Social Change and Women's Reproductive Health Care Nada L. Stotland, MD Professor of Psychiatry and Professor of Obstetrics and Gynecology University of Chicago Chicago, Illinois

Ihe issue of women's reproductive health care lies at the busy intersection of social and medical tradition and social and medical change. No other area of medical practice so closely impinges on emotion-laden attitudes, beliefs, and behaviors or has engendered such rage and conflict, both private and public. The modern practitioner is bombarded with medical change, governmental change, and psychosocial change. 1 Comfortable assumptions crumble; contradictions and complaints abound. Providers and consumers of obstetric and gynecologic (ob/gyn) care are having a hard time understanding and collaborating with each other. Women are bombarded daily by a barrage of advice, unsynthesized data, and highly emotional opinions about reproductive health care from sources other than personal care providers: friends, self-designated health experts, and the media. 2 They are subject to historical, psychological, and environmental influences on the conduct of their reproductive lives. There is no way for the obstetrician/gynecologist to stay on top of developments in the specialty, conduct a practice, maintain a personal life, and follow both lay and expert influences on reproductive issues. The medical practice model on which our health care training is based is one that has disappeared from many health care systems. 3 Perhaps for that reason, some observers of medical care issues tend to romanticize it. The old-fashioned doctor role had both advantages and disadvantages. Its purported limitations are what modern medicine has triumphed over, and its idealized interpersonal skills are what some critics of modern medicine mourn. It was assumed for centuries that the physician came from, or was at least familiar with, the social setting in which the patient lived. Often the doctor treated every member of a family for decades. They knew his (most doctors were male) style, and he knew theirs. Much of the care was delivered in the familiar surroundings and amongst the familiar people of the patient's home. While this environment had certain medical disadvantages, it offered the doctor an opportunity to assess the effects of family dynamics and circumstances on the patient's complaints, treatment, and recovery. 4 While a medical free-enterprise system theoretically allowed doctors and patients to form compatible relationships, choices were often limited by geographic and other factors.

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4 STOTLAND: SOCIAL CHANGE AND REPRODUCTIVE HEALTH CARE

Originally published as the "Inlxoduction" in Social Change and Women's Reproductive Health Care: A Guide for Physicians and Their Patients (Praeger Publishers, an imprint of

Greenwood Publishing Group, Inc, New York), pp 1-11. © 1988 by Praeger Publishers. Reprinted (with adaptalfion) with permission.

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It is worthy to note that throughout the centuries although doctors had very little to offer in the way of technical skill, diagnostic acumen, and effective pharmacotherapeutics, people nonetheless called for medical help for injuries, illnesses, and complications of delivery. The doctor organized the chaotic situation by making a diagnosis and prognosis, giving orders, and standing by to observe the outcome. These interventions seem to be intrinsically reassuring, even necessary, to the human organism in distress. Family practice gave way to specialization and specialties to sub-specialties. Today, gynecologists often serve as primary care physicians for women over decades of their lives, sometimes by choice and sometimes at patients' insistence. A 1975 study indicated that 78.2% of patient encounters with obstetrician/gynecologists were for primary care. s However, at this point in our history, a complex medical problem often leads by a circuitous route to the encounter of two total strangers just when familiarity would have been most enlightening to one and reassuring to the other. Solo private practice is being replaced by private groups and salaried practice. Over half of the physicians in the United States are salaried, and the physicians of Canada and other Western nations work largely or totally, willingly or unwillingly, for government-operated health plans. Institutional practice, governmental regulations, and insurance constraints combine to restrict severely the doctor's independent decision making, and all of the above changes limit the freedom of doctors and patients to choose each other. How have medical school curricula and residency training been adapted to these new pressures? Considerable academic attention has been directed to humanism, that is, to viewing the patient as a whole person, rather than as a group of organ systems, and to developing skills in doctor-patient communication and psychosocial assessment and intervention. 6,7 The number of medical schools requiring or, at least, offering courses in human sexuality has grown, as has the number of programs successfully using trained professional model patients for teaching pelvic and other examinations. However, the increased mass of technical and quantitative information to be mastered often overpowers these attempts. Ob/gyn is a physically and intellectually demanding specialty. The acquisition of requisite knowledge and skills during the time allotted for training does not allow for learning family practice as well. Despite the intellectual awareness that both medical and medical-legal realities are closely linked to knowledge of the patient's stage of life and social environment, house officers are differentially rewarded for displays of technical facility and knowledge over mastery of psychosocial issues. As a result, many otherwise well-trained physicians become frustrated in practice because the demands of social reality and change, not addressed in their training, interfere with their delivery of care despite their scientific acumen. Recent changes in reproductive possibilities and sexual behaviors also intrude into the doctor-patient relationship. There has been a tremendous increase in overt discussion and display of sexuality, which in some quarters causes consternation and in others has been welcomed and legitimized. 8 According to the media, women today are not only permitted, but entitled, to full sexual gratification and reproductive choice. Of course, it is very difficult to define full or even normal in either of these areas. Entitlement to satisfaction may lead to performance demands for frequency and intensity of sexual encounters and orgasm, which leave at least some women feeling inadequate. Reproductive choice may lead to an overwhelming array of possibilities and responsibilities. Without clear priorities, supports, and rewards from society, some women experience freedom as anxiety-provoking rather than liberating. The old rules, like the old corsets, were constricting but structuring. WHI Vol. 1, No. 1 Fall 1990

