 1... V‘- Vi ‘V‘; ‘.\ \.“ and professional gynecology has constructed hysterectomy as a conventional practice, making it an acceptable and familiar option to women with gynecologic problems. It is likely that most women who are deciding to have a hysterectomy know other women who’ve had a hysterectomy, which may make the decision to have hysterectomy appear unexceptional or routine. The more normalized hysterectomy is perceived, the less likely women will be to question their physician’s recommendation for hysterectomy. Hysterectomy viewed in this manner may make it more likely for women to expect to be hysterectomized at some point in their life, and to anticipate a physician’s diagnosis of their gynecologic problems to result in hysterectomy. Yet hysterectomy is not a natural event, it is a social artifact, a procedure which was historically developed and socially constructed, and is a result of, and part of, the mechanisms of institutional power. It is not “natural” or “normal” but it has been normalized. From this perspective, understanding how women's experiences of and decisions to have hysterectomy are part of the relations of ruling can only be determined by looking to the multiple standpoints of women who experience the medical power relations leading to hysterectomy . 79 ¢ . N\s ... .fin According to standpoint theorists, “some social locations are better than others as starting points for knowledge projects that seek to understand oppressive social relations” (Mann & Kelley, 1997;397). Harding (1997) asserts, standpoint theorists use the “naturally occurring” relations of class, gender, race, or imperialism in the world around us to observe how different “locations” in such relations tend to generate distinctive accounts of nature and social relations....Distinctive gender, class, race, or cultural positions in social orders provide different Opportunities and limitations for “seeing” how the social order works (p. 384). From this perspective, women who have the least power (i.e., women of color, those less educated, and those who are more economically marginalized) are most likely to be aware of power relations, but may be less likely to directly question authority. This suggests that more marginalized women will be more conscious of the power relations of hysterectomy, but may be less inclined to directly question a physician’s recommendation for hysterectomy. Women's relation to medical power (as well as other ruling institutions) contributes to the shaping of their standpoints, and it is, at least partially, the medical disregard of women's standpoints from medicine's conceptual Practices which constructs “scientific” hysterectomy. The dagree to which women who’ve had elective hysterectomies 8O accept or question medical expertise may be an indicator of consciousness of the power relations of hysterectomy. Women who question medical knowledge and authority over their bodies, even though they may not do so directly, may do so because of their distinctive standpoints within the relations of ruling. Collins (1997) contends that “gender represents a distinctly different intellectual and political project within standpoint theory” (p, 378), because women represent an extremely diverse group in terms of race, class and gender. Women occupy many different locations, comprising what Collins (1990) refers to as a socially structured “matrix of domination.” The various standpoints of women who have hysterectomy will reflect this matrix, and, therefore, women's experiences with medical power relations and hysterectomy are likely to differ depending on their locations as they are determined by race, ethnicity, class, age, and sexuality. Therefore, the meaning of hysterectomy and reproductive organs, and the decision process leading to hysterectomy are likely to be influenced by the varying combinations of women’s differing social locations. Additionally, the likelihood of women resisting, and the forms their resistance takes may also be influenced by the diverse social locations of women. 81 S . A D ‘1‘ “v s b 6.. HI ’1 ' r (I: According to Smith (1987) the production of privileged knowledge (knowledge production associated with the standpoint of the ruling apparatus) is accomplished through observation from outside the lived reality of the people or the relations it tries to explain and present as “truth.” This way of thinking results in an incomplete view of the social relations that oppress marginalized people. Likewise, it is the partial perspective of medicine that obscures the relationship between the medical practice of hysterectomy and the relations of ruling. These relations remain concealed through the methods of knowledge production, in this case the scientific method, which objectifies the relations and subject in question (women and their biology), and abstracts knowledge in a manner that excludes the everyday actual experiences of the subject as authentic or valid knowledge (Harding, 1986). From such a perspective, women’s experiences with hierarchical power relations cannot be fully understood or recognized by the creators of privileged knowledge (i.e., social scientists, as well as scientists, etc.) because women’s oppression is also concealed in the objective and objectifying language used to structure the social relations of knowledge (Smith, 1987). This characteristic of the relations of ruling and the associated knowledge claims is 82 typical of scientific medical jargon. The effects of medical knowledge claims and its attending language are implicated in the power relations specific to hysterectomy. Women undergoing hysterectomy may or may not be conscious of these relations, and how women experience and perceive these relations (and, therefore, the relations themselves) can only be gleaned from women's experiences and perceptions of the power relations specific to hysterectomy. According to Smith (1987) knowledge is generated from a particular standpoint, but because conceptual practices of power present knowledge claims as “subjectless” knowledge, it appears as unmediated reality. Conversely, standpoint methodology is based upon the conceptualization of social processes (or possibly “reality”) as, the ongoing concerting of actual practices of actual individuals. We see, then, people very much as they are, the competent practitioners of their everyday worlds, active in definite material and social contexts, desiring, thinking, feeling, and actively engaged with others in producing the actualities of the world they have in common with one another....These practices, these objects, our world, are continually created again and again....they are always coming into being as local historical process (Smith, 1987;125). This assumption means that the typical sociological methods for discerning the nature of power relations are inadequate because those methods are part of the ruling relations, and the manner in which sociological knowledge is 83 n- *4 .s \ traditionally produced, and the knowledge itself, only serves to reinforce the relations of ruling. In order to reveal the relations of ruling in their full complexity, multiple vantage points must be voiced and counted as knowledge (Collins, 1997), and, in this way, the relations of ruling may be subverted (Smith, 1987). To accomplish these ends, Smith (1987) suggests a methodology which inverts power relations by privileging the knowledge claims of marginal groups. This is why standpoint methodology begins with the “everyday/everynight” lives of the subjects in question. Harding explains standpoint methodology as, “knowledge projects...designed for local situations,” (p. 387) and as arising from “conceptual frameworks developed to answer questions arising in their [women’s] lives” (p. 385). Hysterectomy, from the standpoint of women's everyday lives, may be perceived by women who have elective hysterectomy as a means of changing the balance of power relations. In mythology, Amazon women were depicted as so powerful that they would cut off a breast if it hampered their ability to shoot a bow and arrow (Tyrrell, 1984). Analogous to the removal of a breast, hysterectomy may possibly represent freedom or power to some women; freedom from pain, freedom from the social constraints posed by a menstruating body, guaranteed freedom from unplanned 84 .4 n; m p: (I) pregnancies, or the power to be women who are not self- or socially-defined by their reproductive functions/capacities. Privileging women's knowledge of the hysterectomy process means accepting their understandings of their bodies and lives and not assuming that they are passive victims who have been deceived by medical science. Rather, the assumption is that women are aware to varying degrees of the hidden power relations that shape their lives. From this perspective, women’s decisions to have hysterectomy may entail a process of negotiation, in which hysterectomy may be understood as an acceptable alternative to various physical and social constraints. Standpoint theories and methodologies require researchers to reveal their location in relation to power and to the subjects of their knowledge projects, and to allow the voices of their subjects to generate situated accounts of social relations, rather than acting as agents and managers of power by determining the “truth” of their subjects lives (Harding, 1997). Standpoint theories are perspectives on the relation between power and knowledge that attempt to, identify ways that male supremacy and the production of knowledge have coconstituted each other in the past and to explore what heretofore unrecognized powers might be found in women’s lives that could lead to knowledge that is more 85 useful for enabling women to improve the conditions of our lives (Harding, 1997;383). Through women’s telling of their (pre-surgical) hysterectomy experiences with medicine, and how these experiences influenced their decisions to undergo hysterectomy, the reality of women’s lives, as “socially constructed discursive formations” (Harding, 1997;388) in the relations of ruling, can be better understood. .Medicalization Medicalization, as it specifically relates to the practices of professional medicine, refers to the process by which a variety of problems come under the purview of professional medicine. Medicalization is considered a form of social control and biomedicine as a principal institution of social control (Zola, 1981). Medicalization is a sociocultural process which also occurs outside the direct influence of professional medicine (Conrad, 1992). Recently, the concept of medicalization as a hierarchical ordering of power in which representatives of the medical profession are characterized as all-powerful and patients as submissive victims has been questioned (Oinas, 1998; Broom & Woodward, 1996; Wiles and Higgins, 1996; Bransen, 1992; Becker & Nachtigail, 1992; Dull & West, 1991). Although this is a primary theoretical area in the sociology of health and illness, little empirical effort has 86 been made to investigate medicalization as a more relational concept (Williams and Calnan, 1996). The medicalization of women's “problems” is only one component of the social control carried out by biomedicine. Nevertheless, it is an important element because it places women and their lives under the moral scrutiny of biomedicine (Zola, 1981), thereby creating the opportunity for medical professionals to define and treat “disease” in a manner that supports dominant social ideology (Illich, 1976). Through encounters with the health care system, particularly at the point of doctor-patient interaction, women are exposed to messages, images, advice, and treatments which both reflect and support the social inequality of women (Wuest, 1994). That they are advanced by medical professionals makes these messages all the more powerful because of the authority of biomedicine (Fisher, 1994). Iatrogenic effects have always been are part of medical practice (Illich, 1976), but as medicalization has increased to include women’s bodies (e.g., reproductive organs) their natural functions (e.g., childbirth, menstruation, menopause, sexual functioning, aging, etc.), and women’s “problems” in general (e.g., weight problems), professional medicine exposes women to the ever greater possibility of 87 .4. m (I) n: :1 N x W Ce t‘.‘~ a Q“. L‘mxfi "A v "7." v.“ lh:\ ‘t \ Q iatrogenesis. Additionally, medicalization results in professional medicine's support of roles and behaviors which may not be beneficial to patients' health (Illich, 1976). Biomedicine, through medicalization, also influences women's well-being beyond the experience of health, for in its support of structural inequality it helps to maintain the material conditions which influence many women’s physical and mental health problems (Verbrugge, 1989). Martin’s (1987) critique of biomedicine suggests that the biological and scientific basis of the medical model constrains medicine from looking to social causes of disease. Its emphasis on individual etiologies results in scientific rationalizations that make gender inequality seem natural, necessary and even desirable (Markens, 1996). Although biomedicine is a powerful institution of social control having the capacity to greatly impact women’s (and men's) health and well-being, and certainly society in general, it does not operate independent of its social context. Therefore, scientific medicine may itself be influenced and changed by social forces, such as political movements. Ruzek (1980) describes professional medicine's response to challenges to its hegemonic medical authority as following a particular pattern. According to Ruzek initial 88 challenges are resisted by the majority of physicians. Later, demands for change (those perceived as not jeopardizing physicians’ medical control, material interests or status) are accepted by some physicians. Conversely, many physicians aggressively contest those challenges to their authority which they perceive as compromising their medical dominance. If repressive efforts fail, attempts will be made to co-opt health care programs in order to regain control. Challenges to biomedicine’s medical hegemony from the women's health movement and feminist scholarship have resulted in numerous changes in organized medicine. These include a growing acceptance of modern midwifery, more women taking an active role in their own health care, the development of alternative health institutions and practices, and legislative, administrative and policy reform (Ruzek, 1980; Auerbach & Figert, 1995). Yet, only those changes which do not threaten the enduring dominance of professional medicine are permitted to continue, and are often co-opted by physicians to “relegitimate” their control and reduce demands for change (Ruzek, 1980;339). The relationship between women, their health and well— being, and medical control may be viewed as interactive, if not exactly reciprocal, in the sense that women do resist 89 medical control on numerous levels and in many different ways. Nevertheless, as yet, women have not organized to an extent which would seriously challenge biomedicine’s professional, cultural, social or political dominance. Despite recent structural changes, organized medicine has retained the social resources (e.g., social, economic and political power) necessary to persist in aggressively opposing such challenges. The primary focus in the medicalization of women's bodies and lives has been on women’s reproductive capacities. The medicalization of women's reproduction refers to the expropriation by health professionals of women's power to determine how women's reproductive organs and their functions and capacities should be defined and treated to achieve optimal health/well-being. Elements of women's reproduction, which organized medicine has defined and exerts control over, include gestation (Parrott & Daniels, 1996), childbirth (Nelson, 1996), contraception (Pies, 1997; Owen & Caudill, 1996) infertility, menopause (Foster, 1995), menstruation (Stoppard, 1992), PMS (Markens, 1996) and numerous other conditions of the reproductive organs. Disease is socially constructed and experienced. Medicine does respond to women's concerns and experiences, but it is medicine that determines what bodily states may be 90 b—J I” T! defined as legitimate medical concerns, and in so doing medicine structures reality in medical scientific terms. The influence of medicine is pervasive in that it extends far beyond direct interactions between medical professionals and patients. As stated above, medicalization is a sociocultural process which also occurs outside the direct influence of professional medicine. For example, physicians, as experts, endow legitimacy to intellectual projects through various modes of communication. Women's exposure to various publications exposes them to popular and professional21 articles or books authored by medical experts, or non-medical authors who exploit the authority of medical experts to support their views (Markens, 1996). Another example of the widespread influence of medical influence is the presentation of educational media to adolescent girls' in order to inform them about their own developing bodies. This media focuses on the biological rather than social aspects of development (Koff & Rierdon, 1995) and represents one of numerous points of contact with medical expertise and authority. According to feminist literature professional medicine has addressed some of women’s demands for scientific 2|For example, pediatric and gynecologic offices are frequented by women and usually have a large assortment of lay and professional reading materials. 91 assistance, but it has not responded to women’s demands by devising health care which would expand women’s autonomy. Rather, it has truncated women's power to determine the nature of their own health care, and has rationalized its medicalization of much of women’s lives as necessary to women’s health and well-being. Summary The medicalization of women’s reproductive organs and their functions have resulted in numerous medical treatments (e.g., hysterectomy) each of which constitute sets of practices that are implicated in the reproduction of dominant structural arrangements. Medical power relations are implicated in the construction of gender and women’s subordinate status through women’s experiences of various medical treatment processes. Feminist analyses of medical power relations involved in treatment processes begin by problematizing biomedical management of women's reproductive organs and functions, but differ in their conceptualizations of power. These analyses suggest how their varied perspectives may be useful in an analysis of the medical power relations involved in the hysterectomy process. 92 CHAPTER 3 METHODS Locating women who’d had hysterectomies and were willing to be interviewed about their hysterectomy experiences entailed devising, pursuing and abandoning a number of designs to establish initial contact with women who'd recently undergone hysterectomies. The original plan was to attempt to gain access to hysterectomy patients through various gynecologic practices or physicians. Telephone calls were made to attempt to make initial contact with physicians directly. Only one physician, who declined to allow access to his patients, was contacted in this manner. In all other instances telephone calls resulted in conversations with receptionists or office managers, who requested letters be sent to the physicians for whom they worked. Consequently, introductory/explanatory letters were mailed to gynecologists in an attempt to gain their permission to provide contact sheets to their patients soliciting volunteers to participate in this study. After a period of time, follow-up telephone calls were made to these physicians in an attempt to make contact and obtain some response. Those physicians I was able to contact declined to grant access to their patients. Most physicians never responded to the letter. 93 In hopes of locating a doctor who would grant access to her/his patients, I began to canvass friends and colleagues to determine if they had connections with physicians. Although this afforded me the opportunity to talk directly with a few physicians, it did not result in access to physicians’ patients. The reasons physicians gave for choosing not to cooperate included (a) a lack of available time, (b) no interest in the project, and (C) a concern for patient welfare. Another approach in my attempt to gain access to an ample number of women who’d had recent hysterectomies involved meetings with hospital administrators. Most administrators declined to meet with me. At the meetings I was able to schedule, I explained my research and requested permission to distribute contact sheets to women patients who would be discharged post-hysterectomy. Some of the administrators expressed their opinion that it would be highly unlikely that the physicians on their internal review boards (IRB) would look favorably upon my request due to the nature of the research. Others detailed complicated and lengthy review procedures and discouraged beginning the process since likelihood of gaining permission was deemed exceedingly small. Clearly, the doctors and hospital 94 administrators I spoke with were practicing medical “gatekeeping.” Yet another method to obtain participants for this study involved attempts to contact Parent-Teacher Organizations (PTOs) or Parent—Teacher Associations (PTAs). The plan was to present a brief presentation of my research and request voluntary participation. Although Emily Martin (1987) was very successful in using these methods to solicit participants for her study, the presidents of the local PTA and PTO chapters declined to give me permission to speak at their meetings. Another unsuccessful attempt to contact possible participants involved having a contact sheet distributed to parents who’s children attended a local daycare facility. This attempt was also unsuccessful as there was no response on the part of parents. Consequently, the participants for this study were contacted and asked to participate primarily through word of mouth. A few women who’d had hysterectomies and were willing to be interviewed were rejected because they had undergone hysterectomy due to gynecologic cancer. A local fitness center did allow a contact sheet to be posted, which included tags providing a telephone number to be called, and although numerous tags were detached, only one woman actually called and volunteered to participate in the study. A number of women who were interviewed for this study were 95 identified as having had a hysterectomy by members or employees of the fitness center. These women were asked to participate in the study and consented to be interviewed. In addition, women friends, family members and acquaintances volunteered to ask their friends, family members and co- workers to participate in this study. Conversation I had with any individual was used as an opportunity to locate women who'd had hysterectomies. This type of sample, the result of female networking, would be considered a convenience sample. This resulted in a sample comprised of all white women, which is problematic in that it limits the variety of standpoints available. Nevertheless, there is sample heterogeneity in terms of education, family income, and age. Due to the difficulty of locating women who’d had hysterectomies, virtually any women who'd had a hysterectomy for elective reasons was asked to participate in the study, as long as she indicated she clearly recalled the experience. This meant that the time span between a woman's hysterectomy and her participation in this study became incidental. The initial proposal indicated that study participants would be limited to women who’d had elective hysterectomies within three years of the interview. This was intended to increase the likelihood of distinct and 96 accurate recollections of the experience, yet, as it turned out, the women interviewed for this research had very little difficulty recalling their hysterectomy experiences, no matter what length of time had passed since their surgery. One possible reason for this is that the nature of the experience was a highly significant and meaningful process for all of the women participating this study. Fifteen of the interviews took place in the women’s homes, four of the women were interviewed in a private office made available to me by the manager of the fitness center, and one woman was interviewed in a private office at her place of employment. The length of the interviews ranged from forty minutes to two hours. All interviews were recorded through interviewer notes and the use of a tape recorder. The tapes were transcribed at a later date. The interviews followed a semi-structured format and included the use of a number of open-ended questions. An interview protocol sheet (Appendix A) was used to guide the course of each interview, but the women’s responses to the questions outlined by the protocol sheet were also used to identify the pertinent issues and generate other related questions. The participants were not reinterviewed due to time constraints, as well as the women's various degrees of reluctance to discuss highly personal or sensitive subject 97 matter. Although some of the participants were eager to discuss their experiences, a number of the women expressed some degree of preliminary or ongoing discomfort about discussing certain issues. At the beginning of each interview the participants were informed that they could choose to not address any question they felt uncomfortable answering. The subject and methods of the present study (face-to—face interviews), and the perspectives of some of the women regarding gynecologic matters, negatively influenced the gathering of a sample. It is also possible that the data gathered may have been influenced by the sensitive nature of the subject being explored. The present research uses feminist methods to understand the nature and impact of medical power relations involved in hysterectomy. The research problem is generated from the perspective of women's experiences and explores multiple axes where possible (i.e., age and SES), and locates the researcher in the same plane as the research subject (Harding, 1987). The study incorporates aspects of standpoint theory in order to provide an understanding of medical power relations from the standpoint of women who've experienced the hysterectomy process. According to Smith (1987) standpoint methods require using women's standpoint to construct a perspective that reflects the actual lived 98 ("I (I) reality of women’s lives. This is accomplished in stages, with the first stage consisting of asking open-ended questions about a particular social relation or experience to establish the issues of consequence from the women's perspective. This distinctive perspective is then used to build an inquiry based on women's accounts of their experiences (Smith, 1987). The present research attempts to give priority to women's standpoint in constructing a perspective on the medical power relations involved in the hysterectomy process. Although the commencement of this research may be understood to have begun with the formal research proposal, in actuality, the intellectual and political basis which influenced the formulation of research issues and questions began years earlier. After my own experience of the hysterectomy process at age twenty-one, I wanted to determine if other women had similar experiences. At every opportunity I sought information from the women I met who had undergone hysterectomies. This lead to numerous, in- depth conversations with women who’d had hysterectomies. Although I was not conscious of it at that time, during the course of the present research I realized that these conversations contributed to the construction of a standpoint perspective in much the same way that Smith 99 (1987) recommends. Those early conversations eventually coalesced into an informal standpoint of women's perspectives on hysterectomy which informed and influenced the methods used to carry out this study. Although the formal requirements of conducting dissertation research within academe require specific articulation of the problem under question, and thereby limits the ways in which standpoint methods may be employed, the present research has endeavored to apply standpoint methodology through various means. The questions asked during the interview were formulated based on informal conversations with women who’d had hysterectomy, on the empirical and theoretical literature, and on issues the study participants raised during the course of interviews. During the interviews, the study participants were asked numerous open-ended questions. For example, the women were asked to describe how they felt about their periods, what they remembered about their menarche, how they felt about going to gynecologists, and to describe their hysterectomy. The women focused on particular aspects of the hysterectomy process which were personally salient. The analysis proceeds in light of the women's standpoint in relation to these issues. 100 Similar to Smith’s (1987) efforts to devise research in terms of women's perspectives, that is to proceed from the standpoint of women, the inquiry for the present study proceeded from the women’s accounts of their experiences of hysterectomy. Early on in the interviewing, I recognized that my prior assumptions about the nature of medical power relations (specifically that women were victims of an overwhelmingly powerful medical system) were not supported by the women’s accounts of their experiences. Consequently, the analysis of the data reflect this conceptual shift which was brought about through privileging the women’s actual lived realities. However, this process was not as simple as it may appear. Although I too had experienced the hysterectomy process, my personal standpoint may be understood to be biased by my own position in the relations of ruling. As a doctoral candidate my perspective reflects a dominant discourse to which the participants of this study had little or no access. Therefore, in order to limit the influence of my bias (as sociologist and feminist) on interpretations of the women’s accounts, I had to discount firmly held personal beliefs about the nature of power and the types of actions which constitute empowerment. In order to allow the women's standpoint to guide the data collection (the questions 101 asked) and the analysis, I began to look for attitudes and actions which the women themselves considered beneficial or empowering. For example, I had assumed that women who recognized the power relations involved in hysterectomy would seek alternative forms of health care. However, the women’s accounts proved this not to be the case, rather, many of the women spoke of searching for better doctors when they were dissatisfied with their physicians. Consequently, I started to ask the women about the characteristics they preferred in their physicians, and began to see how the women's standpoint revealed how medical power relations are constructed through both physicians and patients. This represents a “conceptual shift” (Smith, 1987) which enabled the research analysis to reflect women’s perspectives. Smith (1987) states, The movement of research is from a woman’s account of her everyday experience to exploring from that perspective the generalizing and generalized relations in which each individual's everyday world is embedded (p. 185). An attempt was made to structure the interviews using event sequencing. The interviews most usually began with a general explanation of the nature of the research. The women were asked to first describe their early attitudes towards and experiences of (a) menstruation, (b) their reproductive functions, and (c) their relationships with 102 physicians. Later questions asked about these experiences and relationships in the time period directly preceding their hysterectomies. The women were also questioned about the health problems that motivated them to seek the medical care that resulted in hysterectomy, as well as the benefits and costs of having had a hysterectomy. The interview questions elicited information about the women’s (a) socioeconomic status, age, race, marital status and number of children, (b) general attitudes towards and experiences of biomedicine, (c) experiences during the medical consultation and diagnosis that resulted in hysterectomy, (d) problematic experiences with gynecologic examinations, and (e) knowledge of hysterectomy prior to medical interactions that resulted in hysterectomy. Other questions asked the women how they felt about their surgeon's expertise to diagnose their need for, and to perform a hysterectomy, and whether or not their physician had provided a sufficient amount of information regarding the nature of the surgery, and the short- and long-term benefits and costs of hysterectomy. The transcribed interviews were coded by assigning alpha—numeric tags identifying the primary and related concepts under question. The coded data was categorized into a number of data grids in order to facilitate (a) the 103 identification of relevant phenomena, (a) the collection of examples of those phenomena, and (c) analysis of those phenomena to ascertain commonalities, differences, patterns and structures (Seidel & Kelle, 1995;55—56). The data were analyzed by identifying patterns in the women's experiences and attitudes. The primary issues were determined by identifying the extent to which most or all of the women addressed an issue, engaged in particular activities, or expressed attitudes toward a particular phenomenon. For example, gynecologic experiences prior to those which resulted in hysterectomy were identified as relevant to women’s understanding of their own bodies and bodily functions (i.e., menstruation) because nearly all of the women reported having had pronounced responses to those experiences. Similarly, the women’s adolescent experiences also emerged as an important precursor to their adult interactions and relationships with physicians. Once the primary issues were identified, differences in the women’s attitudes toward, perceptions of, and responses to various experiences were explored. As is typical of complex data (in fact, of humans in general) the women expressed some ambivalence with regard to the various issues in question. Rather than attempt to homogenize or simplify their responses to produce an unambiguous analysis, the 104 complex character of their perspectives was retained in order to develop an accurate and nuanced understanding of the nature of medical power relations. The expression of ambivalent attitudes by the women is considered an aspect of the social relations under question. As Smith (1987) states, The simple notion of the everyday world as problematic is that social relations external to it are present in its organization. How then are their traces to be found in the ways that people speak of their everyday lives in the course of interviews of this kind. We do not expect them to speak of social organization and social relations. The methodological assumptions of this [standpoint] approach we are using are that the social organization and relations of the ongoing concerting of our daily activities are continually expressed in the ordinary ways in which we speak of them....How people speak of the forms of life in which they are implicated is determined by those forms of life...the same social organization is present as an ordering procedure in how people tell others about the original setting (p. 188). The analysis begins in chapter four with an examination of the women’s adolescent exposure to medical ideology and health care. This portion of the analysis illustrates the context in which women come to understand their bodies and selves in relation to medical ideology and health care. The analysis proceeds in chapter five by examining how the women's adult gynecologic health care experiences construct gender and influence the women’s views of their bodies and selves. Chapter six examines the character of medical power 105 relations associated with the women's gynecologic experiences and the hysterectomy process. The women’s experiences are assessed in terms of the degree to which they may be typified as predominantly traditional or relational forms of power relations. The final portion of the analysis, chapter seven, examines the influence of medical power relations (the character of these relations having been specified in the previous chapter) on women's decisions to have hysterectomies. Sample Description The sample consists of twenty women, each of whom had a hysterectomy at some point in time prior to being interviewed. The expanse of time between the women’s hysterectomies and their participation in this study ranged from five months to twenty-five years. Seven women had hysterectomies within the last three years, five women had hysterectomies between four and ten years ago, and eight women had hysterectomies over eleven years previous to their participation in this study. The women range in age from thirty to sixty-seven years of age, but most of the women (13) are under fifty years of age.