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Why Another Book on
Women's Health?
A large headline scowls from the front page of a metropolitan daily. Below it, a
grainy photo captures a middle-aged man frowning over his bifocals. EXPERTS
QUESTION SAFETY OF MAJOR BREAST CANCER STUDY, the heavy
type proclaims. A line of smaller print identifies the man, a medical school
professor, as a "leading critic of the tamoxifen trial."
A blond movie actress beams at an even blonder toddler on an eye-level rack
above a supermarket checkout counter. Over her head marches the bright-red
name of a national women's magazine. Next to her, lines of variegated type
promise a late bulletin about the Kennedy family, announce the advent of a
surefire weight loss plan, and pose a pair of disquieting queries: WHAT TO DO
ABOUT MENOPAUSE? IS HORMONE THERAPY FOR YOU?
_ ssues involving women's health are everywhere these days. Ques
tions once discussed only in the privacy of the consulting room,
_ ~ matters formerly considered either too personal or too technical for
general conversation, decisions that used to be left to experts, now pop up
across kitchen tables, in parking lots, and over office coffee machines
across the nation. How much the nation spends on what kinds of medical
research, once an esoteric interest of academics, now inspires protest
marches. Concern about reproductive diseases, once whispered among
close friends, now finds expression in bits of ribbon pinned to lapels.
The last decades have seen a truly startling change. From the
3
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I N H E R O WN R ~ G HT
specialized concerns of a small number of activists, clinicians, and scholars,
women's health issues have grown into a major preoccupation of political
leaders, medical researchers, and the popular media. The first edition of
the now-perennial bestseller, Our Bodies, Ourselves, constituted a daring
departure from accepted thinking. A White House announcement that
the First Lady faced breast cancer surgery created a national sensation,
linking the President's family to the then-unprintable words "breast" and
cc ,,
cancer.
A new generation of women began to develop a new sense of
themselves as consumers of health care services. And the unprecedented
official candor about Betty Ford's and, soon afterward, Second Lady Happy
Rockefeller's, mastectomies made the subject instantly respectable, sent
millions of women to seek mammograms, and sparked reformers to begin
questioning the disfiguring orthodoxy of total breast removal.
Today, as female physicians stream out of medical schools and
residency programs in record numbers, health issues important to women
have moved along with other formerly ignored issues like family leave
and pay inequities to the forefront of national consciousness. Major dai-
lies now headline developments in diseases once considered unfit for men-
tion in family newspapers. Women's magazines delve into the choices
open to informed health care consumers. Television newscasts highlight
controversial research results. Bookstore shelves overflow with volumes
on every aspect of the female mind and body. Videos, tapes, newsletters,
computer bulletin boards, and every other available mode of communica-
tion constantly add to the rising torrent of information, guidance, and
. .
Oplmon.
So why should the Institute of Medicine (IOM), a scientific
body chartered by the U.S. Congress to provide expert consultation on
pressing public issues, enter so crowded a field? Why should an organiza-
tion customarily devoted to detailed consideration of technical matters
give a popular treatment to an already over-covered topic? And perhaps
most significantly for the reader, why add yet another voice to the din?
The most pressing reason is that din is exactly what all too
often answers a thoughtful citizen's efforts to stay informed. As authors of
particular books, advocates for selected diseases, and proponents of various
theories compete on talk shows and in op-ed pieces and magazine articles
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C HA P T E R ~ ~ Why Another Book on Women's Health?
for viewers' and readers' limited attention, no sense of priority or relative
importance orders the discussion. Every disease appears equally dreadful,
every threat equally dire, every risk equally grave. In the new world of
health awareness, however, ordinary citizens are no longer patients
shepherded by fatherly medical advisors but consumers of services and
information in a competitive marketplace. Confronted with any impor-
tant medical problem, ordinary people are increasingly encouraged, even
required, to make the kind of decisions once the exclusive province of
doctors.
In this new atmosphere, understanding how to frame intelli-
gent questions has become surpassingly important. What are the risks and
benefits of various forms of birth control? What are the health costs of
delaying childbearing or of proceeding with it too early? Should a meno-
pausal woman take hormone replacement therapy? And if so, for how
long? Should a breast cancer patient opt for lumpectomy or mastectomy?
For post-surgical medication? Issues like these real, serious questions with
real, serious, though not necessarily knowable, consequences face more
and more people in our age of informed consent and increasingly imper-
sonal care. Where once those without medical training left such matters in
the hands of a trusted adviser who knew us personally and took a paternal-
istic interest in our welfare, today, professionals increasingly expect lay
people, frequently under extreme emotional stress, to quickly learn enough
gynecology or oncology or cardiology to participate in the deliberations
and make the final choices among available options.
In this new age, then, anyone who has ever been or expects to
be a patient, or who has ever had or expects to have responsibility for the
health care of others, needs a framework to organize what they know, to
give fragments of information the meaning and priority only possible as
parts of a systematic body of understanding.
