Table of contents(11 chapters)
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 and health are social constructions and that gender is an embedded part of them (see Lorber, 1997). The essays reveal that embedded with gender in the institution of medicine are race, class, and sexuality. Taken as a whole, the volume offers a 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, and questions of agency, responsibility and control.
Epidemiology is often described as “the basic science of public health” (Savitz, Poole & Miller, 1999; Syme & Yen, 2000). This description suggests both a close association with public health practice, and the separation of “pure” scientific knowledge from its application in the messy social world. Although the attainability of absolute objectivity is rarely claimed, epidemiologists are routinely encouraged to “persist in their efforts to substitute evidence for faith in scientific reasoning” (Stolley, 1985, p. 38) and reminded that “public health decision makers gain little from impassioned scholars who go beyond advancing and explaining the science to promoting a specific public health agenda” (Savitz et al., 1999, p. 1160). Epidemiology produces authoritative data that are transformed into evidence which informs public health. Those data are authoritative because epidemiology is regarded as a neutral scientific enterprise. Because its claims are grounded in science, epidemiological knowledge is deemed to have “a special technical status and hence is not contestable in the same way as are say, religion or ethics” (Lock, 1988, p. 6). Despite the veneer of universality afforded by its scientific pedigree, epidemiology is not a static or monolithic discipline. Epidemiological truth claims are embodied in several shifting paradigms that span the life of the discipline. Public health knowledges and practices, competing claims internal and external to epidemiology, and structural conditions (such as current political economies, material technologies, and institutions) provide important contexts in which certain kinds of epidemiological knowledge are more likely to emerge.
The medicalization thesis derives from a classic theme in the field of medical sociology. It addresses the broader issue of the power of medicine – as a culture and as a profession – to define and regulate social behavior. This issue was introduced into sociology 50 years ago by Talcott Parsons (1951) who suggested that medicine was a social institution that regulated the kind of deviance for which the individual was not held morally responsible and for which a medical diagnosis could be found. The agent of social control was the medical profession, an institutionalized structure in society that had been given the mandate to restore the health of the sick so that they could resume their expected role obligations. Inherent in this view of medicine was the functionalist perspective on the workings of society: the basic function of medicine was to maintain the established division of labor, a state that guaranteed the optimum working of society. For 20 years, the Parsonian interpretation of how medicine worked – including sick-role theory and the theory of the profession of medicine – dominated the bourgeoning field of medical sociology.
We are in the midst of a broad societal change in which women’s sexual problems are becoming increasingly medicalized, characterized as treatable medical conditions and defined and understood as a largely physiologically based disease, called “female sexual dysfunction” (FSD). When a condition is medicalized, a medical framework is used to understand it, and medical interventions are used to treat it. As part of this process, then, over the last several years, researchers and pharmaceutical companies have turned attention to developing medical treatments for FSD. As this medicalization continues to unfold with potentially important impacts, it is crucial that we understand the forces working to shape it.
THE CONTINUUM: SOMATIC DISTRESS TO MEDICALIZATION IN WOMEN WITH BREAST CANCER: THEORETICAL AND EMPIRICAL ASSESSMENT
The sequence of stress, distress and somatization has occupied much of the late twentieth-century psychological research. The anatomy of stress can be viewed from interactional and hybrid theories that suggest that the individual relates with the surroundings by buffering the harmful effects of stressors. These acts or reactions are called coping strategies and are designed as protection from the stressors and adaptation to them. Failure to successfully adapt to stressors results in psychological distress. In some individuals, elevated levels of distress and failed coping are expressed in physical symptoms, rather than through feelings, words, or actions. Such “somatization” defends against the awareness of the psychological distress, as demonstrated in the psychosocial literature. The progression of behavior resulting from somatic distress moves from a private domain into the public arena, involving an elaborate medicalization process, is however less clear in sociological discourse. The invocation of a medical diagnosis to communicate physical discomfort by way of repeated use of health care services poses a major medical, social and economic problem. The goal of this paper is to clarify this connection by investigating the relevant literature in the area of women with breast cancer. This manuscript focuses on the relationship of psychological stress, the stress response of distress, and the preoccupation with one’s body, and proposes a new theoretical construct.
Scholars and activists working both within and outside the massive health-related machinery of government and the private sector and within and outside communities of color address the same fundamental questions: Why do health disparities exist? Why have they persisted over such a long time? What can be done to significantly reduce or eliminate them?
