Gender Perspectives on Health and Medicine, Volume 7: Key Themes (Advances in Gender Research Series)

328 Pages·2003·1.77 MB·English

by  Marcia Texler Segal

CONTENTS
GENDEREDPERSPECTIVESONMEDICINE:
ANINTRODUCTION
MarciaTexlerSegalandVasilikieDemoswith
JennieJacobsKronenfeld 1
SITUATINGEPIDEMIOLOGY
BethE.Jackson 11
GENDERINGTHEMEDICALIZATIONTHESIS
ElianneRiska 59
“BIGPHARMA”INOURBEDROOMS:ANANALYSISOFTHE
MEDICALIZATIONOFWOMEN’SSEXUALPROBLEMS
HeatherHartley 89
THECONTINUUM:SOMATICDISTRESSTOMEDICALIZATION
INWOMENWITHBREASTCANCER:THEORETICALAND
EMPIRICALASSESSMENT
EricaS.Breslau 131
INTERSECTIONALITYANDWOMEN’SHEALTH:CHARTING
APATHTOELIMINATINGHEALTHDISPARITIES
LynnWeberandDeborahParra-Medina 181
“WE’RENOTAPARTOFSOCIETY,WEDON’THAVE
ASAY”:EXCLUSIONASADETERMINANTOFPOOR
WOMEN’SHEALTH
ColleenReid 231
v
vi
RARIUANDLUOWOMEN:ILLNESSASRESISTENCE
TOMENANDMEDICINEINRURALKENYA
NancyLuke 281
ABOUTTHEAUTHORS 323
INDEX 327
GENDERED PERSPECTIVES ON
MEDICINE: AN INTRODUCTION
Marcia Texler Segal, Vasilikie Demos with
Jennie Jacobs Kronenfeld
This is a volume about gender, health and medicine broadly defined. It is based
on the now widely-held assumption in the sociology of medicine that medicine
andhealtharesocialconstructionsandthatgenderisanembeddedpartofthem
(seeLorber,1997).Theessaysrevealthatembeddedwithgenderintheinstitution
ofmedicinearerace,class,andsexuality.Takenasawhole,thevolumeoffersa
critique of exclusively biomedical approaches to personal and public health and
calls for more sociological input and qualitative research to help us understand
aspects of health and illness. Among the recurrent themes in the seven essays
are the medicalization of personal and social problems, the commodification of
healthcare,andquestionsofagency,responsibilityandcontrol.
Theproportionsofwomenandmeninvariousmedicalandalliedhealthfields
fluctuatecreatinganimbalanceintherelativepowerthatwomenandmenhavein
research,diagnosis,healthpolicyandtreatment.Thehealth-relatedconcernsand
accesstoalternativestoaddressthoseconcernsvarywidely.Thevocabulariesthat
weusetodiscusshealth-relatedissuesandthewaysinwhichwedefinewhatis
relevant to our health and well-being are bound by gender as well as race, class
andsexuality.
Medicalization refers to the definition of a particular set of circumstances as
biomedical in nature, in need of research by scientists trained in biology and
medicine and treatment by a physician or other medical practitioner, typically
with drugs or other forms of medical technology. Examples of medicalization
GenderPerspectivesonHealthandMedicine:KeyThemes
AdvancesinGenderResearch,Volume7,1–9
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ISSN:1529-2126/doi:10.1016/S1529-2126(03)07001-2
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2 M.T.SEGAL,V.DEMOSWITHJ.J.KRONENFELD
are menopause and attention deficit/hyperactivity disorder (ADHT). In the
case of menopause these circumstances might be considered a normal part of
aging and therefore not “treatable,” or in the case of ADHT, behavior within
the normal range of childhood variation or an educational problem requiring
alternative teaching methods. Instead, they are currently treated by physicians
with prescription medications. (See, for example, Horwitz, 2002, for a recent
discussionoftheredefinitionormedicalizationofmanybehaviorsandreactions
tosocialconditionsoreventsasmentalillness.)