- The majority of the women are married (16), two are single, having never married, one is divorced and one is widowed. All but three of the women have at least one 106 biological child. Their approximate yearly household income is between less than $10,000 to $250,000. Eleven of the women are employed full-time, and four of the women are employed part-time, in white- or pink-collar occupations. Two of the women are homemakers, two are retired, and one is a free-lance writer. The women's education ranges from some high school to advanced degrees. Two of the women completed some high school, five are high school graduates, six have some college, an associates degree, or trade school certification. Two women have some graduate school, four have M.A.s, and one woman has a Ph.D. A table describing the sample is provided in Appendix B. 107 CHAPTER 4 EARLY EXPOSURE TO AND ACCEPTANCE OF MEDICAL AUTHORITY AND MANAGEMENT This chapter examines the study participants' adolescent exposure, through a variety of means, to biomedical ideology and health care in order to establish the context leading to the women's experiences of the hysterectomy process. The women's participation in the medical power relations associated with hysterectomy is predicated on their lifelong exposure to general social acceptance of (a) biomedicine’s efficacy in reproductive health care, and (b) its legitimate authority to define normal and abnormal bodily states and appropriate gender behavior and roles. For the women interviewed for this study, exposure to biomedicine's expertise and authority, and their participation in medical power relations, commenced prior to the consultations with their doctors that resulted in hysterectomy. Throughout adolescence and adulthood the women were exposed to medical ideology and influence through diverse modes of contact. As adolescents, the women encountered medical authority in various forms of educational media and agents conveying information on female development and counsel on appropriate gender behavior. Five of the women experienced menstrual problems early in life, three at 108 menarche, pro into a prolon their problem with medical medical managq examination a: various encour medical author the women acce EXPOsure to me C‘3’“'-pliarlc:e, am 0f rESistance. All Of the upon traditiOna their reproduCt; I 1 a‘ternative heal r , y ‘ erredy their pro, 6",th S I Such as menarche, prompting them to begin what eventually turned into a prolonged search for a medical means to alleviate their problems. As adults, the women routinely interacted with medical professionals as they submitted themselves to medical management (e.g., annual or periodic pelvic examination and Pap test,22 pregnancy care, etc.). These various encounters greatly increased their exposure to medical authority and management, but the extent to which the women accepted medical management was somewhat variable. Exposure to medical power did not necessarily produce compliance, and, in some cases it actually engendered acts of resistance. All of the women relied and continue to rely solely upon traditional Western medicine for the health care of their reproductive organs and/or internal and external genitalia. They did not seek out or consider any type of alternative health care providers or medicines to attempt to remedy their problems, or to deal with normal reproductive events, such as pregnancy. This is not surprising given the pervasive influence of Western medicine in society and the conservative tendencies of populations in the Midwestern ZWA Pap test is a diagnostic procedure in which a sample of cells from and near the cervix are collected and tested to determine the presence of infection, abnormal cells, or cancer (National Cancer Institute, Cancerweb, 2000). 109 communities i Furthermore. women in the care and rely population fr: may be less 1: The womer lonQ-term relj and manage orc‘ tO their reprc visit to a 91m thsician fOr 1 number of the ‘ which their pe; menstrual Prob] biomediCine . SOClet Ypi. communities in which this research was conducted. Furthermore, the nature of this study precluded including women in the study sample who totally eschew medical health care and rely on alternative health care. Consequently, the population from which the sample for this study was drawn may be less likely to engage in alternative health care. The women in this study described varying degrees of long-term reliance on Western medicine to inform them about and manage ordinary and problematic bodily states related to their reproductive organs.23 Even before their initial visit to a gynecologist, or to a family or general practice physician for menstrual problems or routine examinations, a number of the women had experiences during adolescence in which their personal management of menstruation and menstrual problems24 was influenced and informed by biomedicine. 23This is typical of most individuals in Western societies, as the majority of the U.S. population rely on medical doctors when they are ill or injured, and for preventive medical measures to maintain health (Cockerham, 1995). 2‘Although not all health problems of the reproductive organs are made apparent through changes in women's menstrual patterns, many are (Scambler & Scambler, 1993) this is typically the case for women who’ve been diagnosed as having endometriosis (Shohat, 1998). 110 Adol escence an Gender Exposure acceptance of l woman’s life. consumers of me they are contrc caretakers. Ag medical health commonly the mo Utility of medi of health. Nev many Years of c Adolescence and Medicalization: The Medical Construction of Gender Exposure to medical expertise and authority, and acceptance of medical management, may begin very early in a woman’s life. Children, as a group, are prodigious consumers of medical care (van der Geest, 1996) however much they are controlled and directed by parents and adult caretakers. As a child or adolescent, a girl's exPosure to medical health care may be determined by her parent's (most commonly the mother’s) attitudes towards doctors and the utility of medical care in general, as well as her own state of health. Nevertheless, from the moment of birth, through many years of childhood illnesses, injuries, and mandated school immunizations, the majority of children in the United States do indeed have some degree of exposure to medical care and the associated power relations. Medical expertise and authority, or the “clinical gaze,” (Foucault, 1975) is widely accepted in Western societies (Mechanic, 1994) but attitudes towards, and acceptance of biomedicine's role in everyday life may be especially reinforced for girls during adolescence. At some point during adolescence girls experience menarche, their first menstruation. Menarche has been identified as an important developmental period for girls, with most women being able to vividly recall their first menstruation (Golub 111 & Catalano, 1 period has be of incompeten: which girls 11 1994). The s< requires a 9i] in terms of a; 1990) . The menst restrictioHS E of a Woman's n awareness, par influences the about mens1:rUa refers to thes & Catalano, 1983). For adolescent girls this developmental period has been associated with a loss of efficacy, feelings of incompetency, and the cultivation of a “false self”” which girls learn as a response to patriarchy (Pipher, 1994). The social experience of adolescence/menarche requires a girl to learn how to monitor and control her body in terms of appearance (Houppert, 1999) and behavior (Laws, 1990). The menstruating female is subject to a host of social restrictions placed on her behavior. For example, the fact of a woman’s menstruation must be concealed from public awareness, particularly male awareness, and this stricture influences the ways in which individual's may communicate about menstruation (Laws, 1990; Golub, 1992). Laws (1990) refers to these socially imposed restrictions as “menstrual etiquette" which refers to a “set of social practices which express and reinforce the distinction between people of different social statuses, without implying anything about supernatural belief” (as would be the case in using the term “taboo”) (p. 16). Brown and Gilligan (1992) summarize the experience of adolescence and/or menarche for girls in Western societies. 25The cultivation of a false self involves denial of parts of the self along with adoption of culturally prescribed feminine attributes and behaviors (Pipher, 1994). 112 Seeing 1 hearing that the can be 1 struggle experier know ant At menar it is “an eve mmbolizing t &Sasser-Coen adolescence 1: its state of the eXpectati. PerfeCtiOn tlr &Sasser-c0en transitiOn to bring their “5 fr . agmentat10n‘ adol . CSCent 911 in . patrlarcha] SOCieties I Seeing themselves seen through the gaze of others, hearing themselves talked about in ways that imply that they can be perfect, and that relationships can be free of conflict and bad feeling, they struggle between knowing what they know through experience and knowing what others want them to know and to feel and to think (p. 164). At menarche, a different status is conferred on girls, it is “an event that centers attention on the body, symbolizing the transition from childhood to womanhood” (Lee & Sasser-Coen, 1996;109). At one and the same time, female adolescence brings attention to a girl’s body, as well as its state of functioning (normal or abnormal), along with the expectation that to be a woman means striving for perfection through manipulation of one's body and self (Lee & Sasser-Coen, 1996). Above all else, for girls the transition to womanhood entails a social process intended to bring their “self” under control. This is a process of fragmentation, a separation of body and self, which adolescent girls must navigate in order to achieve womanhood in patriarchal society (Pipher, 1994). In Western societies, the experience of adolescence and menarche may generate girls’ earliest exposure to, and acceptance of the belief that female bodies are inherently morbid, and require, and benefit from medical management. 113 Menstrua ti o Menstrual E In the related ver} Although a f first menstr of menarche 1 related that been informed exPerience wi remembered he; 1 think 3 it: but p kind of E women had no p findings in otl Menstruation as Pathology: Biomedical Reinforcement of Menstrual Etiquette In the present study all but one of the participants related very distinct memories of their first menstruation. Although a few of the women had mixed feelings about their first menstruation, the majority of the women’s experiences of menarche were highly negative. A few of the women related that they felt embarrassed or afraid, despite having been informed to some degree about what they could expect to experience with menstruation. When Cheryl was asked why she remembered her menarche, she responded, I think it’s because, you know, you're told about it, but when it comes it’s kind of scary. It was kind of scary. Although most of the women in the present study reported varying degrees of preparation for menarche, a few women had no preparation whatsoever. Similar to the findings in other research (e.g., Lee & Sasser-Coen, 1996) for these women, menarche was a terrifying experience because they thought they were wounded or dying. It happened when I was 14 years old. I do remember because I didn’t know what it was. My mother never told me that was going to happen to me [....] I was just babysitting down the street for this lady [....] the next morning when I got up and I went to the bathroom, I was bleeding. And I thought I was dying. Went home and my mom was, “oh, don't be ridiculous! Go over to the store and get you some napkins.” I thought, my mother wants napkins and I’m dying! I’m dying! I couldn't believe she told me that. I said, “but 114 mother.” Pitchforc napkins. “my mothe out for r Pitchforc crying, a want map? your peri says, “0) this stre children corner Cc stores, 5 here you' a b81t, 5 do. And was okay Wen asked Whe Alice replied, Seven p.n mother.” She said just go over there to Pitchfords, little market over there, get some napkins. And all the way over there I’m crying, “my mother hates me, I’m dying and she sends me out for napkins.” And when I got over there Mrs. Pitchford was very sweet. She could see I'd been crying, and all this, and she says, “you don't want napkins for the table, you want napkins for your period, right?" I said, “my what?” She says, “oh, no, another one of those." So she, this strange lady, that was always so good to the children on our street, had one of these little corner confectionary, you know, everything type stores, she says, “well hon, you take this home, here you’ll need this belt. She gave me, sold me a belt, she said take this home, this is what you do. And this lady told me what to do, and that it was okay and I wasn't dying (Carol). When asked whether she could remember her first period, Alice replied, Seven p.m., Sunday, August 12, 1962! [....] It was the worst day of my life. I had had no preparation for any of this; my mother had never spoken to me about any of this. [....] I had just turned eleven and I had no idea what was going on, I thought it was something terrible. Like many little girls who have been told nothing, all of a sudden you’re seeing blood and saying "My God, what did I do to myself?" And even then my mother was not helpful, she mostly tried to avoid answering any questions and I remember asking her if, for example, our dog who was also female went through this, and she said she just didn't know. And she made it a point to stress that she didn't know much about it and what she did know about it she was not going to tell me about. And that, I think, really started me off on the wrong foot because I couldn't tell if what was happening to me was normal, or extreme or whatever. Because of that I couldn't tell whether I should be asking to be taken to a doctor or not. She describes the experience as being disconcerting and confusing because she initially assumed she was wounded or 115 injured. Whé assumption, E quantity of ‘t Even more rev girls may acc their menstru she understan; wound. Alice what constitut scientific ex; her meflstIUati biomedical Sci determine whet normal or abno determined to ] interVerltion. reliance On bic irr . egularities injured. What is implied by Alice’s statement is her assumption, even as a child, that an injury producing a quantity of blood must certainly require medical attention. Even more revealing about the degree to which adolescent girls may accept medical influence and medical management of their menstruation/reproductive organs is her response once she understands her menarchal blood is not the result of a wound. Alice remedied her lack of information regarding what constitutes normal menstruation by seeking out scientific explanations in order to determine whether or not her menstruation was normal. What she learned was that biomedical science, through physicians, had the expertise to determine whether a female's menstrual experiences are normal or abnormal, and that menstruation medically determined to be “extreme” or abnormal necessitates medical intervention. Alice’s assumption demonstrates an acceptance and reliance on biomedicine to not only treat menstrual irregularities, but to define what types of menstrual experiences constitute normal and abnormal menstruation. Alice had no knowledge of menstruation prior to her own menarche, had not engaged in conversations about menstruation with her friends, and had not observed that her mother was a menstruator. Alice was on the receiving end of 116 flawlessly e] fronts. Con: was SUCCESSfl finally manii turn to an e: Lack of negative expe menstrual etj Etiquette whj polluting (La (Martin, 1987 influenced by and women's b generating Sc biology as de‘ English, 1981 flawlessly enacted menstrual etiquette, on a variety of fronts. Consequently, because the existence of menstruation was successfully concealed from her until menstruation was finally manifested by her own body, Alice felt compelled to turn to an expert on the subject, biomedical science. Lack of menstrual information and the resulting negative experience of menarche is a consequence of menstrual etiquette and the social meanings behind the etiquette which construct menstrual blood as unclean and polluting (Laws, 1990), and menstruation as pathological (Martin, 1987). Medical science has historically been influenced by negative social constructions of menstruation and women’s biology in general (Hubbard, 1990) and through generating scientific explanations has rationalized women's biology as deviant, pathological and morbid (Ehrenreich & English, 1981; Martin, 1987). In so doing, biomedicine constructs, maintains and promotes menstrual etiquette. Gynecologists treat menstrual problems and along with helping some girls/women to find relief from pain and suffering, they encourage and enable women to conceal menstrual flow. Menstrual etiquette requires a woman to maintain a certain level of secrecy about her menstruation, and, although some women do share a limited amount of information with each other (Hubbard, 1990), menstrual 117 etiquette cor determine if range of norm Althougl strictures it not feel adec reproduction and at some 1 and care for allow her to mother that E adOleSCEnt. Like TOD healthy fOrm C reinforced her etiquette compels women to turn to medical experts to determine if their menstrual experiences are within the range of normal. Although a mother may simply be following the strictures imposed by menstrual etiquette, some mothers may not feel adequately prepared to teach their daughters about reproduction and menstruation. Most mothers, to some degree and at some point, rely on medical experts to help them rear and care for their children.26 Toni’s mother would not allow her to use tampons because her doctor advised her mother that pads were “safer" than tampons for an adolescent. Like Toni, a number of the women reported that they were not allowed to use tampons as adolescents. In Toni’s case, her mother's use of medical authority, to establish a healthy form of “sanitary protection” for her daughter, reinforced her own parental authority. This example may be interpreted as demonstrating the mother's acceptance of medical expertise and authority, as well as her appropriation of medical authority (which may be independent of beliefs about medical expertise) to effect a particular 29A cursory examination of any bookstore's shelves of self—help books on parenting suggests the degree to which parents may be influenced by medical experts, such as Dr. Spock and Dr. T. Berry Brazelton. 118 behavior in ] nature of mec nature of po'. particular. The use not a medical cause, or inf cannot be cor. That an indiv authority for this Case med it may be tra; Toni's mOther mediCal pOh’Er‘ legitimacy of indeperldent Of exercised it behavior in her daughter. This example of the appropriable nature of medical authority illustrates both the extent and nature of power in general, and medical power relations in particular. The use of medical authority by an individual who is not a medical professional to support or advance their cause, or influence another’s behavior, suggests that power cannot be construed as being possessed by an individual. That an individual, without license, may use medical authority for their own purposes suggests that power, in this case medical power, is fluid and transferable, although it may be transformed in the process of appropriation. Toni’s mother did not become a medical expert in her use of medical power, but in her act of appropriation, the legitimacy of medical knowledge and authority was retained independent of the medical professional who initially exercised it. The legitimacy was retained but the character of medical power was transformed in her use of it to control her daughter's behavior. Medical authority and parental authority became commingled, such that, for Toni, each enhanced the other. This example also demonstrates that medical power relations may entail negotiation. Toni's mother, although highly influenced by medical authority, could have chosen to not ask her doctor about appropriate 119 tools or she as “truth.” Cindy t heavy menstr and social p her mother 11 I was a had to 1 the kids spells s the doc: have to Cindy's phySiCianS ac oppressive ge: and abIlOrmal I menStI‘uatOrs V or behavioral) must alSO prac recommendat i On DWHiC/priVate Construction of tools or she could have chosen to not advance the knowledge as “truth.” Cindy began to menstruate at age nine and had very heavy menstrual bleeding which caused tremendous physical and social problems for her. Her mother’s doctor advised her mother how to deal with Cindy's problem. I was a very, very, very heavy bleeder. I always had to take one week a month out of school, and the kids always knew why. I even had fainting spells sometimes, that’s how heavy I'd bleed, and the doctor just told my mom she was just going to have to keep me at home. Cindy’s experience underscores the degree to which physicians actively maintain menstrual etiquette and condone oppressive gender norms through their power to define normal and abnormal bodily states. Yet, it is not just abnormal menstruators who must conceal all outward evidence (physical or behavioral) of their menstruation, normal menstruators must also practice menstrual concealment. The physician’s recommendation to keep her at home reinforces the public/private dichotomy, and articulates the medical construction of menstruation as pathological and deviant. His recommendation also validated her perception that menstruation is a shameful bodily state which she took extreme measures to conceal. I would wear very loose clothes cause I was always on the heavy side, so no one really knew [that she was menstruating]. When you’d wear tight pants 120 people knew [....] some girls you could tell, you could see their pads. You know, they had the little strings [belts] we used to have to use, not the kind that stick. So, I always wore loose clothes [....] It was very private for me. Adolescent girls’ exposure to and acceptance of medical authority is often mediated by their mothers. When parental authority is rationalized through appropriation of medical authority, it is because the authority of medicine frequently transcends that of other types of authority, including parental. Although the relationship between medical authority and other forms of authority is by no means straightforward or without contention (Mechanic, 1994), the use of medical authority is common because medical scientific knowledge produces accepted “truths” (Foucault, 1973). Appeals to medical authority as the arbiter of appropriate menstrual behavior and appliances sends a consequential message to adolescent girls. As a female whose body is in the midst of developing and whose knowledge of its development is primarily experiential, the message that it is medical professionals who have the authority to determine what is appropriate for one's body calls into question and devalues her own experiential knowledge of her body and bodily states. It is this process of devaluation, which adolescent girls experience on a number of fronts, in 121 which biomedicine constructs femaleness, femininity and the female body as pathological and in need of medical management. This is a process of alienation from the self, resulting in feelings of fragmentation and lack of control (Pipher, 1994; Martin, 1987). The public/private dichotomy is at issue in girls’ experiences of menarche. Whether the women started to menstruate in public or private influenced their feelings about their first menstrual experience. Several of the women started while they were in school and describe the experience as being embarrassing, frightening, or shameful. I was in school when it happened and I had to walk about six blocks home [....] I was embarrassed because I had to get up and leave. I could feel something was wrong (Mary). I happened to be in the eighth grade and it was toward the end of my school year, we had a picnic going on an I had white shorts on and I had boys that treated me like the piece of crap because I had started my period. And I was like the laughing stock U.S.A. (Terri). I was scared and unhappy because I started in school. When I got up out of the chair it was on my chair, so of course everybody made fun of me so, I went to the nurse's station (Denise). Public menarche/menstruation can be an alienating and demoralizing experience when a girl is ridiculed for being unable to accomplish appropriate gender behavior, that is, menstrual concealment. Such negative social sanctioning serves to reinforce the strictures of menstrual etiquette 122 and compels girls to monitor and objectify their own bodies as something alien or difficult to control. Terri described how public ridicule of her inability to achieve menstrual concealment made her feel. Well, it was all tied into my self-worth, that's how I perceived it...it was totally degrading, it was if I were some alien experiencing this all by myself. I felt alone and isolated. Denise’s reliance on the school nurse to help her to conceal the fact of her menstruation demonstrates yet another point of contact with medical expertise and authority for adolescent girls. It suggests that the purpose of medical professionals in the education system is partly to facilitate socially approved gender behavior, in this particular case, menstrual concealment. Medical Construction of Gender Through the Education System Adolescent girl’s exposure to medical expertise and authority is also found in the efforts of the educational system to inform girl’s about female reproductive development from a scientific perspective. Ann saw a film on female development in the sixth grade, it was shown in a sex-segregated classroom27 by the school nurse. Agnes viewed a film on female development and reproduction in 27Although educational films on female development have traditionally been shown to female audiences, this practice may be less common today. 123 eighth grade, which was also shown by the school nurse. She commented on the highly scientific nature of the developmental film. The films didn't show the outer physical parts of the body, just the organs themselves, and how they showed the uterus and the ovaries and that's all you saw. Developmental films are typically informed by and present adolescent development from a biomedical scientific paradigm (Martin, 1997). Therefore, they represent yet another point of contact with medical authority for adolescent girls. In assisting adolescent girls to understand their bodies (from a strictly scientific perspective) through educational media, biomedicine, however unintentional, reinforces conventional menstrual etiquette. In so doing, the force of medical authority maintains denigrating constructions of women and their biology as anomalous, pathological and polluting, and in need of being controlled through medical management. Educational films prior to the 19905 depict menstruation as failure (failed conception) and menstrual blood as waste. Female characters are passive while the functions of the reproductive organs are dynamic and autonomic (Martin, 1997). Developmental films informed by medical science promote fragmentation as the female internal organs are presented as having a manifest destiny, 124 a biological imperative to reproduce, independent from social relationships, gender ideology and individual desires. Seven of the women in this study felt they had begun menstruating earlier or later than the normal or common age at which most girls experience menarche. What is interesting is the variety of ages at menarche that the women determined to be atypical. It appears that almost any age at which a girl begins to menstruate may be regarded as anomalous. Cheryl believes she started early at age eleven as most of her friends had not experienced menarche at that point, while Toni considered herself to be “late blooming” since she started at age twelve. She felt she was late because among her friends she was the last to start. Cindy was only nine years old at menarche and felt out of place because she was the first girl in her peer group, by a number of years, to start. Becky started at age sixteen and felt out of place because she believed she was the last girl in her peer group to start. She felt her peers were judging her and worried they might think something was “wrong” with her. Michelle was eleven. Feeling that she'd started much earlier than her friends she did not talk to her friends about menstruation in order to conceal the fact that she was a menstruator . 125 Debra was ten years old and felt that was far too young of an age for a girl to take up the responsibility that menstruating and the start of womanhood entailed. She stated, ...I was only ten years old and for a very active and athletic girl that was far too young to be bothered [....] I'm not sure about my status as number one [among her peers] because it wasn’t something I told everyone about [....] I feel and felt that after high school would have been a better time to deal with “womanhood,” not at ten years old. I feel that responsibility was thrust upon me way too early. When Jill experienced menarche at age seventeen, her mother expressed relief that she’d finally started. Jill expressed her dismay at having been made to feel that she was somehow deficient or abnormal because she had not started menstruating earlier. I wasn’t upset [about experiencing menarche at age 17] I got upset at what was said to me. It was the tone of voice. Well, my mom said “Oh, well, it's about time." Then that put the damper on it and it had the connotation that it was real negative. I'll never forget that. Adolescent girls are not expected to consult medical professionals at menarche, unless their first period is early, late or problematic (Lorber, 1997) but interpretations of the normalcy of a girl's menarche and menstruation may be medicalized because determinations of normal bodily states are the domain of Western medicine (Bransen, 1992; Scambler & Scambler, 1993). 126 Additionally, female development is highly variable, but medical science’s attempt to rationalize female bodily functions has resulted in a standard age range at which menarche is most likely to occur (Lee & Sasser-Coen, 1996). In defining a standard age range for menarche, and reporting this range in various educational media, medical science may influence the ways in which girls view themselves (normal or abnormal) and other girls with regard to menarche. Although recent studies suggest that adolescents do not retain much of the biomedical scientific information or terminology on sexual development learned in school (Ammerman, Perelli, Adler, Irwin, 1992; Hockenberry-Eaton, Richman, Dilorio, Rivero & Mailbach, 1996), this does not negate the possibility that adolescents retain the gender images and attitudes of such educational efforts. In the present study the women’s recollections of their adolescent perceptions of what age constitutes early or late menarche were based on local and experiential knowledge, primarily comparisons with their friends’ experiences, rather than on medical statistics. The difficulty adolescents have retaining scientific information on sexual development may leave this area of bodily knowledge open to individual interpretation. 127 The presentation of highly technical or abstract information may serve to reinforce belief in the validity of expert knowledge because of its perceived inaccessibility to the average person. This suggests that dominant discourses like biomedicine may exert influence and engender acceptance of its authority through the inability of individuals or groups to comprehend or retain highly technical or abstract information. Acceptance of disciplinary knowledge as “truths” especially if these truths are indecipherable to the lay populace, produces reliance on knowledge regimes (McHoul & Grace, 1993). Adolescent girls receive information about menstruation from a variety of sources, much of it from the media and their peers, but from their mothers as well (Stoltzman, 1986). All of the various sources may influence a girl’s/woman’s attitude towards menstruation (Golub & Donnolo, 1980). Women who were adolescents in the 19603, and 1970s are more likely than older women to have received information on menstruation and reproduction from sex education/female development classes, and/or films shown at school (Lee & Sasser-Coen, 1996). 