II.

Sitting Woman (painting) IN N ALL KNOWN SOCIETIES AND CULTURES THERE IS A division of the population in two categories of persons - we usually call them men and women. The biological definition of these categories is quite clear. But it is more difficult to try to define what is masculine and what is feminine behaviour. Anthropologists have given us many different definitions depending on which group or culture they are studying. The variations are amazing; what is regarded as masculine in one culture is viewed as feminine in another. To be a woman in Sweden and a woman in New Guinea are two quite different things, but nevertheless they still have much in common. By using the concept of gender it is possible to analyze the various dimensions of the male or female sex.

The most common definition of gender is to separate certain factors from sex. Sex is declared to be determined by genes and biology, whereas gender is understood as a social construction. In one of WHO's reports, gender takes into account "personality traits, attitudes, feelings, values, behaviours and activities that society ascribes to the gender analysis, two sexes on a differential basis." This is important. Yet I would like to go beyond that definition, because it leaves biological and genetical factors outside the analysis of gender, which leads to a continued support of the false dichotomies between nature and nurture, i.e. between environmental and social influences. We have to integrate physiological differences between the sexes into the analysis, otherwise the standard used to measure women will continuously lead to the conclusion that to be a woman is to be in bad health.

I would like to advocate a definition of gender which includes both social and cultural, psychological and purely physical factors. The anthropologist Cecil G Helman gives an interpretation of the concept of gender that is based on four fundamental aspects of the human being:

Genetic gender, based on genotype, and combinations of the two sex chromosomes X and Y (XX being female and XY being male).
Somatic gender, based on phenotype, especially physical appearance which depends on the influence of hormones and determines the sex characteristics of the foetus (external genitalia, breasts, voice and distribution of body fat and hair).
Psychological gender, based on a person's own self-perception and behaviour.
Social gender, based on cultural categories, how men and women are viewed in society, how he or she must look, think, feel, dress, deal with, behave and value the world they live in.

These four dimensions are by no means unambiguous. At the genetic level it sometimes happens that combinations other than XX and XY appear. Take for example Turner's syndrome (XO) and Klinefelter' 5 syndrome (XXY), Y poly-somy (XYY) or even true hermaphroditism (XX/XY).

AT THE SOMATIC LEVEL THE HORMONAL INFLUENCE can lead to another gender identity than that of the chromosomal determination. If a female foetus with the chromosomes XX is exposed to masculine sex hormones during some vulnerable phase in the pregnancy, the child will be born as a boy. If a masculine fetus with chromosomes XY doesn't receive any masculine hormones during certain phases, the child will look like a normal girl. Pseudohermaphroditism, where an individual has the genetic constitution and gonads of one sex, but the external genitalia of the other belongs to this category. It has also been discussed that homosexuality can depend on early hormonal influences. We don't yet have enough knowledge, however.

One can have both a man's genotype and phenotype, be viewed as a man by society, but nevertheless behave, dress and view oneself mainly as a woman, as is evident in some transvestites. We don't yet know if this is a psychological gender identity or if there is a biological basis to the behaviour.

The social gender is influenced by both the social and the cultural environment, and is to a high degree flexible and sensitive to manipulation by society's structural influences. The male-gendered roles generally carry higher prestige than the female-gendered service roles which carry less significance and credibility, and which are also less valued and less protected.

Gender differences have often been described with great drama and little understanding, such as when Freud called women "the dark continent," or when August Strindberg in The Father exclaims, "If it's true we are descended from the ape, it must have been from two different species. There's no likeness between us, is there?" But the biological differences between the sexes are not about such a total difference but about a reproductive difference which also means that men and women are dependent upon one another.

People, regardless of sex, have a common nature, common unconscious possibilities which are coded into our DNA. That doesn't mean that our DNA determines our behaviour. Culture creates a number of different possibilities in addition to our genetic material. And as individuals we "answer" both to genetic and environmental signals. The genetic undercurrent is still not sufficiently researched.