When circumstances are medicalized they tend also to be treated as “private
troubles” rather than “public issues” to use C. Wright Mills’ (1959) oft-quoted
words. Individuals and their families are made responsible for complying with
the course of treatment prescribed, and any possible part played by the broader
community is ignored. A current pattern, popular since the identification of the
TypeApersonality(astereotypicallywestern,masculinesetoftraits),withheart
disease, is the identification of behavioral or genetic medical risk factors. (See,
for example, “Measuring Behaviors that Endanger Health” on the United States
CentersforDiseaseControlandPreventionwebsite.)Oncetheseareidentified,in-
dividualsareconsideredresponsiblefortheirownhealth.Socialfactorsandpublic
policythatmightcontributetooralleviatetheproblemareignored.AsCockerham
(2000) has pointed out, a person’s life chances are often largely determined by
theirsocioeconomicstatus,age,gender,race,ethnicityandotherfactorsthatshape
healthlifestylechoices.Obesityisanexample.Poordietandeatinghabitsplace
one at risk for obesity which further puts one at risk for heart disease, diabetes
and other ailments. That poor diet and eating habits are more common in some
segmentsofthepopulationthanothers–indicatingasocialstructuraldeterminant
ofobesity–islikelytobeoverlookedbythedominantparadigmofhealth.This
extends beyond medicine, to pubic health, the focus of several of the articles
inthisvolume.
As several of the essays in this volume point out, identifying risk factors and
placing responsibility on the shoulders of individuals is a neo-liberal approach
tohealthandwellness.Itcanbeproblematicwhenitdetractsfromthepossibility
thatwewillrecognizeandrectifysocialcircumstancesthatimpactpeople’shealth
(Barbee&Little,2003).Itmayleadtoblamingthevictimsoflife–andhealth-
threateningconditions,ashasbeenpointedoutinresearchinmedicalsociology
forover20years,aswellasinnewermaterialthatdiscussesneo-liberalapproaches
tohealth(Kronenfeld,1979).Asourauthorsalsonote,however,medicalization
can have the effect of denying people, especially women and the poor, agency
andcontrol.
Oncethemedicalprofessiontakesover,peoplebecomepatients.Theynolonger
define their symptoms and cannot control their course of treatment except by
GenderedPerspectivesonMedicine 3
failing to comply with the prescribed regimen. Girls being treated for anorexia
nervosa, for example, may refuse to reach their prescribed “target weight” as a
way of maintaining control over their lives (Gremillion, 2002). Finally, whole
socialmovementshavebeenbuiltaroundthedesiretohaveasetofcircumstances
medicalizedorde-medicalized.AdvocatesforthosesufferingwithGulfWarand
chronic fatigue syndromes sought medicalization as a form of validation and in
order to obtain research and treatment (Williams, 2000). Gay men, lesbians and
theiradvocatessoughttohavehomosexualityde-medicalizedtoremoveastigma
andprovideacknowledgmentthattreatmentwasnotneeded.Parentsofchildren
withbehaviorproblemsareambivalentaboutwhethermedicalizationisthebest
approach(Stolberg,2002).
ThepapersbyHeatherHartley,ColleenReidandNancyLukearedata-based.
ThosebyBethJackson,ElianneRisku,EricaBreslau,LynnWeberandDeborah
Parra-Medina are largely theoretical. Each of the authors, however, points indi-
rectly or directly to the importance of using qualitative methods in researching
healthandhealthcare.
It is obvious from all the statistics available (see, for example, the statistics
on the distribution of chronic diseases on the United States Centers for Disease
ControlandPreventionwebsite)thathealthandwellnessareunevenlydistributed
inoursociety.Thestatistics,however,allowonlyapartialviewofpeoples’well-
being. The authors in this volume and its forthcoming companion, that focuses
more closely on reproductive health, argue that a more complete understanding
ofapopulation’shealthandhealthcareneedsispossibleonlythroughtheuseof
qualitativeresearchmethods.Suchmethodsaresensitivetothevoicesofpeople
seekinghealthcare.Particularlywithrespecttolessprivilegedgroupssuchaspoor
women, qualitative methods permit us to learn how people define health-related
issues, when, where and how they seek treatment and the barriers that they
perceive.Theircommentsgobeyondthenarrowconfinesofthemedicalestablish-
menttoissuesofaccesstoinformation,recreationalfacilities,andchildcare.We
cannoteliminatedisparitiesinhealthandwellnesswithoutplacingtheissuesina
broadercontext.