128 Medical Cbnstruction of Gender Through Developmental Media Although some of the women in this study did view educational films or had classes28 on the subject, and some talked about menstruation with their girlfriends, five of the women reported that their mothers provided various types (e.g., verbal and/or published) and amounts of information on reproduction and/or menstruation. [...] friends talked about it, and there were booklets put on the bed, stuff like that (Jill). Mom talked to me and, you know, girl talk (Mary). Oh, my mom sat down and explained everything to me and my sisters, and we knew what was going to happen (Toni). We had the taboo. My mom gave us these life-cycle books. There was a six book series and she made us read each one (Becky). Michelle’s mother also supplied her with a series of books written by a physician to inform girls about the physiological processes they could expect to go through. I think the book that I read was Dr. “Somebody” talks to the eight-year-old, then the ten-year- old, and then the twelve-year—old. It was really good. 28It is revealing that the educational classes and/or films on the subject of reproduction attended by the women in this study were all sex-segregated, with one exception. Such sex segregation conveys one possible message to these women, which is that reproduction is only important to, or is the sole responsibility of girls/women. 129 With the ascendency of professional medicine in the 19”‘century, the literature on proper menstrual etiquette was primarily authored or informed by medical professionals (Golub, 1992). Although much of the more modern literature and media designed to introduce adolescent girls to female development and menstruation is now produced by the sanitary protection industry, its legitimacy rests on the information presented as being informed by medical science (Houppert, 1996). These types of media are written and produced for adolescent female audiences, and constitute another point of contact in which medical expertise, authority, and management of female reproductive organs and their functions are conveyed as normative. The information provided by their mothers on menstruation focused on proper menstrual etiquette. For example, how to hygienically attend to menstrual flow, how to deal with menstrual cramps, which types of activities could be safely engaged in during menstruation, and how to achieve and maintain successful concealment of their menstrual flow. Some of the women’s mothers also initiated their first gynecologic consultations. The mothers’ understandings of proper menstrual etiquette included strictures on which types of hygienic devices their daughters were permitted or required to use. Cheryl’s 130 mother insisted she use a “sanitary belt,” Denise’s mother, like Toni's, would not allow her to use tampons. Although it is not known to what extent the women’s mothers’ attitudes and beliefs about menstruation and reproduction are influenced by medical ideology, the influence of medical expertise and authority on women’s attitudes (including mothers) towards menstruation and reproduction is evident in the literature (Martin, 1987; Oinas, 1998). Initial Gynecologic Encounters At some point, virtually all children are taken by their parents, usually their mothers, to physicians or pediatricians for vaccinations and childhood illnesses, but only adolescent girls and young women are taken, or go of their own accord to physicians for routine examinations of their reproductive organs, as well as reproductive organ problems. Ten of the women experienced their initial gynecologic consultation as teenagers. Cindy was taken to a physician by her mother because her mother wanted her to be on birth control pills. I was in high school, I was having trouble with bleeding so bad. Mom sat me down and talked to me about it. I was thirteen or fourteen, I guess. She figured I was dating and she sat me down, “things happen, I don’t want you to have to ruin your life because they do. So we’ll take you up there and see about having you put on the pill.” Went up there and of course he gave her the 131 lecture that she should have had me put on the pill long before to regulate my bleeding. Because I bled so much [....] he just did a pelvic thing, like a pap smear type thing, to kind of ease her mind. I said, “tell my mother whether I’m a virgin or not.” I’ll never forget that. I was very open, and he goes, “well, you’ve had an accident but, yes, you are still a virgin.” I had an accident on a bike when I was 7 or 8 years old. This incident demonstrates the extent and character of medical authority in a number of ways. First, in this instance it was the daughter, rather than the mother, who made an appeal to medical authority, in order to confirm her status as a virgin to her mother. This demonstrates that at least some adolescent girls are well aware of not only the magnitude of medical authority (that it can, at times, supersede parental authority) but that medical professionals have the power to interpret and define bodily states and gender statuses. Second, the mother is submitting her daughter to medical management to avoid an unwanted pregnancy, as well as a stigmatized status (teenage mother). Third, in lecturing the mother on Cindy’s need for birth control pills in order to “regulate” her menstrual periods, the doctor is both redefining the condition for which Cindy requires (and for which he will give her written authorization in the form of a “prescription") birth control 132 pills, and asserting medical authority over parental authority. Janice’s initial gynecologic experience demonstrates another instance in which medical authority superseded parental authority. Actually the first time I guess I was about 16 or 15 something like that and I was having, I was anemic. I didn’t know it, I was just really tired all of the time and I went to the doctor and you know, all this kind of stuff [...] and he said “You’re just losing blood too much each month.” He told my mom that, and my mom was standing there, and I’ll never forget, he goes “We’re just going to have to put her on birth control.” Oh, my mother just freaked, “birth control! Oh my God!” And he goes, “It will control her periods where she won’t lose so much blood and she won’t be anemic no more” but my mom associated birth control pills with having sex, therefore, I would be this woman of ill repute who would be running around sleeping with everybody, this is how she, in her mind, that’s just how — my mom is older. I mean, so, you know [....] I went on them much to her dismay, actually. With the exception of two woman, all of the women interviewed reported having very distinct memories of their first gynecologic encounter. The women were between the ages of thirteen and nineteen when they saw a physician for gynecologic reasons for the first time. Most of the women visited a gynecologist (rather than a GP or other type of doctor) for their initial gynecologic examination, a few saw their family physician, or, in one women’s case, a 133 pediatrician. All of the women’s initial gynecologic examinations were performed by male physicians. The reasons for their initial gynecologic exam varied. Most report that they were seeking medical help to alleviate painful periods and excessive bleeding. Other women had their first gynecologic exam because a) they either knew or suspected they were pregnant, b) it was accepted that such exams are necessary or required, or c) they (or their mothers for them) were seeking birth control. A few women conveyed that their initial gynecologic examination wasn’t difficult or memorable in any way, or that “it was just a part of life” (Jill). The absence of any response (emotional or otherwise) to gynecologic examinations may indicate a woman’s acceptance of medical authority and need for medical management. Jill assumes, without question, the need for her reproductive organs to be medically managed. Similarly, Debra’s experience was that, “It really didn’t make an impression on me one way or another. In fact, I remember thinking I didn’t know what the fuss was about, how women dread it.” Out of all the women, Debra and Jill are by far the most athletically inclined, and had been so throughout their lives. Their attitudes towards their initial gynecologic examination may be a reflection of a general pragmatic view of bodies 134 overall, that is, the body as a tool. However, these types of responses are the minority, most of the women describe their first gynecologic examination in decidedly negative terms. Despite the fact that a gynecologist has the legitimate authority to examine women both externally and internally, eight of the women described feeling embarrassed and uncomfortable about exposing their bodies to a man, and a few women conveyed feeling uncomfortable about revealing their bodies to a medical professional of either sex. As adults the experience of a gynecologic examination did not become any more comfortable or less embarrassing for many of these women. The following comments typify how the women felt about their initial gynecologic examination. Well, it wasn’t nice. I didn’t enjoy it. It was embarrassing (Mary). [...] it was just kind of embarrassing that you had to disrobe and have an examination and I never felt real comfortable about that, nor do I now (Agnes). It was uncomfortable, well, a man looking at me. Back then there weren't many female doctors that I knew of. I think I’ve trained myself to look at things clinically because of the experience (Becky). I was kind of embarrassed and shy, and it was a man and, you know, I was apprehensive. I knew he was a good doctor and I knew he would be nice to me, but I was apprehensive [....] It was the first time a man had ever seen me without my clothes on (Michelle). 135 Michelle went on to say that the first gynecologic experience doesn’t seem “normal” because women are taught all their lives to keep their legs together and to keep their private areas covered, and then the first thing a woman is required to do in a gynecologist’s examination room is to “spread your legs wide open [as they] put you in the stirrups.” Pat conveyed a similar attitude, “I was embarrassed about having to spread my legs in front of some man I’d never met." Carol described her first gynecologic experience as “very embarrassing,” and stated, It was a man and I was mortified, that is why I [now] have a female gynecologist. To have a man examine me, that’s not my husband mortifies me [....] he had been my doctor all my life. He was very kind and he knew I was mortified [...] but the whole thing was just humiliating. Other women expressed that they felt afraid and apprehensive during their initial gynecologic examination. Cheryl states, I was scared to death [....] Even back then I didn’t relish the thought of going, but I knew for my own sake I needed to go. Some women felt violated and invaded. I was about 15, and I just remember, yes, it was very scary, I was very intimidated by the whole thing [....] you feel invaded, I know I felt invaded [....] I didn’t like it at all. Even in to having my babies, even now, I’m a little more comfortable, but even now, I still hate it [....] There’s got to be a better way! (Kelly). 136 Paula described her initial gynecologic examination as an adolescent as being so traumatic that she’d felt raped. I was probably 15. It was my pediatrician. It was a horrible experience because I felt I’d been violated, and you know my uterus was tipped and so they were trying to figure out why I had so much pain. And I didn't feel he was very sensitive [....] He did a pelvic and tried to move the uterus and it was stupid. What was he doing? He should have referred me to someone else and, you know, I don't think I ever went back to him. When I came out of there I really felt like I had been raped, and I just, I was just stunned. I remember my mom, I mean, she made sure nobody messed with me, kept my sisters away, I didn't want to talk to anybody [....] It took a long time, I remember it was days before I felt like - It took me quite a bit to work through that, and to not feel guilty, and see I felt like I’d done something wrong and yet... The women’s experiences indicate that gynecological examinations can be highly negative and even traumatic events. A girl’s or women’s self—integration can be compromised, even through legitimate means such as a gynecologic examination, when she yields authority over her body to another, even if that person is a physician. A gynecologic examination is an invasive procedure and requires a girl/woman submit their genitalia, to the scrutiny of physicians, parts of themselves of which they have much embodied knowledge, but little direct observational or comparative knowledge. Nevertheless, medical science discounts women’s experiential knowledge and promotes the superiority of observational knowledge 137 (Hubbard, 1990). The medical protocols of gynecology require submission, and can invalidate women’s expertise of and authority over their own bodies. Adolescents, who have limited autonomy, can choose to resist authority, although doing so will likely result in negative consequences. Paula did not know prior to her initial experience that gynecologic examinations can sometimes be painful and induce fragmentation. Therefore, in her uninformed choice to comply with medical scrutiny, to temporarily surrender control over her body to the clinical gaze, Paula may have briefly felt responsible for the pain and psychological strain she experienced. It took me quite a bit to work through that, and to not feel guilty, and see I felt like I’d done something wrong and yetm Paula’s experience demonstrates the process of fragmentation adolescent girls and women may encounter in their interactions with biomedicine. Martin (1987) concurring with Frank, (1981), contends, many elements of modern medical science have been held to contribute to a fragmentation of the unity of the person. When science treats the person as a machine and assumes the body can be fixed by mechanical manipulations, it ignores, and it encourages us to ignore other aspects of our selves (p. 19-20). Despite their fear and embarrassment, and even traumatic experiences during gynecologic examinations, all 138 the women participants in this study (prior to hysterectomy) report that as adults they routinely visited their gynecologists for pelvic examinations and Pap tests on a regular or semi-regular basis. In doing so, they submit to physicians (most frequently male) the most private parts of their bodies which women are socially prohibited from exposing. Intentional public exposure of women’s external genitalia is considered deviant behavior and can produce judgements concerning gender status. Yet, the authority of medicine is so compelling that during physical examinations by male physicians, women must temporarily disregard gender norms regarding a woman’s body and behavior and submit her body (internal, as well as external) to medical scrutiny. Although such medical scrutiny may be deemed normative, ten of the participants in the present study conveyed varying degrees of uneasiness about gynecologic examinations. A number of women explained how they coped with the difficulties involved with submitting one’s body to gynecologic examinations. Ann explained that her first gynecologic examination was required by her long—time family doctor because she’d turned twenty—one. Because he always made you. You were supposed to do that after you were twenty-one. That was the doctor’s rules. 139 Ann was “terrified" and felt embarrassed about being examined by her doctor. She described the way she coped with the experience both then and later. Counted the dots in the ceiling. That’s what I did every year, was count the dots in the ceiling. Pat explained that she tried to not think of the whole experience, and Denise also relates a similar coping technique. I just laid there staring at the ceiling, just, you know, clenching my hands, then you get the tears down your eyes, just waiting. You block it out and wait for it to be over with. That’s what I remember about it. Becky described how she felt during her first gynecologic exam, and how she coped both then and later with the experience. It was uncomfortable, well, a man looking at me. Back then there weren’t many female doctors that I knew of. I think I trained myself to look at things clinically because of that experience [....] To this day I still do that. Everything [during a gynecologic examination] is clinical for me. These women describe various processes by which they are able to disassociate their selves from their bodies during gynecologic examinations. They do so in order to create distance from the discomfort and psychological strain associated with gynecologic examinations. “Dividing the self defends against the pain a person would otherwise feel, if he had to submit the whole of himself to a society which 140 makes his position a vulnerable and anxiety-laden one” (Sennett & Cobb, 1972;208). Fragmentation is one method women use to deal with the experience of submitting their bodies to the invasive authority of physicians. Martin (1987) proposes that the “separation of parts of the self may be adaptive in some situations” (p. 18), but such coping mechanisms are not necessarily beneficial. Summary The influence of medical expertise and authority and its wide social acceptance may be found at numerous and diverse junctures in adolescent girls’ lives. The pervasive social acceptance of medical expertise and authority is transmitted through educational forums, developmental media, and the attitudes and beliefs of peers and family members. The women’s acceptance, as adolescents, of the belief that the female body requires medical management is demonstrated by the fact that they submitted their bodies to uncomfortable and self-alienating medical examinations, primarily for reproductive health problems, but also for initial routine gynecologic examinations, or for prescribed birth control. Through the aforementioned social relations, the women, as adolescents, were also subject to negative biomedical interpretations of women’s reproductive organs 141 and functions, and the promotion of medically sanctioned gender behavior. Despite the fact that it is commonly a stressful and self—alienating experience, submitting to invasive medical management at some point after menarche is considered normative female behavior by the women participants in this study. To some degree, their adolescent acceptance of medical authority and management as normative and necessary, and their expectation that medical management is usually beneficial can be viewed as a compelling factor in the women’s continued adult participation in medical health care and their eventual decision to undergo hysterectomy. 142 CHAPTER 5 WOMEN'S EXPOSURE TO AND ACCEPTANCE OF MEDICAL EXPERTISE, AUTHORITY AND MANAGEMENT This chapter is an extension of chapter four in that it examines how the women’s participation in gynecologic medical interactions construct gender and mediate the women’s views of their selves, bodies, and appropriate social roles. As adults, the women in this study experienced greater direct contact with medical authority than they did as adolescents, partly through their reliance on gynecologists/obstetricians for reproductive health care, but also in their capacities as the primary care givers and medical consumers in their families. Fourteen of the women had children and received obstetrical care during each of their pregnancies. All of the women reported that, at some point in their adult lives, they began to visit their gynecologists or family physicians for routine gynecologic examinations on a regular or semi-regular basis. The routine monitoring of women’s reproductive organs is recommended and encouraged by physicians as a means of practicing preventive health care. Additionally, ten of the women describe prolonged searches for medical help to relieve the pain and heavy flow 143 of their menstruation.” This entailed either returning to one’s physician on a regular basis to discover if there were new treatments available, or changing physicians because the women (a) hoped to find a physician who could provide a cure, (b) were dissatisfied with the manner in which their physician treated them, (c) they moved to a new location, or (d) their insurance changed and necessitated switching to a new physician. Although two of the women report continuing health problems, for most of the women who experienced long-term health problems, their search for medical interventions to alleviate their menstrual problems ended with their hysterectomies. Kelly’s search lasted twenty-four years and although this was the longest time period any of the women suffered with problematic menstruation, others report similar long-term involvement with gynecologists; Alice for seventeen years, Carol and Agnes ten to eleven years, Becky, Paula, and Mary for eight years, and Pat, Debra, Cindy, and Janice for three to five years. Over various time spans ‘many of the women report physical symptoms, most commonly 29Nearly half (9) of the women in this study were diagnosed, at some time prior to their hysterectomies, with endometriosis, five were diagnosed with fibroids or excessive menstrual flow. The symptoms of these types of disorders frequently include pelvic pain and excessive Inenstrual bleeding (Shohat, 1998). 144 extreme pain, copious menstrual flow, and physical and mental exhaustion. These women reported that they experienced emotional and/or psychological distress due to the nature and severity of their reproductive health problems, as well as intense frustration over their inability to obtain effective medical treatments. Each of the instances in which the women interacted with their physicians for pregnancy, routine gynecologic examinations, prescription birth control, and menstrual/ reproductive health problems represents a point of contact in which medical expertise and authority were encountered. The women also experienced medical encounters with non— gynecologic health professionals as they tended to their non-reproductive and families’ health needs. WOmen’s Acceptance of Routine Gynecologic EXaminations/Screenings The majority of the women visited their gynecologists or family physicians for routine pelvic examinations and Pap tests. Their acceptance of the necessity of these particular types of medical screening procedures,30 despite their aversions to the experience, are evidenced by the following statements. 3°The problematizing of medical management of reproductive organs does not deny the possible health benefits of regular medical screening. 145 I remember thinking, totally dreading the whole idea, just dreading it. I still don’t like going to the gynecologist. I love my gynecologist, but I totally dread the whole idea of having someone asking me to spread my legs while they stick their hand in my pelvis area. And it’s like, it just seems inhumane, cold, and, what else can we do? You know, but go along with this for our exam and our checkup, or whatever. And you know those cold utensils up my, I mean, you know, it’s not been fun! It’s like...It’s, you know, when they do that, what do they call it, when they put that clamp in, that utensil, or whatever, I don’t even know those terms. And they go and do the pap smear? Why crap! This is, you know, I don’t like this! (Terri). I never liked going to the doctor then. I don’t really like going to the doctor now, so it’s just something you have to do because you have to, you know, you have to find out what’s going on, if something isn’t right or you’re not being normal, you have to go so I just accepted that it was part of life. You had to do it whether you liked it or not and so you did (Agnes). It was fine, and the gynecologist was a doctor, it was just accepted that he was a doctor. It was part of his job, and going to see a gynecologist was part of what you need to do to stay healthy (Jill). Even back then I didn’t relish the thought of going, but I knew for my own sake I needed to go (Cheryl). [I went] Regularly, every year for a Pap smear. He makes me see him every year (Toni). It was for health....It was something that you just had to deal with and just go do it (Ann). Michelle expressed the fact that going to her gynecologist for regular examinations was something she did 146 as a matter of course. She used the analogy of automotive maintenance. I would have it once a year. I didn’t have any problems, so it was just not a big deal. I would go get my 20,000 mile checkup - checked the oil. What is interesting is that Michelle’s attitude towards her body echoes the medical model (bodies as machine-like) and expresses unquestioned acceptance of women’s need for particular types of medical management. Similar to many of the women in Martin’s (1987) study, Michelle’s analogy demonstrates a fragmented sense of self, that is, a separating of her body from her self, which emulates medical objectification of the human body. Most of the women express an aversion to gynecologic examinations. As addressed in chapter four, many of the women found their initial gynecologic examination difficult, invasive, painful, and/or embarrassing, and some of the women expressed their feelings that the experience did not get any better or easier as an adult. That most of the women report having gynecologic examinations on a regular basis, despite their objections to the experience, suggests that they must have strong motivation to do so. Their reliance on gynecologists for regular routine examination of their internal genitalia suggests that the women are not inclined to practice self—examination. Unlike 147 the promotion of breast self-examination, biomedicine does not promote self-examination of internal/external genitalia, although various women’s organizations do. For example, the Boston Women’s Health Book Collective (1992) has promoted self-examination of internal/external genitalia as a health maintenance option for over thirty years through the publication of their book Our Bodies. Our Selves: A Book by and for Women. Even after their hysterectomies, sixteen of the women continue to have regular gynecologic examinations. Jill wasn’t sure why she needed to go, but felt going regularly somehow insured her continued health. When asked why she goes to the gynecologist for regular examinations after her hysterectomy, Jill replied, “I wasn’t sure why, I didn’t really question it." Denise believes that avoiding going to the gynecologist’s for regular examinations as a young woman actually lead to her hysterectomy. Now, after her hysterectomy, she has annual checkups without fail. That many of the women believe medical monitoring is necessary and beneficial even after hysterectomy is due, in part, to the fact that half of the women retained one or both ovaries and have concerns about developing ovarian cancer. However, with the exception of a few women, most of the women who did 148 not retain their ovaries during their hysterectomies, like Jill, also continue to receive regular or semi-regular gynecologic examinations/screenings. The above statements demonstrate that the women accept certain forms of medical management (gynecologic) because medical expertise is viewed as necessary for and beneficial to women’s reproductive health. The women believe that a physician’s primary purpose is to maintain or improve a patient’s health state, and that a woman needs regular gynecologic monitoring in order to preserve her health. However, acceptance of medical management for particular health needs does not mean that the women unquestioningly accept all medical efforts to regulate their health or behavior. Rejection of Routine Gynecologic Ekaminations/Screenings A few women discontinued their regular gynecologic checkups after having a hysterectomy. When asked if she went regularly to the gynecologist, Cindy replied, “no, why should I?” Some time after Mary's hysterectomy her doctor insisted she have a Pap test, but she refused and changed doctors because of the incident. The choice to discontinue regular gynecologic examinations/screenings may be interpreted as behavior based on a woman's belief that her health does not rely on medical management. Yet another 149 possible interpretation is that some women may believe that the absence of reproductive organs significantly reduces a woman’s risk for serious, life-threatening illnesses. It is also possible that these women have decided to simply avoid the unpleasant experience of gynecologic examinations. Although Mary and Cindy have similar views regarding gynecologic checkups, they differ in age and socioeconomic status, and do not appear to have other similar attitudes. Some women, prior to their hysterectomies, chose to have gynecologic examinations on an irregular basis. Their reasons for not having regular checkups on a strictly annual basis varied. Pat tried to avoid gynecologic visits because she was concerned about negative medical appraisals of both her health and her person. I still don’t care for the experience, as it can still be painful to get a Pap test done, and I feel they may be judgmental of how I look, physically. You know, being judged by my physical appearance, being too fat. I sometimes avoid going to the doctor for that reason, but if the problem is severe enough I’ll go....I went to see a ob/gyn usually when I had a problem, the only regular thing was to get a Pap test done, and I didn’t do that every year. I avoid them for multiple reasons, fear of finding out bad news, not wanting to have to expose my personal self to that, and possible judgment of the doctor... Pat’s ambivalence towards gynecologic examinations and gynecologists suggests that she accepts the need for medical health care, but is aware, and wary of the power of medical 150 professionals to judge normalcy. In bypassing regular checkups, Pat appears to be consciously avoiding the possibility of being medically defined as abnormal. Medical standards determining normal ranges for many physical conditions or bodily states (e.g., pregnancy) also construct gender norms (Queniart, 1992). Pat’s statement suggests that she is protecting her self-concept, or self- integration, by not exposing herself too frequently to the invasive and judgmental experience of a gynecologic examination. In effect, Pat’s confidence in her knowledge of her own body and her resistance to being judged deviant, lessens the extent to which she relies on biomedicine to manage her health care. Although Pat avoids medical evaluation of her body and self, like the other women in this study she relies on biomedicine to effect particular aspects of her health care, and is therefore subject to medical authority (although on a more variable basis). For example, controlled pharmaceuticals may only be dispensed by licensed physicians and pharmacists, therefore, lawful efficacious alternatives to traditional medical care do not exist for many health problems. To obtain a prescription for controlled medications, Pat is forced to see a physician. While control over medications and medical procedures serves to 151 safeguard individuals, it is also a means of requiring direct contact with medical professionals who then have the opportunity to do ideological work (Waitzkin, 1983). Ethel tried to visit her gynecologist on a regular basis but always seemed to delay going. One reason she avoided regular examinations was because the medical protocol of gynecologic examinations required her to present herself to the physician in a vulnerable position. She states, I say whenever you take your clothes off you feel exposed, you’ve got your shields down. You’re just, well, vulnerable to anything. Ethel is a medical professional herself, a pediatric nurse practitioner, who has a different status in relation to biomedicine than do the other women in this study. Her insider status and knowledge of medical ideology may make her particularly cognizant of the mechanisms by which medical power relations play out. Although she believes in the necessity and benefits of medical monitoring, by delaying routine examinations she restricts how frequently she feels exposed and vulnerable. Ethel, to some extent, is conscious of power differentials during gynecologic examinations and effectively limits the extent of her exposure to medical power relations through procrastination. 