The Cosmetic Industry:  The Externalization of Women’s Identity

Patricia J. Anderson

Advanced Psychology of Women, 561

De Paul University, Chicago, Illinois

1995

The Cosmetic Industry: The Externalization of Women’s Identity

                                       Abstract

Personal experience with the use of cosmetics led me to look at how the cosmetic industry got started and how it “hooked” women psychologically into believing that artificial beauty was a requirement of femininity. Patriarchal images of beauty have gone far beyond “powdered noses”. Beauty that was initially obtained through makeup and hair care products led to surgical procedures like facelifts and breast augmentation. While cosmetic surgeons’ knives carve into a women’s physical body, the scars are actually inflicted much deeper, into a women’s core – her sense of self. For this reason, I also look at the “choice” involved in cosmetic surgery through a feminist ethical lens.

Personally

My reason for doing research on makeup and cosmetic surgery was very personal. I started wearing makeup around age thirteen, in response to peer pressure from my friend Iris. She applied mascara to my reddish-blonde lashes and eyebrow pencil to my also light brows. What a drastic difference it made! For years I had lived with barely visible lashes and brows – how had I survived without makeup? I was hooked. I could never again go back to being plain and colorless.

My dad’s initial response to seeing me with makeup on was quite emphatic, “No daughter of mine is gonna wear that crap on her face! Go wash it off!” But dad wasn’t in charge of makeup – it was mom’s thing and mom said okay.

A few months later I came to the breakfast table without makeup on. Dad immediately threw up his hands covering his eyes (to shield himself from my ugliness) and said, “Jesus Christ, redhead go and put your makeup on”! Dad was kidding, right? He WAS a kidder. I’ll never know.  

At thirteen my beauty ego was very fragile, girls at this age are very influenced by what their fathers think of them. I was shattered! I really believed I was ugly without makeup on. Despite the fact that my feminist consciousness was raised a long time ago and the fact that I’ve never had a lover express any negativity about my appearance without makeup, I still rarely leave the house without makeup.

       Creating a Market for Makeup

According to Kathy Peiss (1994), Victorian times viewed women’s makeup as illegitimate and unrespectable. Many women had refrained from wearing makeup due to, religious beliefs, cultural traditions, and cost. Most working-class women who wore makeup were prostitutes, so respectability was an issue. A boundary had existed between respectability and promiscuity, gentility and vulgarity – paint marked that boundary (Peiss 1994).  

Things changed in the late nineteenth and early twentieth century, American women started wearing face powder, rouge, lipstick, and other visible cosmetics – makeup turned into an essential sign of femininity (Peiss 1994). Naomi Wolf (1991) says that since the industrial revolution, women’s “beauty” was used as a form of currency among men. Ideas about beauty and money became parallel economically (Wolf 1991). Capitalism set out to redefine a woman’s everyday needs; cosmetics became enmeshed within the mass consumer industry. The challenge was to define women’s external appearance and then make their cosmetics compelling to women (Peiss 1994). They did.

              Making Beauty a Necessity

Women’s faces started to look different in the culture’s mirrors: motion pictures, women’s periodicals and advertising store windows, fashion runways, and department stores. National advertising in women’s magazines became a dominant force by the early nineteen twenties. Advertising stressed the safety and cleanliness of the products and even claimed the product’s invisibility, guaranteeing women that they wouldn’t appear immoral or painted (Peiss 1994).

Egalitarian marketing techniques were employed. High-priced items were marketed in exclusive salons aimed at wealthy customers; lower-priced products were marketed to teenagers and working-class women in drugstores and discount beauty outlets. There were also specific ethnic markets that targeted African American, Hispanic, Asian, and other women of color (Peiss 1994).

To women who had devoted themselves to their families, the message made beauty an irresistible duty. One cosmologist said, “Don’t be ashamed of your desire for beauty” (Peiss 1994, p. 375). The logic of the popular idea that everyone could be beautiful led to the assertion that all women should be beautiful–it was a duty to husbands, and children, necessary for business success and vital to the attainment of romance. If you weren’t beautiful, you had yourself to blame (Peiss 1994).  

The relationship between femininity and appearance was reshaped by a beauty industry that promoted the externalization of the gendered self to be achieved cosmetically (Peiss 1994). The multi-billion dollar industry convinced women using deeply embedded feelings of fear, anxiety, and self-hatred to seek “hope in a jar” (Peiss 1994, p. 391).

   Cosmetics and African American Women

African American women’s lower economic status limited their ability to buy cosmetics. However, growing racial segregation and the migration of the Black middle class to the cities led entrepreneurs to develop businesses marketed to Black consumers. One of the leading Black businesses pioneered the development of beauty products for African American women (Peiss 1994).  

Black women’s grooming centered around hair care. Entrepreneurs marketed hair tonics (straighteners for kinky hair) to Black women by way of almanacs and ad cards that used African American ministers and school teachers to promote the products (Peiss 1994).

Black women found good employment opportunities in a sex and race-segregated market within the beauty culture. Here was a business that was in great demand, easy to learn, and required little capital to get started. This resulted in the establishment of businesses in homes, small shops, and door-to-door sales. High Brown face powder was sold door to door by an army of agents (Peiss 1994).      

White racism in the beauty culture exploited issues like the natural inferiority of Blacks noting their unruly hair, promiscuity, and sloppy dress, and marketed toward the Black woman’s desire for respectability. There was controversy over the adaptation of white aesthetics, but the fact that products were marketed door to door among friends and neighbors fostered a web of support and assistance to Black woman’s culture (Peiss 1994).

Female Development of a Remade Self

The hospital nursery sweeps an infant girl’s hair into a curl, by age one year her ears are pierced, by age two her nails are polished, she has ribbons in her hair, and ruffles on her skirts. Femininity becomes associated with beauty, beauty becomes a part of a girl’s self-perception; pretty is the framework for her self-image (Freedman 1990).       

Rhoda Unger and Mary Crawford (1992) discuss the fact that much of girls’ play revolves around glamour. Makeup is flavored like candy and geared toward girls as young as three. Toy stores market numerous hair and nail products, especially for little girls (Unger & Crawford 1992). The prettiest, most popular fashion doll, Barbie, even has her own makeup. Cosmetic kits for the girls themselves, reassure parents that they are suitable for children as young as three and promise to help their daughters create dozens of fashion looks. After all, she’s only putting on the same disguise that mommy wears. Parents approve of her beautifying herself; she learns that her own face, though pretty, is inadequate, needing to be made lovelier–a double message fostering negative body image and self-doubt (Freedman 1990). Girls learn that their faces and bodies are not good enough and need improvement (Unger & Crawford 1992). Girls are surrounded by constant subtle demands for beauty that become invisible once internalized. They believe that beauty is something they want – it’s a fun choice they make.  

Beauty contestants can be very young. Freedman (1990) discusses the opinions of pediatrician Lee Salk about beauty contests for girls. Girls feel tremendous pressure to accept and identify with exaggerated images of beauty. When they realize that they lack the winning look, suffer deep feelings of inadequacy. Nearly half of twenty thousand teenage girls in a survey said they frequently felt ugly (Freedman 1990).  

Compared to boys, twice as many teen girls want to change their appearance and a greater number of girls are unhappy with a part of their body. Girls think other girls are better looking than they are; boys think other boys are less attractive than themselves. The smarter a boy is, the more satisfied he is with his looks; there is no similar correlation among girls (Freedman 1990). Freedman (1990) thinks that’s probably because the brighter a girl is the more she realizes “she can never attain the beauty ideal” (p. 390).

The socialization of girls teaches them to seek their identity through male attention. To obtain that attention they must conform to societal demands for beauty defined by white heterosexual males. Under these circumstances, girls really don’t have a choice in seeking beauty. The connection between appearance and worthiness can be so deeply ingrained in puberty that a woman is insecure about her appearance (and herself) for the rest of her life (Freedman 1990). This is true of feminist women, as I serve to demonstrate.

Puberty is the time when differences in self-esteem between the sexes start to take place (Unger & Crawford 1992). The enactment of the beauty role is shaped by the way a girl’s father reinforces her appearance (Freedman 1990). I now understand why my dad’s behavior had such a powerful impact on my emerging sense of self.

Makeup has become an essential prop necessary to the development of womanhood. Babysitting money is spent on mascara and bust developers (Freedman 1990). When I was eighteen I told my friends that I didn’t need much A newspaper printed an ad to potential money while I lived at home – my only expenses were makeup and hair spray! Little did I realize just how true and how sad that was.

A newspaper printed an ad to potential advertisers from a teen magazine: “Seventeen readers don’t love you and leave you. As adults 34% still rinse with the same mouthwash and 33% use the same nail polish. Talk to them in their teens and they’ll be customers for life” (Freedman 1990, p. 392). Cosmetic advertisers have been shown to affect the “conception of reality” of teen girls; a girl learns rather than to ask the mirror, “Who am I?” to ask, “What should I look like?”, illustrating a distorted identity that sees its goal as packaging the self as a product (Freedman 1990, p. 392).

Susan Brownmiller (1984) said it well, “Cosmetics have been seen historically as proof of feminine vanity, yet they are proof if anything, of feminine insecurity, an abiding belief that the face underneath is insufficient unto itself.” (Brownmiller 1984, p. 158-159).

Even cosmetic surgery is directed at young girls through advertisements in teen magazines. Parents pay for girls, not boys, to have plastic overhauls, provided by a medical system that reinforces myths about female beauty (Freedman 1990). Girls learn that their desirability is measured by their looks and that they can never measure up, no matter how hard they try (Unger & Crawford 1992). These societal messages will keep cosmetic manufacturers and cosmetic surgeons in business.   

Patriarchy profits financially and perpetuates its control of women through this psychological phenomenon. Women who are beautiful, don’t see themselves such, but their so-called success makes them vulnerable to exploitation – because of their beauty (Freedman 1990). Women really can’t win.

     Cosmetic Surgery: A View of the Knives

Morgan (1991) displayed a page of knives, scissors, needles, and sutures used in cosmetic surgery in her essay, “Women and the Knife: Cosmetic Surgery and the Colonization of Women’s Bodies”. She suggested that her readers look at them carefully, for a long time, and to imagine them cutting into your skin (Morgan 1991). I did.

As a nurse, my first glance simply revealed surgical instruments – no big deal. Then I looked at them with care, for a long time, and imagined them being used on me as the author suggested. When I looked through my feminist lens, I saw mutilating, controlling devices used by patriarchy to manipulate women, to make women fit the image of beauty defined by white men. I saw how far beyond powder the industry had come and how enormous the greed for profit and control had taken patriarchy.

The technological beauty imperative gives cosmetic surgeons the powerful and explicit mandate to explore, break down, and rearrange women’s bodies (Morgan 1991). Cosmetic surgery is an example of the medical system’s power to define, not only what is normal or pathological, but what is beautiful. No aspect of medical training certifies physicians to evaluate beauty. The message is: “The ideal woman is made, not born, with a little help from the surgeon’s scalpel” (Unger & Crawford 1992, p. 334).

Kathryn Morgan (1991) quotes a plastic surgeon (director of plastic surgery education at a university): ” … I think people who go for surgery are more aggressive, they are the doers of the world. It’s like makeup. You see some women who might be greatly improved …, but they’re, I don’t know, granola-heads or something, and they just refuse.” (Morgan 1991, p. 26). Frightening, this man teaches future surgeons and no doubt perpetuates these attitudes.      

Weight standards for attractive women have been reduced in our society (Unger & Crawford 1992). Even Barbie has gotten thinner than since her appearance in nineteen fifty-nine (Unger & Crawford 1992; Freedman 1990). In such a society, puberty itself has negative consequences for girls whose normal development includes increases in fatty tissue. Girls are seen as lacking what’s defined as normal – boys’ lean bodies, also causing a girl to deviate from the “ideal” thin female image (Unger & Crawford 1992).

The most popular cosmetic surgery in nineteen ninety was liposuction. Fat cells are vacuumed from beneath the skin – never to return. Women risk their lives in surgical procedures that promise to make them fit the imposed image of a lean body. Liposuction has resulted in at least twelve deaths from hemorrhages or embolisms (Morgan 1991).

Facelifts (an umbrella term for several procedures) are recommended to women in their early forties with subsequent repeats every five to fifteen years, costing $2,500 to $10,500. Various styles of rhinoplasties (nose jobs) are available and styles go in and out of fashion from time to time. For $2,000 to $3,000 they will whittle down your nasal bone or add a piece of bone from another part of your body that will answer fashion’s call (Morgan 1991). In one study thirty percent of women said they would have a face-lift if they could afford it (Unger & Crawford 1992).     

Dr. Robert Mendelsohn (1982) says women frequently ask him about getting plastic surgery, women he knows are looking to cure problems in their marriages that they attribute to their inability to qualify as a model for Vogue. He doesn’t encourage plastic surgery and thinks its use other than in correcting true traumatizing disfigurement, ” … is the biggest rip-off on the medical scene” (Mendelsohn 1982, p. 39). Mendelsohn (1982) mentions one female plastic surgeon who said that some of her peers act as if they’re hairdressers and “give the field a bad name” (Mendelsohn 1982, p. 39).

            Feminist Biomedical Ethical Perspectives

One of the reasons Morgan (1991) gives for writing about cosmetic surgery is that the field of bioethics has been relatively silent about the issues present in this area of medicine, feminist or otherwise. Morgan (1991) thinks that feminists need to ask why women would reduce themselves to potentialities to fit the heterosexual image, illustrated by an enormous and growing demand for cosmetic surgery. Women invest years of their savings to fix natural flaws through dangerous and painful operations to make their bodies fit images designated by fashion editors (Morgan 1991).

The relationship between the means and the ends is no longer unilinear, it has become circular, with the new technologies presenting the possibility of new ends. The possibility of what one might desire has new objectives added. Technology’s role has become to transcend, control, transform, exploit, and destroy; its object is viewed as inferior, thus justifying it’s higher purpose in providing a fix (Morgan 1991). This is congruent with what traditional bioethics has historically done – used rationalization to justify what doctors are already doing (Sherwin 1992).

We’ve become technological subjects and objects, transformable with the ability to literally create ourselves with biological engineering. Technology plays the role of transcendence, transformation, control, exploitation, or destruction of the object, viewed as inferior.  A higher purpose is served in perfecting the object because it’s harmful or evil. To the Western medical model, the body is a machine whose parts can be replaced (Morgan 1991). One plastic surgeon clarifies his role, “Patients sometimes misunderstand the nature of cosmetic surgery. It’s not a shortcut for diet and exercise. It’s a way to override the genetic code” (Morgan 1991, p. 31). 

Most women are socialized to accept the knives of technology in Western societies. Knives can be used to heal: saving the life of a baby in uterine distress, removing cancerous growths, straightening crooked spines, or giving back functioning to arthritic fingers. But other knives perform episiotomies and other types of genital mutilation, remove our deviant tendencies by cutting out our ovaries, unnecessarily amputate our breasts with prophylaxis used as justification, or in cases where less drastic measures could have been employed, slice out uteruses of women beyond childbearing age or of those of undesirable color, and perform unnecessary cesarean sections so doctor’s time isn’t delayed by nature (Morgan 1991).

The skin is nature’s vital protective barrier that protects and contains our body’s integrity; any time skin is broken you are at risk. It should never be taken lightly (Morgan 1991). Morgan (1991) refers to the knives of cosmetic surgery as, magic knives, in a patriarchal white supremacist culture. I’m afraid of these knives that have historically illustrated great ease in penetrating and controlling women – beyond the skin.  

After listening to the voices of women who underwent cosmetic surgery, Morgan (1991) gives examples and assessments of their various reasons: “I’ve gotten my breasts augmented. I can use it as a tax write-off” – professional advancement and economic benefit (33); “There will be a lot of new faces at the Brazilian Ball”, – class and status symbol (33); “If your parent had puffy eyelids and saggy jowls, your going to have puffy eyelids and saggy jowls”, – control, liberation from parents, avoid hereditary (33); “… we want a nose that makes a statement, with tip definition and strong bridge line”, – domination and strength (33); “A teacher who looks like an old bat or has a big nose will get a nickname”, – avoid cruelty and aging (33); “I’ll admit to a boob job” (Miss America 1986), – competitiveness, attain prestige and status (33); “People in business see something like this as showing an overall aggressiveness and go-forwardness the trend is to, you know, be all that you can be”, – success and personal fulfillment (33). Her list went on to include reasons such as a gift to self, erasing a decade of hard work, economic gain, possible denial of grandmotherhood, emotional control, and happiness (Morgan 1991).

Sixty to seventy percent of cosmetic surgery patients are female. Why, when the risks are so great, are women willing to sacrifice other parts of their lives to have reconstructed bodies? Risks include bleeding, infection, embolism, unsightly scars, skin loss, blindness, disability, pulmonary edema, facial nerve injury, and death. Despite these facts, medical ethics don’t discuss these issues (Morgan 1991). As a feminist health professional, I feel that our silence on the issue makes us complicit in enlarging the scope of avenues to patriarchal power.

The extent that patients and cosmetic surgeons are committed is shocking to what Morgan (1991) sees as, “one of the deepest of original philosophical sins, the choice of the appearance over the real” (p. 28). Technologically created appearances are perceived as being real (Morgan 1991).        

Morgan (1991) thinks we are technologizing women’s bodies in Western culture. Cosmetic surgery is moving out of the sleazy, suspicious, deviant, or pathologically narcissistic, to the norm. With this shifting, it may actually become deviant not to have cosmetic surgery. This changing societal perception has the potential to lead to viewing those who don’t elect cosmetic surgery as deviant (Morgan 1991). Cosmetic surgery has gone far beyond the “duty” that makeup became in the nineteen twenties. Morgan’s prophecy is not at all far-fetched. 

                    Silicone Breast Implants

Breast augmentation with silicone implantation is the second most frequently performed plastic surgery. Over one million women have had these implants, costing from $1,500 to $3,000 (Morgan 1991). “Jacobs (a plastic surgeon … ) constantly answers the call for cleavage. `Women need it for their holiday ball gowns'” (Morgan, 1991, p. 25).

Augmented women appear to have a higher incidence of breast cancer (Morgan 1991). To date, there have been seventy-two deaths and ninety-one thousand injuries related to silicone implants (Winfrey 1995a).

Plastic surgeons and manufacturers rationalize that silicone breast implants are a matter of a woman’s free choice, after all, it’s an “elective” procedure. However, women should think seriously about trusting physicians and manufacturers who not only stand to profit significantly by satisfying women’s “choices”, but who are the very same white males who dictate the patriarchal beauty images that women “choose” to comply with. 

Oprah Winfrey (1995a) recently did a show on the controversy over breast silicone implants; she had Dow Corning’s Stephanie Burns, Manager of Women’s Health and FDA Issues, and Dow’s chairman and CEO Richard Hazleton on the show. Audience members described symptoms they began to experience soon after receiving silicone breast implants: migraines, numbness in hands and fingers, terrible rashes on the chest, axilla, and down their sides, rock-hard breasts, and burning pain in the breasts and armpits (Winfrey 1995a).

Other than migraines, these signs directly relate to the areas of the body near the breasts. However, doctors told these women they didn’t know what caused their symptoms and mammograms failed to show abnormalities (Winfrey 1995a). Recent studies demonstrate that mammograms are very difficult to interpret because implants block X-rays by casting a shadow on surrounding tissue (Morgan 1991). 

It’s now common knowledge that Dow Corning suppressed negative data about the safety of their silicone gel implants. Women who have received the implants say that they have led to the development of autoimmune diseases; diseases in which the body’s own cells attack themselves. A disease that may very well correlate with the psychological phenomenon involved in the negative body image that led women to obtain implants. It’s almost as if the body was speaking out metaphorically through the development of autoimmune responses; the body’s way of expressing the evil it has experienced.   

Audience members (Winfrey 1995a) knew their doctors thought they were crazy because they couldn’t find answers to their symptoms; the women felt like they were losing their minds. Miraculously, their symptoms went away when the implants were removed. Some women who had had implants learned, after having other types of surgeries, that their surgeons found silicone gel on their livers, uteruses, and ovaries. Autopsies have revealed gel in the brains of implanted women (Winfrey 1995a). 

Stephanie Burns (Winfrey 1995a) said that the implants can cause local complications: infection, capsule formation around the implant, hardening of the breast, and rupture and that when rupture outside of the capsule occurs, the gel can migrate. Burns (Winfrey 1995a) also admitted that when migration occurs the gel and implants must be removed. One woman showed the actual gel that had leaked out of her implant into her rib cage and lymph nodes. It was obvious that the sticky, stringy material would be difficult, if not impossible, to remove from the inside of the body (Winfrey 1995a).        

Burns (Winfrey 1995a) said that eighteen studies have come to the same conclusion, there is no correlation

between the implants and autoimmune or other diseases.

Burns (Winfrey 1995a) said this despite the fact, (brought out by audience members), that the package inserts actually LISTS scleroderma and rheumatoid arthritis (autoimmune diseases) as possible side effects. Women in Winfrey’s (1995a) audience said that they didn’t see package inserts – the packages are opened in surgery and physicians have not shared the package inserts with them. I wonder if the physicians themselves read the inserts? My guess is that the good old boy network mentality could allow some doctors to simply trust the manufacturer. 

Richard Hazleton said he doesn’t believe the implants are causing the women’s problems. Hazleton suggested that women needed to get beyond their anger and really need to understand the facts. He repeatedly referred to women’s choice in having implants (Winfrey 1995a).   

Many of the women said Dow did not follow ethical standards because women were not informed of the possible dangers. According to an audience member, the FDA said that it’s up to the company to prove that the implants were safe, not the responsibility of the medical community to prove that they’re not safe (Winfrey 1995a). I think both the manufacturer and the physicians are responsible. One woman in the audience said that “buyer beware” is not an acceptable practice (Winfrey 1995a). Both of Dow’s representatives kept citing the evidence from the studies that claim no correlation between the implants and any disease. A woman in the audience said, “We are the evidence. Study us!” (Winfrey 1995a). A great idea!

Historically women have been socialized to use beauty as a power (Morgan 1991). Morgan (1991) includes a quote from Mary Wollstonecraft from 1792, “Taught from infancy that beauty is a woman’s scepter, the mind shapes itself to the body and roaming round its gilt cage, only seeks to adorn its prison” (p. 34). Morgan (1991) asks whether women today are making free choices to have cosmetic surgery or are too simply adorning their prisons?

            Psychological Aspects of the “Choice?”

An inexcusable tragedy is that women expect that plastic surgery will fix their lives, not just change their features. They soon discover that even fixed, they’re not good enough and the same problems still exist. The psychological impact is likely to produce an even deeper depression than before the surgery when the subsequent disillusionment sets in (Mendelsohn 1982).

Women receive complex negative messages about their bodies which can lead to low self-esteem and alienation from one’s physical and sexual selves. These negative attitudes remain throughout a woman’s life and can result in constant worry over weight, looks, and feeling unsatisfied with her physicality. Despite the fact that these negative body images are distorted one researcher claims that there is an “epidemic of `flesh loathing’ among women (Unger & Crawford 1992, p. 333). Cosmetic surgery is increasingly viewed as a cure for aging and body variance (Unger & Crawford 1992).  

Beauty’s affirmation brings with it privileged heterosexual affiliation which includes forms of power not available to the plain, ugly, old, or those unable to reproduce. Women who seek cosmetic surgery have compelling voices; their voices tell of their search for transcendence, achievement, liberation, and power. The youth and beauty artificially created by the surgery doesn’t only appear to, but often actually does (emphasis added) give a woman a sense of identity that she, to some extent, had a choice in. Increasing her desirability to men (especially white men) offers the possibility to raise her status socially and economically (Morgan 1991). 

A woman’s beauty is a valued commodity. Beauty may be a kind of power for women, but their looks can be used in exchange for financial and material gains. Furthermore, when males treat females well it validates their beauty and enhances their social standing (Unger & Crawford 1992).

In the commitment to pursue beauty, a woman integrates her life with a consistent set of values and choices, bringing with it societal approval which results in an increased sense of self-esteem. The process of acquiring cosmetic surgery may expose a woman to people who treat her body in a caring way, something women frequently lack in their lives on a daily basis. The pursuit of beauty through transformation is frequently associated with experiences of self-creation, fulfillment, transcendence, and being cared for – powerful experiences. At the same time that beauty can confer an increase in self-esteem to a woman, it also involves being entrapped by its interrelated contradictions (Morgan 1991).

According to cosmetic surgeons, women come to their offices demanding: “Bo Derek” breasts, and nose reductions, frequently sought by Jewish women to obtain an Aryan look, Western eyes, sought by Asian women, and light skin, through the use of toxic bleaching agents, sought by Black women. The goal isn’t simply beautiful, but to mold oneself to fit racist, anti-Semitic, White, Anglo-Saxon, and Western images (Morgan 1991). For women, this molding is at the expense of their precious selves.   

Initially one might argue that it’s a choice, but Morgan (1991) argues what appears to be the result of reflection, deliberation, and a self-creating choice signals conformity at a deeper level. The images of male-identified beauty sometimes live as ghosts in the reflective awareness of women clothed in a diffuse manner. It’s not always obvious to women that their bodies are being viewed as raw material, primitive entities, seen only as potentials for exploitation by the colonizing culture (Morgan 1991). 

Sometimes the culture’s power source is explicit, it’s brothers, fathers, male lovers, or cosmetic surgeons who offer free advice on how they can cure deformities and problems at women’s gatherings. Sometimes the diffuse power dominates a woman’s consciousness without an apparent outside source (Morgan 1991). That unapparent source is her own internalization of patriarchal values. 

Women who are involved in self-surveillance behaviors, like fixing their make-up all the time, or monitoring everything they eat, are maintaining obedience to the patriarchal powers that be. The men that women transform themselves for are male-supremacist, heterosexist, ageist, ableist, racist, anti-Semitic, and classist (Morgan 1991). Women don’t see this because their so-called decision comes out of internalized values that tell them they’re not pretty enough. The same self-blame that occurred in the nineteen twenties in regard to the use of makeup, happens to women today in regard to cosmetic surgery. The basic phenomenon is the same, the behavior that results from the internalization digs in deeper today.         

Coercion and domination are frequently camouflaged by theories and rhetoric that appear benevolent, voluntary, and therapeutic. Technology’s ideological manipulations serve to destroy and disadvantage aspects of women’s integrity. Rather than escaping the constraints of their given physicality they are becoming more vulnerable, in seeking independence they are actually more dependent on male assessment (Morgan 1991).

The woman who seeks cosmetic enhancement seems to fit the paradigm of making a rational choice, but she makes that choice at a significant cost to herself in terms of lengthy post-operative pain and in terms of financial costs (health insurance doesn’t cover elective cosmetic surgery). The term elective has a seductive role in the ideological camouflage regarding apparent choice (Morgan 1991).

Loni Anderson discussed her cosmetic surgeries on the Oprah Winfrey Show. Loni admitted to having two breast reductions and having her eyes done. Winfrey (1995b) asked Loni, “You believe if you can do it – do it?” Loni answered, “I think it’s maintenance, it’s not changing, it’s maintenance” (Winfrey 1995b). Like car maintenance, if you don’t change the oil every three thousand miles you’re engine will be destroyed. What will happen to women’s identities if they don’t do maintenance? Maintenance is certainly a frighteningly harmless-sounding description of what is increasingly becoming an expectation for women. 

Morgan (1991) quotes an article marketed toward homemakers, “For many women, it’s no longer a question of whether to undergo plastic surgery—but what, when, by whom and how much” (28). Just as makeup came to define femininity in the nineteen twenties, today’s cosmetic surgery is becoming necessary for the “maintenance” of femininity.

As cosmetic surgery becomes more and more normalized in the media, women who refuse to submit will be viewed in one way or another as deviant. Their stigmas will include being viewed as unliberated, and uncaring about their appearance, which is considered a disturbed gender identity by some healthcare professionals, and as refusing to be all they can be (Morgan 1991). Imagine an ad where therapists offer to help women to overcome their fear of cosmetic surgery: “Gentle, caring therapist will help you overcome your fear of plastic surgery. You just need a little help – we can help you to attain YOUR dream of ultimate beauty!”

“…  the technological imperative and the pathologic inversion of the normal are coercing more and more women to “choose” cosmetic surgery (Morgan 1991, p. 41). Normal variations in women’s bodies are redefined as deformities, ugly protrusions, inadequate breasts, and unsightly fat areas, all designed to magnify feelings of shame, and disgust and see relief in what cosmetic surgeons offer (Morgan 1991). 

Although admittedly not likely to ever be achieved, Morgan (1991) says that women could collectively choose to exercise their power and refuse cosmetic surgery. Refusal holds the possibility of drastically affecting the market, possibly leading surgeons back to healing (Morgan 1991).

Morgan (1991) suggests that feminists not turn away from women who chose cosmetic surgery, as this decision may be one of the only decisions that she perceives as having power over her life. It is essential that we acknowledge the power of the gender-constituting, identity-confirming role femininity plays in bringing a woman into existence, while at the very same time making her a patriarchal-defined object. Under these circumstances, refusal may mean renouncing one of the only life-conferring choices a woman may have. While cosmetic surgeons are flooded with new clients and new research in the field is rapidly leading to more body parts becoming objects of redoing, it may be that the best we can hope for is to increase awareness of the numerous double-binds and compromises that affect all women’s lives (Morgan 1991).

In Conclusion

Morgan suggests that women could protest in a culturally liberated manner with events such as Ms. Ugly/America/Canada contests utilizing cosmetic surgery to attain the right look (Morgan 1991). If we cringe at the idea of women altering themselves to win a Ms. Ugly contest, Morgan (1991) says it may just make the point of how strongly the beauty imperative has us all hooked. One might think of these surgeries as mutilations, but Morgan (1991) says it’s just as mutilating to de-skin and alter healthy tissues to go with the flow of fashion.

A revolt Morgan (1991) suggests is to parallel the current market for breast implants with commercial protest booths (set up at health conventions and outside of cosmetic surgeons’ offices) with before and after photos of penises, the display signs might read, “The Penis You Were Always Meant to Have” (p. 46).  

Perhaps feminists could also develop a continuum of handsomeness for males, similar to the one-to-ten model devised to judge female beauty. It might be fun for feminists and has the potential to even raise the consciousness of non-feminists. Women might be more inclined to see how ridiculous and damaging the beauty imperative is.       

Cosmetic surgery’s language fits with the surreal images that women are expected to comply with. Another word for cosmetic surgery is plastic surgery, the word “plastic” is actually more descriptive of the image imposed. Even the word augmentation is revealing to one with a feminist consciousness. Wolf (1991) summed things up well, “The beauty myth generates low self-esteem for women and high profits for corporations as a result” (p. 49). The cosmetic industry demonstrates how very personal the political/economical really is.

                                    Work Cited

Brownmiller, S. (1984). Femininity. New York: Linden Press/Simon Schuster.

Freedman, R. (1990). “Myth America grows up”. In Issues in feminism an introduction to women’s studies. (Ed) Sheila Ruth. Second Edition. Mountain View, CA: Mayfield Publishing, pp. 384-393.

Mendelsohn, R, M.D. (1982). Male practice: How doctors manipulate women. Chicago: Contemporary Books.

Morgan, K. Pauly. (1991, Fall). “Women and the knife: Cosmetic surgery and the colonization of women’s bodies”  Hypatia. 6  (3), pp. 25-53.

Peiss, K. (1994). “Making faces: The cosmetic industry and the cultural construction of gender, 1890-1930”. In Unequal sisters. Second Edition. (Eds) Vicki L. Ruiz & Ellen Carol DuBois. New York: Routledge, pp. 372-394.  

Sherwin, S. (1992). No longer patient feminist ethics and health care. Philadelphia: Temple University Press.

Unger, R., & Crawford, M. (1992). Women and gender feminist psychology. New York: McGraw-Hill.

Winfrey, O. (1995a, October 13,). Topic: Controversy over silicone breast implants. On The Oprah Winfrey Show. The American Broadcasting Company, Channel 7. Chicago: Harpo Productions, Inc.    

Winfrey, O. (1995b, November 9,). Topic: Loni Anderson speaks out about her divorce from Burt Reynolds. On The Oprah Winfrey Show. The American Broadcasting Company, Channel 7. Chicago: Harpo Productions, Inc.    

Wolf, N. (1991). “Work”. The beauty myth: How images of beauty are used against women. New York: William Morrow & Company, pp. 20-57.

Lesbians: Coming Out for Equality

Pat Anderson

De Paul University, Fall 1996

Inequality in American Society, PSC 324

Stan Howard, Ph.D.

Lesbian Lives: Historical Plight for Inclusion

            Other than the occasional sighting of a “stone bull dyke,” the stereotypical lesbian drag king, lesbians have been relatively invisible. Before I came out as a lesbian five years ago I had never knowingly met a lesbian and initially had no idea where I might find “them.” Within the last few years lesbian visibility has become more common. Most heterosexuals could probably actually think of a lesbian they knew by name: Rock star, Melissa Etheridge, recording artist, K.D. Lang and Martina is all you need to say to bring the tennis legend to mind. Of course, this has not been always been the case …

            Historians have discovered lesbian ghettos all the way back to the early sixth century BC. Because of the stigma and shame implied, women of past generations rarely admitted their attraction to women. Closeted lifestyles kept them from social critique (Ettorre 248).

            According to Arlene Stiebel (1992), historically speaking there was no such thing as a lesbian (154). She has written about the relative ease of lesbian relationships during the Renaissance. Lesbian authors wrote openly about their romantic friendships with each other without fear of discovery. During the Renaissance there was no sex without penetration, thus lesbian relationships could only be viewed as innocent. Queen Victoria once asked, “What could women do” (Stiebel 158)? Phallocentric culture defines sex around the penis, so sex without a male is impossible (Stiebel 158).          

            The history of the word homosexual is illustrative of society’s abnormal and distorted image of it. When it was first used in the eighteen fifties, homosexual referred to males and females and meant the inability to have a “normal” erection (Unger & Crawford 345). During the nineteenth century, many North American women lived and wrote about their lesbian lives together, yet they were not labeled lesbians (Unger & Crawford 346).

            Traditional discourse on homosexuality has revolved around males. Lesbians had little credibility and their social relevance was merely to delight male fantasies. Acceptable sexuality for women always involved male partners (Ettorre 247).

            Lesbians were originally excluded from the civil rights, women’s and gay liberation movements of the late nineteen sixties. Many gay men in the Gay Liberation Front (GLF) held the same sexist assumptions about women’s roles as heterosexual men (Marotta 238). They faced sexism within the gay liberation movement itself.  Lesbian issues were even excluded within the National Organization for Women (NOW).

            According to Toby Marotta (1981) lesbians were forced to begin their own separate lesbian feminist movement outside of NOW. One of the groups formed to work toward lesbian inclusion was the Radicalesbians (Marotta 230). Rita Mae Brown was forced to resign from NOW after failing to obtain NOW’s approval to include lesbian concerns. NOW leaders were uneasy about Brown’s open lesbianism and weren’t willing to officially use their voice to speak for lesbians (Marotta 234). Just the mention of the word lesbian and NOW’s Executive Committee would have a collective heart attack (Marotta 235).

            Brown tried to get NOW members to see that by excluding lesbians they were oppressing other women. Brown reminded NOW members that the image they were trying to uphold was male-oriented (Marotta 235). By excluding lesbians, they were being obedient to patriarchy.

            The Radicalesbians had to encourage each other to express themselves freely due to the fact that male-identified lesbians had been ostracized for not meeting “female” standards of appearance and behavior (Marotta 314). In the nineteen seventies lesbians weren’t free to be who they really were even among themselves. Just like heterosexual women, lesbians internalize male-defined identities and inferiorities which results in self-hatred and group in-fighting. If feminists and gay men wanted to exclude lesbians, it’s not hard to extrapolate that society wasn’t any where near ready for lesbians to leave their closets.

            Historically, due to the denial of lesbian existence, heterosexuals were the ones in the closet. But once society stuck its awareness out of the closet and saw lesbians, it was lesbians who were shoved into the closet.  

Origin

            Heterosexism and homophobia are two theoretical frameworks that are inseparable in explaining lesbian exclusion. Heterosexism is the institutionalized assumption that everyone is heterosexual and if they’re not, they should be. This assumption then sets the stage for homophobia by assuming that the world is and must be heterosexual (Pharr 16). Heterosexism is also a value that uses religion to enforce homophobia. Heterosexist family values makes women loving males inherently superior and gives it the right of dominance.

            Because it’s a value of the ruling class, heterosexism holds enormous power. Pharr explains that its power is in defining norms and standards of righteousness that others are often judged in relation to (53). Norms are empowered through institutionalization, economic power and violence to make them complete. These norms represent the few with power (Pharr 53). Audre Lorde (1992) refers to American norms as “mythical norms”, they include being white, thin, male, heterosexual, Christian and financially secure (Lorde 214).  

            Homophobia is an irrational fear and hatred of people who love and sexually desire their own sex (Pharr 1). Homophobia acts as a social control because it encourages males to act more masculine just to prove they’re not gay. It also separates masculinity and femininity by discouraging men from exhibiting caring, gentleness or nurturing for fear of being accused of a so-called feminine trait (Anderson 37). Lesbians are threatening because they expose contradictions in our beliefs about biology, culture, sexuality, femininity and women in general (Ettorre 243). Our society is male-oriented and propagates sexual ideas that cater to the interests of the elite males (Ettorre 244).

            The power of homophobia and heterosexism is profound because it’s so intricately entrenched in American culture that most heterosexual people don’t see it and the harm it inflicts on lesbians. At a recent Anti-Homophobia workshop at De Paul University, Richard Friend (1996), referred to homophobia and heterosexism as a “loud silence.” Silent unconscious assumptions of heterosexuals that scream at the consciousness of homosexuals.

            Heterosexism and homophobia are enforcers of patriarchal power (Pharr 16-17). Together they attempt to control and limit sexuality. Heterosexuality is the only sexuality allowed. Lesbian sexuality excludes men so it’s labeled abnormal, unnatural and is relegated to closet expression.

                     Persistence        

            Homophobia and heterosexism maintain, reinforce and are actual off-springs of the Anglo-Saxon Protestant ethic. This dominant elite morality controls sexuality through heterosexism and homophobia. Because of its enormous power it’s morality is afforded credibility among most traditional religions. Rugged individualism is a value attributed to males. Lesbians are seen as disobedient “Others”, despite the rugged individualism it takes to survive in a hostile heterosexist culture.

            Internalized homophobia has worked to keep lesbians isolated from other lesbians and when combined with compulsory heterosexuality makes lesbians feel unacceptable. Without visible role models in society, lesbians feel different, alone and end up blaming themselves (Pharr 71).

            Passing, or appearing to be heterosexual, is a tactic that has allowed many lesbians to hide, thus attaining heterosexual privilege. But passing prevents lesbians from meeting and bonding with one another (Pharr 72). This phenomenon has also prevented lesbians from becoming politically and socially active in fighting homophobia (Pharr 73).      

            Religious words and phrases like “abomination”, “crime against nature”, “sick”, “evil”, “sinful” are used to label homosexuals. When you grow up internalizing these ideas it makes it difficult to accept being a lesbians to one’s self, let alone to develop a political consciousness or more importantly a healthy self-worth (Ettorre 247). This powerful degradation of the self is similar to what blacks have experienced through fallacious claims of inferiority.

            The fear of lesbianism is so bad in the black community that it has led Black women into testifying against each other; some have been led into destructive alliances, others into isolation and despair. Black lesbians are viewed as threats to Black nationhood, as enemies and as un-Black. This keeps black women in hiding between homophobia of blacks and racism of white women (Lorde 219-220). Being a lesbian adds an additional cultural layer to one’s identity. Diverse identities among women has separated them from other cultural aspects of themselves and from each other.

            Our culture has institutionalized sexuality and uses all its avenues to implant the dominant ideology about sexuality. Social status is granted for obeying the norms (Ettorre 244). Those who don’t fit are viewed as “Other” and labeled abnormal, deviant, inferior and not completely human. Norms don’t understand the “Others”, but “Others” always understand the “Norm” in order to protect themselves. The “Other’s” life is kept invisible, if an oppressed group is not seen it enforces the notion that the “Norm” is the majority – “Others” don’t exist or count (Pharr 58). Unless we demand expansion of the “Norms” to include alternative sexualities, lesbian status as “Other” will be maintained, even among women and lesbians themselves.    

            “Others” are labeled with negative stereotypes that dehumanize them and serve to allow “Norms” to justify exclusion (Pharr 59). Homophobic labels depict lesbians as child molesters and perverts; they’re threatening to “family values” and they recruit heterosexual women. (One wonders what societal perks are used as sales tactics by recruiters). These labels provide plenty of rationale for discriminating against lesbians. Lesbians internalize these negative stereotypes and images that also blame them for their situation; this leads to low self-esteem and self-blame (Pharr 59). Heterosexist “norms” and values maintain women’s dependence on men, male/female role playing and penile sexuality.

            Lesbians share a zero-sum phenomenon similar to what African Americans have experienced – any perceived gains for blacks are seen as losses for whites. Some criticize the feminist movement and assumed that work done on behalf of women is work done against men (Pharr 24). It is assumed that because lesbians have stepped out of sexual and economic dependence on men that they hate and are against men. Lesbians threaten male dominance, control and the nuclear family (Pharr 18). This ideology poses a threat to all women in that any woman who fights for the rights of women or steps out of her prescribed role risks being labeled a lesbian. Once labeled as a lesbian there is no real way to prove one’s sexuality (Pharr 19). This fear prevents many women from joining the feminist movement and decreases the odds that all women’s inclusion will be attained. It is wrongly assumed that most feminists are lesbians and that all lesbians are feminists. Thus many women who believe in feminist ideology deny being a feminist because it means being labeled a man-hater and/or lesbian (Pharr 24). Many heterosexual women see lesbians as standing in contradiction to the sacrifices they make in conforming to mandatory heterosexuality (Pharr 18). These commonly held misperceptions serve to perpetuate the exclusion of lesbians and women in general. The effects of homophobia and heterosexism go hand in hand maintaining lesbian exclusion. 