Healthcare is commodified. As David A. Rochefort states in his review of a
recent book on the subject: “The transformation of the U.S. health system has
alienatedpatients,incensedorganizedmedicine,andgivenprivateentrepreneurs
a profitable new area for financial investment” (2002, p. 228). Heathcare is
marketed,boughtandsold,nolongerimplyingorrequiringatraditionalrelation-
ship of trust between healthcare recipient and healthcare provider. In fact, one
way that some medical sociologists have suggested to reconceptualize the older
conceptofthedoctor-patientrelationshipinthenewmillennium,giventheimpact
of managed care, is as a buyer-beware, consumer protection model, in which
4 M.T.SEGAL,V.DEMOSWITHJ.J.KRONENFELD
recipientsofhealthcarecannolongerassumethattheproviderofcarewillhave
thebestinterestsoftheconsumerasamajorconcern.Aswithothercommercial
transactions, recipients of care must be their own advocates for quality and
appropriate care (Kronenfeld, 2001). Managed care intervenes to lower costs
in ways that may have unanticipated consequences for patients and the system.
Treatmentsareoftenfocusedonnewdrugsandtechnology-based.Theysavetime
butdrivecosts.Drugscanbeprescribedevenwithoutaclearideaoftheproblem
as with psychotropic drugs for various anxiety disorders or when there really is
noproblemaswithperformanceenhancingdrugsorcosmeticsurgery.AsErica
S.Breslauexplainsinthisvolume,thepotentialexiststoshortcircuitdiagnosis.
Weneedtoasktowhatextentthesomaticsymptomsexperiencedbysomebreast
cancer patients are symptoms of the disease, symptoms caused by the treatment
orsymptomsreflectingthestressthepatientisunder.
In“SituatingEpidemiology,”thefirstessayinthevolume,BethJacksonprovides
a feminist critique of epidemiology, “the basic science of public health (p. 11),”
andbyimplication,modernmedicine.Jacksontracesthehistoryofepidemiology
asapublichealthhistory,andidentifiesseveralperiodsofepidemiology,particu-
larlyastheyapplytoCanadianhealthcare.Shecritiquescurrentepidemiological
researchaspositivist,microbiological,quantitative,anduniversally-orientedand
maintainsthattheneo-liberaltendenciesofthe1990sandtheearly21stcentury
anditsindividualstatisticalapproachtohealthoverlooksspecificsub-populations
ofpeople.
Looking to Nancy Krieger’s (1994) proposal for an eco-social epidemiology,
Jacksonarguesfor“re-situatingepidemiology”moreinlinewithanearliercon-
ception of public health, one that takes a broad-based population approach. She
furtherpointstotheimportanceofusingamultiplicityofmethodstocollectdata
abouthealthcareandoflocating“truthclaims”withinasocialcontext,informed
bothsociologicallyandbiologically.Jacksonconcludes,
Butifscientificknowledgeissocialknowledge(Longino,1992,1996),thenbiologicalknowl-
edgedoesnothaveaprimarystability,anddespitearealistcommitment,wecanneitherassume
atruthofbiologythatis‘coveredover’bymisdirectedorinadequateinvestigation,northat
thereisasignificantdistinctionbetweenbiologicalandsocialfacts.Ifecosocialepidemiology
istobefullyinformedbyfeministlocationalepistemologies,itmustleaveopenthepossibility
thatthe‘truth’ofthebiologicalworldisjustaselusiveandfragileasthatofthesocial.
In“GenderingtheMedicalizationThesis,”ElianneRiskareviewsthehistoryof
thethesisfromitsemergenceinthe1970sandanalyzesthathistorywithrespect
to the part gender has played in it. Riska identifies three gendered periods of
medicalization. Officially the first period, just prior to the 1970s, was a gender-
neutral period; actually, it was a time when studies were conducted primarily
on men, work on hyperactivity in children focused on boys, Type A Personality
GenderedPerspectivesonMedicine 5
wasbasicallyassociatedwiththeriskofheartdiseaseinmen,andalcoholismwas
treatedasamen’sdisease.Thesecondperiodbeganinthe1970sasfeministsbegan
identifyinganover-medicalizationofwomen,andliberalfeministspointedtothe
practiceofmedicineaspatriarchalwithwomentreatedoffensivelyasstereotypes
bythemale-dominatedmedicalprofession.The1990susheredinthethirdperiod,
atimeinwhichmenhavebeenmedicalized.Thedevelopmentofviagrahasledto
the“viagricization”ofmen’shealthandaconcernwithpenilehealthandsexual
potency,andwithariseinmen’sconcernwithbodyimage.