152 If avoidance of regular gynecologic examinations is a result of a woman’s recognition (at some level) that medical power differentials exist, and that the exercise of medical power is not necessarily beneficial to her, limiting her exposure to the exercise of power constitutes agenic resistance to medical power relations. In essence, when a woman acts upon her own knowledge, and accepts or rejects medical knowledge, recommendations, or constructions of reality by privileging her own knowledge (including experiential knowledge), she demonstrates relative autonomy. Such cases suggest, as Foucault (1979) asserted, that resistance is an inherent part of power. Conversely, avoidance of gynecologic examinations motivated by reasons other than a recognition of medical power relations and their adverse effects, may not stem from, nor necessarily create agency for the individual woman. Agenic empowerment comes partly from recognition of one’s personal ability to make informed choices that are beneficial to one’s health, rather than relying solely or primarily on medical expertise. However, the impact of agenic resistance on medical power relations, beyond the individual benefits, is negligible. Agenic resistance to medical power relations does not necessarily empower others, 153 or create political coalitions, and does not significantly alter medical power relations. With the exception of the two women (Mary and Cindy) who avoid gynecologic exams entirely, and the three women (Terri, Pat and Ethel) who have irregular gynecologic checkups, all of the women receive regular gynecologic exams. Although most of the women expressed an aversion to gynecologic examinations/screenings, the majority of the women expressed a common belief that such monitoring was necessary to prevent illness. Those who avoid or delay gynecologic exams appear to believe that the quality of their lives and health do not depend on medical experts. There are no discernable similarities among the women who demonstrate less reliance, than the other women, on gynecologic health care. However, avoidance and procrastination may be strategies for directing one’s own health care, and viewed in this manner, these women may be similar to those women who attempt to direct their own health care by other means. WOmen’s Acceptance of Medicalized Views of WOmen’s Bodies as Inherently'MOrbid All but one of the women believed they needed, and therefore actively pursued medical monitoring of their reproductive organs. Their beliefs in this regard and a lack of health care alternatives places them under medical 154 authority in which patient autonomy is discouraged. However, many of the women make efforts to direct their own health care. The directing of one’s health care is impossible during medical procedures requiring the patient to be anesthetized. Two of the women had their ovaries removed by their physicians although they each explicitly directed their doctors to leave one ovary. Terri’s doctor intentionally removed both of her ovaries with the full knowledge that she wanted to retain one. ...he took everything, and I felt angry at him after that. I felt like, you know, but I even said prior to surgery, do whatever you have to do but don’t take both ovaries, you know, do not take both my ovaries....He explained that it was a “had to” situation. Had to take them both....So, I cried and cried....Now I didn’t have any choice. My choices were taken from me as far as hormone therapy, as far as that was my body and that was decided, that was done....I felt totally violated. Jill’s doctor inadvertently removed both of her ovaries during her hysterectomy, although she had directed him to leave one ovary. I had told him to leave one ovary and the one, just so that I had one....And he was only supposed to take out one ovary and he took out two by mistake, and I went into the weepies, and I was in the hospital and he hadn’t read the report until after my, he was the ob-gyn. My general internist had read the report before he [ob-gyn] had read it, and he didn’t realize he’d taken both of them out. And by this time I’d gone really down hill because all the estrogen was gone. I wasn’t on hormones or anything. And I got so mad at him, 155 and I said, “I am not going to be a walking medicine cabinet!" I said, “I am really ticked!” I could have sued him but he’d been so nice over the years, it wasn’t worth it, to do it. I had it in writing, I had a second person there. I could have cleaned him. Neither Terri or Jill wanted to have to rely on hormone replacement therapy (HRT) and each had made this clear to their doctors. Terri’s doctor was unapologetic because the consent papers Terri signed prior to surgery allowed him to remove whatever organs he determined were “diseased." Jill’s doctor admitted his error. After realizing his mistake, Jill’s doctor ordered an estrogen shot for Jill, which she initially refused in what may be interpreted as an attempt to limit the degree to which she would need to rely on medical management in the future. He said, “we need to give you an estrogen shot." I said, “I don’t want one of those suckers, don’t give it to me." And finally he says, “do I have to come down there and give it to you?” I said, “no, fine, just have them give me an estrogen shot.” So they did. Although Terri’s and Jill’s experiences may be extreme examples of physicians exercising coercive control over a patient, it demonstrates that challenges to medical authority may be met with increased control efforts on the part of physicians. These examples of medical power relations cannot be characterized as processes of 156 negotiation. Jill’s submission to her doctor’s authority may have been based on their long-standing relationship as he’d been her gynecologist for over eighteen years. She trusted his medical expertise, although she commented that perhaps she shouldn’t have in light of his mistake, and believed he would act in her best interest. Jill was accustomed to accepting her physician’s interpretation of her body and bodily needs as factual reality. The nature of their relationship is made obvious when Jill’s doctor met her refusal of estrogen with a firm counter-challenge. Jill submitted to her doctor’s authority rather than risk the possibility that he would carry out his threat to personally administer the estrogen injection. Such a situation could have resulted in an embarrassing and demeaning incident if Jill had continued to resist her physician’s authority, and he had continued to insist she acquiesce to his wishes. The fact that she was still in the hospital recuperating from her surgery may have also influenced her decision to accede to her doctor’s demands. Jill’s choices were constrained by the fact that she was physically restricted to a locale populated by medical personnel who’s behavior is also constrained and regulated by physician authority. 157 Jill explained that she’d had a terribly difficult recovery which lasted for months after her surgery. Although she’d been extremely angry because her doctor’s error caused her to suffer abrupt menopause and necessitated HRT, she eventually came to view her doctor’s mistake as a fortunate accident. In response to the comment that such an accident changes a woman’s life, Jill replied, Actually, I think he changed it for the better. Well, this way I won’t have ovarian cancer. It was a very bad mistake on his part. But actually, in the long run, it was fine, because first of all I was already in the late 405...second thing, in the long run, I’ve already been through menopause because it caused me to go right through it without the estrogen. So I went right through it, so I had not had to go through all those years of ups and downs, and downs and ups. As she indicated later in the interview, Jill’s accommodation to the fact that both ovaries were removed was based on the recognition that her former bodily state could not be restored. The process of rationalizing her doctor’s error demonstrates the degree to which Jill accepts her physician’s authority, so much so that even his egregious mistake was eventually justified as being beneficial. Jill’s response also demonstrates acceptance of medicalized views of women’s reproductive organs. She assumes female reproductive organs are inherently morbid, that the mere presence of ovaries in a woman’s body entails a significant risk for cancer, and that menopause always 158 entails problematic symptoms. Possibly because she experienced a cessation of menopause symptoms after receiving estrogen, Jill generalized her experience and assumed that menopause was emotionally and physically problematic for all women. She may have also been influenced in this regard by physician’s attitudes towards menopause and the numerous media messages characterizing menopause as a debilitating disease (Parlee, 1994). Contrary to Jill’s assumptions, most women who go through natural-onset menopause experience no, or minimal symptoms, (Avis & McKinlay, 1995), although this may not be the case with surgically induced menopause. In spite of this, natural-onset menopause has been medically constructed as a disease requiring medical monitoring and treatment (Lorber, 1997). Jill’s beliefs about cancer may also be influenced by biomedical attitudes and widespread medical promotion of annual pelvic examinations and Pap tests. That such screening is recommended by virtually every gynecologist, and on an annual basis, suggests that women’s reproductive organs are prone to cancer and disease, and that women must be hyper-vigilant and submit to regular gynecologic screenings in order to survive. The women’s fear of cancer, influenced by medical constructions of female biology as 159 inherently pathological, was a primary motivation for obtaining routine gynecologic examinations. Jill’s belief that women’s reproductive organs are prone to cancer are fairly typical of the women interviewed for this study. Kelly, (post-hysterectomy) has gynecologic examinations bi-annually because of her fear of cancer. A number of women feel that a benefit of hysterectomy is that they no longer have to worry about gynecologic cancer. Debra’s comment on the subject concisely summarizes many of the women's feelings regarding the necessity and benefits of routine gynecologic inspection. She states, “I think dying from ovarian or uterine cancer is a far worse fate than anything endured in a doctor’s office.” Although ovarian cancer is certainly an aggressive and deadly disease, with a five-year survival rate of less than fifty percent (Landis, Murray, Bolden & Wingo, 1999), a woman’s lifetime risk for ovarian cancer is only 1.8% (American Cancer Society, 1998). In addition, gynecologic screening for ovarian cancer has not proved to be effective because ovarian malignancies are difficult to detect with simple pelvic palpation. Consequently, routine screening for ovarian cancer does not commonly result in early detection or reductions in mortality rates (Ries, et al., 1998). Despite societal acceptance of medical expertise and 160 efficacy, doctors have had relatively little impact on detecting, and preventing death from ovarian cancer. Since the lay population’s knowledge of cancer, however scientifically unsophisticated or inaccurate, is not possible without medical science as its source, concerns and fears about cancer emanate from the production, dissemination and use of scientific knowledge. From a Foucauldian perspective, biomedicine, as a knowledge/power regime, produces both knowledge about cancer and women’s fears of their own bodies turning cancerous, thereby creating a need for medical monitoring. Through such discourse, biomedicine’s “will to power” is accomplished. That the women’s apprehensions about gynecologic cancer motivates them to seek gynecologic monitoring of their reproductive organs suggests that many women accept the medicalized view of women’s reproductive organs as inherently pathological and in need of medical management. These types of views of women’s reproductive organs influenced some of the women’s decisions to undergo hysterectomy, a subject addressed more thoroughly in chapter seven. When Debra was in her mid-thirties she sought medical help, from her GP, for extremely painful, heavy, and irregular menstruation which left her feeling exhausted. 161 According to her physician, the etiology of Debra’s severe menstrual problems, at age thirty—five, was normal aging. She states, When I first started telling him about my problems, heavier and longer flow, pain, he would brush me off by saying it was just the aging process and I had to expect some changes. Apparently, according to Debra’s physician, the “normal” aging of women’s reproductive organs constitutes a pathological process. Debra initially accepted this medical interpretation of her bodily state, that is, her reproductive organs and their functions as inherently pathological. Yet the increasing severity of her menstrual problems and her doctors inadequate response to her concerns lead her to pursue medical care which validated her experiential knowledge. Then he put me on birth control to control the symptoms. He addressed the safety and appropriateness of them by saying he had his own daughter on them. Looking back, I should have questioned the appropriateness of treating women who had a twenty year age difference between them in the same way....It gave some relief, but then it seemed my body built an immunity to them and I was back where I started. Slowly things were getting worse over the years, but I thought that was the price of aging. When I would go in for the annual checkup or for off-visits for bursitis, and other things, he would ask me about it and I would say it was getting worse and he would change the subject....When he stepped out of the room, I asked his nurse if she could recommend a good gynecologist, thinking that a woman in the medical profession could make a good recommendation, because I wanted to get a complete exam. And as 162 soon as the doctor came back in she told him as if she were tattle-telling on me and he kind of turned on me and said, "why would you want to do that, he's just going to do the same thing I do here and tell you the same thing." At that very moment, I decided he was a jerk and was not going to have him do gynecologic exams anymore and didn't particularly like him as a GP either. Debra’s experience demonstrates the patrism31 of medical authority, Her depiction of the incident also suggests that the nurse was protecting the doctor’s authority. That the nurse was enacting medical gatekeeping on his behalf illustrates how the gendered structure of the medical profession supports and mirrors physicians’ authority over patients. This influences the ways in which medical power relations between women and their physicians play out. Lorber (1997;9) states, “Differences of opinion are suppressed by the hierarchy of patient—nurse-physician, which is reinforced when the patient and the nurse are women and the physician is a man...” For a physician, especially a gynecologist, having a subordinate female assistant is assumed, as is a physician’s authority to determine a female patient’s normal/abnormal bodily states and bodily needs. 3‘Turner (1984) coined the term “patrism” to differentiate between patriarchy, a comprehensive system of institutionalized legal, political, religious and economic restraints on women, and patrism, a widespread culture of discriminatory, prejudicial and paternalistic beliefs about the inferiority of women which was left over after the breakdown of institutionalized patriarchy (p. 156). 163 Although it is not unusual for patients to ask for referrals from their physicians, Debra’s request for a recommendation to a gynecologist was interpreted as a challenge to her doctor’s medical competence. The doctor responded by questioning the validity of Debra's rationale for wanting to be examined by a doctor other than himself, and by asserting his gynecologic proficiency. Debra’s experience suggests that perceived challenges to a physician’s authority or expertise may rarely go uncontested. The women’s concern’s about cancer and various other diseases of female reproductive organs are influenced by medicine’s authority to interpret women’s bodies, bodily states and needs. Many of the women in this study demonstrate extensive acceptance of medicalized views of female biology as inherently pathological. However, as Debra’s case illustrates, acceptance of medicalized views of their bodies does not prevent a woman from privileging experiential knowledge of her own body over a particular physician’s interpretation. Yet, doing so directly may be interpreted as a challenge to medical authority and ezxpertise, and is likely to be met with a counter-challenge. ’Fhe impact of privileging experiential knowledge over pflrysician expertise is agenic, but it is more likely to lead 164 to a change of doctors rather than a change in the character of medical power relations. The medicalization of women’s bodies and lives may hinge upon women’s acceptance of the medical construction of women’s bodies and bodily functions as inherently morbid and, therefore, needing medical management. The women’s acceptance of, or desire for medical management, even in cases where it is perceived as a “necessary evil,” suggests that women perceive their bodies and selves from a medicalized perspective. WOmen’s Acceptance of Medicalized Views of Menstruation Menstruation, vaginal discharges, and childbirth are tin: only physical/material output of women’s internal reproductive organs. Consequently, along with the medicalization of women’s reproductive organs and functions, women’s experiences of these outputs (or lack thereof) are a primary catalyst for seeking gynecologic medical evaluation and treatment. Menstruation, in particular, has been the subject of medical discourse which has depicted it as highly ‘problematic. It is considered a biological function which is prone to disorder and in need of medical management (Oinas, 1998). For example, in the last decade a remarkable amount of attention, by both medical and feminist 165 investigators, has been given to Premenstrual Syndrome (PMS) .32 The literature on attitudes towards menstruation in Western societies describes the general view of menstruation as a bodily experience which is highly negative. Menstruation is considered debilitating and pathological, and menstrual flow/discharge as dirty, polluting, shameful, and, above all else, necessary to conceal (Brooks-Gunn & Ruble, 1980; Golub, 1981; Golub, Daly, Ingrando & Murphy, 1981; Martin, 1987; Laws, 1990; Golub, 1992; Lee & Sasser- Coen, 1996; Houppert 1999). Although adult women are more likely to have mixed feelings towards menstruation (Chrisler, Johnston, Champagne & Preston, 1994), most of the women in this study viewed menstruation as primarily a debilitating and distressing experience. The majority of women interviewed described various, longstanding menstrual problems.33 All but three of the 32Premenstrual syndrome (PMS) is a medical term referring to a variety of physical and emotional experiences that 'women encounter prior to the start of their cyclical menses. This medicalized conceptualization of women’s premenstrual states is a highly contested issue among medical practitioners/researchers and feminists, as well as among feminists themselves (Lorber, 1997). 33In conducting this research from the standpoint of women, it is assumed that the women’s descriptions of their 'various menstrual problems reflect actual experiences, and are not manifestations of psychological pathology or simply responses to negative social constructions of menstruation. 166 women described their periods as somewhat to extremely painful, and/or producing excessively heavy bleeding. Kelly described experiencing extreme pain and excessive menstrual bleeding which began with her first period at eleven years of age, and persisted until she had a hysterectomy twenty- four years later. Sick as far as, it was like having the flu. I would be nauseous and I had real bad cramps, severe. And I would go for 8 days, heavy, heavy [....] two weeks out of the month I was literally sick. To where it really felt like what you’d feel like when you had the flu, where you’re nauseous. I would lay in bed, and I didn’t want anybody to even touch the bed [....] and it was that way, and it just continually, it actually just got worse and worse and worse [....] I had them in my ovaries real bad, but I also had them in my lower back, you know, to where I would have, there were times I had a heating pad on my back, ice packs on my ovaries, and then I’d be switching, I’d be crying. I’d be crying, full of Darvocet, they [doctors] tried everything with me. The Anaprox, I went from starting with Motrin, to the Tylenol 3, then next thing you know it went to Anaprox, and then it went to the Darvocet. So it was rough. Initially, because her mother had similar periods, Kelly judged her own periods as normal. As a teenager, Kelly and her friends shared information about their periods, and she learned that her friends weren’t experiencing extreme pain and heavy bleeding. As a result Kelly redefined her menstrual experiences as abnormal, and this influenced her to begin a search for medical 167 interventions which would improve or rectify her menstrual problems. The severity of her symptoms were debilitating and negatively influenced the quality of her life with every menstrual period. All but three of the women interviewed report similar experiences, although the severity of their menstrual problems varied. The women also describe similar searches for medical interventions to alleviate their problems. The fact that many of the women experienced problematic menstruation throughout their menstrual careers may explain the fact that all but two of the women in this study describe their menstruation in highly pejorative terms. Indeed, it is possible that their own problematic menstrual experiences influenced many of the women to view female reproductive organs as intrinsically pathological. However, regardless of how painful or debilitating a woman’s period may be, it does not explain the sense of shame and embarrassment the women so frequently associated with their menstruation. With the exception of two women who indicated an acceptance of their periods as being just a part of life, all the other women conveyed various degrees of disdain for their menstruation. A number of women, some of whom had few menstrual problems, stated that they “hated,” “dreaded,” or 168 “didn’t like” their periods. Some of the women characterized their menstruation as being a “nuisance,” as “gross," and/or “embarrassing.” The women’s attitudes towards their menstruation correspond to the generally negative attitudes towards menstruation in Western societies (Golub, 1992). Although there’s no question that many of the women suffered painful and debilitating periods, sometimes for many years, the literature shows that even women who have relatively brief and painless periods often find them to be a highly negative experience due to the social constraints imposed by menstrual etiquette (Lee & Sasser-Coen, 1992). Weideger (1978) contends that the gynecologist is in a position of “leadership as the enforcer of the menstrual taboo" (p. 144). The biomedical perspective centers on disease and disorder, and since very little scientific research focuses on normal menstruation, gynecologists have relatively little objective scientific knowledge on the subject (Laws, 1990). In Laws’ (1990) examination of the treatment of Inenstruation in medical textbooks, she found that Inenstruation tended to be described in terms which suggest that menstruation is a contaminant or dirty, and needs to be (mantrolled. Additionally, menstruation and the uterus were 169 depicted as central to women’s femininity, and as influencing women’s emotional states. In the present study the women’s menstrual attitudes stem from the combined influence of their physical suffering, and the social constraints and medical validation of menstrual etiquette. Medical constructions of women’s bodies and menstruation reflect and reinforce the menstrual etiquette in Western cultures and can impose impossible requirements on women who have problematic menstruation. When women have severe pain and excessive bleeding with their periods, attempting to follow menstrual etiquette can be exceedingly difficult and requires an inordinate amount of attention paid to contingency plans. Achieving successful concealment when a woman is in pain and cannot contain her menstrual flow can be impossible. Inability to achieve successful concealment can prompt negative social sanctioning, and the embarrassment associated with such social interactions can be highly distressful. Most of the women mentioned the various difficulties they encountered in attempting to conceal the fact of their Inenstruation. Toni wore three sanitary pads and kept extra pads in the glove compartment of her car because she so :freqmently bled through. Alice’s period lasted sixteen days 170 at a stretch, she described one episode that was impossible to conceal. I was at home...and I was having a period and I realized it was flowing very hard because I had been horizontal all night and all of a sudden I became vertical and there was just blood all over the carpeting going from my bedroom into the bathroom. Paula describes an episode in which she had an “accident" in public. I mean, it was so bad, I was afraid to go anywhere. You know, you never know when you’re going to start because I was nonstop sometimes, I mean, and it didn’t matter the medicine. I mean, I would just start and ruin my clothes, I mean, I had to leave work one day because I had ruined a chair I was sitting in at work in my office. I had ruined my clothes. I mean, you know it’s pretty bad, embarrassing. I went to a party one night with people from church and I was sitting in the chair and, thank God it was metal because it was all over the chair and I didn’t even know it had happened. That is what was so funny, I mean, it was really weird because I got up out of the chair and the girl said “Janice, you might want to look down.”....You know, so I was like “Oh, wow." In their descriptions of their menstrual flows the ‘women defined “heavy flow” primarily in terms of their difficulty or inability to conceal their menstrual blood from public detection. Irregularity also created problems in terms of concealment. If a woman can’t determine when to expect her period, precautionary measures for concealment Inust be continuously available. Consequently, the social construction of appropriate gender behavior, as stipulated 171 by menstrual etiquette, influenced whether or not the women considered their menstruation normal or abnormal. Menstruation that is difficult or impossible to conceal is defined by the women in this study as abnormal, and as requiring medical intervention. The women in this study accept stigmatizing social and biomedical views of menstruation, and rely upon medical expertise to help them to achieve “normal" menstruation, which is a level of menstrual flow and regularity which is able to be concealed. Besides the fact that intense menstrual pain can be highly unpleasant and debilitating, it also creates difficulty in achieving menstrual concealment. The women who experienced severe menstrual pain expressed how it impacted them emotionally, and how it diminished their ability to perform daily tasks, or maintain a customary schedule of activities. Kelly described how the extreme pain and heavy flow of her periods influenced her work. To stand up and hemorrhage, and, you know, have everything drop to the floor, you know. And I remember going to work, I started feeling embarrassed because I want to be healthy and productive, someone they’re proud of having on their team, so to speak, and then, to see me sick two weeks out of the month. They’re not knowing what’s wrong with me, everyone around me. And I was always totally drugged down and sick and embarrassed about myself because I couldn’t give what was really in my mind to give, and that my body wouldn’t let me. 172 Kelly’s experience illustrates that highly problematic menstruation can interfere with daily tasks and responsibilities. Successfully concealing the fact of that one is menstruating can be difficult to achieve when painful menstruation interrupts routine activity. The need to conceal menstruation can be stressful. In attempting to avoid negative sanctioning for failure to conceal her menstruation, Kelly concealed the fact of her menstruation, but in so doing she risked negative evaluations of her competency as an employee (possibly jeopardizing her job). This suggests that the distress of severe menstrual pain and heavy bleeding can be magnified by social strictures requiring concealment. Another aspect of highly problematic menstruation which make it difficult to conceal is that it can interfere with a woman’s ability to perform reproductive labor. Agnes’ was unable to engage in sexual intercourse because of pain and this created conflict in her relationship with her husband. Toni had difficulty performing her housework and caring for her twins because of her difficult periods. Many of the 'women sought medical interventions for their reproductive health problems so that they could adequately function, and perform their daily tasks and routines. They wanted to improve the quality of their lives, their relationships, and 173 their ability to achieve menstrual etiquette, and believed that medical expertise would enable them to do so. When women seek help from physicians for physical aspects of problematic menstruation, they are also seeking help for the social aspects of problematic menstruation. Summary Virtually all of the women accept the notion that women’s bodies are to some degree pathological and require medical management. The women’s reliance on biomedicine for their reproductive health care places them squarely in the domain of medical authority, in which medicine can and does perform ideological work. In the case of enabling and promoting achievement of menstrual etiquette ideological work being performed is the construction and promotion of gender norms. As adults, the women in this study turned to their physicians seeking health maintenance and relief from the physical ailments of their reproductive organs, which, in turn, means relief from the oppressive gender norms that 3patriarchal society imposes on women. In turning to loiomedicine for help the women encounter medical authority .and.become participants in medical power relations. 174 CHAPTER 6 WOMEN’S PARTICIPATION IN MEDICAL POWER RELATIONS: THE PRODUCTION OF GENDERED BODIES Feminist accounts of medical power relations contend that women’s bodies and lives have become highly medicalized (Ehrenreich & English, 1979; Lorber, 1997). Two pnerspectives dominate the feminist medicalization lriterature, each proceeding from two different cgc>nceptualizations of power. Those accounts using a traditional notion of power explain medical power relations in terms of patriarchal society, of which medicine is a part (e.g., Ehrenreich & English, 1979; Oakley, 1980; Corea, 1985; Daly, 1990). Medical power is defined as hierarchical and repressive. Accounts of medical power relations using a more relational/transactional notion of power contend that women are active participants in their medicalization (Gabe & Calnan, 1989; Denny, 1996) and that women do not constitute a homogenous group, and thus are not impacted in the same manner by medicalization (Riessman, 1983; Lorber, 1994; Doyal, 1995). Medical power relations are defined as a process of negotiation in which women experience both benefits and costs. 175 .Medical Power Relations as a Relational Form of Power Using Foucault’s conceptualization of power, Oinas (1998) characterizes medicalization as medical attempts at social control, but also as a vehicle by which women <:onstruct themselves through medical interpretations of normal female bodies and gender behavior. In other words, znedical power relations are characterized by both health aware professional’s attempts to exercise control and women’s gitztempts to employ medical care as a means to achieve enormative bodily states. Women are viewed as actively participating in the creation of medical power relations, rather than as passive victims. From a Foucauldian informed perspective, the production of medical knowledge is created through the manner in which power moves between shifting positions/statuses, rather than through individual possession of power (McHoul & Grace, 1993). Consequently, the power of a physician, as a primary interpreter of medical scientific truths, is only possible when understood in relation to patients, medical assistants and those who enter into interaction with a physician as she/he employs the knowledge/power techniques of medicine. Outside that discursive field, a physician may have difficulty exercising power or creating power relations 176 (although that discursive field may be very broad in the case of a physician). In order to depict modern forms of power, as opposed to the repressive power typified by the historical relationship Ibetween a sovereign and his subjects, Foucault (1977) utilized the analogy of the Panopticon. The Panopticon was a: design for prisons consisting of a central tower encircled try'cells, which created constant surveillance and required In:inimum supervision of the inmates. Hence the major effect of the Panopticon: to induce in the inmate a state of conscious and permanent visibility that assures the automatic functioning of power. So to arrange things that the surveillance is permanent in its affects, even if it is discontinuous in its actions; that the perfection of power should tend to render its actual exercise unnecessary; that this architectural apparatus should be a machine for creating and sustaining a power relation independent of the person who exercises it; in short, that the inmates should be caught up in a power situation of which they are themselves the bearers (Foucault, 1977;201). In medical power relations physicians are the experts of scientific truths of the body. Through their claims to scientific “truths” they create patients who willingly enter into medical power relations in order to gain health or a particular social status. The patient’s acceptance of medical truths creates self-regulation, for in order to produce health, a normative body, or a particular social status through the use of medical knowledge and/or physician 177 expertise, the lay person must submit their bodies to medical surveillance. However, a physician need not be present or exercise power directly because patients have adopted the truths of medical knowledge, and, to varying degrees, the use of medical knowledge/power in order to obtain a normal or healthy bodily state. According to Foucault’s (1975) understanding of power, observation and correction (as in the panopticon) are the techniques through which medical power relations are formed. As participants in the construction of medical power relations patients are trained to observe their own bodies, to look for and expect abnormalities as defined from a medical perspective. When an individual suspects that some bodily correction is necessary, they submit themselves for medical inspection and correction. Individuals who conceive of themselves as in need of medical care are already engaged in self-regulating behavior. According to Foucault’s conception of power, resistance is a part of all power relations and consists primarily of competing truth claims. Consequently, negotiation typifies power relations, but the outcome depends on the effectiveness of the techniques employed. Presently the most effective power technique is the use of truth claims based.on scientific knowledge (McHoul & Grace, 1993). 