A New Biopolitics of Gender and Health?
“Gender-specific Medicine” and Pharmaceuticalization in the Twenty-First Century
Medicalization, pharmaceuticalization and gender have a long, intertwined and well-documented history stemming back to at least the women’s health movement of the 1970s. Although early deliberations on medicalization were framed as “gender-neutral” (Riska 2003, 2010), they occurred around the same time that feminists were criticizing male control of the female body and mind expressly through the technological management of childbirth (e.g., Arms 1975; Ehrenreich and English 1978; Reissman 1983) and prescription of antidepressants to remedy the unhappiness of life in a patriarchal world (Chesler 1972). Interest in the gendered aspects of medicalization has grown exponentially over subsequent years. Four developments are especially noteworthy. First, medicalization has been part of the groundswell of interest in men’s health as gendered (which began around the mid-1990s), particularly in relation to sexuality and sexual health (see, e.g., Rosenfeld and Faircloth 2006; Fishman 2010). Second, attention has shifted away from the medical profession and the expansion of medical social control as key drivers of medicalization toward biotechnology, particularly the pharmaceutical industry and genetics (Conrad 2004, 2007, 2013; Bell and Figert 2012). Thus Clarke and colleagues consider that by around the mid-1980s biotechnology was of such importance to necessitate the replacement of medicalization with biomedicalization (Clarke et al. 2010a; Clarke and Shim 2011). They argue that while medicalization processes typically emphasize the control over medical phenomena, such as diseases, injuries and bodily malfunctions, biomedicalization processes concern transformations of bodies and lives. Gender is pivotal to technoscientific developments in areas such as genomics which turn the body “inside out as decisions once made on the basis of the inspectable surfaces of the body become the province of the (now visible) genome” (Turney and Balmer 2003:412–13). For example, the ‘“technologization” of vitality in the life sciences is palpable in the molecular vision of the organism within regenerative medicine (Rose 2013), an umbrella concept which refers to the replacing, engineering or regeneration of human cells and tissues. This is highly gendered as more often than not it is women’s bodies which are plundered for embryos, oocytes, fetal tissue, menstrual blood and umbilical cord blood (Waldby and Cooper 2010).
As Riska (2010) relates, biomedicalization directs attention to the material body not only as a major site of biomedical discourse but also public discourse. Perforce a third and related development is the shift of attention toward consumers (Figert 2011). The activities of individuals and social groups in seeking out medical diagnoses, treatments and bodily enhancements have been conceptualized by some as “medicalization from below” (see Furedi 2006; Conrad 2013). In the USA and New Zealand this has been fostered by the bypassing of medical prescription for drugs, such as Viagra (for erectile problems) and Paxil (for anxiety and “social phobia”), by direct-to-consumer advertising (DTCA) on television, at various venues (such as sports events) and on public transport. More widely “medicalization from below” has been supported by the emergence of online pharmacies (Miah and Rich 2008) and advocacy amongst online support groups – many of whom are supported by the pharmaceutical industry – for a wide range of conditions (Barker 2011; Goldacre 2012). Flanking this is the fourth notable development of “pharmaceuticalization,” or “the translation or transformation of human conditions, capabilities and capacities into opportunities for pharmaceutical intervention” (Williams, Martin and Gabe 2011:711; and see also Abraham 2010; Conrad 2013; Greene 2015, Chapter 5, this volume; Samsky 2015, Chapter 6, this volume; Cuthbertson 2015, Chapter 7, this volume). As will be discussed in detail later in the chapter, essentialized biological categories of sex (and race) are a vital part of pharmaceuticalization processes.
Although there has been a tendency until fairly recently to depict medicalization as a product of modernity, an “inexorable juggernaut” (Davis 2010:231) moving in one direction toward increasing medical control, most social science commentators now recognize the process to be far more complex (see Bell and Figert 2012; Conrad 2013). As Clarke puts it, “the localization of biomedical innovation is everywhere tempered and complicated by medical pluralisms, partialisms [the partial and contingent availability of various medicines], and multiple forms and loci of stratification” (2010:389). Hence she and others argue that medicalization is often highly stratified as assorted medical goods and procedures are targeted to different categories of persons, groups and populations. “Gender-specific medicine” (GSM) is one example of such a “targeting” and stratification process. Hence a detailed examination of GSM has the potential to extend our understanding of the relationship between gender and medicalization as well as the more recently developed but allied concepts of biomedicalization and pharmaceuticalization. In what follows we first provide a brief overview of the rise of GSM, its drivers, defining characteristics and connections to (bio)medicalization. We then place GSM in the context of recent developments in technoscience as they concern gender. Specifically we speculate on the connections between the emerging paradigm of the “gender-specific body” (Annandale and Hammarström 2011) and the gendered “customization” of pharmaceuticals.
GSM is a rapidly expanding field as observed by the books and legion articles in medical and allied journals delineating and advocating its principles and further development. There are several “gender-specific” healthcare and research centers, such as the Partnership for Gender-specific Medicine at Columbia University New York, the Centre for Gender Medicine at the Karolinska Institutet in Stockholm and European Gender Medicine under the auspices of Charité Universitätsmedizin in Berlin. Additionally, several organizations advocate sex differences research, even though they may not always employ the “gender-specific” lexicon, such as the Organization for the Study of Sex Differences (founded by the Society for the Study of Women’s Health Research) in the USA, the Men’s Health Forum in the UK and the International Society for Gender Medicine. Journals have grown up, such as Gender Medicine and Biology of Sex Differences, as well as an increasing number of national and international congresses, such as the International Congress for Gender and Sex Specific Medicine, now in its seventh year.
