Orly Shachar
Department of Mass Communication
Iona College
715 North Avenue, New Rochelle, NY 10801, U.S.A
Tel: 914-633-2165
Fax : 914-637-2797
E-mail: oshachar@iona.edu
The Invisible Female Patient: The New Reproductive Technologies Discourse in the Medical Literature
Abstract
The idea that infertility is mainly a technical problem, which can be remedied with the new reproductive technologies, has become paramount to popular media coverage of these new procedures. Over the past decade, studies of the popular press have generally found that the news media promote assisted reproduction as a technological marvel and champion doctors as miracle workers. The media usually anchor these procedures with two main actors: the doctor and the fetus, thus positioning the patient (mother/father) outside the realm of the medical experience.
Few studies have focused on the portrayal of reproductive arrangements in the medical news media and even fewer projects have concentrated on doctors as news writers. This study proposes to direct attention to physicians’ communicative skills. Using textual analysis, the project examines medical representations in professional periodicals such as the New England Journal of Medicine, the British Medical Journal and the Journal of Obstetrics and Gynecology.
Findings demonstrate that as news writers, journalists and doctors practice similar reporting instruments related to news sourcing, news worthiness and story dramatization. Physicians pack their medical linguistic practices with professional jargon, almost entirely isolating the outcome (fetus/baby) from the sources (mother/father).
Finally, examples are provided to illustrate how medical jargon can follow proposed journalistic techniques to create a “patient-friendly” inclusionary vocabulary when writing about female patients.
- Introduction
The new reproductive technologies (artificial insemination by donor, super ovulation, in vitro fertilization, embryo flushing and transfer, surrogate motherhood and sex predetermination) have recently been hailed by the popular media as miraculous triumphs providing hope to infertile patients. Focusing on the role of medical researchers and physicians, the media’s emphasis on medical control of fertility, gestation, and birth serves as a catalyst for creating an unusual alliance between feminist scholars, consumer movement advocates, and legal practitioners. They argue that these technologies are making women “transparent” and that their roles in conception, gestation and birth are becoming increasingly marginalized [1-3].
Missing from the public dialogue is a discussion of what physicians say about their patients, their experiences and roles, and their involvement with these reproductive procedures. One way to examine medical discourse is to consider the language used by medical professionals to describe their female patients. This study will review the language employed by obstetricians and gynecologists with regard to the new reproductive technologies in the relevant medical journals. The textual analysis will explore the following questions: Assuming the role of news reporters, what expressive rhetorical strategies do physicians employ when they report to their peers about new reproductive technologies issues in medical periodicals? What linguistic mechanism is used in the assisted reproduction medical jargon? And what images are constructed in the doctor-patient communication involving reproductive technologies?
- Literature Review
Feminist scholars are wary of the new reproductive arrangements [4-7]. Wikler [8] divides feminist response to the new reproductive technologies into two themes. First, these scientific developments reflect and perpetuate the existing imbalance of power between males and females. Second, feminists fear that the application of the new reproductive technologies will be manipulated so as to limit women’s autonomy. Women’s reproductive capacities will be used in the interest of male‑dominated social order. Central to this theme is the conflict between governmental control over reproduction and a woman’s right to control her body.
To demonstrate the validity of their arguments, feminist writers submit that in the new procreative medical and legal literature, women are likened to fetal containers [9], female hatcheries [4] and reproductive bodies [10]. Women’s roles are relegated “to the role of vessel or field for their [men’s] seed” [11]. Physicians involved with reproductive technologies procedures are called egg farmers [10] and egg snatchers [12].
2.1. The machine discourse. Symbolic language, used by physicians to describe their female patients, frames the public debate about these technologies. As Kathy Ferguson argues, “When we are busy arguing about the questions that appear within a certain frame, the frame itself becomes invisible; we become enframed within it” [13]. In the debate over the new reproductive technologies, this process of framing takes place not only in doctors’ offices and science labs but also in the professional literature, legitimizing the disproportionate power of doctors to define the social reality for their patients and society. Treichler [2] maintains that the U.S. medical discourse defines labor as a “medical event” in which the physician’s presence is crucial. Her research on definitions of childbirth in medical discourse underscores the theme of childbirth as a woman-less happening with a textual example from an obstetrics textbook: “Labor is the physiological process by which the uterus expels, or attempts to expel, its contents…through the cervical opening and vagina to the outside world” [2].