178 The women in the present study seek out and rely on medical care to enable achievement of normative bodily states and gender behavior/display. In that process they become subject to medicalized notions of normal female bodies, as well as notions of appropriate or normal gender behavior. Medical power relations are productive in the sense that the participants, doctors and patients alike, create reality. However, women patients may privilege other types of knowledge, such as experiential knowledge and selectively comply with, or disregard medical constructions of reality (Abel & Browner, 1998). Although medical power relations may be characterized as producing a negotiated reality, there is nevertheless an asymmetrical component in power relations because medical professionals are recognized as the expert interpreters of scientific truths regarding the body, which are accepted as legitimate knowledge claims. Consequently, the exercise of medical power can occur through discursive techniques in which medical scientific knowledge claims are privileged over other types of knowledge claims (e.g., experiential bodily knowledge). The Relational Character of Medical Power Relations .Associated with Hysterectomy This relational view of medical power relations is supported by the experiences of the women in the present 179 study. Although most of the women report being satisfied overall with their interactions with physicians, fifteen of the women also gave accounts of particular instances in which they objected to physicians’ attempts to exercise authority over them. The likelihood of resistance to a physician’s attempt to exercise power over a woman depended on the woman’s assessment of a physician’s (a) exercise of authority as appropriate or inappropriate, (b) diagnosis as an accurate or inaccurate interpretation of her bodily state, and (c) provision of medical care as proficient, beneficial and unbiased, or as inadequate, harmful and biased. The women’s reactions to the exercise of physician authority consisted of two strategies. They directly challenged a physician’s interpretation, medical expertise, or her/his authority based on counter knowledge claims, usually those based on embodied knowledge, and/or terminated their relations with a particular physician. .Negotiation as Patient Challenge and Physician Resistance Most of the women describe at least one difficult or distressing medical encounter. When asked if she’d ever had an experience with a gynecologist that was difficult or upsetting, Jill did not refer to the incident in which her doctor mistakenly removed both of her ovaries. She chose to 180 relate an incident in which her physician refused to supply her with her preferred form of birth control. Only when the doctor and I disagreed about IUDs. He thought a person shouldn’t have an IUD, and I was very angry at him [....] I wanted, he just didn’t think it was something to do, and I got very upset with him. I wrote him a nasty letter and then later apologized [....] I thought he was very closed-minded. So I decided it was time to find somebody else [....] I just thought, “how could you not recommend something like that?” But that must have been his strong belief, so, that’s okay. Jill attempted to persuade her doctor to give her an IUD, but could not compel him, through various means (e.g., anger), to comply with her wishes. As long as Jill remained as his patient, her doctor’s power and authority to determine which birth control device he’d prescribe for Jill to use was absolute. Although Jill initially challenged his authority to determine what type of birth control she could use, she eventually accepted his right to not prescribe certain forms of birth control because he had a “strong belief.” Jill did not question his medical competency, nor his interpretation of her bodily state. Her resistance was based on her objection to having her access to a medically sanctioned form of birth control restricted. Eventually, Jill accepted her physician’s authority to determine appropriate birth control devices based on his expertise, but she privileged her own knowledge and agency, and 181 terminated her relationship with that doctor. Jill obtained the type of birth control she preferred from another medical professional who complied with her request for an IUD. Jill’s perception of what type of medical encounter constitutes a “difficult” or “upsetting” interaction prompted her to speak of an incident in which her doctor directly refused to comply with her wishes by prescribing an IUD. The power struggle between them is obvious, and Jill was fully aware of the nature of their interaction. However, Jill did not depict the incident in which her physician (a different physician from the above) removed both ovaries as a power struggle. Only when Jill spoke of her doctor’s reaction to her refusal to take estrogen, did she portray the interaction as an instance in which her physician was exercising power. Since the actual deed was done during surgery, a time period when Jill was unconscious, direct confrontation was delayed until after surgery, at which point Jill's objections could have no impact upon her already altered bodily integrity. During surgery Jill was absolutely powerless and under the complete authority of her physician. In order to be treated she had to submit her docile (anesthetized) body to her physician. The power relations remained obscured until Jill was given the information that 182 her doctor had made a mistake, that is, altered her body in a way she had not wanted. They also remained obscured by the representation of her doctor’s actions as unintentional, as intending no harm, despite the fact that harm was done. In addition, Jill rationalized her physician’s actions as essentially not harmful to her since she was already near the age at which she believed her ovaries would cease to function. Based on a medicalized understanding of menopause, Jill mistakenly assumed that she’d have had to eventually take hormones whether her doctor had removed her ovaries or not. Consequently, Jill rationalized that her doctor’s error was not egregious because she perceived her surgically altered bodily state as equivalent to natural menopause. The exercise of power is obvious in the face of direct conflict and explicit intent to harm, but when power is exercised for the overtly expressed benefit of a patient, and that individual has temporarily released authority over her body so a physician may effect health care or body normalization, the exercise of power is obscured. The fact that medical power relations most frequently entail negotiation also masks power differentials, since the concept of negotiation presumes a certain equality of each individual to assert their particular perspectives. The 183 fact that power relations may include negotiation does not preclude attempts to exercise coercive power, on the part of either the physician or patient. According to McHoul and Grace (1993), Foucault’s argument is that because the strategies of power in medical (and other dominant discourses) discourse are not recognized as power tactics, such power is far more effective in producing power relations. Foucault contends that power is primarily productive in that it “produces reality” (Foucault, 1977;194). Such power focuses on the production of self-regulated bodies, and is characteristic of most medical power relations. As demonstrated in the case of Jill’s physician’s refusal to prescribe an IUD, the coercive exercise of power by physicians is not effective in producing self-regulated bodies as patients may seek medical help elsewhere. Coercive power is more likely to produce resistance in the form of direct challenges to a physician’s authority, or passive actions in which a patient simply removes herself/himself from a physician’s particular domain of authority. Although in doing so, an individual remains a participant in the discursive field of medicine. Jill, as all the other women, had a longstanding reliance on medical health care. The women pursue medical management to insure health and to achieve sufficient gender 184 display/status. As women, their accomplishment of certain behaviors, such as reproductive labor and menstrual etiquette, creates a reliance on medicine because medical “truths" are perceived as the optimal method for enabling individual bodily control. However, the women’s participation in medical power relations is a result of, and results in exposure to and acceptance of medically mediated production of normative gendered bodies. For the most part, the women accept medicine’s gendered interpretation of their bodies as reality. Consequently, most of the women did not question their physician’s diagnoses and recommendations for hysterectomies. Patient Response to Physician Exercise of Coercive Power Terri’s response to having both ovaries removed during her hysterectomy, despite her expressed wishes to the contrary, stands in direct contrast to Jill’s. Although the two women are similar in that they both have advanced degrees and are white, they differ in that Terri had her hysterectomy at a very young age, whereas Jill was in her late forties. Terri felt betrayed and violated by her physician’s actions, while Jill eventually viewed her physician’s mistake as beneficial. Perhaps the most significant difference between the two women’s experiences is that the power relations remained 185 obscured in Jill’s case, but were quite obvious in Terri’s case. Terri’s gynecologist initially recommended a partial oophorectomy, which she declined because she wanted to have more children. I said, “oh, I’m not ready. I want to have kids.” [he stated] “Oh, well, you can have kids, you can still have kids with one ovary.” Later, he recommended a partial hysterectomy. Even though he’d told Terri that she only needed a partial hysterectomy, her doctor removed both of her ovaries intentionally and defended his right to do so since Terri had signed consent forms allowing him to remove whatever organs he considered necessary. Terri defined her physician’s behavior as the exercise of coercive power that made her feel dehumanized. You know, he did his job, I was an insurance claim that he made money off of. That’s kind of how I felt....I felt like a number. I did I felt like I was just another surgery output for him....I felt totally violated....I was devastated when I came to and found out he had taken everything, I was so... first my reaction was, I just sat cried, I just sat and cried. I cried like a baby. And then my next reaction was, I thought, you know, why? And I asked him “why?” And he was like “I had to do this. I had to do this because of all the mass. I saved you a lot of problems. We’d have to go back in there in another year anyway at the most.”....His messages were, “you’ll get over it, go with it” So here was this man who had no problem pulling out what he wanted to pull out of me, couldn’t see me through the process, is how I felt. It was just very, very cold. 186 Terri’s response consisted of a challenge to his medical authority by questioning his right to remove both ovaries after he’d assured her that only one ovary needed to be removed, and she had directed him to leave one ovary. His competing knowledge claim relied on two different sources of power, medical and legal. He insisted that the state of her ovaries necessitated removal of both, and when that did not satisfy Terri, he referred to the consent papers she’d signed. Terri later switched to another gynecologist because of this incident. Although she did not directly challenge him on the basis of harmful and biased medical care, she believed that to be the case. She felt it was possible that her doctor’s actions may have been motivated by disdain for women in general. She states, You know, I was just like, I wonder if he doesn’t like women? I had that, you know, I wonder if he’s a woman hater, or is this his way of, you know? And I switched doctors, of course. This suggests that Terri is cognizant of a gender component to medical power relations. Although Terri relied on and continues to rely on medical management like the other women, her experience of repressive medical power engendered a different attitude towards her present medical health care. She states, “I see them as skilled workers who do the best that they can and if not I move on." She related the following incident. 187 I recently went to a doctor that I was referred to because of a problem....with my foot. It was swelling for a long time, so my foot doctor, a podiatrist...said, “ I’m not sure what the problem is, but I’m going to send you to someone else, we’ll take look.” He sent me to this doctor who, first time I met him I felt like a number. “Ah well, I don’t think there’s anything wrong...” I said “but wait a minute, I have a problem here, it’s uncomfortable, are you going to treat it?” “Well I’ll run a test then...” So he ran a test, I had to call him a week later for the results, “oh, everything’s okay” I still didn’t pay that bill and I went back to this podiatrist and I said, “that was awful.” ‘Cause, I mean, a week later here they were doing surgery on me because I ended up having this huge tumor growth on my foot. So I just said that guy is just a jerk and I was just so glad I didn’t like him. Terri privileged her embodied knowledge and sought help elsewhere. Her resistance also took an economic and more indirect form. By refusing to pay, Terri is sending an indirect message that is meant to convey her questioning of the second doctor’s medical competence. However, she also indicated she would not return to that doctor. Such measures may be empowering to the individual who feels ill- served, but is likely to have little impact on the overall character of medical power relations. Patient Challenge Through Appeal to Legal Power Cindy relates a similar type of experience with a physician who did not take her concerns seriously. I had my last experience with a doctor when I had a severe bacterial infection in my body....It was right around the time my mother was dying. He said, “oh, it’s stress.” I said “I can’t breath.” 188 of her own bodily state. I said, “my chest hurts.” I said, “I can’t even smoke, I just set my cigarettes down." I said, “I don’t know what’s wrong, I’m tired all the time, I get dizzy. I just don’t feel good.” And I don’t go to the doctor unless I don’t feel good....And he kept telling me, “oh, there’s nothing wrong,” trying to insinuate that I was a hypochondriac! The last time I went into his office I was sitting there and I was so stressed because I did not feel good. I couldn’t breath and I sat there and cried. I said, “well fine.” I said, “when I end up in the hospital you'll be the first one that I call, after I call my lawyer!” I was pissed! I said, “I am not a hypochondriac! How many times have you seen me since I’ve been here? Except for whenever I get my upper respiratory infections. I said, “that’s it!" I said, “I told you something is wrong. This isn’t right.” So he gets this little book out, “I want you to go for a special test.” He must have called 5 times on that answering machine, while I was at work, telling me I had to call him immediately. I was right in the process of having respiratory shutdown. I would have ended up on a respirator in a week. What he says to me is “I’m so sorry, I will listen more closely to your symptoms next time.” [....] I didn’t say anything, I was too angry....He had me come in his office a week later, see how I was doing, you know, looked me in the eye and apologized. I just looked at him and flat out told him. I said, “You hurt me, you made me to where I said at least I wanted to come to a doctor. She persisted in her attempts to force him to acknowledge the authenticity of her experiential knowledge system and her right to sue by threatening to take legal validity of her illness claim. acquiesced to her demand to be taken seriously, action if her doctor did not acknowledge and respond to the 189 Cindy used the power of the legal Although her doctor finally it wasn’t until he received the results of scientific (objective) tests that he accepted the “fact” that Cindy was truly ill. He was trying to tell me that there was nothing wrong with me. “Oh, you’re just tired and stressed out from your mother’s death.” [....] I know my own body, I know when something’s wrong. Even a sense to where, You know when you’re sick enough, you know [....] You feel it. You know your own body. All they’re [physicians] going to do is give you a diagnose of why. Like Kelly, Cindy felt this physician assumed that she didn’t know her own body. The discounting of a woman’s embodied and experiential knowledge is a discursive technique whereby physicians assert the “truth” of medical science, as well as their authority to interpret bodily states. Such truth claims tended not to be questioned by the women in this study unless they were, in the women’s estimation, highly inaccurate. Since the women tend to view their bodies and bodily states from a medicalized perspective, conflicting interpretations of the women’s bodies are less likely to occur. Cindy’s attitude towards doctors demonstrates that Cindy, under circumstances she determines to be important, privileges her experiential knowledge of her own body over medical expertise. Cindy relies on medical expertise to provide health care, but she doesn’t feel overwhelmed by their authority, in fact, she is directive and can be demanding in her health care. Her threat to take legal 190 action is a knowledge/power technique in which Cindy is using both the knowledge claims of science and the authority of law. Presumably any legal action taken by Cindy would include a competing medical truth claim that verified Cindy’s illness in conflict with her doctor’s conclusions. Within medical power relations, competing scientific knowledge in the form of a second medical opinion combined with legal knowledge/power, can be used by patients to create a doctor who is a sanctioned subject. This suggests that power is not possessed by an individual but is created through various techniques of knowledge/power regimes (e.g., medicine, law, etc.) as Foucault suggested. Selective Acceptance of Medical Authority When Carol began menopause she started experiencing “sweats” and turned to her physician for help. I had a male doctor when I started in to the change of life. I didn’t have any paranoia or anything, but I had sweats, and it wasn’t just night sweats. It would happen to me during the day, at church, when I was shopping [....] Soaked! My top, you could wring it out. When I told him about it he said, “It’s a natural thing in life, get use to it.” He was really ornery. Rather than confront her doctor’s refusal to help her alleviate what she determined were the uncomfortable and embarrassing effects of menopause, Carol switched to another doctor who responded to her problems in a manner Carol deemed satisfactory. Her physician’s attempt to “de- 191 medicalize” or redefine Carol’s beliefs about menopause and knowledge of her bodily state was unsuccessful, not because Carol felt he lacked medical competence, but because Carol objected to his manner of exercising his authority. Not only did he not validate Carol’s interpretation of her bodily state, but in advancing a competing knowledge claim he did not provide relief from either the physical problem or social dilemma of profuse sweating. In other words, her physician did not enable her to enact appropriate gender behavior as defined by Carol. Instead, her physician advanced a view of gender behavior/display in which women’s experiences of menopausal sweating is normalized and medically authorized. When Becky’s physician recommended a hysterectomy she went to another gynecologist for a second opinion. She was one of three women in this study who sought a second opinion. She indicated that her experiences with physicians over the years lead her to believe that physicians discount what she knows about her own body. And that all started from before I had my hysterectomy because I wanted a second opinion. I was 26 years old and I was to the point where this doctor was saying hysterectomy, I wanted to make sure. I went to another doctor and he told me I needed psychological help and that it was all in my head. Charged me seventy-five dollars to do that. My mother was in the waiting room and I just bawled. So, from that moment on, my - I sat there and had a six page pathology report on my 192 uterus and I wanted to take and shove it up his nose. Her attitude towards doctors in general suggests that Becky is aware of medical power relations and that she is determined to be in control of her health care. She stated that her attitude began with her experience of the hysterectomy process. The following statement suggests that Becky does not have blind faith in medical expertise, and although she relies on medical care for her health, she challenges medical authority. Doctors, uh, basically I have to prove it to them. There’s two types of people I would look at the world as; there are people who have whole faith, and everything is going to work for them, and then there’s me. I’m the kind that I have to do it myself. And unless you [a hypothetical doctor] are going to fully work with me on this, it’s not going to get solved to my satisfaction. You’re just blowing me over with a snow blower. I’m very independent and I will be an active part of health, whether you let me or not [....] You're not going to tell me what it is, I’m going to tell you what it is. That’s my role with physicians now. If I can’t go in and talk to you and tell you what the problem is and have you listen, it’s going to end up an argument and I’m going to be walking out. Some of the women related experiences in which a physician explicitly defined appropriate gender behavior. For example, Marie met with resistance from her gynecologist when she asked him to tie her tubes. Maybe I should say that I knew when I was probably about twenty-two that I did not want to have children. And in fact tried to have my 193 gynecologist have my tubes tied. I was not marriedmhe said he didn’t feel comfortable doing that because I was single and very young and what if I met someone who wanted to have children and I changed my mind and blah, blah. So I didn’t do it, but I already knew at that time of my life that I didn’t want children som Her physician’s interpretation of appropriate gender behavior or life goals assumes compulsory heterosexuality, marriage and childbearing for all women. Although Marie did not pursue the issue of getting her tubes tied, she rejected her physician’s stereotypical interpretation of normative female behavior. These examples illustrate the complex nature of women’s relationships with biomedicine. The medical authority expressed in each incident is similar in that the physicians attempted to exercise power over the women through various strategies, including the definition of the women’s bodily states in opposition to each of the women’s assessment of her own bodily state and needs. Jill’s doctor simply refused to prescribe an IUD, and although Kelly’s doctor eventually appeared to acquiesce to her request for a particular drug, it was actually an attempt to mollify Kelly. Carol’s physician offered no help and little explanation. In each instance, the physician attempted to exercise power, but the women responded by either directly challenging their physician’s authority, diagnosis, and/or 194 medical competency, or by rejecting their physician’s interpretation of their bodily states in favor of their own. Very few women in this study chose to directly challenge their physicians. The women most commonly responded by terminating their relations with problematic doctors and establishing relations with other physicians who they hoped would validate their bodily experiences and enable them gain health and achieve normative gendered bodily states. These experiences with physicians demonstrate that women are cognizant of overt medical efforts to exercise power by subjectively defining the reality of women’s bodily experiences in contradiction to a woman’s experiential reality of her own bodily state. The physicians in these examples discounted the women’s knowledge of their own bodies and made competing knowledge claims. They resisted the women’s desires for particular types of medical interventions, and relied instead on their medical expertise or scientific tests to interpret the medical reality of women’s bodily states and exert medical power. The women’s experiences suggest that challenges to physicians, whatever precipitates them, may be met with resistance and can frequently be futile. This may be the primary reason why women choose to switch doctors rather than directly challenge physicians. 195 The women pursued medical consultations in efforts to obtain relief from health problems, to validate and understand their bodily experiences, and to achieve appropriate gender behavior/display. When a physician’s diagnosis contradicts a woman’s understanding of her bodily state, and imposes a differing interpretation, a woman may choose to accept, or reject the physician’s interpretation. If a woman accepts the physician’s diagnosis, she must then decide whether or not to comply with prescribed medical treatments. Women who reject a diagnosis based on knowledge of her own body (and other societal influences) can choose to directly challenge a physician’s attitude or diagnosis. If her knowledge claim is discounted, she must choose between submitting to her physician’s authority, or finding a different physician who will confirm her interpretation of her bodily state and treat her accordingly. The above examples demonstrate the women’s awareness of particular aspects of medical power relations. A number of the women recognized physicians’ propensity to exercise power, as well as the fact that physician exercise of power can oppose and devalue a woman’s knowledge of her own body. In denying the validity of women’s knowledge of their own bodies and bodily needs, some physicians presume women to be incapable of understanding and managing their own bodies and 196 health care. The women recognize this and attribute such behavior to individual doctors, rather than to the power of biomedicine as a whole. These women believed that some physicians are difficult or have debasing attitudes towards patients and/or women. Although some of the women made attempts to challenge physicians’ authority, most reported changing doctors in order to deal with overt power struggles. Many women learn from their experiences with medical power relations, and consequently those experiences influence future medical experiences by shaping the women’s attitudes towards doctors in general. This is not to imply that all the women’s experiences with physicians were problematic or contentious in nature. By far, most of the women feel that the majority their interactions with doctors, if not always helpful, were at least not problematic. Shopping for Doctors The women’s criticisms of medical care focused on either the way in which particular physicians conduct the process of managing their reproductive health, or the way in which the current practice of medicine is generally carried out. Their experiences with physicians influenced their attitudes towards physicians in general and the types of 197 characteristics they would prefer in the physicians from whom they seek medical care. The women’s experiences and resulting attitudes towards ideal physician qualities illustrate various aspects of medical power relations. Agnes believes that doctors, in general, have become less caring. From my point of view now, I really kind of judge doctors now compared with how they were when I was younger. Maybe they didn’t have as much knowledge when I was younger, but they took a lot more interest in your complaints and your history, and now it’s like they don’t have the time, they don’t want to be bothered with your history, you know. And they don’t read your charts, they tell you they don’t have the time so every time you go in, you have to go through the whole thing all over again and it gets really confusing to me because I forget. When I tell them dates and that and they have it in there, I think that they should refer back to that and they don’t. I asked about that one time and they said, “well, we don’t have the time.” Well, you know, I think that should be part of their job. They should take the time....I just don’t feel like they probably have the bedside manner that they used to have years ago. They might not have had as much information but they took more of an interest in you as an individual... Agnes is frustrated with doctors in general, and feels they are not responsive to her needs, and she feels she has very little impact on how they practice medicine. Similar to the other women who accept their need for particular types of medical management, Agnes feels her power to influence how physicians carry out that responsibility it 198 highly limited. Cheryl has a similar attitude towards doctors. I find them sometimes not so helpful. Sometimes you go in there, and it almost seems like maybe you do have some concerns, and they just kind of blow it off, “Oh, well, that’s this, this and this” you know? Instead of saying, “well, let me take a good look at this.” They kind of are skimming over it and not paying enough attention to things. Becky also dislikes doctors in general, and recognizes that medical knowledge claims discount her experiential knowledge of her own body. I have a very low opinion of doctors, very low....Because they don’t listen. I can sit there and tell them exactly what it is and they just know more than you, you know. Janice doesn’t like doctors in general because she’s had experiences with physicians who did not appear to respect her because she is a woman. During the interview she related the following experience. Some of them are very, don’t have no bedside manner, I mean, very rude, some of them are like “why are you here?” “well I’m sick, that’s why I’m here.” You know? Some of them are condescending to you, you know, very and my husband says he sees it a different way. My husband says that he likes the doctor. You know, the doctor and him get along. Well, he’s a man. You know, this is how I feel, I mean I feel as a woman. For instance I took my daughter to this one, our regular physician, not the one I’m going to now, but a different physician, not a gynecologist, but just a regular physician. She was having stomach pains really bad....So I took her to the doctor, well he just gave her the third degree, “Are you having sex?” “Are you taking drugs?” “Are you doing this, 199 are you doing that?” She just says “No, No, No.” “Are you making bad grades?” She always made good grades but she was just stressed out....well anyway, it just irritated me that he asked that. I’m sitting there, okay, and he says “Well, you’re sitting here awfully cute and real,” you know, “you’re sitting there like you’re just telling me the truth and I don’t believe it, I believe you’re lying.” And he said “You need a psychiatrist.” He says “I have a card if you want one.” I said “Thanks, but no thanks” and we walked out and left and I never went back....I don’t like being called a liar by anybody, much less a doctor and I was really aggravated, you know. Although Paula is very satisfied with the relationship she has with her present gynecologist, and has had mainly satisfactory experiences with most of the physicians with whom she’s interacted, she indicates that she’s had problems with doctors in the past. Her benign attitude is interesting given the fact that successive mistakes made by her various physicians contributed to years of pain, multiple surgeries, and the end of her much-valued capacity to bear children. Prior to leaving the United States Paula’s tubal pregnancy was missed by her physician, and later, was incorrectly treated by multiple physicians in Ecuador. She experienced massive internal bleeding and scarring which fused various organs (her uterus and a fallopian tube) and internal structures (large intestines) together. This caused Paula to suffer through years of agonizing pain despite numerous surgeries to correct the problem. Although 200 her hysterectomy eliminated most of her pain for a time, she eventually had yet another surgery for a recurrence of pain. Similar to most of the other women, rather than generalizing from her negative experiences with particular physicians, Paula’s attitudes towards physicians was based on an evaluation of individual physicians’ behaviors and attitudes. She stated that previous experiences with some physicians made her feel that they didn’t take her seriously, and hypothesized that it may have been because she’s a woman. Let's just say I don't feel as negative about it as I do about going to the dentist. I would rather go to my gynecologist than the dentist. He is a really, really good, kind, sensitive doctor and he is unlike most....it's not like I looked forward to my appointments because for me they are always painful, but I have a lot of things that are wrong. And yet he is always very careful, he talks to me, he explains and makes sure I’m all right. He doesn't push me too far. He lets my husband come in ....I have had a few where I felt like they did not take me seriously and when I felt like, that I have given them a few opportunities, and if I found that I really didn't think they were taking me seriously, I changed doctors....I’m very particular that I want a doctor who is not going to make me feel like, oh, it's just because I’m a woman, or you know, I want to make sure that they are taking everything into consideration. Some of the women’s statements demonstrate a vague awareness of the gendered aspect of their interactions with particular physicians. However most of the women did not depict the nature of ordinary medical interactions as 201 gendered. Gender tended to be an issue only in circumstances in which a woman felt a physician was treating her experiential knowledge as invalid. The women were very specific about the types of characteristics and behaviors they prefer in their physicians. Twelve of the women “shopped” for doctors when they were dissatisfied with their physicians, although frequently the woman’s health insurance or HMO determined the pool of doctors from whom she could choose. Many of the women’s attitudes are similar to Ethel’s. If they aren’t helpful I don’t go to them. My experience is, if they don’t answer my questions, if they don’t have time for me, I will never go back....I will shop for a doctor. The qualities the women preferred in a physician include a compassionate, direct, and responsive style of communication, and the ability to really listen and consider what the women feel they need. Nine of the women said they preferred a woman physician. They explained that they felt women physicians were either naturally more compassionate and listened better, or that women had the same biological makeup and would thus be able to better understand what they were experiencing. With the exception of Cheryl, who preferred a male physician, the rest of the women felt that the quality of care they received was independent of the physician’s sex. 202 Privileging Experiential Knowledge Self-regulation is an aspect the women’s participation in medical power relations. The women know medical protocol and how to behave as a “patient.” They may dislike certain aspects of medical management, but they generally accept the necessity for invasive medical procedures and have adopted mechanisms in order to cope with distressing medical experiences. They do resist being treated in demeaning ways, and being discounted as ignorant of their own bodies, but, ultimately, the women rely on medical expertise for their reproductive health care and the achievement of socially and medically sanctioned gender behavior/display. When they experience physical problems that they do not understand or cannot control, especially those which have social implications, they seek out medical experts to effect an amelioration of symptoms, or a cure. Nevertheless, the women in this study did not accept medical diagnoses or knowledge unquestioningly, especially if it contradicted strongly held beliefs or personal experiences. In their interactions with physicians, the women judged medical knowledge using experiential knowledge, or embodied knowledge, which is acquired from women’s perceptions of and experiences with their bodies, and from other women’s reports of bodily experiences (Abel & Browner, 203 1998;315). The women in this study expressed that they know their bodies in a way that physicians do not. They gave credence to their bodily experiences even in situations in which physicians discounted and contradicted their experiential knowledge. Kelly described the following incident in which she felt patronized and demeaned by a physician who used evasion and subterfuge to exercise medical authority. I went in and I said, “I believe I have a sinus infection, I’m running a low—grade fever, yada, yada, yada, and I also wanted to talk to you about the problems I'm having with my arthritis, now I believe it’s gone to my elbows,” whatever, I went on to explain. And I had waited an hour, and she says to me, “well, here’s a prescription for your sinusitis.” Well, wait, are you going to look in my ears are you going to listen to my, you know, nothing. You know what I mean, things that are common sense. And they’re just rushing you through, and you know they don’t even care. And then she says, “as far as your arthritis, I see you’re having problems here, can we reschedule for that because we’re really busy today?” [....] I said, “no, I cannot reschedule for that, I have been waiting an hour.” So then she hands me a prescription for Motrin. I said, “I take Motrin, everyday, I wouldn’t be coming to you, I’m tired of this, I need something more. Now it’s come to the point where I’m in pain every day. That’s why I’m coming to you about this. My elbows hurt me every day.” I’m just so disappointed with all of that. So then, I said, “what about the Celabrix?” [the doctor said] “Well, that’s an expensive drug.” I said, “well I have insurance, we’ll see if my insurance will cover this, and we’ll go from there.” [doctor] “Well, okay.” So she writes me a prescription and hands it to me. I didn’t realize she wrote me a two week prescription. Fourteen days! Just enough to shut me up. And then when I called back for more, she wouldn’t give me more. 204 You’re supposed to take this every day for it to help you. So when I called back, “no, it’s rather an expensive drug, the insurance doesn’t really like to [pay for it]. I don’t know what is happening over there. Kelly’s anger over the incident was apparent as she related her story. When asked what message she felt the doctor was conveying, she replied, She’s telling me that I know nothing about my body, first of all, and I absolutely do, and they treat you like you’re stupid, you know [....] So, I’m not going back to that doctor. So, I’ve had a lot of that through the years. Kelly defined her physician’s attempt to control her to be an unacceptable. She attempted to be directive in her health care but was thwarted by her physician’s power maneuver. Kelly also described another experience in which a physician didn’t believe she was experiencing extreme pain during her periods. There was a woman who told me it was all in my mind. Yes! A woman....I said, “no, it’s not all in my mind."