How is the “gynecological norm” constructed, the control of women’s bodies? Why is andrology so underdeveloped? What makes the burden of contraception still very clearly rests solely on women?
These questions, Aurore Koechlin examines them after five long-term field surveys. It invites people to become aware of this health standard that weighs on women by giving them a better knowledge of their bodies. Pursuing a sociology of gender, the author highlights the “political potential of feminism”.
How do you define gynecological “standard” and “career”?
I define the gynecological norm as the norm that enjoins women to regularly consult a health professional for gynecological follow-up, in particular for contraception and screening. I call gynecological career the act of entering into gynecological follow-up, and pursuing it regularly, ideally once a year, for life.
When does the systematic and regular gynecological examination of women, whose “impossible banality” you stress, date?
The specialty of gynecology predates the development of the gynecological standard: its first form of institutionalization can be dated to the creation of the French Society of Gynecology (SFG) in 1931. Initially, it aimed to treat both medically and surgically gynecological pathologies (infertility, cancer, etc.). In this context, we consult punctually, in connection with a specific problem that needs to be solved.
The changeover took place at the time of the Neuwirth law of 1967: a consensus was established around the legalization of contraception, provided that it was medicalised, with gynecologists making themselves the guarantors of its proper use, and with the idea that contraception will prevent abortions. In addition, as there was then a lack of hindsight as to the effects of contraception in the long term, systematic screening began to become part of professional practice. It is then that we pass from a logic of treatment of pathologies to a preventive logic, therefore from an exceptional consultation, linked to a circumscribed and temporary medical question, to a regular consultation, without precise reason, insofar as prevention requires close follow-up of patients. The gynecological standard was born.
Who are the actors and actresses of this career? You mention the role of mothers and other “helpers outside the medical community”.
I sought to understand how this norm was reproduced today: I thus showed the central role of mothers, women in the family, and friends, in convincing people to enter the gynecological career and to pursue it.
Among these various adjuvants, it is the mothers who play the most central role. Geneviève Cresson has shown that women are indeed at the center of the work that produces health, especially for the family. This is replayed at the gynecological level: they prescribe and proscribe behaviors, socialize with different standards, advise on contraception, push to consult a gynecologist.
Peers (friends, female relatives of the same age) play a supportive role, in particular by making certain aspects of gynecological follow-up desirable. One day, in consultation, a patient explains for example that she wants to take the pill, and specifically that of her sisters because a whole game has taken place between them around the pill: they take it together at the same time, exchange it, lend it to each other. The patient somehow wants to join their club.
What do you think of cases of gynecological violence? Would the creation of a new offense make it possible to combat them?
This is a complicated question because the term itself is not entirely stabilized in its definition, even if there is agreement that gynecological violence has to do with the non-respect of consent to the medical act. I don’t think at all that creating a new offense is a solution. The law already guarantees the “free and informed consent” of the patient (law of March 4, 2002).
The challenge is to adequately train health and care professionals in these issues, in particular by offering them training in sociology and psychology throughout their careers (which is, moreover, the request of many between them and them). This would make it possible to change practices, by establishing an explicit and systematic request for the patient’s consent before any act. But of course such an approach involves means.
Have prevention and contraception strategies concentrated the threats and risks on women alone?
In fact, the equivalent of gynecology for men, andrology, does not exist in the same proportions. Yet they are equally concerned about contraception in heterosexual relationships, and about genital infections, diseases and cancers. This disparity is therefore astonishing, which is why I question it in my book.
Two things can partly explain it. On the one hand, we inherit the “diseases of women”, named after the treatise of Hippocrates. In this conception, the female body is essentially a weakened and diseased body due to the uterus. Even if our representations have evolved since… On the other hand, Nelly Oudshoorn drew attention to a very important phenomenon: it is that medicalization leads to medicalization. She thus showed that, at the time of the discovery of sex hormones, research very quickly developed on the side of so-called female hormones. We had access to the urine of pregnant women via the obstetrics services and to these patients to carry out the necessary clinical tests. A previous medicalization makes possible a new medicalization, which in turn reinforces it. The same is true with gynecology.
What are the effects on women of this medical pressure caused by this gynecological follow-up?
It must be repeated that the gynecological consultation constitutes a resource space for many patients: in terms of information about their body, access to contraception, the possibility of carrying out preventive tests which save lives.
At the same time, individualization often leads to extreme responsibility in the management of one’s health and causes, in many patients, more or less diffuse anxiety. I interpreted this anxiety as a symptom of the difficulty of being both patient and sentinel of the symptoms of one’s body, what Patrice Pinell called Homo medicus. At the same time, patients are asked to monitor and have their bodies monitored and they are not given access to the knowledge necessary to do so, which leads them to misunderstand the symptoms observed.
Moreover, as Patrice Pinell reminds us, modern medicine is built on the principle of exteriority: we manage to objectify bodies and act on them precisely because they are not ours. Having a subjective and objective relationship to one’s own body is a source of tension and, according to him, impossible. This is the whole difficulty of preventive medicine, of which gynecology is a part.
Would it then be a question of all women getting out of this gynecological norm? Is “autogynecology” a possible solution?
My goal is not to say that patients should stop conforming to the gynecological norm. For me, it is necessary to walk on these two legs: to move forward in the demedicalization and the deprofessionalization of certain aspects of gynecology, while improving the medical practice of the latter. Often, the two are placed in opposition, but, for me, they must be thought of in a complementary way. We must move towards a decompartmentalization of practices and knowledge about the body, in particular by training in medicine from high school, by developing autogynecology and self-examination, by making certain body technologies such as hormones more accessible.
We must also demand more resources for health, which are essential for good care. This involves training health professionals in sociology and psychology, and integrating into practices the systematic request and before any act of patient consent. As such, I really think gynecology could pave the way for the rest of medicine.
Do you think that the feminist struggle also has the function of restoring a certain balance between men and women in contraception?
To ask the question of why andrology does not exist in the same way as gynecology is to question the gynecological norm, but it is also, of course, to question the absence of the same care for men. . They have a responsibility in the consequences of the sexual act and can also have pathologies or cancers. As often, feminist struggles denounce gender inequalities, so they can question the sometimes very material advantages of men and, at the same time, fight against social norms whose effects can be unfavorable even to men. It is their strength to design a social project where we would all be subject to our own standards.
Author in 2019 of “the Feminist Revolution”, Aurore Koechlin is a doctor in sociology. She devoted her thesis to the paradoxes of gynecology in France. Activist of the Féministes Révolutionnaires collective, she supports a convergence of anti-capitalist, anti-racist and feminist struggles.
The Gynecological Standard. What medicine does to women’s bodiesby Aurore Koechlin.
Editions Amsterdam/Alary/Passés/Composites. 320 pages, 20 euros.