Woman (painting) ALL DISEASES HAVE A SOCIAL AND A CULTURAL DIMENSION. They also have a gender dimension, and we could indeed talk about diseases of male and female gender. Let me present seven different aspects of this complex issue.

To begin with, we can see differences in the disease panorama of men and women as an expression of underlying societal and cultural differences between the sexes. To be ill can be described as a more socially acceptable behaviour for women than for men. Men should be strong, and this stoicism may lead men to ignore symptoms of serious disease and may in the end be counterproductive to good health but ironically creates statistically healthier men. Women are viewed as being more sensitive to their symptoms and thus are seen with more tolerance and given greater societal permission to be sick. The supposedly greater confidence of women in the health care system is another reason why they seek help more often.

A second explanation concerns the distinction between disease and illness. That is, the difference between a medically established disease diagnosis and a person's own subjective experience of illness. Disease can occur without illness, for example in early forms of cancer, high blood pressure, etc. and the opposite is true as well, pain and exhaustion do not always find a diagnosis. Men contract far more diagnosed diseases while women suffer from more unspecified illnesses.

Women constitute a majority concerning "undetermined illnesses," such as muscle and joint pain or psychiatric conditions where a disease diagnosis can not be established so easily. This failure of definition or establishing a diagnosis also limits the possibility for answering with a rational and effective medical treatment and leads to extended illnesses.

A third explanation operates to the contrary of the explanation just named above, namely, that labelling with an inaccurate diagnosis can worsen treatment. This especially concerns certain illnesses that are symptoms of more deep rooted injuries and where the primary cause is untreated. We know that incest and psychological violence against children often goes undetected. Women and men often handle early traumas in different ways. In adult life men may express different defence/attack reactions, by being abusive or apathetic. This "closing off' of oneself, this internalization, can lead men to earlier deaths while women more often deny outside factors and blame themselves: a woman's body becomes a seismograph for the subconscious, often reacting with diffuse pain. Women are raised to turn conflicts and rage inwards, with depression as a result, while men are raised to be aggressive.

A fourth explanation concerns what I would call frustration diseases, which have their roots in a feeling of not being adequate. It is a poor state of health which can be characterized by an inability to handle the contradictory influences of modern society. On the one hand domestic roles are still emphasized, but on the other hand women are expected to work outside their homes and contribute to the household economy. These role conflicts increase different health risks; a contest between the outer life's realities and the inner life's needs. This tension leads to poor accounting between a person's emotional coping powers and the body's energy system. One could indeed call it poor accounting - a weak "inner economy" which increases human vulnerability.

A fifth explanation is discussed in a Finnish doctoral thesis by M.L. Honkasalo, which concerns women in assembly work. She shows that women have many of their own lay theories as explanations for their symptoms. Examples such as "moon craziness", seasonal changes and unhappy romances, as well as breast feeding, care of infants, care of sick children and miscarriage to name a few. Unsatisfactory conditions at the workplace, for example problems with superiors and co-workers, piecework and noise, are also viewed as reasons. Interestingly enough, these explanations are not followed by biomedical explanations. Symptoms such as tiredness, sleep disturbances, nervousness, depression, headaches, pain, itching and stomach trouble are not understood as conditions of disease. And the treatments preferred have more to do with conversation, jokes and laughter than with medicine.

A sixth explanation is provided by the French psychoanalyst Julia Kristeva and concerns a woman's intimate relationship with her own body. For thousands of years women have had the task of tending to, caring for and helping to heal the human body from life's first trembling seconds until its end. This sense of one's own body is transferred from mothers to their daughters, who early on learn to observe their own bodies. A woman's cyclical biology means that during a major part of her life she is consciously and unconsciously sensing where she is in a cycle. This alertness underlies the discovery of symptoms, signs and disease.