....She told me, “I don’t see anything wrong with you, I believe this is all in your mind. You just don’t like having your periods.” Kelly does not like doctors in general because her experiences have made her very aware of the power struggles one can encounter in medical interactions, as well as what Kelly considers the limited impact of her attempts to direct her health care. She attributes such problems to individual doctor's personalities, and to the fact that her insurance 205 limits the pool of doctors from which she can choose. Kelly attempts to avoid participating in conflictual interactions, but recognizes what she considers to be physicians’ blatant attempts to define her body and bodily experiences in conflict with her experiential knowledge of her own body. Similar to the findings of Abel and Browner (1998), Kelly selectively complied with medical authority, but privileged her experiential knowledge when she determined is was more beneficial for her to do so. When competing knowledge claims are made in medical power relations, those claims of the doctor generally hold sway since medical scientific “truths” are accepted as reality. Nevertheless, Kelly privileged her experiential knowledge and her agenic power to switch doctors. Despite the constraints imposed by her insurance, when given the opportunity Kelly searches for a physician who will listen to her, explain procedures thoroughly, and treat her experiential knowledge as valid. The production of meaning in medical power relations can be viewed as a process of negotiation, with the participants privileging various knowledges. A physician can either validate or invalidate a woman’s experiential knowledge, and a woman may accept or reject a physician’s medical knowledge based on her experiential knowledge, as 206 well as other sources of both medical and non-medical knowledge. As Pat states, By my age I've been enough times I can usually tell them what’s wrong....I guess you could say I feel going to a doctor is like getting an educated guess. It’s the doctor who’s giving the educated guess, I don’t always agree with them. I tell them when I’m describing my symptoms to them, “yes, I think I know what’s going on with me physically as I have had a lot of experiences and try to educate myself. Many of the women expressed similar attitudes, like Kelly and Cindy who indicated that they knew their own bodies and didn’t like it when doctors treated them as if they didn’t. In addition, the women are knowledgeable medical consumers, many of whom seek out medical knowledge beyond that of their physicians. Debra and Alice sought out a variety of information on endometriosis and its medical treatment, and this knowledge combined with their experiential knowledge influenced them to eventually pursue a hysterectomy. In their decisions to have hysterectomies, many of the women also relied on the experiential knowledge of other women who’d experienced hysterectomies to inform them of the possible consequences. According to Abel and Browner (1998) biomedical knowledge is a framework which influences the manner in which women give meaning to the physical experience of their bodies. However, women selectively chose to comply with or reject both medical 207 constructions of their bodies and bodily states, and medical recommendations for interventions. Women’s participation in medical power relations can be viewed as beginning with a woman’s attitude towards herself, her bodily state and biomedicine, and her choice to pursue traditional Western medical care as a means of redressing gynecologic health problems and managing normal reproductive functions (e.g., pregnancy, birth control). It is women’s experiential knowledge of their own normal bodily states (and that in comparison with other women’s experiential knowledge) which often brings women to the point where they are ready or eager to consult with physicians, who may or may not validate the women’s experiential knowledge. For example, it wasn’t until Kelly spoke with her friends, and compared her experiential knowledge of her menstruation to theirs, that she began to believe that her menstrual experiences were not normal. Kelly’s desire to seek medical help began when she first defined her periods to be abnormal. When you start out with it that young, it was just the way it was. You know what I mean, I thought that was the way it was. Because my mom always had the same problems. My mom would, she called it hemorrhaging, I mean she would, the whole bed. So it was normal to me. Then I talked to my girlfriends and they weren’t having the same problems, you know, but then I just really started searching and going to doctors for the pain. 208 Experiential knowledge motivated the women to seek medical help and also influenced their interactions with physicians. For example, Becky, Michelle, and Alice actively pursued hysterectomies after experiencing gynecologic health problems and a variety of ineffective medical interventions. These women describe experiencing extreme health problems that motivated their searches for medical means to alleviate their suffering. However, their various physicians resisted the women’s requests for hysterectomies. Alice and Michelle eventually switched doctors in order to obtain hysterectomies, whereas Becky succeeded in convincing her physician, despite his reservations, that she needed and desired a hysterectomy. Becky describes the interactions with her physician which eventually lead to his consenting to performing a hysterectomy. I had to beg him to do it. He was, “ I think you need to do counseling before.” I said, “ no, it’s coming out.” I had gotten to that point, it was that bad....he thought I was too young....he made sure, I mean he brought my husband in and talked to me and my husband, you know, “what if you want to have one more kid?” “Well, I just proved to you with a miscarriage, bringing a baby in a bowl to you, what more do you want from me?” I mean we tried everything....I did have to beg him, he knew it needed done, he was one of the top female specialists. He knew what needed to be done, he just wanted to wait a little bit, you know....When my husband came in for the final [consultation] he took us into the office and really talked it over. He said, “ are you sure this is what you want? You 209 haven’t been through counseling, are you sure?” It took both me and my husband to get him to finally [agree]....With him it definitely was [a power struggle], he was just as head strong as I was. I wasn’t going to sway his, he made it known, you know, “you’re not going to make me do something I feel shouldn’t be done.” He’s talked that wait to me before. I had to convince him, yes, it’s time to do it...and he wasn’t going to backslide until I did convince him. According McHoul & Grace (1993), for Foucault, power is everywhere because power relations are a part of all social interaction. The form of power may vary, and the creation of the subject may be specific to the types of power relations that are being created, but all individuals are constituted through power. Consequently, the notion of resistance takes on new meaning in relation to a Foucauldian conception of power. Medical (in fact all) power relations consist of at least two people, the physician has a greater claim to truth by virtue of his/her relation to specific dominant knowledges, whereas the patient has a lesser claim. However, a patient’s power lies in having final authority over her/his own body, and the ability to privilege other sources of knowledge. Summary Women patients become participants in direct medical nywer relations the moment they seek medical help to aalleviate a health or social problem. Resistance is always anrt of power in that power techniques may be used by any 210 individual as power relations are created. Women can push for hysterectomies and women can resist hysterectomies, but as long as they (like nearly everyone else) rely on medical health care they are participants in medical power relations. Given some of the women’s recognition and refusal to accept particular types of physicians’ attempts to exercise power, it is difficult to try and characterize medical power relations as a hierarchical, monolithic repressive force. The women display autonomy in various experiences, or they push for the type of medical interventions they desire. That hysterectomy was decided upon, pursued and embraced by some, while it was resisted by others demonstrates that medical power relations are not stable and unchanging, but are rather processes of negotiation. Hysterectomy is a way for women to change the personal impact of embodied gender relations. For most of the women in this study, hysterectomy represents freedom and power; freedom from pain, freedom from the social constraints posed by a menstruating body, guaranteed freedom from unplanned pregnancies, and the power to be women who are not solely defined by their reproductive functions/capacities. The ‘women are aware to varying degrees of the hidden power relations that shape their lives, including medical power 211 relations. The women’s decisions to have hysterectomy entail a process of negotiation, in which hysterectomy is understood as an acceptable alternative to various physical and social constraints. 212 CHAPTER 7 BIOMEDICAL INFLUENCE ON WOMEN’S DECISIONS TO HAVE HYSTERECTOMIES The women in this study have relied on biomedicine for reproductive and non-reproductive health care for the majority of their lives, in part because effective and legitimate alternative sources of health care are limited. Pervasive societal acceptance of biomedical expertise and efficacy predisposes the women to assume medical health care as a normative aspect of life. The women have also accepted medicalized views of their reproductive organs as morbid, and have integrated such views into their concepts of body and self. Their concerns regarding the likelihood of reproductive disease and their expectations of efficacious gynecologic medical intervention, both partly generated by biomedical promotion of routine screening, motivated the women to maintain long-term gynecologic management of their reproductive organs. Furthermore, the problematic menstruation of many of the women, in terms of physical suffering and social restrictions/sanctions, also influenced the women to seek medical interventions over numerous years. The fact that these medical interventions proved ineffective in alleviating the women’s menstrual/reproductive organ 213 problems, or that some doctors were unresponsive to the women’s complaints, compelled the women to continue seeking some type of medical remedy. These factors represent various aspects of medical power relations that the women experienced over time, prior to their actual decisions to have a hysterectomy. The women’s beliefs about their bodies, their acceptance and execution of gender norms (e.g., menstrual etiquette), and their acceptance of biomedical expertise and authority form the social context in which the women made decisions to have hysterectomies. The Influence of the Belief in the Efficacy of Hysterectomy on the women’s Decisions to have Hysterectomies The primary motivating factor in the women’s decisions to have hysterectomies was their belief that hysterectomy would eliminate their reproductive health problems. This belief was predicated on their acceptance of the expertise of biomedicine to determine the nature of their health problems and its ability to effect a cure. When asked what were the main factors involved in her decision to have a hysterectomy, Mary replied, “I think because I wouldn’t be in pain anymore. I’d have a normal life.” The other women’s replies were similar. Kelly expected hysterectomy to be a permanent solution to her pain, excessive bleeding and suffering. She stated that instead of taking pain medication which only masked the symptoms, made her feel 214 drugged, and which she’d relied on for twenty-four years, she wanted a “cure.” She, like most of the other women, believed that hysterectomy would insure a better quality of life. Michelle stated, “I guess I just expected to go to sleep and when I woke up I knew I’d have a little pain, but then after a few days I would feel like a new person, and I did.” Carol stated that she’d expected hysterectomy to “Stop the flowing so that I could be human again.” Many of the women expressed similar reasons for deciding to have a hysterectomy. Prevalent throughout the women’s explanations of why they chose to have a hysterectomy is the notion that it would return them to “normal.” All of the women believed or hoped that hysterectomy would remedy their reproductive health problems, and this was a highly influential factor in the women’s decisions to undergo hysterectomy. The Influence of the Biomedical View of the Function of WOmen’s Reproductive Organs on WOmen’s Decisions to have Hysterectomies As revealed by many of the women’s attitudes towards their bodies (e.g., menstruation), the notion of normal functioning is produced through social interaction, as well as through bodily experiences. These corporeal experiences are socially mediated, they are socially defined and given meaning. As Birke (1993) contends, “our bodies are social, 215 too, and our experiences of, and engagement with a gendered world is as embodied persons” (p. 76) . The biological reductionism of medical science constructs women’s health and essential nature (their normalcy) as dependent on their reproductive organs. The purpose of women’s reproductive organs, according to biomedicine, is to produce children (Martin, 1987) , and once this has been achieved the benefits of retaining reproductive organs are highly diminished. With recent advances in pharmaceutical technology, hormone replacement therapy is viewed as a safe and effective alternative to re taining normal reproductive organs which have some chance 05 becoming morbid (Lorber, 1997) . Given the prevalence of e1 ective hysterectomies in the United States, it appears that many physicians assume that the health risks associated With having female reproductive organs is greater than those associated with hysterectomy and subsequent hormone replacement therapy. The women’s experiences suggest that Once a woman has achieved motherhood, or is past the rrledically sanctioned age for motherhood, reproductive organs are viewed by many physicians as hazardous to women’s health. Some of the women related conversations they’d had with tZheir physicians, during consultations leading to 216 hysterectomy, in which the issue of whether or not they desired to have children, or more children, was raised. (thidy, who was twenty-two years of age at the time of her hys terectomy, states , He asked me about children, if I wanted more children. I said I’d like to have more but I’d like to live in order to raise the two I already have. He said, “you have two children, take that into consideration.” If I didn’t have any children they would have tried to do the best that they could, there was no guarantee I’d still be able to have children. Her physician may simply be attempting to enable Cindy t£> make a fully informed choice by determining her wishes, but he is also implying that having two children is a Stifficient number, while having no children would influence vfilether or not they could wait to do a hysterectomy. This Sklsygests that her reproductive status has the power to alter fries treatment recommendation. Yet, Cindy related that her Physician felt it was necessary to perform the hysterectomy wwit:hout delay. The only delay that was deemed reasonable by her physician was for reproduction. Paula had episodes of depression after her hYsterectomy. In attempting to console her, Paula’s gynecologist assured her that what she was experiencing was on 1 y natural . I would still go through periods where it really bothered me that I could not have a baby and he was very kind about it. He said that I was still 217 in my prime reproductive years and it was natural for somebody my age to have that yearning, and, you know, it wasn’t being excessively depressive to feel that way. Although this conversation occurred post-hysterectomy, it .illustrates the doctor’s view on the primacy of regrroduction. His statement implies that Paula’s “yearning" for: another child would have been abnormal if she were cflxfler, that it is normal for women of a certain age to want cheildren, and, by extension, abnormal if they do not. His bellief in a “natural” (biological) urge to reproduce suggests that female biology is uncontrollable and creates dessires over which women (or society) have little influence. Thiis view assumes not only a division between body and self, bult.a.state of existence for women in which body versus Seellf. The gender message is that women are at the mercies Of their biology. Cheryl’s physician frightened her when he mentioned titrat.tests revealed pre-cancerous cells. Nevertheless, he Presented her with a few options. ...he says “you can take your chances and not do anything, or we can hold off if you’d like to have a child, or we can do a hysterectomy.” This statement reveals some ambivalence on the part of 11631: physician. In providing alternatives he enabled Cheryl ‘t63 make a more fully informed decision, but the possibility fo developing cancer, however likely, was understood by 218 Cheryl to be an extremely serious or dangerous situation. However, according to her doctor, the type of pre-cancerous cells present were not so serious that she couldn’t wait to have a hysterectomy until after she had a child. His presentation of the options available to Cheryl suggests that either the likelihood of developing gynecologic cancer was not great, in which case a hysterectomy was not imperative, or the importance of producing children (if she chose) outweighed the risk of developing cancer. Cheryl chose hysterectomy over reproducing because she was terrified of the possibility of developing cancer. In fact, a number of the women, all of whom had elective hysterectomies and were not diagnosed with QYnecologic cancer, report their doctors used the term “pre— cancerous” which influenced some of the women to view hYSterectomy as a prophylactic measure. Even those women Whose doctors had not used the term “pre-cancerous” exPressed, post-hysterectomy, relief that hysterectomy had eliminated the possibility of developing gynecologic cancer. Consequently, the women’s fears of cancer, influenced by t1Their physician’s promotion of the view that women’s organs are likely to develop cancer, motivated many of the women to In fact, View hysterectomy as essential to their longevity. it is possible that some physicians use women’s fears of 219 cancer to motivate women to have hysterectomies. Whether intentional or not, when a physician mentions the possibility of a woman developing gynecologic cancer, she/he effectively ends a woman’s desire to conceive and motivates a desire to survive. Such behavior demonstrates the relations of ruling, which Smith (1987) contends have a gendered subtext that is obscured by those relations. The power relations involved in the hysterectomy process are obscured by the scientific medical production of knowledge which defines women’s reproductive organs as prone to developing cancer and as useless outside the production of offspring. Physician Promotion of hysterectomy to avoid the possibility of developing cancer may be interpreted as obscured attempts to Control reproduction . Becky was twenty—six years of age when she had her hysterectomy. She had spent eight years in excruciating Pain, had been able to have one child, but after miscarrying Becky decided she could no longer tolerate her pain and inability to function adequately. After numerous years of attempts to remedy her health problems through various medical means, Becky began to pressure her doctor to perform a hysterectomy. Becky had decided that the only possible rel'uedy left for her was to have a hysterectomy. She’d 220 decided, even though she’d have liked to have another child, that the pain she was suffering was not worth it. She indicated that even had she not had a child that she’d have opted for the hysterectomy. Her physician’s attitude towards reproduction assumed a level of priority that was not shared by Becky. These examples suggest that a physician’s attitudes towards the value of reproduction reflect societal gender norms and influence his/her recommendations for hysterectomy, as well as other types of treatments. They a]. so illustrate that doctors may promote gender ideology through medical consultations and treatment recommendations. The assumption of some physicians that reproduction is natural and uniformly important to all women reinforces the gender ideology originating in biomedical reductionist assumptions, that the motivating force in women’s behavior and psychological constitution is primarily biological. Women are assumed to have a “natural" (uncontrollable) biological urge to procreate. The fact that many women profoundly value motherhood and/or the experience of pregnancy and bearing children does not discount the numerous (non-biological) influences on women’s attitudes t‘-<>wards motherhood, children, or any number of other goals and enterprises . 221 The Influence of the Accomplishment of Motherhood on WOmen’s .Decisions to Have Hysterectomies With the exception of Marie, all the women in this snnldy placed varying degrees of emphasis on motherhood. For enuample, Debra, who chose not to have children, felt that nmn:herhood is a highly meaningful undertaking. She states, “I think motherhood is the most important thing a woman can (R), but I was never interested in the long—term Ixasponsibility of it.” Many of the women assumed that they umyuld have children, and some eagerly anticipated nm>therhood. Some of the women assumed that they would evrentually have children, but never assumed motherhood to be tkie primary or sole purpose of their existence. Six of the women in this study did not have children. Meatrie, Cheryl, and Debra made conscious decisions to remain (Ikiild-free, whereas Alice, Ethel, and Jill felt that they Ilerver had the right circumstances to have children. The CDtIher women had children, and for some of these women II“Otherhoodwas a central feature of their self-concepts. Ehalila described how she felt about having children. And I really thought that when I had Danielle it was, that was such an unbelievable experience, you know, and labor with her was really awful and yet I wanted to do it again a lot. I mean I wanted, I felt there was nothing I wanted more than to be pregnant [....] [when pregnant] I felt really whole! I mean I really felt like I was complete, I was a woman all the way. There was absolutely no part of me that wasn't a woman [....] I mean it 222 was really neat. It summed up a whole of who I wanted to be. Kelly was eager to have children, she states, I remember at a very young age that, you know, that I looked forward to being a mother....To me it was the most important thing and always has been, from a very young age. Toni stated, I've always wanted to have children. I think it’s the most important thing I’ve done for my life. I mean, I love my three children and would give nothing [sic] for them. That’s a very big part of my life. For some of the other women who’d had children motherhood was not the primary feature of their self- concepts. However, the fact that they'd had children was a primary factor in a number of the women’s decisions to have hysterectomies. For many of the women their reproductive organs had but one purpose; to produce children. Janice had waited until she was in her late twenties before having twins, and afterwards had no desire for more children. She felt her reproductive organs had accomplished their purpose and that there was no longer any reason or necessity for retaining them. She did not feel having a hysterectomy compromised her femininity. I mean I've heard women say, “Oh, you know, I feel like part of me is gone.” I’m glad that part of me is gone. I didn’t want it. I could care less. Some women say, they’re like “I feel less of a woman.” I didn’t. I feel like I’m just as much of a woman as I did before, there were just parts 223 of the body that weren’t functioning right anymore and I wanted them out....Well, after I’d had kids and I don’t know, I just didn’t seem them as any vital part of me that needed to be around, I mean, you know, they weren’t doing anything anymore. Janice defined her reproductive organs as simply a means to an end, having children. The organs are not viewed as a necessary and beneficial part of her self. Agnes had similar views towards her reproductive organs. She wanted children but not the problems she associated with having female reproductive organs. She states, “Well, that's all I wanted to do anyway is to have babies so that was pretty neat. I just felt they could have bypassed that other [menstruation].” Like Janice, Agnes has a fragmented sense of self, her reproductive organs and what they produce are seen as separate from her self, as if they are not a necessary and beneficial part of her self. When Toni was asked if she had any regrets associated with having a hysterectomy, she replied, “No. We were done having children.” Although Carol had already been advised to not get pregnant again, she was nonetheless upset after her doctor told her she needed a hysterectomy because it meant “no more children.” Marie, who stated that her self- concept was never associated in any way with motherhood, defined her reproductive organs solely in terms of their having the purpose of bearing offspring, “I didn't and I 224 still don’t associate any of my own identity with my [reproductive] organs at all....but that could be because I didn’t want children. I knew I had no maternal instincts.” On the other end of the spectrum from Marie is Becky, who as a young woman believed that her main purpose in life was to reproduce. She states, I was Catholic, and my mother, we were blessed to be like that [able to reproduce]. I agree with that. I really do, even to the point that when I got married that was my main goal. My reproductive organs were put there to have a baby, that’s the first thing you need to do. As illustrated by these women’s statements, many of the women believe that their reproductive organs are for the sole purpose of producing children. Although not all of the women had or wanted to have children, the importance of motherhood itself, or the consideration of the possibility of motherhood was at issue in most of the women’s decisions to have hysterectomies. For some of the women, the accomplishment of motherhood influenced their acceptance of, or desire for a hysterectomy. It is difficult to discern whether physicians are merely echoing many women’s concerns about, and desires for motherhood or additional children, or if their attitudes influence the importance of motherhood for women. It is likely that both situations occur. However, when a physicians’ assumptions about gender and motherhood 225 influence the manner in which medical care is provided and the types of treatment recommendations are provided, and interfere with the expressed wishes of patients, such assumptions may be considered part of medical power relations. The assumption that the accomplishment of motherhood is of primary importance to all women highlights how medical assumptions construct gender in the hysterectomy process. The Influence of Fragmentation on WOmen’s Decisions to have Hysterectomies For many of the women and their physicians the primary importance of women’s reproductive organs is to produce children. Women’s reproductive organs are not largely viewed as a necessary, integral, or beneficial part of the self. Fragmentation of the women’s selves is demonstrated by some of the women’s views on the importance of producing children with organs/bodies specifically designed for but one purpose. According to Martin (1987) there is, ...a fair amount of fragmentation and alienation in women’s general conceptions of body and self. Ordinary women do not seem aware of the underlying fragmentation implied in the ways they speak and the assumptions they make about their selves and bodies...Although women resist specific medical procedures...they seem unable to resist the underlying assumptions behind those procedures; that self and body are separate...(p. 89). 226 In the present study, the women’s decisions to have hysterectomies are partially a result of their fragmented senses of self which derive from a sense of lacking control, and actual lack of control, over their own bodies. Social restrictions, like menstrual etiquette, demand that women deny crucial components of the self in order to achieve sufficient gender behavior/display. The medical care that women receive on a routine basis requires that women temporarily submit authority over their bodies to physicians who have the authority to define the women’s bodies as normal or abnormal. Fragmentation is not just a product of medical power relations, it is a prevalent, but largely unrecognized result of gender relations in a patriarchal society (Pipher, 1994). Although some of the women may occasionally challenge the manner in which their health care is carried out, their need for such care is not questioned. Many of the women have become accustomed to feeling fragmented, especially in medical encounters, and this facilitates their acceptance of the fragmenting effects of hysterectomy. Certainly all *women do not experience fragmentation to the same degree, or in the same manner, and many women resist and avoid common [alienating experiences typical of patriarchal society. Ihowever, for many of the women in this study the alienating 227 experiences typical of medical health care, as unpleasant as they may be, are expected and generally accepted as necessary and beneficial to their health, and quality and length of life. With the exception of Terri, none of the women explicitly expressed feeling that hysterectomy resulted in a loss of part of their “self.” In fact, Terri provided a critique of the biomedical perspective towards women and their reproductive organs. I think that doctors think that, hey this is your body, okay you’ll be able to have children—~or you won’t be able to have children. They look at it as a mommyhood thing. You’re either going to be a mommy, you’re going to reproduce. Its reproduction only, I think, to a certain degree. But it’s much, much more than just reproduction. It’s so much more, it is a part of you. I can only imagine, people talk about losing a breast, well this is also losing a significant body part. Terri describes her hysterectomy experience as fracturing her former sense of wholeness, and although she has continued semi-regular routine gynecologic screening (with a different physician), she stated that she avoids going to the gynecologist. She remarked, “I stay the hell away from.there.” Her emphatic response is a result of feeling betrayed and violated by the gynecologist who removed both of her ovaries despite her directions to leave <1ne ovary. Her recognition of the gendered character of ‘medical power relations may be due to the very “unobscured” 228 nature of her physician’s exercise of coercive power during her hysterectomy surgery. Although Toni did not explicitly express that she felt she’d lost a significant part of her self, she commented on how she felt when she realized that she would no longer menstruate after the hysterectomy. “It was like, okay, these are things I’ve had since I was twelve, and now it’s going to stop. You’re kind of taken back a little.” Toni had viewed her menarche and menstruation in more positive terms than most of the other women, and not only considered her periods trouble-free, but beneficial. She indicated that accepting the loss of her periods was an emotional issue she’d had to confront post-hysterectomy. Even though Toni was not traumatized, for her, hysterectomy separated her from the body she once knew and appreciated and the change represented a transition. For some of the women the permanent loss of their <3apacity to bear children was a highly salient aspect in their decisions to have hysterectomy. .At some point during ‘thezhysterectomy process most of the women had to come to terms with that aspect of hysterectomy. Due to cxmnplications from a tubal pregnancy, Paula had difficulty getting pregnant and came to resent her very painful and problematic reproductive organs. 