In Western culture social constructions of maternity have been firmly anchored in the idea of women’s vulnerability. For instance, giving birth was deemed as manifestation of a woman’s need for assistance. Emily Martin [14] demonstrates the underlying metaphor of production as it relates to images of the body and birthing. For example, she likens the human body—-in this case, the uterus–to that of a mass-produced product, not unsimilar to a car. She views the body as an information processing system with a hierarchical structure for purposes of continuous production. Medical texts describe the process of birthing as work in progress. For example, amniotomy—-breaking the amniotic sac—-results in an increase in “work performed by the uterus” [15]. Yet, if her body or rather a part of her body, seems to be involved in the birthing, the woman herself is treated as absent. Uterine contractions are “involuntary” and the uterus-machine performs most of the work automatically, unless intervention is needed to fix the machine-like body.
Robbie Davis-Floyd [16] equates obstetrics clinic with well-run factories, where efficient production is the primary value. She claims that this particular view transformed the labor experience of women into a technological oriented event. Delivery rituals reinforce an assembly line pattern of birth. Women undergo different procedures, diagnostic or therapeutic, in different rooms. These services may be even given by different specialists, similar to the treatment of production assembly-line style. Moreover, Davis-Floyd identifies the woman’s body as a machine. The machine either works properly (the mother is productive) or it can break down (her labor becomes unproductive). For example, labor contractions that do not produce outcome are categorized by physicians as unproductive contractions. This technological metaphor evokes a certain type of relationship between patients and the attending physicians and nurses. Since the woman is viewed as the product as well as the producer-worker, the medical staff considers themselves as part of the labor management team. As such, they decide the pace of the work by speeding up the process with drugs or slowing down by telling women not to push through at the end of labor.
2.2. Women and Language. Sociolinguistic scholars, their counterparts, and feminist researchers markedly differ in their perspective on the issue of women and language. Mainstream scholars explain the differences between male and female use of linguistic practices as a result of their different sex specific socialization experiences [17], that language is neutral and arbitrary.
In contrast, feminist researchers are linking language and power issues in their pursuit to explain sex differences in the use of language. A common thread among feminist studies on women and language has been the way men seem “to control the means by which their particular perspectives are privileged, through their control of political, religious, and literary discourses” [18]. In general, this theory postulates that sex differences are not naturally coded as difference, but that this coding is a consequence of a prior differentiative factor, which is power. McKinnon claims that a deceptive perspective common in scholarship, politics and the law is “the persistent treatment of gender as if it is truly a question of difference, rather than treating the gender difference as a construct of the difference gender makes” [19].
2.3. Mass Media Accounts of Reproductive Technologies. The early 1980s saw a burst of mass mediated interest in reproductive technologies. With the introduction of methods such as in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT), the general public was exposed to a barrage of newspapers and magazine articles about these fertility treatments [3, 20]. For the most part, the coverage was very positive and heralded these treatments as miracle solutions to fertility problems. It also reflected a bias towards the technological perspective of the treatment, investing physicians with control over their patients since these procedures are all lab-based. In her study of newspaper and magazine coverage of reproductive technologies in the late 1980s, Celeste Michelle Condit writes about the manner in which the press constructed the images of physicians as “life givers,” and even as parents to these children [21]. Condit argues that the press position women as dependent on others when it comes to making medical decisions, unlike the framing of abortion as a “woman’s choice,” free of constraints. It would appear that when life is the focus of the press coverage, woman cannot make decisions for herself. In contrast, women are portrayed usually as the sole responsible party for killing (the fetus).
- Method
This study spans the time period beginning in 1994 through 1998. Articles were lifted from indexes such as Infotrac and Proquest. Only peer-reviewed medical periodicals were considered. They are: Journal of Obstetrics and Gynecology, The New England Journal of Medicine, Human Reproduction, Fertility & Sterility, British Medical Journal, The Lancet, and The Journal of the American Medical Association (JAMA).
The analysis is grounded in extensive quotations emerging from dense readings rather than quantitative sampling since the goal of this study is to report on what is written in these journals. I will focus on styles and vocabularies employed in medical texts.
- Medical Discourse
My first task with this section is to show how the obstetrical literature looks at women undergoing assisted reproductive procedures. The language in which medical texts describe the outcome of intervention points directly at the metaphor of the doctor as managing the process of reproduction. Anne Karpf [22] identifies a collective myth concerning doctors. She argues that doctors are perceived as magicians, gods or evil forces. They are either seen as selfless possessors of scientific knowledge or selfish evil wizards in pursuit of control of human life.
Female patients are hardly mentioned in medical articles discussing their problems. They are called ‘subjects’ as in “subjects at risk” or “an affected subject” [23]. Mostly, they are represented by their “cycles” of assisted fertilization with sperm injection [24]. If mentioned at all, women are only visible through the organs that are involved in the fertility treatment. They are present as ghosts and are represented by their “uterine cavity” [24]. As such, some physicians chose to describe the procedures as ‘woman-free’ and so there is no reference to women’s reproductive organs at all. For example: “A maximum of three embryos were transferred” [25], and “18 ococytes were obtained by transvaginal ultrasound guided retrieval” [26]. This vocabulary is obviously selected to exclude reference to the place where these embryos were implanted or from where they are taken.
