Magnificent menopause. The ageing body (m/f) in
a risk-culture.
Paper for
workshop The controversial body: Ageing in women’s theories, literatures and
cultures. DRAFT VERSION
4th
European Feminist Research Conference
Body,
gender, subjectivity. Crossing borders of disciplines and institutions
Bologna, 28
September - 1 October 2000
Ineke
Klinge
Genderstudies
in health and health care
Faculty of
Health Sciences, ZW/GEW
Maastricht University
i.klinge@zw.unimaas.nl
Health care
today can be characterized as a risk-culture.
A few decades ago, people only sought the help of a doctor when they
experienced complaints. A doctor usually could classify their symptoms as
belonging to a well-described disease or to some syndrome, for which, in most
cases, some kind of treatment was at hand.
Today’s
situation is completely different. It is no longer the presence of complaints
that bothers men and women and prompts them to visit their doctor. Instead, the
idea that one may be the carrier of one or more risk factors for a certain
condition now dominates health care seeking behaviour of populations as a whole
and of individuals in particular. What has triggered this change from a
complaint related medicine to a risk oriented medicine?
Developments
within the fields of genetics have had a major impact. Although the connection
between genetics / heredity and health stems from insights of the beginning of
the 20th century, of late this relationship has become a lot
tighter. Genetic research shifted its focus from research into the genetic
structure of human beings to research into the relationship between genes and
disease. The term genetic disease was introduced (Fox Keller, 1992). The Human
Genome Project, an international research project, aimed at mapping the
sequence of all buildings blocks of human DNA was fuelled by the idea of future
control. If the relation between
genes and diseases should have been settled, it would open up possibilities for
the prevention of disease. This development was accompanied by a particular
style of thought: what had been considered as fate now became transformed into risk (Vries, Hortsman, & Haveman, 1997). The concept of risk
refers to the chance that some unwanted event with a disagreeable effect will
happen in the future. The concept of risk also creates a continuum between
being healthy and disease. It has a strong influence on the relationship with
oneself, one’s body, other people and nature.
Next to the
more well known conditions in which genetics play a role, a number of more
common conditions like for instance heart disease have become inserted into the
domain of risk medicine. In this case there is no single gene or set of genes
that determines the disease, rather a number of risk factors have been
identified which all affect the chance of developing the disease. Many of you
will be acquainted with the risk factors for heart disease: smoking,
overweight, high cholesterol, high blood pressure, lack of exercise and so on.
Some of these factors have been labelled as life style factors, which means
that they are subject to control. A person can decide whether or not to change
one of these life style factors and thus influence his or her future condition.
However, risk factors, which differ in relative weight, can only predict disease, it is never certain if
one will develop the disease, nor if eliminating one of the risk factors will
be effective. Nevertheless, measuring risk factors has become a ubiquitous
practice.
Deborah
Lupton has analysed how health has become a moral issue (Lupton, 1995). In the
era of predictive medicine health is no longer a given thing, but health has to
be crafted. Lifestyle issues like exercise and nutrition have become health
issues. Health has become a personal responsibility and one’s morality is at
stake in controlling one’s risk factors. It has resulted in an enormous
pressure to take preventive measures.
I would
like to illustrate the shift from a complaint related medicine to a risk
oriented medicine with the example of the climacteric (m/f) or menopausal
transition, also called the Change (Greer, 1991). When ageing, women and men
inevitably will encounter the menopause / andropause or the climacteric. This
change in hormonal status of women and men is known for a long time in the
literature. There are of course differences in the dynamics of the changing sex
hormone levels, but the male climacteric has been described in large detail as
early as 1947 (J.H.G., 1946). The climacteric complaints described for men were
strikingly similar to those for women. After it had become possible to
synthesize sex hormones in the laboratory, treatment options for the
climacteric expanded enormously. Decreasing hormone levels could be
supplemented. At the same time the quick and easy to produce chemicals
represented a growth potential for pharmaceutical firms. From that time on, sex
hormones became settled as treatment for menopausal complaints.
Next, the
potential of sex hormone therapy for a number of other conditions became object
of research interest among which osteoporosis, the brittle bone disease (cf,
Drugs looking for diseases (Oudshoorn, 1994) (Vos, 1989). It was the clinician
Albright who already in 1941 successfully launched hormone treatment as a
therapy for osteoporosis (Albright, Smith, & Richardson, 1941). He and his
collaborators conducted clinical studies in women and men with administration
of ‘male’ (androgens) and ‘female’ (estrogens) sex hormones (Henneman &
Wallach, 1957). The clinical studies with different combinations of estrogens
and androgens which were conducted in men and women yielded positive results.
The calcium balance - as a parameter of bone metabolism - which was negative,
became positive again. However, the conclusions that were made based on these
studies were remarkable in two respects:
The first
point concerns the risk of cancer. Sex hormones have the potential to induce
cancer: cancer of the uterus in women and cancer of the prostate in men. These
cancer risks were well known in the literature. How curious to see that these risks were weighed differently:
although a therapy with sex hormones was effective against osteoporosis, the
risk of cancer in men was judged as unacceptable. The cancer risk in women was
judged acceptable and could be countered by monitoring and by giving the
hormones intermittently.