          Consequences

            Lesbians share economic parity with women in general who make less money than men. The combined income of two lesbians is less than a household with a male and female or two gay men. Sometimes the sheer force of economics encourages lesbians who are dating to move in together before either of them are ready to do so emotionally.

            Economics is a weapon used to control women and lesbians. The National Commission on Working Women claims that the average woman earns sixty four per cent of what men earn (Pharr 10). The economic weapon works particularly well to keep lesbians in the closet for fear of loosing their jobs. In order to survive financially they’re sometimes forced to tolerate abuse and isolation at work (Pharr 12-13).

            Lesbians loose jobs, fail to get a promotions, face discrimination or can even be seen as a liability in the work place because of their sexuality. It’s as if heterosexuals could be corrupted and contaminated in the presence of a lesbian (Ettorre 246).

            Lesbians who develop committed relationships with one another do not enjoy equal status with heterosexual couples. They have not been recognized as a couple so even the idea of domestic partnership benefits, marriage, survivor benefits, hospital visitation rights for partners, adoption of one of the partners children and even maintaining custody of their own children has been a struggle for those who dared to admit being lesbians.

            Lesbians risk loosing custody of their children just because they’re lesbians, even if the other parent is a known abuser (Pharr 21). There are written and unwritten laws that prevent lesbians from adopting and fostering children due to an irrational fear that children will be influenced to become homosexual or will be abused. Despite the fact that ninety five percent of child sexual abusers are heterosexual men there are no policies to prevent heterosexual men from teaching or working with children (Pharr 22).

            In nineteen ninety six, the Federal Employment Non-Discrimination Act (ENDA) failed to pass by one vote. This law would have outlawed workplace discrimination on the basis of sexual orientation. Today lesbians and gays can be fired or not hired merely for being homosexual.

            In nineteen ninety six lesbians and gays rights were given another blow when the Defense of Marriage Act (DOMA) passed. This act truly demonstrated the homophobia of legislators. They pass a bill preventing recognition of gay marriages BEFORE gay marriages are even legal! It was certainly defensive posturing of congressional officials. It’s almost as if the gain of lesbian and gay marriage would somehow mean losses for heterosexual marriages – zero sum thinking again. Homophobia propagates the myth that if lesbians and gays are allowed to marry and gain spousal benefits there won’t be enough for heterosexuals. Wouldn’t marriage actually make lesbians conform? This is an example of wasteful discriminatory energy.   

            Many lesbians are not accepted by their own family and friends. Many are literally thrown out of their homes when they come out. Inferiority is a powerful control mechanism propagated by homophobia and heterosexism. It takes a profound toll on the self esteem of lesbians. They suffer serious psychological problems accepting themselves because of societal rejection. One young woman described her experience growing up in a homophobic home. It was as if she were a Jewish kid raised in a Nazi home (Friend 1996). 

            Lesbians and gay men are subjected to being beaten, raped, killed, subjected to aversive therapy and placed in mental hospitals just for being who they are (Pharr 23). Despite the fact that the American Psychiatric Association removed homosexuality from their list of diagnosis in nineteen seventy three (Unger & Crawford 347), a recent 20\20 show (American Broadcasting 1996) told the story of teenage girl whose mother kidnapped her and brought her to a mental hospital for treatment when she found out she was a lesbian. The girl reported that many of the other teens there were also being treated for being gay.

            Depression and suicide can be the results of being subjected to societal hatred (Pharr 23). According to Richard Friend (1996) suicide is epidemic among gay young people and is the leading cause of death in gay teens. Its two to three times higher than the heterosexual rate. The leading indicator of a potential suicide in a gay male teen is effeminacy; they’re most likely to be harassed and to commit suicide. This also reflects the drastic nature of sexism in that a male is most hated for being like a female (Friend 1996).

            The right-wing perspective sees women’s self determination and control over their own bodies as threatening to the nuclear family so one of their main focuses has been on homosexuality (Pharr 17). The religious right exhibits it’s heterosexism and homophobia through it’s sin theory that relies upon the bible for evidence. Discrimination against homosexuals is justified through biblical translations, despite the fact that the word homosexual doesn’t appear in the bible. English biblical translations exhibited bias against homosexuals that has served to limit their civil and human rights (Pharr 3). Eight alleged biblical references to homosexuals must be looked at within the context of hundreds of references to the need to justly distribute wealth. Not many people reference the bible to argue for a redistribution of wealth (Pharr 3).

            Concerns of the religious-political right are shared even by those who don’t necessarily identify with their view about homosexuality being a prime contributor to America’s spiritual degeneracy (Corbett 187). Surveys have shown that eighty percent of Americans think that homosexuality is nearly or always wrong (Corbett 188). Being labeled immoral is spiritually degrading.

            Homosexuals are the most frequent victim of hate crimes. A recent Jenni Jones show demonstrated just how bad people feel about gays. A gay man on the show said that he liked a man who was heterosexual. The heterosexual man shot and killed the gay man simply for saying he liked him. Apparently it’s better to be known as a murderer than to being in any way associated with being gay (Friend 1996).

            Last August two anti-gay murders were committed in Oklahoma. Albert Bixler was beaten to death with a tire iron and Charles Meers was beaten, stabbed, shot, doused with gasoline and then lit on fire. Fred Mangione was stabbed to death outside of a bar in Houston. An Oregon lesbian couple, Michelle Abdill and Roxana Kay Ellis, were murdered last September (Outlines 20).

            In order to maintain power violence and the threat of violence must be used (Pharr 55). The interplay of institutional and person violence is expressed against gays and lesbians through written and unwritten laws. Whether or not it’s police harassment or lack of police protection gays and lesbians are assaulted (Pharr 56). Lesbians also face rape, battering and abuse, the same as heterosexual women, which is frequently not honored in the courts (Pharr 57).

            David Mixner (1993) is an openly gay man and political consultant. He’s also been a close personal friend to Bill Clinton. He receives four to five death threats a week.

            The Gay, Lesbian and Straight Teachers Association asked teachers how their gay and lesbian students were doing. Teachers responded that they had no idea – a telling revelation about the school room climate. Several teachers at the Anti-Homophobia Workshop used the phrase, “hostile hallways” to describe what gay young people face going from class to class.  

            Lesbians and gays experience systematic exclusion within education because there are no images or role models presented. When “greats,” like Walt Whitman, Gertrude Stein, Virginia Woolf (and many others) are discussed in classrooms there is no mention that they were gay. As a lesbian, if you don’t learn about lesbians who did anything worthwhile you think you’re worthless (Anti-Homophobia Workshop). 

            School libraries (grammar and secondary) present a catch twenty two to gay students looking for information on homosexuality. Books on gays are in the reference section, kids who are looking for these books don’t want to ask for them. The libraries put the books in reference because the kids are so desperate for information that they’re afraid they’ll steal the books. Another problem is that information on homosexuality is placed with prostitution, pedophilia, deviance and women in prison (Anti-Homophobia Workshop).

            Members of the Gay, Lesbian and Straight Teachers Association say that schools fail to protect lesbian and gay young people. Teachers fail to intervene when young people talk negatively about gays, they fear that if they speak up about gay bashing someone will think that they’re gay (Anti-Homophobia Workshop).

            On July 31, 1996, in the case of Nabozny v. Podlesny a school district in Wisconsin was found guilty for failing to stop anti-gay abuse. The United States Court of Appeals, for the Seventh Circuit, ruled that schools could be held liable under the federal equal protection act. The court covers Illinois, Indiana and Wisconsin and has in effect said that the “boys will be boys” excuse for ignoring gay abuse is illegal (Lambda). 

          Amelioration… Well Underway

            The nineteen eighties was a decade that brought positive media visibility to African Americans. The Bill Crosby show is only one example that attempted to dispel harmful myths and to present positive role models of African Americans. The nineteen nineties media is doing the same for lesbians. An example of one of innumerable television shows about lesbian and gay people was called, “The Gay 90’s: Sex, Power and Influence,” in which Maria Shriver (1993) labeled this decade the “Gay 90’s.” The show featured prominent and ordinary lesbians and gays who were proud of their identity.

            Visibility has the power to provide role models, dispel fear and enhance self esteem of lesbians. The willingness to be visible says that you’re not ashamed, that there is nothing to be ashamed of in being different. If lesbians can rise above the societally imposed shame about who they are on an individual level, they can, in turn teach society about the harmful nature of heterosexism and homophobia that we’ve all internalized.  Lesbians have to tell the world about their painful subjective experiences – how else could the world know? 

            One of the cures for phobias used by psychologists and counselors is desensitization. Desensitization provides gradual encounters with the fearful objects or situations allowing people to adjust and see that they can maintain control in the presence of cats or snakes, for instance. As more and more lesbians and gays come out hopefully the general public will become desensitized to homosexuality and overcome their homo “phobia”. People can and will learn  that walls don’t crumble in the presence of a lesbian or gay person.

Gay political organizations such as the Log Cabin Republicans, The Human Rights Campaign Fund, The National Gay and Lesbian Task Force, Astraea National Lesbian Action Foundation and The Illinois Federation for Human Rights are a big part of the solution. The Illinois states attorney’s office has lesbian and gay advocates available to assist lesbians and gays facing legal problems. This year the city of Chicago formed a gay chamber of commerce. 

            Classes at DePaul University such as: Lesbian Studies: Contemporary Fiction, Psychology of Women, and The Social Lesbian are very empowering for lesbian identity. Public radio (WBEZ) has shows discussing lesbians and gays issues almost daily. Prime time situation comedy’s now include gay characters. Almost everyone knows that Ellen’s character on Ellen is about to come out in the script. This show has the potential to use humor to teach precious lessons about understanding and tolerance. 

            I think amelioration is progressing well. More and more lesbians are coming out in all aspects of their lives. As more and more lesbians come out, it empowers more to come out. David Mixner (1993) said studies reveal that people who actually know a lesbian or gay person believe that they deserve equal rights. When we are invisible it’s easy to criticize and hate us.    

Works Cited

American Broadcasting Company. (1996) 20\20. ABC Television. September 27.

Anderson, Margaret L. 1993. Thinking About Women. Third  Edition. New York: MacMillan Publishing

Company.

Anti-Homophobia Workshop. DePaul University. October 24, 1996, Room, SAC 254.

Astrachan, Anthony. 1990. “Dividing Lines: Men’s Response to  Women’s Demands for Equality and Power”.            In Issues in Feminism. Ed. Sheila Ruth. Mountain View, CA: Mayfield Publishing Company. 72-79.

Corbett, Julia Mitchell. 1994. Religion in America. Second  Edition. Englewood Cliffs, NJ: Prentice Hall. 

Ettorre, E. M. 1990. “A New Look at Lesbianism”. In Issues in  Feminism. Ed. Sheila Ruth. Mountain View,            CA:  Mayfield Publishing Company. 243-251.

Friend, Richard. (1996). “Interrupting Homophobia in the Schools.” Anti-Homophobia Workshop. DePaul            University. October 24, 1996, Room, SAC 254.

Lambda Legal Defense and Education Fund, Inc. 1996. Handout, Victory in the First Case Against a School    for Anti-Gay Abuse. “Lambda’s Nabozny Case: A Fact Sheet”.

Lorde, Audre. 1992. “Age, Race, Class and Sex: Women  Redefining Difference”. In Ethics: A Feminist      Reader.  Eds. Elizabeth Frazer., Jennifer Hornsby., & Sabina Lovibond. Cambridge  USA:    Blackwell. 212-222. 

Marotta, Toby. 1981. The Politics of Homosexuality. Boston: Houghton Mifflin.   

Mixner, David. 1993. The Gay 90’s: Sex, Power and Influence. Channel Five, WMAQ – TV: Chicago, IL. The             National Broadcasting Network. Television production called “First Person.”

Outlines: The Voice of the Gay and Lesbian Community. 1996. National News Round Up. October, vol 10, no          5:  20.

Pharr, Suzanne. 1988. Homophobia: A Weapon of Sexism.  Little  Rock, AR: Chardon Press. Shriver, Maria.    1993. The Gay 90’s: Sex, Power and Influence. Channel Five, WMAQ -TV: Chicago, IL. The National          Broadcasting Network. Television production called “First Person.”

Stiebel, Arlene. 1992.  “Not Since Sappho: The Erotic Poems of Katherine Philips and Aphra Behn.”              Homosexuality in  Renaissance and Enlightenment England: Literary Representations in Historical    Context. Ed. Claude J. Summers. New York: Harrington Press, 103-134.

Unger, Rhoda and Crawford, Mary. 1992. Women and Gender:  A Feminist Psychology. New York: McGraw-    Hill, Inc.

Bibliography

American Broadcasting Company. (1996) 20\20. ABC Television. September 27.

Anderson, Margaret L. 1993. Thinking About Women. Third Edition. New York: MacMillan Publishing       Company.

Anti-Homophobia Workshop. DePaul University. October 24, 1996,  Room, SAC 254.

Astrachan, Anthony. 1990. “Dividing Lines: Men’s Response to Women’s Demands for Equality and Power”.            In Issues in Feminism. Ed. Sheila Ruth. Mountain View, CA: Mayfield Publishing Company. 72-79.

Corbett, Julia Mitchell. 1994. Religion in America. Second Edition. Englewoon Cliffs, NJ: Prentice Hall. 

Ettorre, E. M. 1990. “A New Look at Lesbianism”. In Issues in Feminism. Ed. Sheila Ruth. Mountain View, CA:     Mayfield Publishing Company. 243-251.

Friend, Richard. (1996). “Interrupting Homophobia in the Schools.” Anti-Homophobia Workshop. DePaul            University. October 24, 1996, Room, SAC 254.

Freud, Sigmond. “Femininity”. In Issues in Feminism. Ed. Ruth,  Sheila. Mountain View, CA: Mayfield             Publishing Company. 97-108.

Hagan Leigh, Kay. 1991. “Orchids in the Arctic: The Predicament of Women Who Love Men.” MS. November/December: 31-33.

Lambda Legal Defense and Education Fund, Inc. 1996. Handout, Victory in the First Case Against a School    for Anti-Gay Abuse. “Lambda’s Nabozny Case: A Fact Sheet”.

Lorde, Audre. 1992. “Age, Race, Class and Sex: Women  Redefining Difference”. In Ethics: A Feminist      Reader.  Eds. Elizabeth Frazer., Jennifer Hornsby., & Sabina Lovibond. Cambridge ,USA:    Blackwell. 212-222. 

Marotta, Toby. 1981. The Politics of Homosexuality. Boston: Houghton Mifflin.   

Mixner, David. 1993. The Gay 90’s: Sex, Power and Influence. Channel Five, WMAQ – TV: Chicago, IL. The             National Broadcasting Network. Television production called “First Person.”

Mueller, Janel. 1992. “Lesbian Erotics: The Utopian Trope of Donne’s `Sapho to Philaenis.'” Homosexuality            in Renaissance  and Enlightenment England: Literary Representations in Historical Context. Ed.    Claude J. Summers. New York: Harrington Press, 103-134.   

Outlines: The Voice of the Gay and Lesbian Community. 1996. National News Round Up. October, vol 10, no          5: 20.

Pharr, Suzanne. 1988. Homophobia: A Weapon of Sexism. Little Rock, AR: Chardon Press.

Pogrebin, Letty Cottin. 1993. “The Secret Fear that keeps Us from Raising Free Children”. In Feminist  Frontiers.  Eds. L. Richardson and V. Taylor. 110-114.

Sherwin, Susan. 1992. No Longer Patient: Feminist Ethics in Health Care.

Shriver, Maria. 1993. The Gay 90’s: Sex, Power and Influence. Channel Five, WMAQ -TV: Chicago, IL. The National  Broadcasting Network. Television production called “First Person.”

Stiebel, Arlene. 1992.  “Not Since Sappho: The Erotic Poems of Katherine Philips and Aphra Behn.” Homosexuality in Renaissance and Enlightenment England: Literary Representations in Historical             Context. Ed. Claude J. Summers. New York: Harrington Press, 103-134.  

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Nursing’s Ethics of Caring: A Feminist Ethical Perspective from the Trenches

Pat Anderson

Women Across Cultures, Masters in Liberal Studies 441, Spring 1995

Professor Aminah B. McCloud

September 4, 1995

Abstract

I examine nursing’s ethics of caring from the feminist perspective of a practicing registered nurse. Academic research is combined with thirty years of nursing experience: as a nurse’s aide, licensed practical nurse, and registered nurse. Opinions of philosophers, educators, researchers in psychology, and nurses are included. The view through my feminist and experiential lens, reveals an ethics of care that acts as a link in a chain of internalized oppression that merely enables nurses to survive in the patriarchal medical system. When the psychology of the health care system is illuminated and finally blended with the historical devaluation of women, it will become clear that the ethics of care is a tool to perpetuate the oppression of a predominately female profession. I go so far as to compare the psychology involved in the battered woman syndrome to the role of a nurse. The practical effect that the ethics of caring has on nursing, outside of “academic ivory towers,” negates its altruistic, humanitarian intention because nurses themselves are neither cared for nor valued. 

Table of Contents

Abstract

Nursing’s Ethics of Caring: A Feminist Ethical Perspective From The Trenches 

Ethics and Emotionality

Differences: Male\Doctor Versus Female\Nurse 

Impossible Expectations and No Decision Making Power

In-Between Status

No Where to Go to Deal With Ethical Issues

No Care for the Care Givers

Nurse Stress\Illness: Physical\Psychological

Health Care’s Hierarchal/Stratified “Family”

Psychology of the System

Solutions

Empowerment Ethics

Nursing Consciousness Raising

Nursing Ethics Committees

Revolution

Policy Making

Conclusion

References

Nursing’s Ethics of Caring: A Feminist Ethical Perspective from the Trenches

   Some authors claim the ethics of caring stemmed from traditional male theories, while others assert that it came about as a result of Gilligan’s work in the early eighties illustrating women’s “different voice” in morality. Regardless of it’s origination, the result has been that nursing’s ethics of caring has not functioned to empower nurses. Despite the fact that caring is indeed what most nurses feel and do, caring is not appropriate as an ethical framework. The ethics of caring is simply descriptive of what nurses do. My passionate belief in the basic tenets of feminist ethics and my experiential knowledge, from nursing’s trenches, is what has fueled by arguments. 

The main premise of feminist ethics is that people’s oppression must be included in the ethical discourse for it to truly be ethical. By denying oppression, patriarchy rationalizes that there isn’t a moral imperative to include it in their discussions. Not only does the health care system and traditional medical ethics not include nurse’s oppression in its discourse, its hierarchal structures maintain the oppression of nurses – thus treating nurses UNethically.

Medical ethics has the same hierarchal structure as the rest of society (Sherwin, 1992). Ethicists concern themselves with issues faced by doctors because they’re the ones in power. Problems vital to nurses and other health care workers are not addressed, suggesting whose work is valued and viewed as worth studying. Problems faced by caregivers are treated as irrelevant, despite the fact that difficulties they face might have a powerful effect on patient care (Sherwin, 1992). 

Traditional theories stem from abstract, universal rules where moral agents are not concrete individuals with their own lives that encompass unique histories, emotions, and desires. To traditional theorists, relationships, communities, and friendships do not affect moral judgments. Sichel (1992) compares a traditional moral agent with a placemark, a variable in an algebraic formula, being no better or worse than anybody else in that moral situation. Women’s morality stems from relational, caring perspectives in which each person and situation is considered in its uniqueness within its historical and sociological context including emotions. Despite caring’s focus on attitudes, feelings, and emotions, reasoning and intelligence also serve to enhance sentiment (Sichel, 1992).  

Fry (1992) says the development of nursing ethics stemmed from traditional male theories and principles, such as autonomy, beneficence, theologically-based contract theory, theories of justice, and secular-based theories of human rights. Biomedical theories are not directly applicable to developing a theory of nursing ethics because they don’t fit the practical realities of a nurse’s workplace; as a result, theories tend to deplete a nurse’s moral agency, rather than enhance it (Fry, 1989). 

To fit the context of nursing practice, which includes the context of the nurse\patient relationship, a moral point of view of persons, rather than a theory of moral action or a moral justification system is needed (Fry, 1989). 

Nursing is ninety-eight percent women and is culturally viewed as feminine (Miller, 1991). Eighty-three percent of physicians are male (Rounds, 1993). Boyer and Nelson (1990) have noted that nursing ethics takes little note that the profession is almost all women, despite this, the theories postulated came from male theories like contract theory, consequentialism, and other perspectives that don’t fit women’s life experience. If scholars could leave out gender, it illustrates how successful the obscuring forces are (Boyer & Nelson, 1990). (Theorists not only left out gender, but they also left out anyone who is not a white-heterosexual-male.)

The ethics of care gained popularity around the same time as Gilligan’s (1982) famous work, In A Different Voice. Gilligan’s work illustrated that women make moral decisions differently than men, due to their very different life experiences. Sherwin (1992) summarized Gilligan’s empirical study that identified a gender difference in women’s moral thinking. Women seek creative solutions that consider all parties involved and look for solutions that avoid harm to anyone (Sherwin, 1992). Men try to find the right rules for a situation, select an action that goes with the rule, even if someone’s interests must be sacrificed to justice (Sherwin, 1992). Women frequently feel a responsibility not to sacrifice anyone, which explains why women frequently see situations in a more complicated manner than men. To men, the right rule or theory is the “bottom line”.   

Gilligan (1982) illustrated that women look to the contextual details of relationships to solve moral dilemmas and judge themselves on their ability to care and actually define themselves within relationships. Male theories of psychological development have devalued women’s caring (Gilligan, 1982). Gilligan (1992) suggests both care and justice perspectives be included in moral discourse.

What Gilligan learned about women certainly fits nursing. Nurses’ roles demand they please everyone. The nurse’s interests are sacrificed within male justice models. Parker sees Gilligan’s framework as a challenge to nursing to go beyond the idea of care, to reach for a level that would include the need to care for oneself that is as vital as the directive to provide care (Parker, 1990).  

Noddings (1989) relational ethics stems from an ethics of care perspective, that differs dramatically from traditional individual ethics that judges acts by their conformity to rules or theories. Relational ethics not only considers physicality but includes the feelings and reactions of others within situations (Noddings, 1989). 

Relational ethics comes out of and depends on natural caring which mothering exemplifies, the caring one responds to the needs of the one requiring care. This mode of response is characterized by: engrossment (nonselective attention or total presence to the other during the caring interval), displacement of motivation (her motive energy flows toward the other’s needs), and responsibility and response (Noddings, 1989).  

Noddings (1989) claims in traditional ethics the ethical point of view is viewed as higher than natural caring. Within the relational perspective caring stems from our experience of caring, being cared for, and from a commitment to respond with care to others. Relational ethics validates its actions on the response of a genuine other, rather than through a principle or theory, and does not require all humankind to act in the same manner, in a similar situation. The ethical thinking strengthens and is informed within relationships (Noddings, 1989). 

Relational ethics may have been historically overlooked and even despised because of connections to the subordinate feminine – compelled to retain caring relations as a survival tactic (Noddings, 1989). Traditional ethics ignores questions of importance to women, and doesn’t address feelings that predispose people to break the rules (Noddings, 1989).   

Engrossment is impossible in nursing because you have too many patients to care for. While engrossed with one patient you’re tortured, knowing if you take time with one, you are jeopardizing another’s care. Nurses face this ethical dilemma every day. It’s a common expectation for nurses to displace their own needs to everyone in the health care system. Relating ethics to mothering describes a “martyr mother syndrome” that nursing certainly does exemplify.

While on the phone asking questions about a position advertised in a nursing publication, I became aware that being a nurse was not a requirement. I asked why they were looking to have a nurse fill the job. The answer I received was quite telling, We’re looking for someone with a nurse’s work ethic. Someone who is very caring, perfectionistic, and willing work very hard, long hours, for very little money.

   Institutions profit from nurses accepting exploitive expectations. The more patients each nurse cares for the less money the institution has to expend on salaries. No one cares what caring imposes upon nurses. The nurse is expected to care about the patient, care about following doctor’s orders without question, care about the institution saving costs, follow institutional policies to the letter and not complain about low financial compensation. 

Indeed our responsibility is to respond to patients, but we are asked to respond selflessly, in lieu of ourselves, making the ethics of care unethical.   

Although Noddings relational ethics attempts to be contextual and avoids traditional male abstract rules, it still does not include a nurse’s realistic contexts. The nursing profession certainly does exemplify mothering in its caring, however, it’s problematic to expect a female profession to adopt an ethics that will serve to perpetuate its oppression. Mothering has been historically devalued by men and was partially defined by men to fit their purposes. Mothering is not an ethical model that will empower or help nurses find solutions to their problems. The same “blame the victim” mentality that blames mothers for multiple societal problems, is used to blame nurses when unrealistic expectations aren’t met. Our professional ethics must come from our own “knowing” gained through experience, not from male theories. The only escape from internalized oppression lies within and among ourselves. We must demand an ethics that empowers.   

Noddings relational ethics seems to fit what is practiced by a hospice team. The dying person’s whole family is included in the team’s care plans in order to keep the family functioning under the challenging situation. The internalized oppression is so powerful that despite the fact that hospice team members tell family care givers to care for themselves, the lack of care toward the nurse caregivers is not acknowledged. No matter how much I can theoretically see that Noddings relational ethic is altruistic and stems from a nurturing intent toward patients, I cannot separate my experiential knowledge that informs me on a daily basis that I don’t have the power or ability to fulfill the caring responsibilities expected of me without sacrificing myself (due to the tremendous workload).

In reference to traditional philosophy, Hoagland (1991) asserts that principles don’t inform us when to apply them and end up, in the long run, only working when they aren’t really needed. Hoagland (1991) does not suggest that we throw out rules altogether, but suggest they be used as guides rather than arbiters of actions.

In criticizing Nodding’s analysis of caring that uses mothering as a model, Hoagland (1991) objects to its unidirectional descriptions of caring found in displacement and engrossment. The unidirectional nature of one-caring reinforces oppressive institutions. Noddings focuses on an unequal mother\child relationship where the child’s dependency elicits a maternal response – a mother’s natural caring is turned into a moral caring (Hoagland, 1991). 

Hoagland (1991) questions an ethics of caring whose model stems from a relationship in which one party is dependent; it justifies the inequality of the relationship and lacks an expectation of reciprocity from the cared-for.  

Hoagland (1991) suggests we ask what values are promoted by using an unequal relationship as an ideal, instead of something to be overcome or worked on. In our society, an ethics that addresses how we meet each other morally must induce change and challenge oppression.  Motivational displacement and engrossment involve acting on behalf of another, suggesting the appropriateness of taking control over another’s situation and making it all right, thus actually undermining the moral ability of both parties. (Hoagland, 1991). Adults don’t require parenting when they’re ill, so the mother model truly does not fit. 

I have seen nurses act like judgmental, controlling mothers in trying to enforce and implement doctor’s orders. They’re justification being – they must see to it that doctor’s orders are carried out. Internalized oppression mandates that nurses carry out doctor’s orders even when the nurse thinks the orders are not right. She was told not to question the male-dominated medical model, sadly she frequently doesn’t. 

Hoagland (1991) says we need something far more radical than an ethical appeal to the feminine because femininity itself has been defined by men. If an ethics of caring was to be morally successful in replacing a male morality of rules and duties, it must consider an analysis of oppression, function under oppression, acknowledge a self that is separate and related to others and provide a vision for change that challenges the values of the fathers (Hoagland, 1991).     

Ethics and Emotionality

In patriarchal societies, female values are not only secondary, they’re viewed as defective; the argument is that they’re based on emotion rather than logic and incapable of shaping ethical decisions (Toufexis, 1993). The ethics of caring demands an emotional involvement and an expectation to practice in a selfless manner that would not be expected of a male-dominated profession. It’s unethical to expect emotionality and self-sacrificing behaviors from a profession.

Curzer (1993) claims that the sort of care described by Noddings involves an emotional attachment, a sort of friendship with a patient which can cause serious problems in nursing’s context. The emotionality proposed by Noddings is a vice, not a virtue because it can lead health professionals toward favoritism, injustice, inefficiency, lack of objectivity, and burn-out (Curzer, 1993). 

Fry (1989) wants to use the concept of care, to forge a special unique spot for nursing ethics separate from medical ethics, thus committing nurses to have a higher priority of duty to care for patients than other people have to care for others (Curzer, 1993). This commitment also leads to the implausible view that nurses have more of a duty to care for patients than doctors do (Curzer, 1993). The slogan, “Doctors cure and nurses care” relates to this implausible view (Curzer, 1993, p. 179). 

Feminists reject the idea of a moral theory being totally separate from sentiment (Sherwin, 1992). I once served as a nurse on a hospital ethics committee. While discussing whether or not a woman should be taken off a respirator, I said that I couldn’t even fully think about the situation without seeing the patient and getting a “feel” for her and her family. The director of nursing, the only other woman involved in the discussion, said that we should not bring emotions into the decision-making, we were supposed to use rationality. I knew she was speaking from a traditional perspective. She detached herself from her past bedside experience so she could maintain her status with “the boys”. Having just recently completed extensive research in feminist ethics, I could not and no longer felt obligated to ignore my emotional perspective – I had learned to value it.  

This incident also serves as an example of how nurses in management use their internalized oppression to sanction nurses who do speak up and question the status quo from a woman’s perspective. Instead of empowering their staff, managers maintain subservience to patriarchy.         

Feminist ethics recognizes women’s different moral views, including the ethics of care, and seeks to include caring in our ethical discourse (Sherwin, 1992). Sherwin (1992) warns that we demonstrate caution in using our caring philosophies because the very nurturing and caring we’re so good at were developed as coping mechanisms for women to live next to oppressors. A possible danger lies in caring, women concentrate their energy on others – even to the point of providing protection to the oppressors (Sherwin, 1992). Feminist ethicists ask when is caring okay, and when is it best withheld (Sherwin, 1992). A tough question.

   We expect doctors and nurses to use their scientific knowledge. Society does not expect doctors to become involved emotionally, doctors are trained not to get emotionally involved with patients. The ethics of caring includes the expectation of emotional involvement on nurses that it does not expect of doctors. If nurses behave without emotional involvement, they are criticized for being cold. Imagine an ethics of caring as an expectation of an accountant, an attorney or other traditionally male profession. The added expectation of emotionality certainly explains why nurses have high burn-out rates. The added emotional investment drains psychological and physical energy faster.    

Differences: Male\Doctor Versus Female\Nurse 

Life-enhancing tasks which women have been responsible for (child care, nursing the sick) are the virtues we’ve learned to admire in ourselves as women and affect our views of morality. Physicians, because they don’t participate in direct caring for patients, lack equal opportunity with nurses to develop the attitudes of caring that hands-on work engenders (Noddings, 1989). Women have centuries of experience with the helpless and needy which stimulates and predisposes them to caring (Noddings, 1989).  

Noddings (1989) cites an example of a former minister who became an orderly in a nursing home, as evidence that the tasks involved in nursing trigger caring responses. His theoretical education had taught him caring, but the hands-on activity taught him something different (Noddings, 1989). The hands-on experience prompted him to become involved in patient’s rights – the hands-on taught him that patients don’t have any (Noddings, 1989). 

The training nurses receive may affect their attitude and ways of being on the job (Noddings, 1989). A nurse’s proximity to sufferers prevents her from being distracted by technology and predisposes her to be an advocate of healing, which presents a daily dilemma when doctors hold the power (Noddings, 1989).

While caring for a physician, dying from cancer, I asked him how he felt about the care he was receiving from his doctors. He said his doctors, (also his friends), peaked their heads in the room (many did not even step inside the room), asked a few questions, and were gone in seconds. Nurses don’t have this option (Noddings, 1989).  

This physician’s experience as a patient taught him that the doctors left the caring to nurses because they could not deal with the emotionality of his situation. 

Impossible Expectations and No Decision Making Power

  The decisions that need to be made in health care are not only scientific in nature (Sherwin, 1992). A physician’s scientific knowledge qualifies him to share this information with people trying to make health-related decisions, but does not qualify him to make their decisions (Sherwin, 1992). The training that physicians receive is technical, not ethical, and yet society has afforded doctors ethical authority (Warren, 1992). Nurses are not to make decisions, they are to follow doctor’s orders and nurture (Warren, 1992). A nurse’s intimate contact with patients sensitizes her to their needs holistically, combined with her scientific knowledge, actually makes her more qualified to facilitate patient decision-making.

In 1981, The National Commission on Nursing reported that major issues in nursing involved nurse-physician, nurse-administration relationships, and the lack of organizational structures to allow nurses to impact decision-making related to nursing care (Aroskar, 1985). The conflict between men and women, such as power and authority is also at stake in the nurse-physician relationship (Aroskar, 1985).

One health care model that Aroskar (1985) discusses relates an image of a hospital as a doctor’s workshop with other health professionals accountable to follow his orders. This view has been reinforced historically using the family concept to paint the institutional framework. Nurses serve as the hospital mothers, meeting everyone’s needs (Aroskar, 1985). Nurses are expected to take full responsibility when doctors are absent and relinquish all authority when doctors return. Nurses must also support the institution, especially its male members (Aroskar, 1985). 

Nursing school teaches that it is the nurses responsibility to refuse to follow doctor’s orders when they know they are incorrect. However, nurses risk severe sanctions when they do question a doctor’s order, no matter how wrong the order is. This duality places her in a no-win, powerless and unethical situation.   

This paternalistic view with the physician as the primary decision maker perpetuates the nurse-physician game. The nurse has to appear passive when making suggestions, so it appears that the idea actually came from the doctor. This relationship is unethical because it denies that nurses and physicians together are valuable to a patient’s care; neither should use the other as a means to an end decided by the other (Aroskar, 1985). 

In-Between Status

Bishop and Scudder (1991) describe nursing’s status in health care as in-between physicians, patients, and agency bureaucrats. Nurses are expected to actually bring together medical contributions, regulative controls, and permissions, and the desires of their patients to create a system to provide daily care (Bishop & Scudder, 1991).  

Making moral decisions in health care requires considering what is medically correct, what the institution will allow, and what the patient desires (Bishop & Scudder, 1991). A nurses in-between position and close proximity to patients places her in the unique position of being able to bring these perspectives together in an advocate role (Bishop & Scudder, 1991). Nurses certainly do function in this in-between status, which is an impossible burden on nurses. Without any legitimate authority to act on what truly is her unique informed perspective, the nurse is trapped in a difficult and powerless position.

Thompson (1985) discusses three mindsets about health care that may prohibit or limit the ethical practice of nursing. One is that health care revolves around medical cases, the major goal is to cure disease. Here the nurse may see herself as accountable to the doctor, his values dominate and her job is to follow his orders (Thompson, 1985). 

The second is that health care a commodity to be sold, making nurses accountable to the employer. Concern for individual patients may have a low priority on the hierarchy of the institution’s values (Thompson, 1985). 

The third centers on the patient’s right to relief from pain and comfort, making the nurse’s obligation to the patient, thus demanding that nurses and institutions run by patient needs (Thompson, 1985). If nurses view their role as subordinate to patients and physicians they might find it difficult to implement autonomy, promote health in an illness-dominated system or practice in an ethical manner (Thompson, 1985). I can see all three of these mindsets functioning at the same time. 

No Where to Go to Deal With Ethical Issues 

    The typical nurse does not have access to a forum to discuss or spend time reflecting on ethical issues (Fry, 1992). Paying nurses to discuss ethical issues does not fit into a cost-effectiveness analysis of nursing productivity. A nurse’s ethical reflection has not been deemed to have monetary or moral value.

I spoke to a nursing instructor at a Chicago University and asked her what ethical problems she faced teaching nursing. She said as a feminist, the most problematic issue is knowing how much to encourage and empower students to speak up. She wants to be sure to limit it at the point where they would lose their jobs. I know this to be true. I worked as an intensive care nurse through agencies and was on many occasions banned from a hospital because I had the nerve to speak up about unsafe practice.

Another dilemma for her is teaching students that their role is one of collegiality with physicians,  knowing the realities about physicians condescending attitudes towards nurses. 

Eleven years ago when I took ethics in nursing school it was awarded two credit hours compared to eight or ten credit hours awarded to other nursing classes. This weight disparity illustrates the value placed on ethics by the university. I asked the Chicago University nursing instructor how ethics was taught in the nursing program she teaches in. She said they included ethics in all the classes, but they don’t have a specific class in nursing ethics. I find it very problematic for a nurse’s education not to address ethics specifically when she will face ethical dilemmas every day in her work. This is a poor start for a profession so entrenched in science, technology, and humanity. Right from the start, she is told that what she thinks morally is not valued. 

I think ethics should be studied on its own and incorporated into classes. Nurses also desperately need to have their consciousness raised by teaching them about feminist ethics and women’s morality. Ethical discourse should also be made available to practical nurses and nurses aids. Ethical issues should be for everyone to discuss and be informed about.  

The day that I spoke to the Chicago University nursing instructor, her students were lobbying in Springfield to attain independent functioning in Illinois for nurse practitioners. Nurse practitioners are allowed to practice independently in many states. Can you imagine a male-dominated profession being told they could not practice what they spent years studying? Our caring is educated and experienced. We study health scientifically and should have the power to act on our caring and scientific knowledge independently.

I interviewed a woman in administration at a prominent ethics establishment, who told me that nurses were not allowed to ask for an ethics consultation, only doctors and families could do so. I asked what nurses were to do when they perceived an ethical dilemma. She said their nurse ethicist would tell them to encourage the family to ask for a consult. 

Expectations of selfless caring remains the rule, despite the fact that nurses voices and concerns were banned from being heard directly. “Shut up and care” is the message I hear. By following what we are told to do ethically we are participants in maintaining our own ethical oppression – just what patriarchy wants. 

No Care for the Care Givers

If caring were valued in society and in health care, adopting an ethics of caring would not only be ideal, it would be smart. Caring is not valued, so the ethics of caring functions to perpetuate caregivers abuse within health care institutions. The recipients of this ethics of caring are patients, health care institutions, physicians and society, but not the nurses aides, practical nurses, registered nurses, and least of all minority caregivers. 

Boyer and Nelson (1990) suggest that the nurse’s need to care for herself be explored, along with the propensity of the care morality to reinforce women’s oppression. The reality of the exploitation of nurses begs feminists to take it into consideration to ensure that patriarchy’s deeply entrenched patterns are challenged (Boyer & Nelson, 1990).  

Hine (1989) discusses mixed messages nurses get from society, they are frequently described as being special, but are also taken for granted. Society has an ingrained tendency to devalue women’s work and nursing is the most female of all professions. Unless a person is devastated by disease and needs a nurse, her value is not appreciated and once she is no longer needed she is quickly forgotten (Hine, 1989). Whether working in intensive care or in hospice, I always felt that no matter how much I did or how much I cared, it just wasn’t enough or was perceived as, just my job. Beyond the call of duty is expected.

   A philosophy of practice itself obligates practitioners to seek reform and the expansion of its authority whenever patient care requires it (Benner, 1991). Benner (1991) fears that the philosophy of care is being used to maintain status inequity and subservience but fears that if we were to abandon our caring in lieu of freedom for ourselves it might require the loss of our voice in nursing to heal and provide comfort. 

I wish to add an obligation to ourselves. When through consciousness-raising we become aware of how we are being objectified and set up as the system’s trapped middle person, we have an obligation to do what we can to facilitate our own authority and to demand ownership of how we use our professional knowledge. As we begin to see that we are acting in ways that maintain our own patriarchal oppression we must make attempts to achieve autonomy. What good is it to attain knowledge that can only be used with someone else’s permission or order? Nurse are not truly free to heal now. How healing can you be while being exploited? Nurses are like battered women trying to help their children heal from abuse while still being beaten themselves.        

Noddings (1989) discusses Gladys, a black nurse and midwife who worked long hours, was involved in many volunteer activities, while raising a large family, as portraying the essence of the ethic of care. Her life is a testimony of goodness far beyond the call of duty (Noddings, 1989). This example illustrates the unreasonable expectations nurses try to meet. Superwoman, the ideal image of a perfect female under patriarchy: passive, selfless, perfectionistic, a martyr doing it all for everyone and well.

Nurse Stress\Illness: Physical\Psychological

Medical ethics has not addressed the stresses that health care workers face on their jobs, despite higher than usual rates of alcohol and drug abuse, and high divorce and suicide rates among health professionals. In addition to the personal being political, the personal is professional. What may be seen as personal problems can certainly have a major effect on what occurs on the job. Because of this, stresses faced by nurses should be addressed by medical ethics, but they are not (Warren, 1992). Nurses must not wait for traditional ethics to address their problems. We must demand that our issues be addressed. Those in positions of power will never offer to do so.

Pulitzer (1993), in her article, “Short Staffed and Working Scared-Can Nurses Just Say `No’?”, shares results from The National Nurse Survey that documents for the first time some of what nurses face as a result of inadequate staffing. The survey illustrated that the increased workloads damaged patient care, led to decreased job satisfaction, increased stress, and life-threatening health problems among nurses. Nurses report much higher rates of stress and stress-related diseases: high blood pressure, heart disease, ulcers, colitis, and depression. Nurses cannot refuse an assignment no matter how unsafe or unethical the nurse thinks it is (Pulitzer, 1993). Thus the nurse has no power to facilitate her caring. If a nurse cannot refuse an unsafe assignment, she is a puppet whose caring is actually a weapon used against her. 

  The following accusatory words and/or phrases are used by hospital and nursing management to label nurses who speak up about unsafe assignments: abandonment, unprofessional, incompetent, unorganized, insubordinate, not functioning within the scope of nursing; in addition, hospitals may request that the state board examine her license (Pulitzer, 1993). Accusing a nurse of abandoning her patients is as bad as accusing a mother of abandoning her child. Hearing the above words repeatedly, nurses take these criticisms to heart and blame themselves for speaking up about safety, ethics and unreasonable expectations?  

      Health Care’s Hierarchal/Stratified “Family”

Glenn (1994) illustrates the family symbolism in the gender constructions in health care. The physician plays the authoritarian father. The nurses play the mother who is subject to the ultimate authority of the physician. Patients are dependent children with practical nurses and nurses aids playing the part of servants (Glenn, 1994). 

