Inaugural May Cohen Lectureship
in Women's Health: Gender as a Determinant of Health
by Hon. Monique Begin, October 27, 1997
I have the honour and great personal pleasure to be giving tonight the inaugural May Cohen Lecture in women's health. A few words about a woman and a family physician extraordinaire are therefore in order. Her curriculum vitae is most modest, not to say silent, on her achievements in the academy as well as in the community around, achievements which contributed significantly to social change for men and women, but for women in a very special way. Dr. Cohen completed her medical degree at University of Toronto the same year that I graduated from Teacher's College at Rigaud (QC). But when I was in a class of 100% female students - teaching being one of the three so-called women's occupations - May was one of the less than 7% of female students in medicine in Canada.
Dr. May Cohen is a complete humanist, for she is also a feminist since as far back as she can recall. Both her parents had always been involved in social activism in the Jewish community and the need to work for a better world around her was a given for May Cohen. But I was interested in how, if it applied, she started calling herself a feminist. Was there any particular moment, an event, an encounter, a personal experience. With her inimitable way at story telling, May recreated for me over the phone a sunny afternoon in the backyard, overlooking the children who were playing, and reading Betty Friedan's hot from the press Feminine Mystique (1963), saying: it's me! Raising three children while practicing medicine instead of being a good housewife and a mother at home with five kids, always feeling guilty, and only thinking of herself after everybody else had been looked after - if there was time left! Ten years later, a second epiphany occurred when Dr. Henry Morgentaler was first tried for practicing abortions and a 25 cents campaign was organized to help pay his legal fees. It is around the same time that Dr. Cohen was appointed Chair of the Abortion Committee of the Branson hospital and that its medical director warned her that the Committee could approve abortions only in the case of a 12 year old who had been raped or a 45 year old woman if she had severe high blood pressure! As May commented gently: It is all the women in between that interested me... Fighting for women to have real choices and teaching human sexuality became additional battlefields: "You wouldn't have abortions if people understood and were comfortable with their sexuality".
The third "click" goes back to her sabbatical in Australia in 1987-1988 with Gerry, where May heard of a formal institutional approach to the broader subject matter of women's health. One thing leading to another, she was instrumental in setting up the very first academic women's health office in Canada. The history of the McMaster's Faculty of Health Sciences Women's Health Office, created in 1991, has been inspired by the work of a group of women physicians in the OMA, in the late '80's, on wife abuse. Back from a presentation by that group to representatives of the five Ontario schools of medicine, May and one of her colleagues concluded that their University was hypocritical: no action, just words. It took ten months to develop the concept. (May and the team who worked on it with then Dean Stuart McLeod feel they were all very clever politically!) From the action around the Women's Health Office flowed the famous WHISCC (Women's Health Inter School Curriculum Committee) and all the ensuing gender committees in faculties of medicine and in organized medicine in Canada. Besides the extraordinary struggles of individual women professors of medicine, what has helped tremendously in improving medical education, the experience of female students and the status of women professors, is the institutionalization of women's health in one of the most prestigious faculties of health sciences in the country. I have great admiration for that accomplishment, knowing only too well the culture of our medical schools. When discussing the subject of women's health with deans and professors of medicine, the reaction is still typically one of physicians' positivism: "Bring me the evidence!", they rebut...
One trademark course of May Cohen since 1989 as been her Gender as a Determinant of Health annual presentation. And here I am tonight with the same topic to cover!
Since my own experience in teaching "women and health" has been with students of faculties of arts, social sciences and nursing, and since it stemmed from a social critique of medicine and is rooted in the women's health movement, I will focus on the need to study and research women's health from the angle of "the influences that mediate disease rather than on specific diseases themselves" to borrow a definition from a very interesting article in the June 1997 issue of the Journal of Women's Healthi. In other words, I will be sharing with you the reflections of someone outside the field of bio-medical scholarship.