GSM can be dated from the mid-1990s as a visible movement within medicine. But its multifaceted origins can be traced back several decades. As far as women are concerned, the GSM ethos owes much to the questioning by feminists and others of the historical depiction of the human standard of the body in medical thinking and practice as male (except where reproduction is concerned) and the related call to include women in biomedical research and practice (Annandale and Hammarström 2011). In the USA, protectionist policies and guidelines on the exploitation of vulnerable subjects had emerged in the wake of the tragic consequences of the use in pregnancy of the drugs thalidomide (to treat nausea and morning sickness) and diethylstilbestrol (DES) (to prevent miscarriage) (Bell 2009). Researchers became averse to including women in their studies given the risks to those who become pregnant and potentially vulnerable during drug-related research. This began to change in the early 1990s when a US Government Accounting Office (GAO) report to Congress documented the failures of the National Institutes of Health (NIH) to institute the recommendations of the 1985 Public Health Taskforce on Women’s Health Issues which stated that biomedical and behavioral research should be expanded to a focus on conditions and disease unique to or more prevalent amongst women (Auerbach and Figert 1995; Eckman 1998). In the late 1990s, the US Institute of Medicine (IOM) formed the Committee on Understanding the Biology of Sex and Gender Differences which was intended to evaluate the “factors and traits that characterize and differentiate males and females across the life span and that underlie sex differences in health (including genetic, biochemical, physiological, physical, and behavioral elements)” (Wizeman and Pardue 2001:2). The subsequent report, Exploring the Biological Contributions to Human Health. Does Sex Matter? (Wizeman and Pardue 2001), which is cited frequently by authors in support of sex differences research in health, concluded that “sex, that is, being male or female,” matters and should be considered when designing and analyzing biomedical and health-related research. This would be facilitated by the evolution of the study of sex differences “into a mature science” (Wizeman and Pardue 2001:3). These developments had the effect not only of bringing women and the female body into medical research, but of bringing them in as specific beings distinguishable from men (and vice versa). This clearly resonates with the GSM mandate to value what is gender-specific in experience. A year after the IOM report, progenitor and major protagonist, US cardiologist Marianne Legato published the book Eve’s Rib, with the rather theatrical subtitle, “The New Science of Gender-specific Medicine and How It Can Save Your Life” (Legato 2002). Establishing herself as “a rigorously trained biomedical scientist” (Legato 2002:xi), Legato asserts in the book that “as we compare men and women, we are finding that in every system of the body, from the very hairs on our heads to the way our hearts beat, there are significant unique sex-based differences in human physiology” (Legato 2002:xii).
Difference and the Dominion of Sex
Difference is an essential platform for establishing and furthering the enterprise of GSM. As Schofield has identified more generally, almost without exception the representation of gender in health research is a “binary one of sex-based aggregations of numerical contrasts in health indicators” (Schofield 2004:20). First and foremost, GSM constructs two gender-based constituencies – women’s health and men’s health – at the heart of which is a robust binarism between the bodies and experiences of men and women. However, GSM is not only comparative, but also internally competitive. At various times and in relation to legion health problems, women are posed as disadvantaged by comparison to men, and men are posed as disadvantaged by comparison to women. Thus the proposition that a gender-specific approach advantages men and women alike sits uncomfortably alongside calls for the resources to be targeted to men’s or targeted to women’s health. As Wadham (2002) has argued in relation to men, though not with direct reference to GSM, research and policy justifies itself by a strategy of comparison and equivalence, that is, by comparing the health of men to the health of women to make the argument that while the resources accorded to each should be equivalent, they are not, a point which can be applied equally to research on women. Thus it is common for the importance of men’s or of women’s gender-specific health to be shored up by what we call “gap identifying” rhetoric. To take one example, on the website of the UK Men’s Health Forum, the “key data” for health professionals are commonly interpreted through the lens of comparative disadvantage with men, for example, framed as “more commonly” and “more likely” to experience the health problem at issue. This then interpolates into a “gap closing” rhetoric which, in turn, helps authorize investment of resources.
A further guiding message of GSM is that differences between males and females are far more extensive than generally appreciated and extend way beyond the reproductive body. Thus Legato writes, “everywhere researchers look for differences between men and women, they find them” in the brain, the gastrointestinal tract, the heart and circulatory system, the immune system, the skeleton, the skin, the lung, in drug metabolism, in sexual dysfunction, in pain (Legato 2002:240; see also Baggio et al. 2013). So, as the term specific in “gender-specific medicine” readily connotes, difference is elemental. Without it “gender-specific medicine” would have no existence.
The push for individuating women from men invariably begins with a demand by the lay public (usually communicated to political groups rather than to the medical establishment) for more attention to women’s unique health needs. Once involved, the body politic appropriates money and resources to expand what’s known beyond reproductive biology and, as the medical establishment begins to use that money to support investigation, it finds that males and females have striking and completely unexpected differences in every system of the body. (Legato 2004:61)
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