The family metaphor also has racial implications (Glenn, 1994). Since historically most doctors were white males, it only makes sense in this hierarchal ideology that the mothers, or the registered nurses, had to be white. Eighty-seven percent of nurses in 1980 were white, despite there being only seventy-seven percent of the population (Glenn, 1994). This dysfunctional family set up functions to maintain doctors’ power over patients, nurses, women, and minorities. 

Psychology of the System

  Summers (1993) refers to health care institutions as dysfunctional families; according to family systems theory, if one person is sick, the whole family is sick. Each family member plays a part in enabling other members (Summers, 1993). The following letter was written by a nurse to a hospital’s administration: 

In the past, nurses have always said “Okay.” But soon we’re going to have to stand up and say “No, we need care too!” It’s an insidious problem, something we all bought into, though sometimes I wonder if we nurses aren’t seen as women who have taken it because “they care,” and so will continue to take it.  … how can we care for patients authentically when we are so desperately in need of care ourselves? (Summers, 1993, p. 87). 

A dysfunctional system is a closed system whose members feel powerless, develop survival patterns, and function using learned coping behavior (Summers, 1993). Summers (1993) lists the rules that keep a dysfunctional system or family going, taken from Subby’s book, Codependency, an Emerging Issue: don’t talk, don’t feel, don’t rock the boat, be strong, be good, be right, and be perfect. When the expectations of a nurse include these rules, it’s likely there’s a dysfunctional system at work (Summers, 1993). I have sensed these rules on every job.  

Summers (1993) describes how Schaef’s and others work have described an addictive system. In this type of system, nurses impose unrealistic demands on themselves, expect that they should know all the answers and never make mistakes. Despite being at 110% efficiency, nurses are told to sign out early, reduce staff and not work overtime – and they go along. Nurses feel powerless over doctor’s decisions, an example being full code status on an aging patient who is begging the nurse to let them die. It’s hard to be around patients like this and not able to act on their wishes. The nurse’s feelings of rage and injustice may be pushed down, knowing that her feelings don’t matter in the system (Summers, 1993).

Nurses have to shut off their feelings of fear, anxiety, anger, as they would be a liability in a system that doesn’t provide an environment to express or experience them. Without acceptance for their feelings, they refuse to experience what they see and know, denying their own reality (Summers, 1993).   

Noddings (1989) claims that one who moves a pain-racked body feels sympathetic pain and develops psychic pain within themselves. I wonder what influence this has on nurses not speaking up for themselves more politically. Does their intimate knowledge of such profound human suffering lead them to see their own pain as minuscule when viewed in the holistic scheme of life? Does sensing another’s pain so exquisitely inhibit self-advocating behaviors? And if this is even possibly the case, then nurses should be provided with avenues to deal with their psychic pain. It’s unethical for the health care system to place nurses in positions that affect them so deeply on an emotional level without attempting to empower them in their work and provide them with support.    Summers (1993) draws from Schaef’s book The Addictive Organization that claims that demanding managers keep staff afraid and out of touch with themselves and too busy to challenge the system. Members of the system blame members at other levels for problems, keeping parties in conflict with one another, thus preventing the system from being challenged (Summers, 1993). Overwhelming, impossible workloads prevents people from having the time or psychological energy to advocate for themselves.    

Summers (1993) discussed Woititz’s book The Self Sabotage Syndrome in which Woititz says that guilt works as a motivator for nurses. Self-sacrificing “angels of mercy” don’t see “no” as an acceptable way to deal with limitations (Summers, 1993, p. 89). 

Instead of rewarding positive behaviors, nursing evaluations frequently focus on the negative. Institutional peers reviews use external referencing to compare nurses, making one person better than another. The shaming messages hit home with similar messages heard as children – we’re not good enough (Summers, 1993). This constantly reinforced devaluing prevents nurses from self-advocating.

Klebanoff (1991) says that nurses face a serious occupational hazard – codependency\internalized oppression. Klebanoff (1991) defines codependency as a set of survival skills adapted to live with internalized oppression in patriarchy. It’s a defense against patriarchy that’s also used by patriarchy to label and define its handmaidens and “victims” (Klebanoff, 1991, p. 152). As a label and method of social control, codependency serves as today’s witchcraft. From a feminist perspective, sexism and codependency exist as one (Klebanoff, 1991). 

The idea of codependency stemmed from family systems therapies used to treat addiction. The codependent, non-addicted partner exhibited the same behaviors even after the addicted partner was treated (Klebanoff, 1991). 

Having internalized patriarchy’s dominant value of inferiority, nurses act in a ways that supports this value; they are “trained” to sacrifice themselves (Klebanoff, 1991, p. 157). I view the internalization and training that nurses and women have received as brainwashing. The only solution is de-programming by way of feminist consciousness-raising, without which true empowerment will not be obtainable.       

The psychology involved in the battered women’s syndrome is the same psychology that disempowers nursing. What keeps the ideology of the battering situation going is that both sides of the situation believe that things should be as they are.   

Typical questions nurses and battered women ask themselves are similar and illustrate the self-blaming process. A battered woman might ask herself: Maybe I did undercook the chicken? Maybe I should have had dinner ready ten minutes earlier? Maybe I shouldn’t have bought myself a new jacket? Maybe I should do what he says? After all, he knows more than I do.

Similarly, nurses ask themselves: Maybe I am incompetent and unorganized? Maybe I should be able to take care of two, fresh, unstable, open-heart patients at the same time? Maybe it is unprofessional to discuss salary with a peer? Maybe I am abandoning patients if I refuse to accept a patient load that I think is unsafe? My nurse manager knows more than I do?

These questions paint a picture that illustrates the internalization of the abuser’s accusations, whether a lover or a health care institution. Nurses are asking themselves these questions every day while attempting to honor the ethics of care. The health care system blames the nurse and the nurse blames herself for the system’s behavior, giving credit to the institution’s desires and accusations, in the same way, that a battered woman does with her lover. Because I understand and see this victim-blaming and exploitation of nurses, I find it almost impossible to function in the field of nursing. 

It was difficult to understand the battered woman’s syndrome until feminists researched the phenomenon and made it clear how the abuse worked to keep women in its clutches. Nurse abuse will continue until the intricate mechanisms are brought to light. Under these circumstances, the ethics of care is complicit in perpetuating the abuse, despite the desperate need our clients have for our caring and despite the fact that nurses really want to care. Our concentration on caring blinds us to our own abuse. Nurses deny that they are not cared for at all. They frequently leave one horrible job, only to end up in another horrible job – like an abused woman who leaves one abuser and miraculously ends up with another. 

Solutions

  Warren (1992) questions the way we conduct ethics itself and challenges us to pose philosophical questions from various perspectives, not only from a doctor’s vantage point. She further suggests that ethicists leave their “philosophical armchairs” and go beyond asking what a Hispanic woman needs from ethics by actually going to the barrio and asking the women about their problems (Warren, 1992, p. 40). Warren (1992) realizes this kind of inquiry would involve a lot of listening but thinks this is what ethics has to do. 

We definitely need to find a way to incorporate diverse perspectives and values into nursing’s ethical framework – much knowledge and appreciable insights will be gained. Sisterhood, in actuality, is not global. A myriad of different perspectives can be found among nurses and women themselves. Our challenge is to holistically include contextual experience. 

I think nursing would be a good place to initiate Warren’s (1992) recommendation. There is no other way to correct historic non-listening. Listening to nurses would not only benefit the profession but would also provide valuable insights about caring for patients. The inclusion of nurse’s ethical issues would approach a true ethics of caring.

Warren (1992) discusses how those in academia relate to each other and suggests that this very discourse be dissected to bring out its moral dimension. The ethics game sometimes includes attempts to one-up each other; arguments are used as weapons that don’t resolve morally complicated issues. Ulterior motives and competition run the risk of harming others (Warren, 1992). The intellectual forest prevents one from seeing the trees. From my bedside perspective, it’s as if the academics are looking down at the forest, obviously not seeing the trees that I work in every day as a nurse.

    Warren (1992) recommends co-authorship of philosophical papers, especially those relating to relationship issues. Warren (1992) also suggests anonymous authorship to bypass reputation and concentrate on ideas. I think there would be much to be learned if a feminist philosopher and myself were to co-author a paper on nursing ethics, chocked full of practical data obtained from the trenches.

  Another suggestion Warren (1992) poses is to appeal to the entire reader’s personality, not just their intellect. We might inspire others by writing about people’s lives, encouraging them to express their ambivalence which could lead to self-knowledge. Feminist theory should not come from on high by “experts”, even feminist experts, it should be constructed from life experience (Warren, 1992, p. 42). No matter what the books tell us, we should trust our own judgment, listen to ourselves and regular folks. (Warren, 1992). “If knowledge is power, `life precedes theory’ is social revolution” (Warren, 1992, p. 42).

Warren (1992) claims to pose a radical question in asking whether our goal should be to find a small set of moral principles or values for everyone at all times in their lives. I don’t see this suggestion as radical. However, including non-traditional values might sound radical to traditional thinkers. 

Nursing could serve as a model of inclusion, it’s an ideal place for feminist ethics to become reality. Women must include themselves in moral matters – whether traditionalists like it or not. I imagine an ethical framework that is alive with the context of all our voices, allowing diverse values to breathe through it, freely and naturally.

Empowerment Ethics

All levels of nursing must find empowerment from its ethics, whether a nurse’s aid, staff nurse, manager, administrator or academic. Nursing must reject its hierarchal setup that mirrors male stratification models. True self esteem and personal power will not come from a stratification spot. If nurse’s aides are devalued, all of nursing is devalued. Men frequently find power in the layered system that places them at the top. Real power is the ability to empower all participants in health care to feel important, involved, appreciated, and cared for. Nursing ethics needs to be practical and available for each nurse to use for her patients and for herself. 

  Nursing Consciousness Raising

 Patriarchy ideology continues in health care because nurses are not aware of their internalized oppression. Miller (1991), in a quote from Ashley, says that nurses are not only the most conservative of conservatives, but are rarely feminist. Miller (1991) agrees with Ashley that this failure has led to nursing’s inability to liberate its education and practice. We must get beyond the internalization by deprogramming with feminism.

Nurses need to do their own ethics. Radical feminists think that we have to think for ourselves and not think in terms of what men have taught us to think. In the future, I would like to develop programs to raise nurses consciousness about feminist ethics. Hopefully, once the seeds of feminist consciousness are planted, methods will be developed and time would be allocated for nurses to become involved in the process of developing the profession’s ethics. 

Nursing Ethics Committees

Nurses need their own ethics committees. Multidisciplinary ethics committees have not addressed the unique concerns of nurses; the focus and missions of nurses and physicians are different (Buchanan & Cook, 1992). A few dilemmas Buchanan and Cook (1992) suggest for nursing ethics committees are: withholding treatment, communication, the use of technology, inadequate resources, and working conditions that threaten safe practice. 

Most ethical dilemmas involve patient care that nurses assume most of the responsibility for, but nurses are outside of the decision-making process (Buchanan & Cook, 1992). When ethical dilemmas are unresolved it leads to frustration and conflict which leads to inefficient care, burn-out, and staff turnover. A nursing ethics committee could provide the forum for avoiding burn-out from passive administration of another’s orders, facilitating nurses discussion of their concerns and an opportunity to strategize about solutions. Nursing ethics committees could also benefit administration by fostering work satisfaction and motivation, thus lessening turnover which is cost-effective (Buchanan & Cook, 1992). 

The only thing I disagree with Buchanan and Cook (1992) about is they suggest that nurses should become knowledgeable about ethical principles and theories. I think nurses have to inform the theories and principles through their contextual, relational experiences. I think nursing ethics committees would be an ideal place to initiate feminist consciousness-raising and begin the deprogramming process. Nursing’s non-feminist, patriarchal values block their ability to challenge the health care system. 

Revolution

    One great solution already in progress is a new and different nursing journal called Revolution: Journal of Nurse Empowerment. Rounds (1993) quotes its publisher, Laura Gasparis Vonfrolio: 

Why should we be well-adjusted to a maladjusted situation?  Silence means consent. We must put a stop to passive obedience, self-effacing dedication, and loyalty to institutions. Nursing education must consist of finance and economics and be grounded in a historical perspective on sexism (Rounds, 1993, p. 38).

Rounds (1993) discussed a favorite term of Gasperis’s, “horizontal violence” which describes how a hospital pits nurses against each other with things like, “primary nursing”, “shared governance”, and “career ladders” (p. 38). 

Policy Making

Backer, Nikitas, Costello, Mason, McBride, and Vance (1993) say that nurses have the potential to transform public policy by instilling an ethic of caring into health policies; nurses with feminist values will bring new skills to the formation of policies and their implementation. Women have had to struggle to bring their voices to policy tables, but are beginning to realize that their work and values have been demeaned and devalued (Backer et al, 1993).

Devaluing has led to oppressed modes of behavior, such as shame, self-hatred, isolation, horizontal violence, and passivity. Patriarchy has perpetuated nursing’s attitude of second best, and of lacking faith in one’s self (Backer et al, 1993). 

By valuing our voices we can create a new world view that would value caring, integrating diverse values. Nurses need to reformulate work, relationships, and leadership from feminist values. The feminist model of caring encompasses values of wholeness, process, support, interconnectedness, equality, collaboration, and diversity, contrasting patriarchal values of individualism, inequality, and competition (Backer et al, 1993). 

Caring in nursing includes being responsive rather than judgmental and hierarchal, in a system that is not only disease management (Backer et al, 1993). It includes a range of nurturing, protective acts devoted to assessing and responding to patients and being involved at the macro (social values and policies) and micro (interpersonal processes and caring acts) levels. It involves a system that empowers nurses and patients in a “web of inclusion” model that affirms relationships (Backer et al, 1993, p. 73-74). Collaboration is encouraged and diversity and equality are highly valued. Improvisation combines familiar and unfamiliar components sensitive to context, process, and intuition, not excluding objective approaches (Backer et al, 1993).

The conflict of doing work that is not valued by society has taken its toll on nursing (Backer et al, 1993). Backer et al (1993) suggest that nurses suggest a redistribution of power among diverse voices, rather than taking power away. Nurses’ voices can be especially effective in policymaking because the ethics of care encompasses both instrumental (objective, rational) and expressive (affective values, belief components of an issue); feminist and traditional voices should be heard in policymaking (Backer et al, 1993).  

I think that persons actively involved in practicing nursing should be involved in formulating nursing’s ethics. Its origins should not only come from academia, administrators or even feminist philosophers. Our ethics must be informed from the bedside and from nursing’s unique diversity.

Conclusion

The idea of an ethics of caring looks nice on paper sounds nice in conversation, but the practical reality is that it sets up impossible expectations, and perpetuates the exploitation of nurses. 

Before nurses can make their voices heard they must first be made aware of the danger their caring poses in a male-dominated world that has devalued caring. We must raise the consciousness of nurses, deprogramming their internalized oppression. We must find ways to infuse nursing’s exhaustion with hope from feminism. Society has a stake in nurses not sacrificing themselves to care for others. At one time or another, each of us is likely to be dependent on nursing’s care. 

References

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Feminist Ethics in the Health Care of Women

Feminist Ethics in the Health Care of Women

Pat Anderson

DePaul University, School For New Learning

Major Piece of Work, Winter, 1993

Academic Mentor: Catherine Marienau

Professional Advisor: Ann Stanford

Introduction

Historically, the field of philosophy has been dominated by white males. If asked to name philosophers, the average person would probably name Aristotle, Plato or St. Thomas Aquinas. It’s doubtful many people would be able to name one female ethical theorist. The field of bio-medical ethics has experienced a similar history because most doctors have also been white males. As a result of this male dominance, theories about ethics and the practice of medicine have come from male perspectives; women’s perspectives, values, and life experiences have been left out.

Having spent twenty-six years in the medical profession in a traditional female role, that of a nurse’s aide, practical nurse and registered nurse, I know from first hand experience the negative effect that patriarchy has on patients. My biases and assumptions come from viewing patients contextually and emotionally, always keeping in mind the relationality that forms the core of their lives. I view patients from a mode of caring; doctors view patients in abstraction; they tend to use rationality in forming their professional ethics. My bias is that the patriarchal nature of medicine seeks to control women; I assume that this hurts women. I hope to learn if feminist ethicists share my assumptions and biases. Do they share my opinion that the vulnerability of patients (especially women) puts them in perfect position for the hierarchical medical institution to control them?

I will address the basic philosophical differences between feminist and traditional ethicists. I will then go on to discuss more specifically, the area of feminist ethics in the health care of women today. Some of the areas include, abortion, reproductive technology, pregnancy, menstruation, cosmetic surgery, research, cancer, and health care workers other than doctors.

I will use sources and personal experience to make the argument that the health care institution itself and the very field of medical ethics serves to maintain women’s oppression and devalued state in society. I plan to show that technology is being used to camouflage the fact that men are still using their power to control women’s bodies – things haven’t changed within patriarchy just because the science has become more sophisticated. The very mechanisms of oppression prevent women from seeing what is happening to them. Patriarchy is like a massive religious cult trapping all women whether they have had their consciousness raised or not.

I hope to illustrate that the manner in which women are oppressed by medicine is frighteningly not far removed from terrorism or brain washing. Yes, this is extreme – I mean it to be!

I hope to illustrate through an extensive review of the literature, and through my own practical experience that women’s oppression has been and still is being perpetuated by a bio-medical ethics that devalues women.

I hope to learn what women have to say about the field of medical ethics.

       -Do other feminists who have experienced health care differently than I perceive the system as I do?    

       -Do women offer viable solutions to today’s ethical dilemmas in the field of bioethics?

       -Could a combined perspective that would include feminist and “old school” ethical ideas be of use in a field like reproductive technology?

       -Could a combination of solutions actually approach justice?

       -What do male ethicists have to say about feminist ethics?

       -Would adding the feminist viewpoint change the relationship of the people involved in the biomedical environment? (doctors, nurses, patients, technicians and social workers).

       -Does the oppression of women affect feminist ethics? Are there male ethicists who are aware of and admit the oppression of women?

       -And what role do they see feminist ethics playing in bioethics today and in the future?

       -I will offer solutions posed by feminist ethicists and some of my own.  

Feminist Ethics in the Health Care of Women

Sexist Ethics

The very same hierarchical structures found in larger society organize the bioethics in health care. The primary concerns of medical ethics are issues that confront physicians. Doctors are in power so it’s their views that are usually adopted. Problems faced by nurses and other health care workers are frequently not dealt with at all. This suggests whose work is seen as important and worth studying. The complexities and tensions that exist among the care givers themselves are seen as irrelevant, thus ignoring the fact that their problems have an enormous effect on the quality of care given to patients (Sherwin 3).

Sexism and gender oppression can be so subtle and pervasive that without feminist inquiry they would be overlooked. Bioethics literature has not addressed the oppression of women, making that reason enough to peak feminist suspicions. Feminism should ask that bioethics include in its inquiries questions about whether their decisions affect women’s oppression in society (Sherwin 4). The medical field has been given the power of legitimacy because of it’s scientific knowledge and the power that it has over our health. The institution of medicine has been designed to reinforce sexism; sexism hurts women. We need to identify the connections between the practice of medicine and patriarchy.

“People’s lives can be poisoned by oppression as well as by toxins, and both elements merit consideration in moral evaluations of health care practices” (Sherwin 7).

“One of the central insights of feminist work is that the greatest danger of oppression lies where bias is so pervasive as to be invisible” (Sherwin 10).

Sherwin asserts that we need to questions assumptions we have held about health care (Sherwin 10).

Mendelsohn goes as far as saying that the religion of modern medicine is surrounded by a mystique that intimidates patients into accepting whatever the doctor says (Mendelsohn 4). He says that mortality rates show that when compared with a century ago, (excluding those saved by sanitation, nutrition and a few breakthroughs in epidemiology) Americans are not as healthy as 100 years ago, despite the wonders of technology and the religion of medicine (Mendelsohn 6).

Mendelsohn agrees with feminists that women certainly face sexist attitudes that can hurt them throughout society but,

       “the chauvinism of a physician or a surgeon, however, may condemn the same woman to a lifetime of dependence on drugs or cost her the life or health of her baby, to say nothing of the loss of her breasts, her uterus, her ovaries, and even her life” (Mendelsohn 28).

As far back as Hippocrates’s time, during the 5th and 4th centuries b.c., doctors thought a female’s reproductive system was the cause of women’s insanity and hysteria. As a result, for over two thousand years, women who were considered deviant, (who did not exhibit passivity and humility) were cured by hysterectomy. Ovariectomies discovered in 1809, were also used to cure insanity, psychological disorders and to keep women under the social control of men; female castration was thought to assure obedience from women. The medical profession used these justifications to remove ovaries until 1946 (Mendelsohn 30)!

G. J. Barker Benfield claimed, in his medical history book, The Horrors of the Half-Known Life, that the gynecological specialty was brought about to support retaliation against and for the control of women; doctors resented women’s entering the work force in the Industrial Revolution and the women’s movement associated with it. Doctors exploited their power as physicians and attempted to showed women who was boss by performing aggressive surgeries (such as ovariectomies and clitorectomies) (Mendelsohn 33).   

There are several main issues ethicists must address that are faced by women in the health care system; the unequal treatment of women, the roles of doctors and nurses and issues that relate to power struggles in relationships. Today’s medical ethics addresses emergency type issues and avoids everyday maintenance issues (Warren 32).

One issue, involves how ethical debates themselves take place and how ulterior motives effect what is believed and what is included in the arguments. Louder than the messages spoken with our lips may be what we select and what we neglect to chose to study – the games we play also sends a strong message (Warren 32).

Warren postulate that a sexist ethics would frame moral questions from a male perspective and use these male perspectives to formulate solutions. The moral dilemmas chosen would involve authority, status and power. For instance, who has the right to make a final decision about your health care, you or your physician? The solutions posed would ignore matters of vital importance to women and children. Warren uses an excellent example in that to save costs, patients are sent home sooner than before. When they get home a female family member will likely be involved in caring for the person; their unpaid labor is without social weight and is not valued (Warren 33).

Second a sexist ethics, would be hidden in a way to make it appear to be neutral. Ideal moral agents have been those who could use rationality or calculate the utility of a solution. In using these types of ethics people whose life experiences do not fit mainstream ideologies, like women, gays, lesbians or blacks are ignored. If we do not address their unique life experiences they will be made invisible even to themselves. By using universal perspectives, we are saying that all human beings are the same or generic. The fact that women’s bodies, emotions, and relationship are different than men are thus made irrelevant (Warren 33).

Third Warren says that a sexist ethics would frame debates in a manner that keeps women on the defensive; it would invite women into the framework, promising to address their problems – provided they don’t rock the patriarchal boat too much. Women are also on the defensive because one of the most popular debates lately has been abortion where women are pitted against a defenseless fetus (Warren 33-34). 

Warren suggests we look at inequalities, sexist occupational roles, personal issues, and relationship issues. She suggests we look at the inequalities toward women in health care and then seek solutions. She uses IVF (in vitro fertilization) as an example: the technology excludes women who are single or lesbians – you must seek to raise a child with a man to be considered for the technology (Warren 35-36).

Nurses have historically been delegated the passive female role; in these passive roles how do nurses resolve their ethical issues when the issues of the powerful doctors are the ones that are valued and taken up for ethical discussion? The training that doctors get is technical, not ethical and yet they have been given the authority in this field. Nurses are supposed to nurture, and rather than make decisions, they are supposed to follow doctor’s orders. These roles definitely follow gender edicts (Warren 36).

Medical ethics has not addressed stresses faced on the jobs of health care workers, despite higher than usual rates of alcohol and drug abuse among health care professionals. Divorce and suicide rates are also high. In addition to the personal being political, the personal is professional – what may be seen as personal may have a profound effect what happens on and off the job – for this reason it should be addressed by medical ethics (Warren 36-37). 

Oppression

“Marilyn Frye has defined oppression as an interlocking series of restrictions and barriers that reduce the options available to people on the basis of their membership in a group” (Sherwin 13).

These restrictions are insidious. The practices that make up the system of barriers appear harmless when looked at separately, but when looked at within a set of institutionalized norms, the patterns become clear. The ideologies that oppress are virulent because they are internalized by the oppressor AND the oppressed (Sherwin 14).

  Men

Unless men (and women) engage in demolishing patriarchal structures, they are complicit in maintaining them. Sexism gives men a choice of exercising their power. Those interested in real gender equality must do more than not using their choice – they should take active steps to get rid of the unjust power men hold merely by being male (Sherwin 25).

Jonathan Mann, of The Global AIDS Policy Coalition, served as a model of how men can help to stop the oppression of women. He appeared on “Good Morning America”, to discuss solutions to the problem of AIDS in Ugandan women. He sees the empowerment of women as a solution to the spread of AIDS among the women of Uganda. Mann says that if women were allowed to, get divorced,  own property, have rights, demand the use of protection from disease, refuse sex, or have a say in their lives, they might stand a chance to prevent themselves from contracting AIDS. He says that medical means are not the only ways to stop the spread of disease. Mann further stated that at the start of the AIDS crisis, 25% of the patients with AIDS were female, and now it is up to 40% (Mann 92).

“Although medical and surgical overkill are routinely inflicted on all Americans, its primary victims are women”  (Mendelsohn x). Mendelsohn wrote his book Male Practice to help women avoid the disastrous fate he knows many women have faced in the medical profession. He claims he purposefully used the male pronoun in the title because most doctors in the U.S. are men (Mendelsohn x). Mendelsohn is one of the few men who speak out clearly in support of women’s rights; he serves as an example as to how men can help overcome women’s oppression.   

Philosophical Ethics 

The study of philosophical ethics is concerned with value questions about human conduct; it studies the legitimacy of using categories like: good, bad, ought, should, right, wrong, obligation, responsibility, justice, injustice, praise or blame. Philosophical ethics seeks to specify appropriate grounds of justification for moral judgments. Most philosophers don’t prescribe commandments or suggest punishments from some high authority the way that churches do. Ethicists seek to make sense of underlying cultural values and types of considerations that determine the moral assessment of practices. Feminist ethics, however, considers oppression of women along with moral judgments (Sherwin 36).

Traditional Ethics

To distinguish traditional mainstream (malestream) ethics from feminist ethics we must compare and contrast their concepts (Sherwin 37).

Arthur Zucker lists in his preface the topics NOT included in his anthology, some of them are: nursing ethics, alternative concepts of medicine, and minorities in medicine. In the first paragraph he states that it’s not that he finds these topics unimportant, but he thinks that if a student comprehends the material he includes in his book, that the student will be able to think through other issues for her or himself with ease (Zucker ix). Yet if not introduced to taking oppression into account how can he know that students will be able to? The historical fact that women’s oppression has NOT been considered in traditional ethics illustrates the importance of his pointing it out. He acts as if he, as a teacher, has no power of influence over what his students think is important.

If Zucker gave a priority to the issues of the oppressed, he could give future students of ethics a sensitivity to oppression rather than not exposing students to oppression by excluding it from his anthology – NOT including oppression and other issues relating to women and minorities is a loud message about their value.

Zucker claims that the role of ethical theory is to identify relevant moral factors. By helping us to focus on specific aspects of a problem, theory gives us direction to sort things out (Zucker 10). By choosing not to include nursing, minorities and alternative health care options Zucker favors a discussion that would serve the status quo. If one does not factor in oppression as a relevant factor, how can moral agents say that they have looked all the moral

factors? Correcting the immoralities of women’s oppression is a morally relevant factor.

Zucker claims that theory provides us with a common vocabulary to the discuss the issues (Zucker 11). To a feminist, ethical discourse whose vocabulary is devoid of the word oppression is lacking a fundamental relevant factor. 

Zucker further states that the fact that theories are limited, allows for alternative interpretations, due to their complexities, theories impose artificial simplicity (Zucker 11). Feminists certainly see alternative interpretations in that they perceive that the traditional male devised theories serve to maintain a stratified social structure that keeps men at the top.

Deontologicalists

These theorists are involved in deciding which actions are required or prohibited as a matter of moral duty. Actions are deemed right or wrong because they are either required by moral laws or rules and are considered to be binding, independent of a person’s specific interests. The most influential deontologist was Immanuel Kant (1724-1804) whose theories, despite the fact that they were published over 200 years ago, are still used by some philosophers in 1992 (Sherwin 37).

Kant proposes we decide on the rightness of an action according to a logical principle. Moral duties are identified by rational, free persons using abstract reason; these duties must be above any personal considerations. This does NOT allow for specific facts in a situation. To Kant, the moral thing to do is to follow moral laws, not to try to attain the results we want. His theories require that we follow some actions despite the consequences (Sherwin 37).

Kant was critical of teleological theories (actions measured by their consequences) because one could not be sure of what the consequences of an act would be, so it left the morality questionable – they lacked universality. He thought that an ethical theory must tell us with certainty whether an action is right or wrong for all people in a given circumstance, even before they acted. Rightness or wrongness of an act depends on the motivation. For Kant it’s the quality of the will, not the quality of pleasure as a result of an act. Correct motivation depends upon reason (Zucker 4). Kant’s “categorical imperative” states,

“Act only according to that maxim whereby you can at the same time will that it should become a universal law”(Zucker 5).   

The idea of having to pass a “categorical imperative” test and having to think ahead so that you end up with a rule that applies to similar situations is ridiculous to me. Who decides what maxims are generalizable? An example of this type of maxim might be, all patients with cancer will receive chemotherapy, after all, the intention is good. 

These theories don’t fit women’s life experiences that are contextual in nature, which is opposite from the rational perspective that influenced the development of the categorical imperative. 

Kant assumed only men could be moral agents; they were able to ignore personal sentiments in making decisions. Feminists reject the very notion of a moral theory totally separated from sentiment (Sherwin 39).  

Teleological Consequentialism

The moral worth of an action is measured in terms of the worth of the consequences (Sherwin 39). (Which is quite different from deontologists who evaluate the correctness of an act by laws and rules they think must be followed, despite ignoring the contexts of specific situations).

These theorists say that the evaluation and decision regarding an actions rightness are based on whether the action maximizes the outcome when compared to alternatives (Sherwin 39). Using the example of all cancer patients receiving chemotherapy, we would be required to evaluate the consequences; consequences could be nausea, diarrhea, weight loss, extreme discomfort, depletion of infection fighting cellular function, multiple infections, longer life, cure, or death itself from the side effects. Who decides what is the prominent criteria to be used to evaluate these consequences?

Utilitarianism

In this theoretical framework, the consequences of ethical decisions are evaluated by accumulated effects on the welfare of persons. These theorists recommend not following rules if the outcomes are less than desirable, even if they appear rational in the abstract. Their analysis focuses on concrete or abstract experiences and denies that the feelings and attitudes of agents and those affected by the action should be considered. On an abstract plane rightness is calculated by the total amount of happiness and suffering created by an act without regard to whose happiness or suffering is involved; this theory is not concerned with merit or fairness. So, if a mother had to decide whether to help her children (2 of them) or her enemies (15 of them), she would simply have to go by the numbers to know which group will allow her to please the most people. This theory does not concern itself with WHO will be pleased, so a mother might be obligated to go against her family by following this theory. These theories demand impartiality of agents which many find repulsive (Sherwin 40).

The founder of utilitarianism, Jeremy Bentham (1748-1832), thought that we humans were subject to 2 masters: pain and pleasure; these powerful incentives control what we do. He coined the phrase, “principle of utility”, and wrote,   

       “By the principle of utility, is meant that principle which approves or disapproves of every action whatsoever, according to the tendency which it appears to have to augment or diminish the happiness of the party whose interest is in question” (Zucker 3).

He even developed a hedonistic calculus for moral agents to use to calculate the potential amount of pleasure and pain a specific action might take. Bentham’s theories did not address what to do if two actions yielded the same amounts of pleasure (Zucker 3).

(As a feminist, I know who would decide in a sexist, racist and classist society whose pleasure was of more value – rich, white men!)    

John Stuart Mill (1806-1873), claimed that a utilitarian needn’t use calculus to come to moral decisions. He thought that one could evaluate acts in advance and come up with guidelines and/or rules to speed things up. Mill thought that pleasure of the mind was of more value than the physical. If 2 acts yielded the same pleasure then “competent judges” were called who had experience with many pleasures to decide on the close calls (Zucker 3).

I can imagine that with this type of thinking the intellectuals could rationalize oppression quite well. If pleasures of the mind hold more value then they as intellectuals would be favored over the needs of the poor, women (who were certainly not seen as intellectuals in those days), blacks and Native Americans and others. They were free to sit in their ivory towers deciding on their own pleasures and ignore the oppressed people’s mere physical needs.

Both of the above theories require distancing one’s self from personal experiences. Kant is into universal laws, and consequentialists tell agents to weigh their own interests equal to everyone else, without moral evaluation of the interests themselves. Both theories deny weight to details of positions in dominance hierarchies. This type of abstract neutrality is objectionable to feminists, who look at the socio-political contexts of people in moral deliberations (Sherwin 41).       

W. D. Ross (1877-1971) attempted to combine Kantianism and utilitarianism. He identified “prima facia” duties and “actual duties”; prima facia duties are the ones that we see at first glance, ones that our reason sees as moral commands, that are self evident and obvious to rational persons. Our actual duties are not self evident, nor can they be logically obtained from prima facia duties; people with keen minds and moral sensibilities can differ on actual duties even if they agree on prima facia duties. Ross’s theories are weak in that he doesn’t tell us how to decide among the prima facia duties (Zucker 6,7,8).     

Ross says to measure the rational intuition of the “plain man”. He fails to take conflicting issues into account. Whose rational intuition is followed between the oppressor and the oppressed? These theories do not leave room to consider feminist concerns (Sherwin 38). Ross does not identify WHO is the “plain man”. 

Bernard Gert, a contemporary American philosopher, has also combined Kantianism and Utilitarianism. He sees morality as a public system applying to all rational people – the goal is to minimize evil. Gert claims that all rational persons would agree that certain things are evil: death, pain, disability, loss of pleasure, opportunity or freedom. He postulates 10 moral rules as the core of human moral experience that should never, without adequate reason, be violated:

“Do not kill. Do not cause pain. Do not disable. Do not deprive of freedom or opportunity. Do not deprive of pleasure. Do not deceive. Keep your promises. Do not cheat. Obey the law. Do your duty (in your job or your profession)” (Zucker 14).

Gert then goes on to identify questions to ask about the specific problem being addressed; the key terms in his analysis involve rationality, impartiality and irrationality. Zucker says that Gert’s moral theory addresses the type of problems encountered by health care professional and, “yields fresh insight about the moral experience of humankind” (Zucker 15).

Gert’s fundamental concept is rationality; in order to justify morality, the act must at the very least be rational because everything else depends upon rationality. Impartiality, he claims, is universally recognized as an essential part of morality. The rules of the game are known by all and all involved are required to act rationally. He discusses rationality as thus:

“A person with sufficient knowledge and intelligence to be a moral agent acts irrationally when he acts in a way that he knows, (justifiably believes) or should know, will significantly increase the probability that he will suffer death, pain, disability, loss of freedom or loss of pleasure, and he does not have an adequate reason for so acting. A reason is a conscious belief that one’s action will help anyone, not only oneself, avoid one of these evils, or gain some good, viz., ability, freedom, or pleasure, and this belief is not obviously inconsistent with what one knows” (Zucker 17).

As far as public rules, the following describes Gert’s description of a justified moral system:

“Everyone is always to obey the rule unless an impartial rational person can advocate that violating it be publicly allowed. Anyone who violates the rule when an impartial rational person cannot advocate that such a violation be publicly allowed may be punished” (Zucker 19).

Who are these impartial rational persons? Who decides who gets to make these decisions due to their status as being impartial and rational? Gert admits that impartial rational persons may disagree on the ranking of evils due to ideological differences, but does not offer solutions to these differences. Gert assumes that we have an egalitarian system. If Gert had come up with his moral system with the hierarchical nature of our world in mind his system would have to be vastly different. Under hierarchy in the medical field the doctors would be considered the impartial rational persons who are qualified to make judgments on how much suffering is morally allowable. In society at large, under hierarchy, those in power positions would be the ones making decisions about what’s evil and what is right. His ethics is dehumanizing to those without power who would be labeled partial and irrational; they would be viewed as needing those in power to “take care of” them.

Contractarianism/Social Contract Theory

Social contract theory is similar to the above three, but places objects in a social context. It makes the assumption that people are independent, self interested and view morality as though it were on a par with like trying to get cooperation among competitors. This theory appeals to a “social contract” or hypothetical agreement, the logical outcome of a reasonable negotiation with separate self-interested persons. These selves share a mutual gain – avoiding violence. Morality is a rational option to limit the dangers of life (Sherwin 41).

Only abstract features of significance to everyone have meaning in developing the contract. (no emotionality or contextual data). It does not address the morality of persons who do not meet ideal moral standards. Nor do they (the proponents of the specific theory) check out the moral relationship existing among people of unequal status. Details like whether or not someone is disabled, has talent or social status compromises the legitimacy of the contract (Sherwin 41).

Feminists say that these contracts developed under a “veil of ignorance” perpetrate oppressive practices. The theorists act as if traits like race and sex can be treated the same as eye color; they fail to identify mechanisms that maintain oppression (Sherwin 42).

Feminine Ethics

Sherwin discusses 2 distinct groups of concerns about traditional ethics:

       1.    “Feminine” ethics – how traditional approaches fail to address the moral experiences and intuitions of women (Sherwin 42).

Anti-women bias is seen in much of the traditional theoretical ethics work. As the leading moral theorists show, existing ethics proposals don’t get at their objective – impartial theories and most theories show gender bias and misogynist values; it is not insignificant that most moral theorists have historically been male (Sherwin 43). 

Aristotle’s theory of virtues is illustrative: men’s virtues were those needed for freedom and political life; women were those about obedience and silence. Only male virtues were the subject of philosophical interest or given value. Aristotle’s sphere of influence, which included most of our church fathers, lasted for centuries; his followers not only accepted his ideas about gender specific moral worth, but made them the centerpiece of a theology that has shaped Western values ever since (Sherwin 43).

Many of the historical moral theorists like, Thomas Aquinas, Jean-Jacques Rousseau, GWF Hegel, Friedreich Nietzsche, Jean-Paul Sartre, and Kant saw women quite differently from men. They thought that women were morally unfocused and not interested in the level of generality required for moral thought. To them it was obvious that men were naturally associated with reason. Women’s shortcomings justified excluding them from active participation in political life and for limiting their power and influence to the home. These theorists thought that the subordination of women was natural and saw in women a willingness to accept these facts passively. Sherwin quotes Rousseau who said bluntly that women were suited by nature, “… to please and to be subjected to man … Woman is made to put up even with injustice from him. You will never reduce young boys to the same condition, their inner feelings rise in revolt against injustice; nature has not fitted them to put up with it” (Sherwin 44).

Sherwin says that even the modern theorist, John Rawls (71), thought he could come up with an equitable theory without the special perspective of women. He suggested that “heads” of households could simply represent the whole family. He did not address the patriarchal societal tendency to allow men to disregard and regularly violate their wives and children. Neither did Rawls address the sexual division of labor (Sherwin 44).

Robert Nozick’s Anarchy, State and Utopia (74) and David Gauthier’s Morals By Agreement (86), illustrate that the presumption that philosophy can be gender-neutral perpetrates male privilege. Nozick and Gauthier assume women are moral agents, but the moral concerns examined are always most salient from a male point of view (Sherwin 44).

Sherwin relates complex ways in which the implications for women of traditional moral theory lead to “moral madness”. Traditional theories follow one or more patterns:

       “1.   They deny that women are capable of full moral reasoning;

        2.   They draw a distinction between public and private moral thought, restrict women to the domain of the private and then deny that the private domain constitutes moral thought;

        3.   They force women into a series of perverse moral double binds; 

        4.   They make invisible the domains wherein women’s moral decision-making is concentrated.” (Sherwin 44-45).

Freud thought women were incapable of justice because they were too personal and were unwilling to evaluate ethical claims using abstractions. Kohlberg deliberately excluded women from his study on the development of moral reasoning, as their inclusion would contaminate the data. He was actually acknowledging that women used different patterns to develop moral reasoning skills. Kohlberg was right in that when the tests he developed, using male norms, are applied to women, men score higher (Sherwin 45).

Women needn’t bother trying to convince men that their moral reasoning abilities are equal, but that the gender differences both deserve recognition as legitimate, important elements and need to be added to the public sphere of discourse (Sherwin 46).

A study showed that women focus on the details of relationships and are innovative in trying to find solutions to help all and avoid harm to anyone. Men tend to identify appropriate rules that govern the situation, select the solution most compatible with the dominant rule, even if someone’s interests may be sacrificed to justice. Gilligan named the way of women, as an ethics of responsibility of care and the men’s, as an ethics of justice. An ideal ethics would include both frames of reference. Gilligan asks that we expand moral considerations that consider feminine thinking to be relevant – not deficient (Sherwin 46).

Gilligan noticed problems interpreting women’s development and began to connect these problems to the fact that women have been historically excluded from theory building studies about the psychological development of morality (Gilligan 1). She found disparities between what women experienced and what the developmental charts said was supposed to happen at different points of development. It was previously judged that women’s not fitting in male designed stages was a problem with the women (Gilligan 2). Instead feminists argue that it’s a problem of not including women in developing the theories in the first place that is the real problem.

Gilligan attributed the different “voices” she heard from the women she studied to the different social context they lived in: social status, power differences, reproductive biological differences and the relations between the sexes themselves all worked to shape the different experiences men and women face in their moral development (Gilligan 25).

Gilligan discusses discoveries in social science where formerly considered “neutral” theories are now seen to reflect observational and evaluative biases. She notices how accustomed women have become to viewing the world through men’s eyes. The theories about moral development have adopted male life experience as scientific “norms”; society and women themselves have tried to fashion women out of male cloth. Freud built his theory of psychosexual development around the male child leading to his Oedipus Complex; in the 1920’s Freud tried to fit women into the male conceptions and then came to his famous “envy” conclusion that said women failed at this developmental stage (Gilligan 6,7). 