The concept of the determinants of health organized in a theoretical framework, as far as I can make out, is not yet ten years old. It was first explored formally by a team at the Canadian Institute for Advanced Research (CIAR); and then, it made its way through the first Premier's Council on Health Strategy (Ontario) (198.-1991) and the second Premier's Council on Health, Well-Being and Social Justice (Ontario) (1991-1994). This is not to suggest that public health professionals have not sensed, since decades, that factors other than biology profoundly influence the health status of individuals and of communities. Scholarship has adopted Thomas McKeown's research on England over the last 150 years on the decline in mortality from infectious disease as the metaphor for discussing the determinants of health - i.e. circumstances other than the individuals' genetic endowment which are experienced collectively and which affect the health status of the group.
Tonight, relying on a life-cycle approach, I chose to focus on three seasons
or moments of women's life: adolescence, mid-age and old age. For each of these
ages in life, I have been searching a significant feature or trait capturing
how society not only influences but determines women's health in our Western
world culture. I will therefore not discuss the over- and under-medicalization
of women's health, or the gender-based power structure of the health care
sciences, two topics I have often analyzed in public. Nor will I focus on
specific women's health conditions and diseases, unless identifying them en
passant. I want instead to try to understand from within why it is that young
girls become anorexic and middle aged women become depressed and addicted to
substance abuses in important numbers, when boys and men do not. I want to discuss
how the Canadian society affect the health of its 15 million females.
Why choose adolescence - pre-teen and teen ages, the 10 to 19 years old -
and not, say, early childhood or early school years? Because adolescence,
although in a way the healthiest stage of life, is also the stage of crucial
transitions - the fastest physical changes after infancy - where personal
choices with life long consequences are made. Singling out adolescence is consequently
most significant, since points of critical transitions in the life-cycle should
be adopted as top priorities in the development of strategies for maintaining
as well as improving the health status of any given population. Young people
need good physical and mental health to make the most of the opportunities for
learning and growth, and to prepare themselves for adult responsibilities. Too
often, adolescents feel invincible and immortal. (Considering the
risks they take, we could also add infertile and immune!). The
"baby boom echo generation" is no exception. It needs help, support
and guidance to experiment life moments healthily, avoid dangerous risks, and
make appropriate choices, finding good coping strategies, from educational
decisions to personal relations. These choices, although made individually, are
however the product of childhood experiences, family and community environment,
peer influences, and society's expectations. That is where adolescent girls
become particularly vulnerable. A remarkable book on teenage girls by Edmonton-based author Myrna
Kotash, guides us "from within" into that key period of life. We will
never repeat enough youth's need to be believed, trusted, and taken seriously.
This is the opposite of relationships of power and control, although it is not
to say that parents should not remain parents. Age 14 and 15 is the age of girl
friendship, the time of "the best friend", with its resulting deep
satisfaction of being understood in the best and the worst times, and of
learning of interpersonal skills that will stay for life. Peer groups have then
more influence than parents. Only 65% of teenagers report that the family is
very important to them, yet 90% say that they "highly value"
friendship and love. Reasons for choosing schools are not pedagogical but
affective:
When asked about which characteristic we should try to change in political
women's behaviour, and without accusing women for it, I immediately think of
the low self-esteem which I observed, however well-hidden, by these successful
"women at the top", in a great many of us. In other words, when we do
not like or approve of ourselves as teenagers, it will not easily disappear
later on in life! But this tendency to harsh self-criticism and abusive anxiety
about perfection is not the trait I would offer to characterize women in their
mid-age. Healthy stress would rather be my choice for understanding the
common denominator leading to health problems in women in their mid-age.