A seventh explanation concerns biological differences. The entire central nervous system works differently for men than for women; hormonal cycles, reproduction, etc. We don't yet know how and if this influences our understanding of things, if it means that we see, comprehend and act differently. During the last 10 years we have had a boom in biological and biochemical research. A conclusion we could reach with the acquisition of this new knowledge could be: because society is structured according to the masculine brain' sway of working, a woman's special needs automatically present an unhealthy picture compared to man's standards.

Woman (painting) THUS, WE CAN NOT AUTOMATICALLY ASSUME THAT because of women's higher degree of health care consumption and absence from work because of illness, that they are sicker and feel worse than men. It is important to clarify the gender-specific differences between mortality and morbidity rates, number of official sick leaves, hospital care and drug consumption versus health. The level of illness (which in most countries is recorded through the occurrence of sick leave from work, occupational injuries and early retirement) is very sensitive to market conditions and changes in government and their policies. The questions we should be asking are rather: how do our behaviour and responses vary between generations, concerning sick leave, hospital care and drug consumption, and how through time and between cultures do we differ and what effect has gender on health?

I maintain that women per se cannot be said to be sicker than men, but rather see themselves as sick and feel unwell as well. If you constantly view and treat a person as sick, some will of course be just that. And this relationship doesn't necessarily have anything to do with women's longer life expectancy.

These seven explanations for women's higher degree of illness and sick leave than men ought to be part of a more general theory concerning ill health and disease. As is well known, there are a countless number of more or less gifted, so-called scientific models which claim to explain the occurrence and causes of disease. Nevertheless, it is interesting that in general these models do not take up the differences between the sexes. The seven approaches for women's illness which are discussed above do not in general exist in these models. Scientific models have often more to do with different genetic/physiological, social, psychological and cultural aspects without making distinctions between the sexes. Thus, there is a need for models which approach physiological, psychological, structural and cultural positions from a gender perspective.

We need to develop different methodologies which are less masculine and less oriented to the industrialized Western world's way of thinking. It must also include both epistemological and cosmological aspects.

But to be successful in the analysis and building of scientific models we also need to know more about the different male and female mentalities that thrives beneath the surface.

III.

ballet dancer (painting) FOR THE PURPOSE OF ANALYZING WHY WE KNOW SO much less about female diseases and health than we know about male, I have deliberately chosen an expression which isn't a proper word in the English language - "unknowledge". We can talk about the unknowable, things that we cannot know, that for now, lie far beyond our capacities to get answers. We can also talk about the unknown - the unknown soldier or the Great Unknown etc., but unknowledge is something quite different. It is not just ignorance. Unknowledge can be defined as unconscious patterns of behaviour-, belief-, or thought systems, relayed through tradition and mentalities.

It is the systematic effects of unknowledge that result in neglect for women's specific needs. We know that some diseases affect women differently than men, some are more prevalent or more serious in women and some have different risk factors for women or require different interventions. But we don't have gender-specific knowledge to further explore those differences. How is that to be understood? Why do we know so much less about her disease than about his?

The pattern of unknowledge can be explained by three vital conditions:

As a consequence of male dominance through history.
Limited research methods in order to avoid risks to the foetus produces systematic errors and lack of information.
Failure to acknowledge adequately women's more pronounced life cycles, including the menstrual cycle, reproduction and menopause which complicate scientific results.

Attitudes and beliefs about women's nature have existed since ancient times. Aristotle described woman as passive and man as active. "The masculine seed contributes energy and movement to the embryo, the woman materia, or the passive principle." But even if nature was ascribed to women (i.e. Mother Nature), it was actually first in the 1600's, when modern science emerged, that this picture was established. And it is really with the transition to an industrial society that the picture of the woman painted black made its widespread impact and the sick and weak woman came about.