From the developmental differences Freud found in women he theorized, “for women the level of what is ethically normal is different from what it is in men,” he further concluded that women “show less sense of justice than men”, that they are less ready to submit to the great exigencies of life, that they are more often influenced in their judgments by feelings of affection or hostility” (Gilligan 7). Part of a boy’s developing a male identity involves separating from his mother; for girls their identity formation is intermingled with attachment to the mother. Thus, the male identity is threatened by intimacy, and the female identity threatened by separation. As a result, males have more trouble with relationships and females have more trouble with individuation. If these insights are put together with the psychological development markers made from studying men, it is clear to see why females are seen to “fail” because of their difficulty with separation (Gilligan 8,9).

Women find self definition within their relationships and judge themselves based on their ability to care. A woman’s place in a man’s life has been that of caretaker; male dominated theories of psychological development, have tended to minimize the value of women’s caring. When development scales get to stages of maturity and stress autonomy, women are seen as weak because of their continued concern for relationships (Gilligan 17).

Gilligan describes Kohlberg’s 6 stages of moral development; research which functioned on the assumption that females “didn’t exist”; he studied the moral development of 84 boys over a 20-year period. Despite the obvious exclusion of girls in his work he claims his stages are universal; it is rare however, that females ever reach his higher stages of development (Gilligan 19,20,21).

When the moral development of women is studied, problems derive from conflicting responsibilities, not competing rights; the resolution of these conflicts comes in contextual and narrative form, not from abstraction and formality. By adding a new dimension of interpreting girl’s thought, it becomes possible to perceive development that was not perceptible before. By doing so, one can consider differences with understanding rather than in terms of better or worse (Gilligan 19).

Erickson noted that women’s identity had as much to do with intimacy as with separation, but he did not incorporate his observation in his developmental chart (Gilligan 12,13).

Gilligan suggests the contrasting images of hierarchy in children’s moral development illustrate two views of morality that are complementary rather than oppositional or sequential. She admits that it goes against the bias of developmental theory that attempts to maintain the hierarchical system (Gilligan 173,174).

Miller calls for a new language in psychology that would separate the vocabulary of oppression and inequality from descriptions of caring and relationships, in addition to a call for social equality (Gilligan 48,49).

Noddings goes further than Gilligan and says caring is not only morally significant, but is the only legitimate moral consideration; the proper locus of ethical thought is the quality of relationships. She urges that we explore the mothering relationship as an alternative to the contractarian anonymous, isolated individual model (Sherwin 47).

Sherwin says that theories should involve models of human interaction paralleling the complexities involved in relationships and recognize the moral significance of actual ties that bind in relationships (Sherwin 49).

Feminist Ethics

Feminist ethics differs from feminine ethics in that it comes from the explicitly political perspective of feminism; the oppression of women is not morally and politically acceptable. It goes beyond women’s actual experience and moral practices, criticizing practices that form their oppression. Feminist ethics recognizes women’s moral perspective, the ethics of care, and seeks to expand our moral agenda to include caring. (Sherwin 49).

Sherwin warns that we must be careful with our caring philosophies because the very nurturing and caring we excel at are survival skills developed in an oppressed group that lives next to the oppressor. A potential danger of feminist ethics is that caring about others leads women to concentrate their energies on the needs of others – even to the point of protecting their oppressors (Sherwin 50).

A job for feminist ethics is to distinguish when care is appropriate and when it is best withheld. In feminist ethics, evaluating the moral value of specific acts and patterns of caring involves making political judgments (Sherwin 50).

We should guard against letting preferences, especially ones tied to feelings, be granted full range in ethical matters. Morality must respect sentiment, but not give it full moral authority. Feminist ethics involves a commitment to justice and to caring (Sherwin 52).

People don’t exist in abstraction, separate from social circumstances; moral directives to disregard the personal under a “veil of ignorance” are pernicious for political and ethical analysis. Feminist think that moral analysis needs to examine persons and their behavior in the context of political relations and experiences that are missing from most ethical debates (Sherwin 53). The goals of feminist ethicists are to include context, relationships, life experience and the oppression of women to ethical debates.

It is also important to distinguish liberal ethics from feminism. Communitarian theories are conservative, committed to protecting community values without evaluating their status in the hierarchies of oppression. They privilege the status quo; feminist ethics challenges it. The principle insight in feminist ethics is that oppression, however it is practiced, is morally wrong. Feminist ethics demands that the effects of any decision on women’s lives be a feature of moral discussion and decision making. Feminist ethics applies to political perspectives and how ethics must be revised to address the dominance and oppression affecting women. Feminist ethics has taken the lead in pursuing the analysis of all forms of oppression in its ethical analysis (Sherwin 54).

Feminism and Moral Relativism

Metaethics involves theorizing about the nature of ethics. Much of its work is abstract and uses technical language that is exclusionary and elitist. Few feminists have patience for intellectual puzzles that really have no practical relevance. Absolutist principles are often oppressive, and seem to undermine the strength of moral arguments against oppression (Sherwin 58-59).

Feminist Ambivalence About Relativism

Feminist ethics can’t go along with gender discrimination despite its overwhelming acceptance in our society. Moral relativism says moral judgments must be made by the existing norms of the community, but the whole of our community oppresses women (Sherwin 60).

Feminists do not only say that sexist practices are wrong for subjective reasons, they think they are wrong objectively also. Relativism is certainly not a theory that feminists can abide by. According to relativism, genital mutilation is ok in countries that accept its practice. A survey in 1983 in northern Sudan found 82% of women and 87.7% of men approved of the practice (Sherwin 62).

Relativism promotes authoritarianism in ethics. Our culture is structured on dominant relationships. Moral authority is claimed by the dominant group and is a part of the structure of oppression. Negative moral judgments toward women are very powerful because we were taught that part of our very femininity was to attempt moral approval – these authoritarian models maintain social order, (they maintain us in our places). Relativism is a way for ethics to legitimize the oppressive social organization (Sherwin 63).

Feminists are aware that the very same event can be seen quite differently i.e. the birth of a child, a miscarriage, or permanent sterilization, by different women depending on their vantage point and life situation. How someone perceives the world is not a given. Each person sees reality according to what the dominant forces in their world have taught them to see. That is until their consciousness is raised through political analysis; learning about alternative views can give someone other ways to perceive reality. We remain oppressed when we perceive only what the oppressors perceive, when we are held back by their values and categories (Sherwin 64).

To presume that it is a possible goal to come up with one moral theory or rule leads to domination by the people who are in power to enforce that view. Moral theory must retain the authority to assert moral judgments, while at the same time, allowing for the diversity among women’s perceptions of reality (Sherwin 65).

Sherwin discusses Trebilcot’s three principles in the context of women’s space:

       “I speak only for myself I do not try to get other wimmin to accept my beliefs in place of their own There is no “given””  (Sherwin 66).   

Even Treblicot says that these do not fit in a patriarchal milieu. This suggests that the application of relativism itself depends on the absence of patriarchy (Sherwin 66). In other words, if the entire community has an equal say in decision-making then relativism might work, but not in patriarchy.

Feminist Moral Relativism

To evaluate relativism, we must first know the context of the issue and the community in which we are talking, along with how the standard was reached, whose interests were served and what are the procedures for discussion and change. We cannot treat all communities the same; (what about a lesbian community) nor should we grant authority to all moral standards accepted in the community. Power relations shape the very values of the community and are interconnected within the political structures. So, we must pay attention to the existence of oppressive practices in a community (Sherwin 67).

A problem is that to many feminists the communities’ moral standards are not totally trustworthy so we need a much deeper measure than community agreement to find moral truth. How a community gets to moral decisions and the reasons for those decisions must be taken into account in evaluating them (Sherwin 67).

We cannot understand morality by reason alone, with each rational agent using reflection to come up with a moral law. We learn about moral standards by talking about them within our community and they can’t be worked out separate from their context. To be democratic about developing moral standards ALL in the community must partake in developing the standards – not just those with political power. If developed through oppressive forces it is not likely that safeguards will be in place to avoid further exploitation of the already oppressed (Sherwin 68-69). 

It is unlikely that one moral code would be adapted by all communities, hence absolutism is out of the question. Criteria are needed to limit the acceptable modes of moral standards in a community. From a feminist perspective, we must address whether or not oppressive circumstances limit input from some in the community and whether the compliance of the oppressed has been coerced or reflects real support (Sherwin 70).

The Advantage of Feminist Moral Relativism

Sherwin discusses Wong and his theory that relativism should allow for each side to have differing opinions as long as they can justify them and that each side should be tolerant of the other’s views and seek to coexist (Sherwin 70).

Sherwin thinks that testing the moral views of each side of an issue (like abortion) should not simply include their connection with a “well- established moral system”. Rather the justifiability of the side must be determined by the nature of its particular moral system; how did it evolve, whose interests are served, and most important whose interests are sacrificed? With abortion, conservatives base their argument on the life of the fetus. Their arguments are linked to a history of patriarchal control over women’s sexual and reproductive lives. They protect the life of the fetus while it is in the mother’s body; they do not illustrate concern for the millions of starving and abused children now living in the world. They do not campaign to get women the needed housing, child care, and educational services that many women need if they are to give birth to their fetuses instead of aborting them. Many antiabortionists are actually engaged in limiting these kind of supports (Sherwin 71). Their attitude is, you gave birth to them now you must take care of them. 

Among the staunchest antiabortion groups is the Catholic church, run undemocratically by celibate males. Women are not included on the decision making here. Almost every nation’s laws about abortion come from legislative bodies that are mostly male. Sherwin thinks Wong’s justification principle leaves out the history of oppression in favor of established traditions (Sherwin 72).

Until conservatives are willing to develop a moral policy on abortion in conjunction with all the women who will be affected by it, their position doesn’t constitute a moral position that we are obliged to respect. To use the example of genital mutilation, unless there is evidence to believe that women, free of patriarchal tyranny, would choose this practice we cannot see it as an acceptable local custom (Sherwin 74).

Feminist moral relativism is absolutist about the moral unacceptability of oppression, but is relativist on other moral matters (Sherwin 75).

Feminist Ethics of Health Care: Context’s Role

Sherwin discusses several theorists who agree that we must take into account, especially in matters of life and death, the context and the people in the situations involved and not just some abstract principles. The pursuit of universal, rather than contextual, ethics seems to restrict the very scope and analysis of ethics; broad principles are inadequate to apply to the complexities of bioethics and they obscure the most important facts about a situation. We must be precise about the term “context” because mainstream ethics does include context, but is not feminist in nature (Sherwin 76).

Sherwin calls the 1970’s the early days of medical ethics. At that time theorists tried to solve dilemmas using Kant, utilitarianism etc, and soon it became obvious that it wouldn’t work. She uses several examples of male theorists who agree that we must solve things on an individual case basis. She discusses Albert Jonsen and Stephen Toulmin’s book The Abuse of Casuistry 1988; they recommend an informal model of moral reasoning called, casuistry built around a, “recognition of significant particulars and informed prudence” (Sherwin 79).

Sherwin recommends using the concrete circumstances of actual cases and the specific maxims in front of the people involved. When one looks at ethics journals and articles about ethical issues today one can see that specific cases are used, not universal rules (Sherwin 80). I agree that the people involved should certainly be involved in ethical decisions concerning them. This goes along with my goal of having ethics be practical, not simply intellectual discourse, so that it cam meet the patient’s needs.

Theory-Based Alternatives

A basic assumption in medical ethics is that the health care providers are obligated to place priority on the welfare of their patients, even if greater utility could be gained by other means. Feminist ethics goes further and asks that we also consider things on the basis of the person’s place within hierarchical structures; special weight should be given to help undermine oppressive practices. Situation ethics is popular with health professionals because it’s user friendly. It directs agents to seek a loving and humane solution, but does not identify which solution is loving and humane (Sherwin 81).

Most medical ethicists and many feminist ethicists see a place for principles in ethics, but deny that principles alone are enough. Oppression is not a phenomenon that can be studied in the abstract; specific details about the form of oppression and the relevant features of the situation must be considered to make sense of the moral concerns involved (Sherwin 82).

Similarities: Feminist and Medical Ethics

Both feminist and medical ethicists are critical of traditional assumptions, made by mostly contractarians, that the role of ethics is to clarify the obligations that hold among persons viewed as pragmatically equal, independent, rational and autonomous (Sherwin 82).

Both agree with feminine ethics that we pay attention to interdependent, emotionally varied, unequal relationships that are our lives. Medical ethics does admit that the relationship between doctors and patients is far from equal, and the model of contracts negotiated by rational independent agents does not fit. The patient is dependent, vulnerable, and in a disadvantaged position due to illness (Sherwin 82-83).

Both evaluate behavior in terms of the effect on quality of relationships involved. Both agree that the establishment of trust is vital between physician and patient. Both use the considerations of caring, they call it beneficence, and assume it is owed to patients. Compassion is frequently claimed to be more important than honesty or justice in medical ethics. It may then appear that medical ethics is also feminist, but medical ethics fails to be committed to ending oppression the very core of feminist ethics (Sherwin 84).

Silence as Tolerance

Sherwin call physicians “the patriarchs of the body”. She asserts that current medical practice is a powerful institution that is involved in the oppression of women. It thrives on hierarchical power structures that themselves serve to maintain domination and subordination (Sherwin 84).

Feminist criticisms include: the institutional structures, authoritarian control, different treatment of male and female patients, doctors’ obsessive interest in women’s reproductive functions, their perpetration of sex-role stereotypes, reinforcing women’s subservience in the family. Medical researchers set their agendas with respect to women’s conditions according to male-defined interests in women. They authoritatively dictate patterns of normalcy in mental and physical health that serve the interests of men (Sherwin 85).

Women are discouraged from developing self-help behaviors that would give them power over their health. They are urged to measure their behavior with standards that most women can’t meet, so the women are blamed for overeating, smoking, not exercising enough, or for doing the above too much. Women are encouraged to be dependent on medical opinion rather than to listen to their intuitions about the welfare of their bodies and the people they care for. Men are in the positions of power in medical institutions, women are support staff and caretakers. Doctors decide if a woman’s request for an abortion is legitimate and when her reproductive organs become unnecessary and a threat to her well being. Doctors go along with advertiser’s design of the ideal woman and help us fit these expectations with plastic surgery and diet programs. With a male dominated legislature and legal system, doctors decide how much money to spend on life saving measures to a preemie infant, while funds are not available to protect millions of women and children from starvation (Sherwin 85).

Doctors medicate women with socially induced depression and anxiety which helps perpetrate oppression and deflects attention from the injustice of their situation. Having the authority to define normal and pathological and to coerce compliance to its norms, medicine strengthens gender roles and racial stereotypes thus reinforcing already existing power structures. Some offer advice that explains and excuses wife battering, incest and male sexual aggression and thus inhibits evaluation of these practices in moral and political terms (Sherwin 85).

Institutionalized medicine is accepted in society without question. Medical ethics has not addressed feminist issues and thus helps to legitimize the existing system. Lately medicine has incorporated ethics into their credentialing; they have a few questions on their exams and spend a few hours of their schedule in studying ethics. This is suspicious because it makes the public think that they are concerned with ethics and serves to further maintain the public’s trust. When abuses become public doctors renew their commitment to moral education; doctors are not required to soul search or to change their traditional ways (Sherwin 86). Doctors use ethics to inspire trust and thus maintain their public image of being the “kings of morality”.

Medical literature and conferences are concerned with establishing ethical rational for the practices already in place in health care. Criticism is reserved for new practices like fetal tissue research, paternalism because it goes against social norms and controversial issues like abortion. There is little evidence that medical ethics has addressed the oppression of women, people of color or the disabled (Sherwin 87).

Definition of Context

Sherwin asserts that most non-feminist ethicists examine medical practices separately (genetics, abortion) isolated from historical and political contexts that they occur in. When considered only abstractly, it is concluded that there are no violations of moral rules. They say the only moral dilemmas of each practice will be ones that concern specific cases. Then in a case study approach it is assumed all details can be clarified with a short description. Developing a context-specific approach to case analysis for an issue like surrogacy, often shapes the outcome of the analysis; it is easy to identify strong grounds in specific cases by illustrating an example that is benign and desirable – and vice versa (Sherwin 90).

From a feminist perspective we need to clarify the practice within the broader patterns of women’s subordination. We need to ask what affect will increase surrogacy have on the status of women’s oppression? (Sherwin 90).

Other Features of a Feminist Ethics of Health Care

Both medical and feminist ethics are concerned with quality and the nature of particular relationships, because both understand that rights and responsibilities depend on roles and relationships that exist among people with differing status and power. New models of interaction are needed to develop a system that is less hierarchical and less focused on power and control (Sherwin 92).

Feminist ethics will demonstrate that the role of the patient is feminine and thus requires submission to authority and being grateful for attention. Most women know they’re vulnerable to medicine’s power and laugh with suffering to avoid hostility and impatience and frequently apologize for needing attention. Feminism is invested in redefining feminine roles that will be great in health care too (Sherwin 92).

Medical practice perceives the body, under patriarchy, as feminine; medicine’s role is to explore, manipulate, and modify the body, the female body is particularly important. Sherwin relates from Body/Politics: Women and the Discourses of Science by Jacobus, Keller, and Shuttleworth, that there are significant political and moral questions about the relations between medicine and the female body. Discourses common to medicine and science reflect and support attitudes that reinforce patriarchy (Sherwin 93).

Many women find alternative practices in health care more empowering for them than traditional allopathic medicine (Sherwin 93).

The agenda of traditional bioethics has been concerned about the responsibilities of the health professional; feminist ethics reaches much farther and explores roles open to patients and non-professionals in seeking health and health policy (Sherwin 93).

Disability

We need a feminist theory of disability, which would show how disability is a socially construed response to a biological condition. Medicine has created arrangements and constructed attitudes that lead to the disabled feeling alienated from their bodies and frustrated by their socially supported sense of failure (Sherwin 90,91). 

Thirty million women in the U.S. have disabilities and are among the most frequent users of health care; the overlap of sexism combined with the discrimination against those with disabilities severely limits employment and education to these women. Even to obtain non-medical services (wheelchairs, transportation, Social Security benefits and personal care attendants) these women must obtain certification of need from a doctor, despite the fact that doctors have not been trained in or exposed to people with disabilities (Saxton 36).

Medical schools offer virtually no training in political or social problems posed by being disabled; nor do they learn about the further impacts of sexism, racism or homophobia on disabled women (Saxton 36).

The medical system lags in addressing the reproductive health needs of disabled women; there are myths that disabled women are not sexual beings let alone capable of motherhood. Most medial research in this regard has focused on male sexual function and reproductive abilities (Saxton 36).

Because women have not worked long enough in the Social Security System to qualify for Medicare, they must fight harder than men to obtain any benefits due to them. “Skimming”, a strategy to weed out patients who are a financial risk to insurance companies, hits women the hardest. Women with disabilities tend to be poor, unemployed, and unlikely to file lawsuits against abuses they face; they require pro bono legal services and societies encouragement to speak out (Saxton 36,37).

Feminists should certainly join with disabled women in their outrage that doctors are allowed to be seen as experts in matters they don’t even know about.

Abortion

Feminist ethics differs from what liberal arguments usually offer. Feminists evaluate abortion policy within a broader framework according to its place among social institutions that support the subordination of women. In contrast, non-feminists consider moral and legal permissibility of abortion in isolation. They ignore (and thereby obscure) relevant connections with other social practices, including the ongoing power struggles in the sexist society over the control of women and their reproduction. Feminists take into account actual concerns that particular women use in decision making on abortion. (i.e. the nature of her feelings about the fetus, relationship with partner, other kids she might have, various obligations to herself and others). In contrast, non-feminists, evaluate abortion decisions in the abstract (what sort of being the fetus is); from this perspective specific questions of context are irrelevant. In addition, non-feminists in support of choice, grounded in masculinist conceptions of freedom (privacy, individual choice, person’s property rights with own body) which don’t meet the needs, interests, and intuitions of many of the women concerned. Feminist see the moral issue involved differently. Non-feminists focus on morality and legality of doing abortions, feminists say that accessibility and delivery of services must be addressed (Sherwin 99-100).

Feminist ethics supports a model for the provision of services. We should develop an explicitly feminist morality regarding abortion that reflects deep appreciation for complexities of life, refusing to polarize and adopt simplistic formulas (Sherwin 100). 

Women and Abortion

The biggest difference with feminist perception on abortion is the attention it gives to the interests and experiences of women. We regard the effects on the lives of women individually with unwanted pregnancies and collectively as the main element in moral examination of abortion. It is considered self evident that the woman is subject of principle concern. Many non-feminists don’t see the pregnant woman as central and is thus rendered invisible; most of the attention has focused on the moral status of the fetus (Sherwin 100-101).

Due to recent threats regarding the loss of abortion rights women have developed self-help groups that get together to examine their breast and cervixes, explore home type remedies for infections and openly discuss sexuality and health. Although medically and legally controversial, some groups do menstrual extractions to remove the contents of the uterus either during menstruation or to remove a pregnancy, taking the power over their reproductivity out of legal or medical hands (Reinhard 94).

In 1971, The Federation of Feminist Women’s Health Centers, was started by Carol Downer. Downer used herself as a model to teach women how to examine their own cervixes. With this knowledge women could tell the medical establishment where to go – they could use knowledge to empower themselves (Reinhard 94).

In the United States the self-help groups stay underground to avoid the hostility directed against abortion clinics. Downer estimates that 20,000 menstrual extractions have been performed in other countries of the world over the last 20 years. The extractions are done in groups using a device called a Del-Em, put together with medical and household equipment; a flexible plastic tool, like a straw, is hooked up to a syringe with a one-way valve, after it’s placed in the uterus it can pump the uterine contents into a jar. These sterile procedures can be done within the first 8 weeks of pregnancy (Reinhard 94). 

Doctors warn these extractions can lead to infections and other complications. The California Food And Drug Administration says that the Del-Em is not legal, as all medical devices must be tested. Abortion must be done by a licensed physician by law, but it would be difficult to prove whether a woman was extracting menstrual blood or a pregnancy (Reinhard 94).

As a nurse, I know that any abortion can lead to an infection or other complication. Knowing too well how doctors break sterile technique and put patients at high risk for infection all the time, I would bet that women themselves, having more at risk – their own health and bodies, would be VERY cautious about sterile technique. (As if any woman couldn’t learn sterile technique). The question of legality is absurd because if it were not for the legal system’s nonsupport of women’s right to control their bodies, they wouldn’t have to take such desperate measures.

Feminists look at the role of abortion in women’s lives; the need can be intense, no matter how appalling or dangerous the conditions, women from diverse cultures and historical times have sought abortions. Antiabortion activists seem to accept the costs despite life threatening facts when abortion is legal; feminists value women, and judge the loss of women’s lives a matter of fundamental concern (Sherwin 101).

Feminists realize women get abortions for compelling, not frivolous reasons. Lack of access to abortion may mean that some women will be forced to remain in oppressed conditions. Only the woman is in position to weigh relevant facts. Feminists reject abstract rules to say when abortion is morally justified. A woman’s personal deliberations involve commitments to all concerned; there is no formula to evaluate all these complex concerns (Sherwin 101).

Women’s personal deliberations about abortion involve considerations that reflect their commitments to the needs and interests of all involved including themselves, the fetus, and other members of the family. No formula can balance all this. Feminists resist philosophers and moralists setting agendas for these considerations. Women must be acknowledged as their own moral agents. Even if a woman makes a mistake, no one else should be able to overrule or judge her decision (Sherwin 102).

Having a child affects major physical, psychological, social, and economic aspects of a woman’s life; she should have control over the timing, frequency and incidence as it involves most of what is valued in her life. It’s also linked to her sexuality. Her subordinate status often prevents women from refusing men’s sexual advances; if they cannot end unwanted access to their bodies, they then become even more vulnerable to these particular men due to greater financial need and less opportunities to earn money due to child care – she is forced into increased dependence – the cycle of oppression continues (Sherwin 103).

Non-feminists act as if women can simply avoid pregnancy by avoiding intercourse; these attitudes show little appreciation for the power of sexual politics in an oppressive culture. Patterns of male dominance frequently leave women with little control over their sex lives; they are victims of rape from husbands, boyfriends, bosses, friends, uncles, employers, customers, brothers, as well as strangers. Sexual coercion is often not seen as such, even by participants, but is the price of “good will”, popularity, economic survival, peace and simple acceptance. Women are frequently physically or psychologically threatened into intercourse; women are socialized to be compliant, sensitive to the feelings of others, scared of physical power; men are socialized to take advantage of opportunity to get sex and use it in obtaining dominance and power (Sherwin 103).

Women cannot rely on birth control; no form is fully safe and reliable. For most who want temporary protection the pill and the IUD are the most effective but carry significant health risks. Both additionally pose threats of involuntary sterilization (Sherwin 104).

Because only women experience the need for abortion, abortion policies affect them uniquely. It is vital to evaluate how the policies affect the oppression. Feminists see this as the principle consideration (Sherwin 105).

The Fetus

Contrasting with how feminists perceive moral acceptability, non-feminists judge abortion on the moral status of the fetus – whether or not the fetus lacks personhood. They argue about whether we give the fetus human status equal to ourselves. The woman on whom the fetus depends is seen as secondary; actual experience and responsibilities of real women are not seen as morally relevant (unless it can be PROVED she is “innocent” too, due to rape or incest). In some contexts, women are viewed as containers, mere mechanical life support system (Sherwin 105).

Antiabortionists say that the genetic make-up of fetus is determined at conception and genetic code is without question human. They show pictures of it, even call ultrasound an infant’s first picture. The fetus in its early stages is microscopic and indistinguishable from other species, lacks capacities that make life human and of value. They try to use sympathy to make the mother appear to be a killer, as if she’s involved in an adversarial relationship with fetus. Antiabortionists encourage people to identify with the unborn and not the woman whose life is at issue (Sherwin 106).

Arguments that focus on similarities with the fetus and infant fail to acknowledge that the fetus is wholly dependent; the newborn infant is independent in maintaining its own vital functions (despite needing care). Women who carry the fetus are seen as passive hosts whose only role is not to abort or harm the fetus (Sherwin 107).

Medicine supports these attitudes with rapidly expanding fetal medicine – they refer to the mother as a “maternal environment”. Fetal surgeons see the fetus as their patient, rather than the woman. They are ACTIVE agents in saving the fetus’s life (unlike the mom whose role is passive). In the medical model of pregnancy, the mother and the fetus are separate and in a conflict of interest. Increasingly women are described as irresponsible or hostile toward their fetus; out of concern for the fetus, doctors are seen as licensed to intervene and ensure women comply with their advice. Courts are called in to support doctors’ orders when moral pressures are not enough to assure cesarean sections and technologically monitored births. Some states are even beginning to imprison women for drug abuse or other socially unaccepted behaviors (Sherwin 107).

Physicians have joined antiabortionists in encouraging a cultural acceptance of the fetus as a unique individual separate from the mother, deserving their own distinct interests. Pregnant women are ignored or seen as deficient, so they can be coerced for the sake of their fetus. The interests of women are assumed to be the same as the fetus; a woman’s interests are seen as irrelevant, immoral, unimportant or unnatural. By focusing on the fetus as independent, it has led to denying women their role as independent moral agents in deciding what becomes of the fetus they are carrying. The moral question of the fetus’s status is quickly translated into a license to interfere with a woman’s reproductive freedom (Sherwin 107-108).

A Feminist View of the Fetus

In a feminist account, fetal development is seen in the context it occurs – in women’s bodies, rather than in the isolation of imagined abstraction. Their very existence is relationally defined, reflecting development in a particular woman’s body; that relationship gives those women reason to be concerned about them. Rather than seeing the fetus as an independent being, feminists suggest a more valuable understanding of pregnancy, “as a biological and social unit” (Sherwin 109).

The fetus is morally significant but its status is relational rather than absolute. Unlike us, fetuses don’t have independent existence. It is not sufficient to consider persons simply as Kantian atoms of rationality; persons are embodied, conscious beings with their own social history. Personhood is a social category, not an isolated state. Persons are members of a community, not undifferentiated conceptual entities (Sherwin 109).

No one other than the pregnant woman can do anything to support or harm a fetus without doing something to the woman who nurtures it. Because of this inexorable biological reality, responsibility and privilege of determining the fetuses specific social status and value must rest with the mother. The value the woman places on her fetus is the sort of value that attached to a budding human relationship (Sherwin 110).

Fetuses are not persons; they have no capacity for relationships; newborns are immediately persons because of their communication and response (Sherwin 111).

Abortion’s Politics

Sexual hierarchy must be taken into account with abortion. Most abortion opponents oppose sex outside of heterosexual marriage and support patriarchal patterns of dominance in these marriages. They say abortion allows women to get away with sex outside of marriage and supports a woman’s independence from men. The intensity of the antiabortion movement correlates with increasing strength of feminism. The original campaign against abortion can be traced to the middle of the 19th century – the time of the first significant feminist movement in the US. To both sides the emancipation of women is involved. More is involved than the life of the fetus (Sherwin 112-113). 

If we place abortion within the larger political framework, we see that most antiabortionists support conservatism that seeks to maintain dominance. Led by the Catholic church and other conservative institutions who not only endorse fetal rights, but male dominance in the church and home. Most abortion opponents also oppose birth control and all forms of sexuality other than monogamous reproductive sex; they also resist having women in leadership roles in their institutions. They also support economics that support the wealthier classes and ignore the needs of the oppressed and disadvantaged. Although they say they are committed to human life, many systematically work to dismantle social programs that give necessities to the poor (Sherwin 113).

To antiabortionists, abortion is not an isolated practice, their opposition centered on the social values that support the oppression of women. Most deny any legitimate grounds for abortion, other than to save the woman’s life – some, not even then. They think pregnancy can and should be endured; if the mother doesn’t want to care for the child, they assume adoption is easy (Sherwin 113).

This, in a world full of homeless babies and children desperately needing to be adopted: AIDS babies, handicapped, and minority babies. Even if you give birth to a healthy child and have people waiting to adopt, it is very difficult to give a baby up for adoption. An intense bond forms over the full-term pregnancy. Pregnancy is not just a 9-month commitment, it’s a lifetime responsibility which places a disproportionate responsibility on the woman. An ethics that cares about women would recognize that abortion can be their only recourse (Sherwin 114).

Expanding the Agenda

Feminists look at abortion in context of power and oppression, they look beyond moral or legal acceptability. Feminists say we must evaluate the morality of ensuring the safety of abortion. This includes removing class, racial, economic and geographical barriers to all women (Sherwin 114).

Feminism demands respect for women’s choices and moral agency. Many political campaigns for abortion rights make it a medical matter, not personal, suggesting that doctors can be trusted to make choices for women (Sherwin 114).

Antiabortion advocates have personalized their attacks and focused on harassing women with their protests as they enter and leave clinics. This is certainly not conducive to positive health care and is objectionable to the ethics of health care. Feminists need to develop an analysis of reproductive freedom to include sexual freedom as defined by women, not men; it would include a woman’s right to refuse sex. Freedom from oppression itself an element of reproductive freedom (Sherwin 115).

Feminists value fetuses that are wanted by the women who carry them and oppose practices that force women to have unwanted abortions. We must see that women get adequate support services to care for the children they would otherwise be forced to abort and with support would choose to carry (Sherwin 116).

Reproductive Technologies

Feminist writers take a broad perspective when looking at reproductive technologies; non-feminists take a narrow view. A definition of the new reproductive technologies: to facilitate conception or to control the quality of fetuses that are produced, including artificial insemination, ova and embryo donation, invitro fertilization (IVF), gamete intrafallopian transfer (GIFT), embryo freezing, prenatal screening, and sex preselection. Up coming technologies are embryo flushing for genetic inspection for transfer to another woman, genetic surgery, cloning, and ectogenesis (fetal development wholly in an artificial womb), racial eugenic planning, contractual pregnancy (surrogate mothering), almost all of this is done to women and their fetuses (Sherwin 118).

The basic concern according to Sherwin, about the new reproductive technologies is that they are being marketed and developed in ways that increase doctor’s control over women’s bodies (Sherwin 25 (Holmes & Purdy)).

Private & Public Interests

It is useful to remember that historically humans have wanted to control reproduction. Usually technological and reproductive choices are seen as private decisions; feminist think we should evaluate them within the broader domain of oppression. Must look at the political, social and economic effects along with the effect on the lives of those concerned (Sherwin 118).

Medicine is bent toward technology (technological favoritism) as medical education, public policy and the profit motive give technology as a measure of medical progress. Implementation decisions are usually left with those involved, despite societal effects (Sherwin 118).

There are patterns governing the use of technology. Initially innocent help for specific problems, end up nearly universal, coercive application to the public. (Electronic fetal monitors, ultrasound, prenatal screening and IVF). Private decision making is not sufficient because the broad effects go beyond specific users (Sherwin 119).

These technologies are likely to bring about profound cultural changes. With the increased possibility for intervention, there is a greater opportunity for those in power to control technology. Throughout history, those in positions of power and authority have sought to exercise it over the reproductive and sexual lives of those without power. (Plato saved for the philosopher-kings, the authority to arrange the reproductive pairing for all. The American South slave owners bred slaves like cattle) (Sherwin 120).

In this century, legislators and religious leaders have tried to restrict sex to married people, by proclaiming sex outside of marriage illicit. Women who engage in extramarital sex are whores and their offspring are labeled illegitimate (Sherwin 100).

Reproductive technologies can give people some control, but the actual control lies with someone else (Sherwin 120).

IVF in Bioethics Literature

Test-tube babies, circumvent rather than cure barriers to conception, usually caused by blocked fallopian tubes or low sperm counts (Sherwin 121).

Artificial hormones that stimulate egg production, often leading to dramatic emotional and physical changes. The released ova are harvested from the woman’s body by laparoscopic surgery. Semen is collected from the male. Washed ova and sperm are combined to promote fertilization. Newly fertilized eggs are transplanted into woman’s uterus. The woman’s blood and urine are monitored daily at 3-hour intervals. Women must undergo extremely uncomfortable ultrasounds to tell doctors when ovulation occurs. Some programs require the woman to remain immobile for 48 hours after the eggs are inserted and some require 24 hours in the head down position. Procedure may fail at any time and do most of the time. Most women endure the process several times and may be dropped from the program at any time. Many practitioners have attempted to obscure the fact that at best, only 10 to 15 % of the cases are selected as suitable (Sherwin 121).

The issues bioethicists have raised vary. Some religions, object to all reproductive technology as unnatural because it gets in the way of God’s plan (Sherwin 121).

Some worry that our humanness won’t survive the technology and that we will treat the artificially induced embryos as objects. Some fear we will not be able to trace the usual categories of parenthood and lineage and this will lead to our loosing aspects of our identity (Sherwin 122).

Those from secular tradition treat these issues as superstition with no clear sense of what’s natural and no sense that demands special moral status. All medical (and maybe all human) activity can be seen as an interference with nature, but don’t necessarily present grounds for avoiding such action (Sherwin 122).

Some theologians object to fertilization outside the body, without joining of human persons, as they say it takes away the value of the language of the bodies. Secular philosophers dismiss objections against asexual reproduction in a properly sanctified marriage. Nurturance of the child (which is the vital thing) does not depend upon the sexual act (Sherwin 122).

Sometimes IVF and artificial insemination are used to produce extra fertilized eggs whose moral status is questionable. Theologians worry that we can anticipate cloning which violates God’s plan. Theologians are concerned about cultural changes if reproduction is viewed as a scientific enterprise; they are concerned that we won’t foresee the future outcome and that we are on a slippery slope that will lead to more troubling practices (Sherwin 123).

Secularists see things differently; they think scientists are moral people and capable of evaluating each technology on its own merit. So, IVF must be judged on its own consequences and not with some future results that it may be linked to (Sherwin 123).

In order to obtain eggs, superovulation is chemically induced to produce multiple eggs. Collection of the eggs is difficult and the odds against conception are great. Several are obtained at once with the hope that if several are injected into the uterus, at least one will “take”. There are also some extras produced, we don’t have answers to what should be done with them? Should they be frozen or donated to other women who either can’t produce eggs or whose eggs are not genetically desirable? Should they be used for research or thrown away? (Sherwin 124).

What if 4 eggs injected actually implant? A woman’s body cannot deal with carrying this many fetuses. If you limit the number of available eggs collected you risk not having enough for fertilization (Sherwin 124).

Non-feminist theorists are concerned about safety in reproductive technology, usually that of the fetus. There is a higher rate of birth complications and defects with IVF, though most think it is safe enough. No mention is made of danger to the mother or of the similarities between clomid (artificial hormone that causes multiple ova release) and DES (the female hormone that caused cancer in the offspring of women who took it). There is no mention of other dangers such as the uncertainties about superovulation, ultrasound, general anesthesia for egg harvest and embryo transfer, very high rate of surgical births, and the emotional costs (Sherwin 125).

Most bioethicists focus on patient autonomy and individual rights and refer to IVF as a private matter. Conception is private so bioethicists think people who are infertile should not be denied parenthood if it is attainable. The desires and needs of individuals are used as the argument in favor of these technologies (Sherwin 125).

There is a question about distributing costs. IVF is very expensive (and profitable), costing several thousand per attempt. Since it is not usually covered by public or private insurance, it is only open to those with money (Sherwin 126).

The Feminist Perspective

Feminists call for looking at all the effects on the women involved before making bioethical evaluations. The way in which IVF is usually practiced it does not totally foster personal reproductive freedom. It is controlled by medical experts – not by the women who seek it. It is NOT made available to all women medically suitable, only to those judged worthy by the medical practitioners. There are many musts:

       -Be in a stable (preferably married) relationship with a male partner

       -Have “appropriate resources”, not only to pay for the  procedures, but to raise the potential child

       -Must demonstrate they “deserve” this support

       -None to: single women, lesbians, those not in the middle class or beyond, those with genetic handicap, or someone who is defined as deficient in mothering by the medical specialist. Because it is denied to single women, IVF can be accurately described as a technology for men who are judged worthy, despite the fact that it is carried out on their wife’s body. So, it ends up establishing super power to societies favored groups (Sherwin 127).

There is a clear pattern of ever-increasing medical control over our reproductive lives. (I recall worrying whether the doctor would LET me get my tubes tied. Who are they to tell me whether I want more children?) Canada and the US’s medical societies have removed midwives, thus eliminating women-controlled reproduction. Medically supervised pregnancies and hospital births are demanded of us all. Women who fail to comply may even be subject to criminal prosecution for endangering her fetus’s health. In the hospital setting, who controls the amount of technology to be used? They even get court orders for Cesarean sections if the woman doesn’t “consent” (Sherwin 127).

An interventionist medical approach alienates women from their reproductive experiences, treat women as passive bodies, focuses on the technology, and is more concerned with the product than with the process of reproduction. The more reproductive technology, the more power will be in the hands of the “experts” (Sherwin 128).

Informed consent is questionable because some technologies are presented as though they are proven treatments, when they are actually experimental. Often techniques are transferred from animal husbandry directly to women without clinical trials on primates. The mid-70’s was a time with many devastating experiences for women: thalidomide, DES, the Dalkon Shield, wide spread fetal x-rays, belated warnings about chemical contraceptives, and the latest – silicone breast implants. Bioethicists seem willing to rely on doctors’ assurances about product safety (Sherwin 129). Can we women?

Many IVF clinics are poor with record keeping and rarely offer full information about their low success rates. They encourage media exposure of the mom with a baby, but leave out the dangers involved for the woman and the high failure rate (Sherwin 129).

IVF in Context

Feminists look to see how reproductive technologies fit in maintaining women’s oppression. Since technology is not neutral, we must ask who controls it, who gains from it and how does it affect the oppression of women? (Sherwin 129).

IVF definitely serves the interests of the scientists who create and manipulate it. While obstetrical business falls, reproductive technology fills the void with prestige and high profit. The new technologies show that Ob-gyn doctors know more about pregnancy and women’s bodies than they do themselves.  

“it is NOT the concerns of people with fertility problems that matter most. Much higher priority is given to the concerns of those who invent, practice and promote the new technologies” (Sherwin 130).

Why do so many couples feel compelled and desperate to use these technologies? Some ethicists say it’s a basic instinct to want your own child and that it makes it ok ethically to use the technology. They don’t seem interested in the expectations placed on people to develop these desires. It may be a self-fulfilling prophecy that society tells them they must be desperate and the health professional assumes that they are. They seek “normalcy” and thus verify the professional’s assumptions. Feminist ethics looks at the social arrangements and values that drive people to take on the high risks of IVF and other technologies. Women are told that they are unfulfilled without motherhood (Sherwin 131).

Children also serve a symbolic function in that they hold together the institution of heterosexuality. We invest large sums of money in IVF to assure people their true genetic offspring, while leaving the needs of starving children unfulfilled (Sherwin 132).

Feminist must evaluate whether the technology reinforces social prejudices of oppression. Doctors use THEIR values (which reflect privilege) to determine who qualifies for the technology and who is sterilized. The black community has significantly higher infertility rates, but infertility programs are overwhelmingly directed at whites. Embryo transfers allow a dominant class couple to pay a poor woman of lower class to gestate their fetus, sparing the genetic parents the risks and inconveniences of pregnancy yet assuring the right genetic make-up of the child. Sex-selection allows for the social preference for males, more males means increased influence of male values (Sherwin 133). 

Most non-feminist bioethicists treat the reproductive technology like it was a consumer freedom to buy the technology. Rather than increasing a woman’s freedom from oppression the narrow concept of freedom of choice may help entrench the patriarchal idea of woman as child bearer (Sherwin 133).

To feminists, the main question is whether technology threatens to reinforce the lack of autonomy most women experience in our culture. Technology with the potential to further control women’s reproduction makes for a slippery slope (Sherwin 134). 

Mendelsohn included a quote by Gloria Steinem about the ability to learn the sex of a baby, “Given the increasing ability to predetermine a baby’s sex—plus the bias toward having more sons and the development of extrauterine birth—the worst of my fantasies passes through decades of decreasing female population, and ends in some zoo of the future with a dozen of us in cages beneath a sign: “Please don’t feed the women” (Mendelsohn 186, 187).