Midlife, the years approximately between 45 and 64, is more a life stage than a
particularly significant chronological period. But, as is the case with
adolescents' health status, the health status of women in their mid-age is
heavily responsive to major shifts in social roles and expectations affecting
women. Two thirds of women 45 to 54 years of age and one third of women 55 to 64
years, are gainfully employed. Another 25%+ of women find themselves in
part-time employment (against 8% for men), and since this category of jobs is
rapidly growing with the downsizing and structural changes to the economy, it
will make it more difficult for women to get full-time jobs. In general: "Women's employment is sharply etched by inequalities in pay, job
benefits, and advancement opportunities. Despite growing numbers of women
entering managerial and professional occupations, the majority of female
employees are concentrated in low-status, low-paid, dead-end 'job ghettos' in
the clerical, sales, and service sectors. These three occupations combined accounted
for 57% of all paid female employment in 1987, compared to 25% of all male
employment.".ix And: "Unlike men, the majority of women in Canada work a double
day".x Saturday's Globe & Mail offered this unusual and provocative
description of women's work: "Using Statistics Canada's 30-hour definition
for full-time work, most Canadian women work part-time in the paid labour force
and full-time in the unpaid. The 1992 General Social Survey identified
housekeeping as the main activity of 3.4 million Canadians, making it the
largest occupation in the country - if it were considered an occupation, which
it isn't, officially." xi
More than men, women have multiple roles to fulfill in society. Some roles
are rewarded with money, prestige and status: paid employment should provide a
few good examples. Others used to be rewarded at the symbolic level, by the
official discourse of society: motherhood comes immediately to mind. Other
roles, yet, are ignored or invisible: women as caregivers of disabled or older family
members embody such role. Most of these roles, even when recognized under one
form or another, are undervalued. "Caring", the undervalued
ingredient of most women's work, is their common denominator, be it in paid
employment (for example: nurses, teachers, secretaries, social workers, daycare
workers, service jobs, etc.) or at home (homemakers, spouses, mothers). "Caring
can be rewarding, but it also has its costs in the form of guilt, conflict,
added burdens and pressures."xii In addition, when women collectively in Canada are still paid some 70 cents
in the dollar for full-time jobs compared to men, despite women's rapidly
rising university education, their work is undervalued. When they do not get
promoted, or not as rapidly, their work is undervalued. When women
participating in the labour force find themselves massively as a group at the
bottom of the power structures, as is the case in the health care system in
particular, their participation is undervalued. When having the final
responsibility, and often the full responsibility, for the care of children is
not recognized by support services and programmes from government and the
private sector, that role is undervalued. When unpaid domestic work is not even
accounted for in national statisticsxiii, let alone rewarded, the message is
that full-time and part-time homemakers work is undervalued; in fact, it is not
even considered seriously as work. When the caring of older parents or of a
disabled family member falls systematically on the shoulders of the 45+ woman
as her "natural" role instead of being recognized for the heavy and
continuous responsibility it is, it is undervalued. And if what women do is
undervalued, women are undervalued. Health research after health research signal that, in today's society,
full-time housewives are far more at risks for their health than women in paid
employment who consistently score better overall health. In other words, women
who experience more roles have better health trends. This statement does not
apply equally: race, language and culture, and socio-economic status, are
obvious qualifying factors. For example, the industrial sewing homework done by
so many immigrant women, usually a form of exploitation, may on the contrary
lead to strains and ultimately, to illness or disease. It remains that labour
force participation often has positive effects on health. Some authors suggest
that one reason may be that employment buffers the stresses of child-rearing by
providing social support and time away from children's demands and by providing
alternative, more structured and perhaps more readily controllable sources of
gratification. Full-time homemaking, characterized by autonomy and initiative,
is also defined by monotony, boredom, fragmentation and, worse, social isolation,
intensifying frustrations and job dissatisfaction. Evening and weekend
homemaking -- the double day of working women -- result in fatigue and applies
to all adult women with families. (For the generation of women age 25 to 44
who believe that women now have it equal, it can best be expressed as the