IN CONNECTION TO WESTERN SOCIETY'S TRANSITION from an agrarian society to an industrial society, women's daily life changed profoundly. Urbanization became widespread and women were forced to choose home life before working life. That choice, exclusive for women, created a division that was historically new. In order to explain why women had no place in public life there sprang up a whole new rhetoric around women. She was said to be weak and fragile, incapable of long-term thinking. Woman and man, who had previously worked side by side, became strangers to one another. Intellectual work was said to destroy women's feminine nature and women were not educated in order to retain good health and balance.

In the transition from farming to an industrial society there appeared a group of new diseases or new explanations for the old. Neurasthenia (nervous tiredness), aenemia, chlorosis and hysteria became fashionable illnesses. Women were seen to be particularly hysterical, the diagnosis based on a mishmash of different psychological ailments. People talked about a "nervous age period." A partly new disease panorama was created of so-called women's diseases.

Some researchers have pointed out how these new diseases appeared and were institutionalized "just because they were needed." Many of these diseases were in a sense cultural. We can see how the concept of illness changes over time as a dynamic human creation. Many disease diagnoses are based not on knowledge of a strictly scientific nature but rather on a jumble of assumptions, myths and attitudes. One such assumption, which has consequences for our time, is the view of woman's nature.

Woman was described increasingly as a periodically unpredictable organism who is a prisoner of her own biology. Women's and men's disease panoramas were viewed as dramatically different. The woman's nervous system was seen as more irritable than a man's and she was described as a special psychological type, steered by her womb and her female cycles. These pictures were presented as "truths," despite the fact that a quick look in the official statistics on diagnoses could show that infectious diseases, particularly tuberculosis, as well as cancer, and all kinds of deficiency diseases, were the most common reasons for death and disease in both sexes around the world. So why did people think that they saw something entirely different from what actually existed?

One of the more general explanations of this pattern of unknowledge about women is accounted for in David Noble's work A World Without Women. He states that ignorance about women depends on "a masculine culture of science which has somehow come to appear so normal." We can find the origin of this in the 17th century's paradigm shift.

Francis Bacon played a decisive role in this scientific revolution. He gladly made use of feminine metaphors, his "visions" also served as a pedagogic model for the founding of the Royal Society in 1660, one of the world's most respected scientific academies. The original program is rife with sexual symbolism: "Nature is a woman, which the scientific man will subdue. He will methodically and systematically reveal Mother Nature, expose her secrets, penetrate to her womb and thus force her to complete submission." It doesn't require much imagination to understand that a woman researcher would not feel at home in such a research environment. And even if she had been interested, it would not have been possible. The scientific academies did not accept women members.

To gain acceptance, many women researchers today avoid conducting research about women. Those women who "succeed" are generally keen on emphasizing that they are not feminists and that they are never discriminated against. Despite this low-profile, there are a few women who have reached influential positions in the male-dominated world of science.

Ballet dancer 2 (painting) THE SECOND EXPLANATION FOR WHY WE KNOW LESS about women's diseases than men's is that clinical tests on women are consciously avoided because of the inherent risks, not for the woman herself but to the foetus. This relates in particular to clinical drug trials and goes back to the tragedies that came of pregnant women taking pills of thalidomide: 10,000 babies were born with serious malformations.

Therefore initial drug testing uses mainly men, young men, often medical students, or men doing their military service, as subjects. In most Western countries women who volunteer as subjects for initial drug trials must prove that they don't have "child-bearing potential", which can mean providing a written affidavit that they are taking both contraceptive pills and have an IUD. This is of course unusual. Only in later phases of the trials are women generally included in the tests.

Can results of tests mainly carried out on men always be considered applicable to women?

No, drugs used for diagnosis or treatment often have a different effect on men and women. Men's and women's bodies metabolize drugs differently. We also know that women's monthly menstrual cycles can influence the effect of a drug.

When the drug eventually moves from the laboratory into the home we therefore don't know how it will affect women and the elderly.