229 I never recovered from it and I had wanted lots of babies and then I couldn’t have anymore and no matter what the doctors did, you know, they could not fix it. It could not be fixed. Then I hated them [her reproductive organs]. Then I was like, why do I have these things that just give me misery if it doesn’t work. Paula’s alienation from her reproductive organs is apparent. According to Freund and McGuire (1991), illness that is experienced as overwhelming, unpredictable, and uncontrollable can impact one’s self-concept because it incapacitates a person’s ability to act and manage one’s life in a customary fashion. Extremely ill individuals frequently develop a certain amount of alienation from their body because it no longer feels familiar or normal. However, in attempts to eliminate her pain and to conceive, Paula had undergone countless consultations, and submitted her body for numerous diagnostic tests and surgeries. It is likely that her illness, chronic pain and the innumerable invasive examinations and procedures she endured contributed to her objectification of her reproductive organs. Even though Paula couldn’t manage to conceive, she felt a great loss after her physician recommended a hysterectomy. She realized that even if medical science eventually jproduced a technology that could have enabled her to cxnuceive, it would not benefit her post-hysterectomy. Her feelings towards her reproductive organs, as useless since 230 they were not capable of achieving their sole purpose, influenced her decision to actively pursue a hysterectomy in order to eliminate her chronic pain. Paula indicated that had her physician given her any hope of conceiving that she would not have had a hysterectomy. After doing extensive research on endometriosis and hysterectomy, and after years of trying alternative treatments, Debra decided that hysterectomy was her only remaining option. Even Debra, who had never seriously considered having children, had to come to terms with the ending of her reproductive capacity. I also think that even though having biological children was never a big deal to me, the finality did strike me at times. I'm sure even if I didn't have the surgery I wouldn't have had children anyway, but being backed into the wall and having to say it out loud takes emotional effort. Cheryl had also decided not to have children prior to having her hysterectomy, “It was a very tough decision for Ine because I was giving up something I really did want. I really did want children." Yet, after having a hysterectomy (jheryl felt a sense of loss and felt less feminine. “I :never did have children, and now the choice is gone.” Many of the women in this study express beliefs that :suggest that the primary importance of female reproductive cargans is to produce offspring. Most of the women demonstrate fragmentation of self in which their 231 reproductive organs are considered as separate from their selves, rather than as necessary and beneficial parts of an integrated self. Even the women who did not have chronic pain, or were not incapacitated by their health problems, demonstrate alienation from their reproductive organs, therefore, the women’s fragmentation is not simply the result of chronic illness. Although there are likely numerous social forces, particularly in a patriarchal society, which contribute to the women’s fragmentation, invasive medical practices and the authority of physicians to both determine health care protocols and to define patient’s bodies and bodily states are contributing factors to a fragmented sense of self. Therefore, the medical construction of gender through common unedical practices and treatments, contributes to the women’s fragmentation and can be viewed as indirectly influencing vumnen’s decisions to have hysterectomies. No matter what their attitudes were regarding the desirability of bearing children, the women’s decisions to have hysterectomies focused more on the impact of the elimination of their reproductive capacities, rather than on the effect of having a part of their selves removed. 232 The Influence of Physician EXpertise and Authority on WOmen’s Decisions to have HYsterectomy Overall, the women report having had mostly satisfactory relationships with various physicians over their lifetimes. Without exception the women report having had, at the time of their hysterectomies, complete confidence in their physician’s ability to diagnose their need for a hysterectomy. Similarly, none of the women questioned their physician’s ability to successfully perform a hysterectomy. However, Jill, Mary, Marie and Terri had some regrets that they’d done so. Jill was forty-six years of age at the time of her hysterectomy. Her doctor inadvertently removed both ovaries during the surgery. When she was asked if she was confident in her doctor’s ability to operate successfully, she replied, “Yeah! I was until he didn’t do what I asked.” Nevertheless, Jill did not regret having had the hysterectomy and eventually felt that it had been a beneficial decision. Mary did have regrets about having had the hysterectomy, but only later after she’d developed osteoporosis, which she attributed to having her reproductive organs removed. At the time of her surgery Mary was forty—three years old. She had such complete confidence in her doctor and respect for his authority that She never questioned her need for a hysterectomy. 233 He just said, “well, we’re going to do a hysterectomy,” that’s it. I said, “okay." You believed him, he was your [my] doctor for thirty- some years....So he said, “we’ll just do a hysterectomy,” and not looking for a second opinion or nothing in them days, you just did what your doctor said, you trusted him. Mary feels that if she were to face the decision to have a hysterectomy at this point in her life that she’d proceed differently. At the time of her hysterectomy, twenty-four years previous, she feels she related to doctors differently than she does presently. Mary felt that if she’d known about the possible long-term consequences of having a hysterectomy that she might not have unquestioningly accepted her doctor’s decision. Although she was satisfied with her doctor’s explanation of hysterectomy at the time, Mary indicated that if she were presently faced with the decision, “I would like to have a second opinion, find out more about it.” At thirty years of age, Marie also had complete confidence in her doctor. She stated that she knew of no other options at that time and that her physician did not present other options to hysterectomy. Although she doesn’t regret having had a hysterectomy, like Mary, she indicated that she would not proceed in the same manner if she were presently facing the decision to have a hysterectomy. Well, you know, I would do things differently....Maybe I would have gone to another 234 doctor for one thing, for a second opinion. I didn’t know that then....now I think I would ask a lot of questions than I probably did then, and I would have more doubts about one physician having all the answers....and I would probably research things and I would be more concerned than back then. Like all the other women, Terri , who had a hysterectomy at twenty—three years of age, also had complete faith in her doctor. She had initially resisted having a hysterectomy, but her doctor pressured her and presented hysterectomy as the only option to alleviate her problematic menstruation. Terri felt he’d essentially made the decision for her. She related that her physician informed her that, “We’ve reached the point where we need to do hysterectomy on you.” You know, I was young, stupid....He was a god, he was a doctor. I thought doctors knew it all. At that age in my life. Now? Today? No. But that age in my life, okay he’s the doctor, and I’m the “yes” mam....I thought he knew exactly what was going on with my body. At the time of the hysterectomy Terri completely accepted her physicians authority to determine how to best enable her to be normal. She was confident that her physician would only perform a partial hysterectomy, as he’d initially suggested and which she’d later requested, but he performed a complete hysterectomy, taking both ovaries against her expressed wishes. Terri had terrible difficulties after her hysterectomy and regrets that she trusted her physician. 235 Denise also regrets her decision because she’s suffered extreme depression and menopausal symptoms (despite HRT) ever since her hysterectomy, but she’d had total confidence in her physician and believed she had no other options at that time. She admits that she’s not certain that her depression is entirely due to her hysterectomy because her husband died shortly prior to her surgery, but she attributes her physical health problems entirely to her hysterectomy. These women based their decisions to have hysterectomy primarily on the fact that their physicians had determined their need for hysterectomies. Although other factors were influential in the decision-making process (e.g., a desire to end their reproductive health problems, an end to their need to deal with the social difficulties associated with heavy and painful menstruation, the fact that they’d had or did not want children) they trusted that their doctors’ knowledge and medical ethics would ensure a beneficial outcome. The women did not question the motives of their doctors. They assumed their physicians’ behavior was determined by medical ethics. Only later, after Terri had already had organs removed that she’d expressly directed her doctor to retain, did Terri question the motives of her physician. 236 The Influence of.Medically Promoted Benefits of Hysterectomy on the WOmen’s Decisions to have.Hysterectomies The messages conveyed by Cheryl’s physician defined female reproductive organs and menstruation as a burden. He mentioned that not having a period any longer would be a benefit of hysterectomy. At Ann’s follow up visit after her hysterectomy her physician inquired, “Well, did you have a burning party?” She was asking if Ann had burned her tampons and pads. The implication of the doctor’s question is that menstruation is a burdensome and problematic bodily function which women are better off without. However, the message does not problematize the social relations surrounding menstruation, rather it implicates women’s bodies as producing problematic or morbid effluvium and in need of medical transformation. Hysterectomy is medically promoted as a routine, safe and effective cure for women’s inherently morbid reproductive organs. Women accept negative medicalized views of their reproductive organs because they echo and reinforce societal gender norms. Pat’s doctor told her that since she’s older and didn’t want to have more children, the simplest thing to do was to have a hysterectomy. “He gave me a booklet and seemed very matter of fact about it all, kind of like no big deal....he said this was the only way to cure the bleeding.” Jill assumed hysterectomy was not a 237 dangerous surgical procedure and that recovery was a uncomplicated matter. Well, I didn’t know what to expect, I didn’t know it [the hysterectomy] was going to be harmful, I figured it’s just routine, because it’s so routine for everybody who had them. Pat stated, “I think I felt this was a normal course of events for women.” Medical promotion of hysterectomy as normative and being exposed to other women’s acceptance of hysterectomy as a normal and uncomplicated medical procedure to reduce disease risk, increase longevity, and improve a woman’s quality of life contributed to some of the women’s decisions to have hysterectomies. In addition, nine of the women chose the more radical procedure and had both ovaries removed upon the recommendation of their physicians. Such choices were viewed by some women, either pre- or post-hysterectomy, as a means of maximizing their chances for continued health by avoiding ovarian cancer and/or possible future gynecologic surgery. Although women’s reproductive organs are generally viewed as morbid, physicians and the women view the various reproductive organs as having slightly different value. Retaining the uterus is not considered at all beneficial once a woman has reproduced, whereas conserving one ovary was regarded as advantageous. The ovaries, under the 238 biologically reductionist perspective of biomedicine, have value in that they produce mood regulating hormones. Since scientific research has demonstrated a possible health advantage to possessing functioning ovaries, some physicians and women were concerned about keeping one ovary. Nevertheless, retention of one ovary was still considered risky because of its potential to develop disease. Leaving one ovary was considered, by many of the women and their physicians, a trade-off. Conserving one ovary was sufficient to maintain a woman’s psychological balance while still lowering her risk of developing disease. Cindy wanted to retain her ovaries if her doctor determined during surgery that it was in her best interest to do so. She wanted to avoid taking HRT because she believed it would make her nervous. I knew people that did [have total hysterectomies] , yeah, I knew girls that did. Of course the only thing that worried me was everybody was always a nervous wreck because they were on hormone pills. And since I was a high strung person...he said he’d do everything in his power to try and keep my ovaries. Historically, health care practitioners believed women were dominated by their wombs (Bart & Scully, 1979). The women’s experiences with the hysterectomy process suggests that, along with medical technological advances which can measure hormone production, the ovaries have taken the place 239 of the uterus as the locus of women’s psychological stability or instability. Even though Cheryl has informed her doctor that she’s experiencing physical symptoms associated with menopause, her doctor denies she’s experiencing menopause because he did not remove her ovaries. However, Cheryl discounts this knowledge claim in favor of her embodied knowledge. I feel weird. I get warm, the doctors check me and check me. He says there’s nothing wrong....They say, “you can’t be getting any warmer, you still have your ovaries.” Ha! When the ovaries are determined by the physician to be too diseased or damaged to conserve, or they are deemed too likely to “turn bad” the next best option is to remove them and place a woman on HRT. Physicians assume that HRT is an effective alternative to natural hormones, however a number of women in this study reported that they experienced physical problems usually associated with naturally occurring menopause. Jill, Pat, Denise, and Terri all described having problems either initially, or for a number of years after surgery, even though they were taking HRT. This suggests that the efficacy of HRT may be exaggerated. For some of the women, their fear of developing ovarian cancer and the possibility of having to go through another surgery motivated them to have both ovaries removed. Paula states, 240 I didn’t care if they took the [remaining] ovary or left the ovary. I preferred actually that they take it all out instead of running the risk of having to go back in and take it out. And he said that was one of his concerns, that you [he] couldn’t guarantee that the ovary wouldn’t go bad. Ethel felt that having her ovaries removed in a complete hysterectomy would eliminate the need for future gynecologic operations and the possibility of gynecologic cancers. Similar to many gynecologists, she viewed hysterectomy as a prophylactic measure to prevent ovarian cancer. Alice pursued a hysterectomy because she felt that it would rid her of “these disgusting periods,” and she wouldn't have to ever worry about giving birth to a deformed child. Despite her physician’s protests, she insisted he do a complete or radical hysterectomy to avoid being opened up again. The women’s acceptance of negative medical constructions of female reproductive organs made them more amenable to medical promotion of hysterectomy as a preventive health measure. Viewing hysterectomy (more accurately “oophorectomy” but few women make the distinction) as a prophylactic measure influenced some of the women’s decisions to have more radical surgeries which removed an ovary or ovaries along with a woman’s uterus. Additionally, the medical promotion of hysterectomy as a routine, safe and effective remedy for women’s inherently 241 morbid reproductive organs also influenced some of the women to decide to have hysterectomies. The Influence of.NOn-Physician Sources of Information on the WOmen’s Decisions to Have Hysterectomies Some differences do exist in how the women came to accept their need for hysterectomy. Although some of the women relied solely on their doctor’s diagnoses and unquestioningly accepted their need for hysterectomy to ameliorate their problems, many of the women who’d tried a variety of medical treatments decided on hysterectomy based on their experiential knowledge. Seven of the women sought out information about their specific health problems beyond that supplied by their physicians. Debra conducted extensive research, reading medically informed books on women’s reproductive health, hysterectomy and endometriosis. She also researched these tOpics on-line. Alice conducted similar, but less extensive research. Terri consulted members of her family who are nurses. Janice watched various television programs, such as “Oprah,” addressing the subject of hysterectomy. Additionally, a few of the women spoke with friends or family members who'd had hysterectomies. These women sought out a variety of other sources of knowledge in order to increase their understandings of the nature of their health problems, and/or the medical 242 treatments available (including hysterectomy) and their associated risks. Therefore, although the influence of their physicians’ expertise and authority may have been highly influential in their decisions to have hysterectomies, the women who sought information from non- medical sources empowered themselves to make more fully informed decisions concerning their need for hysterectomy. The women who did not seek out other sources of information were more likely to rely on their physicians’ expertise and authority in order to make their decisions. The two women who performed the most extensive research are similar in that they both hold advanced degrees. Debra has an M.A. and Alice has a Ph.D. Terri, who also has an M.A. sought information from family members who are medical professionals. Advanced education may account for the types of resources (medically informed texts/agents) to which these women turned for information. The other women who sought information tended to rely on experiential knowledge to become more informed about hysterectomy. However, both types of information are to some degree influenced by medical ideology, although the extent to which other women's experiences of hysterectomy accurately reflect medical ideology and care as promoted by physicians cannot be determined. 243 A few of the women’s decisions to have hysterectomies were also influence by the experiences of friends or family who’d had hysterectomies. Even so, as in Cheryl’s case, it is possible to privilege physician expertise over actual experience. For example, although Cheryl’s sister-in-law related information about her own terrible experience with her hysterectomy, Cheryl relied on her physician’s expertise who dispelled the “myths” promoted by Cheryl’s sister-in- law. Conversely, Kelly’s step-mother positively supported hysterectomy. Kelly states, “His wife was very supportive, she had gone through it so she was very supportive, and she kept telling me how much better she felt after hers.” Cindy spoke with friends who’d had hysterectomies. In these instances, the experiential knowledge of friends simply supported the women’s physicians’ stance on hysterectomy. Ann expected her hysterectomy to be beneficial and problem free because of witnessing what her mother experienced and from talking to her friends who’d had hysterectomies. Ann states, I mean my mother had one and she was great...and there were several people that I know that had had them and nobody had ever had a bad word to say about them. Terri received mixed messages about the effects of hysterectomy from her aunts and felt ambivalent about having a hysterectomy. 244 I remember my aunts would be talking about, “just wait till you go through those hot flashes, I tell ya’.” And another aunt was like, “oh my, I had a hysterectomy, it was the best thing that ever happened to me.”....I remember one of my aunts talking like, “oh, I don’t know what was worse, having that hysterectomy or being on hormones.” Terri had reluctantly agreed to undergo a hysterectomy, and only consented after being pressured by her physician. She experienced great difficulties (depression, feeling fragmented and less feminine) after her hysterectomy. It is possible that Terri’s negative post-hysterectomy experiences may have been partly a result of her feelings of ambivalence produced by her aunts’ mixed messages. Whatever their eventual impact post-hysterectomy, these messages influenced Terri’s reluctance to undergo hysterectomy, nevertheless, she privileged her physician’s expertise and authority and had a hysterectomy. Debra had witnessed her mother’s long-term reproductive health problems and felt that her mother’s hysterectomy had an exceedingly beneficial impact on her mother’s health and quality of life. Four of my aunts had had the surgery, but most of my experience came from my mother's surgery. She had suffered for many years--which now I see was pretty much the same symptoms as mine, but she seemed to hemorrhage a great deal and had to have blood transfusions. At one point her blood count was so low a nurse couldn't understand how she could be conscious and standing. At the time, in Illinois, a woman couldn't have a hysterectomy until after she was 40 years old. You don't want 245 to know my opinion on that piece of male-induced legislation. So she suffered until then and by the time she had it, she was so worn out, it took her a long time to recover. She was in bed a long time. But it made quite a difference in her, she seemed to blossom after. She learned to drive, she was always afraid before and went to college and became a nurse. I don't mean to say that a hysterectomy opens the kingdom doors and great and wonderful things transpire, but I think, for some women, it frees up a lot of time and energy that otherwise is spent dealing with medical problems. Debra’s witnessing of her mother’s hysterectomy process was highly influential in her decision to have a hysterectomy. Based on her mother’s hysterectomy results, Debra expected a highly positive outcome from her own hysterectomy. This influence, combined with Debra’s painful and debilitating health problems, her own research, a lack of desire to have children, and her trust in her physician’s expertise, convinced Debra that hysterectomy was her best option. Few of the other women were as informed about their health problems and hysterectomy as was Debra. The Influence of Receiving Alternative.Medical Therapies on the WOmen’s Decisions to have Hysterectomies Whether or not their physicians presented or tried alternative medical therapies had no impact on the women’s perceptions of their doctor’s competence, but it did influence their decisions to have hysterectomies. Fourteen of the women tried one or more medical treatments prior to deciding to have a hysterectomy. Three of these women felt 246 that they’d tried every type of medical procedure or medication available to treat their problems. For these women, hysterectomy represented their last hope for eliminating the basis of their health problems. Six of the women report that their physicians did not offer any alternative to hysterectomy, nor did they ask their physicians if alternatives were available. For these women, their confidence in their physicians’ expertise to diagnose their need for, and perform hysterectomy strongly influenced them to decide to have a hysterectomy. Prior to their hysterectomies, the women did not question the motives or competencies of their physicians. Cindy is the only woman in the study who consulted another physician for the purpose of confirming her physician’s diagnosis and recommendation of hysterectomy. However, six of the women had already consulted numerous physicians over the years because of the enduring nature of their health problems. The influences on the women’s decisions to have hysterectomy include (a) their physicians’ authority and expertise to define “normalcy,” and determine treatment options, (b) the women’s acceptance of medicalized notions of women’s reproductive organs as inherently morbid and useless outside of reproduction, (c) a desire to be free 247 from a host of physical and social problems associated with their reproductive organs, (d) experiential and non- physician medical information, and (e) ineffective alternative medical therapies. Problems and Costs Associated with Hysterectomy Although a number of the women describe difficult experiences with various doctors over the course of their lifetimes, as well as experiencing some concerns about the process of hysterectomy, at some point they came to accept their physicians’ diagnoses and recommendations for hysterectomy as their only remaining option. However, their acceptance did not negate feelings of ambivalence for many of the women. Despite the fact that the women generally report having no regrets about having had their reproductive organs removed, and most detailed the benefits of hysterectomy, they also spoke about the various problems/costs that hysterectomy entails or produces. Although some of the women sought scientific and/or experiential information on hysterectomy, the majority relied on their physicians to inform them about the manner in which the procedure would be carried out, and the possible health repercussions of having one’s reproductive organs removed. None of the women’s physicians discussed the possible long-term effects of hysterectomy. Seven of 248 the women felt their doctor’s explanation of hysterectomy was not thorough, that they were not adequately prepared or given information about what to expect during and after a hysterectomy. The remaining thirteen women described their doctor’s explanation of hysterectomy as either adequate or thorough. Ambivalence towards their medical care during the hysterectomy process is demonstrated by the women’s explanations of what they actually experienced, rather than by their response to direct questions. For example, the majority of women felt that their doctors’ explanations about hysterectomy were either adequate or thorough, yet some of these same women describe hysterectomy experiences for which they’d obviously not been prepared. For example, Jill’s attitude towards hysterectomy prior to surgery was that it was a common procedure that would entail an uncomplicated recovery. Her experience proved her assumptions wrong and during the interview she remarked that perhaps her doctor had not informed her as well as she’d thought. My knowledge was, oh, you have a hysterectomy, no problem, you get over it real easily. Took me three months....I knew that some people very quickly they’d get over it, you know, and be walking. I was just terrified, terrified because I had other stuff going on in my life so I thought, this is it....I was scared I wasn’t going to make it....Very stressful. And nobody told me 249 my insides were going to have to move around, so every time I turned over in bed the insides would switch. Well nobody told me that this was going to happen, so I was not prepared for what was going to happen afterwards. That I think they need to do a much better job....Well, I didn’t know what to expect, I didn’t know it was going to be harmful, I figured it’s just routine because it’s so routine for everybody who had them. Mary, Denise, and Cheryl had menopausal symptoms despite having HRT, and even though Mary’s only stated regret was that she had to take estrogen, she later commented, Well, now I don’t think I needed it [hysterectomy], but it took me all these years to figure that out, but I really could have gone without it, and probably wish I hadn’t because of the estrogen and all that [osteoporosis]. Kelly, Paula and Cheryl report unexpected difficulties during their recoveries. Alice and Janice experienced unexpected pain when they each became conscious during their surgeries. Alice had hoped that her hysterectomy would cure her endometriosis, but recently has experienced a return of the symptoms which lead her to seek a hysterectomy in the first place. Cheryl, Denise, Terri and Pat report post- hysterectomy depression, and Debra, Cheryl and Terri conveyed feeling less sexual. The women’s experiences of the costs of hysterectomy suggest that they were not fully informed prior to consenting and actually undergoing a hysterectomy. Even the 250 physicians who provided extensive information on hysterectomy failed to include important information which may have influenced the women’s decisions to have hysterectomies. The Benefits of Hysterectomy When asked if they were satisfied with the results of their hysterectomy, most of the women were quite adamant in conveying their satisfaction with having had their reproductive organs removed. The majority of the women mentioned various “freedoms” they had gained because they no longer had reproductive organs. Those women who had suffered painful menstruation or non-menstrual abdominal pain remarked on how wonderful they felt to be free of the pain. Virtually every woman, even those who had not experienced pain prior to their hysterectomy, expressed pleasure at no longer having to deal with menstruation. The women mentioned being free from the “mess” of menstruation, the embarrassment when they were unable to conceal their menstruation, the worry about starting a period in public without having any pads or tampons, having to always be prepared in case they started, and having to buy menstrual products. When the women spoke of the benefits of no longer having a menstrual cycle, many were delighted, with some of the women expressing their joy in a humorous or smug 251 fashion. Becky states, “I have no regrets, none whatsoever. Except for when my daughter has friends over and they come to me and ask have you any Tampax? No, sorry, I don’t use them anymore!” Ann expressed her delight in the following way. Well you know, you think ha ha, should I really say this? I guess I could. I have a twelve and a half year old daughter who now has her monthly cycle and shame on mother for thinking ha ha, she doesn’t have to go through that anymore. Naughty, Naughty mother....I know, but she dealt with it all those years so it’s somebody else’s turn.... I know that I don’t have to deal with that anymore. Oh, that’s the best part! Ethel had not experienced any pain prior to her hysterectomy and had not had excessive menstrual bleeding, but she too was delighted to be a non-menstruator. I say now, now that it’s all over with, if I’d known I had to have a hysterectomy I would have done it a lot earlier, because then I’d have eliminated all this mess for years and years and years and years!....I knew I’d already made the decision not to have children. Like I said, if I’d known I wasn’t going to use it, it would have been nice to have it out a long time ago. Agnes also felt happy to be freed from her menstruation which she had always disliked. Well for me it made a very positive difference and not only relief but comfort! I still, people have asked me about it, didn’t it bother me that I had to have one, and I said, well, because of the outcome it was fine, but as far as I was concerned it was the greatest thing that happened to me. I didn’t have to, you know, a few years sooner I got rid of the mess. I never did like that part, I never embraced that part of womanhood. 252 Pat also had never liked her periods and states, “I didn’t miss my period, I was thankful as they were always painful, messy and disrupted my life.” Cheryl stated she was frightened prior to her hysterectomy, but indicated that had she only realized what it was like to never have a period again she would have just been happy rather than afraid to have a hysterectomy. Well, I mean, now I don’t have to worry about if on Christmas Eve, Christmas day, or New years, or anytime, when we’re going on vacation, the day we’re going to leave....I’m not going to start! I mean that is like one of the major advantages. We all laughed about it, “yeah, I felt bad for about a month, and then I realized I wasn’t going to have a period and I’ve been feeling really good about the whole situation.” No birth control, no nothing! You’re like this free woman!...Probably the most positive is this newfound freedom, I don't always have to be concerned with whether I’m going to start or not....I have liked the freedom, like I said, that I don’t have to be concerned about the period thing anymore. And that is a big load off the shoulders. And the cramps and having to buy all that stuff. Michelle, like three of the other women, also mentioned that the freedom from worrying about unplanned pregnancies was a benefit of no longer having reproductive organs. I had more energy and I felt like it gave me a freedom that I hadn’t had for a long time, because I wasn’t tied to the periods like I’d been for so long....The whole thing [sexual intercourse] is better because I felt better, more relaxed, I don’t have to worry about an “oops!”....Or pain. I find the whole thing a lot more enjoyable. 