Bionic Woman Syndrome, and it is based on quite a social lie.) To complete the picture of midlife potential stressors, we must take into
account the hormonal changes of the menopause (still at the median age of 51)
and the re-adjustments reached by women. Menopause itself is lived differently
in different countries, and is more or less of a burden depending on
socio-cultural factors surrounding it. While 90% of women experience menopause
without any serious disorders (50% of all women with no problem at all), they
are still the victims of North America's negative clichJs and stereotypes about
menopausal women, cultural attitudes often perpetuated by physicians and
psychiatrists who still take pre-conceived ideas for biological realities. One
links menopause and depression; others refer to mood swings, emotional
instability and irritability. Many other factors may be the cause, starting
with demographic imbalances. Up until age 45, women and men are in almost equal numbers in our North
American society. At age 45, a gap first show, and when women reach age 65,
they are suddenly faced with a dramatically different ratio of two men to each
three women, ratio which will become, at age 75, of one men only to three
women. Mid-age is also the time of widowhood, separation or divorce. If
mid-years bring personal growth and expansion, they also bring, to mothers
especially, a number of losses, the first ones being that of grown up children
leaving. And they bring to all women the loss of fertility and the fear of
breast cancer - the secret fear of any woman. The relationship of bad stress to breast cancer is not yet known, although a
strong suspicion is growing among survivors that there exists such a
relationship. What would the stressors be exactly has also to be studied. Women
know that risks of breast cancer increase dramatically with age, from midlife
to old age. They also believe that not enough research -- in causes, treatment
and prevention -- is conducted on breast cancer compared to investigations of
other cancers, despite its critical importance for women's health and survival,
when it is estimated that, in 1997, 14 women will die of breast cancer every
day in Canada. (Let me note here that it is not breast cancer, however
serious a disease, that is the first cause of mortality of women in Canada.
Like in some other industrialized countries, the leading cause of death of
women is cardiovascular disease.) Far less serious but still damageable are other health problems of mid-age
women: eating disorders (again!) is one of them. Obesity does not seem to be
yet in Canada the problem it is in the U.S., but weight problems are. Although
being overweight is not a disease, obesity is associated either directly or
indirectly with serious diseases, including diabetes, hypertension, menstrual
and reproductive abnormalities, arthritis, gout, arteriosclerosis, abnormal
heart size and function, and gallbladder disease. A Quebec survey shows that
the highest rate of obesity was found in women age 45 to 64 where 18% are obese
against 9.7% of menxiv. Obesity could be called a social disease in that its
socio-economic dimensions are significant: cheap high fat food outlets are
found in areas with concentrations of low-income and minority ethnic families.
Each time, studies link problems of being overweight and of obesity with the
perceptions by respondents to be less in control of their environment and their
lives as a whole. Unhealthy stress is also connected to the abuse by women (11% of them in
midlife) of minor tranquilizers and antidepressant drugs, which, like alcohol,
are viewed as a solution before becoming a problem.xv (The highest rate of
these prescriptions now seems to be shifting to women caring for pre-school
children.) The women's health movement has taken a strong stand against the
abusive prescription of these drugs to women -- two women are given such
prescriptions against one man -- by general practitioners and psychiatrists. By
way of consequence, the movement has often attacked the pharmaceuticals
themselves, and the industry's advertising in medical journals. May I submit
here that medical practitioners should take the blame for this
over-prescription and should reflect on the reasons why it takes place.
Medicine as a science is best in diagnosing and treating specific pathologies.
Most women's consultations ending with prescriptions of Valium and the like are
for non-specific symptoms expressing fatigue, sleeplessness, loss of energy and
psychological distress. Not knowing how to assist the patients, physicians
prescribe tranquilizers and antidepressants. Another pitfall of medicine in its
treatment of women lies in problems presented by individual patients and
treated by medicine as individual pathologies which are, in fact, collective
problems requiring societal, not chemical solutions. Midlife, in a sense one of the most rewarding stages of women's lives, is
unfortunately spoiled with society's prejudices, with the lack of proper
infrastructures to support families, and with the denial of simple justice for
women and their work.