Raymond quoted scientist Erwin Chargaff about the new reproductive technologies, “the demand was less overwhelming than the desire of the scientists to test their new techniques. The experimental babies produced were more of a by-product” (Raymond 29). Raymond compares reproductive technologies in medicine to religious fundamentalism and explains that medical fundamentalism has two principles: The new reproductive dogma says that infertility is a disease that they have the cure for; the second is that anything that just might bring about a pregnancy is fair game to be tried on the desperate women (Raymond 29).

The technology however, does not cure infertility, it merely provides children to a very small number of the women. They don’t make it known that most of the technology is experimental, can be damaging to the women, and only sends 5-10% of the women home with babies. If the new reproductive technologies were viewed in the same light as other medical treatments, they would only be used for life threatening situations (Raymond 29).

A double standard is involved in the ideology of infertility; if it was the main concern, why not address the research to finding out how to prevent and cure the causes of infertility? Some of the causes are pollution, STD’s (sexually transmitted diseases), IUD’s (intrauterine devices), and PID (pelvic inflammatory disease). The U.S. National Center for Health Statistics (NCHS) and the U.S. Office of Technology Assessment (OTA) say the infertility occurrence is one in twelve couples; their studies do not show an increase in infertility from 1965 to 1982. The infertility experts claim the figure to be one in six or seven couples (Raymond 29).

The definition of infertility has gone from the inability to conceive after 5 years of unprotected sex to 1 year. (Now it can be called the inability to conceive quickly). The portrayal of infertility in the media is deceptive; a large percentage of the women who undergo IVF have had children in the past with a different partner, many go through it because of their spouse’s infertility, not their own, (estimates claim the percentage to be 25%). Many infertility experts never even test the husband’s sperm because they are reluctant to be tested (Raymond 29).

IVF once seen as a way out technology is now the most conservative when compared to what has grown from the initial getting the sperm and the egg together in a petri dish. Frozen embryos, embryo transfer from one woman to another, sex determination, and use in genetic experimentation and manipulation have surpassed IVF (Raymond 29,30).

Many of the women undergo IVF several times (some as many as 10); the average cost per cycle is $5,000. A large number of the IVF centers are for-profit as they are not federally funded, they must depend upon funds from universities, hospitals, drug companies, private organizations (often from venture capital) and patients. There is a real entrepreneurial spirit among infertility doctors. Doctors at the Northern Nevada Center say it will become a $6 billion a year business. Researchers showed in 1985 that half the clinics reporting success never actually had a live birth. Some claimed success by relating the number of implantations that never followed to a birth or used the number of women whose hormone levels became positive but did not necessarily mean they had an intact pregnancy. A congressional subcommittee reported in 1989 that the rate for taking home babies was 9%, but many of the clinics do not include live births in their numbers (Raymond 30).

The number of healthy babies born is another hidden statistic. There are reports citing increases in premature births, low birth weights, more birth defects, and four times higher mortality rates among IVF babies. (Raymond 30). We cannot afford to trust an industry that is using us as experimental victims and also making big profits for doing so. This is highly unethical behavior.    

Believe it or not the industry has used its very failures to justify developing more technologies. The problem of multiple fetuses caused by superovulation and multiple implantations has led to the need to justify aborting some of the fetuses, known as selective termination. It’s not just that it leads to some of the fetuses being discarded, but the procedure where doctors inject saline into the uterus to dispel some of the fetuses can cause bleeding, premature labor to the mother and loss of or damage to all the fetuses (Raymond 30). I would not at all be surprised if these same infertility experts were on conservative band wagons damning poor women for daring to seek abortions.

I agree with Raymond that IVF is being used as tool to perpetrate violence against women with society’s sanction in the name of medicine. Hyperstimulation of the ovaries and cysts frequently are the result of the superovulation required to obtain numerous ovum required to do IVF, to say nothing of the pain and trauma that are perceived as technical imperfections by the experts (Raymond 30).

An Australian female student observed a vaginal harvesting of eggs, done in full view of a medical school class. “At each follicle puncture he (the doctor) retracted the needle and then drove it in hard. The woman asked him to stop, because she was in great pain. But Dr. M. would have none of that…and so (more) follicles were punctured against her will…again each puncture unmistakably resembled a penetration” (Raymond 32).

Technical reproduction should not be included in the pro-choice platform because it doesn’t really promote women’s rights. Feminists have been accused of undermining reproductive rights, by being opposed to technology; the opposite is actually true. The new technologies favor the fetus’s and the potential father’s rights, but challenges the most basis rights of the mother. As technology takes the fetus from the mother’s body more and more so will it diminish the woman’s rights (Raymond 32).

Whose rights are valued in the case of India where 80,000 female fetuses were aborted within a five-year period ending in 1983 after undergoing amniocentesis to determine the sex of the child? (Raymond 32). Somehow, I know that the mothers are not willingly asking for the amniocentesis to avoid having daughters. The language used in the new reproductive technologies are illustrative of the desire to control and blame women when the product (a baby) is not forthcoming. The very term infertile gets public sympathy and support for technology. Doctors and medical researchers distance themselves from women when they say that they “harvest” eggs from the “uterine environment” or that the uterine environment was “hostile” when an IVF attempt did not implant – the person disappears. The hormones used to make a woman give out multiple ovums for IVF sometimes lead to implantation of quintuplets, doctors blame the woman and call what happened her having an atypical response or an inappropriate response to the drugs (hormones), rather than researching the drugs themselves. There is even a new technique that will “allow” a woman to be a “human incubator” for her own eggs (Rowland 38).

Some other language includes, “endocrinological environments”, “alternative reproductive vehicles”, “surrogate uteruses”, “in vitro ovary” and The American Fertility Society discussed women in an ethics report as “therapeutic modalities.” Terms used with surrogacy are: “host womb”, “gestational surrogate”, “gestational mother,” “host mother,” “agent of gestation,” “total surrogacy,” “partial surrogacy,” (as if a mother could do a half way job of carrying a pregnancy), this type of referencing takes away from the mother’s status in lieu of the genetic donor, the fetus is made somehow personal by referring to it as the “gestation of choice”. When women get used to being viewed as incubators they are dehumanized (Rowland 38,39,40).

A physician from Columbia University expressed irritation that medicine had to go along with a woman’s body rhythms, “It means you have to be available at the right time: you have to be a prisoner of that woman’s cervical mucous and her ovulation time” (Rowland 40). 

Medical texts describe the normal menopausal state of the ovaries as “unresponsive” or say that they have “regressed” or even “senile” (Rowland 38). I recently watched “Lifetime Medical Television” (a show for doctors only); I heard obstetricians talk about “controlling” the blood pressure despite the widespread non-compliance of the women. When asked how they decided whether or not to “control” a patient’s blood pressure at home or in the hospital, one doctor said, “when they are at home they can get up and walk around and do as they please, but in the hospital you have them as a “captive audience.” I heard them explain to one another how they decided when to “deliver” as if the mother had nothing to do with it. I HEARD them differently than before – I now realize they had been saying those type of things all along. We HEAR differently with our consciousness raised.

One last language tid-bit, the word obstetrician has its root in Latin and means, “to stand in the way”. (Rowland 41).  

Paternalism

There is much debate lately in non-feminist ethics about less paternalism in health care. Physicians have traditionally treated as they saw fit, patient consent was treated as a formality. There is pressure growing to halt this clash between autonomy and beneficence (Sherwin 137).

Traditional theorists assume patients are not always rational and don’t always act in their own best interests. They see autonomy as a concept built to establish self-rule within a conceptual framework structured around dominance relations (Sherwin 137).

Paternalism refers to the widespread practice in which doctors make decisions for patients, without their full understanding or consent. The basis of the decision is the patient’s best interest. Whether or not it brings about the best consequences is questionable because it is the physician’s perception of good, not the patients. It is an infringement on patient’s autonomy, usually thought justified only when the patient is incapable of making decisions. Feminism teaches us that we may be mistaken to assume a powerful, authoritarian father (like the role the doctor plays) will always act in the best interests of his wife and children. The power in this type or arrangement easily abused (Sherwin 139).

The fact that the patient is in need of care means he or she is vulnerable, weak, and frightened. Many doctors still believe it’s their privilege and responsibility to make decisions for patients; medical ethics decides what circumstances justify paternalism. Paternalism supporters claim: illness compromises reason, decisions can only be made by one with technical knowledge – the doctor, the patient’s belief in the doctor’s mystified power is vital, and must be done in a confident authoritative manner (Sherwin 140).

Patients & Reasoning

Women are patients far more often than men and are usually the ones who bring others to the doctor and are the ones to speak on their behalf. Women have heightened contacts with the medical institution; their oppressed status requires us to pay special attention to ways in which paternalism contributes to their disempowerment (Sherwin 141).

The status of a patient is feminine – they are expected to submit gracefully to the powerful rational authority. Paternalism mirrors and strengthens attitudes that support domination of what is perceived as female (Sherwin 141).     

“Reason” has been used as an ideological tool by those in power to serve political purposes. Changing normative concepts of reason play an integral part in politics of dominance. Reason has political power, it’s a mistake to accept unqualified appeals to the quality of someone’s reasoning ability without also assessing whose interests are being served. Because of the roles men and women play in health care, it’s important to reflect on ways in which gendered assumptions about reason have infected the norms of medical practice (Sherwin 141).

There certainly are some conditions that do cloud a patient’s reasoning ability: high fevers, serious accidents or neurological disorders. However, many interactions between women and doctors are not about illness; the medicalization of her normal reproductive cycle has been brought under medical control. Healthy women see doctors for contraceptives and for monitoring pregnancies. Even when women bring others to see physicians and are not themselves sick, they may still be dismissed as incapable of making decisions (Sherwin 142).

The fear of illness distorting reason, and increasing dependence is affected by the fear itself, and is sometimes magnified by the medical community itself. There are documented cases where doctors manipulated women into having hysterectomies by using the fear that “it” may return; “it” was the presence of pre-cancerous cells, NOT CANCER cells on a Pap smear. By mystifying and assuming its too complex doctors use medical information as a weapon that encourages dependency and fear. The power of the healer is maintained by fear rather than strength. If it is the case that fear really clouds reasoning ability, then open honest communication by the physician could do a lot to prevent fear that impedes reasoning (Sherwin 143).

How can we rely on the objective decisions from doctors when many hold stereotypes about women that they are irrational or stupid (especially minority women)? (Sherwin 143).

A second condition must be present for a doctor to make a decision for a patient, there must be a reasonable probability of harm. When patients truly are not able to make their own decisions, their needs can be addressed by someone who will be able to make decisions for them that go along with the patient’s values and interests. Doctors see themselves in this role as their scientific outlook makes them objective and knowledgeable. Feminists say scientific knowledge does not guarantee objectivity, nor is objectivity the big concern – Caring would be better. Most physicians are trained with an orientation to science over humanistic care, they may be especially bad in this role (Sherwin 144). 

Sherwin suggests we explore means of revising the patient-physician relationship to seek ways of empowering those who are not able to assert their own will (Sherwin 144).

Medicine & Science

The authoritarian medical model assumes that only doctors have skills and capacities to make decisions. Patients, and their guardians, are too uneducated, too emotionally distraught, or too stupid in the face of illness to make decisions. Other health professionals have only partial training, without complete training (and supervision) a little knowledge is thought to be dangerous (Sherwin 145).

The evolution of specialized fields has resulted in one doctor not being able to make decisions outside of his specialty. Doctors committed to technology, have learned to trust instruments rather than their own assessments or their patient’s reports. Labs take precedence over (patients) subjective symptoms. This type of environment is alienating and intimidates patients. Medicine has narrowed its focus to objectively measurable symptoms rather than a holistic look at a person. As a consequence, doctors don’t give TLC (tender loving care) (Sherwin 146).

TLC is viewed as feminine and has been devalued in health care. As a nurse who believes wholeheartedly in the actual healing power of TLC, I believe that without it there cannot be true healing. I HAVE included TLC while giving emergency care to patients experiencing a heart attack. The two concepts, healing via technical knowledge and caring enhance one another and give each other more power. The patient gains power within himself to aid healing when he is treated humanely; it boosts self his esteem and can lead to more positive thinking which is known to help us heal.    

Technical measures lend an aura of objective truth to the findings in medicine. This science supports doctors claims to dominance over health care workers and patients. It is unclear how much of their judgement rests on a scientific foundation. There is a great deal of intuitive reasoning and uncertainty involved in medical practice today, in addition to scientific facts. In claiming authority medicine presumes a degree of authority inappropriate to its level of knowledge (Sherwin 147).

Nurses certainly develop intuitive reasoning experientially, but it is not valued or taken seriously by physicians and some patients.

       Medical science is not infallible. The “scientific objectivity” of medicine tends only to observe what it looks for and what it expects to see. Many women have long complained of menstrual cramps, nausea in pregnancy, labor pain and infantile colic, these were declared psychological, and not organically possible because their existence was denied (Sherwin 147).

Mystifying, exclusionary language helps to defend its hierarchical structures and discourages challenges. Science accepts only a narrow sense of reason and knowledge, knowledge of personal experience is subjective, so it’s unreliable. Knowledge belonging to patients, who are mostly women, is discredited (Sherwin 147).

Science is far from objective. As an institution it reflects and supports interests and ideologies of dominant societal groups. It is NOT a neutral social instrument; it continues the oppression of women (Sherwin 148).  

Doctors cannot claim privilege in decision making because of scientific knowledge, it’s only one aspect of data required for decision making. The right treatment for a patient is not simply a scientific matter. Expertise in science makes doctors qualified to provide information to people trying to make health related decisions, but it does not license them to make their decision (Sherwin 148).

Paternalism & Trust?

The third argument is that a doctor’s authority is essential to healing. A patient’s belief in their doctor does seem to help them heal (Sherwin 148). I have seen that (and empirical studies have shown) that the placebo effect (a patient’s belief in a sugar pill will help him), is known to be powerful physically and psychologically.

This does not mean that the patient must be kept in the dark or that he should be kept dependent. Much evidence shows that patients who actively are involved in their care do much better (Sherwin 148-149).

Nursing’s goals are opposite from those of physicians – our goal is independence. Nurses goals are for patients to take care of themselves, to be in control with knowledge and confidence.

If patient’s having confidence in their healer is to work then the relationship must be based on trust. Faith that patients put in doctors to heal them should not come out of blind trust. Sherwin discusses a moral test for trust relationships: “they be able to survive awareness by each party to the relationship of what the other relies on in the first to ensure their continued trustworthiness or trustingness” (Sherwin 149).

Patients, especially female patients, have reason to be suspicious about the trust in their relationships with physicians. If patients sought to learn what their doctors rely on to ensure continued trust, it is unlikely that using the above definition a trust relationship would be sustained (Sherwin 149).

Women have different roles and experience with the health care system than men. Women are the major health care consumers and are a majority of the workers in heath care; men however, hold the positions of power. The model is based on a powerful paternalistic authoritarian directing subordinates in the treatment of (ideally) compliant, passive patients. These patterns of dominance mirror and reinforce social expectations of men as authorities and women as servants who follow through, but do not initiate treatment (Sherwin 149).

Gender imbalance in health care encourages doctors to accept the social attitudes about women and illness. In medical literature organic diseases have used male patients as their model and feminine models for mental diseases and with symptoms that cannot be answered organically. You can believe men’s symptoms of disease, but women are high strung. Ads for medications use men with pain relief and women with tranquilizers. Women are portrayed as weak and in need of calming. Gender is not the only stereotype used in dominance relations in medicine: race, class, ethnicity, sexual orientation, age and degrees of disability also affect whether or not the doctor accepts your report at face value (Sherwin 150).

Historically doctors have used whatever means was most salient at the time to ensure their monopoly over health care. Before the late 19th century physicians had to compete with other healers: wise women, midwives, quacks, sectarians and bonesetters. The 15th and 16th centuries illustrate the worst medical hostility that was combined with church-based misogyny. It fostered mass murders of alternative healers (mostly women) under the guise of witchcraft. During these times in history there was no interest in caring for women and children, they concentrated on middle-aged and elderly men. Their sought to maintain dominance by caring for those who were highly valued in society. The care of women was left to a widespread network of women’s culture (Sherwin 150). Interesting that we still have an underground network of women who educate each other about their health (see page 49).

In the latter half of the 19th century competition was fierce and doctors saw that a large market of their services was women; if they got this market, they had access to the other family members, so they focused on women, especially services involved in pregnancy and worked to get rid of access to other providers. They succeeded in getting a monopoly in health care and drove other health workers into subservient positions that required them to practice under the eyes of physicians. They lobbied for legislation to get control over women’s fertility and cut women off from abortion and contraceptive services. This control over women’s bodies improved their economic, social and political positions; the benefits to women are unclear (Sherwin 151).

By defining what is “normal” and healthy for women, doctors ensure women’s dependence. It continues today as evidenced by the new reproductive technologies. Today’s competition is severe among profit seeking hospitals. One of their strategies has been marketing to women with women’s health centers. Because women are the medical gatekeepers in most families, if an institution gets her loyalty, they will thus have access to the rest of her family – just like they did in the late 19th century (Sherwin 151). Being the subject of medical attention is not necessarily good for women. Dangerous and unneeded procedures have been carried out on women at terrifying rates. More surgical interventions in childbirth has led to increased mortality rates. There have been excessive numbers of surgeries on female organs. All women with breast cancer were subjected to radical mastectomies without scientific evidence that they were needed to increase survival (Sherwin 151).

A six-year study of communication patterns and structures of decision making between doctors and female patients, found that many more hysterectomies were recommended than were actually needed; this reflects an attitude that if reproduction capacity has ended, then the uterus is a dangerous organ and is best removed. A quote from a major gynecological text,

“Menstruation is a nuisance to most women and if this can be abolished without impairing ovarian function, it would probably be a blessing not only to the women but to her husband” (Sherwin 152).  There has not been a corresponding trend to remove cancerous testicles or prostate glands from men, as routine when reproduction is completed, despite their serious health threat (Sherwin 152). 

In mental illness, women are treated more aggressively and frequently than men. Behavior perceived as healthy for adults is seem as pathological for women. Psychiatrists have found a great deal of normal female behaviors, lesbianism, political resistance and not wanting children, as unhealthy. Women who seek support after sustaining injuries and psychological distress from battering, rape, sexual harassment, incest or racism are commonly treated with tranquilizers (or worse) to help them adjust to their situations. Women are twice as likely as men to be prescribed psychotropic drugs (Sherwin 152).

So, it is clear that when women seek treatment for conditions unique to women, they definitely risk harm instead of help. Paternalism encourages patients to trust and not question medical authority; it should not be accepted as common medical practice (Sherwin 153).     

Feminist Views

If particular situations are known to compromise one’s ability to reason doctors should seek to minimize these effects. They should help to mitigate the effects of diminished capacity by fostering a decision-making process sensitive to the patient’s overall interests. Medicine should be directed at maximizing a patient’s ability to make reasonable informed decisions. When paternalistic interventions are truly needed it should come from someone who can be counted on to give back authority to the patient as soon as possible – usually this person is not the doctor (Sherwin 154).

Physicians should earn trust – it should not be assumed. Trust is built through sharing information, particularly the medical knowledge that might bear on the patient’s expectations and deliberations. In the medical context, earning trust requires that the physician respect the decision-making authority of the PATIENT. An open health care process should include the patient in decision making and is more likely to get results that are in the best interest of the patient (Sherwin 154).

Most bioethicists recognize that doctors have technical knowledge essential to decision making, but they lack other kinds of knowledge needed to make decisions about a particular patient’s needs. They are not expert to the centrally relevant knowledge of each patient’s distress, values or coping strategies. Medical training does NOT provide them with knowledge about the social context in which the patient’s needs for health care arise (Sherwin 154).

Feminists and non-feminist colleagues in bioethics can agree and insist that physicians tell patients the information they need to make their own decisions. Most do not need technical terms or biochemical theories, they need to know what treatment is recommended and why, what their options are, and the consequences of each that are likely, what risks involved of treatment and of declining treatment that would likely be (Sherwin 155).

If physicians were to receive training in communication skills, they would be better equipped to give patients information and patients would have the information needed so that paternalism could be discarded. There is a danger however, that if doctors knew more about communication skills they would be even better at paternalism because it would aid them in manipulating patients and thus strengthen paternalism. Feminists demand an ideological change in doctor-patient relations. Physician’s knowledge is distorted by their own biased expectations and those of the scientists that they learn from (Sherwin 155).

Communication involves at least 2 parties. Ethicists should be concerned with the role of each participant when examining relationships between patients and doctors. Feminist ethics recommends that we not only advise physicians about how they should behave but also put priority on helping patients obtain information they need and to learn how to weigh and interpret the medical advice they receive (Sherwin 155).

This is what I want to help patients to do. I have called it helping them with their ethical needs. We have not used the term “ethical needs” but I am starting it because I see a need to help patients with taking control over their own “ethics of health care”. We have long used terms like social needs, sexual needs, biological needs, spiritual needs, why not ethical needs? Why not help patients say for themselves what their moral needs are? We may find, if we ask them, answers that could facilitate changing the system to meet their needs. They may tell us how we can meet their ethical needs.

In traditional approaches, when sources of potential physician biases are uncovered, the conclusion is to reject paternalism and go to autonomy. Many feminists are not comfortable with autonomy as an alternative. The concept of autonomy carries too many associations of isolation and independence to capture feminist conceptions of agency. In its place we could explore more of the relational concepts that different feminists have purposed, which might support the agency of patients without abandoning them to their rights (Sherwin 155-156). I agree with Sherwin that a feminist, relational, contextual, perspective that includes the patient’s voice would be helpful in empowering patients.

Sherwin discusses “autokoenony” which stands for “the self in the community”; it captures a sense of being free from dominance without suggesting self-domination. Autokoenony refers to: “a self who is both elemental and related, who has a sense of herself making choices within a context created by community”. (Sherwin 156).  An autokoenonous person interacts with others and makes decisions in consideration of her own place and of others in the community. In the medical setting it suggests an understanding that patients exist in a social world, where their ends and activities are defined in conjunction with others they trust. It’s a more realistic perspective of patients choosing in the company of others who help shape their lives. When patients are confronted with difficult decisions, physicians and patients might include others trusted by the patient to be included in the decision-making process. When patients are isolated, and have no others that they can trust, they could be helped to form relationships that could foster their decision making in an interactive way. Self help groups of patients with a common condition, for instance, usually provide patients with an opportunity to explore the complexities of their decisions in a nonhierarchical environment (Sherwin 156). The type of environment I have in mind.

The ethical question is not autonomy versus paternalism, it’s a question of how to strengthen the patient’s agency, how to help her make decisions that will serve her. It requires radical rethinking (just what I am in the process of doing) of the physician-patient relationship and development of improved patterns of communication and mutual respect (Sherwin 156).

Hopefully if patients can come to a place and talk, get information along with encouragement and support they will then go back to their physicians and demand control of their health care. We must demand respect from those in power – they will not GIVE it to us.

How about inventing a practice “amicalism”, built on a model of friendship? The intention would be to enlist friends or family in decision making, rather than treating medical choice like a contest between an isolated patient and a physician. When patients feel unable to make decisions on their own (or they are incompetent) they could be helped to communicate with others they trust – who have already demonstrated a commitment to them as individuals (Sherwin 157).  The health information centers could be a place where the whole family could come to talk about a health care decision.  

Research

Feminists are concerned about how the subject population is selected and what measures are used to obtain informed consent. In non-feminist bioethics, the ethical questions center on matters of participation and consent. Who can be asked to participate? What about subjects who cannot consent? What limits exist about the degree of risk they will be exposed to? What is legitimate research? What about the degree of spending (Sherwin 159)?

Feminist ask: How are topics chosen? Which issues are investigated and which ignored? Whose interests are served and whose are ignored? Who controls research conditions? Whom are researchers accountable to? Recognizing that patterns of oppression extend into medicine, feminists take a special interest in research done on women. Their study of women’s health care leads them to question what guidelines determine whether procedures are experimental or established. They recommend models of the subject-investigator relationship that differ from conceptions that govern most research practices (Sherwin 159).

Research & Oppression 

The central question is, what constraints should govern the use of human subjects. In double blind studies neither the investigator nor the subject knows whether the patient receives the treatment or the placebo. There is a risk that her condition could get worse either because she’s not getting the treatment or the treatment itself is dangerous. The general principle common to ethical debates is the subject must freely choose to participate. Women constitute a special consideration in research because women’s oppression consists in the subordination of women’s interests to those of others – be wary of any proposal to use women’s services for some greater social good. Women’s relatively powerless role in society and their disproportionate use of medical interactions makes them especially vulnerable. Researchers should be required to take special precautions against exploitation of women. We need ethical guidelines to govern women’s participation in medical research (Sherwin 161).  

Evidence reveals that we should be worried about research on women. Researchers have always been inclined to use as subjects those who are less valued in the society: prisoners, elderly, disabled, institutionalized, and the poor. Women, as an oppressed population, are considered expendable, making them candidates for risk exposure (Sherwin 161).

A former director of the public health department in Oak Park, IL, claimed that women were the best guinea pigs; they take the Pill with no questions asked, they pay for the right to take it and as experimental animals go, they are the only ones who feed themselves and clean up after themselves (Mendelsohn 35).

Patriarchy devalues women when they are no longer able to fulfill their childbearing role; women in post-operative surgical wards are vulnerable to multiple exploitation. Sherwin relates a case where researchers, in 1964, at a Jewish Chronic Disease Hospital, used 22 residents without their consent in a cancer study. They deliberately refrained from telling patients that they were being injected with cancer cells knowing no one would accept them – the patients were debilitated (600 others from prior trials had also been used) (Sherwin 162). Sherwin quoted Katz, “for two years we have been doing the tests routinely on all postoperative patients on our gynecological service” (Sherwin 163). These post-op patients were uninformed and non consenting. Bioethicists have debated research on prisoners and ill patients, but neglect to address what was routinely done to “healthy” gynecological patients (Sherwin 163).

Oppressed people are in coercive environments that leave them vulnerable to be exploited in research. Women should not be subjects of research that will not benefit women. If being female (black, disabled, poor) is not relevant to a study then don’t use them (Sherwin 165).

Women as Subjects

Most research that affects men and women is done on men; the results are then used as the norm. Expecting that women will respond differently than men, they leave women out to avoid “distorting” the data. We lack adequate information on how to treat women with heart disease or cancer. We understudy diseases affecting blacks, disabled, and Native Americans. It is of serious moral concern that doctors do not have information on diseases in these groups (Sherwin 166).

Data with research done on middle-aged white men is abundant in medical libraries. (Even research on rats excludes females). Where medicine like aspirin is concerned, physicians are left to make their best guess about whether it will help prevent coronary artery disease in women because no women were included in the studies. (Apparently the fact that heart disease is the number 1 killer of women means nothing) (Cotton 1049).

The same holds true for drugs like beta blockers and antidepressants. It holds true despite the fact that over the past 10 years much evidence has surfaced about the importance of how different drugs effect women, the elderly and racial minorities (Cotton 1049).

The National Institutes of Health (NIH), The Food And Drug Administration (FDA) and The Pharmaceutical Manufacturers Association claim that the issue is being looked into, however, no changes have been noted in research habits (Cotton 1049).

The Congressional Caucus on Women’s Issues has asked the General Accounting Office in Washington, DC., for proof that the NIH is including oppressed groups in their studies, as their policy dictates (Cotton 1049). 

A spokesman for the FDA says if rules are too strict they get in the way of research designs and it leads to drug companies dropping a study because it’s too expensive. He says rules to include the elderly are a waste of time because the drug companies know what they need to do, but they have no figures to illustrate that. A spokesman from the Pharmaceutical Manufacturers, Lionel Edwards MD, (chair of their Special Populations Committee) said that studies could be sub grouped to death and they would never get the new products out (Cotton 1049).

According to Michelle Harrison, MD, assistant professor of psychiatry at University of Pittsburgh, one thing that seems to get in the way of researchers using women is their menstrual cycles and pregnancy. We do however, USE these drugs on those with the confounding factors (Cotton 1049-1050).

Jean Hamilton, MD, Director of the Institute for Research on Women’s Health says that we frequently “stumble” onto information and that information is only the beginning of what we need to learn. Jerry Avorn, MD, a geriatrician and associate professor of social medicine at Harvard university Medical School says that the idea that white males present fewer confounding factors to researchers is made because white men run the country (Cotton 1050).

The common excuse for excluding women, teratogenic liability, can only be resolved through legislation. As more and more women are involved as researchers the menstrual cycle will cease to be a confounding problem (Cotton 1050).

Anne Willoughby, MD, MPH, chief of the pediatric, adolescent and maternal AIDS branch at the NIH’s, National Institute of Child Health and Human Development, says,

“We have to anticipate the barriers and address them aggressively up front”, (Cotton 1050) referring to the needs that must be addressed if we are going to use women in research. Needs like transportation and child care must be taken into consideration if women are to be involved in research (Cotton 1050).  

A New Zealand study in 1966, sought to prove the assumption that early signs of abnormal cell changes in cervix were unlikely to lead to cervical cancer. The researcher did not offer regular treatment to women diagnosed pre-cancerous; they were also denied relevant information about treatment options. No consent was obtained, but they were monitored and subjected to repeated invasive exams to establish “natural history of carcinoma in situ”. Over 20 years, 30 women died of cervical cancer and a variety of other health problems. The untreated had vastly higher rates of invasive cancer and death than those treated. Many in the medical community knew and disapproved of the study, but it wasn’t stopped until women mounted political pressure to force a public inquiry. Absence of political pressure in the medical community illustrates their willingness to tolerate needless death and suffering of women rather than restrict academic freedom of one of their own (Sherwin 166).

For decades radical amputation was the treatment for any evidence of cancer or even prospect of cancer in a woman’s reproductive organs. (Even if they only suspected it might develop). Only recently have studies been done to evaluate the effect of these “therapies” (Sherwin 166-167). 

Most medical research that has been done on women has centered on their reproductive functions – why? Much of the research done on oppressed groups seeks to find differences between oppressed groups and dominant ones, but little to meet the needs of the oppressed groups. By centering their efforts on having control of reproductive functions, researchers reflect a view of women defined in terms of their reproductive function. The research community and those who fund it thus perpetrate the oppression of women (Sherwin 167).

The earliest tests on the “Pill” were done on poor uneducated women in Puerto Rico and Mexico. Drug companies chose to avoid the limits of human-subject research in the West by going to underdeveloped nations (Sherwin 168).

Experimental treatments are monitored strictly, but established treatments are not. Patients think if they are not specifically asked to be involved in a research study that they are getting established treatment – this is often wrong. A fine, permeable line separates established from experimental in women’s health care (Sherwin 168).

Millions of women have used contraceptive devices and drugs they thought were tested and safe, but thorough testing had not been done on the Dalkon Shield. The Pill was marketed for 10 years before federal hearings on safety revealed risks and hazards of long-term use (Sherwin 169).

This failure to distinguish between research and therapy is found with infertility treatment too. Despite serious side effects and possible death adequate testing is overlooked before drugs are given as routine therapy. Fertility clinics all over the world are offering therapies that are expensive, dangerous, painful, traumatizing, even life threatening and for the most part unsuccessful; they experimented with techniques without saying they were researching them, thus leaving them not being subject to ethical scrutiny. Despite high failure rates with in vitro fertilization, it is seen as an established therapy. By tolerating the blurring of these boundary lines, they are limiting woman’s ability to make informed decisions about taking part in data collection for new means of controlling fertility (Sherwin 169).

Women’s need to control their fertility makes them especially vulnerable. The contraception and fertility industries are VERY profitable. Women’s powerless position in society makes it important that we guard against exploitation from pharmaceutical companies. Patients must be informed when we don’t know the long-term effects of drugs. The political implications of research should not be overlooked during ethical review (Sherwin 170).

Research & Organization

In research nature is objectified and scientific knowledge pursued so that it can be exploited and controlled. The knower is distinct from and dominant over what is known (Sherwin 170).

Feminists suggest a new scientific model – close the gap between the self and research object, by identifying with the biological material forming an emotional bond. To see what is missed by others using the standard scientific model, with distance between researcher and object. Get a feeling for the organism and learn to listen to the material – a model that connects the knower with the known (Sherwin 171).

Science projects an image of dispassionate objectivity and a search for truth. Science is an expensive, competitive institution; researchers do projects that they can obtain funding for. They need to attract grant money and get results and are inclined to shape research to objectives of funding sources. Projects are tied to interests of those with money and power to support the research. Much research is funded by the defense department with military interests. Much of the research in health care is funded by drug companies or the biotechnological industry. Even public money reflects the political clout of special interests. Despite knowledge that cancer prevention promises to save more lives than treatment, more money is spent on cure – it will bring more profit to industry and the latter threatens to reduce profits (Sherwin 171).

Biotechnology promises fame and prestige to doctors, scientists, and corporations involved and is a product for export. Sherwin says a doctor with a private in vitro facility in the U.S. could eventually generate 6 billion dollars a year (Sherwin 172)! This makes prevention of infertility unprofitable.

Western culture expects and celebrates technological solutions. Careers and institutional reputations are made on break throughs, and big profits go to innovators. Many forces lead to there being a market for high technology. There is little support for less dramatic, less-rewarding work with prevention and management of disease (Sherwin 172).

Medical research speaks of wars against cancer and heart disease, but they are not finding ways to avoid the battle. We hear of the demand for a cure for AIDS, but why not how to avoid or respond to the secondary infections that AIDS patients usually die from? Research for technology is readily funded and when successful, readily put into use. No where in the research phase do, they measure the implications for the new discoveries in the overall distribution of resources. We now have public hospitals with tons of technology, but having to close beds because they do not have money to pay their staff (Sherwin 172).

Technology is expensive and is available only in developed countries (and perhaps only to the wealthy). Western attention on technology has led to our abandoning responsibility for the health needs of under developed countries and the poor at home. Research leads to changes in health policy, there should be a way to review and anticipate the affects of it because once available it is irresistible (Sherwin 172).

The first large study on women with AIDS, by the government sponsored ACTG protocol 076, is to focus on pregnant women of color. African American and Latino women who have been affected the most by AIDS would like the right to decide for themselves whether or not to risk being in the study, but due to a federal requirement the fetuses FATHER must give approval for the woman to be part of the study. The National Institute of Allergy and Infectious Diseases claims that local boards can try to find loopholes, but that the 1975 rule is mandatory (Byron 95). Here the male government, the male father of the fetus and the male research establishment combine forces to maintain a women’s control over her own body.

Illness Labels

“one of the most characteristic and ubiquitous features of the world as experienced by oppressed people is the double bind—situations in which options are reduced to a very few and all of them expose one to penalty, censure or deprivation” (Sherwin 179). Medical authorities have created this for women by characterizing as pathological various bodily and mental states typical for women. Men have set the norms of health and illness and have given themselves control over their manipulation. Their viewing menstruation, pregnancy, menopause, body size, and feminine behavior as diseases is an integral part of women’s oppression. Defining ordinary female experiences as pathological justifies treating them. Their wide scale management is seen as beneficent (Sherwin 179).

Moral critiques of excessive medicalization do not imply that all menstruation, pregnancy etc are healthy, medical experts certainly do have therapies to help women (Sherwin 180).

History of Menstruation as Illness

As medicine grew in the mid-nineteenth century, gynecology evolved into a distinct specialty. The fashion at that time said that women were disabled during menstruation and the week before and recommended that they refrain from regular activities at these times. Scientific evidence claimed that the uterus competed with the brain for energy and blood, making it necessary for women to refrain from serious mental or intellectual work – it may harm them. By the end of the nineteenth century doctors led the crusade to get women out of the universities and the suffrage movement that brought them into politics (Sherwin 181). With the change in economic needs came a need for women to work, medical authorities revised their advice and said it was helpful for women to be very active during menstruation (Sherwin 182).

Premenstrual Syndrome

In 1931, Robert T. Frank is credited with labeling the week before menstruation as a sick time for women. He was concerned about a woman’s ability to work during this time and coined the term “premenstrual tension”. This was his way of saying just how pathological he saw this time of the month and wanted women to be excused from work during this time. This was convenient to the times in that women were supposed to be giving up their jobs to men because of the Depression and the war being over. World war II’s need for women in the work force miraculously brought another change in the prescription for premenstrual women when they again were needed in the work force (Sherwin 181).

Premenstrual Syndrome (PMS) was recently added to American Psychiatric Association’s official diagnostic list (Sherwin 180).

Katharina Dalton, a physician who saw herself as a sufferer from PMS, widely publicized the broad range of symptoms we now know as PMS. She claimed it to be a hormone deficiency and thought it should be treated by replacement. She said women can’t work properly at those times, were more accident prone, and are so crabby that they even make their husbands less efficient at these times. This was affecting our economy with the number of lost work days and it made PMS a “public” and a “private” threat (Sherwin 184).

There are at least 150 symptoms related to PMS without medical agreement on which should be included, about etiology or about treatment, yet it is seen as a real illness worthy of medical intervention. (The medical community does widely reject Dalton’s suggestion of hormone therapy) (Sherwin 184).

In the late 1970’s, coincidentally when feminism showed its face again, women went back to the work force en mass. Women are now demonstrating their abilities in fields previously thought of as only male allowing menstruation to be seen as a real liability for women. Doctors gladly offer evidence to maintain the claim that menstruation is an illness that gets in women’s way of their being able to compete. Males again use it as a weapon against us being equal (Sherwin 184).

Sherwin quotes Zita in her summarization of the medical perspective on PMS as a disease, “the codification of symptoms results in the morbidification of a sex difference which renders all women inherently disadvantaged in a man’s world”. (Sherwin 185). So, what ends up happening is that PMS functions politically in justifying and making sense of women’s economic and politically oppressed status (Sherwin 185).

PMS

Some women find positive validation with the labeling of PMS because in the past their symptoms had been trivialized. Many find relief offered in the women’s self-help press, others seek medical intervention. The fact that this labeling has helped some women is apparent, but feminists are ambivalent about it (Sherwin 197).

Some of the symptoms of PMS are behavioral. These behavioral symptoms don’t fit the norm of female passivity. They are less able to tolerate discipline, and monotony in their lives. They become irritable, depressed and angry at constraints in their lives. Perhaps these details in their lives that women hate are due to their subordinate status. Feminists would not see this anger as negative. PMS may be a social manifestation of rage about oppression (Sherwin 184).

Amenorrhea as Illness

Now that we know that we are diseased if we menstruate, we must also face the fact that if we don’t menstruate, we are also seen as “ill”. Some of the symptoms of PMS have been discovered in females too young or too old to menstruate and women who have had hysterectomies have had the worst symptoms. Some feminist theorists think that cyclicity itself is perceived as a problem in Western culture (Sherwin 185).  

Menstruation is seen as a problematic medical event. Sherwin discusses Martin who documented the ways that textbooks make negative references to menopause; the ovaries become “unresponsive” and start to “regress”. The hypothalamus gives inappropriate commands. Other words used in reference to female organs at this time of life are: faltering, withering and senile (Sherwin 185).

The World Health Organization recently defined menopause as an “estrogen deficiency disease” and thus requires major life changes for the woman. Many physicians prescribe hormone replacement. They claim that it will prevent osteoporosis, heart disease and the vaginal drying that occurs after menopause (Sherwin 186).

There are serious side effects involved with artificial hormone replacement. On Prime Time Live January 28, 1993, Diane Sawyer asked Bernadine Healy whether women should use hormone replacement after menopause. She said that we can’t tell whether they should or not, studies show that it will benefit their bones and heart, but there is worrisome information about them increasing a woman’s risk for cancer. She regrets and feels that it is unacceptable that we don’t have the answer for that. She said that we should and will do research on how to prevent heart and bone disease in women. The Women’s Health Initiative has appropriated $625,000 to study the effects of hormone replacement and vitamins on port-menopausal women (Healy, Prime Time Live).

I think that prevention is more cost effective economically, and in the emotional toll it takes on patients.

In a discussion of feminist ethics with Carol Krohm MD, she told me that what really infuriated her was she recently heard 2 male obstetrical\gynecological doctors talking about how they are going to start adding male hormones (androgens\testosterone) to female hormones given to post-menopausal women. They said there was a need to give it to them because of their complaints of decreased libido. Dr. Krohm said that she doesn’t believe that, she says the problem is probably the opposite – it’s the men who can’t get it up at that age who are the problem. She says if the women are not interested in sex after menopause it’s probably because they are so angry at having to put up with the men all those years (Krohm 92).

Mendelsohn says that women have been convinced that they need an annual Pap smear which he says is not necessary. The test results are frequently inaccurate and their main purpose is to keep gynecologists rich and busy. He says that if the results show the slightest change the women will be advised to have a hysterectomy. (In case there are any bad cells hanging around her uterus). While they’re in there they will also remove her tubes and ovaries, then she will need hormone replacement which will then possibly lead to her getting breast cancer. To say nothing of the pursuant sexual changes that may lead her to a psychiatrist. The surgeon who removes her breast will for sure not tell her that the hormones she took for 15 years and kept her gynecologist rich off her having to return for prescription renewals, caused her to get the breast cancer (Mendelsohn 3).      

Pregnancy as Illness

Women also stop menstruating with pregnancy; here is another women’s disease for medical science to oversee. Pregnancy is defined in medicine as a state requiring intense monitoring and almost constant preparation for radical intervention. Women are ordered to modify their lifestyle, report for regular checkups, be subject to potentially hazardous tests and above all else get themselves to the hospital before the birth so that doctors can control their birth. This encourages dependency on the medical system and gets in the way of women thinking for themselves how they want their pregnancies and birth to happen. If they even question not going along with the system they are seen as irresponsible (Sherwin 186).

The American College of Obstetrics and Gynecology says that they are to be credited with the decline in infant and maternal deaths during the last 100 years, but they leave out the fact that most of the decline happened at a time when babies were delivered at home without medical intrusion (Mendelsohn 6).

Two and a half million women in the United States had Dalkon Shields inserted between January 1971 and 1974, before they were taken off the market by The Food and Drug Administration. These intrauterine devices (IUD) had been used despite the fact they had not been tested properly and caused harmful side effects soon after they went on the market. Approximately 1,100,000 women have since had acute pelvic infections, 1/5 of them were left sterile, and seventeen have died from the Dalkon Shield. Physicians were not notified by A.H.Robins (the manufacturer) until September 1980 to remove the IUDs from any patients who still had them in (due to large amounts of publicity about the problem). This after $55 million had been paid out by their insurance company to cover damages from 600 court actions and 300 pending claims (Mendelsohn 35).