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Patients may now expect doctors to replace the old-fashioned structure, to which they may react with either relief or resentment, or simply need an empathic, well-informed, neutral, and benevolent adviser as they make reproductive decisions and undergo reproductive experiences that are central in their lives. A curious phenomenon has arisen as a facet of the new sexual and reproductive freedom. The once almost one-to-one links between the t w o - sexuality and reproduction--have been weakened biologically, psychologically, and cognitively. Population surveys indicate that most adults in the United States have a solid intellectual grasp of the relationship between sexual arousal, sexual intercourse, and conceptionfl But a number of social and scientific developments have weakened this relationship. The links are not so clear when a donated semen sample is exposed in the laboratory to an ovum obtained at laparoscopy. Nor are they evident in the increasingly vocal and visible homosexual population. And although no one doubts that it is sexual activity that leads to pregnancy, pregnancy is not 'sexy'; pregnant models do not sell products, and pregnant patients worry about appearing unappealing to their mates. Recently, individuals and organizations have addressed what they consider to be these paradoxes and gaps in the psychobiological continuum. La Leche League, for example, is a breastfeeding organization. Through meetings and publications the League attempts to integrate erotic and maternal elements in mammary and other mothering functions and sensations. Researchers like Niles Newton have noted hormonal and behavioral similarities among orgasm, the second stage of labor, and breastfeeding. In the 1950s, human lactation was widely felt to be unhygienic and primitive, and was often not recommended by health care providers. 1°,11 This attitude was associated with the lowest incidence of breastfeeding ever recorded in this country. This social phenomenon led in turn to a dearth of accurate medical information, experience, and support in the professional population. La Leche League was founded at this time, in 1956, to actively support the concept that nursing an infant was not only optimal for the child, but was a gratifying and attractive process that was the natural culmination of a mature woman's sexuality. This stance soon expanded to include other areas of parenting. La Leche League families, for example, were less likely to be preoccupied with establishing conditions for parental sexual intimacy than with being available to their children at all hours of the day and night to comfort, feed, and reassure them. Membership in the organization grew quantitatively and geographically, as did the incidence of breastfeeding in the United States. A similar movement took place in the sphere of labor and delivery. One of the m a n y rationales offered for the exclusion of husbands from these events in the 1940s and 1950s was the belief that birth involved such an unattractive display of the female genital organs that exposure to it would have an adverse effect on men's subsequent interest in the behavior that ultimately resulted in birth. Again, sexuality and reproduction were socially and medically divorced. Although it is quite inappropriate to draw simplistic conclusions about events with such deep cultural traditions, taboos, and feelings, many couples today report that their relationships are enriched by the collaborative preparation, effort, and experience of birth. People in the United States, in general, no longer consciously experience conception as a divinely ordained or biologically driven outcome of sexual activity, but rather as a rational choice. It is fascinating to see enlightened, advantaged, intellectual young adults attempt to rationalize their reasons for wanting to have children, now that some of the old explanations are not