253 Post-hysterectomy, the women felt free to go whenever and wherever they pleased without taking, or even considering precautionary measures to prevent menstrual “accidents.” The women’s attitudes towards the elimination of their menstruation are at least partly a result of the oppressive societal attitudes towards women and menstruation, as demonstrated by the strictures of menstrual etiquette. Above all else, the stigma associated with menstrual blood requires that it must be concealed, that is, controlled (Laws, 1992). Many of the women disliked their menstruation because it was difficult to control, (which can be true of normal menstruation) and failure to control it was associated with negative self and social evaluations which reflected on their status as sufficiently feminine. The medicalization of menstruation produces self- regulation of menstruation, such that women monitor the “normlacy” of their menstruation and present themselves to gynecologists when that normalcy is in question. The medical management of their menstruation is also carried out during their regular gynecologic examinations. The careful medical management of women’s reproductive organs results in frequent exposure to gynecologists who are trained to expect pathologies and to use surgical means to treat pathologies. Consequently, the possibility exists that some of the women 254 in this study may have had normal periods and/or reproductive organs which were medically defined as abnormal because of the prevalent negative social and medical meanings associated with menstruation. All of the perceived benefits of hysterectomy had to do with the women’s perceptions of greater freedom. They mentioned the freedom of no longer having to worry about or be responsible for birth control which enabled them to have greater freedom to engage in sexual relations without worrying about unwanted pregnancies. When asked if having a hysterectomy changed her life in any way, Jill responded, Well, I don’t’ have to worry about birth control, other than condoms say....I don’t have to worry about what color I wear, in case things get too heavy, for the period. Women are primarily responsible for birth control and along with this responsibility comes a host of inconveniences and possible health problems. For example, being on “the pill” can have health repercussions and, although it is considered one of the most convenient forms of birth control its effectiveness depends on whether or not a woman remembers to take it on a regular basis. However, its distribution is controlled by physicians, as are many other types of birth control. Women are compelled to consult physicians in order to obtain certain methods of 255 birth control. Therefore, the women's views concerning the freedom hysterectomy provides in terms of birth control may mean that hysterectomy also diminishes their reliance on medicine to provide certain forms of birth control. Menstrual etiquette includes strictures against sexual intercourse/relations while a woman is menstruating (Golub, 1992). For many heterosexual women, adequate birth control and/or not being on their period are two conditions that must be met in order for them to be willing to participate in sexual relations. Hysterectomy enables women to have both conditions met simultaneously. Therefore, hysterectomy permits greater sexual freedom for the women because they have been relieved of the responsibility for birth control, and the end of their menstruation allows them to participate in sexual relations on a discretionary basis. However, hysterectomy also removes a socially accepted rationale for the avoidance of sex, being on one’s period (Laws, 1990) and, therefore, it can also create the perception that women who don’t have periods are continuously sexually available. Only a few of the women stated that getting rid of their periods, which were considered abnormal and pathological, was one of the primary reasons they decided to have a hysterectomy. All of the women, even Tony and Terri who hadn’t objected to their periods, were quite pleased 256 that they no longer had to deal with the socially problematic aspects of menstruation. Hysterectomy also enabled women to achieve normative gender behaviors and bodily states. For example, Cindy states, “I felt wonderful, I started losing weight, wasn’t even trying." When Carol was asked if she felt any different about herself after her hysterectomy, she replied, Probably different than other women, because they always feel like less of a woman. I’ve had so many tell me that, but I felt better. I felt like a human being again. I mean it just, when you go through something like that, for so many years, you suffer depression. And you don’t feel like a human being. So you don’t feel like a woman, you don’t feel, and after that [hysterectomy] all those feelings came back, and I felt better about myself. So, for me it was just a tremendously positive experience....I think I felt like I’d been re-born after I had my hysterectomy. I became a person again. Because I had had such a time for eleven years. Eleven years is a long time to go through that. The list of all the freedoms the women mentioned, and their highly appreciative attitudes towards the benefits of no longer having reproductive organs, suggests that having female reproductive organs in a patriarchal society is highly oppressive. The feelings Cheryl vocalized seems to sum up the benefits most of the women experienced, “You’re like this free woman!” For many of the women, such freedom had not been experienced since before their menarche, a bodily function signifying womanhood (Golub, 1992). 257 Summary The primary influence on the women’s decisions to have hysterectomies was their belief that hysterectomy would eliminate their reproductive health problems. This belief was predicated on the women’s acceptance of the expertise of biomedicine to determine the nature of their health problems and its ability to effect a cure. The women’s decisions were also influenced by medical constructions of women’s reproductive organs as inherently morbid, and useless and/or dangerous once they had produced children. Although not every woman expressed concern about the possibility of developing gynecologic diseases, the majority engaged in gynecologic screening, the purpose of which is to detect gynecologic disease. A fear of cancer was also a contributing factor in some of the women’s decisions to have hysterectomies. The women’s concerns regarding the likelihood of reproductive disease is partly generated by biomedical promotion of routine screening, but also by the fact that some of their physicians used the term “pre- cancerous” during consultation. Other influential factors contributing to several of the women’s decisions to have hysterectomies included the frequently demanding responsibility of achieving menstrual etiquette. Physicians promote notions of what constitutes 258 “normal” menstruation, even though medical science lacks a great deal of information on normal menstruation (Golub, 1992). Biomedicine also situates itself as an enabler of menstrual etiquette. Therefore, physicians, through consultation and treatment, construct embodied gender and contribute to women's oppression by fostering the very social conditions which help to create women’s need to seek medical intervention. Women rely on medical care to help them meet the strictures of menstrual etiquette, however, biomedicine focuses on individual solutions to gendered social problems. Consequently, biomedicine’s reinforcement of menstrual etiquette influenced some of the women’s decisions regarding hysterectomy. Other medical views and behaviors that influenced some of the women’s decisions to have hysterectomies include (a) the assumption that, for women, HRT is a safe and effective alternative to retaining potentially hazardous reproductive organs, (b) the promotion of hysterectomy is a highly beneficial medical treatment, and (c) the failure of physicians to inform women about the long-term risks associated with hysterectomy. Other influences on the women's hysterectomy decisions included, (a) fragmentation of the self, (b) the experiential knowledge of other women who’d had hysterectomies and medical knowledge gained 259 through independent research, (c) a woman’s own lack of desire for children, and (d) having received alternative medical therapies. From the women’s standpoint, hysterectomy achieves a number of benefits for women. Primarily, hysterectomy eliminates health problems for those women who experienced pain, excessive bleeding and exhaustion from their menstruation, although for some women hysterectomy was not the permanent cure they were seeking. Hysterectomy also enabled the women to permanently achieve menstrual etiquette, they no longer have to worry about negative social sanctioning for failure to achieve menstrual concealment. By eliminating the physical health and social problems associated with problematic menstruation, hysterectomy enabled the women to improve their quality of life and more fully engage in the tasks and activities of daily living (which include but are not limited to social reproduction). Hysterectomy also eliminated the women’s responsibility for birth control, which enabled some of the women to participate more easily in sexual relations. Hysterectomy means freedom for many women because they are released from many responsibilities and certain aspects of oppression based on the fact of their embodied gender. 260 The primary cost of hysterectomy is hidden, women’s lives and bodies continue to be defined and altered according to medical knowledge and authority which does not fully consider women’s knowledge and desires. Women need a non-fragmenting, or less invasive treatment for the numerous reproductive health problems which are, at present, too frequently treated through hysterectomy. 261 CHAPTER 8 SUMMARY AND CONCLUSIONS Feminist perspectives contend that all social institutions are gendered and that the power relations within them construct gender (Abbott & Wallace, 1990), including those produced through women’s participation in medical health care (Martin, 1987). Although numerous feminist analyses have sought to delineate the character of medical power relations, only a handful have examined how specific medical diagnostics or treatments construct gender. Analyses addressing the medical power relations associated with medical treatments or diagnostics differ in terms of how power relations are characterized. The present study problematizes the hysterectomy process and examines the medical power relations involved in this process in order to gain an understanding of the nature and impact of these relations on women’s perceptions of their selves, bodies and appropriate gender roles. Standpoint theory was used to develop a perspective driven methodology emanating from the lived realities of women’s participation in the medical power relations involved in the hysterectomy process. Discussion The women’s participation in the medical power relations associated with hysterectomy was highly influenced 262 by their lifelong exposure to general social acceptance of biomedicine’s efficacy, and its legitimate authority to define normal and abnormal bodily states and appropriate gender behavior and roles. The women’s exposure to, and varying levels of acceptance of biomedicine’s expertise and authority, and their participation in medical power relations, commenced prior to the consultations with their doctors that resulted in hysterectomy. Throughout adolescence and adulthood the women were exposed to medical ideology and influence through diverse modes of contact. As adolescents, the women encountered messages from a variety of social agents (educational, media, and their mothers) which promoted the legitimacy and efficacy of biomedicine, and the normative functions of medical expertise, authority, and management in women’s lives. These messages also included strictures on appropriate gender behavior, particularly female behavior during menstruation (menstrual etiquette). As is evidenced from the women’s adolescent experiences, the medical construction of gender occurs both during and outside direct medical encounters. The medical construction of gender, throughout an individual’s life, occurs as one part of a complex gender system in which diverse social institutions 263 and agents independently and conjunctionally define and promote appropriate gender behavior. Several of the women experienced menstrual problems early in life, some at menarche, prompting them to initiate a long-term associations with various gynecologists. As adults, the women routinely interacted with gynecologists and other medical professionals as they sought preventive health care (e.g., periodic pelvic examinations and Pap tests, prenatal care, etc.) and/or a means to address health problems. The women’s belief that females need to have their reproductive organs medically monitored is demonstrated by the fact that all of the women, at some point in their lives, engaged in routine pelvic exams and Pap smears, despite their dislike of these experiences. The women relied, and most continued to rely post-hysterectomy, solely upon traditional Western medicine for the preventive health care of their (remaining) reproductive organs, and internal/external genitalia. The problematic menstruation and gynecologic health problems of many of the women in this study also reinforced the women’s acceptance of medical notions of women’s biology as inherently pathological and needing medical management. However, even those women who did not experience prior, or long-term gynecologic problems accepted stigmatized medical 264 notions of female biology and viewed routine gynecologic monitoring as beneficial and necessary. Most of the women accepted medical characterizations of the female body (i.e., female reproductive organs) and bodily functions (i.e., menstruation) as inherently morbid, and, therefore, as needing regular medical monitoring. Negative medical characterizations of the female body, and the standard medical recommendation for routine gynecologic screening based on those characterizations, also reinforced the women’s understandings of gynecologic monitoring as necessary and beneficial behavior. The women’s various encounters with gynecologic health care influenced their attitudes toward medical efficacy, authority and management, but the extent to which the women accepted medical management was variable. The women’s exposure to messages promoting medical authority and efficacy, and their direct experiences with medical management did not produce unquestioning compliance, and, in some cases, their interactions with physicians actually triggered acts of resistance. The women attempted to direct their health care within the confines imposed by the doctor-patient relationship. All of the women made various efforts to direct their health care, including (a) direct confrontations with physicians, 265 (b) shopping for a new doctor when dissatisfied with their jphysician, (c) delaying routine gynecologic exams, (d) determining amounts and types of medicines they would take, and (e) requesting and pressing their physicians to provide particular medicines or treatments, and/or perform medical treatments or diagnostics in particular ways (including hysterectomy in a few of the women’s cases). The implications of the women’s behavior in medical interactions, their acceptance of medical authority and efficacy, and belief in their need for gynecologic management notwithstanding, is that medical power relations appear to be more relational, rather than traditional, in nature. The Relational Character of.Medical Power Relations Involved in the Hysterectomy Process This study’s analysis of the power relations involved in the women’s experiences of the hysterectomy process demonstrates the relational character of those relations. Accounts of medical power relations using a relational notion of power contend that women are active participants in their medicalization (Gabe & Calnan, 1989; Denny, 1996). The medical power relations associated with the hysterectomy process are experienced by the women as a process of negotiation in which women experience both benefits and costs. Similar to Oinas (1998), who uses a Foucauldian 266 informed conceptualization of power, the present research found that medical power relations includes medical attempts at social control, but are also a means by which women construct themselves through medical interpretations of normal female bodies and gender behavior. In other words, medical power relations are characterized by both health care professional’s attempts to exercise control over women, and women’s attempts to employ medical care as a means to achieve normative bodily states and gender statuses. The women are active participants in the creation of medical power relations and the construction of gender. They are not passive victims. The women’s experiences demonstrate that they seek out and rely on medical care to enable achievement of normative bodily states and gender behavior/display. In that process they are subjected to medicalized notions of normal female bodies, as well as notions of appropriate or normal gender behavior. The medical power relations are negotiated and productive in the sense that the participants, doctors and patients alike, create reality. For example, in various instances, the women chose to privilege other types and sources of knowledge, such as experiential knowledge. Consequently, they selectively accepted and/or disregarded medical constructions of reality. 267 Although most of the women were satisfied overall with their interactions with physicians, some of the women also gave accounts of particular instances in which they recognized and objected to physicians’ attempts to exercise authority over them. A woman’s resistance to a physician’s attempts to exercise power over them depended on the woman’s assessment of a physician’s (a) exercise of authority as appropriate or inappropriate, (b) diagnosis as an accurate or inaccurate interpretation of her bodily state, and (C) provision of medical care as proficient, beneficial and unbiased, or as inadequate, harmful and biased. The women’s reactions to the attempted exercise of physician authority consisted of two strategies. They chose to directly challenge a physician’s interpretation, medical expertise, or her/his authority based on counter knowledge claims, usually those based on embodied knowledge, and/or terminated their relations with a particular physician. A number of women described medical encounters in which their physicians discounted the woman’s knowledge of her own body, as well as her intellectual ability to understand complex medical concepts. The discounting of a woman’s embodied and experiential knowledge is a discursive technique whereby physicians assert the “truth” of medical science, as well as their authority to interpret bodily 268 states. Most truth claims tended not to be questioned by the women in this study unless they were, in the women's estimation, highly inaccurate. Since many of the women, to varying degrees, tended to view their bodies and bodily states from medicalized perspectives, conflicting interpretations of their bodies occurred only occasionally. Consequently, few women in this study chose to directly challenge their physicians, rather, the women most commonly responded by terminating their relations with problematic doctors and establishing relations with other physicians. The women hoped that a different physician would be more likely to validate their bodily experiences and enable them gain health and achieve normative gendered bodily states. The women’s problematic experiences with physicians demonstrate that women, in certain instances, are aware of overt medical efforts to exercise power by subjectively defining the reality of women’s bodily experiences in contradiction to a woman’s experiential reality. However, the women’s physicians in these cases discounted the women’s knowledge of their own bodies and made competing knowledge claims. In most cases, they resisted the women’s requests for particular types of medical interventions, and relied instead on their medical expertise or scientific tests to 269 interpret the medical reality of women’s bodily states and exert medical power. The women’s experiences suggest that challenges to physicians are likely to be met with resistance. This may be a primary reason why, in the face of overt physician attempts to exert control, women choose to switch doctors rather than directly challenge physicians. Additionally, the women tended not to generalize the behavior of one physician to all other physicians, therefore, they expected to be able to secure health care from a physician who would accept their embodied, experiential knowledge. Few of the women demonstrated an awareness of the gendered aspect of their interactions with physicians. Gender tended to be an issue only in circumstances in which a woman felt a physician was treating her experiential knowledge as invalid. Privileging Experiential Knowledge Self-regulation influences the women’s participation in medical power relations. The women know and follow medical protocol, that is, how to behave as a “patient." They may dislike certain aspects of medical management, but they generally accept the necessity for invasive medical procedures and have learned ways to cope with the distress they engender. They do resist being treated in demeaning 270 ‘ ways, and being discounted as ignorant of their own bodies, but, ultimately, the women rely on medical expertise for their reproductive health care and the achievement of socially and medically sanctioned gender behavior/display. Nevertheless, the majority of women in this study did not accept medical diagnoses or knowledge unquestioningly. In their interactions with physicians, the women judged medical knowledge using experiential, or embodied knowledge. Many of the women in this study privileged their own bodily experiences over medical interpretations. Therefore, the production of meaning in medical power relations can be viewed as a process of negotiation, with the participants privileging various knowledges. A physician can either validate or invalidate a woman’s experiential knowledge, and a woman may accept or reject a physician’s medical knowledge based on her experiential knowledge, as well as other sources of both medical and non-medical knowledge. Biomedical knowledge provides a framework which influences the manner in which women give meaning to the physical experience of their bodies (Abel & Browner,1998). However, the women in this study selectively chose to comply with or reject both medical constructions of their bodies and bodily states, and medical recommendations for interventions. 271 Women’s participation in medical power relations can be viewed as beginning with a woman’s attitude towards herself, her bodily state and biomedicine, and her choice to pursue traditional Western medical care as a means of redressing gynecologic health problems and managing normal reproductive functions (e.g., pregnancy, birth control). It is women’s experiential knowledge of their own normal bodily states (and that in comparison with other women’s experiential knowledge) which often brings women to the point where they are ready or eager to consult with physicians, who may or may not validate the women’s experiential knowledge. The Influence of Medical Power Relations on the WOmen’s Decisions to have Hysterectomies The primary influence on the women’s decisions to have hysterectomies was their belief that hysterectomy would eliminate their reproductive health problems, and, secondarily, the social problems associated with achieving adequate gender behavior or roles. This belief was based on the women’s acceptance of the expertise of biomedicine to determine normalcy and its efficacy to remedy the aforementioned problems. The women’s decisions were also influenced by stigmatizing medical constructions of women’s reproductive organs as inherently morbid, and useless and/or dangerous once they had produced children. 272 Other influential factors contributing to the women’s decisions to have hysterectomies included (a) biomedicine’s reinforcement of menstrual etiquette (b) the assumption that HRT is a safe and effective alternative to retaining potentially hazardous reproductive organs, (c) the promotion of hysterectomy is a highly beneficial medical treatment, (d) the failure of physicians to inform women about the long-term risks associated with hysterectomy, (e) the women’s experiences of fragmentation, (f) the experiential knowledge of other women who’d had hysterectomies and medical knowledge gained through independent research, (9) a woman’s own lack of desire for children, and (h) having received ineffective alternative medical therapies. The benefits of hysterectomy from the women’s perspectives included (a) the elimination of health problems, (b) the achievement of menstrual etiquette, and (c) the elimination of the women’s responsibility for birth control. These benefits contributed to the improvement of the women’s overall quality of life by alleviating their physical suffering and releasing the women from certain aspects of gender oppression based on the fact of their embodied gender. However, hysterectomy also entailed numerous costs. 273 With the exception of Terri, the women did not address the costs of hysterectomy in terms of its implications for gender oppression. Therefore, the primary cost of hysterectomy is not fully recognized by the women in this study. Through negotiation of the hysterectomy process, women’s lives and bodies are impacted by medical knowledge/power in ways that frequently reconstitute an oppressive gender system. The women’s perspectives tended to be highly individualized. Although it is possible that this was due to the types of questions they were asked, it may also be partly due to either the highly valued norm of individuality found in the United States, or the individualizing effects of a reductionist medical model. Hysterectomy is viewed by biomedicine as a corrective for women’s deviant and pathological bodies. The women accept and internalize medicalized views of women’s reproductive organs. The very organs, women’s reproductive organs, which are socially constructed as the signifier of womanhood at menarche, are the organs most commonly extracted in the United States, (recall that over one-fifth of women in the United States have had hysterectomies, (CDC, 2000). Nevertheless, most of the women did not report feeling like they were less feminine, or less of a woman, 274 nor did most of the women feel disempowered by the experience. Medical power relations constitute subjects by producing normal gendered bodies. Hysterectomy is a medically sanctioned intervention enabling women to achieve health and dispense with the socially produced burden of reproductive organs, while retaining appropriate and medically constructed gender status. The women did not simply abandon their socially defined reproductive responsibilities, they used medical power to authorize their agenic empowerment. Most of the women had already produced children, and had medically sanctioned legitimate menstrual abnormalities. By providing hysterectomies, biomedicine served as a vehicle by which the women could gain health and freedom by dispensing with the bodily aspects of both pain and disease, as well as gender oppression. From a Foucauldian perspective, “The effects of power, rather are quite material, and potentially empowering; and their site is more often than not the body.” (Mchoul & Grace, 1993). Although gender oppression produces the context in which women seek out medical means for health and bodily normalization, the women do not generally see themselves as passive victims. Nevertheless, the women are highly influenced by medical ideology because professional 275 medicine has limited the field of possible options for lawful and efficacious health care. However, the women are conditionally accepting of medical expertise and authority, as long as its exercise is perceived as beneficial, appropriate (not excessive), authenticating or clarifying of their experiential and embodied knowledge. As long as medical care meets their needs in a non-coercive manner, including the enablement of normative gender status, most of the women do not view their relationships with physicians as defined by power struggles, but as a process of negotiation. The women selectively privileged embodied and experiential knowledges over medical knowledge claims, consequently, they believed that the best medical alternative available to them was hysterectomy. The high rates of hysterectomy are likely due to a combined effect of a) limited alternative medical treatments which are as effective in ending the physical and social problems associated with problematic reproductive organs, and b) the gender bias in biomedicine which has resulted in the lack of effective medical alternatives to hysterectomy. The women’s experiences of the hysterectomy process demonstrate that the associated medical power relations are processes of negotiation, but that attempts to exercise power may be coercive, and may be undertaken by either the 276 physician or the patient. This does not negate the fact that women’s participation in medical power relations both reproduces gender and helps women to achieve socially determined appropriate gender norms in terms of bodily states and reproductive functions. Negotiated medical power relations entail both costs and benefits for women. Women are not passive victims, but, rather, are active participants in the medical construction of gender. Contributions to the Literature This study advances the literature on the medical construction of gender in several ways. First, it demonstrates that traditional conceptualizations of power do not enable an accurate understanding of medical power relations and suggests that the use of traditional notions of power may serve to reinscribe gender oppression through the depiction of women as passive and powerless. The notion of relational power is demonstrated as more helpful in understanding the character of medical power relations. This study also advances feminist theory by explicating the relationship between a specific medical process (hysterectomy) and medical power relations and the construction of gender, thereby revealing a specific venue in which the scientific medical production of knowledge obscures the relations of ruling. 277 This study also examines women’s decisions to have hysterectomy as they are influenced by medical power relations, an issue largely neglected in the sociological and feminist literature. This study also contributes to an understanding of the ways in which standpoint theory may be used as a methodological strategy. This study was structured according to Smith’s (1987) standpoint theory. The methods used were developed out of women’s distinctive perspective on medical power relations associated with their experiences of the hysterectomy process. Therefore, the use of standpoint theory in the present study enables a more critical perspective on its use in feminist and sociological research. Limitations and Future Research This study was limited in numerous ways. Due to the difficulties of locating women who’d had elective hysterectomies who were willing to participate in this study, the resulting sample did not include women of various races and ethnicities. Nor did it include only those women who’d had recent hysterectomies. The sensitive nature of the subject matter also influenced the types of women who were willing to talk about their hysterectomy experiences. Consequently, the findings may not include the experiences of women who had extremely problematic hysterectomy 278 experiences. Conversely, it is also possible that the experiences of women who felt hysterectomy was an insignificant or uncomplicated process may not be represented in the findings of this study. This study was also limited by the fact that the participants were not reinterviewed. Ideally, according to standpoint theory, as issues are clarified and perspectives emerge, it is advisable to query participants with regard to the evolving perspective. However, time limitations and the lack of many of the participants availability for further interviewing prevented reinterviewing. Future research on medical power relations associated with medical treatments might compare men’s and women’s experiences to determine differences and similarities between their experiences in negotiating power relations. Such research would clarify and further articulate the various aspects involved in medical power relations. Research on physicians’ experiences of the medical power relations associated with the hysterectomy process may also contribute to the understanding of the medical construction of gender. However, in terms of standpoint theory, such research would not have liberatory potential since the physician perspective is part of the relations of ruling. 279 APPENDIX A Interview Protocol Sheet Name: .Age: .Age at hysterectomy: Race/Ethnicity: Education: Occupation: Place of Employment: Children: Marital Status: Partner’s Occupation & approximate income Questions: Do you remember your first period? How did you feel about your periods? Do you remember when you first learned about women’s reproductive organs? What did you think of all that? How did you feel about being a human being who had periods and could get pregnant and have babies? Do you remember the first time you saw a doctor for female problems? Can you describe that experience? How old? Did you go on your own? How did you feel about going to a gynecologist or “female” doctor then? How do you feel now about going to a gynecologist or “female” doctor? When would you go to see this doctor? Regularly? Or just when you had a problem? In general, how do you feel now about going to see doctors? How are they helpful? How are they not so helpful? Have you ever had an experience at the gynecologist that was difficult, or that upset you? Can you describe that experience? Was your surgeon male or female? 280 Prior to the time when you actually went to the surgeon who performed your hysterectomy, what did you know about the operation? Had you heard of it? From whom? Did you have any regrets associated with having had a hysterectomy? Starting when you first had symptoms or problems, can you describe your hysterectomy? What factors seemed most important in deciding whether to have a hysterectomy or not? What was good about the experience? What was bad? How did you find out you might need a hysterectomy? (Suspect on own or from friend or gynecologist?) Was it a surprise to learn that you might need a hysterectomy, or did you suspect you might need one? What were the problems that brought you to see your doctor? Who was involved in the final decision to have a hysterectomy? (Parents, spouse, friends, children, doctor?) Prior to surgery how confident were you in the abilities of your doctor to diagnose your need for a hysterectomy? How confident were you in his/her ability to operate successfully? What did you learn about hysterectomy from your gynecologist? Was there any other place you got information on hysterectomy? Before you had the actual surgery, do you remember what you expected to happen? What were your worries surrounding the surgery? Did the doctor tell you how it would happen? How did your doctor explain what would occur during the operation? Were there any surprises? What things did you like about how your doctor explained hysterectomy to you? 281 What things would you have changed (added, improved or eliminated) about your doctors explanation? Did your physician present alternatives to hysterectomy? Did you feel any pressure from your doctor to have the hysterectomy? Did you consider alternative therapies? If so, which ones did you consider and which ones did you actually try? Were they at all helpful? If so, for how long? After having the hysterectomy, how did you feel about yourself? Did how you feel about yourself prior to the surgery change in any way after the surgery? Have you experienced any problems over the years that you attribute to having had a hysterectomy? Are there any emotional issues you’ve had to confront due to having a hysterectomy? Did having a hysterectomy change your life in any way? Given your experience with hysterectomy and what you now know, would you choose to have a hysterectomy if given the chance to choose all over again? 282 APPENDIX B Sample Description Age at Marital* Name Age Hyst. Status Education Occupation Jill 55 46 S M.A. Retail Clerk Kelly 40 35 M H.S Trainer Mary 67 43 )4 some H.S. Homemaker Cheryl 4O 37 M A.S. 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