During the 1940’s and 1970’s DES (diethylstilbestrol, a synthetic female hormone) was used to prevent miscarriages. It was used without real knowledge of whether or not it actually prevented miscarriages or what the potential side effects might be. These facts did not get in the way of doctors prescribing the drug or the drug companies from marketing it (Mendelsohn 35,36).

After a while the University of Chicago did do research on DES using 2,000 healthy pregnant women who were told the drug was a vitamin; they were not told that they were being used like rats to test the drugs effectiveness. The researchers did learn what they wanted and that was that DES did not prevent miscarriages. The drug was still prescribed (Mendelsohn 36).

It only took until 1972 for the side effects to start showing up: breast cancer in the mothers who took it, vaginal cancer to their daughters and genital malformations in their sons. Most of the women who took DES from the experimenters were sought out to inform them of its dangers, but the medical system did not have a way to seek out and notify the children of all these women who were at risk. Mendelsohn feels that every doctor who gave out DES is morally obligated to alert their patients and children who are risk; he doubts that with the threat of law suits that many would do so (Mendelsohn 36).

I remember well an experience I had with DES. I worked as an LPN (licensed practical nurse) in the late 60’s in an obstetrical unit. I recall looking up the drug DES before giving it to a pregnant patient as the doctor prescribed. I had been severely warned against giving any medication to a pregnant woman, so since I had not even heard of the drug, I wanted to know what I was giving. I remember the absolute uproar it caused when I refused to give the pill because the Physician’s Desk Reference said it could cause fetal damage if given to pregnant women. I was the criminal at that time. I dared to question one of the “GOD Boys”. I dared to use my head and to care about and use the knowledge I had gained simply by taking the initiative to learn about the drug before giving it. Oh, I remember so well, I feel the same rage I did then, only now I like myself for what I did. Now I’m glad I got in so much trouble. I’m glad I had a big mouth. I actually used to feel that something was wrong with me that made me speak up about things like that.

A major turning point in childbirth control was when doctors placed women flat on their backs with their knees raised on a high table to give birth. What this did was disallow nature to assist the woman in giving birth; contractions combined with gravity were taken away in lieu of the doctor’s control and interventions. This simple position change made women actually NEED assistance to give birth. It has made giving birth very difficult, risky, painful and gave doctors rationales to AID women with their once natural process. (Anyone who has ever had to try to use a bedpan to have a bowel movement laying flat in bed will understand how unnatural this position is for evacuating from down below).

Studies had been done in the 1930’s that proved that intra-abdominal pressure was the strongest in the sitting position; there has never been a study to scientifically justify laying women down to give birth. It was done for the doctor’s convenience. The trauma created to the birth process by using this position makes birth a pathological event (she has to go against gravity and the upward curve of the pelvis) and gives obstetricians a reason to exist (Mendelsohn 152,153).

Mendelsohn says that the flat maternal position requires that an episiotomy be done, the need for surgery then justifies the need for the position to do the surgery easier. When mothers give birth in natural positions, the already remarkably flexible perineum becomes even more flexible with body changes that occurs during labor – women don’t need episiotomies! (This is when the vagina is cut before birth supposedly to prevent tearing.) (Mendelsohn 177).

Childers reported that it has recently been shown that episiotomies are not medically necessary, despite the fact that they are done on 70-80% of vaginal deliveries in this country! (Childers 92).

I have often wondered why nature would not have made it feasible for a woman’s body to let out a baby without a man cutting into her vaginal tissue. I wonder what the incidence of tears would be if they dared to allow nature to take its course. It seems similar to removing pre-cancerous organs or removing things to prevent cancer from coming at all or coming back.

Mendelsohn is my hero in speaking for the desperate need to develop a feminist ethics of health care. 

Pap Smears

Pap smears, believe it or not, have never been tested to see if they are effective or not. But that doesn’t stop physicians from using them to gain access to patients once a year. If you ask a doctor about the effectiveness of the test, they will tell you how the rate of cervical cancer is down – but the rates were down BEFORE Pap smears were around. A recent study, at Yale University Medical School, showed that Pap smears were inaccurate, had never been involved in trials and that there was no evidence that it had any effect on the death rate from cervical cancer (Mendelsohn 41,42).      

Mammograms

Mendelsohn relates a true story of a friend’s wife whose mammogram showed a tumor. A frozen section (fast) biopsy was done which came back positive; she had her breast removed. The post-operative pathology report (which is much more accurate, but takes a couple days) showed no evidence of cancer (Mendelsohn 43).

I am also aware of this happening to women. Women were asked to sign consents for mastectomies at the same time they signed for their biopsies. This is truly ridiculous because the very reason biopsies are done is to learn whether or not there is cancer. Frozen section biopsies (the ones done immediately after tissues removal) are known to be less reliable than full pathology reports. The fact that medicine did not mandate full pathology reports before doing procedures as devastating as mastectomies is an example of how medicine has devalued women – to put it mildly!

Necessary Drugs & Women?

In 1979 alone 160 million prescriptions for tranquilizers, sedatives and stimulants were written. (Only 10% of these were written by the specialists trained in their effects, psychiatrists). A federal report showed that 80% of amphetamines, 60% of mind-altering drugs and 71% of antidepressants were prescribed for women. Women with the same symptoms as men, were prescribed twice the amount of drugs as men (Mendelsohn 60).

Congresswoman Cardis Collins of Illinois is the head of the congressional task force on women and drugs. She says we are accustomed to thinking of drug abuse in terms of male heroin or cocaine addicts, but there are 2 million women addicted to prescription drugs. Doctors frequently tell male patient to use physical exercise to deal with their problems, a woman with the same symptoms is advised to take Valium. Roche Laboratories profits a half a million dollars a year in Valium. Valium leads to 50,000 emergency room visits a year, 90% of these visits are women (Mendelsohn 61).

I recall a patient I took care of in an intensive care unit who was there after a suicide attempt. She said it was her eighth attempt in the past 2 years. I reviewed all the medications she was prescribed by her psychiatrist and found 3 of them had side effects that led depressed patients to attempt suicide! I asked the patient if she was aware of the side effects of the medications she was taking. She said no, but showed no indication of “getting” what I was saying. She “got” it on an intellectual level, but could not see that her doctor might have had any responsibility in her frequents suicide attempts. She was being treated for depression. When she told me about her life, I thought it was horribly depressing as she was being abused by her ex-husband, her sons, and, in my opinion, her psychiatrist – she sure had reason to be depressed to me. When giving report to the next nurse I told her about the drugs and that I had been unable to get a hold of the doctor to notify him of the side effects that I had read about (I even wrote out the side effects and the page numbers in the drug book) this patient’s drugs. This nurse thought I was some kind of freak – we don’t tell doctors about side effects – they’re supposed to know – they’re the doctors – they prescribe them. Why was I as a nurse taught to NEVER give a drug unless I knew about it? Why was I taught that if I gave a drug that I knew would be harmful I should tell the doctor and refuse to give it? It just doesn’t seem to work that way in real practice.

Surgery

Doctors who are paid a salary do 50-100% less surgery than those whose income depends upon the number of procedures they perform. In 1980 Blue Cross and Blue Shield stopped paying for 28 procedures that they thought were not helpful to patients. In order to do these surgeries doctors would have to work hard to justify them to patients and interestingly a 75% drop occurred among these procedures (Mendelsohn 81).

Mendelsohn illustrates very well the risk we face under a surgeon’s knife. In 1974, 15,000 people died as a result of knives. Three thousand of them were murdered and 12,000 were from surgeons. At the time of Mendelsohn’s writing he predicted that if present rates continued, “one of every two women in the country will part with her uterus before she reaches the age of 65” (Mendelsohn 97).

Dr. Niles Newton, professor of psychiatry at Northwestern University did a study on the consequence of hysterectomy that may not be of much importance to male gynecologists, that is decreased libido. She found that 60% of women experienced suppression of their sex drive after removal of the uterus and ovaries. (Male gynecologists had told women it would enhance their sex life because they would not have to worry about pregnancy) (Mendelsohn 102).      

Breast Cancer

Dr. Halsted’s radical mastectomy was developed in 1882 when most breast cancers were not treated until very late stages. Studies have illustrated that 1/4 of all married women experience depression so severe that they contemplate suicide after mastectomy. Another 25% describe deteriorated sex lives. More than half have phantom breast pain (they feel pain in the breast that is gone). Psychologists who see these patients and have studied these patients blame the symptoms on lack of emotional support from doctors who did the operations and the husbands with whom they live (Mendelsohn 111,112).

It only took 90 years to have controlled studies done on alternative treatments. (Other studies had already shown that the Halsted did not have a better survival rate than less devastating treatments, but the Halsted was still used)! A 1970 study finally showed that 3 different treatments, Halsted radical, simple mastectomy and simple mastectomy with radiation were exactly the same in respect to reoccurrence of cancer (Mendelsohn 112).

The Pill & The IUD

The FDA approved the birth control Pill in 1960, but that approval was based on some despicable research. One hundred and thirty-two Puerto Rican woman took the Pill for a year or more, “five of them died during the study, and no effort was even made to find out why” (Mendelsohn 119)! This was some of the scientific evidence that the FDA used to approve the Pill, endangering 50 million women. Despite 20 years of use it has not been proved to be safe for women. In fact, 100 studies have linked the Pill with over fifty side effects. And yet, the FDA then said, “there is no conclusive scientific evidence that oral contraceptives are not safe for human use” (Mendelsohn 120).

For some women adverse effects show up right away, but for others they may not show up for 20 years. Some of the risks are: cancer of the cervix, uterus, breast and liver; In addition, the pill has been linked to heart attacks, strokes, diabetes, gall bladder problems, high blood pressure, depression, pulmonary embolism, vaginal infections, hair loss, growth of hair on the face, and diabetes. One also may learn that when one goes off the Pill and try to get pregnant, one is sterile. The side effects of women NOT using the Pill faced by the FDA and the drug manufacturers are LOST PROFITS; to them the end, population control, justifies the means (Mendelsohn 121).

Mendelsohn quoted Dr. J. Robert Willson, of the University of Michigan School of Medicine, at an International Conference held by the Population Council, they were discussing infections that IUD’s might cause: “perhaps the individual patient is expendable in the general scheme of things, particularly if the infection she acquires is sterilizing but not lethal” (Mendelsohn 126). What kind of medical ethics allows doctors to view their patients as expendable along the road to achieving social goals? (Mendelsohn 126,127).

Only 8.8% of female staff members of Planned Parenthood took the Pill compared to 70% of their clients; they knew about the harmful effects but their clients did not (Mendelsohn 129).

Eating Patterns as Illness

Our culture is fixated on the shape of women’s bodies; culture demands women to be attractive and or fat free. In addition to cultural pressure to be thin, women are also pressured by medicine telling them that it is unhealthy to be overweight. Ninety five percent of people in weight-reduction are women and 75% of American women perceive that they are over weight. Women are in addition, blamed for their lack of control in getting their weight down (Sherwin 188).

When women show that they cannot control their weight medical science is there to receive payment for stomach stapling, enforced dieting, mouth wiring, medications to decrease appetite, surgical removal of fat and even removing parts of their stomach or intestines (Sherwin 188).

Empirical evidence illustrates that weight charts telling women how much they should weigh according to their height are very low. They even show that women are healthier with a few extra pounds on them (10-15 pounds above charts). Research has not shown women to exhibit poor health with extra weight; research showing correlations between obesity, heart and diabetes were done with men and even more specifically showed the excess weight that caused harm was around the waist, not around the whole body, the way women carry excess weight (Sherwin 188).

The very advice given to women by medicine – to diet – can actually endanger their health. Dieting is rarely effective. Ninety five percent of dieters gain back the weight plus a few more pounds, and fluctuations in weight are harder on the body than a steady weight above the weight charts (Sherwin 188).

Medical science also labels a person “ill” if they don’t eat. Eating disorders such as anorexia nervosa and bulimia leave women easy prey to hospitalization and psychiatric treatment. They are an example of women taking cultural norms of what is required to be feminine to the ultimate. Whether you eat too much or too little you are subject to medicine’s interventions. Could it be that the norms for health could be off, and not women? If so, many women have eating problems then it may be cultural in origin and medical control may not be the best solution (Sherwin 189).

Cosmetic Surgery

Kathryn Morgan displayed a page of knives, scissors, needles, and sutures used in cosmetic surgery in her paper, “Women and The Knife: Cosmetic Surgery and the Colonization of Women’s Bodies”. She suggested that her readers look at them carefully, for a long time and to imagine them cutting into your skin (Morgan 26). I did.

As a nurse, my first glance simply revealed surgical instruments – no big deal. Then I looked at them with care for a long time, and imagined them being used on me, as Morgan suggested. I then looked at them as a feminist; I then saw them as mutilating, controlling devices used by patriarchy to manipulate women, to make women fit the image of beauty as defined by men, especially white men. (Not to mention the enormous profit they make from assisting us to look good for men).  This is another example of the medical system defining not only what is normal, or pathological, but outward appearance. What aspect of medical training certifies them to evaluate appearance?

One of the reasons Morgan gives for writing about the topic of cosmetic surgery is that she says it is or has been silenced in the fields of mainstream bioethics and virtually no discussion, feminist or otherwise, of the issues that may be present in this area. She thinks we, as feminists, need to ask, why women reduce themselves to potentialities (to fit the heterosexual image) as women. An enormous and growing demand exists for cosmetic surgery. Women are willing to sacrifice other parts of their lives for reconstructed bodies. Why, when the risks are so great? Risks such as: bleeding, infection, embolism, unsightly scar formation, skin loss, blindness, disability, pulmonary edema, facial nerve injury, and even death (Morgan 28).

As a feminist, and as a health professional, I feel that our silence makes us complicit in enlarging the scope of avenues to patriarchal power.  Women invest years of savings in the cosmetic surgery industry to “fix” natural flaws through dangerous and painful operations to make their bodies fit the norms of the fashion editors (Morgan 28).

Morgan also sees this topic as a part of the technologizing of women’s bodies in Western culture. We are seeing cosmetic surgery evolve to the point of being viewed as normal. This changing perception may lead to those who don’t “elect” cosmetic surgery will be seen as deviant (Morgan 28).

We are all witness to the controversy about silicone breast implants. Over one million women have had these implants. Two recent studies show that they block x-rays and cast a shadow over surrounding tissue, making mammograms very difficult to interpret. There also appears to be a higher incidence of cancer in those with implants (Morgan 29).

I personally knew a woman who had implants done, she was my next-door neighbor for many years. I had seriously wondered about her sanity in doing so because she chose to do it when her second child was 9 months old. I knew how challenging it was to change the diaper of and dress a 9-month-old. She was restricted from using her arms to lift or to do much of anything for 6-8 weeks after the surgery. (She did have her mother close by to assist). I remember telling her I could not understand her choice to have it done in the first place, but to have it done with her child that age I really didn’t understand. I told her I did however, realize that her reasons must be quite profound and vital to her very existence. Indeed, her decision came from her desperate desire to obtain her husband’s love. Despite my realizing that it must have been an act of desperation, I still needed to hear it from her. I still develop “wet” eyes when I think about what women will do to obtain acceptance and love.     

Morgan says she is shocked at the extent to which patients and cosmetic surgeons are committed to what she sees as “one of the deepest of original philosophical sins, the choice of the apparent over the real” (Morgan 28). Technologically created appearances become what is perceived as the real; youthfulness over the reality of age (Morgan 28).

In 1990, the most popular cosmetic surgery was liposuction; fat cells are vacuumed from beneath the skin never to return. At least 12 deaths have resulted from hemorrhages or embolisms. Sixty to seventy percent of cosmetic surgery patients are female (Morgan 29).

The relationship between the means and the ends are unilinear, but with the new technologies it has become circular; they present new possible ends. New objectives are added to the possibility of what one might desire. The role of technology has become transcendence, control, transformation, exploitation and destruction. The object of the technology is viewed as inferior; the higher purpose becomes to “fix” with the technology that justifies its existence (Morgan 30).

For most women, success is seen through interlocking patterns of compulsions: compulsory attractiveness, motherhood, and. Their attractiveness is determined my the tastes of men; a woman’s eroticism not dwelling on the penis is seen as either nonexistent, or pathological. Our reproductive services are to particular men or to male dominated institutions (Morgan 32). 

Most women in Western societies are socialized to accept the knives of technology. Those knives can be for healing purposes: saving the life of a baby from uterine distress, removing cancerous growths that threaten our breasts; they can straighten our spines, or can give function back to arthritic fingers. There are, however, other knives that perform episiotomies and other types of genital mutilation, cut into our bodies to remove ovaries and thus our “deviant tendencies”, some that amputate our breasts unnecessarily in the name of prophylaxis or simply in cases where less drastic measures would have sufficed, some get rid of our uteruses when we are beyond child bearing years or when we are of an undesirable color, and some knives that do unnecessary cesarean sections so the doctor can be on his way. Morgan admits to being afraid of the knives of plastic surgery, they manipulate our bodies to please the patriarchal, white supremacist culture (Morgan 32).

Isn’t it interesting that another word for cosmetic surgery is plastic surgery. The “plastic” certainly is more correctly descriptive to the images involved. Even the word augmentation is revealing.    

Women have historically been socialized to used their beauty as power. A quote from Mary Wollstonecraft (1792),

“Taught from infancy that beauty is a woman’s scepter, the mind shapes itself to the body and roaming round its gilt cage, only seeks to adorn its prison” (Morgan 34). Are women today making free choices to have cosmetic surgery or are they too simply adorning their prisons (Morgan 34).

The power that beauty yields is heterosexual affiliation not equally accessible to the who don’t fit the image of beauty patriarchy defines: the plain, ugly, old or unable to reproduce. The voices of women who seek cosmetic surgery are compelling. The youthful appearance they gain gives them a sense of identity that they did decide to acquire, to a certain extent. It enhances her status socially and economically, as it will better her potential for affiliation with heterosexual white men. Her pursuit of beauty brings her an approval that fits society’s values and thus increases her self esteem. The people she meets in the process of acquiring cosmetic surgery may treat her body in a caring way, this may be something lacking in her life. The accumulative results of the pursuit of beauty via transformation, are associated with self-fulfillment, self creation, self transcendence, and being cared for. While the power offered through acquiring beauty can boost a woman’s self image, it also gets her stuck in a mire of interrelated contradictions (Morgan 34,35).            

Some of the reasons women seek the expertise of plastic surgeons are to obtain glamorous breasts like the movie stars, to reduce their noses (often Jewish women), to Westernize eyes (Asian women), and to bleach dark skin. The results they hope to gain are more than just beauty; they are trying to mold themselves to fit to a white, Anglo-Saxon, Western image, to better function in a racist and anti-Semitic society. We might initially say that they have a choice, but actually they are seeking to conform. The appreciation women may gain from men in their newly acquired femininity is actually intrusive when it is obtained through incisions, sutures, staples and scars. Morgan identifies three paradoxes that choice involves:

       1. What simulates choice may actually be conformity at a deeper level (Morgan 35,36).

Who is really exercising the power involved in cosmetic surgery? The colonizing power comes from fathers, brothers, male friends and lovers and the cosmetic surgeons who offer their knives to fix a woman’s deformities. The power can even be present from within the woman herself, clothed in a diffuse manner. Women who are involved in self-surveillance behaviors like fixing their make-up all the time, or monitoring everything they eat, are maintaining obedience to the patriarchal powers that be (Morgan 37).

       2. The men in society that women transform themselves for are male-supremacist, heterosexist, ageist, ableist, racist, anti-Semitic and classist (Morgan 38).

       Health insurance policies do not cover elective cosmetic surgery, so women who want it must do so at significant cost financially and in terms of lengthy post-operative pain (Morgan 38).

       3. The technological imperative to be beautiful and the pathological inversion of what is normal convinces more women every day to have cosmetic surgery (Morgan 41).  

       Although admittedly not likely to ever be achieved, Morgan suggests that if women collectively chose to exercise their power, they could refuse cosmetic surgery and drastically affect the status of the market. This might also have the positive effect of leading surgeons back to healing again. Morgan suggests that we should not turn away from women who chose to have cosmetic surgery; this decision may be one of the only decision powers she may have in her life (Morgan 42).

Plastic surgeons rationalize that silicone breast implants are a matter of a woman’s free choice. We should think seriously about trusting companies that stand to profit $300 million dollars by going along with women’s “choices”. Anyone who listens to the afternoon news has probably heard that Dow Corning Wright was suppressing negative data about the silicone gel filled implants. Doctors don’t follow their patients to know about adverse effects and their medical society doesn’t demand a registry for patients to facilitate keeping tract of women and their adverse effects.

Applications of Concepts – Health & Illness

What medical science labels sick is taken as God’s solemn truth. The labeling of a condition to be a disease has enormous political and social implications. This is especially true with diseases associated with behavior judged socially unacceptable like alcoholism, drug addiction, mental illness and homosexuality (Sherwin 190).

Having a physical or mental disease can get in the way of obtaining equal opportunity. The way the definitions of health and illness are used shape social roles and set boundaries for medical authority; they also describe boundaries of those labeled as ill. If ill, you may be excused from some responsibility and get special treatment. Or they may be easy prey to stigmatization, paternalism and be judged unqualified for certain activities. Our society has given doctors a free hand in assigning powerful labels and the power to “fix” what they label as ill (Sherwin 190).

The medical model of health is tied in with value judgments. Sherwin quotes Englehart, in his book The Foundations of Bioethics,  “Medicine medicalizes reality. It creates a world. It translates sets of problems into its own terms. Medicine molds the ways in which the world of experience takes shape; its conditions reality for us” (Sherwin 191).

This reality is then reinforced by being considered socially acceptable; thus, the reality they create is socially dominating. The very defining of a problem as medical creates expectations and influences a person’s future – it changes our very social relations. Hidden policy and value judgments can also shape the “medical facts.” Doctors place far too much emphasis on laboratory theory and their clinical world of symptoms and not nearly enough on the expressed experiential data offered by patients about what they are experiencing (Sherwin 191).  

Feminist Views – The Health Illness Debate

Feminists fear medicine having authority in social and emotional spheres since their training does not give them expertise in these fields. Medical experts, coming from their homogenous class background, should not have authority to make decisions about lifestyle choices. Most feminists support a holistic attitude toward health; social ills are surely associated with poverty, oppression, ignorance and stress. Doctors, speaking from personal places that are not impoverished, non-oppressed, and certainly not ignorant should not be making judgments of those whose lives are affected by these social conditions. Medicine’s values and authority should not serve as filters for attempts to fulfill social needs (Sherwin 193).

Feminists think that decisions about what is illness as far as women’s health should be made among the women’s community, not within the very society that oppresses us. Medicine’s ascribing illnesses to oppressed groups may actually be a sign of or an effect of the group’s oppression; it may even serve to perpetuate their oppression. Labeling of illnesses of those within oppressed groups has enormous political ramifications. They may as a result face stigmatization, being seen as passive and thought of as less than competent (Sherwin 195).

The medicalization of menstruation, pregnancy, and menopause, assumes that these ordinary events in the lives of women are not valued – they have to be “fixed.” When body parts are labeled as diseased they become subject to the control of medicine; women themselves may thus feel an alienation from these body parts. Some important aspects of women’s oppression are the fact that their bodies are objectified and alienated in the process (Sherwin 196).

Medical objectification of our bodies in a sexist society reduces those bodies to sexual or reproductive functions under patriarchal rule (Sherwin 198-199).

Sherwin suggests that we only label the atypical menstrual changes that are harmful to women as diseased. To properly label what menstrual symptoms suggest disease we must first truly understand what is normal menstruation which has not been fully explored (Sherwin 199).

If we accept a medical model of PMS as a disease that affects 95% of women, we are accepting a sex difference that places us at a disadvantage societally. It serves to maintain our bodies under the authority of medicine (Sherwin 200).

We must keep in mind who gains from PMS being viewed as a disease; drug companies and medical specialists stand to profit, while we are subject to them and maintain our oppression (Sherwin 200).

The cyclic changes women experience must be perceived as normal; by rejecting the norm of PMS as a medical problem we gain some control over our bodies, lives, and the way society views us (Sherwin 200).

Illness and Oppression

A person’s health care needs usually vary inversely with their power and economic status. Poverty has a profound affect on a person’s health. One may not have adequate nutrition, shelter, clothes, heat, sanitary conditions, or clean water. Those living in poverty are also more likely to work at a job that presents health risks, are less likely to have health insurance and are more likely to suffer from a mental illness and be addicted to drugs or alcohol. Without money for health care one may let an illness go to an advanced stage, thus compromising recovery potential (Sherwin 222).

Those more likely to be poor are a societies oppressed segments: women, children and other minorities. Oppression itself causes illness due being exposed to high stress levels which leads to many serious illnesses. The very factors that cause a person to be oppressed societally also affect his/her treatment in the medical domain (Sherwin 222-223).

Serious or chronic illness may lead to poverty from fear and discrimination; the chronically ill then also face class oppression. Bioethicists have an enormous responsibility to address to connections of oppression and illness and to modify these connections. If ethicists don’t consider oppression’s role in destroying health they become complicit in maintaining the oppression (Sherwin 223).

Patients in Oppressed Groups

Women consume much more health care than men. (Seven times more according to Mendelsohn 1). Sherwin discusses a study that was presented to the American Medical Association which revealed gender disparities in clinical decision making. Despite the fact that women are likely to have more medical procedures done than men with the same symptoms, they have much less access to major interventions. Women are 30% less likely to get a kidney transplant; 50% as likely to receive tests for lung cancer; and only 10% as likely to receive cardiac catheterization than men. Other than the biological differences between the patients, nothing justifies the treatment imbalances other than gender bias. Cardiovascular disease is the leading cause of death in women in the U.S., but all the research has been done on men (Sherwin 223).

“If a man comes in with chest pain, we instantly worry about organic heart disease. A woman comes in with chest pain,  Hmm…Well, what is she upset about” (Healy, Prime Time Live)?  Heart disease kills 20% more women than men. One major prevention study not only didn’t include women, but it called the study “Mr. Fit”.  When researchers studied the effects of estrogen on preventing heart disease, it failed to show that estrogen would prevent heart disease, but the trouble was they did the study on MEN (Healy, Prime Time Live)!        

Another study found that when women were treated, they were subject to excessive testing, surgery and drugs. Most women seeking fertility control from professionals are placed on the birth control pill, interestingly, the majority of these health professionals or their spouses used barrier methods with less risks (Sherwin 224).

Doctors are educated to view women as anxious, deviant, unintelligent and not to take their complaints seriously. Research studies have shown doctors to be condescending to women, withhold information because they don’t think they can understand (Sherwin 224-225).

“the darker a woman’s skin and/or the lower her place on the economic scale, the poorer the care and efforts at explanation she received” (Sherwin 225).

The reasons for lack of safe, effective birth control, abortion and prenatal care are not just economic, but are even more political. Black women are four times more likely than whites to die in childbirth, three times more likely to have their newborns die, are twice as likely to die from hypertensive cardiovascular disease, have three times the rate of high blood pressure and lupus and are more likely to die of breast cancer even though they have lower incidence, are twelve times more likely to get AIDS and four times more likely to die of homicide (Sherwin 226). Many of the working poor do not qualify for Medicaid; even those who do qualify face doctors and hospitals who will refuse them. A 1985 study revealed that four out of ten obstetrical physicians refused to treat Medicaid patients (Sherwin 226).

Most affluent women will find nutritional guidance to assist them in loosing weight in their neighborhoods; few women on welfare have access to information on how to stretch their welfare dollars to get the most nutrition possible. When women are abused, they get patched up in an emergency room, and if a space is available may be referred to a shelter temporarily. There are not usually services available to assist the abuser in finding alternative methods of treating his spouse. Women then end up back with the abuser, showing up at the emergency room with more serious injuries, while their children are being given models of how people treat one another which they will then carry on to their own families (Sherwin 227).

Justice is often raised as a principle in bioethics literature; the main moral concern, however, is access. But even in Canada where universal health insurance exists, poor women still don’t have access because they lack money for transportation to get to the health facility. The fact is that some women are at risk for violence, developing addictions, and malnutrition and this affects their ability to care for their health needs. They are at risk because of our social system that allows one group to oppress others. Bioethics must address the needs of oppressed people (Sherwin 227-228).

Health Care’s Organization

The medical establishment is set up with the same stratification systems as society in general. So in addition to reflecting the same biases as society, the medical system also serves to maintain (Sherwin 228).

Women do most of the work in the medical system, but are not involved in policy making. They are the ones who provide home health, take care of their own families, (both of which are not for pay, so they go unrecorded and are not reflected in health care statistics), they have no authority, and the knowledge they acquire through experience is negated by those in the health care power structure (Sherwin 228).

Women do 80% of the work in health care institutions while men sit in the seats of power. Those in positions to set policy are overwhelmingly male: administrators, physicians and legislators. Most medical instructors, textbooks writers and hospitals directors are men. Women who do function in health care administration are middle managers where they do not have power over policy. Most research is controlled by men; research standards were set by privileged men to meet their requirements. They do not reflect ideas from female philosophers and scientists such as: adding space in a project’s design to measure participant control, decrease separation between subject and object, and resisting restrictive medicalized analysis (Sherwin 228-229).

The jobs with the lowest income and status in health care facilities are filled by working-class minorities: nurses’ aides, kitchen and cleaning staff etc. They have no voice in the system. There is certainly no research specifically to discover the needs of these minority women. Black women make up only 1% of the nation’s physicians. They have been kept out by hospitals refusing them internships or, if they did complete their training hospitals would refuse them admitting privileges (Sherwin 230).

Problems with sexism and racism have been made worse by oppressed groups being led to perceive that their interests were in conflict with one another, thus dividing them and decreasing their power potentialities. Sherwin sites Hine who showed that racial divisions have been in nursing since 1890, white nurses tried to keep black women out of the profession. Rather than joining with black nurses to counter racial prejudice, they feared for their own status and helped to sustain oppression on fellow women (Sherwin 230).

Not only are nurses oppressed by the predominantly male medical system, but they are also downright abused by the system. A survey conducted by The American Journal of Nursing revealed, far and wide, nurses are performing (mostly not even under physician supervision) exactly the same services for which doctors are billing patients, Medicare and insurance companies for. Researchers have suspected this for many years. The American Public Health Association says that physician payments have risen 17% per year, compared to 9% for other hospital costs and 4% in other parts of the economy. Congress is currently targeting physician payment reform (Griffith, Thomas and Griffith 22).

Carol Lockhart RN, Ph.D., is a member of the Physician Payment Review Commission, advised congress that we must address all health care providers. She encourages nurse to document their role in Medicare Part B, “We have little or no data showing how much of a particular service, now billed by a physician, is done by a nurse – or how many services are delivered by the nurse and billed under the physician’s name” (Griffith, Thomas & Griffith 24). The authors suspect that policy makers will be hesitant to include providers other than doctors because it would complicate things dramatically. They assert that the alternative is certainly not OK. They urge nurses not to allow policy makers to treat them as “invisible worker bees” of the health care system (Griffith, Thomas & Griffith 27).

Some of the services mentioned in the study were: giving intramuscular injections, starting intravenous infusions, giving blood transfusions, inserting urethral catheters, training in activities of daily living, interpreting an electrocardiogram, performing CPR, and suctioning of the upper airways (Griffith, Thomas & Griffith 27).

Having spent 26 years working hospitals, I know that doctors do not perform most of these procedures. (Just try to picture a doctor teaching a patient how to wash himself with a cast on). When a doctor does do one of these procedures it is in a teaching hospital, only so he can do it once or twice for the experience). I was appalled to learn that doctors billed for things like the above; I realize that I was so doing all of these procedures and that I had never thought about who got the money for them. It makes me wonder how much they charge for each of these and how wealthy I would probably be if Medicare reimbursed ME for each thing I did for a patient. Imagine also if listening, supportive touch, hugs, crying with families, and teaching patients to stay healthy were valued for their roles in healing.

The hierarchical system encourages competition rather than cooperation among social groups. It makes us all obedient to our superiors and hostile to those below ourselves; thus, all groups become complicit in maintaining the hierarchical structures. The health care system then reinforces the oppressive attitudes of the rest of society (Sherwin 231).

Effects on Health Care

It’s not only unjust to distribute health care with biases, but it also affects the quality of care. When most health care decisions are made by wealthy, white, well-educated males, it is obvious that they will make decisions that stem from their value systems which may be very different from those of the patients. It is also likely that their views of women, especially poor, uneducated minority women will be from a paternalistic vantage point. These physicians make decisions where cultural communication gaps exist – care suffers as a result (Sherwin 232).

Minorities and women frequently fill the health care institutions with dead-end, demoralizing jobs; they lack the power and influence to interject their cultural values into the system, as do the patients who are also frequently minority and female (Sherwin 233).

Researchers are inclined do study things that effect people in their world: heart disease, cancer and infertility. They are less inclined to be concerned about poverty, malnutrition or sickle cell anemia (effects mostly black in this country). What ends up happening is that those who need the system the most find the system foreign to them. Most family’s health needs are tended to by women who must try to operate in a male dominated system that is costly and hospital-based. They have to attempt finding their way around the system to obtain the right care, then they have to try to translate what they are told by the professionals and attempt to communicate their needs so that the professionals can understand it. Thus, the consumer and the providers must function across cultural and language barriers in times of illness, which are stressful enough (Sherwin 233).              

Child care and transportation are not included in health care resources, despite the fact that without them care will be almost impossible to obtain for many. White doctors and nurses are paternalistic in regard to minority patients; if they don’t follow “orders” they are treated with hostility and anger due to their noncompliance. It is frequently not considered that the patient may not have had the money for the medicine or the patient missed a scheduled exam because he feared loss of his job (Sherwin 233).

Chronic health problems that occur because of oppression itself do not receive proper care. Priorities for child and woman abuse are very low; the health care profession offers them drugs and lectures (Sherwin 233).

In order to obtain ongoing support survivors of sexual abuse, breast cancer patients and parents with chronically ill children must form groups to help themselves. I have run across more than one physician who became angry that I, as a nurse, informed their patients that there were cancer support groups available to them. They, male physicians, did not believe in “those groups.” How dare I offer something THEY did not approve of for THEIR patients. I know that they do not intend to offer their patients the intimate, ongoing, support and caring as the months go on. I know that they do not understand or sympathize with their patients’ losses, yet they try to “stand in the way” of their patients obtaining the help they need. (I would always call The Cancer Society from home, anonymously, for patients.)    

Ideological Influences: Gender, Race, & Class

The hierarchical health care system reflects society’s sexist, racist, and classist attitudes; it supports them and keeps them going as do all of our major institutions: the justice system, universities, the business world, and the world of civil service. Those in power are white males; they are supported by undervalued white professional women; mere physical work is done by minority unskilled labor. This stratified societal structure is of great moral concern (Sherwin 234).

Doctors have been justified in their dominance because the end – health, is of such high value that their means have been, by and large, acceptable. They “command” health care teams, “lead campaigns” against dangerous life-styles, and “battle” illnesses. They are allowed to give “orders” to nurses, physical therapists, other health care professionals and their patients; because of their expertise they rule all. White female nurses accept following doctors’ orders and thus serve as an example of how things should be done to minority nurses. These nurses in turn have authority over non-skilled hospital workers of color which perpetrates race oppression. So, the health care establishment serves as a perfect role model for how people keep stereotypes and oppression going (Sherwin 235).

It has been recognized for some time that stress is a major factor in illness. The standards used to evaluate levels of stress were developed from a male in authority perspective, the high-powered business executive. The image of stress found in an American study of stress at work found that it’s the lower level jobs were people have high work loads and no control over their work situations. It is poor women who have no control over their jobs and who must struggle to meet child care responsibilities who face the most stress – they receive little support societally nor any relief. Instead of being helped, they are judged when they develop poor coping mechanisms like alcohol abuse, smoking or the use of drugs. Traditional lists of stressful events included things like, being promoted at work, being drafted or having one’s wife start working. These lists do not include, being raped, having an abortion, loss of child care to a single working mother, working in a situation where you are being sexually harassed or having received an especially severe beating from your male partner (Sherwin 237).            

Those in power of health care resources cannot identify with these women and thus are not likely to be aware of their life stresses – so they receive no real help. Doctors use their power to reinforce negative attitudes about women; nineteenth century physicians had theories about women’s uteruses being in competition with their brains with the hopes of keeping them out of universities and “protecting” them from politics. Many doctors today promote estrogens in post-menopausal women, despite cancer risks, to help them avoid the undesirable effects of aging. Depending upon the current fashion, doctors have “helped” to maintain women’s feminine passive role with treatments like, genital surgery, psychosurgery, psychotherapy, hormone replacement, or tranquilizers. It has not been considered by the medical profession that perhaps changing the roles women have been relegated to might alleviate some of their life stress thus relieving physical complaints (Sherwin 237).

It is OK for women to develop illness as a response to overwhelming life stress because it fits the image of being passive, feminine and weak; it is NOT OK for women to question male authority by getting angry and rebelling. So, women unconsciously took the socially acceptable mode of stress relief – it is much less threatening.

The medical model has put its own knowledge at the top of the hierarchy and made other types of knowledge and experience subservient to that knowledge. This hierarchical structure is morally unacceptable simply because it is hurting people. It responds differently to different people’s needs; giving low quality and value to oppressed groups. Its structure supports oppression. It rationalizes that this hierarchy is essential to accomplish its ends; it tolerates unequal distribution of care, power and prevents equality (Sherwin 238).

Research Recommendations

Research is social and political and affects all of our lives. Unless there is more democratic representation among decision makers in research, the science will be a science that supports interests of the dominant groups in society. Scientists need to see their role in perpetuating existing power structures and increase the connection with subjects of their work; they must learn to see themselves as responsible to the people at large and not just to corporations and institutions that support them. It’s necessary to examine political and societal affects of research as well as its acceptance by subjects when evaluating its ethics. The dominant class controls research institutions and funding agencies, the values pursued reflect their class, gender and racial backgrounds which are powerful. Research pursued on women usually is chosen by privileged men (occasionally by women trained by such men). When research serves women’s interests it is because it coincides with those in control or because altruism was involved in a particular case. Or it may end up serving privileged women: white, middle class, educated and heterosexual (Sherwin 173).     

Research decisions should be public and should ensure accountability to the community affected. Oppressed groups should have a say in the goal setting and guides for research. Poor women and women of color will be harmed by fertility research on privileged women if the result is that eggs “harvested” from valued women, matured and fertilized in lab and transplanted into vulnerable women for gestation and delivery. These methods assure “proper” genetics without the risks and discomforts of pregnancy and birth for the “valued” women. (Sherwin 174-175).

Some feminists’ solutions to infertility are: research and treatment of sexually transmitted diseases (STD’S) and other causes of pelvic inflammatory disease which blocks tubes; a significant percent of female infertility is preventable. Prevention of involuntary sterilization. Direct attention to cause and cure of male infertility. Research into eliminating environmental and social factors that contribute to it (i.e. malnutrition). Pursuing techniques that will allow safe and reversible sterilization in men and women, and providing better fertility control (Sherwin 135).

Bernadine Healy said, on Prime Time Live, that the National Institutes of Health plans to use 625 million dollars through the Women’s Health Initiative to finally study the effects of hormone replacement and vitamin supplementation on postmenopausal women (Healy, Prime Time Live).

Solutions     

Sherwin cites Warren who suggests we must examine the fact that medical ethics requires an examination of the context of engaging in ethics itself. The context and methods of ethical analysis are themselves significant to the outcomes proposed. A “Sexist Ethics” is one in which men use their perspective to frame moral questions and propose solutions; its habit of cloaking itself in gender neutrality and selection of topics that ensure women are kept on the defensive by making matters of concern to them a constant subject of controversy. i.e. abortion, affirmative action (Sherwin 91).

Warren suggests three feminist themes that could direct the way medical ethics is discussed:

       1. DIVERSITY – Historically women’s theories and insights have been left out. After including women in ethical theories, we then must figure out how ethics can be inclusive to diversity. One way is to ask philosophical questions from varying vantage points rather than the traditional doctor-based ethics. Feminists could go beyond asking what a Hispanic woman from the barrio would need from ethics, by actually tagging along with a social worker to the barrio and ask women in the barrio what matters to them and what medical problems they face. Feminists question having universal theories fit multiplicity and suggest making room in the theory for particular others (Warren 40).  

       2. RELATIONSHIPS – How do people in academia relate to each other in ethical discussions? The motives and respect accorded to others in these discussions counts. When ulterior motives are involved, we are playing the ethics game. Winning the competitive argument does not lead to truth in solving ethical dilemmas. Feminists might do well to seek variations in the ethics game to find the moral benefits. Perhaps collective, anonymous authoring or using pseudonyms could be attempted. This could bypass reputation and stimulate concentration on the ideas. We could also appeal to the whole personality of the reader, not just his/her intellect. If we could inspire others to voice their ambivalence it could lead to self-knowledge and social harmony (Warren 41).   

       3. BASING THEORY ON ORDINARY EXPERIENCE – Feminist theories should not originate from ivory towers, but from real life experiences of real everyday people. Listening to ourselves would enhance trusting our own judgments, despite the fact that books may say something different. Doing so also challenges the experts. “If knowledge is power, ‘life precedes theory’ is social revolution” (Warren 42).

Warren suggests that in addition to questioning the power structure between doctors and patients, we should also question it between philosophers, students and ourselves (Warren 43).

Warren suggests ethicists might consider ways to resolve power conflicts, perhaps a sort of preventative ethics; rather than getting into who is in charge, the doctor or the patient, we could look to prevent the very power struggle itself. Medicine’s very educational set up and the organization of hospitals may be required. In addition, we might ask how health professionals can help to diminish the power disparities and enhance someone’s self worth. We might attempt to eliminate discrimination with a radical strategy: educate people to value themselves without it necessitating putting someone else down in the process. (Warren 38,39).