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acceptable. Most do not need extra hands on the farm, nor do they see procreation as God's will or one's duty to society--quite the contrary. Some argue that in light of global population pressures, biological reproduction in affluent countries is a personal indulgence, the creation of another individual who will consume vastly more than a just share of the world's resources. Proand antiparenthood partisans label each other narcissistic, immature, and selfish. Social policies about reproduction are inconsistent, contradictory, and paradoxical. We mandate universal access to prenatal and well-baby care, and require free education for children and adolescents. We debate abortion rights, while we offer very little financial or other support to the parent whose reproductive efforts result in tragically overwhelming financial and emotional burdens, as when a severely handicapped child is born, or even to the parent who must work outside the home for the financial maintenance of a healthy child. The questions of the social function of reproduction are also surfacing in the third-party payment arena that looms so large in current medical practice. Are patients entitled to reimbursement for infertility treatments, in vitro fertilization, and routine obstetric ultrasound, on the same basis as for unpremeditated and undesired illnesses? Changes in societies' attitudes toward reproduction have been obvious in the public arena. Issues hotly debated in legislative and judicial arenas have been wide-ranging, from publicly funded or even legalized abortion to child care, child custody for male and homosexual parents, and the reporting and handling of child abuse. All of these issues importantly, whether directly or indirectly, affect the practice of obstetrics and gynecology. The willingness of citizens to discuss these topics reflects the questioning of traditional family obligations, g e n d e r roles, life styles, reproductive constraints, and autonomy, and the recognition that the family consisting of employed father, homemaker mother, and dependent children is no longer the rule.12 Although specific problems such as those mentioned above receive considerable media attention for periods of time, the overarching social challenges have been given scant research and social support. What are to be the relationships among paid employment, parenthood, and society? The United States is one of the only Western countries without a parental-leave policy. How can our society weigh the costs and benefits of job security and maternity leaves for our new mothers? Abortion on demand? How can it afford not to? While numbers of women, and mothers, in the work force increase, child care resources do not, and women continue to earn far less than men. After a decade of "superwomen," there are news reports of highly educated mothers dropping out of executive, managerial, and professional positions where the strain of integrating them with motherhood in a nonsupportive society no longer seems worthwhile. 13 Parenthood versus career problems continue to be a gender-linked issue with repercussions for women's reproductive and general health. The growing proportion of women in ob/gyn residency programs brings the problem home, so to speak. The January 1985 American College of Obstetricians and Gynecologists newsletter urges residencies to "adopt policies on leaves. ''14 Lifestyle changes are also intrinsically related to parenting, reproduction, and medical care. Consumerism, affluence, and narcissism combine to produce an interest in wellness and fitness. Most doctors are not trained to deal with questions of macrobiotic diets, yogurt douches, and the effects of vigorous exercise on pelvic structures during pregnancy, nor with patients who, skeptical of medical expertise, pose these questions. In many cases no careful studies have been performed. A host of alternative health care

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systems have emerged in response to the perceived inattention of the traditional medical community to wellness issues. Doctors must also recognize and take into account the changes in traditional family groupings alluded to previously. A majority of American children do not live in households composed only of married mother and father and minor children. A majority of American mothers with preschool children are employed outside the home. Single parents, stepparents, extended family, and other groupings are common, while many couples marry later, delay childbearing, and work out elaborate shared or hired childcare schemes rather than assuming that motherhood implies a temporary or permanent end to career ambitions and activities for the mother. On the other hand, survey results indicate that while fathers are more interested, involved, and active in the family than ever before, the overwhelming bulk of managerial and physical childcare tasks are still assumed by, or left to, the mother. Concessions to parenthood in the workplace are more publicized than practiced. Many young mothers today feel as though they have exchanged their own mothers' secure but limited possibilities for lives of unlimited and unsupported responsibilities. Often their own mothers are relatively unavailable because of geographical separation and/or involvement in building careers or pursuing interests of their own, or have little similar experience from which to offer intergenerational wisdom. Many women feel that discussions of maternal issues are considered unprofessional in the workplace.IS Access to the traditional parenting discussions, for example, at the neighborhood playground, is limited by working hours and the need to fit domestic responsibilities into evening and weekend time, and the pool of experienced mothers of a number of children of varying ages is appreciably diminished. Obstetrician/gynecologists, as primary and reproductive health care physicians for these mothers, are confronted with the psychosomatic symptoms, exhaustion, and reproductive questions that this combination of role overload and lack of social support produces. Analogous situations arise at other reproductive stages. As mentioned before, fewer of these patients will be well known to their health care providers over time than in previous generations, and medical training offers few opportunities to master psychosocial skills and information. A related social change is the increase in consumer sophistication about medical issues. 2 Side by side with deplorable conditions in the public school system and appalling educational levels and drop-out rates among the underprivileged, the educational levels attained by middle-class Americans, both men and women, have consistently risen. Not only do more women work outside the home, but more attain advanced degrees and enter professions or careers, rather than mere jobs. There is a parallel, but smaller, increase in the proportions of women in high-level managerial and executive positions. Sophisticated lay media presentations on scientific subjects, and the medical literature itself, are accessible to a significant proportion of the female population. Questions about research findings published in the New York Times are posed to the doctor in the consulting room before the New England Journal of Medicine from which they were obtained has arrived in the mail. Some patients become skeptical of medical care, while others either worshipfully or angrily expect utter expertise and optimal outcomes from every health care encounter. The women's liberation movement adds other dimensions to sexual and reproductive issues for women. Questioning traditional feminine roles led to a period of denigration of motherhood and rigorous separation between sexual expression and reproduction; as men were viewed with suspicion,