Riskaarguesthatbeginninginthe1980s,medicinehasbeenincreasinglyreduc-
tionistdrivenbyeffortstocontainhealthcarecostsandafocusongenetically-based
riskfactorsfordisease.SimilartoJackson,shepointstotheeffectofneo-liberal
economics,andnotesthathealthandmedicineisviewedasanindividualproblem
withtheconsequencethatmanypeoplearemarginalizedbythedominanthealth
caresystem.
R. W. Connell (2000) has noted that such masculine practices as automobile
racing,drinkingandusingdrugsarebadformen’shealth.Yet,herejectsdefining
men as victims in the same way women are defined as victims. All women are
subjugatedtomasculinity,butmenhavemorepowerthanwomen.Men’spower
points to the complexity of gender equity. Some men – those who have the
opportunity and the desire – practice hegemonous masculinity, dominate over
other men, and have access to health care. Thus, working class gay men find
themselvesmoreisolatedandvulnerableindealingwithHIV-AIDSthanmiddle
class gay men, and research on HIV-AIDS was delayed because of its initial
associationwithasubordinatedformofmasculinity,gaymanhood.
Riska sees the completion of the gendering of the medicalization thesis, as a
pathtotherecognitionofdiversehealthcareneeds.InlinewithConnell(2000),
shearguesthatthefeminizationofmedicalizationvictimizesallwomen,butthat
itsmasculinizationdoesnotdothesametoallmen.Pointingtonotonebutmany
masculinities,Riskanotesmasculinityrepresentsbothhealthrisksandprivilege,
and urges a more complex view of medicalization taking into account multiple
masculinitiesandtheimpactofraceandclassongenderinhealthcare.
HeatherHartley,also,considersthemedicalizationthesisasitrelatestogender.
Herfocusisonthecriticalroleofpharmaceuticalcompaniesinthemedicalization
ofsexuality.In“BigPharmainourBedrooms:AnAnalysisoftheMedicalization
of Women’s Sexual Problems,” Hartley focuses on women and “female sexual
dysfunction.”Shenotesthat“androgendeficiencysyndrome”hasbeenidentified
asahealthconditionwithoutthesubstantiationofinterest-freeresearch.
Hartleyarguesthatthemarketplacesuccessofviagraandthemedicalizationof
men’s sexuality has prompted the pharmaceutical industry to attempt to achieve
similar success with women’s sexuality. Based on her participant observation
6 M.T.SEGAL,V.DEMOSWITHJ.J.KRONENFELD
at conferences on sexuality, interviews with key researchers, and analyses of
variousdocumentsrangingfromscholarlyjournalsandFDAreportstonewspaper
articles, Hartley demonstrates the enormous power pharmaceutical companies
have in controlling the definition of a medical condition and the marketing of
therapy to deal with it. She details how the proliferation of research centers
unrelated to universities has made it possible for pharmaceutical companies to
better control the publication of adverse research findings, and how researchers
both in and out of universities failing to obtain research funding from the FDA
becomeobligatedtothepharmaceuticalcompaniesthatdoprovidethefunding.
In“TheContinuum:SomaticDistresstoMedicalizationinWomenwithBreast
Cancer,”EricaS.Breslauthroughatheoreticalandempiricalassessmentconsiders
the problems generated when somatization is medicalized. Somatization is the
physical symptom manifestation of distress, an inability to cope. Breslau notes
thatsomatizationhasbeenrecognizedasanumberofconditionsincludingChronic
FatigueSyndrome,butthatitisunspecifiedindealingwithbreastcancer.
Breslauexplainsthatbecausemanyofitssymptomscanmimicthesymptoms
ofbreastcancer,somatizationisdifficulttotreat.Atthesametime,sheiscriticalof
thebiomedicalapproachtosomatizationanditsmedicalization.Inbreastcancer
patients,particularly,medicalizedsomatizationresultsintheapplicationofhigh
techexpensivetherapiescontrolledbyinsurancecompaniesandphysicians,and
a loss of control over care by the patient. Breslau’s argument for research on
somatizationinbreastcancerpatientsiscompelling.Suchresearchwouldmake
possible more accurate diagnoses in breast cancer patients and appropriate non-
medicallow-costtreatments.