The first actual test period for women is when the drug is used at hospitals or prescribed by a doctor. What was unethical during the first controlled testing phase is no longer an issue, with the release of drugs to the public after tests mainly conducted on men (and on mail mice!). In the later phases, when the drug is approved, there is less emphasis on taking extreme caution. Eventual side-effects, damages and birth defects are reported and complemented with epidemiological studies. Approval of a new drug is a process that takes up to ten years. We can ask ourselves how ethical it is to shift this problem from the laboratory to the layman's home.

WE KNOW THAT WOMEN SOMETIMES REACT DIFFERENTLY to various drugs than men do, but we need to know when this occurs and to what degree. The drug's introductory period on the market is also used to determine dosages. Women and men often need different dosages, depending on body weight, metabolism, hormones, etc. The total distribution of the drug in the body varies with the menstruation cycle. Many fertile women use contraceptive pills. We know that contraceptive pills interact with certain drugs but we don't always know how; we also know that the use of contraceptive pills affects the dosage. For each individual it can often become a question of trial and error.

The speed at which the stomach is emptied varies between men and women. It is slower in women but varies with the menstrual cycle and is affected by contraceptive pills. These differences influence absorption of the drug. Women have considerably more subcutaneous fat than men. Because most drugs are fat-soluble there is a risk that they can be stored in the body's fat layers, for example, subcutaneously, or in the liver. Concentration levels of the drug in the liver alone can be serious; in the liver there are enzyme systems which break down and convert body fat. And we know that liver function differs between sexes and that metabolism is affected by hormones.

A drug always affects the body's homeostasis. Sometimes it affects many different functions at the same time. Some of these effects are still not known. Women consume far more drugs than men do. In the past 30 to 40 years pharmaceutical drug development has revolutionized the treatment of certain diseases. As a consequence, about half of today's drugs are less than 15 years old. This is good. To prescribe a drug is a qualified medical act. Many doctors are careful in prescribing new drugs for women. Which means that men will have access to the new drugs and women will get the drugs that have proved effective over time. We need considerably more and better studies about how drugs are prescribed and their effects regarding women.

Woman (painting) THIRDLY: FEMALE BIOLOGY CAN SEEM STRANGE TO A man. During half of her lifetime, a woman's biology revolves around ovulation. Woman is poetically described as a sea, where the moon's waves surge forward and back month after month. The words "moon", ''month'', and ''menstruation" also all share the same etymological origin.

Menstruation is much more common today than before. Today, the onset of menarche, a woman's first menstruation occurs many years earlier in a woman's lifetime, than fifty years ago, here, as well as in developing countries. Falls in birth rates, reduction in the average number of pregnancies per woman, a decline in infant and maternal mortality, increased life-expectancy for women, all contribute to the fact that a greater proportion of women live to the menopausal age and experience on average many more years of menstruation in a female life span. This increasing number of menstrual cycles experienced by women leads to an urgent need to enlarge our knowledge about these cycles.

There is a tendency to connect the cycles solely to different hormonal fluctuations. Even if hormones play a central part, it is dangerous to see hormonal effects as the only influences on menstrual cycles. It means that we see what we expect to see (hormonal influence), while other factors remain undiscovered. The human organism is steered by many different rhythms which are regular in character, such as heart rhythms, sleep rhythms, and the menstrual cycle. These are steered in turn, by the blood's sugar content and by different hormones, not just sex hormones.

Women's ageing is often associated with menopause - the last menstruation as a sort of "rite of passage" from the fertile to the infertile phase of life. This transition has been the subject of widespread research in the last few decades. The perspective is often a medical one and the condition is described as a deficiency disease. But menopause is in general improperly looked upon. Often the woman is held up to ridicule. One talks about menopause as "the time between mens and incontinence" or it's onset is described as "when a woman becomes an old lady."

There are many descriptions of menopausal women as unhappy, depressed and irritated. Women are portrayed as passive victims to their hormones, and often affected by an assortment of physiological aches and pains. But it is interesting to note how these differ between cultures.