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conception, if desired, might be achieved via artificial insemination performed either by a doctor or by one's friend using a turkey baster. There was, within this social movement, pressure for publicly funded child care, joint custody of children of divorced parents, and very little support for maternal responsibility and involvement with children. To many observers from within and without the movement, it now appears that some of the resultant changes were for the worse. For example, divorce court judges assume, incorrectly, that women are able to earn the same incomes as men, not only in general but while caring for dependent children; their decreased alimony and child support awards have left many women and children in straitened, if not impoverished, circumstances. Participants in the women's liberation movement also attacked the traditional reticence about female genital anatomy and physiology in literature, the visual arts, and polite conversation. An art exhibit entitled "Dinner Party," organized by Judy Chicago and collaboratively produced, toured the nation. It consisted of a larger-than-life dinner table at which each place setting is an artistic rendering of the perineum by an individual female artist. Rebellion against the male dominance of women's health care was acted out in women's health clinics offering menstrual extraction, abortion, and the kinds of personal genital examination and interpersonal genital comparisons that have been much more a part of normal male development and experience than female. Masturbatory, homosexual, and heterosexual gratification were extolled as ends in themselves, apart from marital commitments and concerns about reproduction and legitimacy. 16 Female biological functions of pregnancy, childbearing, and breastfeeding, because of their association with rigid and limited female roles, were often ignored or belittled. There is still considerable conflict and consternation amongst feminists about the biological, social, and psychological origins and implications of the maternal role. 17 Time, maturity, and a backlash by women in traditional roles have resulted in considerable softening of some stances. There is now a greater appreciation of the joys and powers of mothering, of the unresolved conflicts between it and other opportunities, and of the demands on women. The effects of changes in attitudes toward women and their sexuality go far beyond reproductive decision making and adjustment to the maternal role. They complicate women's decisions about their fertility and reactions to their infertility. For women who become mothers, they also raise profound questions about childrearing and daffy events in family life. As the woman patient is grappling with her own roles, adaptation, sexuality, and health care, she is dealing with these same questions in the lives of her children. There are some consistent themes, with variations as the children m a ~ r e . Their experiences and needs, changes in social mores, and the impact of both on her may force her to reconsider her attitudes toward nudity, masturbation, genital modesty, and interpersonal sexual behavior. The mother wants to allow her children to enjoy their own bodies, to protect them from sexual exploitation and abuse, and to teach them neither to abuse nor exploit others. Whether she decides to accept or reject traditional rules and limitations, she must actively consider what sexual attitudes, behaviors, and experiences are consistent with the family's values and the child's developmental level. She, like her health care providers, is constantly bombarded with new scientific data. 18 She may read or hear that toddlers of opposite sexes are traumatized by being diapered in each other's presence, that confrontation with parental coitus is or is not common and is or is not traumatic, that sex education for schoolchildren should begin at one age or another and consist of one content or another, and that she should or should not bring her adolescent daughter

