Motherhood can take a woman to the heights of ecstasy and the depths of despair; it can offer her protection and reverence. But it can also deny a woman consideration as anything more than a vehicle for human reproduction. Women’s reproductive function fits within a social framework of gender that affects women’s capacities and health. While traditional cultures established laws to protect women’s reproductive functions, these laws have confined women to the extent that they have been denied almost all additional and alternative opportunities to flourish as individuals and to achieve complete health in their communities and wider societies. Emphasizing that health is more than a matter of an individual’s medical condition, the World Health Organization (WHO) asserts that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1
It has been only recently recognized that states must address the protection and advancement of women’s health interests through gender planning, to achieve not simply the abstract value of justice, but to conform to legally binding international human rights obligations as well. Gender planning concerns both practical and strategic needs of women in developing and industrialized countries.2 Their practical needs are addressed through programs like the Safe Motherhood Initiative, co-sponsored by several UN agencies and international nongovernmental organizations.3 This program focuses on reducing the rates of maternal mortality, unwanted pregnancy, and sexually transmitted diseases, including HIV infection. Comparable programs address women’s health and nutritional needs throughout the life cycle.4
Women’s strategic needs transcend such practical needs however, because they address the value of women to society—a value extending beyond motherhood and service in the home. Focusing on strategic needs promotes women’s roles in such areas as the economic, political, spiritual, professional and cultural life of communities. Most importantly, it opens the way to women’s achievement of complete health as defined by WHO.
There is a paradox in addressing women’s practical and strategic needs: those concerned with practical needs may develop concepts whose effects, and perhaps whose purpose, confine women to maternal, domestic and subordinate social roles. This denies women’s legitimate strategic needs and prevents them from flourishing to their full capacity within the family, community and society.
This chapter addresses how the gender role in society occupied primarily by women has constrained women’s growth to the detriment of their complete health. It also outlines how international human rights law obliges states to liberate women from this constraint to permit women’s pursuit of health and achievement in areas of their own choice.
Sex and Gender
Medicine has historically used male physiology as the model for medical care, based on research studies involving exclusively men.5 Accordingly, women have been considered only to the extent that they are different from men, focusing medical attention on reproductive characteristics.
Further, medicine progressed from being an art of human interaction to a science dominated by biological revelations achieved in laboratories. More and more, it is driven by the institutional demands of hospital-based medicine, where results of laboratory science and, more recently, medical engineering and technology, can be applied. In moving the locus of their functions from the community to the laboratory and hospital, doctors have become isolated from those social realities that condition the lives and health status of their patients.
In many regions of the world, health agencies are increasingly recognizing how functions performed by community members can protect and enhance people’s health, and how important it is to reassess how an individual woman’s self-esteem and health status are affected by the value placed on women by her community.6 Health professionals themselves are becoming more sensitive to the health impact of patients’ social experiences. For example, the 1994 World Report on Women’s Health, issued by the International Federation of Gynecology and Obstetrics, concluded that future improvements in women’s health require not only improved science and health care, but also social justice for women and removal of socially and culturally conditioned barriers to women’s equal opportunity.7
The experiences of women in their families and communities are different from those of men. The difference transcends reproductive functions, although the reproductive role of women in the creation and maintenance of families has commonly been used to justify women’s subordination and denial of equal opportunity. The dominant view that women are distinguishable from men only as regards their biological constitution and reproductive role hides the profound psychological and social differences based on gender that societies have created, and that compromise women’s complete health.8
The terms sex and gender are frequently used interchangeably. The latter is often preferred over the crude and salacious connotations of the former; but strictly speaking, the terms are different. Sex is a matter of biological differentiation, whereas gender is a social construct by which various activities and characteristics are associated with one or the other sex. For instance, leadership through success in battle is male gendered, whereas caring for the dependent young, sick, and elderly is female gendered. Popular imagery of leadership in, for example, politics, commerce, industry, the military, and religion is male gendered, whereas nursing and domestic service are female gendered. It is obvious that women can be political and industrial leaders, and that men can be care-givers, but it has been considered exceptional for people to assume a gender role at variance with their sex. Activities and characteristics are preconceived via gender stereotypes, which determine the parameters of the normal. “Masculine” behavior in women, and “feminine” behavior in men have long been considered deviant. That which is normal or self-evident escapes special attention, because it is taken as the norm from which only departures are of interest. Behavior that is in accordance with conventional expectations and presuppositions of gender roles is generally unremarkable.
Women’s Subordination and Exclusion
In societies around the world, female-gendered status is inferior and subordinate to male-gendered status. The male protects the female through the attributes of gallantry and chivalry, he is bold in courtship, aggressive in initiative, and forthcoming among peers. The female is passive, renders service in modest fulfillment of duty, and offers comfort in responsive obedience. Societies have modelled their role expectations on these assumptions of the natural order of humankind. Historic social structures, including the organization and conduct of warfare, the hierarchical ordering of influential religious institutions, the attribution of political power, the authority of the judiciary, and the influences that shape the content of the law, reflect this gender difference of male dominance and female subordination.
Because women naturally tend to behave in female-gendered ways, they have been vulnerable to confinement to female status by social, political, religious and other institutions, populated exclusively by men, that act in male-gendered ways. Women have accordingly been subordinated to assume only inferior, servile social roles, and have traditionally been excluded from centers of male-gendered power by legal and other instruments. These include legislatures, military institutions, religious orders, universities, and the learned professions, including medicine. This is still the age of “first women,” such as the first woman medical school dean, the first woman Supreme Court justice, and the first woman head of a medical association.