“WE’RE NOT A PART OF SOCIETY, WE DON’T HAVE A SAY”: EXCLUSION AS A DETERMINANT OF POOR WOMEN’S HEALTH
The association between income distribution and measures of health has been well established such that societies with smaller income differences between rich and poor people have increased longevity (Wilkinson, 1996). While more egalitarian societies tend to have better health, in most developed societies people lower down the social scale have death rates two to four times higher than those nearer the top. Inequities in income distribution and the consequent disparities in health status are particularly problematic for many women, including single mothers, older women, and women of colour. The feminization of poverty is the rapidly increasing proportion of women in the adult poverty population (Doyal, 1995; Fraser, 1987).
The connection between women’s empowerment and health has been a growing concern among demographers and other social scientists, who theorize that empowering women – or enhancing their ability to define and make strategic life choices – will improve their reproductive health (Kabeer, 1999). The importance of empowering women became a central theme at the International Conference on Population and Development (ICPD) held in Cairo in 1994. The Cairo policy document codified the notion that women must be empowered in order for them and societies as a whole reach their reproductive health goals, including lowering fertility and population growth, stemming the spread of sexually transmitted diseases (STDs) and HIV/AIDS, and ensuring healthy pregnancy and delivery (Hodgson & Watkins, 1997; Sen & Batliwala, 2000).
Erica S. Breslau, Ph.D., M.P.H. is a scientific program director in the Applied Cancer Screening Research Branch, in the Behavioral Research Program within the Division of Cancer Control and Population Sciences at the National Cancer Institute. Dr. Breslau’s research interests focus on women’s oncology issues in general, and specifically as they pertain to the social, behavioral, and psychological influences associated with breast, gynecological and colorectal cancer screening. Recent efforts include ensuring that research is able to inform and improve the quality of health services among women disproportionately affected with breast and cervical cancer through the dissemination of evidence-based intervention approaches. She has conducted population-based research in the area of infectious diseases, including HIV/AIDS and sexually transmitted diseases in military populations, and has implemented large-scale health promotion approaches to improve the adoption of prevention practices. Dr. Breslau received her Ph.D. in Public Health from The Johns Hopkins Bloomberg School of Public Health, and her Master’s in Public Health from Tulane University, School of Public Health and Tropical Medicine.Vasilikie Demos is a Professor of Sociology at the University of Minnesota-Morris. She has studied ethnicity and gender in the United States and is currently completing a monograph on her study of Kytherian Greek women based on interviews in Greece and among immigrants in the United States and Australia. With Marcia Texler Segal, she is co-editor of the Advances in Gender Research series and Ethnic Women: A Multiple Status Reality (General Hall, 1994). She is a past president of Sociologists for Women in Society and of the North Central Sociological Association, and has been an Honorary Visiting Professor at the University of New South Wales in Australia.Heather Hartley is an Assistant Professor of Sociology at Portland State University. Dr. Hartley’s research interests include the sociology of health and medicine, the sociology of gender, the sociology of sexualities, and political sociology. Within these general specialty areas, her work focuses on the politics of women’s health, the pharmaceutical industry and the changing distribution of power within the health care system.Beth E. Jackson is a Doctoral Student in Sociology at York University in Toronto, Canada. Drawing on the traditions of feminist epistemologies and critical social studies of science, her dissertation research puts questions of epistemic authority and the nature of evidence into the specific context of public health and epidemiology. Specifically, she explores the conditions, contexts, tools and processes through which public health knowledge claims are made, by focusing on a particular technology of “population health” i.e. the National Population Health Survey (NPHS) (a longitudinal, biennial survey of the mental and physical health of Canadians and their use of health care services). Her research also speaks to policy implications of “situated” data and evidence – in this case, the implications of how “women’s health” is defined, and the extent to which a gendered analysis of health is considered in the construction and analysis of the NPHS.Jennie Jacobs Kronenfeld is a Professor in the Department of Sociology, Arizona State University. She conducts research in the areas of health policy, health across the life course, health behavior including preventive health behavior, and research into AIDS in geographically mobile populations. She has recently authored Health Care Policy: Issues and Trends (Praeger, 2002). She has conducted research in a variety of topics related to child health, including recruitment into CHIP (child health insurance program) and has published a book on the impact of school based health clinics, Schools and the Health of Children (Sage, 2000). She is a past president of Sociologists for Women in Society and past chair of the Medical Sociology Section of the American Sociological Association.Nancy Luke is an Assistant Professor