Warren also brings up an idea of feminists discussing relationship ethics. How can we train health care professionals to be sensitive, what should their work conditions be and how involved should they get with their patients? With the abortion debate we might add the relationship between the mother and child, not just whose rights are prominent (Warren 39). Warren suggests as a solution to the power struggles that we view the doctor as an educator rather than an authority figure. (Nurses traditionally have been delegated to do patient teaching simply due to their gender) (Warren 39).

“Teaching skills are hard won–requiring practice, experimentation, and sensitivity to audience. The medical model down-plays the difficulties of teaching well, tends to attribute failures of communication to patients and lets physicians who are poor teachers off the hook” (Warren 40).   

We should not keep trying to separate theory from nurturing. Nurturing needs to be valued monetarily and it should be incorporated into technical and theoretical education (Warren 36).

Sherwin suggests that the institution of medicine be transformed away from emergency treatments and concentrate on empowering people to help themselves stay healthy. She even suggests a nurse-patient model because nurses see their role as empowering and informing – not controlling. Nurses however, like mothers are limited by the fact that they themselves are oppressed (Sherwin 28, (Holmes & Purdy)).

The principle task is for feminists to develop a conceptual model to restrict the power involved in healing, by giving out specialized knowledge that will give people maximum control over their own health. To clarify how excessive dependence can be reduced, how caring can be offered without paternalism and how health care can become worthy of trust. The goal should be to spread information widely and foster self-help. Medical expertise should be seen as a social resource under the control of patients and those who care for them (Sherwin 28, (Holmes & Purdy)).

Instead of crisis management the main thrust should be – health empowerment. When counseling a family on saving a critically ill infant, one should keep in mind that, the mother will be the one doing the care, seldom with adequate support; not only should this lack of support should be included in the decision making process, but we should have supports available to make caring for the disabled child reasonable for the woman to do (Sherwin 94-95).

Patients don’t HAVE to all have the same condition to be able to help one another. Why couldn’t we have groups of patients who were in need of information come together; why couldn’t a patient with a terminal heart condition talk to a person with terminal cancer – they may indeed be able to give each other insight into how they can wrangle the system to get what they want in their medical care. How about a general information place for health care? A place that is non hierarchical, has no loyalties to doctors or hospitals, is just interested in helping patients to make their own informed decisions? That’s what I am envisioning myself doing. Why not be government subsidized? Could I be free with this type subsidy?

Feminists will press for change in status of women and children from breeder and possession, to valuing them. They will challenge the idea that having your wife produce a child with a man’s own genes is sufficient cause for their wives to undergo the physical and emotional assault IVF and genetic technology involve (Sherwin 135).

Conclusions

Doctors, because of their “power of legitimacy” in health care, could use their power to destroy patriarchal attitudes about women; they could dispel myths about racism, homophobia, and classism to begin to destroy oppression. Because the traditional medical model perpetuates oppression, we must develop different models in order to attain ethical acceptability (Sherwin 237-238).

A feminist ethics would expand health and the expertise involved with it. It would not dwell on the physiological, but would consider the social aspects of our lives that have profound effects on our health. It would bring the morality of oppression and its solutions into health care discourse. It would make clear that those in power are morally mandated to seek solutions to oppression. It would necessitate drastic changes in present health care policies. When oppression is considered in medical ethics, the authoritarian model in which the physician is the expert on all matters of health will shatter. A feminist ethics would recognize that experiential knowledge is vital to understanding how oppression effects health and how it can be reduced. Feminist ethics would require political along with moral understanding of health and health care (Sherwin 238-239).

A feminist model would produce social equality by empowering those who have been traditionally oppressed. It would limit the authoritarian scope of those who have gotten so used to being in control. The equalization of structures would foster higher standards of health and health care to those oppressed. It would hear those unheard voices and respond to their needs (Sherwin 239).

The medical model focuses on “cure” and that “curing” belongs to the providers. A feminist approach would ensure empowerment to the consumers of health care by giving them the information and the means to make life changes that would facilitate their health. The medical model is closed to alternative healing modes that increases the power of patients and diminishes medicine’s power over them. “A feminist model would be user-controlled and responsive to patient concerns” (Sherwin 239).

Such changes in our health care structures would direct our priorities to the necessities of healthy living and helping patients to obtain them, rather than waiting to address the damaging consequences. The democratization of the medical model may also lead to reduction in health care costs and be more effective at the same time. Most patients are much less interested (compared to providers) in crisis intervention and the use of high technology as solutions to their health care needs; most patients would prefer prevention (Sherwin 240).

Feminist ideals would seek to alleviate the maintenance of oppression in the health care system. It would attempt to provide fair distribution of health care resources and try to undermine the assumptions on which the rationale for oppression exists. Feminist alternatives are required for both ethics and health (Sherwin 240).

We must start with a democratization bioethics itself; medical ethics must recognize the value of incorporating diversity in its discourse and analysis. Bioethics is similar to other disciplines in that it is judged by the opinions of its participants. Let the moral analysis itself be moral by the inclusion of diverse voices and values in the attempt to develop solutions (Sherwin 240).    

It seems to me that, since women have bought into men’s moral theories it’s no wonder, they have been so guilt ridden when they somehow sense things are not right with the system, but feel, “who are they” to question the very core of things. Perhaps that’s why it has taken so long for women to evolve out of the guilt and accompanying loss of self esteem to even think about developing their own ethical theories that FIT in most people’s lives – not just those of women. Feminine ethics is involved in caring, but that was a way to deal with our oppressors – so we must use caution. Feminist ethicists ask when is caring ok and when is it best withheld?  Sherwin says we must consider justice AND caring (Sherwin 240).

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Sex Object: A Memoir

Sex Object: A Memoir

February 28, 2017

By Jessica Valenti

New York Times Bestseller

“Sharp and prescient… The appeal of Valenti’s memoir lies in her ability to trace objectification through her own life, and to trace what was for a long time her own obliviousness to it…Sex Object is an antidote to the fun and flirty feminism of selfies and self-help.” – New Republic

Hailed by the Washington Post as “one of the most visible and successful feminists of her generation,” Jessica Valenti has been leading the national conversation on gender and politics for over a decade. Now, in a memoir that Publishers Weekly calls “bold and unflinching,” Valenti explores the toll that sexism takes on women’s lives, from the everyday to the existential. From subway gropings and imposter syndrome to sexual awakenings and motherhood, Sex Object reveals the painful, embarrassing, and sometimes illegal moments that shaped Valenti’s adolescence and young adulthood in New York City.

In the tradition of writers like Joan Didion and Mary Karr, Sex Object is a profoundly moving tour de force that is bound to shock those already familiar with Valenti’s work, and enthrall those who are just finding it.

Above review from Amazon.com

Feminist “Scores:” Their Impact on Psychological Testing

By Patricia J. Anderson

Psychological Assessment I (LAP 501), Spring 1997, Dr. Karen Jaffe

After testing nine thousand three hundred thirty seven people in his Anthropometric Laboratory in eighteen eighty four, Sir Frances Galton summarized his findings this way, “women tend in all their capacities to be inferior to men” (Lewin & Wild 1991, p. 582). Over a hundred years later, this erroneous type of belief still lies deeply internalized within the minds of many men and women.

In their essay, Miriam Lewin and Cheryl Ward include the findings of women psychologists whose findings dispute those of Galton. In eighteen ninety five, Mary Whiton Calkins and her student Cordelia Nevers repeated work done by Joseph Jastrow (a follower of Galton) on the “mental traits of sex” (Lewin & Ward 1991, p. 582). Calkins and Nevers results did not demonstrate female inferiority (Lewin & Ward 582).

Helen Thompson Woolley argued against the popular views of Darwin and Galton in her book, The Mental Traits of Sex (1903). A psychology student of Woolley, Leta Stetter Hollingworth also challenged male theories about women’s biological inferiority.

During the nineteen twenties work by Beth Wellman, Marie Skodak and Harold Skeels on intelligence testing had a vital impact by demonstrating the profound effect of social environment on supposedly static intelligence traits. Their work has been crucial to debunking sexist and racist thinking within psychological testing (Lewin & Ward 582).

Rhoda Unger and Mary Crawford (1992) also discuss Galton’s work. Galton measured things like reaction time, grip strength and height because he thought these were innate and were a mirror to intelligence (76). The only people who questioned Galton’s theories were women, but because of their perceived inferior status, were not heard when they posited that opportunity and life experience were involved in intelligence (Unger & Crawford 76). Despite future testing that revealed no differences in variability, brain structures or intelligence between the sexes, the belief in women’s inferiority lives on to this day (Unger & Crawford 76). From the vantage point of today, it’s relatively easy to see how racism and sexism among past researchers might have led them to find justification for labeling women and people of color inferior (Unger & Crawford 77).

Despite the not doubt hard work of these aforementioned feminists, I have not found their names cited in any of the numerous books on psychological testing that I have been reading. The textbook for this class Psychological Testing (1997) makes no mention of these early feminists work that challenged Sir Frances Galton’s findings. Unless these harmful and erroneous findings are actively challenged traditional assumptions of female inferiority are left to linger in our brains. If the works of these women were included in psychology programs, along with the history of men like Galton, today’s students would be much more enlightened about the issues of sex differences and testing. Teacher comment: These sex differences are not mentioned in our textbook.

Lewin and Ward have provided an update on the progress, or lack there of, that has resulted since the recent inclusion of women’s voices in the field of psychological testing. They specifically discuss the Strong Campbell Interest Inventory and the Minnesota Multiphasic Personality Inventory (MMPI).

There are many reasons why feminists have criticized psychological tests. One is that some measures discriminate against females. Some measures address things from the perspective of typical males in stereotypical male settings. Secondly, feminists have found that assumptions have been made (without adequate evidence) that women as a group have less of a particular characteristic if their scores were lower than men’s.  Teacher comment:  Like what?   No one considers males as lacking in any way when they score less of a stereotypical female trait. A third reason for feminist criticism are traditional concepts about femininity and masculinity, masochism, violence and rape as variables (Lewin & Ward 582). If not for feminist inquiry, new concepts such as androgyny, sexual harassment, date rape, and the Rape Myth Acceptance Scale wouldn’t be in existence (Lewin & Ward 582-3). Fourth, feminists posit that operational definitions must be of concern if the originating conceptual definitions are questionable. They offer an example in which femininity was measured via a criterion group of thirteen gay males without first proving that gay males were validating examples of femininity. Lastly, feminists have thought that biases within tests and measures resulted in women being denied admission to schools, denied jobs, and were improperly diagnosed with mental illnesses, when their actual problems stemmed from oppressive environments (Lewin & Ward 583).

Women’s historical not measuring up to male standards on tests created by males, has been used to prove women’s lower status and to justify men’s higher status and power in society. Feminists refute the notion that the standards that we should all be directed to or measured against are those that come from dominant males. Some feminists would go so far as to say that “their way” held the possibility of being “… even better than, the stereotypical male way” (Lewin & Ward 1991, p. 583).

Lewin and Ward ask, “How can we approach truth”? (1991, p. 584). Surely truth cannot come only from male or female perspectives. Surely a combination that includes the experience and “knowing” of women can come closer to “truth” than historic masculinist models.

The most widely used psychological test is the MMPI. It’s most extensive revision the MMPI-2, was put out in nineteen ninety. Scale 5, Mf (masculine-femininity) was validated for femininity in nineteen fifty six by a criterion group of thirteen gay males. Original descriptions of the scale clearly attest to the fact that their attempt to measure “sexual inversion” was a failure (Lewin & Ward 1991, p. 585). However, this fact was less prominent in test manuals (Lewin & Ward 585).

Feminists had minimal success in effecting change within the MMPI. Only four of the sixty items on the Mf scale were deleted due to their offensive nature. New norm samples were drawn on the United States population to get new means, percentiles and scale score distributions. Despite these new means the basic Mf scale 5 was never validated by correlating to any type of criteria (Lewin & Ward 585). Among revisions made on the F scale of the MMPI, one was done because of sexist language (Rothke, et al 1994).

The new MMPI-2 now includes scales that can be used for both sexes; the Gm (masculine gender role scale) and the Gf (feminine gender role scale) were taken from items on the old scale. These new scales include only items that seventy percent of one sex respondents label true and no more than sixty percent of the other sex respondents agree. Items are scored for extremes only. Lewin and Ward give the example of how the question, “I like to read mechanics magazines” is scored: Because men split about half in agreeing with this item, men will get no point no matter how they answer this question; when a female answers false to this question gets point in favor of femininity due to the fact that seventy percent or more of women in the sample answered false (585-586). The authors rightfully question whether we can gauge femininity and masculinity in this manner (Lewin & Ward 586). Also couldn’t one be feminine and like to read mechanics magazines? Couldn’t a man be masculine without enjoying mechanics magazines? These measures serve to trivialize the meaning of both genders.

Face validity is also questionable as far as the meaning of the concepts rated. Women get positive femininity on items such as, “I like to talk about sex”, “I am worried about sex” when they answer false to these questions; males gets points for answering true to these. What do these concepts mean (Lewin & Ward 586)? Could it not be that men and women like to talk about and worry about sex?

Lewin and Ward call into question the manual’s explanation of characteristics used to gauge femininity and masculinity. The manual claims that males scoring highly feminine are likely to be sensitive, aesthetic, passive and may even have a low heterosexual drive in contrast to males who score low and are deemed to be aggressive, crude adventurous, reckless with narrow interests – no evidence is offered to substantiate these claims about these traits. Despite the fact that the authors of the MMPI-2 have admitted that the Mf scale is ambiguous, people who use the test may not know this (Lewin & Ward 586).

This leaves feminists to ask whether this test ought to be used to screen people looking for jobs. Employer bias could occur in either direction. Masculine men may be thought unlikely to be happy in a creative type job and a woman who scores high on femininity may be questioned as far as her ability to fire someone if she were in management. There is a class action suit pending in California against a department store that used the old MMPI as a hiring tool (Lewin & Ward 587).

The Mf (MMPI) scale isn’t a valid measure of sexual preference or of how masculine or feminine a person is. The fact that femininity was measured against responses from gay males speaks for itself (Lewin & Ward 587). The fact that test creators would even consider using gay men to measure women demonstrates the extent to which men are consistently used to develop “norms” that women are expected to measure up. The criterion also wrongly assumes that gay men are feminine.

According to Friedman, expert on the MMPI, Scale 5 (masculinity-femininity) of the MMPI-2 was originally used to detect homosexuality. Today it’s used to measure interest patterns (Friedman 1997). Friedman says that low scores on this scale reflect the fear of being cared for and the missing joy of being card for (1997). He used a fellow author and friend to demonstrate how a male can be married with kids, but also love fashion and shopping (Friedman 1997). Clearly his description of the Mf scale does represent evidence of feminist influence. His description gave me hope that, at least within psychology, stereotypical attitudes about gender are being challenged.

Friedman (1997) also says that the MMPI can detect men who would commit date rape. As a feminist, I immediately ask myself why the test hasn’t been used to weed out potential rapists? What use of testing could be more important than the protecting women from harm? If the test can detect date rapists, then the test could also be used to detect therapists who would take advantage of their clients by having sex with them. Since rape is about control and power, not sex, therapists in essence do rape clients when they have sex with them. Why isn’t this test being used to prevent harm? Teacher comment: Individual rights are protected on both sides.

One of the major causes cited for malpractice claims against therapists is sexual misconduct. Occurrence rates for sexual intimacies and harassment inflicted by therapists are shocking and have been increasing (Corey 1996, 74). Corey credits better reporting procedures and increased public awareness with these increases (1996). With shocking rates of sex occurring between therapists and clients wouldn’t it make sense to use a psychological test that could weed out potential client abusers?

Feminists have yet to make a dent in the way people are assessed for Post Traumatic Stress Disorder. Not a single study used women to develop the measures. Women rape or incest victims, or army nurses could have been used in the seventeen studies done with male combat veterans and prisoners of war (Lewin & Ward 587).

Lewin and Ward also talk about the Strong Campbell Interest Inventory as an example of where feminist critique has had a positive result. Here feminists asked whether women should be judged by what a typical male feels about his occupation. After studying sex bias in the inventory, the American Measurement and Evaluation in Guidance Commission found that the fourth edition had been much improved. The fourth edition was found to have only five out of two hundred and seven occupations lacking in samples taken from men and women (Lewin & Ward 588).

The evolution of the Standards for Educational and psychological Testing is evidence of the inclusion of women. It’s nineteen eighty five revision says that there is a concern about the role of testing in the attainment of social goals. New developments such as, gender specificity, cultural bias, validity generalizations, interpretations done via computer and scores flagged for those with disabilities are some cautions that were brought out (Lewin & Ward 589). The previous nineteen seventy four standards didn’t address gender issues; the nineteen eighty five revision does address differences in gender, bias of certain items and differential predictive measures. The Code of Fair Testing Practices in Education (1988) agrees with the nineteen eighty five revision, along with all majors testing organizations in education (Lewin & Ward 589).

Women score lower on the Scholastic Aptitude Test (SAT) than men, but these tests fall short of predicting how women will perform in college because women are known to get better grades in higher education (Unger & Crawford 87) . On the actual abilities gained from courses reflected on the tests girls continually attain higher grades (Unger & Crawford 93).  As a result of women’s lower test scores they loose out on many scholarships; more than seven hundred and fifty organizations award scholarships according to a test score. Women also loose when they are wrongfully denied inclusion in gifted programs. These concrete losses are compounded by the fact that lower test scores effect women’s sense of confidence about their ability to succeed in school (Unger & Crawford 87).

The Educational Testing Service mandated a sensitivity review process in nineteen eighty. Its effect resulted in changes in the SAT Verbal tests to a more balanced referencing of males and females. Items that were thought to be related to being male or female specifically were dropped from scoring (Lewin & Ward 590-591). There has also been an increase in the number of women on test committees. In nineteen seventy-seventy one, there were only six percent women on the testing committee for the Graduate Record Exam (GRE), compared to twenty nine percent in nineteen ninety-ninety one. Other programs demonstrate moves in the same direction (Lewin & Ward 591).

Unger and Crawford (1992) explain that it’s language that has described women and men as “opposite sexes” (67). The journal Psychological Abstracts reported 16,416 articles on sex differences between nineteen sixty seven and nineteen eighty five. They claim that the differences thought to be discovered between women and men are rarely related to biology. They refer to sex differences as carrier variables in personal history and experience. Thus feminist psychologists describe differences found as gender-related  (Unger & Crawford 1992 p. 67).

Feminist critique the very definition of gender-related differences, the problem of measuring them, and understanding the results due to issues of interpretation and values. Feminist researchers discovered that historically women’s unequal status was justified by differences documented as scientific facts. Finding new differences between the sexes neglects to explain the societal influences that led to the differences. Feminists argue that differences between women and men are far less actual commonalties (Unger & Crawford 67). The notion of statistical significance can be far removed from the practical meaning of the word significance. “… Statistical significance is not the same as importance” (Unger & Crawford 69).

Unger and Crawford use the image of looking through a microscope as way to explain how researchers perceive their hypothesis in terms of results. If the researcher gazes through the microscope and views what was expected the hypothesis is deemed correct. If the view down the microscope shaft is blurry or shows nothing, the methods are blamed, the procedures are tried again, instead of concluding that the hypothesis was wrong to begin with (Unger & Crawford 70).

Within studies of gender-related differences many times researchers have studied only one of the sexes and posited the results as difference between the sexes. Measuring only hormonal differences as they correlate with mood among women, and then saying that only females experience this phenomenon (Unger & Crawford 71). Feminists also question taking samples for many research studies from college students. These female and male students may have equal levels of formal education, but may differ greatly on the types of classes taken from the start of high school and will frequently be very different while in college. These differences may be crucial to women’s lives (Unger & Crawford 72).

My own experience serves to validate what Unger and Crawford have said. The Miller Analogies Test that had little face validity for me. I never had a college math, philosophy or literature course. I studied nursing, physical and social science and medical ethics. Despite the fact that I graduated with honors from my nursing associate degree program, held a 4.0 GPA (four point scale) in the rest of my baccalaureate studies, and had already obtained A’s on five graduate courses at DePaul University, I failed this test. Out of one hundred questions, I got twenty eight correct, placing my score within the twenty fifth to thirtieth percentile. I can now see that the courses I chose to study did indeed explain why its face validity prepared me for failing. Thanks only to my feminist education and due to the last ten years of excellence in undergraduate and graduate school, my self confidence was not affected by this apparent failure.

My experience validates the claim of Unger and Crawford that, “A valid psychology of gender difference must account for how individual experiences and situational variables interact with sex (Unger & Crawford 74). Even new sophisticated techniques of meta-analysis do not lead us to any conclusions about the causes of differences historically found in published studies (Unger & Crawford 75). Traits usually connected with people of color and women, when compared to those of the “reference group,” are less affirming and desirable. “… Separate but equal …” stratifications remains illusive (Unger & Crawford 77).

Most psychological research measures behaviors outside of their social environment, which feminists question as far as then extrapolating real world validity; taken out of context, objectivity faces a mirage (Unger & Crawford 98). According to testing specialist, Phyllis Teitelbaum, standardized tests are androcentric in their epistemology in that they fail to measure skills such as creativity, intuition, verbal and non-verbal communication, cooperatives, sensitivity and supportiveness, all of which reinforce the androcentric model’s values and way of seeing the world. When something’s not tested it’s less valued than items included on tests (Unger & Crawford 98).

Because of feminist inquiry some psychological tests have been revised for the better. Sexism is more likely to be challenged today because of the work of feminists, despite the failure to promote change on the MMPI-2 Mf scale. The field of psychology and testing will evolve slowly along with the increasing presence of women in the field (Lewin & Ward 593).

Work Cited

Anastasi, Anne., and Urbina, Susana. (1997). Psychological Testing. Prentice Hall: New Jersey.

Corey, Gerald. (1996). Theory and Practice of Counseling and Psychotherapy. Fifth Edition. Brooks/Cole Publishing Company: New York.

Friedman, Alan. (1997). Lecture on the MMPI Test. National-Louis University, Wheeling Campus. May 5.

Lewin, Miriam., and Wild L. Cheryl. (1991). “The Impact of the Feminist Critique on Tests, Assessment, and        Methodology.” Psychology of Women Quarterly, 15, (pp. 581-596).

Rothke, Steven E., Friedman, Alan F., Dahlsrom, W. Grant., Greene, Roger L., Arredondo, Rudy., and Mann, Anne Whiddon. (1994). “MMPI-2 Normative Data for the F-K Index: Implications for Clinical Neuropsychological, and Forensic Practice.” Assessment. vol 1, number 1, pp. 1-15.

Unger, Rhoda., Crawford, Mary. (1992). Women and Gender: A Feminist Psychology. New York: McGraw-Hill, Inc.

Feminist Therapy: Valuing Women

Feminist Therapy: Valuing Women

By Patricia J. Anderson

Frida Kerner Furman, MALS 477, Feminist Ethics, March 14, 1996

 

My interest in feminist therapy stems out of my own difficult experience with non-feminist therapy. Like many women, I have gone into therapy at various times in my life, basically wondering, What’s wrong with me? Why was I so unhappy? Why was I so sad, incompetent, and worthless? I was sure that the inner inferiority and confusion was within me, that it was my fault.

I will illustrate how “traditional and/or family values” have actually had a part in causing women’s mental health problems. I will tease through feminist therapy ideas, principles, disorders common to women, and women’s diversity to illuminate the feminist values that inform this field that offers real promise to women’s mental health.

Feminist Therapy, Do We Really Need It?

A personal friend’s experience with therapy provides an insightful example of the need for feminist therapy. She sought therapy to help her get away from an abusive husband. She began to tell me some of the therapist’s responses to her explanations of the type of abuses her husband inflicted upon her. It became clear to me that this therapy was never going to help her to gain the psychological strength she needed to escape.

Examples of the therapist’s responses to her depictions of the physical and psychological abuse were: Maybe you should stay home on Saturdays and do housework; Do you really have to go to the movies with your girlfriends?; Have you really tried to cook the foods that he likes?; Maybe it’s a good idea to let him handle your paychecks, maybe he’s better with money?

It took months to convince my friend that this therapist was not only not helping her, but was functioning to maintain the abusive relationship. The therapist was blaming her for the abuse, trying to get her to conform to the passive, obedient feminine role that would support her husband’s dictates! The solution was simply for her to follow the prescribed feminine role and her marriage would be alright. It was assumed that the problem stemmed from inside her, her patriarchal disobedience was in need of fixing!

Rather than empowering her to act in defense of her self, the therapist reinforced her internalized inferiority. My friend’s experience with psychotherapy is not an isolated one. Many women have had similar experiences, although perhaps not as obvious and easy to articulate. Therapy’s perpetuation of oppression can be as subtle and invisible as it sometimes is in society, especially when combined with the client’s emotional vulnerability.

Medicine and Morals

Kathryn Morgan describes women’s moral status as akin to a moral groupie, dependent upon males deemed capable of full moral integrity (149-150). The male moral model claims that “… women’s bodies are interpreted as capable of acting on the mind so as to occlude consciousness, thought, and moral feeling” (Morgan 150). If women lack societal power to live according to their own values, it serves to explain why women are so frequently unhappy.

According to Rhoda Unger and Mary Crawford, the male medical model sees “… a direct connection between the uterus and the mind” (572). Throughout history the uterus has been blamed for women’s so-called hysteria/insanity. The term most women are very familiar with, hysterectomy, refers to the removal of the uterus – the source of women’s insanity. Hysteria is used to label stereotypical behaviors of exaggerated femininity including: “… being demandingly childlike, overly dramatic, scatterbrained, and sexy, but frigid” and according to Rachel Mustin, may actually depict, “… a caricature of women”, not a mental illness (597).

Imagine an opposite affliction in males, “testeria.” Despite common accusations that men think with their penises, “We need never worry about disabling testeria in men” (Morgan 151). Sometimes turning things around can illuminate the preposterous nature of the masculinist arguments about women’s so-called “hysteria.” Can you imagine books titled, Men Who Love Too Much or Men Who Feel Guilty When They Say No?

The Genderization of Women’s Psychological Disorders

Many psychological disorders are actually exaggerations of masculinity and femininity. In our society characteristics that define femininity also define maladaptive behaviors. Thus the gendered societal norms that we have internalized are at the root of many of the psychological problems frequently seen in women.

Traditional therapists see the world through the same gender-colored lenses that the rest of society does. Women are diagnosed and treated by a system that places women’s psychological disorders within the individual women. However, many of women’s problems are the result of societal oppression.

The development of mental illness may be influenced by sex roles that demand that women repress negativity, strive to satisfy men, be passive, helpless and at times to even exaggerate their femininity (Mustin 595). Judith Rodin and Jeannette Ickovics say that a person whose social role lacks power and control is more likely to be victimized by violence, sexual discrimination and harassment (1018). It’s not healthy to be confined within a role prescribed by someone else, let alone some one else who seeks control.

Unger and Crawford describe the social constructionist view of mental illness which claims that psychological distress encompasses personal and social aspects (Unger & Crawford 569). Morgan recommends, “… a vigilant deconstructionist attention to sexist, racist, heterosexist and class presuppositions” (161) as one solution to women’s internalized “moral madness”. The personal is political definitely applies to women’s psychotherapy.

Women’s unequal status has robbed them of the power to define and even to name themselves. Men have held the power to name and/or diagnose the acceptability of women’s behaviors. “The power to name is also the power to control” (Unger & Crawford 569). “… Under some circumstances, simply being a woman is sufficient reason to be considered `mad'” (Unger & Crawford 571). Many disorders common to women come out of stereotypical roles expected of them, thus the naming and treatment of their disorders can’t be value-free (Unger & Crawford 571). Within this cultural power dynamic how could women’s therapy be therapeutic, let alone ethical?

Despite a lack of knowledge about women’s psychology, mental health services for women have flourished due to the pervasive nature of women’s unhappiness. Women’s responses to oppressive “… social, economic, ethical and legal conditions,” instrumental in causing women’s problems, are labeled pathological, and are thus subject to psychiatric intervention (Mustin 593).

Erickson explains women’s masochism in allowing their own exploitation by theorizing that women only find identity when they figure out who to marry (Mustin 594). Erickson’s theory is a patriarchal rationalization and justification for female exploitation. The notion of a woman’s self, found only in conjunction with a male, dependent upon exploitation for development is beyond unethical – it’s evil. Applying Nel Noddings’ theory of evil, this notion has caused women great psychic and physical pain and has separated women from their sense of self. And as a result of the internalization process, harmful ideologies become invisible, leaving women helpless in escaping their psychological grasp (91).

Typical Genderizations

Morgan quotes Andrea Canaan regarding intellectual growth and its connection with her womanly virtue of altruism, “The open heart and forgiving soul stifled my rightful indignation, gagged my rage, and forced my fear, my needs, my rage, my joys, my accomplishments, inward” (154).  Psychological disorders reflect gender roles. Women become depressed, anxious, passive and unassertive; their behaviors are viewed as mental health issues (Unger & Crawford 597). Men exhibit psychic disorders through acting out, which involves anti-social behaviors–toughness–and because they’re dealt with in the criminal justice system, aren’t seen as psychological disorders (Unger & Crawford 597-600). The fact that women take their psychic pain inward and seek mental health services makes it look like women have more mental disorders (Unger & Crawford 600).

Depression

Studies show that married women experience depression more than men and that husbands of housewives experience the least depression. Conflicting expectations between trying to care for children and maintaining a job plus the stress of multiple roles plays a part in the depression married women experience (Unger & Crawford 579). The Task Force on Women and Depression of the American Psychological Association found that women’s low social status, poverty, and sexual/physical abuse was depressing to women (Unger & Crawford 579). How … shocking!

The medical model posits a connection between women’s biology and depression. Three basic syndromes are blamed for women’s depression: Premenstrual syndrome (PMS), postpartum depression and menopausal syndrome. There are also three no’s that apply to these diagnoses: No symptoms or pattern of signs define them, there are no tests to prove their existence and there is no cure or effective treatment for them (Unger & Crawford 581). Contrary to the claims of medicine, studies have demonstrated that menopause is rarely a crisis to women (Mustin 596). And yet the pathologizing goes on.

Women’s cyclicity has not been valued. Biological connections with female emotionality is just another way to justify and rationalize women’s inferiority, lower status and vulnerability to psychological problems (Unger & Crawford 581-582). The knowledge of all this alone is depressing.

Healthy self-esteem protects people from depression and self-esteem reflects cultural values. Signs and symptoms of psychological disturbances are likely to occur when people are prevented from expressing behaviors that enhance their self-esteem (Unger & Crawford 579). Women are likely to experience poor self esteem because they’re not valued in society.

Anorexia and Bulimia

Unger and Crawford suggest that the pandemic nature of women’s “normative discontent” with their weight is inseparable from the fact that women are the major victims of anorexia and bulimia (585). The connection between this disorder and the societal mandate for thinness is obvious. Traditional mental health has no effective treatment to offer patients with these life threatening conditions (Unger & Crawford 588). The collective rejection of the perfect, skinny female body could prevent this disease but presents a monumental task.

Agoraphobia

Agoraphobia serves as a perfect example of a disease that is inseparable from notion of femininity gone too far – the phrase, “a woman’s place is in the home” fits this disease. Agoraphobia is usually seen in married women and means “fear of the marketplace.” Another name for it is “housewife’s disease.” The client fears leaving home or a safe place (Unger & Crawford 590). The severity of symptoms ranges from fearing elevators, crowds, expressways to fearing separation from home or trusted person (Unger & Crawford 590-591). Agoraphobia requires relationality. They’re passive, dependent on others for basic needs, and unable to make decisions. Husbands of agoraphobics report satisfaction with their marriages, perhaps due to the wife’s obvious femininity (Unger & Crawford 591).

Self-defeating Personality Disorder

Self-defeating personality disorder (a concept derived from psychoanalytic theory) serves as a label for women’s masochism exhibited by remaining in abusive situations. Victims of interpersonal violence have high rates of mental illness, yet a study of this diagnosis never asked the three hundred women about abuse (Unger & Crawford 593). Interestingly, when removed from abusive situations for six months, symptoms were diminished or disappeared altogether, thus arguing against a disorder of personality itself (Unger & Crawford 593).

This diagnosis is an example of a double bind that blames women if they fail to keep the family together, but labels them crazy if they don’t get out of abuse (Unger & Crawford 593). If we twist the diagnosis to fit males, a new diagnostic category  blooms into being: “Delusional Dominating Personality Disorder,” describing the pathological social norm of the “real man” (Unger & Crawford 569).

Traditional Therapy and The Male Medical Model

The Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) classifies disorders of the American Psychological Association (1987). Judith Worell and Pam Remer assert that the DSM-III-R is an offshoot of the sexist medical model. It focuses on personal pathology, denying oppression and institutional stressors (153). Established norms come from healthy male models, making pathology itself genderized (Worell & Remer 156-8).

Over seventy percent of psychotropic medications are prescribed to women (Mustin 595; Rodin & Ickovics 1018), despite the fact that they were not included in most of the research done on these drugs. The disproportionate use of these drugs among women is linked to the fact that, instead of being viewed as a psychosocial issue, stress has been designated as a medical pathology (Rodin & Ickovics 1027).

Studies examining clinicians’ beliefs about normal and appropriate characteristics of men and women parallel the rest of society. Therapists don’t make distinctions between healthy adults and healthy males (Unger & Crawford 597). If male behavior is the norm – no wonder women seem crazy.

According to The President’s Commission on Mental Health (1978), providers and administrators of health care are mostly male, but most clients are women. There’s no reason to believe that these males have less oppressive attitudes toward women than any other male. Male therapists have encouraged women to accept and adjust to the unhealthy behaviors implicit in our societal roles; males frequently lack insight into women’s experience and reinforce the patriarchal power that brought women into therapy to begin with (Mustin 594).

Over the last forty years, psychoanalytic and psychodynamic theories have dominated psychotherapy that specify, “… women’s innate nature as passive, dependent, and morally inferior to men” (Mustin 594). Rarely even recognized by therapists is the injustice women face within the traditional family (Mustin 596). With a chauvinistic physician you risk your physical health; with a chauvinistic therapist you risk your sanity.

Psychodynamic therapy assumes problems are “all in the head” of the individual stemming from unconscious forces (Unger & Crawford 601). Androcentrism is more likely to view behaviors of women and minorities as disordered, thus traditional psychotherapy acts as a social control (Unger & Crawford 601, 602). Women are expected to the behave within male norms; when they deviate from these norms they’re labeled less than. Freud’s penis envy theory places a penis in a “better than” position with vagina and uterus (Worell & Remer 85).

Traditional therapy denies the oppressive social context of women’s problems, thus denying the lack of justice at the root of many woman’s problems. A misogynistic society guarantees large numbers of unhappy women for mental health professionals to treat (Unger & Crawford 602). The mental health system also stands to profit from its misogyny. If traditional therapy maintains women’s oppression while making a profit, how therapeutic might it be?

Feminist Therapy’s Values

Susan Sherwin posits that the basic criticism that feminist ethicists have with traditional biomedical ethics is that its discourse excludes people’s oppression, thus it’s unethical (54). Biomedical ethics addresses issues of importance to doctors and ignores problems of importance to women, minorities and other health professionals, despite the serious effect they have on patient care (Sherwin 4). The mental health system’s same lack of ethicality is compounded by the fact that the exclusion of women’s values and oppression has itself caused many of women’s mental health problems.

Inclusion of Diversity

Inclusion is a fundamental value for feminist therapy. Traditional therapy has not addressed the needs of the many diverse varieties of women. Psychological diagnosis and symptomology include assumptions about class, race, ethnicity, age and sexual orientation that are enmeshed in the labels attributed to people (Unger & Crawford 570).

African-American Women

Angela Neal and Midge Wilson discuss how Black women have not only been compared to the norms of healthy males, but to the beauty standards of white women. In therapy, Black women frequently need to deal with anger and resentment about an additional discrimination they face in their own community related to skin color and features. A light-skinned Black women may be concerned about her ancestral history and may feel guilty about privileges that she might enjoy because of her light complexion and Caucasoid features. A dark-skinned woman may feel unattractive and might resent Black men who prefer lighter skinned women (330). Therapy can help Black women to realize that images of white beauty are inappropriate and must be redefined within the Black community (Neal & Wilson 332). Therapy and social change must fit the context and needs of particular women’s experience.

Asian-American Women

Connie Chan says that Asian women have been viewed as sexual objects and prostitutes by American soldiers (34). Their portrayal in Western media as exotics has fostered the fantasy of Asian women as passive sex slaves and created a booming market for mail-order brides in America (Chan 34-35). Mail-order brides are prime targets for exploitation and abuse for several reasons: they come from desperate poverty, to a strange country with a new language and culture, to a husband of a different race and nationality who has enormous power over them (Chan 35).

Asian-American women seem quiet, submissive, unlikely to be rejecting, and invisible while at the same time alluring. Values developed from her Asian-American culture make it likely that women will be agreeable, gentle and will defer to the needs of others. Chan shares that in her practice with Asian-American women there is a conflict between their own values, and feeling unrespected and abused within the American system that values placing one’s own needs first (36). They frequently use denial to deal with uncomfortable feelings of objectification by men (Chan 36). After initially feeling vulnerable when they realize how they’re stereotyped, they experience ambivalence about the desire for invisibility and wanting attention for who they really are (Chan 36-37). Like most women, they blame themselves for their problems (Chan 37).

Hispanic-Latina Women

Lillian Comas-Diaz describes Marianismo as a concept taken from the Catholic church’s Virgin Mary that serves as an example of female superior spirituality that provides women with the strength to endure male abuse (43). This image forbids women to express interest in sex, even after marriage, but expects men to be interested in sex all the time (Comas-Diaz 43-44).

Machismo is about male virility, male as provider and protector of female relatives from other men’s advances. The extreme form of machismo includes alcoholism and physical abuse. Hembrismo, a sort of revenge to machismo, is an image of female strength similar to feminists (Comas-Diaz 44). In Puerto Rican culture Hembrismo women use their power in a spiritual sense which might be compared to the superwoman image in America (Comas-Diaz 45).

Acculturation issues sometimes mandate role reversal. The fact that female immigrants find work easier than men in America has led some Chicana women to reinforce machismo in their mate as a means to soothe their lower status (Comas-Diaz 48-49).

Physical and psychological problems aren’t separated in Hispanic/Latino culture and it’s believed that strong emotions lead to physical illness. Somatization is not only an accepted way to express one’s needs, but is rewarded with support from the family (Comas-Diaz 51).

Lesbians

Laura Brown discussed three themes that explain the lesbian and gay identity: Biculturalism, marginality, and normative creativity (New Voices 452). The bicultural aspect allows lesbians and gays to incorporate the ambiguous nature of more than one cultural identity at the same time (Brown, New Voices 452). “The experience of having both self and other within one’s identity development creates a singular and potentially powerful heuristic model for self-understanding” (Brown, New Voices, 450).I would go beyond biculturalism to multiculturalism. Being a lesbian or gay man adds another separate cultural layer of identity, in addition to being Black or white, Asian or Hispanic, Jewish or Hindu. There are Jewish Black lesbians.

Another layer of identity involved in lesbianism is the butch\fem\androgyny concept. This involves women developing various degrees of stereotypical masculinity, femininity or a combination of the two. There is much confusion and ambivalence within the lesbian community about this topic. Research is needed in this area of psychological development to help lesbians avoid mirroring the dominant culture’s harmful stereotypes.

Living along the margins, inside and outside of dominant culture, provides lesbians a view into both homosexual and heterosexual worlds (Brown, New Voices, 452). The feminist value of inclusion demands that we value lesbian identities that include multicultural visions of the world not available to heterosexuals.

Brown describes normative creativity as the ability to invent workable limits where there were none, and with make-shift tools (New Voices 453). Brown says that her experience with psychotherapy ethics sees “… ethical action as a continuous variable” and that “… having rules about what to do narrowed my thinking and excluded that which had never been considered, thus making it invisible” (New Voices 453). A great argument for a creative ethicality in feminist therapy in general.

In the context of large number of homosexuals who have received or are in therapy, Brown questions whether it’s due to pathology or whether it’s a health-seeking mechanism to deal with the societal ambiguity they live in (New Voices 456)?

Principles/Feminist Values in Therapy

Your therapist’s values CAN hurt you! Worell and Remer warn that, without conscious awareness, each therapist’s values will be communicated in therapy. They discuss three basic principles of feminist therapy: The personal is political, egalitarian relationships, and valuing the female perspective (Worell & Remer 91). Feminist values lie within their context.

The Personal is Political

This very basic feminist principle asserts that what happens to individuals also has political aspects and acknowledges that social experiences are at the core of women’s problems. This principle leads feminists to address three areas of therapy: Separating the external from the internal, reframing pathology, and initiating social change (Worell & Remer 92).

Therapy’s goal is to assist clients to externalize problems so that their societal core becomes visible. Clients can then choose whether or not they want to work on change, not only within themselves, but in their environment. Instead of looking for ways to cope with dysfunctional situations, therapists focus on the unhealthy situation (Worell & Remer 92). Thus women’s societal experience is valued.

Instead of blaming the client, therapists help clients to see their “pathology” as coping mechanisms to deal with numerous societal dysfunctions. This reframing would make symptoms of depression natural, “normal,” and even logical in the face of discrimination. This perceptual change has the power to remove the “crazy” label imposed upon the client’s self and can lead women to understand that nothing is wrong with them; Thus the fuel of empowerment to facilitate change is instilled (Worell & Remer 92).

Women aren’t only taught to express their anger, but to use it’s energy to effect change. The client is also held responsible for making changes (Worell & Remer 92). Feminist therapists also assist clients to become involved in social change within their communities. Social change becomes enmeshed in preventative mental health care for women (Worell & Remer 93).

The ultimate goal of women’s therapy is to help women to see and overcome* the ways in which they facilitate their own oppression and to help women to see their power (Unger & Crawford 602).

Egalitarian Relationships

The therapist/client relationship itself serves as a model of egalitarianism. Therapy’s use as social control is minimized, the therapist’s values are not imposed and the imbalance of power so often experienced by women is rejected. Rather than an expert\sick mode, therapy is a collaborative process that empowers the client by viewing her as expert on herself and her experience (Worell & Remer 94). This egalitarian process starts with the therapist sharing her values with clients, educating clients about feminist therapy itself, along with its goals, thus making the client an informed consumer (Worell & Remer 95).