The second
point concerns libido. Although combinations of androgens and estrogens were
effective in women, later regimens consisted of estrogens alone because of
“excessive stimulation of libido”. In
men the estrogens were removed from the therapeutical combination because they
were decreasing libido and promoting
the growth of breasts.
As a
result, therapies with sex hormones became widely established for women as
treatment for menopausal complaints and also for osteoporosis. On the other
hand, the male climacteric and osteoporosis in men disappeared from the
research agenda. Menopause and osteoporosis became labelled as ‘female’
diseases and in my view this explains the fact that men have been neglected as
object of research for osteoporosis deep into the nineties.
The
spreading of hormone therapy for menopausal complaints has been gigantic. In
the 1960s the gynaecologist Wilson had promoted this therapy in women in a very
misogynous way: not so much menopause or other conditions were at stake, but
being a woman, and femininity. In short, without a supply of estrogens, a woman
would no longer be a woman but should be considered a castrate. His writings
have had a very deep impact on gynaecologists especially in the US but also in Europe.
The 1970s witnessed the straightforward drama of the neglect of the risk of
cancer: estrogen therapy for menopausal complaints had resulted in 4-8 times
increase in the risk of endometriumcancer. Fierce debates in the literature
followed on the risks and benefits of hormone therapy.
The cancer
problem was solved by the following solution: future estrogen therapy should
always be combined with a second hormone, namely progesterone, which would
counter the effects of estrogen (in much the same way as both hormones act
during the menstrual cycle). At the same time the benefits of hormone therapy
for other conditions and especially for osteoporosis, were heavily defended.
The gynaecologist Gordan testified on the safety and efficacy of estrogens to
the FDA, which had to take a new decision on admission of estrogen therapy
after the cancer drama. According to him the cancer discussion had “resulted in many women being denied estrogens,
receiving such toxic “treatment” as calcium, fluoride and vitamin D” (Gordan,
1980). He further stated: “ estrogens are effective in prevention of
postmenopausal bone loss and risks are acceptable”. And the legion of
gynaecologists advocating hormone therapy for osteoporosis has been ever
growing since.
At the same
time a feminist resistance against hormone therapy was awakening. The debate
was dominated by questions of medicalisation. Was the menopause another natural
process in a woman’s life that had become a disease to be treated by doctors?
In whose’ interest was it that women stayed ‘feminine’? And who profited from
the selling of hormone therapy to half of the population over 50? I will not go
into the details of this debate now, others have done that extensively (Coney,
1994), but I want to point here to the fact that this feminist resistance has
triggered a change in strategy from the part of the medical profession. Instead
of focussing on treatment of menopausal complaints
the emphasis shifted to prevention of
future conditions. Menopause became the moment in time to take preventive
actions. And the “naturalness” of a newer generation of estrogens was
emphasized.
The issue
of femininity disappeared from the professional agenda. Instead menopause
became connected to thinking about prevention. A number of conditions were on
the waiting list: osteoporosis, cardiovascular disease and even Alzheimer’s
disease. Menopause had now entered the age of prevention and the domain of a
risk oriented medicine. Even in the absence of menopausal complaints a woman
had to consider the risks of future conditions. Taking hormones for prevention
of osteoporosis or cardiovascular disease became a clear-cut health issue. The
message to stay healthy instead of ‘feminine’ should do away with feminist
resistance against hormone therapy. But to take preventive action you should
know your risk factors, for you don’t have complaints at the moment. A
responsible person should be concerned about one’s risk profile and should pay
attention to the respective risk factors. Knowledge of these risk factors is to
be gained from many sources ranging from measurements by the doctors to the
completion of a risk test in women’s magazines. At this point I want to stress
the impact of medical technologies. As example is the measurement of bone mass.
This technology called densitometry
gives a value for your bone mass, which has to be compared to peak bone mass or
to the average bone mass of a same age and sex group. Based on an abstract
value representing your bone mass you should consider preventive measures. This
has profoundly changed the way we experience the body and bodily events
(Klinge, 1998). Not what we feel at
this very moment is decisive but what can happen.
A man or a woman needs to be convinced, by whatever argument, of the benefit in
the long term, before going along with a preventive therapy. The choice for a
particular preventive strategy requires a cost/benefit analysis. And here
quantitative assessments of the quality of life are of little value. What does
the knowledge to live for 0.1 to 1 year longer - in case you belong to the risk
group for hip fractures - mean to a woman if to obtain that benefit, she should
take hormone therapy for 30 years during which time her risk of breast cancer
duplicates every ten year? How to evaluate this kind of risk information? Is it
worth your investment?