The most common symptom in the West of menopause is hot flashes: 75 percent of women in the West experience these over a shorter or longer period. In Japan women complain more about back pain, stiffness and cold hands and feet; that is, physical difficulties which are more often associated with the general ageing process. In the Japanese language there is no word for hot flashes, and the phenomenon is also rare. So, what is due to culture and what is pure biology?

It seems like these problems could indicate societal changes in women's roles. With menopause, a new phase begins in a woman's life. Women become more like men, from a hormonal viewpoint. In earlier societies - beginning with the hunting and gathering societies and onwards almost to the beginning of the industrial age - women's societal function was important. She was extroverted, was given greater responsibility, and took part actively in the planning of the group's survival. These active roles for 'menopausal-women do not exist in today's modern Western societies. The fact that we no longer have an awareness of the female life-cycle's different phases is probably the one most important common factor in explaining women's ill health.

IV.

Woman portrait (painting) IN MODERN SOCIETY, FUNDAMENTAL STRUCTURAL AND biological determinants do not enhance but rather counteract each other. We have today, a societal structure well-suited to the male's biology but which contributes to ill health among women. The future, however can very well provide a society responsive to life cycles in balance for both men and women.

The cardiologist and chaos theorist, Ary L. Goldberg, at the Harvard School of Medicine, maintains that ageing and morbidity represent primarily a "loss of variability", a lack of the ability to adapt and change. Many of our accepted "truths", however, about health and disease prove to the contrary, that a life of regular sleep and fixed meal-times, fixed routines for hospitals and geriatric care, rigid school curricula and schedules as well as inflexible work routines, etc., all represent "the good." We operate today as if predictability and stability were the norm, while reality is ever-changing, incalculable, almost chaotic. When values and reality are so far apart, we react with frustration.

When it comes to examining more complex disease causation, we can begin to speak of different syndromes. During the next century, the dominating paradigm may well become "the cosmological syndrome." The world view of people and their outlooks will change; rapid shifts will threaten our most deeply held values and ideas.

The very purpose of life may become obscure. This failure to connect will, when coupled with environmentally induced diseases and the effects of the constant random mutations of nature, determine the future major disease panorama.

If we value change as an opportunity for positive development, then basic feminine behaviours such as environmental awareness, high-level simultaneous abilities, strategic and intuitive action should be treasured qualities in the societies of the year 2000 and beyond.

It is necessary from a gender perspective to clarify how the slowly changing arena, consisting of institutional rules, tangible and non tangible networks, knowledge and basic values can be expected to develop for women in the coming decades.

GLOBALLY CONDUCTED RESEARCH CAN TODAY BE DON through networking with researchers in other countries. The electronic communication systems now being developed give us new possibilities to carry out such comparative research. Of course researchers still need to meet and share their findings. But at the same time, we must be careful to ensure that the widespread data available is assimilated without being reduced to simplified quantitative entities, which has often been the case with the first generation of computerized research.

The threat against women's health is, to a large extent, global. The UN's labour market organization, ILO, gave as an example in a report on women's global labour that women's visible labour has certainly increased, but not their salaries. On the contrary, the salary gap has widened. At the same time men are working less around the globe. The ILO report states that "when men's salaried work decreases, they spend those hours in leisure activities rather than with caring for the children or household tasks." Once again, we recognize a pattern.

ILO's projection for the future isn't particularly bright either. We can count on both the number of economically active women and their salaries declining through the turn of the century, and that the situation of women on a global level will worsen.

Projections - which are never very well substantiated -certainly do not determine the future. However, the 21st century's economically active women are not a theoretical entity - they've already been born. This statistical analysis of the world's development must be taken seriously. At the same time it is important to consider also the other part of the course of events. The strength of the ecological movement, Terra Femina, and the many networks being built, are good examples. The years leading to the next century will be filled with decisive change. We are indeed on the eve of a breakthrough, to a whole new way of thinking and being.

Essay built on the book "Att vara kvinna är ingen sjukdom"
Nordstedts 1994, 405 pp

Bi in the sandpit (photo)