InherstudyofJewishandAfrican-Americanwomenwhoweremothersinthe
1930sand1940s,JacquelineS.Litt(2000)usesan“intersectional”approach.She
demonstratesthatmedicalizedmotherhoodisnotonlyagenderissue,but,alsoan
ethno-racialone.Theirracialandsocialclasssituationsmeantthewomenfound
themselvesonthemarginsofthewhite-dominatedpatriarchalmedicalsystem.
Lynn Weber and Deborah Parra-Medina’s and Colleen Reid’s papers explic-
itly focus on the “intersectional” concerns of Jacqueline S. Litt. Weber and
Parra-Medina continue a critique of the biomedical approach to health in their
article, “Intersectionality and Women’s Health: Charting a Path to Eliminating
HealthDisparities.”Turningtheirattentiontotheconsequencesofhealthforrace,
genderandclass,WeberandParra-Medinacallforanintersectionalapproachto
eliminating disparities in health and health care that is similar to the arguments
Jackson makes about re-situating epidemiology. They identify a number of
problemswiththeindividuallyorientedbiomedicalmodelofhealth,andobserve
that race, class, gender and sexuality are treated in varying ways in biomedical
research. Thus, discrimination is acknowledged in race studies and sometimes
GenderedPerspectivesonMedicine 7
mentioned in gender research, but never mentioned with respect to class. They
note, also, that the American ideological meta-narratives of race and gender as
ascribedareembeddedinresearchasisthemeta-narrativeoftheAmericanDream
withitsfocusonequalityofopportunityandclassasachieved.
WeberandParra-Medinaobservethe“downstream”biomedicalmodelfocuses
on the individual thereby ignoring group processes, and on the distribution of
variablesinapopulationattheexpenseofexplaininghowtheseareexperienced
inindividuallives.Theynotethatnooneistotallyoppressedandnooneistotally
oppressing, and argue for using an “upstream” model of health in which the
intersectionofrace,gender,classandsexualitypoweristakenintoaccount.Insuch
amodelpatternsofdominanceareseenasa“matrixofpower”notadichotomy.
Weber and Parra-Medina, also, point to methodological weaknesses of the
biomedical model of health. They are critical of quantitative studies stating that
these do not get at relational aspects of power. In addition, they are critical of
the treatment of less privileged members of the population noting that research
is funded by dominant members of the population whose interests drive the
research. In order to even obtain information about less privileged members, an
“over-sampling” is conducted and sample results are compared with population
“norms”therebytreatingthelessprivilegedmembersasdeviants.Thus,inaddition
tousinganintersectionalupstreammodelofhealthresearch,similartothepublic
healthmodeldiscussedinJackson’spaper,WeberandParra-Medinaadviseusing
qualitativeresearchmethods.TheyargueforusingPatriciaHillCollins’s(1986)
conceptofthe“outsiderwithin”–theindividualwhohasintimateinsideknowl-
edgeofasituation,butwhoispreventedfromfullparticipationinit,thusallowing
a detached observation – as a critical source of knowledge. Just how powerful
such an approach can be is demonstrated by anthropologist Susan Greenhalgh
in her recent autoethnography, Under the Medical Gaze: Facts and Fictions of
ChronicPain(2001).
Colleen Reid is in agreement with Weber and Parra-Medina. In her article,
“We’reNotaPartofSociety,WeDon’tHaveaSay”:ExclusionasaDeterminant
of Poor Women’s Health,” Reid agrees with Weber and Parra-Medina’s implied
argument for public health and explicit call for qualitative health research and,
consequent,equity.Usingqualitativeresearchtechniques,workinginawomen’s
collectiveasaprojectmanageranddoctoralresearcher,Reidexplorestheeffect
of exclusion on poor women’s health in Canada. She finds that although there
isuniversalhealthcareinCanada,thesystemistwo-tieredandpoorwomenare
invisibleandstigmatized.Poorwomenfacelackofaccesstohealthcareresources,
the discriminatory attitudes of health care professionals, and differential health
careservices.Asaresultoffeelingexcluded,poorwomenexperienceshamewhich
ismanifestedbylowself-esteem,depressionandanumberofotherconditions.