Women’s experience of a painful intrusive procedure is described as “assisted hatching and fragment removal.” The textual medicalized account of women’s experience shades of women as lead characters while endorsing instruments, cells and physicians-technicians as the ultimate pivot. These features become autonomous actors with personality traits. For example, embryos are described in terms of their “good quality”. A Scottish IVF researcher reports of choosing the best embryos because they “look nice and round” [27].
Reporting on human conception, pregnancy and birthing are described as “in vivo development of embryos,” “in utero growth,” and “subsequent delivery of offspring” [24]. The numerous procedures required at an infertility clinic before a woman become pregnant are depicted in terms of the technical instruments that were administered to certain bodily parts: “twelve oocutes were retrieved after ovarian stimulation by an association of gonadotropin-releasing hormone analogs and human menopausal gonadotropins” [28]. Woman-less female organs are transformed to represent the whole and women patients are only present by their ‘otherness.’ The following is the opening paragraph of a medical report in the Journal of Obstetrics and Gynecology: “It is estimated that over 40,000 ovarian cycles are stimulated with gonadotropin preparations annually in the UK, either for assisted conception, or for conventional induction of ovulation” [23].
In fact, only one article in the sampling yields any reference to the physical toll this procedure may exact on a woman. This is because the article focuses on the problem of hormonal overstimulation of a patient’s ovaries. A woman’s pains and a relatively long hospital stay are described in the following manner: “Mrs. C. was admitted with a diagnosis of OHSS complaining of severe dysponea and abdominal pain and distention requiring paracentesis and hospitalization for 10 days in the intensive care unit for observation and supportive therapy” [26].
Doctors’ reductionist approach to their patients is based, in part, on scientific constructs and concepts similar to that of a machine [15]. The human body is seen, therefore, as a collection of parts, big (organs) and small (cells and genes). The machine construct allows the medical community to provide for imagined entities, separate and autonomous, with distinct borders within the context of ethics and legal rights. Thus, women are recognized only for their parts, and their reproductive capacities are viewed as removable physiological components.
Furthermore, the medical reports often frame accounts of assisted technological reproduction by defining the treatment rather than the woman and her actual experience. Van Dyck applies the metaphor of invasion of an army to the process of assisted reproduction. He maintains that these procedures turn “the womb into a mere site of struggle, and the egg into a trophy of an all-male military contest” [20]. This conceptualization contributed to the process of the othering of women. Pat Spallone writes about the promotion of embryos and the establishment of pre-embryos as separate actors. She concludes that the embryo discourse has contributed immensely to positioning women outside the realm of reproduction: “woman’s body largely remained outside representations of the pre-embryo, only to be reallocated when the story is spun out” [29]. She illustrates the effectiveness of the empowerment of the embryo or the pre-embryo by quoting Dr. Penelope Leach, a well-known psychologist and author who, while defining the term embryo, excludes any mention of the mother-woman and in fact argues that since “fertilization does not start an individual baby,” a pregnant woman is not pregnant anymore [29].
In her effort to map public debate of the new reproductive technologies, Jose Van Dyck [20] singles out the invention of technical assistance as “not ideological neutral; the ‘invisible’ consequence of these technological advancements may be that specific female reproductive functions, such as gestations and childbirth, get less attention than the moment of conception and the product of reproductive labor. As a result, the fetus may gain status at the expense of a woman’s reproductive body” [20].
Sue Halpern [30], a journalist writing for Ms magazine, claims that medical journal texts are often written as advertisements. Accordingly, medical discourse becomes advertising discourse simply by an emphasis on a sales pitch for potential clients. Thus, a ninety percent chance of failure with these treatments is reported as a success rate of one out of ten, The use of drugs as part of the procedures is omitted, and scientific research results focusing on numbers further confuses the audience into believing the notion of objectivity and superiority amongst fertility specialists.
Accordingly, a 1998 editorial published in the New England Journal of Medicine provides its readers with a pitch headline similar to those that can be found as part of an advertisement for a product. It Reads: “Two-embryo transfer—the future looks bright” [31]. It continues to say that “we expect that transfer of two blastocysts will resolve these issues by achieving a high rate of success…” and immediately offers a disclaimer or a reason as to why the present state of this technology does not match the glorious future prediction—“unfortunately, pressures from couples and programs to maximize results make these goals difficult to achieve in practice.” The promotional tone of the text echoes the romanticized language of popular articles in newspapers and magazines. Janice Raymond provides a worldwide account of international media revealing in the technological promises of “unlimited possibilities of progress” [3].