Self-disclosure is used to reveal common experiences, divert the focus from internal causes and reduce role distance and power (Worell & Remer 95). Self-involvement is a tool that allows the therapists to respond emotionally to the client, allowing the client to safely test how she is perceived. When feelings are mutually expressed, vulnerability is reduced and the therapeutic relationship models healthy communication along with acceptance of and the expression of anger (Worell & Remer 95). The traditional model of “the objective, emotionally- distant, expert-therapist” is replaced by feminist values of “… empathy, sharing of common experience, nurturance, and mutual respect (Worell & Remer 95-96).

Valuing the Women’s Perspective

By helping women connect with devalued parts of their self, feminist therapists help women to rethink weaknesses and negativity in terms of strength and positivity. Harmful double binds are pointed out so they can be disregarded (Worell & Remer 97). Women can be assisted to reject male definitions of femininity. Therapists help them to validate, value and trust their experience, offering the opportunity for self discovery and for the development of women-centered world views (Worell & Remer 97-98). Feminist values: Empathy, nurturance, cooperation, intuition, interdependence and relationship are priorities. Valuing the female self and female relationships can lead to self-nurturance, healing and social change (Worell & Remer 98).

Brown’s value system also includes self-care for the therapist (Ethical Issues 333). Feminist therapists need to be valued as much as their clients. Within small communities the number of feminist/lesbian therapists may be limited. As a leader in the community the therapist may feel obligated to always project an image of competence and complete mental health which may result in her personal feelings being ignored. A therapist whose role stress and self-care is ignored is more likely to slide down the ethical continuum toward problematic action (Brown, Ethical Issues 333). If you don’t take care of yourself you’re more likely to make “ethical errors.”

Ann Stanford eloquently synthesizes the work of three African-American fiction writers whose characters find healing outside of the medical/mental systems. Stanford’s synthesis artfully blends connections between personal health and societal illness, so that their inseparability is unquestionable. She argues that health professionals have not only overlooked social change as a therapeutic option, but their very treatments serve as a means of duplicating and perpetuating oppression (Stanford 30). The African-American women authors refuse to name the illnesses of their characters, illustrating that without medical labels illnesses “… are out of medicine’s reach” (Stanford 31). She refers to a poignant metaphoric phrase taken from one of the novels, “… the `poison of reality,'” spreading like gangrene through a woman’s body (Stanford 39). One might envision oppressive ideologies causing psychological gangrene that destroys parts of a woman’s self.

Finally

Unless therapy comes out of women’s experience it harms women and as a result is unethical. For women’s therapy to be truly therapeutic it must deconstruct the social context and so-called symptomology attributed to their so-called madness. Women themselves must create a feminist paradigm of therapy that comes out of lived experience. We must de-internalize patriarchy’s notions of who we are. Within a racist and sexist society, “… the community is both the disease and the cure” (Stanford 34).

I think feminism itself is therapeutic, simply sharing feminist values among women offers the potential to heal societal wounds. Any therapeutic environment must honor women’s experience, diversity, and values. It needs to address the unjust and oppressive environment women live in and must emphatically reject blaming women for their situations. Feminist therapy teaches women they’re not crazy, that the craziness lies in the ill society. Internalized “norms” that have actually caused women’s disproportionate unhappiness must be revealed and rejected. Feminist values themselves contain the power to heal societal wounds and ills. If women lived in a society that valued and really loved them, most women wouldn’t need therapy.

One last thought. If one believes that the mind, body and spirit are inseparable, it would make sense that if we improve women’s psychological health we stand a good chance of also improving their physical health. If you feel good about yourself, odds are you’ll be less likely to become physically ill. I think feminist therapy has the potential to also enhance women’s physical health and well being. A loved self and valued body is less vulnerable to stress and illness.

Teacher comments:  This particular stance might be arguable. More convincing would be to say that standard therapy harms women and it is unethical.

Works Cited

Brown, Laura S. “Ethical Issues in Feminist Therapy: Selected Topics.”  Psychology of Women Quarterly 15 (June 1991):  323-336.

___.  “New Voices, New Visions: Towards a Lesbian and Gay Paradigm for Psychology.”  Psychology of Women Quarterly 13 (1989): 445-458.

Chan, Connie S. “Asian-American Women: Psychological Responses to Sexual Exploitation and Cultural Stereotypes.” Women and Therapy 6 (1987): 33-38.

Comas-Diaz, Lillian. “Feminist Therapy with Hispanic/Latina Women: Myth or Reality?” Women and Therapy 6 (1987): 39-61.

Morgan, Kathryn Pauly. “Women and Moral Madness.”  Feminist Perspectives  Eds. Lorraine Code et al. (n.d.): 146-167.

Mustin, Rachel Hare T.  “An Appraisal of the Relationship Between Women  and Psychotherapy: 80 Years After the Case of Dora.” American Psychologist (May 1983): 593-601.

Neal, Angela M., and Wilson, Midge L. “The Role of Skin Color and Features in the Black Community: Implications for Black Women and Therapy.”  Clinical Psychology Review 9 (1989): 323-333.

Noddings, Nel. Women and Evil. Los Angeles: U of California P, 1989.

Rodin, Judith, and Ickovics, Jeannette R. “Women’s Health: Review and Research Agenda as We Approach the 21st Century.” American Psychologist 45, no 9, (Sept 1990): 1018-34.

Sherwin, Susan. No Longer Patient: Feminist Ethics in Health Care. Philadelphia: Temple UP, 1992.

Stanford, Ann Folwell. Mechanism of Disease: African-American Women Writers, Social Pathologies, and The Limits of Medicine. NWSA Journal 6, no 1, (Spring 1994): 28-47.

Unger, Rhoda, and Crawford, Mary. Women and Gender: A Feminist Psychology.  New York: McGraw-Hill, 1992.

Worell, Judith, and Remer, Pam. Feminist Perspectives in Therapy: An Empowerment Model for Women. New York: Wiley, 1992.

 Bibliography

Brown, Laura S.  “Ethical Issues in Feminist Therapy: Selected Topics.” Psychology of Women Quarterly 15 (June 1991): 323-336.

___.  “New Voices, New Visions: Towards a Lesbian and Gay Paradigm for Psychology.” Psychology of Women Quarterly 13 (1989): 445-458.

Chan Connie S. “Asian-American Women: Psychological Responses to Sexual Exploitation and Cultural Stereotypes.”  Women and Therapy 6 (1987): 33-38.

Comas-Diaz, Lillian. “Feminist Therapy with Hispanic/Latina Women: Myth or Reality?” Women and Therapy 6 (1987): 39-61.

Enns, Carolyn. and Hackett, Gail. “Comparison of Feminist and Nonfeminist Women’s Reactions to Variants of Nonsexist and Feminist Counseling”.  Journal of Counseling Psychology 37, no 1, (Jan 1990): 33-40.

Enns, Carolyn., Hacket, Gail., and Zetzer, Heidi. “Reactions of Women to Nonsexist and Feminist Counseling: Effects of Counselor Orientation and Mode of Information Delivery.” Journal of Counseling Psychology 39, no 3 (July 1992): 321-330.

Gilbert, Lucia Albino, and Osipow, Samuel. “Feminist Contributions to Counseling Psychology.”      Psychology of Women Quarterly 15, 1991: 537-547.

Glidden, Cynthia, and Tracey, Terence. “Women’s Perceptions  of Personal Versus Sociocultural Counseling Interventions.” Journal of Counseling Psychology 36, no 1, (Jan 1989): 54-62.

Koss, Mary P. “The Women’s Mental Health Research Agenda:  Violence Against Women.” American Psychologist 45, no 3, March. 1990: 374-380.

Lerman, Hannah. and Porter, Natalie, eds. Feminist Ethics in Psychotherapy. New York: Springer, 1990.

Marecek, Jeanne., Mustin, Rachel Hare,. “A Short History of the Future: Feminism and Clinical Psychology.”  Psychology of Women Quarterly 15 (Dec 1991): 521-536.

Miller, Jean Baker.  Toward a New Psychology of Women.  2nd ed. Boston: Beacon Press, 1986.

Morgan, Kathryn Pauly. “Women and Moral Madness.” Feminist Perspectives. Eds. Lorraine Code et al. (n.d.): 146-167.

Mustin, Rachel Hare T. “An Appraisal of the Relationship Between  Women and Psychotherapy: 80 Years After the Case of Dora.” American Psychologist (May 1983): 593-601.

Neal, Angela M., and Wilson, Midge L. “The Role of Skin Color and Features in the Black Community: Implications for Black Women and Therapy.”  Clinical Psychology Review 9 (1989):  323-333.

Noddings, Nel. Women and Evil. Los Angeles: U of California P, 1989.

O’Connell, Agnes N., and Russo, Nancy Felipe. “Women’s  Heritage in Psychology: Past and Present.” Psychology of Women Quarterly 15 (1991): 495-504.

Robbins, Joan Hamerman., and Siegel, Rachel Josefowitz, eds.  Women Changing Therapy: New Assessments, Values, Strategies in Feminist Therapy.  New York: Haworth P, 1983.

Rodin, Judith, and Ickovics, Jeannette R. “Women’s Health: Review and Research Agenda as We Approach the 21st Century.” American Psychologist 45, no 9 (Sept 1990): 1018-34.

Stanford, Ann Folwell. Mechanism of Disease: African-American Women Writers, Social Pathologies, and The Limits of Medicine. NWSA Journal 6, no 1, (Spring 1994): 28-47.

Steinbuch, Thomas. “`Take Your Pill Dear’: Kate Millett and Psychiatry’s Dark Side.” Hypatia 8, no 1 (Winter 1993): 197-204.

Travis, Cheryl Brown. Women and Health Psychology: Mental Illness Issues. New Jersey:  Lawrence Erlbaum, 1988.

Unger, Rhoda, and Crawford, Mary. Women and Gender: A Feminist Psychology. New York: McGraw-Hill, 1992.

Worell, Judith, and Remer, Pam. Feminist Perspectives in Therapy: An Empowerment Model for Women. New York: Wiley, 1992.

The Cosmetic Industry

The Cosmetic Industry: The Externalization of Women’s Identity

By Patricia J. Anderson

Dr. Midge Wilson, Advanced Psychology of Women, 561

De Paul University, Chicago, Illinois, November 15, 1995

                                      Abstract

Personal experience with the use of cosmetics led me to look at how the cosmetic industry got started and how it “hooked” women psychologically into believing that artificial beauty was a requirement of femininity. Patriarchal images of beauty have gone far beyond “powdered noses”. Beauty that was initially obtained through make up and hair care products led to surgical procedures like face lifts and breast augmentation. While cosmetic surgeon’s knives carve into a women’s physical body, the scars are actually inflicted much deeper, into a women’s core – her sense of self. For this reason, I also look at the “choice” involved in cosmetic surgery through a feminist ethical lens.

Personally

My reason for doing research on make up and cosmetic surgery was very personal. I started wearing make up around age thirteen, in response to peer pressure from my friend Iris. She applied mascara to my reddish-blonde lashes and eye brow pencil to my also light brows. What a drastic difference it made! For years I had lived with barely visible lashes and brows – how had I survived without make up? I was hooked. I could never again go back to being plain and colorless.

My dad’s initial response to seeing me with make up on was quite emphatic, “No daughter of mine is gonna wear that crap on her face! Go wash it off!” But dad wasn’t in charge of make up – it was mom’s thing and mom said okay.

A few months later I came to the breakfast table without make up on. Dad immediately threw up his hands covering his eyes (to shield himself from my ugliness) and said, “Jesus Christ, redhead go and put your make up on”! Dad was kidding, right? He WAS a kidder. I’ll never know.

At thirteen my beauty ego was very fragile, girls at this age are very influenced by what their fathers think of them. I was shattered! I really believed I was ugly without make up on. Despite the fact that my feminist consciousness was raised a long time ago and the fact that I’ve never had a lover express any negativity about my appearance without make up, I still rarely leave the house without make up.

                 Creating a Market for Make Up

According to Kathy Peiss (1994),Victorian times viewed women’s make up as illegitimate and unrespectable. Many women had refrained from wearing make up due to, religious beliefs, cultural traditions, and cost. Most working class women who wore make up were prostitutes, so respectability was an issue. A boundary had existed between respectability and promiscuity, gentility and vulgarity – paint marked that boundary (Peiss 1994).

Things changed in the late nineteenth and early twentieth century, American women started wearing face powder, rouge, lipstick and other visible cosmetics – make up turned into an essential sign of femininity (Peiss 1994). Naomi Wolf (1991) says that since the industrial revolution, women’s “beauty” was used as a form of currency among men. Ideas about beauty and money became parallel economically (Wolf 1991). Capitalism set out to redefine a woman’s everyday needs; cosmetics became enmeshed within the mass consumer industry. The challenge was to define women’s external appearance and then make their cosmetics compelling to women (Peiss 1994). They did.

              Making Beauty a Necessity

Women’s faces started to look different in the culture’s mirrors: motion pictures, women’s periodicals and advertising, store windows, fashion runways and department stores. National advertising in women’s magazines became a dominant force by the early nineteen twenties. Advertising stressed the safety and cleanliness of the products and even claimed product’s invisibility, guaranteeing women that they wouldn’t appear immoral or painted (Peiss 1994).

Egalitarian marketing techniques were employed. High priced items were marketed in exclusive salons aimed at wealthy customers; lower priced products were marketed to teenagers and working class women in drugstores and discount beauty outlets. There were also specific ethnic markets that targeted African American, Hispanic, Asian and other women of color (Peiss 1994).

To women who had devoted themselves to their families the message made beauty an irresistible duty. One cosmologist said, “Don’t be ashamed of your desire for beauty” (Peiss 1994, p. 375). The logic of the popular idea that everyone could be beautiful led to the assertion that all women should be beautiful–it was a duty to husband, children, necessary for business success and vital to the attainment of romance. If you weren’t beautiful, you had yourself to blame (Peiss 1994).

The relationship between femininity and appearance was reshaped by a beauty industry that promoted the externalization of the gendered self to be achieved cosmetically (Peiss 1994). The multi-billion dollar industry convinced women using deeply imbedded feelings of fear, anxiety and self-hatred to seek “hope in a jar” (Peiss 1994, p. 391).

           Cosmetics and African American Women

African American women’s lower economic status limited their ability to buy cosmetics. However, growing racial segregation and the migration of Black middle class to the cities led entrepreneurs to develop businesses marketed to Black consumers. One of the leading Black businesses pioneered with the development of beauty products for African American women (Peiss 1994).

Black women’s grooming centered around hair care. Entrepreneurs marketed hair tonics (straighteners for kinky hair) to Black women by way of almanacs and ad cards that used African American ministers and school teachers to promote the products (Peiss 1994).

Black women found good employment opportunities in a sex and race segregated market within the beauty culture. Here was a business that was in great demand, easy to learn and required little capital to get started. This resulted in the establishment of businesses in homes, small shops and door to door sales. High Brown face powder was sold door to door by an army of agents (Peiss 1994).

White racism in the beauty culture exploited issues like the natural inferiority of Blacks noting their unruly hair, promiscuity and sloppy dress and marketed toward the Black woman’s desire for respectability. There was controversy over the adaptation of white aesthetics, but the fact that products were marketed door to door among friends and neighbors fostered a web of support and assistance to Black woman’s culture (Peiss 1994).

             Female Development of a Remade Self

The hospital nursery sweeps an infant girl’s hair into a curl, by age one year her ears are pierced, by age two her nails are polished, she has ribbons in her hair, and ruffles on her skirts. Femininity becomes associated with beauty, beauty becomes a part of a girl’s self perception; pretty is the framework for her self image (Freedman 1990).

Rhoda Unger and Mary Crawford (1992) discuss the fact that much of girls play revolves around glamour. Make up is flavored like candy and geared to girls as young as three. Toy stores market numerous hair and nail products especially for little girls (Unger & Crawford 1992). The prettiest, most popular fashion doll, Barbie, even has her own make up. Cosmetic kits for the girls themselves, reassure parents that they are suitable for children as young as three and promise to help their daughters create dozens of fashion looks. After all, she’s only putting on the same disguise that mommy wears. Parents approve of her beautifying herself; she learns that her own face, though pretty, is inadequate, needing to be made lovelier–a double message fostering negative body image and self doubt (Freedman 1990). Girls learn that their faces and bodies are not good enough and need improvement (Unger & Crawford 1992). Girls are surrounded with constant subtle demands for beauty that become invisible once internalized. They believe that beauty is something they want – it’s a fun choice they make.

Beauty contestants can be very young. Freedman (1990) discusses the opinions of pediatrician Lee Salk about beauty contests for girls. Girls feel tremendous pressure to accept and identify with exaggerated images of beauty. When they realize that they lack the winning look, suffer deep feelings of inadequacy. Nearly half of twenty thousand teenage girls in a survey said they frequently felt ugly (Freedman 1990).

Compared to boys, twice as many teen girls want to change their appearance and a greater number of girls are unhappy with a part of their body. Girls think other girls are better looking than they are; boys think other boys are less attractive than themselves. The smarter a boy is, the more satisfied he is with his looks; there is no similar correlation among girls (Freedman 1990). Freedman (1990) thinks that’s probably because the brighter a girl is the more she realizes “she can never attain the beauty ideal” (p. 390).

The socialization of girls teaches them to seek their identity through male attention. To obtain that attention they must conform to societal demands for beauty defined by white heterosexual males. Under these circumstances girls really don’t have a choice in seeking beauty. The connection between appearance and worthiness can be so deeply ingrained in puberty that a woman is insecure about her appearance (and herself) for the rest of her life (Freedman 1990). This is true of feminist women, as I serve to demonstrate.

Puberty is the time when differences in self esteem between the sexes starts to take place (Unger & Crawford 1992). The enactment of the beauty role is shaped by the way a girl’s father reinforces her appearance (Freedman 1990). I now understand why my dad’s behavior had such a powerful impact on my emerging sense of self.

Make up has become an essential prop necessary to the development of womanhood. Babysitting money is spent on mascara and bust developers (Freedman 1990). When I was eighteen I told my friends that I didn’t need much money while I lived at home – my only expenses were make up and hair spray! Little did I realize just how true and how sad that was.

A newspaper printed an ad to potential advertisers from a teen magazine: “Seventeen readers don’t love you and leave you. As adults 34% still rinse with the same mouthwash and 33% use the same nail polish. Talk to them in their teens and they’ll be customers for life” (Freedman 1990, p. 392). Cosmetic advertisers have been shown to affect the “conception of reality” of teen girls; a girl learns rather than to ask the mirror, “Who am I?” to ask, “What should I look like?”, illustrating a distorted identity that sees its goal as packaging the self as product (Freedman 1990, p. 392).

Susan Brownmiller (1984) said it well, “Cosmetics have been seen historically as proof of feminine vanity, yet they are proof, if anything, of feminine insecurity, an abiding belief that the face underneath is insufficient unto itself.” (Brownmiller 1984, p. 158-159).

Even cosmetic surgery is directed at young girls through advertisements in teen magazines. Parents pay for girls, not boys, to have plastic overhauls, provided by a medical system that reinforces myths about female beauty (Freedman 1990). Girls learn that their desirability is measured by their looks, and that they can never measure up, no matter how hard they try (Unger & Crawford 1992). These societal messages will keep cosmetic manufacturers and cosmetic surgeons in business.

Patriarchy profits financially and perpetuates its control of women through this psychological phenomenon. Women who are beautiful, don’t see themselves such, but their so-called success makes them vulnerable to exploitation – because of their beauty (Freedman 1990). Women really can’t win.

            Cosmetic Surgery: A View of the Knives

Morgan (1991) displayed a page of knives, scissors, needles, and sutures used in cosmetic surgery in her essay, “Women and the Knife: Cosmetic Surgery and the Colonization of Women’s Bodies”. She suggested that her readers look at them carefully, for a long time, and to imagine them cutting into your skin (Morgan 1991). I did.

As a nurse, my first glance simply revealed surgical instruments – no big deal. Then I looked at them with care, for a long time, and imagined them being used on me as the author suggested. When I looked through my feminist lens, I saw mutilating, controlling devices used by patriarchy to manipulate women, to make women fit the image of beauty defined by white men. I saw how far beyond powder the industry had come and how enormous the greed for profit and control had taken patriarchy.

The technological beauty imperative gives cosmetic surgeons the powerful and explicit mandate to explore, breakdown, and rearrange women’s bodies (Morgan 1991). Cosmetic surgery is an example of the medical system’s power to define, not only what is normal or pathological, but what is beautiful. No aspect of medical training certifies physicians to evaluate beauty. The message is: “The ideal woman is made, not born, with a little help from the surgeon’s scalpel” (Unger & Crawford 1992, p. 334).

Kathryn Morgan (1991) quotes a plastic surgeon (director of plastic surgery education at a university): ” … I think people who go for surgery are more aggressive, they are the doers of the world. It’s like make up. You see some women who might be greatly improved …, but they’re, I don’t know, granola-heads or something, and they just refuse.” (Morgan 1991, p. 26). Frightening, this man teaches future surgeons and no doubt perpetuates these attitudes.

Weight standards for attractive women have been reduced in our society (Unger & Crawford 1992). Even Barbie has gotten thinner than since her appearance in nineteen fifty nine (Unger & Crawford 1992; Freedman 1990). In such a society, puberty itself has negative consequences for girls whose normal development includes increases in fatty tissue. Girls are seen as lacking what’s defined as normal – boys lean bodies, also causing a girl to deviate from the “ideal” thin female image (Unger & Crawford 1992).

The most popular cosmetic surgery in nineteen ninety was lipo-suction. Fat cells are vacuumed from beneath the skin – never to return. Women risk their lives in surgical procedures that promise to make them fit the imposed image of a lean body. Lipo-suction has resulted in at least twelve deaths from hemorrhages or embolisms (Morgan 1991).

Facelifts (an umbrella term for several procedures) are recommended to women in their early forties with subsequent repeats every five to fifteen years, costing $2,500 to $10,500. Various styles of rhinoplasties (nosejobs) are available and styles go in and out of fashion from time to time. For $2,000 to $3,000 they will whittle down your nasal bone or add a piece of bone from another part of you body that will answer fashion’s call (Morgan 1991). In one study thirty percent of women said they would have a face-lift if they could afford it (Unger & Crawford 1992).

Dr. Robert Mendelsohn (1982) says women frequently ask him about getting plastic surgery, women he knows are looking to cure problems in their marriages that they attribute to their inability to qualify as a model for Vogue. He doesn’t encourage plastic surgery and thinks its use other than in correcting true traumatizing disfigurement, ” … is the biggest rip-off on the medical scene” (Mendelsohn 1982, p. 39). Mendelsohn (1982) mentions one female plastic surgeon who said that some of her peers act as if they’re hairdressers and “give the field a bad name” (Mendelsohn 1982, p. 39).

        Feminist Biomedical Ethical Perspectives

One of the reasons Morgan (1991) gives for writing about cosmetic surgery is that the field of bioethics has been relatively silent about the issues present in this area of medicine, feminist or otherwise. Morgan (1991) thinks that feminists need to ask why women would reduce themselves to potentialities to fit the heterosexual image, illustrated by an enormous and growing demand for cosmetic surgery. Women invest years of their savings to fix natural flaws through dangerous and painful operations to make their bodies fit images designated by fashion editors (Morgan 1991).

The relationship between the means and the ends is no longer unilinear, it has becomes circular, with the new technologies presenting the possibility of new ends. The possibility of what one might desire has new objectives added. Technology’s role has become to transcend, control, transform, exploit and destroy; its object viewed as inferior, thus justifying it’s higher purpose in providing a fix (Morgan 1991). This is congruent with what traditional bioethics has historically done – used rationalization to justify what doctors are already doing (Sherwin 1992).

We’ve become technological subject and object, transformable with the ability to literally create ourselves with biological engineering. Technology plays the role of transcendence, transformation, control, exploitation, or destruction of the object, viewed as inferior.  A higher purpose is served in perfecting the object because it’s harmful or evil. To the Western medical model the body is a machine whose parts can be replaced (Morgan 1991). One plastic surgeon clarifies his role, “Patients sometimes misunderstand the nature of cosmetic surgery. It’s not a short cut for diet and exercise. It’s a way to override the genetic code” (Morgan 1991, p. 31).

Most women are socialized to accept the knives of technology in Western societies. Knives can be used to heal: saving a the life of a baby’s in uterine distress, removing cancerous growths, straightening crooked spines, or giving back functioning to arthritic fingers. But other knives perform episiotomies and other types of genital mutilation, remove our deviant tendencies by cutting out our ovaries, unnecessarily amputate our breasts with prophylaxis used as justification or in cases where less drastic measures could have been employed, slice out uteruses of women beyond child bearing age or of those of undesirable color, and perform unnecessary cesarean sections so doctor’s time isn’t delayed by nature (Morgan 1991).

The skin is nature’s vital protective barrier that protects and contains our body’s integrity; any time skin is broken you are at risk. It should never be taken lightly (Morgan 1991). Morgan (1991) refers to the knives of cosmetic surgery as, magic knives, in a patriarchal white supremacist culture. I’m afraid of these knives that have historically illustrated great ease in penetrating and controlling women – beyond the skin.

After listening to the voices of women who underwent cosmetic surgery, Morgan (1991) gives examples and assessments of their various reasons: “I’ve gotten my breasts augmented. I can use it as a tax write-off” – professional advancement and economic benefit (33); “There will be a lot of new faces at the Brazilian Ball”, – class and status symbol (33); “If your parent had puffy eyelids and saggy jowls, your going to have puffy eyelids and saggy jowls”, – control, liberation from parents, avoid hereditary (33); “… we want a nose that makes a statement, with tip definition and strong bridge line”, – domination and strength (33); “A teacher who looks like an old bat or has a big nose will get a nickname”, – avoid cruelty and aging (33); “I’ll admit to a boob job” (Miss America 1986), – competitiveness, attain prestige and status (33); “People in business see something like this as showing an overall aggressiveness and go-forwardness the trend is to, you know, be all that you can be”, – success and personal fulfillment (33). Her list went on to include reasons such as: a gift to self, erasing a decade of hard work, economic gain, possible denial of grand motherhood, emotional control, and happiness (Morgan 1991).

Sixty to seventy percent of cosmetic surgery patients are female. Why, when the risks are so great, are women willing to sacrifice other parts of their lives to have reconstructed bodies? Risks that include: bleeding, infection, embolism, unsightly scars, skin loss, blindness, disability, pulmonary edema, facial nerve injury, and death. Despite these facts medical ethics doesn’t discuss these issues (Morgan 1991). As a feminist health professional, I feel that our silence on the issue makes us complicit in enlarging the scope of avenues to patriarchal power.

The extent that patients and cosmetic surgeons are committed is shocking to what Morgan (1991) sees as, “one of the deepest of original philosophical sins, the choice of the apparent over the real” (p. 28). Technologically created appearances are perceived as being real (Morgan 1991).

Morgan (1991) thinks we are technologizing women’s bodies in Western culture. Cosmetic surgery is moving out of the sleazy, suspicious, deviant or pathologically narcissistic, to the norm. With this shifting it may actually become deviant not to have cosmetic surgery. This changing societal perception has the potential to lead viewing those who don’t elect cosmetic surgery as deviant (Morgan 1991). Cosmetic surgery has gone far beyond the “duty” that make up became in the nineteen twenties. Morgan’s prophecy is not at all far fetched.

                        Silicone Breast Implants

Breast augmentation with silicone implantation is the second most frequently performed plastic surgery. Over one million women have had these implants, costing from $1,500 to $3,000 (Morgan 1991). “Jacobs (a plastic surgeon … ) constantly answers the call for cleavage. `Women need it for their holiday ball gowns'” (Morgan, 1991, p. 25).

Augmented women appear to have a higher incidence of breast cancer (Morgan 1991). To date there have been seventy two deaths and ninety one thousand injuries related to silicone implants (Winfrey 1995a).

Plastic surgeons and manufacturers rationalize that silicone breast implants are a matter of a woman’s free choice, after all it’s an “elective” procedure. However, women should think seriously about trusting physicians and manufacturers who not only stand to profit significantly by satisfying women’s “choices”, but who are the very same white males who dictate the patriarchal beauty images that women “choose” to comply with.

Oprah Winfrey (1995a) recently did a show on the controversy over breast silicone implants; she had Dow Corning’s Stephanie Burns, Manager of Women’s Health and FDA Issues and Dow’s chairman and CEO Richard Hazleton on the show. Audience members described symptoms they began to experience soon after receiving silicone breast implants: migraines, numbness in hands and fingers, terrible rashes on chest, axilla, and down their sides, rock hard breasts, and burning pain in the breasts and armpits (Winfrey 1995a).

Other than migraines, these signs directly relate to the areas of the body near the breasts. However, doctors told these women they didn’t know what caused their symptoms and mammograms failed to show abnormalities (Winfrey 1995a). Recent studies demonstrate that mammograms are very difficult to interpret because implants block X-rays by casting a shadow on surrounding tissue (Morgan 1991).

It’s now common knowledge that Dow Corning suppressed negative data about the safety of their silicone gel implants. Women who have received the implants say that they have led to the development of autoimmune diseases; diseases in which the bodies own cells attack itself. A disease that may very well correlate with the psychological phenomenon involved in the negative body image that led women to obtain implants. It’s almost as if the body was speaking out metaphorically through the development of autoimmune responses; the body’s way of expressing the evil it has experienced.

Audience members (Winfrey 1995a) knew their doctors thought they were crazy because they couldn’t find answers their symptoms; the women felt like they were loosing their minds. Miraculously, their symptoms went away when implants were removed. Some women who had had implants learned, after having other types of surgeries, that their surgeons found silicone gel on their livers, uteruses, and ovaries. Autopsies have revealed gel in the brains of implanted women (Winfrey 1995a).

Stephanie Burns (Winfrey 1995a) said that the implants can cause local complications: infection, capsule formation around the implant, hardening of the breast and rupture, and that when rupture outside of the capsule occurs, the gel can migrate. Burns (Winfrey 1995a) also admitted that when migration occurs the gel and implants must be removed. One woman showed the actual gel that had leaked out of her implant into her rib cage and lymph nodes. It was obvious that the sticky, stringy material would be difficult, if not impossible, to remove from the inside of the body (Winfrey 1995a).  Burns (Winfrey 1995a) said that eighteen studies have come to the same conclusion, there is no correlation between the implants and autoimmune or other diseases. Burns (Winfrey 1995a) said this despite the fact, (brought out by audience members), that the package insert actually LISTS scleroderma and rheumatoid arthritis (autoimmune diseases) as possible side effects. Women in Winfrey’s (1995a) audience said that they didn’t see package inserts – the packages are opened in surgery and physicians have not shared the package inserts with them. I wonder if the physicians themselves read the inserts? My guess is that the good old boy network mentality could allow some doctors to simply trust the manufacturer.

Richard Hazleton said he doesn’t believe the implants are causing the women’s problems. Hazleton suggested that women needed to get beyond their anger and really need to understand the facts. He repeatedly referred to women’s choice in having the implants (Winfrey 1995a).

Many of the women said Dow did not follow ethical standards because women were not informed of the possible dangers. According to an audience member, the FDA said that it’s up to the company to prove that the implants were safe, not the responsibility of the medical community to prove that they’re not safe (Winfrey 1995a). I think both the manufacturer and the physicians are responsible. One woman in the audience said that “buyer beware” is not an acceptable practice (Winfrey 1995a). Both of Dow’s representatives kept citing the evidence from the studies that claim no correlation between the implants and any disease. A woman in the audience said, “We are the evidence. Study us!” (Winfrey 1995a). A great idea!

Historically women have been socialized to use beauty as a power (Morgan 1991). Morgan (1991) includes a quote from Mary Wollstonecraft from 1792, “Taught from infancy that beauty is a woman’s scepter, the mind shapes itself to the body and roaming round its gilt cage, only seeks to adorn its prison” (p. 34). Morgan (1991) asks, whether women today are making free choices to have cosmetic surgery or are they too simply adorning their prisons?

        Psychological Aspects of the “Choice?”

An inexcusable tragedy is that women expect that the plastic surgery will fix their lives, not just change their features. They soon discover that even fixed, they’re not good enough and the same problems still exist. The psychological impact is likely to produce a even deeper depression than before the surgery when the subsequent disillusionment sets in (Mendelsohn 1982).

Women receive complex negative messages about their bodies and can lead to low self esteem and alienation from one’s physical and sexual self. These negative attitudes remain throughout a woman’s life and can result in constant worry over weight, looks and feeling unsatisfied with her physicality. Despite the fact that these negative body images are distorted one researcher claims that there is an “epidemic of `flesh loathing’ among women (Unger & Crawford 1992, p. 333). Cosmetic surgery is increasingly viewed as a cure for aging and body variance (Unger & Crawford 1992).

Beauty’s affirmation brings with it privileged heterosexual affiliation which includes forms of power not available to the plain, ugly, old or those unable to reproduce. Women who seek cosmetic surgery have compelling voices; their voices tell of their search for transcendence, achievement, liberation and power. The youth and beauty artificially created by the surgery doesn’t only appear to, but often actually does (emphasis added) give a woman a sense of identity that she, to some extent, had a choice in. By increasing her desirability to men (especially white men) it offers the possibility to raise her status socially and economically (Morgan 1991).

A woman’s beauty is a valued commodity. Beauty may be a kind of power for women, their looks can be used in exchange for financial and material gains. Further more, when males treat females well it validates her beauty and enhances her social standing (Unger & Crawford 1992).

In the commitment to pursue beauty, a woman integrates her life with a consistent set of values and choices, bringing with it societal approval which results in an increased sense of self esteem. The process of acquiring cosmetic surgery may expose a woman to people who treat her body in a caring way, something women frequently lack in their lives on a daily basis. The pursuit of beauty through transformation is frequently associated with experiences of self-creation, fulfillment, transcendence, and being cared for – powerful experiences. At the same time that beauty can confer an increase in self esteem to a woman, it also involves being entrapped by its interrelated contradictions (Morgan 1991).

According to cosmetic surgeons, women come to their offices demanding: “Bo Derek” breasts, nose reductions, frequently sought by Jewish women to obtain an Aryan look, Western eyes, sought by Asian women and light skin, through the use of toxic bleaching agents, sought by Black women. The goal isn’t simply beauty, but to mold oneself to fit racist, anti-Semitic, White, Anglo-Saxon, and Western images (Morgan 1991). For women, this molding is at the expense of her precious self.

Initially one might argue that it’s a choice, but Morgan (1991) argues what appears to be the result of reflection, deliberation and a self-creating choice signals conformity at a deeper level. The images of male identified beauty sometimes live as ghosts in the reflective awareness of women clothed in a diffuse manner. It’s not always obvious to women that their bodies are being viewed as raw material, primitive entities, seen only as potentials for exploitation by the colonizing culture (Morgan 1991).

Sometimes the culture’s power source is explicit, it’s brothers, fathers, male lovers, or cosmetic surgeons who offer free advice on how they can cure deformities and problems at women’s gatherings. Sometimes the diffuse power dominates a woman’s consciousness without an apparent outside source (Morgan 1991). That unapparent source is her own internalization of patriarchal values.

Women who are involved in self-surveillance behaviors, like fixing their make-up all the time, or monitoring everything they eat, are maintaining obedience to the patriarchal powers that be. The men that women transform themselves for are male-supremacist, heterosexist, ageist, ableist, racist, anti-Semitic and classist (Morgan 1991). Women don’t see this because their so-called decision comes out of internalized values that tell them they’re not pretty enough. The same self blame that occurred in the nineteen twenties in regard to the use of make up, happens to women today in regard to cosmetic surgery. The basic phenomenon is the same, the behavior that results from the internalization digs in deeper today.

Coercion and domination are frequently camouflaged by theories and rhetoric that appear benevolent, voluntary and therapeutic. Technology’s ideological manipulations serve to destroy and disadvantage aspects of women’s integrity. Rather than escaping the constraints of their given physicality they are becoming more vulnerable, in seeking independence they are actually more dependent on male assessment (Morgan 1991).

The woman who seeks cosmetic enhancement seems to fit the paradigm of making a rational choice, but she makes that choice at significant cost to herself in terms of lengthy post-operative pain and in terms of financial costs (health insurance doesn’t cover elective cosmetic surgery). The term elective has a seductive role in the ideological camouflage regarding apparent choice (Morgan 1991).

Loni Anderson discussed her cosmetic surgeries on the Oprah Winfrey Show. Loni admitted to having two breast reductions and having her eyes done. Winfrey (1995b) asked Loni, “You believe if you can do it – do it?” Loni answered, “I think it’s maintenance, it’s not changing, it’s maintenance” (Winfrey 1995b). Like car maintenance, if you don’t change the oil every three thousand miles you’re engine will be destroyed. What will happen to women’s identities if they don’t do maintenance? Maintenance is certainly a frighteningly harmless sounding description of what is increasingly becoming an expectation for women.

Morgan (1991) quotes an article marketed toward homemakers, “For many women, it’s no longer a question of whether to undergo plastic surgery—but what, when, by whom and how much” (28). Just as make up came to define femininity in the nineteen twenties, today’s cosmetic surgery is becoming necessary for “maintenance” of femininity.

As cosmetic surgery becomes more and more normalized in the media, women who refuse to submit will be viewed in one way or another as deviant. Their stigmas will include being viewed as unliberated, uncaring about their appearance, which is considered a disturbed gender identity by some health care professionals, and as refusing to be all they can be (Morgan 1991). Imagine an ad where therapists offer to help women to overcome their fear of cosmetic surgery: “Gentle, caring therapist will help you overcome you fear of plastic surgery. You just need a little help – we can help you to attain YOUR dream of ultimate beauty!”

“…  the technological imperative and the pathologic inversion of the normal are coercing more and more women to “choose” cosmetic surgery (Morgan 1991, p. 41). Normal variations in women’s bodies are redefined as deformities, ugly protrusions, inadequate breasts, unsightly fat areas, all designed to magnify feelings of shame, disgust and see relief in what cosmetic surgeons offer (Morgan 1991).

Although admittedly not likely to ever be achieved, Morgan (1991) says that women could collectively chose to exercise their power, and refuse cosmetic surgery. Refusal holds the possibility of drastically affecting the market, possibly leading surgeons back to healing (Morgan 1991).

Morgan (1991) suggests that feminists not turn away from women who chose cosmetic surgery, as this decision may be one of the only decisions that she perceives as having power over in her life. It is essential that we acknowledge the power of the gender-constituting, identity-confirming role femininity plays in bringing a woman into existence, while at the very same time makes her a patriarchal defined object. Under these circumstances, refusal may mean renouncing one of the only life-conferring choices a woman may have. While cosmetic surgeons are flooded with new clients and new research in the field is rapidly leading to more body parts becoming objects of redoing, it may be that the best we can hope for is to increase awareness of the numerous double-binds and compromises that affect all women’s lives (Morgan 1991).

In Conclusion

Morgan suggests that women could protest in a culturally liberated manner with events such as Ms. Ugly/America/Canada contests utilizing cosmetic surgery to attain the right look (Morgan 1991). If we cringe at the idea of women altering themselves to win a Ms. Ugly contest, Morgan (1991) says it may just make the point of how strongly the beauty imperative has us all hooked. One might think of these surgeries as mutilations, but Morgan (1991) says it’s just as mutilating to de-skin and alter healthy tissues to go with the flow of fashion.

A revolt Morgan (1991) suggests is to parallel the current market for breast implants with commercial protest booths (set up at health conventions and outside of cosmetic surgeons offices) with before and after photos of penises, the display signs might read, “The Penis You Were Always Meant to Have” (p. 46).

Perhaps feminists could also develop a continuum of handsomeness for males, similar to the one to ten model devised to judge female beauty. It might be fun for feminists and has the potential to even raise the consciousness of non-feminists. Women might be more inclined to see how ridiculous and damaging the beauty imperative is.

Cosmetic surgery’s language fits with the surreal images that women are expected to comply with. Another word for cosmetic surgery is plastic surgery, the word “plastic” is actually more descriptive of the image imposed. Even the word augmentation is revealing to one with a feminist consciousness. Wolf (1991) summed things up well, “The beauty myth generates low self esteem for women and high profits for corporations as a result” (p. 49). The cosmetic industry demonstrates how very personal the political/economical really is.

                                   Work Cited

Brownmiller, S. (1984). Femininity. New York: Linden Press/Simon Schuster.

Freedman, R. (1990). “Myth America grows up”. In Issues in feminism an introduction to women’s studies. (Ed) Sheila Ruth. Second Edition. Mountain View, CA: Mayfield Publishing, pp. 384-393.

Mendelsohn, R, M.D. (1982). Male practice: How doctors manipulate women. Chicago: Contemporary Books.

Morgan, K. Pauly. (1991, Fall). “Women and the knife: Cosmetic surgery and the colonization of women’s        bodies”  Hypatia. 6  (3), pp. 25-53.

Peiss, K. (1994). “Making faces: The cosmetic industry and the cultural construction of gender, 1890-1930”. In Unequal sisters. Second Edition. (Eds) Vicki L. Ruiz & Ellen Carol DuBois. New York: Routledge, pp. 372-394.

Sherwin, S. (1992). No longer patient feminist ethics and health care. Philadelphia: Temple    University Press.

Unger, R., & Crawford, M. (1992). Women and gender a feminist psychology. New York: McGraw-Hill.

Winfrey, O. (1995a, October 13,). Topic: Controversy over silicone breast implants. On The Oprah Winfrey Show. The American Broadcasting Company, Channel 7. Chicago: Harpo Productions, Inc.

Winfrey, O. (1995b, November 9,). Topic: Loni Anderson speaks out about her divorce from Burt Reynolds. On The Oprah Winfrey Show. The American Broadcasting Company, Channel 7. Chicago: Harpo Productions, Inc.

Wolf, N. (1991). “Work”. The beauty myth: How images of beauty are used against women. New York: William Morrow & Company, pp. 20-57.