Health as individual responsibility
Men and
women alike are to make an evaluation of risk factors for a rising number of
conditions, in the context of strong pressures in society. A society which can
be characterized as a health culture. The efforts to convince women to start
preventive regimes are numberless. Strategies of pharmaceutical firms but also
of professional medical organizations have employed as diverse issues as the
costs of healthcare, fear of the future, personal guilt and moral
responsibility.
From feminist issue to health issue
The
strategies employed by producers of hormonal products in the 1990s are of
particular interest. Because their largest target group consist of baby boomers
they make use of second wave feminist thought. Taking hormones for prevention
of for instance osteoporosis is promoted as “ the right of a woman to decide”,
referring to the debate about abortion in the 1970s (Klinge, 1998). In this way
distance is taken from promoting “ femininity”, hoping to change hormone
therapy from a feminist issue into health issue.
Today
talking about menopause no longer takes place in private self-help groups as in
the 1970s. Instead it has become a public issue which is discussed on Internet.
Present day information on the menopause addresses the quality of life. Now
that the emancipation of women has reached its completion, a 50-year-old woman
does not want to be bothered by the menopause. To make a fuss of menopause is
obsolete. All kinds of women’s glossies tell us that: “Menopause is not as bad
as that”. “ The Change does not have to change a woman”. “A complaint-free passage through
menopause”. Whoever’s bodily timing does not tally with the rhythm of society,
only has to swallow a pill or stick on a plaster (Klinge, 1999). Menopause can
be managed elegantly and efficiently, and neither the woman nor her husband or
work has to suffer from it. Menopause will pass inadvertently. It all depends
on the right measures taken at the right time. This message could also be found
in the List discussions I followed. Women ask questions like: when is it time
to take measures and what symptoms should I be looking for? Which test do you
need to have performed to know if you already are perimenopausal?
It
illustrates how in managing menopause and its long term effects normalizing
technologies are pervasive. A recent
advertisement A colourful second youth
on hormone therapy states: “ the dream of every doctor: freed from menopausal
complaints your patient starts her second youth”. Lupton has stated that women
who take up the action of HRT are precisely engaging in the type of rational
action and prevention strategies that are highly valued and considered
important in our wider society (Lupton, 1996). Just as youth and attractiveness
are privileged in late modern societies so too good health, longevity and
physical fitness are valued and promoted. Medical and health professionals have
stimulated individuals to engage in body maintenance activities. In a context
in which irrationality, emotional instability ageing, sexual dysfunction and
ill health are negatively valued - and
menopause is portrayed as involving all of these- it is, according to Lupton,
not surprising that women should seek to counter its effects by taking hormone
therapy. Emily Martin analysed this portrait of menopause as breakdown of
central control resulting in chaos (Martin, 1988). However it is still found today.
A special report in Orgyn, a
journal reaching 120.000 gynaecologists all over the world, describes menopause
as the “ successful maintenance of the regular menstrual cycle as the
performance of a symphony which is going to change” (Diamond, 1998). The idea
behind is the pervasive metaphor that a woman’s rhythm in life is determined by
the rise and fall of her egg cell production. Work has to be done to counter
the effects. The conclusion can be that the years after menopause are not an
Indian summer, but are filled with an extensive body management to prevent
future conditions.
The revival of
andropause
And men??
In 1998 the first world congress on the ageing male was held. Prominent feature
was the revival of the male climacteric. Again in Orgyn the symptoms are addressed. A hormonal pension for the ageing
male? It is now called PADAM, partial androgen deficiency in ageing men. And it
looks a serious syndrome. 25% of males
between 60-80 have complaints comparable to women. Less muscular power,
fatigue, osteoporosis and depression in men should be countered by hormone
therapy (Smals, 2000). Even newspapers in the Netherlands reported the issue.
How should we explain this renewed attention after some 50 years of the first
description of the male climacteric? : Jealousy for women’s “quality of
life”? The Orgyn interview with dr Lunenfeld somehow reflected this idea.
Effectiveness and safety of androgen therapy on the long run will have to be
studied. As a new feature, there is
work to be done for men also.
In the
interview dr Lunenfeld stressed that hormone therapy for the male climacteric
will only be a success if it stays disconnected from issues of potency or
virility. Otherwise men will negate or resist the problem. It should be
represented as a health issue and a preventive activity. This stands in
contrast to the latest trend in marketing hormone therapy for women. Some producers
now openly promote the increase of female libido by hormone therapy. Who is
hot?
Risk
assessments are a new phenomenon. Now
that medicine has changed from a complaint related to a risk oriented medicine,
people will frequently be confronted with their risk for disease. Which at the
same time is an appeal to do something about it. It is no command but a
personal choice. But the pressure is there and will be followed by an
irresistible offer from the pharmaceutical industry. In my view, the
confrontation with a risk-assessment is not a confrontation with one’s fate.
Instead, at stake is how to deal with uncertainties and probabilities. Science
produces multiple knowledge fragments. It will be ever more necessary to get
insight in the construction of scientific knowledge as dependent upon time and
place of production. Body representations of men and women do matter a lot and
need to be analysed. Because the body management that it entails concerns
interventions in a healthy body.
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