In fact, many similarities can be found between journalism discourse and the medical lingo practices used by physicians. In addition to the promotional tone, assisted reproductive procedures are portrayed as dramatic events. The long process of administrating drugs to women in doctors’ offices before and after their visit for the procedures themselves are condensed to a chain of actions, reported in rapid succession outside of the context of time and space. For example: “in February 1995, the patient began treatment with metrodin (follicle-stimulating hormone injection followed by human chorionic gonadotropin injections; vaginal progesterone suppositories, 50 mg every night during the luteal phase; and intrauterine insemination” [32]. A highly invasive treatment was reduced, in this description, to one frame without referencing the patient’s enormous physical as well as emotional input.
More unique in its approach is the report on a couple with infertility in the Journal of the American Medical Association [32]. It consists of three parts: the first section describes the treatment in medical terms. The second section provides quotation of the couple to whom the particular treatment was administered. The last part concludes with questions posed by gynecologists during a clinical conference. For the most part, the physicians excluded any major reference to the emotional, psychological and physiological effects these assisted technologies have on the female patient and her husband. None of the questions asked at the end of the article referred to these factors. However, the personal account of the patient and her husband focused totally on these effects. This creative strategy of offering the patient’s point of view alongside that of the doctor’s certainly helps humanize the discourse.
5. Conclusion
Feminist scholars have often charged the medical profession with devaluing the role of women in conception, gestation and birth. These researchers assert that physicians demonstrate a desire to control women’s procreative power. They have also argued that obstetricians and gynecologists, as well as other physicians, subscribe to a reductionist ideology since they treat women not as whole beings, but only as parts.
Results of this study suggest that most obstetricians and gynecologists are indeed reductionists, as reflected in their medical writings. Research reported in these journals focus on bodily parts rather than on the human women behind them. The “subject” of these articles is described as the “uterine milieu” or the “embryo transfer site.” Women “house pregnanc[ies],” and those who are involved in reproductive technologies procedures go through “embryo harvesting” while “embryos migrate” and “are deposited or replaced” in the uterus.
Second, in reading these medical articles, one may conclude that female reproductive capacities are used by these physicians as laboratories. Thus, justifiably raising the issue of conflict between the medical profession’s control over procreation and a woman’s right to control her own body.
Third, through the accessibility of medical literature on the Internet, people can connect with what used to be privileged knowledge. Medical discourse, through the revolution of technological information has become public discourse. Therefore, It cannot any longer be considered communication by medical practitioners for medical practitioners’ consumption. This, in turn, helps demystify science and medical news. At the same time, the authors-practitioners should articulate a more inclusionary vocabulary (rather than exclusionary vocabulary) by describing their patients as whole human beings. This “new and improved” technical lingo should leave behind the oppositional perspective physicians so often subscribe to and celebrate the partnership between themselves and their patients.
In vitro fertilization (IVF) pioneer Carl Wood provided a preliminary example of current medical thinking when he wrote: “it is quite possible that the artificial system will improve natural reproduction” [11]. Consequently, writers, of articles about reproductive technologies ignore, or at best, marginalize women by assigning them detached and passive roles. This, I will suggest, is a result of two factors. First, in an effort to establish a medical jargon concerning new reproductive technologies, physicians often assume a gatekeeping role and monopolize information related to the procreative process. This highly medicalized and technological language is considered normative amongst obstetricians and gynecologists. Second, the new reproductive technologies medical literature is a manifestation of a stubbornly persistent aspect of patriarchal ideology, which is reflected and translated into the forms and language of an “objective science” [33]. The writings in medical journals emphasize a transfer of control over the process of procreation from mothers to doctors. Accordingly, only technical aspects of the procreative process, using reproductive technologies, are deemed important and thus, deserve center stage.
- Practical Implication
So, what can be done differently? Susan Bell, one of the authors of “The New Our Bodies, Ourselves,” offers a translation-of-science strategy. This book, providing comprehensive information about women’s health and sexuality, has been printed since its first edition in 1984 in 12 languages and sold over 3 million copies. Bell revised her chapter on birth control in the 1992 edition. The revision process included “translation of knowledge about birth control works to render the sexist and specializes language of science into nonsexist language accessible to people who are not scientific specialists” [34]. New reproductive technologies practitioners can use a similar approach; by using a language that reattaches the part to the whole, recognizing the major impact these procedures have on their patients and securely anchoring the technology to the human factor.
In addition, the recently redesigned curriculum in some American Medical schools include new programs intended to inspire future physicians to be more human in their relationship with their patients [35]. These programs range from community service requirements to self-designed curriculum that can include electives in arts and literatures. Rise Jane Samra suggested that perhaps medical schools should also teach enough plain language and bedside manners to their students. Their patients would like to be treated as significant human beings [36]. This will constitute a tremendous improvement in physician-patient communication.
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