Clearly, no untrained person can expect to acquire, nor can
any popular book claim to deliver, the detailed, comprehensive grasp that
a health professional has. But high-level expertise is not what best serves
today's intelligent health care consumer. Rather, she or he needs a way of
thinking about medical information, a way of sorting out claims and
weighing results. How, for example, does one know if a drug is "safe"
(considering that all medications have side effects and taking any at all
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I N H E R O WN R ~ G HT
constitutes a bet on expected benefits over possible harm)? What are the
major health threats a woman should take care to guard against (consider-
ing that, contrary to popular impression, heart disease kills many more
females than breast cancer)? What is the best way to counter obesity
(remembering that some weight loss methods in themselves represent
threats to health)? Providing a framework for thinking about such issues is
what this book aims to do.
Two circumstances spurred this effort, one relating to the sub-
ject itself, the other to the nature of the IOM. Many of the topics that
flash across the national consciousness and briefly flood the popular media
are fads or frivolities. The current interest in women's health clearly is not.
A number of the changes in thinking taking place not only among the
general public but also among health professionals represent, at their intel-
lectual base, a thoroughgoing and long overdue reassessment.
The medical enterprise, both in scientific research and in clini-
cal practice has traditionally viewed female lives and bodies through a lens
of masculine experience and assumptions. Indeed, the name of the medi-
cal specialty that studies female reproduction, gynecology, means "science
of woman" in Greek. No corresponding specialty of "andrology" studies
the distinctive reproductive features of men. Male reproduction falls in-
stead under urology, literally, "the science of urine," which, according to
a leading medical dictionary, encompasses "the study, diagnosis and treat-
ment of diseases of the genitourinary tract, especially the urinary tract in
both sexes and the genital organs in the male.") Male genitalia, in other
words, form a subdivision of a larger, more general, bodily system, while
female reproductive organs occupy a special realm, distinct from the body
at large, and one that also just happens to define their owner's essential
nature.
The effort to remove this distorting lens, to see and treat the
female person as a whole and normal human being in her own right,
rather than as a subsidiary or deviant version of the dominant male, is
already well under way. The need to incorporate female experience and
perceptions into medical thinking has become obvious across the health
care community.
Informing the public of the issues at stake is basic to this effort
of reexamination and reform. Realigning a field of knowledge, reformu
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C HA P T E R ~ ~ Why Another Book on Women's Health?
rating an area of endeavor, requires a new architecture for thought and
analysis. In the famous phrase of the historian of science Thomas Kuhn, it
requires a "paradigm shift." Scholars and scientists have already begun
sketching out a new paradigm for women's health, a new image of the
physical and mental well-being of half the human race. To show how this
new thinking applies to the lives of real people of both genders is the goal
of this book.
The Institute of Medicine brings to this effort two special re-
sources, the breadth of its exposure to health issues and the depth of its
expertise. Throughout its history, IOM has assembled committees of rec-
ognized experts to study major health issues and has organized meetings to
present the latest and most authoritative views in fast-moving research
fields. A quarter-century of unbiased study and consensual decision mak-
ing, besides creating a large body of trustworthy information, offers pro-
tection from the vagaries of fashion and the extremes of ideology. In the
changing world of women's health, as with many other major social
changes, important and sometimes well-financed interests have lined up
on various sides of various questions. In its many studies and meetings,
IOM has striven for fair, balanced, and responsible consideration.
A subject long central to the Institute's work has now moved
to the center of the nation's attention. Concerns specific to women
reproductive technology, breast cancer, osteoporosis, menopause now
receive wide coverage. Issues shared with men but predominantly affect-
ing women aging, depression, obesity, sexual harassment, child care-
increasingly dominate the news. Newly salient policy questions, like the
design of clinical trials, crop up in the popular media.
Symbolizing and enhancing the new prominence of women's
concerns, the Institute and its constituent body, the Food and Nutrition
Board, have explored them in a variety of publications and at two major
conferences. In December 1991, FNB examined nutrition audits effect
on women's health. In October 1992, IOM used its annual meeting to
take stock of gender as it relates to health and health care. Covered in
both professional and popular media, these gatherings focused attention
on factors that crucially affect the physical and mental well-being of
women and girls around the world. Though the meetings involved differ-
ent scholarly bodies and emphasized different scientific disciplines, both
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I N H E R O WN R ~ G HT
sought answers to the same central questions: Which factors contribute
to or detract fro~women's mental and physical well-being? How
can that well-being be improved? What accounts for discrepancies in the
health of men and women? How can inequities be corrected?
Or, as a Food and Nutrition Board conference speaker, Susan
Scrimshaw, Ph.D., professor and associate dean at the UCLA School of
Public Health,* put it most succinctly, the question comes down to "Why
women?" Why do the things that happen specifically to women happen
to them and not to men? Why do they face numerous health risks much
rarer among men breast cancer, eating disorders, high rates of anemia
and depression, to name just a few? What is it about their lives that opens
them to these problems? How can those conditions be improved?