of Research in the Population Studies and Training Center at Brown University and a Research Fellow in the Center for Population and Development Studies at Harvard University. Her primary research interest is the impact of social organization on health and well-being, particularly among women and adolescents. She is presently co-Principal Investigator of two research projects, both of which include collection of household survey and ethnographic data. A project in Kenya studies the influence of marriage and economic transactions on sexual behavior in an area of high HIV/AIDS prevalence, and a project in India examines women’s empowerment in a context where norms sanction intimate partner violence. She has also collaborated with numerous non-governmental organizations on research projects pertaining to reproductive health and gender equity in developing countries. Dr. Luke has a Ph.D. in Demography and Sociology from the University of Pennsylvania and an M.A. from Johns Hopkins School of Advanced International Studies.Deborah Parra-Medina, Ph.D., M.P.H., is Assistant Professor at the University of South Carolina with joint appointments in the Department of Health Promotion, Education and Behavior (HPEB) and Women’s Studies. She received her Ph.D. in Epidemiology at the UC San Diego, an M.P.H. in Health Promotion at San Diego State University and a B.A. in Social Science at UC Berkeley. She has extensive experience working with under-served communities, having worked in several chronic disease prevention and control efforts including cancer screening, tobacco control, weight loss and nutrition. Her research based on a participatory action model emphasizes the intersections of race, class and gender and the influence of socio-cultural environment on adaptive and maladaptive health behaviors. This perspective is exemplified in her current research. She is Principle Investigator of the SC American Legacy Empowerment (SCALE) Evaluation Project that is examining how to effectively engage youth as agents for social change within the context of tobacco prevention and control. Dr. Parra-Medina was recently awarded a pilot study grant from NCI, the broad goal of this project is to foster individual and organizational empowerment among the emerging Hispanic population in South Carolina in relation to cancer prevention and health promotion through the development of the South Carolina Hispanic Health Coalition: Partnership for Cancer Prevention (PCP).Colleen Reid recently completed her Ph.D. in Interdisciplinary Studies in health promotion research at the University of British Columbia in Vancouver, Canada. Her doctoral dissertation was a feminist action research project with a group of women on low income. Together they examined the relationship between exclusion and health, the women’s varied discourses of poverty and health, and the promises and challenges of engaging in feminist action research. Dr. Reid has also been involved in community health research projects with organizations including the Vancouver YWCA, AIDS Vancouver, Literacy B.C., and the B.C. Centre of Excellence for Women’s Health.Elianne Riska is von Willebrand-Fahlbeck Professor of Sociology at Åbo Akademi University, Finland since 1985. She has been Chairperson of the Department of Sociology 1985–1997 and Director of the Institute of Women’s Studies at Åbo Akademi University 1986–1993. Elianne Riska received her Ph.D. in Sociology at the State University of New York at Stony Brook in 1974. She was an Assistant Professor and an Associate Professor of Sociology in the Department of Sociology and College of Human Medicine at Michigan State University from 1974 to 1981. She was Academy Professor of the Academy of Finland 1997–2002. She is currently the President of the Research Committee of the Sociology of Health (RC15) of the International Sociological Association (2002–2006). Her most recent books are Gender, Work and Medicine (Sage, 1993), Gendered Moods (Routledge, 1995) and Medical Careers and Feminist Agendas: American, Scandinavian, and Russian Women Physicians (Aldine de Gruyter, 2001).Marcia Texler Segal is Associate Vice-Chancellor for Academic Affairs, Dean for Research and a Professor of Sociology at Indiana University Southeast. Her research and consulting focus on education and on women in Sub-Saharan Africa and on ethnic women in the United States. With Vasilikie Demos, she is co-editor of the Advances in Gender Research series and Ethnic Women: A Multiple Status Reality (General Hall, 1994). She is a past president of the North Central Sociological Association and past chair of the American Sociological Association Sections on Sex and Gender and Race, Gender and Class.Lynn Weber is a Director of the Women’s Studies Program and Professor of Sociology at the University of South Carolina. For the 2002–2003 year, she is Visiting Professor in the Consortium for Research on Race, Gender, and Ethnicity and the Department of Women’s Studies at the University of Maryland. Her research and teaching explore the intersections of race, class, gender, and sexuality particularly as they are manifest in women’s health, in the process of upward social mobility and work, and in the creation of an inclusive classroom environment. In 2001 and 2002, she published two books, Understanding Race, Class, Gender, and Sexuality: A Conceptual Framework and Understanding Race, Class, Gender, and Sexuality: Case Studies (NY: McGraw-Hill) which are intended to move the field of intersectional scholarship ahead by serving as a guide to facilitate intersectional analyses and to foster more integrative thinking in the classroom. Dr. Weber is also co-author of The American Perception of Class.