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to the gynecologist for a pelvic exam and birth control counselling at a given age. The family must decide when or whether to allow adolescent or preadolescent children to entertain friends of the opposite sex alone in their rooms and what to do when college or young adult children threaten not to come home unless their live-in sexual partners of the same or opposite gender can share their bedrooms. The woman patient with adult children must come to terms with the lifestyles and sexual behaviors they choose in these changing times, and their impact on her feelings and activities. At many points along this reproductive path, a woman's obstetrician or gynecologist can serve as a psychological support, a provider of counsel and/ or scientific information, a referral resource, as well as a medical care provider for the woman and female members of her family. Some gynecologists have also become actively involved in political and public educational activities. The American College of Obstetricians and Gynecologists, of course, has active legislative and educational divisions that act on behalf of both the public and the profession and offer support to individual practitioners who wish to become involved. The practitioner is also at an advantage w h e n aware of social changes and their impact on the individual patient. This is one reason for the renewed interest in family practice among both medical graduates and patients. Medical care is imbued with personal and social values and beliefs, although this fact is not often acknowledged. Care providers have a significant effect on the patient's ability to cooperate in, and her experience of, the medical encounter and the feelings about her genitalia, her personality, and the medical profession that she takes back into the rest of her life. All of the social upheavals described heretofore affect doctors as well as patients. Doctors are susceptible to a variety of accusations of sins of commission and omission. If they question traditional behaviors, they risk offending patients who are seeking traditional forms of care. If they are honest about espousing traditional values, they risk the ire of nonconforming patients, a9 It is difficult to quickly assess a patient's beliefs; overt markers such as clothing and lifestyle are not always accurate indicators, and attitudes may not be at all consistent from one issue and occasion to another. A woman may bring her daughter in for care, but hope her daughter will not behave as she does. A pregnant woman may insist at prenatal visits that she fully participate in all decisions and avoid all pharmacological and technological interventions, and then, in labor, refuse to hear the pros and cons of contemplated treatment and demand instant anesthesia. Patients encounter analogous dilemmas in selecting and dealing with doctors, who, being human, are not always consistent from issue to issue and incident to incident. The current era has also brought psychosocial double binds about reproductive problems into focus. Scientific and therapeutic interest in symptoms associated with reproductive events, such as menstruation, pregnancy, and menopause, can be construed as either validating and addressing women's concerns and needs, or as undermining their attempts to gain equality by unnecessarily stressing socially insignificant aspects of their reproductive experiences. 2° Neither women nor doctors have an easy time of it at this point in history.

REFERENCES 1. Hellerstein D. The training of a gynecologist: How the "old boys" talk about women's bodies. Ms 1984;November:136-7. 2. Dreifus C, ed. Seizing our bodies: The pofitics of women's health. New York: Vintage, 1978. 10 STOTLAND:SOCIALCHANGEANDREPRODUCTIVEHEALTHCARE

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3. Bloom SW, Wilson RN. Patient-practitioner relationships. In: Freeman HE, ed. Handbook of medical sociology. Englewood Cliffs, NJ: Prentice-Hall, 1979:27596. 4. Thomas L. The youngest science: Notes of a medicine-watcher. New York: Viking, 1983. 5. University of Southern California Division of Research in Medical Education and the American College of Obstetricians and Gynecologists. Cooperative study of obstetric-gynecologic manpower. 1975. 6. Gordon JS, Jaffe DT, Bresler DE. Mind, body, and health: Toward an integral medicine. New York: Human Sciences Press, 1984. 7. Pellegrino EE. Humanism and the physician. Knoxville, TN: University of Tennessee Press, 1979. 8. Creaturo B. Are we too candid about sex? Woman's Day 1984;16 October:23. 9. American College of Obstetricians and Gynecologists. ACOG Newsl January 1985. 10. Craig WS. Care of the newly born infant, 2nd ed. Baltimore: Williams & Wilkins, 1961:107-11. 11. Sacharin RM, Hunter MHS. Pediatric nursing procedures, 2nd ed. London: E & S Livingstone, 1969:90. 12. US Department of Labor. Bureau of Labor Statistics. Washington, DC: US Government Printing Office, 1984-1985. 13. Fleming AT: The American wife. New York Times Magazine 1986;26 October:28. 14. American College of Obstetricians and Gynecologists. ACOG Newsl January 1985. 15. Applegarth A. Women and work. In: Bernay T, Cantor DW, eds. The psychology of today's woman: New psychoanalytic visions. HiUsdale, NJ: Analytic Press, 1986:211-29. 16. Dodson B. Liberating masturbation: A meditation on self love. New York: Author, 1974. 17. Filene PG. Him/her self: Sex roles in modern America. New York: Harcourt, Brace, Jovanovich, 1974. 18. Friedman EA. The obstetrician's dilemma: How much fetal monitoring and cesarean section is enough? N Engl J Med 1986;315:641-3. 19. Scully D, Bart P. A funny thing happened on the way to the orifice: Women in gynecology textbooks. In: Huber J, ed. Changing women in a changing society. Chicago: University of Chicago Press, 1973:283-8. 20. Lewin E, Oleson V. Women, health, and healing: Toward a new perspective. New York, Tavistock/Methuen, 1986.

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Social change and women's reproductive health care.

Social Change and Women's Reproductive Health Care Nada L. Stotland, MD Professor of Psychiatry and Professor of Obstetrics and Gynecology University...
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