Three themes that form the leitmotifs of IOM work lead the
way toward answers: different biologies and physiologies, divergent life
courses, and unequal social statuses. Males and females have bodies that
differ in important respects. They still have remarkably dissimilar experi-
ences in growing up, during maturity, and as they age. And, despite the
rapid social change of the last generation, they still play different roles in
society and face different pressures and expectations.
No one of these factors in itself completely explains such
puzzles as women's higher morbidity but lower mortality, their greater
susceptibility to depression, or the inadequate nourishment they receive in
many parts of the world. Clearly, differences in the genders' patterns of
health and illness arise both from physical factors like women's more
responsive immune systems and from social factors like their greater expo-
sure to children and the sick. The health care system also treats the gen-
ders differently, for example, in its approach to cardiac illness.
Dietary differences also carry important consequences. Com-
mon conditions like anemia and osteoporosis arise from a combination of
dietary and behavioral causes. The former occurs often among poorly
nourished but frequently pregnant women, and the latter among those
who consumed too little calcium in their youth and got too little exercise
in maturity. A similar combination of food and lifestyle specifically, high
fat and late childbearing is heavily implicated in the industrialized West
*The affiliations cited for the speakers throughout this volume have not been updated ED.
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C HA P T E R ~ ~ Why Another Book on Women's Health?
em countries' high rates of breast cancer. Along with their special social
roles, women clearly face distinctive nutritional challenges, especially when
the heavy demands of childbirth and nursing come on top of general
requirements for good health.
But beyond those uniquely feminine processes, a constellation
of physiological and social factors conspires to threaten women's welfare.
Many cultures erect specific obstacles that prevent females from eating
adequately, barriers not equally applicable to males. In developing coun-
tries, most women do heavy labor and endure repeated, closely spaced
pregnancies but have less chance than men and children to eat what they
need. In the developed world the ideal of slenderness takes hold before
adolescence and persists into middle age and beyond, pressing in most
severely during the very same adolescent and early adult years when a
woman must lay down in her bones a supply of calcium to last her lifetime
and when she conceives and bears her children. And in the United States
the increasingly parlous state of young women a confusion of life goals
compounded by increasing sexual pressure has brought on a growing
rash of depression, addiction, and eating disorders. Each of these situations
merits asking "Why women?" Each affords clues to the realities shaping
female lives.
From cases like these and from IOM's work on women's health
emerge three overarching themes that form this book's intellectual frame-
work.
Health is the intersection of an individual's physical
endowment and life experience. Except in very rare cases, no single
factor determines the state of an individual's physical or mental health.
Rather, physiology, diet, developmental history, emotional and intellec-
tual experience, social opportunities, physical environment, and other ele-
ments all enter the equation.
A woman's health evolves across her entire life span.
This statement deserves special note because, surprisingly enough, it rep-
resents a departure from the traditional view of the female, which cen-
tered on childbearing. Women's reproductive capacity has long formed a
major focus of attention. Improving or controlling the ability to bear
healthy babies has been the goal of much scientific and clinical work. The
study of women's health has often paid more attention to the health of a
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I N H E R O WN R ~ G HT
woman's children than to the mother herself and devoted more resources
to improving their welfare than hers. In much of the developing world, it
has focused on childbirth and lactation with little concern for the decades
before and after.
Central to the new woman-centered notion of women's health,
however, and to this book, is the understanding that women's health
concerns deserve to be addressed as they affect women, persons who have
lives before and after the possibility of childbearing and whose well-being
matters whether or not they ever bear children. As is also true for men,
health status at every stage of life affects the stages that follow, often in
complex, subtle, and unexpected ways. As more and more women live to
older and older ages, the total shape of the female life span, of which
reproduction constitutes only a limited period, must come into clearer
view.
"In 1988 . . . Ithel articulation of a 'life-cycle' approach to
thinking about female health was novel and innovative," observes a
ground-breaking report of IOM's Committee to Study Female Morbidity
and Mortality in Sub-Saharan Africa.2 This perspective assumes the need
to articulate the major causes of health status not solely in women of
reproductive age, but in "an individual's entire life experience from birth
to death, whether or not that includes reproduction."3
Women's life experiences and social roles differ from
men's in ways that affect physical and mental health. These differ-
ences bear heavily on many aspects of health, including such diverse issues
as what and how much a woman eats, how and where she gets medical
care, and whether the factors affecting her health get appropriate attention
in research.
Through its leadership role in medicine, IOM has over the
years accumulated a large body of information and insight that illuminates
many of the issues surrounding women's health today and tomorrow.
This book endeavors to use that resource specifically, the findings of a
variety of reports and conferences to explain what women (and men)
need to know.
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C HA P T E R ~ ~ Why Another Book on Women's Health?
NOTES
1. Stedman's Medical Dictionary, 25th ea., s.v. "urology."
2. In Her Lfetime: Female Morbidity and Mortality in Sub-Saharan Africa, 2.
3. Ibid, 3.
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Representative terms from entire chapter:
popular media