The historic subordination, silencing, and imposed inferiority of women (beginning at birth as an expendable and often unwanted girl child) has been invisible because it has been considered not simply a natural feature of society, but the very condition by which society can exist. Traditional forces emphasizing that women’s “natural place” is in the home and that their natural functions in the rearing of children must always be protected, cannot envisage that women can aspire to and achieve the same advances in areas of male-gendered activities as men; nor do they acknowledge that it is oppressive of women’s human rights to confine them to servile functions traditionally considered natural to their sex.
It is becoming increasingly recognized that an individual’s health status is determined not only by chance genetic inheritance and the geographical availability of nutritional resources, but also by socioeconomic factors.9 Relatively affluent people, and those content with their lives, enjoy better health status than impoverished, frustrated, and oppressed people who suffer disrespect in their communities and poor self-image. The determinants of earned income, including education, literacy, employment opportunities, and, for instance, financial credit for launching income initiatives, all show how women have been disadvantaged by their inferior gender role. Even within affluent families, women have often suffered frustrations-through male preference in inheritance, education preceding marriage, and training to occupy positions of influence and power within their communities. Women have been denied a commitment of family resources for these opportunities, in the belief that upon marriage, they will attenuate association with their own families (reflected, for example, in their shedding family names) and will assume a role of service within their husbands’ families.
Complex social dynamics have produced a modern reality, common to communities across the full spectrum of economic and industrial development, of women being primary or sole economic supports of their families, and also being unmarried, widowed, or abandoned mothers of their children. Women’s unequal opportunities to participate in the resources and well-being of their communities, and to contribute to political, economic, spiritual, and related leadership has a serious impact. It deprives those families that financially depend on women of equal opportunities for well-being; and it robs women themselves of the economic, psychological, and social determinants of health. Women’s vulnerability to sexual subordination through the greater physical, military, and social force of men produces harmful health consequences in women extending beyond pain, indignity, unwanted pregnancy, and venereal infection.
How Health Professions have Constructed Women
Members of the health professions have done much to mitigate the health consequences of women’s gendered disadvantage. They have cared for the distressed and violated, relieved physical pain, and eased women through unwanted and, at times, violently imposed pregnancy. As participants in traditional communities, however, undertaking the male-gendered functions of decision-making and leadership, doctors have tended to share prevailing perceptions of women’s natural role, and exhibit blindness toward women’s gender-specific health risks. Indeed, in the past, doctors have considered women constitutionally unsuited to political, commercial, and professional life, prone to swoon under stress and to require nine months of bed rest while pregnant.
When society blamed women for resorting to prostitution as a means of economic maintenance, while denying them alternative opportunities to support themselves and their families, doctors, among others, promoted the image of women as vectors of disease. Accordingly, when, for instance, victorious soldiers returned to the United States from 1918 to 1920, 18,000 women-alleged to be prostitutes were detained in a medically supported governmental initiative, for fear that they would spread venereal infection.10 Women’s image as vectors of disease to sexual partners and to children they conceive has been recycled in the modern pandemic of AIDS. 11
In many parts of the world, medicine retains marks of its gendered practice, for instance in placing women under the patriarchal control of men and others who exercise male-gendered authority. For example, in some countries, a woman’s request for health care is accepted only with the express authorization of her husband.12 Women’s requests for control over their reproduction have so threatened male dominance of women’s fertility that birth control and voluntary sterilization were condemned until recently, as Crimes Against Morality.13 Voluntary abortion remains a major point of contention almost universally within institutions of traditional power, which are male-gendered. Whether it is discriminatory and socially unconscionable to criminalize a medical procedure that only women need is a question that usually goes not simply unanswered, but unasked.
Medicine Serving the Status Quo
By focusing its attention on the distress of individual women in clinical settings, medicine in general and psychiatry in particular have inadvertently served as agents of the continued subordination and oppression of women.14 Women have suffered feelings of ill health and emotional dissonance with family and community, as a reaction to denial of equal opportunities to seek their own achievements and their confinement to seeking satisfaction in the care of children, the sick and the dependent. Health professionals have conscientiously looked for physiological and psychiatric causes of maladjustment in patients’ lives, and for other medical reasons for unhappiness and discontent.15 Illness alone was used to explain women’s unhappiness in the midst of affluence and caring family members, a situation that by conventional standards should produce contentedness.
One effect of modern feminist sensitivity has been to expose feelings of frustration and anger as not being unnatural reactions to natural conditions, but as natural healthy reactions to social injustice. By diagnosing women’s discontent and “disorders” as medical problems, physicians have reinforced and perpetuated the injustice of the prevailing social order, which prejudices women’s health, rather than acting as instruments of remedy.
Medicine has a history of paternalism. Patients have been infantilized and denied social status, for example, by being called by their first names and presumed incapable of exercising informed choice among treatment options. A legal recognition of only recent evolution is that treatment choices are not to be medically dictated, but are to be medically-informed personal choices made by patients as an act of self-determination. Physicians are increasingly required by law to afford patients respect as equals—capable of and responsible for making critical life decisions—by providing them the medical information they need to fully exercise choice.
However, while meeting this objective standard of medical disclosure, doctors must recognize how women’s experiences in female-gendered roles have affected their medical histories and health prospects. The critical transition is from doctors treating women as inferior to men, physiologically different only in reproductive functions, to recognizing women as equal to men, only different because of the gendered experiences that affect their health.